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Dural dryness makes suturing difficult during dural closure after craniotomy. In this case, dural plasty is often performed using a membrane taken from the surrounding tissue (e.g., fascia or periosteum) or an artificial replacement membrane. Herein, we introduce our novel "roll-up technique" to reduce the utilization of substitute membranes and explore its effectiveness in dural closure. We retrospectively examined the medical records of 50 patients who underwent craniotomy for the first time for supratentorial intracranial lesions between 2015 and 2022. Furthermore, we divided them into two groups: (1) the conventional technique group, which consisted of patients in whom the dura mater was flipped after incision and protected with a moistened gauze (n = 23), and (2) the roll-up technique group, which consisted of patients in whom the dura mater was incised in a U shape, rolled up, and protected with a moist gauze (n = 27). After surgery, we compared the success rates of primary closure, operating time, craniotomy area, and percentage of complications (e.g., cerebrospinal fluid [CSF] leakage or infection) between the groups. Dural closure without dural substitutes using the roll-up technique had a higher success rate than that using the conventional technique (26/27 [96.3%] cases vs. 14/23 [60.9%] cases; P = 0.003). Postoperative CSF leakage or infection did not occur, and no statistically significant difference was observed in the operating time between the groups (P = 0.247). The roll-up technique for dural closure may effectively prevent post-incisional dural shrink after craniotomy.

Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular malformations that can occur anywhere in the spine. Most SDAVFs lead to slow aggressive myelopathy due to venous congestion at a level adjacent to the shunt point. However, rare cases of localized brainstem edema without spinal cord lesions have been reported. In this study, we present a case of a lower cervical SDAVF that showed localized congestive edema of the medulla in the absence of an edematous change in the cervical spinal cord. The patient was a 57-year-old woman who experienced vertigo and vomiting without myelopathy that did not improve with conservative treatment. Magnetic resonance imaging (MRI) revealed high signal intensity in the left medulla on T2-weighted imaging (T2WI), while angiography revealed an SDAVF at the right C8 segmental level supplied by the right thyrocervical trunk. She underwent surgical interruption of the draining vein, which led to a rapid improvement in her symptoms. A subsequent follow-up MRI confirmed resolution of both the medullary edema and the dilated draining vein. SDAVFs may cause vertigo and vomiting, which are brainstem symptoms. Early diagnosis and surgical intervention are crucial for successful treatment outcomes., Competing Interests: The authors declare no conflicts of interest (COI) associated with this paper. Authors who are members of the Japan Neurosurgical Society have registered online self-reported COI Disclosure Statement Forms., (© 2024 The Japan Neurosurgical Society.)

Objectives: Whether elderly patients with adverse comorbidities or strong vascular meandering benefit from mechanical thrombectomy to the same degree as patients who participated in the pivotal randomized controlled trials on this procedure (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, DAWN, and DEFUSE 3) remains unknown. We aimed to investigate the predictors of reperfusion and 90-day functional outcome using real-world clinical data, without excluding elderly patients with adverse comorbidities or patients in whom vascular access could not be achieved., Materials and Methods: We retrospectively reviewed consecutive patients with acute ischemic stroke who underwent or in whom mechanical thrombectomy was attempted at Japanese Red Cross Matsue Hospital from April 2015 to June 2020., Results: Altogether, 111 mechanical thrombectomies in 111 patients (average age 77.2 years) were attempted for acute ischemic stroke. Vascular access was not achieved in 8 (7.2%) cases. In the multivariable analysis, age ≥85 years (odd ratio [OR] 0.191, 95% confidence interval [CI] 0.057-0.641, p = 0.007) and presence of adverse comorbidities (OR 0.265, 95% CI 0.090-0.659, p = 0.016) were associated with failed reperfusion. The diffusion-weighted imaging (DWI)-ASPECT score ≥6 (OR 4.650, 95% CI 1.610-13.40, p = 0.005) was associated with good 90-day functional outcomes. Presence of adverse comorbidities was not a predictor, but it had a relatively strong correlation with poor functional outcome., Conclusions: Mechanical thrombectomy in elderly patients should be considered very carefully if they are aged ≥85 years, have low DWI-ASPECT score and have clear evidence of pre-existing adverse comorbidities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Dural arteriovenous fistula of the anterior condylar confluence (ACC-DAVF) is a rare subtype of DAVFs that occurs around the hypoglossal canal. Transvenous embolization (TVE) with coils has been performed for most ACC-DAVFs with a high clinical cure rate. However, some reports call attention to hypoglossal nerve palsy associated with TVE due to coil mass compression of the hypoglossal nerve caused by coil deviation from the ACC to the anterior condylar vein (ACV). Herein, we report a case of ACC-DAVF in which an intraoperative cone-beam computed tomography (CT) contributed to avoiding hypoglossal nerve palsy., Case Presentation: A 74-year-old man presented with left pulse-synchronous tinnitus. An angiography detected left ACC-DAVF mainly supplied by the left ascending pharyngeal artery and mainly drained through the ACV. The two fistulous points were medial side of the ACC and the venous pouch just cranial of the ACC. We performed TVE detecting the fistulous points by contralateral external carotid angiography (ECAG). The diseased venous pouch and ACC were packed with seven coils but a slight remnant of the DAVF was recognized. Because a cone-beam CT revealed that the coil mass was localized in the lateral lower clivus osseous without deviation to the hypoglossal canal, we finished TVE to avoid hypoglossal nerve palsy. Postoperatively, no complication was observed. No recurrence of symptoms or imaging findings were detected during a five-month follow-up period., Conclusion: An intraoperative cone-beam CT contributed to avoiding hypoglossal nerve palsy by estimating the relationship between the coil mass and the hypoglossal canal during TVE of ACC-DAVF., (© The Author(s) 2016.)

