Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry.

BACKGROUND: Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear. METHODS: We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT. RESULTS: We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups. CONCLUSIONS: The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.

Clinical Trial of the New Stent Retriever Tron FX for both Proximal and Distal Intracranial Large Vessel Occlusions.

BACKGROUND: In all of randomized controlled trials of mechanical thrombectomy, the target vessels were proximal. Herein we report a clinical trial of the Tron FX stent retriever, including the smallest size of 2/15 mm for distal intracranial large vessel occlusion (LVO). OBJECTIVE: Eligible patients presented within 8 h of onset with proximal or distal LVOs, and the Tron FX 4/20 mm or 2/15 mm were used as the first-line device. METHODS: The primary endpoints were rate of modified Thrombolysis in Cerebral Infarction (mTICI) grade 2a-3 immediately after using Tron FX only, and mortality rate 90 d. We compared the outcomes between sizes 4/20 and 2/15 mm. RESULTS: The clinical trial was conducted in 50 cases, of which 44% presented with distal LVO and 15 cases were treated using only Tron FX 2/15 mm. The overall rate of mTICI grade 2a-3 was 80.0% (75.8% with Tron FX 4/20 mm, and 86.7% with 2/15 mm), and a 90-day modified Rankin Scale ≤ 2 or improvement of National Institute of Health Stroke Scale after thrombectomy ≥ 10 was achieved in 66.7% of cases (61.3% with Tron FX 4/20 mm, and 80.0% with 2/15 mm). The overall 90-day mortality rate was 8.0%, and symptomatic intracranial hemorrhage within 24 h occurred in 2.0% of cases. CONCLUSION: In this clinical trial using the Tron FX, which included the size of 2/15 mm for distal LVO, its efficacy was similar and its safety was superior compared with previous studies.

Microbiome composition comparison in oral and atherosclerotic plaque from patients with and without periodontitis.

There is no conclusive evidence regarding a causal relationship between periodontitis and atherosclerosis. In this study, we examined the microbiome in the oral cavity and atheromatous plaques from atherosclerosis patients with or without periodontitis to investigate the role of oral bacteria in the formation of atheromatous plaques. We chose four patients with and without periodontitis, who had undergone carotid endarterectomy. Bacterial samples were extracted from the tongue surface, from periodontal pocket (during the oral examination), and from the atheromatous plaques (APs). We investigated the general and oral conditions from each patient and performed next-generation sequencing (NGS) analysis for all bacterial samples. There were no significant differences between both groups concerning general conditions. However, the microbiome patterns of the gingival pocket showed differences depending on the absence or presence of periodontitis, while those of the tongue surface were relatively similar. The microbiome pattern of the atheromatous plaques was entirely different from that on the tongue surface and gingival pocket, and oral bacteria were seldom detected. However, the microbiome pattern in atheromatous plaques was different in the presence or absence of periodontitis. These results suggested that oral bacteria did not affect the formation of atheromatous plaques directly.

Clinical features and efficacy of reperfusion therapy in minor ischemic stroke patients with atrial fibrillation.

The efficacy of reperfusion therapy (RT) using intravenous infusion of recombinant tissue plasminogen activator and/or endovascular therapy for minor ischemic stroke (MIS) has not yet been established. The present study aimed to elucidate the clinical features of MIS patients with atrial fibrillation (AF) and examine whether they could be potential candidates for RT. Data of MIS patients, defined as those with a score ≤ 5 on the National Institute of Health Stroke Scale, were extracted from patients admitted to our hospital between 2006 and 2018, and clinical characteristics were compared between the AF and non-AF groups. Thereafter, the impact of RT on outcomes in the AF- group was evaluated using the modified Rankin scale (mRS) score 3 months after onset and compared to that of standard medical therapy (SMT) using propensity score matching (PSM). Of 10,483 stroke patients, 3003 were shortlisted, and 457 AF patients and 2546 non-AF patients were finally selected. Patients in the AF group had more RT (13.3% vs. 5.7%, p < 0.001) than those in the non-AF group. Using PSM, 53 patients each were extracted from the AF-RT and AF-SMT groups. The frequencies of mRS = 0 or 1 for the AF-RT and AF-SMT groups were 69.8% and 64.2% (p = 0.536), respectively, with a significant difference in mRS = 0 (56.5% vs. 34.0%, p = 0.019). The present study found that MIS patients with AF underwent more RT than those without AF and that RT compared favorably with SMT for them; further study is warranted to examine whether these patients could be good candidates for RT.

