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Atsuhiro Nakagawa, Ching-Chan Su, Kiyotaka Sato and Reizo Shirane

Object. Circulating blood volume (cBV) is reported to decrease in patients who suffer a subarachnoid hemorrhage (SAH), but little is known about the correlation between changes in cBV, and patient clinical condition and time course after SAH, especially during the very acute stage. To determine appropriate management of patients with SAH, the authors measured cBV by using pulse spectrophotometry immediately after patient admission. They also evaluated whether the timing of surgery influenced changes in cBV.

Methods.Circulating blood volume was measured in a total of 73 patients who were divided into the following three groups: Group A (very acute SAH) consisted of 14 SAH cases, Group B (acute SAH) included 34 SAH cases, and Group C (controls) included 25 other neurosurgical cases. All patients in Group A underwent aneurysm clipping within 6 hours after onset of SAH, whereas all patients in Group B underwent aneurysm clipping within 72 hours after onset. Hypervolemic therapy was not performed in patients with SAH.

Before surgery, cBV was significantly lower in patients in Group B than in those in Group C, but there was no significant difference in this parameter when comparing Groups A and C. Although there was a transient drop in cBV in Group B patients for at least 3 days after surgery, there was no significant change in cBV in Group A patients during the study period. None of the Group A patients suffered from symptomatic vasospasm; however, four Group B patients did experience symptomatic vasospasm.

Conclusions. The authors assert that normovolemic fluid management is appropriate for patients who undergo surgery during the very acute stage of SAH, whereas a relatively hypervolemic therapy is necessary for 3 to 5 days after operation to prevent early hypovolemia in patients who undergo surgery during the acute stage of SAH.

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Reizo Shirane, Ching-chan Su, Yasuko Kusaka, Hidefumi Jokura and Takashi Yoshimoto

Object. Craniopharyngiomas frequently grow from remnants of the Rathke pouch, which is located on the cisternal surface of the hypothalamic region. These lesions can also extend elsewhere in the infundibulohypophyseal axis. The aim of this study was to establish the usefulness of the frontobasal approach made through a relatively small craniotomy window for the removal of tumors protruding from the sellar—suprasellar region into the third and basal cistern.

Methods. Thirty-one patients who were surgically treated for craniopharyngiomas extending outside the sellar—suprasellar region were evaluated. The diagnoses were established in all cases by using magnetic resonance and computerized tomography imaging. The initial symptoms and signs were increased intracranial pressure in eight, vision impairment or visual field defect in 16, hypopituitarism in 17, and psychological disturbances in three cases. All patients underwent surgery via the frontobasal interhemispheric approach, and the average follow-up period was 30 months.

Total removal of the lesion was achieved in 22 cases, six patients underwent subtotal resection, and three underwent partial removal due to tumor recurrence after previous surgeries performed with or without adjunctive radiotherapy. Major complications, including impairment of the cranial nerves, were not observed in the immediate postoperative period. One patient exhibited transient memory disturbance due to infarction of the perforating vessels; after 3 months this symptom was ameliorated. None of the patients died during long-term follow up; however, four of the 22 who underwent total removal and six of the nine patients who underwent subtotal or partial removal suffered recurrence. Of the 10 patients with recurrence, six experienced a small recurrence of the lesion (average 3 months postsurgery); after gamma knife surgery (GKS), the size of two of the lesions was unchanged and in four reoperation was performed due to tumor enlargement during the follow-up period. Ultimately, a total of eight patients (four with recurrence and four who had been treated with GKS) underwent reoperation, with gross-total removal via the same approach or combined with the orbitozygomatic approach in patients with very short optic nerves. In no patient was deterioration of visual acuity and visual field observed after surgery. Although all patients except four children and one adult were receiving some form of hormone replacement therapy, their endocrine status was stably controllable.

Conclusions. In the authors' experience, the frontobasal interhemispheric approach, even made through a small craniotomy window, is a valid choice for the removal of craniopharyngiomas extending outside the sellar—suprasellar region. Via this approach, tumors can be removed without significant sequelae related to the surgical method, due to ease of preservation of the pituitary stalk, hypothalamic structures, and perforating vessels. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.

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Reizo Shirane, Toshihiro Kumabe, Yasuko Yoshida, Ching-chan Su, Hidefumi Jokura, Kunihiko Umezawa and Takashi Yoshimoto

Object. To determine the safety and usefulness of performing surgery via the occipital transtentorial approach to treat anterosuperior cerebellar tumors, evaluation of 14 patients was performed over a 5-year period.

Methods. The study was performed in 14 patients, aged 6 months to 71 years, who harbored anterosuperior cerebellar tumors of the posterior fossa including four hemangioblastomas, three cerebellar astrocytomas, three medulloblastomas, two metastatic tumors, one recurrent astrocytoma, and one rhabdoid cell tumor. All patients underwent surgical treatment by the same surgical team and via the same surgical approach. Endoscopy combined with neuronavigation was used for large, deep-seated tumors extending to the fourth ventricle. Of the 14 patients, total or gross-total removal was achieved in 12 patients and subtotal removal in two patients. There was no incidence of mortality or morbidity in the 14 patients, and all functional outcomes were good to excellent postoperatively. Postoperative magnetic resonance imaging revealed that none of the patients had suffered brain damage or infarction around the cerebellum, brainstem, or occipital lobe.

Conclusions. Although this study was the first in which a specific examination of the efficacy of the occipital transtentorial approach in patients with anterosuperior cerebellar tumors was undertaken, our findings suggest that this surgical approach is very useful, safe, and accurate for removing the primary tumor and evaluating the surrounding anatomy, as well as for determining operative strategy.