Neurologia medico-chirurgica

Pathophysiology of Cerebral Ischemia

R. Loch MACDONALD, Marcus STOODLEY

1998 Volume 38 Issue 1 Pages 1-11
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.1

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The purpose of this manuscript is to briefly review the pathophysiology of cerebral ischemia. Ischemic thresholds are well-defined in lower animals. The concept of the ischemic penumbra may include regions of brain around deeper regions of ischemia but has also been defined in terms of brain salvageable by reperfusion or by pharmacological therapies. The principal pathophysiological processes in cerebral ischemia are energy failure, loss of cell ion homeostasis, acidosis, increased intracellular calcium, excitotoxicity, and free radical-mediated toxicity. The underlying biochemical processes are similar regardless of the amount of brain that is made ischemic or the duration of ischemia. The relative contributions of each process are believed to vary significantly especially in relation to the level of cerebral blood flow. Neurons may die by necrosis or apoptosis. In the core of an infarct where blood flow is very low, the predominant process is energy failure and rapid necrotic cell death. Reperfusion of ischemic tissue produces an influx of inflammatory cells and of oxygen that can cause increases in oxygen-derived free radicals. Free radicals are also important in prolonged ischemia. There is interest in changes in gene expression after ischemia. Induction of heat shock proteins suggests that gene expression changes may protect neurons from death. Changes in gene expression also may initiate apoptosis or other detrimental processes. Although advances have been made, there are still no proven pharmacological therapies to rescue ischemic human neurons. Such therapies do appear to be on the horizon.

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Arterial Occlusive Lesions Following Wrapping and Coating of Unruptured Aneurysms

Shingo KAWAMURA, Hiromu HADEISHI, Akifumi SUZUKI, Nobuyuki YASUI

1998 Volume 38 Issue 1 Pages 12-19
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.12

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Seven patients (mean age 57 years) developed arterial occlusive lesions following both wrapping and coating during surgery for unruptured aneurysms. Five patients had no risk factors for arteriosclerosis, and two had hypertension or diabetes mellitus. The aneurysms were located in the middle cerebral artery in four cases, and the internal carotid artery in three. Both 100%-cellulose cotton (Bemsheet®) and cyanoacrylate glue (Biobond®) were used as reinforcement materials. Postoperative angiography revealed complete clipping, and no parent artery stenoses, although one patient had a non-symptomatic diffuse narrowing in the entire carotid fork 7 days following surgery. Three patients had progressive stroke 4-5 weeks following surgery, and two had no symptoms. Both reinforcement materials were used as little as necessary in the last two patients, but they had either transient ischemic attacks or progressive stroke 2 months following surgery. Arterial steno-occlusion was confirmed angiographically in all patients. These vascular lesions were probably induced by both direct toxicity of the cyanoacrylate glue and fibrosis or granuloma formation caused by the cotton fibers. The observed angiographical reversibility suggests that the cyanoacrylate glue is more likely to be the cause of the lesions than the cotton fibers.

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Acute Traumatic Subdural Hematoma Originating from a Convexity Meningioma —Case Report—

Eiji MORIYAMA, Hiroichi BECK, Kazuhiro TAKAYAMA, Tsukasa OKAMOTO

1998 Volume 38 Issue 1 Pages 20-23
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.20

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A 68-year-old male presented with a traumatic subdural hematoma originating from a convexity meningioma the day after a motorcycle accident. Computed tomography disclosed a right temporal subdural and/or epidural mass. Emergent craniotomy revealed a convexity meningioma with thin subdural hematoma. The underlying brain was apparently healthy. The histological diagnosis was angiomatous meningioma with hemorrhagic foci. The operative and histological findings indicated that the tumoral tissue was the source of the subdural hematoma.

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Multiple Remote Brain Hemorrhages after Removal of a Giant Colloid Cyst of the Third Ventricle —Case Report—

Kazuhiro YAMANAKA, Yoshiyasu IWAI, Hideki NAKAJIMA, Yasutsugu KOBAYASH ...

1998 Volume 38 Issue 1 Pages 24-27
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.24

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A 59-year-old male presented with progressive gait and memory disturbance. Computed tomography (CT) showed a huge high density mass, of about 45 mm maximum diameter, in the third ventricle with marked hydrocephalus. Magnetic resonance imaging showed the mass as mixed iso- to hypointensity on T₂-weighted imaging and high intensity on T₁-weighted imaging. Bifrontal craniotomy was carried out. The histological diagnosis was colloid cyst. Six hours after the operation, a large quantity of cerebrospinal fluid (CSF) was discharged via an epidural drainage, accompanied by generalized convulsion. CT showed multiple brain hemorrhages and subarachnoid hemorrhage remote from the operative field. The cause of hemorrhages is obscure, but postoperative overdrainage of CSF through epidural drainage over a short time following excessive intraoperative CSF aspiration may have contributed to this rare complication.

