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Stereotactic radiosurgery as adjuvant treatment for residual solitary fibrous tumor

Case report

Kuniaki Nakahara, Masaru Yamada, Satoru Shimizu, and Kiyotaka Fujii

✓ This 50-year-old woman presented with headache and visual disturbance. Neuroimaging results demonstrated a well-demarcated tumor attached to the falx cerebri near the transverse sinus, and the lesion was subtotally removed. Based on histological and immunohistochemical evaluation, a solitary fibrous tumor (SFT) was diagnosed. During the next 32 months, the size of the residual tumor increased slightly at the transverse sinus. Stereotactic radiosurgery (SRS) was performed as an adjuvant treatment. Over the course of the next 4 years the tumor decreased in size. The authors suggest that SRS constitutes good adjuvant treatment for regrowing residual SFTs not amenable to reoperation.

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Intracranial vertebral artery dissection with subarachnoid hemorrhage: clinical characteristics and outcomes in conservatively treated patients

Masaru Yamada, Takao Kitahara, Akira Kurata, Kiyotaka Fujii, and Yoshio Miyasaka

Object. Intracranial vertebral artery (VA) dissection with subarachnoid hemorrhage is notorious for frequent rebleeding and a poor prognosis. Nevertheless, some patients survive with a good final outcome. The factors associated with the prognosis of this disease are not fully understood and appropriate treatment strategies continue to be debated. The authors retrospectively evaluated the clinical features of conservatively treated patients to elucidate the relationship between the clinical and angiographic characteristics of the disease and final outcomes.

Methods. This study includes 24 patients who were treated by conservative methods between 1990 and 2000. Conservative treatment was chosen because of delayed diagnosis, poor clinical condition, or anatomical features such as bilateral lesions and contralateral VA hypoplasia.

Of nine patients with an admission Hunt and Kosnik Grade I or II, eight had good outcomes (mean follow-up period 8 years and 4 months). All 15 patients with Grade III, IV, or V died and in 10 of these the cause of death was rebleeding. Among the 24 patients, 14 suffered a total of 35 rebleeding episodes; in 10 (71.4%) of these 14 patients rebleeding occurred within 6 hours and in 13 (93%) within 24 hours. Compared with the survivors, there was a female preponderance (0.022) among patients who died. These patients also had significantly shorter intervals between onset and hospital admission (p = 0.0067), a higher admission Hunt and Kosnik grade (p = 0.0001), a higher incidence of prehospitalization (p = 0.0296) and postadmission (p = 0.0029) rebleeding episodes, and a higher incidence of angiographically confirmed pearl-and-string structure of the lesion (p = 0.0049).

Conclusions. In our series of preselected patients, poor admission neurological grade, rebleeding episode(s), and lesions with a pearl-and-string structure were predictive of poor outcomes. Our findings indicate that patients with these characteristics may be candidates for aggressive attempts to prevent rebleeding during the acute stage. Patients without these characteristics may be good candidates for conservative treatment, especially those who survive the acute phase without rebleeding.

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Prognostic factors of balloon kyphoplasty for osteoporotic vertebral fractures with diffuse idiopathic skeletal hyperostosis

Yuji Tsuchikawa, Naosuke Kamei, Kiyotaka Yamada, Toshio Nakamae, Nobuo Adachi, and Yoshinori Fujimoto

OBJECTIVE

The authors aimed to determine the poor prognostic factors of balloon kyphoplasty for the treatment of fractures of the most distal or distal-adjacent vertebrae in ankylosing spines with diffuse idiopathic skeletal hyperostosis (DISH).

METHODS

Eighty-nine patients with fractures of the most distal or distal-adjacent vertebrae of ankylosing spines with DISH were included and divided into two groups: those with (n = 51) and without (n = 38) bone healing 6 months postoperatively. Clinical evaluation included age, sex, time from onset to surgery, the visual analog scale score for low-back pain, and the Oswestry Disability Index (ODI). The VAS scores and ODI were measured both preoperatively and at 6 months postoperatively. Radiological evaluations included bone density; wedge angles of the fractured vertebrae in the supine and sitting positions on lateral radiographs; differences in the wedge angles (change in wedge angle); and the amount of polymethylmethacrylate used.

RESULTS

The preoperative ODI, vertebral wedge angles in the supine and sitting positions, change in wedge angle, and amount of polymethylmethacrylate were significantly different between the two groups and were significantly associated with delayed bone healing in univariate logistic regression analysis. Multivariate logistic regression analysis showed that only a change in the wedge angle was significantly associated with delayed healing, with a cutoff value of 10°, sensitivity of 84.2%, and specificity of 82.4%.

