Central nervous system (CNS) solitary fibrous tumors (SFTs) are rare but aggressive, often metastasizing to extracranial regions, with no established treatments apart from surgery. Pazopanib, a multikinase angiogenesis inhibitor, is used to treat extracranial SFTs; however, its efficacy for treating CNS SFTs remains unclear. To address this issue, the efficacy of pazopanib was investigated, focusing on tumor density and size in CNS SFTs with extracranial metastases after initiation, interruption or resumption of pazopanib treatment. The present study retrospectively reviewed 3 consecutive cases of CNS SFTs showing extracranial metastases that were referred to Kochi Health Sciences Center (Kochi, Japan) between January 2018 and April 2024 and were treated with pazopanib. All measurable lesions observed via contrast-enhanced computed tomography (CT; 50 lesions) and magnetic resonance imaging (MRI; 21 lesions) were evaluated. Cases 2 and 3, meeting the Choi criteria, showed stable disease and achieved partial response after pazopanib initiation, respectively. In Case 1, both intracranial and extracranial tumor CT densities decreased after initiation and resumption of pazopanib treatment. However, both tumor CT sizes increased after interruption of pazopanib treatment. In Case 2, MRI revealed decreases and increases in the intracranial tumor size after initiation and interruption, respectively. Notably, pazopanib interruption caused rapid infratentorial tumor growth and death. Case 3 showed decreased extracranial tumor CT densities and sizes after pazopanib initiation, with pazopanib administered for 3.5 years. Thus, pazopanib may offer the potential to control both intracranial and extracranial tumors in patients with CNS SFTs with extracranial metastasis; however, treatment interruption requires careful consideration.

Background/Objectives: Aneurysmal subarachnoid hemorrhage (SAH) requires prompt treatment, yet hospital admission is occasionally delayed, and the optimal treatment strategy for such patients remains to be established. We aimed to investigate treatment modality, treatment timing, and outcomes in patients with SAH with respect to early versus delayed admission. Methods: A total of 1080 patients with SAH and a defined onset date were included in this prefecture-wide, multicenter, registry-based study. Baseline characteristics, late SAH complications (including vasospasm), and functional outcomes were compared between early and delayed admission groups at Day 4 or later (Day 0 = SAH onset). Additionally, the association of treatment choice (endovascular therapy or direct surgery) with treatment timing was analyzed in the delayed admission group. Results: Delayed admission was observed in 69 (6.4%) patients. The neurological status upon admission was significantly better in the delayed admission group, with more World Federation of Neurological Societies grades I–II (89.8% vs. 56.2% in the early admission group). Delayed admission was significantly associated with an increased incidence of symptomatic vasospasm by multivariable logistic regression analysis (odds ratio 2.51: 95% confidence interval 1.26–5.00, p = 0.009), while a significant difference in poor functional outcomes (modified Rankin scale 3–6) was not revealed. Although endovascular therapy use did not increase in the delayed admission group, the interval from admission to endovascular therapy was significantly shorter than that in the direct surgery group (0 [0–1] days vs. 1 [1–8] days: median [interquartile range], p = 0.007, Mann–Whitney U test). Conclusions: Delayed admission was a risk factor for symptomatic vasospasm; however, functional outcomes were not exacerbated. These results were obtained under the treatment strategy of multiple institutions, where the timing of endovascular therapy was earlier than that of direct surgery in patients with delayed admission.

