The importance of the palatine bone for endoscopic endonasal skull base surgery

Endoscopic endonasal skull base surgery is increasingly prevalent, with its scope expanding from pathogens in the midline region to those in the paramedian region. Maximizing anterior sphenoidectomy is important for the median approach, and lateralizing the pterygopalatine fossa is crucial for the paramedian approach. Maximizing the surgical corridor in the nasal cavity and minimizing damage to neurovascular structures are vital for establishing a surgical field with minimal bleeding, ensuring safe, precise, and gentle procedures. However, the relationship between the maxillofacial and skull base bones in endoscopic endonasal skull base surgery is difficult to understand because these bones are intricately articulated, making it challenging to visualize each bone's outline. Understanding important bones and their related neurovascular structures is essential for all skull base surgeons to maximize the surgical corridor and minimize iatrogenic injury to neurovascular structures. This study aimed to elucidate the role of the palatine bone from a microsurgical anatomical perspective. Three dry skulls were used to demonstrate the structure of the palatine bone and its relationship with surrounding bones. A formalin-perfused cadaveric head was dissected to show the related neurovascular structures. The arteries and veins of the cadaveric heads were injected with red- and blue-colored silicon. Dissection was performed using a surgical microscope and endoscope. In addition, the utilization of the palatine bone as a landmark to identify neurovascular structures, which aids in creating a wider surgical field with less bleeding, was shown in two representative cases. The palatine bone consists of unique complex structures, including the sphenoidal process, ethmoidal crest, pterygopalatine canal, and sphenopalatine notch, which are closely related to the sphenopalatine artery, maxillary nerve, and its branches. The ethmoidal crest of the palatine bone is a well-known structure that is useful for identifying the sphenopalatine foramen, controlling the sphenopalatine artery and nerve, and safely opening the pterygopalatine fossa. The sphenoidal process of the palatine bone is a valuable landmark for identifying the palatovaginal artery, which is a landmark used to safely and efficiently expose the vidian canal. The sphenoidal process is easily cracked with an osteotome and removed to expose the palatovaginal artery, which runs along the pharyngeal groove, just medial to the vidian canal. By opening the pterygopalatine canal (also known as the greater palatine canal), further lateralization of the periosteum-covered pterygopalatine fossa contents can be achieved. Overall, the sphenoidal process and ethmoidal crest can be used as important landmarks to maximize the surgical corridor and minimize unnecessary injury to neurovascular structures.

The surgical intervention for pineal region tumors

Histological and molecular characterization is essential for the diagnosis of pediatric brain tumors. In the pineal region tumors, it is necessary to remove a sufficient tumor volume to make a diagnosis. However, surgery in this region is challenging due to its deep anatomical location and surrounded by critical structures and complex venous system. Knowledge of the anatomy and function of the pineal region and tumor histological types is imperative for the successful management of pineal region tumors. This article describes surgical approaches to pineal tumors, focusing on the occipital transtentorial approach and adding the author's experience to what has been known in the literature. Recent innovations have made this approach more popular and can be applied to occipital fossa lesions.

Utility of real-time polymerase chain reaction for the assessment of CDKN2A homozygous deletion in adult-type IDH-mutant astrocytoma

The World Health Organization Classification of Tumors of the Central Nervous System 5th Edition (WHO CNS5) introduced a newly defined astrocytoma, IDH-mutant grade 4, for adult diffuse glioma classification. One of the diagnostic criteria is the presence of a CDKN2A/B homozygous deletion (HD). Here, we report a robust and cost-effective quantitative polymerase chain reaction (qPCR)-based test for assessing CDKN2A HD. A TaqMan copy number assay was performed using a probe located within CDKN2A. The linear correlation between the Ct values and relative CDKN2A copy number was confirmed using a serial mixture of DNA from normal blood and U87MG cells. The qPCR assay was performed in 109 IDH-mutant astrocytomas, including 14 tumors with CDKN2A HD, verified either by multiplex ligation-dependent probe amplification (MLPA) or CytoScan HD microarray platforms. Receiver operating characteristic curve analysis indicated that a cutoff value of 0.85 yielded optimal sensitivity (100%) and specificity (99.0%) for determining CDKN2A HD. The assay applies to DNA extracted from frozen or formalin-fixed paraffin-embedded tissue samples. Survival was significantly shorter in patients with than in those without CDKN2A HD, assessed by either MLPA/CytoScan or qPCR. Thus, our qPCR method is clinically applicable for astrocytoma grading and prognostication, compatible with the WHO CNS5.

A Case of Tardive Dystonia with Task Specificity Confined to the Lower Extremities only during Walking

Background

Task-specific dystonia (TSD) confined to the lower extremities (LE) is relatively rare. This report describes dystonia confined to the LE only during forward walking. This case required careful neurological and diagnostic assessment because the patient was taking several neuropsychiatric drugs that cause symptomatic dystonia, such as aripiprazole (ARP).

Case

A 53-year-old man visited our university hospital with a complaint of abnormalities in the LE that appeared only during walking. Neurological examinations other than walking were normal. Brain magnetic resonance imaging revealed meningioma in the right sphenoid ridge. The patient had been treated for depression with neuropsychiatric medications for a long time, and his abnormal gait appeared about 2 years after additional administration of ARP. After the meningioma was removed, his symptoms remained. Surface electromyography showed dystonia in both LE during forward walking, although his abnormal gait appeared to be accompanied by spasticity. The patient was tentatively diagnosed with tardive dystonia (TD). Although dystonia did not disappear clinically, it was alleviated after discontinuing ARP. Administration of trihexyphenidyl hydrochloride and concomitant rehabilitation improved his dystonia until return to work, but some residual gait abnormalities remained.

