Intracranial transplantation of the omentum for cerebrovascular moyamoya disease: a two-year follow-up study

Intracranial transplantation of the omentum was performed on a patient with moyamoya disease who presented with diffuse cerebral ischemic symptoms and blindness. Anastomoses were made between the superficial temporal artery and the gastroepiploic artery of the transplanting omentum, and between the superficial temporal and gastroepiploic veins. Postoperative angiography demonstrated branches of the middle cerebral artery through the anastomosed gastroepiploic artery. Postoperatively the patient was able to walk with a cane without further ischemic attacks for the next two years. The blindness did not improve.

Subependymal hematoma in "Moyamoya" disease

A 27-year-old woman in the ninth month of her pregnancy suddently developed nausea and motor weakness of her right lower extremity while shopping. Subsequently a disturbance of consciousness and right-sided hemiparesis developed. Spinal puncture yielded clear CSF but CT scan demonstrated a left subependymal hematoma. Angiographical examination led to a diagnosis of "Moyamoya" disease. The source of the intracranial hemorrhage could not be identified. The hematoma could not have been diagnosed accurately without the CT scan.

Treatment of moyamoya disease with STA-MCA anastomosis

Moyamoya disease is a chronic occlusive cerebrovascular disease of unknown etiology for which no effective treatment has been found. The authors report the result of 23 superficial temporal-middle cerebral artery (STA-MCA) anastomoses and seven encephalomyosynangioses, performed on 13 cases with moyamoya disease and on four additional atypical cases. There were 10 children and seven adults in this study. The follow-up period ranged from 1 year and 4 months to 4 years and 1 month postoperatively; nine patients had excellent results, five good, and one fair; two patients were unchanged. The anastomotic procedure was most effective for transient ischemic attacks, reversible ischemic neurological deficits, and even minor or moderate neurological symptoms. The STA-MCA anastomosis appears to be an effective treatment for moyamoya disease.

[The combination of STA-MCA anastomosis with another operation for the occlusive cerebrovascular disease (author's transl)]

Case 1. A 65 year old male had left hemiparesis with sudden onset since 8 years ago, which gradually aggravated for these 2 years. On Sept. 27, 1973, he was admitted to the Department of Neurosurgery, Kitano Hospital. There was left spastic hemiparesis with hemisensory disturbance and he could not walk without help for the maked spasticity. Left carotid angiogram revealed the complete occlusion of the internal carotid artery and marked stenosis of the external carotid artery at the common carotid bifurcation. External carotid endarterectomy was performed on Nov. 19, 1973, which was followed by STA-MCA anastomosis 2 months later. The spasticity of extremities and left hemisparesis were gradually improved and he was able to walk without help. Case 2. On Apr. 14, 1974, a 63 year old female developed complete stroke with right hemiparesis and speech disturbance after transient ischemic attacks of 5 days duration. On Aug. 9, he was admitted and had emotional incontinence, right hemiparesis, Gerstmann's syndrome and motor aphasia. Left carotid angiogram revealed a saccular aneurysm of the middle cerebral artery and the occlusion of the distal middle cerebral arterys. These findings suggested that the occlusion was caused by embolus from the middle cerebral aneurysm, and the combined surgery with STA-MCA anastomosis and operation for the aneurysm was planned. On Aug. 30, 1974, under left frontotemporal craniotomy, aneurysmal neck clipping and aneurysmectomy were performed and thereafter, STA-MCA double anastomosis was done. One week after operation, the gradual improvement of pre-operative symptomes was noted. Recently, STA-MCA anatomosis is well known to be one of the effective operative methods for the occlusive methods for the occlusive cerebrovascular diseases and in addition, we found that the combination of STA-MCA anastomosis with other operations was effective for unusual cases presenting in this report. Furthermore, except for the occlusive cerebrovascular diseases, we usually plan STA-MCA anastomosis for the cases of 1) carotid ligation or trapping for carotid-cavernous sinus fistula and some internal carotid aneurysms, 2) some intracranial tumors with the danger involving the main cerebral arteries by operation to protect the cerebrovascular insufficiency.

