The Strategy of Dural Arteriovenous Fistula with Isolated Sinus

We treated 7 cases of dural arteriovenous fistulas (dAVF) with isolated sinus by transvenous direct embolization.

The fistulas located in the transverse-sigmoid sinus in 5 cases, superior sagittal sinus in 1 case and transverse-sigmoid and superior sagittal sinus in 1 case.

The initial symptoms were generalized convulsion in 2 cases, disturbed consciousness in 1 case, tinnitus in 2 cases and transient ischemic attack in 2 cases. We performed sinus packing with coils in all cases following transarterial embolization.

All patients improved neurologically after the treatments and AVFs completely disappeared in all cases.

Endovascular Treatment for Internal Carotid Stenoses

Seventy four cases of internal carotid stenoses greater than 60% were treated by PTA and/or stenting 86 times. Sixty one cases of cervical ICA stenosis were treated 71 times. 11 cases of high cervical - intracranial ICA stenosis were treated 13 times. Two cases of ICA dissection were treated by stent deployment.

Stenotic ratio reduced from 79% to 29% in cervical ICA stenosis and 71 % to 32% in high cervical to intracranial ICA stenosis in average. Morbidity related to PTA and/or stenting was 2/74 (2.7%) and mortality was 0%. One was an ischemic complication and the other was a hemorrhagic complication due to hyperperfusion. Restenosis (stenosis greater than 70%) rate was 32%. Asymptomatic cerebral embolism were found in three cases (4.2%) on angiogram immediately after PTA and/or stenting. The complication rate related to PTA and/stenting was low but asymptomatic emboli were found in three cases.

Considering these results, the indication for PTA and/stenting should be restricted to patients with high risk group, such as cases with high medical risks or difficult CEA cases, if appropriate protective systems for cerebral emboli were not available.

Multiple cerebral aneurysms with persistent primitive trigeminal artery

We report a patient with a persistent primitive trigeminal artery (PPTA) detected incidentally during cerebral angiography for the ruptured aneurysm. Cerebral angiography revealed a PPTA and eight anterior circulation cerebral aneurysms. Although cerebrovascular fragility, hemodynamic stress and hypertension are well known as etiologic factors for development of cerebral aneurysms, there is a known association of aneurysms with a PPTA, fetal carotid-basilar anastomosis. Furthermore, this case is rare from the viewpoint of aneurysm multiplicity.

Stenting for Left Subclavian Artery Stenosis before and after Coronary Artery Bypass Grafting Using the Internal Mammary Artery: A Report of Three Cases

SUMMARY

Stenosis of the subclavian artery proximal to the origin of the internal mammary artery (IMA) used for coronary artery bypass grafting may produce flow reversal (steal syndrome) and cause myocardial ischemia. We present three cases of subclavian artery stenosis proximal to the IMA before and after CABG. The first case developed symptomatic myocardial ischemia resulting from a variant of coronary-subclavian steal syndrome. The second case had asymptomatic subclavian artery stenosis proximal to the IMA used for CABG. In the third case we planned to perform CABG using the left IMA to treat cardiac ischemia. All of the patients were successfully treated by stent placement without the use of a protection device. In the first and second cases, cardiac ischemia did not appear during balloon inflation of the subclavian artery and no embolic complication occurred. In the third case, CABG was performed six months after stenting. Subclavian artery stenting is a valid alternative to surgical treatment to restore the flow to the IMA before or after CABG.

The study on the patency of the perforating arteries after stent placement in atherosclerosis induced rabbits

SUMMARY

The number of successful case reports with percutaneous transluminal angioplasty (PTA) / stenting for intracranial atherosclerotic stenoses is recently increasing with the advent of flexible coronary stents. However, it is not well known whether the perforating artery is occluded or not after stent placement in the atherosclerotic stenotic vessels. We investigated this issue using five New Zealand white rabbits. We deployed stainless steel stents in the atherosclerosis-induced abdominal aorta across the lumbar artery in which the diameters of the abdominal arteries were similar to those of human intracranial arteries. We evaluated the patency of lumbar artery by angiography and scanning electron microscopy three months after stent placement. The lumbar arteries were patent in four out of five rabbits. However, SEM findings demonstrated stent struts were covered with thick neointima and the ostia between stent struts were partially occluded. It is possible that stent placement in the atherosclerotic arteries can cause the obliteration of the perforating arteries.

