Usefulness of the Glove Finger Pad for Ultrasonography in Nasal Fracture Reduction.

The treatment of nasal bone fractures involves closed reduction, in which the reduction position is generally evaluated indirectly by visual examination and palpation. While more direct evaluation methods using ultrasonography can improve treatment outcomes, ultrasonography of the nasal bones requires acoustic coupling materials to hold the entire ultrasonography probe in close contact with the nose. We report the use of the Glove Finger Pad, a homemade acoustic coupling material made from a medical glove. The Glove Finger Pad is easy to prepare and use and produces good images. We believe that the Glove Finger Pad will further enhance the usefulness of ultrasonography for the treatment of nasal fractures.

Clinical Evaluation of Cerebrospinal Fluid p217tau and Neurofilament Light Chain Levels in Patients with Alzheimer's Disease or Other Neurological Diseases.

BACKGROUND: The cerebrospinal fluid (CSF) levels of tau phosphorylated at threonine 217 (p217tau) or 181 (p181tau), and neurofilament light chain (NfL) are definite biomarkers of tauopathy and neurodegeneration in Alzheimer's disease (AD). OBJECTIVE: To validate their utility in excluding other neurological diseases and age-related changes in clinical settings. METHODS: We developed monoclonal antibodies against p217tau and NfL, established novel ELISAs, and analyzed 170 CSF samples from patients with AD or other neurological diseases. RESULTS: In AD, p217tau is a more specific and abundant CSF component than p181tau. However, CSF NfL levels increase age-dependently and to a greater extent in central and peripheral nervous diseases than in AD. CONCLUSIONS: CSF p217tau correlates better with AD neurodegeneration than other tau-related biomarkers and the major phosphorylated tau species. The clinical usage of NfL as a neurodegeneration biomarker in AD requires exclusion of various central and peripheral neurological diseases.

[Intracranial Anatomy and Surgical Techniques for Extended Orbital Exenteration for Sinonasal Malignancy with Orbital Apex Extension].

Gross total tumor resection for sinonasal malignancy with orbital apex extension requires orbital exenteration and bony skull base resection around the orbital apex with sufficient margins. With a detailed discussion of the anatomy, we describe our surgical procedure for extended orbital exenteration with orbital apex resection for sinonasal malignancy.

A Three-Dimensional Anterior and Middle Cranial Fossa Model for Skull Base Surgical Training with Two Layers of the Colored Dura Mater.

BACKGROUND: Adequate epidural procedures and anatomical knowledge are essential for the technical success of skull base surgery. We evaluated the usefulness of our three-dimensional (3D) model of the anterior and middle cranial fossa as a learning tool in improving knowledge of anatomy and surgical approaches, including skull base drilling and dura matter peeling techniques. METHODS: Using a 3D printer, a bone model of the anterior and middle cranial fossa was created based on multi-detector row computed tomography data, incorporating artificial cranial nerves, blood vessels, and dura mater. The artificial dura mater was painted using different colors, with 2 pieces glued together to allow for the simulation of peeling the temporal dura propria from the lateral wall of the cavernous sinus. Two experts in skull base surgery and 1 trainee surgeon operated on this model and 12 expert skull base surgeons watched the operation video to evaluate this model subtlety on a scale of 1 to 5. RESULTS: A total of 15 neurosurgeons, 14 of whom were skull base surgery expert, evaluated, scoring 4 or higher on most of the items. The experience of dural dissection and 3D positioning of important structures, including cranial nerves and blood vessels, was similar to that in actual surgery. CONCLUSIONS: This model was designed to facilitate teaching anatomical knowledge and essential epidural procedure-related skills. It was shown to be useful for teaching essential elements of skull-base surgery.

Multiscope Technique Combining an Endoscope and Exoscope for Neck Clipping of Cerebral Aneurysms.

