[Analysis of Rupture during Follow-up of Unruptured Aneurysm].

OBJECT: To elucidate clinical aspects of ruptured aneurysms, we retrospectively investigated associations between risk factors and ruptured and unruptured cases during conservative management. METHODS: Two hundred and twenty-nine patients with 291 unruptured cerebral aneurysms treated between 2000 and 2012 were analyzed. Mean duration of observation was 62 months (1183.4 person-years). We investigated the following six risk factors: history of subarachnoid hemorrhage;multiplicity;location of aneurysms;aneurysm size ≤5mm;bleb or irregular forms;and follow-up period <1 year. RESULTS: Twenty-two aneurysms in 22 patients (19 women;86.4%) ruptured during this study. The annual rate of rupture was 1.86%. In ruptured cases, mean age was 66.7 years. According to univariate analysis, aneurysm size≥5mm(p=0.000), bleb or irregular form(p=0.006)and duration of observation<1 year (p =0.000) were significantly associated with aneurysmal rupture. In multivariate analysis of these factors, aneurysm size≥5mm(p =0.0188;odds ratio(OR), 3.4;95% confidence interval (CI), 1.2-9.7) and duration of observation<1 year (p=0.006;OR, 5.0;95% CI, 1.6-14.9) represented independent risk factors for aneurysm rupture. CONCLUSIONS: The results of this study were almost the same as those of the UCAS Japan study. In addition, duration of observation <1 year was a risk factor for aneurysm rupture. When we decide on surgical treatment after considering factors such as aneurysm size, form, and surgical risk, surgery should be performed as soon as possible.

Effectiveness of intraarterial administration of fasudil hydrochloride for preventing symptomatic vasospasm after subarachnoid hemorrhage.

OBJECTIVE: We examined the effect of intraarterial administration of fasudil hydrochloride (IAFC), a Rho kinase inhibitor, for the prevention of symptomatic vasospasm after SAH by evaluating cerebral circulation. METHODS: We evaluated IAFC cases of 57 sides of 38 patients (12 men and 26 women, average age 60.2 years old) diagnosed with aneurysmal subarachnoid hemorrhage (SAH) from February 2012 to November 2012. All cases were treated by clipping or coil embolization within 48 h after onset. Indication for IAFC was the existence of a spastic change on follow-up digital subtraction angiography (DSA) compared with that of onset. RESULTS: Clipping was performed in 30 cases and coil embolization in 8 cases. IAFC was performed an average of 6.6 days after onset. Color gradient mapping demonstrated reduction of the circulation time after IAFC compared with before IAFC on 39 sides, no change on 15 sides, and extension on 3 sides. Average arterial circulation time before IAFC was 2.25 ± 0.57 s and after IAFC was 1.95 ± 0.55 s. IAFC significantly shortened average arterial circulation (P = 0.005). No case developed symptomatic vasospasm after IAFC. CONCLUSION: IAFC significantly reduced the cerebral circulation time after aneurysmal SAH and might be effective for the prevention of symptomatic vasospasm.

[An operated case of a giant fusiform aneurysm of the middle cerebral artery with alternating radiological findings within a short period].

We report an operated case of a giant fusiform aneurysm of the middle cerebral artery (MCA). An 18-year-old man presenting with a 6-month history of severe left temporal headache was admitted to our department. On admission, MRI revealed a mass lesion measuring 45 mm in diameter in the left frontal lobe. A left carotid angiogram revealed aneurysmal dilatation and stenosis in the M2 portion of the left MCA, which was diagnosed as a giant fusiform dissecting aneurysm. An intracarotid amobarbital test (Wada test)demonstrated ischemic tolerance to occlusion of the parent artery. Spontaneous occlusion of the parent artery and obliteration of the aneurysmal lesion incidentally occurred 15 days after admission. Follow-up 3D-CT angiography revealed recurrence of the aneurysmal dilatation in the same segment of the artery 6 days after the spontaneous obliteration. The lesion was then successfully resected without revascularization. Histopathological examination revealed a pseudolumen and loss of the three-layer structure of the aneurysmal wall. The postoperative course was uneventful and the patient was discharged without neurological deficits. We present the case report and a review of the literature.

A case of dural arteriovenous fistula presenting as acute subdural hematoma.

