Vasoconstriction of external carotid arteries after the rupture of intracranial aneurysm (author's transl)]

A patient in whom vasospasm of not only intracranial but also extracranial arteries was demonstrated after the rupture of an intracranial aneurysm was reported. A 55-year-old male was admitted with a ruptured left IC-PC aneurysm. Intracranial direct operation and continuous ventricular drainage were performed 33 hours after the rupture. Six days after the surgery, right hemiparesis and consciousness disturbances developed. Angiography revealed severe vasospasm of intra-and extracranial arteries, especially branches of the external carotid artery. The symptoms improved markedly following the superior cervical ganglionectomy and perivascular sympathectomy of cervical internal carotid artery on the left side. Vasospasm of the external carotid system, which has not been reported, was further investigated angiographically in 23 patients who had vasospasm of the intracranial arteries after aneurysm rupture. In about 50% of these patients was found vasospasm of the external carotid system too. These changes were not found in control cases without vasospasm of the intracranial arteries. Pathogenesis of the vasospasm of the external carotid system was discussed with particular emphasis on the relationship with the sympathetic nerves.     

Pseudo-occlusion and/or Pseudo-stenosis of the Intracranial Internal Carotid Artery

This report summarizes our recent experience with two patients who presented with symptoms ipsilateral to a severe carotid stenosis at the bifurcation, with one having a severe stenosis at the siphon and the other an occlusion of the internal carotid artery in its intracranial portion. These lesions were documented on preoperative angiography. In both instances, persistence of symptoms, despite maximal medical therapy, led us to proceed with carotid endarterectomy. In both cases, intraoperative angiography confirmed a normal intracranial internal carotid artery, contrary to what had been seen on preoperative angiography. Carotid endarterectomy was performed, with resolution of clinical symptoms in both cases. This experience suggests that the appearance of the intracranial portion of the carotid artery can be significantly affected by the presence of a proximal lesion at the bifurcation. Stenosis and/or occlusion of the intracranial portion of the carotid artery may appear on preoperative angiography secondary to flow alterations as a result of the more proximal lesion. This, in part, may explain why many patients with combined extracranial and intracranial arterial disease improve after carotid endarterectomy and suggests that, in the presence of a severe extracranial lesion, further evaluation be undertaken to exclude the possibility of pseudo-stenosis or pseudo-occlusion of the intracranial carotid artery.     

Raeder's syndrome associated with intracranial internal carotid artery aneurysm

Raeder's syndrome consists of oculosympathetic paresis and ipsilateral facial pain, with variable involvement of the trigeminal and oculomotor nerves. A 63-year-old woman experienced severe facial pain, a partial Horner's syndrome, and restriction of ocular movements on the left side. A left carotid angiogram disclosed a giant aneurysm of the cavernous portion of the internal carotid artery. This is the third reported case of Raeder's syndrome due to aneurysm of the intracranial internal carotid artery. Her facial pain was relieved by carotid ligation, and serial computed tomographic scans showed decrease of aneurysmal size.     

Hyperperfusion Syndrome after Carotid Endarterectomy

The hyperperfusion syndrome is a rare delayed postoperative complication of carotid endarterectomy (CEA) characterized by headache and seizure, with or without intracranial edema or hemorrhage. Between January 1996 and December 2003, 1,602 CEAs were performed. Six patients (0.4%) developed symptoms of hyperperfusion within 2 weeks of surgery. All patients had critical stenoses, five ≥90% and one 80-90%, with poor backbleeding from the distal internal carotid artery noted at operation in all cases. Five patients were asymptomatic prior to operation; one had a hemispheric transient ischemic attack. Three patients had severe contralateral internal carotid disease (two occlusions and one severe stenosis). Two patients developed severe, self-limiting headache that prolonged hospitalization. Three patients had ipsilateral intracranial bleeding, two occurring after an uneventful postoperative course. After initial discharge from the hospital, severe intracranial hemorrhage caused death in two patients. One patient experienced focal seizures 1 week after discharge. Hypertension did not appear to be related to the symptoms in any case. During the study period, the hyperperfusion syndrome caused three of five perioperative strokes (60%) and two of seven deaths (29%) in the entire endarterectomy population. Although rare, the hyperperfusion syndrome accounts for a significant percentage of the neurological morbidity and mortality following CEA.Presented at the Twenty-second Annual Meeting of the Southern California Vascular Surgery Society, La Jolla, CA, April 30-May 2, 2004.     

