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To our knowledge, anatomical knowledge about the lacrimal vein (LV) is missed. Therefore, this retrospective study aimed to explore them using magnetic resonance imaging (MRI).Eighty-one patients who underwent contrast-enhanced MRI and three donated bodies to science were enrolled.On the sagittal images, the measured mean right long (LD) and short diameters (SD) of the lacrimal gland (LG) were 17.3 ± 2.4 mm and 13.7 ± 2.1 mm, while the left LD and SD were 17.0 ± 2.6 mm and 13.6 ± 2.6 mm, respectively. Laterality or sex differences were not found in the LD and SD groups. In addition, no specific age range was associated with a significantly longer LD or SD. LVs were identified in 94% of axial images. Their course was classified into as follows: three types: connecting to the superolateral cavernous sinus (CS), to the superior ophthalmic vein (SOV), and the diploic channels of the greater wing of the sphenoid bone (DCGW). The CS type was the most frequently identified, followed by the SOV and DCGW types. In dissected specimens, the LVs consistently coursed between the posterior margin of the LG and the superolateral part of the CS, above the upper margin of the lateral rectus muscle.The LV may consistently emerge from the upper posterior margin of the LG. It commonly pours into the SOV or superolateral part of the CS.

Purpose: No study has investigated intermammillary relationships using neuroimaging modalities. This study aimed to explore them using magnetic resonance imaging (MRI).Materials and Methods: We enrolled 72 patients who underwent conventional MRI examinations followed by constructive interference steady-state sequence in the coronal plane. The intermammillary distances (IMDs) were measured at the uppermost level of the intermammillary gap (IMDupp) and the lowest level (IMDlow) of the mammillary bodies (MBs).Results: MBs with varying morphologies were consistently delineated. The appearance of both MBs could be classified into four patterns based on the size and relative levels, with the symmetrical type being the most common. Intermammillary relationships exhibited five patterns. In 69%, the IMDupp was discernable and measured 0.7±0.4 mm, while it was not discernible in 31% due to the presence of intermammillary connection and adhesion. The age distribution did not differ between populations with and without discernible IMDupp. The IMDlow was measured 4.4±0.9 mm. Although the IMDlow was not significantly different between both sexes, it was longer in subjects in their 70s.Conclusions: Intermammillary relationships show variable morphologies with gaps formed between both MBs. The IMDlow may become more evident in association with age-related increase in the width of the third ventricle and atrophy of the MBs.

No study has documented the oculomotor nerve (OMN) segment lying between the posterior cerebral (PCA) and superior cerebellar (SCA) arteries adjacent to the brainstem. The present study aimed to characterize it.A total of 71 patients underwent thin-sliced, sagittal T2-weighted magnetic resonance imaging for analysis.The OMN segments lying between the PCA and SCA were identified in all patients. The OMN segment in relation to the PCA and SCA was classified into five types. Of them, the PCA-OMN contact type was the most frequent and found in 35.2% of 71 sides on the right and 39.4% on the left. Also, the PCA-OMN compression type was identified in 12.7% on the right and 15.5% on the left. In these types, the mean distance between the brainstem and contact/compression sites were measured 4.4 ± 2.3 mm on the right and 4.4 ± 1.6 mm on the left. In more than forty percent, the sites were located at the level of the pontomesencephalic junction.The OMN may be frequently in contact with the PCA near the brainstem. The site located more distal than the central-peripheral myelin junction of the OMN can attribute to a low frequency of neurovascular compression syndrome of the nerve.

Background: To the best of our knowledge, there are no reports of penetrating orbitocranial injury (POCI) caused by a shoji frame. Case Description: A 68-year-old man fell in his living room and was stuck headfirst by a shoji frame. At presentation, marked swelling was noted in the right upper eyelid, with the edge of the broken shoji frame exposed superficially. Computed tomography (CT) revealed a hypodense linear structure located in the upper lateral sector of the orbit, partially protruding into the middle cranial fossa. Contrast-enhanced CT revealed intact ophthalmic artery and superior ophthalmic vein. The patient was managed with frontotemporal craniotomy. The shoji frame was extracted by pushing out the extradurally located proximal edge from the cranial cavity and simultaneously pulling the distal edge from the stab wound in the upper eyelid. Postoperatively, the patient received intravenous antibiotic therapy for 18 days. Conclusion: POCI can be caused by shoji frames as a result of an indoor accident. The broken shoji frame is evidently delineated on CT, which can result in prompt extraction.