Discussion

We report an unusual case of TD with task specificity confined to the LE. The TD was induced by the administration of ARP in combination with multiple psychotropic medications. Careful consideration was required for clinical diagnosis, rehabilitation, and assessment of its relevance to TSD.

Anatomy of small canals around the jugular foramen: Special reference to Jacobson's and Arnold's nerves

The jugular foramen harbors anatomically complex bony, venous and neural structures. It is closely associated with small canals including the mastoid, tympanic, and cochlear canaliculi, and the stylomastoid foramen. The minute intraosseous branches of Arnold's and Jacobson's nerves (<1 mm in length) remain difficult to study with current imaging techniques, and cadaveric dissection is the most reliable approach. Our aim was to examine the variations of Jacobson's and Arnold's canaliculi and nerves and to provide detailed cadaveric graphics. To reveal the anatomical structures of small canals around the jugular foramen, 25 sides of dry skulls and 14 sides of cadaveric heads were examined. Intraosseous branches varied more in Arnold's nerve than Jacobson's nerve. In our cadaveric dissection, all specimens formed a single canal for Jacobson's nerve connecting the jugular foramen to the tympanic cavity. The intraosseous course of Arnold's nerve varied in its communication with the facial nerve. A descending branch crossing the facial nerve was identified in five of 14 sides, an ascending branch in 13. In two specimens, an ascending branch clearly reached the base of the stapedius muscle. Classical anatomical studies of cadavers remain a supplementary tool for analyzing these tiny structures. The present study confirms Gray's findings of 1913. Variations of these nerves could be even more complex than previously reported. Our study provides additional information regarding the anatomy of Jacobson's and Arnold's nerves.

ETMR-08. Treatment strategy for pineoblastoma in infant

Pineoblastoma is a rare malignant brain tumor that occurs in infancy and young adulthood. Although its prognosis has improved in recent years, it remains one of the difficult tumor types to treat. We will retrospectively review the treatment of pineoblastoma at our hospital and propose the possibility of a new treatment for this tumor type. Three cases were studied. All of them presented at less than three years of age and were treated for hydrocephalus simultaneously as the biopsy. Chemotherapy was administered after a possible resection, and local radiotherapy was administered at the age of 3 years. Overall survival ranged from 7 to 91 months, with one case of long-term survival. To date, the prognostic factors for pineoblastoma are the age of onset and the presence of radiation therapy. This is interpreted to mean that the prognosis is worse in infants and young children who cannot be immediately treated with radiation therapy, indicating that radiation therapy is essential for treating this tumor type. On the other hand, radiation therapy for infants can significantly interfere with the development of the central nervous system, and there is much controversy about its potential compatibility with tumor control. We have identified a favorable prognosis group based on the molecular biological background of this tumor type. We propose that early radiotherapy may improve the prognosis.

Case of penetrating brain injury caused by a ventriculoperitoneal shunting procedure

Brain injury with ventricle puncture is a well-known complication of ventriculoperitoneal (VP) shunting. However, parenchymal injuries caused by a shunt tunneller are rare. Herein, we present a case of penetrating brain injury caused by a shunt tunneller during VP shunting. An 83-year-old woman with brainstem glioma underwent VP shunting to control hydrocephalus due to tumour growth. She underwent brainstem tumour biopsy with a lateral suboccipital approach. After the shunting, CT showed a linear haematoma in the left occipital lobe far from the site of the ventricular puncture. MRI revealed a small contusion in the left cerebellar hemisphere, disconnection of the left tentorial membrane and linear haematoma on a straight line. These facts suggested that the shunt tunneller had penetrated the skull through the craniotomy of the posterior fossa. This is a rare complication of VP shunting, with limited cases reported in the literature.

A case of solitary subependymal giant cell astrocytoma with histopathological anaplasia and TSC2 gene alteration

We report a case of subependymal giant cell astrocytoma (SEGA) with anaplastic histological features in a 3-year-old girl. She had no clinical manifestations of tuberous sclerosis complex (TSC) and no relevant family history. A few cases have been reported in which patients with SEGA had no other clinical manifestations of TSC (solitary SEGA). Genetic analysis using a blood sample from the patient showed no germline alterations in TSC1 or TSC2 genes, while the tumor tissue exhibited loss of heterozygosity (LOH) in TSC2. SEGAs are benign, slowly growing tumors that rarely have significant mitotic activity. However, histopathological examination in the present case revealed high mitotic activity and necrosis besides the typical large plump cells arranged in sheets. This may be the first genetically proven case of a solitary SEGA with histopathological anaplastic features. In this report, we reviewed solitary SEGAs and histopathological malignancy in SEGA.

PATH-08. THE IMPORTANCE OF RE-DIAGNOSIS OF TUMORS PREVIOUSLY CLASSIFIED AS CENTRAL NERVOUS SYSTEM PRIMITIVE NEUROECTODERMAL TUMORS

BACKGROUND

The recent molecular analyses have revealed that central nervous system primitive neuroectodermal tumors (CNS PNETs) those having clusters of small round tumor cells are genetically different tumors. However, the concepts of CNS PNET are complicated, and it is difficult to diagnose them appropriately in clinical field. To overcome this difficulty, we reviewed previous studies associated with CNS PNETs, and carried out several approaches, those are relatively easy access to use in clinics, for our 8 samples of embryonal brain tumors diagnosed CNS PNETs in our institution, initially.

