Fenestration and Duplication of the Vertebrobasilar Artery Detected by Conventional Angiography and Magnetic Resonance Angiography

OBJECTIVE: The purpose of our study is to examine the clinical significance of vertebrobasilar artery(VBA) fenestration and duplication. In addition, we review its incidence and pathogenesis. METHODS: Cerebral angiography was performed in 803 patients and magnetic resonance angiography(MRA) in 880; the patients had or were suspected to have cerebrovascular disease. We retrospectively reviewed angiography and MRA. RESULTS: Fifteen patients (eight men, seven women, 3 to 77 years of age, median age = 58 years) had a VBA fenestration and duplication. Seven (7/803 = 0.87%) of the patients undergoing cerebral angiography revealed fenestrations and one duplication of VBA. Ten patients (10/880 = 1.14%) among 880 patients that underwent MRA demonstrated fenestration of basilar artery(BA). Two of 66 patients that underwent both conventional cerebral angiography and cranial MRA showed a fenestration of BA. Twelve fenestrations were located in the proximal portion of the BA and one was in the mid portion of the BA. One vertebral artery(VA) fenestration was located in the intracranial portion of the right VA, and one VA duplication was at the level of C1-2 in the left VA. CONCLUSION: In addition to medial defects, flow phenomena at the proximal end of fenestrations, where hemodynamic stress and increased turbulence are present, may contribute to aneurysm formation. And arterial fenestration is a predisposing factor in vascular injury and cerebral ischemia.

Persistent Hypoglossal Artery

The persistent hypoglossal artery(PHA) is a rare anomaly that belongs to the group of embryonic carotid-basilar artery anastomoses that may occur in adults. The most commonly reported type of such an anastomosis is the primitive trigeminal artery, followed by the PHA. We report a 35-year old man, hospitalized because of an intraventricular hemorrhage, who was found to have a right persistent PHA. Three-dimensional computed tomography(CT) angiography provided excellent anatomical topology of the anomaly. To our knowledge, this patient is the first case of a PHA identified by this means in Korea.

Cerebral Vasospasm after Surgical Clipping Versus GDC Embolization in Ruptured Intracranial Aneurysm

OBJECTIVE: The purpose of this study is to analyze the influence of the treatment modality(surgical cilpping versus GDC embolization) on development of cerebral vasospasm in a non-randomized retrospective analysis of 93 patients of aneurysmal subarachnoid hemorrhage. METHODS: The following parameters were retrospectively reviewed in our institution's data base and analyzed in association with vasospasm-related ischemic infarctions: 1) Hunt and Hess(H&H) grade, 2) Fisher group, 3) location of aneurysm, 4) treatment modality(surgical cilpping versus endovascular treatment). RESULTS: Of the 93 patients, 39 (41.9%) patients suffered delayed ischemic infarctions. The incidence of delayed ischemic infarctions were increased as higher H&H grade and Fisher group but was not related with the location of aneurysms and the treatment modalities. CONCLUSION: Even with vigorous removal of the subarachnoid blood clots in the surgical clipping group, there is no statistical differences in the incidence of cerebral vasospasm between the two treatment modalities.

Effect of Intraarterially Administered Abciximab(Glycoprotein IIb-IIIa Inhibitor) in the Acute Cerebral Vascular Occlusion

OBJECTIVE: The authors report the safe recanalization after intraarterial injection of abciximab(glycoprotein IIb-IIIa inhibitor) in the acute cerebral vascular occlusion from the thromboembolism. METHODS: Eight patients with acute occlusion of cerebral arteries were treated by using an intraarterial infusion of urokinase and abciximab(Reopro(R)). Six patients had acute thromboembolic complication of endovascular therapy and two patients had acute basilar artery occlusion. Authors used mean 428, 000 units of the urokinase, and mean 6.2mg of the abciximab. In six cases, intraarterial urokinase and abciximab were infused shortly after the event of thrombosis duration endovascular procedure. RESULTS: In all cases, successful recanalization of thrombotic artery was achieved by using intraarterial abciximab and urokinase without bleeding complication. Seven patients recovered without neurologic deficit and one patient remained in locked-in neurological state. CONCLUSION: The authors believe that the intraarterial infusion of abxicimab even in small dose is effective and safe recanalization method in acute thrombotic occlusion of cerebral arteries, but further evaluation and study are needed.

