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Differentiation of suprasellar xanthogranuloma (XG) from adult craniopharyngioma (CP) can be problematic in endoscopic extended transsphenoidal surgery.We reviewed the clinical data, preoperative imaging, intraoperative endoscopic findings, and intraoperative frozen section pathology in newly diagnosed adult CPs (19 patients) and XGs (6 patients).Intracystic signal intensity was often high on T1-weighted magnetic resonance images in the XGs but low in the CPs (P = 0.015). Capsular intensity was low on T2-weighted imaging in XGs but iso to high in CPs (P0.001). Capsular gadolinium enhancement was often seen in CPs and not in XGs (P0.001). CPs often had a solid component with contrast enhancement but none in XGs (P0.001). Intraoperative endoscopic observations frequently found a whitish solid component in the CPs but yellow to brown fibrous granulomatous lesions in XGs (P0.001). The tumor capsule was dark grayish and soft in CPs, whereas it was fibrously hard in XGs (P = 0.002). Yellowish hemosiderin deposits were seen in all XGs (P = 0.003). Intraoperative pathologic diagnosis of CP was all verified whereas no evidence of tumor was found in XGs (P0.001). Partial removal was performed in 4 patients with XGs. No recurrence was observed in these patients during the follow-up period (1.5-8 years).Careful interpretation of preoperative magnetic resonance imaging, intraoperative endoscopic findings, and intraoperative frozen section diagnosis may be important for the differential diagnosis between XG and CP. In endoscopic-extended transsphenoidal surgery, intentional partial removal can be effective for XG after careful diagnosis.

The aim of this study was to evaluate the course of occluded distal vessels before mechanical thrombectomy (MT) for acute large vessel occlusion (LVO) with non-contrast magnetic resonance imaging (MRI). The variable flip-angle three-dimensional turbo spin-echo (VRFA-3D-TSE) method was used to evaluate the course of occluded distal vessels quickly and clearly in acute LVO cases before MT.Patients with acute LVO who were indicated for MT between April 2021 and March 2022 were examined by the VRFA-3D-TSE method to evaluate the distal course of occluded vessels. We included internal carotid artery (ICA) occlusion, M1 occlusion of the middle cerebral artery, and basilar artery (BA) occlusion. Preoperative images were compared to the angiographic findings after recanalization or with follow-up magnetic resonance angiography, and the results were assessed by 2 endovascular treatment specialists as excellent, good, or poor imaging.MT was performed in a total of 27 patients. There were 17 patients with intracranial occlusion of the ICA, M1, and BA. Occlusion was found in the intracranial ICA in 6 patients, the M1 in 7, and the BA in 4. VRFA-3D-TSE MRI was performed in all patients, and the imaging was rated (by the 2assessors) as excellent in 12 of 17 and 14 of 17 cases, good in 5 of 17 and 3 of 17 cases, and poor in 0 of 17 cases.In patients with acute LVO, VRFA-3D-TSE MRI enabled rapid and good depiction of the course of occluded distal vessels before MT without the use of contrast medium.

Asymmetric features of nonfunctioning pituitary adenoma (NFPA) are poorly understood. We investigated the asymmetry in NFPA on magnetic resonance imaging.We reviewed preoperative magnetic resonance imaging findings of patients initially treated for NFPA. The internal carotid artery (ICA) often seemed to cause an indentation in the external shape of the tumor (i.e., the ICA notch).Two cases with a normal pituitary gland located at the midline were excluded. The remaining 66 cases were examined. The side where the normal gland was located was defined as the normal pituitary side and the opposite side as the cavernous sinus side. The Knosp grade was significantly higher on the cavernous sinus side (P 0.001), and the vertical distance of the ICA was significantly greater on the cavernous sinus side (P 0.001). The ICA notch was found in 87.9% of all cases on the normal pituitary side, but in only 45.5% on the cavernous sinus side (P 0.001). In cases with a single-side ICA notch (34 of 68), the ICA notch was found in 91.2% of cases and on the cavernous sinus side in 8.8% (P 0.001).Magnetic resonance imaging of NFPA frequently shows asymmetry. The tumor does not extend laterally on the normal pituitary side but extends laterally more freely on the cavernous sinus side. The ICA notch is often found on the normal pituitary side where the position of ICA does not move. This may be useful as a preoperative sign to indicate the normal pituitary side.

