Akihiko Takechi

Primary intracerebral hemorrhage in Izumo City, Japan: incidence rates and outcome in relation to the site of hemorrhage.

OBJECTIVEThe aim of this community-based study was to investigate the incidence rates and outcome of primary intracerebral hemorrhage (ICH) in relation to the site of hemorrhage. METHODSThe subjects were 350 patients with primary first-ever ICH who were treated during the 8-year period 1991 to 1998 in Izumo City, Japan. RESULTSThe crude and age- and sex-adjusted incidence rates for all types of ICH were 52 and 47 per 100,000 population, respectively, for all ages. The most common site of ICH was the putamen (120 patients, 34%), followed by the thalamus (115, 33%), lobar areas (53, 15%), brainstem (30, 9%), cerebellum (25, 7%), and caudate nucleus (7, 2%). The crude and age- and sex-adjusted annual incidence rates per 100,000 population were 18 and 16 for putaminal, 17 and 15 for thalamic, 8 and 7 for lobar, 4 and 3 for cerebellar, 4 and 4 for brainstem, and 1 and 1 for caudate hemorrhages, respectively. The Glasgow Coma Scale scores on admission were best in patients with cerebellar hemorrhage and worst in those with brainstem hemorrhage. Surgery was performed for 34% of putaminal, 9% of thalamic, 14% of caudate, 21% of lobar, and 32% of cerebellar hemorrhages but not for brainstem hemorrhages. The 30-day case fatality rate was 11% for putaminal, 9% for thalamic, 14% for caudate, 11% for lobar, 0% for cerebellar, and 53% for brainstem hemorrhages. When patients with ICH were analyzed as a whole, the overall survival rates at 30 days, 3 months, and 3 years were 87, 83, and 73%, respectively. Both the short-term and long-term outcomes after ICH were directly related to the site of hemorrhage and the severity of bleeding, which was assessed by the hematoma volume and Glasgow Coma Scale score. Overall, 190 (54%) of 350 patients had a favorable outcome, and 55 (16%) had died at discharge. CONCLUSIONMarked differences were observed in the incidence rates and outcome of primary ICH in relation to the site of hemorrhage. The differences in outcome were primarily a result of differences in the severity of bleeding for each ICH subtype.

Embolisation of orbital varix

A 34-year-old man with intermittent exophthalmos, found to have a large varix in the right orbit, was treated by endovascular surgery. Percutaneous transfemoral venous catheterisation and embolisation of the orbital varix was performed on two occasions. A tracker 18 microcatheter was introduced through the righ inferior petrosal sinus, cavernous sinus, superior ophthalmic vein and then into the varix, following a guidewire. Superselective venography of the right ophthalmic vein showed the varix. A total of 204 platinum microcoils was used to pack the varix. At the time of discharge, the exophthalmos had largely resolved. As this technique is much less invasive than surgical resection, we recommend an attempt at endovascular embolisation of orbital varices prior to surgical removal.

Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report

BACKGROUND Vertebral artery dissecting aneurysm is now increasingly recognized as a cause of posterior circulation stroke in young adults. Here, we report a case of bilateral VADA with SAH, treated by bilateral coil occlusion using GDCs. CASE DESCRIPTION A 64-year-old woman was admitted to our hospital with consciousness disturbance (Hunt and Kosnik: grade 4). Computed tomography showed diffuse SAH with a thick hematoma in the left C-P angle. Magnetic resonance angiography, 3D-CTA, and cerebral angiography revealed bilateral VADAs. First, the ruptured left VADA involving the PICA and a perforating branch was treated by occluding the lower half of the VADA and the proximal VA with GDCs in the acute stage. Thereafter, the residual VADA and contralateral VADA exhibited enlargement on cerebral angiography and MRA for 2 months after the initial surgery; thus, the right VADA was occluded by GDCs just proximal to the right PICA after confirming BTO tolerance. CONCLUSION Staged bilateral VA coil occlusions combined with BTO may be one of the treatment strategies for bilateral VADA with SAH in cases presenting surgical difficulty due to anatomical factors or severe grade of SAH.

Spontaneous disappearance of an aneurysmal malformation of the vein of Galen.

We describe spontaneous disappearance of an aneurysmal malformation of the vein of Galen (AMG), an anomaly that occurs most often in children, with a high mortality due to the accompanying severe cardiac failure. Spontaneous thrombosis of an AMG is rare. In this case, the AMG has been closed for about 5 years, without radiological evidence of thrombosis, and no active treatment. Proposed mechanisms of spontaneous thrombosis include slow flow shunts and severe obstruction of the venous outflow. However, in this case, the disappearance of the AMG without evidence of thrombosis indicates a different mechanisms, namely, obstruction of the feeding artery.

Ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate : Case report

OBJECTIVE AND IMPORTANCE We report a rare case of a ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate. CLINICAL PRESENTATION A 44-year-old woman had undergone microvascular decompression for a right-sided facial spasm. The preoperative vertebral angiogram did not show any aneurysmal dilation. The right anteroinferior cerebellar artery, which was compressing the exit zone of the facial nerve, was detached and fixed to the dura mater with ethyl 2-cyanoacrylate. Nine years later, the patient suffered a subarachnoid hemorrhage caused by the rupture of a newly developed aneurysm of the right anteroinferior cerebellar artery. INTERVENTION The aneurysm was clipped 2 days after onset of the subarachnoid hemorrhage. It consisted of two bulges in the arterial wall on the proximal side of the meatal loop. One bulge was stuck to the dura mater of the pyramis by ethyl 2-cyanoacrylate, which had been used in the microvascular decompression 9 years previously. CONCLUSION This is the first reported clinical case of a de novo aneurysm induced by a cyanoacrylate adhesive. Ethyl 2-cyanoacrylate can damage the arterial wall and induce a de novo aneurysm.

Cerebral Hemodynamics in Arteriovenous Malformations

Cerebral hemodynamics were studied in 3 patients with supratentorial arteriovenous malformations (AVMs). Cerebral blood flow (CBF) was measured by the methods using 123 I-IMP SPECT (IMP SPECT) and stable xenon CT (Xe-CT) before and after surgery. In addition, the cortical blood flow (CoBF) adjacent to AVMs was monitored during surgery using laser Doppler flowmetry. Preoperative CBF measurements were performed more than a month after stroke. Case 1: A 48-year-old man developed disturbance of consciousness, right hemiparesis and motor dysphasia. Cerebral angiography disclosed a 3.5 cm left frontal AVM fed by middle cerebral artery. In preoperative IMP SPECT and Xe-CT, hypoperfusion and low CBF were observed in the left frontoparietal region adjacent to the AVM. The CoBFs of the left frontal lobe were increased moderately during clipping of feeders and after excision of the AVM. Case 2: A 51-year-old woman had vomiting and right hemiparesis. Angiography demonstrated a 2.0 cm left parietal AVM. In preoperative CBF studies, neither hypoperfusion nor low CBF was seen in the areas surrounding the AVM. There were no alterations of CoBFs before and after excision. Case 3: A 62-year-old man had a 5.0 cm left frontoparietal AVM supplied by anterior and middle cerebral arteries. Preoperative CBF studies showed marked hypoperfusion and ischemia in the regions adjacent to as well as distant from the AVM. A large increase in CoBF up to two or three times the preexcision value was noted after total excision of the AVM. He developed the normal perfusion pressure breakthrough (NPPB) syndrome after operation. High dose barbiturate anesthesia combined with induced hypotension was maintained for 5 days and resulted in good outcome. From reported clinical observations and hemodynamic data in this study, it is suggested that factors contributing to the development of NPPB syndrome include: (1) a large, high-flow AVM; (2)

Coexistence of dural arteriovenous malformation in the posterior fossa and multiple cerebral aneurysms

後頭蓋窩硬膜動静脈奇形の成因については先天性説と後天性説があり意見の一致をみていない.我々は多発性脳動脈瘤を合併した後頭蓋窩硬膜動静脈奇形の1例を経験した.症例は76歳女子で激しい頭痛, 嘔吐で発症し, CT scanで脳室内穿破を伴うクモ膜下出血と診断された.脳血管写では前交通動脈瘤と左中大脳動脈瘤が, また左後頭動脈硬膜枝を流入動脈とし左横静脈洞, S字状静脈洞を流出静脈とする後頭蓋窩硬膜動静脈奇形が発見された.本例の後頭蓋窩硬膜動静脈奇形は, 多発性脳動脈瘤の合併という点からは先天性の発生が示唆されるが, 脳動脈瘤の破裂により偶然に高齢で発見されるまで無徴候で, また流出静脈である左横静脈洞, S字状静脈洞に静脈洞血栓症による壁の不整と狭窄がみられた点からは後天性の発生が示唆された.本症例を基に後頭蓋窩硬膜動静脈奇形の成因について文献的考察を加え, 我々の仮説を報告した.

A case of middle cerebral atrery occlusion with moyamoya phenomenon

最近一つの症例群として提唱されつつあるモヤモヤ血管網を伴った特発性中大脳動脈閉塞症の1例を経験した.症例は13歳女子で左前頭葉皮質下出血で発症し, 脳血管撮影にて左中大脳動脈M2部の狭窄とその周囲にモヤモヤ血管網がみられ, また前交通動脈より起始しright anterior insular pointに至る右副中大脳動脈がみられた.1年2ヵ月後に行った脳血管撮影では左中大脳動脈M2部の狭窄の改善とこれに伴いモヤモヤ血管網の減少が認められた.現在迄, 本症例群において閉塞, 狭窄の改善とモヤモヤ血管網の減少例や先天性血管奇形である副中大脳動脈合併例の報告はなく, 我々の症例は本症例群の疾患概念, 病因を検討する上で極めて興味ある症例と思われ, 文献的考察を加え報告した.