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Progressive stenosis and radiological findings of vasculitis over the entire internal carotid artery in moyamoya vasculopathy associated with graves’ disease: a case report and review of the literature

BMC Neurology201919:34

https://doi.org/10.1186/s12883-019-1262-1

  • Received: 29 August 2018
  • Accepted: 19 February 2019
  • Published:
Open Peer Review reports

Abstract

Background

Moyamoya vasculopathy (MMV) associated with Graves’ disease (GD) is a rare condition resulting in ischemic stroke accompanied by thyrotoxicity. Radiological findings of vasculitis have been reported in the walls of distal internal carotid arteries (ICAs) in these patients; however, no reports have described in detail the processes of progression of the lesions in the proximal ICA. Moreover, treatments to prevent recurrence of ischemic stroke and progression of MMV have not yet been sufficiently elucidated.

Case presentation

We report a progressive case of MMV associated with GD and review the literature to clarify relationships among recurrence, progression, thyrotoxicity and treatment. Our patient developed cerebral infarction during thyrotoxicity with no obvious stenosis of ICAs. Five months later, transient ischemic attacks recurred with thyrotoxicity. Antiplatelet therapy and intravenous methylprednisolone stopped the attacks. Stenosis of the left ICA from the proximal to distal portion and champagne bottle neck sign (CBN) were found. She declined any surgery. Afterward, gradual progression with mild thyrotoxicity was observed. Eventually, we found smooth, circumferential, concentric wall thickening with diffuse gadolinium enhancement of the left ICA from the proximal to the distal portion on T1-weighted imaging, suggesting vasculitis radiologically. The clinical and radiological similarities to Takayasu arteritis encouraged us to provide treatment as for vasculitis of medium-to-large vessels. In a euthyroid state and after administration of prednisolone and methotrexate, improved flow in the cerebrovascular arteries on magnetic resonance angiography was observed. Based on our review of the literature, all cases with recurrence or progression were treated with anti-thyroid medication (ATM) alone and accompanied by thyrotoxicity. CBN was observed in all previous cases for which images of the proximal ICA were available.

Conclusions

We report the details of progressive stenosis from a very early stage and radiological findings of vasculitis over the entire ICA in MMV associated with GD. Cerebral infarction can occur with no obvious stenosis of the ICA. We treated the patient as per vasculitis of a medium-to-large vessel. Management of GD by ATM alone seems risky in terms of recurrence. Adequate management of GD and possible vasculitis may be important for preventing recurrence and progression.

Keywords

  • Moyamoya vasculopathy
  • Graves’ disease
  • Recurrence
  • Champagne bottle neck sign
  • Vasculitis

Background

Graves’ disease (GD) is rarely complicated by moyamoya vasculopathy (MMV), resulting in ischemic stroke during thyrotoxicity [1, 2]. Management of GD is considered important to prevent recurrence [3], but MMV may progress despite the control of GD [4]. A case was recently reported in which the wall of the distal ICA was enhanced on contrast-enhanced (CE) T1-weighted imaging (T1WI), suggesting vasculitis [5]. However, no reports have described the details of the processes of progression and the lesions of the proximal ICA in MMV associated with GD. Moreover, results have not been described in these patients after treatment for vasculitis of medium-to-large vessels and several issues remain uncertain, such as treatments to prevent recurrence and progression, and characteristic radiological findings.

