Sheath formation around peritoneal tube: possible explanation for unknown cause of ventriculoperitoneal shunt failure.

Ventriculoperitoneal (VP) shunt failures are common and are frequently associated with an obstruction of the peritoneal tube. This study aimed to explore the possible causes of peritoneal tube obstruction, which are largely unknown. From January 1981 to June 2018, we performed VP shunting in 646 patients with hydrocephalus. Among the procedures performed, 148 shunt revision procedures were performed in 98 patients with VP shunt failure. Of the study participants, 64 (43.2%) patients were diagnosed with peritoneal tube obstruction and five patients developed sheath formation that obstructed the end of the peritoneal tubes. Sheath formation around the peritoneal tube is a possible cause of VP shunt dysfunction.

[Endarterectomy for Internal Carotid Artery Occlusion, with an Aberrant Branch of the Internal Carotid Artery Maintaining Blood Flow Distal to the Complete Occlusion:A Case Report].

Doppler sonography accurately identifies occlusion of the internal carotid artery(ICA)and current surgical guidelines do not list an occluded ICA as an indication for carotid endarterectomy(CEA). We encountered an unusual case, for which we performed CEA. The left ICA was occluded by atherosclerosis, and was reconstituted via an aberrant branch of the occipital artery. A 71-year-old man was referred following brain infarction. Carotid duplex sonography(CDS)demonstrated occlusion of his left ICA, with flow in the distal ICA beyond the occlusion("Sandwich stump sign"). 3D computed tomography angiography and cervical angiography diagnosed ICA occlusion with flow in the distal ICA, and the patient underwent CEA. Careful evaluation is required when apparent occlusion of the ICA is detected to avoid overlooking a flow pattern beyond the occlusion and to determine whether repair is possible.

[Subarachnoid Hemorrhage of Unknown Origin at Initial Imaging Investigation].

In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

Tris-acryl gelatin microspheres versus gelatin sponge particles in uterine artery embolization for leiomyoma.

Background Tris-acryl gelatin microspheres (TAGM) and gelatin sponge particles (GS) have been used in uterine artery embolization (UAE) for leiomyoma. No direct comparisons of both embolic agents have been reported. Purpose To compare the outcomes of UAE with TAGM with those of UAE with GS for uterine leiomyoma. Material and Methods This was a non-randomized, single-institute, non-inferiority study. Between July 2008 and August 2015, 67 consecutive patients with symptomatic leiomyoma underwent UAE. GS was used for the first 49 patients and TAGM was used for the following 18 patients. The primary endpoint was tumor infarction on contrast-enhanced magnetic resonance imaging (MRI) 1 week after UAE. The secondary endpoints were changes in symptoms and quality-of-life scores with UFS-QOL questionnaires at 4 months, and adverse events (AEs) in the 4 months after UAE. Results The baseline characteristics of both groups were similar. Complete or nearly complete tumor infarction (≥90%) was achieved in 94.4% (17/18) of the TAGM group and 93.6% (44/47) of the GS group. This difference (0.8%; 95% CI, -11.9% to 13.5%) indicated the non-inferiority of the TAGM group to the GS group, with a pre-specified non-inferiority margin of 20%. No significant differences were observed in improvements in symptoms or quality-of-life scores at 4 months ( P = 0.56 and P = 0.19) or in 4-month AEs ( P = 0.29). Conclusion The outcomes of UAE with TAGM were comparable to those of UAE with GS, suggesting that both embolic agents are acceptable for the treatment of leiomyoma.

[Emergency Decompressive Craniotomy in the Emergency Room was Effective in Severe Acute Subdural Hematoma Treatment:Two Case Reports].

