Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
Volume 51, Issue 2
Displaying 1-21 of 21 articles from this issue
Original Articles
  • Kentaro MORI, Takuji YAMAMOTO, Yasuaki NAKAO, Takanori ESAKI
    Article type: Original Article
    2011 Volume 51 Issue 2 Pages 93-96
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Posterior circulation revascularization is a challenging technique because microanastomosis must be performed in deep locations. A reproducible simulation model is proposed for training. The prototype three-dimensional skull model with artificial brain was used. The mesencephalic segment of superior cerebellar artery (SCA) and the caudal loop of the posterior inferior cerebellar artery (PICA) were made from artificial blood vessels and glued on the brain. The skull model was drilled to perform the presigmoid transpetrosal approach and then superficial temporal artery-SCA anastomosis was performed under the operating microscope. The skull model was also drilled to perform the far lateral approach and then occipital artery-PICA anastomosis was performed. The skull model with artificial brain and arteries allows simulation and training in the surgical techniques of posterior circulation revascularization with skull base approaches.
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  • Yoichiro KAWAMURA, Osamu NARUMI, Masaki CHIN, Sen YAMAGATA
    Article type: Original Article
    2011 Volume 51 Issue 2 Pages 97-100
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Variant deep cerebral venous drainage, primarily involving the basal vein of Rosenthal (BVR), may be a cause of idiopathic subarachnoid hemorrhage (SAH). In this study, deep venous drainage was compared between 13 patients with idiopathic SAH and 35 control patients with aneurysmal SAH diagnosed by digital subtraction angiography (DSA). Venous return was evaluated by DSA on 25 sides in patients with idiopathic SAH and 67 sides in patients with aneurysmal SAH, and the relationship between the BVR and the vein of Galen was classified into 3 categories: types A (normal continuous), B (normal discontinuous), and C (primitive variant). The occurrence rates of the three categories were: idiopathic SAH, type A 24%, type C 40%; and aneurysmal SAH, type A 49.3%, type C 10.4% (p = 0.003). Combined bilateral venous drainage was classified as normal combination (AA), discontinuous combination (AB, BB), and primitive combination (AC, BC, CC), with rates: idiopathic SAH, normal 0%, primitive 58.3%; and aneurysmal SAH, normal 42.4%, primitive 21.2%. Venous drainage on either the left or right side was more commonly type C (primitive) in idiopathic SAH (p = 0.006). Three patients with left-right differences in hematoma distribution on brain computed tomography had types A, B, and C on the SAH dominant side in one patient each. No clear trend was observed between hematoma distribution and primitive variant side. Some patients with idiopathic SAH had thick hematoma in the basal cistern. Further, 3 patients with idiopathic SAH had an aneurysmal pattern, rather than a perimesencephalic pattern. All these patients had type C either on the left or right side. Therefore, although the mechanism of involvement of venous drainage in idiopathic SAH is unknown, hemorrhage is not limited to a perimesencephalic pattern. The present findings support a previous hypothesis that variant venous drainage is involved in the occurrence of idiopathic SAH. The absence of a normal combination of venous drainage is an important factor to diagnose idiopathic SAH.
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  • Toshiyuki TAKAHASHI, Junya HANAKITA, Manabu MINAMI, Fumiaki HONDA, Kei ...
    Article type: Original Article
    2011 Volume 51 Issue 2 Pages 101-107
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    The clinical outcome and resumption of work were investigated in 21 patients with lumbar discogenic pain (15 males and 6 females, mean age 37.2 years), who failed to respond to intensive conservative therapy, treated by transforaminal lumbar interbody fusion (TLIF) augmented with the pedicle screw system from January 2005 to December 2007. Perioperative assessment was performed using the modified Japanese Orthopaedic Association (mJOA) score, the Oswestry Disability Index, and the visual analogue scale (VAS). Type of occupation and work status of the patients were also assessed before and after surgery. Preoperative occupation was divided into two groups according to the work content (heavy labor vs. light labor). Follow-up period was mean 26.1 months, and greater than 1 year in all patients. Perioperative assessment showed postoperative improvement with statistical significance. Recovery rates at final follow-up examination were 53% of the mJOA score and 65% of the VAS. This study showed that postoperative overall resumption rate was 90%. However, only 23% of the heavy labor group returned to the previous work compared with 71% of the light labor group. TLIF is thought to be a safe and effective technique in patients with intractable chronic lumbar discogenic pain with an acceptable overall work resumption rate, whereas complete return to previous jobs was limited in the heavy labor group.
