[A Case of Radiation Necrosis in the Right Occipital Lobe Accompanied with Massive Hemorrhage:Histopathological Analysis].

Radiation necrosis with massive hemorrhage is a rare complication of radiotherapy. We report the case of a male patient who had undergone radiotherapy therapy 18 years earlier and presently underwent gamma knife radiosurgery for a metastatic brain tumor in his right occipital lobe. The patient showed aberrant behavior with left homonymous hemianopsia and a gradual deterioration of cognitive function after radiotherapy. A CT scan showed the presence of an intracerebral hematoma over the right occipital lobe with mass effect, and small spotty enhancements on the lesion when enhanced on gadolinium contrast-enhanced MRI. Intraoperative findings revealed necrosis of the occipital surface and a hematoma in the occipital lobe. Pathological findings showed damage to the walls of the sinusoidal capillaries and vitreous degeneration of the inner membrane with a spongiform hemangioma. After surgery, the cerebral edema resolved, and the patient's clinical symptoms improved. The cause of the radiation necrosis and bleeding in this patient was assumed to be due to the breakdown of the congested walls of the sinusoidal capillary vessels.

Carotid Endarterectomy for Pseudo-occlusion of the Cervical Internal Carotid Artery.

OBJECT: This study described clinicopathological characteristics of pseudo-occlusion (PO) of the internal carotid artery (ICA) with regards to the pathological mechanism and the benefit of carotid endarterectomy (CEA). METHODS: We retrospectively reviewed 17 PO patients who underwent CEA. Clinical presentation, angiographic findings, surgical outcomes and plaque components obtained from CEA were investigated. RESULTS: PO plaques had more fibrous and two different pathological features, including total occlusion with recanalization and severe stenosis. Plaques of the total occlusion with recanalization (8 patients) were composed of thrombotic total occlusion and lumen recanalization by large neovascular channels, whereas those with severe stenosis (9 patients) were fibrous or fibroatheromatous plaque with severe stenosis of the original lumen. Of all the patients who underwent a carotid angiogram 2 weeks after surgery, 16 were successfully treated, but one showed complete occlusion of the ICA. At the follow-up period, two patients showed restenosis of the ICA. Three patients with complete occlusion or restenosis had histologically fibrous sclerotic plaques. CONCLUSION: Patients with PO had more fibrous plaques and two different histological features, including total occlusion with recanalization or severe stenosis. The plaque histology may be related to the pathogenesis and the surgical outcome.

Surgical strategy for intracranial endodermal cyst--case report.

Two cases of endodermal cyst of the posterior fossa are reported. A 12-year-old girl presented with severe headache and vomiting caused by increased intracranial pressure. Computed tomography and magnetic resonance (MR) imaging showed a cystic mass occupying the ambient and quadrigeminal cisterns. A 65-year-old woman presented with dizziness, and MR imaging revealed a cystic mass in the posterior fossa. The two patients underwent surgery for decompression and resection of the cyst. Surgical specimens of the cyst walls consisted of a single layer of ciliated columnar epithelium. The diagnoses were endodermal cyst. The optimal surgical goal is total resection of the cyst wall, but the cyst wall sometimes tightly adheres to the adjacent nerves, vessels, and vital structures. The cyst must communicate adequately with the surrounding cerebrospinal fluid space, and a newly closed cyst space must be avoided, by the widest possible resection of the cyst wall.

[A case of herpetic meningoencephalitis associated with massive intracerebral hemorrhage during acyclovir treatment: a rare complication].

We report a case of a 35-year-old female with herpetic meningoencephalitis confirmed by polymerase chain reaction and immunohistochemical study for herpes simplex virus-1 accompanied with a massive intracerebral hematoma as a complication. A hematoma localized at the medial temporal lobe and the medial frontal lobe occurred on the 11th day after initiation of acyclovir treatment. She subsequently required emergency surgery for temporal lobectomy, as well as hematoma and external decompression. Intracerebral hematoma with MR imaging showed gyral pattern along the cortex of the medial temporal lobe and the base of the medial frontal lobe. We speculate that the hemorrhage occurred by rupture of small vessels affected by vasculitis in addition to hypertension caused by increased intracranial pressure. We therefore emphasize the risk of intracerebral hemorrhage at an early stage or during acyclovir treatment, especially during one or two weeks after initiation of the treatment, and the necessity of careful observation during these periods.

Ruptured aneurysm of the distal anterior cerebral artery: clinical features and surgical strategies.

Ruptured aneurysms of the distal anterior cerebral artery (ACA) are relatively rare and surgical management provides some unique technical challenges. This retrospective analysis of 20 patients with distal ACA aneurysms evaluated the clinical features and surgical strategies. The characteristic findings were small and common concurrent aneurysms, and frequent intracerebral hematoma (ICH). Aneurysms were divided by location on the genu (n = 13), infracallosal (n = 5), and supracallosal portions (n = 2). All patients except one underwent surgery via an interhemispheric route. Unilateral craniotomy was performed for aneurysms on the genu portions without massive ICH. Bilateral craniotomies were selected for aneurysm located on the infracallosal portion or combined with massive ICH. No intraoperative rupture was observed. Favorable outcomes were achieved in 15 of 20 patients, and only one patient died. The preoperative Hunt and Kosnik grade was closely correlated with the outcome.

