Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 49, Issue 12
Displaying 1-16 of 16 articles from this issue
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Original Articles
  • Endorsement of the FOUR Score for Consciousness Assessment in Neurosurgical Patients
    Phuping AKAVIPAT
    2009 Volume 49 Issue 12 Pages 565-571
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.565
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    The Full Outline of UnResponsiveness (FOUR) score was previously developed for neurological assessment, but has not been validated in neurosurgical patients, so was compared to the Glasgow Coma Scale (GCS) in practice. Four groups of raters, expert clinicians, novice clinicians, experienced nurses, and inexperienced nurses, assessed 64 patients in awake, drowsy, stuporous, and comatose conditions to investigate rater reliability. Then, 36 patients were evaluated by 1 expert clinician and 1 from the other groups randomly to test the difference. Spearman’s correlation was used to find the correlation between both scores from 68 patients. The estimation of FOUR score cut points was validated by weighted kappa compared with the GCS to establish the risk prognosis. Score feasibility was analyzed by nonparametric test. Intraclass correlation in each group was over 0.9, with no difference between expert and inexperienced raters (p > 0.05). The correlation was 0.78. Low, intermediate, and high risk prognosis were associated with 0-7, 8-14, and 15-16 FOUR scores with kappa of 0.92. The feasibility of the FOUR score was lower than that of the GCS (p < 0.01). The FOUR score is reliable and valid for consciousness evaluation with some consequences for practicability. Extensive implementation would increase familiarity.
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  • Novel Antitumor Effect of Carboplatin Delivered by Intracerebral Microinfusion in a Rat Malignant Glioma Model
    Yuichi TANGE, Masahiro MIYAZAKI, Junko IWATA, Yasuhisa AIKO, Shinichi ...
    2009 Volume 49 Issue 12 Pages 572-579
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.572
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    Carboplatin loaded osmotic mini-pumps were implanted in 24 9L malignant glioma-bearing rats to investigate the implications of direct intracerebral microinfusion. Carboplatin using 0.1 mg/ml (low dose group) or 1.0 mg/ml (high dose group) with eight rats in each group, or 5% D-glucose (control group) in eight rats were infused at 1 μl/hr for 7 days. The tumor volume was serially measured by magnetic resonance (MR) imaging with gadolinium as the enhanced area, and the survival periods and histological findings were also examined. Separately, to examine the effects of intracerebral carboplatin infusion on vascular permeability, tumor-bearing rats received intravenous administration of 2% Evans blue at 21 days after infusion. The high dose group showed transient increase of enhanced volume at 21 days associated with mass effect, and significantly decreased tumor volume at 28 and 35 days compared with the control and low dose groups. The high dose group showed significant longer survival time than the control and low dose groups. Histological examination of the high dose group at 21 days showed the central tumor necrotic area around the infusion site and Evans blue leakage into the surrounding enhanced rim and the necrotic core. Therefore, leakage of plasma fluid into the necrotic area was considered to be the cause of apparent transient swelling. The present study demonstrated quantitatively using MR imaging that intracerebral carboplatin microinfusion significantly inhibited the rapid growth of experimental rat glioma but that the high dose required carries the risk of transient swelling of the target tumor.
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  • Surgical Strategy for Tumors Located in or Extending From the Intracranial Space to the Infratemporal Fossa
    —Advantages of the Transcranial Approach (Zygomatic Infratemporal Fossa Approach) and the Indications for a Combined Transcranial and Transcervical Approach—
    Kazunari YOSHIDA, Takeshi KAWASE, Toshiki TOMITA, Kaoru OGAWA, Hiromas ...
    2009 Volume 49 Issue 12 Pages 580-586
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.580
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    The surgical strategy for tumors located in or extending from the intracranial space to the infratemporal fossa was analyzed in 12 cases with various pathologies. A case of mandibular nerve schwannoma, which extended 1 cm below the external orifice of the foramen ovale, was completely removed via the epidural subtemporal approach without zygomatic osteotomy with partial removal of the middle cranial base. The inferior margin of infratemporal tumor could be accessed via the transcranial route with zygomatic or orbitozygomatic osteotomy without complications including facial nerve injury in nine cases, and the lowest level of the infratemporal tumors was approximately 4.5 cm below the outer surface of the middle cranial base. In five of these 9 cases (2 schwannomas, 1 myxoma, 1 chondrosarcoma, and 1 malignant peripheral nerve sheath tumor), the tumors were localized in the infratemporal fossa, and in the other 4 cases (2 meningiomas, 1 glioblastoma, and 1 ameloblastoma), the tumors extended to both the intracranial space and the infratemporal fossa. In two cases (recurrent jugular schwannoma and mandibular osteosarcoma), a combined transcranial and transcervical approach (mandibular swing approach) was essential, because the resection line of the lower margin was too far from the middle cranial base. These results indicate that the transcranial approach, with or without zygomatic or orbitozygomatic osteotomy (zygomatic infratemporal fossa approach), is safe and effective for removal of some infratemporal tumors, and that a combined transcranial and transcervical approach is useful for removing infratemporal tumors with extensive downward extension.
