Neurologia medico-chirurgica

Review Articles

“Sulcal Root” Generic Model: a Hypothesis to Overcome the Variability of the Human Cortex Folding Patterns

Jean RÉGIS, Jean-François MANGIN, Taku OCHIAI, Vincent F ...

2005 Volume 45 Issue 1 Pages 1-17
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.1

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The great variability of cerebral cortical folding patterns raises major problems for the systematic study of functional-structural relationships. This paper describes a novel perspective for explaining this variability, a perspective that relies on gyri buried in the depth of the sulci. From this perspective we propose a generic model of folding, based on indivisible units, called sulcal roots, which correspond to the first folding locations during antenatal life. These units are organized according to a basic scheme allowing us to describe the cortical surface using a system of meridians and parallels. This scheme is thought to be stable across individuals at the fetal stage, and may be related to the protomap model. Variability at the adult stage is thought to result from the chaotic behavior of the folding process: inter-individual differences in cortical areas can lead to qualitatively different folding patterns. We have tested the capacity of this model to match actual cortical anatomy with a database of magnetic resonance images of 20 normal subjects, using new three-dimensional visualization tools giving access to shapes buried in the cortex.

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National Healthcare Spending in the U.S. and Japan: National Economic Policy and Implications for Neurosurgery

James R. BEAN

2005 Volume 45 Issue 1 Pages 18-24
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.18

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Growth of national healthcare spending is a problem confronting national governments of all industrially advanced countries. Healthcare spending in the U.S. reached 13.9% of the Gross Domestic Product (GDP) in 2003, compared to only 8% in Japan. In the U.S., health insurance is voluntary, with 15% of the population uninsured. In Japan, health insurance is mandatory and virtually universal, with growth in national health costs about half the rate of growth in the U.S.
U.S. healthcare costs are projected to reach 18.4% of GDP 2013. The predicted growth in health care costs is expected to cause strain on the federal budget and a growing inability of employers and employees to pay for private insurance.
Different national policies are the reason for different national health care costs in the U.S. and Japan. The U.S. has higher healthcare prices for salaries, equipment, supplies, and pharmaceuticals as compared to Japan. Higher prices, higher service intensity and volume during hospitalization create higher total cost in the U.S. Price controls in Japan kept medical inflation low at 0.46%/yr from 1980-2000.
Market-pricing mechanisms in the U.S. have proven ineffective in controlling national healthcare costs, while Japan’s national fee and price control policies have kept national costs among the lowest within the Organization for Economic Cooperation and Development. To guide insurance coverage policy, neurosurgery and other highly technical specialties should better define the comparative health benefit of high price technical services by prospective outcome studies.

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Original Articles

Surgical Anatomy of the Cervical Carotid Artery for Carotid Endarterectomy

Nakamasa HAYASHI, Emiko HORI, Yuko OHTANI, Osamu OHTANI, Naoya KUWAYAM ...

2005 Volume 45 Issue 1 Pages 25-30
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.25

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Carotid endarterectomy (CEA) is the main treatment for atherosclerotic plaque of the cervical internal carotid artery. The surgical anatomy of the carotid arteries was studied in the carotid triangle of 49 cadavers. The carotid bifurcation was located at the level of the lower third of C-3. The superior thyroid artery arose from the anterior wall of the external carotid artery in 70% of specimens and from the distal portion of the common carotid artery in 30%. The lingual artery arose as a separate trunk between the origins of the superior thyroid and facial arteries in 81% of specimens, with the facial artery from a common trunk in 18%, and with the superior thyroid artery in 1%. The occipital artery arose from the posterior aspect of the external carotid artery above the level of origin of the facial artery in 57% of specimens, between the origins of the facial and lingual arteries in 32%, and below the origin of the lingual artery in 11%. The origin of the occipital artery was positioned low and the distal portion of the occipital artery was crossed by the hypoglossal nerve in 20%. The ascending pharyngeal artery arose from the posterior wall of the external carotid artery above the level of origin of the lingual artery in 66% of specimens, below the origin of the lingual artery in 9%, from the proximal portion of the occipital artery in 19%, from the carotid bifurcation in 2%, and from the internal carotid artery in 2%. The branches of the external carotid artery are the key landmarks for adequate exposure and appropriate placement of cross-clamps on the carotid arteries. It is necessary to understand the surgical anatomy of the carotid arteries to carry out successful removal of plaque and minimize postoperative complications in a bloodless surgical field.

