NMC case report journal最新文献

Congenital hydrocephalus manifesting in old age is exceptionally rare. We present a case of hydrocephalus in an older woman, where congenital hydrocephalus was suggested following a thalamic hemorrhage. A woman in her 90s gradually developed gait and cognitive impairments. Eight months before her admission, she suffered a thalamic hemorrhage, after which she became bedridden and was transferred to our hospital following impaired consciousness from asphyxiation. Upon admission, her Japan Coma Scale score was 200. A head computed tomography scan revealed significant ventricular enlargement. A tap test was conducted to diagnose normal pressure hydrocephalus, resulting in a slight improvement in her Japan Coma Scale score to 20. Consequently, a ventriculoperitoneal shunt was performed. Two weeks after the ventriculoperitoneal shunt, her consciousness improved to a Japan Coma Scale score of 2, and she resumed oral intake. Two months after the surgery, head magnetic resonance imaging revealed tetraventriculomegaly, an open aqueduct, a wide foramen of Magendie, and a large cisterna magna. These findings raised the suspicion of previously undetected congenital hydrocephalus, exacerbated by panventriculomegaly with a wide foramen of Magendie and a large cisterna magna, revealed after the thalamic hemorrhage. At the final evaluation, she required only minimal assistance with oral intake, showing significant improvement not only compared with her condition before the ventriculoperitoneal shunt procedure but also to her state before the thalamic hemorrhage.

A man in his 60s was referred to our hospital due to a large basilar artery aneurysm incidentally detected 12 years before. Cerebral angiography revealed the basilar artery aneurysm and another 2 aneurysms at the left middle cerebral artery. Coil embolization was performed for the basilar artery aneurysm, and the middle cerebral artery aneurysms were to be monitored because of their small size. The middle cerebral artery aneurysms had enlarged on magnetic resonance imaging over 8 years, and therefore we recommended surgery. Clipping was performed 4 years after the recommendation and intraoperative findings revealed that there were 3 aneurysms at the left middle cerebral artery, one of which closest to the M2 superior trunk harbored an entirely sclerosed dome wherein no blood inflow was observed. Rather than simple growth of the 2 middle cerebral artery aneurysms initially found 12 years before, it appeared that one of the 2 middle cerebral artery aneurysms had spontaneously occluded, and another had been newly formed and enlarged. Spontaneous occlusion of small, unruptured saccular, intracranial aneurysms is rare, and just 10 cases have been reported in the literature. To the best of our knowledge, this is the first report in which the spontaneous occlusion of such an aneurysm was directly observed during microscopic surgery.

We report a case of syringomyelia in a 55-year-old man with a unique obstruction of Magendie's foramen. Spinal magnetic resonance imaging revealed a large syrinx extending from C1 to C3, with intermittent syringomyelia extending down to Th11. While the obstruction was not clearly evident on T2-weighted imaging, three-dimensional constructive interference in steady-state imaging demonstrated a thickened membranous tissue blocking the cerebrospinal fluid outlet, leading to syrinx formation. Surgical intervention, involving the resection of the thickened membrane to open the foramen of Magendie, resulted in considerable improvement in the syringomyelia and neurological symptoms. Histopathological examination revealed gliomesenchymal tissue, suggesting an embryonic origin of the obstruction. This case highlights the importance of detailed imaging, particularly three-dimensional constructive interference in steady-state sequence, in diagnosing foramen of Magendie obstruction and the potential for successful surgical treatment in selected cases. Histopathological examination is crucial for differentiating gliomesenchymal tissue from adhesive arachnoiditis.

Spontaneous spinal epidural hematoma is a clinical entity as a hematoma occurring in the spinal epidural space with unknown etiology. It is known to sometimes show spontaneous regression, and recurrence is rare and repeating even rarer. We had an experience of repeated recurrent spontaneous spinal epidural hematoma, eventually leading to surgery. A 25-year-old man, a habitual exerciser of strength training, had a sudden onset of cervical back pain during sleep the same night after training. Radiological examinations revealed a cervical epidural hematoma but no vascular anomalies, and the patient's symptoms and the hematoma resolved rapidly and spontaneously in a day. Within 2.5 years, he had another three more similar hemorrhagic episodes with rapid and spontaneous resolution. On the 5th episode, the patient underwent surgical treatment with removal of the epidural tissue and packing of the epidural space. The pathological diagnosis was only the normal connective tissue and veins. He has had no recurrence in the 1.5 years after surgery with the same strength training as before. The appropriate timing and method of treatment for recurrent spontaneous spinal epidural hematoma with rapid resolution is still under debate, but surgery should be considered if there are multiple recurrences. It is important to collapse the epidural space with packing to prevent further recurrence.

