Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 54, Issue 3
Displaying 1-18 of 18 articles from this issue
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Original Articles
  • Differential Gene Expression in Relation to the Clinical Characteristics of Human Brain Arteriovenous Malformations
    Yasushi TAKAGI, Tomohiro AOKI, Jun C. TAKAHASHI, Kazumichi YOSHIDA, Ak ...
    2014 Volume 54 Issue 3 Pages 163-175
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 25, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0422
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    Arteriovenous malformations (AVMs) of the central nervous system are considered as congenital disorders. They are composed of abnormally developed dilated arteries and veins and are characterized microscopically by the absence of a capillary network. We previously reported DNA fragmentation and increased expression of apoptosis-related factors in AVM lesions. In this article, we used microarray analysis to examine differential gene expression in relation to clinical manifestations in 11 AVM samples from Japanese patients. We categorized the genes with altered expression into four groups: death-related, neuron-related, inflammation-related, and other. The death-related differentially expressed genes were MMP9, LIF, SOD2, BCL2A1, MMP12, and HSPA6. The neuron-related genes were NPY, S100A9, NeuroD2, S100Abeta, CAMK2A, SYNPR, CHRM2, and CAMKV. The inflammation-related genes were PTX3, IL8, IL6, CXCL10, GBP1, CHRM3, CXCL1, IL1R2, CCL18, and CCL13. In addition, we compared gene expression in those with or without clinical characteristics including deep drainer, embolization, and high-flow nidus. We identified a small number of genes. Using these microarray data we are able to generate and test new hypotheses to explore AVM pathophysiology. Microarray analysis is a useful technique to study clinical specimens from patients with brain vascular malformations.
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  • Mechanical Evaluation of Long Titanium Alloy Clip: Comparison of Cobalt Alloy Clip
    Tetsuyoshi HORIUCHI, Kiyoshi ITO, Kazuhiro HONGO, Masato SHIBUYA
    2014 Volume 54 Issue 3 Pages 176-179
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: November 20, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2013-0042
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    Long titanium aneurysm clips have recently been released. In the present study, comparative study of long titanium and cobalt alloy clips was performed. Two kinds of Sugita long clips (straight clips of 25- and 35-mm blade length) made of titanium and cobalt alloys were tested by measuring the closing force, the anti-scissoring torque, and the maximum opening width. There were some differences between the two materials. In the 25-mm blade length clip, closing force and maximum opening width of titanium alloy clip were greater than those of cobalt alloy clip. By contrast, the anti-scissoring torque of 35-mm blade length titanium clip was stronger than that of the cobalt. The long titanium clips would have equivalent endurance to long cobalt clip and are safe for clinical use.
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  • The Significance of Intraoperative Monitoring of Muscle Motor Evoked Potentials during Unruptured Large and Giant Cerebral Aneurysm Surgery
    Seiji TAKEBAYASHI, Hiroyasu KAMIYAMA, Katsumi TAKIZAWA, Tohru KOBAYASH ...
    2014 Volume 54 Issue 3 Pages 180-188
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: December 27, 2013
    DOIhttps://doi.org/10.2176/nmc.oa.2013-0001
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    The goal of this study was to characterize the utility of muscle motor evoked potentials (MMEPs) elicited by direct cortical stimulation as a means of monitoring during unruptured large and giant cerebral aneurysm surgery. This analysis focused on intraoperative changes in MMEPs and their relationship to postoperative motor function. The study population consisted of 50 patients who underwent surgery for large (n = 31) or giant (n = 19) cerebral aneurysms. Intraoperative MMEPs were continuously and successfully obtained in muscles belonging to the vascular territory of interest. There was no postoperative motor paresis in 31 (62%) patients in whom intraoperative MMEPs remained unchanged. Transient MMEP change occurred in 15 (30%) of the 50 patients, but 9 of those patients had no postoperative motor deficits, 5 had transient motor deficits, and 1 suffered permanent motor deficits resulting from postoperative delayed blood flow insufficiency due to arteriosclerosis of the parent artery. Permanent MMEP loss occurred in 4 (8%) of 50 patients, all of whom developed severe and permanent postoperative motor deficits. MMEP is a useful monitoring modality in patients undergoing surgery for large or giant cerebral aneurysms. This strategy can help predict functional prognosis or guide the neurosurgeon intraoperatively in an effort to promote better outcomes.
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Case Reports
  • Usefulness of V3-Radial Artery Graft-V4 Bypass in Bilateral Fusiform Aneurysms of Vertebral Artery: Case Report
    Norihiro SAITO, Hiroyasu KAMIYAMA, Katsumi TAKIZAWA, Seiji TAKEBAYASHI ...
