In patients with an unresectable epileptic focus, such as an undefined focus or epileptic focus within functional areas, various neuromodulation therapies, including vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, have been adopted as alternative treatment modalities. Vagus nerve stimulation, the earliest approved neuromodulation therapy in Japan, may be indicated irrespective of the epilepsy type and offers several advantages, including craniotomy not being required; however, its efficacy remains limited. Among deep brain stimulation targets, the anterior nucleus of the thalamus has the most established efficacy, and anterior nucleus of the thalamus-deep brain stimulation has been covered by the national health insurance system of Japan for the treatment of epilepsy since 2023. It is considered to be particularly effective for seizures originating from the limbic structures. Although it is not approved for insurance coverage in either Japan or the United States, another effective target is the centromedian nucleus of the thalamus, particularly for generalized epilepsies, including Lennox-Gastaut syndrome. While evidence is limited, deep brain stimulation targeting the hippocampus, subthalamic nucleus, pulvinar nucleus, posteromedial hypothalamus, nucleus accumbens, and cerebellum has also been reported. Responsive neurostimulation, though not yet approved in Japan, records electroencephalographic activity via intracranial electrodes and delivers automatic electrical stimulation upon seizure detection. It is useful for patients with an unresectable seizure focus, that is, eloquent cortex involvement or bilateral temporal lobe epilepsy. This review outlines neuromodulation therapies for epilepsy.

Intra-aneurysmal thrombus formation is crucial for the healing of endovascularly treated aneurysms. This study evaluated whether T1-weighted black blood imaging can monitor thrombus formation by examining the relationship between chronological signal intensity changes and aneurysm occlusion status after flow diverter stenting and coil embolization. We retrospectively analyzed 78 patients with 83 aneurysms (flow diverter stenting: 28, coil embolization: 55) who underwent T1-weighted black blood imaging at 1 week, 3 months, and 6 months post-treatment. Relative signal intensity was calculated as the signal intensity of the aneurysmal sac divided by the signal intensity of the genu of the corpus callosum. Satisfactory occlusion (O'Kelly-Marotta grades C or D) at 6 months was the primary endpoint for flow diverter stenting, while residual intra-aneurysmal blood flow during the follow-up was defined as recurrence after coil embolization. In flow diverter stenting cases, relative signal intensity was elevated at 3 months and remained stable. Relative signal intensity 3 months after flow diverter stenting was significantly higher in the satisfactory occlusion group than the non-satisfactory occlusion group (0.99 ± 0.55 vs. 0.51 ± 0.34, p = 0.03) and independently associated with satisfactory occlusion (adjusted odds ratio per 0.1 increase = 1.35, p = 0.01). In coil embolization cases, relative signal intensity was highest at 1 week and decreased linearly. Higher relative signal intensity 1 week after coil embolization was associated with lower recurrence rates (0.60 ± 0.22 vs. 0.41 ± 0.12, p = 0.002) and independently linked to aneurysm recurrence (adjusted odds ratio per 0.1 increase = 0.55, p = 0.004). Relative signal intensity changes on T1-weighted black blood imaging differ between flow diverter stenting and coil embolization. High relative signal intensity 3 months after flow diverter stenting and relative signal intensity 1 week after coil embolization were significantly correlated with favorable outcomes.

For resectable malignant peripheral nerve sheath tumors, the additional benefits of radiotherapy remain controversial. This study aims to investigate whether there is an additional benefit of radiotherapy for resectable malignant peripheral nerve sheath tumors. We retrospectively collected data on malignant peripheral nerve sheath tumor cases from the Surveillance, Epidemiology, and End Results database. Overall, 926 malignant peripheral nerve sheath tumor cases occurred in soft tissues, with surgical resection performed in 783 cases. After excluding cases with distant metastasis, incomplete follow-up, rare tumor sites, and unrecorded tumor diameter, 339 malignant peripheral nerve sheath tumor cases with highly complete information were included in the study. Cox analysis and propensity score matching were used to evaluate the prognosis. Cancer-specific survival was selected as the endpoint for this study. Subgroup analyses were applied based on tumor diameters and sites. In both regressions on total and post-propensity score matching data, radiotherapy was not identified as an independent risk factor for cancer-specific survival. Further results from subgroup analyses indicated that radiotherapy was not a significant risk factor for cancer-specific survival in each subgroup of the total study data and the post-propensity score matching data. In conclusion, radiotherapy provided limited benefits on Cancer-specific survival for resectable malignant peripheral nerve sheath tumors. Subgroup analyses based on tumor diameter and location also failed to demonstrate positive outcomes. However, the benefits of radiotherapy for controlling local tumor recurrence still need to be explored through prospective randomized controlled clinical trials in the future.

