Poor surgical technique in cervical plating leading to vertebral artery injury and brain stem infarction--case report

BACKGROUND: Lateral mass plating is a safe fixating system for lower cervical fractures. Brain stem infarction after cervical lateral mass screw plating has not been reported in previous literature. We report a case of poor surgical technique leading to vertebral artery injury and brain stem infarction after cervical lateral mass plating. CASE DESCRIPTION: A 41-year-old male patient was transferred to our hospital because of hemiparesis and dysarthria immediately after lateral mass plating for fracture and dislocation of the fifth and sixth cervical vertebrae. Brain magnetic resonance imaging showed infarction of the left posterior inferior cerebellar artery territory, and the vertebral artery angiography showed complete occlusion of the left vertebral artery. The cervical computed tomography revealed a left screw of the fifth and sixth cervical vertebrae penetrating the central portion of the transverse foramen. The patient was managed with anticoagulant and supportive therapy only, with subsequent improvement of hemiparesis and dysarthria. CONCLUSIONS: Poor surgical technique of lateral mass plating in the cervical spine could lead to vertebral artery injury and even brain stem infarction. Postoperative brain infarction in cervical fusion could be a complication of the usually safe lateral mass plating of the cervical spine.     

The ELANA technique: Constructing a high flow bypass using a non-occlusive anastomosis on the ICA and a conventional anastomosis on the SCA in the treatment of a fusiform giant basilar trunk aneurysm

Summary A patient with a partially thrombosed fusiform giant basilar trunk aneurysm presented with devastating headache and symptoms of progressive brain stem compression. Having an aneurysm inaccessible for endovascular treatment, and after failing a vertebral artery balloon occlusion test, he was offered bypass surgery in order to exclude the aneurysm from the cerebral circulation and relieve his symptoms. A connection between the intracranial internal carotid artery and the superior cerebellar artery was created whereupon the basilar artery was ligated just distally to the aneurysm. The proximal anastomosis on the internal carotid artery was made using the excimer laser-assisted non-occlusive anastomosis (ELANA) technique, while a conventional end-to-side anastomosis was used for the distal anastomosis on the superior cerebellar artery. Intra-operative flowmetry showed a flow through the bypass of 40ml/min after ligation of the basilar artery. An angiogram 24 hours later showed normal filling of the bypass and the vessels supplied by it, but also disclosed a subtotal occlusion of the proximal ipsilateral middle cerebral artery with delayed filling distally. The patient, who had a known thrombogenic coagulopathy, died the following day. Autopsy showed no signs of ischemia in the territories supplied by the bypass, but a thrombus in the proximal middle cerebral artery and massive acute hemorrhagic infarction with swelling in its territory and uncal herniation. Multiple fresh thrombi were found in the lungs. The ELANA anastomosis showed re-endothelialisation without thrombus formation on the inside.     

Acute aortic dissection with new massive cerebral infarction - a successful repair with ligature of the right common carotid artery.

It remains unclear whether or not the infarcted brain caused by aortic dissection should be reperfused when an emergency operation is needed for aortic arch dissection. A 64-year-old woman presented with severe back pain and syncope with a sudden left hemiplegia. CT scan demonstrated an aortic dissection of the entire aorta, obstruction of the right common carotid artery by extended aortic dissection, cerebral infarction of the right middle cerebral artery territory, brain edema and pericardial effusion. Though she was unable to communicate with us, she underwent an emergent aortic arch replacement and ligature of the right common carotid artery nine hours after the onset of stroke, when massive cerebral infarction was established. She survived the operation and regained full consciousness. When brain infarction was established by extended aortic dissection in emergent aortic surgery, concomitant ligature of the responsible artery to the brain infarction may be allowed for avoiding cerebral damage leading to brain death.     

Serious complications of microvascular decompression operations for trigeminal neuralgia and hemifacial spasm

Serious complications of microvascular decompression operations for trigeminal neuralgia or hemifacial spasm are reported. Among 278 patients who underwent microvascular decompression, 9 serious complications were observed: 1 intracerebellar hematoma with acute hydrocephalus, 1 cerebellar swelling with acute hydrocephalus, 1 supratentorial acute subdural hematoma, 2 status epilepticus, 1 infarction of the brain stem, 1 subarachnoid hemorrhage due to traumatic aneurysm, and 1 infarction in the territory of the posterior cerebral artery. Of the 9 patients with such complications, 2 died. The possible causes of such serious complications are discussed.     

