Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 52, Issue 7
Displaying 1-17 of 17 articles from this issue
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The 70th Annual Meeting Special Topics — Part I: Validation and Prospects for Neuromodulation
  • Validation and the Future of Stimulation Therapy of the Primary Motor Cortex
    Youichi SAITOH
    2012 Volume 52 Issue 7 Pages 451-456
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.451
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    The use of electrical motor cortex stimulation (EMCS) for post-stroke pain was established in Japan and has spread globally. EMCS has been used for the treatment of neuropathic pain, Parkinson's syndrome, and recovery of motor paresis. Since 2000, repetitive transcranial magnetic stimulation (rTMS) has been developed for the treatment of various neurological disorders. rTMS is a non-invasive method with almost no adverse effects. In the USA, rTMS of the left dorsolateral prefrontal cortex was approved for the treatment of major depression in 2008. rTMS of the primary motor cortex (M1) has been studied worldwide for the treatment of neuropathic pain, Parkinson's disease, motor paresis after stroke, and other neurological problems. New methods and devices for rTMS therapy are under development, and rTMS of the M1 is likely to be established as an effective therapy for some neurological disorders. The present review discusses EMCS and rTMS of the M1 concisely.
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  • Validation and Perspectives of Neuromodulation in Japan
    Takaomi TAIRA, Shinichi GOTO
    2012 Volume 52 Issue 7 Pages 457-462
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.457
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    Neuromodulation in functional neurosurgery is closely related to the development and availability of devices such as implantable electric stimulators and pumps. All such devices used in Japan are developed and made in foreign countries, and no made-in-Japan device exists. Introduction and approval by the government took many years for most devices, during which time many patients had to continue to live in our medically conservative country. The history of neuromodulation is summarized in Japan and the problems surrounding neuromodulation pointed out. Everyone has to aware of such circumstances and make every effort to improve the internationally unusual situation of neuromodulation in Japan. Otherwise, Japan will become a medically isolated country in the near future.
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  • Neuromodulation Using Intrathecal Baclofen Therapy for Spasticity and Dystonia
    Takuya UCHIYAMA, Kinya NAKANISHI, Norihito FUKAWA, Hiromasa YOSHIOKA, ...
    2012 Volume 52 Issue 7 Pages 463-469
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.463
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    Intrathecal baclofen (ITB) therapy is a treatment for intractable spasticity due to a variety of causes. Continuous intrathecal administration of baclofen, an agonist of the inhibitory neurotransmitter γ-aminobutyric acid, inhibits excitation of motor neurons at the spinal level and thus suppresses spasticity. This therapy was introduced clinically in the Europe and the United States in the 1990s, and was finally approved by the Japanese Ministry of Health, Labour and Welfare in Japan in 2005. Clinical use has been permitted since 2006, and reports of therapeutic efficacy are now appearing in Japan. ITB therapy is a non-destructive treatment that enables administration of baclofen from an implantable pump under the control of a programmer, and represents an outstanding treatment method offering both reversibility and adjustability. Indications for ITB therapy have been expanding in recent years to include not only spasticity, but also various causes dystonia. And ITB therapy can greatly improve activities of daily living and quality of life, and this treatment is attracting attention as a neuromodulatory therapy that also affects metabolic and respiratory functions and even state of consciousness. We here report the surgical methods and therapeutic outcomes for 22 patients who underwent ITB therapy for spastic and dystonic patients in our hospital, together with an investigation of the effects on metabolic and respiratory functions.
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  • Spinal Cord Stimulation for the Treatment of Abnormal Posture and Gait Disorder in Patients With Parkinson's Disease
    Takashi AGARI, Isao DATE
    2012 Volume 52 Issue 7 Pages 470-474
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.470
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    Patients with advanced Parkinson's disease (PD) often present with axial symptoms, including abnormal posture, postural instability, and gait disorder. Although spinal cord stimulation (SCS) is effective for pain, little is known about the effect of SCS on motor function in PD patients. The present study investigated the effect of SCS on posture and gait in 15 PD patients, 5 men and 10 women aged 63-79 years (mean 71.1 years), with low back pain and leg pain who received SCS. A visual analog scale (VAS) was used for pain evaluation pre- and postoperatively. The Unified Parkinson's Disease Rating Scale, Timed Up and Go tests, and Timed 10-Meter Walk tests were used to evaluate motor function and activities of daily living of patients. Preoperative mean VAS score was 8.9 (range 7.8-10), which showed significant postoperative improvement at 3 months to mean VAS score of 2.0 (range 0-3.3). The improvements in VAS scores persisted at 12 months after surgery with mean VAS score of 2.3 (range 0-4). Posture and postural stability motor subscores were improved at 3 months after SCS, and gait had significantly improved at 3 months and 1 year after surgery. Timed 10-Meter Walk tests also demonstrated that patient gait was significantly improved at 3 months and 12 months after surgery. Most advanced stage PD patients suffer considerable pain that causes abnormal posture and gait disturbance. SCS is expected to lead to both amelioration of pain and improvement of motor function in such patients.