The outcome of severe acute subdural hematoma is unfavorable. In particular, patients with levels of consciousness of Glasgow Coma Scale(GCS)3 or 4 tend to be refractory to treatment. Decompressive craniotomy should be promptly performed to remove hematoma. However, if an operating room is not immediately available, emergency burr hole surgery is sometimes performed in the emergency room(primary care room)prior to craniotomy. A previous study has reported that the interval from injury to surgery influences the outcome of severe acute subdural hematoma. Therefore, emergency decompression is important to effectively treat patients with severe acute subdural hematoma. We present the cases of two patients with acute subdural hematomas. In both cases, emergency decompressive craniotomy(hematoma removal after craniotomy and external decompression)was performed in the emergency room of the Emergency and Critical Care Center. In both cases, the surgery was followed by favorable outcomes. Case 1 was a 36-year-old female. The patient's level of consciousness upon arrival was GCS 3. The interval from injury to diagnosis on the basis of CT findings was 75 minutes. Surgery began 20 minutes after diagnosis. Case 2 was a 25-year-old male. The second patient's level of consciousness upon arrival was GCS 4. The interval from injury to diagnosis on the basis of CT findings was 60 minutes. Surgery was begun 40 minutes after diagnosis. In both patients, we observed anisocoria and the loss of the light reflex. However, the postoperative course was favorable, and both patients were discharged. In summary, to treat severe acute subdural hematomas, early emergency decompressive craniotomy is optimal. Emergency decompressive surgery in the emergency room is independent of operating room or staff. Therefore, emergency decompressive craniotomy may improve the outcome of patients with severe acute subdural hematomas.

[Clinical features of unruptured vertebral artery dissection presenting as isolated occipital headache and/or neck pain].

Vertebral artery dissection(VAD)presenting as isolated occipital headache and/or neck pain is being increasingly diagnosed because of the development of magnetic resonance imaging(MRI). While a majority of the patients diagnosed with this condition shows a favorable prognosis, the pain may be a predictor of fatal stroke in some patients. We aimed to find out the features of headache with VAD, identify the clinical manifestations indicative of VAD, and determine the ideal diagnostic approach to this condition to avoid fatal stroke. We reviewed medical records of 41 consecutive patients who showed VAD with isolated headache and were diagnosed between 1995 and 2008. All patients experienced pain in the occipitocervical area ipsilateral to the affected VA. Pain showed a sudden onset in 21(51%)patients, was persistent over several days in 31(76%)patients, and was severe enough to disable daily life activities in 34(83%)patients. Progression of stenosis or aneurysmal dilatation of the vessel was identified on follow-up imaging(angiography, magnetic resonance angiography)in 7 patients(17%), and was found within 14 days after pain onset in 6 of these patients(86%). Patients with persistent, severe, and unilateral pain in the occipitocervical area should undergo MRI examination, including surface anatomy scanning(SAS)imaging, and the possibility of VAD should be considered in their diagnosis. Once VAD is diagnosed, the patient should undergo meticulous blood pressure control, bed rest, and repeated MRI examination for at least 2 weeks after onset.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution.

BACKGROUND: Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution. METHODS: Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details. RESULTS: There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging. CONCLUSIONS: Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

Inside Out Cranioplasty: A Novel Technique for One-Stage Reconstruction of Persistent Scalp Necrosis.

BACKGROUND: Cranioplasty can be a challenging procedure in certain patients, such as those with scalp necrosis, or when performed after multiple surgical procedures. Herein, we present a patient in whom a part of the skull was placed inside out in a setting where the scalp wound could not be simply sutured because of multiple previous operations. METHODS: A 66-year-old patient with a history of multiple craniotomies to resect an intracranial tumor suffered significant skin flap necrosis after harvesting the superficial temporal artery for a bypass intending to ligate the internal carotid artery. He subsequently underwent a one-stage reconstruction surgery, in which the central part of the bone was excised, turned over, and fixed at the inner plate of the bone flap on the outside, and the outer plate on the inside. RESULTS: This technique reduced the skin tension and reduced the epidural dead space, allowing skin flap healing with acceptable cosmetic results. CONCLUSION: "Inside out cranioplasty" is a valid option for one-stage reconstruction in the cases with scalp necrosis.

Repeated shunt dysfunction due to Barium allergy that was difficult to differentiate from shunt infection.

We encountered a case of repeated shunt dysfunction caused by barium allergy. The patient was a 60-year-old male who underwent ventricular peritoneal shunting for hydrocephalus following subarachnoid hemorrhage due to a ruptured aneurysm;however, it malfunctioned many times. A patch test performed after the third reconstruction was positive for barium. To the best of our knowledge, this is the first case report of shunt malfunction due to barium allergy. The patch test is useful in cases of suspected allergy-related dysfunction. We recommend the introduction of barium into antigen testing using the patch test. J. Med. Invest. 70 : 521-523, August, 2023.

Adhesion between an extruded coil and the oculomotor nerve: Unexpected interference due to coil extrusion.

