Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 52, Issue 10
Displaying 1-16 of 16 articles from this issue
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The 70th Annual Meeting Special Topics — Part III: Multidisciplinary Treatment for Skull Base Tumors
  • Neuroendoscopic Transnasal Surgery for Skull Base Tumors: Basic Approaches, Avoidance of Pitfalls, and Recent Innovations
    Masahiro SHIN, Kenji KONDO, Nobuhito SAITO
    2012 Volume 52 Issue 10 Pages 697-703
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.697
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    Since the introduction of endoscopic technology in the neurosurgical field, the role of transnasal surgery has been dramatically enlarged. With this technique, we can approach the anterior cranial base, parasellar region, clivus, cavernous sinus, and craniovertebral junction, less invasively than with conventional microsurgery. This review describes the two major approach methods in endoscopic skull base surgery, the endonasal approach and the transseptal approach. The endonasal approach uses two nostrils without nasal specula and the mucosa on the sphenoid rostrum and the posterior margin of the nasal septum are removed. In the transseptal approach, only a single nostril is available, but using the nasal speculum, sufficient surgical field can be obtained with only a small incision on the septum. In either approach method, it is very important to avoid excessive mucosal damage and to select the appropriate approach for each patient. The endoscopic skull base approach is one of the least invasive surgical procedures, which is a very promising therapeutic choice with potential for further advances. For better surgical outcomes and further progress, cooperation with rhinolaryngologists who have much more knowledge and experience about nasal surgery than neurosurgeons is essential. We believe this article will contribute to the development of safe and effective surgical procedures, and to the benefit of the patients suffering with intractable skull base lesions.
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  • Therapeutic Strategy and Long-term Outcome of Meningiomas Located in the Posterior Cranial Fossa
    Toru MATSUI
    2012 Volume 52 Issue 10 Pages 704-713
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.704
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    The clinical and surgical findings of 41 consecutive cases of posterior cranial fossa meningiomas operated on between January 1987 and December 2011 at Saitama Medical Center/Saitama Medical University were reviewed. The 31 female and 10 male patients were aged from 19 to 74 years (mean 54 years). The tumors were located in the petroclival (N = 15), craniovertebral junction (N = 6), lateral tentorial (N = 12), and cerebellopontine angle (N = 8) regions. Mean tumor equivalent diameter was 4.3 cm (range 2-9 cm). Head pain (46.3%) and gait disturbance (26.8%) were the most common presenting symptoms, and cranial neuropathies were the most common neurological signs on admission. Mean preoperative performance status (Karnofsky scale) was 83% (range 40-100%). Surgical approaches to these tumors included presigmoidal transpetrosal, retrosigmoidal, transcondylar, and combined approaches. In 4 cases, a staged procedure was performed. Gross total resection was achieved in 85.4% of patients, and subtotal/partial resection in 12.2%. Surgical mortality was 2.4% and complications were encountered in 11 patients (26.8%) including temporary neurological deficits in 4 patients. The mean follow-up period was 8.2 years, ranging from 1 to 24 years, and the mean performance status of patients at 12 months after the last surgery was 92% (range 0-100%). Recurrence or progression of disease was found in 9.8% of cases. Postoperative adjuvant therapy was performed in 6 cases. My experience suggests that although posterior cranial fossa meningiomas represent a continuing challenge for contemporary neurosurgeons, such tumors may be completely or subtotally removed with low rate of mortality and acceptable morbidity, allowing most of these patients to achieve good outcome in long-term follow up.
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  • Gamma Knife Radiosurgery for Benign Cavernous Sinus Tumors: Treatment Concept and Outcomes in 120 Cases
    Motohiro HAYASHI, Mikhail CHERNOV, Noriko TAMURA, Manabu TAMURA, Ayako ...
