OBJECTIVE To avoid ischemic complications, it is important to consider the arteries in resection planning for lesions such as a vascular intraparenchymal tumor and arteriovenous malformation. Here, the clinical application of laser speckle flow imaging (LSFI) as a complementary method for the management of mass lesion-related arteries during surgery was evaluated. METHODS LSFI was performed in 12 patients with mass lesion-related arteries and brain tumor or arteriovenous malformation. The portable LSFI device was centered over the surgical field, and the relative cerebral blood flow (CBF) before and after the temporary interruption of the arteries was measured through continuous recording. CBF fluctuations permitted the classification of 3 kinds of artery-a feeding artery (FA), a "passing through" artery (PA), and a combined FA and PA (FA+PA)-based on decreased relative CBF in the inner resection area and unchanged CBF in the surrounding area (FA), unchanged CBF in the inner area and decreased CBF in the surrounding area (PA), or decreased CBF in both areas (FA+PA). This information allowed the appropriate management of these arteries and avoidance of postoperative ischemic complications. RESULTS Good visualization of CBF in the surgical field and relative CBF measurements in the regions of interest were achieved in real time with excellent spatiotemporal resolution. In 11 patients (92%) and 20 regions of interest, a decline in CBF was observed after temporary interruption of the FA (n = 8), PA (n = 2), and FA+PA (n = 2) types. There was a significant average reduction in CBF of 15.3% ± 29.0%. There were no ischemic complications, and only 1 patient had a postoperative ischemic lesion caused by resection through an artery that could not be viewed by LSFI due to a positional problem. CONCLUSIONS LSFI permits noninvasive and rapid intraoperative real-time recognition of mass lesion-related vasculature. This information can be used to avoid ischemic complications as a procedure complementary to neurophysiological monitoring.
We describe an 18-year-old man with acute renal failure due to inadvertent ingestion of antifreeze that contained ethylene glycol (EG). A relatively small amount of EG was ingested, but nausea and vomiting were observed soon after ingestion. During admission to a local hospital, consciousness became impaired and generalized convulsion was noted. He was transferred to our hospital because of rapid deterioration of renal function. Emergency hemodialysis was begun. The patient underwent one treatment session of hemodialysis each day, for a total of 8 hemodialytic sessions before his renal function recovered. Examination of the renal biopsy specimen revealed degeneration of the renal tubular epithelium and presence of intratubular calcium oxalate crystals. The clinical features of the patient were mild except for acute renal failure. These findings suggest that even a small amount of EG will have toxic effects on the kidney.
The object of this study was to evaluate the efficacy of a new neurovascular decompression technique in relieving symptoms of cochlear nerve dysfunction.Nineteen patients with slowly progressive hearing loss, low-frequency fluctuating hearing loss, and high-pitched tinnitus due to neurovascular compression (NVC) of the eighth cranial nerve in a triangular space between the seventh and eighth cranial nerves (the VII-VIII triangle) of the cerebellopontine angle (CPA) were treated using a new technique for microvascular decompression that was developed by anatomical study in 24 cadaver specimens of the CPA. In 12 of 19 patients the anterior inferior cerebellar artery (AICA) was observed to cause compression in the VII-VIII triangle and this vessel was easily mobilized medially for placement of a silicone sponge or Teflon cushion between the compressing artery and nerve. Postoperatively, hearing loss of 20 dB or more that was present in 11 of the 19 patients with NVC improved by more than 5 dB in seven (64%), including the patient with the most severe hearing loss. Of 18 patients presenting with tinnitus preoperatively, eight (44%) had no tinnitus and an additional nine (for a total of 94%) had good improvement in tinnitus after surgery and at long-term follow up.The microvascular decompression technique described is highly successful in treating symptoms due to direct or indirect compression of the cochlear nerve, with minimal risk of complications. Recordings of auditory brainstem responses confirmed the clinical diagnosis of NVC of the eighth cranial nerve and correlated with clinical results after microvascular decompression of the cochlear nerve.
The recent clinical results are reviewed of stereotactic radiosurgery/radiotherapy for the treatment of pituitary adenomas. The outcomes of pituitary adenomas treated by stereotactic radiosurgery/radiotherapy with gamma knife, CyberKnife, or linear accelerator (LINAC) radiosurgery were evaluated from articles published after 2004. Each study was evaluated for the number of patients, radiosurgical parameter (marginal dose), length of follow up, tumor growth control, rate of hormonal normalization in secretary adenomas, and adverse events. After gamma knife radiosurgery, the tumor reduction rates varied from 42.3% to 89% in non-secreting adenomas. However, the tumor control rates in non-secreting adenomas were more than 90% in most studies. In growth hormone-secreting adenomas, the rates of insulin-like growth factor-1 normalization ranged from 36.9% to 82%. In adrenocorticotropin-secreting adenomas, the rates for 24-hour urine free cortisol normalization ranged from 27.9% to 54%. In prolactin-secreting adenomas, the prolactin normalization ranged from 17.4% to 50%. New hormonal deficits ranged from 0% to 34%. New visual deficits were relatively low. The number of patients treated with CyberKnife and LINAC radiosurgery/radiotherapy was small and follow-up periods were relatively short compared to those with gamma knife treatment, but the clinical outcomes after these therapies were similar to those after gamma knife therapy. Image-guided stereotactic radiosurgery/radiotherapy with the gamma knife, CyberKnife, or LINAC system is effective and safe against pituitary adenomas. Careful long-term follow up of the patients is necessary because of long-term anti-tumor effects and delayed adverse events.
The objective of the study was to investigate the correlation between differences between imaging modalities and histological heterogeneity in minimally enhancing glioma. A prospective study was performed in 11 patients with minimally enhancing glioma (<1 cm3 volume) in the T2 or FLAIR hyperintense (T2/FL+) area who simultaneously underwent 11C-methionine (MET)-PET, and had a volume-based discrepancy between the T2/FL+ area and MET accumulation (MET+) area (tumor to normal cortex (T/N) ratio ≥1.3) of >10%. The correlation between the imaging discrepancy and histological heterogeneity was investigated. The average T/N ratio for the T2/FL+/MET+ area in grade II glioma (2.08 ± 0.4) was smaller than that in grade III (4.19 ± 2.4), whereas that for the T2/FL+/MET− area was similar in grade II (1.07 ± 0.2) and III (1.07 ± 0.1). The average T/N ratio for the T2/FL+/MET+ area in grade II and III was higher than that for the T2/FL+/MET− area (p < 0.0005 for grade II, p < 0.05 for grade III). In the T2/FL+/MET− area, 8 cases showed no neoplastic features, while the other 3 cases had neoplastic features with comparatively lower grade than the T2/FL+/MET+ area. The volumetric ratio of the MET+ area (16.8 ± 16.0 cm3) to the T2/FL+ area (41.5 ± 20.9 cm3) was 43.4%, and the volumetric difference in grade II cases (61.6%) tended to larger than that in grade III (50.6%). In immunohistochemical findings, the only MIB1 labeling index differed between grade II (5.5 ± 2.1) and III (23.2 ± 18.0) with significantly difference. In the T2/FL+/MET− area, 3 of 6 grade II gliomas had neoplastic features, whereas all 5 grade III gliomas had normal brain including one gliosis histologically. The discrepancy between the T2/FL+ and MET+ areas could reflect spatial heterogeneity in histological findings. An understanding of the correlation between imaging and pathology based on spatial heterogeneity may assist with appropriate diagnosis and treatment for patients with glioma.
