Factors associated with decreasing diffusion-weighted imaging-positive area volume after mechanical thrombectomy in patients with large early ischemic changes.

OBJECTIVES: This study aimed to evaluate the factors associated with decreasing diffusion-weighted imaging (DWI) positive areas in patients with large early ischemic changes after mechanical thrombectomy (MT). MATERIALS AND METHODS: This retrospective single-center clinical study was conducted between January 2013 and December 2022. We included consecutive patients who underwent MT for acute large-vessel occlusion of the anterior circulation with low pretreatment DWI-Alberta Stroke Program Early Computed Tomography Scores (ASPECTS) (0-5), effective recanalization [thrombolysis in cerebral infarction (TICI) 2b or TICI3], and magnetic resonance imaging (MRI) acquired before and after MT. We measured the DWI-positive area volume before and after MT. The primary endpoint was the after/before-MT DWI-positive area-volume ratio. RESULTS: In total, 28 patients were included in this study. Eight patients (29%) had an after/before-MT DWI-positive area-volume ratio of <1. The median mean apparent diffusion coefficient (ADC) levels of the DWI-positive areas in the groups with a ratio of <1 or >1 were 717 × 106 mm2/s and 637 × 106 mm2/s, respectively (p = 0.011). Multivariate logistic regression analysis showed that ADC level (OR, 1.020 [95% confidence intervals (CIs), 1.001-1.040]; p = 0.040) was an independent predictor of a decreased DWI-positive area after MT. There was a negative correlation between the mean ADC level and the after/before-MT DWI-positive area-volume ratio (p < 0.001, |ρ| = 0.650), and the mean pretreatment ADC cutoff level was 649 × 106 mm2/s (area under the curve (AUC) = 0.806) for predicting a volume ratio of <1. CONCLUSIONS: The mean ADC level before-MT correlated with the after/before-MT DWI-positive area-volume ratio. A mean pretreatment ADC cutoff level of 649 × 106 mm2/s predicted a decreased DWI-positive area after MT.

Comparison of Early Postoperative Diffusion Weighted Magnetic Resonance Imaging Findings After Resection of Gliomas and Meningiomas.

OBJECTIVE: Glioma and meningioma require vastly different surgical approaches, even if only involving a simple craniotomy procedure. Diffusion weighted imaging (DWI) is useful for the postoperative evaluation of ischemic damage. The present study evaluated the expected but unproven differences in DWI findings. METHODS: A total of 41 patients with meningiomas and 63 with gliomas met the inclusion criteria for adult cases with superficial lesions treated through simple supratentorial craniotomy. Postoperative DWI findings of DWI-positive rate, DWI-positive area type, and relationship with neurological deficits were evaluated. RESULTS: The DWI-positive rate (P = 0.01) and the proportion of rim-type lesions (P < 0.01) were significantly more common in gliomas. Patients with meningiomas and DWI-positive areas presented with higher rates of new neurological deficits (P < 0.01), and patients with meningiomas on the left side were more likely to develop new neurological deficits (P = 0.02). Patients with gliomas tended to develop new deficits with larger DWI-positive area volumes (P = 0.04). CONCLUSIONS: Postoperative early DWI-positive rate and rim-type lesions are more common after glioma resection than meningioma resection. Larger volumes of DWI-positive areas may be associated with postoperative neurological symptoms in gliomas. DWI-positive finding is less common after meningioma than glioma resection but more likely to be associated with new neurological symptoms. These differences are important for adequate postoperative DWI evaluation of common supratentorial brain tumors.

Radiological features of internal carotid artery occlusion caused by pituitary apoplexy: illustrative case.

