Surgical treatment of spinal extradural arteriovenous fistula with parenchymal drainage: report on 5 cases.

BACKGROUND AND IMPORTANCE: Spinal extradural arteriovenous fistula (SEDAVF) with parenchymal drainage (type A) is a rare clinical entity that causes venous congestive myelopathy. Treatment includes endovascular and open microsurgical interventions. We reviewed the clinical records of patients treated for a type A SEDAVF to evaluate the feasibility of our treatment strategy. CLINICAL PRESENTATION: Between 2004 and 2010, 5 patients with a type A SEDAVF were treated at our institutes (4 men and 1 woman; mean age, 60 years). We performed endovascular transvenous embolization (TVE) when lesions were accessible transvenously; otherwise, microsurgical perimedullary drainer occlusion was performed. Follow-up ranged from 23 to 94 months (mean, 45.8 months). One patient was treated with TVE, and the remaining 4 were treated with microsurgical drainer occlusion. After a simple intradural drainer occlusion, an epidural venous lake was completely thrombosed in 2 patients. In 1 patient, postoperative angiography revealed that a part of the epidural component had persisted; however, the patient has been asymptomatic. In the remaining case with multiple intradural draining veins, sole drainer occlusion was not sufficient. A second surgery was required to meticulously coagulate the venous lake. As a consequence, parenchymal drainers disappeared. Overall, all patients stabilized or improved neurologically and experienced no recurrence. CONCLUSION: To treat a type A SEDAVF, either TVE or microsurgical intradural drainer occlusion can be used for satisfactory long-term results with minimal surgical risks. For a case with multiple intradural draining veins, detachment of the venous lake should be considered.

Angiocentric glioma and surrounding cortical dysplasia manifesting as intractable frontal lobe epilepsy--case report.

A 26-year-old man presented with a case of angiocentric glioma manifesting as medically refractory epilepsy. Magnetic resonance imaging revealed a hyperintense lesion in the right superior frontal gyrus on T(2)-weighted imaging, with cortical hyperintense rim on T(1)-weighted images and minimum contrast enhancement. Video-electroencephalography (EEG) monitoring characterized his seizures as originating from the right frontal lobe. Long-term EEG recording from implanted subdural electrodes disclosed epileptic activities extending beyond the margin of the radiological lesion. Extended cortical resection of the superior frontal gyrus including the tumor and the surrounding epileptic cortices was performed. Postoperatively, he became seizure-free with antiepileptic medication during a 12-month follow-up period. Histological examination of the surgical specimen showed the characteristic findings of angiocentric glioma. Associated cortical dyslamination consistent with cortical dysplasia was found in the surrounding cortex. Angiocentric glioma is a slow-growing or stable tumor frequently presenting with intractable epilepsy. Surgical treatment would be aimed primarily at control of epilepsy. Complete lesionectomy usually results in postoperative seizure freedom, but the present case shows evidence for associated cortical dysplasia with this tumor entity. Careful pre-surgical evaluation for epilepsy is necessary to achieve better seizure outcome.

Hemosiderin detected by T2*-weighted magnetic resonance imaging in patients with unruptured cerebral aneurysms: indication of previous bleeding?

Previous bleeding from a cerebral aneurysm indicates a higher risk of rupture. Hemosiderin may be detected during aneurysm surgery or by preoperative imaging sensitive to hemosiderin. The detection of hemosiderin deposits by T(2)*-weighted magnetic resonance (MR) imaging was evaluated in 49 patients with unruptured cerebral aneurysms who underwent open surgery. MR imaging was performed using 3.0 tesla MR scanner. Two sequences of T(2)*-weighted imaging, and proton density images were obtained. Preliminary study in patients with old subarachnoid hemorrhage provided the definitions of likely pathological findings during surgery and on T(2)*-weighted imaging due to previous hemorrhage. Hemosiderin deposits in the subarachnoid space were observed during surgery in 9 of the 49 patients, although no obvious rupture site was detected around the aneurysm wall. Size, presence of bleb, location, and number of aneurysms showed no significant difference between patients with and without hemosiderin deposition. Hypointense areas on T(2)*-weighted imaging were recognized in four patients. The mean size of the aneurysms in these patients was 9.8 mm, significantly larger than those in other patients (p = 0.029). Hemosiderin deposits were observed during surgery in sites close to the lesions on T(2)*-weighted imaging in two of these four patients. Hemosiderin deposits are not rare in patients with unruptured aneurysms, and preoperative T(2)*-weighted imaging can detect such deposits.

Magnetic resonance imaging for preoperative identification of the lenticulostriate arteries in insular glioma surgery. Technical note.

Aggressive resection of insular tumors is possible using a meticulous surgical approach based on the regional insular anatomy, with high rates of gross-total resection and low rates of permanent neurological deficits. However, the risk of postoperative morbidities remains high, often caused by disruption of the vascular supply to the surrounding eloquent structures, especially the lenticulostriate arteries (LSAs) that supply the internal capsule. Three-dimensional 3-T time-of-flight (TOF) MR imaging was performed pre- and postoperatively in patients with insuloopercular gliomas. This 3D 3-T TOF MR imaging clearly visualized the LSAs and the relationships with the tumor margins. These findings were confirmed intraoperatively. Three-dimensional 3-T TOF MR imaging of the LSAs in patients with insuloopercular gliomas can help to maximize the extent of resection without neurological complications, preserve the LSAs during surgery, and assist in patient selection.

[Stab injury of the brain by kitchen knife].

A 32-year-old male attempted suicide by stabbing his forehead with a kitchen knife, and was sent to our hospital. On admission, he was confused (20-30/JCS), but was able to move his both extremities. Skull X-p, CT scan indicated that the kitchen knife penetrated the frontal bone, reached the cerebrum by way of the frontal sinus. Cerebral angiography was performed, and showed no vascular lesions. Emergent craniotomy was performed and the kitchen knife was removed with minimum movement. Traumatic intracerebral hematoma was removed, and injured frontal sinus, dura mater and frontal bone were repaired. Postoperative course was excellent and he was discharged with the wounds well healded, no neurological deficits on the 17th day after the operation. There are several reported cases of such stab injury. Stab injury of the brain was discussed in the literature.