Sendai-shi, Japan
Sendai-shi, Japan

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Inoue T.,Kohnan Hospital | Shimizu H.,Kohnan Hospital | Fujimura M.,Sendai Medical Center | Saito A.,Kohnan Hospital | Tominaga T.,Tohoku University
Journal of Neurosurgery | Year: 2012

Object. In this paper, the authors' goals were to clarify the characteristics of growing unruptured cerebral aneurysms detected by serial MR angiography and to establish the recommended follow-up interval. Methods. A total of 1002 patients with 1325 unruptured cerebral aneurysms were retrospectively identified. These patients had undergone follow-up evaluation at least twice. Aneurysm growth was defined as an increase in maximum aneurysm diameter by 1.5 times or the appearance of a bleb. Results. Aneurysm growth was observed in 18 patients during the period of this study (1.8%/person-year). The annual rupture risk after growth was 18.5%/person-year. The proportion of females among patients with growing aneurysms was significantly larger than those without growing aneurysms (p = 0.0281). The aneurysm wall was reddish, thin, and fragile on intraoperative findings. Frequent follow-up examination is recommended to detect aneurysm growth before rupture. Conclusions. Despite the relatively short period, the annual rupture risk of growing unruptured cerebral aneurysms detected by MR angiography was not as low as previously reported. Surgical or endovascular treatment can be considered if aneurysm growth is detected during the follow-up period.


Takano R.,Tohoku University | Misu T.,Tohoku University | Takahashi T.,Yonezawa National Hospital | Sato S.,Kohnan Hospital | And 2 more authors.
Neurology | Year: 2010

Introduction: Loss of aquaporin 4 and glial fibrillary acidic protein (GFAP) with necrosis and demyelination is a prominent pathologic feature of neuromyelitis optica (NMO). However, the clinicopathologic significance of astrocytic damage and its relation with demyelination are unknown. Objective: To analyze clinical and pathologic values of a CSF biomarker of astrocytic damage in NMO. Methods: We measured the levels of GFAP, S100B, myelin basic protein (MBP), and neurofilament H (NF-H) in CSF obtained from patients with NMO (n = 33), multiple sclerosis (MS) (n = 27), acute disseminated encephalomyelitis (ADEM), ischemia, meningitis, and other neurologic disease controls (OND). Results: The CSF-GFAP levels during relapse in NMO (2,476.6 ± 8,815.0 ng/mL) were significantly higher than those in MS (0.8 ± 0.4 ng/mL) and OND (0.7 ± 0.5 ng/mL), and much beyond those in ADEM (14.1 ± 27.4 ng/mL). The sensitivity and specificity of CSF-GFAP for NMO was 90.9% and 76.9% in all, but the specificity improved above 90% in cases limited to demyelinating diseases. CSF-S100B showed a similar trend but was less remarkable. In contrast, MBP and NF-H are not different between NMO and MS. Following treatments, the CSF-GFAP rapidly decreased to a normal level, but CSF-MBP remained high. There were strong correlations between the CSF-GFAP, CSF-S100B, or CSF-MBP levels and Expanded Disability Status Scale (EDSS) or spinal lesion length in the acute phase (r > 0.6). Only CSF-GFAP correlated with EDSS at 6-month follow-up (r = 0.51) in NMO. Conclusions: Astrocytic damage reflected by elevated CSF glial fibrillary acidic protein is a clinically relevant, primary pathologic process in neuromyelitis optica, and is far more severe than demyelination. Copyright © 2010 by AAN Enterprises, Inc. All rights reserved.


