Co-existence of unruptured cerebral aneurysms in patients with hypertensive intracerebral hemorrhage.

OBJECTIVE: Primary hypertensive intracerebral hemorrhage (PICH) is caused by a rupture of a small endartery, and diagnosis is made either by computed tomography (CT) or magnetic resonance imaging (MRI). Vascular abnormalities are not always evaluated in detail. In this study, we aimed to clarify the incidence of co-existing vascular abnormalities, especially unruptured cerebral aneurysms by reviewing selective intraarterial digital subtraction angiography (DSA) images in PICH patients. METHODS: The cases of 169 hypertensive PICH patients who underwent selective intra-arterial DSA were reviewed. In all cases, CT or MRI showed no abnormality other than PICH, such as subarachnoid hemorrhage, component of arterio-venous malformation or cerebral tumor. The main reason for performing DSA was to exclude other causes of intracerebral hemorrhage such as ruptured cerebral aneurysm or small arterio-venous malformation prior to surgical removal of the hematoma. RESULTS: There were 33 patients with vascular abnormalities: unruptured cerebral aneurysm (n = 24, 14.2%), major vessels occlusion or stenosis (n= 8, 4.7%), and dural arterio-venous fistula (n = 1). Unruptured cerebral aneurysms were found in 9.4% of men and 20.5% of women. CONCLUSION: Vascular abnormalities co-existing with PICH are not rare, suggesting the necessity for angiographic evaluation. Special attention should be given to female PICH patients who have a high incidence of having an unruptured cerebral aneurysm.

Vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery: a case report.

BACKGROUND: Vertex epidural hematomas are rare. We describe the features of a vertex epidural hematoma associated with an arteriovenous fistula (AVF) of the meningeal artery created by a laceration of the dura mater underlying a linear skull fracture. Although AVF associated with convexity epidural hematomas has been reported, we know of no such previous report of vertex epidural hematomas. CASE DESCRIPTION: A 65-year-old woman presented with generalized headache following head injury. On hospital day 3, she developed a left hemiparesis. Magnetic resonance imaging (MRI) disclosed a thick epidural hematoma at the vertex. Cerebral angiography showed an AVF between the middle meningeal artery and a venous lake. On hospital day 4, the epidural hematoma was evacuated. CONCLUSION: Although coronal MRI was important for diagnosis of this vertex epidural hematomas, the case particularly illustrates the importance of cerebral angiography. The delayed onset of hemiparesis most likely reflected a continuing increase in hematoma volume because of bleeding from the lacerated meningeal artery.

Cosmetic and functional reconstruction achieved using a split myofascial bone flap for pterional craniotomy. Technical note.

Cosmetic deformities that appear following pterional craniotomy are usually caused by temporal muscle atrophy, injury to the frontotemporal branch of the facial nerve, or bone pits in the craniotomy line. To resolve these problems during pterional craniotomy, an alternative method was developed in which a split myofascial bone flap and a free bone flap are used. The authors have used this method in the treatment of 40 patients over the last 3 years. Excellent cosmetic and functional results have been obtained. This method can provide wide exposure similar to that achieved using Yasargil's interfascial pterional craniotomy, without limiting the operative field with a bulky temporal muscle flap.

[Surgical treatment of unruptured cerebral aneurysms and complications in patients with ischemic cerebrovascular disease].

Patients who have unruptured intracranial aneurysms associated with ischemic cerebrovascular disease are a high-risk group for surgery. We have done clipping surgery in 15 patients among 40 with ischemic cerebrovascular disease. The criteria for surgery included an age below 65 years, CBF of more than 35 ml/100 g/min, and favorable ADL comparable to Rankin score 0-III. Two patients received simultaneous aneurysm clipping and superficial-middle cerebral artery anastomosis. Only one patient suffered from ischemia-related permanent neurological worsening, and one had direct optic nerve injury. Surgical mortality was 0%, and morbidity was 15%. There were two patients who had transient neurological worsening. These results suggest that surgical treatment of unruptured cerebral aneurysms is not contraindicated in patients with ischemic brain disease, but careful selection and careful perioperative management are mandatory for preventing surgical complications.

Cerebral aneurysm associated with an anomalous hyperplastic anterior choroidal artery.

