Publications by authors named "Soichi Oya"

63 Publications

Risk factors of meralgia paresthetica after prone position surgery: Possible influence of operating position, laminectomy level, and preoperative thoracic kyphosis.

J Clin Neurosci 2021 Jul 21;89:292-296. Epub 2021 May 21.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Obesity and a prolonged surgical duration are reported risk factors for meralgia paresthetica (MP) after prone position surgery; however, this fails to explain why MP seldom occurs after prone position craniotomy. We reviewed the incidence of MP after spinal surgery and craniotomy in the prone position and investigated whether unidentified factors are involved in the mechanism of postoperative MP. Between January 2014 and March 2020, we performed 556 prone position surgeries. We excluded patients aged ≤16 years and those who were comatose or who required redo-surgery, and reviewed 446 eligible patients (124 who underwent craniotomies and 322 who underwent posterior spinal surgeries). Postoperative MP occurred in 46 (10.3%) patients with a higher incidence after spinal surgery than after craniotomy (13.7% vs. 1.6%, p < 0.001). Among the 322 patients who received posterior spinal surgery, thoracic and lumbar laminectomies were associated with a higher incidence of MP than cervical laminectomy. Analyses limited to those patients who received thoracic and lumbar laminectomies revealed that the preoperative thoracic kyphosis (TK) angle was significantly greater in patients with MP than in those without MP (average TK angle, 38.9° vs. 23.1°; p < 0.001), and that the preoperative lumbar lordosis angle did not significantly differ between the two groups. Apart from the known predisposing factors, we found that thoracolumbar-sacral laminectomy in patients with a greater TK angle is also a risk factor for MP after prone position surgery.
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http://dx.doi.org/10.1016/j.jocn.2021.05.022DOI Listing
July 2021

Effect of adjuvant radiotherapy after subtotal resection for WHO grade I meningioma: a propensity score matching analysis of the Brain Tumor Registry of Japan.

J Neurooncol 2021 Jun 17;153(2):351-360. Epub 2021 May 17.

Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan.

Purpose: This study aimed to improve the understanding of the role of adjuvant radiotherapy (AR) after subtotal resection (STR) of World Health Organization (WHO) grade I meningiomas.

Methods: We retrospectively reviewed the Brain Tumor Registry of Japan database. Among 7341 patients diagnosed with intracranial meningioma during 2001-2008, we identified 406 patients with WHO grade I meningioma treated with STR as initial treatment. Data on progression-free survival (PFS) were assessed for their relevance to clinical factors including age, sex, tumor location and size, presence of preoperative symptoms, and AR.

Results: AR was administered for 73 patients (18.0%). Regrowth occurred in 90 cases (22.2%) during the median follow-up period of 6.0 years (interquartile range, 2.7-7.7 years). Multivariate Cox regression analysis of the entire cohort showed that no AR was associated with significantly shorter PFS (hazard ratio [HR] 2.52, 95% confidence interval [CI] 1.33-5.42, p = 0.004). The therapeutic effect of AR was confirmed for skull base, but not non-skull base, meningiomas (p = 0.003 and 0.69, respectively). Propensity score matching analysis balanced the influence of confounding factors to generate AR+ and AR- cohorts of 73 patients each. PFS was significantly longer in the AR+ cohort than in the AR- cohort (HR 3.46, 95% CI 1.53-8.59, p = 0.003). Subgroup analysis demonstrated the favorable effect of AR only for skull base meningiomas.

Conclusions: Our study revealed that AR improves tumor control after STR in WHO grade I meningiomas. However, this beneficial effect might be limited to skull base meningiomas.
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http://dx.doi.org/10.1007/s11060-021-03775-xDOI Listing
June 2021

Trigeminal neuralgia caused by an arachnoid cyst in Meckel's cave: A case report and literature review.

Surg Neurol Int 2021 10;12:45. Epub 2021 Feb 10.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.

Background: We present a rare case of trigeminal neuralgia (TN) caused by an arachnoid cyst (AC) in Meckel's cave (MC).

Case Description: A 35-year-old man presented with facial pain in the left maxillary and mandibular regions. Since the initial magnetic resonance (MR) imaging showed no apparent offending vessels or tumors, the patient was diagnosed with idiopathic TN, for which carbamazepine was initially effective. When his pain worsened, he was referred to our hospital. A slightly asymmetric shape of MC and distorted course of the trigeminal nerve was confirmed on the initial and repeat MR images. His pain was characterized as electric-shock-like pain, which was triggered by touching the face. Under the tentative diagnosis of an AC confined to MC compressing the trigeminal nerve, the exploration of MC through suboccipital craniotomy was performed. Intraoperatively, the AC was identified in the rostral portion of MC. The indentation of the trigeminal nerve was also observed at the orifice of MC, indicating severe compression by the AC. The wall of the AC was fenestrated. The patient's pain was relieved immediately after surgery. Postoperative MR images showed that the course of the trigeminal nerve was straightened. Although our literature review found five similar cases, the size of the AC was the smallest in our case.

Conclusion: Although it is rare, the AC confined to MC can cause TN. The findings of this study emphasize the importance of evaluating subtle radiological findings of compression on the trigeminal nerve in cases of TN seemingly without neurovascular compression.
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http://dx.doi.org/10.25259/SNI_734_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911133PMC
February 2021

Rationale and Design of BeatNF2 Trial: A Clinical Trial to Assess the Efficacy and Safety of Bevacizumab in Patients with Neurofibromatosis Type 2 Related Vestibular Schwannoma.

