Cilostazol restores autophagy flux in bafilomycin A1-treated, cultured cortical astrocytes through lysosomal reacidification: roles of PKA, zinc and metallothionein 3.

Cilostazol, a phosphodiesterase 3 inhibitor, reduces the amyloid-beta (Aß) burden in mouse models of Alzheimer disease by as yet unidentified mechanisms. In the present study, we examined the possibility that cilostazol ameliorates lysosomal dysfunction. Astrocytes treated with bafilomycin A1 (BafA1) exhibited markedly reduced DND-189 and acridine orange (AO) fluorescence, indicating reduced lysosomal acidity. In both cases, BafA1-induced alkalization was reversed by addition of cilostazol, dibutyryl cAMP or forskolin. All three agents significantly increased free zinc levels in lysosomes, and addition of the zinc chelator TPEN abrogated lysosomal reacidification. These treatments did not raise free zinc levels or reverse BafA1-mediated lysosomal alkalization in metallothionein 3 (Mt3)-null astrocytes, indicating that the increases in zinc in astrocytes were derived mainly from Mt3. Lastly, in FITC-Aß-treated astrocytes, cilostazol reversed lysosomal alkalization, increased cathepsin D activity, and reduced Aß accumulation in astrocytes. Cilostazol also reduced mHtt aggregate formation in GFP-mHttQ74-expressing astrocytes. Collectively, our results present the novel finding that cAMP/PKA can overcome the v-ATPase blocking effect of BafA1 in a zinc- and Mt3-dependent manner.

Arachnoid Membrane Suturing for Prevention of Subdural Fluid Collection in Extracranial-intracranial Bypass Surgery.

OBJECTIVE: Water-tight closure of the dura in extracranial-intracranial (EC-IC) bypass is impossible because the superficial temporal artery (STA) must run through the dural defect. Consequently, subdural hygroma and subcutaneous cerebrospinal fluid (CSF) collection frequently occur postoperatively. To reduce these complications, we prospectively performed suturing of the arachnoid membrane after STA-middle cerebral artery (STA-MCA) and evaluated the clinical usefulness. MATERIALS AND METHODS: Between Mar. 2005 and Oct. 2010, extracranial-intracranial arterial bypass (EIAB) with/without encephalo-myo-synangiosis was performed in 88 cases (male : female = 53 : 35). As a control group, 51 patients (57 sides) underwent conventional bypass surgery without closure of the arachnoid membrane. Postoperative computed tomography (CT) scan was performed twice in three days and seven days later, respectively, for evaluation of the presence of subdural fluid collection and other mass lesions. RESULTS: The surgical result was excellent, with no newly developing ischemic event until recent follow-up. The additional time needed for arachnoid suture was five to ten minutes, when three to eight sutures were required. Post-operative subdural fluid collection was not seen on follow-up computed tomography scans in all patients. CONCLUSION: Arachnoid suturing is simple, safe, and effective for prevention of subdural fluid collection in EC-IC bypass surgery, especially the vulnerable ischemic hemisphere.

The role of reciprocal activation of cAbl and Mst1 in the oxidative death of cultured astrocytes.

The protein kinase Mst1 (mammalian Sterile 20-like kinase 1) likely plays a role in oxidative neuronal cell death as a target of its activator, cAbl. We previously found that H2O2-induced death of astrocytes is mediated by cAbl in a metallothionein-3 (Mt3)-dependent manner. In the present study, we examined a possible role for Mst1 in the oxidative death of astrocytes. Treatment of cortical astrocytes with 170 µM H2O2 activated Mst1. Knockdown of Mst1 reduced H2O2-induced cell death, indicating that Mst1 activation contributes to astrocytic cell death. STI571, an inhibitor of cAbl, blocked induction/activation of Mst1 and H2O2-induced cell death. However, Mst1 silencing also inhibited induction/activation of cAbl, suggesting that the two kinases are regulated by a reciprocal activating mechanism. The zinc chelator TPEN blocked induction/activation of cAbl and Mst1, indicating that these phenomena are dependent on the rise of intracellular zinc. Moreover, H2O2 exposure did not increase free zinc levels in Mt3-null astrocytes, suggesting that the increased levels of free zinc were largely from Mt3. Consistent with the involvement of FoxO1/3, which may play a role in the Mst1-cell death cascade, we found an increase in the level of phosphorylated FoxO1/3 in H2O2-treated astrocytes. Moreover, inhibition of cAbl or Mst1 reversed this effect. The present results suggest the interesting possibility that cAbl and Mst1 are reciprocally activated under oxidative stress conditions in astrocytes. Both kinases appear to be regulated by changes in the levels of free zinc originating from Mt3 and contribute to oxidative cell death through a FoxO-dependent mechanism.