An unruptured internal carotid artery (ICA) aneurysm arising at the origin of a hyperplastic anomalous AchoA was identified together with a second unruptured middle cerebral artery aneurysm during angiography performed to investigate a striatal and intraventricular haemorrhage in a 55-years-old woman. The anomalous hyperplastic AchoA supplied the left temporal and occipital lobes, and the aneurysm arose proximal to its origin. The patient underwent clipping of the aneurysms, and intra-operative observation revealed that several perforating branches arose directly from the ICA between the AchoA and the ICA bifurcation.

[Cigarette smoking increases the risk of developing a cerebral aneurysm and of subarachnoid hemorrhage].

Despite recent advances in diagnostic and therapeutic techniques, subarachnoid hemorrhage (SAH) is still a serious condition associated with high mortality and morbidity. There are no effective treatments other than surgical intervention. However, another option for decreasing the occurrence of SAH may be prevention of aneurysms formation and of their rupture by controlling risk factors. Cigarette smoking has been recently shown to be one of the major risk factors for SAH. We investigated whether cigarette smoking increased the risk of developing cerebral aneurysms and of SAH. Degree of smoking was investigated in 182 patients with SAH and in 123 patients with an unruptured cerebral aneurysm incidentally detected during investigation of other diseases. Sixty-nine patients with other diseases who were shown to be free of cerebral aneurysms through MR angiography served as controls. Smoking significantly increased the risk of both aneurysm formation and SAH; The odds ratio for SAH was 2.4, and for unruptured cerebral aneurysm 1.7. Smoking especially increased the occurrence of SAH in women and in youngsters. However, smoking did not influence the occurrence of cerebral vasospasm and multiplicity of aneurysms. These data suggest the importance of avoiding smoking to prevent the occurrence of cerebral aneurysms and of SAH.

Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage.

Recurrence of chronic subdural hematoma after burr-hole craniostomy and closed system drainage is not uncommon. We sought to identify risk factors for recurrence. In 121 patients, various factors including age, initial neurologic status, hematoma thickness, computed tomographic density of the hematoma, midline shift, multiplicity, systemic disease, and drainage volume were compared retrospectively between nonrecurring cases and recurring cases. Recurrence was noted in 10 cases (8.3%). In recurring cases, the drainage volume was significantly larger than in nonrecurring cases, and the recurrence rate increased in proportion to drainage volume. Other factors significantly influencing recurrence were hematoma thickness and associated diabetes mellitus. Drainage contents mainly derived from either exudate within the subdural membrane or cerebrospinal fluid leakage. Entry of cerebrospinal fluid into the hematoma cavity or continuing leakage of serum components through opened endothelial gap junctions are considered to be major causes of increased drainage volume, leading in turn to recurrence of the hematoma.

[A case of traumatic subacute subdural hematoma presenting symptoms arising from cerebral hemispheric edema].

Traumatic subacute subdural hematoma is a condition in which the major symptoms affecting prognosis most appear in the subacute stage after head trauma, while traumatic acute subdural hematoma is treated conservatively when the symptoms are mild. The cause of the major symptoms occurring in the subacute stage is mostly expansion of the subdural hematoma volume. The authors report a case of traumatic subacute subdural hematoma in which the cause of the major symptoms was cerebral hemispheric edema instead of expansion of the subdural hematoma volume. To our knowledge, only one similar case to the present case has been previously reported. A 44-year-old female fell from the stairs on July 21, 1995 and was suffering from headache. On July 23, she was admitted to our hospital because of generalized convulsion. On admission, she was drowsy but showed no convulsion. Head CT showed an acute subdural hematoma on the right side with a slight midline shift and no other abnormalities. She was treated conservatively because of the mildness of the symptoms and two days later became alert with no symptoms. Thereafter she only complained of occasional headache which was controlled with medicine. On August 3, she suddenly fell into coma. Head CT showed severe cerebral hemispheric edema on the right side without change of the subdural hematoma size. Emergency cerebral angiography showed no definitive abnormalities such as occlusion of the arteries or of the venous sinuses. Craniotomy associated with external decompression was performed. The hematoma was composed of red-brown jelly accompanied with some liquid component and had a thin black-brown outer membrane. While removing the hematoma, bleeding from a vein on the cerebral surface around the sylvian fissure was observed and this location was suspected to be the sources of the bleeding point. Postoperatively, she received steroid and barbiturate therapy associated with moderate hypothermia under hyperventilation. She tolerated this treatment well and left the hospital, on September 26, 1995 with only diplopia during downward gaze. Although the mechanisms of the cerebral hemispheric edema occurring in the subacute stage was unclear, a failure in the cerebral venous circulation arising from compression to the bridging veins, which may be hypoplastic, by the subdural hematoma was suspected to have been the cause.

