[Peripheral branch (P4 segment) aneurysm of the posterior cerebral artery: a case report]

Four to fifteen percent of all intracranial aneurysms reported are peripheral aneurysms of the posterior fossa. Peripheral branch aneurysm of the posterior cerebral artery has only rarely been described. A 69-year-old woman had sudden onset of severe headache and vomiting and was transferred to our hospital. On admission the patient showed mild mental impairment. She had signs of meningeal irritation and right homonymous hemianopsia. CT scan showed intracerebral hematoma in the left occipital lobe, large hematoma in the left lateral ventricle and subdural hematoma in the interhemispheric region. The left carotid angiogram showed an aneurysm on the parieto-occipital artery of the left posterior cerebral artery. On the 13th day from onset left occipital craniotomy was performed. When the dura was opened, subdural hematoma was seen and removed by suction. A saccular aneurysm measuring 4 X 8 mm in diameter was seen on the parieto-occipital artery. Neck clipping for the aneurysm was successfully performed and the aneurysm disappeared completely in the postoperative angiographical study. Postoperative course was uneventful and the patient was discharged.

[Two cases of ruptured fusiform aneurysm of the proximal anterior cerebral artery (A1 segment)]

Two rare cases of fusiform aneurysms of A1 segment of the anterior cerebral artery are reported. Case 1: A 62-year-old woman was admitted with sudden onset of severe headache and loss of consciousness, on August 22, 1982. CT scan showed subarachnoid hemorrhage at the basal cisterns. Left carotid angiography revealed a spindle shaped aneurysmal dilatation in the A1 segment of the anterior cerebral artery. Four-vessel angiography was performed twice but no other aneurysm was found. She was treated conservatively and the clinical course was not eventful. She was discharged with no neurological deficit one month after the admission. Case 2: A 49-year-old man complained of sudden onset of severe headache, nausea and vomiting on August 24, 1986. He was transferred to a local hospital and CT scan showed subarachnoid hemorrhage at the basal cisterns. Angiography revealed a fusiform aneurysm of the proximal anterior cerebral artery. He was referred to our hospital on the day of onset. He was operated on via bifrontal interhemispheric approach. The fusiform aneurysm of A1 segment was trapped successfully using temporary occlusion of A1 and A2 bilaterally under the administration of Sendai-Cocktail. V-P shunt was performed 1 week after the aneurysmal operation. The post-operative course was uneventful. He was discharged with no neurological deficit three months after operation. As far as we know, there are 6 cases of fusiform aneurysm of A1 segment of anterior cerebral artery in the literature. In this report, our two cases were described and treatment of such aneurysms were discussed.

Sympathetic skin response in diabetic neuropathy

Sympathetic function test was undertaken using the sympathetic skin response (SSR), a technique for assessment of sudomotor activity, in 67 diabetics, and the results were compared with those from 45 age-matched normal subjects. The SSR was readily elicitable in normal subjects, but absent in six patients with diabetes. In 28 patients, the SSR was preserved, but their amplitude was below the normal range. The decrease in the SSR amplitude correlated well with a fall in motor and sensory conduction velocity. The SSR magnitude correlated well to the impaired R-R interval variation during deep breathing and the heart rate increase and the blood pressure change on standing, indicating a close correlation between the disturbance of sudomotor function and that of other sympathetic and parasympathetic functions. Most of the patients with clinical evidence of dysautonomia and with insulin treatment revealed diminished or absent SSR.

[Computed tomographic evaluation due to ruptured intracranial aneurysms in the posterior fossa]

From April, 1978 through December, 1984, computed tomographic (CT) findings were carefully examined in 34 cases of initial subarachnoid bleeding due to a single ruptured aneurysm in the posterior fossa. All of the patients were hospitalized within 3 days of the onset of symptoms. High-density areas, which indicate the presence of subarachnoid clots, were evaluated in the interhemispheric and Sylvian fissures and the interpeduncular, prepontine, ambient, and quadrigeminal cisterns. The CT data suggest that hematomas in the four cisterns are thicker than those in the supratentorial subarachnoid spaces. Only one patient had an intracerebral hematoma. Hydrocephalus accompanied aneurysms of the posterior fossa more frequently than those of the anterior circulation.

