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Brain metastases of a chondrosarcoma are extremely rare, and treatment remains controversial. A 54-year-old woman had undergone surgical treatment for a femoral chondrosarcoma and its lung metastases. She presented with visual disturbance and dizziness 22 months after the initial surgery; imaging studies of the brain revealed a metastatic tumor in the left parieto-occipital lobe. Surgical tumor resection was performed; however, only 2 months after gross total resection of the tumor, rapid tumor recurrence was observed. Surgical resection was performed again, followed by intensity-modulated radiation therapy. Three months later, another small brain lesion was detected in the right parietal lobe and was treated with gamma knife stereotactic radiosurgery. No recurrence has been reported 20 months after this radiosurgery for brain metastasis. Thus, surgical treatment combined with several adequate radiation therapy sessions may be a viable treatment strategy for brain metastases of chondrosarcomas., (© 2023 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Background: Transradial mechanical thrombectomy (MT) is increasingly used because it is associated with a low incidence of vascular access site complications. However, transradial carotid cannulation can be technically challenging to perform in patients with an unfavorable supra-aortic takeoff. In this study, the feasibility and safety of a new transradial MT system with a radial-specific neurointerventional guiding sheath-6F Simmons guiding sheath was evaluated-in patients with anterior circulation large-vessel occlusions. Additionally, a literature review was performed., Methods: We retrospectively analyzed data from our institutional database about consecutive patients who underwent transradial MT for anterior circulation large-vessel occlusion. After the 6F Simmons guiding sheath was engaged into the target common carotid artery, a triaxial system (Simmons guiding sheath/aspiration catheter/microcatheter), was established. MT using the continuous aspiration prior to intracranial vascular embolectomy technique was performed. Then, procedural success rate, successful revascularization, and procedure-related complications were assessed., Results: A total of 13 patients who had transradial MT were included in the analysis. All 13 patients underwent successful thrombectomy without catheter kinking or system instability, and 12 of them achieved successful revascularization (modified Thrombolysis in Cerebral Infarction score of ≥2b). No complications occurred., Conclusions: To the best of our knowledge, this is the first case series on transradial MT using a radial-specific neurointerventional system for anterior circulation large-vessel occlusions. This method may increase the success rate of transradial MT. Based on our initial experience, transradial MT, using this system, was feasible and safe for anterior circulation large-vessel occlusions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Kissing aneurysms are an unusual type of multiple intracranial aneurysms having different origins with partially adherent walls. Although endovascular treatment is a useful alternative to surgical clipping, endovascular management for small wide-necked kissing aneurysms has not been adequately investigated to date. Herein, we present a case of small wide-necked kissing aneurysms successfully treated with transradial stent-assisted coiling (SAC) using the "dual-jailing" technique. We also performed a review of the relevant literature., Case Presentation: A 64-year-old woman who was diagnosed with small wide-necked kissing aneurysms relating to the ophthalmic artery underwent SAC using the dual-jailing technique. After a 6F Simmons guiding sheath was delivered into the target common carotid artery via transradial access, a 6F intermediate catheter was navigated into the petrous internal carotid artery to achieve both triple microcatheter manipulation and contrast injection. Two coil-delivery microcatheters were cannulated into each aneurysm, followed by a Neuroform Atlas stent deployment over the aneurysm necks via a third stent-delivery microcatheter. By using the jailed microcatheters, SAC of the kissing aneurysms was successfully achieved, preserving the ophthalmic artery. The postprocedural course was uneventful. A follow-up magnetic resonance angiography showed no evidence of recanalization 2 years 3 months post procedure., Conclusions: The dual-jailing technique may provide simple and time-saving SAC compared with previous reported method. This technique can be a useful treatment option for small wide-necked kissing aneurysms., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Shinshu University Hospital has advanced operating rooms including a mobile computed tomography (mCT) room, Smart Cyber Operating Theater (SCOT) with intraoperative magnetic resonance imaging, hybrid operating room (hOR) with intraoperative image-guided surgery, and conventional operating rooms. We investigated the characteristics of cases assigned to each operating room., Methods: Five hundred forty neurosurgery cases from January 2018 to April 2021 were analyzed. We analyzed the selection of operating room according to pathology, surgical device requirement, and urgency, and we examined associations between operating room characteristics and these factors., Results: Neurological surgeries were performed in an mCT room, an hOR, a SCOT, and a conventional operating room in 333 (61.7%), 64 (11.9%), 49 (9.1%), and 94 (17.4%) cases, respectively. mCT rooms were more frequently selected than other rooms for vascular/extra-axial tumors, which have a lower need for intraoperative image guidance. Spinal surgeries with segment diagnosis or intraoperative bone removal tended to be performed in the hOR. The rate of SCOT use tended to be higher for intra-axial tumors with poorly circumscribed borders than for vascular/extra-axial tumors. Endoscopic procedures were more frequently performed in the SCOT and mCT rooms than in hORs and conventional operating rooms. Emergency surgeries were often performed in the conventional operating rooms, even in cases where SCOT and hOR seemed suitable., Conclusions: Intraoperative image-guided surgeries were performed according to the characteristics of each operating room best suited for various diseases and operative methods. Further research is needed to prove whether operating room selection improves neurosurgical outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Various devices exist for glioma image-guided surgery to improve tumor resection. These devices work as stand-alone units, making the flow of operative information complicated and disjointed. A novel networked operating room, the Smart Cyber Operating