Intracystic hematoma of middle fossa arachnoid cyst caused by rupture of internal carotid-posterior communicating artery aneurysm.

A 46-year-old woman was admitted with generalized convulsion and deep coma which occurred 3 weeks after sudden onset of severe headache and pyrexia. Initial computed tomography did not reveal any abnormal findings except for an arachnoid cyst in the right middle fossa. Three weeks later repeat computed tomography showed intracystic hematoma in the arachnoid cyst with uncal herniation. Angiography revealed a right internal carotid-posterior communicating artery aneurysm. The neck of the aneurysm was clipped successfully, but hemiparesis was persistent postoperatively. Angiography is required for investigation of intracystic hematoma of an arachnoid cyst, especially in the absence of head injury, to avoid delayed diagnosis of any ruptured aneurysm.

[Mechanism of injury in acute subdural hematoma and diffuse brain injury: analysis of 587 cases in the Japan Neurotrauma Data Bank].

OBJECTIVE: The aim of this study was to analyze and compare the epidemiology of injury mechanisms in acute subdural hematoma (ASDH) with those of diffuse brain injury (DBI) in the Japan Neurotrauma Data Bank. METHODS: Data in the Japan Neurotrauma Data Bank were reviewed for 1,002 patients with severe head injury treated at hospitals between 1998 and 2001 (ASDH, n=246; DBI, n=341). Clinical variables including mechanisms of injury were evaluated. RESULTS: Patients with DBI were significantly younger, with higher incidence of skull fracture, lower Glasgow coma scale score and higher injury severity score than patients with ASDH. Different mechanisms of injury were involved, with ASDH occurring much more commonly in non-vehicular injuries, particularly falls (47.2%), while DBI resulted almost exclusively from vehicular injuries (79.7%). Impact sites on the head with ASDH were more commonly occipital or temporal, while those for DBI were frontal, temporal or facial. Alcohol use was involved in 13.8% of drivers with ASDH and 33.6% of drivers with DBI. CONCLUSION: The principal mechanical damage in DBI was to the brain itself, while primary damage in ASDH occurred to surface blood vessels. ASDH and DBI remain the two worst and most-important types of traumatic brain injury, although the pathogenesis differs with age and mechanism injury.

[Acute subdural hematoma associated with diffuse brain injury: analysis of 526 cases in Japan neurotrauma data bank].

OBJECTIVE: Traumatic acute subdural hematomas (ASDH) in Japan Neurotrauma Data Bank were categorized into focal brain injury (FBI) group and diffuse brain injury (DBI) group, and were analyzed to clarify the pathophysiological and therapeutic aspects of these injuries. METHODS: Data in Japan Neurotrauma Data Bank were reviewed for 1,002 severely head-injured patients treated at hospitals between 1998 and 2001; 526 of these patients had ASDH. ASDH in this data bank were categorized into FBI group and DBI group on the findings of CT scan. The clinical variables in these injuries were evaluated. RESULTS: Of 526 patients with ASDH, 246 (46.8%) were categorized into FBI group, 280, (53.2%) were DBI group. The patients with DBI group were younger, injured in traffic accident, lower Glasgow Coma Scale (GCS), higher Injury Severity Score, poorer outcome, compared to those with FBI group. The patients in DBI group, who underwent decompressive craniectomy and craniotomy, had a significantly better outcome than those who underwent hematoma evacuation via burr hole. There were no relationship between the time from injury to operation and outcome in the patients with DBI group, whereas patients with early surgery in FBI group showed significantly poorer outcome. Hypothermia and the placement of intracranial pressure monitor improved outcome only in patients of DBI group. CONCLUSION: It seems that the pathophysiological and therapeutic aspects of ASDH associated with DBI might differ from that with FBI alone.

[A case of infected subdural hematoma].

