Long-term follow-up study of unruptured vertebral artery dissection: clinical outcomes and serial angiographic findings

OBJECT: Although the spontaneous occurrence of an unruptured vertebral artery (VA) dissection has increasingly been recognized as a relatively common cause of stroke, and the clinical aspects of this lesion have gradually been determined, its natural course remains obscure. The main goal of this study was to clarify the management protocol for this condition by examining serial angiographic changes in patients with unruptured VA dissections. METHODS: Seventeen patients with unruptured VA dissections, including 13 men and four women, were clinically and angiographically examined between 1993 and 1998. All patients were observed using serial angiography studies. The initial angiography examinations most frequently revealed stenotic lesions (appearance of a pearl-and-string sign or string sign) in eight (47.1%) of 17 cases. In 15 cases (88.2%), changes in the lesions were evident on follow-up angiography studies. Stenotic lesions resulted in occlusion in four cases, normalization in three, and subsequent formation of an aneurysm in one case, which was treated successfully by proximal occlusion of the affected vessel performed using a detachable balloon. Occluded lesions, which were initially observed in three patients, recanalized in two patients and remained unchanged in one patient. Fusiform dilation alone was demonstrated in three patients during the initial angiography session; these lesions became normalized or were unchanged on follow-up studies. Saccular aneurysms were observed in two patients. In one of these cases, proximal ligation of the parent artery was successfully performed because of subsequent aneurysm enlargement. A double lumen, which appeared in one patient with an extradural VA dissection, became occluded. Magnetic resonance T2-weighted imaging studies revealed infarction corresponding to the posterior circulation in seven cases. During long-term observation in this series, good or excellent recovery was obtained in 14 (87.5%) of 16 patients, and moderate or severe disability in two (12.5%); one patient was lost to follow up after the second angiography study. CONCLUSIONS: A follow-up angiography study must be performed during the early stage (within approximately 3 weeks after onset of symptoms) to confirm the formation or enlargement of an aneurysm, because such conditions may be amenable to surgical treatment. Unruptured VA dissection could otherwise be treated and followed conservatively. Although the majority of dissected lesions seem likely to stabilize within a few months, as evidenced on angiography, in some cases a longer observation period is required.     

A case of squamous cell carcinoma of the lung with a high titer of proteinase 3 antineutrophil cytoplasmic antibody]

A 57-year-old man who had a history of sinusitis was admitted to Ryugasaki-Saiseikai hospital in April 2002 because of productive cough and bloody sputum. Chest radiographs and CT scans showed mediastinal lymphadenopathy and a solitary mass lesion with an irregular margin and cavity in the left lower lung field. Proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA) was positive, and this is a sensitive and specific indicator of Wegener's granulomatosis. The pathological findings from transbronchial biopsy revealed squamous cell carcinoma of the lung, without the presence of vasculitis, accompanied by Wegener's granulomatosis. A partial response was finally obtained after three courses of paclitaxel and carboplatin. The serum level of PR3 ANCA decreased from 142 EU to 16 EU. This case appears to have had parallel time courses of progression of squamous cell carcinoma of the lung and changes in serum PR3 ANCA level. This is of importance in considering the relationship of lung cancer and paraneoplastic vasculitis.     

Peritoneal shunt migration into the pulmonary artery--case report

A 48-year-old man underwent ventriculoperitoneal shunting for hydrocephalus secondary to subarachnoid hemorrhage due to left vertebral artery dissection, which had been successfully treated by trapping. The peritoneal catheter was correctly positioned via a right upper abdominal incision, and symptoms related to the hydrocephalus disappeared. One month later, the patient began to complain of pain on the right side of the neck. Chest radiography revealed that the peritoneal end of the catheter had migrated into the right pulmonary artery. The catheter route was explored through a small neck incision, and was found to enter the external jugular vein. The catheter was extracted and repositioned into the peritoneum. This type of shunt migration is quite unusual, but could be lethal by causing pulmonary infarction or arrhythmia. The catheter had probably entered the external jugular vein through a perforation caused by the shunt guide during the ventriculoperitoneal shunt operation. Follow-up radiography should be scheduled to detect such a complication.     