[The usefulnessof STA-MCA anastomosis in trapping vascular disorder (author's transl)]

Huge aneurysm taking place within the cavernous sinus or at the junction of the internal carotid artery with the ophthalmic artery must be treated by intra- and extracranial ligation of the internal carotid artery because of its anatomical specificity, if it is to be radically treated. Carotid-cavernous fistula which cannot be cured by embolization must also be treated by ligation of the internal carotid artery. However, if there is only a poor collateral circulation over the area distal to ligated portion, the operation surely incurs severe neurological deficit, so that trapping must be abandoned in such cases. Nevertheless, by establishing a bypass through anastomosis between the superficial temporal artery and the middle cerebral artery, the operation can be done safely. Further, even in cases of aneurysm taking place on the cerebral main vessel in which the aneurysm must be extirpated despite the presence of an important branch shooting-off from the aneurysm, or in some other cases (sphenoidal ridge meningioma, for instance) in which total extirpation of the tumor must necessarily be associated with sacrifice of the main vessel because it is involved in the brain tumor, we think that the operation can be performed rather safely through anastomosis with the vessel to be sacrificed. Some representative examples of such cases are described, and the usefulness of anastomosis between the superficial temporal artery and the middle cerebral artery in trapping of vascular disorders.

[Surgery of vertebral aneurysms at the origin of PICA (author's transl)]

Thirteen cases of vertebral aneurysm at the origin of PICA (VA-PICA aneurysm) were operated on at the Department of Neurological Surgery of Kitano Hospital from March, 1970 through July, 1975. Those included 9 cases of saccular aneurysm and 5 cases of fusiform aneurysm (Table 1). The incidence of VA-PICA aneurysms among our whole series of intracranial aneurysms was 4.2%. Patients with subarachnoid hemorrhage were subjected to our routine 4 vessel angiography. For those with suspected vertebral aneurysm vertebral angiography was performed in a transoral projection. In this method, when the angle between the film and the horizontal plain of Frankfurt is fixed at 50 degrees, the origin of PICA is projected on the film between the upper and lower teeth line. Since X-ray beam falls vertically on the origin of PICA, the resultant vascular shadow is free from shortening, elongation and distortion, leading to precise demonstration of anatomical arrangement of the vessels. At surgery a lateral suboccipital incision was made. With the position of VA-PICA junction the surgical approach was slightly different. When the junction was located higher than the line between the lowest point of the occipital bone and the basion by 1 cm or more, the approach was made through the middle of the sigmoid sinus which was exposed by suboccipital osteoclastic craniectomy (mid-lateral cerebellar approach). When the VA-PICA junction was situated lower than the line by 1 cm or more, the operation was initiated at the upper limit of the lower one-third of the sigmoid sinus (lower-lateral cerebellar approach). Since VA-PICA junction is ventrally situated to the lower cranial nerves, surgical attack to the junction can be attained only through the space among the nerves. Two spaces are available for this direct attack. One is the space between the facial nerve, acoustic nerve and the group of vagal nerves. The other is between accessory nerve bundles or between the group of accessory nerves and the hypoglossal nerves. The former procedure is employed for reaching the aneurysm by mid-lateral cerebellar approach and the latter by lower-lateral cerebellar approach. In the patients in acute stage of ruptured VA-PICA aneurysm, hemisuboccipital craniectomy and laminectomy of the atlas were carried out for the purpose of decompression. Surgical procedures used included coating in 2 cases, trapping in 2, proximal ligation of the vertebral artery in 2 and neck clipping in 6. Two patients died due to grastrointestinal bleeding. Surgical complications noted were hypoglossal nerve palsy in 1 case mild sensory disturbance contralateral to the aneurysm in 3 cases. Those symptoms were thought to be caused either by direct injury to the lower cranial nerves or circulatory disturbance in the medullary branches of the vertebral artery. To eliminate those postoperative complications it is desirable to devise smaller aneurysm clips and smaller clip foreceps.