A giant aneurysm of the internal carotid artery treated by intracranial direct surgery--with a special reference to the anatomical relationship between the cavernous sinus and the internal carotid artery (author's transl)]

There have been a few reports about intracranial giant aneurysms treated by intracranial direct approaches. Especially, for giant aneurysms of the internal carotid artery, direct operation has been thought to be difficult to perform because of the anatomical particularity and the danger of rupture during surgery. So the cervical carotid ligation has frequently been indicated. However, the carotid ligation does not relieve the symptoms caused by the giant aneurysm as an "intracranial mass lesion". The authors have reported here, a cured case of a giant aneurysm of the intracavernous portion of the internal carotid artery, to which, as the first step, ligation of the internal carotid artery in the cervical region was performed, and as the second step, endaneurysmorrhaphy was carried out for the remaining symptoms caused by the "intracranial mass lesion". Furthermore, the surgical techniques for treatment of giant aneurysms of the internal carotid artery were discussed citing literatures, and the authors concluded that the combined operation of carotid ligation and endane-urysmorrhaphy could be effective to giant aneurysms in this region. Meanwhile, a new concept concerning the anatomy of the carotid-cavernous region already proposed by Bedford, was confirmed by our observation at operation. It may be considered that the intracranial direct approach to aneurysms in this region and also to carotid cavernous fistulae should more frequently be indicated than ever performed, according to the new concept of the anatomy in this region.     

Resection for pulmonary metastasis of gastrointestinal stromal tumor of the stomach at 10 years after gastrectomy; report of a case

A 70-years-old male, who had received gastrectomy for leiomyosarcoma of the stomach 10 years ago, was found to have a left lung tumor on chest X-ray and computed tomography (CT). The tumor was diagnosed to be a pulmonary metastasis of gastric leiomyosarcoma. On admission, another tumor was detected at left occipital region by brain CT and was thought to be meningioma. Left lower lobectomy and brain tumor resection were performed serially. The histologic and immunohistochemical findings showed that both tumors were metastases of gastrointestinal stromal tumor (GIST) of the stomach after long disease-free interval. Compared with the primary tumor, cellular density, mitotic figures, bizarre nuclei, and necrotic foci were prominent in the metastatic tumors. This case suggest that GIST may recurrent as pulmonary metastasis after long disease-free interval and should be follow up longer after resection. Patient prognosis with pulmonary metastases is considered to be reflected more exactly in biological malignant potential of metastatic tumor rather than that of primary tumor.     

Avoidance of vascular compression in decompressive surgery for brain edema caused by trauma and tumor ablation.

BACKGROUND: In case of severe brain swelling especially caused by trauma or other operative manipulation (tumor ablation), decompressive craniectomy with durotomy has not resulted in significant chances of recovery. Decompressive craniectomy has been defined only as an option within guidelines. METHOD: A new operative technique was developed to improve the efficacy of decompressive surgery. With an increase in intracranial pressure (ICP) threatening with brainstem herniation, wide bilateral craniectomy was carried out, followed by dura opening and subsequent formation of a vascular tunnel in a simple way--using hemostatic sponge cushions--around the main cortical veins at the entering points of the herniated area. The maintenance of vessel patency prevents the herniated brain segment from venous congestion, i.e., from further swelling and necrosis. RESULTS: Twenty operations with traumatic brain edema were performed using this vascular tunnel method. All patients were exposed to surgery in the state of coma. One operation was performed after tumor removal. The results were promising in comparison with the well-known surgical or conservative treatment. DISCUSSION: Applying very strict selection criteria (Glasgow coma scale < 6, signs of severe edema on CT, or intracranial pressure permanently > or = 30 mmHg) in this small series of patients with severe brain injury, good results were achieved using the new operative technique. In case of postoperative edema after tumor ablation, it also showed promising results.     

Hemoperitoneum caused by a ruptured GIST located in the posterior gastric wall managed by endoscopic diagnosis and laparoscopic treatment: case report and literature review

A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with <1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall.     

Intracranial internal carotid artery aneurysm as a cause of raeder's paratrigeminal syndrome

A 26-year-old woman was first seen with severe facial pain, partial Horner's syndrome, and restriction of ocular movements on the right side—all features of Raeder's paratrigeminal syndrome. Right carotid angiogram revealed an aneurysm of the internal carotid artery. This is the second reported case of Raeder's syndrome due to an aneurysm of the intracranial portion of the internal carotid artery. The mechanism of facial pain and sympathetic involvement are discussed.     