Curr Oncol 2021 01 31;28(1):726-739. Epub 2021 Jan 31.

Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan.

Neurofibromatosis type 2 (NF2) causes bilateral vestibular schwannomas (VSs), leading to deafness. VS is treated by surgery or radiation, but neither treatments prevent hearing loss. Bevacizumab was found to be effective in suppressing the tumor's growth and may help to improve hearing. We are conducting a randomized, double-blind, multicenter clinical trial to verify the efficacy and safety of bevacizumab in NF2-related VS. The primary objective is to evaluate the efficacy of bevacizumab in improving hearing in the affected ear. One of the secondary objectives is to evaluate bevacizumab's efficacy in rechallenge treatment in relapsed cases. Sixty patients will randomly receive either bevacizumab or a placebo and will be clinically observed for 48 weeks in the initial intervention phase. In the first half (24 weeks), they will receive either 5 mg/kg of bevacizumab or a placebo drug. In the second half, all patients will receive 5 mg/kg of bevacizumab. If hearing function deteriorated in a patient who had shown improvement during the first phase, a rechallenge dose with bevacizumab would be offered.
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http://dx.doi.org/10.3390/curroncol28010071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985777PMC
January 2021

In-Hospital Complications After Surgery in Elderly Patients with Asymptomatic or Minor Symptom Meningioma: A Nationwide Registry Study.

World Neurosurg 2021 04 11;148:e459-e470. Epub 2021 Jan 11.

Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.

Background: Asymptomatic or minor symptom meningiomas (AMSMs) in the elderly are incidental findings, with no consensus reached on the optimal management strategy. In the present study, we aimed to determine the surgical risk factors for elderly patients with AMSMs using a nationwide registry database in Japan.

Methods: We identified patients with surgically treated AMSMs using the Diagnosis Procedure Combination database from 2010 to 2015 and reviewed the medical records for age (<65 years; pre-elderly, 65-74 years; and elderly, ≥75 years), sex, Barthel index (BI) score, medical history, tumor location, and complications. An AMSM was defined by a BI score of 100 points at admission. The risk factors for all stroke complications, BI deterioration at discharge, and in-hospital mortality were determined using multivariate logistic regression analyses.

Results: From a total of 10,535 patients with meningioma, 6628 were included. Advanced age was a significant risk factor (odds ratio, 3.54; 95% confidence interval, 2.80-4.46) for BI deterioration but not for all-stroke complications or in-hospital mortality. Midline and posterior fossa tumors, diabetes mellitus, and chronic heart disease were significant risk factors for in-hospital mortality.

Conclusions: For elderly patients with surgically treated AMSMs, advanced age was a prominent risk factor for functional decline at discharge. Our study identified several factors that should be evaluated before proceeding with surgery for AMSMs in elderly and pre-elderly patients. These findings could, not only improve decision-making among clinicians treating patients with AMSMs, but also help in predicting the results of surgery for elderly patients with AMSMs.
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http://dx.doi.org/10.1016/j.wneu.2021.01.001DOI Listing
April 2021

Nation-wide Brain Tumor Registry-based Study of Intracranial Meningioma in Japan: Analysis of Surgery-related Risks.

Neurol Med Chir (Tokyo) 2021 Feb 23;61(2):98-106. Epub 2020 Dec 23.

Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan.

Although surgical resection is the most preferred treatment for intracranial meningiomas, a detailed analysis of the surgery-related risks based on large population data has not been conducted to date. In this study, we analyzed the nation-wide brain tumor registry to assess the surgical risk factors for intracranial meningiomas to provide information for an optimal treatment strategy. Data of 4081 meningioma patients who underwent initial resection between 2001 and 2008 were extracted from the Brain Tumor Registry of Japan (BTRJ) database and reviewed for postoperative mortality, aggravation of Karnofsky Performance Score (KPS), and complications. The total in-hospital mortality rate was 0.59%. Male sex and tumor size ≥30 mm were independent risk factors for mortality. Among 4081 cases, 4.4% of patients had KPS that were lowered by 20 or more points at the time of discharge after surgery. Age ≥65 years, higher WHO grading, tumor location at the skull base, tumor size ≥30 mm, and non-gross total resections were associated with lowering of KPS scores by 20 or more points. The overall incidence of surgical complications was 19.3%. The rate of occurrence of new postoperative seizure in patients with supratentorial meningioma was 10.9%. All complications except for vascular complications occurred with significantly lower frequencies in asymptomatic patients than in symptomatic patients. Our results provide useful information regarding the surgical risks when surgical intervention is being considered for intracranial meningiomas. Surgery is an important option for asymptomatic meningiomas as the mortality rate and complication rate in the current study were sufficiently low.
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http://dx.doi.org/10.2176/nmc.oa.2020-0304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905297PMC
February 2021

A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma.

Neurol Med Chir (Tokyo) 2021 Jan 19;61(1):12-20. Epub 2020 Nov 19.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University.

Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.
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http://dx.doi.org/10.2176/nmc.oa.2020-0287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812313PMC
January 2021

Masked malignant phenotype with a benign appearance: beat-up copy number profile may be the key for hemangioblastoma dissemination.

Brain Tumor Pathol 2021 Jan 18;38(1):71-77. Epub 2020 Oct 18.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.

