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Surgical treatment of brainstem arteriovenous malformation (AVM) is challenging and associated with a higher risk of complications and a lower rate of gross-total resection. The authors present their experience with the surgical management of lateral pontine AVM using the middle cerebellar peduncle approach. All cases presented with neurological deficits that were caused by hemorrhage before surgery. In all cases, the AVM was not visualized on postoperative angiography, and there was no deterioration of neurological symptoms. In this video, the authors report the treatment results of one case and describe the technique with a review of the literature.The video can be found here: https://youtu.be/bFvEMtMnrKw

Study design Single-center retrospective case series. Objective To compare outcomes of instrumented fusion and two methods of decompression for degenerative spondylolisthesis. Summary of background data There is no consensus on the surgical indications or optimum techniques for lumbar degenerative spondylolisthesis. Methods We analyzed the data of 140 patients treated by fusion (n = 80; mean follow-up, 77.9 months) or decompression (n = 60; mean follow-up, 38.0 months) and examined changes in surgical indications over a 12-year period. We compared the outcomes of instrumented fusion with the outcomes of two decompression techniques, the first employing a unilateral approach for bilateral decompression and the second employing a bilateral approach for contralateral decompression, with contralateral foraminal decompression as needed. Postoperative evaluation was made at the final follow-up visit beginning in 2007 by analyzing patient interviews and neurological examination data. We compared results with the Japanese Orthopedic Association symptom score before surgery and at final follow-up. Results Surgical indications for fusion narrowed over time, with fusion used less frequently and decompression used more frequently. Similar decreases in clinical symptoms, including low back pain, were achieved with all methods. In the decompression groups, preoperative slip distance and instability, and postoperative slip progression or development of instability, did not correlate significantly with clinical outcome. Slip progression occurred in 8 of 10 levels in patients with preoperative translation ≥5 mm, but these patients showed no increase in instability, defined as translation ≥ 2 mm, at final follow-up. Conclusion Our findings raise a question about the value of the radiologic criteria for performing fusion used in the late period, namely translation ≥5 mm and/or rotation ≥ 10°. If discogenic pain is excluded, decompression alone may be suitable even for patients with severe low back pain and translation ≥5 mm. Level of evidence 4.

Standard strategy for the treatment of subacute in-stent stenosis after carotid artery stenting remains controversial. We report the successful application of stent-in-stenting in 2 patients with subacute in-stent stenosis of the internal carotid arteries (ICA). The postoperative courses of both patients were uneventful, and the patency of the ICA was confirmed at the 2-year follow-up. In this study, medical treatment was not effective, and therefore, stent-in-stenting was used as an alternative treatment for subacute in-stent stenosis.

While the radicality of resection for cerebral arteriovenous malformation (AVM) is superb, it is regarded as a difficult type of neurosurgical operation. One reason for this is the risk of uncontrollable intraoperative hemorrhage. Preoperative embolization or staged operations are conducted to avoid this. We examined recent cases at our hospital. Among 124 cases of AVM treated at our hospital between January 2005 and June 2010, complete resection was conducted in 90 cases. We examined the operative procedures and outcomes of these 90 cases retrospectively. The Spetzler-Martin grade (S-M grade) in the 90 cases was 1-2 in 45 cases, 3 in 35 cases and 4 in 10 cases, with no cases of Grade 5. Preoperative embolization was conducted in 33 of the 90 cases (37%), while a staged operation was conducted in 12 cases (13%). In the cases with S-M Grade 3-4 (45 cases), preoperative embolization was conducted in 25 cases (56%) and a staged operation was conducted in 12 cases (27%). The outcome was undesirable in 0% of S-M Grade 1, 4% of S-M Grade 2, 11% of S-M Grade 3 and 30% of S-M Grade 4. Uncontrollable intraoperative hemorrhage did not occur in any of the cases. Although examination of the individual cases is necessary, the recent outcomes at our hospital demonstrate the utility of preoperative embolization and staged operations for high-grade AVM.

Silicone plates sutured together to form blocks were used for extradural elevation of the sella floor in two patients who underwent chiasmapexy for visual disturbance associated with empty sella syndrome. A 36-year-old woman had been treated for prolactinoma for about 19 years with bromocriptine and then presented with left visual disturbance. A 79-year-old man presented with right blurred vision of unknown cause other than empty sella. The sella turcica was accessed via the endonasal transsphenoidal approach under endoscopic guidance. The bony sellar floor was opened with a drill. Two or three pieces of 1-mm-thick silicone plate were sutured to make a block. Two or three blocks were inserted into the epidural space to elevate the sellar contents. Visual symptoms improved in both patients. Silicone is biocompatible and not absorbable. Silicone plates are elastic and easy to handle during insertion, but firm enough to support the sella. The elevation can be adjusted by changing the number of plates in the block. The endonasal endoscopic approach is minimally invasive and particularly suitable for transsphenoidal extradural chiasmapexy for empty sella syndrome.

