Impact of polyunsaturated fatty acid consumption prior to ischemic stroke.

OBJECTIVE: The Japanese have higher levels of n-3 polyunsaturated fatty acids (PUFAs) such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in their diets. These facts may contribute to the lower rates of atherosclerosis in Japanese. The purposes of this study were to assess the PUFA levels in patients with subtypes of acute ischemic stroke and to assess the relationship between severity and PUFA levels. MATERIAL AND METHODS: We studied 75 patients with lacunar infarction (LI; n = 25), atherothrombotic infarction (AT; n = 32), and cardiogenic embolism (CE; n = 18). The patients underwent blood examinations in a fasting state next morning of hospitalization, including examination of low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglyceride (TG), blood glucose, hemoglobin A1c (HbA1c), uric acid, and fatty acid fractions of EPA, DHA, dihomo-γ-linolenic acid (DGLA), and arachidonic acid (AA). We used the modified Rankin Scale (mRS) to assess clinical severity at discharge. RESULTS: There was no significant difference in the EPA/AA and DHA/AA ratio among the three stroke subgroups, although the DGLA/AA ratio was significantly higher in patients with LI than in patients with CE. Considering the confounding factors, the mRS was negatively correlated with EPA/AA and positively correlated with age, DHA/AA, and blood glucose. CONCLUSIONS: High EPA/AA ratio was associated with good outcome in ischemic stroke. Our paper suggests that prestroke dietary habits affect the severity in patients with ischemic stroke.

Preoperative embolization of meningiomas with N-butyl cyanoacrylate.

Meningiomas are often embolized before their surgical resection to reduce blood loss during surgery. Polyvinyl alcohol (PVA) particles have been the most frequently used material for embolization of meningiomas. We have used n-butyl cyanoacrylate (NBCA) as the first-choice material since 2001. Thirty-one meningiomas were embolized with NBCA. We report the result of embolization of meningiomas with NBCA in comparison with PVA particles.

Giant intracranial aneurysm of the anterior communicating artery treated by direct surgery using A3-A3 side-to-side anastomosis and A3-RA graft-STA anastomosis.

We describe a giant aneurysm of the anterior communicating artery (ACoA) which was treated with a STA-RA graft-A3 bonnet bypass and A3-A3 side-to-side anastomosis. A giant and partially thrombosed ACoA aneurysm was partially coated 3 years before his current presentation, its gradual increase producing visual field disturbances. An A3-A3 side-to-side anastomosis and STA-RA graft-A3 bonnet bypass were performed. The aneurysm was dissected, and the thrombus removed under transient parent-artery occlusion. The aneurysmal neck was successfully clipped without encountering ischemic changes. This strategy may be useful for treating giant or thrombosed aneurysms in the region of the ACoA.

[A case of iatrogenic carotid artery dissection treated with radial artery graft].

A case of iatrogenic intracranial artery dissection is reported. A 52-year-old female developed severe headache and nausea. Brain CT showed diffuse subarachnoid hemorrhage. On admission, carotid angiography revealed an aneurysm in the right middle cerebral artery and the intact right internal carotid artery. The aneurysm was clipped successfully. Carotid angiography on day 7 revealed dissection in the right internal carotid artery. Repeated angiograms at 10 and 31 days showed progression of the carotid artery dissection. Findings of ECD-SPECT on day 31 (Balloon occlusion test) suggested low perfusion of the right internal carotid artery territory. The patient underwent surgical reconstruction of the right internal carotid artery using a radial artery. She presented with right abducens nerve palsy three days after the radial artery graft. The patency of the radial artery graft was proved by the post-operative angiography. Internal carotid artery dissection may occur spontaneously or as a result of trauma. An iatrogenic dissection is an uncommon complication of cerebral angiography. There are no evidence-based guidelines for the treatment although anticoagulation therapy is most commonly used. The present case emphasizes the usefulness of radial artery graft for traumatic carotid artery dissection.

