Definitive radiotherapy consisting of external beam radiotherapy without central shielding and 3D image-guided brachytherapy for patients with cervical cancer: feasibility for Japanese patients and dose-response analyses for local control in the low-dose range.

OBJECTIVE: To assess the feasibility of external beam radiotherapy without central shielding in definitive radiotherapy for Japanese patients with cervical cancer. METHODS: We retrospectively analysed the data of cervical cancer patients treated with definitive radiotherapy consisting of external beam radiotherapy without central shielding and three-dimensional-image-guided brachytherapy. RESULTS: The study included 167 patients (T1 + 2 = 108, T3 + 4 = 59) from eight Japanese institutions. For three-dimensional-image-guided brachytherapy, intra-cavitary and interstitial brachytherapy was utilized in 33 patients (20%). The median follow-up was 26.6 months (interquartile range, 20-43.2). The maximum rectal D2 (75 Gy)/bladder D2 (90 Gy) constraints were deviated by 6%/10% and 10%/5% for T1 + 2 and T3 + 4, respectively. The 2-year incidence of ≥grade 3 proctitis/cystitis was 4%/1% for T1 + 2 and 10%/2% for T3 + 4. The 2-year local progression-free survival was 89% for T1 + 2 and 82% for T3 + 4. For T1 + 2, the 2-year local progression-free survival for the high-risk clinical target volume D90 ≥ 68 Gy (indicated by receiver operating characteristic analysis; area under the curve = 0.711) was 92% versus 67% for <68 Gy (log-rank; P = 0.019). Cox multivariate analysis indicated that the high-risk clinical target volume D90 was one of independent predictors of local failure (P = 0.0006). For T3 + 4, the 2-year local progression-free survival was 87% for the high-risk clinical target volume <82 cm3 (area under the curve = 0.67) and 43% for ≥82 cm3 (P = 0.0004). Only the high-risk clinical target volume was an independent predictor of local failure (P = 0.0024). CONCLUSIONS: Definitive radiotherapy consisting of external beam radiotherapy without central shielding and three-dimensional-image-guided brachytherapy was feasible for Japanese patients with cervical cancer. Dose de-escalation from the current global standards is suggested for patients with T1 + 2 disease.

A Third-Generation Adaptive Statistical Iterative Reconstruction for Contrast-Enhanced 4-Dimensional Dual-Energy Computed Tomography for Pancreatic Cancer.

OBJECTIVES: The objective of this study was to assess the objective and subjective qualities of the contrast-enhanced 4-dimensional dual-energy computed tomography using adaptive statistical iterative reconstruction (ASiR) and ASiR-V. METHODS: The virtual monochromatic images at 60 keV were reconstructed using filtered back projection, ASiR, and ASiR-V (10%-100%) for 14 patients with pancreatic cancer. The contrast-to-noise ratio (CNR) was calculated, and the subjective measurements were compared based on a 5-point score scale. RESULTS: The ASiR-V yielded a significantly higher CNR than ASiR (P < 0.05). The subjective image quality (peak) was significantly improved (P < 0.01) with ASiR (50%) (3.8, 3.5, and 4.0; overall image quality, tumor delineation, and noise, respectively) and with ASiR-V (50%) (3.9, 3.5, and 4.2, respectively) compared with the filtered back projection (3.2, 3.2, and 3.0, respectively). CONCLUSIONS: The ASiR-V yielded higher CNR than ASiR and provided the highest subjective scores regarding the overall image quality.

Subarachnoid hemorrhage induces neuronal nitric oxide synthase phosphorylation at Ser1412 in the dentate gyrus of the rat brain.

