Silent brain infarction after minimally invasive cardiac surgery with retrograde perfusion.

BACKGROUND AND AIM: There is no report on silent brain infarction (SBI) after minimally invasive cardiac surgery (MICS) with retrograde perfusion. Thus, the current study aimed to investigate the incidence of SBI after MICS using magnetic resonance imaging (MRI). METHODS: This study included 174 patients who underwent MICS with retrograde perfusion between July 2014 and July 2018. Preoperative computed tomography (CT) angiography was routinely performed and vascular pathology was evaluated for patient selection. Postoperative MRI was performed to investigate the occurrence of SBI. RESULTS: Out of the total 174 patients, 26 (14.9%) presented with SBI. A total of 61 SBI lesions were found in the 26 patients; of these, 34 (56%) SBI lesions were in the right hemisphere and 27 (44%) in the left hemisphere. SBIs were primarily observed in the posterior cerebral artery territory. Multivariate analysis revealed aortic stenosis to be the only risk factor of SBI. CONCLUSIONS: Retrograde perfusion via femoral cannulation may not increase the incidence of SBI in selected MICS patients based on preoperative CT findings.

Usefulness of thallium-201 SPECT in the evaluation of tumor natures in intracranial meningiomas.

INTRODUCTION: Although intracranial meningiomas are regarded as benign tumors, some of them behave clinically as malignant tumors. Past reports suggest that MIB 1 and vascular endothelial growth factor (VEGF) in postoperative tumor specimens correlate with the aggressive nature of tumors, but preoperative prediction of such a nature is more useful for therapeutic planning for the tumor. The purpose of this study was to assess the usefulness of preoperative thallium-201 chloride single-photon emission computed tomography (Tl SPECT) to evaluate biological behavior in intracranial meningiomas. METHODS: Tl SPECT was performed on 39 patients with intracranial meningioma and Tl uptake indices were calculated. The difference in the Tl uptake index between atypical meningiomas and other pathological types of meningioma was evaluated. Moreover, correlation of Tl uptake indices with the MIB1 labeling index was estimated. Tl uptake indices were also compared between VEGF strongly positive and weakly positive meningiomas. RESULTS: The delayed index of atypical meningioma was significantly higher than that of the other pathological types (p = 0.036). Significant correlation was found between the Tl uptake index in the delayed image and MIB1 labeling index (p < 0.0001, R (2) = 0.36). Moreover, VEGF strongly positive meningiomas exhibited a significantly higher Tl uptake index compared to VEGF weakly positive meningiomas in both the early image and the delayed image (p = 0.029, 0.023, respectively). CONCLUSIONS: Tl uptake index may be a possible preoperative surrogate marker of MIB1 and VEGF that is useful in detecting aggressive natures in intracranial meningiomas.

Correlation of MIB-1 staining index and (201)Tl-SPECT retention index in preoperative evaluation of malignancy of brain tumors.

MIB-1 staining provides a useful index of the malignancy of brain tumors. However, because of the difficulty of evaluating malignancy based on the preoperative imaging findings, we investigated the correlation between the (201)Tl-SPECT retention index (RI) and MIB-1 staining index (MIB-1 SI) to determine the usefulness of RI for preoperative evaluation of the malignancy of brain tumors. The subjects of this study were 47 patients who underwent tumor removal surgery at our hospital in 2006 and 2007. The tumors consisted of 16 intraaxial tumors (all gliomas: 9 glioblastomas, 2 anaplastic astrocytomas, 2 anaplastic oligoastrocytomas, 1 oligodendroglioma, and 2 ependymomas), 8 other malignant brain tumors, and 23 extraaxial tumors (10 meningiomas, 7 pituitary adenomas, and 6 schwannomas). The mean RI and mean MIB-1 SI of the intraaxial tumors were 0.628% and 32.0%, respectively, and after MIB-1 SI was converted to the natural logarithm (log MIB-1 SI), Pearson's coefficient for the correlation between them was significant (r = 0.752, P < 0.001). The mean RI and mean MIB-1 SI of the extraaxial tumors were 0.377% and 3.01%, respectively, and after MIB-1 SI was converted to log MIB-1 SI, Pearson's coefficient for the correlation between them was significant (r = 0.803, P < 0.001). Thus, the MIB-1 SI values of highly malignant intraaxial tumors was strongly correlated with their RI values, and the (201)Tl-SPECT RI values were useful as an index of malignancy. RI values may also be useful for evaluating apparently benign extraaxial tumors for possible malignancy.