BACKGROUND: Pituitary apoplexy rarely causes internal carotid artery (ICA) occlusion and acute ischemic stroke. Some cases have been reported, but the neuroimaging findings, including cerebral angiography, have not been discussed. OBSERVATIONS: A 55-year-old male suffered the sudden onset of right cervical pain and left mild hemiparesis. Computed tomography indicated a pituitary mass, and magnetic resonance angiography showed a right ICA occlusion. The initial diagnosis was ICA occlusion caused by ICA dissection. His symptoms worsened and the region of cerebral infarction expanded, so the patient was transferred to our hospital. Magnetic resonance imaging and cerebral angiography showed the sudden stoppage of right ICA blood flow caused by local compression of the tumor near the distal dural ring. The diagnosis was acute ischemic stroke resulting from ICA pseudo-occlusion caused by pituitary apoplexy, and emergent endoscopic transsphenoidal resection was performed. Postoperatively, the right ICA was completely patent, and hemiparesis was improved with rehabilitation. LESSONS: ICA occlusion caused by pituitary apoplexy is very rare, but emergent treatment is necessary. However, the pathology is difficult to diagnose quickly. Neuroimaging findings showing that the ICA is easily stenosed or occluded if rapidly compressed by the tumor near the distal dural ring may be useful to rapidly diagnose and treat.

Postoperative Serum C-Reactive Protein and Cerebrospinal Fluid Leakage after Endoscopic Transsphenoidal Surgery.

Objective Postoperative cerebrospinal fluid (CSF) leakage in endoscopic transsphenoidal surgery is a potential risk that requires immediate repair. We investigated the potential of common postoperative hematological examinations for diagnosing postoperative CSF leakage. Methods We retrospectively studied 214 consecutive cases who underwent endoscopic transsphenoidal approach (ETSA; transsellar approach) or extended ETSA (E-ETSA). Patients with postoperative CSF leakage were defined the leak group (group L), and patients without were defined as the nonleak group (group N). Postoperative C-reactive protein (CRP) was compared between the ETSA and E-ETSA groups, and between the N and L groups. Results The values of white blood cell count and CRP 1 to 7 days after surgery were significantly higher in the L group. Especially, CRP was clearly elevated in the L group ( p < 0.001). The CRP value was higher in patients in the N group after E-ETSA than after ETSA ( p < 0.001). CRP increased on the day after surgery but decreased gradually thereafter in patients after ETSA and in the N group. In contrast, CRP value tended to increase gradually after surgery in the L group. In particular, the CRP on the day before the CSF leak was confirmed was clearly higher than on the fifth to seventh days in the N group. Conclusion Elevated CRP after endoscopic endonasal transsphenoidal surgery is a potential marker of CSF leakage.

Impact of craniotomy area on improvement of cerebral blood flow in combined revascularization surgery for moyamoya disease.

OBJECTIVE: To investigate factors associated with improvements in cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) after combined revascularization surgery for moyamoya disease, with special attention to the size of craniotomy. METHODS: We retrospectively analyzed 35 hemispheres in 27 patients with adult and older pediatric moyamoya disease. CBF and CVR were measured separately in the MCA and ACA territories from acetazolamide-challenged single-photon emission computed tomography before and after 6 months postoperatively, and associations with various factors were analyzed. RESULTS: Postoperative CBF improved in patients with lower preoperative blood flow in both ACA and MCA territories. Postoperative CVR improved in 32 of 35 patients (91.4%) in the MCA territory and in 30 of 35 patients (85.7%) in the ACA territory, with more prominent improvement in the MCA territory than in the ACA territory (MCA territory 29.7% vs ACA territory 21.1%, p = 0.015). Craniotomy area did not correlate with postoperative CBF and only MCA territory was associated with good (≥30%) CVR improvement (odds ratio 9.33, 95% confidence interval 1.91-45.6, p = 0.003). CONCLUSIONS: Postoperative CBF improved in adult and older pediatric cases, reflecting preoperative CBF. Postoperative CVR improved in most cases, although the degree of improvement was more prominent in the MCA territory than in the ACA territory, suggesting a contribution of the temporal muscle. Large craniotomy area was not associated with improved blood flow in the ACA territory and should be applied prudently.

The Significance of the Intercarotid Distances for Transsphenoidal Pituitary Surgery: A Magnetic Resonance Imaging Study.

