Extraskeletal Cervical Epidural Ewing's Sarcoma: Case Report and Review of the Literature

A patient with extraskeletal cervical epidural Ewing's sarcoma who presented with cervical radiculopathy is reported. A 58-year-old woman presented with right posterolateral neck pain and upper extremity radiculopathy. The computed tomography myelography showed epidural and paravertebral masses on right side, with widening of the ipsilateral neural foramina at the C2-C3 level. On magnetic resonance images, the mass was isointense to soft tissue on T1-weighted images, hyperintense on T2-weighted images, and showed diffuse enhancement on GdTA enhanced T1-weighted images. The staged, combined posterior and anterior approach were done and the tumor mass was subtotally removed. During postoperative adjuvant chemotherapy with Cytoxane, Adriamycin, Vincristine, Prednisolone regimen, the patient died of severe compression of upper cervical cord by recurrent, extended tumor mass in the spinal canal.

Surgical Approaches to the Middle Cranial Base Tumors

OBJECTIVE: We analysed various surgical approaches and surgical results of 28 middle cranial base tumors for the purpose of selecting optimal surgical approach to the middle cranial base tumor. METHODS: In this retrospective review, 28 patients, including 16 meningioma, 6 trigeminal neurinoma, 2 pituitary adenoma, 2 craniopharyngioma, 1 facial neurinoma, and 1 metastatic tumor, underwent surgical treatment using skull base technique. Of theses, 16 tumors were mainly confined to middle cranial fossae, 5 tumors with extension into both anterior and middle fossa, and 7 tumors with extension into both middle and posterior fossa. Tumors that confined to the middle cranial fossa or extended into the anterior cranial fossa were operated with modified pterional, orbitozygomatic or Dolen'c approach, and tumors that extended into the posterior cranial fossa were operated with anterior, posterior or combined transpetrosal approach. Completeness of tumor resection, surgical outcome, postoperative complication, and follow up result were studied. RESULTS: Total tumor removal was achieved in 9 tumors of 10 tumors that did not extended to the cavernous sinus, and was achieved in 7 tumors of 8 tumors that extended to the lateral wall of the cavernous sinus. Of 10 tumors that extended to the venous channel of the cavernous sinus, only 2 were removed totally. Surgical outcome was excellent in 14 patients, good in 10, fair in 2 and poor in 2. There were no death in this series. Dumbell type tumor which extended into both middle and posterior fossae showed tendency of poor prognosis as compared with tumors that confined middle cranial fossa and extended into both anterior and middle cranial fossa. Postoperative dysfunctions were trieminal hypesthesia in 3, oculomotor nerve palsy in 2, abducens nerve palsy in 2, hemiparesis in 2, cerebellar sign in 1, facial palsy in 1 and hearing impairment in 1. CONCLUSION: Based on our findings and a review of the literature, we conclude that, when selecting the surgical approach to the middle cranial fossa tumors, the most important factors to be considered were exact location of the tumor mass and existence of the cavernous sinus invasion by tumor mass. We recommend modified pterional or orbitozygomatic approach in cases with tumors located anterior and middle cranial base, without cavernous sinus invasion. In cases with tumors invading into cavernous sinus, we recommend Dolen'c or orbitozygomatic approach. And in lateral wall mass and the cavernous sinus, it is preferred to approach the tumor extradurally. For the tumor involing with middle fossa and posterior fossa(dumbell type) a combined petrosal approach is necessary. In cases with cavernous sinus invasion and internal carotid artery encasement, we recommend subtotal resection of the tumor and radiation therapy to prevent permanent postoperative sequele.

Spinal Extradural Angiolipoma: Case Report

No abstract available.

Surgical Management of Trigeminal Neurinoma

No abstract available.