OBJECTIVE: In aneurysm clipping, the use of an endoscope improves the visualization of the anatomic structures around the aneurysm, allowing for improved dissection and clipping techniques. Furthermore, it makes the surgery less invasive. The disadvantage of using the endoscope and microscope together is that the surgeon must move the line of sight significantly between viewing the operative field through the eyepiece of the microscope and viewing the endoscope monitor. This disadvantage makes it difficult for the surgeon to safely insert the endoscope in the optimal position. This study presents a new method for observing the surgical field with a picture-in-picture system using both an endoscope and an exoscope that can overcome the disadvantage of multiscope surgery. METHODS: The endoscope was used when the anatomic structures around the aneurysm could not be observed with the exoscope only. An image from the endoscopic monitor was inserted into the exoscopic monitor. The surgeon inserted the endoscope in the optimal position while viewing the endoscope monitor and ensured that the structures in the path of the endoscope were not damaged while they viewed the exoscope monitor. RESULTS: Three patients underwent aneurysm clipping. The use of an endoscope made the procedure less invasive, and the surgeon was able to safely insert the endoscope in the optimal position. Only slight movement of the line of sight was required to view the 2 monitors. CONCLUSIONS: The endoscope and exoscope multiscope picture-in-picture system can facilitate safer aneurysm clipping compared with combined microscopic and endoscopic surgery.

Tumor doubling time as preoperative predictor of malignancy and recurrence in newly diagnosed meningioma.

Most meningiomas are benign, and the indications for surgery are determined by size and symptoms, but some are malignant and have a high recurrence rate. Currently, no preoperative prognostic factors have been established. The purpose of this study was to investigate whether tumor doubling time (Td) is useful in predicting tumor prognosis. Patients who underwent surgery for newly diagnosed meningioma at our hospital between 2007 and 2021 with preoperative magnetic resonance (MR) imaging evaluation over a period of 6 months were included in this study. We calculated the Td from the preoperative MR images and examined the correlation between Td and WHO grade, MIB-1 SI, and other conditions. A total of 269 newly diagnosed meningiomas were operated on during the study period, of which 62 met inclusion criteria. The median Td was 1082 days (54-8579 days), and MIB-1 SI was 2.45% (0.7-14.6%). Td and MIB-1 SI had a negative correlation (r = - 0.319, p = 0.0122). MIB-1 SI was higher in patients with Td < 3 years than in those with Td ≥ 3 (p = 0.005), and the incidence of high WHO grade (grade2) was higher in patients with Td < 1 year than in patients with Td ≥ 1 (p = 0.014). Meningiomas with Td < 3 years had significantly higher MIB-1 SI, and tumors with Td < 1 year had a higher likelihood of malignancy. Therefore, early treatment should be considered in patients with short Td meningioma even if asymptomatic, and further consideration could be given to radical resection at the time of surgery.

Histopathological Investigation of Meningioma Capsule with Respect to Tumor Cell Invasion.

No previous study has histopathologically investigated whether a meningioma capsule presents with tumor cells. We investigated which types of tumor capsules (TCs) included tumor cells to help intraoperatively determine those TCs that do not need to be removed and have a low recurrence risk. We investigated 22 specimens of 14 newly diagnosed meningiomas from February 2011 to June 2021. The capsules were classified into three types: TC, capsule-like thickened arachnoid membrane (CAM), and extended membrane (EM). Capsule properties were scored by hardness (soft = 1, medium = 2, hard = 3) and transparency (high = 1, medium = 2, low = 3). The hardness, transparency, and score sums were compared between capsules with and without tumor invasion in the CAM and EM types. The mean follow-up duration was 40.6 months, and there was only one recurrence in a remote location from the residual capsule. Nine capsules were classified as TC, seven as CAM, and six as EM. The tumor cells invaded 88.9% of TCs, 42.9% of CAMs, and 50% of EMs. The hardness, transparency, and score sums for CAMs with tumor invasion were lower than those for CAMs without tumor invasion, although not significant (P = 0.114, P = 0.114, P = 0.057, respectively). A thickened TC or soft and highly transparent CAM indicated a high risk for tumor cell invasion; thus, such cases require a careful and long-term follow-up. Hard and low transparent residual CAMs may have had a low risk for tumor invasion; therefore, leaving such capsules that tightly adhere to the eloquent cortex can be theoretically justified to avoid damaging the brain surface.

Correlation of Intraoperative 5-ALA-Induced Fluorescence Intensity and Preoperative 11C-Methionine PET Uptake in Glioma Surgery.

