The importance of considering competing risks in recurrence analysis of intracranial meningioma.

BACKGROUND: The risk of recurrence is overestimated by the Kaplan-Meier method when competing events, such as death without recurrence, are present. Such overestimation can be avoided by using the Aalen-Johansen method, which is a direct extension of Kaplan-Meier that accounts for competing events. Meningiomas commonly occur in older individuals and have slow-growing properties, thereby warranting competing risk analysis. The extent to which competing events are considered in meningioma literature is unknown, and the consequences of using incorrect methodologies in meningioma recurrence risk analysis have not been investigated. METHODS: We surveyed articles indexed on PubMed since 2020 to assess the usage of competing risk analysis in recent meningioma literature. To compare recurrence risk estimates obtained through Kaplan-Meier and Aalen-Johansen methods, we applied our international database comprising ~ 8,000 patients with a primary meningioma collected from 42 institutions. RESULTS: Of 513 articles, 169 were eligible for full-text screening. There were 6,537 eligible cases from our PERNS database. The discrepancy between the results obtained by Kaplan-Meier and Aalen-Johansen was negligible among low-grade lesions and younger individuals. The discrepancy increased substantially in the patient groups associated with higher rates of competing events (older patients with high-grade lesions). CONCLUSION: The importance of considering competing events in recurrence risk analysis is poorly recognized as only 6% of the studies we surveyed employed Aalen-Johansen analyses. Consequently, most of the previous literature has overestimated the risk of recurrence. The overestimation was negligible for studies involving low-grade lesions in younger individuals; however, overestimation might have been substantial for studies on high-grade lesions.

Twelve-year single critical care center experience of nicardipine prolonged-release implants in patients with subarachnoid hemorrhage: a propensity score matching analysis.

OBJECTIVE: To develop a nicardipine prolonged-release implant (NPRI) to prevent cerebral vasospasm in patients with subarachnoid hemorrhage in 1999, which may be used during craniotomy, and report the results of our recent 12-year single critical care center experience. METHODS: Of 432 patients with aneurysmal subarachnoid hemorrhage treated between 2007 and 2019, 291 were enrolled. 97 Patients were aged >70 years (33%), 194 were female (67%), 138 were World Federation of Neurological Societies grades 1, 2, and 3 (47%), 218 were Fisher group 3 (75%), and 243 had an anterior circulation aneurysm (84%). Using a propensity score matching method for these five factors, the severity of cerebral vasospasm, occurrence of delayed cerebral infarction, and modified Rankin Scale (mRS) score at discharge were analyzed. RESULTS: One hundred patients each with or without NPRI were selected, and the ratios of coil/clip were 0/100 and 88/12, respectively. Cerebral vasospasm and delayed cerebral infarction were both significantly less common in the NPRI group (p=0.004, OR=0.412 (95% CI 0.223 to 0.760) and p=0.005, OR=0.272 (95% CI 0.103 to 0.714, respectively); a significant difference was seen in the mRS score at discharge by Fisher's exact test (p=0.0025). A mRS score of 6 (dead) was less common in the group with NPRI, and mRS scores of 0 and 1 were also less common. No side effects were seen. CONCLUSIONS: NPRIs significantly reduced the occurrence of cerebral vasospasm and delayed cerebral infraction without any side effects. The NPRI and non-NPRI groups showed different patterns of short-term outcomes in the single critical care center, which might have been due to selection bias and patient characteristics. Differences in outcomes may become clear in comparisons with patients treated by craniotomy.

Hemifacial Spasm Caused by Veins Confirmed by Intraoperative Monitoring of Abnormal Muscle Response.