Visual dysfunction due to sellar and suprasellar lesions is thought to be caused by chiasmatic compression and bending of the optic nerve at the entrance of the optic canal. We examined the relationship between visual field impairment and magnetic resonance (MR) imaging.This study reviewed 122 consecutive patients with sellar and suprasellar tumors. We have newly devised a simple visual field impairment score (SVFIS) that was divided into 12 areas. SVFIS is classified into four grades as mild (0-3 points), moderate (4-6 points), severe (7-9 points), and most severe (10-12 points) for each eye. We investigated the relationship between SVFIS grades and MR imaging, including the recently reported optic nerve-canal bending angle (ONCBA) and visual acuity.Ipsilateral visual acuity tended to deteriorate with increased SVFIS grade. Larger ONCBA was associated with increased SVFIS grades. Bitemporal hemianopia occurred in the early stage (mild case), but the central visual field within 30° was particularly likely to be impaired. The visual field disturbance progressed clockwise (counterclockwise on the left side) from the upper temporal side. Disorders of the central visual field within 5° were associated with ipsilateral large ONCBA.The newly developed SVFIS grades are closely associated with indicators of visual pathway impairment on MR imaging, and are useful as indicators of the severity and progression of visual field impairment due to sellar and suprasellar lesions. Disorders of the central visual field within 5° were found to be associated with ipsilateral large ONCBA.

Summary Ferroptosis, a type of oxidative stress cell death, has been implicated in cell injury in several diseases, and treatments with specific inhibitors have been shown to protect cells and tissues. Here we demonstrated that a treatment with the nitroxide radical, 2,2,6,6-tetramethylpiperidine-N-oxyl (TEMPO), prevented the ferroptotic cell death in an airborne manner. Other TEMPO derivatives and lipophilic antioxidants, such as Trolox and ferrostatin-1, also prevented cell death induced by erastin and RSL3; however, only TEMPO exhibited inhibitory activity from a physically distant location. TEMPO vaporized without decomposing and then dissolved again into a nearby water solution. Volatilized TEMPO inhibited glutamate-induced cell death in mouse hippocampal cell lines and also reduced neuronal cell death in a mouse ischemia model. These results suggest that TEMPO is a unique cell protective agent that acts in a volatility-mediated manner.

A case of ruptured anterior cerebral artery (ACA) dissection was treated with multiple neck-bridge stents, with modification of antiplatelet administration according to changes in the shape of the aneurysm in the acute phase. A 67-year-old woman presented with severe subarachnoid hemorrhage and fusiform dilatation was observed in the left ACA between the A1 and A2 segments. The use of stents in the acute phase is associated with high risk of ischemic complications. Prasugrel administration, which is considered to have low drug resistance, may have allowed safe stent use in the acute phase.

BACKGROUND A vertebral artery–anterior spinal artery (VA-ASA) aneurysm is very rare. The authors report a case of successful coil embolization of a ruptured aneurysm of the VA-ASA. OBSERVATIONS A 54-year-old man with World Federation of Neurosurgical Societies grade II subarachnoid hemorrhage presented with an aneurysm located at the region involving the origin of ASA on the VA. Endovascular treatment was chosen to prevent rerupture and preserve the perforating branches. The catheter shape was modified with steam forming to allow access to the aneurysm. Partial embolization was performed to preserve the ASA. The authors also prevented further rupture. On day 16, angiography showed thrombosis within the aneurysm and preserved blood flow in the ASA despite a neck remnant. The patient was discharged home with a modified Rankin Scale score of 0. Careful follow-up has been continued. LESSONS Endovascular coiling in the acute phase of rupture of a VA-ASA aneurysm achieved favorable results. The aneurysm could be safely treated by selecting the appropriate device and catheter geometry.

