Showing papers in "No shinkei geka. Neurological surgery in 2001"

[Functional outcome of primary pontine hemorrhage: conservative treatment or stereotaxic surgery].

Abstract: In this study we compared the outcome of patients with primary pontine hemorrhage (PPH) in those who underwent stereotaxic aspiration and those treated non-surgically. Out of 75 PPHs, 37 patients were selected. Their consciousness on admission was somnolent to semicoma (alert and deeply comatose cases were excluded). Patients admitted between 1988 and 1990, and between 1995 and 1996 underwent CT guided stereotaxic aspiration (18 cases: Surgical Group), and those admitted between 1991 and 1994 were treated conservatively (19 cases: Conservative Group). The outcome was analyzed three months after the onset from the viewpoint of level of consciousness and severity of paresis, according to the location of the hemorrhage. With regard to consciousness, 13 of 18 cases in the Surgical Group showed remarkable improvement, while only 8 of 19 cases in the Conservative Group did. The severity of paresis was evaluated only among the patients who could obey commands three months after the onset. Paresis improved in 7 of 13 patients in the Surgical Group, vs. in 3 of 8 patients in the Conservative Group (p < 0.05). According to the location of hemorrhage (CT classification), in the Unilateral tegmental type and the Massive type, the Surgical Group and the Conservative Group showed no difference. On the other hand, in the Bilateral tegmental type and the Basal tegmental type, surgery seemed to be more effective than conservative treatment. In conclusion, CT guided stereotaxic aspiration may improve not only the consciousness level but also the functional outcome.

[A case of the spinal subdural hematoma formation following ventriculoperitoneal shunting for von Recklinghausen's disease associated with aqueductal stenosis].

Abstract: Von Recklinghausen's disease associated with hydrocephalus due to non-tumoral aqueductal stenosis is rare. Furthermore the formation of subdural hematoma within the spinal canal is also a very rare complication of ventriculoperitoneal shunt. We presented a case of spinal subdural hematoma formation following ventriculoperitoneal shunting for von Recklinghausen's disease associated with aqueductal stenosis. A 10-year-old girl with von Recklinghausen's disease was referred to our hospital for gait disturbance during the previous 8 months. Magnetic resonance imaging (MRI) revealed hydrocephalus due to non-tumoral aqueductal stenosis, and ventriculoperitoneal shunt was instituted. Three months later, the patient developed lumbar pain and paraplegia. MRI revealed subdural hematoma in the lumbosacral spinal canal, and bilateral intracranial subdural hematoma were shown on computerized tomography (CT) scans. Subdural hematoma in the lumbosacral spinal canal was evacuated by laminectomy. Improvement of her neurological deficit was obtained postoperatively, and intracranial subdural hematomas disappeared spontaneously. Spinal subdural hematoma is assumed to be formed by the migratory movement of intracranial subdural hematoma under the influence of gravity. A characteristic finding of MRI is that such a subdural hematoma in the lumbosacral canal is located around the cauda equina.

[Distal anterior inferior cerebellar artery aneurysms: report of three cases and literature review].

Abstract: Aneurysm at the distal portion of the anterior inferior cerebellar artery (AICA) is uncommon and only 55 cases have been documented in the literature Here we report an additional three cases with review of the literature All three patients presented with subarachnoid hemorrhage The ruptured aneurysms were located at the meatal loop of the AICA in all three patients and one patient had another unruptured aneurysm at the lateral branch distal to the meatal loop Two patients underwent surgical trapping of the aneurysms, and the other patient was treated with endovascular coiling because of poor clinical condition Increase of hearing disturbance was found in two patients who underwent surgery or endovascular coiling, respectively Clinical features and treatment of these rare lesions are discussed with reference to the 7th and 8th nerve impairments as preoperative symptoms and postoperative complications

Stenting for the occlusive carotid and subclavian arteries in Takayasu arteritis

Abstract: The authors report the initial results of stenting in four patients of Takayasu arteritis for 11 occlusive carotid and subclavian arteries between January 1999 and December 2000. The lesions included stenoses of two right subclavian, three right common carotid, two left common carotid, and two left subclavian arteries, and total occlusion of two subclavian arteries. A total of 14 stents were implanted in 10 arterial lesions, resulting in a 91% procedural success rate. One failure was due to inability to cross the total occlusion of the subclavian artery. Procedural complications and problems were pain during balloon angioplasty in three patients, vaso-vagal reflex in two, carotid artery perforation associated with transient horseness in one, and stent migration in one. There was no permanent morbidity. Follow-up over a mean duration of 12 months revealed one symptomatic recurrence of left subclavian stenosis, followed by a successful re-dilatation. The results of the current study indicated that primary stenting is an excellent therapeutic option for the occlusive carotid and subclavian arteries in Takayasu arteritis. A long-term follow-up is required to determine the response or behavior of stented segments of the affected arteries.

