Endoscopic ventriculo-cystomy for non-communicating hydrocephalus secondary to quadrigeminal cistern arachnoid cyst

INTRODUCTION

Intracranial arachnoid cysts are developmental, anomalous collections of cerebrospinal fluid (CSF), and occasionally cause symptoms when large enough to obliterate the CSF outflow pathway and give rise to non-communicating hydrocephalus. The treatment of choice for symptomatic arachnoid cysts has been surgical excision or fenestration of the cyst, but less invasive endoscopic fenestration has been attempted with favorable preliminary results.

CASE REPORT

We report a case of non-communicating hydrocephalus caused by a quadrigeminal cistern arachnoid cyst in a 35-year-old woman who presented with worsening headaches. She was successfully treated by endoscopic third ventriculostomy and fenestration of the cyst (ventriculo-cistomy).

DISCUSSION

Endoscopic fenestration of symptomatic arachnoid cysts can be as effective as open surgery in terms of short-term efficacy, and it is certainly less invasive than open surgery. However, its long-term outcome remains unknown, and these rare cases require careful clinical and radiological follow-up.

Survival of a subarachnoid hemorrhage patient who presented with prehospital cardiopulmonary arrest: case report and review of the literature

A 63-year-old woman was admitted to the intensive care unit after resuscitation from prehospital cardiopulmonary arrest (CPA). A brain CT scan revealed a subarachnoid hemorrhage (SAH), which was considered to be the cause of the CPA. The patient recovered neurologically after admission, and the elevated intracranial pressure (ICP) was controlled by inducing mild hypothermia. The day after admission, cerebral angiography revealed a ruptured cerebral aneurysm. The aneurysm was successfully treated with detachable coils by an endovascular technique. Mild hypothermia was continued for 3 days, and the patient was gradually rewarmed. After rehabilitation, the patient was discharged to her home with severe disability. Although aneurysmal SAH is one of the most common causes of CPA, survival of SAH patients after CPA is rare. This case illustrates the ability and possibility of multidisciplinary treatment, including the use of endovascular techniques and mild hypothermia, to improve the outcome of SAH patients with CPA who have been considered to be inoperable and untreatable.

Ruptured vertebral artery-posterior inferior cerebellar artery aneurysm associated with facial nerve paresis successfully treated with interlocking detachable coils--case report

An 81-year-old female presented with severe headache. Computed tomography revealed subarachnoid hemorrhage. She developed right facial nerve paresis on the next day. Angiography revealed a right vertebral artery-posterior inferior cerebellar artery aneurysm. The aneurysm was successfully occluded with interlocking detachable coils (IDCs) on the 7th day. Magnetic resonance (MR) imaging 1 month after IDC placement showed partially thrombosed aneurysm near the internal acoustic meatus. Ten months after the ictus, MR imaging revealed marked resolution of the intra-aneurysmal thrombus and reduction of the aneurysm size. Her facial nerve function gradually recovered during this period. Her facial nerve paresis was probably caused by acute stretching of the facial nerve by the ruptured aneurysm that was in direct contact with the nerve. Intra-aneurysmal thrombosis using coils can reduce aneurysm size and alleviate cranial nerve symptoms.

[Skull base metastasis from renal cell carcinoma presenting as abducens nerve paresis: report of two cases]

We report two cases of skull base metastasis from renal cell carcinoma. Case 1: A 55-year-old female presented with a skull base tumor located on the clivus. Partial removal of the tumor was performed via the transsphenoidal approach. Case 2: A 44-year-old male presented with a skull base tumor occupying the orbital, nasal, and paranasal cavities. The first operation, partial removal of the tumor, was performed via the transsphenoidal approach. Thereafter, the tumor regrowth and the patient's symptoms were progressive, so a second operation was performed via Le-Forte I craniotomy to prevent cranial nerve dysfunction and air way obstruction. The initial symptom of these two cases was abducens nerve paresis, which is caused by the tumor extending from the clivus to the cavernous sinus. The neuroradiological features were the destruction of skull base bone and angiographic tumor stain. Histopathological examination of the surgically resected specimens revealed clear cell carcinoma, and thereafter they were diagnosed as skull base metastasis from renal cell carcinoma. We emphasize the necessity of a thorough medical workup to enable speedy diagnosis of renal cell carcinoma in such cases.

