Angioarchitecture of the hemorrhagic developmental venous anomaly with stenosis of the collecting vein and cavernous malformation: a case report.

We herein report a case of developmental venous anomaly (DVA) with venous congestion caused by stenosis of the collecting vein that presented with intracerebral hemorrhage (ICH). A 74-year-old woman was referred to our hospital a few days after the onset of motor aphasia. Computed tomography (CT) and magnetic resonance imaging (MRI) showed ICH in the left frontal lobe. Angiography revealed DVA in the left frontal lobe in the late venous phase. Stenosis of the collecting vein of DVA at the entrance to the superior sagittal sinus was detected and accompanied by cavernous malformation (CM) beside DVA. Cone-beam CT revealed the absence of the left septal vein and hypoplastic transverse caudate veins. The patient was treated by blood pressure management and no additional neurological symptoms were detected. DVA develops to compensate for the absence of pial or deep venous systems, and generally benign and clinically asymptomatic. However, the outflow restriction of DVA causes chronic venous hypertension and the formation of CM. These abnormalities are considered to occur during post-natal life and may result in ICH. The risk of hemorrhage needs to be considered in cases of DVA with restricted venous outflow or CM.

Usefulness of rapid MR angiography using two-point Dixon for evaluating carotid and aortic plaques.

PURPOSE: Recently, various magnetic resonance imaging (MRI) modalities have been developed to easily detect carotid and aortic plaques, but these techniques are time-consuming and vulnerable to motion artifacts. We investigated the utility of a gradient echo MRI technique known as liver acquisition with volume acceleration flexible (LAVA-Flex) to detect carotid and aortic atherosclerotic plaques. METHODS: Ten patients who underwent carotid endarterectomy (CEA) were assessed regarding the correspondence between LAVA-Flex findings and the histopathology of excised carotid plaques. In addition, 47 patients with cryptogenic ischemic stroke underwent LAVA-Flex and transesophageal echocardiography (TEE) for detection of embolic sources in the thoracic aorta. We analyzed the relationship between the thickness of the aortic plaque measured by TEE and the presence of high-intensity lesions on LAVA-Flex. RESULTS: Nine of 10 patients (90.0%) who underwent CEA showed a high-intensity carotid lesion on LAVA-Flex, which corresponded pathologically to plaques containing large lipid cores and hemorrhage. Twenty-four (51.1%) of 47 cryptogenic stroke patients showed a high-intensity lesion in the thoracic aorta on LAVA-Flex; of these, 21 (87.5%) also demonstrated a large plaque (thickness ≥4 mm) on TEE. Twenty-two (95.7%) of 23 patients without a high-intensity lesion on LAVA-Flex demonstrated no large plaque on TEE. LAVA-Flex had a sensitivity of 95.5% and a specificity of 88.0% in patients with large plaques. CONCLUSION: This study showed that LAVA-Flex successfully detected carotid and aortic plaques. This imaging technique may be useful to rapidly diagnose and evaluate carotid and aortic plaques, which are critical risk factors for aortogenic stroke.

Clinical characteristics of acromegalic patients with empty sella and their outcomes following transsphenoidal surgery.

PURPOSE: To analyze the clinical characteristics of acromegalic patients with empty sella (ES, herniation of the subarachnoid space within the sella turcica) and the impact of ES on transsphenoidal surgery in such patients. METHODS: Seventy-eight patients, newly diagnosed with acromegaly who underwent transsphenoidal surgery were included. ES was defined as the pituitary gland and adenoma occupying less than 50% of the sella turcica on midsagittal magnetic resonance (MR) imaging. RESULTS: Twelve patients (15.4%), predominantly female (10 women, p = .047), had ES in preoperative MR imaging. ES patients had smaller mean tumor diameter (6.3 mm) than non-ES patients (11.2 mm, p = .001). In preoperative MR imaging, occult adenoma was found in three (25%) ES and three (4.5%) non-ES patients (p = .044). Intraoperative cerebrospinal fluid (CSF) leakage was more frequent in the ES patients than in the non-ES patients (58.3 vs. 25.8%, p = .024). This led to an increased rate of sellar floor reconstruction using abdominal fat and/or postoperative lumber drainage in the ES patients (ES: 41.7 vs. non-ES: 16.7%, p = .063). Endocrinological remission after surgery was more frequent in the non-ES patients (72.7%) than in the ES patients (58.3%) (p = .248). CONCLUSIONS: Co-existence of acromegaly with ES is not rare, and is associated with occult adenoma, intra/postoperative CSF leakage, and a worse endocrinological outcome after transsphenoidal surgery; although, the underlying mechanism remains unclear.

Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage.

PURPOSE: Although hemorrhage within pituitary adenomas frequently exacerbates the symptoms, there are many grades of severity. Moreover, the contributing factors for symptom severity are still controversial. METHODS: This retrospective study included 82 patients who underwent transsphenoidal surgery for pituitary adenomas with intratumoral hemorrhage. The grades of preoperative symptoms were classified into group A, asymptomatic or minor symptoms; group B, moderate symptoms sufficient for complain; and group C, severe symptoms disturbing daily life. RESULTS: The hemorrhage volume within an adenoma was significantly higher in group C (92.6%) than in groups A (48.6%) and B (58.7%). Both headache and diplopia were dominant in group C, occurring in 72.2% and 27.8% of the patients, respectively. In group C, there was no significant difference in frequency between adenoma extensions into the sphenoid sinus (0%) and involvement of the cavernous sinus of Knosp grade 4 (0%), and extensions into the suprasellar region were not common (38.9%). The most distinctive feature was that "no extrasellar extension" was found only in group C (41.2%), and "multidirectional extension" was not detected in this group (0%). Multiple regression analysis revealed that the most powerful determining factors were the high frequencies of intratumoral hemorrhage and lack of extrasellar and multidirectional extensions. CONCLUSION: Rapid volume expansion of a hematoma and lack of extension or unidirectional extension might lead to significant compression of the sellar and surrounding structures. Of note, the integrity of the sellar dura might contribute to the acute onset of symptom manifestations caused by hemorrhage in pituitary adenomas.

Prediction of postoperative diabetes insipidus using morphological hyperintensity patterns in the pituitary stalk on magnetic resonance imaging after transsphenoidal surgery for sellar tumors.

PURPOSE: Diabetes insipidus (DI) remains a complication of transsphenoidal surgery (TSS) for sellar and parasellar tumors. Antidiuretic hormone (ADH) appears as hyper intensity (HI) in the pituitary stalk and the posterior lobe of the pituitary gland on T1-weighted magnetic resonance (MR) imaging. Its disappearance from the posterior lobe occurs with DI, indicating a lack of ADH. The appearance of HI in the pituitary stalk indicates disturbances in ADH transport. METHODS: This retrospective study included 172 patients undergoing TSS for sellar tumors at our institute from 2006 to 2014. Sequential T1-weighted MR images without enhancement were evaluated for HI in the pituitary stalk and the posterior lobe to assess the localization of ADH before and at intervals after TSS. DI was assessed pre- and postoperatively. HI in the pituitary stalk showed the following morphology: (1) ovoid in the distal end of the pituitary stalk (group A), (2) linear in the distal part of the pituitary stalk (group B), (3) linear in the whole pituitary stalk (group C). RESULTS: Preoperative DI occurred in 6 patients (3.5 %) with no HI observed in the posterior lobe. Postoperative DI was transient in 82 patients (47.7 %), and permanent in 11 (6.4 %). One week after surgery, HI was absent in the posterior lobe in 74 patients (43.0 %), and present in the pituitary stalk in 99 patients (57.6 %); both were significantly correlated with postoperative DI (p < 0.001). The absence of HI in the posterior lobe (A, 48.9 %; B, 68.3 %; C, 92.3 %), persistence of DI (A, 3.7 days; B, 45.9 days; C, 20.5 months), and duration until HI recovery in the posterior lobe (A, 3.6 months; B, 6.8 months; C, 22.9 months) were greatest in group C, followed by group B, and then group A. Fourteen group A patients did not have postoperative DI despite having HI in the pituitary stalk and the posterior lobe. Four group C patients developed permanent DI with persistence HI in the pituitary stalk. CONCLUSION: HI in the pituitary stalk and its absence in the posterior lobe indicated postoperative DI, which was transient if HI was detected in the pituitary stalk. DI duration could be predicted by the length of HI in the pituitary stalk, which corresponded to the degree of ADH transport obstruction.

