[A case of a persistent primitive proatlantal intersegmental artery with a ruptured basilar bifurcation aneurysm].

A case of persistent primitive proatlantal intersegmental artery (PPPIA) associated with a ruptured basilar bifurcation aneurysm was reported. A 44-year-old male with sudden headache was admitted to our hospital. CT scan revealed subarachnoid hemorrhage. Cerebral angiography revealed anomalous anastomosis between the internal carotid artery and the vertebral artery at the proatlantal region. This anastomosis branched off from the left internal carotid artery at the C4 level and joined the horizontal portion of the left vertebral artery. It was thought to be PPPIA. Angiography also revealed an aneurysm of the basilar bifurcation which was responsible for the patient's subarachnoid hemorrhage. The aneurysm was successfully treated by endovascular embolization with Guglielmi detachable coils in an acute stage, and resulted in good outcome. PPPIA with basilar bifurcation aneurysm has not been presented or reported in the literature to date. To our knowledge, this is the first report of such an association of vascular anomalies. The frequency of PPPIA combined with the intracranial aneurysm is relatively high, whereas the occurrence of PPPIA is extremely rare. Therefore, it was suggested that some congenital and/or hemodynamic factors changed by PPPIA may affect the pathogenesis of intracranial aneurysms.

[Differential diagnosis between aneurysm and infundibular dilatation in the IC-PC region with 3D-CTA].

In cases of asymptomatic internal carotid-posterior communicating artery (IC-PC) protrusions, it is sometimes difficult to differentiate infundibular dilatation (ID) from aneurysm by digital subtraction angiography. We applied three-dimensional CT angiography (3D-CTA) in 32 cases of these IC-PC protrusions. SOMATOM PLUS 4 was used under such conditions as to provide images with high spatial resolution. The shaded surface display (SSD) method was adopted to reconstruct the 3D images because of its advantage in separating overlapped vasculature. We also made reference to source images and maximum intensity projection (MIP) to make sure of our diagnoses. In all cases including 4 aneurysms and 28 IDs, we were able to distinguish between ID and aneurysm. The accuracy of 3D-CTA was confirmed by 9 surgical cases. Our technique was as follows: 1) To inject a high dose of diluted contrast medium rapidly to smaller arteries for opacification of contrast medium. 2) To exclude neighboring useless structures except for the very close structures such as posterior clinoid process from the target image focusing on the IC-PC region. 3) To observe the reconstructed image of MIP and SSD from various angles. The contralateral and craniocaudal view were valuable. 4) To change the threshold level gradually and observe the configurational changes of the apex of protrusion. Poorly developed PcomA was mostly delineated at the optimum threshold level. Otherwise, the apex of protrusion remained spherical in an aneurysm and became pyramidal in shape in an ID when the threshold level was gradually decreased. In conclusion, 3D-CTA was a useful modality for IC-PC protrusions to distinguish between ID and aneurysm.

[Prevention of MRSA spread in the neurological field: intranasal application of mupirocin calcium ointment].

From September 1997 to March 1998, forty patients with cerebral disorders were investigated. They were divided into two groups: one treated and the other untreated. Mupirocin calcium ointment (MCO) was applied three times a day for three days into the nasal cavities of the patients in the treated group. In order to check the growth of MRSA (methicillin-resistant Staphylococcus aureus), bacterial isolation culture from the nasal cavity was carried out on admission, one week after admission and one month after admission. MRSA was nor detected in isolation culture of any of the cases on admission. One week later MRSA was detected in isolation culture of one case of the 20 MCO treated patients and in three of the 20 untreated patients. There was no significant difference between treated and untreated groups. In isolation culture after one month, MRSA was recognized in four cases of 16 in the MCO treated group (three patients were discharged and one expired). On the other hand, it was recognized in eight cases of thirteen in the untreated group (seven cases were discharged). MRSA infection of the nasal cavity decreased significantly due to MCO treatment (p < 0.05). It is suggested that the nasal carriage of MRSA was prevented by intranasal application of MCO on admission.

