With the coronavirus disease 2019 pandemic and state of emergency declaration, individuals’ lives have become concerned on infection control. We examined whether the number of neurosurgical disease cases changed under these circumstances. The participants were patients who were hospitalized from January 2017 to December 2022 at our hospital’s neurosurgical department. We divided the target cases from 2017 to 2019 (before the pandemic) and from 2020 to 2022 (during the pandemic) and compared the total number. Furthermore, the cases were divided into brain tumors, cerebrovascular diseases, neurotraumas, chronic subdural hematomas, and others, and the numbers of cases were compared. The annual average values before and during the pandemic decreased in all cases, excluding the total number and cerebrovascular diseases. The total number declined in 2020, remained unchanged in 2021, and declined further in 2022. In 2020, brain tumors and cerebrovascular diseases decreased, and from 2021 onwards they returned to the pre‒pandemic levels. Neurotraumas and others decreased in 2020, remained unchanged in 2021, and decreased further in 2022. Chronic subdural hematomas remained unchanged in 2020, decreased in 2021, and remained unchanged in 2022. Hospital and patient‒side factors were considered. The number of neurotraumas may decrease because of the reduced amount of traffic due to refraining from going out.
At the present time, there is no evidence that establishes the effectiveness of endovascular treatment for intracranial vascular stenosis. Aggressive medical treatment for such stenoses does not provide satisfactory results. In clinical practice, endovascular treatment is sometimes performed for symptomatic and progressive intracranial stenotic lesions. Here, we retrospectively analyzed our hospital’s cases of stent placement for intracranial vascular stenosis (n＝26 patients; 21 males, five females, age 67.2 years [range 52‒85 years]). The lesions were at the internal carotid (IC) in six patients, M1 in 14, M2 in one, vertebral artery (VA) in four, and basilar artery (BA) in one patient. The stent placement was successful in all cases. There was only one case of asymptomatic subarachnoid hemorrhage, which occurred as a complication during the perioperative period. Restenosis occurred in two patients within 3 months, but no patients underwent additional treatment. Although the SAMMPRIS trial did not demonstrate the usefulness of endovascular treatment in similar cases, the WEAVE and WOVEN trials reported relatively favorable outcomes with strict intraoperative management and moderate vasodilation at facilities with extensive experience. The outcomes of stent placement for symptomatic intracranial vascular stenosis were favorable in the present patients. An experienced operator will use strict indications; a conservative percutaneous transluminal angioplasty (PTA) will prevent complications, and frequent imaging examinations will be important to monitor the possibility of restenosis.
CEA and CAS in the acute phase of cerebral infarction are not well‒founded in the stroke treatment guidelines 2021. This time, we examined the efficacy and safety of the recent emergency CEA and CAS performed at our facility. From June 2018 to April 2020, there were 5 consecutive cases in which CEA or CAS was urgently performed on the day of onset or the next day, 3 of which were emergency CAS on the day of onset, 1 was emergency CEA on the day after onset, 1 An example was an emergency CAS the day after the onset. The age ranged from 47 to 89 years, with an average of 77.0 years, and all 5 cases were male. Regarding internal carotid artery stenosis in the neck, all 5 cases were severely stenotic, and 3 cases were pseudo‒occlusion. In addition, 3 of 5 cases had a known progression of stenotic lesions. In the pathology of the CEA case, intimal plaque presents with findings such as intrinsic breakdown, lipid richness, and thrombosis due to secondary aggregation, suggesting instability and disease progression, suggesting the adequacy of emergency treatment. Revascularization was successful in all 5 cases, and all were discharged with mRS 0‒1 on the 8th to 20th postoperative days. Emergency CEA or emergency CAS performed before the severity of cerebral infarction in advanced stroke or in patients with suspected progressive stroke was a relatively safe and effective revascularization method. However, sufficient attention must be paid to unstable plaques, postoperative hyperperfusion, and hemorrhagic cerebral infarction, and the decision to intervenion is an issue that requires further investigation.
