Katsuaki Sakoda

Metastasis of malignant struma ovarii to the cranial vault during pregnancy.

Malignant struma ovarii is a rare type of ovarian teratoma; only 16 cases with distant metastases have been reported previously. We report an extremely rare case of malignant struma ovarii metastatic to the cranial vault, which developed during pregnancy. A 28-year-old woman in the 26th week of pregnancy, who had undergone resection of an ovarian tumor 3 years previously, noticed a mass in her left frontal region that had enlarged gradually in 6 months. Magnetic resonance imaging revealed a massive extradural tumor growing through the cranium. Under fetal heart monitoring, the patient underwent total resection of the tumor, including the adjacent cranial bone and dura, and a healthy infant was delivered at full term. Pathological examination showed that the tumor was a follicular adenocarcinoma. Because there was no abnormality in the patients thyroid gland, this tumor was considered to be a metastasis from the ovarian tumor, a malignant struma ovarii, resected 3 years previously. The management of brain tumor during pregnancy is also discussed.

Zinc, copper, manganese, and selenium metabolism in patients with human growth hormone deficiency or acromegaly

Summary This study was designed to evaluate trace metal metabolism in patients with known abnormalities of human growth hormone (hGH). The mean concentration of zinc in plasma and urine decreased in patients with hGH deficiency after hGH injection, whereas, after adenomectomy, in patients with acromegaly, zinc increased in plasma, remained the same in erythrocytes, and decreased in urine. There was a negative correlation between plasma zinc and serum hGH levels and a positive correlation between urinary zinc excretion and serum hGH levels in acromegaly. In hGH deficiency, the copper content remained unchanged in plasma and erythrocytes and rose in urine after treatment; however, in acromegaly, the copper content increased in plasma and remained unchanged in erythrocytes and urine after surgery. The mean concentration of erythrocyte manganese did not change significantly after treatment in patients with hGH deficiency or acromegaly, but the pre hGH treatment level of erythrocyte manganese in hGH deficiency was lower than in the controls. Plasma selenium concentrations were decreased in hGH deficiency and increased in acromegaly patients after therapy. These results suggest that hGH affects the metabolism of zinc, copper, manganese, and selenium. hGH treatment level of erythrocyte manganese in hGH deficiency was lower than in the controls. Plasma selenium concentrations were decreased in hGH deficiency and increased in acromegaly patients after therapy. These results suggest that hGH affects the metabolism of zinc, copper, manganese, and selenium.

Coincidental pituitary adenoma and parasellar meningioma: case report.

We report a patient who had pituitary adenoma and parasellar meningioma coincidentally, with neither irradiation nor a history of head injury. Preoperative computed tomographic (CT) scan had shown a large intrasellar mass with ring-like enhancement; in contact with this mass, another well-enhanced mass had been shown. Histopathologically, the intrasellar mass was diagnosed as chromophobic pituitary adenoma and the other mass as meningotheliomatous meningioma. We present clinical, radiological, and histopathological findings and discuss previously reported cases of coincidental pituitary adenoma and meningioma without irradiation. This is the first case report since the advent of CT that pituitary adenoma and parasellar meningioma in contact with each other could be clearly demonstrated by CT.

Intrauterine Depressed Skull Fracture

Two cases of intrauterine depressed fracture are presented. In each case, the mother had no history of abdominal trauma during pregnancy, the children were delivered normally without the use of forcep

CT scan of pituitary adenomas

SummaryCT scan is an extremely useful, almost harmless means of diagnosing pituitary adenomas. Growth hormone (GH)-secreting adenomas tend to have higher absorption coefficient on plain CT than the nonfunctioning and prolactin (PRL)-secreting adenomas. The absorption coefficient on contrastenhanced CT does not identify the specific type of adenoma. Ring-like enhancement was observed in five nonfunctioning and four PRL-secreting adenomas with suprasellar extension, while cystic components were observed in four nonfunctioning and four PRL-secreting adenomas. In three of ten cases of PRL-secreting microadenomas, the site corresponding to the adenoma was not enhanced, whereas the normal pituitary was. A correlation exists between the size of PRL-secreting adenoma and the serum PRL level, but not between the size of GH-secreting adenomas and the serum GH level.

Stent-assisted angioplasty for intracranial atherosclerosis

We report on two patients with intracranial atherosclerosis of the carotid artery or vertebral artery treated with stent-assisted angioplasty. Both patients have severe intracranial atherosclerosis (>70%) with refractory symptoms despite optimal medical treatment. In both patients, a coronary balloon-expandable stent was successfully placed using a protective balloon technique without procedural complications. The patients were asymptomatic and neurologically intact at a mean clinical follow-up of 13 months. Follow-up angiograms did not show restenosis 3 or 4 months after procedure, respectively. Stent-assisted angioplasty for intracranial atherosclerosis in the elective patient has proven effective, with an acceptable low rate of morbidity and mortality.

Primary hypothyroidism associated with pituitary enlargement, slipped capital femoral epiphysis and cystic ovaries

A case of primary hypothyroidism with pituitary enlargement, slipped capital femoral epiphysis and cystic ovaries is reported. The pituitary abnormality and cystic ovaries disappeared dramatically after thyroid hormone therapy. Hip pinning was performed. The recognition of these associations may eliminate unnecessary surgery and lead to the choice of hormone replacement therapy.