INTRODUCTION: We previously demonstrated that cyclic AMP-dependent protein kinase (PKA) phosphorylates neuronal nitric oxide synthase (nNOS) at Ser1412 in the hippocampal dentate gyrus after forebrain ischemia; this phosphorylation event activates NOS activity and might contribute to depression after cerebral ischemia. In this study, we revealed chronological and topographical changes in the phosphorylation of nNOS at Ser1412 immediately after subarachnoid hemorrhage (SAH). METHODS: In a rat single-hemorrhage model of SAH, the hippocampus and adjacent cortex were collected up to 24 h after SAH. Samples from rats that were not injected with autologous blood were used as controls. NOS was partially purified from crude samples via an ADP-agarose gel. Levels of nNOS, nNOS phosphorylated at Ser1412 (p-nNOS), PKA, and p-PKA at Thr197 were studied in the rat hippocampus and cortex using Western blot analyses and immunohistochemistry. RESULTS: According to the Western blot analysis, levels of p-nNOS at Ser1412 were significantly increased in the hippocampus, but not in the cortex, between 1 and 3 h after SAH. Immunohistochemistry revealed the phosphorylation of nNOS at Ser1412 and PKA at Thr197 in the dentate gyrus, but not in the CA1 area, 1 h after SAH. An injection of saline instead of blood also significantly increased levels of p-nNOS at Ser1412 in the hippocampus 1 h after the injection. CONCLUSIONS: An immediate increase in intracranial pressure (ICP) might induce transient cerebral ischemia and promote the PKA-mediated phosphorylation of nNOS at Ser1412 in the dentate gyrus. This signal transduction pathway induces the excessive production of nitric oxide (NO) and might be involved in cognitive dysfunction after SAH.

How Well Does Dual-Energy Computed Tomography With Metal Artifact Reduction Software Improve Image Quality and Quantify Computed Tomography Number and Iodine Concentration?

OBJECTIVE: The objective of this study was to assess the accuracy of the quantitative measurements obtained using dual-energy computed tomography with metal artifact reduction software (MARS). METHODS: Dual-energy computed tomography scans (fast kV-switching) are performed on a phantom, by varying the number of metal rods (Ti and Pb) and reference iodine materials. Objective and subjective image analyses are performed on retroreconstructed virtual monochromatic images (VMIs) (VMI at 70 keV). RESULTS: The maximum artifact indices for VMI-Ti and VMI-Pb (5 metal rods) with MARS (without MARS) were 17.4 (166.7) and 34.6 (810.6), respectively; MARS significantly improved the mean subjective 5-point score (P < 0.05). The maximum differences between the measured Hounsfield unit and theoretical values for 5 mg/mL iodine and 2-mm core rods were -42.2% and -68.5%, for VMI-Ti and VMI-Pb (5 metal rods), respectively, and the corresponding differences in the iodine concentration were -64.7% and -73.0%, respectively. CONCLUSIONS: Metal artifact reduction software improved the objective and subjective image quality; however, the quantitative values were underestimated.

Peripheral artery disease is associated with frailty in chronic hemodialysis patients.

Objectives The clinical condition of frailty is a common problem in the elderly population. However, the relationship between peripheral artery disease and frailty in hemodialysis patients remains unknown. The aim of this study was to identify the relationships between peripheral artery disease and frailty in Japanese chronic hemodialysis patients. Methods A total of 362 chronic hemodialysis patients who regularly visited six institutions were enrolled. To evaluate frailty, the modified Fried's frailty phenotype adjusted for Japanese were used. Peripheral artery disease was defined as ankle-brachial index <0.9. Results Of 362 patients, 62 patients (17.1%) were categorized as peripheral artery disease group and 300 patients (82.9%) as Non-peripheral artery disease group. The prevalence of frailty in the peripheral artery disease group was significantly higher than in the Non-peripheral artery disease group (34% vs. 18%, P = 0.0103). Non-shunt side grip strength was significantly stronger in the Non-peripheral artery disease group (23.6 kg vs. 17.0 kg, P < 0.0001). Thigh circumferences were also significantly larger in the Non-peripheral artery disease group (41.7 cm vs. 39.7 cm, P = 0.0054). A multivariate logistic regression analysis demonstrated that the factors independently associated with peripheral artery disease were as follows: frailty (odds ratio = 2.06, 95% confidence interval 1.09-3.89) and myocardial infarction (odds ratio = 3.74, 95% confidence interval 2.05-6.83). Conclusions It is concluded that peripheral artery disease is closely associated with frailty in hemodialysis patients.

