Revisit of aneurysm clip closing forces: comparison of titanium versus cobalt alloy clip.

Although closing force of cobalt alloy clip is well studied, there is only little information of titanium alloy clip available in the literature. In the present study, we examined and compared closing forces of various types and points of cerebral titanium and cobalt aneurysm clips for cerebral aneurysms. Straight, temporary, bayonet, angled, and fenestrated titanium or cobalt alloy clips were tested by measuring the closing forces at various points along their blade length. Closing forces of all the tested clips linearly increased from tip to base of clip blades. Sugita Titanium II clips had bigger closing forces than Elgiloy clips in all type clips except for the temporary clips. The closing forces of Sugita Titanium II and Yasargil titanium clips were similar in straight permanent type clip although there were some differences in closing forces between other types of Sugita and Yasargil clips. Our data showed that the closing forces differed depending not only on manufacturers but also on materials and shapes.

Expression of RECK in endothelial cells of glioma: comparison with CD34 and VEGF expressions.

Angiogenesis is thought to be involved in the progression of glioma grades, and reversion-inducing cysteine-rich protein with Kazal motifs (RECK) has been said to be involved in maturation of vessels. In this study, we aimed to determine whether high micro-vessel density (MVD) expressed by RECK in glioma tissue is correlated with grades of glioma. We also compared RECK expression with that of the formerly known vessel marker, CD34, and vascular endothelial growth factor (VEGF). RECK, CD34, and VEGF immuno-reactivities of 72 glioma tissues were studied. RECK was seen in microvessels of glioma tissues. CD34 showed a similar pattern to RECK, whereas VEGF showed positive staining in cytoplasm of tumor cells and endothelial cells. Average MVD with RECK was 107.6 microvessels (range 7-290). RECK was positively correlated with grades of glioma. RECK and CD34 also showed a strong correlation (P = 0.001). Higher frequency of VEGF staining was also correlated with higher grade of glioma. This is the first study describing expression of RECK in glioma, and its angiogenesis-related nature may provide a potential therapeutic target for glioma treatment in the future.

Comparison of manual and digital microvascular density counting of RECK expression in glioma.

A microvascular density (MVD) counting method for reversion-inducing cysteine-rich protein with Kazal motifs (RECK) expression, using a digital image analysis tool, has advantages over manual counting by microscope. Thirty glioma cases with RECK staining were photographed at a magnification of 200× high power field and the photographs in RGB images were analyzed, and stained vessels were captured and were counted automatically. MVD with RECK expression using a digital image analysis tool showed comparable results to those of the manual method. RECK intensity expression could show linear correlation with grades of glioma by the digital method, which was superior compared to the manual method. The present method is recommended to researchers undertaking MVD study for glioma.

Reversion-inducing cysteine-rich protein with kazal motifs and matrix metalloproteinase-9 are prognostic markers in skull base chordomas.

Prognosis of chordomas is difficult to predict based solely on histological findings. The purpose of this study was to assess expressions of reversion-inducing cysteine-rich protein with kazal motifs (RECK) and matrix metalloproteinase (MMP)-2, MMP-9 in skull base chordomas and to find out their correlations to outcome. Immunohistochemical study was performed in 19 samples (initial, n = 11; recurrent, n = 8) from 11 patients. The correlations among expression of RECK, MMP-2, MMP-9, and their prognostic values were analyzed. Significant correlation between RECK and MMP-9 was found, but there was no correlation found between MMP-2 and MMP-9. Higher MMP-9 expression significantly influenced outcome. Furthermore, MMP-9/RECK ratio showed significant correlation to outcome, showing their inverse relationship in the disease progress of skull base chordoma. RECK and MMP-9 can be valuable markers to predict prognosis in skull base chordomas.

Early changes in tissue perfusion after tissue plasminogen activator administration in hyperacute ischemic stroke: initial experiences with arterial spin labeling perfusion magnetic resonance imaging.