Efficacy of the Insertion-support Guiding Catheter in Approaching Intracranial or Craniocervical Lesions in Patients with the Difficulty of Extracranial Trans-arterial Access.

Objective: We aimed to investigate the efficacy of the insertion-support guiding catheter (ISGC) for approaching target lesions during endovascular therapy in patients with severe atherosclerotic or tortuous arteries. Case Presentations: The ISGC is an 8 Fr, JB2 shape, stiff-type, short guiding catheter. We used ISGC for 52 patients between April 2007 and March 2018, microcatheters or therapeutic devices were delivered to target lesions via ISGC in 46 (88.4%) of the 52 patients, and none of them developed associated complications. Herein, we present three representative cases. Conclusions: An ISGC is useful for vascular intervention in patients with atherosclerotic or tortuous arteries.

Takotsubo Cardiomyopathy and Neurogenic Pulmonary Edema After Carotid Endarterectomy.

BACKGROUND: Takotsubo cardiomyopathy (TCM) and neurogenic pulmonary edema (NPE) are rare complications of an acute ischemic stroke. In particular, TCM and NPE following carotid endarterectomy (CEA) are extremely rare. In general, TCM- and NPE-associated ischemic strokes are caused by excess catecholamine release after sympathetic nervous stimulation following stroke onset, but the mechanism triggering this stimulation is still unknown. CASE DESCRIPTION: An 88-year-old man underwent left CEA for symptomatic carotid artery stenosis (North American Symptomatic Carotid Endarterectomy Trial, 65%). After the surgery, his respiratory condition rapidly worsened, and chest radiography revealed an infiltrative shadow on both lung fields. Transthoracic echocardiography revealed left ventricular dysfunction, suggesting TCM. Postoperative magnetic resonance imaging revealed a small infarction in the left anterior insular cortex. Eventually, his respiratory and cardiac functions gradually improved. He was finally discharged on his own from the hospital on postoperative day 9. CONCLUSIONS: We described a very rare case of TCM and NPE following CEA. The mechanisms of TCM and NPE involve excess catecholamine release after sympathetic nervous stimulation. Our findings suggest that surgery-associated transient ischemia and reperfusion injury to the left insular cortex stimulate sympathetic nerves.

Excellent Outcomes of Large-Volume Epidural Blood Patch Using an Intravenous Catheter in 15 Consecutive Cases with Cerebrospinal Fluid Leak.

OBJECTIVE: The effects of large-volume epidural blood patch (EBP) remain unclear in patients with cerebrospinal fluid (CSF) leak. We report excellent outcomes from 15 consecutive CSF leak cases that underwent a large-volume EBP using an intravenous catheter from a single lumbar entry point, together with outcomes from 4 patients who underwent direct surgical closure or drip-and-rest therapy during the same period. METHODS: Nineteen patients with idiopathic CSF leaks were enrolled in this study since November 2011 (12 women; mean age, 43.3 ± 14.0 years). Patient demographic data, radiologic findings, symptoms, administrated therapies, complications, and clinical courses were investigated retrospectively. RESULTS: Different types of headache were observed, including typical orthostatic headache alone (n = 10), orthostatic headache with chronic subdural hematoma (CSDH) (n = 3), and posture-unrelated headache accompanied with CSDH (n = 6). Regarding treatments, in 1 case, direct surgical closure was performed. In 15 cases, large-volume EBPs were performed, and the volume of injected blood was 44.8 ± 21.6 mL. The other 3 cases were treated by simple drip infusion regardless of the drainage for CSDH. Out of 9 cases with accompanied CSDH, recurrence of subdural hematoma was completely prevented by the application of an EBP after drainage in 5 cases and without drainage in 3 cases, and by simple intravenous drip-and-rest therapy after drainage in 1 case. Among 10 patients suffering from typical orthostatic headache alone, symptoms disappeared completely in 7 cases and were relieved in 3 cases. CONCLUSIONS: We demonstrate here a perfect control of spinal CSF leaks with the administration of a large-volume EBP through an intravenous catheter.