Objective Postoperative cerebrospinal fluid (CSF) leakage in endoscopic transsphenoidal surgery is a potential risk that requires immediate repair. We investigated the potential of common postoperative hematological examinations for diagnosing postoperative CSF leakage. Methods We retrospectively studied 214 consecutive cases who underwent endoscopic transsphenoidal approach (ETSA; transsellar approach) or extended ETSA (E-ETSA). Patients with postoperative CSF leakage were defined the leak group (group L), and patients without were defined as the nonleak group (group N). Postoperative C-reactive protein (CRP) was compared between the ETSA and E-ETSA groups, and between the N and L groups. Results The values of white blood cell count and CRP 1 to 7 days after surgery were significantly higher in the L group. Especially, CRP was clearly elevated in the L group (p Conclusion Elevated CRP after endoscopic endonasal transsphenoidal surgery is a potential marker of CSF leakage.

Objective It is challenging to safely treat blood blister–like aneurysms (BBAs) of the internal carotid artery. Endovascular surgery has been reported, but the optimal strategy is yet to be established. We report our endovascular treatment strategy using the Low-profile Visualized Intraluminal Support (LVIS) stent. Methods Twelve patients with ruptured BBAs including 1 patient with 2 separate aneurysmal bulges were treated from December 2017 to January 2020. Single LVIS stent-assisted coil embolization was performed as the initial treatment. If the coil could not be placed in the aneurysm, or follow-up angiography showed persistent filling or regrowth of the aneurysm, a second LVIS stent was deployed as an overlapping stent. Clinical characteristics, treatment details, and clinical outcomes were retrospectively examined. Results Single stent-assisted coiling was performed in 8 patients (69%), 2 overlapping stents with coiling in 1 (8%), a single stent in 2 (15%), and 2 overlapping stents in 2 (15%). Three patients with persistent filling or regrowth of the aneurysm were re-treated with overlapping stents. Follow-up angiography confirmed complete occlusion in 12 aneurysms (92%). No re-rupture occurred. Postoperative symptomatic ischemia was confirmed in 4 patients (33%), and all 4 patients suffered severe subarachnoid hemorrhage. Modified Rankin scale was 0–2 in 8 patients (67%). Conclusions LVIS stent-assisted coil embolization is effective in preventing re-rupture of BBAs. However, the morphology of the aneurysm may change within a short period, so careful angiographic follow-up is needed. Appropriate preoperative antiplatelet administration and optimal timing of the treatment may reduce the risk of postoperative ischemic complication.

Objectives The effects of thalamic stimulation of the anterior part of the ventral posterolateral nucleus (VPLa) for central poststroke pain (CPSP) and the pain-related electrophysiological characteristics of this structure were investigated. Materials and methods Nine patients with CPSP manifesting as hemibody pain were enrolled. Stereotactic thalamic VPLa stimulation was implemented, and intraoperative electrophysiological studies on hyperactive and unstable discharges (HUDs) and responses to sensory and electrical stimulation were performed in the sensory thalamus. A preoperative somatosensory-evoked potential (SEP) study was carried out in all nine patients and in eight other patients with localized pain. Results The patients were classified into two groups: a HUD-dominant group (group H, n = 5) and a sensory response-dominant group (group R, n = 4). HUDs were frequently encountered in the thalamic VPLa in the former group. The total number of HUDs and the number along the trajectory to the VPLa in group H were significantly larger than those in group R. The improvements on the pain numeric rating scale in group H were significantly higher than those in group R two years after surgery. The amplitude ratio of the SEP N20s in the ipsilateral to the contralateral side of CVD lesion in the study group was significantly lower than in the localized pain group. Conclusions Adequate and stable pain relief with thalamic VPLa stimulation is obtainable in patients with CPSP who exhibit hyperactivity and electrical instability along the trajectory to this nucleus. Both responders and nonresponders were found to have severe dysfunction of the lemniscal system.