Cerebral sinovenous thrombosis after closed head injury.

BACKGROUND: Cerebral sinovenous thrombosis (CSVT) after closed head injury is an uncommon but potentially serious complication. The aim of this study was to determine whether diffusion weighted imaging (DWI) provide predictive information regarding prognosis. METHODS: We retrospectively reviewed a series of 11 patients with CSVT after closed head injury. Each patient underwent computed tomography and magnetic resonance imaging within 24 hours of onset of symptoms, including DWI, magnetic resonance venography, and conventional sequences. Apparent diffusion coefficient (ADC) values were measured in seven regions of interest in 7 of 11 patients using DWI. Follow-up imaging and clinical outcome were assessed 6 months or later after initial presentation. RESULTS: The most affected sinus was the posterior portion of the superior sagittal sinus. There was a mean time interval of 4.1 days between subsequent venous stroke and the initial insult. Brain edema improved in 6 of 11 patients on follow-up imaging. Six of 11 patients recovered successfully, although high or mixed DWI intensity associated with moderately decreased ADC (0.53-0.57 x 10(-3) mm2/s). Two other patients with hematomas developed venous infarction, despite mixed DWI with heterogeneous ADC value (0.55-1.11 x 10(-3) mm2/s). The other three patients, with high DWI and strongly decreased ADC values (0.26-0.27 x 10(-3) mm2/s), developed severe brain atrophy after superior sagittal sinus thrombosis. CONCLUSIONS: The prospective cutoff point of ADC value may be higher in CSVT after head injury with traumatic hematoma. The territory of venous infarction was found to be larger in infants after treatment failure. In infants, CSVT can demonstrate initially cytotoxic brain edema, which is reversible with anticoagulation therapy.

Risk factors for postoperative systemic complications in elderly patients with brain tumors. Clinical article.

OBJECT: In elderly patients with brain tumors, the prevention of postoperative systemic complications is extremely important, and identification of the risk factors would be useful for planning therapy. The authors investigated ways to avoid postoperative complications by identifying risk factors. METHODS: The study population included 84 patients, 70 years of age or older, who underwent surgical brain tumor removal. The following independent factors were assessed by univariate and multivariate analyses: sex, age, preoperative underlying diseases and complications, histopathological findings, preoperative Karnofsky Performance Scale (KPS) score, preoperative whole blood hemoglobin (Hb) level, preoperative serum total protein (TP) level, operation time, intraoperative blood loss, change in Hb level (difference between pre- and postoperative values), and change in TP level (difference between pre- and postoperative values). The cutoff values for significant independent factors were also determined. RESULTS: Overall, 35 (41.7%) of the 84 patients had a total of 56 postoperative systemic complications. Univariate analysis identified the preoperative KPS score, intraoperative blood loss, change in Hb level, and change in TP level as risk factors for postoperative complications, and multivariate analysis extracted the following risk factors: the preoperative KPS score (p = 0.0450, OR 4.020), intraoperative blood loss (p = 0.0104, OR 6.571), and change in Hb levels (p = 0.0023, OR 9.301). The cutoff values were: KPS score < 80%, intraoperative blood loss >or= 350 ml, and change in Hb level >or= 2.0 g/dl. CONCLUSIONS: In elderly patients with brain tumors, low preoperative KPS score, high intraoperative blood loss, and a large difference between pre- and postoperative Hb levels are significant risk factors for postoperative systemic complications.

[Role of coil embolization and arterial injection in elderly subarachnoid hemorrhage patients: preliminary report].

