Spinal Extradural Arachnoid Cyst: A Case Report

Spinal arachnoid cyst is a rare cause of myelopathy secondary to spinal cord compression. We report a case presenting extradural arachnoid cyst of probable traumatic origin leading to irreversible neurological deficits including paraparesis and neurogenic bladder. The patient presented progressive paraparesis and voiding difficulty. Magnetic resonance imaging (MRI) of the spine revealed long segmental cystic lesion of cerebrospinal fluid (CSF) signal intensity at dorsal extramedullary space of T11 to L3 level suggesting arachnoid cyst with diffuse cord compression. On the operation, an ovoid shaped dural defect was identified at right sided dorsolateral aspect of the dura mater between nerve root sleeves at T11 and T12 level. The patient was treated by microsurgical repair of the dural defect and intraoperative findings revealed no further leakage of CSF. The neurological status of the patient was stationary on follow-up examination postoperatively. We postulate that delayed-onset post-traumatic extradural arachnoid cyst should be taken into consideration on the differential diagnosis of intrapinal cysts.

Factors Affecting Postoperative Recurrence of Chronic Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Considerable recurrence rates have been reported for chronic subdural hematoma (CSDH) following surgical evacuation. The aim of this study was to determine the independent factors and features of CSDH that are associated with postoperative recurrence. METHODS: Retrospective analysis of 136 consecutive patients diagnosed with CSDH who were surgically treated from September 2005 to December 2011 was performed. The demographic data, clinical characteristics, radiologic features were analyzed to clarify the correlation between independent variables and postoperative recurrence of CSDH. RESULTS: CSDH was resolved within 1 month following surgery in 51 patients (37.5%), between 1 to 3 months in 59 patients (43.4%), and past 3 months in 14 patients (10.3%). A total of 12 patients (8.8%) experienced recurrence of CSDH, and reoperation was performed in all recurred cases. The average duration between initial surgery and reoperation was 20.1 days. Delayed resolution and recurrence were more commonly presented in bilateral CSDH, but this data was not statistically significant. Large hematomas with maximum thickness over 20 mm were significantly correlated with higher recurrence rates of CSDH (p=0.032). In addition, the incidence of recurrence was significantly higher in the cases with high-density and mixed-density hematomas according to brain computed tomography (CT) findings (p=0.0026). CONCLUSION: The thickness and density of the hematoma is significantly correlated with higher recurrence rates of CSDH. Discerning these risk factors could be beneficial in predicting the postoperative recurrence of CSDH.

Symptomatic Tarlov Cyst Following Spontaneous Subarachnoid Hemorrhage

Most of Tarlov or perineurial cysts remain asymptomatic throughout the patient's life. The pathogenesis is still unclear. Hemorrhage has been suggested as one of the possible causes and trauma with resultant hemorrhage into subarachnoid space has been suggested as an origin of these cysts. However, Tarlov cysts related to spontaneous subarachnoid hemorrhage has not been reported. The authors report a case of Tarlov cyst which was symptomatic following spontaneous subarachnoid hemorrhage.

Myoclonus Induced by the Use of Gabapentin

Myoclonus is a rare side effect of gabapentin (GBP) and has been reported in patients with preexisting myoclonus, mental retardation, chronic static encephalopathy, diffuse brain damage, impaired renal function, or end stage renal disease. We report a case of myoclonus in a patient with normal renal function and no previous disorders. A 69-year-old female underwent diskectomy and foraminotomy at the left L4-L5 level. Postoperatively,she complained of paresthesia in her left leg, which was thought to be due to root manipulation during surgery. To relieve the paresthesia, she was given tramadol, an oral opioid agonist, and GBP. One week after GBP was increased to 900 mg per day, myoclonus developed, which severely impaired her normal activity. Her symptoms resolved 2 days after discontinuation of GBP. The coadministration of tramadol and GBP may mutually enhance the myoclonic potential of each drug. The causal relationship between GBP and myoclonus was suggested by cessation of myoclonus after GBP discontinuation despite continued therapy with tramadol.

Craniovertebral Junction Tuberculosis with Atlantoaxial Dislocation: A Case Report and Review of the Literature

Craniovertebral junction (CVJ) tuberculosis is a rare disease, potentially causing severe instability and neurological deficits. The authors present a case of CVJ tuberculosis with atlantoaxial dislocation and retropharyngeal abscess in a 28-year-old man with neck pain and quadriparesis. Radiological evaluations showed a widespread extradural lesion around the clivus, C1, and C2. Two stage operations with transoral decompression and posterior occipitocervical fusion were performed. The pathological findings confirmed the diagnosis of tuberculosis. Treatment options in CVJ tuberculosis are controversial without well-defined guidelines. But radical operation (anterior decompression and posterior fusion and fixation) is necessary in patient with neurological deficit due to cord compression, extensive bone destruction, and instability or dislocation. The diagnosis and treatment options are discussed.

