RESUMEN
Hemorrhagic pilocytic astrocytomas (PAs) are rare, accounting for 1.1%-8.0% of all PA cases. They are reported to occur more frequently in older populations, with a male predominance. In this study, we report a case of a 14-year-old boy who presented with a headache, vertigo, and diplopia. As per his brain computed tomography scan, a small hematoma was observed in the left inferior cerebellar peduncle. Follow-up magnetic resonance imaging (MRI) revealed repeated minor bleeding from the lesion and mild expansion, with no neurological deficits. Four years later, the patient developed nausea, vomiting, and left abducens palsy. MRI revealed a mulberry-shaped mass surrounded by a hypointense rim, suggesting a cavernous angioma. The lesion was surgically resected via midline occipital craniotomy with the opening of the cerebellomedullary fissure. Histopathological examination of the lesion revealed PA. Next-generation sequencing analyses revealed that PAs harbored mutations in the ARID1A, ATM, and POLE genes but not in the BRAF gene. To the best of our knowledge, there are yet no reported studies on these mutations in PAs to date. Thus, PA should be considered in the differential diagnosis of cerebellar hemorrhage, especially in young adults and childrenï¼.
RESUMEN
Keyhole surgery is partly replacing the standard pterional approach in patients undergoing surgery to treat aneurysms of the anterior circulation. We describe the pterional keyhole approach for the clipping of anterior circulation aneurysms and discuss the efficacy and safety of our keyhole craniotomy procedure. We treated 103 patients with 111 intracranial aneurysms by surgical clipping via the pterional keyhole approach and retrospectively compared the characteristics and clinical outcomes of the keyhole procedure and the standard pterional approach. We also compared the surgical results of the keyhole approach when the operator was an experienced neurosurgeon or a less experienced neurosurgeon guided by an experienced colleague. All keyhole operations were carried out successfully without enlargement of the craniotomy or a change to a different approach. The outcomes of the keyhole and the standard pterional approach in patients with subarachnoid hemorrhage were not significantly different. Favorable outcomes were obtained in patients with unruptured aneurysms treated by either experienced or less experienced surgeons. The pterional keyhole approach offers the same surgical possibilities as conventional pterional approaches for the treatment of anterior circulation aneurysms. It is safe and simple and yields favorable outcomes even if the operators are less experienced neurosurgeons. Careful patient selection and sufficient opening of the sylvian fissure are the key points for good outcomes and the prevention of intraoperative complications.
Asunto(s)
Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Neuroquirúrgicos/métodos , Anciano , Aneurisma Roto/cirugía , Angiografía Cerebral , Craneotomía , Femenino , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Minimized frontal and frontolateral approaches have been proposed for the clipping of aneurysms and for removal of deep-seated supra- and parasellar lesions. To avoid postoperative facial nerve palsy, anatomical studies have been conducted; however, only one electrophysiological investigation has been reported. We studied the course of the facial nerve in the temporal region and identify the optimal pterional keyhole craniotomy from the perspective of facial nerve protection. MATERIALS AND METHODS: We stimulated the temporal branch of the facial nerve in nine healthy volunteers and identified its course electrophysiologically. Electromyographic (EMG) responses were recorded from the superior orbicularis oculi, corrugator, and frontal muscles. The course of the temporal branch of the facial nerve was identified by tracking the stimulation points that elicited the best EMG responses. RESULTS AND CONCLUSION: The distances from the tragus to the canthus, the tragus to the point where the facial nerve crosses over the zygomatic arch, the tragus to the first nerve bifurcation, the tragus to the second nerve bifurcation, and from the orbit to the middle rami were 80.8 ± 1.8 mm, 40.2 ± 1.6 mm, 58.1 ± 2.8 mm, 79.1 ± 3.4 mm, and 16.4 ± 0.9 mm, respectively. We found that the temporal branch of the facial nerve innervates each muscle in posterior-anterior direction. Based on these results, we prefer the pterional keyhole approach and incise the skin at a site posterior to the temporal branch of the facial nerve.
