Neurologia medico-chirurgica

Original Articles

Cooperative Study of Ruptured Vertebrobasilar Artery Aneurysms in the Tohoku District in Japan

Nobuyuki YASUI, Hiromu HADEISHI, Hiromi NISHIMURA, Kazuo UEMURA, the ...

2003 Volume 43 Issue 5 Pages 219-227
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.219

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A multicenter study investigated the clinical characteristics and overall outcome of 342 cases of ruptured vertebrobasilar artery aneurysms among 6783 ruptured intracranial berry aneurysms in 73 hospitals across the Tohoku district in Japan between 1992 and 1996. The incidence of ruptured vertebrobasilar artery aneurysms was less frequent than previously reported. The incidence was 5% among all intracranial berry aneurysms. One hundred eleven patients had aneurysms of the basilar artery bifurcation, 98 had vertebral-posterior inferior cerebellar artery aneurysms, 44 had basilar-superior cerebellar artery aneurysms, and 28 had distal posterior inferior cerebellar artery aneurysms. Aneurysm clipping was performed in 238 cases (70%), intravascular treatment in 22 (6%), drainage in 22 (6%), and conservative treatment in 60 (18%). Approximately 50% of patients were in good condition at admission. At 3-month follow up, 46% had good recovery, 14% had moderate disability, 10% had severe disability, 4% were vegetative state, and 27% died. Vertebral artery aneurysms showed favorable outcomes compared to basilar artery bifurcation aneurysms. Surgical results in the 238 operated cases were good recovery in 60%, moderate disability in 18%, severe disability in 10%, vegetative state in 2%, and death in 11% of cases. Worse postoperative outcomes were observed in patients with high preoperative Hunt and Kosnik grades or aneurysms larger than 10 mm, and in patients over 70 years of age.

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Long-term Outcome for Surgically Treated Cervical Spondylotic Radiculopathy and Myelopathy

Satoru KADOYA, Hideaki IIZUKA, Tsutomu NAKAMURA

2003 Volume 43 Issue 5 Pages 228-241
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.228

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Long-term follow-up results were examined to verify the efficacy of anterior osteophytectomy for cervical spondylotic myelopathy and radiculopathy, in particular the outcome for patients with developmentally narrow cervical canals and patients with associated ossification of the posterior longitudinal ligament (OPLL). One hundred thirty-nine patients who had undergone anterior osteophytectomy with interbody fusion between 1976 and 1990 were followed up for 1 to 22.5 years (mean 11.4 years). Overall results evaluated by the neurosurgical cervical spine scale scoring and grading showed significant improvement in both improvement score (2.7 ± 2.3) and improvement rate (52.3 ± 45.7%). Lower extremity motor function improved in 66.1% of patients, upper extremity motor function in 82.0%, and sensory/pain function in 70.5%. Improvement ranged from one to three grades. Severely affected patients showed good recovery. Outcome for patients with narrow cervical canals (41 patients, 29.5%) did not differ significantly from that for patients with normal canals (98, 70.5%). Patients with associated OPLL (32 patients, 23.0%) had approximately the same outcomes as those with only spondylosis (107, 77.0%). Fifteen patients (10.8%) underwent reoperation because of myelopathy due to disc degeneration adjacent to the fused level (11 patients) or OPLL (4 patients). Anterior osteophytectomy with interbody fusion can achieve good outcomes in patients with cervical spondylotic myelopathy and radiculopathy, regardless of the size of the spinal canal and association with OPLL.

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Case Reports

Severe Tension Pneumocephalus Caused by Opening of the Frontal Sinus by Head Injury 7 Years After Initial Craniotomy

—Case Report—

Takashi KON, Hiroaki HONDO, Mitsuo KOHNO, Kazuma KASAHARA

2003 Volume 43 Issue 5 Pages 242-245
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.242

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A 46-year-old man presented with severe tension pneumocephalus triggered by mild head injury 7 years after craniotomy. He had a history of subarachnoid hemorrhage due to ruptured anterior communicating artery aneurysm, coating of the aneurysm performed via a craniotomy, and a ventriculoperitoneal (VP) shunt inserted. He fell from bed in a rehabilitation hospital. Eight hours after the injury, he became comatose and suffered general convulsion. He was then transferred to our hospital. Radiography and computed tomography (CT) revealed a large amount of intracranial air and a widely opened frontal sinus. On the day of admission, the shunt tube was ligated. Surgery was performed to repair the dura mater and close the frontal sinus. Postoperative CT revealed reduction in the amount of air and frontal sinus obstruction. The patient had a good postoperative course without meningitis. Tension pneumocephalus may occur as a complication several years after a craniotomy because of the chronic lowering of intracranial pressure induced by a VP shunt. Complete frontal sinus repair is important during the initial craniotomy.