A 87-year old male was admitted to our hospital due to generalized convulsion with loss of consiousness. He was afebrile and his blood sampling was not infectious. Computed tomography scan suspected left chronic subdural hematoma. Burr hole drainage was performed to remove the hematoma, but the abscess was aspirated in the subdural space. Infected subdural hematoma is rare. We discuss the clinical presentation, diagnosis and. treatment, and also briefly review the literature.

Perisacral gastrointestinal stromal tumor with intracranial metastasis. Case report.

A 68-year-old woman presented with an extremely rare intracranial metastasis from a gastrointestinal stromal tumor (GIST) manifesting as left hemiparesis 2 years after resection of a sacral tumor adjacent to the coccygeal bone. Magnetic resonance imaging revealed an intracranial tumor in the right parietal lobe. Craniotomy was performed to completely remove the tumor. Although the tumor was located extra-axially, only internal carotid angiography showed mass staining. Seven months after surgery, the tumor recurred. Repeat craniotomy was performed to remove the recurrent tumor. Immunohistochemical analysis showed that the tumor cells were positive for c-kit and CD34, and the tumors were identified as intracranial metastasis of GIST. Following the second intracranial surgery, the patient developed severe lower back pain caused by metastatic tumor invading the lumbar spine and ureter. To avoid surgical complications and to reduce tumor volume, imatinib mesylate (Gleevec) was administered. The severe pain was relieved, although the tumor was not reduced. In this case, the extra-axial tumor was fed only by the internal carotid artery.

[Serum S-100B protein and neuron-specific enolase after traumatic brain injury].

OBJECTIVE: The aim of this study was to investigate S-100B protein and NSE as a serum marker of brain cell damage after traumatic brain injury. MATERIAL AND METHODS: Forty-one patients with traumatic brain injury were included in this prospective study. Venous blood samples for S-100B protein and NSE were taken after admission and on the next day. Serum levels of S-100 protein and NSE were compared with Glasgow Coma Scale score, computed tomographic findings and outcome after 3 months. RESULTS: Serum S-100B protein and NSE were significantly correlated with Glasgow Coma Scale score and outcome after 3 months. The significant correlation was found between the initial S-100B and NSE (P < 0.001). In patients without parenchymal injuries on computed tomographic scan such as epidural hematoma and concussion, the elevation of S-100B protein and NSE was observed. The initial values of S-100B and NSE in acute subdural hematomas with unfavorable outcome were significantly higher than in those with favorable outcome. Secondary increase of serum markers was associated with the presence of secondary insult such as hypoxia or hypotension, and was found to have an unfavorable outcome. CONCLUSIONS: Serum concentration and kinetics of S-100B protein and NSE provide the clinical assessment of the primary brain damage and have a predictive value for outcome after traumatic brain injury.

[A case of non-functional pituitary adenoma associated with Rathke's cleft cyst].

A very rare case of non-functional pituitary adenoma associated with Rathke's cleft cyst is reported. A 42-year-old male suffering from visual disturbance and headache was admitted. Visual acuity was 1.2 on the right and 0.5 on the left, and visual field examination showed bitemporal hemianopsia. Endocrinological study disclosed that the basal serum level of prolactin was elevated slightly to 52.6 ng/ml, whereas those of other hormones were within normal limits. MRI showed a dumbbell-shaped cystic sellar mass extending to the suprasellar region beyond the diaphragm sellae, which consisted of two isolated components around the sellar turcica. At the middle of May, the tumor was partially removed by bifrontal craniotomy. The suprasellar tumor tightly adhered to the frontal lobe and the optic nerve, the tumor was grayish cyst and cyst fluid from the suprasellar mass had the appearance of motor oil and the intrasellar tumor contained old hematoma. Histological findings revealed that the suprasellar mass was Rathke's cleft cyst and the intrasellar mass was diagnosed as pituitary adenoma (non-functional). Visual acuity was improved following surgical operation. So far twenty-three cases of pituitary adenoma associated with Rathke's cleft cysts have been reported in the literature, but there was only one case reported of a non-functional pituitary adenoma associated with a Rathke's cleft cyst. Etiology and pathogenesis of the coexistence of non-functional pituitary adenoma and Rathke's cleft cyst in the present case were not elucidated.

Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients.

OBJECT: The diagnosis and management of idiopathic normal-pressure hydrocephalus (NPH) remains controversial, particularly in selecting patients for shunt insertion. The use of clinical criteria coupled with imaging studies has limited effectiveness in predicting shunt success. The goal of this prospective study was to assess the usefulness of clinical criteria together with brain imaging studies, resistance testing, and external lumbar drainage (ELD) of cerebrospinal fluid (CSF) in determining which patients would most likely benefit from shunt surgery. METHODS: One hundred fifty-one patients considered at risk for idiopathic NPH were prospectively studied according to a fixed management protocol. The clinical criterion for idiopathic NPH included ventriculomegaly demonstrated on computerized tomography or magnetic resonance imaging studies combined with gait disturbance, incontinence, and dementia. Subsequently, all patients with a clinical diagnosis of idiopathic NPH underwent a lumbar tap for the measurement of CSF resistance. Following this procedure, patients were admitted to the hospital neurosurgical service for a 3-day ELD of CSF. Video assessment of gait and neuropsychological testing was conducted before and after drainage. A shunt procedure was then offered to patients who had experienced clinical improvement from ELD. Shunt outcome was assessed at 1 year postsurgery. CONCLUSIONS: Data in this report affirm that gait improvement immediately following ELD is the best prognostic indicator of a positive shunt outcome, with an accuracy of prediction greater than 90%. Furthermore, bolus resistance testing is useful as a prognostic tool, does not require hospitalization, can be performed in an outpatient setting, and has an overall accuracy of 72% in predicting successful ELD outcome. Equally important is the finding that improvement with shunt surgery is independent of age up to the ninth decade of life in patients who improved on ELD.

[Acute spontaneous subdural hematoma of arterial origin].

BACKGROUND: Acute subdural hematoma is usually associated with cerebral contusion or laceration of the bridging veins following a head injury. However, several cases of acute subdural hematoma without head injury (acute spontaneous subdural hematoma) have been reported. METHODS: Among 162 cases of acute subdural hematoma admitted to our departments between 1996 and 2003, we repoort eight cases of acute spontaneous subdural hematoma. These cases fulfilled the following criteria. 1) Head injury was either trivial or absent. 2) Neither aneurysm nor arteriovenous malformation was apparent. 3) CT scan revealed neither brain contusion nor traumatic subarachnoid hemorrhage. 4) At operation, laceration of the cortical artery was observed. In this article, we describe the clinical feature (age, sex, Glasgow Coma Scale [GCS] Score on admission, past history, CT appearance, and outcome) associated with this condition. RESULTS: Patients ranged in age from 68 to 85 years (average 74.8 years), and were comprised of 3 males and 5 females. Previous medical history included cerebral infarction in 6 of the 8 patients and myocardial infarction in 1 patient. These seven patients were taking antiplatelet manifestation. GCS on admission ranged from 4 to 13. Five of the 7 patients on antiplatelet medication had secondary insults, such as hypoxia. On CT, hematoma thickness ranged from 13.2mm to 42.5mm (average 22.6mm), and midline shift ranged from 10.0mm to 24.0mm (average 16.5mm). Neurological outcome evaluated using the Glasgow Outcome Scale was as follows, good recovery n = 2, moderate disability n = 2, severe disability n = 3, persistent vegetative state n = 1. CONCLUSION: The mechanism of acute spontaneous subdural hematoma is influenced by the presence of pre-existing cerebrovascular disease and by the use of antiplatelet agents. In such cases, the possibility of cortical arterial bleeding should be taken into account, and craniotomy should be performed.

[Therapeutic effect of spinal cord stimulation for a patient suffering spasticity after hypoxia of the brain].