    2014 Volume 54 Issue 3 Pages 189-191
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: January 28, 2014
    DOIhttps://doi.org/10.2176/nmc.cr.2012-0216
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    A 55-year-old woman with bilateral vertebral artery (VA) aneurysms was transferred to our hospital. She suffered from a minor stroke. Magnetic resonance imaging (MRI) for the stroke incidentally revealed bilateral VA aneurysms. Due to its size, more observation was recommended, and the patient was found eager to be treated. Both side surgeries were found inappropriate because of severe lower cranial nerve disturbances. The right aneurysm involved the posterior inferior cerebellar artery (PICA) and the V4 segment was deviated to the right side. Therefore, the smaller right aneurysm was treated first with an occipital artery (OA)-PICA bypass and a V3-radial artery graft (RAG)-V4 bypass followed by proximal clipping of the PICA and the right VA. The right VA was successfully remade by RAG and the right aneurysm was not revealed on postoperative examination. By doing so, the opposite aneurysm was able to be eliminated by the parent artery occlusion even by using an interventional radiology (IVR). The V3-RAG-V4 bypass is a useful method for treating bilateral VA aneurysms. This is a new bypass which has not been reported so far to the best of our knowledge.
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  • Advantage of Microscope Integrated for Both Indocyanine Green and Fluorescein Videoangiography on Aneurysmal Surgery: Case Report
    Hideyuki YOSHIOKA, Hiroyuki KINOUCHI, Yoshihisa NISHIYAMA, Kazuya KANE ...
    2014 Volume 54 Issue 3 Pages 192-195
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0256
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    Neck clipping of a large middle cerebral artery aneurysm was performed using a newly developed surgical microscope integrated with modules for both indocyanine green (ICG) and fluorescein videoangiography. During surgery, ICG and fluorescein videoangiography by intra-arterial or intravenous injection were safely carried out without interrupting the surgical procedure. Based on the findings obtained from the case, we evaluated the differences between the dyes and the injection routes. With intra-arterial injection, fluorescein offered sharper contrast images and was better at depicting fine arteries than ICG. Patchy staining of vessel walls was observed in intravenous fluorescein videoangiography, while it was not evident in ICG. Intra-arterial injection method had a great advantage in the rapid clearance of the dyes, which allowed us to perform repeated videoangiography within a short period, and was useful in detecting incomplete clipping in this case; however, catheter insertion requires additional work and carries a potential risk. Use of a microscope integrated for both ICG and fluorescein videoangiography would be another method for repeated evaluation. Namely, alternate use of the dyes enables us to perform videoangiography in a short time even via intravenous injection.
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  • Subarachnoid Hemorrhage After an Ischemic Attack Due to a Bacterial Middle Cerebral Artery Dissecting Aneurysm: Case Report and Literature Review
    Atsushi SAITO, Tomohiro KAWAGUCHI, Emiko HORI, Masayuki KANAMORI, Shin ...
    2014 Volume 54 Issue 3 Pages 196-200
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0251
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    A 78-year-old woman suffered sudden-onset left hemiparesis. There were no remarkable infectious findings. Computed tomography (CT) demonstrated a low-intensity area supplied by the right middle cerebral artery (MCA). The diagnosis was cerebral ischemia and she was conservatively treated with hyperosmotic fluids. Two days after the ischemic stroke she suddenly became comatose. CT showed diffuse subarachnoid hemorrhage (SAH) in the basal cistern associated with a right intra-Sylvian and a right frontal subcortical hematoma. Three-dimensional (3D)-CT angiography demonstrated occlusion of the M2 portion of the right MCA. Four days after the ischemic onset she died of brain herniation. Autopsy revealed arterial dissection in the intermediate membrane of the right MCA bifurcation and occlusion of the M2 portion of the thrombosed right MCA. Gram staining showed remarkable bacterial infection in the thrombus. SAH after an ischemic attack due to MCA dissection is extremely rare. We suspect that bacterial infection was involved in the formation of her fragile dissecting aneurysm.
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  • A Ruptured Aneurysm Located at a Collateral Artery That Extended From the Proximal A2 Segment to the M1 Segment, Associated With an Anomalous Branch of the Anterior Choroidal Artery and Middle Cerebral Artery Hypoplasia: Case Report
    Naoki OTANI, Kojiro WADA, Fumihiro SAKAKIBARA, Satoru TAKEUCHI, Kimihi ...