Dissemination of histologically benign hemangioblastoma is rare; approximately 30 cases have previously been reported, and all cases occurred several months to years after surgical resection. Herein, we report a case of hemangioblastoma in which leptomeningeal dissemination occurred 2 years after hypofractionated radiation therapy (39 Gy/13 fractions). The tumor was treated primarily with radiation without surgical resection. Biopsy of the disseminated lesion confirmed histological diagnosis as histologically benign hemangioblastoma. Ki67 index was not remarkably elevated for hemangioblastomas. In addition, the methylation class determined by the methylation profiling classifier developed by the German Cancer Research Center (DKFZ)/University Hospital Heidelberg/German Consortium for Translational Cancer Research was consistent with that of common hemangioblastomas. However, genetic analyses showed significant gains and losses throughout the whole genome, indicating that highly aberrant copy number profiles may be the key to elucidating this rare but life-threatening clinical entity. Accumulation of more detailed case reports based on the comparison of specimens obtained before and after surgery or radiation is necessary to better understand the pathophysiology of the dissemination phenotype of hemangioblastoma.
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http://dx.doi.org/10.1007/s10014-020-00387-7DOI Listing
January 2021

Carotid endarterectomy restores decreased vision due to chronic ocular ischemia.

Acta Neurochir (Wien) 2021 06 7;163(6):1767-1775. Epub 2020 Oct 7.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Background: The therapeutic effect of carotid endarterectomy (CEA) on visual disturbance caused by chronic ocular ischemia due to carotid artery stenosis has not been validated. This prospective observational study aims to investigate whether CEA is associated with an increase in ocular blood flow (OBF) and postoperative visual improvement.

Methods: In total, 41 patients with carotid artery stenosis treated by CEA between March 2015 and September 2018 were enrolled in this study. OBF was evaluated by laser speckle flowgraphy, which can measure the mean blur ratio (MBR) which is well correlated to the absolute retinal blood flow. Visual acuity was assessed before and after CEA by subjective improvement and objective visual assessment using CSV-1000, an instrument used to test contrast sensitivity.

Results: OBF increased after CEA on the operated side (mean MBR 33.5 vs 38.2, p < 0.001) but not on the non-operated side (mean MBR 37.8 vs 37.5, p = 0.50). After CEA, 23 patients (56.1%) reported subjective visual improvement on the operated side. The mean CSV-1000 score among the patients with increased OBF after CEA (5.44 vs 5.88, p = 0.04) but not among those without increased OBF (5.48 vs 5.95, p = 0.09). The mean CSV-1000 scores increased significantly after CEA in 18 patients with decreased vision and decreased OBF (4.51 vs 5.37, p < 0.001), but not in the 23 patients without those (6.19 vs 6.31, p = 0.6).

Conclusion: CEA may successfully reverse visual dysfunction caused by chronic ocular ischemia due to carotid artery stenosis by increasing OBF.
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http://dx.doi.org/10.1007/s00701-020-04603-3DOI Listing
June 2021

Extirpation of a Ruptured Anterior Spinal Artery Aneurysm Accompanied by Dural Arteriovenous Fistula at the Craniovertebral Junction via a Posterolateral Approach: The Management of Extradural Venous Congestion.

J Neurol Surg B Skull Base 2019 Dec 17;80(Suppl 4):S344-S345. Epub 2019 Oct 17.

Department of Neurosurgery, Saitama Medical Center/University, Saitama Japan.

 This study was aimed to discuss how to control extradural venous congestion with an increased pressure in cases of arteriovenous shunt disease of the craniovertebral junction.  The study is presented through an operative video.  A 77-year-old patient with subarachnoid hemorrhage had a dural arteriovenous fistula located at the C1-C2 level. Left vertebral angiography showed a fistula between the left C2 radiculomeningeal muscular artery and perivertebral plexus. Furthermore, right vertebral angiography showed a ruptured aneurysm at the aberrant branch of the anterior spinal artery originating from the contralateral vertebral artery (VA), possibly formed because of the concurrently increased pressure of the perimedullary veins. Aneurysm extirpation was planned through a posterolateral approach. To reduce venous bleeding during the approach, preoperative embolization of the radiculomeningeal muscular artery was performed. During surgery, the suboccipital triangle was exposed following layer-by-layer dissection of the suboccipital muscles ( Figs. 1 and 2 ). Subperiosteal dissection of the paravertebral plexus surrounding the VA around the C1 lamina was effective to avoid venous bleeding. A bloodless operative field was achieved, and key anatomical structures, such as the C2 nerve root, feeder, and V3 portion of the left VA, were clearly identified. With a sufficient amount of lateral exposure, the ruptured anterior spinal artery aneurysm was successfully extirpated with bipolar coagulation. The patient was discharged with no neurologic deficit. Fig. 1 ( ) The initial CT scan showing the subarachnoid hemorrhage. ( ) Left vertebral angiogram demonstrating a dural arteriovenous fistula at the craniovertebral junction. ( ) Right vertebral angiogram showing an aneurysm (arrow) arising at the aberrant branch of the anterior spinal artery. ( ) The postoperative angiogram demonstrating the extirpation of the aneurysm (arrowhead). Fig. 2 ( ) Intraoperative photograph showing the subperiosteal dissection technique to protect the vertebral artery and minimize the bleeding from the paravertebral plexus. ( ) The sufficient posterolateral exposure was obtained with minimal bleeding. C1, C1 lamina; C2, C2 lamina; Occ, occipital bone.  Controlling extradural venous congestion is essential to obtain a clear operative field in cases of arteriovenous shunt disease at the craniovertebral junction. The link to the video can be found at: https://youtu.be/fCT69WtAQbo .
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http://dx.doi.org/10.1055/s-0039-1697981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864108PMC
December 2019

Prevention of Thromboembolic Infarction After Surgery for Traumatic Cervical Fracture with Vertebral Artery Occlusion by Preoperative Endovascular Coil Embolization.