Clinical results of percutaneous transluminal angioplasty and stenting for intracranial vertebrobasilar atherosclerotic stenoses and occlusions

SUMMARY

Eighteen patients with intracranial vertebrobasilar stenosis and occlusion were treated by PTA or stenting. In 11 of 18 cases, only PTA was performed and in seven of 18 cases, we used stents. The mean stenosis before and after PTA/stenting was 82.8% and 22.3%, respectively. In 11 cases of PTA only, the stenotic rate decreased from 81.8% to 29.6%, while 85.0% of the stenotic rate remarkably reduced to 6.0% in seven cases of stenting. The 30 days morbidity and 30 days mortality rate were 5.5% and 5.5%, respectively. There was only one haemorrhagic complication (cerebellar haemorrhage) in cases of stenting, and no ischemic events during or after the procedures. Restenosis (more than 50% stenosis) occurred in four of 18 cases(22.2%) during mean followup period of 12 months. Two patients with VA occlusion before treatment, developed restenosis and reocclusion. Complete total occlusion seems to be a high-risk lesion and strict follow-up is required. In this study, PTA/stenting for intracranial vertebrobasilar artery stenosis or occlusion is an effective treatment, but strict indications may be required because procedure-related 30 days morbidity rate was 5.5% in addition to unclear natural history.

Endovascular treatment of unruptured cerebral aneurysms

76 consecutive patients with 78 unruptured cerebral aneurysms underwent endovascular therapy from July 1999 to May 2004 in our institute. For the wide-necked aneurysms, the remodeling technique, double microcatheter technique, or stent-assisted coil embolization was used, while a parent artery occlusion or covered stent was applied for the giant or fusiform aneurysms. Immediate angiographical results demonstrated 33 complete occlusions, 26 neck remnants, and 14 dome fillings. Four cases were treated with parent occlusion or stenting only, and one case was not treated with embolization but with clipping due to the rupture of the aneurysm during coil embolization. Immediate angiographic findings demonstrated that in aneurysms between 5 to 10 mm, the rate of complete occlusion was 48%, that of neck remnants 33%, and that of dome fillings 27%. In aneurysms between 11 to 25 mm, the rate of complete occlusion was 14%, that of neck remnants 28%, and that of dome fillings was 58%. In the angiographic follow-up results, all aneurysms smaller than 5 mm showed complete occlusion. In aneurysms between 5 to 10 mm, 74% of the aneurysms showed complete occlusion, and 21% showed neck remnants, and 5% showed dome filling. In aneurysms between 10 to 24 mm, 25% showed complete occlusion, while 75% showed dome filling. The overall mortality rate was 0% and the morbidity rate was 3.7% (2 major strokes, 1 minor stroke) at 30-days after embolization. In the clinical follow-up study, one case of a large basilar tip aneurysm caused a fatal rupture 28 months after the initial embolization. Endovascular therapy was performed on the unruptured aneurysms and was found to be an acceptable treatment, except for durability in cases of large aneurysms.

Technique and Clinical Results of Carotid Stenting under Distal Protection

SUMMARY

We perfomed carotid artery stenting(CAS) in 215 patients from August 1997 to October 2003 mainly using the distal protection technique. Our technique and clinical results are described in this paper.