Dural arteriovenous fistula (AVF) presenting with subdural hematoma is relatively rare. We report a case of dural AVF presenting as acute subdural hematoma (ASDH) and provide a review of the literature. A 56-year-old man presented with disturbance of consciousness. Computed tomography demonstrated a right ASDH and a small right occipital subcortical hematoma. Cerebral angiography showed a dural AVF on the occipital convexity draining into the cortical veins. Emergent endovascular embolization was immediately performed and the shunt flow disappeared. Hematoma removal and external decompression were safely conducted. Combined therapy successfully recovered the patient's consciousness level. This rare case of dural AVF presenting with ASDH was treated with combined treatments of endovascular and open surgery.

B-cell malignant lymphoma presenting as otitis media and mastoiditis associated with sinus thrombosis.

Cerebral venous thrombosis as a manifestation of paraneoplastic angitis and otitis media, revealing non-Hodgkin B-cell lymphoma (NHBL), is extremely rare. A 57-year-old woman presented with headache, auditory disturbance and recalcitrant otitis media. Magnetic resonance imaging showed brain edema in the temporal lobe and transverse sinus thrombosis. External drainage under antibiotic treatment was repeated based on a diagnosis of invasive otitis media and mastoiditis associated with infectious sinus thrombosis, but the condition deteriorated progressively. Open surgery for otitis media was performed 6 years after the initial symptoms and after a tumorous lesion had been detected in the middle ear. Pathological findings revealed NHBL. We report a rare case of NHBL presenting as otitis media and mastoiditis associated with sinus thrombosis, and a literature review.

Brain metastasis from invasive thymoma mimicking intracerebral hemorrhage: case report.

A 55-year-old man with an 8-year history of invasive thymoma presented with sudden onset of left hemiparesis. Computed tomography (CT) and magnetic resonance (MR) imaging showed a right frontal lobe intracerebral hemorrhage and the possibility of brain metastasis could not be rejected. The patient underwent removal of the hematoma. Histological examination showed brain metastasis from invasive thymoma. To the best of our knowledge, this is the first reported case of hemorrhagic brain metastasis from invasive thymoma (non-cancerous) mimicking intracerebral hemorrhage.

Arachnoid cyst in the middle cranial fossa presenting with pulsatile exophthalmos: case report and literature review.

A 20-year-old woman suffered gradual progression of right pulsatile exophthalmos and slight headache. Computed tomography (CT) demonstrated outward and downward displacement of the right globe and an arachnoid cyst in the right middle cranial fossa associated with thinned and anterior protrusion of a bony orbit. Microscopic cystocisternotomy was performed and the cerebrospinal fluid (CSF) inside of the cyst communicated into the carotid cistern and cistern in the posterior cranial fossa. Pulsatile exophthalmos improved immediately after surgery. Arachnoid cyst in the middle cranial fossa presenting with exophthalmos is rare. Microscopic cystocisternotomy might successfully improve CSF flow and relieve exophthalmos.

Subarachnoid hemorrhage after an ischemic attack due to a bacterial middle cerebral artery dissecting aneurysm: case report and literature review.

A 78-year-old woman suffered sudden-onset left hemiparesis. There were no remarkable infectious findings. Computed tomography (CT) demonstrated a low-intensity area supplied by the right middle cerebral artery (MCA). The diagnosis was cerebral ischemia and she was conservatively treated with hyperosmotic fluids. Two days after the ischemic stroke she suddenly became comatose. CT showed diffuse subarachnoid hemorrhage (SAH) in the basal cistern associated with a right intra-Sylvian and a right frontal subcortical hematoma. Three-dimensional (3D)-CT angiography demonstrated occlusion of the M2 portion of the right MCA. Four days after the ischemic onset she died of brain herniation. Autopsy revealed arterial dissection in the intermediate membrane of the right MCA bifurcation and occlusion of the M2 portion of the thrombosed right MCA. Gram staining showed remarkable bacterial infection in the thrombus. SAH after an ischemic attack due to MCA dissection is extremely rare. We suspect that bacterial infection was involved in the formation of her fragile dissecting aneurysm.

A case of difficult management of fluid-electrolyte imbalance in choroid plexus papilloma.

