Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
Volume 49, Issue 9
Displaying 1-16 of 16 articles from this issue
Original Articles
  • Nariyoshi NANKO, Motoki TANIKAWA, Mitsuhito MASE, Masataka FUJITA, His ...
    2009 Volume 49 Issue 9 Pages 379-385
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    Vascular endothelial growth factor (VEGF), a potent inducer of angiogenesis and vascular permeability in diverse physiological and pathological conditions, may be involved in the pathophysiology of chronic subdural hematoma (CSDH). The present study investigated the source and mechanisms for the induction of VEGF in CSDH by measuring the concentration of VEGF in the hematoma of 102 patients (122 hematomas) using the enzyme-linked immunosorbent assay technique. The relationship between the VEGF concentration in hematoma and the intrahematoma membranous structure confirmed by preoperative T2*-weighted magnetic resonance image was examined in 46 of these patients. VEGF and hypoxia-inducible factor-1α (HIF-1α) expression was immunohistochemically studied and microvessel density (MVD) in the outer membrane was identified using anti-CD31 antibody in 30 patients. VEGF and HIF-1α were positive in the outer membranes of all 30 patients. VEGF expression was significantly correlated to HIF-1α expression (rs = 0.651, p = 0.0084) and VEGF concentration in the hematoma (rs = 0.654, p = 0.0013). VEGF concentration in layered hematomas, which have intrahematoma membranous structure, was significantly higher than in non-layered hematomas (p < 0.01). Although MVDs of the outer membranes were comparable to those described in tumors, there was no significant relationship with VEGF expression. The present study suggests that VEGF in CSDH, which may be induced in the neomembrane by HIF-1 release, may give rise to the excessive development of fragile microvessels and hyperpermeability, resulting in the enlargement of CSDH.
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  • Mahmoud M. TAHA, Masayuki MAEDA, Hiroshi SAKAIDA, Kenji KAWAGUCHI, Nao ...
    2009 Volume 49 Issue 9 Pages 386-393
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    Distal embolism is an important periprocedural technical complication with carotid angioplasty and carotid artery stenting (CAS). We evaluated the safety and efficacy of protection devices used during CAS by detecting new cerebral ischemic lesions using diffusion-weighted magnetic resonance imaging in 95 patients who underwent 98 CAS procedures: 34 using single PercuSurge GuardWire, 31 using double balloon protection, 15 using proximal flow reverse protection devices, 14 using Naviballoon, and 4 using filter anti-embolic devices. Diffusion-weighted imaging was performed preoperatively and postoperatively to evaluate the presence of any new embolic cerebral lesions. Postoperative diffusion-weighted imaging revealed 117 new ischemic lesions. Three patients had new ischemic stroke, two minor and one major, all ipsilateral to the treated carotid artery. The remaining patients had clinically silent ischemia. The incidence of new embolic lesions was lower using the proximal flow reverse protection device than with the double balloon protection (33% vs. 48.4%), but the volume of ipsilateral new ischemic lesions per patient was 136.6 mm3 vs. 86.9 mm3, respectively. Neuroprotection with Naviballoon yielded ipsilateral lesions of large volume (86.6 mm3) and higher number (5.7 lesions per patient) than using the filter anti-embolic device (34.8 mm3 and 1 lesion per patient). New cerebral ischemic lesions after neuroprotected CAS are usually silent. The lower incidence of distal ischemia using proximal flow reverse and double balloon protection devices is limited by the larger volume and higher number of ischemic lesions.
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  • Takeshi NAKAJIMA, Toshihiro KUMABE, Masayuki KANAMORI, Ryuta SAITO, Ma ...
