Posterior inferior cerebellar artery aneurysm located in the spinal canal--case report.

A 30-year-old male presented with subarachnoid hemorrhage, due to a rare peripheral posterior inferior cerebellar artery aneurysm located in the spinal canal. Angiography and magnetic resonance imaging disclosed the aneurysm of 15 mm diameter at the C-1 level. After aneurysmal neck clipping and ventriculoperitoneal shunt implacement, he was discharged without neurological deficit. Histological examination revealed no layer formation, only hemorrhage and organization in the aneurysmal wall. This case may be an example of giant aneurysm formation caused by repeated bleeding and organization.

Carbon dioxide gas replacement of chronic subdural hematoma using single burr-hole irrigation.

In order to achieve complete irrigation, reduce air in the hematoma cavity, and obtain rapid reduction of the cavity without drainage, we use burr-hole evacuation of the hematoma followed by irrigation using physiologic saline solution and replacement of the hematoma with carbon dioxide (CO2) gas. We have treated 19 cases between the ages of 41 and 84. With the exception of one case with dementia of 5 years' duration, all cases were asymptomatic postoperatively. Computed tomography (CT) scans obtained immediately postoperatively showed the gas to fill the hematoma cavity, but on the following day, the gas and the hematoma cavity had nearly disappeared. There was no surgical mortality nor morbidity and there were no side effects of the CO2 gas. Recurrence was found in one case (5.3%). By filling the hematoma cavity with CO2, disappearance of the cavity is rapid and drainage is not needed. Moreover, this technique implies no restrictions on postoperative motility, and is thus suitable for elderly patients.

[Orbito-cranial reconstruction and unilateral optic canal release in a patient with left fronto-orbital fibrous dysplasia: a case report].

A surgical case of monostotic fibrous dysplasia of the left frontal and sphenoidal bone in a 14-year-old girl is described. This girl was admitted to our hospital in March, 1992, with a chief complaint of facial deformity and asymmetry due to a painless and progressive bony bulging over the left fronto-orbital region. But she denied any symptoms such as proptosis, diplopia, optic atrophy and visual loss. Other data found on neurological examination and laboratory tests were normal. In addition, she had no history of skin lesions, precocious puberty or other endocrine abnormalities. Plain craniogram showed remarkable thickening of the left frontal bone and of the anterior cranial fossa of the sphenoidal bone with irregular stenosis of the left optic canal. CT scan showed the diffuse enlargement of the affected bone and involvement of the paranasal sinuses. Angiography revealed no positive findings. On December 10, 1992, orbito-cranial reconstruction and unilateral optic canal release were performed using an extradural approach through a left fronto-temporal craniectomy. Histological findings confirmed the lesion to be typical fibrous dysplasia. She recovered completely one month after the operation, but she suffered transient blurred vision, diplopia and left ptosis. Most of the decreased vision caused by fibrous dysplasia cannot be reversed after surgical treatment. So, if optic canal stenosis is evident, even when visual loss is not clear, release of the optic canal stenosis should be done as early as possible in association with experienced neurosurgeons and with meticulous dissection.

Pineal yolk sac tumor in a 65-year-old man.

A 65-year-old man presented with a case of pure yolk sac tumor in the pineal region. The patient was admitted with a gait disturbance and elevated alpha-fetoprotein levels in serum and cerebrospinal fluid. He underwent total resection of the tumor. Cisplatin-vinblastine-bleomycin therapy was interrupted because of severe syndrome of inappropriate secretion of antidiuretic hormone, and there was recurrence of the tumor. Five months after the operation, he died in spite of carboplatin-etoposide therapy. A review of the literature revealed no previous report of pineal yolk sac tumor in an elderly patient. Problems in the diagnosis and treatment of such cases are discussed.

[A case of traumatic syringomyelia which disappeared after anterior decompression: a suggestion for surgical treatment of syringomyelia].

A 37-year-old man had received cervical spinal-cord injury 20 years previously. Recently, he complained of progressive spastic gait and was shown to have fracture dislocation of the C5 vertebral body which compressed the spinal cord posteriorly. He also had a syrinx from the C5 to C2 vertebral level. Postoperatively, this syrinx disappeared after anterior decompression of the C4 and C5 vertebral bodies. Such a case as this has never been reported, and this case may give a suggestion for surgical treatment of syringomyelia, because it is very natural that the most reasonable treatment of any disease is removal of the cause.

[A case of systemic lupus erythematosus associated with an aneurysm of the lenticulostriate artery].

We describe a patient with established systemic lupus erythematosus (SLE) in whom an intracerebral hemorrhage developed secondary to a ruptured aneurysm of the lenticulostriate artery (LSA). A 24-year-old woman with a four-year history of SLE was admitted to the department of internal medicine of Iwate Medical University for the treatment of lupus nephritis in 1985. She suddenly complained of severe headache and nausea, and soon lost consciousness. The computed tomographic scan revealed intracerebral hemorrhage in the left front-temporal region and subarachnoid hemorrhage. Left common carotid angiography demonstrated a 3 X 3 mm aneurysm of the LSA and displacement of other LSAs and anterior cerebral artery. The incidence of intracerebral hemorrhage in SLE was about ten percent in the reported central nervous system SLE, and it seemed that the prognosis of SLE with intracerebral hemorrhage was poor. The mechanisms of the intracerebral hemorrhage and the aneurysmal formation in SLE seemed to be due to lupus angiitis, but without clinical, radiologic and pathologic correlation. In operation, a ruptured aneurysm without neck was found in LSA and extirpated. In the pathological study, there was transmural angiitis, which fibrinoid necrosis, elastic tissue disruption and infiltration of inflammatory cells were found. Inflammatory cells were chiefly lymphohistiocytic with some polymorphonuclear leukocytes. It seemed that pathologic studies confirmed transmural angiitis with secondary aneurysm formation.