Significant improvement of intractable headache after transsphenoidal surgery in patients with pituitary adenomas; preoperative neuroradiological evaluation and intraoperative intrasellar pressure measurement.

OBJECT: Headache is the most common symptom of both primary and metastatic brain tumor, and is generally considered the primary symptom in patients with large pituitary adenomas. However, patients with small pituitary adenomas rarely complain of intractable headache, and neurosurgeons are unsure whether such small adenomas actually contribute to headache. If conventional medical treatments for headache prove ineffective, surgical removal of the adenoma can be considered as an alternative management strategy. METHODS: We conducted a retrospective review of 180 patients who underwent transsphenoidal surgery (TSS) for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. Patients with acute phase intratumoral hemorrhage were excluded. We identified nine patients with intractable headache as the chief complaint associated with small pituitary adenoma (diameters 15.8 ± 2.6 mm, 11-20 mm), non-functioning in eight, and prolactin-secreting in one. The preoperative neuroradiological studies and headache characteristics were assessed retrospectively, and the intrasellar pressure evaluation was performed during TSS in the last seven patients. RESULTS: All nine patients had complete or substantial resolution of their formerly intractable headache after TSS. Headaches consisted of ocular pain ipsilateral to the adenoma localization within the sella in four cases and bifrontal headache in five. Magnetic resonance imaging of these patients revealed small diaphragmatic foramen, which were so narrow that only the pituitary stalk could pass. Computed tomography scans showed ossification beneath the sellar floor in the sphenoid sinus, presellar type in six cases, and choncal type in three. The adenomas included cysts in seven cases. There was no cavernous sinus invasion. Intrasellar pressure measurements averaged 41.5 ± 8.5 mmHg, range 34-59, significantly higher than in control patients without headache (n = 12), namely 22.2 ± 10.6 mmHg (16-30). CONCLUSION: In this study, the authors demonstrated the validity of TSS in the treatment of intractable headache associated with pituitary adenoma. The presence of ocular pain, especially ipsilateral to the adenoma, integrity of the diaphragm sella, and ossification in the sphenoid sinus, cyst or hemorrhage and the absence of cavernous sinus invasion were the indications for TSS for patients complaining of intractable headache and having pituitary adenomas.

Simultaneous ventriculoperitoneal shunt removal and endoscopic third ventriculostomy for three patients previously treated for intracranial germ cell tumors more than 20 years ago.

BACKGROUND: Obstructive hydrocephalus is the most common complication of intracranial germ cell tumors (IGCTs). Although ventriculoperitoneal shunts (VPSs) were previously used for treating this condition, they have recently been replaced by endoscopic third ventriculostomy (ETV), as the latter can avoid various complications caused by a VPS and can preserve physiological cerebrospinal fluid (CSF) dynamics. Therefore, if a VPS malfunctioned in patients who had previously been treated for IGCTs, it seems reasonable to consider removing the problematic VPS, followed by ETV, as long as magnetic resonance imaging reveals third ventricle floor ballooning and the cause of obstruction in the ventricular system, which are indicators for ETV. CASE PRESENTATION AND DISCUSSION: Here, we present the cases of three patients who underwent simultaneous removal of malfunctioning VPSs and ETV, more than 20 years (range 20-27 years) after initial treatment for IGCT and relevant obstructive hydrocephalus. Despite a relatively long shunt dependency, their obstructive hydrocephalus was well-managed by ETV, probably because CSF absorptive capacity remained intact after IGCT ablation by radio-chemotherapy. CONCLUSION: Patients with previously treated IGCTs can thus be released from the need for a VPS, regardless of long-term shunt dependency.

