Search

This study sought to explore the existence and clinical significance of intratumoral heterogeneity of proliferative potential in vestibular schwannoma (VS). Rapid intraoperative flow cytometry was utilized with raw samples to measure the proliferative ability of VS. The proliferation index (PI) was defined as the ratio of the number of cells with greater than normal DNA content to the total number of cells. A total of 66 specimens (26 from the intrameatal portion and 40 from the cisternal portion) were obtained from 34 patients with VS. There was a moderate correlation between the PI and MIB-1 labelling index values (R = 0.57, p < 0.0001). In contrast, the patterns of heterogeneity, represented by the proportion of intrameatal PI to cisternal PI, were associated with tumor size (p = 0.03). In addition, preoperative hearing tended to be poor in cases where the intrameatal PI was higher than the cisternal PI (p = 0.06). Our data demonstrated the presence of intratumoral heterogeneity of proliferative potential in VS and its relationship with tumor characteristics. The results of this study may advocate the resection of the intrameatal portion of large VSs treated with planned subtotal resection, especially in cases of poor preoperative hearing function.

The pretemporal transcavernous anterior petrosal (PTAP) approach and the combined petrosal (CP) approach have been used to resect petroclival meningiomas (PCMs). In this cadaveric anatomical study, a two-stage combined PTAP and endoscopic endonasal far medial (EEFM) approach (the PTAPE approach) was compared morphometrically to the CP approach. A case study provides a clinical example of using the PTAPE approach to treat a patient with a PCM. The key elements of the approach selection process are outlined.Five cadaveric specimens underwent a CP approach and 5 underwent a PTAPE approach. The area of drilled clivus, length of multiple cranial nerves (CNs), and the area of brain stem exposure were measured, reported as means (standard deviations) by group, and compared.The total area of the clivus drilled in the PTAPE group (695.3 [121.7] mmA combined open-endoscopic paradigm is proposed for managing large PCMs. This approach incorporates the EEFM approach to address the limitations of the PTAP and the CP approach in a systematic fashion. Understanding the anatomical findings of this study will aid in tailoring surgical approaches to patients with these complex lesions.

Nervus intermedius (NI) dysfunction after the management of vestibular schwannoma (VS) is underreported and is experienced by patients undergoing stereotactic radiosurgery and surgical resection. The aim of this study was to present NI outcomes in a series of patients who underwent all treatment modalities for VS and to review the existing literature.We performed a retrospective review of all patients with VS who were treated at our institution between January 1, 2008, and December 31, 2018. Demographic data, tumor size, Koos grade, treatment modality, extent of resection, postoperative facial nerve function, and hearing function were collected. NI outcomes were determined from phone interview using a previously published functional questionnaire.Of 222 patients who were reviewed, 98 patients responded to the questionnaire. Patients were stratified into 3 groups: group 1, 54 patients who underwent radiation; group 2, 27 patients who underwent surgical treatment; group 3, 17 patients who underwent both radiation and surgery. Of patients, 28% presented with preoperative NI dysfunction, most commonly dry eye followed by taste dysfunction and lacrimation dysfunction. Following treatment, 79% of patients experienced NI dysfunction, most commonly dry eye. Statistical differences in dry eye and taste dysfunction were observed when comparing the treatment groups.NI dysfunction is common following treatment for VS and should be included in pretreatment counseling of patients, as it may impact treatment choice and quality of life. Additional studies are warranted to fully characterize NI dysfunction after treatment.