Improvement of Cerebrovascular Reserve Capacity by Bypass Surgery in Patients with Hemodynamic Cerebral Ischemia

To study the effect of extracranial-intracranial(EC/IC) bypass on symptomatic patients with hemodynamic cerebral ischemia, we prospectively reviewed 14 patients who underwent EC/IC bypass surgery. A series of 14 patients treated in a 2 years period met the following criteria, 1) symptomatic internal carotid artery(ICA) or middle cerebral aetery(MCA) obstruction or stenosis over 80M, 2) decrease in basal cerebral blood flow(CBF) over 10%, 3) hyporeactivity to acetazolimide of CBF Amomg these, the type of ischemic episode was transient ischemic attack(TIA) or reversible ischemic neurological deficit(RIND) in 4, minor stroke in 8, and major stroke in 2. Of these, 10 patients had multiple episode of ischemic attack. CT or MRI were showed infarction of the MCA territory in 3, border zone infarction in 5, basal ganglia infarction in 2 and multiple lacunar infarction in 4. Based on our criteria, superficial temporal artery(STA)-MCA anastomosis was performed in 13 cases and EC-IC bypass grafting using radial artery in one. Average follow up period was 24 months. Postoperative course was uneventful in 12 patients. One patient suffered a postoperative stroke with complete recovery and another suffered operative wound infection. Of the 14 patients 12(85.7 % ) have had an excellent to good outcome with complete resolution or significant improvement of preoperative neurologic symptom, remaining two show no improvement of preoperative neurologic deficit. Bypass patency was confirmed by postoperative angiography in all cases except for one. Postoperative follow up studies of the basal CBF and response to the acetazolamide of the CBF showed significant increased CBF activity to acetazolamide in 12 cases(85. 7%) while the basal CBF was essentially unchanged in all cases except for two. In view of these finding, the authors suggest that EC-IC bypass surgery to be considered as an appropritate therapy for improvement of the cerebrovascular reserve capacity in patients with hemodynamic cerebral ischemia, defined using the strict selection criteria employed in this study.

Result of Stereotactic LINAC Radiosurgery of AVM

There are several treatment modalities of cerebral arteriovenous malformation, among these, stereotactic radiosurgery is effective means of obliteration of AVM with minimal morbidity. Since July 1988 to May 1998, our institute have conducted 98 radiosurgery for arteriovenous malformations. During this period, there were 2 major changes in delivering radiation, the first one is introduction of compute r dose planning system at september 1996(CUMC normal mode), the next was CUMC Stereotactic mode using non-flat filter delivery system since september 1997. Authors report the results of the first generation LINAC(linear Accelerator) radiosurgery before introduction of computer dose planning system for radiosurgery. During the first generation period(July 1988 to september 1996), 70 patients have had stereotactic radiosurgery for vascular malformation. Among these, 49 patients could be followed at least for 2 year with angiography or MRA(magnetic resonance angiography). Hemorrhage was the most common presenting causes of undergoing radiosurgery, the parietal lobe was the most prevalent area undergoing radiosurgery for vascular malformations. With grouping of volumes, vascular malformations we re grouped as 1) volumes less than 1 ml(n= 14 ), 2) 1- 4ml (n=21), 3) 4-10ml (n=4 ), 4 ) 10-14ml(n=4 ), 5 ) volumes over 14ml (n=6). the results are as follows ' for group 1 ), total occlusion rate were 85.7 F, for group 2 ) total occlusion rate were 71.4 %, for group 3 ),4 ),5 ), total occlusion rate were 50%. As a gross result of 49 patients, total occlusion rate was 69.4%, partial occlusion was 22.4%, no response 14.3 %. 4 cases of 70 radiosurgery for vascular malformation rebleeded (5.7 %) and 2 of these patients died of bleeding (2.9%). There was no symptomatic radiation complication, but 6 patients showed increased signal intensity on T2 weighted image on follow up magnetic resonance imaging.

A Clinical Analysis of the Ventriculoperitoneal Shunt with Programmable Shunt Divice

CSF shunting procedures are widely employed in the treatment of hydrocephalus and other disturbances of the dynamics of CSF such as a rachnoid cyst and syrinx. The relative simplicity of this operation with respect to other neurosurgical procedures is matched by a high incidence of complications. Many kinds of shunt devices have been developed to reduce complications. Yet, this operation frequently requires surgical revision. Traditional shunts were primarily designed to manage hydrocephalus by regulating intracranial pressure. Those devices, in some circumstances, can cause to underdrain or overdrain CSF and may need a surgical revision to adjust the pressure Authors have treated 28 patients with the disturbaces of CSF dynamics using pressuread justable valve system (Codman-Medos p rogrammable Hakim valve system). Two patients had arachnoid cysts and the others had hydrocephalus with various etiologies. Subdural hygroma was developed in 5 patients and underdrainage was observed in 9 patients on CT scan. By adjusting the pressure, Authors achieved clinical improvements without a need for surgical revision. The optimum pressure was 97.4+17.4mmHO for the patients with hydrocephalus with various etiologies in adults. In conclusion, the incidence of shunt revision by using this shunt device for the treatment of hydrocephalus and arachnoid cysts was decreased.

