Publications by authors named "Kazuhito Takeuchi"

42 Publications

Effect of cilia-induced surface velocity on cerebrospinal fluid exchange in the lateral ventricles.

J R Soc Interface 2022 Aug 3;19(193):20220321. Epub 2022 Aug 3.

Graduate School of Engineering, Kobe University, Kobe 657-8501, Japan.

Ciliary motility disorders are known to cause hydrocephalus. The instantaneous velocity of cerebrospinal fluid (CSF) flow is dominated by artery pulsation, and it remains unclear why ciliary dysfunction results in hydrocephalus. In this study, we investigated the effects of cilia-induced surface velocity on CSF flow using computational fluid dynamics. A geometric model of the human ventricles was constructed using medical imaging data. The CSF produced by the choroid plexus and cilia-induced surface velocity were given as the velocity boundary conditions at the ventricular walls. We developed healthy and reduced cilia motility models based on experimental data of cilia-induced velocity in healthy wild-type and Dpcd-knockout mice. The results indicate that there is almost no difference in intraventricular pressure between healthy and reduced cilia motility models. Additionally, it was found that newly produced CSF from the choroid plexus did not spread to the anterior and inferior horns of the lateral ventricles in the reduced cilia motility model. These findings suggest that a ciliary motility disorder could delay CSF exchange in the anterior and inferior horns of the lateral ventricles.
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http://dx.doi.org/10.1098/rsif.2022.0321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9346361PMC
August 2022

Efficacy and safety of the endoscopic "wet-field" technique for removal of supratentorial cavernous malformations.

Acta Neurochir (Wien) 2022 Jun 22. Epub 2022 Jun 22.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Turumai-cho, Nagoya City, Aichi, 466-8550, Japan.

Objective: Cerebral cavernous malformations (CMs) presenting with focal neurological symptoms or mass effects require surgical removal. In recent years, cylindrical retractors have been widely utilized for the removal of deep-seated lesions during both microscopic and endoscopic surgery. In the present study, we evaluated the efficacy and safety of endoscopic transcylinder removal of CMs using a novel wet-field technique.

Methods: We included 13 patients with supratentorial CMs who had undergone endoscopic transcylinder surgery between April 2013 and March 2022. One patient experienced recurrence of the CM and underwent a second endoscopic transcylinder surgery. Therefore, we retrospectively evaluated 14 procedures. The surgical field was continuously irrigated with artificial cerebrospinal fluid to maintain expansion and visualization of the tumor bed. We termed this method as the "wet-field technique." Patient characteristics, symptoms, and pre- and postoperative magnetic resonance imaging results were obtained from medical records.

Results: The average maximum CM diameter was 35.3 mm (range: 10-65 mm). Cylinder diameters were 6 mm in eight procedures, 10 mm in four procedures, and 17 mm in one procedure. Wet-field technique was applied in all cases. The endoscope provided a bright field of view even under water. Continuous water irrigation made it easier to observe the entire tumor bed which naturally expanded by water pressure. Gross total resection was achieved in 13 procedures, while subtotal resection was achieved in one procedure. No surgical complications were observed.

Conclusions: The endoscopic transcylinder removal using wet-field technique is safe and effective for the removal of symptomatic intracranial supratentorial CMs.
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http://dx.doi.org/10.1007/s00701-022-05273-zDOI Listing
June 2022

Direct intracranial invasion of eccrine spiradenocarcinoma of the scalp: a case report and literature review.

BMC Neurol 2022 Jun 18;22(1):223. Epub 2022 Jun 18.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

Background: Eccrine spiradenocarcinoma (SC), also known as malignant eccrine spiradenoma, is a rare malignant cutaneous adnexal neoplasm arising from long-standing benign eccrine spiradenoma. Malignant skin tumors rarely show direct intracranial invasion. However, once the intracranial structure is infiltrated, curative excision with sufficient margins can become extremely difficult, particularly when the venous sinuses are involved. No effective adjuvant therapies have yet been established. Here, we report an extremely rare case of scalp eccrine SC with direct intracranial invasion, which does not appear to have been reported previously.

Case Presentation: An 81-year-old woman presented with a large swelling on the parietal scalp 12 years after resection of spiradenoma from the same site. The tumor showed intracranial invasion with involvement of the superior sagittal sinus and repeated recurrences after four surgeries with preservation of the sinus. The histopathological diagnosis was eccrine SC. Adjuvant high-precision external beam radiotherapy (EBRT) proved effective after the third surgery, achieving remission of the residual tumor. The patient died 7 years after the first surgery for SC.

Conclusions: Scalp SC with direct intracranial invasion is extremely rare. Radical resection with tumor-free margins is the mainstay of treatment, but the involvement of venous sinuses makes this unfeasible. High-precision EBRT in combination with maximal resection preserving the venous sinuses could be a treatment option for local tumor control.
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http://dx.doi.org/10.1186/s12883-022-02749-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9206259PMC
June 2022

Case of a Pregnant Woman with Capillary Hemangioma of the Parasellar Region.

NMC Case Rep J 2022 21;9:77-82. Epub 2022 Apr 21.

Department of Neurosurgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan.

