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An approach which improves on the conventional suboccipital craniectomy was used to explore a jugular foramen, a hypoglossal neurinoma, and a tentorial meningioma. A postero-medial mastoidectomy supplemented by the conventional suboccipital craniectomy made it possible to expose the entire sigmoid sinus. Subsequent medial retraction of the exposed sigmoid sinus and continuous dura mater and the extradural removal of petrous bone around the jugular foramen exposed the whole extracranial portion of the tumours. The tumours were totally removed by this approach in which the extradural route corresponded to the extracranial portion of the tumours and the suboccipital route to the intracranial portion. Facial nerve and hearing disturbances, which are frequent complications of the previous approaches, did not occur in our cases. Providing adequate exposure with simple surgical procedures and showing no adverse postoperative sequelae, this approach is most suitable for surgery upon jugular foramen tumours with extracranial extension.

Aim: In-stent intimal hyperplasia (ISH) observed after carotid artery stenting (CAS) may lead to in-stent restenosis. We aimed to investigate whether contrast-enhanced carotid ultrasonography (CEUS) and magnetic resonance imaging (MRI) plaque imaging prior to CAS are predictive for ISH at 6 months after CAS.Material and method: A total of 14 patients (13 men, 1 woman; mean age, 74.2 years) were prospectively enrolled. CEUS and MRI plaque imaging were performed before CAS. ISH was diagnosed by carotid angiography at 6 months after CAS. Patients were divided into two groups based on the thicknessof ISH and age, risk factors, enhancement in CEUS, MRI plaque imaging and number of replaced stents were compared between groups.Results: Carotid angiography at 6 months after CAS revealed ISH in 10 patients. Plaque enhancement on CEUS was observed in 6 patients, all of whom showed ISH. A significant association was seen between plaque enhancement on CEUS and development of ISH (χ2 test, CEUS enhancement (+) 100% vs. CEUS enhancement (-) 50% p=0.040). Carotid plaques in 12 patients were diagnosed as unstable by MRI plaque imaging. Presence of ISH was significantly associated with unstable plaque diagnosed by MRI plaque imaging (χ2 test, unstable 83% vs. stable 0%; p=0.016).Conclusion: Carotid plaque MRI and CEUS may be useful to predict ISH after CAS.

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A long-term follow-up study covering between one and twenty-two years after surgery was carried out on 177 patients with direct operations for cerebral aneurysms. Rebleeding was detected in five out of 18 patients with incomplete operations; one patient within 6 months and four patients within 5 to 8 years after surgery. The rebleeding rate of incompletely operated patients in the first decade was similar to that of untreated patients with ruptured aneurysms. This suggests that wrapping, coating and incomplete clipping procedures provide some protection against rebleeding in the first 6 months but little in the period extending beyond 5 years after surgery. Showing two types of newly-formed aneurysms after complete surgery and enlarged residual aneurysms after incomplete surgery, the possibility of rebleeding from these aneurysms is discussed in the present report.