Neurologia medico-chirurgica

Review Article

Hypothalamic Hamartoma

Kazunori ARITA, Kaoru KURISU, Yoshihiro KIURA, Koji IIDA, Hiroshi OTSU ...

2005 Volume 45 Issue 5 Pages 221-231
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.221

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The incidence of hypothalamic hamartomas (HHs) has increased since the introduction of magnetic resonance (MR) imaging. The etiology of this anomaly and the pathogenesis of its peculiar symptoms remain unclear, but recent electrophysiological, neuroimaging, and clinical studies have yielded important data. Categorizing HHs by the degree of hypothalamic involvement has contributed to the accurate prediction of their prognosis and to improved treatment strategies. Rather than undergoing corticectomy, HH patients with medically intractable seizures are now treated with surgery that targets the HH per se, e.g. HH removal, disconnection from the hypothalamus, stereotactic irradiation, and radiofrequency lesioning. Although surgical intervention carries risks, total eradication or disconnection of the lesion leads to cessation or reduction of seizures and improves the cognitive and behavioral status of these patients. Precocious puberty in HH patients is safely controlled by long-acting gonadotropin-releasing hormone agonists. The accumulation of knowledge regarding the pathogenesis of symptoms and the development of safe, effective treatment modalities may lead to earlier intervention in young HH patients and prevent the decline in their cognitive abilities and quality of life. This review of hypothalamic hamartomas presents current classifications, pathophysiologies, and treatment modalities.

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Original Articles

Clinical and Radiological Prognostic Factors of Anaplastic Oligodendroglioma Treated by Combined Therapy

Seok-Gu KANG, Jong Hyun KIM, Do Hyun NAM, Kwan PARK

2005 Volume 45 Issue 5 Pages 232-239
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.232

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The clinical and radiological prognostic factors were investigated in 32 patients with newly diagnosed anaplastic oligodendroglioma treated by combined therapy using surgery, postoperative radiation therapy, and adjuvant chemotherapy between September 1994 and December 2002. Surgery aimed at total removal was followed by radiotherapy, and 3 weeks later by adjuvant chemotherapy repeated at 6- to 7-week intervals. Survival analysis showed that younger age, absence of preoperative headache, good postoperative Karnofsky Performance Status (KPS) score (≥80), and relatively small tumor volume (<50 cm³) were predictors for longer survival in univariate analysis (p < 0.05). Age and good postoperative KPS score were independent prognostic factors in multivariate analysis (p < 0.05). Median survival was 58 months after diagnosis, and the 5-year survival rate was 49%.

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Surgical Treatment for Ulnar Nerve Entrapment at the Elbow

Shunji ASAMOTO, Dieter-Karsten BÖKER, Andreas JÖDICKE

2005 Volume 45 Issue 5 Pages 240-245
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.240

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The outcomes of 81 operations were assessed for the treatment of ulnar nerve entrapment at the elbow performed on 55 males (bilateral operations in one) and 25 females during the period from January 1995 to December 2000. Before operation, neurophysiological examination was performed in all patients. Simple ulnar nerve decompression or anterior transposition of the ulnar nerve (subcutaneous or intramuscular) was performed with or without the operating microscope. Nine patients were lost to follow up. The outcome was excellent or good in 63 of 72 cases, no change in eight cases, and poor in one case. The outcomes of procedures performed with the operating microscope tended to be superior.

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Case Reports

Unusual Variant of the Anterior Cerebral Artery

—Case Report—

Nobuyuki MARUYAMA, Atsushi FUKUMA, Ikuo IHARA, Seiichi ANDO, Toshiki Y ...

2005 Volume 45 Issue 5 Pages 246-248
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.246

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A rare abnormality of the A₁ segment of the anterior cerebral artery (ACA) is reported. The right ACA bifurcated into two parts at the middle point of the A₁ segment, and these segments did not rejoin. The superior right A₁ segment connected with the left A₁ and formed a single pericallosal artery. The inferior right A₁, from which the right ophthalmic artery originated, had no connection with the left A₁.

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Postoperative Rupture of an Untreated Aneurysm on the 3rd Day After Subarachnoid Hemorrhage Surgery

—Case Report—

Yuji HASHIMOTO, Yoshifumi HORITA, Toshio IMAIZUMI, Jun NIWA

2005 Volume 45 Issue 5 Pages 249-252
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.249

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A 58-year-old male presented with severe consciousness disturbance and left hemiparesis. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) and acute subdural hematoma caused by a ruptured right middle cerebral artery aneurysm. The aneurysm was clipped and the hematoma was evacuated. The patient had almost recovered without new neurological deficits on the next day. Arterial systolic blood pressure was postoperatively controlled within 120 to 150 mmHg. Continuous ventricular and cisternal drainage from the level 10 cm above the external auditory meatus was performed to drain bloody cerebrospinal fluid and prevent vasospasm. Three days after surgery, the patient suddenly lapsed into a coma. CT demonstrated diffuse SAH and bilateral intraventricular hemorrhage caused by rupture of an anterior communicating artery aneurysm. Neck clipping was performed immediately. Unfortunately, the patient died of primary damage due to SAH 3 days after the second surgery. In this case, cisternal drainage was probably important in the aneurysm rupture because of decreased intracranial pressure and change in the perianeurysm environment. Postoperative management of patients with residual untreated aneurysms must consider the possibility that cisternal drainage may result in higher transmural pressure, leading to rupture of the untreated aneurysms.

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Rescue Revascularization Therapy With a Stent-in-Stent Technique for Acute Intracranial Internal Carotid Artery Occlusion

—Case Report—

Toshiyuki OKAZAKI, Junichiro SATOMI, Koichi SATOH, Motohiro HIRASAWA, ...