Stroke in patients on maintenance hemodialysis: a 22-year single-center study.

BACKGROUND: Few studies have reported the detailed clinical features of stroke in patients with end-stage renal disease. We examined the frequency of the subtypes, mechanism, and outcome of stroke in patients receiving hemodialysis (HD). METHODS: We studied 151 consecutive patients who developed an acute stroke among the maintenance HD population in our kidney center during 22 years, divided into the initial 17-year (n = 61) and the more recent 5-year (n = 90) groups. For purposes of comparison, we also studied 1,017 stroke patients with normal renal function. RESULTS: Stroke patients receiving HD were younger (age, 64 +/- 10 versus 67 +/- 13 years; P < 0.02) and more frequently had hypertension (87% versus 43%; P < 0.0001) and diabetes (53% versus 23%; P < 0.0001) compared with stroke patients with normal renal function. In the initial HD group, brain hemorrhage was the major subtype of stroke (52%), whereas in the more recent group, brain infarction (BI) replaced hemorrhage as the leading subtype (68%; P < 0.005). In patients with BI, large-artery atherosclerosis was more prevalent in the more recent group than in the initial HD group (33% versus 12%; P < 0.05). A vertebrobasilar territory infarct was more prevalent for HD patients than for those with normal renal function (48% versus 33%; P < 0.05). BI (especially large-artery atherosclerosis and cardioembolism) occurred more frequently during or less than 30 minutes after the dialysis procedure (34%) than brain hemorrhage (19%; P < 0.05). Receiving HD was an independent indicator for poor functional outcome and mortality after stroke. CONCLUSION: In our maintenance HD population, stroke showed several unique characteristics compared with the control population, including a predominance of vertebrobasilar arterial territory infarcts. The dialysis procedure itself seems to be associated more frequently with ischemic rather than hemorrhagic strokes.

[Clinical analysis of the patients with hemodialysis associated with intracerebral hematoma].

We treated 64 hemodialysis patients with cerebral hemorrhage over an 18-year period between 1986 and 2003. Clinical features, prognostic factors, and therapeutic strategy were reviewed in these cases. Thirty of the cases were in the 13-year period between 1986 and 1998, and 34 cases, in the 5-year period between 1999 and 2003. In recent years, the incidence of cerebral hemorrhage has risen with the increase in the number of hemodialysis patients. There were 21 patients with at least a 10-year history of hemodialysis. The underlying cause of renal failure was diabetic nephropathy in 25 patients and glomerulonephritis in 24 patients. The most frequent sites of bleeding were the basal ganglia and thalamus, the cerebellum being involved in only one patient. Many patients had severe bleeding with hematomas greater than 61 ml. Outcome assessment by the Glasgow Outcome Scale showed 24 patients with good recovery, 8 with moderate disability, 4 with severe disability, and 28 who died. Good recovery was seen more often in patients in their 50s and 60s, whereas death occurred more often in patients aged 70 and older. Although there is now less morbidity than previously, the prognosis is not uniformly favorable in all cases. Factors associated with a poorer prognosis included mixed hemorrhage, hematomas greater than 61 ml, and age 70 and older. Hematoma size and age were particularly important prognostic factors. Improved management and prognosis in these patients requires acute intensive treatment similar to that for hypertensive cerebral hemorrhage.

Intraventricular rupture of Nocardia brain abscess--case report.

A 71-year-old male presented with left hemiparesis and confused conversation. Computed tomography showed a mass lesion with rim enhancement in the right parietal lobe. He developed meningeal irritation the day after admission. Emergent fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) imaging revealed a clear hyperintense component in the right lateral ventricle and niveau formation inside the intracerebral lesion, indicating intraventricular rupture of the brain abscess. The patient underwent aspiration of the abscess and ventricular drainage with antibiotic administration. Nocardia asteroides was isolated from the aspirated pus, so systemic and direct administration of effective antibiotics was subsequently commenced. These procedures resulted in gradual improvement of his clinical course, and he left our hospital. Several days after discharge, he developed acute pan-peritonitis due to malignant lymphoma. He appeared to be progressively deteriorating after an exploratory laparotomy, and died on the 17th day after the laparotomy. Intraventricular rupture of nocardia brain abscess can be successfully treated after early definitive diagnosis with FLAIR MR imaging.

Pediatric blunt carotid injury--case report.

A 5-year-old boy was struck by a pickup truck, and admitted with Glasgow Coma Scale score of 14. Initial computed tomography (CT) showed no evidence of intracerebral lesions except for a skull fracture. Repeat CT 5 hours later showed hyperdense middle cerebral artery (MCA) sign, but he did not show any focal signs. Eighteen hours after the accident, he developed left hemiparesis. CT revealed a fresh infarction in the right MCA territory, associated with definite hyperdense MCA sign. He was immediately transferred to our hospital for further evaluation. Emergent angiography revealed a rat tail-shaped occlusion of the right internal carotid artery at the C-3 level. Cross-filling of the right MCA territory was insufficient for collateral circulation. He was treated conservatively because of the significant risk of hemorrhagic change from the established infarction. His hemiparesis improved gradually, and he was discharged on foot. Hyperdense MCA sign in a child is an important clinical sign for the early detection of cerebral ischemia after blunt carotid injury, before any focal signs appear.