Extensive extracranial growth of spheno-orbital meningioma: illustrative case.

BACKGROUND: Spheno-orbital meningioma (SOM) typically presents with a classic triad of symptoms (i.e., proptosis, visual impairment, and ocular paresis), resulting from intraorbital tumor invasion. The authors present a very rare case of SOM in which the chief complaint was swelling of the left temporal region, which, to the best of their knowledge, has not been reported previously. OBSERVATIONS: The patient presented with marked extracranial extension to the left temporal region but unremarkable intraorbital extension, even on radiological examination. Physical examination of the patient showed almost no exophthalmos or restriction of left eye movement, consistent with the radiological findings. Four separate meningioma specimens were removed by extraction (i.e., one each from the intracranial, extracranial, and intraorbital segments of the tumor and one from the skull). The World Health Organization grade was 1 and the MIB-1 index was less than 1%, indicating a diagnosis of a benign tumor. LESSONS: SOM may be present even in patients with only temporal swelling and few ocular-related symptoms, and detailed imaging evaluations may be required to identify the tumor.

Microvascular Decompression for Glossopharyngeal Neuralgia in the Semi-Sitting Position: A Report of Two Cases.

The semi-sitting position is well known to neurosurgeons. However, there are few reports of microvascular decompression surgery for glossopharyngeal neuralgia performed using the semi-sitting position. The semi-sitting position is not widely adopted in Japan, but it is considered to be a very useful neurosurgical position. Microvascular decompression surgery for glossopharyngeal neuralgia is a relatively rare procedure, and the semi-sitting position is very effective, considering the possibility of intraoperative cardiac arrest and postoperative complications of lower cranial nerve palsy. This report describes two cases of glossopharyngeal neuralgia operated in the semi-sitting position. Microvascular decompression was performed on both patients, and postoperative pain controls were good and no complications were observed. We show that the use of the semi-sitting position to perform microvascular decompression for glossopharyngeal neuralgia provides an excellent surgical view of the brainstem.

Responses of oral-microflora-exposed dental pulp to capping with a triple antibiotic paste or calcium hydroxide cement in mouse molars.

INTRODUCTION: Responses of oral-microflora-exposed dental pulp to a triple antibiotic paste (TAP), a mixture of ciprofloxacin, metronidazole, and minocycline in ointment with macrogol and propylene glycol, remain to be fully clarified at the cellular level. This study aimed to elucidate responses of oral-microflora-exposed dental pulp to capping with TAP in mouse molars. METHODS: A cavity was prepared on the first molars of 6-week-old mice to expose the dental pulp for 24 h. The exposed pulp was capped with TAP (TAP group) or calcium hydroxide cement (CH group), in addition to the combination of macrogol (M) and propylene glycol (P) (MP, control group), followed by a glass ionomer cement filling. The samples were collected at intervals of 1, 2, and 3 weeks, and immunohistochemistry for nestin and Ki-67 and deoxyuride-5'-triphosphate biotin nick end labeling (TUNEL) assay were performed in addition to quantitative real-time polymerase chain reaction (qRT-PCR) analyses. RESULTS: The highest occurrence rate of pulp necrosis was found in the control group followed by the CH group at Weeks 2 and 3, whereas the highest occurrence rate of healed areas in the dental pulp was observed in the TAP group at each time point. Tertiary dentin formation was first observed in the dental pulp of the TAP group at Week 2. In contrast, bone-like and/or fibrous tissues were frequently observed in the CH group. qRT-PCR analyses clarified that TAP activated the stem and dendritic cells at Weeks 1 and 2, respectively. CONCLUSIONS: The use of TAP as a pulp-capping agent improved the healing process of oral-microflora-exposed dental pulp in mouse molars.

Limitations of median nerve somatosensory evoked potential monitoring during carotid endarterectomy.