Theater (SCOT), has been developed, integrating stand-alone medical devices using the OPeLiNK communication interface. We report and evaluate the impact of SCOT for glioma surgery and our initial experiences., Methods: Patients with gliomas who underwent tumor resection in SCOT between July 2018 and June 2021 were retrospectively reviewed. Various types of intraoperative information were integrated, managed, and shared with the surgical strategy desk using OPeLiNK. Patients' demographics, tumor characteristics, treatment details, and outcomes were obtained. The impact of the SCOT system was evaluated., Results: Twenty-seven patients, with a mean age of 48.6 years (range, 13-88 years), met the inclusion criteria. We successfully completed all the surgical procedures using SCOT. The mean operation time was 420.6 minutes (range, 225-667 minutes).Gross total resection was accomplished in 13 patients (48.1%), subtotal resection in 4 (14.8%), and partial resection in 10 (37.0%). The main surgeon in the operating room and other neurosurgeons at the strategy desk shared and discussed the information in real time during the procedures., Conclusions: The use of SCOT was shown to be safe and feasible in glioma surgery. This study suggests that SCOT may improve surgical outcomes and educational impact by sharing information in real time with the strategy desk., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The fence post technique, which involves insertion of catheters as fence posts around a tumor, has been widely used to demarcate the tumor border for maximal resection of intraparenchymal tumors, such as gliomas. However, a standard procedure for fence post insertion has not been established, and there are some limitations. To overcome this problem, a simple microscopic navigation-guided fence post technique was developed. The feasibility and efficacy of this novel technique during glioma surgery were assessed., Methods: The microscopic navigation-guided fence post technique was used in 46 glioma surgeries performed in 42 patients. Intraoperatively, the preplanned trajectory was overlaid on the microscopic surgical field, and the microscope angle was changed until the entry and target points of the trajectory overlapped. A fence post catheter was inserted as planned under microscopic view, and the tumor was resected with fence post guidance. Preoperative tumor characteristics and surgical outcomes were evaluated., Results: Mean age of patients was 50 years (range, 16-78 years), and 19 (45%) of 42 patients were women. Maximal safe resection was successfully achieved in 45 surgeries (97.8%), which was planned preoperatively with identification of the tumor border with fence posts without adverse effects of brain shift. No surgical complications attributable to fence post insertion occurred., Conclusions: Clinical experience indicated that the microscopic navigation-guided fence post technique, in which fence posts can be placed without requiring the surgeon to take their eyes off the microscope, is safe and useful in glioma surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Severe intraventricular hemorrhage (IVH) is associated with a high mortality rate and poor functional outcome, even with recent neurosurgical developments. IVH requires emergent surgery to save the patient's life, but the optimal surgical strategy remains controversial. We assessed the results obtained with our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus., Methods: Consecutive patients with severe IVH owing to intracerebral hemorrhage who were treated with endoscopic surgery in the acute phase were retrospectively reviewed. Both rigid and flexible endoscopes were used for removal of hematoma in the whole ventricular system. Endoscopic third ventriculostomy and septostomy were performed as appropriate in each individual case., Results: Eight patients met the inclusion criteria and were included in the analysis. Sufficient IVH removal without neglecting the fourth ventricle was achieved with our technique in 6 of 8 cases (75.0%). Endoscopic third ventriculostomy and septostomy were added in 4 cases each (50.0%). Four patients (50.0%) had a marked recovery and a good outcome (modified Rankin Scale score ≤2) despite disease severity at onset. The procedure was completed successfully in all cases, and there were no surgery-related complications., Conclusions: This study showed that our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus may be beneficial., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: A next-generation networked operating room, Smart Cyber Operating Theater (SCOT), has been developed in cooperation with medical engineers that integrates standalone medical devices, including intraoperative magnetic resonance imaging (MRI) using the OPeLiNK communication interface. Here, we report the application of this newly developed advanced type of operating theater for the endoscopic endonasal approach (EEA), along with an evaluation of our initial experiences., Methods: The study population consisted of 18 patients with parasellar tumor. All patients underwent surgery via the EEA in SCOT. During all procedures, various types of intraoperative information, including electrophysiologic monitoring, anatomic orientation with navigation system, intraoperative MRI, and endoscopic images of the operative field, were collected and stored by OPeLiNK. Furthermore, the intraoperative information was shared with the surgical strategy desk, where a senior neurosurgeon can direct and manage the surgical procedure in real-time., Results: We successfully completed the surgical procedures in SCOT in all cases. Using OPeLiNK, operators in SCOT were able to share various data, such as images obtained intraoperatively and surgical instrument position from navigation systems, as well as images of the surgical field, with senior neurosurgeons at the surgical strategy desk in all cases. Surgically relevant information from these sources was transmitted through an application and displayed to all surgical staff. The necessary nuances were reflected in the surgical procedures., Conclusions: SCOT, which is considered an innovative operation system in neurosurgery, enables both quality and safety in the EEA. Furthermore, the use of SCOT may also contribute to the education of young neurosurgeons., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Spontaneous cerebrospinal fluid (CSF) rhinorrhea associated with untreated prolactinomas is rare, which is in contrast to medical treatment-induced CSF rhinorrhea. Previous studies have suggested that cessation of drug administration should be the first line of treatment for prolactinoma with medically induced CSF rhinorrhea. On the other hand, there is no standard treatment strategy for prolactinoma with the