Case presentation

A 37-year-old woman presented with gradually progressing weakness of the right arm. She had a medical history of asthma only in her childhood and no notable family history. On physical examination, she showed mild paralysis of the right arm. Although she felt palpitation and sweating at times, exophthalmic and enlarged thyroid lobes were not observed. Diffusion-weighted imaging (DWI) showed cortical and subcortical infarcts in the left MCA territory (Additional file 1: Figure S1), but magnetic resonance angiography (MRA) showed almost-normal cerebral arteries or very mild stenosis of the left ICA (Figs. 1a, 2a). The vessel wall seemed thicker in the left ICA than in the right on three-dimensional (3D)-T1WI, but the difference was not clear (Additional file 2: Figure S2A). Hyperthyroidism [levels of free T3, free T4, and thyroid stimulating hormone (TSH); 10.58 pg/mL, 2.70 ng/dL, and 0.01 μU/mL, respectively], and autoantibodies related to GD [anti-thyroid peroxidase antibody (anti-TPO Ab, 148.0 IU/mL), and TSH receptor antibody (TRAb, 8.3 IU/mL)] were identified (Fig. 3). Other laboratory investigations showed unremarkable results except for leukopenia, anti-SS-A antibody (89.5 IU/mL; normal range, < 7.0 IU/mL), anti-SS-B antibody (12.4 IU/mL; normal range, < 7.0 IU/mL) and thrombin-antithrombin complex (TAT, 2.5 ng/mL; normal range, < 0.3 ng/mL). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were negative. She was diagnosed with GD, but not with Sjogren’s syndrome, based on the normal results of Schirmer’s test and a salivary flow-rate test. Rather than methimazole, she was treated with potassium iodide (150 mg/day) for GD due to leukopenia. MRA excludes over 50% stenosis of intracranial and extracranial cerebral arteries and we could not find any major risks of cardioembolic source of embolism, through electrocardiography, echocardiography, and cardiac rhythm monitoring for over 24 h, so heparin, then warfarin (4 mg/day) were administrated as treatments for stroke as unknown etiology. Mild weakness remained at discharge.
Fig. 1
Fig. 1

Brain magnetic resonance angiography in the course. a Brain MRA did not show obvious stenosis of ICAs. b-d Stenosis in cerebral arteries on brain MRA progressed during thyrotoxicity. e Eighteen months after recurrence, brain MRA suggests improved blood flow through improved flow of the left ICA and MCA

Fig. 2
Fig. 2

Cervical magnetic resonance angiography in the course. a Cervical MRA showed very mild or no obvious stenosis in the first episode. b Cervical MRA showed progressed stenosis of the left ICA at proximal portion and CBN was observed in the second episode for the first time. c Eighteen months after recurrence, cervical MRA also suggests improved blood flow through improved flow in the proximal left ICA

Fig. 3
Fig. 3

Clinical course of moyamoya vasculopathy and Graves’ disease. Thyroid function and titers of the autoantibodies related to GD (anti-TPO Ab and TRAb) seemed to be associated with progression of MMV and occurrence of ischemic stroke. Thyroid function, anti-TPO Ab and TRAb normalized after administration of PSL, MTX, and in a euthyroid state

Five months later, she presented with intermittent transient weakness of the right arm and leg. DWI did not show new infarction. Stenosis of the left ICA progressed on MRA (Figs. 1b, 2b). Thyrotoxicity was exacerbated (Fig. 3). Although argatroban was administered, attacks recurred 5 times. We started intravenous methylprednisolone (IVMP; 1000 mg/day on days 2–6), clopidogrel (300 mg on day 1, and 75 mg/day from day 2), and aspirin (300 mg on day 1, and 100 mg/day from day 2). The attacks subsequently stopped. Catheter angiography showed stenosis of the left ICA from the proximal to distal portion and CBN (Fig. 4a, b). High intensity lesion on T1 W1 in the distal portion of the left ICA was observed (Additional file 2: Fig. S2B). MMV associated with GD was diagnosed. She refused any surgery. Methimazole (15 mg/day) was started, but mild thyrotoxicity continued (Fig. 3).
Fig. 4
Fig. 4

Cerebral angiograms in the second episode, 1 year and 2 years later. a Cerebral angiograms of the terminal portion of the left ICA in the second episode showed severe stenosis of the distal portion. b Cerebral angiograms of the proximal left ICA showed stenosis at proximal ICA and CBN in the second episode. c Cerebral angiograms 12 months after the second episode showed progression of stenosis of the distal portion and net-like vessels might have been developed (arrowhead-yellow), but incomplete occlusion (arrow). d Cerebral angiograms 24 months after the second episode showed improved blood flow in the left ACA, MCA and ICA (arrowhead-white), as well as mild improvement of stenosis of the terminal portion of the left ICA (dashed arrow). We consider that since the progression of MMV stopped after administration of PSL and MTX, and in the euthyroid state, cerebral angiograms did not show complete occlusion of distal ICA. Afterward, the net-like vessels might have developed only in the limited space around the distal ICA region. Improved blood flow through the net-like vessels and mild improvement of stenosis in cerebral arteries on cerebral angiograms might have increased blood flow in the left ICA and MCA on MRA

