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Journal: No shinkei geka. Neurological surgery

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In cerebral revascularization surgery in Japan, the preferred solution for rinsing and intraoperative storage of saphenous vein or radial artery grafts is a heparinized saline solution with albumin. On the other hand, most cardiac surgeons routinely use solutions of heparinized autologous blood during surgery. Here we used the latter type of solution for cerebral revascularization surgery and evaluated its efficacy. Patients and methods:Since December 2011, we have used heparinized autologous blood for saphenous vein grafts during cerebral revascularization surgery. For this, 20mL of the whole blood was obtained from an arterial line;this blood was then mixed with 20mL of a heparinized saline solution containing 500IU of heparin and 40mg of papaverine hydrochloride. The saphenous vein was harvested using standard procedures and immersed in the autologous blood solution just before implantation. Results:Between December 2011 and March 2013, six revascularizations using saphenous vein grafts were performed using this solution. None of the anastomoses presented complications related to revascularization procedures, and all grafts were clearly present postoperatively. Discussion:There is still no evidence that the storage in autologous blood is superior to the use of a saline solution with albumin. However, the national health insurance does not cover the use of albumin products, which carries an additional cost. Furthermore, the autologous blood medium is a red-colored solution that indicates the presence of unfavorable graft leaks when the wall of the graft turns red. Conclusion:We recommend the use of heparinized autologous blood for intraoperative rinsing and storage grafts.

Concepts: Blood, Heart, Surgery, Artery, Vein, Coronary artery bypass surgery, Great saphenous vein, Radial artery

25

We encountered a rare case of intraventricular ganglioglioma associated with neurofibromatosis type 1. A 42-year-old woman presented with a feeling of heaviness of the head and dizziness. She was diagnosed with neurofibromatosis type 1 because she had multiple subcutaneous neurofibromas and café au lait spots. On admission, she deteriorated slightly(Japan Coma Scale 1)and suffered from cognitive dysfunction and right hemiparesis. A computed tomography(CT)scan showed that she had an obstructed hydrocephalus with a long and circular mass lesion, 2cm in diameter, in the anterior horn of the left lateral ventricle. The mass showed low signal intensity(SI)on the T1-weighted image(WI), heterogeneous high SI on the T2-WI, and dense enhancement on a Gd-DTPA contrast MRI, extending from the head of the left caudate nucleus to the lateral ventricle. The patient underwent an urgent operation via an anterior transcallosal approach because of an obstructed hydrocephalus. The tumor was removed in its entirety, including its origin at the caudate head. The pathological diagnosis was a ganglioglioma grade 1 according with the classification of the World Health Organization. Here we describe this case and discuss the rare association between gangliogliomas and neurofibromatosis type 1.

Concepts: Brain, Oncology, Cerebral cortex, Neurology, Ventricular system, Neurofibromatosis, Neurofibroma, Lateral ventricles

0

Chronic subdural hematoma(CSDH)generally occurs in the elderly, and is usually treated by burr-hole craniotomy with closed-system drainage. Treatment of recurrent CSDH is more challenging, especially when the hematoma is multi-lobular. A variety of approaches to the management of multi-lobular CSDH have been described, including evacuation through a wide craniotomy, placement of an Ommaya reservoir, subdural peritoneal shunting, and embolization of the middle meningeal artery. We have previously reported a method of evacuating multi-lobular CSDH through a small craniotomy using a rigid endoscope and aspiration tube. The objective of this study was to compare our operative method with others from the literature.

Concepts: Subdural hematoma, Meninges, Middle meningeal artery, Dura mater

0

Cervical carotid aneurysms are rare, and surgical treatment should be planned for each patient. The authors report 9 cases of cervical carotid aneurysm in 9 patients(mean age, 53.7 years;5 men)who were treated surgically between 2005 and 2014. The aneurysm was located in the internal carotid artery in 6 patients, the common carotid artery in 2 patients, and the carotid bifurcation in 1 patient. Four aneurysms were recurrences after a previous endovascular intervention(parent artery coil embolization, covered stent placement, or stent with coil embolization). The mean interval between the endovascular therapy and the onset of the present illness was 6 years. All the patients presented a mass effect at the neck, including lower cranial nerve dysfunction in 1 patient. Two patients presented with ischemic events presumably due to thromboembolism from the target aneurysms. Surgical treatments included local vascular reconstruction procedures in 6 patients(interposition vein or artificial graft bypass in 5 patients and in situ bypass in 1 patient). Four aneurysms were then resected. Two patients with rich collateral blood flow were treated with ligation of the parent artery proximal to the aneurysm. Surgical complications included embolic stroke and cranial nerve dysfunction in 2 patients, respectively, both presumably due to surgical manipulation. The modified Rankin scale(mRS)score at discharge was 0 in 5 patients, 1 in 1 patient, 2 in 2 patients, and 6 in 1 patient(vascular tumor). Surgical treatment of cervical carotid aneurysms seems a reasonable treatment of choice, but lower nerve dysfunction and embolism from the aneurysm should be avoided.

