Navigation-assisted full-endoscopic spine surgery: a technical note.

BACKGROUND: Full-endoscopic spine surgery (FESS) necessitates the use of X-ray fluoroscopy for intraoperative guidance and orientation. However, the two-dimensional X-ray fluoroscopic images do not provide real-time guidance. The authors developed a new real-time three-dimensional (3D) navigation technique for FESS that entails the use of intraoperative cone beam computed tomography (CBCT) in a hybrid operating room (OR). METHODS: A total of 23 patients undergoing FESS using real-time 3D navigation system were enrolled. Preoperative and intraoperative CBCT data were registered in the navigation system. The 3D navigation was used to intraoperatively determine the trajectory and obtain position information. The feasibility and usefulness of the navigation system were retrospectively analyzed. RESULTS: Twenty patients had lumbar spine disease, whereas three patients had cervical spine disease. The 3D navigation was successfully used for intraoperative guidance and provided accurate information in all patients. X-ray fluoroscopy was not required in any of the patients. No complications associated with the use of 3D navigation system were encountered. CONCLUSIONS: The use of real-time 3D navigation system in the hybrid OR was found to be safe and effective in providing intraoperative guidance for FESS.

Optimum concentration of iodine contrast agent injection for best stent visualization using Neuroform Atlas stent during stent-assisted coil embolization: Case reviews based on in vitro experiments.

BACKGROUND: The present study aimed to evaluate the influence of contrast agent concentration (Conc) on the visibility of Neuroform Atlas in vitro and in clinical cases. METHODS: A plastic tube was filled with several Conc. in saline (experiment 1) and blood (experiment 2). Thereafter, the Neuroform Atlas was placed around the plastic tube in an acrylic shield case. In experiment 3, the Neuroform Atlas was placed in the internal carotid artery of the endo vascular evaluator endovascular training system with an injection of several Conc in saline. Five slices of the axial images obtained using the 3D-cone-beam computed tomography (3D-CBCT) with the digital subtraction angiography system were evaluated. A 1-cm2 circular center, which showed the contrast agent in saline or blood, was determined as the region of interest, and its pixels were evaluated. RESULTS: Radiation density (Rd) was directly proportional to the contrast agent in saline and blood (experiment 1: (Rd (pixel)) = 6.8495 × (concentration (%)) + 152.72 (R2 = 0.99), experiment 2: (Rd (pixel)) = 6.2485 × (concentration (%)) + 167.42 (R2 = 0.9966), experiment 3: (Rd (pixel)) = 10.287 × (concentration (%)) + 108.26 (R2 = 0.993)]. Rd calculated similarly in our cases (concentration varied from 5% to 8%) was between the range of "Rd of experiment 2" and "Rd of experiment 3." CONCLUSION: Based on our in vitro experiments, with 5-8% concentration, Neuroform Atlas stent deployment with complete neck coverage by the bulging stent and wall apposition was visualized on 3D-CBCT.

Supratentorial convexity schwannoma unrelated to cranial nerves: Case report and review of the literature.

BACKGROUND: Intracranial schwannoma not related to cranial nerves is rare entity, and difficult to be diagnosed preoperatively. Here, we experienced a case of convexity schwannoma mimicking convexity meningioma, and discuss about the characteristics of such cases based on the past published reports. CASE DESCRIPTION: A 48-year-old man presented with a sudden onset of seizures. Brain magnetic resonance image (MRI) revealed a small mass lesion in the peripheral aspect of the right parieto-frontal lobe. The mass was isointense on T1-weighted and hyperintense on T2-weighted MRI, with homogenous enhancement after contrast medium administration. After the feeder embolization on the previous day, removal of the tumor was performed. The tumor revealed a well-demarcated, firm, spherical tumor beyond, and beneath the dura and was relatively easy to be separated from the brain. Histologically, the tumor was observed to be in subarachnoid space extending to outer space of dura-mater, intimately attached to the pia mater. The histological diagnosis was schwannoma. CONCLUSION: In our case, MRI findings are similar to convexity meningioma; however, the pathological diagnosis was schwannoma. Cerebral convexity is an extremely rare location for schwannoma. We emphasize that schwannoma, not related to cranial nerves, may arise in the subdural convexity space.

