The Predictors of Survival and Functional Outcome in Patients with Pontine Hemorrhage

OBJECTIVE: Pontine hemorrhages usually result in a much higher morbidity and mortality than any other intracranial vascular lesion. The purpose of this study was to evaluate survival and the contributing factors for patients with pontine hemorrhage. METHODS: Of the 41 patients who were admitted to our hospital with their first acute pontine hemorrhage from 1997 to 2005, 35 patients were included in this study. Medical records were reviewed to confirm the accuracy of diagnosis and collect demographic, clinical and radiological data. The patients were divided into two groups, survivors and deceased patients; then the survivors were divided again into a group of patients with good results and those with poor results. The location of the hematoma, maximum anteroposterior (AP) diameter, maximum transverse diameter, hematoma volume, ventricular extension, extension into the midbrain, hydrocephalus and initial Glasgow coma scale (GCS) were evaluated. RESULTS: The two year survival rate was 58.5%. The survival of patients with pontine hemorrhage was affected by initial GCS score and transverse hematoma diameter. Functional outcome of patients who survived was affected by initial GCS, maximum transverse diameter, maximum AP diameter and hematoma volume. CONCLUSION: The rate of survival after pontine hemorrhage is associated with the transverse diameter of the hematoma and more importantly the initial GCS. Long-term outcome of survivors is influenced by the initial GCS, transverse diameter, AP diameter and volume. Through the multivariate analysis, initial GCS is the only significant factor on survival. Strictly speaking, initial GCS is not modifiable. However, surgical reduction may be considered to amend theses decisive factors. Additional study for indication, timing and method of surgical management is needed.

The Eyebrow Approach to Anterior Communicating Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: This study reviewed the clinical outcomes of patients with anterior communicating artery (AComA) aneurysms that were treated surgically using an eyebrow approach. The indications and limitations of this approach for the treatment of AComA aneurysms are also suggested. METHODS: Between October 1999 and June 2006, 121 procedures were performed on 115 patients with 146 cerebral aneurysms via a superior orbital rim craniotomy through an eyebrow incision. Of them, 51 patients with AComA aneurysms were reviewed retrospectively according to the patient's age and gender, the Hunt-Hess grade upon admission, the Fisher grade of the subarachnoid hemorrhage, the size of the aneurysm, the direction of the aneurysmal sac, the outcome at 3-month follow-up period, complications and the intraoperative problems. RESULTS: Overall, excellent and good outcomes were achieved in 47 patients (92.1%) and one patient died (2.0%). Clinically, there were 7 patients with a poor grade (Hunt-Hess grade 4); 3 showed a good outcome, 2 fair, 1 poor and 1 died. Premature rupture of the aneurysm during surgery occurred in 5 patients. One procedure was converted to the pterional approach due to severe brain swelling. Postoperative subdural fluid collection was noted in 9 patients, of whom 2 patients required temporary drainage and 1 patient needed a permanent subdural fluid diversion. Vasospasm and a subsequent infarction were observed in 4 patients. Hydrocephalus that required a ventriculoperitoneal shunt was found in only 2 patients. CONCLUSIONS: The favorable indications for eyebrow surgery include good grade patients with a ruptured or unruptured AComA aneurysm, and patients with small and medium sized aneurysms. Furthermore, the poor grade or high Fisher grade patients with or without multiple concomitant aneurysms can also be treated with eyebrow surgery.

Pituitary Apoplexy Complicated by Chemical Meningitis and Cerebral Infarction

A 41-yr-old man was admitted with acute headache, neck stiffness, and febrile sensation. Cerebrospinal fluid examination showed pleocytosis, an increased protein level and, a decreased glucose concentration. No organisms were observed on a culture study. An imaging study revealed pituitary macroadenoma with hemorrhage. On the 7th day of the attack, confusion, dysarthria, and right-sided facial paralysis and hemiparesis were noted. Cerebral infarction on the left basal ganglia was confirmed. Neurologic deficits gradually improved after removal of the tumor by endoscopic transnasal transsphenoidal approach. It is likely that the pituitary apoplexy, aseptic chemical meningitis, and cerebral infarction are associated with each other. This rare case can serve as a prime example to clarify the chemical characteristics of pituitary apoplexy.

