Dura arteriovenous malformation of the posterior fossa-clinical and angiographical analysis of 6 cases

Dural arteriovenous malformation of the posterior fossa was infrequently reported in the literatures. We presented 6 cases of dural arteriovenous malformation of the posterior fossa with the presentation of typical examples. Up to the end February, 1974, 119 cases of intracranial arteriovenous malformation were experienced in our clinic, in which there were 6 cases of dural arteriovenous malformation. The ages of our series ranged from 41 to 75 years old and 57 years old in average. Tinnitus and headache were two main symptoms which developed in most of the cases. As for the older symptoms, visual disturbance was seen in 4 cases, unilateral pulsating exophthalmos in 1 case and papilledema in 3 cases. There wers two cases which progressive dementia was developed by the cerebral anoxia due to arteriovenous shung. On examination, a pulsatile bruit was audible at the mastoid region in all cases and a thrill could be palpated along the occipital arteries. Many kinds of durl and/or tentorial arteries which were drained directly into the sinuses at the occipital portion as the feeding arteries were visualized angiographically. Moreover, the angiographical patterns of feeding arteries into the sinuses showed dynamic changes after the operation. As for the treatments, many kinds of surgery were carried out for the cases by the combination method of the next 6 ways. 1. ligation of external carotid artery 2. ablation of periosteum from occipital bone 3. occipital and/or suboccipital craniectomy 4. clipping of almost of all feeding arteries at dura mater and tentorium 5. ligation of threocervical trunk 6. ventriculo-atrial shunt or ventriculo-peritoneal shunt From our experiences, the most effective treatment is thought to be a direct closure of intradural arteriovenous shunt near the sinus at the occipital portion in the early stage.     

Subarachnoid hemorrhage and pontine hemorrhage followed by an embolization procedure of left occipital giant arteriovenous malformation: a case report

A 42-year-old woman suddenly developed headache and nausea on July 26, 1991, and the computed tomography (CT) scan showed a moderate-sized hematoma in the left occipital lobe. After one month's conservative treatment, she had recovered to a neurologically intact state. Cerebral angiography demonstrated a giant arteriovenous malformation fed by enlarged branches of the left posterior cerebral artery as well as small branches arising from the middle cerebral artery, anterior cerebral artery and the meningeal branches of the middle meningeal artery and the occipital artery. Preoperative embolization was planned on February 24, 1992. During an attempt at catheterization of the basilar artery and the left posterior cerebral artery with a balloon catheter and a Tracker-18 catheter, the patient complained of an intensification of her headache, nausea and vomiting. So the embolization procedure was stopped. The CT scan taken immediately at that time showed a severe subarachnoid hemorrhage (SAH). She became comatose about 40 minutes later. CT scan taken next day revealed also a complication of the pontine hemorrhage. Neurologically, she had gradually recovered and could communicate with some simple words 3 months after SAH. The total removal of the AVM was performed on May 26, 1992. Postoperative course was uneventful. She showed rapid and remarkable improvement in her neurological state suggesting that the blood flow in the surrounding brain area had been corrected. A blood deficit had no doubt been caused when blood had been stolen by the giant AVM.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diffuse cerebral artery vasospasm following total resection of posterior fossa meningioma: a case report]

Diffuse cerebral artery vasospasm following brain tumor resection is a rare complication. The authors reported a case of symptomatic diffuse cerebral artery vasospasm of early phase following resection of a left posterior fossa meningioma. A 50-year-old female patient was admitted to our hospital complaining of headache. No neurological deficits were detected at the time of admission. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a large mass in the left posterior fossa. Cerebral angiography demonstrated mildly diffuse stenosis of the bilateral internal carotid artery. The tumor was resected totally. CT after operation showed a small amount of subarachnoid hematoma in the superior aspect of the cerebellum. Pathological specimen of the tumor showed fibrous meningioma. One day after this radical operation, the patient was found to have weakness in her left leg. Then she developed left hemiparesis, weakness in the right leg and left homonymous hemianopsia. MRI showed ischemic lesions in the bilateral parietal and the occipital lobe. Angiography demonstrated diffuse severe vasospasm throughout the whole cerebral artery. Ten days after the operation, angiographical findings were improved. This case indicates that vasospasm may occur even after resection of brain tumors which are localized outside the suprasellar area.     

