Preliminary Results on Radiological Hypermobility at Upper Adjacent Disc Level in Posterior Lumbar Interbody Fusion Compared to Advanced Dynamic Stabilization.

Whether posterior lumbar interbody fusion (PLIF) is effective in patients older than 55 years remains questionable because of the high prevalence of adjacent segment disease. We retrospectively investigated early clinical outcomes and radiological changes at upper adjacent disc (UAD) level in such age-group patients who underwent advanced dynamic stabilization (ADS) or PLIF. ADS or PLIF were performed in patients with grade 1 spondylolisthesis or disc degeneration complicated by apparent vacuum phenomenon. All patients suffered from neurological symptoms in lower limbs with/without low back pain. In all, 16 patients (six females; mean age, 69.0 ± 8.5 years) who underwent ADS and 14 patients (seven females; mean age, 67.8 ± 9.3 years) who underwent PLIF were followed-up, and preoperative and postoperative final disc height (DH) and range of motion (ROM) were investigated retrospectively using dynamic radiography at the operated and UAD levels. Clinical data of patients who underwent ADS and PLIF were as follows: postoperative follow-up, 459.3 ± 263.5 and 507.7 ± 288.3 days; preoperative Japanese Orthopaedic Association (JOA) score, 14.4 ± 4.1 and 13.4 ± 4.5; and recovery rate of JOA score, 67.5 ± 18.5 and 50.1 ± 23.4%, respectively. Recovery rate of JOA score in ADS group was significantly high compared to PLIF group (P = 0.044). At UAD level, ROM decreased from 4.7 ± 2.9° preoperatively to 3.6 ± 2.6° postoperatively in the ADS group and increased from 3.4 ± 4.1° preoperatively to 5.6 ± 2.8° postoperatively with significant hypermobility (P = 0.020) in the PLIF group. ADS has the advantage in clinical outcomes even in the postoperative early stage, avoiding the early hypermobility at UAD level, compared to PLIF in patients older than 55 years.

Facet Joint- and Nuchal Ligament-Sparing Laminectomy is Not Inferior to Conventional Open-Door Laminoplasty from Clinical and Radiologic Perspectives.

OBJECTIVE: To investigate the noninferiority of facet joint- and nuchal ligament-sparing laminectomy (FNL) compared with conventional open-door laminoplasty. METHODS: This retrospective study analyzed 31 patients who underwent FNL (7 women; median age, 71 years) and 29 patients who underwent laminoplasty (9 women; median age, 61 years) with cervical myelopathy due to degenerative cervical spine diseases. The surgical concept in laminectomy was to spare the facet joints and nuchal ligament, providing laminectomy with deviation to the side of dominant symptoms. In both groups, recovery rate of Japanese Orthopaedic Association (JOA) score, mean decompression ratio (decompressed width/distance between outermost edges of the lateral mass on computed tomography ×100) at decompressed laminas, and pre- and postoperative final cervical Cobb angle and cervical sagittal vertical axis were mainly examined. RESULTS: Clinical and radiologic median data with interquartile range for patients who underwent FNL and laminoplasty were as follows: postoperative follow-up, 783.0 days (535.0-1128.0 days) and 731.0 days (524.0-1213.5 days); preoperative JOA score (full score 17), 13.0 (9.5-15.0) and 13.0 (10.0-14.0); recovery rate of JOA score, 72.2% (33.3-100.0%) and 50.0% (31.0-75.0%); and mean decompression ratio, 41.9% (40.0-43.6%) and 51.6% (48.9-55.4%), respectively. The FNL group showed a comparable recovery rate of JOA score to the laminoplasty group, despite the significantly smaller mean decompression ratio (P < 0.001). Furthermore, no significant differences in pre- or postoperative median cervical Cobb angle or sagittal vertical axis were observed between groups. CONCLUSIONS: FNL was not inferior to conventional open-door laminoplasty in terms of clinical or radiologic outcomes, reducing the detachment of muscle from each lamina.

Ability of the Ankle Brachial Index and Brachial-Ankle Pulse Wave Velocity to Predict the 3-Month Outcome in Patients with Non-Cardioembolic Stroke.