BACKGROUND: Hemifacial spasm (HFS) is a benign disease caused by the hyper excitement of facial nerves owing to vessel compression. The offending vessels are usually arteries, such as anterior and posterior inferior cerebellar or vertebral arteries, but there are few reports of vein involvement cases. OBJECTIVE: The aim of this study was to investigate veins as offending vessels in patients with HFS confirmed by abnormal muscle response (AMR). METHODS: We analyzed 5 patients with HFS caused by veins among 78 patients with HFS over the past 10 years. All patients underwent microvascular decompression (MVD) with AMR monitoring, whereas 3 of them underwent a second MVD. The mean follow-up time was 97 months. RESULTS: Arteries were thoroughly decompressed in 3 patients with a failed first MVD surgery who received a second surgery, during which veins at the root exit point (RExP) were decompressed with the disappearance or a significant decrease in the amplitude of AMR. Two patients showed spasm resolution after the first surgery when veins were decompressed together with the disappearance of AMR. The location of veins was RExP and the cisternal portion. All patients had excellent outcomes within 3 months, and no complications were observed. CONCLUSIONS: Veins can be offending vessels in HFS patients. AMR is useful to determine the endpoint in these cases. Once arteries are decompressed thoroughly with residual AMR, surrounding veins at unusual sites, such as the RExP or the cisternal portion, must be checked to prevent persistent HFS. Complete decompression of veins leads to a good clinical outcome.

[A Case of Segmental Arterial Mediolysis:Subarachnoid Hemorrhage Followed by Abdominal Bleeding].

We describe a case involving subarachnoid and intraperitoneal hemorrhage due to segmental arterial mediolysis(SAM). A 77-year-old female patient with sudden subarachnoid hemorrhage was immediately transferred to our institution. The hemorrhage was classified as grade 2 according to the World Federation of Neurosurgical Societies system. The patient was a non-smoker and did not drink alcohol regularly. A right internal carotid aneurysm was detected using CT angiography and was clipped during frontotemporal craniotomy. Bleeding was observed from the anterior wall of the internal carotid artery, and the tear was clipped. The patient had an uneventful postoperative course until sudden cardiopulmonary arrest eight days after craniotomy. She died of massive intraperitoneal hemorrhage. Autopsy revealed that the hemorrhage was due to dissection of the celiac artery. Tunica media denaturation was observed not only in the celiac artery, but also in the splenic and internal carotid arteries, which exhibited ruptured aneurysms, and the patient was diagnosed with segmental arterial mediolysis(SAM). SAM is an arterial degenerative disease affecting the medial layer of the arterial and dissecting walls. Multiple lesions are sometimes found. Radiographic imaging findings of SAM are similar to those of dissecting aneurysms, which are characterized by a single continuous dissection of the medial layer. As observed in this case, abdominal bleeding caused by SAM can occur after intracranial bleeding. When surgeons encounter unusual intracranial dissecting aneurysms, SAM should be considered as a differential diagnosis.

Acute cholecystitis in patients with stroke.

BACKGROUND: Although acute cholecystitis after stroke is rare, an immediate diagnosis and treatment is required. MATERIAL AND METHODS: In the past five years, we observed six patients with acute cholecystitis during the initial hospitalization for stroke. RESULTS: Three patients had cardiac embolism, two had subarachnoid hemorrhage, and one had intra-cerebral hemorrhage. Four had calculous cholecystitis and two had acalculous cholecystitis. One of the patients with acalculous cholecystitis had hemorrhagic cholecystitis. The most commonly presented symptom was fever (50%), whereas only one patient (17%) had abdominal pain. Three patients (50%) were completely asymptomatic. CONCLUSIONS: Acute cholecystitis and stroke are closely associated, and anti-thromboembolic drugs may cause hemorrhagic cholecystitis. Stroke patients tend to have atherosclerotic risk factors resulting in ischemic injury of the gallbladder. Furthermore, severe hemiparesis, a fasting state, dehydration, or bacteremia, which are occasionally exhibited by stroke patients, are known risk factors for acalculous cholecystitis. Stroke patients, especially patients with aphasia and consciousness disturbance, require immediate abdominal examination, if acute cholecystitis is suspected.

Identification of shared genomic aberrations between angiomatous and microcystic meningiomas.

