Late neurological dysfunction in adult lumbosacral lipoma with tethered cord

The case of a 59-year-old man with adult-onset neurological dysfunction secondary to a tethered cord and a lumbosacral lipoma is presented. This condition not only affects children, but is known to produce neurological dysfunction in adults and should be kept in mind in the differential diagnosis of patients with sacral root deficits.     

Superior sagittal sinus thrombosis followed by subdural hematoma

A case of superior sagittal sinus thrombosis followed by a subdural hematoma is reported. A 33-year-old woman, who presented with serious neurological deficits, made a remarkable recovery with mild residual. She had a thin subdural fluid collection, which eventually developed into a subdural hematoma. After evacuation of the hematoma, she had no neurological deficits. Treatment of cerebral venous and dural sinus thrombosis is discussed.     

Cerebral venous malformations

Although cerebral venous malformations have been reported to cause epilepsy, progressive neurological deficits, and hemorrhage, their clinical significance remains controversial. In an attempt to clarify the natural history of the lesion and suggest an appropriate management strategy, the authors review their experience with 30 patients. In four patients with cerebellar venous angioma, an acute episode of ataxia was documented. The coexistence of a cavernous malformation was pathologically confirmed in the two patients who underwent surgery for bleeding presumed caused by the venous angioma. Infarction was shown in two patients and a tumor in two others. Follow-up periods ranged between 18 and 104 months, with only five patients symptomatic at the time of this report. Rebleeding had not occurred, nor had acute episodes of neurological dysfunction been documented. This clinical experience suggests that a venous malformation is frequently associated with other, more symptomatic conditions and is often erroneously identified as the source of the symptoms. Because the nature of the relationship between the venous malformation and the allied conditions remains ambiguous, it is recommended that patients harboring a "symptomatic" venous malformation undergo high-field magnetic resonance imaging to rule out underlying pathology, and that any such pathology be treated independently of the venous malformation.     

Successful evacuation of a pontine hematoma secondary to rupture of a venous angioma

A middle-aged woman presented with progressive brainstem neurological deficits. Clinical manifestations and preoperative radiological examination were indicative of an expanding intrapontine mass. At operation, an intrapontine hematoma and a venous angioma adherent to the floor of the fourth ventricle were discovered. Successful evacuation of the hematoma was followed by an excellent recovery. Postoperative angiography demonstrated the venous angioma. To our knowledge, this is the first case of angiographically proved ruptured venous angioma of the pons treated successfully by an operation.     

Preoperative embolization of upper cervical cord hemangioblastoma concomitant with venous congestion--case report

A 16-year-old male presented with a large, solid hemangioblastoma located in the upper cervical cord manifesting as hyperactive reflexes, subtle weakness, and diminished position sense in all extremities. Neuroimaging studies indicated venous congestion due to arteriovenous shunt through the tumor. Preoperative embolization was accomplished without morbidity, and resulted in marked devascularization of the tumor and elimination of an early filling vein. Four days after embolization, the tumor was totally excised without excessive intraoperative bleeding. His neurological deficits gradually improved after surgery. Preoperative embolization is a valuable adjunct to surgical excision of large intramedullary hemangioblastomas, especially those associated with arteriovenous shunt, as cord dysfunction related to venous congestion and the risk of torrential intraoperative bleeding are reduced.     

Presentation of a previously asymptomatic Chiari I malformation by a flexion injury to the neck.

Flexion injury and/or whiplash injury to the neck in car accidents are usually trivial injuries with no serious neurological deficits. Our intention was to point out the importance to proceed with diagnostic procedures if neurological deficits do occur in order to reveal the true cause of the deficit. The paper presents the case of a 35-year-old woman who sustained a flexion injury to the neck. A relatively trivial injury to the neck promoted a progressive neurological deterioration. The standard diagnostic procedures (x-ray, computed tomography scan) were normal. Further diagnostics with magnetic resonance imaging was required to reveal an underlying Chiari I malformation. Finally, the operative decompression of the craniocervical junction was performed. Following the surgical treatment, the patient's clinical symptoms regressed. One year after her discharge, she remains in good physical condition. To our knowledge, this case is the first report of the manifestation of Chiari I malformation in the adult as a result of a flexion or whiplash injury of the neck. This unusual case suggests that in a trivial flexion injury to the neck sustained in a car accident, which presents with serious neurological dysfunction, and where the standard diagnostic procedures are normal, the possibility of underlying congenital abnormality, such as Chiari I malformation should be considered.     