Efficacy and Safety of REVIVE SE Thrombectomy Device for Acute Ischemic Stroke: River JAPAN (Reperfuse Ischemic Vessels with Endovascular Recanalization Device in Japan).

REVIVE SE (REVIVE) is a closed-ended, self-expanding stent retriever used in the RIVER JAPAN study. We present our early experience with REVIVE for revascularization of acute ischemic stroke (AIS) in patients who have failed or are ineligible for intravenous recombinant tissue plasminogen activator treatment. This prospective, single-arm, non-randomized, multicenter registry study followed up patients undergoing mechanical thrombectomy with REVIVE for 90 days. The primary endpoint was a post-procedure Thrombolysis in Cerebral Infarction (TICI) score ≥2a. Secondary endpoints were clot migration/embolization; recanalization without symptomatic intracranial hemorrhage (ICH) at 24 h; symptomatic ICH; good neurological outcome (modified Rankin Scale score ≤2 National Institute of Health Stroke Scale (NIHSS) score decrease ≥10) at day 90; device- or procedure-related serious adverse events (SAEs) and mortality at day 90. To confirm non-inferiority of REVIVE, results were compared with historical data of the Merci Retriever. About 49 patients were enrolled (median age 73 years; males 46.9%; middle cerebral artery (MCA) occlusion 83.7%; median NIHSS score 17). A post-procedure TICI score ≥2a was observed in 73.5% (36/49, 95% confidence interval [CI] 58.9-85.1) of patients. No post-procedural clot migration/embolization events occurred. Successful recanalization without symptomatic ICH was observed in 62.5% (30/48, 95% CI 47.4-76.0). The good neurological outcome was achieved in 66.7% (32/48) patients. Symptomatic ICH and device- or procedure-related SAEs were reported in 6.3% and 12.2% of patients, respectively. Two deaths were reported. REVIVE demonstrated equivalent efficacy and safety as the Merci Retriever. Results suggest that REVIVE is effective and safe in recanalizing occluded intracranial arteries in AIS.

Novel Assessment of Cerebrospinal Fluid Dynamics by Time-Spatial Labeling Inversion Pulse Magnetic Resonance Imaging in Patients with Chiari Malformation Type I.

OBJECTIVE: We investigated cerebrospinal fluid (CSF) dynamics at the craniocervical junction (CCJ) using Time-SLIP magnetic resonance imaging to demonstrate the significance of ventral and dorsal combined CSF dynamics in assessing CSF flow disturbance in patients with Chiari malformation type I. METHODS: Fifteen examinations were performed in 9 cases of CM-I (3 female patients; mean age, 24.7 years; age range, 11-46 years) before or after craniocervical decompression. The longitudinal maximum movement of the caudal edge of tagged midsagittal CSF at the CCJ was measured as length of motion (LOM), and total on the ventral and dorsal sides was defined as total LOM. RESULTS: In 8 conditions, where it was concluded that no craniocervical decompression was necessary or where symptoms improved following craniocervical decompression based on the clinical symptoms, total LOM was 49.8 ± 13.1 mm. In contrast, in the 7 cases where craniocervical decompression was mandatory, total LOM was 23.2 ± 9.2 mm. Significant differences were identified between the 2 groups. Total LOM <35.0 mm resulted to indicate the insufficiency of CSF dynamics, because it corresponded to the necessity of craniocervical decompression based on patients' symptoms. CONCLUSIONS: Time-SLIP MRI enabled clinicians to use novel dynamic indices, such as CSF motions, in addition to the conventional findings acquired by MRI. In particular, it was essential to examine combined ventral and dorsal CSF dynamics in assessing CSF patency at the CCJ in patients with CM-I.

Contrast-less stent placement for vertebral artery origin stenosis.

We performed stent placement under intravascular ultrasound (IVUS), without the use of contrast medium, in a male patient in his 70s who had vertebral artery origin stenosis and decreased renal function. Satisfactory dilatation was achieved without complications, and the patient remained asymptomatic at 2 years of follow-up. We now report the details of this procedure. Stent placement under IVUS guidance may be useful in patients in whom contrast medium is contraindicated.

