Kimihiro Yoshino

Neurofibromatosis type 1-associated extracranial vertebral artery aneurysm complicated by vertebral arteriovenous fistula after rupture: Case report and literature review.

BACKGROUND Extracranial vertebral artery aneurysm related to neurofibromatosis type 1 (NF1) is rare. Aneurysmal rupture typically induces such symptoms as cervical hematoma, hemothorax, and hypotension. Here we report a case of ruptured extracranial vertebral artery aneurysm in a patient with NF1 who, rather than cervical hematoma, hemothorax, or hypotension, developed a vertebral arteriovenous fistula (AVF) after aneurysm rupture. CASE DESCRIPTION A 35-year-old woman with a family history of NF1 presented with sudden-onset right neck and shoulder pain. Computed tomography angiography showed a right extracranial vertebral artery aneurysm. She had neither a cervical hematoma nor hypotension; however, angiography showed an AVF secondary to aneurysmal rupture. The patient was treated with endovascular coil embolization to prevent re-rupture. Postoperatively, her right neck and shoulder pain improved, and she was discharged without further neurologic deficits. CONCLUSIONS This patients clinical course suggests that if there is minimal bleeding from an NF1-associated ruptured extracranial vertebral artery aneurysm, then typical symptoms, such as cervical hematoma, hemothorax, and hypotension, may be absent. Thus, ruptured extracranial vertebral artery aneurysm should be considered in the differential diagnosis of patients with NF1 with sudden-onset radiculopathy, even in the absence of typical symptoms. The detection of a vertebral AVF provides a useful clue to the diagnosis of aneurysm rupture in such cases.

A case of dumbbell-shaped epidural cavernous angioma in the lumbar spine.

Background: Most spinal cavernous haemangiomas occur in the vertebral body and purely extradural cavernous hemangiomas without any vertebral body involvement is rare and account for only 4% of all extradural spinal tumors. Dumbbell-shaped spinal cavernous angioma is extremely rare, only 10 cases have been reported in the literature. Case Description: A 77-year-old female presented with a one-year history of lumbago and right-sided L3 dermatomal hypoesthesia. A dumbbell mass at the L2/3 vertebral level was identified on lumbar MRI. The lesion was irregularly shaped and isointense on T1W and hyperintense on T2W and DWI images with homogenous contrast enhancement. A presumptive diagnosis was schwannoma, but other malignant neoplasms were also considered because of its irregular shape, minimally dilated neural foramen and the involvement of the non-enhanced L3 nerve root. The patient underwent surgery with a lateral extracavitary approach. A histopathological examination revealed cavernous hemangioma. Conclusion: Cavernous hemangioma should be included in the differential diagnosis of dumbbell-shaped spinal tumors when the intervertebral foramina is not highly dilated and non-enhanced nerve root is identified in the tumor.

Percutaneous balloon angioplasty for acute occlusion of intracranial arteries.

BACKGROUND The benefits of intravenous thrombolysis for acute ischemic stroke are still limited. OBJECTIVE To evaluate the safety and efficacy of double-lumen balloon catheter-based reperfusion therapy with or without intra-arterial thrombolysis for acute occlusion of intracranial arteries. METHODS Fifty-nine patients with acute occlusion of intracranial arteries were enrolled. A Gateway balloon catheter was used to disrupt clots or dilate atheromatous plaques in every patient. The technical details, technique-related complications, recanalization rates, and clinical outcomes were analyzed. RESULTS The occlusion sites were internal carotid arteries in 17 patients, M1 segments in 32 patients, the M2 segment in 1 patient, a vertebral artery in 1 patient, and basilar arteries in 8 patients. Twenty-four patients (41%) were treated with thrombolysis first, and 20 patients (34%) were treated with percutaneous transluminal angioplasty (PTA) followed by thrombolysis. PTA alone was performed in 15 patients (25%). The mean dose of urokinase was 205 × 103 U. The extent of recanalization was complete (Thrombolysis in Myocardial Infarction [TIMI] score of 3) in 17 patients (29%), and partial (TIMI 1/2) in 28 patients (47%). Functional independence at discharge was preserved in 76%, 25%, and 7% of patients with TIMI 3, TIMI 1/2, and TIMI 0, respectively. A combination of PTA and thrombolysis resulted in a significantly higher recanalization rate than PTA only. Seven patients (12%) experienced hemorrhagic events after treatment. Severe parenchymal hemorrhage with neurologic deterioration was observed in 2 patients (4%), and vessel rupture was encountered in 1 atherosclerotic case. CONCLUSIONS Mechanical angioplasty using a Gateway catheter combined with a low-dose thrombolytic agent is a safe and effective treatment for acute intracranial embolic and atherosclerotic occlusion with a low risk of hemorrhagic complications.

