Recent investigation suggests that the dorsal anterior cingulate cortex (ACC) is involved in the interplay between cognition and emotion. The present study described three patients who underwent removal of brain tumors just above the right dorsal ACC. These patients had residual tumor following surgery and showed anxiety disorder (AD) both before and after surgery. Visual memory or attention was abnormal before surgery in these patients, but these deficits improved following surgery, possibly due to a decrease in compression of the right dorsal ACC. These results suggest that damage to the right dorsal ACC is involved in AD and well as in deficits in visual memory or attention. Therefore, the right dorsal ACC might play a role in vision-related cognition and emotion, such as anxiety.

Background In neurosurgery, it is important to inspect the spatial correspondence between the preoperative medical image (virtual space), and the intraoperative findings (real space) to improve the safety of the surgery. Navigation systems and related modalities have been reported as methods for matching this correspondence. However, because of the influence of the brain shift accompanying craniotomy, registration accuracy is reduced. In the present study, to overcome these issues, we developed a spatially accurate registration method of medical fusion 3-dimensional computer graphics and the intraoperative brain surface photograph, and its registration accuracy was measured. Methods The subjects included 16 patients with glioma. Nonrigid registration using the landmarks and thin-plate spline methods was performed for the fusion 3-dimensional computer graphics and the intraoperative brain surface photograph, termed mixed-reality computer graphics. Regarding the registration accuracy measurement, the target registration error was measured by two neurosurgeons, with 10 points for each case at the midpoint of the landmarks. Results The number of target registration error measurement points was 160 in the 16 cases. The target registration error was 0.72 ± 0.04 mm. Aligning the intraoperative brain surface photograph and the fusion 3-dimensional computer graphics required ∼10 minutes on average. The average number of landmarks used for alignment was 24.6. Conclusions Mixed-reality computer graphics enabled highly precise spatial alignment between the real space and virtual space. Mixed-reality computer graphics have the potential to improve the safety of the surgery by allowing complementary observation of brain surface photographs and fusion 3-dimensional computer graphics.

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Background Intraoperative rupture is the most fatal and catastrophic complication of surgery for unruptured intracranial aneurysms (UIAs); thus, it is extremely useful to predict reddish and thin-walled regions of the UIA before surgery. Although several studies have reported a relationship between the hemodynamic characteristics and intracranial aneurysm wall thickness, a consistent opinion is lacking. We aimed to investigate the relationship between objectively and quantitatively evaluated bleb wall color and hemodynamic characteristics using phase-contrast magnetic resonance angiography (PC-MRA). Methods Ten patients diagnosed with UIA who underwent surgical clipping and preoperative magnetic resonance imaging along with PC-MRA were included in this study. Bleb wall color was evaluated from an intraoperative video. Based on the Red (R), Green, and Blue values, bleb wall redness (modified R value; mR) was calculated and compared with the hemodynamic characteristics obtained from PC-MRA. Results The wall redness distribution of 18 blebs in 11 UIAs in 10 patients was analyzed. Bleb/neck inflow velocity ratio (Vb/Va: r = 0.66, P = 0.003) strongly correlated with mR, whereas bleb/neck inflow rate ratio (r = 0.58, P = 0.012) correlated moderately. Multivariate regression analysis revealed that only Vb/Va ( P = 0.017) significantly correlated with mR. There was no correlation between wall shear stress and mR. Conclusions The bleb redness of UIAs and Vb/Va, calculated using PC-MRA, showed a significantly greater correlation. Thus, it is possible to predict bleb thickness noninvasively before surgery. This will facilitate more detailed pre- and intraoperative strategies for clipping and coiling for safe surgery.

OBJECTIVEThe posterior petrosal approach is an established surgical method offering wide access to skull base lesions through mastoid air cells. The authors describe their experience with the endoscopic transmastoid “posterior petrosal” approach (EPPAP) for skull base tumors involving the internal auditory canal (IAC), jugular foramen, and hypoglossal canal.METHODSThe EPPAP was performed for 7 tumors (3 chordomas, 2 chondrosarcomas, 1 schwannoma, and 1 solitary fibrous tumor). All surgical procedures were performed under endoscopic visualization with mastoidectomy. The compact bone of the mastoid air cells and posterior surface of the petrous bone are carefully removed behind the semicircular canals. When removal of cancellous bone is extended superomedially through the infralabyrinthine space, the surgeon can expose the IAC and petrous portion of the internal carotid artery to reach the petrous apex (infralabyrinthine route). When removal of cancellous bone is extended inferomedially along the sigmoid sinus, the surgeon can safely reach the jugular foramen (transjugular route). Drilling of the inferior surface of petrous bone is extended further inferoposteriorly behind the jugular bulb to approach the hypoglossal canal and parapharyngeal space through the lateral aspect of the occipital condyle (infrajugular route).RESULTSOf the 7 tumors, gross-total resection was achieved in 4 (57.1%), subtotal resection (> 95% removal) in 2 (28.6%), and partial resection (90% removal) in 1 (14.2%). Postoperatively, 2 of 3 patients with exudative otitis media showed improvement of hearing deterioration, as did 2 patients with tinnitus. Hypoglossal nerve palsy and swallowing difficulty were improved after surgery in 2 patients and 1 patient, respectively. In 1 patient with severe cranial nerve deficits before surgery, symptoms did not show any improvement.CONCLUSIONSThe authors present their preliminary experience with EPPAP for skull base tumors in the petrous part of the temporal bone and the lateral part of the occipital condyle involving the cranial nerves and internal carotid arteries. The microscope showed a higher-quality image and illumination in the low-power field. However, the endoscope could offer wider visualization of the surgical field and contribute to minimizing the size of the surgical pathways, necessity of brain retraction, and eventually the invasiveness of surgery. Thus, the EPPAP may be safe and effective for skull base tumors in the petrous region, achieving balance between the radicality and invasiveness of the skull base surgery.