CNS aspergillosis with mycotic aneurysm,cerebral granuloma and infarction

Summary We are reporting a case of an immunocompromised patient with invasive aspergillosis (IA) who developed aspergillotic granulomas and a mycotic aneurysm of the superior cerebellar artery. The route of infection of the central nervous system (CNS) was hematogenous spread from a pulmonary focus. IA was detected with the Galactomannan (GM) technique. However, despite treatment with amphotericin B, progressive involvement of the vessel wall occurred causing fatal subarachnoid hemorrhage and massive brainstem and cerebellar infarction.This case provides pathologic-imaging correlation of one of the most devastating types of fungal involvement affecting the CNS with a fungal aneurysm. Finally the literature regarding the pathogenetic, and diagnostic investigations and the management of CNS aspergillosis is reviewed.     

Aneurysms of the distal posterior inferior cerebellar artery--analysis of 14 aneurysms in 13 cases

Thirteen cases of distal posterior inferior cerebellar artery (PICA) aneurysms are reported here. All the aneurysms were found after a subarachnoid hemorrhage. Dissecting aneurysm, incidentally found unruptured aneurysms, and aneurysms associated with arteriovenous malformation have been eliminated from this study. Characteristics for this type of lesion are a high rate of recurrent hemorrhage and rapid death due to direct compression of the brain stem, which clearly indicates the necessity of early surgery. Attention should be paid to the fact that angiography cannot always reveal aneurysms, especially when they are located in the peripheral PICA. One should also pay attention to multiple lesions and rapid growing acute subdural hematoma as initial findings for ruptured distal PICA aneurysm. Prognostic factors for these lesions are, vasospasm, especially when the aneurysm is located proximally in the PICA, and direct compression of the brain stem due to intraventricular hemorrhage when the aneurysm is located distally. It has been suggested that the pathogenesis of this lesion could be hemodynamic stress or embryogenesis. The shape and anomalous arterial structures of the 14 aneurysms presented here tend to agree with this suggestion. Our results suggest that the pathogenesis is hemodynamic stress that had developed due to embryological and/or arteriosclerotic factors.     

A case of embolic infarction originating from extracranial vertebral artery stenosis by cervical spondylosis at C5/6: its pathogenesis and surgical treatment

We report a case of right brainstem and cerebellar infarction induced by head rotation. The infarction was due to an artery to artery embolism originating from extracranial vertebral artery stenosis resulting from C5-6 cervical spondylosis. A-64-year-old man with cervical spondylosis experienced swallowing difficulty and vertigo while eating dinner. Neurological examination at admission indicated lateral medullary syndrome (Wallenberg syndrome). MRI (FLAIR) revealed multiple high-intensity signal areas in the right lateral medulla and the cerebellar hemisphere in the territory of the posterior inferior cerebellar artery (PICA). Right vertebral angiogram demonstrated marked stenosis in the neutral position and occlusive changes with head rotation to the right (30 degrees) at C5-6. Rotation induced substantially delayed filling of the right vertebral artery. To remedy this, we resected the osteophyte, fused the uncovertebral joint and connective tissue adhering tightly to the right vertebral artery at C5-6 level, and unroofed the transverse foramens at C5 and C6. Post-operative angiogram confirmed the disappearance of marked stenosis and improved antegrade filling of the right vertebral artery. In the present report, the pathogenesis and surgical treatment of this particular case are discussed.     

Myocardial infarction complicating aortic valve replacement.

One hundred consecutive aortic valve replacements were studied. Fifteen patients had a myocardial infarction as a result of the operation, and four of the five deaths in the series stemmed from this group. In the four deaths from infarction, autopsy revealed occlusion of a main coronary artery. This was attributable to coronary perfusion in three instances. All of the 11 survivors who sustained an infarct were free of angina and left ventricular failure 6 weeks after the operation. Patients with infarcts had longer bypass times and larger aortic systolic gradients than the patients who did not have an infarct. It is suggested that an infarct can occur as the result of occlusion of a main coronary artery; this is a fatal event commonly related to trauma from the coronary perfusion cannula. Alternatively, infarction may result from regional ischemia, perhaps without vessel occlusion, and is associated with long bypass times and with large aortic valve gradients. In such cases the prognosis is good. However, myocardial infarction was the major cause of death in this series.     