development of spontaneous CSF rhinorrhea, because of its complicated pathology. Here, we report a case of giant invasive macroprolactinoma with spontaneous CSF rhinorrhea, and discuss the treatment strategy for this complicated condition with a review of the relevant literature., Case Description: A previously healthy 39-year-old man presented with 1-year history of intermittent clear fluid nasal discharge with headache and vomiting. Magnetic resonance imaging showed a large parasellar mass with destruction of the skull base. This tumor was diagnosed as prolactinoma with hypopituitarism based on the results of hormone examinations. Tumor resection with skull base reconstruction in the endoscopic endonasal approach was performed because CSF rhinorrhea was aggravated by bromocriptine loading test and administration of dopamine agonist. Life-threatening bacterial meningitis occurred after surgery, which was cured with antibiotics along with resolution the CSF rhinorrhea., Conclusions: Careful consideration is necessary before applying standard first-line protocols with dopamine agonist administration in patients with prolactinoma, especially in cases with spontaneous CSF rhinorrhea. An appropriate treatment strategy should be planned according to the individual case, including factors such age, sex, pituitary function, tumor mass size, prolactin concentration, and condition of CSF leakage., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Generally, asymptomatic epidermoid cysts (ECs) or ECs with minor symptoms controlled by medication are not treated further. Although epidermoid carcinomas are only sporadically reported, the possibility of malignant transformation of ECs is of concern., Case Description: A 77-year-old man under observation for a left cerebellopontine angle tumor presented with no symptoms, including headache, dizziness, or other cranial nerve abnormalities typical of cerebellopontine angle tumors. The tumor manifested as an extra-axial mass in the left cerebellopontine angle and measured 24 × 16 mm (length × width) on magnetic resonance imaging (MRI). As he was asymptomatic, his primary physician did not pursue invasive treatment but ordered follow-up MRI every 2 years. The tumor decreased in size 2 years after the initial MRI, and no tumor fragmentation was observed on the patient's spinal MRI. Ultimately, the tumor shrank to 19 × 11 mm over 22 years., Conclusions: The reduction of an EC is extremely rare. We report a case of spontaneous regression of an EC and consider similar previous cases., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: In cardiac intervention, the transradial approach (TRA) is increasingly used as the first-line approach owing to numerous advantages over the transfemoral approach. Neurointerventional TRA, especially in intracranial interventions, is predominantly restricted to an alternative approach, as transradial carotid cannulation using a conventional transfemoral system can be technically challenging for patients with unfavorable acute takeoff of the target common carotid artery. This study evaluated the feasibility and safety of first-line TRA with a radial-specific neurointerventional guiding sheath for a large series of consecutive intracranial anterior circulation aneurysm embolizations., Methods: We retrospectively analyzed our institutional database of first-line TRA for consecutive coil embolizations of anterior circulation aneurysms conducted between June 2018 and March 2020. A radial-specific 6-F Simmons guiding sheath (0.088-inch inner diameter) was engaged into the target common carotid artery, and subsequently a triaxial or quadraxial system was created for the embolization procedure. We assessed procedural success and procedure-related or vascular access site complications., Results: A total of 119 patients with intracranial anterior circulation aneurysms underwent 121 coil embolization procedures. Of these, 101 patients who underwent 103 (85.1%) embolization procedures treated with first-line TRA were included. After the triaxial or quadraxial system was constructed, the embolization procedure was successful for all 103 cases without catheter kinking, system instability, or complications., Conclusions: A transradial 0.088-inch triaxial or quadraxial system provided sufficient stability and kink resistance for intracranial aneurysm embolization. This method is feasible, highly successful, and safe for intracranial anterior circulation aneurysm embolization., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Trans-cell approach for the Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA) is occasionally unsuccessful as a microcatheter can become stuck in the struts. This study aimed to evaluate the passability and impassability of 0.0165-inch microcatheters through the Neuroform Atlas stent using a simplified benchtop model., Methods: The distal struts of the target cell, referred to as the concave or convex crown, were found to interfere with microcatheter advancement during the trans-cell approach. The procedure was performed across each crown using the 1.7-Fr SL-10 and 1.6-Fr Headway Duo microcatheters (MicroVention-Terumo, Aliso Viejo, CA), and it was repeated 20 times. We evaluated the procedural success rate, passability of each microcatheter using the maximum moving distance of the target crown in successful procedures, and device behaviors., Results: The procedural success rate across the concave crown was significantly higher than that across the convex crown in both microcatheters. The maximum moving distance of the concave crown was significantly shorter in the Headway Duo microcatheter than in the SL-10 microcatheter. All procedures across the convex crown were not successful because the sharp end of the crown fell into the interspace inside the microcatheter tip, which is referred to as the crown jackpot phenomenon. The trapped microcatheter was never released from the crown unless it was pulled back proximally., Conclusions: Target crowns and microcatheters affected the use of the trans-cell approach through the Neuroform Atlas stent. The passability was excellent in a lower profile 0.0165-inch microcatheter. Moreover, neurointerventionalists must be knowledgeable of the crown jackpot phenomenon, which might cause fatal stent migration., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: In coronary intervention, the transradial approach (TRA) is increasingly used as the primary vascular access because of its numerous advantages over the transfemoral approach. However, in neurointerventions, conventional TRA with a straight-shaped guiding system is used as an alternative vascular access because transradial carotid cannulation can be technically challenging for right common carotid artery (CCA) lesions with steep angulation to