Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 50, Issue 9
Displaying 1-33 of 33 articles from this issue
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Anniversary Essays
Review Articles
  • A Revised Clinical Assessment of Motor and Memory Disturbances
    Kenichi UEMURA
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 707-712
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.707
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    For clinical assessment of motor disturbances, the motor system is better classified into the voluntary versus automatic motor systems than into the pyramidal versus extrapyramidal motor systems. The voluntary motor system is related to externally guided movements initiated by the premotor area while the automatic motor system is related to memory guided automatic movements initiated by the supplementary motor area and supported by an appropriate posture and associated movements. Among the pyramidal tract signs, muscle weakness alone is related to involvement of the corticospinal fibers of Betz cell origin while hyperreflexia and spasticity is related to involvement of the reticulospinal fibers running medial to the corticospinal fibers in the spinal cord. The earliest clinical manifestation of cervical myelopathy due to cervical spondylosis is always hyperreflexia and spasticity without any muscle weakness. The memory depends upon the 3 processes of encoding, retention, and recall, and must be classified into the immediate memory or recall lasting for only several seconds tested by the digit span test, the intermediate memory lasting for up to 2 years at maximum at the hippocampus whose disturbance can best be tested by the digit learning test, and the long-term memory which can last as long as one lives which can be tested by asking one's experience before more than 2 years. The classical dichotic concept of recent (short-term) versus remote (long-term) memories must be abandoned.
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  • Standard Therapy for Glioblastoma— A Review of Where We Are
    Ryo NISHIKAWA
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 713-719
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.713
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    Glioblastoma is the most common primary malignant brain tumor in adults and is a challenging disease to treat. The current standard therapy includes maximal safe surgical resection, followed by a combination of radiation and chemotherapy with temozolomide. However, recurrence is quite common, so we continue to search for more effective treatments both for initial therapy and at the time of recurrence. This article will review the current standard of care and recent advances in therapy for newly-diagnosed and recurrent glioblastomas, based on the most authoritative guidelines, the National Cancer Institute's comprehensive cancer database Physician Data Query (PDQ®), and the National Comprehensive Cancer Network Clinical Practice Guidelines in OncologyTM for central nervous system cancers (V.1.2010), to elucidate the current position and in what direction we are advancing.
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  • Surgical Treatment for Glioma: Extent of Resection Applying Functional Neurosurgery
    Nobuhiro MIKUNI, Susumu MIYAMOTO
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 720-726
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.720
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    Current treatments for gliomas, including surgery, chemotherapy, and radiation therapy, frequently result in unsuccessful outcomes. Studies on glioma resection were reviewed to assess better treatment outcomes applying the newest neurosurgical multimodalities. We reviewed reports of surgical removal of gliomas utilizing functional brain mapping, monitoring, and other functional neurosurgery techniques such as neuronavigation and awake surgery. Attempts to maximize the extent of glioma resection improved survival. A close proximity of the resection to the eloquent areas increased the risk of perioperative neurological deficits. However, those deficits often improved during the postoperative rehabilitation and recovery period when the essential or the compensative eloquent areas remained intact. Pre- and intraoperative application of the latest brain function analysis methods promoted safe elimination of gliomas. These methods are expected to help explore the long-term prognosis of glioma treatment and the mechanism for recovery from functional disabilities.
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  • Gene Therapy for High-Grade Glioma
    Ken-ichiro IWAMI, Atsushi NATSUME, Toshihiko WAKABAYASHI
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 727-736
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.727
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    High-grade glioma is the most frequently occurring primary brain tumor and is associated with a poor prognosis. Current treatment regimens have had only a modest effect on the progressive course despite recent advances in surgery, radiotherapy, and chemotherapy. Gene therapy for brain tumors represents a novel and promising therapeutic approach and has been investigated clinically for the last two decades. The strategies of gene therapy include suicide gene therapy, immune gene therapy, oncolytic viral therapy, tumor suppressor gene therapy, and antisense therapy. Here, we review gene therapy approaches considering the clinical results, limitations, and future directions.