We reported a case of severe spasticity of the bilateral upper and lower limbs which was improved by cervical spinal cord stimulation (SCS). A 53-year-old man was suffering from sudden cardiopulmonary arrest while walking. After receiving cardiopulmonary resuscitation for 40 minutes, his cardiopulmonary function re-started, but he failed to regain consciousness. MRI revealed a hypoxic brain in his bilateral basal ganglia and occipital lobes. After 2 months, his consciousness advanced to a vegetative state and the muscle tone of his bilateral upper and lower limbs deteriorated to severe spasticity. SCS was performed in the expectation of improving his consciousness. Contrary to this anticipated result, his vegetative state continued but the severe spasticity of his upper and lower limbs improved during the SCS. Single photon emission computed tomography (SPECT) during the period of stimulation revealed a high blood flow, especially in the area of the basal ganglia, thalamus, brain stem and cerebellum, compared with off-stimulation blood flow. The neurophysiologic mechanisms of these abnormal fields and the underlying aberrant afferent nerve impulses from the posterior funiculus in the cervical cord to the cerebral sensory cortex, which may indeed be secondary to ischemic brain, may be regulated by SCS, also adding the effect of increased blood flow to the brain.

[Spontaneous regression of primary central nervous system lymphoma: a case report].

A rare case of primary central nervous system lymphoma that regressed spontaneously as shown on serial cranial magnetic resonance imagings (MRI) is described. A 60-year-old woman was admitted to our hospital with a well-enhanced mass lesion in the cerebellum although MRI had demonstrated no abnormal findings 4 months before admission. On admission, She complained of headache, but no neurological deficits were observed. The patient underwent exploratory craniotomy and the tumor was partially removed on February 14. Pathologic examination suspected B-cell type of malignant lymphoma. Postoperative MRI performed on February 23, 2001 showed disappearance of the mass lesion without further treatment. Different polymerase chain reaction (PCR) assays detected clonal immunoglobulin heavy chain gene rearrangements in paraffin-embedded tissues diagnosed as B-cell lymphoma. The patient was discharged without any neurological deficits for two weeks and was followed up on MRI. One year after operation, MRI revealed an abnormal finding in the cerebellum without apparent neurological deterioration. Radiation therapy of the whole brain and the local site was carried out with a total dose of 50Gy. MRI demonstrated complete remission of the tumor following radiation therapy. She was admitted again to our hospital with right hemiparesis on May, 2003. Subsequently, systemic chemotherapy was carried out. The patient died 2 years and 10 months after her initial presentation.

[A multicentric glioma presenting different pathological appearances: a case report].

We report a multicentric glioma case which revealed different pathological appearances. A 45-year-old male had been admitted to our hospital complaining of an attack of transient sudden aphasia. On magnetic resonance imaging (MRI), T1-weighted images revealed a low intensity and T2-weighted images demonstrated a homogeneous high intensity abnormal mass in the frontal lobe, which was not enhanced with gadolinium. Removal of the tumor was performed through a right frontal transcortical approach in March, 2002. Histological diagnosis was gemistocytic astrocytoma. The patient's condition was uneventful and postoperative MRI revealed a marked decrease in the volume of the tumor. A total of 54 Gy radiation to the brain in the locality was performed. Four months after the initial surgery, the patient suffered from incomplete right hemiparesis. MRI showed a left parietal abnormal mass which had a ring formation enhancement after gadolinium administration. This Neuro-radiological examination demonstrated complete independence from the initial right frontal tumor. A second surgery which was concerned with cyst aspiration was carried out on August 10, 2002. During the next month, a third operation for partial removal of a left parietal abnormal mass was performed. Histological diagnosis was anaplastic astrocytoma. The right frontal and left parietal tumors revealed neither continuous relation suggesting intracerebral invasion, nor dissemination through the subarachnoid space nor intracerebral metastasis. Our case was diagnosed as multicentric glioma with different pathological appearances, of which only 9 cases have been reported previously.

[Intracranial metastasis of pituitary adenoma: a case report].