Pediatric symptomatic Rathke cleft cyst compared with cystic craniopharyngioma.

INTRODUCTION: Symptomatic Rathke cleft cysts (RCCs) are rarely detected in neuroradiological screening and are less commonly found in children than in adults. However, when RCCs are observed in children, it is important to carefully distinguish a RCC from a cystic craniopharyngioma (CP) even if surgically treated or conservatively followed up. METHODS: We conducted a retrospective review of clinical data from 11 patients with symptomatic RCCs whose ages were under 18 years and compared the data with data from 15 age- and sex-matched patients with cystic CP who were treated at our institute. RESULTS: The mean age of the patients with RCCs was 12.2 years (range, 6-18). There were six males and five females. As initial symptoms, nine patients presented with headache, while two each had impaired visual function, diabetes insipidus, and activity loss. The 14 patients with CP suffered from impaired visual function. Magnetic resonance imaging (MRI) mainly showed hyperintensity on T1-weighted images (WIs) and hypointensity on T2-WI in patients with RCC. However, patients with CP had characteristic hyperintensity on T2-WI. The average maximum diameter of the RCCs was 19.0 mm on average (range, 8-33 mm). The RCCs were thus significantly smaller than CPs (34.9 mm; range, 21-54 mm). The RCCs were usually oval or dumbbell-shaped and regular in appearance, while the larger CPs were lobular and irregular. A preoperative endocrinological evaluation revealed insufficiencies in four axes in five patients with RCC. Postoperative endocrinological status improved in three patients, remained unchanged in three, and worsened in one. The gonadotropin axis was damaged in a majority (nine) of the patients with CP preoperatively. Postoperative evaluation revealed deficits in five axes in 14 patients with CP, which is a significantly different trend than observed in patients with RCC. Eight patients underwent surgical procedures (transsphenoidal surgery (TSS) in four, craniotomy in four). Two of these patients experienced a recurrence of the cysts. One of these patients subsequently underwent two craniotomies followed by radiation and other underwent TSS. Among the three conservatively treated patients, two experienced a transient worsening of their symptoms along with cyst enlargement. However, none of the three conservatively treated patients required an operation. CONCLUSIONS: When RCCs become symptomatic in children, the most common symptom they lead to is headache. The cysts are commonly small, regular, and oval in shape. Hypointensity of cyst contents on MRI is a characteristic of RCCs, which distinguishes them from CPs. Surgical intervention can be effective and lead to the relief of symptoms without a high rate of complications. However, there seems to be a relatively high recurrence rate following surgery. Thus, if the patient's symptoms remain minor, the surgical treatment option should be used only when prudent, as the patient's symptoms may improve over time.

A Case of Cerebral Infarction due to Internal Carotid Artery Occlusion Accompanied by Persistent Primitive Trigeminal Artery.

An 85-year-old woman with a history of diabetes mellitus became aware of motor weakness of the left lower extremity. Magnetic resonance imaging showed multiple small cerebral infarctions in the right corona radiata. Angiography revealed persistent primitive trigeminal artery (PPTA) originating from the right internal carotid artery (ICA) and connecting to basilar artery, and the right ICA occluded distal to PPTA. Collateral blood circulation had developed, and sufficient collateral blood flow was expected. From these findings, the right ICA was considered to show stenosis due to atherosclerotic changes before occlusion. Conservative treatment was conducted with the transoral administration of rivaroxaban. It is important to correctly diagnose the anatomy and existence of an anomalous vessel in a stroke patient, not only when endovascular treatment is planned, but also for conservative medical treatment. Rapid and accurate radiological examinations facilitate safe and effective treatment.

"The microcatheter contrast injection technique": A novel technique to detect the proximal end of a thrombus in mechanical thrombectomy.

