Pathognomonic consideration of clinical features of dural arteriovenous malformations

Dural arteriovenous malformations (dural AVMs) were reported sporadically. However, the diagnosis has become easier due to recent developments in clinical imaging modalities. It is known that dural AVMs present various signs and symptoms according to locations and/or specific pathophysiological conditions and occasionally cause serious neurological deficits with intracranial hemorrhage or venous infarction. There are few reports which describe the management of patients with dural AVMs. In this paper, clinical features of dural AVMs observed in our service are reviewed with special attention to angiographic findings. Seventy-five cases of dural AVM treated between 1976 and 1995 were divided into two groups : 69 cases with single lesions and 6 cases with multiple lesions. The lesions were located in anterior fossa (AF), cavernous sinus (CS), transverse-sigmoid sinus (TS) or superior sagittal sinus (SSS). From their pathognomonic aspects, the cases were classified into two types : the apoplectic type (hemorrhage or venous infarction) and the non-apoplectic type (no evidence of hemorrhage or venous infarction). Among 69 cases with single lesions, 8 involved the AF, 28 CS, 31 TS and 2 SSS. Patients of 60-69 years age predominated in our series. Males predominated in AF cases (M : F = 7 : 1), females in CS cases (M : F = 5 : 23). Among these, intracranial hemorrhages were noted in 5 AF, 1 CS, 11 TS and 2 SSS, respectively. On the other hand, venous infarctions were noted in 5 TS and 1 SSS. Twelve of 13 hemorrhagic cases exhibited intracerebral hematoma. The rate of apoplectic attacks by location was 63 % in the AF, 4 % in CS, 35 % in TS and 100 % in SSS, respectively. All cases of the apoplectic type demonstrated cortical venous reflux in the angiograms, whereas reflux was seen in only 7 (14 %) out of 50 non-apoplectic cases. Among the 19 apoplectic cases, 17 (89 %) showed the so-called isolated sinus, which was noted in only 4 (8 %) out of 50 non-apoplectic cases. A venous lake, meaning a dilated draining vein such as a saccular aneurysm of the vein, was also thought to be a warning sign of apoplexy. Draining vessels were cut at proximal sites in 7 out of the 8 AF cases surgically and successfully. Most of the CS lesions were treated by embolization and/or radiation therapy, and the TS lesions by embolization or conservative method. No episode of rebleeding has occurred after treatment. Most of the patients had an excellent or good outcome, although 3 cases demonstrated a fair or poor outcome in the apoplectic group. There were 6 cases (14 lesions) with multiple dural AVMs. However, 5 out of the 14 lesions caused apoplexy, all of these cases had an excellent or good outcome after treatment. There were 5 cases (83 %) of sinus thrombosis and 3 (50 %) of thrombosis in the deep vein of the legs, indicating that multiple dural AVMs may be associated with generalized thrombosis of the venous system. In conclusion, if dural AVMs are associated with cortical venous reflux, isolated sinus and/or a venous lake angiographically, the lesions have a high risk of intracranical hemorrhage or venous infarction. Therefore, such patients need urgent treatment

ノウケッカンナイ チリョウ

We reported the resent advansement of endovascular treatment for cerebral strokepatients, coil embolization for aneurysm, local fibrinolytic therapy for acute major cerebralartery occlusion and stent inplantation for cerebral artery stenosis. Detachable coil embolizationwas done for 101 patient with (105) cerebral aneurysms. Detachable coil treatment technologyfor cerebral aneurysms were effective and safe. We treated intraarterial local fibrinolysisfor 94 patients of acute major cerebral artery occlusion. Our clinical trial may indicate abetter choice for cases with acute ischemic cerebral stroke. Especially early treatment within4 hours from onset may lead to have more enhance of good clinical improvemant. Stentinplantation for carotid artery, vertebral artey and subculavian artery was done for 11patients with arterio-screlotic stenosis. Stent inplantation for cerebral artery stenosis iseffective, although we need more safety protection for embolism and prevention technologyagainst restenosis

