Daisuke Wakui

Steroid-resistant Tolosa-Hunt syndrome with a de novo intracavernous aneurysm: A case report

Background: We report a case of steroid-resistant Tolosa–Hunt syndrome (THS) with recurrent bilateral painful ophthalmoplegia, accompanied with sphenoid sinusitis, pituitary abscess, and an aneurysm arising from the cavernous portion of the internal carotid artery. Case Description: A 53-year-old woman suffered severe left painful ophthalmoplegia. A magnetic resonance image (MRI) revealed thickness of the left cavernous sinus (CS). Steroid was administrated under the diagnosis of THS, and the symptom transiently diminished. However, painful ophthalmoplegia fluctuated bilaterally after tapering the steroid. An MRI showed development of bilateral cavernous lesions associated with sphenoid sinusitis, pituitary abscess, and an aneurysm in the left C4 segment. Biopsy and drainage of the lesions were performed with an endoscopic transsphenoidal procedure. The histological examination showed nonspecific granulomatous inflammation. The methotrexate (MTX) was effective to reduce the CS and pituitary lesions; however, the aneurysm slightly increased and remained unchanged in size thereafter. Conclusions: To our knowledge, this is the first report of a growing de novo C4 aneurysm in THS. Surgical intervention and administration of MTX should be attempted in steroid-resistant THS. Careful observation with serial MRI and MR angiography is important to manage the complicated THS.

Acute phase endovascular intervention on a pseudoaneurysm formed due to rupture of an anterior communicating artery aneurysm

A 79-year-old woman presented with a subarachnoid hemorrhage. Angiography revealed pseudoaneurysm formation due to rupture of a true saccular anterior communicating artery aneurysm. Coil embolization, limited to the true aneurysm, was performed successfully with a favorable clinical outcome. This procedure can be considered as an alternative treatment option for similar aneurysms in cases where surgical clipping is contraindicated.

Outflow occlusion with A3-A3 anastomosis for a doughnut-shaped partially thrombosed giant A2 aneurysm

Background: A doughnut-shaped aneurysm, which is defined as a round-shaped aneurysm composed of an intraluminar thrombus and marginal parent artery, is an extremely uncommon subtype of partially thrombosed giant aneurysms. Surgical treatment of this characteristic aneurysm is technically challenging. Case Description: We report a rare case of a 79-year-old man with a symptomatic doughnut-shaped giant aneurysm at the A2 portion, which was successfully treated by outflow occlusion with an A3–A3 side-to-side anastomosis. Postoperative angiograms demonstrated no filling of the doughnut-shaped aneurysm and perfusion in the distal right anterior cerebral artery territory via the anastomosis. Follow-up magnetic resonance imaging 1 year after the surgery demonstrated significant diminution of the aneurysm. Conclusions: Outflow occlusion with distal revascularization could be an effective surgical option for such a unique aneurysm. To the best of our knowledge, this is the first report of outflow occlusion as a therapy for doughnut-shaped aneurysms.

A case of meningitis due to Neisseria subflava after ventriculostomy

Surgical site infection (SSI) is an emerging problem in all fields of surgery, as well as in neurosurgery, with numerous strategies against SSI initiated in many countries. In this report, we describe a case of SSI caused by Neisseria subflava a month after ventriculostomy placement for acute hydrocephalus. A 53-year old man was referred to our hospital, and was diagnosed with a thalamic hemorrhage with ventricular rupture. Bilateral ventriculostomies were performed on the day of presentation. After intensive care for the acute stage, an SSI at the left ventriculostomy site was recognized on the 39th hospital day. The installed reservoir and ventricular tube was removed on the 40th hospital day. The CSF cell count was 2064/3, and N. subflava was recovered from the CSF culture. N. subflava is a common inhabitant found in the human upper respiratory tract, and is reported to be a rare cause of meningitis. There is one case report of meningitis caused by N. subflava transmitted during myelography from medical staff who did not wear facemasks during the procedure. Meningitis caused by N. subflava is rare, and transmission via a medical procedure is extremely rare. Although reported to be only rarely pathogenic, we must recognize that N. subflava can indeed be pathogenic, and can in rare cases be the cause of postoperative meningitis.