We subsequently identified gradual progression in the left ICA and middle cerebral artery (MCA) on MRA (Fig. 1b-d) and 3D computed tomographic angiography. Finally, we found smooth, circumferential, concentric wall thickening with diffuse gadolinium enhancement of the left ICA from the proximal to distal portion on 3D-T1WI (Fig. 5a, b). We considered the possibility of vasculitis of medium-to-large vessels and administered prednisolone (PSL; 1 mg/kg/day) and methotrexate (MTX; 4 mg/week). Subsequently, thyroid function normalized (Fig. 3).
Fig. 5
Fig. 5

Radiological findings of vasculitis over the entire internal carotid artery. Six months after recurrence, 3D-T1WI (a) and CE 3D-T1WI (b) of the ICAs were performed (Upper 2 figures: axial images of the distal portion; Lower 2 figures: coronal images of the proximal portion in Figure a, b). a 3D-T1WI showed smooth, concentric wall thickening over the entire left ICA (arrow). b CE 3D-T1WI showed diffuse contrast enhancement on vessel walls (dashed arrow in Figure b) over the entire left ICA, suggesting vasculitis radiologically [23, 24]

Six months later, PSL was reduced to 0.1 mg/kg/day, and MTX increased to 14 mg/week. Signal intensity in the left ICA and MCA increased on MRA. Catheter angiography showed development of net-like vessels, and incomplete occlusion of the ICA (Fig. 4c). By 18 months after recurrence, further improved flow in the left ICA and MCA on MRA was observed (Fig. 1e), but the vessel wall of the left ICA from the proximal to the distal portion still remained enhanced on CE 3D-T1WI in the same way as the previous one. Two years after recurrence, catheter angiography also showed improved blood flow in the left ACA, MCA and ICA, as well as mild improvement of stenosis of the terminal portion of the left ICA (Fig. 4d). We evaluated the polymorphism in c.14576 G > A (rs112735431) in the RNF-213 gene, a susceptibility gene for Moyamoya disease, using genomic DNA samples from the patient. Genetic analysis of RNF-213 showed wild type.

Discussion and conclusions

Review of the literature

We reported a patient with recurrent ischemic stroke and progressive stenosis of MMV associated with GD who had no obvious stenosis in the first stroke. We also reviewed previous reports with follow-up for over 4 months to clarify long-term relationships among recurrence of ischemic stroke, progression of MMV, thyrotoxicity and treatment. We conducted a Medline search for articles using the key words “cerebrovascular diseases”, “moyamoya”, “thyrotoxicity”, and “Graves’ disease”. To confirm long-term relationships, we selected case reports followed-up for over 4 months among these candidates [1, 26-18], and excluded review articles and cases showing recurrence or repeated transient ischemic attacks within 3 months (Table 1), because we wanted to know whether treatment and control of GD over the long term was associated with recurrent ischemic stroke or progression of MMV. We also examined the presence of stenosis of ICAs, and champagne bottle neck sign (CBN) in all candidates [19].
Table 1

Reported cases of MMV associated with GD with follow-up for over 4 months

Case

Age (years)

Sex

Angio or MRA

Presentation

Thyroid condition at vascular accident

Treatment (thyroid)

Treatment (cerebrovascular disease)

Thyroid condition during follow-up

Neuro imaging

Recurrence

Thyroid condition at recurrence

Outcome

Follow-up period (months)

Reference

1

29

F

Bilateral distal ICA stenosis

TIA

Thyrotoxic

ATM/PE

Aspirin

Normal range

Improvement

none

Good

6

Yamashita

7

2005

2

26

F

Rt ICA stenosis

Ischemic stroke

Thyrotoxic

ATMATM

Antiplatelet therapy

Normal range

Improvement

none

-

Good

12

Nakamura

8

2014

3

45

F

Bilateral distal ICA occlusion

TIA

Thyrotoxic

PSL/radioactive iodine

Antiplatelet therapy

Normal range

Improvement

none

-

Good

4

Uftk

9

2004

4

47

F

Bilateral net-like vessels

TIA

Thyrotoxic

PSL/radioactive iodine

Aspirin

n.d.

n.d.