[Intracerebral hemorrhage associated with nephrotic syndrome-Prevalemce and clinical characteristics].

Of the 11,161 cases of stroke observed for over 9 years, 21 cases in which both levels of serum albumin and cholesterol were < 3 g/dl and > 250 mg/dl, respectively, were identified. Out of these 21 cases, cases of severe proteinuria, i.e., nephrotic syndrome were selected. These included 10 cases of arterial ischemic thrombosis, 2 cases of cerebral venous sinus thrombosis, and 4 cases of intracerebral hemorrhage. The incidence of intracerebral hemorrhage associated with nephrotic syndrome was 0.18% of total stroke or 0.036% intracerebral hemorrhage. Nephrotic syndrome essentially induced a hypercoagulable state. The 4 cases with intracerebral hemorrhage associated with nephrotic syndrome, however, had strong risk factors for intracerebral hemorrhage, suggesting that they overcame the risk for thrombophilia. The diseases associated with the nephrotic syndrome were diabetic nephropathy and amyloidosis in 3 cases and in 1 case, respectively. The nephrotic syndrome tends to be associated with a risk for venous or arterial thrombosis. In addition, we must pay attention to intracerebral hemorrhage associated with nephrotic syndrome in cases of stroke.

Seizures after intracerebral hemorrhage; risk factor, recurrence, efficacy of antiepileptic drug.

OBJECTIVE: This study aimed to determine the risk factors for recurrent post stroke seizure (PSS) and the efficacy of anti-epileptic drugs (AED) in patients having intracerebral hemorrhage (ICH) with initial seizure. METHODS/SUBJECTS: A total of 1920 consecutive patients with ICH from 2004 to 2012 were investigated retrospectively. The relationships among the baseline clinical and radiological data, administration of AED, and incidence of initial and recurrent PSS were evaluated using multiple logistic regression analysis. RESULTS: Seizures occurred in 127 (6.6%) of the 1920 patients, displaying statistically significant relationships with cortical involvement of a cerebral lesion (P<0.001), non-hypertensive ICH (P<0.001), younger age (P<0.001), and severe neurological deficits (P<0.001). Early (4.3%) and late seizure (2.3%) had no significant relationship with the development of recurrent PSS. Larger volume of hematoma was the only independent factor associated with recurrence of PSS (OR 1.03; 95% CI 1.00-1.05; P=0.027). A Kaplan Meier survival analysis revealed that AED treatment had a poor association with recurrence of PSS (P=0.750). CONCLUSIONS: Larger volume of hematoma was predictive of recurrence of PSS. AED therapy had poor association with preventing the recurrence of PSS.

[The Clinical Features of Cerebrospinal Fluid Leaks--Based on Our Experiences].

Cerebrospinal fluid (CSF) leak, which usually occurs idiopathically or traumatically as a rare situation, is a rare disease that causes orthostatic headache or idiopathic chronic subdural hematoma (CSDH). We report our therapeutic experience of consecutive 20 cases for this disease, and review the current status and problems. Consecutive 20 patients (11 women; age 44.7±12.1 years) between April, 2006 and March, 2014, who were diagnosed by MRI and/or CT myelography (CTM), were evaluated retrospectively about clinical features. The main symptoms were as follows: orthostatic headache only; 10 cases, orthostatic headache with CSDH; 6, and none-orthostatic headache accompanied with CSDH; 4. As a treatment, direct surgeries were performed in 2 cases. Epidural blood patch (EBP) was applied in 14 cases (direct surgery was performed finally in the early one case), and widespread EBP with a single lumbar entry point utilizing an intravenous catheter was performed especially in the latest 9 cases. Another 5 cases were treated simply with the administration of a drip infusion regardless of the drainage for CSDH. Of 10 cases suffering from headache only, the headache disappeared completely or it was relieved in 9 cases. Of 10 cases accompanied with CSDH, recurrence of hematoma was prevented in all cases with a drip infusion after the drainage in one case and EBP after the drainage in another 9 cases. It was certified that we could diagnose CSF leak correctly with MRI and/or CTM and control this disorder almost completely with widespread EBP utilizing an intravenous catheter.

[Chronic intracerebral hemorrhage in the basal ganglia: Report of two cases and prevalence].