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  • Role of Gamma Knife Radiosurgery in Neurosurgery: Past and Future Perspectives
    Tomoyuki KOGA, Masahiro SHIN, Nobuhito SAITO
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 737-748
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.737
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    The gamma knife was the first radiosurgical device developed at the Karolinska Institute in 1967. Stereotactic radiosurgery using the gamma knife has been widely accepted in clinical practice and has contributed to the development of neurosurgery. More than 500,000 patients have been treated by gamma knife stereotactic radiosurgery so far, and the method is now an indispensable neurosurgical tool. Here we review long-term outcomes and development of stereotactic radiosurgery using the gamma knife and discuss its future perspectives. The primary role of stereotactic radiosurgery is to control small well-demarcated lesions such as metastatic brain tumors, meningiomas, schwannomas, and pituitary adenomas while preserving the function of surrounding brain tissue. The gamma knife has been used as a primary treatment or in combination with surgery, and some applications have been accepted as standard treatment in the field of neurosurgery. Treatment of cerebral arteriovenous malformations has also been drastically changed after emergence of this technology. Controlling functional disorders is another role of stereotactic radiosurgery. There is a risk of radiation-induced adverse events, which are usually mild and less frequent. However, especially in large or invasive lesions, those risks are not negligible and pose limitations. Advancement of irradiation technology and dose planning software have enabled more sophisticated and safer treatment, and further progress will contribute to better treatment outcomes not only for brain lesions but also for cervical lesions with less invasive treatment.
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  • Stereotactic Radiosurgery/Radiotherapy for Pituitary Adenomas: A Review of Recent Literature
    Koji KAJIWARA, Ken-ichi SAITO, Koichi YOSHIKAWA, Makoto IDEGUCHI, Sada ...
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 749-755
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.749
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    The recent clinical results are reviewed of stereotactic radiosurgery/radiotherapy for the treatment of pituitary adenomas. The outcomes of pituitary adenomas treated by stereotactic radiosurgery/radiotherapy with gamma knife, CyberKnife, or linear accelerator (LINAC) radiosurgery were evaluated from articles published after 2004. Each study was evaluated for the number of patients, radiosurgical parameter (marginal dose), length of follow up, tumor growth control, rate of hormonal normalization in secretary adenomas, and adverse events. After gamma knife radiosurgery, the tumor reduction rates varied from 42.3% to 89% in non-secreting adenomas. However, the tumor control rates in non-secreting adenomas were more than 90% in most studies. In growth hormone-secreting adenomas, the rates of insulin-like growth factor-1 normalization ranged from 36.9% to 82%. In adrenocorticotropin-secreting adenomas, the rates for 24-hour urine free cortisol normalization ranged from 27.9% to 54%. In prolactin-secreting adenomas, the prolactin normalization ranged from 17.4% to 50%. New hormonal deficits ranged from 0% to 34%. New visual deficits were relatively low. The number of patients treated with CyberKnife and LINAC radiosurgery/radiotherapy was small and follow-up periods were relatively short compared to those with gamma knife treatment, but the clinical outcomes after these therapies were similar to those after gamma knife therapy. Image-guided stereotactic radiosurgery/radiotherapy with the gamma knife, CyberKnife, or LINAC system is effective and safe against pituitary adenomas. Careful long-term follow up of the patients is necessary because of long-term anti-tumor effects and delayed adverse events.
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  • Endoscopic Endonasal Pituitary and Skull Base Surgery
    Naokatsu SAEKI, Kentaro HORIGUCHI, Hisayuki MURAI, Yuzo HASEGAWA, Toyo ...