Multiple cerebral syphilitic gummas mimicking brain tumor in a non-HIV-infected patient: A case report.

We present a unique case of symptomatic early neurosyphilis in a non-HIV-infected patient. A 47-year-old man with a history of diabetes mellitus presented with generalized seizures. He did not manifest any neurological deficits. At first, multiple brain tumors were suspected based on findings from magnetic resonance imaging of the brain. However, serological and cerebrospinal fluid tests for syphilis yielded positive results, and the masses were reduced using amoxicillin. Multiple cerebral syphilitic gummas were therefore diagnosed. High-dose penicillin therapy was initiated and syphilitic gummas disappeared after five months. Treponema pallidum could invade the central nervous system at an early phase, and sometimes may be difficult to distinguish from malignant brain tumor. If intracranial lesions are identified in a syphilis-infected patient, cerebral syphilitic gumma should be considered as a differential diagnosis.

Transdural Indocyanine Green Videography for Superficial Temporal Artery-to-Middle Cerebral Artery Bypass-Technical Note.

BACKGROUND: Neurosurgical application of indocyanine green (ICG) videography before performing a dural opening, known as transdural ICG videography, has been used during surgery of meningiomas associated with venous sinuses as well as cranial and spinal arteriovenous malformations. However, its use for a superficial temporal artery (STA)-to-middle cerebral artery (MCA) bypass has not been reported. METHODS: We performed a retrospective analysis of medical records of patients who underwent transdural ICG videography during STA-MCA bypass performed between January 2012 and March 2015. The primary outcome was visualization of recipient cortical arteries; secondary outcomes were surgical modifications and complications as well as any adverse events associated with transdural ICG videography. RESULTS: We analyzed 29 STA-MCA bypass procedures performed in 30 hemispheres with atherosclerotic steno-occlusive disease and found that the proper recipient was identified in 28 hemispheres. Subsequently modified procedures for those were a tailored dural incision and craniotomy correction. No complications associated with ICG administration were encountered; during the postoperative course, transient aphasia was noted in 1 case, chronic subdural hematoma was noted in 1 case, and subdural effusion was noted in 2 cases. CONCLUSIONS: Transdural ICG videography for atherosclerotic steno-occlusive disease facilitates modifications during STA-MCA bypass procedures. Recognition of the proper recipient cortical arteries before a dural incision allows the neurosurgeon to perform a tailored dural incision and extension of the bone window, although the contribution to surgical outcome has yet to be determined.

Endovascular Therapy for the Steal Phenomenon due to the Innominate Artery Severe Stenosis and Bilateral Internal Carotid Artery Severe Stenosis.

BACKGROUND: Symptomatic innominate artery stenosis presenting as hemodynamic bilateral cerebral ischemia is uncommon. We present a rare case of the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery that induced hemodynamic cerebral ischemia after ipsilateral axillary artery-bilateral femoral artery bypass and was treated with stent replacement of the innominate artery and right internal carotid artery. CASE REPORT: A 64-year-old woman who previously had undergone right axillary artery-bilateral femoral artery anastomosis for abdominal aorta high obstruction had been suffering from chronic dizziness and so visited our department. Findings of the examination included the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery, causing hemodynamic cerebral ischemia. She underwent stent replacement of the innominate artery and right carotid artery stenting via a right transbrachial approach. Her symptoms were relieved postoperatively. DISCUSSION: For the sake of improving the hemodynamic cerebral ischemia, we performed stent replacement for innominate artery stenosis and right carotid artery stenting. Endovascular treatment of subclavian and innominate artery disease is a safe procedure. In addition, for the protection of thromboembolic migration, we performed balloon protection of the external carotid artery and filter protection of the internal carotid artery. CONCLUSIONS: Stent replacement for these lesions can be performed safely with the right approach and protection methods, even when the only accessible route is the right brachial artery.

[A Case of a Pituitary Adenoma Diagnosed as Carney Complex Syndrome in an Older Female Patient].