[Aneurysms of the distal posterior inferior cerebellar artery--analysis of 14 aneurysms in 13 cases].

Abstract: Thirteen cases of distal posterior inferior cerebellar artery (PICA) aneurysms are reported here. All the aneurysms were found after a subarachnoid hemorrhage. Dissecting aneurysm, incidentally found unruptured aneurysms, and aneurysms associated with arteriovenous malformation have been eliminated from this study. Characteristics for this type of lesion are a high rate of recurrent hemorrhage and rapid death due to direct compression of the brain stem, which clearly indicates the necessity of early surgery. Attention should be paid to the fact that angiography cannot always reveal aneurysms, especially when they are located in the peripheral PICA. One should also pay attention to multiple lesions and rapid growing acute subdural hematoma as initial findings for ruptured distal PICA aneurysm. Prognostic factors for these lesions are, vasospasm, especially when the aneurysm is located proximally in the PICA, and direct compression of the brain stem due to intraventricular hemorrhage when the aneurysm is located distally. It has been suggested that the pathogenesis of this lesion could be hemodynamic stress or embryogenesis. The shape and anomalous arterial structures of the 14 aneurysms presented here tend to agree with this suggestion. Our results suggest that the pathogenesis is hemodynamic stress that had developed due to embryological and/or arteriosclerotic factors.

[Extracranial metastasis of glioblastoma to the lung and heart with a histological resemblance to small cell carcinoma of the lung: an autopsy case].

Abstract: An autopsy case of small cell glioblastoma, showing multiple extracranial metastases, is reported with special reference to histopathological differentiation from metastatic small cell carcinoma. Widely spread lesions in the bilateral lungs were developed after an operation and chemo-radiotherapy for glioblastoma, and the lung lesions led to fatal respiratory failure. Postmortem examination revealed multiple tumors in the lung, lymph nodes, and the heart, as well as local invasion of the primary tumor to the dura, skull, and the scalp. The mechanism of extracranial metastasis of brain tumor is discussed.

[Spontaneous intracranial hypotension complicating subdural hematoma: unilateral oculomotor nerve palsy caused by epidural blood patch].

Abstract: We report a case of a 41-year-old man with a 1-month history of postural headache due to spontaneous intracranial hypotension (SIH). His MRI revealed bilateral chronic subdural hematoma (CSH) and diffuse dural enhancement after gadolinium infusion. Indium-111 radionuclide cisternography revealed a CSF leak from the cervico-thoracic junction and rapid accumulation of radioisotope in the bladder. Postural headache failed to resolve with prolonged bed rest. The patient became restless and suffered recent memory disturbance. We therefore decided to treat the CSF leak with an epidural blood patch. After the procedure, the patient's headache resolved completely. However one day later, left oculomotor nerve palsy developed. MRI revealed enlargement of the left CSH with mass effect and midline shift. After hematoma drainage, the patient became alert and oculomotor palsy recovered gradually. To treat cases of CSH with SIH, the best method is to repair the CSF leakage and treat subdural hematoma at the same time. If the patient shows depressed consciousness, we recommend initial drainage of the subdural hematoma, because, following the repair of CSF leakage, mass effect such as uncal herniation may occur.

A case of suprasellar hemangioblastoma with thoracic meningioma

Abstract: Supratentorial hemangioblastoma is encountered very rarely, with only about 110 cases reported. This report concerns a case of a suprasellar hemangioblastoma associated with thoracic meningioma. A 62-year-old man was admitted with visual disturbance of the left eye. T2-weighted magnetic resonance imaging (MRI) showed a high signal intensity mass in the suprasellar region without perifocal edema. T1-weighted MRI with gadolinium showed a homogeneously enhanced mass. The angiogram revealed remarkable tumor staining originating from the right and left internal carotid arteries (ICA) and the left external carotid artery (ECA). On the basis of the pre-operative diagnosis of tuberculum sellae meningioma, total tumor removal was performed. Photomicrographs of the specimen showed numerous capillaries divided by stroma cells. Positive immunostaining for factor VIII related antigen (F VIII RAg) was observed in endothelial cells, but immunostaining for epithelial membrane antigen (EMA) was not observed in any cells. A diagnosis of suprasellar hemangioblastoma was made on the basis of these findings. The patient suffered paraparesis on the postoperative seventh day. Since MRI showed a thoracic tumor, a second total tumor removal was performed. The tumor was diagnosed as a meningothelial meningioma. The patient was discharged without evidence of new neurological deficits. Our experience shows that, when a mass is vascularized in the cerebral hemisphere, the possibility of hemangioblastoma needs to be taken into consideration.