Surgical Management of Suprasellar Meningioma

OBJECTIVE: Suprasellar meningioma have in general been difficult lesions to treat because of their vicinity to the optic apparatus and major vessels, and high vascularity. This study was performed to analyze clinical outcome of patients with histopathologically identified suprasellar meningioma. METHOD: Between 1989 and 1998, 37 patients(30 women, 7 men: average 47.5years) with histopathologically identified meningiomas originating from the suprasellar region underwent surgical tumor removal in our institution. The medical records and clinical data of these patients are retrospectively analyzed. RESULT: The tumor size ranged from 2.1cm to 6.5cm(average 5.1cm) in diameter. The tumors have been approached basically through the pterional and bifrontal routes. Skull base technique was also applied in large or complicated cases. Total resection rates and overall outcome including visual function was better in patients with tumor of less then 3cm. A considerable increase of mortality, morbidity and failure of visual improvement were seen in case of the tumors size of 3cm or more. CONCLUSION: Early diagnosis and treatment were important factors in the successful management of these suprasellar meningioma. In large complicated cases encasing major vessels or invading cavernous sinus or anterior skull base, surgeons need to operate with extreme caution and piecemeal removal of the tumor without injuring optic apparatus and major vessels utilizing skull base technique.

Surgical Approach to Large Anterior Basal Meningioma

Anterior basal meningiomas, which belong the olfactory groove and suprasellar meningioma account for 12 to 22% of all intracranial meningioma. Anterior cranial base meningioma are difficult to operate on because of their proximity to the important neurovascular structure. The authors report 25 cases of large meningiomas of the anterior. cranial base operated on during recent 5-year period. The tumor ranged from 3cm to 6.5cm in diameter. Fifteen tumors were located in the suprasellae(included tuberculum sellae, planum sphenoidale, diaphragma sellae,and anterior clinoid process), ten on olfactory groove. The mean age of 19 female and 6 male patient was 55years. The main clinical symptom were visual disturbance, anosmia, headache, and psychotic syndrome. Tumors were approached in 11 cases by pterional, in 9 cases by bifrontal, in 3 cases by transbasal, in 2 case by orbitozygomatic infratemporal and in 1 case by combined approach with tranabasal and orbitozygomatic infratemporal. Total tumor removal was performed in 80% of cases. Postoperative complication include accentuated psychotic syndrome in two cases, worsening of visual function in two, major vessel injury in one, infection in one, CSF rhinorrhea in one, and oculomotor palse in one. Postoperative death was in four(16%). Results at follow up of the 21 survivours were good in 17(68%), fair in 4(16%). Selection criteria for operative approach is discussed with review of pertinent literature.

Surgical Decompression for Acute Brain Infarction

We present 15 patients with progressive neurological deterioration while on medical treatment for massive cerebral or cerebellar edema due to large cerebral or cerebellar infarction. Clinical signs of uncal herniation were present in 10 of these patients. Remaining five patients showed progressive neurological deterioration accompanied with impending herniation. Brain CT confirmed mass effect from cerebral or cerebellar edema in all cases. All 15 patients were treated with decompressive craniectomy, duroplasty and/or ventriculostomy. Nine patients showed good results and six patients had poor results. As compared with poor result group, good result group had high score of Glass Gow Coma Scale(GCS) on admission(12.8 vs. 8.3 on average) and time from worsening to operation is shorter(8.8 vs. 21.3hrs on average). Infarction was all on right side and hearniation sign just before operation appeared infrequently in good result group. These results suggest that decompressive surgery can be effective life saving procedure for massive cerebral edema after large brain infarction, especially in cases with right side lesion, high GCS score on admission, and pertinent timing of operation(before occurrance of irreversible brain stem damage due to herniation).