BACKGROUND: 5-Aminolevulinic acid (5-ALA) is widely employed to assist fluorescence-guided surgery for malignant brain tumors. Positron emission tomography with 11C-methionine (MET-PET) represents the activity of brain tumors with precise boundaries but is not readily available. We hypothesized that quantitative 5-ALA-induced fluorescence intensity might correlate with MET-PET uptake in gliomas. METHODS: Adult patients with supratentorial astrocytic gliomas who underwent preoperative MET-PET and surgical tumor resection using 5-ALA were enrolled in this prospective study. The regional tumor uptake of MET-PET was expressed as the ratio of standardized uptake volume max to that of the normal contralateral frontal lobe. A spectrometric fluorescence detection system measured tumor specimens' ex vivo fluorescence intensity at 635 nm. Ki-67 index and IDH mutation status were assessed by histopathological analysis. Use of an antiepileptic drug (AED) and contrast enhancement pattern on MRI were also investigated. RESULTS: Thirty-two patients, mostly with Glioblastoma IDH wild type (46.9%) and anaplastic astrocytoma IDH mutant (21.9%), were analyzed. When the fluorescence intensity was ranked into four groups, the strongest fluorescence group exhibited the highest mean MET-PET uptake and Ki-67 index values. When rearranged into fluorescence Visible or Non-visible groups, the Visible group had significantly higher MET-PET uptake and Ki-67 index compared to the Non-visible group. Contrast enhancement on MRI and IDH wild type tumors were more frequent among the Visible group. AED use did not correlate with 5-ALA-induced fluorescence intensity. CONCLUSIONS: In astrocytic glioma surgery, visible 5-ALA-induced fluorescence correlated with high MET-PET uptake, along with a high Ki-67 index.

Early postoperative complications and their measures after skull base reconstruction: A study from the standpoint of plastic and reconstructive surgeons.

OBJECTIVE: In skull base surgery, postoperative complications may be lethal and it is important to know how to deal with these. There are several reports on complications after skull base reconstruction, but it is difficult to understand which are important for plastic surgeons in charge of reconstruction. The objective of this study is to clarify the early postoperative survival-related complications after skull base reconstruction of which plastic surgeons should participate in treatment. METHODS: One hundred and seventy-seven patients who underwent skull base reconstruction at our department over the last 12 years were retrospectively surveyed. The cases of early complications in which plastic surgeons were actively involved in treatment were investigated and the preventive measures actually taken at our facility are examined in addition to treatment methods after development. RESULTS: Plastic surgical complications were wound infection in seven patients, impaired blood flow in transplanted tissue in two patients, cerebrospinal fluid leakage in five patients, and intracranial compression in three patients. Total number of postoperative complications were seventeen and the total complication rate was 9.6%. Complication rates tended to be higher in anterior-middle skull base cases than in anterior or middle alone cases and higher with free tissue transfer than with locoregional flap. Multivariate analysis revealed that operation time was a significantly higher risk factor (p=0.012) and preoperative chemotherapy was a significantly lower risk factor (p=0.033) for the development of complications. It was also found that the hospitalization length was significantly longer when complications occurred (p<0.0001). Wound infection was treated with removal of the cause, sufficient drainage, and irrigation. Regarding preventive measures, it is necessary to pay attention especially to intracranial contamination with epithelial components. Rapid surgical measures were necessary when blood flow of the transplanted tissue was impaired. For pedicle flaps, conservation of the feeding vessel is needed, and for free flaps, reliable vascular anastomosis is needed as preventive measures. Plastic surgeons play a role in reducing the risk of cerebrospinal fluid leakage through covering the repaired dura mater with tissue with favorable blood flow, especially in reoperation after development of leakage. Skull base reconstruction with soft tissue may cause intracranial compression, and sometimes, it is not resolved by conservative treatment and reoperation is selected. CONCLUSION: Plastic surgical postoperative complications were clarified, and treatment methods and preventive measures for them were examined. Careful consideration of blood flow, placement, and volume of the transplanted flap is important to prevent complications.

Molecular characterisation of carbapenem- and tigecycline-resistant Klebsiella pneumoniae strains isolated from blood and bile samples.