[Surgical indication and problems of patients aged over 70 years with unruptured aneurysms].

Surgical indication and problems of patients aged over 70 years with unruptured aneurysms were investigated. Clinical features of eighteen cases of unruptured cerebral aneurysms were analyzed. The location of the cerebral aneurysms were in the internal carotid artery in five cases, in the middle cerebral artery in ten cases, in the anterior cerebral artery in 2 cases and in the basilar artery in 1 case. The size of the aneurysms was less than 10 mm in diameter in 17 cases and giant in one case. Treatment of these aneurysms was classified into two groups as follows; the conservative treatment group (four cases) and the surgical treatment group (14 cases). The therapeutic results of the conservative group were good recovery in 2 cases, and death in 2 cases. On the other hand, the results of surgical group were good recovery in 12 cases and fair in 2 cases. Operative complications were recognized in two cases. Consciousness disturbance and left hemiparesis was recognized in one case. Right hemiparesis was recognized in the another case. Postoperative MR imagings or CT scan presented small cerebral infarctions in the corona radiata in both cases. The cause of infarction was thought to be the occlusion of lenticulostriate arteries. From these data, in patients aged over 70 years with unruptured cerebral aneurysms, surgery should be considered not only from the aspect of aneurysmal size and its site, but also from the aspect of cerebral blood flow of the patient.

The relationship between moyamoya disease and bacterial infection.

To examine the relationship between Moyamoya disease and bacterial infections, authors studied the serum of 85 cases of Moyamoya disease and the influence of Propionibacterium acnes (P. acnes) infection on intracranial arteries in rats. The serum levels of P. acnes antibody, IgM, transferrin (Tf), alpha 2-macroglobulin (alpha 2M) were significantly higher in Moyamoya disease than in normal volunteers. Moyamoya-like changes of the intracranial internal carotid arteries were histopathologically demonstrated in P. acnes infectious rats. These findings suggest that P. acnes and immunological factors might play a role in the pathogenesis of Moyamoya disease.

Studies on cytomegalovirus and Epstein-Barr virus infection in moyamoya disease.

In this study, measurement of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) viral antibody titers and analysis of both viral genomic sequences using polymerase chain reaction (PCR) were performed to clarify the correlation of viral infection and Moyamoya disease. Serum samples were obtained from 64 patients with Moyamoya disease. The ages ranged from 5 to 66 years, with a mean age of 35.1 years. There were 23 males and 41 females. The serum antibody titers to CMV and EBV were measured by means of compliment fixation test and fluorescent antibody method respectively. Those titers of the patients were compared with those of 13 patients of atherosclerotic internal carotid occlusion and 34 normal volunteers. On the other hand, CMV and EBV genomic sequence using PCR, which was utilized with specific primer pairs, were performed in 22 patients of Moyamoya disease and ten normal volunteers. The following results were obtained; The antibody titer of EBV in Moyamoya disease was significantly higher than that in controls. However, no significant difference of antibody titer against CMV was detected. In EBV DNA analysis by use of PCR, EBV DNA was proved in 15 out of 20 patients with Moyamoya disease and four out of nine normal controls. Namely, EBV DNA was seen more frequently in patients with Moyamoya disease, compared with normal controls. In inverse, CMV DNA was not seen in patients with Moyamoya disease nor normal controls. In conclusion, the antibody titer of EBV revealed high levels in Moyamoya disease and EBV DNA was also detected more frequently in patients with Moyamoya disease. These results suggested a possibility that EBV infection might be involved in the pathogenesis of Moyamoya disease.

Surgical treatment of cavernous angioma involving the brainstem and review of the literature.

Five cases of symptomatic cavernous angioma involving the brainstem are reported. Magnetic resonance (MR) imaging is of greatest value in the diagnosis and for surgical indication. All cases were treated by radical extirpation. All of them improved postoperatively. The surgical indications for this lesion of the brainstem are briefly discussed with a review of the literature, including 28 previous cases, operated on directly.