    2009 Volume 49 Issue 9 Pages 394-401
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    Differential diagnosis between radiation necrosis and tumor recurrence is important in the clinical management of glioma. Multi-modality imaging including proton magnetic resonance spectroscopy (1H-MRS) and positron emission tomography (PET) with L-[methyl-11C]methionine (MET) was evaluated. Eighteen patients underwent sequential 1H-MRS and MET-PET. The expressions of metabolites including choline-containing compounds (Cho), creatine phosphate (Cre), and lactate (Lac) were calculated as the ratios of Cho to Cre (Cho/Cre) and Lac to Cho (Lac/Cho). The uptake of MET was determined as the ratio of the lesion to the contralateral reference region (L/R). The final diagnoses were determined by histological examination and/or follow-up MR imaging and clinical course. The Lac/Cho ratio was 0.63 ± 0.25 (mean ± standard deviation) in recurrence (7 cases) and 2.35 ± 1.81 in necrosis (11 cases). The Lac/Cho ratio was significantly different between the two groups (p < 0.01). Consecutive investigation of 1H-MRS revealed temporary elevation of Cho in 4 of 9 cases of necrosis, which could be identified as false positive findings for recurrence. Including those cases, MET-PET demonstrated significant difference in the L/R ratio between the two groups (2.18 ± 0.42 vs. 1.49 ± 0.35, p < 0.01). According to a 2 × 2 factorial table analysis, the borderline values of Lac/Cho and L/R to differentiate recurrence from necrosis were 1.05 and 2.00, respectively. 1H-MRS is reliable and accessible for the differentiation of recurrence and necrosis, although the temporary elevation of Cho in the course of necrosis should be recognized. Additional MET-PET imaging can establish the diagnosis.
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Case Reports
  • —Two Case Reports—
    Ryuta NAKAE, Masaru IDEI, Kiyoshi KUMANO, Shinji OKITA, Kanji YAMANE
    2009 Volume 49 Issue 9 Pages 402-406
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    CREST syndrome is a variant of scleroderma characterized by calcinosis, Raynaud’s phenomenon, esophageal hypomotility, sclerodactyly, and telangiectasia, and is a collagen vascular disease characterized by inflammation and fibrosis of multiple organs/tissues. Neurological and cerebrovascular abnormalities are uncommon in CREST syndrome. Here, we report two patients with CREST syndrome harboring intracranial aneurysms. A 53-year-old woman with a 6-month history of CREST syndrome had multiple intracranial aneurysms that arose from the right middle cerebral artery, the left middle cerebral artery, the choroidal segment of the left internal carotid artery, and the left anterior cerebral artery. A 64-year-old woman with a 2-year history of CREST syndrome had a fusiform aneurysm located on the insular segment of the left middle cerebral artery. These patients were treated surgically and good outcome was achieved in both cases. The pathogenesis of cerebral aneurysms associated with collagen diseases, including CREST syndrome, remains unclear. Early treatment of CREST syndrome and other collagen diseases may prevent arteritis from progressing to affect the intracranial arteries and thus reduce the occurrence of aneurysms. The prognosis for patients with collagen diseases after rupture of cerebral aneurysm seems to be poor because the multiplicity, atypical morphology, and atypical location of their aneurysms make treatment difficult. Thus, early detection and treatment are important to improve the prognosis.
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  • —Case Report—
    Satoshi TSUTSUMI, Yuzaburo SHIMIZU, Yasuomi NONAKA, Yusuke ABE, Yukima ...
    2009 Volume 49 Issue 9 Pages 407-409
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 59-year-old male presented with generalized seizure. The patient had not been aware of any traumatic head injuries or preceding infection, and had no contributory medical history. On admission, he was alert and well oriented, without neurological impairment or headache. He was afebrile and blood examination showed no abnormal findings. Computed tomography revealed an irregular intracerebral hematoma, 3 × 1.5 cm in diameter, in the left rectal gyrus. Cerebral angiography showed an arteriovenous fistula (AVF) in the anterior cranial fossa supplied only by the persistent primitive olfactory artery (PPOA) originating from the anterior cerebral artery, forming a shunt to an ascending cortical vein, and drained by the superior sagittal sinus. The patient underwent endovascular obliteration of the AVF via the transarterial route. Immediately after successful isolation, angiography showed that the bilateral anterior ethmoidal arteries supplied the AVF. The feeding branches from the left anterior ethmoidal artery were completely occluded via the ophthalmic artery, but introduction of the catheter into the right ophthalmic artery markedly decreased the stump pressure. Follow-up angiography performed at 3 and 8 weeks following embolization showed spontaneous resolution of the residual AVF without findings of recanalization or new abnormal channels. AVF arising in the anterior cranial fossa may be associated with an unusual pattern of the blood supply when including the PPOA.