[Twenty-six cases regarding the proximal anterior cerebral artery]

The authors report twenty-six aneurysms of the proximal anterior cerebral artery (A1 segment). Fourteen cases were male and twelve cases were female. Saccular aneurysms were twenty-four and fusiform aneurysms were two. The incidence of the A1 aneurysms was 0.76%. Clinicopathologically, multiplicity of this aneurysm was distinctive, and eleven cases had multiplicity (42.3%). In the seven cases among them, the A1 aneurysms bled (63.6%). These 26 aneurysms were classified into five types according to the mode of the origin of the aneurysm from the A1 segment: (a) fifteen aneurysms originating from the junction of the A1 segment and the small perforating artery, (b) five from the A1 directly, (c) three from the proximal end of the fenestration of the A1, (d) two were fusiform aneurysms, (e) one from the junction of the A1 and the cortical branch. In CT scan of these aneurysms, bleeding extending to the septum pellucidum is very similar to that of the anterior communicating artery aneurysms.

[Two cases of spontaneous occlusion of the internal carotid artery due to a giant intracranial internal carotid artery aneurysm]

Although spontaneous thrombosis of a giant intracranial aneurysm is comparatively common, its parent artery occlusion is rare. Recently we experienced two cases in which spontaneous thrombosis of giant intracranial internal carotid artery aneurysm and occlusion of its parent artery were occurred. Case 1. A 49-year-old man, complaining esotropia was referred to us by an ophthalmologist. He had no particular past history. Neurological examination revealed left oculomotor, abducens palsy and disturbance of left trigeminal first branch. CT scan revealed a round high density mass in the left middle fossa. The size was 3 cm in diameter. Left CAG revealed severe stenosis of left internal carotid artery and in delayed phase, faint shadow was seen near posterior clinoid process. MRI revealed a high intensity mass of the intraaneurysmal thrombus in the left middle fossa with small low intensity area indicating residual lumen. With conservative treatment, the symptom was gradually improved and one month after admission, complete occlusion of the left internal carotid artery was seen by angiography. The patient returned to his previous occupation. Case 2. A 21-year-old man was admitted to our hospital complaining dysarthria and left hemiparesis. He had been diagnosed as left internal carotid giant aneurysm 5 years before when he had suffered from right visual disturbance. Neurological examination revealed left hemiparesis and dysarthria. CT scan revealed high density mass which extended from the base of the right middle fossa to the third ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Post-traumatic occlusion of the anterior cerebral artery]

A rare case with cerebral infarction in the region of the anterior cerebral artery after minor head injury is reported. A 44-year-old male sustained a blow in the occipital area and became unconscious for a moment when he was driving a car and was involved in a rear-end collision. There being no significant signs, he drove home. About 30 minutes after the traffic accident, he felt weakness in the right limbs and speech difficulty and immediately visited our clinic. The patient was alert, but right hemiparesis and mild motor aphasia were present. There was no apparent evidence of head injury. A plain skull roentgenogram revealed no fracture. Computed tomography two hours after the trauma was normal. A left carotid angiogram showed an evident dilatation of A2 and the proximal portion of A3 of the anterior cerebral artery, tapering off to an occlusion of the callosomarginal artery in the arterial phase, delayed filling of the anterior cerebral artery in the capillary phase, and pooling of the callosomarginal artery in the venous phase. Three days later, computed tomography showed a low density area on the medial surface of the left frontal lobe. The symptoms of the patient improved with conservative treatment. Sequential changes in angiographic findings were observed. One month after admission, severe irregularity and stenosis of the pericallosal artery and revascularization of the callosomarginal artery was noted. By this time most of his symptoms had disappeared. Two months after admission, stenosis of the pericallosal artery increased. Three months after admission the stenosis improved slightly. The patient was discharged with no neurological deficit. Seven months after the initial trauma, a left carotid angiogram showed further regression of the stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Three cases of an intracranial wooden foreign body]