OBJECTIVE: Hypoperfusion during carotid artery cross-clamping (CC) for carotid endarterectomy (CEA) may result in the major complication of perioperative stroke. Median nerve somatosensory evoked potential (MNSSEP) monitoring, which is an established method for the prediction of cerebral ischemia, has low sensitivity in detecting such hypoperfusion. In this study the authors sought to explore the limitations of MNSSEP monitoring compared to tibial nerve somatosensory evoked potential (TNSSEP) monitoring for the detection of CC-related hypoperfusion. METHODS: The authors retrospectively analyzed data from patients who underwent unilateral CEA with routine shunt use. All patients underwent preoperative magnetic resonance angiography and were monitored for intraoperative cerebral ischemia by using MNSSEP, TNSSEP, and carotid stump pressure during CC. First, the frequency of MNSSEP and TNSSEP changes during CC were analyzed. Subsequently, variables related to stump pressure were determined by using linear analysis and those related to each of the somatosensory evoked potential (SSEP) changes were determined by using logistic regression analysis. RESULTS: A total of 94 patients (mean age 74 years) were included in the study. TNSSEP identified a greater number of SSEP changes during CC than MNSSEP (20.2% vs 11.7%; p < 0.05). Linear regression analysis demonstrated that hypoplasia of the contralateral proximal segment of the anterior cerebral artery (A1 hypoplasia) (p < 0.01) and hypoplasia of the ipsilateral precommunicating segment of the posterior cerebral artery (P1 hypoplasia) (p = 0.02) independently and negatively correlated with stump pressure. Both contralateral A1 hypoplasia (OR 26.25, 95% CI 4.52-152.51) and ipsilateral P1 hypoplasia (OR 8.75, 95% CI 1.83-41.94) were independently related to the TNSSEP changes. However, only ipsilateral P1 hypoplasia (OR 8.76, 95% CI 1.61-47.67) was independently related to MNSSEP changes. CONCLUSIONS: TNSSEP monitoring appears to be superior to MNSSEP in detecting CC-related hypoperfusion. Correlation with stump pressure and SSEP changes indicates that TNSSEP, and not MNSSEP monitoring, is a reliable indicator of cerebral ischemia in the territory of the anterior cerebral artery.

Porphyromonas bronchialis sp. nov. Isolated from Intraoperative Bronchial Fluids of a Patient with Non-Small Cell Lung Cancer.

Porphyromonas strains, including Porphyromonas-like strains, have been isolated from oral and various other systemic infections. The characterization of such strains is a crucial issue, because such information contributes to both the taxonomy of anaerobic bacteria and the clinical aspects of infectious diseases. We previously isolated four Porphyromonas-like strains from intraoperative bronchial fluids of a patient with non-small cell lung cancer. This study aimed to characterize the genetic, biochemical and chemotaxonomic aspects of these isolates. Each strain only grew under anaerobic conditions and their colony morphology was convex, 0.1-1.0 mm in diameter, light gray, and slightly glistening colony, with no black or brown pigmentation on blood agar plates after five-day incubation. The pigmentation was helpful to differentiate the isolates from other Porphyromonas, as most of Porphyromonas species show the pigmentation. In the 16S rRNA gene phylogenetic analysis (98% sequence identity of isolates indicates the same species), the four isolates were closely related to one another (99.7-100.0%), but not related to Porphyromonas (P.) catoniae, the closest species (96.9%). In addition, the DNA-DNA hybridization data revealed less than 16% similarity values between a representative isolate and the P. catoniae, indicating that the strains were genetically independent. Biochemically, the isolates could be differentiated from closely related species, i.e., P. catoniae, P. gingivalis, P. gulae, and P. pogonae, with trypsin activity (negative only in the isolates) and leucine arylamidase activity (positive only in the isolates). We therefore propose a new species to include these isolates: Porphyromonas bronchialis sp. nov.

Severe impaction of the primary mandibular second molar accompanied by displacement of the permanent second premolar.

