Ruptured proximal middle cerebral artery traumatic pseudoaneurysm treated with bypass-assisted trapping surgery: A case report.

Background: Traumatic pseudoaneurysms are rare but have a high mortality rate; therefore, immediate diagnosis is vital. Most pseudoaneurysms are in the internal carotid artery or peripheral arteries, while proximal middle cerebral artery pseudoaneurysms have rarely been reported. We present a case of ruptured traumatic pseudoaneurysm located at the M1-M2 bifurcation. Case Description: A 42-year-old man was injured in a motorcycle accident and his Glasgow coma scale score on admission was 7 (Eye opening1, Verbal response2, Motor response4 [E1V2M4]). Head computed tomography (CT) showed thick subarachnoid hemorrhage (SAH). We suspected a ruptured aneurysm, but three-dimensional CT angiography (3D-CTA) did not detect any vascular defects. Head magnetic resonance angiography showed progressive right M1 stenosis suggesting arterial dissection. 3D-CTA on day 20 showed a small aneurysm in the proximal portion of the M2. Although surgery was scheduled for day 26, suddenly left hemiparesis appeared on day 24. Head CT detected fresh SAH and emergency surgery was performed on day 25. We dissected around the ruptured point under M1 temporary occlusion with superficial temporal artery-M2 assist bypass. Contrary to our expectations, there was only a small laceration in the right M2 superior trunk. We trapped the laceration and the proximal portion of the M2 superior trunk while preserving antegrade blood flow from the M1 to the M2 inferior trunk. On the 5-month follow-up, the patient was able to walk independently. Conclusion: Unreasonably thick traumatic SAH or spastic stenosis after head injury may indicate a traumatic pseudoaneurysm and require repeated neurovascular evaluation. If a pseudoaneurysm is detected, immediate surgical intervention is mandatory.

A case of middle cerebral artery large circumferential aneurysm treated with bypass-assisted trapping surgery.

M1 large circumferential aneurysms are clinically challenging because they cannot be treated by simple neck clipping and they may involve the lenticulostriate arteries (LSAs). Although some reports have described endovascular and direct surgical treatment of these aneurysms, the optimal treatment approach remains uncertain. We report a case involving a ruptured large M1 circumferential aneurysm that was treated with bypass-assisted trapping surgery and showed favorable outcomes. The patient was a 47-year-old man presenting with subarachnoid hemorrhage. Digital subtraction angiography revealed a large circumferential aneurysm in the right middle cerebral artery M1 segment with involvement of the lateral and medial LSAs. We successfully performed trapping surgery with the assistance of a superficial temporal artery (STA)-M2 bypass while preserving the medial and lateral LSAs. Although left hemiparesis caused by medial LSA thrombosis appeared in the early postoperative period, the patient showed good recovery from symptoms with rehabilitation and could independently perform daily activities at the five-month follow-up. The treatment of M1 large circumferential aneurysms should involve considerations for prevention of rebleeding, blood supply to the distal area, and preservation of perforating arteries. The treatment strategy for this challenging aneurysm should be planned based on the patient's condition and individual anatomy.

Catastrophic Propeller Brain Injury with Large Scalp Defect Treated with Omental Flap.

In this study, we report a case of catastrophic propeller brain injury with large scalp defect treated with omental flap reconstruction. A 62-year-old man was accidentally caught in a powered paraglider propeller during maintenance. The rotor blades impacted the left part of his head. On arrival at the hospital, he presented with a Glasgow Coma Scale score of E4V1M4. On some areas on his head, skin was noticeably cut off, and the brain tissue out-slipped through an open skull fracture. Continuous bleeding from the superior sagittal sinus (SSS) and the brain surface was observed during emergency surgery. Massive bleeding from the SSS was controlled using a number of tenting sutures and hemostatic agents. We evacuated the crushed brain tissue and coagulated the severed middle cerebral arteries. Dural plasty using the deep fascia of the thigh was performed. The skin defect was closed using an artificial dermis. The administration of high-dose antibiotics has failed to prevent meningitis. Moreover, the severed skin edges and fasciae were necrotic. Plastic surgeons performed debridement and vacuum-assisted closure therapy to promote wound healing. Follow-up head computed tomography revealed hydrocephalus. Lumbar drainage was performed; however, sinking skin flap syndrome was observed. After removing the lumbar drainage, cerebrospinal fluid leakage occurred. We then performed cranioplasty with a titanium mesh and omental flap on day 31. After the surgery, perfect wound healing and infection control were achieved; however, severe disturbance of consciousness remained. The patient was transferred to a nursing home. Primary hemostasis and infection control are mandatory. An omental flap has been determined to be effective in controlling infection by covering the exposed brain tissue.

A Case of Proximal Posterior Inferior Cerebellar Artery (PICA) Aneurysm Treated with PICA-to-PICA Bypass and Trapping Surgery: Comparison with Occipital Artery-PICA Bypass.