Large diffuse arteriovenous malformation affecting the right cerebral and cerebellar hemispheres: case report

A cerebral vascular malformation was triggered in a 24-year-old man by left hemiparesis resembling transient ischemic attack. Cerebral angiography revealed slight dilation of the right anterior cerebral artery, middle cerebral artery, superior cerebellar artery, and posterior inferior cerebellar artery, as well as marked capillary blush and dilation of medullary veins involving the right cerebral hemisphere, especially the frontal lobe and cerebellar hemispheres. This vascular malformation, a clinical rarity, seemed to be in the same family as diffuse arteriovenous malformation or "medullary venous malformation." Single photon emission computed tomography showed a decline in cerebral blood flow in the right cerebral hemisphere, which was the probable cause of the left hemiparesis.

[Cooperative multicentric study on posttraumatic epilepsy]

A multicenter cooperative study was conducted to investigate factors influencing posttraumatic epilepsy (PTE) and to evaluate the prophylactic effect of anticonvulsants. A retrospective study of 102 PTE patients revealed the following typical clinical features: occurrence in young males, traffic accidents, contusion and/or cerebral hematoma. The latent period after the injury was longer in children. The percentage of EEG paroxysmal activity gradually increased as the generalized abnormality diminished. A retrospective-prospective study of 1998 patients who suffered a head injury between 1984 and 1988 was conducted till 1994. During the follow-up period, 62 patients (3.1%) developed PTE. The drop-out cases were excluded, and the 154 cases followed at least two years were analyzed. Statistical analysis of differences between patients with and without PTE suggested following factors: young, immediate early epilepsy (within 24 hours after injury; IMEE) and early epilepsy (within one week after injury). The risk with the highest relative risk rate was early epilepsy. Multiple regression analysis revealed that three factors, IMEE, early epilepsy and young age, contributed to the prediction of PTE. There was no significant difference in the percentage of patients having PTE in the group treated with anticonvulsants and the untreated group. Anticonvulsant treatment after head injury was unlikely to have a prophylactic effect on the development of PTE.

Usefulness of hemilaminectomy for microsurgical management of intraspinal lesions

Hemilaminectomy is a limited, unilateral approach to the spinal cord that provides excellent exposure of the dorsolateral and ventral portions of the spinal canal. This approach is most suitable for microsurgical management of the majority of extramedullary tumors. Contrary to conventional laminectomy, the posterior supporting structures of the spine are completely preserved on the contralateral side with this access route. The procedure has been applied in 3 patients who harbored a cervical neurilemmoma, a cervical lipoma, and a thoracic neurilemmoma, respectively. Optimal exposure of the lesion was achieved in each case, and each patient's symptoms improved or completely resolved postoperatively. There were no surgical complications. It is concluded that hemilaminectomy combined with microsurgical techniques should be given priority over standard laminectomy in the surgical management of extramedullary lesions arising in the spinal canal.

Sympathetic responses in out-of-hospital cardiac arrest

To determine the clinical relevance of the sympathetic response to out-of-hospital cardiac arrest, we measured plasma concentrations of catecholamine and cortisol in ten such arrested patients on their arrival. The duration of cardiac arrest was estimated from 9 to 200 min before basic life support was initiated by ambulance personnel. Two of the patients developed spontaneous pulses in response to ALS and were resuscitated, and the others were not, although the length and the extent of ALS were not different between the two groups. Plasma concentrations of epinephrine (EN), norepinephrine (NE) and cortisol prior to ALS in both groups were markedly elevated. In particular, the patients who never regained spontaneous pulses showed 58-fold and 12-fold increase in the plasma EN and NE levels, respectively, which were much higher than those in the resuscitated cases; 8- and 1.7-fold increase, respectively. These massive EN and NE discharges correlated well with the arrest time (r = 0.96 and 0.94, respectively) and the degree of acidosis (r = -0.82 and -0.82, respectively).