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  • Kyongsong KIM, Toyohiko ISU, Atsushi SUGAWARA, Ryoji MATSUMOTO, Masano ...
    Article type: Original Article
    2011 Volume 51 Issue 2 Pages 108-112
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Posterior decompression of the cervical spine is an accepted treatment for patients with cervical canal disease, but some patients experience postoperative axial pain and C5 or C6 palsy that affect their quality of life. Here we describe selective posterior decompression using a spinous process-splitting approach to prevent these complications performed in 17 patients with myelopathy treated at median 2.4 levels by selective posterior decompression via the transspinous approach. Clinical symptoms, axial pain, and C5 or C6 palsy were compared before and after treatment. The range of motion of the cervical spine and shift of the cervical cord were studied at the C5 level. All patients experienced symptom improvement and none suffered deterioration or required reoperation. The Japanese Orthopaedic Association score improved from 10.9 to 14.4 points and none of the patients reported C5 or C6 palsy or axial pain at the last follow-up visit. There was no statistically significant change in pre- and postoperative cervical alignment and range of motion. The posterior shift of the spinal cord at the C5 level was 1.7 mm. None of our 17 patients experienced significant postoperative axial pain after selective posterior decompression via the transspinous approach. Minimal spinal cord shift at the C5 level may have contributed to the reduced incidence of postoperative C5 or C6 palsy in our series. Selective posterior decompression is less invasive and effective in some patients with cervical canal disease.
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Case Reports
  • —Two Case Reports—
    Takayuki MIZUNARI, Yasuo MURAI, Kyongsong KIM, Shiro KOBAYASHI, Hiroya ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 113-116
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Two patients presented with post-traumatic carotid-cavernous sinus fistulae (CCFs) that were successfully treated by high-flow bypass using a radial artery graft after initial unsuccessful attempts at obliteration by intravascular embolization. Case 1 was a 20-year-old man with a CCF detected by magnetic resonance imaging and angiography following an accident. Although the CCF appeared partially occluded by intravascular embolization, serial angiography revealed CCF recurrence. The CCF was trapped by placing a high-flow bypass. Case 2 was a 21-year-old man who presented with bilateral CCFs after sustaining face trauma. The bilateral CCFs were directly treated because of recurrence after balloon occlusion. At present, intravascular surgery is the first treatment choice, but placing a high-flow bypass with trapping of the CCF gained time to treat the CCF and may be useful for treating post-traumatic CCF that cannot be effectively eliminated by intravascular techniques.
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  • —Case Report—
    Naoki YAMAMOTO, Yuzo TERAKAWA, Yumiko OKADA, Yutaka MITSUHASHI, Akimas ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 117-119
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.
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  • —Case Report—
    Seung-Jae HYUN, Sung-Nam HWANG, Taek-Kyun NAM, Seung-Won PARK, Jun-Soo ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 119-122
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 44-year-old woman presented with severe headache, drowsy mentality, and right hemiparesis. Brain computed tomography and magnetic resonance angiography revealed non-aneurysmal subarachnoid hemorrhage (SAH). Thoraco-abdominal and pelvic computed tomography angiography showed multiple steno-occlusive lesions involving the aorta and its large branches suggesting Takayasu's arteritis. Spine magnetic resonance imaging was taken because of prominent right hand muscle atrophy on the 14th hospital day, which showed subacute stage of hematomyelia in the cervical cord and conus medullaris. Aneurysmal or non-aneurysmal SAH is rare in patients with Takayasu's arteritis but SAH with coincidental hematomyelia is even more unusual. This case emphasizes the rarity of the coincidental spinal hematomyelia and its importance in the differential diagnosis.
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  • —Case Report—
    Shinri ODA, Masami SHIMODA, Kaori HOSHIKAWA, Hideki SHIRAMIZU, Mitsuno ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 123-127
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 45-year-old woman presented with extensive deep cerebral venous thrombosis (DCVT) identified by typical direct thrombosed sign in the internal cerebral vein, vein of Galen, and straight sinus on both computed tomography and T2*-weighted magnetic resonance imaging. Moreover, rare direct sign, probably of the direct lateral vein, was also obtained. Direct sign of the thrombosed vein or sinus is important for the diagnosis of DCVT. The present case indicates the usefulness of attenuated vein sign and T2*-weighted imaging for the diagnosis of direct thrombosed vein in patients with DCVT.