The Comparison of Exercise Programs for Trunk Stability in the Patients with Microscopic Lumbar Discectomy

OBJECTIVE: To compare an isotonic lumbar extension exercise program utilizing lumbar extension exercise machines with modified combination program of isotonic lumbar extension exercises, including dynamic stabilization exercise, to improve and maintain trunk stability in the patient with microscopic lumbar discectomy. METHOD: We studied 41 male workers who underwent microscopic lumbar discectomy. Group 1 (n=24) was treated with the isotonic lumbar extension exercise program. Group 2 (n=17) was treated with the modified combination program of dynamic lumbar stabilization exercise and isotonic lumbar extension exercise. The categories that were evaluated and measured were trunk stability, isometric peak torque of lumbar extensor, weight distribution rate of both leg and trunk muscle balance, and Oswestry low back pain (LBP) disability index. RESULTS: After 3 months, group 1 revealed higher isometric peak torque, weight distribution rate of both leg and trunk muscle balance compared with that of group 2. At the end of 6 months, group 2 revealed higher isometric peak torque compared with that of group 1. CONCLUSION: We suggested that combined exercise program, that included the dynamic lumbar stabilization exercise and the isotonic lumbar extension exercise, was a valuable treatment for postoperative lumbar rehabilitation.

Early Aneurysm Surgery using Eyebrow Incision for Poor Grade Patients

OBJECTIVE: This study is aimed to assess the clinical outcome in early and minimally invasive surgery using an eyebrow incision for the patients with poor grade aneurysm. METHODS: The authors retrospectively reviewed all 46 poor grade patients of Hunt and Hess(H-H) grade IV and V who suffered aneurysmal subarachnoid hemorrhage(SAH) between 1999 and 2004. All 35 patients harboring 43 aneurysms who underwent early surgery within 72 hours were included in this study. Clinical outcome was assessed by Glasgow outcome scale(GOS) and compared with that of conventional pterional approach. RESULTS: Twenty four patients were operated with conventional pterional approach and 11 with eyebrow approach within 72 hours after SAH. Seven multiple aneurysm patients harbor 15 aneurysms. Forty one aneurysms were treated with clippings. All 11 patients of eyebrow surgery group(ESG) were in H-H grade IV, 3 in Fisher grade III and 8 in Fisher grade IV. Among 24 patients of pterional approach group(PAG), 20 were in H-H grade IV and 4 in H-H grade V, 3 were in Fisher grade III and 21 in Fisher grade IV. Overall favorable outcome was achieved in 41.7% and 54.5% in PAG and ESG, respectively. Favorable outcome of H-H grade IV in PAG showed 45.0%. Overall mortality rate was 14.3%. CONCLUSION: It is concluded that the clinical outcome of early and minimally invasive aneurysmal surgery using eyebrow incision in the selected poor grade aneurysm patients can be compatible with that of conventional pterional surgery.

Treatment of Meningitis Caused by Vancomycin-Resistant Enterococcus with Synercid

Vancomycin-resistant enterococci(VRE) are rare cause of meningitis, occurring in immunocompromised patients, severely ill, hospitalized patient, and patients who have undergone neurosurgical procedures. Resistance to vancomycin has increased in frequency during the past few years. Limited therapeutic options are available for VRE infections and the optimum therapy has not been established. We report a case of VRE meningitis that was successfully treated with administration of quinupristindalfopristin (Synercid) by both intravenous and intraventricular routes. A brief review of the literature is provided, which indicates that optimal management with Synercid should include daily intraventricular doses of at least 2 mg and intravenous 0.5 mg/kg every 8 hours. We also review the previously reported cases of VRE meningitis.

