[Possible Cerebral Infarction due to Multiple Segmental Cerebral Vasospasms after Carotid Artery Stenting: A Case Report].

A 62-year-old man was admitted due to consciousness disturbance and motor aphasia. Magnetic resonance (MR) images demonstrated watershed infarctions in the territory of the left middle cerebral artery, occlusion of the left internal carotid artery, and severe stenosis of the right internal carotid artery at the neck. He was treated with a recombinant tissue plasminogen activator. One month later, angiography revealed recanalization of the left internal carotid artery with residual severe stenosis at the neck. We attempted carotid artery stenting (CAS) on the left internal carotid artery, but could not pass the guide wire through the stenosis. Therefore, we performed CAS on the right carotid artery instead. At the second day after CAS, the patient showed consciousness disturbance, right hemiparesis, and motor aphasia. MR images showed a new infarction in the left cerebral hemisphere and bilateral multifocal segmental arterial constrictions. By keeping his blood pressure at a high enough level for one week, his symptoms were relieved, and MR images showed resolution of the vessel constrictions. From this case, we can conclude that this kind of multiple segmental vasospasms after CAS require contrasting treatments to those for hyperperfusion syndrome. Interventionalists should be aware of this condition and its treatments.

[Hemangiopericytoma on the intradural thoracic spinal cord: a case report].

Hemangiopericytoma develops from many organs. In the central nervous system, most tumors arise in the intracranial portion, and tumors originating from the spinal cord are rare. Its clinical course and neurological characteristics have not been disclosed. We present a case of a 51-year-old woman with gradually progressing paraparesis. Magnetic resonance (MR) images of the thoracic spine demonstrated an intradural tumor at the 6 and 7 thoracic vertebral body level. The patient underwent total excision of the tumor. The histological diagnosis was hemangiopericytoma. MR images after the operation showed no residual tumor and the patient was followed up without adjuvant therapy. However, 5 years later, the patient complained of back pain and gait disturbance again, and MR images showed a recurrence of the tumor. We resected the tumor under motor evoked potential (MEP) monitoring and removed the extradural part of the tumor, but the part of the tumor which had infiltrated the spinal cord was left due to the lowering of MEP amplitude. The operation resulted in partial resection. Spinal intradural hemangiopericytoma is very rare, and only 15 cases including the present case have been reported. This paper will discuss the clinical characteristics and treatment for this tumor.

[A clinical feature and therapeutic strategy in pituitary adenomas associated with intracranial aneurysms].

We studied the clinical feature and treatment strategy of pituitary adenomas associated with intracranial aneurysms. Among 102 pituitary adenoma patients (mean age: 54.8 years old) who received MR angiography and/or 3D-CT angiography, seven patients (6.9%) had intracranial aneurysms. The association of an aneurysm was more common in large size adenomas (p<0.05). According to the location of the aneurysms, five patients had these in the paraclinoid portion or cavernous portion of the internal carotid artery. Using MR images, we classified the aneurysms associated with pituitary adenomas as non-adjacent, adjacent, and intra-adenoma types. In non-adjacent types, an aneurysm is located apart from the adenoma, and has less chance of exposure during transsphenoidal surgery. In adjacent types, an aneurysm is located adjacent to the adenoma, and could be exposed during transsphenoidal surgery. In intra-adenoma types, an aneurysm is encased in the adenoma. In non-adjacent type aneurysms, a resection of the pituitary adenoma can be carried out before aneurysm treatment due to the low risk of rupture during surgery. In adjacent types, a tumor resection can precede aneurysm treatment in cases of low rupture risk aneurysms and untreatable aneurysms. In intra-adenoma types, adenoma resection should come after treatment of the aneurysms. Neurosurgeons should be careful about not only the presence of aneurysms in preoperative images during transsphenoidal surgery planning, but also their locations and proximity to adenomas. Such information may be crucial in deciding the order of treatment.

[Subdural hematoma at the cranio-vertebral junction following head trauma: a case report].

We report a 62-year-old woman patient who slipped and hit the occipital portion of her skull and suffered an acute spinal subdural hematoma caused by head injury. She complained of headache, neck pain, vomiting, dizziness, and was transferred to our hospital. A skull roentgenogram and CT showed occipital bone fracture and thin subarachnoid hemorrhage, and a small amount of acute subdural hematoma on the contra lateral side. Three hours after the accident, she complained of aggravating neck pain. A repeated CT showed acute subdural hematoma at the cranio-vertebral junction extending to the C3 vertrebral body level. At the emergent operation, we found a dural laceration at the foramen magnum just beneath the fracture, and acute spinal subdural hematoma. After evacuation of the hematoma, the patient recovered completely. Spinal acute subdural hematomas after head injuries are relatively rare. In this case, the migration of the extradural hematoma through the dural laceration at the cranio-vertebral junction was supposed to be responsible for the spinal subdural hematoma. It is crucial that a cervical CT be taken to rule out the possibility of spinal hematoma for patients with head injuries complaining of neck pain.

Recurrent meningioma with metastasis to the skin incision--case report.

A 70-year-old woman presented with meningioma with metastasis to the skin incision. Neuroimaging demonstrated a tumor of the falx extending to the frontal bone. The tumor was grossly totally resected through a coronal skin incision. The histological diagnosis was meningotheliomatous meningioma. The tumor recurred in the ethmoid sinus 2 years later, and was resected through the transfacial approach. One year later, the tumor recurred in the ethmoid sinus and orbit, and was resected through the transcranial approach. Six months later, she noticed an isolated small mass under the skin incision, distant from a further recurrence of the tumor. Both tumors were resected. The histological diagnosis was atypical meningioma. Resection of atypical meningioma carries the risk of iatrogenic metastasis. Surgeons should wash out the operative field carefully and change surgical tools frequently.