Cerebral perfusion monitoring is an important component of hyperacute stroke treatment. Arterial spin labeling (ASL) perfusion magnetic resonance (MR) imaging provides a noninvasive method of cerebral perfusion observation. Rapid changes in cerebral perfusion were demonstrated in two patients admitted one hour after onset of hyperacute stroke who underwent recombinant tissue plasminogen activator (rt-PA) treatment. Serial MR images and ASL images were taken on admission and after rt-PA administration. Cerebral blood flow (CBF) values were obtained using the CBF workstation and analysis software. Interpretable ASL images were taken in both patients. Perfusion deficits were consistent with symptoms and/or MR angiography imaging abnormalities. Delayed arterial transit effect was present in one patient; serial imaging showed improvement of CBF after rt-PA treatment in both patients. ASL perfusion MR imaging can provide rapid noninvasive multislice imaging in hyperacute ischemic stroke, and can depict early perfusion deficit and quantify regional CBF concomitantly.

Pontine infarction caused by medial branch injury of the basilar artery as a rare complication of cisternal drain placement.

We present a rare complication of cisternal drain placement during aneurysm surgery. A ruptured anterior communicating artery aneurysm was clipped through a right pterional approach. A cisternal drain was inserted from the retro-carotid to the prepontine cistern. Postoperatively, a left-sided paresis of the upper extremity had developed. A CT brain scan revealed that the drain was located between the pons and the basilar artery, resulting in a pontine infarction. Vascular neurosurgeons should keep this complication in mind when placing a cisternal drain tube. The drain tube should not be inserted too deep into the prepontine cistern.

Operation-microscope-mounted touch display tablet computer for intraoperative imaging visualization.

OBJECTIVE: The authors have developed a novel sterile draped touch display solution for convenient intraoperative access to imaging data. This study describes the technology and clinical experience of the system. METHODS: We developed a flexible, mounted touch display solution (Apple iPad) that allows fixation of the display on the operation microscope and fine adjustments during surgery when the microscope is moved. We compared this setup with a conventional wall-mounted flat-panel and a mobile display stand in illustrative cases of vestibular schwannoma. RESULTS: The surgeon was able to employ the system without the need to leave the operation field or the need for external assistance while referring to imaging data. Commanding through imaging data with sterile gloves on the touch display was more convenient, more precise, and faster compared with other modalities. CONCLUSION: The operation-microscope-mounted touch display provides useful assistance for intraoperative imaging visualization in neurosurgical procedures.

Three-dimensional magnetic resonance imaging based on time-of-flight magnetic resonance angiography for superficial cerebral arteriovenous malformation--technical note.

Direct surgery remains important for the treatment of superficial cerebral arteriovenous malformation (AVM). Surgical planning on the basis of careful analysis from various neuroimaging modalities can aid in resection of superficial AVM with favorable outcome. Three-dimensional (3D) magnetic resonance (MR) imaging reconstructed from time-of-flight (TOF) MR angiography was developed as an adjunctive tool for surgical planning of superficial AVM. 3-T TOF MR imaging without contrast medium was performed preoperatively in patients with superficial AVM. The images were imported into OsiriX imaging software and the 3D reconstructed MR image was produced using the volume rendering method. This 3D MR image could clearly visualize the surface angioarchitecture of the AVM with the surrounding brain on a single image, and clarified feeding arteries including draining veins and the relationship with sulci or fissures surrounding the nidus. 3D MR image of the whole AVM angioarchitecture was also displayed by skeletonization of the surrounding brain. Preoperative 3D MR image corresponded to the intraoperative view. Feeders on the brain surface were easily confirmed and obliterated during surgery, with the aid of the 3D MR images. 3D MR imaging for surgical planning of superficial AVM is simple and noninvasive to perform, enhances intraoperative orientation, and is helpful for successful resection.

Correlation between squamous suture and sylvian fissure: OSIRIX DICOM viewer study.

