Dysphagia following C1 laminectomy and posterior atlantoaxial fixation for retro-odontoid pseudotumor: a case report.

Purpose: Although dysphagia is known potential complication of cervical spine surgery, it rarely occurs after a posterior approach. We describe an unusual case of a retro-odontoid pseudotumor that suffered dysphagia following a C1 laminectomy and posterior atlantoaxial fixation.Materials and methods: A 79-year-old man presented with progressive tetraparesis and bladder and bowel dysfunction due to severe compression to cervical cord at C1 from a retro-odontoid pseudotumor. After C1 laminectomy and atlantoaxial fixation, the symptoms improved, but dysphagia and aspiration developed, associated with pharyngeal and esophageal stases on videofluoroscopy.Results and conclusions: Possible explanations for postoperative dysphagia include limitation of cervical spine motion, and cervical cord reperfusion injury in addition to the baseline anterior osteophyte and aging. This is the first case of dysphagia developing after laminectomy and posterior atlantoaxial fixation not involving the occipital bone.

Aphasia Following Left Putaminal Hemorrhage at a Rehabilitation Hospital.

OBJECTIVE: We aimed to clarify the relationship between aphasia and hematoma type/volume in patients with left putaminal hemorrhage admitted to a rehabilitation facility. METHODS: We evaluated the relationship between the presence, type, and severity of aphasia and hematoma type/volume in 92 patients with putaminal hemorrhage aged 29-83 years. Hematoma type and volume were evaluated on the basis of CT images obtained at stroke onset. The Standard Language Test for Aphasia was conducted as part of the initial assessment. RESULTS: Aphasia was observed in 79 of 92 patients. A total of 31 patients had fluent aphasia, while 48 had non-fluent aphasia. Non-fluent aphasia often involved hematoma on the anterior limb of the internal capsule, while fluent aphasia often involved hematoma on the posterior limb of internal capsule. When the hematoma volume exceeded 20 mL, patients experienced difficulty in repeating spoken words. When hematoma volume exceeded 40 mL, non-fluent aphasia was observed in all patients. CONCLUSION: Our findings suggest that hematoma type and volume not only influence the development of aphasia following putaminal hemorrhage but also play a major role in determining the patient's fluency and repetition ability.

Factors necessary for independent walking in patients with thalamic hemorrhage.

BACKGROUND: Thalamic hemorrhages cause motor paralysis, sensory impairment, and cognitive dysfunctions, all of which may significantly affect walking independence. We examined the factors related to independent walking in patients with thalamic hemorrhage who were admitted to a rehabilitation hospital. METHODS: We evaluated 128 patients with thalamic hemorrhage (75 men and 53 women; age range, 40-93 years) who were admitted to our rehabilitation hospital. The mean duration from symptom onset to rehabilitation hospital admission was 27.2 ± 10.3 days, and the mean rehabilitation hospital stay was 71.0 ± 31.4 days. Patients' neurological and cognitive functions were examined with the National Institutes of Health Stroke Scale (NIHSS) and Mini-Mental State Examination (MMSE), respectively. The relationship between patients' scores on these scales and their walking ability at discharge from the rehabilitation hospital was analyzed. Additionally, a decision-tree analysis was used to create a model for predicting independent walking upon referral to the rehabilitation hospital. RESULTS: Among the patients, 65 could walk independently and 63 could not. The two patient groups were significantly different in terms of age, duration from symptom onset to rehabilitation hospital admission, hematoma type, hematoma volume, neurological symptoms, and cognitive function. The decision-tree analysis revealed that the patient's age, NIHSS score, MMSE score, hematoma volume, and presence of ventricular bleeding were factors that could predict independent walking. CONCLUSIONS: In patients with thalamic hemorrhage, the neurological symptoms, cognitive function, and neuroimaging factors at onset are useful for predicting independent walking.

Top of the basilar syndrome in a young adult initially presenting with a convulsive seizure.

