Transnasal penetrating brain injury with a ball-pen

We report a case of a 44-year-old man with 1 day's history of epistaxis. He was an in-patient in a psychiatric ward with a history of depression. He had CSF rhinorrhoea, was confused and had no focal neurological deficits. A full length pencil was removed from his left nostril in the emergency department. CT of the brain revealed a tract, but also suggested another foreign body in the inter-hemispheric space. He had a para-sagittal craniotomy and a 14 cm ball-point pen was found lying between the two cerebral hemispheres. This was removed and the patient made an uneventful recovery. This is the first report of an attempted suicide by transnasal insertion of a ballpoint pen intracranially.     

Cavernous hemangioma extending to extracranial, intracranial, and orbital regions. Case report

Extraaxial cavernous hemangiomas are rare intracranial lesions that can be located in different cranial compartments. Extension across different tissue planes such as the subcutaneous tissue, skull, orbital cavity, intracranial dura mater, and extracranial trigeminal divisions within the same patient has not been previously reported. This 32-year-old woman suffered left exophthalmos, left sixth nerve palsy, and trigeminal neuropathy. Magnetic resonance imaging studies revealed an extensive multicompartmental lesion, with enhancement following Gd administration. A left orbitopterional approach allowed removal of several cavernomatous lesions located in the orbit, frontotemporal dura, and lateral wall of the cavernous sinus. A histologically based diagnosis of extraaxial cavernous hemangioma was made. In the postoperative period the patient experienced a regression of her symptoms. The authors report on a case of cavernous hemangioma with a unique extension to different intracranial/extracranial compartments. Although radical removal of the lesion was not feasible, partial excision allowed for satisfactory clinical control of the patient's symptoms.     

Spinal cord cavernous malformation in a patient with familial intracranial cavernous malformations

The case of a 30-year-old woman with a hemorrhage caused by a rare intramedullary cavernous malformation is presented. The patient underwent laminectomy with total removal of the lesion. A cranial magnetic resonance imaging scan demonstrated multiple cavernous malformations. The patient's asymptomatic sister also had multiple intracranial cavernous malformations, one of which was associated with a venous malformation.     

Cavernous carotid aneurysm presenting with epistaxis

BACKGROUND: Carotid artery aneurysms are a rare cause of epistaxis. The most common presentation for nontraumatic cavernous internal carotid artery aneurysms is mass effect, with only 3% presenting with hemorrhage. We present a case of epistaxis caused by a nontraumatic cavernous internal carotid artery aneurysm. METHODS: A 73-year-old white woman was seen with a 1-month history of recurrent right-sided epistaxis. The patient had essential hypertension and a family history of intracranial aneurysm. A complete otolaryngologic, neurologic, and ophthalmologic examinations were normal. Contrast-enhanced CT of the paranasal sinuses revealed a trilobed aneurysm of the cavernous segment of the right internal carotid artery. Coil embolization of the cavernous aneurysm and right internal artery was performed. RESULTS: The patient has had no further episodes of epistaxis and has remained neurologically intact. CONCLUSION: Carotid artery aneurysms must be considered in the differential diagnosis of profuse epistaxis.     

Intracranial stent placement for the treatment of a carotid-cavernous fistula associated with intracranial angioplasty. Case report

The authors report a case of an iatrogenic carotid-cavernous fistula (CCF) associated with intracranial angioplasty. Angioplasty was performed using a 3 x 10-mm Open Sail coronary balloon in a patient with high-grade stenosis of the left cavernous internal carotid artery (ICA). After angioplasty, a perforation developed in the cavernous ICA, resulting in a CCF. A 3.5 x 9-mm S670 coronary stent was used to treat the fistula. To the authors' knowledge, this is the first reported case in which a CCF developed after angioplasty was performed using a coronary balloon. Long-term angiographic and clinical evaluation is needed to test the suitability and durability of intracranial angioplasty and stent placement in the treatment of symptomatic intracranial stenosis.     

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors’ knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.     

