Japanese Journal of Neurosurgery
Online ISSN : 2187-3100
Print ISSN : 0917-950X
ISSN-L : 0917-950X
Volume 27, Issue 11
Displaying 1-9 of 9 articles from this issue
SPECIAL ISSUES Surgical Approach from Positioning to Microsurgery
  • Hiroshi Nishioka
    2018 Volume 27 Issue 11 Pages 796-802
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      Tumors originating in the suprasellar region have previously been considered a contraindication for transsphenoidal surgery (TSS). However, in the late 1980s, the transsphenoidal removal of suprasellar tumors became possible with the adoption of extended TSS, which allows excellent midline access and visibility to the suprasellar region without brain retraction and with minimal neurovascular manipulation. Recently, the endoscopic endonasal approach has become a valid alternative to transcranial approaches for the surgical treatment of craniopharyngiomas in many cases. For a safe and effective surgery, a wide surgical corridor, fine microsurgical procedures, and a secure repair of cerebrospinal fluid leakage are essential. A direct and wide exposure of the craniopharyngioma and the surrounding vital structures can be obtained following an accurate and careful approach. There are some pitfalls involved in this approach ; therefore, thorough understanding of the procedure in each anatomical step (nasal sinus, skull base, and suprasellar cistern) is required to achieve successful outcomes. In addition to tumor extensions and characteristics (such as size, configuration, and calcification), anatomical conditions that can most affect the approach are positions of the chiasm and stalk.

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  • Tetsuyoshi Horiuchi, Kazuhiro Hongo
    2018 Volume 27 Issue 11 Pages 803-809
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      First described by Hamby and later established by Yasargil, the pterional approach is considered one of the most useful approaches in neurosurgery. Operation of aneurysms at the anterior circulation and basilar bifurcation as well as tumors of the sellar and parasellar, orbital, subfrontal, chiasmatic, and interpeduncular regions has become possible through this approach. Here, we describe the historical background and technical aspects of the pterional approach with modifications introduced by us.

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  • Kotaro Oshio, Masashi Uchida, Takashi Matsumori, Hidemichi Ito, Hirosh ...
    2018 Volume 27 Issue 11 Pages 810-817
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      An interhemispheric approach (IHA) is applied to midline cerebral lesions and emcompasses anterior, middle, and posterior IHAs. Ideally, excess brain retraction should be avoided to prevent venous congestion and brain contusion. Preoperative radiographical assessment, bridging vein preservation, and appropriate head position are critical to avoid surgical complications. We introduced horizontal IHA to reduce these complications. The brain’s own weight is used to minimize the use of a brain spatula as well as to secure a wide operative field in the horizontal direction. Here, we describe the technical details, including the patient position, head fixation, and microscopic procedures, of this approach.

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  • Masahiro Toda, Kazunari Yoshida
    2018 Volume 27 Issue 11 Pages 818-827
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      The subtemporal approach is applied to the middle cranial fossa and infratemporal fossa in addition to the tentorial incisura, petroclivus, and brain stem lesions. To minimize compression damage to the temporal lobe, it is essential to perform the craniotomy along the middle cranial fossa, to remove the zygomatic arch for supratentorial lesions, and to remove the petrous pyramid for infratentorial lesions. To avoid venous damage, the drainage pathways of the superficial sylvian vein and bridging veins, including Labbé’s vein, should be preoperatively evaluated. Furthermore, with the recent advances in endoscopic surgery, it has become possible to approach the middle cranial fossa and infratemporal fossa endonasally. In the endonasal approach, surgical simulation is important because of the variations in the nasal cavity and paranasal sinus structures. In this article, we outline the surgical anatomy of the middle cranial fossa required for the subtemporal approach, including the endonasal approach, and variations in the venous drainage of the superficial sylvian vein and petrosal vein. Moreover, we describe the treatment of pontine lesions by the subdural subtemporal approach, Meckel cave lesions by the epidural subtemporal approach, petroclival lesions by the anterior transpetrosal approach, and infratemporal lesions by the endonasal approach.

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  • Masahiko Wanibuchi
    2018 Volume 27 Issue 11 Pages 828-834
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      The posterior transpetrosal approach, which can provide a better ventral surgical view than the lateral suboccipital approach, is required for the surgical treatment of skull base lesions extending to the petrous bone. In this paper, the microsurgical anatomy of the mastoid and surgical manipulation involved in mastoidectomy are explained.