ノウコウソク ノ キュウセイキ チリョウ : Stroke Care Unit オ チュウシン トシテ

Stroke remains the second or third leading cause of the death and major cause of adultdisability in Japan. Cerebral infarction is major cause of stroke, therefore, it is very importantthat precious diagnosis and acute treatment of cerebral infarction should be done.Recently diffusion-weighted (DWI) and perfusion-weighted MRI (PWI) were clinically used andsensitivity of these stools is superior to T2-MRI in diagnosis of acute cerebral infarction.We performed acute intra-arterial thrombolysis and evaluated this efficacy by DWI andPWI. For the patients with embolic cerebral infarction, anticoagulant therapy should beperformed and tarns-esophageal heart echography in acute stage of infarction is useful fordetection of embolic source. Stroke Care Unit (SCU) was opened in our hospital since lastNovember and 8 patients per month were admitted to SCU. Over 75% of patients weretreated conservatively, and 6 patients were performed intra-arterial thrombolysis. Over80% of patients with cerebral infarction in SCU showed good clinical recovery. We needmore patients to show the superiority compared to the general medical wards

Transarterial embolization for convexity dural arteriovenous fistula

Background: Convexity dural arteriovenous fistulae (dAVF) usually reflux into cortical veins without involving the venous sinuses. Although direct drainage ligation is curative, transarterial embolization (TAE) may be an alternative treatment. Case Description: Between September 2018 and January 2021, we encountered four patients with convexity dAVFs. They were three males and one female; their age ranged from 36 to 73 years. The initial symptom was headache (n = 1) or seizure (n = 2); one patient was asymptomatic. In all patients, the feeders were external carotid arteries with drainage into the cortical veins; in two patients, there was pial arterial supply from the middle cerebral artery. All patients were successfully treated by TAE alone using either Onyx or N-butyl cyanoacrylate embolization. Two patients required two sessions. All dAVFs were completely occluded and follow-up MRI or angiograms confirmed no recurrence. Conclusion: Our small series suggests that TAE with a liquid embolic material is an appropriate first-line treatment in patients with convexity dAVFs with or without pial arterial supply

ノウソッチュウ シンダン ノ サイゼンセン

Stroke Care Unit （SCU） in Tokushima University Hospital has been opened since November １９９９. Patients with acute stroke in SCU were diagnosed by stroke MRI and biomarker immediately after their admission. Diffusion MRI could diagnose the ultra-acute ischemic and hemorrhagic lesion except brainstem ischemic lesion within ３ hrs after onset. Diffusion-Perfusion mismatch was useful to indicate intra-arterial thrombolytic therapy. ３T-MRI was introduced since March ２００４，and it can measured functional MR spectroscopy and tractography more quickly compared to １．５T-MRI. Plasma oxidized LDL in patients with acute cerebral infarction was significantly higher than that in healthy control and it became peak level during ３‐５ day after stroke onset. In conclusion, stroke MRI and plasma oxidized LDL are useful diagnostic tools for acute stroke