Background: Atypical meningiomas rarely originate from the spinal accessory nerve at the C1–C2 level. Case Description: A 57-year-old female presented with a 1-month history of headache. The cervical MR revealed a well-demarcated intradural/extramedullary tumor compressing the spinal cord at the C1–C2 level that measured 12 mm × 10 mm × 25 mm. She underwent microsurgical tumor resection. Intraoperatively, the tumor was adherent to the spinal accessory nerve, rather than the dura mater. Gross total tumor resection was performed, and the pathology was consistent with an atypical meningioma. Conclusion: Atypical meningiomas rarely originate from the spinal accessory nerve. Gross total resection is the procedures of choice to mitigate the risk of tumor recurrence.

Background: To the best of our knowledge, no study using neuroimaging modalities has documented calvarial diploic veins (DVs) connected to the extracranial sites. This study aimed to characterize them using magnetic resonance imaging (MRI). Methods: A total of 88 patients underwent thin-sliced contrast MRI. In addition, the DVs coursing through the pterional area were observed on three injected cadaver heads. Results: On postcontrast MRI, the DVs of the pterional area directly drained into the temporalis muscle or supplied branches coursing into the muscle in 43% on the right side and 40% on the left. The DVs and their branches were highly variable in diameter and number. In 9% of cases, the DV of the pterional area was found to drain into an extracranial site and connected to large venous channels distributed in the temporalis muscle. Furthermore, in 17% of cases, the DVs drained into the extracranial sites in the frontal skull region, followed by 9% in the parietal, 2% in the occipital, and 1% in the temporal regions. The DVs coursed superficially in the pterional area on both sides of all three cadaver heads. On one side, the DV in the area was open to an extracranial site. Conclusion: Part of the diploic venous flow drains extracranially in the pterional area. This area may provide an important interface between the calvarial DVs and the extracranial venous system.

Background: Subsequent bilateral intracerebral hemorrhage (SBICH) in the putamen and thalamus is a rare condition. Herein, we report four such cases. Case Description: Case 1: A 47-year-old woman presented with the left hemiparesis and elevated blood pressure. Neuroimaging revealed a right thalamic hemorrhage and a small left thalamic hemorrhage accompanying the hyperdense rim on computed tomography (CT) and the hypointense rim on gradient-echo T2*-weighted imaging (T2*WI). Case 2: A 53-year-old man presented with a disturbance of consciousness and elevated blood pressure. Neuroimaging revealed a left putaminal hemorrhage and a small right thalamic hemorrhage that appeared hyperdense on CT and hypointense on T2*WI. Case 3: A 65-year-old woman presented with the right hemiparesis and elevated blood pressure. Neuroimaging revealed a left putaminal hemorrhage and a small right thalamic hemorrhage accompanied by a hyperdense rim on CT and a hypointense rim on T2*WI. Case 4: A 75-year-old woman presented with the right hemiparesis and elevated blood pressure. Neuroimaging revealed a left thalamic hemorrhage and small hemorrhages in the right thalamus and cerebellar hemisphere. These hemorrhages appeared hyperdense on CT and hypointense on T2*WI. Conclusion: SBICHs are rare bilateral hemorrhages that may present with asymptomatic microbleeds in the putamen or thalamus coupled with symptomatic, subsequent hemorrhages in the contralateral counterparts. The latter hemorrhage may develop during the subacute phase of microbleeds in the putamen or thalamus.

