[Anterior Interosseous Nerve Palsy with Isolated Flexion Palsy of the Thumb or Index Finger as an Initial Symptom:Two Case Reports].

Case 1: A 73-year-old man who had undergone neurolysis for right cubital tunnel syndrome complained of difficulty using chopsticks. Froment's sign test showed that the interphalangeal(IP)joint of the right thumb that had flexed preoperatively was extended. This finding was considered to indicate recovery from ulnar neuropathy, and the patient was closely followed up. One year later, the patient was unable to push a camera shutter button and was unable to flex the IP joint of the thumb and the distal interphalangeal(DIP)joint of the index finger, a characteristic symptom of anterior interosseous nerve(AIN)palsy. Therefore, the patient underwent AIN neurolysis and subsequently reported slight improvement in his condition. Case 2: A 60-year-old woman reported difficulty performing computer mouse clicks with her right hand. As flexing the index finger DIP joint was difficult, a local lesion was suspected, and the patient was closely followed up. One year later, the patient was unable to push the button of a ballpoint pen with her thumb. Extension of the thumb and index finger indicated AIN palsy. The patient refused treatment and was only followed up. The following year, the patient reported that the weakness improved. Simultaneous flexion palsy of the thumb and index finger can lead to a diagnosis of AIN palsy. However, flexion palsy of a single finger in incomplete AIN palsy, as reported here, is often overlooked because of its similarity to the flexor tendon rupture. Awareness regarding this incomplete form of AIN palsy is needed for early and correct diagnosis.

Aneurysms Arising from Persistent Arteries in the Vertebrobasilar Paramedian Longitudinal Axis: Two Case Reports.

A 50-year-old man and a 69-year-old woman with consciousness disturbance were diagnosed to have suffered from subarachnoid hemorrhage (SAH) involving the posterior fossa. In both cases, the initial 3D CT angiogram failed to reveal the SAH source in the vertebrobasilar system. Delayed 3D rotational angiography revealed aneurysms on unfamiliar aberrant arteries. One was a dissecting aneurysm located between the proximal part of the posterior inferior cerebellar artery and the distal part of the intracranial vertebral artery. It was trapped and resected; the patient subsequently presented with lateral medullary symptoms. The other aneurysm was between the distal posterior and the distal anterior inferior cerebellar artery. It was successfully embolized; there were no complications. We think that the aberrant aneurysm-harboring vessels encountered in these two patients were primitive arteries on or adjacent to the vertebrobasilar paramedian longitudinal axis and that they persisted past the embryologic stage. Such aneurysms arising from unfamiliar persistent arteries beside the brainstem are extremely rare but must be considered when the SAH source is not detected in the trunk of the vertebrobasilar system.

Half-tied Stay Suture Technique for Cerebrovascular End-to-side Anastomosis: A Technique to Expand the View of the Hidden Ostium.

In cerebrovascular end-to-side anastomosis, thick, hard donor arteries overlying thin recipient arteries impair the view of the ostium, and may result in occlusion of the anastomosis. To improve the intraoperative view, we modified the stay sutures. After performing standard recipient arteriotomy and placing the first stay suture, we half-tied the second stay suture to leave a loop: half-tied stay suture (HSS). The thread of the HSS was secured with a clip to avoid slippage. For suturing side A, the clip pulling on the HSS was gently moved to the opposite side of side A, i.e. to side B, and the donor artery was revolved by several degrees to side B; the first stay suture was used as the fulcrum. Under the expanded view of the ostium, untied interrupted sutures were placed on side A. Then the donor vessel was revolved to the opposite side and side B was sutured in the same manner. At last, the HSS and all other sutures were tied fully. Our HSS method was used in three adults who underwent superficial temporal- to middle cerebral artery anastomosis despite anticipated poor visibility of the ostium. Compared with the conventional method, the view of the ostium was expanded with less manipulation of the vessel walls. There were no complications, and the anastomosis remained patent in all three patients. This simple modification of the stay sutures reduces the risk of anastomotic occlusion due to iatrogenic vascular damage by excessive manipulation under a restricted view.

[Formation of a Subcutaneous Amputation Neuroma after Incomplete Endoscopic Carpal Tunnel Release Resulting in Complex Regional Pain Syndrome:A Case Report].

