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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.
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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.
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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.
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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.
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INTRODUCTION: Traumatic retroclival epidural hematoma is rare. It is more common in pediatrics than in adults. Although it has been known that these cases are frequently associated with abducens nerve palsy, internal carotid artery stenosis is rarely found with those hematomas. CASE REPORT: An 8-year-old girl was transferred to our hospital following a traffic accident. She had clear consciousness with right abducens nerve palsy. Computed tomography revealed the left side of both retroclival hematoma without clival fracture and subarachnoid hemorrhage at the Sylvian fissure. She also had a fracture of left femoral neck and ipsilateral lung contusion. Magnetic resonance imaging revealed a retroclival hematoma located in the epidural space and severe stenosis of left internal carotid artery (ICA) from the cavernous to supraclinoid portion without evidence of brain contusion. She was managed conservatively, and her right abducens nerve palsy recovered completely without deterioration of other neurological findings. Neuroradiological findings suggested this ICA stenosis as traumatic dissection. She was discharged home 2 months after the traffic accident. CONCLUSION: Retroclival epidural hematoma without clival fracture associated with ipsilateral ICA stenosis is extremely rare. Although the exact mechanism of the ICA stenosis remains unclear, cerebral vascular events should be considered in the cases with traumatic retroclival hematoma.
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Estenosis Carotídea , Hematoma Epidural Craneal , Hematoma Espinal Epidural , Adulto , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Niño , Femenino , Hematoma Epidural Craneal/complicaciones , Hematoma Epidural Craneal/etiología , Hematoma Espinal Epidural/complicaciones , Humanos , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Pediatric meningiomas are rare, and only a few cases attributed to trauma and characterized by development at the site of bone fracture have been reported. Both pediatric and traumatic meningiomas have aggressive characteristics. OBSERVATIONS: An 11-year-old boy who sustained a head injury resulting from a left frontal skull fracture 8 years previously experienced a convulsive attack. Imaging revealed a meningioma in the left frontal convexity. Total removal of the tumor with a hyperostotic section was successfully achieved. Intraoperative investigation showed tumor invasion into the adjacent frontal cortex. Histologically, the surgical specimen revealed a transitional meningioma with brain invasion and a small cluster of rhabdoid cells. This led to a final pathological diagnosis of an atypical meningioma with rhabdoid features. The postoperative course was uneventful, and no recurrence of the tumor was found after 2 years without adjuvant therapy. LESSONS: This is the first report of a pediatric meningioma with rhabdoid features occurring at the site of a skull fracture. Meningiomas that contain rhabdoid cells without malignant features are not considered to be as aggressive as rhabdoid meningiomas. However, the clinical course must be carefully observed for possible long-term tumor recurrence.
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Papillary glioneuronal tumor (PGNT) is a low-grade biphasic neoplasm with astrocytic and neuronal differentiation. This tumor occurs most commonly in the frontal and temporal lobes, close to the ventricles, and rarely in the cerebellum, brainstem, and pineal gland. However, there has been no report of this tumor in the suprasellar region to date. In this paper, we report a case of PGNT in the suprasellar region in a 16-year-old girl. Magnetic resonance imaging (MRI) revealed a cystic tumor with calcification that progressed from the anterior skull base to the suprasellar and temporal regions. Preoperatively distinguishing this tumor from craniopharyngioma was difficult because of the patient's age, localization of the tumor, and neuroimaging results. This case showed a backward shift of the chiasma, which is observed in only 4.7% of craniopharyngioma, as well as normal endocrine findings. Endocrinological examination and an MRI evaluation of the chiasmal shift may be useful for discrimination.
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Optic nerve avulsion is an exceedingly rare condition. Here, we describe a case of optic nerve avulsion in a 74-year-old man with temporal hemianopia in the contralateral eye after a bear attack. Magnetic resonance imaging (MRI) revealed separation of the optic nerve distal to the optic chiasma, whereas the high signal in diffusion-weighted imaging suggested nerve injury from the left side of the optic chiasma to the left optic tract. MRI slices parallel to the optic chiasma were obtained and used for evaluating the site of optic nerve avulsion and nerve injury, which were responsible for temporal hemianopia in the contralateral eye.