Analysis of Complications related to Endovascular Therapy for Dural Arteriovenous Fistulae

SUMMARY

In this paper, we reviewed our cases of dural arteriovenous fistulae (dural AVFs) and analyzed periprocedural complications. In 157 procedures, we encountered 14 complications. Overall, complication rate of 9% was seen.We divided these complications into five subgroups such as cranial nerve palsy, coil-related trouble, thromboembolic complication, vessel perforation, and radiation-related trouble. There were five transient abducent nerve palsies in cases with cavernous sinus dural AVFs. There were two cases of coil unraveling and two cases of coil migration. In two cases, direct puncture of the internal jugular vein was performed to retrieve the unraveled coil by using dual microcatheter and guidewire snare technique. We encountered two thromboembolic complications. In one case, venous infarction was recognized after polyvinyl alcohol particle embolization. In two cases of vessel perforations, there were no new neurological deficits except one case with transient Gerstmann syndrome. In endovascular treatment of dural AVF, serious complications are rare and can be prevented if maximum attention is paid during the procedure.

Standard Technique of PTA/stenting for Atherosclerotic Intracranial Arterial Stenosis

SUMMARY

PTA/stenting for the intracranial arteriosclerotic lesion is effective and novel treatment. Our standard technique to avoid serious complications, such as vessel rupture or acute occlusion was introduced in this paper.

Complications associated with stenting for cerebral arteries

SUMMARY

We have experienced total 116 stenting for 102 of cranio-cephalic arteries and 14 of intracranial arteries including occlusive cerebrovascular diseases, aneurysms, and fistulas.Ten complications were encountered. Three were ischemic complication, four stent migration, two restenosis, and one aneurysmal perforation during coiling across the stent strut. The mechanism and preventive method of these complications were discussed in this paper.

Clinical results of stenting for cervical internal carotid stenoses

SUMMARY

Total 89 patients with cervical ICA stenosis were treated by stenting. In 74 cases of stenting, we used our blocking balloon systems to prevent distal embolism. The morbidity and the mortality rate was 4.5% and 0%, respectively.Two(3%) of 74 cases showed distal embolism when blocking balloon catheter systems(BBCS) were used, while distal embolism occurred in four (27%) of 15 cases of stenting without BBCS. On diffusion- weighted MRI (DWI), hyperintense areas were detected in seven (47%) of 15 lesions when we used BBCS only during postdilatation. On the other hand, use of BBCS during predilatation as well as postdilatation reduced hyperintense areas on DWI, which were detected in three (25%) of 12 patients. Our blocking balloon catheter system is a useful device to reduce the risk of distal embolism, especially when we use it during not only postdilatation but predilatation.

Factors Leading to and Treatment of Aneurysmal Perforation during Coil Embolization. Analysis of 105 Consecutive Cases

SUMMARY

It is important to know the characteristics of aneurysms that tend to cause perforation and treatment of these perforations to reduce the morbi/mortality of the endovascular treatment for intracranial aneurysms. Factors leading to aneurysmal perforation were analyzed from the view points of aneurysmal status (ruptured or unruptured), size and direction of aneurysmal dome from the parent artery and treatment of perforation during GDC embolization was discussed in 105 consecutive cases. Perforation occurred in three small aneurysms (less than 3 mm in diameter or depth) where the direction of the dome is the same as that of microcatheter advancement. Perforation occurred when a microcatheter was advanced to counteract catheter recoil caused by coil deployment. Haemorrhage occurred in all cases immediately following microcatheter and coil perforation into the subarachnoid space. In all cases, bleeding was controlled by deploying the coil so that it extended from the subarachnoid space back into the intraaneurysmal cavity. In two cases, surgical clipping was required to treat the incompletely obliterated aneurysm. No additional permanent neurological deficit occurred as a result of any of the three perforations. Special care should be taken during the embolization of small aneurysms (less than 3 mm in minimal diameter) where, owing to the shape of the lesion, or fixation of a microcatheter by the stent strut, the antegrade force of the canulating microcatheter is transmitted directly toward the aneurysm dome.

Indirect carotid cavernous fistula appeared after balloon embolization of direct CCF

The authors describe a case of indirect carotid cavernous fistula (CCF) appearing five months after embolization for traumatic direct CCF, which was treated six months after the trauma. Long-term (six months) venous hypertension to the affected cavernous sinus due to direct CCF and cavernous sinus thrombosis following a balloon embolization were considered as an etiology of the de novo dural arteriovenous fistula. The recurrent symptoms of CCF are usually related to detached balloon disorder, but delayed recurrence may be caused by the de novo dural AVF, if the direct CCF was treated in the chronic state.

