Effect of clot removal and surgical manipulation on regional cerebral blood flow and delayed vasospasm in early aneurysm surgery for subarachnoid hemorrhage.

BACKGROUND: Effect of clot removal and surgical manipulation on cerebral blood flow (CBF) and delayed vasospasm was studied in early aneurysm surgery for subarachnoid hemorrhage (SAH). METHODS: Thirty-two patients in this study fulfilled the following criteria: ruptured anterior communicating aneurysms, computed tomography (CT) within 2 days and unilateral pterional approach within 3 days after the ictus, bilaterally symmetrical clots without intracerebral hematoma, no postoperative complication, and CBF studies with single photon emission computed tomography (SPECT) with 123I-IMP. RESULTS: Postoperative regional hypoperfusion due to brain retraction was frequently recognized on 123I-IMP-SPECT without infarction. The regional CBF (rCBF) showed a continuous fall during the first 4 weeks after the ictus, followed by improvement. The rCBF in the vicinity of the surgical route was significantly lower, especially in the acute stage (Day 3-7). A significant association between decrease of cisternal blood after surgery and the degree of local vasospasm and local CBF values during spasm stage was observed in the interhemispheric cisterns, A2 and medial frontal cortex, but not in the sylvian fissure or insular cisterns, M1 or M2, and frontal watershed and temporal cortex. CONCLUSIONS: The present study provides evidence for the effectiveness of direct clot removal by early surgery for SAH on local vasospasm and CBF reduction. However, a potential improvement in local CBF with clot removal could be masked by brain retraction, which was demonstrated to affect rCBF adversely. Therefore, it is critical to perform brain retraction as gently as possible.

Influence of degree of carotid artery stenosis and collateral pathways and effect of carotid endarterectomy on cerebral vasoreactivity.

OBJECTIVE: The goal was to determine the influence of the degree of internal carotid artery (ICA) stenosis and collateral pathways on cerebral vasoreactivity (CVR). The effect of carotid endarterectomy on CVR is also presented. METHODS: For 36 patients with unilateral ICA stenosis of at least 70%, regional cerebral blood flow (rCBF) and regional CVR (rCVR) were investigated before and after carotid endarterectomy, with resting and acetazolamide-challenge single photon emission computed tomographic scans. The degree of ICA stenosis and the status of the collateral pathways (sizes of the A1 segment and the posterior communicating artery) were evaluated by angiography. RESULTS: Thirteen patients were classified as Type N/N (normal rCBF and normal rCVR), 5 as Type R/N (reduced rCBF and normal rCVR), 6 as Type N/R (normal rCBF and reduced rCVR), and 12 as Type R/R (reduced rCBF and reduced rCVR). The degree of ICA stenosis correlated with rCVR status. The size of the A1 segment was a second-rank factor and was less effective in affecting rCVR. The size of the posterior communicating artery was not associated with rCVR. The predictive value of reduced rCVR for postoperative improvement (100%) was significantly higher than that of reduced rCBF (50%). CONCLUSION: The present results indicate that the degree of ICA stenosis is a more significant determinant of CVR than are the collateral pathways in patients with carotid artery stenosis. The high predictive rate of reduced rCVR for postoperative improvement implies that acetazolamide-challenge single photon emission computed tomographic scanning might be useful in selecting patients with asymptomatic ICA stenosis who might benefit from carotid endarterectomy.

Multiple burr-hole operation for adult moyamoya disease.

Excellent results from multiple burr-hole operations for adult moyamoya disease are reported in this study. Ten patients had between one and four burr holes (mean 2.1) drilled in each hemisphere. In four patients new burr holes were added on the opposite side after depression of cerebral blood flow (CBF) was detected by follow-up single-photon emission computerized tomography imaging of the brain with N-isopropyl-p-[123I]iodoamphetamine. The postoperative follow-up period ranged from 6 to 62 months (mean 34.7 months). Beginning at 6 months postsurgery, angiograms disclosed rich neovascularization at 41 of 43 burr holes, first from the middle meningeal artery, then from the superficial temporal artery. Neovascularization did not occur at two burr holes at which there was subdural effusion and local cerebral atrophy, respectively. Progression of stenosis of the major vessels was seen in six patients. Moyamoya vessels were decreased at six sites in four patients. The CBF study revealed that the reactivity to acetazolamide improved in all six patients tested. Transient ischemic attacks disappeared in all six patients presenting with this symptom, and preoperative symptoms improved in both of the patients who presented with cerebral infarction and in both patients with intraventricular hemorrhage. There was no mortality or morbidity, and no new neurological deficits or rebleeding developed during the follow-up period. The authors strongly recommend the multiple burr- hole operation as the surgical treatment of choice for adult moyamoya disease because of its safety and effectiveness.