INTRODUCTION: The number of carbapenem-resistant Klebsiella pneumoniae (CRKP) strains are increasing, further raising healthcare concerns worldwide. In this study, we isolated three CRKP strains from bile and blood samples of an elderly patient (90s) with acute cholangitis and characterised the features and antimicrobial resistance mechanism of CRKP isolates. METHODS: Three CRKP isolates were characterised by Pulsed-field gel electrophoresis (PFGE), whole genome sequencing using the NovaSeq 6000, and antimicrobial susceptibility testing. Transcriptional levels of resistance-associated genes were measured by real-time RT-qPCR. RESULTS: PFGE analysis revealed highly similar patterns for these isolates. Furthermore, they showed resistance to not only carbapenem but also tigecycline. Genomic analysis of the blood isolate identified the exogenous resistance genes blaCTX-M14, tet(A), tet(D), opxAB, and qnrS1 but not any carbapenemase-encoding genes. In addition, nonsense mutations were found in both the outer membrane protein K36 (ompK36) and transcriptional regulator ramR, suggesting that this isolate developed multidrug resistance by acquiring both exogenous resistance genes and nonsense mutations. The extended-spectrum ß-lactamase-producing carbapenem-susceptible K. pneumoniae isolate exhibited the same susceptibility pattern, except to ß-lactams, as prior CRKP isolates. CONCLUSIONS: Antimicrobial susceptibility to carbapenem and tigecycline should be continuously monitored, because it might change from susceptible to resistant during another antimicrobial treatment, even if an isolate initially shows susceptibility, and the patient has not been exposed to these agents.

The different concepts of surgical managements between anterior and lateral skull base reconstructions based on surgical purposes.

OBJECTIVE: Anterior and middle cranial fossa defects require different strategies, depending on their anatomical location. The aim of this study was to elucidate the surgical managements for the defects based on surgical purposes and to clarify the conceptional differences relating to anterior and lateral skull base reconstructions. METHODS: This study included patients who had undergone reconstructive surgery for anterior or middle cranial fossa defects in our institution between July 2008 and June 2019. It consisted of 66 patients who had been subject to anterior skull base reconstructions, and 84 patients who had experienced lateral skull base reconstructions. The medical records were examined retrospectively, and the surgical purposes and procedures performed were reviewed. The surgical purposes were divided into four groups: Separation, Restoration, Augmentation, and Coverage. RESULTS: Regarding anterior skull base reconstructions, the Separation group included 65 patients, who represented 98% of this category. There were 26 cases in the Separation-only group, 20 of which were reconstructed with locoregional flaps, and 6 of which with free tissue transfers. A Combination group, which consisted of Separation and Other purposes, consisted of 40 cases. Within this group, 5 cases were reconstructed with locoregional flaps, and 35 with free tissue transfers. Regarding lateral skull base reconstructions, the Separation group included 34 patients, who represented 40% of this category. The rate of the Other purposes represented the majority. In the Separation-only group of 24 patients, 16 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In the Combination group of 10 patients, 2 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In groups other than the Separation group, 27 cases were reconstructed with locoregional flaps and 23 cases with free tissue transfers. CONCLUSION: In most anterior cranial fossa defect cases, the surgical purpose is separation. In middle cranial fossa defect cases, there are many cases in which the surgical purpose is not separation. In the Separation groups, relating to both anterior and lateral skull base reconstructions, the use of locoregional flaps was an effective measure. Free tissue transfers were required in many cases of the Combination group. Outside of the Separation group associated with lateral skull base reconstructions, the use of locoregional flaps and free tissue transfers were almost equal in proportion, and the selection of reconstructive procedures tended to change from locoregional flaps to large free flaps with increase in the numbers of surgical purposes.

Novel detection of the CAMTA1-WWTR1 fusion gene in extra-adrenal myelolipoma-like lesion: a case report.