Concepts: Stroke, Internal carotid artery, Common carotid artery, External carotid artery, Carotid sinus, Internal jugular vein, Brachiocephalic artery, Subclavian artery

0

Intracranial injury resultant from a chopstick penetrating the oral cavity is often fatal in children, and only 5 clinical cases have been reported. If the depth of penetration is indeterminable, due to the chopstick being removed or the remaining piece not being located, then injury management is challenging; here, we report such a case. A 26-month-old girl fell over with a plastic chopstick in her mouth. The chopstick was removed immediately and without breakage by her father. He noted that around 3 cm of the pointed end had pierced the palate. CT revealed air bubbles in the retropharyngeal space but no abnormality in the cranium. Subsequent complications included bacterial meningitis and right hemiparesis but neither MRI nor any alternative imaging modality could aid in locating the intracranial lesion that induced the weakness. Neurological findings suggested injury of the right lateral corticospinal tract at the lower end of the medulla oblongata. An axial T2-weighted MRI showed a 30-mm high signal path of penetration from the posterior nasopharyngeal wall to the dura at the craniocervical junction. When the route is extended 36 mm intracranially from the wound orifice, the path makes superficial contact with the right lateral portion of the medulla oblongata, which corresponds with the lateral corticospinal tract. We therefore hypothesize that this was the lesion location but that it was too small to be detected using MRI.

Concepts: Spinal cord, Brain, Intracranial pressure, Meninges, Medulla oblongata, Brainstem, Corticospinal tract, Lateral corticospinal tract

0

We report the case of a patient who has progressed well over 5 years following single-stage aneurysm clipping and superficial temporal artery-middle cerebral artery(STA-MCA)double anastomoses in the acute phase, for a ruptured distal anterior choroidal artery(AChA)aneurysm accompanied by a twig-like MCA. The patient was a 49-year-old female who developed a sudden severe headache and disturbance of consciousness due to subarachnoid hemorrhage and intraventricular hemorrhage(IVH). Cerebral angiography showed a right twig-like MCA associated with an abnormal vascular network and a ruptured aneurysm in the distal AChA. A day after emergency ventricular drainage for acute hydrocephalus, right frontotemporal craniotomy enabled distal AChA aneurysm clipping, together with removal of the IVH via transchoroidal fissure approach, in addition to STA-MCA double anastomoses to prevent recurrence of hemorrhage. The IVH resolved after surgery and no new infarct area was observed. Cerebral angiography revealed the disappearance of the aneurysm, good patency of the double bypass, and reduction of the abnormal vascular network. The patient gradually recovered without any neurological deficits, except for mild memory disturbance. Five years after the surgery, the patient has experienced no recurrence. The single-stage operation of aneurysm clipping and STA-MCA double anastomoses was made possible by devising an approach for a ruptured cerebral aneurysm, even in the acute stage. The successful improvement of cerebral circulation and prevention of cerebral hemorrhage from an early stage could serve as a reference for the treatment of similar hemorrhagic cases.