the right subclavian artery or left CCA lesions with a nonbovine origin. The purpose of the present study was to evaluate the feasibility and safety of TRA as the primary vascular access with a pre-shaped Simmons guiding sheath for anterior circulation interventions., Methods: Between June 2018 and September 2019, 130 consecutive patients (75 carotid artery stenting and 55 cerebral aneurysm coiling cases) who underwent TRA as the primary vascular access were included in this study. A 6-Fr Simmons guiding sheath was introduced into the target CCA by selecting a cannulation technique based on preprocedural image assessment. We retrospectively analyzed the carotid cannulation success, procedural success, and periprocedural or vascular access site complications., Results: Carotid cannulation (69 right CCA, 6 left CCA with a bovine origin, and 55 left CCA with a nonbovine origin) and the subsequent procedure were successfully performed for all 130 patients without periprocedural or vascular access site complications., Conclusions: TRA with a 6-Fr Simmons guiding sheath for anterior circulation interventions is highly successful and safe for all target CCAs and aortic arch types. This method can be utilized as the primary vascular access for anterior circulation interventions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: When medical devices and equipment in an operating room are connected to a network, vast amounts of data concerning the progress of the operation and the patient's condition can be comprehensively processed to improve the precision and safety of the surgical procedure. To make this possible, a next-generation networked operating room, "Smart Cyber Operating Theater" (SCOT), has been developed with medical-engineer cooperation. SCOT integrates stand-alone medical devices using the "OPeLiNK" communication interface. Using OPeLiNK, medical devices are connected and various data, such as intraoperative magnetic resonance imaging, neuromonitoring, biochemical monitoring, and navigation system, are integrated and displayed in the same timeline., Case Description: The authors succeeded in clinical tumor resection via the endoscopic endonasal approach using the SCOT system in a 79-year-old man with a large nonfunctioning pituitary adenoma. The surgeons performed the operation while sharing information in real time between all staff in the operating room and supervising expert surgeons at the surgical strategy desk. Any decisions, such as intraoperative surgical procedures, were made with discussion between the operating room and the surgical strategy desk. The patient's postoperative course was uneventful., Conclusions: This is the first case report of endoscopic endonasal approach performed successfully in the SCOT. Further developments in this technology may lead to innovations in not only microscopic neurosurgery but also endoscopic neurosurgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The benefits of the right transradial approach for anterior circulation lesions using a 6F Simmonds guiding sheath have been reported. However, this technique can be anatomically challenging in the type I aortic arch. Furthermore, to the best of our knowledge, no studies have reported on neurointervention using a Simmonds guiding sheath and the left transradial approach. We devised a novel technique using the contralateral subclavian artery as an "anchor" to reform the Simmonds curve, named the subclavian artery anchoring technique (SCAT). The purpose of the present study was to evaluate the feasibility, safety, and usefulness of neurointervention with the SCAT for patients with a type I aortic arch treated with the right transradial approach and patients treated with the left transradial approach., Methods: Ten consecutive patients treated from June 2018 to January 2019 were included in the present study. We retrospectively analyzed: 1) the success rate for reforming the Simmonds curve using the SCAT; 2) the success rate for introducing the 6F Simmonds guiding sheath into the target common carotid artery; 3) the success rate for completing the procedure; 4) periprocedural complications; and 5) vascular access site complications., Results: In all 10 patients, the Simmonds curve was reformed, and a 6F Simmonds guiding sheath was introduced into the target common carotid artery. The procedure was successfully achieved for all 10 patients without periprocedural or vascular access site complications., Conclusions: The results of the present study have shown that this technique is a feasible, safe, and useful method for patients with type I aortic arch treated with a right transradial approach or a left transradial approach. SCAT makes up for a deficiency in the transradial approach with a 6F Simmonds guiding sheath., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The endoscopic endonasal approach for the craniovertebral junction (CVJ), instead of the microscopic transoral approach, has been widely adopted and accepted, especially in resection of the odontoid process for basilar invagination. However, there is concern regarding insufficient resection of odontoid and surgical complications, including vessel injuries, because this is a historically immature procedure. Here, we report a surgical case of endoscopic endonasal odontoidectomy (EEO) in the hybrid operating room (hOR) for improvement of its safety and reliability., Case Description: A 70-year-old man presented with a 2-month history of myelopathic gait disturbance and swallowing disturbance. Neuroimaging analysis indicated medulla oblongata compression associated with basilar invagination. The patient underwent EEO in the hOR after posterior instrumented fixation. With the hOR, the extent of bone resection and anatomic orientation were confirmed intraoperatively. Postoperative course was uneventful, and symptoms were improved after surgery., Conclusions: The application of the hOR may make the EEO safe and precise for anterior decompression of the CVJ. To our knowledge, this is the first case report describing clinical experience of EEO in the hOR., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The availability of magnetic resonance imaging (MRI) has led to an increase in the detection of pituitary incidentaloma (PI). However, there are no robust data on surgical treatment of PI on which to base therapeutic recommendations. This study was performed to investigate the significance of surgery for asymptomatic nonfunctioning pituitary adenoma (NFPA) among PIs., Methods: A total of 180 patients that underwent tumor resection of pituitary adenoma via the transsphenoidal approach between 2005 and 2017 were reviewed. Thirty-three consecutive patients with subjectively asymptomatic NFPA were included in this study. Our surgical indications for asymptomatic