A case of basilar artery occlusion successfully treated with tissue plasminogen activator]

This case concerns a stroke in the basilar artery territory that was successfully treated with a tissue plasminogen activator (t-PA). A 44-year-old man suddenly lost consciousness. It took fifty minutes to arrive to our hospital after the onset. On admission, his consciousness was in a coma state. A head CT revealed normal findings but a cerebral angiography showed complete occlusion in the basilar artery. We gave 240,000 units t-PA intravenously for 60 minutes. The intravenous t-PA dramatically improved his state of consciousness. After treatment, the brain CT scan showed low-density areas in the left occipital area and right pons. The cerebral angiography showed arterial sclerosis in the basilar artery. There was no parenchymal hemorrhage or hemorrhagic infarction in the patient. The hitherto reports showed the intravenous infusion of t-PA may be particular value in patients with thromboembolic occlusion in the middle cerebral artery. In contrast, our results support its efficacy in strokes in the basilar artery territory.     

支架成形术治疗椎动脉狭窄

目的评价椎动脉狭窄支架成形术的疗效。方法采用球囊扩张支架对椎动脉狭窄段进行支架成形术,使椎动脉狭窄段恢复正常管径。结果23例病人共放置27枚支架,椎动脉狭窄率术前平均为73．2%,术后为25．7%,造影示狭窄段全部成形良好,无并发症发生。随访3～18月,患者临床症状消失18例,症状明显改善4例,症状复发1例。结论支架成形术治疗椎动脉狭窄是一种安全有效的方法。     

双侧椎动脉V4段重度狭窄引起双侧小脑梗死一例

双侧小脑梗死是相对少见的脑梗死,临床表现类似于单侧小脑梗死,发病机制包括动脉粥样硬化性血栓形成、心源性栓塞及动脉到动脉栓塞等,本文报道双侧椎动脉V4段重度狭窄引起双侧小脑梗死一例。     

A case of pregnant woman with severe obsessive-compulsive disorder successfully treated by modified-electroconvulsive therapy]

Obsessive-compulsive disorder (OCD) is rare psychiatric disorder during pregnancy, and is often therapy-resistant. We report a 36-year-old pregnant woman with severe obsessive-compulsive disorder successfully treated by modified-electroconvulsive therapy. During the pregnancy, severe mysophobia and compulsive washing appeared, so severely that she was unable to lie down, endangering the life of the fetus. Since the pharmacotherapy was ineffective, modified electroconvulsive therapy (m-ECT) was performed in cooperation with the obstetrician and the anesthesiologist, along with monitored cardiotocography throughout the procedure. During the second therapy late deceleration on the fetal cardiotocogram occurred, but rapid intravenous administration of ritodrine led to the cessation of abnormal uterine contraction. Two courses of m-ECT markedly diminished her symptoms, and she delivered a healthy infant without complications. M-ECT can be an alternative treatment for pregnant patients with OCD.     

A case of basilar artery stenosis treated by stent placement]

Symptomatic basilar artery stenosis invariably has poor prognosis owing to limited treatment options. Modernized stent system delivery technology has paved the way for treating tortuous vascular segments of intracranial system. The authors hereby report on the use of intracranial stent to treat basilar artery stenosis. A-61-year old man presented with one month history of recurrent dizziness and dysarthria. He remained symptomatic despite having oral antiplatelets. Magnetic resonance image showed pontine ischemic lesion. Stenosis of proximal portion of basilar artery was detected by magnetic resonance angiography (MRA). Although balloon angioplasty was performed, restenosis was demonstrated by MRA four months later. Stenting was then performed with excellent angiographic results, and there were no procedural complications. The availability of new flexible intravascular stents, allowing access to tortuous proximal intracranial vessels, provides a new therapeutic approach to basilar artery stenosis cases. However long term follow-up is advised to assess the durability of this approach.     

A case of brain nocardiosis successfully treated with minocycline]

A 60-year-old man with surgically treated nocardia pyothorax was referred to our hospital since he became drowsy. Brain MRI revealed multiple brain abscesses. His cerebrospinal fluid (CSF) showed increase in polymorphonuclear cells and decrease in glucose. Since he was allergic to sulfamethoxazole * trimethoprim, ceftriaxone and then minocycline were given. Minocycline resulted in dramatic improvement of neurological symtoms, MRI findings and CSF cell count. PCR analysis of 16S ribosomal DNA using his resected thoracic wall revealed that nocardia from his tissue was strain IFM0860. Strain IFM0860 nocardia was found to be sensitive to minocycline but not to sulfamethoxazole * trimethoprim and ceftriaxone. Intravenous administration of minocycline was followed by three-year per os administration of minocycline during which he had no recurrence of brain abscess. Thus, brain nocardiosis could be successfully treated with appropriate antibiotics. The lesson from the present case is that identification of the type of nocardia by PCR analysis of 16S ribosomal DNA could help accomplish tailor-made antibiotic therapy.     

