Clinical Analysis of Spontaneous Subarachnoid Hemorrhagic Patients

From the young neurosurgeon's standpoint, the authors analyzed eighty patients of spontaneous subarachnoid hemorrhage who were admitted to the department of neurosurgery in Taejeon Eulji General hospital from May 1989 to Jan. 1992. The results of analysis were as follow: 1) Of 80 total cases, sixty six were managed from beginning to end, and forty two were operated on for neck clipping. The most common cause of SAH was aneurismal rupture(70%), and the idiopathic comprised 30%. The male versus female ratio was 1:1.7, and the most frequently involved decade was the 7th. 2) Fifty six of total aneurismal cases turned out to be ruptured prior to admission. Common locations of aneurysms were A-com., P-com., and M.C.A. in order of descending frequency. Mirror aneurysms were 4%, and the multiple, 21%. The smallest size of aneurysm that had already ruptured was 3mm in its largest diameter of sac. The giant cases were 2(4%). 3) The most common chief complaint was headache(62.5%), and the most common symptom and/or sign was vomiting(90%). The hypertension accompanied in 29% and the most common neurological sign was nuchal rigidity(71%). 4) The brain CT was performed with the frequency of 1.44 per patient, and it detected SAH in 86%, The most frequently obliterated cistern was basal cistern. In 11 cases(14%), there were no evidence of SAH at all. Contrastingly in 12 cases(15%), aneurismal sacs were directly visualized in post-contrast films. 5) The angiographic study was performed in 59 cases(74%) to detect abnormality in 54 cases all of which turned out to be aneurysms. The mean size of detected 69 sacs was 7.7mm in diameter, and of 26 cases(44%) of normal variation, hypoplasia was the most frequent type. It occurred most frequently at right A1 portion. 6) Of 66 patients who were managed from start to finish, the mortality was 43%, and that of 46 operated cases, 21%. The best operative results were harvested in delayed operation group, the next in intermediate one, and the worst in early one.

A Case of Lipomatous Meningioma

A case of lipomatous meningioma is described. On pre-enhanced CT study the lesion was radioluscent but after enhancement almost half of the lesion was strongly enhanced and the other half was still radioluscent. A review of the literatures showed few similar reported cases.

A Case of Giant Mucocele at Frontal Sinus

Authors report a case of giant mucocele at frontal sinus. It was so large that almost whole portion of ipsilateral frontal lobe was compressed. Nevertheless presenting symptom was exceptionally trivial. With brief review of literatures, we discuss the etiology, pathogenesis, and so on.

A Case of Cerebral Leptomeningeal Melanomatosis Associated with Large Hairly Nevi in Adult

Malignant melanoma is a relatively rare tumor. It represents 1.4-15.7% of all malignant tumors. Melanin-containing cells are normally found in the pia mater of adult human subjects. A wide variety of disorders ranging from a simple increase in normal leptomeningeal pigmentstion to highly malignant melanoma may be encountered. However, whether benign or malignant, primary melanoma of the nervous system are extremely rare. The diagnosis was confirmed by operation and biopsy. This case, which we have experienced recently, is reported with a review of the literatures.

Chronic Extradural Hematoma: Report of Two Cases

Extradural hematomas are usually acute and rapidly progressing and the lucid intervals generally varies from a few moments to several hours. However, not uncommonly, an epidural hematoma may have a lucid interval lasting weeks, months or even years, which may present as a chronic epidural hematoma. Two cases have recently come under our care, demonstrating a paucity of objective neurologic abnormalities, but with extensive compressive extradural hemorrhage, which were found incidentally during the screening examination with the CT scanning.

Clinical Evaluation of the Traumatic Subdural Hygroma

Traumatic subdural hygroma has received little attention in the literature, the authors experienced 17 cases of traumatic subdural hygroma after introduction of Computerized Tomography(CT) since October 1977 in Kyung Hee University Hospital. Characteristics in CT of our experienced traumatic subdural hygromas were almostly bilateral and located on the anterior aspect of the interhemispheric fissure, frontal and frontotemporal side with decrease density as like cerebrospinal fluid. Subdural hygroma easily differentiated with subdural hematoma by use of the CT scan. Subdural hygroma usually respond readily to evacuation of watery yellowish or cerebrospinal fluid-like fluid through simple burr hole, conservative treatment effected only 3 cases out of 17 subdural hygromas.