FDG PET/CT Assessment of the Biological Behavior of Meningiomas

OBJECTIVE: We investigated the pattern of glucose uptake in meningiomas using (18)F-fluoro-2-deoxy-D-glucose(FDG) PET/CT. It was hypothesized that the degree of glucose uptake in each tumor could predict the histologic grade. METHODS: In 19 patients with meningiomas, the Ki-67 proliferative index, standardized uptake values(SUV) of FDG uptake, tumor to contralateral gray matter ratio(TGR) of SUV, tumor size, edema grade, vascular endothelial growth factor(VEGF) expression, histopathologic grade and the blood supply pattern were assessed. RESULTS: Of the 19 meningiomas, 8 were meningothelial, 1 fibrous, 2 transitional, 1 psammomatous, 2 angiomatous, and 5 atypical. The tumor proliferative index of Ki-67, tumor size, and peritumoral edema were larger in the histopathologic grade-2 meninigiomas than in the grade-1 meningioma group. There were no significant differences in SUV and TGR between two groups. Tumor size and peritumoral edema were significantly larger in VEGF-positive tumors than in negative tumors. Conventional angiography was performed in 12 patients. Dural supply was noted predominantly in 2 patients. Four patients had mainly pial cortical supply patterns. In tumors with more pial supply, VEGF was more frequently positive. There was a significant relation between SUV and Ki-67 and between SUV and peritumoral edema. CONCLUSION: We found FDG uptake in meningiomas is associated with proliferative potential, however, no clear limits of SUV and TGR can be set to distinguish between grade-1 and grade-2 meningiomas, which makes the assessment of malignancy grade using PET scan metabolic imaging difficult in individual cases.

Tension Pneumocephalus Following Eyebrow Aneurysmal Surgery

We report a rare case of tension pneumocephalus after eyebrow surgery for the treatment of a saccular aneurysm at posterior communicating artery. The patient's consciousness was suddenly aggravated due to the tension pneumocephalus on fifth postoperative day, which was treated by repairing the frontal sinus. The patient was recovered completely and uneventfully after this revision surgery.

Prevalence of OXA-23 Extended-Spectrum beta-Lactamase-Producing Clinical Isolates of Acinetobacter baumannii in a University Hospital, Busan, Korea / 대한임상미생물학회지

BACKGROUND: Acinetobacter baumannii is a glucose-nonfermenting gram-negative rod and is a well-recognized nosocomial pathogen. In recent years, A. baumannii strains showing resistance to carbapenems by producing metallo-beta-lactamases or OXA-type beta-lactamases have increased, and it is considered to be a serious clinical problem. But genotypes of carbapenemases produced by A. baumannii isolates in Korea have been rarely reported. The purpose of this study was to investigate the prevalence of imipenem-resistant A. baumannii and to determine the mechanism of resistance. METHODS: During the period of January through September, 2003, susceptibilities to imipenem of A. baumannii isolates from patients admitted in Kosin University Gospel Hospital in Busan, Korea were investigated. The modified Hodge and EDTA-disk synergy tests were performed for screening of carbapenemase and metallo-beta-lactamase-production. Minimal inhibitory concentrations (MICs) were determined by the agar dilution method. For detection of IMP, VIM and OXA-type beta-lactamases genes, polymerase chain reactions (PCR) were performed, and the DNA sequences of OXA-type beta-lactamases genes were determined by using the dideoxy-chain termination method. The isoelectric points of beta-lactamases were determined by isoelectric focusing. Pulsed-field gel electrophresis (PFGE) of the SmaI-digested genomic DNA was performed. RESULTS: A total of 193 strains of A. baumannii were collected from patients during the surveillance period. Twenty-seven percents (52/193) of A. baumannii isolates were resistant to imipenem. Among the 52 imipenem-resistant isolates, 41 isolates (78.8%) showed positive results in the modified Hodge test, but none of the isolates showed positive results in the EDTA-disk synergy test. Thirty-eight modified Hodge test-positive isolates harbored blaOXA-23 gene, but none of the isolates harbored IMP- or VIM-type metallo-beta-lactamases genes. Analytical isoelectric focusing revealed that all the 38 isolates had a nitrocefin-positive band at pI of 6.65. Thirty-five OXA-23-producing isolatesshowed a similar PFGE pattern when digested by SmaI endonuclease. CONCLUSION: Thirty-eight clinical isolates of A. baumannii acquired resistance to imipenem by producing OXA-23 beta-lactamase. Among them were 35 isolates thought to be originated from the same source, because they contained a similar chromosomal type. To the best of our knowledge, this is the first time that OXA-23 beta-lactamase has been detected in Korea.