Ogawa Y.,Kohnan Hospital | Kawaguchi T.,Kohnan Hospital | Tominaga T.,Tohoku University
Clinical Neurology and Neurosurgery | Year: 2014

Objective The transsphenoidal approach has been increasingly used for the surgical treatment of craniopharyngiomas with/without sellar enlargement. However, the optimum indications for the extended transsphenoidal approach with opening of the posterior ethmoidal sinus in addition to opening of the sellar floor are still controversial. Methods Forty-two patients with craniopharyngiomas treated by the extended transsphenoidal approach were retrospectively studied from a series of 993 cases of pituitary surgeries between April 2004 and September 2013. Removal rate, visual function, endocrinological changes, and mid-term prognosis were investigated. Results Gross total removal was achieved in 31 of 42 patients (73.8%) overall, in 24 of 27 patients (88.9%) undergoing initial treatment, and in 7 of 15 patients (46.7%) undergoing re-treatment after previous transcranial tumor removal and/or radiation therapy. The major cause of abandonment of surgery in the re-treatment group was tight adhesion and/or encasement of the perforating arteries. The rate of total removal showed a significant difference between initial treatment and re-treatment groups (logrank test, p < 0.001). Only one patient suffered tumor recurrence after total removal, but the others remained disease-free during the follow-up period. Postoperative visual acuity was improved in 20 of 40 patients evaluated, remained steady in 20, and deteriorated in none, indicating good ophthalmological outcomes in all 40 patients. The pituitary stalk was intentionally sectioned in 18 of 42 patients, and 9 of the 18 patients could discontinue usage of antidiuretic hormone in the follow-up period. All patients were discharged without neurological deficits, except for two patients with preoperative dysfunction of the mammillary bodies, and all maintained independence in daily life with hormonal supplementation. No other complications including cerebrospinal fluid leakage were experienced in the follow-up period. Conclusions Maximum and radical removal through the extended transsphenoidal approach achieved high rate of total removal and good visual outcomes. However, re-treatment still presents challenges. © 2014 Elsevier B.V.


Ogawa Y.,Kohnan Hospital | Watanabe M.,Tohoku University | Tominaga T.,Tohoku University
Acta Neurochirurgica | Year: 2013

Background: Rathke's cleft cyst (RCC) with significant squamous and/or stratified epithelium including smooth transition from single cuboidal to squamous epithelium (tRCC) is rare and possibly represents an intermediate form to craniopharyngioma. Methods: Twelve patients with histologically confirmed tRCC were retrospectively investigated from a series of 167 cases of RCC and 96 cases of craniopharyngiomas. Clinical data were reviewed, and immunohistochemistry findings for cytokeratins and β-catenin were examined. Results: All lesions were located in the sella turcica with marked extension to suprasellar cistern. Six of the 12 patients had suffered postoperative re-enlargement, and three of these six patients required more than two additional operations and irradiation. CAM5.2 was positive in the glandular epithelium in all tRCCs and focally positive in the squamous epithelium of all these tRCCs. 34βE12 was positive in the squamous epithelium in all tRCCs and focally positive in the glandular epithelium in all but one tRCC. The findings of cytokeratin expression of tRCCs were very similar to those of craniopharyngioma. β-Catenin showed nuclear translocation in five cases. All patients with nuclear translocation of β-catenin suffered postoperative re-enlargement. Conclusions: tRCC carries an extremely high risk of re-enlargement. Cytokeratin expression resembles that in craniopharyngioma, which might indicate a very close origin of these pathologies. Nuclear translocation of β-catenin may be related to the aggressive clinical course. © 2013 Springer-Verlag Wien.


Shimizu H.,Tohoku University | Matsumoto Y.,Kohnan Hospital | Tominaga T.,Tohoku University
Clinical Neurology and Neurosurgery | Year: 2010

Objective: Parent artery occlusion with/without bypass surgery is one of the treatment choices for the internal carotid artery (ICA) aneurysm difficult to treat by clipping or coiling. There have been few reports regarding postoperative cerebral blood flow (CBF) changes after surgery. This study evaluated the present bypass selection strategy based on balloon test occlusion (BTO) in terms of clinical and hemodynamic outcomes. Methods: Twenty-one consecutive patients with ICA aneurysms underwent parent artery occlusion. High flow bypass (n = 9), superficial temporal artery-middle cerebral artery bypass (n = 10), or no bypass (n = 2) was performed depending on the changes in clinical symptoms and CBF during BTO. Quantitative CBF measurement with acetazolamide challenge was performed in the chronic stage. Results: Overall outcome at discharge was good recovery 18, moderate disability 2, and severe disability 1. Two patients suffered symptomatic embolic or perforator infarction associated with the surgical manipulations. Preoperative cranial nerve pareses improved completely or partially in all patients except one. CBF in the chronic stage (n = 18) demonstrated no significant difference between the surgical and non-surgical cerebral hemispheres. No cerebral ischemic event was observed during the follow-up period (mean 2.9 years). Conclusion: The present surgical strategy based on preoperative BTO provides a reliable tool to achieve acceptable clinical and hemodynamic outcomes in patients with complex ICA aneurysms to be treated by parent artery occlusion. © 2009 Elsevier B.V. All rights reserved.