Background:Flow diverter (FD) placement is generally effective for intractable internal carotid artery (ICA) aneurysms. However, salvage treatment for the aneurysm enlarging even after FD placement remains to be elucidated. Additional overlapping FD placement is considered the first-line treatment for residual or recurrent aneurysms. However, it is unclear whether overlapping FD is also effective for enlarging giant aneurysms that are considered impending rupture status. Although parent artery occlusion is a promising option, treatment strategy must be optimized, especially when a critical perforating artery is involved.Case Description:A 74-year-old woman experienced rapid symptomatic growth of her giant supraclinoid ICA aneurysm 10 months after FD placement. We assumed that reinforcement of flow diverting effect alone would be less effective for this extremely intractable aneurysm with more aggressive clinical feature so that surgical bailout by parent artery occlusion was planned. Complete ICA obliteration underneath the aneurysm was unavailable due to the presence of anterior choroidal artery. Thus, we took a flow alteration strategy, where we created minimal retrograde flow through the parent artery by a combination of an extracranial-intracranial bypass and targeted endovascular proximal parent artery obliteration, resulting in prevention of aneurysmal rupture and further growth.Conclusion:Impending rupture of the intracranial giant aneurysm after FD placement may be controllable with a tailor-made parent artery occlusion strategy even when a critical perforating artery is involved.

Background: Use of 5-aminolevulinic acid for photodynamic malignant tumor diagnosis reportedly causes intraoperative hypotension (systolic blood pressure < 70 mmHg) during urologic surgery. However, its association with intraoperative hypotension in malignant glioma surgery and underlying mechanisms has not yet been elucidated.. This study aimed to investigate whether 5-aminolevulinic acid administration is associated with intraoperative hypotension in malignant glioma surgery and explore the mechanisms of 5-aminolevulinic acidinduced hypotension in vitro. Methods: In this retrospective multicenter cohort study, we investigated intracellular nitric oxide as a candidate mediator of hypotension in response to 5-aminolevulinic acid in vitro in human umbilical vein endothelial cell cultures. Results: Of 142 patients, 94 underwent 5-aminolevulinic acid-guided surgery. Systolic blood pressure was significantly lower throughout surgery with 5-aminolevulinic acid administration. 5-Aminolevulinic acid administration was an independent risk factor for intraoperative hypotension according to multivariable logistic regression analysis (89% vs. 56%; odds ratio = 6.72, 95% confidence interval [2.05-22.1], P = 002). In subgroup analysis of the 5-aminolevulinic acid group, increasing age and use of renin-angiotensin system inhibitors had a synergistic effect with 5-aminolevulinic acid on decreased blood pressure. In the vascular endothelial cell culture study, 5-aminolevulinic acid induced a significant increase in intracellular nitric oxide generation. Conclusions: 5-Aminolevulinic acid administration was associated with intraoperative hypotension in malignant glioma surgery, with increasing age and use of renin-angiotensin system inhibitors boosting the blood pressurelowering effect of 5-aminolevulinic acid. According to in vitro results, the low blood pressure induced by 5-aminolevulinic acid may be mediated by a nitric oxide increase in vascular endothelial cells.

Differential diagnosis between dural sinus compression and cerebral venous thrombosis (CVT) in neonates will ensure adequate treatments and improve patient care. However, differential diagnosis can be difficult, particularly when involving a potentially fatal intracerebral hemorrhage (ICH), which may be caused by CVT. We present the case of a female neonate who experienced ICH but was adequately diagnosed using magnetic resonance venography with rotated positioning, contributing to successful duplication of the features of superior sagittal sinus compression with occipital bone depression. Computed tomography further demonstrated wide lambdoid and posterior sagittal sutures along with a depressed occipital bone, which may serve as a reference for dural sinus compression. We prevented unnecessary anticoagulant therapy and recommended head rotation while sleeping to reduce the potential risk of CVT development. This simple, informative rotated positioning provided adequate diagnosis and treatment of neonatal dural sinus compression, even with concomitant ICH.

Objective:The objective of this study was to evaluate the reproducibility of three-dimensional (3D) images of the aortic arch reconstructed using a novel image processing algorithm for non-enhanced computed tomography (CT) images of the cervicothorax and abdomen obtained before emergency endovascular surgery.Case Presentations:In all, 46 patients who underwent acute mechanical thrombectomy between January and December 2018 were examined. The anatomical variations of the aortic arch were reproduced in all cases; however, the reproduction of the carotid arteries was difficult.Conclusion:Our novel 3D analysis system enables obtaining information on the aortic arch easily from plain CT data that may be useful in acute endovascular treatment.

