Initial Dead Space and Multiplicity of Bone Flap as Strong Risk Factors for Bone Flap Resorption after Cranioplasty for Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Bone flap resorption (BFR) is a complication of cranioplasty (CP) that increases the risk of brain damage and can cause cosmetic defects. In this study, the risk factors for BFR were examined to improve the prognosis of patients after CP for traumatic brain injury (TBI). METHODS: This study was conducted in 80 patients with TBI who underwent decompressive craniectomy and CP with an autologous bone graft between August 2006 and August 2017. BFR was defined as a >0.1 ratio of the difference between the initial bone flap area and the last bone flap area to the craniectomy size and a < 0.5 ratio of the last bone flap thickness to the bone thickness of the contralateral region on computed tomography scans and plain skull radiographs. The patients were divided into the BFR and non-BFR groups, and medical data were compared between the two groups. RESULTS: Among the 80 patients, 22 (27.5%) were diagnosed as having BFR after CP. The earliest cases of BFR occurred at 57 days after CP, and the latest BFR cases occurred at 3,677 days after CP. Using multivariate logistic regression analyses, the initial dead space size (odds ratio [OR], 1.002; 95% confidence interval [CI], 1.001–1.004; p=0.006) and multiplicity of the bone flap (OR, 3.058; 95% CI, 1.021–9.164; p=0.046) were found to be risk factors for BFR. CONCLUSION: The risk factors for BFR in this study were the initial dead space size and multiplicity of the bone flap.

Aortic Injury during Transforaminal Lumbar Interbody Fusion

Aortic injury during transforaminal lumbar interbody fusion (TLIF) is a rare but severe complication. We experienced aortic injury during TLIF at L3–4 with a 59-year-old woman diagnosed with an adjacent segment disease at L3–4. Severe bleeding occurred during disc space expansion, and the blood pressure dropped to 60/40 mmHg. The patient’s vital sign stabilized after compression with gauze and Gelfoam in addition to blood transfusion. The patient was treated with endovascular repair using a percutaneous technique after intertransverse fusion at L3–4 was completed. She recovered and is being followed-up in the outpatient department.

Management and Outcome of Spontaneous Cerebellar Hemorrhage

OBJECTIVE: Spontaneous cerebellar hemorrhage (SCH) is less common than supratentorial intracerebral hemorrhage. This study investigated the treatment of SCH and the relation between its clinical and radiological manifestation and outcome. MATERIALS AND METHODS: We presented a SCH management protocol in our institute and analyzed the clinical and radiological findings in 41 SCH patients. The outcomes of each method (surgery and conservative treatment) were compared among patients with initial Glasgow Coma Scale (GCS) score of 9-13 and hematoma volume greater than 10 mL. RESULTS: Two (4.9%), 16 (39%), and 23 (56.1%) patients had an initial GCS score of 3-8, with 3-8, 9-13, and 14-15, respectively. Initial GCS score showed significant correlation with Glasgow Outcome Scale (GOS) score (p = 0.005). The mean largest hematoma diameter was 3.2 +/- 1.5 cm, and the mean volume was 11.0 +/- 11.5 mL. Both of them showed significant inverse correlation with GOS score (p < 0.001). Among patients with an initial GCS score of 9-13 and hematoma volumes greater than 10 mL, 3 (50%) had good outcome and 3 (50%) had poor outcome in the surgical, and all of those in the conservative treatment group had poor outcomes. The outcome distribution differed significantly in the surgical and conservative groups (p = 0.030). CONCLUSION: Initial GCS score and largest hematoma diameter and volume on brain computed tomography are important determinants of outcome in SCH patients. The surgery group showed better outcome than the conservative treatment group among those with an intermediate neurological status and large hematomas.