Endovascular treatment for intracranial atherosclerotic stenosis. Pitfalls and problems

SUMMARY

Fourty-five cases of intracranial atherosclerotic stenoses greater than 70% for intradural lesions or 60% for extradural lesions were treated by PTA or stenting. The stenotic lesions were successfully dilated in 44/45 patients and future stroke was prevented during a mean 29 month follow-up period. Stenotic ratio significantly reduced in stent-treated group compared with PTA-treated group and stenting was effective for cases refractory to PTA, such as elastic recoil or restenosis. However, stenting had its own drawbacks, such as difficulty in delivery, migration, and acute thrombosis.

Clinical results and problems of percutaneous transluminal angioplasty and stenting for extracranial internal carotid stenoses. Is the blocking balloon catheter system useful for prevention of distal embolism?

SUMMARY

110 patients with extracranial ICA stenosis were treated by PTA or stenting. In 21 of 55 cases of only PTA and in 40 of 55 cases of stenting, we used our blocking balloon systems to prevent distal embolism. The morbidity and the mortality rates were 5.4% and 0%, respectively. There was only one embolic complication in cases of PTA or stenting where blocking balloon systems were used. In contrast, distal embolism occurred in 3 of 34 cases of PTA without blocking balloon systems (one symptomatic case) and in 4 of 15 cases of stenting without blocking balloon systems (3 symptomatic cases). Our blocking balloon catheter system is a useful device to reduce the risk of symptomatic distal embolism.

Memory impairment and spatial disorientation following a left retrosplenial lesion

We treated a patient in whom a left retrosplenial lesion resulted in memory impairment and spatial disorientation. A 31 year old, right handed man was admitted to our hospital after the sudden onset of headache. He was alert, attentive and cooperative, and showed no motor or sensory deficits. Although intelligence was preserved, memory was obviously deficient. The patient proceeded in wrong directions after he left his hospital room and subsequently his home. Neuroimaging revealed a subcortical hematoma in the left cingulate isthmus, while single-photon emission computed tomography demonstrated decreased perfusion in the splenium and left parietal lobe.

Haemorrhagic complication following percutaneous transluminal angioplasty for carotid stenosis

We report 2 cases with haemorrhagic complications following percutaneous transluminal angioplasty (PTA) for carotid stenosis. Computed tomography (CT) scanning of these cases demonstrated diffuse subarachnoid haemorrhage in 1 case, and intracerebral haemorrhage in the other case on the next day after PTA. In the latter case, we measured cerebral blood flow velocity and mean transit time with transcranial doppler (TCD) and dynamic CT scan, which demonstrated remarkable increases in the blood flow velocity and peak height, respectively. From these results, postoperative hyperperfusion was suggested to have caused haemorrhagic complications.

Endovascular Surgery for Internal Carotid Stenoses. Results of PTA vs. Stenting

SUMMARY

This paper will overview our results of endovascular therapy (PTA or stenting) for cervical ICA stenosis and discuss the advantages and disadvantages of each treatment. 60 cases with 62 lesions were treated with PTA 68 times, while 36 cases with 37 lesions were treated with stenting 37 times. A total of 99 lesions were treated with PTA or stenting 105 times. In the PTA group arterial stenosis improved from 76.4% to 21%. In the stent group the stenosis improved from 82.3% to 8.3%. The morbidity rate was 2/60 (3.3%) in PTA group, although two cases had minor neurological deficits, while in stent treated group, morbidity rate was 1/36 (2.8%), although it showed one major neurological deficit. Mortality was 0% in each group. The restenosis rate in PTA group was 15/58 (26%), while it was 0/20 (0%) in stent treated group. Stenting brings significant reduction of stenosis and reduces the rate of restenosis compared to PTA. However, stenting has its own disadvantages such as hypotension and distal kinks when deployed in tortuous ICA stenosis.