Summary: Introduction: For acute ischemic stroke caused by large artery occlusion, prompt significant reperfusion is essential. Standardization of device selection and surgical techniques may be useful in this regard.

Objective:We report two cases of acute proximal anterior circulation occlusion after pulmonary lobectomy. Case Presentation:Case 1 was a 64-year-old male who presented with occlusion of the right middle cerebral artery (MCA) one day after left lower lobectomy. Case 2 was a 68-year-old male who presented with occlusion of the right internal carotid artery (ICA). In both cases, mechanical thrombectomy was performed for complete recanalization and symptoms were improved. Conclusion:Prompt mechanical thrombectomy in the acute phase after pulmonary lobectomy improved the prognosis of patients with acute proximal anterior circulation occlusion. It is important to share information about ischemic complications with medical staff engaged in thoracic surgery.

Removal, irrigation, and reconstruction of the damaged parts are performed for open cranial injuries. These procedures are highly dependent on the cause and effect of the injuries. Herein, we report a case of neuroendoscopic surgery performed for the craniofacial injury caused by a grass cutter. A 60‒year‒old male accidentally collapsed while operating the grass cutter and suffered from left facial injury due to a direct cut by an engine‒driven cutting blade. His level of consciousness on emergency admission was GCS E3V5M6. The facial incised wound extending from the left forehead to the zygomatic bone was 15 cm long and 4 cm deep. His left eyeball was also injured. Head computed tomography(CT)revealed linear bone fracture along the open wound, left frontal lobar contusion, and pneumocephalus. Emergency surgery was performed by neurosurgeons, ophthalmologists, and plastic surgeons. Craniectomy of 3 cm width was performed on the frontal bone utilizing the open incised wound. Rigid neuroendoscope was inserted through the damaged dural opening. Under observation by a rigid neuroendoscope, contusional hematoma and fractured bony pieces were removed. The damaged dura mater of the frontal cranial base was peeled off, trimmed, and sutured. After the peeling off of the frontal sinus mucosa, the frontal sinus was filled with periosteum. Cranioplasty was performed using a titanium plate. Neither wound infection nor spinal fluid leakage followed. The patient was discharged on day 16. In conclusion, the neuroendoscopic procedure was useful in the restoration of injured deep dura mater and skull base from the limited surgical opening. (Received August 24, 2018;accepted September 21, 2018)

Object: The purpose of this study was to investigate the safety and efficacy of intravenous low-dose alteplase for acute ischemic stroke patients with relative contraindications. Methods: The consecutive series of patients admitted within 4.5 hours of ischemic stroke onset between September 2012 and April 2017 were retrospectively evaluated. A good outcome at 90 days and symptomatic intracerebral hemorrhage were evaluated to determine the association with intravenous low-dose alteplase, especially in the presence of relative contraindications. Results: Intravenous low-dose alteplase was administered to 219 of 315 patients (70%). A significantly higher number of patients treated with intravenous low-dose alteplase achieved a good outcome compared with those treated without alteplase (60% versus 44%; P = .014). The incidence of symptomatic intracerebral hemorrhage was not significantly different between the treatment groups. Multivariable logistic regression analysis of good outcome revealed that the significant independent factors were age of 81 years or older (odds ratio, .33; 95% confidence interval, .18-.60), National Institutes of Health Stroke Scale (NIHSS) of 4 or less (compared with NIHSS, 5-25; odds ratio, 3.3; 95% confidence interval, 1.8-6.4), modified Rankin scale score of 1 before stroke (odds ratio, .32; 95% confidence interval, .14-.73), and large changes on first brain imaging (odds ratio, .16; 95% confidence interval, .058-.44). Even with these relative contraindications, intravenous low-dose alteplase was still associated with good outcome (odds ratio, 3.1; 95% confidence interval, 1.6-5.8). Conclusions: Intravenous low-dose alteplase treatment can be safe and effective in relative contraindication patients with acute ischemic stroke.

