Clinical analysis of a series of vertebral aneurysm cases.

We reviewed 38 cases of aneurysms of the vertebral artery treated over the last 10 years: 26 (68%) located at the junction of the vertebral and posterior inferior cerebellar arteries, 10 (26%) at the vertebral artery, and 2 (5%) at the vertebrobasilar union. There were three distinct forms of aneurysms: 20 saccular (53%), 10 fusiform (26%), and 8 dissecting (21%). Among these 38 aneurysms, 33 (87%) had ruptured: 18 of the saccular aneurysms (90%), all 10 of the fusiform aneurysms (100%), and 5 of the dissecting aneurysms (63%). Computed tomography of the 28 ruptured aneurysms revealed diffuse subarachnoid hemorrhage in the basal cistern combined with intraventricular hemorrhage in 24 cases (86%). Magnetic resonance imaging was useful for differentiating between fusiform and dissecting aneurysms. Abnormalities such as a double lumen of the vertebral artery were demonstrated in four of the dissecting aneurysms. The overall surgical results were good for 22 of the 27 surgically treated cases (81%). New bleeding was observed in 8 (24%) of the 33 ruptured aneurysms. The rate of new bleeding was high (60%) in the patients with dissecting aneurysms, and occurred mostly in the acute stage. The incidence of vasospasm was 27%, and only two patients suffered permanent neurological deficits. These findings indicate that the rate of new bleeding tends to be high in patients with saccular and dissecting aneurysms, and thus, they should be treated as early as possible. A preoperative balloon occlusion test should be conducted if proximal occlusion of the vertebral artery is necessary, since proximal occlusion is not always safe, despite angiographic evidence of sufficient contralateral arterial flow.

Carrier-mediated transport systems for glucose in mucosal cells of the human oral cavity.

The in vitro uptake study was performed using the isolated cells of human oral mucosa, buccal and the dorsum of the tongue, to investigate the mechanisms of glucose uptake. The uptake of D-glucose was much larger in cells of the dorsum of the tongue than in buccal cells and was inhibited more extensively by 2-deoxy-D-glucose, a substrate of facilitative glucose transporters, than by alpha-methyl-D-glucoside, a specific substrate of SGLT1, suggesting the larger contribution of a facilitative transporter than Na(+)/glucose cotransporter. Furthermore, from the results of inhibition studies by several sugar analogues including maltose and D-mannose, GLUT1 and/or GLUT3 were suggested to take part in the glucose uptake by oral mucosa. Therefore, we have attempted to confirm the expression of glucose transporters on the oral mucosa by employing Western blotting. As a result, it was suggested that SGLT1, GLUT1, GLUT2, and GLUT3 are expressed in the epithelial cells of human oral mucosa.

Correlation between blood parameters and symptomatic vasospasm in subarachnoid hemorrhage patients.

Serial changes in platelet and white blood cell (WBC) counts and other blood parameters were analyzed in 103 patients with aneurysmal subarachnoid hemorrhage (SAH). The WBC counts during days 3-5, 6-8, 9-11, and 12-14 after the onset of SAH were significantly higher in patients with than in patients without symptomatic vasospasm. Platelet counts during days 0-2, 3-5, 6-8, 9-11, 12-14, 15-17, 18-21, and 22-28 after SAH were significantly higher in patients with than in patients without symptomatic vasospasm. Monitoring of platelet and WBC counts may provide an indicator of the occurrence of symptomatic vasospasm.

Significance of acute cerebral swelling in patients with sylvian hematoma due to ruptured middle cerebral artery aneurysm, and its management.

A retrospective study of 75 patients treated surgically for ruptured middle cerebral artery (MCA) aneurysm within 48 hours evaluated clinical grade at admission, secondary development and management of cerebral swelling associated with space-occupying hematoma, cerebral infarction caused by vasospasm, development of hydrocephalus, and clinical outcome. Clinical grade at admission was significantly better in patients without than in those with hematoma (p < 0.01). Twenty-seven patients with sylvian hematoma caused by ruptured MCA aneurysm often developed ipsilateral cerebral swelling in the early period after subarachnoid hemorrhage. Seventeen of these patients developed serious cerebral swelling and received barbiturate therapy. Nine of these 17 patients had good outcome, but six patients died of cerebral swelling. The incidence of hydrocephalus was significantly higher in patients with than in those without hematoma (p < 0.01). The incidence of infarction was more pronounced in patients with sylvian hematoma. Clinical outcome was significantly better in patients without than in those with sylvian hematoma (p < 0.01). Development of cerebral swelling in patients with sylvian hematoma due to ruptured MCA aneurysm has a significant effect on outcome, and improvements in management are required.