Carney complex syndrome is an autosomal dominant familial tumor syndrome first described by Carney et al. in 1985. The diagnostic criteria include endocrine hyperactivity and spotty skin pigmentation. A 73-year-old woman with cerebral infarction was referred to our department because her brain magnetic resonance imaging(MRI)revealed a pituitary tumor. Her blood tests revealed elevated levels of growth hormone(GH), thyroid stimulating hormone(TSH), and insulin-like growth factor-1(IGF-1). We suspected the presence of a GH-secreting tumor and performed the operation. The pathological finding was a TSH-positive pituitary adenoma. Her cervical computed tomography(CT)revealed a thyroid tumor and the tumor removal was performed. The pathological diagnosis was papillary carcinoma. She had skin pigmentation bilaterally on her face, forearms, hands, and legs. We diagnosed this case as Carney complex syndrome based on these findings.

Effectiveness of Intracranial Percutaneous Transluminal Angioplasty or Stenting for Atherosclerotic Vertebrobasilar Artery Occlusion in the Acute Phase of Ischemic Stroke.

OBJECTIVE: Although short-term clinical outcomes after basilar artery stent placement have been reported previously, effectiveness of intracranial stenting for vertebrobasilar artery occlusion in the acute phase of ischemic stroke is unclear. METHODS: We clinically investigated 8 patients with intracranial percutaneous transluminal angioplasty (PTA) or stenting as our protocol for symptomatic atherosclerotic vertebrobasilar artery occlusion (age range, 54-80 years; mean age, 69 ± 11 years; 6 men and 2 women) who were admitted to our hospital between August 2013 and December 2015. RESULTS: Two patients underwent PTA of the vertebrobasilar artery 2-5 months before stent placement. The other 6 patients underwent intracranial stenting just after PTA. Within the first 30 days after vertebrobasilar artery stent placement, 2 ischemic stroke complications affected patients. Ischemic complications were significantly associated with prestent lesion lumen greater than 0.5 mm. The modified Rankin Scale score and clinical outcome were significantly associated with complications. Clinical outcomes correlate with ischemic complications and vertebrobasilar anatomy. CONCLUSIONS: Stent angioplasty may be a reasonably good treatment option for patients with technically favorable lesions, especially in vertebrobasilar atherosclerotic occlusion with medically or PTA only refractory symptoms. Despite a significant complication rate, most of our patients experienced good to excellent clinical outcomes and were free of vertebrobasilar ischemia at late midterm follow-up.

Coil Embolization for Ruptured Basilar Tip Aneurysm After Mechanical Thrombectomy for Acute Basilar Artery Occlusion.

BACKGROUND: There is no published report of ruptured cerebral aneurysm accompanied by target vessel occlusion. We present a case of ruptured basilar tip aneurysm with concomitant basilar artery (BA) occlusion. CASE DESCRIPTION: A 53-year-old man presented to our emergency room with the acute onset of disturbance. Plain head computed tomography showed diffuse subarachnoid hemorrhage. Computed tomography angiography and digital subtraction angiography showed a BA tip aneurysm with BA trunk occlusion. Endovascular treatment with mechanical thrombectomy using a stent retriever and coil embolization was performed. Clinical and radiologic results were good. The patient was discharged 30 days after onset (modified Rankin Scale score = 1). CONCLUSIONS: We were able to recanalize the BA trunk and perform coil embolization of the ruptured BA tip aneurysm. Our case is the first published report of a ruptured aneurysm with target large-vessel occlusion. Awareness of the issues raised in this case is required to determine the best treatment strategy, and preoperative consideration allows neurointerventionalists to avoid unpleasant surprises in the angiography suite.

Brain Metastasis of Pleural Mesothelioma after a Subarachnoid Hemorrhage.

Malignant pleural mesothelioma (MPM) is an uncommon, fatal neoplasm induced by asbestos exposure. Brain metastases from MPM are extremely rare, with most such cases diagnosed only at the time of autopsy. This report describes what we believe to be the first case of MPM metastasizing to the brain after a subarachnoid hemorrhage, as well as the subsequent surgical removal of the brain metastasis.

Relationship Between Clinical Features and T2-Weighted Magnetic Resonance Images in Symptomatic Rathke Cleft Cysts.