Asunto(s)
Músculos Faciales/fisiología , Nervio Facial/fisiología , Adulto , Electromiografía , Electrofisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
Aneurysms located at the distal portion of the posterior inferior cerebellar artery (PICA) are rare, and their clinical features are not fully understood. We report the clinical features and management of 30 distal PICA aneurysms in 28 patients treated during the past decade at Kagoshima University Hospital and affiliated hospitals. Our series includes 20 women and eight men. Of their 30 aneurysms, 24 were ruptured, and six were unruptured; there were 27 saccular and two fusiform aneurysms; one was dissecting. Their location was at the anterior-medullary (n = 4), lateral-medullary (n = 9), tonsillomedullary (n = 7), telovelotonsillar (n = 6), and cortical (n = 4) segment of the PICA. In 18 patients, angiographic features suggested hemodynamic stress including an absent contralateral PICA or ipsilateral anterior inferior cerebellar artery, termination of the vertebral artery (VA) at the PICA, and hyperplasia or occlusion of the contralateral VA. As three patients died before surgery, 27 aneurysms in 25 patients were surgically treated. Of these, 6 were unruptured aneurysms; 20 were clipped via midline or lateral suboccipital craniotomy, and 5 were embolized with Guglielmi coils; in one, the PICA flow was reconstructed by OA-PICA anastomosis, and in the other one, the PICA was resected. Of the 25 surgically treated patients, 22 (88%) had good outcomes. The predominant contributor to the development of distal PICA aneurysms is thought to be increased hemodynamic stress attributable to anomalies in the PICA and related posterior circulation. Both direct clipping and coil embolization yielded favorable outcomes in our series. However, considering the difficulties that may be encountered at direct clipping in the acute stage and the availability of advanced techniques and instrumentation, aneurysmal coiling is now the first option to address these aneurysms.
Asunto(s)
Enfermedades Cerebelosas/diagnóstico , Enfermedades Cerebelosas/terapia , Arterias Cerebrales/patología , Aneurisma Intracraneal/diagnóstico , Aneurisma Intracraneal/terapia , Adolescente , Adulto , Anciano , Angiografía Cerebral , Circulación Cerebrovascular , Femenino , Cefalea/etiología , Humanos , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Náusea/etiología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Trastornos de la Visión/etiologíaRESUMEN
A mother and daughter presented with a rare combination of moyamoya disease and Graves' disease. A 19-year-old woman experienced numbness in her right hand due to cerebral infarction during therapy for Graves' disease. Cerebral angiography demonstrated stenoses of the bilateral internal carotid arteries and net-like abnormal collateral vessels indicative of moyamoya disease. Her 52-year-old mother with a history of Graves' disease presented with left hemiparesis due to intracerebral hemorrhage; she recovered after hematoma evacuation. Postoperative angiography demonstrated stenoses of the bilateral internal carotid arteries and net-like abnormal collateral vessels indicative of moyamoya disease. Another otherwise healthy daughter manifested slight stenosis of the left internal carotid artery. After cerebral revascularization surgery the patients were able to return to their normal daily lives. These familial cases of moyamoya disease and Graves' disease indicate hereditary involvement in both diseases.
Asunto(s)
Infarto Cerebral/etiología , Enfermedad de Graves/complicaciones , Hemorragias Intracraneales/etiología , Enfermedad de Moyamoya/genética , Angiografía Cerebral , Infarto Cerebral/terapia , Revascularización Cerebral , Femenino , Enfermedad de Graves/terapia , Humanos , Hemorragias Intracraneales/terapia , Persona de Mediana Edad , Enfermedad de Moyamoya/complicaciones , Enfermedad de Moyamoya/diagnóstico , Linaje , Resultado del Tratamiento , Adulto JovenRESUMEN
The efficacy and safety of cerebellar hemorrhage evacuation by key hole craniotomy and the importance of thorough evacuation and irrigation of the hematoma in the fourth ventricle to resolve obstructive hydrocephalus were assessed in 23 patients with spontaneous cerebellar hemorrhage (SCH) greater than 3 cm or with brainstem compression and hydrocephalus. A 5-cm elongated S-shaped scalp incision was made, and a 3-cm key hole craniotomy was performed over a cerebellar convexity area. The hematoma was immediately evacuated through a small corticotomy. The hematoma in the fourth ventricle was gently removed through the hematoma cavity, followed by thorough saline irrigation to release obstructive hydrocephalus. Patients classified retrospectively into favorable and poor outcome groups using the Glasgow Outcome Scale (GOS) scores of 4-5 vs. 1-3 showed significant differences with respect to the preoperative Glasgow Coma Scale, hematoma size and volume, and brainstem compression. Only 2 of the 23 patients required ventricular drainage and no postoperative complications were recorded. Patients treated by experienced and inexperienced surgeons showed no significant differences in the hematoma evacuation rate, postoperative GOS, and interval from skin incision to start of hematoma evacuation. Our simplified method of key hole craniotomy to treat SCH was less invasive but easy to perform, as even inexperienced neurosurgeons could obtain good surgical results. Thorough cleaning of the fourth ventricle minimized the necessity for ventricular drainage.
