[Effect of Gorei-san with tranexamic acid for preventing recurrence of chronic subdural hematoma].

OBJECT: Chronic subdural hematoma is often seen in elderly patients. One burr hole surgery with subdural drainage has been performed and prognosis is good, but the recurrence rate is still about 10%. To prevent the recurrence, we used Kampo-medicine Gorei-san with tranexamic acid after surgery. The purpose of this study is to investigate if the recurrence is able to prevent by using these drugs. METHODS: From January 2008 to December 2010, 199 consecutive cases with chronic subdural hematoma were examined at Nagatomi Neurosurgical Hospital. Patients were divided into four groups according to the administered drugs; Gorei-san, tranexamic acid, Gorei-san with tranexamic acid and no drug groups. The recurrence rate was compared between each group. The chi-square test was performed as a statistical analysis. RESULTS: In all patients, the mean age was 77.7±10.5 years. There were 140 males and 59 females. Overall recurrence rate was 7.0%. Each recurrence rate was 8.3% in the Gorei-san administration group, and 10.9% in the tranexamic acid group, and 2.9% in Gorei-san with tranexamic acid group, and 5.7% in the no-drug group. There was no significant difference between the four groups in statistical analysis. CONCLUSIONS: Gorei-san with the tranexamic acid administration group had the minimum recurrence. There was no significant difference but these drugs would be preventable recurrence of chronic subdural hematoma. We need to accumulate more cases as a prospective study in the future.

Acute calcific prevertebral tendonitis mimicking tension-type headache.

A 74-year-old woman was admitted to our hospital due to severe nuchal pain and occipitalgia. Neurological examination found neck stiffness but no throat pain or dysphagia. Blood examination showed slight elevation of white blood cell count, but C-reactive protein level was normal. Cerebrospinal fluid examination found no abnormalities. Computed tomography (CT) and magnetic resonance (MR) imaging demonstrated no abnormalities in the brain. Cervical CT showed a small calcification in front of the C1 body. Cervical T(2)-weighted MR imaging showed a high intensity area in front of the upper cervical vertebral body from C1 to C4, suggesting inflammation of the longus colli muscles. We diagnosed acute calcific prevertebral tendonitis. She was administered nonsteroidal anti-inflammatory drugs. Her symptoms gradually improved and she was discharged without neurological deficit 8 days after admission. It is important to be aware of the possibility of this rare disease in a patient with severe occipitalgia but no sign of intracerebral lesion.

Ruptured anterior cerebral artery aneurysm at the origin of the accessory middle cerebral artery.

A 36-year-old female patient was admitted to our hospital with a rare case of aneurysm at the origin of the accessory middle cerebral artery (MCA) manifesting as severe headache and vomiting. Neurological examination did not detect any abnormalities or consciousness disturbance. Computed tomography demonstrated diffuse subarachnoid hemorrhage. Magnetic resonance angiography showed an aneurysm in the horizontal portion of the left anterior cerebral artery (A(1)). Digital subtraction angiography and three-dimensional digital subtraction angiography demonstrated a saccular aneurysm originating at the junction of the left A(1) and accessory MCA. Another accessory MCA originated at the proximal portion of the left A(2) without an aneurysm. Two accessory MCAs were found on the left. Neck clipping was performed via a left pterional approach. One month after admission, she was discharged without neurological deficits.

Double stent technique for the treatment of an internal carotid artery pseudoaneurysm caused by zone III stab injury.

A 77-year-old man was transferred to the hospital with swelling of his neck and oropharynx after a stab injury to his oral cavity with pruning shears. Findings at complete neurologic examination were normal. Contrast-enhanced computed tomography (CT) and angiography revealed a pseudoaneurysm at the pharyngeal portion of the right internal carotid artery. Endovascular treatment was undertaken by using the double bare stent technique. The pseudoaneurysm was completely occluded immediately after the procedure. There were no complications. There were no further symptoms or evidence of recurrence of the aneurysm during the 18-month follow-up period. The double bare stent technique is safe and effective for the treatment of zone III carotid artery stab injuries.

Unique infiltrating morphology of a meningioma-a case report.