Aneurysm of the distal posteroinferior cerebellar artery of extracranial origin: case report.

OBJECTIVE AND IMPORTANCE: We describe a very rare case involving a ruptured intracranial aneurysm at the distal posteroinferior cerebellar artery (PICA) branching from the extracranial vertebral artery. CLINICAL PRESENTATION: A 53-year-old woman experienced the sudden onset of a severe occipital headache and vomiting. Computed tomographic scanning revealed subarachnoid and intraventricular hemorrhage. Cerebral angiography of the left vertebral artery demonstrated the left PICA branching from the extracranial segment of the extracranial vertebral artery at the level of C2; a saccular aneurysm arose from the intracranial portion of the distal PICA. INTERVENTION: Via the transcondylar approach, we were able to obtain adequate visualization without retracting important structures. To avoid injury to the anomalous PICA, the aneurysm was clipped. CONCLUSION: Only four other cases of a distal aneurysm of the PICA branching from the extracranial vertebral artery have been reported in the literature. In all cases, the aneurysm originated at the intradural extracranial portion of the PICA. To our knowledge, the case presented here is the first report of a ruptured aneurysm at the level of the intracranial portion of the PICA branching from the extracranial segment of the vertebral artery.

Spontaneous regression of a germinoma in the pineal body after placement of a ventriculoperitoneal shunt.

The authors report a case in which a germinoma in the pineal body displayed spontaneous regression after placement of a ventriculoperitoneal (VP) shunt. Spontaneous regression of malignant tumors is extremely rare, occurring in only one of 60,000 to 100,000 patients. Although in rare cases spontaneous regression is known to occur in patients with testicular seminomas, only one case of spontaneous regression of a primary pineal germinoma has so far been reported. In the present case a 17-year-old man presented with headache. A tumor in the pineal body and acute hydrocephalus were revealed by head computerized tomography (CT) and magnetic resonance (MR) imaging, and VP shunt placement was performed. Computerized tomography scanning of the head was performed four times during a 2-week period following the operation, and the patient was temporarily discharged to return to school. At the time of discharge, CT scanning demonstrated no change in the size of the tumor. Two months later, the patient was readmitted to the hospital to undergo surgery. At that time, head MR imaging revealed regression of the tumor. The pathological diagnosis of the lesion was germinoma. The patient underwent three courses of chemotherapy, during which carboplatin and etoposide were administered, in addition to a 24-Gy dose of radiotherapy. No manifestations of nerve impairment were noticed, and the patient was observed on an outpatient basis. The authors think that the factors involved in tumor regression included the effects of the VP shunt, the effects of radiation absorbed during head CT scanning, and the role of the patient's own immune response. However, no conclusion has been reached concerning the actual cause.

[An ultrasonic study of the relationship between extracranial carotid atherosclerosis and intracerebral hemorrhage].

We have evaluated the relationship between carotid atherosclerotic change and intracerebral hemorrhage patients. Forty-eight patients with intracerebral hemorrhage treated at our institution were included in this study. Their ages ranged from 38 to 86 years old (average: 61.5 years). There were 28 cases of putaminal hemorrhage and 20 cases of thalamic hemorrhage. Evacuation of hematoma or ventricle drainage was performed in 18 cases within 3 days after the onset of symptoms. The outcome in these cases was that 40 patients survived and 8 patients died. Carotid atherosclerosis was evaluated by B mode-ultrasonography. The severity of carotid atherosclerosis was assessed by using two indicators; incidence of carotid atherosclerosis and maximum percentage diameter of the stenosis. Carotid atherosclerosis on B mode-ultrasonography was detected more frequently in patients with thalamic hemorrhage (84.2%) than in those with putaminal hemorrhage (51.7%). Maximum percentage stenosis of thalamic hemorrhage (17.2 +/- 15.2%) was higher than maximum percentage stenosis of putaminal hemorrhage (6.4 +/- 9.7%). In conclusion, carotid atherosclerosis was an effective indicator of not only ischemical cerebrovascular disease but also of intracerebral hemorrhage.