This 64-year-old woman had undergone endoscopic carpal tunnel release(ECTR)for right carpal tunnel syndrome 16 months earlier. Thereafter, she reported persistent dysesthesia in the thumb and index finger, developed burning pain in the middle and ring finger, paleness, coldness, and edema of the hand, a decreased range in hand motion, and a painful subcutaneous nodule just distal to the portal in the forearm. Based on physical, radiological, and electrophysiological studies, the diagnosis was incomplete carpal tunnel release associated with complex regional pain syndrome(CRPS). At open revision surgery, the carpal tunnel was released completely and the nodule was removed. Symptoms other than hypesthesia in the middle and ring fingers improved. Pathologically, the nodule was an amputation neuroma. Her CRPS was attributed to ECTR complications; i.e., persistence of median nerve compression and the formation of an amputation neuroma in the palmar cutaneous branch of the ulnar nerve at the portal. Surgeons must be aware that ECTR, a less invasive technique, may result in serious complications including CRPS.

[Extendable Cords to Prevent Tumbling of a Suction Device during Craniotomy].

OBJECTIVE: Suction is necessary during craniotomy, and intraoperative tumbling of the suction device interrupts operative procedures. To avoid this, we developed a technique that would fasten the device to an extendable cord as is used to secure cell phones. SURGICAL TECHNIQUE: We used this technique in more than 300 craniotomies at the specific point of time when the suction device tends to tumble, i. e., during the opening and closure of a wound, which requires frequent instrument exchanges. Extendable cords fastened to the tip of the suction hose using a gift tie were attached to the drapes to secure the suction device next to the operative field. During the operation, the extendable cord followed the suction device manipulations. Consequently, although there was some tension in the cord during its extension, the maneuverability of the suction device was maintained. As the hanging suction device was closer to the operative field than devices stored in conventional pockets, its manipulation was easier and quicker. Upon release, the suction device automatically returned to its original position without distracting the surgeon. Tumbling of the device was prevented, and there were no procedure-related complications. CONCLUSIONS: Our simple modification using extendable cords prevented tumbling, avoided unnecessary replacements, and eased the manipulation of a suction device.

Modified One-piece Supraorbital Approach for Orbital Tumors: Widely Preserved Orbital Roof in a Self-fitting Flap.

Objectives The one-piece supraorbital approach is a rational approach for the removal of orbital tumors. However, cutting the roof through the orbit is often difficult. We modified the technique to facilitate the osteotomy and improve the cosmetic effect. Design Three burr holes are made: the first, the MacCarty keyhole (burr hole 1), exposes the anterior cranial fossa and orbit; the second is placed above the supraorbital nerve (burr hole 2); and the third on the superior temporal line. Through burr hole 2, a small hole is created on the roof, 10 mm in depth. Next the roof is rongeured through burr hole 1 toward the preexisting small hole. Seamless osteotomies using a diamond-coated threadwire saw and the preexisting four holes are performed. Lastly the flap is removed. On closure, sutures are passed through holes in the cuts made with the threadwire saw, and tied. Results We applied our technique to address orbital tumors in two adult patients. The osteotomies in the roof were easy, and most parts of the roof were repositioned. Conclusions Our modification results in orbital osteotomies with greater preservation of the roof. Because the self-fitting flap does not require the use of fixation devices, the reconstruction is cosmetically satisfactory.

Intraoperative Ultrasonography during Drainage for Chronic Subdural Hematomas: A Technique to Release Isolated Deep-seated Hematomas--Technical Note.

