[Intracranial occlusion of the internal carotid artery after minor closed head injury].

Thrombosis of the extracranial portion of the internal carotid artery as a result of nonpenetrating head and neck injury is not uncommon. However, intracranial occlusion of the internal carotid artery after minor head and neck injury without skull fracture is rare. We report a case of 14-year-old male who suffered a minor head injury during an athletic meeting of his school and developed a right hemiparesis and a lethargy state resulting from thrombosis of the supraclinoid portion of the left internal carotid artery. On admission, skull films and a CT scan revealed no abnormality. One hour later, he fully recovered. One day later, no definite lesions were detected on T1-weighted and T2-weighted image of MRI, but an abnormal high signal lesion in the left frontal lobe was detected on diffusion-weighted image of MRI. On additional MR angiography, intracranial occlusion of the internal carotid artery due to dissection was demonstrated.

Endarterectomy for narrowing of the external carotid artery in a patient who underwent extracranial-intracranial bypass for occlusion of the internal carotid artery--case report.

A 56-year-old man had undergone extracranial-intracranial (EC-IC) bypass surgery for occlusion of the right internal carotid artery. Six years later, he complained of transient episodes of numbness in the left arm, occurring periodically over the previous 3 months. Neuroimaging showed the right external carotid artery was severely narrowed and cerebral blood flow (CBF) was diffusely low. Endarterectomy of the right external carotid artery was performed. Postoperative CBF was markedly improved, suggesting that EC-IC bypass became effective again by endarterectomy of a parent artery.

[Multiple brain abscesses associated with Rendu-Osler-Weber disease: report of two cases].

Two cases of multiple brain abscesses associated with congenital pulmonary arteriovenous fistula are reported. A 57-year-old male with Rendu-Osler-Weber disease complicated by pulmonary arteriovenous fistula developed multiple brain abscesses in the right parietal region. He responded well to surgical drainage and antibiotic therapy, and the pulmonary arteriovenous fistula, located in the left lower lobe, was resected. A 26-year-old female with Rendu-Osler-Weber disease complicated by pulmonary arterivenous fistula developed recurrent multiple brain abscesses in both the frontal and right parietal regions. The brain abscesses were successfully treated with aspiration and antibiotic therapy. She had a history of two previous brain abscesses in the right parietal regions that were excised on separate occasions at 16 and 23 years of age. Although pulmonary arteriovenous fistula was confirmed by angiography, in this case surgical removal of the pulmonary lesions was not indicated due to multiple vascular shunting. The patient had no recurrence of brain abscess with oral antibiotic therapy.

[Craniopharyngioma with rapid regrowth--role of MIB-1 labeling index].

The treatment of craniopharyngioma becomes quite difficult when it extends into the third ventricle. In a 4-year-old boy, we encountered a large cystic craniopharyngioma which grew into the third ventricle. Initially, the tumor was successfully removed via a right transcallosal transchoroidal approach. A residual part seemed to have remained in the right perioptic region. Even though the patient had an episode of SIADH, his postoperative course was uneventful. He developed visual disturbance 4 months after the initial operation. CT and MRI revealed a large suprasellar mass. The tumor was totally resected via a right pterional approach. Careful follow-up disclosed again a small recurrent lesion in the anterior commisure. Gamma knife therapy was used to successfully reduce the volume of the tumor. The MIB-1 labeling index (LI) of the specimen taken at the time of the first operation was at 9.2% and that of the second operation at 21.2%. Recently, the importance of MIB-1 LI for assessing proliferative activity of this tumor was reported. In patients whose MIB-1 LI is higher, they have more significant rate of recurrence. Our results also indicate that in cases where MIB-1 LI indicates a high value, careful follow-up is necessary. Through fact of the necessity of two operations and additional gamma knife therapy, we would like to stress the importance of MIB-1 LI in indicating the proliferative activity of this tumor. These surgical procedures are presented here, and the role of MIB-1 LI in determining the proliferative activity of craniopharyngioma is also discussed.

[A case of aneurysm of the peripheral middle cerebral artery undetectable on preoperative angiogram].