Tooth impaction is defined as any tooth that fails to erupt into a normal functional position and remains unerupted beyond the time at which it should normally erupt. Reports of impaction and eruption failure in primary teeth are relatively rare compared to permanent teeth. We report 2 rare cases where the second premolar was located on the occlusal side of the impacted mandibular second primary molar. In the first case, the succedaneous permanent tooth erupted after extraction of the primary tooth, fenestration, and traction. In the second case, the succedaneous permanent tooth erupted without fenestration or traction. Although the etiology of the tooth displacement was unknown in both cases, inhibition of the eruptive movement of the primary molar may have been associated with displacement of the succedaneous permanent premolar.

Late-type port-site recurrence of unexpected gallbladder carcinoma 11 years after laparoscopic cholecystectomy.

A 55-year-old man had laparoscopic cholecystectomy for acute cholecystitis and unexpected gallbladder cancer, followed by a liver bed resection and lymph node dissection. Eleven years later, he had a port-site recurrence of gallbladder cancer requiring resection; at that time, no other site of recurrence was observed. The patient has survived for 20 months without another recurrence. Although a rare finding, clinicians should be alert to the possibility of such a recurrence even 11 years after complete cure of the primary tumor, particularly in patients who have undergone laparoscopic cholecystectomy for unexpected gallbladder cancer.

Clinical and radiographic findings and usefulness of computed tomographic assessment in two children with regional odontodysplasia.

Regional odontodysplasia is a rare, severe, and nonhereditary developmental disorder in tooth formation and involves epithelial and mesenchymal-derived dental tissue. On radiographs, affected teeth have an abnormal morphology, a hypoplastic crown, and only a faint outline of hard tissue, a condition termed "ghost teeth." We report clinical and radiographic findings from two children with regional odontodysplasia. Using computed tomography (CT), we calculated attenuation coefficients (i.e., Hounsfield units) for affected teeth and assessed the condition of dental follicles. To measure density, regions of interest were delimited and CT values were calculated. In our two patients, the CT values for enamel were lower in affected teeth than in sound teeth, while CT values for dentin were similar for affected and sound teeth. The average CT value for dental follicles in affected teeth was about 65 to 120, which suggests that dense fibrous connective tissues or hard tissue-like structures might be present in dental follicles. Analysis of CT values may be quite useful in the diagnosis and treatment of regional odontodysplasia.

Early water intake restriction to prevent inappropriate antidiuretic hormone secretion following transsphenoidal surgery: low BMI predicts postoperative SIADH.

OBJECTIVE: The goals of this study were to assess the incidence of and risk factors for the syndrome of inappropriate antidiuretic hormone secretion (SIADH) in patients following transsphenoidal surgery (TSS), and to validate the effectiveness of early prophylactic restriction of water intake. DESIGN: Retrospective analysis was performed for 207 patients who had undergone TSS, including 156 patients not placed on early prophylactic water restriction. Sixty-four patients received treatment for SIADH. METHODS: We compared the incidence of SIADH between patients with and without early water intake restriction, and analyzed various risk factors for SIADH using statistical analyses. RESULTS: BMI was significantly lower for patients with SIADH than for those patients without SIADH. Statistical analysis revealed that the threshold BMI predicting SIADH was 26. Serum sodium levels on postoperative days 5-10 and daily urine volumes on postoperative days 5-10 were significantly lower in patients with SIADH than in those without SIADH. Postoperative body weight loss on days 6, 8, 10, and 11 was significantly higher in patients with SIADH. The incidence of SIADH after starting prophylactic water intake restriction (14%) was significantly lower than the rate before early water restriction (38%; P<0.05). CONCLUSIONS: SIADH is relatively common after TSS, and serum sodium concentrations and daily urine volumes should be carefully monitored. Patients with low preoperative BMI should be closely observed, as this represented a significant preoperative risk factor for SIADH. Early prophylactic water intake restriction appears effective at preventing postoperative SIADH.

