Walk-In Hospital Admission of Patients with Subarachnoid Hemorrhage: Clinical Presentation and Outcome.

OBJECTIVE: Neurosurgeons occasionally encounter cases of subarachnoid hemorrhage (SAH) in admitted walk-in patients, termed "walk-in SAH." However, their clinical characteristics have not been fully understood. We thus, aimed to investigate several characteristics of patients with walk-in SAH and compare them with those of patients with good grade SAH who arrived at the hospital by ambulance. METHODS: Between January 2011 and January 2018, consecutive patients with World Federation of Neurosurgical Society (WFNS) grade I and II aneurysmal SAH were enrolled. They were dichotomized into walk-in and ambulance groups, and their demographic and disease-related characteristics were compared. Furthermore, predictors associated with unfavorable outcomes were investigated in patients with walk-in SAH. RESULTS: Of 171 patients with World Federation of Neurosurgical Society grade I and II SAH, 68 (39.8%) were categorized as walk-in SAH. The mean time for diagnosis in patients with walk-in SAH was significantly longer than that in patients who arrived by ambulance (P < 0.01). Multivariate analysis demonstrated that a lower rate of hypertension, high grades on the Barrow Neurological Institute scale, and Early Brain Edema Score were significantly associated with walk-in SAH (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.21-0.91, P = 0.03; OR 0.32, 95% CI 0.13-0.76, P = 0.007; OR 0.11, 95% CI 0.02-0.51, P < 0.0001, respectively). Additionally, severe angiographic vasospasm was a significant predictor of unfavorable outcomes in walk-in SAH (OR 37.7, 95% CI 1.10-1290.90, P = 0.04). CONCLUSIONS: Patients with walk-in SAH exhibit radiological characteristics associated with a more favorable outcome among patients with good grade SAH. Therefore, these patients may have a positive prognosis.

[A Case of Cervical Internal Carotid Artery Occlusion Presenting with Subarachnoid Hemorrhage Caused by Rupture of Leptomeningeal Anastomosis].

A 71-year-old man was admitted to our hospital with a diagnosis of subarachnoid hemorrhage (SAH). Angiographies revealed neither aneurysms nor vascular anomalies. However, these images elucidated the occlusion of the left cervical internal carotid artery as well as developed leptomeningeal anastomoses through the ipsilateral posterior cerebral artery, which resulted in blood perfusing the ipsilateral middle and anterior cerebral artery territories. Because the localization of SAH coincided with the developed leptomeningeal anastomosis, we speculated that the rupture of the developed leptomeningeal anastomosis in the basal cistern was the cause of SAH. We performed superficial temporal and middle cerebral artery bypass surgery to prevent rebleeding and ischemic stroke. In patients with occlusion of the internal carotid artery, SAH induced by the rupture of aneurysm formed by hemodynamic stress was recognized. However, rupture of developed leptomeningeal anastomosis should be considered as a possible cause of SAH of unknown origin. (Received March 7, 2016; Accepted August 31, 2016; Published January 1, 2017).

[A Case of Suprasellar Germinoma that Spontaneously Regressed before Endoscopic Biopsy].

We present a very rare case of suprasellar germinoma that spontaneously regressed before endoscopic biopsy. An 8-year-old boy was admitted to our hospital due to headache, polydipsia, and polyuria. Neurological examination performed on admission revealed bitemporal hemianopia. Enhanced MRI demonstrated a homogeneously enhanced tumor mass in the suprasellar region obstructing the foramen of Monro. Tests for all serum tumor markers were negative. Plain X-ray and CT scan were performed once and twice, respectively, for seven days between admission and endoscopic biopsy. The total dose of diagnostic radiation exposure before surgery was 110 mGy. Endoscopic observation during surgery revealed that the tumor had markedly decreased in size and the foramen of Monro had reopened. A very small piece of the tumor was harvested during surgery. Plain CT scan just after surgery showed a marked decrease in the tumor size, compared with the preoperative CT scan. The pathological diagnosis of the tumor was pure germinoma. The patient then underwent chemotherapy(four courses of CARE regimen)followed by radiation therapy with a dose of 24 Gy/15 fr. The tumor completely disappeared after treatment, and no recurrence was observed in the past four years.

Headache attack followed by rapid disease progression in pediatric moyamoya disease--how should we manage it?