Improvement of extrapulmonary lesions of eosinophilic granuloma after cessation of smoking]

We encountered a case of pulmonary eosinophilic granuloma complicated with pneumothorax. A 24-year-old man was admitted to our department because of respiratory difficulty. Chest radiography on admission showed a right pneumothorax. A thoracic catheter was therefore inserted, and the pneumothorax was improved. A chest radiograph obtained after treatment showed diffuse linear reticular shadows; and a chest CT scan showed starlike nodular lesions and multiple cysts in the lungs, and a large nodule in the left rib. Because an ulcer had been diagnosed in the oral cavity 1 year previously, a mandible biopsy was performed, and a granulomatous lesion consisting of eosinophils was recognized. Taken together with the pulmonary findings, an eosinophilic granuloma was diagnosed. The patient was instructed not to smoke and the clinical course was observed. The pulmonary, mandibular, and costal lesions improved.     

Simple and safe exposure of the sigmoid sinus with presigmoid approaches

Although entire exposure of the sigmoid sinus has been recognized as a complicated procedure in presigmoid approaches, we developed a new technique to expose the sigmoid sinus quite safely and simply without tough bone work. This study aims to demonstrate our technique in detail and present the effect of the procedure. Between January 2004 and December 2010, 77 patients underwent operations via presigmoid approaches in our institute. In all cases, the sigmoid sinus was completely exposed with our new surgical technique. The key step to expose the sigmoid sinus in our technique is dissection of the sinus from the overlying inner cortical bone in an antegrade direction from the junction of the transverse–sigmoid sinus to the jugular bulb using a bone dissector, avoiding meticulous bone drilling. We retrospectively examined a surgical video of all cases and determined the operative time required to entirely expose the sigmoid sinus from the transverse–sigmoid junction to the jugular bulb. In all 77 cases, the sigmoid sinuses were safely exposed with our new technique, and there was no episode of sinus injury. The operative time required to expose the sigmoid sinus ranged from 9.4 to 28.2 min (mean, 14.5 min). Standard drilling techniques took 32.3 min (range, 18.4–46.6 min) in last 20 cases before adoption of new technique. The new technique significantly shortened the surgical time to expose the sigmoid sinus (p?<?0.01, Welch’s t test). Our new technique is very useful for safely and simply exposing the sigmoid sinus, especially for standard neurosurgeons.     

Production of hepatocyte growth factor from human lung microvascular endothelial cells induced by interleukin-1beta.

To investigate the possible role of hepatocyte growth factor (HGF) in the reconstruction process following inflammatory damage in lung tissue, we compared HGF production of human lung microvascular endothelial cells (HLWECs) and human umbilical vein endothelial cells (HUVECs) after stimulation by interleukin(IL)-1beta. In an HLMEC-conditioned medium, large amounts of total (single and 2-chain) HGF were detected, and were 26- to 28-fold higher than those in HUVECs or human lung fibroblasts. The production of total HGF increased in a dose-dependent manner (4.7 to 9.2 times) with IL-1beta. In contrast, the amount of HGF in an HUVEC-conditioned medium was unaffected by IL-1beta treatment. The amount of cell-associated HGF also showed a dose-related increase (140% to 160%) in HLMECs, but not in HUVECs with IL1beta. In addition, HGF and c-met (HGF receptor) mRNAs in HLMECs and HUVECs were examined by the RT-PCR method. HGF and c-met mRNAs were clearly detected in HLMECs before and after treatment with IL-1beta, but not in HUVECs. These results suggest that increases in HGF production from HLMECs may play a role in the reconstruction process following inflammatory damage in lung tissue.     

Glomus jugulare tumor with intra- and extracranial extension: a case report with MRI study

A case of glomus jugulare tumor with intra- and extracranial extension is described. The patient was a 63-year-old woman who complained of gait and memory disturbances. On admission neurological examination revealed recent memory disturbance, left deafness, left XI, XIIth cranial nerve palsies, and slight ataxic gait. Roentgenogram of the skull showed an enlarged left jugular foramen with bone erosion. Plain X-ray computerized tomography scan (X-CT) indicated obstructive hydrocephalus and X-CT with contrast enhancement revealed a mass lesion in the left posterior cranial fossa extending through enlarged left jugular foramen to the extracranial space toward the level of C2. Cerebral angiography demonstrated a large mass with blood supply from branches of left external carotid and vertebral arteries. The tumor stain was not remarkable. Left internal jugular vein was completely obstructed at the level of the second cervical vertebral body. Magnetic resonance imaging (MRI) clearly showed the tumor extending from the anterolateral portion to the second cervical vertebral body through the enlarged jugular foramen to the posterior cranial fossa. Brain stem and cerebellar hemisphere which were markedly compressed by the mass were clearly visualized. At first a ventriculo-peritoneal shunt was made and four weeks later subtotal removal of the tumor was undertaken. Histopathology of tumor specimen showed typical glomus jugulare tumor. MRI was considered to be very useful for the diagnosis and treatment of the glomus jugulare tumor with intra- and extracranial extension.     

