Neurologia medico-chirurgica

Original Articles

Preoperative Assessment of Trigeminal Neuralgia and Hemifacial Spasm Using Constructive Interference in Steady State-Three-dimensional Fourier Transformation Magnetic Resonance Imaging

Iwao YAMAKAMI, Eiichi KOBAYASHI, Shinji HIRAI, Akira YAMAURA

2000 Volume 40 Issue 11 Pages 545-556
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.545

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Results of microvascular decompression (MVD) for trigeminal neuralgia (TN) and hemifacial spasm (HFS) may be improved by accurate preoperative assessment of neurovascular relationships at the root entry/exit zone (REZ). Constructive interference in steady state (CISS)-three-dimensional Fourier transformation (3DFT) magnetic resonance (MR) imaging was evaluated for visualizing the neurovascular relationships at the REZ. Fourteen patients with TN and eight patients with HFS underwent MR imaging using CISS-3DFT and 3D fast inflow with steady-state precession (FISP) sequences. Axial images of the cerebellopontine angle (CPA) obtained by the two sequences were reviewed to assess the neurovascular relationships at the REZ of the trigeminal and facial nerves. Eleven patients subsequently underwent MVD. Preoperative MR imaging findings were related to surgical observations and results. CISS MR imaging provided excellent contrast between the cranial nerves, small vessels, and cerebrospinal fluid (CSF) in the CPA. CISS was significantly better than FISP for delineating anatomic detail in the CPA (trigeminal and facial nerves, petrosal vein) and abnormal neurovascular relationships responsible for TN and HFS (vascular contact and deformity at the REZ). Preoperative CISS MR imaging demonstrated precisely the neurovascular relationships at the REZ and identified the offending artery in all seven patients with TN undergoing MVD. CISS MR imaging has high resolution and excellent contrast between cranial nerves, small vessels, and CSF, so can precisely and accurately delineate normal and abnormal neurovascular relationships at the REZ in the CPA, and is a valuable preoperative examination for MVD.

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Cerebral Oximetry for the Detection of Cerebral Ischemia During Temporary Carotid Artery Occlusion

Naoya TAKEDA, Katsuzo FUJITA, Shigenori KATAYAMA, Norihiko TAMAKI

2000 Volume 40 Issue 11 Pages 557-563
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.557

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The near-infrared spectroscopy cerebral oximeter was assessed as a monitoring device for detecting and/or predicting cerebral ischemia during carotid endarterectomy (CEA) and the balloon occlusion test in 24 patients, 12 males and 12 females aged 28 to 77 years (mean 59.9 years). Tolerance testing of complete internal carotid artery (ICA) occlusion by balloon inflation for 20 minutes was performed in nine patients (cerebral aneurysm 6, neck tumor 3) and CEA was performed in 15 patients. The probe of the cerebral oximeter was placed on the forehead of the affected side and regional cerebral oxygen saturation (rSO₂) was monitored continuously during all procedures. Stump pressure was measured just after ICA occlusion. Collateral circulation detected by digital subtraction angiography was classified into three groups: good, moderate, or poor. Stump pressure was 41-90 mmHg (mean 61.3 mmHg) in the good collateral circulation group, 40-43 mmHg (41.5 mmHg) in the moderate group, and 14-30 mmHg (23.8 mmHg) in the poor group. Change in rSO₂ after ICA occlusion was +3.5-−4.2% (mean −1.6%) in the good collateral circulation group, −1.2-−6.6% (−3.2%) in the moderate group, and −2.4-−10.2% (−6.6%) in the poor group. Changes in rSO₂ were significantly different between the good and poor collateral circulation groups (p < 0.01). A greater than 5% fall in rSO₂ was observed in 0 of 15 patients in the good collateral circulation group, one of five in the moderate group, and three of four in the poor group. The cerebral oximeter is a useful, real-time, non-invasive method to measure brain oxygenation during CEA, skull base surgery, or other procedures which need to evaluate brain ischemia. A fall of greater than 10% from the rSO₂ baseline value is dangerous, but less than 5% is safe.

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Increased Expression of Deoxyribonucleic Acid Methyltransferase Gene in Human Astrocytic Tumors

Yoshie OKADA, Takashi OKADA, Masayuki NUMATA, Yutaka HAYASHI, Tetsumor ...

