Morphological Pattern and Classification of the Superficial Middle Cerebral Vein by Cadaver Dissections: An Embryological Viewpoint.

In this study, we used 45 adult cadaveric cerebral hemispheres to investigate the anatomical classification of the superficial middle cerebral vein (SMCV) based on the number of stems, course, and anastomosis at the distal portion. We classified the SMCVs into five types based on embryological concept. Type A (18 cases, 40.0%) is that the frontosylvian veins (FSVs) merge with the vein of Trolard (VT) and the vein of Labbé (VL) at the distal portion of the sylvian fissure. Type B (5 cases, 11.1%) is that the temporosylvian veins (TSVs) merge with the VT and the VL at the distal portion. Type C (13 cases, 28.9%) is that no vein merge with the VT and the VL at the distal portion. The VT merges with the SMCV from the FSV and the VL merges with the SMCV from the TSV. They course along the sylvian fissure and merge at the proximal portion. In Type D (eight cases: 17.8%), the VT and the VL merge at the distal portion, and the SMCV from the FSV and the SMCV from the TSV join their confluence without merging. Type E (one case, 2.2%) show an undeveloped SMCV. Formation rate of intravenous anastomoses or bridging veins(BVs) at the distal portion between the frontosylvian trunk (FST) and the temporosylvian trunk (TST), between the FST and the temporal lobe, and between the TST and the frontal lobe was very low, because these formation may be difficult to occur during the embryological process in which the SMCV is formed from the telencephalic vein.

Endovascular Coil Embolization with Low-Profile Visualized Intraluminal Support Junior Stent for Ruptured Dissecting Aneurysm of Proximal Superior Cerebellar Artery-Case Report and Literature Review.

BACKGROUND: Superior cerebellar artery (SCA) aneurysm arising from the SCA itself is rare, and treatment of this aneurysm is challenging because of the important anatomic structures, such as the perforating arteries to the brainstem and cranial nerves. We describe a successful coil embolization with a Low-profile Visualized Intraluminal Support Junior (LVIS Jr.) stent for the proximal SCA dissecting aneurysm. CASE DESCRIPTION: A 50-year-old woman presented with right oculomotor nerve palsy and subarachnoid hemorrhage. Cerebral angiography showed a dissecting wide neck aneurysm at the anterior pontomesencephalic segment of the right SCA (diameter 1 mm). The patient was treated with coiling assisted by an LVIS Jr. stent. Postoperative angiography demonstrated a complete embolized aneurysm and parent artery preservation. CONCLUSIONS: Endovascular treatment assisted with LVIS Jr. stent for proximal SCA dissecting aneurysm arising from small parent artery was safely and effectively feasible.

[Treatment of a Traumatic Direct Carotid Cavernous Fistula with an Intradural Internal Carotid Artery Pseudoaneurysm Using a Low-profile Visualized Intraluminal Support(LVIS)Stent:A Case Report].

Traumatic carotid cavernous fistula(CCF)is known to present a direct connection between the cavernous segment of the internal carotid artery(ICA)and the cavernous sinus(CS). In rare cases, the fistula is formed between the intradural internal carotid artery(ICA)and the cavernous sinus(CS)via a pseudoaneurysm(pAN), requiring appropriate management and aggressive surgical treatment. We describe a 58-year-old man who sustained a severe head injury diagnosed as traumatic CCF treated with an intradural pAN procedure and transarterial coil embolization combined with a Low-profile Visualized Intraluminal Support(LVIS)stent. While slow arteriovenous shunt flow persisted at the end of the surgery, the fistula was completely occluded on the digital subtraction angiography obtained 2 weeks after the procedure. It was suspected that the flow-diversion effect of the LVIS stent might have caused the curable progression of the fistula occlusion.

Importance of frailty evaluation in the prediction of the prognosis of patients with chronic subdural hematoma.