World Neurosurg 2019 Sep 14;129:e838-e844. Epub 2019 Jun 14.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Background: Vertebral artery injuries (VAIs) caused by cervical trauma include irregularities with narrowing of the arterial wall, dissection, pseudoaneurysm formation, occlusion, and transection. Although recent guidelines have recommended anticoagulant or antiplatelet therapy to prevent subsequent stroke in patients with traumatic VAIs, regardless of the type of vascular injury, the clinical role of endovascular surgery in the treatment of traumatic VAIs remains to be elucidated.

Methods: We retrospectively evaluated the treatment outcomes of 23 patients with cervical fracture and vertebral artery occlusion (VAO) who had required cervical surgery in the acute stage.

Results: No patient received antiplatelet or anticoagulant therapy, because the VAs had already become occluded. After cervical surgery, 5 of the 23 patients developed radiologically confirmed thromboembolic stroke after cervical surgery. None of these 5 patients with postoperative infarction had undergone preoperative VA embolization. Univariate analysis revealed that only the implementation of preoperative VA embolization was associated with the prevention of postoperative infarction (P = 0.004). Factors such as age, reduction, level of VAO, and diabetes mellitus did not correlate with increased risk.

Conclusions: The clinical role of endovascular surgery for traumatic VAI has not been previously established; however, a more specific selection of patients according to the VAI type might be necessary. Our data have indicated that preoperative embolization of the occluded VA significantly reduces the risk of postoperative infarction in a specific cohort of patients with traumatic VAI (i.e., patients with post-traumatic VAO who require cervical surgery).
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http://dx.doi.org/10.1016/j.wneu.2019.06.046DOI Listing
September 2019

Intraoperative quantification of meningioma cell proliferation potential using rapid flow cytometry reveals intratumoral heterogeneity.

Cancer Med 2019 06 16;8(6):2793-2801. Epub 2019 Apr 16.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Background: Standard sampling methods to evaluate the proliferative ability of meningioma have not been established.

Methods: This prospective study was conducted to evaluate the effectiveness of intraoperative rapid flow cytometry (iFC) using raw samples for the quantitative assessment of proliferative ability in meningioma cells and to investigate intratumoral heterogeneity. Proliferation index (PI) was defined as the ratio of aneuploid cells with an abnormal number of chromosomes to the total cells.

Results: From 50 patients, 118 specimens were analyzed. There was a statistically significant correlation between the postoperative MIB-1 labeling index (LI) and PI (R = 0.59, P < 0.0001). A higher PI was correlated with a higher annual growth rate (AGR, cm /y) (R = 0.50, P = 0.0002, 26 patients). AGR showed a correlation with the intratumoral distribution of PI. PI was the highest at the center or the peripheral section of the tumor in tumors with high AGR, whereas it was highest at the dural attachment in tumors with low AGR (P = 0.039, n = 20). Pial feeders were more frequently observed when PI was high in the center or in the peripheral section (P = 0.006, n = 37).

Conclusions: Rapid iFC may thus become a substitute for MIB-1 LI. Intratumoral heterogeneity of cellular proliferative potential exists in meningiomas and is related to tumor biological characteristics such as AGR and development of pial feeders. This observation underscores the importance of standardization in the sampling method to accurately estimate the risk of meningioma recurrence.
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http://dx.doi.org/10.1002/cam4.2178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6558493PMC
June 2019

Superficial temporal artery-superior cerebellar artery bypass and trapping of a fusiform aneurysm using intradural anterior petrosectomy: technical case report and anatomical study.

Neurosurg Focus 2019 02;46(2):E9

1Department of Neurosurgery, Saitama Medical Center; and.

Aneurysms at the distal portion of the superior cerebellar artery (SCA) are very rare. Because of the deep location and a propensity for nonsaccular morphology, aneurysm trapping or endovascular occlusion of the parent artery are the usual treatment options, which are associated with varying risks of ischemic complications. The authors report on a 60-year-old woman who had a 3.5-mm unruptured aneurysm in the lateral pontomesencephalic segment of the SCA with a significant interval growth to 8 mm. Direct surgical intervention comprising trapping of the aneurysm through a subtemporal approach and intradural anterior petrosectomy combined with revascularization of the distal SCA using the superficial temporal artery (STA) was performed. This approach provided sufficient space for the bypass instruments to be introduced into the deep surgical field at a more favorable angle to enhance microscopic visualization of the anastomosis with minimal retraction of the temporal lobe. The patient was discharged with no neurological deficit. Preservation of the blood flow in the distal SCA should be attempted to minimize the risk of ischemic injury, particularly when the aneurysms arise in the anterior or lateral segment of the SCA. The authors demonstrate the safety and effectiveness of the intradural anterior petrosectomy for STA-SCA bypass along with a relevant anatomical study.
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http://dx.doi.org/10.3171/2018.11.FOCUS18432DOI Listing
February 2019

Ultra-Early Optic Nerve Decompression for the Resection of Anterior Clinoidal Meningioma.