Background: An aspiration catheter needs to attach to a thrombus in order to achieve first-pass recanalization by mechanical thrombectomy (MT) for acute ischemic stroke (AIS), particularly that using a direct aspiration first pass technique. The meniscus sign, which is defined as meniscoid contrast opacification indicating the proximal edge of a thrombus, has been suggested to contribute to successful recanalization. In some cases, the meniscus sign is not detected following an injection of contrast medium through a guiding catheter. To precisely identify the location of a thrombus, we use "the microcatheter contrast injection (MCI) technique," which accurately shows the proximal edge of a thrombus. We herein introduce this novel technique and discuss its efficacy in MT. Methods: In cases without the meniscus sign, a microcatheter was advanced to the distal end of contrast opacification, and contrast medium was injected through the microcatheter to detect the meniscus sign. An aspiration catheter was then advanced to the thrombus indicated by the meniscus sign and slowly withdrawn under aspiration. Results: 29 patients underwent MT for AIS using the MCI technique. Even in cases without the meniscus sign on initial angiography, the MCI technique accurately revealed the proximal edge of the thrombus. Moreover, middle cerebral artery occlusion due to atherosclerotic stenosis and displacement of the aspiration catheter and thrombus axis were detected using this technique. Conclusions: The MCI technique may effectively reveal the exact site of a thrombus and increase the success rate of first-pass recanalization.

Bow hunter's syndrome treated by anterior decompression with fusion: A case report.

Background: Bow hunter's syndrome (BHS) is a rare condition induced by occlusion or compression of the vertebral artery (VA) during head movement or rotation. Here, we report a patient with BHS effectively treated with an anterior cervical discectomy and fusion (ACDF). Case Description: A 75-year-old male experienced recurrent embolic strokes to the posterior circulation. This was attributed angiographically to transient stenosis of the right VA due to a right-sided C5-C6 osteophyte when the head was rotated to the right; the stenosis was improved when the patient rotated his head to the left. The patient successfully underwent a C5-C6 ACDF for removal of the right-sided lateral osteophyte which resulted in no further transient right-sided VA occlusion. Conclusion: Following a C5-C6 ACDF for removal of a right lateral osteophyte, a 75-year-old male's intermittent right-sided VA occlusion responsible for multiple posterior circulation emboli was relieved.

Carotid artery stenting for spontaneous internal carotid artery dissection presenting with hypoglossal nerve palsy: A case report.

Background: Some studies reported cases of internal carotid artery (ICA) dissection (ICAD) that was treated by carotid artery stenting (CAS). Symptoms of ICAD resulting from the lower cranial nerve palsy are rare and the treatment strategy is not clearly defined. We report a patient with ICAD showing hypoglossal nerve palsy alone that was treated by CAS. Case Description: A 47-year-old man presented with headache, dysphagia, dysarthria, and tongue deviation to the left. He had no history of trauma nor any other significant medical history. Axial T2-CUBE MRI and MRA showed dissection of the left ICA accompanied with a false lumen. These findings indicated that direct compression by the false lumen was the cause of hypoglossal nerve palsy. Although medical treatment was continued, symptoms were not improved. Therefore, CAS was performed to thrombose the false lumen and decompress the hypoglossal nerve. His symptoms gradually improved after CAS and angiography performed at month 6 showed well-dilated ICA and disappearance of false lumen. Conclusion: CAS may be an effective treatment for the lower cranial nerve palsy caused by compression by a false lumen of ICAD.

Cerebral Infarction Due to Occlusion of Main Trunk of Middle Cerebral Artery in Patient with Accessory Middle Cerebral Artery.

The existence of an accessory middle cerebral artery (AMCA) usually has no pathological significance. Three patients developed cerebral infarction due to thromboembolic occlusion of the main trunk of the middle cerebral artery (MCA). In these patients, AMCA originating from the anterior cerebral artery was intact, and ran to the lateral side along the main MCA. Emergency endovascular treatment to remove the thrombus in the main MCA was performed, and MCA was recanalized. In one patient, the main MCA re-occluded and cerebral infarction developed on the next day. The diameter of AMCA is commonly smaller than that of the main MCA. Therefore, volume of ischemic region depends on the collateral blood flow to the left MCA territory by AMCA. Once an anomalous MCA is detected in a patient with cerebral infarction involving the MCA territory, close examinations to assess the anatomy of both the main and anomalous MCA are mandatory.

