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Toshihiro Kumabe, Shuichi Higano, Shoki Takahashi and Teiji Tominaga

Object

Opercular glioma inferolateral to the hand/digit sensorimotor area can be resected safely using a neuronavigation system and functional brain mapping techniques. However, the surgery can still sometimes cause postoperative ischemic complications, the character of which remains unclear. The authors of this study investigated the occurrence of infarction associated with resection of opercular glioma and the arterial supply to this region.

Methods

The study involved 11 consecutive patients with gliomas located in the opercular region around the orofacial primary motor and somatosensory cortices but not involving either the hand/digit area or the insula, who had been treated in their department after 1997. Both pre- and postoperative diffusion-weighted magnetic resonance (MR) imaging was performed in the nine consecutive patients after 1998 to detect ischemic complications. All patients underwent open surgery for maximum tumor resection. Postoperative MR imaging identified infarction beneath the resection cavity in all patients. Permanent motor deficits associated with infarction involving the descending motor pathway developed in two patients. Cadaveric angiography showed that the distributing arteries to the corona radiata were the long insular arteries and/or medullary arteries from the opercular and cortical segments of the middle cerebral artery.

Conclusions

Subcortical resection around the upper limiting sulcus of the posterior region of the insula and wide resection in the anteroposterior and cephalocaudal directions of the opercular region were considered to be risk factors of the critical infarction. Surgeons should be aware that resection of opercular glioma can disrupt the blood supply of the corona radiata, and carries the risk of permanent motor deficits.

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Shunji Mugikura and Shoki Takahashi

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Daddy Mata-Mbemba, Shunji Mugikura, Atsuhiro Nakagawa, Takaki Murata, Kiyoshi Ishii, Shigeki Kushimoto, Teiji Tominaga, Shoki Takahashi and Kei Takase

OBJECTIVE

The objective of this study was to test the hypothesis that midline (interhemispheric or perimesencephalic) traumatic subarachnoid hemorrhage (tSAH) on initial CT may implicate the same shearing mechanism that underlies severe diffuse axonal injury (DAI).

METHODS

The authors enrolled 270 consecutive patients (mean age [± SD] 43 ± 23.3 years) with a history of head trauma who had undergone initial CT within 24 hours and brain MRI within 30 days. Six initial CT findings, including intraventricular hemorrhage (IVH) and tSAH, were used as candidate predictors of DAI. The presence of tSAH was determined at the cerebral convexities, sylvian fissures, sylvian vallecula, cerebellar folia, interhemispheric fissure, and perimesencephalic cisterns. Following MRI, patients were divided into negative and positive DAI groups, and were assigned to a DAI stage: 1) stage 0, negative DAI; 2) stage 1, DAI in lobar white matter or cerebellum; 3) stage 2, DAI involving the corpus callosum; and 4) stage 3, DAI involving the brainstem. Glasgow Outcome Scale–Extended (GOSE) scores were obtained in 232 patients.

RESULTS

Of 270 patients, 77 (28.5%) had DAI; tSAH and IVH were independently associated with DAI (p < 0.05). Of tSAH locations, midline tSAH was independently associated with both overall DAI and DAI stage 2 or 3 (severe DAI; p < 0.05). The midline tSAH on initial CT had sensitivity of 60.8%, specificity of 81.7%, and positive and negative predictive values of 43.7% and 89.9%, respectively, for severe DAI. When adjusted for admission Glasgow Coma Score, the midline tSAH independently predicted poor GOSE score at both hospital discharge and after 6 months.

CONCLUSIONS

Midline tSAH could implicate the same shearing mechanism that underlies severe DAI, for which midline tSAH on initial CT is a probable surrogate.

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Ryuta Saito, Toshihiro Kumabe, Yukihiko Sonoda, Masayuki Kanamori, Shunji Mugikura, Shoki Takahashi and Teiji Tominaga

Object

The atrium of the lateral ventricle is often affected by tumors, and some patients with these tumors suffer neurological deficits, including hemiparesis after surgery. The authors of this study investigated the possible mechanisms causing the relatively high incidences of ischemic complications associated with surgery approaching the atrium of the lateral ventricle.

Methods

Clinical records and radiological images of 28 patients were retrospectively studied. These patients had their lateral ventricles opened at the atrium during the resection of gliomas as well as other nonbenign brain tumors, and were treated for gliomas at our tertiary referral center in the Tohoku district, Japan, between January 2008 and December 2010.

Results

Routine postoperative diffusion-weighted MR images obtained within 72 hours after surgery detected infarction in the periatrial/periventricular regions in 7 patients, presumably corresponding to the lateral posterior choroidal artery (LPChA) territory. Five of these 7 patients suffered neurological sequelae with varying severities. The choroid plexus at the atrium was coagulated to achieve hemostasis during the surgery in all of these patients. Detailed analysis of microangiograms revealed ventriculofugal arteries arising from the lateral ventricle. Damage of the subependymal artery that supplies the ventriculofugal arteries caused by coagulation of the choroid plexus at the atrium probably resulted in the infarction in these patients.

Conclusions

Neurosurgeons must be aware of the possibility of LPChA territory infarction during surgery in the atrial or periatrial regions caused by subependymal artery obstruction after manipulating or coagulating the choroid plexus near the atrium.