Value of indocyanine green videoangiography in deciding the completeness of cerebrovascular surgery.

OBJECTIVE: Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. METHODS: Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. RESULTS: Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. CONCLUSION: ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery.

The usefulness of electromagnetic neuronavigation in the pediatric neuroendoscopic surgery.

OBJECTIVE: Neuroendoscopy is applied to various intracranial pathologic conditions. But this technique needs informations for the anatomy, critically. Neuronavigation makes the operation more safe, exact and lesser invasive procedures. But classical neuronavigation systems with rigid pinning fixations were difficult to apply to pediatric populations because of their thin and immature skull. Electromagnetic neuronavigation has used in the very young patients because it does not need rigid pinning fixations. The usefulness of electromagnetic neuronavigation is described through our experiences of neuroendoscopy for pediatric groups and reviews for several literatures. METHODS: Between January 2007 and July 2011, nine pediatric patients were managed with endoscopic surgery using electromagnetic neuronavigation (AxiEM, Medtronics, USA). The patients were 4.0 years of mean age (4 months-12 years) and consisted of 8 boys and 1 girl. Totally, 11 endoscopic procedures were performed. The cases involving surgical outcomes were reviewed. RESULTS: The goal of surgery was achieved successfully at the time of surgery, as confirmed by postoperative imaging. In 2 patients, each patient underwent re-operations due to the aggravation of the previous lesion. And one had transient mild third nerve palsy due to intraoperative manipulation and the others had no surgery related complication. CONCLUSION: By using electromagnetic neuronavigation, neuroendoscopy was found to be a safe and effective technique. In conclusion, electromagnetic neuronavigation is a useful adjunct to neuroendoscopy in very young pediatric patients and an alternative to classical optical neuronavigation.

Laminotomy with continuous irrigation in patients with pyogenic spondylitis in thoracic and lumbar spine.

OBJECTIVE: Pyogenic spondylitis often results in acute neurological deterioration requiring adequate surgical intervention and appropriate antibiotic treatment. The purpose of this study was to conduct an analysis of the clinical effect of continuous irrigation via laminotomy in a series of patients with pyogenic spondylitis in thoracic and lumbar spine. METHODS: The authors conducted a retrospective investigation of 31 consecutive patients with pyogenic thoracic and lumbar spondylitis who underwent continuous irrigation through laminotomy from 2004 to 2008. The study included 22 men and 9 women, ranging in age from 38 to 78 years (mean 58.1 years). The average follow-up duration was 13.4 months (range, 8-34 months). We performed debridement and abscess removal after simple laminotomy, and then washed out epidural and disc space using a continuous irrigation system. Broad spectrum antibiotics were administered empirically and changed according to the subsequent culture result. Clinical outcomes were based on the low back outcome scale (LBOS), visual analogue scale (VAS) score, and Frankel grade at the last follow-up. Radiological assessment involved plain radiographs, including functional views. RESULTS: Common predisposing factors included local injection for pain therapy, diabetes mellitus, chronic renal failure, and liver cirrhosis. Causative microorganisms were identified in 22 cases (70.9%) : Staphylococcus aureus and Streptococcus spp. were the main organisms. After surgery, LBOS, VAS score, and Frankel grade showed significant improvement in most patients. Spinal stability was maintained during the follow-up period, making secondary reconstructive surgery unnecessary for all patients, except one. CONCLUSION: Simple laminotomy with continuous irrigation by insertion of a catheter into intervertebral disc space or epidural space was minimally invasive and effective in the treatment of pyogenic spondylitis. This procedure could be a beneficial treatment option in patients with thoracolumbar spondylitis combined with minimal or moderate destructive change of vertebrae.

Post-traumatic cerebral infarction : outcome after decompressive hemicraniectomy for the treatment of traumatic brain injury.

