Neurologia medico-chirurgica

Original Article

Local Injection of Botulinum Toxin Type A for Hemifacial Spasm

Hirofumi OYAMA, Akira IKEDA, Shigeo INOUE, Yasuhiro NAKASHIMA, Masato ...

2002 Volume 42 Issue 6 Pages 245-249
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.245

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The preliminary experience of botulinum toxin treatment for hemifacial spasm is reported in this study. Five patients were treated with 10 injections of botulinum toxin in total. Botulinum toxin had a good to excellent effect in all cases. Improvement was observed 2 weeks to 1 month after the injection. The duration of improvement was 0-9 months (mean 4.2 months). The peak rank tended to decrease and the duration of improvement increased after several treatments. Hemifacial spasm caused by the anterior inferior cerebellar artery tended to subside easily. In contrast, compression by the vertebral artery was more refractory. Continuous facial spasm caused by operative trauma subsided after the injection, but paroxysmal spasm still occurred when eating or laughing. Spasm caused by trauma disappeared 4.5 months after the injection. The complications, which were facial nerve paresis in two cases (3 injections, 30%) and diplopia in one case (1 injection, 10%), were transient and subsided in 2 weeks.

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Case Reports

Anterior Cerebral Artery Dissections Manifesting as Cerebral Hemorrhage and Infarction, and Presenting as Dynamic Angiographical Changes

—Case Report—

Shigeyuki SAKAMOTO, Tetsuji INAGAWA, Fusao IKAWA, Hitoshi KAWAMOTO, Na ...

2002 Volume 42 Issue 6 Pages 250-254
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.250

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A 65-year-old woman presented with multiple dissecting aneurysms of the anterior cerebral artery (ACA) manifesting as hemiparesis on the right with dominance in the lower extremity. Computed tomography revealed hematoma in the left frontal lobe, corresponding to the area perfused by the callosomarginal artery. Initial angiography showed string sign and occlusion in the distal portion of the left callosomarginal artery and abnormal feeding suggesting double lumen of the A₂ portion of the left ACA. The patient was treated conservatively under a diagnosis of multiple spontaneous dissecting aneurysms of the left ACA. Repeat angiography on Day 8 showed improvement of the string sign and occlusion in the left callosomarginal artery, and change of the double lumen of the A₂ portion into string sign. Further angiography on Day 36 showed normalization of the left callosomarginal artery and improvement of the string sign in the A₂ portion. Multiple spontaneous dissecting aneurysms of the ACA are extremely rare. Serial angiography beginning in the early stage will be important for correct diagnosis.

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Subarachnoid Hemorrhage Caused by Dural Arteriovenous Fistula of the Sphenobasal Sinus

—Case Report—

Sadahiro NOMURA, Shigetaka ANEGAWA, Setsuko NAKAGAWA, Makoto TOMOKIYO, ...

2002 Volume 42 Issue 6 Pages 255-258
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.255

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A 59-year-old woman presented with a rare middle fossa dural arteriovenous fistula (AVF) unrelated to the cavernous sinus manifesting only as subarachnoid hemorrhage. Angiography revealed shunts between the meningeal branches of both the internal and external carotid arteries and the sphenobasal sinus. The AVF drained into the superficial middle cerebral vein (SMCV) which had a varix and an anastomosis to a superior cerebral vein. The arterial supply vessels were eliminated surgically and the sinus was excised. Bleeding did not recur and there was no venous infarction. Dural AVF of the sphenoparietal sinus is associated with pulsatile exophthalmos and dural AVF of the sphenopetrosal sinus with tinnitus, but dural AVF of the sphenobasal sinus has no obvious symptom. Simple interruption of the SMCV at the penetration of the arachnoid membrane was possible because of the absence of a draining vessel to preserve AVF patency, but the arteries were eliminated in this patient to prevent formation of another AVF.

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Intramedullary Spindle Cell Hemangioendothelioma of the Thoracic Spinal Cord

—Case Report—

Jafri Malin ABDULLAH, Samerendra Singh MUTUM, Noor Azam NASUHA, Biswa ...

2002 Volume 42 Issue 6 Pages 259-263
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.259

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A 28-year-old Malay man presented with progressive paraparesis over a period of 6 months. Magnetic resonance imaging of the spine revealed a thoracic intramedullary spinal cord tumor at the T-7 level with homogeneous enhancement following intravenous gadolinium administration. Laminectomy and partial decompression of the tumor was performed. Histological examination of the tumor revealed features of spindle cell hemangioendothelioma. The patient was managed with limited field radiotherapy followed by systemic interferon therapy. Good neurological improvement was seen subsequently. The patient has survived 48 months with growth restraint at the primary site, although residual neurological deficit persists. Immunotherapy should be considered as a treatment modality for intramedullary hemangioendothelioma of the spinal cord after surgery and radiotherapy.