A case of intracranial multiple nonspecific granulomas related to rheumatic disease: with special reference to magnetic resonance imaging]

We encountered a rare case of a 48-year-old man with intracranial multiple granulomas secondarily caused by rheumatic disease. This was proven surgically after an 11-year course of remissions and deteriorations. In 1980, at the age of 32 years, the patient was first seen at the clinic of Neurology of the University Hospital, complaining of swelling and arthralgia of the joints of the knee, ankle, and wrist and with remittent fever and visual disturbance. The patient was diagnosed as having possible rheumatoid arthritis, and treated with administration of 30mg/day of prednisolone, which greatly improved the symptoms. The administration of 5 to 10mg/day of prednisolone had been continued after discharge from hospital. In 1985, visual acuity of the left eye decreased, and left facial hypesthesia developed. The patient was rehospitalized at the same clinic, and treated with 100mg/day of prednisolone, which again diminished the symptoms. Computed tomography(CT) on admission showed a high density mass with contrast enhancement in the left cavernous region. In addition to the left cavernous mass, a high density mass was detected by CT in the left parietal lobe, in 1987. Visual acuity of the left eye deteriorated in 1989. Because his response to prednisolone had decreased, the visual symptom was treated with gold sodium, which acted effectiveness. Symptoms deteriorated again in 1990. Early in 1991, CT and magnetic resonance imaging showed a new mass at the right frontal lobe, while the mass in the left cavernous region had increased in size. The patient was transferred to the clinic of Neurosurgery for surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Traumatic anterior communicating artery pseudoaneurysm with cavernous sinus fistula

A traumatic carotid-cavernous fistula and an intracranial pseudoaneurysm are uncommon but well-known complications of head trauma. A rare subtype of arteriovenous fistula may occur from a pseudoaneurysm of the anterior communicating artery (AcoA) instead of the internal carotid artery. We describe a patient with a traumatic pseudoaneurysm of the AcoA with a cavernous sinus fistula treated with endovascular treatment. A 68-year-old man presented with a severe head injury after a fall. Coronal view multiplanar reformatted images with contrast medium showed gradual expansion of the pseudoaneurysm of the AcoA and the enhanced area of the cavernous sinus. Five weeks after the injury, the patient had a subarachnoid hemorrhage. A cerebral angiogram showed a fistula between the pseudoaneurysm of the AcoA and the cavernous sinus. The AcoA, left anterior cerebral artery and part of the pseudoaneurysm were obliterated by coil embolization. A postoperative angiogram showed no flow through the pseudoaneurysm and the cavernous sinus fistula. A traumatic AcoA pseudoaneurysm with a cavernous sinus fistula may occur as an extremely rare complication of head injury.     

Cavernous carotid artery aneurysm associated with Marfan's syndrome: treatment by balloon embolization therapy

Intracranial aneurysms arising in the region of the cavernous carotid artery are difficult to manage surgically because of the surrounding cavernous sinus. With recent advances in microballoon technology and permanent solidification agents, it is now possible to treat certain intracranial aneurysms by detachable balloons and preserve the parent vessel. A patient with Marfan's syndrome presented with severe retroorbital pain, ophthalmoplegia, and headaches. Cerebral angiography demonstrated a large cavernous carotid artery aneurysm measuring 17 X 9 X 6 mm. This was successfully treated by placing three detachable balloons within the aneurysm and preserving the carotid artery via a transvascular approach. Intravascular detachable balloon embolization may offer a form of alternative therapy for the management of surgically difficult aneurysms.     

Suprasellar displacement of intracavernous internal carotid artery: case report

OBJECTIVE AND IMPORTANCE: We present a previously undescribed variant of the cavernous internal carotid artery (ICA) and review the literature concerning other variants of the cavernous ICA. CLINICAL PRESENTATION: The patient, a 53-year-old woman with fibromuscular dysplasia and multiple intracranial aneurysms, underwent cerebral angiography in preparation for clipping of a terminal ICA bifurcation aneurysm that demonstrated a redundant loop of the cavernous ICA abutting the supraclinoid carotid artery. INTERVENTION: The patient underwent a pterional craniotomy to approach a terminal ICA bifurcation aneurysm. During the procedure, an unexpected vascular anomaly was discovered. On further dissection, we confirmed that the vascular abnormality was a segment of the ICA that had herniated through the superomedial cavernous sinus wall. CONCLUSION: This case demonstrates that the cavernous ICA may become dehiscent from the cavernous sinus wall and herniate into the suprasellar space. Knowledge and anticipation of anatomic variants of the cavernous carotid artery are essential to avoid inadvertent vascular injury during surgery.     