OBJECTIVEVisual acuity impairment due to sellar and suprasellar tumors is not fully understood. The relationship between these tumors and disturbance of visual function was examined using preoperative MRI.METHODSThis study reviewed 93 consecutive patients with sellar and suprasellar tumors. Best-corrected visual acuity (BCVA) and visual impairment score (VIS) were used for estimation of visual impairments. Preoperative MR images were examined to obtain several values for estimation of chiasmatic compression. Additionally, the optic nerve–canal bending angle (ONCBA) was newly defined as the external angle formed by the optic nerve in the optic canal and the optic nerve in the intracranial subarachnoid space at the junction, using preoperative sagittal T2-weighted MR images.RESULTSThe mean ONCBA was about the same on the right (44° ± 25°) and the left (44° ± 24°). Sagittal ONCBA was defined as large (> 45°) and moderate (≤ 45°) on each side. Preoperative VIS was found to be significantly worse if the right or left ONCBA (or both) was large (right side: ONCBA large [median 20, IQR 8–30] > ONCBA moderate [median 10, IQR 3–17], p = 0.003, Mann-Whitney U-test; left side: ONCBA large [median 22, IQR 9–30] > ONCBA moderate [median 10, IQR 2–16], p = 0.001). A large ONCBA showed a significant relationship with unfavorable ipsilateral BCVA (> logMAR, 0; right side, p = 0.001, left side, p = 0.001, chi-square test). The ONCBA had a positive correlation with ipsilateral BCVA (right: r = 0.297, p = 0.031; left: r = 0.451, p = 0.000, Pearson’s correlation coefficient). Preoperative BCVA was significantly lower on the same side in the large ONCBA group compared with the moderate ONCBA group (right side: large ONCBA 0.169 ± 0.333 [logMAR, mean ± standard deviation] vs moderate ONCBA 0.045 ± 0.359, p = 0.026, Student t-test; left side: large ONCBA 0.245 ± 0.346 vs moderate ONCBA 0.025 ± 0.333, p = 0.000). This visual acuity impairment improved after resection of the tumors.CONCLUSIONSSagittal bending of the optic nerve at the entrance from the intracranial subarachnoid space to the optic canal may be related to ipsilateral deterioration of visual acuity in sellar and suprasellar lesions. Sagittal T2-weighted MRI is recommended for preoperative estimation of the optic nerve bending.

Objective Larger craniotomy is expected to increase blood flow over a wider range after indirect revascularization. However, the optimal size of craniotomy has not been established. In this study perioperative complications in revascularization surgery for moyamoya disease are evaluated, focusing on craniotomy size. Methods We retrospectively analyzed 87 hemispheres in 65 patients with moyamoya disease who had undergone revascularization surgery. Areas and types of craniotomy were classified as 1-piece craniotomy in the middle cerebral artery (MCA) territory (1-piece group) in 54 hemispheres (mean area of craniotomy, 40.6 ± 13.5 cm2); 2-piece craniotomy in the MCA territory with anterior cerebral artery (ACA) territory (2-piece group) in 16 hemispheres (mean area of craniotomy, 55.4 ± 12.0 cm2); and 1-piece craniotomy in both MCA and ACA territories (large group) in 17 hemispheres (mean area of craniotomy, 84.2 ± 11.0 cm2). Perioperative complication rates in each craniotomy group were analyzed. Results Perioperative complications occurred in 45 hemispheres (52%). Transient, moderate, and severe complications occurred in 38 hemispheres, 3 hemispheres, and 4 hemispheres, respectively. Complication rates in the 1-piece, 2-piece, and large groups were 41%, 63%, and 76%, respectively. Large craniotomy was associated with a significantly higher frequency of complications (P = 0.01). However, no significant difference was found among groups when limiting analysis to moderate and severe complications. Multivariate analysis showed large craniotomy as the only factor independently related to complications (odds ratio, 2.93; 95% confidence interval, 1.08–7.92; P = 0.034). Conclusions Large craniotomy is associated with more frequent perioperative complications, especially transient symptoms.

Stroke patients with hemiplegia can sometimes achieve independent life at home or in light care facilities after rehabilitation. This study examined the outcomes of rehabilitation in stroke patients with severe hemiplegia.This study included 50 patients with Brunnstrom recovery stage I-II hemiplegia at the start of rehabilitation for stroke. Good outcome after rehabilitation was defined as independent life with functional independence measure (FIM) score of 100 or greater. Predictors for post-rehabilitation functional recovery were statistically analyzed.FIM scores of 100 or greater in 12 of 50 patients (24%) allowed independent life after stroke rehabilitation. According to univariate analysis, factors associated with a FIM score of 100 or greater and good prognosis after rehabilitation were younger age (70 years), paralysis caused by intracerebral hematoma (ICH), no cortical lesions, short time from admission to comprehensive inpatient rehabilitation (CIR) for stroke (within 1 month), and good status at the start of early rehabilitation and CIR. Eleven of the 12 patients with good prognosis (FIM ≥100) had ICH and a basal ganglia lesion with no cortical damage. Analysis of the location of lesions suggested that many patients with basal ganglia ICH lesions and little cortical involvement have good prognoses.Stroke patients with severe hemiplegia showed a slightly different distribution of lesions between ICH and cerebral ischemia. Cortical involvement may be a prognostic factor for outcome after rehabilitation in stroke patients with severe hemiplegia. More aggressive rehabilitation interventions may be important for patients with severe hemiplegia, especially without cortical involvement.

