Use of a stent-retriever for treatment of iatrogenic vasospasm secondary to mechanical thrombectomy.

The treatment strategy for iatrogenic intracranial vasospasm has not been established. We reported a rare case of stent-retriever use for the treatment of iatrogenic vasospasm after mechanical thrombectomy. The patient presented acute ischemic stroke due to the occlusion of the left middle cerebral artery (MCA). The patient underwent a successfully mechanical thrombectomy, however, severe stenosis was visualized in MCA, which was considered to be an iatrogenic mechanical vasospasm. This vasospasm was successfully treated with the Solitaire stent device, and the patient recovered from ischemic symptoms. A stent-retriever is a safe and effective treatment for iatrogenic vasospasm after mechanical thrombectomy.

[Consideration of the Mechanism for Anterior Condylar Confluent Dural AVF Diagnosed with Neck Pain].

OBJECTIVE: Anterior condylar confluent dural arteriovenous fistula(ACC-dAVF)constitutes 3.7% of the total dAVF cases reported and has been regarded as a rare disease in the past. However, encounters with this disease are increasing due to MRI and awareness of this condition. The symptoms of this disease have been reported as tinnitus(75%), ocular symptoms(31%), sublingual nerve palsy(12%), spinal cord symptoms(11%), and intracranial bleeding(5%). Here, we report our identification of a case of ACC-dAVF, which is different from conventional reports, and the associated findings. CASE PRESENTATIONS: We experienced a series of 3 cases of ACC-dAVF with the chief complaint of neck pain. The symptoms in all three patients disappeared after transvenous embolization. Based on the pathophysiology of cervical pain, we presumed that the blood flow dynamics of the odontoid arcade was involved. As expected, after the blood flow near the transverse ligament of the atlas was normalized the symptoms disappeared. CONCLUSION: We could not find previous reports of ACC-dAVF where the main symptom was cervical pain. We report the possibility of a mechanism of dAVF different from those reported previously.

Prognosis for severe traumatic brain injury patients treated with bilateral decompressive craniectomy.

PURPOSE: Decompressive craniectomy for traumatic brain injury patients has been shown to reduce intracranial hypertension, while it often results in increased brain edema and/or contralateral space-occupied hematoma. The purpose of this study was to determine the prognosis of bilateral decompressive craniectomy in severe head injury patients with the development of either bilateral or contralateral lesions after ipsilateral decompressive craniectomy. METHODS: Twelve patients underwent bilateral decompressive craniectomy among 217 individuals who had been treated with decompressive craniectomy with dural expansion from September 1995 to August 2006. The following patient data were retrospectively collected: age, neurological status at admission, time between injury and surgical decompression, time between first and second decompression, laboratory and physiological data collected in the intensive care unit, and outcome according to the Glasgow Outcome Scale. RESULTS: Patient outcomes fell into the following categories: good recovery (three patients); mild disability (one patient); severe disability (two patients); persistent vegetative state (one patient); and death (five patients). Patients with good outcomes were younger and had better pupil reactions and neurological statuses on admission. Other factors existing prior to the operation did not directly correlate with outcome. At 24 h post-surgery, the average intercranial pressure (ICP), cerebral perfusion pressure (CPP), glucose level, and lactate level in patients with poor outcomes differed significantly from those of patients with a good prognosis. CONCLUSION: Head injury patients with either bilateral or contralateral lesions have poor prognosis. However, bilateral decompressive craniectomy may be a favorable treatment in certain younger patients with reactive pupils, whose ICP and CPP values are stabilized 24 h post-surgery.

[A case of traumatic middle meningeal arteriovenous fistula on the side of the head opposite to the injured side].

A rare case of a traumatic middle meningeal arteriovenous fistula on the side of the head opposite to the injured side was reported. A 21-year-old man was admitted to our hospital after a traffic accident in which the right side of his head was hit. CT scans and MR images on admission showed a right temporal bone fracture, traumatic subarachnoid hemorrhage, and a left frontal lobe contusion. Three months after the head injury, he complained of tinnitus and exophthalmos. One year after the head injury, left external carotid angiograms showed a dural arteriovenous fistula fed by the left dilated middle meningeal artery and draining into the middle meningeal vein. Early filling of the sphenoparietal sinus, cavernous sinus, superior ophthalmic vein, and the cortical vein were also detected. Transarterial embolization of the left middle meningeal fistula was performed, resulting in the disappearance of the lesion. The postoperative course was uneventful.

[A case of meningitis complicated by brainstem infarction].

