Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 49, Issue 6
Displaying 1-11 of 11 articles from this issue
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Original Articles
  • Remote Cerebellar Hemorrhage (Zebra Sign) in Vascular Neurosurgery: Pathophysiological Insights
    Eberval Gadelha FIGUEIREDO, Robson Luis Oliveira de AMORIM, Manoel Jac ...
    2009 Volume 49 Issue 6 Pages 229-234
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.229
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    Hemorrhage in regions remote from the site of initial intracranial operations is rare, but may be fatal. Postoperative cerebellar hemorrhage as a complication of supratentorial surgery, with a radiological appearance known as zebra sign, is an increasingly recognized clinical entity and is associated mainly with vascular neurosurgery or temporal lobe resection. The pathophysiology remains unclear. Three cases of remote cerebellar hematoma occurred after neck clipping of anterior communicating artery aneurysms. All patients had similar clinical findings and underwent pterional craniotomy with the head in accentuated extension. One patient died and the two were discharged without symptoms. Cerebellar hemorrhage probably has a multifactorial origin involving positioning associated with abundant cerebrospinal fluid drainage causing cerebellar sag with resultant vein stretching and bleeding, and use of aspirin or other antiplatelet agents.
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  • Cilostazol May Prevent Cerebral Vasospasm Following Subarachnoid Hemorrhage
    Tetsuyuki YOSHIMOTO, Tomohide SHIRASAKA, Shin FUJIMOTO, Takeshi YOSHID ...
    2009 Volume 49 Issue 6 Pages 235-241
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.235
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    Cilostazol is an antiplatelet aggregation inhibitor drug associated with increased cerebral blood flow and inflammation suppression. This study evaluated administration of cilostazol to prevent cerebral vasospasm following subarachnoid hemorrhage (SAH) in 50 patients treated surgically from December 2004 to November 2006. All patients, excluding those with Hunt and Kosnik grade 5 or who had undergone late surgery, were classified into two groups: 26 patients who received 200 mg/day cilostazol from postoperative day 1 to day 14 and 24 control patients. The frequency and the degree of cerebral vasospasm, occurrence of ischemic lesion, and clinical symptoms due to vasospasm were compared between the two groups. The appearance of severe vasospasm on angiography, persistent symptomatic spasm, and new cerebral infarction due to vasospasm demonstrated by neuroimaging were apparently lower in the cilostazol group than in the control group, suggesting that cilostazol may significantly suppress cerebral vasospasm following SAH.
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  • Effect of Intervertebral Disk Degeneration on Spinal Stenosis During Magnetic Resonance Imaging With Axial Loading
    Tae-Joon AHN, Sang-Ho LEE, Gun CHOI, Yong AHN, Wei Chiang LIU, Ho-Jin ...
    2009 Volume 49 Issue 6 Pages 242-247
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.242
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    Magnetic resonance (MR) imaging with axial loading can simulate the physiological standing state and disclose spinal stenosis undetected or underestimated in the conventional position. Intervertebral disk degeneration may be an important factor in spinal stenosis. This study investigated whether intervertebral disk degeneration increases spinal stenosis during axial loading. MR imaging with and without axial loading was obtained in 51 patients with neurogenic intermittent claudication and/or sciatica and reviewed retrospectively. The grade of disk degeneration was rated in four disk spaces from L2-3 to L5-S1. The dural sac cross-sectional area (DCSA) was measured on MR images taken in both conventional and axial loading positions, and the change in the DCSA was calculated. The effect of disk degeneration on the DCSA was statistically analyzed. Significant decreases in the DCSA occurred with grade 4 disk degeneration (mean ± standard deviation, 20.1 ± 14.1 mm2), followed by grade 3 (18.3 ± 15.1 mm2) and grade 2 (8.9 ± 13.1 mm2). DCSA decreased considerably with increased severity of disk degeneration with axial loading, except for grade 5 disk degeneration. More accurate diagnosis of stenosis can be achieved using MR imaging with axial loading, especially if grade 2 to 4 disk degeneration is present.
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Case Reports
  • Susceptibility-Weighted Magnetic Resonance Imaging Detects Impaired Cerebral Hemodynamics in the Superior Sagittal Sinus Thrombosis
    —Case Report—
    Masahito KAWABORI, Satoshi KURODA, Kohsuke KUDO, Satoshi TERAE, Makoto ...