Relationship of postoperative residual air and recurrence in chronic subdural hematoma

Abstract: The possibility exists that residual air after surgery is one cause of recurrence of chronic subdural hematoma. We have devised a new simple method which decreases postoperative residual air, using external drainage and an endoscope. First, we make endoscopic observations of the inner aspect of the hematoma cavity. Then, we insert external drainage apparatus into the most frontal area of the hematoma cavity, we regard this location as the most appropriate place to ensure most effective drainage. The present study included 37 chronic subdural hematomas in 32 patients who had been treated between January and December, 1999. Their ages ranged from 48 to 86 years old, with an average of 72 years. Insertion of external drainage in the most frontal area of the hematoma cavity was successfully achieved in 27 (73%, Group I) out of 37 cases and resulted in no recurrence. In the remaining 10 hematomas (27%, Group II), external drainage was not able to be inserted in the most frontal area, and four hematomas (40%) had recurrence (p < 0.01 vs Group I). Insertion in the most frontal area of the hematoma cavity decreases residual air after surgery, and may be effective for the prevention of recurrence of chronic subdural hematoma.

[Spontaneous dissection of the anterior cerebral artery presenting subarachnoid hemorrhage and cerebral infarction: a case report].

Abstract: A case is reported of anterior cerebral artery dissecting aneurysm presenting with subarachnoid hemorrhage and cerebral infarction. A 50-year-old man presented with sudden onset of weakness of the left lower limb was admitted to our hospital. CT scan on admission showed a subarachnoid hemorrhage in the interhemispheric fissure and CT on the 6th day demonstrated a cerebral infarction on the right medial frontal lobe. A carotid angiogram 12 hours after the onset showed no aneurysmal lesion, but, the angiogram repeated 11 days after the onset revealed an aneurysmal dilatation with distal narrowing at the right A2-A3 segment. To prevent rebleeding, we performed a wrapping procedure through the interhemispheric route on the 18th day after onset. The postoperative course was uneventful. We reviewed 27 previously reported cases with symptomatic dissecting aneurysm confined to the anterior cerebral artery.

[Neuro-Behcet disease mimicking a thalamic tumor].

Abstract: A case of neuro-Behcet disease presenting as a thalamo-lenticular expanding lesion is reported. A 41-year-old female was admitted with mental deterioration and right hemiparesis. She had been suffering from recurrent oral and genital ulcers and erythema nodosum for several years before admission. Neurological examination on admission revealed poor mental activity, dysarthria and right hemiparesis. Lumbar puncture showed CSF pleocytosis. CT and MRI revealed a thalamo-lenticular expanding lesion. CT showed a homogeneous hypodense lesion of the left lenticulothalamic region, which was enhanced in the central part, exerting a mild mass effect. MRI also revealed the lesion better. The T2 weighted images showed a high intensity signal in the left thalamo-lenticular region and the left peduncle. The T1 weighted images showed a low signal in the corresponding areas with a central enhancement with Gd-DTPA. EEG, SPECT and angiography indicated normal findings. Histologic study of the brain biopsy tissue ruled out a tumor but did not show any specific diagnosis. The patient improved with steroid therapy. In conclusion, the clinical and radiological presentation of neuro-Behcet disease can mimic a cerebral tumor. In such cases, stereotactic biopsy is useful to exclude suspicion of a cerebral tumor.

