Mitsuru Baba

Indirect carotid-cavernous sinus fistula: Transvenous embolization from the external jugular vein using a superior ophthalmic vein approach. A case report

A case of indirect carotid-cavernous sinus fistula treated by combined transarterial and transvenous embolization is described. A 49-year-old woman with a right indirect carotid-cavernous sinus fistula draining solely to the right superior ophthalmic vein was treated first by transarterial embolization with polyvinyl alcohol particles. Then, by approaching through the superior ophthalmic vein from the right external jugular vein, the cavernous sinus was embolized with platinum wire using a tracker microcatheter, which resulted in marked clinical improvement. Transvenous embolization by approaching from the external jugular vein through the superior ophthalmic vein represents a promising alternative when shunted blood drains anteriorly to the superior ophthalmic vein.

Magnetic resonance imaging: lumbosacral lipoma.

To evaluate the clinical efficacy of magnetic resonance imaging (MRI) of lumbosacral lipomas, the magnetic resonance images of nine patients were reviewed. T1- and T2-weighted spin echo sequences were used with a 0.5-T magnetic resonance system. The tethered or low-positioned conus medullaris, the lipoma itself, the lipoma--cord interface, the subarachnoid space, and hydromyelia were clearly disclosed. The nerve rootlets were not as clear. These results indicate the possible discontinuance of myelography and metrizamide computed tomography (CT) cisternography for such imaging. The diagnostic modalities of choice for lumbosacral lipoma imaging are plain spine films, plain CT scan, and MRI.

A new microcatheter system for endovascular treatment of cerebral arteriovenous malformations

A new microcatheter system was used for diagnostic and therapeutic purposes in three cases of arteriovenous malformation. This microcatheter is used with a steerable guidewire and provides high selectivity of the target vessels and greater catheter maneuverability than does balloon catheters. Tissue adhesive was safely injected for the therapeutic embolization in two of the cases. With this system, however, the utmost attention is necessary to prevent reflux of the tissue adhesive and to avoid lacerating the feeding vessels with the guidewire. This microcatheter system was found to be very useful for diagnostic and therapeutic procedures in endovascular treatment of cerebral arteriovenous malformations.

A clinical analysis of 32 brainstem haemorrhages; With special reference to surviving but severely disabled cases

SummaryThirty-two patients with CT-documented primary brainstem haemorrhage were reviewed retrospectively to obtain a clearer overall clinical picture, especially of the severely disabled survivors. They were divided into 3 groups according to outcome: eleven cases (Group 1) died within 1 month following haemorrhage, 11 cases (Group 2) survived but became bedridden, necessitating full living support, and 10 cases (Group 3) showed minimal neurological deficits and resumed normal activities. Owing to CT and improved critical care, the survival rate was 66% for the whole series. Group 2 comprised 34% of all cases. These patients were mostly alert, quadruplegic, and communicated only with great difficulty.The most common initial symptoms and CT finding in each group were as follows;Group 1: unconsciousness, respiratory disturbance, negative light reflex, tachycardia, and haematoma >3.0 cm;Group 2: disturbance of consciousness, respiratory disturbance, positive light reflex, normal heart rate, and 2.0> haematoma <3.5 cm; andGroup 3: alertness or only slight disturbance of consciousness, normal respiration, positive light reflex, normal heart rate, haematoma <2.5 cm. Although there is an overlap among them, these findings will be useful to distinguish the three groups from each other. Patients with disturbance of consciousness, respiratory disturbance, positive light reflex, normal heart rate, and 2.0> haematoma <3.5 cm, have a chance to survive, but in severely disabled condition, if they were treated with vigorous intensive care in the acute stage.

Percutaneous endoscopic gastrostomy, duodenostomy and jejunostomy.

Although enteral feeding by nasal gastric tube is popular for the patients who have a swallowing disability and require long-term nutritional support, but have intact gut, this tube sometimes causes aspiration pneumonia or esophageal ulcer. For these patients, conventional techniques for performance of a feeding gastrostomy made by surgical laparotomy have been used so far. However, these patients are frequently poor anesthetic and operative risks. Percutaneous endoscopic gastrostomy (PEG) which can be accomplished with local anesthesia and without the necessity for laparotomy has become popular in the clinical treatment for these patients. PEG was performed in 31 cases, percutaneous endoscopic duodenostomy (PED) in 1 case, and percutaneous endoscopic jejunostomy (PEJ) in 2 cases. All patients were successfully placed, and no major complication and few minor complications (9%) were experienced in this procedure. After this procedure, some patients could discharge their sputa easily and their pneumonia subsided. PED and PEJ for the patients who had previously received gastrostomy could also be done successfully with great care. Our experience suggests that PEG, PED, and PEJ are rapid, safe, and useful procedures for the patients who have poor anesthetic or poor operative risks.

