安達 一英

BACKGROUND AND PURPOSE: Tumor embolization through the meningohypophyseal trunk and inferolateral trunk is known to be effective in skull-based tumors; however, microcatheter cannulation into these arteries is difficult, and the number of cases that can be safely embolized is limited. In this study, we present a novel embolization procedure for meningohypophyseal trunk and inferolateral trunk using the distal balloon protection technique and detail its clinical efficacy and complication risks. We developed this procedure to allow safe embolization in patients who cannot be adequately cannulated with microcatheters into these arteries. MATERIALS AND METHODS: Patients who underwent meningohypophyseal trunk or inferolateral trunk embolization using the distal balloon protection technique for skull-based tumors at our institution between 2010 and 2023 were included. In this procedure, the ICA was temporarily occluded with a balloon at the ophthalmic artery bifurcation, the microcatheter was guided to the meningohypophyseal trunk or inferolateral trunk vicinity, and embolic particles were injected into the arteries. The balloon was deflated after the embolic particles, that had refluxed into the ICA, were aspirated. RESULTS: A total of 25 meningohypophyseal trunks and inferolateral trunks were embolized during 21 surgeries. Of these 25 arteries, only nine (36.0%) were successfully cannulated with microcatheters. Nevertheless, effective embolization was achieved in all cases. Permanent complications occurred in only one case (4.8%), in which the central retinal artery was occluded during inferolateral trunk embolization, resulting in a visual field defect. No permanent complications resulting from the embolic cerebral infarction were observed. Of 16 cases that underwent MRI within a week after embolization, however, 11 (68.8%) demonstrated embolic cerebral infarctions. CONCLUSIONS: In patients with skull-based tumors with meningohypophyseal trunk or inferolateal trunk feeders that cannot be catheterized directly, embolization using the distal balloon protection technique for tumor supply can be considered as a salvage technique. ABBREVIATIONS: MHT = meningohypophyseal trunk; ILT = inferolateral trunk; GC = guide catheter; AC = aspiration catheter; FR = flow reverse.

BACKGROUND: In >70% of patients with hemifacial spasm (HFS), the offending artery is either the anterior inferior cerebellar artery (AICA) or posterior inferior cerebellar artery (PICA), without a tortuous vertebrobasilar artery (VBA). We hypothesized that anchoring perforators around the root exit zone (REZ) of the AICA or PICA might induce vascular deviation and compression. We investigated the occurrence of these perforators from the AICA or PICA and the extent of VBA tortuosity to reveal the pathology of vascular compression. METHODS: This retrospective review included 110 patients after excluding those with vertebral artery (VA) compression alone. The occurrence of perforators was determined according to operative findings within 5 mm of the REZ, and VBA tortuosity was evaluated using MATLAB. We analyzed the association between perforators, VBA tortuosity, and the surgical implications. RESULTS: The occurrence of perforators from the offending AICA or PICA around the REZ was significantly higher in the group without VA compression (Group A) than in the group with VA compression (Group B). VBA tortuosity was significantly lower in Group A. VBA tortuosity was inversely correlated with the presence of AICA or PICA perforators in all 110 patients. Operative results were similar between the groups, although patients with low VBA tortuosity tended to require interposition in decompression procedures. CONCLUSIONS: Anchoring perforators around the REZ play a crucial role in vascular compression for patients with less tortuous VBAs. Moreover, surgeons should be prepared to deal with multiple perforators in a more complicated surgery in cases of less tortuous VBA.

Ischemia-induced postoperative scalp necrosis in the superficial temporal artery (STA) region is known to occur after STA-middle cerebral artery anastomoses. However, no reports have evaluated the risk of postoperative scalp necrosis in the occipital artery (OA) region. This study examined the surgical procedures that pose a risk for postoperative scalp necrosis in the OA region following posterior cranial fossa surgery. Patients who underwent initial posterior fossa craniotomy at our institution from 2015 to 2022 were included. Clinical information was collected using medical records. Regarding surgical procedures, we evaluated the incision design and whether a supramuscular scalp flap was prepared. The supramuscular scalp flap was defined as a scalp flap dissected from the sternocleidomastoid and/or splenius capitis muscles. A total of 392 patients were included. Postoperative scalp necrosis occurred in 19 patients (4.8%). There were 296 patients with supramuscular scalp flaps, and supramuscular scalp flaps prepared in all 19 patients with postoperative necrosis. Comparing incision designs among patients with supramuscular scalp flap, a hockey stick-shaped scalp incision caused postoperative necrosis in 14 of 73 patients (19.1%), and the odds of postoperative scalp necrosis were higher with the hockey stick shape than with the retro-auricular C shape (adjusted odds ratio: 12.2, 95% confidence interval: 3.86-38.3, p = 0.00002). In all the cases, ischemia was considered to be the cause of postoperative necrosis. The incidence of postoperative necrosis is particularly high when a hockey stick-shaped scalp incision is combined with a supramuscular scalp flap.

