Investigation of factors that contribute to the outcome of endoscopic transsphenoidal surgery as reviewed from our own cases

In order to improve the treatment outcome of endoscopic transsphenoidal surgery (eTSS), it is important to identify the factors that contribute to the tumor resection rate and/or post-operative complications, and to devise a surgical strategy for each case. In the present study, we retrospectively evaluated our own experience of eTSS for primary pituitary adenoma (PA), and sought the factors that are related to patients’ surgical outcomes. Thirty-three cases of primary PA operated on by eTSS at our institution in a recent 5-year period were investigated. The patients’ data for age, sex, Knosp grade, operating time, sellar floor opening rate, tumor resection rate and post-operative complications were evaluated. The median rate of tumor resection was 91.3%, and the tumor resection rate demonstrated significant linear relationships with age (Z = −0.41, p = 0.02), sex (Z = −0.42, p = 0.01) and sellar floor opening rate (Z = 0.47, p = 0.01). A significant linear relationship was also found between sex and sellar floor opening rate (Z = −0.51, p < 0.01). However, post-operative cerebrospinal fluid (CSF) leakage occurred in 2 cases where the sellar floor was opened widely. We reviewed the details of these 2 cases in this article. The gender difference observed in this study results was thought to be due to the difference in size of the nostril; however, further verification is required. Although wide sellar floor opening can contribute positively to aggressive PA resection in eTSS, this may increase the risk of CSF leakage. If a case requires a higher resection rate, especially in functional PA invading the cavernous sinus, the surgeon should adopt and perform advanced techniques of sellar floor reconstruction according to those carried out in the expanded endonasal approach for the frontal skull base or clivus area

Erroneous resection of a cerebellar infarction – Lesson learned

We describe the clinical process and treatment details in a noteworthy case with a cerebellar lesion which achieved a satisfactory clinical course. A 64-year-old female presented with nausea and vomiting. The patient had exhibited progressive gait disturbance for several days. Magnetic resonance (MR) imaging disclosed a mass, which was low-intense on T1 weighted imaging, high-intense on T2 weighted imaging, and low-intense on diffusion weighted imaging, in the left cerebellar hemisphere. The clinical symptoms rapidly deteriorated within a few days and the lesion extended to the cerebellar peduncle and brain stem with a contrast enhancement effect on part of the margin. Since the onset and transition of the symptoms were inconsistent with the course of an infarction, the patient underwent resection surgery in view of the possibility of cerebellar glioma, including glioblastoma. The lesion was removed as much as possible and her clinical symptoms became significantly improved. Post-operative MR imaging revealed that a T2 high-intense area remained in the cerebellar peduncle and brain stem. Since a neoplastic lesion was strongly suspected from the imaging findings, chemoradiation therapy was planned. However, we failed to find tumor cells in resected samples, although the material was sufficiently large to discount sampling error. We finally diagnosed it for cerebellar infarction. The lesion did not undergo change thereafter, and no recurrence or progression was observed at 6 months after the operation. Sufficient lesion resection with decompression proved effective in the present case, as we continued to suffer difficulty in reaching an accurate pathological diagnosis for the lesion in the cerebellum. Accurate diagnosis with various studies and flexible selection of treatment strategy are considered to be crucial in for the treatment of cerebellar lesions

Novel threading device for central dural tenting sutures: Technical note

Central dural tenting sutures are surgical routine procedure in craniotomy which requires passing the thread through a small bone hole, which is time consuming and both physically and mentally stressful. We have developed a novel surgical device to easily perform these procedures and to reduce stress. This study evaluated the convenience, ease, and accuracy compared to conventional methods. We evaluated the time taken using the bone hole threader with an artificial bone model with 10 bone holes. The time required to pass the sutures through the bone hole was compared after 11 neurosurgeons performed using each of three methods twice: one surgeon and another assistant using the conventional method, one surgeon using the bone hole threader, and one surgeon and another assistant using the bone hole threader. These results were statistically analyzed using SPSS. Mean time reduction of 15.9 s was obtained for the bone threader use by one surgeon compared with conventional method by two operators (p = 0.03). Mean time reduction of 24 s was obtained for the bone threader use by two operators compared with one operator (p < 0.01). Use of the bone threader enables time saving even by a single surgeon, and two operators further reduced the required time. Our novel threading device provides a new, quick, and available technique for threading the central dural tenting suture, and will be useful during neurosurgery