Primary CNS lymphoma arising in the region of the optic nerve presenting as loss of vision: 2 case reports, including a patient with a massive intracerebral hemorrhage.

We report 2 cases of primary central nervous system (CNS) lymphoma arising in the region of the optic nerve. For both patients, diagnosis of lymphoma was impossible without histological examination because of the rarity of the lymphoma location. The first case involved an 84-year-old woman who developed loss of vision and hypopituitarism. Intraoperative finding was optic glioma; histological diagnosis was diffuse large B cell lymphoma, however. The second case involved a 67-year-old man who developed loss of vision. The pre-surgical diagnosis was optic nerve neuritis; this was then revised to granuloma. The tumor arose in the optic nerve. Methotrexate and rituximab were administered and the patient remained in complete remission for 3 years. However, a sudden intratumoral hemorrhage occurred. Although most of the lymphoma cells obtained from the initial surgery were negative for vascular endothelial growth factor (VEGF) immunoreactivity, high levels of VEGF immunoreactivity in lymphoma cells was detected in the specimen obtained after intratumoral bleeding at recurrence, and correlation between VEGF reactivity and tumor recurrence was suggested. To date, primary CNS lymphomas with intracerebral hemorrhage have been reported in 3 cases only, and a correlation between intratumoral hemorrhage and the degree of VEGF expression has been suggested. VEGF also might have predictive significance for recurrence.

Multiple oligodendroglioma with pseudoprogression.

A 72 year-old male hospitalized with aphasia, abnormal behavior, and rapidlyprogressive dementia.Magnetic resonance imaging (MRI) enhanced by contrast media demonstrated multiplebrain tumors in left parietal lobe and left paraventricular region. Biopsy was performed,andhistopathological examination and genetical evaluation revealed anaplasticoligodendroglioma. Local radiation 50Gy was given, and Temozolomide via orallyadministered for 42 days. After the chemoradiotherapy, even though the parietal tumorshowed lessening of the size, enlargement of the tumor in the left paraventricularregion was observed, and we considered that phenomenon was pseudoprogression. 5courses of Temozolomide therapy was added, but cerebellar tumor appeared andenlarged with hydrocephalus, and died 1 year and 3 months after the firsthospitalization.

Ki-67 expression for predicting progression of postoperative residual pituitary adenomas: correlations with clinical variables.

Reliable prognostic parameters indicating progression in residual pituitary adenoma after surgery are necessary. The World Health Organization classification of tumors of endocrine organs defines atypical pituitary adenomas as tumor with Ki-67 labeling index higher than 3%, excessive p53 immunoreactivity, and increased pleomorphism. The real value of Ki-67 labeling index correlating with tumor progression is controversial. We investigated the relationship between positive labeling for MIB-1 and clinical features of 39 patients with pituitary adenomas with and without rapid re-growth after initial surgery. Ki-67 expression revealed pituitary adenomas with progression (re-growth within 5 years after initial surgery) had a mean proliferation index of 3.66 ± 3.00% (mean ± standard deviation [SD], n = 12), which was significantly higher than in tumors without progression of 1.89 ± 1.25% (mean ± SD, n = 27) (p < 0.05, Mann-Whitney test). Receiver operating characteristic analysis showed a threshold level of Ki-67 expression greater than 2.0% predicts progression with high specificity. Younger patients had higher MIB-1 index and more progression (p < 0.05). Adenomas with cavernous sinus invasion, functioning adenomas, and giant adenomas had higher MIB-1 index (p < 0.05). There was no significant correlation between tumor size or cavernous sinus invasion and progression. More completely removed tumors were less progressive. A threshold of 2% for the MIB-1 labeling index predicts higher risk of progression of residual adenomas after surgery, so shorter interval of follow-up neuroimaging, and early initiation of adjuvant therapy might be required.

Rapid quantification of bacteria in infected root canals using fluorescence reagents and a membrane filter: a pilot study on its clinical application to the evaluation of the outcomes of endodontic treatment.

