Neurologia medico-chirurgica

Original Articles

Intraoperative Hemodynamic Measurements of the Vertebral Artery and Common Carotid Artery

Yoshikazu OKADA, Takeshi SHIMA, Masahiro NISHIDA, Kanji YAMANE, Itsuo ...

2004 Volume 44 Issue 10 Pages 509-515
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.509

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The hemodynamics in the vertebrobasilar artery (VBA) system were investigated in patients with vertebrobasilar insufficiency (VBI). Vertebral artery (VA) stump pressure and blood flows in the VA and common carotid artery (CCA) were intraoperatively measured in 45 patients who underwent surgical correction of the first segment of the VA (V₁) for angiographic tortuosity, kinking, and/or stenosis manifesting as symptomatic VBI. The effects of changes in the systemic arterial blood pressure (SABP) induced by trimethaphan, phenylephrine, and cervical epidural anesthesia were also investigated. The VA stump pressure was 79.3 ± 13.6 (mean ± SD) mmHg and the ratio of the VA stump pressure to the SABP was 0.87 ± 0.08. The baseline values were SABP 90.5 ± 10.1 mmHg, VA blood flow 53.4 ± 33.0 ml/min, and CCA blood flow 204.3 ± 50.3 ml/min. During changes in the SABP, autoregulation of the blood flow in the VA appeared tighter than in the CCA. During cervical epidural anesthesia, blood flows in both the VA and CCA were significantly reduced in response to SABP reduction. This study demonstrated that the VBA system maintains excellent autoregulation with good collateral flows and cervical sympathetic nerve function. However, this autoregulatory capacity may be overwhelmed by unexpected occlusion of the VA due to postural changes associated with tortuosity, kinking, and/or stenosis of the V₁ segment.

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Detection of Enlarged Cortical Vein by Magnetic Resonance Imaging Contributes to Early Diagnosis and Better Outcome for Patients With Anterior Cranial Fossa Dural Arteriovenous Fistula

Mohammad A. JAMOUS, Koichi SATOH, Junichiro SATOMI, Shunji MATSUBARA, ...

2004 Volume 44 Issue 10 Pages 516-521
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.516

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Twelve patients (10 men, 2 women) with anterior cranial fossa dural arteriovenous fistula (AVF) were treated at our institute between January 1976 and March 2002. Intracranial hemorrhage was the presenting symptom in six patients. Magnetic resonance (MR) imaging findings identified abnormal cortical veins as flow voids in four of five patients. Angiography was the basis of the diagnosis in all patients. Surgery was the primary treatment in nine patients. The other three patients refused intervention and managed conservatively. Surgical morbidity was negligible and the treatment outcome was highly dependent on the clinical status at presentation. In contrast to the reported high incidence of intracranial hemorrhage in patients with dural AVF in the anterior cranial fossa, only half of our study population presented with hemorrhage. Enlarged cortical veins in the frontobasal area could be detected as flow voids on MR images. This finding contributed to the early diagnosis and treatment of patients treated at our institution for dural AVF in the anterior cranial fossa, and to the better outcomes we obtained in these patients.

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Frameless Stereotactic Surgery Using Intraoperative High-Field Magnetic Resonance Imaging

Christopher NIMSKY, Atsushi FUJITA, Oliver GANSLANDT, Boris von KELLER ...

2004 Volume 44 Issue 10 Pages 522-534
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.522

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This study evaluated the clinical validity of frameless stereotaxy using high-field intraoperative magnetic resonance (iMR) imaging combined with an in-room neuronavigation system. A 1.5 Tesla MR scanner in conjunction with a ceiling-mounted neuronavigation system was used during 32 frameless stereotaxy procedures consisting of 19 brain biopsies and 13 catheter placements between April 2002 and mid-October 2003. Evaluation of the procedure was based on either the rate of histological diagnostic yield or the ability to accurately position the catheter in the target region. This technique allowed successful registration with a mean error of 1.2 ± 0.8 mm and resulted in successful placement of the instrument within the target tissue. Intraoperatively, frozen section analysis showed all biopsy samples contained pathological tissue and locations of sampling points were confirmed by iMR imaging. Specific final diagnosis was made in all 19 brain biopsies. The tip of the catheter was successfully placed into the target in all 13 patients confirmed by iMR imaging. The catheter was repositioned based on iMR imaging in four of 13 patients, increasing the rate of successful placement. There were no procedure-related neurological deficits or mortality, but we encountered two cases of wound infection, one needing surgical revision. Total additional procedure time related to the induction of iMR imaging was 76.7 ± 23.3 minutes. This initial experience of the combination of conventional frameless stereotaxy and high-field iMR imaging improved the quality of frameless stereotaxy with low morbidity and mortality, but did not translate into a significant reduction of procedure-related time.