Management and Outcome of Spontaneous Cerebellar Hemorrhage

OBJECTIVE: Spontaneous cerebellar hemorrhage (SCH) is less common than supratentorial intracerebral hemorrhage. This study investigated the treatment of SCH and the relation between its clinical and radiological manifestation and outcome. MATERIALS AND METHODS: We presented a SCH management protocol in our institute and analyzed the clinical and radiological findings in 41 SCH patients. The outcomes of each method (surgery and conservative treatment) were compared among patients with initial Glasgow Coma Scale (GCS) score of 9-13 and hematoma volume greater than 10 mL. RESULTS: Two (4.9%), 16 (39%), and 23 (56.1%) patients had an initial GCS score of 3-8, with 3-8, 9-13, and 14-15, respectively. Initial GCS score showed significant correlation with Glasgow Outcome Scale (GOS) score (p = 0.005). The mean largest hematoma diameter was 3.2 +/- 1.5 cm, and the mean volume was 11.0 +/- 11.5 mL. Both of them showed significant inverse correlation with GOS score (p < 0.001). Among patients with an initial GCS score of 9-13 and hematoma volumes greater than 10 mL, 3 (50%) had good outcome and 3 (50%) had poor outcome in the surgical, and all of those in the conservative treatment group had poor outcomes. The outcome distribution differed significantly in the surgical and conservative groups (p = 0.030). CONCLUSION: Initial GCS score and largest hematoma diameter and volume on brain computed tomography are important determinants of outcome in SCH patients. The surgery group showed better outcome than the conservative treatment group among those with an intermediate neurological status and large hematomas.

Erector Spinal Muscular Schwannoma of the Dorsal Ramus Nerve: A Case Report

We present a rare case of intramuscular schwannoma originating from the dorsal ramus nerve in a 62-year-old woman. The mass grew slowly, with pain developing upon touch five years prior. No neurological deficit was detected. The mass was observed in the erector spinae muscles in magnetic resonance imaging (MRI), and surgical excision was performed. The mass was well encapsulated with clear margin. The lesion appeared to originate from the cranial side. We completely removed the mass including the origin. Histopathology confirmed a schwannoma diagnosis. This is the first report, to our knowledge, of a dorsal ramus-nerve schwannoma within the erector spinae muscles.

Clinical Features According to the Histological Types of the Outer Membrane of Chronic Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: The aim of our study was to classify the outer membrane of chronic subdural hematoma (CSDH) histologically and to determine the clinical and radiological meaning of the classified membranes. METHODS: The outer membrane specimen of 31 patients who underwent surgery for CSDH were acquired in this study. The specimen was classified into four types and each were analyzed of the symptoms on the admission day and during the period from trauma to surgery. The radiological features such as subdural fluid density, Hounsfield number, thickness of the hematoma, and midline shift were analyzed. RESULTS: There were 6% of type I, 29% of type II, 39% of type III, and 26% of type IV neomembranes. The cases of CSDH accompanied by neurologic deficit were highest from type IV of 63%, followed by type II with 56%. On the radiological findings such as Hounsfield unit, hematoma thickness and midline shift, only hematoma thickness between type II and III were statistically significant (p=0.021). The hematoma thickness and midline shift were greatest in type II. On computed tomography scans, the isodense, hyperdense and laminar type that shows the high recurrence rate formed 75% of type II and 67% of type IV while type III had the low possibility of recurrence rate (33%). CONCLUSION: We have identified that the outer membrane have the tendency to develop from type I to IV in time while type II and type IV may have more risk of neurologic deficit and the high possibility of recurrence.

Stereotactic Hematoma Removal of Spontaneous Intracerebral Hemorrhage through Parietal Approach

OBJECTIVE: To determine the advantages of parietal approach compared to Kocher's point approach for spontaneous, oval-shaped intracerebral hemorrhage (ICH) with expansion to the parietal region. METHODS: We divided patients into two groups : group A had burr holes in the parietal bone and group B had burr holes at Kocher's point. The hematoma volume, Glasgow coma scale (GCS) score, and modified Barthel Index (mBI) score were calculated. At discharge, we evaluated the patients' Glasgow outcome scale (GOS) score, modified Rankin Scale (mRS) score, motor grade, and hospitalization duration. We evaluated the patients' mBI scores and motor grades at 6 months after surgery. RESULTS: The hematoma volume in group A was significantly less than that in group B on postoperative days 1, 3, 5, 7, 14, and 21. Group A had significantly higher GCS scores than did group B on postoperative days 1 and 3. Group A had higher mBI scores postoperatively than did group B, but the scores were not significantly different. No differences were observed for the GOS score, mRS score, motor grade at discharge, or duration of hospitalization. The mBI score of group A at 6 months after surgery was significantly higher, and more patients in group A showed muscle strength improvement. CONCLUSION: In oval-shaped ICH with expansion to the parietal region, the parietal approach is considered to improve the clinical symptoms at the acute phase by removing the hematoma more effectively in the early stages. The parietal approach might help promote the long-term recovery of motor power.