Background: Langerhans cell histiocytosis (LCH) arising in the skull is rare in adulthood. Case Description: A 58-year-old woman experienced a durable headache. Cerebral magnetic resonance imaging (MRI) at presentation showed no abnormalities; however, MRI and computed tomography (CT) performed 6 weeks later revealed the emergence of a well-demarcated, heterogeneously enhancing calvarial tumor accompanied by irregular-shaped bone erosion. On MRI, the temporalis muscle and subcutaneous tissue adjacent to the tumor were extensively swollen and enhanced. The patient underwent en bloc resection. The microscopic appearance of the tumor was consistent with that of LCH. Postoperative systemic 18F-fluorodeoxyglucose positron emission tomography/CT did not detect any abnormal accumulation. Conclusion: LCH may develop within a short period. It should be considered as a differential diagnosis when a rapidly growing calvarial tumor is encountered, even when the patient is an adult. Prompt histological verification is recommended in such cases.

Background: Angiomatous meningioma is a rare subtype of meningiomas. To the best of our knowledge, there have been no reports of intradiploic angiomatous meningioma. Case Description: A 53-year-old previously healthy woman was diagnosed with a calvarial lesion during a brain checkup. Cerebral magnetic resonance imaging showed an intradiploic tumor, 11 × 14 × 12 mm, in the right parietal bone. It was an enhancing, lobular tumor presenting as isointensity on T1- and hyperintensity on T2-weighted sequences, with an intense enhancement of the adjacent dura mater. Computed tomography revealed bone erosion at the tumor site, extending predominantly into the inner side, and sclerotic changes in the surrounding bone. Total resection was performed. Microscopically, the tumor tissue comprised cells with low-grade meningioma and intervening prominent vasculatures, consistent with angiomatous meningioma. Conclusion: Angiomatous meningioma should be considered as a differential diagnosis when an intradiploic tumor shows a lobular structure, intense enhancement of the adjacent dura mater, and sclerotic changes in the surrounding skull. These findings can support prompt tumor resection.

Spontaneous spinal epidural hematoma is a rare disease, and the critical form may mimic cerebral infarction in the acute stage. Consequently, misdiagnosis of a cerebral infarction may result in unnecessary antithrombotic therapy. The present study investigated 19 cases of spontaneous spinal epidural hematoma first diagnosed as cerebral infarctions and treated with antithrombotic therapy. Of these, 16 cases(84.2%)presented with pain in the neck, shoulder, and back on admission, 19 cases(100%)with hemiplegia not including the face, 7 cases(36.8%)with limb sensory disturbance, and all 19 cases(100%)underwent MRI findings for definite diagnosis. After diagnosis, 6 of the 19 cases(31.6%)were treated with recombinant tissue-type plasminogen activator(rt-PA)administration, 13 cases(68.4%)with surgical treatment, and 9 cases(47.4%)were without after effect and showed good progress. MRI is effective in detecting spontaneous spinal epidural hematoma, however, CT is also used for this diagnosis. The most common site of spontaneous spinal epidural hematoma is the cervicothoracic spine junction or thoracolumbar spine junction, but occurrence in the upper cervical vertebra may present with hemiplegia similar to cerebral infarction. Pathognomonic symptoms include pain in the neck, shoulder, and back, however, symptoms such as hemiplegia not including the face, cervical spine, and cervical cord lesion may be important indicators. Although, some cases may not present with pain and sensory disturbance symptoms, therefore an initial misdiagnosis of cerebral infarction may be made and subsequent antithrombotic therapy can result in increased bleeding and serious after-effects. In particular, 4 of the 6 cases(66.7%)treated with hyperacute phase thrombolytic therapy(rt-PA treatment)in this study required surgical treatment, and the time until definite diagnosis was shorter compared with other antithrombotic agents, presumably due to the rapid increase in hematoma. Therefore, the possibility of spinal cord epidural hematoma should be considered before beginning rt-PA therapy with careful examination to confirm the presence of lesions in the cervical spine and cervical cord.