AIM: The present study aimed to clarify the relationship between frailty and prognosis of patients with chronic subdural hematoma. METHODS: This retrospective study involved 211 patients aged ≥65 years with chronic subdural hematoma, who underwent surgery at Higashihiroshima Medical Center, Hiroshima, Japan, between July 2011 and May 2017. The study outcome was the patient's modified Rankin Scale score at 3 months after surgery. A logistic regression analysis was carried out to analyze factors that influenced the outcome. RESULTS: Chronic subdural hematoma patients with frailty had a poorer prognosis than those without (median modified Rankin Scale: 4 and 2, P < 0.001; proportions of patients discharged to home: 35% and 91%, P < 0.001, respectively). After adjusting for patients' background, the patients' modified Rankin Scale scores at 3 months after surgery were found to be associated with age, controlling nutritional status score and recurrence, but not with frailty. However, receiver operating characteristic curves of the model with the Clinical Frailty Scale were more accurately correlated with prognosis than those of the model without this scale (area under the curve 0.98, 95% confidence interval 0.96-0.99; and 0.87, 95% confidence interval 0.82-0.91, respectively.) CONCLUSIONS: Chronic subdural hematoma patients with frailty had poorer prognosis than those without. The evaluation of the presence of frailty on admission can be an important factor in the prediction of the prognosis of chronic subdural hematoma patients. Geriatr Gerontol Int 2018; 18: 1173-1176.

The Effect of Irrigation Solutions on Recurrence of Chronic Subdural Hematoma: A Consecutive Cohort Study of 234 Patients.

Chronic subdural hematomas (CSDHs) occur often in elderly persons and can occur with mild head trauma. With burr-hole irrigation as standard treatment, symptoms usually improve and can be cured, and outcomes are good, but postoperative recurrences are a common problem. This study investigated the effectiveness and recurrence rates when using artificial cerebrospinal fluid (ACF) instead of normal saline (NS) as an irrigation solution for burr-hole irrigation in patients with CSDH. This prospective study included 234 consecutive patients who underwent initial surgical treatment by burr-hole irrigation for a CSDH between April 2008 and June 2015. The irrigation solution used was changed from NS to ACF in June 2011. Factors examined with regard to recurrence included age, sex, unilateral or bilateral surgery, computed tomography (CT) findings, antiplatelet or anticoagulant drug use, past history, and irrigation solution (NS or ACF). These were analyzed by univariate and multivariate analyses. Univariate analyses (chi-square test) with a significance level <5% showed that recurrence rates were significantly lower in the ACF group than in the NS group (P = 0.003). Multivariate analysis (multiple logistic regression analysis) showed that the risk of recurrence was reduced 3.14-fold in the ACF group compared to the NS group (odds ratio, 3.143; 95% confidence interval, 0.1504-0.6733; P = 0.0028). None of the other factors were significantly different. In burr-hole irrigation for CSDH, the use of ACF instead of NS as an irrigation solution significantly reduces recurrence rates.

Frequency and Predicting Factors on Chronic Expanding Intracerebral Hematoma in Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Chronic expanding intracerebral hematoma is a well-known complication of spontaneous intracerebral hemorrhage. However, because chronic expanding intracerebral hematoma is relatively rare, it has not been studied systemically. The purpose of this study was to characterize a patient population with chronic expanding intracerebral hematoma, and to identify the predictive factors for it. METHODS: We retrospectively evaluated 112 patients with spontaneous putaminal hemorrhage who were treated at our institution between January 1, 2010 and December 31, 2015. Data on age, sex, Glasgow Coma Scale score, presence of intraventricular hemorrhage, and intracerebral hemorrhage volume were collected, and their predictive values for chronic expanding intracerebral hematoma were investigated. We also evaluated the predictive value of a characteristic radiological finding at onset called the "layer sign," which was represented as a fluid level adjacent to the clot. RESULTS: Chronic expanding intracerebral hematoma was observed in 4 patients (4.9%) with spontaneous intracerebral hemorrhage. Only the layer sign was significantly related to chronic expanding intracerebral hematoma (P = .003), and was found to be independently associated with chronic expanding intracerebral hematoma in a multivariate analysis (odds ratio, 18.6; 95% confidence interval, 1.19-291.0; P = .037). CONCLUSIONS: The frequency of chronic expanding intracerebral hematoma in those with spontaneous intracerebral hemorrhage was estimated at 4.9%. The layer sign was a useful factor for predicting chronic expanding intracerebral hematoma.

