Middle meningeal artery embolization before craniotomy for infected organizing chronic subdural hematoma: A case report and review of the literature.

Background: Organizing chronic subdural hematoma (OSDH) is intractable and its radical treatment remains controversial. Middle meningeal artery embolization has emerged as an adjunctive treatment to craniotomy for OSDH. Case Description: The patient is an 86-year-old man. He had been taking warfarin for atrial fibrillation and was referred to the department for the treatment of bilateral chronic subdural hematoma (CSDH), which was found on head computed tomography after a fall. Bilateral burr hole drainages were performed, but his hematomas were organized, so the hematomas could not be drained sufficiently. The patient was discharged from the hospital without any neurological symptoms. Two months later, the patient presented with persistent fever and headache and had recurrent bilateral CSDHs. The hematoma on the right side was larger. Based on the initial intraoperative findings, OSDH was suspected, and craniotomy was performed on the right hematoma. Propionibacterium acnes were detected in the hematoma culture, and antimicrobial therapy was started postoperatively. Since the right hematoma recurred on the 7th postoperative day, bilateral middle meningeal artery (MMA) embolization with 20% n-butyl-2-cyanoacrylate was performed, followed by craniotomy for the left hematoma and drainage for the right recurrent hematoma. Antimicrobials were administered for 2 weeks after the last operations. Six months after the operations, both bilateral hematomas had almost disappeared. Conclusion: Craniotomy is effective for the treatment of infected OSDH, and MMA embolization is useful to reduce the risk of bleeding complications in the perioperative period, and may also reduce the recurrence of CSDH.

Brain metastasis from urachal carcinoma.

BACKGROUND: Urachal carcinoma (UC) is a rare variant of bladder carcinoma. Only seven cases of brain metastasis from UC have been reported in the literature thus far. CASE DESCRIPTION: A 77-year-old female was diagnosed with a brain tumor in her left cerebellum 2 years after she underwent surgery for a primary UC in the bladder. Surgery was performed via a midline suboccipital approach and the tumor was totally removed. The excised lesion was pathologically diagnosed as a metastasis and displayed typical pathological features of urachal adenocarcinoma with abundant mucin mixed with signet ring cells. A recurrence was observed at the site of tumor removal 6 months after surgery, and then, gamma knife radiotherapy was performed to the lesion. CONCLUSION: According to the five previously reported similar cases and our case, tumor removal is the treatment of choice. Routine whole brain radiotherapy is not the best treatment choice; however, local radiotherapy including conventional local radiotherapy or gamma knife radiotherapy could be implemented instead.

Intradural Combined Transpetrosal Approach for Primary Pontine Hemorrhage.

OBJECTIVE: The standard combined transpetrosal approach (CTPA) is fundamentally an epidural approach that has been quite successfully practiced for many decades. However, it has some disadvantages, such as cosmetic problems, difficulties with custom-tailored petrosectomy, and cerebrospinal fluid leakage, as it is a complicated epidural procedure. We describe here a case of primary pontine hemorrhage via intradural CTPA (iCTPA), which is a modified technique of CTPA and includes intradural anterior petrosectomy and partial posterior petrosectomy without mastoidectomy and skeletonization of the sigmoid sinus. METHODS: A 63-year-old woman with primary pontine hemorrhage underwent surgery via iCTPA to improve postoperative functional outcomes. After the temporal craniotomy without mastoidectomy and skeletonization of the sigmoid sinus, Kawase's triangle and Trautmann's triangle were identified from the intradural space. Resection of Kawase's triangle and partial resection of Trautmann's triangle were performed to approach the frontotemporal surface of the pons. The hematoma was irrigated and totally removed after corticotomy on the pons. RESULTS: The postoperative symptoms of the patient improved within 2 weeks without surgical complication. CONCLUSIONS: The intradural approach allows for custom-tailored petrosectomy and is more straightforward than the epidural route, although it can injure the vein of Labbé. Moreover, it can also reduce cosmetic problems and cerebrospinal fluid leakage. iCTPA could provide enough working space for the frontolateral surface of pontine and petroclival lesions without the need for mastoidectomy and skeletonization of the sigmoid sinus.

