Vascular Reconstruction for Radiation-induced Bilateral Internal Carotid Artery Occlusion and Unilateral External Carotid Artery Stenosis by a Combination of Surgical and Endovascular Method: Case Report.

We present a case of a 63-year-old male presenting with right hemiparesis and diagnosed as cerebral infarction. He had a previous history of left pharyngeal carcinoma, which was treated by radial dissection and radiation therapy 10 years before. Magnetic resonance imaging (MRI) showed multiple cerebral infarction in the bilateral cerebral hemisphere, predominantly on the left. Cerebral angiography showed occlusion of bilateral internal carotid arteries and severe stenosis at the orifice of the left external carotid artery (ECA). Single photon emission tomography (SPECT) showed reduced cerebral blood flow and decreased cerebral vascular reserve in the bilateral anterior cerebral artery and left middle cerebral artery territories. He was successfully treated by a combination of carotid stenting for the left ECA and left superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. He did not have further ischemic symptom for more than 2 years. Radiation-induced carotid vasculopathy often involves multiple arteries and treatment is often complex and difficult. Safer and less invasive treatment strategy should be considered using both endovascular and direct surgery.

Asymmetric bilateral effect of the supplementary motor area proper in the human motor system.

OBJECTIVE: This study aimed to clarify the function of human supplementary motor area proper (SMA) by the single-pulse electric stimulation method and its clinical usefulness for SMA mapping. METHODS: We studied five patients with epilepsy or brain tumour who underwent invasive functional mapping with subdural electrodes. Single-pulse electric stimulation of primary motor area (MI) and SMA was carried out through pairs of subdural electrodes, and motor-evoked potentials (MEPs) were recorded from surface electromyogram on both sides and also cortico-cortical-evoked potentials (CCEPs) from electrocorticogram. RESULTS: SMA stimulation elicited: (1) MEPs and following silent periods (SPs) in the contralateral upper and lower extremities, (2) SPs with or without minimal MEPs in the ipsilateral upper extremity and (3) CCEPs in the somatotopically corresponding region of the ipsilateral MI. Compared with MI stimulation, SMA stimulation required higher stimulus intensities (mean 14.2 mA (SMA) vs. 8.5 mA (MI)) to elicit MEPs and showed significantly longer onset latencies in upper extremity (range: 4-10 ms). CONCLUSIONS: The results demonstrated an asymmetric bilateral effect of human SMA upon the corticospinal pathway. SIGNIFICANCE: Single-pulse electric cortical stimulation would be clinically useful for distinguishing SMA from MI. The asymmetric bilateral effect of SMA might be conveyed through the direct descending pathway.

Intravenous methylprednisolone reduces the risk of propofol-induced adverse effects during Wada testing.

The adverse effects and risks associated with intracarotid propofol injection during Wada testing were retrospectively compared in two groups of patients with (n = 75) and without (n = 58) intravenous methylprednisolone administered before intracarotid propofol injection. The incidences of all adverse effects were decreased in the methylprednisolone group. In particular, severe adverse effects such as increased muscle tone with twitching and rhythmic movements or tonic posture, which could adversely affect Wada test results, were seen in one patient in the methylprednisolone group and seven patients in the control group, indicating 92% risk reduction. This study suggests that Wada testing using intravenous methylprednisolone administration prior to propofol injection is a safe approach to the preoperative evaluation of brain tumors, epilepsy, and arteriovenous malformations.

Clinical significance of cerebrospinal fluid tap test and magnetic resonance imaging/computed tomography findings of tight high convexity in patients with possible idiopathic normal pressure hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is a treatable syndrome with a classical triad of symptoms. The Japanese iNPH guidelines indicate that the cerebrospinal fluid (CSF) tap test and tight high-convexity on magnetic resonance (MR) imaging are important for the diagnosis. The relationships between the effectiveness of CSF shunt surgery in possible iNPH patients, the tap test result, and the MR imaging/computed tomography (CT) findings of tight high-convexity were evaluated in 88 possible iNPH patients (mean age 75 years) with one or more of the classical triad of symptoms, and mild to moderate ventricular dilation. All patients underwent the tap test in the outpatient clinic, and patients and caregivers assessed the clinical changes during one week. The tap test was positive in 47 patients and negative in 41 patients. Surgery was performed in 19 patients with positive tap test, and was effective in 17 patients. Although the findings were inconsistent in some patients, the result of the tap test was found to be highly correlated with the MR imaging/CT finding of tight high-convexity (p < 0.0001), confirming that both these diagnostic tests are promising predictors of shunt effectiveness.