Epilepsy with Eyelid Myoclonia Complicated by Polycystic Ovary Syndrome: Valproate Withdrawal, Vagus Nerve Stimulation, and Seizure Reduction.

Epilepsy with eyelid myoclonia is a childhood-onset generalized epilepsy, which is more common in women. Over 90% of the patients continue antiseizure medications, especially valproate, and more than 60% of cases are refractory. The efficacy of vagus nerve stimulation in treating eyelid myoclonia is still unknown. Polycystic ovary syndrome is highly prevalent in women with epilepsy receiving valproate; nevertheless, no reports on the complication of polycystic ovary syndrome in women with epilepsy with eyelid myoclonia were found. In this report, a case of a woman with epilepsy with eyelid myoclonia who developed polycystic ovary syndrome while receiving valproate and underwent vagus nerve stimulation is described. A 26-year-old female patient has been administered valproate since the occurrence of generalized seizures at the age of 12 years and then developed polycystic ovary syndrome. When the dose of valproate was reduced as an adult, her epilepsy became intractable. Information from her mother led to a video electroencephalography re-evaluation, and she was finally diagnosed 15 years after onset. The patient underwent vagus nerve stimulation. In a short-term follow-up, she achieved >50% seizure reduction at low output currents of <1.00 mA. Polycystic ovary syndrome was cured 15 months after valproate withdrawal. There are three key points presented in this case: Vagus nerve stimulation therapy was useful for treating epilepsy with eyelid myoclonia with absence. Women with epilepsy with eyelid myoclonia taking valproate must be aware of the risk of polycystic ovary syndrome and monitor their menstrual cycles. Information from the family, such as home videos, helped with the diagnosis.

Macrovascular Decompression with the Transposition Method Using Teflon Sling for Trigeminal Neuralgia Caused by the Vertebrobasilar Artery.

OBJECTIVE: Complete separation of the vertebrobasilar artery (VBA) from the trigeminal nerve by microvascular decompression is technically challenging. This paper evaluates the transposition method using Teflon sling for trigeminal neuralgia (TN) caused by the VBA. METHODS: Retrospective review of 32 patients including 2 patients with tic convulsif. Mobilization of the VBA in the anteromedial-caudal direction and repositioning of the VBA using Teflon sling and fibrin glue were performed. Pre- and postoperative pain were evaluated with the Barrow Neurological Institute (BNI) pain intensity score. Duration of surgery and postoperative neurologic complications were reviewed. RESULTS: Preoperative BNI score ranged from III to V. Postoperative BNI score I was observed in 30 patients, II in 1 patient, and V in 1 patient as recurrence. Abducens nerve palsy was observed in 9 patients but was transient in 8. Permanent hearing loss was observed in 6 patients. Transient mild lower cranial nerve palsy was recorded in 2 patients with tic convulsif. Average surgical time was 290 minutes. CONCLUSIONS: Our method for trigeminal neuralgia caused by VBA was very effective, but the complication rate of cranial nerve disorders was also high. A high rate of complications implied the technical difficulty of extensive vascular mobilization requiring long duration of surgery. Macrovascular decompression surgery is more descriptive of this surgery instead of microvascular decompression surgery.

Infrafloccular approach effectively prevents hearing complication in microvascular decompression surgery for hemifacial spasm.

OBJECTIVE: The infrafloccular approach in microvascular decompression (MVD) surgery for hemifacial spasm (HFS) was investigated for the prevention of hearing complications. METHODS: Retrospective analysis of 136 patients who underwent MVD for HFS in 2019. The infrafloccular approach for MVD was adopted to resolve the symptom and protect hearing function. Postoperative hearing function was evaluated subjectively and objectively within 30 postoperative days, and later mainly subjectively. Postoperative condition of mastoid air cells based on the CT scan of the following day was also recorded. RESULTS: No final postoperative subjective hearing impairment was found in all patients. Mastoid air cells were opened in 105 patients, and subjective hearing impairment was recorded in 57 patients within 30 postoperative days, but all improved later. Increases in thresholds of greater than 10 dB in air conduction were observed in 28 patients, including 26 of transient conductive hearing loss (increases in the threshold of less than or equal to 10 dB). The other 2 patients with increases in the threshold of greater than 10 dB in both air and bone conduction had improvement confirmed by later audiometry. CONCLUSIONS: Infrafloccular approach in MVD for HFS provides a good hearing outcome. Inclusion of postoperative hearing conditions in the later period is ideal for a precise hearing evaluation.

Transoral penetration of a half-split chopstick between the basion and the dens.

A 6-year-old girl was admitted for transoral penetrating injury by a half-split chopstick. Subsequent CT imaging examinations showed that the chopstick had passed between the basion and the dens and reached the subarachnoid space just at the medulla oblongata. A sagittal reconstructed CT scan was useful for the evaluation of the injury. Imaging findings and their clinical relevance are discussed.

Effects of head-down tilt on the intracranial pressure in conscious rabbits.

