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To investigate the causes of failure and recurrence after microvascular decompression (MVD) for trigeminal neuralgia (TGN) and to analyze the results of redo surgery. Sixty-three cases of redo surgery were retrospectively reviewed. Reasons for re-exploration were categorized into 4 groups based on the operative findings. Patient characteristics, outcomes of re-exploration, and operative complications were analyzed by Kaplan–Meier and logistic regression analyses. Reasons for redo surgery were divided into arterial compression in 13 patients (21%), venous compression in 11 patients (17%), prosthesis-related in 25 patients (40%), and adhesion or negative exploration in 14 patients (22%). Immediate pain relief was obtained in 59 patients (94%) postoperatively with newly developed facial numbness in 17 patients (27%). Of these, 48 patients (76%) maintained pain-free 1 year postoperatively. Overall recurrence was noted in 17 patients (27%) during the median 49-month follow-up period. Most recurrences occurred within 1 year after redo surgery, but the prosthesis-related patients showed a continuous recurrence up to 4 years. Patients having vascular compression showed significantly better pain control than those without vascular contact in Kaplan–Meier analyses (p = 0.0421). No prognostic factor for pain-free 1 year after redo surgery was found. Redo surgery is effective for patients with remaining vascular compression rather than those without vascular contact. Teflon contact onto the nerve root should be avoided because it is a potential risk for recurrence and causes poor prognosis after redo surgery.

Trigeminal neuralgia (TGN) caused by the vertebrobasilar artery (VBA) is uncommon. The abducens nerve root is frequently dislocated by a tortuous VBA near the trigeminal nerve root. This unusual location of the root is not well known. This study aimed to investigate the location of the stretched abducens nerve root. The objective is 26 patients with VBA-related TGN who underwent microvascular decompression (MVD). We retrospectively investigated the course of the abducens nerve root with magnetic resonance imaging (MRI) with three-dimensional (3D) imaging and surgical findings. The displacement of the abducens nerve root on the affected side was compared to the contralateral side. The abducens nerve root was distorted by a tortuous VBA (46.2%) or the anterior inferior cerebellar artery (53.8%). The average length of the cisternal segment was stretched to 23.4 mm versus 12.4 mm on the contralateral side. The peak point of the elevated abducens nerve root was mostly located rostro-medial (65.4%) or caudo-medial (34.6%) to the neurovascular compression site of the trigeminal nerve with a mean distance of 9.1 mm. Contact with the trigeminal nerve root was observed in 7 patients (26.9%). Three-dimensional imaging was consistent with the surgical findings and useful in predicting the location of the abducens nerve root. No abducens nerve palsy was noted in our series. The abducens nerve root is located near the trigeminal nerve root in VBA-related TGN. Preoperative understanding of the unusual course of the abducens nerve root contributes to avoiding accidental nerve injury during MVD.

Neurosarcoidosis (NS) affects various sites of the central nervous system, including the cranial nerve, meninges, brain parenchyma, hypothalamus, and pituitary gland. NS rarely causes intracerebral vasculitis and subsequent strokes, or cerebral infarction and hemorrhage, which are associated with high mortality. Herein, we report a 71-year-old woman's case of stroke associated with NS, which showed aggressive cerebral vasculitis with brain herniation; it was resolved with corticosteroid therapy after accurate histopathological diagnosis. This case highlights the necessity of expecting NS to sometimes follow an aggressive course, presenting with vasculitis. Most patients with NS satisfactorily respond to corticosteroids, but this is not always the case. In cases of unfamiliar ischemic or hemorrhagic lesions, the possibility of NS must be considered.

Background One possibly problematic feature of lumboperitoneal shunt (LPS) placement involves inaccuracy in handling the shunt valve compared with ventriculoperitoneal shunt. Flushing the valve to ascertain shunt patency and adjusting the valve pressure in LPS are often more difficult than with ventriculoperitoneal shunt, particularly when the valve is routinely located in abdominal fat. To overcome this inaccuracy, we applied a simple alteration to the usual LPS procedure. We changed the valve location from the abdominal fat to a lumbar posterior site where the paravertebral spinal muscle, in contrast to the nonsupportive abdominal fat, offers a good anchoring point for valve implantation. Methods We retrospectively reviewed 51 consecutive patients undergoing LPS placement for normal pressure hydrocephalus. We divided the patients into 2 groups, anterior or lateral and posterior, and analyzed these 2 groups, focusing on technical features and outcomes. Results In the anterior or lateral group, 1 patient showed an inverted valve position, and errors occurred when adjusting the valve pressure in 3 patients. There were no wound complications, such as skin erosion. Two patients experienced periumbilical discomfort. In the posterior group, no patients showed an inverted valve position or errors associated with adjustment of the pressure. There were no wound complications, such as skin erosion, or reports of discomfort. Conclusions In this series, our modification increased the accuracy of handling the valve without increasing discomfort.

Background Contact of the main stem of the petrosal vein (PV) to the nerve root is a rare cause of trigeminal neuralgia (TGN). The implication of the PV in relation with neurovascular contact (NVC) is not fully understood. Objective To assess the operative procedures in microvascular decompression (MVD) in patients with PV involvement in the long-term. Methods We retrospectively reviewed 34 cases (7.0%) in 485 consecutive MVDs for TGN, whose PV main stem had contact with the trigeminal nerve root (PV-NVC). PV-NVCs were divided into 2 groups: concomitant arterial contact or no concomitant arterial contact. Surgical techniques, outcomes, complications, and recurrence were assessed. Results The anatomical relationship of the PV with the trigeminal nerve root was consistent with preoperative 3-dimensional imaging in all patients. Pain relief was obtained in most patients immediately after surgery (97.1%) by separating the PV from the nerve root. Postoperative facial numbness was noted in 9 patients (26.5%). Symptomatic venous infarctions occurred in 2 patients (5.9%). Recurrence of facial pain occurred in 3 patients (8.8%) with a median 48 mo follow-up period. Re-exploration surgery revealed adhesion being the cause of recurrence. The statistical analyses showed no difference in the surgical outcomes of the 2 groups. Conclusion Separating the PV from the nerve root contributes to pain relief in patients with PV conflict regardless of concomitant arteries. Preserving venous flow is crucial to avoid postoperative venous insufficiency.