Iatrogenic Intraspinal Epidermoid Cyst

Epidermoid cyst is generally regarded as congenital disease, and commonly related to other congenital spinal anomalies. However, it also develops iatrogenically. We report one rare case of epidermoid cyst that we experineced among intradural extramedullary tumors. A 21-year-old female patient was admitted to the hospital due to low back pain with radiating pain into a right lower extremity that initiated about a month ago. She complained sensory lose and motor weakness (grade 4+) on her right extremity as well as urinary dysfunction and sphincter dysfunction. She had a lumbar puncture three times due to Pneumococcal meningitis when she was 13 years old. The well-circumscribed intradural extramedullary mass of 1.8x1.6x4 cm size was found on the L4-5 in a magnetic resonance image. Gross total tumor removal was garried out after the total laminectomy L5 and partial laminectomy L4. The tumor mass was gray-colored and so fragile that it was easy to be removed. The histological diagnosis confirmed epidermoid cyst without malignancy. After the operation, the patient progressively showed remarkable neurological recovery. In this case, the cause of epidermoid cyst is considered iatrogenic concerning history of several times of lumbar puncture as meningitis.

The Clinical Course of Subdural Hygroma with Head Injury / 대한신경손상학회지

OBJECTIVE: Traumatic subdural hygroma (T-SDG) has been generally treated using conservative management rather than surgical methods. This study was performed to evaluate the clinical course of T-SDG with radiologic studies. METHODS: A retrospective study was conducted among patients diagnosed with T-SDG from January 2011 to December 2011. The patients were categorized into two groups. Group A has the widest width of T-SDG below 8 mm, Group B more than 8 mm. Computed tomography (CT) and magnetic resonance imaging (MRI) were carried out in both groups. RESULTS: Seventy-four patients were confirmed with T-SDG and were grouped as follows: 44 patients in Group A and 30 patients in Group B. There was no significant difference in age and sex ratio between group A and B. It took more time to resolve T-SDG in Group B (95.2+/-86.4 days) than Group A (14.4+/-6.7)(p<0.001). However, no significant difference was observed in the Glasgow Coma Scale (GCS) between the groups. In 10 patients of Group B, T-SDG developed into chronic subdural hematoma and one of these patients underwent surgery. CONCLUSION: Most T-SDGs were resolved after some period in this study. Surgery does not seem to be necessary in resolving T-SDG.

The Clinical Course of Subdural Hygroma with Head Injury / 대한신경손상학회지

OBJECTIVE: Traumatic subdural hygroma (T-SDG) has been generally treated using conservative management rather than surgical methods. This study was performed to evaluate the clinical course of T-SDG with radiologic studies. METHODS: A retrospective study was conducted among patients diagnosed with T-SDG from January 2011 to December 2011. The patients were categorized into two groups. Group A has the widest width of T-SDG below 8 mm, Group B more than 8 mm. Computed tomography (CT) and magnetic resonance imaging (MRI) were carried out in both groups. RESULTS: Seventy-four patients were confirmed with T-SDG and were grouped as follows: 44 patients in Group A and 30 patients in Group B. There was no significant difference in age and sex ratio between group A and B. It took more time to resolve T-SDG in Group B (95.2+/-86.4 days) than Group A (14.4+/-6.7)(p<0.001). However, no significant difference was observed in the Glasgow Coma Scale (GCS) between the groups. In 10 patients of Group B, T-SDG developed into chronic subdural hematoma and one of these patients underwent surgery. CONCLUSION: Most T-SDGs were resolved after some period in this study. Surgery does not seem to be necessary in resolving T-SDG.

