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Jun-Ichi Kuratsu and Yukitaka Ushio

✓ This survey consists of 1117 residents of Kumamoto Prefecture who were diagnosed with primary intracranial tumors between 1989 and 1994. Age, sex, tumor type, and date of diagnosis were recorded in all cases; 79% of the diagnoses were confirmed histologically. The overall age-adjusted incidence rate was 9.47 per 100,000 population per year. Among males, the age-adjusted incidence rate was 8.24 per 100,000 per year, and the breakdown included 2.36 gliomas, 1.56 meningiomas, 1.46 pituitary tumors, and 0.99 neurinomas. Among females, the comparable overall rate was 10.7; that included a rate of 3.95 for meningiomas, 2.04 for gliomas, 2.16 for pituitary tumors, and 0.75 for neurinomas. Meningiomas were the most common tumor, with an average annual age-adjusted incidence of 2.76 per 100,000 population. The highest incidence of meningiomas was 13.02 per 100,000 among women aged 70 to 79 years. The highest incidence of gliomas (5.71 per 100,000 males and 5.29 per 100,000 females) was seen in patients between 60 and 69 years of age. Meningiomas, pituitary adenomas, and malignant lymphomas occurred at a higher rate in females (male/female ratio: 0.39, 0.68, and 0.81, respectively). On the other hand, gliomas, neurinomas, and germ-cell tumors occurred more often in males (male/female ratio: 1.16, 1.32, and 4.29, respectively). Meningiomas and germ-cell tumors tended to exhibit gender specificity.

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Jun-ichi Kuratsu and Yukitaka Ushio

✓ Platelet-derived growth factor (PDGF) is produced by glioma cells. However, there is heterogeneity among glioma cell lines in the production of PDGF. It has been demonstrated that U251MG cells produce a PDGF-like molecule while U105MG cells do not.

Trapidil, a specific antagonist of PDGF, competes for receptor binding with PDGF. Therefore, the inhibitory effect of trapidil on the proliferation of glioma cells was investigated in vitro using two glioma cell lines. At 100 µg/ml, trapidil significantly inhibited the proliferation of U251MG cells (which produce the PDGF-like molecule). At the same trapidil concentration, the proliferation of U105MG cells (which do not produce the PDGF-like molecule) was not inhibited. The inhibitory effect of trapidil was remarkable on Days 3 and 4 of culture. After 4 days of incubation, the proliferation of U251MG cells was 46% of the control preparation. Trapidil enhanced the antitumor effect of 3-((4-amino-2-methyl-5-pyrimidinyl)ethyl)-1-(2-chloroethyl)-1-nitro-sourea (ACNU) against U251MG cells. The enhancing effect was highest on Days 4 and 6 of culture. After 6 days of incubation in the presence of 100 µg/ml trapidil and 1 µg/ml ACNU, the proliferation of U251MG cells was 18% of the control preparation. These findings suggest that trapidil interrupts the autocrine loop at the PDGF and PDGF-receptor level and that combination therapy with trapidil and ACNU may be useful in the treatment of glioma.

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Jun-ichi Kuratsu, Yasuhiko Matsukado and Masaki Miura

✓ A prolactin-secreting pituitary adenoma containing amyloid substance was studied by light and electron microscopy. The tumor was found in a 32-year-old woman who presented with a short history of amenorrhea and galactorrhea. Pituitary adenoma containing amyloid substance is a very rare entity, and the implications of this association are discussed. Previous reports, suggesting that mesenchymal cells or hormone-secreting tumor cells in pituitary adenomas produce amyloid substances, are reviewed.

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Jun-ichi Kuratsu, Masato Kochi and Yukitaka Ushio

Object. The increased use of computerized tomography (CT) and magnetic resonance (MR) technology has led to an increase in the detection of asymptomatic meningiomas, although the surgical indication for these tumors remains undetermined. The authors investigated the incidence of asymptomatic meningiomas and their clinical features.

Methods. An epidemiological survey was conducted of primary intracranial tumors diagnosed in Kumamoto Prefecture between 1989 and 1996. Follow-up neuroradiological imaging and clinical studies for asymptomatic meningiomas were performed.