Separation of the vertebrobasilar artery (VBA) from the trigeminal nerve root in microvascular decompression (MVD) is technically challenging. This study aimed to review the clinical features of VBA involvement in trigeminal neuralgia and evaluate surgical decompression techniques in the long term. We retrospectively reviewed the surgical outcomes of 26 patients (4.4%) with VBA involvement in 585 consecutive MVDs for TGN using a Teflon roll for repositioning the VBA. The final operative status of the nerve decompression was categorized into two groups: the separation group and the contact group. Separation of the VBA from the nerve root was completed in 13 patients in the separation group, and slight vascular contact remained in the remaining 13 patients of the contact group. The clinical features of VBA-related TGN were investigated and the operative results were analyzed. Multiple arteries are involved in neurovascular compression (NVC) in most cases. The anterior inferior cerebellar artery was the most common concomitant artery (69%). The site of the NVC varies from the root entry zone to the distal portion of the root. All patients were pain-free immediately after surgery and maintained medication-free status during the follow-up period, except for one patient (3.8%) who had recurrent facial pain 8 years after surgery. Postoperative facial numbness was observed in six patients (23%). Of these, one patient showed improvement within 3 months and the other five patients had persistent facial numbness (19.2%). Other neurological deficits include one dry eye, one diplopia due to trochlear nerve palsy, two decreased hearing (

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

Highlights • There is little information regarding severe intraventricular hemorrhage casting associated with moyamoya disease. • Performing only external ventricular drainage in such a case is preferred way, however, there are no scientific date supporting this rule. • This is the description of aspiration of severe intraventricular hemorrhage in moyamoya disease patients in acute phase. • Our two cases suggested that early endoscopic aspiration of severe intraventricular hemorrhage may prevent poor outcomes., Introduction When severe intraventricular hemorrhage (IVH) casting in moyamoya disease (MMD) is mentioned, experts advocate not to evacuate the IVH in acute phase. However, the devastating outcomes derived from this empirical rule have not been addressed. Herein, we report two MMD cases undergoing obliteration of ruptured aneurysm and early complete aspiration of severe IVH casting, and showed good outcomes. Presentation of cases Case 1: A 55-year-old woman was admitted to our hospital. Her initial Glasgow Coma Scale (GCS) was 4 and a computerized tomography (CT) scan showed severe IVH. Cerebral angiography (CAG) revealed MMD and an aneurysm. Direct surgery was performed for the ruptured aneurysm, followed by endoscopic complete aspiration of residual IVH. The modified Rankin Scale (mRS) was 1 at discharge. Case 2: A 44-year-old woman was admitted to our hospital. Her initial GCS was 4 and the CT scan showed a severe IVH. CAG revealed MMD and an aneurysm. Transcatheter arterial embolization was carried out for the aneurysm, followed by endoscopic complete aspiration of the residual IVH. The mRS was 2 at discharge. Discussion Performing only external ventricular drainage in acute phase for such IVH casting is generally preferred way, however, there are no scientific date supporting this empirical rule. Early surgical removal of severe IVH casting is an approach for severe IVH casting in MMD. Conclusion Early aspiration of severe IVH casting is an option for managing MMD with critical intracranial pressure, and it has the potential to prevent poor outcomes in MMD patients with severe IVH.

Background: Saccular aneurysm in the distal segment of the middle cerebral artery (DMCA) occurs very rarely and often represents with a rupture. We report a successful surgical case of a DMCA aneurysm rupture with large cerebral and subarachnoid hemorrhage. Case Description: A 44-year-old female presented a sudden onset headache and coma (the Glasgow Coma Scale was 3). Head computed tomography (CT) revealed a subarachnoid hemorrhage around the right Sylvian fissure and large intracranial hematoma in the right parietal lobe. The CT angiography showed a saccular aneurysm in the peripheral cortical segment of the right angular branch of the right DMCA. We decided to perform a right craniotomy to evacuate hematoma and interrupt the aneurysm. Just after the dural incision, the aneurysm ruptured again. We applied a temporary clip on the artery proximal to the aneurysm before excising it. Conclusion: Aneurysm in DMCA can be treated safely with surgical excision and risk of sudden recurrent hemorrhage needs to be anticipated.

Background To assess efficacy and safety of a newly developed decompression technique in microvascular decompression for hemifacial spasm (HFS) with vertebral artery (VA) involvement. Methods A rigid Teflon (Bard® PTFE Felt Pledget, USA) with the ends placed between the lower pons and the flocculus creates a free space over the root exit zone (REZ) of the facial nerve (bridge technique). The bridge technique and the conventional sling technique for VA-related neurovascular compression were compared retrospectively in 60 patients. Elapsed time for decompression, number of Teflon pieces used during the procedure, and incidences of intraoperative manipulation to the lower cranial nerves were investigated. Postoperative outcomes and complications were retrospectively compared in both techniques. Results The time from recognition of the REZ to completion of the decompression maneuvers was significantly shorter, and fewer Teflon pieces were required in the bridge technique than in the sling technique. Lower cranial nerve manipulations were performed less in the bridge technique. Although statistical analyses revealed no significant differences in surgical outcomes except spasm-free at postoperative 1 month, the bridge technique is confirmed to provide spasm-free outcomes in the long-term without notable complications. Conclusions The bridge technique is a safe and effective decompression method for VA-involved HFS.

Anterior cerebral artery dissection (ACAD), especially simultaneously presenting with subarachnoid hemorrhage (SAH) and cerebral infarction (CI), is rare. Only a few cases of severe SAH due to ACAD have been reported. Herein, we present an unusual case of severe SAH with simultaneous CI caused by ACAD. A 56-year-old male was brought to our hospital for severe disturbance of consciousness. Head computed tomography (CT) disclosed SAH with intracerebral hematoma. We suspected ruptured anterior communicating artery saccular aneurysm on CT angiography. Emergency craniotomy was performed to avoid cerebral herniation which confirmed the ruptured ACAD of right A2. The dissecting site was treated by wrapping with a Goretex sheet. ACAD of A2 may present with a severe hemorrhagic event.

