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  • Arachnoid thickening as a possible

    2018-10-22

    Arachnoid thickening as a possible factor for typical TN has seldom been reported. We observed two cases (7.7%) of arachnoid thickening that appeared to be associated with neuralgia development. After adhesiolysis, the immediate postoperative outcome was excellent and good in the two cases. Ishikawa et al suggested that arachnoid thickening between the nerve roots and surrounding structures could cause a tethering effect, resulting in a pulsatile movement of the trigeminal nerve root. On the basis of the present findings, we postulate that an artery attached to the arachnoid thickening results in the metalloproteinase of the trigeminal nerve. After lysis of the arachnoid bands, the artery may be therapeutically detached from the trigeminal nerve, resulting in the decompression of the trigeminal nerve. However, the study findings are limited by the small sample size. Additional cases of MVD concerning venous contact and arachnoid thickening are required to validate the observations.
    Acknowledgments The study was supported by a grant from the Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (TCRD-TPE-105-41). This study was sponsored in part by the grant TCRD-TPE-103-RT-7.
    Introduction Surgical intervention is one of the major treatment modalities for moyamoya disease. Both direct and indirect revascularizations are widely used surgical options. However, a superior surgical technique is required for direct revascularization. In direct revascularization, anastomosis of the superficial temporal artery (STA) to the middle cerebral artery (MCA; denoted as STA–MCA) is commonly performed; however, this procedure can cause complications. Here, we report the case of a patient with moyamoya disease who developed an aneurysm in the STA–MCA anastomotic site following direct revascularization. The successful treatment of the aneurysm prevented its catastrophic sequelae.
    Case Report A 42-year-old man with hypertension under medication experienced an acute onset of weakness in the right limbs with slurred speech for 2 years. He was initially treated with hydration and aspirin at a local clinic for a suspected transient ischemic attack. He was then transferred to our department for further evaluation. At our hospital, brain MR(Magnetic Resonance) angiography revealed luminal narrowing in the M1 segment (from the origin of middle cerebral artery to its bifurcation) and total occlusion of the right M1 segment of the MCA (Figure 1A). Digital subtraction angiography demonstrated severe stenosis of the M1 segment of the right MCA with moyamoya vessels in the M1 region, in addition to total occlusion of the left M1 segment with compensated collateral flow from the left ECA(External Carotid Artery) and moyamoya vessels to the right M1 and right ophthalmic area. Laboratory investigation revealed no significant abnormality. Moyamoya disease with superimposed ischemic symptoms was diagnosed. Regional cerebral perfusion SPECT (Single-Photon Emission Computed Tomography) performed for preoperative preparation revealed significant hypoperfusion in the left frontal cortex, left basal ganglion, and right frontoparietal junction as well as relative hypoperfusion in the right temporal cortex and right thalamus (Figure 2). To prevent additional ischemic stroke attacks, direct revascularization using an STA–MCA bypass procedure was suggested. A left STA–MCA anastomosis was immediately performed followed by a right STA–MCA anastomosis 6 months later. Postoperative noncontrast brain computed tomography (CT) performed 1 day after the right-side STA–MCA bypass procedure revealed intracranial hemorrhage (ICH) in the right temporal region (Figure 1B). Medical treatment with tentative blood pressure control was preferred during the immediate postoperative period owing to the absence of new neurological deficits. During a follow-up visit at our outpatient clinic 5 months later, brain CT angiography revealed favorable patency of both anastomoses; metalloproteinase however, an 8-mm aneurysm was noted at the right STA–MCA anastomotic site (Figure 3). Surgical clipping was performed 7 days later (Figure 4A). The neurological condition returned to the preclipping status without any neurological deficits.