Saccular aneurysms of the proximal (M1) segment of the middle cerebral artery.

We report A series of 20 consecutive patients with 21 saccular aneurysms of the proximal (M1) segment of the middle cerebral artery. The incidence of M1 aneurysms was 3.0% among 660 patients with intracranial aneurysms and 12.9% among 155 patients with middle cerebral artery aneurysms in our center. Of the 20 patients, 2 were men and 18 were women. The aneurysms were classified into two types: the superior wall type (9 cases), arising at the origin of the lenticulostriate or fronto-orbital artery, and the inferior wall type (12 cases), arising at the origin of the early temporal branches. Twelve (60%) patients had ruptured M1 aneurysms. The incidence of multiple aneurysms was high (nine patients, 45%), and M1 aneurysms were responsible for subarachnoid hemorrhage in four patients. Of 14 M1 aneurysms greater than 5 mm in diameter, 11 (78.6%) ruptured. In contrast, only one (14.3%) of seven small (< or = 5 mm) aneurysms ruptured. In 12 patients with ruptured M1 aneurysms, intracerebral hematomas were recognized in 6 (50%). Intracerebral hematomas by the superior wall M1 aneurysms were located in the frontal lobe, and those by the inferior wall M1 aneurysms were in the temporal lobe. Fifteen patients (75%) made a useful recovery 6 months after surgery. Four patients (20%), who were in poor grade condition preoperatively, remained severely disabled. One patient died of sepsis 2 months after she recovered well from the operation. Special attention to the lenticulostriate arteries to avoid injury is critical for successful surgical treatment.

Blade-deviated fenestrated clips for anterior communicating artery aneurysms.

Blade-deviated fenestrated clips developed by one of the authors were applied very successfully in 15 cases of A Com A aneurysms which corresponded to 32% of the aneurysms upon which were operated. Of the 15, 13 cases were projected superiorly, which is the most difficult and hazardous type if ruptured at the neck. The characteristic feature of the clip is the lateral deviation of occluding blades. The superiorly projecting type A Com A aneurysm is located posterolateral to the A Com A in the operative field, and the clips were extremely useful in the aneurysms in providing safer and more exact occlusion via parallel closure of the A Com A or the aneurysm neck.

[Binswanger's disease with normal pressure hydrocephalus. Case report].

A 72-year-old hypertensive male was hospitalized with progressive gait disturbance (small step gait), urinary incontinence, and dementia. Computed tomography (CT) showed ventriculomegaly with periventricular lucency. T2-weighted magnetic resonance imaging revealed wide periventricular high-signal intensity and small infarctions in the basal ganglia. CT cisternography demonstrated ventricular stasis and convexity stasis of the contrast medium. Continuous intracranial pressure monitoring showed increased B wave percentage, low pressure volume index, and high outflow resistance. These findings indicated the coexistence of normal pressure hydrocephalus. After ventriculoperitoneal shunting, gait disturbance was greatly improved and urinary incontinence disappeared. The development of Binswanger's disease may be partially due to disturbed cerebrospinal fluid (CSF) dynamics. The possible pathophysiology of CSF dynamics in relation to Binswanger's disease is discussed. Detailed investigations of CSF dynamics are important in patients with Binswanger's disease, especially in the early stage.

[Disproportionately large, communicating fourth ventricle. Case report].

A 39-year-old male was admitted because of slowly progressive disturbance of consciousness, diplopia, and ataxia after laparotomy. Ventriculoperitoneal shunting and removal of an arteriovenous malformation had been performed previously. Neurological examination on admission revealed drowsiness, rotatory nystagmus, Parinaud's sign, and truncal ataxia. Computed tomography scan revealed extraordinary dilatation of the fourth ventricle compared with other dilated ventricles, and old low-density areas in the cerebellar hemispheres. After an external ventricular drainage (EVD) was inserted, all the ventricles decreased in size and the symptoms disappeared. The authors confirmed the patency of the aqueductal canal. One week later, the EVD was replaced by a ventriculoperitoneal shunt. A disproportionately large, communicating fourth ventricle (DLCFV) should be differentiated from an isolated fourth ventricle, which consists of marked enlargement of the fourth ventricle with obstruction of both the inlet and outlet of the fourth ventricle. The authors propose the importance of the fragility to pressure of the brain parenchyma and cerebellar hemispheres around the fourth ventricle as the mechanism of producing DLCFV.

[Intraosseous meningioma. Case report].

