Endovascular Treatment for Ruptured VA Dissecting Aneurysm Involving the Origin of PICA.

SUMMARY: Ruptured vertebral artery dissecting aneurysms (VADA) re-bleed frequently especially during first 24 hours, which makes the prognosis of the patients with this disease poor. Recently endovascular trapping with detachable platinum coils at an acute stage has been done for preventing re-bleeding. However, for the cases with dissecting aneurysm involving the origin of the posterior inferior cerebellar artery (PICA), these methods are hardly indicated because of the risk of ischemic complication in the PICA territory. We proposed a simple and effective therapeutic method for these cases. We occluded the affected vertebral artery (VA) near its root intending to introduce collateral blood flow from the deep cervical artery into the VA trunk. The controlled antegrade VA flow and retrograde flow from the contralateral VA make a watershed at the dissecting aneurysm, which promotes thrombosis of pseudolumen with preserving the antegrade blood flow of PICA.We treated two cases with ruptured VADA involving PICA, and in both cases thrombosis of aneurysm was obtained without any ischemic complication. This method would be considered as a treatment of choice to the cases with VADA involving PICA.

[Dural arteriovenous malformation presenting venous ischemia].

We report three patients with dural arteriovenous malformation (DAVM) in the posterior fossa presenting the venous ischemia and the pathophysiology and the clinical characteristics of DAVM presenting the venous ischemia are discussed. Associated with occlusive changes in the venous sinuses, DAVM in the posterior fossa develops the venous hypertension of the straight sinus and the venous ischemia of cerebral white matter and basal ganglia. The venous ischemia presents progressive symptoms consisting of dementia with or without the ensuing consciousness disturbance. Multiple parenchymal lesions and abnormally dilated and tortuous veins are the characteristic findings in MRI/CT.

[Prognostic value of spectral analysis of electroencephalogram in patients with severe head injury].

To determine the prognostic value of electroencephalogram (EEG) in patients with severe head injury, fifteen adult patients were examined for three months after trauma. All patients (age: 16-74 years old) remained comatose (Glasgow Coma Scale: less than 8) for more than 72 hours. Ten out of 15 cases were surgically treated. Barbiturates were not used in any patient for the sake of controlling the increased intracranial pressure. Three months after trauma, the clinical outcome of each patient was evaluated using Glasgow Outcome Scale (GOOD: good recovery/moderate disability, POOR: severe disability/persistently vegetative/dead). EEG was examined repeatedly for 3 months after trauma; 56 EEG recordings were performed on 15 cases. Each EEG recording was never for less than 12 hours and EEG was recorded from the bilateral parietal electrodes. Using EEG TREND MONITOR (NIHONKODEN), the spectral analysis of EEG was performed in five frequency bands (delta, theta, alpha-1, alpha-2, beta) and the EEG power of each frequency band was shown as the percentage of total EEG power (% FREQ BAND). The findings of each % FREQ BAND was classified into the following four groups. 1) slow-monotonous: The EEG power was comprised invariably and almost exclusively of low frequency bands (i.e. delta and theta), and the "slow-fast constant" which is the power of slow waves (delta and theta) divided by the power of fast waves (alpha-1, alpha-2, and beta) was stable.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of CT-guided stereotactic hematoma aspiration in mild cases with putaminal hemorrhage].

Reported here is the effectiveness of surgical management in mild cases with putaminal hemorrhage (neurological grading 1 or 2, described by Kanaya, et al.). Ten cases were treated by CT-guided stereotactic hematoma aspiration (aspiration group), and another 10 cases were treated by only medical therapy (conservative group). The mean interval from the onset to operation was 7.2 days. In both groups, serial change in the motor function of the upper extremity was examined and the neuropsychological function was also evaluated at 2 weeks after onset. Perifocal low-density area around the hematoma was estimated on CT scan at 2 weeks after onset. Mean hemispheric cerebral blood flow (mCBF) was measured at 5-days, 2 weeks and 6 months after onset, respectively in each group. The activity of daily life (ADL) was evaluated at 6 months after onset. There was no statistically significant difference in age, neurological grading and CT findings on admission between the 2 groups. At 2 weeks after onset, no case had deteriorated in motor function in the aspiration group. On the other hand, 2 cases had deteriorated in the conservative group. The neuropsychological function was considerably improved in the majority of cases in the aspiration group. Perifocal low area was significantly narrow on CT scan in the aspiration group. At 2 weeks after onset, the mCBF of the affected side was 53.8 +/- 6.0 ml/100g/min in the aspiration group, whereas it was 42.0 +/- 5.7 ml/100g/min in the conservative group. This difference was statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Dissecting aneurysms of the posterior inferior cerebellar artery.