CONCLUSIONS

Treatment with balloon kyphoplasty alone should be avoided in patients with a difference ≥ 10° in the wedge angle of the fractured vertebrae between the supine and sitting positions.

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Endovascular surgery for very small ruptured intracranial aneurysms

Technical note

Sachio Suzuki, Akira Kurata, Taketomo Ohmomo, Takao Sagiuchi, Jun Niki, Masaru Yamada, Hidehiro Oka, Kiyotaka Fujii, and Shinichi Kan

✓Application of endovascular surgery for very small aneurysms is controversial because of technical difficulties and high complication rates. The aim in the present study was to assess treatment results in a series of such lesions at one institution.

Since 1997, endovascular surgery has been advocated for very small ruptured aneurysms (<3 mm in maximum diameter) that fulfill the criterion of a fundus/neck ratio greater than 1.5. Twenty-one patients were treated, for whom the World Federation of Neurosurgical Societies classification before treatment was Grade I in 10, Grade II in two, Grade III in two, Grade IV in five, and Grade V in two. The aneurysm location was the internal carotid artery in four, the anterior communicating artery in 11, the middle cerebral artery in one, and the vertebrobasilar system in five. In all patients, endovascular surgery was performed using Guglielmi detachable coils after induction of general anesthesia. Initially, the presumed volume of the lesions was calculated for each aneurysm. Thereafter, the appropriate coil length was decided according to the volume embolization ratio, as 30 to 40%. In all attempts to obliterate aneurysms a single coil was used.

All aneurysms were completely obliterated as confirmed by postembolization angiography, without procedure-related complications. During the follow-up period only one patient needed additional coil embolization for a growing aneurysm. Final outcomes were good recovery in 15 patients, moderate disability in five, and severe disability in one.

Appropriate selection of patients and coils, and use of sophisticated techniques allow a good outcome for patients with very small aneurysms.

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A new transvenous approach to the carotid-cavernous sinus via the inferior petrooccipital vein

Clinical article

Akira Kurata, Sachio Suzuki, Kazuhisa Iwamoto, Kuniaki Nakahara, Madoka Inukai, June Niki, Kimitoshi Satou, Masaru Yamada, Kiyotaka Fujii, Shinichi Kan, and Toshiro Katsuta

Object

The transvenous approach via the inferior petrosal sinus (IPS) is commonly used as the most appropriate for carotid-cavernous fistula (CCF) or cavernous sinus sampling. However, sometimes the IPS is not accessible because of anatomical problems and/or complications, therefore an alternative route is needed. In this paper, the authors present and discuss the utility of a transvenous approach to the cavernous sinus via the inferior petrooccipital vein.

Methods

Four patients, 3 with dural CCFs and the other with Cushing disease, in whom endovascular surgical attempts failed using a conventional venous approach via the IPS, underwent a transvenous approach to the cavernous sinus via the inferior petrooccipital vein (IPOV). One dural CCF case had only cortical venous drainage, the second CCF also mainly drained into the cortical vein with slight inflow into the superior ophthalmic vein and inferior ophthalmic vein, and the third demonstrated drainage into the superior and inferior ophthalmic veins and IPOV.

Results

In all cases, the cavernous sinus could be accessed successfully via this route and without complications.

Conclusions

The transvenous approach to the cavernous sinus via the IPOV should be considered as an alternative in cases when use of the IPS is precluded by an anatomical problem and there are no other suitable venous approach routes.

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Clinical results of cervical myelopathy in patients older than 80 years of age: evaluation of spinal function with motor evoked potentials

Clinical article

Nobuhiro Tanaka, Kazuyoshi Nakanishi, Yoshinori Fujimoto, Hirofumi Sasaki, Naosuke Kamei, Takahiko Hamasaki, Kiyotaka Yamada, Risako Yamamoto, Toshio Nakamae, and Mitsuo Ochi

Object

In this prospective analysis the authors describe the clinical results of surgical treatment in patients > 80 years of age in whom spinal function was evaluated with motor evoked potential (MEPs) monitoring.

Methods

The authors included 57 patients > 80 years of age who were suspected of having cervical myelopathy. The mean age of the patients was 83.0 years (range 80–90 years). The central motor conduction time (CMCT) was calculated from the latencies of the MEPs following transcranial magnetic stimulation and from M and F waves following peripheral nerve stimulation.