Vertebral and carotid artery dissection following chiropractic cervical manipulation

A 50-year-old woman presented a sudden left occipital headache and a posterior circulation stroke after cervical manipulation for neck pain. Magnetic resonance imaging documented a left intracranial vertebral artery occlusive dissection associated with an ipsilateral internal carotid artery dissection with vessel stenosis in its prepetrous tract. This is the first reported case showing an associate vertebral and carotid artery dissection following cervical manipulation. Carotid dissection was asymptomatic and, therefore, its incidence may be underestimated. We emphasize that cervical manipulation should be performed only in patients without predisposing factors for artery dissection and after an appropriate diagnosis of neck pain. Received: 25 October 1997 / Accepted: 19 August 1998     

Intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery in a patient with polycystic kidney disease

We report a rare case with polycystic kidney disease (PKD) having an intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery. A 55-year-old man with chronic renal failure due to PKD presented with headache. CT scan and MRI showed no abnormal findings. MRA showed cervical occlusion of the right internal carotid artery and an ipsilateral intracranial carotid aneurysm. At surgery, the saccular aneurysm protruded anterolaterally at the C2 portion of the right internal carotid and was clipped. Hemodynamic stress of the blood flow through the posterior communicating artery and the fragility of arteries because of PKD were considered to be two main causes of aneurysmal formation in this case.     

Spinal subdural hematoma: a sequela of a ruptured intracranial aneurysm?

BACKGROUND: A case of spinal subdural hematoma (SSDH) following subarachnoid hemorrhage (SAH) because of a ruptured internal carotid aneurysm is described. Such a case has never been reported. CASE DESCRIPTION: A 52-year-old woman underwent a craniotomy for a ruptured internal carotid aneurysm. A computed tomography scan showed that SAH existed predominantly in the posterior fossa and subdural hematoma beneath the cerebellar tentorium. Intrathecal administration of urokinase, IV administration of fasudil hydrochloride, and continuous cerebrospinal fluid (CSF) evacuation via cisternal drainage were performed as prophylactic treatments for vasospasm. On the sixth postoperative day, the patient complained of severe lower back and buttock pain. Magnetic resonance imaging showed a subdural hematoma in the lumbosacral region. Although the mass effect was extensive, the patient showed no neurologic symptoms other than the sciatica. She was treated conservatively. The hematoma dissolved gradually and had diminished completely 15 weeks later. Her pain gradually subsided, and she was discharged 7 weeks later without any neurologic deficit. CONCLUSION: Although the exact mechanism of SSDH in this case is unclear, we speculate that this SSDH was a hematoma that migrated from the intracranial subdural space. Low CSF pressure because of continuous drainage and intrathecal thrombolytic therapy may have played an important role in the migration of the hematoma through the spinal canal. It is important to recognize the SSDH as a possible complication of the SAH accompanied with intracranial subdural hematoma.     

Emergency Pylorus-Preserving Pancreatoduodenectomy Followed by Second-Stage Pancreatojejunostomy for a Gastrointestinal Stromal Tumor of the Duodenum with an Intratumoral Gas Figure: Report of a Case

We report a case of a duodenal gastrointestinal stromal tumor (GIST) necessitating urgent surgery because of a gas figure on computed tomography (CT). A 46-year-old woman, complaining chiefly of upper abdominal pain and tarry stools, consulted a local doctor. A gastrointestinal fiberscopy revealed an ulcer in the second part of the duodenum, and the patient was admitted to our hospital where a dynamic CT scan showed a hypervascular solid tumor in the pancreatic head. A repeat CT scan done 4 days later showed a gas figure in the tumor, necessitating an emergency pylorus-preserving pancreatoduodenectomy (PpPD). First, we performed a tube pancreatostomy for complete external drainage of the pancreatic juice, and planned a second-stage pancreatojejunostomy for the near future. Histopathologically, the tumor was diagnosed as a GIST originating in the duodenum. The patient was discharged on postoperative day 23 after an uneventful postoperative recovery. Her local doctor completed the second-stage pancreatojejunostomy.     