Background We describe a unique anastomosis procedure involving successful middle meningeal artery (MMA) to cortical middle cerebral artery (MCA) bypass, as well as superficial temporal artery (STA) to cortical MCA bypass. Case Description A 46-year-old woman with hemorrhagic Moyamoya disease underwent an anastomosis procedure with the MMA and STA serving as donor arteries. We performed a small craniotomy at the areas closest to the donor STA, MMA, and recipient cortical MCA, and completed STA-MCA and MMA-MCA direct bypass procedures. Conclusions This is a rare case of successful MMA-to-MCA revascularization to prevent rebleeding in a patient with Moyamoya disease. The MMA can be used as a donor artery for extracranial-intracranial anastomosis procedures in clinical practice settings.

Watertight dural closure is a crucial step in preventing postoperative cerebrospinal fluid (CSF) leak and subsequent infection in posterior fossa surgery. The aim of this study is to assess an alternative use of collagen matrix double grafting in microvascular decompression (MVD). Dural closure using double collagen matrix grafts was retrospectively compared with autologous fascial grafting in 120 patients who underwent MVD. Double collagen matrix grafting technique, a combination use of inlay and onlay grafting (DuraGen®, Integra Lifesciences, Plainsboro, NJ, USA, $700–800 for an MVD craniotomy size), was applied in 60 patients (the collagen matrix group). In the remaining 60 patients, an autologous fascial graft was sutured in a watertight fashion to the dural defect (the fascia group). Postoperative wound complications, such as CSF leak and infection, were retrospectively compared between the two groups. CSF leaks were observed in 3 patients (5.0%) in the fascia group and in 2 patients (3.3%) in the collagen matrix group. All cases of CSF leakage presented with pseudomeningoceles except one patient who developed an incisional CSF leak. A repair surgery for CSF leak was required in this one patient in the fascia group. Subcutaneous abscesses were noted in 2 patients (3.3%) in the fascia group. There was no patient who developed a subcutaneous abscess in the collagen matrix group. One patient in each group developed aseptic meningitis. Statistical analyses revealed that the collagen matrix group showed non-inferior outcomes to the fascia group in CSF leaks and infectious complications. Double grafting technique with a combination of inlay and onlay collagen sheets is a safe and secure alternative for watertight dural closure despite a cost limitation.

We introduce a structural deterioration determination system that automatically measures the deflection of concrete utility poles from a 3D model created by using 3D point cloud data. As pole deflection is an accurate precursor of cracking, our automated deflection assessment system improves the efficiency of utility pole inspection, by replacing the conventional visual inspections needed to identify cracking. We show that the time and effort of inspection can be reduced by about 52% compared with conventional visual inspection work.

The trigeminocerebellar artery (TCA) is an infrequent anatomic anomaly of the branches originating from the basilar artery. It is clinically identifiable by the presence of the ipsilateral superior cerebellar artery and the anterior inferior cerebellar artery, and its course from the basilar artery to the cerebellar hemisphere. Because of its anatomic proximity to the trigeminal nerve root, the TCA often causes trigeminal neuralgia (TGN). Unlike other common arteries, repositioning the TCA is not always feasible when it penetrates the trigeminal nerve root (the intraneural type of TCA). In addition, the rich perforators originating from the TCA may limit its movability. The nerve decompression technique in such a rare condition has not yet been fully assessed. In this video, we present the nerve-splitting method for the intraneural type of TCA, in which sufficient isolation of the sensory root is achieved. The motor root of the trigeminal nerve originates from the brainstem slightly rostral of the root entry zone of the sensory root. Dissecting the motor root from its exit to the porous trigeminus allows mobilization of the root together with penetrating TCA away from the sensory root. The movability of the TCA increases by dissecting its perforators to the nerve root and brain stem. Sufficient separation of the sensory root contributes to ensuring the surgical result of nerve decompression and reducing the risk of recurrence due to adhesion. No complications of motor root retraction, such as masseter weakness and malocclusion, were noted in our experience. All data identifying the patients were anonymized. All procedures performed in this study were in accordance with the ethical standards of our institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study also obtained approval from the ethics committee of our institution. Written informed consent was obtained from all individual participants, as well as their first-degree relatives, included in this study.

Background Craniocervical junction arteriovenous fistula (CCJAVF) has a variety of forms, including dural and perimedullary arteriovenous fistulas. Owing to this anatomic variety, the terminologies for classifying CCJAVF, most of which aim to describe angiographic structures, have yet to be firmly established, and the current taxonomic classifications do not facilitate surgical strategies. Herein we focused on the existence of intradural feeder vessels, allowing the identification of 2 types of CCJAVF. This retrospective study aimed to assess the usefulness of our diagnostic classification for CCJAVF surgery. Methods We divided CCJAVF into 2 types: CCJAVF with an intradural feeder vessel and CCJAVF without an intradural feeder vessel. For the former type, we set the surgical goal of interrupting the intradural feeder and the draining veins behind the posterior spinal nerve. For the latter type, the surgical goal was to interrupt the draining veins behind the posterior spinal nerve. We retrospectively analyzed the outcomes of our surgical cases. Results Of 12 patients with CCJAVF, 8 underwent direct surgery. No patients showed exacerbation of neurological symptoms after surgery. One patient needed a second operation for residual shunt, and another patient developed an asymptomatic angiographic recurrence in the epidural space detected on follow-up imaging. The overall outcomes of surgical cases were good with an average modified Rankin Scale score of 1.0. Conclusions Our results indicate that our diagnostic classification for CCJAVF has the potential to simplify CCJAVF treatment without compromising patient outcomes.

Background Catheter-based endovascular thrombectomy has gained popularity for use in patients with acute large-vessel occlusion; however, various complications have been reported. Herein, we present a unique, serious procedure-related complication. Case Description A 91-year-old woman with acute middle cerebral artery (MCA) occlusion underwent endovascular thrombectomy with a stent retriever, but the device could not be retrieved from the horizontal segment of MCA during the procedure. Subsequently, she underwent emergency craniotomy. The lodged stent was extracted with microforceps using a counter-stretch of the vessels, so as not to avulse the perforating arteries. The stent device was retrieved uneventfully through a sheath introducer that was inserted through the femoral artery. Postprocedural indocyanine green video angiography showed complete recanalization of the MCA and internal cerebral artery. Conclusions This is a rare case in which successful open surgery was performed to retrieve a snagged stent retriever, with successful recanalization of the large cerebral artery occlusion.