The efficacy of spinal drain (SD) placement for cerebrospinal fluid (CSF) leakage prevention after the anterior transpetrosal approach (ATPA) remains unclear. Thus, we aimed to assess whether postoperative SD placement improved postoperative CSF leakage after a skull base reconstruction procedure using a small abdominal fat and pericranial flap and clarify whether bed rest with postoperative SD placement increased the length of hospital stay. This retrospective cohort study included 48 patients who underwent primary surgery using ATPA between August 2011 and February 2022. All cases underwent SD placement preoperatively. First, we evaluated the necessity of SD placement for CSF leakage prevention by comparing the postoperative routine continuous SD placement period to a period in which the SD was removed immediately after surgery. Second, the effects of different SD placement durations were evaluated to understand the adverse effects of SD placement requiring bed rest. No patient with or without postoperative continuous SD placement developed CSF leakage. The median postoperative time to first ambulation was 3 days shorter (P < 0.05), and the length of hospital stay was 7 days shorter (P < 0.05) for patients who underwent SD removal immediately after surgery (2 and 12 days, respectively) than for those who underwent SD removal on postoperative day 1 (5 and 19 days, respectively). This skull base reconstruction technique was effective in preventing CSF leakage in patients undergoing ATPA, and postoperative SD placement was not necessary. Removing the SD immediately after surgery can lead to earlier postoperative ambulation and shorter hospital stay by reducing medical complications and improving functional capacity.

OBJECTIVE: Although a qualitative diagnosis of plaque causing carotid stenosis has been attempted with carotid computed tomography angiography (CaCTA), no clear findings have been reported. We examined the correlation between the plaque CT values and plaque images obtained by magnetic resonance imaging to derive a qualitative diagnosis of the plaque using CaCTA. METHODS: Preoperative CaCTA images acquired from patients stented for carotid stenosis were retrospectively analyzed with respect to magnetization-prepared rapid acquisition with gradient echo and time-of-flight magnetic resonance angiography data. Carotid plaques in the stenosed region were quantified in terms of CT density and the plaque/muscle ratio (magnetization-prepared rapid acquisition with gradient echo), and correlations between these 2 features were determined. Plaques were classified as stable or unstable based on the plaque/muscle ratio, with the smallest plaque/muscle ratio observed among plaques positive for intraplaque hemorrhage set as the cutoff value (1.76). RESULTS: A total of 165 patients (179 plaques) were included. Perioperative complications included minor stroke (n = 3), major stroke (n = 1, fatal), and hyperperfusion (n = 2). The correlation between CT density and the plaque/muscle ratio was nonlinear (P = 0.0139) and negative (P < 0.0001). The cutoff point (1.76) corresponded to a CT density of 83 HU, supporting this value as a standard reference for plaque stability. CONCLUSIONS: Computed tomography density exhibits a nonlinear (P = 0.0139) and highly negative correlation (P < 0.0001) with the plaque/muscle ratio. Our results demonstrate that plaque characteristics can be meaningfully diagnosed based on CaCTA image data.

Evacuation of middle fossa trigeminal schwannomas (TS) warrants a subtemporal interdural approach through the lateral wall of the cavernous sinus (CS). The dura comprises the dura propria, which follows the trigeminal nerve and develops into the epineurium, and periosteal layer. The interdural approach involves peeling off the dura propria and exposing the epineural sheath. The venous route around the CS is often obstructed due to TS progression. The interdural approach based on venous route preservation remains to be discussed. The laterocavernous sinus (LCS) is formed in these layers, draining to either the medial or lateral route. In the lateral route, the LCS drains to the pterygoid plexus via the middle cranial fossa foramen. Exposure of the interdural space disturbs the lateral route's venous flow. We describe an operative strategy for venous route preservation in TS via the LCS lateral route. The venous route can be preserved by peeling off the dura propria from the posterior end of the foramen ovale short of the venous drainage route to the pterygoid plexus epidurally and then cutting from the middle cranial fossa dura posterior to the venous route subdurally to the exposed interdural space. This technique helps in avoiding postoperative venous complications.

BACKGROUND: Diploic veins may act as collateral venous pathways in cases of meningioma with venous sinus invasion. Diploic vein blood flow should be preoperatively evaluated to consider preserving the veins. In this study, we evaluated the use of time-resolved whole-head computed tomography angiography (4D-CTA)-which is less patient-intensive than digital subtraction angiography (DSA)-for assessing diploic vein blood flow and the positional relationship between typical craniotomy approaches and diploic veins. METHODS: We retrospectively examined 231 patients who underwent surgery for intracranial meningioma. We performed contrast-enhanced magnetic resonance imaging (MRI) to evaluate diploic vein pathways and compared the visualization rates of diploic vein blood flow assessed using 4D-CTA and DSA. Subsequently, we evaluated the rates of the diploic veins transected during craniotomy by comparing the pre- and postoperative contrast-enhanced MRI. RESULTS: The diagnostic performance of 4D-CTA was assessed in 45 patients. Of the 320 diploic veins identified in these patients, blood flow in 70 (21.9%) diploic veins was identified by 4D-CTA and DSA, and both results were consistent. To assess the transection rates of the diploic veins, 150 patients were included. A trend towards a high transection rate of the diploic vein in the basal interhemispheric, frontotemporal, orbitozygomatic, combined transpetrosal, and convexity craniotomy approaches was observed. CONCLUSIONS: In patients with meningiomas, both 4D-CTA and DSA are useful in evaluating diploic vein blood flow. In meningiomas with venous sinus invasion, determining the extent of craniotomy after understanding the pathways and blood flow of diploic veins is recommended.