Spontaneous thrombosis of a residual arteriovenous malformation in eloquent cortex after surgery: case report

OBJECTIVE AND IMPORTANCE: The presence of a residual arteriovenous malformation (AVM) on postoperative angiograms is typically an indication for prompt return to the operating room to complete resection, because of the risk of early hemorrhage. This approach, however, may involve risks of neurological deficits when the residual AVM is in eloquent cortex. We present a case of complete thrombosis of a residual AVM after surgery. This residual AVM tissue was located in eloquent cortex. Complete spontaneous thrombosis of residual AVMs after surgery has only rarely been reported. This phenomenon raises questions regarding the most appropriate management for residual AVMs in eloquent cortex. CLINICAL PRESENTATION: The patient was a 43-year-old, right-handed, male patient with an AVM centered in the left precentral gyrus. The patient presented with medically intractable seizures and progressive right hemiparesis. After AVM resection, angiography revealed a residual AVM with early venous drainage. Angiography performed 1 week later demonstrated a persisting AVM nidus without early venous drainage. Angiography performed 3 months later demonstrated complete thrombosis of the residual AVM. INTERVENTION: The patient has been monitored for more than 1 year, without additional symptoms or therapy. CONCLUSION: We continue to advocate prompt return to the operating room when postoperative angiography reveals a residual AVM with persistent shunting. When the residual AVM is in eloquent cortex and is small, with a single draining vein, however, observation of the patient (with strict blood pressure control) and repeat angiography after 1 week represent an alternative strategy that is supported by this case report. As this case demonstrates, it is possible for small residual AVMs to thrombose. This may avert the need for reoperation for residual AVMs in eloquent cortex, with the potential for neurological deficits.     

Neurological deficit as a presentation of occult metastatic thyroid carcinoma

Three cases of occult metastatic thyroid carcinoma presenting with neurological deficits are reviewed. In each case the patient's initial presentation was with symptoms of neurological deficiency secondary to a spinal cord compression. All patients received a combination of surgery, external beam radiotherapy and postoperative thyroxine treatment. Two of the three patients are alive and well, able to mobilize with minor neurological dysfunction. The diagnosis and management of the patients, as well as their outcomes are reviewed, with a discussion on further management issues alongside a review of the current published work.     

Occlusive hyperemia: a radiosurgical phenomenon?

OBJECTIVE: Causes of neurological deficits after arteriovenous malformation (AVM) radiosurgery, including hemorrhage, radiation injury, and delayed cyst formation, are described. CONCEPT: Occlusive hyperemia has been described as a reason for neurological deterioration after AVM resection. Thrombosis of draining veins or dural sinuses is thought to cause postoperative bleeding or neurological deficits secondary to venous hypertension. In a similar manner, local hemodynamic changes can occur in the brain adjacent to an AVM after radiosurgery if venous outflow is obstructed. Two patients are presented whose cases demonstrate this phenomenon. CONCLUSION: Patients can experience clinical worsening after AVM radiosurgery from premature thrombosis of draining veins. Local hemodynamic changes could explain why imaging changes thought to be radiation related occur more frequently after radiosurgery of AVMs than of tumors.     

Occlusion of the great vein of Galen associated with a huge meningioma in the pineal region. Case report

The authors report a case in which the great vein of Galen was occluded during removal of a huge meningioma in the pineal region. The patient recovered satisfactorily without any serious neurological deficits after the operation. Preoperative angiography had shown marked stenosis of the great vein of Galen and anastomoses between the deep and the superficial venous systems. Occlusion of the great vein of Galen may be well tolerated in particular cases if this vein is already compromised.     

Conus medullaris syndrome without lower-extremity involvement in L-1 burst fractures: report of four cases

Conus medullaris injury from burst fractures is known to occur in conjunction with other neurological deficits, including lower-extremity motor weakness or sensory changes. Rarely does an isolated conus medullaris injury occur from an extradural cause without other neurological deficits. The authors report four cases of L-1 burst fractures in which conus medullaris dysfunction was the sole neurological injury in the absence of lower-extremity involvement.     