CASE REPORT: A 4-year-old female was presented at our hospital with frequent right frontal headache attack. She was diagnosed with moyamoya disease and was conservatively followed up. One year later, the frequency of headache gradually decreased. However, follow-up MR imaging revealed that the disease stage markedly progressed in the right side and cerebral infarction occurred in the temporal lobe with atrophy of the right frontal lobe. She underwent direct and indirect revascularization on the right side. CONCLUSION: Aware of this case, we would like to emphasize that headache may be one subtype of ischemic attacks and require frequent MR follow-up to see the disease course. If there is any sign of disease progression, immediate surgical intervention should be indicated to avoid irreversible brain damage.

[Repeat bypass surgery for intracranial hemorrhage 30 years after indirect bypass for moyamoya disease].

A 39-year-old man had been diagnosed with moyamoya disease and underwent a bilateral encephalo-duro-arterio-synangiosis(EDAS)intervention at the age of 9 years. During the 30 years after his bilateral EDAS, he experienced no cerebrovascular events. However, at age 39, he suddenly presented with mild consciousness disturbance and vomiting and was transferred to a local hospital. Brain CT showed an intracerebral hemorrhage associated with ventricular hematoma. He was referred to our hospital for further investigation and treatment. Cerebral angiography showed faint collaterals through the site of the bilateral EDAS and development of basal moyamoya vessels. SPECT showed decreased cerebral blood flow(CBF)and cerebrovascular reactivity(CVR)in the right frontal lobe. We diagnosed him with delayed cerebral hemorrhage due to delayed rupturing of fragile moyamoya vessels after indirect bypass. The patient underwent a repeat bypass surgery(STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis;EDMAPS)on the right side. He showed improvement in cerebral hemodynamics after surgery, and has since remained free from cerebrovascular events. Hemorrhagic events occurring a very long time after indirect bypass surgery in pediatric-onset moyamoya disease are rare. In such cases, a lifelong follow-up strategy may be necessary. Repeat bypass surgery may be a powerful tool to prevent such hemorrhagic events.

[Neuroendoscopic surgery for intra- and para-ventricular tumors:impacts on biopsy and hydrocephalus treatment].

In this report, the authors retrospectively review and discuss their results for neuroendoscopic surgery for intra- and para-ventricular tumors. This study included 28 patients who were admitted to our hospital for intra- or para-ventricular tumors between January 2005 and March 2013. There were 17 males and 11 females, and their age varied widely from 1 to 75 years. Using a neuroendoscopic technique, tumor biopsy was attempted in all 28 patients. Biopsy was possible in 25 patients(89.3%)but not in the other 3(10.7%)because of hypervascularity or tumor bleeding. Of these 25 patients, pathological diagnosis was possible in 23(92%), but not in other 2(8%)because of incomplete sampling. In 18 of 28 patients, various forms of hydrocephalus were observed. Neuroendoscopic procedures were quite useful to improve cerebrospinal fluid dynamics in 13 of these patients, including endoscopic third ventriculostomy(ETV)in 9(except for 1 patient with ETV failure), septostomy with ventriculoperitoneal shunting(VPS)in 3, and cystostomy in 1. Simple VPS was performed in the other 4 patients. These results suggest that neuroendoscopic surgery is valuable as a minimally invasive procedure for pathological diagnosis and hydrocephalus treatments in patients with intra- and para-ventricular tumors. Further development of neuroendoscopic equipment is warranted to accurately diagnose tumors with hypervascularity and subependymal tumors.

Syringomyelia associated with Paget disease of the skull.

A 38-year-old man presented with a rare case of syringomyelia associated with Paget disease of the skull. Syringosubarachnoid (SS) shunting was performed. We speculate that deformation of the skull secondary to Paget disease caused narrowing of the foramen magnum with progressive impairment of the cerebrospinal fluid circulation, which led to syringomyelia and neurological symptoms. SS shunting is safe, effective, and technically simple, so may be a useful initial treatment for syringomyelia associated with Paget disease of the skull.

New dried human amniotic membrane is useful as a substitute for dural repair after skull base surgery.