Background: When direct clipping is performed for a recurrent aneurysm after coil embolization, there are sometimes findings of the coil adhering to the surrounding tissue, after it has been extruded from inside the aneurysm into the subarachnoid space and brain parenchyma. However, there have only been few previous reports on extruded coils adhering to the cranial nerves, preventing aneurysm dissection and clip application. Case Description: We performed the coil embolization of a ruptured aneurysm originating from the bifurcation of basilar artery and superior cerebellar artery in a 36-year-old male patient. Recurrence was confirmed 5 years after embolization and direct clipping was performed. The intraoperative finding was that part of the coil was strongly adhering to or encircling the oculomotor nerve, making it difficult to achieve sufficient mobility of the cerebral aneurysm. Conclusion: When direct clipping is performed after coil embolization of an intracranial aneurysm, part of the coil may be extruded from the aneurysm and then adhere strongly to the cranial nerve.

String-like mobile echodensities on postoperative ultrasound after CEA: A retrospective observational study.

BACKGROUND: String-like mobile echodensities (SLMEs) are sometimes found on postoperative duplex ultrasound (DUS) performed after carotid endarterectomy (CEA); however, they may not be visible on intraoperative DUS. The reasons for these echo findings and associated clinical course remain unknown. METHODS: Routine postoperative DUS evaluation after CEA was retrospectively examined in 101 consecutive patients (107 lesions) who underwent CEA between April 2015 and December 2021, at our institution. RESULTS: Ten SLMEs were identified in eight patients. All SLMEs were 1-3 mm long, mobile, and extended straight from the intima-media complex of the wall of the common carotid artery or carotid bulb. Most lesions resolved spontaneously; a few lesions were observed repeatedly, albeit not causing cerebral infarction or transient ischemic attacks. CONCLUSIONS: SLMEs can be observed in a small percentage of patients after CEA, and they do not seem to be of clinical significance.

Posttraumatic rapid growing extradural meningioma: A case report on the effectiveness of echosonography.

BACKGROUND: Most meningiomas related to head trauma have been reported to show intradural lesions; however, they can also occur as primary extradural meningiomas (PEMs) and have often been reported to histologically demonstrate atypical or malignant subtypes. Therefore, early detection and complete resection of related tissues are required; however, to date, only a few PEM cases related to trauma or injury have been reported. Herein, we present a patient with a rapidly growing posttraumatic PEM, in which echosonography is efficient not only for early diagnosis but also for intraoperative strategies. CASE DESCRIPTION: A 62-year-old male presented to a nearby clinic with a complaint of a painless head bump that gradually grew larger in relation to trauma 6 weeks earlier. He underwent echosonography and pointed out the possibility of a cranial tumor and consulted our hospital. Although preoperative imaging studies, such as computed tomography or magnetic resonance imaging, did not provide reliable information on dura mater invasion, echosonography demonstrated dural invasion and intradural lesions in which large vessels passed the surface of the lesion. Based on these findings, we could safely resect the lesion within a sufficient range. CONCLUSION: Echosonography may not only be a cue for an early diagnosis but also provide important information for the treatment strategy of PEM that is related to head trauma.

Global identification and mapping of socio-ecological production landscapes with the Satoyama Index.

Production landscapes play an important role in conserving biodiversity outside protected areas. Socio-ecological production landscapes (SEPL) are places where people use for primary production that conserve biodiversity. Such places can be found around the world, but a lack of geographic information on SEPL has resulted in their potential for conservation being neglected in policies and programs. We tested the global applicability of the Satoyama Index for identifying SEPL in multi-use cultural landscapes using global land use/cover data and two datasets of known SEPL. We found that the Satoyama Index, which was developed with a focus on biodiversity and tested in Japan, could be used globally to identify landscapes resulting from complex interactions between people and nature with statistical significance. This makes SEPL more relevant in the global conservation discourse. As the Satoyama Index mapping revealed that approximately 80% of SEPL occur outside recognized conservation priorities, such as protected areas and key biodiversity areas, identifying SEPL under the scheme of other area-based conservation measures (OECM) may bring more conservation attention to SEPL. Based on the issues identified in the SEPL mapping, we discuss ways that could improve the Satoyama Index mapping at global scale with the longitudinal temporal dimension and at more local scale with spatial and thematic resolution.

