BACKGROUND Hemorrhagic moyamoya disease (MMD) and the fragile periventricular collaterals are known to have a causal relationship. Digital subtraction angiography and magnetic resonance angiography have shown the presence of fragile periventricular moyamoya vessels. However, dynamic fragile periventricular moyamoya vessels have never been observed under direct vision. OBSERVATIONS The authors treated two patients with hemorrhagic MMD: a 42-year-old man with intraventricular hemorrhage and a 47-year-old woman with intracerebral hemorrhage. Endoscope-integrated indocyanine green video angiography (EICG angiography) could visualize the dynamic fragile periventricular collaterals. In particular, EICG angiography enabled visualization of invisible moyamoya vessels buried in the subependyma and characterization of the blood flow in the moyamoya vessels located inside the lateral ventricles and hematoma cavity. LESSONS EICG angiography can confirm the fragile periventricular collaterals associated with MMD by direct visualization. The high spatial resolution and real-time imaging can help to avoid accidental hemorrhage in and after evacuation of hemorrhage in patients with MMD.
Although the synchronous occurrence of testicular seminoma and systemic sarcoidosis has been reported, that of intracranial germinoma and systemic sarcoidosis is unknown. A 26-year-old man presented with symptoms of panhypopituitarism and consciousness disturbance. Imaging demonstrated a large nodule in the upper right lung field and swelling of multiple bilateral pulmonary and mediastinal lymph nodes in addition to the bifocal pineal and suprasellar tumors with obstructive hydrocephalus. The pathological diagnosis of the intracranial bifocal tumors was pure germinoma, whereas that of the mediastinal lymph nodes was epithelioid granuloma. Three courses of chemotherapy using carboplatin and etoposide were administered, followed by whole ventricle irradiation. The intracranial tumors completely disappeared, but the lung nodule and mediastinal lymph nodes progressed. Whole-body fluorine-18-fluorodeoxyglucose positron emission tomography demonstrated accumulation in the mediastinal lymphadenopathy, lung masses, and multiple lymph nodes of the whole body. Transbronchial lung biopsy revealed epithelioid granuloma with multinucleated giant cells. In conjunction with the high blood concentration of angiotensin-converting enzyme and soluble interleukin-2 receptor, these findings established a diagnosis of sarcoidosis. This is the first report of synchronous occurrence of intracranial germinoma and sarcoidosis. Such coexistence is extremely rare, but we should mind that sarcoidosis can occur with intracranial germinoma.
BACKGROUND The authors report a rare case of coexistence of dural arteriovenous fistula (DAVF) and arteriovenous malformation (AVM), with a common trunk drainer from both DAVF and AVM in the left anterior cranial fossa (ACF) with simple DAVF in the right ACF. OBSERVATIONS A 63-year-old female presented with seizure. Cerebral angiography showed bilateral DAVFs in the ACF and AVM in the left frontal lobe. A dilated frontal vein acted as a simple drainer of the right DAVF. In contrast, a dilated vein with large varix was the common drainer of both the left DAVF and the AVM. During surgery, indocyanine green videoangiography was performed with direct observation. In the left ACF, the drainer occlusion of the DAVF resulted in partial shrinkage of the varix and decreased distal blood flow. Additional main feeder occlusion of the AVM could decrease the blood flow further, but not completely because of the residual pial supplies for the AVM. Finally, the nidus of the AVM with varix was removed by en bloc resection. LESSONS Neurosurgeons should be aware of the coexistence of DAVF and AVM with a common trunk drainer. Only simple occlusion of the drainer from DAVF is not sufficient, so removal of the AVM is essential.
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