Primary intracranial tumors were diagnosed in 1563 residents. Of these lesions, 504 (32.2%) were meningiomas, and of these meningiomas 196 (38.9%) were asymptomatic. The incidence of asymptomatic meningiomas was significantly higher in individuals older than 70 years of age. Furthermore, the incidence of asymptomatic meningiomas was significantly higher in female than in male patients. Of the asymptomatic meningiomas in 196 patients, 87 (44.4%) were surgically removed, whereas 109 (55.6%) were treated conservatively. Of these conservatively treated patients, 63 received follow-up care for more than 1 year. In 20 of these 63 cases, the tumors increased in size over the 27.8-month average follow-up period (range 12–87 months), whereas in the other 43 cases, the tumor size did not increase during a 36.6-month average follow-up period (range 12–96 months). There was no significant difference with respect to age, tumor size, and male/female ratio between the patient group in which the tumor size increased and the group in which it did not increase during the follow-up period. Asymptomatic meningiomas that evidenced calcification on CT scans and/or hypointensity on T2-weighted MR images appear to have a slower growth rate.

Conclusions. Among patients older than age 70 years who underwent operation for asymptomatic meningioma, the neurological morbidity rate was 23.3%; it was 3.5% among younger patients. This indicates that the advisability of surgery in elderly patients with asymptomatic meningiomas must be considered very carefully.

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Kenji Fujimoto, Masaki Miura, Tadahiro Otsuka and Jun-ichi Kuratsu

OBJECT

Rotterdam CT scoring is a CT classification system for grouping patients with traumatic brain injury (TBI) based on multiple CT characteristics. This retrospective study aimed to determine the relationship between initial or preoperative Rotterdam CT scores and TBI prognosis after decompressive craniectomy (DC).

METHODS

The authors retrospectively reviewed the medical records of all consecutive patients who underwent DC for nonpenetrating TBI in 2 hospitals from January 2006 through December 2013. Univariate and multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used to determine the relationship between initial or preoperative Rotterdam CT scores and mortality at 30 days or Glasgow Outcome Scale (GOS) scores at least 3 months after the time of injury. Unfavorable outcomes were GOS Scores 1–3 and favorable outcomes were GOS Scores 4 and 5.

RESULTS

A total of 48 cases involving patients who underwent DC for TBI were included in this study. Univariate analyses showed that initial Rotterdam CT scores were significantly associated with mortality and both initial and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes. Multivariable logistic regression analysis adjusted for established predictors of TBI outcomes showed that initial Rotterdam CT scores were significantly associated with mortality (OR 4.98, 95% CI 1.40–17.78, p = 0.01) and unfavorable outcomes (OR 3.66, 95% CI 1.29–10.39, p = 0.02) and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes (OR 15.29, 95% CI 2.50–93.53, p = 0.003). ROC curve analyses showed cutoff values for the initial Rotterdam CT score of 5.5 (area under the curve [AUC] 0.74, 95% CI 0.59–0.90, p = 0.009, sensitivity 50.0%, and specificity 88.2%) for mortality and 4.5 (AUC 0.71, 95% CI 0.56–0.86, p = 0.02, sensitivity 62.5%, and specificity 75.0%) for an unfavorable outcome and a cutoff value for the preoperative Rotterdam CT score of 4.5 (AUC 0.81, 95% CI 0.69–0.94, p < 0.001, sensitivity 90.6%, and specificity 56.2%) for an unfavorable outcome.

CONCLUSIONS

Assessment of changes in Rotterdam CT scores over time may serve as a prognostic indicator in TBI and can help determine which patients require DC.

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Takuichiro Hide, Shigetoshi Yano, Naoki Shinojima and Jun-ichi Kuratsu

OBJECT

To avoid disorientation during endoscopic endonasal transsphenoidal surgery (ETSS), the confirmation of anatomical landmarks is essential. Neuronavigation systems can be pointed at exact sites, but their spatial resolution power is too low for the detection of vessels that cannot be seen on MR images. On Doppler ultrasonography the shape of concealed arteries and veins cannot be visualized. To address these problems, the authors evaluated the clinical usefulness of the indocyanine green (ICG) endoscope.

METHODS

The authors included 38 patients with pituitary adenomas (n = 26), tuberculum sellae meningiomas (n = 4), craniopharyngiomas (n = 3), chordomas (n = 2), Rathke's cleft cyst (n = 1), dermoid cyst (n = 1), or fibrous dysplasia (n = 1). After opening the sphenoid sinus and placing the ICG endoscope, the authors injected 12.5 mg of ICG into a peripheral vein as a bolus and observed the internal carotid arteries (ICAs), cavernous sinus, intercavernous sinus, and pituitary.

RESULTS

The ICA was clearly identified by a strong fluorescence signal through the dura mater and the covering thin bone. The intercavernous and cavernous sinuses were visualized a few seconds later. In patients with tuberculum sellae meningiomas, the abnormal tumor arteries in the dura were seen and the vague outline of the attachment was identified. At the final inspection after tumor removal, perforators to the brain, optic nerves, chiasm, and pituitary stalk were visualized. ICG fluorescence signals from the hypophyseal arteries were strong enough to see and spread to the area of perfusion with the passage of time.

