Pulsatile wall movement of spinal arachnoid cyst deteriorates spinal cord symptoms: report of three cases.

INTRODUCTION: Symptomatic spinal arachnoid cyst is a rare disease and the pathophysiology causing spinal cord symptoms has not been well clarified. PATIENTS AND METHODS: The authors report three symptomatic cases of spinal arachnoid cyst at the thoracic level. These patients, aged from 70 to 73 years, showed progressive gait disturbance for a few months before admission. Phase-contrast cine magnetic resonance imaging demonstrated significant compression at the rostral side of the cyst during the diastolic phase of the cardiac cycle. Intraoperative ultrasonography demonstrated that the maximum expansion of the cyst and compression of the dorsal spinal cord occurred when the cerebrospinal fluid moved rostrally during diastole. All patients showed good improvement of their symptoms after surgical removal of the arachnoid cyst. CONCLUSION: This report proposes the pathophysiology that the pulsatile enlargement of the arachnoid cyst during diastolic cardiac phase can be an important factor for deterioration of spinal cord symptoms.

Quantitative analysis of adverse events in neurosurgery.

OBJECTIVE: : It is well recognized that the occurrence rate of adverse events related to surgical procedures is considerably high in neurosurgery compared with other specialties. The purpose of this study was to quantitatively determine the occurrence rate of adverse events related to surgery and endovascular intervention in neurosurgery. METHODS: A conference on adverse events related to treatments (morbidity and mortality conference) has been held every month for the past 2 years in our department. At these conferences, all adverse events are evaluated and discussed. Adverse events include not only the unexpected complications, but also the neurological and general deterioration predicted before surgery. All the adverse events are discussed in terms of the conceivable causes, their association with the procedures, and the possibility of prediction and avoidance. RESULTS: One hundred eighty-two events (28.3%) among 643 neurosurgical interventions over 2 years were recognized as adverse events. Among these 182 adverse events, 165 (90.7%) were closely related to procedures and 125 events (68.7%) were predictable before or during the procedures. However, even when retrospectively reviewed, only 6 (3.3%) of events were deemed avoidable. Of these 6 avoidable events, there were only 2 (1.1%) that were considered to have been caused by error. CONCLUSION: Adverse events are not invariably rare in neurosurgery. Most of them are predictable; however, their avoidance is not necessarily easy. Avoidable adverse events caused by medical errors were observed in only 1.1% of cases.

Reversible hyperintense lesion after balloon occlusion test.

We report a unique case of a reversible high signal intensity lesion observed on a magnetic resonance (MR) image accompanied by transient neurological deficits related to a balloon occlusion test. This abnormality was considered to be vasogenic edema caused by the disruption of the blood-brain barrier (BBB) due to a long history of uncontrolled hypertension and transient ischemia induced by the balloon occlusion test.

Clinical manifestations and surgical results for paraclinoid cerebral aneurysms presenting with visual symptoms.

BACKGROUND: Clipping a paraclinoid aneurysm is difficult if the patient has a visual disturbance. Visual function sometimes deteriorates postoperatively for patients with a large aneurysm. In this study, we report the long-term follow-up of patients with visual impairments attributed to optic nerve compression when paraclinoid aneurysms are surgically treated. METHODS: Seventeen patients with optic nerve impairment induced by compression of paraclinoid ICA aneurysms were treated. All of the aneurysms were large, including 6 giant aneurysms. The aneurysms displayed partial thrombosis or calcification of the aneurysmal wall in 6 cases. RESULTS: Direct surgery such as neck clipping or wrapping of the aneurysm was performed in 9 aneurysms and indirect procedures in 8 others (ICA occlusion, 1; ICA occlusion + bypass, 7). Of 17 patients, 11 (65%) showed improvement in several dysfunctions of visual acuity or visual field. Of 6 patients, whose vision had not recovered well, 5 underwent direct surgery. Moreover, these 5 patients had an intra-aneurysmal thrombosis or calcification of the aneurysmal wall. Nevertheless, 1 patient whose aneurysm with partial thrombosis was treated via indirect procedure had good recovery of vision. CONCLUSIONS: Direct clipping is the treatment of choice for patients with a mass effect on the optic nerve due to paraclinoid aneurysm. However, it is difficult to achieve sufficient decompression of the optic nerve when the aneurysm is accompanied by partial thrombosis or calcification of the aneurysmal wall. In those cases, an indirect procedure seems to be a relatively safe, effective treatment.

Transorbital intracranial penetrating injury from impaling on an earpick.

An inebriated 86-year-old man impaled himself on a wooden earpick that penetrated through the superior orbital fissure into the prepontine cistern. The patient underwent surgery immediately by a lateral suboccipital approach, and the earpick was pulled out through the wound with control of hemorrhage from the cavernous sinus. He survived this event with no neurologic deficits apart from complete ipsilateral ophthalmoplegia and ptosis. Prompt imaging and surgical intervention allowing direct visualization of the foreign body and prevention of intracranial complications are part of proper management of this problem.

Delayed thromboembolic infarction associated with reconfiguration of Guglielmi detachable coils--case report.

A 77-year-old woman presented with delayed thromboembolic infarction of a basilar artery trunk aneurysm that occurred 2 weeks after coil embolization of the unruptured aneurysm. The postoperative course was uneventful until the patient suffered sudden onset of consciousness disturbance 13 days after the treatment. Computed tomography showed no abnormality, but digital subtraction angiography revealed a thrombus extending from the aneurysm neck to a point distal to the basilar artery. Thrombolysis was achieved by the infusion of urokinase. Reconfiguration of the coil at the aneurysm neck was revealed compared with the initial configuration of the coil immediately after embolization. Magnetic resonance imaging obtained after the thrombolysis showed hyperintense areas in the bilateral occipital lobes and thalami. Periprocedural thromboembolic complications associated with coil embolization of an aneurysm are well known. However, delayed thromboembolic complications may occur in some patients after successful coil packing of an aneurysm.