Two unusual cases of ruptured distal posterior inferior cerebellar artery(PICA)aneurysm on the cortical segment were successfully treated with open surgery. A 76-year-old woman presented with a Hunt and Kosnik(HK)grade II Subarachnoid hemorrhage(SAH). CT showed a slight SAH in the cisterna magna and around the vermis, and fourth intraventricular hematoma. Cerebral angiography revealed an aneurysm on the cortical segment of the distal PICA. Intraoperative findings identified the aneurysm as fusiform. Trapping of the aneurysm was performed, and the indocyanine green angiography fiuding confirmed aneurysmal flow disappearance and good circulation in the cerebellar cortex. An 89-year-old woman presented with HK grade II SAH. CT revealed a thick SAH in the posterior cranial fossa, and third to fourth intraventricular hematoma with hydrocephalus. Cerebral angiography revealed an aneurysm on the cortical segment of the distal PICA. Intraoperative findings showed that the aneurysm was fusiform. Trapping and resection of the aneurysm were performed. Thirteen previous cases of aneurysms on the cortical segment of the distal PICA have been reported. Distal PICA aneurysms apparently show rebleeding more frequently than do aneurysms at other locations, so immediate direct surgery is necessary to avoid rebleeding. After proximal ligation or trapping of the aneurysm, indocyanine green angiography is useful to determine the need for revascularization.

Objective To describe our experience of extradural optic nerve decompression via the trans–superior orbital fissure approach for traumatic optic neuropathy (TON) and retrospectively analyze its advantages and pitfalls. Methods Between September 2009 and August 2014, 8 consecutive patients with TON underwent extradural optic canal decompression via the trans–superior orbital fissure approach. We retrospectively reviewed medical charts, radiologic findings, surgical techniques, complications, and final surgical results. Results All 8 patients presented with visual disturbance caused by head injury; 2 patients had no light perception, 6 had light perception, and 2 had ophthalmoplegia. All patients underwent extradural optic canal decompression and high-dose steroid administration within 24 hours after injury. Postoperative visual acuity on discharge was improved in 6 patients and unchanged in 2. The 2 patients with ophthalmoplegia gradually recovered by 3 months after operation. The postoperative outcome was good recovery in 7 patients and moderate disability in 1 patient. There were no complications related to the surgical procedure. Conclusions Emergent optic canal release has been recommended in patients with TON. The advantage of the extradural optic canal decompression via the trans–superior orbital fissure approach is easy identification of the optic canal after partial removal of the anterior clinoid process, resulting in fewer surgical complications. In addition, this procedure can achieve intraorbital decompression if necessary. We recommend this modified approach with mini-peeling as a safe and reliable procedure in patients with TON.

Background: The efficacy of endoscopic surgery for spontaneous intracerebral hemorrhages (ICH) has been previously reported, but differences in the effect between early and late elderlies remain unclear. Methods: Ninety-seven patients diagnosed with putaminal hemorrhage (age, ≥65 years; hematoma volume, ≥30 mL) were included in this retrospective analysis and separated into three treatment groups: craniotomy surgery (CR), endoscopic surgery (EN), and non-surgical (NS) groups. The patients were additionally subdivided into two groups according to age: patients aged 65–74 years (“early elderlies”) and patients aged ≥75 years (“late elderlies”). Their clinical data and outcomes at discharge were compared using statistical analyses. Results: The CR and the EN groups were associated with lower mortality rates (P < 0.001), lower modified Rankin Scale (mRS; P = 0.007), and lower National Institutes of Health Stroke Scale (NIHSS; P = 0.029) compared to the NS group. Early elderlies in the CR and EN groups with ICH scores of 3 also had significantly better outcomes (P = 0.001). The proportion of patients with mRS ≤ 4 was highest in the early elderlies of the EN group (P = 0.553). Although significant differences in the change of NIHSS scores between the early and late elderlies was not observed, significantly improved NIHSS scores were observed in the EN group compared to the NS group, even in the late elderlies (P = 0.037). Conclusion: The evacuation of deep-seated intracranial hematomas using the endoscope might improve functional outcomes and mortality, regardless of age.