Meningioma associated with subdural hematoma--case report.

The case of a 49-year-old female with a left parietal convexity meningioma associated with an acute subdural hematoma is described. She was admitted because of sudden onset of severe headache accompanied by nausea and vomiting. She was also confused, and 6 hours after admission she developed lethargy, right hemiplegia, and left mydriasis with no pupillary reaction to light. Computed tomography disclosed a round, extra-axial mass in the left parietal region; it was heterogeneously enhanced. Emergency craniotomy, performed after carotid angiography, revealed a tumor with a massive underlying subdural hematoma. The histological diagnosis was meningotheliomatous meningioma, and there were many meningothelial cells within the hematoma.

Computed tomographic features of central descending transtentorial herniation--case report.

Computed tomographic (CT) features of central descending transtentorial herniation (DTH) were identified in a patient who presented with subarachnoid hemorrhage. The main features were symmetrical deformity of the brainstem and downward displacement of the third ventricle. The authors believe these findings will contribute significantly to the establishment of CT diagnostic criteria for central DTH.

Rapid resolution of acute subdural hematoma--report of four cases.

We report four cases of acute subdural hematoma (ASDH) in which the hematoma rapidly resolved. Three of the four hematomas were traumatic. The outcome was good in three cases and fair in one. Spontaneous resolution of ASDH is rare.

Primary intracranial squamous cell carcinoma--case report.

A 50-year-old female presented with primary intracranial squamous cell carcinoma (SCC) at the right cerebellopontine angle manifesting as right facial nerve paresis. She had undergone gross total removal of a right cerebellopontine angle epidermoid cyst 10 years before and had done well until recently. Magnetic resonance imaging showed a heterogeneous tumor with markedly enhanced irregular margin. Subtotal removal of the tumor was achieved. Histological examination showed moderately differentiated SCC. After surgery, she underwent chemotherapy and gamma radiosurgery. She is now well 5 years after the diagnosis of SCC.

Clinical analysis of recurrent subarachnoid hemorrhage after neck clipping surgery.

The clinical features of recurrent subarachnoid hemorrhage (SAH) after neck clipping surgery were investigated in a series of 1,436 consecutive patients treated between 1980 and 1994, and seven patients treated prior to 1980. Recurrent SAH occurred within 1 month in seven patients and between 1.5 and 20 years in 20 patients (mean interval 9.2 years) from the first surgery. The patients were aged from 31 to 76 years (mean 49.8 years) at the first SAH. There were 19 females and eight males. Recurrent SAH occurred at the same site as the prior aneurysms in 12 cases, at an infundibular dilatation in three cases, de novo aneurysms in nine cases, untreated multiple aneurysms in two cases, and unknown in one case. The main causes for early recurrent SAH were incomplete clipping or untreated multiple aneurysms, whereas late recurrent SAH was due to de novo aneurysms, untreated multiple aneurysms, or regrowth aneurysm at the prior site. The outcomes of late recurrent SAH were good in eight cases, moderate disability in two, severe disability in three, and dead in seven, whereas most cases of early recurrent SAH resulted in poor outcome. Immediate postoperative angiography is desirable in cases with incomplete clipping, because early recurrent SAH resulted in poor outcomes. De novo or regrowth aneurysms caused late recurrent SAH, so follow-up angiography is strongly recommended for young patients, even if complete clipping was achieved.

Brain tumors manifesting as intracranial hemorrhage.

The clinical course and computed tomographic (CT) findings of 23 patients with brain tumors manifesting as tumoral hemorrhage were reviewed. The most common symptoms were headache and clouding of consciousness. A CT finding of a lesion located next to a solid or irregular clot indicated intratumoral hemorrhage. Precontrast CT demonstrating an indent on the hematoma surface was a valuable indicator of tumoral hemorrhage. A CT finding of accumulated levels of blood/fluid or a hyperdense mass containing small hematoma indicated intratumoral hemorrhage, and obscure hyperdensity indicated intratumoral hemorrhagic infarction. Such findings were often difficult to distinguish from spontaneous intracerebral hemorrhage due to other factors. The incidence of rebleeding from residual tumors was high, carrying a very poor prognosis, so radical removal of brain tumors with hemorrhage is very important.

