RESUMEN

BACKGROUND: It is extremely rare for primary non-Hodgkin's lymphomas to occur singly in the cranial vault. One case diagnosed as primary diffuse large B-cell lymphoma is reported, initially misdiagnosed as metastatic skull tumor, complicated with Trousseau syndrome. CASE DESCRIPTION: The patient was a 60-year-old Japanese woman with no particular previous medical history. In a head computed tomography examination for vertigo, bone destructive skull tumor covering the right frontal, parietal, and temporal bones was incidentally discovered. As positron emission tomography indicated an abnormal accumulation in the large intestine and multiple cerebral infarctions suspicious of Trousseau syndrome were observed on magnetic resonance images, a metastatic skull tumor due to colorectal cancer was first considered. However, various tumor markers were negative, and colonoscopic biopsy indicated no colorectal abnormality. After pathological examination of the resected tumor, it was diagnosed as diffuse large B-cell lymphoma. The tumor affected muscles and skin but did not develop in the brain or the dura mater. As further general examination revealed no other abnormalities, we considered that it was primary diffuse large B-cell lymphoma in the cranial vault associated with Trousseau syndrome. Treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone and high-dose methotrexate reduced the residual lesion; coagulation abnormalities, which are frequently associated with Trousseau syndrome, also improved. CONCLUSIONS: Skull tumors can result from a variety of malignancies, and their diagnosis may be complicated with Trousseau syndrome. However, even in cases of a single lesion in the cranial vault without invasion of the central nervous system, diffuse large B-cell lymphoma should be considered as a differential diagnosis.

Asunto(s)

RESUMEN

BACKGROUND: Neurofibromatosis type 1 causes various lesions in many organs including the skin, and the incidence of complications with intracranial aneurysms is 9-11%. Here we report a case of neurofibromatosis type 1 with subarachnoid hemorrhage due to multiple and de novo aneurysms. CASE PRESENTATION: The patient was a 49-year-old Japanese woman with a history of neurofibromatosis type 1. She was transported to our hospital owing to disturbance of consciousness and was diagnosed with subarachnoid hemorrhage by computed tomography. Computed tomography angiography revealed multiple, small intracranial aneurysms, and we suspected that one of them in the peripheral branch of the left middle cerebral artery was the source of hemorrhage based on the distribution of hematoma. The patient underwent emergency surgery. Because it was difficult to identify an aneurysm in the most peripheral part of the left middle cerebral artery in the initial surgery, only one aneurysm was clipped. Later, a peripheral aneurysm was clipped using the navigation system. Because both aneurysms were small intracranial aneurysms (< 2 mm), either of them could be the source of hemorrhage. The postoperative course was good, and the patient was discharged in healthy condition. Because brain magnetic resonance imaging performed in the previous year did not find aneurysms at the same site, she was diagnosed with rupture of a de novo aneurysm. Neurofibromatosis type 1 might have caused the rupture of multiple intracranial aneurysms in a short period in this patient. CONCLUSION: Neurofibromatosis type 1 may be complicated by the formation of multiple intracranial aneurysms in a short period.

Asunto(s)

RESUMEN

The present study evaluated the indications for microvascular decompression (MVD) in elderly patients based on the new classification of the elderly population proposed by the joint committee of the Japan Gerontological Society and the Japan Geriatrics Society in 2017.Retrospective analysis of 171 patients with hemifacial spasm (HFS), trigeminal neuralgia (TN), and glossopharyngeal neuralgia (GPN) who underwent MVD in 2018. Patients were divided into three groups based on the proposal: old group, 75-89 years; pre-old group, 65-74 years; and not-old group, 64 years or younger. Preoperative comorbidities were divided into five types and the American Society of Anesthesiologists Physical Status (ASA-PS) was recorded. Outcome of the surgery and neurological complications were evaluated in June 2019.No decrease in activity of daily living occurred in any patient and surgical results showed no difference among the three groups. Rate of preoperative cardiovascular diseases was higher in both the pre-old and old groups compared with the not-old group (p <0.001 and Cramer V = 0.429). In terms of ASA-PS classification, only ASA-PS I and II were found, and rate of ASA-PS II was higher in the pre-old and old groups compared with the not-old group (p <0.001 and Cramer V = 0.407). Some patients suffered from elevated blood pressure after surgery, but were successfully managed.In conclusion, MVD for elderly patients can be achieved safely with careful patient selection and perioperative management. Data should be continuously accumulated for the future development of decision-making algorithm for MVD in the elderly.

Asunto(s)

RESUMEN

BACKGROUND: The infrafloccular approach was introduced as a variation in microvascular decompression (MVD) for hemifacial spasm. However, the rate of postoperative lower cranial nerve (CN) palsy can be high. This study investigated the surgical factors in relation to the occurrence of postoperative lower CN palsy. METHODS: The case records of 103 patients who underwent MVD were reviewed. Dissection around the lower CNs to approach the root exit zone of CN VII was divided into two steps - incision of the rhomboid lip at the root of the lower CNs and separation of CN IX and flocculus/choroid plexus. The correlations of these steps and other characteristics to the occurrence of lower CN palsy were analyzed. RESULTS: Ten of the 103 patients suffered from postoperative transient lower CN palsy. The rhomboid lip was incised in 30 cases (29.1%), separation of CN IX and flocculus or choroid plexus was necessary in 24 cases (23.3%), and both steps were required in 7 cases (6.8%). The steps showed no correlation with postoperative lower CN palsy. Posterior inferior cerebellar artery (PICA) as the offending vessel was significantly correlated with postoperative lower CN palsy (P < 0.05). CONCLUSIONS: Our study showed that the offending PICA was the only significant factor for postoperative lower CN palsy. Therefore, correct dissection around the lower CNs, particularly for complicated PICA, is necessary to reduce the risk of postoperative lower CN palsy.

