Neurologia medico-chirurgica

Original Articles

Subdural Hyperintense Band on Diffusion-Weighted Imaging of Chronic Subdural Hematoma Indicates Bleeding From the Outer Membrane

Seikou KUWAHARA, Masaaki FUKUOKA, Yoko KOAN, Hirohisa MIYAKE, Yuko ONO ...

2005 Volume 45 Issue 3 Pages 125-131
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.125

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The diffusion-weighted magnetic resonance (MR) imaging characteristics of chronic subdural hematoma and the correlation between hematoma liquidity and apparent diffusion coefficient (ADC) were investigated in 26 consecutive patients, 16 males and 10 females aged 42 to 92 years (mean ± SD 73.3 ± 13.1 years), with 31 chronic subdural hematomas. The chronic subdural hematomas were divided into homogeneous, separate, and trabecular types based on diffusion-weighted MR imaging findings. Almost all hematomas were low intensity on diffusion-weighted imaging, and the mean ADC value was 1.81 ± 0.79 × 10^-3 mm²/sec. The high intensity areas in the subdural hematomas consisted of several types: high intensity line along the dura mater (subdural hyperintense band), high intensity along the intrahematoma septum, and laminar shape along the inner membrane. The subdural hyperintense bands accounted for almost all high intensity areas in the subdural hematomas. The mean ADC value of the high intensity areas was 0.76 ± 0.24 × 10^-3 mm²/sec, close to that of the normal brain. The subdural hyperintense bands were considered to be intracellular and/or extracellular methemoglobin based on the T₁- and T₂-weighted imaging and intraoperative findings. The subdural hyperintense band is an important finding indicating relatively fresh bleeding from the outer membrane. Diffusion-weighted imaging shows liquid subdural hematoma as low intensity, and measurement of the ADC values can differentiate between liquid and solid components of the chronic subdural hematoma.

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Management and Survival of Pineoblastoma: An Analysis of 34 Adults From the Brain Tumor Registry of Japan

John Y. K. LEE, Toshihiko WAKABAYASHI, Jun YOSHIDA

2005 Volume 45 Issue 3 Pages 132-142
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.132

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Pineoblastoma is a rare tumor in adults, and factors influencing survival are poorly understood. Data from the Brain Tumor Registry of Japan (BTRJ) was analyzed to examine patient, tumor, and treatment characteristics associated with increased survival in adults with pineoblastomas. All pineoblastoma cases in adults aged 16 years or older were identified in the BTRJ. Data were extracted on demographics, presentation, tumor characteristics, treatments, and outcomes. Kaplan-Meier plots, the log rank method, and p value <0.15 was used to screen variables for inclusion in a multivariate Cox regression estimating survival. In the final Cox multivariate model, all variables with p values <0.05 were considered significant predictors of survival, and all variables with p values 0.05-0.099 were considered trends. The BTRJ contained 34 adults with pineoblastomas diagnosed from 1969-1998. The patients were predominantly male (22 patients), with a median age of 35 years (range 16-66 years). Median survival from diagnosis was 25.7 months, with a median follow up of 20.5 months. Median surgical resection was 75-94%, and five of the 34 patients had gross total resection. Twenty-nine of the 34 patients received cranial irradiation therapy with a median dose of 50 Gy (range 30-70 Gy). In the final multivariate model, cranial irradiation ≥40 Gy (p = 0.014) and gross total resection (p = 0.034) were associated with improved survival. There was a trend towards improved survival for women (p = 0.099). Adult pineoblastoma patients have poor survival prognosis. Cranial irradiation therapy using at least 40 Gy and complete surgical resection are associated with improved survival.

