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Takeshi Satow, Shigeki Yamada, Miyuki Yagi and Masaaki Saiki

The authors report a case of superficial siderosis of the CNS that developed after ventriculoperitoneal (VP) shunt placement for normal-pressure hydrocephalus.

A 65-year-old woman had undergone VP shunt insertion for normal-pressure hydrocephalus. Her gait disturbance, memory disturbance, and urinary incontinence all improved after the procedure. Two years later, however, her gait became ataxic and her appetite became poor. Brain MR imaging revealed a rim of hypointensity on T2-weighted sequences, enveloping the surface of the cortical fissure, cerebellum, and brainstem. Superficial siderosis of the CNS was diagnosed. Steroid administration improved her symptoms.

The authors know of only one case of superficial siderosis developing after VP shunt surgery in the English-language literature. Superficial siderosis should be acknowledged as a possible complication of VP shunt.

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Yuya Matsui, Yohei Mineharu, Takeshi Satow, Noriyoshi Takebe, Eiji Takeuchi and Masaaki Saiki

Cobb syndrome is a rare, noninherited, neurocutaneous disease characterized by vascular abnormality of the spinal cord and is associated with vascular lesions in the skin at the same metamere. The majority of spinal vascular lesions are arteriovenous malformations, and skin lesions are mostly port-wine angiomas. The authors report the first case of multiple intramedullary cavernous angiomas (CAs) accompanied by skin CAs within the same metamere. A 42-year-old man presented with an acute onset of gait disturbance, low-back pain, and urinary incontinence. Magnetic resonance imaging of the thoracolumbar spine showed homogeneously enhanced lesions on a contrast-enhanced T1-weighted image and a hypointense area on a T2*-weighted image surrounding this enhanced lesion, between the T-12 and S-1 levels. Purple protruding skin lesions were detected on the left side of his gluteal region. The patient received a laminectomy followed by evacuation of a hematoma and partial removal of the tumor, which completely resolved his neurological symptoms. Pathological examinations showed that the spinal and skin lesions were CAs, suggesting that these vascular lesions developed congenitally. Cavernous angiomas associated with Cobb syndrome present with multiple lesions spanning more than 3 vertebral levels, making it difficult to completely resect these tumors. Although Cobb syndrome is an uncommon disease entity, it should be considered if a patient manifesting with neurological deficits has skin vascular lesions, including CAs.

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Kazuhiko Shiokawa, Junya Hanakita, Hideyuki Suwa, Masaaki Saiki, Masashi Oda and Motohiro Kajiwara

Object. A variety of factors may affect surgery-related outcome in patients with ossification of the ligamentum flavum (OLF) of the thoracic spine. The aim of this study was to determine these factors on the basis of preoperative clinical and radiological findings.

Methods. The authors treated 31 cases of symptomatic thoracic OLF between 1988 and 1999. The following factors were retrospectively studied: patient age, sex, morbidity level, initial symptoms, chief complaint, duration of symptoms, patellar reflex, Achilles reflex, computerized tomography (CT) finding, presence of intramedullary change determined by magnetic resonance imaging, coexistent spinal lesions, preoperative grade, and postoperative grade.

A decompressive laminectomy was performed in all cases. In 29 patients (94%) improved symptoms were demonstrated postoperatively. In terms of functional prognosis, the preoperative duration of symptoms was significantly shorter in the group of patients with excellent outcomes than in those with fair outcomes (p < 0.05).

No significant difference was observed in the correlation between other factors. To evaluate the degree of preoperative thoracic stenosis and the severity/extent of OLF-induced spinal compression, we used an original OLF CT scoring system. A score of excellent on the CT scale tended to indicate an excellent prognosis (p < 0.01).

Conclusions. Thoracic OLF frequently develops in the lower-thoracic spine in middle-aged men, and it is complicated by various spinal lesions in many cases. Early diagnosis and treatment are important for understanding the clinical symptoms and imaging diagnosis because the present findings suggest that a delay in diagnosis and treatment correlates with the functional prognosis postoperatively.

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Masaomi Koyanagi, Hitoshi Fukuda, Masaaki Saiki, Yoshihito Tsuji, Benjamin Lo, Toshinari Kawasaki, Yoshihiko Ioroi, Ryu Fukumitsu, Ryota Ishibashi, Masashi Oda, Osamu Narumi, Masaki Chin, Sen Yamagata and Susumu Miyamoto

OBJECTIVE

Shunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH.

METHODS

The authors’ multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH.

RESULTS

A total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score–matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2–4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3–6) at discharge (OR 4.3, 95% CI 2.6–7.3; p < 0.001).

CONCLUSIONS

SDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.