Stenting of extracranial carotid artery stenosis.

SUMMARY: The purpose of this study is to evaluate our cases of cervical internal carotid artery stenosis for safty stenting.We investigate the preoperative internal carotid artery stenosis using by integrated backscatter (IBS) method of ultra sonography, comparing with the thirty five surgical specimens as to their nature, histological structure, thickness of fibrous cap. We choose the protection method according to plaque structure, and placed Easy-Wall stent or Smart stent after prePTA. We added post PTA according to the extent of expansion and IVUS findings. Calibrated IBS = IBS value (ROI) /intinal IBS value of 'bleeding', 'lipid', 'thrombus', 'fiber', 'hyalinization' were -27.5, -22.5, -15.2, -11.1, +2.1. That of the thin fibrous cap were -10.9*, that of thic fibrous cap were -2.4 (*p < 0.001). There was a good coleration between the extent of expansion and expected histological findings. All conplications were two cases of small cerebral infarction and a case of bleeding from the complicated lung cancer. The protection at prePTA lead to no comploications in case of acute cerebral infarctions. It is very important to check the histological specimen carefully for safty stenting.

[A case of high flow CCF with congestive hemorrhage].

The authors report a case of high flow CCF with intracerebral hemorrhage during treatment with endovascular coil embolization. A 52-year-old woman had been in good health until a sudden onset of orbital bruit and left orbital tinnitus occurred. Conjunctival chemosis and diplopia caused by left abducens palsy gradually progressed. Left internal carotid arteriography revealed a carotid-cavernous sinus fistula with direct high-flow shunt. The fistula drained into the superior orbital vein, inferior petrosal sinus, intercavernous sinus and sphenoparietal sinus with significant cortical reflux. The attempt at transarterial balloon occlusion failed. Then transvenous coil embolization was performed. During the course of endovascular treatment, follow up CT depicted intracerebral hemorrhage. Intracerebral hemorrhage was asymptomatic and thought to be caused by venous hypertension from cortical reflux. The patient underwent direct occlusion of the left sphenoparietal sinus for prevention of further hemorrhage via craniotomy. Lastly, the cavernous sinus was completely occluded by transvenous coil embolization. The signs and symptoms resolved 3 months after the procedures.

Direct clipping of a large basilar trunk aneurysm via the posterior petrosal (extended retrolabyrinthine presigmoid) approach--case report.

A 53-year-old female presented with an unruptured, large basilar trunk aneurysm manifesting only as headache with no neurological deficits, including absence of cranial nerve dysfunction. Cerebral angiography disclosed a large aneurysm with a wide neck arising from the midbasilar artery. We treated the aneurysm surgically via the posterior petrosal approach. Five angled clips were applied sequentially to the aneurysm and the basilar artery was successfully reconstructed. Electrophysiological monitoring was continued during the operation and showed no changes. Following the operation, the patient suffered from transient right abducens nerve palsy, which persisted for 3 months. Postoperative angiography showed that the aneurysm was obliterated, and the patency of the basilar artery was preserved.

Ventral T-1 neurinoma removed via hemilaminectomy without costotransversectomy--case report.

A 39-year-old male presented with a spinal neurinoma originating from the T-1 anterior root and located ventral to the spinal cord. The tumor was removed by hemilaminectomy with only partial facetectomy without costotransversectomy. No stabilization was necessary, and no complications secondary to surgery occurred. Costotransversectomy is not necessary for neurinoma ventral to the spinal cord within the spinal canal at T-1 level because the transverse process protrudes more laterally and the spinal canal of the T-1 vertebra is wider than at other thoracic levels.

[Brain surface clear cell ependymoma: case report].

We report a case of brain surface clear cell ependymoma. A 13-year-old boy presented with complaints of right hypesthesia. Computed tomography and magnetic resonance image showed a left fronto-parietal cystic, calcified mass lesion. He underwent total resection of the tumor including cyst wall. The tumor located on the surface of the parietal lobe was sharply demarcated from the surrounding brain tissue and there was no continuity with the ventricular wall. Histological examination of the surgical specimens showed oligodendroglioma-like cells that had round unclei, clear cytoplasm which formed perivascular pseudorosettes, and immunoreactivity for glial fibrillary acidic protein (GFAP). Electromicroscopically, microvilli were seen. The findings were compatible with clear cell ependymoma. The cyst wall was lined with a layer of single cuboidal cells and, immunohistochemically, had no basal membrane. The inner surface of the cyst was positive for EMA, and the cuboidal cells were positive for GFAP. We discuss possible mechanisms for tumor growth in our case and the histogenesis of its cyst.

