NMC Case Report Journal最新文献

Pituitary gamma knife surgery (GKS) is a treatment option for poststroke thalamic pain syndrome. Complications such as hypopituitarism, transient enuresis, and transient hyponatremia have been reported. However, cerebrospinal fluid (CSF) leakage has not yet been reported as a complication of pituitary GKS for poststroke thalamic pain syndrome. Herein, we report a case of delayed CSF rhinorrhea that developed 9 years after GKS for poststroke thalamic pain syndrome. A 64-year-old man presented to our hospital with bacterial meningitis and CSF rhinorrhea. Pituitary GKS for poststroke thalamic pain had been performed 9 years prior to his admission to our hospital. Computed tomography revealed pneumocephalus, fluid in the sphenoid and maxillary sinuses, and a partial bony defect of the sella turcica floor with communication between the paranasal and intracranial spaces. The CSF rhinorrhea resolved with bed rest and a lumbar CSF drain but recurred several days later. The patient underwent direct endoscopic surgical repair of the skull base. The sellar floor was covered with an autologous fascia graft harvested from the rectus sheath, and the sphenoid sinus was packed with abdominal fat grafts. The patient recovered, and the CSF rhinorrhea has not recurred for 2 years. Long-term follow-up is necessary after pituitary GKS, considering the complication of delayed CSF leakage.

Internal carotid artery aplasia or hypoplasia above the cervical bifurcation is rare, occurring in less than 0.01% of the general population. Unilateral neurocristopathy complicated by unilateral internal carotid artery agenesis or hypogenesis has been reported, but bilateral internal carotid artery hypoplasia is rare and scarcely reported. Herein, we report a novel case of Treacher Collins syndrome complicated by bilateral internal carotid artery hypoplasia. A 94-year-old woman presented with complaints of headache and vomiting. Computed tomography revealed a subarachnoid hemorrhage and dysplasia of the bilateral zygoma, mandible, and external auditory meatus. The patient had severe hearing loss and visual impairment. Computed tomography angiography revealed bilateral internal carotid artery hypoplasia and multiple aneurysmal changes in the intracranial arteries. We diagnosed the patient with a ruptured anterior inferior cerebellar artery aneurysm and performed coil embolization. The patient's unique facial features were consistent with neurocristopathy, especially Treacher Collins syndrome. Developmental anomalies of neural crest cells can present as vascular abnormalities and craniofacial malformations. Special care is required for endovascular treatment and airway management in cases of neurocristopathy because of the specific craniofacial anomalies.

We report a rare case of isolated internal carotid artery occlusion complicated by central retinal artery occlusion that was successfully treated with mechanical thrombectomy for internal carotid artery occlusion. A 59-year-old man visited the emergency room because of right monocular blindness. Magnetic resonance imaging showed multiple acute small embolic infarctions in the right frontal lobe, and magnetic resonance angiography revealed right internal carotid artery occlusion without the associated occlusion of the circle of Willis, which indicates the patency of the anterior and middle cerebral arteries. An electrocardiogram showed atrial fibrillation. Therefore, we performed mechanical thrombectomy with a stent retriever under continuous manual aspiration with a balloon-guiding catheter and confirmed complete recanalization, anterograde flow in the right ophthalmic artery, and retinal brush. The procedure was completed without complications, and the patient noticed an improvement in visual acuity immediately after the procedure. When a patient with atrial fibrillation complains of monocular blindness, it is important to consider internal carotid artery occlusion due to cardioembolism, to perform an examination promptly, and to consider early treatment, including mechanical thrombectomy.

Syringomyelia is often associated with Chiari malformation, trauma, infection, and spinal cord tumor. Although they are relatively rare diseases, arachnoid cysts and its related pathology, "arachnoid web" can sometimes lead to syrinx formation at the thoracic vertebral level. However, syrinx formation caused by degenerative spinal disorders, particularly at the thoracic vertebral levels, has rarely been reported. Herein, we present a case of syringomyelia with thoracic ossified yellow ligament (OYL) in a 79-year-old man, who underwent initial posterior decompression followed by arachnoid web removal. Posterior decompression via laminectomy of thoracic vertebra 2 and removal of the OYL improved the syrinx partially, but dorsal indentation of the spinal cord and a remnant syrinx were observed in post-operative magnetic resonance images, subsequent to the second surgery's successful removal of the arachnoid web, which had dorsally compressed the spinal cord. After the second operation, the syrinx shrunk further, and the patient could walk independently at 5 months after the operations. In our case, both the OYL and arachnoid web were responsible for syrinx formation. Therefore, the coincidence of degenerative vertebral diseases with a syrinx might indicate the coexistence of an underlying lesion. Furthermore, the arachnoid web in this case might have formed due to the denaturation of the arachnoid cyst triggered by the OYL.

[This corrects the article DOI: 10.2176/jns-nmc.2022-0017.].

Cerebral edema around the lead has been reported as a complication of deep brain stimulation; however, the causes remain unknown. Herein, we present a rare case of sudden cerebral edema around the lead occurring after deep brain stimulation. This was accompanied by cerebrospinal fluid (CSF) leakage into the subcutaneous thoracic pocket around the implantable pulse generator in a 53-year-old man with Parkinson's disease. No such case has been reported thus far. Lumbar drainage was performed to improve CSF leakage. The cerebral edema initially responded to steroids, but then it stopped responding to treatment. The edema appeared alternately on the left and right sides, and cyst formation was noted around the left lead. There are some reports of cyst formation around the lead; however, in our case, images were used to monitor the edema and cyst from their appearance to their disappearance. Our data suggest that cyst formation and cerebral edema are related.