Here we report a rare case of capillary hemangioma (CH) in a 28-year-old woman suffering from gradual worsening diplopia at 28 weeks of pregnancy. Magnetic resonance imaging (MRI) showed a mass lesion (about 3 cm in diameter) in the right parasellar region. We decided to observe as she was pregnant, and had no symptoms other than right abducent nerve palsy. Fortunately, her symptoms did not worsen until delivery. Computed tomography, enhanced MRI, and angiography after delivery revealed that the lesion was highly calcified and vascularized. A dorsum sellae meningioma or highly calcified pituitary adenoma was suspected and the endoscopic transsphenoidal approach was used for tumor removal. The postoperative course was uneventful. The histological diagnosis was CH. Intracranial CHs or CHs of skull are rare vascular tumors. These tumors are reportedly more common in female patients and may change in size in adults according to menstrual cycle and pregnancy. Only six cases, including that of the present study, were diagnosed during the perinatal period. Some of them experienced rapid symptom progression and tumor growth in their course; thus, we should pay further attention to pregnant or peripartum patients with brain tumor, suspected hemangiomas.
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http://dx.doi.org/10.2176/jns-nmc.2021-0326DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9107939PMC
April 2022

Quick and simple dural threading technique for transsphenoidal surgery - dural tenting, haemostasis and skull base reconstruction.

Acta Neurochir (Wien) 2022 06 2;164(6):1619-1622. Epub 2022 May 2.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Turumai-cho, Nagoya City, , Aichi, 466-8550, Japan.

Background: Dural suturing is one of the most robust reconstruction methods in transsphenoidal surgery; however, the technique is considered difficult, primarily due to the restricted range of needle movement.

Method: We performed dural threading during transsphenoidal surgery by holding the needle with forceps as a hook and moving the needle in a distal to proximal direction.

Conclusion: Our dural suturing technique is simple and quick. It can be used not only for dural closure but also for other procedures, such as controlling haemostasis from the intercavernous sinus and dural tenting.
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http://dx.doi.org/10.1007/s00701-022-05227-5DOI Listing
June 2022

Modified Shoelace Dural Closure with Collagen Matrix in Extended Transsphenoidal Surgery.

Neurol Med Chir (Tokyo) 2022 Apr 16;62(4):203-208. Epub 2022 Mar 16.

Department of Neurosurgery, Nagoya University Graduate School of Medicine.

Extended endonasal transsphenoidal surgery (eTSS) offers a wide surgical field for various parasellar lesions; however, intraoperative high-flow cerebrospinal fluid (CSF) leakage is inevitable. Therefore, secure sellar reconstruction methods are essential to prevent postoperative CSF leakage. Although collagen matrix has been applied for dural reconstruction in neurosurgery, its suitability for application in extended eTSS remains unclear. Eighteen patients underwent modified shoelace dural closure using collagen matrix after lesionectomy via extended eTSS. In this technique, a collagen matrix, which was placed subdurally (inlay graft), was continuously sutured with both open dural edges like a shoelace. Then, another collagen matrix was placed epidurally (onlay graft), and rigid reconstruction was performed using the septal bone and a resorbable fixation mesh. Postoperative CSF leakage did not occur in 17 patients but did occur in 1 patient with tuberculum sellae meningioma. In this case, the CSF leakage point was detected just around the area between the coagulated dura and the adjacent collagen matrix. The collagen matrix harvested from this area was pathologically examined; neovascularization and fibroblastic infiltration into the collagen matrix were not detected. On the other hand, neovascularization and fibroblast infiltration into the collagen matrix were apparent on the surface of the collagen matrix harvested from the non-CSF leakage area. Our novel dural closure technique using collagen matrix could be an effective option for sellar reconstruction in extended eTSS; however, it should be applied in patients in whom normal dural edges are preserved.
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http://dx.doi.org/10.2176/jns-nmc.2021-0355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9093673PMC
April 2022

A Case of Primary Leptomeningeal Lymphoma Presenting with Hydrocephalus Characterized by Disproportionately Large Fourth Ventricle.

NMC Case Rep J 2021 9;8(1):399-404. Epub 2021 Jul 9.

Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan.

Primary leptomeningeal malignant lymphoma (PLML) is a rare variant of primary central nerve system malignant lymphoma (PCNSL) which is restricted to leptomeninges. The lesions of PLML can often be detected as abnormal enhancement on the surface of central nervous system or the ventricular wall on magnetic resonance imaging (MRIs). Cerebrospinal fluid (CSF) evaluation together with such MRI findings provides the definitive diagnosis of PLML. Here, we present a 45-year-old female case of PLML in which hydrocephalus with disproportionately large fourth ventricle was observed at presentation with gait instability. Head MRI revealed no abnormal enhancement and CSF cytology was negative, leaving the cause of hydrocephalus undetermined. Endoscopic third ventriculostomy (ETV) was effectively performed for hydrocephalus and her symptoms disappeared. Nearly 2 years later, she was brought to emergent room due to unconsciousness with the recurrence of hydrocephalus. MRI showed expanded fourth ventricle and abnormal enhancement on the ventricular wall. The endoscopic surgery for improving CSF flow was successful and inflammatory change was endoscopically observed on the ventricular wall involving aqueduct. Pathological diagnosis of the specimen from the ventricular wall proved B-cell lymphoma. Because neither brain parenchymal masses nor systemic tumors were identified, she was diagnosed with PLML and treated by high-dose methotrexate. She was in a stable state 2 years after the diagnosis of PLML. We report and discuss the characteristics of this case.
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http://dx.doi.org/10.2176/nmccrj.cr.2020-0215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8769436PMC
July 2021

Risk Factors for Cerebral Infarction Early After Revascularization in Children Younger than 5 Years with Moyamoya Disease.

World Neurosurg 2022 Apr 4;160:e220-e226. Epub 2022 Jan 4.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan.

Objective: Cerebral revascularization is necessary for pediatric patients younger than 5 years with moyamoya disease (MMD). However, they have a high risk of developing cerebral infarction early after surgery. This study aimed to analyze the risk factors for developing cerebral infarction among these patients.

Methods: The charts of 21 consecutive patients with MMD (39 surgeries) younger than 5 years who had undergone revascularization at our hospital were retrospectively analyzed. Because cerebral infarction occurring within 1 month after surgery was the primary end point, other clinical information was evaluated, including each surgical procedure. Multivariate analysis of the risk factors for postoperative cerebral infarction was performed.