Two patients presented with chronic intracerebral hemorrhage (CIH) in the basal ganglia. A 48-year-old man (Case 1) was admitted to our hospital because of hypertensive right putaminal hemorrhage. On day 14, his hematoma surrounding the edema had grown without re-bleeding as seen on head CT, which was then removed endoscopically on day 28. Biopsied specimen of the hematoma capsule showed granulomatous tissue with vascularity. A 54-year-old man (Case 2) was admitted to our hospital because of bilateral intracerebral hemorrhage in the basal ganglia of the right putamen and left thalamus. On head CT, both hematomas were found to be enlarged without change in his symptoms on the 11th day after onset. His symptoms and signs subsided with medical treatment for 4 weeks. Cerebral angiography showed no abnormality of cerebral vessels. The patient had intracerebral hemorrhage in the basal ganglia or cerebral lobes 5 times in the past 10 years. Although no arterial or venous abnormality was detected by cerebral angiography and MRI/MRA, the abnormality of vessels including capillaries was strongly suggested. CIH should be considered a possibility when the symptom or hematoma does not improve even 2 weeks after the onset. The prevalence of CIH in our hospital was 0.08% of total intracerebral hemorrhages and 0.15% of hemorrhages in the basal ganglia.

[A child who developed internal carotid artery obstruction 2 weeks after incurring an intraoral blunt injury: A case report].

This report describes a 9-year-old boy with an internal carotid artery (ICA) injury caused by a fall with the blunt edge of a toothbrush held in the mouth. The initial injury appeared trivial, but 2 weeks later, generalized convulsion and left hemiparesis occurred. Magnetic resonance imaging and magnetic resonance angiography revealed an infarction of the right striatum, right ICA occlusion, and stenosis of the right middle cerebral artery, which were caused by the dissection or intimal damage of the ICA due to the blunt trauma. For children, intraoral blunt trauma sometimes causes ICA occlusion and consecutive strokes after the latent interval of days to weeks. Therefore, a careful clinical observation is essential to prevent overlooking strokes. This patient was an unique case with a long latent interval among the past literatures.

[Clinical and radiological studies of seizure in chronic subdural hematoma--case control study].

We studied the mechanism underlying seizure induction in patients with chronic subdural hematoma. In our study population of 1,009 patients with chronic subdural hematoma, 26 (2.6%) had seizure-related complications. Six of them had already been diagnosed with epilepsy (4 patients) or suspected of having secondary epilepsy (2 patients) after experiencing traffic accidents or cerebral bleeding. Twenty patients (seizure group) had been tentatively diagnosed as having hematoma-induced convulsion. Of the remaining 989 patients without convulsion, 40 randomly sampled patients were included in the non-seizure group by matching with clinical terms. Intergroup comparisons showed that patients with dementia were more common in the seizure group than in the non-seizure group; however, no intergroup differences were observed for other clinical parameters. Radiological examinations showed that bilateral hematomas were relatively more common and sulcal hyperintensity on FLAIR MR images was significantly more frequent in the seizure group than in the non-seizure group. Interestingly, many patients presenting with sulcal hyperintensity exhibited mixed-density hematomas on CT images. These findings suggest the mechanism by which hematoma content infiltrates into the brain parenchyma and the subsequent induction of convulsions by the stimulatory component.

A novel technique of multiple-site epidural blood patch administration for the treatment of cerebrospinal fluid hypovolemia.