    2012 Volume 52 Issue 10 Pages 714-723
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.714
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    Availability of modern computer-aided robotized devices, such as the Automatic Positioning System (APSTM; Elekta Instruments AB, Stockholm, Sweden) and PerfexionTM (Elekta Instruments AB), allowed us to develop the original concept of robotic gamma knife microradiosurgery, which is based on the very precise irradiation of the lesion with regard to conformity and selectivity; intentional avoidance of the excessive irradiation of functionally-important anatomical structures, particularly cranial nerves, located both within and in the vicinity of the target; and delivery of sufficient irradiation energy to the tumor with the intention to attain lesion shrinkage, while keeping the marginal dose sufficiently low for prevention of possible complications. The results of such treatment strategy were evaluated retrospectively in 120 patients with benign cavernous sinus neoplasms (pituitary adenomas, meningiomas, schwannomas, and hemangiomas), who were followed up from 24 to 78 months (mean 47 months) after radiosurgery. Tumor growth control and shrinkage rates were 98% and 68%, respectively. More than 50% volume reduction was noted in 25% of lesions. The most prominent volumetric tumor response was observed in hemangiomas, followed by schwannomas, pituitary adenomas, and meningiomas. Treatment-related complications were marked in 7% of cases, and were mainly related to transient isolated cranial neuropathy appearing within several months after radiosurgery. Major morbidity was limited to one patient (0.8%). Application of microradiosurgical treatment principles provides effective and safe management of benign cavernous sinus tumors and is associated with high probability of lesion shrinkage and minimal risk of complications.
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Original Articles
  • Aspiration Versus Excision: A Single Center Experience of Forty-Seven Patients With Brain Abscess Over 10 Years
    Arif Hussain SARMAST, Hakim Irfan SHOWKAT, Altaf Rehman KIRMANI, Abdul ...
    2012 Volume 52 Issue 10 Pages 724-730
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.724
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    The efficacies of two different surgical approaches, aspiration and excision, were investigated for the management of large solitary encapsulated pyogenic brain abscess located in superficial non-eloquent areas, and the impact on length of hospital stay, duration of postoperative antibiotic use, improvement in neurological status, and morbidity and mortality were compared. This retrospective study at Sher-i-Kashmir Institute of Medical Sciences included 47 patients with pyogenic brain abscess from a total of 114 patients evaluated in the Department of Neurosurgery over a period of 10 years from October 2001 to October 2011. Comparisons were made between aspiration and excision in terms of duration of antibiotic use, length of hospital stay, and overall treatment cost. Aspiration was performed in 29 patients (61.7%), of whom 7 patients needed second aspiration, and 18 patients underwent excision (38.3%) of the abscess capsule. The mean duration of antibiotic use in the excision group was significantly shorter at 2.7 weeks (standard deviation [SD] ± 1.1) compared to the aspiration group at 3.8 weeks (SD ± 1.3) (p = 0.006). Similarly, mean length of hospital stay was significantly shorter in the excision group at 18.1 days (SD ± 7.7) compared to the aspiration group at 24.9 days (SD ± 6.6) (p = 0.002). In addition, significantly earlier improvement in neurological function (p = 0.025) and significantly lower rate of re-surgery (p = 0.0238) were found in the excision group compared to the aspiration group. Excision is better than aspiration as far as duration of antibiotic use, length of hospital stay, and overall cost of treatment is concerned, with no significant difference in morbidity and mortality.
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  • Bumping Phenomenon During Continuous Coagulation With Bipolar Forceps
    Takeshi MIKAMI, Masahiko WANIBUCHI, Nobuhiro MIKUNI
    2012 Volume 52 Issue 10 Pages 731-735
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.731
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    During continuous bipolar coagulation, the coagulum sometimes ruptures suddenly and audibly, leading to hemostasis failure and damage to the surrounding tissues. Such coagulum rupture is a phenomenon that is similar to microwave bumping, which occurs because of unequal heat distribution as a result of sudden elevation in temperature. The present study investigated the conditions under which bumping can occur during bipolar coagulation using samples of whole blood. Two types of bipolar forceps were assessed: forceps with gold-plated tips and IsoCoolTM forceps. The time until the bumping phenomenon occurred was measured, and the occurrence rate of bumping was calculated. Thermal characteristics were then assayed using a thermographic camera. As the output of the bipolar coagulator increased, the time until bumping decreased whereas the occurrence rate of bumping during coagulation increased. At lower outputs, the occurrence rate of bumping was significantly lower using IsoCoolTM forceps than that using forceps with gold-plated tips (p < 0.0001). Furthermore, bumping during coagulation could be prevented if the tips of the forceps at the coagulation site were repeatedly opened and closed. The bumping phenomenon is influenced by various factors such as heat, electrical power, equipment, and coagulation technique. Neurosurgeons should understand the technical certain aspects of these surgical tools and develop appropriate advanced techniques for temperature control.