Tentorial cavernous angioma with calcification in a neonate

A cavernous angioma of the tentorium cerebelli, first disclosed by perinatal serial ultrasonographic studies, was extirpated totally without remarkable neurological deficit in a neonate. The tumor was accompanied by a calcified expansive hematoma in the posterior fossa. To our knowledge, this is the first case not only of cavernous angioma treated surgically and verified histologically in a neonate, but also of a calcified hematoma revealed on a conventional skull x-ray film at birth. This case suggests the possibility of hemorrhage from intracranial cavernous angioma early in life, even prenatally, and emphasizes the necessity for early diagnosis and early treatment of intracranial cavernous angiomas.     

Perimesencephalic non-aneurysmal subarachnoid hemorrhage caused by cavernous sinus thrombosis: case report

A 37-year-old man presented with perimesencephalic non-aneurysmal subarachnoid hemorrhage associated with cavernous sinus thrombosis. Anticoagulant therapy was administered to treat the cavernous sinus thrombosis, but provoked severe intracranial hemorrhage, severely disabling the patient. Perimesencephalic non-aneurysmal subarachnoid hemorrhage is a benign clinical entity with generally good prognosis, but the association with cavernous sinus thrombosis requires careful investigation prior to treatment.     

Isolated intracranial infection with Mycobacterium avium complex

Mycobacterium avium-M. complex (MAC) has been linked to devastating respiratory and systemic illnesses in patients, especially in those who are immunosuppressed. The purpose of this study is to describe a case of isolated central nervous system (CNS) infection with MAC. This is a single case report of a patient with isolated intracranial mycobacterial infection. Setting: the patient was treated and the immunohistochemical investigations were undertaken at the National Institutes of Health in Bethesda, Maryland, USA. Intervention: the patient initially was treated with a cocktail of antimycobacterial medications. However, because his disease was refractory, he underwent a suboccipital craniotomy and evacuation of his cerebellar mass. The patient was determined to have a low production of interferon-gamma (INF-gamma) and tumor necrosis factor-alpha (TNF-alpha) when compared to normal values. Despite extensive radiographic imaging studies and biopsies, there was no evidence of another focus of MAC infection in this patient. We conclude that intracranial infectious lesions in patients such as ours should be treated with conventional systemic antibiotic regimens as the first-line of therapy. We suggest neurosurgical intervention in medically refractory cases of intracranial infections.     

Hepatectomy cures a cough: giant cavernous hemangioma in a patient with persistent cough

Cavernous hemangiomas are the most common type of benign liver tumor. Although these tumors are often asymptomatic, they can occur with an array of symptoms. The authors describe a case of a 51-year-old man who presented to the emergency department with a relentless cough, nausea, and abdominal pain. Results of a computed tomography scan suggested the patient had a giant cavernous hemangioma on his liver; microscopic evaluation confirmed this diagnosis. The hemangioma was initially deemed unresectable and the patient was treated with one session of hepatic artery embolization. The embolization was unsuccessful at easing the patient's symptoms, however, and a hepatic lobectomy and resection was performed. After surgical intervention, the patient's symptoms resolved. The present case illustrates an unusual instance in which chronic cough was cured through hepatectomy for giant cavernous hemangioma. To our knowledge, no reports of coughing as a primary symptom of giant cavernous hemangioma have been previously reported in the literature.     

