Early prophylactic surgery for asymptomatic spinal lipomas remains a topic of debate and an appropriate consensus has not been reached. To solve this problem a randomized controlled trial is proposed, but there are problems such as the difficulty of matching the two groups and ethical reasons.
  The authors analyzed the clinical pictures of 158 spinal lipoma patients regarding their neurological deficits, and investigated the long-term follow-up results of 51 asymptomatic patients who were followed over 7 years after surgery.
  Eighty-six asymptomatic patients and 72 symptomatic patients were included in this study. Sixty percent of lipomyelomeningocele (LMMC) or transitional type case were symptomatic. Sixty-seven percent of the operations were conducted in the patient's first year of life. Median age at the first operation was 0.45 years, 0.4 years for asymptomatic and 0.7 years for symptomatic. During the long-term follow-up periods (7.6 years～25.4 years) of 51 asymptomatic patients, 10 of them (19.6%) presented with neurological deficits and 5 (9.8%) received a second untethering.
  LMMC, sacral lipoma, and large lipoma are likely to develop neurological deficits in the first year of life. Spinal herniation, early diagnosis of neurogenic bladder with urological study, and neural compression by large lipoma were considered to be the cause of early clinical deterioration.
  In conclusion, from our results, LMMC, sacral lipoma, and large lipoma were considered best to be operated on by the age of one year old and other types of lipomas such as dorsal or filar type by the age of three years old.

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  The purpose of this study was to review the modern standard surgical methods for craniosynostosis (CS), define management problems for the near future and evaluate the long-term surgical outcomes of CS patients treated at the author's institution. A retrospective chart review of all patients who underwent traditional cranial vault remodeling or the cranial distraction method for CS was performed at the Saitama Children's Medical Center from August 1, 1984 to January 31, 2011.
  One hundred thirty three patients were identified for the study, diagnoses included nonsyndromic CS (90 cases), syndromic CS (37 cases) and others (6 cases). Information regarding types of CS, operative methods, long-term surgical results and reoperation rates was analyzed. Long-term surgical results were graded according to the grading system reported by Wagner JD et al (1995), as follows ; grade I : 77 cases, grade II : 32 cases, grade III : 20 cases and deceased : 4 cases. Overall the reoperation rate in the 129 surviving cases with CS was 26%.
  Cranial distraction procedures were applied to 31 cases with nonsyndromic or syndromic CS from October 1, 2000 to March 31, 2011. The advantages of using the cranial distraction procedure are that it offers a less invasive technique, shorter operation time and a small amount of bleeding. Long-term surgical results and reoperation rates of syndromic CS following the frontoorbital advancement were improved by using a cranial distraction procedure.
  Cranial distraction procedures should be more readily applied allowing for these advantages to the surgical treatment of craniosynostosis.

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  Brain tumors are the second most prevalent cancers in children (after leukemia) and remain the leading cause of cancer-related mortality in childhood. Treating children with brain tumors begins with an absolute requirement for the correct diagnosis, accurate staging of the extent of the disease and determination of the prognostic subgroup. Throughout treatment, every child with brain tumor should have the benefit of an expert pediatric cancer care team. The Japanese Ministry of Health, Labor and Welfare designated 15 hub hospitals to administer such comprehensive pediatric cancer care in 2013.
  Medulloblastoma is the most common malignant childhood brain tumor. Overall survival rates for patients with medulloblastoma have reached 70-80% using treatment protocols that include a combination of surgery, cranio-spinal radiotherapy (in children ≥3 years of age) and chemotherapy. Current risk stratification tools are solely based on clinical features, including age at diagnosis, extent of surgical resection, metastatic status. Molecular subclassification is rapidly informing the clinical management of medulloblastoma. These findings are currently making their way into risk-adapted treatment. Molecular characterization approaches have also yielded insights into new therapeutic targets.
  Current management of ependymoma includes surgical resection followed by adjuvant radiotherapy. Children are especially difficult to manage because they often experience multiple recurrences. Numerous studies have shown that ependymoma is still a surgical disease. Recent advances in molecular studies have found that ependymomas have unique molecular signatures with distinct gene expression patterns, chromosomal changes, and protein expression. Through an improved understanding of the molecular and genetic basis of ependymoma, it is anticipated that patients will be risk-stratified and treated in the future.
  The recent designation of pediatric cancer hub hospitals and molecular characterization approaches will hopefully lead to improved patient outcomes with reduced sequelae.