Comparative Study on the Period of Absolute Bed Rest of Vertebral Compression Fracture

OBJECTIVE: As a conservative treatment of compression fractures, absolute bed rest (ABR) for a certain period has been recommended, but no guideline on the period has yet been established. Considering that a long ABR period may adversely affect patients, the difference in prognosis according to the ABR period was investigated in this study. METHODS: A prospective study was conducted who were diagnosed with compression fracture. Groups A and B were put on ABR (one week for group A and two weeks for group B). X-ray images at baseline, 1, 2, 4, and 8 weeks were obtained from both groups, for assessment purposes. RESULTS: The compression rates of both groups were no significant difference at baseline, 1, 2, 4, and 8 weeks. The conditions of 25.9% and 21.2% of the subjects deteriorated in groups A and B, showing no significant difference. Between the groups of age and bone mineral densities (BMD), no significant difference was observed in the incidence of deterioration. In terms of complications development including constipation and other Gastrointestinal problems, voiding difficulty, etc., group A reported 57.4%, and group B, 84.8%, showing a significant difference (p-value=0.001). CONCLUSION: No significant difference in the conservative period was observed between the groups. Group B, however, reported a higher complications development rate than group A. Therefore, a short ABR period may be helpful in the early stage of conservative treatment.

Spinal Epidural Hematoma Related to Intracranial Hypotension

A 45-year-old female patient visited the hospital complaining of severe sudden headache and posterior neck pain. The patient did not have any traumatic history or abnormal neurologic finding. The patient had sudden quadriplegia and sensory loss. Cervical spine MRI scan was taken, and the compatible findings to acute epidural hematoma were shown. The emergency operation was performed. After the operation, the patient recovered all motor and senses. As there was CSF leakage in the postoperative wound, this was confirmed by cervical spinal computed tomography (CT). Then lumbar drainage was thus performed. The opening pressure upon lumbar puncture was not measured as it was very low. As a result of continous CSF leakage, dural repair was performed. After the operation, the patient had been discharged without neurologic deficits. In this case, it is sensible to suspect intracranial hypotension as a possible cause of spinal EDH.

The Comparative Morphometric Study of the Posterior Cranial Fossa : What Is Effective Approaches to the Treatment of Chiari Malformation Type 1?

OBJECTIVE: The objective of this study was to investigate changes in the posterior cranial fossa in patients with symptomatic Chiari malformation type I (CMI) compared to a control group. METHODS: We retrospectively reviewed clinical and radiological data from 12 symptomatic patients with CMI and 24 healthy control subjects. The structures of the brain and skull base were investigated using magnetic resonance imaging. RESULTS: The length of the clivus had significantly decreased in the CMI group than in the control group (p=0.000). The angle between the clivus and the McRae line (p<0.024), as the angle between the supraocciput and the McRae line (p<0.021), and the angle between the tentorium and a line connecting the internal occipital protuberance to the opisthion (p<0.009) were significantly larger in the CMI group than in the control group. The mean vertical length of the cerebellar hemisphere (p<0.003) and the mean length of the coronal and sagittal superoinferior aspects of the cerebellum (p<0.05) were longer in the CMI group than in the control group, while the mean length of the axial anteroposterior aspect of the cerebellum (p<0.001) was significantly shorter in the CMI group relative to control subjects. CONCLUSION: We elucidate the transformation of the posterior cranial fossa into the narrow funnel shape. The sufficient cephalocaudal extension of the craniectomy of the posterior cranial fossa has more decompression effect than other type extension of the craniectomy in CMI patients.