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  • —Case Report—
    Takahito OKAZAKI, Masaaki SHIBUKAWA, Yoshihiro KIURA, Shigeyuki SAKAMO ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 127-129
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    An 18-year-old man presented with a rare case of a ruptured internal carotid artery (ICA)-persistent primitive anterior choroidal artery (PPAchA) manifesting as sudden onset of headache. Computed tomography (CT) showed subarachnoid hemorrhage. Three-dimensional CT angiography showed a saccular aneurysm at the right ICA-AchA region. Right internal carotid angiography showed a PPAchA and saccular aneurysm. Endovascular treatment of the aneurysm achieved complete aneurysm occlusion.
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  • —Two Case Reports—
    Mika KOMATSU, Fuminari KOMATSU, Hitoshi TSUGU, Tatsumi YAHIRO, Shinya ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 130-133
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    The incidence of vitamin K deficiency in infancy has decreased markedly, due to prophylactic administration of vitamin K during the neonatal period. However, vitamin K deficiency bleeding may occur during or after the neonatal period despite prophylactic administration in Japan. Two cases are reported of intracranial hemorrhage associated with coagulopathy in full-term infants who had received prophylactic administration of vitamin K. More reliable methods for prophylactic administration should be established.
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  • —Case Report—
    Takahisa KANEKO, Izumi KOYANAGI, Tomohiro MURAKAMI
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 134-136
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 47-year-old woman underwent decompressive suboccipital craniectomy and C1 laminectomy with duroplasty in the prone position for Chiari malformation type I and syringomyelia. The arachnoid membrane was not injured. Intraoperative echography showed good enlargement of the subarachnoid space. No closed subcutaneous drain was used. The patient complained of repeated nausea and vomiting 3 hours after the operation, and computed tomography revealed remote cerebellar hemorrhage on postoperative day 1. The cerebellar hemorrhage was treated conservatively, and the symptoms continued only for 3 days after surgery. Dural opening with rapid loss of cerebrospinal fluid (CSF) has occurred in every reported case of remote cerebellar hemorrhage complicating intracranial and spinal procedures. Loss of CSF is the main pathogenesis of this condition. In our case, the most probable pathomechanism seems to involve stretching of the infratentorial cerebellar bridging veins due to cerebellar sagging because of dural opening in the prone position and drop in CSF pressure. Such a complication is rare but should be considered after foramen magnum decompression surgery if the patient shows unusual symptoms of repeated vomiting.
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  • —Case Report—
    Takao FUKUSHIMA, Kazunari YACHI, Akiyoshi OGINO, Takashi OHTA, Takao W ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 136-140
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 33-year-old female presented with an isolated well-enhanced intracerebral lesion with peritumoral edema in the frontal lobe, which was tentatively diagnosed preoperatively as either a primary intraparenchymal neoplasm or metastatic brain tumor. However, histological examinations yielded a diagnosis of Rosai-Dorfman disease. Isolated intracranial Rosai-Dorfman disease is very rare, and without dural attachment, as in our case, is exceptional. The present case mimicked intraparenchymal neoplasm. Rosai-Dorfman disease should be considered in the differential diagnosis of isolated intraparenchymal tumors. Magnetic resonance imaging including diffusion-weighted imaging may be helpful in the diagnosis of isolated intracranial Rosai-Dorfman disease.
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  • —Case Report—
    Chihiro AKIBA, Takanori ESAKI, Maya ANDO, Tsuyoshi FURUYA, Kazuyuki NO ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 140-143
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 62-year-old male presented with a rare case of possible neuro-Sweet Disease (NSD) mimicking brain tumor in the medulla oblongata, manifesting as numbness in the bilateral upper and lower extremities, gait disturbance, dysarthria, and swallowing disturbance which gradually deteriorated over 3 months. Magnetic resonance imaging showed a mass lesion in the medulla oblongata, extending to the upper cervical cord with rim enhancement by gadolinium. The preoperative diagnosis was brain tumor, such as glioma, or inflammatory disease. His neurological symptoms gradually deteriorated, so biopsy was performed through the midline suboccipital approach. Histological examination showed infiltration of inflammatory cells, mainly lymphocytes and macrophages. Human leukocyte antigen typing showed Cw1 and B54 which strongly suggested possible NSD. Steroid pulse therapy was started after surgery and the clinical symptoms improved. Neurosurgeons should be aware of inflammatory disorders such as NSD mimicking brain tumor.
