A Case of Carotid Sinus Reflex Caused by Manual Aspiration Thrombectomy Using a Balloon Guide Catheter.

When starting a mechanical thrombectomy, manual aspiration with balloon guide catheters inserted into the internal carotid artery (ICA) is an efficient method for thrombus aspiration. However, no complications associated with this procedure have been reported. This study describes the case of a 76-year-old man who presented to our hospital with total aphasia and complete right-sided paralysis due to chronic atrial fibrillation and left occlusion of the ICA. When the balloon guide catheter was inserted and inflated at the origin of the left ICA, the patient's systolic blood pressure suddenly decreased from 114 mm Hg to 44 mm Hg. This sudden hypotension may have been caused by the carotid sinus reflex. Hypotension improved following balloon deflation. The procedure was continued, resulting in complete recanalization of the left ICA. The patient died from acute exacerbation of interstitial pneumonia. Although this complication is rare, similar phenomena have been recognized in carotid artery stenting and the use of flow-diverting devices. To the best of our knowledge, this is the first report of a case wherein the carotid sinus reflex was induced by manual aspiration using a balloon guide catheter placed in the ICA. Clinicians should recognize the importance of ensuring that the proximal end of the balloon crosses the carotid sinus when dilating and occluding the ICA with a balloon to avoid the carotid sinus reflex.

Brain metastasis of chondrosarcoma: A case report and literature review.

Brain metastases of a chondrosarcoma are extremely rare, and treatment remains controversial. A 54-year-old woman had undergone surgical treatment for a femoral chondrosarcoma and its lung metastases. She presented with visual disturbance and dizziness 22 months after the initial surgery; imaging studies of the brain revealed a metastatic tumor in the left parieto-occipital lobe. Surgical tumor resection was performed; however, only 2 months after gross total resection of the tumor, rapid tumor recurrence was observed. Surgical resection was performed again, followed by intensity-modulated radiation therapy. Three months later, another small brain lesion was detected in the right parietal lobe and was treated with gamma knife stereotactic radiosurgery. No recurrence has been reported 20 months after this radiosurgery for brain metastasis. Thus, surgical treatment combined with several adequate radiation therapy sessions may be a viable treatment strategy for brain metastases of chondrosarcomas.

Tailor-Made Endoscopic Surgical Strategy for Severe Intraventricular Hemorrhage with Obstructive Hydrocephalus.

BACKGROUND: Severe intraventricular hemorrhage (IVH) is associated with a high mortality rate and poor functional outcome, even with recent neurosurgical developments. IVH requires emergent surgery to save the patient's life, but the optimal surgical strategy remains controversial. We assessed the results obtained with our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus. METHODS: Consecutive patients with severe IVH owing to intracerebral hemorrhage who were treated with endoscopic surgery in the acute phase were retrospectively reviewed. Both rigid and flexible endoscopes were used for removal of hematoma in the whole ventricular system. Endoscopic third ventriculostomy and septostomy were performed as appropriate in each individual case. RESULTS: Eight patients met the inclusion criteria and were included in the analysis. Sufficient IVH removal without neglecting the fourth ventricle was achieved with our technique in 6 of 8 cases (75.0%). Endoscopic third ventriculostomy and septostomy were added in 4 cases each (50.0%). Four patients (50.0%) had a marked recovery and a good outcome (modified Rankin Scale score ≤2) despite disease severity at onset. The procedure was completed successfully in all cases, and there were no surgery-related complications. CONCLUSIONS: This study showed that our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus may be beneficial.

[Chronic Subdural Hematoma with Middle Cranial Fossa Arachnoid Cyst Concomitant with Bilateral Papilledema:A Case Report].

Arachnoid cysts(AC)are benign cystic lesions often diagnosed in childhood. Although usually asymptomatic, AC can become symptomatic when the lesion size increases or coexists with a subdural hygroma or hematoma. AC patients with signs of increasing intracranial pressure(IICP)or neurological deficits may need surgical intervention; this usually results in a good prognosis. However, whether asymptomatic AC patients should undergo surgical treatment is controversial. Although trivial head trauma, such as that from contact sports, can cause subdural hematoma in AC patients, there are currently no definite criteria regarding sports participation for children with AC. CASE: A 12-year-old boy who belonged to a soccer club visited an ophthalmologist with the chief complaint of having had diplopia for two weeks. He was identified as having bilateral papilledema. Since he had been diagnosed with a right middle cranial fossa AC five years earlier, he was referred to our outpatient clinic. Cranial CT scans showed right chronic subdural hematoma alongside the AC. The patient subsequently underwent burr hole surgery and was discharged after one week. In this case, the patient did not present with the typical signs of IICP, such as headache or vomiting. This experience indicates that care must be taken when encountering patients with atypical symptoms, particularly children. In addition, it is important to carefully consider sports participation for children with AC.

Primary central nervous system malignant melanoma with leptomeningeal melanomatosis: a case report and review of the literature.

