Anatomical variations of the ten triangles around the cavernous sinus

The dimensions of the 10 triangles around the cavernous sinus were measured to define the anatomical characteristics of the triangles and to compare their consistency in shape and area. Twelve tissue blocks containing the bilateral cavernous sinuses and medial two-thirds of the middle cranial fossae were obtained from Japanese adults at autopsy, fixed to a stereotactic frame, and examined with an operative microscope. The dimensions of each triangle were measured with calipers and compared, based on the same point and border. The anteromedial triangle and the superolateral (Parkinson's) triangle were more consistent in shape than the paramedial and oculomotor triangles, but the oculomotor triangle was larger in area than these other triangles. The posteromedial (Kawase's) triangle was more consistent in shape and larger than the anterolateral, lateral, and the posterolateral (Glasscock's) triangles. The anteromedial and superolateral (Parkinson's) triangles are important for the combined epi- and subdural approach to cavernous sinus lesions. The posteromedial (Kawase's) triangle is important for gaining access to the posterior cranial fossa from the middle cranial fossa.

Impairment and restoration of the endothelial blood-brain barrier in the rat cerebral infarction model assessed by expression of endothelial barrier antigen immunoreactivity

Endothelial barrier antigen (EBA) can be used to detect the blood-brain barrier in the central nervous system of rats. This study investigated the temporal profile of antigen expression in cerebral vessels after infarction and assessed the relationship between re-establishment of this antigen in newly formed vessels and astrocytes around these vessels. Rats were subjected to cerebral ischemia for 2 h by the intraluminal thread method, then killed after 1, 3, 7, 14 and 28 days. Perfusion-fixed paraffin-embedded brains were immunostained for detection of EBA and glial fibrillary acidic protein (GFAP) by the streptavidin-biotin-peroxidase complex method. EBA immunostaining in vessels in the infarcted lesion was reduced at day 1 and had almost disappeared by day 3. Newly formed vessels were found from day 3, but were not stained at day 7. However, these new vessels were weakly stained at day 14 and definitely stained at day 28. GFAP immunostaining was completely negative around these proliferating vessels. The temporal profile of disappearance and re-expression of EBA in cerebral infarcted lesion may be associated with aggravation and improvement of brain edema, although barrier permeability was not explored in this study. The expression of this antigen has no relationship to the formation of astrocyte/endothelial contacts.

Serial angiography and endovascular treatment of dissecting aneurysms of the anterior cerebral and vertebral arteries. Case report

This 47-year-old man was admitted to the hospital with disturbance of consciousness due to subarachnoid hemorrhage caused by a ruptured dissecting aneurysm of the left anterior cerebral artery (ACA). Conservative treatment resulted in improvement in the patient's consciousness; however, repeated rupture occurred during the chronic stage. Endovascular coil embolization of the parent artery was successful. Serial angiography demonstrated all stages in the development of the aneurysm. Follow-up angiography demonstrated an incidental dissecting aneurysm of the right vertebral artery. This aneurysm was also treated by endovascular embolization. No new neurological deficit appeared during or after the treatment. Multiple dissecting aneurysms are rare, especially those involving both supra- and infratentorial regions. A ruptured dissecting aneurysm of the ACA is also an uncommon vascular disorder. This case shows that rebleeding may occur, even during the chronic stage, and thus appropriate treatment for the prevention of subsequent bleeding is essential. Incidental dissecting aneurysms can be treated using the endovascular technique, but further study is necessary.

Treatment of intradural paraclinoidal aneurysms

Intradural paraclinoidal aneurysm still presents conceptual confusion and technical surgical problems. The clinical features of 68 consecutive patients with paraclinoidal aneurysms were analyzed. The pterional approach was used in all patients. Subarachnoid hemorrhage (SAH) occurred in 37 patients from the paraclinoidal aneurysm and in 10 patients from another associated aneurysm. Thirty-four of the 37 ruptured paraclinoidal aneurysms were clipped, two blister-like aneurysms required trapping, and one blister-like aneurysm was coated. Thirteen of the 31 unruptured paraclinoidal aneurysms, consisting of 10 with ruptured associated aneurysm, four symptomatic, and 17 incidental, were clipped and 18 were coated. Favorable outcomes were obtained in 38 of 47 patients with SAH and 17 of 21 patients without SAH. Nine unfavorable outcomes in SAH patients were caused by primary brain damage (5), vasospasm (2), cerebral infarction after trapping (1), and pneumonia (1). All four unfavorable outcomes in non-SAH patients were due to surgical procedures for giant aneurysms or associated basilar artery aneurysm. Removal of the anterior clinoid process was performed to secure the proximal neck in 15 patients with large or giant aneurysms. Multiple clips with or without fenestrated clips were required in all giant aneurysms, and exposure of the cervical internal carotid artery (ICA) in 17 giant or large aneurysms. Fenestrated clips were also useful for one small aneurysm projecting posteriorly. A favorable outcome was achieved in 17 of 19 patients undergoing coating. Coating without clipping might be better for some blister-like ICA aneurysms, even if ruptured. Paraclinoidal aneurysms can be clipped with favorable results using these techniques except for giant aneurysms and associated basilar artery aneurysm.

Oculomotor nerve palsy after surgery for upper basilar artery aneurysms

OBJECTIVE

The goals of this study were to evaluate the relationship between postoperative oculomotor nerve palsy and other clinical factors and to improve preoperative estimations of the risk. Such an evaluation has not been previously described in the literature.