Results: Cerebral infarction occurred after 7 of 39 surgeries (17.9%). Of the 39 surgeries, 23 (59%) included direct and indirect combined revascularization. The incidence of cerebral infarction did not differ significantly between the combined (21.7%) and indirect (12.5%) groups (P = 0.46). Logistic regression showed no association between the revascularization procedure and the occurrence of cerebral infarction after surgery (P = 0.3). However, younger age at surgery was correlated with a higher risk of developing cerebral infarction in the early postoperative period (P = 0.05).

Conclusions: No differences were found in the risk of developing cerebral infarction early after surgery as a result of surgical procedures. However, younger patients had higher postoperative risk. Further multicenter research should examine this issue for young pediatric patients with moyamoya at high risk of developing cerebral infarction.
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http://dx.doi.org/10.1016/j.wneu.2021.12.115DOI Listing
April 2022

Challenging direct bypass surgery for very young children with moyamoya disease: technical notes.

Neurosurg Rev 2022 Apr 31;45(2):1799-1807. Epub 2021 Oct 31.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan.

Cerebral revascularization for moyamoya disease (MMD) is an effective treatment for improving cerebral ischaemia and preventing rebleeding. Although direct bypass surgery is commonly performed on older children and adults, it is challenging in very young children due to the high difficulty level of the procedure. The subjects were MMD patients under 3 years of age on whom surgery was performed by a single surgeon (Y.A.). Preoperative clinical findings, information related to direct bypass surgery, bypass patency, and the incidence of postoperative stroke were investigated. Combined revascularization, including direct bypass surgery, was performed on 3 MMD patients (3 sides) under 3 years of age. The average diameter of the grafts used in direct bypass was 0.8 mm. The average recipient diameter was 0.8 ± 0.17 (range 0.6-1) mm. In all cases, the anastomotic procedure was completed using 11-0 monofilament nylon thread, and patency was confirmed. Direct bypass for MMD patients under 3 years old is technically challenging. However, despite the anatomical differences between very young children and elderly individuals, direct bypass surgery could certainly be completed. In addition, a rapid recovery from cerebral blood flow insufficiency could yield a promising neurological outcome.
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http://dx.doi.org/10.1007/s10143-021-01685-0DOI Listing
April 2022

A novel endoscopic ventriculocisternostomy and stenting technique with a transparent acryl puncture needle for a trapped temporal horn: a technical report and literature review.

Neurosurg Rev 2022 Apr 2;45(2):1783-1789. Epub 2021 Oct 2.

Department of Neurosurgery, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Japan.

Trapped temporal horn is a rare type of noncommunicating focal hydrocephalus, and no standard treatment has been established yet for trapped temporal horn. Recent studies have shown the efficacy of endoscopic ventriculocisternostomy by opening the choroidal fissure; however, some surgical complications were reported during the procedure. Thus, we aimed to report a novel endoscopic ventriculocisternostomy and stenting technique for trapped temporal horn. In this technique, a 5.8-mm transparent acryl puncture needle with a 2.7-mm 0° rigid endoscope was used to open the choroidal fissure. It can fenestrate the choroidal fissure under real-time endoscopic observation of the critical neurovascular structures over the choroidal fissure. Moreover, the dull tip of the needle is less likely to injure the critical neurovascular structures, resulting in safer ventriculocisternostomy than the previously reported technique. Then, a stent is placed along the tract to prevent future obstruction of the stoma. Six trapped temporal horns in four patients were treated using the technique. All the patients showed improved symptoms with no surgical complications. None of the patients showed recurrence of trapped temporal horn during the mean follow-up period of 39.3 months. The combination of endoscopic ventriculocisternostomy and stenting with a transparent acryl puncture needle is a safe and effective treatment option for trapped temporal horn.
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http://dx.doi.org/10.1007/s10143-021-01634-xDOI Listing
April 2022

A new primate model of hypophyseal dysfunction.

Sci Rep 2021 05 24;11(1):10729. Epub 2021 May 24.

Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan.

For pituitary regenerative medicine, the creation of a hypophyseal model in monkeys is necessary to conduct future preclinical studies; however, previous studies reported that hypophysectomy in monkeys is not always safe or satisfactory. This study aimed to create a hypophyseal dysfunction model in a cynomolgus monkey using a safer surgical technique and establish the protocol of pituitary hormone replacement therapy for this model. Surgical resection of the pituitary gland of a 7.8-year-old healthy adult cynomolgus male monkey weighing 5.45 kg was performed to create a hypophyseal dysfunction model for future regenerative studies. Endoscopic transoral transsphenoidal surgery was used to perform hypophysectomy under navigation support. These procedures were useful for confirming total removal of the pituitary gland without additional bone removal and preventing complications such as cerebrospinal fluid leakage. Total removal was confirmed by pathological examination and computed tomography. Hypopituitarism was verified with endocrinological examinations including stimulation tests. Postoperatively, the monkey's general condition of hypopituitarism was treated with hormone replacement therapy, resulting in long-term survival. The success of a minimally invasive and safe surgical method and long-term survival indicate the creation of a hypophyseal dysfunction model in a cynomolgus monkey; hence, this protocol can be employed in the future.
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http://dx.doi.org/10.1038/s41598-021-90209-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144576PMC
May 2021

Importance of Hydrostatic Pressure and Irrigation for Hemostasis in Neuroendoscopic Surgery.

Neurol Med Chir (Tokyo) 2021 Feb 29;61(2):117-123. Epub 2020 Dec 29.

Department of Neurosurgery, Nagoya University, Nagoya, Aichi, Japan.