With the recent advanced aging seen in society, the number of elderly patients with aneurismal subarachnoid hemorrhage (SAH) is increasing. We focused on current management of SAH in patients who were over 75 years old. From January 1st, 2004 to the end of June, 2007, we had treated 170 SAH patients including 39 who were over 75 years old. We divided the patients into three groups : Coiling Group, Clipping Group, and conservative treatment group (Conservative Group). We analyzed the Hunt-Kosnik grade (H-K), the rate of symptomatic vasospasm, the rate of shunting operation, the Glasgow Outcome Scale (GOS) at 30 days after the onset of SAH, bed rest periods and rate of shunt operation retrospectively. The Conservative Group included many H-K poor grade cases. Symptomatic vasospasm occurred significantly less in the Coiling Group. Rates of shunting operation did not have any significant change. GOS of the Coiling Group and Clipping Group had no significant change, due to the effectiveness of arterial injection for vasospasm. Patients in the Coiling Group started walking significantly earlier than members of other groups. Twenty-five percent of the Clipping Group needed a shunt operation but no patients of the Coiling Group needed a shunt. For elderly SAH patients, we recommend doing coil embolization or clipping and maintaining the patients' activity in daily life. Interventional treatment is necessary to improve results for elderly SAH patients.

Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report.

BACKGROUND: Vertebral artery dissecting aneurysm is now increasingly recognized as a cause of posterior circulation stroke in young adults. Here, we report a case of bilateral VADA with SAH, treated by bilateral coil occlusion using GDCs. CASE DESCRIPTION: A 64-year-old woman was admitted to our hospital with consciousness disturbance (Hunt and Kosnik: grade 4). Computed tomography showed diffuse SAH with a thick hematoma in the left C-P angle. Magnetic resonance angiography, 3D-CTA, and cerebral angiography revealed bilateral VADAs. First, the ruptured left VADA involving the PICA and a perforating branch was treated by occluding the lower half of the VADA and the proximal VA with GDCs in the acute stage. Thereafter, the residual VADA and contralateral VADA exhibited enlargement on cerebral angiography and MRA for 2 months after the initial surgery; thus, the right VADA was occluded by GDCs just proximal to the right PICA after confirming BTO tolerance. CONCLUSION: Staged bilateral VA coil occlusions combined with BTO may be one of the treatment strategies for bilateral VADA with SAH in cases presenting surgical difficulty due to anatomical factors or severe grade of SAH.

[Two cases of main trunk artery occlusion associated with multiple cerebral aneurysms].

We report 2 cases of multiple aneurysms (AN) associated with main trunk artery occlusion. CASE 1: A 52-year-old male was admitted to our hospital with dysarthria and weakness of the right side of the body. Computed tomography (CT) showed cerebral infarction in the left corona radiata. MR angiography and conventional angiography showed occlusion of the left middle cerebral artery (MCA) and saccular aneurysms (ANs) at the origin of the anterior communicating artery (A-com) and bifurcation of the right MCA. Subsequent 123I-IMP-single photon emission tomography (SPECT) revealed marked reduction of cerebral blood flow and disturbed reactivity to acetazolamide in the left cerebral hemisphere. Superficial temporal artery (STA)-MCA anastomosis was performed to improve cerebral blood flow and reduce hemodynamic stress for AN of the A-com and right MCA. At 5 months after the first operation, neck clipping was performed successfully for the non-ruptured A-com AN and right MCA AN. CASE 2: A 65-year-old male was admitted to our hospital. CT revealed subarachnoid hemorrhage (SAH), and 3D-computed tomographic angiography (CTA) and cerebral angiography showed basilar top AN, A-com AN and right MCA AN associated with right internal carotid artery occlusion. Right ACA and MCA territories were visualized from the A-com artery and posterior cerebral artery. STA-MCA anastomosis was performed to improve cerebral blood flow and reduce hemodynamic stress for ANs. In the same operation, successful neck clipping was performed for BA top AN and right MCA AN. In such cases as these, particularly in ischemic cases associated with main trunk artery occlusion, it was important to consider surgery for AN after STA-MCA anastomosis in anticipation of improved cerebral blood flow and reduce hemodynamic stress for AN.