Decompressive craniectomy for massive infarction of middle cerebral artery territory

Abstract: There is continuing controversy about the benefits of decompressive craniectomy for the treatment of massive infarction of middle cerebral artery (MCA) territory. Under conservative therapy, the mortality rate for this stroke is reported to be up to 80%. So the authors have actively carried out decompressive craniectomy since 1997, and have compared the outcome with patients who were admitted before 1997 and, consequently treated with conservative therapy. Fifteen consecutive victims of massive infarction of MCA territory were studied. Seven patients (male: 1, female: 6, mean age: 79.8 years) were treated with conservative therapy, and 8 patients (male: 3, female: 5, mean age: 71.8 years) were treated with decompressive craniectomy. There were no significant differences in age and consciousness level distribution between the two groups. Mortality rate in the conservative therapy group was 85.7% against 12.5% in the surgery group (p < 0.05). Functional performance, which was evaluated by activity in daily life (ADL), was also better in the surgery group e.g. 3 patients in ADL 3, and 3 in ADL 4 (1 patient died from a non-neurological cause). Even among the patients with speech-dominant hemispheric stroke, all except one were able to communicate in some way and understand language. Even though patients in this study were elderly, decompressive craniectomy reduced mortality and improved functional performance, so it seems that this surgery should be aggressively considered for massive infarction of MCA territory.

A case of intrasellar meningioma mimicking pituitary adenoma

Abstract: The authors report a patient with a rare intrasellar meningioma mimicking pituitary adenoma. A 60-year-old man was admitted to our hospital for evaluation of general fatigue. He had no neurological deficit including visual function. Endocrinological tests revealed panhypopituitarism. The craniogram showed slight enlargement of the sella turcica with thinning of the dorsum sellae. CT scan and MR imaging demonstrated a homogeneously enhanced intrasellar mass with slight suprasellar extension. Partial removal of the mass was performed via the transsphenoidal approach because it was extremely firm and hemorrhagic. Histological diagnosis was transitional meningioma. The patient has been well for two years after surgery without tumor progression on MR imaging. It is mandatory to distinguish intrasellar meningioma from pituitary adenoma preoperatively because of marked difference in their treatment strategies. Despite recent advances in neurodiagnostic imaging, it may still be difficult to differentiate pituitary adenoma from intrasellar meningioma. When we re-evaluated the MR imaging, we recognized that the tumor had demonstrated specific findings, ruling out pituitary adenoma, namely bright and homogeneous enhancement, dense enhancement in the early phase on the dynamic MR study, and flow void signal within the mass. The authors emphasize that careful evaluations of MR imaging will allow the correct preoperative diagnosis in patients with intrasellar meningioma mimicking pituitary macroadenoma.

True posterior communicating artery aneurysm

Abstract: We report a case of a true posterior communicating artery aneurysm. A 51-year-old male suffered a subarachnoid hemorrhage with severe headache and vomiting. A true posterior communicating artery aneurysm was recognized after repeated angiography on the seventh day. Right frontotemporal craniotomy was performed and the aneurysm was successfully clipped. The incidence of true posterior communicating artery aneurysms ranges from 0.1-2.8%, and 21 cases including our case have been reported in detail. There are no reported cases in which the aneurysm arises from the branching site of perforating arteries. In almost all cases the dome of the aneurysm projects inferiorly or posteriorly or laterally, so perforating arteries from the posterior communicating artery rarely interfere with dissection of the aneurysm or neck clipping. In a few cases, true posterior communicating artery aneurysms had been diagnosed as IC-PC aneurysms preoperatively, leading to intraoperative aneurysmal rupture or postoperative neurological deficit or death. In the cases of a fusiform aneurysm or an aneurysm of wide-based neck, there may be no other choice than trapping of the aneurysm. It is difficult to predict whether trapping causes postoperative ischemic complications.

Continuous intrathecal administration of nicardipine using a portable infusion pump system for management of vasospasm after subarachnoid hemorrhage

Abstract: We studied the feasibility of intrathecal nicardipine administration using a portable infusion pump system in five cases (two males and three females) of subarachnoid hemorrhage (SAH). All of the five cases manifested severe SAH of Hunt & Kosnic grade 3 or 4, and Fisher CT group 3. Aneurysmal sites of five cases were as follows: three internal carotid-posterior communicating artery (IC-PC) aneurysms and two anterior communicating artery (Acom) aneurysms. The container of the infusion pump system was filled with 105 ml of nicardipine-saline solution (2:1), and this system was connected to the cisternal tube. The solution was continuously injected at a daily dose of 12 ml (8 mg of nicardipine). This therapy was continued for 14 days, and new nicardipine solution was supplied only once at 8 days after the operation during this therapy. No postural restraint of patients was necessary, even during physical movement for rehabilitation. Postoperative angiography was performed in three of five cases at one week after the operation. No angiographic vasospasm was observed in any of the three cases. Symptomatic vasospasm was observed in one case of right IC-PC aneurysm as a transient total aphasia and right hemiplegia, which recovered within several hours due to induced hypervolemia and hypertension therapy. Mild meningitis at 14 days after the operation complicated this treatment in one case, but it improved in a few days after the cisternal tube was removed. It was speculated that meningitis was caused by cerebrospinal fluid leakage from the scalp exit site of the cisternal tube. All of the five cases had obtained good recovery at three months after the operation. These results show that, although this method involves a risk of infection, it has the advantage of easiness and convenience over conventional methods. Though further improvement of this method is required, this preliminary stage is potentially useful for delivering not only nicardipine, but also for other drugs which may be used in intrathecal administration therapy.