A 40-year-old man with a rare case of dissecting aneurysm of the distal middle cerebral artery(MCA, M2 segment)presented with ischemic stroke, manifesting as headache, nausea, and visual disorder. Computed tomography(CT)scan revealed cerebral infarction, and three-dimensional CT angiogram revealed stenotic change at the M2 segment. The patient was conservatively treated and remained neurologically stable. Ten months later, CT scan and magnetic resonance imaging(MRI)revealed outpouching of the M2 segment at the location of the initial stenosis. Angiogram revealed pearl and string sign at the M2 segment of the inferior trunk. The preoperative diagnosis was spontaneous dissecting aneurysm of the right distal MCA. The patient was treated with direct surgery for aneurysm resection and revascularization using the superficial temporal artery. The brain surface in contact with the dissecting aneurysm was colored xanthochromic, so minor bleeding from the dissecting aneurysm was highly suspected. Previously, 19 cases of dissecting aneurysm of the distal MCA have been reported. Distal dissecting aneurysms seem to rupture more frequently in the MCA than in the proximal segment. Long-term follow-up MRI and angiogram might be important, not only in the acute stage in patients with atypical caliber changes in the distal MCA. Immediate direct surgery is indicated to avoid hemorrhagic stroke if dilatation of the major trunk at the dissection is suspected.

Temozolomide (TMZ) is one of the few effective anticancer agents against gliomas. However, acquisition of TMZ resistance or adaptation by gliomas is currently a crucial problem, especially increased invasiveness which is critical for the determination of clinical prognosis. This study investigated the molecular regulatory mechanisms of TMZ resistance in gliomas involved in invasiveness, particularly invadopodia formation, a molecular complex formed at the invasive front to cause extracellular matrix degradation during cellular local invasion. The TMZ-resistant clone of the U343 MG human glioma cell line (U343-R cells) was established. U343-R cells demonstrated higher invadopodia formation compared with U343 cells without TMZ resistance (U343-Con cells). Immunoblot analysis of DNA damage-related mitogen-activated protein kinase signals found increased phosphorylation of c-Jun terminal kinase (JNK) and higher activation of its downstream signaling in U343-R cells compared with U343-Con cells. Treatment of U343-R cells with specific inhibitors of JNK or siRNA targeting JNK suppressed up-regulation of invadopodia formation. In addition, paxillin, one of the known JNK effectors which is phosphorylated and affects cell migration, was phosphorylated at serine 178 in JNK activity-dependent manner. Expression of paxillin with mutation of the serine 178 phosphorylation site in U343-R cells blocked invadopodia formation. The present findings suggest that increased formation of invadopodia in U343-R cells is mediated by hyperactivation of JNK-paxillin signaling, and both JNK and paxillin might become targets of novel therapies against TMZ-resistant gliomas.

The spread of human immunodeficiency virus(HIV)infection may result in an increased likelihood of surgery in patients with HIV infection. We treated a patient with intracranial malignant lymphoma associated with acquired immunodeficiency syndrome(AIDS)caused by HIV infection. The recommendations of the countermeasure manual for AIDS were followed. Only surgical staff without finger injury or inflammation were permitted to be involved in the operation. All staff were dressed in a waterproof, full-body surgical gown, and wore double gloves, double foot covers, and an N95 mask. The surgery could be performed safely with such infection control measures. Histological examination revealed a diffuse large B-cell lymphoma. The patient was referred to the Division of Infectious Diseases and Respiratory Medicine for chemotherapy.

A case of coexistent glossopharyngeal neuralgia and hemifacial spasm was treated by transposition of the vertebral artery. A 60-year-old man was referred to our hospital due to pain in the left posterior part of the tongue that was difficult to control with oral medication at a local hospital. The diagnosis was left glossopharyngeal neuralgia based on the symptoms, imaging findings, and lidocaine test results. Moreover, the patient had left hemifacial spasm. Microvascular decompression was performed, which confirmed that the vertebral artery was compressing the lower cranial nerve and the posterior inferior cerebellar artery was compressing the root exit zone of the facial nerve. The vertebral artery and posterior inferior cerebellar artery were transposed using TachoSil

We report a case of foramen magnum meningioma manifesting as hypoglossal nerve palsy. A 72-year-old woman presented with progressive hypoglossal nerve palsy and lingual atrophy on the left side. Gadolinium-enhanced T1-weighted magnetic resonance imaging revealed a heterogeneously enhanced mass lesion with dural tail sign partially extending into the hypoglossal canal. The transcondylar approach was performed to expose the hypoglossal canal and resect the tumor completely. Histological examination revealed a transitional meningioma. The postoperative course was uneventful. Hypoglossal nerve palsy improved gradually after the operation.