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 756-764
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.756
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    Here we describe the procedures of endoscopic pituitary and skull base surgery in our institute. We also review the literature to reveal recent advances in this field. Endonasal approach via the sphenoid ostium was carried out for pituitary lesions without the nasal speculum. Postoperative nasal packing was basically not needed in such cases. For meningiomas, craniopharyngiomas, and giant pituitary adenomas, which required intra-dural procedures, nasal procedures such as middle nasal conchotomy and posterior ethmoidectomy, and skull base techniques such as optic canal decompression and removal of the planum sphenoidale were carried out to gain a wider operative field. Navigation and ultrasonic Doppler ultrasonography were essential. Angled endoscopes allowed more successful removal of tumors under direct visualization extending into the cavernous sinus and lower clivus. If cerebrospinal fluid (CSF) leakage occurred during operation, the dural opening was covered with a vascularized mucoseptal flap obtained from the nasal septum. Lumbar drainage system to prevent postoperative CSF rhinorrhea was frequently not required. Angled suction tips, single-shaft coagulation tools, and slim and longer holding forceps, all of which were newly designed for endoscopic surgery, were essential for smoother procedures. Endonasal endoscopic pituitary surgery allows less invasive transsphenoidal surgery since no postoperative nasal packing and less dependence on lumbar drainage are needed. Endoscopic pituitary surgery will be more common and become a standard procedure. Endoscopic skull base surgery has enabled more aggressive removal of extrasellar tumors with the aid of nasal and skull base techniques. Postoperative CSF leakage is now under control due to novel methods which have been proposed to close the dural defect in a water-tight manner. Endoscopic skull base surgery is more highly specialized, so needs special techniques and surgical training. Patient selection is also important, which needs collaboration with ear, nose, and throat specialists. As a safe and successful procedure in skull base surgery, this complex procedure should be carried out only in specialized hospitals, which deal with many patients with skull base lesions.
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  • Cerebrovascular Surgery Update
    Hirotoshi SANO, Sachin MAHAJAN
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 765-776
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.765
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  • Unruptured Intracranial Aneurysms: Current Perspectives on the Origin and Natural Course, and Quest for Standards in the Management Strategy
    Akio MORITA, Toshikazu KIMURA, Masaaki SHOJIMA, Tetsuro SAMESHIMA, Tet ...
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 777-787
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.777
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    Unruptured intracranial aneurysms are relatively common, and can cause subarachnoid hemorrhage. Management of unruptured intracranial aneurysms requires knowledge of the natural course and management risks of individual aneurysms. Current knowledge on the natural course and management risks is summarized and our current management strategy presented. Extensive literature review was conducted to identify risk factors influencing the natural course and management outcome of unruptured intracranial aneurysms. Our consecutive surgical series from October 2006 through June 2009 were reviewed retrospectively. The risk factors for rupture were size and location, as well as history of subarachnoid hemorrhage in small aneurysms. Management morbidity was significantly influenced by the size, location, and patient's age. Since 2006, we have monitored motor evoked potentials in all surgeries of cerebral aneurysms and utilized endoscope control, and skull base and bypass techniques in selected cases. In 133 consecutive surgeries, two patients (1.5%) suffered severe neurological morbidity. Unruptured intracranial aneurysms have various clinical characteristics and we need to stratify management strategy according to the aneurysm features such as size, location, shape, and patient's clinical status. In Japan, with national efforts to elevate management standards, morbidity associated with the treatment of the unruptured intracranial aneurysms is relatively low. To improve future care further, we need to continue seeking better and less invasive management modalities and technique.
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  • Symptomatic Unruptured Cerebral Aneurysms: Features and Surgical Outcome
    Isao DATE
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 788-799
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.788
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    Development of less invasive imaging studies, such as magnetic resonance angiography, has increased the chances that unruptured cerebral aneurysms are found. The rupture risk of “symptomatic” aneurysms is higher than for “asymptomatic” aneurysms; so “symptomatic” aneurysms are more often surgically treated. Many reviews examine “asymptomatic” unruptured cerebral aneurysms, but few evaluate “symptomatic” aneurysms. The author has treated many patients with symptomatic unruptured cerebral aneurysms and found that improved cranial nerve signs can be expected if the surgical treatment is performed before the symptoms become irreversible; the critical period is approximately 3 months. It is important to suppress the pulsation of the aneurysms compressing the cranial nerves; both a clipping procedure and endovascular coiling are effective. Cranial nerve signs are more commonly the symptoms of unruptured cerebral aneurysms, but large to giant aneurysms can also be the causes of hemiparesis, hydrocephalus, epilepsy, or even cerebral infarction. This review summarizes the features and surgical outcome of symptomatic unruptured cerebral aneurysms.
