Tatsuya Mizoue

Trans-sellar color Doppler ultrasonography during transsphenoidal surgery.

OBJECTIVE To improve the safety and efficacy of transsphenoidal pituitary adenoma surgery, we investigated transsphenoidal intraoperative color Doppler ultrasonography using a biplane transducer system. METHODS We studied 23 patients with pituitary adenomas (18 patients with macroadenomas and 5 patients with microadenomas) who underwent transsphenoidal surgery. The Hitachi EUB555 color Doppler ultrasound system (Hitachi Medical, Tokyo, Japan) was used with a pediatric biplane transesophageal echo cardiography probe (EUP-ES533, 7.5 MHz, biplane phased array sector probe, 9.8-mm tip). The probe was inserted into the saline-filled sphenoid sinus after the sellar floor was opened. Intra- and suprasellar images were obtained just before dural incision and after the tumor removal was thought to have been accomplished. RESULTS In all patients, the tumor was depicted as a slightly hyperechoic mass, as compared with the cerebrum. Using color Doppler imaging, major cerebral arteries were depicted clearly in 74% of patients. The pituitary glands, pituitary stalks, and optic chiasms were observed in patients with small adenomas, but not when large adenomas were present. Cavernous sinus invasion, concomitant aneurysm, and residual tumor were clearly visualized. In patients with large adenomas, the end point of surgery was decided when there was an ultrasonographically demonstrated collapsed tumor capsule, subcapsular total vacancy, and reappearance of the optic chiasm. CONCLUSION Trans-sellar color Doppler ultrasonography seems to be a useful intraoperative guiding system that may improve the safety and efficacy of transsphenoidal surgery.

MIB1 immunopositivity is associated with rapid regrowth of pituitary adenomas

SummaryPituitary adenomas are generally regarded as benign tumours, but they may recur. We identified eight patients with pituitary adenomas that showed rapid regrowth within 2 years of initial surgery. We estimated the percentage of cells in each specimen that showed positive immunostaining for MIB1 (a novel anti-Ki-67) and compared the values to those of 40 adenomas that showed no regrowth. The mean MIB1 index for 40 adenomas that showed no evidence of regrowth was 0.19±0.06%. This was significantly (p<0.0001) lower than that for adenomas that showed rapid regrowth (1.27±0.31%), based on the initial resected specimens. Immediately after detection of rapid regrowth and in adenomas that were resistant to bromocriptine or irradiation, the MIB1 index was always greater than 1.0%. Most patients with rapidly regrowing adenomas were well controlled by radiation therapy.Our results suggest that a MIB1 index greater than 1.0% may be a useful predictor of rapid regrowth of pituitary adenomas and may be useful for planning of therapy.

Matrix metalloproteinase-9 secretion by human pituitary adenomas detected by cell immunoblot analysis

SummaryTwenty-two pituitary adenomas were examined on the secretion of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) using a cell immunoblot assay, and discussed regarding an association between cavernous sinus invasion and the secretion of these proteins. The cell immunoblot assay, a kind of immunoblot procedure, is able to detect proteins at the single cell level and to detect the incidence of tumour cells secreting the target proteins in the total tumour cell population. The incidence of tumour cells secreting MMP-9 was significantly higher in invasive adenomas than in noninvasive ones. On the other hand, TIMP-1 secretion was not detected in any adenomas in this study. This result suggested that MMP-9 secretion, and especially the number of MMP-9-secreting cells, may be associated with cavernous sinus invasion of pituitary adenomas.

Dissecting aneurysm of basilar artery presenting with recurrent subarachnoid hemorrhage.

Abstract Spontaneous basilar dissecting aneurysms secondary to subarachnoid hemorrhage are rare, usually presenting with ischemia rather than a subarachnoid hemorrhage (SAH). A 63-year-old man who had SAH repeatedly from a ruptured basilar dissecting aneurysm was treated with endovascular occlusion of the unilateral vertebral artery. Postoperative angiograms 1 month after the procedure showed complete obliteration of the aneurysm. The clinical follow-up at 20 months showed no evidence of recurrent hemorrhage.

Secretion of Matrix Metalloproteinase-9 and Tissue Inhibitor of Metalloproteinase-1 by Meningiomas Detected by Cell Immunoblot Analysis

Summary To identify features of meningiomas that infiltrate dura mater, and to examine the role Matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) secretion in meningiomas, a cell immunoblot assay study was performed in 20 meningiomas. MMP-9 secretion was detected in 20 (100%) meningiomas and was independent of histological features. TIMP-1 secretion was detected in 8 (40%) meningiomas. For a cell immunoblot volume which included approximately 1350 cells, there were 50.4±49.4 dots which showed immunoreactivity to MMP-9 and 2.0±4.2 which showed immunoreactivity to TIMP-1. The number of dots that showed immunoreactivity to MMP-9 was not significantly different between tumours with atypical and benign histological features. TIMP-1 secretion was found in only 8 (40%) specimens and the percentage of TIMP-1 secreting cells was significantly lower than that of MMP-9 secretion. Thus, we propose that meningiomas classified histologically as both atypical and benign have the potential to infiltrate dura mater.

