Takashi Funakoshi

The use of frozen autogenous bone flaps in delayed cranioplasty revisited.

OBJECTIVETo reevaluate the use of frozen autogenous bone flaps for patients undergoing delayed cranioplasty. METHODSIn the past 12 years, 49 patients have undergone delayed cranioplasty using frozen autogenous bone flaps. Bone flaps removed during the initial operation were sealed in three sterilized vinyl bags and stored at −35°C (n = 37) or −84°C (n = 12) for 4 to 168 days (mean, 50.6 d). The bone flaps were thawed at room temperature and replaced in their original positions. After cranioplasty, we monitored resorption of the bone flaps with computed tomography and evaluated the clinical and aesthetic results. Follow-up periods ranged from 14 to 147 months (mean, 59.2 mo). RESULTSFor 47 patients (95.9%), there were no complications during the follow-up period; there was slight thinning of the bone flap in some cases, but clinical and aesthetic results were highly satisfactory. Resorption was observed for a 12-year-old boy who had undergone cranioplasty, using two pieces of bone flap, 66 days after the initial operation. A 14-year-old boy with a cerebral contusion experienced a bone flap infection. Both patients underwent a second cranioplasty procedure, with ceramic plates. CONCLUSIONThe clinical and aesthetic results of delayed cranioplasty using frozen autogenous bone flaps were satisfactory. The most important factor for success was excellent contiguity between the flap and the bone edge.

Clinical analysis of a series of vertebral aneurysm cases.

We reviewed 38 cases of aneurysms of the vertebral artery treated over the last 10 years: 26 (68%) located at the junction of the vertebral and posterior inferior cerebellar arteries, 10 (26%) at the vertebral artery, and 2 (5%) at the vertebrobasilar union. There were three distinct forms of aneurysms: 20 saccular (53%), 10 fusiform (26%), and 8 dissecting (21%). Among these 38 aneurysms, 33 (87%) had ruptured: 18 of the saccular aneurysms (90%), all 10 of the fusiform aneurysms (100%), and 5 of the dissecting aneurysms (63%). Computed tomography of the 28 ruptured aneurysms revealed diffuse subarachnoid hemorrhage in the basal cistern combined with intraventricular hemorrhage in 24 cases (86%). Magnetic resonance imaging was useful for differentiating between fusiform and dissecting aneurysms. Abnormalities such as a double lumen of the vertebral artery were demonstrated in four of the dissecting aneurysms. The overall surgical results were good for 22 of the 27 surgically treated cases (81%). New bleeding was observed in 8 (24%) of the 33 ruptured aneurysms. The rate of new bleeding was high (60%) in the patients with dissecting aneurysms, and occurred mostly in the acute stage. The incidence of vasospasm was 27%, and only two patients suffered permanent neurological deficits. These findings indicate that the rate of new bleeding tends to be high in patients with saccular and dissecting aneurysms, and thus, they should be treated as early as possible. A preoperative balloon occlusion test should be conducted if proximal occlusion of the vertebral artery is necessary, since proximal occlusion is not always safe, despite angiographic evidence of sufficient contralateral arterial flow.

Selection of eligible patients with supratentorial glioblastoma multiforme for gross total resection.

The purpose of this study is to clarify whether gross total tumor resection can prolong the survival in adult patients with supratentorial glioblastoma multiforme (GBM), and to clarify what subset of these patients obtains a survival advantage by gross total tumor resection without postoperative neurological deterioration.Eighty-two adult patients with supratentorial GBM were retrospectively reviewed. Overall, the median survival time was 13 months, and the 1- and 2-year survival rates were 53.7% and 14.6%, respectively. In a univariate analysis for survival rate by log-rank test, age (>40 years), Karnofsky performance scale (KPS) score (70–100%) and extent of surgery (gross total resection) were revealed to be significant good prognostic factors. A Cox proportional hazard multivariate regression analysis confirmed that the KPS and extent of surgery were independent, significant good prognostic factors. Nine patients (11%) suffered postoperative neurological deterioration.A topographical GBM staging system (Stages I, II and III) with the integration of tumor location, size and eloquence of adjacent brain based on MRI (for explanation of Stages see text) was originally proposed. In Stage I, gross total resection had a strong tendency toward a better prognostic factor in a univariate analysis and was revealed to be a significant independent good prognostic factor in a multivariate analysis. In also Stage II, the survival of patients who underwent gross total resection was better than that of patients with less than gross total resection, although not significant. In Stage III, there were no patients who underwent gross total tumor resection. Risk probabilities of postoperative neurological deterioration, overall, were 0%, 22.2%, and 20% in Stages I, II, and III, respectively, and those after gross total resection were 0% and 16.7% in Stages I and II, respectively.Although gross total tumor resection is associated with prolongation of the survival time of patients with GBM, the risk of postoperative neurological deficit increases with radical tumor resection. To select an eligible subset of patients that benefit in survival from gross total tumor resection without postoperative risk, the following surgical policy for GBM resection is suggested. GBM in Stage I should be resected as radically as possible. Regarding Stage II, risky surgical resection extending to the area adjacent to the critical zone should be avoided and more meticulous and careful surgical planning is needed than that in Stage I. In Stage III, radical gross total tumor resection is not recommended at present.