[Preoperative scoring and operative complications of unruptured cerebral aneurysms].

Low risk of mortality and morbidity are necessary pre-conditions for surgical treatment of unruptured cerebral aneurysms. We assessed retrospectively 132 patients with angiographically confirmed cerebral aneurysms using an unruptured aneurysm score. Among them, 84 patients were treated surgically. The score consists of the sum of scores for the following factors: associated disease (none: 0, one: 1, two or more: 2); aneurysm size (below 14 mm: 0, 15-24 mm: 1, 25 mm or more: 2); location (anterior circulation: 0, carotid cave: 1, posterior circulation: 2); and multiplicity (single: 0, two or more: 1). Eleven patients had complications and the morbidity rate including asymptomatic lesions was 13.1%. Five patients had permanent neurologic deficits (final morbidity rate 5.9%). The majority of patients with scores less than 1 underwent operations and the morbidity rate was low, whereas patients with scores between 2 and 4 had a higher morbidity rate. Preoperative scoring is useful for predicting surgical risks associated with unruptured cerebral aneurysm.

Hypothalamic pilocytic astrocytoma presenting with intratumoral and subarachnoid hemorrhage.

A 45-year-old male presented with sudden onset of severe headache. Computed tomography and magnetic resonance imaging demonstrated an irregularly enhanced suprasellar mass with intratumoral and subarachnoid hemorrhage. The mass was removed in two operations. Histological examination of the tumor revealed pilocytic astrocytoma. The relatively rich vascularity and perivascular tumor cell proliferation observed in this benign lesion were probably the causes of this extremely rare association.

[A case of rhinocerebral phycomycosis].

Rhinocerebral phycomycosis is an uncommon opportunistic infection with ubiquitous fungi of the class Phycomycetes, starting in the nose and extending to the paranasal sinuses and then intracranially. The condition is often characterized by poor prognosis because of occlusion of the internal carotid artery. This disease is commonly associated with predispositions such as uncontrolled diabetes mellitus, which is the most common, immunosuppressive states and metabolic bankruptcy including leukemia, lymphoma, myeloma, malnutrition, uremic or diarrheal acidosis, severe burns, anemia, carcinoma, radiotherapy, liver cirrhosis, hemochromatosis, tuberculosis, septicemia, long-term medication of steroid, antibiotics and antimetabolite, drug addiction, cytotoxic drug administration and AIDS. Cases with unknown predisposition, however, have been infrequently reported in the literature. The authors report a case of rhinocerebral phycomycosis in which concurrence of Candida species instead of the above-mentioned common predispositions was considered a potential predisposition. To our knowledge, only 1 report in which Candida species are referred to as a potential predisposition for this disease has been previously issued. A 85-year-old man was admitted to our hospital on March 2, 1994 because of generalized convulsion. He had received a total extirpation of an ascending colon cancer in July 1993. On admission, physical inspection showed no abnormalities and neurological examination revealed obtunded consciousness without other abnormalities. He had no diabetes mellitus. Hematological and blood chemistry values were normal except for CA19-9 of 45 U/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Nodding attacks (infantile spasms) associated with temporal lobe astrocytoma--case report.

A 2-year-old boy suffered nodding attacks (infantile spasms) that were refractory to anticonvulsants. Computed tomography showed a mass with cystic components in the right temporal lobe, and electroencephalography (EEG) disclosed polyspike and wave discharges in the bilateral temporoparietal regions. At surgery, a firm, gray, well circumscribed tumor was radically removed. The nodding attacks disappeared immediately after surgery and EEG improved gradually. The pathological diagnosis was grade 1 astrocytoma with abundant capillaries and calcospherites. He remained free of seizures during the following 6 years.

[Neurofunctional disturbances as related to cortical ischemia and white matter ischemia].