Intratemporal facial nerve neurinoma--case report

A 59-year-old female had episodes of vertigo for 13 years, right tinnitus for 6 years, and right hearing difficulty for 2 years. She had no facial nerve dysfunction or other neurological deficits. Postcontrast computed tomography (CT) did not show abnormalities, but a wide, high-window CT scan revealed erosion of the petrous pyramid on the right side. Magnetic resonance imaging clearly delineated the entirety of a small tumor transecting the petrous bone. At operation a neurinoma was found to originate from the facial nerve proximal to the geniculate ganglion; it was totally removed. This case is unique in that she had a long history of signs and symptoms of acoustic nerve disturbance, but no facial nerve dysfunction whatsoever.     

Reversal of a dense, persistent, holohemispheric neurological deficit after an endarterectomy of the carotid artery: case report

The role and timing of a carotid endarterectomy in the setting of an acute ischemic stroke-in-evolution remain controversial. Although computed tomographic (CT) scans typically show no abnormalities in the acute stage, it is generally agreed that a dense neurological deficit (hemiplegia) and/or multiple modality neurological disturbance (involving motor, sensory, gaze, and visual field impairment) represent contraindications to surgical intervention. We present a case of an acute right holohemispheric neurological deficit including dense hemiplegia, hemisensory loss, gaze disturbance, hemineglect, and impaired level of consciousness. This persisted for 4 days while serial CT scans showed no evidence of infarction. Angiography revealed pre-occlusive stenosis of the right internal carotid artery with sluggish antegrade flow. The anterior collaterals of the circle of Willis were impaired, and the right middle cerebral artery territory filled via the posterior communicating artery. Despite the dense neurological deficit persisting for 4 days, a carotid endarterectomy was performed. Gradual neurological improvement was noted within hours of the operation, and all neurological deficits resolved within the subsequent 3 days. This case is consistent with prolonged holohemispheric hemodynamic compromise below the threshold of neurological dysfunction, but above the threshold of tissue infarction ("idling neurons"). Features assisting in the recognition of this unusual scenario and the indications and risks of revascularization in this setting are discussed.     

Endovascular thrombolysis for symptomatic cerebral venous thrombosis.

OBJECT: The authors sought to treat potentially catastrophic intracranial dural and deep cerebral venous thrombosis by using a multimodality endovascular approach. METHODS: Six patients aged 14 to 75 years presented with progressive symptoms of thrombotic intracranial venous occlusion. Five presented with neurological deficits, and one patient had a progressive and intractable headache. All six had known risk factors for venous thrombosis: inflammatory bowel disease (two patients), nephrotic syndrome (one), cancer (one), use of oral contraceptive pills (one), and puerperium (one). Four had combined dural and deep venous thrombosis, whereas clot formation was limited to the dural venous sinuses in two patients. All patients underwent diagnostic cerebral arteriograms followed by transvenous catheterization and selective sinus and deep venous microcatheterization. Urokinase was delivered at the proximal aspect of the thrombus in dosages of 200,000 to 1,000,000 IU. In two patients with thrombus refractory to pharmacological thrombolytic treatment, mechanical wire microsnare maceration of the thrombus resulted in sinus patency. Radiological studies obtained 24 hours after thrombolysis reconfirmed sinus/vein patency in all patients. All patients' symptoms and neurological deficits improved, and no procedural complications ensued. Follow-up periods ranged from 12 to 35 months, and all six patients remain free of any symptomatic venous reocclusion. Factors including patients' age, preexisting medical conditions, and duration of symptoms had no statistical bearing on the outcome. CONCLUSIONS: Patients with both dural and deep cerebral venous thrombosis often have a variable clinical course and an unpredictable neurological outcome. With recent improvements in interventional techniques, endovascular therapy is warranted in symptomatic patients early in the disease course, prior to morbid and potentially fatal neurological deterioration.     

Neurologische postpartale Komplikationen nach geburtshilflicher Periduralanalgesie Fallbericht und Literaturübersicht

Regional analgesia provides effective pain relief during delivery. Postpartal neurological deficits may be due to pressure of the fetal head on nerve structures at the pelvic rim or may be a complication of epidural analgesia. Nerve injuries due to spontaneous delivery and instrumental delivery are much more common than neurological deficits from epidural analgesia such as epidural hematoma or epidural abscess. The pattern of nerve damage is usually unilateral and non segmental. This case report describes the differential diagnosis of neurological deficit after spontaneous delivery under epidural analgesia and a discussion of the recent literature. Finally recommendations for the treatment of neurological deficits after delivery under epidural analgesia are presented.     