Objective. The bacterial examination has been performed during the course of the root canal treatment. In the present pilot study, the new developed method, using fluorescence reagents and a membrane filter, was applied to the detection and quantification of bacteria in infected root canals, in order to evaluate the outcomes of the treatment. Methods. Six infected root canals with periapical lesions from 5 subjects were included. Informed consent was obtained from all subjects (age ranges, 23-79 years). Samples from infected root canals were collected at the beginning of the treatment (termed #25 First), the end of the first day of treatment (termed #55 First), and the next appointment day (termed #55 Second). Then, the bacterial count (CFU) was measured using fluorescence reagents (4',6'-diamidino-2-phenylindole and propidium iodide) and the polycarbonate membrane filter by Bioplorer. Results. The mean ± SD of CFU in the sample of "#25 First" was (1.0 ± 1.4) × 10(5). As the root canal treatment progressed, the CFU decreased as 7.9 × 10(3) (#55 First) and 4.3 × 10(2) (#55 Second). Conclusion. In the present pilot study, rapid detection and quantification of bacteria in infected root canals were found to be successfully performed using fluorescence reagents and a membrane filter (Bioplorer analysis).

Cultivable anaerobic microbiota of infected root canals.

Objective. Periapical periodontitis is an infectious and inflammatory disease of the periapical tissues caused by oral bacteria invading the root canal. In the present study, profiling of the microbiota in infected root canals was performed using anaerobic culture and molecular biological techniques for bacterial identification. Methods. Informed consent was obtained from all subjects (age ranges, 34-71 years). Nine infected root canals with periapical lesions from 7 subjects were included. Samples from infected root canals were collected, followed by anaerobic culture on CDC blood agar plates. After 7 days, colony forming units (CFU) were counted and isolated bacteria were identified by 16S rRNA gene sequencing. Results. The mean bacterial count (CFU) in root canals was (0.5 ± 1.1) × 10(6) (range 8.0 × 10(1)-3.1 × 10(6)), and anaerobic bacteria were predominant (89.8%). The predominant isolates were Olsenella (25.4%), Mogibacterium (17.7%), Pseudoramibacter (17.7%), Propionibacterium (11.9%) and Parvimonas (5.9%). Conclusion. The combination of anaerobic culture and molecular biological techniques makes it possible to analyze rapidly the microbiota in infected root canals. The overwhelming majority of the isolates from infected root canals were found to be anaerobic bacteria, suggesting that the environment in root canals is anaerobic and therefore support the growth of anaerobes.

Presence of genes for type III secretion system 2 in Vibrio mimicus strains.

BACKGROUND: Vibrios, which include more than 100 species, are ubiquitous in marine and estuarine environments, and several of them e.g. Vibrio cholerae, V. parahaemolyticus, V. vulnificus and V. mimicus, are pathogens for humans. Pathogenic V. parahaemolyticus strains possess two sets of genes for type III secretion system (T3SS), T3SS1 and T3SS2. The latter are critical for virulence of the organism and be classified into two distinct phylogroups, T3SS2α and T3SS2ß, which are reportedly also found in pathogenic V. cholerae non-O1/non-O139 serogroup strains. However, whether T3SS2-related genes are present in other Vibrio species remains unclear. RESULTS: We therefore examined the distribution of the genes for T3SS2 in vibrios other than V. parahaemolyticus by using a PCR assay targeting both T3SS2α and T3SS2ß genes. Among the 32 Vibrio species tested in our study, several T3SS2-related genes were detected in three species, V. cholerae, V. mimicus and V. hollisae, and most of the essential genes for type III secretion were present in T3SS2-positive V. cholerae and V. mimicus strains. Moreover, both V. mimicus strains possessing T3SS2α and T3SS2ß were identified. The gene organization of the T3SS2 gene clusters in V. mimicus strains was fundamentally similar to that of V. parahaemolyticus and V. cholerae in both T3SS2α- and T3SS2ß-possessing strains. CONCLUSIONS: This study is the first reported evidence of the presence of T3SS2 gene clusters in V. mimicus strains. This finding thus provides a new insight into the pathogenicity of the V. mimicus species.