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  • —Case Report—
    Masaki ITO, Hiroyasu KAMIYAMA, Takatoshi NAKAMURA, Hideki NAKAJIMA, Jo ...
    2009 Volume 49 Issue 9 Pages 410-412
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 47-year-old man presented with a rare case of dural cavernous hemangioma of the cerebellar falx incidentally detected as a mass lesion in the posterior cranial fossa. Neurological examination revealed no deficits or physical symptoms. Computed tomography demonstrated a well-demarcated hyperdense mass, with no calcification, in the cerebellar vallecula. Magnetic resonance imaging showed the extra-axial mass as homogeneously isointense on T1-weighted images, and hyperintense on T2-weighted images, compared to the adjacent cerebellar parenchyma that had no hypointense halo. The cerebellar vermis was slightly compressed ventrally, the adjacent brain parenchyma was not swollen, and there was no evidence of hydrocephalus. The mass and the attached cerebellar falx were homogeneously enhanced by contrast medium. The dural enhancement was considered a dural tail. No other intracranial vascular malformations were found. The preoperative diagnosis was posterior cranial fossa meningioma attached to the cerebellar falx. Median suboccipital craniotomy exposed the reddish mass attached to the cerebellar falx. The arachnoid plane was well preserved. Total en bloc resection was performed with minimal blood loss. The postoperative course was unremarkable. The resected mass had a reddish-brown mulberry appearance, with spongy cross section with multiple blood-filled spaces. Histological examination identified dilated blood-containing channels lined with flattened endothelium and separated by fibrous tissue, but no luminal thrombus or hemorrhage. The histological diagnosis was dural cavernous hemangioma of the cerebellar falx. Preoperative radiosurgery or embolization is recommended for most of the dural cavernous hemangiomas, but surgery for the present dural cavernous hemangioma of the cerebellar falx was performed safely.
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  • —Case Report—
    Tomoji TAKIGAWA, Yuji MATSUMARU, Takeshi KUBO, Noriaki FUKUHARA, Mikit ...
    2009 Volume 49 Issue 9 Pages 413-417
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 70-year-old male presented with transient ischemic attacks manifesting as right hemiparesis and motor aphasia due to severe left cervical internal carotid artery stenosis. Carotid artery stenting (CAS) using a flow-reversal system was performed without complications. However, the patient exhibited transient right hemiparesis and motor aphasia 10 days after CAS. Emergent angiography demonstrated in-stent restenosis. In-stent percutaneous transluminal angioplasty and CAS were performed successfully using a distal protection system. However, duplex ultrasound scanning revealed progressive in-stent restenosis, 3 and 6 days after the re-treatment. Emergent angiography again demonstrated in-stent restenosis. Urgent stent removal and carotid endarterectomy were performed. Plaque had prolapsed through the stent. Histological examination revealed that the specimen was mainly plaque consisting of cholesterol crystals and macrophages. The patient was able to return to independent life without neurological deficit. Repeated endovascular surgery with appropriate antiplatelet and anticoagulation therapy should be attempted initially to treat in-stent restenosis. Endarterectomy with stent removal should be considered as a rescue option, especially if plaque protrusion is identified.
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  • —Case Report—
    Toshiyuki AMANO, So TOKUNAGA, Tadahisa SHONO, Masahiro MIZOGUCHI, Keni ...