    2014 Volume 54 Issue 3 Pages 201-204
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0219
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    We here describe the first case of a ruptured aneurysm located at a collateral artery that extended from the proximal A2 segment to the M1 segment, which was associated with an anomalous branch of the anterior choroidal artery and middle cerebral artery (MCA) hypoplasia. The aneurysm was revealed by angiograms and intraoperative findings. No previous accounts have been published of such an extremely rare vessel anomaly. In practice, this case highlights the urgent need to preoperatively recognize such vascular anomalies, as well as to better understand the collateral blood supply in cerebral ischemia associated with these MCA anomalies. Such knowledge will be helpful for planning optimal surgical procedures.
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  • A Case of Thrombosed Giant Aneurysm of the Azygos Anterior Cerebral Artery: Clipping Under Monitoring of Motor Evoked Potentials of the Lower Extremities
    Hiroshi YONEDA, Michiyasu SUZUKI, Hideyuki ISHIHARA, Hiroyasu KOIZUMI, ...
    2014 Volume 54 Issue 3 Pages 205-210
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0343
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    Giant aneurysms of the distal anterior cerebral artery (ACA), especially the azygos ACA, are rare. We treated a patient with giant aneurysm of the azygos ACA who underwent aspiration of thrombus and clipping under monitoring of motor evoked potentials of the lower extremities (L-MEPs), resulting in remarkable recovery of motor and intellectual function. A 72-year-old male was admitted with left motor weakness persisting for 2 weeks. Neurologically, disorientation and intellectual impairment were also noted. Imaging disclosed a 60-mm diameter aneurysm with heterochronous thrombi arising from the distal bifurcation of the azygos ACA. One month after the onset, radical surgery was scheduled. The azygos ACA was secured and the aneurysm was dissected, and the distal parts of the azygos ACA were confirmed. After removal of the thrombus, the neck was reconstructed with eight clips. L-MEPs disappeared due to occlusion of the azygos ACA for 20 minutes but reappeared after 22 minutes and normalized 78 minutes after reperfusion. Motor weakness improved entirely with mini-mental state examination score of 29 points at 1 month after surgery. One year later, Wechsler Adult Intelligence Scale-Third Edition and Wechsler Memory Scale-Revised scores reached normal levels. Review of reported cases found this aneurysm tends to occur in males in their 50s to 70s presenting with mass sign. Decompression of the aneurysm in the frontal lobe and monitoring of L-MEPs during temporary occlusion of the ACA are important.
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  • Penetration of the Optic Nerve and Falciform Ligament by an Internal Carotid Artery-Ophthalmic Artery Aneurysm
    —Case Report—
    Yasushi TAKAGI, Susumu MIYAMOTO
    2014 Volume 54 Issue 3 Pages 211-213
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0424
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    We report a case of an internal carotid artery (ICA)-ophthalmic artery aneurysm with penetration of the opticnerve. In addition, this case penetrated the falciform ligament, which severely disturbed optic canal unroofing during surgery. This is the first reported case in which penetration of the optic nerve and falciform ligament has been shown. To remove the anterior clinoid process in this case, the ultrasonic bone curette was a useful tool.
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  • Ptosis as Partial Oculomotor Nerve Palsy Due to Compression by Infundibular Dilatation of Posterior Communicating Artery, Visualized with Three-Dimensional Computer Graphics: Case Report
    Yuta FUKUSHIMA, Hideaki IMAI, Masanori YOSHINO, Taichi KIN, Megumi TAK ...
    2014 Volume 54 Issue 3 Pages 214-218
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: November 08, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0383
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    Oculomotor nerve palsy (ONP) due to internal carotid-posterior communicating artery (PcomA) aneurysm generally manifests as partial nerve palsy including pupillary dysfunction. In contrast, infundibular dilatation (ID) of the PcomA has no pathogenic significance, and mechanical compression of the cranial nerve is extremely rare. We describe a 60-year-old woman who presented with progressive ptosis due to mechanical compression of the oculomotor nerve by an ID of the PcomA. Three-dimensional computer graphics (3DCG) accurately visualized the mechanical compression by the ID, and her ptosis was improved after clipping of the ID. ID of the PcomA may cause ONP by mechanical compression and is treatable surgically. 3DCG are effective for the diagnosis and preoperative simulation.
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  • Discrepancy between Preoperative Imaging and Postoperative Pathological Finding of Ruptured Intracranial Dissecting Aneurysm, and Its Surgical Treatment: Case Report
    Nakao OTA, Rokuya TANIKAWA, Hiroyasu KAMIYAMA, Takanori MIYAZAKI, Kosu ...