Recently neurosurgical operations have been carried out with water irrigation such as endoscopic third ventriculostomy and tumor resections in ventricles. Water irrigation is one of several published methods that promote hemostasis; however, not enough experimental evidence exists on its efficacy. In this study, we investigate whether hydrostatic pressure and persistent irrigation promote hemostasis in neuroendoscopic surgery. We dissected tails of 12-16-week-old C57BL/6 male mice at 5 mm proximal from the tip and checked for bleeding times under dry and wet conditions at pressures of 0 cmHO, 10 cmHO, 15 HO, and 20 cmHO without persistent irrigation to bleeding point and 10 cmHO with persistent irrigation. We then examined the dissected edge with hematoxylin-eosin staining and measured the size of vessels. The average bleeding time of each group is as follows: dry: 203.4 sec, wet: 164.4 sec, 5 cmHO: 138.6 sec, 10 cmHO: 104.6 sec (P <0.001), 20 cmHO: 56 sec (P <0.001), and 10 cmHO with persistent irrigation: 72.8 sec (P <0.01 compared to 10 cmHO without persistent irrigation). The maximum caliber of mice's tail artery was 50-60 μm. Hydrostatic pressure and irrigation are important factors contributing to hemostasis.
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http://dx.doi.org/10.2176/nmc.oa.2020-0278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905298PMC
February 2021

Endoscopic-assisted paramedian infratentorial supracerebellar approach for pineal cyst - How I do it Video clip.

Surg Neurol Int 2020 15;11:336. Epub 2020 Oct 15.

Department of Gastroenterology, Fujita Health University Banbuntane Hospital, Nagoya, Aichi, Japan.

Background: The endoscopic supracerebellar-infratentorial (SCIT) approach is a viable method to access pathology of the posterior incisura, but a narrow working space and frequent instrument conflict can potentially limit its surgical efficacy. We planned an endoscopic-assisted paramedian infratentorial supracerebellar approach for pineal cyst.

Case Description: Patient was placed in prone position under general anesthesia. His head was rotated to the left side slightly. The location of the transverse sinus was detected with navigation system. A 5 cm linear skin incision was performed, and a 2 cm craniectomy was performed about 2 cm left of the median. The transverse sinus was little bit exposed. Dura was incised in a U-shaped incision with the transverse sinus at the base. The endoscope was advanced along with the culmen. At that time, we observed inferior and superior vermian vein. After reaching to the thick arachnoid near by galenic system, the arachnoid membrane was incised and the CSF was evacuated. After that, the cerebellum became soft and the surgical corridor became large. The arachnoid membrane was incised widely. Pineal cyst, precentral cerebellar vein, bilateral internal occipital vein and great vein of galen were exposed. There were some small veins on the pineal cyst, but the adhesion was not so severe. The cyst was dissected from these small veins. There was no adhesion between the cyst and surrounding brain except for the pineal recess. Bilateral ICV was seen behind the cyst. There was feeding artery and draining vein on the antero-lateral part of the cyst. These vessels were coagulated and cut, then the cyst was removed. After the removal, we confirmed complete removal of the cyst and hemostasis.

Conclusion: Endoscopic-assisted paramedian SCIT approach for pineal cyst in prone position is a reasonable and efficient access for posterior third ventricular lesions. The learning curve, maneuverability in small space, and instrument conflict limit efficacy.
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http://dx.doi.org/10.25259/SNI_354_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656027PMC
October 2020

Novel Endoscopic Technique for Inserting a Sheath into a Slit Ventricle: The Water-Slide Technique.

World Neurosurg 2021 01 4;145:1-4. Epub 2020 Sep 4.

Department of Neurosurgery, Nagoya University, Nagoya, Japan.

Background: The efficacy and safety of endoscopic procedures for slit ventricle syndrome (SVS) have been presented in recent studies. However, inserting a sheath into a target ventricle is essential in the beginning of endoscopic procedures for SVS, and this maneuver is challenging owing to the quite narrow ventricular space. We report a novel flexible endoscopic technique, the water-slide technique, that can effectively guide a sheath into a slit ventricle without the use of other adjunctive devices, such as a neuronavigation system and an ultrasound machine.

Methods: Ten endoscopic procedures using the water-slide technique were performed in 9 patients with SVS. All patients had undergone ventriculoperitoneal shunt placement. Using the technique, the sheath was first placed on the flexible endoscope. The endoscope was then inserted into the lateral ventricle along the tract around the pre-existing ventricular catheter with irrigation of artificial cerebrospinal fluid via the working channel of the endoscope. After the endoscope reached the ventricle, the sheath was inserted into the ventricle along the endoscope. The endoscope was then used as a stylet. The endoscopic procedure was performed afterward. Continuous irrigation of artificial cerebrospinal fluid via the working channel is important when using this technique.

Results: In all cases, the sheath was successfully introduced to the slit ventricle without the use of adjunctive devices. There were no postoperative complications correlated with the maneuver.

Conclusions: This novel endoscopic technique is effective and safe for inserting a sheath into a target ventricle in the management of SVS.
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http://dx.doi.org/10.1016/j.wneu.2020.08.206DOI Listing
January 2021

Fully Endoscopic Transcylinder Trans-Magendie Foraminal Approach for Fourth Ventricular Cavernoma: A Technical Case Report.

World Neurosurg 2020 10 27;142:104-107. Epub 2020 Jun 27.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan.

Background: Neuroendoscopy offers wide and close surgical views with fine illumination, even in deep surgical sites. Furthermore, transcylinder surgery has the advantage that a tubular retractor can protect critical neurovascular structures in the surgical corridor. These advantages of neuroendoscopy and transcylinder surgery can contribute to safer and less invasive surgical approaches for deep-seated fourth ventricular lesions, for which various critical neurovascular structures exist along the surgical route.

