Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 52, Issue 11
Displaying 1-10 of 10 articles from this issue
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Guideline
  • Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus: Second Edition
    Etsuro MORI, Masatsune ISHIKAWA, Takeo KATO, Hiroaki KAZUI, Hiroji MIY ...
    2012 Volume 52 Issue 11 Pages 775-809
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.775
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    Among the various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. After the publication of the first edition of the Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus in 2004 (the English version was published in 2008), clinical awareness of iNPH has risen dramatically, and the number of shunt surgeries has increased rapidly across Japan. Clinical and basic research on iNPH has increased significantly, and more high-level evidence has since been generated. The second edition of the Japanese Guidelines was thus published in July 2011, to provide a series of timely evidence-based recommendations related to iNPH. The revision of the Guidelines has been undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project on “Studies on the epidemiology, pathophysiology, and treatment of normal pressure hydrocephalus.” This English version of the second edition of the Guidelines was made to share these ideas with the international community and to promote international research on iNPH.
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Original Articles
  • Measurement of Inflammatory Cytokines and Thrombomodulin in Chronic Subdural Hematoma
    Masatoshi KITAZONO, Hiroyuki YOKOTA, Hidetaka SATOH, Hidetaka ONDA, Ga ...
    2012 Volume 52 Issue 11 Pages 810-815
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.810
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    Inflammation and the coagulation system may influence the genesis of chronic subdural hematoma (CSDH). The appearance of CSDH on computed tomography (CT) varies with the stage of the hematoma. This study investigated the pathogenesis and the recurrence of CSDH by comparing cytokine levels with the CT features of CSDH in 26 patients with 34 CSDHs who underwent single burr-hole surgery at our hospital between October 2004 and November 2006. The hematoma components removed during the procedure were examined, and the hematoma serum levels of cytokines measured such as thrombomodulin (TM), interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and interleukin-10 (IL-10). Using CT, mixed density hematomas were distinguished from other homogeneous hematomas, and found that the TM level was significantly higher in mixed density hematomas than in homogeneous hematomas (p = 0.043). Mixed density hematomas were classified into three subtypes (laminar, separated, and trabecular hematomas). The TM level was significantly higher in laminar and separated hematomas than in other hematomas (p = 0.01). The levels of IL-6, TNFα, and IL-10 were extremely high, but showed no significant differences in relation to the CT features. Mixed density hematomas had high recurrence rate, as reported previously, and TM level was high in mixed density hematomas such as laminar and separated mixed density hematomas. The present findings suggest that the types of CSDH associated with high TM levels tend to have higher recurrence rate.
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  • Retrospective Analysis of Hinge Technique for Head Trauma or Stroke
    Tomoaki KANO, Shuhei KUROSAKI, Hirochiyo WADA
    2012 Volume 52 Issue 11 Pages 816-821
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.816
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    Hinge technique is a new method for cerebral decompression that allows the bone flap to move outward in response to brain swelling and essentially allows reconstruction of the cranial vault as a minor procedure under local anesthesia. This retrospective study assessed outcomes following the use of this new decompressive technique. During an approximately 7-year period (June 2004 to March 2011), 58 patients who had suffered head trauma or stroke underwent cerebral decompression using the hinge technique or conventional decompressive craniectomy. Patients were assessed with the Glasgow Coma Scale (GCS), the Glasgow Outcome Scale (GOS), and the modified Rankin scale (mRS). Twenty-one patients (16 males, 5 females; age range, 21-78 yrs; mean age, 57.4 ± 15.5 yrs) underwent cerebral decompression using the hinge technique, and 37 patients (18 males, 19 females; age range, 5-83 yrs; mean age, 54.1 ± 20.9 yrs) underwent conventional decompressive craniectomy. There was no significant difference in preoperative GCS or postoperative GOS or mRS between the two groups. Six patients in the decompressive craniectomy group and none of the patients in the hinge technique group developed bone flap infection (p = 0.02). The bone flap was removed in two cases in the hinge technique group due to low cerebral perfusion pressure as well as elevated intracranial pressure (ICP). The hinge technique with ICP monitoring was effective and safe for management for head trauma or stroke and was not associated with bone flap infection.