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Aneurysm and Fenestration of the Azygos Anterior Cerebral Artery

—Case Report—

Satoshi IHARA, Kazuya UEMURA, Atsurou TSUKADA, Kiyoyuki YANAKA, Tadao ...

2003 Volume 43 Issue 5 Pages 246-249
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.246

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A 78-year-old female suffered sudden onset of nausea and headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage. Cerebral angiography demonstrated an aneurysm arising from the right A₁ segment of the azygos anterior cerebral artery, and the hypoplastic left A₁. A right frontotemporal craniotomy was performed to obliterate the aneurysm by neck clipping. Surgical exploration found the fenestration of the right A₁ and showed that the aneurysm had originated from the bifurcation of the fenestrated A₁ and a small perforating artery arising from the fenestration. This unusual combination of an aneurysm associated with a fenestration of the right A₁ and contralateral A₁ hypoplasia may have been caused by local hemodynamic stress.

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Large Vertebral Arteriovenous Fistula Treated With Stent-Grafts

—Case Report—

Akiyo SADATO, Tetsu SATOW, Akira ISHII, Motohiro TAKAYAMA, Nobuo HASHI ...

2003 Volume 43 Issue 5 Pages 250-254
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.250

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A 24-year-old woman presented with neck bruit and thrill. Neurological examination revealed no focal abnormality. Angiography and magnetic resonance imaging showed an arteriovenous fistula (AVF) at the C4-5 levels of the right vertebral artery (VA). The fistula had a single orifice that drained into the epidural veins via the C4-5 intervertebral foramen. A stent-graft was made of a 3.9 cm balloon-expandable stent and an expandable polytetrafluoroethylene graft sutured outside the stent. The stent-graft was advanced through the femoral artery up to the VA but did not pass far enough distally to seal the entire fistula because of the high friction between the bulky device and the small vessel. Another 2 cm stent-graft was delivered and successfully positioned across the fistula. The AVF completely disappeared and the right VA was well preserved. Follow-up angiography at 3 weeks and 5 months after the treatment showed no fistula and no stenosis inside the stent-grafts. Stent-grafts are useful to treat AVF with a large orifice. The stent-graft is a promising technology to treat neurovascular diseases, although improvement is required for use in smaller vessels.

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Brainstem Congestion Caused by Direct Carotid-Cavernous Fistula

—Case Report—

Hidetoshi MURATA, Takeshi KUBOTA, Masao MURAI, Hiroshi KANNO, Satoshi ...

2003 Volume 43 Issue 5 Pages 255-258
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.255

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A 41-year-old woman presented with tinnitus in the left ear and headache, followed by diplopia and pain in the left cheek. Angiography showed a left high-flow direct carotid-cavernous fistula (CCF), causing steal of the blood flow from the internal carotid artery into the cavernous sinus. A few days later, she rapidly developed right hemiparesis, dysarthria, and ocular conjugate deviation to the right, and became somnolent. Angiography at that time revealed occlusion of the superior petrosal sinus, causing engorgement of the veins in the surrounding brainstem. The CCF was completely embolized with interlocking detachable coils. Her consciousness disturbance and ophthalmoparesis dramatically improved within a few days, and the right hemiparesis and dysarthria gradually resolved. Magnetic resonance (MR) imaging after the treatment showed small pontine hemorrhage and perifocal edema but no ischemic lesions in the cerebral hemisphere. Re-evaluation of the MR imaging with gadolinium taken on admission demonstrated engorged veins in the brainstem parenchyma, which corresponded to the hemorrhagic lesion in the brainstem. Brainstem congestion caused by direct CCF is very rare, but it can be life-threatening. Good outcome can be expected if the CCF is completely occluded before congestive hemorrhage occurs.