Case Description: A 54-year-old man with a fourth ventricular cavernoma underwent tumor resection via the endoscopic transcylinder trans-Magendie foraminal approach. A 6.8-mm transparent sheath (cylinder) was introduced into the fourth ventricle via the foramen of Magendie without incisions in the inferior medullary velum or the tela choroidea, resulting in the minimal retraction of and trauma to critical neurovascular structures in the surgical corridor. Under the view of a 2.7-mm rigid neuroendoscope, the lesion was completely removed with preservation of a venous anomaly on the ventral side of the aqueduct of Sylvius. Neuroendoscopy could offer a fine surgical view even under continuous irrigation with artificial cerebrospinal fluid; it prevented collapse of the fourth ventricle and facilitated anatomic understanding by the surgeons. The postoperative course was uneventful.

Conclusions: Our novel approach can be an effective surgical option for fourth ventricular lesions with minimal cerebellar retraction and injury.
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http://dx.doi.org/10.1016/j.wneu.2020.06.171DOI Listing
October 2020

Endoscopic Treatment Strategy for a Disproportionately Large Communicating Fourth Ventricle: Case Series and Literature Review.

Neurol Med Chir (Tokyo) 2020 Jul 12;60(7):351-359. Epub 2020 Jun 12.

Department of Neurosurgery, Graduate School of Medicine, Nagoya University.

An isolated fourth ventricle (IFV) is characterized by fourth ventricular dilation due to obstruction of its inlet and outlet. A disproportionately large communicating fourth ventricle (DLCFV) is a rare subtype of IFV, characterized by dilation of the fourth ventricle, regardless of the size of the lateral ventricles, with no apparent obstruction of the cerebral aqueduct. To our knowledge, this is the first case series describing endoscopic diagnosis and treatment strategy for DLCFV. We retrospectively reviewed six cases of DLCFV in which endoscopic surgery was performed at our institution and affiliated facilities between June 2013 and March 2017. DLCFV was diagnosed using radiographic imaging and intraoperative endoscopy. We also conducted a PubMed search and included only original studies related to DLCFV treatment written in English in our review of the literature. Endoscopic third ventriculostomy (ETV) was performed in all patients. Additional endoscope-assisted placement of a fourth ventriculoperitoneal (VP) shunt was performed in two patients who could not be managed with ETV alone because of severe adhesion of the interpeduncular cistern due to subarachnoid hemorrhage (SAH). The patients' symptoms and the size of the fourth ventricle improved with surgical treatment, without complications. Endoscopic surgery for DLCFV appears to be a safe and effective treatment. Based on our treatment strategy, ETV is the first-line treatment for DLCFV. Endoscope-assisted placement of the fourth VP shunt can be treatment for severe adhesion of the interpeduncular cistern.
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http://dx.doi.org/10.2176/nmc.oa.2019-0299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358780PMC
July 2020

Trautmann-focused mastoidectomy for a simple, safe presigmoid approach: technical note.

J Neurosurg 2020 Mar 27;134(3):843-847. Epub 2020 Mar 27.

The presigmoid approach (PSA) is selected to obtain more lateral access to cerebellopontine angle tumors, brainstem cavernous malformations, or vertebrobasilar artery aneurysms than the standard retrosigmoid approach. However, mastoidectomy for the PSA can be considered time-consuming and to carry a higher risk of complications due to the anatomical complexity of the region. The authors established a method of minimized mastoidectomy focused on exposing Trautmann's triangle as the corridor for the PSA while maximizing procedural simplicity and safety and maintaining a sufficient operative view. The authors present their method of minimized mastoidectomy in a cadaver dissection and operative cases, showing potential as a useful option for the PSA.
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http://dx.doi.org/10.3171/2020.1.JNS193179DOI Listing
March 2020

H3F3A mutant allele specific imbalance in an aggressive subtype of diffuse midline glioma, H3 K27M-mutant.

Acta Neuropathol Commun 2020 02 5;8(1). Epub 2020 Feb 5.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.

Diffuse midline glioma, H3 K27M-mutant is a lethal brain tumor located in the thalamus, brain stem, or spinal cord. H3 K27M encoded by the mutation of a histone H3 gene such as H3F3A plays a pivotal role in the tumorigenesis of this type of glioma. Although several studies have revealed comprehensive genetic and epigenetic profiling, the prognostic factors of these tumors have not been identified to date. In various cancers, oncogenic driver genes have been found to exhibit characteristic copy number alterations termed mutant allele specific imbalance (MASI). Here, we showed that several diffuse midline glioma, H3 K27M-mutant exhibited high variant allele frequency (VAF) of the mutated H3F3A gene using droplet digital polymerase chain reaction (ddPCR) assays. Whole-genome sequencing (WGS) revealed that these cases had various copy number alterations that affected the mutant and/or wild-type alleles of the H3F3A gene. We also found that these MASI cases showed a significantly higher Ki-67 index and poorer survival compared with those in the lower VAF cases (P < 0.05). Our results indicated that the MASI of the H3F3A K27M mutation was associated with the aggressive phenotype of the diffuse midline glioma, H3 K27M-mutant via upregulation of the H3 K27M mutant protein, resulting in downregulation of H3K27me3 modification.
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http://dx.doi.org/10.1186/s40478-020-0882-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001313PMC
February 2020

Preservation of Olfactory Function Following Endoscopic Single-Nostril Transseptal Transsphenoidal Surgery.

World Neurosurg 2019 Dec 20;132:e665-e669. Epub 2019 Aug 20.

Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan.

