ObjectThe combination approach of Ommaya reservoir placement and Gamma Knife surgery (GKS) was evaluated for the treatment of large cystic metastatic brain tumors.MethodsThe medical records of 22 patients harboring 28 tumors, who underwent Ommaya reservoir placement followed by GKS for large cystic metastatic brain tumors were retrospectively reviewed. The patients' ages ranged 26 to 77 years (mean 57.1 years). The most common locations of primary malignancy were the breast (11 patients) followed by the lung (seven patients). The mean maximum diameter of the tumor was 40.1 mm before Ommaya reservoir placement and 31.2 mm at GKS (mean reduction of 19.9%). The mean calculated tumor volume at GKS was 13.4 cm3. The mean tumor margin dose was 16 Gy in 17 patients treated by GKS only and 11 Gy in five patients treated using both GKS and external radiotherapy. The mean follow-up period was 11.5 months. Nineteen (67.9%) of the 28 tumors were controlled. The median patient survival time was 7 months. Asymptomatic intracystic hemorrhage associated with Ommaya reservoir placement was seen in two patients with four tumors, but no serious complication occurred.Conclusions Ommaya reservoir placement followed by GKS is relatively effective and safe for large cystic metastatic brain tumors. Gamma Knife surgery should be performed within a few days of Ommaya reservoir placement. Reaccumulation and high viscosity of cystic content must be considered.

BACKGROUND Although balloon-based ablation catheters are expected to improve the feasibility and quality of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF), they must be introduced to physicians in the proper setting to ensure their correct usage.OBJECTIVE To identify the optimal clinical settings for learning the techniques for 3 balloon-based ablation catheters (Cryoballoon, Hotballoon, and Laserballoon).METHODS We introduced 3 balloon catheters in 50 consecutive patients with paroxysmal AF each during the introduction periods. Clinical parameters were compared among the groups and between these groups and their steady-state controls. RESULTSThe completion rate of PVI by sole balloon procedures was 56% with the Hotballoon catheter, which was lower than those of the Cryoballoon and Laserballoon catheters (each 88%). Radiofrequency touch-up was most frequently required at the bottom aspect of the inferior pulmonary veins (PVs) in the Cryoballoon group and at the anterior aspect of the superior PVs in the Hotballoon and Laserballoon groups. The Laserballoon catheter had the longest average PVI procedural time (89.2 6 40 vs 58.4 6 22 minutes for Hotballoon, 65.1 6 25 minutes for Cryoballoon, P , .001), but the difference was ultimately removed by the learning curve. There was no significant difference in the major complication or recurrence-free survival rates among the catheter types.CONCLUSIONS All 3 balloon-based catheter types allowed feasibility and quality for PVI, even during the learning period. To introduce these new catheters without complications, an experiences of 20 cases with specific clinical settings should be met for each catheter type.

BackgroundCadmium-zinc-telluride (CZT) cameras have improved the evaluation of patients with chest pain. However, inferior/inferolateral attenuation artifacts similar to those seen with conventional Anger cameras persist. We added prone acquisitions and CT attenuation correction (CTAC) to the standard supine image acquisition and analyzed the resulting examinations.Methods and resultsSeventy-two patients referred for invasive coronary angiography (CAG), and who also underwent rest/stress myocardial perfusion imaging (MPI) on a CZT camera in the supine and prone positions plus CTAC imaging, to examine known or suspected CAD between April 2013 and March 2014 were included. A sixteen-slice CT scan acquired on a SPECT/CT scanner between rest and stress imaging provided data for iterative reconstruction. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios (LRs) were calculated to compare MPI with CAG on a per-patient basis. Per-patient sensitivity, specificity, and accuracy of supine images to predict coronary abnormalities on CAG were 35% [95% confidence interval (CI) 19–52], 86% (95% CI 80–92), and 74% (95% CI 66–82); those of prone imaging were 65% (95% CI 45–81), 82% (95% CI 76–87), and 78% (95% CI 68–85); and those of CTAC were 59% (95% CI 41–71), 93% (95% CI 87–97), and 85% (95% CI 76–91), respectively.ConclusionsProne acquisition and CTAC images improve the ability to assess the inferior/inferolateral area.

Objective Falcotentorial meningioma occurs close to the falcotentorial edges and the confluence of the vein of Galen. The posterosuperior approach conventionally used to reach this site does not allow direct visualization of the tumor matrix, making detachment difficult. Meningiomas at this location are therefore among those that are not well amenable to radical resection. We devised an alternative anterolateral approach that, when used in addition to the posterosuperior approach, provides an operating field which allows to overview large, bilaterally extending tumors. We report this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach, together with associated procedural modifications. Methods We used the approach in four patients with falcotentorial meningioma between February 2008 and July 2017. We began by extending a parieto-occipital craniotomy slightly beyond the midline, to pass across the most caudal bridging vein on the rostral side. We then created a fan-shaped fenestration as large as possible in the falx, between the superior sagittal sinus and the inferior sagittal and straight sinuses (window 1). We further performed wedge-shaped resections of both tentorial edges to the left and right of window 1 (windows 2 and 3). Tumor debulking was then carried out via these three windows (the triple-window method). Finally, we detached the tumor in the area of the falcotentorial edges and the confluence of the vein of Galen. To obtain a superorostral operating field as wide as possible from laterally, thereby exposing the potential blind spots, the operating surgeon used both hands while retracting the precuneus, and the assistant surgeon used both hands to turn over the falcotentorial edges (twosome four-hand retractorless microsurgery). Results The wide operating field provided by this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach and twosome four-hand retractorless microsurgery provides a direct view of delicate structures at the falcotentorial edges and the confluence of the vein of Galen, a site that is most likely to be a blind spot in conventional approaches. Retraction of the precuneus on the nondominant side enabled radical resection with no neurologic deficit in any of the patients. Conclusions The parieto-occipital interhemispheric transfalcine, trans-bitentorial approach with the triple-window method opens an anterolateral operating field in addition to a posterosuperior operating field in large tumors located in the falcotentorial and pineal region, extending anteroposteriorly and bilaterally. The twosome four-hand retractorless technique via this approach enables visualization of the tumor matrix at sites, which are barely visible with the conventional approach. Thus, the tumor can be removed more radically and safely.

Background Delirium is associated with high mortality after cardiac surgery. However, evidence on the epidemiology of delirium in patients with acute decompensated heart failure (ADHF) is limited. This study aimed to assess the incidence and prognostic impact of delirium in patients with ADHF. Methods This single-center prospective observational study enrolled 132 consecutive patients with ADHF. We utilized the Diagnostic and Statistical Manual of Mental Disorders, fifth edition and classified the patients into two groups according to the presence or absence of delirium. The primary endpoint was 90-day all-cause mortality. The prognostic impact and risk factors of delirium were evaluated using multivariable Cox and logistic regression analyses, respectively. Results The median patient age was 83 (interquartile range, 75–87) years. Approximately 51.5% were men. Delirium occurred in 36 (27.3%) patients, and hyperactive delirium was the most frequent type (86.1%). The 90-day all-cause mortality was higher in the patients with delirium than in those without (21.6% versus 3.9%, log-rank p = 0.002). Delirium was associated with higher mortality with an adjusted hazard ratio of 6.8 (95% confidence interval, 1.1–42.6, p = 0.042). The risk factors associated with delirium included advanced age, male sex, higher clinical frailty scale score, and dementia. Conclusions Delirium was associated with a higher 90-day all-cause mortality in the older adult patients with ADHF. Hyperactive delirium was the most common subtype.