BACKGROUND: We report on the case of a patient with meningioma that was correctly identified through biopsy. CASE DESCRIPTION: A 69-year-old woman presented with slight headache and was then examined at our hospital. Neurologic and physical examinations found no abnormality. Magnetic resonance imaging demonstrated a well-enhanced huge, dural-based, and plaque-like mass extending throughout the parietooccipital convexity and the posterior fossa. Tumors pressed the adjacent brain cortex while extending along the Virchow-Robin space. A CT scan also showed hyperostosis on the parietooccipital bone. Angiography demonstrated a vascular blush that appeared to be of a tumor-like shape. A biopsy was performed to confirm the diagnosis. The histologic findings demonstrated meningothelial meningioma with infiltration into the Virchow-Robin space. CONCLUSIONS: Many radiographic patterns of meningioma have been reported, but the present case is quite rare. The radiographic and pathologic findings in our patient are discussed.

Gamma Knife surgery for primary central nervous system lymphoma: usefulness as palliative local tumor control.

OBJECT: Although there is no established treatment for primary central nervous system lymphoma (PCNSL), therapeutic protocols involving high-dose methotrexate therapy followed, in some cases, by whole-brain radiotherapy (WBRT) have generally been adopted, and they have yielded relatively favorable results. Gamma Knife surgery (GKS) is a stopgap measure to treat patients with PCNSL. The authors summarize the results of their cases and evaluate the efficacy and usefulness of GKS. METHODS: Between June 1999, and June 2005, 22 patients suffering from PCNSL were treated with GKS at the authors' institution and were followed up for more than 6 months. Some combination of chemotherapy and/or WBRT and/or microsurgery had been performed in 18 of the 22 patients before GKS. The remaining four patients had not undergone any previous treatment. In these patients, the mean tumor volume was 4.14 cm3, and the tumors were treated with a mean margin dose of 16.5 Gy to the 52.8% isodose line. Magnetic resonance imaging demonstrated the disappearance of the GKS-treated lesions; however, new lesions were observed in other regions of the brain in 10 patients and repeated GKS was performed in some cases. No local recurrences were observed an average of 19.4 months after GKS, and good level of quality of life (QOL) was maintained during this period. CONCLUSIONS: Gamma Knife surgery should be performed only for local tumor control as a stopgap measure in the treatment of PCNSL. It is noninvasive and safe, and its effects occur rapidly. Its use improves prognosis and enhances the patient's quality of life. Gamma Knife surgery should be considered one of the treatment strategies for patients with PCNSLs.

Tolerance dose in gamma knife surgery of lesions extending to the anterior visual pathway.

OBJECT: The authors performed a retrospective analysis of the radiation dose to the anterior visual pathway (AVP) to assess its tolerance to gamma knife surgery. METHODS: They examined five cases followed for more than 3 years. The AVP was treated with 10-Gy doses or higher. The mean maximum delivered dose to the AVP was 14 Gy. Ten gray or more was delivered to 25.5% of the ipsilateral AVP, 12 Gy or more to 12.5% of the ipsilateral AVP, and 14 Gy or more to 5.7% of the ipsilateral AVP. Although the mean follow-up period was 40.8 months (36-51 months), no cases of visual function deterioration developed. CONCLUSIONS: The tolerance dose of the AVP is considered to be less than 8 to 10 Gy; however, although the delivered dose to the AVP definitely exceeded the tolerance dose in all five cases, no visual disturbance has been identified. Longer follow up is required before any final conclusions may be drawn. Nonetheless, it is suggested that a visual disturbance may be avoided by using careful accurate dose planning even if the dose delivered to the AVP is higher than currently believed to be acceptable.

Fulminant subdural empyema treated with a wide decompressive craniectomy and continuous irrigation--case report.

A 56-year-old male presented with fulminant subdural empyema manifesting as rhinorrhea, periorbital cellulitis, fever, convulsions, and consciousness disturbance. Neuroimaging showed pansinusitis with skull destruction and extensive subdural empyema. Decompressive craniectomy, irrigation of the empyema, and subdural drainage were performed. Endoscopic sinus surgery was performed to remove the source of infection at the same time. Streptococcus milleri was cultured from the pus. Continuous irrigation of the subdural space with saline containing gentamicin for 7 days resulted in prompt elimination of pus and debris. The patient was discharged with only a slight neurological deficit.