Pleomorphic Xanthoastrocytoma with an Intracystic Hemorrhage: A Case Report and Literature Review

Pleomorphic xanthoastrocytoma (PXA) has been considered as a low grade tumor of adolescents and young adults. Although this tumor often shows cystic component, the hemorrhage within the cyst is extremely rare. The authors report a rare case of cystic PXA with a hemorrhage within the cyst and the mural nodule in the left frontal lobe. A 64-year-old male presented with a week history of the right side hemiparesis. After gross total resection of the tumor, the patient was fully recovered from neurological deficit. It is suggested that this typically benign tumor could be presented with hemorrhage, causing a rapid neurological deterioration. Prompt surgical intervention, especially total removal of the tumor can provide an excellent functional recovery.

Immediate Postoperative Epidural Hematomas Adjacent to the Craniotomy Site

OBJECTIVE: The authors present eight cases of immediate post-operative epidural hematomas(EDHs) adjacent to the craniotomy site, describe clinical details of them, and discuss their pathogenesis. METHODS: Medical records of eight cases were retrospectively reviewed and their clinical data, operation records, and radiological findings analyzed. Any risk factors of the EDHs were searched. RESULTS: In 5 of 8 cases, adjacent EDHs developed after craniotomies for the surgical removal of brain tumors. Three cases of adjacent EDHs developed after a pterional approach and neck clipping of a ruptured anterior communicating artery aneurysm, a ventriculoperitoneal shunt, and a craniotomy for a post-traumatic EDH, respectively. In all eight cases, brain computed tomography (CT) scans checked immediately or a few hours after the surgery, revealed large EDHs adjacent to the previous craniotomy site, but there was no EDH beneath the previous craniotomy flap. After emergent surgical removal of the EDHs, 7 cases demonstrated good clinical outcomes, with one case yielding a poor result. CONCLUSION: Rapid drainage of a large volume of cerebrospinal fluid or intra-operative severe brain collapse may separate the dura from the calvarium and cause postoperative EDH adjacent to the previous craniotomy site. A high-pressure suction drain left in the epidural space may contribute to the pathogenesis. After the craniotomy for brain tumors or intracranial aneurysms, when remarkable brain collapse occurs, an immediate postoperative brain CT is mandatory to detect and adequately manage such unexpected events as adjacent EDHs.

Ischemic Optic Neuropathy in Ruptured Anterior Communicating Artery Aneurysm

A case of persistent monocular blindness probably resulting from the post-subarachnoid hemorrhage ischemic injury of the posterior optic nerve is reported. On admission, the patient was assessed as Hunt-Hess classification grade III, Fisher group IV. Uneventful surgery for clipping the neck of her small saccular anterior communicating artery aneurysm was performed on second hospital day via left pterional approach. She complained of total blindness of her left eye as she recovered from drowsy consciousness to be lethargic on first post-operative day; her left eye showed sluggish direct pupillary light reflex and normal optic fundoscopy. Her ensuing hospital course had been complicated by symptomatic vasospasm, bleeding tendency, subacute epidural hematoma, and hydrocephalus. She was independent on discharge. Ophthalmologic evaluation on 60th post-subarachnoid hemorrhage day showed total blindness and optic disc atrophy of her left eye. Probable ischemic optic neuropathy is another cause of the post-subarachnoid hemorrhage visual disturbance, especially after the rupture of anterior communicating artery aneurysms.

Hemorrhage in the Cisterna Magna after Acupuncture

Acupuncture is one of the most popular complimentary therapies these days not only in Asia, but also in USA and Europe. Acupuncture is generally regarded as a safe procedure in the general public. However, acupuncture is not free of risk; complications of acupuncture have been repeatedly reported in the medical literatures. The authors report a rare case of hemorrhage in the cisterna magna after acupuncture. Acute frontal headache, dizziness, neck pain, neck stiffness, and paresthesia or tingling discomfort at arms and legs developed immediately after an acupuncture treatment that had been performed to treat her chronic posterior neck pain. Computerized tomography scans and magnetic resonance images(MRI) showed a 1.2x0.8cm-sized high density and high signal mass within the cisterna magna. It is probable that the acupuncture needle had been inserted deep enough to enter the cisterna magna and provoked a small hemorrhage in the cistern. She gradually recovered from the symptoms. Physicians and acupuncture therapists should be aware of the adverse events associated with acupuncture.

Subarachnoid Hemorrhage Due to a Ruptured Middle Cerebral Artery Bifurcation Aneurysm Superimposed by an Idiopathic Intracerebral Hematoma

A rare case of idiopathic subcortical intracerebral hematoma superimposed on the subarachnoid hemorrhage due to the rupture of an ipsilateral middle cerebral artery bifurcation aneurysm is reported and pertinent literatures are reviewed.

