Functional prognosis after treatment of spinal dural arteriovenous fistulas.

We statistically evaluated the functional outcome after surgery or embolization therapy of 43 patients with spinal dural arteriovenous fistula including 10 patients of our own and 33 previously reported cases in the literature. This study prompted us to consider that a patient under 70 years old who is treated within 2 years 6 months after the onset of symptoms and whose gait or urinary disturbance is slight or moderate without absence of deep tendon reflexes in the lower extremities is expected to get a good functional prognosis after treatment.

Preserved musical abilities following right temporal lobectomy.

It has been widely accepted that the right temporal lobe plays a major role in the processing of music. One of the main lines of evidence was derived from Milner's study, published in 1962, which reported that right temporal lobectomy led to a decline in patient scores on four of the six subtests (Tonal Memory, Timbre, Loudness, and Time subtests) of the Seashore Measures of Musical Talents. That finding had led some surgeons and patients to hesitate in choosing right temporal lobectomy as a treatment for intractable epilepsy. The authors examined performance on the Seashore Measures before and after operations in 20 patients with right temporal lobectomy and nine patients with left temporal lobectomy. No disturbances in the Seashore Measures were detected after temporal lobectomy on either side. The extent of these temporal lobectomies was smaller than that of the temporal lobectomies in Milner's study, as measured along the sylvian fissure (1.5-4 cm; mean 2.7 cm, standard deviation (SD) 0.92 cm) and the base of the temporal lobe (3.5-5.5 cm; mean 4.7 cm, SD 0.63 cm). These findings indicate that the region resected on right temporal lobectomy in the present study is not essential for basic musical processing.

A cervical dural arteriovenous fistula in a patient presenting with radiculopathy. Case report.

A 51-year-old man presenting with radiculopathy a rare cervical dural arteriovenous fistula (AVF) is reported. Angiography revealed that the cervical dural AVF was fed mainly by the left C-3 and C-4 radicular arteries and drained into the internal vertebral venous plexus with no communication with intradural structures. The dural AVF was treated surgically after embolization therapy. Although the AVF showed mass effect on computerized tomography (CT) scanning, abnormal vessels, which were suspected to drain the AVF, were observed intraoperatively to compress the left C-4 and C-5 nerve root sleeves. After resection of these abnormal epidural vessels, monoparesis of the left proximal upper extremity was markedly improved. In this patient, dynamic CT scanning was useful in the initial diagnosis, and the preoperative embolization therapy was very effective.

Cortical and subcortical SEPs following posterior tibial nerve stimulation.

Intra-operative cortical and subcortical SEPs from the cerebral convexity and from the inter-hemispheric fissure were recorded following posterior tibial nerve (PTN) stimulation. Cortical and subcortical SEPs from the cerebral convexity after contra-lateral PTN stimulation consisted of N38 and P46, and their polarity reversed when the ipsi-lateral site was stimulated. On the other hand, cortical SEPs from the inter-hemispheric fissure always showed P38 and N46, whether the right or the left PTN was stimulated. Cortical and subcortical SEPs from the inter-hemispheric fissure showed clear cut polarity reversals. These findings provide good evidence for the existence of a tangential dipole oriented perpendicular to the inter-hemispheric fissure in the foot sensory area of the primary sensory cortex. SEPs recorded from the superficial part of the inter-hemispheric fissure showed smaller amplitudes and longer latencies than those of SEPs from the deeper regions. These findings suggest the existence of another dipole responsible for the generation of SEPs after PTN stimulation.

Instrumentational posterior fusion for atlanto-axial subluxation in a young child with Down's syndrome--case report.

A 3-year-old girl with Down's syndrome and myelopathy caused by atlanto-axial subluxation (AAS) was treated by C-1 to C-2 posterior fusion with a one-piece cervical device (OPCD). Instrumentation was required because the posterior arch of C-1 was too tiny and fragile to tolerate wiring. Postoperative immobilization was another major problem in this mentally retarded young child, but a hard plastic cervical corset effectively restrained the neck. She had been confined to bed by severe quadriparesis, but became able to walk without assistance 8 months after surgery. We recommend OPCD instrumentation and postoperative immobilization using a hard plastic corset for the treatment of AAS associated with Down's syndrome in young children.

Functional prognosis after treatment of spinal radiculomeningeal arteriovenous malformations.