Measurement of the intracranial arterial wedge pressure in cases of acute cerebral arterial occlusion to determine the indication of intraarterial thrombolytic therapy

SUMMARY

Wedge pressure of the occluded major cerebral artery (distal pressure beyond the occlusion) was measured to estimate the residual cerebral blood flow in thirteen patients with acute ischemic stroke. There existed the relationship that patients with higher wedge pressure tolerated longer ischemic insults than those with lower wedge pressure. Wedge pressure is measured with minimum time loss before starting thrombolytic therapy and may be a good indicator to estimate the brain tissue reversibility.

The strategy for internal carotid stenosis with thrombus

SUMMARY

We report 3 cases of internal carotid artery (ICA) stenosis with thrombus. The initial symptom is transient ischemic attack (TIA) in 1 case, and cerebral infarction due to artery-to-artery embolism in 2 cases.We started anticoagulation and antiplatelet therapy after the angiography on admission in all cases. Carotid endarterectomy (CEA) was performed in 1 case after confirming the disappearance of the thrombus 1 month after the initial attack, although small cerebral embolic infarction happened during this period. In the other cases, percutaneous transluminal angioplasty (PTA) and stenting was performed using the protective technique about 2 weeks after the initial attack without embolic complication. Postoperative angiography showed sufficient dilatation. It seemed that PTA/stenting using the protection system was one of the alternatives for ICA stenosis with thrombus.

Regression of a presumed meningioma with the antiestrogen agent mepitiostane. Case report

This 68-year-old woman underwent a distal gastrectomy for gastric cancer in August 1994. A presumed meningioma of the falx was found incidentally on a staging examination of the gastric cancer, but the meningioma was not treated with surgery. Instead, after gastrectomy the patient received tegafur as adjuvant chemotherapy until February 1996, when she was readmitted to the hospital because of loss of appetite and emaciation but with no recurrence of the gastric cancer. A computerized tomography scan obtained during this second admission showed no change in the meningioma. To improve her general condition, tegafur was discontinued and she was started on a course of the antiestrogen agent mepitiostane. Administration of mepitiostane for approximately 2 years resulted in a marked regression (73%) of the meningioma. This is the first reported case of a presumed meningioma that regressed as a result of use of the antiestrogen agent mepitiostane.

[Agenesis of the right internal carotid artery associated with complicated anastomosis of middle cerebral artery: a case report]

A 57-year-old female was admitted to our hospital because of headache, nausea, and vomiting. Head CT scan demonstrated subarachnoid hemorrhage. Cerebral angiography showed the absence of the right internal carotid artery, and skull base CT of the bone window level revealed the absence of the right carotid canal. The right middle cerebral artery (MCA) and anterior cerebral artery (ACA) were opacified from the left internal carotid artery. The right A1 portion was hypoplastic and the distal portion of the right M1 portion was replaced by several minute complicated anastomotic vessels connected to the right M2 portion. The right MCA territory was mainly supplied by collateral flow from the right ACA and the right posterior cerebral artery via the leptomeningeal anastomosis. These was neither aneurysm nor arteriovenous malformation. The second angiography, 1 week after the initial angiography, showed the same hemodynamic pattern and aneurysms were not found. We diagnosed the patient as agenesis of the right internal carotid artery and the etiology of subarachnoid hemorrhage was suspected to be a rupture of the anastomotic vessels between the right M1 and M2. She was discharged on the 21st hospital day without any neurological deficit.