Recanalization by mechanical thrombectomy for cerebral infarction due to brachiocephalic artery occlusion; case report

The effectiveness of mechanical thrombectomy for acute ischemic stroke of extracranial vascular embolism remains controversial. Cerebral infarction with brachiocephalic artery occlusion is rare, and treatment strategy have not been adequately discussed. We describe a rare case of cerebral infarction due to brachiocephalic artery occlusion treated by mechanical thrombectomy. Although the time delay to treatment caused poor outcome, mechanical thrombectomy could be expected to be effective in cerebral infarction due to brachiocephalic artery occlusion, since partial reperfusion was achieved in the present case. When a patient is diagnosed with brachiocephalic artery occlusion, it is important that the possibility of cerebral infarction should be recognized at the primary contact to ensure prompt diagnosis and treatment

Peripheral circadian rhythms in the liver and white adipose tissue of mice are attenuated by constant light and restored by time-restricted feeding.

Disturbance of circadian rhythms underlies various metabolic diseases. Constant light exposure (LL) is known to disrupt both central and peripheral circadian rhythms. Here, we attempted to determine whether the effects of LL are different between various peripheral tissues and whether time-restricted feeding restores the circadian rhythms especially in white adipose tissue (WAT). Six-week-old mice were subjected to three feeding regimes: ad libitum feeding under light/dark phase (LD), ad libitum feeding under LL cycle, and restricted feeding at night-time under LL cycle with a normal chow. After 3 weeks, we compared body weight, food intake, plasma levels of lipids and glucose, and the expression patterns of the clock genes and the genes involved in lipid metabolism in the liver and WAT. The mice kept under LL with or without time-restricted feeding were 5.2% heavier (p<0.001, n = 16) than the mice kept under LD even though the food intakes of the two groups were the same. Food intake occurred mostly in the dark phase. LL disrupted this pattern, causing disruptions in circadian rhythms of plasma levels of triglycerides (TG) and glucose. Time-restricted feeding partially restored the rhythms. LL eliminated the circadian rhythms of the expression of the clock genes as well as most of the genes involved in lipid metabolism in both liver and WAT. More notably, LL markedly decreased not only the amplitude but also the average levels of the expression of the genes in the liver, but not in the WAT, suggesting that transcription in the liver is sensitive to constant light exposure. Time-restricted feeding restored the circadian rhythms of most of the genes to various degrees in both liver and WAT. In conclusion, LL disrupted the peripheral circadian rhythms more severely in liver than in WAT. Time-restricted feeding restored the circadian rhythms in both tissues

Esterification of 4β-hydroxycholesterol and other oxysterols in human plasma occurs independently of LCAT

The acyltransferase LCAT mediates FA esterification of plasma cholesterol. In vitro studies have shown that LCAT also FA-esterifies several oxysterols, but in vivo evidence is lacking. Here, we measured both free and FA-esterified forms of sterols in 206 healthy volunteers and 8 individuals with genetic LCAT deficiency, including familial LCAT deficiency (FLD) and fish eye disease (FED). In the healthy volunteers, the mean values of the ester-to-total molar ratios of the following sterols varied: 4β-hydroxycholesterol (4βHC), 0.38; 5,6α-epoxycholesterol (5,6αEC), 0.46; 5,6β-epoxycholesterol (5,6βEC), 0.51; cholesterol, 0.70; cholestane-3β,5α,6β-triol (CT), 0.70; 7-ketocholesterol (7KC), 0.75; 24S-hydroxycholesterol (24SHC), 0.80; 25-hydroxycholesterol (25HC), 0.81; 27-hydroxycholesterol (27HC), 0.86; 7α-hydroxycholesterol (7αHC), 0.89. In the individuals with LCAT deficiency, the plasma levels of the FA-esterified forms of cholesterol, 5,6αEC, 5,6βEC, CT, 7αHC, 7KC, 24SHC, 25HC, and 27HC were significantly lower than those in the healthy volunteers. The individuals with FLD had significantly lower FA-esterified forms of 7αHC, 24SHC, and 27HC than those with FED. Of note, even in the three FLD individuals with negligible plasma cholesteryl ester, substantial amounts of the FA-esterified forms of 4βHC, 5,6αEC, 7αHC, 7KC and 27HC were present. We conclude that LCAT has a major role in the FA esterification of many plasma oxysterols, but contributes little to the FA esterification of 4βHC. Substantial FA esterification of 4βHC, 5,6αEC, 7αHC, 7KC and 27HC is independent of LCAT