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Case Reports
  • Traumatic Aneurysm of the Supraclinoid Internal Carotid Artery
    —Case Report—
    Shigeo OHBA, Yoshiaki KUROSHIMA, Keita MAYANAGI, Joji INAMASU, Ryoichi ...
    2009 Volume 49 Issue 12 Pages 587-589
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.587
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    A 23-year-old male was admitted after a motor vehicle accident with acute epidural hematoma, diffuse subarachnoid hemorrhage (SAH) in the basal cistern, and fractures at the anterior cranial base. Angiography revealed an aneurysm of the right supraclinoid internal carotid artery (ICA). His consciousness suddenly worsened on the 23rd day. Expansion of the SAH in the basal cistern and two hump aneurysms were detected. He underwent endovascular embolization of these aneurysms and the right ICA with Guglielmi detachable coil. Traumatic aneurysms are difficult to diagnose in the early period after injury and are associated with a high mortality. Endovascular treatments for traumatic aneurysms have lower mortality rate, and can be performed under local anesthesia.
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  • Unstable Stenosis of the Internal Carotid Artery Caused by a Craniofacial Nail-Gun Injury
    —Case Report—
    Tetsuya HIRAISHI, Tadashi KAWAGUCHI, Tsutomu KOBAYASHI, Masaru TOMIKAW ...
    2009 Volume 49 Issue 12 Pages 590-593
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.590
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    A 30-year-old carpenter suffered accidental piercing of his jaw by a 3-inch nail from a nail gun. No neurological deficits were found on admission. Computed tomography showed that the tip of the nail had reached the foramen lacerum. Cerebral angiography revealed severe stenosis at the C4 portion of the left internal carotid artery (ICA) and marked decrease in the flow of the distal ICA. He had developed right hemiparesis and sensory aphasia by the following morning. T2-weighted and fluid-attenuated inversion recovery magnetic resonance imaging showed a focal hyperintense signal in the left central region indicating cerebral infarction. Repeat angiography demonstrated that the antegrade blood flow from the occluded point on the admission day had partially resumed, and endovascular trapping of the ICA was successfully carried out. The nail was then removed safely without problematic bleeding. The patient suffered no additional deficit, and his sensory aphasia and right hemiparesis gradually improved. The fluctuating blood flow through the unstable stenosis of the ICA related to nail movement possibly caused the delayed cerebral infarction. To avoid the occurrence of such events, rapid treatment after necessary investigations is recommended in patients with craniofacial penetrating injuries that affect the ICA.
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  • Brain Stem Hemorrhage Following Burr Hole Drainage for Chronic Subdural Hematoma
    —Case Report—
    Kyung-Jae PARK, Shin-Hyuk KANG, Hoon-Kap LEE, Yong-Gu CHUNG
    2009 Volume 49 Issue 12 Pages 594-597
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.594
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    A 76-year-old man presented with brain stem hemorrhage after burr-hole drainage for bilateral chronic subdural hematomas. Neuroimaging demonstrated resolution of the transtentorial herniation but also detected new brain stem hemorrhage, manifesting as gait disturbance. He recovered after conservative treatment. Asymmetrical and rapid decompression, which leads to vascular disruption and/or sudden increase in cerebral blood flow, was probably responsible for the secondary brain stem hemorrhage. Therefore, simultaneous and bilateral decompression with a slow rate of evacuation of massive bilateral chronic subdural hematomas is recommended to prevent serious complications such as secondary intracranial hematoma.
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  • Rebleeding From a Vertebral Artery Dissecting Aneurysm After Endovascular Internal Trapping: Adverse Effect of Intrathecal Urokinase Injection or Incomplete Occlusion?
    —Case Report—
    Kenji SUGIU, Koji TOKUNAGA, Shigeki ONO, Ayumi NISHIDA, Isao DATE
    2009 Volume 49 Issue 12 Pages 597-600
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.597
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    A 67-year-old woman suffered rebleeding from a ruptured vertebral artery dissecting aneurysm after endovascular internal trapping. The dissecting aneurysm was initially successfully occluded with the affected vertebral artery using detachable coils. However, rebleeding from the aneurysm occurred on the next day. The rebleeding may have resulted from the thrombolytic effect of urokinase, which was injected intrathecally 3 hours before rebleeding occurred, or the relatively loose coil packing of the aneurysm. This case indicates the potential risk of intrathecal use of thrombolytic agents and the importance of complete tight coil packing of the whole dissected site in the treatment of ruptured vertebral artery dissecting aneurysms.
