Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas.

BACKGROUND: Chronic subdural hematoma (CSDH) is generally treated by burr hole irrigation. However, sometimes repeated recurrence is observed, and treatment may consequently become difficult. We examined the efficacy of embolization of the middle meningeal artery (MMA) for such cases. METHODS: We considered embolization of the MMA for three patients who had refractory CSDH with repeated recurrence and two CSDH patients who were at risk of recurrence and showed signs of recurrence after surgery. A microcatheter was advanced through the MMA as peripherally as possible, and embolization was performed with 15-20% n-butyl-2-cyanoacrylate or 200 µm polyvinyl alcohol particles. RESULTS: EMBOLIZATION WAS PERFORMED IN THE THREE PATIENTS WHO HAD REFRACTORY CSDH WITH REPEATED RECURRENCE: The procedure was performed after burr hole irrigation of the hematoma in two patients and before the irrigation in one patient. In the two CSDH patients at risk of recurrence, embolization was performed when signs of recurrence appeared. The timing of embolization differed for each patient. However, in all the patients, the hematoma tended to decrease in size, and no recurrence was observed. CONCLUSION: Embolization of the MMA is effective for refractory CSDH or CSDH patients with a risk of recurrence, and is considered an effective therapeutic method to stop hematoma enlargement and promote resolution.

Dural suturing for repair of cerebrospinal fluid leak in transnasal transsphenoidal surgery.

OBJECTIVE: Repair of a cerebrospinal fluid (CSF) leak after transsphenoidal surgery (TSS) is usually accomplished using various graft materials. These methods are effective in most, but not all, cases. METHODS: Since 2006, we have been directly suturing the sellar floor dura in patients with an intraoperative CSF leak. Fat and/or fascial grafts were utilized only when a major CSF leak developed. The incidence of postoperative CSF rhinorrhea was compared before and after the suture. RESULTS: Postoperative CSF rhinorrhea developed in 3.7% (7 out of 188) of cases before 2005, but never since the dural suture was introduced (0 out of 136, 0%; P = 0.0229). Although watertight closure was not achieved in some cases, narrowing the dural defect and supporting the intrasellar graft was attained in every case. Surgical time was approximately 30 min longer in patients who underwent dural suture (148 +/- 42 min) than those who did not (119 +/- 37 min; P = 0.0001). CONCLUSION: Direct suturing of the sellar dura is a simple, safe, and reliable surgical technique for repairing CSF leaks after TSS. Using this procedure, more than 70% of patients with an intraoperative CSF leak can avoid autologous tissue grafts.

Photodynamic therapy of C6-implanted glioma cells in the rat brain employing second-generation photosensitizer talaporfin sodium.

OBJECT: The usefulness of photodynamic therapy (PDT) as a local therapy for malignant glioma was evaluated by investigating histological changes in a rat C6 glioma model treated with a combination of talaporfin sodium, a water-soluble photosensitizer derived from chlorophyll and exposure to a diode laser. METHODS: Glioma cells (C6) at the confluence stage were transplanted stereotactically into the right frontal lobe of SD rats. Five days later, the rats underwent right frontal craniotomy and intravenous administration of talaporfin sodium. One hour after talaporfin sodium administration, each rat was irradiated by a 664 nm diode laser beam. The brain was removed 1, 3 or 6h after laser irradiation for histological examination of tumor-affected brain tissue and surrounding normal brain tissue. RESULTS: In addition to the tumor mass, tumor cells invading surrounding edematous brain tissue were seen in untreated rats, ranging from the brain surface to a depth of 2mm. One hour after PDT, coagulation necrosis as well as disappearance of indication of cell viability such as disappearance of tumor cell processes and foamy changes of cytoplasm were noted in the tumor tissue at a depth of 0.5mm, accompanied by reduction of cytoplasmic glial fibrillary acidic protein (GFAP) expression and appearance of granular M30 cytodeath positivity. Three hours later, the cytoplasm of the residual tumor cells showed disappearance of GFAP expression and increased expression of M30 cytodeath. Six hours later, the foamy cytoplasm of swollen tumor cells demonstrated strong positivity for M30 cytodeath. CONCLUSION: PDT using talaporfin sodium induced coagulation necrosis and apoptosis in rats with C6 glioma.

Epithelioid glioblastoma: a case report.

A 43-year-old woman who had undergone breast cancer surgery 1 year previously complained of headache and nausea. Her brain computed tomography (CT) scan and magnetic resonance imaging (MRI) showed a well-circumscribed, heterogeneously enhanced tumor in the right thalamus. She underwent gross total resection of the tumor followed by radiochemotherapy, and her clinical course was uneventful after surgery. Histological examination revealed a moderate number of tumor cells with fine bipolar processes in a mucoid matrix, which suggested pilocytic astrocytoma. The tumor was associated with microvascular proliferation but did not show significant mitosis or necrosis. In some areas, it had an epithelioid appearance, with ribbon-like, cribriform, and pseudoglandular patterns involving cuboid-shaped cells showing nuclear atypia and mitotic figures. Immunohistochemically, the tumor cells were positive for glial fibrillary acidic protein (GFAP) and vimentin in the area resembling pilocytic astrocytoma, but in the epithelioid area they were negative for GFAP and vimentin as well as for breast cancer markers, including AE1/AE3. The proliferating potential, represented by the MIB-1 labeling index, was high (82.5%) in the area of epithelioid appearance, compared to only 3% in the area of pilocytic astrocytoma-like appearance. As a rare histoarchitectural variant of glioblastoma, the epithelioid pattern may represent a very primitive tumor cell phenotype. Typically, this pattern is characterized by well-circumscribed masses, although its clinical significance is unknown.