J Neurol Surg B Skull Base 2018 Feb 18;79(Suppl 2):S231-S232. Epub 2018 Jan 18.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Improvement in vision is one of the main goals of surgery for anterior clinoidal meningiomas with visual deficits. Early optic nerve decompression surgery has been advocated in previous studies to achieve the best visual outcome. Through this video, the authors describe their surgical techniques to decompress the optic nerve at the very early stage of surgery. A 35-year-old patient presented with subjective blurry vision in the right eye over the last 8 months. Magnetic resonance images showed a 3.2-cm meningioma arising at the right anterior clinoid. Preoperative ophthalmological test was within the normal range, but the patient wished to have surgical resection after a detailed discussion of benefits and risks related to surgical resection. The surgical strategy consisted of the right lateral subfrontal approach that includes a standard right frontotemporal craniotomy, extradural anterior clinoidectomy, and early optic nerve decompression prior to tumor resection. The tumor was divided into compartments defined by the arteries and resected. Simpson grade II resection was achieved without complications. The patient's symptoms disappeared. In anterior clinoidal meningiomas that cause visual deficits, the optic nerve is assumed very vulnerable to any further injuries related to the operative maneuver. Ultra-early optic nerve decompression can be performed in anterior clinoidal meningiomas regardless of their size by extradural unroofing of the optic canal and sectioning of the optic canal sheath, which we believe contributes to better visual improvement. The link to the video can be found at: https://youtu.be/RIFi4ecWAhQ .
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http://dx.doi.org/10.1055/s-0038-1623521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954281PMC
February 2018

Rapid intracranial pressure drop as a cause for posterior reversible encephalopathy syndrome: Two case reports.

Surg Neurol Int 2017 5;8:103. Epub 2017 Jun 5.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on radiological examinations as well as symptoms of altered consciousness and seizures. To date, the underlying mechanism remains largely unknown.

Case Descriptions: Case 1 is a 72-year-old man with a history of hypertension presented with a subarachnoid hemorrhage. Fourteen days after the successful clipping of a ruptured aneurysm; he experienced inadvertent overdrainage via the intraventricular drain. Nine hours later, he started to have seizures followed by disturbances in consciousness. An emergency magnetic resonance imaging showed multiple high-intensity lesions in the frontal, temporal, parietal, and occipital lobes, basal ganglia, brainstem, and cerebellar hemispheres bilaterally, which are compatible with typical magnetic resonance findings in PRES patients. He was treated conservatively and recovered well. Case 2 is a 68-year-old woman with a mild history of hypertension and a ventriculo-peritoneal shunt for obstructive hydrocephalus, who underwent a cysto-peritoneal shunt placement because of an enlarging symptomatic arachnoid cyst. Immediately following surgery, she experienced disturbances in consciousness and developed status epilepticus. Radiological examinations revealed remarkable shrinkage of the arachnoid cyst and multiple edematous lesions, which led us to strongly suspect PRES. With conservative treatment, her symptoms and the radiological abnormalities disappeared.

Conclusion: Based on the previous literature and our cases, we believe that the association between rapid reduction of intracranial pressure (ICP) and the development of PRES should be recognized because most neurosurgical procedures such as craniotomy or cerebrospinal fluid diversion present a potential risk of rapid reduction of ICP.
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http://dx.doi.org/10.4103/sni.sni_55_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473084PMC
June 2017

Letter to the Editor: Simpson grading system.

Authors:
Soichi Oya

J Neurosurg 2017 01 23;126(1):341-343. Epub 2016 Sep 23.

Saitama Medical Center, Saitama Medical University, Saitama, Japan.

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http://dx.doi.org/10.3171/2016.5.JNS161302DOI Listing
January 2017

Limitations of Routine Verification of Nasogastric Tube Insertion Using X-Ray and Auscultation: Two Case Reports of Life-Threatening Complications.

Nutr Clin Pract 2016 Dec 10;31(6):780-784. Epub 2016 Jul 10.

1 Department of Neurosurgery, Saitama Medical University, Kawagoe Saitama, Japan.

Several bedside approaches used in combination with thoracoabdominal X-ray are widely used to avoid severe complications that have been reported during nasogastric tube management. Although confirmation by X-ray is considered the gold standard, it is not yet perfect. We present 2 cases of rare complications in which the routine verification methods could not detect all the complications related to the nasogastric tube placement. Case 1 was a 17-year-old male who presented with a brain tumor and repeatedly required nasogastric tube placement. Despite normal auscultatory and X-ray findings, the patient's condition deteriorated rapidly after resuming the enteral nutrition (EN). Computed tomography images showed the presence of hepatic portal venous gas (HPVG). Urgent upper gastrointestinal endoscopy showed esophagogastric submucosal tunneling of the tube that required an emergency open total gastrectomy. Case 2 was a 76-year-old man with long-term EN after stroke. While the last auscultatory verification was normal, he suddenly developed extensive HPVG due to gastric mucosal injury following EN, which resulted in progressive intestinal necrosis, general peritonitis, and death. These 2 cases indicated that routine verification methods consisting of auscultation and X-ray may not be completely reliable, and the awareness of the limitations of these methods should be reaffirmed because expeditious examinations and necessary interventions are critical in preventing life-threatening complications.
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http://dx.doi.org/10.1177/0884533616648324DOI Listing
December 2016

Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery.

J Korean Neurosurg Soc 2016 Jan 20;59(1):52-7. Epub 2016 Jan 20.

Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.

Objective: Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction.

Methods: We conducted a retrospective review of operations performed by the senior author from 2004-2011 identified collagen matrix (DuraGen) use in 84 posterior fossa operations. Wound complications such as CSF leak, infection, pseudomeningocele, and aseptic meningitis were noted. Fisher's exact test was performed to assess risk factor association with specific complications.

