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ABSTRACT: BACKGROUND: Cognitive impairment is a frequent complication of moyamoya disease (MMD) in adults. Chronic hypoperfusion in frontal lobes can lead to subtle brain injury, resulting in cognitive dysfunctions. Apparent diffusion coefficient (ADC) in normal-appearing white matter on conventional magnetic resonance imaging correlates with cerebral hemodynamics in the frontal lobe. OBJECTIVE: The purpose of this study was to examine the relationship of ADC with executive function in patients with MMD. METHODS: Thirty-one patients (25 women and 6 men; mean age, 32.6 ± 10.4 years) were included in this study. Executive function was evaluated by the Frontal Assessment Battery (FAB) at 21.5 ± 7.5 years after disease onset. ADC was measured in the normal-appearing frontal white matter. RESULTS: ADC was statistically related to the occurrence of executive dysfunction in multivariate analysis (P = .0179). Total FAB score and ADC were negatively correlated (r(2) = .22; P = .0072; Spearman correlation coefficient, -.41; P = .024). Elevated ADC predicted executive dysfunction (area under the receiver operating characteristic curve, .73; 95% confidence interval, .55-.91; P = .029). CONCLUSIONS: The association of ADC with executive function might suggest that ADC is useful in screening for executive dysfunction during follow-up in the outpatient setting.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 04/2013;
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ABSTRACT: We report a case of blood blister-like aneurysm(BBA)on the posterior wall of the internal carotid artery(ICA)causing subarachnoid hemorrhage(SAH). A 45-year-old man suffering from SAH(WFNS grade 5)was referred to our hospital. 3D-CT angiography showed a BBA on the posterior wall of the ICA. The aneurysm had been enlarged for a few days. Therefore we performed coil embolization. Four weeks after the operation, the aneurysm was found to have regrown. In the second operation the aneurysm was successfully treated by the ICA proximal occlusion with extracranial-intracranial bypass. Postoperative follow-up cerebral angiography detected no aneurysm. To our knowledge, BBA on the posterior wall of the ICA is rare. Radical surgery with bypass should be performed as soon as possible when the BBA is found to regrow. We discuss the clinical characteristics with a review of the literature.
No shinkei geka. Neurological surgery 03/2013; 41(3):229-34. · 0.13 Impact Factor
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ABSTRACT: A 48-year-old Japanese woman with Behçet's disease suffered successive rupture of thoracic aortic and cerebral aneurysms within one year. The patient underwent successful surgical treatment for both aneurysms. Histological examination of the aneurysm walls revealed lymphocyte infiltration into the adventitia with smooth muscle cell hyperplasia in the thickened intima. This is an extremely unusual presentation of Behçet's disease associated with both cerebral and aortic aneurysms.
Neurologia medico-chirurgica 01/2013; 53(3):189-91. · 0.61 Impact Factor
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ABSTRACT: Object The cerebellomedullary fissure (CMF) is a space between the cerebellum and the medulla oblongata, which often adhere to each other. The purpose of the present study was to demonstrate the importance of the unilateral CMF dissection for clipping vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms. Methods Five adult cadaveric specimens were studied after colored silicone was infused into the arteries and veins. The microsurgical anatomy of the CMF and the trans-CMF approach for VA-PICA aneurysm surgery were examined in stepwise dissections. In addition, 6 patients underwent surgery for VA-PICA saccular aneurysms (2 ruptured and 4 unruptured aneurysms) via posterolateral approaches, with wide opening of the unilateral CMF to obtain good visualization and a wide working space in the lateral part of the cerebellomedullary cistern. Clinical data including neurological and radiological findings and patient outcomes were analyzed in all 6 cases. Results In all cases, the aneurysm was successfully clipped and no permanent neurological deficits remained. The wide opening of the unilateral CMF on the lesion side made it possible to retract the inferolateral part of the cerebellum easily, provided a wide operative field in the cerebellomedullary cistern, and enabled successful clip placement without difficulty. Conclusions For safe and effective VA-PICA aneurysm surgery, it is very important to dissect the CMF on the lesion side as well as to remove the lateral part of the foramen magnum. Direct clip placement is very safe and useful in cases involving VA-PICA aneurysms.
