[Perforating Artery Injury during Microsurgery for Internal Carotid Artery Bifurcation Aneurysms].

Internal carotid artery bifurcation aneurysms(ICB-ANs)are relatively rare and are difficult to occlude by direct clipping without perforating artery injury(PAI). We retrospectively analyzed 11 aneurysms in 10 cases. PAI was identified in 5 of 10 cases on postoperative computed tomography(CT)or magnetic resonance imaging(MRI), and 2 of these patients were symptomatic. PAIs were distributed in the caudate nucleus and/or the genu of the internal capsule. PAI occurred in 3 of 5 cases in which indocyanine green videoangiography(ICG-VAG)was performed. ICG-VAG is a helpful tool visualizing blood flow of vessels in surgical fields. However, PAI is a potential risk in direct clipping of ICB-ANs even if adjacent perforating arteries were observed using ICG-VAG.

Takotsubo cardiomyopathy induced by dobutamine infusion during hypertensive therapy for symptomatic vasospasm after subarachnoid hemorrhage -case report-.

A 65-year-old female with subarachnoid hemorrhage (SAH) developed takotsubo cardiomyopathy induced by dobutamine infusion for vasospasm 9 days after onset of SAH. She underwent neck clipping of the ruptured cerebral aneurysm on day 1. Course after surgery was uneventful, but she developed motor aphasia on day 9. Hypertensive therapy was carried out under the diagnosis of symptomatic vasospasm. Half an hour after initiation of dobutamine infusion at 6 microg/kg/min, sudden symptoms of takotsubo cardiomyopathy developed. Fortunately, her symptoms recovered in a few days with supportive therapy without any consequences. Takotsubo cardiomyopathy is one pattern of cardiac dysfunction occasionally encountered after SAH. Possible mechanisms of this disorder include epicardial catecholamine cardiotoxicity. Therefore, generally, cardiac function is worst at the early stage of SAH, when sympathetic activity is highest, and recovers thereafter. Dobutamine infusion seems to have triggered the takotsubo cardiomyopathy in the present patient even 9 days after onset of SAH. Inotropic agents including dobutamine are often used during the course of SAH, and since takotsubo cardiomyopathy can occur in patients with SAH, this complication must be considered.

[A case of subarachnoid hemorrhage complicated by acquired hemophilia].

We report a rare case of subarachnoid hemorrhage (SAH) in a man who acquired factor VIII inhibitor and suffered coagulopathy a month after disease onset. Acquired factor VIII inhibitors in patients without hemophilia is a rare disease characterized by severe bleeding as a result of antibody against factor VIII. A 61-year-old male, who had a past history of hypertension, underwent resection for colon cancer at the local hospital. Ten days after surgery he suffered septic shock that required intensive use of antibiotics. Two days after this episode, he had a sudden loss-of-consciousness attack, and was referred to our hospital with the diagnosis of SAH. Emergency angiography revealed a dissecting aneurysm at the right intracranial vertebral artery distal to the origin of the posterior inferior cerebellar artery. The aneurysm was successfully treated with endovascular parent artery occlusion. However, after a placing ventriculo-peritoneal shunt a month later, he developed severe coagulopathy due to acquired factor VIII inhibitor.

[A case of repeated intracerebral hemorrhage due to a ruptured aneurysm of collateral circulation from the posterior cerebral artery to the middle cerebral artery].

We present a case of ruptured distal middle cerebral artery aneurysm associated with occlusion of the anterior trunk of the ipsilateral middle cerebral artery. An 83-year-old man had right homonymous hemianopsia and right mild hemiparesis. CT scan revealed hematoma and a perifocal low density area at the left occipital subcortex without subarchnoid hemorrhage (SAH). MRI showed repeated bleeding at the same location as the CT scan. Moreover, cerebral angiograms disclosed an aneurysm on the leptomeningeal anastomosis from the left posterior cerebral artery to the middle cerebral artery. The anterior trunk of the left middle cerebral artery was occluded at the origin. The aneurysm was not situated at the bifurcation and was trapped without new neurological complications. This case suggested that hemodynamic stress due to occlusion of the main artery contributed to the development of an aneurysm at the collateral artery. Even if intraparenchymal hematoma presents without SAH, and even if it is located at a rare site for aneurysms, we should inspect the source of bleeding considering factors preventing SAH arising from aneurysms.

[Non-cardiogenic pulmonary edema induced by non-ionic radiographic contrast media during the coil embolization for a ruptured cerebral aneurysm].

We describe a 48(correction of 44) year-old woman, who presents a non-cardiogenic pulmonary edema caused by non-ionic radiographic contrast medium. She suffered from subarachnoid hemorrhage due to dissecting aneurysm of right vertebral artery. Cerebral angiography followed by coil embolization for the aneurysm was performed. During the interventional procedure, saturation of blood oxygen suddenly declined and chest X-ray photography obviously revealed pulmonary edema. At first we dealt with it as neurogenic phenomenon but subsequently interpreted it to non-cardiogenic pulmonary edema induced by radiographic contrast medium, since intra-arterial injection of contrast medium at follow-up angiography led the symptoms into more fulminant status. Intensive care including endotracheal intubation and continuous positive airway pressure ventilation consequently achieved complete remission and the patient discharged without any sequelae. Although low osmolar, non-ionic contrast medium has been regarded as relatively safe, severe reaction such as dyspnea, hypotension and cardiac arrest could emerge at certain intervals. We must perceive the adverse effects of it because the usage of contrast medium will dramatically increase with development of diagnostic radiographical methodology and interventional neurosurgery.

Brain abscess following transorbital penetrating injury due to bamboo fragments--case report.

A 56-year-old female presented with transorbital penetrating injury caused by bamboo fragments, which resulted in brain abscess 2 weeks after the injury. Initial computed tomography (CT) of the head did not reveal the foreign bodies. However, follow-up CT demonstrated a well-defined hyperdense abnormality of 1.0 cm length in the left orbit and brain abscess in the left temporal lobe. The lesion corresponding to the hyperdense abnormality on CT appeared isointense on T1-weighted magnetic resonance (MR) imaging and hypointense on T2-weighted MR imaging. The bamboo fragments were surgically removed, and aspiration and continuous drainage were performed for the brain abscess. The postoperative course was uneventful and the patient was transferred to a local hospital with minor neurological deficits. Bamboo foreign bodies may show changes in properties on CT and MR imaging in the subacute stage. Careful radiological examination and follow-up monitoring are required for the correct diagnosis and treatment of such injuries.