We describe a case of ischemia in the posterior inferior cerebellar artery (PICA) region due to progressive dissection, which started with posterior neck pain and dizziness. Emergency stent placement from the vertebral artery (VA) into the PICA was useful in preserving blood flow in the PICA. A 54‒year‒old male presented with posterior neck pain and dizziness and was diagnosed with right vertebral artery dissection involving the PICA bifurcation based on head magnetic resonance angiography (MRA) and basi‒parallel anatomical scanning (BPAS). The patient had no symptoms other than headache and was treated conservatively. After admission, acute ischemia was identified in the right cerebellar hemisphere on magnetic resonance imaging (MRI). Digital subtraction angiography (DSA) revealed an occluded PICA, and thus PICA stenting was subsequently performed, and the PICA was recanalized. After the surgery, the patient was discharged home without neurological deficit, and the disease has not recurred. As in the present case, even in patients with only headache, a dissected lesion can change rapidly in the acute phase, and close follow‒up imaging is important. Stenting of the stenosis may also be useful to preserve blood flow in the PICA in cases of vertebral artery dissection.
We report a case of infarction extending from medulla oblongata to cervical cord that developed after coil embolization of a ruptured basilar artery aneurysm. A 54‒year‒old comatose woman was brought to us, and was diagnosed as WFNS Grade V subarachnoid hemorrhage caused by a ruptured basilar‒left superior cerebellar artery aneurysm. She underwent coil embolization next day after onset. The procedure ended without incident, and patency of anterior spinal artery (ASA) had been confirmed throughout the procedure. It was found that, however, she had been tetraplegic and her spontaneous respiration drive had disappeared. Cervical spine MRI 14 days after onset showed infarction extending from the medulla to the cervical cord. After rigorous rehabilitation, she achieved neurological recovery and was referred to a rehabilitation hospital 123 days after onset. After reviewing an intraoperative video, it was thought that wedge of a guiding catheter into the vertebral artery might have been the cause. Literature review found several similar cases. We learned that wedge of a guiding catheter be avoided as much as possible, and when it happens, proactive therapeutic measures to prevent ASA hypoperfusion be taken.
Calcification of the ligamentum flavum (CLF) in the lumbar spine is a relative rare lesion that causes radiculopathy and/or cauda equina syndrome. We report the case of a very elderly patient with CLF in the lumbar spine showing progressive urinary retention after mild trauma. A 90‒year‒old Japanese man who had been hospitalized because of a cerebral infarction presented with progressive urinary retention after a hitting his hip in a fall. Lumbar MRI and CT revealed canal stenosis due to CLF at the L4/5 level. There was no clear cause of the patient’s urinary retention other than the CLF at the L4/5. Although medications were administered, there was no improvement in his urinary retention. We performed posterior decompression 10 days after the onset, and the urinary retention improved immediately after the procedure. Surgical treatment for lumbar canal stenosis in very elderly patients should be selected when the patient’s general condition is stable.
Infundibular dilatation (ID) is a dilatation of ＜ 3 mm at the bifurcation between the internal carotid artery and the posterior communicating artery (PcomA), from the tip of which the PcomA branches. ID is considered anatomically normal and is a dilation without pathological significance. However, there have been reports of rupture of the ID itself or the rupture of a cerebral aneurysm arising from ID. We report the case of a rupture of a microaneurysm arising from ID. A 69‒year‒old Japanese woman came to our hospital with the sudden onset of headache and disturbance of consciousness. Head CT showed a diffuse, thick subarachnoid hemorrhage. Digital subtraction angiography (DSA) performed on Day 0 showed a microaneurysm arising from ID. On Day 3, DSA revealed a change in the shape of the microaneurysm and its enlargement. We performed stent‒assisted coil embolization. The patient had a good postoperative course. We also provide a literature review of cases of microaneurysms arising from ID.
A 94‒year‒old Japanese man was found to have an infected subdural hematoma (ISH) during a detailed examination and treatment for a fever of unknown origin. Although the route of infection was unknown, the pathogens were found to be Group G hemolytic streptococcus and anaerobic gram‒positive cocci. The patient responded well to subdural drainage and antimicrobial treatment. Despite his advanced age, the patient had a good outcome and was discharged from the hospital. Proper treatment can result in a favorable outcome; however, an ISH can affect the central nervous system, and several ISH cases have been fatal. Clinicians should be aware that patients with a chronic subdural hematoma and a fever of unknown origin may have infection complications, and thus prompt medical intervention is required.