[Bilateral aplasia of the internal carotid artery: a case report].

We report a case of bilateral aplasia of the internal carotid arteries. A 59-year-old man was admitted with generalized convulsions. Computed tomography and magnetic resonance imaging of the head showed normal findings. Three-dimensional computed tomography, angiography, and intra-arterial digital subtraction angiograms showed bilateral aplasia of the internal carotid arteries. The bilateral ophthalmic arteries were filled from the hypoplastic carotid arteries, and the anterior and middle cerebral arteries were filled from the basilar artery via the posterior communicating arteries. Associated with this bilateral aplasia of the internal carotid arteries, intracranial aneurysms and megadolicho-basilar anomaly were reported. Angiography is to be recommended if IC aplasia is suspected.

[A huge idiopathic brain stone in the posterior fossa].

We report a case of idiopathic brain stone occurring in the posterior fossa. A 72-year-old woman with a huge calcified mass in the posterior fossa on plain craniogram was referred to us. She had suffered from intractable tinnitus and mild cerebellar ataxia for twenty years. CT scan revealed a dense bony mass in the posterior fossa. Angiogram only showed an avascular huge mass in the posterior fossa. MRI clearly revealed the shape, heterogenous composition and anatomical relation to the surrounding structure of the mass. The mass was totally removed uneventfully under ABR and SEP monitoring. The patient was discharged with improvement of subjective symptoms. The mass was histologically diagnosed as an idiopathic brain stone because its components were mainly calcified tissues and collagen fiber of unknown etiology; no viable cells were found in any of the specimens. Idiopathic brain stones are very rare and only eight cases have been reported in the literature. The etiology and clinical symptoms of this condition are briefly discussed.

[Dural AVF of the posterior fossa associated with sinus occlusion presenting as intracerebral hemorrhage: case report].

A 69-year-old man was admitted because of sudden onset of consciousness disturbance. Neurological examination on admission revealed slightly disturbed consciousness, sensory aphasia and right hemiparesis. CT scan disclosed a hematoma in the left posterior temporal lobe. Left carotid angiograms showed dural AVF of the transverse/sigmoid sinus fed mainly by the left occipital and posterior auricular arteries. On the angiograms the left sigmoid sinus was completely occluded. This was associated with retrograde venous flow into the cortical veins, the superior petrosal sinus and the contralateral traverse sinus. After stabilizing the condition, we totally resected the dural AVF including the left transverse sinus. The postoperative course was uneventful. Histopathological examination of the surgically resected specimen revealed that the dural A-V fistula per se existed in the sinus wall.

Effects of intravenous nitroglycerin combined with dopamine on intracranial pressure and cerebral arteriovenous oxygen difference in patients with acute subarachnoid haemorrhage.

The effects of intravenous nitroglycerin (NTG) combined with dopamine on intracranial pressure (ICP) and cerebral arteriovenous oxygen difference (AVDO2) were studied in 11 patients with acute subarachnoid haemorrhage (SAH). The study was performed on Days 1 to 3 of SAH after aneurysmal clipping. Treatment consisted of an intravenous drip infusion of NTG in increasing incremental doses of 0.5, 1.0, 1.5, 2.0, and 2.5 micrograms/kg/min at one-hour intervals. Dopamine (5 to 10 micrograms/kg/min) was also given concurrently to maintain systemic blood pressure. ICP values before NTG administration ranged from 7 to 24 mmHg (mean. 11.91 +/- 5.30 mmHg). ICP began to increase immediately after the administration of NTG 0.5 microgram/kg/min and peaked at 14.64 +/- 5.93 mmHg 10 minutes after onset of infusion. Thereafter, ICP gradually returned to pretreatment levels. Increasing the dose of NTG failed to induce further significant rises in ICP. Mean AVDO2 before NTG administration was 4.69 +/- 0.62 ml/dl. This parameter showed no significant change during NTG infusion, although cerebral perfusion pressure decreased to between 75% to 94% of the control value after NTG administration. These results indicate that continuous NTG infusion combined with dopamine does not have adverse effects on ICP (the ICP increase is minimal and transient) and may even have beneficial effects on CBF in patients with acute SAH.