After the drainage of chronic subdural hematomas (CSDHs), residual isolated deep-seated hematomas (IDHs) may recur. We introduce intraoperative ultrasonography to detect and remove such IDHs. Intraoperative ultrasonography is performed with fine transducers introduced via burr holes. Images obtained before dural opening show the CSDHs, hyper- and/or hypoechoic content, and mono- or multilayers. Images are also acquired after irrigation of the hematoma under the dura. Floating hyperechoic spots (cavitations) on the brain cortex created by irrigation confirm the release of all hematoma layers; areas without spots represent IDHs. Their overlying thin membranes are fenestrated with a dural hook for irrigation. Ultrasonographs were evaluated in 43 CSDHs (37 patients); 9 (21%) required IDH fenestration. On computed tomography scans, 17 were homogeneous-, 6 were laminar-, 16 were separated-, and 4 were trabecular type lesions. Of these, 2 (11.8%), 3 (50%), 4 (25%), and 0, respectively, manifested IDHs requiring fenestration. There were no technique-related complications. Patients subjected to IDH fenestration had lower recurrence rates (11.1% vs. 50%, p = 0.095) and required significantly less time for brain re-expansion (mean 3.78 ± 1.62 vs. 18 ± 5.54 weeks, p = 0.0009) than did 6 patients whose IDHs remained after 48 conventional irrigation and drainage procedures. Intraoperative ultrasonography in patients with CSDHs facilitates the safe release of hidden IDHs. It can be expected to reduce the risk of postoperative hematoma recurrence and to shorten the brain re-expansion time.

[Modified Technique for Primary Dural Closure in the Lateral Suboccipital Approach:Dural Moisturizing with Fibrin Glue Coating].

OBJECTIVE: When employing the lateral suboccipital approach, the thin dura shrinks due to the drying effect of illumination and air exposure, and dural substitutes are often needed for closure. We developed a new technique involving dural moisturizing with fibrin glue coating that facilitates primary dural closure. PATIENTS AND METHODS: We used this technique in 12 adults who underwent the lateral suboccipital approach for 5 hemifacial spasms, 3 trigeminal neuralgias, 2 cerebellopontine meningiomas, 1 vestibular schwannoma, and 1 vertebral artery aneurysm. Fibrin glue was sprayed on the outer surface before opening the dura, and additionally sprayed on the inner surface of the reflected dural flap after opening the dura. After the intradural procedures the dura was closed with the usual knotted sutures. RESULTS: Dural closure was performed 65-340 minutes (mean: 161.9 minutes) post-durotomy. This technique resulted in primary dural closure with a sufficient area of preserved dura in all but one patient. In this patient, the dura shrank due to coagulation of the dural attachment to the meningioma for which a small autologous substitute was required. There were no procedure-related complications such as cerebrospinal fluid leakage and meningitis. CONCLUSIONS: Dural moisturizing with fibrin glue coating is simple, protects the dura from drying and shrinkage, and facilitates primary dural closure in patients undergoing the lateral suboccipital approach.

Hanging foot switch for bipolar forceps: a device for surgeons operating in the standing position: technical note.

For surgeons operating in the standing position, the manipulation of foot switches involves shifting of the weight to the pivoting leg and the possible loss of contact between the switch and the foot. We solved this problem by changing the position of the switch that operates bipolar forceps. Our novel device is made of aluminum plates. The base plate features a foot strap and a height-adjustable overhang over the switch-operating foot. A commercially-available disc type foot switch is attached to the underside of the overhang in upside-down position, so the switch is operable with the toe. To turn on the switch, the toe is flexed dorsally to push the switch pedal, so the action is limited to the part distal to the metatarsophalangeal joints. Our switch was used in more than 100 consecutive microsurgeries performed by surgeons operating in the standing position. The switch manipulation required no shifting of the weight and was easier and quicker than manipulation of conventionally-placed switches. The surgeons were able to change the foot position freely with the modified switch, thereby avoiding loss of contact with the switch. The modified switch placement reduced physical fatigue in the lower extremities, annoyance related to the manipulation of conventionally-placed switches, and increased the comfort of surgeons operating in the standing position.

An operation in the park bench position complicated by massive tongue swelling.

This paper presents a case of massive tongue swelling as a complication after an operation in the park bench position. A 43-year-old male who had undergone a resection of a mass in the petrous bone of the clivus showed massive tongue swelling after the surgery in the left park bench position. A direct compression of the bite block caused the swelling of tongue. Tongue swelling may become fatal if it progresses to an airway obstruction; therefore the intraoperative and postoperative management is important.

Primary central nervous system lymphoma in acquired immune deficiency syndrome mimicking toxoplasmosis.

