東口 彩映子

BACKGROUND: In intraventricular surgery using a flexible endoscope, the lesion is usually aspirated via the working channel. However, the surgical view during aspiration is extremely poor because the objective lens is located adjacent to the working channel. METHOD: To address this issue, we developed a novel surgical procedure using an angiographic catheter. In this procedure, the catheter is inserted into the working channel, and the lesion is aspirated through the catheter. Besides, continuous intraventricular irrigation is performed via the gap between the catheter and the working channel. CONCLUSION: This procedure maintains a clear view during surgery and reduces complications.

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.

<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>

<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: Meningiomas often invade venous sinuses, but intravenous sinus meningiomas remain within the intracranial cavity. This case report describes an extremely rare case of tentorial meningioma with venous sinus invasion, extending intraluminally into the lower part of the internal jugular vein in a 59-year-old man.Case presentation: The patient's initial surgery involved the supratentorial component of a right tentorial meningioma, which invaded the right transverse and sigmoid sinuses. The supratentorial component of the tumour did not enlarge during the 2-month waiting period for the first surgery. The patient received postoperative radiation therapy for the residual tumour in the intravenous sinus. Despite radiation, the residual tumour developed caudally and ultimately extended into the right internal jugular vein. The average regrowth speed of the extracranial mass was 3.6 mm/month. The patient underwent surgery for the recurrent tumour located in the transverse sinus, sigmoid sinus, jugular bulb, and internal jugular vein, 46 months after the initial surgery. The pathological features of both surgeries were the same; WHO grade I meningothelial meningioma.Conclusions: To the best of our knowledge, there have been few case reports of benign meningioma with intraluminal extension into the internal jugular vein, and there have been no reports of long-term observation of such cases. Detailed observation of the present case suggests that the difference in growth speed between the intracranial and venous cavity depends on the surrounding environment.

INTRODUCTION: The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study. MATERIALS AND METHODS: All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months. RESULTS: There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale. CONCLUSION: Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.

INTRODUCTION: Posterior circulation aneurysm constitutes 15%-20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms. MATERIALS AND METHODS: We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality. RESULTS: Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study. CONCLUSION: Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.

Conventionally ventrally located spinal tumor is approached through anterior vertebrectomy which requires bony fixation and then immobilization for a couple of months. The alternative route to deal with such type of tumor is anterolaterally to avoid the surgical and nonsurgical complications. We are reporting a minimally invasive anterolateral approach for C2 neurofibroma in an 84-year-old patient. Postoperatively this patient did not require cervical brace and postoperative discomfort was minimal. It was observed that dumbbell-shaped cervical tumor with no intradural pathology and wide neural foramina could also be taken care through the anterolateral route which did not require bony fusion or immobilization, but the expertise of the surgeon is necessary for performing these types of minimally invasive procedure to achieve the best results.

Middle cerebral aneurysms constitute almost one-third of all anterior circulation aneurysms. Most of the saccular aneurysms originate from the arterial branching sites, but origins other than at the branching site are extremely rare. In this article, we are describing a unique M1 segment middle cerebral artery aneurysm which is not related with any branching site. Our literature search suggests that atherosclerotic changes in the arterial wall and local hemodynamic forces play an important role in the development of these types of aneurysm. Surgical management is not so unique in this type of aneurysm, but due to atherosclerotic parent arterial wall and thin-walled aneurysm sac, a neurosurgeon should be more cautious.

BACKGROUND: The management of cavernous carotid aneurysms (CCAs) poses a significant dilemma to the treating surgeon. Asymptomatic CCAs usually are managed conservatively with clinical and radiologic follow-up. Large size, intradural extension, sphenoid bone erosion, and increasing size on follow-up are usual indications for treating asymptomatic CCAs. However, there are no clear-cut guidelines in literature. We share our experience of 40 asymptomatic CCAs treated by endovascular and surgical methods. METHODS: All the asymptomatic CCAs treated between January 2014 and December 2018 were analyzed retrospectively. Patient demographics, aneurysm characteristics, postprocedural complications, and clinical and radiologic follow-up data were obtained from records. Outcome was evaluated in terms of aneurysm obliteration and maintained cerebral perfusion, postoperative complications, recurrence, and clinically significant complications during follow-up. RESULTS: Endovascular coiling, balloon-assisted coiling, and stent-assisted coiling were performed in 27 (75%), 5 (13.9%), and 4 (11.1%), respectively. Raymond-Roy occlusion classification grade I occlusion was achieved in 88.9% of cases. No immediate or delayed complications were noted. Coil compaction was seen in 4 (11.1%) patients. In the surgery group, all patient underwent high-flow bypass with radial artery graft. Aneurysm exclusion with good graft patency was achieved in all 4 cases without any permanent morbidity or mortality. CONCLUSIONS: The current study demonstrates excellent outcomes of asymptomatic CCAs after treatment. In view of the technical advancements of both surgical and endovascular methods, consideration for treatment should be given to asymptomatic CCAs. Each aneurysm should be individually assessed by experts for choosing the best endovascular or surgical treatment option.

Basilar apex aneurysms constitute 5%-8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular. This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.

INTRODUCTION: Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons. AIMS AND OBJECTIVES: The aim of this study is to elucidate the optimal management of RAs after EC. MATERIALS AND METHODS: Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS). RESULTS: There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5. CONCLUSION: Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.