ICP Trend in Massive ICH Patients After Decompressive Craniectomy / 대한뇌혈관외과학회지

OBJECTIVE: Massive intracerebral hemorrhage (ICH) is devastating neurosurgical disease. Decompression surgery has been performed to manage the uncontrolled increased intracranial pressure and good clinical result has been reported. Authors analyze the ICP trend after the decompression surgery and report the clinical usefulness. METHODS: Thirty patients data with massive ICH were analyzed retrospectively. Surgical indication was constantly followed in these patient ; Glasgowcoma scale score less than 8, midline shift more than 6 mm on brain CT. In all patients ventricular puncture was done before the decompression and monitored the ventricular pressure changes during and after the surgery. RESULTS: In massive ICH patients, the ICP was maintained in physiological range if the hematoma was removed more than 80%. And when we tried additional therapies like hypothermia or coma therapies in another group, the ICP was elevated at the time of the additional therapy. CONCLUSION: From this study, if the ICH removed more than 80% and The ICP was not exceed 20 mmHg during the first post-operation day, the ICP hardly exceed 20 mmHg after than. Authors thought that decompression surgery is not an essential treatment for the massive ICH patient if their hematoma removed enough.

The Post-operative Outcomes of Spinal Epidural and Subdural Hematoma Patients Without Spinal Fracture

OBJECTIVE: Spinal epidural hematoma (SEDH) and spinal subdural hematoma (SSDH) are rare diseases and they may have various causes such as trauma, lumbar puncture, anticoagulant therapy, tumor, blood dyscrasia and vascular malformation. In general, SEDH and SSDH are regarded as surgical emergency. We reviewed our cases with patients with SEDH or SSDH. They were surgically treated or conservatively treated. We examined the relationship between the surgical timing and the neurological outcome. METHODS: Twelve patients (8 cases for SEDH, 4 cases for SSDH) were included in our study. There were seven male and five female patients (mean age: 50.2 yrs, ranged from 18 to 87 years). Ten patients were surgically treated (7 cases for SEDH, 3 cases for SSDH) and two patients were conservatively treated (1 case for SEDH, 1 case for SSDH). We checked preoperative Frankel grade, time interval between onset of symptom and operation and post-operative neurologic change of each case. We investigated relationship between surgical timing and neurological outcome and also relationship between pre-operative Frankel grade and post-operative outcome. RESULTS: In seven cases (70%) of operated cases, there were postoperative improvements in clinical symptoms. Two cases had time interval within 6 hours from onset of symptoms to operations and their neurologic deficits were not improved. There were 2 cases with time interval of more than 6 hours and within 12 hours. And there were 6 cases with time interval over 12 hours. Seven of eight cases with time interval over 6 hours were improved after surgical treatments. CONCLUSION: There are various factors which may affect post-operative neurologic prognosis. Surgical timing is generally regarded as one of the most critical factors. However, in our study, preoperative neurologic status of patients functioned as the most important factor in clinical outcomes. We thought that the initial neurologic status of patient, as well as the surgical timing, may predict the prognosis.

Clear Cell Meningioma of Cauda Equina without Dural Attachment

We report a 17-year-old woman presented with a one-month history of lower back pain and radiating pain in the left leg. Examination revealed Lasegues sign in left leg with mild weakness of the plantar flexion of the left big toe. Magnetic resonance image revealed a well enhanced intradural lesion at the S1-2 level. Following a subtotal laminectomy of S1 and an intradural exposure, the roots of the cauda equina draped the tumor loosely without any attachment to the dura or cauda equina. The tumor was removed en bloc. The patient's recovery was uneventful. Histological examination confirmed a clear cell meningioma.

Current Indication of Extracranial-Intracranial Bypass Surgery / 대한뇌혈관학회지

Since the negative results of the international extracranical-intracranial bypass surgery (EIBS), this procedure is rarely employed in the treatment of patients with ischemic stroke. However, recent evidence suggests that patients with hemodynamic cerebral ischemia (HCI) are at particular risk for subsequent stroke compared to those with similar occlusive lesion but intact cerebrovascular reserve (CVR). Furthermore, several investigators have suggested that EIBS is effective in preventing recurrent ischemic attacks in patients with HCI due to occlusive disease and insufficient collateral blood supply. In addition, EIBS has been frequently used for the patients with moyamoya disease and for the patients who need therapeutic occlusion or sacrifice of a parent vessel during the treatment of complex intra or extracranial aneurysms or cranial base tumors. Based on a review of literature the rationale and the indication of EIBS will be summaried.

