中江 俊介

Fence-post catheter techniques are used to use tumor margins when resecting gliomas. In the present study, deep electrodes instead of catheters were used as fence-posts. The case of a 25-year-old female patient whose magnetic resonance images (MRI) revealed a tumor in the left cingulate gyrus is presented in this study. She underwent daily seizures without loss of consciousness under the administration of anti-seizure medications. Despite video electroencephalography (EEG) monitoring, the scalp inter-ictal EEG did not show obvious epileptiform discharges. We were consequently uncertain whether such frequent seizures were epileptic seizures or not. As a result, deep electrodes were used as fence-posts: three deep electrodes were inserted into the tumor’s anterior, lateral, and posterior margins using a navigation-guided method. The highest epileptic discharge was detected from the anterior deep electrode. As a result, ahead of the tumor was extendedly resected, and epileptic discharges were eliminated using EEG. The postoperative MRI revealed that the tumor was resected. The patient has never experienced seizures after the surgery. In conclusion, when supratentorial gliomas complicated by frequent seizures are resected, intraoperative EEG monitoring using deep electrodes as fence-posts is useful for estimating epileptogenic areas.

Vagus nerve stimulation (VNS) is an effective surgical option for intractable epilepsy. Although the surgical procedure is not so complicated, vagus nerve detection is sometimes difficult due to its anatomical variations, which may lead to surgical manipulation-associated complications. Thus, this study aimed to visualize the vagus nerve location preoperatively by fused images of three-dimensional computed tomography angiography (3D-CTA) and magnetic resonance imaging (MRI). This technique was applied to two cases. The neck 3D-CTA and MRI were performed, and the fused images were generated using the software. The vagus nerve and its anatomical relationship with the internal jugular vein (IJV) and common carotid artery were clearly visualized. The authors predicted that the vagus nerve was detected by laterally pulling the IJV according to the images. Intraoperatively, the vagus nerve was located as the authors predicted. The time of the surgery until the vagus nerve detection was <60 min in both cases. This novel radiological technique for visualizing the vagus nerve is effective to quickly detect the vagus nerve, which has anatomical variations, during the VNS.

Distinguishing primary central nervous system lymphoma (PCNSL) from glioblastoma, isocitrate dehydrogenase (IDH)-wildtype is sometimes hard. Because the role of operation on them varies, accurate preoperative diagnosis is crucial. In this study, we evaluated whether a specific kind of chemical exchange saturation transfer imaging, i.e., amide proton transfer-weighted (APTw) imaging, was useful to distinguish PCNSL from glioblastoma, IDH-wildtype. A total of 14 PCNSL and 27 glioblastoma, IDH-wildtype cases were evaluated. There was no significant difference in the mean APTw signal values between the two groups. However, the percentile values from the 1st percentile to the 20th percentile APTw signals and the width1–100 APTw signals significantly differed. The highest area under the curve was 0.796, which was obtained from the width1–100 APTw signal values. The sensitivity and specificity values were 64.3% and 88.9%, respectively. APTw imaging was useful to distinguish PCNSL from glioblastoma, IDH-wildtype. To avoid unnecessary aggressive surgical resection, APTw imaging is recommended for cases in which PCNSL is one of the differential diagnoses.

<sec> <title>BACKGROUND</title> A common surgical approach for dominant insular lesions is to make a surgical corridor in asymptomatic cortices based on functional mapping. However, the surgical approach is difficult for posterior insular lesions in a dominant hemisphere because the posterior parts of the perisylvian cortices usually have verbal functions. </sec> <sec> <title>OBSERVATIONS</title> We present the case of a 40-year-old male whose magnetic resonance images revealed the presence of contrast-enhancing lesions in the left posterior insula. Our surgical approach was to split the sylvian fissure as widely as possible, and partially resect Heschl’s gyrus if the cortical mapping was negative for language tests. Because Heschl’s gyrus did not have verbal functions, the gyrus was used as a surgical corridor. It was wide enough for the removal of the lesion; however, because intraoperative pathological diagnosis eliminated the possibility of brain tumors, further resection was discontinued. The tissues were histologically diagnosed as tuberculomas. Antituberculosis drugs were administered, and the residual lesions finally disappeared. According to the neurophysiological tests, the patient showed temporary impairment of auditory detection, but the low scores of these tests improved. </sec> <sec> <title>LESSONS</title> The transsylvian and trans-Heschl’s gyrus approach can be a novel surgical option for excising dominant posterior insular lesions. </sec>