Isolated neurosarcoidosis presenting with multiple cranial nerve palsies.

BACKGROUND: As an extremely rare subtype of sarcoidosis that develops exclusively in the nervous system, isolated neurosarcoidosis is difficult to diagnose. In addition, its exact clinical features are not known. CASE DESCRIPTION: A 61-year-old man presented with right ear hearing loss, diplopia, and fever. Computed tomography (CT) and magnetic resonance imaging revealed mass lesions in the right cerebellum and left side body of the lateral ventricle. Neither systemic CT nor positron emission tomography revealed extracranial lesions. A neuroendoscopic biopsy was performed on the lateral ventricle lesion, and a histopathology analysis revealed epithelioid granulomatous inflammation. By systematic exclusion of other possible granulomatous diseases, isolated neurosarcoidosis was diagnosed. The lesions disappeared immediately upon corticosteroid (methylprednisolone) treatment and had not recurred as of a 12-month follow-up examination. CONCLUSIONS: Isolated neurosarcoidosis is difficult to diagnose. Successful diagnosis requires compatible clinical findings, histological demonstration of noncaseating granulomas, and exclusion of other granulomatous diseases. Isolated neurosarcoidosis has a relatively good clinical prognosis, which could be characteristic of the disease.

[Apixaban-Related Convexal Subarachnoid Hemorrhage:A Case Report].

The risk of anticoagulant-associated intracranial hemorrhage(ICH)is relatively low in patients treated with non-vitamin K antagonist oral anticoagulants(NOAC). The anticoagulant-associated ICH comprises mainly intraparenchimal hemorrhage. Subdural hematoma and subarachnoid hemorrhage(SAH)are rare complications after treatment with NOAC, trauma being the most common cause for these two types of ICH. We report a case of non-traumatic convexal SAH(cSAH)associated with Apixavan. A 68-year-old man with repeated history of cerebral embolism with cardiogenic cause presented with weakness of the lower limbs. Magnetic resonance imaging revealed infarctions, and treatment with apixaban(5 mg twice per day)was administered. Three days later, SAH in the right superior frontal sulcus was discovered incidentally on computed tomography(CT). NOAC-associated SAH is a rare manifestation. Cerebral amyloid angiopathy(CAA)is the most common cause of cSAH in the elderly, and cSAH is supposed to be a warning sign of cerebral hemorrhage in CAA. Patients with CAA started on NOAC require careful monitoring.

A Japanese pedigree of familial cerebral cavernous malformations--a case report.

Familial cerebral cavernous malformations (FCCM) are autosomal-dominant vascular malformations. At present, 3 cerebral cavernous malformation genes (KRIT1/CCM1, MGC4607/CCM2, and PDCD10/CCM3) have been identified. Few genetic analyses of Japanese FCCM have been reported. A Japanese pedigree of 4 patients with FCCM has been reported that includes the genetic analysis of one of the patients. All 4 patients showed multiple lesions in the brain. Surgical removal was performed at our hospital due to enlargement or hemorrhage of the intracranial lesions in a 21-year-old female (Case 1) and a 30-year-old male (Case 2). The histological diagnoses were cavernous malformations. A 62-year-old female (Case 4), the mother of Cases 1, 2, and 3, suffered from intramedullary hemorrhage at T6-7 and surgical removal was performed at another hospital. Only one patient, a 32-year-old female (Case 3), did not show symptoms. The genetic analysis of Case 2 demonstrated heterozygous partial deletions of exons 12-15 of the KRIT1 gene.

Differences between middle cerebral artery bifurcations with normal anatomy and those with aneurysms.