Meningiomas are a common pathology in the central nervous system requiring complete surgical resection. However, in cases of recurrence and post-irradiation, accurate identification of tumor remnants and a dural tail under bright light remains challenging. We aimed to perform real-time intraoperative visualization of the meningioma and dural tail using a delayed-window indocyanine green (ICG) technique with microscopy. Fifteen patients with intracranial meningioma received 0.5 mg/kg ICG a few hours before observation during the surgery. We used near-infrared (NIR) fluorescence to identify the tumor location. NIR fluorescence could visualize meningiomas in 12 out of 15 cases. Near-infrared visualization during the surgery ranged from 1 to 4 h after the administration of ICG. The mean signal-to-background ratio (SBR) of the intracranial meningioma in delayed-window ICG (DWIG) was 3.3 ± 2.6. The ratio of gadolinium-enhanced T1 tumor signal to the brain (T1BR) (2.5 ± 0.9) was significantly correlated with the tumor SBR (p = 0.016). K^trans, indicating blood–brain barrier permeability, was significantly correlated with tumor SBR (p &amp;lt; 0.0001) and T1BR (p = 0.013) on dynamic contrast-enhanced magnetic resonance imaging (MRI). DWIG demonstrated a sensitivity of 94%, specificity of 38%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 75% for meningiomas. This is the first pilot study in which DWIG fluorescence-guided surgery was used to visualize meningioma and dural tail intraoperatively with microscopy. DWIG is comparable with second-window ICG in terms of mean SBR. Gadolinium-enhanced T1 tumor signal may predict NIR fluorescence of the intracranial meningioma. Blood–brain barrier permeability as shown by K^trans on dynamic contrast-enhanced MRI can contribute to gadolinium enhancement on MRI and to ICG retention and tumor fluorescence by NIR.

Schwannomas of the trochlear nerve are relatively rare, and most patients present with preoperative diplopia because of trochlear nerve palsy. We describe the case of a 61-year-old male patient with a trochlear nerve schwannoma and no pre- and postoperative diplopia, despite his trochlear nerve being cut during the operation. We aimed to investigate the frequency of postoperative diplopia associated with intraoperative trochlear nerve disturbance by reviewing previous case reports, wherein postoperative diplopia did not occur after the trochlear nerve was cut intraoperatively. We recorded the frequency of diplopia because of intraoperative trochlear nerve disturbance, such as the trochlear nerve being cut, in cases without pre- and postoperative diplopia. We searched the PubMed, Medline, and Google Scholar databases for works published from 1976 to 2020 and followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We reviewed 36 publications and found 92 cases of trochlear nerve schwannoma. Surgical resection was performed for 43 patients, of whom 40 were kept under observation and 9 were treated with radiation therapy. Of the 43 cases, 9 without preoperative diplopia underwent gross total resection. We analyzed ten cases (including ours) without preoperative diplopia to check for postoperative diplopia. In total, four cases, including ours, did not display postoperative diplopia despite the trochlear nerve being cut. This may be attributed to the preoperatively acquired motor and sensory fusion in the patient's vision because of tumor progression. Our findings may benefit neurosurgeons who treat patients with schwannomas and help them predict patients' outcomes.

Digital subtraction angiography (DSA) assesses the necessity of preoperative embolization in meningioma cases but entails complication risks. Previous studies evaluating meningiomas' angiographic vascularity using perfusion-weighted imaging (PWI) have performed subjective visual assessments, not managing to assess the need for preoperative embolization. We objectively assessed the angiographic stain of meningiomas and examined the usefulness of two parameters of dynamic susceptibility contrast (DSC)-PWI, normalized cerebral blood volume (nCBV) and cerebral blood flow (nCBF), in predicting vascularity and the necessity of preoperative embolization. We retrospectively examined 52 patients who underwent surgery for primary meningioma and preoperative DSA and DSC-PWI. We calculated the normalized luminance (nLum) of the tumor stain in DSA. In 29 meningioma cases with a single feeding artery, we determined the DSC-PWI parameter that correlated with meningioma angiographic vascularity and predicted the necessity of preoperative embolization. We also compared vascularity between meningiomas with single and multiple feeding arteries and between convexity and skull-base meningiomas. nCBF (cut off: 3.66, P = 0.03, area under the curve [AUC] = 0.80) alone could predict the necessity of preoperative embolization and was more significantly correlated with the nLum than nCBV (P = 0.08, AUC = 0.73). Vascularity did not differ between meningiomas with single and multiple feeding arteries; skull-base meningiomas were more vascularized than convexity meningiomas (P = 0.0027). Our objective, quantitative assessments revealed nCBF as the most suitable parameter for evaluating meningioma vascularity. Tumor vascularity assessment using nCBF values and CBF images may aid predicting the necessity of preoperative DSA.

