Hiroyuki Koizumi

Primary germinoma arising from the midbrain.

SummaryA 29-year-old man presented with diplopia, dysarthria, anisocoria, oculomotor nerve paralysis, abducens nerve paralysis, right facial palsy, and spastic hemiparetic gait. Magnetic resonance imaging (MRI) showed a homogenously enhanced mass in the midbrain. MRI-guided stereotactic biopsy was performed, and the histologic diagnosis was pure germinoma. The tumor disappeared after chemotherapy and radiotherapy. Germinoma should be included in the differential diagnosis of midbrain lesions in young adults. MRI-guided stereotactic biopsy provided a helpful diagnostic clue in a patient with a midbrain lesion.

An Operation in the Park Bench Position Complicated by Massive Tongue Swelling

This paper presents a case of massive tongue swelling as a complication after an operation in the park bench position. A 43-year-old male who had undergone a resection of a mass in the petrous bone of the clivus showed massive tongue swelling after the surgery in the left park bench position. A direct compression of the bite block caused the swelling of tongue. Tongue swelling may become fatal if it progresses to an airway obstruction; therefore the intraoperative and postoperative management is important.

Moist-condition Training for Cerebrovascular Anastomosis: A Practical Step after Mastering Basic Manipulations.

As cerebrovascular anastomosis is performed in moist conditions that may impede precise manipulations, surgeons must undergo extensive preoperative training. We developed a simple moist-condition training method. It involves placing a free-floating inner platform hosting an artery from a chicken wing in an outer container filled with tap water to just below the specimen. Trainees performed anastomosis under magnification. Training sessions mimicked difficulties encountered during operations such as poor visibility of the lumen and problems handling the sutures. A retrospective comparison of 100 wet- and 100 dry-condition training sessions for end-to-side anastomoses with 8 stitches showed that under moist condition the time required for the entire procedure was significantly longer (17.8 ± 2.1 vs. 15.3 ± 2.1 min, p < 0.01) and the incidence of wrong stitching was greater (0.38 vs. 0%, p = 0.04). In 8 cases after introducing moist-condition training, the time required in superficial temporal artery to middle cerebral artery bypass surgery was significantly shorter than 8 cases before introducing the training (32.3 ± 5.6 min vs. 48.3 ± 15.9 min, p = 0.01). Incidence of wrong stitches was less in cases after introducing moist-condition training (2.7 vs. 7.4%, p = 0.10). Those indicate that moist-condition training is a useful and practical step and a bridge between training for basic manipulations under dry conditions and actual surgery.

Endosaccular embolization for a ruptured distal anterior inferior cerebellar artery aneurysm.

We report a rare case of a ruptured distal anterior inferior cerebellar artery aneurysm that was successfully treated by endosaccular embolization, and review the literature on the results of endovascular surgery for this condition.

Relationship between Stroke Events during Pachinko Play and Prognosis

BACKGROUND This study investigated whether pachinko play influences the outcome of stroke events, and identified the significant variables affecting outcomes. METHODS We reviewed the medical and imaging records of 2075 consecutive patients with stroke from January 2003 through June 2012. The remaining patients were divided into 2 groups, the pachinko players group (PP) and the non-pachinko players group (NPP). Background factors were recorded on admission. Multivariate logistic regression analysis was used to identify the factors significantly correlated with Glasgow Outcome Scale (GOS) score and risk of death at the time of discharge. RESULTS The PP group exhibited higher prevalence of hypertension and current smoking compared with the NPP group. However, no difference was found in outcomes between the PP and NPP groups. Multivariate analysis identified the dependent predictive variables for GOS as age (adjusted β = -.18, 95% confidence interval [CI]: -.22 to -.14, P <.001), Glasgow Coma Scale (GCS) score on admission (adjusted β = .64, 95% CI: .60 to .68, P <.001), and history of hypertension (adjusted β = -.06, 95% CI: -.10 to -.02, P = .007). Logistic regression analysis showed that age (odds ratio = 1.02, 95% CI: 1.01 to 1.04, P <.001) and GCS score on admission (odds ratio = .72, 95% CI: .69 to .75, P <.001) were significantly associated with death at the time of discharge. CONCLUSIONS Patients with stroke during playing pachinko have higher prevalence of hypertension and higher smoking rate, but pachinko play itself was not a critical factor determining the outcome of patients with stroke in our emergency center.

Extendable Cords to Prevent Tumbling of a Suction Device during Craniotomy

OBJECTIVE Suction is necessary during craniotomy, and intraoperative tumbling of the suction device interrupts operative procedures. To avoid this, we developed a technique that would fasten the device to an extendable cord as is used to secure cell phones. SURGICAL TECHNIQUE We used this technique in more than 300 craniotomies at the specific point of time when the suction device tends to tumble, i. e., during the opening and closure of a wound, which requires frequent instrument exchanges. Extendable cords fastened to the tip of the suction hose using a gift tie were attached to the drapes to secure the suction device next to the operative field. During the operation, the extendable cord followed the suction device manipulations. Consequently, although there was some tension in the cord during its extension, the maneuverability of the suction device was maintained. As the hanging suction device was closer to the operative field than devices stored in conventional pockets, its manipulation was easier and quicker. Upon release, the suction device automatically returned to its original position without distracting the surgeon. Tumbling of the device was prevented, and there were no procedure-related complications. CONCLUSIONS Our simple modification using extendable cords prevented tumbling, avoided unnecessary replacements, and eased the manipulation of a suction device.

Repeated Subarachnoid Hemorrhage Due to a Ruptured Radiation-Induced Aneurysm in a Patient with Suprasellar Germinoma Treated By RadiationTherapy 27 Years Previously: A Case Report

Background: Radiation-induced intracranial aneurysm (RIICA) is a rare complication. From the literature, 74.1% of the reported RIICA ruptured with aneurysmal subarachnoid hemorrhage (SAH), and the mortality rate was 42.3%. Here, we report a case of repeated SAH due to a RIICA after surgical clipping. Case description: A 42-year-old woman presented with SAH. She had undergone radiotherapy for suprasellar germinoma 27 years previously. Digital subtraction angiography (DSA) showed an aneurysm at the anterior wall of the non-branching site of the left internal carotid artery and multiple luminal narrowing. The aneurysm was located within the radiation field, and was not detected by previous DSA. Surgical clipping was performed, but bleeding repeated after 3 months. We performed a second neck clipping and confirmed that the clip had slipped from the neck of the aneurysm. Thirty-nine days after the second operation, DSA revealed an enlargement of residual neck of the aneurysm. Therefore, we performed an endovascular stent-assisted coil embolization of the aneurysm. At the end of the endovascular coiling, the small residual neck of the aneurysm was still observed. The follow-up DSA obtained three weeks after the coil embolization demonstrated enlargement of the residual neck. At 6 months after the first coil embolization, we performed an additional coil embolization which achieved complete obliteration of the aneurysm. Her cranial nerves were intact, and motor and sensory examinations revealed no deficits. Close followup by imaging is in progress. Conclusion: A careful annually follow up, with not only MR imaging but also MR angiography as well, is important for the patients who had a full response to radiation therapy for germinoma in childhood. Special attention must be paid in the treatment of RIICA patients, because of fragility of arterial wall adjacent to the RIICA and the radiation-induced severe atherosclerotic change.

Anterior-wall aneurysm of the internal carotid artery successfully treated solely by stenting: With special reference to etiology

In this case, a ruptured anterior wall aneurysm of the internal carotid artery disappeared on angiography immediately after stent placement. We focus on the underlying nature of the lesion and this possible alternative treatment.