NFPAs were categorized as follows: macroadenoma with optic chiasma compression (group A, n = 14), solid tumor ≥2 cm in size (group B, n = 7), and tumor growth on follow-up MRI (group C, n = 12). The clinical outcomes were analyzed accordingly., Results: Seven patients (50%) in group A showed subjective improvement of visual function after tumor resection even though they had no complaints preoperatively. On the other hand, no changes occurred in any cases in group B or group C. Although there were no critical complications in this series, the incidence of nonnegligible nasal complications was relatively high (24.2%) and may decrease the patient's quality of life., Conclusions: Surgery should be recommended for asymptomatic NFPA with optic chiasma compression to improve visual outcome. On the other hand, immediate intervention for other asymptomatic NFPA to reduce the likelihood of the appearance of tumor-related symptoms remains questionable considering its invasiveness to the nose., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Superficial siderosis (SS) associated with craniopharyngioma is an extremely rare occurrence. To our knowledge, only 3 cases have been reported in literature. Two of the cases occurred following resection of the tumor. Similar to the present case, 1 of the cases was discovered before surgical intervention, "pure tumor-related" SS. The clinical presentation, diagnosis, management, and outcome are discussed in this article., Case Description: A 50-year-old man presented with an 11-month history of left-sided tinnitus, hearing impairment, and a 2-month history of visual disturbance. Cerebellar ataxia and gait disturbance were found on examination. Brain magnetic resonance imaging findings were consistent with SS. Cerebrospinal fluid (CSF) analysis before surgery revealed xanthochromia confirming an existing chronic sustainable subarachnoid hemorrhage. He underwent a tumor resection in endoscopic endonasal approach followed by stereotactic radiosurgery. On follow-up, the visual symptoms resulting from craniopharyngioma subsided, whereas hearing impairment, cerebellar ataxia, and gait disturbance associated with SS did not progress but were unchanged despite subsequent evidence of watery-clear CSF., Conclusions: In the present case, SS could be associated with craniopharyngioma on the basis of CSF findings and clinical symptoms. Detection and early treatment aimed at eliminating the bleeding source offer the best chance of halting the disease process., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Based on our previous reports, stabilizing the surgeon's arm with an intraoperative armrest is linked to improved precision of microsurgical and endoscopic procedures. We developed the robotic intelligent surgeon's arm supporting system iArmS, which automatically follows the surgeon's arm and fixes it at an adequate position., Methods: iArmS has 3 states-free, hold, and wait-which can be carefully chosen automatically as follows: In free state, the armholder follows the surgeon's arm. In hold state, iArmS supports the surgeon's arm weight by fixing the armholder. In wait state, the surgeon can move his or her arm away from the armholder. Also, the surgeon can change the armrest position while looking through the microscope and can continue the microsurgical procedure while holding surgical instruments. From February 2015 to January 2017, iArmS was used in 108 microsurgeries at 3 of the authors' institutions by 14 board-certified neurosurgeons, including the authors. After using iArmS, to quantify neurosurgeons' satisfaction, a scaling evaluation guide based on visual analog scales was designed to be completed by contributing neurosurgeons, including authors., Results: iArmS decreased fatigue and reduced hand trembles experienced by surgeons. Continuous accurate motions of microinstruments were performed without any difficulties. There were no complications related to use of iArmS., Conclusions: iArmS allows continuous precise manipulations that provide high-quality surgical results in neurosurgical techniques. Moreover, iArmS is a useful automatic tool for holding and following the surgeon's arm., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Inflammatory lesions of the pituitary gland including hypophysitis are poorly understood, and it is difficult to make a correct diagnosis on the basis of only clinical and radiologic findings., Case Description: An otherwise healthy 68-year-old man presented with sudden onset of headache, visual impairment, and pituitary insufficiency. Magnetic resonance imaging revealed a pituitary mass with cystic component showing changing intensity on follow-up images. Also, changing density of the lesion was demonstrated on computed tomography over a short period of time. These findings suggested a hemorrhagic lesion, and a preoperative diagnosis of pituitary apoplexy associated with a preexisting pituitary adenoma was made on the basis of clinical and radiologic findings. In the endoscopic endonasal approach for tumor resection, there was neither hematoma nor adenoma. Histopathologic diagnosis was lymphocytic hypophysitis., Conclusions: To the best of our knowledge, this is the first case report of hypophysitis with radiologic signal changes over a short period. Vigilant attention regarding the clinical diagnosis of such rare entity is paramount., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Entrapment of the temporal horn, known as isolated lateral ventricle (ILV), is a rare type of noncommunicating focal hydrocephalus, and standard treatment has not been established. We report 2 cases of endoscopic surgery for ILV and highlight the anatomic surgical nuances to avoid associated surgical risks., Case Description: The first patient presented with recurrent ILV following initial shunt placement for ILV, owing to shunt malfunction. In the second patient, ILV recurred secondary to choroid plexus inflammation caused by cryptococcal infection. Endoscopic temporal ventriculocisternostomy was effective in both cases. However, in the second case, the choroidal fissure was fenestrated, which led to cerebral infarction in the territory of the choroidal artery zone, attributed to damage of the branches of the choroidal segment of the anterior choroidal artery., Conclusions: Although endoscopic temporal ventriculocisternostomy is considered a safe and less invasive procedure for treatment of symptomatic ILV, the technique is still associated with risks. To avoid complications, it is necessary to be familiar with the anatomy of the choroidal arteries and the pertinent endoscopic intraventricular orientation. Additionally, sufficient experience is required before it can be recommended as the treatment of choice., (Copyright © 2017 Elsevier Inc. All rights reserved.)

