Does the Size of Unilateral Decompressive Craniectomy Impact Clinical Outcomes in Patients with Intracranial Mass Effect after Severe Traumatic Brain Injury? / 대한신경손상학회지

Objective@#Decompressive craniectomy (DC) is one of the treatment modalities in severe traumatic brain injury (TBI), however, there was a lack of evidence for optimal craniectomy size. The authors aimed to investigate optimal DC size and analyze clinical outcome according to craniectomy size. @*Methods@#We retrospectively reviewed the medical data of 87 patients with a space occupying lesion following TBI who underwent unilateral DC. Craniectomy size was measured by anterior-posterior (AP) diameter and surface estimate (SE). Mortality, clinical outcome, and complications were collected and analyzed according to craniectomy size. @*Results@#Nineteen patients (21.8%) died and 35 patients (40.2%) had a favorable outcome at last follow-up (a mean duration, 30.3±39.4 months; range, 0.2–132.6 months). Receiver operating curve analyses identified AP diameter more than 12.5 cm (area under the curve [AUC]=0.740; p=0.002) and SE more than 98.0 cm2 (AUC=0.752;p=0.001) as cut-off values for survival, and AP diameter more than 13.4 cm (AUC=0.650; p=0.018) and SE more than 107.3 cm2 (AUC=0.685; p=0.003) for favorable outcome. Large craniectomy resulted in a significantly lower mortality rate and a higher rate of favorable outcome than small craniectomy (p=0.005 and p=0.014, respectively). However, procedure related bleeding occurred more frequently in the large craniectomy group (p=0.044). @*Conclusion@#Unilateral DC size is associated with clinical outcome of patients with a space occupying lesion following severe TBI. Large craniectomy is needed for survival and favorable outcome.

The Effect of Preoperative Antiplatelet Therapy on Hemorrhagic Complications after Decompressive Craniectomy in Patients with Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Traditionally, it is generally recommended that antiplatelet agent should be discontinued before surgery. However, decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) is performed emergently in most cases. Therefore, DC cannot be delayed to the time when the effect of antiplatelet agent on bleeding tendency dissipates. In this study, we evaluated the effect of preinjury antiplatelet therapy on hemorrhagic complications after emergent DC in patients with TBI. METHODS: We retrospectively investigated patients with TBI who underwent emergent DC between 2006 and 2015. The patients were separated into two groups according to the use of preinjury antiplatelet agent: group 1 (patients taking antiplatelet agent) and group 2 (patients not taking antiplatelet agent). The rate of hemorrhagic complications (postoperative epidural or subdural hemorrhage, newly developed, or progression of preexisting contusion or intracerebral hemorrhage within the field of DC) and the rate of reoperation within 7 days after DC were compared between two groups. RESULTS: During the study period, DC was performed in 90 patients. Of them, 19 patients were taking antiplatelet agent before TBI. The rate of hemorrhagic complications was 52.6% (10/19) in group 1 and 46.5% (33/71) in group 2 (p=0.633). The rate of reoperation was 36.8% (7/19) in group 1 and 36.6% (26/71) in group 2 (p=0.986). No statistical difference was found between two groups. CONCLUSION: Preinjury antiplatelet therapy did not influence the rate of hemorrhagic complications and reoperation after DC. Emergent DC in patients with TBI should not be delayed because of preinjury antiplatelet therapy.

Seizures after Spontaneous Intracerebral Hemorrhage

OBJECTIVE: In patients with spontaneous intracerebral hemorrhage (ICH), the risk factors for seizure and the effect of prophylactic anticonvulsants are not well known. This study aimed to determine the risk factor for seizures and the role for prophylactic anticonvulsants after spontaneous ICH. METHODS: Between 2005 and 2010, 263 consecutive patients with spontaneous ICH were retrospectively assessed with a mean follow-up of 19.5 months using medical records, updated clinical information and, when necessary, direct patient contact. The seizures were classified as early (within 1 week of ICH) or late (more than 1 week after ICH). The outcomes were measured with the Glasgow Outcome Scale at discharge and the modified Rankin Scale (mRS) at both 2 weeks and discharge. RESULTS: Twenty-two patients (8.4%; 9 patients with early seizures and 13 patients with late seizures) developed seizures after spontaneous ICH. Out of 263 patients, prophylactic anticonvulsants were administered in 216 patients. The prophylactic anticonvulsants were not associated with a reduced risk of early (p=0.094) or late seizures (p=0.326). Instead, the factors associated with early seizure were cortical involvement (p<0.001) and younger age (60 years or less) (p=0.046). The risk of late seizure was increased by cortical involvement (p<0.001) and communicating hydrocephalus (p=0.004). The prophylactic anticonvulsants were associated with a worse mRS at 2 weeks (p=0.024) and at last follow-up (p=0.034). CONCLUSION: Cortical involvement may be a factor for provoked seizures. Although the incidence of early seizures tended to decrease in patients prescribed prophylactic anticonvulsants, no statistical difference was found.