Journal of Neurosurgery 11/2012; · 2.96 Impact Factor
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ABSTRACT: OBJECTIVE: We report a rare case of hydrocephalus following aqueductal stenosis caused by developmental venous anomaly (DVA). METHODS: Four years after the incidental discovery of asymptomatic DVA, the 10-year-old boy presented with symptoms of hydrocephalus. Enhanced computed tomographic scans and magnetic resonance images showed supra- and infratentorial DVAs with caput medusae appearances in the right basal ganglia and cerebellum. Three dilated collector veins in the right basal ganglia, floor of the third ventricle, and floor of the fourth ventricle gathered together to drain into the great vein of Galen. Three-dimensional fusion images showed that the serpentine dilated vein from the posterior fossa coursed in the aqueduct and caused the aqueductal stenosis, which was confirmed by operative endoscopy. RESULTS: Endoscopic third ventriculostomy was performed and the hydrocephalus was relieved. CONCLUSIONS: Although aqueductal stenosis caused by DVA is rare, it is important to be considered in the differential diagnosis of hydrocephalus. Three-dimensional reconstruction and fusion images are very useful.
Child s Nervous System 10/2012; · 1.54 Impact Factor
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ABSTRACT: Patients with moyamoya disease (MMD) exhibit narrowed internal carotid arteries (ICAs) because the distal ends of the bilateral ICAs have become progressively stenosed, starting mainly in childhood. Accordingly, the petrous carotid canals in MMD patients are suspected to be more hypoplastic than those in control subjects. In this study, the diagnostic value of conventional computed tomography for MMD patients was retrospectively evaluated by comparing the caliber of the bilateral carotid canals in MMD patients with that in control subjects.
Thirty-five patients with MMD (15 males, 20 females; age range/average age: 6-71 / 26.1 years old) and age- and sex-matched control subjects underwent conventional head computed tomography. The maximal petrous carotid canal diameters of the two groups were measured and compared.
The maximal petrous carotid canal diameter was significantly smaller in the moyamoya patients (mean +/- standard deviation [mm] = 4.70 +/- 0.61) than in the control subjects (5.62 +/- 0.61, p < 0.01).
Conventional head computed tomography revealed narrowed petrous carotid canals in the MMD patients. This basic information could be utilized to screen patients who will require further examination, especially among those with underlying MMD.
Fukuoka igaku zasshi = Hukuoka acta medica 10/2012; 103(10):206-14.
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ABSTRACT: Recent reports have shown that gamma-knife radiosurgery provides a safe and effective strategy for the management of brain
tumors. To evaluate the role of stereotactic radiosurgery in the management of meningiomas, we investigated the histopathology
of two patients. The patients, a 37-year-old man and a 54-year-old woman, presented with visual field disturbance or headache.
Imaging studies demonstrated intracranial meningiomas-tentorial and sphenoid ridge, respectively. Each patient undewent subtotal
surgical resection (more than 90% in both patients), followed by gamma-knife radiosurgery of the remnant tumor marginal doses
of 15 Gy. Pathological examination of the original tumors revealed a meningothelial meningioma and an atypical meningioma,
respectively. Enlargement of the remnant tumors 4 months after radiosurgery resulted in total surgical resection in both patients.
Thirteen months later, the patient with the atypical meningioma underwent a third operation for early recurrence of the tumor.
Histopathology was investigated, and MIB-1, p53, and bcl-2 labeling indexes (LI) were analyzed immunohistochemically. Histopathologically,
the specimens showed necrosis and intratumoral vessel obliteration after radiosurgery in both cases. However, more remnant
tumor cells survived in the atypical meningioma. Immunohistochemically, increased wild-type p53, decreased bcl-2 expression,
and decreased MIB-1 LI were observed in the benign meningioma. In the atypical meningioma, on the contrary, MIB-1 LI was decreased
and mutant-type p53 and bcl-2 expression were unchanged. The specimen from the third operation revealed an anaplastic meningioma,
and MIB-1 LI was markedly increased. These findings suggest that the efficacy of radiosurgery may differ between benign and
atypical meningiomas.