BACKGROUND: Angiomatous and microcytic meningiomas are classified as rare subtypes of grade I meningiomas by World Health Organization (WHO). They typically exhibit distinct histopathological features as indicated by their WHO titles; however, these angiomatous and microcystic features are often intermixed. Recently, angiomatous meningiomas were reported to show characteristic chromosomal polysomies unlike the other WHO grade I meningiomas. In the present study, we hypothesize that microcystic meningiomas share similar cytogenetic abnormalities with angiomatous meningioma. METHODS: We performed copy number analysis using single nucleotide polymorphism (SNP) arrays for three angiomatous and eight microcystic meningiomas. Of these, three angiomatous and three microcystic meningiomas were also analyzed by whole exome sequencing and RNA sequencing. RESULTS: We first analyzed three angiomatous and three microcystic meningiomas for which both frozen tissues and peripheral blood were accessible. Copy number analysis confirmed previously reported multiple polysomies in angiomatous meningiomas, which were entirely replicated in microcystic meningiomas when analyzed on different analytical platforms with five additional samples prepared from formalin-fixed paraffin-embedded tumors. Polysomy of chromosome 5 was found in all cases, along with chromosome 6, 12, 17, 18, and 20 in more than half of the cases including both angiomatous and microcystic meningiomas. Furthermore, next generation sequencing did not reveal any distinctive somatic point mutations or differences in gene expression characterizing either angiomatous or microcystic meningiomas, indicating a common genetic mechanism underlying tumorigenesis. CONCLUSIONS: Angiomatous and microcystic meningiomas have substantially similar genetic profiles represented by the characteristic patterns of multiple polysomies originating from chromosome 5 amplification.

Intraoperative and Postoperative Bleeding in Microvascular Decompression for Trigeminal Neuralgia.

OBJECTIVE: The surgical approach for the trigeminal nerve involves veins connected to the superior petrosal and tentorial sinus, and we should pay special attention to these veins. We investigated intraoperative and postoperative bleeding using our database. METHODS: A prospectively accumulated database of 247 microvascular decompression surgeries for trigeminal neuralgia over the past 10 years was analyzed. Intraoperative and postoperative bleeding was confirmed with surgical records, videos, and computed tomography. Of 235 patients, 161 were female; 85 patients were >70 years old at the time of surgery; 96 surgeries involved the left side. RESULTS: Intraoperative venous bleeding was encountered in 29 surgeries (12%): from the superior petrosal vein/sinus in 18 and the hemispheric bridging vein/tentorial sinus in 11. Massive bleeding occurred from the superior petrosal sinus owing to tear of the entrance of the superior petrosal vein in 4 surgeries and from the tentorial sinus in 3; bleeding was controlled by Surgicel with fibrin glue. Postoperative bleeding occurred in 11 surgeries (4%): intracerebellar hematoma in 2, subarachnoid hemorrhage in 3, subdural hemorrhage in 3, supratentorial subdural hemorrhage in 2, and supratentorial epidural hematoma in 1. These lesions were associated with intraoperative bleeding in 1 case, a trans-horizontal fissure approach in 1 case, coagulation of the petrosal vein in 2 cases, and unknown reasons in 7 cases. Cure without medication was achieved in 218 surgeries at an average follow-up of 4.2 years. CONCLUSIONS: Microvascular decompression for trigeminal neuralgia involves potential risks of intraoperative and postoperative bleeding.

Progesterone Receptor Is Responsible for Benign Biology of Skull Base Meningioma.

OBJECTIVE: Many studies have been performed to evaluate the roles of estrogen receptor and progesterone receptor (PGR) in meningiomas, but their influence on tumor behavior remains unclear. METHODS: We retrospectively analyzed patients with meningioma who underwent surgical resection at our institute. Patients with data for immunohistochemical staining of estrogen receptor, PGR, and Ki-67 were included. RESULTS: The study included 161 patients comprising 61 skull base and 100 non-skull base meningiomas. Histologically, the number of patients with World Health Organization (WHO) grade I, II, and III disease were 132 (82.0%), 22 (14.7%), and 7 (4.4%), respectively. Tumor recurrence was observed in 21 (13.0%). Negative PGR, high Ki-67 index, incomplete resection, and WHO grade II or III were significantly correlated with tumor recurrence and shorter recurrence-free survival. Skull base meningiomas were difficult to remove entirely; 31 patients (50.8%) with skull base and 77 patients (77.0%) with non-skull base meningiomas had overall complete removal (P = 0.0006). Ki-67 indices, proportion of WHO grade II or III, and recurrence rate or recurrence-free survival did not differ between the tumor locations. The only difference was the proportion of patients with positive PGR, which was significantly higher for skull base meningiomas (61.5 ± 33.4% vs. 42.2 ± 35.7%, P = 0.0009). CONCLUSIONS: Although skull base meningiomas are often incompletely resected, there were no differences in recurrence-free survival or recurrence rate between skull base and non-skull base meningiomas. As the Ki-67 index and WHO grade were not different between these locations, the high rate of positive PGR may be responsible for the benign biology of skull base meningiomas.