Results: Incisional CSF leak rate was 8.3% and non-incisional CSF leak rate was 3.6%. Incidence of aseptic meningitis was 7.1% and all cases resolved with steroids alone. Incidence of palpable and symptomatic pseudomeningocele in follow-up was 10.7% and 3.6% respectively. Postoperative infection rate was 4.8%. Previous surgery was associated with pseudomeningocele development (p<0.05).

Conclusion: When primary dural closure after posterior fossa surgery is undesirable or not feasible, non-watertight dural reconstruction with collagen matrix resulted in incisional CSF leak in 8.3%. Incidence of pseudomeningocele, aseptic meningitis, and wound infection were within acceptable range. Data from this study may be used to compare alternative methods of dural reconstruction in posterior fossa surgery.
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http://dx.doi.org/10.3340/jkns.2016.59.1.52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754587PMC
January 2016

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids with a Significant Elevation of β-2 Microglobulin Levels.

J Korean Neurosurg Soc 2015 Nov 30;58(5):487-90. Epub 2015 Nov 30.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Tokyo, Japan.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a relapsing-remitting disorder for which steroid administration is a key to control the progression. CLIPPERS can exhibit radiological features similar to malignant lymphoma, whose diagnosis is confounded by prior steroid administration. We report a case of CLIPPERS accompanied by abnormal elevation of β-2 microglobulin in the cerebrospinal fluid (CSF). A 62-year-old man started to experience numbness in all fingers of his left hand one year ago, which gradually extended to his body trunk and legs on both sides. Magnetic resonance imaging demonstrated numerous small enhancing spots scattered in his brain and spinal cord. CSF levels of β-2 microglobulin were elevated; although this often indicates central nervous system involvement in leukemia and lymphoma, the lesions were diagnosed as CLIPPERS based on the pathological findings from a biopsy specimen. We emphasize the importance of biopsy to differentiate between CLIPPERS and malignant lymphoma because the temporary radiological response to steroid might be the same in both diseases but the treatment strategies regarding the use of steroid are quite different.
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http://dx.doi.org/10.3340/jkns.2015.58.5.487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688322PMC
November 2015

Stent-assisted Coiling for Ruptured Basilar Artery Dissecting Aneurysms: An Initial Experience of Four Cases.

Neurol Med Chir (Tokyo) 2016 11;56(1):43-8. Epub 2015 Dec 11.

Department of Neurosurgery, The University of Tokyo Hospital.

No treatment strategy has been established for subarachnoid hemorrhages due to basilar artery (BA) trunk dissecting aneurysms. Our aim was to report our initial experience performing stent-assisted coiling (SAC) for ruptured BA dissecting aneurysms to validate the effectiveness of this treatment. We experienced four consecutive cases of ruptured dissecting BA trunk aneurysm treated with SAC between 2008 and 2014 at three institutions. Aneurysm rebleeding was prevented without causing severe brainstem ischemia in all cases. In our opinion, both the blockage of the inflow to aneurysms and the preservation of the antegrade flow of the BA can be achieved by SAC, although controversies regarding long-term stability and appropriate antiplatelet therapy remain.
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http://dx.doi.org/10.2176/nmc.cr.2015-0233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728149PMC
April 2017

Multiple hemorrhagic intraparenchymal tumors presenting with fatal intracranial hypertension: A rare manifestation of systemic epithelioid hemangioendothelioma.

Surg Neurol Int 2015 6;6:156. Epub 2015 Oct 6.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Background: Epithelioid hemangioendotheliomas (EHE) is an extremely rare tumor that can arise not only intracranially but also systemically. Its radiological characteristics and the mechanism underlying the multiple organ involvement in EHE are poorly understood.

Case Description: A 24-year-old woman with a 7-month history of coughing and blood-stained sputum complained of visual disturbance in the right eye that had persisted for 1-month. Magnetic resonance (MR) imaging revealed multiple intraparenchymal masses with low-intensity on MR susceptibility-weighted images with minimal enhancement with gadolinium. Systemic computed tomography revealed multiple nodules in both lungs and the liver. Because her neurological status rapidly deteriorated, brain biopsy of the right frontal mass was performed. The pathological diagnosis was EHE. Over the following 3 months, the patient gradually developed disturbance of consciousness. She died at 4 months after admission because of significant intracranial hypertension.

Conclusion: Although intracranial EHEs are extremely rare, they should be included in the differential diagnoses of multiple small-sized masses with low-intensity on MR susceptibility-weighted images. We also emphasize that the systemic involvement of this tumor was more compatible with multicentric development than metastasis.
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http://dx.doi.org/10.4103/2152-7806.166799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604639PMC
November 2015

Ruptured Basilar Tip Aneurysm in a Patient with Bilateral Internal Carotid Artery Occlusion Successfully Treated with Bilateral Superficial Temporal Artery-Middle Cerebral Artery Anastomoses: Case Report.

World Neurosurg 2016 Feb 13;86:512.e5-8. Epub 2015 Oct 13.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Background: Some ruptured intracranial aneurysms concomitant with major artery occlusion may not be amenable for standard clipping or coiling due to the specific hemodynamic conditions. The long-term effect of flow reduction therapy for such aneurysms is largely unknown.

Case Presentation: A 45-year-old woman presented with subarachnoid hemorrhage due to a ruptured basilar tip aneurysm. Angiography revealed that the bilateral internal carotid arteries were hypoplastic and that the anterior circulation was fed by the collateral flow through the bilateral posterior communicating arteries and the posterior choroidal arteries. Endovascular treatment failed because it was extremely difficult to secure the catheter at the neck of the aneurysm and insert the coil safely because it was a small aneurysm with a wide neck. In addition, direct clipping was risky due to the location and projection of the aneurysm. We therefore adopted the 2-stage bilateral superficial temporal artery-middle cerebral artery bypass to alleviate the vascular demand on the anterior circulation, with the aim of reducing the hemodynamic stress to the basilar bifurcation. The patient had no rebleeding for 4 years after surgery, with gradual shrinkage of the aneurysm.