Highly Efficient Access to Both Geometric Isomers of Silyl Enol Ethers: Sequential 1,2-Brook/Wittig Reactions.

Novel sequential 1,2-Brook/Wittig reactions were developed for the preparation of silyl enol ethers. This method enables highly selective preparation of both geometric isomers of glyoxylate silyl enol ethers, using aldehydes (E-selective) and tosylimines (Z-selective) as a Wittig electrophile. The salt-free conditions of this reaction system are likely to be advantageous for switching the selectivity. The optimal reaction conditions and generality of the reaction were investigated, and plausible explanations for the observed selectivity were also discussed.

[Effects of long-acting insulin degludec on type 2 diabetic hemodialysis patients with poor glycemic control].

BACKGROUND: The ratio of elderly complicated diabetes mellitus (DM) to all hemodialysis (HD) patients has increased. The number of elderly DM patients with poor glycemic control has also increased due to complications, such as dementia. By means of appropriate glycemic control, the risk of cardiovascular disease might decrease among diabetic HD patients, and improvement of their prognosis could be expected. When glycemic control is poor when treating diabetic HD patients with oral hypoglycemic agents, insulin treatment could be indicated. METHODS: Using continuous glucose monitor (CGM), we evaluated the differences in glucose variability of 3 type 2 diabetic HD patients with poor glycemic control when switching from insulin glargine to degludec. RESULTS: Case 1 was a 72-year-old man with poor dietary self-management, whose glycated albumin (GA) level was 27%, and was administered lispro 6-6-6 U plus glargine 8 U daily. He was switched from glargine to degludec 6 U daily. Eight weeks later, his glycemic control improved as seen in his GA level (19%) and CGM. Case 2 was an 84-year-old solitary woman with dementia. Her GA level was 28.4%, and she was administered glargine 8 U (after HD, 3 times/week). She was switched from glargine to degludec 6 U (after HD, 3 times/week). Her glycemic control improved as seen in her GA level (25.1%) and CGM thereafter. Case 3 was a 65-year-old solitary man with liver cirrhosis and chronic pancreatitis. His GA level was 26.6%, and he was administered glargine 8 U (every day). He was switched from glargine to degludec 12 U (after HD, 3 times/week). His glycemic control improved as seen in his GA level (21.3%) and CGM thereafter. CONCLUSIONS: These results suggest that degludec is more effective than glargine in improving glycemic control and reducing the insulin dose in type 2 diabetic HD patients.

[A case of moyamoya disease with a subarachnoid hemorrhage treated with endovascular technique].

We report a case of a moyamoya disease presenting with subarachonoid hemorrhage (SAH) due to a ruptured aneurysm. A 40-year-old woman presented with sudden onset of headache and vomiting. Computed tomography (CT) showed diffuse thick SAH localized around basal cistern. 3D-CT Angiography (3D-CTA) and digital subtraction angiography (DSA) demonstrated a saccular aneurysm at the bifurcation of the left superior cerebellar artery and basilar artery. In addition, the both carotid arteries were occluded at the terminal portion and the territory of both middle cerebral arteries were perfused by abnormal moyamoya vessels. The aneurysm was completely embolized by endovascular embolization. The SAH due to a ruptured aneurysm associated with moyamoya disease is rare. We think endovascular therapy is safe and effective. However, a vasospasm of the catheter technique occurred during the operation. This fact is very important to consider when we treat diseases such as this in the future.

Cerebral hemorrhage and cerebral infarction in 30 cases of adult moyamoya disease: comparison between conservative therapy and superficial temporal artery-middle cerebral artery anastomosis.