[Intracranial capillary hemangioma: a case report].

Abstract: Capillary hemangiomas are the most common tumor of the neck and head in children. Intracranial capillary hemangioma without generalized neuro-cutaneous hemangiomatosis is extremely rare, with only one report in the literature. We report a case of intracranial capillary hemangioma originating from the temporal base. An 8-year-old boy presented with a severe headache and nausea. A CT scan showed a low-density area in the left temporal lobe and an iso-density mass at the temporal base. This mass was enhanced by contrast medium. The mass lesion appeared as an iso-intensity area on T1-weighted MR images and as a high-intensity area on T2-weighted MR images, and the mass was enhanced almost uniformly by gadoliniumdiethylene triaminepenta-acetic acid. Cerebral angiography showed abnormal staining fed by the anterior temporal artery. An operation was performed, and all of the tumor with the dura attached was removed. The histological diagnosis was capillary hemangioma. The tumor consisted of a proliferation of capillary vessels lined by a single layer of endothelial cells. In this paper, we review the clinical features, neuro-imaging findings and proposed etiology of capillary hemangioma.

A case of a persistent primitive proatlantal intersegmental artery with a ruptured basilar bifurcation aneurysm

Abstract: A case of persistent primitive proatlantal intersegmental artery (PPPIA) associated with a ruptured basilar bifurcation aneurysm was reported. A 44-year-old male with sudden headache was admitted to our hospital. CT scan revealed subarachnoid hemorrhage. Cerebral angiography revealed anomalous anastomosis between the internal carotid artery and the vertebral artery at the proatlantal region. This anastomosis branched off from the left internal carotid artery at the C4 level and joined the horizontal portion of the left vertebral artery. It was thought to be PPPIA. Angiography also revealed an aneurysm of the basilar bifurcation which was responsible for the patient's subarachnoid hemorrhage. The aneurysm was successfully treated by endovascular embolization with Guglielmi detachable coils in an acute stage, and resulted in good outcome. PPPIA with basilar bifurcation aneurysm has not been presented or reported in the literature to date. To our knowledge, this is the first report of such an association of vascular anomalies. The frequency of PPPIA combined with the intracranial aneurysm is relatively high, whereas the occurrence of PPPIA is extremely rare. Therefore, it was suggested that some congenital and/or hemodynamic factors changed by PPPIA may affect the pathogenesis of intracranial aneurysms.

[Treatment of spontaneous carotid-cavernous fistula by the transvenous approach via the facial and angular route].

Abstract: We report a case of a patient with a spontaneous carotid-cavernous sinus fistula (CCF) who was successfully treated by the facial vein approach. This 66-year-old female had a 3-month history of right chemosis and exophthalmos. Angiograms showed a spontaneous right CCF with primary drainage via the superior ophthalmic vein. As both inferior petrosal sinuses were hypoplastic, the transvenous approach could not be used to gain access to the right cavernous sinus. With effort, we were able to traverse the sharp angle at the corner of the angular vein and the superior ophthalmic vein with a microcatheter. Thereafter, it was easily navigated into the right cavernous sinus. Successful placement of Guglielmi detachable coils resulted in complete closure of the fistula. When it is difficult to gain access to the cavernous sinus via the inferior petrosal sinus, the facial vein approach is a useful alternative.