Background The neurological conditions of brainstem cerebral cavernous malformation (BCM) patients are usually ascertained using Karnofsky Performance Status (KPS) or the modified Rankin scale (mRS). However, these scales do not reflect slight changes in brainstem function, because neither KPS nor mRS includes brainstem symptoms such as worsening of swallowing or diplopia. The main problem when managing the BCM patients is that we can neither systematically record neurological changes nor conduct clinical outcome investigations of BCM due to the lack of an adequately detailed assessment system. Purpose We investigated the usefulness of the Kurtzke expanded disability status scale (EDSS), which is already in widespread clinical use for multiple sclerosis because it provides certainty in evaluating brainstem symptoms. Methods We retrospectively analyzed neurological transitions in surgical BCM cases using the modified Rankin scale (mRS), Karnofsky performance status (KPS), and EDSS. We compared each neurological score transition, and determined which scale allows the most accurate recording of neurological changes in patients. Results We proposed lesion removal for patients who showed both neurological deterioration and lesion enlargement caused by re-bleeding, and the surgery was accepted by 10 patients. EDSS allowed us to assess patient status more accurately than KPS or mRS particularly during the perioperative period. In the statistical analysis, only EDSS differed significantly during the period between the initial proposal of surgery and the immediate preoperative period. Conclusion Our results suggest EDSS to be superior for managing BCM patients, as compared to KPS and mRS. Thus, EDSS may serve as an alternative scale for assessing BCM patients.

We experimentally investigate the cutoff wavelength shortening effect that occurs when the cladding diameter is reduced. The influence of coating thickness, and thus, cladding diameter, on the transmission loss is also discussed. We derive an empirical model of cutoff wavelength and transmission loss as a function of the cladding diameter and coating thickness. The empirical model reveals that a further reduction in the cladding diameter of step index type bending-loss insensitive fiber (BIF) is possible. The validity of the proposed BIF design is confirmed using a 70-μm cladding diameter BIF and jumper cords. This BIF enables us to construct optical fiber networks with higher reliability.

Objective In direct aneurysm surgery, tentative clipping is frequently applied to facilitate aneurysm dissection. However, no systemic review on the pros and cons of tentative clipping has been conducted. This study aimed to investigate the efficacy and concerns of tentative clipping. Methods A total of 867 direct clippings in 737 patients were performed to treat intracranial aneurysms between 1994 and 2015. We retrospectively investigated the frequency, purpose, location, and adequacy of tentative clipping. Results Tentative clipping was performed in 149 of the 867 aneurysms that were clipped (17.2%). The purpose of tentative clipping was to dissect an aneurysm in 141 (94.6%), separate the vessels from the surface of a sac in 5 (3.4%), and prevent slipping of the final clip in 3 (2.0%) cases. Further dissection revealed that tentative clipping completely excluded the blood flow into the aneurysm in 126 (84.6%) of the 149 cases and incompletely shut it out in 23 (15.4%) cases. Five (21.7%) of the 23 patients with incomplete clipping had intraoperative aneurysm ruptures subsequently. Conclusions Tentative clipping facilitates dissection of the aneurysm sac from the surrounding structure but can occasionally lead to intraoperative rupture. Before applying tentative clips, surgeons should prepare for temporary clipping or additional tentative clipping in case of a rupture.

Background Kawasaki disease (KD) is an acute systemic vasculitis that primarily affects the coronary artery, but it does not commonly affect the carotid artery. Cerebral infarction (CI) with internal carotid artery stenosis (ICS) in patients with KD has not been reported until now. We report a patient with CI as a remote-phase complication of KD. Case Presentation A 32-year-old man presented with impaired consciousness. Magnetic resonance imaging and digital subtraction angiography confirmed CI and ICS. He successfully underwent carotid endarterectomy. The resected plaque had pathologic findings of KD, which suggested that the internal carotid artery suffered from chronic inflammation. Conclusion KD in childhood may cause symptomatic ICS as a sequela of a remote phase.

Background The trigeminocerebellar artery (TCA) is a variant branch of the basilar artery supplying the trigeminal nerve root and cerebellar hemisphere, which may contribute to trigeminal neuralgia (TGN). Despite its unique anatomic description, information regarding the preoperative diagnosis and surgical management of TCA is lacking. Objective To evaluate our preoperative diagnosis of TCA using 3-dimensional (3D) images and surgical management of TGN cases with TCA involvement. Methods We reviewed our 15 patients with TCA involvement (3.3%) among 460 consecutive patients undergoing microvascular decompression for TGN. In this study, all patients were examined using 3D images using GammaPlan (Elekta, Stockholm, Sweden). TCAs were divided into 2 groups based on surgical findings: encircling type and intraneural type. Biographical data, radiological findings, and operative video recordings were reviewed retrospectively. Surgical outcomes and follow-up were assessed and compared between the 2 groups. Results TCA involvement was confirmed preoperatively in 14 of the 15 patients using 3D images. All patients were operated with our unique transposition technique and became pain free immediately after the surgery. Pain-free status was maintained during the follow-up period (3.5 ± 2.6 yr) in all patients but one in whom pain recurred 4 yr after the initial surgery. Re-exploration revealed an adhesion between the Teflon felt and the nerve root. Conclusion Although TCA involvement is rare, an accurate preoperative diagnosis is essential because the decompression technique may differ from those used for other common cases. Scrutinizing anatomically rare variation with 3D images is recommended for predicting TCA involvement.