BACKGROUND: Although it is known that diploic veins frequently communicate with the dural venous sinuses, the role of diploic veins in patients with venous sinus invasion from meningiomas remains unknown. METHODS: We retrospectively examined the medical records of 159 patients who underwent their first craniotomies for intracranial meningiomas. Contrast-enhanced magnetic resonance imaging was used to evaluate diploic vein routes, and digital subtraction angiography (DSA) was used to evaluate diploic vein blood flow. When high blood flow was visualized concurrently with the venous sinuses, the veins were classified as of the "early type." Diploic vein routes were classified into five routes. RESULTS: DSA was performed in 110 patients, with 14 showing superior sagittal sinus (SSS) invasion (SSS group) and 23 showing non-SSS venous sinus invasion (non-SSS group). The proportion of early type diploic veins was significantly higher in the SSS group (27.1%) than in other patients (patients without venous sinus invasion, 2.1%; non-SSS, 4.3%) (p < 0.01). In patients not in the SSS group, diploic veins were sacrificed during craniotomy in 76 patients, including four patients with veins of the early type. No patients demonstrated new neurological deficits postoperatively. In the SSS group, diploic veins were sacrificed in all patients, and early type diploic veins were cut in five patients. Two of these five patients showed postoperative neurological deficits. CONCLUSIONS: In the SSS group, diploic veins may function as collateral venous pathways, and attention is recommended for their interruption. In patients without SSS invasion, diploic veins, even of the early type, can be sacrificed.

Pial arteriovenous fistulas (AVFs) are rare vascular lesions; their exact pathophysiology is largely unknown. Pial AVFs have been reported to develop within capillary malformation-arteriovenous malformation (CM-AVM); however, only a few cases have been reported. Variants in the RASA1 gene have been reported as a cause of CM-AVM. We report the case of an adult patient with pial AVF, who carried variants in the RASA1 and COL4A2 genes. The patient in the current report was likely to have been affected by CM-AVM and the RASA1 variant seemed to be the primary factor in the pathogenesis of pial AVF. However, COL4A2 may have also contributed to the development of pial AVF because the COL4A2 and RASA1 variants have a common pathophysiology, wherein the patient develops lesions due to collagen type IV deficiency.

<sec><title>Background</title>Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel. </sec><sec><title>Methods</title>Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU &lt;240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint. </sec><sec><title>Results</title>The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group. </sec><sec><title>Conclusion</title>The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications. </sec>

Abstract Background: Although high dose-methotrexate therapy has been performed for primary central nervous system malignant lymphoma (PCNSL), R-MPV (rituximab, methotrexate (MTX), procarbazine and vincristine) therapy is currently the first line therapy for (PCNSL) in our hospital. This study examines the results of R-MPV therapy comparing with past treatment. Method/Subjects: Thirty-seven patients treated at our hospital from 2009 to 2020 were included. Overall survival time, progression free survival time, and toxicities were evaluated. Results: The average age of patients was 65.7 years. Patients included 21 males and 16 females. Thirty-six patients were diagnosed DLBCL by resected brain tumor tissues, and one was diagnosed DLBCL by vitreous biopsy. As initial treatment, rituximab±HD-MTX therapy (R±MTX group) was performed in 20 cases, HD-MTX therapy plus radiation (R±MTX+RT group) was performed in 12 cases, and RMPV therapy was performed in 5 cases (R-MPV group). Median OS of all cases was 69 months and median PFS was 38 months. Median OS was 69 months in R±MTX group and could not be calculated in R±MTX+RT, and R-MPV groups. Median PFS was 16 months and 56 months in R±MTX group and R±MTX+RT, respectively, and could not be calculated in the R-MPV group. Although the R-MPV group had a short follow-up period, the results were considered to be comparable to those of the R±MTX+RT group. On the other hand, grade 3/4 adverse events occurred in 50%, 25%, and 100%, respectively. Conclusion: R-MPV therapy may delay the timing of radiation and reduce the amount of radiation. On the other hand, the frequency of adverse events is high, and more strict management of treatment is required.

BACKGROUND: The extent of resection has been reported to be associated with overall survival in gliomas. The use of 5-aminolevulinic acid (5-ALA) has been recognized to increase the extent of tumor resection. OBJECTIVE: To evaluate what factors affect the intraoperative fluorescence after administration of 5-ALA in gliomas. METHODS: Correlation of intraoperative fluorescence and several clinical, radiographic, molecular biologic, and histopathologic characters was retrospectively evaluated in 104 patients (53 males and 51 females; mean age 54.2 yr) with gliomas at our institution. To clarify the mechanisms that mutant isocitrate dehydrogenase (IDH) affect the intraoperative fluorescence, in Vitro experiments using genetically engineered glioma cells harboring mutant IDH1 were performed. RESULTS: Intraoperative fluorescence was observed in 82 patients (78.8%). In addition to age, magnetic resonance imaging enhancement, World Health Organization grades, and MIB-1 index, the status of IDH was revealed to be correlated with intraoperative fluorescence. In Vitro assay revealed that mutant IDH indirectly reduced the amount of exogenous 5-ALA-derived protoporphyrinogen IX in glioma cells by increasing activity of ferrochelatase and heme oxygenase 1. CONCLUSION: Mutant IDH1/2-induced metabolite changes of exogenous 5-ALA were suggested to contribute to the lesser intraoperative fluorescence in gliomas with mutant IDH1/2 than in those without.