Surgical Management of Dural Arteriovenous Fistula of the Anterior Cranial Fossa after Failure of Embolization Therapy: Case Report

Dural arteriovenous fistula (DAVF) of anterior cranial fossa is a rare entity. The authors report a 57 year-old man presented with retro-orbital headache caused by a large hematoma in the right frontal lobe. Angiography demonstrated a DAVF of anterior cranial fossa fed by branches of middle meningeal and anterior ethmoidal artery. Endovascular therapy using N-butyl cyanoacrylate was tried, however, was failed to occlude the fistula. After than, the lesion was successfully obliterated by surgical means. The therapeutic roles and pitfalls of endovascular treatment and surgical treatment for the anterior fossa DAVF are discussed.

Atretic Cephalocele

We report a case of atretic cephaloce in a 7-month-old girl who presented with a growing left parietal painful mass, which was covered with excessive growth of thick scalp hairs and purplish discolored skin. Preoperative radiological studies revealed the left parietal round skull defect and epidural well enhancing mass without significant intradural parenchymal and vascular malformation. Total excision was done and histological diagnosis of atretic cephalocele was done. Characteristic histopathological features of this rare congenital anomaly with pertinent review of literatures were presented.

Atretic Cephalocele

We report a case of atretic cephaloce in a 7-month-old girl who presented with a growing left parietal painful mass, which was covered with excessive growth of thick scalp hairs and purplish discolored skin. Preoperative radiological studies revealed the left parietal round skull defect and epidural well enhancing mass without significant intradural parenchymal and vascular malformation. Total excision was done and histological diagnosis of atretic cephalocele was done. Characteristic histopathological features of this rare congenital anomaly with pertinent review of literatures were presented.

A Fatal Complication Associated with Combined Posterior Petrous and Suboccipital Approach to a Giant Jugular Foramen Schwannoma

Schwannomas of the jugular foramen, originating from the glossopharyngeal nerve, vagus and accessory nerve represent approximately 0.17-0.72% of all intracranial tumor, and consists of 1.4-2.9% of all intracranial schwannomas. The clinical presentation of these tumors varies significantly according to originated nerve and it's growth pattern. Magnetic resonance(MR) image and temporal bone computed tomography(CT) scan have a major role for diagnosis of such tumor. The treatment of choice is total resection whenever possible. Generally, suboccipital approach is sufficient for the removal of the tumor, but in case with large size, combination of resection of petrous part of temporal bone with or without transection of sigmoid sinus is may be necessory. We have recently experienced one case of giant jugular foramen schwannoma and postoperative fatal complication in a 34-year-old male who was treated with combined posterior petrous and suboccipital approach with transection of sigmoid sinus.

Infantile Myofibromatosis of the Skull: Case Report

No abstract available.

Repeated Transsphenoidal Surgery for Pituitary Tumors

No abstract available.

A Case of Traumatic Cerebral Infarction due to Injury of the Petrosal Internal Carotid Artery Resulting from Head Trauma

Deteriorated mental status and new neurological deficits after head trauma signify the formation of intracranial hematoma or brain edema. In a case of head trauma accompanied by basal skull fracture, even if without intracranial hematoma formation or edema, we should be alert to the possibility of injury of the petrosal carotid artery which needs prompt diagnostic evaluation and management. We report a case of traumatic cerebral infarction due to injury of the petrosal internal carotid artery and review the literatures.