Results

Preoperative electrophysiological evaluation demonstrated significant elongation of CMCT or abnormalities in MEP waveforms in 37 patients (65%), and 35 patients of these underwent laminoplasty. In 30 patients cervical spondylotic myelopathy was diagnosed and 5 patients ossification of the posterior longitudinal ligament was diagnosed. The preoperative mean Japanese Orthopaedic Association Scale score was 8.6 (range 3–12.5) and the mean postoperative score was 12.6 (range 6–14.5) with an average recovery rate of 45% (range −21 to 100%). There were no major complications in any of the patients during the operative period and there were no cases of death resulting from operative intervention.

Conclusions

Sufficient clinical results are expected even in patients with myelopathy who are older than 80 years of age, provided the patients are correctly selected by electrophysiological evaluation with MEPs and CMCT.

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Modulation of the secondary injury process after spinal cord injury in Bach1-deficient mice by heme oxygenase–1

Laboratory investigation

Kiyotaka Yamada, Nobuhiro Tanaka, Kazuyoshi Nakanishi, Naosuke Kamei, Masakazu Ishikawa, Toshiyuki Mizuno, Kazuhiro Igarashi, and Mitsuo Ochi

Object

Oxidative stress contributes to secondary injury after spinal cord injury (SCI). The expression of heme oxygenase-1 (HO-1), which protects cells from various insults including oxidative stress, is upregulated in injured spinal cords. Mice deficient in Bach1 (Bach1−/−), a transcriptional repressor of the HO-1 and beta-globin genes, express high levels of HO-1 mRNA and protein in various organs. The authors hypothesized that HO-1 modulates the secondary injury process after SCI in Bach1−/− mice.

Methods

Male C57BL/6 (wild-type) and homozygous Bach1−/− C57BL/6 mice were subjected to moderate SCI, and differences in hindlimb motor function, and electrophysiological, molecular biological, and histopathological changes were assessed for 2 weeks.

Results

Functional recovery was greater, and motor evoked potentials were significantly larger in Bach1−/− mice than in wild-type mice throughout the observation period. The expression of HO-1 mRNA in the spinal cord was significantly increased in both mice until 3 days after injury, and it was significantly higher in Bach1−/− mice than in wild-type mice at every assessment point. Histological examination using Luxol fast blue staining at 1 day after injury showed that the injured areas were smaller in Bach1−/− mice than in wild-type mice. The HO-1 immunoreactivity was not detected in uninjured spinal cord, but 3 days postinjury the number of HO-1–immunoreactive cells was obviously higher in the injured area in both mice, particularly in Bach1−/− mice. The HO-1 was primarily induced in microglia/macrophage in both mice.

Conclusions

These results suggest that HO-1 modulates the secondary injury process, and high HO-1 expression may preserve spinal cord function in the early stages after SCI in Bach1−/− mice. Treatment that induces HO-1 expression at these early stages may preserve the functional outcome after SCI.

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Regeneration of peripheral nerve after transplantation of CD133+ cells derived from human peripheral blood

Laboratory investigation

Yasumu Kijima, Masakazu Ishikawa, Toru Sunagawa, Kazuyoshi Nakanishi, Naosuke Kamei, Kiyotaka Yamada, Nobuhiro Tanaka, Seiichi Kawamata, Takayuki Asahara, and Mitsuo Ochi

Object

Despite intensive efforts in the field of peripheral nerve injury and regeneration, it remains difficult to achieve full functional recovery in humans following extended peripheral nerve lesions. In this study, the authors examined the use of blood-derived CD133+ cells in promoting the repair of peripheral nerve defects.

Methods

The authors transplanted phosphate-buffered saline (control), mononuclear cells, or CD133+ cells embedded in atelocollagen gel into a silicone tube that was used to bridge a 15-mm defect in the sciatic nerve of athymic rats (12 animals in each group). At 8 weeks postsurgery, molecular, histological, and functional evaluations were performed in regenerated tissues.

Results

The authors found that sciatic nerves in which a defect had been made were structurally and functionally regenerated within 8 weeks after CD133+ cell transplantation. From macroscopic evaluation, massive nervelike tissues were confirmed only in rats with CD133+ cell transplantation compared with the other groups. Morphological regeneration in the samples after CD133+ cell transplantation, as assessed using toluidine blue staining, was enhanced significantly in terms of the number of myelinated fibers, axon diameter, myelin thickness, and percentage of neural tissue. Compound muscle action potentials were observed only in CD133+ cell–treated rats. Furthermore, it was demonstrated that the transplanted CD133+ cells differentiated into Schwann cells by 8 weeks after transplantation.

Conclusions

The results show that CD133+ cells have potential for enhancement of histological and functional recovery from peripheral nerve injury. This attractive cell source could be purified easily from peripheral blood and could be a feasible autologous candidate for peripheral nerve injuries in the clinical setting.