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Case Reports

Incomplete Oculomotor Nerve Palsy Caused by an Unruptured Internal Carotid-Anterior Choroidal Artery Aneurysm

—Case Report—

Yasutaka KUROKAWA, Eri ISHIZAKI, Ken-ichi INABA

2005 Volume 45 Issue 3 Pages 143-147
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.143

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A 59-year-old woman visited our institute with the chief complaint of dizziness which persisted whenever she tried to focus on objects. She had not experienced apparent double vision and had no history of intracranial bleeding. Neurological examination revealed no abnormality except for exotropia at the mid-position and at upper gaze. Cerebral angiography revealed that the intracranial portion of the left internal carotid artery ran more horizontally and also identified an unruptured left internal carotid-anterior choroidal artery (IC-AChA) aneurysm of 3.0 mm diameter. The aneurysm at the origin of the AChA was confirmed during surgery. The proximal lateral wall of the aneurysm was in contact with the oculomotor nerve. This contact was released after complete obliteration of the aneurysm. The exotropia resolved 3 months later. Oculomotor nerve palsy usually indicates the presence of internal carotid-posterior communicating artery (IC-PcomA) aneurysm. Since sacrifice of the AChA will result in severe neurological deficits, accurate neuroimaging information is needed prior to the operation. Conventional angiography and/or three-dimensional computed tomography angiography should be performed to ascertain whether the aneurysm is an IC-PcomA or IC-AChA aneurysm, even if some neurosurgeons insist that conventional angiography is not always needed before surgery for an unruptured aneurysm.

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Spontaneous Intracranial Internal Carotid Artery Dissection Treated by Intra-arterial Thrombolysis and Superficial Temporal Artery-Middle Cerebral Artery Anastomosis in the Acute Stage

—Case Report—

Hideki OGIWARA, Keiichirou MAEDA, Takayuki HARA, Toshikazu KIMURA, Haj ...

2005 Volume 45 Issue 3 Pages 148-151
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.148

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A 22-year-old man presented with sudden onset of right retro-orbital headache followed by left hemiparesis. Right carotid angiography demonstrated almost total occlusion of the intracranial internal carotid artery (ICA) and severe stenosis of the middle cerebral artery (MCA), presumably caused by arterial dissection. Local arterial injection of urokinase was performed 2 hours after onset. The ICA became patent, but the M₂ portion of the MCA was still occluded, and the left hemiparesis did not improve. Superficial temporal artery-MCA anastomosis was immediately performed. The left hemiparesis disappeared completely 6 days after this procedure. Angiography 2 weeks after the onset revealed occlusion of the ICA, and maintenance of blood flow to the right cerebral hemisphere via the anastomosis. Magnetic resonance imaging showed small infarcts in the right cerebral cortex. Repeat angiography after 5 months showed recanalization of the right ICA and the right MCA. Combination of thrombolytic therapy and bypass surgery may be a useful treatment option for patients with sudden occlusion of the intracranial artery caused by dissection.

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Three-Dimensional Computed Tomography Angiography for the Investigation of Superficial Temporal Artery Pseudoaneurysms

—Two Case Reports—

Takuya HIGASHINO, Masatou KAWASHIMA, Hiromichi MANNOJI

2005 Volume 45 Issue 3 Pages 152-155
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.152

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An 89-year-old man and a 60-year-old man presented with superficial temporal artery (STA) pseudoaneurysms which developed secondary to trauma. Conventional cerebral angiography and three-dimensional computed tomography (3D CT) angiography clearly demonstrated the STA pseudoaneurysms. The patients underwent surgical excision of the aneurysms based on the conventional cerebral angiography findings in one patient and 3D CT angiography findings in other patient. 3D CT angiography is an excellent noninvasive diagnostic method for detecting extracranial aneurysms such as STA pseudoaneurysm, especially the relationship between the aneurysm and surrounding structures, including the calvarium.

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Primary Cerebral Angiitis Containing Marked Xanthoma Cells With Massive Intraparenchymal Involvement

—Case Report—

Eiichi ISHIKAWA, Koji TSUBOI, Shingo TAKANO, Hiroshi KIMURA, Tsukasa A ...

2005 Volume 45 Issue 3 Pages 156-160
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.156

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A 27-year-old woman was referred to our hospital with mild disorientation, bilateral abducens nerve palsy, and mild left hemiparesis. Magnetic resonance (MR) imaging revealed diffuse mass lesions resembling malignant glioma in the right frontal intraparenchymal region, with enhancement of multiple meningeal and intraparenchymal nodules. Partial resection of the frontal lesion was performed. Histological examination revealed that the specimens consisted of brain tissue, with marked perivascular infiltration of histiocytes and sheets of xanthomatous cells. The diagnosis was primary cerebral angiitis containing marked xanthoma cells. Steroid therapy was administered over 1 week. MR imaging showed that the remaining lesions resolved gradually, and had disappeared 2 years after surgery. No neurological symptoms or recurrence of the tumor has been observed during the 6-year period since the operation.