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Case Reports
  • Bilateral Chronic Subdural Hematomas of the Posterior Fossae
    —Case Report—
    Kota KURISU, Masahito KAWABORI, Yoshimasa NIIYA, Yuzuru OHTA, Shoji MA ...
    2012 Volume 52 Issue 11 Pages 822-825
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.822
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    An 86-year-old female presented with rare bilateral chronic subdural hematomas (CSHs) of the posterior fossae which were successfully treated by surgical intervention. She had experienced mild head trauma one month before admission. She was transferred to our hospital because of consciousness disturbance and tetraparesis. Magnetic resonance (MR) imaging showed simultaneous occurrence of supratentorial and infratentorial CSHs. We tried to evacuate the CSHs of the bilateral posterior fossae because brainstem compression was markedly severe. Through bilateral burr-hole trepanations, chocolate-colored fluid, not containing clotted components, gushed out under great pressure. Postoperative course was uneventful. MR imaging revealed that the CSHs of the posterior fossae had completely disappeared and brainstem compression had also improved. The patient's neurological deficits were immediately improved after the operation. The patient was discharged one month after the operation for further rehabilitation. Trepanation and evacuation of the hematoma through the posterior fossa might be one of the therapeutic options for posterior fossa CSH, which is similar to supratentorial CSH. However, we considered that the emergency of this rare entity and the method of anesthesia were quite different from supratentorial CSH.
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  • Encapsulated Acute Subdural Hematoma Mimicking Acute Epidural Hematoma on Computed Tomography
    —Case Report—
    Shunichiro MIKI, Keishi FUJITA, Wataru KATAYAMA, Masayuki SATO, Takao ...
    2012 Volume 52 Issue 11 Pages 826-828
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.826
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    An 87-year-old woman presented with an atypical case of acute subdural hematoma (ASDH) manifesting as disturbance of consciousness and left hemiparesis. Computed tomography revealed a high density lentiform lesion in the right convexity, which was thought to be acute epidural hematoma preoperatively. Emergent decompressive craniotomy revealed an encapsulated solid fresh clot in the subdural space and a bleeding small cortical artery under the clot. The arachnoid membrane and the brain parenchyma were intact, and no other abnormal feature such as aneurysm or arteriovenous malformation was observed. The encapsulated ASDH was removed en bloc and the patient fully recovered. Histological examination confirmed that both the outer thicker and the inner membrane were fibrinous single structures without vasculature. The red blood cells constituting the clot in the capsule maintained their cell structure. The reported pathological mechanisms of lentiform ASDH are adhesion of the arachnoid membrane and the dura mater or intracapsular bleeding from sinusoidal vessels in the outer membrane of the chronic subdural hematoma. However, in our case, the arachnoid membrane had not adhered to the dura mater and the capsule was a fibrinous single structural membrane without vasculature, which probably resulted from a previous hematoma due to initial bleeding from the cortical artery. The possible mechanism in our case was that the re-bleeding dissected and flowed into the fibrinous single structural membrane, resulting in formation of the lentiform ASDH.
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  • Combined Endovascular and Endoscopic Surgery for Acute Epidural Hematoma in a Patient With Poor Health
    —Case Report—
    Tomotaka OHSHIMA, Hayato TAJIMA, Kentaro FUJII, Masamune NAGAKURA, Tos ...
    2012 Volume 52 Issue 11 Pages 829-831
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.829
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    A 74-year-old woman presented with right acute epidural hematoma (AEDH) associated with a skull fracture after a fall. Emergency craniotomy under general anesthesia could not be performed because of her poor medical condition. Therefore, transfemoral endovascular embolization and hematoma evacuation via a burr hole were performed using endoscopy under local anesthesia. The patient recovered and was discharged without neurological deficits. AEDH is a common traumatic disease often requiring emergency craniotomy to prevent death and restore neurological function. The present combined surgical approach was effective in treating AEDH that could not be treated under general anesthesia in a patient with poor medical condition.
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  • Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus Caused by a Large Upper Basilar Artery Aneurysm After Coil Embolization
    —Case Report—
    Masayuki SATO, Yasunobu NAKAI, Tomoji TAKIGAWA, Shingo TAKANO, Akira M ...
