Carotid-Cavernous Sinus Fistula caused by Persistent Primitive Trigeminal Artery Aneurysm rupture: A case report

Carotid-Cavernous sinus fistula (CCF) caused by a ruptured aneurysm of persistent primitive trigeminal artery (PPTA) is exceptionally rare. Herein, we reported the case of a 64-year-old female who presented with headache, pulsatile tinnitus, and diplopia. Angiography showed a PPTA and CCF. Three-dimensional digital subtraction angiograms revealed a direct shunt between the PPTA aneurysm and the left cavernous sinus. The trigeminal carotid fistula was successfully treated with detachable coils and Onyx, and the PPTA was preserved. Hence, coil and Onyx occlusion of the cavernous sinus is a safe and effective treatment for trigeminal carotid fistula.     

Subclavian steal phenomenon complicating an upper extremity arteriovenous fistula for hemodialysis]

We report a case of 47-year-old man with subclavian steal phenomenon (SSP). He affected chronic renal failure and received an upper extremity arteriovenous fistula creation for hemodialysis. Angiography showed SSP from right vertebral artery to left subclavian artery (SA), and mild stenosis of left SA. We consider that the course of SSP was synergetic effect of mild SA stenosis and hemodynamic effect due to arteriovenous access creation.     

Transient ischemic attacks before and after occlusion of the internal carotid artery

Among 60 cases with occlusion of an internal carotid artery (ICA), 47 p. 100 suffered warning TIA's in the corresponding area. In 7 p. 100 the TIA's were the only manifestation of the disease. The occurrence of warning TIA's significantly correlated with a small volume (less than 20 cm3, p 0,001) and a deep localization (p less than 0,002) of infarction, and also with a better initial neurologic ability and long-term functional prognosis (p less than 0,05) than in patients without warning TIA's. Twenty eight p. 100 of the 60 cases showed delayed TIA's distal to the occlusion. In 12 p. 100 TIA's had not been present before the occlusion. The delayed TIA's were strongly (p less than 0,0001) associated with an atheromatous stenosis of the external carotid artery (ECA) or a stump of the occluded ICA and an important collateral supply through ECA channels, suggesting a micro-embolic mechanism via ECA pathways. Much more rarely hemodynamic factors, and exceptionally probable emboli from the contralateral ICA, appeared to be involved. The occurrence of delayed TIA's was not a warning sign of further stroke, and did not correspond to a poorer functional prognosis. Three p. 100 of the 60 cases suffered TIA's in the contralateral ICA territory, in relation to an atheromatous stenosis of the ICA. Twenty p. 100 showed vertebrobasilar TIA's, usually without associated disease of the vertebral or subclavian arteries (75 p. 100). This point and the evidence of absent or weak collateral circulation (p less than 0,0001) and of an associated contralateral ICA stenosis (p less than 0,01), suggested a hemodynamic mechanism with an intracranial steal from the vertebrobasilar system towards the carotid circulation.(ABSTRACT TRUNCATED AT 250 WORDS)     

A Dural Arteriovenous Fistula of the Anterior Cranial Fossa Angiographically Mimicking an Anterior Ethmoidal Artery Aneurysm

Venous aneurysm or varix at the venous side of the fistula commonly exist in dural arteriovenous fistula (DAVF) of the anterior cranial fossa, which may be initially mistaken with aneurysm on computed tomography and magnetic resonance imaging, but always identified by angiography. We report a very unusual case of anterior cranial fossa DAVF angiographically mimicking an anterior ethmoidal artery aneurysm, which was ultimately corrected by surgery. A 41‐year‐old male presented with right frontal intraparenchymal hematoma with intraventricular extension. Angiography revealed a vascular lesion adjacent to the anterior fossa mimicking an anterior ethmoidal artery aneurysm, which was surgically proven to be a partially thrombosed venous varix of drainaging vein originated from the cribriform plate. A diagnosis of anterior cranial fossa DAVF was made, and venous varix was excised. Follow‐up angiography after the operation revealed complete disappearance of the lesion. Our case illustrates a unique occasion that a proximal venous varix without obvious outflow angiographically in DAVF might be mistaken with an aneurysm.     

A case of recurrent bacterial meningitis by delayed cerebrospinal fluid (CSF) leakage due to a head trauma]

A 42-year-old man was admitted due to recurrent bacterial meningitis, as he had been treated here for bacterial meningitis three years prior to the current event. He had a remote history of head injury that he had almost forgotten, and his laboratory data showed no immunodeficiency state. 111In-DTPA cisternography showed an abnormal radioactive accumulation in the frontal lobe adjacent to the left frontal sinus at 23 hours after intrathecal injection, and MPR CT images revealed the left frontal sinus bone fracture. These findings indicated that he had a head injury by which a delayed CSF fistula has been formed. He was surgically treated for a CSF leakage. Although a combination therapy of ABPC and CTRX was efficacious for this patient, this regimen may not be ideal, as meningitis by PRSP has been increasing in incidence. Pneumococcal meningitis, once not a difficult infection to treat, could be a difficult one, as resistant strains to ABPC and CTRX have been more common.     