The authors present three cases of dissecting aneurysms of the posterior inferior cerebellar artery (PICA). A literature search revealed only three previous cases. Analysis of these six cases showed a unique clinical picture. Three patients developed subarachnoid hemorrhage, and the other three had ischemia. All patients complained of occipital headache or neck pain, regardless of the initial symptoms. Heralding episodes were recorded in four cases. Angiography showed a characteristic fusiform dilatation of the PICA and a narrowing proximal to and distal to the lesion. Various surgical treatments were performed in five cases. Intraoperative observation showed a sausage-like swelling of the PICA or one of its branches with various discoloration depending on the age of the intramural clot. The outcomes were favorable.

[A case of hypertrophic cranial pachymeningitis].

A case of hypertrophic cranial pachymeningitis was reported. A 58-year-old female presented the symptoms of headache and vomiting. At the age of 27, she had suffered from tuberculosis. Neurological examination on admission revealed bilateral papilledema, bilateral hearing disturbance, right hypoglossal nerve palsy, ataxic gait, and bilateral intentional tremor. CT scan showed dilatation of the lateral and third ventricles, and compression of the fourth ventricle with marked enhancement of cerebellar tentorium. A ventriculoperitoneal shunt was installed bringing about improvement in bilateral papilledema, ataxic gait, and bilateral intentional tremor. One month later, ataxic gait and bilateral intentional tremor recurred, and monoparesis of the left upper extremity developed. MRI demonstrated hypertrophic dura mater in the posterior fossa and compressed cervical spinal cord. Decompressive surgery was performed bringing about remarkable clinical improvement. The pathological specimen showed thickening of the dura mater with concentric layers of dense fibrous tissue infiltrated with plasma cells. A diagnosis of hypertrophic cranial pachymeningitis was established. Three years later, the clinical features were found unchanged, but contrast enhancement of cerebellar tentorium had progressed markedly. Hypertrophic pachymeningitis is a uncommon disease. But it should be noted that intracranial involvement is very rare. The etiology, symptomatology, neuroradiology, and treatment are discussed and the literature is reviewed.

[Simultaneous, multiple hypertensive intracerebral hematomas: report of 5 cases and review of literature].

Five cases of multiple hypertensive intracerebral hematomas which occurred simultaneously but in different locations were described in this report. The diagnoses of all five cases were established by computed tomography, and the location of the hematomas was as follows; case 1. bilateral putamen, case 2. bilateral thalamus and right parietal subcortex, case 3. cerebellum and left thalamus, cases 4 and 5. cerebellum and right putamen. These represented 0.7% of all the patients (679 cases) who suffered from hypertensive intracerebral hematoma and were admitted to our two institutions in the last five years. We also reviewed the other 11 cases which have been reported in literature, and the total 16 cases were analyzed with respect to clinical characteristics, pathogenesis of multiple hematomas, indication of operation and prognosis. 1. The age distribution had a peak in the 70's and was similar to that of single hematoma. 2. Sixteen cases had 34 intracerebral hematomas. Eleven cases had bilateral supratentorial lesions. Four cases had cerebellar and supratentorial lesions. The remaining had two supratentorial lesions ipsilaterally. The distribution of 34 hematomas (16 in cerebral basal ganglia, 10 in thalamus, 4 in cerebellum, 4 in cerebral subcortex and none in pons) was well correlated to the distribution of usual hypertensive intracerebral hematomas. 3. The clinical symptoms were characterized by severe consciousness disturbance and severe neurological deficits. Their outcome was poor. 4. As for the possible mechanism of simultaneous multiple hemorrhages, we suspected either that two or more primary bleedings occurred simultaneously in the different regions, or that a primary bleeding was followed a short time after by a secondary bleeding in the other site.(ABSTRACT TRUNCATED AT 250 WORDS)