[Background and purpose] Classical medullary syndromes in patients with medullary infarctions (MIs) often display incomplete neurological manifestations. Recently, new radiological classifications employing MRI have been proposed by Kameda et al. (2004). In this study, we attempted to classify MIs based on MRI findings. [Methods] We studied 46 patients with MIs at our hospital between April 1995 and March 2005. The diagnosis of the MIs was made on the basis of the neurological findings and MRI in each case. All patients were classified into three groups based on the MRI classification system proposed by Kameda. The risk factors for the medial medullary infarction (MMI) group were compared with those for the lateral medullary infarction (LMI) group by multivariate logistic regression analysis. [Results] Twenty-one of the patients with MIs were diagnosed as showing incomplete medullary syndromes. However, there are no incomplete manifestations on the MRI classification. According to the anatomical region, we speculated that the patients diagnosed as Wallenberg syndrome could be classified mainly as beings of the dorsolateral type, and the patients diagnosed as Dejerine syndrome could be classified mainly as being of the paramedian type. However, the correlation between clinical symptoms and MRI findings may sometimes be inconsistent. The mean age of the patients with dissection of the vertebral artery was significantly younger than that of those without dissection in the LMI group (p=0.012). Diabetes mellitus was significantly associated with the MMI group (OR, 6.500; p=0.035). [Conclusion] Radiological classification of MIs may be useful for the identification of clinical-topographical correlations, and for evaluation of the pathophysiological mechanisms and risk factors in patients with MIs.

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Our department is located in the Tsugaru district, which is famous for heavy snow fall, and the small number of neurosurgeon centers in the urban areas leads to an inadequate distribution of neurosurgeons for patients in this region. Such geographical and social constraints have made it difficult to offer sufficient neurosurgical care to all patients in the region. We describe the usefulness of a telemedicine triage system using an image transfer system in the treatment of neurosurgical emergent cases. Image transfer systems have been installed at our hospital and 11 regional hospitals in the Tsugaru district, and have been utilized for teleconsultation regarding neurosurgical patients via transferred computed tomography images since 1989. Consultations regarding 2,858 cases were directed to our department between 1989 and 2006, including 1,615 cases of stroke, 869 cases of head trauma, 97 cases of brain tumor, and 277 cases with other disorders. 84% of subarachnoid hemorrhage cases and 22% of head trauma cases needed emergent transfer. The state of consciousness in intracerebral hemorrhage, and the state of consciousness and time of consultation in head trauma were statistically significant factors for emergent transfer. The presert telemedicine triage system was useful for ensuring correct diagnosis and appropriate primary neurosurgical care in the regional hospitals without neurosurgical units, resulting in a reinforcement of the relationships among the regional hospitals and the efficient transfer of emergent neurosurgical patients.

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A 70-year-old otherwise healthy man presented with sudden onset of severe headache. CT and MRI studies revealed subarachnoid hemorrhage mainly in the posterior fossa. Left vertebral artery dissection was suspected after 3D-CTA and MRA studies. Cerebral angiography did not reveal any evident vascular anomaly, although right vertebral angiography was not performed satisfactorily. Repeated cerebral angiography revealed early filling of the perimedullary vein of the posterior fossa supplied from the proximal right vertebral artery at the C1 level. A diagnosis of cervical spinal dural arteriovenous fistula was made, and surgical obliteration of the perimedullary draining vein was performed. The postoperative course was uneventful and the patient was discharged with no apparent neurological deficits. Cervical spinal dural AVF is one of the important causes of SAH: however, it is infrequently encountered and accurate diagnosis is not easy. Complete four-vessel studies including proximal vertebral angiography of the cervical segment are considered mandatory.

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We report a case of a patient with cerebral infarction due to tuberculous meningitis with occlusion of the MCA demonstrated by chronological MRA. A 65-year-old male developed headache and loss of activity for 2 weeks. On admission, neurological evaluations revealed confusion of the consciousness state, meningeal irritation, exaggerated deep tendon reflexes in all four extremities and positive bilateral Babinski reflexes. The cerebrospinal fluid cell count was 271/mm³, protein was 166mg/dl, and ADA was 15.9IU/l. Bacterial and acid-fast bacterial cultures of the cerebrospinal fluid were negative. Mycobacterium tuberculosis DNA detection by PCR was positive. Brain MRI and MRA showed normal aging signs. Chest X-ray and CT examinations revealed normal findings. The diagnosis was tuberculous meningitis. Anti-tuberculosis chemotherapy and steroids improved his symptoms. After 4 weeks, the steroid treatment was reduced gradually. At 45 days after admission, a brain MRI scan showed infarction of the right basal ganglia. At 56 days, another brain MRI scan showed infarction of the left middle cerebral artery, and brain MRA revealed occlusion of the left middle cerebral artery. The neurological sequela was tetraparesis. This patient represents a rare case of occlusive change of the MCA demonstrated by MRA before and after infarction. Evidence based medicine should be investigated concerning the dose and period of corticosteroid for the treatment of tuberculous meningitis.

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We report a successful case of emergent carotid artery stent placement (CAS) for high-grade stenosis of the internal carotid artery (ICA) at the origin presumably due to an acute alteration of plaque morphology in a serious ischemic stroke patient. A 79-year-old man was admitted to our institution due to a comatose state, ataxic respiration, right-sided hemiparesis and monoparesis of the left lower extremity. His magnetic resonance images demonstrated multiple infarction in the left hemisphere, and his emergent cerebral angiography revealed high-grade stenosis of the left ICA at the origin presumably due to an acute alteration of plaque morphology. Since we considered that his serious symptoms were probably due to an acute progression of the stenotic lesion causing low perfusion, we performed emergent CAS. Immediately after completing the procedure, the patient's symptoms except for the motor aphasia and right-sided hemiparesis improved rapidly, and he was transferred to another institution on the 23rd day. This case experience suggests that emergent CAS represents a potential treatment for occlusive lesions of the cervical ICA due to acute alterations of plaque morphology in serious ischemic stroke patients.

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We report a case of ruptured AVM after minor head injury in a 9-year-old boy. At 3 hours after minor head injury, he complained of headache, vomiting and right hemiparesis. A CT scan revealed intracerebral hemorrhage of 5cm in diameter in the left parietal lobe. Due to developing disturbance of consciousness and worsening of the right hemiparesis, evacuation of the hematoma was performed. After the operation, the neurological deficits were improved. An angiogram demonstrated AVM in the left parietal lobe. Total resection of the AVM was carried out. It is difficult to confirm whether ruptured AVM is caused by an external force or natural bleeding. In the present case, the location of the AVM ranged from the deep venous system via the paracentral lobe to the superficial cortex. It seems likely that this formation was affected by the shear strain of an external force. In this report, we also discuss this relationship.

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119 cases of lacunar infarction were divided within 24 hours of symptom onset into three groups (one receiving antithrombotic drug monotherapy, one receiving edaravone monotherapy, and one receiving antithrombotic and edaravone combined therapy), and were examined retrospectively. The percentage of progressive cases was 15%, 11.1%, and 3.8%, respectively. The differences were not statistically significant, although the progression in the combined therapy group was less than that in the other two groups. In addition, 11 cases that showed progression deteriorated within 5 days after the onset. These results indicate that combined therapy as a primary care might decrease the frequency of lacunar infarction advancement, and our findings suggest that it may be desirable to consider changing to monotherapy after the 5^th day from symptom onset.

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