Kazuhiko Fujitsu

Orbitocraniobasal Approach for Anterior Communicating Artery Aneurysms

We describe an orbitofrontotemporobasal craniotomy technique that allows excellent access to anterior communicating artery aneurysms. This orbitocraniobasal approach is particularly useful for the surgical treatment of ruptured aneurysms in the acute stage of subarachnoid hemorrhage, when retraction of the brain needs to be kept to a minimum. With this approach, retraction of the orbital contents decreases the amount of retraction of the brain to such an extent that a brain spatula is not necessary for access to the anterior communicating artery complex. The procedure is described, as is a modification of the approach for removal of large tumors on the skull base.

Traumatic Intraventricular Hemorrhage: Report of Twenty-six Cases and Consideration of the Pathogenic Mechanism

A series of 26 patients suffering traumatic intraventricular hemorrhage (IVH) after closed head injury is reviewed, and the pathogenic mechanism of the traumatic IVH is discussed considering the site of origin of the IVH. Computed tomographic detection of the origin of the IVH was possible in 15 patients (Group 1): 6 had frontal or temporal contusional intracerebral hemorrhage spreading into the ventricle (Subgroup A), 5 had the original hemorrhage in the caudate nucleus (Subgroup B), and 4 originally bled in the thalamus (Subgroup C). The origin of the IVH was not determined in 11 patients (Group 2): 6 had concomitant hemorrhage around the brain stem (Subgroup D), and 5 had small IVH with or without small intracerebral hemorrhage (Subgroup E). The site of impact was not uniform in Subgroup A, whereas the other four subgroups usually had frontal or occipital impact. In Subgroup A, the IVH was discovered more than several hours after trauma. In the other four subgroups, however, the IVH was detected in as short a time as 0.5 to 1.5 hours after trauma. In Subgroups B and C, the impact along the long axis of the skull and the early occurrence of hemorrhage in the basal ganglia suggest that shear injury between the perforating vessels and the basal ganglia may be the responsible mechanism. The several other possible mechanisms in Subgroups D and E are reviewed and discussed in relation to diffuse brain injury.

Computed tomography of intracranial chondroma with emphasis on delayed contrast enhancement.

Intracranial chondroma is an unusual cartilaginous tumor originating from the base of the skull. We report on two cases of intracranial chondroma that showed delayed contrast enhancement on CT after high-dose administration of contrast medium. This CT feature may be useful to differentiate chondromas from other tumors of the skull base such as meningiomas and neurinomas.

Thrombotic occlusion of the middle cerebral artery

Background and Purpose: Epidemiological study of middle cerebral artery occlusion is important because the indication for extracranial-intracranial arterial bypass remains in dispute. To help clarify this issue, we investigated the prognosis of thrombotic middle cerebral artery occlusion in Japanese patients. Methods: We studied 40 patients with thrombotic middle cerebral artery occlusion who were selected on the basis of clinical features, computed tomographic findings, and angiographic findings. Patients with causes of embolism (i.e., cardiomyopathy, valvular heart disease, cardiac arrhythmia, and carotid ulceration) were excluded. The 40 patients were classified into three groups according to the site of middle cerebral artery occlusion: there were 13 patients with occlusion of the proximal portion of the Ml segment, 13 with distal Ml segment occlusion, and 14 with occlusion of the M2 segment. Results: Good collateral circulation was associated with improved outcomes both clinically and by computed tomography in patients with occlusion of the proximal and distal portions of the Ml segment but not in those with M2 occlusion. Conclusions: It is reasonable to assume that not only collateral circulation but also the site of occlusion plays an important role in the outcome of middle cerebral artery occlusion. Our finding that good collateral circulation improves the outcome for thrombotic occlusion of the proximal and distal Ml segments supports the possible benefits of such surgery.