Moyamoya disease and arteriovenous fistula of the epiaortic vessels

The association of Moyamoya disease (MD) with other cerebrovascular disease has been reported in literature but not the occurrence of MD and arteriovenous fistula of the epiaortic vessels. A 61-year old Italian woman was admitted to our Department because of the sudden onset of Broca’s aphasia. At general examination she presented a murmur above the right clavicle. Brain magnetic resonance imaging (MRI) showed an ischemic lesion involving left frontal and temporal lobes. Cerebral digital subtraction angiography (DSA) showed moyamoya vessels and an arteriovenous fistula between vertebral artery and internal giugular vein in right laterocervical region. This is the first report of the association of MD with arteriovenous fistula of the epiaortic vessels.     

Dural arteriovenous fistulas with intracranial hemorrhage: diagnostic and therapeutic aspects

Seven patients presented with intracranial hemorrhage due to arteriovenous dural fistula. Six patients showed intracerebral hemorrhage combined with subdural hematoma and intraventricular hemorrhage in one case respectively, and one patient had infratentorial subarachnoid hemorrhage. Location of the fistulae was frontobasal (n=2), tentorium (n=2), transverse sinus (n=2), and superior sagittal sinus (n=1). Angiography revealed reflux into cortical veins in all cases. Therapy was surgery in both cases with fistula of the anterior cranial fossa with good results. An endovascular intraarterial therapy was performed in a case with circumscribed fistula of the superior sagittal sinus, this patient developed a second dural fistula during follow-up. Two patients with tentorial fistulae had primary endovascular treatment complicated by infarction of both thalami in one case and a recurrence of the fistula in the other. In the last case the fistula was closed by surgery. Out of two patients with widespread fistulae of the transverse sinus one made a good clinical recovery and the other remained unchanged. In the first case definite closure of a remnant of the fistula was refused, in the second no further therapy was recommended.     

Dissociated roles of the middle frontal gyri in the processing of Chinese characters

The present study examined a hypothesis that the right middle frontal gyrus participates in processing orthography of Chinese characters, while the left middle frontal gyrus mediates access to phonology and semantics. Brain activation during three character tasks, which required processing orthography, phonology, or semantics of Chinese characters, respectively, was measured by functional magnetic resonance imaging. Comparable neural activity in the right middle frontal gyrus was observed in all three character tasks that always demand orthographical processing. In contrast, the left middle frontal gyrus showed greater activation in the phonological and semantic tasks than in the orthographic task. These results suggest that the right and left middle frontal gyrus have dissociable functions in achieving Chinese character recognition.     

Brain function during multi-trial learning in mild cognitive impairment: a PET activation study

We explored functional brain changes with positron emission tomography (PET) in mild cognitive impairment (MCI) patients and elderly normal controls by employing an episodic memory task that included two successive encoding trials of semantically related word-pairs and final retrieval. Both groups demonstrated significant learning across the two trials. The control group showed predominantly left frontal activity during encoding, and right frontal plus left temporal activity during retrieval. However, the MCI patients recruited partly different brain regions. They failed to activate right frontal and left temporal areas during retrieval, and failed to show any different activation for encoding on the first and second trials, whereas the controls activated a region of posterior cingulate. There was indication of compensatory increases in rCBF of the occipital cortex during incremental learning and the left frontal lobe during retrieval in the patients. These results suggest different episodic memory processing in the MCI group, and a possible over-reliance on semantic processing. Subtle functional changes occur in the pre-Alzheimer brain before there are marked structural or behavioural abnormalities.     

Right frontal EEG and pregnancy/neonatal outcomes

Fifty-two pregnant women recruited during their second trimester were given EEGs and divided into greater relative right and left frontal EEG activation groups. The greater relative right frontal EEG women had lower dopamine levels during their second trimester and lower dopamine and higher cortisol levels during the neonatal period. The newborns of the right frontal EEG mothers also showed greater relative right frontal EEG, had lower dopamine and serotonin levels, spent more time in indeterminate sleep and had inferior Brazelton scores. A discriminant function analysis based on the mothers' prenatal depression scores and biochemical measures correctly classified 74% of the women as greater relative right or left frontal EEG group members.     

A case of posterior ischemic optic neuropathy in a posterior-draining dural cavernous sinus fistula.

