Coincidental Nasopharyngeal Carcinoma and Ventral Foramen Magnum Meningioma:Case Report and Review of the Literature

Multiple primary tumors at adjacent site are rare. We report a rare case of coincidentally found nasopharyngeal cancer and ventral foramen magnum meningioma. The 68-year-old male patient presented with a year history of ataxia. Radiological examination revealed lesions in the nasopharyngeal space and ventral foramen magnum. A needle aspiration biopsy for nasopharyngeal space and surgical removal for foramen magnum lesion were performed. The pathological diagnoses were nasopharyngeal cancer and meningioma, respectively. The concomitant occurrence of these two tumors is very rare and there is no known association between these two tumors. We report a case of ventral foramen magnum meningioma simultaneously present with nasopharyngeal carcinoma.

Cerebral Arterial Stenosis in Patients with Spontaneous Intracerebral Hemorrhage

OBJECTIVE: Spontaneous intracerebral hemorrhage (ICH) and ischemic stroke share common vascular risk factors such as aging and hypertension. Previous studies suggested that the rate of recurrent ICH and ischemic stroke might be similar after ICH. Presence of cerebral arterial stenosis is a potential risk factor for future ischemic stroke. This study investigated the prevalence and factors associated with cerebral arterial stenosis in Korean patients with spontaneous ICH. METHODS: A total of 167 patients with spontaneous ICH were enrolled. Intracranial arterial stenosis (ICAS) and extracranial arterial stenosis (ECAS) were assessed by computed tomography angiography. Presence of ICAS was defined if patients had arterial stenosis in at least one intracranial artery. ECAS was assessed in the extracranial carotid artery. More than 50% luminal stenosis was defined as presence of stenosis. Prevalence and factors associated with presence of ICAS and cerebral arterial stenosis (presence of ICAS and/or ECAS) were investigated by multivariable logistic regression analysis. RESULTS: Thirty-two (19.2%) patients had ICAS, 7.2% had ECAS, and 39 (23.4%) patients had any cerebral arterial stenosis. Frequency of ICAS and ECAS did not differ among ganglionic ICH, lobar ICH, and brainstem ICH. Age was higher in patients with ICAS (67.6±11.8 vs. 58.9±13.6 years p=0.004) and cerebral arterial stenosis (67.9±11.6 vs. 59.3±13.5 years, p<0.001) compared to those without stenosis. Patients with ICAS were older, more frequently had diabetes, had a higher serum glucose level, and had a lower hemoglobin level than those without ICAS. Patients with cerebral arterial stenosis were older, had diabetes and lower hemoglobin level, which was consistent with findings in patients with ICAS. However, patients with cerebral arterial stenosis showed higher prevalence of hypertension and decreased kidney function compared to those without cerebral arterial stenosis. Multivariable logistic regression analyses showed that aging and presence of diabetes independently predicted the presence of ICAS, and aging, diabetes, and hypertension were independently associated with presence of cerebral arterial stenosis. CONCLUSION: 19.2% of patients with spontaneous ICH had ICAS, but the prevalence of ECAS was relatively lower (7.2%) compared with ICAS. Aging and diabetes were independent factors for the presence of ICAS, whereas aging, hypertension, and diabetes were factors for the cerebral arterial stenosis.

Positional Intraocular Pressure between Phakic and Pseudophakic Eyes after Cataract Surgery in a Single Eye

PURPOSE: In the present study, the dependence of intraocular pressure (IOP) on body position was compared between pseudophakic and phakic eyes after cataract surgery performed at least 3 months prior. METHODS: IOP was measured in 214 patients over 40 years of age who received cataract surgery at least 3 months prior. The present study included 104 patients who did not have any other ocular disease which could influence visual acuity or IOP. The IOP was measured in 4 different positions, sitting, supine, right decubitus, and left decubitus by a single skilled researcher using Icare tonometer. In addition, IOP was compared between the phakic and pseudophakic eyes, specifically, the dependent eye in the decubitus position. RESULTS: The comparison between the phakic and pseudophakic eyes in patients after cataract surgery in a single eye showed IOP was not different between the sitting and supine positions; however, in the decubitus position, IOP in the dependent eye was significantly higher than the non-dependent eye (p = 0.001). Additionally, regardless of lens status, IOP was significantly higher in the dependent eye than non-dependent eye. CONCLUSIONS: Both body position and lens status can affect IOP. After cataract surgery, regardless of lens status, IOP was higher in the dependent eye than non-dependent eye of patients in the decubitus position.