Neuroendoscopic hematoma removal with a small craniotomy for acute subdural hematoma.

The present study evaluated the safety and effectiveness of neuroendoscopic hematoma removal with a small craniotomy for the treatment of acute subdural hematoma (ASDH). Five patients (4 men and 1 woman) with ASDH underwent neuroendoscopic surgery with a small-size craniotomy between October 2016 and June 2018. The mean age was 87.4 years (range, 82-94). The eligibility criteria were as follows: 1) the presence of symptoms; 2) no moderate or massive brain contusion or edema; and 3) inability to use a large craniotomy because of poor general condition or absence of an anesthesiologist. After performing the small craniotomy, a 4-mm rigid endoscope was inserted and the hematoma was evacuated. Endoscopic surgery was performed under general or local anesthesia. The bleeding origin was a cortical artery in 2 cases, a bridging vein in 2 cases, and unknown in 1 case. The hematoma was completely removed without re-bleeding and the procedure was lifesaving in all cases. Three patients were discharged with independent gait following rehabilitation whereas 2 patients died due to causes unrelated to ASDH. Despite some surgical limitations, neuroendoscopic hematoma evacuation of ASDH is a safe and effective method that minimizes operative complications in some cases. Small craniotomy was sufficient for inserting and maneuvering ordinal neurosurgical instruments. This technique should be considered carefully before surgery in cases of ASDH.

Autologous bone dust technique for one burr hole surgery to prevent severe skin depression.

OBJECTIVE: One burr hole surgery is a common treatment modality for initial chronic subdural hematoma and stereotactic hematoma surgery, but severe skin depression is often a postoperative complication. We report the autologous bone dust technique, which uses autogenous bone dust generated during burr hole creation to prevent cosmetic deformity. PATIENTS AND METHODS: The autologous bone dust technique was performed for 51 sides on which burr hole surgery was conducted mainly for chronic subdural hematoma and stereotactic hematoma removal. As much bone dust as possible was collected during the burr hole creation and preserved until closure and the burr hole was plugged with the autologous bone dust. The skin depression after surgery was classified as "no or mild" or "severe" by palpating the postoperative scar. The postoperative osteogenesis was evaluated with a bone window or three-dimensional bone computed tomography (CT). RESULTS: The rate of no or mild skin depression was 86.3%. Osteogenesis in the bone window or on three-dimensional bone CT was observed in 88.6% of the cases with no or mild skin depression, whereas no osteogenesis was found in 11.4%. The rate of no or mild skin depression in patients aged greater than 82 years old (74.1%) was significantly lower than that in those aged less than 82 years old (100%). CONCLUSIONS: The autologous bone dust technique is effective in preventing skin depression after one burr hole surgery without using artificial materials.

Surgical Treatment for Primary Brainstem Hemorrhage to Improve Postoperative Functional Outcomes.

BACKGROUND: It remains controversial whether primary brainstem hemorrhage (PBH) should be managed conservatively or treated promptly by surgical evacuation of the hematoma. In the present study, we discuss 5 cases of PBH that were treated surgically and the ability of surgical management to improve postoperative functional outcomes. METHODS: The 4 patients with pontine and medullary hemorrhage underwent surgery via the lateral or midline suboccipital and trans-rhomboid fossa approach in the half-sitting position. The patient with a midbrain hemorrhage underwent surgery via the subtemporal approach in the supine lateral position. We analyzed the postoperative functional outcomes 1 week after surgery and the modified Rankin scale scores 6 months after discharge. RESULTS: Three patients with disturbance of consciousness experienced improvement in their level of consciousness. Four patients with hemiparesis improved in motor function. Oculomotor nerve function improved in 2 of 3 cases. Facial nerve function improved in 2 of 2 cases. Spontaneous respiration improved in 1 patient. The postoperative modified Rankin scale scores improved in all 5 cases. CONCLUSIONS: Because of the good results with these 5 patients with PBH, this surgical strategy could be encouraged with exclusion criteria for early initiation of rehabilitation strategies. We hope to increase our number of patients to accumulate further evidence.