Objective: Olfactory dysfunction is a significant postoperative complication related to endoscopic transsphenoidal surgery (TSS). This study aimed to determine the impact of endoscopic TSS on olfactory function.

Methods: We conducted a prospective study of 32 patients with sellar or parasellar tumors who were treated with endoscopic TSS between December 2013 and October 2016. TSS was performed via a right transseptal approach. We performed the Toyota and Takagi olfactometer test and the venous olfaction test for the evaluation of olfactory function preoperatively and at 1 and 3 months postoperatively.

Results: The results of the Toyota and Takagi test showed that olfactory function deteriorated in 4 of 32 (12.5%) patients 1 month postoperatively and improved to preoperative baseline levels in all patients 3 months after the procedure. Olfactory function deteriorated in 1 of 31 (3.2%) patients 3 months after the procedure. The venous olfaction test revealed no response in 1 of 31 (3.2%) patients 1 month postoperatively, with no improvement 3 months after the procedure.

Conclusions: Endoscopic single-nostril transseptal TSS for sellar or parasellar tumor resection has minimal impact on olfactory function.
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http://dx.doi.org/10.1016/j.wneu.2019.08.051DOI Listing
December 2019

Peel-off resection of the pituitary gland for functional pituitary adenomas: pathological significance and impact on pituitary function.

Pituitary 2019 Oct;22(5):507-513

Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

Purpose: Functional pituitary adenomas (FPAs) lacking a well-defined pseudocapsule can invade the adjacent pituitary gland. In such situations, peel-off resection of the adjacent pituitary gland after selective adenomectomy might lead to complete tumor removal, resulting in optimal endocrinological outcomes. Here, we present the significance of peel-off resection of the pituitary gland in patients with FPA in whom complete extracapsular tumor removal cannot be achieved.

Methods: We performed a retrospective review of 21 patients with FPA who underwent transsphenoidal surgery (TSS). After selective adenomectomy, peel-off resection of the adjacent pituitary gland was performed in 13 patients because complete extracapsular resection could not be achieved, while peel-off resection was not performed in the remaining 8 patients because complete extracapsular resection was accomplished. The clinical outcomes of these groups were compared. The pituitary tissues obtained by peel-off resection were pathologically examined for tumor cells.

Results: Early postoperative biochemical remission was achieved in 20 patients (95.2%). Anterior pituitary functions were not aggravated postoperatively in any patient: however, transient diabetes insipidus (DI) occurred in 2 patients. There were no statistically significant differences in the clinical outcomes of the two groups. A pseudocapsule was pathologically detected in the adjacent anterior pituitary even in patients in whom no pseudocapsule was intraoperatively detected. Tumor cells were pathologically detected in 7 (58.3%) of 12 pituitary tissues examined.

Conclusions: Peel-off resection of the pituitary gland, which can remove a small tumor cell remnant in the adjacent pituitary, might maximize the effectiveness of TSS with minimal impact on postoperative pituitary function.
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http://dx.doi.org/10.1007/s11102-019-00980-wDOI Listing
October 2019

Removal of the Medial Wall of the Cavernous Sinus for Functional Pituitary Adenomas: A Technical Report and Pathologic Significance.

World Neurosurg 2019 06 5;126:53-58. Epub 2019 Mar 5.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan.

Background: Removal of the medial wall of the cavernous sinus (MW) is challenging for neurosurgeons. We describe a practical method of endoscopic MW removal via endonasal transsphenoidal approach to minimalize intraoperative blood loss and postoperative morbidities. We also present the pathologic significance of this technique for functional pituitary adenomas (FPAs).

Methods: We performed MW removal in patients with FPA with no well-defined pseudocapsule and a tumor in direct contact with the MW. The MW was judged to have tumor invasion based on the intraoperative appearance, and it was removed regardless of the appearance of MW involvement. Intraoperative findings and postoperative clinical, endocrinologic, and pathologic outcomes were retrospectively reviewed.

Results: Fourteen patients underwent MW removal for FPA, including 12 patients with acromegaly and 2 with Cushing disease. Mean intraoperative blood loss was 170 mL (range, 32-400 mL), and none of the patients required blood transfusion. Among the 7 patients without intraoperative apparent MW involvement, 4 (57.1%) had pathologically confirmed tumor invasion into the MW (occult invasion). Biochemical remission by surgery alone was achieved in 13 patients (92.9%). Transient oculomotor palsy occurred in 1 patient (7.1%).

Conclusions: Occult tumor invasion into the MW was often detected in patients with FPA without a well-defined pseudocapsule but in direct contact with the MW. Our technique can enhance the effectiveness of surgery with minimal postoperative morbidities.
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http://dx.doi.org/10.1016/j.wneu.2019.02.134DOI Listing
June 2019

Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery.

J Neurosurg 2018 10 1:1-7. Epub 2018 Oct 1.

OBJECTIVE: Transsphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results. METHODS: All patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect. RESULTS: There were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito's grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively. CONCLUSIONS: Dural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.
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http://dx.doi.org/10.3171/2018.4.JNS18366DOI Listing
October 2018

Quality of Life Changes Before and After Transsphenoidal Surgery for Sellar and Parasellar Lesions.

World Neurosurg 2019 Feb 14;122:e1202-e1210. Epub 2018 Nov 14.

Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan.

Objective: Although reports regarding the relationship between surgical complications and quality of life (QOL) exist, a general consensus regarding this issue is lacking. The aim of this study was to evaluate QOL after endoscopic transsphenoidal approach.

Methods: We assessed patients with sellar or parasellar lesions that were removed with endoscopic transsphenoidal approach or extended endoscopic transsphenoidal approach between January 2010 and December 2016. 36-Item Short Form Health Survey and 30-Item General Health Questionnaire QOL scores were obtained preoperatively and 1 month and 6 months postoperatively.