Outcome of External Ventricular Drainage according to the Operating Place: the Intensive Care Unit versus Operating Room / 대한구급학회지

BACKGROUND: External ventricular drainage (EVD) is an important procedure for draining excessive cerebrospinal fluid (CSF) and monitoring intracranial pressure. Generally, EVD is performed in the operating room (OR) under aseptic conditions. However, in emergency circumstances, the operation may be performed in the intensive care unit (ICU) to save neuro-critical time and to avoid the unnecessary transfer of patients. In this study, we retrospectively analyzed the risk of EVD-induced CNS infections and their outcomes according to the operating place (ICU versus OR). In addition, we compared mortalities as well as hospital and ICU days between the CNS infection and non-CNS infection groups. METHODS: We reviewed medical records, laboratory data and radiographic images of patients who had received EVD operations between January, 2013 and March, 2015. RESULTS: A total of 75 patients (45 men and 30 women, mean age: 58.7 +/- 15.6 years) were enrolled in this study. An average of 1.4 catheters were used for each patient and the mean period of the indwelling catheter was 7.5 +/- 5.0 days. Twenty-six patients were included in the ICU group, and EVD-induced CNS infection had occurred in 3 (11.5%) patients. For the OR group, forty-nine patients were included and EVD-induced CNS infection had occurred in 7 (14.3%) patients. The EVD-induced CNS infection of the ICU group did not increase above that of the OR group. The ICU days and mortality rate were higher in the CNS infection group compared to the non-CNS infection group. The period of the indwelling EVD catheter and the number of inserted EVD catheters were both higher in the CNS infection group. CONCLUSIONS: If the aseptic protocols and barrier precautions are strictly kept, EVD in the ICU does not have a higher risk of CNS infections compared to the OR. In addition, EVD in the ICU can decrease the hospital and ICU days by saving neuro-critical time and avoiding the unnecessary transfer of patients. Therefore, when neurosurgeons decide upon the operating place for EVD, they should consider the benefits of ICU operation and be cautious of EVD-induced CNS infection.

Delayed Ischemic Stroke after Flow Diversion of Large Posterior Communicating Artery Aneurysm

For securing large, giant, and wide-neck aneurysms, conventional coil embolization has substantial limitations, such as incomplete occlusion, recanalization, and a high recurrence rate. To overcome these limitations, a novel paradigm was suggested and, as a result, flow-diverting device was developed. The flow-diverting device is an innovative and effective technique to allow securing of large, giant, and wide-neck aneurysms. In numerous studies, the flow-diverting device has shown better outcomes than coil embolization. However, the flow-diverting device has also some risks, including rupture of aneurysm, intracerebral hemorrhage, and ischemic stroke. In addition, with more experience, unexpected complications are also reported.5) 7) In the present case, we experienced a delayed ischemic stroke at 27 days after endovascular treatment. The patient had multiple aneurysms and, among them, we treated a large posterior communicating artery aneurysm using Pipeline™ Embolization Device. The patient was tolerable for 25 days, but then suddenly presented intermittent right hemiparesis. In the initial diffusion magnetic resonance imaging (MRI), there was no acute lesion; however, in the follow-up MRI, an acute ischemic stroke was found in the territory of anterior choroidal artery which was covered by Pipeline Embolization Device. We suspect that neo-intimal overgrowth or a tiny thrombus have led to this delayed complication. Through our case, we learned that the neurosurgeon should be aware of the possibility of delayed ischemic stroke after flow diversion, as well as, long-term close observation and follow-up angiography are necessary even in the event of no acute complications.