Coexistence of intracranial and spinal cavernous angiomas: case report]

A case of a 43-year-old man with coexistence of intracranial and spinal cavernous angiomas is presented. The patient had a 2-year history of severe back pain incurred by neck flexion, and he became aware of weakness of the right lower extremity and paresthesia of the left lower extremity. Neurological examinations at the time of the first admission demonstrated incomplete Brown-Séquard syndrome. Myelograph, myelo-CT and contrast enhanced CT showed an intramedullary mass at the Th3-Th5 level. The patient received laminectomy with total removal of the lesion. Pathological diagnosis was cavernous angioma. Six years later, the patient complained of subacute weakness and numbness of the left upper extremity. Head CT demonstrated a high density lesion of about 2cm in diameter in the right frontal lobe. MRI showed a mixed signal intensity lesion with a marked low-intensity rim in the same area. Total extirpation of the lesion was performed. Pathological diagnosis of the intracerebral lesion was also cavernous angioma. Intramedullary cavernous angioma is very rare. Furthermore, bifocal cavernous angiomas involving both the spinal cord and the brain are extremely rare, and, only 5 cases have been reported in the literature. To our knowledge, this is the first case diagnosed by surgical specimens of coexisting intramedullary and intracerebral lesions.     

Multiple intracranial aneurysms and vascular abnormalities associated with neurofibromatosis type 1: a case report

We present an unusual case of multiple intracranial aneurysms, persistent primitive trigeminal artery (PPTA), and fenestration of the middle cerebral artery (MCA), associated with type 1 neurofibromatosis (NF 1). The patient was a 55-year-old woman in a state of semicoma. We observed widespread neurofibromas and café au lait spots on her trunk and limbs. Computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage and right frontal intracerebral hemorrhage (WFNS grade IV, Fisher's classification group 4). Cerebral angiography showed two intracranial aneurysms at the anterior communicating artery, an aneurysm at the cavernous portion of the right carotid artery, a PPTA, and MCA fenestration. The patient remained in an apallic state, even after successful clipping of the anterior communicating artery aneurysms.     

A case of cavernous sinus dural arteriovenous fistula presenting with intracranial hemorrhage

Intracranial cavernous sinus dural arteriovenous fistula (CS-dAVF) rarely causes intracranial hemorrhage. We report a case of CS-dAVF presenting with intracranial hemorrhage. A 62-year-old man presented tonic clonic convulsion with consciousness disturbance and was transferred to our hospital. CT scan revealed subarachnoid hemorrhage and right frontal subcortical hemorrhage. Angiography revealed right CS-dAVF which drained only into the vein of the right sylvian fissure. Transvenous embolization was performed using detachable coils. After embolization, CS-dAVF had completely disappeared and the patient was discharged without any symptom. We summarized the fourteen reported cases, including ours, of CS-dAVF with intracranial hemorrhage. All of them had retrograde drainage through cerebral veins.     

Carotid cavernous fistula following Fogarty catheter thrombectomy

A patient had carotid cavernous fistula following Fogarty catheter thrombectomy. The patient was successfully treated by percutaneous detachable balloon closure of the fistula. Intraoperative angiography may be helpful in detecting unsuspected injuries of the intracranial carotid artery following thrombectomy.     

The Supposed Intracavernous Sinus Arachnoid Cyst with Abducens Neuropathy: A Case Report

Intracavernous sinus arachnoid cysts are rare intracranial congenital lesions. When present, their anatomic location frequently results in cranial nerve palsy. A 15-year-old boy was admitted to our hospital with diplopia, which had gradually worsened over the previous several months. An arachnoid cyst was identified within the right cavernous sinus and fenestration surgery was performed. The patient recovered well and three months after the surgery, diplopia was disappeared. Surgical decompression of the intracavernous sinus arachnoid cyst is beneficial for symptomatic patients with this condition.     

Trigonal cavernous angioma presenting with selective ventricular exclusion

We present a case of a patient with an intraventricular cavernous angioma originating from the splenium of the corpus callosum presenting with intracranial hypertension syndrome. In our case the growth of the lesion from the corpus callosum toward the ventricular spaces determined the direct exclusion of the occipital and temporal horn of the left lateral ventricle.