none

-

Good

10

BEATRIZ

10

1997

5

37

F

Bilateral distal ICA stenosis

Ischemic stroke

Thyrotoxic

PSL/ thyroidectomy

Antiplatelet therapy

Normal range

n.d.

none

-

Good

6

BEATRIZ

10

1997

6

19

F

Bilateral net-like vessels

Ischemic stroke

Thyrotoxic

n.d

STA-MCA bypass

n.d.

n.d.

none

-

Good

24

Ran

11

2009

7

21

M

Rt distal ICA stenosis

Ischemic stroke

Thyrotoxic

ATM

Aspirin

Normal range

n.d.

none

-

Lt minor leg weakness

11

Carlos

12

1998

8

46

F

Right net-like vessels

Ischemic stroke

Hypothyroidism

none

STA-MCA bypass

Hypothyroidism

n.d.

none

-

Good

24

Ohba

2

2011

9

23

F

Bilateral distal ICA stenosis

Ischemic stroke

Thyrotoxic

ATM

none

n.d.

No change

none

-

Good

13

Nakamura

13

2003

10

54

F

Bilateral distal ICA stenosis

Ischemic stroke

Subclinical thyrotoxic

ATM

none

n.d.

No change

none

-

Good

6

Nakamura

13

2003

11

19

F

Bilateral net-like vessels

Ischemic stroke

n.d (immediately after thyroidectomy)

Thyroidectomy

STA-MCA bypass

n.d.

n.d.

none

-

Good

60

Tokimura

14

2010

12

35

F

Rt distal ICA stenosis

Ischemic stroke

Thyrotoxic

ATM/thyroidectomy

Cloidogrel

Normal range

No change

none

-

Good

6

Gon

5

2017

13

19

F

Bilateral net-like vessels

Ischemic stroke

Thyrotoxic

ATM

none

Thyrotoxic

n.d.

none

-

Lt hemiparalysis

60

Kushima

15

1991

14

26

F

Bilateral net-like vessels (recurrence)

TIA

Thyrotoxic

ATM

none

n.d.

n.d.

Recurrence

Thyrotoxic

Rt hemiparalysis

50

Kushima

15

1991

15

23

F

Bilateral distal ICA occlusion

Ischemic stroke

Thyrotoxic

ATM

Aspirin

Thyrotoxic

Progression

Recurrence (TIA) → EDAS

Thyrotoxic

Good

22

Shaneela

1

2011

16

16

F

Bilateral net-like vessels

TIA

Thyrotoxic

ATM

n.d

Thyrotoxic

Progression

Recurrence (Ischemic stroke)→ STA-MCA bypass

Thyrotoxic

n.d.

72

Im

16

2005

17

22

F

Rt MCA occlusion

Ischemic stroke

Thyrotoxic

ATM

Heparin edaravone in acute phase

Thyrotoxic

Progression

none

-

Lt hemiparalysis

36

Ishigami

17

2014

18

42

F

Bilateral net-like vessels

Ischemic stroke

Thyrotoxic

ATM (poor compliance)

EDAS

n.d.

n.d.

Recurrence

Thyrotoxic

Death

12

Ku

18

2015

19

15

F

Bilateral distal ICA stenosis

Non-automatic movement

Thyrotoxic

ATM

n.d

n.d.

Progression

Recurrence

Thyrotoxic

n.d

72

Ni

19

2014

20

37

F

No obvious stenosis

Ischemic stroke

Thyrotoxic

ATM (potassium iodine)

Warfarin

Thyrotoxic

Progression

Recurrence (TIA)

Thyrotoxic

Rt mild hemiparalysis

5

Our case

 

2017

F female, M male, TIA transient ischemic attack, n.d. not described, Rt right, Lt left, ICA internal carotid artery, MCA middle cerebral artery, ATM anti-thyroid medication (here, we define methimazole, propylthiouracil, or potassium iodine as ATM), PSL prednisolone, PE plasma exchange, STA-MCA bypass superficial temporal artery-middle cerebral artery bypass, EDAS encephoduroarteriosynangiosis

Patients

The 20 patients included, 19 female and 1 male, with a mean age of 30.1 years (range, 15–54 years). The majority of the patients were female. Mean duration of follow-up was 22.3 months (range, 4–72 months).