Management of small vestibular schwannomas (VSs) remains controversial. When surgery is chosen, the preservation of facial and cochlear nerve function is a priority. In this report, we introduce and evaluate a technique to anatomically preserve the vestibular nerves to minimize manipulation and preserve the function of the facial and cochlear nerves.The vestibular nerve preservation technique was prospectively applied to resect small VS tumors in patients with serviceable preoperative hearing (American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B). Clinical and radiological data were recorded and analyzed.Ten patients met the inclusion criteria. The mean (SD) age was 40.4 (12.5) years. Follow-up ranged from 6 weeks to 2 years. The maximum tumor diameter parallel to the internal auditory canal ranged from 10 to 20 mm (mean, 14.9 (3.1) mm). There were three Koos grade 3 and seven Koos grade 2 tumors. Gross total resection was achieved in all cases. Both the facial and cochlear nerves were anatomically preserved in all cases. Postoperatively, 7 patients (70%) remained in the AAO-HNS class A or B hearing category. None of the patients had new vestibular symptoms, and all had House-Brackmann grade 1 facial function. Nervus intermedius dysfunction was observed in 1 patient preoperatively, which worsened postoperatively. Two patients had new nervus intermedius symptoms postoperatively.Improvement of facial nerve and hearing outcomes is feasible through the intentional preservation of the vestibular nerves in the resection of small VSs. Longer follow-up is required to rule out tumor recurrence.

A 55-year-old man with an 8-year history of invasive thymoma presented with sudden onset of left hemiparesis. Computed tomography (CT) and magnetic resonance (MR) imaging showed a right frontal lobe intracerebral hemorrhage and the possibility of brain metastasis could not be rejected. The patient underwent removal of the hematoma. Histological examination showed brain metastasis from invasive thymoma. To the best of our knowledge, this is the first reported case of hemorrhagic brain metastasis from invasive thymoma (non-cancerous) mimicking intracerebral hemorrhage.

Lactococcus lactis cremoris (L. lactis cremoris) infections are very rare in humans. Only three case reports of brain abscess have been reported and the infectious routes and pathological features are still unknown. We experienced a subdural empyema due to L. lactis cremoris in an immunocompetent adult. A 33-year-old man was admitted with fever, right facial pain, left hemiparesis, and left hemianopsia. Computed tomography demonstrated low density fluid collection in the right falcotentorial subdural space. Magnetic resonance (MR) images revealed a high signal lesion on a diffusion-weighted image (DWI) and fluid attenuated inversion recovery (FLAIR) images in the right paratentorial and parafalcine subdural space, right maxillary sinus, and bilateral ethmoidal sinus. He underwent two sequential open surgeries for removal and drainage of empyema and was treated with antibiotics including meropenem and ampicillin. To our knowledge, this is the first report of subdural empyema caused by L. lactis cremoris infection. We report the case and discuss the pathological features with the previous literature.

Background Myofibroma is a fibrous tumor of infancy that sometimes affects a single patient in a multiple fashion (infantile myofibromatosis). Its intracranial involvement is extremely rare, and its clinical picture has been poorly characterized. Here we report an interesting case of myofibromatosis with an intracranial lesion that behaved like an aggressive tumor and yet demonstrated very benign pathology. Case Description A 36-year-old man had never been diagnosed with infantile myofibromatosis despite his lifelong history of multiple tumors of various diagnoses. He presented with simple partial seizure and progressive right finger paresis. A series of brain magnetic resonance imaging scans revealed a rapidly growing lesion at his left frontal convexity, which corresponded to a high uptake area on a 18 F-fluorodeoxyglucose-positron emission tomography scan, highly suspicious of malignancy. He underwent complete tumor resection and his symptoms quickly resolved postoperatively. The pathological diagnosis was myofibroma with a MIB-1 labeling index of 1%−2%. A retrospective review of his previous tumors demonstrated the same pathology, which led to the diagnosis of myofibromatosis. Follow-up magnetic resonance imaging illustrated stabilization or regression of other preexisting lesions as well as formation of a new intracranial lesion. Conclusions The discrepancy between rapid tumor growth associated with increased uptake on metabolic imaging and benign pathologic findings with a low proliferative index is noteworthy and should be recognized in the management of an intracranial lesion in a patient with infantile myofibromatosis. Given de novo formation of a lesion in this adult patient, long-term follow-up is essential in this disease.