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Animales Salvajes , Lesiones por Aplastamiento/diagnóstico por imagen , Traumatismos Faciales/diagnóstico por imagen , Imagen por Resonancia Magnética , Quiasma Óptico/diagnóstico por imagen , Quiasma Óptico/lesiones , Traumatismos del Nervio Óptico/diagnóstico por imagen , Anciano , Animales , Lesiones por Aplastamiento/cirugía , Diagnóstico Diferencial , Imagen de Difusión por Resonancia Magnética , Hemianopsia/diagnóstico por imagen , Hemianopsia/etiología , Humanos , Masculino , Quiasma Óptico/cirugía , Traumatismos del Nervio Óptico/cirugía , UrsidaeRESUMEN
BACKGROUND: A duplicated middle cerebral artery arises from the internal carotid artery and supplies blood to the middle cerebral artery territory. A duplicated middle cerebral artery is sometimes associated with an intracranial aneurysm. Most aneurysms associated with duplicated middle cerebral artery are located at the origin of the duplicated middle cerebral artery. An aneurysm located at the distal middle cerebral artery is not common. CASE PRESENTATION: We encountered a 62-year-old Asian man with duplicated middle cerebral artery associated with aneurysms at the M1/M2 junction of the duplicated middle cerebral artery and top of the internal carotid artery. CONCLUSIONS: In cases of duplicated middle cerebral artery, association with a distal aneurysm on the duplicated middle cerebral artery is rare. However, the aneurysm may be formed on the thicker middle cerebral artery due to hemodynamic stress.
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Aneurisma Intracraneal , Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/patología , Angiografía Cerebral , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Arteria Cerebral Media/diagnóstico por imagen , Arteria Cerebral Media/patologíaRESUMEN
Background In cases of subarachnoid hemorrhage due to aneurysm rupture, the administration of an anticoagulant or antiplatelet agent involves the risk of rebleeding from the aneurysm. There is a possibility of inducing thromboembolic events during the endovascular embolization of ruptured cerebral aneurysms. Patients and methods From April 2006 to March 2017, we treated a total of 70 patients with ruptured cerebral aneurysms with an endovascular technique. Among them, five patients (7.1%) showed intra-arterial thrombus formation. The aneurysms were located at the anterior communicating artery and basilar artery in two patients each, and on the internal carotid artery at the bifurcation of the anterior choroidal artery (AChoA) in one. In these patients, the clinical course, radiological findings, and management were retrospectively reviewed. Results Thrombus formation was observed in the posterior cerebral artery, anterior cerebral artery (A2), AChoA, and middle cerebral artery. The timing of thrombus formation was during coil delivery in four cases, and guiding catheter advancement in one. As for thrombus management, for all patients, administrations of heparin and antiplatelet agents were performed. For four patients, urokinase injection into the affected arteries was added after the completion of embolization. Cerebral infarction was postoperatively identified in two patients, but no hemorrhage was noted. Conclusion Administrations of heparin and antiplatelet drugs should be performed appropriately during procedures, and close observation of the arterial condition on angiography is necessary. Once thromboembolism occurs during the endovascular embolization of ruptured cerebral aneurysms, adequate heparinization, and antiplatelet therapy should first be performed.