Traumatic Epidural Hematoma of the Posterior Cranial Fossa / 대한신경손상학회지

OBJECTIVE: Epidural hematoma of posterior fossa is less common than epidural hematoma of supratentorial area, and there are not many articles about epidural hematoma of posterior fossa. This study investigated patients who underwent surgery of epidural hematoma of posterior fossa, and the relation between the clinical manifestation and postoperative outcome. METHODS: A retrospective analysis performed of 27 patients who underwent operation for acute traumatic epidural hematoma of posterior fossa from January 2004 to December 2011. Analyzed factors were gender, age, Glasgow Coma Scale (GCS) measured upon presentation to the hospital, preoperative GCS score, cause of trauma, time elapsed from the accident to the presentation to the hospital, time elapsed from the presentation to the hospital to the surgery, radiographic findings (brain CT findings), and Glasgow Outcome Scale (GOS). RESULTS: Two patients (7.4%) had GCS score on admission of 3-8, 11 (29.6%) had 9-12, and 17 (66.7%) had 13-15. In 1 (3.7%) patient, GCS score changed from 13 to 10, and preoperative GCS score was significantly correlated with GOS score (p<0.05). Mean thickness of hematoma was 19.3+/-7.5 mm, and was significantly correlated with GOS score (p<0.05). GOS score was 4-5 in 24 patients (88.9%), 3 (severe disability) in 1 patient (3.7%), and 1 (death) in 2 patients (7.4%). CONCLUSION: In the patients underwent surgery for epidural hematoma of posterior fossa, 88.9% had favorable outcome (in GOS score of 4 or more). Preoperative GCS score and thickness of hematoma on brain computed tomography are important determinants of prognosis.

Rapid Spontaneous Reduction of a Huge Intracerebral Hematoma

Rapid reduction of a large acute subdural hematoma has been frequently reported. In my knowledge, however, it was rarely reported that rapid spontaneous reduction occurred in large volume of spontaneous intracerebral hematoma (sICH). We describe a patient with a rapid spontaneous decrease in the volume of a large hematoma. A 73-year-old man presented semi-comatose mentality. Initial brain computed tomography (CT) revealed the huge sICH. An emergency operation was planned, but was not performed due to the refusal of patient's family. Therefore, we decided to treat with conservative therapy. However, follow-up brain CT 16 hours after initial scan showed a remarkable reduction of previous sICH. The mechanism involving the spontaneous rapid decrease of the hematoma is presumed to occur through redistribution in brain atrophy, compression effect from the increased intracranial pressure and dilution through a wash out by the cerebrospinal fluid.

Propriospinal Myoclonus Induced by a Herniated Lumbar Intervertebral Disc at a Young Age: A Case Report

The cause of propriospinal myoclonus (PSM) is idiopathic. Cervical trauma, ischemic myelopathy secondary to a spinal dural arteriovenous fistula, syringomyelia, Lyme neuroborreliosis, human immunodeficiency virus central nervous system infection, and cervical disc herniation can be the cause of PSM, but lumbar herniated intervertebral disc (HIVD) induced PSM has not been reported. We describe a patient who presented with PSM induced by HIVD and was treated with an epidural steroid injection using a transforaminal approach.

Optimal Treatment in Patients with Ruptured Middle Cerebral Artery Aneurysms and Intracranial Hematoma According to Hematoma Distribution / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to determine the clinical courses and optimal treatments for patients suffering from ruptured middle cerebral artery (MCA) aneurysms with either intracerebral (ICHs) or sylvian hematomas (SylH), based on hematoma distribution. METHODS: We grouped 49 patients with Fisher grade III or IV subarachnoid hemorrhages, who underwent aneurysmal neck clipping and hematoma evacuation within 24 hours of developing an intracranial hematoma, according to hematoma distribution. Group A comprised 21 patients who had ICHs<30 ml, while group B comprised 28 patients with dense SylHs<30 ml. Result: Immediate postoperative brain computerized tomography findings showed residual hematomas in 3 group A patients (14.3%) and 20 group B patients (71.7%). We noted post-operative brain edema in 5 group A (23.8%) and 15 group B patients (53.6%). Vasospasm developed in 4 group A (19.0%) and 20 group B patients (71.4%; p<0.05). In group A, 12 patients (57.1%) had focal neurologic deficits upon discharge, while 5 patients died. In group B, 9 patients (32.1%) had focal neurologic deficits upon discharge, while 8 died (p<0.05). Normal pressure hydrocephalus developed in 1 patient (4.8%) in group A and 5 in group B (17.9%). Favorable outcomes were achieved in 9 patients (42.9%) in group A and 4 (14.3%) in group B. CONCLUSION: Patients who experienced ruptured MCA aneurysms with SylHs had more severe clinical courses and poorer outcomes than patients with ICHs did. The SylH patients had a higher incidence of both vasospasm and brain edema. Therefore, physicians must consider differences in clinical features based on hematoma distribution when choosing an appropriate therapeutic approach for patients with ruptured MCA aneurysms and intracranial hematomas.

