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Yoshikazu Ogawa and Teiji Tominaga

OBJECT

Treatment with dual antiplatelet agents associated with coronary stenting procedures and long-term anticoagulant therapy is increasingly common, but the treatment carries risks during surgical procedures. Evidence-based recommendations have proposed discontinuation of antithrombotic treatment or introduction of bridging therapy in some procedures less invasive and with lower risk of bleeding. However, neurosurgical procedures without discontinuation of antithrombotic treatment and perioperative management have received little investigation.

METHODS

Between October 2008 and January 2014, 15 consecutive patients (11 males and 4 females; age range 51–75 years [mean 68.2 years]), with sellar and parasellar tumors were treated through the transsphenoidal approach without discontinuation of antithrombotic therapy. Clinical data were compared with another 15 patients, who underwent transsphenoidal surgeries without preoperative antithrombotic therapy.

RESULTS

Gross-total removal of the tumor or total aspiration of the content of Rathke's cleft cyst was achieved in 13 patients, and subtotal removal was achieved in 1 patient with a small remnant in the cavernous sinus. No difference was found in intraoperative bleeding between the antithrombotic agent group and the control group (mean 255 ml vs 215 ml, Mann-Whitney U-test, p = 0.547), and no patient required transfusion. No difference was found in operation time between the antithrombotic agent group and the control group (167.8 minutes vs 150.0 minutes, Mann-Whitney U-test, p = 0.262). All patients were discharged on postoperative Day 12 without neurological deficits.

CONCLUSIONS

The present study suggests that discontinuation of antithrombotic therapy may be unnecessary before the typical transsphenoidal surgery. Large randomized clinical trials at multiple centers are needed to confirm these findings.

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Teiji Tominaga, Toshiyuki Takahashi, Hiroaki Shimizu and Takashi Yoshimoto

✓ Vertebral artery (VA) occlusion by rotation of the head is uncommon, but can result from mechanical compression of the artery, trauma, or atlantoaxial instability. Occipital bone anomalies rarely cause rotational VA occlusion, and patients with nontraumatic intermittent occlusion of the VA usually present with compromised vertebrobasilar flow.

A 34-year-old man suffered three embolic strokes in the vertebrobasilar system within 2 months. Magnetic resonance imaging demonstrated multiple infarcts in the vertebrobasilar territory. Angiography performed immediately after the third attack displayed an embolus in the right posterior cerebral artery. Radiographic and three-dimensional computerized tomography bone images exhibited an anomalous osseous process of the occipital bone projecting to the posterior arch of the atlas. Dynamic angiography indicated complete occlusion of the left VA between the osseous process and the posterior arch while the patient's head was turned to the right. Surgical decompression of the VA resulted in complete resolution of rotational occlusion of the artery.

An occipital bone anomaly can cause rotational VA occlusion at the craniovertebral junction in patients who present with repeated embolic strokes resulting from injury to the arterial wall.

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Yoshikazu Ogawa and Teiji Tominaga

A Rathke cleft cyst is considered to arise from the remnants of the Rathke pouch, and it consists of single cuboidal or columnar epithelium including cilia and goblet cells, which secrete mucus into the cyst. Magnetic resonance imaging characteristically shows a thin membranous cystic wall that enhances with Gd, and homogeneous intensity of the content suggesting fluid collection. Cases with an irregularly thickened and/or calcified cyst wall, presumably due to chronic inflammation of the wall, are rare.

A 21-year-old woman presented with an extremely rare case of a solid and cystic Rathke cleft cyst with partial ossification, manifesting as bitemporal hemianopia. Magnetic resonance imaging showed a massive solid sellar lesion extending upward and compressing the optic chiasm and floor of the third ventricle. Transsphenoidal surgery was performed, resulting in total removal of the lesion and immediate recovery of visual function. Postoperative histological examination disclosed that the major part of the lesion consisted of various phases of clotting and granulation with significant fibrosis. Mature bone formation and abundant cholesterin clefts were also seen. Single cuboidal epithelium including goblet cells and cilia was found along this granulation, and the diagnosis was a Rathke cleft cyst. An ossified Rathke cleft cyst is extremely rare, and a solid Rathke cleft cyst has not before been reported. This case illustrates the extremely long and complex nature of this disease.

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Teiji Tominaga, Hiroshi Shamoto, Hiroaki Shimizu, Mika Watanabe and Takashi Yoshimoto

✓ The histological changes that occur in brain tissue have rarely been documented in patients with dural arteriovenous fistulas (AVFs). In this study the authors report on two patients with dural AVFs in the transverse—sigmoid sinus who presented with subarachnoid hemorrhage or progressive dementia. Histological studies of the cerebellar cortices showed a selective loss of Purkinje cells, indicating an ischemic insult caused by venous hypertension. Admission N-isopropyl-p-123I-iodoamphetamine single-photon emission computerized tomography scans demonstrated a decrease in cerebral blood flow, including flow through the cerebellum. Venous hypertension caused by transverse—sigmoid sinus dural AVFs provokes an ischemic condition severe enough to cause selective neuronal damage in the cerebellum.

