Clinical Analysis of Traumatic carotid Cavernous Fistula

We analyzed 20 cases of traumatic carotid cavernous fistula(CCF) during the recent 10 years The results are summarized as follows: 1) In 18 cases(90%), the clinical symptoms & signs of CCF occurred within 2 months after trauma. 2) The sites of fistulae were common in horizontal segment(40%) and at the junction(30%) between horizontal segment and posterior ascending segment of cavernous portion of internal carotid artery. 3) The main draining veins of CCF were the superior ophthalmic vein(90%) and the inferior petrosal sinus(70%). 4) The methods of treatment were occlusion of fistula with balloon(9 cases), occlusion of cavernous ICA with balloon(2 cases), ligation of cervical ICA with Poppen's clamp(4 cases) and trapping(2 cases). Two patients were not treated and another patient was healed spontaneously. 5) The frequency and severity of complication was significantly decreased in cases treated by detachable balloon occlusion than by direct cervical ICA ligation or trapping procedures. 6) The procedure using the self-sealed goldvalve balloon was simple, but had a risk of premature separation and premature deflation.

A Study on the Incidence and Patterns of Early and Late Seizures after Head Injury

Post-traumatic seizure is a known consequence of head trauma and a major public problem. But the surveillance study of this problem in our country is very rate. The purpose of the current study was to determine the incidence, clinical patterns and the outcome of the post-traumatic seizure in our institute. A retrospective review of management in 5053 patients with head injury was performed in our department between 1983 and 1992. In our series, the frequency of post-traumatic epilepsy was 254 patients, giving 1 5.0% incidence rate(early seizure occurred in 2.2% and late seizure occurred in 2.8% of patients). Of these, the records of 203 patients who received follow-up care for at least 2 years was reviewed. The first early epileptic attack occurred within 24 hours of injury in one third of the cases(33.3%), and the first late epileptic attack occurred within 1 year was about two thirds of the cases(64.6%). On CT scan findings, the early epilepsy had a higher incidence in scans that showed diffuse brain swelli ng and the late epilepsy had a higher incidence in subdural and intracerebral hematoma. 57.5% of early seizure were focal type, and 55.2% of late seizure were generalized convulsive seizure. The outcome of severe head injury patients with early seizure was better than that of late seizure group. The severity of head injury was related to the occurrence of late post-traumatic seizure.Development of new antiepileptic drugs, increasing knowledge of preventing post-traumatic sequelae and demand for surgical treatments have allowed the reduction of the incidence of the post-traumatic seizures. But further survey or study is recommanded in order to achieve more improvement in the management of post-traumatic seizures.

Familial Occurrence of Von hippel-Lindau Disease: Case Report

Hemangioblastoma is an uncommon tumor of the central nervous system, accounting for only 1 % to 2.5% of all intracranial neoplasms. Hemangioblastoma can occur either sporadically or as a manifestation of von Hippel-Lindau diseasean inherited disorder of the autosomal dominant trait-characterized by tumors or tumor-like lesions developing in several organs including angioma of retina, pheochromocytoma, cyst or carcinoma in kidney and pancreas. We have encountered a family in which two male members were histologically diagnosed as suffering from von Hippel-Lindau disease and another male member was clinically suspected of suffering from spinal hemangioblastoma. The pathophysiology and genetic aspect of von Hippel-Lindau disease are discussed with review of literatures.

Cystic Intracranial Hemangiopericytoma; Case report

Hemangiopericytomas is a rare malignant tumor of the central nervous system having an incidence of 1-3.8% of all primary intracranial meningeal tumors, and the occurrence of cystic hemangiopericytomas is even rarer. We report our recent experience of a case of cerebral hemangiopericytoma associated with a large cyst in a 38 year-old man. The patient presented with 1-month history of headache. Computerized tomography(CT) and magnetic resonance image(MRI) showed a huge-sized, cystic tumor in the left frontal region. Histopathological report of the excised tumor confirmed cystic hemangiopericytoma. Over the years, the issue of classifying hemangiopericytoma as a form of meningioma has been controversial. Since hemangiopericytoma differs from that of ordinary meningiomas because of its extremely malignant behavior and different histological and ultrastructural properties, the author suggest that hemangiopericytoma classified not with meningiomas. Regardless of classification, total surgical removal of this tumor is crucial due to its tendency for local recurrence despite aggressive resection.

