Tsunenori Ozawa

Surgical experience with massive lobar haemorrhage caused by cerebral amyloid angiopathy

SummaryNineteen patients with massive lobar haemorrhage without angiographic lesions received direct or stereotactic surgery, and biopsy specimens were examined histologically. Ten patients (53%) were found to have vessels positive for Congo-red staining, and demonstrating amyloid angiopathy. In the patients with amyloid angiopathy, CT scan and surgical findings were investigated. Subarachnoid haemorrhage (9/10), irregularly shaped haematoma (9/10) and fluid-blood density level in the haematoma cavity (7/10) were frequently found on CT scan. The characteristic surgical findings in patients treated by direct surgery were subarachnoid haemorrhage adjacent to intracerebral haematoma (8/8) and the existence of a tangle of vessels in the haematoma cavity (4/8). Evacuation of haematomas was relatively easy, and difficulty of haemostasis was not encountered during surgery.

Primary angiitis of the central nervous system: report of two cases and review of the literature.

Two cases of primary angiitis of the central nervous system with subarachnoid hemorrhage are reported. One patient was admitted with very thin and localized sulcal subarachnoid hemorrhage, followed by the development of multiple parenchymal edema. Although the first angiography showed only a mild narrowing of an artery, the second angiography demonstrated multiple segmental narrowings of arteries. An open biopsy failed to show histological changes. The second patient suffered from sylvian subarachnoid hemorrhage along with multiple intracerebral hemorrhages, with angiography that was diagnostic for angiitis. In both cases, predonine was initiated and further angiography clearly demonstrated a resolution of the angiitis. The usefulness of serial angiography for diagnosis in comparison with surgical biopsy and for monitoring the treatment of this disease is discussed. The occurrence of subarachnoid hemorrhage in this disease is also reviewed.

MRA Demonstration of “Periarteritis” in Tolosa-Hunt Syndrome

Summary Background. Modern magnetic resonance imaging (MRI) diagnosis of Tolosa-Hunt syndrome rests upon demonstration of cavernous sinus abnormalities. We present a case of Tolosa-Hunt syndrome who has no abnormal mass lesion in the cavernous sinuses on MRI but with a diagnostic lesion on magnetic resonance angiography (MRA). Clinical Presentation. A 48-year-old woman developed acute periorbital pain and abducens palsy of the right side at the first episode, and subacute peri-orbital pain and rapidly deteriorating visual acuity on the left side at the second episode with a four months interval. MRI showed no soft-tissue abnormality in the cavernous sinuses. Findings. MRA demonstrated a narrowing of the right cavernous carotid artery at the first episode, and narrowings of the left clinoid carotid and ophthalmic arteries at the second episode. Based on these findings, the patient underwent urgent steroid therapy and the symptoms resolved dramatically in each episode. Follow-up MRA confirmed resolution of arterial narrowings. Interpretation. MRA may help prompt the noninvasive diagnosis in certain cases of Tolosa-Hunt syndrome with little inflammatory reaction in the cavernous sinus but with predominant intra- and juxta-cavernous periarteritis.

Simultaneous multi-section perfusion CT and CT angiography for the assessment of acute ischemic stroke

SummaryBackground. Introduction of helical computed tomography (CT) scanning has enabled rapid imaging of the vascular status by means of CT angiography and perfusion CT. By virtue of recent multi-detector technology, helical CT has the ability to perform both CT angiography and multi-section perfusion CT simultaneously. This study investigated the clinical feasibility of simultaneous assessment of perfusion CT and CT angiography in patients with acute ischemic stroke.Method. Perfusion CT and CT angiography were performed simultaneously in a series of consecutive 31 acute ischemic stroke patients. The time required for the entire processing was about 15 minutes. Contrast agent was used in a total dose of 100 ml (35 ml for perfusion CT and 65 ml for CT angiography).Findings. Simultaneous perfusion CT scans and CT angiographies were of diagnostic quality for 29 patients (94%). In large territorial infarct patients, perfusion CT could predict all perfusion deficits of the final lesions (10 out of 10 lesions) and CT angiography could detect 9 of 10 occlusions of major cerebral arteries (90%). In patients with small lacunar or subcortical infarcts, perfusion CT could predict 9 out of 19 lesions (47.4%), and false-negative were encountered in small lesions (three patients) or in inadequate coverage of data acquisition (seven patients). Acute stage thrombolytic intervention could be carried out based on the findings, and the success of thrombolytic therapy could be demonstrated by follow-up study.Conclusions. Simultaneous perfusion CT and CT angiography is the very useful tool for the rapid and adequate diagnosis of almost all of the large territorial infarcts and some of non-territorial lacunar infarcts. It is an easy-to-perform and safe imaging technique to assess acute ischemic stroke.

