[Social Support for Patients with Higher Brain Dysfunction in the Chronic Phase].

Higher brain dysfunction inhibits social rehabilitation in patients with stroke or brain injuries. First, magnetic resonance imaging should be performed in the acute phase to predict higher brain dysfunction in the chronic phase. Second, patients' complaints should be carefully considered. Vocational rehabilitation is provided after medical rehabilitation from various sources. Information for social support is provided. The homepage of the National Rehabilitation Center for Persons with Disabilities is a resource for such information. We plan vocational rehabilitation for such patients. We provide medical certificates, such as that required to file for disability pension, because economical support is crucial. Peer support should also be provided to patients and their families. Recovery from higher brain dysfunction occurs gradually over a prolonged period. Therefore, patients should be offered continuing treatment on an outpatient basis in the chronic phase.

[Endosaccular embolization of an intrasellar aneurysm with hypopituitarism: case report].

An 81-year-old male presented with weight loss and hyponatremia. A baseline endocrinological examination revealed anterior pituitary dysfunction. A computed tomography and MRI revealed a large, unruptured intrasellar aneurysm protruding from the right internal carotid artery and pushing the pituitary stalk leftward. The patient developed polyuria and polydipsia from 10 days after commencing corticosteroid supplementation and was diagnosed with partial central diabetes insipidus (DI). Balloon assisted endosaccular embolization was performed about one month after the posterior pituitary dysfunction was identified. The unruptured aneurysm was successfully embolized with Guglielmi detachable coils (GDCs) without narrowing of the parent vessel. DI resolved completely and the posterior pituitary dysfunction improved soon after endosaccular embolization. The remission of DI after coil embolization suggested that the DI might have been induced by the progressive mass effect of the aneurysm rather than by the steroid. An endocrinological evaluation and cerebral angiography confirmed partial recovery of anterior pituitary dysfunction and almost complete obliteration of the aneurysm, respectively at 1 year after the operation. We report a case of hypopituitarism secondary to the large intrasellar aneurysm. This aneurysm was embolized with GDCs, resulting in partial recovery of anterior pituitary dysfunction and complete recovery of posterior pituitary dysfunction.

[Stent-assisted coiling of an acutely ruptured large aneurysm of the internal carotid artery: case report].

A 48-year-old female was referred to our hospital for the management of a ruptured 22-mm-diameter internal carotid aneurysm, located immediately distal to the ophthalmic artery. The right internal carotid artery was completely involved in the aneurysm. Because the right carotid siphon was relatively nontortuous stent-assisted coiling of the aneurysm was attempted 4 days after subarachnoid hemorrhage. A new coil-type coronary stent, a DRIVER stent, was deployed after microcatheter insertion into the aneurysm dome under systemic heparinization, followed by dome packing using Guglielmi detachable coils. Systemic heparinization was continued for 18 hours postoperatively, and aspirin (100 mg/day) was administered orally immediately after the embolization. However, 4 hours after heparin administration cessation, left hemiparesis became apparent. Immediate magnetic resonance angiography revealed a right internal carotid artery occlusion. Diffusion-weighted images demonstrated ischemic spots in the watershed zones of the right cerebral hemisphere. Following an immediate thrombolysis of the right internal carotid artery, systemic heparinization was continued for 5 days, and aspirin and ticlopidine were administrated orally. The patient was discharged on day 37, following the recovery from left hemiparesis within ten days. A DRIVER stent is a low profile coil-type coronary stent, which can be used for the stent-assisted coiling of large internal carotid aneurysms, located distal to the carotid siphon. It seems necessary to continue systemic heparinization for more than 2 days and to administer increased dose or two types of antiplatelet after the stent-assisted coiling of large cerebral aneurysms.

Trigeminal neuralgia: evaluation of neuralgic manifestation and site of neurovascular compression with 3D CISS MR imaging and MR angiography.

