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In this section, new arsenals for neurological treatment based on an open source are introduced. "Delytact" and "Stemirac" are discussed in this section. These two new arsenals have been accepted as cell and gene therapy products by the Ministry of Health, Labor, and Welfare. "Delytact" is a viral-gene therapy that targets malignant brain tumors, such as malignant gliomas, while "Stemirac" targets against spinal contusion via self-mesenchymal implantation. Both are permitted clinical arsenals in Japan.

A hybrid operating room(Hybrid OR), where operative equipment and flat panel angiography are both available, is becoming common for complex cerebrovascular surgery. However, the current Hybrid OR remains suboptimal as it is not cost-effective and contains uncomfortable operating beds, and a single-plane flat panel. Therefore, we introduced a novel Hybrid OR system, which has a biplane flat panel detector and three mutually exchangeable tailor-made operating beds. In this article, we report our preliminary experience of this novel Hybrid OR, focusing on improved cost-effectiveness by the availability of diagnostic angiography and standard endovascular surgery, optimal selection of three different types of operating beds, and procedural workflow in individual hybrid cerebrovascular surgery.

Introduction: Astroblastoma is a rare, supratentorial glial tumor, occurring predominantly in children and young adults. However, treatment strategies have not yet been established for this rare disease., Case Presentation: A 6-year-old boy presented with headache and nausea. CT and MRI revealed a left frontal mass lesion with slight edema and macrocalcifications. Gross tumor resection was performed. Histological examination found neoplastic cells with astroblastic characteristics, and a striking perivascular array of pseudorosettes. The final diagnosis was high-grade astroblastoma. MRI 13 months after surgery suggested local recurrence, and an enlargement was found 3 months later. Stereotactic radiotherapy(SRT)was performed. MRI after SRT showed enhanced cyst formation around the tumor bed, suggesting tumor recurrence. However, 11 C-methionine positron emission tomography(PET)revealed radiation necrosis. The last follow-up MRI 15 months after SRT showed no further recurrence., Conclusion: Astroblastoma is rare, therefore, no optimal management is known. SRT may be effective to treat recurrent astroblastomas. 11 C-methionine PET/CT was useful to differentiate metastatic disease from radiation necrosis.

Unruptured posterior communicating artery aneurysms with oculomotor nerve palsy are at high risk of rupture, and early intervention is recommended to prevent aneurysm bleeding and to improve oculomotor function. Both surgical clipping and endovascular coiling are available, and either of them is applied according to the anatomical condition and patient's comorbidity. In this article, we describe a case of an unruptured posterior communicating artery aneurysm with oculomotor nerve palsy, which was initially treated with surgical clipping. Owing to ventricular tachycardia during surgery, the craniotomy was discontinued and switched to endovascular coiling. In this operation, use of a hybrid operating room for coiling enabled adequate heparinization and immediate recraniotomy to prevent ischemic and hemorrhagic complications, respectively.

The authors report a rare case of a symptomatic hemifacial spasm caused by a dissecting vertebral artery aneurysm and by an anterior inferior cerebellar artery(AICA). A 54-year-old man presented with left hemifacial spasm persisting for 5 years, and the spasm had undergone acute aggravation. Brain magnetic resonance imaging and digital subtraction angiography showed a vertebral artery dissecting aneurysm and an AICA compressing the root exit zone of the left facial nerve. Microvascular decompression of the facial nerve with proximal clipping of the vertebral artery dissecting aneurysm was successfully performed. The hemifacial spasm disappeared immediately after the surgery.

Objective: The aim of the present study is to assess whether the technique of surgical microscope-based indocyanine green videoangiography (ICG-VA) and the FLOW800 system are efficient for hemodynamic evaluation during carotid endarterectomy (CEA)., Methods: 20 CEAs for 19 patients were performed from January to July 2011. Before and after endarterectomy, ICG was injected intravenously. After the procedure, ICG-VA was analyzed by FLOW800. Regions of interest were the common carotid artery, the plaque, the internal carotid artery, and the external carotid artery to evaluate changes in each intensity value., Results: The distal end of carotid plaque and the proximal end were identified in 85% of CEAs and 78.9% of cases. In 5 cases (26.3%) with more severe stenosis (>90%), the decrease of blood flow intensity in the internal carotid artery was delayed before endarterectomy. After endarterectomy, the finding was improved in all the 5 cases. After the endarterectomy, the intensity values in the common carotid artery, the plaque, the internal carotid artery, and the external carotid artery had increased 162 ± 129, 337 ± 212, 139 ± 151 and 177 ± 143. Especially in the value of the plaque, there was a great improvement., Conclusions: ICG-VA provides information of the plaque location and the patency of the arterial vessel during CEA. Using FLOW800, semiquantitive information of hemodynamics was able to be acquired, especially for the case of severe stenosis with collapse of the internal carotid artery.

Dissecting aneurysm of the intracranial arteries is a well known clinical entity, and its angiographic findings are also well recognized. We encountered a case with dissecting aneurysm of the vertebral artery presented with subarachnoid hemorrhage (SAH). The initial angiography was normal but repeated angiography demonstrated a dissecting aneurysm. This case is reported here, and the relevant literature is reviewed. A 46-year-old woman had been well until she complained of headache. She was admitted to a local hospital and found to have SAH. She was transferred to our clinic for further examination. On admission the patient was drowsy but able to be aroused. Her neurological state was normal except for a mildly stiff neck. Computed tomography (CT) demonstrated massive SAH in the basal cistern and intraventricular hemorrhage in all ventricles. CT also demonstrated acute hydrocephalus. Four-vessel cerebral angiography was performed using transfemoral catheterization. No definite abnormalities, except for a small aneurysm in the cavernous portion of the right internal carotid artery, were found. Because aneurysm in the cavernous portion could not cause SAH, we could not define the origin of the SAH. However, retrospectively, a slightly irregular wall of the left intracranial vertebral artery was evident. Repeated angiography performed 28 days later revealed aneurysmal dilatation of this left vertebral artery. Double density of the contrast material was found in the aneurysmal dilatation. Retention of the contrast medium was also seen in the late capillary phase. From these angiographic findings, the aneurysm was diagnosed as being a dissecting aneurysm. Direct surgical attack on the vertebral aneurysm was performed via a left suboccipital craniectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Only 2.0-6.8% of extranodal malignant lymphomas are found in the nasal region and paranasal sinuses. Primary malignant lymphoma of the paranasal sinuses usually occurs in the maxillary or ethmoid sinuses, and is very rare in the sphenoid sinus. Here we report a rare case of primary malignant lymphoma of the sphenoid sinus that was found accompanying orbital apex syndrome. The patient's progressively deteriorating neurological condition was improved after surgery via the transsphenoidal approach. A 52-year-old man was admitted with reduced left visual acuity, diplopia, and retroorbital pain. CT showed an isodense mass in the sphenoid sinus with slight enhancement, and MRI showed that the lesion was slightly hypointense on T1-weighted images, hypointense on T2-weighted images, and slightly enhanced by Gd-DTPA. On January 19, 1989, the patient suddenly became blind. An operation via the transsphenoidal approach was done as an emergency procedure to decompress the sphenoid sinus and the left optic canal. The histological diagnosis was non-Hodgkin's lymphoma of the diffuse large cell type (B cell lymphoma). Malignant lymphoma in the paranasal sinuses is usually biopsied and treated by chemotherapy and/or radiotherapy without surgical resection. In this rare case, an operation via the transsphenoidal approach was effective in improving the patient's visual acuity.