A Case of Symptomatic Intraluminal Internal Carotid Artery Thrombus in a Patient with Essential Thrombocythemia Surgically Treated by CEA.

We report a patient with a symptomatic intraluminal internal carotid artery thrombus clinically revealed by cerebral infarction. In the preoperative evaluation, it was revealed that essential thrombocythemia existed in the background. Therefore, medical treatment with antithrombotic agents in conjunction with hydroxycarbamide for essential thrombocythemia was initiated, but the thrombus was not dissolved by three weeks. At this time, the patient underwent carotid endarterectomy, which removed the thrombus completely with its adjacent plaque without any perioperative stroke. The possibility of essential thrombocythemia may also be kept in mind when an increased platelet count is observed in patients with internal carotid artery thrombus. It is a reasonable option to precede medical treatment, including anticoagulant therapy, by setting the time limit for surgical intervention in such a disease state.

Endoscopic Occipital Transtentorial Approach for Supracerebellar Lesions.

The occipital transtentorial approach (OTA), which is often applied for superior cerebellar lesions, has an inevitable risk of homonymous hemianopsia due to the retraction of the occipital lobe. The endoscopic approach provides increased visibility of the surgical field due to the wide-angled panoramic view and is minimally invasive in approaching deep brain lesions compared to the conventional microscopic approach. However, little is known regarding endoscopic OTA for the removal of cerebellar lesions. We experienced a case of a hemangioblastoma in the paramedian superior surface of the cerebellum that was successfully treated with endoscopic OTA combined with gravity retraction while avoiding postoperative visual dysfunction. A 48-year-old woman was diagnosed with a hemangioblastoma in the superior surface of the cerebellum. She underwent tumor removal with endoscopic OTA combined with gravity retraction of the occipital lobe instead of using brain retractors. The narrower space was sufficient for surgical manipulation with a panoramic view obtained by endoscopy. The simultaneous observation of the lesion with both an endoscope and a microscope revealed the superiority of infratentorial visualization with an endoscope. Gross total removal was achieved with no postoperative complications, including visual dysfunction. Endoscopic OTA may reduce the risk of postoperative visual dysfunction because of its minimally invasive nature, which is enhanced when combined with gravity retraction. Additionally, the panoramic view of the endoscope allows favorable visualization of an infratentorial lesion, which is otherwise hidden partly by the tentorium. The use of endoscopy is compatible with OTA, and endoscopic OTA could be an option for superior cerebellar lesions for avoiding visual dysfunction.

Volumetric measurement of paranasal sinuses and its clinical significance in pituitary neuroendocrine tumors operated using an endoscopic endonasal approach.

Objective: Endoscopic endonasal surgery (EES) for deep intracranial lesions has gained popularity following recent developments in endoscopic technology. The operability of invasive pituitary neuroendocrine tumors (PitNETs) depends on the anatomy of the nasal cavity and paranasal sinus. This study aimed to establish a simple volume reconstruction algorithm of the nasal cavity and paranasal sinus. Additionally, this is the first study to demonstrate the relationship between the segmentation method and the clinical significance in patients with PitNET. Methods: Pre-and postoperative tumor volumes were analyzed in 106 patients with primary (new-onset) PitNETs (80 nonfunctioning and 26 functioning) who underwent EES. The efficiency and accuracy of the semiautomatic segmentation with manual adjustments (SSMA) method was compared with other established segmentation methods for volumetric analysis in the nasal cavity and paranasal sinuses. Correlations between the measured nasal cavity and paranasal sinus volumes and the extent of tumor removal were evaluated. Results: The SSMA method yielded accurate and time-saving results following the volumetric analyses of nasal cavity and paranasal sinuses with complex structures. Alternatively, the manual and semiautomatic segmentation methods proved time-consuming and inaccurate, respectively. The sphenoid sinus volume measured by SSMA was significantly correlated with the extent of tumor removal in patients with nonfunctioning Knosp grade 3 and 4 PitNET (r = 0.318; p = 0.015). Conclusion: The volume of sphenoid sinus potentially could predict the extent of resection due to better visualization of the tumor for PitNETs with CS invasion.

