Yoshio Taguchi

Comparative Study of Magnetic Resonance and CT Scan Imaging in Cases of Severe Head Injury

The distribution, frequency, and appearance of head injuries were evaluated with MRI and CT in a prospective study of 155 patients with acute (n = 124) and chronic (n = 31) head injuries. MRI was significantly more sensitive than CT in the detection of intraaxial injury at any stage. In severe cases, central structure lesions were detected in approximately 80% of patients. Severity on admission was compatible with MR findings. However it was difficult to decide on neurobehavioural prognosis from initial MRI findings only.

Recurrent craniopharyngioma with nasopharyngeal extension.

We report the case of a 10-year-old boy having a recurrent craniopharyngioma with nasopharyngeal extension during a course of growth hormone therapy, in whom the nasopharyngeal craniopharyngioma was totally resected despite its extensive growth by using a transbasal approach. There has been no evidence of recurrence during 6 years of follow-up. A literature review was made with respect to nasopharyngeal extension of craniopharyngiomas, and the efficacy of the transbasal approach for those tumors is discussed.

Cementifying fibroma in the ethmoidal sinus extending to the anterior cranial base in an 11-year-old girl: a case report

A case of an 11-year-old female with cementifying fibroma in the ethmoidal sinus extending to the anterior cranial base was presented. She complained of slowly progressive nasal obstruction and anosmia. Magnetic resonance imaging (MRI) revealed a tumor in both ethmoidal and sphenoidal sinuses and nasal cavity. Although a tumor reduction surgery was attempted through a transnasal approach, tumor size increased gradually and right exophthalmos subsequently appeared. The pathological diagnosis was cementifying fibroma of the nose. Total tumor removal was consequently accomplished through the intracranial anterior transbasal approach. The surgical approach should be selected according to the site and expansion of the lesion in individual patients.

Contralateral transcondylar approach for aneurysms of the posterior inferior cerebellar artery-vertebral artery complex.

We report a patient with an aneurysm of the left vertebral artery (VA)-posterior inferior cerebellar artery (PICA) complex that was treated successfully via a contralateral transcondylar approach. The aneurysm was small, pointed laterally to the right, and was located across the midline just above the level of the foramen magnum. This unusual location required special consideration during diagnostic evaluation and surgical planning. To simulate the operative view, the patients head was turned 45 degrees. This extreme oblique view offered useful information with respect to the choice of side from which the surgical approach should be made. Removal of the posteromedial part of the occipital condyle allowed us to clip the aneurysmal neck without difficulty although the surgical approach was made on the side contralateral to the parent artery. We conclude that the contralateral approach for VA-PICA aneurysms should be considered when aneurysms cross the midline, and that extradural removal of the basal bony structures, including the occipital condyle, can provide a wide wirking space without excessive retraction on the brain stem.

Frontotemporal orbitozygomatico-alar approachfor skull surgery

Mobilisation of the zygoma has been reported to offer excellent exposure of the cranial base with minimal brain retraction. This study describes our operative technique and presents our experiences of 22 patients. Fifteen patients had a skull base neoplasm and 7 had a complex cerebral aneurysm. To facilitate access to these lesions, two separate bone flaps were created: (1) A free frontotemporal bone flap; and (2) en bloc removal of the superior and lateral orbital rims with the attached zygomatic arch. Because the latter bone flap includes both the orbital roof and the posterolateral wall of the orbit with the greater wing of the sphenoid bone, unnecessary bony defects which could cause enophthalmos or other cosmetic problems are avoided. Among the 22 patients, 17 have returned to their previous life style and four require assistance for personal care. Operative mortality was zero. The incidence of postoperative complications directly related to this approach was minimal and cosmetic results were acceptable in most patients. We recommend this approach for medially located skull base neoplasms or complex cerebral aneurysms.

En bloc mastoidectomy to avoid postoperative retroauricular deformity in the transpetrosal approach

The authors describe a surgical technique to avoid postoperative retroauricular deformity following the transpetrosal approach. After removing a one-piece temporal and suboccipital bone flap, the mastoid process is cut obliquely by using a sagittal saw towards an imaginary line drawn from the point on the petrous ridge just lateral to the arcuate eminence to the burr hole opened medial to the occipital groove. This technique allows en bloc removal of the mastoid process without resulting bone defects. Three patients who were treated with this technique and followed up for more than 1 year showed good cosmetic results with no complications including cerebrospinal fluid leakage. We believe this en bloc mastoidectomy offers a definite advantage in regard to avoid postoperative retroauricular deformity.