Carotid artery stenting (CAS) has a fatal complication of intracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome (CHS), i.e. brain hemorrhage and subarachnoid hemorrhage (SAH). Although SAH accounts for a small percentage of these patients, it is difficult to make a differential diagnosis of this syndrome from CHS without ICH because the clinical presentations resemble each other. Furthermore, not only does the cause of SAH following CAS remain unclear but also the role of controlling postoperative blood pressure is not detected in preventing ICH after CAS. Herein, we report a case of SAH following CAS and review previous literature to discuss the mechanism and the management of this fatal complication. A 78-year-old woman with a history of arteriosclerotic obliteration and myocardial infarction was referred to our department for intervention to asymptomatic severe stenosis of the right internal carotid artery. We performed CAS under local anesthesia. Although her blood pressure was controlled to normotension during the procedure, the patient complained of headache following predilation. Postoperative emergent non-contrast computed tomography revealed SAH with leakage of contrast medium occupying the right sylvian fissure. We continued strict blood pressure control, and the patient was discharged without any neurological deficit. A well-opened lumen of the stent was recognized three months later at the outpatient visit. Strict control of intraoperative and postoperative blood pressure may improve the outcome of SAH following CAS though the role in preventing ICH after CAS is unclear., (© The Author(s) 2015.)

The goal of this study was to investigate the relationship among immunohistochemical expression of epithelial growth factor receptor (EGFR) family proteins, p21, p27 and prognosis in patients with high-grade astrocytoma. Expression of EGFR family proteins (c-erbB-1, c-erbB-2, c-erbB-3, c-erbB-4), p21 and p27 and Ki-67 labeling index (LI) were studied in 59 samples of high-grade astrocytoma. Expression of protein levels was analyzed by immunohistochemical staining of formalin-fixed and paraffin-embedded sections. Results were analyzed in relation to age, gender and survival. Overexpression of c-erbB-1, c-erbB-2, c-erbB-3 and c-erbB-4 was found in 40 (67.8%), 17 (28.8%), 3 (5.1%) and 42 (75.0%) samples, respectively. Similarly, low expression of p21 and p27 was observed in 50 (84.8%) and 27 (45.8%) samples. Mean Ki-67 LI was 17.3 +/- 1.1. Cox multiple regression analysis showed that c-erbB-1 (Hazard rate(HR) 1.57, 95% Confidence interval (CI) 1.08-2.36; p = 0.017), c-erbB-4 (HR 1.79, 95% CI 1.20-2.74; p = 0.004) and p27 (HR 0.50, 95% CI 0.30-0.82; p = 0.006) were significantly associated with survival. High expression of c-erbB-1 and c-erbB-4 and low expression of p27 were associated with poor prognosis in these patients.

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.

A 21-year-old man presented with aspergilloma in the prepontine cistern that developed after treatment for cerebellar hematoma following rupture of an arteriovenous malformation. He became bedridden with neurological signs of tetraparesis, disturbed ocular movement, and bulbar palsy, despite alert consciousness. Repeat magnetic resonance imaging 1 year later revealed a space-occupying lesion in the prepontine cistern along the clivus. This multilobular enhanced mass lesion gradually enlarged towards the brainstem over the following 4 years, resulting in loss of spontaneous breathing and dependence on a mechanical respirator. Surgical treatment via a lateral suboccipital approach was selected to reduce the size of the mass lesion and confirm the diagnosis. Histological examination revealed the presence of Aspergillus fumigatus. Treatment with amphotericin B (1 mg/kg/day) and fluconazole (100 mg/kg/day) injected into the peripheral veins was initiated, but was stopped due to the appearance of renal dysfunction. An Ommaya tube was then inserted into the prepontine cistern via a transsylvian approach to provide high concentrations of amphotericin B around the granulomatous lesion. He gradually improved, corresponding to the decreased size of the aspergilloma just after surgery. Surgical reduction of granuloma combined with local administration of antifungal agent is a good treatment option in patients with aspergilloma refractory to systemic administration.