BACKGROUND: We performed surgical treatment successfully in six patients with spinal radiculomeningeal arteriovenous malformation (AVM); however, only four patients showed improvement of gait function postoperatively. METHODS: These experiences prompted us to review the clinical findings and their possible association with the functional outcome in 33 reported cases of radiculomeningeal AVM together with those in our six patients. RESULTS: Statistical analysis revealed that the duration from onset of symptoms until diagnosis, the age at the time of treatment, the condition of the deep tendon reflexes (DTR) in the lower extremities, as well as the severity of both gait and urinary disturbance before treatment were significantly correlated with the functional outcome. CONCLUSIONS: A patient under 70 years old, who is treated within 2 years 6 months after the onset, whose gait or urinary disturbance is slight or moderate, and without absence of DTR in the lower extremities, is expected to have a good functional prognosis after treatment.

[Surgical outcome of cervical flexion myelopathy in young adults].

We encountered five young male patients with cervical flexion myelopathy, and treated them all surgically. Symptoms were first noted at 15 to 18 years of age (mean: 16.6 years), and their ages at the time of admission to our hospital, ranged from 19 to 25 years old (mean: 20.8 years). Anterior decompression and fusion of the cervical spine with long bone graft following resection of two vertebrae was performed in three cases. The other two patients were treated by posterior fusion of five laminas (C3-C7) using Rogers' method. In selecting the surgical approach, we favored anterior fusion because it allows removal of anterior structures (vertebral bodies, intervertebral discs or osteophytes) compressing the cervical spinal cord in flexed neck position. Posterior fusion was performed in patients whose anterior structures compressing the cervical spinal cord extended over a wide area. Postoperative improvement of muscle weakness was observed in four patients, and sensory disturbance was alleviated in the remaining patient. However, the abnormal deep tendon reflexes and muscle atrophy in the upper extremities observed in all of the patients preoperatively improved in only two of them. Thus, all of the patients showed some neurological improvement, and surgical fusion of the cervical spine appeared to be an effective means of treating cervical flexion myelopathy in young adults. Both the anterior and the posterior approach were useful in treating cervical flexion myelopathy, but it was impossible to conclude which approach is more effective based on this small number of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Lateral temporal polar approach to mesial temporal lesions.

A newly developed lateral temporal polar surgical approach to the mesiobasal temporal region was applied to 25 consecutive patients with mesially confined temporal lobe lesions. This approach is characterized by a very limited resection of the lateral temporal cortex and a direct approach to the uncal area. The advantages of this method are clear orientation to the mesial temporal structures, easy access to the posteromesial part of the temporal lobe, and preservation of functionally important structures, such as the lateral temporal speech area, optic radiation, and temporal stem. Details of the surgical procedure are described.

[Congenital extradural cyst causing a 30-year history of myelopathy with long-term remission].

We reported a peculiar case of a patient with a thoracic extradural cyst, who had a 30-year history of thoracic-myelopathy with a very long-term remission. A 42-year-old male was admitted to our hospital complaining of gait disturbance and hypesthesia of his bilateral lower limbs. Neurological examination revealed that he had spastic paraparesis and hypesthesia of all sensory modalities below Th11/12 dermatomes. Investigation of his past history disclosed that he had experienced gait disturbance due to paraplegia 29 years previously and had been able to move only with the aid of wheel-chairs. However these signs had resolved themselves gradually in a period of 3 years, and after that he had been able to live almost without any neurological handicaps until the recent appearance of weakness in both of his legs. Neuroradiological study revealed that plain X-Ps of the thoracic spine showed thinning of the pedicles and widening of the interpedicular distances between Th4-Th7 vertebrae. The old iodine contrast media injected 29 years previously for myelography in an other hospital was also observed. MRI showed a dorsal cystic mass compressing the thoracic spinal cord and subarachnoid space. Myelography showed also that the spinal cord and subarachnoid space were compressed anteriorly between the level of Th3 to Th7 by the dorsal mass. CT myelography disclosed that soon after the injection of contrast media a small part of the cyst was visualized as having direct communication with the subarachnoid space. The contrast media penetrated the major part of the cyst only 19 hours after its injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracarotid amobarbital injection produces hippocampal EEG changes in patients with temporal lobe epilepsy.

EEGs of hippocampi of both sides were analyzed during intracarotid amobarbital tests in 12 patients with temporal lobe epilepsy. The number of paroxysms occurring 1 min before the injection ipsilaterally and contralaterally was compared with that occurring 1 min after the injection. The hippocampal EEG ipsilateral to the injection showed an increase in paroxysms irrespective of the laterality of the epileptogenic side. Contralateral to the amobarbital injection an increase in paroxysms was observed in the epileptogenic hippocampus only.