METHODS

We used in combination with immunohistochemistry (IHC), Sanger sequence, Pyrosequence, polymerase chain reaction (PCR), real time PCR and copy number analysis referring recent reports.

RESULTS

In terms of the diagnosis three out of 8 cases were changed based on the results in this study from previous diagnoses.

CONCLUSION

In this review, it seemed that either the histopathological evaluation or molecular analyses would be not enough to make accurate diagnosis of CNS embryonal brain tumors, and it is essential to combine both of them including recent comprehensive analysis methods.

SURG-15. THE SURGERY OF THALAMIC LESIONS IN PEDIATRIC BRAIN TUMORS

BACKGROUND

Pediatric brain tumors are occurred in the center of central nervous system. Since mid-line glioma has defined in the new classification, thalamus has attracted attention as a site that requires surgical intervention. However, the surgery for thalamus is a challenging procedure for neurosurgeons. In this study, we studied our surgical cases of patients suffering from pediatric brain tumors in thalamus and/or thalamic regions to evaluate the safety of surgeries and the consideration of appropriate surgical approaches.

METHODS

We reviewed neuroradiological images, medical record, and, surgical videos for the assessment of surgical fields in patients under the age of 15 who had surgical treatments at our institution.

RESULTS

We had six cases that could be analyzed. The lesions in the posterior parts of the thalamus had been operated by the occipital transtentorial approach. The lesions in the superior parts of thalamus were treated with transcortical transventricle approach. It was possible to achieve sufficient removal of tumors and have good surgical view. The monitoring of motor function and visual function was used in all cases. After removal, we could have a nice view of the important structures around thalamus.

CONCLUSIONS

The surgeries for thalamus and thalamic regions were safety with enough considerations for neurological examinations and radiological imaging. The intra operative monitoring for motor and visual function should be used.

Classification of crista galli pneumatization and clinical considerations for anterior skull base surgery

Cerebrospinal fluid (CSF) leakage caused by frontal sinus exposure is a serious complication in the basal interhemispheric approach (BIHA). Crista galli pneumatization (CGP) is often observed on preoperative computed tomography (CT) scan. The aim of this study was to classify and describe variations in anatomical measurements of CGP. We examined CT images of 300 patients with brain tumors to assess the morphology and incidence of CGP. Crista galli were classified according to their location relative to the cribriform plate and the presence of pneumatization. The paranasal sinuses were investigated as the origin of CGP. We assessed 24 patients using the BIHA for skull base tumors; these patients were included as clinical cases to assess the range of skeletonization of the crista galli and determine the route of CSF leakage in the other 276 patients. CGP was found in 28/300 CT scans, including upper, middle, and lower type CGPs. The origin of CGPs was the frontal sinus or ethmoid sinus. All CGPs were localized in the anterior half of the crista galli. In the 24 consecutive clinical cases, there were 13 tuberculum sellae meningiomas, 3 craniopharyngiomas, and 8 with other pathologies. The preoperative crista galli height was 12.3 mm and the distance from the top of the skeletonization to the cribriform plate was 5.2 mm. CGP originating from the paranasal sinuses can lead to CSF leakage. In cases where CGP originates from the ethmoid sinus, care should be taken to seal the exposed crista galli intradurally.

EPID-04. THE SINGLE CENTER STUDY FOR BRAIN METASTASES OF UNDIAGNOSED PRIMARY TUMOR AND THE ROLE OF SURGICAL REMOVAL

BACKGROUND

The diagnosis of a brain metastases is generally made during the follow up examinations of patients with primary known cancer. However, there are some patients presenting brain metastases as the first manifestation of a previously undiagnosed primary tumor (UDP) pathological confirmation of the diagnosis. The timing of a subsequent neurosurgical intervention is influenced by the distribution of primary tumors in UDP patients. The purpose of this study was to investigate the optimal diagnostic approach and the role of surgery for UDP patients.

METHODS

In a retrospective study, 35 patients admitted to our institution and underwent brain tumor removal from 2017 to 2019 with the diagnosis of cerebral metastases and diagnosed lung cancer as primary tumor subsequently, or previously diagnosed lung cancer.

RESULTS

UDP patients represented 46% of the whole group. Primary tumor subtype was the adenocarcinoma (n=13, 81%), small cell carcinoma (n=2, 13%), and neuroendocrine carcinoma (n=1, 6%). They did not have bronchoscopy nor excision of lung cancer. On the other hand, the patients previously diagnosed lung cancer represented 54% and subtype was adenocarcinoma (n=14, 74%) and small cell carcinoma (n=5, 26%). EGFR mutation was detected from 7 patients (44%) in UDP group and treated by EGFR tyrosine kinase inhibitor.

CONCLUSION

The significance of surgical intervention in metastatic brain tumors has been limited. However, active surgical intervention in UDP patients could identify not only histological diagnosis but also molecular biological characteristics. Our study suggests the possibility to avoid whole brain radiation in UDP patient by the active surgery.

Application of intra-operative magnetic resonance imaging for intracranial epidermoid cysts

The effectiveness and safety of intraoperative magnetic resonance imaging (iMRI) are evident from many reports over the past decade. However, these reports have mainly concerned surgeries for glioma and other intra-axial tumours, and applications of this approach for extra-axial tumours are poorly documented. We retrospectively examined three cases in which iMRI was used to assist in the removal of epidermoid cysts. T2-weighted images and diffusion-weighted images were acquired during the surgeries. The value to surgeons of images generated by iMRI, the length of interruption of surgery, and the safety of the patients were assessed. In this study, the images obtained through iMRI provided were clear representations of remnant tumours, even with a low-field system (0.4 Tesla). These images generated enough information to help surgeons decide whether to use an assistance device, such as an endoscope, to remove remnant tumours and whether further retraction of the brain was safe for patients and useful in tumour removal. Intraoperative MRI has long been thought unnecessary for surgery for tumours that are well demarcated and clearly visible under a surgical microscope; in this study, however, intraoperative MRI proved to be useful and safe for patients undergoing epidermoid cyst resection.