Transcavernous Approach for Invasive Pituitary Adenoma

OBJECTIVE: Surgical management of invasive pituitary tumor is challengeable with conventional transsphenoidal approach(TSA) or pterional intradural approach alone. Gross total resection of pituitary adenoma influences its prognosis favorably, so transcavernous approach(TCA) is essential in invasive pituitary tumor. This study is performed to evaluate and analyze the surgical results of TCA in cases of invasive pituitary adenoma. METHODS: From November 1995 to May 2002, nine cases of invasive pituitary adenoma were treated. The authors reviewed medical records and radiological findings. Pterional transzygomatic or orbitozygomatic transcavernous approach was selected for tumors extended below or above the third ventricle floor respectively and intradural removal of tumor with suprasellar extension was combined. Surgical results including hormonal function, recurrence, completeness of tumor resection, and postoperative complications were evaluated and analyzed. RESULTS: Eight patients were treated with TSA followed by TCA and one with TCA alone. Total resection was achieved in seven cases, subtotal resection in one, and partial resection in one. Postoperative complications included temporary third nerve palsy in four cases and facial paresthesia in two. There was no recurrence during follow-up period. CONCLUSION: Transcavernous approach alone or combined with TSA is essential surgical procedure for total removal of invasive pituitary adenomas with acceptable morbidities.

Diagnosis of Antibiotic-Associated Diarrhea and Pseudomembranous Colitis by Direct Detection of Clostridium difficile Toxin B Gene / 감염과화학요법

BACKGROUND: Clostridium difficile is the major cause of antibiotic-associated diarrhea (AAD) and pseudomembranous colitis (PMC). This study was designed to investigate predisposing factors of AAD or PMC and to evaluate the efficiency of nested PCR assay for direct detection of toxin B gene in the treatment and prognosis of these diseases. METHODS: From January to December, 2002, stool specimens from 142 patients in Kosin Medical Center, Busan, were tested for the detection of toxigenic C. difficile strains. Toxin B gene in C. difficile was detected by nested PCR. And chart review was performed to investigate the antibiotics or anticancer drug history, clinical symptoms, treatment regimens, and prognosis. RESULTS: Among 142 stool specimens, 56 specimens showed positive for the toxin B gene in C. difficile strains by PCR. Forty two percents (47/113) of stool specimens from patients with AAD and all of specimens from eight patiens with PMC were C. difficile toxin B gene positive. Administration of antibiotics or anticancer drugs was stopped in 92.7% of toxin B gene-positive cases, but those were stopped in only 48.5% of toxin B gene-negative cases. The cure rate was higher in positive cases (82%) than negative ones (71%). CONCLUSION: It is concluded that nested PCR assay for the direct detection of C. difficile toxin B gene was helpful in rapid diagnosis and treatment of AAD or PMC.