OBJECT: An epidural blood patch (EBP) is a widely accepted standard procedure to treat CSF hypovolemia, especially when the epidural CSF leak is detected by spinal MRI or CT myelography (CTM). In quite a few cases, however, the leaked CSF is spread over a large area along the spinal epidural space, making it difficult for the surgeon to clearly identify the true leakage points. In such cases, autologous blood can be infused at multiple spinal levels with multiple entries. In this paper, the authors have devised a new multiple-site EBP method with a single lumbar entry point by way of using an intravenous catheter as a slidable device for continuous infusion. In this report, they introduce this new, single-entry, continuous multiple-site EBP administration technique and report some of the results that they have obtained. METHODS: An EBP was applied via an epidural catheter in 5 patients with spontaneous CSF hypovolemia (3 men and 2 women; mean age 47.2 years, range 34-65 years). The detection of an epidural CSF leak was based on MRI and/or CTM findings. In all cases, however, the leakage sites could not be identified clearly. The main symptoms of these patients were recurrent spontaneous chronic subdural hematoma with orthostatic headache (3 patients) and orthostatic headache only (2 patients). All patients underwent surgery in the prone position on an angiography table, and biplane fluoroscopy was used for accurate manipulation. After administration of a local anesthetic, the authors inserted a 4-Fr short sheath (which is standard in angiography) through the lumbar interlaminar window and placed it in the dorsal epidural space. They then introduced a 4.2-Fr straight catheter through the sheath and navigated it upward along a 35-gauge guidewire whose tip was moved upward beyond the cranial end of the detected CSF leakage. Blood was obtained from each patient from a previously secured venous entry on the forearm, and it was injected slowly into the epidural catheter. Each time, the authors tried to infuse as much autologous blood as possible into the epidural space, while moving the catheter gradually in the caudal direction in response to the patient's expression of pain. RESULTS: In all 3 cases of chronic subdural hematoma, its recurrence was prevented. In 1 patient, the orthostatic headache disappeared completely, and it was relieved in the other 4 patients. CONCLUSIONS: An efficient treatment option for CSF hypovolemia is provided by the new application method of EBP with the aid of an intravenous catheter as a slidable device, which enables infusion of a sufficient amount of autologous blood into multiple epidural areas with a single lumbar entry point.

Intraarterial colforsin may improve the outcome of patients with aneurysmal subarachnoid hemorrhage: a retrospective study.

OBJECTIVE: Papaverine hydrochloride (PPV) has been widely used for pharmacologic angioplasty to dilate spastic vessels after aneurysmal subarachnoid hemorrhage (SAH). Colforsin daropate hydrochloride (CDH) has also recently been reported to be useful for reversal of cerebral vasospasm (CV). In this study, we compared the impacts of intraarterial PPV and CDH on the outcomes of SAH patients. METHODS: A consecutive series of SAH patients were retrospectively analyzed. Ninety-eight and 133 patients were included in the study during 1998-1999 (group A) and 2003-2005 (group B), respectively. PPV or CDH was the only agent used for pharmacologic angioplasty in groups A and B, respectively. Good outcome was defined as a modified Rankin scale score ≤ 2 at discharge. RESULTS: The percentages of patients without CV who had good outcomes were similar in groups A (78%) and B (81%, P = 0.91). However, the percentage of patients with CV with a good outcome was significantly higher in group B (66%) than in group A (34%, P = 0.032). Logistic regression revealed that age ≤ 65 years (P = 0.0001), World Federation of Neurological Surgeons (WFNS) grade ≤ 2 (P < 0.0001), CV (P = 0.0001), and group B (P = 0.0069) were independent causative factors for good outcome in the overall patient population. Age ≤ 65 (P = 0.0002) and WFNS grade ≤ 2 (P < 0.0001) were independent causative factors for good outcome in patients without CV, whereas only group B (P = 0.0089) was an independent factor for good outcome in patients with CV. CONCLUSION: CDH appears to be associated with a better outcome in patients with SAH.

Intramedullary schwannoma of the conus medullaris complicated by dense adhesion to neural tissue.

A 29-year-old man presented with an intramedullary schwannoma of the conus medullaris manifesting as an 8-month history of mild bladder dysfunction, sexual impotence, and paresthesia in the buttocks. Subtotal removal of the lesion was achieved, as part of the tumor showed dense adhesion to the rostral neural tissue, with only postoperative transient deterioration of bladder dysfunction. Intramedullary schwannoma, especially involving the conus medullaris and the proximal spinal cord, is relatively rare and the pathogenesis and pathophysiology are unclear. Complete resection is often advised to avoid recurrence, but tumor adhesion to neural tissue sometimes renders complete resection difficult, and may create the risk of unacceptable operative morbidity. The present case shows that transient neurological deterioration may occur even with just subtotal removal, leaving the adherent part. Therefore, recognition of the particular features and the strategy for treatment in intramedullary schwannoma of the conus medullaris is essential for making appropriate decisions on the degree of removal.