METHODS

Patient records for 77 basilar tip aneurysm cases and 28 basilar superior cerebellar artery aneurysm cases treated between 1981 and 1997 were reviewed. Clinical and radiological parameters were separately analyzed using the chi2 test, and then multiple-regression analysis was used.

RESULTS

Postoperative oculomotor palsy occurred in 25 (32%) patients with basilar tip aneurysms and 11 (39%) patients with basilar superior cerebellar artery aneurysms, in addition to 2 patients with basilar tip aneurysms and 3 patients with basilar superior cerebellar artery aneurysms who exhibited oculomotor palsy before surgery. For both type of aneurysms, the size and direction of the aneurysms were closely related to oculomotor nerve palsy. The complication also tended to occur in early surgery cases, in younger patients, and in patients of poor-clinical grade status.

CONCLUSION

In this study, some clinical and radiological factors were found to be associated with postoperative oculomotor nerve palsy.

Palatal myoclonus induced by extirpation of a cerebellar astrocytoma. Case report

A 45-year-old woman developed a rare case of palatal myoclonus with no other neurological signs after undergoing extirpation of a small cerebellar low-grade astrocytoma that was located in the right dentate nucleus. The palatal myoclonus has persisted for 4 years after the operation. Magnetic resonance T2-weighted imaging revealed a high-intensity lesion in the left inferior olive. Palatal myoclonus associated with the removal of cerebellar tumors is unusual but may easily be overlooked.

Cochinolide, a new gamma-alkylidene bicyclic butenolide with antiviral activity, and its beta-glucopyranoside from Homalium cochinchinensis

A new gamma-alkylidene bicyclic butenolide designated as cochinolide (1) and its beta-glucopyranoside (3) were isolated from the root bark of Homalium cochinchinensis (Flacoutiaceae). Their structures, except absolute stereochemistries, were determined by spectroscopic means. Cochinolide (1) showed moderate antiviral activities against HSV-1 and -2.

Intradural retroclival chordoma without bone involvement: no tumor regrowth 5 years after operation. Case report

Chordomas are most commonly located in the extradural region. A 56-year-old man presented with a large chondroid chordoma located totally within the intradural retroclival region. The tumor was resected via the petrosal approach. Five years after subtotal removal, the residual tumor showed no sign of regrowth despite the fact that radiation therapy had not been used. The patient was free of symptoms except for moderate, conductive hearing loss in his right ear. The position of the intradural tumor could be preoperatively diagnosed by neuroimaging and, thus, the petrosal approach was selected. Primary intradural extraosseous chordomas are very rare and difficult to differentiate from ecchordoses physaliphorae on the basis of histological and radiological features; however, MIB-1 staining may be useful.

Effect of recirculation on exacerbation of ischemic vascular lesions in rat brain

Using electron microscopy, we investigated the small arteries and veins in ischemic lesions induced by occlusion of the ostium of the middle cerebral artery in 42 rats. We observed endothelial denudation in the small arteries of rats receiving occlusion for greater than 6 hours. When the occluding cylinder was removed to allow for reperfusion, however, 2 hours of occlusion was sufficient for endothelial denudation to occur. Medial smooth muscle cells seemed to be more vulnerable to ischemia than endothelial cells because ultrastructural changes in the former cells preceded endothelial denudation. Moreover, endothelial denudation definitely exacerbated vascular changes so that medial necrosis appeared to be complete beneath the denuded areas, allowing erythrocytes, platelets, and exogenous tracers to penetrate into the cytoplasm of smooth muscle cells. These arterial lesions seemed to be repaired 10 days after removal of the occluding cylinder following 2 hours of occlusion. On the other hand, small veins in the ischemic lesion did not show endothelial denudation or medial necrosis. Our study suggests that arterial changes in ischemic lesions play a role in exacerbating the brain edema caused by recirculation after ischemia.

[Ruptured cerebral aneurysm followed by primary intracranial malignant lymphoma: case report]

Reported herein is a case of ruptured anterior cerebral aneurysm followed by primary intracranial malignant lymphoma. A 73-year-old female was admitted to our hospital on October 20, 1986, with a severe subarachnoid hemorrhage. Microsurgery was performed immediately on the day of admission because cerebral angiography revealed bilateral distal anterior cerebral artery aneurysms. Consciousness gradually deteriorated due to cerebral vasospasm from the 3rd day following surgery. To protect the brain, corticosteroid (methylprednisolone 1500 mg, dexamethasone 252 mg) was administered for 26 days after surgery. In spite of treatment, in March 1987 neurological examination revealed akinetic mutism, but CT scan did not reveal any evidence of tumor. CT scan performed on May 2, 1987, revealed a mass lesion in the left frontotemporal lobes and left basal ganglia. Histological diagnosis of malignant lymphoma (diffuse, large-cell type) was obtained by stereotactic biopsy. Radiotherapy (41 Gy of 60Co) was carried out. The CT scan performed on August 26, 1987 revealed that the abnormal enhanced lesion had disappeared. However, neurological findings had not remarkably improved. The patient died of renal failure in February 1988, but tumor recurrence had not been noted in CT scans. Autopsy could not be performed. Whole body CT scan and 67Gd scintigram did not reveal any other tumors except in the brain. Ruptured cerebral aneurysm followed by primary intracranial malignant lymphoma is very rarely reported. In such cases, which have unusual clinical courses and CT findings, we recommend stereotactic biopsy to treat this kind of radiosensitive tumor. The connection between malignant lymphoma and immunosuppression has been considered.(ABSTRACT TRUNCATED AT 250 WORDS)