Posterior inferior cerebellar artery (PICA) aneurysms often require cerebral vascular reconstruction for surgical treatment because of their characteristic morphology. Despite its potential complications, the occipital artery-to-posterior inferior cerebellar artery (OA-PICA) bypass is a typical treatment because of its versatility. Although a few cases of intracranial-to-intracranial bypass have been reported, this type of vascular reconstruction is only regarded as an alternative to the OA-PICA bypass because of the uncertainty of bypass feasibility and potential risk of ischemic complications. In this article, we report a case of proximal PICA ruptured aneurysm that was treated with a PICA-to-PICA (PICA-PICA) bypass. A 79-year-old man presented with a chief complaint of sudden, severe headache and disturbances in consciousness. Radiological examination revealed a right proximal PICA fusiform aneurysm. The patient had many systemic disorders such as microscopic polyangiitis and steroid-induced diabetes mellitus that could have caused wound dehiscence and cerebrospinal fluid (CSF) leakage. We performed the PICA-PICA bypass and trapping surgery rather than the OA-PICA bypass to avoid skin problems and CSF leakage. The postoperative course was uneventful, and the patient was discharged on day 64 without any neurological disorders. In comparison with the OA-PICA bypass, the PICA-PICA bypass is less likely to cause CSF leakage and skin complications, although it carries the risk of specific ischemic complications and requires advanced surgical techniques. For some patients with systemic disorders, the PICA-PICA bypass could be an optimal treatment option for proximal fusiform PICA aneurysms rather than as an alternative to the OA-PICA bypass.

Deficiency of p62/Sequestosome 1 causes hyperphagia due to leptin resistance in the brain.

The cytoplasmic regulatory protein p62 (Sequestosome 1/A170) is known to modulate various receptor-mediated intracellular signaling pathways. p62 deficiency was shown to result in mature-onset obesity in mice, but the mechanisms underlying this abnormality remained unclear. Here we report that hyperphagia due to central leptin resistance is the cause of obesity in p62(-/-) mice. We found that these mice show hyperphagia. Restriction of food to the amount eaten by wild-type mice prevented excess body weight gain and fat accumulation, suggesting that overfeeding is the primary cause of obesity in p62(-/-) mice. Brain-specific p62 deficiency caused mature-onset obesity to the same extent as in p62(-/-) mice, further supporting a neuronal mechanism as the major cause of obesity in these mice. Immunohistochemical analysis revealed that p62 is highly expressed in hypothalamic neurons, including POMC neurons in the arcuate nucleus. Central leptin resistance was observed even in young preobese p62(-/-) mice. We found a defect in intracellular distribution of the transcription factor Stat3, which is essential for the action of leptin, in p62(-/-) mice. These results indicate that brain p62 plays an important role in bodyweight control by modulating the central leptin-signaling pathway and that lack of p62 in the brain causes leptin resistance, leading to hyperphagia. Thus, p62 could be a clinical target for treating obesity and metabolic syndrome.

[Case of spontaneous bilateral VA dissecting aneurysm presenting with SAH].

We report a case of bilateral vertebral artery (VA) dissecting aneurysm presenting subarachnoid hemorrhage (SAH). It was difficult to decide which side was responsible for SAH because the patient's symptom and head CT suggested that the left VA aneurysm had ruptured, but angiography and MRA showed an irregular pearl and string sign on the right side. He was successfully treated by trapping of the right VA dissecting aneurysm and we confirmed by intraoperative evaluation that the right VA dissecting aneurysm had ruptured. The left unruptured aneurysm decreased its size spontaneously. In the treatment of the bilateral VA dissecting aneurysms, angiography needs to be performed over and over again because contralateral unruptured aneurysm may grow or rupture due to increased hemodynamic stress. Various combinations of direct sugery with or without arterial reconstruction and endovascular treatment should be considered when treating bilateral VA dissecting aneurysms.

Multiple neurenteric cysts in the posterior fossa and cervical spinal canal--case report.

A 46-year-old woman presented with multiple neurenteric cysts in the posterior fossa and spinal canal. Neuroimaging demonstrated neurenteric cysts in the interspace between the left cerebellar hemisphere and vermis, the lateral side of the right cerebellar hemisphere, and the ventral side of the spinal cord at the C-2 and C-4 levels. Total resection of the paravermian cyst and partial removal of the spinal cyst at the C-4 level were performed. Histological examination showed the cyst wall consisted of single or multiple layers of columnar epithelial cells with secretory granules, with mucin secretion verified by periodic acid-Schiff staining. Immunohistochemical staining showed the walls were positive for the cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen, and negative for glial fibrillary acidic protein and S-100 protein. These findings confirmed the endodermal origin. The diagnosis was neurenteric cyst. The paravermian cyst disappeared, but the spinal cyst at the C-4 level recurred 8 months later. Reoperation became necessary 16 months later. The other two cysts also showed enlargement at 6 or 15 months. Total removal of neurenteric cyst is recommended if possible.

Local injection of botulinum toxin type A for hemifacial spasm.

The preliminary experience of botulinum toxin treatment for hemifacial spasm is reported in this study. Five patients were treated with 10 injections of botulinum toxin in total. Botulinum toxin had a good to excellent effect in all cases. Improvement was observed 2 weeks to 1 month after the injection. The duration of improvement was 0-9 months (mean 4.2 months). The peak rank tended to decrease and the duration of improvement increased after several treatments. Hemifacial spasm caused by the anterior inferior cerebellar artery tended to subside easily. In contrast, compression by the vertebral artery was more refractory. Continuous facial spasm caused by operative trauma subsided after the injection, but paroxysmal spasm still occurred when eating or laughing. Spasm caused by trauma disappeared 4.5 months after the injection. The complications, which were facial nerve paresis in two cases (3 injections, 30%) and diplopia in one case (1 injection, 10%), were transient and subsided in 2 weeks.