Craniocervical junction dural arteriovenous fistula (CCJ‒dAVF) is a rare disease. We report the case of a patient with CCJ‒dAVF who presented with hiccups, single leg paralysis, and Horner’s syndrome due to medullary edema. A 72‒year‒old Japanese male was admitted to our hospital with nausea, hiccups, and weakness of the left lower extremity. An MRI FLAIR image showed edema on the dorsal side of the right medulla oblongata, and a T2‒weighted image showed many flow voids on the anterior surface of the brainstem between the vertebral arteries (VAs). Cerebral digital subtraction angiography (DSA) showed an arteriovenous (AV) shunt near the transdural junction of the right VA and a dilated drainer vein ascending to the anterior surface of the brainstem. A craniotomy for shunt point obliteration was performed on the 13th day of hospitalization. After surgery, the patient’s preoperative symptoms improved, and postoperative DSA showed disappearance of the AV shunt. The patient was transferred on postoperative day 30. In cases with myelopathy/brain stem disorder due to venous congestion of the spinal cord/brain stem, the disease often progresses. Early intervention is thus necessary, and direct surgery can be considered as the first choice. To the best of our knowledge, the present report is the first published description of a patient with CCJ‒dAVF, hiccups, and Horner’s syndrome, and this combination is extremely rare.
A 66‒year‒old Japanese woman came to our hospital because of recurrent severe headache that occurred 2 months prior to the first headache. Computed tomography and magnetic resonance imaging of the head revealed a pure acute subdural hematoma (pASDH) without subarachnoid hemorrhage (SAH), a 14‒mm‒sized left internal carotid‒posterior communicating artery (IC‒PcomA) aneurysm with a bleb connected to the pASDH, and a left persistent primitive trigeminal artery (PPTA). Although the blood supply to the posterior cerebral artery (PCA) is sometimes dependent on the PcomA or PPTA, our patient’s peripheral PCA received blood flow from both the left PcomA and the left P1 pre‒communicating segment. Since the hematoma volume of her pASDH was small, we performed coil embolization of the left IC‒PcomA aneurysm. Aspirin was administered postoperatively, and the patient had no perioperative ischemic complications. However, MRI performed 1 week after the surgery showed a mild increase in the pASDH, and close follow‒up by CT confirmed that the pASDH had disappeared at 3 months post‒surgery. A rare condition coexisted with a carotid‒basilar anastomosis in this patient, highlighting the necessity of (i) confirming the responsible vessels in the posterior circulation and (ii) carefully monitoring the postoperative development of a pASDH due to the use of antiplatelet agents in similar cases.
Cardiac myxoma, one of the causes of cerebral infarction in young patients, is complicated by a systemic embolism in 30％‒40％ of the cases. Cerebral embolism is the most common systemic embolism associated with cardias myoma, but it is rare. We describe a cerebral embolism caused by a giant left arterial myxoma, which was resected to prevent sudden death within the day of cerebral infarction. A 48‒year‒old Japanese man was transferred to our hospital for dysarthria and sensory disturbance in his upper limb when he woke up. His medical history and blood tests were unremarkable. He had no atrial fibrillation. Although head MRI revealed a cerebral infarction in his bilateral cerebellum and right occipital lobe, intravenous tissue plasminogen activator (t‒PA) or mechanical thrombectomy was not indicated. Transthoracic echocardiography revealed a 51‒mm × 40‒mm mobile giant myxoma attached to the atrial septum. Because his myxoma was considered at high risk of inducing cardiac sudden death, the patient was transferred by helicopter to a hospital in which cardiac surgery was available. His myxoma was resected by open‒heart surgery, and he was discharged home on day 30 with the modified Rankin Scale value of 1. The causes of cerebral embolism in young individuals are distinct from those in the elderly, and they can include fatal entities. This patient’s case emphasizes the need to perform immediate echocardiography for a cerebral embolism to rule out rare fatal entities, especially in young patients without atrial fibrillation.