The authors describe a rare case of an aneurysm of the peripheral middle cerebral artery. A 63-year-old female with a past history of hypertension suddenly fell into a comatose state, and was brought to our hospital. On admission, CT scan showed intracerebral hematoma located in the right putamen with diffuse subarachnoid hemorrhage. To exclude vascular lesions, an angiography was performed just after admission. The right carotid angiogram showed an aneurysm at the cavernous portion of the internal carotid artery (ICA), but failed to show any aneurysms in the rest of the intracranial circulation. Just after the angiography, emergent operation was performed for the main purpose of evacuation of the hematoma, and with only the secondary purpose of searching for undetectable aneurysms. The patient underwent a right frontotemporal craniotomy. After partial evacuation of the hematoma through the corticotomy of the right frontal operculum, the Sylvian fissure was opened widely. No aneurysm was observed either in the main trunk of the right ICA or the middle cerebral artery (MCA). During the final stage of evacuation of the hematoma through the corticotomy, arterial bleeding occurred. While evacuating the blood, we detected a saccular aneurysm arising from MCA branch (M2-M3 junction) and we clipped the aneurysm. We discuss peripheral MCA aneurysms with a review of the literature.

[Aneurysms of the distal posterior inferior cerebellar artery--analysis of 14 aneurysms in 13 cases].

Thirteen cases of distal posterior inferior cerebellar artery (PICA) aneurysms are reported here. All the aneurysms were found after a subarachnoid hemorrhage. Dissecting aneurysm, incidentally found unruptured aneurysms, and aneurysms associated with arteriovenous malformation have been eliminated from this study. Characteristics for this type of lesion are a high rate of recurrent hemorrhage and rapid death due to direct compression of the brain stem, which clearly indicates the necessity of early surgery. Attention should be paid to the fact that angiography cannot always reveal aneurysms, especially when they are located in the peripheral PICA. One should also pay attention to multiple lesions and rapid growing acute subdural hematoma as initial findings for ruptured distal PICA aneurysm. Prognostic factors for these lesions are, vasospasm, especially when the aneurysm is located proximally in the PICA, and direct compression of the brain stem due to intraventricular hemorrhage when the aneurysm is located distally. It has been suggested that the pathogenesis of this lesion could be hemodynamic stress or embryogenesis. The shape and anomalous arterial structures of the 14 aneurysms presented here tend to agree with this suggestion. Our results suggest that the pathogenesis is hemodynamic stress that had developed due to embryological and/or arteriosclerotic factors.

[Spontaneous epidural hematoma after open heart surgery: case report].

Acute epidural hematoma not associated with head injury is rarely encountered and is known as spontaneous epidural hematoma. To our knowledge, only five cases with epidural hematoma after open-heart surgery have been published. Pathogenesis and preventive measures have not yet been determined. We report a case of such spontaneous epidural hematoma and consider the possible pathogenesis. A 12-year-old female received a radical operation for severe subaortic stenosis. The intraoperative course was uneventful except for massive hemorrhage which was adequately controlled. Postoperatively, she was moved to the CCU still not having aroused from anesthesia. Eleven hours later, it was found that her pupils were fixed and dilated. CT scan demonstrated a huge bifrontal epidural hematoma with disappearance of the basal cistern. Even though immediate emergency evacuation was performed, the patient died of acute brain swelling four days after the operation.

Diffuse calvarial meningioma. Case report and review of the literature.

An extremely unusual calvarial meningioma in a 77-year-old woman is reported. The meningioma spread widely and symmetrically within the calvaria and grew extracranially within the scalp as well as intracranially. Reactive dural hyperplasia induced narrowing of the intracranial space and occlusion of the superior sagittal sinus, resulting in intracranial hypertension. After external decompression, the patient's symptoms markedly resolved. The authors review the literature on calvarial meningioma, discuss its pathogenesis, and propose mechanisms responsible for the patient's intracranial hypertension.

[Effects of long-term administration of cilostazol on chronic cerebral circulatory insufficiency--with special reference to cerebral blood flow and clinical symptoms].