Diagnosis of Antibiotic-Associated Diarrhea and Pseudomembranous Colitis by Direct Detection of Clostridium difficile Toxin B Gene / 감염과화학요법

BACKGROUND: Clostridium difficile is the major cause of antibiotic-associated diarrhea (AAD) and pseudomembranous colitis (PMC). This study was designed to investigate predisposing factors of AAD or PMC and to evaluate the efficiency of nested PCR assay for direct detection of toxin B gene in the treatment and prognosis of these diseases. METHODS: From January to December, 2002, stool specimens from 142 patients in Kosin Medical Center, Busan, were tested for the detection of toxigenic C. difficile strains. Toxin B gene in C. difficile was detected by nested PCR. And chart review was performed to investigate the antibiotics or anticancer drug history, clinical symptoms, treatment regimens, and prognosis. RESULTS: Among 142 stool specimens, 56 specimens showed positive for the toxin B gene in C. difficile strains by PCR. Forty two percents (47/113) of stool specimens from patients with AAD and all of specimens from eight patiens with PMC were C. difficile toxin B gene positive. Administration of antibiotics or anticancer drugs was stopped in 92.7% of toxin B gene-positive cases, but those were stopped in only 48.5% of toxin B gene-negative cases. The cure rate was higher in positive cases (82%) than negative ones (71%). CONCLUSION: It is concluded that nested PCR assay for the direct detection of C. difficile toxin B gene was helpful in rapid diagnosis and treatment of AAD or PMC.

Characterization and Prevalence of Escherichia coli and Klebsiella pneumoniae Isolates Producing an Extended-Spectrum beta-Lactamase from Korean Hospitals / 대한진단검사의학회지

BACKGROUND: The aim of this study was to survey the nationwide susceptibilities of E. coli and K. pneumoniae against third generation cephalosporins and aztreonam in order to determine the prevalence of extended-spectrum beta-lactamase (ESBL)-producers and to characterize genotypes of ESBLs. METHODS: A total of 6, 567 E. coli and 2, 652 K. pneumoniae non-duplicate strains were isolated from 13 hospitals in April to June 2002. Antimicrobial susceptibilities were tested by the disk diffusion method. Twenty isolates of E. coli and 20 K. pneumoniae were collected from each hospital. ESBL production was determined by a double-disk synergy test. The ceftazidime-resistance of the ESBL-producers was transferred to azide-resistant E. coli J53 by conjugation. MICs of beta-lactam antibiotics to transconjugants were determined by the agar dilution method. Searches for blaTEM , blaSHV , blaCTX-M and blaCMY genes in transconjugants were performed by PCR amplification. RESULTS: Eighty-nine percents of E. coli and 71% of K. pneumoniae isolates were susceptible to ceftazidime. Nine percents of E. coli (23/249) and 30% (78/260) of K. pneumoniae isolates showed positive results in the double-disk synergy test. Ceftazidime-resistance of 13 (57%) E. coli and 42 (53%) K. pneumoniae isolates were transferred to E. coli J53 by conjugation. Among 55 transconjugants, 46 strains were resistant to ceftazidime, while only 16 strains were resistant to cefotaxime. Twelve transconjugants were also resistant to cefoxitin and cefotetan. Banding patterns of PCR amplification showed that the blaTEM , blaSHV , blaCTX-M and blaCMY genes were harboured by 44, 39, 4 and 5 transconjugants, respectively. CONCLUSIONS: E. coli and K. pneumoniae isolates producing TEM-, SHV-type, or CTX-M-type ESBLs are wide spread in Korean hospitals. The spread of ESBL genes could compromise the future usefulness of 3rd generation cephalosporins and aztreonam for the treatment of E. coli and K. pneumoniae infections.