Results: We analyzed 89 patients with nonfunctioning pituitary adenoma (NFPA) and 39 patients with acromegaly. Physical QOL decreased 1 month after surgery but recovered after 6 months in both groups. Mental QOL improved postoperatively compared with preoperatively. Patients with acromegaly had a worse Physical Component Summary (PCS) on 36-Item Short Form Health Survey (48.7, 28.9, and 41.0) at 6 months than patients with NFPA. The low preoperative PCS group did not improve until 6 months postoperatively. Multiple regression analysis revealed the following factors were key to postoperative QOL: age (NFPA PCS 6 months postoperatively; correlation coefficient = -0.489), preoperative Mental Component Summary (MCS) (NFPA MCS 6 months postoperatively, correlation coefficient = 0.573), body mass index (acromegaly PCS 6 months postoperatively; correlation coefficient = -0.376), preoperative PCS (acromegaly PCS 6 months postoperatively; correlation coefficient = 0.905), and preoperative MCS (acromegaly MCS 6 months postoperatively; correlation coefficient = 0.726).

Conclusions: Endoscopic transsphenoidal approach can improve QOL in patients by 6 months postoperatively. In patients with acromegaly with significant QOL impairments preoperatively, surgery sometimes may be unable to normalize QOL.
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http://dx.doi.org/10.1016/j.wneu.2018.11.017DOI Listing
February 2019

Endoscopic clipping of intraventricular aneurysms using the "wet-field" technique.

J Neurosurg 2018 Jul;131(1):104-108

1Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya City, Aichi; and.

Intraventricular hemorrhage and intracerebral aneurysms are relatively frequent complications associated with moyamoya disease. Prevention of aneurysm rerupture is important because it significantly decreases the morbidity and mortality rates. Aneurysms arising distal to collateral flow are sometimes observed in patients with intraventricular hemorrhage; however, the treatment of these aneurysms remains challenging because of their deep-seated location in the brain and accompanying narrow surgical corridor. The authors describe a neuroendoscopic aneurysm clipping technique performed in 2 cases using a small-diameter tubular retractor for intraventricular aneurysms of the distal lateral posterior choroidal artery. In this technique, the surgical field was continuously irrigated with artificial CSF to keep the ventricle size intact, and aneurysm clipping was performed through a tubular retractor that was introduced with neuronavigational guidance. The patients' postoperative courses were uneventful, and CT angiography revealed complete clipping of the aneurysms and patent parent arteries. Endoscopic clipping using a tubular retractor is an effective and less invasive alternative for treating intraventricular aneurysms. The wet-field endoscopic technique is performed in an aqueous field and maintains an intact ventricle size, allowing for a clear surgical view and a wider, enhanced surgical field.
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http://dx.doi.org/10.3171/2018.1.JNS172393DOI Listing
July 2018

Accurate estimation of a phase diagram from a single STM image.

Sci Rep 2018 May 1;8(1):6841. Epub 2018 May 1.

Department of Materials Science and Engineering, Kyoto University, Sakyo, Kyoto, 606-8501, Japan.

We propose a new approach to constructing a phase diagram using the effective Hamiltonian derived only from a single real-space image produced by scanning tunneling microscopy (STM). Currently, there have been two main methods to construct phase diagrams in material science: ab initio calculations and CALPHAD with thermodynamic information obtained by experiments and/or theoretical calculations. Although the two methods have successfully revealed a number of unsettled phase diagrams, their results sometimes contradicted when it is difficult to construct an appropriate Hamiltonian that captures the characteristics of materials, e.g., for a system consisting of multiple-scale objects whose interactions are essential to the system's characteristics. Meanwhile, the advantage of our approach over existing methods is that it can directly and uniquely determine the effective Hamiltonian without any thermodynamic information. The validity of our approach is demonstrated through an Mg-Zn-Y long-period stacking-ordered structure, which is a challenging system for existing methods, leading to contradictory results. Our result successfully reproduces the ordering tendency seen in STM images that previous theoretical study failed to reproduce and clarifies its previously unknown phase diagram. Thus, our approach can be used to clear up contradictions shown by existing methods.
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http://dx.doi.org/10.1038/s41598-018-25283-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5931564PMC
May 2018

Neuroendoscopic Cylinder Surgery and 5-Aminolevulinic Acid Photodynamic Diagnosis of Deep-Seated Intracranial Lesions.

World Neurosurg 2018 Aug 23;116:e35-e41. Epub 2018 Mar 23.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Background: Microscopic detection of intracranial brain tumors with 5-aminolevulinic acid (5-ALA) has proven extremely useful, and reports the use of 5-ALA have recently increased. However, few reports have described 5-ALA photodynamic diagnosis (PDD) using a neuroendoscope. We performed neuroendoscopic 5-ALA PDD for various brain lesions and present a procedure using only a neuroendoscope.

Methods: We describe the diagnosis of 20 intracranial brain lesion cases with a 5-ALA-guided fluorescence endoscope. A light-emitting diode that emitted either white light or 400- to 410-nm violet light was attached to a neuroendoscope. We performed cylinder surgery with a transparent sheath under observation with a rigid neuroendoscope.

Results: Neuroendoscopic biopsies were performed in 11 patients, and resections were performed in 9 patients. All lesions were observed with a neuroendoscope under sequential white light and violet light. We confirmed the presence of a red fluorescent lesion under violet light in 15 patients, including 4 of 5 glioblastoma cases (80%); 1 of 2 anaplastic astrocytoma cases (50%); 4 of 5 diffuse large B cell lymphoma cases (80%); 2 of 2 metastatic brain tumors; 1 of 1 case each of diffuse astrocytoma, pilocytic astrocytoma, inflammatory change, and germinoma (100%); and no cases of anaplastic ependymoma or cysticercosis. Pretargeted lesions were accurately harvested from all biopsy specimens. Gross total resection was achieved in 5 of 9 patients using a resection procedure.