Asunto(s)
Enfermedades Cerebelosas/cirugía , Craneotomía/métodos , Hematoma/cirugía , Hidrocefalia/prevención & control , Hemorragias Intracraneales/cirugía , Anciano , Tronco Encefálico/irrigación sanguínea , Tronco Encefálico/patología , Enfermedades Cerebelosas/etiología , Cerebelo/irrigación sanguínea , Cerebelo/patología , Descompresión Quirúrgica , Femenino , Cuarto Ventrículo/irrigación sanguínea , Cuarto Ventrículo/cirugía , Escala de Coma de Glasgow , Hematoma/complicaciones , Hematoma/patología , Humanos , Hidrocefalia/etiología , Hidrocefalia/cirugía , Hemorragias Intracraneales/complicaciones , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estadísticas no Paramétricas , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Based on a series of 632 patients who underwent craniotomy without head shaving, we report the efficacy and safety of our simplified procedure and document the usefulness of the electrosurgical scalpel. METHODS: After brushing a chlorhexidine-alcohol solution onto the craniotomy site, the hair was parted from the incision line and fixed with adhesive paper drapes. In recent cases, electrosurgical scalpels were used for scalp- and subcutaneous dissection. At the end of surgery, the wound was closed in the usual manner, taking care that no hair was in the wound and the hair and wound were rinsed with clean water in the operating room. We did not apply disinfectant for postoperative wound care, rather, the hair was shampooed on the 2nd, 4th, and 6th postoperative day. RESULTS: Among 632 patients who underwent cranial surgery without head shaving, only 7 (1.1%) developed postoperative wound infections. None of the 34 patients who underwent craniotomy using the electrosurgical scalpel developed wound infections. CONCLUSIONS: Our simplified cranial surgery without head shaving does not increase the risk of wound infection. Because the use of the electrosurgical scalpel for skin and soft tissue dissection minimizes bleeding, the probability of wound infection appears to be reduced.
Asunto(s)
Craneotomía/métodos , Cabello , Anciano , Antiinfecciosos Locales/uso terapéutico , Clorhexidina/uso terapéutico , Electrocirugia , Etanol/uso terapéutico , Estudios de Seguimiento , Preparaciones para el Cabello , Remoción del Cabello , Hematoma/cirugía , Hematoma Subdural/cirugía , Humanos , Estudios Retrospectivos , Seguridad , Neoplasias Craneales/cirugía , Cinta Quirúrgica , Infección de la Herida Quirúrgica/etiología , Técnicas de Sutura , Resultado del TratamientoRESUMEN
Revisible posterior leukoencephalopathy syndrome (RPLS) is a syndrome defined predominantly by a characteristic pattern of MR images but heterogeneity and reversibility of the abnormalities is unclear. Three patients with characteristic neuroimaging of RPLS are described. Case 1. A 29-year-old woman underwent cesarean section 3 days before developing headache, visual disturbance, mild conscious deterioration and increased blood pressure. MRI on admission showed predominantly white matter edema bilaterally affecting the occipital, temporal and posterior parietal lobes. Lesions were iso-, hypointense on T1 weighted and hyperintense on T2 weighted and fluid-attenuated inversion recovery (FLAIR) images. Diffusion-weighted image (DWI) did not demonstrate hyperintensity in the same regions. She responded well to initial treatment and showed complete recovery. Case 2. A 67-year-old man had headache and visual disturbance after thromboendarterectomy of the left femoral artery. Initial DWI demonstrated hyperintensity in the occipital lobe. The patient had visual abnormality at discharge. Case 3. A 40-year-old woman with early gastric cancer had headache immediately after the injection of contrast material during abdominal computed tomography (CT) examination followed by generalized convulsion. On the third day, she had severe headache and vomiting. Her consciousness deteriorated to lethargy. CT showed marked brain edema, intracerebral hemorrhage, thin subdural hematoma and midline shift. External decompression and hematoma evacuation was performed. She had left hemianopia and left hemiplegia 1 month later. This report has important implications concerning the accurate early diagnosis of RPLS using MRI including DWI and its utility in prompting initial treatment. It should be noted that some cases demonstrating the characteristic neuroimaging pattern of RPLS do not attain full recovery and that surgical intervention is required in some cases.