The trigeminal nerve is often displaced by petroclival meningioma (PCM) compression, making it difficult to locate during PCM surgery. This study investigated whether the deviated position of the trigeminal nerve could be easily predicted using the main tumor feeding artery. We retrospectively examined 32 patients who underwent surgery for primary PCM. The deviation of the trigeminal nerve was classified as either Type 1 (displacement toward the back of the cerebellar tentorium), Type 2 (toward the back of the superior petrosal sinus), Type 3 (toward the back of the petrous apex dura), Type 4 (toward the inferior aspect of the tumor), or Type 5 (toward the surface of the brain stem). The main feeding artery was determined by preoperative angiography. The trigeminal nerve was classified as Type 2 in 60% of cases where the proximal tentorial artery (TA) was the main feeding vessel. The nerve was Type 5 where the distal portion of the TA was the main feeding vessel (60% of the cases). The nerves were Type 3 and Type 4 where the proximal inferior lateral trunk (ILT) (60%) and distal ILT (75%), respectively, were the main feeding vessels. In 66.7% of the cases where the dorsal meningeal artery was the main feeding vessel, the nerve was Type 3. Type 1 classification applied in all cases where the ascending pharyngeal artery was the main feeding artery. The main feeding artery can be used to predict trigeminal nerve transposition during PCM surgery.

Superficial siderosis is a rare disease resulting from the deposited hemosiderin owing to repeated subarachnoid hemorrhage. It has been reported that hemosiderin deposits on the brain surface and brain parenchyma causes nerve disorder, resulting in progressive and irreversible hearing loss, cerebellar ataxia and pyramidal disorder. The brain tumor is one of the cause of superficial siderosis. A 16-year-old female present a nearby hospital with complaints of absence seizure. A magnetic resonance imaging (MRI) revealed a heterogeneously enhanced mass at the right temporal lobe. Susceptibility-weighted imaging revealed diffuse and extensive superficial siderosis on the brain surface. The tumor was gross totally removed and diagnosed as glioneuronal tumor. The patient had been well, although susceptibility-weighted imaging performed one year after the surgery showed superficial siderosis remained. Early diagnosis and prevention of bleeding sources are recommended to prevent symptom progression associated with superficial siderosis. Susceptibility-weighted imaging is considered useful for early detection of superficial siderosis.

Abstract BACKGROUND The pharmacokinetics of temozolomide in patients with severe renal impairments (creatinine clearance less than 36 mL/min/m2) or in hemodialysis patients has not been investigated. Temozolomide and its metabolic products are mainly excreted in urine, as retention of these in the body may result in increased adverse events in hemodialysis patients harboring a high-grade glioma. METHODS Eight hemodialysis patients with high-grade gliomas from seven institutions were included in the study. Patient characteristics, treatment schedule, clinical course, pathological/molecular findings, and adverse events were evaluated. RESULTS The histopathological diagnoses were Isocitrate dehydrogenase (IDH) wild-type glioblastoma in four cases, Not other specified (NOS) glioblastoma in two cases and IDH-mutant anaplastic astrocytoma in one case. Five of the seven patients completed radiotherapy (48–60 Gy) with concomitant temozolomide (75 mg/m2) followed by adjuvant 5-day temozolomide (150 mg/m2) every 28 days. During the entire course of treatment with temozolomide, severe (Common Terminology Criteria for Adverse Events (CTCAE) more than grade 3) lymphocytopenia occurred in 57%(41.7–61%: non hemodialysis patients data, the same as below), neutropenia in 0%(1–15.4%) and thrombocytopenia in 14%(0–16.7%) of the patients. Generally, the frequency and degree of myelosuppression do not increase in hemodialysis patients with high-grade gliomas. Two of the seven (28.5%) patients died of infectious disease despite having no direct correlation to myelosuppression that is similar rate of 21.9% of the death results from infection in hemodialysis patients in Japan. CONCLUSIONS The high-grade glioma patients under study on hemodialysis did not require decreasing doses of Temozolomide during concomitant radiochemotherapy and maintenance therapy. However, careful clinical and hematological observation is required to avoid critical hematotoxicity and infection.

Background The revascularization of carotid stenosis can increase ipsilateral cerebral blood flow (CBF). Occasionally, elevated CBF is also evident on the contralateral side, but this phenomenon is poorly understood. Objective To analyze retrospectively the relationship between a contralateral CBF increase and several clinical and radiologic features. Materials and methods We retrospectively analyzed 40 patients with unilateral cervical carotid stenosis treated by carotid artery stenting (CAS). Using 123 I-iodamphetamine single-photon emission computed tomography (SPECT) we compared pre-and postoperative hemispheric CBF on both sides. We investigated the influence of the following five factors on the increase of the contralateral hemispheric CBF: stenosis grade (≥50% or &lt 50%, according to the North American Symptomatic Carotid Endarterectomy Trial criteria) age the presence of anterior and posterior communicating arteries postoperative hyperperfusion on the stenotic side and the presence of cerebral steal phenomenon during preoperative acetazolamide-challenge SPECT. Results Following unilateral CAS, mean hemispheric CBF increased significantly on both sides: from 33.4±5.6 (mean ± SD) to 38.7±7.8 mL/min on the operated side (paired t test, p&lt 0.001) and f35.4±5.4 to 39.2±7.2 mL/min on the contralateral side (p&lt 0.001). In a general linear model, stenosis grade (≥50%) alone was significantly correlated with the increase of the CBF on the contralateral side (p=0.03). Conclusion Revascularization by CAS for unilateral carotid stenosis can increase hemispheric CBF on both sides. Increase of the contralateral CBF is correlated with stenosis grade (≥50%).