Intracranial Cavernous Hemangioma

Intracranial cavernous hemangioma is one of vascular malformations composed of thin walled sinusoidal spaces lined with endothelium. The authors described 7 cases of cavernous hemangioma that were verified histologically and 5 lesions that were diagnosed only with symptoms, radiological and magnetic resonance imaging(MRI) findings. The clinical features are as follows:7 patients had seizures, 3 focal neurological signs and 2 intracaranial hematomas. Computed tomography(CT) usually demonstrated nodular or irregular hyperdense lesions without significant mass effect. MRI usually revealed central area of mixed signal intensity and peripheral rim of low signal intensity. Angiography usually showed an avascular area or normal angiographic appearance. The combination of a clinical history with CT, angiography and MRI findings would suggest cavernous hemangioma. Four epilepsy patients underwent surgical procedures, resulting in improved seizure control and/or lessened neurological deficit.

Huge Sized Intraventricular Teratoma

Teratomas are rare neoplasms, constituting 0.5% to 1.2% of all intracranial tumors;nevertheless, they account for 2% to 4% of intracranial tumor in children. The most common location for these tumor is in the midline pineal region, but teratoma in the lateral ventricle is very rare. A report is presented here of the total extirpation of a huge sized teratoma located in the lateral ventricle of a 4-year old man. This unique tumor is revealed various tissue components, ectodermal and mesodermal derivatives such as skin appendages and neuroglial tissue partially lined by ependmal cells.

Surgical Exercise Intramedullary Cysticercosis in Thoracic Cord

Cysticercosis of the central nerve system seldom involves spinal structures. When it does, the parasites grow much more often in the subarachnoid space than within the cord or epidural space. Recently we have experienced a cases of intramedullary cysticercosis in thoracic cord, which was characterized by paraparesis and voiding difficulty of 1 1/2 years duration in 34-year old man, and the patient's symptoms were improved after operation. We discuss this rare condition with brief review of the literature relevant to spinal cysticercosis.

Stereotactic Evacuation of Spontaneous Intracerebellar Hemorrhage

The incidence of spontaneous cerebellar hemorrhage is a range of between 0.3% and 0.7% in several large series and accounts for 10% of all intracranial hemorrhages. The course and prognosis of spontaneous intracerebellar hemorrhage, regardless of treatment, is poor. The Cosman-Robert-Wells(CRW) stereotactic instrument is recently developed modification, based on an arc-radius design, of the Brown-Roberts-Wells(BRW) stereotactic frame utilizing the exising fixation and fiducial components of the BRW stereotactic system localize and verify target data. During the year of 1989 through 1991, 25 patients with spontaneous cerebellar hemorrhage operated on using CRW stereotactic instrument and fibrinolysis. The age incidence was most frequent in 7th decade. 19 cases(76%) obtained a favorable outcome after operation and 4 cases(16%) death. 2 cases subsequently developed postoperative rebleeding and a case infection. The short operating time, the relatively low risk involved, and the lack of danger to healthy brain support the use of CT-guided stereotactic removal and fibrinolysis. In our opinion, CT guided sterotactic removal is simple, effective and safe method for spontaneous cerebellar hematoma.

A Case of Traumatic Giant Aneurysm

The authors are reporting traumatic giant aneurysm arising from supraclinoid portion of internal carotid artery. The patients was a 22-years old man who had suffered a major head injury in a traffic accident. On admission he was comatous and there were multiple abrasion over the body and severe hemorrhage comming from the left ear with open fracture in left parietal. 4 weeks later, computed tomographic scan demonstrated large well enhanced mass in the suprasellar region. Carotid angiography showed giant aneurysm fed by supraclinoid portion of internal carotid artery. After frontotemporal craniectomy, direct approach was performed using surgical microscope.

