[Basal Ganglia Arteriovenous Malformation in an Elderly Patient Presented with Putaminal Hemorrhage, Diagnosed after Hematoma Evacuation by Imaging: A Case Report].

A 67-year-old male patient presented with disturbance of consciousness, anisocoria, and right hemiparesis. Computed tomography (CT) scans demonstrated a large putaminal hemorrhage on the left. An emergent operation was performed and the hematoma was removed. Postoperative magnetic resonance angiographic (MRA) images and carotid angiography (CAG) revealed a basal ganglia arteriovenous malformation (AVM). The AVM was resected completely. Putaminal hemorrhages due to basal ganglia AVM rupture are very rare in the elderly. Although most AVMs are angiographically occult, in the current case, the AVM was diagnosed using MRA and CAG. Thus, preoperative examination such as MRA and 3D-CT angiography should be performed in putaminal hemorrhages, even in the elderly. (Received April 22, 2016; Accepted September 7, 2016; Published January 1, 2017).

[Intracerebral and subarachnoid hemorrhages after administration of recombinant tissue plasminogen activator in a patient with acute ischemicstroke due to anterior cerebral artery dissection: a case report].

A 45-year-old man was admitted to our hospital for treatment of right hemiparesis. At admission, he was alert and well oriented. His verbal comprehension seemed good, but his speech was not fluent. He could not stand or walk owing to the right hemiparesis, which was severe in the lower extremity. Computed tomographic (CT) scans on admission showed no abnormality. Diffusion weighted magnetic resonance imaging performed after the CT showed a high-intensity lesion in the left cingulate gyrus. Magnetic resonance angiography (MRA) revealed occlusion and irregularity of the left A2 portion of the anterior cerebral artery (ACA). At 1 h 50 min after the onset of the hemiparesis, recombinant tissue plasminogen activator (rt-PA; 0.6 mg/kg) was administered intravenously. At 1 h after the administration of rt-PA, he became drowsy and his right hemiparesis deteriorated. CT scans performed again showed a hematoma in the left frontal lobe and subarachnoid hemorrhage in the anterior interhemispheric fissure. He was treated conservatively. MRA performed on the 18th day after admission showed recanalization of the left ACA and abnormal dilatation of the left A2 segment. The abnormal dilatation was also depicted by 3D-CT angiography (3D-CTA) performed on the 26th day after admission and even on the 33rd and 77th days. As seen in our case, the definite diagnosis of dissection confined to the ACA frequently needs serial angiographies; therefore, its diagnosis immediately after the onset is often difficult. Thrombolytic therapy by intravenous administration of rt-PA for cerebral infarction caused by dissection of the ACA may recanalize the occluded site and facilitate the progression of the dissection, resulting in intracerebral and/or subarachnoid hemorrhages. In patients with cerebral infarction due to ACA dissection, strict control of blood pressure and careful observation are necessary after thrombolytic therapy by rt-PA.

[Cerebrospinal fluid edema occurred in normal pressure hydrocephalic patients with functioning ventriculo-peritoneal shunts: report of three cases].

We describe three cases of cerebrospinal fluid edema (CFE) which occurred in hydrocephalic adult patients who underwent ventriculo-peritoneal shunt operations. After shunt operations, the shunt systems were functioning well and symptoms due to hydrocephalus were resolved. However, computed tomographic scans demonstrated CFE around the ventricular catheters in all patients. The patients were free from symptoms due to CFE and observed conservatively. The one-way valve mechanism is thought to be a possible mechanism of CFE in these cases. Although CFE is a very rare complication to occur after shunt operations, it is necessary to follow up the patients even if the shunt is functioning well.

[Medulla and upper cervical cord compression by bilateral vertebral artery presented with myelopathy and drop attack: case report].

A 51-year-old man had suffered from attacks of quadri-paresis and unconsciousness for previous three years prior to presentation. Prior to admission, he had been received anticonvulsants, but his symptoms showed no improvement. Neurological examination revealed hyper-reflexia of his left lower extremity and moderate decrease of sense of pain, temperature, and tactile sensation in his left extremities and trunk, while vibratory sensation was normal. Magnetic resonance(MR) imaging revealed a flow-void area in the craniocervical junction and marked narrowing of the medulla oblongata and upper cervical cord by compression of the vertebral arteries(VA). CT myelography also showed the compression and narrowing of the spinal cord. Vertebral angiography demonstrated symmetrical running course of the arteries, which curved medially at the level of craniocervical junction. Suboccipital craniectomy and C1 and upper half of C2 laminectomies were performed. After dural opening, the ventrolateral aspects of the lower medulla oblongata and the upper cervical cord were found to be compressed by the VA. The arteries were retracted dorsolaterally by GORE-TEX tapes so as to decompress the medulla oblongata and cervical cord, and the tapes were anchored to the residual part of C1 posterior arch. Postoperative MR imaging and CT myelography showed complete decompression, and the patient was relieved of his previous neurological symptoms.