Three cases of intracranial wooden foreign body are reported discussing the diagnostic and therapeutic problems. First case is a 50-year-old man. After drinking, he drove a bike and fell to the ground. On admission the wooden foreign body could not been detected in appearance. CT scan showed low density area similar to air in bilateral anterior horn of lateral ventricle. The patient was treated for traumatic pneumocephalus at first. Later, it proved that he was stabbed with a foreign body penetrating into the contralateral frontal lobe through the left nasal cavity. It was extracted by endonasal approach by otolaryngologist, fortunately without trouble. The foreign body was a branch of tree. The second case is an 18-year-old man. He was driving a car, and suffered injury. He was stabbed with a wooden stake penetrating into his left eye. Immediately, bifrontal craniotomy was performed and the stake was withdrawn carefully. Moreover bone fragments were removed. The third case is a 61-year-old man. When he cut the timber by chain saw, a piece of wood hit and stabbed his right eye directly. Immediately right front temporal craniotomy was performed. The piece of wood was withdrawn from the right eye, and pieces of glass, wood and bone fragments were evacuated. It is difficult to confirm intracranial foreign body accurately by means of only plain skull film and usual CT scans. It is necessary to utilize various function of CT scanner. For example, it is useful to know CT values or select measure mode with window width and level or make reconstruction image to sagittal or coronal section, and so on.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pseudoaneurysm of the cortical artery associated with chronic subdural hematoma--a consideration on traumatic middle cerebral artery aneurysm]

A 62-year-old man was admitted to our hospital, since chronic subdural hematoma was showed after he complained of mild headache and nausea. Two years ago he had head trauma at the left parietal region after drinking. On admission there was no paresis and mild choked disc is detected. Computed tomography with contrast enhancement showed abnormal enhancement and left chronic subdural hematoma. Cerebral angiography showed an aneurysm of the angular artery. Operation was done and the aneurysm was trapped. Aneurysmal wall was histologically a pseudoaneurysm. Post-operative result was good. We considered the relationship between the cortical pseudoaneurysm and chronic subdural hematoma. We reviewed the traumatic middle cerebral artery aneurysm in the literature, 56 cases.

[Traumatic anterior cerebral artery aneurysms--experiences in 4 cases and review of the literature]

Five cases of traumatic anterior cerebral artery aneurysms are reported with special emphasis on the initial CT findings of these cases. One case was already reported by Endo (1974). The cases are three in children and two in adults, male four cases and female one case. Four cases had closed head injury, one open. Consciousness level on admission were diversely from clear to semicomatose. Three cases experienced rupture of aneurysms. Time of diagnosis from trauma was from two days to 34 days. Location of aneurysms were near the junction of callosomarginal artery three cases, frontopolar artery one case, and A1-A2 junction one case. Operation was performed in four cases. Results were good in three cases and fair in a case. A case of no operation had fracture of anterior skull base and died from massive nasal and oral bleeding. Autopsy showed an aneurysm of A1-A2 junction, extending to sphenoid sinus. Histological findings of aneurysmal walls were pseudoaneurysm in all cases. There were 48 cases of traumatic anterior cerebral artery aneurysms in the literature. Most of cases are near the junction of callosomarginal artery. As the etiology of the aneurysm it is said that falx cerebri damages the arterial wall. We consider tear of junction of callosomarginal artery is a important factor, since the brain can easily move at the anterior portion of falx. It is very difficult to diagnosis traumatic aneurysms before rupture. But in our three cases of traumatic anterior cerebral artery aneurysms, computed tomographies of very early stage of trauma showed interhemispherical high density area, hematoma and hemorrhage of corpus callosum.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cerebral cysticercosis--report of an operated case]