Treatment of restenosis after percutaneous transluminal angioplasty for internal carotid artery stenosis

The efficacy of repeated percutaneous transluminal angioplasty (PTA) and carotid endarterectomy (CEA) was examined in patients with restenosis after PTA for carotid stenosis. After percutaneous transluminal angioplasty (PTA) for 63 cases of internal carotid stenoses 13 cases of restenosis appeared. They were treated by PTA or carotid endarterectomy. The treatment was chosen by the patient after explanation of each treatment. We initially treated seven patients by repeat PTA and six by carotid endarterectomy. The degree of stenosis improved from 82% to 30% on average after repeated PTA. However, one patient in the PTA group had restenosis, and carotid endarterectomy was then performed. The other cases also had restenosis and were treated by PTA. The six cases treated by carotid endarterectomy were successfully treated without difficulty. The success rate of PTA was 5/7 (71%) in the restenosis cases. Patients with a greater residual stenosis after initial PTA had significantly more frequent restenosis. Repeat PTA and CEA both appeared effective treatment for restenosis after initial PTA, although PTA had a restenosis rate similar to that of initial PTA.

[Dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack: a case report]

A 58-year-old male was admitted to our hospital because of repeated transient ischemic attack of right hemiparesis and speech disturbance. A CT scan did not demonstrate any remarkable findings. No significant cerebral arterial stenosis or occlusion was found on angiography. However, dural arteriovenous fistula fed by the radiculo-meningeal artery was found at the cranio-cervical junction on left vertebral angiography. The shunt flow from the arteriovenous fistula drained into the superior petrosal sinus and sigmoid sinus in a retrograde fashion. On the angiographic findings when his transient ischemic attack (TIA) had disappeared, the venous drainage had returned to its normal fashion. Venous hypertension around the brain stem was supposed to have caused the transient ischemic attack in this case. We performed coagulation of the draining vein and fistula surgically. After surgery, the patient's TIA completely disappeared. We report the first case of dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack.

Transcortical sensory aphasia due to a left frontal subcortical haemorrhage

A case of transcortical sensory aphasia caused by a cerebral haemorrhage in the left frontal lobe is presented. A 72-year-old right-handed woman was admitted to the hospital, with a history of acute onset of speech disturbance and headache. On initial assessment, her spontaneous speech was fluent. She had no difficulty initiating speech, articulated normally, and did not exhibit logorrhea. Her ability to repeat phonemes and short sentences (5-6 words) was fully preserved, however she had severe difficulty with visual recognition of words, and with aural comprehension at the word level, although she was able to read words aloud. Computed tomography and magnetic resonance imaging showed cerebral haemorrhage in the left frontal lobe, involving the superior and middle frontal gyrus. Single photon emission CT revealed a wider area of low perfusion over the entire left frontal lobe, including the superior, middle and inferior frontal gyrus. The aphasia symptoms, mainly poor comprehension, disappeared quickly several weeks after the event. This may have been due to a reduction in the size of the haematoma and a resolution of the oedema around the haematoma. Clinically, the transcortical sensory aphasia in this case was indistinguishable from that caused by damage to the posterior language areas. Further case reports of transcortical sensory aphasia associated with frontal lobe lesions would help to confirm whether a relatively rapid recovery is characteristic in cases such as this.

A case of amnestic syndrome caused by a subcortical haematoma in the right occipital lobe

A case of an amnestic syndrome caused by a subcortical haematoma in the right occipital lobe is reported. A 62-year-old right-handed man presented with a sudden onset of headache to the hospital. On admission, he had a left homonymous hemianopsia, disorientation and recent memory disturbance, but had normal remote memory and digit span. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a subcortical haematoma in the right occipital lobe. These findings suggest that the patient's amnesia was caused by a lesion of the retrosplenial region in the non-dominant hemisphere.

[Construct validity of a new computer-assisted cognitive assessment battery in normal adults]

