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ABSTRACT: A 34-year-old female presented with trigeminal neuralgia caused by a venous malformation in the right cerebello-pontine region. Computed tomography and magnetic resonance imaging demonstrated the abnormal draining veins from the venous malformation. The dilated vessels extended around the trigeminal nerve and compressed the root entry zone. Microvascular decompression (MVD) was performed, and her trigeminal neuralgia was completely relieved without neurological deficits. The offending vessel in most cases of trigeminal neuralgia is an arterial branch. Veins may also be associated with trigeminal neuralgia. The present rare case shows that MVD may be useful for the treatment of trigeminal neuralgia associated with venous malformation. Good outcome depends on decompression of the root entry zone without injury to the vessel. Surgical injury in this region can cause severe neurological deficits. Several treatment options should be prepared for the surgery, such as MVD or rhizotomy.
Neurologia medico-chirurgica 01/2013; 53(1):40-3. · 0.61 Impact Factor
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Clinical neurology and neurosurgery 05/2012; · 1.30 Impact Factor
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ABSTRACT: To evaluate intracisternal injection of magnesium sulfate (MgSO(4)) solution via a lumbar catheter for the treatment of cerebral vasospasm in the canine subarachnoid haemorrhage (SAH) model.
SAH was induced in 7 beagle dogs using the dual haemorrhage model. Vertebral angiography was repeated on Day 1 (before SAH), and on Day 7 (during cerebral vasospasm) before and 1.5 hours after injection of 0.5 mL/kg of 15 mmol/L MgSO(4) in Ringer solution via the tip of a microcatheter placed in the cisterna magna from the lumbar spine.
After injection of MgSO(4) solution, the cerebrospinal fluid magnesium ion concentration significantly increased to 3.89 ± 0.97 mEq/L (P < 0.01) from the baseline value (1.49 ± 0.07 mEq/L). The arterial diameters of the basilar artery (BA), vertebral artery (VA), and superior cerebral artery (SCA) on Day 1 were 1.26 ± 0.19 mm, 1.10 ± 0.13 mm, and 0.74 ± 0.21 mm, respectively. On Day 7 before injection, the arterial diameters of the BA, VA, and SCA significantly decreased to 0.75 ± 0.27 mm, 0.74 ± 0.25 mm, and 0.36 ± 0.21 mm, respectively (P < 0.01), due to vasospasm, and were significantly increased to 0.91 ± 0.27 mm (P < 0.01), 0.91 ± 0.31 mm (P < 0.05), and 0.54 ± 0.14 mm (P < 0.01), respectively, after intracisternal injection of MgSO(4) solution.
Intracisternal MgSO(4) therapy using a microcatheter from the lumbar spine may be effective against vasospasm in the clinical setting of endovascular treatment of ruptured aneurysm.
British Journal of Neurosurgery 07/2011; 26(1):64-8. · 0.88 Impact Factor
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ABSTRACT: the temporal profiles of the effects of intracisternal injection of magnesium sulfate (MgSO(4)) on vasodilation and cerebrospinal fluid (CSF) magnesium ion (Mg(2+)) concentration were investigated in the canine subarachnoid hemorrhage (SAH) model.
cerebral vasospasm was induced using the two-hemorrhage model in seven female beagles. On day 7, 0.5 ml/kg of 15 mmol/l MgSO(4) in Ringer solution was injected into the cerebellomedullary cistern. Angiography was performed on day 1 (before SAH), and before and 1, 3, and 6 h after the intracisternal injection on day 7. CSF Mg(2+) was measured at the same time.
the diameters of the basilar artery (BA), vertebral artery (VA), and superior cerebellar artery (SCA) before the intracisternal injection on day 7 were 0.59 ± 0.15, 0.41 ± 0.17, and 0.35 ± 0.17 mm, respectively, and were significantly decreased (p < 0.01) compared with the baseline diameters on day 1. The BA diameters at 1 h (0.74 ± 0.16 mm) and 3 h (0.73 ± 0.13 mm), the VA diameter at 1 h (0.64 ± 0.14 mm), and the SCA diameter at 3 h (0.54 ± 0.08 mm) after the injection were significantly increased (p < 0.05). The CSF Mg(2+) concentration was significantly increased (p < 0.01) at 1 h (3.59 ± 0.76 mEq/l) and 3 h (2.00 ± 0.31 mEq/l) after the injection compared with the baseline value (1.35 ± 0.23 mEq/l).
the reversible effect of intracisternal MgSO(4) solution injection on the spastic artery depends on maintenance of the optimal CSF Mg(2+) concentration.
