Cerebral veins show wide variation, and unexpected veins occasionally limit surgical procedures for clipping of cerebral aneurysms. This study was undertaken to assess the utility of ...three-dimensional CT angiography (3D-CTA) in the evaluation of venous anatomy before surgical clipping of cerebral aneurysms.
3D-CTA was performed in 19 patients before pterional craniotomy. The venous anatomy visualized by use of 3D-CTA was compared retrospectively with intraoperative findings.
3D-CTA clearly depicted the superficial sylvian veins (SSVs) in 17 of 19 cases. In three of these 17 cases, 3D-CTA failed to reveal the additional connecting veins from SSVs to the midportion of the sphenoid wing. 3D-CTA also depicted bridging veins from: 1) the basal vein of Rosenthal to the sphenoparietal sinus (SPS) (three cases); 2) a junction of the anterior cerebral vein and the deep middle cerebral vein to the SPS (two cases); 3) the anterior cerebral vein into the cavernous sinus (one case); and 4) the deep middle cerebral vein to the cavernous sinus in one case. Surgical findings corresponded well with the angiographic findings. 3D-CTA depicted bridging veins from the frontal base into the SPS in two cases; retraction of the frontal lobe was severely limited in these cases. 3D-CTA also exhibited anatomic variation of deep cerebral veins, which suggests the utility of 3D-CTA in evaluating the risks carried by sacrifice of some bridging veins. In two patients, aneurysmal dissection was restricted because of adhering veins. 3D-CTA depicted these cerebral veins to be lying in contact with the aneurysm. In one case, the contiguous vein was hidden behind a large middle cerebral artery aneurysm; 3D-CTA was helpful for visualization of this vein.
3D-CTA can clearly depict the venous anatomy of the brain and is useful for surgical planning of a pterional or temporopolar approach for cerebral aneurysms.
High-resolution magnetic resonance (MR) image has been introduced to diagnose and follow-up moyamoya disease and visualized moyamoya vessels and internal carotid artery stenosis. This study was ...performed to assess the utility of MR angiography (MRA) for the evaluation of anastomotic channels through the external carotid artery (ECA) in moyamoya disease patients.
Twenty patients with moyamoya disease were reviewed. The cortical anastomosis and superficial temporal artery (STA), middle meningeal artery, and deep temporal artery by MRA were evaluated and were compared with those by digital subtraction angiography if obtained. Fifteen patients (24 hemispheres) underwent bypass surgery, including encephaloduroarteriosynangiosis in 14 hemispheres and STA–middle cerebral artery anastomosis with encephalomyosinangiosis in 10 hemispheres. Five patients did not undergo any surgery.
MRA could show these vessels and the patency of anastomosis formed by the surgery and also showed naturally formed anastomosis and ECA tributaries in the patients who did not undergo any surgery.
MRA provides useful information for follow-up evaluation on the development of the ECA system in moyamoya disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
With the current prevalence of tuberculosis, the incidence of intracranial tuberculoma may be on the rise in industrialized nations. However, clinical findings suggestive of systemic tuberculosis are ...frequently subtle or absent in patients with intracranial tuberculoma, and no specific neuroradiologic characteristics of tuberculoma have been defined as yet. We report two cases of ring-enhanced intracranial tuberculoma in which magnetic resonance (MR) proton spectroscopy and diffusion-weighted (DW) imaging were useful in the differential diagnosis between tuberculoma and other ring-enhanced mass lesions. Pulmonary tuberculosis had been diagnosed in one patient, but radiologic lung study and tuberculin skin test were negative in the other. DW imaging showed bright signal intensity in the core of all lesions in both patients. Malignant gliomas and metastatic brain tumors do not have this characteristic. Proton MR spectroscopy of lesion cores showed lipid peaks and a choline peak in one, and a lipid/lactate mixture pattern in the other, which differed distinctively from those of the pyogenic brain abscess. In each case, one lesion was surgically removed. Antituberculosis drugs were started before surgery for one patient and after surgery for the other. In both, the remaining lesions were reduced significantly in size. We discuss the diagnostic potential of these MR techniques and management options of intracranial tuberculoma. Neurol Res 2002; 24: 537-543
Little is known regarding the optimal management of a ruptured blisterlike aneurysm of the ICA. Because of the high risk for intraoperative bleeding, direct surgical treatments of these fragile ...lesions have generally been associated with a poor outcome. We herein report a very rare case of a ruptured blisterlike aneurysm that was successfully treated with coil embolization in the late period.
The patient was 21 years old when he had a Hunt and Hess grade IV subarachnoid hemorrhage. At the time of the hemorrhage, 3D-CTA demonstrated a minimal aneurysmal enlargement located in the left C2 portion of the ICA. Because of his poor neurological condition and the risk for a premature rupture during early surgery, delayed surgery was thus scheduled. Cerebral angiography, 13 days later, revealed the shape and size of the aneurysm to have changed in form from a blisterlike aneurysm to a saccular-type one. Initially, we planned to treat the aneurysm by trapping with bypass surgery on the 15th day. However, we instead performed coil embolization on the 19th day because a thick thrombus was found to cover the aneurysm at the time of surgery on the 15th day.