Neuroprotective Effects of Genome-Edited Human iPS Cell-Derived Neural Stem/Progenitor Cells on Traumatic Brain Injury.

Despite developing neurosurgical procedures, few treatment options have achieved functional recovery from traumatic brain injury (TBI). Neural stem/progenitor cells (NS/PCs) may produce a long-term effect on neurological recovery. Although induced pluripotent stem cells (iPSCs) can overcome ethical and practical issues of human embryonic or fetal-derived tissues in clinical applications, the tumorigenicity of iPSC-derived populations remains an obstacle to their safe use in regenerative medicine. We herein established a novel treatment strategy for TBI using iPSCs expressing the enzyme-prodrug gene yeast cytosine deaminase-uracil phosphoribosyl transferase (yCD-UPRT). NS/PCs derived from human iPSCs displayed stable and high transgene expression of yCD-UPRT following CRISPR/Cas9-mediated genome editing. In vivo bioluminescent imaging and histopathological analysis demonstrated that NS/PCs concentrated around the damaged cortex of the TBI mouse model. During the subacute phase, performances in both beam walking test and accelerating rotarod test were significantly improved in the treatment group transplanted with genome-edited iPSC-derived NS/PCs compared with the control group. The injury area visualized by extravasation of Evans blue was smaller in the treatment group compared with the control group, suggesting the prevention of secondary brain injury. During the chronic phase, cerebral atrophy and ventricle enlargement were significantly less evident in the treatment group. Furthermore, after 5-fluorocytosine (5-FC) administration, 5-fluorouracil converted from 5-FC selectively eliminated undifferentiated NS/PCs while preserving the adjacent neuronal structures. NS/PCs expressing yCD-UPRT can be applied for safe regenerative medicine without the concern for tumorigenesis.

A simple combined approach using anterior transpetrosal and retrosigmoid approach: A case report.

Background: A combined transpetrosal approach (CTP) is often used for large lesions in the posterior cranial fossa (PCF). Although CTP provides a wide surgical corridor, it has complex and time-consuming bony work of mastoidectomy and cosmetic issues. Here, we describe a simple combined surgical technique to approach the supratentorial region, anterolateral surface of the brainstem, petroclival region, and foramen magnum by drilling only the petrous apex with a combination of retrosigmoid approach (RA). Clinical presentation: A 27-year-old female was referred with extra-axial left cerebellopontine angle space-occupying epidermoid cyst extending to the prepontine cistern, anterior to the basilar artery, superior to the chiasma, and caudally to the foramen magnum. A one-stage surgical procedure using the anterior transpetrosal approach (ATP) and RA was performed after one-piece temporal-suboccipital craniotomy. These two approaches complemented each other well. Near-total removal was achieved. Conclusion: A one-stage surgical procedure using ATP and RA provides the wider viewing and better visualization of the PCF with minimal technical difficulty.

Prognostic significance of preoperative neutrophil-to-lymphocyte ratio in surgically resected schwannomas.

Objective: The goal of schwannoma resection is to control the tumor while preserving neurological function. Schwannomas have a variable postoperative growth pattern, therefore preoperative prediction of a schwannoma's growth pattern is favorable. This study aimed to examine the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR) and postoperative recurrence and retreatment in patients with schwannoma. Methods: We retrospectively examined 124 patients who underwent schwannoma resection in our institution. Associations between preoperative NLR, other patient and tumor characteristics, and tumor recurrence and retreatment were analyzed. Results: Median follow-up was 2569.5 days. Postoperative recurrence occurred in 37 patients. Recurrence that required retreatment occurred in 22. Treatment-free survival (TFS) was significantly shorter in patients with NLR ≥2.21 (P = 0.0010). Multivariate Cox proportional hazards regression showed that NLR and neurofibromatosis type 2 were independent predictors of retreatment (P = 0.0423 and 0.0043, respectively). TFS was significantly shorter in patients with NLR ≥2.21 in the following subgroups: sporadic schwannoma, primary schwannoma, schwannoma ≥30 mm in size, subtotal resection, vestibular schwannoma, and postoperative recurrence. Conclusions: Preoperative NLR ≥2.21 before surgery was significantly associated with retreatment after schwannoma resection. NLR may be a novel predictor of retreatment and assist surgeons in preoperative surgical decision making.