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Stereotactic Radiosurgery for Recurrent Pleomorphic Adenoma Invading the Skull Base

—Case Report—

Tohru KAMIDA, Tatsuya ABE, Ryo INOUE, Hidenori KOBAYASHI, Masashi SUZU ...

2005 Volume 45 Issue 3 Pages 161-163
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.161

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A 38-year-old man presented with a recurrent pleomorphic adenoma in the parapharyngeal space invading the skull base 19 years after the first operation for a parotid gland tumor. Stereotactic radiotherapy was performed to control the tumor growth using a marginal dose of 8 Gy and maximum dose of 18 Gy with care taken to minimize the dose to nearby structures. The symptoms were reduced within a few months. Magnetic resonance imaging over 5 years showed that the tumor was controlled with no regrowth. Stereotactic radiotherapy is a therapeutic option for the treatment of pleomorphic adenomas.

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Giant Intrasellar Arachnoid Cyst Manifesting as Adrenal Insufficiency Due to Hypothalamic Dysfunction

—Case Report—

Keitaro YASUDA, Youichi SAITOH, Kohei OKITA, Shayne MORRIS, Makoto MOR ...

2005 Volume 45 Issue 3 Pages 164-167
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.164

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A 67-year-old man first noticed loss of pubic and axillary hair in 1992 and then a visual field defect in 2001. He experienced loss of consciousness attributed to hyponatremia in April 2002. Magnetic resonance imaging showed a giant intrasellar cystic mass, 40 mm in diameter, that had compressed the optic chiasm. The patient complained of chronic headache, and neurological examination revealed bitemporal hemianopsia. Preoperative endocrinological examination indicated adrenal insufficiency, and hypothyroidism due to hypothalamic dysfunction. The patient underwent endonasal transsphenoidal surgery. The cyst membrane was opened and serous fluid was drained. Histological examination identified the excised cyst membrane as arachnoid membrane. The patient’s headaches resolved postoperatively, but the bitemporal hemianopsia and endocrinological function were unchanged. This arachnoid cyst associated with hypothalamic dysfunction might have been caused by an inflammatory episode in the suprasellar region.

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Spinal Tanycytic Ependymoma With Hematomyelia

—Case Report—

Kazufumi SATO, Toshihiko KUBOTA, Masaki ISHIDA, Yuji HANDA

2005 Volume 45 Issue 3 Pages 168-171
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.168

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A 58-year-old man presented with an extremely rare case of “pure type” spinal tanycytic ependymoma associated with hematomyelia manifesting as sensory disturbance of the bilateral hands and weakness of the right arm. Magnetic resonance imaging demonstrated a tumor in the spinal cord from C-2 to C-4 levels. The soft gelatinous tumor was subtotally resected and the adjacent chronic liquid hematoma was aspirated. The immunohistochemical and ultrastructural findings indicated a diagnosis of tanycytic ependymoma.

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Knife Blade Penetrating Stab Wound to the Brain

—Case Report—

Masaki IWAKURA, Tetsuro KAWAGUCHI, Kohkichi HOSODA, Yuji SHIBATA, Hide ...

2005 Volume 45 Issue 3 Pages 172-175
Published: 2005
Released on J-STAGE: March 22, 2005

DOIhttps://doi.org/10.2176/nmc.45.172

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A 28-year-old man attempted to kill himself with a knife stab into the parietal area. Neuroimaging showed no vascular impairment except slow venous flow around the knife due to tamponading. After obtaining informed consent, the knife was removed through a craniotomy without new brain injury. Postoperative neurological findings showed no deficit. Follow-up angiography revealed no vascular impairment. No infection occurred. Brain stab wounds cause numerous complications, such as intracranial hemorrhage, injury of important vessels, and infections. Minimal blade movement during removal and precautions to prevent massive hemorrhage are essential.

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