[Epilepsy after operation for ruptured intracranial aneurysm].

Fifty-five patients who underwent surgery for ruptured aneurysm of the anterior circulation were evaluated with respect to postoperative epilepsy. Prophylactic treatment with anticonvulsants had been carried out in all patients. The overall incidence of the postoperative epilepsy was 23.6% (13/55). The mean latency between the operation and the first seizure was 11 months (range, 8 days to 5 years). The most important risk factors by statistical analyses were multiple aneurysms, preoperative severity, severe subarachnoid hemorrhage, intracerebral hematoma, normal pressure hydrocephalus, EEG abnormalities in the chronic stage, intracerebral low density area on CT-films and neurological deficit. Other risk factors were aneurysm of MCA and early operation for aneurysm. Our opinions concerning postoperative anticonvulsant therapy for aneurysmal patients are as follows. 1) Prophylactic treatment with anticonvulsant should be administered to all patients who have undergone aneurysm surgery. 2) The risk factors should be considered in determining the duration of medication with the anticonvulsant. 3) The treatment with the anticonvulsant should be performed while monitoring the clinical course, EEG findings, plasma concentration level of the anticonvulsant and side effects of the drugs.

[Vertebral artery injury following mild neck trauma: report of two cases].

Two cases of vertebral artery injury following mild neck trauma are reported. A 52-year-old man was hospitalized with gait disturbance 7 days after mild traffic accident. Right vertebral angiogram revealed complete occlusion of the rt. vertebral artery (VA) and MR images revealed infarction in the rt. cerebellar hemisphere and rt. dorsolateral part of the medulla oblongata and revealed the thrombus in the rt. VA. He underwent anticoagulation and became asymptomatic. Angiogram 6 months later revealed the vessel to be normal. A 23-year-old man who has a habit of self-manipulation of his neck was hospitalized on the day when he experienced dysesthesia in the left part of his face and left upper and lower extremities and unsteady gait. MR images revealed multiple infarction in bilateral cerebellar hemispheres and thrombus in bilateral VAs. Bilateral vertebral angiogram revealed severe stenoses of bilateral VAs. He underwent anticoagulation and wore soft collar. Angiogram 20 days after onset revealed improvement of bilateral VA stenoses. He was discharged with no neurological deficit. It is said that vertebral artery injuries in association with head and neck trauma are relatively rare, but this condition is possible to be more common than realized, considering that the case of unilateral VA occlusion or the case with well developed collateral circulation is sometimes well tolerated for ischemia and that this condition can occur even after mild head and neck injury. The diagnosis must be established by vertebral angiogram, but MRI and MRA are very useful as ancillary methods. The therapeutic point is to prevent propagation of the thrombus and distal embolism, accordingly wearing a collar and anticoagulation are important.

[A case of recurrent internal carotid stenosis, after carotid endarterectomy, due to strangulation by scarring].

A case of recurrent internal carotid stenosis, one year after carotid endarterectomy, due to strangulation by scarring composed of digastric muscle, hypoglossal nerve and a branch of external carotid artery (ECA) is reported in this paper. A 34-year-old male suddenly became nauseated and developed right hemiplegia and dysphasia. He was admitted to a hospital, and the symptoms and signs improved gradually during a period of several weeks. A left carotid angiography, performed in another hospital, revealed a stenosis and wall irregularity around the highly-situated carotid bifurcation. He was transferred to our clinic with a view to being operated on. On admission, neurological examination disclosed a mild right motor weakness and motor dysphasia. A right carotid angiography revealed good cross circulation to the opposite. An EEG monitoring under the Matas test showed no outbreaks. With diagnosis of an embolism arising from carotid atheromatous plaque, a carotid endarterectomy was performed successfully. A postoperative angiography revealed good patency without stenosis nor wall irregularity around the carotid bifurcation. The postoperative and out-clinic condition was uneventful. However, one year after the operation, a left carotid angiography revealed recurrent internal carotid stenosis in a high degree. A second operation was performed and the operative findings showed an internal carotid stenosis due to strangulation by scarring composed of digastric muscle, hypoglossal nerve, a branch of ECA and connective tissue. The scarring was decompressed and a postoperative angiography revealed an improvement of the stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Central nervous cryptococcosis giving rise to ascites after ventriculo-peritoneal shunting--a case report].

