Five cases of nontraumatic intradiploic arachnoid cysts in elderly patients are reported. All cysts were located in the occipital bone and appeared as well-demarcated radiolucent lesions. The cysts were multiple in three cases. Presenting symptoms included headache or dizziness, but most lesions were asymptomatic and found incidentally. In the most recent three cases, magnetic resonance (MR) im aging revealed intradiploic cysts containing cerebrospinal fluid (CSF) with cerebellar herniation. Operation found the cysts filled with CSF and dural defects through which cerebellar tissue was herniating. In two patients, CSF leakage from the outer table occurred. Intradiploic arachnoid cyst seems to be congenital in origin but commonly found in the elderly. MR imaging is the most useful diagnostic method for differential diagnosis from other osteolytic skull lesions.
BACKGROUND AND PURPOSE:Because intravenous (IV) recombinant tissue plasminogen activator (rtPA) does not always lead to a good outcome in a considerable proportion of patients, combined IV rtPA and rescue endovascular therapy (ET) have been performed in several recent studies. However, rescue therapy after completion of IV rtPA often results in late ineffective recanalization. We examined the efficacy and safety of combined IV rtPA and simultaneous ET as primary rather than rescue therapy for hyperacute middle cerebral artery (MCA) occlusion.
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.
The authors advocate the use of a 1.7-mm fiberscope to evaluate a hypertensive bilateral tegmental pontine hemorrhage that has ruptured, in part, into the fourth ventricle. In applying this new technique, a fiberscope, which contains a guide tube in the working channel, is inserted into the aqueduct. After the endoscope has been removed, a silicone tube is slid along the guide tube. The hematoma is evacuated through the silicone tube and a potassium titanyl phosphate laser is used to achieve hemostasis.
A 76-year-old woman presented with an enlarged right intracavernous carotid artery aneurysm first identified incidentally when she was hospitalized for thalamic hemorrhage. She was managed conservatively for 1 year, then suffered right total ophthalmoplegia associated with enlargement of the aneurysm. Two months later, she became comatose due to intracerebral hemorrhage in the right temporal lobe. Magnetic resonance imaging demonstrated further enlargement of the aneurysm. Emergency craniotomy found the lateral dural wall of the cavernous sinus was markedly expanded and torn by compression from the aneurysm. Rupture of the aneurysm into the intradural space through this dural defect was confirmed. The aneurysm was trapped after high-flow bypass, but the patient did not recover and died. Symptomatic enlarged intracavernous carotid artery aneurysm is potentially fatal and may indicate prompt surgical management.
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