A Case of Neuromyelitis Optica(Devic's Disease)

An 8 year-old boy was presented with typical symptoms of neuromyelitis optica. Hematologic data revealed leucocytosis and elevated erythrocyte sedimentation rate(ESR). CSF analysis showed elevated protein and lymphocyte dominant leucocytosis. Treatment with high dose steroid was administered. He recovered fully within a few weeks after the onset or paraparesis. Neuromyelitis optica is a clinical syndrome. Pathophysiologically, it is a autoimmune process involving the optic nerve and the spinal cord. It is characterized by rapid progressive paraparesis and bilateral visual disturbance. There are no definitive laboratory clues for diagnosis. Treatments including the use of steroid, ACTH, antiviral agent and immunosuppresant, all result in variable effect. Prognosis is very variable ranging from full recovery to death. The most common cause of death is respiratory failure with the cord lesions. Neuromyelitis optica is very rare in Korea. We report the case with review of the literature.

A Case of Normal Volume Hydrocephalus

The normal volume hydrocephalus is a serious, late complication of cerebrospinal fluid shunting procedures. It is characterized by persistent symptoms of headaches, vomiting and/or lethargy in shunted patients and is associated with normal-sized or slightly decreased ventricles. The subependymal gliosis that has been described in experimental and human hydrocephalus was offered as an explanation for the increased elastance in this condition. This 21-yearold male was shunted at 13 years of age for hydrocephalus secondary to pineal gland tumor. He remained asymptomatic for approximately 7 years before admission, when headaches and vomiting developed. A brain CT showed nearly normal-sized ventricles and spinal tapping documented elevated intracranial pressure (300mg CSF). A metrizamide shuntgram suggested obstruction of distal abdominal shunt catheter. After a revision of the distal shunt catheter, the patient became asymptomatic. On follow-up brain CT, no significant decrease in ventricle size was noted.

Role of Stereotactic Surgery for Treatment of Spontaneous Intracerebral Hematomas

Computerized tomography(CT) have been available for diagnosis and localization of intracerebral hematoma. CT-guided stereotactic evacuation of spontaneous intracerebral hematoma was performed in 34 cases; 25 basal ganglionic hematomas with or without ventricular perforation, 4 subcortical, 3 thalamic, 1 cerebellar and 1 pontine. The biplane CT image were taken to determine the coordinates of the target point, which was the center of the hematoma. The liquefied or solid portion of the hematoma was aspirated through a burr-hole under local anesthesia. And a silastic tube(3.3mm in outer diameter and 2.0mm in inner diameter) was then inserted into the center of the hematoma. Immediately after the first trial of hematoma aspiration, urokinase(6000IU/5ml saline) was administered through the tube. Subsequently, aspiration and infusion of urokinase were repeated every 6 or 12 hours until the hematoma was almost completely evacuated. The follow-up results indicate that this procedure was more superior over the conventional craniotomy. This CT-guided stereotactic operation has the following advantages; 1) the procedure is simple and safe; 2) the procedure can be performed under local anesthesia; and 3) the hematoma can be completely drained with the aid of urokinase. This procedure can be used as a standard treatment for intracerebral hematoma. We have draw the following conclusions; As a result of the above study 1) Stereotactic surgery is more effective in the patients with neurologic grade 3 than conservative one (p<0.05). 2) To use urokinase or perform the early surgery within 24 hours did not seem to be the cause of rebleeding. 3) In the case of pons or cerebellar hemorrhage, stereotactic surgery had definite benefit in the recovery of consciousness even if recovery of motor function was dismal. 4) In patients with spontaneuous ICH, the favorable prognostic indicatiors were as follows: the size of hematoma less thas 50ml, no signs of transtentorial herniation and patient's age under 60.

The Clinical Analysis of EVD of the Spontaneous Intraventricular Hemorrhage

The authors analysed retrospectively 41 cases of spontaneous IVH(intraventricular hemorrhage) which were treated with EVD(extraventricular drainage). In cases of poor drainage of CSF(cerebrospinal fluid) through the EVD catheter, infusion of urokinase was tried. The most common age groups of IVH patients were the 5th and 6th decades. Sexual incidence was 23 : 18 in male vs. female. The etioligies of the spontaneous IVH in order of frequency were hypertension, aneurysm rupture, AVM. The overall mortality rate was 49%, but a poor outcome was noted in 64% of the cases. The cases of high Graeb score & low GCS(Glasgow coma scale) score on admission showed poor outcome. Incidence of complication was 27%. Ventriculostomy was effective in many cases of IVH, especially in the early stage of stroke.