A computer-assisted battery for neuropsychological tests (CNT) has been designed to screen adults for cognitive impairment. The aim of this study was to gather evidence for the construct validity of CNT and also investigate the relationship between CNT and conventional neuropsychological tests. Subjects were 45 healthy adults (21 men and 24 women), who ranged in age from 20 to 70 years (mean = 33.5, SD = 1.9) with no history of substance abuse, or of psychotic or neurological disorders. The CNT in our study consists of six subtests designed to assess various components of driving, such as digit span, visual scanning, visual and verbal memory, complex reaction time, and vigilance. Mini-mental state test, Kana-hiroi test, word fluency, the auditory-verbal learning test and Raven's colored progressive matrices were also performed as conventional neuropsychological tests. Results showed there were high correlations between each CNT subtests and conventional neuropsychological tests. A factor analysis (with varimax rotation) identified 4 factors with eigen values greater than 1, which accounted for over 70% of the variance. CNT was able to estimate each factor related to cognitive function such as learning and memory, attention, judgment, and visual scanning selectively. CNT may thus be a useful tool for detection of cognitive impairment, although this test has important limitations. Broader applications of these tests will require extensive population-based validation.

Treatment of Restenosis after PTA for Internal Carotid Stenosis

SUMMARY

Thirteen cases of restenosis occurred after percutaneous transluminal angioplasty (PTA) in 63 cases of internal carotid stenoses. They were treated by PTA or carotid endarterectomy. The patients were sufficiently informed of each treatment. Seven of them were initially treated by repeated PTA. The stenosis ratio improved from 82% to 30% after repeated PTA on average. However, one case in the PTA treated group resulted in restenosis and then carotid endarterectomy was performed. The other case also caused restenosis and was treated by PTA. Six cases were initially treated by carotid endarterectomy and all cases were successfully treated without difficulty. The success rate of the PTA was 2/7 (29%) in restenosis cases. One case causing re-restenosis had severe calcification in the arterial wall. PTA was thought to be effective for the restenosis cases after initial PTA if the arterial calcification was not severe.

Carotid endarterectomy and simultaneous percutaneous transluminal angioplasty for tandem internal carotid stenoses

We treated three patients with tandem internal carotid stenoses in single procedures including carotid endarterectomy (CEA) for the proximal stenosis and percutaneous transluminal angioplasty (PTA) for the distal stenosis. We devised a Y-shaped shunt tube for the CEA, through which a balloon catheter was introduced to perform PTA guided by mobile digital subtraction angiography. No cerebrovascular events occurred during follow-up. Our approach avoids the risk of a second procedure while effectively treating tandem stenoses.

[A case of agraphia due to cerebral infarction in the left parietal lobe]

A case of agraphia due to cerebral infarction in the left parietal lobe was reported. A 63-year-old right-handed man was admitted to our hospital with writing disturbance. His spontaneous speech was fluent, and object naming, word fluency, repetition, verbal comprehension, and reading were fully preserved. However, his writing was slow and required effort. He showed hesitation in spontaneous writing and dictation. His power to copy was better than his power to write spontaneously or to take dictation, but he had some difficulty in copying letters and complex figures. The patient showed abnormal sequences of strokes and completed his strokes by piecing out of several fragments. CT scan and MRI showed a cerebral infarction in the left parietal lobe which included the superior parietal lobule. The amytal (Wada) test, which was performed via the left internal carotid artery, revealed that the left hemisphere was dominant for language. The characteristics of his agraphia much more closely resembled "apractic agraphia", as reported by Alexander et al (1992), than spatial agraphia or pure agraphia. Agraphia in this patient might result partially from the loss or unavailability of the memory of motor patterns necessary for writing letters.

[A case of cerebral aneurysm using a goose neck snare to stabilize the guiding catheter during embolization]

Severe arteriosclerotic changes often prevent navigating a guiding catheter into an appropriate position during aneurysm embolization. A basilar superior cerebellar artery aneurysm was found in a patient who had had subarachnoid hemorrhage 6 months previously. We selected embolization for this aneurysm using Guglielmi detachable coils (GDC) because of its highly located position from the dorsum sellae. We could not introduce a guiding catheter into the distal portion of the vertebral artery because of severe arteriosclerotic changes and it easily prolapsed into the aorta when a microcatheter was navigated through the guiding catheter positioned in the proximal vertebral artery. We were able to successfully perform embolization of the aneurysm by fixing a guiding catheter at the origin of the left vertebral artery with a goose neck snare wire introduced from the left brachial artery. The authors emphasize that a snare wire is useful not only for retrieval of foreign bodies but also for fixing a guiding catheter during aneurysm embolization, especially in which prolapse of the guiding catheter may cause a serious complication.