Arteriovenous malformation in the territory of the occluded middle cerebral artery with massive intraoperative brain swelling: case report

We present an extremely rare case of an arteriovenous malformation (AVM) in the territory of the middle cerebral artery, the main trunk of which was occluded asymptomatically. Immediately after an uneventful excision of the entire AVM, massive brain swelling occurred unexpectedly and was treated successfully with high dose barbiturate therapy associated with other standard measures of controlling increased intracranial pressure. The underlying pathophysiological mechanisms leading to the massive intraoperative brain swelling in this case are discussed.     

Analysis of ischemic brain damage in cases of acute subdural hematomas

BACKGROUND: Ischemic damage of the brain is one of the most important factors for the sequelae of acute subdural hematomas (ASDHs). However, ischemic damage is infrequently addressed in a systematic manner in the clinical setting. METHODS: The analysis of ischemic brain damage was performed based on serial computed tomography (CT) scans in 80 patients with traumatic ASDHs. Single photon emission computed tomography (SPECT) for regional blood flow and/or magnetic resonance imaging (MRI) were also performed. RESULTS: Follow-up CT scans showed ischemic brain damage in 19 patients and no significant damage in 35 patients. The remaining 26 patients progressively deteriorated to the point of brain death. The ischemic brain damage was seen most frequently in the territory of the anterior cerebral artery (13 cases), followed by the territory of the posterior cerebral artery (12 cases). The ischemic damages in the pallidum, the hypothalamus and the thalamus were demonstrated in 4, 8, and 4 cases, respectively. The ischemic damage in the underlying brain that was probably because of the direct compression of the hematoma was seen in only two cases. CONCLUSIONS: Most of the ischemic brain damage noted in this study was because of arterial compression secondary to the brain shift and brain herniation, rather than the direct effect of the hematoma upon the underlying brain. Ischemic brain damage adversely affects outcome morbidity, and the difficulty in preventing ischemic damage in cases with marked brain shift leads to poor outcome in patients with ASDHs.     

Asymptomatic versus symptomatic infarcts from vasospasm in patients with subarachnoid hemorrhage: serial magnetic resonance imaging

OBJECTIVE: By use of serial magnetic resonance imaging (MRI), we prospectively investigated the incidence of and the risk factors associated with infarction caused by vasospasm with or without a delayed ischemic neurological deficit (DIND) in patients with subarachnoid hemorrhage (SAH). METHODS: In 125 patients who underwent surgery for early aneurysms, postoperative MRI scans were obtained at four time points. We defined an infarct from vasospasm as a new lesion not present on the initial MRI within 3 days after SAH and therefore not attributable to primary brain damage or surgical complications. RESULTS: Overall, symptoms of infarction (i.e., DIND) occurred in 38% of patients (48 of 125); DIND with a new infarct on MRI was evident in 34% (43 patients), whereas 4% (5 patients) showed no new lesion but had a DIND. However, 29 patients (23%) showed a new infarct but no DIND on MRI studies (asymptomatic infarction). Asymptomatic ischemic lesions due to vasospasm tended to involve noneloquent brain areas in the territory of intraparenchymal perforators. Multivariate analysis identified variables associated with symptomatic infarction to be of poor SAH grade, advanced age of the patient, angiographic findings of vasospasm, multiple cortical infarcts on MRI studies consistent with vasospasm, and chronic hydrocephalus. CONCLUSION: Analysis of the data confirmed the occurrence of asymptomatic infarcts due to vasospasm. These infarcts often developed in noneloquent areas representing perforator territory. MRI investigation of vasospastic lesions referable to intraparenchymal vessels such as perforators complements the study of extraparenchymal major vessel vasospasm in patients with SAH by computed tomographic angiography.     