Brain Tumor Pathology 04/2012; 18(2):61-66. · 1.19 Impact Factor
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ABSTRACT: In recent years, new procedures for fourth ventricular surgeries have been developed with good results. In particular, the trans-cerebellomedullary fissure approach, which exposes the fourth ventricle without splitting the inferior vermis, has proven successful. For optimum results, specialized techniques should be employed in order to effectively open the roof of the fourth ventricle and obtain a wide exposure of its interior. These techniques include the following steps: (1) placement of an incision over the teania extending from the foramen of Magendie to the ventricular entrance of the lateral recess; (2) lateral extension of the incision to the roof of the lateral recess to facilitate its exposure; (3) implementation of the same procedure on the contralateral side. Upon completion of these steps, the bilateral cerebellar tonsils can be easily retracted superolaterally; this eventually exposes a wide interior of the ventricle. In order to ensure successful surgeries, explicit and accurate descriptions of technique are vital. In this article, we employ detailed illustrations to precisely demonstrate the operative procedures and techniques for fourth ventricular surgeries.
Neurosurgical Review 04/2012; 35(4):563-72. · 2.04 Impact Factor
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ABSTRACT: Many surgical treatments for moyamoya disease have been developed over the past 40 years. The optimum treatment for ischemic-type moyamoya disease is almost established. The first surgical treatment for the disease was the superficial temporal artery to middle carotid artery (STA-MCA) anastomosis. The discovery of spontaneous collateral formation following the STA-MCA anastomosis surgery led to the development of various indirect bypass procedures. Collateral formation and clinical outcomes from direct and indirect procedures have been compared to assess the merits and limitations of each technique. Experience and a greater understanding of the surgical effects of moyamoya disease have led to the development of surgical procedures combining various direct and indirect bypass techniques for optimal restoration of perfusion. This review of the historical development and efficacy of each procedure will aid surgeons in selecting the most appropriate surgical procedure for patients of different ages with different symptoms and disease severities.
Neurologia medico-chirurgica 01/2012; 52(5):278-86. · 0.61 Impact Factor
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ABSTRACT: Two cases of cavernous sinus thrombophlebitis (CST) caused by dental infection are described. A 64-year-old woman presented with palsies of the left oculomotor and trochlear nerves after tooth extraction for dental caries in the left maxilla. A 54-year-old man presented with palsy of the left trochlear nerve, sensory disturbance in the ophthalmic and maxillary divisions of the left trigeminal nerve, ptosis, proptosis, and chemosis after dental treatment for caries and periodontitis in the left maxilla. In both patients, computed tomography and magnetic resonance imaging with contrast medium showed non-enhanced lesions within the left cavernous sinus and dilation of the superior ophthalmic veins, which indicated CST. These conditions were resolved by administration of broad-spectrum antibiotics. CST is rare but lethal, so prompt diagnosis is crucial, and immediate appropriate treatment is essential.
Neurologia medico-chirurgica 01/2012; 52(10):757-60. · 0.61 Impact Factor
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ABSTRACT: In the surgeries of the upper part of the cerebellopontine angle (CPA), the petrosal vein (PV) is an obstacle, and the resection of the PV sometimes causes postoperative complications such as cerebellar hemorrhagic infarction. On the other hand, it can be an anatomical landmark during the surgery. We have used three-dimensional (3D) CT images for preoperative evaluation. We, herein, report 4 cases of CPA lesions.
The PV was imaged with neighboring structures using CT and a workstation. We paid attention especially to the vein of the cerebellopontine fissure (VCPF).
The four cases include one case of trigeminal neuralgia, two meningiomas and one case of acoustic schwannoma. 3D CT images showed (1) the anatomical formation such as course of the PV, (2) relationship to the neighboring structures of the tumors, (3) expectation of complications after sacrificing the PV. By observing the preoperative 3D CT images, we were able to plan safety operative approaches and procedures.
3D CT images of the PV are very useful for preoperative evaluation of surgery in CPA lesions.
