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Objective To examine a potential association between intranidal microhemodynamics and rupture using a phase-contrast magnetic resonance angiography (PCMRA)-based flow quantification technique in arteriovenous malformations (AVMs). Methods We retrospectively collected data on 30 consecutive patients with AVMs (23 unruptured and 7 ruptured). Based on PCMRA data, maximal (Vmax) and mean (Vmean) intranidal velocities were calculated. Logistic regression analysis was performed to assess factors associated with previous AVM rupture. Results All ruptures occurred within 6 months before PCMRA. The mean nidus volume was 4.7 mL. Eleven patients (37%) had deep draining vein(s), and 6 patients (20%) had a deep-seated nidus. The mean ± standard deviation Vmean and Vmax were 9.6 ± 2.8 cm/second and 66.7 ± 26.2 cm/second, respectively. The logistic regression analyses revealed that higher Vmax (P = 0.075, unit odds ratio [OR] = 1.05, 95% confidence interval [95% CI] = 1.00–1.10) was significantly associated with prior hemorrhage. The receiver-operating curve analyses demonstrated that a Vmean of 10.8 cm/second (area under the curve = 0.671) and Vmax of 90.2 cm/second (area under the curve = 0.764) maximized the Youden Index. A Vmax > 90 cm/second was significantly associated with AVM rupture both in the univariate (P = 0.025, OR = 9.0, 95% CI = 1.3–61.1) and multivariate (P = 0.008, OR = 51.7, 95% CI = 2.8–968.3) analyses. Conclusions Presence of faster velocities in intranidal vessels may suggest aberrant microhemodynamics and thus be associated with AVM rupture. PCMRA-based velocimetry seems to be a promising tool to predict future AVM rupture.

Background Ganglion cysts mostly occur in the knuckles and wrists, but they rarely present in the odontoid process and can cause neurological symptoms by compressing the spinal cord. They are mostly localized in the epidural space, but may very rarely appear in the intradural space. There are no reports of cases of intradural ganglion cyst involving syringobulbia. Case Description We report the presentation and management of 2 cases of an intradural ganglion cyst of the odontoid process. Several treatment options for ganglion cysts of the odontoid process have been reported, such as rest and use of a neck collar, posterior decompression and fusion, and transoral anterior decompression. Because our 2 cases progressed rapidly and had severe neurological symptoms, surgical treatment was performed for rapid decompression and definitive pathological diagnosis. The mass was resected as much as possible using the lateral occipital fossa approach, and the operation was completed without dissection of the brain stem or manipulation of the syringobulbia. Postoperatively, neurological symptoms promptly improved, and the syringobulbia reduced. Conclusions For intradural ganglion cysts with syringobulbia, we suggest relief of the compression by resection of the mass and treatment of the syringobulbia in 2 stages, if necessary, to avoid the risk of damage to the brainstem.

Background In neurosurgery, it is important to inspect the spatial correspondence between the preoperative medical image (virtual space), and the intraoperative findings (real space) to improve the safety of the surgery. Navigation systems and related modalities have been reported as methods for matching this correspondence. However, because of the influence of the brain shift accompanying craniotomy, registration accuracy is reduced. In the present study, to overcome these issues, we developed a spatially accurate registration method of medical fusion 3-dimensional computer graphics and the intraoperative brain surface photograph, and its registration accuracy was measured. Methods The subjects included 16 patients with glioma. Nonrigid registration using the landmarks and thin-plate spline methods was performed for the fusion 3-dimensional computer graphics and the intraoperative brain surface photograph, termed mixed-reality computer graphics. Regarding the registration accuracy measurement, the target registration error was measured by two neurosurgeons, with 10 points for each case at the midpoint of the landmarks. Results The number of target registration error measurement points was 160 in the 16 cases. The target registration error was 0.72 ± 0.04 mm. Aligning the intraoperative brain surface photograph and the fusion 3-dimensional computer graphics required ∼10 minutes on average. The average number of landmarks used for alignment was 24.6. Conclusions Mixed-reality computer graphics enabled highly precise spatial alignment between the real space and virtual space. Mixed-reality computer graphics have the potential to improve the safety of the surgery by allowing complementary observation of brain surface photographs and fusion 3-dimensional computer graphics.