Two cases showing subarachnoid hemorrhage from angioblastic meningioma and vascular hamartoma (author's transl)

As a causative factor in spontaneous subarachnoid hemorrhage, vascular anomalies, especially aneurysm or arteriovenous malformation, have been generally recognized. On the other hand, subarachnoid hemorrhage from brain tumor and cryptic vascular malformation are rare. We experienced two cases showing subarachnoid hemorrhage from angioblastic meningioma and vascular hamartoma as an initial symptom. Case 1: A 48-year-old woman, who complained of severe headache and vomiting on Feb. 10th, 1972, gradually became lethargic. Lumbar puncture revealed moderately hemorrhagic C.S.F.. On the fifth day after the onset, she was admitted to our hospital. On admission she showed disorientation and disturbance of resent memory. Aphasia and agnosia were slightly observed. On ophthalmologic examination right homonymous lower quadrant hemianopsia was observed. The carotid angiogram showed slight square shift of the anterior cerebral artery to the right side, elevation of the middle serebral artery and a homogeneous tumor stain in the occipital region in capillary phase. A walnut sized tumor invading the middle portion of the left lateral sinus and showing firm adhesion to the tentrium was found. There was an intracerebral hematoma behined the tumor. The tumor, the tentrium and the lateral sinus were extirpated en bloc and the intracerebral hematoma was aspirated. Histologically, the tumor was angioblastic meningioma. Case 2: A 7-year-old boy, who complained of severe abrupt headache, nuchal pain and vomiting on Sept. 17th, 1972, became gradually lethargic. Lumbar puncture revealed hemorrhagic C.S.F., On the tenth day after the onset, he was admitted to our hospital. He showed confusion and agitation. The carotid angiogram showed an unrolling of the pericallosal artery, but no findings of space taking lesions. An air study indicated a globular filling defect protruding into the anterior horn of the right lateral ventricle. The tumor located in the laterobasal wall of the anterior horn was removed picemiel by transventricular approach. Histologically, the tumor was vascular hamartoma. Furthermore, we discussed various brain tumors showing subarachnoid hemorrhage as an initial symptom, its frequency and bleeding mechanism on the literature.     

Benign fibroosseous lesions involving the skull base, paranasal sinuses, and nasal cavity. Report of two cases

We report a case of a basilar artery migraine in a 17-year-old boy with transient CT and MR abnormalities after each of two migraine episodes. A repeat MR study 6 months after the last event showed complete resolution of the lesion. Transient abnormalities on brain images similar to those shown in our case have been reported in patients with migraine and other neurologic conditions and are most likely related to cerebral vasogenic edema.     

Etiology of immune stromal (interstitial) keratitis

BACKGROUND: Subarachnoid hemorrhage (SAH) with a spinal origin is a rare clinical entity. The most common source of SAH is an arteriovenous malformation. Only six cases of spinal hemangioblastomas causing SAH have been reported. CASE DESCRIPTION: This 48-year-old man had experienced severe headache 12 years earlier, which was diagnosed as SAH by computed tomography (CT) scan and lumbar puncture. However, cerebral angiography could not detect either aneurysm or arteriovenous malformation. Thereafter, he spent an uneventful life until he was incidentally diagnosed with a cervical tumor on magnetic resonance imaging (MRI) study for Meniere's disease. The tumor was situated at the cervicomedullary junction, and fed by the left vertebral artery. Histologic findings of the tumor showed features typical of hemangioblastoma. CONCLUSIONS: We describe a case of cervical spinal extramedullary hemangioblastoma with a past history of SAH. In our case, the SAH of 12 years ago perhaps occurred from the cervicomedullary junction hemangioblastoma. Since the etiology of SAH could not be detected at the first angiography, not only follow-up reangiography, but also MRI of the spinal cord and spinal angiography could have played an important role.     