At our hospital, the initial surgical treatment of Rathke's cleft cysts is simple drainage and wall biopsy by opening the cyst. If intraoperative cerebrospinal fluid leakage occurs, subarachnoid space cisternostomy is added to prevent reaccumulation of cyst contents. We aimed to determine whether the addition of cisternostomy to simple drainage decreases postoperative reaccumulation and reoperation rates. Rathke's cleft cysts initially operated on between January 2011 and December 2021, with postoperative follow-up of more than 1 year, were retrospectively reviewed. The postoperative course was compared between Group A (simple drainage) and Group B (addition of cisternostomy in the upper part of the cyst to communicate with cyst and prechiasmatic cistern, or addition of cisternostomy at the arachnoid of the dorsum sellae behind the cyst to communicate with cyst and prepontine cistern). Ninety-five patients were identified: 84 in Group A and 11 in Group B. Statistical analysis was performed between Groups A and B. The median follow-up periods were 46 (12-137) and 56 (16-115) months, respectively. The reaccumulation rate of cystic fluid during follow-up was 48.8% (n = 48) in Group A and 45.5% (n = 5) in Group B. The median times to reaccumulation were 8 (0-42) and 20 (6-46) months in Groups A and B, respectively. Among these patients, 5 (6.0%) were reoperated in Group A and 2 (18.2%) in Group B. In summary, cisternostomy performed in the subarachnoid space by perforation or partial removal of the cyst wall does not reduce postoperative reaccumulation or reoperation rates compared with simple drainage.

Microvascular proliferation on the cerebral surface is a hallmark feature of Moyamoya disease (MMD); however, studies on this phenomenon are limited. This study evaluated whether preoperative cortical microvascularization on partial maximum intensity projection (MIP) using three-dimensional rotational angiography corresponds to increased intraoperative pial arteries in MMD. We analyzed 24 hemispheres from 22 patients with MMD who underwent cerebral angiography and bypass surgery between October 2018 and July 2023. Control groups included patients with unruptured cerebral aneurysms (n = 15) and major cerebral artery occlusion (n = 10). Microvascular density (MVD) was calculated by measuring vascular area surgical videos. Cortical artery and periventricular anastomosis development were graded (0-2) using MIP images, with grade 2 indicating well-developed vessels. The mean age of the 22 patients was 41.3 ± 13.7 years, of which and 4 (18.1%) were male. Cortical microvascularization was observed in 12 hemispheres (50%). The mean MVD in MMD was 24.8 ± 5.9%, which was significantly higher than that in unruptured cerebral aneurysms (17.5 ± 2.4%; p < 0.001) and major cerebral artery occlusion (18.0 ± 2.2%; p < 0.001). MVD was significantly higher in hemispheres with cortical microvascularization (p = 0.014) and in those with well-developed thalamic arteries (THA; p < 0.001), however not in those with developed lenticulostriate or choroidal arteries. Our findings demonstrate that elevated intraoperative pial arteries in MMD correlate with cortical microvascularization and THA development in preoperative imaging. Further investigation into the vascular pathophysiology of MMD may refine diagnostic and therapeutic approaches.