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Case Reports

Cerebral Infarction and Fluid Collection Due to an Enlarged Dissecting Aneurysm of the Middle Cerebral Artery

—Case Report—

Hideo IIDA, Mari KUSUMI, Takao SAGIUCHI, Tetsuo MITOMI

2004 Volume 44 Issue 10 Pages 535-539
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.535

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A 53-year-old man presented with cerebral infarction associated with a dissecting aneurysm of the left middle cerebral artery (MCA), with enlargement and fluid collection. Anticoagulant therapy was performed as the first stage treatment for cerebral infarction. Serial magnetic resonance imaging showed that the dissecting aneurysm had enlarged and fluid collection adjacent to the aneurysm had developed since the first admission. Surgery was performed to ligate the MCA proximal to the aneurysm. Intraoperative findings showed the branch of the MCA was obstructed by intramural hemorrhage of the aneurysm dome. Histological examination showed direct obstruction of the MCA branch artery by intramural hemorrhage of aneurysm dome had caused the cerebral infarction and the fluid collection surrounding the aneurysm resulted from minor leakage or exudation of intramural hemorrhage to the outer surface of the dissecting aneurysm.

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Intracranial Atypical Fibromuscular Dysplasia With Ruptured Aneurysm

—Case Report—

Hiroshi OOBA, Yu TAKEDA, Yoshie KATO, Hikaru MARUIWA, Hidenori KOBAYAS ...

2004 Volume 44 Issue 10 Pages 540-543
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.540

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A 53-year-old woman was admitted with severe subarachnoid hemorrhage due to rupture of an aneurysm associated with atypical intracranial fibromuscular dysplasia (FMD). Angiography demonstrated the aneurysm and very irregular form of the left internal carotid artery (ICA), the right ICA, and right proximal middle cerebral artery (MCA). Other arteries showed signs of atherosclerosis. The aneurysm was treated by embolization, but she subsequently died of shock of unknown cause. Detailed examination of serial angiograms detected enlargement of the aneurysm and progression of the irregular appearance of the ICA. FMD is a non-inflammatory and non-atheromatous arteriopathy that commonly affects the cervical ICA and sometimes the intracranial ICA. The association with saccular aneurysm is widely known and the prevalence of incidental aneurysms is higher than that in the general population. The common “string of beads” finding is easily distinguished from other vascular diseases, but non-specific findings such as “tubular stenosis” and “diverticular-like outpouching” are harder to differentiate. FMD is associated with various complications and appropriate periodic follow-up examination is required. Detailed analysis of serial angiograms may facilitate diagnosis of this condition.

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Stent-Supported Coil Embolization for Carotid Artery Pseudoaneurysm as a Complication of Endovascular Surgery

—Case Report—

Masaomi KOYANAGI, Shogo NISHI, Itaro HATTORI, Fumihiko HORIKAWA, Koich ...

2004 Volume 44 Issue 10 Pages 544-547
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.544

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A 57-year-old male presented with right amaurosis fugax and left transient ischemic attack caused by stenosis of the intracranial segment of the right internal carotid artery (ICA). Percutaneous transluminal angioplasty with stenting was successfully performed to dilate the stenosis. However, serial angiography revealed the development of a large pseudoaneurysm in the cervical ICA, probably as a result of carotid wall injury caused by the guiding catheter during the procedures. The patient underwent a second endovascular angioplasty. A Palmaz stent was placed across the aneurysm neck to stabilize the carotid wall. Guglielmi detachable coils were then inserted into the aneurysm cavity through the stent struts to successfully obliterate the aneurysm. Both the angiographical results and the patient's outcome were favorable. Stent-supported coil embolization is an effective and safe technique for medically refractory pseudoaneurysms, and may be a useful alternative to direct surgery.

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Spontaneous Carotid-Cavernous Fistula in a Patient With Ehlers-Danlos Syndrome Type IV

—Case Report—

Takashi MITSUHASHI, Masakazu MIYAJIMA, Rikizou SAITOH, Yasuaki NAKAO, ...

