Takao Kuroki

Strict closed-system drainage for treating chronic subdural haematoma.

Summary.A comparative study chiefly of the recurrence rate of chronic subdural haematoma after two treatment modalities was conducted. Patients were divided into a burr hole strict closed-system drainage group (SCD group; n=56) and a burr hole closed-system drainage with irrigation group (CDI group; n=45). The burr hole strict closed-system drainage involved simply inserting a drainage tube into the haematoma cavity as quickly as possible after minimally incising the haematoma capsule. The introduction of air into the haematoma cavity was prevented, and irrigation was not performed.Symptoms in both groups disappeared soon after surgery, with no postoperative complications. Haematoma recurred in one patient (1.8%) of the SCD group compared with 5 (11.1%) of the CDI group. The rate of recurrence was significantly lower for the SCD than for the CDI group (p<0.05). In 4 of 5 recurrences in the CDI group, the volume of residual intracapsular air was sufficient after initial surgery. These results suggested that postoperative residual intracapsular air is a factor contributing to recurrence.Burr hole strict closed-system drainage is a simple, less invasive procedure with which to treat chronic subdural haematoma and the outcome is excellent. Furthermore, prevention of intracapsular air intrusion during surgery might help prevent recurrence.

Topoisomerase IIα Expression in Pituitary Adenomas and Carcinomas: Relationship to Tumor Behavior

DNA topoisomerase IIα (Topo IIα) is a molecular and immunohistochemical marker that indicates proliferation rate and is the target for several antineoplastic agents. The present immunohistochemical study of a large series of surgically removed pituitary tumors was designed to assess the prognostic significance of Topo IIα expression relative to patient age, gender, tumor type and size, invasiveness, metastasis, MIB-1–labeling index and angiogenesis. Changes of Topo IIα expression in the tumors treated with bromocriptine and octreotide, a long-acting somatostatin analogue were also investigated. Topo IIα immunopositivity was detected only in the nuclei of tumor cells. Gonadotroph adenomas, null cell adenomas, and ACTH-producing adenomas had the lowest Topo IIα indices, whereas primary pituitary carcinomas and silent type 3 adenomas presented the highest counts. The statistical study demonstrated no significant correlation between Topo IIα expression, patient gender, and vascularity. In contrast, significant negative correlation was found between Topo IIα expression and patient age. Topo IIα expression was significantly higher in invasive than noninvasive tumors. A tendency to have higher counts was also observed in microadenomas compared with in macroadenomas. Although Topo IIα and MIB-1 indices were similar in most tumor types, no significant correlation between Topo IIα and MIB-1–labeling indices (r = .16, P = .09) was found. Only non-functioning adenomas showed positive correlation (r = .41, P = .006) between both proliferation markers. Our results demonstrated a significant decrease in Topo IIα index in octreotide-treated, GH-producing adenomas, compared with untreated tumors, but no significant changes were observed in bromocriptine-treated, PRL-producing adenomas. The present study showed no significant advantage of Topo IIα over MIB-1 as a prognostic marker; however, Topo IIα may provide crucial information regarding selection of adenohypophyseal tumors responsive to antineoplastic therapy, such as invasive pituitary adenomas and pituitary carcinomas, which exhibit a high Topo IIα index.

Analysis of β-catenin mutations and α-, β-, and γ-catenin expression in normal and neoplastic human pituitary tissues