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Aneurisma Roto/cirugía , Embolización Terapéutica/métodos , Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/cirugía , Trombosis Intracraneal/etiología , Complicaciones Posoperatorias/etiología , Hemorragia Subaracnoidea/etiología , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma Roto/diagnóstico por imagen , Anticoagulantes/administración & dosificación , Angiografía Cerebral , Femenino , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Trombosis Intracraneal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo , Hemorragia Subaracnoidea/diagnóstico por imagen , Resultado del TratamientoRESUMEN
A 28-year-old man without a significant medical history visited our hospital complaining of a headache. Computed tomography (CT) demonstrated thick, calcified vertebral artery (VA) and basilar artery (BA), despite the patient being young. Magnetic resonance angiography demonstrated the absence of the left internal carotid artery (ICA). The right ICA, the bilateral VA, and the BA were well developed and dolichoectatic. CT revealed the absence of the carotid canal on the left side. The condition was diagnosed as congenital agenesis of the left ICA with dolichoectatic changes in 3 other arteries. In a young patient with thick, calcified intracranial arteries, close examination is necessary, because vascular anomalies such as ICA agenesis may exist.
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Arteria Basilar , Arteria Carótida Interna/anomalías , Malformaciones Vasculares/complicaciones , Arteria Vertebral , Insuficiencia Vertebrobasilar/etiología , Adulto , Arteria Basilar/diagnóstico por imagen , Arteria Carótida Interna/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Humanos , Angiografía por Resonancia Magnética , Masculino , Malformaciones Vasculares/diagnóstico por imagen , Arteria Vertebral/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico por imagenRESUMEN
Background and Objective Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is a procedure to reconstruct cerebral blood flow in the MCA territory. In some cases, the STA wall is thickened and the size discrepancy between STA and MCA is apparent. In such a situation, STA-MCA bypass is challenging. We present two patients who underwent STA-MCA bypass using STA in which a thickened intima was removed. We discuss the usefulness of this rescue technique. Patients and Results A patient with an atherosclerotic MCA occlusion and another with an occluded internal carotid artery are included. Endarterectomy of STA was performed before or during anastomosis, and the intima-resected STA was anastomosed to MCA. In both cases, the STA was thick and hard, and it was difficult to anastomose the STA as it was to the MCA. Patency of the bypass was confirmed by postoperative angiography. Conclusion Endarterectomy of a thickened STA might be an effective rescue technique in cases with severely atherosclerotic STA in STA-MCA bypass.
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Revascularización Cerebral/métodos , Endarterectomía/métodos , Infarto de la Arteria Cerebral Media/cirugía , Arteria Cerebral Media/cirugía , Arterias Temporales/cirugía , Anciano , Anastomosis Quirúrgica/métodos , Circulación Cerebrovascular/fisiología , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoAsunto(s)
Revascularización Cerebral/métodos , Arteria Cerebral Media/diagnóstico por imagen , Arteria Cerebral Media/cirugía , Arterias Temporales/diagnóstico por imagen , Arterias Temporales/cirugía , Ultrasonografía Doppler/métodos , Adulto , Anciano , Femenino , Humanos , Masculino , Procedimientos Neuroquirúrgicos , Adulto JovenRESUMEN
Objective The prevalence of the non-convulsive type of late seizure after stroke is unknown. The aim of the present study was to clarify the characteristics of late seizure in clinical practice, mainly focusing on the prevalence of non-convulsive seizure. Methods A total of 178 consecutive patients who were admitted and diagnosed with late seizure after stroke were retrospectively enrolled, and the data of 127 patients for whom the complete seizure was observed by a bystander were analyzed. Clinical information was obtained from the medical records and nursing notes. Results A non-convulsive seizure was observed in 37 patients (29%). A focal seizure and its secondary generalization accounted for 79% of the seizure types. Status epilepticus was observed in 60 patients (47%), including 11 patients (9%) without convulsion. The patients with non-convulsive seizures were significantly younger than those with convulsive seizures, but there were no other significant differences between the two groups with respect to sex, classification or the lesion of stroke. Conclusion There was a high rate of non-convulsive seizures in patients with late seizure after stroke. A non-convulsive seizure may be caused by any type or location of preceding stroke. More attention is needed in the differential diagnosis of neurological deterioration after stroke.