The objectives of this study were to elucidate the normal anatomy of middle cerebral artery (MCA) bifurcations and to analyze the differences in patients with MCA aneurysms. In the present study, 62 patients underwent three-dimensional magnetic resonance angiography, and no intracranial lesions were noted. The widths of M1 and the superior and inferior M2 branches, as well as their respective lateral angles, were measured. These values were used to calculate the daughter artery ratio (DA ratio; width of larger M2/width of smaller M2) and the lateral angle ratio (LA ratio; lateral angle between M1 and larger M2/lateral angle between M1 and smaller M2). The DA and LA ratios of 54 MCA aneurysm patients (34 with ruptured aneurysms, 20 with unruptured aneurysms) were also calculated, using three-dimensional digital subtraction angiography, and compared with the normal values. In normal patients, the widths of M1 and the branches of M2, the lateral angles, and the LA and DA ratios were not significantly different between the right and left sides. The bilateral superior and inferior lateral angles of normal MCAs were significantly wider than those of MCAs with aneurysms. The DA ratio was 1.5 ± 0.4 in normal MCAs and 1.7 ± 0.7 in MCAs with aneurysms; this difference was significant (p < 0.05). The LA ratio was 1.3 ± 0.4 in normal MCAs and 2.1 ± 1.4 in MCAs with aneurysms; these values were also significantly different (p < 0.01). Normal cerebral artery bifurcations show close to symmetric structure in the M2 branches and the lateral angles, whereas aneurysmal MCAs do not show this symmetry.

[Accessory nerve schwannoma of the intracisternal type: a case report].

Accessory nerve schwannomas are extremely rare and they are classified into three types according to their locations; intrajugular, intracisternal and spinal canal type. We report a case of intracisternal schwannoma that arose from the spinal accessory nerve roots and we describe it's clinical characteristics. A-48-year-old female was admitted to our hospital with a complaint of left occipital pain. Magnetic resonance imaging (MRI) showed a well-defined mass 2.5×1.5 cm in the left cerbellomedullary cistern. It was enhanced heterogeneously with gadolinium. Cerebral angiography showed a mildly hypervascular lesion. Total removal of the tumor was performed by the left lateral suboccipital approach and the histological diagnosis was schwannoma.

Morphological differences between ruptured and unruptured cases in middle cerebral artery aneurysms.

OBJECTIVE: To elucidate the morphological differences between ruptured and unruptured aneurysms, three-dimensional digital subtraction angiography was performed in 44 cases (20 unruptured, 24 ruptured) of middle cerebral artery aneurysm. METHODS: When the neck was located on the extension of the midline of the parent artery, it was defined as Type C; when it was not, it was defined as Type D. Aspect ratio (AP ratio; dome/neck ratio) and daughter artery ratio (DA ratio; diameter of the larger daughter artery/diameter of the smaller daughter artery) were calculated, and these ratios were compared for ruptured and unruptured cases. RESULTS: Nineteen cases were Type C and 25 cases were Type D. chi2 test revealed that there were significantly more ruptured cases among Type C (14 out of 19) compared with Type D (10 out of 25) (P < 0.05). AP ratios were 2.24 +/- 0.75 for ruptured cases and 1.56 +/- 0.58 for unruptured cases. DA ratios were 1.53 +/- 0.54 in ruptured cases and 2.14 +/- 0.80 for unruptured cases. Both showed significant differences (P < 0.01). In cases with an AP ratio of 1.8 or greater and a DA ratio less than 1.7, 13 out of 15 (87%) were ruptured cases. On the contrary, in cases with an AP ratio less than 1.8 and a DA ratio of 1.7 or greater, 12 out of 13 (92%) were unruptured cases. CONCLUSION: Type C and equality of the diameters of two daughter arteries, together with high AP ratios, seem to be morphological factors that associate with aneurysmal rupture.

The characteristics of the anterior communicating artery aneurysm complex by three-dimensional digital subtraction angiography.