2000 Volume 40 Issue 11 Pages 564-571
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.564

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The relationship between the grade of astrocytic tumor and the expression of deoxyribonucleic acid methyltransferase (DNA-MTase) gene was examined. The levels of DNA-MTase messenger ribonucleic acid (mRNA) were measured by semiquantitative reverse transcriptase-polymerase chain reaction in surgical specimens from 12 astrocytic tumors (4 astrocytomas, 6 anaplastic astrocytomas, and 2 glioblastomas) and two normal brain tissues, and in four glioma cell lines. Compared to normal brain tissues, the levels of DNA-MTase mRNA were increased by 16- to 55-fold in low grade astrocytomas, and significantly increased by 200- to 4500-fold in high grade astrocytomas (anaplastic astrocytomas and glioblastomas) and more than 4500-fold in glioma cell lines. In situ hybridization with paraffin-embedded surgical specimens of human astrocytic tumors showed DNA-MTase mRNA was abundantly expressed in high grade astrocytomas. The detection of increased DNA-MTase expression in astrocytic tumor indicates involvement in the tumorigenesis and suggests that blocking of this change with specific inhibitors may offer new therapeutic strategies for malignant astrocytic tumors.

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Case Reports

Infratentorial Arteriovenous Malformation Associated With Persistent Primitive Trigeminal Artery

—Case Report—

Yasunobu NAKAI, Susumu YASUDA, Akio HYODO, Kiyoyuki YANAKA, Tadao NOSE

2000 Volume 40 Issue 11 Pages 572-574
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.572

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A 58-year-old male presented with a rare association of an infratentorial arteriovenous malformation (AVM) and ipsilateral persistent primitive trigeminal artery (PPTA) manifesting as sudden onset of headache and vomiting. Computed tomography revealed subarachnoid hemorrhage, and digital subtraction angiography demonstrated an infratentorial AVM mainly fed by the left superior cerebellar artery via the left PPTA. The patient refused radical treatment for the AVM, and was conservatively treated. The adjacent AVM may have been important in the preservation of the PPTA, as blood flow into the infratentorial AVM via the PPTA and the hemodynamic stress to the PPTA could have disturbed the spontaneous closure of the PPTA.

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Cavernous Sinus Hemangioma Treated with Gamma Knife Radiosurgery: Usefulness of SPECT for Diagnosis

—Case Report—

Yoshinobu SEO, Seiji FUKUOKA, Takehiko SASAKI, Masami TAKANASHI, Atsuh ...

Article type: Others
Subject area: Others
2000 Volume 40 Issue 11 Pages 575-580
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.575

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A 79-year-old female presented with cavernous sinus hemangioma manifesting as double vision due to right oculomotor and trochlear nerve pareses. Computed tomography and magnetic resonance imaging revealed bony erosion and a right cavernous sinus tumor with “tail sign” after contrast medium administration. Thallium-201 (²⁰¹Tl) single photon emission computed tomography (SPECT) showed low uptake within the tumor, and technetium-99m-human serum albumin-diethylenetriaminepenta-acetic acid SPECT disclosed high uptake within the tumor. ²⁰¹Tl SPECT usually shows very high uptake in meningiomas and malignant tumors, so the tumor was considered to be an unrelated benign tumor. The patient underwent partial resection of the tumor. Histological examination of the specimen confirmed cavernous hemangioma. The oculomotor nerve paresis partially improved. Gamma knife radiosurgery was carried out 4 months after the operation. The tumor markedly shrank with full recovery of extraocular movement 6 months after radiosurgery. SPECT is useful for distinguishing cavernous sinus hemangiomas from other cavernous tumors. Radiosurgery should be performed after partial resection or biopsy for cavernous sinus hemangiomas and may be the initial treatment for patients with small cavernous sinus hemangioma if the diagnosis can be established based on neuroimaging.

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Gliosarcoma Associated With a Huge Cyst

—Case Report—

Masamichi KUROSAKI, Seijiro TANIURA, Satoshi TANAKA, Atsumi TAKENOBU, ...

Article type: Others
Subject area: Others
2000 Volume 40 Issue 11 Pages 581-584
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.581

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A 55-year-old female presented with a unique case of gliosarcoma with a huge cystic component manifesting as loss of consciousness, left-sided hemiparesis, and anisocoria. Computed tomography demonstrated a large cyst in the right frontal lobe, and enhancement of the mural nodule after administration of contrast medium. Emergent operation was performed. Xanthochromic fluid was aspirated, and the tumor was resected. The histological diagnosis was gliosarcoma based on the presence of gliomatous and sarcomatous components. She underwent a second operation because of tumor regrowth 3 weeks after the first operation. The postoperative course was satisfactory during radiation therapy with 60 Gy and chemotherapy. The diagnosis of gliosarcoma was difficult to make preoperatively because of the neuroradiological findings similar to low-grade gliomas. Gliosarcoma should be included in the differential diagnosis of huge cystic tumors.