      The posterior transpetrosal approach for petroclival lesions has been reported from the 1970s to the early 1990s. This approach is typically performed in combination with other approaches, leading to several variations. The surgery is performed in the lateral position. The posterior neck muscles are retracted to avoid muscle injury. After the occipital bone and mastoid had been exposed, occipital craniotomy and mastoidectomy are performed. A triangular shape is drilled into the mastoid with the following anatomical landmarks as vertices : the posterior point of the root of the zygoma, mastoid tip, and asterion. Subsequently, the sigmoid sinus plate and mastoid antrum are exposed. After confirming the lateral semicircular canal inside the mastoid antrum, the superior and posterior semicircular canals are also exposed. Finally, the facial nerve and jugular bulb are identified.

      Precise anatomical knowledge and a safe skull base drilling technique are required to achieve success with the use of the posterior transpetrosal approach, resulting in a wide and shallow surgical field for skull base lesion.

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  • Hirofumi Nakatomi, Taichi Kin, Nobuhito Saito
    2018 Volume 27 Issue 11 Pages 835-844
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      The standard procedures of lateral and midline suboccipital approaches (SOAs) were summarized with special reference to head, neck, and body positioning ; scalp elevation ; muscle dissection ; craniotomy ; and cerebellomedullary fissure (CMF) dissection. In particular, complete dissection of the lateral CMF is extremely important for lateral SOA and medial CMF for midline SOA. Acknowledgment of these sequential surgical steps will help the surgeons to execute the lateral and midline SOA safely and steadily as well as avoid serious complications.

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LEARNING OLD CREATING NEW
CASE REPORTS
  • Yohei Miyake, Kazuhiko Mishima, Yusuke Kobayashi, Tomonari Suzuki, Jun ...
    2018 Volume 27 Issue 11 Pages 847-851
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      A 68-year-old male with primary central nervous system lymphoma in the deep brain was intravenously administered with a high dose of methotrexate (MTX) as the initial treatment. The patient developed fever a few hours after MTX administration. His laboratory tests revealed elevation of serum creatinine and C-reactive protein levels, suggesting acute kidney injury caused by MTX or some kind of infection. However, systemic computed tomography and various culture tests did not show any focus of infection. Gallium scintigraphy demonstrated uptake in the bilateral kidneys and eosinophiluria was found. Drug-induced lymphocyte stimulation test revealed a positive reaction to MTX. These examinations suggested that the acute kidney injury and inflammatory response resulted from acute interstitial nephritis (AIN) caused by allergic reaction to MTX. Although the serum creatinine level spontaneously improved, we avoided a second course of MTX to prevent AIN recurrence. The patient underwent whole-brain radiation therapy and achieved complete response. His follow-up MRI did not reveal any tumor recurrence for 7 months. To the best of our knowledge, AIN has not been reported in relation to MTX administration in the literature. Although this was a rare cause of acute kidney injury by MTX, the recognition of such a mechanism is important because AIN can occur even independent of MTX administration, which can deem MTX re-administration fatal.

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  • Daichi Hagita, Shigeo Yamashiro, Masatomo Kaji, Daisuke Muta, Tatsuya ...
    2018 Volume 27 Issue 11 Pages 852-857
    Published: 2018
    Released on J-STAGE: November 25, 2018
    JOURNAL FREE ACCESS

      We report a case of a small aneurysm arising from the anterior communicating artery (ACOM) that rapidly enlarged with repeated thrombosis and recanalization over a short time. A 64-year-old woman presented with a minor headache. Magnetic resonance imaging (MRI) showed a 3 mm diameter aneurysm arising from the ACOM, and there was stenosis of the end of the left internal carotid artery and the moyamoya arteries in the left hemisphere. The aneurysm was not visualized by contrast-enhanced three-dimensional (3D) computed tomography angiography (CTA) after 20 days ; however, conventional angiography showed the neck of the aneurysm on day 21. The disappearance and recanalization of the aneurysm neck was confirmed on repeated examination. Since there was a high risk of aneurysm rupture, microsurgical clipping of the aneurysm neck was performed on day 36. Intraoperative examination of the aneurysm revealed a thin wall, with the majority of dome thrombosed. Immediate treatment should be recommended for an aneurysm that shows thrombosis, recanalization and enlargement over a short time because of a high risk of rupture. In addition, we speculate that unilateral moyamoya disease is partially associated with the occurrence and growth of the aneurysm.

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