AIM: Both the ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are surrogates for atherosclerosis. In this study, we aimed to evaluate the ability of ABI and baPWV to predict stroke outcome in patients with first-ever non-cardioembolic stroke. METHODS: This study included consecutive patients with first-ever non-cardioembolic stroke admitted within 1 week after onset to Ota Memorial Hospital between January 2011 and December 2013. Baseline characteristics and National Institutes of Health stroke scale scores at admission were noted. ABI and baPWV were evaluated within 5 days of admission. The patients were categorized according to ABI (cut-off 0.9) and baPWV (cut-off 1870 cm/s) determined using the receiver operation curve for poor outcome. Clinical outcomes were defined based on the modified Rankin scale (mRS) scores 3 months after stroke onset as good (0 and 1) or poor (2-6). RESULTS: A total of 861 patients were available for evaluation. ABI ＜0.9 and baPWV ＞1870 cm/s were associated with poor outcome in the univariate analysis (p＜0.001 and p＜0.001, respectively). After adjusting for factors that showed differences between groups, ABI ＜0.9 was associated with poor outcome. Among patients with ABI ≥ 0.9, higher baPWV showed a slight association with poor outcome after adjustment [odds ratio 1.46 (95% CI 0.95-2.27)]. CONCLUSION: Our study suggests that the stroke outcome can be predicted using ABI and to an extent using baPWV when ABI ≥ 0.9 in patients with non-cardioembolic stroke.

Ischemic Stroke Mortality Is More Strongly Associated with Anemia on Admission Than with Underweight Status.

BACKGROUND: Underweight patients have recently been reported as a group with a high risk of poststroke death. Anemia also increases mortality rates in stroke patients. However, the causal associations between body weight and anemia resulting in stroke-related death remain unclear. We examined the association of weight status and hemoglobin levels with 3-month mortality after ischemic stroke. METHODS: The study enrolled all consecutive patients with acute ischemic stroke and no history of stroke admitted to our hospital between January 2010 and December 2013. The patients were categorized into 4 body mass index (BMI) categories (underweight, normal-weight, overweight, and obese). Anemia was evaluated according to the World Health Organization criteria (men, <13 g/dL; women, <12 g/dL). RESULTS: A total of 1733 acute ischemic stroke patients (149 underweight, BMI < 18.5 kg/m2; 1076 normal-weight, BMI = 18.5-24.9 kg/m2; 436 overweight, BMI = 25-29.9 kg/m2; and 72 obese, BMI > 30 kg/m2) were included. Death within 3 months occurred in 65 patients (underweight, 10.1%; normal-weight, 3.4%; overweight, 2.3%; and obese, 5.6%). Compared to nonanemic patients, those with anemia (n = 329, 19.0%) had lower BMI (21.8 kg/m2 versus 23.7 kg/m2, P <.001) and higher mortality rates (9.1% versus 2.5%, P <.001). Underweight status was associated with 3-month mortality after adjusting for age, sex, comorbidities, and initial stroke severity. However, in the models that included laboratory findings, it was anemia status (odds ratio, 2.81; 95% confidence interval, 1.46-5.43), not underweight status, that was independently associated with 3-month mortality. CONCLUSION: Anemia on admission was associated with stroke mortality independent of underweight status.

Brain Natriuretic Peptide and Particular Left Ventricle Segment Asynergy Associated with Cardioembolic Stroke from Old Myocardial Infarction.