A case of recanalized basilar artery following basilar artery occlusion due to spontaneous dissection

An 85-year-old man who did not have any previous history of heart disease was admitted to our hospital with the chief complaints of disturbance of consciousness, tetraparesis, and bilateral Babinski signs. On admission, intravenous digital subtraction angiography (DSA) showed bilatral vertebral arteries without filling the basilar artery. On the second hospital day, MRI showed a septum in the basilar artery, and no infarctions were noted in the brain stem. He gradually improved with heparin therapy. On the tenth hospital day, intravenous DSA disclosed filling of the basilar artery. On the sixteenth hospital day, conventional cerebral angiography revealed filling of the basilar artery from the left vertebral artery, and string sign and linear shadow (intimal flap) was noted in the basilar artery. He was diagnosed to have the basilar artery dissection. The patient became ambulatory and was discharged independently. This is very rare case of the basilar artery dissection with a good prognosis.     

Evaluation of laser surgery against brain tumor (author's transl)

A surgical carbon dioxide laser unit (Laser) has been used in 26 cases of various brain tumors, including 10 meningioma (4 sphenoid ridge, 3 parasagittal, 1 falx, 1 olfactory, 1 posterior fossa); 12 glioma (7 glioblastoma, 5 astrocytoma); two metastatic brain tumors; 1 hemangioblastoma, and 1 AVM. Criteria for Laser use based on evaluation and location of meningioma were: grade 1, convenient but adjuvant; grade 2, also necessary; grade 3, indispensable. Most meningioma in convexity and parasagittal were grade 1-2, with those in the sphenoid ridge grade 2-3. In the glioma group, hemorrhage in 3 cases of glioblastoma was easily Laser-controlled, and the tumors wasted away in a short time with vaporization. There was minimal mechanical effect on the adjacent tissue. Conclusion: In neurosurgery, Laser is obligatory in sphenoid ridge meningioma to dissect the internal carotid artery, middle cerebral artery, cavernous sinus, sphenoid ridge, etc. It is very useful in glioma, especially glioblastoma, considering shortened surgical duration, decreased blood loss and extended tumor resection. Laser surgery is proposed as most appropriate for brain tumors in elderly and poor risk cases mainly for its vaporizing function.     

Ophthalmoplegia, hemiparesis and cheiro-oral syndrome in basilar artery migraine

A patient with migraine developed ophthalmoplegia, hemiparesis and cheiro-oral syndrome on the left side. T2-weighted MRI showed infarcts in the tegmentum of bilateral midbrains and right pons but no lesion in the cerebral or cerebellar hemisphere. Infarction in the tegmentum of brainstem secondary to the involvement of perforating arteries has not been reported in basilar artery migraine until now.     

Mental health assessment for older people

Marked arteriovenous malformation in the left parietooccipital area manifested only by symptoms of associative migraine involving changes of visual fields indicative of impaired functions of symmetrical compartments of the other brain hemisphere. Visual evoked potentials were changed in this patient because of dysfunction of both hemispheres and largely because of disorders in brain structures symmetrical to the site of arteriovenous malformation. This can be regarded as a manifestation of the so-called stealing phenomenon, when blood supply to one brain compartment is decreased because of excessive blood delivery to other regions of the brain. The results permit us to hypothesize regulation of blood supply to symmetrical compartments of brain hemispheres.     

Sleep deprivation in the treatment of depression

A case of spinal cord arteriovenous malformation was reported, in whom serial selective spinal angiogram and pantopaque myelogram showed a successful demonstration of intramedullary nidus. A 25-year-old male was admitted with paraparesis, impotence, hypesthesia and hypalgesia in his legs in 1974. He was diagnosed to have a spinal cord arteriovenous malformation of so-called "glomus type" with intramedullary nidus by the selective spinal angiogram and pantopaque myelogram. The nidus was fed by the anterior spinal artery through the 8th intercostal artery, from which a major draining vein extended caudally, but there was also some cranial drainage. The arteriovenous malformation was treated by surgical excision combined with afferent vessels coagulation in order to prevent the rupture of the remaining intramedullary nidus. After operation the patient develop a transient analgesia and girdle pain at T9-10 level, but after 42 days he regained full muscle power in his legs and could run by himself, while sensory disturbance remained about the same as before surgery.     