Microvascular decompression for hypoglossal nerve palsy secondary to vertebral artery compression: A case report and review of the literature.

BACKGROUND: Neurovascular-compression syndrome (NCS) is described as a prominent pathological contact between cranial nerves and vessels. Trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia are typical clinical entities associated with NCS. On the other hand, the hyoglossal nerve is rarely affected by NCS. CASE DESCRIPTION: We present a case of hypoglossal nerve palsy (HNP) secondary to vertebral artery (VA) compression. A 47-year-old man presented to our hospital with a 1-month history of dysarthria and dysphagia. Neurological examination revealed left HNP, with an intact swallowing reflex and no oropharyngeal or palatal weakness. Magnetic resonance imaging (constructive interference in steady state) revealed left hypoglossal nerve compression by the V4 segment of the left atherosclerotic VA. He underwent microvascular decompression (MVD) surgery. Intraoperatively, the VA was compressing the hypoglossal nerve. The left VA was moved and attached to the dura matter using a polytetrafluoroethylene (Teflon®) sheet and fibrin glue. Postoperatively, the patient exhibited gradual recovery of HNP in 3 months without dysfunction of lower cranial nerves. CONCLUSION: In patients with isolated HNP, vascular compression should be considered as a cause of these symptoms, and subsequent MVD can lead to resolution.

Clinical Predictors of Intracranial Injuries in Infants with Minor Head Trauma.

OBJECTIVE: Minor head trauma is common in children. Although most cases are nonsignificant, minor head trauma can lead to preventable intracranial injuries. The aim of this study was to identify clinical predictors of intracranial injuries in infants with minor head trauma. METHODS: Between 2006 and 2013, we retrospectively enrolled infants <11 months old with minor head trauma. Data recorded included age, sex, cause of trauma, fall height, vomiting, bad temper, size and location of scalp hematoma, fracture, and intracranial injuries on computed tomography. RESULTS: Of 549 enrolled infants, 15 (3%) sustained traumatic intracranial injuries: epidural hematoma in 7, subarachnoid hemorrhage in 4, subdural hematoma in 3, and cerebral contusion in 1. Intracranial injuries were found in 8 of 98 infants who had fallen from a >60 cm height, 1 in 197 with fall height >30 cm, and none in 44 with fall height ≤30 cm (P = 0.0001); 1 of 2 with scalp hematomas >6 cm, 10 of 35 with hematomas >3 cm, and 2 of 121 with hematomas ≤3 cm (P = 0.0001); and 9 of 28 with temporal hematoma, 2 of 15 with parietal hematoma, 2 of 22 with occipital hematoma, and none of 98 with frontal hematoma (P = 0.0001). Logistic regression analysis showed that scalp hematoma was related to intracranial injuries (hazard ratio = 21.127, P = 0.0001), whereas age, sex, fall, vomiting, and bad temper were not. CONCLUSIONS: Fall height and size and location of scalp hematoma were associated with intracranial injuries. These factors should be considered when making decisions on radiologic examinations of infants with minor head trauma.

[Immediate improvement of ischemic oculopathy after stenting for internal carotid artery stenosis].

Ocular ischemic syndrome occurs when ocular circulation becomes impaired owing to various causes, leading to disturbances in the visual function. It ultimately progresses to neovascular glaucoma and loss of sight. Therefore, the early diagnosis and treatment of patients with ocular ischemic syndrome has a major effect on their visual prognosis. Herein, we describe a patient who complained of decreased vision in one eye. The patient was subsequently diagnosed with internal carotid artery stenosis because of neovascularity (rubeosis iridis) around the iris in the anterior eye. The vision of the patient improved immediately after carotid artery stenting. A review of the literature indicated that the visual improvement could be attributed to the reversal of retrograde blood flow, caused by internal carotid artery stenosis, to normal levels; the resolution of rubeosis in the anterior eye; and improvement in the visual field constriction.

[Trigeminal neuralgia caused by cerebellopontine angle lipoma:a case report and review of the literature].