    2012 Volume 52 Issue 11 Pages 832-834
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.832
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    A 76-year-old female presented with a large upper basilar artery (BA) aneurysm causing obstructive hydrocephalus after coil embolization manifesting as diplopia. Magnetic resonance (MR) imaging and MR angiography showed a large BA top aneurysm. Coil embolization was performed. More than 6 months after the first coil embolization, the aneurysm had re-grown and we performed a second coil embolization. Soon after that, obstructive hydrocephalus at the aqueduct of the midbrain occurred. MR imaging was performed to evaluate whether there was enough space at the prepontine cistern for a third ventriculostomy and also to verify the posterior direction of the aneurysm growth because of the risk of rupturing the aneurysm during the operative procedure. Then, we performed an endoscopic third ventriculostomy (ETV) via a left-sided approach. We could easily identify the infundibular recess, mamillary bodies, and tuber cinereum in the third ventricular floor. We detected a pulsating upper BA aneurysm that appeared to have caused a reddish color change in the right mammillary body and the right side of the thalamus and midbrain. If there is sufficient space in the prepontine cistern for the surgical procedure, ETV is a good choice for the treatment of obstructive hydrocephalus associated with cerebral aneurysms.
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  • Visual Disturbance Following Shunt Malfunction in a Patient With Congenital Hydrocephalus
    —Case Report—
    Hirofumi OYAMA, Kenichi HATTORI, Akira KITO, Hideki MAKI, Tomoyuki NOD ...
    2012 Volume 52 Issue 11 Pages 835-838
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.835
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    A 25-year-old woman presented with complaints of nausea and headache. She had been treated with a ventriculoperitoneal shunt for hydrocephalus when she was 7 months old. Her bilateral optic discs showed moderate atrophy. Right visual acuity allowed only perception of hand movement and left visual acuity was 0.02 (1.2). Computed tomography (CT) showed mild ventricular dilation but no periventricular lucency. Intracranial pressure (ICP) was not high when the shunt valve was punctured. Her visual acuity deteriorated 5 days after the consultation. She was referred again 8 days after the first consultation. The bilateral optic discs were completely pale. Both pupils were dilated on admission, and the bilateral direct light reflexes were absent. The patient could slightly detect only green light stimulus. CT showed moderate enlargement of the ventricle. ICP was 47 cmH2O when the shunt valve was punctured. Shuntgraphy showed obstruction of the shunt at the distal end of peritoneal catheter. Emergent total shunt revision was performed. She could detect dark stimulus and the still-dilated left pupil had recovered direct light reflex on the next day. The visual acuity was 0.01 (0.7) on the left 6 months after the operation, although she was blind in the right eye and the bilateral optic discs were completely pale. Visual loss associated with shunt failure remains a major morbidity in shunted congenital hydrocephalus. Early diagnosis and shunt revision may allow visual recovery.
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  • Formation of Abdominal Cerebrospinal Fluid Pseudocyst
    —Case Report—
    Shigeo OHBA, Yu KINOSHITA, Mai TSUTSUI, Toru NAKAGAWA, Kazuhiko SHIMIZ ...
    2012 Volume 52 Issue 11 Pages 838-842
    Published: 2012
    Released on J-STAGE: November 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.838
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    A 63-year-old man who underwent insertion of a lumboperitoneal shunt developed gait disturbance. He had undergone surgery for gastric cancer 7 years and for ileus 5 years previously. Head computed tomography (CT) revealed enlargement of the ventricles. Abdominal CT revealed a cyst in the abdominal region and the distal segment of the peritoneal shunt tube located within the cyst. Laparotomy revealed the cyst located between the small intestine, colon, and peritoneum. The anterior wall of the cyst was excised. The distal segment of the peritoneal shunt tube was replaced in the rectovesical pouch. Histological examination showed that the cyst wall consisted of inner fibrous tissue and outer fat tissue without epithelial lining, and invasion of lymphocytes. The diagnosis was pseudocyst. Only 29 cases of abdominal cerebrospinal fluid (CSF) pseudocysts have been reported in adults. Although the mechanism underlying the formation of abdominal pseudocyst remains to be clarified, several predisposing factors for cyst formation have been reported including changes in absorption of CSF due to inflammation or infection, peritoneal adhesions due to previous abdominal surgery, and increase in the protein content of the CSF. In our case, the medical history and histological features of the cyst wall indicated that formation of the abdominal pseudocyst was associated with previous surgery or inflammatory reaction.
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Editorial Committee
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