A rare case of cerebral cysticercosis is reported. The patient, a 49-year-old man, had been to Central America several times since 1963. He had an episode of seizure in March 1980 and again in August 1983, and was admitted to our hospital. Skull X-ray, cerebral angiography, scintigraphy, EEG, CSF examination, Chest X-ray, blood and urine examinations were all normal. CT scan only revealed a small lesion in the left frontal lobe as a well circumscribed round low density area with ring-like enhancement. An operation was performed for a suspected brain tumor. However, a cyst was found in the left frontal lobe and was totally extirpated. The microscopic examination revealed a scolex, hooks, and a cyst characteristic of cysticercosis. Postoperative examinations, X-ray of extremities, abdominal CT and immunological reactions of cysticercosis showed no abnormal findings. Cerebral cysticercosis, a rare disease in Japan, may increase proportionally with the increase of world travel. In this case, CT scan was useful for the diagnosis of cysticercosis.

[Ruptured cerebral aneurysm of the median artery of the corpus callosum (accessory anterior cerebral artery): case report]

A rare case of ruptured cerebral aneurysm of median artery of corpus callosum (accessory anterior cerebral artery: Acc ACA) is reported. A 66-year-old hypertensive female suddenly lost consciousness for 5 minutes and later complained of severe headache. On admission, the next day, consciousness was clear and she showed no neurological deficit except for right motor weakness. CT scan revealed subarachnoid hemorrhage, and carotid angiography showed triplicated anterior cerebral artery with a saccular aneurysm on the Acc ACA. Twenty hours after the onset, an operation was performed to clip the aneurysm neck. Post-operative course was uneventful and she was discharged on the 25th postoperative day without neurological deficits. When the median artery of corpus callosum(MACC), a branch of anterior communicating artery distributes to one or to both hemispheres, it is called Acc ACA. It is thought to be a vascular anomaly and which has an incidence of 20%. However, cases of aneurysm of MACC (or Acc ACA) have not been reported and our case is considered to be the first.

[Traumatic arteriovenous fistula of the deep temporal artery--a case report]

A rare case of traumatic AV fistula of the deep temporal artery is reported. The patient, a 33 years old male, struck his forehead and left temporal region in a traffic accident on March 30, 1983. He noticed the swelling at his temporal region 5 days after the accident as it became pulsative and enlarged. He was admitted on May 23 and left external carotid angiography revealed an AV fistula which was fed by the deep temporal artery and drained into the superficial temporal vein. The operation was performed on May 27 and showed that the AV fistula was not in the subcutaneous tissue, but buried in the temporal muscle. Total extirpation was performed. Postoperative course was uneventful and he was discharged on June 10. Microscopic examination of the AV fistula demonstrated some traumatic findings, such as tear of the wall of vein, thrombosed artery and an aneurysm-like protrusion of the wall of the artery.

Intracranial hemorrhage secondary to von Willebrand's disease and trauma

A rare juvenile case of traumatic hemorrhage in the basal ganglia with intraventricular hematoma, associated with von Willebrand's disease, is reported. Hemostatic management of von Willebrand's disease and our surgical method for treatment of intraventricular hemorrhage are discussed briefly.

Analyses of risk factors of ischemic heart disease in diabetics--multivariate analyses

In order to confirm the principal risk factor of ischemic heart disease (IHD) in diabetes, multivariate analyses were performed. ST depression in electrocardiogram (ST-ECG) and 18 other clinical-laboratory findings (sex, age, duration of diabetes, blood pressure, cholesterol, HDL-cholesterol, triglyceride, etc.) were measured in 70 non-insulin dependent diabetes mellitus patients. ST-ECG findings were divided into five ranges as an index of the severity of IHD, based on the assumption that the degree of ST-ECG would provide a reasonable correlation to the grade of IHD. In partial correlation analysis, the degree of ST-ECG was significantly correlated both to the level of triglyceride (r = 0.455, p less than 0.001) and to blood pressure (r = 0.392, p less than 0.01), but not to the other 16 variables. Three selected variables (blood pressure, triglyceride and atherogenic index) were sufficient to provide a satisfactory discrimination between patients with and without IHD. Five selected variables (sex, blood pressure, triglyceride, atherogenic index and weight index) were sufficient for evaluation of regression. These results suggest that the high level of triglyceride and hypertension are essential risk factors of IHD in diabetes. It is noticeable that the high level of triglyceride is one of the independent risk factors of IHD in diabetes; it does not depend on the degree of control of hyperglycemia or on the other variables.