Importance of Recognizing Carpal Tunnel Syndrome for Neurosurgeons: A Review

Idiopathic carpal tunnel syndrome (CTS) is a common complaint, reflecting entrapment neuropathy of the upper extremity. CTS produces symptoms similar to those of other conditions, such as cervical spondylosis or ischemic or neoplastic intracranial disease. Because of these overlaps, patients with CTS are often referred to a neurosurgeon. Surgical treatment of CTS was started recently in our department. Through this experience, we realized that neurosurgeons should have an increased awareness of this condition so they can knowledgeably assess patients with a differential diagnosis that includes CTS and cervical spinal and cerebral disease. We conducted a literature review to gain the information needed to summarize current knowledge on the clinical, pathogenetic, and therapeutic aspects of CTS. Because the optimal diagnostic criteria for this disease are still undetermined, its diagnosis is based on the patient’s history and physical examination, which should be confirmed by nerve conduction studies and imaging modalities such as magnetic resonance imaging and ultrasonography. Treatment methods include observation, medication, splinting, steroid injections, and surgical intervention. Understanding the clinical features and pathogenesis of CTS, as well as the therapeutic options available to treat it, is important for neurosurgeons if they are to provide the correct management of patients with this disease.

Brain abscess caused by Nocardia asiatica.

Background: Nocardia infection of the central nervous system leading to brain abscess is a rare condition but has a high mortality rate. Among the species of Nocardia, only three cases of brain abscess due to Nocardia asiatica infection have been reported. Case Description: A 65-year-old man with a history of autoimmune hemolytic anemia treated with prednisolone presented to our hospital because of occipital headache. Brain magnetic resonance imaging showed bilateral occipital lesions. The patient underwent craniotomy and resection of the left occipital lobe lesion. N. asiatica was identified by 16S rRNA sequencing of the resected specimen. Treatment with trimethoprim/sulfamethoxazole led to a complete resolution of the brain lesion. Conclusion: Because of the different antimicrobial sensitivity patterns among Nocardia species, both appropriate subtyping and susceptibility testing of uncommon species such as N. asiatica are required for the successful treatment of nocardial infections.

Tandem cervical/intracranial internal carotid artery occlusion due to cardiac myxoma treated successfully with mechanical endovascular thrombectomy.

Dear Editor, Ischemic stroke due to cardiac myxomas is a rare condition without established therapeutic strategies. Acute cervical internal carotid artery (ICA) occlusion due to cardiac myxoma has a poor prognosis, especially when there are tandem lesions caused by intracranial migration of tumorous emboli [3, 8]. Here, we describe the first reported case of a patient with tandem cervical ICA/ICA terminus occlusion subsequent to cardiac myxoma that was successfully treated with mechanical endovascular thrombectomy. A 70-year-old right-handedman who reported sudden right hemiparesis and speech disturbance was transported to our hospital 46 min after symptom onset. His National Institute of Health Stroke Scale (NIHSS) score was 11. Brain magnetic resonance imaging (MRI) using diffusion-weighted imaging demonstrated bilateral multiple small increased-signal lesions due tomultiple small emboli (Fig. 1a). Onmagnetic resonance angiography (MRA) of the head and neck, there was a lack of signal corresponding to the left common carotid artery (CCA) and to the ICA (Fig. 1b, c). Intravenous recombinant tissue plasminogen inhibitor (rtPA) was administered 2 h and 55min after symptom onset but did not achieve neurological improvement. Emergent cerebral angiography was performed via the right femoral artery. Immediately after the start of angiography, the patient’s level of consciousness decreased. Although MRA before rtPA showed collateral flow to the left MCA through the anterior communicating artery, angiography of the right CCA now showed a left carotid T-occlusion (Fig. 1d). Angiography of the left CCA showed left cervical ICA occlusion (Fig. 1e). Together, these results suggested the migration of a large emboli distally into the left ICA terminus, resulting in neurological deterioration. A balloon guide catheter was placed in the left cervical ICA. Three passes with a Penumbra 5MAX ACE catheter (Penumbra, Alameda, CA, USA) resulted in revascularization of the left ICA and the left M1 segment, but the left inferiorM2-branch remained occluded. A single pass with a Trevo retriever (Stryker Neurovascular, Mountain View, CA, USA) resulted in successful recanalization, thrombolysis in cerebral infarction (TICI) grade 2B (Fig. 1f) [5], 6 h and 20 min after symptom onset. The retrieved emboli were whitish-to-reddish, gelatinous, and friable, with a total length >10 cm (Fig. 1g). A postoperative brain MRI showed new symptomatic ischemic lesions in the left MCA territory, but those were limited to the frontal lobe (Fig. 1h). Recanalization of the left ICA and the MCA was observed on MRA (Fig. 1i, j). A pathological examination showed that the retrieved emboli consisted of tumorous tissue from a myxoma (Fig. 1k). Transesophageal echocardiography results confirmed a mass in the left atrium (Fig. 1l). The cardiac mass was resected by open-heart surgery 6 days after the stroke. Three months after the stroke, the patient’s NIHSS score was 1, because of mild aphasia and the modified Rankin Scale score was 2. Although cardiac myxoma is responsible for <1 % of all cases of ischemic stroke [1], it should be considered in the differential diagnosis. The cerebral artery most commonly affected by ischemic stroke due to cardiac myxoma is the MCA (65 %) [12]. ICA involvement by embolic occlusion due to cardiac myxoma is relatively rare (11 %) [12], and cervical ICA occlusion due to cardiac myxoma even rarer. To our knowledge, there are only three reported cases of cervical ICA occlusion subsequent to cardiac myxoma including our * Atsuhito Uneda uneda-oka@umin.ac.jp