An 82-year-old female was admitted with slowly progressive aphasia and right hemiparesis, accompanied by a hard, 5 x 5 cm subcutaneous swelling in the left frontotemporal region. Plain X-ray film showed a well-circumscribed round radiolucency in the left pterional region. Computed tomography (CT) scans showed an intraosseous mass lesion, homogeneously enhanced postcontrast, extending to the intracranial cavity. Bone CT demonstrated a concave appearance and partial destruction of the inner table, strongly suggesting an intradiploic origin of the tumor. Left carotid angiography revealed the mass supplied by the middle meningeal artery. Left frontotemporal craniectomy demonstrated that the inner surface of the skull was destroyed, and the dura was compressed but not invaded. Histological examination found meningotheliomatous meningioma with many psammoma bodies.

Spontaneous dissecting aneurysms of the basilar artery presenting with a subarachnoid hemorrhage. Report of two cases.

A spontaneous dissecting aneurysm of the basilar artery is a rare disorder, usually presenting with ischemia rather than a subarachnoid hemorrhage (SAH). Two cases are described of a dissecting aneurysm of the basilar artery presenting with an SAH. Vertebral angiography revealed a double lumen to the basilar artery. Magnetic resonance (MR) imaging detected the intramural hematoma. One patient was treated conservatively, and the other underwent operative intervention with wrapping of the aneurysm. The usefulness of MR imaging in the diagnosis and the treatment options are discussed.

Successful reconstruction of completely obstructed right CCA in Takayasu's disease: usefulness of rapid sequence scanning method--case report.

The authors describe a case of Takayasu's disease accompanied by complete occlusion of the bilateral subclavian, left vertebral (VA), and right common carotid arteries (CCA) and by severe stenosis of the right VA and left CCA. The patency of the right external and internal carotid arteries was demonstrated preoperatively by rapid sequence computed tomographic scanning. The right CCA was successfully reconstructed with an aorta-CCA bifurcation bypass. Simultaneously, the stenotic left CCA was also reconstructed with an aorta-CCA bypass using a Y-shaped woven Dacron graft.

Flunarizine treatment in poor-grade aneurysm patients.

A cerebral Ca2+ overload blocker--flunarizine hydrochloride--was used with excellent results for prophylaxis of delayed ischaemic neurological deficit (DIND) in severe subarachnoid haemorrhage. The drug was administered orally at a dose of 10 mg, four times daily for four days, followed by three times daily for three days and twice daily for 14 more days. Of 72 patients treated with flunarizine, only one developed permanent DIND. 37 consecutive patients who were in Fisher's group III and were treated with flunarizine from immediately after early surgery were compared retrospectively with the 37 consecutive Control Group patients, who also belong to Fisher's group III. Among the Control Group patients, eight died from DIND and ten developed infarction from DIND, while flunarizine strongly prevented (p less than 0.001) DIND. Furthermore, the only one DIND was attributable to failure of administration of flunarizine. There were no side-effects from flunarizine. The association of severe angiographic vasospasm was less frequent in the Flunarizine Group (18% vs 57%, p less than 0.02). From this evidence, it might be concluded that flunarizine significantly inhibits the occurrence of severe neurological deficit due to delayed vasospasm. This highly beneficial effect on severe delayed vasospasm might be attributable to its intense inhibitory action on intracellular Ca2+ overloads especially in severe pathological situations.

[Ossifying fibroma of the cranial vault. Case report].

A 68-year-old female was admitted with mild headache in the right frontal region. Physical and neurological findings were normal. Plain X-rays revealed a poorly circumscribed, osteoblastic lesion in the right frontal bone. Computed tomography scan showed that the diploic space was destroyed but that the inner and outer tables were intact. On 99mTc bone scan, a hot lesion was visible in the same region. The lesion was expressed as a low-signal intensity area on T1-weighted magnetic resonance (MR) image and as a high-signal intensity area on T2-weighted MR image. The tumor was broadly resected together with peripheral normal bone, and cranioplasty using a resin plate was performed. The tumor was mainly composed of mature, regularly aligned bone (lamellar bone) and intermingled fibrous tissue. Ossifying fibroma is a rare, benign fibro-osseous tumor that mainly involves the craniofacial bone. A few cases involving the cranial vault alone have been reported. The relevant literature is reviewed, and discussion focuses on the differential diagnosis between ossifying fibroma and monostotic fibrous dysplasia.

Intragastric migration of a ventriculoperitoneal shunt catheter.

A child developed bacterial meningitis and shunt dysfunction 2 years after the insertion of a ventriculoperitoneal shunt for posttraumatic hydrocephalus. The distal end of the shunt catheter had penetrated the gastric wall. We found no other report of intragastric shunt catheter migration with successful treatment.