BACKGROUND: It is not known when surgery is appropriate for the treatment for incidental Rathke cleft cysts because knowledge of their natural history is lacking. In this study, we sought to determine whether symptomatic Rathke cleft cysts could be distinguished by their signal intensities in magnetic resonance (MR) images. We analyzed the relationship between these signal intensities and clinical manifestations of the cysts and their patterns of expansion. METHODS: MR signal intensities on T1-weighted (T1W) and T2-weighted (T2W) images for 52 cases were categorized into 3 types. Type 1 (20 cases) showed low signal intensities on T1W images and hyperintensity on T2W images. Type 2 (10 cases) showed hyperintensity on both T1W and T2W images. Type 3 (22 cases) showed hypointensity on T2W images. RESULTS: A significantly higher proportion of patients with type 1 signal intensities had large cysts compressing their third ventricle than patients with the other 2 types of signal intensities. Patients with type 1 signal intensities also frequently had visual disturbances. Anterior pituitary dysfunction was observed more often in patients with type 2 or 3 signal intensities than in patients with type 1 intensities. CONCLUSIONS: We conclude that Rathke cleft cysts that show an MR signal intensity similar to that of cerebrospinal fluid grow slowly and are frequently diagnosed as cysts associated with visual disturbance when they become large. It may be possible to predict the clinical progression of Rathke cleft cysts by assessing MR signal intensities.

Carotid artery stenosis is exacerbated in spontaneously obese model rats with diabetes.

AIM: Population studies have shown obesity and diabetes to be risk factors for atherosclerosis. We assessed changes in the common carotid arteries in rat models of obesity and diabetes without hypertension. METHODS: Twenty 30-week-old male spontaneously diabetic and obese model Otsuka Long-Evans Tokushima Fatty (OLETF) and 20 control Long-Evans Tokushima Otsuka (LETO) rats were used in the experiments. The animals were considered diabetic if the plasma glucose level peaked at >300 mg/dL and remained at >200 mg/dL for 120 minutes. Blood gas physiological parameters were continuously monitored under anesthesia, and the flow of the carotid artery was assessed with ultrasonography. All animals were sacrificed with an overdose of anesthesia at the end of the experiment. Sections of the middle portion of the internal carotid artery were cut and stained with hematoxylin and eosin to assess the overall morphology. RESULTS: All OLETF rats were diabetic, and all LETO rats were non-diabetic. The physiological parameters did not differ significantly between the control and model rats, whereas the carotid artery wall thickness (19.3 ± 3.2 vs. 6.1 ± 4.5 µm) was significantly different between the two groups. The blood flow velocity in the common carotid artery determined using ultrasonography and color Doppler sonography was significantly increased during systole in the model rats compared with that observed in the control rats (203 ± 20.3 vs. 55.3 ± 21.4 cm/sec). CONCLUSIONS: The OLETF rats were obese, and diabetes worsened the degree of carotid artery stenosis. These results indicate the possibility of new therapies for carotid artery stenosis in obese and diabetic patients.

[Intra-tumoral hemorrhage of a relapsed CNS diffuse large B-cell lymphoma: a case report].

We report a case of a relapsed central nervous system(CNS)lymphoma with an intra-tumoral hemorrhage. A 75-year-old man was transferred to our hospital because of sensory aphasia. He was diagnosed with a left temporoparietal brain tumor having intra-tumoral hemorrhage. Emergency resection of the tumor was performed. The pathological diagnosis was diffuse large B-cell lymphoma(DLBCL). Chemotherapy and radiation therapy were performed, and the patient achieved remission. Isolated relapsed CNS DLBCL accompanied by an intra-tumoral hemorrhage has been very rarely reported. Immunohistochemistry findings showed increased expression of vascular endothelial growth factor(VEGF)in the cytoplasm of tumor cells. This may correlate to the intra-tumoral hemorrhage, as indicated by previous reports.

Pituitary apoplexy caused by hemorrhage from pituitary metastatic melanoma: case report.