A 37-year-old man, a hepatitis B virus carrier due to mother-to-child transmission, had a medical examination in September 2008 in nearby hospitals due to anorexia and weight loss. He was transported to our hospital because computed tomography (CT) detected intracranial lesions, and he had a positive human immunodeficiency virus (HIV) antibody test. Head computed tomography (CT) revealed multiple hemorrhagic lesions and enhancement effect, suggesting a thin wall. Also, an enhancement effect was present in the ventricle walls and the subarachnoid space. No accumulation was found in the thallium-201 scintigraphy. The enhancement effect of the ventricle walls and the subarachnoid space disappeared after oral administration of pyrimethamine, sulfadiazine, and calcium folinate, contributing to the diagnosis of an abscess and meningitis due to toxoplasma. However, mass lesions did not reduce. A biopsy was performed on 30 October, and the pathological diagnosis was malignant lymphoma. He died from respiratory function deterioration on 8 November. Lymphoma cells were found in ventricle wall tissue and the subarachnoid space at the autopsy. Toxoplasmosis will typically occur as a brain lesion most commonly in acquired immune deficiency syndrome (AIDS), whereas malignant lymphoma commonly manifests as a brain neoplastic lesion. However, differentiating between images of these lesions is difficult, so diagnosis by early biopsy is recommended.

[Effect of Chai-ling-tang (Sairei-to) for methotrexate concentration degradation delay by methotrexate high-dose therapy].

When methotrexate (MTX) salvage chemotherapy is performed for primary brain malignant lymphoma, use of leucovonrin rescue must often be extended due to delays in the degradation of blood concentration. We examined whether delay in MTX blood concentration degradation could be prevented by chai-ling-tang (Sairei-to) which has diuretic action. In the five cases examined were MTX blood concentration 72 hours after MTX administration was more than 1 x 10(-7) M. A single dose of 3 g of chai-ling-tang was administered three times on the day the MTX salvage chemotherapy was subsequently performed. MTX blood concentration at 72 hours post MTX administration and subsequent chai-ling-tang administration was less than 1 x 10(-7) M in all five cases. In addition, urea nitrogen and creatinine levels in serum increased and creatinine clearance decreased following MTX administration, however these changes induced by MTX administration were reduced by chai-ling-tang administration. Chai-ling-tang was effective in preventing an MTX deferent delay in MTX high-dose therapy by improving renal blood flow.

Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction.

OBJECTIVE: The study compared the endoscopic anatomy of the transnasal and transoral approaches to the craniovertebral junction (CVJ). METHODS: Structures examined and compared with both the straight and angled telescopes in 10 cadaveric specimens included the pharyngeal walls and adjacent musculature, resected anterior arch of the axis and odontoid, cruciform, axial, and apical ligaments, clival and dural openings, and the intradural exposure. RESULTS: There is considerable overlap at the pharyngeal level in the structures that can be viewed by the transoral and transnasal routes. The transoral approach provides a wider corridor with less restricted manipulation of instruments than the transnasal approach, but the transnasal approach provides a better view of the clivus, upper part of the CVJ, and the structures posterior to the removed odontoid and anterior arch of C1. Combining the two approaches provides significantly better access to the midline anterior CVJ than either approach alone, allows the scopes to be advanced in one cavity and the surgical instruments in the other cavity, and reduces the need to split the palate, tongue, or mandible in order to reach the target area. The transnasal approach also allows access to the superior part of the occipital condyles, paraclival areas, and hypoglossal canals without removal of the condyles, but these structures can be exposed by the transoral route only after at least partial removal of the condyles. CONCLUSION: The endoscopic transoral and transnasal approaches to the CVJ should be viewed as complementary routes as opposed to strict alternatives.

Microsurgical and endoscopic anatomy of the supratentorial arachnoidal membranes and cisterns.