To clarify the effect of surgery on the prevention cerebral hemorrhage in adult moyamoya disease, we compared postoperative courses between superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and conservative therapy. The study subjects were 30 adults with moyamoya disease. Unilateral STA-MCA anastomosis was conducted in 7 of these 30 cases, and bilateral STA-MCA anastomosis was conducted in 8 of these 30 cases. Therefore, anastomosis was performed in a total of 23 sides. The postoperative clinical course was observed for more than 5 years after the STA-MCA anastomosis. Cerebral hemorrhage occurred after operation in 2 sides (8.7%) among the 23 sides that received STA-MCA anastomosis. On the contrary, hemorrhage occurred during conservative therapy in 5 sides (13.5%) among 37 non-operation sides (no significance in chi2 test). Cerebral infarction occurred in 3 sides (13%) among 23 sides treated with STA-MCA anastomosis. However, the infarction occurred in 2 sides (5.4%) among the 37 non-operation sides (no significance in chi2 test). Cerebral hemorrhage tended to occur less frequently after STA-MCA anastomosis, and bypass surgery was suggested to have some beneficial effect in preventing cerebral hemorrhage in adult moyamoya disease. However, it was revealed that STA-MCA anastomosis exacerbated the brain ischemia. Therefore, strict management is mandatory in the perioperative period.

Atherothrombotic lesion of the middle cerebral artery: report of 21 cases with stenotic and obstructive lesions.

This was a retrospective analysis of 12 consecutive cases of middle cerebral artery stenosis and 9 consecutive cases of middle cerebral artery occlusion that presented to our hospital with acute cerebral ischemia. The degree and area of the cerebral infarctions were assessed with the Alberta Stroke Program Early CT Score (ASPECTS) and ASPECTS-DWI (APSECTS with assessment of white matter lesion using diffusion-weighted image). As for cerebral infarctions in the region of the perforating artery, lesions that were more than 20 mm long in the caudal-cranial direction were diagnosed as branch atheromatous disease (BAD). Activities of daily living (ADL) were poorer in the cases with lower ASPECTS and ASPECTS-DWI. ADL tended to be worse in cases with BAD than in those without. The prognosis was significantly poorer in the group with ASPECTS< or =7 points. ASPECTS tended to be lower in cases with BAD than in those without. ADL, ASPECTS and the presence of BAD were not significantly different between the stenosis and obstruction groups. In summary, the neurological prognosis was dependent on the extent of the cerebral infarction and was related to BAD to some extent. These findings will be important when considering medical treatment at the outpatient clinic setting.

[Factors which affect the neurological condition in subarachnoid hemorrhage].

The factors which were related to the neurological condition were analyzed in 233 cases of subarachnoid hemorrhage. Bivariate analysis and multiple(binomial)logistic regression analysis were performed as for Hunt & Kosnik grade, modified Rankin Scale at discharge and modified Rankin Scale in the out-patient department to detect the factors which were related to the neurological condition. Hematoma-filled intraventricular hemorrhage, intracerebral hemorrhage with midline shift, acute subdural hematoma and aneurysm of the vertebrobasilar system were the representative factors which caused poor neurological condition. Hunt & Kosnik grade was poor when rebleeding occurred or hematoma was formed in the sylvian fissure. Hunt & Kosnik grade and modified Rankin Scale at discharge tended to be poor in the cases with acute hydrocephalus. The elevation of intracranial pressure was the major factor in neurological deterioration.

[Subarachnoid hemorrhage caused by dissection of the basilar artery: a case report].

We report a case of subarachnoid hemorrhage, which was caused by dissection of the basilar artery during treatment for diabetes mellitus. The patient was a 60-year-old male who consulted our hospital complaining of sudden-onset of a severe headache. Head CT scan showed subarachnoid hemorrhage around the basilar artery, but 3D-CT angiography revealed no abnormality. The basilar artery was shown to be normal during cerebral angiography on Day 1. However, in retrospect pseudolumen of the basilar artery was suspected in the proximal portion of the branching point of the anterior inferior cerebellar artery. During a second cerebral angiography on Day 17, blood pressure elevated to 185/83mmHg and 30 minutes later this patient's consciousness deteriorated to 10 points of the GCS(E4, V2, M4). The double lumen in the basilar artery was identified around the branching point of the anterior inferior cerebellar artery. Head MRI on the same day showed intramural hemorrhage of the basilar artery as a high intensity lesion. Head MRI on Day 18 revealed multiple cerebellar infarctions in the region of the bilateral anterior inferior cerebellar arteries. His consciousness recovered to almost normal by reducing the blood pressure. Transient gait disturbance also recovered thereafter. Head MRI on Day 90 indicated disappearance of the intramural hemorrhage in the basilar artery. It was important to reduce the blood pressure to prevent recurrence of the arterial dissection.