It is often difficult to definitively diagnose dural lesions with hypertrophy as they exhibit nonspecific imaging findings and clinical symptoms. Most cases require histopathological evaluation with surgical intervention (such as biopsy). However, complications related to surgical interventions remain as matter of concern. Herein, we analyzed and verified the significance of surgery in 39 patients with hypertrophic dural lesions who were histopathologically diagnosed with surgical interventions. Specimens of dural lesions were obtained successfully, and it was possible to make a definitive diagnosis for each case based on histopathological findings. All patients tolerate the procedures well, and there were no evidences of surgery-related complications during surgical approach to the dura mater. Preoperative and pathological diagnoses varied in eight cases. Our results indicate that histopathological evaluation is important for distinguishing diseases showing dural hypertrophy even if surgical invasiveness is concerned. Neurosurgeons should not hesitate to perform surgery for management of dural lesions with hypertrophy in order to achieve accurate diagnosis., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Cerebral sparganosis is a rare zoonotic infestation that often mimics glioma and metastatic tumors., Case Description: A 71-year-old man presented with disturbing dysarthria. Initial neuroimages were suggestive of glioma. However, the histology was suggestive of inflammatory lesion. Follow-up neuroimages and serology were suggestive of sparganosis. He subsequently had craniotomy with ultrasound-guided aspiration of a live worm. Saline-soaked Surgicel was used to provide an acoustic window., Conclusions: Ultrasonography was helpful in the intraoperative localization of the worm and is recommended when intraoperative magnetic resonance is not readily available., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Various techniques are available for occipital skull exposure with muscle dissection, as well as different types of skin incisions in the lateral suboccipital approach to vestibular schwannoma (VS) surgery. The skin incisions are generally classified as S-shaped, J-shaped, or C-shaped. In each method, the technique used for muscle dissection differs in terms of cut, single layer, and multiple layers. This study was performed to identify the relationships among muscle dissection method, skin incision type, and muscle atrophy in the lateral suboccipital approach to surgery for VS., Methods: Between 2002 and 2011, we performed surgical resection in 53 patients with VS at Shinshu University Hospital. Of these 53 patients, 35 with radiographic annual follow-up for >3 years after surgery were evaluated retrospectively. These patients included 14 who underwent an S-shaped incision, 6 with a J-shaped incision, and 15 with a C-shaped incision. Bilateral areas of the skin and occipital muscles were measured, and rates of atrophy were calculated and compared among the 3 methods., Results: Postoperative muscle atrophy was significantly advanced in the second postoperative year, but did not tend to develop further after the third year. The postoperative muscle atrophy ratio was significantly lower in the C-shaped incision group (mean ± SD, 4.0% ± 6.9%) compared with the S-shaped (17.1% ± 9.8%) and J-shaped (17.6% ± 10.0%) incision groups within 2 years after surgery (P < 0.05)., Conclusions: The C-shaped skin incision with multilayer muscle dissection was associated with significantly reduced postoperative muscle atrophy compared with the other methods., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Spinal meningeal cysts are a rare benign disease that can cause myelopathy. In most cases, spinal meningeal cysts consist of an arachnoid membrane. To the best of our knowledge, few articles have report on intradural spinal meningeal cyst consisting of dura mater., Case Description: A 58-year-old man presented to our institute with aggravation of clumsy hands and dysesthesia of the feet. Magnetic resonance imaging of the entire spine revealed a cystic lesion compressing the spinal cord posteriorly. Cyst fenestration and placement of the cyst-subarachnoid shunt was performed via an anterior approach. Postoperatively, the histopathologic results revealed that the cyst wall consisted of a dura mater-like membrane. The patient's symptoms resolved without the appearance of any new neurologic deficits., Conclusions: The etiology of spinal meningeal cysts remains unclear. Spinal meningeal cysts consisting of dura mater (spinal dural cysts) are extremely rare. Treatment with only decompression with laminectomy causes enlargement of the dural cyst later. Cyst fenestration and placement of a cyst-subarachnoid shunt for the spinal dural cyst resulted in the resolution of myelopathy and cyst shrinkage., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Primary lymphomas of the cranial nerves are extremely rare except for optic nerve lymphoma, and it is difficult to make a correct diagnosis in the initial stage. Here, we report a case of primary malignant lymphoma of the left trigeminal nerve that presented as trigeminal nerve disorder., Case Description: A 47-year-old man presented with aggravating left facial pain and hypesthesia within all three divisions of the trigeminal nerve. Magnetic resonance imaging (MRI) revealed a swollen left trigeminal nerve with gadolinium homogenous enhancement. An open biopsy had to be taken from two different locations of the tumor via the lateral suboccipital approach followed by subtemporal approach because adequate specimen volume was not obtained for definitive diagnosis at the first surgery. Histopathological