Clinical Observation on the Pineal Tumors

Tumors of the pineal area are a small proportion of neoplasm of the brain and the majority of these tumor are pathologically classified as pinealoma, Until recently, ventriculography was the most useful diagnostic methods in suspected cases of pineal tumor. However, the diagnosis of posterior third ventricular tumor may be established easily with computed tomography(CT) and its size, shape, component of tumor and the direction of expansion may be visualized. Authors had experienced nine cases of the pineal tumor during about two years from October 1977 to July 1979, which were diagnosed with CT, EMI-5005 in type. We presented a clinical findings for our cases and attempted to assess clinically. The result were summarized as following; 1. The age range was from 5 months after birth to 39 years. Of 9 cases, 6 cases were below age of 20 years and 3 over age of 20 years. All but one were found in males. 2. The duration of symptoms varied from two weeks to eighteen months. The average was approximately 7 months. 3. The symptoms and signs depend on the route taken by the expanding tumors. In our series, headache found in all cases initially, vomiting in 7 cases, and papilledema in 7 cases on admission. Parinaud's sign showed in 5 cases of all patients and papillary change in 3 cases. Of 9 cases, 3 cases had a transient DI symptoms and 2 cases manifested cerebellar dysfunction in corresponding to CT findings. 4. We had performed CT scan on all cases and diagnosed pineal tumor. In pre-enhancement CT, increased density around pineal area showed in 5 cases, isodensity in 2 cases and low density in 2 cases. Among the 9 cases, 5 cases, showed well outlined a lesion by contrast enhancement. All of the cases showed symmetrical dilatation of lateral ventricles with variable degree and distortion and compression defect to the posterior third ventricle disclosed in 6 cases. 5. We had treated 8 cases with V-P shunt following irradiation therapy ranged 3000-600 Rad. in total amount for 5-6 weeks. A case of the pineal tumor had treated with V-P shunt alone because of full coma at admission. We performed biopsy through the infratentorial supracerebellar approach in one case only and confirmed pineocytoma histopathologically. 6. The result of treatment obtained as follows with excellent in 3 cases, good in 4, poor in one, and death in one case. Two cases with exellent result of treatment spend their life happily without any symptoms and follow up CT disclosed no evidence of previous tumor shadow and normal sized ventricles. A poor case developed quadriplegia during irradiation therapy due to tumor seeding to cervical cord probably.

Granular Cell Myoblastoma of the Orbit: A Case Report

Granular cell myoblastoma is a relatively uncommon lesion of debatable history appearing as a small, solitary but occasionally multiple neoplasm and usually benign course. Most granular cell myoblastoma have been observed tongue, skin and subcutaneous tissue and in the breast but only rarely in the orbit and we know of only 12 well-documented orbital myoblastoma at present. We have recently seen a orbital granuloma cell myoblastoma occurring in a 39 year-old woman, the tumor was firmly attached to the muscle cone and caused exophthalmos with exodeviation of the left eye and was totally removed from the transcranial-orbital unroofing procedure.

CT-Guided Biopsy of the Paravertebral Lesion: Case Report

The accuracy of percutaneous needle aspiration and biopsies is related to localization of pathology and of the needle tip. Localization methods of percutaneous needle aspiration currently in use are fluoroscopy, ultrasound and angiography. The authors believe that localization by computed tomography is the most accurate method for performing biopsies. The authors have performed the biopsy of the paravertebral lesion under the CT-scan using EMI-5005 on Aug. 23, 1978, at the Department of Neurosurgery, Kyung Hee University Hospital.