[Ischemic myocardial disorder in acute phase subarachnoid hemorrhage: clinical study of 52 patients]

Fifty-two cases of acute phase subarachnoid hemorrhage were studied by brain CT scanning to determine the presence and incidence of ischemic myocardial disorder, the relationship between ischemic change and severity, disease prognosis, and the relationship between acute phase circulatory dynamics and so-called neurogenic pulmonary edema. In all cases, ECGs were carried out and CPK-MB determined. Some of the patients underwent Tl myocardial scintigraphy, echocardiography, cardiac catheterization, as well as circulatory dynamic investigation (by Swan-Ganz catheter) and arterial blood gas analysis. In 31 of the 52 cases (59.6%), 3-day ECG series revealed ischemic changes. These findings were backed up by other cardiac function tests, thus suggesting that myocardial ischemia was present. Results in cases undergoing cardiac catheterization revealed that the myocardial ischemic changes were not due to organic constriction of the coronary artery. Included in those cases in which ECG markedly changed and CPK-MB rose substantially were many patients for whom the prognosis was poor. Evaluation of respiratory function and circulatory dynamics in cases of so-called neurogenic pulmonary edema seemed to indicate decline in cardiac function owing to myocardial ischemic change. This could account for onset of symptoms. These findings support the need for adequate circulatory management in cases of acute subarachnoid hemorrhage with pulmonary edema and/or changes on ECG. In such cases, concurrent catheterization and cerebral angiography (cerebro-cardiac catheterization: CCC) proved effective for evaluating cardiac function and determining whether heart disease was also present.

[Reconstruction of the large scalp defect by free flap transplantation]

The reconstruction of a large scalp defect is extremely difficult on many occasions and repeated operations or a long-term hospitalization is often required. In addition, unsatisfactory results are not unusual. However, it is now possible to perform reconstruction by a one-stage operation of free tissue transplantation (free flap) using microsurgical vascular anastomosis which has rapidly developed in the past ten years. We performed reconstructions applying latissimus dorsi musculocutaneous, greater omentum, groin and scapular flaps. The advantages with the free flap are: (1) one-stage reconstruction is possible; (2) no restrictions on the postoperative position, (3) the flap, which is independent of the blood supply from the recipient, well survives on the recipient with an insufficient blood supply and (4) the damage at the donor site can be minimized. On the other hand, its disadvantages are as follows: (1) the operation requires microsurgical vascular anastomoses; and (2) recipient vessels should be normal. The above report was based on favorable results we obtained in 6 cases of reconstruction with free flap applying microvascular techniques.

Intracerebellar hemorrhage due to rupture of angiomatous malformations in the cerebellum

Two infants were reported with intracerebellar hemorrhage due to rupture of angiomatous malformations in the cerebellum. There have been only a few reports on intracerebellar hemorrhage under 6 years of age, which was due to angiomatous malformation in all cases. The results of operations for intracerebellar hemorrhage in infants were more favorable than those in adults, so even if the infant patient shows severe neurological symptoms preoperatively, an operation should be performed.

[Case of histiocytosis X with a large intracranial mass]