This report deals with a study of the effectiveness, safety, and usefulness of long-term administration of Cilostazol for the improvement of cerebral blood flow and clinical symptoms in 24 patients with Chronic Cerebral Circulatory Insufficiency. Cerebral blood flow was investigated quantitatively using the Patlak plot method. Cilostazol was orally administered for 209 days on average. In the global improvement rating assessed on the basis of all subjective symptoms, the final improvement rate, comprising all cases showing moderate or better improvement, was 52.2%. Regarding individual symptoms, dizziness, orthostatic syncope, dull headache, and headache showed improvement rates of 30% or more. Regional cerebral blood flow (rCBF) was increased in both cerebral and cerebellar hemispheres. The global improvement rating for subjective symptoms and the delta % rCBF for every region except the cerebral hemispheres were positively correlated. However, there was no positive correlation between the global improvement rating for psychiatric symptoms and the delta % rCBF for any region. Regarding individual subjective symptoms, dizziness showed an especially high positive correlation of above 0.7 between the improvement rating and the delta % rCBF in the left temporal lobe, basal ganglia, and cerebellum. Headache was observed as an adverse drug reaction in 8 of 24 patients, but it disappeared with reduction of the dose or discontinuation of administration. No other severe adverse drug reactions were noticed. In summary, it was concluded that Cilostazol was useful for treating chronic cerebral circulatory insufficiency.

[Choroidal artery aneurysms of the posterior inferior cerebellar artery presented with fourth ventricular hemorrhage: report of 2 cases].

Two cases involving a ruptured aneurysm in a choroidal branch of the posterior inferior cerebellar artery are reported here. Case 1: A 61-year-old woman was admitted after an episode of severe headache with persistent vomiting. A CT revealed an intraventricular hemorrhage within the fourth ventricle. An angiography showed an aneurysmal shadow in the choroidal artery branching from the telovelotonsillar segment of the distal posterior inferior cerebellar artery (PICA). The operation disclosed a fusiform aneurysm in the choroidal artery which was successfully trapped using Yasargil's mini-clips. The postoperative course was uneventful and the patient was discharged without any neurological deficit. Case 2: A 64-year-old woman became unresponsive after complaining of a severe headache. On admission, she was semicomatose with positive bilateral Babinski's sign. A CT scan showed that the fourth and third ventricles were packed and dilated by a massive hematoma. An angiography demonstrated an aneurysmal shadow in a branch from the PICA with an occlusion of the right vertebral artery. Furthermore, the left vertebral artery was also occluded and the basilar artery was fed by collateral circulation. The patient underwent an operation immediately. The fusiform aneurysm was resected after ligation. Her postoperative course was satisfactory. She was able to go home without neurological deficit. There has been only one article about "pure" choroidal artery aneurysm, reported by Uranishi, et. al in 1994. They suggested that the pathogenesis of this lesion could be due to hemodynamic stress. Our two cases also present the same characteristics, in the shape of the aneurysms as well as in the anomalous structures in the posterior circulation. Our results offer further evidence concerning the pathogenesis of that type of lesion.

Cerebellopontine angle meningioma causing asymptomatic syringomyelia--case report.

A 36-year-old female was admitted with a 3-month history of headache and gait disturbance. Magnetic resonance imaging demonstrated a large tumor in the right cerebellopontine angle and syringomyelia in the upper cervical cord associated with caudal displacement of the cerebellar tonsil. Complete removal of the tumor resulted in disappearance of these associated conditions. Herniation of the cerebellar tonsil and distortion of the brain stem had probably caused disturbance of cerebrospinal fluid flow, which combined with obstruction of the spinal canal, caused the syrinx.

[Orbital neurinoma presenting orbital apex syndrome].

A 75-year-old man presented a twelve-day history of double vision and retro-ocular pain with rapid deterioration of visual acuity. Neurological examination on admission demonstrated right oculomotor palsy and abducence palsy, visual loss in the right eye, and hypesthesia and pain in the right supraorbital nerve. CT scan and MRI disclosed a mass in the right orbital apex. An emergency operation via a frontotemporal extradural approach was performed to decompress the optic nerve. The anterior clinoid process and minor wing of the sphenoid were drilled to expose the optic canal and superior orbital fissure. When the periorbita just beside the optic sheath was opened, a grayish colored mass was observed beneath the superior rectus muscle. The mass was dissected from the surrounding intraorbital tissue and was removed completely. The postoperative course was uneventful. The patient experienced complete disappearance of the ocular pain and complete restoration of his visual acuity. Orbital neurinoma is a benign tumor accounting for between 2.1 and 6.8% of all orbital tumors in the large series. The salient clinical symptom is exophthalmos followed by mass palpability. However, an orbital neurinoma presenting orbital apex syndrome is quite rare. In the case with orbital apex syndrome, it is sometimes impossible to recover visual acuity even though the optic nerve decompression is promptly performed. In such a case, only an emergency approach to the lesion can rescue the visual acuity.