The authors report a retrospective review o f 70 patients followed up for the presence of incidental, asymptomatic meningiomas. A survey was conducted of primary intracranial tumors diagnosed in Hiroshima Prefectural Hospital between 1995 and 2004. The neuroradiological imaging and clinical studies for asymptomatic meningiomas were performed during the 57.5-month mean follow-up period. Of the asymptomatic 70 meningiomas, 34 (mean age 58.3yrs) were surgically removed just after diagnosis, whereas 36 (mean age 72.1yrs) were treated conservatively. There was no permanent morbidity. Five patients (13%) had the transient operation-related neurological morbidity, which was caused by venous congestion near eloquent area, or operative manipulation at the craniotomy. The transient morbidity in patients over 70 years was 20%, although it was 12% in patients under 70 years. Eight patients (21%) were complained of chronic pain at the wound and 5 of them had medication. In 11(30.6%) of these 36 cases treated conservatively, the tumor size increased by mean 0.24 cm/year. Three of them had operation. The tumor growth rate was 0.33 cm/year in the operative group, whereas it was 0.09 cm/year in the conservative group. Histological grading of 3 cases revealed WHO grade I meningiomas. The absence of calcification and high intensity on T2 weighted-imaging were significantly associated with the higher growth rate (p<0.05). We should decide the strategy for treatment, paying attention to the radiological features, the tumor growth rate, age and operative difficulty. In addition that, we should keep in mind that over 20% patients were suffered from postoperative painful wound.

Patients with severe neurological impairment requiring tube feeding may have concomitant hydrocephalus. Coplacement of percutaneous endoscopic gastrostomy (PEG) and ventriculoperitoneal (VP) shunting is currently standard in such cases. The present study investigated the risk factors for shunt infection in such patients. The medical records of 23 patients with PEG and VP shunting were retrospectively reviewed. Correlations between shunt system infection and potential risk factors were analyzed including order of PEG and VP shunting, position of abdominal shunt catheter, diabetes mellitus, tracheostomy, and activities of daily living. Twelve patients underwent VP shunting after PEG and 11 underwent PEG after VP shunt placement. Four patients experienced shunt infection, and three required shunt revision. Three of these four patients underwent VP shunting after PEG. The period between PEG and VP shunt placement was 18, 19, and 25 days, shorter than the mean period of 29.3 days. VP shunting can be combined with PEG, but a larger study is required to clearly identify the risk factors. Administration of prophylactic antibiotics and a period of at least 1 month between the procedures are recommended, particularly if the shunt is placed after the PEG tube.

An 11-year-old boy developed occlusion of the left internal carotid artery (ICA) following surgical correction of atypical coarctation of the aorta. The patient was admitted to our hospital after presenting with severe hypertension secondary to abdominal aortic hypoplasia and renal artery stenosis. Reconstruction of the abdominal aorta with bypass grafting was performed without complication. However, in the postoperative period, the patient experienced recurrent transient ischemic attacks manifesting as paresthesia of the right upper limbs, dysarthria, and right-sided weakness. Cerebral angiography revealed occlusion of the C(2) portion of the left ICA and decreased resting cerebral blood flow in the left hemisphere. Extracranial-intracranial arterial bypass was performed, and the patient suffered no further adverse neurological events. Coarctation of the aorta is an uncommon congenital condition that may result in cerebral ischemic disease. The cerebrovascular circulation should be evaluated, even in patients without a pre-existing history of cerebral ischemic symptoms.

A 74-year-old man presented with a rare metastatic leiomyosarcoma of the brain manifesting as subacute development of multiple cerebral hemorrhages. Cerebral angiography demonstrated no tumor staining or vascular malformation. Whole body computed tomography revealed abnormal masses in the liver, left adrenal gland, and duodenum. Histological examination of an open biopsy specimen identified the lesion as metastatic leiomyosarcoma. Whole brain irradiation controlled the intracranial lesions, but the patient's general condition progressively deteriorated and he died of pneumonia. Metastatic leiomyosarcoma is a very uncommon tumor in the central nervous system with a poor response to existing treatment options. Consequently, new approaches to the treatment of this disease are needed.