The authors experienced a case of histiocytosis X with a large intracranial mass resulting in a convulsive seizure. The patient showed left exophthalmos and a skin rash one year and two months after birth. Histiocytosis X was diagnosed from a skin biopsy, and predonine, endoxan and vincristine were administered. The rash disappeared, but the exophthalmos remained. At the age of two years and nine months, punched-out lesions appeared in the skull and 4,000 rads of radiation was applied. Thereafter, the exopthalmos persisted but there was no particular problem in the course. However, a convulsive seizure with fever suddenly appeared at nine years and ten months of age and the patient was hospitalized. At the time of admission, the general condition was good and there were no abnormalities in neurological tests. In neuroradiological examinations, a calcified and poorly vascularized mass 8 cm in maximum diameter was found to occupy the left middle cranial fossa. Chondrosarcoma was strongly suspected from these findings, but there was also symmetrical thickening of bone cortex in the peripheries of the long bones of the extremeties which appeared to be the recovery process from bone destruction caused by histiocytosis X. Therefore, the formation of an intracranial mass by histiocytosis X was diagnosed and surgery was performed. When left osteoplastic fronto-temporal craniotomy was performed, the mass was found to be raising the temporal lobe and it could be easily separated from the surrounding tissue. However, these was firm adherence to dura mater of the middle cranial fossa (especially that of the superior orbital fissure). Histologically, there were many cells with small nuclei, no polymorphism, abundant and clear cytoplasm which were darkly stained and slightly atypic. These findings matched those for histiocytosis X. Cases of histiocytosis X rarely show symptoms of the central nervous system or infiltration of the central nervous system. Only 31 such cases were seen in the literature investigated by the authors. Neurological symptoms include pyramidal symptoms such as hemiparesis and impairment of the cranial nerves, particularly paresis of the optic, trigeminal, facial and acoustic nerves. Convulsive seizures were seen in only five cases including the one reported here. It is also rare for intracranial masses to be formed in cases of histiocytosis X and only six cases, including the authors', have been found with masses of a maximum diameter of more than 5 cm.

[A case of primary malignant lymphoma of the brain which showed a remarkable response to prednisolone]

We have recently had a case of a patient with primary malignant lymphoma in whom the diagnosis was difficult and prednisolone was remarkably effective. The patient was a 59-year-old man. Mental signs developed rapidly over a period of approximately 1 month. On admission, he was confused; his orientation was disturbed and his impressibility and understanding were markedly decreased. CT scan on admission revealed a remarkable enhancement of a nodular high density area in front of the lateral ventricles, accompanied by a surrounding diffuse low density. Angiography failed to reveal a tumor stain. When prednisolone was administered to the patient, the high density area disappeared and neurological findings returned to normal. After that, left hemiparesis occurred twice and disappeared following the administration of prednisolone. After that, however, he was readmitted to our hospital because his left hemiparesis advanced rapidly. CT scan revealed a high density area in the right basal ganglia. It also decreased in several days after the administration of prednisolone. Malignant lymphoma was strongly suspected by operation. He was then readmitted to our department because of a gait disturbance, decrease in impressibility, and incontinence of urine about one year and a half after onset. CT scan revealed symmetrical ventricular dilatation. Although a shunt procedure was considered, gastrointestinal bleeding occurred, followed by rapid deterioration of his general condition and neurological signs. CT scan 2 days before death revealed a mass lesion in the left basal ganglia. Autopsy revealed that a gelatinous tumor, primarily in the left basal ganglia, was verified macroscopically, but that there was no specific tumor at any other site. Light microscopic examination revealed a diffuse infiltration of tumors cells around the blood vessels in the subependymal area of the lateral ventricle. Because tumor cells were not verified in any other organ, primary malignant lymphoma of the brain was considered. These results suggest that in the development of malignant lymphoma, once a mass lesion is formed, it is widely invasive especially along blood vessel walls. As far as we know, there have been no reports which describe a tumor decreasing or disappearing on CT scan following administration of steroid hormone alone.

Ultrastructure, immunohistochemistry and hormone release of pituitary adenomas in relation to prolactin production

Fifteen cases of pituitary adenoma, 14 of which were associated with hyperprolactinemia, were studied by observation and granule morphometry of electron micrographs, immunohistochemistry and sequential observation of in vitro release with regard to hormone production, storage and secretion. Adenoma cells of 6 cases with marked elevation of plasma prolactin were sparsely granulated, showed characteristic ultrastructures including the presence of small secretory granules, well developed Golgi and rough membranes, misplaced exocytosis, and positive or negative immunostaining for prolactin. These adenomas also showed vigorous release of the hormone into the circulation and/or culture medium. In vitro studies showed that negative immunostaining of adenoma cells did not preclude the production and secretion of the hormone. One densely granulated adenoma containing cells with numerous lactotroph type granules showed moderate release of prolactin into the circulation. In an acromegalic case associated with both high plasma growth hormone and prolactin, some cells were shown by immunohistochemistry to store both hormones There were 4 adenomas which could not be shown to produce, store and secrete prolactin by any method available.