Background Intraoperative rupture is the most fatal and catastrophic complication of surgery for unruptured intracranial aneurysms (UIAs); thus, it is extremely useful to predict reddish and thin-walled regions of the UIA before surgery. Although several studies have reported a relationship between the hemodynamic characteristics and intracranial aneurysm wall thickness, a consistent opinion is lacking. We aimed to investigate the relationship between objectively and quantitatively evaluated bleb wall color and hemodynamic characteristics using phase-contrast magnetic resonance angiography (PC-MRA). Methods Ten patients diagnosed with UIA who underwent surgical clipping and preoperative magnetic resonance imaging along with PC-MRA were included in this study. Bleb wall color was evaluated from an intraoperative video. Based on the Red (R), Green, and Blue values, bleb wall redness (modified R value; mR) was calculated and compared with the hemodynamic characteristics obtained from PC-MRA. Results The wall redness distribution of 18 blebs in 11 UIAs in 10 patients was analyzed. Bleb/neck inflow velocity ratio (Vb/Va: r = 0.66, P = 0.003) strongly correlated with mR, whereas bleb/neck inflow rate ratio (r = 0.58, P = 0.012) correlated moderately. Multivariate regression analysis revealed that only Vb/Va (P = 0.017) significantly correlated with mR. There was no correlation between wall shear stress and mR. Conclusions The bleb redness of UIAs and Vb/Va, calculated using PC-MRA, showed a significantly greater correlation. Thus, it is possible to predict bleb thickness noninvasively before surgery. This will facilitate more detailed pre- and intraoperative strategies for clipping and coiling for safe surgery.

OBJECTIVEThe posterior petrosal approach is an established surgical method offering wide access to skull base lesions through mastoid air cells. The authors describe their experience with the endoscopic transmastoid “posterior petrosal” approach (EPPAP) for skull base tumors involving the internal auditory canal (IAC), jugular foramen, and hypoglossal canal.METHODSThe EPPAP was performed for 7 tumors (3 chordomas, 2 chondrosarcomas, 1 schwannoma, and 1 solitary fibrous tumor). All surgical procedures were performed under endoscopic visualization with mastoidectomy. The compact bone of the mastoid air cells and posterior surface of the petrous bone are carefully removed behind the semicircular canals. When removal of cancellous bone is extended superomedially through the infralabyrinthine space, the surgeon can expose the IAC and petrous portion of the internal carotid artery to reach the petrous apex (infralabyrinthine route). When removal of cancellous bone is extended inferomedially along the sigmoid sinus, the surgeon can safely reach the jugular foramen (transjugular route). Drilling of the inferior surface of petrous bone is extended further inferoposteriorly behind the jugular bulb to approach the hypoglossal canal and parapharyngeal space through the lateral aspect of the occipital condyle (infrajugular route).RESULTSOf the 7 tumors, gross-total resection was achieved in 4 (57.1%), subtotal resection (> 95% removal) in 2 (28.6%), and partial resection (90% removal) in 1 (14.2%). Postoperatively, 2 of 3 patients with exudative otitis media showed improvement of hearing deterioration, as did 2 patients with tinnitus. Hypoglossal nerve palsy and swallowing difficulty were improved after surgery in 2 patients and 1 patient, respectively. In 1 patient with severe cranial nerve deficits before surgery, symptoms did not show any improvement.CONCLUSIONSThe authors present their preliminary experience with EPPAP for skull base tumors in the petrous part of the temporal bone and the lateral part of the occipital condyle involving the cranial nerves and internal carotid arteries. The microscope showed a higher-quality image and illumination in the low-power field. However, the endoscope could offer wider visualization of the surgical field and contribute to minimizing the size of the surgical pathways, necessity of brain retraction, and eventually the invasiveness of surgery. Thus, the EPPAP may be safe and effective for skull base tumors in the petrous region, achieving balance between the radicality and invasiveness of the skull base surgery.