A 22-month-old boy presented with nausea and gradual deterioration of gait disturbance. Computed tomography (CT) demonstrated an intraventricular mass lesion in the right lateral ventricle. He was referred to our department 3 weeks after onset. Acute hydrocephalus gradually proceeded 4 days after admission, and external ventricular drainage (EVD) was performed. EVD revealed cerebrospinal fluid (CSF) overproduction (800-1,500 mL/day) under constant pressure of 10 cm H2O above external auditory meatus. Magnetic resonance imaging showed a multi-lobular mass in the inferior horn of the right lateral ventricle. A choroid plexus tumor was suspected. The ratio of blood urea nitrogen:creatinine (BUN:Cre) remained between 30 and 40, and hemoglobin was between 14.0-17.0 mg/dL, suggesting marked dehydration. Serum sodium varied between 117 and 140 mmol/L, and serum potassium between 2.2 mmol/L and 6.9 mmol/L. The amount of EVD was unstable and fluid balance management was difficult. Hypotonic fluid with sodium chloride supplement was used to adjust the fluid and electrolyte imbalance. Surgical removal of the tumor was performed 6 days after EVD and tumor was grossly and totally removed. The high BUN:Cre ratio decreased to about 15 and hemoglobin recovered to 7.5-9.0 mg/dL after removal. Electrolytes returned to the normal range. Overproduction of CSF also markedly improved to < 300 mL/day. Histopathological examination diagnosed choroid plexus papilloma.We experienced a case of choroid plexus papilloma associated with fluid-electrolyte imbalance due to over-drainage after EVD, which could not be effectively controlled before tumor removal. Cautious fluid management and emergent surgical resection might be required to manage the overproduction of CSF and fluid-electrolyte imbalance.

Subdural empyema due to Lactococcus lactis cremoris: case report.

Lactococcus lactis cremoris (L. lactis cremoris) infections are very rare in humans. Only three case reports of brain abscess have been reported and the infectious routes and pathological features are still unknown. We experienced a subdural empyema due to L. lactis cremoris in an immunocompetent adult. A 33-year-old man was admitted with fever, right facial pain, left hemiparesis, and left hemianopsia. Computed tomography demonstrated low density fluid collection in the right falcotentorial subdural space. Magnetic resonance (MR) images revealed a high signal lesion on a diffusion-weighted image (DWI) and fluid attenuated inversion recovery (FLAIR) images in the right paratentorial and parafalcine subdural space, right maxillary sinus, and bilateral ethmoidal sinus. He underwent two sequential open surgeries for removal and drainage of empyema and was treated with antibiotics including meropenem and ampicillin. To our knowledge, this is the first report of subdural empyema caused by L. lactis cremoris infection. We report the case and discuss the pathological features with the previous literature.

Expression of the TGF-ß-ALK-1 pathway in dura and the outer membrane of chronic subdural hematomas.

Neovascularization of the outer membrane plays a critical role in the development and enlargement of chronic subdural hematomas (CSHs) and vascular endothelial growth factor (VEGF) may promote their progression. However, the precise mechanisms remain to be determined. We focused on the signaling pathway upstream of VEGF, transforming growth factor ß (TGF-ß), and activin receptor-like kinase 1 (ALK-1) to identify the mechanisms underlying the neovascularization of the outer membrane of CSH. Retrospective comparative study was conducted on 15 consecutive patients diagnosed as CSH with burr-hole drainage. Dura and the outer membrane were collected. We immunohistochemically examined the expression of VEGF, integrin-α, TGF-ß, and ALK-1 on the outer membrane and dura of CSH and compared our findings with control samples and the signal intensity of hematomas on computed tomography (CT) scans. VEGF and integrin-α expression was markedly up-regulated in both the dura and outer membrane of CSH, the expression of TGF-ß and ALK-1 in the dura was slightly increased in the dura and markedly up-regulated in the outer membrane. There was no significant correlation between their expression and CT density. Here we first report the expression of TGF-ß and ALK-1 in the outer membrane and dura mater of CSH. We suggest that the TGF-ß-ALK-1 pathway and VEGF affect neovascularization and the progression of CSH.

Subarachnoid hemorrhage in a patient with a meningioma and an unruptured aneurysm.