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Panhypopituitarism Induced by Cholesterol Granuloma in the Sellar Region

—Case Report—

Kazuki YONEZAWA, Kunio SHIRATAKI, Yoshio SAKAGAMI, Eiji KOHMURA

2003 Volume 43 Issue 5 Pages 259-262
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.259

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A 67-year-old man with generalized fatigue and weight loss developed hyponatremia. Endocrinologic examination demonstrated panhypopituitarism. Magnetic resonance imaging showed a pituitary mass extending slightly to the suprasellar region. Transsphenoidal resection of the tumor was performed. Histological examination found exclusively granulomatous tissue with cholesterol clefts, and no epithelial component. This cholesterol granuloma may be classified as xanthogranuloma of the sellar region.

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Orbital Malignant Fibrous Histiocytoma With Extension to the Base of the Skull

—Case Report—

Ryo UEDA, Takuro HAYASHI, Kaori KAMEYAMA, Kazunari YOSHIDA, Takeshi KA ...

2003 Volume 43 Issue 5 Pages 263-266
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.263

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An 18-year-old woman presented with a malignant fibrous histiocytoma (MFH) originating in the orbit and invading the frontal and temporal base of the skull manifesting as exophthalmos and double vision that had persisted for 2 months. Magnetic resonance imaging revealed a tumor in the left orbit that extended as far as the frontal and temporal base of the skull. The tumor was treated by radical resection with conservation of the eyeball and its contents, followed by orbit wall reconstruction. The histological diagnosis was MFH. Local radiotherapy was administered postoperatively. The preoperative symptoms improved, and there has been no evidence of local recurrence or metastasis in the year since the surgery. In this case, radical resection of the tumor was essential. Furthermore, the adjuvant therapy was apparently successful, probably because this histological type of tumor is highly sensitive to radiotherapy.

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Fracture and Lateral Dislocation of the T12-L1 Vertebrae Without Neurological Deficit

—Case Report—

Kamil Melih AKAY, Alper BAYSEFER, Hakan KAYALI, Altay BEDUK, Erdener T ...

2003 Volume 43 Issue 5 Pages 267-270
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.267

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A 21-year-old man suffered T12-L1 vertebrae fracture and lateral dislocation without neurological deficit. Computed tomography and magnetic resonance imaging demonstrated the fracture and lateral dislocation of the thoracolumbar spine. The injured spine was realigned with rods and screws, and bony fusion of the affected vertebrae was performed. Patients with thoracolumbar fracture-dislocation without neurological deficit may suffer unintended neurological injury secondary to maneuvers that cause further dislocation of the spine. Severe spinal injury without neurological deficit should be evaluated in detail, especially with spinal computed tomography. Internal fixation and reduction are recommended if the patient's condition is suitable for surgery.

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Technical Note

Head and Neck Extension-Fixation With a Head Frame for Exposure of the Distal Internal Carotid Artery in Carotid Endarterectomy

—Technical Note—

Tomoji TAKIGAWA, Kiyoyuki YANAKA, Muneyoshi YASUDA, Hiroyuki ASAKAWA, ...

2003 Volume 43 Issue 5 Pages 271-273
Published: 2003
Released on J-STAGE: May 27, 2005

DOIhttps://doi.org/10.2176/nmc.43.271

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Adequate exposure of the distal internal carotid artery (ICA) for carotid endarterectomy may be difficult to achieve because of the position of the mandible and associated soft tissues. A simple yet effective use of a head frame is described to gain several centimeters of exposure of the distal ICA. The patient's head and neck are fixed in an extension position using a radiolucent head frame. Nasotracheal intubation and secure taping of the chin are also employed to keep the mouth closed and to prevent the mandible from spontaneously hanging down. The head frame tightly fixes the patient's neck, so the mandible does not disturb the surgical field throughout the operation. This simple method maximizes exposure of the distal ICA. The radiolucent head frame also enables intraoperative angiography to confirm the patency of the ICA and the absence of flap formation. This simple technique is useful for exposing the distal ICA.

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