Orbito-zygomatic craniotomy is a widely accepted skull-based technique, but osteotomy at the malar eminence (ME) is complicated. We have developed a safe fronto-orbito-zygomatic (FOZ) osteotomy by creating small guide burr holes in the superior and lateral parts of the orbital wall and cutting the bone using a diamond-coated threadwire saw. This method involves standard two-piece osteotomy by creating small superior and lateral guide orbital burr holes instead of sectioning into the superior and inferior orbital fissures. The guide burr holes are connected using a diamond-coated threadwire saw to create the FOZ bar. This method was applied to the treatment of four patients with skull-based tumors or internal carotid and basilar artery aneurysms. Postoperative three-dimensional bone density computed tomography showed minimum bone gap in the ME. No craniotomy-related complication has occurred. FOZ osteotomy by creating guide burr holes in the orbital wall and cutting the bone using a diamond-coated threadwire saw is safe and results in minimum bone gap in the ME.

Cotton surgical patties are essential to control vessel bleeding. However, conventional cotton surgical patties tend to adhere to vessels through capillary action, especially when used in combination with hemostats. Consequently, after the bleeding is controlled, rebleeding often tends to occur after removal of the adhered cotton patty. Polyester film－coated non－woven fabric has replaced conventional gauze for the protection of burn wounds, because this material does not tend to adhere to the wound but retains the same capacity to absorb fluid discharges from the wound. We describe our manufacture of a new type of polyurethane－coated surgical patty, which was evaluated for its bleeding control when used in conjunction with a hemostat and for undesirable vessel adherence. Our newly developed surgical patty is made of 100％ cotton, with only the contact surface coated with polyurethane. The coated side contains many holes, so aspiration through the surgical patty is possible from both sides. For our evaluation, we used a surgical patty with or without polyurethane coating together with a gelatinous sponge for bleeding control in the sagittal sinus, with fibrin glue－soaked oxidized cellulose cotton for bleeding control in the cavernous sinus, and with a collagen sheet for bleeding control in brain capillary vessels, in 5 patients for each use. We found that the newly developed surgical patty could be removed from the hemostat and vessels without difficulty and rebleeding was not observed. The new polyurethane－coated surgical patties appear to be more effective for vessel bleeding control when used with several types of hemostats in different applications and at different locations as compared to conventional non－coated surgical patties. （Received December 26, 2013；accepted February 4, 2014）

Surgical clipping of paraclinoid aneurysm can be very difficult because strong adhesions may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience with using retrograde suction decompression during the clipping of paraclinoid aneurysms and discuss the relative advantages and pitfalls.This study included 23 patients with large and giant paraclinoid aneurysms who underwent surgical treatment consisting of direct clipping with suction decompression between March 2004 and August 2014. Direct puncture of the common carotid artery (CCA) was performed with a 20-gauge needle. The aneurysm was temporarily trapped by clamping of the CCA and external carotid artery (ECA), followed by temporary clipping of the intracranial internal carotid artery (ICA) distal to the aneurysm neck. Blood was then gently aspirated through a catheter introduced into the cervical ICA, resulting in collapse of the aneurysm. Therefore, safe aneurysm dissection was feasible during interruption of the blood flow, which could be maintained for up to 5 min. This procedure was repeated until dissection and clipping of the aneurysm were completed.Seven patients were admitted with SAH, 11 with asymptomatic unruptured aneurysm, and 5 with symptomatic unruptured aneurysm. The aneurysms were located on the paraclinoidal segment of the ICA in 15 cases, on the ICA-posterior communicating artery (PComA) in 6, at the ICA bifurcation in 1, and on the anterior wall of the ICA in 1. None of them suffered complications related to the CCA puncture. Surgical outcome was good recovery in 13 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1.Retrograde suction decompression through direct puncture of the common carotid artery is a useful adjunct technique for the clipping of paraclinoid ICA aneurysms.