Outcome of External Ventricular Drainage according to the Operating Place: the Intensive Care Unit versus Operating Room / 대한중환자의학회지

BACKGROUND: External ventricular drainage (EVD) is an important procedure for draining excessive cerebrospinal fluid (CSF) and monitoring intracranial pressure. Generally, EVD is performed in the operating room (OR) under aseptic conditions. However, in emergency circumstances, the operation may be performed in the intensive care unit (ICU) to save neuro-critical time and to avoid the unnecessary transfer of patients. In this study, we retrospectively analyzed the risk of EVD-induced CNS infections and their outcomes according to the operating place (ICU versus OR). In addition, we compared mortalities as well as hospital and ICU days between the CNS infection and non-CNS infection groups. METHODS: We reviewed medical records, laboratory data and radiographic images of patients who had received EVD operations between January, 2013 and March, 2015. RESULTS: A total of 75 patients (45 men and 30 women, mean age: 58.7 +/- 15.6 years) were enrolled in this study. An average of 1.4 catheters were used for each patient and the mean period of the indwelling catheter was 7.5 +/- 5.0 days. Twenty-six patients were included in the ICU group, and EVD-induced CNS infection had occurred in 3 (11.5%) patients. For the OR group, forty-nine patients were included and EVD-induced CNS infection had occurred in 7 (14.3%) patients. The EVD-induced CNS infection of the ICU group did not increase above that of the OR group. The ICU days and mortality rate were higher in the CNS infection group compared to the non-CNS infection group. The period of the indwelling EVD catheter and the number of inserted EVD catheters were both higher in the CNS infection group. CONCLUSIONS: If the aseptic protocols and barrier precautions are strictly kept, EVD in the ICU does not have a higher risk of CNS infections compared to the OR. In addition, EVD in the ICU can decrease the hospital and ICU days by saving neuro-critical time and avoiding the unnecessary transfer of patients. Therefore, when neurosurgeons decide upon the operating place for EVD, they should consider the benefits of ICU operation and be cautious of EVD-induced CNS infection.

The Relationship between Vitamin D and Glaucoma: A Kangbuk Samsung Health Study

PURPOSE: To investigate the relationship between vitamin D and glaucoma. METHODS: This retrospective, cross-sectional study included subjects who underwent a health screening at the Health Screening Center of Kangbuk Samsung Hospital from August 2012 to July 2013. All fundus photographs were reviewed by ophthalmologists. The ophthalmologists determined if an eye was glaucomatous based on the criteria set forth by the International Society of Geographical and Epidemiological Ophthalmology and by the appearance of the retinal nerve fiber layer and optic disc. If the subjects previously underwent an ophthalmologic examination, they were enrolled based on the documented history. In addition to fundus photographs, each participant underwent a systemic examination including blood sampling and sociodemographic and behavioral questionnaires. The subjects were divided into five groups according to serum 25-hydroxyvitamin D (25(OH)D) level. Multivariate logistic regression models were constructed to assess possible associations between elevated glaucoma risk and systemic factors with a p < 0.2 on univariate analysis. RESULTS: Of the 169,208 subjects older than 20 years, 123,331 were eligible for the study. There was no difference in the prevalence of glaucoma according to quintile of serum 25(OH)D level based on sex (p = 0.412 for males, p = 0.169 for females). According to the multivariable-adjusted logistic analysis, the odds ratio of glaucoma for the fourth quintile was significantly lower than that of the first quintile in females (odds ratio, 0.713; 95% confidence interval, 0.520 to 0.979). CONCLUSIONS: Lower 25(OH)D level was significantly associated with an elevated risk of glaucoma in females compared with higher 25(OH)D level. Further evaluation is needed to investigate the relationship between glaucoma and vitamin D.