Growth hormone-secreting pituitary adenoma is usually benign, and distant metastases are extremely rare. A case of growth hormone-secreting pituitary adenoma with multiple dural metastases is reported. A 53-year-old male was initially admitted to our hospital complaining of visual loss, presenting a pituitary abnormal mass with suprasellar extension. At the initial surgery, transsphenoidal surgery was selected, and the histological finding was benign pituitary adenoma. Seven and 16 months after the initial surgery, second and third surgeries via a transcranium route were performed for recurrence of the pituitary tumor. Histological findings revealed an appearance similar to the initial tumor in both surgical specimens. After the third operation, radiation therapy (local irradiation: total; 44 Gy) was performed. Six years after the first surgery, three tumors were located in the right frontal, parietal convexity and cerebellar tentorium. The tumors were totally removed by 4th and 5th surgeries. Histological examination showed malignant transformation from the primary benign growth hormone-secreting pituitary adenoma, with dural metastasis. Immunohistochemical staining with MIB-1 antibody demonstrated a high index of 7%. The patient is still alive after more than one year since the diagnosis of distant metastasis. According to previous reviews, few patients have survived more than one year. We conclude patients with benign pituitary adenoma should be carefully followed up for fear of malignant transformation or dural metastasis.

Acute subdural hematoma associated with diffuse brain injury and hypoxemia in the rat: effect of surgical evacuation of the hematoma.

The aim of this study was to assess the effect of rapid or delayed surgical evacuation on the physiological consequence and brain edema formation in a rat model of acute subdural hematoma (SDH) coupled with either diffuse brain injury (DBI) or hypoxemia. The SDH was made by an autologous blood injection, while DBI was induced using the impact acceleration model (mild, 450 g/1 m; severe, 450 g/2 m). Physiological parameters measured included intracranial pressure (ICP), mean arterial blood pressure (MABP), cerebral blood flow (CBF), and brain tissue water content. At 1 h (rapid evacuation) or 4 h (delayed evacuation) after the SDH induction, surgical evacuation following a craniotomy was performed using saline irrigation and forceps. The study consisted of three different series, including 400 microL of SDH alone (Series 1), SDH400 + mild DBI (Series 2), and SDH300 + severe DBI + 20 min hypoxemia (Series 3). The hypoxemia was added in Group 3 to produce a steadily increasing ICP. In Series 1 and 2, all rats were randomized into the three following groups: non-, rapid, and delayed evacuation; Series 3 had two groups: non- and rapid evacuation. In Series 1, the surgical evacuation showed no beneficial effects on the brain edema formation assessed at 5 h post-injury. In Series 2, the rapid, but not delayed, evacuation significantly reduced both the increased ICP level and brain water content. The additional insult of hypoxemia (Series 3) resulted in a progressive ICP elevation, persistently depressed CBF, and severe brain swelling. Under this situation, the rapid evacuation exacerbated brain edema. These results have clinical implications for the management of severe traumatic SDH, especially its operative indication and timing.

[Two cases of lymphocytic infundibuloneurohypophysitis].

We report two cases of lymphocytic infundibuloneurohypophysitis (LIH). A 32-year-old male and a 13-year-old male were admitted to our hospital because of a sudden occurrence of the diabetes insipidus (DI). MRI of both patients showed the disappearance of hyperintensity of the posterior pituitary in T1WI, pituitary stalk swelling and enlargement of the pituitary gland, with homogeneous enhancement by gadolinium. We thereby diagnosed LIH, so neither patient was operated on, but both were followed-up conservatively. We reviewed 51 cases of LIH. The patient's ages ranged from 4 to 74 years (mean 45.4 years). Based on the initial symptoms, DI was found in all cases. Almost all these cases revealed characteristic MRI findings similar to those in our cases. The mean follow-up period was 3.1 years. The rate of disappearance of radiological abnormalities was 56.2%, but only 13.7% of DI improved. If we encounter a patient presenting with idiopathic DI whose MRI is strongly suggestive of LIH, and barring the necessity of an urgent operation, careful conservative treatment is advised.