[Symptomatic arteriovenous fistula in a patient with neurofibromatosis type I].

This paper reports the case of a 54-year-old woman who had a history of neurofibromatosis (NF I) presenting progressive quadriplegia and urinary incontinence due to a cervical arteriovenous fistula (AVF). MRI revealed a huge flow void mass in the cervical subcutaneous tissue as well as within the spinal canal. These flow voids originated in the left vertebral artery. A high intensity lesion was observed in the spinal cord adjacent to the flow void. Angiography revealed that the cervical AVF was fed by the third segment of the left vertebral artery with a rich communication with the intraspinal veins. Furthermore, an aneurysmal dilatation of the proximal vertebral artery and occlusion of the right middle cerebral artery with moyamoya vessels were found. Endovascular treatment using a Goldvalve detachable balloon successfully obliterated the AVF. Postoperative MRI and angiography showed evidence of the disappearance of AVF and postoperatively, the patient's neurological signs improved gradually. Sixteen reported AVFs accompanied with NF were reviewed.

Linear transverse forehead incision for patients with alopecia praematura--technical note.

A method for craniotomy via a transverse linear scalp incision on the forehead wrinkle line with cosmetic reconstruction is described. The method requires minimal knowledge of plastic surgical techniques. Operative scars are inconspicuous and the normal appearance of the forehead can be retained, which is especially valuable for patients with alopecia praematura.

[Orbital varix presenting orbital apex syndrome].

On 7 July 1993, a 61 year-old female presented a seven-day history of double vision and retro-ocular pain. Neurological examination on admission demonstrated right oculomotor palsy and pain in the right frontal nerve. Routine CT scan and MRI disclosed no abnormalities. Her symptoms deteriorated progressively and increased in severity, resulting in complete ptosis and visual disturbance in the right eye, for which she was hospitalized. Angiography also failed to demonstrate any lesion. Herrical CT scan demonstrated a small mass lesion at the right orbital apex. A frontotemporal extradural approach operation was performed on July 6, 1993. The anterior clinoid process and minor wing of the sphenoid were drilled to expose the optic canal and the superior orbital fissure. When the periorbita just beside the optic sheath was opened, a large vein was observed to be impinging on the optic nerve and nerves which pass through the superior orbital fissure. This vein was carefully dissected, coagulated and removed. The postoperative course was uneventful. Her severe retro-ocular pain completely disappeared immediately after the operation. Although complete remission of ptosis and return of eye movements to normal were noted, her visual acuity is at present limited to hand movement. Orbital varix is a common cause of unilateral intermittent proptosis. However, there has been no report in the literature of orbital varix with orbital apex syndrome as the initial clinical appearance. In this type of patient with orbital varix and retrobulbar hemorrhage or impairment of intraorbital nerves, surgical intervention using a transcranial approach to the lesion should be undertaken.

[Vitreous hemorrhage after accidental head injury with chest compression--case report].