Influence of Intra-Operative Regional Cerebral Blood Flow and the Carbon Dioxide Partial Pressure Difference between Arterial and End-Tidal on the Neurologic Outcome

OBJECTIVE: End-tidal partial pressure of carbon dioxide(PETCO2) is often used as an estimate of arterial partial pressure of carbon dioxide(PaCO2), with the understanding that PaCO2 usually exceeds PETCO2. During craniotomies, because hyperventilation is used to therapeutically lower intracranial pressure, the difference between arterial and end-tidal partial pressure of carbon dioxide(P(a-ET)CO2) has therapeutic implications. To determine how much information concerning neurosurgical operation and clinical outcome is provided by the PETCO2, PaCO2 and P(a-ET)CO2 during surgery, we evaluated 81 patients who had neurosurgical operation. METHODS: There were 51 males and 30 females with a mean age of 50.3 years(range 7-85 years). After the induction of general anesthesia, body temperature was maintained in a normothermia, endtidal CO2 was maintained 28-34mmHg and the systolic blood pressure was kept 90-120mmHg. ETCO2, PaCO2 and regional cortical blood flow(rCoBF) were checked at the time of dura closure. Neurologic outcome was evaluated at 8 hours after operation to rule out other factors which may influence on the patient's long-term outcome. Data were collected and compared by student's t-test or chi-square analysis. RESULTS: The PaCO2 was 34.6+/-5.2mmHg(range, 24.9-54.8), PETCO2 was 29.9+/-4.1mmHg(range, 20.0-45.0) and P(a-ET)CO2 was 4.7+/-3.5mmHg(range, -1.1-18.6). The correlation between the PaCO2 and PETCO2 was statistically significant(PETCO2=13.3-0.57xPaCO2). But there was no correlation of rCoBF with PaCO2 and ETCO2. P(a-ET)CO2 values less than 8mmHg were correlated well with good neurologic outcome compared with higher P(a-ET)CO2 patients. PaCO2, rCoBF, mean arterial blood pressure, arterial pH and initial Glasgow coma scale showed statistically significant correlation with neurologic outcome(p<0.05). CONCLUSION: Based on our study, P(a-ET)CO2 value could be used as a good prognostic factor during the neurosurgical operation and anesthesiologist should be tried to decrease this value. And in patients who has a intact brain autoregulation, rCoBF was not influenced by PaCO2 and ETCO2, entirely.

The Effect of Albumin Therapy for Reperfusion Injury Following Transient Focal Cerebral Ischemia in Rats

OBJECTIVE: Albumin is a very useful drug for the improving of cerebral blood volume and the oncotic effect in cerebral ischemia or cerebral vasospasm. The purpose of this study was to examine the morphological and neurological effect of albumin therapy on reperfusion injury following transient focal cerebral ischemia. MATERIALS AND METHODS: 18 Male Sprague-Dawley rats weighing 270-320g were used. The ischemia model was produced by 2-hour period of transient middle cerebral artery occlusion with a poly-L-lysin coated intraluminal suture. The agent(20% human serum albumin[HSA]) or control solution(NaCl 0.9%) was administered intravenously at a dosage of 1% of body weight immediate after reperfusion following a 2-hour period occlusion. Neurological function was evaluated by the postural reflex and the forlimb placing test during occlusion(at 60 min) and daily for 3 days thereafter. The brain was perfusion-fixed, and infarct volumes and brain edema were measured. RESULTS: The HSA significantly improved the neurological score in treated group. The rats of albumin treatment group showed significantly reduced total infarct volume(by 34%) and brain edema(by 81%) compared with saline-treated rats. CONCLUSION: HSA showed a substantial effect on the transient focal cerebral ischemia and reperfusion injury model. These results may indicate its usefulness in treating reperfusion injury patients after thrombolysis treatment for the thrombo-embolic major cerebral artery occlusions.

Intracranial Pressure and Cerebral Blood Flow Monitoring after Bilateral Decompressive Craniectomy in Patients with Acute Massive Brain Swelling