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  • Combined Transmastoid/Middle Fossa Approach for Intracranial Extension of Middle Ear Cholesteatoma
    Keiji TABUCHI, Tetsuya YAMAMOTO, Hiroyoshi AKUTSU, Kensuke SUZUKI, Aki ...
    2012 Volume 52 Issue 10 Pages 736-740
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.736
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    A retrospective review was performed of patients treated for middle ear cholesteatoma with bone defects of the skull base via a combined transmastoid/middle fossa approach at the University of Tsukuba Hospital from 2006 through 2011 to determine the safety and effectiveness of a combined transmastoid/middle fossa approach for the treatment of cholesteatoma involving the middle cranial fossa. The bone defects of the skull base were reconstructed with a galeal flap pedicled with a parietal branch of the superficial temporal artery and an autologous bone flap. The clinical and radiological data were analyzed. This series included 8 patients (6 men and 2 women) with a mean age of 46.3 years (range 10-67 years). One of the patients preoperatively exhibited meningoencephalocele of the middle fossa skull base, and in the remaining 7 patients, petrous bone involvement such as involvement of the supralabyrinthine cells was observed. The cholesteatoma lesion was totally removed and inner ear function preserved in all the patients. Cerebrospinal fluid leakage was observed in 1 patient during and after the surgery. Neither meningitis nor recurrence was observed in any patient during the follow-up periods (mean 29.4 months, range 6-64 months). The combined transmastoid/middle fossa approach allowed complete removal of cholesteatoma with middle cranial fossa involvement while preserving hearing and preventing postoperative cerebrospinal fluid leakage and meningitis.
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Case Reports
  • Spontaneous Hemorrhage From Orbital Cavernous Hemangioma Resulting in Sudden Onset of Ophthalmopathy in an Adult
    —Case Report—
    Junkoh YAMAMOTO, Mayu TAKAHASHI, Yoshiteru NAKANO, Takeshi SAITO, Take ...
    2012 Volume 52 Issue 10 Pages 741-744
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.741
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    A 61-year-old woman presented with a very rare case of spontaneous bleeding from an orbital cavernous hemangioma manifesting as sudden onset of ophthalmic pain, proptosis, diplopia, and nausea. Magnetic resonance (MR) imaging and computed tomography (CT) revealed an intraconal, well-demarcated cystic mass with hemorrhage. The mass was immediately removed through a transcranial approach. Histological examination showed that the mass was a cavernous hemangioma. Ophthalmopathy was resolved by surgery. Orbital cavernous hemangioma is very common in adults, but spontaneous bleeding is extremely rare relative to intracranial cavernous hemangiomas. This rare case emphasizes the importance of careful neuroimaging evaluation with MR imaging and CT for diagnosing orbital cavernous hemangioma associated with spontaneous bleeding.
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  • Hemophilic Pseudotumor of the Temporal Bone With Conductive Hearing Loss
    —Case Report—
    Daina KASHIWAZAKI, Shunsuke TERASAKA, Yuuta KAMOSHIMA, Kanako KUBOTA, ...
    2012 Volume 52 Issue 10 Pages 745-747
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.745
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    A 46-year-old man with factor VIII deficiency presented with a rare case of hemophilic pseudotumor in the temporal bone manifesting as severe conductive hearing loss and external ear bleeding. The pseudotumor expanded and destroyed the temporal bone and skin of the external ear over the course of 8 years. The pseudotumor was surgically excised, and the patient's symptoms improved. Histological examination of a specimen collected from inside the pseudotumor demonstrated blood products in various stages of evolution and showed that the outer membrane consisted of a collagen layer. Hemophilic pseudotumors are rare complications occurring in 1-2% of patients with mild or severe hemophilia. Pseudotumors are chronic, slowly expanding, encapsulated cystic masses, and most are located in the long bones and pelvis. The present case suggests that cranial pseudotumor should be considered in the differential diagnosis of cranial lesion in a patient with hemophilia.