Cerebral venous thrombosis following spontaneous intracranial hypotension diagnosed by craniotomy: A case report and diagnostic pitfalls.

BACKGROUND: Cerebral vein and dural sinus thrombosis (CVT) is a rare but important complication of spontaneous intracranial hypotension (SIH). The diagnosis is difficult in cases lacking typical symptoms and typical imaging findings. CASE DESCRIPTION: A 29-year-old male patient with a seizure attack was admitted to our hospital. Based on the head imaging findings, we misdiagnosed the patient with primary cerebral parenchymal lesion and performed an open biopsy. However, during the procedure, the patient was diagnosed with low cerebrospinal fluid pressure and cerebral cortical vein thrombosis. CONCLUSION: Thus, CVT due to SIH should be considered as a probable cause of secondary parenchymal lesions.

A comparative analysis of the modified Rankin Scale, Karnofsky Performance Status and Kurtzke expanded disability status scale in the perioperative management of patients with brainstem cavernous malformations.

BACKGROUND: The neurological conditions of brainstem cerebral cavernous malformation (BCM) patients are usually ascertained using Karnofsky Performance Status (KPS) or the modified Rankin scale (mRS). However, these scales do not reflect slight changes in brainstem function, because neither KPS nor mRS includes brainstem symptoms such as worsening of swallowing or diplopia. The main problem when managing the BCM patients is that we can neither systematically record neurological changes nor conduct clinical outcome investigations of BCM due to the lack of an adequately detailed assessment system. PURPOSE: We investigated the usefulness of the Kurtzke expanded disability status scale (EDSS), which is already in widespread clinical use for multiple sclerosis because it provides certainty in evaluating brainstem symptoms. METHODS: We retrospectively analyzed neurological transitions in surgical BCM cases using the modified Rankin scale (mRS), Karnofsky performance status (KPS), and EDSS. We compared each neurological score transition, and determined which scale allows the most accurate recording of neurological changes in patients. RESULTS: We proposed lesion removal for patients who showed both neurological deterioration and lesion enlargement caused by re-bleeding, and the surgery was accepted by 10 patients. EDSS allowed us to assess patient status more accurately than KPS or mRS particularly during the perioperative period. In the statistical analysis, only EDSS differed significantly during the period between the initial proposal of surgery and the immediate preoperative period. CONCLUSION: Our results suggest EDSS to be superior for managing BCM patients, as compared to KPS and mRS. Thus, EDSS may serve as an alternative scale for assessing BCM patients.

Recurrence of internal carotid artery dissection associated with elongated styloid process: A case report.

BACKGROUND: An elongated styloid process is known to cause ischemic stroke. Previous reports claim that internal carotid artery (ICA) dissection due to the elongated styloid process has good outcomes when treated conservatively; however, long-term follow-up has not been attempted and recurrence in the later period has not been reported so far. We report a case of recurrence of symptoms over a decade after the initial onset. CASE DESCRIPTION: A 59-year-old man experienced a transient ischemic attack (TIA) 10 years ago. Six years ago, he experienced hemispheric TIA, and magnetic resonance angiography revealed a diminished signal of the left ICA; however, no further examination was performed. Four years ago, he experienced another transient amaurosis attack and was treated with antiplatelet therapy because no embolic source was detected using ultrasonography examination, and he was diagnosed with idiopathic ICA dissection. Recently, he experienced a third amaurosis fugax attack. Digital subtraction angiography and cone-beam computed tomography demonstrated left cervical ICA dissection due to elongated styloid process. He underwent surgical resection of the left styloid process and cervical stent placement. He had no ischemic attacks postoperatively. CONCLUSION: The elongated styloid process may cause recurrent ischemic attacks over a decade due to ICA dissection.

Colored ligature: Trivial but innovative modification.

BACKGROUND: Vascular ligation and its detachment remain a necessary skill for a surgeon. We often use two threads of the same color to ligate a vessel. However, some problems (grasping the mixed-up threads and/or difficulty in releasing the entanglement) may occur while using same colored ligatures. To solve these problems, we devised to use ligatures of different colors, and here, we present this ingenious idea. METHODS: When a vessel is encountered that needs to be cut, we pass two different colored threads behind it. RESULTS: We can grasp the two threads without mixing them up. In addition, in case of entanglement, unwinding of the entangled threads is quicker. We then finally tie a knot with these threads and cut the vessel visible between them. CONCLUSION: Using different colored ligatures enhance surgical convenience in the operating room.