The authors evaluated various clinical courses of ruptured infectious cerebral aneurysms associated with infective endocarditis in 4 patients. The first case: A 60-year-old male, who had a large hematoma resulting from rupture of a distal anterior cerebral artery aneurysm at the left frontal lobe co-existing with cerebral infarction at the right temporo-occipital lobe, with complications of renal and liver embolisms and pyogenic spondylitis, was treated with antibiotic therapy. However, he died of rupture of another newly formed aneurysm 29 days after onset. The second case: A 71-year-old female presented cerebral infarction in the right occipital lobe at onset. Two days later, abrupt occurrence of a large hematoma at the left parietal lobe led to deterioration of her consciousness. She underwent emergent evacuation of a large hematoma containing the infectious cerebral aneurysm proven histologically afterwards. The third patient: A 49-year-old female was suffered from a large hematoma and subdural hematoma accompanied distal posterior cerebral artery aneurysm at the right occipital lobe. She was operated by removal of the hematoma and the aneurysm proven as a bacterial infectious aneurysm. The fourth patient: A 71-year-old female had hemiplegia caused by a brain abscess and cerebral hemorrhage in the right temporal lobe and a distal middle cerebral artery aneurysm adjacent to the same region. Trapping of the aneurysm was undertaken and clinical course was uneventful. Attention needs to be paid to the various cerebrovascular condition arising from the bacterial embolus of infective endocarditis.

Objective and Importance: We report an instructive case of repetitive shunt obstruction caused by mischievous turning of the valve by the patient., Clinical Presentation: A 7-year-old boy underwent shunt replacement for hydrocephalus caused by intraventricular hemorrhage at birth; the shunt had been revised a month earlier. The boy experienced occasional episodes of headache and vomiting after the revision. A shunt survey revealed a twisted tube just proximal to the valve., Intervention: After the valve was returned to its original position, the symptoms resolved. The patient confessed to a recent habit of turning the valve., Conclusion: Although turning of the valve may be a potential cause of shunt obstruction, the use of craniography and/or a shunt series should be able to reveal these changes.

The authors present a case of a subependymal giant cell astrocytoma (SGCA) not associated with tuberous sclerosis. On admission, a six-year-old boy had obstructive hydrocephalus caused by a huge intraventricular tumor. Preoperative T1-weighted MR images with gadolinium showed heterogeneous enhancement of the lesion. The tumor was totally removed through a right transcortical approach with frontal craniotomy. Immunohistochemical staining for glial fibrillary acidic protein (GFAP) showed a positive reaction in some of the large tumor cells and the labeling index of MIB-1 was < 1.0%. Histological examinations revealed SGCA. He has no other evidence of tuberous sclerosis at present, but the patient in this case is an infant, so there is a possibility of his being diagnosed as tuberous sclerosis in the future. Therefore, systemic regular follow-up is recommended, even when his condition is asymptomatic.

We present a case of ruptured distal posterior inferior cerebellar artery (PICA) aneurysm, and review the literature and discuss the treatment strategy. A 77-year-old woman presented with the sudden onset of severe headache, nausea and vomiting. Computed tomography revealed an intraventricular hemorrhage, predominantly in the fourth ventricle and hydrocephalus with a thin subarachinoid hemorrhage (SAH). Angiography revealed an aneurysm arising at the turning point of the vessel, from the telovelotonsillar segment of the right PICA. On the 17th day after the onset, repeated angiography revealed a smaller aneurysm than the one detected on the first day at the same place and with no spasm. On the 22nd day, the aneurysm was proved to be partially thrombosed and was safely clipped via a right lateral suboccipital approach. SAH with a fourth ventricular hemorrhage or an isolated fourth ventricle hemorrhage should raise the suspicion of a distal PICA aneurysm. Aneurysms of the distal PICA have often been reported to arise at a turning point of the artery rather than at a junction of the vessel. It is suggested that the pathogenesis could be hemodynamic stress that has developed due to embryological factors. Distal PICA aneurysms have often gone detected in many previous cases because of thrombosis inside the aneurysms. Thus, particularly in the case of intentionally delayed surgery, we recommend repeated angiography under various conditions to identify how the aneurysm develops just before surgery.

A 58-year-old male presented with a dissecting aneurysm of the basilar artery manifesting as dysarthria, left hemiparesis, and numbness of the left side. Angiography revealed a double lumen at the midportion of the basilar artery which was consistent with a diagnosis of dissecting basilar artery aneurysm. The patient was treated conservatively, and remained neurologically stable for a 5-year period following initial presentation, but serial magnetic resonance imaging revealed growth of the aneurysm compressing the brain stem. His condition then worsened. Computed tomography revealed obstructive hydrocephalus. Ventriculoperitoneal shunting was performed and the patient's symptoms improved. However, he died of subarachnoid hemorrhage. Autopsy showed the patient had had a type 3 "dolichoectatic dissecting aneurysm." Surgical treatment should be seriously considered for treating the patients with dissecting basilar artery aneurysm causing brain stem ischemia, especially if the aneurysm is growing. High-flow bypass and proximal occlusion may be the choice in patients with poor collateral circulations.