The ascites retention as a complication after ventriculo-peritoneal shunting (V-P shunt) is very rare. In this paper, a case of central nervous cryptococcosis giving rise to ascites after a V-P shunt is presented. A 45-year-old female was referred to Prefectural Gifu Hospital complaining of nausea and disturbance of recent memory. She had no remarkable medical history. CT scan films on admission showed enlarged ventricles except for the fourth ventricle, indicating an obstructed hydrocephalus. Lumbar cerebrospinal fluid (CSF) examinations revealed an increase in cell counts (mostly lymphocytes) and protein content, and positive Pandy and Nonne-Apelt reactions. Based on this information, it was tentatively suggested that she had a certain infection in the central nervous system such as mycosis or tuberculosis etc. Continuous ventricular drainage was performed for about three weeks. During this period, several lumbar and ventricular CSF cultures were negative. Therefore, a V-P shunt operation was performed. However, about seven weeks after the V-P shunt, she developed abdominal distention without any peritoneal signs. Abdominal CT scan films showed an abnormal ascites retention. Laboratory tests revealed positive CRP and increased ESR values. Again, it was suggested that she had not only a central nervous but also a peritoneal infection giving rise to ascites. From samples of ventricular CSF and ascites, cryptococcus neoformans was cultured. The lumbar CSF revealed positive latex agglutination titer for cryptococcal antigen, although the culture was negative. The ascites examination revealed an increase in cell counts (mostly lymphocytes) and protein content, and positive Rivalta and Runneberg reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of facial arteriovenous malformation].

Arteriovenous malformations (AVMs) of the face are notoriously difficult lesions to manage because of the abundant vascular network in this region. We report three cases in which AVMs of the face were treated with endovascular embolization. Two cases with small AVM of the face and auricle were treated with direct puncture of the nidus and embolization with a small amount of n-butyl-cyanoacrylate (NBCA). In the third patient with a large AVM of the cheek, the external carotid artery (ECA) of which had been previously ligated surgically, percutaneous direct puncture of the ECA was performed. Superselective catheterization of each of the feeding arteries and embolization with a small amount of NBCA was then achieved. All cases demonstrated clinical and angiographical improvement. In two cases with a small AVM of the face and auricle, complete obstruction of the nidus was achieved. Direct puncture of the nidus and embolization with a small amount of NBCA was a safe and effective technique for the treatment of facial AVM.

[Pulmonary embolism complicated with stroke: analysis of 5 cases].

Though pulmonary embolism (PE) has been thought to be rare, the incidence seems to be increasing recently. During the past 10 years the authors have encountered 5 cases of PE among stroke patients. There were 2 males and 3 females, aged 51 to 71 years (mean age; 63 years). The mean time between admission and onset of PE was 23 days. As to the primary disease to be treated, 5 patients had subarachnoid hemorrhage and one had intracerebral hemorrhage. Generally, PE tends to be overlooked or misdiagnosed because of the fact that stroke patients are often in a state of unconsciousness. In our series, only one patient complained of dyspnea and the other 4 patients due to unexplained sudden tachycardia, tachypnea and hypoxemia were suspected to have PE. Deep venous thrombosis known as the risk factor leading to PE was presented in 3 patients. Especially in one patient, femoral venous catheterization was considered as a risk factor possibly leading to deep venous thrombosis. Regarding the diagnosis of PE, the roles of electrocardiogram and of chest x-ray film were small. In 3 patients, the elevation of the diaphragm was the only abnormal finding on chest X-ray. On the other hand, the lung scintigram with 99mTc-MAA was a useful method for definitive diagnosis of PE. In 3 patients, filling defects were demonstrated on the lung perfusion scintigrams. Consequently, we emphasize that PE must be kept in mind when tachycardia, tachypnea and hypoxemia appear suddenly. Prompt diagnosis and treatment are required.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of a persistent primitive proatlantal intersegmental artery with a ruptured basilar bifurcation aneurysm].