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  • What is the Role of Clipping Surgery for Ruptured Cerebral Aneurysms in the Endovascular Era? A Review of Recent Technical Advances and Problems to be Solved
    Tatsuya ISHIKAWA
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 800-808
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.800
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    Craniotomy and clipping have been robust treatments for ruptured cerebral aneurysm for more than 50 years, with satisfactory overall outcomes. Technical advances, such as developments in microsurgical tools and equipment, adjunctive therapy, and novel monitoring methods enable safer and more efficient treatment. However, overall surgical results have not shown any major improvements, as outcomes are mainly determined by the damage from initial bleeding, and new treatment strategies are not always free from associated complications and problems. Recent advances in endovascular treatment are shifting the treatment for ruptured cerebral aneurysm from craniotomy and clipping to intravascular coil embolization. However, craniotomy and clipping are very important for the treatment of ruptured cerebral aneurysm. This paper discusses recent advances and future perspectives in the field of clipping surgery for ruptured aneurysms.
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  • Memorial Review Celebrating the 50th Year of Publication of NMC
    —Neuroendovascular Therapy—
    Waro TAKI
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 809-823
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.809
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  • Moyamoya Disease: Recent Progress and Outlook
    Jun C. TAKAHASHI, Susumu MIYAMOTO
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 824-832
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.824
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    Moyamoya disease as a clinical entity has been known for more than 40 years. Constant efforts have been directed at clarifying the pathogenesis of this disorder and improving therapeutic methods for the ischemic and hemorrhagic stroke caused by the characteristic vasculopathy of this disease. Although much knowledge has been gained, unresolved problems remain, such as the true epidemiology of this disease, elucidation of the genetic mechanism, and prevention of repeated hemorrhagic events. In this paper, we review recent progress and discuss the outlook for this disorder.
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  • Diagnostic Neuroimaging by Magnetic Resonance Imaging: Update
    Yukihiko FUJII, Tsutomu NAKADA
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 833-838
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.833
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    Magnetic resonance (MR) imaging remains the most versatile technique in diagnostic imaging. In addition to conventional imaging sequences such as T1-weighted imaging, T2-weighted imaging, or fluid-attenuated inversion recovery imaging, various techniques specific for certain pathological conditions are being continuously introduced. Pulse sequences for various imaging contrasts are becoming mature, and studies on high (3 T), or even ultra-high (7 T) field systems are emerging as a golden standard for neurosurgical practices. MR spectroscopic imaging capable of providing a pictorial display of the chemical properties of the brain and microscopic imaging providing images with significantly high anatomical resolution equivalent to histological preparations are now becoming essential for presurgical evaluation.
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  • Application of Focal Cerebral Cooling for the Treatment of Intractable Epilepsy
    Masami FUJII, Hiroshi FUJIOKA, Takayuki OKU, Nobuhiro TANAKA, Hirochik ...
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 839-844
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.839
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    Epilepsy is usually treated with medication, but adequate seizure control is still not achieved in over 30% of epilepsy patients, even with the best available agents. Surgical treatment is also performed for such patients, but is not always successful. Focal cooling of the brain using a thermoelectric device has recently been evaluated as an alternative to epilepsy surgery. Brain cooling was first proposed approximately 50 years ago as an effective method for suppressing epileptic discharges (EDs). Recent studies indicate that focal cooling of the brain to a cortical surface temperature of 20°C to 25°C terminates EDs without inducing irreversible neurophysiological dysfunctions or neuronal damage in the brain tissue. Several mechanisms have been proposed for the antiepileptic effects of focal cooling, including reduction in neurotransmitter release, alternation of activation-inactivation kinetics in voltage-gated ion channels, and the slowing of catabolic processes. Developments in the implantable cooling device with closed-loop cooling systems for seizure detection and focal cooling have been promoted in the field of neuromodulation, but several aspects remain uncharacterized concerning the hardware. Recent advances in precision devices have enabled the optimization of the implantable local cooling system, which may become clinically applicable in the near future.