A 59-year-old man presented with right trigeminal neuralgia of the second branch, which had been treated with carbamazepine. The pain could not be controlled adequately because of side effects. CT and MRI revealed a 2-cm lesion in the right cerebellopontine angle. Retrosigmoid lateral suboccipital craniectomy was performed, and a soft yellowish mass was found to be associated with the 5th, 7th, and 8th cranial nerves, anterior inferior cerebellar artery, and small vessels. The lipoma was partially resected from around the root entry zone(REZ)of the 5th nerve and small vessels were coagulated around the REZ. After surgery, there was no trigeminal neuralgia, but facial numbness and cerebellar signs were noted. Postoperative MRI showed decompression of the trigeminal nerve and venous infarction in the middle cerebellar peduncle. Reviewing similar cases, we found 19 lipoma patients presenting with trigeminal neuralgia. Symptoms of involvement of other cranial nerves were also present in 11 patients, and 14 were younger than 30 years old. Of 17 surgical cases, total resection was not attempted apart from one case. Although pain relief was achieved in all surgical cases, complications developed in 11. Surgery should be performed only in patients with disabling and uncontrolled symptoms.

[A case of acute aortic dissection presenting with cerebral ischemic symptoms: utility of 3D CT angiography and CT perfusion for the diagnosis of acute stroke].

A 76-year-old woman presented at our hospital complaining of loss of consciousness, dysarthria, and upper extremity paresis. Head CT showed no remarkable findings. 3D CT angiography (CTA) and CT perfusion (CTP) revealed acute aortic dissection (AAD) involving the innominate artery and decreased cerebral blood flow in the right cerebral hemisphere, although there were no clinical signs of AAD. The patient underwent emergency allograft replacement performed by cardiovascular surgeons. The symptoms disappeared within several days and no cerebral infarction developed. Although patients with AAD and neurological symptoms can show a fatal course when they receive tissue plasminogen activator (tPA), it is difficult to exclude patient with AAD as candidates for tPA treatment. Routine use of 3D CTA and CTP in the diagnosis of acute stroke may help overcome the above problem.

Sensitivity of CT perfusion for the diagnosis of cerebral infarction.

We aimed to determine the sensitivity of CT perfusion (CTP) for the diagnosis of cerebral infarction in the acute stage. We retrospectively reviewed patients with ischemic stroke who underwent brain CTP on arrival and MRI-diffusion weighted image (DWI) after hospitalization between October 2008 and October 2011. Final diagnosis was made from MRI-DWI findings and 87 patients were identified. Fifty-five out of 87 patients (63%) could be diagnosed with cerebral infarction by initial CTP. The sensitivity depends on the area size (s): 29% for S < 3 cm(2), 83% for S ≥ 3 cm(2) - < 6 cm(2), 88% for S ≥ 6 cm(2) - < 9 cm(2), 80% for S ≥ 9 cm(2) - < 12 cm(2), and 96% for S ≥ 12 cm(2) (p < 0.001). Sensitivity depends on the type of infarction: 0% for lacunar, 74% for atherothrombotic, and 92% for cardioembolism (p < 0.001). Sensitivity is not correlated with hours after onset. CT perfusion is an effective imaging modality for the diagnosis and treatment decisions for acute stroke, particularly more serious strokes.

[A case of cavernous sinus epidermoid: anatomical classification and surgical approach].

Epidermoid rarely appears in the cavernous sinus. We encountered a 41-year-old man with left abducens nerve palsy. A round-shaped, low-density lesion on CT was located lateral to the left cavernous sinus with a compressed and thinned lateral wall of the sphenoid sinus. We could not identify cranial nerves in the cavernous sinus, which was found to be packed with a non-enhanced, high-intensity tumor on both T1 and T2 MRI. Part of the tumor capsule and its pearly contents were removed with an intradural subtemporal approach, and an inner membranous layer with cranial nerves and a tumor capsule were seen at the bottom of the tumor cavity. Postoperatively, complete cure was achieved. Reviewing similar cases, we found 18 cavernous sinus epidermoids:extracavernous type in 5;interdural in 10;and intracavernous in 3. The interdural type could be further divided into two subtypes:superficial cavernous sinus and inner membranous types. The present case belongs to the former. Frontotemporal and subtemporal procedures via both intra- and extradural approaches are relatively safe for lesions except for the intracavernous type, because cranial nerves are not located in the lateral wall of the tumor. MRI provides more useful information on cranial nerves and aid in choosing a better treatment strategy.