Severe Head Injury:Clinical Prognostic Factors

A clinical analysis was carried out retrospectively with 54 cases of severe head injured patients(Glasgow Coma Scale score 3 to 8) to identify prognostic factors. Unawareness for over 1 month, abnormal papillary reaction, abnormal motor response pattern, and diffuse head injury with basal cisternal compression prove to be the most reliable predictors. Individual predictions of outcome provide a powerful too for assessing the relative efficacy of alternative treatments.

Clinical Study of Intra- and Suprasellar Tumor

Tumorous lesion of intra- and suprasellar area showed unique clinical pictures and also was very hazardous and difficult to remove surgically because of the surrounding important anatomical structures. Here, authors analyzed 28 confirmed tumor of this area during last two and half years retrospectively. Histopathologically, 28 cases were classified in 14 pituitary adenoma cases(6 cases of nonfunctioning adenoma, 1 GH-secreting adenoma and 7 cases of prolactinoma), 7 craniopharyngioma cases, 3 meninigioma cases and each one case of germinoma, Rathke's cleft cyst, pituitary abscess and hamartoma. Sexual incidence was 6:22 in male vs female ratio. Twenty two cases were measured its diameter over 2cm and they extended to suprasellar area in all cases. Five cases of microadenoma were analyzed and they were all enclosed in sella turcica. Visual impairment was the most frequent and prominent clinical symptom, of which incidence was 78.57%(22 cases). The next frequent symptoms were headache and generalized lethargy. Diabetes insipidus was a presenting symptom in 4 cases and hydrocephalus was noted in 4 cases preoperatively. Surgical intervention was carried out in 23 cases, by the way, the performed type of surgery in 21 cases was a conventional transcranial frontotemporal(pterional) microsurgical method. Post-operatively, diabetes insipidus was complicated in 78.26% and pituitary hypofunction was noted 34.78%. Two cases of intracranial hemorrhage was developed after surgery and one was died. Through 6 to 28 months follow up, 82.1% of cases were improved in its clinical status including 7 cured cases.

Fracture and Dislocation of the Upper Cervical Spine: A Review of 42 Cases

This review of high cervical spine injuries includes patients admitted to Paik Hospital, Seoul during the period 1981 to 1990. 250 patients had cervical fractures or instability. 42 had involvement of the high cervical spinal column and 13 had neurological deficits. 20 had odontoid fracture. Patients with combination C1-2 fracture-subluxation injuries should be studied with thin section computed tomogram or conventional tomogram. Appropriate treatment is determined by the type of axis fracture and includes surgical and nonsurgical strategies. An experience with 42 patients with high cervical fracture and dislocation is presented as management and follow-up guidelines are reviewed.

Peripheral Neuroepithelioma Arising from the Cauda Equina: Case Report

An unusual case of intraspinal peripheral neuroepithelioma arising from the cauda equina is reported. The patient, a 21-year old female, suffered from low back pain with radiation to the posterior aspect of both legs. Myelographic, computed tomographic scan and magnetic resonance imaging studies of lumbosacral spine showed the intradural extramedullary mass lesion on the L3-S1 level which was excised surgically, but recurred rapidly. It could be diagnosed by the histopathologic findings. The postoperative radiotherapy and chemotherapy were administered. We report this rare case with review of the literatures.

A Case of Metastatic Intracranial Melanoma

Malignant melanoma is known to metastasize to all organs of human body and accounted for the third most frequent primary neoplasm in the intracranial metastases. In a series of melanomas, cerebral symptoms have developed clinically only in 6% although the metastatic cerebral lesions were found by autopsy as high as 39%. The authors have experienced a case of metastatic melanoma on the Rt. Frontoparietal lobe with Jacksonian epilepsy as its presenting symptom.