Rapid Visual Deterioration Caused by Posterior Fossa Arachnoid Cyst

Posterior fossa is a site next to the middle fossa where arachnoid cyst frequently occurs. Generally, most arachnoid cysts are asymptomatic and are found incidentally in most cases. Although arachnoid cysts are benign and asymptomatic lesions, patients with posterior fossa arachnoid cysts often complain of headaches, gait disturbance, and ataxia due to the local mass effects on the cerebellum. We observed a patient with a posterior fossa arachnoid cyst who had visual symptoms and a headache, but did not have gait disturbance and ataxia. We recommended an emergency operation for decompression, but the patient refused for personal reasons. After 7 days, the patient revisited our hospital in a state of near-blindness. We suspected that the arachnoid cyst induced the hydrocephalus and thereby the enlarged third ventricle directly compressed optic nerves. Compressed optic nerves were rapidly aggravated during the critical seven days; consequently, the patient's vision was damaged despite the operation. Considering the results of our case, it is important to keep in mind that the aggravation of symptoms cannot be predicted; therefore, symptomatic arachnoid cysts should be treated without undue delay.

Clinical Analysis of Risk Factors for Recurrence in Patients with Chronic Subdural Hematoma Undergoing Burr Hole Trephination / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma (CSDH) is one of the most common types of intra-cranial hemorrhages usually associated with trauma. Surgical treatment is the treatment of choice and burr hole trephination (BHT) is widely performed. The recurrence rate in the patients with CSDH is 3.7-30%. This study investigated the risk factors associated with the recurrence of patients with CSDH who underwent BHT. METHODS: One hundred twenty-five patients with CSDH underwent BHT. Eight of 125 patients (6.4%) underwent reoperation for recurrent CSDH. We retrospectively analyzed demographic, clinical and radiological findings, catheter tip location and drainage duration as the risk factors for the recurrence of CSDH. RESULTS: Recurrence of CSDH in the high- or mixed-density groups was significantly higher than those in the low- or iso-density groups (p<0.001). Placement of catheter tip at the temporoparietal area was associated with a significantly higher recurrence rate of CSDH than placement at the frontal area (p=0.006) and the brain re-expansion rate (BRR) was much lower than placement at the frontal area (p<0.001). CONCLUSION: The operation may be delayed in high- and mixed-density groups, unless severe symptoms or signs are present. In addition, placing the catheter tip at the frontal area helps to reduce the incidence of postoperative recurrence of CSDH and to increase the BRR.

Various Techniques of Stent-Assisted Coil Embolization of Wide-Necked or Fusiform Middle Cerebral Artery Aneurysms : Initial and Mid-Term Results

OBJECTIVE: To evaluate the feasibility and clinical and angiographic outcomes of stent-assisted embolization for complex middle cerebral artery (MCA) aneurysms. METHODS: The records of 23 consecutive patients with 24 MCA aneurysms, who underwent stent-assisted embolization of the aneurysm, were retrospectively evaluated. RESULTS: Fifteen aneurysms were treated with one stent and 8 were treated using more than two stents (5 a stent-within-a-stent, 1 triple stents, and two Y-stent). Angiographically, complete or near complete occlusion was achieved in 15 aneurysms (65.2%), residual neck in five (21.7%), and residual aneurysm in three (13.1%). Five aneurysms demonstrated thrombosis within the stent during the procedure and hospitalization, and were resolved by intraarterial and intravenous Tirofiban injection. Symptomatic thromboembolic complications were developed in five patients and permanent deficits demonstrated in two patients with modified Rankin Scale 1 and 2, respectively. Treatment-related permanent morbidity and mortality rates were 8.3% and 0% with relatively high complication rate. Angiographic follow-up was available in 17 aneurysms at 6-31 months (mean, 13.2 months) and showed stable or improved in 15 (88.2%) and major and minor recurrence in one, respectively. CONCLUSION: Complex MCA aneurysms could be treated by stent-assisted coiling and showed lower recanalization rate during mid-term follow-up by effective flow diversion due to various stent-assisted techniques. Our results warrant further study with a longer follow-up period in a larger sample.