Cerebral revascularization for ischemic disease in the 21st century

Shortly after the first extracranial to intracranial (EC-IC) carotid artery bypass was performed by Yasargil in 1967 for internal carotid artery occlusion, cerebral revascularization became widely accepted in the neurosurgical field, and the procedures became increasingly used as practitioners began to master the technical aspects of the surgery. The procedures were performed for intracranial arterial stenosis and occlusion and used as an adjunct in the treatment of large aneurysms and skull base tumors. The results of the EC-IC bypass group trial in 1985 were surprising to many and sobering to all; EC-IC bypass for stenosis or occlusion of the high internal carotid artery or middle cerebral artery did not decrease the risk of subsequent stroke compared with medical management. Rather, the incidence of stroke increased, and the events were noted to occur sooner than with medical therapy alone. Despite the known limitations of this landmark study, the number of EC-IC bypass procedures fell precipitously over the ensuing decades. Despite this significant setback, cerebral revascularization is not obsolete. This article revisits the sequence of events leading to the rise of revascularization surgery and recaps the impact of the EC-IC bypass trial. The limitations of the trial are discussed, as are current studies evaluating the efficacy of cerebrovascular bypass procedures for symptomatic carotid occlusive disease. The authors review the accepted indications for bypass surgery in the early 21st century.     

1例巨大小肠间质瘤伴肝转移的MDT治疗

目的探讨多学科协作团队(MDT)在诊治胃肠间质瘤(GIST)伴肝转移中的作用及意义。方法对川北医学院附属医院2018年8月收治的1例巨大(直径>10 cm)小肠间质瘤伴肝转移患者展开MDT讨论治疗的经验进行总结。结果该例患者为一46岁女性,初次就诊时即确诊GIST伴肝转移,已失去手术机会,采用新辅助治疗后肿瘤缩小,后经2次MDT讨论后成功完成了原发灶及转移灶的R0切除,患者术后继续口服伊马替尼600 mg/d治疗,截至目前总生存期已达31个月,复查未见肿瘤复发征象,仍继续随访中。结论酪氨酸激酶抑制剂联合手术治疗是GIST伴肝转移患者最适合的治疗方式,能提高患者生存期。在临床工作中,可合理运用MDT诊疗方式并贯彻于GIST伴肝转移患者的整个治疗过程中,为其提供最佳的治疗选择。     

The association of intracranial meningioma with arteriovenous malformation and aneurysm (author's transl)

A rate case was reported in which a brain tumor was also found in a patient who had an intracranial arteriovenous malformation and a cerebral aneurysm separately. A 56-year-old man was admitted with motor weakness and repeated convulsions in the left lower limb. Preoperative right and left carotid angiograms showed an arteriovenous malformation in the left parietal region and a left internal carotid artery aneurysm, but both the carotid angiograms and brain scintigrams could reveal no brain tumor. After the radical operation for these two lesions, pneumoencephalography, right serial carotid angiography and brain scintigraphy were performed, demonstrating a right parasagittal tumor. The tumor was totally removed and histological findings were fibrous meningioma.     

Gastrointestinal Stromal Tumor of the Rectum Resected by Laparoscopic Surgery: Report of a Case

A 53-year-old man visited our hospital with the chief complaint of pain on urination. On digital rectal examination, a rigid immobile tumor mass with a smooth surface was palpated on the anterior wall on the right side of the rectum near the anal canal. Computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis revealed a heterogeneous tumor mass measuring 6.5 cm in diameter, which occupied the cavity of the lesser pelvis. This rectal tumor was diagnosed to be a gastrointestinal stromal tumor (GIST) based on the results of a transrectal needle biopsy. A laparoscopic abdominoperineal resection of the rectum was performed to remove the mass. The intraoperative findings showed an ambiguous boundary between the tumor and the rectum but clear boundaries between the tumor and the peripheral organs, and the use of a laparoscope allowed for a good separation by providing a good visual field. The bleeding volume was approximately 80 ml and the operative time was 320 min. The macroscopic findings of excised specimens of the mass showed the tumor, measuring 6.5 × 5.5 × 5.0 cm, to be growing extrinsically from the anterior wall on the right side of the rectum. A histological examination of the excised specimens revealed at most 5 mitoses per 50 high-power fields (×400). The tumor mass was diagnosed to be a GIST of low-grade malignancy based on these findings. The postoperative course was favorable, and there were no postoperative complications. The patient was discharged on the 8th hospital day. Laparoscopic surgery is a minimally invasive surgical procedure for rectal GIST, which is excellent in terms of esthetics. Laparoscopic surgery is therefore considered to be useful for a resection of the rectum, because the magnifying effect allows surgical maneuvers with a favorable visual field within the pelvis.     