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  • —Case Report—
    Ichiyo SHIBAHARA, Tomohiro KAWAGUCHI, Masayuki KANAMORI, Shingo YONEZA ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 144-147
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Pilocytic astrocytoma sometimes transforms to a malignant type, and previous radiation therapy is considered to be a key factor. We report a case of pilocytic astrocytoma with histological malignant features without previous radiation therapy. A 21-year-old man presented a sudden onset of severe headache. Neuroimaging had detected a cystic mass in the posterior fossa at the age of one year without therapeutic intervention. On admission, computed tomography depicted a brain tumor in the posterior fossa with cystic components, intratumoral hemorrhage, and upward herniation. Urgent surgery was performed, and histological examination revealed some features of pilocytic astrocytoma but also broad necrosis, high cellularity, and MIB-1 labeling index of more than 20%. The histological diagnosis was pilocytic astrocytoma with malignant features. This tumor had continued a benign clinical course for 20 years, but had eventually transformed to a malignant type. Therefore, pilocytic astrocytoma may undergo spontaneous malignant transformation during its natural clinical course.
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  • —Two Case Reports—
    Yuko SADAMURA, Kazuhiko SUGIYAMA, Hiroyuki UCHIDA, Ryosuke HANAYA, Kun ...
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 148-152
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Two boys aged 8 and 12 years presented with intracranial germinoma manifesting as cerebral hemispheric atrophy, hemiparesis, and decline in academic performance. First magnetic resonance (MR) imaging showed no enhanced lesions, but follow-up MR imaging obtained 12 or 23 months after the first visit showed new mass lesions in the temporal lobe or pituitary gland. Biopsy of these lesions resulted in a histological diagnosis of germinoma. Chemoradiation therapy produced complete remission but both patients continued to manifest mild hemiparesis and impaired cognitive function. Review of 18 previous and our 2 patients presenting with hemispheric atrophy revealed strong male predominance (18:2), mean age of 12.8 ± 5.2 (standard deviation) years, hemiparesis in all patients, and cognitive decline in 9 patients. Initial MR imaging detected mass lesions in only 9 patients, but follow-up MR imaging performed 10-38 months later detected new mass lesions in 5 patients. Radiation with/without chemotherapy provided good tumor control in all patients, but none of the 9 patients with cognitive dysfunction recovered their intellectual ability. We recommend early diagnosis based on biopsy of the atrophic site and timely treatment to improve the quality of life in these patients.
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  • —Case Report—
    Yasuyuki MIYOSHI, Takao YASUHARA, Isao DATE
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 153-156
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 29-year-old man presented with a rare case of far-out foraminal stenosis with radiculopathy caused by osteophyte formation secondary to an anomalous articulation between the transverse process and the sacral ala. Diagnosis of unilateral far-out foraminal entrapment of the L5 spinal nerve below a transitional vertebra (TV) depended on selective radiculography and nerve root block. Computed tomography after selective radiculography clearly demonstrated foraminal entrapment of the L5 nerve root via the osteophytes. The patient underwent posterior decompression by resection of the osteophytes using an operating microscope and experienced good relief of radicular pain. This case illustrates the effectiveness and some refinements of posterior decompression for radicular pain caused by far-out foraminal stenosis below a TV and compression of the L5 spinal nerve.