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  Moyamoya disease is a chronic occlusive cerebrovascular disease with unknown etiology that is common in children and young adults with a female predominance. Wound trouble is a potential complication of revascularization surgery for moyamoya disease, while the optimal procedure of the cranioplasty and skin closure is undetermined. To minimize the postoperative physical stress to the typically thin scalp with poorer blood supply found in most moyamoya patients, we used a bio-absorbable polymer system (80% poly-L lactic acid and 18% poly-glycolic acid ; LactoSorb^®) adjacent to the incision in combination with a titanium plate for cranium fixation in 48 surgeries for 43 patients aged from 10 to 62 years (mean 38.9). There was no wound trouble during the mean follow-up period of 13.8 months. None of the 43 patients suffered from wound infection, subcutaneous cerebrospinal fluid collection, nor the delayed wound healing that frequently affects a patient's admission schedule. There was no adverse effect from the bio-absorbable polymer system itself including delayed inflammation around the site of fixation.
  Combined use of a bio-absorbable polymer system with a titanium plate is a safe and effective procedure for treating moyamoya disease that can also avoid surgical complications on the scalp.

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  A 64-year-old man initially presented with dysuria to another institution's department of urology. He developed tetraplegia soon after admission. Neuroradiological examinations revealed a shunting point in the vicinity of the cerebellar tentorium and a dural arteriovenous fistula (dAVF) descending to the surface of the spinal cord.
  To the best of our knowledge, there have been no reports of a time lag between urinary retention as the only initial manifestation and the development of other spinal symptoms, although there have been occasional reports on an intracranial dAVF caused by myelopathy associated with urinary retention.
  The tracts for urination are usually located in the lateral and dorsal funiculi, and the afferent tract, in particular, is located in the dorsal funiculus. Based on previous reports and from an anatomical standpoint, we speculated the following course in the present case : venous congestion first occurred in the lateral horn, causing a disturbance in the adjacent lateral funiculus, thereby resulting in the development of urinary retention symptoms, which in turn affected the surrounding tissues. Finally, the patient developed tetraplegia.

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  Bow hunter's syndrome (BHS) is defined as symptomatic vertebrobasilar insufficiency by mechanical occlusion of the vertebral artery (VA) at the atlanto-axial level during contralateral head rotation. A 52-year-old man underwent anterior cervical discectomy and fusion at the C_4/5 level for cervical spondylosis. Six months later, he suffered syncope during 90°head rotation to the left. Cerebral angiography with leftward head rotation showed physiologic stenosis of the right VA at the C_1/2 level and stenosis of the left VA at the C₃ level. Cervical Computed Tomography (CT) showed an osteophyte at the superior-lateral side of the C₄ vertebral body. The patient underwent osteophytectomy and decompression of the left VA at the C₃ level. The symptoms resolved and cerebral angiography showed that the left VA stenosis had disappeared after surgery.

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  We report here in a case of meningioma with marked bone deformity. A 72-year-old man presented with progressive right hemiparesis, motor aphasia, and dementia.
  Initial 3-dimensional computed tomography demonstrated marked thickness and deformity of the skull from the left fronto-parietal side across to the superior sagittal sinus. Initial magnetic resonance imaging showed a mass lesion in the left frontal lobe and en plaque mass just below the markedly thickened skull. We performed removal of the abnormal skull and tumor due to the progressing symptoms.
  After pathological examinations, tumor was diagnosed as meningothelial meningioma. Symptoms gradually improved, and he resumed his previous daily life. We discuss this unique tumor with reference to the literatures.

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  A 77-year-old woman was referred to our hospital by a primary care physician for further evaluation of oculomotor paralysis. We diagnosed Tolosa-Hunt syndrome and prescribed prednisolone 30 mg/day, after which her symptoms improved. Approximately 1 year after the onset of Tolosa-Hunt syndrome, she presented with abducens paralysis and ocular hyperemia, and a bruit was heard in her right orbit.
  Findings from cerebral angiography indicated a diagnosis of cavernous sinus dural arteriovenous fistula. Her condition required immediate medical attention, and we thus performed endovascular coil embolization by microcatheter insertion into the right cavernous sinus via the bilateral inferior petrosal sinuses. After the procedure, the bruit disappeared and her abducens paralysis and ocular hyperemia improved. A cerebral angiogram 6 months after the procedure confirmed the disappearance of the cavernous sinus dural arteriovenous fistula. The precise cause of intracranial dural arteriovenous fistulas has not been determined, although secondary factors such as inflammation, trauma, surgery, tumors, previous infections, and sinus thrombosis have all been implicated in the past.
  We hypothesize that in this instance, inflammation that remained due to inadequate prednisolone dosing induced the cavernous sinus dural arteriovenous fistula in our patient.
  Correct diagnosis and adequate treatment of Tolosa-Hunt syndrome are important. In addition, the careful evaluation of patients with a history of Tolosa-Hunt syndrome may aid in diagnosing cavernous sinus dural arteriovenous fistula.

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