A 79-year-old man presented with progressive ptosis, diplopia, and headaches, which led to the diagnosis of a rare primary malignant melanoma of the sphenoid sinus. Imaging revealed extensive bone destruction and aggressive tumor behavior. The rarity of primary malignant melanoma in the sphenoid sinus complicates early detection. Despite undergoing surgical decompression, immunotherapy, and radiation therapy, the tumor rapidly recurred, necessitating supportive care. This case highlights the need for neurosurgeons to include primary malignant melanoma in the differential diagnosis of skull base tumors, particularly in the sphenoid sinus, due to its potential for aggressive local invasion and significant impact on critical neurovascular structures. Early recognition and intervention are crucial for managing this rare and aggressive malignancy effectively.

Hydrocephalus following Gamma Knife surgery for vestibular schwannoma is typically treated with cerebrospinal fluid diversion. However, additional cerebrospinal fluid diversion (shunt placement) causes a lifelong risk of shunt malfunction and infection. We report two cases of vestibular schwannoma in which the hydrocephalus with progressive tumor growth after Gamma Knife surgery was treated by an initial tumor removal, resolving hydrocephalus without cerebrospinal fluid diversion and causing long-term tumor control. Patient 1 underwent Gamma Knife surgery for a 22-mm tumor vestibular schwannoma of Koos grade III and developed symptomatic hydrocephalus with progressive tumor growth. Tumor removal at 17 months after Gamma Knife surgery resolved the hydrocephalus without tumor recurrence 8 years after surgery. Patient 2 underwent Gamma Knife surgery for an 18-mm tumor vestibular schwannoma of Koos grade IV and developed rapid tumor growth and symptomatic hydrocephalus 2 years after Gamma Knife surgery. Patient 2 underwent subtotal tumor removal at 40 months after Gamma Knife surgery resolving hydrocephalus without residual tumor progression at 14 years after Gamma Knife surgery. Subtotal tumor removal may be a primary treatment option in patients with vestibular schwannoma treated with Gamma Knife surgery and developing hydrocephalus with tumor progression. This might help avoid cerebrospinal fluid diversion with long-term tumor control.

Rheumatoid meningitis is a rare central neurological complication associated with rheumatoid arthritis. We report an unusual case of rheumatoid meningitis presenting with clinical and radiological findings resembling subarachnoid hemorrhage, with no history of rheumatoid arthritis diagnosis and negative serum rheumatoid factor. A woman in her fifties presented with a severe headache and loss of consciousness. Magnetic resonance imaging suggested subarachnoid hemorrhage involving the interhemispheric fissure and adjacent bilateral cerebral sulci. Cerebral angiography did not reveal any vascular abnormalities, and an initial diagnosis of subarachnoid hemorrhage of unknown etiology was made. Follow-up magnetic resonance imaging failed to identify a source of bleeding, evidence of hematoma resolution, or new vascular lesions. Although she had a family history of rheumatoid arthritis, she had no formal rheumatoid arthritis diagnosis, and serum rheumatoid factor tests were negative. Contrast-enhanced magnetic resonance imaging showed leptomeningeal thickening along the falx cerebri, raising suspicion of an inflammatory condition such as meningitis. Her symptoms progressively worsened, and on day 16, a meningeal biopsy was performed. Histopathological examination confirmed meningitis and subsequent blood tests revealed positive anticyclic citrullinated peptide antibodies. A comprehensive evaluation ultimately led to the diagnosis of rheumatoid meningitis. This case highlights that rheumatoid meningitis can mimic the clinical and imaging findings of subarachnoid hemorrhage, even in patients without a prior rheumatoid arthritis diagnosis or with negative serum rheumatoid factor. Furthermore, rheumatoid meningitis may show progressive deterioration, emphasizing the importance of early meningeal biopsy during the acute phase for accurate diagnosis and improved prognosis. Clinicians should closely monitor changes in clinical and radiological findings and consider early biopsy in such cases.