Surgical removal of an arteriovenous malformation in the anterior perforated substance in a pregnant woman

Background: A tailor-made treatment is often required in arteriovenous malformations (AVMs) depending on the individual situation. In most cases, treatment strategy is usually determined according to the patients Spetzler–Martin grade. However, in the present case, we were not able to treat the patient following the usual guidelines because of neurological symptoms and pregnancy. Case Description: We describe a rare case of a 31-year-old woman in the 15th week of gestation who presented with an AVM in the anterior perforated substance (APS). She suffered a sudden coma and hemiplegia. A computed tomographic scan showed an enhanced mass and a huge hematoma in the basal ganglia and temporal lobe. The hematoma was successfully evacuated in an endoscopic procedure. Angiography showed that a 25-mm nidus in the APS was fed by the anterior choroidal arteries (AChAs) and the lenticulostriate arteries (LSAs). Therefore, we attempted to remove the nidus because the patient became alert with mild aphasia and hemiparesis 10 days after hemorrhage. The feeding arteries were cut under motor evoked potential (MEP) monitoring, and the nidus was totally resected leaving two of four AChAs and a single artery with several LSAs. The postoperative course was uneventful, and she gave birth to a healthy baby by caesarian delivery 122 days after the hemorrhage with only minor sequelae. Conclusions: Surgical strategy with a device-administered anesthesia are suitable for removing large AVMs even in pregnant women and for the successful outcome of their pregnancies. Even after recovering from a coma and hemiplegia, MEP monitoring is effective for removing large AVMs even when located in the APS.

Risk Factors of Contralateral Microembolic Infarctions Related to Carotid Artery Stenting

This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.

Impact of Aneurysmal Neck Position in Endovascular Therapy for Anterior Communicating Artery Aneurysms

Anterior communicating artery (ACoA) aneurysms have a complex architecture and many variations, making endovascular therapy more difficult in some cases. The aim of this study was to investigate whether the neck position of an aneurysm was identifiable for determining the immediate angiographic success and procedural complications in the coiling of the ACoA aneurysms. We conducted a retrospective case review of 40 patients with ACoA aneurysms treated by endovascular therapy from 2008 to 2015. The mean age was 66.8 years. Thirty-five aneurysms were ruptured; five were unruptured. For the analysis, the patients were divided into two groups according to the neck position of aneurysms: the true ACoA group, 9 patients with the neck located on the ACoA itself; and the other ACoA group, 31 patients with the neck at the junction of the A1 and A2 portions of an anterior cerebral artery. Morphological characteristics (dome size, dome direction, rate of wide neck, and angulation of aneurysms in relation to the parent artery) were analyzed along with immediate angiographic results, volume embolization ratio (VER), and procedural complications. Small aneurysms with superior dome projection and acute angulation of the aneurysm direction occurred more often in the true ACoA group. The rates of complete obliteration, VER, and procedural complications were 33.3%, 32.3%, and 22.2% in the true ACoA group and 54.8%, 36.3%, and 6.5% in the other ACoA group, respectively. True ACoA aneurysms could present an anatomical difficulty in endovascular coiling. Aneurysmal neck position should be accurately assessed to achieve successful embolization of the ACoA aneurysms.

[Dural cavernous angioma:a case report and review of the literature].

Here, we report a case of dural cavernous angioma. A 54-year-old man presented with headache in his right frontal area for the previous few weeks. Computed tomography (CT) and magnetic resonance imaging revealed a well-demarcated extramedullary mass, 3 x 2.5cm in size, within the subdural space at the right frontal region. The mass was not enhanced on a contrast-enhanced CT scan, and heterogeneously enhanced after administration of Gd-DTPA on magnetic resonance images. Cerebral angiography revealed an avascular mass. Right frontal craniotomy was performed. On surgery, the mass was found to be mainly extramedullar, and partially intramedullar. No adhesion between the mass and the overlying dura was observed. It was removed in an en bloc fashion. The pathological diagnosis was cavernous angioma. The patients headache was resolved soon after surgery. Cavernous angiomas are usually intramedullar in the subcortical white matter of the cerebral hemispheres;extramedullary cavernous angiomas are rare. Extramedullary dural cavernous angiomas located in the subdural space at the cerebral convexity are extremely rare. They usually present with headache or mass signs, and resemble meningioma radiologically. During surgery they are easily resected with minimal blood loss. Dural cavernous angiomas should be considered in the differential diagnosis of intradural extramedullary mass at the cerebral convexity.