[A case with Stanford type A acute aortic dissection that presented with consciousness disturbance and hemiparesis].

The patient was a 63-year-old female who had a past history of hypertension. She suddenly complained of agonizing pain and became comatose soon thereafter. Upon admission, she was in a state of shock, with upper airway obstruction and a coma. The pupils were dilated on both sides. The laboratory data showed that D-dimer was >80µg/mL. Brain CT scan and diffusion weighted MRI of the brain showed no abnormality. On brain 2D-CT angiography, the visualization of the right internal carotid artery and the right vertebral artery was poor. She eventually was able to nod her head in response to verbal commands, but her left extremities were completely hemiplegic. Cerebral angiography showed occlusion of the right vertebral artery at the branching point from the brachiocephalic artery, and was visualized in a retrograde fashion through the left vertebral artery. The brachiocephalic artery was severely stenotic in aortography. During angiography, she became able to speak and complained of back pain. Chest CT just after angiography showed a dissection in the aortic arch. Therefore, she was directed to the cardiovascular surgeon for immediate consultation. During the operation, the aortic dissection was revealed to be Stanford type A. Laceration of the intima was found in the ascending aorta and cardiac tamponade was also found. Total arch replacement was performed. The pathological examination showed that the arterial dissection occurred in the layer of elastic fiber, and the minimum arterial thickness of the medial layer was 0.2mm. The patient improved after the operation and her neurological deficits disappeared completely 13 days after operation. Brain and spinal MRI 15 days after the operation showed no abnormality.

Unique vascular structures of a radicular arteriovenous fistula at the craniocervical junction along the first cervical spinal nerve: A case report.

Background: An arteriovenous fistula (AVF) at the craniocervical junction (CCJ) is a rare vascular malformation. Definitive diagnosis and curative treatment of CCJ AVF are challenging. Case Description: A 77-year-old man presented with subarachnoid hemorrhage. Cerebral angiography showed an AVF at the CCJ, which drained into a radicular vein. The lesion was fed by a vertebral artery, anterior and lateral spinal arteries (LSAs), and the occipital artery (OA). There were two unique structures: the LSA originating from the posterior inferior cerebellar artery of the extracranial V3 segment and the OA feeding the shunt. Curative treatment involved two steps: endovascular embolization of feeders using Onyx and surgical shunt disconnection. Feeding arteries were blackened by Onyx, which helped identify the location of the shunt. The shunt was located behind the first cervical (C1) spinal nerve, and the draining vein was confirmed on the deep side of the nerve. A clip was applied to the draining vein distal to the shunt. Tiny vessels supplying the shunt were then coagulated referring to blackened arteries. Conclusion: A radicular AVF at the CCJ along the C1 spinal nerve had unique vascular structures. Definitive diagnosis and curative treatment were achieved by combining endovascular embolization using Onyx and direct surgery.

Objective evaluation of tongue diagnosis ability using a tongue diagnosis e-learning/e-assessment system based on a standardized tongue image database.