Traumatic extracranial vertebral artery dissection treated with coil embolization--a case report]

We reported a 37-year-old man who developed vertigo, dysarthria and left hemiparesis following neck pain. Magnetic resonance imaging (MRI) demonstrated infarct in the right superior cerebellar artery (SCA) territory. Duplex color-flow imaging detected dissection (double lumen) in the right vertebral artery (VA) at the level of the C4-C6 vertebra (V2 segment). Cerebral angiography showed irregular narrowing in the right V2, and occlusion of the right SCA. These findings suggested that dissection in the right V2 caused artery-to-artery embolism in the right SCA. Despite administration of anti-thrombotic agents, he recurrently suffered from transient ischemic attacks. Serial duplex color-flow imaging echography revealed that the dissection of the right VA gradually became more stenotic and extended to the distal site. Coil-embolization of the right VA by endovascular therapy was performed, and thereafter the dissecting lesion of the right VA was completely occluded and ischemic attacks disappeared.     

Basilar and distal vertebral artery stenosis: long-term follow-up

Forty-four patients with greater than or equal to 50% stenosis of a distal vertebral artery (VA) and/or basilar artery (BA) were followed up for an average of 6.1 years. Angiography was performed for definite vertebrobasilar (VB) transient ischemic attacks (TIA) in 19 (43%), for VB infarcts in 13 (30%) and for non localizing symptoms in 12 (27%). Stenosis in the BA with or without VA involvement was present in 28 patients (64%), while 16 patients (36%) had occlusive disease in one or both distal VA sparing the BA. In follow up, 7 patients (16%) had definite VB TIA and 3 patients had possible VB TIA. Eight patients (18%) sustained a stroke, 5 of which were in the VB territory. The observed stroke rate was 17 times the expected rate for a matched normal population. Eight patients died during follow up, three patients due to stroke (2 brainstem infarctions, one intraventricular hemorrhage). The observed 5 year survival rate was 78% compared to 90% in a matched normal population. In comparing this data with our previous study of 93 patients with proximal VA occlusive disease, distal VB occlusive disease appears to carry a higher risk for brainstem ischemia.     

A giant fusiform basilar aneurysm treated by bilateral vertebral artery occlusion.

OBJECTIVE AND IMPORTANCE: Fusiform aneurysms of the vertebrobasilar arteries that progressively enlarge causing symptomatic brainstem compression are dangerous and their treatment is difficult. A patient with such an aneurysm treated successfully with staged, microsurgical occlusions of the proximal vertebral arteries is described, and the literature pertaining to this rare condition is briefly reviewed. CLINICAL PRESENTATION: A 48-year-old man with a fusiform basilar trunk aneurysm of uncertain etiology presented initially with transient ischemic attacks (TIAs) of the posterior circulation that ceased with anticoagulation. Four years later he presented again with progressive ataxia, dysphagia and dysphonia due to considerable enlargement of the aneurysm causing brainstem compression. INTERVENTION: Staged microsurgical vertebral artery occlusions proximal to the aneurysm were performed. The second (left) vertebral artery was clipped only after the patient passed its temporary occlusion with an endovascular test balloon. The aneurysm subsequently thrombosed, the distal basilar artery kept patent by a single (left) posterior communicating artery. The patient's clinical condition improved markedly over a number of months as the aneurysm mass atrophied. CONCLUSION: Giant vertebrobasilar aneurysms are rare but treacherous lesions, sometimes justifying aggressive management. Carefully selected patients with progressive and severe symptoms due to brainstem compression may tolerate proximal vertebral artery occlusions, provided there is adequate collateral flow to the basilar termination and all of its perforating branches.     

A case of hypoxic brain damage induced by severe asthma successfully treated by hypothermia therapy]

We experienced a case of hypoxic brain damage induced by severe asthma who was successfully treated by hypothermia. A 20-year-old woman with a history of bronchial asthma suffered from severe respiratory distress and she stopped breathing for about 20 minutes. She was admitted to our hospital with respiratory arrest, deep coma, mydriasis and weak motor response to pain. She was intubated and mechanically ventilated with 100% oxygen. She was cooled down to 33 degrees C within 4 hours of her arrival. Her body temperature was maintained at about 33 degrees C for 2 days, and then gradually rewarmed. During hypothermia, PaCO2 was quite high(80-100 mmHg), but the intracranial pressure was kept low. After hypothermia therapy, she became free from consciousness disturbance and there were no neurological disorders except for mild myoclonus. Hypothermia has a possibility of effective therapy for patients with hypoxic brain damage after respiratory distress.     