To elucidate clinical aspects of ruptured aneurysms, we retrospectively investigated associations between risk factors and ruptured and unruptured cases during conservative management.Two hundred and twenty-nine patients with 291 unruptured cerebral aneurysms treated between 2000 and 2012 were analyzed. Mean duration of observation was 62 months (1183.4 person-years). We investigated the following six risk factors: history of subarachnoid hemorrhage;multiplicity;location of aneurysms;aneurysm size ≤5mm;bleb or irregular forms;and follow-up period1 year.Twenty-two aneurysms in 22 patients (19 women;86.4%) ruptured during this study. The annual rate of rupture was 1.86%. In ruptured cases, mean age was 66.7 years. According to univariate analysis, aneurysm size≥5mm(p/i=0.000), bleb or irregular form(p/i=0.006)and duration of observation1 year (p =0.000) were significantly associated with aneurysmal rupture. In multivariate analysis of these factors, aneurysm size≥5mm(p =0.0188;odds ratio(OR), 3.4;95% confidence interval (CI), 1.2-9.7) and duration of observation1 year (p=0.006;OR, 5.0;95% CI, 1.6-14.9) represented independent risk factors for aneurysm rupture.The results of this study were almost the same as those of the UCAS Japan study. In addition, duration of observation1 year was a risk factor for aneurysm rupture. When we decide on surgical treatment after considering factors such as aneurysm size, form, and surgical risk, surgery should be performed as soon as possible.

We examined the effect of intraarterial administration of fasudil hydrochloride (IAFC), a Rho kinase inhibitor, for the prevention of symptomatic vasospasm after SAH by evaluating cerebral circulation.We evaluated IAFC cases of 57 sides of 38 patients (12 men and 26 women, average age 60.2 years old) diagnosed with aneurysmal subarachnoid hemorrhage (SAH) from February 2012 to November 2012. All cases were treated by clipping or coil embolization within 48 h after onset. Indication for IAFC was the existence of a spastic change on follow-up digital subtraction angiography (DSA) compared with that of onset.Clipping was performed in 30 cases and coil embolization in 8 cases. IAFC was performed an average of 6.6 days after onset. Color gradient mapping demonstrated reduction of the circulation time after IAFC compared with before IAFC on 39 sides, no change on 15 sides, and extension on 3 sides. Average arterial circulation time before IAFC was 2.25 ± 0.57 s and after IAFC was 1.95 ± 0.55 s. IAFC significantly shortened average arterial circulation (P = 0.005). No case developed symptomatic vasospasm after IAFC.IAFC significantly reduced the cerebral circulation time after aneurysmal SAH and might be effective for the prevention of symptomatic vasospasm.

To clarify the influence of age on the occurrence of symptomatic vasospasm (SVS), we retrospectively compared 34 elderly (over 70 years) and 71 nonelderly patients with aneurysmal subarachnoid hemorrhage (SAH).Between 2008 and 2010, at our hospital 105 patients (Hunt and Kosnik grades I-IV) underwent aneurysm surgery within 72 h of the insult. They were divided into four groups based on their age (younger/older than 70 years) and treatment (aneurysmal clipping or coiling). In all patients, we used the same protocol, which included the delivery of intrathecal urokinase and intravenous fasudil chloride; in patients with angiographic evidence of vasospasm, we also injected fasudil chloride intra-arterially.Among the elderly patients, 4.3% of those treated by clipping and 9.1% of those treated by coiling experienced SVS; the comparative incidence in younger patients was 6.5% and 4.0%, respectively. The differences were not statistically significant (p = 0.40). The ratio of ventriculo peritoneal (VP) shunts was higher in the elderly patients (p = 0.00007). The incidence of favorable treatment outcomes was significantly lower in elderly patients (p = 0.00004).Under our treatment protocol, patient age did not affect the incidence of SVS. Our protocol may be effective for the prevention of SVS after aneurysmal SAH regardless of patient age.