A case report of hemiparesis due to compression of the medulla oblongata by an elongated vertebral artery

Abstract: The authors report a case of a 53-year-old woman who developed symptoms and signs of compression of the left medulla oblongata by the elongated and curved left vertebral artery with normal diameter. Twelve days before admission to the hospital, the patient suddenly noticed severe occipital-nuchal headache and nausea with vomiting, while she was unloading a burden. Neurological examination revealed left facial hyperalgesia, right hemihypesthesia and mild right hemiparesis. Hoarseness was observed, but the movement of the uvula and tongue was normal. Hypertension was noticed (180/100). Cerebral and vertebral angiography revealed no aneurysm, but demonstrated an elongated and curved V4 portion of the left vertebral artery with normal diameter. Coronal plain of T2 weighted image of MRI and CT scan with metrizamide administered into the CSF, clearly demonstrated an elongated and curved left vertebral artery compressing the ventro-lateral portion of the left medulla oblongata, neurovascular decompression of the V4 from the medulla oblongata was performed. Through the operating microscope, it was observed that the elongated and curved V4 portion of the left vertebral artery with normal configuration was compressing the left medulla oblongata ventro-laterally, making a compression notch at the outlets of the cranial nerves IX and X. Transposition of the V4 portion was impossible. Some pieces of Taflon felt, thick enough to prevent the pulsatile movement of the V4 from compressing the medulla oblongata, were inserted between the V4 and the medulla oblongata. Two months after the operation, the patient's right hemiparesis and sensory disturbances were gradually improving and her blood pressure had become normal. The authors emphasize that, among patients with symptoms and signs of compression of the medulla oblongata, there is at least one patient for whom neurovascular decompression was an effective treatment.

Spontaneous resolution of cervical syringomyelia. A case report

Abstract: A 54-year-old man visited our hospital with complaints of severe pain in the neck and the right upper limb. His MR (magnetic resonance) imaging showed a cervical syringomyelia associated with Chiari I malformation. After one month, his complaints vanished smoothly, and the repeated MR imaging revealed shrinkage of the syrinx. The mechanisms of spontaneous resolution of syringomyelia were discussed according to some relevant literature.

[Anterior cerebral artery dissecting aneurysm associated with fibromuscular dysplasia (FMD): a case report].

Abstract: We have recently encountered a rare case of anterior cerebral artery dissecting aneurysm, presenting cerebral infarction and subarachnoid hemorrhage, associated with fibromuscular dysplasia (FMD). A 50-year-old woman was admitted to our hospital with complaints of headache and hemiparesis. A right carotid angiogram obtained 9 hours after the onset revealed stenosis and slight dilatation in the A1 portion of the anterior cerebral artery. At 12 hours after the onset, the patient fell into a coma. CT scan showed diffuse subarachnoid hemorrhage. An angiogram had revealed aneurysmal dilatation and double lumen in the A1 portion, but, 34 days after the onset, angiogram showed growth of the aneurysm in the A1 portion and stenosis in the A2 and A3 portions. At 38 days after the onset, the trapping of the dilated aneurysm to prevent rerupture was performed. Pathological diagnosis was concluded to be FMD. We concluded that FMD caused stenosis as well as the formation and rupture of the dissecting aneurysm in the anterior cerebral artery.

A case of fatal herpes encephalitis presenting massive cerebral hematoma

Abstract: A 53-year-old woman was admitted to the hospital because of headache and disturbance of consciousness. She was afebrile. No inflammatory reaction was identified on serologic examination. Radiological findings showed acute-subacute, massive intracerebral hemorrhage in the right temporal lobe, compressing the brain stem contra-laterally. On the day of admission, she underwent a right temporal craniotomy for the removal of the mass lesion. The resected brain tissue demonstrated a small hemorrhage and edema accompanied by the infiltration of lymphoid cells into the subarachnoid space. Several days after surgery, the patient became lethargic and showed urinary incontinence. Late onset of fever and CSF findings suggested she was suffering from viral encephalitis. Serological findings, however, disclosed no antibody production against HSV, HZV, or CMV. For the diagnosis, a biopsy of the brain was carried out and herpes encephalitis was subsequently proved. Unfortunately, her condition deteriorated quickly and she died without anti-viral treatment.

[Dissecting aneurysm of the posterior inferior cerebellar artery--studied by serial angiography].

Abstract: We report the case of a 34-year-old male with cerebellar hemorrhagic infarction caused by a dissecting aneurysm of the left posterior inferior cerebellar artery (PICA). The patient suffered from a headache and vomiting for two days and was transferred to our hospital with sudden deterioration of consciousness. On admission, he was semicomatose. A CT scan revealed hemorrhagic infarction in the left cerebellum and upward herniation. The emergency operation for posterior fossa decompression was performed. Postoperatively, his consciousness level improved promptly and he had no neurological deficits except for slight gait disturbance. The first vertebral angiography was performed on Day 27. It showed a sausage-like dissecting aneurysm of the left distal PICA. We planned conservative therapy with careful observation because of there being no indication for an operation. Serial angiography was performed and demonstrated the regression of the dissecting aneurysm on Day 258. Dissecting aneurysms of the distal PICA are rare and their natural history is not well understood. Conservative therapy for vertebrobasilar dissecting aneurysms has often been reported. We suggest that conservative therapy with serial angiography is the treatment of choice especially for ischemic-type dissecting aneurysms. We review 17 cases of dissecting aneurysm of the distal PICA in this study.