OBJECTIVE: Posttraumatic cerebral infarction (PTCI), an infarction in well-defined arterial distributions after head trauma, is a known complication in patients with severe head trauma. The primary aims of this study were to evaluate the clinical and radiographic characteristics of PTCI, and to assess the effect on outcome of decompressive hemicraniectomy (DHC) in patients with PTCI. METHODS: We present a retrospective analysis of 20 patients with PTCI who were treated between January 2003 and August 2005. Twelve patients among them showed malignant PTCI, which is defined as PTCI including the territory of Middle Cerebral Artery (MCA). Medical records and radiologic imaging studies of patients were reviewed. RESULTS: Infarction of posterior cerebral artery distribution was the most common site of PTCI. Fourteen patients underwent DHC an average of 16 hours after trauma. The overall mortality rate was 75%. Glasgow outcome scale (GOS) of survivors showed that one patient was remained in a persistent vegetative state, two patients were severely disabled and only two patients were moderately disabled at the time of discharge. Despite aggressive treatments, all patients with malignant PTCI had died. Malignant PTCI was the indicator of poor clinical outcome. Furthermore, Glasgow coma scale (GCS) at the admission was the most valuable prognostic factor. Significant correlation was observed between a GCS less than 5 on admission and high mortality (p<0.05). CONCLUSION: In patients who developed non-malignant PTCI and GCS higher than 5 after head injury, early DHC and duroplasty should be considered, before occurrence of irreversible ischemic brain damage. High mortality rate was observed in patients with malignant PTCI or PTCI with a GCS of 3-5 at the admission. A large prospective randomized controlled study will be required to justify for aggressive treatments including DHC and medical treatment in these patients.

Endoscopic treatment of transnasal intracranial penetrating foreign body.

Transnasal intracranial penetrating injury is rare. We report a case of transnasal intracranial penetrating metallic chopstick, which was removed successfully by endoscopic approach, and management of transnasal intracranial penetrating injuries.

Traumatic epidural haematoma of the posterior cranial fossa.

A posterior fossa epidural haematoma (EDH) is uncommon and the diagnosis is difficult because the clinical symptoms are non-specific. Therefore, a computed tomography scan is important for the early diagnosis and management. Thirty-four patients with a posterior fossa EDH were admitted between 2001 and 2008. A retrospective analysis of the clinical and radiographic findings with regard to outcome and prognostic factors was carried out. The Glasgow Coma Scale (GCS) score on admission was recorded to be: one in 3-5, five in 6-8, six in 9-12 and 22 patients in 13-15. The admission GCS score was the most valuable prognostic factor. Among the 28 patients with a GCS score of more than 9, 27 patients survived with good results; for the six patients with a GCS score of less than eight, two patients had good recovery and four patients had unfavourable outcome. The 15 patients that were conservatively treated and 14 out of the 19 patients surgically treated had a good recovery. Among the other surgically treated patients, two were moderately disabled, two remained in a vegetative state and one died (overall mortality 2.9%). An occipital fracture was present in 28 cases. Six patients with a diastatic fracture of the lambdoid suture had a more complicated venous sinus injury requiring early surgery compared to those with a simple linear fracture. The patients admitted with associated intracranial injuries, such as a contrecoup injury including subdural haemorrhage or traumatic subarachnoid haemorrhage had a poor outcome. The initial GCS score on admission and the presence of associated intracranial injuries were important factors associated with the patient prognosis. A diastatic fracture of the lambdoid suture was associated with complicated venous sinus injuries making surgery more difficult.

Essential oil of Curcuma longa inhibits Streptococcus mutans biofilm formation.

Curcuma longa (C. longa) has been used as a spice in foods and as an antimicrobial in Oriental medicine. In this study, we evaluated the inhibitory effects of an essential oil isolated from C. longa on the cariogenic properties of Streptococcus mutans (S. mutans), which is an important bacterium in dental plaque and dental caries formation. First, the inhibitory effects of C. longa essential oil on the growth and acid production of S. mutans were tested. Next, the effect of C. longa essential oil on adhesion to saliva-coated hydroxyapatite beads (S-HAs) was investigated. C. longa essential oil inhibited the growth and acid production of S. mutans at concentrations from 0.5 to 4 mg/mL. The essential oil also exhibited significant inhibition of S. mutans adherence to S-HAs at concentrations higher than 0.5 mg/mL. S. mutans biofilm formation was determined by scanning electron microscopy (SEM) and safranin staining. The essential oil of C. longa inhibited the formation of S. mutans biofilms at concentrations higher than 0.5 mg/mL. The components of C. longa essential oil were then analyzed by GC and GC-MS, and the major components were α-turmerone (35.59%), germacrone (19.02%), α-zingiberene (8.74%), αr-turmerone (6.31%), trans-ß-elemenone (5.65%), curlone (5.45%), and ß-sesquiphellandrene (4.73%). These results suggest that C. longa may inhibit the cariogenic properties of S. mutans.