Adalimumab Induced Acute Exacerbation of Rheumatoid Arthritis Related Interstitial Lung Disease

A 69-year-old woman with 6 years history of seropositive rheumatoid arthritis (RA) and asymptomatic interstitial lung disease (ILD) began taking adalimumab for ongoing arthritis despite intakes of sulfasalazine and hydroxychloroquine for treatment. ILD progressed noticeably after 10 weeks of starting adalimumab. We discontinued adalimumab and added methylprednisolone 40 mg, and the patient's clinical findings gradually improved. The beneficial and adverse effects of tumor necrosis factor-alpha (TNF-alpha) inhibitors on RA associated ILD are unclear but this case reports adalimumab could abruptly exacerbate known ILD. We emphasize cautions on the use of adalimumab, one of the TNF-alpha inhibitors, in elderly RA patients with preexisting ILD.

A Case of Anisakiasis Invading the Stomach and the Colon at the Same Time after Eating Anchovies

Anisakiasis of the gastrointestinal tract is caused by the ingestion of raw fish or uncooked food infested with Anisakis larvae. A large number of cases of gastric anisakiasis have been reported in countries where the eating of raw fish is customary. However, there have been few reports of anisakiasis of the colon confirmed by colonoscopy and also very few reports of endoscopic ultrasonographic findings of anisakiasis. A 47-year-old man had epigastric pain with nausea after eating raw anchovies. Endoscopy found a living tubular structure penetrating into the lesser curvature of the stomach and the midtranseverse colon area. It was withdrawn with biopsy forceps. We report a case of anisakiasis simultaneously invading the stomach and the colon confirmed by endosopic utrasonographic findings and biopsy findings.

A Case of Neuroblastoma in Old Age / 대한내과학회지

Neuroblastoma originates in the sympathetic division of the autonomic nervous system, and is the most common extracranial solid malignancy in children; rarely developing in adults. Generally this primitive neuronal malignancy develops during fetal development or in early childhood. However, we have cared for one elderly patient with neuroblastoma. The 84-year-old woman suffered from several symptoms, such as general weakness, weight loss, and hematuria. Her abdominopelvic computed tomography showed an 8.5 x 8 cm mass, which originated from the right kidney. Pathological examination by explorative laparotomy indicated neuroblastoma. She was treated by radical nephrectomy. One year later, there has been no recurrence or solid organ metastasis, and the patient has been in good clinical condition.

A Comparative Study of Local versus General Anesthesia for Chronic Subdural Hematoma in Elderly Patients Over 60 Years / 대한신경손상학회지

OBJECTIVE: The purpose of this study is to compare the surgical and anesthetic complications of the local and general anesthesia in chronic subdural hematoma (CSDH) patients. METHODS: We retrospectively analyzed the medical record and brain CT of CSDH patients over 60-years-old, who were treated surgically in our institution between January 2005 and December 2012. RESULTS: One hundred six patients with CSDH were enrolled for this study and 61 patients had a burr hole craniostomy under the local anesthesia. In local anesthesia group, surgical complication was not increased than general anesthesia group. But in general anesthesia group, heart disease such as arrhythmia, acute myocardial infarction was relatively increased than local anesthesia group (p=0.04). And the hospitalization period of local anesthesia group was shorter than that of general anesthesia group (p=0.001). CONCLUSION: In this present study, there was no significant difference of surgical complications between the local and general anesthesia group. But the general anesthesia group had more cardiovascular complications and longer hospitalization periods. In conclusion, when we planned the burr hole craniostomy for the elderly patients with CSDH, local anesthesia should be considered more actively for postoperative prognosis.