BACKGROUND: It is important to determine the usage of anticoagulants by defining the actual risk of cardioembolic stroke in patients with old myocardial infarction. In the present study, we aimed to more precisely evaluate the risks of each segment associated with cardioembolic stroke using a 16-segment model. The usage of the plasma brain natriuretic peptide (BNP) associated with cardioembolic stroke was also evaluated in comparison with a left ventricle ejection fraction less than 40%. METHODS: There were a total of 190 ischemic stroke patients who had premorbid myocardial infarction. The study included a total of 143 ischemic stroke patients with old myocardial infarction who were available for evaluation and excluded patients with atrial fibrillation or acute myocardial infarction. Their left ventricle wall motion abnormality and the level of plasma BNP at their admission were analyzed. RESULTS: Hypertension and a plasma BNP level of 206.9 pg/mL or higher, determined from the receiver operating characteristic curve, were independently associated with cardioembolic stroke (χ(2) = 35.6, R(2) = .30, P < .001). Adjusting for these factors, statistically independent high risk was observed at the basal-inferior, basal-inferolateral, mid-anterior, mid-anteroseptal, apical-anterior, and apical-septal left ventricles. CONCLUSION: High plasma BNP levels and left ventricular wall motion abnormalities in the segments perfused with left anterior descending coronary artery or right coronary artery show a high risk for cardioembolic stroke in patients with old myocardial infarction. Considering these factors, it could be possible to more precisely define the risk of cardioembolic stroke and to perform appropriate antithrombotic treatments in old myocardial infarction patients.

[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.

Dynamic stabilization for degenerative spondylolisthesis and lumbar spinal instability.

Lumbar interbody fusion is a widely accepted surgical procedure for patients with lumbar degenerative spondylolisthesis and lumbar spinal instability in the active age group. However, in elderly patients, it is often questionable whether it is truly necessary to construct rigid fixation for a short period of time. In recent years, we have been occasionally performing posterior dynamic stabilization in elderly patients with such lumbar disorders. Posterior dynamic stabilization was performed in 12 patients (6 women, 70.9 ± 5.6 years old at the time of operation) with lumbar degenerative spondylolisthesis in whom % slip was less than 20% or instability associated with lumbar disc herniation between March 2011 and March 2013. Movement occurs through the connector linked to the pedicle screw. In practice, 9 pairs of D connector system where the rod moves in the perpendicular direction alone and 8 pairs of Dynamic connector system where the connector linked to the pedicle screw rotates in the sagittal direction were installed. The observation period was 77-479 days, and the mean recovery rate of lumbar Japanese Orthopedic Association (JOA) score was 65.6 ± 20.8%. There was progression of slippage due to slight loosening in a case with lumbar degenerative spondylolisthesis, but this did not lead to exacerbation of the symptoms. Although follow-up was short, there were no symptomatic adjacent vertebral and disc disorders during this period. Posterior dynamic stabilization may diminish the development of adjacent vertebral or disc disorders due to lumbar interbody fusion, especially in elderly patients, and it may be a useful procedure that facilitates decompression and ensures a certain degree of spinal stabilization.

[Clinical manifestations of 16 patients with spontaneous spinal epidural hematoma -stroke mimic and pitfalls for diagnosis].

Clinical manifestations of 16 patients with spontaneous spinal epidural hematoma were presented. We examined the point similar to that of stroke. During the initial visit of our hospital, the patients showed the hemiplegia in 10 cases (62.5%), Horner syndrome in 4 cases (25%), the painless onset in 1 case (6.3%). And one case showed the impairment of consciousness due to vagal reflex in severe pain onset, which was similar to those of subarachnoid hemorrhage. MRI images are useful to confirm the diagnosis. The frequent site of hematoma was the lower cervical spinal cord. The oval shaped hematomas shifted to the left or right in spinal canals, compressed spinal cords in axial image, which was a cause of hemiplegia. Many cases developed during active periods, and the hemorrhage might be relevant to oral antithrombotic agent, C hepatitis, and chronic renal failure. Rapidly progressive cases were indications for emergency surgery, but conservative therapy is also possible and was better prognosis.

Safety evaluation of substituting clopidogrel for ticlopidine in Japanese patients with ischemic stroke--Hiroshima ticlopidine, clopidogrel safe exchange trial.