OBJECTIVEOne of the technical problems encountered in performing lumboperitoneal shunt (LPS) surgery involves operative positioning of the patient. To insert the spinal catheter into the subarachnoid lumbar space, LPS is usually performed with the patient in the lateral decubitus position. However, laparotomy around the periumbilical region, especially in obese patients in the lateral decubitus position, can be quite difficult. Thus, the authors added a simple modification to the laparotomy for LPS, altering the laparotomy site to the lateral side of the patient’s trunk. The aim of this study was to analyze this method in terms of technical features and outcomes.METHODSTwo LPS procedures were compared: routine periumbilical anterior abdominal laparotomy and our modified method using lateral abdominal laparotomy. The first 11 consecutive cases underwent routine anterior abdominal laparotomy with position changes or tilting of the operative bed, whereas the next 17 consecutive cases underwent lateral abdominal laparotomy not requiring position changes.RESULTSIn the anterior abdominal laparotomy group, the mean operative time was 72.36 ± 24.63 minutes. One patient had a spinal tube tear that required revision of the LPS 2 years postoperatively. In the lateral abdominal laparotomy group, the mean operative time was 38.82 ± 13.87 minutes. One patient experienced a postoperative headache and exhibited a thin, chronic subdural hematoma on imaging studies, which disappeared after adjustment of the valve pressure.CONCLUSIONSIn the current series, the operative duration was shorter in the lateral abdominal group compared with the anterior abdominal group, with no differences in complication rates. Lateral abdominal laparotomy simplifies LPS.

Background: Some patients come to the hospital presenting with ischemic neurological deficits due to postsubarachnoid hemorrhage (SAH) cerebral vasospasm. In such a situation, neurosurgeons tend to avoid direct clipping, since mechanical irritation to the vessels could worsen the vasospasm and exacerbate ischemic symptoms. The optimal timing of direct clipping in patients with evidence of vasospasm is undetermined. Herein, we present the case of a patient who underwent direct clipping in the presence of severe symptomatic and post-SAH angiographic vasospasm. During surgery, we coated the severely spastic artery with nicardipine. Case Description: A 49-year-old woman was admitted to our hospital with the diagnosis of ruptured intracranial aneurysm and severe vasospasm. On the admission day, we performed direct clipping together with direct application of nicardipine to the spastic artery. Postoperative immediate cerebral angiography showed complete disappearance of the vasospasm. Conclusion: Direct clipping should not be contraindicated during the vasospasm period in patients with a ruptured aneurysm, and direct application of nicardipine on the spastic artery would completely relieve vasospasm.

Background Intraosseous hemangioma is a rare bone tumor, accounting for 0.7%–1.0% of all bone tumors. It can occur at any age, but only 9% of cases are younger than 10 years old. Although this tumor is usually slow-growing and clinically silent, we experienced 2 pediatric patients undergoing surgery for skull hemangioma who presented with uncommon clinical manifestations. Case Decription Case 1 was a 9-year-old boy who presented with sudden onset of headache and was referred to our hospital. Radiologic images revealed an osteolytic oval lesion in the right parietal bone and acute subdural hemorrhage in the right cerebral hemisphere. The right parietal lesion was removed surgically. The lesion was found to have grown into the dura and to be adherent to the pia matter. The removed lesion was histologically confirmed to be a hemangioma. Case 2 was an 8-year-old girl who was referred to our hospital with an elastic mass that had been slowly enlarging for 7 years. Radiologic images revealed an osteolytic oval lesion in the right parietal bone. Surgical removal was thus planned. The lesion was found to be attached to the dura, and we removed the lesion with the surrounding bone and attached dura. Histologic examination confirmed the lesion to be a hemangioma. Conclusions Although skull hemangiomas show clinical heterogeneity, surgical removal is usually diagnostic and leads to good patient outcomes. On occasion, however, this tumor causes secondary changes in the dura, such that dural incision and dural plasty should be planned in advance of lesion removal.

Background The headache preceding an intracranial aneurysm rupture is called a sentinel headache (SH), and it is characterized by a sudden, intense, and persistent headache. As subarachnoid hemorrhage (SAH) often develops within several weeks of SH, its rapid diagnosis and treatment can improve the prognosis. Case Description A 52-year-old woman with migraine in her medical history visited the outpatient clinic due to left orbital pain. There was no neurologic deficit. Although magnetic resonance imaging examination found no SAH, a left internal carotid artery–posterior communicating artery bifurcation aneurysm was detected by magnetic resonance angiography. Ten days after the onset of orbital pain, the patient consulted our hospital for a second opinion. We scheduled an elective clipping because the irregular shape of the aneurysm had a high risk of rupture. On the day before surgery, the aneurysm ruptured and led to SAH. Clipping was performed immediately. The patient was discharged with no neurologic deficit. Conclusion Clinicians must take into consideration that unilateral orbital pain, though atypical, may be a symptom of SH.

Highlights • We experienced a patient with a brain abscess within a cerebellar metastasis. • A brain abscess within a brain neoplasm is a small entity, and only five cases harboring an abscess within a metastatic brain tumor have been reported to date. • Surgical procedures for brain abscesses and brain tumors are completely different; however, even today, it is difficult to differentiate a brain abscess from a necrotic brain tumor in advance. • Differentiation between the two is important due to different methods of management; preoperative assumption of the possible coexistence of both types of lesions could lead to a good outcome when we encounter a lesion which has both the imaging characteristics. • The preferred treatment of a case with both an abscess and a brain metastasis is complete surgical removal of the tumor and targeted antibiotic therapy for the abscess. The present case highlights the importance of considering coexisting diseases prior to surgery., Introduction The managements of brain abscesses and brain tumors including brain metastases differ greatly, especially in terms of surgical procedures. Therefore, differentiating between the two is essential for assuring optimal treatment. However, on rare occasion, these two lesions coexist. Only five cases with both a brain tumor and an abscess have thus, far been reported. We experienced a patient with a brain abscess within a cerebellar metastasis. Case presentation A middle-aged man receiving treatment for bile duct cancer presented with headache and nausea. Computed tomography (CT) and magnetic resonance (MR) imaging revealed two lesions, one in each cerebellar hemisphere. Although these lesions appeared to be brain metastases, the right lesion showed high intensity on diffusion-weighted images (DWI), and magnetic resonance spectroscopy (MRS) findings suggested an abscess. Surgical puncture of the lesion identified it as a brain abscess histologically, and we thus, administered antibiotics. However, since the lesion grew, we performed a second surgery for removal, which histopathologically the lesion to be a well-differentiated adenocarcinoma. The final diagnosis was an abscess within a cerebellar metastasis. Discussion/conclusion Modern diagnostic tools such as DWI and MRS are reportedly reliable for differentiating brain tumors from brain abscesses, though they are not specific in cases with both lesions. The present case highlights the importance of considering coexisting diseases prior to surgery when we encounter a lesion which has the imaging characteristics of both a tumor and an abscess. The patient may have a better outcome if, preoperatively, surgeons take into consideration the possibility of the coexistence of a brain tumor and a brain abscess.