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  • Spinal Cord Stimulation for Treatment of Patients in the Minimally Conscious State
    Takamitsu YAMAMOTO, Yoichi KATAYAMA, Toshiki OBUCHI, Kazutaka KOBAYASH ...
    2012 Volume 52 Issue 7 Pages 475-481
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.475
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    Minimally conscious state (MCS) is characterized by inconsistent but clearly discernible behavioral evidence of consciousness, and can be distinguished from coma and the vegetative state (VS). Ten MCS patients were evaluated neurologically and electrophysiologically over 3 months after the onset of brain injury, and were treated by spinal cord stimulation (SCS). A flexible four-contact, cylinder electrode was inserted into the epidural space of the cervical vertebrae, and placed at the C2-C4 levels. Stimulation was applied for 5 minutes every 30 minutes during the daytime at an intensity that produced motor twitches of the upper extremities. We used 5 Hz for SCS, considering that the induced muscle twitches can be a useful functional neurorehabilitation for MCS patients. Eight of the 10 MCS patients satisfied the electrophysiological inclusion criteria, which we proposed on the basis of the results of deep brain stimulation for the treatment of patients in the VS. Seven patients recovered from MCS following SCS therapy, and were able to carry out functional interactive communication and/or demonstrate the functional use of two different objects. Cervical SCS increased cerebral blood flow (CBF) diffusely in the brain, and CBF increased by 22.2% during the stimulation period compared with CBF before stimulation in MCS patients (p < 0.0001, paired t-test). Five-Hz cervical SCS could increase CBF and induce muscle twitches of the upper extremities. This SCS therapy method may be suitable for treating MCS.
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Original Articles
  • Cost-Effectiveness Analysis of Intrathecal Baclofen Therapy in Japan
    Naoyuki HATTORI, Teruyasu HIRAYAMA, Yoichi KATAYAMA
    2012 Volume 52 Issue 7 Pages 482-487
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.482
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    Intrathecal baclofen (ITB) therapy was approved for health insurance coverage in 2005 for the treatment of patients whose spasticity could not be adequately controlled by conventional therapy, and is currently being used to treat around 300 patients nationwide in Japan. Various reports have examined the efficacy and safety of ITB therapy, but no report has evaluated the patient quality of life and medical costs in Japan. A cost-utility analysis of ITB was conducted by time period in six severely spastic patients admitted to our university hospital between 2005 and 2010 for ITB therapy. The average cost of ITB therapy per quality-adjusted life year (QALY; number of years survival in perfect health) 5 years after surgery was 1,554,428 yen, below the 6 million yen willingness-to-pay threshold for 1 QALY. This study shows that ITB therapy in Japan is an outstanding treatment in medicoeconomic terms.
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  • Early Cerebral Circulatory Disturbance in Patients Suffering Subarachnoid Hemorrhage Prior to the Delayed Cerebral Vasospasm Stage: Xenon Computed Tomography and Perfusion Computed Tomography Study
    Mitsuru HONDA, Shigeru SASE, Kyosuke YOKOTA, Ryo ICHIBAYASHI, Katsunor ...