Acta neurochirurgica. Supplement 01/2011; 110(Pt 2):39-42.
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ABSTRACT: Posterior circulation revascularization is a challenging technique because microanastomosis must be performed in deep locations. A reproducible simulation model is proposed for training. The prototype three-dimensional skull model with artificial brain was used. The mesencephalic segment of superior cerebellar artery (SCA) and the caudal loop of the posterior inferior cerebellar artery (PICA) were made from artificial blood vessels and glued on the brain. The skull model was drilled to perform the presigmoid transpetrosal approach and then superficial temporal artery-SCA anastomosis was performed under the operating microscope. The skull model was also drilled to perform the far lateral approach and then occipital artery-PICA anastomosis was performed. The skull model with artificial brain and arteries allows simulation and training in the surgical techniques of posterior circulation revascularization with skull base approaches.
Neurologia medico-chirurgica 01/2011; 51(2):93-6. · 0.61 Impact Factor
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ABSTRACT: A 62-year-old male presented with a rare case of possible neuro-Sweet Disease (NSD) mimicking brain tumor in the medulla oblongata, manifesting as numbness in the bilateral upper and lower extremities, gait disturbance, dysarthria, and swallowing disturbance which gradually deteriorated over 3 months. Magnetic resonance imaging showed a mass lesion in the medulla oblongata, extending to the upper cervical cord with rim enhancement by gadolinium. The preoperative diagnosis was brain tumor, such as glioma, or inflammatory disease. His neurological symptoms gradually deteriorated, so biopsy was performed through the midline suboccipital approach. Histological examination showed infiltration of inflammatory cells, mainly lymphocytes and macrophages. Human leukocyte antigen typing showed Cw1 and B54 which strongly suggested possible NSD. Steroid pulse therapy was started after surgery and the clinical symptoms improved. Neurosurgeons should be aware of inflammatory disorders such as NSD mimicking brain tumor.
Neurologia medico-chirurgica 01/2011; 51(2):140-3. · 0.61 Impact Factor
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ABSTRACT: The optimal CSF Mg(++) concentration for vasodilation of spastic cerebral arteries after subarachnoid hemorrhage (SAH) and its duration are unknown. The temporal profile of the vasodilatory effect and optimal CSF Mg(++) concentration after the intracisternal injection of MgSO(4) solution were investigated in an SAH model in canines.
Cerebral vasospasm was induced by experimental SAH using a 2-hemorrhage model in 26 female beagles. On Day 7, 0.5 ml/kg of 15, 10, 5, or 0 mmol/L MgSO(4) in Ringer solution was injected into the cerebellomedullary cistern. Angiography was performed on Day 1 (before SAH) and before and 1, 3, and 6 hours after the intracisternal injection on Day 7 to measure arterial diameters of the basilar artery (BA), superior cerebellar artery (SCA), and vertebral artery (VA). Cerebrospinal fluid Mg(++) was also measured at the same time.
Arterial diameters of the BA, SCA, and VA were significantly decreased by vasospasm on Day 7. Arterial diameter ratios (ratio of arterial diameter after MgSO(4) injection to diameter before injection on Day 7) of the BA and SCA at 1 and 3 hours after and the VA at 1 hour after intracisternal injection of the MgSO(4) solution were positively correlated with the CSF Mg(++) concentration. All arterial diameter ratios, except 1 point of the SCA, exceeded 1 if the CSF Mg(++) concentration was > 3 mEq/L at 1 hour after injection. Animals with CSF Mg(++) concentrations > 3 mEq/L at 1 hour after injection (11 dogs) showed significantly increased arterial diameters of the BA at 1 and 3 hours after and of the SCA and VA at 1, 3, and 6 hours after injection, as compared with the diameters before injection. The CSF Mg(++) concentration significantly increased at 1 hour (3.73 ± 0.69 mEq/L, p < 0.01) and 3 hours (2.05 ± 0.35 mEq/L, p < 0.01) after the intracisternal injection as compared with the baseline value (1.41 ± 0.20 mEq/L).
The reversible effect of an intracisternal injection of MgSO(4) solution on the spastic artery requires CSF Mg(++) concentrations > 3 mEq/L. The vasodilatory effect continues for 3-6 hours after injection. These results suggest that the continuous infusion or intermittent intracisternal injection of MgSO(4) is needed to maintain the optimal CSF Mg(++) concentration and constantly ameliorate cerebral vasospasm.