OBJECTIVE: We performed magnetic resonance imaging (MRI) to analyze the distance between the left and right internal carotid arteries (ICD) around pituitary tumors for transsphenoidal surgery (TSS). METHODS: Measurements were performed using thin slice T2-weighted MRI, and/or time-of-flight (TOI) MR angiography imaging for 64 nonfunctioning pituitary neuroendocrine tumors (NF-pitNETs), 22 growth hormone-producing pitNETs (GH producing pitNETs), and 46 normal controls. We measured the ICD at 3 anatomic levels: at the distal dural ring (ICD-A); at the most concave point of the C4-C5 bend (ICD-B); and at the most convex point of the C4 bend (ICD-C). Additionally, we measured the sagittal distance between the tuberculum selle and the junction of the sellar floor and clivus on the midsagittal MRI (TS-C). RESULTS: We found that ICD-B was the longest and that ICD-A was the shortest among the 3 distance parameters in all groups (P < 0.001). The comparison of the groups revealed that the NF-pitNET group had longer distances than the normal control group at all ICDs (P < 0.001). The GH producing pitNET group had longer distance than the normal control group at ICD-B (P < 0.001). Tumor volume was correlated with ICD-A and ICD-B in the NF-pitNET, and was correlated with ICD-C in the GH producing pitNET group. CONCLUSIONS: Among the distance parameters, ICD-B is the longest, and was approximately twice the width of the TS-C. The shape of the sella is an ellipse that is widest in the lateral dimension in TSS. A horizontal based dural incision may be more rational than a conventional X-shaped dural incision.

Emergent surgical evacuation of traumatic intracranial hematoma in patients with preoperative thrombocytopenia: surgical risk and early outcome.

BACKGROUND: Surgical evacuation of intracranial hematoma, including epidural, subdural, intracerebral, and intraventricular hematoma, is recommended in patients with traumatic brain injury (TBI) for prevention of cerebral herniation and possible saving of life. However, preoperative coagulopathy is a major concern for emergent surgery on patients with severe TBI. METHODS: We reviewed 65 consecutive patients with severe TBI who underwent emergency craniotomy for intracranial hematomas. RESULTS: Univariate analysis showed preoperative pupil abnormality, absence of pupil light reflex, respiratory failure, preoperative thrombocytopenia (< 100 × 109/L), increased activated partial thromboplastin time (> 36 s), low fibrinogen (< 150 mg/dL), platelet transfusion, red cell concentrate transfusion, and presence of brain contusion and traumatic subarachnoid hemorrhage (SAH) on computed tomography were correlated with poor outcome (death or vegetative state). Multivariate analysis revealed that pupil abnormality (p = 0.001; odds ratio [OR] 0.064, 95% confidence interval [CI] 0.012-0.344), preoperative thrombocytopenia (p = 0.016; OR 0.101, 95% CI 0.016-0.656), and traumatic SAH (p = 0.021; OR 0.211, 95% CI 0.057-0.791) were significant factors. Investigation of the 14 patients with preoperative thrombocytopenia found the emergency surgery was successful, with no postoperative bleeding during hospitalization. However, half of the patients died, and almost a quarter remained in the vegetative state mainly associated with severe cerebral edema. CONCLUSIONS: Emergent craniotomy for patients with severe TBI who have preoperative thrombocytopenia is often successful, but the prognosis is often poor. Emergency medical care teams and neurosurgeons should be aware of this discrepancy between successful surgery and poor prognosis in these patients. Further study may be needed on the cerebral edema regulator function of platelets.

Effect of vasopressin V2-receptor antagonist tolvaptan on syndrome of inappropriate antidiuresis (SIAD) after transsphenoidal pituitary surgery: recovery of measured osmolality.