Background Although a subdural fluid collection frequently is observed, diagnostic methods that differentiate between the subdural collection caused by external hydrocephalus and that caused by subdural hygroma have not been established. Here, we report a case of external hydrocephalus caused by Gliadel-induced eosinophilic meningitis that has been previously reported in only 1 case and can be diagnosed by time-spatial labeling inversion pulse magnetic resonance imaging (time-SLIP MRI). Case Description A tumor located in the left temporal was detected incidentally in an 81-year-old man by examination of a head injury. The tumor was surgically resected and diagnosed as a high-grade glioma during the surgery Gliadel wafers subsequently were implanted. Three weeks after the resection, the patient showed disturbed consciousness, and computed tomography revealed a subdural fluid collection. The out-flow of cerebrospinal through the resection cavity was detected by time-SLIP MRI. Cerebrospinal tests indicated high white blood cell counts and high protein levels, with more than 90% of the white blood cell count comprising eosinophils. Therefore, we suspected that the subdural fluid collection was caused by external hydrocephalus because of Gliadel-induced eosinophilic meningitis. We surgically removed the Gliadel wafers and subsequently performed a surgery to insert a ventriculoperitoneal shunt. Histologic examination indicated eosinophilic accumulation around the Gliadel wafers. The patient's symptoms improved after the insertion of a ventriculoperitoneal shunt. Conclusions In the present case, time-SLIP MRI was a useful and noninvasive method for diagnosing external hydrocephalus which was caused by eosinophilic meningitis because of Gliadel-induced eosinophilic meningitis.

Brainstem glioma is impossible to resect completely, and patients with this type of glioma show a poor prognosis. Therefore, a more effective adjuvant therapy is required to prolong survival. Bevacizumab is an endothelial growth factor monoclonal antibody with strong anti-vascular effects, which may suppress tumor progression. We performed a retrospective study of data from 6 patients with brainstem glioma showing malignant features who were treated with bevacizumab. Tumor-associated lesions, as evaluated by T2 weighted or fluid-attenuated inversion-recovery magnetic resonance imaging, were reduced in all patients, although the timing of the start of bevacizumab administration and pretreatment were not uniform. Clinical symptoms improved in 4 patients and progression was inhibited in 2 patients. The Karnofsky performance status improved from 56.7 to 71.7 on average. The median reduction ratio of tumor-associated lesions was 76.3%, but tumor suppression did not last in any of the cases. Furthermore, 5 patients died of tumor progression, and 1 patient died of a complication of necrotizing colitis. The median progression-free survival after bevacizumab administration was 7 months. The median overall survival after diagnosis was 16.5 months. Bevacizumab might be a potential therapeutic option for progressive brainstem gliomas with malignant features.

Background: The anterior transpetrosal (ATP) approach is the most appropriate approach for petroclival meningiomas (PCMs), which are typically located from the dorsum sellae to the upper border of the internal auditory meatus (IAM). Although neurosurgeons can resect over this area if the tumor is detached from the dura, tumors within the indication area for PCMs are not appropriate for the ATP approach, because it can be difficult to evaluate whether the tumor is attached to or only touching the dura. In this study, we investigated the tumor extension area based on an evaluation of the feeding artery to achieve a more accurate assessment of the dural attachment area. Methods: Using various angiography techniques, we studied 51 feeding arteries from 24 patients who had undergone surgical treatment of primary petroapex meningiomas and PCMs via the ATP approach. We measured the lower and posterior extension distances, the extension rate of the cavernous sinus and Meckel's cave, and the midline extension rate of the tumors. Results: The ascending pharyngeal artery (AphA) was the predominant feeding artery for tumors with lower extension. We determined that tumors extending over the lower border of IAM in cases in which the feeding artery was not the AphA can be resected using the ATP approach. Conclusions: This study shows an association between the predominant feeding artery and tumor extension area and demonstrates that an evaluation of the dural attachment area based on the feeding artery can aid selection of the appropriate surgical approach.

The evaluation of venous drainage patterns prior to surgery for skull base meningioma is important owing to their deep location and the vulnerability of surrounding vascular structures. In recent years, the microsurgical skull base approach has matured as a surgical technique, making it an important option for reducing complications related to skull base meningioma surgery. In addition, knowledge of the venous anatomy can prevent venous drainage route disturbance and potentially life-threatening complications. Hence, this topic review aimed to provide an overview of normal venous anatomy as it relates to the microsurgical skull base approach, discuss known changes in venous drainage routes that are associated with the progression of skull base meningioma and the selection of an appropriate operative approach with the highest likelihood of preserving venous drainage structures.