A new rat model of diffuse brain injury associated with acute subdural hematoma: assessment of varying hematoma volume, insult severity, and the presence of hypoxemia.

The aim of this study was to develop a new rat model of diffuse brain injury (DBI) associated with acute subdural hemorrhage (SDH). In order to make this model more clinically relevant, we determined whether the varying hematoma volume, severity of DBI, or the presence of hypoxemia could influence the physiological consequence. SDH was made by an autologous blood injection, while DBI was induced using the impact acceleration model (mild, 450 g/1 m, severe, 450 g/2 m). Physiological parameters measured included intracranial pressure (ICP), mean arterial blood pressure (MABP), cerebral blood flow (CBF), and brain tissue water content. In the first series, 23 rats were randomized into the five following groups: Group 1, sham; Group 2, 400 (microL SDH; Group 3, SDH400 + mild DBI; Group 4, SDH400 + severe DBI; and Group 5, SDH300 + severe DBI. Results suggested that SDH300 + severe DBI (Group 5) may be the most suitable model, in which the MABP and CBF temporarily decreased during the SDH induction, but thereafter recovered to the baseline. Conversely, ICP was persistently elevated throughout the experiment. The water content was also significantly higher in both hemispheres compared to that of sham. In the second series, the animal was exposed to a hypoxemic insult (10 or 30 min) in addition to SDH300 + severe DBI (Group 6). The prolonged hypoxemia caused both a severe CBF reduction without recovery and a bilateral brain swelling, whereas the brief hypoxemia showed a gradual CBF recovery from the transient reduction and an increased water content only in the SDH side. These results suggest that these models may be potentially useful to study the combination of DBI and SDH with or without hypoxemia.

[Progressive brain injury].

The aim of this study was to evaluate the clinical manifestations and prognostic factors of progressive brain injury following trauma. We reviewed the records of 779 patients with head injury who had an admission Glasgow Coma Scale of 9 or more; 70 (7.0%) developed progressive brain injury as evidenced on serial CT scans. Of these 70 patients, 19 (27.1%) had a subdural hematoma, 19 (27.1%) an epidural hematoma, 16 (22.9%) a cerebral contusion, 13 (18.6%) an intracerebral hematoma, and 3 (4.3%) a diffuse brain swelling. Three months after injury, 36 (51.4%) patients died, 2 (2.9%) were left in a vegetative state and 23 (32.9%) had a favorable outcome. The appearance of progressive brain injury was associated with patient age, admission Glasgow Coma Scale, injury mechanisms, skull fracture and hemorrhagic lesions on the initial CT scan. Patients with the extracerebral lesions deteriorated 4 hours after injury, whereas those with intracerebral lesions deteriorated 8 hours after injury. The outcome based on Glasgow Outcome Scale was significantly associated with age, type of intracranial lesion, Glasgow Coma Scale following deterioration, the mechanism of injury and surgical treatment. It is concluded that early repeated CT scan is indicated in patients with risk factors of developing progressive brain injury.

[Solitary fibrous tumor of the fourth ventricle: case report].

A rare case of solitary fibrous tumor, located wholly within the fourth ventricle, is reported. A 57-year-old male presented with headache and nausea. The preoperative magnetic resonance images revealed a well circumscribed mass in the fourth ventricle that exhibited a low intensity on T1-weighted images and homogeneously enhanced with gadolinium. Vertebral angiogram revealed a tumor stain supplied from the choroidal branches of the posterior inferior cerebellar artery. The tumor was totally resected through a midline suboccipital approach. Histologically, the tumor was composed of spindle-shaped cells growing in fascicles within a collagenous matrix. Immunohistochemical staining demonstrated vimentin and the CD34 positivity of tumor cells. Solitary fibrous tumor is a newly described entity, which should be considered in the differential diagnosis for dural-based lesions.