Background: Delayed hyponatremia after pituitary surgery can be treated with the V2-receptor antagonist, oral tolvaptan. We investigated the pharmacological effect of oral tolvaptan against SIAD in patients with hyponatremia after pituitary surgery. Methods: Thirty-nine patients with pituitary adenoma treated by endoscopic transsphenoidal surgery developed SIAD according to the major guidelines, and 7 patients (17.9%) were treated with tolvaptan. Tolvaptan was administrated orally half a tablet (3.75 mg) once in the first two cases, and half a tablet twice in the other five cases. Serum osmolality, urinary osmolality, urinary sodium concentration, urinary volume, and serum sodium and potassium concentration were evaluated before administration, and after the last oral administration of tolvaptan. Serum osmolality and urine osmolality were physically measured. Results: Serum sodium concentration was significantly increased from 132.1 ± 4.0 to 143.0 ± 2.9 mmol/L (mean ± standard deviation, n = 7, P < 0.001). Serum osmolality was significantly increased from 266.3 ± 7.7 to 289.6 ± 6.7 mOsm/kg (n = 7, P < 0.001). Urine osmolality was significantly reduced from 607.1 ± 240.4 to 262.7 ± 115.6 mOsm/kg (n = 7, P = 0.01). Urinary sodium concentration was significantly decreased from 121.3 ± 48.4 to 36.9 ± 35.0 mOsm/kg (n = 7, P = 0.001). Urine output (24-hour including the first administration) was significantly increased from 1384.2 ± 550.7 to 3291.3 ± 1710.9 mL/day (n = 6, P = 0.026). Conclusions: Oral tolvaptan administration corrects SIAD after pituitary surgery. Hyponatremia after pituitary surgery was confirmed to be due to SIAD.

Functional Recovery after Rehabilitation in Patients with Post-stroke Severe Hemiplegia.

Objectives: Stroke patients with hemiplegia can sometimes achieve independent life at home or in light care facilities after rehabilitation. This study examined the outcomes of rehabilitation in stroke patients with severe hemiplegia. Methods: This study included 50 patients with Brunnstrom recovery stage I-II hemiplegia at the start of rehabilitation for stroke. Good outcome after rehabilitation was defined as independent life with functional independence measure (FIM) score of 100 or greater. Predictors for post-rehabilitation functional recovery were statistically analyzed. Results: FIM scores of 100 or greater in 12 of 50 patients (24%) allowed independent life after stroke rehabilitation. According to univariate analysis, factors associated with a FIM score of 100 or greater and good prognosis after rehabilitation were younger age (<70 years), paralysis caused by intracerebral hematoma (ICH), no cortical lesions, short time from admission to comprehensive inpatient rehabilitation (CIR) for stroke (within 1 month), and good status at the start of early rehabilitation and CIR. Eleven of the 12 patients with good prognosis (FIM ≥100) had ICH and a basal ganglia lesion with no cortical damage. Analysis of the location of lesions suggested that many patients with basal ganglia ICH lesions and little cortical involvement have good prognoses. Conclusions: Stroke patients with severe hemiplegia showed a slightly different distribution of lesions between ICH and cerebral ischemia. Cortical involvement may be a prognostic factor for outcome after rehabilitation in stroke patients with severe hemiplegia. More aggressive rehabilitation interventions may be important for patients with severe hemiplegia, especially without cortical involvement.

Endoscopic Extended Transsphenoidal Approach for Sellar and Suprasellar Xanthogranuloma: Potential Implications for Surgical Strategies in Adult Craniopharyngioma.

OBJECTIVE: Differentiation of suprasellar xanthogranuloma (XG) from adult craniopharyngioma (CP) can be problematic in endoscopic extended transsphenoidal surgery. METHODS: We reviewed the clinical data, preoperative imaging, intraoperative endoscopic findings, and intraoperative frozen section pathology in newly diagnosed adult CPs (19 patients) and XGs (6 patients). RESULTS: Intracystic signal intensity was often high on T1-weighted magnetic resonance images in the XGs but low in the CPs (P = 0.015). Capsular intensity was low on T2-weighted imaging in XGs but iso to high in CPs (P < 0.001). Capsular gadolinium enhancement was often seen in CPs and not in XGs (P < 0.001). CPs often had a solid component with contrast enhancement but none in XGs (P < 0.001). Intraoperative endoscopic observations frequently found a whitish solid component in the CPs but yellow to brown fibrous granulomatous lesions in XGs (P < 0.001). The tumor capsule was dark grayish and soft in CPs, whereas it was fibrously hard in XGs (P = 0.002). Yellowish hemosiderin deposits were seen in all XGs (P = 0.003). Intraoperative pathologic diagnosis of CP was all verified whereas no evidence of tumor was found in XGs (P < 0.001). Partial removal was performed in 4 patients with XGs. No recurrence was observed in these patients during the follow-up period (1.5-8 years). CONCLUSIONS: Careful interpretation of preoperative magnetic resonance imaging, intraoperative endoscopic findings, and intraoperative frozen section diagnosis may be important for the differential diagnosis between XG and CP. In endoscopic-extended transsphenoidal surgery, intentional partial removal can be effective for XG after careful diagnosis.