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Brain Metastasis of Epithelioid Sarcoma

—Case Report—

Hideo TSURUSHIMA, Hirokatsu YONAHA, Takamitsu TAMURA, Tatsuya KINJO, A ...

Article type: Others
Subject area: Others
2000 Volume 40 Issue 11 Pages 585-588
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.585

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A 20-year-old-female first presented with an epithelioid sarcoma of the right thumb, and the right thumb was amputated. Five years later, a metastasis was found in the right lower lung and a partial lobectomy was performed. Three years later, computed tomography showed a metastatic brain tumor in the left frontal lobe, which was removed surgically. Adjuvant radiotherapy and chemotherapy were given after all operations. Histological examination showed all resected tumors were epithelioid sarcoma. She has maintained a good activity of daily living level as an outpatient for 2 years, although subcutaneous metastases and bronchial lymph node metastases have been observed. Such intensive treatment of slowly growing tumors often prolongs survival time, even in patients with multiple metastases.

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Preoperative Embolization of Upper Cervical Cord Hemangioblastoma Concomitant With Venous Congestion

—Case Report—

Kazuhiro OHTAKARA, Yoshihiro KUGA, Kenichi MURAO, Tadashi KOJIMA, Waro ...

Article type: Others
Subject area: Others
2000 Volume 40 Issue 11 Pages 589-593
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.589

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A 16-year-old male presented with a large, solid hemangioblastoma located in the upper cervical cord manifesting as hyperactive reflexes, subtle weakness, and diminished position sense in all extremities. Neuroimaging studies indicated venous congestion due to arteriovenous shunt through the tumor. Preoperative embolization was accomplished without morbidity, and resulted in marked devascularization of the tumor and elimination of an early filling vein. Four days after embolization, the tumor was totally excised without excessive intraoperative bleeding. His neurological deficits gradually improved after surgery. Preoperative embolization is a valuable adjunct to surgical excision of large intramedullary hemangioblastomas, especially those associated with arteriovenous shunt, as cord dysfunction related to venous congestion and the risk of torrential intraoperative bleeding are reduced.

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Migration of the Shunt Tube After Lumboperitoneal Shunt

—Two Case Reports—

Shinzo YOSHIDA, Satoshi MASUNAGA, Mutsumi HAYASE, Yoshifumi ODA

2000 Volume 40 Issue 11 Pages 594-596
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.594

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A 60-year-old male and a 36-year-old female suffered shunt migration after lumboperitoneal shunt procedures, upward into the spinal subarachnoid space and downward into the abdominal cavity, respectively. Defects of the fixation devices in the shunt system are considered the main cause in both cases. Upward migration of the lumbar tube in the subarachnoid space is extremely rare. We suppose that raised abdominal pressure is related to this unusual complication.

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Technical Note

Prevention of Cerebrospinal Fluid Leakage and Delayed Loss of Preserved Hearing After Vestibular Schwannoma Removal: Reconstruction of the Internal Auditory Canal in the Suboccipital Transmeatal Approach

—Technical Note—

Iwao YAMAKAMI, Eiichi KOBAYASHI, Junichi ONO, Akira YAMAURA

Article type: Others
Subject area: Others
2000 Volume 40 Issue 11 Pages 597-601
Published: 2000
Released on J-STAGE: September 02, 2005

DOIhttps://doi.org/10.2176/nmc.40.597

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The suboccipital transmeatal approach uses packing of a muscle or fat graft into the internal auditory canal (IAC) to prevent postoperative cerebrospinal fluid (CSF) leakage. However, preserved hearing after removal of vestibular schwannomas may decline over time because of the progressive constriction of cochlear vascular supply due to scarring of the IAC. We propose a surgical technique for IAC reconstruction, which separates the preserved cochlear nerve and vasculature from the graft, and regains the CSF space in the IAC. Prior to the drilling of the posterior wall of the IAC, the dura mater of the petrous bone forming the posterior wall of the IAC is harvested for IAC reconstruction. After completion of tumor removal, a “roof” of the IAC is reconstructed using the dura mater, and a muscle or fat graft soaked with fibrin glue is placed on the “roof” of the IAC. The IAC was reconstructed using this technique in 26 consecutive patients with vestibular schwannomas who underwent tumor removal via the suboccipital transmeatal approach. Postoperative magnetic resonance imaging confirmed the regained CSF space in the IAC. No delayed hearing loss occurred in four patients with preserved hearing. No CSF leakage occurred after surgery. This new technique of IAC reconstruction may prevent delayed hearing loss as well as postoperative CSF leakage after removal of vestibular schwannomas via the suboccipital transmeatal approach.

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