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  • Direct Clipping of a Thrombosed Giant Cerebral Aneurysm After Thrombectomy Without Bleeding to Minimize the Temporary Occlusion Time
    —Technical Case Report—
    Masao SUGITA, Hiroyuki KINOUCHI, Yoshihisa NISHIYAMA, Kazuya KANEMARU, ...
    2009 Volume 49 Issue 12 Pages 600-603
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.600
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    A 75-year-old man was referred to our hospital with a thrombosed giant middle cerebral artery aneurysm manifesting as progressive memory disturbance and disorientation. Magnetic resonance imaging and conventional angiography revealed a partially thrombosed giant aneurysm of the left middle cerebral artery bifurcation and edema of the adjacent brain which had enlarged compared to 3 months before. Surgery was performed through a left frontotemporal craniotomy. After exposure of the aneurysm neck, we tried to apply a clip, which slipped due to the intraaneurysmal thrombus. Intraoperative motor evoked potential monitoring showed decreased amplitude. Therefore, the aneurysm dome was incised and the intraaneurysmal thrombus near the neck was shaved with the ultrasonic aspirator, followed by neck clipping of the aneurysm. The residual thrombus was safely removed. Transient right hemiparesis was observed after surgery, but his memory disturbance gradually improved. Giant thrombosed aneurysm can be treated by reduction of the thrombus from the far side to the lumen to reduce the duration of parent artery occlusion required for clipping.
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  • Usefulness of Intravascular Ultrasonography Monitoring of Coil Embolization for Traumatic Direct Carotid-Cavernous Fistula
    —Case Report—
    Akimasa NISHIO, Taichiro KAWAKAMI, Yutaka MITSUHASHI, Koji HAYASAKI, M ...
    2009 Volume 49 Issue 12 Pages 604-607
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.604
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    A 61-year-old woman was admitted for head injury after a traffic accident. Two months later, she developed abducens nerve palsy, chemosis, and pulsatile tinnitus. Right internal carotid angiography demonstrated a high flow direct carotid-cavernous fistula (CCF) at the C5 portion with reflux into the superficial and deep sylvian veins, superior ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus. Intravascular ultrasonography (IVUS) revealed a large fistula at the C5 portion of the internal carotid artery (ICA). Coil embolization via transarterial and transvenous approaches under IVUS monitoring was performed. During the procedure, IVUS accurately detected protrusion of a coil into the parent ICA, and the parent artery could be preserved. IVUS monitoring is useful for embolization of direct CCF with coils.
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  • Differentiation of Clear Cell Ependymoma of the Cerebellum From Hemangioblastoma by Thallium-201 Single Photon Emission Computed Tomography
    —Case Report—
    Ken-ichi NAGAMATSU, Toshihiro KUMABE, Mika WATANABE, Yoichi NAKAZATO, ...
    2009 Volume 49 Issue 12 Pages 608-611
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.608
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    A 57-year-old man suffered from dizziness for about one year and truncal ataxia for about one month. Magnetic resonance imaging demonstrated a cystic tumor with a homogeneously enhanced mural nodule located in the cerebellar vermis. Computed tomography angiography revealed a hypervascular nodule. These findings were compatible with hemangioblastoma. Thallium-201 single photon emission computed tomography (201Tl-SPECT) showed moderately high uptake in the early phase and moderately high retention in the delayed phase, whereas hemangioblastoma shows almost no retention in the delayed phase. The patient underwent total removal of the tumor. The histological diagnosis was clear cell ependymoma (CCE). CCE is a rare subtype of ependymoma, which resembles hemangioblastoma in histological and neuroimaging findings, but is considerably more aggressive. 201Tl-SPECT can provide useful information for the preoperative differential diagnosis of infratentorial CCE and hemangioblastoma.
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  • Isolated Recurrence of Granulocytic Sarcoma
    —Two Case Reports—
    Qingsheng XU, Ming WANG, Qihan YOU, Huafeng WANG, Ke YE, Renya ZHAN, Y ...
    2009 Volume 49 Issue 12 Pages 611-615
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.611
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    Two patients presented with rare isolated recurrence of granulocytic sarcoma. A 29-year-old male presented with an extra- and intracranial mass 10 years after bone marrow transplantation for chronic myeloid leukemia. A 34-year-old female presented with an intracranial mass 3 years after complete remission of acute myeloid leukemia-M2a. Both patients underwent surgical resection. The first patient received adequate postoperative radiotherapy and chemotherapy, and achieved complete remission without evidence of diseases during the 6-month follow up. The second patient only received whole brain radiotherapy, failed to respond, and died of systemic leukemia later. These two cases demonstrate that neurosurgeons should pay attention to the occurrence of isolated recurrent granulocytic sarcoma, especially in patients with a history of hematologic neoplasm. Immediate pathological and cytogenetic diagnoses are essential.