A case of vertebral artery dissection with recurrent brain embolism]

We report a 63-year-old case of the vertebral artery dissection with recurrent brain embolisms. She was admitted to the hospital because she suffered a visual symptom. She was examined by magnetic resonance imaging (MRI) and diagnosed a left vertebral artery (VA) dissection. Digital subtraction angiography (DSA) revealed the string sign on the left VA supporting the evidence of dissection. However, after DSA, multiple brain embolic stroke was occurred. She was treated with anti-platelet drug (sodium ozagrel), then, recanalization of the pseudo-lumen at the dissecting lesion was observed by MRI examination. Anti-platelet medicine (cilostazol) was taken for preventing reattack although the dissecting lesion was not closed. Following 4 weeks, brain embolisms were observed in the posterior circulation system. MRI revealed a dilated pseudo-lumen at the dissecting lesion with recurrent VA. This time, she was treated only with free radical scavenger (edarabone). After the occlusion of the dissected VA was observed, she started to take anti-platelet medicine again. It is generally accepted to use anti-platelet drug or anti-coagulant drug as a treatment of VA dissection causing brain ischemia. However, it should be assessed more carefully in cases showing recanalization of the pseudo-lumen as observed in this case. Surgical treatments should be taken into consideration at the early stage, especially for the cases presenting fragile dissecting lesions. Further study need to decide the effective treatment of the vertebral artery dissection.     

颈动脉狭窄闭塞性病变后交通支开放与椎动脉起始段狭窄的关系

目的探讨颈动脉狭窄闭塞性病变(≥70%)患者后交通支开放与否与椎动脉起始段狭窄的关系。方法对160例经血管造影证实颈动脉动脉狭窄(≥70%)并行外科治疗(内膜剥脱术、颈动脉支架术)的患者分为后交通支开放组与后交通支未开放组,术前及术后均采用彩色多普勒血流成像(CDFI)检测双侧颈动脉及椎动脉,分别比较两组患者双侧椎动脉起始段狭窄的发生率。结果后交通支开放组椎动脉起始段局部流速术前(后交通支开放)明显高于术后(后交通支关闭)。后交通支关闭前后椎动脉起始段峰值流速(PSV)与舒张末流速(EDV)分别为100.76±74.84cm/s、81.54±54.29 cm/s(P=0.000);后交通支开放患者占50%(80/160),其中椎动脉起始段存在狭窄支数占45.6%(73/160),后交通支未开放患者占50%(80/160),其中椎动脉起始段存在狭窄支数占28.1%(45/160),两者之间存在显著差异(P=0.002)。结论颈动脉狭窄闭塞性病变后交通支开放患者,椎动脉起始段狭窄的发生率显著升高。     

A case of recurrent basilar artery occlusion successfully treated with repeated intravascular procedures

Basilar artery occlusion has a poor prognosis, but intra-arterial revascularization therapy has been shown to improve outcome. We report the case of a 32-year-old patient who suffered recurrent basilar artery occlusion and was successfully treated first with mechanical and pharmacological thrombolysis, then with stenting, in 2 separate angiographic sessions. An etiology of vascular dissection may account for the early postprocedural recurrence.     

A case of internal carotid artery occlusion successfully treated by encephalo-duro-arterio-synangiosis

In many cases, intracranial occlusive strokes in children are treated symptomatically, with a diagnosis of acute infantile hemiplegia. This is because angiography is more difficult in children and, even if occlusive cerebral arterial disease is diagnosed, there is no definite therapeutic procedure. A case is reported of left internal carotid artery occlusion presenting with acute infantile hemiplegia and followed by repeated transient ischemic attacks. Encephalo-duro-arterio-synangiosis — developed as an operation for moyamoya disease — was performed on this patient, resulting in a marked revascularization of the brain in 8 postoperative months with good improvement in symptoms. This suggests that the operation may be effective in chronic cerebral ischemic diseases other than moyamoya disease.     

A case of post-irradiation lumbosacral radiculopathy successfully treated with corticosteroid and warfarin]

A 33-year-old man underwent post-operative radiation therapy for the left testicular anaplastic seminoma. One year later, the patient developed muscle weakness and sensory disturbance in the left lower extremity, and muscle weakness in the right lower extremity. MRI demonstrated linear and focal gadolinium (Gd) enhancement of the anterior portion of the lumbosacral roots within the cauda equina. The neurological symptoms improved after administration of corticosteroid and warfarin. Radiation myelopathy of this type was classified as "selective anterior horn cell injury or amyotrophy" by Reagan, and the site of the lesion was considered to be the lower motor neurons. However, based on the clinical and MRI findings, we proposed that the disease process was injury to the spinal nerve roots rather than the lower motor neurons. Recent neuropathological studies of this syndrome have demonstrated degeneration of the proximal spinal nerve roots. We consider that primary lesions of this syndrome occur in spinal nerve roots rather than in lower motor neurons, and "lumbosacral radiculopathy" is a more appropriate term for this condition.     