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Reduction of Blood Flow in the Brain Stem and Cerebellum Caused by Petroclival Tumors

Mikhail F. CHERNOV, Tatyana Yu. SKVORTZOVA, Zorya L. BRODSKAYA

2005 Volume 45 Issue 1 Pages 31-36
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.31

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Blood flow in the brain stem (BSBF) and cerebellum (CerBF) was investigated by positron emission tomography in 12 patients with petroclival tumors (study group) and 14 healthy volunteers (control group). ¹⁵O-labeled water was used as the radioisotope tracer. BSBF and ipsilateral CerBF were significantly lower in the study group compared with the control group (p < 0.005). Five of 12 patients in the study group exhibited more than 20% reduction of CerBF ipsilateral to the tumor, whereas no such asymmetry was disclosed in any subject in the control group (p < 0.01). Sex, age, and tumor histology had no statistically significant association with the level of BSBF. Ipsilateral CerBF was significantly lower in patients with vestibular schwannomas, compared to those with sphenopetroclival meningiomas (p < 0.025). No statistically significant association between BSBF and the type of postoperative course was found, whereas four of the five patients with more than 20% reduction of CerBF ipsilateral to the tumor had prominently increased cerebellar ataxia after removal of the neoplasm. Preoperative investigation of the cerebral blood flow may be important for the prediction of outcome after surgical resection of petroclival tumors.

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Case Reports

Combined Surgical and Endovascular Treatment of Infected Pseudoaneurysm After Carotid Endarterectomy

—Case Report—

Hiroshi YASUDA, Satoshi KURODA, Satoshi USHIKOSHI, Tsutomu KATO, Kiyoh ...

2005 Volume 45 Issue 1 Pages 37-40
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.37

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A 67-year-old male presented with a rare pseudoaneurysm caused by infection after carotid endarterectomy (CEA) performed for stenosis of the left internal carotid artery (ICA). Wound infection and recurrent bleeding from the operated ICA developed 1 month after surgery. Serial angiography showed that the post-CEA pseudoaneurysm gradually increased in size. The carotid balloon occlusion test revealed that the patient could not tolerate permanent ICA occlusion because of poorly developed collaterals. Direct surgical exposure of the aneurysm was impossible due to tight adhesion of the surrounding tissue, so common carotid to middle cerebral artery bypass using a radial artery graft was performed followed by ligation of the distal common carotid artery. Subsequently, retrograde blood flow from the ICA to the aneurysm was interrupted by embolization of the external carotid artery coil through the facial artery. Combined surgical and endovascular treatment is a therapeutic option for patients with post-CEA pseudoaneurysm, if either direct or endovascular surgery is unfeasible.

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Very Late Onset of Chronic Subdural Hematoma

—Case Report—

Mitsuo SATO, Masayuki NAKANO, Jinichi SASANUMA, Jun ASARI, Kazuo WATAN ...

2005 Volume 45 Issue 1 Pages 41-43
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.41

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A 56-year-old man developed subdural effusion after mild head trauma, which remained unchanged in volume and density on computed tomography during a follow-up period of 7 months. However, typical chronic subdural hematoma (CSDH) had developed by 9 months after the head trauma. The CSDH was successfully treated by irrigation and drainage. This unusually delayed onset of CSDH suggests that we should be aware of the possibility of very late onset of CSDH in patients with persistent asymptomatic subdural effusion.

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Metastatic Leiomyosarcoma of the Brain Manifesting as Multiple Hemorrhages

—Case Report—

Naoyuki ISOBE, Shuichi OKI, Masayuki SUMIDA, Yukari KANOU, Shinya NABI ...

2005 Volume 45 Issue 1 Pages 44-48
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.44

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A 74-year-old man presented with a rare metastatic leiomyosarcoma of the brain manifesting as subacute development of multiple cerebral hemorrhages. Cerebral angiography demonstrated no tumor staining or vascular malformation. Whole body computed tomography revealed abnormal masses in the liver, left adrenal gland, and duodenum. Histological examination of an open biopsy specimen identified the lesion as metastatic leiomyosarcoma. Whole brain irradiation controlled the intracranial lesions, but the patient’s general condition progressively deteriorated and he died of pneumonia. Metastatic leiomyosarcoma is a very uncommon tumor in the central nervous system with a poor response to existing treatment options. Consequently, new approaches to the treatment of this disease are needed.

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Biopsy of Brain Stem Glioma Using Motor-Evoked Potential Mapping by Direct Peduncular Stimulation and Individual Adjuvant Therapy

—Case Report—

Satoshi TANAKA, Ikuo KOBAYASHI, Satoshi UTSUKI, Kazuhisa IWAMOTO, Junk ...