This is the first report of a ruptured blisterlike aneurysm that was successfully treated with coil embolization in the late period of a subarachnoid hemorrhage after operative confirmation of thrombus formation around the aneurysm. Our findings suggest that coil embolization in the late period appears to be an effective option in the management of selective cases of ruptured blisterlike aneurysms.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Elective surgery for asymptomatic small (<5 mm) unruptured intracranial aneurysms (UIAs) remains controversial. To reveal the current trend and outcomes in the management of (UIAs) in daily clinical ...practice, we retrospectively analyzed treatment options and surgical morbidity of small UIA cases in our institute (Group A: 129 aneurysms) and from the Nagasaki UIA Registry (Group B: 610 aneurysms) over the four recent years (2006–2009). After discreet discussions including recent prospective data of rupture risk and guidelines for treatment of small UIAs as part of informed consent procedure, only 7% (9 aneurysms) of the patients in Group A chose surgical treatment of either clipping or coiling, on which no intra- or post-surgical morbidity was observed. Direct surgical or endovascular interventions were performed in 267 aneurysms in Group B, in which a significant number of complications were reported (mRS≥2=5.9%; mRS 1=7.7%, at three months after the surgery). In view of recent studies suggesting low annual rupture rates (0.3–0.5%/yr) with significant morbidity rates (2–7%) of small UIAs, more conservative management should be considered, especially for UIAs smaller than 5 mm.
Favorable timing of aneurysmal surgery for aged group (≥70 year-old, group A) and non-aged group (≥70 year-old, group B) were evaluated on 1789 patients who were admitted within 48 hours after ...subarachnoid hemorrhage (SAH) and in which cerebral aneurysms were verified with angiogram. Late surgery (day 11 or later) showed significantly favorable results compared to early surgery (within day 3) in all grades of SAH (Hunt and Hess classification) in group B and in good grade (I, II) in group A. Patients with late rebleeding (day 4 or later) before surgery and patients who did not undergo surgery because of vasospasm or initial damage were added to a group of late surgery and they were defined as a late management group. In group B, early surgery revealed higher incidence of favorable outcome than late management in grade I-IV. In group A, late management showed better result in good-risk group (grade I, II), whereas early surgery yielded the significantly higher incidence of favorable outcome than late management in poor-risk patients (grade IV). These results suggest that early surgery is recommended for aneurysmal surgery in non-aged patients regardless of severity. It is also indicated that for aged group, late surgery on good-risk patients and early surgery on poor-risk aged result in better outcome.
Neointima formation associated with vascular restenosis is a complex local inflammatory process actively involving the vascular smooth muscle cell (SMC) proliferation. Nuclear factor-κB (NF-κB) is a ...transactivator of a diverse group of genes whose activation has been strongly associated with the cellular response to inflammation. Since anti-oxidant N-acetylcysteine (NAC) inhibit NF-κB activity in vascular SMC in vitro , we examined the in vivo effect of the NAC on balloon-induced neointimal formation in the carotid artery of rats. Sprague-Dawley rats underwent balloon dilatation injury of the left carotid artery to induce neointimal formation. One group of these rats (n = 9) were treated with daily intraperitoneal injection of NAC (200 mg kg-1) for 14 consecutive days, whereas the control group (n = 9) was treated with saline. Fourteen days after the injury, the left carotid arteries were removed and analyzed under microscope. Several rats underwent the same treatment as above and were sacrificed three days after injury for immunohistochemistry and Western blot studies. A morphometric analysis revealed that there were significant differences in intima/media ratio between the two groups. Immunohistochemical and Western blotting studies demonstrated that NAC suppressed the injury-induced NF-κB activity in the medial SMC layer. Treatment with NAC suppresses vascular NF-κB activation and this inhibition reduced the pathological thickening of the arterial wall. The NF-κB pathway, therefore, represents an attractive therapeutic target for strategies to prevent vascular restenosis. Neurol Res 2001; 23: 731-738
To clarify the role of anoxic depolarization (AD) in ischemic brain injury, we examined the correlation between AD and ischemia-induced neuronal injury. Twenty-eight rats underwent transient ...forebrain ischemia with lowering of blood pressure and bilateral carotid occlusion while direct current shiftslelectrocorticogram, and cortical blood flow (COBF) were epidurally recorded from the right parietal cortex. One week later the right parietal cortex was studied histopathologically. AD appeared 0.5-3.0 min after carotid occlusion in 21 of28 animals. Circulation was reinitiated 75 min afterAD onset in 77 rats (group A) and 10 min after onset in 70 rats (group B). AD did not develop during 20 min of ischemia in 7 rats (group C). All 72 rats (6 from group A and 6 from group B) in which CoBF decreased below 9.5% of control flow exhibited AD. Histopathologic examination disclosed massive neuronal necrosis in 5 of the 6 group A animals with marked flow reduction but in none from group B. CoBF fell between 9.5% and 20% in 74 rats, among these, AD appeared in 9 (5 from group A and 4 from group B) but not in 5 (group C). Massive neuronal necrosis was demonstrated in 3 of5 rats from group A. Ischemic neuronal changes were absent or minimal in only 7/5 ofgroup A animals, a much lower fraction than in group B (4/4, p<0.05) or in group.C (5/5/, p<0.05). When CoBF remained above 20% of control flow during ischemia (2 rats) no AD or irreversible injury occurred. The present study suggests that AD is a more reliable determinant of irreversible brain injury than degree of CBF reduction, and also demonstrates that 75 min is the critical duration of AD for irreversible brain injury at brain temperatures around 37° C. Neural Res 1998; 20: 343-348
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