Treating recurrence after coil embolization of basilar tip aneurysm remains challenging even with the development of endovascular procedures. The present study evaluated long-term durability and recurrence patterns after endovascular treatment of basilar tip aneurysms.Data of 116 consecutive patients treated with endovascular therapy at 3 regional hospitals from 2002-2019 were retrospectively analyzed. Aneurysms were ruptured in 51 cases and unruptured in 65 cases, with a mean maximal diameter of 7.8 mm (15 mm in 14 patients) and a mean follow-up period of 5.8 ± 4.3 years.Recurrence was observed in 24 of the 116 patients (21%), and 14 patients were retreated. The 5-year recurrence-free survival rate was 75.3%. Cox proportional hazards analysis found that recurrence correlated significantly with maximal aneurysm diameter10 mm (P = 0.001; hazard ratio: 3.95, 95% confidence interval: 1.76-8.90) and incomplete occlusion (P = 0.003; hazard ratio: 4.43, 95% confidence interval: 1.63-12.00). Recurrence pattern was classified into 3 types: neck type (9 patients), regrowth type (10 patients), and regrowth type of initially thrombosed aneurysms (3 patients). Rerupture occurred in neck type with de novo aneurysm formation adjacent to the neck (n = 3) and regrowth type with dome filling (n = 4).Recurrence after coil embolization for basilar tip aneurysms is associated with large aneurysms and incomplete occlusion at initial embolization. Understanding the patterns of recurrence is useful for predicting recurrence and selecting treatment strategies.

Patients with glioma often demonstrate epilepsy. We previously found burst discharges in the peritumoral area in patents with malignant brain tumors during biopsy. Therefore, we hypothesized that the peritumoral area may possess an epileptic focus and that biological alterations in the peritumoral area may cause epileptic symptoms in patients with glioma. To test our hypothesis, we developed a rat model of glioma and characterized it at the cellular and molecular levels. We first labeled rat C6 glioma cells with tdTomato, a red fluorescent protein (C6-tdTomato) and implanted them into the somatosensory cortex of VGAT-Venus rats, which specifically expressed Venus, a yellow fluorescent protein in GABAergic neurons. We observed that the density of GABAergic neurons was significantly decreased in the peritumoral area of rats with glioma compared with the contralateral healthy side. By using a combination technique of laser capture microdissection and RNA sequencing(LCM-seq) of paraformaldehyde-fixed brain sections, we demonstrated that 19 genes were differentially expressed in the peritumoral area and that five of them were associated with epilepsy and neurodevelopmental disorders. In addition, the canonical pathways actively altered in the peritumoral area were predicted to cause a reduction in GABAergic neurons. These results suggest that biological alterations in the peritumoral area may be a cause of glioma-related epilepsy.

Preoperative differential diagnosis between primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM) is important because these tumors require different surgical strategies. This study investigated the usefulness of dual isotope, iodine-123-labeled N-isopropyl-p-iodo-amphetamine (Twenty-five PCNSL patients and 27 GBM patients who underwent dual isotope imaging,Delayed phaseDelayed phase