OBJECTIVE: A limitation of previous studies of the arachnoid cisterns and membranes is that the act of opening the sylvian and interhemispheric fissures and basal arachnoid often led to destruction of the cisternal compartments and their membranous walls. The goal of this study was to overcome this limitation by combining the surgical microscope and endoscope for the examination of the cisternal compartments and their membranous walls. METHODS: The supratentorial cisterns were examined in 22 cadaveric brains using both the operating microscope and the endoscope. RESULTS: There are 2 types of arachnoid membranes: outer and inner. The outer arachnoidal membrane surrounds the whole brain, and the inner membranes divide the subarachnoid space into cisterns. Twelve inner arachnoid membranes were identified in the supratentorial area: diencephalic, mesencephalic, medial carotid, intracarotid, intracrural, olfactory, medial and lateral lamina terminalis, and proximal, medial, intermediate, and lateral sylvian membranes. These membranes partially or completely separate the subarachnoid space into 9 supratentorial cisterns: sylvian, carotid, chiasmatic, lamina terminalis, pericallosal, crural, ambient, oculomotor, and interpeduncular. There is a confluent area between the carotid, interpeduncular, and crural cisterns, which frequently has no membrane separating these cisterns. CONCLUSION: Twelve inner arachnoid membranes and 9 cisterns were identified in this study.

Microsurgical and endoscopic anatomy of the vidian canal.

OBJECTIVE: The vidian canal, the conduit through the sphenoid bone for the vidian nerve and artery, has become an important landmark in surgical approaches to the cranial base. The objective of this study was to examine the anatomic features of the vidian canal, nerve, and artery, as well as the clinical implications of our findings. METHODS: Ten adult cadaveric specimens and 10 dried skulls provided 40 vidian canals for examination with x 3 to x 20 magnification and the endoscope. RESULTS: The paired vidian canals are located in the skull base along the line of fusion of the pterygoid process and body of the sphenoid bone. The canal opens anteriorly into the medial part of the pterygopalatine fossa and posteriorly at the upper part of the anterolateral edge of the foramen lacerum. The vidian nerve, when followed posteriorly, reaches the lateral surface of the anterior genu of the petrous carotid and the anteromedial part of the cavernous sinus where the nerve is continuous with the greater petrosal nerve. The bone surrounding the upper part of 12 of 20 vidian canals protruded into the floor of the sphenoid sinus and one canal had a bony dehiscence that exposed its contents under the sinus mucosa. Nine petrous carotid arteries (45%) gave rise to a vidian artery, all of which anastomosed with the vidian branch of the maxillary artery in the vidian canal or pterygopalatine fossa. The vidian canal can be exposed by opening the floor of the sphenoid sinus, the posterior wall of the maxillary, the posterior part of the lateral wall of the nasal cavity, and the medial part of the floor of the middle fossa. CONCLUSION: The vidian canal and nerve are important landmarks in accessing the anterior genu of the petrous carotid, anteromedial part of the cavernous sinus, and petrous apex.

Anatomic study of the infraorbital foramen for radiofrequency neurotomy of the infraorbital nerve.

OBJECTIVE: To examine the anatomy of the infraorbital canal and foramen and the angles at which a radiofrequency probe must be directed to enter the infraorbital foramen and canal, as a guide to performing radiofrequency ablation of the infraorbital nerve in patients with relative or absolute contraindications to lesions of the trigeminal ganglion or posterior root. METHODS: Eleven cadaveric skulls were studied. The infraorbital nerve, after passing through the infraorbital foramen, enters the infraorbital canal and groove in the floor of the orbit before reaching the foramen rotundum. Small probes were placed through the foramen into the infraorbital canal, and pictures were taken in the anteroposterior and sagittal planes. The pictures were analyzed using the ImageTool program (University of Texas Health Science Center, San Antonio, TX) to calculate the anteroposterior and sagittal angles of the probe. The distances of the foramen from the midline, lateral edge of the anterior nasal aperture, and inferior orbital rim were examined. RESULTS: A probe introduced through the cheek from below and medial to the foramen and directed upward and laterally at an angle of approximately 22 degrees in the coronal plane and 120 degrees in the sagittal plane toward a point approximately 26 mm from the midline and 8 mm below the inferior orbital rim will penetrate the infraorbital foramen for placement of the probe's tip in the infraorbital canal. CONCLUSION: The coordinates for placement of the radiofrequency probe through the infraorbital foramen and into the infraorbital canal are reviewed, along with a discussion of pitfalls in radiofrequency ablation of the nerve.

The front door to meckel's cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series.