Partially thrombosed and dissecting giant peripheral aneurysms present significant challenges for treatment with both direct surgical and endovascular approaches. We report a case of partially thrombosed, dissecting giant aneurysm in the peripheral segment of the middle cerebral artery treated with straightforward endovascular parent artery occlusion without saccular packing. A 30-year-old male presented with sudden loss of consciousness and subarachnoid hemorrhage and was transferred to our hospital. On admission, his level of consciousness was assessed as Japan Coma Scale 100 and Glasgow Coma Scale 8 (E1V2M5), with severe paralysis of the right upper and lower limbs. Computed tomography and magnetic resonance imaging demonstrated a partially thrombosed middle cerebral artery aneurysm with a maximum diameter of 31 mm at the M2 non-branching segment of the left middle cerebral artery mid-trunk. Cerebral angiography indicated potential collateral circulation, no retrograde opacification of the aneurysm, and absence of perforating branches near the lesion, so we selected endovascular parent artery occlusion that targeted only the proximal portion of the aneurysm. Postoperative care focused on managing intracranial pressure and overall systemic management. The patient recovered without significant infarction and was discharged home with a modified Rankin Scale score of 1 4 months after the onset. In general, peripheral aneurysms are less likely to cause perforator infarcts, and larger aneurysms are more tolerant of parent artery occlusion. Therefore, simple endovascular parent artery occlusion targeting only the proximal portion of the aneurysm offers both anatomical and pathophysiological advantages and provides a viable option when direct surgery is challenging.

Variations in the posterior inferior cerebellar artery are well-documented. However, bilateral posterior inferior cerebellar artery originating from the posterior meningeal artery is extremely rare, and no such cases have been previously reported. Anastomosis between the anterior inferior cerebellar artery and posterior inferior cerebellar artery is a rare arterial anomaly that may arise due to remnants of the primitive lateral basilovertebral anastomosis during embryonic development. A 61-year-old male presented with headache, vomiting, and left lower extremity ataxia. Brain magnetic resonance imaging revealed an acute infarction in the left medulla, and magnetic resonance angiography suggested a dissection of the left vertebral artery. Digital subtraction angiography revealed the posterior meningeal artery originating from the extracranial vertebral artery, supplying the bilateral posterior inferior cerebellar artery hemispheric branches. The original posterior inferior cerebellar artery from the distal vertebral artery supplied only the cerebellar vermis. Additionally, an anterior inferior cerebellar artery-posterior inferior cerebellar artery anastomosis was observed on the left side. This case highlights two rare arterial anomalies: bilateral posterior inferior cerebellar artery hemispheric branches originating from the posterior meningeal artery and an anterior inferior cerebellar artery-posterior inferior cerebellar artery anastomosis, offering insights into the embryologic development and unique vascular structures involved.

Intracranial solitary fibrous tumor is a rare tumor accounting for 0.4% of intracranial tumors, with a high local recurrence rate and a tendency toward metastasis outside the central nervous system. We experienced a case of distant metastasis to the soft tissues and the kidney without local recurrence after gross total resection of the primary intracranial tumor. A 58-year-old male with cognitive impairment and right hemianopsia had a tumor of 5 cm maximum diameter in the left occipitotemporal convexity. Magnetic resonance imaging examinations showed a tumor with a slightly high signal on T1-weighted images, a low signal on T2-weighted images, and uniform and prominent contrast-enhanced images. Intratumoral flow voids were markedly observed. A head computed tomography performed 3 years earlier showed no mass lesions in the same region. Following tumor embolization, a gross total tumor resection was performed. The pathological diagnosis was grade-1 solitary fibrous tumor according to the 2021 World Health Organization central nervous system 5 criteria. A total of 45 Gy of postoperative local radiation therapy was administered. The patient recovered from his cognitive impairment and his right hemianopsia also improved. Although subsequent imaging studies showed no local recurrence, over 8 years after surgery, distant metastases were found in the subcutaneous soft tissue of the medial right femur and the left kidney, all of which were surgically removed. In a literature review, we identified 213 cases of intracranial solitary fibrous tumor having distant metastases with or without local recurrence from 18 reports and found that ours was the ninth case of distant metastasis despite gross total resection without local recurrence.