The purpose of this study was to investigate whether patients with low preoperative Diffusion-weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) could benefit from mechanical thrombectomy for acute anterior circulation occlusion. This was a retrospective, non-blinded, cohort study. From September 2012 to August 2016, 83 consecutive patients of acute anterior circulation occlusion were treated with thrombectomy using second-generation devices or medical management. The DWI-ASPECTS was scored after the first MRI. Patient characteristics and clinical outcomes were compared between the treatment groups. Significant dependence was defined as a modified Rankin scale score ≥3 at 90 days. As a result, 33 patients underwent mechanical thrombectomy and 50 received medical management. In the mechanical thrombectomy group, the variable of lower DWI-ASPECTS (5, 4-6 vs. 8, 7-8, P < 0.001), especially ≤6, was significantly associated with poor prognosis. However, compared with patients of DWI-ASPECTS ≤ 6 who received medical management, there were significantly fewer patients with poor outcomes in thrombectomy (dependent in 11 of 15 vs. 23 of 23, respectively; P = 0.019). Although patients with lower pretreatment DWI-ASPECTS could benefit less from thrombectomy, their outcomes were still better than medical management. Therefore, mechanical thrombectomy could be considered in some patients with low pretreatment DWI-ASPECTS.

A 64-year-old man was referred to our hospital for treatment of a cerebral aneurysm that was incidentally found. The aneurysm was 7 mm in size and located on the left anterior communicating artery. Using a balloon assisted technique, we performed coil embolization. During the second coil insertion, the first coil was dislodged into the anterior communicating artery. We attempted coil retrieval using a snare, which was unsuccessful. We applied a direct aspiration first pass technique (ADAPT) and advanced a Penumbra 4MAX immediately proximal to the dislodged coil; the dislodged coil was then successfully retrieved. ADAPT is a simple procedure for retrieval of a detached coil, and it can be used as an alternative to the snare technique.

要旨：感染性心内膜炎から外側後脈絡叢動脈領域の脳塞栓症を来し，感染性脳動脈瘤を形成した稀な症例を経験したので報告する．症例は44 歳，女性．倦怠感を自覚し近医受診，血液検査にて炎症反応高値であった．その後他院を受診し，軽度左不全麻痺を指摘．MRI にて，右側の海馬，側頭葉内側，視床，外側膝状体，尾状核体部にかけて病変を認め，当科紹介となった．心エコー検査で僧帽弁に疣贅を認めたため感染性心内膜炎と診断．3DCTA および，脳血管撮影では右後大脳動脈（P2）に動脈瘤の形成を認め，その遠位の閉塞が疑われた．以上より，感染性心内膜炎から脳塞栓症を来し，さらに感染性脳動脈瘤が形成されたと推察した．また虚血性病変は右外側後脈絡叢動脈の灌流域と診断した．外側後脈絡叢動脈に限局した脳梗塞は稀であり，またその鑑別診断には注意を要すると考えられた．