髄膜癌腫症による頭蓋内圧亢進症に対する脳室腹腔短絡術の有用性

　髄膜癌腫症は，がんの集学的治療の進歩による生存期間の延長に伴い，診断される機会も増加している．髄膜癌腫症は患者のQuality of life(QOL) を著しく低下させ，生命予後に直結することが多い．神経症状の軽減によるQOL の改善を考えると，髄膜癌腫症に対する外科治療の介入を検討し直す必要があると思われる．　我々は，髄膜癌腫症に対し外科治療を施行した３症例経験した．外科治療の適応に関し，過去の症例も交え，文献的考察を加え報告する．　【症例１】56歳男性．肺癌を原発とする多発脳転移を伴う髄膜癌腫症と診断された．全脳照射後に全身化学療法を行うも，意識障害をきたし，全身化学療法の継続が困難となった．髄液排除によりPerformance Status（PS）が改善したため，脳室腹腔短絡術を施行した．術後，意識障害は改善し，治療を再開した．PS は改善し，比較的良好な日常生活を送れQOL は改善したと考えられたが，Nivolumab の副作用により，全身状態は悪化し，術後３か月で死亡した．　【症例２】55歳女性．肺腺癌と診断され，頭痛が出現し，髄膜癌腫症と診断された．EGFR-TKIを含む全身化学療法を行い，症状は改善傾向であった．その後，頭痛，嘔気が増悪しPS は低下した．脳室ドレナージ術により，PS は改善し，嘔気・疼痛のコントロールが可能となったため，脳室腹腔短絡術を施行した．術後，緩和医療に移行し，残された時間を有意義に過ごすことができ，QOL は改善したと考えられたが，全身状態の悪化により術後４か月で死亡した．　【症例３】66歳女性．頭痛が出現し，肺癌に伴う，髄膜癌腫症と診断された．疼痛コントロールが困難であり，PS も低下していたため，脳室ドレナージ術を施行したところ，疼痛コントロールが可能となった．PS の改善に伴い，Erlotinib による治療を開始することができた．しかし，間質性肺炎による全身状態の悪化により，脳室腹腔短絡術は施行できず，脳室ドレナージ術から44日で死亡した．　The incidence of leptomeningeal carcinomatosis is increasing with the extension of the survival because of the advances in cancer treatment. This condition significantly deteriorates the patients\u27 quality of life (QOL) and worsens the prognosis. Because the reduction of neurological symptoms can be expected to improve the QOL, it is necessary to reexamine the indications for surgical treatment of leptomeningeal carcinomatosis. We report three cases of surgically treated leptomeningeal carcinomatosis, and we review the literature, including past cases, with regard to the indications for surgical treatment.　Case 1: A 56-year-old man was diagnosed with leptomeningeal carcinomatosis with multiple brain metastases from lung cancer. Whole-brain irradiation was performed, followed by systemic chemotherapy, which was discontinued because of the development of a consciousness disorder. As the patient’s performance status (PS) improved after ventricular drainage, ventriculoperitoneal (VP) shunt was performed. Postoperatively, the consciousness disorder improved, and treatment was restarted. The patient’s PS and QOL improved; he was able to live a relatively good daily life. However, he died 3 months after the surgery because of deterioration of his general condition resulting from the side effects of nivolumab.　Case 2: A 55-year-old woman diagnosed with lung adenocarcinoma complained of headaches. She was diagnosed with leptomeningeal carcinomatosis and underwent systemic chemotherapy, including epidermal growth factor receptor tyrosine kinase inhibitors. Her symptoms initially improved; however, after a while, the headaches and nausea worsened and her PS deteriorated. The ventricular drainage improved her PS; therefore, VP shunt was performed. Postoperatively, her PS and QOL improved and she was switched to palliative care as the nausea and pain became controllable. However, she died because of deterioration of her general condition 4 months after the surgery.　Case 3: A 66-year-old woman complaining of headaches was diagnosed with leptomeningeal carcinomatosis associated with lung cancer. Because pain control was difficult and her PS was reduced, ventricular drainage was performed. Postoperatively, pain control became possible and her PS improved. Although treatment with erlotinib was started, the patient could not undergo VP shunt because of deterioration of her general condition resulting from an interstitial pneumonia, and she died 44 days after the ventricular drainage

破裂脳動脈瘤の発症12日目に別の未破裂脳動脈瘤が破裂した1例

　67歳女性．以前より左中大脳動脈・脳底動脈本幹・左海綿静脈洞部内頚動脈に未破裂脳動脈瘤を指摘されていた．突然に激しい頭痛・嘔気が出現し，その5日後に他院でsubarachnoid hemorrhage（SAH）を指摘されたため，当院紹介となった．CT で左シルビウス裂・左大脳半球脳溝を中心にSAH を認めるも，脳幹周囲には認めなかった．緊急DSA では，左中大脳動脈瘤は4.9mm でbleb を伴っていたが，脳底動脈瘤は6.5mm，左内頚動脈瘤は2.9mm で，いずれもblebはなかった．左中大脳動脈瘤の破裂と考え，緊急で同部位にコイル塞栓術を施行し，ほぼ完全閉塞された．しかし，第12病日に突然昏睡状態となり，CT で橋腹側を中心に新たなSAH を認めた．脳底動脈瘤の破裂と診断し，緊急コイル塞栓術を行った．術後意識状態は改善し，NPH に対しVP シャントを追加し，mRS1で自宅退院となった．短期間で2個の動脈瘤が破裂した比較的稀な症例と考えられ，報告する．　We report a rare case of recurrent bleeding caused by another cerebral aneurysm during the subacute phase of aneurymal subarachnoid hemorrhage (SAH). A 67-yearold woman developed severe headache and visited our hospital on the 5th day from the onset. Her computed tomography (CT) confirmed SAH, and her angiography revealed three intracranial aneurysms: a 4.9-mm left middle cerebral artery aneurysm (MCA An) with bleb formation, a 6.5-mm basilar trunk aneurysm (BA trunk An) without bleb, and a 2.9-mm internal carotid cavernous sinus aneurysm without bleb. As the SAH was present mostly in the left cerebral hemisphere and left Sylvian fissure without the involvement of the basal cistern. MCA An was thought to bleed. Subsequently, she underwent coil embolization and recovered well. However, she suddenly became comatose on the 12th day from the onset. Her CT showed diffuse SAH localized around the prepontine cistern. Second angiography demonstrated the expanded BA trunk An. Coil embolization was then successfully performed. VP shunt insertion was added for hydrocephalus secondary to SAH, and left our hospital with favorable outcome