Fatal aneurysmal rupture: a survey of 60 grade-5 cases.

SummaryThe purpose of the present study was to describe the clinical course of patients with Grade-5 ruptured aneurysms (WFNS grading). Among 250 consecutive cases of ruptured aneurysms, 60 Grade-5 patients were reviewed retrospectively, consisting of 24 males and 36 females with an average age of 58 years. Thirty-two patients were directly transferred to our clinic, while the remaining 28 were referred from other clinics. Duration from rupture to arrival at our clinic was within 1 hour in 25 cases and within 2 hours in 43 cases.Systolic blood pressure on admission was 186 mmHg on average. Obvious misdiagnoses by primary physicians were made in 7 cases. Ventricular drainage and clipping/trapping of the aneurysms were performed in 7 and 25 cases, respectively. Forty-nine patients died and the remaining 11 survived. One made a good recovery, 1 was moderately disabled, 8 severely disabled, and 1 in a vegetative state.The prognosis for Grade-5 patients is well known as being extremely poor, which also was the case in our series. Early referral and early surgical intervention have not changed this poor prognosis. Possible improvement of the outcome of this group might be expected by 1) public health and primary physician education on aneurysmal subarachnoid haemorrhage, and 2) control of blood pressure during referral.

MR imaging: normal and invaded cavernous sinus studied with and without Gd-DTPA

Clinical efficacy of MR imaging for demonstrating the normal and abnormal cavernous sinus (CS) was evaluated. Six normal CS and six CS invaded by pituitary adenomas were studied with a 0.5 T MR scanner using T1-weighted SE sequences. Furthermore, all normal CS and one invaded CS were studied with gadolinium (Gd)-DTPA. The internal carotid artery (ICA) was shown as low intensity and not enhanced with Gd-DTPA. Venous flow in the CS could be divided into two compartments, i.e., rapid and slow flows. Both flows were demonstrated as lower intensity than the white matter and higher than ICA. Slow flow was markedly enhanced with Gd-DTPA, but rapid flow was enhanced to a lesser degree than the slow. Invasion of the CS was demonstrated as follows: the engulfment of the ICA by the tumor; lack of relatively low intensity of venous flow; the extension of the tumor to the lateral wall of the CS; and the marked displacement of the ICA. MR imaging was useful for the recognition of the blood flows and the tumor invasion in the CS.

Percutaneous Endoscopic Gastrostomy, Duodenostomy and Jejunostomy for Alimentation in Gastrectomized Patients

Percutaneous Endoscopic Gastrostomy (PEG) which can be accomplished with local anesthesia and without the necessity for laparotomy is now gaining popularity as a clinical treatment for patients who have difficulties in swallowing and require long term nutritional support but have an intact gut. A total of 40 patients underwent percutaneous endoscopic placement of a feeding tube in our clinic. They included 37 patients who had had PEG, 1 Percutaneous Endoscopic Duodenostomy (PED) and 2 Percutaneous Endoscopic Jejunostomy (PEJ). Of these patients, 3 had previously had a partial gastrectomy and 1 had had an esophagectomy with esophago‐jejunostomy. Three patients who had undergone a previous partial gastrectomy received different procedures; 1 PEG, 1 PED and 1 PEJ, which were considered to be most appropriate for each patient. One patient with a previous esophagectomy had a PEJ. PEG, PED and PEJ for the patients who had previously undergone a gastrectomy were successfully done with great care. Our experience suggests that PEG, PED or PEJ are rapid, safe and useful procedures for patients who are a poor anesthetic or poor operative risk and can be used even for patients who have undergone previous surgery.

A case of heterotopic pancreas in the liver.

総胆管結石, 肝内胆管拡張症の患者に手術を施行し, 切除肝に異所性膵が発見されたまれな症例を経験したので報告する.患者は42歳, 男性.全身倦怠感, 黄疸を主訴に入院す.腹部超音波検査および腹部CT検査にて, 総胆管および肝内胆管左枝の著明な拡張を認め, 総胆管内に結石陰影を認めた.ERCPでは総胆管は著明に拡張し, その中に浮遊する結石陰影を認めた.また, 肝内胆管右枝の拡張は軽度であったが, 左枝の外側枝は径1cmと拡張を認めた.以上の結果より, 総胆管結石症および左肝内胆管拡張症と診断し, 胆摘, 総胆管切石後肝左葉外側区域切除術をあわせて施行した.病理組織学的所見にて不整な形をした胆管と, その周囲に増生する小胆管と小葉構造をとる異所性膵組織が認められた.