Sudden bilateral hearing loss with vertigo due to vertebral artery occlusion]

We report a case of sudden bilateral hearing loss associated with an occlusion of the right vertebral artery. A 66-year-old man was admitted to hospital suffering from sudden onset vertigo, deafness, and vomiting. He could not walk due to truncal ataxia. There was positional nystagmus to the right; spontaneous and gaze-evoked nystagmus were absent. He had no facial nerve palsy, dysarthria, pyramidal tract signs, limb ataxia, and sensory impairment. Pure tone audiometry demonstrated a profound sensorineural deafness of both ears. A tentative diagnosis of sudden deafness was made. He was treated with intravenous infusion of corticosteroid; hearing loss of the left ear slightly improved. Cranial MR imaging demonstrated fresh small infarcts in the right cerebellar tonsil, the left cerebellar medulla, and the left middle cerebellar peduncle. MR angiography demonstrated an occlusion of the right vertebral artery. It is possible that reduced perfusion of the anterior inferior cerebellar arteries and internal auditory arteries on both sides resulted in multiple "border zone" infarcts and damage to the inner ear. Clinicians should be aware of the possibility of vertebrobasilar occlusive disease in case of sudden bilateral hearing impairment, even when brainstem or cerebellar signs are absent.     

A case of spontaneous intracranial hypotension successfully treated with an epidural blood patch]

A 76-year-old woman was admitted to our hospital with complaints of a three-day history of severe postural headache without any apparent cause. Neurological examination revealed nuchal rigidity, and right auditory nerve paresis. Lumbar puncture yielded a low opening pressure of 50mmH2O and an elevated total protein up to 77mg/dl. Cranial magnetic resonance imaging (MRI) using gadolinium revealed diffuse dural enhancement, and effacement of the prepontine cistern. Spontaneous intracranial hypotension was strongly suspected, and to ascertain the presence of a cerebrospinal fluid (CSF) leak, radionuclide cisternography (RNC) was performed, which demonstrated a spinal CSF leak along the nerve root at the level of the lower lumbar spine. Interestingly, computed tomography-myelography (CTM) did not detect these abnormalities. An epidural blood patch with 15 ml of autologous blood at the L3-L4 interspace brought a dramatic symptomatic relief. Follow-up MRI, RNC, and CSF analysis demonstrated that the abnormal findings had disappeared. It is speculated that RNC is more sensitive for detecting small dural tears and CTM for anatomical anomalies including meningeal diverticula and perineural (Tarlov) cysts. We wish to stress, however, that RNC and CTM are complementary and sometimes interchangeable diagnostic modalities, and should be actively employed for detecting CSF leakage in SIH and for appropriate treatment.     

A case of severe motor and intellectual disability with tracheal stenosis due to granulation caused by metal stents treated successfully by silicone stents

A silicone stent (Dumon stent) was used in a severe motor and intellectual disability with severe tracheal stenosis due to granulation caused by an implanted the expanded metal stent (Ultraflex Nitinol Stent). To treat tracheobronchial malacia, diagnosed in infancy, expanded metalic stent was implanted at the ages of 30 and 32 years. However, a few months after the second implantation, progressive dyspnea appeared, and he had to use a respirator under intravenous anesthesia. Bronchoscopy showed re-stenosis of the trachea due to a granulation tissue within the stent. A Dumon stent was applied to control the re-stenosis. He was successfully weaned from a respirator. Since granulation tissue had recurred at the end of the Dumon stent after 3 months, a long term care of the airway and regular observation is necessary after implantation of stents.     

A case of myokymia-cramp syndrome successfully treated with gabapentin

We report a case of "myokymia-cramp syndrome", a rare and benign disease consisting of muscular cramps in the upper and lower limbs associated with generalized myokymias. In our patient, cramps had been present since adolescence and had increased in frequency and duration during the last 3 years, occurring about 8 or 9 times a day. Cramps were mainly nocturnal and also precipitated by walking; a previous treatment with carbamazepine did not improve the symptoms. Gabapentin therapy proved to be very satisfactory in relieving muscular cramps with a relatively low dosage (600 mg/day) and without any remarkable side effects. The possible interpretation of the mechanism involved in gabapentin induced relief of cramps is discussed. Gabapentin should be considered as a safe alternative treatment for muscular cramps.