examinations with flow cytometric analysis revealed diffuse large B cell lymphoma. Chemotherapy followed by whole-brain radiation therapy was effective. No recurrence was observed during a 15-month follow-up period., Conclusions: This is a rare clinical presentation of malignant lymphoma of the trigeminal nerve. It is difficult to establish a correct diagnosis of trigeminal nerve lesions during the initial stages without biopsy. Therefore it is important that a sufficient specimen should be taken for biopsy without hesitation in order to diagnose and treat rapidly. The most suitable operative approach must be selected in trigeminal nerve lesions considering functional preservation, operative difficulty, preference of each surgeon, and quantity of specimen to be removed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Small dense low-density lipoprotein cholesterol (sdLDL-C) concentrations correlate more strongly with coronary heart disease than other LDL-C and large LDL particle concentrations. We investigated the association between carotid artery intima-media thickness (IMT) and sdLDL-C concentrations in Japanese subjects., Methods: Carotid artery IMT, blood pressure (BP), fasting plasma sdLDL-C, glucose metabolism, lipid, and C-reactive protein concentrations were measured in 97 native Japanese subjects. Carotid artery IMT was assessed by ultrasonography, and sdLDL-C concentrations were measured by a homogenous assay. Pearson's correlation coefficient analyses and multiple regression analyses were used to examine the relationships between carotid artery IMT values, sdLDL-C values, and other clinical variables., Results: After multiple regression analysis, including age, sex, body mass index, systolic BP, diastolic BP, fasting plasma glucose, HbA1c, estimated glomerular filtration rate (eGFR), total-C, high-density lipoprotein (HDL)-C, triglyceride, LDL-C, non-HDL-C, large buoyant LDL-C, and sdLDL-C, carotid artery IMT remained significantly associated with age, systolic BP, diastolic BP, and sdLDL-C, whereas sdLDL-C remained significantly associated with age, total-C, HDL-C, triglycerides, and carotid artery IMT., Conclusions: When measured by a homogenous assay, carotid artery IMT may have a closer relationship with sdLDL-C concentrations than other lipid parameters in Japanese subjects. sdLDL-C may be a potentially useful risk marker when assessing carotid artery IMT in Japanese subjects., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Aims: The pathophysiological roles of thyroid hormones in glucose metabolism remain uncertain. Type 3 iodothyronine deiodinase (D3) converts thyroxine (T4) and 3,5,3'-triiodothyronine (T3) to 3,3',5'-triiodothyronine (rT3) and 3,3'-diiodothyronine (T2), respectively, inactivating thyroid hormones in a cell-specific fashion. In the present study, we identified D3 expression in MIN6 cells derived from a mouse insulinoma cell line and examined the mechanisms regulating D3 expression in these cells., Main Methods: We characterized D3 activity using HPLC analysis, and examined the effect of GLP-1 or exendin-4 on D3 expression and cAMP accumulation in MIN6 cells. We also measured insulin secretion from MIN6 cells exposed to GLP-1 and T3., Key Findings: We identified enzyme activity that catalyzes the conversion of T3 to T2 in MIN6 cells, which showed characteristics compatible with those for D3. D3 mRNA was identified in these cells using RT-PCR analysis. Forskolin rapidly stimulated D3 mRNA and D3 activity. Glucagon-like peptide-1 (GLP-1) increased D3 expression in a dose-dependent manner, and this effect was inhibited by the protein kinase A (PKA) inhibitor H-89. Exendin-4, a GLP-1 receptor agonist, also stimulated D3 expression in MIN6 cells. These results suggest that a cAMP-PKA-mediated pathway participates in GLP-1-stimulated D3 expression in MIN6 cells. Furthermore, GLP-1 stimulated insulin secretion was suppressed by the addition of T3 in MIN6 cells., Significance: Our findings indicate that GLP-1 regulates intracellular T3 concentration in pancreatic β cells via a cAMP-PKA-D3-mediated pathway that may also regulate β-cell function., (Copyright © 2014. Published by Elsevier Inc.)

Lignins are major cell wall components formed by the dehydrogenative polymerization of three monolignols, p-coumaryl, coniferyl and sinapyl alcohols. We prepared lignin-carbohydrate complexes (Fr. VI and Fr. VII) from pine cones by acid and ethanol precipitation, and investigated which part of these molecules is essential for expression of biological activities. They showed potent antiviral activity upon direct interaction with the virus. The antiviral activity of Frs. VI and VII required the higher-order structure of polyphenols without polysaccharides. Pretreatment of mice with Fr. VI or VII induced higher antiparasite activity than those of natural and chemically modified antitumor polysaccharides. Fr. VI or VII at higher concentrations enhanced the radical intensity and cytotoxic activity of vitamin C, whereas tannins counteracted the effect of vitamin C. Fr. VI at lower concentrations enhanced the O2(-)-scavenging activity of vitamin C. Frs. VI and VII stimulated mouse macrophage-like cells Raw 264.7 to produce nitric oxide (NO), citrulline (CIT) and asparagine (ASN), via the enhanced expression of iNOS and ASN synthetase, whereas phenylpropenoid monomers and polymers inhibited NO/CIT/ASN production. These data suggest that the polymerized structure of phenylpropenoids in lignin-carbohydrate complexes is required for the induction of antiviral activity, and that the higher-order structure of phenylpropenoid polymers and polysaccharides is required for immunopotentiation, including macrophage activation.

