Ken Nojiri

Persistent primitive hypoglossal artery associated with Arnold-Chiari type I malformation

The case of a 49-year-old woman with persistent primitive hypoglossal artery associated with Arnold-Chiari type I malformation is reported. The hypoglossal artery was located on the left side. The left vertebral artery was hypoplastic, the right vertebral artery could not be visualized angiographically. The clinical significance of a persistent primitive hypoglossal artery is discussed.

Unruptured intracranial aneurysms in polycystic kidney disease.

SummaryTo detect unruptured intracranial aneurysms, we performed cerebral angiography in five patients with polycystic kidney disease (PKD) who had no neurological deficits and no history of subarachnoid haemorrhage. Three of the five patients had unruptured intracranial aneurysms and two underwent surgery with no mortality or morbidity. Our review of the literature revealed that the surgical risk of unruptured intracranial aneurysms is smaller than the risk of bleeding in conservatively treated patients. We discuss the importance of an early diagnosis, and early operation for unruptured aneurysms in patients with polycystic kidney disease and stress the need for intensive care for their renal dysfunction and hypertension during and after the operation.

Ruptured anterior communicating artery aneurysms associated with fenestration of the anterior cerebral artery.

Two patients with ruptured anterior communicating artery aneurysms associated with fenestration of the anterior cerebral artery are reported. In the literature, only 12 angiographic demonstrations of fenestration of the anterior cerebral artery have been reported. All fenestrations were limited to the distal half of the A1 portion, and seven of the 12 cases were associated with aneurysms. The high incidence of coexisting fenestration and aneurysm suggests that congenital factors may play a role in the pathogenesis of cerebral aneurysm.

Persistent Primitive Trigeminal Artery, Cavum Septi Pellucidi, and Associated Cerebral Aneurysm in a Patient with Polycystic Kidney Disease: Case Report

A 51-year-old man with polycystic kidney disease had a persistent primitive trigeminal artery, cavum septi pellucidi, and an unruptured cerebral aneurysm. He had a history of long-standing hypertension, but not of subarachnoid hemorrhage. Computed tomograms revealed cavum septi pellucidi. Because of the polycystic kidney disease, we performed four-vessel cerebral angiography, which revealed a persistent primitive trigeminal artery and a cerebral aneurysm at the bifurcation of the left internal carotid artery. The neck of the aneurysm was clipped successfully without producing any neurological deficit. The clinical significance of the combination of these multiple anomalies and cerebral aneurysms is discussed.

Clinicophysiological Aspect and Treatment in Cases with Spontaneous Carotid-cavernous Fistula

Thirteen cases with spontaneous carotid-cavernous fistula found in our clinic during the last 5 years were analyzed. The age ranged from 24 to 74 years, and 12 were women. Initial symptoms were diplopia in 3 cases, severe orbital pain or headache with nausea and vomiting in 3 cases, dull pain around the orbit in 3 cases, red eye in 2 cases and tinnitus in 2 cases. Sings and symptoms at admission were conjuctival injection in 10 cases, chemosis in 5 cases, exophthalmos ranging from 2 to 9 mm, in 10 cases, bruit in 7 cases, disturbance of ocular movement in 7 cases, impairment of visual acuity in 4 cases, orbital pain or headache in 6 cases and tinnitus in 8 cases. Angiograms showed that in all cases dural branches of the internal carotid artery were contributors to the shunt and in at least 5 cases branches of external carotid artery were also contributors. There were positive correlation between angiographic findings and certain signs and symptoms. In all 3 cases with prominent venous drainage, disturbance of visual acuity and ocular movement were noticed. In another 10 cases, disturbance of visual acuity and ocular movements were found in one case and 4 cases, respectively. Furthermore, in 10 cases with posterior venous drainage via the inferior petrosal sinus, 8 cases complainted of tinnitus, but other 3 cases without showing posterior drainage, did not complain of tinnitus. Cerebral hemodynamic study was performed in 8 cases. In 7 cases rCBF values were normal and the relative shunt rate was small (10 ?? 23%). In another one case rCBF could not be measured because the shunt rate of the affected internal carotid artery was 100%. These results coincided with the angiographic findings. Twelve cases were not operated on and follow-up study ranging from 9 months to 5.2 years were carried out. Clinical symptoms were alleviated in 4 cases and completely disappeared in 8 cases. The follow-up angiography in the latter 3 cases showed disappearance of the shunt. Consequently, in cases with small blood deprivation through the shunt and mild clinical symptoms, conservative treatment is recommended unless exacerbation is not noticed.

Correlation between the Neural Noise in the Thalamus after Cerebrovascular Disease and Computerized Tomography

The case is presented of a 45-year-old man who suffered from a sudden attack of unconsciousness with right hemiplegia and later developed a spastic hemiparesis accompanied by involuntary movement of the right upper limb. CT scan revealed an old putaminal hemorrhage and almost intact thalamus, but neural noise recordings during the stereotactic thalamotomy of this case showed marked decrease of the neural activity in the thalamus suggesting some functional changes.

The Indication for Surgical Treatment in Patients over 60 Years of Age with the Ruptured Intracranial Aneurysm

Fourty-eight cases over 60 years of age with the ruptured intracranial aneurysm were surgically treated. Satisfactory occlusion of the aneurysm with clipping of ligation was attained in 44 cases and plastic coating was performed in 4 cases. In 3 cases with a large intracerebral hematoma, the early operation was carried out and 2 cases died of the gastrointestinal bleeding and progressive cerebral vasospasm after the operation. In 45 cases, the operation was carried out more than 2 weeks after the subarachnoid hemorrhage. In 4 cases (9%), additional neurological symptoms developed after the operation and the occlusion of the main cerebral artery occured in 2 cases out of these cases related to the operative procedure. Three cases (7%) died of rebleeding due to the incomplete clipping, acute emphysema and agranulocytosis respectively. Thirty-five cases were followed up for 3 months to 10 years. At the time of this follow-up study, 25 (71%) were either free from symptoms or only with minor neurological deficits. Seven cases (20%) had moderate to severe symptoms; 4 cases had complications noticed more than 1.5 months after the operation and considered to be unrelated to the surgical maneuvar, 2 cases had various neurological deficits exsisted before the operation and only one case had the deficit related to the operative procedure. Three cases (9%) had died of pulmonary carcinoma and pneumonia 3 months to 10 years after the operation. Eighteen cases, including 10 cases over 65 years of age, were operated with microsurgical techniques more than 2 weeks after the bleeding. In this group, only one case died of agranulocytosis and no case became disabled. These results indicate that the direct intracranial operation using microsurgical techniques should be the first choice of the treatment in aged patients who are able to make a daily living without any complaints and do not have severe complications before the bleeding. Furthermore, even when prolonged initial unconsciousness and arteriosclerosis of intracranial vessels are present, the operation can be performed safely by delicate procedures using microsurgical techniques.