Aphasic seizure caused by focal epilepsy in the left fusiform gyrus.

We report a patient with paroxysmal aphasia evoked by ictal epileptiform discharges localized to the left fusiform gyrus, where a small brain tumor existed. The intracranial EEG recordings during other seizures demonstrated a close functional link between the left fusiform gyrus and Wernicke's area. The patient also showed transient aphasia with electrical stimulation of the left fusiform gyrus.

Mesial temporal subdural electrode as a substitute for depth electrode.

As a substitute for depth electrodes, mesial temporal subdural electrodes were devised. This electrode has a slender trapezoid shape and is easily introduced to the inner uppermost portion of the parahippocampal gyrus. Our results have shown that mesial temporal electrodes can detect not only interictal spikes but also subclinical and clinical seizure discharges from the mesiolimbic structures, and they have excellent capability for lateralization of the mesial temporal epileptic focus. If mesial temporal subdural strips are used in combination with lateral temporal subdural grids, comprehensive understanding of the focus distribution throughout the temporal lobes will be possible without using depth electrodes.

[An infant case of spinal arteriovenous malformation with a large venous aneurysm].

An 18-month-old boy was admitted to our hospital with sudden onset of paraplegia, analgesia of the lower limbs, dysuria and constipation. His gestational and birth histories were unremarkable. Past history revealed he had lymphangioma in his left inguinal region, and had been treated in another hospital. Neurological examination revealed flaccid paraplegia, analgesia below Th12 dermatome and dysuria. MRI revealed an intramedullary high intensity lesion surrounded by round low intensity areas located from TH11 to L2 vertebral levels, suggesting the existence of vascular tumor or spinal AVM. Spinal angiogram revealed arteriovenous fistula with large intramedullary aneurysmal vascular dilatation from T12 to L2 vertebral level. The feeder was the Adamkiewicz artery which branched from the left Th12 intercostal artery. First, artificial embolization with thrombin gelfoam was performed successfully. However, follow-up MRI showed an image of flow void in the aneurysm again, indicating recanalization of the AVF. Therefore, an operation was undertaken on October 24th, 1988. The patient was placed in prone position and osteoplastic laminotomy from Th10-L2 was performed. The thrombus and wall of the aneurysm were mostly removed through the lumbosacral midline myelotomy for decompression. Then, the feeder and drainers were ligated. Postoperative course was uneventful. 2.5 years after the operation, he still had flaccid paralysis at the ankle joints bilaterally, analgesia below L4 dermatome, neurogenic bladder and constipation.(ABSTRACT TRUNCATED AT 250 WORDS)

Problems related to dorsal root entry zone lesions.

Several clinical problems related to the dorsal root entry zone lesions (DREZLs) in 15 patients with chronic pain are presented and discussed in terms of ratings of pain relief following surgery, development of sensory or motor weakness and postmortem histologies. Subjective pain relief exceeding 70% was achieved at around 2 weeks after the operations in most patients (13/15), and then decreased in some to 30 from 70% in the follow-up observations. Our new "objective" pain relief score was tested in these patients. A significant positive correlation between subjective pain relief and our objective pain relief scale was found, but some discrepancies between them were also found during the follow-up. Sensory loss, motor weakness, paraesthesia and a new pain were found as complications in 12, 7, 4 and 6 patients, respectively. Postmortem histological findings of the spinal cord in two patients with systemic lupus erythematosus and uterine cancer, who received bilateral DREZLs twice and bilateral DREZLs plus commissural myelotomy, respectively, indicate that care should be taken to avoid extension of the coagulation beyond the dorsal horn.

[Repair of widely infected scalp defect and osteomyelitis with free radial forearm flap: a case report].

A 60-year-old female was admitted with large frontal scalp defect associated with osteomyelitis due to chronic infection. Debridement of the infected scalp and frontal bone and the transplantation of the free radial forearm flap with vascular anastomosis was carried out. The wound cured uneventfully. Cranioplasty was performed ten months after the first operation. Transplantation of free radial forearm flap was first reported in 1982 by Song in China and has proved to be a very effective operative method, especially for the repair of large infected wounds. This is because good blood supply results from the anastomosis of larger vessels, and its cleansing effects can eradicate infections and prompt rapid wound healing.

Multiple subpial transection (MST) for the control of seizures that originated in unresectable cortical foci.

Multiple subpial transection (MST) was applied to 12 cases with intractable epilepsy, the foci of which were located in unresectable essential areas. The result proved that MST is effective in controlling seizures, and no explicit neurological deficits have incurred postoperatively.