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Convulsiones/epidemiología , Convulsiones/fisiopatología , Accidente Cerebrovascular/epidemiología , Anciano , Anciano de 80 o más Años , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios RetrospectivosRESUMEN
Background Intracranial pseudoaneurysm formation due to a ruptured non-traumatic aneurysm is extremely rare. We describe the radiological findings and management of pseudoaneurysms due to ruptured cerebral aneurysms in our case series and previously reported cases. Patients and methods Four additional and 20 reported patients presenting with subarachnoid hemorrhage (SAH) are included. Radiological findings and clinical features of these patients were reviewed. Results In our series, three-dimensional computed tomographic angiography (3D-CTA) and/or angiography showed an irregular- or snowman-shaped cavity extending from the parent artery. The radiological examination additionally revealed delayed filling and retention of contrast medium. These findings were the same as previously reported cases. One patient underwent direct clipping of the true aneurysm. For the other three patients with aneurysms at the basilar and anterior communicating arteries, the true portion of the aneurysm was embolized with platinum coils. During the procedures, care was taken not to insert the coils into the distal pseudoaneurysm portion to prevent rupture. The review of 24 cases revealed that the location of the aneurysms was most frequent in the anterior communicating artery (41.7%), and 86.7% of patients were in a severe stage of SAH (>Grade 3 in WFNS or Hunt & Kosnik grading) implying abundant SAH. Conclusions Pseudoaneurysm formation in SAH after non-traumatic aneurysm rupture is rare. However, in cases with an irregular-shaped aneurysm cavity, pseudoaneurysm formation should be taken into consideration.
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Aneurisma Falso/etiología , Aneurisma Roto/complicaciones , Aneurisma Intracraneal/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/cirugía , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Angiografía por Tomografía Computarizada , Bases de Datos Bibliográficas/estadística & datos numéricos , Humanos , Imagenología Tridimensional , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Persona de Mediana EdadRESUMEN
BACKGROUND: The internal carotid artery (ICA) usually runs posterolaterally to the external carotid artery (ECA), but occasionally we encounter the twisted carotid bifurcation, a variant in which the ICA courses medially to the ECA during carotid endarterectomy (CEA). Prediction of this anomaly in the preoperative evaluation is mandatory, although descriptions in the literature are limited. We reviewed the clinical features of patients who underwent CEA and analyzed preoperative cerebral angiography, especially the anteroposterior (AP) view to determine whether it could be a predictive modality. METHODS: In 58 consecutive CEA cases, we simply classified them into three groups; type 1 (the ICA runs laterally and the ECA runs medially), type 2 (the ICA and ECA run to overlap each other), and type 3 (the ICA runs medially and the ECA runs laterally), based on the findings of AP view of cerebral angiography. We compared the clinical features and intraoperative findings of these groups. RESULTS: Of 58 cases, types 1-3 were 24, 30, and four cases, respectively. Twisted carotid bifurcations were recognized in seven cases (12.4 %), including three cases in type 2 and four in type 3, and all twisted cases were found on the right side. Twisted carotids and right-sided lesion were significantly frequent in type 3, but no statistical differences of coexisting diseases were recognized among the three groups. CEAs of twisted carotid bifurcations were performed successfully with correction of the carotid position in three and as it was in four cases. CONCLUSIONS: Twisted carotid bifurcations were observed during operation in 10 % in type 2 and 100 % in type 3. CEA of twisted carotid bifurcations can be performed safely with or without correction of the carotid position. AP view of cerebral angiography could be useful for preoperative evaluation.