Clinical Features of Posterior Inferior Cerebella Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The purpose of this study is to characterize the distribution of posterior inferior cerebellar artery (PICA) aneurysm, the computed tomography (CT) patterns of hemorrhage, and the clinical presentation thereof. METHODS: We reviewed the records 1050 patients with intracranial aneurysms treated at our institution between January 1999 and November 2003. Upon clinical review of radiological data and postoperative reports, we found 20 patients with PICA aneurysms. RESULTS: The incidence of PICA aneurysms was 1.9% of all intracranial aneurysms. The location of PICA aneurysms varied. Of the 20 PICA aneurysm cases, ruptured aneurysms accounted for 18 cases. Review of only these ruptured cases resulted in the following observations : Subarachnoid hemorrhage (SAH) was presented in 94.4% of cases. Isolated infratentorial and supratentorial SAH was present in 7 cases (38.9%) and 2 cases (11.1%), respectively. SAH involving the infratentorial and supratentorial region was present in 8 cases (44.5%). Intraventricular hemorrhage (IVH) with or without associated SAH was seen in 77.8% of cases, whereas isolated IVH was seen in only one case. Perimedullary large hematoma was present in 50% of cases, while the hematoma was consistently thicker on the aneurysm side. Hydrochephalus was present in 16 cases (88.9%). Although patients' postoperative outcomes were excellent or good in 70% of the above cases, initial angiograms failed to reveal ruptured PICA aneurysms in 3 cases. CONCLUSION: PICA aneurysm is rare in most aneurysm cases. However, awareness of a possibility of PICA aneurysm and its features are still nonetheless important. IVH and hydrocephalus are commonly presented with a ruptured PICA aneurysm and complete vertebral angiography is a required to recognize this condition.

True Posterior Communicating Artery Aneurysm / 대한뇌혈관외과학회지

A case with a true posterior communicating artery aneurysm is reported, who had been managed by early surgical neck clipping and post-operative intensive cares for numerous complications. The small saccular aneurysm was located at the proximal posterior communicating artery and directed superiorly. A lacunar infarct developed at right anterior thalamus post-operatively, which had resulted probably from the occlusion of a fine posterior communicating arterial perforator. Aneurysms of the posterior communicating artery itself are saccular or fusiform. Great cares should be taken in surgical aneurysmal neck clipping to avoid any injury of the perforators and the oculomotor nerve;trapping of the posterior communicating artery to treat fusiform or wide-necked aneurysms will result in unpredictable outcomes.

Long-term Results of Surgical Treatment of Craniopharyngioma: Experience with 100 Adult Patients

OBJECTIVES: The authors present a retrospective analysis of 100 consecutive adult patients harboring craniopharyngiomas who underwent microsurgical resection between 1981 and 1999 to assess the long-term outcome of surgical treatment and to determine the most optimal management strategy. METHODS: The extent of surgical removal was divided into four categories; GTR(gross total removal), RSTR(radical subtotal removal), STR(subtotal removal),and PR(partial removal). The median follow-up period was 50 months(4-198). CT scan and/or MR imaging and hormonal status were evaluated to the last follow-up. RESULTS: Visual disturbance was the most common presentation, which was improved in 42 cases and aggravated in 19 cases following the operation. Hypopituitarism was detected in 56 patients preoperatively, 82 during the immediate postoperative period, and 76 at the last follow-up. Improvement of pituitary function was not observed in any of these patients. Twenty of 100 patients showed recurrence at the mean of 27 months(3 to 196). The median progression-free survival(PFS) time of all patients was 145 months and 5-year PFS rate was 74%. Five-year PFS rate of GTR or RSTR group(71%) was significantly higher than that of STR or PR group(30%)(p=0.01). Postoperative radiation therapy significantly prolonged the PFS from 94 months in non-radiation group to 182 months(p=0.002). However, there was no statistical difference in number of patients who required hormonal replacement therapy between radiation and non-radiation group. CONCLUSION: Visual disturbance can be improved by early diagnosis and surgical decompression. GTR or RSTR in selected patients is considered a proper surgical strategy. Post-operative radiation therapy for residual tumors must be considered, although the ideal timing of radiation therapy is to be determined.

Two Cases of Intraventricular Arachnoid Cysts: Case Report

Intraventricular arachnoid cyst has been rarely reported. Here we present two cases of symptomatic intraventricular arachnoid cysts in the fourth ventricle and right lateral ventricle. The first patient was a 38-year-old female who complained of headache and left facial hypesthesia. Computed tomography and MR scan revealed large cystic lesion in the fourth ventricle. After cyst wall removal, facial hypesthesia disappeared immediately and headache improved slowly. The second patient was a 9-year-old girl who complained of headache, vomiting and paresthesia in her right low extremity. Cystic lesion in the right lateral ventricle was detected in the CT and MR scan. The symptoms improved after cyst wall removal. Surgical findings of these two cases showed that the cyst walls were attached firmly to the choroid plexus. Symptomatic intraventricular arachnoid cyst must be treated appropriately and we recommend complete cyst wall removal.