[Dermoid tumor in left cerebellum--A case report (author's transl)]

This paper describes a dermoid tumor which developed in the dorso-lateral area of the left cerebellar hemisphere. It is the first to be reported in Japan. The patient was a 31 year old female who suffered from severe occipital headaches, frequent vomiting and gait disturbances. Neurological findings on admission included marked bilateral choked discs, horizontal nystagmus on gaze to the left, and poor coordination on the finger to nose test, nose-finger-nose test and and heel-shin test on the left side. Left suboccipital craniectomy was performed. A tumor was found which displaced the left cerebellum anteromedially and inferiorly. The postero-lateral surface of the tumor was adherent to the overlying dura matter. It was completely removed and found to be about the size of a hen's egg. It contained a yellow, porridge-like substance and short hairs. Histological examination of the capsule of the tumor showed stratified squamous epithelium and cutaneous structures, such as hair follicles and sebaceous glands. The diagnosis was dermoid tumors. We could find as many as 78 cases of the posterior fossa dermoids in the literature. In 72 cases (92.4%), the mass existed along the midline in the posterior fossa. The dermoids developed in the cerebellar hemisphere were reported in only 6 cases (7.6%) including the present case. Laterally growing dermoids are considered to be very rare. The pathogenesis is discussed and the literature reviewed.

[Spinal cord arteriovenous malformation during pregnancy (author's transl)]

On May 7, 1973, a 23-year-old female, para ii, gravida ii, suddenly developed severe chest pain at 10th month of her pregnancy and soon after became paraplegic with sensory impairment lower than the level of 5th thoracic nerve and urinary incontinence. On May 8, she was admitted to our clinic and 4 days after, labour was induced by Caesarean section. Myodil myelography demonstrated "worm like defects" at the level of Th4-Th5, but sabarachnoid block was not found. Selective spinal angiography showed the image of typical arteriovenous malformation at the level of Th2-Th6. On June 26, about 1.5 months after delivery total removal of arteriovenous malformation (from Th2 to Th6)) was performed by the use of operative microscope. 10 months after operation, the patient could walk with her baby in her arms and no urinary incontinence was seen. We discussed the clinical characteristics and the treatment of spinal cord arteriovenous malformation during pregnancy.

[False aneurysm due to mycotic angitis-case report (author's transl)]

Cerebral mycotic angitis takes place as a secondary disease to inflammation which is precipitated on the arterial wall to the artery, most frequently the vasa vasorum, as a result of settlement of infectious embolus into there, and it is usually seen in the patient with cardiac disease. The middle cerebral artery is a major region where the lesion takes place in multitude, and it is only rarely seen in the patient having infection in the brain or dura mater. We have recently experienced a very rare case in which false aneurysm was induced in the internal carotid artery by angitis due to Aspergillus, and this report deals with case. A 26-year-old office-man: He was attacked by loss of consciousness, aphesia, right hemiparesis during work in his office. As left CAG demonstrated evidence of arteriovenous malformation, redical operation was performed. He took a favorable course postoperatively, but developed meningitis on 10th day, when massive antibiotic therapy was started. During treatment, however, his consciousness rapidly decreased, and it was found on left CAG that there was false aneurysm in the cisternal segment of the left internal carotid artery which has previously been completely healthy. Operation was practiced once again to reinforce the wall of the left internal carotid artery, but the patient died of aggravated meningitis. Autopsy demonstrated a very fragile left internal carotidartery associated with perporation which was surrounded byprominent coagula. Histological examinations indicated that the perforation of the vascular wall had been caused by angitis due to Aspergillus infection.

Enlarged anterior spinal artery as collateral circulation

✓The authors report and discuss two cases in which collateral circulation could be angiographically demonstrated passing through the anterior spinal artery. Case 1 proved to have occlusions of the left internal carotid artery and both vertebral arteries. The basilar artery was visualized via the anterior spinal, the primitive trigeminal, and primitive otic arteries. The presence of multiple vascular malformations and an abnormal anterior spinal artery suggested that the latter had been functioning as collateral circulation since an embryonic stage. In Case 2, both internal carotids and both vertebral arteries were occluded by arteriosclerotic changes. It was assumed that the deleted anterior spinal artery visualized angiographically had developed into a collateral circulation with increasing age.