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Arteria Carótida Externa/diagnóstico por imagen , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Angiografía Cerebral , Endarterectomía Carotidea , Anciano , Arteria Carótida Externa/cirugía , Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Hypertension is the prime risk factor for stroke, and primary aldosteronism (PA) is the most common cause of secondary hypertension. The prevalence of PA in stroke patients has never been reported. The aim of this study was to elucidate the prevalence of PA. METHODS: A total of 427 consecutive patients with acute stroke were prospectively enrolled for this study. The screening tests were performed at the initial visit and a week after admission by measuring plasma aldosterone concentration and plasma renin activity. The rapid adrenocorticotropic hormone (ACTH) test was performed as the confirmatory test when both screening tests were positive. The primary endpoint was a final diagnosis of PA. RESULTS: The sensitivity of the dual screening system for the diagnosis of PA was 88.2 %, and PA was finally diagnosed in 4.0 % of acute stroke patients and in 4.9 % of stroke patients with a history of hypertension. Patients with PA were less likely to be male and have diabetes, and they had higher blood pressure at the initial visit, lower potassium concentration, and more intracerebral hemorrhage. The rapid ACTH test was performed safely even in acute stroke patients. CONCLUSIONS: The prevalence of PA is not low among acute stroke patients. Efficient screening of PA should be performed particularly for patients with risk factors. TRIAL REGISTRATION: UMIN-CTR; UMIN000011021 . Trial registration date: June 23, 2013 (retrospectively registered).
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Hospitalización , Hiperaldosteronismo/epidemiología , Hipertensión/epidemiología , Accidente Cerebrovascular/epidemiología , Anciano , Aldosterona/sangre , Comorbilidad , Femenino , Humanos , Hiperaldosteronismo/sangre , Hiperaldosteronismo/diagnóstico , Japón/epidemiología , Masculino , Pruebas de Función Adreno-Hipofisaria , Prevalencia , Renina/sangre , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/sangreRESUMEN
We report a patient with a traumatic middle cerebral artery dissection, which showed hyperperfusion in the territory supplied by the left middle cerebral artery. A 45-year-old man experienced speech disturbance and motor weakness in his right hemibody on the day following mild head trauma. His symptoms worsened on the fourth day. Magnetic resonance imaging showed narrowing in the left M1 portion of the middle cerebral artery. Angiography showed narrowing and dilatation in the left middle cerebral artery trunk. The lesion was diagnosed as a dissection of the middle cerebral artery. Arterial spin labelling of magnetic resonance imaging and single photon emission computed tomography showed increased cerebral blood flow in the left temporal region compared with the right. The patient was treated conservatively and the symptoms gradually improved. The hyperperfusion observed on arterial spin labelling and single photon emission computed tomography gradually improved and disappeared on the 25th day. This is the first reported case of traumatic middle cerebral artery dissection, which showed post-ischaemic hyperperfusion in the territory of the affected artery. To detect hyperperfusion in the brain, arterial spin labelling is a useful technique.
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Disección de la Arteria Carótida Interna/diagnóstico por imagen , Disección de la Arteria Carótida Interna/etiología , Revascularización Cerebral/efectos adversos , Isquemia/cirugía , Imagen por Resonancia Magnética , Humanos , Imagenología Tridimensional , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Marcadores de Spin , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
BACKGROUND: Hemorrhage from an intracranial tumor is well known but uncommon. In cases of subarachnoid hemorrhage, aneurysm rupture is a main cause. CASE DESCRIPTION: A 64-year-old woman presented with sudden-onset motor aphasia. Computed tomography revealed subarachnoid hemorrhage, and intracerebral hemorrhage in the left temporal lobe. From the findings of pre-enhancement computed tomography, hemorrhage from a left middle cerebral artery aneurysm was initially suspected. Further radiological examinations demonstrated an enhanced mass with dural attachment in the left temporal region, but no vascular abnormality. Emergency craniotomy was performed, and the tumor and intracerebral hematoma were removed. The hemorrhage from fragile tumor vessels may destroy the tumor tissue and spread into the temporal lobe and subarachnoid space. Pathological examination of the tumor yielded findings consistent with hemangiopericytoma. Post-operatively, the patient was treated to prevent vasospasm. CONCLUSION: Although an intracranial tumor including hemangiopericytoma uncommonly causes subarachnoid hemorrhage, it should be taken into consideration as a source of intracranial hemorrhage.