Advancements in chemotherapy have extended the survival of patients with metastatic cancer, increasing the need for effective treatment strategies for spinal metastases. Metastasis to the craniocervical junction significantly affects activities of daily living. This study evaluates the safety and effectiveness of cervical pedicle screws in occipitocervical fusion for metastasis to the craniocervical junction and reassesses the role of surgery within a multidisciplinary approach incorporating novel chemotherapy. A retrospective review was conducted on 21 patients with metastasis to the craniocervical junction who underwent occipitocervical fusion with cervical pedicle screws at Nagoya University Hospital and Aichi Cancer Center between November 2017 and August 2024. Clinical data, Eastern Cooperative Oncology Group Performance Status, imaging findings, surgical outcomes, perioperative complications, and adjuvant therapies were analyzed. The revised Tokuhashi score and the Modified Bauer score were used for prognostic assessment. All patients experienced significant postoperative pain relief, and 17 cases showed improvement in Eastern Cooperative Oncology Group Performance Status. Cervical pedicle screws provided rigid stabilization, allowing for limited fusion levels (fixation down to C3 in 11 cases). Seven of the 11 patients who received postoperative chemotherapy survived beyond their predicted prognosis. No intraoperative complications related to pedicle screws were reported. These findings suggest that occipitocervical fusion using cervical pedicle screws effectively stabilizes metastasis to the craniocervical junction while preserving limited fusion levels. A multidisciplinary approach integrating surgery and chemotherapy may improve survival in this challenging patient population.

Stroke care units, which provide intensive management for acute stroke, are widely used in Japan. However, recent legal restrictions on physicians' overtime may challenge continuous specialist coverage, particularly in resource-limited settings. To address this issue, we developed a tele-stroke care units system that provides remote support from stroke specialists. We aimed to evaluate the feasibility and reliability of this system for remote neurological assessment. The system integrates live-streaming and medical image viewing between a local stroke care unit and a remote university hospital through the International Organization for Standardization 27001-compliant Join LiveView application (Allm, Inc., Japan). Remote physicians accessed real-time videos through ceiling-mounted pan-tilt-zoom cameras and communicated bidirectionally using a wireless speaker. We assessed the audiovisual quality, conducted remote National Institutes of Health Stroke Scale examinations in 20 patients with stroke, and compared the results with those of bedside assessments. Remote physicians successfully evaluated all National Institutes of Health Stroke Scale categories using camera-zoom functions, with or without local staff assistance. Video and audio quality were sufficient for clinical assessment and communication. Median total National Institutes of Health Stroke Scale scores were 7.5 (bedside) and 6.5 (remote). Excellent or perfect inter-rater reliability was observed in all 13 categories, with a total score correlation coefficient of 0.998 (p < 0.0001). The tele-stroke care unit system showed sufficient audiovisual quality for effective remote neurological assessment and may serve as a practical solution for acute stroke management in facilities facing workforce shortages, thereby contributing to sustainable stroke care.

Postoperative hematoma formation is one of the most life-threatening complications associated with giant pituitary adenomas, and various surgical methods have been proposed to mitigate this risk. This study aims to report our surgical outcomes in patients with giant pituitary adenomas and to identify risk factors associated with postoperative hematoma formation. We retrospectively reviewed 45 patients with giant pituitary adenomas who underwent surgical treatment. The surgical approaches included conventional transsphenoidal surgery in 24 patients, extended transsphenoidal surgery in 9, and simultaneous combined transsphenoidal surgery and transcranial surgery in 12. Intracapsular resection was performed in 28 patients, while extracapsular resection was carried out in 17 patients. Postoperative hematoma formation was observed in 17 patients; among them, 2 experienced neurological deterioration and subsequently required reoperation for hematoma evacuation. The mean maximum tumor diameter was significantly larger in patients with postoperative hematoma (54 mm) compared to those without (45.3 mm) (p = 0.008). Other tumor characteristics were not significantly associated with postoperative hematoma formation. Combined transsphenoidal surgery and transcranial surgery were more frequently performed in patients who developed postoperative hematoma (p = 0.007), whereas extracapsular resection was more common in those without hematoma (p = 0.001). However, these differences in postoperative hemorrhage incidence among surgical techniques may have been substantially influenced by selection bias. Giant pituitary adenomas with extensive intracranial extension and involvement of critical neurovascular structures remain challenging to manage regardless of the surgical approach. Nevertheless, it is essential to tailor surgical strategies to individual cases to minimize postoperative complications.