Kazunari Oka

Flexible Endoneurosurgical Therapy for Aqueductal Stenosis

We successfully managed 11 patients with aqueductal stenosis of adult or adolescent onset, with no mortality or significant morbidity, by using a flexible ventriculoscope to perform either a third ventriculostomy or an aqueductal plasty. A flexible fiberoptic ventriculoscope and its accessories were newly developed, and surgical techniques were improved. For all patients, cinemagnetic resonance imaging was a critical part of the preoperative and postoperative evaluation of cerebrospinal fluid flow in the third ventricle and in the aqueduct of Sylvius. All of the 11 patients showed patency to cerebrospinal fluid flow at the aqueduct of Sylvius and the floor of the third ventricle. Only one patient subsequently required a lumboperitoneal shunt. Flexible endoneurosurgical management is simple and safe and allows in situ observation and the ability to perform biopsies. Therefore, flexible endoneurosurgical third ventriculostomy and aqueductal plasty are now considered our treatment of choice for aqueductal stenosis in adults and adolescents.

Inhibition of in vivo tumorigenicity and invasiveness of a human glioblastoma cell line transfected with antisense uPAR vectors

Our previous studies showed that glioblastomas express increased urokinase-type plasminogen activator receptors (uPARs) in comparison to low-grade gliomas (Yamamoto et al., Cancer Res., 54, 5016-5020, 1994). To explore whether downregulation of uPAR inhibits tumor formation and invasiveness, a human glioblastoma cell line was transfected with a cDNA construct corresponding to 300 bp of the human uPARs 5¢ end in an antisense orientation, resulting in a reduced number of uPA receptors. Co-culture studies with tumor spheroids and fetal rat brain aggregates showed that antisense SNB19-AS1 cells expressing reduced uPAR failed to invade fetal rat brain aggregates. Intracerebral injection of SNB19-AS1 stable transfectants failed to form tumors and were negative for uPAR expression in nude mice. Thus uPAR appears in this model to be essential for tumorigenicity and invasion of glioblastomas in vivo.

The significance of artificial cerebrospinal fluid as perfusate and endoneurosurgery.

To compare the benefits of physiological saline solution and artificial cerebrospinal fluid (CSF) as perfusates, we investigated 12 patients with presumed symptomatic aqueductal stenosis by clinical course and CSF analysis. In all patients, endoneurosurgical third ventriculostomy and cine magnetic resonance imaging confirmed the patency of ventriculostomy. After endoneurosurgery, patients who received the saline solution experienced high fever, headaches, and elevated cell count in lumbar CSF. Saline solution provoked a striking inflammatory reaction in the CSF. In contrast, the artificial CSF reduced these conditions to a minimum. Artificial CSF used as a physiological perfusate during endoneurosurgery can suppress host reactions within the CSF pathway and is also available for routine neurosurgical procedures.

Endoneurosurgical treatment for hydrocephalus caused by intraventricular tumors

A flexible therapeutic ventriculoscope allowing for the use of a variety of different instruments has been developed. Endoneurosurgical instruments are composed of an endoscopic contact YAG laser endoprobe, grasping forceps and a punctured needle. Endoneurosurgical procedures include biopsies, III ventriculostomy, fenestration of the septum pellucidum, aspirations of cysts and excisions of tumors in the cerebrospinal fluid pathways. Our ventriculoscope allows the initial treatment for progressive hydrocephalus caused by intraventricular tumors to take the form of reducing ventricular size and decreasing intracranial pressure, and it can also be used to perform biopsy examinations, so that acceptable neurological outcomes and an accurate histological diagnosis can be obtained with fewer side effects. The subsequent therapies for hydrocephalus caused by intraventricular tumors include radical surgery for benign tumors, irradiation for radiosensitive tumors, and irradiation and/or chemotherapy for either malignant or disseminated tumors. We have tried to avoid the sequelae of shunt surgery and have achieved maximum effects with the minimum of procedures by using our ventriculoscope.

