Efficacy and safety of the pterional keyhole approach for the treatment of anterior circulation aneurysms.

Keyhole surgery is partly replacing the standard pterional approach in patients undergoing surgery to treat aneurysms of the anterior circulation. We describe the pterional keyhole approach for the clipping of anterior circulation aneurysms and discuss the efficacy and safety of our keyhole craniotomy procedure. We treated 103 patients with 111 intracranial aneurysms by surgical clipping via the pterional keyhole approach and retrospectively compared the characteristics and clinical outcomes of the keyhole procedure and the standard pterional approach. We also compared the surgical results of the keyhole approach when the operator was an experienced neurosurgeon or a less experienced neurosurgeon guided by an experienced colleague. All keyhole operations were carried out successfully without enlargement of the craniotomy or a change to a different approach. The outcomes of the keyhole and the standard pterional approach in patients with subarachnoid hemorrhage were not significantly different. Favorable outcomes were obtained in patients with unruptured aneurysms treated by either experienced or less experienced surgeons. The pterional keyhole approach offers the same surgical possibilities as conventional pterional approaches for the treatment of anterior circulation aneurysms. It is safe and simple and yields favorable outcomes even if the operators are less experienced neurosurgeons. Careful patient selection and sufficient opening of the sylvian fissure are the key points for good outcomes and the prevention of intraoperative complications.

Familial moyamoya disease associated with Graves' disease in a mother and daughter. Two case reports.

A mother and daughter presented with a rare combination of moyamoya disease and Graves' disease. A 19-year-old woman experienced numbness in her right hand due to cerebral infarction during therapy for Graves' disease. Cerebral angiography demonstrated stenoses of the bilateral internal carotid arteries and net-like abnormal collateral vessels indicative of moyamoya disease. Her 52-year-old mother with a history of Graves' disease presented with left hemiparesis due to intracerebral hemorrhage; she recovered after hematoma evacuation. Postoperative angiography demonstrated stenoses of the bilateral internal carotid arteries and net-like abnormal collateral vessels indicative of moyamoya disease. Another otherwise healthy daughter manifested slight stenosis of the left internal carotid artery. After cerebral revascularization surgery the patients were able to return to their normal daily lives. These familial cases of moyamoya disease and Graves' disease indicate hereditary involvement in both diseases.

Cranial surgery without head shaving.

OBJECTIVE: Based on a series of 632 patients who underwent craniotomy without head shaving, we report the efficacy and safety of our simplified procedure and document the usefulness of the electrosurgical scalpel. METHODS: After brushing a chlorhexidine-alcohol solution onto the craniotomy site, the hair was parted from the incision line and fixed with adhesive paper drapes. In recent cases, electrosurgical scalpels were used for scalp- and subcutaneous dissection. At the end of surgery, the wound was closed in the usual manner, taking care that no hair was in the wound and the hair and wound were rinsed with clean water in the operating room. We did not apply disinfectant for postoperative wound care, rather, the hair was shampooed on the 2nd, 4th, and 6th postoperative day. RESULTS: Among 632 patients who underwent cranial surgery without head shaving, only 7 (1.1%) developed postoperative wound infections. None of the 34 patients who underwent craniotomy using the electrosurgical scalpel developed wound infections. CONCLUSIONS: Our simplified cranial surgery without head shaving does not increase the risk of wound infection. Because the use of the electrosurgical scalpel for skin and soft tissue dissection minimizes bleeding, the probability of wound infection appears to be reduced.

Macrophages that have phagocytosed particles are capable of differentiating into functional osteoclasts.

The aim of the current study was to determine whether human macrophages that have phagocytosed particles are capable of differentiating into osteoclastic bone-resorbing cells. Macrophages isolated from human peripheral blood were cultured with latex particles in the presence of receptor activator of nuclear factor (NF)-kappaB ligand (RANKL) and macrophage colony stimulating factor (M-CSF) on dentine slices and coverslips. After 24 h incubation, particles that had not yet been phagocytosed were removed by washing the slices. Histochemistry and immunohistochemistry was used to determine expression of macrophage and osteoclast markers and lacunae resorption, scanning electron microscopy, and transmission electron microscopy were used to examine cells with phagocytosed particles. Isolated macrophages on dentine slices were noted to contain a large number of particles inside, and no particles were identified outside of culture cells after washing. After 14 days of incubation, numerous tartrate-resistant acid phosphatase-positive multinucleated cells that contained particles in their cytoplasm, capable of extensive lacunae bone resorption, formed in these cultures. Our results clearly indicated that macrophages that have phagocytosed particles were still capable of differentiating into osteoclastic bone-resorbing cells. Macrophages that have phagocytosed wear particles in the pseudomembrane surrounding an implant not only produce cytokines but also may differentiate into functional osteoclasts, and influence bone resorption and loosening of a prosthesis.