Coil embolization of a large, wide-necked aneurysm using a double coil-delivered microcatheter technique in combination with a balloon-assisted technique

The present paper describes a double coil-delivered microcatheter technique used in combination with a balloon-assisted technique to treat a patient with a large, wide-necked basilar tip aneurysm with detachable coil treatment. The aneurysm was completely occluded using this technique. There was no recanalization or any neurological deterioration within 12 months of embolization.

Pituitary abnormalities detected by high resolution computed tomography with thin slices in primary hypothyroidism and Turner syndrome

Pituitary hyperplasia, microadenoma or an empty sella was detected in three children with primary hypothyroidism and three with Turner syndrome with the use of high resolution contrast-enhanced computed tomography (CT) with thin slices. Hyperplasia or microadenoma of the pituitary gland frequently occurs secondary to primary hypothyroidism and gonadal dysgenesis, and recognition of these results may eliminate unnecessary surgery in favor of hormone replacement therapy. High resolution contrast-enhanced CT, especially coronal CT, with thin slices is very helpful in demonstrating these pituitary abnormalities.

Double Wire Technique for Intracranial Stent Navigation

Editor: Evolutionary advancement of stent technology allows us to expand the therapeutic options in the field of neuroendovascular treatment. Stent placement for extracranial carotid stenosis can be accomplished at a high rate with acceptably low rates of morbidity and mortality. These excellent results have encouraged neurointerventionalists to place stents for treatment of vascular stenoses and aneurysms involving intracranial vessels (1–3). To advance a stent delivery system in the intracranial vessels, the tip of the guide wire should be placed as distally as possible to allow the best support. The guiding catheter should be positioned as close to the base of the skull as possible to maintain good catheter support during stent navigation. In almost all patients in one reported series, intracranial stent deployment was performed successfully with use of these standard techniques; however, in some patients, this procedure failed to access the objective lesion because of vessel tortuosity. We describe a new technique that can successfully navigate a stent delivery system in these difficult cases. Vessel tortuosity from the base of the skull to intracranial lesions has limited the use of stent therapy. Acute angles of tortuous vessel limit the ability to cross the distal edge of the stent or balloon catheter and stent delivery systems often stop at this site (Figure, parts a, b). At this point, stent navigation with the standard technique should be stopped and the stent delivery system should be withdrawn, leaving the guide wire for the stent delivery system across the intracranial lesion. Another guide wire is advanced across the acute angled curve. Two guide wires are now positioned in the objective lumen. At this time, it is important to deliver the second guide wire on the path of the distal edge of the stent or balloon catheter. Then the stent delivery system is advanced again. When a bare guide wire exists between the arterial wall and the stent, the stent delivery system can pass the acute angled curve with significantly less resistance (Figure, parts c, d). The second guide wire is withdrawn when the stent is positioned at the level of interest, just before expansion. This technique can be adapted to vessels with reference diameters of at least 3 mm in because it is necessary to insert a stent delivery system and another guide wire though the same vessel. In the field of cardiovascular intervention, it is reported that placing stents in vessels smaller than 3 mm causes a higher incidence of acute complications (dissection and acute closure) and a higher incidence of restenosis during follow-up. Therefore, this double-wire technique may be used for the treatment of many intracranial lesions with intracranial stent placement. Endovascular stent placement for cerebrovascular disease has been proven to be a successful treatment option. Stents used for intracranial lesions of cerebral aneurysms or vascular stenoses have primarily been treated with coronary balloon-expandable stents (1–3). Second-generation coronary stents demonstrate excellent flexibility and “trackability” and allow for treatment of intracranial vascular lesions. This procedure promises a new therapeutic era. However, the safe and smooth navigation of a coronary stent system into intracranial lesions is difficult because there are significant differences in physical properties and architecture between the coronary and cerebral vasculatures. Stent system delivery across a tortuous carotid siphon or upper segment of vertebral artery is particularly difficult. Gomez et al (4) reported a 33% success rate of stent navigation into the intracranial carotid artery above the supraclinoid portion with use of standard technique. It is doubtful that uneventful passage of current coronary stent systems has been possible in all patients with cerebral arteriosclerosis. The stent delivery system should be not forced, but gently navigated into intracranial lesion. The friction seen between the distal edge of the stent and the arterial wall prevents smooth navigation of stent delivery systems, and forceful pushing may lead to tremendous complications including stent edge dissection or deformation or migration of the stent. Stent edge dissection can cause pseudoaneurysm, which may cause supraclinoid hemorrhage or cerebral embolism. The deformation and migration of the stent may lead to abrupt closure of the intracranial carotid artery and massive cerebral infarction. Therefore, a technique with safe and smooth intracranial stent navigation is required to perform this endovascular procedure without complications. In the doublewire technique, a second guide wire is placed parallel and adjacent to the stent delivery system. The adjacent wire appears to facilitate the advancement of the stent and stent delivery system in acutely angled vessels. The role of the adjacent wire is to provide a “railway” for the stent and stent delivery system. A possible mechanism for beneficial effects may be that the wire diminishes friction between the arterial wall and the stent delivery system. The adjacent wire should be stuck on a arterial wall and placed between the arterial wall and the stent. Another consideration is that the wire makes an obtuse angle to advance the stent delivery system. Therefore, we recommend selecting a 0.016or 0.014-inch guide wire with stiffness, steerability, and slippery surface as the adjacent wire. The disadvantage of this technique is that it requires additional complex manipulation. It should be considered that a more complex procedure increases the risk of thromboembolic complications compared to the standard technique. Therefore, we believe that strict anticoagulation therapy is needed to prevent thromboembolism durDOI: 10.1097/01.RVI.0000071092.76348.2E Letter to the Editor