Background An aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare congenital anomaly that can present with both ischemic and hemorrhagic stroke. The etiology of this pathology has remained unclear. Here, we report 2 cases of intracerebral hemorrhage (ICH) owing to an Ap/T-MCA in pregnant patients. Case Description In both patients, cerebral angiography revealed a steno-occlusive lesion and an abnormal arterial network on the unilateral middle cerebral artery. One patient was treated conservatively for a putaminal hemorrhage, and a cesarean section was performed uneventfully 6 months after onset of the ICH. The other patient underwent a craniotomy for evacuation of the lobar hemorrhage. Subsequently, a cesarean section was performed uneventfully. Both patients gradually recovered without significant disabilities. Conclusions An Ap/T-MCA is a rare congenital anomaly and is a potential cause of ICH for pregnant patients. A cesarean section is a useful option for pregnant patients with this condition.

OBJECTIVEOne of the technical problems encountered in performing lumboperitoneal shunt (LPS) surgery involves operative positioning of the patient. To insert the spinal catheter into the subarachnoid lumbar space, LPS is usually performed with the patient in the lateral decubitus position. However, laparotomy around the periumbilical region, especially in obese patients in the lateral decubitus position, can be quite difficult. Thus, the authors added a simple modification to the laparotomy for LPS, altering the laparotomy site to the lateral side of the patient’s trunk. The aim of this study was to analyze this method in terms of technical features and outcomes.METHODSTwo LPS procedures were compared: routine periumbilical anterior abdominal laparotomy and our modified method using lateral abdominal laparotomy. The first 11 consecutive cases underwent routine anterior abdominal laparotomy with position changes or tilting of the operative bed, whereas the next 17 consecutive cases underwent lateral abdominal laparotomy not requiring position changes.RESULTSIn the anterior abdominal laparotomy group, the mean operative time was 72.36 ± 24.63 minutes. One patient had a spinal tube tear that required revision of the LPS 2 years postoperatively. In the lateral abdominal laparotomy group, the mean operative time was 38.82 ± 13.87 minutes. One patient experienced a postoperative headache and exhibited a thin, chronic subdural hematoma on imaging studies, which disappeared after adjustment of the valve pressure.CONCLUSIONSIn the current series, the operative duration was shorter in the lateral abdominal group compared with the anterior abdominal group, with no differences in complication rates. Lateral abdominal laparotomy simplifies LPS.

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

We present a case of an intradural arachnoid cyst that was successfully diagnosed via ultrasonography. It is challenging to distinguish between spinal arachnoid cysts and spinal cord herniations on preoperative computed tomography(CT)and magnetic resonance imaging(MRI) . Additionally, these diseases have been reported to coexist. Therefore, a definitive diagnosis is not provided until intraoperative findings sufficiently exclude spinal cord herniation. Differentiating these two entities is vital from a surgical perspective. The treatment of spinal cord herniation requires the division of the dentate ligaments to allow rotation of the spinal cord for adequate inspection of the ventral cord and dura. To exclude spinal cord herniation, adequate exposure should be provided for arachnoid cysts. We experienced a case of an intradural arachnoid cyst that was successfully diagnosed via intraoperative ultrasonography. Making the correct diagnosis minimizes unnecessary surgical invasion by omitting the manipulation required to adequately visualize the ventral spinal cord for the exclusion of a spinal cord herniation. A 54-year-old woman presented with numbness in her lower extremities. Thoracic MRI revealed spinal cord herniation. CT myelography revealed a T6-8 intradural arachnoid cyst. However, there was no finding sufficient to exclude the presence of an arachnoid cyst in her imaging results. To exclude spinal cord herniation, it is necessary not only to remove the arachnoid cyst, but also to perform an invasive surgery for direct observation of the ventral spinal cord. Intraoperative ultrasonography before the cyst resection showed no ventral cord arachnoid space. Ultrasonography performed after the cyst removal showed preservation of the ventral arachnoid space. He was given a definitive diagnosis of an arachnoid cyst, without spinal cord herniation. This study highlights that intraoperative echocardiography is useful in differentiating spinal arachnoid cysts from spinal cord herniations.

Anterior cerebral artery dissection (ACAD), especially simultaneously presenting with subarachnoid hemorrhage (SAH) and cerebral infarction (CI), is rare. Only a few cases of severe SAH due to ACAD have been reported. Herein, we present an unusual case of severe SAH with simultaneous CI caused by ACAD. A 56-year-old male was brought to our hospital for severe disturbance of consciousness. Head computed tomography (CT) disclosed SAH with intracerebral hematoma. We suspected ruptured anterior communicating artery saccular aneurysm on CT angiography. Emergency craniotomy was performed to avoid cerebral herniation which confirmed the ruptured ACAD of right A2. The dissecting site was treated by wrapping with a Goretex sheet. ACAD of A2 may present with a severe hemorrhagic event.