The cadherin-catenin system mediates Ca2+-dependent cell-cell adhesion, and genetic alterations in these molecules play a significant role in multistage carcinogenesis. Mutations in the β-catenin gene, mostly affecting exon 3, have been detected in malignant cell lines and in primary tumors. Immunohistochemical abnormalities in α-, β-, and γ-catenin have been reported in malignant and benign tumors, and nuclear localization of β-catenin has been associated with mutations in exon 3 of this gene.Mutational analysis of exon 3 of the β-catenin gene was undertaken by polymerase chain reaction (PCR) and sequencing using genomic DNA extracted from frozen tissues, including 4 normal pituitaries, 22 pituitary adenomas, and one pituitary carcinoma. Frozen sections from these cases were used for immunohistochemical detection of β-catenin. We also analyzed immunohistochemical expression of α-, β-, and γ-catenin by paraffin sections from 154 pituitary tumors, including 148 adenomas and 6 carcinomas. Genomic DNA was extracted from paraffin sections of 2 gonadotroph tumors showing nuclear staining for β-catenin and was used for PCR and sequencing of exon 3 of the β-catenin gene.No mutations in exon 3 of the β-catenin gene were found in any of the 23 cases analyzed by PCR and sequencing. In addition, the 2 cases studied by paraffin section immunohistochemistry, with nuclear staining for β-catenin, were negative for mutations in this exon. Normal pituitary expressed all three catenin proteins. Immunostaining usually showed a membranous pattern of reactivity and was generally stronger in normal pituitary than in the adjacent adenomas. Stains for α-catenin were positive in fewer tumors than for β-catenin. The lowest frequency immunopositive tumors and the weakest immunostaining was for γ-catenin. All medically treated prolactinomas were negative for γ-catenin, whereas treated growth hormone adenomas were less often positive for both α- and γ-catenin than for untreated tumors. The percentage of positive cases for β-catenin was the same in these two groups. Most pituitary carcinomas were negative for both α- and γ-catenin but were β-catenin positive.These results indicate that (i) mutations in exon 3 of the β-catenin gene are uncommon in pituitary tumors, and (ii) expression of α-, β-, and γ-catenin is decreased in pituitary adenomas compared to normal pituitary tissues.

Peripheral primitive neuroectodermal tumor of the jugular foramen: Case report

OBJECTIVE AND IMPORTANCE Peripheral primitive neuroectodermal tumor (pPNET) is a rare type of tumor, most commonly found in the limbs of children and young adults. The authors report an extremely rare case of pPNET located at the jugular foramen whose clinical course demonstrated rapid progression. CLINICAL PRESENTATION A 23-year-old man presented with a 2-month history of progressive hoarseness and dysphagia. The neuroradiological appearance of the lesion was a jugular foramen tumor. INTERVENTION The patient underwent a partial resection of the tumor through a far lateral suboccipital craniotomy. After surgery, the patient experienced an unexpected deterioration in consciousness. Magnetic resonance images on postoperative Day 18 revealed rapid and large expansion of the residual tumor into the posterior fossa. No adjuvant therapy was administered, and the patient died 6 weeks after diagnosis. CONCLUSIONThe pathological diagnosis of the surgical specimen was pPNET, according to the findings of hematoxylin and eosin and immunohistochemical stainings. To the best of our knowledge, this is the first reported case of pPNET at the jugular foramen.

Unusual occipital condyle fracture with multiple nerve palsies and Wallenberg syndrome

A 52-year-old male presented with an extremely rare fracture of the occipital condyle involving the jugular foramen with marked medial rostrad displacement of the fragments. He had ipsilateral VII through XII nerves palsies and Wallenberg syndrome. Conservative treatment did not improve the cranial nerve palsies. A high-resolution CT-scan is essential to visualize these fractures.

The development of neural visinin-like Ca2+-binding protein 2 immunoreactivity in the rat neocortex and hippocampus

Neural visinin-like Ca(2+)-binding protein 2 (NVP2) immunoreactivity in the rat neocortex and hippocampus was barely detectable by immunoblot analysis on postnatal day 1 (P1), but increased during postnatal weeks 2-3, reaching a plateau on P28. Immunohistochemical analysis revealed moderate immunoreactivity firstly on P7 in some subsets of the hippocampal interneurons and in the hippocampal pyramidal cells and dentate granule cells. Immunoreactivity of the interneurons decreased during postnatal weeks 2-3 and disappeared by P28. In contrast, immunoreactivity of the cortical and hippocampal pyramidal cells and dentate granule cells abruptly increased during postnatal week 2. The distinctly immunoreactive cells were distributed throughout the neocortex, especially in the cortical plate, and the stratum pyramidale of Ammons horn and granular layer of the dentate gyrus on P14. Immunoreactivity was homogeneously concentrated in the cell bodies and proximal dendrites at this stage, whereas thereafter immunoreactivity in the neuropil gradually increased, and underwent a relative decrease in the cell bodies. By P28, the higher and granular immunoreactivity in the neuropil covered whole layers of the neocortex, Ammons horn and the dentate gyrus, the same as in adults. Differential expression of NVP2 in different neuron populations may reflect the differential functional consequences for neuronal development.

