Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

Angiographic Features and Clinical Outcomes of Intra-Arterial Nimodipine Injection in Patients with Subarachnoid Hemorrhage-Induced Vasospasm

OBJECTIVE: The aim of this study was to determine the role of intra-arterial (IA) nimodipine injections for cerebral vasospasm secondary to ruptured subarachnoid hemorrhage (SAH) and to investigate the factors that influence vasodilation and clinical outcomes. METHODS: We enrolled 29 patients who underwent aneurysm clipping for ruptured cerebral aneurysms between 2009 and 2011, and who received IA nimodipine after subsequently presenting with symptomatic vasospasm. The degree of vasodilation shown in angiography was measured, and the correlation between the degree of vasodilation and both the interval from SAH to cerebral vasospasm and the interval from clipping to cerebral vasospasm was determined. The change in blood flow rate after IA injection was assessed by transcranial Doppler ultrasound. Multiple clinical parameters were completed before and after IA nimodipine injection to evaluate any improvements in clinical symptoms. RESULTS: For eight patients, Glasgow Coma Scale (GCS) scores increased by two or more points. The regression analysis demonstrated a positive correlation between the change in GCS scores after IA nimodipine injection and the change in blood vessel diameter (p=0.025). A positive correlation was also observed between the interval from SAH to vasospasm and the change in diameter (p=0.040); and the interval from clipping to vasospasm and the change in diameter (p=0.022). CONCLUSION: IA nimodipine injection for SAH-induced vasospasm led to significant vasodilation in angiography and improvement in clinical symptoms without significant complications. Our findings suggest that IA nimodipine injection should be utilized when intractable vasospasm develops despite rigorous conservative management.

A Case of Chronic Gonorrheal Orbital Cellulitis

Authors have experienced a case of long standing chronic gonorrheal orbital cellulitis in a 50 years old Korean male. Surgical evacuation of pus discharges and microscopcially confirmed the gram negative intncellular and extracellular gonococcus. A brief review of the related literatures is present.

Treatment of Angiomatosis Retinae

Meyer-Schwickerath(1959) has successfully treated the angiomatosis tumor by means of Xenon-light coagulation with minimal damage to the affected eye ball. Though cryothenny was first tried by Lincoff et al. (1967) it resulted only in the shrinkage of the tumor. Amoils and Smith(1969) succeeded through repeated application of cryothermy to completely destory the tumor itself which was followed by disapperance of the surrounding choroidal and retinal vessels. In our case, an angiomatosis tumor in the right eye, one and a half times the size of the optic disc, was shrunk to two-thirds of the disc size by an application of cryothermy, repeated three times at minus 60 degrees C for about two minutes at varying intervals. Then the tumor was completely destroyed by means of Xenon-arc photocoagulation repeated two times each at about three weeks' intervals. In the left eye, even though the angiomatosis retinae was complicated by secondary retinal detachment, the tumors were partially destroyed by diathermy application in the same manner that ignipuncture is ordinarily done. Subsequently after reattachment of the retine by performing an encircling buckle procedure with autogenic fascia lata, the tumors were completely destroyed by means of Xenon-arc photocoagulation, with prevention of the complications of angiomatosis retinae such as secondary glaucoma or phthisis bulbi. Angiomatosis tumor can be destroyed by cryothermy but in the case of a large tumor, cryothermy will be required in repeated applications. This may cause atrophy of choroid and retina so severe that a distinct line of demarcartion between the diseased and normal retina will be formed. Therefore repeated applications of cryothermy increase the danger of rupture of the retina. According cryothermy will be effective only in the treatment of small angiomatosis tumor. In the case of a large angiomatosis tumor or other complicated condition, Xenon-arc photocoagulation is an easy and suitable method of treatment to destroy the tumor.

The Retinal Detachment Surgery Utilizing Human Tissue: II. Sling Technique

The authors are presenting the SLING TECHNIQUE, utilizing human tissue for the retinal detachment caused by a macular break. In the literature on the surgical technique of the retinal detachment caused by a macular hole, the sling technique of Margherio and Schepens is considered the operation of choice among the modalities currently available. They used the following procedure. The lateral rectus and the inferior oblique muscles are temporaily detached from the globe and the eye is then rotated superonasally. The macular hole is perforated exactly by a fine perforated needle under visual control with a binocular ophthalmoscope. A single diathermy current is then released. A silicone band is placed over the posterior half of the globe in the meridian extending from 12 to 6 o'clock, the middle of the band being over the macula and its end near the insertion of the superior rectus and the inferior rectus muscles respectively. An 8mm. grooved piece of silicone is placed under the band in the macular region. When the buckle is in the conect position and of the desired hight, the suture on the end of the band is tied permanently. Modifying the Margherio and Schepens Procedure, we used minimal cryothermy (-60 degrees C, 20 sec.), amniotic tissue and fascia lata instead of the pentrating diathermy, silicone piece and silicone band respectively. A sufficient adhesive chorioretinitis was caused by the minimal cryothermy and the additional implantation of amniotic tissue over the macular area. We did not attempt to see whether there would be sufficient adhesive chorioretinitis with implantation of amniotic tissue only and without cryothermy. Subretinal fluid was drained in every case, because of the fact that spongiosis chorioideae does not take place easily on the posterior pole due to the histologic charecteristic of the choroid in this region. This technique causes less complications and the resulting improvement in vision is excellent.