A case of foramen magnum meningioma in which case enhanced three-dimensional CT scan was valuable for preoperative evaluation of the surgical approach

We report a case of foramen magnum meningioma in which case enhanced three-dimensional CT scan was valuable for preoperative evaluation of the surgical approach. A 53-year-old woman had suffered from stiffness and pain in the left occipital region and numbness of the left side of the face for about 2 years before admission. She had also weakness and numbness of the left side of her body for about 2 months before admission, and dysphagia and pain in the occipital region and in the posterior region of the neck produced by straining for about 1 month before admission. Neurological examination revealed left hemiparesis, and hypalgesia and tactile hypesthesia of the left side of the body, including the face. Plain X-P was normal. Enhanced CT scan and gadolinium enhanced MRI revealed a well-enhanced mass attached to the left anterolateral part of the foramen magnum. The left occipital condyle was observed at the lateral side of the attachment part of this mass. Angiography revealed tumor feeders from the meningeal branches of the left vertebral artery and the left ascending pharyngeal artery. Enhanced three-dimensional CT scan clearly showed that the tumor was attached to the left anterolateral part of the foramen magnum, that the left occipital condyle was at the lateral side of the attachment part of this mass and that the jugular foramen and jugular tubercle were situated superolateral to the attachment part of this mass. Considering these factors, we decided that removal of the posterior part of the left occipital condyle was necessary, but removal of the left jugular tubercle was not necessary for a good operative view from the left posterior lateral direction. The tumor was totally removed successfully and good results were obtained by the transcondylar approach without removal of the jugular tubercle. Histology of the tumor revealed meningothelial meningioma. In this case, preoperative evaluation with enhanced three-dimensional CT scan was helpful for deciding the surgical approach. With enhanced three-dimensional CT scan, it is easy to judge whether removal of the posterior part of the occipital condyle and/or the jugular tubercle is necessary for a good operative view, and we can get good images revealing the relationships between the tumor and surrounding structures. Preoperative evaluation with enhanced three-dimensional CT scan is very useful especially in this kind of situation.     

Vascular distribution of paradoxical emboli by transcranial Doppler

BACKGROUND AND PURPOSE: Paradoxical embolism through a patent foramen ovale is a contributory mechanism to stroke and may be diagnosed by contrast echocardiography. The intracranial distribution of these emboli has not been previously reported. METHODS: We used transcranial Doppler combined with agitated saline contrast injection to determine whether there was a preferential distribution of the contrast into the anterior or posterior intracranial circulation of patients with an acute stroke or transient ischemic attack. RESULTS: Forty-nine patients were studied--27 men and 22 women, with a mean age of 62.7 +/- 13.3 years (range, 29 to 85 years). Microcavitations were detected in the proximal right middle cerebral artery in 12 of 49 patients (24%). A patent foramen ovale was confirmed in all cases by simultaneous transesophageal echocardiography. Of the 12 patients, microcavitations were also detected in the proximal basilar artery in nine (75%). CONCLUSIONS: While paradoxical embolism appears to occur more frequently in the anterior circulation, the high rate of detection of microcavitations in the basilar artery suggests that paradoxical embolism to the posterior intracranial circulation may be more frequent than generally believed.     

Aneurysms related to cerebral arteriovenous malformations: superselective angiographic assessment in 58 patients

PURPOSE: To report the comprehensive superselective angiographic characteristics of aneurysms associated with cerebral arteriovenous malformations. METHOD: One hundred consecutive patients referred for cerebral arteriovenous malformation embolization underwent preembolization superselective angiography. Superselective angiograms were obtained after microcatheterization of arteriovenous malformation pedicles, and assessed for number and location of aneurysms related to the malformation. A chi 2 test was conducted to correlate these parameters with the onset of intracranial hemorrhage. RESULTS: Aneurysms were demonstrated in 58 of 100 patients. Single aneurysms were found in 24 patients and multiple aneurysms in 34. Presence and number of aneurysms were found to correlate significantly with a clinical presentation of hemorrhage. CONCLUSION: Superselective angiography was found to be of paramount importance in elucidating the precise and detailed angioarchitecture of brain arteriovenous malformations.     