OBJECTIVES: The management of massive brain swelling remains an unsolved problem in neurosurgical field. Despite newly developed medical and pharmacological therapy, the mortality and morbidity due to massive brain swelling remains high. According to many recent reports, surgical decompression with dura expansion is superior to medical management in patients with massive brain swelling. We performed surgical treatment on the first line of treatment, and followed medical management in case with refractory increased intracranial pressure(ICP). To show the quantitative effect of decompressive surgery on the intracranial pressure, we performed ventricular puncture and checked the ventricular ICP continuously during the decompressive surgery and postoperative period. MATERIALS AND METHODS: Fifty-one patients with massive brain swelling, undergoing bilateral decompressive craniectomy with dura expansion, were studied in this study. In all patients, ventricular puncture was performed at Kocher's point on the opposite side of massive brain swelling. The ventricular pressure was monitored continuously, during the bilateral decompression procedures and postoperative period. RESULTS: The initial ventricular ICP were varied from 13mmHg to 112mmHg. Immediately after the bilateral craniectomy, mean ventricular ICP decreased to 53.1+/-15.8% of the initial ICP(ranges from 5mmHg to 87mmHg). Dura opening decreased mean ICP by additional 36.7% and made the ventricular pressure 16.4+/-10.5% of the initial pressure(ranges from 0mmHg to 28mmHg). Postoperatively, ventricular pressure was lowered to 20.2+/-22.6%(ranged from 0mmHg to 62.3mmHg) of the initial ICP. The ventricular ICP value during the first 24 hours after decompressive surgery was found to be an important prognostic factor. If ICP was over 35mmHg, the mortality was 100% instead of additional medical(barbiturate coma therapy and hypothermia) treatments. CONCLUSION: Bilateral decompression with dura expansion is considered an effective therapeutic modality in ICP control. To obtain favorable clinical outcome in patients with massive brain swelling, early decision making on surgical management and proper patient selection are mandatory.

Intradiploic Meningioma of Orbit Minicking Osteoma: A Case Report

Approximately 1% of all the meningiomas arise from the extradural space. Intradiploic meningiomas constitutes only a very small percentage of this figure. Because of its rarity, it is often confused preoperatively with primary bone tumors of the skull. The intradiploic meningioma of the orbital wall may be considered as a subgroup of intradiploic ectopic meningioma. The following is our report of a recently observed case of intradiploic meningioma of the orbital wall without intracranial or intraorbital involvement. The preoperative tentative diagnosis was osteoma of the orbital wall. Nomenclature and histogenesis of this type of meningioma are discussed.

Intradiploic Meningioma of Orbit Minicking Osteoma: A Case Report

Approximately 1% of all the meningiomas arise from the extradural space. Intradiploic meningiomas constitutes only a very small percentage of this figure. Because of its rarity, it is often confused preoperatively with primary bone tumors of the skull. The intradiploic meningioma of the orbital wall may be considered as a subgroup of intradiploic ectopic meningioma. The following is our report of a recently observed case of intradiploic meningioma of the orbital wall without intracranial or intraorbital involvement. The preoperative tentative diagnosis was osteoma of the orbital wall. Nomenclature and histogenesis of this type of meningioma are discussed.

Effect of Mannitol in Acute Cerebral Ischemia

The development of postischemic irreversible brain damage depends upon the length of ischemia and its severity during arterial occlusion, although release of the occlusion always leads to restoration of normal or above noraml cerebral blood flow. The experiment was planned to determine the effects of mannitol on cerebral ischemia on subsequential regional cerebral blood flow(rCBF) and somatosensory evoked potential(SEP) following reperfusion after ischemia and also define the proper time of vascular occlusion without irreversible brain damage. Cerebral ischemia was induced in cat by transorbital occlusion of the left MCA with a Sugita clip for period of 30 minutes and the ischemic brain was reperfused for 180 minutes by removing the clip. Forty adult cats, weighing 2.5 to 4.0 Kg were divided into 5 group ; control(Group I, n=8), permanent MCA occlusion(Group II, n=8), permanent MCA occlusion with mannitol infusion(Group III, n=8), permanent MCA occlusion with mannitol infusion(Group III, n=8), 30 minutes MCA clipping followed by reperfusion(Group IV, n=8) and 30 minutes MCA clipping with mannitol infusion followed by reperfusion groups(Group V, n=8) respectively. The rCBF and SEP measurents were carried out in each animal immediately, after MCA occlusion, at 30 minutes, 60 minutes, 90 minutes, 120 minutes, 150 minutes and 180 minutes followed by perfusion. The rCBF was measured by the hydrogen clearance technique. Mannitol was given in bolus of lg/kg body weight as a 25% solution delivered via the femoral vein. The results were as follows : 1) Gradual elevation of intracranial pressure(ICP) and systolic blood pressure were observed after MCA occlusion. Treatment with mannitol in MCA occlusion animals(Group III & V) decreased ICP immediately after infusion of mannitol. 2) Normal control rCBF(ml/100 g/min) were 51.94+/-5.05 in the left temporal(LT) and 50.80+/-4.87 in the left perietal lobes(LP). 3) The MCA occlusion resulted in a reduction of the blood flows to 72% of the normal control ones(LT : 14.29+/-4.81 ml/100 g/min) at the left temporal area immediately after occlusion and also a reduction of flows to 80.4% of the normal control ones(LT : 10.24+/-3.69 ml/100 g/min) at 180 minutes after occlusion in Group II. 4) In the mannitol-treated group(group IV), reperfused animals, with removal of the clip on MCA had an improved postischemic recovery of blood flow and ipsilateral cerebral blood flows were restored to 42.5% of the normal control ones(LP : 21.2+/-4.13 ml/100 g/min) at 180 minutes after occlusion in Lt. parietal CBF. 5) In the reperfusion group(group IV), reperfused animals, with removal of the clip on MCA had an increase in rCBF to the level of 83.3% of the control value(LT : 45.78+/-6.80 ml/100 g/min) at 180 minutes after reperfusion and also reperfused animals, with treated mannitol had further increase the blood flow up to the level of 92.5% of the control value(LT : 49.04+/-43.6 ml/100 g/min) at 180 minutes after reperfusion. 6) After the MCA occlusion, the SEP was present but markedly altered in shape and particularly the early components of the SEP were suppressed in the ipsilateral occlusion hemisphere. 7) In the mannitol-treated reperfusion group(Group V) the amplitude of the SEP was restored to 80% of control value. The SEP was significantly suppressed if the rCBF fell below 10-14 ml/100 g/min. These result suggest that provided CBF can be restored to above the 40% threshold well within 30 minutes, prevention of ischemic brain damage can be expected and also the mannitol may of benefit in prolongation of the time threshold for the formation of the cerebral ischmia after vessel occlusion.

