NMC case report journal最新文献

The most frequent of the embryonic persistent arteries that connect the internal carotid artery to the posterior circulation is the persistent primitive trigeminal artery (PPTA), which is recognized on 0.1%-0.6% on the basis of conventional angiography or magnetic resonance imaging (MRI). It is usually asymptomatic; however, in rare cases, symptoms of cerebral neuropathy or vascular disease may take place. The patient was a 50-year-old woman who had a history of dyslipidemia and no history of trauma. After a visit to her local doctor, she was referred to us with complaints of mild headache and unilateral tinnitus. MRI revealed a cavernous sinus fistula. She had temporary symptom relief, but ipsilateral ocular symptoms appeared eventually and extended to the contralateral side. Through cerebral angiography, a direct cavernous sinus fistula due to a ruptured PPTA trunk aneurysm was revealed. Coil embolization was carried out via PPTA. The PPTA aneurysm was partially embolized from within the venous sinus using a fistula. The aneurysm and cavernous sinus fistula disappeared without transvenous embolization while preserving the PPTA. Although reports on the treatment of PPTA aneurysms have been numerous already, this report describes a unique case in which a ruptured spontaneous aneurysm on the PPTA trunk resulted in a cavernous sinus fistula, which was treated successfully.

Treating ruptured aneurysms in deep collateral arteries in moyamoya disease is difficult. Two cases of intracranial hemorrhage due to ruptured aneurysms in the deep collateral vessels after indirect revascularization for moyamoya disease were treated via direct surgery with the assistance of surgical simulation using three-dimensional computer graphics. The three-dimensional computer graphics provided detailed anatomical relationships between the aneurysm and the surrounding structures, which led to successful surgical results in both patients. Ruptured aneurysms in deep collateral vessels in moyamoya disease could be successfully treated via direct surgery with the assistance of surgical simulation through three-dimensional computer graphics.

A 74-year-old woman had a lacunar infarction in the brainstem and was admitted to Takeda General Hospital for treatment. She had significant sequelae and was discharged with a Modified Rankin Scale 0. Imaging follow-up was conducted every year after discharge on an outpatient basis. Seven years later, MRI of the head revealed a previous cerebral hemorrhage in the right basal ganglia. The imaging findings reveal that the patient was diagnosed with cerebral hemorrhage due to a cavernous malformation. The patient was asymptomatic, so imaging follow-up was continued, but the cavernous malformation grew in size over the next 8 years and caused three more hemorrhages. The last hemorrhage caused damage to the right extrapyramidal tract, which resulted in rapid cognitive decline and tremors of the left upper limb. To remove the cavernous malformation, a transsylvian-anterior transinsular approach was employed. Involuntary movements of the left upper limb disappeared postoperatively. A de novo cavernous malformation rarely grows to such a large size as it did in this case. A cavernous malformation in the basal ganglia must be carefully removed, ensuring that the perforating branches of the middle cerebral artery, which includes the lenticulostriate arteries, that may run along the borders of the mass are not damaged.

Isolated abducens nerve palsy (IANP), caused by secondary communicating hydrocephalus, has been rarely documented; in addition, its mechanism and appropriate treatment are not understood well. This study presents a case of bilateral IANP with hydrocephalus in a 62-year-old man who was successfully treated with cerebrospinal fluid (CSF) diversion to correct an enlarged retroclival space during the follow-up of recurrent brain tumor in the right parieto-occipital lobe. The patient was treated with three resections, temozolomide, and irradiation before developing IANP. Magnetic resonance imaging (MRI) revealed a recurrent tumor and ventriculomegaly with an expanded retroclival cisternal space. The patient underwent subtotal tumor resection and external ventricular drain placement in the anterior horn of the lateral ventricle. His bilateral IANP persisted for 4 days after surgery but gradually improved and disappeared by Day 7. Four weeks later, the patient underwent ventriculoperitoneal (VP) shunt surgery to establish a permanent CSF diversion that continued to control the symptoms. Retrospective MRI review revealed the distance between the clivus and pontomedullary junction on the sagittal section (retroclival-pontomedullary distance; RPD) of 9.0, 12.8, 10.7, and 10.6 mm before IANP, on IANP onset, on postoperative Day 4, and post VP shunt surgery, respectively. In conclusion, VP shunt surgery was an appropriate approach for IANP with communicating hydrocephalus to correct the enlarged retroclival cisternal space. RPD thus may be used as one of possible evaluation methods for IANP with hydrocephalus, which can be caused by various factors.

This study involved a 73-year-old man who underwent thalamotomy via magnetic resonance imaging (MRI)-guided, focused ultrasound surgery, in which the left thalamic ventral intermediate nucleus is targeted, as a treatment for action tremor of the right-hand fingers caused by essential tremor. Following treatment, the action tremor of the right-hand fingers mostly disappeared, but new symptoms of paresis and sensory impairment were evident in the left upper and lower limbs. Head MRI exhibited a hyperintense lesion on diffusion-weighted imaging and a decreased apparent diffusion coefficient in a region of the right thalamus following the anterior choroidal artery, medial posterior choroidal artery, and thalamogeniculate artery territory. Through an extensive literature search, only two reports of cavitation were found as a contributory cause of irreversible brain damage during focused ultrasound surgery, and both cases involved damage to the thalamus on the treated side. Along with a review of the literature on the mechanism of onset, a case of irreversible brain damage to the thalamus contralateral to the treated side is reported.