Superior Orbital Rim Approach to the Anterior Circulation Aneurysms: Surgical Technique

OBJECTIVE: With the improvement of surgical techniques, instruments and diagnostic imaging, the aneurysmal surgery could be performed less invasively with less retraction of neural structure and more smaller craniotomy. The authors present a superior orbital rim approach as minimally invasive anterior circulation aneurysm surgery. METHODS: Superior orbital rim approach was performed for the treatment of the anterior circulation aneurysms with or without clinoidectomy. We considered the indications and limitations of this approach and compared this approach with conventional approaches. RESULTS: The operative technique can be used in all cases of anterior circulation aneurysms and could give us excellent results, especially, in internal carotid artery aneurysms. In cases of middle cerebral artery aneurysms, more wide and lateral approaches were used. In general, operation time was shortened and transfusion was not needed. CONCLUSION: The superior orbital rim approach is a good alternative procedure to conventional microsurgical approach in treating anterior circulation aneurysms.

Giant-Cell Tumor of the Middle Cranial Fossa

The authors report a case of giant-cell tumor of the right middle cranial fossa floor a 43-year-old man. His presentation, characteristic magnetic resonance image findings, treatment, and 2-year follow-up result are described. The patient about this rare neoplasm of the skull base are also reviewed.

Alteration of Interleukin-6 Levels in Brain Tissue and Serum of Rats after an Experimental Brain Contusion

PURPOSE: Cerebral contusion is often associated with delayed edema, ischemia, demyelination, and secondary impairment in the neurological function. Early prediction of the outcome for patients with diverse critical illnesses has long been a concern of intensive care unit physicians. Recently, the systemic release of host-derived inflammatory mediators has been used for prognosis assessment in patients with multiple infections, burn injury, and systemic infection. Experimental investigations have revealed the importance of free radicals and calcium currents in cellular damage. Also experimental injuries have caused an early production of cytokines. This study was undertaken to analyze the production of interleukin-6 in the brain and in plasma following a brain contusion. METHODS: Sixty male Sprague-Dawley (SD) rats, each weighing 300-350 g were used in an experimental group following brain contusion, and 18 SD rats were used as a control group following a sham operation. Intracerebral IL-6 and plasma IL-6 were measured by using the ELISA method with a rat IL-6 kit at 3, 6, 24, 48, and 72 hours after the brain contusion. After contusion, the brains were fixed by perfusion via the carotid artery with 40% formaldehyde, glacial acetic acid, and 100% ethanol (1:1:8) at a flow rate of 25 ml/min and stained with hematoxylin and eosin for histologic examination. RESULTS: Brain IL-6 levels increased to reach a maximum of 160.23 pg/ml, at 6 hour after brain trauma. Plasma IL-6 levels increased to 70.02 pg/ml at 3 hour following brain contusion. CONCLUSION: The elevated brain IL-6 level in the injured rat does not seem to reflect a systemic inflammation. Although plasma IL-6 is detected in the sham-operated and the traumatized rats, the levels are too low to account for the increase observed in the brain cortex. This finding shows that the increase in brain IL-6 is related to the dynamics of brain contusion.

Ozone Chemonucleolysis on the Lumbar Intervertebral Disc of the Rabbit

OBJECTIVE: This study is aimed to evaluate the chemonucleolytic effect of medical ozone by investigating the change of the signal intensity on magnetic resonance imaging (MRI) scan after injection of medical ozone into the lumbar intervertebral disc of the rabbit. METHODS: A series of 21 intradiscal injections of 1ml of medical ozone(30microgram of ozone per ml of oxygen) was performed in 7 young adult rabbits. Two control series, which 20 intradiscal injections of 0.1ml of iodine contrast medium in 7 young adult rabbits and 21 intradiscal injections of 0.05ml of chymopapain in 7 young adult rabbits, were performed. T2 weighted MRI scan was performed pre-operatively and at 4 weeks after injection. RESULTS: T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series (n=21) of intradiscal injections of medical ozone at 4 weeks after injection, as compared with the control series of intradiscal injections of 0.1ml of iodine contrast medium. T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series(n=21) of intradiscal injections of chymopapain at 4 weeks after injection. Any neurologic deficit or complication was not found in all groups. CONCLUSION: Intradiscal injections of medical ozone into the lumbar intervertebral disc of the rabbits are proven to have chemonucleolytic effects.