Olfactory neuroblastoma followed by emergency surgery for symptomatic intradural spinal metastasis: A case report

Background: Olfactory neuroblastoma (ONB) is a rare, aggressive tumor of the nasal cavity. It may invade the paranasal cavities and anterior skull base locally but may also metastasize to the cervical lymph nodes, lungs, or distant central nervous system. Case Description: Here, we report a case of ONB in which emergency surgery was performed for intradural spinal metastasis (ISM). The patient was a 52-year-old male who underwent surgery for ONB. The tumor extended from the nasal cavity to the intracranial space and was resected completely. After radiotherapy (60 Gy), the patient was discharged without any neurological deficit except anosmia. Seven months after the surgery, he consulted our department because of progressive tetraparesis. Cervical magnetic resonance imaging demonstrated an intradural spinal mass involving C5–T2 and necessitating emergency surgery. The tumor was resected subtotally followed by 58 Gy whole-spine irradiation. The patients neurological symptoms improved, however, paralysis of the right upper and both the lower limbs remained. During the 4 months between the spinal surgery and his death, there was no further motor deterioration in any of his four extremities. Conclusion: This case demonstrates the need to be aware of potential ISM in the follow-up of patients with ONB. The early detection of ISM by spinal MRI is crucial to ensuring good palliative care.

The Importance of Recognizing Diffuse Idiopathic Skeletal Hyperostosis for Neurosurgeons: A Review

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by calcification and ossification of the soft tissues, mainly ligaments and entheses. The spines of patients with DISH generally become increasingly rigid and osteoporotic, and fractures may occur after even a relatively minor traumatic event such as a ground-level fall. Moreover, the prevalence of DISH may be rapidly increasing in affluent societies. Thus, awareness of this condition is becoming more important for neurosurgeons when assessing trauma patients. For the present article, a literature review was conducted to summarize the current clinical, pathogenetic, and therapeutic knowledge of this disease. Furthermore, current treatment strategies for DISH-related spine injuries are also reviewed. Although the recommended treatment for spinal injuries in DISH patients is surgical, mainly through long-segment posterior fusion, rather than conservative options, stable fractures without any associated neurologic deficits have often been successfully managed with immobilization alone. Percutaneous instrumentation and the use of teriparatide may be useful depending on the surgical risks and patient neurological status.

A Case of Posterior Circulation Ischemic Stroke Caused by Heparin-Induced Thrombocytopenia after Detaining Hepatic Arterial Infusion Catheter

In Japan, hepatic arterial infusion chemotherapy (HAIC) using reservoir system is recommended for patients with hepatocellular carcinoma (HCC) whose hepatic spare ability is favorable. Arterial infusion catheter is commonly detained in hepatic artery via femoral or brachial artery. In our hospital, catheter is often inserted by puncturing the left subclavian or brachial artery considering the patients activities of daily living (ADL) during long-term detaining. However, it rarely causes posterior circulation ischemic stroke because of the left vertebral artery branches on the path of catheter. We herein report a case of posterior circulation ischemic stroke caused by heparin-induced thrombosis (HIT) after detaining hepatic arterial infusion catheter. A 63-year-old man who is under HAIC treatment for HCC was introduced to the department of neurological surgery because of vertigo and vomiting. Magnetic resonance imaging revealed sporadic fresh cerebral infarction in the bilateral cerebellar hemisphere. Carotid ultrasonography detected a floating thrombus around the part of the left vertebral subclavian artery bifurcation. Detained catheter was removed and continuous heparin administration was started immediately. However, thrombocytopenia occurred 5 days after the injection. Because 4Ts score was 6 points, HIT was strongly suspected. We stopped heparin injection immediately and observed the patients physical status strictly. After that, platelet value improved naturally. At the late date, antibodies specific for platelet factor 4/heparin complexes were positive and he was diagnosed with HIT.

Cavernous angioma presenting with subarachnoid hemorrhage which was diffusely distributed in the basal cisterns and mimicked intracranial aneurysm rupture

Intracranial cavernous angiomas (cavernomas, cavernous hemangiomas, cavernous malformations) usually cause intraparenchymal hemorrhage but are rarely described as a cause of isolated subarachnoid hemorrhage (SAH).[2,6,10] Some cases of intracranial cavernous angiomas presenting with isolated SAH have been reported.[3,7,9,10,12] However, cavernous angiomas presenting with so-called angiographically negative aneurysmal-like SAH are rare. To our knowledge, only one case of cavernous angioma presenting with perimesencephalic SAH has been reported.[11] We describe a case of cavernous angioma presenting with SAH, which was diffusely distributed in the basal cisterns and mimicked intracranial aneurysm rupture.