Diffusion-weighted echo planar imaging of acute brain infarction: a preliminary report

The clinical usefulness of diffusion-weighted echo planar imaging (DW-EPI) was studied in 55 patients with acute brain ischemia. Ischemic lesions were identified on DW-EPI as hyperintense regions in all patients before changes were detected by conventional magnetic resonance imaging techniques in 12 cases studied earlier than 6 hours after onset. The earliest case was verified on DW-EPI at 50 minutes after onset. The ultra-fast imaging technique took less than 2 minutes to perform even for restless patients. Three patients had cardioembolic middle cerebral artery occlusion, and emergent percutaneous transluminal recanalization was carried out. Chronological changes in the signal of brain ischemia on DW-EPI depended on the site and size of the lesion, lacunar infarct of basal ganglia, and/or massive infarct due to major vessel occlusion, and were affected by associated hemorrhagic events. Coronal DW-EPI could more easily demarcate ischemia in the brainstem and/or cerebellum than axial scans when susceptibility artifacts were present. Coronal scans also demonstrated the site and direction of the pyramidal tract and its anatomical correlation with the lesions. DW-EPI has potential for the diagnostic and therapeutic planning of patients with acute brain ischemia.     

Primitive trigeminal artery variant aneurysm treated with Guglielmi detachable coils--case report

A 69-year-old woman had suffered from diplopia on right lateral gaze for the last 4 months due to right abducens nerve paresis. Right carotid angiography showed a cavernous internal carotid artery (ICA) aneurysm of 17 x 16 x 14 mm size and a primitive trigeminal artery (PTA) variant supplying the territory of the posterior inferior cerebellar artery. Intraluminal occlusion of the aneurysm was performed with 15 Guglielmi detachable coils. The flow of the PTA variant and the ICA was preserved. Right abducens nerve paresis improved partially. PTA variant is a primitive artery originating from the cavernous ICA supplying the cerebellum without opacification of the basilar artery. Only four of the 67 cases of PTA variant were associated with an aneurysm of the PTA variant. The possibility of this rare association should be considered when treating cavernous portion aneurysm because of the risk of cerebellar ischemia.     

Diagnosis of anterior inferior cerebellar artery occlusion on magnetic resonance angiography with reference to basiparallel anatomic scanning-magnetic resonance imaging

A 67-year-old woman presented with symptomatic infarction in the territory of the anterior inferior cerebellar artery manifesting as vertigo, vomiting, and right facial weakness. Basiparallel anatomic scanning (BPAS) magnetic resonance (MR) imaging combined with MR angiography demonstrated the occluded anterior inferior cerebellar artery. Common anatomic variations and limited detection of the smaller branches on MR angiography sometimes hinder evaluation of the occluded artery. BPAS-MR imaging may have a supplementary role to MR angiography in the diagnosis of cerebellar artery occlusions.     

A growing aneurysm of the posterior inferior cerebellar artery complicated with cerebellar infarction: A case report

Introduction and importanceHereby we describe an instructive patient with cerebellar infarction and a growing aneurysm at the posterior inferior cerebellar artery (PICA), which was not a true cause of infarction.Case presentationA 50-year-old female presented with dizziness and posterior neck pain at our hospital (Mitaka city, Tokyo, Japan). Diffusion weighted magnetic resonance (MR) images showed cerebellar infarction in the left PICA territory and MR angiography study showed an aneurysm at the origin of the left PICA, which grew in 2 weeks. Since we considered cerebellar infarction was caused by thrombosis from the aneurysm, trapping of the PICA and occipital artery-PICA bypass was performed to prevent recurrent cerebellar infarction and rupture of the aneurysm by neurosurgeons. During the operation, dissection was observed at the distal PICA, which was diagnosed to be the true cause of cerebellar infarction. By the follow-up for 12 months at an outpatient, there was no recurrence of cerebral infarction.Clinical discussionA specimen of the artery showing the findings of dissection was not obtained, and the pathological diagnosis could not be made. It would be controversial whether a surgical procedure presented here was the most optimal.ConclusionThis is a first reported case of growing aneurysms and cerebral infarction due to arterial dissection. Even if cerebral infarction is accompanied by growing aneurysms, arterial dissection should be included in the differential diagnoses of a cause of infarction. Posterior cervical pain can be a clue for early appropriate diagnosis in such a case.     