A 79-year-old woman presented with sudden unilateral visual loss after an ocular motor disturbance and pulsatile tinnitus. Neuro-ophthalmologic examination showed a presumed right posterior ischemic optic neuropathy (PION), oculosympathetic, and third, sensory fifth, and sixth cranial nerve pareses. Selective angiography of the right internal and external carotid arteries confirmed a posterior-draining dural carotid cavernous sinus fistula (CCF) fed by the right meningohypophyseal trunk and right middle meningeal artery. Angiography also showed an ophthalmic-middle meningeal arterial anastomosis. We postulate that the PION was caused by an arterial steal, because blood was drawn into the fistula and away from the intraorbital optic nerve.     

Neural correlates of memory organization deficits in schizophrenia. A single photon emission computed tomography study with 99mTc-ethyl-cysteinate dimer during a verbal learning task

Regional cerebral blood flow (rCBF) during a verbal learning task was measured using 99mTc-ethyl-cysteinate dimer and single photon emission computed tomography in 10 patients with schizophrenia and nine normal controls. Verbal repetition was used as a control task. The schizophrenic patients showed failure to spontaneously utilize implicit category information to learn the word lists. In the normal controls, rCBF in the left inferior frontal and left anterior cingulate regions was significantly increased during the verbal learning task, compared with the verbal repetition task. In contrast, there was no significant frontal lobe activation by the verbal learning in the schizophrenic patients. The patients had lower rCBF during the verbal learning task than the controls in the bilateral inferior frontal, left anterior cingulate, right superior frontal, and bilateral middle frontal regions. Activation in the left inferior frontal region was significantly positively correlated with categorical clustering in the task in the controls, but no such correlation was found in the patients. These results indicate that memory organization deficits in schizophrenia may be related to dysfunction in the prefrontal areas, especially in the left inferior frontal region.     

A case of multiple myeloma showing intracranial hypertension due to large cranial mass lesions

It is well known that the case of multiple myeloma shows punched-out lesions of the cranium without intracranial hypertension. In this paper a case of multiple myeloma is reported showing intracranial hypertension due to a large tumor that developed in the left parietal bone. There are only 13 case reports about cranial mass lesion of multiple myeloma since 1928. A 52 year-old female was admitted to Iwate Prefectural Isawa Hospital suffering from headache, nausea and vomiting. She had been already diagnosed as multiple myeloma and treated with chemotherapy using Cyclophosphamide, Melphalan and Prednisolone for 2 years. On admission, a large subcutaneous mass was presented on the left parietal region. Craniogram revealed large osteolytic lesion of the left parietal bone and 3 punched-out lesions of the frontal bone. CT scan revealed a large mass lesion in the left epidural space, diploe and subcutaneous space. Angiography showed avascular area. Brain scintigram showed diffuse hot area. Other skeletal bones showed no abnormality. Laboratory examination revealed high concentration of gamma-globulin and high erythrocyte sedimentation rate. Electrophoresis showed high value of immunoglobulin G; immunoglobulin assay was as follows: IgG-6000 mg/dl, IgA-150 mg/dl, IgM-410 mg/dl, IgE-0 mg/dl. Serum electrolytes were within normal limits. Urine didn't include Bence-Jones protein. The patient was diagnosed as multiple myeloma suffering from intracranial hypertension caused by large tumor which developed in the left parietal bone. On the operation, large tumor was existed in the epidural and subcutaneous space invading into the diploe but without infiltration into the dura mater or cerebral cortex.(ABSTRACT TRUNCATED AT 250 WORDS)     

Refreshing one of several active representations: behavioral and functional magnetic resonance imaging differences between young and older adults

We explored age-related differences in executive function during selection of a target from among active representations. Refreshing (thinking briefly of a just-activated representation) is an executive process that foregrounds a target relative to other active representations. In a behavioral study, participants saw one or three words, then saw a cue to refresh one of the words, saw one word again and read it, or read a new word. Increasing the number of active representations increased response times (RTs) only in the refresh condition for young adults but increased RTs equally in all conditions for older adults, suggesting that they experienced interference from activated irrelevant information during perception and reflection. Consistent with this interpretation, in a functional magnetic resonance imaging study, young adults showed two areas of the left dorsolateral frontal cortex and a medial area of frontal cortex, including anterior cingulate, that were relatively more sensitive to number of active representations during refresh than read trials; for older adults these areas were equally sensitive to number of active items for refresh and read trials. Young and older adults showed activity associated with refreshing on trials requiring selection in left mid-ventral frontal cortex (an area associated with selection from active representations); older adults also showed activity in left anterior ventral frontal cortex (an area associated with controlled semantic activation). Our results support the hypothesis of an age-related decrease in ability to gate out activated but currently irrelevant information, and are consistent with a dissociation of function between left mid-ventral and left anterior ventral frontal cortex.     