BACKGROUND Indirect cerebral revascularization has been generally accepted in the management of brain ischemia in moyamoya disease. We performed indirect cerebral revascularization by using omental flap and muscle flap techniques for the treatment of ischemic cerebrovascular disease. METHODS Ten patients with ischemic cerebrovascular disease including three with adult moyamoya disease underwent this procedure (omental flap on eight sides and muscle flap on five sides). The muscle used for the flap was the serratus anterior muscle on two sides and shaved latissimus dorsi muscle on three sides. Angiography and cerebral blood flow studies were performed in all patients preoperatively and postoperatively. All patients demonstrated severely impaired cerebrovascular reserve capacity due to occlusive disease. RESULTS There was one patient each with perioperative death and intracranial infection following omental flap loss, and two patients had perioperative strokes. The average follow-up period was 23.2 months. Of the nine surviving patients, all eight except for the one with flap loss had good outcome with complete resolution of neurologic episodes. CONCLUSIONS It is concluded that this method seems to be effective in selected patients with ischemic cerebrovascular disease.

Epidermal growth factor (EGF) was demonstrated immunohistochemically in the mammary glands of adult female SHN mice. Immunolocalization was found in all alveolar cells and some luminal contents of the lactating mammary glands, and it became intense during the lactation period. Weak staining was detected in the mammary gland in late pregnancy or in the hypersecretory mammary gland induced by pituitary isograft to the mammary fat pad. EGF staining was found in both intact and sialoadenectomized (sx) mice, and it was more intense in the intact mice than the sx ones, the offsprings mortality of the latter being greater in the first week of lactation. Still, staining in the sx group achieved an intensity comparable to that of the intact group in late lactation. At 7 days after parturition, staining in alveolar cells did not increase in the mother, from which all pups were withdrawn at Day 1 of lactation, though staining was intense in congesting milk. Therefore, the mammary gland itself may produce EGF by a secretory function, especially in lactation stage.

未熟児の全身カンジダ症は多臓器を侵襲し, 予後不良の感染症として近年注目されている.今回我々は, 超未熟児でカンジダによる肺動脈塞栓を伴った全身カンジダ症の1例ならびに小腸断裂時の腹水培養からカンジダを検出した1例を経験したので, 若干の文献的考察を加えて報告した.今回の2症例の経験から, 重症の未熟児・新生児管理中には常にカンジダ症の発症に留意することが必要と考えられた.

Precursor cells in the rapid recovery of Leydig cells after depletion by ethanedimethanesulfonate (EDS) injury to bilateral abdominal testes were examined immunohistochemically 8, 11, and 14 days after an intraperitoneal injection of EDS, 75mg/kg, 2 weeks after cryptorchidization. Compared with shamoperated rats, the repopulation of Leydig cells in cryptorchid rats was accelerated. Row-like arranged fusiform-shaped mesenchymal cells were found in peritubular regions of abdominal testes 14 days after EDS injection. At 11 days after injection, a significant increase of bromodeoxyuridine-incorporated nuclei was noted in peritubular mesenchymal cells of abdominal testes when compared with scrotal testes. In intertubular tissues, both attenuated mesenchymal cells in earlier stages and fusiform-shaped mesenchymal cells in later stages were actin-, desmin-, and vimentin-negative, and the cells later revealed marked pyronophilia. Therefore, division of peritubular mesenchymal cells seems to contribute somewhat to the rapid recovery of abdominal testes, although differentiation through cytoplasmic pyronophilia from a pool of mesenchymal stem cells give rise to the main part of new Leydig cell populations.

Silicone plates sutured together to form blocks were used for extradural elevation of the sella floor in two patients who underwent chiasmapexy for visual disturbance associated with empty sella syndrome. A 36-year-old woman had been treated for prolactinoma for about 19 years with bromocriptine and then presented with left visual disturbance. A 79-year-old man presented with right blurred vision of unknown cause other than empty sella. The sella turcica was accessed via the endonasal transsphenoidal approach under endoscopic guidance. The bony sellar floor was opened with a drill. Two or three pieces of 1-mm-thick silicone plate were sutured to make a block. Two or three blocks were inserted into the epidural space to elevate the sellar contents. Visual symptoms improved in both patients. Silicone is biocompatible and not absorbable. Silicone plates are elastic and easy to handle during insertion, but firm enough to support the sella. The elevation can be adjusted by changing the number of plates in the block. The endonasal endoscopic approach is minimally invasive and particularly suitable for transsphenoidal extradural chiasmapexy for empty sella syndrome.