Intracerebral Metastatic Choriocarcinoma Simulating Cerebrovascular Accident

Choriocarcinoma a rare malignant neoplasm of trophoblastic tissue, is characterized by early blood borne metastasis to distant organs such as lung, liver and brain. Involvement of central nervous system by metastatic choriocinoma may be manifested as acute or subacute apoplexy due to vascular invasion with tumor emboli. Therefore the diagnosis of cerebral choriocarcinoma should be suspected in women of child bearing age presenting the signs of acute or subacute intracranial pathology. We present and discuss 2 cases of intracerebral metastatic choriocarcinoma simulating cerebrovascular accident. One case, a 35 years old Korean housewife, was admitted to the department of neurosurgery, Kyung Hee University Hospital, with the chief complaints of headache, vomiting, focal seizure and right sided hemiplegia for 2 weeks duration. She had a history of irregular vaginal bleeding from 3 months before admission. On admission, there were flaccid paralysis of the right extremities with right sided facial palsy, central type and neck stiffness in moderate degree. Gynecologically, round tumor mass about 1.5cm in size at vagina was palpable and urine HCG was positive. Chest X-ray film showed scattered multiple nodular densities at both lung fields. Carotid angiogram showed vascular tumor in the fronto-parietal region. Brain scan revealed increased uptake in the parietal area. She died suddenly 3 days later at home. Another case, 39 years old housewife, was admitted to the hospital with unconscious state. Although she had and operation of hysterectomy 5 months before admission due to massive vaginal bleeding, she was quite well till several hours prior to admission when she complained of headache and vomiting followed by sudden loss of consciousness. Neurologic examination revealed deep comatose state with full dilated and fixed pupil. Chest film showed several nodular densities at both lung fields. Carotid angiogram revealed avascular space occupying lesion at right posterior partietal region. On operation, Dura was tense and scanty subdural hematoma and massive brain swelling were identified and intracerebral hematoma estimated 80cc was evacuated. Atypical trophoblast was found microscopically from biopsy material. She died on the 2nd postoperative day.

Clinical Analysis of Associated Injuries in Head Injuried Patients

The increase in the prevalence of head injury amongst civilian population and the provision of adequate hospital services have become matters of world-wide concern. Many present-day accidents may result in the victims receiving multiple complex injuries beside head injuries and the prognosis may become unfavorable in these patients. Therefore, the neurosurgeon must be alert to the possibility that his patients have injuries to areas outside the brain and be capable of rendering necessary, often lifesaving, treatment during the initial phase of management. We analysed associated injuries in 1523 head injured patients admitted to Department of Neurosurgery, Kyung Hee University Hospital from October, 1971 till September, 1977. The results were as follows : 1) The incidence of associated injury was 23.6% of all 1523 head injured patients. 2) In all head injuries, male outnumbered female by almost 2 to 1 and the ratio was similar in associated injury group(2.4:1). 3) The age distribution of all head injuries was 3rd, 1st and 4th decases in order, but in associated injury group it was 4th, 3rd and 5th decades in order. 4) Common causes of head injuries were traffic accidents(76.6%) and fall(11.6%), but in associated injury group traffic accident was the most frequent cause(90.8%). 5) The incidence of associated injury was higher in relation to the severity of head injury. 6) The sites of associated injuries were distributed as limbs, chest and face in order and the most frequent nature of associated injuries was fracture. 7) Single associated injury was more frequent than multiple, associated injury, about 5 to 1. 8) Overall mortality rate of all head injuries was 9.3% in contrast that of associated injuries was 17.5%. 9) Surgical mortality rate was significantly higher in associated group(40.3%) than nonassociated group(26.1%). 10) In multiple associated injuries the mortality rate was higher(21.3%) than in single associated injury(16.4%). 11) Mortality rate according to associated injured sites was as follows ; 36% for visceral injuries and 34.1% for chest injuries. 12) The mortality rate was highest in serious chest injuries such as hemo and/or pneumothorax and in hypovolemic shock on admission(60%).

Clinical Assessment and Angiographical Analysis on the Cerebral Rete Mirabile

We have experienced 20 cases of the cerebral rete mirabile from 1969 to 1975. All were proved by bilateral carotid angiography, and clinical assessment and angiographical analysis were attempted. The results were summarized as follows: 1. Age distribution was ranged from 5 to 55. The majority of 20 cases were age over 20 as 15 cases who were distributed evenly in each decade and 5 cases were age below 20. 12 cases were male and 8 female. 2. Authors classified the cases as the group of subarachnoid hemorrhage and non-subarachnoid hemorrhage conveniently. All cases of age below 20 comprised in the group of non-subarachnoid hemorrhage while majority of subarachnoid hemorrhage group were age over 20. 3. There were no contributory factors to cerebral rete mirabile with regard to past history and family background. 4. There were considerable differences in the symptoms and signs between the groups of subarachnoid hemorrhage and non-subarachnoid hemorrhage. Clinical manifestations were mainly headache and impairment of consciousness with meningeal sign in the group of subarachnoid hemorrhage. On the other hand, motor disturbance such as hemiparesis or monoparesis was occurred in the majority of non-subarachnoid hemorrhage and the minority showed speech impairment, seizure and choreiform movement. 5. All cases showed the characteristic angiographic findings of cerebral rete mirabile, which are occlusion or stenosis at the supraclinoid portion of internal carotid artery with abnormal fine vascular network around the base of brain and poor or non-visualizing anterior cerebral and middle cerebral arteries. The interesting picture was rete formation of ophthalmic artery in the orbit of 2 cases. There were no abnormal angiographic findings on the vertebral angiogram except retrograde filling to anterior cerebral and middle cerebral arteries through collateral channel from the posterior cerebral artery. 6. The prognosis of the cerebral rete mirabile seem to be favorable with regard to mortality. There were no death in our 20 cases during the period of observation.

