Myelomeningocele is a malformation that occurs when closure of the neural tube is impaired during early pregnancy. The neural tissue remains open until birth. In most cases, repair of the open neural tissues and treatment of associated hydrocephalus is required during their infancy. However, this treatment does not end in infancy and is required for lifetime. After closure of myelomeningocele, due to adhesion of the repaired site, tethered cord syndrome appears as the patients grow older ; which include exacerbation of the bladder function, lower limb motor and sensory weakness, and especially, lower limb and back pains. It is important to know that these symptoms are reversible by untethering surgery. In order to improve the long-term outcome of patients with myelomeningocele, proper management of the symptoms due to tethered cord syndrome is imperative.

  Improved understanding of vascular anatomy and pathophysiology is crucial to recognize pediatric intracranial and spinal arteriovenous shunts. Apart from the patient's size, their unique physiological characteristics should be considered during endovascular treatment and perioperative management. Such pediatric conditions are complicated and characterized by difficulty in treatment. Endovascular treatment should be considered the first choice medical care. These pediatric diseases were complicated and were characterized by the difficulty in the treatment. The purpose of the treatment is to stabilize the patient's condition and also protect the deterioration of patient's neurological findings. The primary therapy, when implemented, significantly improves the prognosis. Comprehensive pediatric centers for rapid treatment of endovascular embolization for these pediatric arteriovenous shunts are needed.

  Intracranial germ cell tumors are common in adolescents and young adults. Treatment is intended to achieve both tumor control and long-term functional preservation. This review describes the functional outcomes achieved by various treatment strategies for germinoma. Radiation therapy provides high tumor control rates but late complications such as poor performance status, declined intelligence, endocrine disorders, and reduced quality of life may occur. Chemotherapy and reduced dose radiation therapy to the whole ventricle were introduced to avoid these problems without compromising tumor control. Current treatments are reported to preserve intelligence, memory, executive function, and behavior compared to healthy individuals. However, this treatment strategy still has many unsolved problems with longitudinal changes in neurocognitive function and differences in functional outcomes according to the tumor site, age of onset, and other related factors.

  Systematic and comprehensive accumulation of information on functional outcomes and construction of an evaluation system based on multi-disciplinary approaches will be necessary to accurately evaluate functional preservation achieved by future therapies.

   [Purpose] Transitional medicine provides medical care and social support for the management of the pediatric-onset diseases along with newly developing pathologies in each life stage for individual patients, to improve the prognosis of patients with such diseases. Since progress of transitional medicine in pediatric neurosurgery has not been evaluated in Japan, the current status of transitional medicine in this field was studied.

   [Methods] The Japanese Society for Pediatric Neurosurgery (JSPN) conducted a written questionnaire survey mainly within the hospitals of the JSPN councilors.

   [Results] The response rate was 90%. Institutions were categorized into the university hospital group (n=30, 28 university hospitals and 2 local core hospitals) and the pediatric hospital group (n=16, consisting of 13 free-standing children's hospitals, 3 pediatric medical units within a hospital and 2 children's hospitals with close collaboration to an adjacent hospital). In both groups, there was no agreement on transitional medicine in the majority of (pediatric) neurosurgery departments and hospitals, but neurosurgeons in charge were often entrusted with the management of transition. During the past year, although the number of adult outpatients and inpatients in each hospital of the two groups varied greatly; there were no significantly different distribution patterns of these patient between the two groups. In their adulthood, patients were hospitalized in all the original hospitals in the university hospital group, but only in 82% of the hospitals in the children's hospital group. The significantly lower rate in the children's hospital group is presumed to be due to the admission restriction of adult patients in medical facilities constructed only for children. Although there were no such restrictions in the university hospital group, many hospitals in this group complained of shortage of human resources for pediatric neurosurgery.

   [Conclusion] To offer proper transitional medicine in pediatric neurosurgery, the university hospital group needs to secure necessary human resources, and improvements should be made in terms of admission restrictions of adult patients in children's hospitals. To resolve these difficulties, it would be desirable to have pediatric medical units within a single hospital or a close collaboration of children's hospitals with adjacent hospital facilities. JSPN should support these activities in all hospitals, and raise the issues of transitional medicine in pediatric neurosurgery to the Ministry of Health, Labor and Welfare and the general public.

  Prognosis of patients with human immunodeficiency virus (HIV) infection has been changing from a lethal infection to a controllable disease in the past two decades, owing to highly active antiretroviral therapy. However, the diagnosis of intracranial mass lesions related to the infection remains challenging, and repeated examinations, blood tests, lumbar punctures, and image examinations do not lead a definitive diagnosis in some cases. Therefore, brain biopsy has to be performed by neurosurgeons for purpose of the definitive diagnosis. There have been no reports summarizing brain biopsies in patients with HIV infection in Japan. We retrospectively studied HIV infected patients with brain mass lesions, in whom diagnosing the condition was difficult, between 2008 and 2017, especially cases requiring neurosurgical biopsy. The biopsy was performed in 7 out of 19 cases for brain mass lesions that were difficult to diagnose clinically. Among the 7 cases, 5 resulted in accurate pathological diagnosis. For further improvements in diagnosis and early treatment, it is important to use not only various diagnostic modalities but also conduct timely biopsies by neurosurgeons.

  In epilepsy surgery, lesionectomy is challenging, since epileptogenic zone is often located in functionally dominant areas, as in the case of focal cortical dysplasia (FCD). Brain mapping is necessary in such a case to achieve precise resection of the epileptogenic area while preserving brain function. In this report, we presented a case where epileptic focus was identified in the classical Broca's area, that is, the opercular part of the inferior frontal gyrus, and resected under awake craniotomy. Although this area demonstrated positive findings during intraoperative mapping with language tasks, it could be successfully resected with minor deterioration of speech function-phonological paraphasia. This symptom may not be caused by cortical but subcortical damages, and disappeared within two weeks postoperatively. In addition, no apparent seizure was documented postoperatively. The Broca's area is usually refrained from resection if language mapping demonstrates positive findings. There are two major considerations for successful results in this case. Firstly, for preserving language function, a connection of subcortical fibers is important and the cortex itself can be removed without permanent neurological deficits. Secondly, the cortex with the epileptic focus may have already reorganized during relatively long period of disease, and may not be functionally dominant at the time of surgery. This case is interesting for reconsidering the neural plasticity and functional preservation in the classical Broca's area. Here, we report this case along with a review of the relevent literature.