Atsushi Katsumata

The importance of venous hypertension in the formation of dural arteriovenous fistulas: a case report of multiple fistulas remote from sinus thrombosis

Various hypotheses have been reported concerning the pathogenesis of dural arteriovenous fistulas (DAVFs). However, it is still controversial whether sinus thrombosis or venous hypertension has a greater influence on the formation of DAVFs. We present a rare case of multiple DAVFs that developed after sinus thrombosis. Chronic venous hypertension secondary to sinus thrombosis in the left transverse-sigmoid sinus induced the multiple DAVFs, including one in the right cavernous sinus, which was remote from the occluded sinus. This case indicates the importance of venous hypertension in the formation of DAVFs.

Angioplasty and coiling of ruptured aneurysm with symptomatic vasospasm: technical case report

BACKGROUND Treating a ruptured cerebral aneurysm during symptomatic vasospasm is very difficult. We describe the successful endovascular treatment of such a case and discuss its efficacy. CASE PRESENTATION A 34-year-old man had a sudden onset of severe headache. One week later, he was referred to our institute with gradually progressing right hemiparesis and global aphasia. Cerebral angiography demonstrated severe vasospasm of the left internal carotid artery system and an anterior communicating artery aneurysm. With the patient under general anesthesia, 90% occlusion of the aneurysm was achieved with detachable coils after successful dilatation of the spastic vessels. The patient had an uneventful postoperative course and his neurologic symptoms were improved. Seven months after the endovascular treatment, the enlarged neck remnant of the aneurysm was successfully clipped without difficulty. CONCLUSION The simultaneous treatment of a ruptured aneurysm and vasospasm with percutaneous transluminal angioplasty and coils can produce a better outcome for the patient.

Training in Neurovascular Intervention Usefulness of in-Vitro Model and Clinical Practice

We introduce our training tools and system of neurovascular intervention. An in vitro cerebral vascular model was used for the young residents to understand the basic interventional techniques and devices. The model included several vascular lesions such as cerebral aneurysm, dural arterio-venous fistula, or carotid artery stenosis. Endovascular procedures in the model were performed under fluoroscopic or direct visual control, and consecutive haemodynamic changes were visualized by using digital subtraction angiography and direct observation. Thus, traineess could have an easy understanding of clinical conditions. New medical devices, such as platinum coils, were successfully implanted in the model under stable conditions. After the initial training using vascular model, the residents had started clinical experiences under the control of senior surgeons. Although it is difficult to describe usefulness of our clinical training, we believe that we provide enough good quality and quantity of clinical cases to the residents. Because our endovascular team has recently had 150–200 interventional procedures every year, one resident can have experienced more than 100 cases per year. The qualification of a Board Certified Specialist of the Japanese Society of Intravascular Neurosurgery (JSIN) requires that the applicant must have experienced more than 100 cases for four years. So our residents can have enough case materials to qualify the board examination.

A Case of Transorbital Penetrating Brain Injury Caused by a Steel Wire Entirely Embedded in the Brain Parenchyma

Penetrating brain injury(PBI)is very rare in Japan. Because there is a very wide variety of pathological condition of PBI, the guideline for the treatment of PBI has not been established yet. We report the unique case of PBI caused by a steel wire piece completely embedded in the brain parenchyma. A 75-year-old man was brought to the emergency department due to ocular injury caused by a steel wire piece. Neurological examination revealed only left visual disturbance. CT scan revealed a steel wire piece located intraparenchymally between the left frontal lobe and the ventricles, but digital subtraction angiography showed no significant vascular injury in the surrounding structures. We performed an open surgery and removed the steel wire piece. Because the steel wire piece was completely embedded in the brain, we used intraoperative X-ray fluoroscopy to choose a less invasive approach for the brain. The patient suffered no additional neurological deficit and no sign of cerebral infection or seizure after surgery. He was discharged after a 4-week administration of antibiotics. In most cases of PBI caused by low velocity injury, foreign bodies are not completely embedded in the brain except for remnants after surgical removal. This is the first report of low velocity PBI caused by a foreign body completely embedded in the brain.