To elucidate the three-dimensional structure of the anterior communicating artery complex, we performed three-dimensional digital subtraction angiography in anterior communicating (Acom) aneurysm cases. Eighteen patients (six male and 12 female) with Acom aneurysms were studied. The total number of aneurysms was 18, of which three were unruptured and 15 were ruptured. Aneurysmal sizes and angles between the parent artery and each of the two daughter arteries were measured. Two types were defined, based on the daughter arteries. When the sizes of the two daughter arteries were the same, they were defined as AA' type, and when different, they were defined as AB type. Furthermore, aneurysms were classified into two types based on neck location. Thus, when the neck was located on the extension of the midline of the parent artery, it was defined as classical neck type, and when it was not, it was defined as deviating neck type. There were 11 cases of AA' type and seven of AB type. In AA' type all cases were of the classical neck type, and in AB type three cases were of the classical neck type and three were of the deviating neck type. In the deviating neck type, the necks were deviated to the smaller daughter arteries in all cases.

Solitary brain metastasis from renal cell carcinoma 15 years after nephrectomy: case report.

A 77-year-old man presented with a metastatic brain tumor 15 years after nephrectomy for a renal cell carcinoma. Neurological examination showed recent memory disturbance and slight right hemiparesis. Magnetic resonance imaging revealed a round well-demarcated mass extending from the left thalamus to the left trigone of the lateral ventricle. Preoperative angiography showed tumor staining. Surgery was performed by opening the inferior temporal sulcus. Only biopsy could be performed because of extensive bleeding from the tumor. Histological examination identified metastatic renal cell carcinoma. Gamma knife surgery was performed which resulted in resolution of his hemiparesis. Metastatic renal cell carcinoma should be considered even if nephrectomy was performed 10 or more years before presentation.

A ruptured middle cerebral artery aneurysm originating from the site of anastomosis 20 years after extracranial-intracranial bypass for moyamoya disease: case report.

BACKGROUND: Direct revascularization through a superficial temporal artery-middle cerebral artery (STA-MCA) bypass is often performed to prevent ischemic or hemorrhagic attack in patients with moyamoya disease. This is the first reported case of aneurysm formation and rupture due to an STA-MCA bypass in a patient with moyamoya disease. CASE DESCRIPTION: A 52-year-old man who had undergone bilateral STA-MCA bypass for caudate hemorrhage due to moyamoya disease 20 years previously suffered from sudden-onset unconsciousness. Computed tomography revealed a massive intracerebral hematoma (ICH) in the left frontoparietal region. Angiography showed good patency of the anastomoses and stage IV moyamoya disease. However, no other abnormality was found. Emergency evacuation of the hematoma was performed. The patient's postoperative course was uneventful, but consciousness disturbance of sudden onset occurred 1 month later. Computed tomography showed a hematoma in the lateral ventricle and acute hydrocephalus. Repeat angiography revealed an aneurysm on the left side of the anastomosis. Bilateral ventricle drainage tubes were inserted, and the aneurysm was clipped. A ventriculoperitoneal shunt was later performed. CONCLUSION: In patients with moyamoya disease who have undergone extracranial-intracranial bypass surgery, progressive hemodynamic stress may cause the formation of de novo aneurysms after a postoperative period of several decades. Imaging examinations should therefore be performed periodically for follow-up, and a de novo aneurysm should be suspected in a patient who has an unusual ICH.

Reconstruction of pterional key hole using three-dimensional titanium plate: technical note.

Patients who have undergone pterional craniotomy sometimes complain about postoperative cosmetic impairment in the frontotemporal area. This problem occurs as a result of inappropriate repair or no repair of the pterional key hole. The authors have developed an intraoperative hand-made three-dimensional titanium plate, and as a result of using this plate the postoperative cosmetic appearance was satisfactory.

Evaluation of relation among aneurysmal neck, parent artery, and daughter arteries in middle cerebral artery aneurysms, by three-dimensional digital subtraction angiography.

