Osamu Miyagi

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.

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.