Susumu Yoshioka

Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: A case report and review of the literature

BACKGROUND Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction. CASE DESCRIPTION A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2. CONCLUSION This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.

Dissecting aneurysm of the posterior inferior cerebellar artery: case report.

A patient with a dissecting aneurysm of a posterior inferior cerebellar artery who presented with Wallenbergs syndrome is reported. A 31-year-old man suddenly experienced an occipital headache, vertigo, and vomiting, followed by dysphagia. A neurological examination revealed partial Wallenbergs syndrome. Vertebral angiography revealed aneurysmal dilatation at the origin of the left posterior inferior cerebellar artery, with distal luminal narrowing. T1-weighted magnetic resonance imaging demonstrated an area of high-signal intensity, indicating an intramural hemorrhage in the arterial wall of the narrowed lumen. The dissecting aneurysm with a typical intramural hematoma of the posterior inferior cerebellar artery was entrapped with clips after an anastomosis of the left occipital artery to the distal posterior inferior cerebellar artery. The diagnosis and the treatment of dissecting aneurysms of the posterior inferior cerebellar artery are discussed.

Extensive Facial Strawberry Mark Associated with Cerebellar Hypoplasia and Vascular Abnormalities

Strawberry mark is considered a benign hemangioma with a tendency toward spontaneous regression and a benign prognosis (1). Recently, some papers have reported complications of large facial strawberry marks (2–6). We report a infant girl with an extensive strawberry mark on the left side of the face associated with ipsilateral cerebellar hypoplasia and Dandy‐Walker malformation. Abnormal branching of the aortic arch was also found.

Rapidly enlarging chordoid meningioma with abundant mucin production.

This 77‐year‐old woman with a rapidly enlarging chordoid meningioma first noticed a growing, non‐pulsatile, non‐painful soft mass in the left temporal region after a head trauma 2 years earlier. Neuroimaging showed a homogeneously enhanced osteolytic mass lesion in the left temporal bone. Surgery revealed an extradural tumor without significant adhesions. Histopathologically it was a meningioma with features reminiscent of chordoma. Most of the tumor cells contained mucin‐rich chordoid elements. Immunohistochemically, the lesion was positive for vimentin and epithelial membranous antigen; it was negative for cytokeratin and S‐100 protein. Based on these findings a diagnosis of chordoid meningioma was made. We posit that the rapid enlargement of the tumor over a relatively short period was attributable to its high mucin‐producing activity.

Clinical features of moyamoya disease in sibling relations under 15 years of age.

SummaryThis study was undertaken to define the clinical features of moyamoya disease in sibling relations less than 15 years of age. We analysed five pairs of siblings (6 boys, 4 girls) with moyamoya disease from among 56 moyamoya patients less than 15 years of age. Of 56 paediatric patients with moyamoya disease, 5 were sibling pairs. At onset of the disease, all patients were under 10 years of age. Clinical manifestations in the proband and the affected sibling tended to present as transient ischaemic attacks; none of the 10 patients presented with intracranical haemorrhage. The probands were not always the older sibling, however, the time lapse between disease onset in the proband and his/her sibling was less than one year. Among the sibling pairs, there was no striking difference in disease staging based on angiographic findings. The incidence of sibling occurrence of moyamoya disease appears to be higher than previously assumed and the family of children with moyamoya disease should be cautioned that their other children have an increased risk of developing the illness.

De novo appearance of cerebellar cavernous malformation in a patient with moyamoya disease: case report and review of the literature.

The authors report a case of cerebellar cavernous malformation associated with moyamoya disease. An adolescent male with moyamoya disease had undergone bilateral direct and indirect extracranial-intracranial anastomosis at 11 years of age, and the course had been uneventful until MRI detected the appearance of a cavernous malformation in the cerebellum 3 years later. The lesion had grown, bled, and caused headache and disturbance of consciousness 2 years after the initial detection. The cavernous malformation was removed surgically and pathologically verified. The patient has recovered without any neurological deficits. This is a quite rare case with cavernous malformation which appeared in a moyamoya disease patient. The association of the two different vascular disorders in a young patient may suggest the existence of some interaction in the pathogenesis of these diseases. Since cavernous malformations with a de novo appearance may grow and become clinically significant, careful observation is necessary.

Application of the Skull Base Technique to the Repair of Transsphenoidal Meningoencephaloceles

A 2-month-old boy with an anterior basal meningoencephalocele of the transsphenoidal type was successfully treated via the transbasal intra- and extradural approach. Magnetic resonance imaging was useful for obtaining a precise diagnosis, and the transbasal combined approach is suitable for this type of meningoencephalocele.

Benign external hydrocephalus in a boy with autosomal dominant microcephaly

In a 3‐month‐old boy with microcephaly, magnetic resonance imaging (MRI) revealed accumulation of bifrontal extracerebral fluid. Because of the typical MRI findings and the disappearance of these findings later on, he was diagnosed as a case of benign external hydrocephalus. Both his mother and maternal grandmother had microcephaly, without neurological or dysmorphic manifestations. The pedigree is most consistent with an autosomal dominantly inherited microcephaly. This seems to be the first report of benign external hydrocephalus found in a patient with an autosomal dominant microcephaly.

Spontaneous resolution of isolated dissecting aneurysm on the posterior inferior cerebellar artery

SummaryThe authors report a rare example of an isolated dissecting posterior inferior cerebellar artery (PICA) aneurysm with spontaneous resolution. A 41 year-old male suffered sudden dizziness, nausea and vomiting. An angiogram and magnetic resonance imaging (MRI) detected an isolated PICA dissection. The patient was treated conservatively and recovered without any apparent neurological deficit. MRI detected the self-resolution of the dissecting aneurysm. Dissecting PICA aneurysms, especially non-haemorrhagic lesions, have the possibility of spontaneous resolution resulting in a favorable outcome. The treatment strategy for this vascular lesion may be decided based upon neuroradiological changes on careful follow-up.

Moyamoya Disease Associated with Midaortic Syndrome

We report a 1-year-old girl who presented moyamoya disease associated with midaortic syndrome. She had been treated for cardiac failure and severe hypertension due to midaortic syndrome until she suffered seizure and repeated cerebral ischemic attack. Cerebral angiography revealed stenosis of the bilateral internal carotid artery at its terminal portion. She was successfully treated with encephaloduroarteriosynangiosis, and ischemic attack ceased postoperatively. This is the first report of moyamoya disease with midaortic syndrome. Although cerebral ischemic attack has been effectively managed by encephaloduroarteriosynangiosis, renovascular hypertension is still difficult to control.