A mediastinal mass was incidentally detected by chest X-ray in a 44-year-old man. Computed tomography findings revealed that the mass was a possible malignancy in the right and middle mediastinum and was removed by surgical resection. Macroscopically, the resected specimen was a well-demarcated yellowish, brownish, and whitish mass. Microscopically, a solid lesion with cords of epithelioid cells in the extra-adrenal myelolipoma-like lesion was observed. Immunohistochemically, the solid lesion was positive for typical vascular markers and CAMTA1, the expression of which is highly specific for epithelioid hemangioendothelioma (EHE). The endothelial cells and bone marrow elements of myelolipoma-like lesion were also positive for CAMTA1. Fluorescence in situ hybridization examination detected the CAMTA1-WWTR1 fusion gene not only in the solid lesion but also in the endothelial cells and bone marrow elements of myelolipoma-like lesion. To our knowledge, this is the first report suggesting common genetic abnormality, CAMTA1-WWTR1 fusion, in cases of EHE and extra-adrenal myelolipoma.

Polygamous breeding system identified in the distylous genus Psychotria: P. manillensis in the Ryukyu archipelago, Japan.

Distyly is a genetic polymorphism composed of long-and short-styled flowers in a population. The evolutionary breakdown of distyly has been reported in many taxa, and mainly involves a shift toward monomorphism or dioecism. However, a shift toward monoecism has not been reported in distylous species. Psychotria (Rubiaceae), one of the world largest genera, consists of distylous species and their derivatives. In our preliminary study, however, we identified some monoecious individuals in a population of Psychotria manillensis. To understand the breeding system and reproductive biology of P. manillensis, we investigated floral traits, open fruit set, and flower visitors, and performed hand pollination and bagging experiments in five populations of Okinawa and Iriomote islands, Ryukyu Islands, Japan. The populations of P. manillensis were composed mainly of monoecious individuals (54%), followed by female (30%), male (14%), and hermaphroditic (2%) individuals at the time of flower collection. Of the collected flowers, 93% were functionally unisexual (male or female), whereas only 6.5% were perfect (hermaphroditic). However, some individuals changed sex mainly towards increasing femaleness during the flowering period. Moreover, 35% of the studied plants changed their sexual expression over the years. P. manillensis showed self-compatibility and no agamospermy. The fruit set under open pollination varied among populations and years (1.8-21.9%), but it was significantly higher than that of auto-selfing (0.68-1.56%). Wasps and flies were the main flower visitors and probably the main pollinators of the species. In conclusion, P. manillensis was revealed to be polygamous, involving monoecious, female, male, and hermaphroditic individuals. This is the first report of the polygamous breeding system not only in the genus Psychotria, but also in all heterostylous taxa.

A Concept of "Boundary Determination" by the Combination of a Local Flap and Free Tissue Transfer Useful for the Prevention of Postoperative Complications After Complex and Widespread Skull Base Reconstruction.

ABSTRACT: The transplanted tissue is sutured to the stumps of the bones in skull base reconstruction. Concerning reconstruction by free tissue transfer, it is difficult that the tissue is accurately sutured/fixed to a complex three-dimensional structure. The authors devised a technique in which free tissue transfer is combined with a local flap. A pericranial flap is sutured/fixed onto the irregular border between the cranial and nasal cavities. A free tissue graft is transplanted cranial or caudal to the determined border. Clinical presentation 1 is a patient with carcinoma of the frontal sinus (T4bN0M0). Resection of the frontal bone/nasal bone/medial and superior walls of the orbit, frontal lobectomy was performed. Clinical presentation 2 is a patient with carcinoma of the maxillary sinus (T4aN0M0). Extended total maxillectomy, simultaneous resection of the facial skin/temporal muscle were performed. There were no serious postoperative complications related to compression or occlusion of the cerebral parenchyma or paranasal sinus.

Atypical Histological Features as Risk Factors for Recurrence in Newly Diagnosed WHO Grade I Meningioma.