The lateral positioning used for the lateral suboccipital surgical approach is associated with various pathophysiologic complications. Strategies to avoid complications including an excessive load on the cervical vertebra and countermeasures against pressure ulcer development are needed. We retrospectively investigated positioning-related complications in 71 patients with cerebellopontine angle lesions undergoing surgery in our department between January 2003 and December 2010 using the lateral suboccipital approach. One patient postoperatively developed rhabdomyolysis, and another presented with transient peroneal nerve palsy on the unaffected side. Stage I and II pressure ulcers were noted in 22 and 12 patients, respectively, although neither stage III nor more severe pressure ulcers occurred. No patients experienced cervical vertebra and spinal cord impairments, brachial plexus palsy, or ulnar nerve palsy associated with rotation and flexion of the neck. Strategies to prevent positioning-related complications, associated with lateral positioning for the lateral suboccipital surgical approach, include the following: atraumatic fixation of the neck focusing on jugular venous perfusion and airway pressure, trunk rotation, and sufficient relief of weightbearing and protection of nerves including the peripheral nerves of all four extremities.

A 34-year-old man with a 1-week history of diplopia was referred to the authors' hospital. Neurological examination revealed left abducens nerve palsy. Computed tomography showed a lesion in the left sphenoid sinus involving the medial wall of the left internal carotid artery (ICA) and osteolytic change at the clivus bordering the lesion. Magnetic resonance imaging demonstrated an extensive soft-tissue mass occupying the left sphenoid sinus. Surgical intervention by the endoscopic transnasal method allowed most of the lesion to be removed. Only the portion attached to the medial wall of the ICA was not removed. Postoperatively, the lesion was diagnosed as a giant cell tumor (GCT) and the patient received 120 mg of subcutaneous denosumab every 4 weeks, with additional doses on Days 8 and 15 during the first month of therapy. MRI a week after starting denosumab revealed shrinkage of the initially fast-growing residual tumor. The patient was discharged upon completion of the third denosumab administration. GCT is an aggressive stromal tumor developing mainly in young adults. Complete resection is recommended for GCT in the literature. However, size and location of the CGT often limit this approach. Various adjuvant treatments for skull base GCTs have been reported, including radiation and chemotherapy. However, the roles of adjuvant therapies have yet to be clearly defined. Denosumab, a monoclonal antibody, was recently approved for GCT in several countries. Denosumab may permit less invasive treatments for patients with GCTs while avoiding deleterious outcomes, and may also limit disease progression and recurrence.

Background Isolated adrenocorticotropic hormone (ACTH) deficiency is a pituitary disorder characterized by reduction only in the secretion of ACTH. Although the underlying mechanism remains to be elucidated, numbers of cases with this entity have been increasing. We experienced a case presenting with gait disturbance necessitating differential diagnosis from idiopathic normal pressure hydrocephalus (iNPH). Case presentation A 69-year-old female with a complaint of difficulty walking and suspected to have iNPH at a prior hospital was referred to our department. For the prior three years, she had suffered from a progressive gait disturbance. Magnetic resonance imaging (MRI) revealed global ventricular dilatation. The typical features of the gait in iNPH cases were all identifiable. Neuropsychological dementia scale tests showed deterioration. However, the major feature of a disproportionately enlarged subarachnoid-space on MRI was not obvious. The patient developed progressively worsening fatigue during hospitalization. Her symptoms resembled those of hypothalamic-pituitary tumor patients. Serum ACTH and cortisol levels were low. While corticotrophin releasing hormone stress tests showed no response, other stress tests using thyrotropin releasing hormone, luteinizing hormone releasing hormone, and growth hormone releasing hormone yielded normal responses, indicating a diagnosis of isolated ACTH deficiency. We initiated corticosteroid therapy, and her gait disturbance improved promptly. Conclusion Isolated ACTH deficiency may have major significance to the differential diagnosis of iNPH. Early consideration of this entity is anticipated to facilitate making an early diagnosis.

A 5-year-old male was referred to our department for evaluation of a firm elastic mass at the back of his head. Clinical examination revealed no abnormalities but the local area was tender. Further clinical and radiological examinations yielded no pathological findings and no other lesions were detected. The lesion was located in the diploic layer of the left parietal bone. The inner layer of the skull intact but the outer layer showed osteolytic change. The lesion did not adhere to the dura mater. The tumor was completely removed with the surrounding bone. Histological examination revealed a mesenchymal tumor comprised of myoid spindle-shaped cells arranged in whorls between muscle cells and fibroblasts and a vascular component around the spindle cells. The final diagnosis was myofibroma. The patient recovered well after the operation and he was discharged from hospital 10 days after surgery. Clinical and radiological follow-up 6 and 12 months later showed neither recurrence of the primary lesion nor any indications of lesions at other sites. Myofibroma is a benign neoplasm composed of myoid cells with thin-walled blood vessels. This tumor, reported to have a wide range of clinical manifestations, is one of the cranial vault tumors. These tumors occur mainly in children although a few affected infants have been reported. Surgical intervention may contribute significantly to the diagnosis of solitary myofibroma and complete removal achieves good outcomes. Herein, we report a 5-year-old male with solitary myofibroma of the skull, presenting as a firm elastic mass in the left parietal bone.

Bending-loss insensitive fibers (BIFs) have been receiving increasing attention with a view to improving FTTH network installation and maintenance. Several BIFs have been proposed and developed to realize a lower bending loss, and hole-assisted fiber (HAF) can realize both excellent bending loss characteristics and other properties compatible with conventional single-mode fiber (SMF). In this paper, we numerically clarify a design that provides both an allowable bending radius of 5 mm and other properties comparable to conventional SMFs. The calculated results also reveal the much wider single-mode bandwidth of HAF with both a low bending loss and a comparable MFD to that of SMF. We then discuss the applicability of HAF based optical cord for short-length transmission and reveal the sufficiently low multi-pass interference (MPI) characteristics of single-mode HAF, which are independent of the existence of a mode field diameter (MFD) mismatch. Although a large MFD mismatch degrades the MPI characteristics of HAF with a longer cut-off wavelength, we reveal a way to improve the MPI for such a HAF by utilizing the sweep fusion splicing technique.