Objectives Cerebrospinal fluid (CSF) leakage is an undesirable complication of skull base surgery. We used dried human amniotic membrane (AM) as a patch graft for dural repair to determine its efficacy in preventing CSF leakage. Design Frontoparietal craniotomy and removal of dura were performed in 20 Wistar rats. A dried AM was placed to cover the dural defect without suturing in 16 animals. In four animals, an expanded polytetrafluoroethylene was implanted. At 2 weeks and 1, 3, and 6 months, histological examination was performed. Dried AM was also used as a substitute in 10 patients who underwent skull base surgery, after approval by the Ethics Committee of the University of Toyama. Results At 2 weeks after implantation, thick connective tissue completely enclosed the dried AM. At 1 month after implantation, the connective tissue became thin and the implanted AM shortened. At 3 and 6 months after implantation, histological examination revealed disappearance of the dried AM and formation of membranous tissue. In the clinical study, neither CSF leakage nor clinical adverse reactions directly related to the dried AM were observed. Conclusion Dried human AM appears to be an ideal substitute for dura, since it is replaced by natural tissue.

Bilateral subthalamic deep brain stimulation for camptocormia associated with Parkinson's disease.

BACKGROUND: Few multiple case studies of the effects of deep brain stimulation for camptocormia associated with Parkinson's disease have been reported. Although deep brain stimulation was in some cases not effective against camptocormia, it is unclear in which types of patients it was effective in treating camptocormia. OBJECTIVE: We treated 4 Parkinson's disease patients with camptocormia and evaluated their paraspinal muscle status by computed tomography to specify the characteristics of cases of effective treatment. METHODS: The 2 female and 2 male patients in this study were 60-69 years old, with a disease duration from onset to surgery of 7-13 years and a follow-up period of 18-40 months. The electrodes were implanted bilaterally in the subthalamic nuclei. RESULTS: Camptocormia was improved in 3 cases, and was unchanged in the remaining case although other parkinsonian symptoms improved. The computed tomography number of paraspinal muscle in the unimproved patient was much smaller than that in the improved patients. CONCLUSIONS: A relationship may exist between improvement of camptocormia and severity of paraspinal muscle degeneration.

Microvascular anastomosis at 30-50× magnifications (super-microvascular anastomosis) in neurosurgery.

BACKGROUND: We report a safe and precise technique of microvascular anastomosis at higher magnifications (30 - 50 ×) in neurosurgery and evaluate our experiences to examine the utility of this method for cerebral revascularization in various situations. METHODS: A retrospective review was carried out of patients who underwent microvascular anastomosis using a high-magnified operating microscope. This method was performed in 30 patients with 35 microvascular anastomoses in various situations. This microscope has two optical systems, a standard zooming system and a newly developed high magnification system. High resolution and good depth of focus are achieved by a new lens design in the optical system, which makes the image of the object very clear at higher magnifications. In this operating microscope, the combination of a 10 × eyepiece and the 200, 250, and 300-mm objective lens enables a range of final magnifications from 2.9 × to 50.4 ×. RESULTS: This method enabled one to pay attention to performing atraumatic manipulations of small vessels and correct suturing, intima-to-intima, of vessel walls. Microvascular anastomoses were performed safely and precisely at higher magnifications. All anastomoses were patent. CONCLUSION: It is obvious that practical final magnifications of more than 30 × in neurosurgery would be super-magnified operative views. Microvascular anastomosis at 30 - 50 × magnifications (super-microvascular anastomosis) can help neurosurgeons to improve their skills, with good visualization, and to be safe and accurate when conducting cerebral revascularization in various situations.

Middle cranial fossa arachnoid cyst presenting with subdural effusion and endoscopic detection of tear of the cyst--case report.

A 15-year-old boy presented with a case of middle cranial fossa arachnoid cyst associated with subdural effusion and manifesting as headache and vomiting after minor head injury. Computed tomography disclosed a cystic lesion in the left middle cranial fossa and ipsilateral subdural effusion. Fundoscopic examination revealed papilledema. A small tear of the cyst wall was confirmed endoscopically. Fenestration of the cyst was performed under the operating microscope. Postoperative course was uneventful. The tear in the outer wall of an arachnoid cyst may suggest the mechanism of occurrence of subdural effusion associated with middle cranial fossa arachnoid cyst.

[Cerebral infarction suspected due to dissection of intracranial carotid artery in 2 children].