Linear Accelerator-Based Stereotactic Radiosurgery for Acoustic Neurinomas / 대한암학회지

No abstract available

Intraventricular Neurocytomas

The clinical and pathological features of five patients with intraventricular neurocytoma are reported. Distribution among men and women is equal. The patients' age at diagnosis ranged from 20 to 57 years. The lesions were located in the lateral and third ventricles. Raised intracranial pressure was the main cause of the clinical manifestations. An isodense mass with multiple intratumoral cysts and homogeneous contrast enhancement was the characteristic computerized tomographic finding. Cerebral angiography showed homogeneous vascular staining in four patients. Magnetic resonance images revealed a mass isointense with the cerebral cortex on both T1- and T2-weighted images. Gadolinium-diethylenetnaminepenta-acetic acid-enhanced images showed homogeneous enhancement. Total removal of the tumor was performed in five patients. Histologically, all tumors were composed of small uniform cells with perinuclear halo and regular round nuclei. Immunohistochemical studies demonstrated strong positivity for neuron-specif ic enolase in all five cases and for synaptophysin in two cases.

Intraventricular Neurocytomas

The clinical and pathological features of five patients with intraventricular neurocytoma are reported. Distribution among men and women is equal. The patients' age at diagnosis ranged from 20 to 57 years. The lesions were located in the lateral and third ventricles. Raised intracranial pressure was the main cause of the clinical manifestations. An isodense mass with multiple intratumoral cysts and homogeneous contrast enhancement was the characteristic computerized tomographic finding. Cerebral angiography showed homogeneous vascular staining in four patients. Magnetic resonance images revealed a mass isointense with the cerebral cortex on both T1- and T2-weighted images. Gadolinium-diethylenetnaminepenta-acetic acid-enhanced images showed homogeneous enhancement. Total removal of the tumor was performed in five patients. Histologically, all tumors were composed of small uniform cells with perinuclear halo and regular round nuclei. Immunohistochemical studies demonstrated strong positivity for neuron-specif ic enolase in all five cases and for synaptophysin in two cases.

Somatosensory Evoked Potentials Before and During Surgery in Patient with Cerebral Aneurysm

It has been known that the electrical activity of the brain is related to regional cerebral blood flow, and cerebral ischemia developed during the management of aneurysmal subarachnoid hemorrhage(SAH) is one of the major causes of morbidity and mortality. Somatosensory evoked potentials(SEPs) in response to median nerve stimulation at wrist have been recorded before and during surgery in 31 patients with aneurysmal SAH and 30 normal control subjects. The central conduction time(CCT), the time between the N4 peak recorded from the second cervical spine and the N20 peak recorded from the sensory cortex, were observed as an indicator of cortical activity. The results were as follows, 1) In patients with aneurysmal SAH, CCT recorded before surgery were not different from that of controls. 2) In patients with aneurysmal SAH, CCT recorded during surgery were found to be significantly increased by administration of anesthetics. 3) During surgery in aneurysmal SAH, CCT tended to be increased by brain retraction. 4) During surgery in aneurysmal SAH, CCT changes relative to the temporary occlusion of the parent artery were quite variable, ranging from rapid disappearance of N20 by only 2 minutes of temporary occlusion to no significant change after 20 minutes of occlusion. The rapid disappearance of N20 within 2 minutes after temporary occlusion was highly likely to be associated with appreciable neurologic deficit after surgery. These results suggest that somatosensory evoked potentials during the management of patients with aneurysmal SAH is considered to be a valuble indicator of cortical function, especially when temporary occlusion was performed to prevent premature rupture of cerebral aneurysm during surgery.