Background and objective In patients with hypertensive intracerebral hemorrhage (HICH), intravenous nicardipine is primarily used to lower blood pressure (BP). However, there are few studies investigating the role of oral antihypertensives administered after intravenous nicardipine to prevent BP from rising. Angiotensin II receptor blockers (ARBs) may be beneficial in HICH patients not only as antihypertensives but also by lowering plasma catecholamine levels. A prospective randomized study was conducted between January 2015 and March 2016 to comparatively evaluate the efficacy of two ARBs (azilsartan vs. candesartan) following intravenous nicardipine administration on BP reduction. Patients and methods Thirty conscious HICH patients presenting within 6 h of symptom onset were enrolled (15 in each arm). After administering intravenous nicardipine for 24-48 h, the patients were randomized either to the azilsartan (20 mg) arm or to the candesartan (8 mg) arm. Frequency of hematoma expansion, 30-day modified Rankin scale, and temporal profiles of systolic blood pressure (SBP) and plasma norepinephrine/aldosterone were compared. Results Substantial hematoma expansion occurred in two (13%) azilsartan patients and in one (7%) candesartan patient (P=1.00). SBPs were maintained at lower than 140 +/- 20 mmHg in both arms. Neither SBPs nor plasma norepinephrine/aldosterone levels differed significantly. All 30 patients had 30-day modified Rankin scale scores of 1-2. Conclusion Administration of ARBs following intravenous nicardipine effectively prevented BP from rising in HICH patients. However, whether BP should be strictly managed after 24 h of symptom onset should be addressed in future studies focusing not only on neurologic but also on cardiovascular and renal functions of HICH patients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

Recent progress in neuro-oncology has validated the significance of genetic diagnosis in gliomas. We previously investigated IDH1/2 and TP53 mutations via Sanger sequencing for adult supratentorial gliomas and reported that PCR-based sequence analysis classified gliomas into three genetic subgroups that have a strong association with patient prognosis: IDH mutant gliomas without TP53 mutations, IDH and TP53 mutant gliomas, and IDH wild-type gliomas. Furthermore, this analysis had a strong association with patient prognosis. To predict genetic subgroups prior to initial surgery, we retrospectively investigated preoperative radiological data using CT and MRI, including MR spectroscopy (MRS), and evaluated positive 5-aminolevulinic acid (5-ALA) fluorescence as an intraoperative factor. We subsequently compared these factors to differentiate each genetic subgroup. Multiple factors such as age at diagnosis, tumor location, gadolinium enhancement, 5-ALA fluorescence, and several tumor metabolites according to MRS, such as myo-inositol (myo-inositol/total choline) or lipid20, were statistically significant factors for differentiating IDH mutant and wild-type, suggesting that these two subtypes have totally distinct characteristics. In contrast, only calcification, laterality, and lipid13 (lipid13/total Choline) were statistically significant parameters for differentiating TP53 wild-type and mutant in IDH mutant gliomas. In this study, we detected several pre- and intraoperative factors that enabled us to predict genetic subgroups for adult supratentorial gliomas and clarified that lipid13 quantified by MRS is the key tumor metabolite that differentiates TP53 wild-type and mutant in IDH mutant gliomas. These results suggested that each genetic subtype in gliomas selects the distinct lipid synthesis pathways in the process of tumorigenesis.

The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery stenosis are not established. In this retrospective study, we evaluated outcomes for CAS performed within 2 weeks of acute ischemic stroke for 16 patients treated between December 2009 and February 2014. Cases of internal carotid artery occlusion, internal carotid dissection, or intracranial major arterial trunk occlusion were excluded. Five patients were treated with CAS during the hyperacute phase (within 24 h of stroke onset), three in the advanced phase (within 24 h of stroke-in-evolution after admission), and eight in the acute phase (24 h to 2 weeks after onset). We evaluated modified Rankin scale (mRS) scores 90 days after CAS. For patients treated during the hyperacute phase without intravenous tissue-type plasminogen activator (IV-tPA), two had mRS scores of 2 and one had a score of 3. Two patients treated in the hyperacute phase with IV-tPA had scores of 5: one with symptomatic intracerebral hemorrhage and the other with acute brain swelling. For patients treated in the advanced phase, mRS scores were 1, 3, and 5; the patient with 5 had contralateral cerebral infarction. All patients treated in the acute phase had scores of 2 or lower. Patients treated with IV-tPA in advanced or acute phases had no severe post-CAS complications. CAS was effective and safe for treating ischemic stroke within 2 weeks of onset. However, IV-tPA treatment may be a risk factor for CAS treatment during the hyperacute phase.

OBJECTIVE: To elucidate venous drainage patterns to avoid damage to the venous drainage route in the middle cranial fossa and superior petrosal sinus when employing the transpetrosal approach. METHODS: Venous drainage patterns were assessed using three-dimensional computed tomography venography in 22 hemispheres of petroclival meningioma (PCM) cases from patients who underwent primary surgery and 40 hemispheres of control cases. Intracranial venous drainage patterns were compared between control cases and PCM cases. RESULTS: The proportion of hemispheres with complete and medial superior petrosal sinus drainage patterns was lower in PCM cases. With regard to the superficial middle cerebral vein drainage pattern, the proportion of hemispheres with the cavernous sinus capture type was lower and the proportion with the emissary type was higher in PCM cases. The proportion of hemispheres with multiple greater anastomoses of the superficial middle cerebral vein was higher in PCM cases without the emissary-type and cavernous sinus capture-type patterns. When the venous drainage route of the cavernous sinus capture type and/or emissary type was disturbed, in particular, greater anastomosis via the vein of Labbe and the vein of Trolard was needed to control venous drainage flow. CONCLUSIONS: In cases of venous drainage impairment secondary to PCM progression, the drainage route changed to the pterygoid plexus route through the emissary foramen and/or superior sagittal sinus and to the transverse sinus route through the greater anastomosis of the superficial middle cerebral vein. In the anterior transpetrosal approach, peeling off the dura propria of the trigeminal nerve of the foramen rotundum for petrous apex exposure may be associated with the potential risk of pterygoid plexus drainage route impairment.