[A case of rheumatoid factor-positive hypertrophic spinal pachymeningitis].

A 54-year-old female was admitted to our hospital with the complaint of progressive gait disturbance, starting with left abdominal pain 1 month previously. She developed acute paraparesis and stocking-anesthesia type sensory disturbance within a few days. MR imagings on admission, revealed an encircled subdural mass at the Th1-9 vertebral level, and her spinal cord was compressed at several places at the Th5-6. The subdural mass showed low intensity on T1 and T2 weighted image, and was homogenously enhanced after Gd-DTPA administration. Laboratory data revealed elevation of rheumatoid factor, CH50, C3, C4, and C-reactive protein. An emergency operation was performed by left hemilaminectomy from Th4 to Th6. The subdural mass was resected as far as possible, followed by dural plasty and initiation of steroid intraoperatively. Histopathologic examination of the resected lesion documented a hypertrophic pathymeningitis. Postoperatively, her neurological findings were improved immediately, followed by adjuvant therapy. Recurrence was not present on radiographic images 3 years after surgery. Laboratory data normalized within 4 months. Hypertrophic pachymeningitis is a rare case, and it is difficult to diagnose preoperatively. If there are subdural mass lesions at the multiple vertebral levels, we should suspect this disease. Treatment by immediate decompressive surgery and continuous adjuvant therapy was effective in our case.

[A case of high-aged idiopathic spinal cord herniation from dural defect].

Idiopathic spinal cord herniation was assumed to be a rare disease. However, the incidence of discovering this condition appears to have been increasing recently with advances in neuroradiological diagnosis using magnetic resonance imaging (MRI) and computed tomographic myelogram (CTM). We present herein an operated case of high-aged idiopathic spinal cord herniation. A 71-year-old female presented with spastic paresis of the right lower limb and sensory disturbance of pain and temperature below the level of the left Th4 dermatome, consistent with Brown-Séquard syndrome. MRI and CTM revealed right ventral displacement of the spinal cord and dilatation of the dorsal subarachnoid space at Th2/3. Laminectomy of Th1-3 was performed, herniated spinal cord was untethered and repositioned, and the dural defect was sealed with GORE-TEX dura substitute. Postoperative MRI revealed normal location of the spinal cord and neurological state improved slightly. The patient was discharged 1 month after the operation. Among many cases of spinal cord herniations, this is considered to be a rare case of idiopathic spinal cord herniation in an elderly patient.

[Case of clipping of a ruptured aneurysm of the posterior cerebral artery (P2) via the transchoroidal-fissure approach].

A 59-year-old female was found to be drawn in a swimming pool and transferred to our hospital. The patient was comatose on admission (Hunt & Kosnk: Grade IV). Computed tomography (CT) showed diffuse subarachnoid hemorrhage (SAH) with thick hematoma in the left ambient cistern. Conventional cerebral angiography and 3D-digital subtraction angiography revealed aneurysms (ANs) of the left posterior cerebral artery (P2), and bifurcation of the left internal carotid and posterior communicating arteries (IC-PC). Successful neck clipping was performed the same day through the temporal horn via the insula for ruptured P2 AN, and the non-ruptured IC-PC AN was also obliterated using a pterional approach. Postoperative course was uneventful except for initial disturbance of consciousness and aphasia. The patient was discharged with no neurological deficit 1 month after surgery. This approach may be preferable in cases involving high positioned PCA AN in the ambient cistern, particularly in the acute phase of severe SAH, as the brain is protected from the detrimental effects of strong temporal retraction and a wider working space is provided.

Delayed hemorrhage from completely obliterated arteriovenous malformation after gamma knife radiosurgery.