Improvement of Respiratory Depression in a Patient with Primary Medullary Hemorrhage Following Removal of Hematoma in the Half-sitting Position.

Primary medullary hemorrhage is a rare event that may result in ataxic respiration. Although it remains controversial whether primary medullary hemorrhage should be managed conservatively or surgically, recent advancements in neuroimaging and microsurgical techniques have shown promise for improving outcomes and prognosis following surgery. The present report discusses the case of a 70-year-old woman admitted to our institution due to sudden-onset nausea and vomiting. The patient underwent surgical removal of a right medullary hematoma for the treatment of daytime respiratory depression and nocturnal apnea while in the half-sitting position. Following surgery, her spontaneous respiration improved, and she was discharged with independent gait. Despite the risk of venous air embolism, accumulating evidence suggests that the half-sitting position is suitable for brainstem surgery because gravity-assisted blood and irrigation drainage from the surgical field allows for cleaner dissection and reduces the need for bipolar coagulation.

Identification of hemodynamically compromised regions by means of cerebral blood volume mapping utilizing computed tomography perfusion imaging.

The aim of the study was to evaluate the potential role of computed tomography perfusion (CTP) imaging in identifying hemodynamically compromised regions in patients with occlusive cerebrovascular disease. Twelve patients diagnosed with either occlusion or severe stenosis of the internal carotid artery or the M1 portion of the middle cerebral artery underwent CTP imaging. The data was analyzed by an automated ROI-determining software. Patients were classified into two subgroups: an asymptomatic group consisting of three patients in whom perfusion pressure distal to the site of occlusion/stenosis (PPdis) could be maintained in spite of the arterial occlusion/stenosis, and a symptomatic group consisting of nine patients in whom PPdis could not be maintained enough to avoid watershed infarction. Four CTP-related parameters were independently compared between the two groups. Significant differences were determined using a two-sample t-test. When statistically significant differences were identified, cut-off points were calculated using ROC curves. Analysis revealed statistically significant differences between the asymptomatic and symptomatic subgroups only in the measure of relCBV (p=0.028). Higher relCBV values were observed in the symptomatic subgroup. ROC curve analysis revealed 1.059 to be the optimal relCBV cut-off value for distinguishing between the asymptomatic and symptomatic subgroups. The data revealed that, in patients whose PPdis is maintained, relCBV remains around 1.00. Conversely, in patients whose PPdis decreased, relCBV increased. From these findings, we conclude that elevation of relCBV as observed using CTP imaging accurately reflects the extent of compensatory vasodilatation involvement and can identify hemodynamically compromised regions.

Transient expression of laminin alpha1 chain in regenerating murine liver: restricted localization of laminin chains and nidogen-1.

Most interstitia between epithelial and endothelial cells contain basal laminae (BLs), as defined by electron microscopy. However, in liver, the sinusoidal interstitium (called space of Disse) between hepatocytes and sinusoidal endothelial cells (SECs) lacks BLs. Because laminins are major components of BLs throughout the body, whether laminins exist in sinusoids has been a controversial issue. Despite recent advances, the distribution and expression of laminin chains have not been well defined in mammalian liver. Here, using a panel of antibodies, we examined laminins in normal and regenerating mouse livers. Of alpha chains, alpha5 was widely observed in all BLs except for sinusoids, while the other alpha chains were variously expressed in Glisson's sheath and central veins. Laminin gamma1 was also distributed to all BLs except for sinusoids. Although the beta2 chain was observed in all BLs and sinusoids, the expression of beta1 chain was restricted to Glisson's sheath. Detailed analysis of regenerating liver revealed that alpha1 and gamma1 chains appeared in sinusoids and were produced by stellate cells. The staining of alpha1 and gamma1 chains reached its maximum intensity at 6 days after two-thirds partial hepatectomy (PHx). Moreover, in vitro studies showed that alpha1-containing laminin promoted spreading of sinusoidal endothelial cells (SECs) isolated from normal liver, but not other hepatic cells. In addition, SECs isolated from regenerating liver elongated pseudopodia on alpha1-containing laminin more so than did cells from normal liver. The transient expression of laminin alpha1 may promote formation of sinusoids after PHx.