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Toshiyuki Takahashi, Teiji Tominaga, Masayuki Ezura, Kiyotaka Sato and Takashi Yoshimoto

✓ The authors report on a 38-year-old woman with a dislocated hangman fracture associated with unilateral vertebral artery (VA) occlusion. The patient presented with a mild central cord syndrome, as well as anterior subluxation of the C-2 vertebral body upon C-3, bilateral neural arch fractures, and a unilateral locked facet joint. Digital subtraction angiography revealed occlusion of the right VA, with the posterior cerebral circulation entirely dependent on the left VA. Intraoperative angiography demonstrated that complete reduction of the dislocation would have caused severe stenosis of the left VA; partial reduction and anterior fixation were performed instead, with excellent neurological outcome. In this case, intraoperative angiography was particularly useful for preventing brain-related ischemic complications during reduction.

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Noboru Takahashi, Kazunori Fujiwara, Keiichi Saito and Teiji Tominaga

In pterional craniotomy, fixation plates cause artifacts on postoperative radiological images; furthermore, they often disfigure the scalp in hairless areas. The authors describe a simple technique to fix a cranial bone flap with only a single plate underneath the temporalis muscle in an area with hair, rather than using a plate in a hairless area. The key to this technique is to cut the anterior site of the bone flap at alternate angles on the cut surface. Interdigitation between the bone flap and skull enables single-plate fixation in the area with hair, which reduces artifacts on postoperative radiological images and provides excellent postoperative cosmetic results.

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Masaki Iwasaki, Nobukazu Nakasato, Hiroyoshi Suzuki and Teiji Tominaga

A 34-year-old man presented with intractable temporal lobe epilepsy. Three-tesla magnetic resonance imaging revealed increased T2 signal intensity and volume loss limited to the CA4 region of the right hippocampus. A right anterior temporal lobectomy and amygdalohippocampectomy were performed. Histological examination of the hippocampus disclosed severe neuron loss limited to the CA4 region, consistent with the preoperative imaging, which is a pattern known as endfolium sclerosis. Close inspection of the internal hippocampal anatomy with high-field MR imaging is useful in patients with temporal lobe epilepsy, because endfolium sclerosis may be associated with less chance of seizure freedom after temporal lobectomy.

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Masayuki Kanamori, Toshihiro Kumabe, Mika Watanabe and Teiji Tominaga

✓The authors present the case of a 51-year-old man who presented with an anaplastic astrocytoma and anaplastic oligo-dendroglioma that developed 6 years after subtotal resection of a central neurocytoma in his right lateral ventricle. He had received neither radiation therapy nor chemotherapy after the original resection. On readmission, neuroimaging revealed a mass in the right parietal lobe and a diffuse lesion in the right temporal lobe, insula, and corona radiata. Because both lesions extended to the right lateral ventricle wall, they were regarded as recurrent rather than metachronous tumors. Histological examination revealed anaplastic oligodendroglioma in the parietal lobe and anaplastic astrocytoma in the insula. One year later, the anaplastic astrocytoma was found to have transformed into a glioblastoma multiforme. Fluorescence in situ hybridization analysis and immunohistochemical examinations detected deletions of the 1p36 and 19q13 loci, and nuclear accumulation of TP53 protein in the anaplastic oligodendroglioma but not in the glioblastoma multiforme. These findings suggest that central neurocytoma or progenitor cells have the potential for oligodendrocytic and astrocytic transformation with different genetic aberrations.

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Tomomi Kimiwada, Toshiaki Hayashi, Reizo Shirane and Teiji Tominaga

OBJECTIVE

Some pediatric patients with moyamoya disease (MMD) present with posterior cerebral artery (PCA) stenosis before and after anterior circulation revascularization surgery and require posterior circulation revascularization surgery. This study evaluated the factors associated with PCA stenosis and assessed the efficacy of posterior circulation revascularization surgery, including occipital artery (OA)–PCA bypass, in pediatric patients with MMD.

METHODS

The presence of PCA stenosis before and after anterior circulation revascularization surgery and its clinical characteristics were investigated in 62 pediatric patients (< 16 years of age) with MMD.

RESULTS

Twenty-three pediatric patients (37%) with MMD presented with PCA stenosis at the time of the initial diagnosis. A strong correlation between the presence of infarction and PCA stenosis before anterior revascularization was observed (p < 0.001). In addition, progressive PCA stenosis was observed in 12 patients (19.4%) after anterior revascularization. The presence of infarction and a younger age at the time of initial diagnosis were risk factors for progressive PCA stenosis after anterior revascularization (p < 0.001 and p = 0.002, respectively). Posterior circulation revascularization surgery, including OA-PCA bypass, was performed in 9 of the 12 patients with progressive PCA stenosis, all of whom showed symptomatic and/or radiological improvement.

CONCLUSIONS

PCA stenosis is an important clinical factor related to poor prognosis in pediatric MMD. One should be aware of the possibility of progressive PCA stenosis during the postoperative follow-up period and consider performing posterior circulation revascularization surgery.

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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.