Pseudotumor cerebri and lung cancer-associated jugular vein thrombosis: Role of anatomical variations of torcular herophili.

A 71-year-old male appeared at the facility complaining of disturbance of consciousness and bilateral papilledema. The laboratory test revealed anemia and coagulation abnormality. A physical examination and magnetic resonance imaging (MRI) of the brain with and without gadolinium showed no abnormalities. A lumbar puncture showed a high pressure, but a normal cerebrospinal fluid (CSF) cell count. Cerebral angiography showed no morphological abnormalities, but it revealed an asymmetric right dominant type of confluence of the sinuses with the partially-communicating left transverse sinus in the late phase. Furthermore, there was a delay in the cerebral circulation time (CCT). Subsequently, venography and ultrasonography revealed right internal jugular vein thrombosis associated with lung cancer. The patient recovered from the disturbance of consciousness immediately after an emergency ventriculoperitoneal shunt and anticoagulation therapy. This case was diagnosed as secondary pseudotumor cerebri (PTC). In order to facilitate the early detection of secondary PTC, it is important to take note of symptoms of intracranial hypertension with no remarkable intracranial lesions and to consider the possibility of PTC, especially in the patients with high risk factors for coagulopathy including lung cancer.

Apparently asymptomatic arachnoid cyst: postoperative improvement of subtle neuropsychological impediment -case report-.

A 13-year-old right-handed boy sustained minor head trauma in a traffic accident. Computed tomography of the head showed no injuries, but revealed an arachnoid cyst in the left middle fossa. Single photon emission computed tomography revealed relatively decreased cerebral blood flow (CBF) in the left frontal and temporal lobes compared with the contralateral regions. The Wechsler Intelligence Scale for Children-Revised (WISC-R) test showed full scale intelligence quotient (IQ) was normal, but also a discrepancy between verbal IQ and performance IQ. Cyst-peritoneal shunting was performed. Postoperatively, laterality of the CBF in the frontal and temporal lobes was resolved and the verbal IQ/performance IQ discrepancy was normalized. In this case, although the WISC-R score was apparently within normal limits, latent regional ischemia induced by compression due to the arachnoid cyst may have caused neuropsychological dysfunction. CBF study and neuropsychological evaluation by the WISC-R may be useful for selecting patients with apparently asymptomatic arachnoid cysts for surgery.

Acquired hemophilia first manifesting as life-threatening intracranial hemorrhage: case report.

A 74-year-old man presented with life-threatening intracranial hemorrhage and prolonged activated partial thromboplastin time (APTT). The massive subdural hematoma was removed, but multiple intracranial hemorrhages occurred despite the administration of factor VIII and factor IX concentrates. Subdural hematoma, intracerebral hemorrhage in the left temporal lobe, and thalamic hemorrhage subsequently occurred with further prolongation of APTT. He died of enlargement of the thalamic hemorrhage. Acquired hemophilia was diagnosed caused by factor VIII inhibitor. Acquired hemophilia may cause life-threatening hemorrhage, and should be considered in patients with intracranial hemorrhages associated with unexplained prolongation of APTT.

Lumbosacral subdural hematoma. Case report.

An 18-year-old man presented with a rare spinal subdural hematoma (SSH) manifesting as headache, which developed following diving into the sea the day before. Computed tomography of the head revealed no abnormality. His headache persisted followed by neck stiffness and mild lumbago. He came to see us 6 days after the first visit. He underwent lumbar puncture to eliminate the possibility of meningitis. The cerebrospinal fluid showed xanthochromia. Cerebral angiography showed no abnormality. Magnetic resonance imaging of the spine revealed lumbosacral subdural hematoma. The hematoma and his symptoms regressed spontaneously during several weeks of conservative treatment. A sharp increase in intraabdominal and/or intrathoracic pressures following diving may have caused the bleeding. Headache may be an initial symptom associated with subarachnoid hemorrhage concomitant with SSH. Delayed progression of lumbosacral SSH must be considered if the patient complains of lumbago following minor trauma.

Cerebral infarction following pituitary apoplexy--case report.

A 29-year-old man presented with lethargy, headache, high fever, and visual disturbance. Neurological examination showed mydriatic pupil, ptosis, diminished light reflex, and ophthalmoplegia on the left. Magnetic resonance (MR) imaging showed the typical findings of pituitary apoplexy, and cerebral angiography disclosed mild narrowing of the A1 segment of the left anterior cerebral artery (ACA). Transsphenoidal tumor resection was performed. Transient severe right hemiparesis occurred directly after the operation. Computed tomography demonstrated cerebral infarction in the territory of the left Heubner's and medial lenticulostriate arteries. Pituitary apoplexy followed by cerebral infarction is very rare. Vasospasm of the perforating arteries of the ACA probably caused the cerebral infarction. Subarachnoid blood or vasoactive agents released from the tumor were the most likely cause of the vasospasm. MR imaging findings of contrast enhancement around the vessels may indicate reactive processes around the vessels.

Intraoperative angiographic assessment of graft patency during extracranial-intracranial bypass procedures.

The use of intraoperative angiography to monitor graft patency was retrospectively reviewed in extracranial-intracranial bypass procedures. Forty-two patients underwent 43 extracranial-intracranial bypass procedures with the use of intraoperative angiography. Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed in 41 patients (42 procedures) with ischemic cerebrovascular diseases, and vertebral artery-MCA bypass using radial artery graft for intentional ligation of the common carotid artery in one patient with nasopharyngeal carcinoma. Intraoperative angiography provided high-quality subtraction images in every case. There were no complications due to angiography. Graft occlusion was observed intraoperatively in three cases, but an additional procedure reopened the occluded graft in all three cases. Graft patency rate was 100% after surgery. Outcome was excellent in 40 patients and good in one patient who underwent STA-MCA bypass. Intraoperative angiography provides useful information regarding graft patency during bypass surgery. Intraoperative assessment prior to wound closure allows for the recognition and correction of technical failure and decreases the risk of postoperative complications.

Intraoperative angiography evaluation of the microsurgical clipping of unruptured cerebral aneurysms.

Intraoperative angiography evaluation of the clippings of cerebral aneurysms was investigated in a series of 38 consecutive patients with unruptured cerebral aneurysms to determine any favorable impact on the outcome. Unexpected findings including major arterial occlusion or residual aneurysm were identified. Specific variables such as the size and site of aneurysm were analyzed to determine the impact on clinical outcome and the incidence of clip modification. There were 11 large and 27 small aneurysms in this series. Mortality and permanent morbidity after microsurgical clipping were 0.0% and 2.6%, respectively. Unexpected angiographic findings necessitating clip repositioning consisted of residual aneurysm in two cases and distal branch occlusion or parent vessel stenosis in four. The need for clip modification was significantly higher for large than for small aneurysms (p = 0.007), and the rate of clip adjustment increased with increasing aneurysm size (p = 0.008). Intraoperative assessment prior to wound closure allows for the recognition and correction of defects and decreases the risk of postoperative complications. Intraoperative angiography may become important in the microsurgical clipping of unruptured cerebral aneurysms, especially large aneurysms.