PURPOSE: Diffusion tensor tractography (DTT) is a method to estimate the direction of white matter fibers, but it is not easy to verify the relationship with brain functions accurately. We developed mixed reality computer graphics (MRCG) which integrates real space (brain surface image) and preoperative 3DCG (3-dimentional computer graphics). In our previous study, this method allowed high precision registration even after brain shift caused by craniotomy, and target registration error was 0.5 ± 0.04mm (mean±SE). We devised a method to investigate the spatial error of DTT and direct cortical stimulation (DCS) using MRCG. We examine its accuracy and clinical application. METHODS: We covered 4 patients with glioma who were underwent awake surgery. The sex of all the patients was male, and the average age was 40. MRCG was constructed by fusing 3DCG prepared before surgery and brain surface photograph (JPEG format) just after craniotomy using our original method, which is called thin plate spline method with some landmarks. Brain function mapping results by DCS were plotted on MRCG. In the surface photograph, we provided grids of 1cm square, then we jagged the site where positive symptoms appeared by DCS was true, and the negative site was false. The spatial error between the cortical cortex and brain function mapping estimated by arcuate fiber of DTT was measured. RESULTS: In 4 cases, DCS was performed in 36 places (average 9 places / case). The sensitivity and specificity of DTT were 0.21 and 0.68, false positive rate and false negative rate were 0.31 and 0.79, respectively. In surgery, the tumor resection was performed with reference to MRCG reflecting the brain function mapping result. CONCLUSION: The proposed method investigated at real space and virtual space suggests DTT does not necessarily match the results of DCS.

PURPOSE Diffusion tensor-based tractography (DTT) is a method to estimate the direction of white matter fibers, but it is difficult to verify the relationship with brain function spatially with high accuracy. We developed a registration method to fuse the real space (brain surface photograph) and preoperative fused 3D image (virtual space) using the landmark method and thin plate spline method. In our previous study, this method was able to achieve highly accurate alignment registration error 0.7±0.1mm (mean±SE) even after brain shift due to craniotomy. In this study, we proposed a method to examine spatial errors of DTT and direct cortical stimulation (DCS) and verify its accuracy. METHODS We included 7 gliomas performed awake surgery. We created the fused three – dimensional image before surgery and acquired the brain surface photograph immediately after craniotomy, then we aligned them using the proposed method. Sites that showed speech arrest by DCS were plotted on the fused image. A circle with a radius of 15 mm centered on the same site was taken as the range over which the current spreads. The surface area of each of the circles was calculated to make it true if there was arcuate fasciculus drawn with DTT in the circle, and false if it did not exist. By using this method, the accuracy of the DTT was verified. RESULT: In 7 cases, speech arrest was shown at 21 DCS plots. The probability of the presence of DTT within the current spread of DCS was 64.4%. CONCLUSION The proposed method indicates that DTT does not necessarily match the DCS results by verification using real space and virtual space. We present some illustrative cases.

A 53-year-old woman experienced a right retrobulbar pain followed by ipsilateral extraocular palsies in all directions without dilated pupils or ptosis. Because a plain head computed tomography (CT) scan obtained on her initial visit showed no abnormal findings, such as subarachnoid hemorrhage or a giant cavernous aneurysm, her condition was provisionally diagnosed as Tolosa-Hunt syndrome and elective magnetic resonance (MR) imaging was scheduled. The day after her initial visit, however, she suddenly developed complete ptosis and a dilated pupil on the right side. Emergency MR imaging and angiography revealed a clover leaf-shaped aneurysm projecting to the cavernous sinus at the junction of the internal carotid artery and the posterior communicating artery. Her condition was diagnosed as impending rupture of the aneurysm, and she underwent emergency open surgery. Her symptoms completely resolved within the following 2 weeks. Our case demonstrated that a medium-sized internal carotid artery-posterior communicating artery aneurysm can cause simultaneous oculomotor and abducens nerve palsies with retrobulbar pain if the shape of the aneurysm is complicated. Although these symptoms are very similar to those of Tolosa-Hunt syndrome, we believe that prompt radiological examinations such as MR or 3D CT angiography should be performed to prevent subsequent rupture of the aneurysm.

Recent investigation suggests that the dorsal anterior cingulate cortex (ACC) is involved in the interplay between cognition and emotion. The present study described three patients who underwent removal of brain tumors just above the right dorsal ACC. These patients had residual tumor following surgery and showed anxiety disorder (AD) both before and after surgery. Visual memory or attention was abnormal before surgery in these patients, but these deficits improved following surgery, possibly due to a decrease in compression of the right dorsal ACC. These results suggest that damage to the right dorsal ACC is involved in AD and well as in deficits in visual memory or attention. Therefore, the right dorsal ACC might play a role in vision-related cognition and emotion, such as anxiety.