BACKGROUND:Three-dimensional (3-D) stereoscopic vision is theoretically superior to two-dimensional (2-D) vision in endoscopic endonasal surgery. However, only few reports have quantitatively compared endoscopic performance under the two visual conditions. We introduced a newly designed stereoendoscopic system with a "dual-lens and single camera" for endoscopic endonasal surgery and objectively compared the performances under 3-D and high-definition 2-D visualizations on a dry laboratory model.METHODS:Thirty subjects without experience performing endoscopic surgery, computer-simulated training or any 3-D video system were recruited and divided into two groups (Group A and Group B) for performing two different tasks. The novel 4.7-mm-diameter stereoendoscope provided high-definition (HD) images. In Task 1, Group A started the task under the 3-D condition followed by the 2-D condition, and Group B vice versa. In Task 2, Group A started the task under the 2-D condition followed by the 3-D condition, and Group B vice versa. The performance accuracy and speed under the two visual conditions were analyzed.RESULTS:Significant improvement in performance accuracy and speed was seen under 3-D conditions in the both "3-D first" and "2-D first" subgroups during both tasks (P < .001). Regardless of order, the inaccuracy rate and performance time under 3-D conditions was significantly lower than that under 2-D conditions in each subject.CONCLUSIONS:We demonstrated the advantage of 3-D visualization over 2-D visualization for inexperienced subjects. Further quantitative clinical studies are required to confirm whether stereoendoscopy actually provides benefits in clinical settings.

Purpose of the Report: Good outcome of shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) patients are highly dependent on accurate preoperative assessments. Acetazolamide ethylcysteinate-dimer-single photon emission computer tomography (SPECT) was applied to iNPH patients for more exact preoperative evaluation. Patients andMethods: Sixty-five patients were categorized into 3 groups: group I (normals, n = 30), group II (with ventriculomegaly due to age-relating changes, n = 10), and group III (who underwent shunt surgery based on the diagnosis of iNPH, n = 25). Acetazolamide SPECT was performed in all patients, and mini-mental state examination (MMSE) was performed before and 1 month after the surgery in group III.Results: Acetazolamide SPECT study demonstrated normal increase of cerebral blood flow (CBF, more than 40%) in groups I and II. Group III was classified into 2 subgroups on the examination; a mean increasing percentage (% increase) of CBF was less than 20% in group IIIa and more than 40% in group IIIb. One month after the surgery, acetazolamide SPECT showed normal %increase of CBF in IIIa, and the increase in postoperative MMSE score was significantly greater in group IIIa than IIIb (P < 0.05). In iNPH patients, less than 20% increase in preoperative acetazolamide SPECT predicted improvement of MMSE score with 100% sensitivity and 60% specificity.Conclusions: Poor % increase of CBF by acetazolamide implies a low capacity for vasodilation in the brain due to compression and stretching by ventriculomegaly. Acetazolamide SPECT study is not an absolute examination but one of the valuable supplementary objective examinations to determine the surgical indication in iNPH-suspected patients.

A 72-year-old woman presented with a metastatic brain tumor around the pituitary stalk compressing the chiasm anteriorly and upward. After tumor resection by a left pterional approach failed, a three-dimensional (3D) image of the area of interest was reconstructed using the Vecter Vision navigation system and iPlan Cranial planning software version 2.5. Preoperative 3D computed tomography and magnetic resonance imaging data were fused to demonstrate the anatomical relationship between vessels, nerves, and tumor. Clearer demonstration of the optic nerves utilized thin slice axial and sagittal views along the nerves. The 3D reconstructed image demonstrated the spatial relationship of the tumor and surrounding tissue, and suggested the necessity of a right orbitozygomatic approach to create adequate working space for tumor resection. Second surgery according to this preoperative planning was successful. High quality multimodal fusion images in a navigation system has distinct advantages in preoperative assessment of essential structural relationships allowing adequate exposure of certain lesions and surrounding structures in individual patients by defining specific surgical approaches.