Background Preoperative differential diagnosis between primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM) is important because these tumors require different surgical strategies. This study investigated the usefulness of dual isotope, iodine-123-labeled N-isopropyl-p-iodoamphetamine (123I-IMP) and thallium-201 chloride single photon emission computed tomography (201Tl SPECT) for the differential diagnosis. Methods Sixteen PCNSL patients and 20 GBM patients who underwent dual isotope imaging, 123I-IMP and 201Tl SPECT, are included. Early and delayed SPECT images were obtained after 30 minutes and 4 hours, respectively. Tumor to normal (T/N) ratio was calculated from the ratio of maximum tracer counts in the lesion to the mean counts in the contralateral cerebral cortex. The mean and minimum apparent diffusion coefficient values (ADCmean and ADCmin, respectively) on magnetic resonance imaging were also analyzed for comparison of diagnostic accuracy. Results Delayed phase 123I-IMP SPECT was the most useful imaging examination for the differentiation between PCNSL and GBM compared with early phase 123I-IMP SPECT, early and delayed phase 201Tl SPECT, ADCmean and ADCmin. However, the median T/N ratios of PCNSL and GBM were 1.29 and 0.84, respectively, in the delayed phase 123I-IMP SPECT, and the tumor detection was inadequate. On the other hand, the median T/N ratios of PCNSL and GBM were 3.23 and 2.34, respectively, in the delayed phase 201Tl SPECT, with excellent tumor detection. Thirty-five of 36 patients (97.2%) showed a tracer retention rate of 201Tl SPECT 0.7 or higher, which indicates malignant property of brain tumors. Conclusion Delayed phase 123I-IMP SPECT could differentiate between PCNSL and GBM with high accuracy, but T/N ratio was low and tumor detection was poor. 201Tl SPECT was useful for estimation of the localization and the malignant property of the tumors. The combination of these isotopes was useful for the diagnosis of PCNSL and GBM.

White matter infarct induces demyelination and brain dysfunction. We previously reported that transplantation of brain microvascular endothelial cells improved the behavioral outcome and promoted remyelination by increasing the number of oligodendrocyte precursor cells in the rat model of white matter infarct. In this study, we investigated the effects of transplantation of vascular endothelial cells generated from human induced pluripotent stem cells (iPSCs) on the rat model of white matter infarct. Seven days after induction of ischemic demyelinating lesion by injection of endothelin‐1 into the internal capsule of a rat brain, iPSC‐derived vascular endothelial cells (iVECs) were transplanted into the site of demyelination. The majority of iVECs transplanted into the internal capsule survived for 14 days after transplantation when traced by immunohistochemistry for a human cytoplasmic protein. iVEC transplantation significantly recovered hind limb rotation angle as compared to human iPSC or rat meningeal cell transplantation when evaluated using footprint test. Fourteen days after iVEC transplantation, the infarct area remarkably decreased as compared to that just before the transplantation when evaluated using magnetic resonance imaging or luxol fast blue staining, and remyelination was promoted dramatically in the infarct when assessed using luxol fast blue staining. Transplantation of iVECs increased the number of oligodendrocyte lineage cells and suppressed the inflammatory response and reactive astrocytogenesis. These results suggest that iVEC transplantation may prove useful in treatment for white matter infarct., We investigated the effects of transplantation of vascular endothelial cells generated from human induced pluripotent stem cells (iPSCs) on the rat model of white matter infarct. Transplantation of iPSC‐derived vascular endothelial cells (iVECs) ameliorated ischemic demyelinating (DM) lesion in endothelin‐1 (ET‐1)‐treated internal capsule (IC) of a rat brain. iVEC transplantation improved locomotor function when evaluated using footprint (FP) test, and reduced infarct area when monitored using magnetic resonance imaging (MRI). In addition, transplanted iVECs promoted remyelination in the infarct area when examined using luxol fast blue (LFB) staining. Taken together, our results suggest that transplantation of human iPSC‐derived vascular endothelial cells may lead to development of effective therapies for white matter infarct.