Intracranial aneurysms usually occur at arterial bifurcations. However, in middle cerebral artery (MCA) aneurysms, we often find that the aneurysmal neck does not necessarily exist just on the arterial bifurcation. In this study, we have evaluated the relation among aneurysmal neck, parent artery, and daughter arteries in middle cerebral artery aneurysms, by three-dimensional digital subtraction angiography. Twenty consecutive patients (9 men and 11 women) with MCA aneurysms were examined. The total number of aneurysms was 22, of which 10 aneurysms were unruptured and 12 were ruptured. Aneurysmal sizes and angles between the parent artery and each of the two daughter arteries were measured. Furthermore, aneurysms were classified into two types based on neck location. Thus, when the neck was located on the extension of the midline of the parent artery, it was defined as a classical neck type aneurysm, and when it was not, it was defined as a deviating neck type aneurysm. There were 15 cases of deviating and 7 cases of classical neck type. Interestingly, in the deviating neck type, all the aneurysms existed on the side of the daughter arteries of which the angles between parent arteries were narrower, and in 93%, the sizes of the daughter arteries in which the neck existed were smaller compared with other daughter arteries.

[A case of subcutaneous malignant lymphoma with dura mater lesion].

A 63-year-old male was admitted to our hospital, complaining of a scalp mass located at the frontoparietal area of his head. He noticed that it had been growing for 2 months. The mass was elastic hard and non-moving. Computed tomography demonstrated a subcutaneous mass with low density and which was enhanced homogeneously. The skull just below the mass was slightly destroyed, but the structure remained. Magnetic resonance imaging (MRI) demonstrated a mass with low signal intensity on both the T1 weighted image and the T2 weighted image. Gd-DTPA study showed homogeneous enhancement and showed also that the dura just below the mass was enhanced. At this point we couldn't diagnose it confidently, but suspected this lesion to be a malignant lymphoma. We made a general examination, but no other lesion was found. A biopsy of the subcutaneous mass was performed under local anesthesia. The histological diagnosis was large-cell type B-Cell lymphoma. The tumor was treated with chemotherapy, CHOP (cyclophosphamid, doxorubicin, vincristin predonisolone). It responded to this chemotherapy and disappeared. We treated this lesion without radiation therapy. We report a case of subcutaneous malignant lymphoma treated successfully with a minimum invasive method.

A case of venous angioma with arteriovenous shunts--case report.

A 35-year-old man presented with a sudden headache and disturbance of consciousness. On admission, his consciousness level was Japan Coma Scale 100. Computed tomography disclosed a subarachnoid hemorrhage (SAH) and right cerebellar hematoma. Angiography was performed and, at first, arteriovenous malformation of the posterior fossa was diagnosed. Then external decompression of the posterior fossa and ventricular drainage were performed, followed by barbiturate therapy. Repeat angiography revealed that the lesion was a venous angioma with arteriovenous shunts. On day 37, subtotal removal of the lesion was performed. Intraoperatively, acute brain swelling emerged and partial internal decompression of the right cerebellar hemisphere was performed. The postoperative course was comparatively good and the patient was discharged with very mild ataxia. The patient is now being followed up in our outpatient clinic.

[An intradiploic epidermoid cyst of the skull in infancy: case report].

An intradiploic epidermoid cyst of the skull in infancy is rare. We report a case of a 7-month-old girl with an intradiploic epidermoid cyst of the left parietal bone. The patient was admitted to the department of pediatrics in, our hospital in March, 2000, complaining of a lump in the scalp with a diameter of 1.5 cm. The pediatrician doubted that it was a case of Langerhans cell histiocytosis (LCH). In addition, as a result of further tests there were no systemic findings to suggest LCH. The skull x-ray showed round radiolucency of the left parietal bone. CT scans showed an iso density intradiploic mass with destruction of the outer table. Because of the fact that the mass was enlarging, the patient was admitted to our neurosurgical service in April, 2000. We excised the lesion to confirm the histological findings. The histological diagnosis was epidermoid cyst. We discuss the clinical feature and treatment strategy for intradiploic epidermoid cyst in infancy.