About the Play Ana (Hole), written by Fujita Asaya, is a one-act play premiered, under the author's direction, by the theatre company Sanjunin-kai (Thirty People Society) at the Ginza Gas Hall in Tokyo on February 6, 1965 (San'ichi 1972: 475). (1) Hole is a funny yet poignant drama that depicts the dilemma of three unemployed coal miners struggling to survive. Fujita has labeled Hole "modern kyogen" (gendai no kyogen). While it presents a contemporary subject and characters, it is written in a style modeled after the classical drama. His "modern kyogen" is created as part of a movement intended both to revive Japanese theatre after the war and to refresh it with the main currents of postwar thought. The playwright made his motives clear at a symposium held in Tokyo in October 1966: I believe that there exists something uniquely Japanese where Japanese life and theatre meet, and that Western dramaturgy fails to capture. We need to explore such an area so as to discover or create dramaturgy that can express and communicate the Japanese. To me, the real significance of cultural heritage and tradition is to look into them and to get closer to the spirit that has originated and supported the cultural inheritance.... I wondered what kind of kyogen plays those who originated the form would write if they were, say, living in Tokyo in 1966. Those thoughts made me want to write modern kyogen plays. (San'ichi 1972: 457) Fujita is interested in kyogen as his dramaturgical means of telling a contemporary story because of its simple form familiar to Japanese audiences. He is also attracted to the classical drama because he wants to revive in modern theatre "the spirit that has originated and supported the cultural inheritance." To Fujita, the precise nature of the spirit is satire. He believes that the laughter of kyogen in its early developmental stage was very much "satirical in nature that produced laughter and revealed social contradictions at the same time" (San'ichi 1972: 457). The dramatist, in adapting modern stories into the traditional settings, attempts to make the classical form more immediate to the modern audience, at the same time transcending cold and blunt modern issues with a poetic, humorous, and yet satirical telling of them. The issue dealt with in Hole is the unemployment of miners affected by the demise of the coal mine industry in Japan starting in the 1950s. The play's dramatic motif comes from Ueno Eishin's book Owareyuku kofu-tachi (Disappearing Miners), published in 1960 (San'ichi 1972: 71), which documents the hardship of coal miners in Fukuoka's Chikuho region, where coal mines were once the most prosperous enterprises. However, the country's rapid economic growth and the government's new national energy policy in the 1950s and 1960s devastated the coal mine industry in Chikuho and other areas, resulting in the closure of most mines. Accordingly, Fujita's protagonists are the victims of a mine closure, and the mine owner has disappeared without paying the miners' wages. The title of the play indicates the emptiness of the miners daily survival in a hollow life, symbolized by their frustration at not being able to mine real coal, and by the empty tunnel they must dig in order to live. While social satire is the kyogen convention that Fujita employs in his modern work, other kyogen elements also comprise much of his dramaturgy. Kyogen's humor is engendered by human failings, mistakes, and gullibility. Laughter derives from unexpected dilemmas in which wrong-doers, like the ignorant officials and hypocritical priests of traditional kyogen, find themselves. In Hole, the obvious victim is the landlord, whose greed makes him blind to the coal miners' trick. He is made to suffer in a way that seems particularly suitable, and the poetic justice allows the audience to laugh. When laughter stops, however, a sense of pathos sets in. …

The applicability of few-mode fiber (FMF) as a single-multi-single (SMS) sensor is investigated. We examine experimentally the wavelength shift and/or visibility characteristics in an FMF based SMS sensor by changing the external temperature and longitudinal strain individually. We investigate numerically the temperature sensitivity of the fabricated sensor by considering the temperature dependence of the effective refractive index difference. Our results show that an FMF based SMS sensor can be used to measure the relative variation in temperature and strain simultaneously, and whose sensitivity can be tailored easily by designing two LP modes in an FMF.

We realize a multi-core fiber (MCF) fully compatible with conventional single-mode fiber (SMF) in all telecommunication bands while maintaining 125 μm cladding. The designed MCF enables us to construct a full-band SDM transmission link harmonizing with existing SMF links.

A 34-year-old female was admitted at 34 weeks of gestation with sudden onset of a severe headache accompanied by vomiting. Neurological examination revealed neck rigidity, and computed tomography (CT) of the brain revealed a subarachnoid hemorrhage (SAH). Although the hemorrhage was located primarily in the left Sylvian fissure, computed tomography angiography (CTA) performed immediately after CT did not reveal any obvious vascular abnormalities such as an intracranial aneurysm. An emergency cesarean section was performed, and a healthy infant was delivered. Cerebral digital subtraction angiography (DSA) was performed the day following surgery, which revealed a saccular aneurysm measuring 4.3 mm × 2.4 mm in the left middle cerebral artery. Left craniotomy and clipping of the aneurysm were performed. The clot around the aneurysm was relatively solid. This case report is of significance given that initial CTA was negative for SAH during pregnancy, suggesting the requirement for immediate DSA or another CTA in such cases. There are many previous reports on false-negative CTA findings or disappearance and reappearance of aneurysms in SAH patients, and various biophysical and dynamic parameters are suggested to cause such phenomena. However, there are no reports on similar occurrences during pregnancy. Although the precise cause remains unclear, multiple factors associated with homeostasis during pregnancy were possibly associated with the transient disappearance in this patient.

(1) The program, which was developed on the basis of the theme, “Creating a new game through bound ball and dodge ball games, ” was found to meet the curiosity and the interest of children and to deepen their understanding.(2) From test results of the program, the design principle of the programming for the comprehensive study that we propose was found to be valid. Furthermore, it was suggested that experience- sharing in the problem-formation process effectively functioned in “turning others's experience into one's ownself-experience” at the stage of empathy/exchange of problem-solving outcomes and played an important role in deepening understanding.

