No shinkei geka. Neurological surgery
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Cortical venous drainage has been described as one of the major risk factors for dural arteriovenous fistula, which may induce venous hypertension leading to venous ischemia or intracerebral hemorrhage. However, it is rather rare to observe cortical venous drainage manifesting in this way in the cavernous sinus region. We report a case of a 55-year-old gentleman with a right cavernous dural arteriovenous fistula, presenting with conjunctival chemosis, exophthalmus and ocular hypertension on the affected side. ⋯ We emphasize the following points from this rare case in order to facilitate a safer procedure during transvenous embolization for cavernous dural arteriovenous fistula. It is important to obliterate the cortical venous drainage as early as possible, even if the reflux is small or the catheterization is difficult. Repeated, careful sinography is useful for the evaluation of the drainage pattern at certain stages during the transvenous embolization procedure.
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We report a case of a rapidly growing cerebral aneurysm in the basal abnormal vascular network associated with spontaneous middle cerebral artery (MCA) occlusion. The aneurysm disappeared spontaneously shortly after performing STA-MCA anastomosis. A 54-year-old female was admitted to our hospital because of repeated attacks of right hemisensory disturbance and dysarthria. ⋯ An increased hemodynamic stress in the abnormal basal vascular network may produce a true aneurysm in the distal portion of the perforating arteries. STA-MCA anastomosis reduced the TIA attacks, but also decreased the hemodynamic stress on the abnormal basal vascular network and resulted in reduction in size or thrombosis of the aneurysm. STA-MCA anastomosis can be considered effective to treat cerebral aneurysms located in vessels with increased hemodynamic stress.
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Gunshot wounds are rare in Japan because of few regulatory laws against the possession of guns. Nevertheless such wounds are increasing in prevalence these days. Reports on the microscopic findings concerning these intracerebral lesions are fewer than those on the macroscopic findings in the scalp, the skull and the intracranial cavity. In this study we evaluated computed tomographical and histopathological findings in craniocerebral gunshot injuries. ⋯ CT scans were examined in six cases, which revealed a missile track, hemorrhagic contusion, traumatic subarachnoid hemorrhage and marked tension pneumocephalus. In some cases, CT scan also revealed bony and metallic fragments, some deep within the cranial cavity. In the histopathological study, we found marked swollen brain (brain weight over 1500 mg) and hemorrhagic contusion in the vicinity of the missile track and interhemispheric fissure, and widespread traumatic subarachnoid hemorrhage and intraventricular hematoma. We would like to emphasize especially the remote contusion seen in the distant part of the missile track as well as massive exsudation and hemorrhage around the nerve fiber bundles. Remote contusion was observed in the inferior surface of the fronto-temporal lobes, and bilateral hemorrhagic contusion was seen in the vicinity of the superior longitudinal fissure on CT scans and autopsy findings. In one case, the bullet rotated within the intracranial cavity. In conclusion, nine cases of craniocerebral gunshot injuries were examined, while we also reviewed the medical literature concerning the shearing injury produced by gunshot brain wounds. The head injuries were further delineated by the correlation between autopsy and computerized tomography findings.
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Case Reports Clinical Trial
[Analysis of mild barbiturate-moderate hypothermia therapy on the authors' 152 cases].
Mild barbiturate-moderate hypothermia therapy was established for severe head injury and cerebrovascular disease. This study was conducted on 152 patients from April 1984 through July 1995. In this study were included patients with Glagow Coma Scale score of less than 8 points but those with serious systemic complications and elderly and infantile patients were excluded. ⋯ This therapy was found to be particularly effective for preventing ischemic neurological damage in the vasospasm stage following SAH and severe head injury in young patients. However, this therapy did not prevent pneumonia, cardiac failure, arrhythmia and hypopotassemia from occurring frequently. We conclude that this therapy is contraindicated in the elderly, i.e., those older than 65 years.
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We report a case of distal posterior inferior cerebellar artery (PICA) aneurysm associated with acute subdural hematoma (SDH). The patient was a 68-year-old female who was found unconscious at home and transferred to the emergency medical center in a state of deep coma. Her consciousness on admission to the center was 200P (Japan coma scale), E1V1M2 (Glasgow Coma Scale), and the Hunt & Kosnik grade was grade IV. ⋯ The distal portions of the PICA run between the vermis and cerebellar hemisphere, so that if an aneurysm ruptures at these portions, ICHs in the vermis and cerebellum tend to occur. In cases such as ours, because of the characteristic CT findings, effort to detect a distal PICA aneurysm should be made at first surgery, along with ventricular drainage and removal of the SDH. The surgical procedures and outcome of cases with distal PICA aneurysms are also discussed.