BACKGROUND: Clopidogrel is sometimes substituted for ticlopidine when cerebrovascular or cardiovascular patients develop hematologic abnormalities after ticlopidine treatment. However, the adverse event rate after the substitution to clopidogrel remains undetermined. Therefore, in this study, we aimed to define the risk of adverse events after substituting clopidogrel for ticlopidine without a washout period. METHODS: We prospectively enrolled patients older than 20 years who had a history of noncardioembolic strokes, including transient ischemic attacks, were treated with ticlopidine for at least 6 months. This study was conducted from August 26, 2008, when the first patient was enrolled, to January 16, 2012, the date of the last patient examination, at 8 active stroke centers in Hiroshima, Japan. We excluded patients who had severe disabilities, evidence of cardioembolic stroke, or history of a bleeding event. Each patient received clopidogrel (either 50 mg or 75 mg) once a day in place of ticlopidine without a washout period. Follow-up exams were scheduled within 12 months after the medication substitution. The primary end point of this study was adverse events of interest, including clinically significant reduced blood cell counts, hepatic dysfunction, bleeding, and other serious side effects. RESULTS: In this study, 110 patients were enrolled and analyzed in an intent-to-treat manner (modified intent to treat). Within the scheduled follow-up periods, 9 primary end point events were observed in separate patients. The primary end point events were observed at a rate of 8.4% per year (Kaplan-Meier method). At the time of enrolment, 16 patients met the exclusion criteria, of which 8 recovered from their abnormal hematologic results to the institutional normal limit after the substitution of ticlopidine for clopidogrel (57.4% per year). CONCLUSIONS: The adverse event rates after the substitution of ticlopidine for clopidogrel is similar to the adverse event rates of patients who were initially treated with clopidogrel. The substitution of clopidogrel for ticlopidine should be considered for patients who develop hematologic abnormalities from ticlopidine treatment.

Clinical features of SCA36: a novel spinocerebellar ataxia with motor neuron involvement (Asidan).

OBJECTIVE: To characterize the phenotype of spinocerebellar ataxia type 36 (SCA36), a novel dominant disorder (nicknamed "Asidan") caused by a hexanucleotide GGCCTG repeat expansion in intron 1 of the NOP56 gene. METHODS: We investigated the clinical, genetic, and neuropathologic characteristics of 18 patients with SCA36. We performed histologic evaluation of a muscle biopsy specimen from 1 patient with SCA36, and neuropathologic evaluation of an autopsied brain from another patient with SCA36. RESULTS: The (GGCCTG)n expansion was found in 18 ataxic patients from 9 families. The age at onset of ataxia was 53.1 ± 3.4 years, with the most frequent symptoms being truncal ataxia (100% of patients), ataxic dysarthria (100%), limb ataxia (93%), and hyperreflexia (79%). Tongue fasciculation and subsequent atrophy were found in 71% of cases, particularly in those of long duration. Skeletal muscle fasciculation and atrophy of the limbs and trunk were found in 57% of cases. Lower motor involvement was confirmed by EMG and muscle biopsy. The neuropathologic study revealed significant cerebellar Purkinje cell degeneration with obvious loss of lower motor neurons. Immunohistochemical analysis showed that NOP56 was localized to the nuclei of various neurons. Cytoplasmic or intranuclear inclusion staining of NOP56, TDP-43, and ataxin-2 was not observed in the remaining neurons. CONCLUSIONS: This is the first description of the unique clinical features of SCA36, a relatively pure cerebellar ataxia with progressive motor neuron involvement. Thus, SCA36 is a disease that stands at the crossroads of SCA and motor neuron disease.

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.

Efficacy of the free radical scavenger, edaravone, for motor palsy of acute lacunar infarction.

OBJECTIVE: Free radicals are important in causing neural cell injury during cerebral infarction. Although there was a randomized, placebo-controlled, double-blind study at multiple centers in Japan showing the efficacy of the free radical scavenger, edaravone, in acute cerebral infarction, to date the clinical studies are few. This study investigated the effect of edaravone on the outcome of patients with acute lacunar infarction. METHODS: We retrospectively evaluated 124 consecutive patients with first-ever acute lacunar infarctions who were admitted to our hospital within 24 hours after the onset between January 2004 and June 2007. Of these, 59 patients received both edaravone and conventional therapy (edaravone group), and the other 65 underwent conventional therapy only (non-edaravone group). There was no significant difference in patients' baseline characteristics in the two groups. The clinical outcome was assessed by the National Institutes of Health Stroke Scale (NIHSS). RESULTS: The reduction of NIHSS scale during hospitalization (1.5+/-1.0 vs. 1.0+/-1.1; p = 0.007), especially that of the motor palsy scale (1.0+/-1.0 vs. 0.5+/-1.0; p = 0.006) was significantly larger, and the percentage of patients with a favorable outcome (NIHSS at discharge < or =1) (91.5% vs. 78.5%; p = 0.044) was significantly better in the edaravone group. CONCLUSION: Edaravone improves the outcomes of patients with acute lacunar infarction, especially motor palsy, without regard to the conventional therapy performed concomitantly.