Background: In Kampo medicine, tongue examination is used to diagnose the pathological condition "Sho," but an objective evaluation method for its diagnostic ability has not been established. We constructed a tongue diagnosis electronic learning and evaluation system based on a standardized tongue image database. Purpose: This study aims to verify the practicality of this assessment system by evaluating the tongue diagnosis ability of Kampo specialists (KSs), medical professionals, and students. Methods: In the first study, we analyzed the answer data of 15 KSs in an 80-question tongue diagnosis test that assesses eight aspects of tongue findings and evaluated the (i) test score, (ii) test difficulty and discrimination index, (iii) diagnostic consistency, and (iv) diagnostic match rate between KSs. In the second study, we administered a 20-question common Kampo test and analyzed the answer data of 107 medical professionals and 56 students that assessed the tongue color discrimination ability and evaluated the (v) correct answer rate, (vi) test difficulty, and (vii) factors related to the correct answer rate. Result: In the first study, the average test score was 62.2 ± 10.7 points. Twenty-eight questions were difficult (correct answer rate, <50%), 34 were moderate (50%-85%), and 18 were easy (≥85%). Regarding intrarater reliability, the average diagnostic match rate of five KSs involved in database construction was 0.66 ± 0.08, and as for interrater reliability, the diagnostic match rate between the 15 KSs was 0.52 (95% confidence interval, 0.38-0.65) for Gwet's agreement coefficient 1, and the degree of the match rate was moderate. In the second study, the difficulty level of questions was moderate, with a correct rate of 81.3% for medical professionals and 82.1% for students. The discrimination index was good for medical professionals (0.35) and poor for students (0.06). Among medical professionals, the correct answer group of this question had a significantly higher total score on the Kampo common test than the incorrect answer group (85.3 ± 8.4 points vs. 75.8 ± 11.8 points, p < 0.01). Conclusion: This system can objectively evaluate tongue diagnosis ability and has high practicality. Utilizing this system can be expected to contribute to improving learners' tongue diagnosis ability and standardization of tongue diagnosis.

Inflammatory index and treatment of brain abscess.

This study retrospectively analyzed 12 patients with brain abscesses. Half of the patients were diagnosed inaccurately in the initial stage, and 7.2 days were required to achieve the final diagnosis of brain abscess. The patients presented only with a moderately elevated leukocyte count, serum CRP levels, or body temperatures during the initial stage. These markers changed, first with an increase in the leukocyte count, followed by the CRP and body temperature. The degree of elevation tended to be less prominent, and the time for each inflammatory index to reach its maximum value tended to be longer in the patients without ventriculitis than in those with it. The causative organisms of a brain abscess were detected in 10 cases. The primary causative organisms from dental caries were Streptococcus viridians or milleri, and Fusobacterium nucleatum. Nocardia sp. or farcinica were common when the abscess was found in other regions. The primary causative organisms of unrecognized sources of infection were Streptococcus milleri and Prolionibacterium sp. Nocardia is resistant to many antibiotics. However, carbapenem, tetracycline and quinolone were effective for Nocardia as well as many other kinds of bacteria. In summary, the brain abscesses presented with only mildly elevated inflammatory markers of body temperature, leukocyte and CRP. These inflammatory markers were less obvious in the patients without ventriculitis and/or meningitis. The source of infection tended to suggest some specific primary causative organism. It was reasonable to initiate therapy with carbapenem.

Treatment of a cerebral dissecting aneurysm in anterior circulation: report of 11 subarachnoid hemorrhage cases.

This report presents 8 cases of internal carotid artery aneurysms, 1 case of a middle cerebral artery aneurysm, and 2 cases of anterior cerebral artery aneurysms, together with a discussion of the treatment of aneurysms in anterior circulation. All cases showed subarachnoid hemorrhage. Two of the 8 internal carotid artery aneurysms were trapped with a low-flow bypass; however, both patients died of an immediate hemodynamic infarction or vasospasm-induced infarction. Five of the 8 internal carotid artery aneurysms were trapped after revascularization with high flow bypass. Four of those patients were self-supporting at discharge, but one patient was discharged in a vegetative state due to the sacrifice of arterial branches which were included in the dissecting portion. One case of the dissecting aneurysm in the M2 portion of the middle cerebral artery was trapped after low-flow bypass. This patient was self-supporting at discharge. In 2 cases of anterior cerebral artery aneurysms, the lesions were first wrapped with Bemsheets, and then the aneurysmal clip was applied on the wrapped dome. Trapping following high-flow bypass is the best method for treating a dissecting aneurysm in the internal carotid artery. Trapping also can be used to treat a dissecting aneurysm of the middle cerebral artery, after low-flow bypass. Clipping on the wrapped aneurysm can also be performed successfully in the anterior cerebral artery aneurysm.