Thyrotoxicity and cerebrovascular disease in the first episodes

Eighteen patients (90%) showed neurologic symptoms during thyrotoxicity. One patient (5%) presented with subclinical thyrotoxicity and one patient (5%) was in a hypothyroid state.

Treatment

For GD, 14 patients (70%) were treated with anti-thyroid medication (ATM), and 10 of these patients (50%) with ATM alone. Two patients (10%) were treated with only thyroidectomy, 2 patients (10%) with PSL and radioactive iodine therapy (RIT), and 1 patient (5%) with PSL and thyroidectomy. For MMV, 8 patients (40%) were treated with antiplatelet therapy, 1 patient (5%) with anticoagulant, and 4 patients (20%) with neurovascular surgery. There was no report of patients with no treatment.

Outcomes—Recurrence and progression

Six patients (30%) experienced recurrence, and 5 patients (25%) showed progression. All of them showed thyrotoxic states at recurrence or progression and were treated with ATM alone for GD. One patient died of recurrence [17]. In contrast, among 5 patients (25%) treated with thyroidectomy or RIT, no patient experienced recurrence or progression. Three patients (15%) in a euthyroid state showed improved flow in the cerebrovascular arteries on MRA.

Radiographic features

Based on our investigation of previous reports in the literature, our case represents the first description of ischemic stroke with no obvious stenosis of the cerebral arteries. Images of the proximaI ICA were available in 7 cases [1, 5, 12, 14, 2022]. CBN was found in all cases.

The clinical course of our case is illustrated in Fig. 1. Thyroid function and titers of anti-TPO Ab and TRAb seemed to be associated with progression of MMV and occurrence of ischemic stroke. We found smooth, circumferential, concentric wall thickening with diffuse gadolinium enhancement over the entire left ICA, which is the radiological finding of vasculitis [23, 24]. Improved flow in the left ICA and MCA on MRA was observed after administration of PSL and MTX, and in the euthyroid state. The result of genetic analysis of RNF-213 also suggests a different etiology of Moyamoya disease associated with c.14576 G > A variant in the RNF-213 gene.

We noticed similarities between our case and Takayasu arteritis, including the involvement of a young female, findings of medium-to-large vessels on CE MR imaging, progression of stenosis in medium-to-large vessels, and elevated TAT [25, 26]. CRP and ESR can be negative in Takayasu arteritis [26]. In the first episode of our case, a hemodynamic etiology appeared unlikely as the cause of ischemic stroke, because stenosis of the left ICA was not obvious. It has been reported that although little, if any, endothelial change is evident, thrombus formation by vasculitis leads to ischemic stroke in Takayasu arteritis [25]. Thus, the same mechanism can be considered in our case. In the second episode, high intensity lesion on T1 W1 in the distal portion of the left ICA was observed (Additional file 2: Figure S2B). Dissection might be considered as the etiology of this lesion, because dissection shows eccentric wall thickening with T1 bright wall components representing intramural hematoma [24]. Moreover, vasculitis can cause aortic dissection, for example, Takayasu arteritis. T-cell-mediated immunity was reported to play important roles in Takayasu arteritis, GD and MMV [2628]. Immunologic changes related to GD and MMV may have a common pathogenic link involving T-cell dysregulation [28]. The association between MMV and GD in our case and our review of the literature support this hypothesis.

CBN may be a characteristic feature of this disease and may be caused by vasculitis from the proximal ICA. CBN means a rapid, sharp reduction in internal diameter at the proximal ICA, which is observed in some patients with moyamoya disease [6]. In our case, the difference between thickness of the wall of the left and right ICA seemed to become clear gradually (Fig. 5a, b Additional file 2: Figure S2A, B), possibly due to vasculitis. This seemed to contribute to the formation of stenosis of the entire ICA and CBN in our case (Additional file 3: Figure S3). In other cases of MMV associated with GD or moyamoya disease with CBN, the same process might occur. Since the vessel lumen is narrower in the distal than in the proximal portion, occlusion may occur in the distal portion.