We present an evaluation of various non-rigid registration algorithms for the purpose of compensating interfractional motion of the target volume and organs at risk areas when acquiring CBCT image data prior to irradiation. Three different deformable registration (DR) methods were used: the Demons algorithm implemented in the iPlan Software (BrainLAB AG, Feldkirchen, Germany) and two custom-developed piecewise methods using either a Normalized Correlation or a Mutual Information metric (featureletNC and featureletMI). These methods were tested on data acquired using a novel purpose-built phantom for deformable registration and clinical CT/CBCT data of prostate and lung cancer patients. The Dice similarity coefficient (DSC) between manually drawn contours and the contours generated by a derived deformation field of the structures in question was compared to the result obtained with rigid registration (RR). For the phantom, the piecewise methods were slightly superior, the featureletNC for the intramodality and the featureletMI for the intermodality registrations. For the prostate cases in less than 50% of the images studied the DSC was improved over RR. Deformable registration methods improved the outcome over a rigid registration for lung cases and in the phantom study, but not in a significant way for the prostate study. A significantly superior deformation method could not be identified.In vorliegender Arbeit wird eine Evaluierung verschiedener nicht-rigider Registrationsalgorithmen zur Kompensation interfraktioneller Bewegungen des Zielvolumens und von Risikoorganen anhand von vor der Bestrahlung gewonnenen Conebeam-Computertomographien (CBCT) vorgestellt. Drei verschiedene Methoden zur deformierbaren Registrierung (DR) kamen hierbei zur Anwendung: Einerseits wurde der Demons-Algorithmus der iPlan Software (BrainLAB AG, Feldkirchen, Deutschland) verwendet, andererseits kamen zwei Eigenentwicklungen zur stückweise rigiden Registrierung zum Einsatz. Letztere verwendeten entweder eine normierte Korrelationsmetrik (featureletNC) oder eine auf der Mutual Information basierende Bildvergleichsmethode (featureletMI). Diese Verfahren wurden mit einem neuartigen Phantom für die DR- und klinischen CT- bzw. CBCT-Daten von Prostata- und Lungenkarzinompatienten validiert. Die Ergebnisse wurden anhand des Dice- Index (Dice Similarity Coefficient – DSC) für manuell eingezeichnete Konturen und durch die DR generierte Konturen der Zielregionen mit dem Ergebnis einer rigiden Registrierung (RR) verglichen. Im Falle des Phantoms zeigten sich die stückweise rigiden Verfahren leicht überlegen, wobei sich featureletNC bei der intramodalen und featureletMI bei der intermodalen Registration auszeichneten. Im Fall der Prostata konnte nur in etwa 50 % der Fälle eine Verbesserung des DSC gegenüber der RR festgestellt werden. Es zeigte sich, dass DR-Verfahren das Ergebnis einer rigiden Registrierung im Fall der Lunge und auch in der Phantomstudie verbesserten, was im Fall der Prostata nicht signifikant nachgewiesen werden konnte. Eine eindeutig überlegene Methode zur DR konnte ebenfalls nicht ermittelt werden.

BACKGROUND AND IMPORTANCE:We describe a novel technique that uses a goose neck snare for microcatheterization at transvenous embolization (TVE) for dural arteriovenous fistulae (dAVF). We have named our method the "remora technique."CLINICAL PRESENTATION:A 48-year-old man reported with dizziness. Angiography disclosed a transverse-sigmoid sinus (T-SS) dAVF with proximal sigmoid sinus occlusion, an open distal transverse sinus, narrow multiple divided confluence sinus, and multiple retrograde leptomeningeal venous drainage. We attempted TVE via the confluence sinus from the contralateral open side; it was narrow, steep, and divided into cavities, rendering the procedure very difficult. Although we were able to pass a 0.035-inch guidewire to the affected transverse sinus, we could not advance via the same route with the microguidewire. One month later we attempted transfemoral TVE again using the remora technique. We caught the 0.035-inch guidewire in the left internal jugular vein with a goose neck micro snare bearing a microcatheter. By advancing the 0.035-inch wire across the confluence sinus to the affected sinus, we were able to pass the microcatheter through the lesion using the snare like a remora. We then performed transvenous coil packing.CONCLUSION:In TVE for dAVF, passage of the microguidewire is often difficult. Even if the affected sinus can be reached with the stiff 0.035-inch guidewire, it may not be possible to follow with the microguidewire. We report on a patient with T-SS dAVF who underwent successful microcatheterization in which we used our remora technique with a goose neck snare.