Preoperative Magnetic Resonance Imaging Localization of the Normal Pituitary Gland in Nonfunctioning Pituitary Adenoma Patients Using the Radiological Sign of "Internal Carotid Artery Notch".

OBJECTIVE: Asymmetric features of nonfunctioning pituitary adenoma (NFPA) are poorly understood. We investigated the asymmetry in NFPA on magnetic resonance imaging. METHODS: We reviewed preoperative magnetic resonance imaging findings of patients initially treated for NFPA. The internal carotid artery (ICA) often seemed to cause an indentation in the external shape of the tumor (i.e., the ICA notch). RESULTS: Two cases with a normal pituitary gland located at the midline were excluded. The remaining 66 cases were examined. The side where the normal gland was located was defined as the normal pituitary side and the opposite side as the cavernous sinus side. The Knosp grade was significantly higher on the cavernous sinus side (P < 0.001), and the vertical distance of the ICA was significantly greater on the cavernous sinus side (P < 0.001). The ICA notch was found in 87.9% of all cases on the normal pituitary side, but in only 45.5% on the cavernous sinus side (P < 0.001). In cases with a single-side ICA notch (34 of 68), the ICA notch was found in 91.2% of cases and on the cavernous sinus side in 8.8% (P < 0.001). CONCLUSIONS: Magnetic resonance imaging of NFPA frequently shows asymmetry. The tumor does not extend laterally on the normal pituitary side but extends laterally more freely on the cavernous sinus side. The ICA notch is often found on the normal pituitary side where the position of ICA does not move. This may be useful as a preoperative sign to indicate the normal pituitary side.

Retinal ganglion cell analysis in patients with sellar and suprasellar tumors with sagittal bending of the optic nerve.

The study investigated clinical features of sellar and suprasellar tumors with optic nerve bending. Twenty-five patients (13 men/12 women; age, 59.0 ± 12.9 years) with optic nerve bending in one eye who underwent tumor resection for sellar and suprasellar tumors were included. The other eye, without optic nerve bending, was the control. The pre- and postoperative best-corrected visual acuity (BCVA) and ganglion cell layer (GCL) + inner plexiform layer (IPL) thickness were studied retrospectively using optical coherence tomography. Preoperative BCVA in the eye with optic nerve bending was significantly poor and improved significantly after tumor resection. Eyes with optic nerve bending had significantly less GCL + IPL thickness on the temporal side than eyes without optic nerve bending. Preoperative GCL + IPL thickness of the entire macula was reduced in eyes with optic nerve bending and poor postoperative BCVA compared to those with good postoperative BCVA. There was no significant difference in GCL + IPL thickness of eyes with optic nerve bending before and after tumor resection. Optic nerve bending caused by sellar and suprasellar tumors resulted in visual impairment and decreased retinal ganglion cells. Eyes with optic nerve bending and severely reduced GCL + IPL thickness may have less BCVA improvement after tumor resection.

Analysis of visual field disturbance in patients with sellar and suprasellar lesions: relationship with magnetic resonance imaging findings and sagittal bending of the optic nerve.