A rare presentation of a pediatric neurenteric cyst as an intra-axial pontine lesion: A case report with a 5-year follow-up

Background

Intracranial neurenteric cysts are rare, benign, and slow-growing tumors. However, we encountered a pediatric case that the cyst expansion occurred in a short period of time resulting in rapid deterioration of the patient's symptoms.

Case Description

A previously healthy 7-year-old girl had a week history of dysarthric speech and diplopia along with headaches. Her magnetic resonance images (MRI) showed an abnormal cystic mass in her brainstem. Her symptoms were deteriorated for 1 month and her second MRI revealed an enlargement of the cystic lesion. The tumor biopsy and cyst drainage were carried out and histopathological examination of the cyst wall showed columnar epithelium containing ciliated cells. The final diagnosis of her tumor was neurenteric cyst.

Conclusion

We report a pediatric case of a neurenteric cyst in the brainstem, which expanded in a short period, and review this rare entity.

Paediatric migraine with visual hallucination auras appearing in the form of a human body

The most common type of migraine aura is multifaceted visual aura, such as scintillating scotoma or geometrical patterns, visual hallucinations in which a physical body is extremely rare. We report a paediatric case of migraine in which visual hallucinations appeared as auras in the form of a human body. The patient was an 11-year-old girl suffering from migraine with curious visual aura. The auras were atypical visual hallucinations that were sometimes accompanied by auditory hallucinations. Approximately 5-20 min before the headache, the patient would see a middle-aged man wearing sunglasses in her field of vision. Acetaminophen (10 mg/kg) and Japanese herbal medicine administered when necessary effectively treated the headaches. Finally, the patient was no longer complaining of her hallucination auras. Although the pathophysiology of migraines accompanied by auras is unclear, it appears that cerebral blood flow and cortical spreading depression are involved in auras.

PATH-56. PYROSEQUENCING METHOD FOR RAPID DETECTION OF KIAA1549-BRAF FUSION GENES IN PEDIATRIC BRAIN TUMORS

BACKGROUND

Fusion genes driving tumorigenesis have drawn the attention of oncologists and researchers. Recently, independent genomic researchers have identified a tandem duplication of BRAF at 7q34 that leads to several KIAA1549-BRAF gene exon fusions in the majority of pilocytic astrocytoma (PA). Because KIAA1549-BRAF fusion transcripts are usually absent in diffuse astrocytoma, these genetic alterations may have diagnostic value. Despite the importance of such molecular alterations, there are no comprehensive reproducible methods to detect these fusion genes.

METHODS

Samples of brain tumors were selected retrospectively from our institution. 22 pediatric brain tumors of five types, namely PA, oligodendroglioma (OD), anaplastic astrocytoma (AA), glioblastoma (GBM) and, ganglioglioma (GG), were evaluated to detect KIAA1549-BRAF fusion genes using a pyrosequencing-based method following RNA isolation, cDNA synthesis and real-time polymerase chain reaction. We designed the primers to detect the three most common fusion variants: KIAA1549 ex15-BRAF ex9, KIAA1549 ex16-BRAF ex9, and KIAA1549 ex16-BRAF ex11.

RESULTS

Our method successfully detected KIAA1549-BRAF fusion in 16 out of 22 samples, that is, eleven PA, two OD, one AA, one GBM, and one GG. The entire procedure from RNA extraction to obtaining mutation data was performed within 2 hours.

CONCLUSION

A comprehensive method for detecting fusion genes in pediatric brain tumors was evaluated. This method identified KIAA1549–BRAF fusion variants quickly compared to other methods. Our results will be useful for studies on intraoperative diagnosis and classification of tumors for improving surgical decisions.

[Awareness of harm to others from secondhand smoke and smokers' interest in smoking cessation]

Objectives　Because smoking presents various health hazards, smoking cessation is important for health promotion. It is known that awareness of the harm of smoking to smokers themselves is associated with attempts to quit. However, the association between smoking cessation and awareness of harm to others from secondhand smoke has not been well examined. Therefore, in this research, we examined the association between smokers' awareness of the harm to others from secondhand smoke and their interest in smoking cessation, focusing on current smokers in an Internet survey of the general population of Japan.Methods　We conducted a cross-sectional Internet survey of the general population of Japan between January 27 and March 13, 2017. A total of 1,586 respondents aged 15-71 years (1,128 men and 458 women) who were current smokers were analyzed. We used multivariable-adjusted logistic regression to examine the association among awareness of smoking's harm to smokers themselves, awareness of harm to others from secondhand smoke, and the smokers' interest in smoking cessation.Results　Of current smokers, 81.6% of men and 88.2% of women were aware of the harm caused to others by secondhand smoke; 52.7% of men and 64.6% of women were interested in smoking cessation. Using awareness of harm to smokers themselves and awareness of harm to others from secondhand smoke as predictor variables in multivariable-adjusted logistic regression, odds ratios were 2.53 and 2.92, respectively. In the model using both awareness of harm to smokers themselves and harm to others from secondhand smoke, both have a significant independent positive association with smokers' interest in quitting.Conclusions　Current smokers aware of the harm caused to others by secondhand smoke were more interested in quitting than those who were not. Awareness of the harm caused to smokers themselves by smoking and awareness of the harm caused to others by secondhand smoke have a significant independent positive association with smokers' interest in quitting. Although this study is a cross-sectional study and did not investigate causal relationships, the findings suggest that raising awareness of the harm to other people from secondhand smoke may lead to more interest in smoking cessation, and the data can be used to promote tobacco control in the future.