To avoid deterioration of visual function, extended endoscopic endonasal transsphenoidal surgery (TSS) for craniopharyngioma was performed with visual evoked potential (VEP) monitoring using light-emitting diodes (LEDs). The position of the optic chiasm was carefully evaluated on the preoperative midsagittal magnetic resonance (MR) images. Intraoperatively, direct and sharp dissection of the tumor from the optic chiasm was performed under VEP monitoring with LEDs through extended endoscopic endonasal TSS. If the VEP finding changed and became unstable, the operator were informed and stopped the surgical manipulation for the optic chiasm to recover. After 5–10 min, recovery of VEP findings was checked and the procedure resumed. Extended endoscopic endonasal TSS with VEP monitoring was performed in consecutive 7 adult patients with newly diagnosed suprasellar craniopharyngiomas with maximum diameters of 25–41 mm (mean 33.7 mm). VEPs were stable throughout the surgery in 5 cases, but showed temporary instability and amplitude decrease in 2 cases, although the VEPs had recovered at the end of the surgery. Visual function, evaluated using visual impairment score, was improved after surgery in all patients. Gross total removal was achieved in 5 cases, and subtotal removal (90%) in 2 cases. Intraoperative VEP monitoring is the only way to test visual function during surgery, and may be important and helpful in extended endoscopic endonasal TSS, which requires direct dissection between the optic nerve and craniopharyngioma under the endoscope.

Objective Surgical treatment of ruptured blood blister–like aneurysms (BBAs) arising from the internal carotid artery (ICA) is challenging. We retrospectively reviewed the results of our surgical strategies tailored for each aneurysm site. Methods All ruptured ICA BBAs treated between 2003 and 2015 were reviewed. Aneurysms on the lateral side of the ICA were classified as type A, on the medial side of C2 as type B, and on the medial side of C1 as type C. The principal strategy was high-flow bypass (HFB) by use of a radial artery graft, with clipping, trapping, or proximal occlusion selected on the basis of aneurysm type. The results of each treatment were examined. Results This study included 20 patients. There were 11 type A aneurysms (55%), 2 type B (10%), and 7 type C (35%). HFB was used in 13 patients (65%) and low-flow bypass in 4 (20%). Except for 1 case, no other cases of rerupture or recurrence occurred. Severe ischemia due to cerebral vasospasm was confirmed in 4 of 20 patients (20%), 3 of whom had not received HFB. Modified Rankin Scale score was 0–2 in 16 of 20 patients (80%). Conclusion Inadequate cerebral blood flow is a distinct possibility even with HFB, so parent artery flow should be preserved to protect against ischemia whenever possible. However, if preservation of the anterior choroidal artery or posterior communicating artery during clipping or trapping is difficult, HFB combined with occlusion of the proximal portion of the ICA in the neck is a feasible option.

Oculomotor cistern extension (OMCE) of pituitary adenoma through the oculomotor triangle may be one of the major characteristics of multi-lobulated adenoma. The OMCE may be hard to remove only through the endonasal approach. We applied the simultaneous combined supra-infrasellar approach to remove pituitary adenoma with relatively large OMCE. Four (7.3%) of 55 consecutive patients with initially operated pituitary macroadenoma (> 10 mm) had OMCE. The combined supra-infrasellar approach was adopted in two cases with relatively large OMCE. The simultaneous combined supra-infrasellar approach was performed with the transcranial microscopic transsylvian anterior temporal approach and the nasal endoscopic approach. The medial main mass was removed through the nasal side. The lateral OMCE was also removed through the nasal side by pushing the tumor in the sellar direction from the transcranial side. The oculomotor nerve was confirmed with electrical nerve stimulation. The main medial mass and the OMCE were mostly removed in both cases. Remnant tumor in the cavernous sinus was treated by gamma knife radiosurgery. Endoscopic transsphenoidal removal was performed in the other two cases with relatively small OMCE. Pituitary macroadenomas with OMCE are a newly recognized form of progression with important implications for surgical strategy. The combined supra-infrasellar approach performed with the transcranial microscopic transsylvian anterior temporal approach using electrical nerve stimulation and the nasal endoscopic approach may be useful for this type of multi-lobulated pituitary adenoma.