2005 Volume 45 Issue 1 Pages 49-55
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.49

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A 23-year-old man presented with a brain stem glioma manifesting as a 6-month history of right hemiparesis and diplopia. Serial magnetic resonance imaging showed an intrinsic diffuse brain stem glioma that gradually localized to the left cerebral peduncle after initial adjuvant therapy. Surgery was performed through a left subtemporal transtentorial approach under motor-evoked potential (MEP) mapping by direct peduncular stimulation. The lateral aspect of the midbrain was exposed, a train of five bipolar 25 mA pulses was applied, and MEPs recorded from the extremities. MEPs were only recorded from the left extremities even with left cerebral peduncular stimulation. Partial resection of the tumor was safely performed, with slight temporary neurological worsening. The histological diagnosis was anaplastic astrocytoma. Individual adjuvant therapy based on the results of real-time reverse transcription-polymerase chain reaction of O⁶-methylguanine-deoxyribonucleic acid methyltransferase achieved an almost complete tumor response. Surgery under pyramidal tract mapping and intensive postoperative adjuvant therapy resulted in a good outcome despite the presence of a generally intractable intrinsic brain stem glioma.

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Myositis Ossificans of the Temporal Muscle as a Primary Scalp Tumor

—Case Report—

Yuji UEMATSU, Hiroki NISHIBAYASHI, Kohji FUJITA, Hiroyuki MATSUMOTO, T ...

2005 Volume 45 Issue 1 Pages 56-58
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.56

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A 38-year-old woman presented with a rare case of myositis ossificans in the temporal muscle manifesting as left temporal scalp mass with mild pain. The mass was elastic-hard and seemed to be located in the temporal muscle. Magnetic resonance imaging revealed a heterogeneously enhanced mass in the muscle. The tumor was resected. The histological diagnosis was myositis ossificans. The clinicopathological features of scalp myositis ossificans may mimic other soft tissue tumors, requiring care for the differential diagnosis.

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Intracranial Localized Castleman’s Disease

—Case Report—

Ken-ichi MATSUMURA, Satoshi NAKASU, Toshiki TANAKA, Hirofumi NIOKA, Ma ...

2005 Volume 45 Issue 1 Pages 59-65
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.59

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A 68-year-old woman presented with generalized clonic seizure following a 2-month history of initiative loss, incoherent speech, headache, and left hemiparesis. No systemic signs or symptoms were seen and laboratory studies were within normal range. Computed tomography and magnetic resonance imaging demonstrated a well-delineated small mass with homogeneous enhancement in the right parietal convexity, associated with unusually extensive perifocal edema compared to the size of the mass. Cerebral angiography showed a faint stain fed by the middle meningeal artery. These imaging features were very similar to those of meningioma. Full recovery from the symptoms was achieved by total removal of the lesion and no recurrence was found after 3 years. Histological examination identified the hyaline-vascular type of angiofollicular lymph node hyperplasia (Castleman’s disease). Castleman’s disease involving the central nervous system is rare, with only 12 previous cases, but should be considered in the diagnosis of intracranial meningeal tumors. The treatment of choice for localized Castleman’s disease is complete surgical resection, which is curative in most of the cases.

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Spinal Epidural Abscess Caused by Brucellosis

—Two Case Reports—

Özkan ATES, Suleyman R. ÇAYLI, Ayhan KOÇAK, Ramazan ...

2005 Volume 45 Issue 1 Pages 66-70
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.66

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Brucellosis is still an important public health problem in the Mediterranean countries, including Turkey, and is most probably underdiagnosed or underreported. Two rare cases of extradural brucellar granuloma causing spinal cord compression in the thoracic and cervical regions were identified by magnetic resonance imaging. The abscesses were totally excised surgically. Medical treatment was given immediately after diagnosis, but delayed neurosurgical intervention resulted in partial neurological recovery in one patient although the other showed complete neurological recovery. Abscess formation may cause myelopathy due to extradural compression of the spinal cord. Failure to correct this condition may cause irreversible impairment of motor functions. Magnetic resonance imaging should be performed periodically in patients with brucellosis and suspected vertebral involvement to monitor for epidural granuloma formation and prevent extradural cord compression.

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Supplementary Comment on “Histological Study of the Normal Vertebral Artery —Etiology of Dissecting Aneurysms—”

Daniel L. BARROW

2005 Volume 45 Issue 1 Pages 71
Published: 2005
Released on J-STAGE: January 28, 2005

DOIhttps://doi.org/10.2176/nmc.45.71

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