    2014 Volume 54 Issue 3 Pages 219-226
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: November 08, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0433
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    The choice of therapeutic strategy for intracranial dissecting aneurysm is often based on radiographic features, including characteristic geometry (e.g., irregular stenosis, segmental stenosis, aneurysm formation [pearl-and-string sign]), irregular fusiform or aneurysmal dilation, double lumen, and tapering occlusion. However, there is often a discrepancy between preoperative radiographic data and actual dissecting length. The present report describes three cases in which there was a discrepancy between preoperative radiographic data and actual dissecting length in patients undergoing direct trapping with or without revascularization. All three cases experienced good outcomes, but these cases underscore the fact that open surgery is a good option for management of ruptured intracranial dissecting aneurysms for determination of the rupture point, dissecting length, and the relationship between dissecting area and small arteries arising from the associated vessel.
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  • Emerging Sylvian Subpial Hematoma after the Repair of the Ruptured Anterior Cerebral Artery Aneurysm with Interhemispheric Approach: Case Report
    Noriaki MINAMI, Toshikazu KIMURA, Yasumitsu ICHIKAWA, Akio MORITA
    2014 Volume 54 Issue 3 Pages 227-230
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: November 20, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2013-0025
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    A 60-year-old woman was admitted to the hospital due to a sudden loss of consciousness. Computed tomography (CT) revealed a thick subarachnoid hemorrhage in almost all of the parachiasmatic cisterns, including the sylvian cisterns, with mild hydrocephalus. Three dimensional (3D)-CT angiography showed an irregularly shaped aneurysm at the bifurcation of the left A2 and the frontopolar artery. The aneurysm was successfully obliterated by clipping through the interhemispheric approach. CT performed immediately after the operation showed a newly formed left temporal subpial hematoma. The patient’s neurological status improved gradually after surgery, but deteriorated again 2 days after the operation. CT revealed an enlarging right sylviansubpial hematoma. The subpial hematoma was rapidly removed surgically. Slight hemiparesis and impaired higher cognitive function remained after a shunt procedure for subsequent hydrocephalus. Emerging sylvian hematoma associated with a distant site of a ruptured aneurysm is extremely rare. However, adequate attention is required in cases with a thick subarachnoid hemorrhage in distant fissures.
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  • Effective Use of Sertraline for Pathological Laughing after Severe Vasospasm Due to Aneurysmal Subarachnoid Hemorrhage: Case Report
    Hayato TAKEUCHI, Kazuhide IWAMOTO, Mao MUKAI, Tomoaki FUJITA, Hitoshi ...
    2014 Volume 54 Issue 3 Pages 231-235
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: November 08, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0376
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    Pathological laughing, one subgroup of psuedobulbar affect, is known as laughter inappropriate to the patient’s external circumstances and unrelated to the patient’s internal emotional state. The authors present the case of a 76-year-old woman with no significant medical history who experienced pathological laughing after subarachnoid hemorrhage (SAH) due to rupture of an aneurysm, which was successfully treated with craniotomy for aneurysm clipping. In the acute stage after the operation she suffered from severe vasospasm and resulting middle cerebral artery territory infarction and conscious disturbance. As she regained consciousness she was afflicted by pathological laughing 6 months after the onset of SAH. Her involuntary laughter was inappropriate to the situation and was incongruent with the emotional state, and she could not control by herself. Finally the diagnosis of pathological laughing was made and treatment with sertraline, a selective serotonin reuptake inhibitor (SSRI), effectively cured the symptoms. Her pathological laughing was estimated to be consequence of infarction in the right prefrontal cortex and/or corona radiata, resulting from vasospasm. To the authors’ knowledge, this is the first report of pathological laughing after aneurysmal SAH. The authors offer insight into the pathophysiology of this rare phenomenon. Effectiveness of sertraline would widen the treatment modality against pathological laughing.
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  • Trigeminal Neuralgia Caused by Nerve Compression by Dilated Superior Cerebellar Artery Associated with Cerebellar Arteriovenous Malformation: Case Report
    Yoshimasa MORI, Tatsuya KOBAYASHI, Shigeru MIYACHI, Chisa HASHIZUME, T ...
    2014 Volume 54 Issue 3 Pages 236-241
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: November 20, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0370
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    Intracranial arteriovenous malformation (AVM) is a rare cause of trigeminal neuralgia (TGN). In this presented case, successful resolution of AVM-related TGN following embolization and gamma knife stereotactic radiosurgery (GKRS) was obtained. A patient suffered from TGN on the left side, which was thought to be caused by root entry zone compression by dilated superior cerebellar artery (SCA) associated with cerebellar AVM. The cerebellar vermis AVM was embolized in endovascular surgery. The AVM was reduced in size and TGN was partially relieved. The patient subsequently underwent GKRS for the residual nidus. TGN was completely resolved within one year and a half. GKRS following embolization of the nidus improved the flow-related dilation of the SCA and completely relieved TGN.