Thymic hyperplasia is associated with Graves' disease. It has been demonstrated that thyrotropin receptors are expressed in human thymus, and thymic thyrotropin receptors are suggested to be involved in the pathophysiology of Graves' disease. We have studied whether thyrotropin receptors are expressed in rat thymic tissue. Thyrotropin receptor mRNA was demonstrated in 5-day-old, 10-day-old, 20-day-old and adult rat thymus by reverse transcription polymerase chain reaction. Thyrotropin receptor mRNA was also demonstrated in cultured rat thymic epithelial cells. Thyrotropin stimulated cyclic AMP production in cultured rat thymic epithelial cells, suggesting the expression of functional thyrotropin receptors. The present results indicate that thyrotropin receptors are expressed in rat thymus.

It has been known that type II iodothyronine deiodinase activity is present in rat Harderian gland and the activity is significantly increased by isoproterenol administration. We have performed Northern analyses to study whether the transcript for type II iodothyronine deiodinase is expressed in rat Harderian gland and whether the isoproterenol stimulation of type II iodothyronine deiodinase activity in rat Harderian gland is due to the change in its mRNA level. Northern analyses have demonstrated that type II iodothyronine deiodinase mRNA, approximately 7.5 kb in size, is expressed in rat Harderian gland, and the mRNA levels as well as the deiodinase activities are greater in hypothyroid rats than those in euthyroid rats. Type II iodothyronine deiodinase mRNA levels and the deiodinase activities in Harderian gland were increased by isoproterenol administration, and the increase in the mRNA levels preceded that in the deiodinase activities. These results indicate that 7.5 kb transcript for type II iodothyronine deiodinase is expressed in rat Harderian gland and beta-adrenergic stimulation of type II iodothyronine deiodinase activity is due at least in part to the increase in its mRNA level.

In this study, the role of cGMP on growth hormone (GH) release was examined using a static monolayer culture prepared from dispersed rat anterior pituitary cells. Treatment with 8-bromo-cGMP (1 microM to 1 mM) stimulated GH release up to 3.8-fold in a concentration-dependent manner. Elevating cGMP with nitroprusside or the C-type natriuretic peptide was also effective in stimulating GH release. The increase in GH release by cGMP-elevating agents occurred without a concomitant increase in cAMP. Unlike cAMP which increased intracellular Ca2+ concentration, 8-bromo-cGMP caused a small reduction in intracellular Ca2+ concentration. Taken together, these results indicate that i) cGMP appears to be another mechanism that regulates GH release, ii) activation of cytosolic or membranous guanylyl cyclase is equally effective in stimulating GH release; and iii) the cGMP-induced GH release appears to be through a mechanism distinct from that of cAMP.

The role of tyrosine kinase(s) in the regulation of cGMP accumulation in rat pinealocytes was investigated using three tyrosine kinase inhibitors. Treatment with genistein, erbstatin or the active analogues of tyrphostin selectively increased basal cGMP accumulation in a dose-dependent manner without a concomitant increase in cAMP. In contrast to the norepinephrine- and vasoactive intestinal peptide-stimulated cGMP responses, the stimulatory effect of genistein was not blocked by the nitric oxide synthase inhibitor NG-monomethyl-L-arginine. Furthermore, in the presence of isobutylmethylxanthine, a phosphodiesterase inhibitor, neither genistein nor erbstatin had an effect on cGMP accumulation. These results indicate that tyrosine kinase inhibitors increase pineal cGMP accumulation through inhibition of the metabolism of cGMP.

The present study was undertaken to elucidate the effects of okadaic acid, a potent inhibitor of protein phosphatases, on thyrotropin (TSH) and prolactin (PRL) secretion, and on the hydrolysis of inositol phospholipids in rat anterior pituitaries. Preincubation of anterior pituitaries with okadaic acid caused a dose dependent decrease in TRH- and K(+)-induced TSH secretion, whereas basal secretion of TSH was not affected by pretreatment with okadaic acid. In contrast, okadaic acid resulted in a marked inhibition in both basal, and TRH- and K(+)-stimulated PRL release from anterior pituitaries. In addition, pretreatment with okadaic acid caused a slight, but significant decrease in the formation of [3H]inositol phosphate ([3H]IP) in rat anterior pituitaries. The present study suggests that okadaic acid blocks the release of TSH and PRL by inhibiting Ca2+ influx and that inhibitory effects of okadaic acid on PRL release are, at least in part, due to the inhibition of inositol phospholipid hydrolysis.

The effects of thyroid hormones on TSH secretion and inositol phospholipid hydrolysis in response to thyrotropin-releasing hormone (TRH) in rat anterior pituitaries were examined. Experimental hypothyroidism caused a significant increase in [3H]inositol phosphate ([3H]IP) formation in response to TRH in rat anterior pituitaries with a concomitant elevation of blood TSH. In contrast, administration of thyroxine (T4) to hypothyroid rats resulted in a complete restoration of blood TSH and TRH-stimulated [3H]IP formation to the euthyroid control value. Furthermore, in vitro pre-treatment of anterior pituitaries with triiodothyronine (T3) produced a dose-dependent decrease in both TSH secretion and the formation of [3H]IP in response to TRH. These results indicate that thyroid hormones regulate TRH receptor-linked inositol phospholipid hydrolysis in the rat anterior pituitary, suggesting that negative feedback action of thyroid hormone occurs at post receptor event in the rat anterior pituitary, which may, to a certain extent, be responsible for the underlying mechanism of T3 inhibition of TSH secretion.