✓ Reconstruction of the sellar floor after pituitary tumor removal is sometimes difficult because the repair graft is difficult to handle in the narrow space. This is especially problematic if the endonasal endoscopic approach is used. The authors devised a technique to facilitate this procedure by placing a suture knot on the repair splint. This allows the material to be grasped securely with forceps and improves manipulation even within the narrow nasal cavity. This technique has proved useful when performing the endonasal endoscopic approach, and it is also expected to be useful when conducting the conventional sublabial transsphenoidal approach.

OBJECTIVE AND IMPORTANCE: Repair of a cerebrospinal fluid leak is not always easy, especially when a large fistula, with concomitant infection and injured mucosa, has developed from repeated transsphenoidal operations. We repaired such a sellar floor defect with mucosal flaps via the endonasal endoscopic approach and finally obliterated the fistula by promoting granulation-like tissue formation with recombinant human basic fibroblast growth factor (bFGF). CLINICAL PRESENTATION: A 27-year-old woman with intractable cerebrospinal fluid rhinorrhea was referred to our department after repeated operations for a relapsing Rathke's cleft cyst. Endonasal endoscopic examination revealed a large bone defect on the sellar floor through which previously packed fat and fascia were exposed to the nasal cavity. INTERVENTION: Mucosal flaps were harvested endoscopically from the nasal septum and the superior and middle turbinates. These pedicled flaps were transposed to the sellar defect. The flaps survived but did not cover the whole area, resulting in gaps between the flaps through which cerebrospinal fluid still leaked. Recombinant bFGF was repeatedly applied endoscopically to the mucosal flaps. The flaps turned into granulation-like tissue, and complete mucosal covering was finally achieved. CONCLUSION: bFGF has a wide range of biological effects, including stimulation of fibroblast growth and promotion of angiogenesis. It accelerates wound healing and is used clinically to treat dermal ulcers. The method presented here to treat an intractable fistula with mucosal flap and recombinant bFGF may suggest a new clinical application of bFGF. This possibility should be examined in a large number of patients in the future.

BACKGROUND Use of the omentum in the treatment of moyamoya disease is now widely accepted, and, especially in patients with ischemic symptoms of anterior or posterior cerebral artery distribution, omental transplantation or other indirect revascularizations are indicated. CASE REPORT A 39-year-old man, who developed left homonymous hemianopia, was discovered to have occlusion of the distal portion of bilateral internal carotid arteries. We performed indirect revascularization with an omental flap on the left cerebral hemisphere and a serratus anterior muscle flap on the right cerebral hemisphere. RESULTS Subsequent clinical course was uneventful. Cerebral blood flow study and angiography revealed good collateral circulation in both the omentum and muscle flap. The collateral circulation was more developed than that arising from the omental transfer on the contralateral side at the same postoperative period. CONCLUSIONS This type of encephalomyosynangiosis (EMS)-EMS with free muscle flap-is as effective as that with the omental flap in adult moyamoya disease. Especially in a patient who is in need of vascular reconstruction of an extensive ischemic area, serratus anterior muscle flap transfer is one of the alternative methods.

The application of vascularized omental graft for the treatment of four patients with ischemic cerebrovascular disease is presented. The superficial temporal artery and vein were used as recipient vessels, and vascular anastomosis was applied in an end-to-end fashion. The distal parts of the omentum were exteriorized as monitoring segments for about 1 week. Angiography and cerebral blood flow (CBF) studies were performed in all patients postoperatively. There were no major complications, and all patients showed increases of CBF and apparent clinical improvement. It is suggested that this method is effective in selected patients with ischemic cerebrovascular disease.

A transplantable pregnancy-dependent mouse mammary tumor, TPDMT-4, and its ovarian-dependent (T4-OR26) and autonomous (T4-OI96, T4-OI145, T4-OI165, T4-OI320 and T4-OI320CY) sublines were examined immunohistochemically for the expression of keratin 14 and type IV collagen. T4-OI96, T4-OI145, and T4-OI165, but not T4-OR26, T4-OI320, or T4-OI320CY, formed lung colonies (metastasis) after intravenous injection as a single-cell suspension. Despite the similar morphology of TPDMT-4 and its six sublines, only TPDMT-4 and the nonmetastatic sublines revealed a basal cell phenotype as defined by keratin 14 expression. Staining for type IV collagen was complete at the peripheries of the glandular structures in TPDMT-4 and nonmetastatic sublines but was patchy in the metastatic tumors.