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  • Mesenchymal Chondrosarcoma of the Orbit
    —Case Report—
    Shunya HANAKITA, Kensuke KAWAI, Junichi SHIBAHARA, Nobutaka KAWAHARA, ...
    2012 Volume 52 Issue 10 Pages 747-750
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.747
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    A 20-year-old woman presented with a rare case of intraorbital mesenchymal chondrosarcoma manifesting as a 6-month history of progressive ptosis and exophthalmos of her left eye. Computed tomography and magnetic resonance imaging revealed a partially calcified round mass occupying the postbulbar space. Partial removal of the tumor via a left fronto-orbital approach was performed. The histological diagnosis was mesenchymal chondrosarcoma, and additional intraorbital exenteration was performed. Neither chemotherapy nor radiotherapy was performed. She was free from tumor recurrence at the 6-year follow-up examination. Radical resection, including exenteration if possible, is recommended for intraorbital mesenchymal chondrosarcoma.
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  • Clivus Metastasis From Gastric Signet Ring Cell Carcinoma After a 10-Year Disease-Free Interval
    —Case Report—
    Masamichi FUKUSHIMA, Yoichi KATAYAMA, Yutaka SHIGEMORI, Hiroshi MIYAKE ...
    2012 Volume 52 Issue 10 Pages 751-753
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.751
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    A 64-year-old male presented with an extremely unusual case of solitary clivus metastasis from gastric cancer manifesting as mild headache and diplopia 10 years after radical excision of the primary tumor. The patient underwent surgical resection using an endoscopic transsphenoidal approach. Histological examination revealed typical signet ring cell carcinoma (SRC) which was identical to that of the previous gastric cancer. Why the late recurrence occurred such a long time after the first surgery and how it spread to the clivus remain unclear. The characteristics of SRC and the process of “tumor dormancy” may have been involved in the mechanism underlying late metastasis.
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  • Intracranial Germinoma Manifesting as Cavernous Sinus Syndrome
    —Case Report—
    Ai MUROI, Shingo TAKANO, Takashi FUKUSHIMA, Takashi SHIMIZU, Akira MAT ...
    2012 Volume 52 Issue 10 Pages 754-756
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.754
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    An 11-year-old girl presented with a rare case of neurohypophyseal germinoma manifesting as cavernous sinus syndrome with left abducens nerve palsy. Magnetic resonance (MR) imaging showed a mass located in the left cavernous sinus. Biopsy revealed an inflammatory reaction with lymphocytic infiltration. Postoperative MR imaging showed regression of the mass. Her eye movements were also restored. However, after 5 months, she developed right oculomotor and abducens nerve palsy, and MR imaging showed a large suprasellar mass invading the bilateral cavernous sinuses. The transcranial biopsy sample showed positive staining for placental alkaline phosphatase and c-kit, and the diagnosis of germinoma was confirmed. Chemotherapy and radiotherapy were administered, and the patient has been in complete remission for over 4 years.
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  • Cavernous Sinus Thrombophlebitis Related to Dental Infection
    —Two Case Reports—
    Hiroaki OKAMOTO, Atsushi OGATA, Masafumi KOSUGI, Hiroshi TAKASHIMA, Sh ...
    2012 Volume 52 Issue 10 Pages 757-760
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.757
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    Two cases of cavernous sinus thrombophlebitis (CST) caused by dental infection are described. A 64-year-old woman presented with palsies of the left oculomotor and trochlear nerves after tooth extraction for dental caries in the left maxilla. A 54-year-old man presented with palsy of the left trochlear nerve, sensory disturbance in the ophthalmic and maxillary divisions of the left trigeminal nerve, ptosis, proptosis, and chemosis after dental treatment for caries and periodontitis in the left maxilla. In both patients, computed tomography and magnetic resonance imaging with contrast medium showed non-enhanced lesions within the left cavernous sinus and dilation of the superior ophthalmic veins, which indicated CST. These conditions were resolved by administration of broad-spectrum antibiotics. CST is rare but lethal, so prompt diagnosis is crucial, and immediate appropriate treatment is essential.