    2009 Volume 49 Issue 9 Pages 418-420
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 49-year-old man presented with a rare case of cerebellar hemangioblastoma manifesting as only hearing disturbance. He had suffered from hearing difficulty in the right ear for a few months. Magnetic resonance imaging revealed a cystic mass lesion with an internal fluid level and surrounding flow voids in the right cerebellopontine (CP) angle. Cerebral angiography disclosed a vascular-rich tumor fed by both the superior cerebellar and anterior inferior cerebellar arteries. En bloc resection of the tumor was planned under a preoperative diagnosis of cerebellar hemangioblastoma. The tumor protruded into the CP cistern and compressed cranial nerve VIII. The feeding arteries were meticulously coagulated and the tumor was successfully removed. The histological diagnosis was hemangioblastoma. After the operation, the patient’s hearing acuity improved dramatically. Cerebellar hemangioblastoma should be considered in the differential diagnosis of CP angle tumors associated with hearing disturbance.
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  • —Case Report—
    Tomoru MIWA, Kazunari YOSHIDA, Satoka SHIDOH, Tadashige KANO, Jun MUTO ...
    2009 Volume 49 Issue 9 Pages 421-423
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 59-year-old female presented with a huge non-functioning pituitary adenoma which mainly extended from the intrasellar region to the epidural space of the anterior cranial base, manifesting as a 2-year history of disturbance of the visual field. Transsphenoidal surgery was performed to decompress the optic pathway as the first step of a two-staged operation. Postoperative magnetic resonance images unexpectedly showed spontaneous regression of the major portion of the epidural tumor which had not been manipulated during the first operation. The reason for the spontaneous regression remains unclear.
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  • —Case Report—
    Tadashige KANO, Masahito KOBAYASHI, Kazunari YOSHIDA, Takeshi KAWASE
    2009 Volume 49 Issue 9 Pages 424-426
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 55-year-old woman, with a one-year history of headache, gait disturbance, and slight aphasia, was transferred to our hospital after head injury. Magnetic resonance (MR) imaging and computed tomography revealed a large meningioma with peripheral edema. However, priority was given to previously planned gynecological surgery for uterine cancer. She developed severe anemia after the surgery, followed by consciousness disturbance. MR imaging revealed spontaneous tumor necrosis. The meningioma was totally removed. Her consciousness improved, and she was discharged with no neurological deficit. Patients with large meningioma may suffer deterioration of symptoms due to central tumor necrosis triggered by acute anemia.
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  • —Case Report—
    Joji INAMASU, Takumi KURAMAE, Masashi NAKATSUKASA
    2009 Volume 49 Issue 9 Pages 427-429
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 58-year-old man presented with a rare case of glioblastoma masquerading as intracerebral hemorrhage (ICH). He had been medicated for hypertension and diabetes for 10 years before collapsing at home. Brain computed tomography (CT) showed ICH in the right putamen, but CT with contrast medium showed no underlying lesion. He was treated initially with intravenous administration of anti-hypertensive agent under a diagnosis of hypertensive putaminal hemorrhage. ICH aspiration surgery was performed, and serial CT showed ICH resorption. However, he was again admitted for unstable gait and mildly altered mental status 3 months after discharge. Magnetic resonance (MR) imaging with gadolinium showed an enhanced ring-shaped mass around the hematoma cavity. Open biopsy was performed. The histological diagnosis was glioblastoma multiforme, and he was treated with radiation therapy and oral chemotherapy with temozolomide. MR imaging showed marked shrinkage of the tumor, but he died of pneumonia 3 months after the second surgery. In this case, the cause of the hemorrhage was not identified after the seemingly successful hematoma evacuation surgery, and no definitive diagnosis was made until tumor regrowth. Brain tumor should be suspected as a cause of ICH even if the patient has a history of hypertension and the location is typical for hypertensive ICH. Clinical/radiological follow up is essential for detecting subtle neurological deterioration to avoid diagnostic delay.