Decompressive craniectomy for massive infarction of middle cerebral artery territory

There is continuing controversy about the benefits of decompressive craniectomy for the treatment of massive infarction of middle cerebral artery (MCA) territory. Under conservative therapy, the mortality rate for this stroke is reported to be up to 80%. So the authors have actively carried out decompressive craniectomy since 1997, and have compared the outcome with patients who were admitted before 1997 and, consequently treated with conservative therapy. Fifteen consecutive victims of massive infarction of MCA territory were studied. Seven patients (male: 1, female: 6, mean age: 79.8 years) were treated with conservative therapy, and 8 patients (male: 3, female: 5, mean age: 71.8 years) were treated with decompressive craniectomy. There were no significant differences in age and consciousness level distribution between the two groups. Mortality rate in the conservative therapy group was 85.7% against 12.5% in the surgery group (p < 0.05). Functional performance, which was evaluated by activity in daily life (ADL), was also better in the surgery group e.g. 3 patients in ADL 3, and 3 in ADL 4 (1 patient died from a non-neurological cause). Even among the patients with speech-dominant hemispheric stroke, all except one were able to communicate in some way and understand language. Even though patients in this study were elderly, decompressive craniectomy reduced mortality and improved functional performance, so it seems that this surgery should be aggressively considered for massive infarction of MCA territory.     

Retrospective analysis of neurological outcome after intra-arterial thrombolysis in basilar artery occlusion

BACKGROUND: Basilar artery occlusion usually has a very poor outcome and is associated with a high mortality rate. Local intra-arterial thrombolysis may improve the clinical outcome and reduce mortality in the treatment of acute basilar artery occlusion. We evaluated the possible variables affecting recanalization and clinical outcome in patients with basilar artery occlusions undergoing thrombolytic therapy. METHODS: We analyzed retrospectively the clinical course and outcome of a series of 26 patients between 1998 and 2001. All patients who were examined within 24 hours after onset of symptoms underwent emergency cerebral angiography and subsequent intra-arterial thrombolysis. Three patients additionally received percutaneous transluminal angioplasty of underlying stenosis at the site of thrombosis. RESULTS: Outcome was good in 9 patients (34.6%) and poor in 17 (65.4%). Recanalization could be achieved in 24 patients (92.3%) and was not affected by age, sex, site of occlusion, etiology, thrombolytic drugs, or time interval. Good outcome was associated with younger age, good initial clinical condition, and no evidence of brain stem infarction. There was no association between the interval (greater or less than 6 hours) from the onset of symptoms until the end of thrombolysis and survival. CONCLUSIONS: We confirm that intra-arterial thrombolysis reduces mortality in basilar artery occlusion. Young patients (<75 years) without any infarct in brain stem before the start of treatment seem to be the ideal candidates for thrombolysis. Basilar artery thrombosis could and should be reopened, even late (after 6 hours) after symptom onset.     

Basilar artery migraine. Case report

The case of a 40-year-old woman with a 24-year history of basilar artery migraine is described. She was admitted to the hospital after suffering a large cerebellar infarction causing hydrocephalus and deep stupor during an attack of migraine. She recovered after ventricular shunting and removal of the infarct.     

儿童脑梗死临床及MRI表现

目的 观察儿童脑梗死的临床及MRI表现。方法 回顾性分析14例7个月～14岁脑梗死患儿临床及MRI资料,均接受头部常规MRI及弥散加权成像(DWI),11例同时接受MR血管造影(MRA),5例同时接受动脉自旋标记(ASL)灌注成像,观察其相关特点。结果 14例中,5例为先天性心脏病及脑动脉瘤术后,2例脑部外伤,2例颅内病毒感染,1例血管肌纤维发育不良,1例非特异性血管炎,3例病因不明;其中6例病变累及基底核区,4例累及单或双侧脑叶,小脑半球受累2例,脑桥及丘脑受累各1例。常规MRI中,14例病灶T1WI均呈稍低信号、T2WI呈稍高信号,1例基底核区及侧脑室旁梗死区见出血转化,2例液体衰减反转恢复(FLAIR)序列图像示病变周围脑沟内血管扩张;DWI中1例病灶呈低信号外,13例病灶呈高或稍高信号。11例接受MRA,其中6例未见异常、5例脑动脉(椎动脉、基底动脉、大脑后动脉、大脑中动脉、颈内动脉)闭塞或重度狭窄。5例急性及亚急性期患儿接受ASL检查,其中4例病变呈高灌注,1例病变中央呈低灌注、边缘呈高灌注。结论 先天性心脏病术后、脑部外伤及颅内感染是儿童脑梗死常见病因;基底核区及脑叶为儿童...