PURPOSE: To evaluate three-dimensional (3D) constructive interference in steady-state (CISS) magnetic resonance (MR) imaging and MR angiography with multiplanar reconstruction (MPR) for detection of neurovascular compression (NVC) in patients with trigeminal neuralgia and to evaluate the relationship between clinical symptoms related to trigeminal branches and those related to the site of trigeminal nerve compression. MATERIALS AND METHODS: Fifty-four consecutive patients with trigeminal neuralgia were examined at 3D CISS imaging and MR angiography with a 1.5-T MR system. Original transverse and four reformatted images were used for image interpretation. Vascular contact with the trigeminal nerve at the root entry zone (REZ) was determined, and the nature of the involved vessels was identified. The position of the blood vessel compressing the nerve was classified into cranial, caudal, medial, or lateral sites. Statistical analysis was performed with the chi2 test or the Fisher exact test between two groups and with the chi2 test among more than two groups. RESULTS: In 12 of 15 patients who underwent surgery, the artery that was considered a responsible vessel at 3D CISS imaging and MR angiography was confirmed as such. In the other three patients, the vein was the responsible vessel, which was detected only at 3D CISS imaging. Sixteen (89%) of 18 patients with symptoms related to the maxillary division had NVC at the medial site of the REZ, while 16 (76%) of 21 patients with symptoms related to the mandibular division had NVC at the lateral site (P <.001, chi2 test). CONCLUSION: 3D CISS MR imaging with MPR is useful in the detection of NVC in patients with trigeminal neuralgia, compared with MR angiography. A close relationship was found between the region of neuralgic manifestation and the site of trigeminal nerve compression.

Symptomatic de novo arteriovenous malformation appearing 17 years after the resection of two other arteriovenous malformations in childhood: case report.

OBJECTIVE AND IMPORTANCE: This report describes the first case of symptomatic de novo arteriovenous malformation (AVM) appearing ectopically after total resection of other AVMs. We discuss the growth phenomenon and the nature of AVMs. CLINICAL PRESENTATION: A 27-year-old woman with sudden headache and right-sided numbness was admitted to our hospital. Computed tomographic scans revealed a hemorrhage of the corpus callosum and the bilateral lateral ventricles. A cerebral angiogram demonstrated an AVM that was fed by the bilateral pericallosal arteries and drained into the inferior sagittal sinus. Seventeen years earlier, at the age of 10 years, the patient had undergone resection of two other AVMs. At that time, the newly presented AVM was not detected. This AVM had grown markedly and caused hemorrhage after 17 years. INTERVENTION: The AVM, which was located in the bilateral cingulate gyrus and the corpus callosum, was totally removed through a right frontal craniotomy. The patient was discharged without neurological deficits. CONCLUSION: Our findings suggest that patients who undergo complete resection of AVMs may sustain other de novo AVMs some years later. The growth of an AVM seems to be related to the patient's age at onset and the duration of the posttreatment period. We emphasize the importance of long-term follow-up in patients with cerebral AVMs treated during childhood.

Preoperative evaluation of neurovascular compression in patients with trigeminal neuralgia by use of three-dimensional reconstruction from two types of high-resolution magnetic resonance imaging.

OBJECTIVE: To assess the value of three-dimensional (3-D) images reconstructed from 3-D constructive interference in steady state (3-D-CISS) and 3-D fast inflow with steady-state precession (3-D-FISP) images for the visualization of neurovascular compression in patients with trigeminal neuralgia. METHODS: Twenty-four consecutive patients with trigeminal neuralgia underwent preoperative 3-D-FISP and 3-D-CISS imaging. 3-D reconstruction of nerves and vessels was performed with the use of a volume-rendering method. We compared the 3-D reconstructed images with intraoperative findings. RESULTS: 3-D-CISS and 3-D-FISP images scanned from the same position clearly delineated the trigeminal nerve and vessels. 3-D reconstructed images showed the spatial relationship between the trigeminal nerve and causative vessels. The responsible arteries were identified from the 3-D reconstructed images, which closely simulated the microscopic operative view. CONCLUSION: 3-D reconstructions from two types of high-resolution magnetic resonance images (3-D-CISS and 3-D-FISP) are very useful for creating preoperative simulations and in deciding whether to perform surgery in patients with trigeminal neuralgia.