Subarachnoid hemorrhage (SAH) is usually elicited by cerebrovascular disease and infrequently by brain tumors. A 64-year-old woman presented with SAH with a left petrous meningioma and an unruptured left internal carotid-posterior communicating artery (IC-PcomA) aneurysm. She suffered sudden onset of headache and nausea followed by consciousness disturbance 7 days after onset. Computed tomography (CT) revealed diffuse SAH and a tumor at the petrous portion. Angiography demonstrated a left IC-PcomA aneurysm. Under a diagnosis of a ruptured aneurysm and a coincidental meningioma, we performed neck clipping of the aneurysm. However, intraoperatively we found that the aneurysm was unruptured and we subsequently performed tumor resection. Intraoperatively we could not find the cause of SAH during resection of the meningioma. The histological diagnosis was transitional meningioma with deposition of fibrin on the surface of the tumor. The findings of initial CT and magnetic resonance imaging, and pathological results could not conclude the definitive etiology of SAH in this case.

[An operated case of a meningioma causing acute subdural hematoma].

We report a rare case of a meningioma causing acute hematoma. A 67-year-old woman presented with sudden headache. No evidence of trauma was seen. CT demonstrated a subdural hematoma in the convexity of the fronto-temporal lobe. Magnetic resonance imaging showed marked signal heterogeneity in the convexity of the frontal lobe. One week later, the patient underwent hematoma evacuation and tumor resection including the attached dura mater. The histological diagnosis was meningothelial meningioma. The clot was connected directly to the tumor and the origin of the subdural hematoma was identified as the meningioma. Postoperative course was uneventful, and the headache improved. Meningiomas have a relatively benign course but rarely present with hemorrhage. Surgical exploration is the effective and recommended treatment.

Endoscopic surgery for traumatic acute subdural hematoma.

Traumatic acute subdural hematoma (ASDH) is generally addressed by craniotomy under general anesthesia. We report a patient whose traumatic ASDH was treated under local anesthesia by one-burr-hole endoscopic surgery. This 87-year-old woman had undergone coil embolization for a ruptured right middle-cerebral artery aneurysm and placement of a ventriculoperitoneal shunt for normal pressure hydrocephalus 5 years earlier. Upon admission, she manifested consciousness disturbance after suffering head trauma and right hemiplegia. Her Glasgow Coma Scale score was 8 (E2V2M4). Computed tomography (CT) demonstrated a thick, left-frontotemporal ASDH. Due to her advanced age and poor condition, we performed endoscopic surgery rather than craniotomy to evacuate the ASDH. Under local anesthesia, we made a burr hole in her left forehead and increased its size to 15 mm in diameter. After introducing a transparent sheath into the hematoma cavity with a rigid endoscope, the clot was evacuated with a suction tube. The arterial bleeding point was electrically coagulated. A postoperative CT scan confirmed the reduction of the hematoma. There was neither brain compression nor brain swelling. Her consciousness disturbance and right hemiplegia improved immediately. Endoscopic surgery may represent a viable method to address traumatic intracranial hematomas in some patients.

Usefulness of three-dimensional computed tomography to quantify the subarachnoid hemorrhage volume: prediction of symptomatic vasospasm.

We quantified the subarachnoid hemorrhage (SAH) volume in 64 patients on three-dimensional computed tomography (3D-CT) scans and studied the correlation between the SAH volume and the occurrence of symptomatic vasospasm (SVS). We studied 64 patients with SAH onset (day 0) and on days 1, 4, 7, and 14. We compared the hematoma volume by 3D-CT with 2D-CT on day 0 and examined the correlation between the hematoma volume and the occurrence of SVS. The hematoma volume, including the volume of normal structures, was automatically calculated (V1). The volume of normal structures manifesting identical CT numbers was previously calculated in patients without intracranial lesions (V2). The total hematoma volume was defined as V1 minus mean value of V2 (= 12 ml). The mean hematoma volume by 3D-CT was 48 ± 12 ml and by 2D-CT was 31 ± 45 ml (mean ± SD, n = 64). The hematoma volume was significantly larger by 3D-CT than by 2D-CT (p < 0.05). At all time points, the hematoma volumes were significantly larger in patients with than without SVS. We developed a new method for the quantitative determination of the SAH volume by 3D-CT. This method may allow us to quantify the volume of SAH in clinical studies of cerebral vasospasm.

Symptomatic vasospasm in elderly patients with aneurysmal subarachnoid hemorrhage: comparison with nonelderly patients.