Spontaneous resolution of tetraparesis because of postoperative cervical epidural hematoma.

BACKGROUND CONTEXT: Symptomatic postoperative spinal epidural hematoma (PSEH) is a rare but potentially devastating postoperative complication, accounting for 0.1% to 0.2% of cases. PURPOSE: To describe a patient with a PSEH that completely resolved, clinically and radiographically, without surgical treatment. STUDY DESIGN: Case report and review of the literature. METHODS: A 47-year-old man with no history of a bleeding disorder underwent anterior cervical interbody fusion for C5-C6 disc herniation. The dura was exposed through removal of the posterior longitudinal ligament, and extensive decompression of posterior osteophytes of C5 and C6 vertebral bodies was performed. The patient developed tetraparesis and respiratory distress rapidly in the postanesthesia care unit and was reintubated for assisted ventilation. The computed tomography (CT) scan revealed a very large ventral epidural hematoma compressing the dural sac from C1 to C6. RESULTS: The patient was prepared for hematoma evacuation. However, the neurological symptoms and respiration problems began to resolve spontaneously before the surgery was started. The hematoma was markedly improved on the follow-up CT scan, and the patient was discharged 2 weeks after surgery without neurological deficit. CONCLUSIONS: This case illustrates that an unpredictable extensive hematoma can occur after uneventful surgery of the cervical spine in low-risk patients. In case of the dural exposure with a creation of hidden and large epidural space, the spine surgeon must pay particular attention to the possibility of a PSEH during the early postoperative period.

Synovial sarcoma of the posterior neck : a case report and review of literature.

We recently experienced a case of synovial sarcoma in the posterior neck, which involved adjacent bony structures. Synovial sarcoma is rare, malignant soft tissue tumor that occur predominantly in the lower extremities. Wide surgical excision with involved tissue is the treatment of first choice, because most synovial sarcomas reveal aggressive features. We removed the tumor with involved bony structures and patient was given postoperative radiation therapy. Despite these treatment options, the patient died 1 year after surgery. We report this case with a review of the literature.

Spontaneous resolution of a traumatic cervicothoracic epidural hematoma presenting with transient paraplegia: a case report.

STUDY DESIGN: Case description. OBJECTIVE: To clinically and radiographically describe a traumatic spinal epidural hematoma (TSEH) without adjacent spinal column fracture or soft tissue injury that completely resolved, without surgical intervention. SUMMARY OF BACKGROUND DATA: Symptomatic TSEH is an infrequent condition after spinal trauma, accounting for 0.5% to 1.7% of cases. It can result in permanent neurologic deficits if not treated in a timely and appropriate manner. METHODS: A 50-year-old man presented with progressive lower motor weakness and sensory change at 2 days after blunt trauma to the upper back area. Neurologic examination revealed paraplegia and hypesthesia below the T4 sensory dermatome. Magnetic resonance imaging for cervicothoracic spine showed a space-occupying lesion in the dorsal spinal epidural space from C7 to T5. The lesion was consistent with acute stage hematoma of the spinal epidural space. RESULTS: The patient was prepared for decompression surgery. However, the patient's neurologic symptoms began to improve (grade 4/5) at 2 hours after onset of paraplegia. Surgical intervention was delayed, and the patient was treated conservatively with close neurologic monitoring. Three days after onset of symptoms, the patient's neurologic symptoms recovered completely. The follow-up magnetic resonance imaging at 12 days after the event showed complete resolution of the epidural hematoma. CONCLUSION: An unpredictable extensive epidural hematoma can occur after blunt trauma of the cervicothoracic spine in patients at low risk for hemorrhage. This case illustrates that immediate surgical intervention may not always be necessary in certain patients with TSEH. Conservative management with careful observation may play a role as a management option for patients initially presenting with severe neurologic dysfunction if neurologic recovery is early and sustained.

Recurrent primary spinal subarachnoid neurocysticercosis.