    2012 Volume 52 Issue 7 Pages 488-494
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.488
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    Subarachnoid hemorrhage (SAH) causes dynamic changes in cerebral blood flow (CBF), and results in delayed ischemia due to vasospasm, and early perfusion deficits before delayed cerebral vasospasm (CVS). The present study examined the severity of cerebral circulatory disturbance during the early phase before delayed CVS and whether it can be used to predict patient outcome. A total of 94 patients with SAH underwent simultaneous xenon computed tomography (CT) and perfusion CT to evaluate cerebral circulation on Days 1-3. Cerebral blood flow (CBF) was measured using xenon CT and the mean transit time (MTT) using perfusion CT and calculated cerebral blood volume (CBV). Outcome was evaluated with the Glasgow Outcome Scale (good recovery [GR], moderate disability [MD], severe disability [SD], vegetative state [VS], or death [D]). Hunt and Hess (HH) grade II patients displayed significantly higher CBF and lower MTT than HH grade IV and V patients. HH grade III patients displayed significantly higher CBF and lower MTT than HH grade IV and V patients. Patients with favorable outcome (GR or MD) had significantly higher CBF and lower MTT than those with unfavorable outcome (SD, VS, or D). Discriminant analysis of these parameters could predict patient outcome with a probability of 74.5%. Higher HH grade on admission was associated with decreased CBF and CBV and prolonged MTT. CBF reduction and MTT prolongation before the onset of delayed CVS might influence the clinical outcome of SAH. These parameters are helpful for evaluating the severity of SAH and predicting the outcomes of SAH patients.
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Case Reports
  • Subarachnoid Hemorrhage Caused by Ruptured Intracranial Fusiform Aneurysm Associated With Microscopic Polyangiitis
    —Case Report—
    Hidehito KIMURA, Nobuyuki AKUTSU, Ryoji SHIOMI, Eiji KOHMURA
    2012 Volume 52 Issue 7 Pages 495-498
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.495
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    A 44-year-old woman with microscopic polyangiitis (MPA) presented with a ruptured cerebral aneurysm. She was admitted to our hospital for further examination of progressive renal failure. She was found lying on the ward floor. Computed tomography showed subarachnoid hemorrhage, and digital subtraction angiography revealed a saccular-like aneurysm arising from the right distal posterior inferior cerebellar artery (PICA) at the non-branching site. We performed neck clipping of the right distal PICA aneurysm, which recurred 5 days after the operation. Second angiography demonstrated a right distal PICA aneurysm just above the site of the clip. Therefore, we performed trapping of the affected lesion with emergent bypass of the contralateral occipital artery to the ipsilateral PICA. Her postoperative course was uneventful until she coughed up blood and had gross hematuria 3 days after the second surgery. Histological examination of a renal biopsy specimen revealed crescentic glomerulonephritis. MPA was diagnosed on the basis of the cardinal symptoms, including progressive glomerular nephritis and the lung abnormality, as well as the presence of myeloperoxidase-antineutrophil cytoplasmic antibodies. After intensive treatment, she was discharged for rehabilitation without neurological deficit. MPA commonly affects small-sized vessels mainly in the kidneys and lungs and may lead to crescentic glomerulonephritis and pulmonary hemorrhage. MPA is rarely associated with aneurysms of medium-sized muscular vessels. Cerebral aneurysm is extremely rare in patients with MPA, but rupture of an intracranial fusiform aneurysm can be lethal, so screening of the intracranial vessels should be performed by magnetic resonance imaging in patients with MPA.
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  • Subarachnoid Hemorrhage Caused by Ruptured Posterior Inferior Cerebellar Artery Aneurysm Arising From the Extracranial Portion of an Anomalous Vertebral Artery
    —Case Report—
    Makoto KATSUNO, Rokuya TANIKAWA, Nakao OTA, Naoto IZUMI, Masaaki HASHI ...
    2012 Volume 52 Issue 7 Pages 499-501
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.499
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    A 42-year-old woman presented with subarachnoid hemorrhage caused by a ruptured posterior inferior cerebellar artery aneurysm arising from the extracranial portion of an anomalous vertebral artery. We speculated that the aneurysm formed by dissection of the media because of its shape and location. Therefore, the aneurysm was isolated by trapping and excised, with occipital artery to posterior inferior cerebellar artery bypass. Histological examination showed a typical true aneurysm without evidence of dissection. This case suggests that an aneurysm of an anomalous artery is caused by hemodynamic stress and is a true aneurysm, not a dissection.