Distributions of actin and type IV collagen were investigated immunohistochemically as markers for myoepithelial cells and basement membranes. Carnoy's and Methacarn-fixed, paraffin-embedded tissues from 103 human breast lesions from 103 patients were examined; 65 with carcinomas, 27 with mastopathies, 9 with fibroadenomas and 2 with phyllodes tumours. Fifty-five samples of the normal mammary gland tissue adjacent to tumours were also included for comparison. In normal breast and benign breast diseases, type IV collagen was identified around the mammary glandular cells and actin-positive cells were demonstrated to attach to basement membranes. In noninvasive carcinomas, type IV collagen was found as a continuous lining around a cell nest, while actin-positive cells were usually absent in ductal but quite numerous in lobular carcinomas. In invasive carcinomas, type IV collagen was fragmented or absent and actin-positive cells were very uncommon around the fragmentary basement membranes. These results suggest that the different distributions of myoepithelial cells and basement membrane material is useful in the differential diagnosis of surgical pathology of the breast.

Immunoperoxidase staining patterns with a monoclonal antibody against human breast cancer cell membrane, 125B4, were investigated in frozen sections of normal tissues from adult rats of both sexes and of various mammary tumors from 7, 12-dimethylbenz (α) anthracence (DMBA)-treated female rats. In normal tissues, 125B4 preferentially recognizes myoepithelial layers of the mammary, sweat and salivary glands, basally situated epithelial cells of the skin, vagina, esophagus, urethra, urinary bladder, seminal vesicle and epididymis, and endothelial cells of blood vessels. It does not react with luminal cells of the abovementioned organs, epithelial cells of the stomach, intestine, liver, pancreas and uterus, and mesenchymal cells. The reactivity in benign mammary tumors is comparable to that in normal mammary tissue, but it is observed on some adenoma cells scattered spottedly in proliferating fibroadenoma. In malignant mammary tumors, the reactivities are not restricted to the banally localized carcinoma cells and distributed abundantly in the carcinoma foci of squamous cells carcinoma, adenocarcinoma and carcinosarcoma. Neoplastic mesenchymal cells cannot be stained with 125B4, which stains endothelial cells within the tumor stroma. Except for the endothelium, therefore, our data indicate that this antibody may react to the antigens present in basal and myoepithelial cells of rat mammary parenchyma.

Mammary tumours were induced by the direct dusting of 1 mg, 7,12-dimethylbenz(a)anthracene (DMBA) powder onto the mammary gland of both 30-day-old female and male Sprague-Dawley rats, and the tumours were examined histologically. Mammary tumours developed in 43/43 (100%) of the females 11 to 20 weeks after DMBA dusting and 16/23 (70%) of the males 18 to 28 weeks after dusting, while non-mammary spindle cell sarcomas occurred in 5/23 (22%) of the males 15 to 24 weeks after dusting. A variety of benign and malignant mammary tumours of epithelial and/or mesenchymal origin were induced, which are comparable to human mammary tumours. Different histological patterns were observed in different areas of the same tumours. Ovariectomy revealed hormone (ovary)-dependency in 10/17 (59%) of the tumours, revealing regressing epithelial and proliferating mesenchymal tumour elements on histological examination.

Using immunoperoxidase staining of monoclonal antibody 312C8-1 against 51 000 dalton human keratin polypeptide, immunolocalization was observed in frozen sections of normal tissue and mammary tumours of adult female mice and rats. In normal tissue, the epitope was recognized in myoepithelial cells of the mammary, sweat and salivary glands, and in basal and suprabasal cells of the epidermis. However, the antibody did not react with luminal epithelial cells of the above glands or with mesenchymal cells. In spontaneous mammary tumours of mice, marker-positive tumour cells were distributed only in the outer layer of adenocarcinoma Type A, while they were scattered in some foci of adenocarcinoma Type B, and encircled the epithelial foci of pregnancy dependent tumours (plaque). All layers of epidermoid structures in adenoacanthoma revealed positivity. In rat mammary tumours induced by local dusting with 7, 12-dimethylbenz(α)anthracene (DMBA) powder, the staining pattern of benign tumours was comparable to that of the normal mammary gland. But, in addition to basally situated cells, marker-positive tumour cells were found scattered in the foci of adenocarcinoma, and were not restricted to basal cells in squamous cell carcinoma. The marker was not found in sarcomatous tissue. This antibody can therefore also be applied to rodents, and the staining pattern can be used to identify the epithelial subclass specific marker in normal tissue and in mammary tumours.

Sialoadenectomies performed on 8-week-old female SHN and GR mice markedly reduced the numbers of precancerous and cancerous lesions in their mammary glands that had been mildly hypoplastic; the mice were necropsied when they were 30 weeks old. The success rate of the mammary cancer transplantation to isogenic male SHN or C3H mice was lower in the sialoadenectomized animals, and growth of the grafted tumors was delayed after gland removal. Some tumor development resumed in the hosts that received mouse epidermal growth factor after surgery. Therefore, we believe this growth factor may play a role in the multistage process of mouse mammary carcinogenesis.