[Multiple dural arteriovenous fistulas involving both the cavernous sinus and the posterior fossa: report of two cases and review of the literature].

Abstract: Multiple dural arteriovenous fistulas (DAVFs) are rare, accounting for 7% of all intracranial DAVFs. The authors describe two cases of multiple DAVFs involving both the cavernous sinus and the posterior fossa. The first patient was a 45-year-old man who presented with visual disturbance, chemosis, exophthalmus, and tinnitus. Angiograms demonstrated DAVFs involving the right cavernous sinus and the ipsilateral sigmoid sinus. Soon after transarterial embolization via the right occipital artery, the patient's symptoms completely disappeared. Six months later, follow-up angiograms showed disappearance of the cavernous DAVF and a subtle opacification of the sigmoid sinus DAVF. The patient has been free from symptoms for four years. The second patient was a 75-year-old woman who presented with progressive tinnitus two years after stereotactic radiosurgery for right cavernous DAVF. Angiograms showed a new lesion in the contralateral transverse and sigmoid sinuses. Transvenous embolization (TVE) of the affected sinuses was successful and the patient's symptoms disappeared. The patient's course has been uneventful after treatment, and follow-up MR angiograms have not shown any recurrence of lesions. To our knowledge, 25 cases of multiple DAVFs have been reported in the literature, of which we reviewed 12 cases of multiple DAVFs affecting the cavernous sinus. The patients' ages ranged from 43 to 75 years with a mean of 57.4 and their distribution showed female predominance. Other DAVFs occurred mostly in the transverse and sigmoid sinuses. With the exception of our case (second patient), the posterior fossa lesions were located on the same side as the cavernous sinus DAVF. Multiple DAVFs were detected simultaneously in 5 of the 12 cases with the initial angiograms. In the other 7 cases, cavernous DAVFs had been treated, but were followed by posterior fossa lesions occurring after various intervals (4 months to 2.5 years). All the patients presented with ocular signs due to cavernous DAVFs. Based upon our review of the literature, we discuss here three possible hypotheses. The first possibility for formation of multiple DAVFs concerns their primary etiology, viz. that they develop after a huge sinus thrombosis involving several sinuses and its recanalization. A second possibility is the secondary formation of DAVFs. Preexisting cavernous sinus DAVFs induce sinus thrombosis and/or venous hypertension, which results in the formation of multiple lesions. A third possibility is that they are due to other factors, including increased angiogenic activity and some technical problems associated with TVE. Our review indicates that careful follow-up for several years should be made after treatment of cavernous DAVFs.

[A case showing effective radiotherapy for a radiation-induced glioblastoma].

Abstract: Radiation-induced glioblastoma is usually resistant to all treatments. We report a case with radiation-induced glioblastoma, in which radiotherapy was remarkably effective. A 14-year-old female with a history of acute lymphoblastic leukemia, at the age of 7, underwent 15 Gy of radiotherapy to the whole brain. She was admitted to our department due to the development of headache and nausea. Magnetic resonance imaging showed an irregularly enhanced mass in the left frontal lobe. Partial removal of the mass was performed and histological examination showed it to be glioblastoma with a high MIB-1 index. The patient underwent 40 Gy of local radiotherapy and chemotherapy with ACNU and Interferon-beta for 2 years. The residual tumor disappeared after the radiotherapy, and her status is still "complete remission", 29 months after the onset.