OBJECTIVE: Tumors within Meckel's cave are challenging and often require complex approaches. In this report, an expanded endoscopic endonasal approach is reported as a substitute for or complement to other surgical options for the treatment of various tumors within this region. METHODS: A database of more than 900 patients who underwent the expanded endoscopic endonasal approach at the University of Pittsburgh Medical Center from 1998 to March of 2008 were reviewed. From these, only patients who had an endoscopic endonasal approach to Meckel's cave were considered. The technique uses the maxillary sinus and the pterygopalatine fossa as part of the working corridor. Infraorbital/V2 and the vidian neurovascular bundles are used as surgical landmarks. The quadrangular space is opened, which is bound by the internal carotid artery medially and inferiorly, V2 laterally, and the abducens nerve superiorly. This offers direct access to the anteroinferomedial segment of Meckel's cave, which can be extended through the petrous bone to reach the cerebellopontine angle. RESULTS: Forty patients underwent an endoscopic endonasal approach to Meckel's cave. The most frequent abnormalities encountered were adenoid cystic carcinoma, meningioma, and schwannomas. Meckel's cave and surrounding structures were accessed adequately in all patients. Five patients developed a new facial numbness in at least 1 segment of the trigeminal nerve, but the deficit was permanent in only 2. Two patients had a transient VIth cranial nerve palsy. Nine patients (30%) showed improvement of preoperative deficits on Cranial Nerves III to VI. CONCLUSION: In selected patients, the expanded endoscopic endonasal approach to the quadrangular space provides adequate exposure of Meckel's cave and its vicinity, with low morbidity.

Microsurgical anatomy and surgical exposure of the petrous segment of the internal carotid artery.

OBJECTIVE: The petrous segment of the internal carotid artery has been exposed in the transpetrosal, subtemporal, infratemporal, transnasal, transmaxillary, transfacial, and a variety of transcranial approaches. The objective of the current study was to examine anatomic features of the petrous carotid and its branches as related to the variety of approaches currently being used for its exposure. METHODS: Twenty middle fossae from adult cadaveric specimens were examined using magnification of x3 to x 40 after injection of the arteries and veins with colored silicone. RESULTS: The petrous carotid extends from the entrance into the carotid canal of the petrous part of the temporal bone to its termination at the level of the petrolingual ligament laterally and the lateral wall of the sphenoid sinus medially. The petrous carotid from caudal to rostral was divided into 5 segments: posterior vertical, posterior genu, horizontal, anterior genu, and anterior vertical. Fourteen (70%) of the 20 petrous carotids had branches. The branch that arose from the petrous carotid was either a vidian or periosteal artery or a common trunk that gave rise to both a vidian and 1 or more periosteal arteries. The most frequent branch was a periosteal artery. CONCLUSION: An understanding of the complex relationships of the petrous carotid provides the basis for surgically accessing any 1 or more of its 5 segments.

Postoperative reversible deterioration in a spinal dural arteriovenous fistula.

This 61-year-old man presented with weakness and sensory disturbance in the legs. There was a spinal dural arteriovenous fistula (SDAVF) fed by the left sixth intercostal artery with dorsal perimedullary drainage. Surgical division of the perimedullary drainage led to rapid neurological improvement. However, on the second postoperative day he experienced transient deterioration of second neuron function in the left upper lumbar segment resulting in motor weakness of the proximal leg muscles, absence of the patellar deep tendon reflex and thigh pain. No radiological findings explaining this deterioration were obtained. He was treated conservatively and all segmental symptoms and signs subsided by the fifth postoperative day. Although the precise mechanisms underlying the dramatic but often reversible deterioration after radical SDAVF treatment remain to be determined, we postulate that this was attributable to postoperative segmental venous hemodynamic changes based on the neurological changes.

[Superior sagittal sinus thrombosis caused by Crohn's disease and macrocytic anemia : a case report].

A 32-years-old man with a past history of hemorrhoids presenting with hemiparesis was diagnosed as having sagittal sinus thrombosis with hemorrtagic infarction. Laboratory data revealed macrocytic anemia (Hb 11.2 g/d/) with hypoproteinernia (5.5 g/d). After discharge the patient developed abdominal pain, diarrhea, edema in the leg and sustained anemia. Final diagnosis through colon fiberscope findings was Crohn's disease Macrocytic anemia seemed to be induced by Vit. B12 deficiency due to malabsorption. The mechanism and causal relationship between Crohn's disease and sinus thrombosis is discussed.