No shinkei geka. Neurological surgery 12/2011; 39(12):1175-81. · 0.13 Impact Factor
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ABSTRACT: We report a case of the medulla oblongata syndrome successfully treated by microvascular decompression surgery. The patient was a 75-year-old woman and had been suffering from gradual progressive dyspnea since July, 2009. Two month later, intubation and medial ventilator treatments were began because of severe respiratory problems. The central respiratory problems were considered in extensive testing by the physician. The head MR imaging showed that the left vertebral artery had markedly compressed the medulla oblongata. We thought that her respiratory problems were associated with this vertebral artery compression of the medulla oblongata. We performed the microvascular decompression surgery by left trans-condylar fossa approach. Her hypoventilation graduately improved after the surgery and she needed neither ventilator nor oxygen in several months. She is able to perform daily activities by herself. We report the case, and discuss the cause of respiratory problems especially by compression of the medulla oblongata.
No shinkei geka. Neurological surgery 11/2011; 39(11):1085-9. · 0.13 Impact Factor
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ABSTRACT: The purpose of our study was to evaluate the correlation between fluid-attenuated inversion recovery (FLAIR) images of hyperintense vessel (HV), a representative of leptomeningeal vessels (LMVs), and cerebral vascular hemodynamic status in patients with steno-occlusive disease of the internal carotid artery (ICA) and middle cerebral artery (MCA).
Sixty-eight patients with unilateral ICA or MCA stenosis or occlusion were enrolled. Correlations between hyperintense vessel (HV) on FLAIR images and hemodynamic status measured by quantitative single-photon emission computed tomography data were evaluated in four groups: affected (A) and non-affected (B) hemispheres in HV-positive patients, and affected (C) and non-affected (D) hemispheres in HV-negative patients.
The presence of HV was most frequently seen on affected hemispheres in patients with MCA and ICA occlusions. HV was significantly higher in the anterior communicating artery (AcomA) (-), posterior communicating artery (PcomA) (-) group than in other groups, which included either or both AcomA and PcomA (P = 0.008). The presence of HV had a significant correlation with transdural anastomosis (P = 0.046) and LMV (P = 1.64×10(-9)). No significant difference was observed in resting regional cerebral blood flow among the four groups. Vascular reserve in group A was significantly less compared to other groups (P = 0·021).
HV is related to the hemisphere with severe ICA and MCA steno-occlusion when the circle of Willis is insufficient. The HV-positive hemisphere on the steno-occlusive side shows a lower vascular reserve than that in the contralateral hemisphere or HV-negative hemispheres.
Neurological Research 04/2011; 33(3):307-13. · 1.52 Impact Factor
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ABSTRACT: Arterial spin-labeling (ASL) is a noninvasive magnetic resonance (MR) imaging method used to obtain brain perfusion information on various cerebrovascular diseases. We retrospectively compared the use of ASL-MRI and single-photon emission CT (SPECT) imaging to determine absolute cerebral blood flow (CBF) in moyamoya disease.
CBF examinations using ASL-MRI on 3-T MRI and SPECT imagings with iodine-123-N-isopropyl-p-iodoamphetamine at resting (rest-IMP) and after acetazolamide challenge (ACZ-IMP) were performed on 12 patients with moyamoya disease (men, 5; women, 7; age range/average (year), 7-66/35.0). The CBF values determined by ASL-MRI (ASL-value), rest-IMP (rest-IMP-value), and ACZ-IMP (ACZ-IMP-value) of cerebral hemispheres (24 sides) were measured with normalized CBF maps created from data of those 3 perfusion imaging methods. Cerebrovascular reactivity (CVR) was calculated as follows: {(ACZ-IMP-value)-(rest-IMP-value)}/(rest-IMP-value)×100 (%). The ASL-value was compared with the rest-IMP-value, ACZ-IMP-value, and CVR.
The ASL-value, rest-IMP-value, ACZ-IMP-value, and CVR (average±standard deviation) were 26.6±14.8 (mL/100 g/min), 27.5±6.4 (mL/100 g/min), 37.1±13.2 (mL/100 g/min), and 35.9±44.3 (%), respectively. Significant relationships between the ASL-value versus (vs.) the rest-IMP-value (rs=0.500, p<0.05), the ASL-value vs. the ACZ-IMP-value (rs=0.863, p<0.01), and the ASL-value vs. the CVR (rs=0.699, p<0.01) were observed.