Vitreous hemorrhage is relatively common following subarachnoid hemorrhage, but rarely occurs after accidental head injury. In this paper, we report a rare case of vitreous hemorrhage after an accidental head injury with chest compression. A 4-month-old girl was held in her father's arms. After he fell down, she struck her head and her chest was compressed by her father's body. She soon became pale and was immediately transported to our center complaining of disturbance of consciousness on February 6, 1993. On admission, she was semicomatose and had a generalized convulsion. Computed tomography (CT) scan showed a subdural hematoma, although no fracture was detected on the plain X-ray film. Bilateral vitreous hemorrhage was also observed. The anterior fontanelle pressure was a high 330 mmH2O. The patient was treated conservatively with agents to promote hemostasis and reduce the intracranial hypertension. She was discharged after one month with normal consciousness and improved vision. The follow-up CT scan revealed subdural hematoma, hemorrhagic infarction (suggesting rupture of the pontine veins), and cerebral atrophy, corresponding to those of the shaken baby syndrome. Her chest was compressed by her father's body. The anterior fontanelle pressure was a high 330 mmH2O. These findings suggest that shaking or abrupt deceleration, acute intrathoracic hypertension and acute intracranial hypertension, caused retinal hemorrhage, and that extensive retinal hemorrhage possibly resulted in vitreous hemorrhage.

[Multiple cerebral arteriovenous malformations: case report].

A ten-year old girl with right occipital multiple arteriovenous malformations (AVMs) is reported. The clinical presentation at the onset of hemorrhage included coma and signs of tentorial herniation. CT after injection of contrast medium revealed an inhomogenous enhanced lesion in the right occipital lobe. Angiography demonstrated a large plexiform AVM and two AV fistulas, each of which had a different arterial supply and different venous drainage. Three operations successfully removed all the AVMs. Operative findings indicated that the lesion consisted of 4 different AVMs. The patient has recovered very well. Case histories and therapeutic and etiological considerations are discussed.

Intraoperative angiography in the resection of arteriovenous malformations.

Surgical resection of 13 operatively obscure arteriovenous malformations (AVM's) was accomplished with the assistance of intraoperative angiography, which was performed stereographically to provide three-dimensional orientation and was repeated until total resection of the AVM was confirmed. All films obtained were subtracted to improve clarity. The method presented here may be useful for the resection of all types of AVM. Only two patients had residual AVM after the initial operation. No complications attributable to angiography were noted.

Effect of propentofylline and pentoxifylline on cerebral blood flow using 123I-IMP SPECT in patients with cerebral arteriosclerosis.

Propentofylline and pentoxifylline were administered to patients age 65 years or older who were suffering from chronic cerebrocirculatory insufficiency. Changes in clinical symptoms and the level of cerebral blood flow before and after drug administration were compared. 123I-IMP single photon emission computed tomography was used to compare cerebral blood flow before treatment with that 3 months after initiation of therapy. Focal regions of interest were established in the cerebellum, the frontal, temporal, parietal, and occipital lobes, and the thalamus. Comparisons were made between patients age 75 years or older (very old age group) (n = 5) and those age 65 to 74 years (old age group) (n = 7). Complaints of dizziness and slight headache disappeared by the eighth week after the start of therapy in both age groups. Two of the five patients in the very old age group showed elimination of memory disturbance symptoms at the 12th week of treatment. Six of the seven patients in the old age group had no memory disturbance symptoms by the eighth week of treatment, which indicates a high therapeutic effect in this group. In the cerebral blood flow studies, no increases in blood flow after drug administration were observed in the very old age group. This finding is probably related to the poor level of recovery achieved in disturbances in memory in this group. In contrast, improvements in blood flow were observed for all regions of the brain monitored in the old age group, which is consistent with the amelioration of clinical symptoms observed in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Pineocytoma with intratumoral hemorrhage following ventriculoperitoneal shunt--case report.

A 58-year-old female with pineocytoma developed intratumoral hemorrhage after ventriculoperitoneal shunting for hydrocephalus. Neurological examination revealed Parinaud's sign and papilledema. Computed tomography and magnetic resonance (MR) imaging revealed a pineal neoplasm and obstructive hydrocephalus. Serum and cerebrospinal fluid levels of human chorionic gonadotropin, alpha-fetoprotein, carcinoembryonic antigen, and placental alkaline phosphatase were negative or within normal limits. MR images after the ventriculoperitoneal shunting disclosed intratumoral hemorrhage and markedly smaller ventricles. The tumor was totally removed via the occipital transtentorial approach and was diagnosed histologically as a pineocytoma with astrocytic differentiation. The tumor probably shifted away from the surrounding structures following the marked reduction in ventricular size after ventriculoperitoneal shunting, resulting in changed venous circulation in the tumor and the formation of intratumoral hematoma.