OBJECTIVE: To clarify the influence of age on the occurrence of symptomatic vasospasm (SVS), we retrospectively compared 34 elderly (over 70 years) and 71 nonelderly patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: Between 2008 and 2010, at our hospital 105 patients (Hunt and Kosnik grades I-IV) underwent aneurysm surgery within 72 h of the insult. They were divided into four groups based on their age (younger/older than 70 years) and treatment (aneurysmal clipping or coiling). In all patients, we used the same protocol, which included the delivery of intrathecal urokinase and intravenous fasudil chloride; in patients with angiographic evidence of vasospasm, we also injected fasudil chloride intra-arterially. RESULTS: Among the elderly patients, 4.3% of those treated by clipping and 9.1% of those treated by coiling experienced SVS; the comparative incidence in younger patients was 6.5% and 4.0%, respectively. The differences were not statistically significant (p = 0.40). The ratio of ventriculo peritoneal (VP) shunts was higher in the elderly patients (p = 0.00007). The incidence of favorable treatment outcomes was significantly lower in elderly patients (p = 0.00004). CONCLUSION: Under our treatment protocol, patient age did not affect the incidence of SVS. Our protocol may be effective for the prevention of SVS after aneurysmal SAH regardless of patient age.

[Childhood transverse sinus dural arteriovenous fistula treated with endovascular and direct surgery: a case report].

Infantile dural arteriovenous fistula is a rare cerebrovascular malformation carrying a poor prognosis with an anatomic cure of only 9%. Endovascular embolization is mainly selected to treat this entity, aiming to obtain normal development of the patients. We present a case of a 20-month-old girl with epilepsy. Digital subtraction angiography revealed a dural arteriovenous fistula involving the right transverse sinus. The arteriovenous fistula was fed by multiple dural branches from the middle meningeal, occipital, meningohypophyseal, and anteroinferior cerebellar arteries. The right transverse sinus was transvenously embolized with platinum coils. Although the shunt flow remained, the patient was liberated from epilepsy. Nine months later, the patient suffered from a recurrence of epilepsy. Digital subtraction angiography demonstrated some increase in shunt flow. Right middle meningeal, occipital, posterior deep temporal, and tentorial arteries were transarterially embolized using N-butyl cyanoacrylate, followed by complete surgical resection of the right transverse sinus. The shunt flow disappeared after surgery, and her epilepsy improved significantly. Our experience suggests that the combination of endovascular and surgical treatment is effective for recurrent infantile dural arteriovenous fistula.

Distinctive flow pattern of wall shear stress and oscillatory shear index: similarity and dissimilarity in ruptured and unruptured cerebral aneurysm blebs.

OBJECT: The difference in the hemodynamics of wall shear stress (WSS) and oscillatory shear index (OSI) between ruptured and unruptured aneurysms is not well understood. The authors investigated the hemodynamic similarities and dissimilarities in ruptured and thin-walled unruptured aneurysm blebs. METHODS: Magnetic resonance imaging-based fluid dynamics analysis was used to calculate WSS and OSI, and hemodynamic and intraoperative findings were compared. The authors also compared ruptured and unruptured thin-walled blebs for the magnitude of WSS and OSI. RESULTS: Intraoperatively, 13 ruptured and 139 thin-walled unruptured aneurysm blebs were identified. Twelve of the ruptured (92.3%) and 124 of the unruptured blebs (89.2%) manifested low WSS and high OSI. The degree of WSS was significantly lower in ruptured (0.49 ± 0.12 Pa) than in unruptured (0.64 ± 0.15 Pa; p < 0.01) blebs. CONCLUSIONS: Ruptured and unruptured blebs shared a distinctive pattern of low WSS and high OSI. The degree of WSS at the rupture site was significantly lower than in the unruptured thin-walled blebs.

[Operated case of a ruptured aneurysm arising from fenestration of the vertebral artery].

Aneurysm arising from duplication of the vertebral artery (VA) is rare. We report a surgical case of an aneurysm of VA fenestration and provide a literature review. A 42-year-old man suffered from sudden onset of severe headache. CT image revealed subarachnoid hemorrhage predominantly in the posterior fossa. Digital subtraction angiography showed a fenestration of the right VA and the aneurysm arising from the proximal limb of the fenestration. Neck clipping of the aneurysm was performed because embolization was difficult due to the wide neck. The patient was discharged without deficits. Seven cases of an aneurysm of the VA fenestration have been reported. Five cases underwent coil embolization, and 2 underwent craniotomy, trapping, and resection. This is the first case of neck clipping of an aneurysm of the VA fenestration.