Fibromuscular dysplasia with cerebral infarction in children. Case report

A 15-year-old boy suddenly developed a headache, followed by progressive weakness of the right extremities. A computed tomographic scan obtained on admission showed a low-density area in the left putamen extending to the internal capsule. No neurological deficits were observed other than slight dysarthria and right hemiparesis. Left carotid angiography showed the characteristic "string of beads" deformity of fibromuscular dysplasia (FMD) extracranially and complete occlusion of the internal carotid artery at the C2 portion. The right carotid artery and both vertebral arteries were normal. Anastomosis of the left superficial temporal and middle cerebral arteries was performed 1 month after the onset. The patient recovered quickly from the hemiplegia and was discharged with no neurological deficits. Angiograms obtained 3 months later showed not only patency of the bypass, but also recanalization of the intracranial internal carotid artery. Cervico-cephalic FMD mainly affects middle-aged women, and is uncommon in children; only nine childhood cases have been reported. This disorder may play an important role in the genesis of strokes among children.     

Avoidance of vascular compression in decompressive surgery for brain edema caused by trauma and tumor ablation

Background. In case of severe brain swelling especially caused by trauma or other operative manipulation (tumor ablation), decompressive craniectomy with durotomy has not resulted in significant chances of recovery. Decompressive craniectomy has been defined only as an option within guidelines. Method. A new operative technique was developed to improve the efficacy of decompressive surgery. With an increase in intracranial pressure (ICP) threatening with brainstem herniation, wide bilateral craniectomy was carried out, followed by dura opening and subsequent formation of a vascular tunnel in a simple way –using hemostatic sponge cushions – around the main cortical veins at the entering points of the herniated area. The maintenance of vessel patency prevents the herniated brain segment from venous congestion, i.e., from further swelling and necrosis. Results. Twenty operations with traumatic brain edema were performed using this vascular tunnel method. All patients were exposed to surgery in the state of coma. One operation was performed after tumor removal. The results were promising in comparison with the well-known surgical or conservative treatment. Discussion. Applying very strict selection criteria (Glasgow coma scale <6, signs of severe edema on CT, or intracranial pressure permanently ≥30 mmHg) in this small series of patients with severe brain injury, good results were achieved using the new operative technique. In case of postoperative edema after tumor ablation, it also showed promising results. Electronic Publication     

61例直肠胃肠间质瘤临床分析

目的探讨直肠胃肠间质瘤（GIST）的临床特征和治疗及其预后因素。方法对中山大学肿瘤防治中心1990年1月至2012年10月收治的61例直肠GIST患者的临床资料和随访资料进行回顾性分析,并对病理标本进行复核;应用Kaplan。Meier法计算生存率,分别应用Log．rank检验和Cox回归模型对影响预后的因素进行单因素和多因素分析。结果61例直肠GIST患者中,男42例,女19例,中位年龄59岁。18例（29．5％）为术前活检确诊为GIST;46例首次病理诊断为GIST,另15例（24．6％,15／61;其中14例原诊断为平滑肌瘤或肉瘤,1例诊为神经鞘膜瘤）经复核病理标本后修正为GIST。肿瘤位于腹膜反折以上12例（19．7％）,反折以下49例（80．3％）。经手术治疗52例．其中扩大切除术（同时作淋巴结清扫或联合脏器切除）21例,局部切除术（肿瘤剔除或直肠壁部分切除）31例。11例术前予以伊马替尼400mg／d新辅助治疗,41例患者术后或活检诊断后以伊马替尼治疗,其中25例为术后复发姑息治疗。中位随访时间为55（6～391）月,52例手术者1、2、3和5年生存率分别为98．0％、95．6％、86．0％和73．7％;扩大切除术组5年生存率为82．6％,局部切除术组则为77．3％,两组差异无统计学意义（P=0．947）;单因素分析结果显示,生存率仅与复发转移相关（辟0．038）。多因素cox回归分析显示,各项因素均与术后生存率无关（均P〉0．05）。但术后复发及远处转移患者口服伊马替尼治疗者的3年生存率优于未服药者（82．7％比71．4％）。结论直肠GIST多见于直肠下段。外科手术仍是治疗的核心,原则上施行局部完全切除即可,广泛切除或扩大淋巴结清扫不能提高生存率。伊马替尼有助于改善复发转移患者的预后。