STUDY DESIGN: Case description. OBJECTIVE: To describe a patient with a recurrent primary spinal subarachnoid neurocysticercosis (NCC) that was successfully treated with surgical decompression and medical therapy at our center. SUMMARY OF BACKGROUND DATA: Spinal subarachnoid NCC is thought to be the secondary result from larval migration through the ventricular system into the spinal subarachnoid space. However, this entity can develop as a primary infection through blood stream or direct larval migration. It can result in high recurrence and severe neurologic morbidity if it is not treated in an appropriate manner. METHODS: A 50-year-old woman with treatment history of spinal NCC presented with back pain and radicular pain. The lumbar magnetic resonance imaging showed a cystic lesion with septation and slight rim enhancement after gadolinium administration at the L4-S1 area. We performed surgical removal of this lesion and postoperative medical therapy for complete eradication of the parasite. RESULTS: The histopathology was diagnostic for a cysticercal cyst. Adjuvant medical therapy with albendazole was administered for 30 days after surgery. The patient remained symptom-free for 1 year after surgery without any evidence of recurrence. CONCLUSION: We report a rare case of recurrent primary spinal subarachnoid NCC at L4-S1 area. In cases of primary spinal subarachnoid NCC can be treated by adequate combined approach with surgery and medical therapy. Spinal subarachnoid NCC should be added to the differential diagnosis of primary spinal intradural cysts, because this lesion can occur primarily.

Splitting of the oculomotor nerve by the posterior communicating artery--case report.

A 62-year-old woman presented with subarachnoid hemorrhage manifesting as sudden onset of headache, but without visual symptoms or extraocular movement disturbances. Computed tomography angiography showed a 7-mm size aneurysm originating from the internal carotid-posterior communicating artery (PcomA). After the neck of the aneurysm was clipped, the PcomA was confirmed to have split the oculomotor nerve. Splitting of the oculomotor nerve by the PcomA was probably caused by arterial blood pulsation in the tortuous PcomA.

Surgical management of anterior cerebral artery aneurysms of the proximal (A1) segment.

OBJECTIVE: To report a series of 20 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery (ACA. METHODS: The medical records of patients who had undergone surgery for intracranial aneurysms at two institutions between January 1, 1989, and February 1, 2009, were reviewed. Mean patient age was 52.15 years (range 39-69 years). All 20 patients underwent direct surgery, with clipping or trapping, via standard pterional craniotomy. RESULTS: The incidence of A1 segment aneurysm was 0.59%. There were 16 women and 4 men, showing a strong predominance of this lesion in women. Mean aneurysm size was 6.95 mm (range 3-10 mm). Four patients (20%) had multiple aneurysms, and three patients (15%) had associated vascular anomalies. Among patients whose aneurysms originated from perforating arteries, dissection sacrificed the perforating arteries in two patients, and the perforating arteries occluded postoperatively in three patients. In the patients whose aneurysms did not originate from perforating arteries, no perforating arteries were sacrificed during dissection, and perforating arteries became occluded in two patients postoperatively. There was no statistically significant difference between the two groups of patients regarding the incidence of injury or occlusion. Clinical outcomes were as follows: good recovery in 15 (75%) patients, moderate disability in 2 (10%) patients, severe disability in 2 (10%) patients, and death in 1 (5%) patient. CONCLUSIONS: The important consideration in surgery for intracranial aneurysms is preservation of the perforating arteries, through cautious dissection around the neck or dome and avoidance of direct clip compression, even after releasing the retracted frontal lobe.

The clinical utility of the Kopitnik arteriovenous malformation microclip during STA-MCA bypass surgery.

PURPOSE: Yasagil temporary clips have been widely used in extracranial-intracranial (EC-IC) arterial bypass surgery. However, the extremely delicate vessels involved often require the application of finer clips. We report on the use of the Kopitnik arteriovenous malformation (AVM) microclip system for superficial temporal artery-middle cerebral artery (STA-MCA) bypass. METHODS: Kopitnik AVM microclips are new mechanical devices that are used during AVM surgery. They exert a pre-defined closing force of 50-70 g, and also feature a special, pyramid-shaped structure stamped on inner surfaces of the blades. These characteristics avoid vascular intimal injury and provide a secure grip. We prospectively studied their use in 15 patients requiring STA-MCA anastomosis. RESULTS: Clinical results were excellent and there were no new ischemic events during 6-months' follow-up. CONCLUSIONS: Kopitnik AVM microclips have several advantages; they have small and variously sized clip blades (2, 3, 4 and 5 mm), and the small clip head allows the operator an excellent view of the pathology and clip status. The Kopitnik AVM microclip appears to be clinically effective and safe for EC-IC bypass surgery, especially when smaller vessels are involved.

Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms.