Treatment for MMV associated with GD by ATM alone may be risky in terms of recurrence. So far, the treatments, especially without surgery, have not been sufficiently studied. For GD, ATM, RIT, thyroidectomy, PSL and PE were used in previous reports. For MMV, treatments should reportedly be performed the same way as for moyamoya disease through antiplatelet agents and bypass surgery [29]. The similarities with Takayasu arteritis encouraged us to treat our patient with PSL and MTX as treatments for vasculitis, although, to the best of our knowledge, there has been no report of such treatment for this type of patient. Improved flow of the left ICA and MCA on MRA was observed after administration of PSL and MTX, and in the euthyroid state. On the other hand, such a favorable result, the improved flow, can not occur in Moyamoya disease, in which MCA disappears as the next stage in the Suzuki stage [29]. Considering a retrospective study in which progression advanced even when GD was controlled [4], the improvement on MRA in our case might have been due to the treatment of vasculitis. IVMP in the acute phase in the second episode might have worked for both thyrotoxicity and vasculitis. According to our review, recurrence or progression was found in patients treated with ATM alone, while recurrence or progression was not found with RIT or thyroidectomy. This seems to be due to the higher recurrence rate (range, 50–67%) for GD under the usual treatment with ATM compared to 15% with RIT and 10% with thyroidectomy [30]. Notably, 1 patient treated with ATM alone died following recurrence [17]. Since RIT was reported to increase the risk of cerebrovascular events [31], thyroidectomy may be reasonable choice to reduce the risk of recurrence or probable progression.

Our review was limited by the retrospective nature of the data collection. For example, duration of follow-up tended to be longer in recurrent cases. Despite these limitations, the overall review provides important lessons on recurrence.

Conclusions

This report suggests the possibility of vasculitis of medium-to-large vessels in MMV associated with GD. This is the first case where cerebral infarction occurred during thyrotoxicity without obvious stenosis of ICAs. We treated the patient as having vasculitis of medium-to-large vessels with IVMP in the acute phase and with PSL and MTX in the chronic phase. Subsequently, improved flow in the cerebrovascular arteries on MRA was observed in the euthyroid state. Treatment with ATM alone seems to be risky in terms of recurrence. Adequate management of GD and possible vasculitis may be important for preventing recurrence and progression.

Abbreviations

3D: 

three-dimensional

anti-TPO Ab: 

anti-thyroid peroxidase antibody

ATM: 

anti-thyroid medication

CBN: 

champagne bottle neck sign

CE: 

contrast-enhanced

CRP: 

C-reactive protein

DWI: 

diffusion-weighted imaging

ESR: 

erythrocyte sedimentation rate

GD: 

Graves’ disease

ICA: 

internal carotid artery

IVMP: 

intravenous methylprednisolone

MCA: 

middle cerebral artery

MMV: 

moyamoya vasculopathy

MRA: 

magnetic resonance angiography

MTX: 

methotrexate

PSL: 

prednisolone

RIT: 

radioactive iodine therapy

T1WI: 

T1-weighted imaging

TAT: 

thrombin-antithrombin complex

TRAb: 

TSH receptor antibody

TSH: 

thyroid stimulating hormone

Declarations

Acknowledgements

The authors are grateful to Dr. Yasufumi Gon (Osaka University), Dr. Masaaki Ito (Nagoya Univaersity), Dr. Kazunori Shintai, Dr. Hideki Iijima (Nagoya Daini Redcross Hospital), and Kiichi Miyamae (Nagoya Medical Center) for useful discussion and advice.

Funding

None of the authors have received any financial assistance for this work.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Authors’ contributions

HI, SY, KY, TA, RK, HO, SO made the clinical diagnosis, and clinical management decisions. They supervised the drafting of the manuscript. HI drafted the first manuscript and reviewed the literature. RK and SO revised it critically. KU, YA and ST supported making the diagnosis and clinical management decisions as the specialists of Moyamoya disease and performed genetic analysis of RNF-213. They also supervised the drafting of the manuscript and revised it critically. All authors have read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor of this journal.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Department of Neurology, National Hospital Organization Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi, Japan
(2)
Department of Rheumatology, National Hospital Organization Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi, Japan
(3)
Department of Neurosurgery, National Hospital Organization Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi, Japan
(4)
Department of Neurosurgery, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Showa-ku, Nagoya, Aichi, Japan
(5)
Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myouken-cho, Showa-ku, Nagoya, Aichi, Japan

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