A rare case of meningitis complicated by brainstem infarction is reported. A 64-year-old previously healthy female was admitted to our hospital because of a 1-week history of fever and headache. Cefdinir was orally administered for several days before admission. Analysis of cerebrospinal fluid (CSF) on admission showed a white blood cell (WBC) count of 9,013 cells/ micro/(97% polynuclear cells), a protein level of 212.8 mg/d/, and a glucose level of 3 mg/d/. CSF culture was negative for bacteria, including tubercle bacilli, and fungi. A brain computed tomography (CT) scan on admission showed acute hydrocephalus. Six hours after admission the patient developed tetraplegia. Diffusion-weighted magnetic resonance (MR) images on day 2 revealed elevated diffusion coefficients with high signal intensity in the pons and the medulla oblongata. MR angiography demonstrated a narrowing change of the cerebral arteries. Followup MR angiography two months after admission showed normalization of the cerebral arteries. The patient remained tetraplegic at eight months after admission. We speculated that brainstem infarction in our case might have been caused by vascultis or brain edema.

Clinical and radiological findings and surgical management of ruptured aneurysms at the non-branching sites of the internal carotid artery.

Ruptured aneurysms located at the non-branching sites of the internal carotid artery, including blister-like aneurysms, possess unique clinical and technical features. This report presents nine consecutively managed patients with these types of aneurysm, detailing the clinical and radiological characteristics and surgical outcomes. The initial angiography identified aneurysmal lesions in six of the nine patients with two of these patients requiring additional three-dimensional (3D) angiography. In three patients the aneurysm was only diagnosed on second or third angiograms. Six patients had blister-like aneurysms, and two had saccular-shaped aneurysms diagnosed on the basis of intraoperative findings. One patient with a saccular aneurysm died without surgery. Eight patients underwent a microsurgical procedure: clipping in five, clipping on wrapping with suturing in two and trapping in one. Three of these eight patients had an intraoperative rupture. A favorable outcome was obtained in seven patients. Advances in microsurgical techniques to prevent premature rupture and 3D radiological diagnosis with careful pre-operative consideration of the surgical strategies will be required for a further improvement of the clinical outcome.

Clinical features and surgical outcomes of ruptured distal anterior cerebral artery aneurysms in 20 consecutively managed patients.

Optimal surgical management of ruptured aneurysms of the distal anterior cerebral artery continues to provide unique technical challenges. This study presents 20 consecutively managed such patients, with special attention given to the clinical and radiological characteristics, as well as the surgical outcomes. Intracerebral hematoma was seen in 11 of the 20 patients, and intraventricular hemorrhage occurred in 4 (20%). Angiography revealed that 9 (45%) patients had multiple aneurysms. Three patients (15%) had "mirror" distal anterior cerebral arterial aneurysms on the contralateral side. Eleven patients (55%) had aneurysms located at the supracallosal portion of the anterior cerebral artery, while 9 patients (45%) had aneurysms located below the genu of the corpus callosum. The mean aneurysmal diameter was 3.85 mm; 18 aneurysms (90%) were less than 6 mm in diameter. Eighteen patients (90%) underwent a microsurgical procedure; 2 (10%) underwent endovascular coiling due to poor clinical grade. A favorable outcome was achieved in 14 (70%) patients. Advances in microsurgical techniques will be required to further improve clinical outcome.

[Case of venous angioma with chronic encapsulated hematoma].

We would like to report a rare case of a venous angioma with a chronic encapsulated hematoma, in a 31-year-old woman who was admitted to our hospital in November, 2005. Her neurological examination was noted to be normal. A CT was performed which showed an isodense mass in the left cerebellar hemisphere. This finding was confirmed on MR imaging, which showed a hyperintense mass on T1-weighted imaging, and a hypo to isointense area on T2-weighted images. T1-weighted images with Gd-DTPA enhancement revealed a dilated vein and, as a result, an angiogram was obtained. The venous phase demonstrated medullary veins converging on a central vein, which is usually known as a caput medusae. Follow up T1-weighted images with Gd-DTPA enhancement showed peripheral ring enhancement and expansion of the capsulated hematoma. Total removal of the hematoma and its capsule was performed in July, 2006. The hematoma was seen both inside and outside the tough capsule. A histological examination revealed that the capsule consisted of an outer collagenous layer and an inner granulated layer with deposits of hemosiderin. The hemorrhage rate of a venous angioma has been reported as between 0.22-0.61% per year. We thought that the initial small hemorrhage from the venous angioma resulted in the development of an encapsulated hematoma, and the total hematoma had expanded not only inside due to the hemorrhage of the capsule, but also outside because of the venous angioma.