A 43-year-old female was treated with gamma knife radiosurgery (GKS) for right frontal arteriovenous malformation (AVM) manifesting as absence seizures. Complete nidus obliteration was confirmed on angiography 4 years after GKS. However, she experienced recurrence of her previous seizures and delayed hemorrhage occurred within the treated nidus, despite absence of abnormalities by repeated angiography 81 months after GKS. She was treated conservatively and discharged home without neurological deficits. The risk of hemorrhage from obliterated AVM is significantly reduced but not eliminated after radiosurgery. Recanalization of thrombus that is too small to detect by neuroimaging may result in delayed hemorrhage.

Two cases with long-term disease-free survival after resection and radiotherapy for solitary brain metastasis from breast cancer with extensive nodal metastases.

Two rare cases, each with a solitary brain metastasis from breast cancer with extensive nodal metastases as the first site of distant metastasis, were locally treated with surgery and irradiation. The outcome of the two treated cases indicated an excellent and non-recurrent post-therapeutic survival period of more than 3 and 8 years, respectively. In a 50-year-old woman (Case 1), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with doxorubicin and tegafur-uracil (UFT) and hormonal therapy with tamoxifen for left breast cancer. The brain metastasis was treated twice surgically followed by radiotherapy. One year and 6 months later, local recurrence of the brain metastasis appeared and was treated surgically again. No other treatment was done thereafter. Since then, no other distant or lymph node metastasis occurred, and to date her outcome has been non-eventful for 8 years and 5 months. In a 63-year-old woman (Case 2), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with cyclophosphamide, epirubicin and fluorouracil (CEF) for right breast cancer. The brain metastasis was treated locally with surgery and irradiation of 50 Gy. She thereafter received no further treatments. Since then neither distant metastases nor local recurrence have developed, and to date the post-treatment outcome has been uneventful for 37 months. Our findings suggest that patients who developed a solitary brain metastasis as the first site of distant metastasis from breast cancer have a chance of achieving long-term disease-free survival when treated with aggressive local therapy, even in the presence of extensive lymph node metastases at the primary surgery site for breast cancer.

[Currarino triad: a case report].

The authors report a case of Currarino triad with a combination of anterior sacral meningocele and mature teratoma, sacral body deformity, anorectal stenosis, and tethered cord. A newborn girl suffered from vomiting, abdominal distension and constipation. Initially, a diverting colostomy was performed at the age of one month. 7 months later, at the age of 8 months, we performed posterior sagittal anorectoplasty (PSARP): As a result, extirpation of teratoma, excision of meningocele, untethering of the spinal cord, and anorectoplasty were achieved simultaneously without complication. We suggest the use of an MRI to specify the presence of anosacral and spinal cord anomalies in patients with intractable constipation and we recommend combined pediatric and neurosurgical assessment and management for all cases of Currarino triad.

[A surgical case of tectal cavernous malformation presented by hydrocephalus].

We report a surgical case of tectal cavernous malformation presented by hydrocephalus. This 30-year-old man suffered from headache and nausea due to an obstructive hydrocephalus caused by a cavernous malformation in the tectum. Magnetic resonance (MR) images on admission showed a small lesion depicted as isointensity on the T1-weighted image, hyperintensity on the T2-weighted image, and accompanied with peripheral low-signal intensity rim, suggesting a tectal cavernous malformation. After admission, ventricular drainage was performed and the patient's symptoms improved immediately. He underwent a ventriculoperitoneal shunt ten days after the ventricular drainage. Postoperative CT scan showed an enlargement of the tectal mass with hemorrhagic change, but there was no deterioration in his neurological status. Cerebral angiography demonstrated no vascular stain or venous malformation. Microsurgical removal of the tectal mass was then performed via an occipital transtentorial approach. Histopathology proved a cavernous malformation and MR images at follow-up demonstrated total excision. Postoperatively, an upward gaze palsy appeared, but gradually improved within a month. Management strategy of brain stem cavernous malformation is controversial. Occasionally, brain stem hemorrhage may become critical. Therefore, we recommend aggressive surgical extirpation of symptomatic brain stem cavernous malformation, if it is accessible, if hemorrhage is present, and if the patient's condition permits it.