Concepts: Subarachnoid hemorrhage, Cerebral aneurysm, Headache

0

We report a case of tentorial dural arteriovenous fistula(dAVF)treated with transarterial and transvenous embolization using n-butyl-2-cyanoacrylate(NBCA). A 70-year-old man presented with dysarthria and trunk ataxia. Computed tomography(CT)on admission revealed right cerebellar hemorrhage. Right external carotid angiography demonstrated a tentorial dAVF fed by the marginal tentorial artery, petrosquamous branch of the middle meningeal artery, ascending pharyngeal artery, and artery of foramen rotundum. Right internal carotid angiography demonstrated a shunt fed by the meningohypophyseal trunk. The draining vein was the right basal vein with a varix, which drained into the straight sinus. Thin-slice axial images on magnetic resonance angiography demonstrated a shunt point located on the right tentorial incisura. The lesion was diagnosed as Cognard type IV tentorial dAVF. It was initially treated with transarterial embolization using 25% NBCA, which was injected into the marginal tentorial artery and the petrosquamous branch of the middle meningeal artery. However, owing to partial persistence of the shunt after the procedure, transvenous embolization using NBCA was performed. A microcatheter was navigated through the straight sinus into the basal vein, and a balloon catheter was also navigated to the confluence of the straight sinus and the basal vein to interrupt blood flow and prevent the NBCA from flowing back to the sinus. 80% NBCA was injected into the draining vein near the shunt point. Angiography performed immediately after the procedure revealed complete occlusion of the shunt, and postoperative CT showed no evidence of hemorrhage. Transvenous embolization of tentorial dAVF can be an effective method if a microcatheter can be safely advanced close to the shunt point.

Concepts: Common carotid artery, External carotid artery, Arteries of the head and neck, Meninges, Maxillary artery, Middle meningeal artery, Dura mater, Ascending pharyngeal artery

0

Pilocytic astrocytomas are found predominantly in the pediatric population and are extremely rare in elderly patients. We describe a case of pilocytic astrocytoma in an elderly patient who presented with the symptoms of an enlarged tumoral cyst. A 70-year-old woman was found to have an asymptomatic small solid tumor with a cystic component in the right frontal lobe at “Ningen Dock(medical checkup)of the Brain”. She was hospitalized and underwent further examinations including cerebral angiography. At that time, she was opposed to undergoing an operation for tumor removal owing to lack of symptoms. Approximately fourteen years later, she presented with dizziness upon posture conversion and recent memory disturbance. Computed tomography scanning revealed an enlarged cyst in the frontal lobe and perifocal edematous changes. Gadolinium-enhanced magnetic resonance imaging partially revealed the solid tumor and cystic capsule. The solid tumor had not enlarged substantially. The cystic fluid was aspirated and the solid tumor was resected via a frontal transcortical approach. The histological diagnosis was pilocytic astrocytoma without malignant features. After surgery, the patient’s symptoms improved and additional therapy was not provided. After a year of postoperative follow-up, the size of the cystic lesion has reduced, and no recurrence of the solid tumor has been observed.

Concepts: Cancer, Brain, Oncology, Medical imaging, Brain tumor, Astrocytoma, Frontal lobe, Pilocytic astrocytoma

0

We report a rare case of subarachnoid hemorrhage(SAH)due to ruptured extracranial aneurysm originating at the caudal loop of the left posterior inferior cerebellar artery(PICA). A 50-year-old woman presented with severe headache and mild consciousness disturbance. Computed tomography(CT)revealed SAH and intraventricular hemorrhage. Vertebral angiography showed an extracranial aneurysm located on the tonsillomedullary segment of the left PICA. During the surgery, no vessel branches were confirmed near the aneurysm, and the aneurysm was successfully clipped through suboccipital craniotomy with C1 laminectomy. The patient showed significant recovery and was discharged without neurological deficit.

Concepts: Atherosclerosis, Hospital, Stroke, Cerebellum, Subarachnoid hemorrhage, Posterior inferior cerebellar artery, Anterior inferior cerebellar artery, Headache

0

Duplication of the middle cerebral artery(MCA)is an anatomical variant of the MCA, originating from the distal portion of the internal carotid artery(ICA)and supplying blood flow to the tip of the temporal lobe. Cerebral aneurysms rarely develop at the bifurcation of the ICA and the duplicated MCA, but when they do develop, they may result in subarachnoid hemorrhage. We treated a 41-year-old man, who was urgently brought to our hospital because of severe headache. A computed tomography(CT)scan showed subarachnoid hemorrhage due to the rupture of an aneurysm at the origin of the duplicated MCA. The aneurysm was small and projected laterally, and coil embolization was performed employing a balloon catheter. The neck of the aneurysm was not embolized to preserve the origin of the duplicated MCA. The patient had an uneventful postoperative course, and he returned to his usual daily activities. Coil embolization is rapidly developing for treatment of cerebral aneurysms and may be the first-line treatment for duplicated MCA aneurysms. Owing to the relatively small size of such aneurysms, the risk of intraprocedural rupture should be considered, and a carefully performed balloon-assisted procedure is recommended.

Concepts: Temporal lobe, Cerebrum, Middle cerebral artery, Internal carotid artery, Posterior communicating artery, Subarachnoid hemorrhage, Cerebral aneurysm, Headache