Coexistence of schizencephaly and intracranial arteriovenous malformation in an infant

A 9-month-old infant had unilateral closed-lip schizencephaly in the right parietal lobe, which coexisted with an arteriovenous malformation in the nearby temporal area. Cranial MR showed a right parietal cleft lined with gray matter between the right lateral ventricle and the subarachnoid space, and cluster hypointensities throughout the right temporal lobe. Cerebral angiography revealed a right temporal arteriovenous malformation with feeding arteries arising from the right middle and posterior cerebral arteries and draining into the right sigmoid sinus via the engorged vein of Labbé.     

Surgically confirmed incorporation of a chronically retained neurointerventional microcatheter in the carotid artery

A woman reported painful thrombosis of the superficial femoral artery 16 months after a transfemoral microcatheter was glued into a cerebral arteriovenous malformation and transected at the groin. When the catheter was removed, a portion was found to be incorporated into the wall of the carotid artery. This case demonstrates that portions of a retained microcatheter may be incorporated into the arterial wall while other portions may remain mobile and cause late peripheral arterial symptoms.     

Reversible ischemia determined by xenon-enhanced CT after 90 minutes of complete basilar artery occlusion

Intraarterial thrombolytic therapy decreases mortality in the treatment of acute basilar artery occlusion. An acute decrease in cerebral blood flow (CBF) (<12 mL/100 g per minute) has been reported to invariably result in infarction. We report a case of acute basilar artery occlusion, recanalized within 90 minutes, with reversal of CBF of less than 6 mL/100 g per minute. After reperfusion, areas with persistent CBF of 6 mL/100 g per minute resulted in infarctions on subsequent CT studies. Parenchymal viability is possible after 90 minutes of posterior CBF of 6 mL/100 g per minute.     

Chronic myelogenous leukemia received unrelated bone marrow transplantation following surgical resection of cerebral arteriovenous malformation--first case report

We report a 15-year-old boy with chronic myelogenous leukemia who received unrelated bone marrow transplantation (uBMT) after surgical resection of cerebral arteriovenous malformation (AVM). The incidence of cerebral hemorrhage caused by rupture of cerebral ABM in cases of BMT is uncertain. However, since the risk of rupture of AVM was supposed to increase due to both severe thrombocytopenia after intensive chemotherapy and increased intracranical pressure because of total body irradiation (TBI) as preconditioning therapy for BMT, we have first carried out surgical resection of the cerebral AVM, and subsequently performed uBMT. This resulted in a favorable clinical course without serious complications.     

Bilateral encephalomalacia in a pig related to latent Aujeszky''s disease virus infection

Transcranial Doppler studies on the effects of sumatriptan on cerebral hemodynamics have shown conflicting results. We evaluated blood flow velocity changes in 21 patients suffering from migraine with (n = 4) or without aura (n = 17) during a spontaneous attack, before and after treatment with sumatriptan. Flow velocity in the internal and external carotid, middle cerebral, and basilar arteries was measured by means of transcranial Doppler. During the attack, measurements were taken before subcutaneous sumatriptan injection, then after 30 minutes, 2 hours, and 24 hours. An additional measurement was taken 1 week later, in a headache-free state. We found a significant reduction of flow velocity during the attack in the middle cerebral artery on both sides (P < 0.05). After sumatriptan administration, flow velocity increased in the internal carotid artery on both sides (P < 0.05) and in the middle cerebral artery on the headache side (P = 0.0001), but not in the external carotid and basilar arteries (P > 0.05). Flow velocity changes may reflect the vasodilation present at the onset of the migraine attack followed by vasoconstriction in the internal carotid and middle cerebral arteries after sumatriptan treatment. Since vasoconstriction occurs in responders and nonresponders to treatment, it is unlikely to be the primary mechanism by which sumatriptan relieves headache.     

Pulmonary arteriovenous fistula with cerebral arteriovenous malformation without hereditary hemorrhagic telangiectasia. Unusual case report and literature review

An unusual and rare case of a central pulmonary arteriovenous fistula (PAVF) with concomitant cerebral arteriovenous malformation (CAVM) in the absence of hereditary hemorrhagic telangiectasia is reported. Presentation was in the form of a cerebrovascular accident (CVA). Clinical presentations and management strategies of PAVF with associated CAVM are broadly discussed along with a pertinent literature review.