Odontogenic Pericarotid Abscess after Carotid Endarterectomy.

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis have specific risks. Therefore, the accurate evaluation and management of each risk factor are important, especially for patients who are at high risk for both CEA and CAS. We report the case of a 77-year-old man with right ICA stenosis that progressed despite optimal medical treatment. In addition, he had several risk factors for both CEA and CAS, including previous cervical radiation therapy, contralateral ICA occlusion, chronic kidney insufficiency, and severe aortic valve stenosis. CEA was performed with priority given to aortic valve stenosis without complications, and the patient was discharged 10 days postoperatively, without neurological sequelae. However, a pericarotid cervical abscess was detected by carotid echo, computed tomography (CT), and magnetic resonance imaging (MRI) 1 month after CEA that required surgical drainage. The infection was thought to be odontogenic because the pathogen was identified as normal oral bacterial flora, and a wound infection was not apparent. Teeth extraction and abscess drainage, in combination with antibiotic therapy, successfully cured the infection without additional complications. Odontogenic cervical abscesses after CEA can occur, especially if the patient is at risk of infection. Therefore, both preoperative and postoperative dental evaluation and management are recommended. As in this case, a cervical abscess can occur without wound infection, and the abscess diagnosis is sometimes difficult from wound inspection alone. Cervical echocardiogram and CT were useful for detecting fluid collection, whereas MRI was useful for qualitatively evaluating the lesion.

Prolonged Survival and Restored Useful Life by Early Induction of Intrathecal Chemotherapy in a Patient with Leptomeningeal Carcinomatosis from Ovarian Cancer.

Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of advanced cancer. Breast cancer, lung cancer, and melanoma are the three most common causes of LMC, whereas it is rare in ovarian cancer. Here, we report the case of a 59-year-old woman who was diagnosed with LMC from ovarian cancer and was successfully treated with intrathecal chemotherapy via Ommaya reservoir and radiation therapy. The patient had an amelioration of symptoms and prolonged survival. Though LMC from ovarian cancer is thought to be rare, it is not going to remain a rare entity because the incidence of LMC in general is thought to be increasing, which is also the case with ovarian cancer. According to 31 cases whose treatment course is reported in literature, despite the absence of an established treatment for LMC, intrathecal (IT) chemotherapy whose survival benefit has been suggested in past studies might also prolong survival in patients with LMC from ovarian cancer. IT chemotherapy via Ommaya reservoir may be preferred to the lumbar puncture route. The presentation of non-specific symptoms of LMC in patients may hinder its diagnosis; however, early diagnosis and treatment induction is the key for patients' prolonged survival and restored useful life.

Endoscopic Endonasal Reconstruction Using a Pedicled Middle Turbinate Flap for Spontaneous Cerebrospinal Fluid Rhinorrhea.

ABSTRACT: Although endoscopic skull-base reconstruction protocols to reduce cerebrospinal fluid (CSF) leakage are reported, the most effective management strategies have not been determined. We describe the successful repair of a spontaneous CSF leak using a vascularized middle turbinate flap (MTF) via an endonasal endoscopic approach and also discuss the effective reconstruction with other available pedicled flaps. An 11-year-old girl had a 5-month history of intermittent CSF rhinorrhea. Endoscopic endonasal skull base reconstruction was performed using the pedicled MTF technique, which sufficiently covered the unilateral cribriform plate and ethmoidal fovea including suspicious leakage site. Middle turbinate flaps may be good for repairing spontaneous CSF leaks, which commonly have small, low-flow CSF fistulas around a cribriform plate. As spontaneous CSF leaks are known to have a higher recurrence rate, MTF may be advantageous because more of the normal structures are retained.