PURPOSE: Visual dysfunction due to sellar and suprasellar lesions is thought to be caused by chiasmatic compression and bending of the optic nerve at the entrance of the optic canal. We examined the relationship between visual field impairment and magnetic resonance (MR) imaging. METHODS: This study reviewed 122 consecutive patients with sellar and suprasellar tumors. We have newly devised a simple visual field impairment score (SVFIS) that was divided into 12 areas. SVFIS is classified into four grades as mild (0-3 points), moderate (4-6 points), severe (7-9 points), and most severe (10-12 points) for each eye. We investigated the relationship between SVFIS grades and MR imaging, including the recently reported optic nerve-canal bending angle (ONCBA) and visual acuity. RESULTS: Ipsilateral visual acuity tended to deteriorate with increased SVFIS grade. Larger ONCBA was associated with increased SVFIS grades. Bitemporal hemianopia occurred in the early stage (mild case), but the central visual field within 30° was particularly likely to be impaired. The visual field disturbance progressed clockwise (counterclockwise on the left side) from the upper temporal side. Disorders of the central visual field within 5° were associated with ipsilateral large ONCBA. CONCLUSIONS: The newly developed SVFIS grades are closely associated with indicators of visual pathway impairment on MR imaging, and are useful as indicators of the severity and progression of visual field impairment due to sellar and suprasellar lesions. Disorders of the central visual field within 5° were found to be associated with ipsilateral large ONCBA.

Pseudo-intestinal obstruction after transsphenoidal surgery for craniopharyngioma.

Craniopharyngioma surgery is frequently associated with the occurrence of central diabetes insipidus, and oral rehydration therapy is reliable for postoperative management if the patient's thirst is normal. A 61-year-old Japanese male patient underwent extended endoscopic transsphenoidal surgery for craniopharyngioma. He was undergoing acute treatment for postoperative central diabetes insipidus and hypopituitarism in the intensive care unit. Two days after the surgery, he started to vomit occasionally, despite receiving oral rehydration therapy for central diabetes insipidus. Despite increasing the dose of parenteral hydrocortisone, the periodic vomiting persisted during fasting periods and progressed to aspiration pneumonia and severe sepsis. Abdominal computed tomography was performed to identify the cause of persistent vomiting and revealed the presence of a pseudo-intestinal obstruction extending from the small to large intestine. When oral rehydration therapy for central diabetes insipidus is accompanied by vomiting symptoms suggestive of hypopituitarism, a holistic evaluation of the gastrointestinal system is advisable.

Usefulness of dual isotope 123I-IMP and 201Tl SPECT for the diagnosis of primary central nervous system lymphoma and glioblastoma.

BACKGROUND: Preoperative differential diagnosis between primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM) is important because these tumors require different surgical strategies. This study investigated the usefulness of dual isotope, iodine-123-labeled N-isopropyl-p-iodo-amphetamine (123I-IMP) and thallium-201 chloride single-photon emission computed tomography (201Tl SPECT) for the differential diagnosis. METHODS: Twenty-five PCNSL patients and 27 GBM patients who underwent dual isotope imaging, 123I-IMP and 201Tl SPECT, are included. Tumor-to-normal (T/N) ratio was calculated from the ratio of maximum tracer counts in the lesion to the mean counts in the contralateral cerebral cortex. The mean and minimum apparent diffusion coefficient values (ADCmean and ADCmin, respectively) on magnetic resonance imaging were also analyzed. RESULTS: Delayed phase 123I-IMP SPECT was the most useful imaging examination for the differentiation between PCNSL and GBM compared with early phase 123I-IMP SPECT, early and delayed phase 201Tl SPECT, ADCmean, and ADCmin. However, the median T/N ratios of PCNSL and GBM were 1.32 and 0.83, respectively, in the delayed phase 123I-IMP SPECT. On the other hand, the median T/N ratios of PCNSL and GBM were 3.10 and 2.34, respectively, in the delayed phase 201Tl SPECT, with excellent tumor detection. CONCLUSION: Delayed phase 123I-IMP SPECT could differentiate between PCNSL and GBM with high accuracy, but T/N ratio was low and tumor detection was poor. 201Tl SPECT was useful for estimation of the malignancy and localization of the tumors with high T/N ratio. Dual isotope 123I-IMP and 201Tl SPECT was useful for the preoperative diagnosis of PCNSL and GBM.

IgG4-related hypothalamo-hypophysitis.