A case of familial cerebral cavernous angioma and review of Japanese cases

Abstract: We present one pedigree of familial cerebral cavernous angioma (FCCA). Case 1 was a 52-year-old male with right hemiplegia. When he was 37 years old, a left occipital lesion was excised and histologically diagnosed as cavernous angioma. MR image showed many cavernous angiomas in the right temporal lobe, the right paraventriclar white matter, the right frontal lobe, the left basal ganglia, and the left parietal lobe. Stereotactic radiosurgery was undertaken for all the lesions. Although the size of each lesion was unchanged, neither hemorrhage nor neurological deterioration were recognized after radiosurgery. Case 2 was a 24-year-old male, a son of the patient in case 1. He has manifested tonic-clonic type epilepsy since the age of 2. MR image showed cavernous angiomas in the pons, the right frontal, and the left intra-Sylvian regions, and many paraventricular cysts with rims indication of previous hemorrhages. Two de novo lesions were observed on subsequent annual MR screening. Surgical excision for the left intra-Sylvian lesion and stereotactic radiosurgery for all lesions were undertaken. Histological diagnosis was cavernous angioma. In the literature, there were 17 pedigrees and 37 cases of FCCA in Japan. The incidence of both multiple lesions and hemorrhage were less than in found in Spanish or French cases. Stereotactic radiosurgery is considered an useful treatment for FCCA, because lesions are multiple and de novo lesions occur.

[Surgical reconstruction for radiation-induced extracranial vertebral artery stenosis: a case report].

Abstract: We report a case of symptomatic extracranial vertebral artery stenosis after radiation therapy. This 49-year-old female received radiation therapy to the neck for nasopharyngeal carcinoma 11 years earlier, was admitted because of continuous dizziness and a floating sensation. Magnetic resonanse imaging showed no abnormalities, but an aortography demonstrated complete occlusion of the right common carotid artery as well as occlusion of the right vertebral artery and severe stenosis of the left vertebral artery at its origin, which was presumed to be the result of previous radiation therapy. Percutaneous transluminal angioplasty (PTA) for the left vertebral artery was performed using conventional balloon treatment, which resulted in wall dissection. Because of this, she underwent end-to-side vertebral artery to subclavian artery transposition, and she has had no further ischemic events science that time. PTA has been successfully performed as the first treatment of choice for vertebral artery stenosis, but surgical reconstruction can be a therapeutic management of choice for cases of failed PTA.

[Successful treatment with bypass and interventional surgery for a ruptured pseudo carotid artery aneurysm after transsphenoidal surgery: a case report].

Abstract: We report case of a patient who suffered a pseudo internal carotid artery (IC) aneurysm following transsphenoidal surgery. He was successfully treated with bypass surgery and IC occlusion involving the pseudoaneurysm using Guglielmi detachable coils (GDCs). This 50-year-old man with recurrent FSH-releasing pituitary adenoma suffered profuse arterial bleeding during transsphenoidal surgery. The hemorrhage was managed, using oxidized cellulose with bio-bond. His postoperative course was uneventful, but, he developed massive epistaxis 20 days after surgery. Cerebral angiograms showed a pseudoaneurysm arising from the C4 portion of the left IC. He could not tolerate the balloon occlusion test. Using GDCs, we immediately performed left IC occlusion involving the pseudoaneurysm followed by bypass surgery between the left EC and the left middle cerebral artery. Postoperative angiograms showed that the pseudoaneurysm was completely occluded and the bypass was fully patent. When massive arterial bleeding is encountered during transsphenoidal surgery, the patient should be carefully monitored to detect early the development of a pseudoaneurysm. When such an aneurysm is found or has ruptured, interventional surgery has proved effective in the management of this complication.

[Extraaxial primary malignant lymphoma associated with calcified chronic subdural hematoma: a case report].

Abstract: The authors report the case of a 54-year-old male with extraaxial primary malignant lymphoma associated with calcified chronic subdural hematoma. He slowly developed progressive headache accompanied by a bulge in the left forehead. Skull radiogram showed a large biconvex calcification in the left frontoparietal region, with concave change in the overlying bone. Computed tomograms and magnetic resonance images revealed a left frontoparietal chronic subdural hematoma surrounded by a calcified rim, with marginal enhancement in the frontal portion extending upward to the subcutaneous tissue through the underlying bone. The lesion was suspected to be an infectious calcified hematoma. The patient underwent a craniotomy for the removal of the hematoma. It was observed that the tumor was located mainly in the epidural and subdural space. The extent of the tumor corresponded with the enhanced area of the lesion in the preoperative neuroimages. The histological diagnosis was malignant lymphoma of B cell origin. General examination, which included bone marrow study and Ga scintigraphy, failed to prove systemic lymphoma. Extraaxial primary malignant lymphoma is extremely rare, and this is the first report of a lymphoma associated with calcified chronic subdural hematoma. The authors review the literature and discuss the clinical features and the pathogenesis of the lesion.