Leptomeningeal melanomatosis is an extremely rare variant of primary central nervous system (CNS) melanoma and has a poor prognosis and no standard treatment. Primary CNS melanoma is derived from the melanocytes of the leptomeninges. Here, we describe a case of a 37-year-old male who visited our hospital due to worsening headaches. Characteristic imaging findings of this tumor type include hyper-dense lesions that are enhanced by contrast medium on computed tomography and hyper-intensity on T1-weighted magnetic resonance images and iso- to hypo-intensity on T2-weighted magnetic resonance images. Imaging of the CNS in our patient showed several lesions of this type. Pathological diagnosis and exclusion of systemic melanoma are required to confirm primary CNS malignant melanoma. Partial resection of the mass in the left temporal lobe of this patient was performed, and histological analysis showed pigmentation, melanin black-45 positivity, and BRAF mutation. Because no lesions were found outside the CNS following a thorough whole-body search, he was diagnosed with primary CNS malignant melanoma with leptomeningeal melanomatosis. He was treated with whole-brain radiation and the BRAF kinase inhibitor vemurafenib. His condition worsened, and he was given the anti-programmed cell death-1 antibody nivolumab as second-line therapy. This was also unsuccessful, and he died 5 months after treatment initiation. Further studies are needed to improve treatment and prognosis of this rare but serious disease.

Carotid artery stenting for atherosclerotic stenosis associated with non-bifurcating cervical carotid artery.

A 68-year-old man presented with right cervical carotid artery stenosis manifesting as ipsilateral amaurosis fugax. Angiography showed non-bifurcating cervical carotid artery with atherosclerotic stenosis near the branching of the superior thyroid artery. Carotid artery stenting (CAS) was carried out using two balloons for embolic protection of the internal carotid artery and middle meningeal artery because the ophthalmic artery was supplied by the middle meningeal artery. No procedure-related complications or restenosis occurred after stenting. Non-bifurcating cervical carotid artery is a very rare anomaly, in which the branches of the external carotid artery directly arise from the common trunk of the carotid artery without forming a bifurcation. The present patient was successfully treated with CAS for atherosclerotic stenosis associated with non-bifurcating cervical carotid artery.

Ectopic pituitary adenoma associated with an empty sella: a case report and review of the literature.

A case of ectopic pituitary adenoma in the sphenoid sinus associated with an empty sella is reported. The coexistence of an ectopic pituitary adenoma and an empty sella is quite rare. The diagnosis was made with an intraoperative finding of the intact dura mater of the sellar floor. In the present case, the hypointense line that coated the pituitary gland was clearly demonstrated on 3-tesla T2-weighted magnetic resonance imaging. The hypointense line is considered to be the pituitary capsule and was critical in diagnosing this rare entity.

Syringomyelia without hindbrain herniation: tight cisterna magna. Report of four cases and a review of the literature.

Idiopathic syringomyelia, which is not associated with any definite pathogenic lesions, has been treated mainly by shunting of the syrinx and rarely by craniocervical decompression. The authors report four cases of syringomyelia thought to be idiopathic syringomyelia but treated by craniocervical decompression with favorable results. Syringomyelia was present without hindbrain herniation. In such cases, the subarachnoid space anterior to the brainstem at the level of the foramen magnum is usually open but the cisterna magna is impacted by the tonsils, a condition the authors term "tight cisterna magna." All patients underwent foramen magnum decompression and C-1 laminectomy, and the outer layer of the dura was peeled off. Further intradural exploration was performed when outflow of cerebrospinal fluid (CSF) from the fourth ventricle was deemed to be insufficient. Postoperatively, improvement in symptoms and a reduction in syrinx size were demonstrated in three patients, and a reduction in ventricle size was shown in two. Syringomyelia associated with tight cisterna magna should not be classified as idiopathic syringomyelia; rather, it belongs to the category of organic syringomyelia such as Chiari malformation. A possible pathogenesis of cavitation is obstruction of the CSF outflow from the foramen of Magendie, and the cavity may be a communicating dilation of the central canal. Ventricular dilation may depend on the extent to which CSF drainage is impaired from the foramina of Luschka. These cavities may respond to craniocervical decompression if it results in sufficient CSF outflow from the foramen of Magendie, even in cases with concomitant hydrocephalus.

Compartments in arteriovenous malformation nidi demonstrated with rotational three-dimensional digital subtraction angiography by using selective microcatheterization. Report of three cases.

Although in several histological studies of arteriovenous malformation (AVM) nidi the presence of compartments has been documented, no clinical study has been published. The present study was conducted to determine the presence of nidus compartments in clinical cases by using a new radiographic method. Two patients with unruptured and one with a ruptured AVM (all Spetzler-Martin Grade III) were studied. A microcatheter was superselectively introduced into each of two or three feeding arteries of the AVMs under three-dimensional (3D) angiographic guidance to obtain 3D images of the nidus by using rotational digital subtraction angiography. On 3D images the different feeding arteries were found to be independent from one another, which allowed the authors to confirm the presence of compartments. On the other hand, separate feeding arteries often had a common draining vessel. Compartments in AVM nidi were demonstrated by a novel rotational 3D angiographic procedure by using superselective microcatheterization, which should be useful for designing treatment strategies for large and complex AVMs.