A novel surgical approach for intraorbital optic nerve tumors

Although orbital tumors involving the optic nerve are rare, it is well-known that they are very likely to cause serious visual impairment in a patient. Unfortunately, at present, there are no effective interventions that can reliably preserve visual function while controlling tumor growth into intracranial spaces. To ensure visual function of the non-affected side, transection of the optic nerve together with the tumors involved is necessary in some cases. For this procedure large craniotomy and orbital unroofing are commonly utilized. As an alternative, we propose a novel surgical intervention for transection of the optic nerve having optic nerve tumors, which utilizes a lateral orbitotomy approach. To evaluate the invasiveness of different surgical approaches, we compared the days of hospitalization after surgery across patients who underwent the transcranial, lateral, and anterior approaches, respectively. We successfully removed 2 optic nerve tumors using the lateral approach, which required significantly shorter hospitalization than the transcranial approach. The transection of the optic nerve together with tumor removal by the lateral approach may be one of the novel surgical interventions for optic nerve tumors as this method is considerably less invasive than the transcranial removal method.

Prosthetic material degeneration over time as a possible factor in delayed recurrence of hemifacial spasm after successful microvascular decompression

Background:

The effectiveness of microvascular decompression in treating hemifacial spasm is widely accepted. However, some experience recurrence of hemifacial spasm after successful decompression surgery. Especially, delayed recurrence more than 5 years after surgery is rare and the cause of this phenomenon is unknown.

Case Description:

A female underwent microvascular decompression to treat her hemifacial spasm 6 years ago. Six years later, her hemifacial spasm recurred and she underwent a second surgery. The second surgery revealed that the sponge had become fragile, losing the ability to absorb the impact of pulsatile compression of the offending artery on the root exit zone of her facial nerve.

Conclusion:

We report a case in which degeneration of material, a sponge (polyurethane), used in decompression surgery caused delayed recurrence of hemifacial spasm. The selection of appropriate prosthetic materials is essential in such functional surgeries.

A Comprehensive Method for Detecting Fusion Genes in Paediatric Brain Tumours

BACKGROUND

Fusion genes driving tumourigenesis have drawn the attention of researchers and oncologists. Despite the importance of such molecular alterations, there are no comprehensive reproducible methods for detecting fusion genes.

MATERIALS AND METHODS

Nineteen paediatric brain tumours of five types, namely pilocytic astrocytoma, oligodendroglioma, anaplastic astrocytoma, glioblastoma and, ganglioglioma, were examined to detect fusion genes using a pyrosequencing-based method following RNA isolation, cDNA synthesis and real-time polymerase chain reaction.

RESULTS

Our method successfully detected KIAA1549-v-raf murine sarcoma viral oncogene homolog B1 (BRAF) fusion in 14 out of 19 patients suffering from five types of paediatric brain tumours providing information on fusion breakpoints within 2 h.

CONCLUSION

A comprehensive method for detecting fusion genes in paediatric brain tumours was evaluated. This method identified KIAA1549-BRAF fusion variants quickly. Our results may help researchers interested in the role of fusion genes in tumourigenesis.

Microsurgical anatomy of the maxillary artery for extracranial-intracranial bypass in the pterygopalatine segment of the maxillary artery

The extracranial-intracranial (EC-IC) bypass using the maxillary artery (MA) has been successfully completed using a radial artery (RA) graft but the complicated anatomy and narrow exposure make it difficult. The purpose of this article is to define the microsurgical exposure of the MA through the middle fossa and describe the branches, diameter, and length of the MA available for the EC-IC bypass in the sphenopalatine fossa and anterior part of the infratemporal fossa. 5 cadaveric specimens were dissected bilaterally (10 MA dissections) to define the microsurgical anatomy of the MA through an intracranial approach. The exposable branches of the MA at the level of the infratemporal and sphenopalatine fossae were the anterior deep temporal, posterior superior alveolar, and infraorbital arteries. The origin of each branch could be exposed. The available section of the MA for use as a donor vessel is between the origin of the anterior deep temporal artery and the infraorbital artery. The mean exposable length of the MA was 19.4 mm. The mean outer diameter of the donor MA was 3.2 mm. Tension-free EC-IC bypass was possible using a RA graft between the MA and the middle cerebral artery, the MA and the supraclinoid internal carotid artery (ICA), or the MA and the petrous ICA. Exposure of the MA at the infratemporal and sphenopalatine fossae is complicated but provides length and diameter suitable as a donor artery for the EC-IC bypass. Clin. Anat. 31:724-733, 2018. © 2017 Wiley Periodicals, Inc.