[CSF leakage and anosmia in aneurysm clipping of anterior communicating artery by basal interhemispheric approach].

We studied the incidence of postoperative infection related to CSF leakage and anosmia in basal interhemispheric approach (BIH). Between April, 1990 to March, 2009, 142 cases of anterior communicating (Acom) aneurysm including both unruptured and ruptured have been treated by clipping surgery using BIH. We retrospectively obtained clinical informations from medical records and video records about infectious complications, CSF leakage of cerebrospinal fluid (CSF), olfactory dysfunction and intraoperative findings of damage to the olfactory nerve. In most cases (139 patients, 97%), frontal sinus were opened at craniotomy. Of all, CSF rinorrhea occurred in 4 cases (2.8%), and meningitis in 6 cases. There was only one patient who sufferd from meningitis due to CSF rinorrhea. All that patients recovered completely without deficit. Anosmia occurred in 6 cases (4.2%), and intraoperative injuries in 4 cases (2.8%). There was only one patient in whom anosmia was consistent with nerve injury. In conclusion, BIH is an appropriate procedure for infection risk control in Acom aneurysm surgery. It is difficult to avoid olfactory dysfunction completely, even if olfactory nerves are preserved in form.

Characteristics and Management of Ruptured Aneurysms Originating from the Penetrating Artery of the Distal Middle Cerebral Artery.

We report a rare case of an aneurysm originating from the penetrating artery of the distal middle cerebral artery (MCA). A 76-year-old man without a notable past history presented with sudden-onset severe headache, left hemiparesis, and a decreased level of consciousness. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) with intracerebral hemorrhage (ICH) in the right temporal lobe extending into the ventricle. Contrast-enhanced CT (CE-CT) demonstrated a focus of contrast enhancement (CE) adjacent to the hematoma in the right frontal lobe. An aneurysm fed by a penetrating artery branching off from the right distal MCA was found on angiography. The patient underwent emergency resection of the aneurysm and hematoma evacuation. Histological analysis revealed that arterial dissection may be an associated factor in the pathogenesis of this peripheral aneurysm formation. A focus of CE within or adjacent to the hematoma may be useful for diagnosing this peripheral aneurysm. ICH can result in a life-threatening situation. Therefore, microsurgery may be the first treatment choice for aneurysms in this location.

Hemifacial spasm caused by vertebral artery aneurysm treated by endovascular coil embolization.

BACKGROUND: Hemifacial spasm (HFS) caused by vertebral artery (VA) aneurysms is rare. Several cases of HFS caused by VA aneurysms treated by endovascular parent artery occlusion (PAO) have been reported. Recently, we treated a rare case of HFS caused by a saccular VA aneurysm at the bifurcation of the posterior inferior cerebellar artery (PICA), which was successfully treated by endovascular coil embolization, preserving the parent artery, and PICA. We discuss endovascular treatment for HFS induced by VA aneurysms with a literature review. CASE DESCRIPTION: A 59-year-old man presented with the left HFS persisting for 2 months. Magnetic resonance imaging revealed a left saccular VA-PICA aneurysm and demonstrated that a left facial nerve was compressed by the aneurysm at the root exit zone. Angiography revealed that the PICA was branching from the aneurysm neck. Endovascular coil embolization was performed using the balloon remodeling technique to preserve the left VA and PICA. HFS disappeared after treatment. CONCLUSION: Although microvascular decompression was commonly accepted for the standard treatment of HFS, coil embolization of aneurysms without PAO may be an effective treatment for HFS caused by VA aneurysms.

Embolization of a wide-necked basilar bifurcation aneurysm by double-balloon remodeling using HyperForm compliant balloon catheters.