The significance of atypical histological features (AHF) as risk factors for recurrence in benign meningioma is not well understood. This study examined risk factors of World Health Organization (WHO) Grade I meningioma (GIM) recurrence, focusing on AHF. We investigated 150 consecutive newly diagnosed GIM patients who had more than one year of follow-up after resection in our hospital between January 2007 and March 2018. The following factors were reviewed retrospectively: age, sex, tumor location, extent of resection, MIB-1 index, mitotic figures, number and distribution of AHF, and recurrence. The patients were grouped according to the presence or absence of recurrence and comparatively examined. Recurrence was observed in 10 cases (6.7%). Univariate analysis showed that patients with recurrence had a significantly higher MIB-1 index (2.0 vs. 4.3; p = 0.006) and a significantly higher proportion of male patients (21.4% vs. 70.0%; p = 0.002) and patients with sheet-like growth (6.42% vs. 30.0%; p = 0.04). In multivariate analysis, skull base location (odds ratio [OR] 31.424; 95% confidence interval [CI] 1.74-569), gross total resection (OR 0.130; 95% CI 0.0189-0.897), and MIB-1 index (OR 1.939; 95% CI 1.19-3.15) were significantly associated with recurrence. Our study revealed that skull base location, subtotal resection, and high MIB-1 index were independent risk factors for recurrence. Only the presence of sheet-like growth had a significantly higher incidence in patients with recurrence in univariate analysis of AHF. Multivariate analysis found no significant association. Sheet-like growth may be involved in malignancy and recurrence of benign meningioma.

A case of vestibular schwannoma mimicking burning mouth syndrome.

BACKGROUND: An oral burning sensation with unidentified cause in patients with preexisting psychosocial conditions is usually diagnosed as burning mouth syndrome. However, unexpected organic lesions may be detected in rare cases. CASE PRESENTATION: A 35-year-old woman had chief complaints of a burning sensation and numbness of the right side of the lip and tongue, as well as a dry sensation of the mouth with a taste disturbance of the right side of the tongue. The symptoms were continuous and did not show any daily fluctuations. The symptoms started without any recognizable triggering factor six months before her first visit to our clinic,. No abnormality was detected in her mouth. MRI images revealed an approximately 30 × 30 mm well-defined mass localized in the right cerebropontine angle compressing the trigeminal nerve, which was diagnosed as schwannoma of the right auditory nerve. CONCLUSIONS: It is important for clinicians to consider the possibility of brain tumors in their differential diagnosis of BMS. Although it is not always easy to eliminate all diseases that may cause an oral burning sensation in patients with BMS-like symptoms, more attention and careful examination based on the patient's psychosomatic background features and other possible causes are needed to rule out organic diseases.

Management of the temporal bone defect after resection of external auditory canal cancer.

OBJECTIVE: To evaluate the surgical procedures used to treat external auditory canal cancer with respect to avoiding postoperative infection of the temporal bone defect. METHODS: Enrolled in the study were 52 patients with external auditory canal cancer surgically treated between July 2015 and October 2020 (38 lateral temporal bone resections, 12 subtotal temporal bone resections and 2 partial resections, accompanied by various combined procedures). Retrospective chart review was conducted taking into consideration postoperative infection, and univariate analysis of prognostic factors was performed. RESULTS: In cases managed with subtotal temporal bone resection, no postoperative infections occurred. Cases managed with subtotal temporal bone resection demonstrated increased use of free-flap reconstruction, and longer antibiotic infusion period. On the other hand, analysis of cases managed with lateral temporal bone resection revealed 10 out of 38 patients with postoperative infection (26.3%). However, we couldn't find out any factors that contributed significantly to the prevention of postoperative infection, including the surgical procedures used to manage the defected space, which included free-flap implantation, obliteration with fat tissue, muscular flap rotation, and leaving the space empty without obliteration or reconstruction. CONCLUSION: In cases managed with lateral temporal bone resection, leaving the resected space empty did not increase the risk of infection. On the other hand, in cases with subtotal temporal bone resection, filling the surgical defect with an autologous bulk, including the free-flap reconstruction and fat obliteration, seems to prevent the infection. Moreover, prolonged antibiotic infusion may suppress postoperative infection of the temporal bone defect.

[Remarkable Recovery of Chronic Symptoms in an Adult with Middle Fossa Convexity Arachnoid Cyst after Cystoventriculostomy:A Case Report].