Percutaneous flexible neuroendoscopic ventriculostomy in patients with shunt malfunction as an alternative procedure to shunt revision

Three patients with shunt malfunction, who had previously undergone a shunting procedure for noncommunicating hydrocephalus of adolescent and adult onset, successfully underwent a percutaneous flexible neuroendoscopic ventriculostomy. This procedure was performed as an alternative treatment for shunt revision by the use of our newly developed flexible fiberoptic ventriculoscope. All patients were able to remain independent of the shunt system after the ventriculostomy. These results thus suggest that a percutaneous flexible neuroendoscopic ventriculostomy can be effective for the treatment of shunt-dependent patients with shunt malfunction in adolescents and adults.

Xanthoma in meckel's cave a case report

A case of xanthoma located within Meckels cave and the semilunar ganglion is described in a patient with a trigeminal nerve deficit. This is the first case of xanthoma in such a location. The distinctive morphological appearance is illustrated and the possible histogenesis is discussed.

Hydrocephalus due to acute aqueductal stenosis following mumps infection: Report of a case and review of the literature

An acquired form of hydrocephalus due to aqueductal stenosis developing as a sequela of mumps virus infection of the central nervous system is presented. Percutaneous third ventriculostomy and interventriculostomy (aqueduct cannulation) were performed using a flexible fiberoptic ventriculoscope. The aqueduct was blocked with amorphous material but was cleared with the scope. This is the first case of a fulminant phase of mumps ventriculitis leading to aqueductal stenosis, which has been treated using a ventriculoscope for the first time.

An observation of the third ventricle under flexible fiberoptic ventriculoscope: Normal structure☆

The third ventricle, which is deeply seated in the center of the brain, is one of the most inaccessible regions from which to obtain information before surgery. A new flexible fiberoptic endoscope for examination of the ventricles is presented herein. The main advantages of this new device over existing fiberoptic instruments are the extended flexibility of the tip and its small diameter. Using this endoscope, one can observe the third ventricle in situ in patients with hydrocephalus associated with various lesions. The neural and vascular structures in the inner wall of the third ventricle are also illustrated.

Stromal angiogenesis in human glioma: A role of platelet-derived endothelial cell growth factor

BACKGROUND Although several tumor angiogenic factors have been identified previously and characterized, it is not yet fully clear how tumor angiogenic factors induce endothelial cell transformation and proliferation. Platelet-derived endothelial cell growth factor (PD-ECGF) has been recently discovered to be an endothelial cell growth factor initially purified from human platelets. However, there has been no previous report describing the significance of PD-ECGF in the growth of brain tumors by angiogenic stimulation. We report the immunohistochemical localization of PD-ECGF in human gliomas and meningiomas, and discuss whether PD-ECGF could play a role in the modulation of stromal angiogenesis in human glioblastoma multiforme. METHODS Twenty-eight cases of glioma (11 glioblastomas and 17 astrocytomas) derived from the neuroectoderm in embryogenesis and 12 meningiomas from the mesoderm were investigated by both immunohistochemical localization of the PD-ECGF and a semiquantitative assay to determine the degree of stromal angiogenesis. RESULTS Numerous PD-ECGF positive cells were observed within and around the blood vessels of glioblastoma multiforme, especially on the borders of tumor tissue. The PD-ECGF positive cells were negative for anti-von Willebrand factor (vWF) and antiglial fibrillary acidic protein (GFAP) antibodies and were positive for antimacrophage (HAM-56). The expression of PD-ECGF by macrophages closely correlated with the degree of stromal vascularity in glioblastoma multiforme; no such correlation was found in either astrocytoma or meningioma. Proliferating cell nuclear antigen (PCNA) was found to be positive in some endothelial cells of stromal vessels in glioblastoma multiforme. These findings suggest that PD-ECGF expressed by macrophages plays an important role in the growth of glioblastoma multiforme with stromal angiogenesis.

Aqueductal stenosis due to mesencephalic venous malformation: Case report

The authors report the case of a 43-year-old woman with a venous malformation of the mesencephalon occluding the sylvian aqueduct. Neuroradiological investigations suggested aqueductal stenosis, while the presence of a venous malformation was diagnosed by both magnetic resonance imaging and an angiogram, and was visualized using a neuroendoscope. This is the first reported instance of a venous malformation being observed in situ and the subependymal course taken.