Anatomical variations in pneumatization of the anterior clinoid process.

OBJECT: An anterior clinoidectomy can provide enormous benefits, facilitating the management of paraclinoid and upper basilar artery lesions, but it also carries the potential risk of cerebrospinal fluid leaks. The aim of this study was to assess the variation in the pneumatization of the anterior clinoid process (ACP) in an attempt to reduce the complications associated with an anterior clinoidectomy. METHODS: The authors analyzed the anatomical variations in the pneumatization of the ACP and optical strut (OS) in 600 sides of 300 consecutive patients by using multidetector-row computed tomography (CT). Computed tomography scans with a 0.5-mm thickness were obtained, and coronal and sagittal reconstructions of the images were displayed in all cases. Pneumatization of the ACP was found in 9.2% of all sides. The origin of pneumatization was the sphenoid sinus in 81.8% of all the sides, the ethmoid sinus in 10.9%, and both of these sinuses in 7.3%. Pneumatized patterns were divided into three groups according to the route: 74.5% were Type I, in which pneumatization occurred via the OS; 14.5% were Type II, pneumatization via the anterior root (AR); and 10.9% were Type III, pneumatization via both the OS and the AR. The origin of pneumatization and the pneumatization pattern showed statistical dependence (p < 0.001). Pneumatization of the OS beyond its narrowest point was found in 6.8% of all sides. CONCLUSIONS: An awareness of the different variations in pneumatization can prevent destruction of the mucous membrane and facilitate orientation during reconstruction with cranialization. During an anterior clinoidectomy, preoperative CT assessments are necessary to evaluate pneumatization of the ACP.

Alveolar soft part sarcoma in brain with cardiac metastasis: a case report.

Alveolar soft part sarcoma (ASPS) is a rare soft tissue neoplasm. The coexistence of ASPS with cardiac metastasis is quite rare, in particular. In general, the sarcoma is a malignant disease and grows very fast. However, the mean survival time of patients with ASPS is relatively long. Patients who are diagnosed with localized disease usually have a favorable prognosis, while those who present with widespread metastases usually have a poor prognosis and ultimately, succumb to their disease. The use of modern treatment modalities, such as combination of surgery, and radiotherapy, may significantly prolong the survival time in many patients. Because of the long-term period with symptomatic brain tumors in this disease, the patients should be treated even in the presence of multiple metastases in other organs.

[Primary intraosseous cavernous hemangioma in anterior clinoid process].

Primary intraosseous cavernous hemangiomas (PICHs) are rare tumors, and there are no previous reports of cases with a tumor at the anterior clinoid process. We report a case of a PICH at the anterior clinoid process in a 66-year-old female presenting with headaches and visual impairment. CT and MR imaging showed a mass in the anterior clinoid process. The lesion showed hyperintensity on T1- and T2-weighted imaging, and gadolinium was homogenously enhanced. The lesion was removed surgically, and histologically confirmed as a cavernous hemangioma. Preoperative examinations could not provide a definitive diagnosis. A brief clinical and radiological review of the literature is presented.

Entrapment neuropathy of the optic nerve due to hyperostosis associated with congenital anemia.

The authors report on the case of a 14-year-old boy who presented with bilateral visual impairment due to optic canal stenosis caused by hyperplasia of the bone marrow arising from anemia. The patient had hereditary hemolytic anemia with unstable hemoglobin of the Christchurch type. This congenital form of anemia caused hyperplasia of the bone marrow as well as hyperostosis of the entire calvarial bone, which in turn led to optic canal stenosis. The patient underwent surgical decompression of the optic canal, resulting in significant improvement in visual acuity. Pathological findings in the calvarial bone indicated hypertrophic bone marrow with no other specific features such as neoplastic pattern or fibrous dysplasia. With the exception of objective hearing impairment, no other significant cranial neuropathy has been detected thus far. On reviewing the published literature, this case was found to be the first in which hyperostosis due to congenital anemia resulted in symptomatic entrapment neuropathy of the optic nerve. The authors concluded that surgical decompression effectively improves visual acuity.

[Percutaneous transluminal angioplasty in fibromuscular dysplasia of the internal carotid artery: case report].

We report a case of symptomatic cervical carotid artery stenosis associated with fibromuscular dysplasia (FMD) successfully treated by percutaneous transluminal angioplasty (PTA). A 49-year-old female presented with repeated ischemic attacks of right hemiparesis and aphasia. Digital subtraction angiography revealed a string of beads appearance of the left internal carotid artery typical of the medial type of FMD, at the level of the C2 vertebra. Similar findings were also evident in the right internal carotid artery at the level of the C1 vertebra, but without significant narrowing. MR angiogram of the left carotid artery revealed a marked flow gap, suggestive of severe stenosis. Forty days after onset PTA was indicated for symptomatic FMD of the left internal carotid artery because of the relative difficulty in approaching and repairing this highly located lesion surgically. The stenotic lesion was very easily dilated without any procedural complications. Although angiography just after PTA showed slight residual irregularity of the wall, this smoothed up with time. Follow-up MR angiography 7 years after PTA demonstrated long-term patency without clinical evidence of deterioration. Patients with the medial type of FMD in the carotid artery seem to be excellent candidates for PTA.