Conclusion: All the possible treatment options should be carefully assessed because the long-term effect of the flow alternation method to prevent rebleeding has not been proved. However, our case suggests that the strategy of reducing the hemodynamic stress at the parent artery may be effective even in selected cases of ruptured aneurysms for which standard clipping or coiling is not feasible.
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http://dx.doi.org/10.1016/j.wneu.2015.09.096DOI Listing
February 2016

Malignant Transformation of a Neurenteric Cyst in the Posterior Fossa Presenting with Intracranial Metastasis: A Case Report and Literature Review.

NMC Case Rep J 2015 Oct 3;2(4):123-127. Epub 2015 Sep 3.

Department of Neurosurgery, Saitama Medical Center/University, Saitama.

Intracranial neurenteric cysts are relatively rare and almost exclusively benign. Here we present a case of an intracranial neurenteric cyst that was histologically benign in the first surgery and later demonstrated significant growth and intracranial metastasis with malignant transformation. A 47-year-old woman presented with a headache, which had gradually worsened over 1 year. Initial magnetic resonance (MR) images revealed a solitary cystic lesion in the left cerebellopontine angle with significant mass effect. Subtotal resection leaving a small mass strongly adhered to the brainstem was achieved. Histopathological diagnosis was neurenteric cyst with no malignant features. This lesion recurred 4 years after the first surgery in the form of a cystic mass adjacent to the brainstem. In addition, histopathological examination of a specimen from the second surgery revealed malignant transformation. The patient declined to undergo radiation therapy and was conservatively managed. Three years after the second surgery, MR imaging showed recurrence of the solid mass. Although the patient had been treated with subtotal resection and radiation therapy, she died with metastatic masses in the right frontal lobe and cervical cord. A specimen from the third surgery revealed diffuse malignant features similar to mucinous adenocarcinoma. Our case and literature review indicate that, although rare, malignant transformation can occur particularly among intracranial neurentreric cysts. This finding suggests the importance of long-term follow-up for subtotally or partially resected intracranial neurenteric cysts.
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http://dx.doi.org/10.2176/nmccrj.2014-0416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364880PMC
October 2015

Solitary Osteochondroma of the Skull Base: A Case Report and Literature Review.

J Neurol Surg Rep 2015 Jul 2;76(1):e13-7. Epub 2015 Mar 2.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

We report a case of an osteochondroma in the posterior clinoid process that occurred in a 43-year-old man with trochlear nerve palsy. Although the potential preoperative diagnoses based on computed tomography and magnetic resonance imaging included other intracranial tumors such as calcified meningioma, thallium-201 single-photon emission computed tomography effectively differentiated osteochondroma from those possibilities. Via an orbitozygomatic approach, a subtotal resection was achieved with a good relief of symptoms. Twenty-two cases of solitary osteochondromas in the skull base have been reported that have demonstrated little risk of recurrence or malignant transformation. However, surgery for skull base osteochondromas does carry a significant risk with a reported mortality > 10%. Although some previous reports advocate complete resection as the only curative method for skull base osteochondromas, the risks of total resection should be weighed against the chance for recurrence; our review of the literature demonstrated a relatively high mortality and an extremely low incidence of recurrence.
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http://dx.doi.org/10.1055/s-0034-1387189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520987PMC
July 2015

Usefulness of repetitive intraoperative indocyanine green-based videoangiography to confirm complete obliteration of micro-arteriovenous malformations.

Surg Neurol Int 2015 21;6:85. Epub 2015 May 21.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan.

Background: It is difficult to intraoperatively confirm the total disappearance of arteriovenous (AV) shunts during surgery for microarteriovenous malformations (micro-AVMs), especially when the nidus is extremely small or diffuse on preoperative angiography. Although intraoperative angiography is effective for evaluating residual shunts, procedure-related risks raise important concerns. The purpose of this study was to assess the usefulness of intraoperative indocyanine green-based videoangiography (ICG-VA) to determine complete disappearance of micro-AVMs during surgery.

Methods: We retrospectively analyzed eight patients with ruptured micro-AVMs who were treated using craniotomy with ICG-VA at our institution.

Results: Two patients underwent emergency partial evacuation of hematoma and external decompression before the diagnostic angiography. While three patients had a nidus smaller than 1 cm, five patients had only early draining veins without an appreciable nidus. The draining veins were superficial in six cases and deep in two cases. The average interval from onset to surgery was 33 days (range, 2-57). ICG-VA was repetitively conducted until disappearance of the AV shunt was confirmed. No residual AV shunt was observed on postoperative radiological examinations. In all cases, the diagnosis of AVM was confirmed from the results of postoperative pathological examination.

Conclusions: ICG-VA could detect early draining veins more clearly in situ than diagnostic angiography. Although it is not as effective for visualizing lesions with deep draining veins, repetitive ICG-VA was safe and effective for confirming the disappearance of AV shunts with superficial drainage.
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http://dx.doi.org/10.4103/2152-7806.157445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443402PMC
May 2015

Hemichorea-hemiballismus caused by postoperative hyperperfusion after clipping of a giant unruptured middle cerebral artery aneurysm.

Surg Neurol Int 2015 21;6:84. Epub 2015 May 21.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan.