Microsurgical anatomy and approaches around the lateral recess with special reference to entry into the pons

OBJECTIVE The lateral recess is a unique structure communicating between the ventricle and cistern, which is exposed when treating lesions involving the fourth ventricle and the brainstem with surgical approaches such as the transcerebellomedullary fissure approach. In this study, the authors examined the microsurgical anatomy around the lateral recess, including the fiber tracts, and analyzed their findings with respect to surgical exposure of the lateral recess and entry into the lower pons. METHODS Ten cadaveric heads were examined with microsurgical techniques, and 2 heads were examined with fiber dissection to clarify the anatomy between the lateral recess and adjacent structures. The lateral and medial routes directed to the lateral recess in the transcerebellomedullary fissure approach were demonstrated. A morphometric study was conducted in the 10 cadaveric heads (20 sides). RESULTS The lateral recess was classified into medullary and cisternal segments. The medial and lateral routes in the transcerebellomedullary fissure approach provided access to approximately 140º-150º of the posteroinferior circumference of the lateral recess. The floccular peduncle ran rostral to the lateral recess, and this region was considered to be a potential safe entry zone to the lower pons. By appropriately selecting either route, medial-to-lateral or lateral-to-medial entry axis is possible, and combining both routes provided wide exposure of the lower pons around the lateral recess. CONCLUSIONS The medial and lateral routes of the transcerebellomedullary fissure approach provided wide exposure of the lateral recess, and incision around the floccular peduncle is a potential new safe entry zone to the lower pons.

Spatial Restriction within Intracranial Epidermoid Cysts Observed Using Short Diffusion-time Diffusion-weighted Imaging

We report two cases of pathologically proven intracranial epidermoid cysts. Both cases were scanned with diffusion-weighted imaging using pulsed gradient spin-echo (PGSE) and oscillating gradient spin-echo (OGSE; 50 Hz) prototype sequences with diffusion times of 47.3 ms and 8.5 ms, respectively. The apparent diffusion coefficient measured by OGSE was higher than that measured by PGSE, indicating the spatial restriction of water diffusion in the laminated keratin layers within the cyst as demonstrated by histopathology.

Microsurgical and endoscopic approaches to the pulvinar

OBJECTIVE

Approaches to the pulvinar remain challenging because of the depth of the target, surrounding critical neural structures, and complicated arterial and venous relationships. The purpose of this study was to compare the surgical approaches to different parts of the pulvinar and to examine the efficacy of the endoscope as an adjunct to the operating microscope in this area.

METHODS

The pulvinar was examined in 6 formalin-fixed human cadaveric heads through 5 approaches: 4 above and 1 below the tentorium. Each approach was performed using both the surgical microscope and 0° or 45° rigid endoscopes.

RESULTS

The pulvinar has a lateral ventricular and a medial cisternal surface that are separated by the fornix and the choroidal fissure, which wrap around the posterior surface of the pulvinar. The medial cisternal part of the pulvinar can be further divided into upper and lower parts. The superior parietal lobule approach is suitable for lesions in the upper ventricular and cisternal parts. Interhemispheric precuneus and posterior transcallosal approaches are suitable for lesions in the part of the pulvinar forming the anterior wall of the atrium and adjacent cisternal part. The posterior interhemispheric transtentorial approach is suitable for lesions in the lower cisternal part and the supracerebellar infratentorial approach is suitable for lesions in the inferior and medial cisternal parts.

The microscope provided satisfactory views of the ventricular and cisternal surfaces of the pulvinar and adjacent neural and vascular structures. The endoscope provided multi-angled and wider views of the pulvinar and adjacent structures.

CONCLUSIONS

A combination of endoscopic and microsurgical techniques allows optimal exposure of the pulvinar.

Changes in delta ADC reflect intracranial pressure changes in craniosynostosis

BACKGROUND

In patients with craniosynostosis, intracranial pressure (ICP) has been reported to increase even in the absence of overt symptoms. The early and non-invasive detection of intracranial hypertension is important for reducing the risk of abnormal brain development in pediatric patients.

PURPOSE

To assess whether the apparent diffusion coefficient (ADC) of white matter during the cardiac cycle (ΔADC) would change after surgery to relieve ICP in children with craniosynostosis.

MATERIAL AND METHODS

This prospective study included ten patients diagnosed with craniosynostosis and four normal controls. All ten patients underwent magnetic resonance (MR) examinations before and after surgical treatment. Single-shot diffusion MR imaging (MRI) triggered by an electrocardiogram was performed, with regions of interest (ROIs) placed on frontal white matter and basal ganglia.

RESULTS

In all ten patients, ΔADC values after surgery were higher than those before surgery. This difference was statistically significant (Wilcoxon signed-rank test, P = 0.005).

CONCLUSION

The change in ΔADC in the frontal white matter before and after surgery in patients with craniosynostosis indicates that it might reflect the change in ICP. Measurements of ΔADC could be a promising tool for non-invasive monitoring of ICP.

Novel classification of the posterior auricular artery based on angiographical appearance

Purpose

To investigate the length variation of the posterior auricular artery and propose a novel classification of the posterior auricular artery based on angiographical appearance.

Patients and Methods

A series of 234 consecutive patients who had undergone conventional cerebral angiography was analyzed. The posterior auricular artery was examined on the lateral projection of the external carotid or common carotid arteriography. The posterior auricular artery was classified into four groups by length, using the external auditory canal and the top of the helix as radiographical landmarks. Our proposed classification is as follows: Type A, posterior auricular artery terminates between its origin and the center of the external auditory canal; Type B, posterior auricular artery terminates between the center of the external auditory canal and the top of the helix; Type C, posterior auricular artery terminates between the top of the helix and the vertex; and Type D, posterior auricular artery reaches up to the vertex.

Results

A total of 424 (right, 214; left, 210) posterior auricular arteries were analyzed in 111 men and 123 women aged 11 to 91 years (mean, 61.0 years) examined for aneurysms in 78 cases, occlusive vascular diseases in 56, intracranial hemorrhages in 41, tumors in 35, and others in 24. Types A, B, C, and D were found in 15.1%, 34.9%, 48.8%, and 1.2% of the patients, respectively.

Conclusion

A novel classification of the posterior auricular artery identifies four types based on its length on cerebral angiography.