2005 Volume 45 Issue 5 Pages 253-258
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.253

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A 45-year-old woman presented with progressive stroke due to occlusion of the left internal carotid artery at the level of the cavernous portion (C₃/C₄). Revascularization was achieved by stent deployment following percutaneous transluminal angioplasty. Stent thrombosis occurred 7 days after primary stenting; it was successfully treated with the stent-in-stent technique. The patient was able to return to her independent life with no sequelae except for slight hemiparesis. In combination with appropriate antiplatelet treatment, the stent-in-stent technique should be considered as a rescue option in patients with re-occlusion of an intracranial stent.

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Multiple Spontaneous Dissecting Aneurysms of the Anterior Cerebral and Vertebral Arteries

—Case Report—

Toshinori MATSUSHIGE, Katsuzo KIYA, Hideki SATOH, Tatsuya MIZOUE, Kota ...

2005 Volume 45 Issue 5 Pages 259-263
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.259

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A 50-year-old woman presented with rare multiple dissecting aneurysms that appeared first in the anterior cerebral artery (ACA) and shortly afterwards in the vertebral artery (VA). She initially suffered sudden motor weakness in the left lower limb due to acute brain infarction. Angiography revealed diffuse string sign in the right ACA. Conservative treatment resulted in resolution of the deficits. Follow-up angiography performed 1 year later revealed recovery of the ACA stenosis. Fourteen days later, she complained of sudden headache and became comatose. Computed tomography showed diffuse subarachnoid hemorrhage. Angiography revealed a new right VA dissecting aneurysm involving the posterior inferior cerebellar artery (PICA). The orifice of the dissection was not apparent in the operative field and the dissection extended to the median. The patient underwent extracranial right VA ligation, clipping of the proximal PICA, and revascularization between the right occipital artery and distal PICA. Her postoperative course was uneventful and she was discharged without neurological deficits. VA dissecting aneurysms involving the PICA without evident orifice or extending over the median can be treated by extracranial ligation with clipping of the PICA, followed by revascularization.

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Large Cavernous Hemangioma of the Frontal Bone

—Case Report—

Seref DOGAN, Hasan KOCAELI, Soner SAHIN, Ender KORFALI, Özlem SAR ...

2005 Volume 45 Issue 5 Pages 264-267
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.264

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A 53-year-old woman presented with a rare case of cavernous hemangioma of the frontal bone manifesting as right frontal stabbing headache and local swelling. Computed tomography revealed an extensive, well-defined, radiolucent, osteolytic lesion in the right frontal bone. The inner and outer tables of the skull were eroded and the lesion had compressed the brain parenchyma. Right frontal craniotomy was performed, and the lesion with a 1 cm-wide margin of surrounding uninvolved bone was removed. The defect was reconstructed with titanium mesh. The patient did well after the operation. The cosmetic results were satisfactory and follow up at 6 months post-surgery revealed no recurrence.

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Radiological Features of Germinoma Arising From Atypical Locations

—Three Case Reports—

Satoshi UTSUKI, Hidehiro OKA, Yoshinori TANIZAKI, Kouji KONDO, Kiyotak ...

2005 Volume 45 Issue 5 Pages 268-271
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.268

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Three cases of intracranial germinoma arising from atypical locations occurred in 13-, 22-, and 28-year-old males. The location of the tumor was the corpus callosum (2 cases) and the temporal lobe. Computed tomography and magnetic resonance imaging showed all three tumors had a largest dimension, including the internal cyst, of over 6 cm, and the cysts were larger than 2.5 cm. Radiotherapy and chemotherapy caused all tumors to disappear. Large tumor and large cyst are features of germinoma arising from atypical locations.

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Ligamentum Flavum Hematoma in the Lumbar Spine

—Case Report—

Satoshi YAMAGUCHI, Kazutoshi HIDA, Minoru AKINO, Toshitaka SEKI, Shuns ...

2005 Volume 45 Issue 5 Pages 272-276
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.272

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A 62-year-old male presented with a rare case of ligamentum flavum hematoma manifesting as low back pain and gait difficulty beginning 1 month before consulting our institute. He had no history of lumbar spine surgery or lumbar puncture. However, he might have suffered forgotten back injury while practicing martial arts. Magnetic resonance imaging showed a heterogeneous intensity mass lesion with a cystic component at the L3-4 levels. The lesion was totally removed through a hemilaminectomy. Intraoperative and histological findings confirmed the diagnosis of old hematoma with granulomatous change in the ligamentum flavum. Postoperatively, his low back pain and gait difficulty resolved within a few days.

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Acquired Lumbar Epidermoid Cyst in an Adult

—Case Report—

Shigeru MIYAKE, Norikata KOBAYASHI, Naoki MURAI, Takeshi KONDOH, Eiji ...

2005 Volume 45 Issue 5 Pages 277-279
Published: 2005
Released on J-STAGE: May 24, 2005

DOIhttps://doi.org/10.2176/nmc.45.277

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A 61-year-old female complained of low back pain, and had been treated by spinal anesthetic injection more than 70 times over 14 years. Magnetic resonance (MR) imaging, performed at the age of 47 years, revealed no abnormal lesion. However, she developed irritable hypesthetic pain in the left leg at 61 years of age. MR imaging revealed a round mass appearing isointense on the T₁-weighted and slightly hyperintense on the T₂-weighted images. Laminectomy revealed an epidermoid cyst, which was removed. This case clearly demonstrates that adults can acquire epidermoid tumor which very probably has an iatrogenic origin. The incidence of epidermoid tumor is low, but we should be aware of the potential adverse complications such as formation of epidermoid tumors after lumbar puncture.

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