RESUMEN

We carried out a retrospective investigation on the effect of obesity on dexmedetomidine (DEX) requirements when administered with fentanyl (FEN) during mechanical ventilation after major surgeries. After Institutional Review Board approval, 14 obese patients with a body mass index (BMI) ≥ 30 kg/m(2) and the same number of non-obese patients with similar backgrounds to the obese patients were selected from medical records. Doses of DEX in the first 48 h or until the end of sedation or extubation were calculated for comparison. In addition to comparison of dosing between the groups, associations between total body weight (TBW), BMI, and lean body mass (LBM) values and doses of DEX (mcg/h), between BMI and various indices (i.e., amount per TBW per hour and amount per LBM per hour) of DEX doses, and between above indices of DEX and FEN doses were also examined. There were no significant differences in DEX dose indices between the groups. However, DEX requirements (mcg/h) were significantly increased with TBW (kg) (r = 0.51, P = 0.003), BMI (r = 0.49, P = 0.006) and LBM (kg) (r = 0.42, P = 0.02), which might have enhanced the DEX metabolism with physiological changes with obesity. These findings will be beneficial for future clinical pharmacological analysis of DEX.

Asunto(s)

RESUMEN

OBJECT: Amygdalohippocampectomy is a well-established, standard surgery for medically intractable mesial temporal lobe epilepsy (MTLE). However, in the case of MTLE without hippocampal atrophy or sclerosis, amygdalohippocampectomy is associated with decreased postoperative memory function. Hippocampal transection (HT) has been developed to overcome this problem. In HT the hippocampus is not removed; rather, the longitudinal hippocampal circuits of epileptic activities are disrupted by transection of the pyramidal layer of the hippocampus. The present study describes a less invasive modification of HT (transsylvian HT) and presents the seizure and memory outcomes for this procedure. METHODS: Thirty-seven patients with MTLE (18 men and 19 women; age range 9-63 years; 19 with surgery on the right side and 18 with surgery on the left side; seizure onset from 3 to 34 years) who were treated with transsylvian HT were retrospectively analyzed. All patients had left-side language dominance, and follow-up periods ranged from 12 to 94 months (median 49 months). Seizure outcomes were evaluated for all patients by using the Engel classification. Memory function was evaluated for 22 patients based on 3 indices (verbal memory, nonverbal memory, and delayed recall), with those scores obtained using the Wechsler Memory Scale-Revised. Patients underwent evaluation of the memory function before and after surgery (6 months-1 year). RESULTS: Engel Class I (completely seizure free) was achieved in 25 patients (67.6%). Class II and Class III designation was achieved in 10 (27%) and 2 patients (5.4%), respectively. There were differences in memory outcome between the sides of operation. On the right side, verbal memory significantly increased postoperatively (p = 0.003) but nonverbal memory and delayed recall showed no significant change after the operation (p = 0.718 and p = 0.210, respectively). On the left side, all 3 indices (verbal memory, nonverbal memory, and delayed recall) showed no significant change (p = 0.331, p = 0.458, and p = 0.366, respectively). CONCLUSIONS: Favorable seizure outcome and preservation of verbal memory were achieved with transsylvian HT for the treatment of MTLE without hippocampal atrophy or sclerosis.

Asunto(s)

RESUMEN

INTRODUCTION: We envisage the efficacy and safety of intra-arterial infusion of fasudil hydrochloride (IAF) for symptomatic vasospasm (SVS) after subarachnoid hemorrhage (SAH). We compared results obtained from the groups that received selective IAF (a microcatheter inserted in intracranial arteries) and nonselective IAF (a microcatheter inserted in the cervical arteries). Glasgow Outcome Scale (GOS) value and computed tomographic (CT) score were used to evaluate clinical outcome and the extent of infarction due to delayed vasospasm. MATERIAL AND METHODS: Over 2 years, 113 patients with SAH underwent clipping or coiling. Among them, 31 patients (27.4%) developed SVS. We performed nonselective IAF in 10 patients and selective IAF in 10 other patients. Eleven patients with SVS were treated without IAF. The data were statistically analyzed. RESULT: By univariate linear regression analysis, IAF negatively correlated with CT score (p = 0.016), but IAF was significantly correlated with GOS (p = 0.035). By multiple regression analysis, Hunt and Kosnik grade and CT score significantly correlated with GOS. DISCUSSION: CT score significantly correlated with functional outcome. Although IAF, both selective and nonselective, was significantly effective for the treatment of delayed vasospasm, the former seemed to be more beneficial.

Asunto(s)

Asunto(s)