Masaru Abiko

Endovascular Treatment for Dural Arteriovenous Fistula of the Anterior Condylar Confluence Involving the Anterior Condylar Vein A Report of Two Cases

Anterior condylar confluence (ACC) dural arteriovenous fistula (AVF) is a rare anomaly. We describe two cases of ACC dural AVF involving the anterior condylar vein that were successfully treated with selective transvenous coil embolization. The first patient presented with headache and right pulse-synchronous tinnitus, and demonstrated abnormal flow medial to the jugular bulb within the right hypoglossal canal on source image of magnetic resonance angiography (MRA). Arterioangiography disclosed a dural AVF in this area, supplied mainly by the meningeal branches of the bilateral ascending pharyngeal artery. We diagnosed ACC dural AVF involving the anterior condylar vein and transvenous embolization was successfully performed. The second patient presented with right pulse-synchronous tinnitus. Views of source image of MRA and arterioangiography were similar to the first case and, again, transvenous embolization was successfully performed. ACC dural AVF is a rare condition and knowledge of the anatomy of the venous system around the craniocervical junction is required for successful treatment.

Intraoperative Neurophysiologic Monitoring for Degenerative Cervical Myelopathy

Multimodal intraoperative neurophysiologic monitoring is a reliable tool for detecting intraoperative spine injury and is recommended during surgery for degenerative cervical myopathy (DCM). Somatosensory evoked potential (SEP) can be used to monitor spine and peripheral nerve injury during positioning in surgery for DCM. Compensation technique for transcranial evoked muscle action potentials (tcMEPs) should be adopted in intraoperative monitoring during surgery for DCM. Free-running electromyography is a useful real-time monitoring add-on modality in addition to SEP and tcMEP.

Factors Related to Frailty Associated with Clinical Deterioration After Meningioma Surgery in the Elderly

BACKGROUND Older patients are increasingly presenting for surgery with intracranial meningioma because of progress with diagnostic imaging and longer life expectancy. However, older patients have many problems, such as comorbidities and reduced physiological capacity reflected in the frailty index. This study examines the factors affecting clinical deterioration after surgery in older patients, particularly factors associated with frailty. METHODS Two hundred sixty-five patients older than 65 years underwent surgical resection of meningioma at Hiroshima University and related hospitals between 2000 and 2016. Karnofsky Performance Status (KPS) scores before and after surgery were evaluated. Factors related to the deterioration of KPS were analyzed with multivariate logistic regression modeling, including body mass index and serum albumin. RESULTS KPS score deteriorated compared with preoperative score in 56 patients at discharge and in 40 patients at 3 months later, and 2 patients died within 1 year after surgery. Multivariate logistic regression analysis in addition to preoperative body mass index and serum albumin indicated skull base tumor location (odds ratio [OR], 4.67; 95% confidence interval [CI], 2.02-10.8) and serum albumin (OR, 2.38; 95% CI, 1.06-5.34) were risk factors for deterioration of KPS score at discharge. Age (OR, 0.91; 95% CI, 0.85-0.98), skull base tumor location (OR, 4.32; 95% CI, 1.45-12.9), tumor size (OR, 1.03; 95% CI, 1.00-1.05), and serum albumin (OR, 3.53; 95% CI, 1.29-9.61) were significant risk factors for perioperative intracranial complications. CONCLUSIONS Skull base tumor location and serum albumin correlated with deterioration of clinical status after surgery.

Rat Cranial Bone-Derived Mesenchymal Stem Cell Transplantation Promotes Functional Recovery in Ischemic Stroke Model Rats

The functional disorders caused by central nervous system (CNS) diseases, such as ischemic stroke, are clinically incurable and current treatments have limited effects. Previous studies suggested that cell-based therapy using mesenchymal stem cells (MSCs) exerts therapeutic effects for ischemic stroke. In addition, the characteristics of MSCs may depend on their sources. Among the derived tissues of MSCs, we have focused on cranial bones originating from the neural crest. We previously demonstrated that the neurogenic potential of human cranial bone-derived MSCs (cMSCs) was higher than that of human iliac bone-derived MSCs. Therefore, we presumed that cMSCs have a higher therapeutic potential for CNS diseases. However, the therapeutic effects of cMSCs have not yet been elucidated in detail. In the present study, we aimed to demonstrate the therapeutic effects of transplantation with rat cranial bone-derived MSCs (rcMSCs) in ischemic stroke model rats. The mRNA expression of brain-derived neurotrophic factor and nerve growth factor was significantly stronger in rcMSCs than in rat bone marrow-derived MSCs (rbMSCs). Ischemic stroke model rats in the rcMSC transplantation group showed better functional recovery than those in the no transplantation and rbMSC transplantation groups. Furthermore, in the in vitro study, the conditioned medium of rcMSCs significantly suppressed the death of neuroblastoma × glioma hybrid cells (NG108-15) exposed to oxidative and inflammatory stresses. These results suggest that cMSCs have potential as a candidate cell-based therapy for CNS diseases.