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Calcified Metastatic Brain Tumor

—Two Case Reports—

Yoshinori OHMOTO, Takafumi NISHIZAKI, Koji KAJIWARA, Sadahiro NOMURA, ...

2002 Volume 42 Issue 6 Pages 264-267
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.264

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A 29-year-old man and a 46-year-old woman presented with calcified brain metastasis from pulmonary adenocarcinoma. Both patients had a relatively benign clinical course and prolonged survival after total removal of the tumors. The male patient was still alive 2 years 3 months after surgical resection of the metastatic and primary tumors. The female patient had had brain metastasis 8 years after surgical resection of lung cancer, and survived for 3 years 3 months after removal of the brain metastasis. The MIB-1 indexes of the two cases were relatively low compared with other cases of brain metastases. Calcification and low MIB-1 index may indicate longer survival in patients with metastatic tumors if the primary tumor is controlled.

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Multiple Intracranial Seeding of Craniopharyngioma After Repeated Surgery

—Case Report—

Hiroaki NOMURA, Masanori KURIMOTO, Shoichi NAGAI, Nakamasa HAYASHI, Yu ...

2002 Volume 42 Issue 6 Pages 268-271
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.268

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A 17-year-old woman presented with a rare case of intracranial seeding of craniopharyngioma after repeated surgery. She initially presented with secondary amenorrhea and visual impairment. Magnetic resonance imaging revealed a suprasellar mass. Subtotal removal of the tumor was performed. The diagnosis was adamantinomatous craniopharyngioma. Seven months later, the patient underwent a second operation for recurrence of the craniopharyngioma. Subsequently, ventriculoperitoneal (VP) shunting and gamma knife surgery were performed. Twenty-seven months after the first operation, multiple cystic lesions were found in the right frontal and temporal lobes. Positive tumor cytology was observed in the cerebrospinal fluid obtained from the VP shunt chamber. These tumors were subtotally resected. However, the patient died from consecutive tumor recurrence 4 years after the initial diagnosis.

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Anterior Transpetrosal Approach for Pontine Cavernous Angioma

—Case Report—

Nobuhito SAITO, Tomio SASAKI, Emiko CHIKUI, Ryuji YUYAMA, Takaaki KIRI ...

2002 Volume 42 Issue 6 Pages 272-274
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.272

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A 58-year-old male patient presented with headache and unsteady gait. Magnetic resonance imaging revealed hemorrhage from a pontine cavernous angioma. The patient experienced stepwise aggravation of symptoms due to repeated hemorrhages. We decided to surgically remove the pontine cavernous angioma through an anterior transpetrosal approach, since the angioma and hematoma were located near the ventrolateral surface of the pons. The brain stem was incised at a site caudal to the trigeminal nerve and the hematoma and angioma were totally removed. No additional neurological deficits were observed following surgery. Brain stem cavernous angiomas are usually removed via a trans-fourth ventricle or lateral suboccipital approach. However, these approaches may not be appropriate if the angioma is located ventrally to the pons. We propose that the anterior transpetrosal approach is the method of choice for ventrally located pontine cavernous angioma.

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Technical Note

Integration of Ultrasonography and Endoscopy Into Transsphenoidal Surgery With a “Picture-in-Picture” Viewing System

—Technical Note—

Toshiki YAMASAKI, Kouzo MORITAKE, Hidemasa NAGAI, Yoriyoshi KIMURA

2002 Volume 42 Issue 6 Pages 275-278
Published: 2002
Released on J-STAGE: June 18, 2005

DOIhttps://doi.org/10.2176/nmc.42.275

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A technique to integrate ultrasonography and endoscopy is described for transsphenoidal surgery to prevent intraoperative internal carotid artery (ICA)-related, life-threatening complications such as aneurysmal formation and carotid-cavernous fistula. The ultrasound unit helps avoid direct injury to the ICA. The technical advantage of this system is the miniature 1-mm diameter microvascular probe, which does not disturb the operative field. An arterial or venous flow source of even an invisible vessel can be detected easily, noninvasively, and reproducibly. Real-time information with a 100% detection rate for the ICA is helpful for predicting localization even in the intracavernous portion, where the ICA is invisible. The endoscope unit can visualize the dead angle areas of the operating microscope by varying the endoscopic gateways and display on a “picture-in-picture” system. The advantage of both devices is the integration with a video processor, so that the real-time information from each unit can be switched intraoperatively onto the display as required. This method is of particular help for removing lesions with intracavernous invasion or encasement of the ICA.

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