Occipital Neuralgia as the Only Presenting Symptom of Foramen Magnum Meningioma

BACKGROUND: Occipital neuralgia (ON) is a condition characterized by a paroxysmal stabbing pain in the area of the greater or lesser occipital nerves; it is usually regarded by clinicians as idiopathic. Some have suggested that ON can be induced by trauma or injury of the occipital nerves or their roots, but tumor has rarely been reported as a cause of ON. CASE REPORT: We report herein a case of foramen magnum meningioma in a 55-year-old woman who presented with ON triggered by head motion as the only symptom without any signs of myelopathy. CONCLUSIONS: This case indicates that it is important to consider the underlying causes of ON. Precise neurologic and radiological evaluations such as cervical spine magnetic resonance imaging are needed.

Radiosurgery for Intracranial Disorders

Stereotactic radiosurgery offers a broad spectrum armamentarium for the safe treatment of various lesions within the central nervous system. Radiosurgery uses stereotactic targeting methods to precisely deliver highly focused, large doses of radiation to small intracranial tumors and arteriovenous malformations (AVMs). It is widely used for the treatment of metastatic brain tumors, non-resectable tumors, residual or recurrent benign and malignant tumors as well as for the treatment of AVMs, functional diseases, and pain disorders. Although radiosurgery has the potential to produce complications, the majority of patients experience clinical improvement with less morbidity and mortality than those occur in surgical resection.

Paragangliomas in Cauda Equina Region: Clinicopathoradiologic Findings in Four Cases

OBJECTIVE: Four cases of non-secreting paraganglioma of the cauda equina are present with an emphasis on magnetic resonance (MR) images correlated with pathological features. METHODS: From 1973 to 2001, 703 patients with spinal cord tumors had been treated with surgery at our hospital. Among them, four patients had been diagnosed as paragangliomas, all of which occurred in the cauda equina. We analyzed clinical data, including medical records, radiological, and histopathological findings for four patients. RESULTS: Some findings may help us to differentiate spinal paraganglioma from other spinal tumors. The MR images of the tumor were generally nonspecific. However, tumor margins were hypointense on T2-weighted images and serpiginous flow voids were noted in the tumor. Histopathologically paragangliomas were composed of an organoid or `zellballen' arrangement of polyhedral and argyrophilic cells, circumscribed by a richly vascular stroma. Immunohistochemical examination showed positive reaction to synaptophysin, chromogranin, vimentin, neuron specific enolase, and S100 protein. CONCLUSION: Although it is difficult to make a correct diagnosis as paraganglioma preoperatively for the intradural extramedullary tumors, especially in the cauda equina, paraganglioma should be included in the differential diagnoses.

Brucellar Spondylodiscitis: Case Report and Literature Review

Brucellosis is not a rare disease, although it has not been reported recently in Korea. Spondylitis is the most prevalent and important clinical form of osteoarticular involvement in adults infected by Brucella. Concerning brucellosis, clinical diagnosis of brucellosis starts with a suspicion of the disease. Vertebral body signal changes without destructive changes, marked signal increase in the intervertebral disc on T2-weighted and contrast-enhanced sequences, soft tissue involvement without abscess formation and facet joint involvement, can be distinguishing magnetic resonance imaging(MRI) features of brucellar spondylitis. Tuberculous spondylitis, metastasis, spinal degenerative diseases, and postoperative changes Should be differentiated. We report upon the first case of brucellar spondylodiscitis in a Korean, and present review of the literature.