Postoperative cortical venous infarction in tumours firmly adherent to the cortex

It is sometimes difficult to separate extra-axial tumours from the cortical veins in case of tumours attaching tightly to the cortex and the cortical veins. We present two patients having a postoperative cortical venous infarction. A 59 year old female had convexity meningioma above the motor cortex where abnormal cortical anastomotic veins developed. Transient hemiparesis occurred after total removal of the tumour because of venous infarction and cyst formation resulting from sacrifice of these veins which were tightly adherent to the tumour surface. A 15 year old boy with immature teratoma of the pineal region, showing several draining veins around the vascular-rich tumour, presented transient drowsiness, diplopia and partial impairment of bilateral visual acuity postoperatively because of localised cortical brain and venous damage. It is important to make an effort to preserve main cortical veins during operation as much as possible, even if the tumour adheres to the cortical surface.

Expression of epithelial cadherin and cavernous sinus invasion in human pituitary adenomas

Pituitary adenomas generally are regarded as benign tumors,although some invade the cavernous sinus and recur.We examined the epithelial cadherin (E-CD) expression in30 pituitary adenomas (6 with cavernous sinus invasionand 24 without). Immunoreactivity of E-CD were foundin all pituitary adenomas but they were veryvarious. The presence of an association between E-CDexpression and cavernous sinus invasion was assessed. Therewere no significant differences in E-CD expression betweeninvasive and noninvasive adenomas. These results suggest thatE-CD expression is not associated with cavernous sinusinvasion in pituitary adenomas.

Ischemia of the internal capsule due to mild head injury in a child.

We encountered an instructive case of repetitive reversible severe neurological deficit due to ischemia of the internal capsule after mild head injury. A 1-year-old boy fell and hit his head on the floor without losing consciousness. Intermittent episodes of left hemiparesis lasting from 30 s to 30 min developed 4 h later. Magnetic resonance (MR) imaging revealed acute infarction in the left internal capsule and corona radiata on diffusion-weighted imaging, and no microbleeding on susceptibility-weighted imaging. MR angiography of the intracranial and cervical vessels showed no obstruction of the large cerebral arteries. Motor impairment began to improve the next day with conservative therapy. Neurological deficit gradually resolved over the course of 1 month. This tiny lesion of the internal capsule and corona radiata may have represented a small infarction caused by mechanical vasospasm of the perforating vessels branching from the middle cerebral artery after minor injury. Even mild head injuries may cause infarction of the internal capsule, although minor head injuries are common accidents in childhood and usually do not result in severe complications.

A modified burr-hole method 'galeoduroencephalosynangiosis' in a young child with moyamoya disease. A preliminary report and surgical technique.

We performed combined indirect surgical procedures using encephaloduroarteriomyosynangiosis and a burr-hole method according to descriptions by Suzuki et al. and Kawaguchi et al. with some modifications in a 4-year-old child with moyamoya disease. Transient ischemic attacks on both sides completely disappeared within 1 month and never occurred during 2.5 years follow-up period. This surgical procedure may have enough value as the first operation to prevent ischemic damage in the territories of both the anterior cerebral artery and middle cerebral artery in children with moyamoya disease.

Primary angiitis of the central nervous system mimicking dissemination from brainstem neoplasm: a case report

BACKGROUND Diagnosis of PACNS is very difficult because of the variety of clinical manifestation, especially neurologic and MRI findings. We report the case of a 68-year-old woman with PACNS. CASE DESCRIPTION Her clinical symptoms mimicked malignant brainstem neoplasm disseminated to third and fourth ventricles and cervical spinal cord. Brain biopsy could not be correctly diagnostic. In spite of a trial of high-dose steroids, repeated MRI showed an increasing number of lesions. Two weeks after surgery, she died of respiratory dysfunction. Postmortem examination suggested PACNS, after consideration of histories, laboratory and radiologic findings, and the lack of systemic disease. CONCLUSION Although brain biopsy represents the gold standard measure, combination with several other examinations might be necessary to arrive at an early and definitive diagnosis. PACNS should be considered the differential diagnosis of intracranial tumors.