Histopathological Studies of Chronic Nerve Compression

Recently nerve entrapments or nerve root compressions are common clinical symdromes. However, a clear understanding of both pathophysiological and morphological changes is lacking and it may not be completely established in the experimental model for chronic nerve compression, compared with a surprising review of peripheral nerve exposed to various acute damage. Adult Sprague-Dawley rats weighing 250 to 300g were used as the experimental model to elucidate histopathological changes in chronic nerve compression, which were produced by banding the sciatic nerve(normally 1.2mm in diameter) with the length of 1cm silastic tubings with inner diameter, 0.6mm(Group I), 0.9mm(Group II) and 1.5mm(Group III) in each. Specimens were obtained for light and electron microscopic studies postoperatively at 1 and 3 months following by nerve conduction study. Grossly in group I, the sciatic nerve was compressed to approximately 50% of its normal in cuff area and in thin strand on distal part at 1 month and more progressed at 3 months. The sciatic nerve of group II demonstrated 75% of control and distal part in 50% compression at 1 month, but the nerve seemed not to be affected by tubing. Light microscopic findings revealed Wallerian degeneration and diminished large myelinated fiber particularly in the periphery of nerves with 34% of transverse nueral percentage in group I at postoperative 1 month. Above findings were progressed to epineurial scarring and fibrosis at 3 months. There were marked diminution and deformity in large myelinated fiber in group II, but it was not more severe than the ones of group I. Electron microscopic findings in this group revealed the appearance of small regenerating unit clusters and thinly myelinated fibers. In group III, histological findings were not much different from that of normal nerve. Nerve conduction study revealed the decrease in conduction velocity to mean 10 M/sex in group I at 1 month and no electrical conduction at 3 months. In group II, diminution of conduction velocity in 73% of normal range at 1 month was noted, and 82% at 3 months. These findings explain correspondingly the histopathological changes in part of chronic nerve entrapment syndromes and appeal the need of further investigation in this experimental model.

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.

Post-Shunt Complications in Hydrocephalus:Analysis of 64 Operated Patients

The operative treatment of hydrocephalus has been quite challenging to neurosurgeon, because so many kinds of complications were stirred by the procedure even though the operative technique has been steadily improved. All the more they were hardly managed with ease. In the paper, the authors trix to analyze post-shunt complications of 64 patients seen frm 1980 to 1987, to find out any precipitating factors of the complications and to suggest the way to overcome the factors. The rate of post-shunt complication was 31.5%, and the most common complications were shunt malfunction(14.1%), subdural fluid accumulation(10.9%) and infection(9.4%).

Dissecting Aneurysm of the Intracranial Vertbral Artery: Case Report

A case of dissecting aneurysm of the intracranial vertebral artery in 46-year-old man is reported. Dissecting aneurysm of the vertebral artery associated with SAH is very rare. The characteristic angiographic findings of dissecting aneurysm were: 1) retention of contrast medium in the aneurysm; 2) the presence of double lumina; 3) "String" or "Pearl-string" sign. The therapeutic occlusion of the intracranial vertebral artery was performed successfully.