Basal encephalocele in an adult patient presenting with minor anomalies: a case report

IntroductionBasal encephalocele is rare in adults. Congenital and acquired cases have been reported with regard to the developmental mechanism, and the pathology has not been elucidated in detail.Case presentationWe encountered an adult with basal encephalocele strongly suggesting congenital development because of the presence of minor anomalies: strabismus and ocular hypertelorism. The disease manifested as persistent spontaneous cerebrospinal fluid rhinorrhea and repeated meningitis in a 66-year-old Japanese man. On computed tomography, brain tissue protruded through a part of the ethmoid bone of his right anterior skull base, and it was diagnosed as transethmoidal-type basal encephalocele. Regarding his facial form, the distance between his bilateral eyeballs was large compared to his facial width, and his canthal index (defined as inner to outer inter canthal ratio × 100) was calculated as 38.5, based on which it was judged as ocular hypertelorism. In addition, his right eyeball showed strabismus. A right frontotemporal craniotomy was performed for spontaneous cerebrospinal fluid rhinorrhea, and the defective dura mater region was patched with temporal fascia.ConclusionsMild minor anomalies that require no treatment are overlooked in adults, but the presence of several anomalies increases the possibility of congenital disease. Therefore, it may be necessary to examine minor anomalies in cases of adult basal encephalocele when considering the possibility that the disease may be congenital.

Ruptured Aneurysm of the Superior Cerebellar Artery Associated With Cerebellar Hemangioblastoma: A Case Report and Review of Literature

Aneurysms associated with hemangioblastoma are very rare. We encountered a patient in whom an aneurysm of the distal superior cerebellar artery, the main feeding vessel of cerebellar hemangioblastoma, ruptured and caused hemorrhage. On the basis of the computed tomography findings, the superior cerebellar artery aneurysm was identified as the source of hemorrhage, and embolization using a Guglielmi detachable coil was performed in subsequent endovascular surgery. Endovascular embolization was applied to the artery feeding the tumor at 4 weeks after admission, and the tumor was removed using an occipital transtentorial approach. A favorable therapeutic outcome may be expected when using a combination of endovascular therapy and surgical craniotomy for aneurysms associated with hemangioblastoma.

Cerebral Mass Lesion in Medulla Oblongata Causing Intractable Hiccups: A Report of 2 Cases and Review of the Literature

Intractable hiccups caused by an intracranial mass lesion are rare. We encountered surgical cases of cavernous angioma and hemangioblastoma in the medulla oblongata, which manifested with intractable hiccups. Herein, we report on 2 cases: case 1, a 30-year-old woman with a past medical history of surgery for cerebellar hemangioblastoma. The disease manifested with intractable hiccups, and a mass lesion was observed in the medulla oblongata on magnetic resonance imaging (MRI). During surgery, a vascular-rich tumor was localized near the obex of the mid-dorsal portion of the medulla oblongata. The hiccups were resolved immediately after total tumor excision, no event occurred thereafter, and the patient was discharged. The pathologic diagnosis was hemangioblastoma. Case 2, in a 22-year-old man, a lesion was observed in the dorsal portion of the medulla oblongata on computed tomography and MRI was performed to investigate the cause of intractable hiccups. During surgery, a mass lesion was present in the right dorsolateral aspect of the medulla oblongata. The hiccups resolved immediately after total excision of the lesion. No neurological deficit occurred, and the patient was discharged. The lesion was pathologically diagnosed as a cavernous angioma. In conclusion, a search for a dorsal medullary lesion using MRI is necessary when investigating intractable hiccups. To resolve intractable hiccups, the active application of surgical excision of the mass lesion is recommended.

Ruptured aneurysm of the PICA communicating artery: a case report.

A 47-year-old man presented with a rare aneurysm arising from the posterior inferior cerebellar artery communicating artery (PICA com A), manifesting as subarachnoid with intraventricular hemorrhage. Cerebral angiography showed a defect of the left PICA, and the left PICA region was supplied by a communicating artery formed by the fusion of branches from the right PICA and right vertebral artery. Aneurysms arose in the communicating artery, and a small, unruptured fusiform aneurysm was observed adjacent to a ruptured aneurysm. Trapping was performed for the 2 aneurysms with occipital artery (OA)-PICA bypass. Six cases of aneurysms occurring in this vessel including ours have been reported, and hemodynamic factors and congenital fragility of the arterial wall have been suggested as causative factors. Ours is the first case in which a ruptured aneurysm of this vessel was treated surgically with concurrent vascular reconstruction. If the aneurysm has a shape that is difficult to clip, the affected vessel is difficult to preserve, and collateral blood flow to the affected PICA region is considered insufficient, trapping with OA-PICA bypass is recommended.