Percutaneous Transluminal Angioplasty for Bilateral ICA Occlusive Lesions

SUMMARY

We performed Percutaneous Transluminal Angioplasty (PTA) in 50 patients with internal carotid artery (ICA) stenosis. Fifteen of these patients also showed signs of contralateral ICA occlusive lesions. Various neurological symptoms, such as hemiparesis or convulsions, frequently appeared in these patients with contralateral lesions during PTA. The balloon inflation time was restricted in 2 patients who experienced convulsions during PTA, resulting in an unsuccessful dilatation in one case. No permanent neurological deficits appeared as a result of PTA in these cases. The treatment for these cases is discussed in this report.

Endovascular Treatment for Tandem Internal Carotid Stenosis. Development of a New Shunt Tube for PTA

SUMMARY

Three patients with tandem internal carotid stenoses were treated in one operation including carotid endarterectomy (CEA) for the proximal stenosis and percutaneous transluminal angioplasty (PTA) for the distal stenosis. We devised a Y-shaped shunt tube which we used for CEA, while a PTA balloon catheter was introduced via the tube to perform PTA guided by portable digital subtraction angiography (DSA). No cerebrovascular events occurred during follow-up. Our approach avoids the risk of a second procedure while effectively treating tandem stenoses.

[Syringomyelia appearing in a short term after brain abscess]

We describe a rare case of syringomyelia that developed within only 4 months after the cure of the focal cerebritis and abscess. An 18-year-old man who had suffered from meningitis and brain abscess 1.5 years before, presented with pain and sensory disturbance in his left shoulder. Magnetic resonance image (MRI) showed a syrinx formation extending from the upper cervical to the lower thoracic cord. Investigation by MRI during the course of the brain abscess had the appearance of posterior cerebellar arachnoid cyst 3 months after the onset of brain abscess and syrinx developed within 9 months. After posterior fossa decompression and reopening of the Magendie's foramen, his symptom and MRI abnormality improved after one month. In contrast to reported cases of syringomyelia following cerebritis, syrinx formation in our case appeared in relatively a short time. We speculated that basal arachnoiditis and the formation of posterior cerebellar arachnoid cyst caused syrinx formation in a short term after cerebritis.

[A case of spinal dural arteriovenous fistula associated with normal pressure hydrocephalus]

A 62-year-old male presented with urinary incontinence, gait disturbance and dementia for 6 months. Neurological examination revealed severe paraparesis (1/5), sensory disturbance below Th10, neurogenic bladder and absence of patellar and achilles tendon reflexes. CT scan showed mild brain atrophy and symmetric ventriculomegaly with periventricular lucency. Magnetic resonance imaging (MRI) showed a linear flow void lesion on the dorsal surface on the back of his swollen lower spinal cord. Myelography showed a filling defect and flow disturbance of contrast medium in lower thoracic levels, suggesting the presence of adhesive arachnoiditis. Spinal angiography demonstrated a fistula formation between dural branches of bilateral L4 lumbar arteries and ventral spinal and radicular veins on the surface of the dura mater of L4/5 levels. Considering his past history of repeated lumbar puncture for tuberculous meningitis at the age of 22 years, a diagnosis of acquired spinal dural arteriovenous fistula probably due to repeated lumbar puncture was made. Fistulas were embolized with N-butyl cyanoacrylate. And normal pressure hydrocephalus was treated by ventriculoperitoneal shunt. Follow-up CT scans showed a decrease of the size of the ventricular system. Etiology of acquired spinal arteriovenous fistula has been reported. In the case, repeated lumbar puncture may be a possible cause of arteriovenous fistula in the lower spinal dura mater. However, the reason why it took so long to form a fistula after the lumbar puncture remains to be elucidated. We suggest that an increased protein concentration due to disturbance of cerebrospinal fluid flow might be a cause of normal pressure hydrocephalus (NPH).