We report a patient with a wide-necked basilar bifurcation aneurysm that was difficult to address by standard coil embolization because the left and right posterior cerebral artery (PCA) branched from the base of the aneurysm. To preserve both PCAs, the aneurysm was endovascularly embolized using a double-balloon remodeling technique and HyperForm compliant balloon catheters (MicroTherapeutics, Irvine, CA, USA). The aneurysmal neck was not tightly embolized to avoid coil protrusion into the parent arteries. The present technique is an important adjunct to the embolization of wide-necked basilar bifurcation aneurysms.

Contribution of Intrasellar Pressure Elevation to Headache Manifestation in Pituitary Adenoma Evaluated With Intraoperative Pressure Measurement.

BACKGROUND: Headache frequently occurs in patients with pituitary adenoma and is reported in large as well as small adenomas. However, the exact mechanism of headache derived from pituitary adenoma remains unknown. OBJECTIVE: To evaluate the contribution of intrasellar pressure (ISP) to headache manifestation by using intraoperative ISP measurement. METHODS: The records of 108 patients who had first-time transsphenoidal surgery for pituitary adenoma were reviewed retrospectively. Measurement of intraoperative ISP was undergone using intracranial pressure monitoring sensors and compared with radiological assessment. RESULTS: Among 30 patients with headache, 29 (96.7%) presented with significant headache (Headache Impact Score-6, 50 or greater). Intraoperative ISP measurement was conducted successfully in all cases, and revealed higher ISP in patients with headache (35.6 ± 9.2 mm Hg) than in those without headache (15.8 ± 5.2 mm Hg). The ISP reduction after sella floor decompression was greater in patients with headache than that in patients without headache. In patients with headache, the frequency of invasion into the cavernous sinus or sphenoid sinus was significantly lower, and the diameter of the foramen at the diaphragm sellae was narrower. In addition, intratumoral cyst or hematoma was more common in patients with headache. Postoperatively, headache was either diminished or improved in 28 patients (93.3%). CONCLUSION: Headache in patients with pituitary adenomas associated with ISP elevation, results from compromised dural integrity at the sella and intratumoral hemorrhage. The increased stretch force of the sella dura may be a notable etiology of headache in patients with pituitary adenoma.

Pseudoaneurysm at M3 of the middle cerebral artery: Morphological changes on serial radiological examinations.

A 20-year-old man presented with consciousness disturbance and hemiparesis, and computed tomography demonstrated subarachnoid and intracerebral hemorrhage. Angiography on admission demonstrated a slight irregularity of the middle cerebral artery (MCA) branch. Angiography on the 12th day showed a suspicious lesion at M3 of the left MCA. Angiography performed 24 days after the onset disclosed an aneurysm at M3. The aneurysm was trapped and resected after superficial temporal artery-MCA bypass. Pathological examinations revealed that this distal aneurysm was a pseudoaneurysm without vascular components in its dome. Although a lesion that may cause subarachnoid or intracerebral hemorrhage was not detected on the initial angiography, repeated examinations revealed the atypical vascular lesion in distal MCA.

Effectiveness of modified dural incision to preserve the patency of the occipital sinus in foramen magnum decompression for a patient with Chiari malformation type I.

BACKGROUND: Foramen magnum decompression (FMD) has been acknowledged as a standard surgical procedure for symptomatic patients with Chiari malformation type I (CM-I). However, even if dural incision is necessary during FMD, the procedure of cutting off the occipital sinus has not been regarded as a safe option. CASE DESCRIPTION: A 27-year-old woman with intractable occipital headache was diagnosed with CM-I without syringomyelia. Preoperative examination revealed a large oblique occipital sinus on her right side. During the first FMD, the dura mater was not incised to preserve the occipital sinus. However, her headache was not relieved with painkillers and cerebellar tonsillar ectopia remained. During the second FMD, two dural incisions were made, while preserving the occipital sinus patency. The dural patch was made using an autologous fascia for both dural incisions. Postoperatively, headache was completely resolved immediately, and cerebellar tonsil was elevated without any complication. CONCLUSION: This dural incision, which is a modification of the method introduced by Pritz, would be a useful FMD option for patients of CM-I with dominant occipital sinus, which would lead to the serious neurological sequelae if the sinus flow is disturbed.