Ogawa Y.,Kohnan Hospital | Tominaga T.,Tohoku University
Acta Neurochirurgica | Year: 2012

Background Recent advances in minimally invasive surgery have allowed extended transsphenoidal approaches to treat large and complex lesions beyond the sella turcica including basal meningiomas, but the inclusion criteria and limitations of this approach remain unclear. Methods Retrospective review of 19 consecutive patients (5 males and 14 females aged from 43 to 79 years) with tuberculum sellae meningioma with a maximum diameter of less than 30 mm surgically treated between December 2006 and August 2011 by a single surgeon. Operative outcomes and limitation-based indications were investigated. Findings Total removal was achieved in 15 cases including Simpson's grade 1 in 2 cases (78.9%). All tumor remnants were located in the lateral portion of the internal carotid artery (ICA), as indicated by preoperative magnetic resonance (MR) imaging. Additional oblique imaging along the longitudinal axis of the C1-2 portion of the ICA revealed a paradoxical presence of tumor in between both sides of the ICA in some patients, even in the case with lateral extension over the ICA on coronal MR imaging. Total removal could be achieved in these patients, and after the introduction of additional preoperative oblique MR imaging, total removal was achieved in all patients. Visual outcomes of eyes showed improvement in 23, remained steady in 11, and showed deterioration in 4, and 89.5% eyes recovered to a good state. Deterioration was caused by injury of a small vein in one patient and previous disruption of the arachnoidal sheath in the remaining three. One patient suffered cerebrospinal fluid leakage and required re-operation. None of the patients developed endocrinological deficits or required prolonged hormonal supplementation. Conclusions The extended transsphenoidal approach has equivalent potential to transcranial surgery for tuberculum sellae meningiomas with a maximum diameter of less than 30 mm. The tumors with lateral extension over the ICA have fewer chances of total removal. ICA-oriented simulation and surgical planning are important. © Springer-Verlag 2012.


Ogawa Y.,Kohnan Hospital | Tominaga T.,Tohoku University
Journal of Neurosurgery | Year: 2010

A Rathke cleft cyst is considered to arise from the remnants of the Rathke pouch, and it consists of single cuboidal or columnar epithelium including cilia and goblet cells, which secrete mucus into the cyst. Magnetic resonance imaging characteristically shows a thin membranous cystic wall that enhances with Gd, and homogeneous intensity of the content suggesting fluid collection. Cases with an irregularly thickened and/or calcified cyst wall, presumably due to chronic inflammation of the wall, are rare. A 21-year-old woman presented with an extremely rare case of a solid and cystic Rathke cleft cyst with partial ossification, manifesting as bitemporal hemianopia. Magnetic resonance imaging showed a massive solid sellar lesion extending upward and compressing the optic chiasm and floor of the third ventricle. Transsphenoidal surgery was performed, resulting in total removal of the lesion and immediate recovery of visual function. Postoperative histological examination disclosed that the major part of the lesion consisted of various phases of clotting and granulation with significant fibrosis. Mature bone formation and abundant cholesterin clefts were also seen. Single cuboidal epithelium including goblet cells and cilia was found along this granulation, and the diagnosis was a Rathke cleft cyst. An ossified Rathke cleft cyst is extremely rare, and a solid Rathke cleft cyst has not before been reported. This case illustrates the extremely long and complex nature of this disease.


