Surgical Pitfall

Authors report two cases of central neurocytoma with unusual surgical pitfall. The one of these presented with postoperative intraventricular hemorrhage with hydrocephalus. The other case developed motor aphasia and hemiplegia due to brain retration during operation. We describe peripoerative courses of these cases and discuss possible causes of postoperative complications.

Angiographic Analysis of Middle Cerebral Artery Bifurcation Aneurysm

It is generally believed that the important factor in cerebral aneurysmal formation is mural degeneration where sustained hemodynamic stress is maximal. The authors have investigated angiographic findings to evaluate the relationship of aneurysmal formation and anatomical characteristics. Between January 1994 and December 1996, 386 patients with spontaneous subarachnoid haemorrage underwent cerebral angiographic studies. Among these, 83 patients had middle cerebral artery bifurcation aneurysm without intracerebral hematoma in computed tomography and without vasospasm in angiography. These patients were compared with 68 patients with subarachnoid haemorrage who showed normal angiographic finding. Parameters for angiographic measuring were the direction of aneurysm, the length of proximal middle cerebral artery, the ratio of diameter and angles between internal carotid artery, anterior cerebral artery, middle cerebral artery, and superior and inferior trunk of middle cerebral artery. These data were analysed by student t-test, ANOVA, and the results were as follows: 1) Fifty-two cases(63%) of middle cerebral artery bifurcation aneurysm directed laterally. 2) The length of proximal middle cerebral artery was not significantly different from that of control group. 3) Middle cerebral artery bifurcation aneurysms were frequently seen in angiography when angle between anterior cerebral artery and middle cerebral artery was more decreased and angle between superior and inferior trunk of middle cerebral artery was more increased. 4) Middle cerebral artery bifurcation aneurysm revealed to be more inferiorly directed when angle between proximal segment of middle cerebral artery and superior trunk of middle cerebral artery was more increased.

Clinical-Computed Tomographic Correlation of Spontaneous Intraventricular Hemorrhage Patients

Little has been known about clinical outcome in computed tomography(CT) documented intraventricular hemorrhage (IVH), especially in the third and fourth ventricles. A series of 114 patients with IVH in spontaneous intracranial hemorrhage diagnosed by CT, from January 1994 to December 1996, were studied retrospectively. The clinical findings, especially Glasgow Outcome Score(GOS), of these patient were compared with computed tomographic parameters on the Graeb's score, evidence of third ventricular hemorrhage, patency of fourth ventricle and hemorrhagic dilatation of fourth ventricle. The results were as following: 1) The underlying etiologies, in descending order, were hypertensive intracerebral hemorrhage(61.4%), subarachnoid hemorrhage(16.7%), moyamoya disease(13.2%), vascular malformation(5.3%), and unknown cause(3.5%). Moyamoya disease was the most common cause of pure IVH. 2) The bifrontal index (BFI), as an indicator of acute hydrocephalus after IVH, was closely correlated with consciousness level on admission, but not with GOS. 3) Graeb's score was correlated with GOS, but not with the volume of the intracerebral hematoma. 4) The third ventricular hemorrhage was associated with a worse outcome and hemorrhagic dilatation(>10.0mm) was associated with high mortality. 5) The absence of patency and the lateral dilatation(>20.0mm) in the fourth IVH was correlated with outcome. 6) In patients having the hemorrhagic dilatation of the fourth ventricle, Graeb's score and volume of intracerebral hematoma did not affect the outcome. In conclusion, Graeb's score, hemorrhagic dilatation of third ventricle, absence of fourth ventricle patency and lateral dilatation of the fourth ventricular hemorrhage in CT findings are correlated with the outcome in spontaneous IVH.

Simultaneous Bilateral Hypertensive Intracerebral Hemorrhages

The authors describe two cases of simultaneous bilateral hypertensive intracerebral hemorrhage which occurred among 440 patients treated for hypertensive intracerebral hematomas between 1991 and 1996. One patient was a 59-year-old male with bilateral putaminal hemorrhages, and the other was an 82-year-old female with bilateral thalamic hemorrhages; both underwent conservative treatment. The male was discharged with mild facial palsy but the female remained in a vegetative state for over three months. The locations of bilateral hematomas with a chronic history of hypertension suggest that in the pathogenesis of this condition, a subtle degenerative process, caused by hypertension may be active. The literature pertaininig to the pathogenesis of simultaneous multiple intracerebral hematomas is briefly reviewed.

Comparative Study of Microdiscectomy and Automated Percutaneous Discectomy in Lumbar Disc Herniation

Aretrospective study on operative results was carried out in a series of 164 patients who were performed by microdiscectomy and 57 patients by automated percutaneous lumbar discectomy(APLD) for herniated lumbar discs between January 1, 1990 and June 30, 1996. The operative results were analysed, and the correlation between preoperative clinicoradiological factors and postoperative clinical results were statistically assessed. The major results were as follows: 1) Of 164 microdiscectomy cases, 102 were males and 62 were females, mean age was 42.4 years and incidence was the highest in the 5th decade. Among 57 APLD cases, 43 were males and 14 females, mean age 32.2 years, and the highest incidence in the 3rd decade. 2) The preoperative symptoms and signs in microdiscectomy and APLD cases were lumbago(98.2% vs 98.2%), radiating pain(96.3% vs 98.2%), positive straight leg raising test(77.4% vs 70.2%), motor weakness(27.4% vs 17.5%), claudication(13.4% vs 0%) and voiding difficulty(2.4% vs 0%). 3) Number of operated levels were 226 in microdiscectomy and 74 in APLD. The most commonly operated levels in both groups were L4-5. 4) Operative results. (1) The overall success rates by Prolo's scale were 87.1% in microdiscectomy and 80.7% in APLD, respectively. (2) In younger age group(below 30 years) and in non-compensatory group, success rates were significantly higher in microdiscectomy(100%, 89.9% vs 76.7%, 62.5% respectively). (3) As to protrusion and degeneration on MRI, a clinical result, from patients with mild to moderate protrusion and degeneration of discs was significantly better in microdiscectomy group, and that of mild protrusion and degeneration of discs in APLD group was significantly better. (4) The most common cause of failure was inadequately removed disc material in microdiscectomy cases and operated for sequestered discs in APLD cases. There results indicate that there were no differance in overall success rates between microdiscectomy and APLD. But it should be emphasized that clinical results may have been influenced by age, existence of compensation, and the degree of protrusion and degeneration of discs as prognostic factors. The authors believe that if the selection of operative procedure is carefully decided with details of clinical and radiologic findings of the patients, a good outcome can be expected.