Nobuyuki Akutsu

A Preliminary Prediction Model with MR Plaque Imaging to Estimate Risk for New Ischemic Brain Lesions on Diffusion-Weighted Imaging after Endarterectomy or Stenting in Patients with Carotid Stenosis

BACKGROUND AND PURPOSE: Findings on MR imaging of carotid plaques correlate with histologic findings and may be useful in identifying vulnerable plaques. The objective of this study was to show how MR imaging findings and clinical factors could be used to construct a preliminary model and a nomogram for predicting the risk of new ischemic lesions on DWI following CEA or CAS. MATERIALS AND METHODS: One hundred four patients with carotid stenosis undergoing treatment (63 CEA, 41 CAS) were prospectively enrolled (mean age, 71.7 ± 7.0 years; 11 women). T1-SIR and T2-SIR of carotid plaque were measured on MR imaging. Associations among carotid MR imaging findings, treatment procedures, degree of stenosis, cardiovascular risk factors, and occurrence of new ischemic lesions on DWI 1 day after treatment were studied by multivariate logistic regression. RESULTS: One stroke occurred after CAS (2.4%), and none after CEA. New DWI lesions after treatment were observed in 25 patients (24%). Our preliminary prediction model demonstrated that T1-SIR (OR [per 0.5 increase], 3.99; 95% CI, 2.18–7.31; P < .0001) and CAS (OR, 2.06; 95% CI, 1.01–4.24; P = .048 compared with CEA) were positively associated with new DWI lesions on posttreatment DWI scans. T2-SIR (OR [per 0.5 increase], 0.74; 95% CI, 0.55–0.98; P = .037) was negatively associated. The C-index of this model was 0.79 (95% CI, 0.69–0.89), which indicated some utility in predicting the response. CONCLUSIONS: Our preliminary prediction model and nomogram may provide an individualized risk estimate of new ischemic lesions after CEA or CAS and useful information for decision-making regarding treatment strategy.

Endoscopic endonasal translacerum approach to the inferior petrous apex.

OBJECTIVE The surgical approach to lesions involving the inferior petrous apex (IPA) is still challenging. The purpose of this study is to demonstrate the anatomical features of the IPA and to assess the applicability of an endoscopic endonasal approach through the foramen lacerum (translacerum approach) to the IPA. METHODS The surgical simulation of the endoscopic endonasal translacerum approach was conducted in 3 cadaver heads. The same technique was applied in 4 patients harboring tumors involving the IPA (3 chordomas and 1 chondro-sarcoma). RESULTS By removing the fibrocartilaginous component of the foramen lacerum, a triangular space was created between the anterior genu of the petrous portion of the carotid artery and the eustachian tube, through which the IPA could be approached. The range of the surgical maneuver reached laterally up to the internal auditory canal, jugular foramen, and posterior vertical segment of the petrous portion of the carotid artery. In clinical application, the translacerum approach provided sufficient space to handle tumors at the IPA. Gross-total and partial removal was achieved in 3 and 1 cases, respectively, without permanent surgery-related morbidity and mortality. CONCLUSIONS The endoscopic endonasal translacerum approach provides reliable access to the IPA. It is indicated alone for lesions confined to the IPA and in combination with other approaches for more extensive lesions.

Cranial Fasciitis Presenting with Intracranial Mass: A Case Report

We describe a very rare case of cranial fasciitis presenting with intracranial mass in a 3-year-old girl. There was no palpable scalp mass. CT scan and MRI demonstrated an epidural mass adherent to the dura with destruction of the inner table of the skull. The tumor was extirpated completely and the resected specimens were diagnosed as cranial fasciitis. When neurosurgeons, pediatricians and radiologists encounter an epidural tumor in a pediatric patient, cranial fasciitis should be kept in mind.

Subarachnoid Hemorrhage Due to Rupture of an Intracavernous Carotid Artery Aneurysm Coexisting with a Prolactinoma under Cabergoline Treatment

We report an unusual case of subarachnoid hemorrhage caused by intraoperative rupture of an intracavernous carotid artery aneurysm coexisting with a prolactinoma. A 58-year-old man presenting with diplopia was found to have a left intracavernous carotid artery aneurysm encased by a suprasellar tumor on magnetic resonance imaging. His serum prolactin level was 5036 ng/mL. Proximal ligation of the left internal carotid artery with a superficial temporal artery to middle cerebral artery anastomosis was scheduled. Because the patients diplopia had deteriorated, we started him on cabergoline at a dose of 0.25 mg once a week. One month after administration of cabergoline, the diplopia was improved to some extent and serum prolactin was decreased to 290 ng/ml. Six weeks after starting the cabergoline, the patient underwent a left frontotemporal craniotomy to treat the aneurysm. When the dura mater was opened, abnormal brain swelling and obvious subarachnoid hemorrhage were observed. Postoperative computed tomography demonstrated a thick subarachnoid hemorrhage. This case suggests that medical therapy for a pituitary adenoma should be started after treatment for a coexisting intracavernous aneurysm is completed.

Decompressive Surgery for Traumatic Intracranial Hypertension

Intracranial hypertension is the most frequent cause of death or disability following severe traumatic brain injury (TBI). Marked intracranial hypertension due to brain edema reduces the perfusion pressure in capillary blood vessels, leading to hypoxia and further damage to brain tissue through ischemic injury. Thus, intracranial pressure (ICP) monitoring is a recommended standard procedure for the management of severe TBI [1,2]. In addition, first-tier therapies, including head elevation, optimized sedation, normalization of arterial carbon dioxide pressure, and the use of mannitol, hypertonic saline, neuromuscular blockade, and external ventricular drainage are used to control ICP [1]. However, many patients with severe TBI have intracranial hypertension that is refractory to these first-tier therapies, and decompressive procedures, including subtemporal decompression, temporal lobectomy, and hemispheric or bilateral decompressive craniectomy are often required to control ICP. Decompressive craniectomy is the strongest therapy for decreasing ICP. Although the efficacy of the above procedures for improving patient outcome remains controversial, several reports have suggested that decreasing ICP is efficacious [3-6].