Lumboperitoneal Shunt Surgery Using Valve Implantation on the Paravertebral Spinal Muscle.

BACKGROUND: One possibly problematic feature of lumboperitoneal shunt (LPS) placement involves inaccuracy in handling the shunt valve compared with ventriculoperitoneal shunt. Flushing the valve to ascertain shunt patency and adjusting the valve pressure in LPS are often more difficult than with ventriculoperitoneal shunt, particularly when the valve is routinely located in abdominal fat. To overcome this inaccuracy, we applied a simple alteration to the usual LPS procedure. We changed the valve location from the abdominal fat to a lumbar posterior site where the paravertebral spinal muscle, in contrast to the nonsupportive abdominal fat, offers a good anchoring point for valve implantation. METHODS: We retrospectively reviewed 51 consecutive patients undergoing LPS placement for normal pressure hydrocephalus. We divided the patients into 2 groups, anterior or lateral and posterior, and analyzed these 2 groups, focusing on technical features and outcomes. RESULTS: In the anterior or lateral group, 1 patient showed an inverted valve position, and errors occurred when adjusting the valve pressure in 3 patients. There were no wound complications, such as skin erosion. Two patients experienced periumbilical discomfort. In the posterior group, no patients showed an inverted valve position or errors associated with adjustment of the pressure. There were no wound complications, such as skin erosion, or reports of discomfort. CONCLUSIONS: In this series, our modification increased the accuracy of handling the valve without increasing discomfort.

Acute central nervous system vasculitis as a manifestation of neurosarcoidosis: A case report and literature review.

Neurosarcoidosis (NS) affects various sites of the central nervous system, including the cranial nerve, meninges, brain parenchyma, hypothalamus, and pituitary gland. NS rarely causes intracerebral vasculitis and subsequent strokes, or cerebral infarction and hemorrhage, which are associated with high mortality. Herein, we report a 71-year-old woman's case of stroke associated with NS, which showed aggressive cerebral vasculitis with brain herniation; it was resolved with corticosteroid therapy after accurate histopathological diagnosis. This case highlights the necessity of expecting NS to sometimes follow an aggressive course, presenting with vasculitis. Most patients with NS satisfactorily respond to corticosteroids, but this is not always the case. In cases of unfamiliar ischemic or hemorrhagic lesions, the possibility of NS must be considered.

Cytologic diagnosis of central neurocytoma in intraoperative squash preparations: a report of 2 cases.

BACKGROUND: Central neurocytoma is a rare central nervous system tumor typically found in the lateral ventricles and at the spectrum pellucidum. Two patients with central neurocytoma underwent intraoperative frozen section diagnoses, and the cytologic evaluations are described. CASES: Case 1 was a 21-year-old female who complained about reduced visual acuity. Magnetic resonance imaging (MRI) showed enhancement of a ventricular tumor. Over 80% of the tumor was removed, but after 14 months' follow-up, the disease progressed and regrowth occurred. The patient had a second tumor resection with gamma knife surgery. Case 2 was a 30-year-old female who presented with headaches. An MRI showed an enhancement of a ventricular tumor, and complete tumor removal was achieved. Cellular samples of both cases typically revealed ill-defined cytoplarm, oval nuclei with finely granular chromatin and micronucleoli. A fibrillose matrix in the background was noted. A typical appearance of perinuclear halo was also recognized. In both cases histopathologic examination was consistent with a central neurocytoma. Immunohistochemistry of both tumors was synaptophysin(+), NSE (+), NeuN(+), GFAP(-), but MIB-1 labeling index was 3.4% in case 1 and 1.1% in case 2. CONCLUSION: These are 2 illustrative cases in which the authors report cytologic evaluation of central neurocytomna in intraoperative preparations. These tumors possess distinct cellular features that help with the intraoperative distinction from other intraventricular tumors. Moreover, it should be emphasized that immunostains for neural markers are essential for distinguishing them from other clear cell tumors of the brain, especially oligodendroglioma and clear cell ependymomal neoplasm. A combination of imaging, cytomorphology and immunohistochemical features of central neurocytoma can help to differentiate this condition from other intraventricular tumors. It is thought that careful scrutiny of intraoperative preparations allows one to make a distinction.