A case of capillary hemangioma of the cauda equina is reported. Myelography with water-soluble contrast material showed a complete obstruction of the contrast column at the L1-L2 level. Neither plain nor intravenously enhanced CT revealed the tumor. Spinal angiography showed a feeding vessel to the tumor and a faint tumor stain. Magnetic resonance imaging (MRI) showed a mass lesion of slightly higher than cauda equina intensity, which was clearly enhanced with Gd-DTPA. MRI, especially Gd-DTPA-enhanced study, plays the most important role in the diagnosis of a spinal capillary hemangioma. Spinal angiography was interesting in showing a tumour with a capillary blush.
Anatomically, the vertebral artery courses through six foramina transversaria of the cervical vertebrae, passing through the groove on the surface of the arch of the atlas and then penetrating the dura mater. Because of this anatomical course, the vertebral arteries are often affected by head motion. Stenotic change of the vertebral artery can occur at the atlantoaxial level in head rotation. Such a special type of stroke was named "bow hunter's stroke" by Sorensen. We report three cases of bow hunter's stroke and discuss the angiographic examinations. As surgical treatment, we performed partial transversectomy of the atlas vertebra, with favorable results. The usefulness of this surgical procedure is discussed.
In this contribution the clinical features of eleven patients suffering from a neurinoma in the cauda equina and around the conus medullaris are analysed. Because of the relative mobility of the roots and the wide space in the spinal canal, tumours arising in the cauda equina or around the conus medullaris can become larger than any other spinal tumours. Lumbago was the predominant symptom as the initial complaint. Nocturnal pain relieved by walking was noticed in one patient. Two cases showed spontaneous remission and relapse. Multiple tumours were found in 6 cases (55%). Macroscopic cyst formation was found in 5 cases (45%). Among the eleven patients, total removal of the tumour, including the involved root, was performed in ten. The numbers of the resected nerve roots were one root in 6 cases, two roots in 2, and three roots in 2. Only one patient showed postoperative slight weakness of the leg.
Cervical spondylotic myelopathy usually arises in patients in their late 40s or early 50s, most frequently at the C5/6 and C6/7 levels. Recently, excellent results have been attained with microsurgery in cases of cervical spondylosis. On the other hand, treatment of cervical spondylotic myelopathy in patients with athetoid dystonic cerebral palsy entails several problems. The authors report three cases of such troublesome myelopathy. A 34-year-old male with severe athetoid movement showed cervical spondylotic myelopathy. Myelography and magnetic resonance (MR) imaging demonstrated compression of the spinal cord through the C3-C5 levels. A 47-year-old female with athetoid dystonic cerebral palsy presented myelopathy. Myelography and MR imaging showed instability and spinal cord compression at the C5/6 level. A 34-year-old male with spasmodic torticollis showed C6 radiculopathy due to cervical disc hernia at the C5/6 level. Cervical anterior decompression with interbody fusion brought temporary improvement in all the three patients. However, such problems as slippage of Halo-vest, difficulty in eating during Halo-vest fixation, relapse of neurological deficit, were experienced. Due to postoperative cervical instability, cervical laminectomy is considered to be contraindicated in such patients. Anterior decompression with bone fusion has been reported effective, but, if athetoid dystonia continues, there is a potential for myelopathic deterioration due to spondylotic changes adjacent to the fused vertebrae.
Thoracic lesions present several clinical problems, particularly in their diagnosis and treatment, compared with cervical or lumbar lesions. Since 1983, 18 cases of thoracic space lesions, excluding spinal tumors or trauma have been experienced: nine cases of ossification of yellow ligament (OYL), five of ossification of posterior longitudinal ligament (OPLL), and four of disc hernia (DH). In these 18 patients, problems of clinical manifestations, neuroradiological examination, and surgical approaches are analyzed and discussed. As clinical manifestations, there was a preponderant occurrence in males in the OYL group, while in the OPLL group all the patients were females. OYL and DH occurred at lower thoracic levels. Thirteen of the 18 patients showed combined lesions either in the cervical or in the lumbar regions, such as cervical OPLL, cervical spondylosis, lumbar DH, and lumbar canal stenosis. In the neuroradiological examinations diagnosis of the upper thoracic lesions was difficult. Computed tomography (CT) scan with intrathecal metrizamide injection seemed essential for examination of ossified thoracic lesions. However, because CT imaging of the entire spine is impractical, efficient use of this examination requires previous localization of the offending vertebral level from either the neurological findings or other neuroradiological examinations such as myelography. Magnetic resonance imaging seemed most useful for ruling out the thoracic compressing lesions. As for surgical approaches, posterior decompression was effective for OYL and the anterior approach was useful for OPLL and DH. In patients with "tandem lesions," neurological and neuroradiological findings played an important role in deciding the responsible site.
The case of a 43-year-old woman with multiple intracranial arterial ectasia was reported. The arterial ectasia was accompanied by stenosis of the middle cerebral artery and so-called moyamoya vessels. After extracranial to intracranial bypass surgery, the size and contour of the arterial ectasia decreased. Because the arterial ectasia decreased in size after the extracranial to intracranial bypass surgery, this operation might be useful for space-occupying lesions due to arterial ectasia.
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