Serum KL-6 level as an indicator of active or inactive interstitial pneumonitis associated with connective tissue diseases

OBJECTIVE

To elucidate the cut off levels of serum KL-6 indicating patients with interstitial pneumonitis (IP) and patients with active IP associated with connective tissue diseases (CTDs).

METHODS

CTD patients whose serum KL-6 level was measured were included. IP was diagnosed on the basis of medical records including XP/CT findings, and active IP was assumed in case that intervention for IP was newly added. The cut off levels were determined by receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 240 (174 females) patients, 67 (42) had IP and 15 (9) had active IP. The ages of patients with and without IP, and with active IP and with inactive IP were 70.3±9.5 and 62.8±15.3, and 72.8±8.1 and 69.6±9.8, respectively. IP was significantly more prevalent in males and the elderly. The KL-6 levels were 990±90 and 301±12 U/mL in patients with and without IP, and 1,905±236 and 726±54 U/mL in those with active IP and with inactive IP, respectively. ROC curve analysis showed a cut off level of 509 U/mL for indicating IP, and that of 1,051-1,060 U/mL for indicating active IP.

CONCLUSION

A serum KL-6 level of higher than 500 U/mL is a marker of the presence of IP, and a level of higher than 1,000 U/mL is a marker of the presence of active IP associated with CTDs.

[Simultaneous presentation of Tolosa-Hunt syndrome and oculomotor nerve palsy due to the nonruptured internal carotid-posterior communicating artery aneurysm: a case report]

A 45-year-old female developed mild dysesthesia and swelling, followed by ptosisand trigeminal pain, in the right side of the face. Her past medical history was unremarkable, and she had not been aware of any infectious sign. A local otolaryngologist administered glucocorticoid therapy that resolved the face pain, but the ptosis persisted. Neurological examination found complete right oculomotor nerve paresis and mild sensory loss in the first and second segments of the right trigeminal nerve. Blood examination found no abnormalities. Neuroimaging revealed a saccular aneurysm at the branching site of the posterior communicating artery, projecting posteriorly and adjacent to the dorsum sellae, without other intracranial abnormalities. Cerebral angiography demonstrated poor opacification of the superior ophthalmic vein and cavernous sinus on the right side. The patient underwent coil embolization under a diagnosis of symptomatic aneurysm, but her oculomotor neuropathy was only partially improved. We thought that the impairment of the oculomotor function by inflammatory reaction in the cavernous sinus and mechanical compression by the aneurysm had already persisted for too long for post-treatment recovery. We think that the simultaneous occurrence of Tolosa-Hunt syndrome and oculomotor nerve palsy may have resulted because trigeminal neuralgia had increased the blood pressure to induce rapid growth of the preexisting aneurysm, or the inflammatory reaction in the cavernous sinus had promoted the growth of the aneurysm, or that the association was by chance.

[Case with large abdominal abscess associated with a ventriculoperitoneal shunt]

Abdominal abscess is a rare shunt-related complication with few reported cases. A 6-year-old female presented with a large staphylococcal abdominal abscess manifesting as abdominal distension without significant clinical signs or blood and cerebrospinal fluid findings of infection. The patient had undergone repeated surgeries for craniopharyngioma at 2 years of age and had suffered central pontine and extrapontine myelinolysis during the clinical course, had severely impaired hypothalamic function, and was in a vegetative state on presentation. In addition, she had previously suffered epidural, subdural, and cerebral parenchymal abscesses, which had resolved completely. She underwent percutaneous irrigation drainage of pus and removal of the shunt coupled with intense antibiotic administration, which cured the abscess without recurrence. Culture revealed methicillin-resistant Staphylococcus aureus. We thought that preexisting intracranial infection, which had extended down into the abdominal cavity through the peritoneal tube of the shunt, coupled with the patient's impaired immune function, had probably caused the abdominal abscess. Abdominal abscess is a potential complication of ventriculoperitoneal shunting, and timely diagnosis and treatment may achieve a good outcome.

[Massive pulmonary thromboembolism found at autopsy in a patient with a 14-year history of polymyositis-associated nonspecific interstitial pneumonia]

A 64-year-old woman with a 14-year history of refractory nonspecific interstitial pneumonia (NSIP) associated with polymyositis was admitted urgently to our hospital due to acute exacerbation of dyspnea. The first episode of dyspnea had occurred 14 years earlier and the diagnosis of cellular and fibrotic NSIP had been made by radiographic examinations and open lung biopsy. Her NSIP initially responded well to high-dose prednisolone therapy (40mg/day), but flared when the dose of prednisolone was tapered. Three years after the diagnosis of NSIP, a diagnosis of polymyositis was made based on her elevated serum level of creatinine phosphokinase and muscle biopsy findings. Her polymyositis was controlled well by prednisolone therapy, but her NSIP gradually worsened, despite treatment with several courses of methylprednisolone pulse therapy and immunosuppressive agents. She was brought to our hospital by ambulance due to acute progression of dyspnea and was admitted. Chest X-ray film revealed diffuse interstitial shadows and marked enlargement of the right atrium and bilateral pulmonary arteries. Transthoracic echocardiogram revealed severe dilatation of the right atrium and right ventricle with an estimated pulmonary artery systolic pressure of 84mmHg. She died of progressive respiratory failure on day 4 of hospitalization. Autopsy revealed massive thrombi that completely obstructed the bilateral pulmonary trunks. Histological examination revealed that these thrombi were organized, and her interstitial lung disease (ILD) was specified as fibrotic NSIP with microscopic honeycomb. Massive pulmonary thromboembolism is extremely rare in patients with polymyositis-associated NSIP, but it should be considered as a possible cause of acute exacerbation of respiratory failure. This case provides valuable information on the clinical and pathological course of polymyositis-associated NSIP.