We evaluated regional cerebral blood flow (rCBF) by means of hydrogen clearance method as well as [14C]-iodoantipyrine autoradiographic method, cortical auditory evoked potentials (AEP), somatosensory evoked potentials (SEP) induced by forelimb (median nerve) stimulation (SEP-F), and SEP induced by hindlimb (tibial nerve) stimulation (SEP-H) in cats after occlusion of the left middle cerebral artery (MCA) under alpha-chloralose anesthesia. According to the degree of ischemia, the experimental animals were divided into two groups. One was the critical ischemia which was defined as permanent total suppression of AEP, and low residual blood flow in the auditory cortex. And the other was the non-critical ischemia which included transient suppression and spontaneous recovery of the cortical sensory evoked potentials, and high residual blood flow (greater than 15 ml/100 g/min). In one cat with transient suppression of three kinds of sensory evoked potentials, the [14C]-iodoantipyrine (IAP) autoradiograph revealed only a limited ischemic area of subcortical white matter. In the critical ischemia group, ischemia of the primary sensory cortex ranged from the mostly affected primary auditory cortex (supplied by the MCA) to the least affected hindlimb projection area within primary somatosensory cortex (supplied by the ACA). The forelimb projection area of the primary somatosensory cortex (supplied by both ACA and MCA) showed a mild or moderate reduction of rCBF after occlusion. The [14C]-IAP autoradiograph showed severe reduction of the white matter including the somatosensory pathway in the wide range. However, rCBF in the thalamus and hindlimb projection area within somatosensory cortex was almost intact in the cat with ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of primary interhemispheric subdural abscess].

A rare case of primary interhemispheric subdural abscess is reported. This 13 year old boy, who had had high fever for 2 days, was brought into the hospital by an ambulance. He was disoriented and mild stiffness of the neck was noted. A Jacksonian seizure that began in the left leg occurred immediately after admission. The initial CT scan showed no apparent abnormality. His clinical signs and spinal fluid findings showing slight monocytic response and normal sugar content suggested viral meningo-encephalitis. The patient was given steroid and glyceol to control the intracranial pressure and antibiotics was also given. The convulsions disappeared with anticonvulsants and the patient became afebrile on the 7th hospital day. He was discharged on the 53rd hospital day without any neurological deficit. But, he was re-admitted because of recurrence of the convulsion 29 days after the discharge. The CT scan revealed an interhemispheric (rt parafalcial) abscess and the drainage of abscess was performed through a craniotomy. The post-operative course was satisfactory and he was discharged on 33rd post-operative day. It is easy to diagnose the primary interhemispheric subdural abscess on CT scan at the advanced stage. However, it may be difficult to make definite diagnosis at its acute phase and it is important not to miss some characteristic clinical features of the interhemispheric abscess that can be safely cured by appropriate surgical treatment.

[Cortical somatosensory evoked potential associated with experimental chronic cord compression by epidural neoplasm in rabbits].

An experimental model of spinal cord compression was developed in rabbits by epidural neoplasms which were injected anterior to the T 13 vertebral body and grew into the spinal canal through the intervertebral foramina. With this experimental model, the neurological condition of the animals was monitored using a scale and changes of somatosensory evoked potentials (SEPs) were studied to evaluate the neurophysiological effect of experimental chronic cord compression. The animals were immobilized with pancuronium bromide and artificial respiration was maintained through a tracheostomy. SEPs were recorded by silver ball electrodes which were positioned epidurally over the somatosensory cortex through small burr holes. A subcutaneous needle placed at the nose served as a reference electrode. Right hind paw was stimulated via two percutaneous needles with 0.1 msec rectangular impulses sufficiently strong to produce motor responses, ranging from 10 to 20 volt in control rabbits. Electrical stimuli were delivered at a rate of 1 Hz. The intensity of electrical stimulation was raised up to 300 volt, when no consistent SEP was observed in the rabbit with spinal neoplasm. The SEP was summated by averaging 50 successive cortical transients with the analysis time of 200 and 500 msec. The cortical SEPs in the rabbit normally consisted of a positive-negative sequence, which we labelled P1, N1, P2, N2 and so on. Early peaks, P1 and N1, were observed constantly with average latencies of 30.1 and 53.3 msec respectively in normal rabbits. The variability of amplitudes seen even in control animals made them a less useful measure of function than latencies. Normal SEPs were preserved until the animals demonstrated moderate paraparesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Bifrontal epidural hematoma after transsphenoidal operation: report of a case with a rare complication.

We report a patient with a growth hormone-secreting adenoma who developed bifrontal epidural hematomas after a transsphenoidal operation. To our knowledge, this is the first report of such a complication.

Embryonal carcinoma with teratomatous elements in the region of the pineal gland.

An embryonal carcinoma with teratomatous elements arising in the region of the pineal gland of an eight-year-old boy is reported. Radiation therapy, chemotherapy and surgical intervention failed, and he died 16 months after the onset of the symptoms. His clinical and autopsy findings are described.