[Can industrial laundry remove Bacillus cereus from hospital linen?].

Contaminated hospital linen has caused some cases of Bacillus cereus bacteremia in Japan. We analyzed the disinfection efficacy of industrial washing of hospital towels and sheets by counting the number of B. cereus on linen before and after washing. That before washing averaged 7.6 cells/cm2 on unwashed sheets, decreasing to 1.2 cells/cm2 after washing. That on unwashed towels, however, averaged 10(6) cells/cm2 before washing and 1096 cells/cm2 after washing, which was very high and suggested the possibility of causing nosocomial infection.

Management of large and giant pituitary adenomas with suprasellar extensions.

OBJECTIVE AND BACKGROUND: We evaluated the feasibility and effectiveness of transsphenoidal surgery for large and giant pituitary adenomas with suprasellar extensions as these tumors have been therapeutic challenge. SUBJECTS AND METHODS: We retrospectively analyzed 50 cases with 56 surgeries in patients with pituitary adenomas that were surgically treated between January 2005 and January 2010 at Fujita Health University. Among those cases, 39 cases were large or giant pituitary adenomas including 11 cases of giant adenomas. RESULTS: 37 cases 41 approaches were transsphenoidal, 2 approaches were transcranial, and in 1 case transcranial approach following transsphenoidal surgery was performed. The most frequent preoperative symptoms were visual impairment and visual field defect (28 cases, 75.6%), and improvement of visual function after surgery was observed in 18 cases, 64%. As endocrinological results, among the 11 cases of functioning adenomas, improvement of endocrinological examination was observed in 10 cases, and normalization of the hormonal examination and complete remission was seen in 7 cases which was 64%. CONCLUSIONS: Transsphenoidal approach is safe and effective procedure even in large or giant pituitary adenomas, because it allows rapid and appropriate decompression of the optic nerves and chiasm with low morbidity rates. Transcranial approaches were indicated only in irregular shaped adenomas or eccentric extensions that could not be reached through the transsphenoidal route.

Ventricular reservoirs and ventriculoperitoneal shunts for premature infants with posthemorrhagic hydrocephalus: an institutional experience.

OBJECT: The aim of the study was to analyze the outcome of surgical treatment for posthemorrhagic hydrocephalus in premature infants. METHODS: From 1990 to 2006, 32 premature infants underwent surgical treatment for posthemorrhagic hydrocephalus, and their charts were retrospectively reviewed to analyze the complications and outcome with respect to shunt revisions. Multivariate analysis and time series were used to identify factors that influence the outcome in terms of shunt revisions. RESULTS: The mean gestational age was 27+/-3.3 weeks, and mean birth weight was 1192+/-660 g. Temporary reservoir placement was performed in 15 patients, while 17 underwent permanent CSF diversion with a ventriculoperitoneal (VP) shunt. In 2 patients, reservoir tapping alone was sufficient to halt the progression of hydrocephalus; 29 patients received VP shunts. The mean follow-up period was 37.3 months. The neonates who received VP shunts first were significantly older (p=0.02) and heavier (p=0.04) than those who initially underwent reservoir placement. Shunts were revised in 14 patients; 42% of patients in the reservoir group had their shunts revised, while 53% of infants who had initially received a VP shunt required a revision. The revision rate per patient in the reservoir group was half that in the direct VP shunt group (p=0.027). No patient in the reservoir group had >2 revisions. Shunt infections developed in 3 patients (10.3%), and 2 patients in the reservoir group died of nonneurological issues related to prematurity. CONCLUSIONS: Birth weight and age are useful parameters in decision making. Preterm neonates with low birth weights benefit from initial CSF drainage procedures followed by permanent CSF diversion with respect to the number of shunt revisions.