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  • Fulminant Tuberculous Meningitis
    —Autopsy Case Report—
    Mizuya SHINOYAMA, Michiyasu SUZUKI, Sadahiro NOMURA
    2012 Volume 52 Issue 10 Pages 761-764
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.761
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    A 56-year-old Japanese male presented with tuberculous meningitis (TBM) manifesting as irrational behavior. He underwent lumbar puncture, which showed inflammatory cerebrospinal fluid (CSF) findings. Administration of anti-tuberculosis (TB) agents was started on the day after admission (Day 1) because delayed treatment of TBM might be fatal. On Day 4, magnetic resonance (MR) imaging and MR angiography showed fresh infarctions, hydrocephalus, and stenoses of arteries. CSF drainage and biopsy of brain tissue were performed, but the pathological findings were non-specific. Frequent CSF examinations, cultures, and polymerase chain reaction were performed, but no positive finding of TB was obtained. He died on Day 14. Brain autopsy showed Langerhans giant cells and Ziehl-Neelsen-positive TB bodies. Unfortunately, our patient suffered very poor outcome irrespective of early anti-TB treatment starting Day 1, suggesting the probability of delayed admission or drug-resistant TB. TB infection including TBM has become rare in developed countries, and diagnosis remains difficult. Corticosteroid therapy may be effective for TBM, but may be restricted and ameliorate mortality but not morbidity. Further study is required to establish second line treatment if TBM is resistant to anti-TB agents and corticosteroid administration.
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  • Usefulness of L-[Methyl-11C]Methionine Positron Emission Tomography in the Treatment of Idiopathic Hypertrophic Cranial Pachymeningitis
    —Case Report—
    Keisuke MIYAKE, Masaki OKADA, Tetsuhiro HATAKEYAMA, Masanobu OKAUCHI, ...
    2012 Volume 52 Issue 10 Pages 765-769
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.765
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    A 53-year-old man suffered from pulsating headache for 2 months. Magnetic resonance imaging with gadolinium revealed a linear or nodular mass along the left fronto-parietal convexity. Positron emission tomography (PET) with L-[methyl-11C]methionine (11C-MET) demonstrated increased uptake in the enhanced lesion. Biopsy, obtained by craniotomy, demonstrated granulation with lymphocyte and plasma cell infiltration, suggesting inflammatory changes, and a diagnosis of idiopathic hypertrophic cranial pachymeningitis (IHCP) was made. Steroid therapy resulted in improvement of the clinical symptoms and shrinkage of the enhanced lesion in a week. Follow-up 11C-MET PET study, after 18 months of steroid therapy, demonstrated significantly decreased uptake in the lesion, so the steroid therapy was discontinued. Neither clinical nor radiological recurrence was observed one year after discontinuation of the steroid therapy. This case of IHCP with increased 11C-MET uptake, which then decreased after steroid therapy suggests that 11C-MET PET is a useful monitoring modality for therapeutic efficacy against IHCP, and can indicate the appropriate timing of therapy discontinuation.
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  • Neuromyelitis Optica Spectrum Disorder: 2-Deoxy-2-[18F]Fluoro-D-Glucose Positron Emission Tomography Findings
    —Case Report—
    Hirofumi OYAMA, Shigeru MIWA, Tomoyuki NODA, Atsuhiro SOBAJIMA, Akira ...
    2012 Volume 52 Issue 10 Pages 769-773
    Published: 2012
    Released on J-STAGE: October 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.769
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    A 51-year-old female with a history of rheumatoid arthritis rapidly developed anterior neck pain and paresis in the left upper and lower extremities and right lower extremity, sensory disturbance in the left upper and lower extremities, and bladder and rectal disorder. Adduction of the left eye and abduction of the right eye were also disturbed. Spinal magnetic resonance imaging demonstrated severe edema in the C1-T5 levels, which then deteriorated rapidly over 3 days, and lesions enhanced with gadolinium in the C1-C3 and C5-T3 levels. 2-Deoxy-2-[18F]fluoro-D-glucose positron emission tomography study demonstrated the inflammatory sites as segmental enhanced accumulation in the C1-C3, C5-C6, and T1 levels. The serum anti-aquaporin 4 antibody level was positive and she was diagnosed with neuromyelitis optica spectrum disorder. Marked improvement in the neurological conditions, concomitant with reduced spinal cord edema, was obtained by steroid pulse therapy.
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Editorial Committee
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