Recent investigations revealed genetic analysis provides important information in management of gliomas, and we previously reported grade II-III gliomas could be classified into clinically relevant subgroups based on the DNA copy number aberrations (CNAs). To develop more precise genetic subgrouping, we investigated the correlation between CNAs and mutational status of the gene encoding isocitrate dehydrogenase (IDH) of those tumors. We analyzed the IDH status and CNAs of 174 adult supratentorial gliomas of astrocytic or oligodendroglial origin by PCR-based direct sequencing and comparative genomic hybridization, respectively. We analyzed the relationship between genetic subclassification and clinical features. We found the most frequent aberrations in IDH mutant tumors were the combined whole arm-loss of 1p and 19q (1p/19q codeletion) followed by gain on chromosome arm 7q (+7q). The gain of whole chromosome 7 (+7) and loss of 10q (-10q) were detected in IDH wild-type tumors. Kaplan-Meier estimates for progression-free survival showed that the tumors with mutant IDH, -1p/19q, or +7q (in the absence of +7p) survived longer than tumors with wild-type IDH, +7, or -10q. As tumors with +7 (IDH wild-type) showed a more aggressive clinical nature, they are probably not a subtype that developed from the slowly progressive tumors with +7q (IDH mutant). Thus, tumors with a gain on chromosome 7 (mostly astrocytic) comprise multiple lineages, and such differences in their biological nature should be taken into consideration during their clinical management.

Patient outcomes following grade V subarachnoid haemorrhage (SAH) have been dismal, although they may have improved following recent technological advances in endovascular treatment (EVT). A single-centre, retrospective study was conducted to evaluate whether outcomes have improved from 2000 to 2014 for patients with World Federation of Neurosurgical Societies (WFNS) grade V SAH. Coiling has been the preferred first-line treatment for grade V SAH patients in our institution since 2000. Patients who underwent EVT (n = 115) were grouped on the basis of their hospital admission year: 2000-2004 (n = 44), 2005-2009 (n = 37) and 2010-2014 (n = 34). Patient demographics, outcomes and in-hospital mortality rates were compared between the groups. Patient outcomes at discharge were evaluated using the Glasgow Outcome Scale (GOS), with GOS scores of 4-5 defined as favourable outcomes. There were no significant intergroup differences in patient demographics. In addition, there were no significant differences in the frequencies of favourable outcomes (14% in 2000-2004,16% in 2005-2009 and 26% in 2010-2014). Mortality rates were 52% in 2000-2004, 43% in 2005-2009 and 24% in 2010-2014, with a significantly lower mortality rate in 2010-2014 than in 2000-2004 (p = 0.01). Both perioperative rebleeding and delayed cerebral ischaemia decreased over time; however, multivariate regression analysis showed that the former contributed more to the decrease in mortality. Age was the only variable associated with favourable outcomes. The results of this study indicate that EVT is an appropriate therapeutic option for grade V SAH patients. However, multi-centre, prospective trials are required to provide evidence-based verification of the efficacy of EVT. (C) 2015 Elsevier Ltd. All rights reserved.

Background Tight coil packing with density of at least 20%-25% is known to be important for preventing recanalization after embolization of cerebral aneurysms. However, large aneurysms sometimes recanalize regardless of the packing density, suggesting that the absolute residual volume which is determined by aneurysm volume and packing density may be more important risk factor for recanalization. To validate this hypothesis, we analyzed the factors affecting the outcomes of treated aneurysms at our institute. Methods and Findings We included 355 small and large aneurysms. The following six factors were obtained from every case: aneurysm volume (mL), neck size (mm), packing density (%), residual volume (mL), rupture status at presentation, and stent assistance (with or without stent). The data were then subjected to multivariate logistic regression analysis to identify significant risk factors for recanalization. Recanalization occurred in 61 aneurysms (17.2%). Significant predictors for recanalization were aneurysm volume (odds ratio, 15.3; P &lt; 0.001) and residual volume (odds ratio, 30.9; P &lt; 0.001), but not packing density (odds ratio, 0.98; P = 0.341). These results showed that for each 0.1-mL increase in aneurysm volume and residual volume, the risk of recanalization increased by 1.3 times and 1.4 times, respectively. Conclusions The most influential risk factor for recanalization after coil embolization was residual volume, not packing density. The larger the aneurysm volume, the greater the packing density has to be to minimize the residual volume and risk of recanalization. Since tight coil packing has already been aimed, further innovation of coil property or embolization technique may be needed. Otherwise, different treatment modality such as flow diverter or parent artery occlusion may have to be considered.