Characteristic of optic canal invasion in 31 consecutive cases with tuberculum sellae meningioma

Optic canal invasion by tuberculum sellae meningiomas (TSMs) has been reported, but the characteristics of invasion remain unclear. This study was performed to clarify the incidence and characteristics of optic canal invasion by TSM and to determine whether optic canal invasion could be predicted preoperatively by magnetic resonance imaging (MRI). Between February 2002 and August 2014, 31 patients with TSM underwent tumor resection in our institute. In all cases, the optic canal was explored to identify any tumor invasion. We classified the characteristics of optic canal invasion from intraoperative findings. Invasion was classified into four types: type 1: no invasion; type 2: secondary invasion; type 3: partial wall invasion (two subtypes); and type 4: invasion into the supero-medial-inferior walls of the optic canal. Thirty of 31 cases showed optic canal invasion. Of these 30 cases, 9 (30 %) showed bilateral optic canal invasion. The most common finding was type 1 (23 sides). Among cases with optic canal invasion (39 sides), type 4 was the most common pattern (17 sides), followed by type 3-infero-medial (13 sides), type 2 (5 sides), and type 3-supero-medial (4 sides). Blinded prediction of tumor invasion was accurate in 61 % of cases, but characteristics of tumor invasion were undeterminable from preoperative MRI. In conclusion, optic canal invasion was frequently seen in our consecutive series of TSM, characteristics of which were unpredictable preoperatively. Neurosurgeons should be aware of the high incidence and variety of optic canal invasion in planning strategies for TSM treatment.     

Staged ‘intentional’ bridging vein ligation: a safe strategy in gaining wide access to skull base tumors

Background

The venous drainage of the temporal lobe, through bridging veins to the middle cranial fossa, is pivotal in determining the surgical corridor for skull base lesions. In dealing with select cases, where venous drainage was an obstacle in the surgical approach, we hypothesized that staged ‘intentional’ ligation of the dominant pathway of venous drainage would provide a safer and wider access to skull base tumors. We study the indications and safety of this surgical strategy in the management of skull base lesions.

Materials and methods

From 1995 to 2012, 318 patients with skull base tumors were treated at our institute by the fronto-orbito-zygomatic (FOZ) or transpetrosal approaches, eight of whom we planned for staged ‘intentional’ bridging vein ligation. Seven patients underwent planned ligation of the bridging veins from the temporal lobe to the middle cranial fossa floor in the first stage, followed by definitive surgery through the desired skull base approach, in the second stage, while in one patient the strategy was abandoned. These patients were evaluated with respect to their clinical presentation, pre- and post-operative radiology including venogram, intra-operative findings and post-operative course.

Results

Seven patients, four males and three females, with ages ranging from 16 to 63 years, underwent staged ‘intentional’ bridging vein ligation. The diagnoses were recurrent craniopharyngioma in four, and petroclival meningioma, sphenopetroclival meningioma and spheno-orbital meningioma in one each. Six of these lesions were approached from the dominant (left) side, while one lesion was on the right side. Venograms done after the first-stage procedure showed obliteration of the dominant venous drainage with opening up of anastomotic venous channels in all patients. All patients tolerated the first-stage procedure well; only one patient showed asymptomatic mild temporal lobe edema on MRI, which resolved in 3 weeks. None of the patients had venous complications after definitive surgery. One patient with recurrent chordoma, who was planned for staged ligation, did not undergo ligation as, intra-operatively, the draining channel turned out to be a cortical vein, which could be mobilized without ligation.

Conclusion

In an attempt to detether the temporal lobe, the disconnection of the bridging veins from the temporal lobe to the middle cranial fossa floor in the first stage may lead to re-direction of the venous outflow over time. This may allow skull base surgeons a better surgical corridor and ensure safety of venous structures during the definitive surgery.