Although the ASL-value was lower than the rest-IMP-value, the significant relationship between the ASL-value and the rest-IMP-value may suggest that perfusion imaging by ASL-MRI could be used to recognize the condition of brain perfusion. In particular, the stronger correlation coefficient between the ASL-value and ACZ-IMP-value might suggest that perfusion imaging by ASL-MRI could show the potentially dangerous zone for ischemia.
European journal of radiology 02/2011; 80(3):e557-62. · 2.65 Impact Factor
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ABSTRACT: The success of microvascular decompression (MVD) depends on the permanent and complete transposition of the offending vessels. This paper describes the stitched sling retraction techniques for treating trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN), focusing on the stitching point for slinging the offending artery in the appropriate direction. Between January 2007 and March 2009, 28 patients with TN, 5 patients with HFS, and 3 patients with GPN underwent MVD with a sling retraction technique. In cases of TN, MVD was performed using the infratentorial lateral supracerebellar approach, and the offending superior cerebellar artery was superomedially transposed with a sling stitched to the tentorium cerebelli. In cases of HFS, MVD was performed using the lateral suboccipital infrafloccular approach, and the offending vertebral artery was superolaterally transposed with a sling stitched to the petrous dura. In cases of GPN, MVD was performed using the transcondylar fossa approach, in which the posterior inferior cerebellar artery was inferolaterally mobilized with a sling secured to the jugular tubercle. No patient suffered recurrence in the follow-up period. For the sling retraction technique to be performed successfully, it is important for a stitch to be placed at a suitable site to sling the offending vessel in the intended direction. An appropriate surgical approach must be used to obtain a sufficient operative field for performing the stitching procedures safely.
Neurosurgical Review 02/2011; 34(3):373-9; discussion 379-80. · 2.04 Impact Factor
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ABSTRACT: A 76-year-old woman presented with a dural arteriovenous fistula (DAVF) manifesting as typical symptoms of normal pressure hydrocephalus such as progressive dementia, gait disturbances, and urinary incontinence. The cerebrospinal fluid pressure during lumbar puncture was 120 mmH(2)O. Computed tomography and magnetic resonance imaging showed ventricular dilation and diffuse white matter changes, which were consistent with the symptoms of hydrocephalus. Cerebral angiography revealed a DAVF in the transverse-sigmoid sinuses with severe cortical venous reflux into the superior sagittal sinus. Transarterial embolization of the feeding arteries reduced the venous flow from the cortical veins into the superior sagittal sinus. Her symptoms improved with reduction in ventricle size. However, she suffered recurrence of the same symptoms several months later. Computed tomography and magnetic resonance imaging demonstrated ventricular dilation associated with hydrocephalus. Angiography revealed a fistulous channel in the left transverse-sigmoid junction. Transvenous embolization was performed resulting in complete obliteration of the fistula. Magnetic resonance image findings such as ventricular dilation and diffuse white matter disappeared and the symptoms of hydrocephalus improved. Although DAVFs often present as venous hypertensive encephalopathy, this case presented with ventricular dilation and diffuse white matter changes, which are the typical neurological signs of normal-pressure hydrocephalus. Venous hypertension associated with the DAVF in the transverse-sigmoid sinuses may have been caused by normal pressure hydrocephalus.
Neurologia medico-chirurgica 01/2011; 51(3):229-32. · 0.61 Impact Factor
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ABSTRACT: Giant distal anterior cerebral artery (DACA) aneurysms are extremely rare, with only 32 cases reported in the literature. Most giant DACA aneurysms have features that make standard neck clipping difficult, and bypass surgery is sometimes required, although this surgery was performed in only three reported cases. This report presents the fourth case treated with bypass surgery.
A 69-year-old female presented with an unruptured thrombosed giant DACA aneurysm. She underwent wrapping operation 7 years before, but radiological imaging revealed enlargement of the aneurysm at the left pericallosal artery (PerA)-callosomarginal artery (CMA) junction. Before operation, three different strategies were considered for bypass surgery in case the neck could not be clipped. Aneurysm resection and left proximal PerA-CMA end-to-end anastomosis were successfully performed under intraoperative digital subtraction angiography (DSA) and motor-evoked potential (MEP) monitoring.