[Occipital neuralgia caused by the compression of the fenestrated vertebral artery: a case report].

A case is presented of fenestration of the vertebral artery in a 36-year-old woman who had various neurological symptoms with Basedow's disease. We also review 7 cases from the literature. Our patient had had occipital neuralgia and numbness of the left side of the neck and left upper limb several weeks before admission. On admission she had hyperthyroidism. MRI, left vertebral angiography, and 3D-CT scans demonstrated a fenestrated vertebral artery compressing the upper cervical cord. The patient's symptoms gradually improved as her thyroid function was controlled. A possible explanation is that the fenestrated vertebral artery might have compressed the neural structures, resulting in her various symptoms. Occipital neuralgia was apparently caused by the fenestrated artery compressing the C1 and C2 sensory roots. A fenestrated vertebral artery is usually of no clinical significance. The reason for the late onset of symptoms in the present case is unknown, but it may have been due to hemodynamic stress caused by her hyperthyroidism. After her thyroid function was controlled, the hemodynamic stress presumably decreased and the symptoms resolved spontaneously.

[Monostotic fibrous dysplasia of the occipital bone].

A case of monostotic fibrous dysplasia of the occipital bone in a 18-year-old female is described. She was admitted to our hospital with a hard, painless mass (5 x 5 cm) in the occipital region. Neurological examination and laboratory data revealed no abnormalities. Skull x-rays showed a radiolucent lesion with a sclerotic margin in the occipital bone. CT scan revealed an intradiploic multilocular mass separated by bone trabeculae. RI bone scan showed an abnormal uptake in this lesion. T1 and T2 MR image showed an abnormal low-intensity lesion in the occipital region. Operation was performed to verify the nature of the lesion, which was histologically confirmed to be an inactive fibrous dysplasia. Postoperative course was uneventful. Although its occurrence in the occipital bone is uncommon, fibrous dysplasia should be considered in the differential diagnosis of skull tumors.

[Clinical aspects and intracranial pressure monitoring in cases of traumatic posterior fossa hematoma].

Clinical signs, skull X-P, computerized tomography (CT), continuous monitoring of intracranial pressure (ICP), and serial recording of auditory brainstem response (ABR) were examined in 22 cases of traumatic posterior fossa hematoma. Fifteen of the patients were male and seven were female. Their ages ranged from 3 to 86 years old (mean 35.2 years). The causes of the head injuries were traffic accidents in 13 cases and falls in 9 cases. The site of cranial impact was occipital in all cases but one. Sagittal impact was most common and skull fractures were found in the occipital regions in 19 cases. States of consciousness on admission as measured by the Glasgow coma scale (GCS) were GCS 15 in 2 cases, GCS 9-14 in 9 cases and GCS 3-8 in 11 cases. CT findings of posterior fossa included 10 cases of intracerebellar hematoma, 8 cases of epidural hematoma, 2 cases of combined epidural and intracerebellar hematoma and 2 cases of subdural hematoma. Associated CT findings of the supratentorial region were noted in 18 cases (82%), and most of them showed contrecoup injuries in the frontal region. Six cases of 8 epidural hematomas of the posterior fossa indicated combined epidural hematomas in the occipital region. ICP was monitored in 11 of the 22 cases. Pre-operative ICP monitoring (5 cases) indicated an operative decision. ABR was recorded in 5 cases. Serial ABR recording provides reliable information about brain stem function. The hematoma was evacuated in 15 cases. The Glasgow outcome scale administered 3 months after trauma indicated good recovery in 2 cases, moderate disability in 6 cases, severe disability in 2 cases, persistent vegetative state in 1 case and death in 9 cases. It has become obvious that there are many types of CT findings in posterior fossa hematomas, and that continuous ICP monitoring is very important to determine the timing of surgery and to protect against secondary brain damage caused by increased ICP.