Primary osteosarcoma of the skull : a case report and review of the literature

SummaryPrimary osteosarcoma of the skull (POS) in a young man with intracranial involvement is reported. After an initial transient remission by surgical intervention and chemotherapy, he began to deteriorate due to tumor recurrence and intracranial hemorrhage, and died 15 months following the time of diagnosis. The rarity and poor prognosis of POS are emphasized together with the review of the clinical and therapeutic aspects in the previously reported 98 cases in the literature.

Analysis of reruptured cerebral aneurysms and the prophylactic effects of barbiturate therapy on the early stage

During the past seven years, we have studied 661 cases of ruptured intracranial aneurysms. Rebleeding occurred in 65 cases (10%) and, within this group, 43 cases (70%) rebled within the first 6 hours after initial subarachnoid haemorrhage (SAH). Analysis of these 43 cases led to the following conclusions: 22 patients incurred rebleeding from causes such as transfer (6 cases), neuroradiological examinations (13 cases), and tracheal intubation during anaesthesia etc. (3 cases), while no special causative factors were discovered in the other 21 cases. Rebleeding occurred in 19 patients even while on absolute bed rest and in 11 patients who had induced systemic arterial hypotension (under 140 mmHg) through treatment. Six cases experienced rebleeding while undergoing angiography within 6 hours after the first subarachnoid haemorrhage. Eight of 17 reruptured anterior cerebral complex (Acom) aneurysm cases and 8 of 11 reruptured middle cerebral artery (MCA) aneurysm cases had an intracerebral haematoma on initial CT-scan following the first attack, demonstrating that the risk of rebleeding was very high in cases of intracerebral haematoma. The mortality rate for these rebleeding cases was high i.e. 65%. Therefore, because the time factor could precipitate rebleeding, early transfer and operation was considered optimal for minimizing rebleeding soon after an aneurysm rupture, even though angiography within 6 hours of the first SAH was a serious risk. Barbiturate therapy, performed as early as possible for serious cases, was considered to be effective in preventing rebleeding.

Primary pleomorphic adenoma in posterior cranial fossa

A 35-year-old woman had an intradural tumor in the posterior fossa adjacent to the posterior wall of the left pyramidal bone, which was totally removed and histologically diagnosed as a pleomorphic adenoma. Follow-up examination for 2 years showed no recurrence of the tumor. There was no primary lesion in any other gland of the body, and therefore there is no alternative but to conclude a “migration” of some gland cells. The pathogenesis of this tumor remains unclassified.

Recurrent cerebral ischemic attacks in patients with symptomatic atherosclerotic large-artery disease.

症候性脳主幹動脈高度閉塞性病変を有する52症例 (中大脳動脈水平部 [M1] 狭窄11例, M1閉塞14例, 内頸動脈 [ICA] 狭窄13例, ICA閉塞14例) を対象に再虚血発作の時期, 回数, 頻度について検討し, 更に脳血管撮影で病態確認後の再発作に注目して, その頻度を狭窄例と閉塞例で比較検討した.再発作は52例中26例 (50.0%) で64回認め, 初回発作から6～10日の間で最も頻度が高く, 0.0577回/日/例と, 初回発作から20日以降での平均0.0013回/日/例に比べ著しく高かった.症候性M1またはICA高度閉塞性病変における初回発作からの20日間は虚血急性期の脳循環動態不安定期と考えられ, 厳重な患者管理の必要性が示唆された.また脳血管撮影で病変確認後の再発作はM1及びICA閉塞例の全28例中では1例 (3.6%), M1及びICA狭窄例の全24例中では6例 (25.0%) であり, 狭窄例では閉塞例に比し有意に高頻度に再虚血発作を起こした (p<0.025).1.症候性M、またはICA高度閉塞性病変52例中26例 (50.0%) で経過観察中に再発作を認めた.2.症候性M1またはICA高度閉塞性病変例の再虚血発作は初回発作より20日までに多く, この期間は虚血急性期の脳循環動態不安定期と考えられた.3.症候性M1またはICA高度閉塞性病変では脳血管撮影による病変確認後に限定すると, 狭窄例は閉塞例に比べ有意に高頻度に再虚血発作を起こした.

Clinical study of subcortical hematoma

過去4年間に取り扱った外傷脳動脈瘤破裂を除く皮質下出血は68例で, うち特発性28例, 高血圧性17例であった.特発性を病理組織学的にsmall angiomatous malformationが証明されたcryptic AVM群 (13例) と真の特発性, すなわち原因不明群 (15例) に分け, 高血圧群と比較検討した.1) 発症年齢はcryptic AVM群では平均40歳であったが各年齢層に及び, 必ずしも若年者とは限らなかった.又, crypticAVM群には女性が多かった.2) 初発症状は高血圧性が片麻痺, 言語障害で発症したのに対し, cryptic AVMは頭痛, 悪心で発症し進行が緩徐であった。3) 血腫部位は高血圧群, cryptic AVM群は頭頂葉, 原因不明群は後頭葉に多かった.4) 脳血管撮影ではcryptic AVM群の5例にearly venous filling, extravasationなどを認めた.5) cryptic AVMの発見には術中の検索が大切で, 高血圧性と思われても探索を怠ってはならない.6) 予後は高血圧群, cryptic AVM群, 原因不明群とも良好例が多かったが70歳以上の高齢者は合併症の為, 不良であった.