Superior Orbital Rim Approach for Anterior Communicating Artery Aneurysms: A Surgical Series of 27 Patients

There are debatable claims in the optimal approach for clipping of the anterior communicating artery (AcomA) aneurysm. The authors invented the superior orbital rim approach (SORA) as an alternative and minimally invasive approach for the treatment of AcomA aneurysm. The authors reviewed retrospectively all the medical records of 27 patients of subarachnoid hemorrhage due to ruptured AcomA aneurysm. who were admitted to Kosin University Gospel Hospital for last 2yr. Fourteen women (51.9%) and 13 men (48.1%) were from 29 to 79 yr in age. The mean aneurysm size was 6.2 mm ranging from 4 to 12 mm. A favorable Glasgow outcome scale (GOS) of 4 or 5 was achieved in 92.6%, a GOS score of 3 in 3.7%, and 1 death (GOS 1) occurred in 3.7% of the patients. During the follow-up between 4 and 28 months (mean, 17.5 months) after the surgery, the prognosis of the patients and the cosmetic results were favorable compared with conventional approach. We became to believe that it was an alternative, effective and minimally invasive approach to the surgical treatment of AcomA aneurysm.

Deliberate Two-Staged Endoscopic Endonasal Transsphenoidal Surgery in Large Pituitary Adenomas

OBJECTIVE: Two-staged endoscopic endonasal transsphenoidal approach(TSA) has not been reported for the satisfactory removal of large pituitary adenomas with suprasellar extension. This study is aimed to determine whether deliberate two-staged endoscopic endonasal TSA would be effective for the treatment of large pituitary adenomas with suprasellar extensions. METHODS: Since 1998, we have started endonasal endoscopic TSA, so encountered 12 patients of large pituitary adenomas with suprasellar extension in which deliberate two-staged removal was carried out. The extent of tumor removal, improvement of eye symptoms and endocrine functions after staged operation were analyzed retrospectively. RESULTS: Among the 12 patients with large pituitary adenomas, five had prolactinomas; four growth hormone secreting adenomas; three nonfunctioning tumors. The interval between the two surgical procedures ranged from three weeks to 14 weeks(mean 8.4 weeks). Of 12 patients treated by deliberate two-staged endonasal endoscopic TSA, 38.8%(7/18 eyes) recovered normal visual acuity; improvement was noted in another 55.6%(10/18 eyes). The visual fields were corrected in 88%(15/17 eyes). In these large tumors, 58.3%(7/12 patients) was removed totally, 25%(3/12 patients) subtotally, 16.7%(2/12 patients) partially. Endocrine outcome of 9 hypersecretory adenomas was relatively good. There were no significant complications. CONCLUSION: The authors conclude that the patients who have large pituitary adenomas with suprasellar extension are good candidates for deliberate two-staged endoscopic endonasal transsphenoidal surgery, which maximize tumor removal and improvement of eye symptoms, minimize complication and morbidity.

Traumatic Cirsoid Aneurysm of the Scalp Diagnosed by Doppler Ultrasonography: Case Report

The authors report a patient with a small traumatic cirsoid aneurysm of the scalp, diagnosed by duplex doppler ultrasonography. This 15-year-old boy was diagnosed as a cirsoid aneurysm by duplex doppler ultrasonogram which revealed an ovoid cystic lesion at left temporal area of scalp containing vascular flow mapping. The gross appearance showed an aneurysm with arteriovenous fistula, consisting of two feeding arteries and two draining veins. Total removal of mass was made and the histological examination revealed an aneurysm which showing irregular contour of inner surface and thickened fibrotic vascular wall without normal arterial layers. Noninvasive duplex doppler ultrasonography before surgical excision or direct puncture embolization of cirsoid aneurysms of the scalp could be recommended as an alternative management option.