Journal of Neurosurgery 11/2010; 114(4):1168-75. · 2.96 Impact Factor
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ABSTRACT: Extradural anterior clinoidectomy via the trans-superior orbital fissure (SOF) approach can provide extensive exposure of the anterior clinoid process and safe drilling under direct view. This technique requires peeling of the dura propria of the temporal lobe from the lateral wall of the SOF. Therefore, cadaveric dissection is mandatory to acquire surgical technique. However, chances for cadaveric dissection are limited. We propose modification of our three-dimensional (3-D) skull base model made from surgically dissectable artificial bone with artificial cavernous sinus including multiple membranous layers and neurovascular structures to simulate extradural anterior clinoidectomy via the trans-SOF approach. The 3-D skull base model precisely reproduced the dura propria of the temporal lobe, periosteal bridge, and inner reticular layer in the cavernous sinus and SOF using silicone and varnish. The cranial nerves and blood vessels were made from rubber fibers and vinyl tube. Simulation of extradural anterior clinoidectomy via the trans-SOF approach could be performed on the model using a high-speed drill under the operating microscope. The steps of reconstruction of the skull base model and dissection promote clear understanding of the 3-D anatomy and techniques of extradural anterior clinoidectomy via the trans-SOF approach.
Skull Base 07/2010; 20(4):229-36. · 0.66 Impact Factor
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ABSTRACT: Improved educational tools for anatomic understanding and surgical simulation of the cranial base are needed because of the limited opportunities for cadaver dissection. A 3-dimensional cranial base model with retractable artificial dura mater is essential to simulate the epidural cranial base approach.
We developed our 3-dimensional cranial base model with artificial dura mater, venous sinuses, cavernous sinus, internal carotid artery, and cranial nerves, and the extradural temporopolar approach was simulated using this new model.
This model can be dissected with a surgical drill because of the artificial bone material. The periosteal dura was reconstructed in the medial wall of the cavernous sinus, periorbita, and periosteal bridge in the superior orbital fissure with yellow silicone. The meningeal dura was made with brown silicone. The single-layer dura mater could be dissected from the bone surface and retracted with a surgical spatula.
Extradural drilling of the superior orbital fissure and opening of the optic canal were similar to actual surgery. Extradural anterior clinoidectomy was performed via the extradural space by retracting the artificial dura mater. The artificial dura propria of the lateral wall in the cavernous sinus was successfully peeled from the artificial cranial nerves to complete the extradural temporopolar approach.
The improved 3-dimensional cranial base model provides a useful educational tool for the anatomic understanding and surgical simulation of extradural cranial base surgery.
Neurosurgery 06/2010; 66(6 Suppl Operative):339-41; discussion341. · 2.79 Impact Factor
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ABSTRACT: Vasospasm is one of the important factors associated with the functional prognosis after subarachnoid hemorrhage (SAH). Intracisternal administration of thrombolytic agents to dissolve subarachnoid clots may be responsible for bleeding complications. The efficacy and safety of cisternal irrigation therapy using low-dose tissue plasminogen activator were evaluated.
Sixty patients with SAH were treated by surgical clipping, and randomly divided into three groups: 1) the control group (n = 20) treated only with baseline treatment; 2) the intermittent group (n = 20) received intermittent administration of clotlysis agent (tisokinase 960,000 IU); and 3) the continuous group (n = 20) received continuous irrigation using pH-adjusted lactate Ringer's solution containing tisokinase (96 IU/mL) infused at 20 mL/hr for 48 hours. The clearance of subarachnoid clots was measured by laboratory examinations and postoperative computed tomography. Ischemia-related vasospasm was evaluated by neurological status and computed tomography. Neurological outcome was evaluated by the modified Rankin scale at 3 months after onset.
The subarachnoid clot was efficiently and significantly removed without major complication in the intermittent and continuous groups (P < 0.05). The incidence of ischemic lesion in the intermittent group was significantly lower than in the control group (P < 0.05). The intermittent group had significantly better neurological outcome than the control group (P < 0.05).
Cisternal irrigation therapy using low-dose tissue plasminogen activator is effective and safe. Intermittent injection is most effective and may decrease the risk of symptomatic vasospasm in patients with SAH.