Asunto(s)
Imagen por Resonancia Magnética , Síndrome de Leucoencefalopatía Posterior/diagnóstico , Adulto , Anciano , Encéfalo/diagnóstico por imagen , Encéfalo/patología , Imagen de Difusión por Resonancia Magnética , Femenino , Humanos , Masculino , Síndrome de Leucoencefalopatía Posterior/diagnóstico por imagen , Síndrome de Leucoencefalopatía Posterior/patología , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND AND OBJECTIVE: Microbleeds on T2*-weighted magnetic resonance imaging (MRI) represent a hemorrhagic type of small vessel disease. Small vessel disease causes both intracerebral hemorrhages and lacunar infarctions. We studied clinical background and MRI findings of the patients to clarify the correlation between microbleeds and lacunes. METHOD: This study consisted of 180 consecutive patients who underwent brain MRI using 1.5T system in our hospital for a year. We obtained T2*-weighted gradient-echo imaging as well as T1 and T2-weighted images. We statistically identified the factors related to the presence of microbleeds in all patients. The distribution of lacunes and microbleeds on MRI was compared to clarify the correlation of the lesions in the patients who had both lesions. RESULT: The overall prevalence of microbleeds was 41.1% (74 of 180 patients). Logistic regression analysis indicated that previous stroke, leukoaraiosis and lacunes were significantly correlated with microbleeds. In the patients who have both microbleeds and lacunes, lesions are tended to locate in thalamus and basal ganglia, especially incidence of lacunes are significantly greater compared with other regions. Thirty-six of 398 lesions (9.05%) diagnosed as lacunes with T1- and T2-weighted imaging were demonstrated as microbleeds with T2*-weighted gradient-echo imaging. CONCLUSION: Lacunes, leukoaraiosis as a hypertensive change on MRI had statistically significant correlation with the presence of microbleeds. T2*-weighted gradient-echo imaging should be included in the imaging protocol for cerebrovascular disease, because T1- and T2-weighted imaging recognizing some of the microbleeds as lacunar infarction.
Asunto(s)
Infarto Encefálico/patología , Hemorragia Cerebral/patología , Imagen por Resonancia Magnética , Anciano , Anciano de 80 o más Años , Imagen Eco-Planar , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The incidence and characteristics of microbleeds in hemodialysis (HD) patients were investigated to elucidate the clinical significance with T(2)(*)-weighted gradient-echo magnetic resonance (MR) imaging. The 57 patients with chronic renal failure maintained by HD had no previous history of stroke. The control group consisted of 53 patients without previous history of stroke or chronic renal failure. The incidence and the number of microbleeds were assessed in the HD and control groups. The findings of microbleeds with T(2)(*)-weighted gradient-echo MR imaging were compared with those of T(1)- and T(2)-weighted MR imaging in HD patients. The incidence of microbleeds was significantly greater in the HD patients compared with the control patients. T(2)(*)-weighted gradient-echo imaging revealed a total of 44 microbleeds in 11 HD patients. T(2)-weighted imaging demonstrated 13 of 44 microbleeds as hyperintensity, whereas T(1)-weighted imaging demonstrated 12 lesions as hypointensity. T(2)- and T(1)-weighted imagings did not demonstrate any findings in 31 and 32 lesions, respectively. T(2)(*)-weighted gradient-echo MR imaging is effective to detect microbleeds which may be a predictor of intracerebral hemorrhage in HD patients and should be included in the protocol for the study of cerebrovascular disease, because T(2)- and T(1)-weighted MR imaging recognizes microbleeds as lacunar infarction.
Asunto(s)
Hemorragia Cerebral/epidemiología , Diálisis Renal , Anciano , Hemorragia Cerebral/diagnóstico , Imagen Eco-Planar , Femenino , Humanos , Incidencia , Fallo Renal Crónico/terapia , Masculino , Microcirculación , Persona de Mediana EdadRESUMEN
Hypophysitis is an inflammatory disease of the pituitary gland that clinically and radiologically mimics pituitary tumors. We report here a case of xanthogranulomatous hypophysitis mimicking a pituitary neoplasm.A 65-yr-old woman presented with weight loss, fatigue, and visual disturbance. Computed tomography demonstrated a round cystic low-density mass with calcification in the sella. A T1-weighted magnetic resonance imaging scan showed most of the mass as hyperintense. The capsule of the mass was strongly enhanced by gadolinium. Endocrinologic examination revealed hypocorticism and hypothyroidism. Diabetes insipidus (DI) developed after the administration of hydrocortisone. The patient also had hallucination and delusions of persecution. Transsphenoidal surgery was performed. Histologic examination of the removed tissue showed central necrosis surrounded by accumulation of foamy cells and epithelioid cells. Several multinucleated giant cells were also seen. The foamy cells and epithelioid cells were immunopositive for Kp-1, a marker of macrophages. The patient made an uneventful postoperative recovery. Although DI and hypofunction of adenohypophysis persisted, the visual disturbance and psychiatric disorder were resolved. We have described an unusual inflammatory lesion of the pituitary in the sellar region that was mimicking neoplasm. A high level of clinical suspicion of inflammatory disorders is necessary for correct diagnosis and optimal management.