BACKGROUND: Sylvian fissure (SF) is an important corridor in neurosurgery, and the end of sylvian fissure (eSF) represents the optimal target area to expose suitable recipient artery in STA-MCA bypass. Unfortunately little have been addressed concerning its relationship with external cranial surface. OBJECTIVE: Correlation between Squamous Suture (SS) and SF was investigated. METHODS: 50-adult 3D-CTA images were studied using OSIRIX DICOM viewer. The measurement points were determined from external auditory meatus 0, 1, 1.5, 2, 2.5, 3, 3.5 and 4-cm anteriorly, perpendicular from orbitomeatal (OM) line. The distance of SF was compared with the one of SS. RESULTS: SSs were all located below SF at 0 cm. At a distance of 0 to 1.5 cm, SSs were located above SF, then started to merge and went side by side from 2 cm anteriorly. Anterior sylvian point, the most anterior part of SF, was found at 4 cm from OM line. Inferior Rolandic point, which corresponds to the central sulcus inferior extent, was found to be at 2 cm from OM line. The eSF was identified at 0 cm anteriorly from OM, and perpendicularly 1.5 cm above SS. 50% patients had Chater's point (CP) above eSF. Average value for CP was 0.01 below eSF, giving a significantly closer value compared to the one of SS (p<0.01). However, SS showed consistent value of 1.5 below SF. Furthermore, SS is a bony landmark, which has no shifting effect during surgery, therefore drawing a 1.5-cm line upward from SS could lead to exact location of eSF. CONCLUSION: The course of SF and its correlation to SS have been identified, and this is also the first study to investigate the relationship of SS and eSF using OSIRIX DICOM viewer. SS is also comparable to CP, therefore it is usable for a simple landmark of eSF.

De novo aneurysm: case reports and literature review.

BACKGROUND AND IMPORTANCE: Formation of cerebral de novo aneurysms (CDNAs) is rare, and the pathogenesis remains obscure. We analyzed factors involved in formation of CDNAs and suggest guidelines for follow-up of patients. CLINICAL PRESENTATION: We retrospectively reviewed intracranial aneurysms at our institute and published reports from 1964 to 2008. Eleven patients were found with CDNAs, and 138 patients were collected from the published literature. We assessed the clinical characteristics, such as sex, size, and site of CDNA, past history, and time to occurrence of CDNAs. Of 11 patients, 10 were female and 1 was male; the mean age of the first onset was 53 years (range, 25-69 years). The mean time between first aneurysms and CDNAs was 10.6 years (range, 3-29 years). The most common site of occurrence was anterior circulation. One patient experienced contralateral occurrence, and 2 patients changed from anterior to posterior circulation CDNAs. Six (54.5%) patients had a history of arterial hypertension. Results from analysis of the whole series from the literature revealed that the risk of rupture increased with a previous history of hemorrhage. Contralateral occurrence of CDNAs was related to previous location, and multiplicity, whereas the occurrence of anterior to posterior changes of CDNAs and shorter interval only correlated with an older age group. CONCLUSION: Although the formation of CDNAs is rare, several factors may contribute to its occurrence. Female patients with a history of arterial hypertension were at a higher risk for CDNA occurrence. We recommend follow-up imaging studies within 10 years after the initial aneurysms; therefore, at least 50% of CDNAs can be found before rupture.

Cutaneous malignant melanoma "recurred as" or "in coexistence" with meningioma?

BACKGROUND: The authors report a rare case of a patient with previously treated cutaneous malignant melanoma that recurred 1 year later as an intracranial meningioma. CASE DESCRIPTION: A 20-year-old woman presented with exophthalmos, diplopia and a mass in the left supraorbital area. Imaging study revealed an enhanced intracranial extradural mass with bone destruction. The patient had a history of cutaneous malignant melanoma surgery on the same location 1 year before. The patient underwent left frontotemporal craniotomy for total resection of the mass. Histological study revealed the intracranial mass to be an atypical meningioma. CONCLUSION: To our knowledge, this is a rare report of a patient with this tumor occurrence. This case serves to remind neurosurgeons of the potential existence of benign and/ or malignant tumors of neural crest origin.