Most DACA aneurysms are located at the PerA-CMA junction. In some cases, adequate retrograde flow to the distal PerA from the posterior or middle cerebral artery can be expected, making distal PerA reconstruction unnecessary. Moreover, when the distal PerA is cut, proximal PerA-CMA end-to-end anastomosis can be easily performed because of reduced tension in both vessels. We therefore conclude that this strategy should be utilized for treating such patients. We also presented here the effectiveness of intraoperative modalities, such as intraoperative DSA and MEP monitoring, for performing a safe operation.
Surgical neurology international. 01/2011; 2:135.
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ABSTRACT: 3.0-T magnetic resonance (MR) angiography and MR imaging were compared with conventional angiography for the evaluation of moyamoya disease in 13 preoperative patients (26 hemispheres) with moyamoya disease (4 males and 9 females aged 21-54 years). The correlation between MR angiography scores determined by modified Houkin's grading system (MRA score) and conventional angiography stages determined by Suzuki's grading system (CA stage) was analyzed. Other MR findings such as moyamoya vessel scores, "ivy sign" scores, and the presence of small, medium, and large cerebrovascular attack (CVA) lesions were compared with CA stages. MRA scores were significantly correlated with CA stages (p < 0.01). Moyamoya vessel scores correlated well with CA stages (p < 0.01). There was no significant correlation between "ivy sign" scores and CA stages, and no significant differences in CA stages with the presence and absence of CVA lesions of any size. 3.0-T MR angiography can be used as a vascular assessment in moyamoya disease with its priority of noninvasive nature and visual clarity compared with conventional angiography. The findings of 3.0-T MR angiography may reflect the steno-occlusive changes in moyamoya disease.
Neurologia medico-chirurgica 01/2011; 51(3):195-200. · 0.61 Impact Factor
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ABSTRACT: Our surgical results were reviewed to clarify the cause of glossopharyngeal neuralgia (GPN) and the effects of the microvascular decompression (MVD) procedure.
Fourteen cases of idiopathic GPN were operated on through the transcondylar fossa (supracondylar transjugular tubercle) approach. Their clinical data and operative records were retrospectively reviewed.
In every case, vascular compression on the glossopharyngeal nerve was found and MVD was performed without any major complications. In 13 of the 14 cases the neuralgia completely disappeared postoperatively. Recurrence of pain was found in 1 case. Offending vessels were the posterior inferior cerebellar artery (PICA) in 10 cases, the anterior inferior cerebellar artery (AICA) in 2 cases, and both arteries in 2 cases. In 10 of the 14 cases, the high-origin PICA formed an upward loop between the glossopharyngeal and vagus nerves, compressing the glossopharyngeal nerve upward. In those cases, the PICA was transposed and fixed to the dura mater by the stitched sling retraction technique, and MVD was very effective.
The offending artery was the PICA in most cases. MVD is expected to be very effective, especially when the radiological images show the following 3 findings: 1) high-origin PICA, 2) the PICA making an upward loop, and 3) the PICA coursing the supraolivary fossette. The transcondylar fossa approach is suitable for transposing the PICA by the stitched sling retraction technique, and provides sufficient surgical results.
Neurosurgery 06/2010; 66(6 Suppl Operative):275-80; discussion 280. · 2.79 Impact Factor
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ABSTRACT: The authors clarify the anatomic basis and the usefulness of the transcondylar fossa approach (T-C-F A), in which the posterior portion of the jugular tubercle is removed extradurally through the condylar fossa with the atlanto-occipital joint intact. The authors first performed an anatomic study to identify the area to be removed using cadaveric specimens and then applied the T-C-F A to foramen magnum surgeries. The surgeries included clipping a vertebral artery-posterior inferior cerebellar artery aneurysm in 11 cases, microvascular decompression for glossopharyngeal neuralgia in 15 cases, and removing intradural foramen magnum tumors in 17 cases. Only the condylar fossa was removed, but the approach offered very good visualization of the lateral part of the foramen magnum and sufficient working space. These surgeries were performed safely without major complications. This skull base approach is minimally invasive and is not difficult. Therefore, it can be a standard approach for accessing intradural lesions of the foramen magnum. It can be combined with the transcerebellomedullary fissure approach from the lateral side and can also be easily changed to the transcondylar approach, if necessary.
Skull Base 03/2010; 20(2):83-91. · 0.66 Impact Factor