Intracranial cerebral artery dissection in children is very rare. We report 2 children who were diagnosed as having cerebral infarction which was suspected to be due to dissection of intracranial cerebral artery. Case 1: An 11-year-old girl presented with conscious disturbance and hemiparesis after seizure. Computed tomography (CT) showed cerebral infarction in the right frontal lobe. Her symptoms did not change, but angiography demonstrated reversible change. She received conservative therapy. Case 2: A 10-year-old boy complained of headache, and presented nausea and monoparesis of the left upper extremity. CT showed cerebral infarction in the right frontal lobe. He received superficial temporal artery-middle cerebral artery anastomosis because his symptoms fluctuated. In both cases, cerebral angiography showed string sign from the supraclinoid portion of the internal carotid artery to the middle and the anterior cerebral artery. Follow-up angiography showed improvement of stenosis. In pediatric cases of cerebral artery dissection, improvement with conservative therapy is frequently reported. It is necessary to follow-up such patients closely using magnetic resonance angiography or conventional angiography to determine whether or not surgery is indicated.

Neuropsychological changes after endoscopic third ventriculostomy for long-standing overt ventriculomegaly in adults. Case report.

A 39-year-old woman presented with long-standing overt ventriculomegaly in adults (LOVA) manifesting as gradually worsening headache. Past history included treatment for myeloschisis at birth. Intelligence quotient (IQ) was 115 and preoperative psychological assessment using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) showed normal scores in all domains. However, scores for constructional ability were slightly low. Computed tomography revealed severe ventriculomegaly involving the lateral and third ventricles, and magnetic resonance imaging showed aqueductal stenosis. Endoscopic third ventriculostomy was performed under a diagnosis of LOVA. Postoperatively, the headache resolved and the RBANS showed improvements in memory and constructional ability. Detailed evaluation of cognitive function provides a good indicator in the treatment of hydrocephalus with normal IQ.

A rare astrocytic tumor with rhabdoid features.

We report an extremely rare tumor presenting with rhabdoid features in the left temporoparietal lobe near the trigone in an 18-year-old Japanese man. This tumor mainly consisted of medium to large round cells that proliferated diffusely and incoherently with a scant extracellular matrix. These tumor cells had an eccentric nucleus and an eosinophilic cytoplasm containing inclusion bodies and bundles of intermediate filaments. The nuclei of these cells were vesicular with prominent nucleoli. This tumor had an area appearing to be diffuse astrocytoma peripherally and lacked a primitive neuroectodermal tumor component, a mesenchymal component, and epithelial differentiation. INI expression, which is not observed in atypical teratoid/ rhabdoid tumor (AT/RT), was found in this tumor. From these findings, we concluded that this tumor was not AT/RT but an astrocytic tumor with rhabdoid features. We also concluded that the tumor cells exhibiting rhabdoid features had secondarily arisen from the peripheral area presenting an appearance of diffuse astrocytoma.

Malignant transformation of supratentorial clear cell ependymoma.

Recurrence of clear cell ependymoma is not a rare condition, but malignant transformation of clear cell ependymoma has not yet been well presented. The authors report a 44-year-old man who presented with progressive right hemiparesis. A brain tumor in the left frontal premotor area was removed and an initial pathological diagnosis of oligodendroglioma was made. The tumor recurred 4 months later, and reoperation of the tumor and adjuvant local radiotherapy were performed. The patient subsequently underwent surgical removal of recurrent tumors on another four occasions (6 times in total) during a period of 11 years and finally died of the original disease. Histopathological studies of all surgical and autopsy specimens were carried out. The first and second surgical specimens did not contain any ependymal rosettes or pseudorosettes, and thus a diagnosis of oligodendroglioma was made. However, the third surgical specimen showed pseudorosettes. At this time, the tumor had an ultrastructural appearance compatible with ependymoma. Thereafter, the recurrent tumors showed anaplastic features such as nuclear pleomorphisms and necrosis with pseudopallisading. The autopsy specimens resembled a feature of glioblastoma but the tumor was sharply demarcated from the surrounding parenchyma.

A newly designed training tool for microvascular anastomosis techniques: Microvascular Practice Card.