Rapid reduction of syrinx associated with traumatic intracranial hypotension by direct surgery: case report.

A woman in her early twenties presented with cerebellar tonsillar herniation with syrinx in the cervicothoracic spinal cord manifesting as postural headache after suffering trauma to the hip. She was treated under a diagnosis of traumatic intracranial hypotension. Cranial magnetic resonance (MR) imaging demonstrated tonsillar herniation to the upper rim of the C1 lamina, associated with effacement of the basal cisterns and flattening of the pons against the clivus, sagging of the optic chiasm, and protrusion of the pituitary gland into the suprasellar cistern. Spinal MR imaging and computed tomography (CT) myelography showed cervicothoracic syrinx and arachnoid diverticulum. Three applications of epidural blood patches produced no improvement. Surgery identified cerebrospinal fluid leakage from two small holes in the spinal dural sac, slightly proximal from the origin of the left L1 root sleeve, and arachnoid diverticulum. These two holes were sutured and a few sheets of gelatin sponge were placed around the arachnoid diverticulum and sealed with fibrin glue. The cervicothoracic syrinx was reduced significantly and tonsillar herniation disappeared within 10 days. Simple surgical repair of the dural tears may rapidly improve symptoms and imaging findings in patients with tonsillar herniation caused by traumatic intracranial hypotension.

[Lacunar infarction in brain tumor patients: chronic stage complication after radiation therapy].

The authors reported two relatively young adults with lacunar infarction that took place many years after radiation therapy. The first case was that of a 41-year-old male presenting with a slight decrease in consciousness and right hemiparesis of sudden occurrence. MRI revealed a lacunar infarction in the left internal capsule. This patient had received radiation therapy and chemotherapy for a right basal ganglia germinoma when he was 24 years old. The tumor completely disappeared and he was able to return to work. The second case was a 24-year-old female presenting with dysesthesia in the right upper extremity and nausea of sudden occurrence. MRI disclosed a lacunar infarct in the right corona radiata. The patient had received radiation therapy for a suprasellar tumor when she was 11 years old. The tumor considerably decreased in size and the patient conducted normal social life thereafter. MRI showed a lacunar infarction in the right corona radiata. Review of the literature was made and the possibility of radiation therapy as a causative factor of the lacunar infarction in relatively young adults was discussed.

[Hypoglossal nerve palsy caused by hypoplasia of the atlas and ossification of the posterior longitudinal ligament].

A 50-year-old woman developed discomfort of oral cavity and dysarthria. Her tongue showed a slight left-deviation and atrophy in the left side in a month. Examination with X-p, CT, and MRI showed hypoplasia of the atlas and high cervical ossification of the posterior longitudinal ligament (OPLL) from C1 to C5. Thus, combination of congenital hypoplasia of the atlas and acquired high cervical OPLL reduced a function of hypoglossal nerve, which resulted in the palsy. In a case of unilateral hypoglossal palsy, a possible lesion of foramen magnum should be considered.

[Portal-systemic shunt with cerebellar ataxia as the initial neurological manifestation which was dramatically improved by an intravenous administration of branched amino acid].

A 58-year-old woman began to show ataxia at age 45 and dysarthria at age 56. Neurological examination revealed slurred speech, truncal ataxia, and pyramydal sign. Neither history of alcoholism nor hereditary factors were found. The level of serum ammonia was increased. Brain MRI study showed a high signal intensity in the cerebral peduncle and globus pallidus and mild cerebellar atrophy on T1-weighted image. A portal-systemic shunt due to a shunt vessel was found between the left splenic and kidney veins although she did not show any other symptoms or signs due to liver cirrhosis. Her symptoms dramatically improved by an intravenous administration of branched amino acid. The present case suggests an importance in finding a treatable cerebellar ataxia.