The Association of Cerebral Aneurysm and Brain Tumor

The reports of the association of cerebral aneurysm and brain tumor are rare. Recently, we experienced five cases of association of cerebral aneurysm and bain tumor and available literature were reviewed. Of five cases of brain tumor, there were two cases of meningioma, two cases of pituitary adenoma and a case of malignant glioma. Vascular clips were used for aneurysm obliteration in three cases, coating was in a case and four cases of them had favorable outcome. The association of cerebral aneurysm and brain tumor had difficult problems in treatment such as brain swelling and hemorrhage from the aneurysm after removal of tumor.

Cerebral Aneurysms in Childhood and Adolescence

The incidence of intracranal aneurysm is rare in childhood and adolescence. During the period from January 1982 through December 1989, 793 aneurysms were operated on the our department. Of these 8 aneurysms occurred 8 patients under age of 18 years. The average age was 11.6 years(range 4 to 18 years). There were 6 male and 2 females. Presenting sings and symptoms included SAH in 6 aneurysms and focal neurologic deficits in 2 aneurysms. All aneurysms were surgically treated : direct clipping was performed in 6, aneurysmorraphy in 1, trapping alone in 1. The postoperative result were excellent in 5, good in 2, and fair in 1. The rarity of such lesions in childhood and adolescence and their pathogenesis are reviewed briefly.

Clinical Analysis of Early Operation for Elderly Patients with Ruptured Aneurysm

Direct operation for ruptured aneurysm should be the choice of treatment in elderly patients same as in younger cases. The early operation is an effective and reliable method to reduce the occurrence of rebleeding, vasospasm, ischemic complication, medical complication & to shorten lengths of hospitalization. To evaluate the risk of early operation of elderly patients with ruptured cerebral aneurysm. conducted a retrospective analysis 81 elderly patients with ruptured aneurysms who were over aged 60 years between Jan 1985 to June 1988. Of these, 47 case were performed early operation in which the direct intracranial operation was carried out within 3 days after last subarachnoid hemorrage. 77 % had favorable outcome and 13% died.

Clinical Analysis of Giant Intracranial Aneurysm

The authors reported the cases of 23 patients with aneurysms measuring 2.5 cm or greater in diameter found during 7 years period in which we performed 596 operations for aneurysm of the 23 patients, 14 were treated by direct operation, 3 by internal carotid ligation with or without bypass surgery, 2 by trapping, 1 by wrapping and the other 3 by conservative therapy. The overall incidence of giant aneurysms was 3.9% but varied according to location; 9 cases were located on the internal carotid artery; 8 were on the anterior communicating artery; 5 were on the middle cerebral artery. 14 patients had hemorrhagic attacks, 7 had mass effects from the aneurysm, and 2 had ischemic events. Overall favorable outcome was 65% and the mortality was 13%. Based on the review of the literature, the appropriateness of surgery and surgical methods are discussed.

Clinical Study of Intracranial Meningioma

To provide a guideline of accurate diagnosis and proper methods of treatment of meningioma, the most common benign intracranial tumor, the author studied 57 cases of meningioma who had been diagnosed and operated at the Department of Neurosurgery, Inje Medical College, Paik Hospital, Pusan from July, 1983 to June, 1988. The results were as followings. 1) The ratio of male to female was 1 to 2.2 and 31.6% of the 57 patients were in the 5 th decade of age and 29.8% in the 6 th decade. 2) The predilection sites were parasagittal and falx(33.3%), convexity(26.3%) and sphenoid ridge (21.1%) areas. The most frequent histological type was meningotheliomatous type(47.4%) which was followed by transitional(15.8%) and fibroblastic(10.5%) type. 3) The common initial clinical features were headache(29.3%), visual disturbance(24.6%), seizure(22.8%) and motor weakness(10.5%). In radiologic diagnostic tests, there were abnormal findings in 47.4% on plain skull X-ray, the possibility of diagnosis as the meningioma was 91.2% by means of brain CT scan only, which was regarded as the most accurate and safe method. 4) The extent of operation were total(84.2%), subtotoal(12.3%) and partial(3.5%) removal, The surgical outcome were excellent(49.1%) and good(29.8%). 5) The preoperative embolization of feeding artery was effective to reduce the operative bleeding, and the CO2 laser was thought to be effective surgical tool to remove the meningioma, with its unique properties of non-mechanical bloodless evaporation of tumor and minimalizing of brain edema.