Acute exacerbation of preexisting interstitial lung disease after administration of etanercept for rheumatoid arthritis

A 70-year-old woman with a 6-year history of seropositive rheumatoid arthritis (RA) and asymptomatic interstitial lung disease (ILD) began taking etanercept for ongoing arthritis despite treatment with methotrexate (MTX) and bucillamine. MTX was discontinued before introduction of etanercept. She developed lung injury 8 weeks after starting etanercept. Etanercept was discontinued and oral prednisolone 40 mg/day was begun, and her clinical findings gradually improved. Lung injury, although rare, is a recently noticed, potentially fatal adverse effect of all 3 licensed biological anti-tumor necrosis factor (TNF) agents. We recommend caution in the use of anti-TNF agents in elderly RA patients with preexisting ILD.

[A case of systemic sclerosis and Sjogren's syndrome with cardiac tamponade due to steroid-responsive pericarditis]

A 75-year-old woman was admitted to our hospital because of abnormal lung shadow and necrosis of the left feet. She had a history of Raynaud's phenomenon from her twenties. On admission, she was diagnosed as having diffuse systemic sclerosis (SSc) and Sjögren's syndrome (SjS) because of scleroderma, interstitial pneumonia (IP), positive result of anti-Scl-70 and SS-A antibody, sicca, decreased tear excretion, and dysfunction of salivary glands. Seventy days after amputation of her left leg, she presented with edema, hypoxemia, chest discomfort, and fever. Blood test revealed inflammation and cardiac echography revealed pericardial effusion with a collapse sign of right atrium, thereby leading to the diagnosis of cardiac tamponade. After starting the daily dose of 20 mg of prednisolone, the pericardial effusion and cardiac tamponade sign disappeared. Pericarditis is seen in half of patients with SSc and rarely with SjS, and is usually asymptomatic. Pericarditis due to SSc has been reported unresponsive to steroid therapy, but several cases of steroid responsive pericarditis due to SSc or SjS have been reported. Clinically, they shared inflammatory responses and the presence of IP in the cases of SSc, which will be important when considering the pathogenesis and treatment of pericarditis due to SSc or SjS.

Reactive hemophagocytic syndrome in a case of systemic lupus erythematosus that was diagnosed by detection of hemophagocytosing macrophages in peripheral blood smears

A 38-year-old woman with pancytopenia and liver dysfunction was diagnosed with active systemic lupus erythematosus (SLE). On days 9 and 10 of admission, peripheral blood smears showed macrophages phagocytosing platelets, and reactive hemophagocytic syndrome (HPS) was diagnosed. Hemophagocytic syndrome was successfully treated with high-dose prednisolone therapy and one course of methylprednisolone pulse therapy. Detection of hemophagocytosing macrophages in peripheral blood smears would be a useful and noninvasive method of diagnosing SLE-associated HPS.

Sarcoidosis with acute recurrent polyarthritis and hypercalcemia

A 45-year-old woman had bleary eyes and recurrent episodes of fever and arthritis in the knees and ankles. The patient had anterior uveitis, negative findings of the tuberculin test, and an increased serum lysozyme level, but bilateral hilar lymphadenopathy (BHL) was absent. During the course of her disease, the serum calcium and angiotensin-converting enzyme levels gradually increased to above the normal level, and the patient was clinically diagnosed as having sarcoidosis. The clinical features of arthritis were typical of those of Löfgrens syndrome although BHL and erythema nodosum were absent. The patient was successfully treated with 15 mg/day of prednisolone.

Trimethoprim-sulfamethoxazole-induced hypersensitivity syndrome associated with reactivation of human herpesvirus-6

A 27-year-old man who had a history of bronchial asthma, eosinophilic enteritis, and eosinophilic pneumonia presented with fever, skin eruptions, cervical lymphadenopathy, hepatosplenomegaly, atypical lymphocytosis, and eosinophilia two weeks after receiving trimethoprim (TMP)-sulfamethoxazole (SMX) treatment. After the withdrawal of TMP-SMX and the administration of high-dose steroid, these systemic symptoms gradually resolved. During the disease course, the patient showed a transient increase in anti-human herpesvirus (HHV)-6 antibody titers and HHV-6 DNA in the peripheral blood, indicating the reactivation of a latent HHV-6 infection. This is the first case of TMP-SMX-induced hypersensitivity syndrome associated with the reactivation of a latent viral infection.

[Case of congestive heart failure associated with hypereosinophilia developed during antibiotics treatment]

A 92-year-old man with a history of bronchial asthma and allergic rhinitis received antibiotics for sepsis by methicillin-resistant Staphylococcus aureus and multidrug-resistant Enterococcus gallinarum. During the antibiotics treatment, skin eruptions, liver dysfunction, and hypereosinophilia developed, followed by dyspnea, congestive heart failure, electrocardiographic abnormalities, and diffuse mild myocardial hypokinesis. After the discontinuation of the antibiotics and the administration of steroid, skin eruptions, liver dysfunction, and hypereosinophilia improved parallel with the improvement of the congestive heart failure. Vancomycin hydrochloride and teicoplanin were suspected as the causative drugs on the basis of the treatment course. Although congestive heart failure is rare in the case of drug-induced hypereosinophilia, it is one of life-threatening complications. We describe herein a case of congestive heart failure associated with hypereosinophilia developed during antibiotics treatment, successfully treated with steroid after the discontinuation of the causative drug.