Chronic Subdural Hematomas : A Comparative Study of Three Types of Operative Procedures

OBJECTIVE: Several surgical procedures have been reported for the treatment of chronic subdural hematoma (CSDH). We compared the results of treatments for CSDH obtained from one burr-hole craniostomy with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation, and small craniotomy with irrigation and closed-system drainage. METHODS: Eighty-seven patients with CSDH underwent surgery at our institution from January 2004 to December 2008. Our patients were classified into three groups according to the operative procedure; group I, one burr-hole craniostomy with closed system drainage with or without irrigation (n = 25), group II, two burr-hole craniostomy with closed system drainage with irrigation (n = 32), and group III, small craniotomy with irrigation and closed-system drainage (n = 30). RESULTS: Age distribution, male and female ratio, Markwalder's grade on admission and at the time of discharge, size of hematoma before and after surgery, duration of operation, Hounsfield unit of hematoma before and after surgery, duration of hospital treatment, complication rate, and revision rate were categories that we compared between groups. Duration of operation and hospitalization were only two categories which were different. But, when comparing burr hole craniostomy group (group I and group II) with small craniotomy group (group III), duration of post-operative hospital treatment, complication and recurrence rate were statistically lower in small craniotomy group, even though operation time was longer. CONCLUSION: Such results indicate that small craniotomy with irrigation and closed-system drainage can be considered as one of the treatment options in patients with CSDH.

Remote Cerebellar Hemorrhage After Supratentorial Aneurysm Surgery: Report of 2 Cases / 대한뇌혈관외과학회지

Remote cerebellar hemorrhage is a rare complication of supratentorial neurosurgical surgery occurring in approximately 0.3~0.6%, and it is same with the supratentorial aneurysm surgery. Although remote cerebellar hemorrhage is a rare complication of supratentorial neurosurgical surgery, this is often related with significant morbidity and mortality. In spite of its lethal character, the precise mechanism is uncertain. In this article, we present clinical details of two patients with cerebellar hemorrhage after supratentorial aneurysm surgery, and discuss about possible mechanism of this rare complication. In reported articles, seven predisposing factors are correlated with remote cerebellar hemorrhage after supratentorial aneurysm surgery; hypertension, cerebrovasular anomaly, anti-coagulation treatment, coagulopathy, head positioning during surgery, over drainage via epidural closed drainage system with negative pressure, and excessive CSF drainage during or after the surgery. By reporting these two cases, we want to alert neurosurgeons about this rare but lethal complication, and tell about that there are several ways to minimize the possibility of remote cerebellar hemorrhage.

Spinal Schwannoma; Analysis of 40 Cases

OBJECTIVE: This study is to report our experience of 40 cases of spinal schwannoma. METHODS: From 1995 to 2006, medical records were retrospectively reviewed in 40 cases of spinal schwannoma. RESULTS:We treated 40 spinal schwannomas in 38 (22 male and 16 female) patients. The mean age was 50.2. Four cases were sited in the cervical spine, 11 cases in the thoracic spine, and 25 cases in the lumbar spine. Two patients showed recurrences. Thirty-eight cases were intradural-extramedullary type and 2 cases were extradural. Two cases (5%) including 1 recurred case had no postoperative motor improvement. Ninety-five percents of patients improved on postoperative motor grade. CONCLUSION: Spinal schwannoma is mostly benign and extramedullary tumor. There were 2 recurred cases (5%) that had history of previous subtotal removal at first operation and had shown worse prognosis compared with the cases without recurrence. To reduce the recurrence of spinal schannoma, total excision of tumor mass should be done.