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Magnetic Resonance Angiography Visualization of Four Vessel (Bilateral Carotid and Vertebral Artery) Occlusion —Two Case Reports—

Yoshikazu OKADA, Takeshi SHIMA, Masahiro NISHIDA, Reiko KAGAWA

1998 Volume 38 Issue 1 Pages 28-33
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.28

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A 44-year-old female with transient vertigo and a 51-year-old female with headache and numbness of the hand presented with four vessel occlusion of the cerebral arteries (bilateral internal carotid arteries and bilateral vertebral arteries). This is an extremely rare entity, and the clinicoradiological features are not well documented. Magnetic resonance (MR) angiography visualized the cerebral arterial occlusion. Conventional angiography confirmed the diagnosis and demonstrated extensive collateral vessels. MR angiography is a useful method for screening patients with minimal or no symptoms for abnormalities in the cerebral circulation.

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Superior Sagittal Sinus Thrombosis Associated with Primary Antiphospholipid Syndrome —Case Report—

Shoichi NAGAI, Yukio HORIE, Takuya AKAI, Shigenori TAKEDA, Akira TAKAK ...

1998 Volume 38 Issue 1 Pages 34-39
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.34

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A 36-year-old female with a history of recurrent pregnancy loss experienced sudden onset of disturbance in consciousness, with right hemiparesis and total aphasia. Computed tomography revealed a massive hemorrhage in the left frontal lobe, and angiography showed occlusion of the anterior twothirds of the superior sagittal sinus. Laboratory investigations detected the presence of lupus anticoagulant, elevation of the anticardiolipin β₂-glycoprotein I complex antibody level, and a decreased protein S activity level. There were no underlying conditions, such as connective tissue disorders, malignancies, infectious diseases, and drug-induced disorders, so the diagnosis was primary antiphospholipid syndrome. Primary antiphospholipid syndrome should be considered in the evaluation of patients with “idiopathic” or “primary” sinus and cerebral venous thrombosis.

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Association of a Dolichoectatic Middle Cerebral Artery and an Intracranial Cavernous Hemangioma —Case Report—

Yukihide KANEMOTO, Manabu HISANAGA, Hironobu BESSHO

1998 Volume 38 Issue 1 Pages 40-42
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.40

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A normotensive, non-smoking 41-year-old female with a history of generalized seizures from the age of 4 years presented with a left middle cerebral artery (MCA) fusiform aneurysm and an ipsilateral frontal lobe cavernous hemangioma. Surgical exploration demonstrated that the fusiform aneurysm-like lesion was a dolichoectatic MCA with no arteriosclerotic change. The pathogenesis of dolichoectasia is obscure, but the association of a dolichoectatic MCA and an intracranial cavernous hemangioma is suggestive of congenital factors.

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Sigmoid Sinus Dural Arteriovenous Malformation Resulting from Jugular Foramen Schwannoma —Case Report—

Iwao YAMAKAMI, Junichi ONO, Akira YAMAURA

1998 Volume 38 Issue 1 Pages 43-46
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.43

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A 69-year-old male presented with a jugular foramen schwannoma occluding the sigmoid sinus and associated with sigmoid sinus dural arteriovenous malformation. The patient presented with dizziness and pulsatile tinnitus following an extended period of hearing loss beginning several years before. Both lesions were resected successfully after transarterial embolization of the malformation. The sequence of symptom development suggests the dural sinus thrombosis caused the dural arteriovenous malformation.

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Subependymoma in the Lateral Ventricle Incidentally Detected by Routine Brain Examination —Case Report—

Shigenori KATAYAMA, Katsuzo FUJITA, Naoya TAKEDA, Kimio HASHIMOTO, Nor ...

1998 Volume 38 Issue 1 Pages 47-50
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.47

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A 42-year-old male visited our hospital for a routine brain examination, which incidentally identified an intraventricular mass lesion (2.7 × 1.6 × 1.2 cm³). Magnetic resonance imaging showed the tumor was isointense on the T₁-weighted image and hyperintense on the T₂-weighted and proton images. The intraventricular tumor was totally extirpated through the interhemispheric ipsilateral transcallosal approach. The histological diagnosis was subependymoma. Neuroimaging cannot differentiate this benign neoplasm from other more aggressive tumors. Widespread use of the medical checkup system is expected to find a higher incidence of otherwise non-identified asymptomatic lesions. Surgical extirpation is one of the treatment options to establish the correct diagnosis and to prevent symptoms.

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Neuroimaging Appearance of Pituitary Abscess Complicated with Close Inflammatory Lesions —Case Report—

Toshio TAKAHASHI, Seiko SHIBATA, Katsuhiro ITO, Satoshi ITO, Masahiko ...

1998 Volume 38 Issue 1 Pages 51-54
Published: 1998
Released on J-STAGE: March 30, 2006

DOIhttps://doi.org/10.2176/nmc.38.51

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A 13-year-old girl with a pituitary abscess complained of continuous headache and bitemporal hemianopsia after a common cold. However, she had no inflammatory reactions on admission. Computed tomography showed a low-density sellar mass lesion extending to the suprasellar cistern with a peripheral low-density area, and ring enhancement of the capsule with a particularly thick region. Magnetic resonance imaging showed the mass lesion as a low and high-intensity area on the T₁- and T₂-weighted images, respectively. The iso-intense rim of the lesion and the left frontal mass lesion adjacent to the capsule were enhanced by gadolinium-diethylenetriaminepenta-acetic acid. Magnetic resonance imaging also indicated only mild sphenoidal sinusitis which may be representative of the inflammatory process. Careful assessments of neuroimaging findings and preceding trivial inflammatory signs are necessary for the correct diagnosis of a pituitary abscess.

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