Limbic lobe epilepsy with paranoid symptoms: analysis of clinical features and psychological tests

Ten cases of limbic epilepsy with paranoid symptoms were compared with 10 cases of limbic epilepsy without paranoid symptoms and 10 cases of primary generalized epilepsy ( GTC ). The clinical features (onset of seizures, their duration, combination with GTC , seizure control, social adaptability and laterality of foci) and psychological tests (WAIS, Bender-Gestalt, MPI, Y-G, Rorschach) were analyzed. Paranoid epileptics showed poor social adaptation in spite of the seizures being better controlled. They had a low performance IQ, a low object assembly test and a low picture completion test in WAIS. They were less extroversive in MPI, less aggressive and more introversive in the Yatabe -Gilford test. In the Rorschach test, they had a high color response and a form response but the form level was low.

[Acute epidural hematoma in the posterior fossa in patients with hemophilia A--report of two surgically treated cases]

Case I: A 9-year-old boy, diagnosed as having hemophilia A at 8 months, was admitted complaining of slight headache and nausea one day after a minor head trauma. Neurological deficits were absent but CT scan revealed an epidural hematoma in the posterior fossa. Shortly afterwards, he lapsed into coma with apnea and dilated pupils. Following resuscitation, emergency suboccipital craniectomy and total removal of the bilateral supra- and infratentorial extradural hematoma was performed under AHG administration. The patient gradually regained consciousness, but during the subsequent nine weeks he underwent three major operations (laparotomy): the first two for hemostasis of gastrointestinal bleeding, and the last one for strangulated intestinal obstruction. Although this patient necessitated 16 weeks of AHG administration, he was discharged without any side effects after 4 months of hospitalization. Case II: A 10-year-old boy, diagnosed earlier as having hemophilia A, experienced a minor head trauma and was admitted because of headaches and nausea. CT scan revealed an epidural hematoma in the posterior fossa. Removal of the hematoma was successfully completed under AHG administration. The patient was discharged without any neurological deficits. In the above hemophilic cases, we used a high concentrated AHG and maintained at 70% of the plasma concentration of the VIII factor during the first 14 postoperative days. The high concentrated AHG was safe for long term administration, so one should not hesitate operation even in the case of intracranial hemorrhage of hemophilic patients. CT scan should be recommended to the patient of hemophilia A even in minor head trauma.

[Intracranial hemorrhage in von Willebrand's disease.--A case report]

A rare case of intracranial hemorrhage proved associated with von Willebrand's disease was reported. A 4-year-old girl fell down and hit her occipital region against a small wooden case. Soon after she cried for a few minutes, but she gradually became unconscious. Four hours later she was brought to our hospital. On admission she was semicomatose with left hemiparesis. There was no evidence of head injury and plain skull films were normal. CT scan disclosed a hematoma in the right basal ganglia with a ventricular hemorrhage. No vascular malformations were seen on the carotid angiogram. Immediate aspiration of intraventricular hematoma and ventricular drainage were performed bilaterally by a frontal approach. After the operation she recovered consciousness dramatically, and on the following morning she had a clear consciousness. One week later ventriculo-peritoneal shunt was performed. There were no episodes of abnormal bleeding in her past or her family histories. But a prolonged bleeding time was recognized by a routine laboratory examination on admission. The clotting time, platelet count and prothrombin time were normal. As further hemostatic study and factor VIII assay demonstrated the decreased platelet retention rate (Saltzman test), the decreased ristocetin induced platelet aggregation rate (RIPA), and the decreased levels of Coagulant factor VIII (VIII: C), factor VIII-related antigen (VIIIR: AG) and von Willebrand factor (VIII: WF), she was diagnosed as von Willebrand's disease. Fortunately we could perform the operation safely and did not experience the troublesome postoperative bleeding without specific therapy. She was discharged one month later with no neurological deficits and returned to her normal life.