Venous infarction associated with carotid-cavernous fistula]

We report an 88-year-old woman who developed a hemorrhagic venous infarction in the left cerebral hemisphere and brainstem, in association with left carotid-cavernous fistula (CCF). Without aura the patient noticed diplopia due to left abducens palsy, and exophthal mos and congestion of the left eye. Brain CT revealed extrusion of the left eye, and dilatation of left superior orbital vein and cerebral cortical veins. She received diagnosis of CCF. Brain CT also revealed a small mass in the left ethmoidal sinus, which was not attached to the CCF. Biopsy of the mass was done under local anesthesia. On the following she had high fever. Her consciousness level deteriorated and she developed right hemiparesis FLAIR images of MRI showed, extensive high signal lesions in the left frontal and temporal cortices, basal ganglia, thalamus, midbrain and pons. These findings were consisted with venous infarction, possibly associated with peri-operative infection and hypovolemia. Intracranial hemorrhage occur in 3% of cases with CCF, but venous infarction was much rarer. The patients with CCF, who show dilatation of cortical veins in CT or MRI, have a higher risk of cerebral hemorrhage or infarction, and should be carefully observed.     

Complex epileptic palilalia: A case report

Palilalia is a kind of motor perseveration involving speech, consisting in the continuous repetition of words or phrases, or both. Rarely it occurs in seizure disorders as ictal or post-ictal manifestation. We report a case of epileptic palilalia in a 71-year-old patient with a previous history of intracerebral haemorrhage in the left frontal region, characterized by the continuous repetition of the same speech sequence for few minutes. EEG recordings during NREM sleep and wakefulness showed recurrent and prolonged focal subclinical epileptiform paroxysms in the left mesial frontal region. Our case confirms the role of the left frontal lobe, reliably of the supplementary motor area (SMA), as neuroanatomic origin of ictal palilalia.     

Working memory for complex scenes: age differences in frontal and hippocampal activations

Age differences in frontal and hippocampal activations in working memory were investigated during a maintenance and subsequent probe interval in an event-related fMRI design. Younger and older adults either viewed or maintained photographs of real-world scenes (extended visual or maintenance conditions) over a 4-sec interval before responding to a probe fragment from the studied picture. Behavioral accuracy was largely equivalent across age and conditions on the probe task, but underlying neural activations differed. Younger but not older adults showed increased left anterior hippocampal activations in the extended visual compared with the maintenance condition. On the subsequent probe interval, however, older adults showed more left and right inferior frontal activations than younger adults. The increased frontal activations at probe in older adults may have been compensatory for the decreased hippocampal activations during maintenance, but alternatively could have reflected the increased difficulty of the probe task for the older subjects. Thus, we demonstrate qualitatively different engagement of both frontal and hippocampal structures in older adults in a working memory task, despite behavioral equivalence.     

Transient ischemic attacks presenting with a loss of pitch perception

It has been suggested that the non-dominant hemisphere is specialized for receptive and expressive music and prosody. The present report describes a patient who experienced a series of non-dominant hemisphere transient ischemic attacks (TIA's) which included an inability to perceive intonation during one episode, and a failure to perceive melody during another. The perceptual losses during these TIA's are consistent with experimental results which suggest that the non-dominant hemisphere is specialized for complex-pitch processing. In some instances, amusia, dysprosody, and aprosodia reflect a common functional deficit.     

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.     

Frontal asymmetry index in Williams syndrome: Evidence for altered emotional brain circuitry?

Asymmetrical frontal electroencephalography (EEG) activity is associated with motivational neural systems of approach/withdrawal behaviors. Greater left frontal EEG has been linked to increased appetitive tendencies whereas increased right frontal activity is related to the activation of avoidance mechanisms. Williams syndrome (WS) is a genetic condition characterized by a highly sociable personality manifested by a propensity to approach strangers and decreased social fear. Consequently, the current study was designed to investigate the frontal cortical activity during resting state, indexed by relative alpha power, in adults with WS as compared to typically developing (TD) controls, and a subgroup of TD extraverts. Results indicated that participants with WS produced attenuated left frontal activity relative to TD peers, or TD extraverts in particular; yet, no groups differed in their degree of right frontal activity. Finally, while both TD group and the extravert subset showed trends of greater left over right frontal activity, the WS participants demonstrated opposing effect of increased right over left frontal EEG. Importantly, individuals with WS produced deviating frontal activity patterns compared to TD extraverts despite exhibiting common social-affiliative tendencies, underscoring that neural mechanisms that give rise to extraversion in WS may not function similarly to those subserving this personality trait expressed in TD.