Conclusions: Our described method offers a promising technique for achieving precise brain tumor biopsies and safe resection.
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http://dx.doi.org/10.1016/j.wneu.2018.03.112DOI Listing
August 2018

A Novel Dissection Method Using a Flexible Neuroendoscope for Resection of Tumors Around the Aqueduct of Sylvius.

World Neurosurg 2018 Feb 20;110:391-396. Epub 2017 Nov 20.

Department of Neurosurgery, Nagoya University, Nagoya City, Japan.

Background: Flexible endoscopes have both a wide range of movement and a wide field of view and are therefore widely used for endoscopic third ventriculostomy and biopsy. However, tumor resection around the aqueduct of Sylvius using flexible endoscopes has scarcely been reported.

Case Description: We report 2 cases of tumor resection around the aqueduct of Sylvius. The first case is a 38-year-old man presenting with progressive headache, nausea, and diplopia. Magnetic resonance imaging (MRI) revealed a 1.4 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and endoscopic third ventriculostomy (ETV) simultaneously. His symptoms disappeared after the operation. Final pathologic diagnosis was ancient schwannoma. The second case is a 78-year-old woman presenting with progressive disturbance of consciousness (coma). MRI showed 0.7 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and ETV similarly. Her consciousness improved after the operation. Final tumor diagnosis was cavernous malformation. In both cases there was no additional neurologic deficit after the surgery.

Conclusions: By using a flexible endoscope for tumor dissection, resection of a tumor without a neck, which cannot be removed through aspiration alone, becomes possible. To our knowledge, the presented cases are the first to describe the effectiveness of complete resection of a tumor in the third ventricle using flexible endoscopy.
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http://dx.doi.org/10.1016/j.wneu.2017.11.044DOI Listing
February 2018

Fully endoscopic combined transsphenoidal and supraorbital keyhole approach for parasellar lesions.

J Neurosurg 2018 03 28;128(3):685-694. Epub 2017 Apr 28.

1Department of Neurosurgery, Nagoya University Graduate School of Medicine; and.

OBJECTIVE Parasellar tumors that extend far laterally beyond the internal carotid artery or that are fibrous and adhere firmly to critical structures are difficult to remove totally via the endoscopic transsphenoidal approach alone. In such cases, a combined transsphenoidal-transcranial approach is effective to achieve maximal resection in a single stage. In this paper, a new minimally invasive surgical technique for complicated parasellar lesions, a fully endoscopic combined transsphenoidal-supraorbital keyhole approach, is presented. METHODS A retrospective review of patients who had been treated via a fully endoscopic combined transsphenoidal-supraorbital keyhole approach for complicated parasellar lesions was performed. The data for resection rate, perioperative mortality and morbidity, and postoperative outcomes were analyzed. RESULTS A total of 12 fully endoscopic combined transsphenoidal-supraorbital keyhole approaches were performed from March 2013 to February 2016; 10 were for pituitary adenomas and 2 were for craniopharyngiomas. Gross-total resection or near-total resection was achieved in 7 of 12 cases. Among the 11 patients who had presented with preoperative visual disturbances, 7 had visual improvement. However, 1 patient showed deterioration in visual function. No patient experienced postoperative hemorrhage, needed additional surgical treatment, or had postoperative CSF leakage. CONCLUSIONS In the combined transsphenoidal and transcranial approach, safe and effective cooperative manipulation with 2 surgical corridors can be performed for complicated parasellar lesions. The goal of this procedure is not to achieve gross-total resection, but to achieve safe resection. Moreover, this new surgical approach offers neurosurgeons a simpler operative field with less invasiveness than the conventional microscopic combined approach. The fully endoscopic combined endonasal-supraorbital keyhole approach is an efficacious procedure for complicated parasellar lesions with acceptable results.
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http://dx.doi.org/10.3171/2016.11.JNS161833DOI Listing
March 2018

The Multiscope Technique for Microvascular Decompression.

World Neurosurg 2017 Jul 19;103:310-314. Epub 2017 Apr 19.

Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan.

Background: Endoscopic surgery has rapidly become widespread in neurosurgery in recent years. Endoscopy can offer close and panoramic surgical views with fine illumination, even in the deep intracranial area. However, it also has the following serious drawback: an intracranial blind area between the field lens of the endoscope and the site of the dural opening. This blind area cannot be viewed on the endoscopic monitor, and several surgical complications, including accidental intracranial neurovascular structural injury, can occur in this area. In this article, we report a new multiscope surgical technique that can compensate for this serious disadvantage of endoscopic surgery.

Methods: In the multiscope technique, endoscopic and exoscopic systems are used simultaneously with 2 monitors. Microvascular decompression (MVD) is performed fully endoscopically using an exoscope that compensates for the intracranial blind area of the endoscopic view. Two high-definition monitors for the endoscope and exoscope are placed side-by-side in front of the primary surgeon.

Results: Two patients with hemifacial spasm were treated by endoscopic MVD with the multiscope technique. In these procedures, fine surgical views were obtained by both the endoscope and exoscope. Two monitors were placed side-by-side in front of the surgeon; as a result, the physician could easily view them simultaneously during the operation. No surgery-related complications occurred.

Conclusions: The multiscope technique can facilitate the performance of safer neuroendoscopic surgery than conventional endoscopic surgery. This technique can also be adopted in other skull base surgeries, in which the importance of endoscopy is growing.
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http://dx.doi.org/10.1016/j.wneu.2017.04.059DOI Listing
July 2017
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