The Clinical Analysis of 75 Patients which were Operated on MVD

A series of 75 microvascular decompression(MVD) for 23 cases of trigeminal neuralgia, 50 cases of hemifacial spasm and 2 cases of paroxysmal vertigo has been reviewed with assessment of outcome at the last follow-up examination. In hemifacial spasm, average of symptom duration was 7 years, and female had longer duration as trigeminal neuralgia. The offending site was found more frequent in right side of the trigeminal neuralgia and hemifacial spasm. Meaningfully female in hemifacial spasm and male in trigeminal neuralgia was noted more frequent in right side. The offending vessels were considered anterior inferior cerebellar artery and posterior inferior cerebellar artery in hemifacial spasm and superior cerebellar artery in trigeminal neuralgia. There were good or excellent results in 31 cases(62%) of hemifacial spasm and in 15 cases(65%) or trigeminal neuralgia. The serious complications were not occurred in both diseases except one who died of brainstem infarction.

3 Cases of Coincidental Cerebral Aneurysm with Pituitary Tumor

We report three cases of coincidental cerebral aneurysm with pituitary tumor. In our hospital the incidence of such cases was 4.4% of 68 patients with pituitary tumors from March, 1970 to October, 1990. Cases No. 1 was a 47-year-old female suffering from progressive loss of visual acuity. Preoperative brain C-T scan and angiographies revealed unruptured posterior communicating aneurysm with pituitary tumor. Case No. 2 was a 39-year-old male suffering from headache after head trauma with acromegaly. Preoperative brain C-T scan and angiographies appeared unruptured anterior communicating aneurysm and pituitary tumor. Case No. 3 was a 62-year-old female suffering progressive loss of visual acuity and headache. Left middle cerebral artery aneurysm and pituitary tumor were found by preoperative brain C-T scan and angiographies. All cases were operated by transcranial route and performed tumor removal after primary clipping of aneurysm. Postoperatively remained tumor of all cases was treated by radiosurgery successfully.

A Clinical Study on the Syndrome of Inappropriate Secretion of Antidiuretic Hormone in Patients with Cerebral Injuries

Ninety three patients, who sustained craniocerebral injuries were studied and followed up for detection of syndrome of inappropriate secretion of antidiuretic hormone from their admission to the time of their recovery. Their electrolytes in serum and urine, and fluid balance were examined at frequent intervals. Ten cases have manifested. "The Syndrome of the Inappropriate Secretion of Antidiuretic Hormone"(S.I.S.A.D.H.). 1. For the detection of the presence of S.I.S.A.D.H., body weight, fluid balance, central venous pressure, sodium, potassium, chloride, B.U.N. and creatinine content of the serum as well as sodium, potassium, chloride, B.U.N. and creatinine content of the serum as well as sodium, potassium, chloride and 17-ketesteroid content of 24 hours urine specimen had been measured every 2 or 3 days interval, from their admission. 2. To establish the diagnosis of S.I.S.A.D.H., the following conditions were observed. First, there was no evidence of dehydration, second, the level of the sodium content of the serum was decreased below 125mEq/L and third, the amount of urinary sodium was persistently increased. However the functions of the kidney and adrenal gland were normal. 3. In the cases of S.I.S.A.D.H. among Korean craniocerebral injuries, the amount of sodium excreted in the urine was above 110mEq/L. On the other hand, 27 Koreans without craniocerebral injury or pulmonary complication, who had hospital diet which contained about 15gms. of NaCl, the average value of sodium excreted in the urine was 95mEq/L although there had been great individual differences. 4. Out of 33 patients with brain contusion, 4 manifested S.I.S.A.D.H., 27 with epidural hematoma there were 4 cases, of 15 cases of subdural hematoma, there was one case and also one cases of S.I.S.A.D.H. was found among the 11 cases of compound comminuted depressed fracture of the skull. 5. Among the 93 cases of craniocerebral injuries, 10 of them which is equivalent to 10.8% developed S.I.S.A.D.H. In there cases, improvement of the syndrome was observed in a few days by limitation of daily in take to 600cc. The patient who has shown rather severe hyponatremia, the condition was improved by parenteral injection of 3% saline solution with fluid restriction. 6. Among the cases with S.I.S.A.D.H. it was discovered that 3 of them had infection or complications of the lung. 7. Clinical findings among these patients with S.I.S.A.D.H. were:Three cases had mental disturbance, two with anorexia, one had vomiting and one with convulsions. In all the cases consciousness and muscular activity were somewhat impaired. 8. Aside from the patients with craniocerebral injuries, S.I.S.A.D.H. was observed in one case of aneurysm of the anterior communicating artery.