OBJECTIVES: To describe surgical strategies using cerebral revascularization for complex middle cerebral artery aneurysms unsuitable to microsurgical clipping. MATERIALS AND METHODS: In this study, the clinical features, case management, and results in 9 consecutive patients who underwent 10 cerebral revascularization procedures between January 1999 and April 2008 were retrospectively analyzed. The patient population consisted of 6 men and 3 women whose ages ranged from 15 to 71 years (mean, 42.4 years). The size of the aneurysms ranged from 12 to 35 mm (mean, 24.3 mm). Treated aneurysms were located in the M1 segment in 2 patients, the middle cerebral artery (MCA) bifurcation in 3 patients, the distal M3 segment in 3 patients, and the anterior temporal artery (ATA; the early cortical branch of the M1 segment) in 1 patient. A total of 10 revascularizations were performed. Three aneurysms were saccular and six aneurysms were fusiform. For the fusiform aneurysms of the M1 segment in 2 patients, superficial temporal artery (STA) trunk-saphenous vein (SV)-MCA bypasses followed by trapping were performed. For the large saccular MCA bifurcation aneurysms in 3 patients, STA-MCA bypasses followed by complete neck clipping, including the revascularized branch with the preservation of the flow of the other branch, were performed in 2 cases, and a STA trunk-SV-MCA bypass secondary to direct neck clipping with the preservation of both M2 branches was performed in 1 case. For the fusiform distal MCA aneurysms, STA-MCA bypasses in 2 patients and in situ MCA-MCA bypasses in 2 patients were performed. In one case involving distal MCA fusiform aneurysm, STA-MCA bypass and MCA-MCA bypass were performed simultaneously. In a case involving fusiform ATA aneurysm, primary reanastomosis after aneurysm excision was performed in 1 patient. RESULTS: The post-operative 3-month Glasgow outcome scales were good recovery in 6 patients, severe disability in 1 patient, a vegetative state in 1 patient, and death in 1 patient. A follow-up angiography was performed in 6 patients and revealed a patent bypass in 5 patients. In one case treated by direct neck clipping secondary to cerebral revascularization, the angiography obtained 2 weeks later showed graft occlusion, but there were no neurologic symptoms. Among the unfavorable outcomes of 3 patients who did not undergo follow-up angiography, surgery-related morbidity secondary to cerebral infarction was due to the size discrepancy between the donor and recipient vessels in 1 patient with severe disability. In the other 2 patients, the preoperative conditions were Hunt and Hess grade V. CONCLUSIONS: Cerebral revascularization is a safe and effective technique of treatment for selective cases of complex large or giant aneurysms and unclippable fusiform aneurysms in the MCA.

Post-traumatic intradiploic leptomeningeal cyst of the posterior fossa in an adult.

Intradiploic cysts in the posterior fossa are rare. We report a post-traumatic intradiploic leptomeningeal cyst in an adult and review the diagnosis and pathogenesis of this lesion. A 28-year-old woman presented with a headache and a hard mass in the occipital region. She had a history of head injury as she had fallen from a height at the age of 18 months. CT scans and MRI revealed an expanding intradiploic cyst with the density of cerebrospinal fluid (CSF) and thinning of the inner and outer tables. A bony defect of the inner table connecting to the cisterna magna was also visualized. At surgery, we detected free communication of the CSF between the cystic cavity and the subarachnoid space of the posterior fossa via a defect in the dura and inner table. The dural defect was sutured primarily and covered with the autogenous outer table. An intradiploic cyst of the occipital bone can be detected in adults and might be caused by remote head injuries during childhood. Prompt surgical repair of the dural and bony defect in an adult patient has an excellent prognosis.

An unusual stab wound causing a traumatic pseudomeningocele at the craniocervical junction.

A stab wound to the craniocervical junction complicated by a pseudomeningocele has been reported rarely. A 65-year-old man was stabbed with a knife, and the blade penetrated the space between the occipital bone and the atlas. On admission, he presented with quadriparesis; the left arm was predominantly affected. The sensory level was at C2 on the left side. T2-weighted MRI showed a focal area of hyperintensity at the cervicomedullary junction, localized to the left of the spinal cord. The wound was carefully cleaned and closed. Follow-up MRI revealed a large pseudomeningocele along the trajectory, which resorbed completely without intervention. The quadriparesis improved progressively, except for the left arm, which improved only slightly. The asymptomatic insignificant meningocele completely improved spontaneously without surgery.