CONCLUSIONS

The ICA and the patent cavernous sinus were detected with the ICG endoscope in real time and at high resolution. The ICG endoscope is very useful during ETSS. The authors suggest that the real-time observation of the blood supply to the optic nerves and pituitary helps to predict the preservation of their function.

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William T. Couldwell

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Hirofumi Hirano, Koji Tanioka, Shunichi Yokoyama, Shin-ichi Akiyama and Jun-ichi Kuratsu

Object. Thymidine phosphorylase (TP) and vascular endothelial growth factor (VEGF) are known angiogenic factors; however, there are few reports in which the relationship between these two factors is addressed. The authors compared expression patterns of TP and VEGF and investigated their role in the angiogenesis of glioblastoma multiforme (GBM).

Methods. Surgical specimens from 41 cases of GBM were immunohistochemically stained for TP, VEGF, CD68 (a macrophage marker), and CD31 (an endothelial cell marker). Both TP labeling indices and VEGF immunoreactivity displayed significant correlations with vascular density. Although VEGF was diffusely distributed in the tumor, TP was strongly expressed around blood vessels and in vascular proliferation. Double labeling for TP and CD68 in 10 cases indicated that cells that reacted strongly positive for TP were almost always macrophages, and only small numbers of CD68-negative cells weakly expressed TP.

The TP messenger (m)RNA expression was investigated using reverse transcription-polymerase chain reaction in six GBMs. All six specimens expressed TP mRNA. In addition, TP mRNA was detected in two of three groups of cultured GBM cells derived from surgical specimens. Macrophages, the production of which was induced from two volunteers' peripheral blood monocytes by applying macrophage colony-stimulating factor, also expressed TP mRNA. The glioma cell lines U251MG and U87MG, which barely express TP mRNA under normal conditions, expressed TP mRNA in response to interferon-β stimulation or while in an anoxic condition.

Conclusions. Although it is feasible that GBM cells can express TP depending on their growing conditions, the majority of TP-expressing cells present in GBMs appear to be infiltrating macrophages. Coexistence of VEGF and TP may indicate a synergistic upregulation for angiogenesis because VEGF exerts a chemotactic activity on macrophages that express TP.

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Takashi Kamezawa, Jun-Ichiro Hamada, Masaki Niiro, Yutaka Kai, Koichi Ishimaru and Jun-ichi Kuratsu

Object. The authors reviewed angiograms obtained in patients with cavernous malformations to identify and characterize coexisting venous drainage.

Methods. Fifty-seven patients with cavernous malformations treated at the authors' institutions between 1994 and 2002 were classified into three groups according to the venous system adjacent to the malformation on angiography studies. In Group A patients (23 patients) the malformations had no venous drainage; in Group B patients (14 patients) the lesions were associated with typical venous malformations; and in Group C patients (20 patients) the lesions had atypical venous drainage (AVD). The risk of hemorrhage based on the type of associated venous drainage was analyzed, and the usefulness of magnetic resonance (MR) imaging compared with digital subtraction (DS) angiography in demonstrating associated AVD was determined.

Fifty-seven patients harbored 67 cavernous malformations: Group A patients had 29 cavernous malformations with no associated venous drainage; Group B patients had 17 lesions associated with venous malformations; and Group C patients harbored 21 lesions, 20 of which manifested AVD. Symptomatic hemorrhage was present in 10 (43.5%) of 23 Group A patients and in 28 (82.4%) of 34 Groups B and C patients. Although high-resolution MR imaging revealed the presence of associated venous malformations in 11 (78.6%) of 14 Group B patients, such studies demonstrated AVD in only two (10%) of 20 Group C patients.

Conclusions. Patients harboring cavernous malformations plus venous malformations or AVD are more likely to present with symptomatic hemorrhage than are patients with cavernous malformation alone. The actual incidence of associated venous drainage may be underestimated when MR imaging alone is used rather than combined with DS angiography.

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Giant chondroma arising from the dura mater of the convexity

Case report and review of the literature

Masaki Nakayama, Tetsuya Nagayama, Hirofumi Hirano, Tatsuki Oyoshi and Jun-ichi Kuratsu

✓ Chondromas arising from the dura mater are rare intracranial tumors. The authors present a case of intracranial giant chondroma originating from the dura mater of the convexity. Neuroimaging and surgical findings are described. The diagnostic clues are discussed and similar cases from the literature are reviewed.