A Case of Moya-Moya Disease with Arteriovenous Malformation

A case of Moya-Moya disease with AVM is reported. It is well known that Moya-Moya disease sometimes is accompanied by cerebral aneurysm. However, only four case of Moya-Moya disease with AVM have previously been published in the world. A 36-year-old women suffered from sudden onset of mental deterioration & left hemiparesis, Brain CT scan showed intraventricular hemorrage in both lateral & 3rd ventricle. Enhanced CT scan revealed irregular enhancing area in the right posterior parietal cortex. Cerebral angiography showed an arteriovenous malformation fed by basal Moya-Moya vessels & posterior meningeal artery. Emergeny external ventricular drainge was done. 2 weeks later, the patient had operation for excision of AVM & encephalomyosynangiosis.

Clinical Analysis of Multiple Intracranial Aneurysms

Author reviewed the 31 cases of multiple intracranial aneurysms clinically from January 1981 to July 1987, at Inje College Busan Paik Hospital. The results obtained were as follows: 1) The incidence of multiple intracranial aneurysm was 7.8%. In most cases(94%), the number of aneurysm was two. 2) Approximately over 70% of patients were 6th and 7th decades, male to female ratio was 1:3.4. 3) The location of multiple intracranial aneurysms was in order, on the opposite side(39%), on the same side(26%), one in the midline and one on the side(29%). The location of indivisual aneurysms was in order, P-com. A(36%), MCA(25%), A-com. A(17%), ICA(13%). 4) The site of the ruptured aneurysm was determined by CT finding(55%), focal mass effect and spasm in angiography(29%), and others. The accurary was 97%. The possibility of rupture at each location was A-com. A(73%), P-com. A(57%), ICA(38%), MCA(31%). 5) 12 cases among them were treated with one-stage operation and 9 cases with two-stage operation. The post-operative favorable outcome was estimated in 13 cases(54%), the surgical mortality was 13%. There was no statistical difference between two groups.

Clinical Analysis of Multiple Intracranial Aneurysms

Author reviewed the 31 cases of multiple intracranial aneurysms clinically from January 1981 to July 1987, at Inje College Busan Paik Hospital. The results obtained were as follows: 1) The incidence of multiple intracranial aneurysm was 7.8%. In most cases(94%), the number of aneurysm was two. 2) Approximately over 70% of patients were 6th and 7th decades, male to female ratio was 1:3.4. 3) The location of multiple intracranial aneurysms was in order, on the opposite side(39%), on the same side(26%), one in the midline and one on the side(29%). The location of indivisual aneurysms was in order, P-com. A(36%), MCA(25%), A-com. A(17%), ICA(13%). 4) The site of the ruptured aneurysm was determined by CT finding(55%), focal mass effect and spasm in angiography(29%), and others. The accurary was 97%. The possibility of rupture at each location was A-com. A(73%), P-com. A(57%), ICA(38%), MCA(31%). 5) 12 cases among them were treated with one-stage operation and 9 cases with two-stage operation. The post-operative favorable outcome was estimated in 13 cases(54%), the surgical mortality was 13%. There was no statistical difference between two groups.

Clinical Analysis of Posterior Fossa Tumors

We analyzed the 43 cases of the posterior fossa tumors at the Busan Paik Hospital, Inje Medical College from January 1980 to December 1986. The posterior fossa tumors included 12 cases of cerebellar astrocytoma, 10 cases of acoustic neurinoma, 5 cases of medulloblastoma, 5 cases of brain stem glioma, 2 cases of meningioma, 2 cases of hemangioblastoma, 2 cases of tuberculoma, 1 case of glioblastoma multiforme, 1 case of oliodendroglioma, 1 case of rhabdomyosarcoma, 1 case of glomus jugulare tumor and 1 case of arteriovenous malformation. The posterior fossa tumors were occupied on the cerebellar hemisphere in 18 cases, the cerebellar vermis in 8 cases, the cerebellar pontine angle in 12 cases and the brain stem in 5 cases. The 25 cases out of the 43 cases of the posterior fossa tumors were accompanied with hydrocephalus. The 10 cases received the radiation therapy and/or the chemotherapy after operation. After treatment of the posterior fossa tumors, 52.6% favorable outcome, 34.2% unfavorable outcome and 13.2% mortality were estimated.