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  • —Case Report—
    Kazuki MASU, Takaaki BEPPU, Shunrou FUJIWARA, Hideki KIZAWA, Hiroshi K ...
    2009 Volume 49 Issue 9 Pages 430-433
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    Proton magnetic resonance spectroscopy, diffusion-weighted axonography, and diffusion tensor tractography in a patient with tumefactive demyelination plaque (TDP) were evaluated for differential diagnosis from glioblastoma. The findings of glutamate and glutamine elevations on magnetic resonance spectroscopy and apparent tracts within the lesion on axonography and tractography were unlikely to represent glioblastoma, and were thus useful for the preoperative diagnosis of TDP.
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  • —Case Report—
    Kazuhiko SUYAMA, Kenta UJIFUKU, Tomohito HIRAO, Hideaki TAKAHATA, Masa ...
    2009 Volume 49 Issue 9 Pages 434-437
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 28-year-old female presented with a dermoid tumor in the posterior fossa associated with symptomatic syringomyelia. Magnetic resonance (MR) imaging revealed cervical syringomyelia and tonsillar herniation concomitant with an intradural posterior fossa tumor which was totally removed. The histological diagnosis was dermoid tumor. Her symptoms subsided and MR imaging demonstrated complete resolution of the syrinx 12 months after tumor removal. Benign congenital intracranial tumor may cause tonsillar herniation resulting in symptomatic cervical syringomyelia. However, both tonsillar herniation and cervical syrinx may clinically and radiologically resolve following removal of the intracranial lesion and posterior fossa decompression.
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  • —Case Report—
    Hidenobu OCHIAI, Hirokazu KAWANO, Yoshiya SHIMAO, Tohru HAYASHI, Hirok ...
    2009 Volume 49 Issue 9 Pages 438-441
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 75-year-old woman presented with an extremely rare case of malignant fibrous histiocytoma (MFH) arising in the thoracic spine, causing compression fracture and manifesting as rapidly progressive compressive myelopathy resulting in progressive gait disturbance and weakness of the bilateral legs. Computed tomography and magnetic resonance imaging demonstrated a solid enhanced intravertebral mass destroying the vertebral bodies at the T7 and T8 levels. Maximum resection of the lesion was performed through wide laminectomy from T7 through T9, followed by vertebroplasty using calcium phosphate paste and posterior fixation with a spinal fixation system. Histological examination showed proliferation of pleomorphic spindle-shaped cells having large irregular nuclei with hyperchromasia with storiform pattern and collagenous stroma, consistent with a diagnosis of MFH. This case illustrates the possibility of rapid maximum decompression surgery from the posterolateral side if MFH manifests as progressive transverse myelopathy.
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  • —Case Report—
    Pengfei GE, Yinan LUO, Shuanglin FU, Feng LING
    2009 Volume 49 Issue 9 Pages 442-444
    Published: 2009
    Released on J-STAGE: September 25, 2009
    JOURNAL OPEN ACCESS
    A 50-year-old male presented with a recurrent epidermoid cyst with malignant transformation into squamous cell carcinoma. The patient was first hospitalized for intermittent seizures in 2000. Computed tomography (CT) showed a hypodense lesion with enhanced capsule but no peripheral edema in the right temporal lobe. Craniotomy was performed and the lesion was completely removed. The histological diagnosis was epidermoid cyst. Six years later, the patient experienced blurred vision and hemiparesis in the left extremities. CT showed a hyperdense mass with peripheral edema in the right temporal lobe. Repeat CT 2 months later revealed a larger mass. The recurrent lesion was removed, and the histological diagnosis was squamous cell carcinoma. Intracranial epidermoid cyst is a benign tumor which often appears hypodense on CT, so change to hyperdensity in the recurrent tumor may indicate malignant transformation.
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