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  • Intracranial Pial Arteriovenous Fistula Caused by Dural Tenting: Case Report
    Yoshihisa NISHIYAMA, Kazuya KANEMARU, Hideyuki YOSHIOKA, Mitsuto HANIH ...
    2014 Volume 54 Issue 3 Pages 242-244
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0239
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    We describe a rare case where a patient developed intracranial pial arteriovenous (AV) fistula due to dural tenting. The patient was a 63-year-old woman who had undergone neck clipping for an unruptured middle cerebral artery (MCA) aneurysm. The surgery was performed without any problems and her postoperative course was uneventful. Two weeks after cerebral angiography operation revealed a pial AV fistula fed by the right MCA and drained into the vein of Trolard through the Sylvian vein which had not existed before surgery. Being diagnosed as de novo pial AV fistula, surgical repair was performed. The AV fistula was located just beneath the dural tenting. The fistulous point was confirmed with fluorescein video angiography and obliterated using a clip. Although rare, we should pay attention to the AV fistula due to dural tenting as the complications of cranial surgery.
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  • Acquired Pial and Dural Arteriovenous Fistulae following Superior Sagittal Sinus Thrombosis in Patients with Protein S Deficiency: A Report of Two Cases
    Shunji MATSUBARA, Koichi SATOH, Junichiro SATOMI, Toshio SHIGEKIYO, To ...
    2014 Volume 54 Issue 3 Pages 245-252
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 25, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0311
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    Two patients with protein S deficiency with acquired multiple pial and dural arteriovenous fistulae (AVFs) following superior sagittal sinus (SSS) thrombosis are reported. Case 1 is a 38-year-old male with protein S deficiency who developed generalized seizure due to SSS thrombosis. Local fibrinolysis was achieved in the acute stage. His 10-month follow-up angiogram revealed an asymptomatic acquired dural AVF arising from the middle meningeal artery and the anterior cerebral artery with drainage to the thrombosed cortical vein in the right frontal lobe. Furthermore, his 2-year follow-up angiogram revealed a de novo pial AVF from the middle cerebral artery in the Sylvian fissure with drainage to the cortical vein initially thrombosed. However, this asymptomatic pial AVF caused bleeding in the ipsilateral cerebral hemisphere 12 years after onset, whereas the dural AVF spontaneously disappeared. Surgical disconnection was successfully performed to eliminate the source of hemorrhage. Case 2 is a 50-year-old male with a past history of SSS thrombosis with protein S deficiency who developed pulsatile tinnitus and generalized seizure. His angiogram showed a cortical dural AVF in the left parietal lobe and a sporadic dural AVF involving the right sigmoid sinus. The parietal lesion was eliminated by transarterial embolization followed by craniotomy. However, a de novo pial AVF emerged from the middle cerebral artery adjacent to the previously treated lesion. Of four cortical AVFs in two patients, thrombosis of cortical veins caused by protein S deficiency might play an important role in their formation. Long-term follow-up is required because this peculiar disorder has an unusual clinical course.
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  • Isolated Superficial Sylvian Vein Thrombosis With Long Cord Sign: Case Report and Review of the Literature
    Yohei KITAMURA, Koichi HARA, Kenichiro TSUNEMATSU
    2014 Volume 54 Issue 3 Pages 253-259
    Published: 2014
    Released on J-STAGE: March 15, 2014
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0220
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    Isolated cortical vein thrombosis (ICVT) is extremely rare. Only single case or small series of ICVT have been reported; clinical details are still uncertain. We report a case of isolated superficial sylvian vein thrombosis with exceedingly long cord sign. A 14-year-old female with severe sudden onset headache visited our hospital. Fluid attenuated inversion recovery and echo-planar T2* susceptibility-weighted imaging (T2*SW) showed a long cord sign on the surface of the sylvian fissure. The patency of dural sinuses and deep cerebral veins were confirmed by magnetic resonance venography (MRV), and diagnosis of ICVT was made. She recovered completely without anticoagulant agents. To clarify the clinical characteristics of ICVT, we reviewed 51 ICVT cases in the literature. In many cases, T2*SW was the most useful examination to diagnose ICVT. In contrast with general cerebral venous thrombosis, MRV and conventional angiography were either supporting or useless. Anastomotic cortical veins were involved frequently; symptoms of gyri around the veins were common. It also suggested that ICVTs of the silent area might have been overlooked because of nonspecific symptoms, and more patients with ICVT may exist. In cases involving patients with nonspecific symptoms, the possibility of ICVT should be considered.
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