World Neurosurgery 06/2010; 73(6):675-82. · 0.68 Impact Factor
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ABSTRACT: The far lateral approach, transcondylar fossa approach, and transcondylar approach are widely accepted as basic suboccipital lateral skull base techniques to treat various pathologies located in the lateral to anterior regions of the cervico-medullary junction. Surgical simulations were performed to evaluate the differences between these techniques using a three-dimensional dissectable skull base model with an artificial vertebral artery. The far lateral approach provided space around the intradural vertebral artery at the level of the jugular foramen. The transcondylar fossa approach allowed better visualization of the vertebral artery at the level between the jugular foramen and the hypoglossal canal. The transcondylar approach did not offer significantly better visualization of the vertebral artery compared with the transcondylar fossa approach except at the level below the hypoglossal canal. However, the transcondylar approach offered more extensive removal of the jugular tubercle than the transcondylar fossa approach because the removed occipital condyle, including the atlanto-occipital joint provided space for introduction of a surgical drill into the anterior part of this bony protuberance. Evaluation using the dissectable skull base model clearly demonstrated the differences in the surgical exposures of the intradural vertebral artery provided by these skull base approaches.
No shinkei geka. Neurological surgery 03/2010; 38(3):243-50. · 0.13 Impact Factor
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ABSTRACT: A 74-year-old woman presented with malignant progression of remnant epidermoid cyst manifesting as sudden onset of right ptosis and double vision. She had right oculomotor nerve paresis. She had a history of surgery for right cerebellopontine angle epidermoid cyst 20 years previously. T(1)-weighted magnetic resonance (MR) imaging demonstrated a hypointense mass lesion in the right cerebellopontine angle and basal cistern, and an isointense mass in the right paraclinoid region which was strongly enhanced. Diffusion-weighted MR imaging showed hyperintense areas in the right cerebellopontine angle, ambient cistern, and basal cistern, and the paraclinoid mass as hypointense. Surgery was performed using Dolenc's approach. Histological examination revealed that the paraclinoid tumor adjacent to the epidermoid tumor remnant was malignant transformation of epidermoid cyst into squamous cell carcinoma. She was treated with 46 Gy linac radiotherapy. She has been without tumor recurrence for 17 months. Malignant change of epidermoid cyst is extremely rare, but rapid progress of the symptoms suggests malignant transformation. MR imaging with gadolinium is useful for diagnosis.
Neurologia medico-chirurgica 01/2010; 50(3):236-9. · 0.61 Impact Factor
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ABSTRACT: The vasodilatory effect of intra-cisternal infusion of magnesium sulfate solution was evaluated in 10 patients with symptomatic vasospasm after aneurysmal subarachnoid hemorrhage (SAH) who underwent early clipping surgery. Cisternal drainage was installed in the prepontine and/or sylvian fissures. Carotid angiography was performed immediately after the onset of symptomatic vasospasm, then intra-cisternal infusion of 15 mmol/l magnesium sulfate in Ringer solution was started at 20 ml/hr and continued until day 14. Irrigation was performed from the cisternal tube (inlet) to the spinal drainage (outlet). The cerebrospinal fluid magnesium ion concentration (1.2 +/- 0.2 mEq/l) significantly increased after the infusion therapy (6.0 +/- 1.7 mEq/l, p < 0.001). Repeat angiography showed vasodilatory effect on the spastic cerebral arteries at 3 hours after the infusion, especially in the arteries near to the site of cisternal drainage placement. The magnesium infusion also caused decreased mean arterial blood velocity in the spastic arteries in 6 of the 7 measured patients (162 +/- 38 cm/sec to 114 +/- 42 cm/sec, p < 0.001). Finally, 5 of the 10 patients achieved good recovery, 1 patient had moderate disability, 1 patient became severely disabled due to meningitis, and 3 patients were vegetative or dead, due to failure of magnesium irrigation in 1 patient and advanced age in the other 2 (more than 80 years old). This preliminary study indicates that intra-cisternal infusion of magnesium sulfate solution has vasodilatory effect on the spastic cerebral arteries after aneurysmal SAH.
Neurologia medico-chirurgica 04/2009; 49(4):139-44; discussion 144-5. · 0.61 Impact Factor
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Surgery for Cerebral Stroke 01/2008; 36(6):475-481.
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ABSTRACT: Recently, side-to-end hypoglossal-facial anastomosis has been advocated for the treatment of facial nerve paralysis after neurosurgical interventions. However, the treatment of the donor hypoglossal nerve at neurorrhaphy varies from pure without epineurial removal to one-half cross-sectional incision. We evaluate the optimal treatment of the donor hypoglossal nerve for side-to-end anastomosis. Two patients with facial nerve paralysis after cerebellopontine tumor removal were treated by partial (one-third) side-to-end hypoglossal-facial anastomosis. Both patients showed facial reanimation without tongue dysfunction. One-third resection of the hypoglossal nerve for partial side-to-end anastomosis is optimal to ensure satisfactory recovery of facial nerve function without hemihypoglossal disturbance.
Neurosurgery Quarterly 08/2007; 17(3):180-184. · 0.10 Impact Factor