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  • —Case Report—
    Atsushi ARAI, Hideo AIHARA, Shigeru MIYAKE, Yusei HANADA, Eiji KOHMURA
    Article type: Case Report
    2011 Volume 51 Issue 2 Pages 157-159
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    A 50-year-old male presented with back pain and numbness of the lower extremities persisting for 10 years. He had played volleyball for a long period until recently. He had no history of meningitis or traumatic injury. Magnetic resonance imaging revealed a syringomyelia located in the region from T8 to T9 without contrast enhancement or Chiari malformations. Computed tomography showed T9-10 spinal stenosis caused by the right enlarged ossified yellow ligament. Decompressive laminectomy was performed and the ossified ligament removed. Due to the finding of arachnoid thickening and adhesions during the intradural operation, shunting was also performed. Postoperatively, the neuroimaging and clinical findings improved. Syringomyelia is often associated with Chiari malformations, trauma, spinal tumor, hemorrhaging, and meningitis. We suggest that repeated minor mechanical damage caused by physical exercise in addition to long-standing compression of the spinal cord due to spinal spondylosis could induce severe arachnoid fibrotic change similar to adhesive arachnoiditis, which may be one of the main triggers of syringomyelia. Extradural decompressive surgery is considered to be the initial treatment for syringomyelia associated with spinal spondylosis.
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Technical Notes
  • —Technical Note—
    Nakamasa HAYASHI, Hikari SATO, Naoki AKIOKA, Kunikazu KUROSAKI, Satosh ...
    Article type: Technical Note
    2011 Volume 51 Issue 2 Pages 160-163
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    The horizontal head position was adopted in the unilateral anterior interhemispheric approach to treat an anterior communicating artery (ACoA) aneurysm. The patient was placed in the supine position. The patient's head was rotated to the right to orient the midline horizontally, and tilted 45 degrees superiorly. After bicoronal skin incision and bifrontal craniotomy, the dura on the right side (downside) was opened. Dissection of the right interhemispheric fissure allowed gravity to retract the right (downside) hemisphere, which fell away from the falx, while the falx supported the upside hemisphere. The present approach was used in three patients with ACoA aneurysm between January 2009 and April 2010. The aneurysms were adequately clipped with this approach. No complication related to the approach occurred. No patients exhibited anosmia after surgery. This approach is useful for ACoA aneurysms.
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  • —Technical Note—
    Takahiro MURATA, Tetsuyoshi HORIUCHI, Nunung Nur RAHMAH, Keiichi SAKAI ...
    Article type: Technical Note
    2011 Volume 51 Issue 2 Pages 163-167
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Direct surgery remains important for the treatment of superficial cerebral arteriovenous malformation (AVM). Surgical planning on the basis of careful analysis from various neuroimaging modalities can aid in resection of superficial AVM with favorable outcome. Three-dimensional (3D) magnetic resonance (MR) imaging reconstructed from time-of-flight (TOF) MR angiography was developed as an adjunctive tool for surgical planning of superficial AVM. 3-T TOF MR imaging without contrast medium was performed preoperatively in patients with superficial AVM. The images were imported into OsiriX imaging software and the 3D reconstructed MR image was produced using the volume rendering method. This 3D MR image could clearly visualize the surface angioarchitecture of the AVM with the surrounding brain on a single image, and clarified feeding arteries including draining veins and the relationship with sulci or fissures surrounding the nidus. 3D MR image of the whole AVM angioarchitecture was also displayed by skeletonization of the surrounding brain. Preoperative 3D MR image corresponded to the intraoperative view. Feeders on the brain surface were easily confirmed and obliterated during surgery, with the aid of the 3D MR images. 3D MR imaging for surgical planning of superficial AVM is simple and noninvasive to perform, enhances intraoperative orientation, and is helpful for successful resection.
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  • —Technical Note—
    Satoru SHIMIZU, Koji KONDO, Tomoya YAMAZAKI, Kenji NAKAYAMA, Isao YAMA ...
    Article type: Technical Note
    2011 Volume 51 Issue 2 Pages 167-169
    Published: 2011
    Released on J-STAGE: February 25, 2011
    JOURNAL OPEN ACCESS
    Implanted methylmethacrylate may be unexpectedly displaced due to poor adherence to the bone. We developed a simple technique to fix the material plugging the burr holes for use primarily in cosmetically important areas. At the closure of craniotomy, 2-3 small drill holes are made at the rim of the craniotomy burr hole. To address cranial defects in the pterional region, small holes are placed on the bone surface around the key burr hole. The holes extend into the diploic layer and have no parallel relationship. After fixation of the bone flap, a methylmethacrylate filler mixture is manually plugged into the burr hole and pushed into the small holes, thereby forming horns for secure fixation. None among over 100 patients developed an objectionable bulge attributable to displacement of the filler. Our technique requires no special instruments or materials and decreases the risk of cosmetic problems.
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