Usefulness of Preoperative Simulation in Skull Base Approach: A Case Report

&NA; Skull base approach is a neurosurgical challenge requiring dexterity of the operating surgeon for good postoperative outcome. In addition to the experience of the operating surgeon, adequate preoperative information of the tumor is necessary to ensure better outcome. In clinoid meningioma, it is sometimes difficult to determine its relationship with the surrounding structure and the feeding artery. Previously, preoperative simulation has been utilized to determine the intracranial course of the compressed nerves in relation to the petroclival meningioma. We report a case of clinoid meningioma where preoperative fusion of three dimensional computed tomography angiography (3D‐CTA) and 3T‐fast imaging employing steady‐state acquisition (FIESTA) images was useful in determining the exact location of the feeding artery to devascularize the tumor and aid in surgery. Preoperative simulation with three‐dimensional digital subtraction angiography (3D‐DSA) and 3T‐FIESTA fusion images can be a useful adjunct tool to supplement surgery and to train neurosurgical trainees.

Isolated Tuberculoma Mimicking Foramen Magnum Meningioma in the Absence of Primary Tuberculosis: A Case Report

Central nervous system tuberculosis is a devastating complication of systemic tuberculosis. Intradural extramedullary (IDEM) tuberculoma at the foramen magnum is rare, and mimics en plaque meningioma. We report the case of a 53-year-old woman who presented with dysesthesia of the tongue and lower cranial nerve (CN) palsy, with onset 4 months prior to admission. The neurologic examination revealed left upper-limb weakness and hypoesthesia on the sole and dorsum of the left foot. Other physical examinations revealed no features of tubercular infection. Laboratory investigations likewise showed no signs of infection or inflammation. Magnetic resonance imaging of the brain showed an IDEM mass originating from the left intradural surface at the foramen magnum extending to the C2 segment and compressing the brainstem and upper cervical cord. The mass was isointense/hypointense on T1- and T2-weighted images and homogeneously-enhanced on postcontrast images. The lesion also exhibited the dural-tail sign and was preoperatively diagnosed as en plaque meningioma. The patient underwent surgery via the left transcondylar fossa approach with partial laminectomy of the atlas. Intraoperatively, the mass exhibited a dural origin and encased the vertebral artery and lower CNs, with strong adhesions. While the histopathological study of the mass was strongly suggestive of tuberculoma with multifocal granulomas, caseous necrosis, and Langerhans giant cells, extensive diagnostic studies failed to detect Mycobacterium tuberculosis itself. Although the patient had recurrence with multisystem involvement, she responded well to antitubercular treatment. IDEM tuberculoma of the foramen magnum may present as en plaque meningioma. Histopathology is required for a definitive diagnosis. Prompt surgical resection and decompression with adequate antitubercular treatment yield better neurological outcomes.

Concurrent Schwannoma and Meningioma Arising in the Same Spinal Level: A Report of Two Cases

Concurrent multiple tumors developing in the spinal cord are rare, except for in genetic disorders, such as neurofibromatosis and von Hippel-Lindau disease. Furthermore, concurrent tumors arising in the same spinal level with discrete histopathology are much rarer. We report two such cases. Case 1: A 53-year-old man presented with intracranial hemorrhage that manifested as disturbed consciousness and right hemiparesis. Magnetic resonance (MR) angiography demonstrated severe stenosis of the terminal portion of the bilateral internal carotid arteries, implying Moyamoya disease. Cranial MR images showed a hematoma in the left basal ganglia perforating into the lateral ventricle, which was incidentally detected as a spinal tumor compressing the cervical cord at the C2 level. After conservative management for cerebral hemorrhage, the patient underwent total removal of the spinal tumor. Surgical findings showed that the tumor consisted of extra- and intradural components. Histopathological findings showed that the extra- and intradural components were schwannoma and meningioma, respectively. Case 2: A 70-year-old man presented with progressive left hemiparesis and numbness in both lower extremities. Craniocervical MR images demonstrated a paraspinal tumor compressing the spinal cord at C2 level. Surgical findings disclosed that the tumor consisted of major extradural- and minor intradural components. Histopathological study showed that these components had discrete histological findings: extradural lesion was schwannoma and intradural lesion was meningioma. Concurrent tumors with discrete histopathology should be considered in tumors with extra- and intradural components, particularly, when they are located in the high cervical spine.

Navigation of a 6-French guiding sheath into the common carotid artery using a tri-axial catheter system in transbrachial carotid artery stenting:

Background and purpose Placement of a large-bore guiding sheath or catheter into the common carotid artery (CCA) is crucial in transbrachial carotid artery stenting (CAS). Herein, we describe technical tips for the navigation of a 6-French guiding sheath into the CCA using a tri-axial catheter system in transbrachial CAS. Materials and methods A total of 27 patients underwent transbrachial CAS. For the right side, a 6-French straight guiding sheath was navigated directly into the CCA using a tri-axial catheter system, with a 4-French Simmons catheter placed through a 6-French straight guiding catheter. For the left side, a 6-French Simmons guiding sheath was navigated into the CCA using a tri-axial catheter system, with a 4-French Simmons catheter placed through a 6-French Simmons guiding catheter. After the placement of a 6-French guiding sheath into the CCA, CAS was performed under distal filter or balloon protection. Results Fifteen patients had a right carotid stenosis and 12 patients had a left carotid stenosis. The 6-French guiding sheath was safely placed with ease and provided adequate stabilization for CAS. All procedures were successfully performed without any complications. Conclusion The use of a tri-axial catheter system for the navigation of a 6-French guiding sheath into the CCA appears safe and efficient, allowing transbrachial CAS, with 6-French guiding sheath stabilization, to be performed without any complication.