Stepwise improvement in limb shaking achieved by staged angioplasty for severe carotid stenosis.

Cerebral hyperperfusion syndrome is a rare but severe complication of carotid artery stenting or carotid endarterectomy. Staged angioplasty is reportedly an effective strategy to avoid cerebral hyperperfusion syndrome. We encountered a case of internal carotid artery stenosis with a rare clinical presentation of limb shaking that was successfully improved by staged angioplasty. To our knowledge, there are no reported cases of limb shaking treated with staged angioplasty.A 76-year-old woman presented with continuous chorea in her left lower limb and shoulder. Medical examination revealed a tiny cerebral infarction in the right corona radiata and severe right internal carotid artery stenosis. Angiography showed near occlusion of the right internal carotid artery. Staged angioplasty was performed to avoid the risk of cerebral hyperperfusion syndrome. The first angioplasty resulted in an expanded diameter of 2.5 mm and was followed by definitive carotid artery stenting using a closed-cell stent 3.5 weeks later. Limb shaking improved in a stepwise manner along with an improvement in internal carotid artery stenosis and distal flow state with no signs of cerebral hyperperfusion syndrome. Patients with internal carotid artery stenosis or occlusion presenting with limb shaking have been suggested to have impaired cerebrovascular reactivity, which is also thought to be a risk factor for cerebral hyperperfusion syndrome. The stepwise improvement in limb shaking observed in this case supports the idea that the pathophysiology of limb shaking is related to cerebral haemodynamic impairment. Measures to prevent cerebral hyperperfusion syndrome, including staged angioplasty, should be actively considered in patients with limb shaking because the symptoms themselves suggest severe hypoperfusion.

Neuroendoscopic Technique for Recurrent Chronic Subdural Hematoma with Small Craniotomy.

AIM: To present a case series describing an endoscopic technique with a small craniotomy for recurrent chronic subdural hematoma (rCSDH) treatment. MATERIAL AND METHODS: A total of 17 patients with rCSDH underwent neuroendoscopic hematoma removal with a small craniotomy under local or general anesthesia. The skin incision of the initial surgery on the convexity of the skull was extended, and a burr hole was created for a small craniotomy. After the removal of the outer membrane and hematoma through a small craniotomy, the hematoma was evacuated with a suction tube using the rigid endoscope. The entire hematoma cavity circumference was irrigated, while septations and trabeculae in the hematoma were cut. After hematoma evacuation, the inner membrane was incised and removed to allow brain expansion. Postoperative follow-up was performed for at least 6 months. RESULTS: The regrowth rate of rCSDH after the neuroendoscopy was 5.9%. One patient with recurrent chronic subdural hematoma regrowth required neuroendoscopy again, but no re-recurrence was observed for the next 6 months. All cases were successfully managed using this technique and the postoperative seizure rate was 23.5%. CONCLUSION: This neuroendoscopic technique with a small craniotomy could be useful for recurrent chronic subdural hematoma because the hematoma and septations can be visualized and evacuated along the entire circumference of the hematoma cavity, and the inner membrane can be torn to allow brain expansion.

Fibrous Meningioma with Skull Invasion.

In patients with meningiomas, the presence of skull invasion is known to be a predictor of aggressive clinical behavior, which may negatively influence patient outcomes. In the present report, we discuss a case of fibrous meningioma with skull invasion. A 42-year-old woman was referred to our department presenting with hyperostosis in the right parietal bone. T1-weighted magnetic resonance imaging with gadolinium enhancement revealed prominent enhancement of the intraosseous lesion and dura mater. Following the removal of the tumor body and bone lesion, we performed immunohistochemical staining for osteopontin (OPN), matrix metalloproteinase- 2 (MMP2), and integrin ß-1 (CD29). The tumor body was immunoreactive for OPN and CD29, but not MMP2, whereas, the bone lesion was immunoreactive for all the three antigens. The present case suggests that OPN, MMP2, and CD29 play key regulatory roles in bone invasion.

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.