BACKGROUND: We report a newly designed training card (Microvascular Practice Card) that is a non-animal practice tool for surgical training and practicing the skills for microvascular anastomosis techniques. METHODS: The Microvascular Practice Card is a pocketbook-sized card that has silicone tubes affixed to it. On the card, 6 small-diameter, 4-cm-long tubes side by side are arranged in 4 directions with both ends secured. The tubes are available in diameters of 2.0, 1.0, 0.5, and 0.3 mm. The thickness of the tube wall is 0.05 or 0.1 mm. The card includes a record area that allows records to be written. Four directional tubes are arranged on one card, making it possible to practice various directional suturing and anastomosing. RESULTS: Beginners begin to practice suturing with larger diameter tubes (2.0 mm) and refine their skills using 1.0 mm diameter tubes as they get used to the practice. For vascular anastomosis, the card provides for end-to-end anastomosis, end-to-side anastomosis, and side-to-side anastomosis. Furthermore, superfine diameter tubes (0.5 and 0.3 mm) help microsurgeons to gain experience at higher magnifications. Training on this card is performed through a plastic box with a small hole using long microinstruments. CONCLUSION: Microvascular Practice Card is a new training tool for repeatedly practicing microvascular anastomosis in various situations. This non-animal practice tool would help trainees practice under safe and hygienic conditions and reduce the number of laboratory animals used during technical training.

Folliculostellate cell tumor in pituitary gland.

A 33-year-old woman presented with visual field defects. Magnetic resonance imaging demonstrated a pituitary tumor with suprasellar extension. The tumor was partially removed by trans-sphenoidal surgery. Histologically, the tumor was composed of fascicles of spindle cells which were immunohistochemically positive for S-100 protein, Galectin-3, vimentin and EMA. Based on the morphology and immunostaining pattern, diagnosis of folliculostellate cell tumor in the pituitary gland was given.

Pilomyxoid astrocytoma in a patient presenting with fatal hemorrhage. Case report.

The authors report on a rare case of pilomyxoid astrocytoma in a patient presenting with fatal hemorrhage. This 5-year-old boy presented to the outpatient clinic with headache and vomiting. Computed tomography and magnetic resonance imaging studies revealed a mass lesion with partial hemorrhage in the suprasellar region extending into the third ventricle. Partial resection via a transcallosal approach was performed. Because the pathological diagnosis was pilomyxoid astrocytoma, chemotherapy was administered. However, 4 months after the first operation, during chemotherapy, the boy presented with massive intratumoral and intraventricular hemorrhage with hydrocephalus. Although emergent external ventricular drainage was performed, the patient died. In this report, the authors review the literature and discuss the clinical features and treatment of pilomyxoid astrocytoma.

A development of atheromatous plaque is restricted by characteristic arterial wall structure at the carotid bifurcation.

BACKGROUND: It is said atheromatous plaque is located very focally, but there have been few reports regarding this matter. Various aspects of the pathogenesis of the development of atheromatous plaque at the carotid bifurcation have previously been discussed. We have noted the correlation of plaque localization with characteristics of the cervical carotid artery wall. METHODS: Morphological and histopathologic changes in the carotid bifurcation were examined in 72 cadaver cases with or without atheromatous plaque. We determined the level at which the wall structure changed to muscular artery from elastic artery and analyzed its influence on the development of atheromatous plaque. RESULT: Atheromatous plaques at the distal site of the ICA extended within 0 to 37 mm from the carotid bifurcation. The proximal side of the CCA more than 5 mm away from the bifurcation was elastic artery, whereas the distal side of the ICA more than 15 mm from the bifurcation was muscular artery. The area of the carotid bifurcation between elastic artery and muscular artery was a transitional zone. Approximately 80% of them were located within 15 mm, and these areas were coincident with the transitional zone. CONCLUSION: Most atheromatous plaque was located in the transitional zone. The arterial wall structure is related to the development of atheromatous plaque at the cervical carotid bifurcation.

A new training method to improve deep microsurgical skills using a mannequin head.

Neurosurgeons need fine and special microsurgical techniques, such as the ability to suture deep microvasculature. Intensive training is required to perform microsurgery, especially in deep microvascular anastomosis. There have been many previous reports of training methods for typical microsurgical techniques, including suturing of surgical gloves, Silastic tubes, living animals, and chicken wing arteries. However, there have been no reports of training methods to improve deep microsurgical skills under the various hand positions specific to neurosurgical operation. Here, we report a new training method using a mannequin head, water balloons, and clay to mimic actual deep microsurgery in the brain. This method allows trainees to experience microsurgery under various hand positions to approach the affected areas located at various depths in the brain from various angles.