No abstract

Background: Trigeminal neuralgia (TN) occasionally affects older adults, frequently worsens, and becomes refractory to medication. Older adult patients with TN may consider microvascular decompression (MVD) for their treatment. No study examines MVD effects on older adult TN patients’ health-related quality of life (HRQoL). The present study evaluates the HRQoL of TN patients aged 70 years and older before and after MVD. Methods: Adult TN patients who underwent MVD evaluated their HRQoL using the 36-Item Short-form (SF-36) Health Survey before and 6 months after MVD. The patients were divided into four groups according to their decade of age. The clinical parameters and operative outcomes were analyzed statistically. The SF-36 physical, mental, and role social component summary scores and eight domain scale scores were analyzed using a twoway repeated-measures analysis of variance (ANOVA) to compare the effects of age group and preoperative and postoperative time points. Results: Among 57 adult patients (34 women, 23 men; mean age, 69 years; range, 30–89 years), 21 patients were in their seventies, and 11 were in their eighties. The SF-36 scores of patients in all age groups improved after MVD. Two-way repeated-measures ANOVA demonstrated a significant age group effect on the physical component summary and its physical functioning domain. A time point effect was significant on all component summaries and domains. There was a significant interaction between age group and time point effects on the bodily pain domain. These results suggested that patients 70 years and older had significant postoperative HRQoL improvement, but their improvement of physical-related HRQoL and multiple physical pain issues were limited. Conclusion: Impaired HRQoL in TN patients aged 70 years and older can improve after MVD. Careful management of multiple comorbidities and surgical risks enables MVD to be an appropriate treatment for older adult patients with refractory TN.

Intradural extramedullary metastases of renal cell carcinoma are rare. We report a case of intradural extramedullary spinal cord metastasis and intramedullary invasion of renal cell carcinoma after treatment for brain and lung metastases following initial removal. A 43-year-old woman presented with a history of right renal cell carcinoma. She developed sudden disturbances in consciousness and dizziness and was transferred to our hospital at the age of 40 years. The cerebellar metastasis presented with cerebellar hemorrhage. We removed the left cerebellar hemorrhage, which led to the diagnosis of brain metastasis from renal cell carcinoma. The patient underwent cranial radiotherapy and chemotherapy. Three years later, thoracic magnetic resonance imaging(MRI)revealed T2 dorsal and T2-3 ventral intradural extramedullary tumors. The tumor had grown within 6 months, and the patient complained of chest and back pain. She also had bilateral lower-limb paralysis, bilateral lower-limb sensory deficits, and bladder and bowel dysfunctions. Tumor embolization and partial removal of thoracic spinal cord tumors were performed. Intraoperative findings revealed an indistinct boundary between the ventral spinal tumor and spinal cord. We diagnosed the patient with intradural extramedullary metastasis of renal cell carcinoma and medullary invasion of the extramedullary tumor. The patient underwent postoperative spinal radiotherapy and chemotherapy. Neurological symptoms improved postoperatively and were maintained for 18 months postoperatively. Despite the poor prognosis of renal cell carcinoma and its metastasis to the spinal cord, palliative surgery and adjuvant therapy may maintain the quality of life and activities of daily living in patients. (Received：May 24, 2022；accepted：December 16, 2022

While the middle and long-term essential tremor outcome after magnetic resonance-guided focused ultrasound(MRgFUS)is well documented, the immediate and early postoperative tremor outcome is less documented. We aimed to characterize the clinical significance of the immediate and early post-MRgFUS tremor fluctuation in patients with essential tremor. We retrospectively analyzed the consecutive 23 patients with essential tremor who underwent MRgFUS of thalamic ventral intermediate nucleus in our institute. Therapeutic outcomes were scored using clinical rating scale for tremor(CRST)part A and B(part A＋B) . We also measured the areas of MR T2-weighted hypointense (zone 1) and peripheral hyperintense (zone 2) on the immediately postoperative MR images. The clinical characteristics, MRgFUS parameters, CRST part A＋B score, and zone 1＋2 area were compared between the group with more than 50％ improvement and the group with 50％ or less improvement immediately after the MRgFUS. The CRST part A＋B scores were examined from the preoperative to 6-12-month postoperative period using repeated measure analysis of variance(ANOVA) . The odds ratio between the early postoperative tremor fluctuation and the 6-12-month postoperative tremor improvement was calculated. Immediately postopertive CRST part A＋B scores improved by more than 50％ in 18 patients(78％)and by 50％ or less in five patients (22％) . The area for the zone 1＋2 was 13.1±4.2 mm 2 in the patients with improvement and 21.7±8.9 mm 2 in the patients without immediate improvement(p＝0.037) . A repeated measure ANOVA demonstrated that the CRST part A＋B scores improved significantly in each postoperative period compared to the preoperative baseline score(p＜0.001) . Among the 20 patients with 6-12-month follow-up, eight patients(36％)had deterioration of tremor within the first three months and five of them had ineffective outcome in the postoperative 6-12 months. The odds ratio between tremor fluctuation in 1-3 months and ineffective tremor control in 6-12 months was 8.33(p＝0.046) . Patients with ineffective essential tremor control after MRgFUS tend to have a large zone 1＋2 area. Early tremor fluctuation may indicate ineffective tremor control in the middle and long term. Further targeting accuracy is necessary to improve the long-term tremor outcome for patients with essential tremor.

Background: Cerebral vasospasm and infarction are rare complications of transsphenoidal surgery for pituitary adenoma. Cerebral superficial siderosis may result from subarachnoid hemorrhage from a pituitary adenoma. The constellation of cerebral superficial siderosis, cerebral vasospasm, and pituitary adenoma is rare. We describe an extremely rare clinical constellation of immediately postoperative cerebral vasospasm and consequent cerebral infarction in a case with a large pituitary adenoma and cerebral superficial siderosis. Case Description: A 70-year-old man presented with a pituitary adenoma causing a worsening headache. Preoperative magnetic resonance (MR) images revealed cerebral superficial siderosis, suggesting subarachnoid hemorrhage from pituitary apoplexy. MR angiography (MRA) showed no vasospasm. During the transsphenoidal surgery, an intratumoral hematoma was found. The arachnoid membrane was partially torn and intratumoral hematoma entered the subarachnoid space. Intraoperatively, the intracranial vessels remained intact. The suprasellar tumor was almost entirely resected; however, the patient remained comatose postoperatively. Computed tomography revealed ischemic lesions in the bilateral insular and frontotemporal cortex. MRA revealed cerebral vasospasm in the bilateral middle cerebral arteries. The patient was treated with levetiracetam for nonconvulsive status epilepticus and underwent a lumbar peritoneal shunt surgery for secondary hydrocephalus. However, the patient remained listless. Conclusion: Postoperative cerebral vasospasm and infarction are severe but rare complications for a pituitary adenoma after transsphenoidal surgery. Preoperative and intraoperative subarachnoid hemorrhage might have been a risk factor in our case. Similar cases should be warranted to analyze whether cerebral superficial siderosis may also indicate the risk of severe postoperative vasospasm immediately after transsphenoidal surgery for pituitary adenoma.