Intracranial arachnoid cysts(ACs)are thought to develop during infancy and remain clinically asymptomatic in most cases. AC is often diagnosed incidentally during imaging studies. The prognosis for the recovery of newly developed symptoms is usually favorable. However, the prognosis following surgery for chronic symptoms is still unclear. Herein, we report the case of an adult patient with right convexity AC whose chronic symptoms improved after surgery. The patient was a 63-year-old woman who had an AC in her right temporal convexity since the age of 59, without any symptoms, which was incidentally diagnosed on MRI. At 61 years of age, she visited a hospital complaining of slight weakness in her left upper limb. No changes were found on the MRI scan, but her visual field indicated the presence of a left homonymous hemianopia, and her cognitive function had decreased slightly. Two years later, she developed modest left hemiparesis;therefore, she underwent cystoventriculostomy to improve the symptoms of hemiparesis. After the surgery, the left hemiparesis recovered fully, and a remarkable improvement was noted in the left homonymous hemianopia and the degenerated cognitive functions. There are no clear guidelines regarding the surgical indications for AC in adults. Many reports suggest that new symptoms related to AC can be improved with surgery. However, amelioration of chronic symptoms has rarely been reported. The present case indicates that it is possible to improve the chronic symptoms of AC in adults with surgical procedures.

[A Case Report of Clivus Chordoma Presenting with Cerebrospinal Fluid Rhinorrhea].

Chordomas are uncommon tumors occurring from remnants of the notochord. They are mainly localized in the sacrococcygium, the spine and the central skull base. Here we report a rare case of clivus chordoma presenting with cerebrospinal fluid(CSF)rhinorrhea. A 41-year-old man with a 11-year history of recurrent CSF rhinorrhea was found to have a clival lesion. Bone image CT revealed lytic bone destruction at the clivus. MRI showed a cystic mass with a membrane enhanced by gadolinium protruding into the sphenoid sinus thorough the bone defect. However, there was no solid component observed. The membrane was partially resected and the CSF fistula was repaired via endoscopic endonasal approach. The pathological diagnosis was chordoma, and there has been no recurrence for three years after the surgery. It is necessary for chordoma to be considered as a differential diagnosis for cystic lesions of the clivus when the cyst membrane is enhanced by gadolinium.

Radiation history of Asian Asarum (sect. Heterotropa, Aristolochiaceae) resolved using a phylogenomic approach based on double-digested RAD-seq data.

BACKGROUND AND AIMS: The genus Asarum sect. Heterotropa (Aristolochiaceae) probably experienced rapid diversification into 62 species centred on the Japanese Archipelago and Taiwan, providing an ideal model for studying island adaptive radiation. However, resolving the phylogeny of this plant group using Sanger sequencing-based approaches has been challenging. To uncover the radiation history of Heterotropa, we employed a phylogenomic approach using double-digested RAD-seq (ddRAD-seq) to yield a sufficient number of phylogenetic signals and compared its utility with that of the Sanger sequencing-based approach. METHODS: We first compared the performance of phylogenetic analysis based on the plastid matK and trnL-F regions and nuclear ribosomal internal transcribed spacer (nrITS), and phylogenomic analysis based on ddRAD-seq using a reduced set of the plant materials (83 plant accessions consisting of 50 species, one subspecies and six varieties). We also conducted more thorough phylogenomic analyses including the reconstruction of biogeographic history using comprehensive samples of 135 plant accessions consisting of 54 species, one subspecies, nine varieties of Heterotropa and six outgroup species. KEY RESULTS: Phylogenomic analyses of Heterotropa based on ddRAD-seq were superior to Sanger sequencing-based approaches and resulted in a fully resolved phylogenetic tree with strong support for 72.0-84.8 % (depending on the tree reconstruction methods) of the branches. We clarified the history of Heterotropa radiation and found that A. forbesii, the only deciduous Heterotropa species native to mainland China, is sister to the evergreen species (core Heterotropa) mostly distributed across the Japanese Archipelago and Taiwan. CONCLUSIONS: The core Heterotropa group was divided into nine subclades, each of which had a narrow geographic distribution. Moreover, most estimated dispersal events (22 out of 24) were between adjacent areas, indicating that the range expansion has been geographically restricted throughout the radiation history. The findings enhance our understanding of the remarkable diversification of plant lineages in the Japanese Archipelago and Taiwan.