Primary Angiitis of the Central Nervous SystemReport of Two Cases and Review of the Literature

Two cases of primary angiitis of the central nervous system with subarachnoid hemorrhage are reported. One patient was admitted with very thin and localized sulcal subarachnoid hemorrhage, followed by the development of multiple parenchymal edema. Although the first angiography showed only a mild narrowing of an artery, the second angiography demonstrated multiple segmental narrowings of arteries. An open biopsy failed to show histological changes. The second patient suffered from sylvian subarachnoid hemorrhage along with multiple intracerebral hemorrhages, with angiography that was diagnostic for angiitis. In both cases, predonine was initiated and further angiography clearly demonstrated a resolution of the angiitis. The usefulness of serial angiography for diagnosis in comparison with surgical biopsy and for monitoring the treatment of this disease is discussed. The occurrence of subarachnoid hemorrhage in this disease is also reviewed.

Histological evaluation of endothelial reactions after endovascular coil embolization for intracranial aneurysm. Clinical and experimental studies and review of the literature.

The purpose of this study was to evaluate the role of the endothelial cell reaction after endovascular coil embolization for the treatment of intracranial aneurysms. A scanning electron microscopic (SEM) study of the platinum coil, embolized into a middle cerebral aneurysm in a 35-year-old woman and subsequently removed surgically eight months later, revealed no endothelial coverage on the coil. This finding prompted us to perform experimental studies. In the first in vitro study, endothelial cells from gerbil brain microvessels and canine carotid arteries were co-cultured with either bare-form platinum coils or type-1 collagen-coated coils for up to three weeks, and the endothelial cell population on the coils was ascertained. In the second in vivo study, platinum coils coated with type-1 collagen were delivered endovascularly into canine carotid arteries, while the contralateral side was treated with bare-form coils, and endothelialization over the coil was investigated. SEM studies revealed that no endothelial cells, either from gerbil brain microvessels or from canine carotid artery, were found on the uncoated coils, whereas gerbil endothelial cells began to proliferate on the collagen-coated coils in three days, covering extensively in one week and reaching confluence in two weeks in vitro. The in vivo canine study demonstrated that bare-form platinum coils did not show endothelial coverage until two weeks, but endothelial cells proliferated directly on the collagen-coated coils in three days, and coils were completely covered in two weeks. These results supported the SEM study of our case and several human histopathological reports in the literature in that endothelial cell coverage in the orifice of the intracranial aneurysm is exceptional after endovascular treatment. But if some extracellular matrix, like collagen in our study, is prepared, coverage could be possible, as is seen in a few human cases. Biological modification of the platinum coils, such as collagen coating, is awaited for the better long-term results of endovascular coil embolization without recanalization of the treated intracranial aneurysms.

Emergency evacuation of expanding intracerebral haemorrhage in parahaemophilia (coagulation factor V deficiency).

A 62-year-old normotensive woman suddenly developed a left hemiparesis. Computed tomographic (CT) scan showed a haematoma in the right putamen (Figure 1A). She was gradually getting comatose, and follow-up CT scan demonstrated rapid haematoma enlargement (Figure 1B). She had not taken antiplatelet, anticoagulant, or antibiotic agents. Her past history was uneventful. Her family history was negative for haemorrhagic disorders. Pre-operative coagulation examinations after referral to us as a surgical emergency revealed markedly prolonged prothrombin time (PT) 21.5 sec, international normalized ratio (IN) 3.16 sec, and activated partial thromboplastin time (aPTT) 73.7 sec, although her platelet count, bleeding time, and liver function tests were normal. De®ciency or decreased activity of coagulation factors was suspected. Further coagulation study showed markedly low activity of Factor V, under 5% of normal. Both the prolonged PT and aPTT were corrected with normal plasma adsorbed with barium salts to remove the vitamin K-dependent factors. These laboratory ®ndings indicated that her coagulation abnormality could be corrected by FFP. In general, the therapeutic aim should be a Factor V activity level greater than 25% of normal, which su1⁄2ces to stop bleeding or as prophylaxis for surgery [1]. Assuming that the patient weighted 50 kg, the patients plasma volume was approximately 2000 ml (40 ml/kg). Six hundred ml of plasma would raise her factor V to 25± 30%. FFP was immediately transfused for replacement of Factor V. After exclusion of vascular anomalies by cerebral angiography, emergency decompressive craniectomy and evacuation of haematoma were performed without excessive bleeding (Fig. 1). We apActa Neurochirurgica > Springer-Verlag 1999 Printed in Austria Acta Neurochir (Wien) (1999) 141: 667±668