Shimizu H.,Tohoku University | Matsumoto Y.,Kohnan Hospital | Tominaga T.,Tohoku University
Neurosurgical Review | Year: 2010

Non-saccular aneurysms (NSAs) of the internal carotid artery trunk include blood blister-like aneurysms (BBAs) and dissecting aneurysms (DAs), which are susceptible to disastrous intra- and postoperative bleeding. This study was conducted to clarify the clinical features of NSAs and the results of early bypass and trapping. Nineteen ruptured NSAs were identified in 937 patients with subarachnoid hemorrhage (SAH). The principal treatment was to trap the aneurysm following bypass surgery as soon as possible after SAH onset. Angiography revealed nine BBAs and ten DAs. Eight patients (four BBA and four DA) were treated in the chronic stage because of delayed arrival (n = 3) or lack of aneurysm on initial angiography (n = 3), or other reasons (n = 2). The remaining 11 patients underwent early surgery using trapping after bypass, except for one BBA-type (clipped). During surgery, corresponding intraoperative findings were confirmed for each aneurysm type. There were six preoperative reruptures; five were determinant of patient outcome. In 14 patients without preoperative rerupture influencing outcome, 11 patients were independent at discharge and three patients dependent due to surgical complication. There was one case of minor intraoperative bleeding; no postoperative rerupture occurred. There was no delayed vasospasm-related deficit, although temporary symptomatic spasm occurred in three patients. Early bypass and trapping appeared to be an acceptable treatment strategy for these NSAs eliminating intra- and postoperative bleeding and not increasing a chance of delayed vasospasm. © 2009 Springer-Verlag.


Tsubamoto H.,Hyogo College of Medicine | Sonoda T.,Kohnan Hospital | Yamasaki M.,Shinko Hospital | Inoue K.,Meiwa General Hospital
Anticancer Research | Year: 2014

Background: After progression during chemotherapy, persistent ovarian cancer rarely responds to cytotoxic agents. We evaluated the use of adjunctive itraconazole for treating refractory ovarian cancer. Patients and Methods: Medical records of patients with ovarian cancer were retrospectively reviewed to select those with a history of platinum and taxane administration, clinical progression within six months of the last platinum administration, continuation of chemotherapy after the first progression during chemotherapy. Results: Among 55 patients, itraconazole in combination with chemotherapy was administered to 19 patients. The median progressionfree survival (PFS) was 103 days and 53 days for chemotherapy with and without itraconazole, respectively (p=0.014). The corresponding median overall survival was 642 days and 139 days, respectively (p=0.006). The hazard ratio for PFS was 0.24 (p=0.002) and for overall survival was 0.27 (p=0.006) for therapy with itraconazole. Conclusion: Adjunctive itraconazole is promising for patients with refractory ovarian cancer.


Tsubamoto H.,Hyogo College of Medicine | Sonoda T.,Kohnan Hospital | Yamasaki M.,Shinko Hospital | Inoue K.,Meiwa General Hospital
Anticancer Research | Year: 2014

Background: Recurrent ovarian clear cell carcinoma (CCC) rarely responds to cytotoxic agents. Itraconazole is a potent inhibitor of the P-glycoprotein efflux pump, angiogenesis, and the Hedgehog pathway. We evaluated the efficacy of chemotherapy with itraconazole for CCC. Patients and Methods: Medical charts of patients with CCC who had received chemotherapy with itraconazole were retrospectively reviewed. Results: Among nine patients with CCC, five had a history of progression with paclitaxel and carboplatin, and none had received prior treatment with bevacizumab or other targeted therapy. Eight patients received docetaxel (35 mg/m2, day 1) and carboplatin-based (area under the curve, 4 mg·; min-1· mL-1; day 1) chemotherapy with an oral itraconazole solution (400 mg, days -2 to 2), repeated every two weeks. The response rate, median progression-free survival and overall survival were 44% (95% confidence interval [(CI)=12-77%], 544 days (95% CI=82-544 days) and 1,047 days (95% CI=462-1332 days), respectively. Conclusion: Chemotherapy with itraconazole is promising for patients with CCC.

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