•A patient exhibited IgG4-related hypothalamo-hypophysitis.•Prominent high-signal areas of swelling were observed in the hypothalamus, tuber cinereum, infundibulum, and bilateral optic nerve systems.•MRI T1WI with contrast media demonstrated enhanced neurohypophysis and cystic swelling, and compressed anterior pituitary.•MRI findings improved rapidly after 4 days of steroid therapy.

Single-Layer Fascia Patchwork Closure for the Extended Endoscopic Transsphenoidal Transtuberculum Transplanum Approach: Deep Suturing Technique and Preliminary Results.

OBJECTIVE: To describe a single-layer fascia patchwork closure (FPWC) without nasoseptal flap (NSF) and compare postoperative cerebrospinal fluid (CSF) leakage between FPWC using NSF and single-layer FPWC without NSF for the extended endoscopic transsphenoidal transtuberculum transplanum approach. METHODS: Forty-five cases of suprasellar tumor in 42 patients were treated with extended endoscopic transsphenoidal removal, resulting in extensive, high-flow CSF leakage. Following the intradural procedure for treatment of various suprasellar tumors, fascia lata was inlaid subdurally on the cranial base defect and patch-sutured around its entire circumference under endoscope visualization, using an average of 17 stitches. Septal bone or hydroxyapatite plate was used for the hard support material against pulsatile intracranial pressure. NSF was added in the earlier 17 cases. Closure was completed without NSF in the more recent 28 cases when the Valsalva maneuver confirmed watertight closure. Two recent cases required NSF after Valsalva maneuver and were included in the FPWC + NSF group. RESULTS: Postoperative CSF leakage did not occur in the FPWC + NSF group but occurred in 2 patients in the single-layer FPWC group (7.1%) (P = 0.52). There was no significant difference in CSF leakage between single-layer FPWC and FPWC + NSF. The mean suturing time for FPWC was 85.8 minutes, and the shortest was 39 minutes in a recent case (mean, 17 stitches; n = 35, video analysis). CONCLUSIONS: Single-layer FPWC may be a viable technical option for effective skull base reconstruction after the extended endoscopic transsphenoidal transtuberculum transplanum approach.

Subtype-dependent difference of glucose transporter 1 and hexokinase II expression in craniopharyngioma: an immunohistochemical study.

Papillary craniopharyngiomas are characterized by the BRAF V600E mutation. Enhancement of glucose metabolism may be involved in the downstream of the BRAF V600E mutation in many types of tumors. Glucose metabolism was investigated in craniopharyngioma using immunohistochemical analysis. The study included 29 cases of craniopharyngioma (18 adamantinomatous type [ACP], 11 papillary type [PCP]). Immunohistochemical analysis was performed with anti-glucose transporter-1 (GLUT-1), anti-hexokinase-II (HK-II), anti-BRAF V600E, and anti-beta-catenin antibodies. Expressions of GLUT-1 and HK-II were evaluated using a semiquantitative 4-tiered scale as 0, 1+, 2+, 3+, and divided into negative (0 or 1+) or positive (2+ or 3+) group. GLUT-1 expression level was significantly higher in PCPs than ACPs (0, 1+, 2+, 3+ = 2, 12, 4, 0 cases in ACP, respectively, 0, 1+, 2+, 3+ = 0, 2, 5, 4 in PCP, p = 0.001), and most PCPs were classified into positive group (positive rate, 22.2% [4/18] in ACP, 81.8% [9/11] in PCP; p = 0.003). HK-II expression was also conspicuous in PCPs (0, 1+, 2+, 3+ = 7, 9, 2, 0 cases in ACP, 0, 3, 3, 5 in PCP; p = 0.001), and most of them divided into positive group (positive rate, 11.1% [2/18] in ACP, 72.7% [8/11] in PCP; p = 0.001). Expression patterns of BRAF V600E and beta-catenin reflected the clinicopathological subtypes. Both GLUT-1 and HK-II expressions were prominent in PCP. Glucose metabolism might be more enhanced in PCP than ACP. PCP may use the glucose metabolic system downstream of the BRAF V600E mutant protein.