Chronic Subdural Hematoma Associated with Middle Cranial Fossa Arachnoid Cyst. Is Cyst Peritoneal Shunt Treatment of Choice

We reviewed operative results of 9 patients with chronic subdural hematoma accompanied with arachnoid cyst and also 9patients with arachnoid cyst. We also reviewed incidence and age distribution of patients with arachnoid cyst founded by CTscan out of 14998 patients in our university hospital between 1979 and 1986. As for surgical treatment of arachnoid cyst with cyst-peritoneal shunt is considered good treatment of choice. Considering possible disappearance of arachnoid cyst, some of them may not need operation, if they are followed closely. Unsupported vessels on the surface of arachnoid cysts are most likely course of chronic subdural hematoma.

Evolution from Acute Subdural Hematomas to Chronic Subdural Hematomas

We analyzed 52 patients of acute subdural hematoma treated conservatively because of mild clinical symptoms and/or thin subdural hematoma to elucidate the evolution from acute subdural hematomas to chronic subdural hematomas. Based on the follow-up CT findings, these patients were classified into two groups: subdural hematomas increased in size gradually with or without deterioration of clinical manifestations(group 1) and subdural hematomas disappeared spontaneously(group 2). Group 1 included 23 patients. In most patients, CT showed the increase in size with a decrease in hematoma density 8 to 14 days after the insult. Fifteen patients were treated with a burr hole craniectomy and the evacuation of liquid hematoma content because of a deterioration of signs and symptoms. Average time elapsed to be operated was 26 days. The neomembrane similar to the outer membrane of chronic subdural hematomas was verified in 11 out of 15 operated patients. These neomembrane could not be differentiated from that of ordinary chronic subdural hematomas pathohistologically. The average age in 29 patients of group 2 was younger than that of group 1. Despite variable changes in hematoma density, subdural hematomas in group 2 decreased in size gradually or rapidly, and eventually disappeared. Average time elapsed to disappear was 25 days. When chronic subdural hematomas are defined as chronically enlarged and encapsulated subdural hematomas, a part of group 1 is considered to be chronic subdural hematomas and the evolution from acute subdural hematomas to chronic subdural hematomas can be present.

Successfully Treated Traumatic Dislocation of a Thoracic Vertebra Caused by Minor Trauma in a Patient with Neurofibromatosis Type I A Case Report and Literature Review

The authors reported a rare case of young women with neurofibromatosis type I (NF-I) who were successfully treated from the traumatic dislocation of a thoracic vertebra caused by a simple fall, and the relevant literature was reviewed. Due to various spinal dystrophic changes, the conventional posterior spinal fusion surgery was modified for the treatment. Spinal deformity is a common feature of NF-1, and a dystrophic lesion, like dural ectasia, provokes weakness in spinal structural. Unexpectedly, only seven similar cases were found. The review suggested that it is mandatory to thoroughly examine the spine in patients with NF-1, and that a good outcome can be expected even for patients with NF-1 in severe neurological condition after acute spinal cord injuries.

Continuous Monitoring of Jugular Bulb Oxygen Saturation in the Management of Patients with Severe Closed Head Injury

Continuous monitoring of intracranial pressure (ICP) is essential in the management of the patients with severe head injury, and various methods to decrease ICP have been utilized [1]. Hyperventilation, however, may occasionally cause inadequate cerebral perfusion, resulting in secondary brain damage in patients with increased ICP [2]. We have performed experimental and clinical studies using simultaneous monitoring of ICP and jugular bulb oxygen saturation (SjO2) with a fiberoptic catheter to evaluate dynamic changes in cerebral perfusion and cerebral metabolic rate, with the aim of finding an appropriate treatment strategy for patients with severe head injury [3]. On the basis of our previous data [3] and a review of the literature [4, 5], it was considered that a value for SjO2 less than 50% indicated hypoperfusion and a value more than 80% suggested hyperemia. We present herein our early experience of the management of severely head-injured patients by using simultaneous monitoring of ICP and SjO2 and discuss the treatment protocol we have developed.