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  • Surgical Treatment of Spinal Lipoma Without Spina Bifida at Lumbar Region
    —Three Case Reports—
    Atsushi SUGAWARA, Kyongsong KIM, Masanori ISOBE, Ryoji MATSUMOTO, Toyo ...
    2009 Volume 49 Issue 12 Pages 616-618
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.616
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    Three men aged 40 to 60 years presented with rare lumbar spinal intradural lipomas without spina bifida manifesting as worsening numbness, pain of the lower extremities, and bladder dysfunction. All 3 patients underwent decompressive laminectomy. The lipoma and cauda equina nerves were dissected from the dura mater under the operating microscope, untethering the spinal cord and returning the cauda equina nerves to the original position. Duralplasty was performed using an expanded polytetrafluoroethylene sheet. Postoperatively, all patients experienced improvement of their neurological deficits. In the surgical treatment of spinal lipomas, the primary purpose is untethering and decompression, which can be achieved by untethering the spinal cord, returning the cauda equina nerves to the normal position, laminectomy, and duralplasty, without removal of the lipoma.
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  • Focal Hand Dystonia Cured by Removal of Clinoid Meningioma
    —Case Report—
    Satoshi TAKAHASHI, Takayuki OHIRA, Satoka SHIDO, Takeshi KAWASE
    2009 Volume 49 Issue 12 Pages 619-621
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.619
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    A 40-year-old Asian female presented with an unusual case of focal hand dystonia caused by contralateral clinoid meningioma. Magnetic resonance imaging showed that the tumor compressed the caudate nucleus, lentiform nucleus, cerebral peduncle, internal capsule, and a large portion of the white matter surrounding the basal ganglia. The tumor was gross totally removed via a frontotemporal approach with zygomatic osteotomy, resulting in cure of the focal hand dystonia. Magnetic resonance imaging after surgery showed that the compression of the surrounding brain was released. This case shows that secondary focal hand dystonia caused by extra-axial brain tumor can be cured by surgical removal.
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  • Hypophysitis Presenting With Atypical Rapid Deterioration: With Special Reference to Immunoglobulin G4-Related Disease
    —Case Report—
    Shinichiro OSAWA, Yoshikazu OGAWA, Mika WATANABE, Teiji TOMINAGA
    2009 Volume 49 Issue 12 Pages 622-625
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.622
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    Primary hypophysitis is believed to be a chronic inflammation of the pituitary tissue caused by the autoimmune mechanism. The disease can be classified based on morphology and histology simultaneously, but the relationships between these subtypes remain unclarified. Moreover, hypophysitis may occur as a part of systemic immunoglobulin G4 (IgG4)-related plasmacytic disease. A 74-year-old woman was initially diagnosed with infundibulo-hypophysitis. After a long period of stability, she suffered rapid deterioration with evolving endocrinopathies and visual symptoms. Biopsy specimen established the diagnosis as granulomatous hypophysitis with positive reaction for IgG4 in infiltrating plasma cells. Postoperative glucocorticoid administration improved her condition dramatically. This case illustrates two interesting points: The rapid deterioration after a long stable clinical course, and the presence of IgG4-positive tissue in the pituitary gland, which can be considered as “primary” hypophysitis with no systemic IgG4-related disease in other organs.
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  • Blurred Vision With Acute Hypertension Indicating Hypertensive Brainstem Encephalopathy
    —Case Report—
    Kotaro OGAKI, Jiro FUKAE, Kazuyuki NODA, Kenji FUJISHIMA, Nobutaka HAT ...
    2009 Volume 49 Issue 12 Pages 625-630
    Published: 2009
    Released on J-STAGE: December 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.625
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    A 49-year-old woman presented with hypertensive brainstem encephalopathy (HBE) manifesting as visual disturbance and papilledema but no other neurological abnormal findings. Magnetic resonance (MR) imaging showed extensive lesions in the brainstem and bilateral thalami but not in the occipital lobes. The patient also had renal failure and underwent hemodialysis. Her visual disturbance and MR lesions resolved rapidly after antihypertensive treatment. This case of HBE only caused visual disturbance despite the presence of massive brainstem edema. The presence of fetal-type posterior cerebral artery may have spared the occipital lobe. Clinicians should consider HBE in hypertensive patients with blurred vision. HBE is reversible if immediate antihypertensive treatment is initiated, but neurological sequelae may develop if treatment is delayed.
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Editorial Committee
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