We herein report a surgical case of multiple cerebral calculi located within the chiasmatic cistern resulting in visual disturbance. A 61-year-old man experienced homonymous lower right quadrantanopsia a few years prior. Non-enhanced head CT revealed multiple calcified lesions of about 7-mm within the basal cistern. MRI showed the lesion compressing the left optic tract. We could not remove the entire lesion because of severe adhesion to the optic tract. A pathological test showed calcified lesions with lymphocyte infiltration. We diagnosed tuberculoma caused by tuberculous meningitis with degeneration of the calcified lesion because of a history of tuberculosis at a fetal age. After the surgery, the patient was discharged without improvement of the visual disturbance.

Background Surgical clipping of paraclinoid aneurysm can be very difficult because strong adhesions may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience with using retrograde suction decompression during the clipping of paraclinoid aneurysms and discuss the relative advantages and pitfalls.

食道癌切除術後6か月目に再建胃管壊死を来した1症例を経験したので報告する. 症例は62歳の男性で, 食道癌 (Lt, 3型), 胃癌 (体上部小彎, 0-IIc) に対し, 右開胸食道亜全摘, 胃小彎部分切除, 後縦隔経路半切胃管再建を施行した. 術中所見にて原発巣の大動脈への直接浸潤を認め, 同部位の癌遺残に対し, 術後化学放射線療法を施行した. 退院後は外来で経過観察していたが, 発熱と全身倦怠にて当科入院. CT, 上部消化管内視鏡検査にて, 再建胃管壊死と診断し保存的治療を行っていたが, 経過中に胃管気管瘻を併発した. 縦隔ドレナージ術, さらには再手術にて上半胃管部分切除術, 瘻孔閉鎖術, 食道外瘻造設術を施行したが, 多臓器不全に陥り救命しえなかった. 非常にまれではあるが, 食道癌術後数か月を経た時点でも, 縦隔炎症状を呈した場合は, 再建胃管壊死も念頭において早期治療にあたるべきであると思われた.

Background Surgical clipping of complicated internal carotid artery (ICA) aneurysms can be very difficult because strong adhesion may hinder dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience in the clipping of these aneurysms using retrograde suction decompression (RSD) combined with extradural temporopolar approach (ETA) and discuss its advantages and pitfalls. Materials and Methods This retrospective study included 30 consecutive patients with complicated ICA aneurysms treated by direct clipping with RSD assistance between March 2004 and March 2015. Results The aneurysms were located on the paraclinoid ICA in 20 cases, the posterior communicating artery bifurcation in 8, ICA bifurcation in 1, and the anterior wall of the ICA in 1. No patient suffered any complication related to the puncture of the common carotid artery. Surgical outcome was good recovery in 20 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. One patient died of re-rupture of the aneurysm caused by incomplete dome clipping. Two patients suffered cerebral infarction, caused by anterior choroidal artery infarction in 1 patient. Conclusions Retrograde suction decompression combined with ETA is a useful technique for clipping of complicated ICA aneurysms.

Background The extradural temporopolar transcavernous approach can be used to treat central skull base pathologies, but control of bleeding from the opened cavernous sinus is essential. Oxidized cellulose cotton packing and fibrin glue injection can be used, but the effect on the postoperative venous draining pattern remains unclear. Objective To investigate changes in the venous drainage pattern immediately after transcavernous surgery with and without fibrin glue injection into the bleeding cavernous sinus. Methods A total of 82 patients treated via the transcavernous approach were retrospectively divided into 2 groups based on the hemostasis methods. Both pre- and postoperative angiography and/or 3-dimensional computed tomography venography were available for 24 patients in the cotton packing group and 12 patients in the fibrin glue group. Results Postoperative change in the venous draining pattern was observed in 5 of the 24 patients in the cotton packing group and in 3 of the 12 patients in the fibrin glue group. One of the 82 patients showed postoperative brain swelling due to obstruction of the sphenoparietal sinus. The volume of injected fibrin glue ranged from 0.5 to 2.5 mL (mean, 1.1 ± 0.5 mL), but none of the patients had brain swelling. Conclusion Direct fibrin glue injection into the opened cavernous sinus is relatively safe, but a change in the venous draining pattern occurs in 25% of patients. The study indicates the potential danger of the change in the venous draining pattern and recommends limiting the injection volume of fibrin glue in transcavernous surgery to avoid complications related to venous congestion.