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  • Neuroethics of Deep Brain Stimulation for Mental Disorders: Brain Stimulation Reward in Humans
    Hideki OSHIMA, Yoichi KATAYAMA
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 845-852
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.845
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    The theoretical basis of some deep brain stimulation (DBS) trials undertaken in the early years was the phenomenon of “brain stimulation reward (BSR),” which was first identified in rats. The animals appeared to be rewarded by pleasure caused by the stimulation of certain brain regions (reward system), such as the septal area. “Self-stimulation” experiments, in which rats were allowed to stimulate their own brain by pressing a freely accessible lever, they quickly learned lever pressing and sometimes continued to stimulate until they exhausted themselves. BSR was also observed with DBS of the septal area in humans. DBS trials in later years were undertaken on other theoretical bases, but unexpected BSR was sometimes induced by stimulation of some areas, such as the locus coeruleus complex. When BSR was induced, the subjects experienced feelings that were described as “cheerful,” “alert,” “good,” “well-being,” “comfort,” “relaxation,” “joy,” or “satisfaction.” Since the DBS procedure is equivalent to a “self-stimulation” experiment, they could become “addicted to the stimulation itself” or “compulsive about the stimulation,” and stimulate themselves “for the entire day,” “at maximum amplitude” and, in some instances, “into convulsions.” DBS of the reward system has recently been applied to alleviate anhedonia in patients with refractory major depression. Although this approach appears promising, there remains a difficult problem: who can adjust their feelings and reward-oriented behavior within the normal range? With a self-stimulation procedure, the BSR may become uncontrollable. To develop DBS to the level of a standard therapy for mental disorders, we need to discuss “Who has the right to control the mental condition?” and “Who makes decisions” on “How much control is appropriate?” in daily life.
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  • Technical Advancements and Utilization of Spine Surgery
    —International Disparities in Trend-Dynamics Between Japan, Korea, and the USA
    Phyo KIM, Ryu KUROKAWA, Kazushige ITOKI
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 853-858
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.853
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    Spine surgery has made radical advancements in the last two decades and provision has expanded a great deal. The history of the technical development is briefly reviewed. To analyze trends in utilization and to assess the macroeconomic demand for spine surgery, the incidence of all spine surgery per capita is estimated referring to diverse statistical data from the USA, Korea and Japan. When compared internationally, there is a great disparity in the utilization of spine surgery, especially for fusion/instrumentation. Medico-socioeconomic conditions underlying the variations are discussed. Adequate surgeon training has to be supplied in a matched volume, and the number of surgeons to balance the need is estimated.
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  • Hydrocephalus Research Update
    —Controversies in Definition and Classification of Hydrocephalus—
    Shizuo OI
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 859-869
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.859
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    Classification of hydrocephalus is the most crucial but the most complicated academic challenge within the hydrocephalus research field. The major difficulty in this challenge arises from the fact that the classification is based on almost all subjects in hydrocephalus research, i.e., definition and terminology of hydrocephalus, pathophysiology, hydrocephalus chronology, specific forms of hydrocephalus, associated congenital anomalies/syndrome and underlying conditions, diagnostic procedures for hydrocephalus, and treatment modalities in hydrocephalus. The current status of the classification of hydrocephalus in individual subgroups was reviewed and summarized from publications in the last 60 years (1950-2010), and discussed focusing on the variety of characteristics in hydrocephalus, with more and more new aspects recently disclosed not only in fetal and pediatric but also in adult hydrocephalus. A recently-reported classification of hydrocephalus, “Multi-categorical Hydrocephalus Classification” provides comprehensive coverage of the entire aspects of hydrocephalus with current important classification categories and subtypes.
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  • Neurosurgical Management of Patients With Lumbosacral Myeloschisis
    Takato MORIOKA, Kimiaki HASHIGUCHI, Nobutaka MUKAE, Tetsuro SAYAMA, To ...
    Article type: Review Article
    2010 Volume 50 Issue 9 Pages 870-876
    Published: 2010
    Released on J-STAGE: September 25, 2010
    DOIhttps://doi.org/10.2176/nmc.50.870
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    Myeloschisis is the most serious and complex congenital anomaly in spina bifida manifesta (cystica). However, with improvements in medical care and increased understanding of its pathophysiology, the associated long-term morbidity and mortality rates have been significantly reduced. This article reviews various issues associated with the neurosurgical management of patients with myeloschisis, such as perinatal management, repair surgery for myeloschisis, neurosurgical management of hydrocephalus, Chiari malformation type II, tethered cord syndrome and epilepsy, and intrauterine fetal surgery.
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