Background: Movement disorders after the clipping for an unruptured giant aneurysm are rare. The information on the pathogenesis and treatment options for this condition is largely unknown.

Case Description: An 82-year-old female with no neurological deficits underwent a clipping for a giant middle cerebral artery (MCA) aneurysm. Immediately after surgery, she presented with hemichorea-hemiballismus (HC-HB) on the left side. Postoperative angiograms and single-photon emission computed tomography demonstrated the hyperperfusion in the right frontal cortex and the decreased perfusion in the basal ganglia, indicating that the abrupt hemodynamic changes due to the obliteration of the giant aneurysm caused the dysfunction of the frontal cortical and subcortical pathway and the basal ganglia. Administration of tiapride hydrochloride was dramatically effective in controlling the HC-HB until the hyperperfusion resolved. Single-photon emission computed tomography obtained 8 weeks after surgery revealed that the cerebral blood flow had been normalized in the right frontal cortex. The relative hypoperfusion of the right basal ganglia was also resolved. Then tiapride hydrochloride was discontinued without a relapse of HC-HB.

Conclusion: This case appears consistent with the theory that the connecting fibers responsible for the development of HC-HB are also located in the frontal lobe. The treatment of giant aneurysms involving the M1 portion can cause abrupt hemodynamic changes in both frontal cortex and the basal ganglia, which can potentially induce postoperative movement disorders.
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http://dx.doi.org/10.4103/2152-7806.157444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443400PMC
May 2015

Increased flow signal in compressed segments of the spinal cord in patients with cervical spondylotic myelopathy.

Spine (Phila Pa 1976) 2014 Dec;39(26):2136-42

From the Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

Study Design: Prospective controlled trial.

Objective: To describe a newly found increased flow signal in phase-contrast magnetic resonance imaging observed in compressed segments of the spinal cord in patients with cervical spondylotic myelopathy (CSM).

Summary Of Background Data: Derangement of cerebrospinal fluid movement in the spine is a well-known cause of syringomyelia. However, its possible role in CSM has not been studied well, despite the fact that similar derangement takes place in CSM.

Methods: In a consecutive series of 57 patients with CSM, cardiac-gated phase-contrast magnetic resonance imaging was analyzed. The amplitude of the flow signal obtained in the compressed segment of the spinal cord was compared with that obtained in the lesion-free C2 segment. It was also compared with controls obtained from 10 healthy volunteers. We also studied whether the amplitude was correlated with the severity of cervical canal stenosis, neurological symptoms, indication of surgery, and the presence of intramedullary high-intensity signal on T2-weighted images. In 33 patients who underwent decompression surgical procedures, we compared the amplitude of the flow signal between the preoperative and the postoperative study.

Results: Increased flow signal on phase-contrast study was seen in compressed segments of the spinal cord in 36 (63%) patients. The mean amplitude of the signal in the compressed segment was 0.64 ± 0.06 cm/s, whereas that in the C2 segment was 0.27 ± 0.01 and that in the controls was 0.28 ± 0.01. The flow signal linearly increased as the severity of canal stenosis increased. It significantly correlated with the symptom of upper-extremity dysesthesia, and the indication of surgery in these patients. The mean amplitude of the signal tended to be higher in those with intramedullary high-intensity signal than in those without. After decompression surgery, the increased flow signal was markedly diminished, and returned to a level comparable with the controls.

Conclusion: Phase-contrast imaging demonstrated increased flow signal in compressed segments of the spinal cord in a majority of patients with CSM. This suggests a possible role played by derangement of cerebrospinal fluid movement in CSM. It also suggests potential usefulness of phase-contrast study in the management of patients with CSM.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000000607DOI Listing
December 2014

Pearls & Oy-sters: Anorexia and emaciation in patients with cerebellar hemangioblastoma.

Neurology 2014 Sep;83(14):1298-300

From the Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Japan.

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http://dx.doi.org/10.1212/WNL.0000000000000835DOI Listing
September 2014

A Case of the Internal Carotid Artery-Posterior Communicating Artery Aneurysm Mimicking Tolosa-Hunt Syndrome.

NMC Case Rep J 2015 Jan 29;2(1):1-3. Epub 2014 Sep 29.

Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama.

A 53-year-old woman experienced a right retrobulbar pain followed by ipsilateral extraocular palsies in all directions without dilated pupils or ptosis. Because a plain head computed tomography (CT) scan obtained on her initial visit showed no abnormal findings, such as subarachnoid hemorrhage or a giant cavernous aneurysm, her condition was provisionally diagnosed as Tolosa-Hunt syndrome and elective magnetic resonance (MR) imaging was scheduled. The day after her initial visit, however, she suddenly developed complete ptosis and a dilated pupil on the right side. Emergency MR imaging and angiography revealed a clover leaf-shaped aneurysm projecting to the cavernous sinus at the junction of the internal carotid artery and the posterior communicating artery. Her condition was diagnosed as impending rupture of the aneurysm, and she underwent emergency open surgery. Her symptoms completely resolved within the following 2 weeks. Our case demonstrated that a medium-sized internal carotid artery-posterior communicating artery aneurysm can cause simultaneous oculomotor and abducens nerve palsies with retrobulbar pain if the shape of the aneurysm is complicated. Although these symptoms are very similar to those of Tolosa-Hunt syndrome, we believe that prompt radiological examinations such as MR or 3D CT angiography should be performed to prevent subsequent rupture of the aneurysm.
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http://dx.doi.org/10.2176/nmccrj.2014-0125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364924PMC
January 2015
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