Superior sagittal sinus thrombosis suffered as a complication of ulcerative colitis: case report

A case of superior sagittal sinus thrombosis which was complicated with ulcerative colitis is reported. A 16-year-old male patient had a 2-year history of ulcerative colitis. He was admitted to our hospital complaining of abdominal pain, bloody bowel discharge and appetite loss, and was then treated conservatively. Two days after admission, he demonstrated generalized convulsions which were followed by right hemiplegia. MRI showed a low intensity lesion on T1 and an irregular high intensity in the subcortical area of the left frontal lobe on T2 and T2 FLAIR-weighted images. The MRI findings resembled either invasive brain tumor or local inflammation. Cerebral angiography appeared to demonstrate complete obstruction of the superior sagittal sinus with congestion of venous flow in the cortical veins. Ulcerative colitis has been reported to show hypercoagulation, leading to deep vein thrombosis within the body which sometimes causes pulmonary infarction; however, occurrence of venous thrombosis in the intracranial veins and sinus is rare. This report underscores the fact that cerebral venous thrombosis should be suspected in the case of patients with ulceritive colitis who suffer sudden onset of neurological deficits.     

Conservative management of idiopathic anterior atlantoaxial subluxation without neurological deficits in an 83-year-old female: A case report

Atlantoaxial subluxation that is not related to traumatic, congenital, or rheumatological conditions is rare and can be a diagnostic challenge. This case report details a case of anterior atlantoaxial subluxation in an 83-year-old female without history of trauma, congenital, or rheumatological conditions. She presented to the chiropractor with insidious neck pain and headaches, without neurological deficits. Radiographs revealed a widened atlantodental space (measuring 6 mm) indicating anterior atlantoaxial subluxation and potential sagittal atlantoaxial instability. Prompt detection and appropriate conservative management resulted in favourable long-term outcome at 13-months follow-up. Conservative management included education, mobilizations, soft tissue therapy, monitoring for neurological progression, and co-management with the family physician. The purpose of this case report is to heighten awareness of the clinical presentation of idiopathic anterior atlantoaxial subluxation without neurological deficits. Discussion will focus on the incidence, mechanism, clinical presentation, and conservative management of a complex case of anterior atlantoaxial subluxation.     

小脑幕硬脑膜动静脉瘘的诊断和治疗

目的复习有关小脑幕硬脑膜动静脉瘘(DAVF)文献,介绍处理的策略。方法回顾性分析5例小脑幕DAVF患者资料,包括病史、影像学、手术记录和随访资料。结果5例患者中表现为急性蛛网膜下腔出血2例,进行性神经障碍3例。B0rden分级Ⅱ级1例,Ⅲ级4例。瘘口位于小脑幕游离缘3例,外侧1例,内侧1例。经岩骨前入路手术3例,经改良翼点入路1例,经枕叶小脑幕入路1例。术后3例患者行DSA,证实DAVF消失;1例患者行MR见静脉瘤血栓形成,脑干水肿消退;1例见扩张静脉部分血栓。全部患者恢复正常生活和工作,无手术死亡。随访1～2年,未见复发。结论小脑幕DAVF危害性大,应积极采用显微外科手术伴或不伴血管内介入治疗,闭塞瘘口和(或)软脑膜引流静脉。     

Post-traumatic syringomyelia

Progressive post-traumatic cystic syringomyelia is an uncommon and increasingly recognized cause of morbidity following spinal cord injury. We hereby report a 35-year-old gentleman who sustained wedge compression fracture of L-1 vertebral body 15 years back and had complete paraplegia with bowel/bladder involvement. The neurological deficit recovered with minimal residual motor deficits and erectile dysfunction. He presented now with increasing neurological deficits associated with pain and paresthesia. The MRI spine showed a syrinx extending from the site of injury up to the medulla. He underwent a syringo-peritoneal shunt and at followup his pain and motor functions had improved but erectile dysfunction was persisting.     

运动训练诱发脑缺血耐受的机制研究进展

运动训练能够减轻脑缺血发生后的运动功能障碍,临床和基础研究均对其作用机制进行了深入探索。但是,关于缺血前的运动训练减轻脑缺血发生后神经损伤的具体机制尚不明确,本文就其相关机制进行了综述。缺血前运动训练可通过降低炎症反应,减少神经细胞凋亡,减轻血脑屏障功能障碍,改善脑血管系统,减轻谷氨酸毒性,从而诱发脑缺血耐受。运动训练的神经保护作用机制的阐明有利于针对脑卒中高危人群进行运动干预,减轻缺血性脑卒中后神经功能障碍,产生良好的社会效益。