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  • Ruptured Large Basilar Artery Aneurysm Associated With an Arteriovenous Malformation in Hereditary Hemorrhagic Telangiectasia
    —Case Report—
    Daizo ISHII, Akihiko TAKECHI, Go SEYAMA, Takashi SOGABE
    2012 Volume 52 Issue 7 Pages 502-505
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.502
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    A 53-year-old woman presented with intracranial hemorrhage caused by a ruptured cerebral aneurysm. Digital subtraction angiography revealed a large aneurysm arising from the top of the basilar artery and a Spetzler-Martin grade 3 arteriovenous malformation. Endovascular embolization of the aneurysm was completed with a slight neck remnant. Medical examination confirmed that she suffered from hereditary hemorrhagic telangiectasia (HHT). HHT is a rare autosomal dominant disorder characterized by multiple mucocutaneous telangiectasia and associated vascular malformations. This case suggests that the prognosis for HHT patients with treatable aneurysms should be as good as that of healthy individuals. Consequently, neurosurgeons should suspect underlying HHT in all patients with cerebral vascular malformations.
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  • Giant Calcified Thrombosed Varices Secondary to a Pial Arteriovenous Fistula Associated With Hereditary Hemorrhagic Telangiectasia
    —Case Report of Surgical Removal—
    Taku SUGIYAMA, Naoki NAKAYAMA, Shunsuke TERASAKA, Satoshi KURODA, Kiyo ...
    2012 Volume 52 Issue 7 Pages 506-509
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.506
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    A 28-year-old woman presented with an unusual case of giant thrombosed varix with calcified walls that had mass effects secondary to a pial single-channel arteriovenous fistula (AVF) associated with hereditary hemorrhagic telangiectasia (HHT). She consulted our hospital for chronic headache. She had been diagnosed with HHT based on genetic testing when her 3-year-old son presented with subarachnoid hemorrhage due to spinal AVF. Imaging studies revealed pial single-channel AVF with multiple varices. The varices in the right frontal lobe were over 6 cm in diameter and had laminar thromboses and calcified walls. Because of the mass effect, direct surgical flow disconnection was performed followed by removal of the varices using an internal decompression technique. Postoperatively, the patient was discharged with no neurological symptoms and no longer suffered chronic headache. Intracerebral varices are occasionally associated with high-flow AVF, and usually treated by interrupting the feeding arteries leaving the varices intact. This extremely rare case of intracerebral giant thrombosed varices with calcified wall and mass effect indicates that surgical removal of varices should be considered.
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  • Paravertebral Arteriovenous Fistula Treated by Endovascular Coil Embolization
    —Case Report—
    Shinichiro TERAMOTO, Hidenori OISHI, Kensaku YOSHIDA, Munetaka YAMAMOT ...
    2012 Volume 52 Issue 7 Pages 510-512
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.510
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    A 41-year-old man, without underlying health problems or traumatic episodes, presented with a rare paravertebral arteriovenous fistula (AVF) causing radiculopathy manifesting as gradually progressive right grip weakness, and right thumb, index, and middle finger numbness. Digital subtraction angiography revealed a high flow, single hole paravertebral AVF fed by the right thyrocervical trunk that drained into the epidural venous plexus. The patient underwent endovascular embolization of the AVF via the transarterial approach. The fistula was completely occluded by coil embolization. Postembolization, clinical symptoms improved and 6-month follow-up angiography showed no recurrence of the fistula. Paravertebral AVF is a rare vascular malformation occurring outside the dura mater, fed by dural or epidural branches, and draining primarily into the epidural venous plexus. Paravertebral AVF is usually asymptomatic because of a “reflux-impending mechanism” within the dural sleeves that prevents retrograde drainage into the perimedullary veins. However, in the present case, mechanical compression of the radicular nerve due to a dilated epidural venous plexus resulted in neurological symptoms. We conclude that endovascular surgery is an effective treatment strategy for paravertebral AVF.
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  • Rare Variant of Persistent Primitive Hypoglossal Artery, Arising From the External Carotid Artery
    —Case Report—
    Masataka NANTO, Michiko TAKADO, Hidenori OHBUCHI, Ayako MANDAI, Yasuhi ...
    2012 Volume 52 Issue 7 Pages 513-515
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.513
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    A 63-year-old man presented with an extremely rare variant of persistent primitive hypoglossal artery (PHA), which was found incidentally during examination for a contralateral asymptomatic internal carotid artery (ICA) stenosis. This anastomotic vessel arose from the external carotid artery, not the ICA, and joined the vertebrobasilar artery through the hypoglossal canal. Persistent PHA is rare and the reported incidence is 0.027-0.26%. Recognition of the existence of this variant vessel and preservation during neuroradiologic intervention or surgery is important to prevent possible ischemic complications.