    2009 Volume 49 Issue 6 Pages 248-251
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.248
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    An 11-year-old female receiving treatment for acute lymphoblastic leukemia presented with superior sagittal sinus (SSS) thrombosis. T1-weighted, T2-weighted, and fluid-attenuated inversion recovery magnetic resonance (MR) imaging, and MR venography showed that the SSS was totally occluded by thrombus. Susceptibility-weighted MR imaging showed hypointense thrombus in the SSS and markedly dilated cortical veins over the bilateral cerebral hemispheres. Two days later, her symptoms had slightly resolved. Iodine-123 N-isopropyl-p-iodoamphetamine single photon emission computed tomography showed marked decrease of cerebral blood flow in the bilateral frontal lobes, indicating that venous congestion had disturbed the cerebral hemodynamics. MR venography showed that the SSS was still mostly occluded, but susceptibility-weighted imaging showed that the dilation of the cortical veins was less marked, suggesting that collateral venous routes had gradually developed. The finding of dilated cortical veins had almost disappeared at 28 days after the onset. Susceptibility-weighted imaging can be used as a non-invasive method to monitor the severity of venous congestion caused by cerebral venous sinus thrombosis.
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  • Tension Pneumocephalus as a Complication of Lumbar Drainage for Cerebral Aneurysm Surgery
    —Case Report—
    Katsuya SAITO, Joji INAMASU, Takumi KURAMAE, Masashi NAKATSUKASA, Fumi ...
    2009 Volume 49 Issue 6 Pages 252-254
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.252
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    A 66-year-old man developed tension pneumocephalus after failed lumbar drainage before clipping surgery for a ruptured anterior communicating artery aneurysm. After puncture with a Tuohy needle, the spinal catheter could not be inserted into the spinal dura, so surgery proceeded without the catheter placement. The patient’s neurological status deteriorated suddenly into coma within 15 hours after uneventful clipping of the aneurysm. Computed tomography revealed tension pneumocephalus with marked brain shift. Intracranial hypotension was probably caused by continuous cerebrospinal fluid leakage from the iatrogenic spinal dural tear, resulting in air entry and accumulation into the cranium from an unidentified opening of the cranial dura. The patient was immediately treated with autologous epidural blood patch administration in the lumbar spine, followed by reopening of the craniotomy incision and flap to evacuate the accumulated air. The patient made a quick and uneventful neurological recovery after the rescue procedure.
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  • Intratumoral Hemorrhage of Spinal Schwannoma of the Cauda Equina Manifesting as Acute Paraparesis
    —Case Report—
    Tsutomu ICHINOSE, Toshihiro TAKAMI, Naoki YAMAMOTO, Naohiro TSUYUGUCHI ...
    2009 Volume 49 Issue 6 Pages 255-257
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.255
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    A 64-year-old man presented with spinal schwannoma of the cauda equina at the thoraco-lumbar junction manifesting as acute paraparesis and urinary incontinence after intratumoral hemorrhage. Surgical resection of the tumor resulted in significant neurological recovery. T2*-weighted gradient-echo magnetic resonance imaging is very useful to help establish the preoperative diagnosis, leading to early surgical intervention and better outcome after surgery.
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  • Malignant Intracranial Meningioma With Spinal Metastasis
    —Case Report—
    Hiroki KURODA, Hiroshi KASHIMURA, Kuniaki OGASAWARA, Atsushi SUGAWARA, ...
    2009 Volume 49 Issue 6 Pages 258-261
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.258
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    A 48-year-old woman presented with a left cerebellopontine angle mass. Over a 93-month period, the patient underwent seven surgeries, two radiosurgeries, and one external beam radiotherapy. The tumor was histologically benign at the first operation, but exhibited unusually aggressive behavior after failed radiosurgery and demonstrated clinical characteristics of malignancy such as spinal metastasis. The patient underwent gamma knife radiosurgery (GKR) for recurrence after the first operation, despite the tumor being located in a resectable region. The tumor did not respond. Six months after the sixth surgery, the patient presented with progressive lower extremity paraparesis and sensory disturbance below the T11 dermatome. Magnetic resonance imaging revealed multiple intradural mass lesions located at the T2, T11-T12, and L2 levels. She died 4 months after the diagnosis of spinal metastases. Retrospectively, we speculate that if a tumor is located in a resectable region and Simpson grade I or II tumor resection is possible, direct surgery may be a safer option than GKR.
