Delayed Diagnosis of Spinal Cord Injury in a Patient With Intellectual Disability: A Case Report.

Spinal cord injury (SCI) can cause neurogenic shock accompanied by bradycardia and hypotension. If no preceding traumatic episodes are apparent and the neurological examination is complicated by the patient's intellectual disability, SCI is likely to be overlooked. A 63-year-old man with intellectual disability presented to our hospital. The patient had fallen on the floor; however, no apparent head or neck trauma was observed. The patient returned home after confirming the absence of intracranial hematoma on computed tomography. However, the patient was re-admitted because of hypotension and bradycardia, and sick sinus syndrome was suspected. As the manifestations were motor weakness in the extremities and urinary retention, screening spinal magnetic resonance imaging revealed cervical cord injury and spondylosis. Cervical SCI related to a fall was suspected. Cervical decompression surgery and rehabilitation therapy contributed to the improved patient status. Herein, we report a case of intellectual disability in which SCI was initially overlooked. No severe preceding traumatic episode or intellectual disability of the patient could have led to overlooking SCI in our case. Clinicians should be cautious about this rare condition.

Treatment of ruptured cerebral aneurysms - clip and coil, not clip versus coil.

BACKGROUND AND AIMS: Recent advances in neurosurgery and interventional neuroradiology have brought us a new aspect in the treatment of cerebral aneurysms. The present single-surgeon series provides a balanced overview of the treatment of ruptured aneurysms in surgical clipping and coil embolization. CLINICAL MATERIALS AND METHODS: One hundred consecutive patients with ruptured cerebral aneurysms underwent surgical clipping or endovascular coil embolization between January 2005 and December 2007. All patients underwent clipping or coil embolization of at least one ruptured cerebral aneurysm by a single neurosurgeon (YK) who performed both the surgical clipping and endovascular coiling. RESULTS: Of the 48 surgically treated patients, 37 (77.1%) achieved a favorable outcome. Of the 52 patients who underwent endovascular embolization, 37 (71.2%) achieved a favorable outcome. No significant difference was observed regarding the proportion of favorable outcomes between the two treatment modalities. Five patients (9.6%) who underwent endovascular embolization needed re-treatments, while no re-treatment was necessary in the surgically treated patients. The rates of symptomatic vasospasm and shunt dependent hydrocephalus were 18.8% and 14.6%, respectively, in the clipped patients, and 19.2% and 21.2%, respectively, in the coiled patients. Endovascular coiling of ruptured aneurysms has a tendency towards a higher risk of developing shunt dependent hydrocephalus. CONCLUSION: A combined microsurgical-endovascular approach can achieve the best outcomes for patients with ruptured cerebral aneurysms. Our findings support the policy of "Clip and Coil, not Clip versus Coil."

Third ventricular chordoid glioma: case report and review of the literature.

BACKGROUND: Chordoid glioma of the third ventricle is a rare type of brain tumor that was recently characterized as a novel tumor entity. We present a case and review of the literature. CASE REPORT: A 49-year-old woman presented with progressive headache, memory impairment and urinary incontinence. MRI showed a large well-circumscribed tumor in the third ventricle. The tumor was partially removed via a trans-lamina terminalis approach. The histologic findings indicated chordoid glioma. Residual tumor was treated by stereotactic radiosurgery and showed no regrowth at 2-year follow-up. CONCLUSIONS: The ideal therapy is total removal of the tumor. However, according to the literature, total removal of the tumor carries a high risk because of its location, and conventional radiation therapy has little effect on the residual tumor. On the other hand, stereotactic radiosurgery appears more promising, and to date, no regrowth has been reported after gamma-knife therapy.

Tissue plasminogen activator levels after single intracisternal injection in patients with subarachnoid hemorrhage.

Tissue plasminogen activator (tPA) levels were investigated in the cisternal fluid of patients with subarachnoid hemorrhage treated with single intracisternal injection of recombinant tPA during radical surgery for ruptured aneurysms. Seven patients received different doses of tPA: two of 400 microg/ml, three of 500 microg/ml, one of 700 microg/ml, and one of 800 microg/ml in a total amount of 20 ml distilled water at pH 7. Cerebrospinal fluid samples were taken directly from the cisternal fluid at 15-minute incubation after injection, immediately after irrigation during surgery, and by lumbar tap 2 days after surgery. Cisternal tPA levels decreased to about 60% of the mean injected doses after 15-minute incubation. Simple linear regression analysis showed these tPA levels after incubation correlated with the initial doses. After copious irrigation with Ringer solution at pH 8, tPA levels decreased rapidly without correlation with the initial doses. After spinal drainage for 2 days, tPA levels further decreased by an order of 10(-4) to 10(-6) from the initial dose. These values were still greater than normal controls. The final values of tPA levels were not related to the initial dose. None of the patients suffered from systemic or wound complications. Cisternal tPA injection with increased doses and irrigation may be beneficial for the selective rapid removal of blood clots with controllable safety.

Pure vasogenic edema caused by cerebral hyperperfusion after superficial temporal artery to middle cerebral artery anastomosis--case report.

A 63-year-old patient presented with cerebral hyperperfusion manifesting as transient aphasia and general tonic convulsions 3 and 4 days after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis. Diffusion-weighted magnetic resonance (MR) imaging revealed a focal low-intensity area at the site of anastomosis in the left temporal lobe, with high apparent diffusion coefficient, together with focal intense increase in cerebral blood flow in the same region. This lesion was considered to be pure vasogenic edema caused by cerebral hyperperfusion. Additional treatment with intravenous drip infusion of free radical scavenger and reduction in blood pressure with nicardipine improved the patient's symptoms and brain edema. The brain edema gradually decreased on MR imaging and completely disappeared at 3 months after bypass surgery. Cerebral hyperperfusion is often encountered after recanalization of occlusive arteries, removal of arteriovenous malformations, and carotid endarterectomy, but may also occur after STA-MCA anastomosis.