A 72-year-old man who had undergone a lumboperitoneal shunt for idiopathic normal pressure hydrocephalus was admitted to our emergency department with fever and disturbance of consciousness 8 days after placement. Computed tomography scan showed pneumocephalus and a right-sided temporal porencephalic cyst with a small bone defect in the right petrous bone. Shunt valve pressure was raised from 145 mmH₂O to "virtual off" setting. After 2 weeks, follow-up computed tomography showed improvement of pneumocephalus, and the shunt valve pressure was lowered to 215 mmH₂O. Since that time, the patient has a good clinical course without recurrence. Tension pneumocephalus following shunt placement for idiopathic normal pressure hydrocephalus is rare and has never been reported in the early postoperative stage after lumboperitoneal shunt, except for the present one. Temporary raising shunt valve pressure is effective in improving the pneumocephalus. Preoperative screening for congenital bone defects by thin-slice computed tomography may be useful for selecting types of shunt valve and determining postoperative pressure setting.

Spinal cord parenchymal lesions may induce intractable neuropathic pain. However, the efficacy of conventional spinal cord stimulation for the neuropathic pain following spinal cord lesions remains to be controversial. In this study, we present three cases of spinal cord stimulation using a paddle lead at the rostral side of the spinal lesion causing pain symptoms. Good pain reductions were achieved using conventional stimulation in one case and using differential target multiplexed stimulation in two cases. Case 1: A 55-year-old man presented with neuropathic pain affecting his bilateral upper extremities due to a traumatic cervical spinal cord injury. Conventional stimulation via a paddle-type electrode was able to reduce the pain from 8 to 4 via a visual analog scale. Case 2: A 67-year-old man had undergone three spinal surgeries. He presented with pain and numbness of bilateral lower extremities due to a spinal cord lesion by thoracic disc herniation. Differential target multiplexed stimulation via a paddle-type electrode achieved excellent pain reduction, that is, from 9 to 2 on the visual analog scale. Case 3: An 80-year-old man presented with pain in his bilateral upper extremities due to a cervical spinal cord lesion caused by compression and spinal canal stenosis. Posterior cervical decompression and paddle-type electrode placement were performed simultaneously. Differential target multiplexed stimulation was able to achieve excellent pain reduction, from 7 to 2 on the visual analog scale. Spinal cord stimulation using a paddle lead at the rostral side of the spinal lesion and differential target multiplexed stimulation may provide significant opportunities for patients with intractable neuropathic pain following spinal cord lesions.

Cavernous malformations of the midbrain have a higher rate of hemorrhage and a poorer prognosis than vascular malformations of other brain areas. Surgical resection of these lesions is often necessary to avoid neurological deficits in affected patients. Herein, the literature surrounding cavernous malformations was examined, and the case of a 48-year-old man with left hemiparesis and diplopia caused by incomplete right oculomotor nerve palsy, who was diagnosed with a hemorrhage from a midbrain cavernous malformation, was discussed. The lesion expanded gradually on magnetic resonance imaging and was symptomatic; radical removal of the lesion before the onset of irreversible symptoms due to recurring bleeding was therefore considered to be beneficial for the patient. Surgical removal of the entire cavernous malformations of the midbrain was performed using an interhemispheric transcallosal subchoroidal approach, with excellent postoperative results and complete recovery from the oculomotor nerve palsy and left hemiparesis. This case shows that this approach is the most appropriate for surgical resections of lesions in the upper midbrain.

Intimal sarcomas (ISAs) are extremely rare malignant tumors that histologically occur in the tunica intima of large blood vessels of the systemic and pulmonary circulation. Herein, we describe a case of an ISA-based neoplastic aneurysm in the middle cerebral artery (MCA) that resulted in a subarachnoid hemorrhage (SAH). The patient presented to our hospital with severe consciousness disturbance (Glasgow Coma Scale E1V1M2) and anisocoria. On admission, computed tomography (CT) showed a diffuse SAH. At 8 months prior, he presented to a previous hospital with hoarseness. Thoracic CT revealed a threatened rupture of the aorta of the arch. After total arch replacement, he had been diagnosed with ISA from the pathological findings of the resected aorta. Thereafter, he had been treated with adjuvant chemotherapy and radiotherapy without any cerebral vascular imaging studies, before admission at our hospital. Angiogram revealed a multilobar fusiform aneurysm on the right MCA. We performed a superficial temporal artery-MCA anastomosis, trapping, and resection of the affected MCA (including the aneurysm), followed by external decompression. Microscopic hematoxylin-eosin staining showed proliferation of atypical spindle-shaped cells with enlarged nuclei in the lumen of the affected MCA. Immunostaining showed CD31 (±), ERG (+), MDM2 (+), CDK4 (+, slightly), SMA (±), MIB-1 index 13.9%, factor VIII (±), and desmin (-). These pathological findings indicated metastasis of the ISA, which formed the neoplastic aneurysm. An ISA can cause a neoplastic cerebral aneurysm. Therefore, once a patient is diagnosed with an ISA, it is necessary to check periodically the cerebral arteries.