Air vent of vein graft in extracranial-intracranial bypass surgery.

Revascularization with a vein graft is a mandatory method for treatment of dissecting or pseudoaneurysms of the internal carotid artery. We report the necessity for an air vent from the vein graft and explain its use in our two cases. In Case 1, we searched for a great saphenous vein around its junction with a femoral vein during the harvest of vein graft. An accessory branch of that great saphenous vein was also found around the junctional region with a femoral vein, and was temporarily ligated. At first, anastomosis was completed on both the distal and proximal sides. After the proximal side of a vein graft was opened and the ligation of the branch was loosened, an air vent could be made through the branch of the vein graft. Multiple air bubbles and a large quantity of white microemboli were discharged through this branch. The postoperative course was uneventful. In Case 2, the air vent was omitted to shorten ischemia. During the opening of the vein graft, the migrated air was observed to move to the middle cerebral artery. A computed tomography scan demonstrated that brain infarction and dysarthria occurred postoperatively. The air vent of the vein graft is essential in extracranial-intracranial bypass surgery, because the air bubbles or microthrombi are easily trapped around the valve and cause cerebral infarction. An air vent can be easily made if the branch of a vein graft exists in the outflow pathway, because intraluminal air or thrombus can be washed out through the branch at the final stage of surgery.

Postoperative recovery from unilateral blindness caused by tuberculum sellae meningioma.

A 47-year-old female had noticed diminished visual acuity in both eyes 2 months previously. The patient had vision loss (no light perception) in her right eye on admission. Her left visual acuity was 1.2 (naked vision) and an upper temporal quadrant hemianopsia was revealed in her left eye. Optic disc atrophy was also found bilaterally during a fundus examination. The tumor was located at the tuberculum sella. The first operation was performed using a right pterional approach. The right optic nerve was thin and atrophic and was severely encased by the tumor. Considering the deterioration of her visual evoked potential, the operation was terminated in the remaining major part of the tumor. Postoperatively, the patient suffered visual loss in her right eye (no light perception), decreased visual acuity (naked: 0.6 (corrected: 1.0)), and deteriorated visual field defects (upper temporal quadrant hemianopsia) in her left eye. The tumor remnant was resected again 2 weeks later using the right frontobasal and pterional approaches. The tumor around the bilateral internal carotid arteries and optic nerves was not resected. Light perception in the right eye appeared 2 weeks after the operation. Although an opthalmological examination revealed right optic atrophy, finger counting was possible in the upper nasal visual field of the right eye three months after the second operation. Her visual acuity was 0.7 (1.0), and the upper temporal quadrant hemianopia of the left eye improved in comparison with the preoperative one. Our case demonstrated the possibility of a recovery from blindness.

Repair of carotid blow-out using a carotid sheath in a patient with recurrent thyroid cancer.

The patient had thyroid cancer and underwent subtotal thyroidectomy. Local recurrence occurred on both sides 5 years and 6 months later. The sterno-hyoid muscle and sterno-thyroid muscle were severed and the tumor around the cricoid cartilage was removed. The tumor extended into the space between the right common carotid artery and internal jugular vein and was located under the right common carotid artery and vagus nerve on the lateral side. The carotid sheath was peeled off of the carotid artery quite easily. The right common carotid artery ruptured abruptly at the distal side during this procedure. The right common carotid artery had two layers, which were very fragile, so the direct suture or repair with a graft was impossible. The carotid artery could not be trapped with ligation because the cerebral vascular supply was not examined preoperatively. This portion was repaired using the remaining carotid sheath. However, re-bleeding occurred at the proximal portion of the previous laceration spontaneously. Fibrin glue with oxidized cellulose was initially used to seal the second small hole in this lesion. The second ruptured section was repaired using the remaining sterno-thyroid and sterno-hyoid muscles. The proximal portion of the right common carotid artery was reinforced with the harvested external jugular vein. These procedures resulted in hemostasis. Three-dimensional CT angiography showed irregular stenosis just after the operation, but it recovered 11 days later. No cerebral infarction occurred after the operation and the patient's general condition was good.