Head-down tilt (HDT) causes a fluid shift towards the upper body, which increases intracranial pressure (ICP). In the present study, the time course of ICP changes during prolonged exposure to HDT was investigated in conscious rabbits through a catheter chronically implanted into the subarachnoid space. The production of cerebrospinal fluid (CSF) after exposure to 7-days HDT was also examined by a ventriculo-cisternal perfusion method. The ICP increased from 4.3+/-0.4 (mean+/-S.E.M.) mmHg to 8.0+/-0.8 mmHg immediately after the onset of 45 degrees HDT, reached a peak value of 15.8+/-1.9 mmHg at 11 h, and then decreased to 10.4+/-1.1 mmHg at 24 h. During 7-days HDT, it also increased from 4.8+/-0.9 mmHg to 9.2+/-1.6 mmHg immediately after the onset of 45 degrees HDT, reached a peak value of 12.8+/-2.5 mmHg at 12 h of HDT, and then decreased gradually towards the pre-HDT baseline value for 7 days. The rate of CSF production was 10.1+/-0.6 microl/min in rabbits exposed to 7-days HDT, and 9.7+/-0.5 microl/min in control rabbits. These results suggest that the rabbits begin to adapt to HDT within a few days and that the production of CSF is preserved after exposure to 7-days HDT. The time course of ICP changes during HDT in conscious rabbits seems to be considerably different from that in anesthetized rabbits.

Selective occlusion of lumbar arteries as a spinal cord ischemia model in rabbits.

Paraplegia is a devastating complication of operations requiring transient occlusion of the descending thoracic aorta. Many animal models of spinal cord ischemia have been utilized to examine the efficacy of various neuroprotective methods. In this study, we establish a rabbit model of spinal cord ischemia by selective temporary occlusion of lumbar arteries and examine the protective effects of systemic mild hypothermia in this model. Animals were divided into the following four groups: sham group (group A, n = 6); 10 min ischemia, normothermia (39 degrees C) (group B, n = 6); 20 min ischemia, normothermia (group C, n = 6); and 30 min ischemia, mild hypothermia (35 degrees C) (group D, n = 6). After 7 d of reperfusion, three rabbits in group B and five rabbits in group C developed paraplegia (Tarlov's score = 0). In contrast, all rabbits preserved hindlimb motor function (Tarlov's score = 4) in groups A and D. Histological findings indicated that the number of motor neurons in the anterior horns in group C were significantly fewer than in group A. A large number of motor neurons were preserved in group D. Hypothermia is known to be an effective and reliable method of neuroprotection, but the risk of complications rises at deep hypothermia. Our current results confirm that systemic, mild hypothermia is a safe and effective neuroprotective method during ischemia-reperfusion injury of the spinal cord.

Schwannoma of the spinal accessory nerve in the cisterna magna.

BACKGROUND: Intracranial schwannoma of the accessory nerve can be divided into two types. One is a jugular foramen type arising from the accessory nerve of the jugular foramen, while the other is an intracisternal type, which arises from the spinal root of the accessory nerve and is separate from the jugular foramen. The latter type is rare, and only 9 cases have been reported previously. CASE DESCRIPTION: A 46-year-old female presented with a large, midline mass lesion in the posterior fossa manifesting as foramen magnum syndrome. Magnetic resonance imaging (MRI) revealed a huge tumor with cystic lesion located in the cisterna magna with extension to the C1 spinal level. The tumor was totally removed by a suboccipital craniectomy and C1 laminectomy. It originated from the spinal root of the right accessory nerve. Temporary slight atrophy of the right sternocleidomastoid muscle was observed, but the patient was free of disease 2 years after treatment. CONCLUSIONS: We report a schwannoma of the spinal accessory nerve in the cisterna magna. The clinical and neuroradiological findings are discussed with a review of the literature. The initial symptoms were variable without loss of function of the cranial nerve, and the tumor tended to grow in the cisterna magna without laterality. Because of the absence of typical neurologic symptoms, early neuroradiological investigation by MRI is recommended for accurate diagnosis of these tumors.

Effects of head-down tilt on cerebral blood flow in humans and rabbits.

Changes in cerebral hemodynamics, during and after head down tilt (HDT), were examined by means of transcranial Doppler technique (TCD) and near infrared spectroscopy (NIRS) in humans, and laser Doppler flowmetry (LDF) in rabbits. Mean cerebral blood flow (CBF) velocity measured by TCD increased during the first 6 h of HDT compared with the pre-HDT value. NIRS experiments demonstrated that brain oxygenation and hemoglobin concentration increased with postural change from upright to supine. These results suggest that exposure to HDT increases CBF during the early phase of HDT in humans. In rabbits anesthetized with alpha chloralose, on the other hand, 45 degrees HDT did not change CBF significantly in the parietal cortex during 1 h after the onset of HDT. The discrepancy may be explained by the difference in species, tilt angle, or the brain region where CBF has been measured.

Changes of intracranial pressure during head-down tilt in anesthetized and conscious rabbits.

Effects of head-down tilt on intracranial pressure were studied in anesthetized and conscious rabbits. Adult Japanese white rabbits of both sexes, weighing 2.5-3.5 kg, were used in the experiments. Experiment 1. Animals were anesthetized with pentobarbital, and ICP was monitored through a catheter inserted into the subarachnoid space. ICP elevated immediately after the onset of 45 degrees HDT and gradually reduced toward the baseline level in the next 8 hours. Experiment 2. Each rabbit was exposed to 45 degrees HDT for 24 hours and the ICP was measured through a catheter which had been implanted 7 days before. In the conscious rabbits, ICP increased about 4 mmHg after the onset of 45 degrees HDT, further increased gradually to the peak at 11 hours of HDT, and then started to return to the baseline. These results suggest that the time course of the change in ICP during HDT is considerably different between anesthetized and conscious rabbits.