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  • Intramedullary Spinal Cord Abscess Treated With Antibiotic Therapy
    —Case Report and Review—
    Noriaki KURITA, Yasuhisa SAKURAI, Makoto TANIGUCHI, Toru TERAO, Hirosh ...
    2009 Volume 49 Issue 6 Pages 262-268
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.262
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    A 58-year-old man presented with an intramedullary spinal cord abscess (ISCA) manifesting as posterior neck pain, gait disturbance, and urinary retention, and transverse myelopathy 1 week later. Magnetic resonance imaging showed the ISCA at the C7 to T1 levels. He was treated under a diagnosis of cryptogenic ISCA with high-dose ampicillin and third- or fourth-generation cephalosporins, which resulted in complete recovery after 2 months. Review of the literature between January 1998 and August 2007 identified 26 cases of ISCA, including our patient. We also identified two additional nonsurgically treated ISCA patients reported between 1977 and 2007. The most common presentation was motor deficits in all patients, followed by fever, pain, and bladder dysfunction. The mortality rate was 1 of 26 patients, and neurological sequelae were observed in 15 of the 25 surviving patients. There was no significant difference in the frequency of neurological sequelae between surgically and nonsurgically treated patients. Mean length of the abscess in the surgically treated group was significantly larger than that in the medically treated group (5.8 vs. 2.2 vertebral bodies). All three nonsurgically treated patients with neurological sequelae had anaerobic infections and received antibiotic therapy later and for shorter periods than those with complete neurological recovery. Antibiotic treatment is comparable to surgery plus antibiotic treatment. Early broad-spectrum high-dose ampicillin and third-generation cephalosporin, covering Gram-positive, Gram-negative, and anaerobic organisms, should be the first choice of management for patients with ISCA.
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  • Transethmoidal Meningoencephalocele Involving the Olfactory Bulb With Enlarged Foramina of the Lamina Cribrosa
    —Case Report—
    Mika HABU, Masaki NIIRO, Mitsuo TOYOSHIMA, Yoshifumi KAWANO, Shoji MAT ...
    2009 Volume 49 Issue 6 Pages 269-272
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.269
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    A 3-year-old girl presented with a transethmoidal meningoencephalocele manifesting as recurrent rhinorrhea. Initially, she developed meningitis, but after treatment she experienced rhinorrhea. Two months later, she again presented with rhinorrhea. Neuroimaging studies revealed a small protrusion (15 mm × 10 mm) at the roof of the ethmoidal sinus. Nasal endoscopy confirmed the diagnosis of meningoencephalocele. The operative findings revealed a small hole in the left olfactory bulb, which had descended into an enlarged foramen along with the arachnoid membrane. The left olfactory bulb was removed, and the enlarged foramina of the lamina cribrosa were covered with a frontal pericranial flap. The defect in the bone was very small, but contributed to the development of meningitis and leakage of the cerebrospinal fluid. Basal cephalocele should be considered in a patient with recurrent rhinorrhea and intracranial infections, even in the absence of any apparent anomaly.
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Technical Note
  • Concept of Ideal Closure Line for Clipping of Middle Cerebral Artery Aneurysms
    —Technical Note—
    Tatsuya ISHIKAWA, Naoki NAKAYAMA, Junta MOROI, Norikata KOBAYASHI, Hid ...
    2009 Volume 49 Issue 6 Pages 273-278
    Published: 2009
    Released on J-STAGE: June 25, 2009
    DOIhttps://doi.org/10.2176/nmc.49.273
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    The concept of optimum closure line was applied to a series of 51 consecutive middle cerebral artery aneurysms (14 ruptured, 37 unruptured) in 41 patients, 16 men and 25 women aged 29-79 years (mean 59.1 years). Visual inspection through the operating microscope revealed 3 types of aneurysm based on the origin of the aneurysm: bifurcation type (n = 39), trunk type (n = 9), and combined type (n = 3). Clipping along the optimum closure line should restore the vascular structure to the original configuration. Combination clip techniques were useful to form a curved closure line. This technique requires adequate operative fields with dissection of the aneurysm and related arteries from the neighboring structures as far as possible. The closure line concept is helpful to decide how to apply clips for particular aneurysms to avoid risks of ischemic complication and future recurrence. Combination clip techniques are often necessary to match a curved closure line.
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Editorial Committee
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