Intravascular Papillary Endothelial Hyperplasia (Masson tumor) of the Skull : Case Report and Literature Review

A 10-year-old female patient presented with a rapidly growing nodular mass lesion on her right frontal area. On skull radiography and computed tomography (CT) imaging, this mass had a well-demarcated punch-out lesion with a transdiploic, exophytic soft tissue mass nodule on the frontal scalp. Magnetic resonance (MR) imaging revealed the presence of a 1.5x1.2x1 cm sized calvarial lesion. This lesion was hypointense on T1 and heterogenous hyperintense on T2 weighted MR images, and exhibited heterogeneous enhancement of the soft tissue filling the punch-out lesion after intravenous administration of gadolinium. En block removal of the tumor with resection of the rim of the normal bone was performed. The pathological diagnosis was intravascular papillary endothelial hyperplasia (IPEH). After surgery, no recurrence was found for 8 months. IPEH is a rare and benign reactive lesion usually found in thrombosed subcutaneous blood vessels. Involvement of skull bone is rare. In this article, we present a case of IPEH involving the calvarium, in a 10-year-old woman.

Effect of Cisternal Drainage on the Shunt Dependency Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH. METHODS: Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age ( or =70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups ( or =70 years of age). RESULTS: Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (> or =70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus. CONCLUSION: In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.

Inhospital Spontaneous Acute Subdural Hematoma (SADH) Patient with Antiplatelet Therapy due to Acute Cerebral Ischemia: A Case Report / 대한구급학회지

A case of "spontaneous" acute subdural hematoma caused by aspirin and plavix therapy has not been described previously. As an isolated cerebrovascular event related to aspirin and plavix therapy, this is the first report described in the literature. It also represents a new differential diagnosis for nontraumatic acute subdural hematomas.

Comparison of Serum CRP and Procalcitonin in Patients after Spine Surgery

OBJECTIVE: Classical markers of infection cannot differentiate reliably between inflammation and infection after neurosurgery. This study investigated the dynamics of serum procalcitonin (PCT) in patients who had elective spine surgeries without complications. METHODS: Participants were 103 patients (47 women, 56 men) who underwent elective spinal surgery. Clinical variables relevant to the study included age, sex, medical history, body mass index (BMI), site and type of surgery, and surgery duration. Clinical and laboratory data were body temperature, white blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and PCT, all measured preoperatively and postoperatively on days 1, 3, and 5. RESULTS: PCT concentrations remained at <0.25 ng/mL during the postoperative course except in 2 patients. PCT concentrations did not correlate with age, sex, DM, hypertension, BMI, operation time, operation site, or use of instrumentation. In contrast, CRP concentrations were significantly higher with older age, male, DM, hypertension, longer operation time, cervical operation, and use of instrumentation. CONCLUSION: PCT may be useful in the diagnosing neurosurgical patients with postoperative fever of unknown origin.

Minimally Invasive Muscle Sparing Transmuscular Microdiscectomy : Technique and Comparison with Conventional Subperiosteal Microdiscectomy during the Early Postoperative Period

OBJECTIVE: The authors introduce a minimally invasive muscle sparing transmuscular microdiscectomy (MSTM) to treat herniated lumbar disc disease. Its results are compared with conventional subperiosteal microdiscectomy (CSM) to validate the effectiveness. METHODS: Muscle sparing transmuscular microdiscectomy, which involves muscle dissection approach using the natural fat cleavage plane between the multifidus to expose the interlaminar space, was performed in 23 patients to treat a single level unilateral lumbar radiculopathy. The creatine phosphokinase (CPK)-MM serum levels were measured on admission and at 1, 3, and 5 days postoperatively. Postoperative pain was evaluated using a 10-point visual analogue scale (VAS) and recorded on admission and at 1, 3, and 5 days postoperatively. The results were compared to those from the conventional subperiosteal microdiscectomy (43 patients). RESULTS: The CPK-MM levels were significantly lower in the serum of the MSTM group compared to the CSM group on postoperative days three and five (p = 0.03 and p = 0.02, respectively). The clinical scales for back pain using VAS were significantly lower in the MSTM group than in the CSM group on postoperative days three (p = 0.04). The mean VAS scores for leg pain in both groups showed no significant differences during the early postoperative period. CONCLUSION: Muscle sparing transmuscular microdiscectomy is a minimally invasive surgical option to treat lumbar radiculopathy due to herniated disc. The approach affected minimal injury to posterior lumbar supporting structures with alleviated postoperative back pain.

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.