Aneurysms in the V1 segment of the extracranial vertebral artery are extremely rare. Furthermore, half of the cases are giant aneurysms larger than 25 mm. This study reports a case of unruptured giant V1 aneurysm of the right vertebral artery that was successfully treated with endovascular coil embolization. An 85-year-old woman experienced dizziness sporadically. Magnetic resonance imaging demonstrated a mass in the right subclavian region. Radiological examinations showed an aneurysm originating from the V1 segment of the right vertebral artery. The aneurysm was successfully embolized with platinum coils, with preserved patency of the vertebral artery. Although aneurysms in the V1 portion of the vertebral artery are extremely rare, there is a possibility of thrombosis or rupture. Endovascular treatment such as coil embolization may be effective for a V1 vertebral artery aneurysm.

Arachnoid cysts have the potential to rupture, leading to the development of a subdural hygroma following minor trauma. Although surgery may be considered in cases of increased intracranial pressure (ICP) or regional neurological symptoms, the optimal approach remains unclear. We report a case of subdural hygroma due to a ruptured arachnoid cyst (SHrAC) with elevated ICP successfully treated with long-term subdural drainage for over 1 month. A 26-year-old man with persistent headache was admitted to our hospital. Magnetic resonance imaging revealed an arachnoid cyst within the left middle cranial fossa and a subdural hygroma in the left frontotemporal region. He was referred to our neurosurgery department for surgical intervention due to elevated ICP. Although burr hole surgery was initially performed, subsequent recurrence of elevated ICP necessitated the insertion of a subdural peritoneal shunt. However, the shunt was then removed following the development of postoperative meningitis, and a subdural drain was placed to control ICP. Cerebrospinal fluid (CSF) drainage gradually decreased, and the elevated ICP improved. The subdural drain was removed approximately one and a half months after drain placement. The subdural hygroma progressively reduced and completely disappeared 4 months after drain removal. The gradual reduction in the pressure difference between the arachnoid cyst and the subdural hygroma due to long-term CSF drainage and inflammation caused by meningitis may have contributed to close arachnoid membrane laceration. Although alternative approaches, such as shunt insertion and basal fenestration, should always be considered in SHrAC treatment, long-term subdural drainage can be an option.

This detailed case report presents and discusses the endovascular treatment of a large proximal basilar artery fenestrated aneurysm (PBAFA). Aneurysms occur rarely at the vertebrobasilar junction, with a moderate proportion of cases presenting fenestrations. Considering the high risk associated with posterior circulation aneurysms, including estimated rupture risk, periprocedural complications, or treatment difficulties in surgical procedures, endovascular treatment options are becoming increasingly favored, particularly considering the advancements in stent and flow diverter techniques. Our report focuses on a case of a 58-year-old male with a large unruptured PBAFA, treated using overlapping stent with coil embolization (OSCE) and triple catheter technique. This method was selected considering the size of the aneurysm, its complex vascular structure, and the risk of recurrence and complications. Our findings emphasize that a comprehensive understanding of vascular anatomy, hemodynamics, and the characteristics of endovascular treatment devices is essential for the treatment success. In addition, they demonstrate that the OSCE using low-profile visible intraluminal support devices combined with the triple catheter technique are an effective treatment option for large PBAFAs.

Vascular Ehlers-Danlos syndrome (vEDS) is a rare disorder that is characterized by vascular lesions mainly caused by vascular fragility, such as spontaneous carotid-cavernous fistula (sCCF). We experienced a patient who presented with sCCF but suffered postoperative multiple vascular arteriopathy complications caused by undiagnosed vEDS. A 39-year-old woman who had no physical and medical characteristics indicating vEDS was referred to our hospital due to sudden onset of headache and pulsatile tinnitus. Digital subtraction angiography revealed direct sCCF of the left internal carotid artery. Internal trapping with coils was performed using the bilateral transfemoral artery approach, and complete occlusion of the high-flow fistula was achieved. At the end of the procedure, left femoral angiography via the sheath revealed extravasation from the puncture site. Hemostasis using an Angio-Seal hemostasis device under proximal balloon protection standby was immediately performed, and complete hemostasis was achieved. Postoperative abdominal computed tomography (CT) revealed a huge retroperitoneal hematoma. To improve the patient's hypovolemic shock conditions, hypervolemic therapy was administered, and her vital signs normalized. Approximately 10 days after the treatment, abdominal CT revealed pseudoaneurysm at the bilateral puncture sites and dissection of the left external iliac artery. Based on the clinical events, vEDS was strongly suspected. The genetic test revealed collagen type III alpha 1 chain gene abnormality, which led to a definite diagnosis. The symptoms improved, and follow-up CT showed spontaneous healing of both vascular arteriopathies with no recurrence. Attention should be paid to the risk of vascular arteriopathy complications during the perioperative period in patients with vEDS.

In endovascular therapy, the induction and stable placement of the guiding catheter (GC) are not only the initial steps but also crucial techniques influencing treatment success. However, in some cases, GC induction is challenging due to variations in the aortic arch or tortuosity of the blood vessels. In the present case, endovascular therapy was carried out for a ruptured aneurysm in the dorsal portion of the left internal carotid artery. However, conventional GC could not be induced because of the type III aortic arch and extremely steep angle. By switching to an α-shaped GC, employed in conjunction with a distal access catheter, we were able to reach the aneurysm with a microcatheter and successfully complete the treatment. The tip of the α-shaped GC was positioned in the ascending aorta and thus required various considerations in terms of setup and device selection when compared to conventional techniques. This is the first report of the use of this catheter for the acute treatment of ruptured cerebral aneurysms. In this report, we share our experience and the effectiveness of using this catheter while highlighting our considerations.