Telecanthal Approach for Meningiomas in the Ethmoid and Sphenoid Sinuses

In three cases involving meningiomas in the ethmoid and sphenoid sinuses, transbasal spreading of the interocular distance (telecanthal approach) was used for tumor removal and reconstruction of the skull base. This telecanthal approach involves 1) bilateral en bloc removal of the superior lateral rim of the orbit, the nasal bone, and the posterior lateral wall of the orbit; 2) detachment of the medial canthal ligaments; and 3) spreading of the interocular distance. This approach provides a wide working space beneath the anterior half of the midline skull base, and needs neither a facial incision nor significant retraction of the brain. The surgical technique and its modification are described. The discussion focuses not only on comparisons with other techniques, but on the indications for this approach. Meningiomas originating in the paranasal sinuses are rare; a brief review of the literature concerning the clinicopathological features and pathogenesis is also given.

Unusual Angiographic Changes in a Dissecting Aneurysm of the Basilar Artery: Case Report

A patient with unusual angiographic changes of a dissecting aneurysm of the basilar artery is presented. Initial angiography and magnetic resonance imaging revealed a typical dissecting aneurysm. However, a follow-up study demonstrated a saccular aneurysmal dilatation of the proximal part of the dissection. The importance of the follow-up study, particularly in regard to the usefulness of magnetic resonance imaging and the pathogenesis of this change are discussed.

Unusual Angiographic Changes in a Dissecting Aneurysm of the Basilar Artery

ABSTRACTA PATIENT WITH unusual angiographic changes of a dissecting aneurysm of the basilar artery is presented. Initial angiography and magnetic resonance imaging revealed a typical dissecting aneurysm. However, a follow-up study demonstrated a saccular aneurysmal dilatation of the proximal part of

Drainage Pathway of the Superior Petrosal Vein Evaluated by CT Venography in Petroclival Meningioma Surgery.

Objectives This study aimed to clarify the drainage location of the superior petrosal vein (SPV) in relation to Meckels cave and the internal acoustic meatus (IAM) and to discuss its significance in petroclival meningioma surgery. Design Prospective clinical study. Setting Hospital-based. Participants Five patients with petroclival meningioma and 50 patients (primarily unruptured supratentorial aneurysm patients, with a few hemifacial spasm patients) with no posterior fossa lesions. Main Outcome Measures On computed tomography venography (CTV), the drainage site was classified into three patterns based on its relationship to Meckels cave and the IAM: Meckels cave type, Intermediate type, and Meatal type. Results In all patients, the SPV was patent and emptied into the superior petrosal sinus (SPS). In patients without posterior fossa lesions, 35% had Meckels cave type, 54% had Intermediate type, and 11% had Meatal type. Of the five patients with petroclival meningioma, three had Intermediate type, and two had Meckels cave type. Conclusion The SPV is a significant vein that should be preserved to prevent venous complications. Preoperative knowledge of the SPV drainage site is helpful for planning the approach and preserving the SPV in petroclival meningioma surgery.

Coexistence of adamantinomatous and squamous‐papillary type craniopharyngioma: Case report and discussion of etiology and pathology

Craniopharyngiomas are histopathologically classified as adamantinomatous type (AD) and squamous‐papillary type (SP). However coexistence of a mixed type seen on histopathologic specimens has not been reported. In this report, a patient diagnosed with mixed type craniopharyngioma is presented and the etiology and pathologic features are discussed.

Ciliated craniopharyngioma—case report and pathological study

BackgroundCraniopharyngioma has two subtypes: adamantinomatous and squamous-papillary. Squamous-papillary craniopharyngioma may develop from remnants of the craniopharyngial duct, anterior pituitary cells with squamous metaplasia, suprasellar epidermoid cyst, or Rathke cleft cyst.AimWhile ciliated craniopharyngioma is considered to represent a transitional stage between Rathke cleft cyst and squamous-papillary craniopharyngioma, ciliated craniopharyngioma following Rathke cleft cyst at the same site has not previously been described.ResultsWe report a case of ciliated craniopharyngioma developing from Rathke cleft cyst.ConclusionThe clinical course for this case is discussed together with a review of the pathological literature for ciliated craniopharyngioma.