Melanoma metastases to the pituitary gland are extremely rare, with only a few reported cases. We report an unusual case of pituitary metastatic melanoma in which the patient presented with pituitary apoplexy. A 68-year-old man presented general fatigue and anorexia following sudden headache. Neurological examination disclosed bitemporal hemianopsia. Computed tomography (CT) scans revealed a suprasellar mass including intratumoral hematoma. Magnetic resonance (MR) images demonstrated a circumscribed mass lesion in the intra- and suprasellar regions, compressing the optic chiasm. Surgical exploration was performed through a transsphenoidal approach, and a mixture of tumor and necrotic tissue with old hematoma was obtained. The histological examination of the specimen revealed a partly necrotic, malignant tumor with focal melanotic pigmentation. Histopathologically, the diagnosis was consistent with pituitary apoplexy caused by hemorrhage from pituitary metastatic melanoma.

Neuroprotective effect of suppression of astrocytic activation by arundic acid on brain injuries in rats with acute subdural hematomas.

Acute subdural hematoma (ASDH) can cause massive ischemic cerebral blood flow (CBF) underneath the hematoma, but early surgical evacuation of the mass reduces mortality. The aim of this study was to evaluate whether arundic acid improves the secondary ischemic damage induced by ASDH. Our results confirmed that arundic acid decreases the expression of S100 protein produced by activated astrocytes around ischemic lesions due to cytotoxic edema after ASDH as well as reducing infarction volumes and numbers of apoptotic cells around the ischemic lesions. In this study, we also evaluate the relationship of brain edema and the expression of Aquaporin 4 (AQP4) in an ASDH model. The expression of AQP4 was decreased in the acute phase after ASDH. Cytotoxic edema, assumed to be the main cause of ASDH, could also cause ischemic lesions around the edema area. Arundic acid decreased the infarction volume and number of apoptotic cells via suppression of S100 protein expression in ischemic lesions without changing the expression of AQP4.

Early appearance of high grade glioma on magnetic resonance imaging.

The early appearance of high grade glioma on magnetic resonance (MR) imaging was retrospectively reviewed in the clinical records and MR images of 52 patients with intracerebral glioma treated in Osaka General Medical Center between 1997 and 2006. Three patients had no abnormal findings, and four patients had only hyperintense areas on T(2)-weighted imaging at initial MR examination. Five of the seven patients presented with generalized seizures. Six of the seven patients developed tumor progression within only 5 months. All patients underwent surgical tumor resection and the histological diagnoses were all high grade gliomas, glioblastomas in five, gliosarcoma in one, and anaplastic astrocytoma in one. Surveillance MR imaging should be performed at short intervals in adult patients presenting with seizures but with no or minimal abnormalities on initial MR imaging to identify progression of high grade glioma at the earliest opportunity.

[Massive epistaxis due to traumatic internal carotid artery pseudoaneurysm: a case report].

We present a case of traumatic pseudoaneurysm of the internal carotid artery (ICA) accompanied by skull base fracture, which was treated by endovascular trapping of the internal carotid artery. A 70-year-old woman met with a traffic accident and was admitted to our institution with epistaxis and accomapanied with shock. Angiography on day 2 showed carotidcavernous fistula. The patient had no eye symptom and was treated conservatively. A second angiography, two weeks aftrer the trauma, revealed development of a pseudoaneurysm on the C3-4 portion. We attempted balloon test occlusion (BTO) of the right internal carotid artery, and if torelated, the ICA may have been occluded. The day before BTO, she rebleed massively. Endovascular trapping of the ICA was performed. Although epistaxis was controlled completely, she suffered left hemiparesis due to an embolism during the procedure. Epistaxis from a traumatic aneurysm of the internal carotid artery may be fatal and emergency occlusion is proposed.

Basilar trunk aneurysms with associated fenestration treated by using Guglielmi detachable coils: two cases reports.

Basilar trunk saccular aneurysms associated with fenestration are infrequent. Surgical treatment of a basilar trunk aneurysm is difficult because of its anatomic environment and complicated surgical exposure. We experienced two cases of basilar fenestration aneurysm, and the patients were treated using Guglielmi detachable coils. The usefulness of 3-dimensional digital subtraction angiography and efficacy of endovascular treatment for basilar trunk aneurysms with associated fenestration is discussed in this article, and the relevant literature is reviewed.