Surgical evacuation of intracranial hematoma, including epidural, subdural, intracerebral, and intraventricular hematoma, is recommended in patients with traumatic brain injury (TBI) for prevention of cerebral herniation and possible saving of life. However, preoperative coagulopathy is a major concern for emergent surgery on patients with severe TBI. We reviewed 65 consecutive patients with severe TBI who underwent emergency craniotomy for intracranial hematomas. Univariate analysis showed preoperative pupil abnormality, absence of pupil light reflex, respiratory failure, preoperative thrombocytopenia ( 36 s), low fibrinogen (

Objective To describe a single-layer fascia patchwork closure (FPWC) without nasoseptal flap (NSF) and compare postoperative cerebrospinal fluid (CSF) leakage between FPWC using NSF and single-layer FPWC without NSF for the extended endoscopic transsphenoidal transtuberculum transplanum approach. Methods Forty-five cases of suprasellar tumor in 42 patients were treated with extended endoscopic transsphenoidal removal, resulting in extensive, high-flow CSF leakage. Following the intradural procedure for treatment of various suprasellar tumors, fascia lata was inlaid subdurally on the cranial base defect and patch-sutured around its entire circumference under endoscope visualization, using an average of 17 stitches. Septal bone or hydroxyapatite plate was used for the hard support material against pulsatile intracranial pressure. NSF was added in the earlier 17 cases. Closure was completed without NSF in the more recent 28 cases when the Valsalva maneuver confirmed watertight closure. Two recent cases required NSF after Valsalva maneuver and were included in the FPWC + NSF group. Results Postoperative CSF leakage did not occur in the FPWC + NSF group but occurred in 2 patients in the single-layer FPWC group (7.1%) (P = 0.52). There was no significant difference in CSF leakage between single-layer FPWC and FPWC + NSF. The mean suturing time for FPWC was 85.8 minutes, and the shortest was 39 minutes in a recent case (mean, 17 stitches; n = 35, video analysis). Conclusions Single-layer FPWC may be a viable technical option for effective skull base reconstruction after the extended endoscopic transsphenoidal transtuberculum transplanum approach.

IntroductionPreoperative differential diagnosis between glioblastoma (GBM) and primary central nervous system lymphoma (PCNSL) is important because these tumors require different surgical strategies. This study investigated the usefulness of dual isotope, iodine-123-labeled N-isopropyl-p-iodoamphetamine (123I-IMP) and thallium-201 chloride single photon emission computed tomography (201Tl SPECT) for the differential diagnosis.MethodsTwenty-five PCNSL patients and 27 GBM patients who underwent dual isotope, 123I-IMP and 201Tl SPECT are included. Tumor to normal (T/N) ratio was calculated from the ratio of maximum tracer counts in the contrast-enhanced lesion to the mean counts in the contralateral cerebral cortex. The mean and minimum apparent diffusion coefficient values (ADCmean, and ADCmin, respectively) on magnetic resonance imaging were also analyzed. ResultsTumor to normal (T/N) ratios of PCNSL were significantly higher than that of GBM for both isotopes and phases (P < 0.001). Both ADC values of PCNSL were significantly lower than those of GBM (P < 0.001). Delayed phase 123I-IMP gave the most accurate findings for differentiation between PCNSL and GBM with the optimum cut-off value of 1.009, sensitivity 92.0%, specificity 88.9%, and area under the curve 0.945 (95% confidence interval, 0.883-1.000). Fifty of 52 patients (96.2%) showed retention index of 201Tl SPECT 0.7 or higher, which indicates malignant brain tumors. ConclusionsDelayed phase 123I-IMP SPECT could differentiate between PCNSL and GBM with the highest accuracy. 201Tl SPECT was useful for estimation of the malignancy and localization of the tumors. Dual isotope 123I-IMP and 201Tl SPECT was useful for the preoperative diagnosis of PCNSL and GBM.

Background: Symptomatic perineural cysts are rare in pediatric patients. Severe bowel dysfunction caused by the perineural cysts at the sacral level is particularly rare in children. Moreover, the long-term outcome of surgery for the perineural cysts in pediatric patients is uncertain. Here, we describe a rare case of perineural cysts originating in the S3 roots in a pediatric patient that manifested as severe constipation. Case Description: The case was a 13-year-old girl who presented with intractable vomiting and constipation. She also had low back and buttock pain, urinary incontinence, and periproctal sensory disturbance. Radiological studies revealed bilateral perineural cysts originating from the S3 nerve roots, which were considered to be the cause of her symptoms. Microsurgical decompression of the cysts relieved her intractable bowel dysfunction. There has been no recurrence in the 5 years since surgery. Conclusion: This case suggests that microsurgery for severe bowel dysfunction due to symptomatic perineural cysts could have a satisfactory long-term outcome in pediatric patients.