A case of persistent primitive proatlantal intersegmental artery (PPPIA) associated with a ruptured basilar bifurcation aneurysm was reported. A 44-year-old male with sudden headache was admitted to our hospital. CT scan revealed subarachnoid hemorrhage. Cerebral angiography revealed anomalous anastomosis between the internal carotid artery and the vertebral artery at the proatlantal region. This anastomosis branched off from the left internal carotid artery at the C4 level and joined the horizontal portion of the left vertebral artery. It was thought to be PPPIA. Angiography also revealed an aneurysm of the basilar bifurcation which was responsible for the patient's subarachnoid hemorrhage. The aneurysm was successfully treated by endovascular embolization with Guglielmi detachable coils in an acute stage, and resulted in good outcome. PPPIA with basilar bifurcation aneurysm has not been presented or reported in the literature to date. To our knowledge, this is the first report of such an association of vascular anomalies. The frequency of PPPIA combined with the intracranial aneurysm is relatively high, whereas the occurrence of PPPIA is extremely rare. Therefore, it was suggested that some congenital and/or hemodynamic factors changed by PPPIA may affect the pathogenesis of intracranial aneurysms.

[Cavernous angioma in the cerebellopontine angle: a case report].

A rare case of cavernous angioma (CA) in the cerebellopontine angle (CPA) is reported. A 60-year-old female suffered from a right progressive sensorineural hearing loss and a successive right facial paresis over 2 years. A small mass was detected in her right CPA on CT scans. Both T1- and T2-weighted MR images demonstrated an intracanalicular lesion protruding into the CPA as being hyperintense. A small red colored lobulated tumor involving the 7th and 8th cranial nerves was found in the CPA through the suboccipital approach. The tumor contained multiple small hematomas in various stages. Biopsy with evacuation of these hematomas was selected to avoid damaging the cranial nerves. Histological examination of the specimen disclosed it as CA. Postoperatively her facial paresis improved slightly, but her hearing loss remained unchanged. Discussions were carried out concerning clinical and neuroradiological features of CA in the internal auditory canal and CPA. The present case and a previously reported 17 cases were the subjects under discussion.

[Cerebellar infarction: analysis of 33 cases].

During the past 9 years and 2 months we have encountered 33 cases with cerebellar infarction. These patients were classified into 3 types according to their clinical course. Type 1 (18 cases); The course was benign, and symptoms and signs improved without surgical treatment. Type 2 (11 cases); The course was progressive with deterioration of consciousness between 24-72 hours after the onset. Type 3 (4 cases); The course was rapid resulting in lapse into coma within a few hours. Also, its prognosis was fatal due to coexisting brain-stem infarction regardless of any treatment. Surgical intervention was required for Type 2 in which the lesion included the region of the vermis or occupied more than one-third of the cerebellar hemisphere, and had subsequently compressed the brain-stem and caused obstructive hydrocephalus. In 9 cases out of Type 2, ventricular drainage alone was performed and prompt improvement of consciousness level was detected except in one case. We consider that ventricular drainage is not so invasive a method, and it is beneficial. However, in 2 cases of Type 1 and 4 cases of Type 2, hemorrhagic infarction occurred. Thus, one should be aware of the possibility of hemorrhagic infarction, even though it may be asymptomatic infarction. If prompt improvement of consciousness is not detected after ventricular drainage, suboccipital craniectomy should be recommended.

[Peripheral aneurysms of the posterior inferior cerebellar artery; analysis of 15 cases].

Peripheral aneurysms of the posterior inferior cerebellar artery (PICA) are rare. The authors report 15 cases of peripheral PICA aneurysms. Twelve of the aneurysms were discovered after their rupture and two were discovered after rupture of concomitant AVM, and one was detected incidentally. As to the location of aneurysms, more than half of the aneurysms arose at the telovelotonsillar segment. One patient had 2 aneurysms on the same peripheral PICA, which were not obvious on preoperative angiography because the ruptured one was partially thrombosed. Another rare case with aneurysm located at the internal auditory meatus is also reported. The findings of CT were characteristic, namely hemorrhage in the fourth ventricle without obvious hemorrhage in the basal cisterns, or only within the cerebellar vermian cistern. This phenomenon strongly suggested the possibility of rupture of peripheral PICA aneurysms. As to the surgical results, 10 patients (71%) of the 14 patients had a good recovery, and 1 patient (7%) with nonrupture aneurysm had a fair result due to pre-existing pontine hemorrhage. Three patients (21%) died. Rebleeding occurred in 3 patients, but cerebral vasospasm occurred in only 1 patient. Consequently, as peripheral PICA aneurysms are likely to be missed, and rebleeding is an unfavorable factor, one should try to demonstrate aneurysms with angiography, by using various methods such as subtraction or magnification.