A 23-year-old man was admitted to our hospital due to loss of consciousness and a generalized convulsive seizure. He was diagnosed as having primary epilepsy and treated with antiepileptic drugs. Emergency CT scan of the head showed no abnormality. However, MRI scan of the head several days after admission revealed fresh infarctions caused by occlusion of the basilar artery, i.e., "top of the basilar" syndrome. This case indicates the need for precise differential diagnosis of convulsive seizure in an emergency situation. It should also be borne in mind that basilar occlusion with 'onset seizure' can occur even in young adults who have no risk factors for stroke.

Langerhans cell histiocytosis of the skull on cytologic squash preparations.

We present a case in which a primary cytodiagnosis of Langerhans cell histiocytosis (LCH) of the skull was made using squash preparations. The patient, a 25-year-old male, presented with raised intracranial pressure and decreased visual acuity. Magnetic resonance imaging revealed a large skull lesion with osteolytic features in the left frontal bone. The patient underwent surgical resection by the extended basal frontal epidural approach. The squash preparation smears were cellular and demonstrated a mixed population of small, mature lymphocytes, eosinophils, and a high histiocytes content. The histiocytes occurred as isolated or loosely cohesive and clustered. They possessed abundant cytoplasm with rounded cell shape and had characteristic nuclear features, composed of fine chromatin and delicate nuclear membranes. The cytologic features of these histiocytes were consistent with Langerhans cells (LCs). A final impression of LCH of the skull was rendered. Subsequent histopathology confirmed the diagnosis. LCs reacted with both S-100 protein and CD1a immunohistochemically. The demonstration of Birbeck granules on electron microscopic study was also noted. Whenever squash preparation yields a mixed population of mature lymphocytes, eosinophils, and histiocytes, the cytologists should be aware of and consider LCH as a diagnostic possibility.

Intracranial solitary juvenile xanthogranuloma successfully treated with stereotactic radiosurgery.

Juvenile xanthogranuloma (JXG) is a non-Langerhans cell histiocytosis, which primarily affects the skin in young children. Although intracranial involvement is rare, it differs from other systemic JXG because its responsiveness to non-surgical treatment is poor. We present the case of a 2-year-old boy with left abducens nerve palsy. Imaging studies revealed a mass in the left Meckel's cave. Systemic examination showed no other abnormalities including his skin. After partial removal, JXG was diagnosed based on immunohistochemical evaluation. He underwent a stereotactic radiosurgery. Then, the mass decreased, and his abducens nerve palsy improved. This is the seventh case with isolated intracranial JXG, and the first case to be treated with radiosurgery. We consider that stereotactic radiosurgery is an excellent choice for treatment of intracranial JXG.

[Clipping of upward projecting anterior communicating aneurysms via pterional craniotomy: approach from the side of A2 of anterior displacement].

The majority of anterior communicating artery(Acom) aneurysms can be approached via pterional craniotomy. When the fundus points superiorly, craniotomy in the side of A2 of posterior displacement may be advantageous for catching the aneurysm and both ACAs on the same plane. Sometimes, however, surgeons have to deliberately select a "contralateral" craniotomy to deal with other lesions in the same operative session. The first author has operated on 111 patients with Acom aneurysms during the last 8 years; 26 aneurysms projected superiorly, and 7 were approached via contralateral craniotomy because of the aneurysm multiplicity. We reviewed surgical problems in the 7 upward projecting aneurysms approached from the "contralateral" side. All aneurysms were successfully secured without any surgery related complication. However, in each case, aneurysm and both ACAs formed a straight line in the narrow surgical field, and it was difficult to handle the aneurysm behind the ipsilateral A2, particularly when it tightly adhered to the A2. Anticipating this prior to surgery allows the surgeon to know the possible problems in aneurysm dissection that may occur. Practically, wide separation of interhemispheric fissure with removal of the gyrus rectus, and dissection of the posterior aspect of the ipsilateral A2 facilitates the mobilization of A2 and exposure of the aneurysm neck. When the aneurysm is tightly adherent to the A2, however, isolation of the entire aneurysm risks tearing the aneurysm at its A2 junction. An aperture clip should be considered to avoid serious bleeding during dissection.