2004 Volume 44 Issue 10 Pages 548-553
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.548

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A 30-year-old female complained of sudden onset of severe proptosis, chemosis, diplopia, and bruit. Right carotid angiography showed a high-flow direct carotid-cavernous fistula (CCF) draining into the engorged superior ophthalmic vein, inferior petrosal sinus, and pterygoid plexus. The patient experienced retroperitoneal bleeding from a ruptured right renal artery after undergoing cerebral angiography. We suspected Ehlers-Danlos syndrome (EDS) type IV, which was confirmed by showing cultured fibroblasts failed to secrete procollagen type III. Endovascular surgery cannot be considered the treatment method of choice in view of the fragility of the arteries and veins in patients with EDS type IV. We treated our patient with extracranial internal carotid artery ligation. Currently, there is no ideal treatment for CCF in patients with EDS type IV. Since CCF is rarely life-threatening, the investigative approach and course of treatment must consider the associated vascular fragility.

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Posterior Circumferential Decompression for Late Onset Paraparesis Caused by Kyphotic Deformity Due to Infantile Tuberculosis

—Case Report—

Takashi ASAZUMA, Yoshiaki TOYAMA, Nobumasa SUZUKI, Yoshikazu FUJIMURA

2004 Volume 44 Issue 10 Pages 554-557
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.554

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A 46-year-old male presented with late onset of paraparesis caused by kyphotic deformity due to infantile tuberculosis. A posterior circumferential decompression was performed from the sixth thoracic to the eighth thoracic levels. His neurological status improved with no evidence of kyphosis progression at the last follow up (2 years 5 months postoperatively). The paraparesis was caused by bony compression following increasing kyphosis above and below the block vertebrae due to growth. Posterior circumferential decompression is a less invasive surgical intervention for this condition.

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Terminal Syringomyelia: Is It As Innocent As It Seems?

—Case Report—

Hakan EMMEZ, Çagatay GÜVEN, Gökhan KURT, Özg&uum ...

2004 Volume 44 Issue 10 Pages 558-561
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.558

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A 5-day-old newborn girl presented with cutaneous signs of hypertrichosis, skin dimple, and subcutaneous lipoma in the lumbar region. Magnetic resonance (MR) imaging of the thoracolumbar spine demonstrated spinal dermal sinus, type II split cord malformation, and tethered cord. A small terminal syringeal cavity was also present. Five months after the diagnosis, weakness in dorsal flexion of the bilateral feet and toes was detected. Surgery to untether the cord was performed. Her deficits resolved completely. Nearly 4 years later, she was admitted with weakness in dorsal flexion of the right foot and toe. MR imaging of the spine showed holocord syringomyelia, postoperative changes, and tethered cord. No Chiari malformation was seen. Syringosubarachnoid shunt placement was performed. Terminal syringomyelia is common in cases of occult spinal dysraphism, but the natural history and management remain unclear. Progression, regression, or persistence of terminal syringeal cavity can occur whether untethering is performed or not. Progression of the terminal syrinx occurred after tethered cord release and the enlargement of the cavity involved the entire spinal cord in the present case. Terminal syringomyelia requires close follow up for a long time even in asymptomatic cases. Surgical treatment should be considered in symptomatic cases.

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Brucellar Spine Infection

—Four Case Reports—

Mehmet TURGUT, Emre ÇULLU, Ömer Faruk SENDUR, Gülcan ...

2004 Volume 44 Issue 10 Pages 562-567
Published: 2004
Released on J-STAGE: February 05, 2005

DOIhttps://doi.org/10.2176/nmc.44.562

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Brucellosis can be difficult to diagnose because of the nonspecific and variable clinical picture. This systemic disease is still an important public health problem in the Mediterranean Basin. These four cases of brucellar spine infection originated from rural areas around Aydin, Turkey. The systemic complaints of fever, profuse sweating, malaise, polyarthromyalgia, and weight loss indicated the final diagnosis of brucellosis and presumptive diagnoses were made based on agglutination testing for brucellosis. Computed tomography and magnetic resonance imaging indicated signs of bone infection and soft tissue involvement. Good outcomes were obtained with prolonged treatment with anti-brucellar drugs including streptomycin, rifampicin, and tetracycline. Early diagnosis is important and prompt antibrucellar chemotherapy is effective in most cases, but prolonged follow up is necessary in all patients with spinal brucellosis.

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