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  • Deterioration After Surgical Treatment of Spinal Dural Arteriovenous Fistula Associated With Spinal Perimedullary Fistula
    —Case Report—
    Osamu SASAKI, Naoki YAJIMA, Akimichi ICHIKAWA, Shinnya YAMASHITA, Kimi ...
    2012 Volume 52 Issue 7 Pages 516-520
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.516
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    Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of vascular malformations of the spine and are defined as abnormal arteriovenous shunts within the dura. SDAVFs are considered to be acquired and should be distinguished from congenital intradural perimedullary arteriovenous fistulas (PMAVFs). A 32-year-old female presented with both SDAVF and PMAVF, manifesting as a slowly progressive paraparesis over a 6-month period. Initial spinal angiography demonstrated an SDAVF in the sacral region and was terminated with incomplete demonstration of all segmental arteries. The fistula was obliterated by surgery and the patient showed transient postoperative improvement followed by delayed deterioration 2 months later. Magnetic resonance (MR) imaging showed many hypointense flow voids around the cord. The second angiography verified a PMAVF in the lumbar region and complete obliteration of the SDAVF. The fistula was closed by surgery and the patient improved slightly. Surgical results of SDAVFs are generally good. Therefore, if a patient fails to improve or deteriorates further after surgery with persistent perimedullary vessel abnormalities on MR imaging, the possibility of reopening of the fistula or the presence of another fistula should be considered and repeat angiography must be performed, especially if the initial angiography was incomplete.
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Technical Notes
  • Watertight Dural Closure Constructed With DuraSealTM for Bypass Surgery
    —Technical Note—
    Kengo NISHIMURA, Toshikazu KIMURA, Akio MORITA
    2012 Volume 52 Issue 7 Pages 521-524
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.521
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    Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a common procedure for the treatment of cerebral ischemia and is useful for cerebral aneurysms and tumors. The STA has to pass through the dura and the dura cannot be sutured tightly around the STA to prevent vessel narrowing, so subcutaneous cerebrospinal fluid (CSF) collection is common. This study analyzed the feasibility of using a synthetic dural sealant in the STA-MCA anastomosis to establish watertight closure. Twenty-four patients underwent STA-MCA anastomosis for cerebral ischemia or cerebral aneurysm. After creation of a standard STA-MCA anastomosis, the dura was reapproximated closely, leaving a small defect around the STA. Then, DuraSealTM was sprayed over the dural defect, and a negative-pressure drain was positioned before closing the skin. Only two patients developed subcutaneous CSF collection, which was managed conservatively. The patency of the anastomosis was proven by magnetic resonance angiography in all cases, and no ischemic complication suggesting chemical spasm of the STA due to the sealant occurred. With DuraSealTM, watertight dural closure can be obtained easily and safely in bypass surgery.
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  • Direct-Puncture Embolization of Scalp Arteriovenous Fistulae
    —Technical Note on the Circular Compression Device—
    Sung Won YOUN, Nam Joon LEE, Sang Il SUH, Sin Hyuk KANG
    2012 Volume 52 Issue 7 Pages 525-528
    Published: 2012
    Released on J-STAGE: July 25, 2012
    DOIhttps://doi.org/10.2176/nmc.52.525
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    We present our experience of flow control with the aid of a circular compression device (CCD) for embolization of scalp arteriovenous fistulae (sAVFs). A 21-year-old female presented with a pulsating scalp mass with sAVFs fed by the superficial temporal arteries. A CCD with a beveled circular handle and concentric hole was used to treat the condition. After the CCD was compressed over the area of the fistulae, the fistulae were punctured and blood regurgitation was assured. While maintaining flow stasis within the boundary of the CCD and loading heparinized dextrose-saline solution, a 50% mixture of N-butyl-2-cyanoacrylate and Lipiodol was applied during the compression, which was sustained for 1-2 minutes. Finally, the sAVFs were almost completely occluded without complications. Our designed CCD was effective for flow control, and direct-puncture embolization of N-butyl-2-cyanoacrylate during flow control using the CCD was safe and effective for the treatment of sAVFs.
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Editorial Committee
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