We experimentally investigate the effective mode-field diameter (MFD) of coupled type multi-core fibres (MCFs). Effective MFDs of two different coupled MCFs are derived by considering the relationship with the splice loss characteristics. We also examine the applicability of conventional variable aperture (VA) and far-field pattern (FFP) scanning methods by considering the consistency with the effective MFD values. Our results show the potential of the VA method for evaluating the effective MFD characteristics of a coupled type MCF with arbitral field distribution. We also show that the effective MFD can be estimated by considering the widest and narrowest MFD values even if the field distribution becomes a crosswise. These results are useful when we examine the detail characteristics of a coupled type MCF as both transmission and/or sensing medium.

A technique is proposed for evaluating power coupling coefficient distribution in a multi-core fiber. The longitudinal crosstalk characteristic in a two-core fiber is successfully evaluated using a bi-directional OTDR waveform simply obtained with one core.

The impact of multi-core crosstalk on far-field pattern (FFP) measurement is clarified numerically and experimentally. We show that the neighboring core angle against the scanning plane greatly affects the FFP and mode-field diameter characteristics.

The purpose of this study was to clarify the optimum timc for learning of the running high jump.Subjects were 302 children (boys: 153, girls: 149) from the 4th to the 6th grades of elementary school. They had taken 13 lesson units using two methods. One was reverse order of move ment process of running high jump, the other was order of movement process.No significant differences were found for the effect on high jump performance (Height) between grades.However, in the higher grades, the effeet of learning was smaller when evaluated in the clearance skill, but, greater when evaluated in take-off skill. The percent contribution of clearance and take-off skills to increment of performance with practice, was 91.8% and 8.2% for the 4th grade, 66.7% and 33.2% for the 5th grade and 39.3% and 60.7% for the 6th grade, respectively.High jump skill index [HJS=(record-1/2 height)/vertical jump×100] showed the 4th grade; 73.1±20.3 point, the 5th grade; 74.2±17.5 point and the 6th grade; 76.5±15.3 point, respectively, after curses.The 4th grade did not improve the image of the running high jump throughout the courses, that is, the learning effect of the 6th grade in the cognitive domain was much better than that of the 4th and the 5th grades.The present results suggested that the learning of the technique for clearance appeared possible for the 4th grade children, and that the optimum time for learning of the technique for take-off in the running high jump was when children were in the 6th grade in elementary school.

Potential of uncoupled multi-core fiber (MCF) is investigated with viewpoints of space utilization efficiency and the figure of merit (FOM). The impact of longitudinal optical coupling characterization and/or management is discussed using a dual-core fiber.

We numerically clarify the relationship between cutoff wavelength and cladding diameter and derive simple empirical relationship for a step index fiber. A single-mode fiber with lower bending-loss can easily obtained by optimizing the cladding diameter.

The estimation method of the coupled-power coefficient of a weakly-coupled multi-core fiber with a bi-directional OTDR technique is proposed. The estimated crosstalk with the proposed bi-directional OTDR method agrees with the measured crosstalk.

A 63-year-old man suddenly presented with right hemiplegia and was taken to our hospital. Computed tomography (CT) scan revealed subcortical hemorrhage of the left parietal lobe. He had no medical history except hypertension; thus, it initially appeared to be a typical hypertensive hemorrhage. However, blood analysis showed an abnormally elevated activated partial thromboplastin time. One hour after admission, his Glasgow Coma Scale fell from 14 to 11. We performed an echo-guided stereotaxic removal of the hematoma. He improved immediately and was diagnosed with congenital factor XI (FXI) deficiency a few days after surgery. FXI deficiency, described as hemophilic syndrome C, rarely manifests as spontaneous bleeding, but surgical intervention has been known to manifest as bleeding. This case highlights the importance of evaluation of coagulopathies in patients with intracerebral hemorrhage before surgery, and, in cases wherein blood analysis results suggest coexisting coagulation disorders, less invasive surgical methods would likely lead to good outcomes.

(40-Word Limit): We demonstrate 1.01-Pb/s transmission over 52 km with the highest aggregate spectral efficiency of 91.4 b/s/Hz by using low-crosstalk one-ring-structured 12-core fiber. Our multi-core fiber and compact fan-in/fan-out devices are designed to support high-order modulation formats up to 32-QAM in SDM transmission.

This study was designed to investigate age-related differences in isokinetic peak torque and its endurance on normal 172 boys ranging in age from 10 to 18 years served as volunteer subjects. Each subject was given a leg extension/flexion test using an isokinetic dynamometer (Cybex II), and extended/flexed at every speed of 0°, 60°, 120°, 180°, 240° and 300°/sec to measure the peak torque of thigh muscles estimated as muscle strength. He was also given an endurance test used the above Cybex II and extended maximally a leg at 180°/sec, 50 times, An endurance of thigh muscles was calculated as a ratio of (mean value for peak torque of initial 5 times-mean value of final 5 times)/mean value of initial 5 times.The peak torque, measured in the extension/flexion test, clearly increased in order of age. In the endurance test, the initial mean value for peak torque was in almost the same developing pattern as those described above in the leg extension/flexion test, but the final mean value did not respond to age over 16 years old.Therefore, 96 boys, aged 11 to 15 years old organized five age groups, and individual group was divided into two subgroups, i, e, experimental group and control group. The members in the experimental group participated in an isokinetic muscle training used Cybex II, consisted of 3 days/week, and 3 sets/day (1 set was 30-times repetition at 180°/sec) throughout 8 weeks.The training increased considerably the strength and endurance of thigh muscles for boys ages 13 years, compared to another age group. Boys aged 14 and 15 years had a larger increment of muscle strength through the training than 11 and 12 years old boys. Boys of 12 years, however, showed a comparable increase in muscle endurance through the training to those aged 14 and 15 years.As above showed, it was discernible that the effects of training on the muscle strength and endurance generally depended on physical maturing.The effect on muscle strength of thigh flexors through the training was greater than that of thigh extensor, independently of age.The improvement of muscle strength was caused by muscle hypertrophy and neurological factor, especially the latter regardless of age, irrespective of the influence due to hypertrophy extended from 10.3% at the age of eleven to 19.1% at the age of fifteen.

Single-mode hole-assisted-fibre (HAF) based optical cord reveals no multipath interference (MPI) degradation independent of the existence of a mode-field diameter mismatch. Moreover, sweep fusion splicing effectively reduces MPI even if the HAF has extremely strong confinement.