Clinical Observation and Assessment on the Treatment of the Hypertensive Intracerebral Hemorrhage

We have experienced 43 cases of the hypertensive intracerebral hemorrhage who were admitted to the Catholic medical Center, Seoul from November 1969 to February 1973. All these cases were diagnosed by clinical findings and cerebral angiography and assessed the prognostic factors on the result of treatment. The results of the analysis were summarized as follows: 1. Age distribution was ranged from 26 to 67, and 79 per cent of them were in fourth and fifth decade. The ratio of male to female was about 3 to 1. 2. The most frequent site of the hypertensive intracerebral hemorrhage was in the basal ganglia in 76.7 per cent, 27.2 percent of them in the thalamic hemorrhage and 39.5 per cent in the external capsular hemorrhage. The remainder were 9.3 per cent in the subcortical hemorrhage, 11.6 per cent in the pontine hemorrhage and 2.4 per cent in the cerebellar hemorrhage. 3. In the past history, hypertension was noted in 88.3 per cent of them. Simple chest X-ray showed cardiomegaly in 58.1 per cent and left ventricular hypertrophy was found in 41.1 per cent on E.C.G. findings. 4. All of 43 cases had unconscious state with various level at the onset of illness. For 43 cases, 46.5 per cent was in transient impairment of consciousness or drowsy state and 53.6 per cent in stuporous or comatous state. Headache was experienced in 81.3 per cent and 58.1 per cent of them was associated with vomiting. 5. During hospital course improvement of conscious level to alert state was found in 25.6 per cent and drowsy state in 18.6 per cent of all cases. On the aspect of the site of hemorrhage, 81.3 % of the thalamic hemorrhage and all pontine hemmorhage cases had shown stuporous or comatous conscious level. On the other hand, 70.6 per cent of the external capsular hemorrhage and all of the subcortical hemorrhage was found in alert or drowsy state. 6. On the neurological findings, anisocoria was noted in 18.8 per cent, miotic pupil in 20.7 per cent of all cases and pin-point pupils in pontine hemorrhage exclusively. Normal extraocular movement was noted in 60.4 per cent, conjugate deviation in 9.7 per cent of all cases. Inward and downward deviation of the eye-ball was found in 50 per cent of the thalamic hemorrhage. Dissociated eye-ball movement and occular bobbing were noted in the pontine hemorrhage. Motor impairment developed in all cases except one of the subcortical hemorrhage. Hemiplegia or hemiparesis was noted in 86.1 per cent of all cases and quadriplegia in 60 per cent of the pontine hemorrhage. Speech disturbance was noted in 27.9 per cent of all cases. 7. In the hypertensive intracerebral hemorrhage 24 cases were treated surgically and 19 cases were managed conservatively. Mortality and disability rate increased steadily with deepening of level of consciousness. The result of surgical treatment was better in alert and drowsy patients. 8. In addition to conscious level, the site of intracerebral hemorrhage did strongly influence to surgical outcome. Surgical treatment of 9 cases of thalamic hemorrhage resulted 8 death and one with severe disability. On the other hand, of 17 patients of the external capsular hemorrhage 12 were treated surgically and 8 cases showed improvement. 5 patients of pontine hemorrhage was managed conservatively but resulted fatal outcome in 2 cases. 9. There is a conflict of opinion as to the optimal time to operate the hypertensive intracerebral hemorrhage. Early surgery after ictus probably increase the mortality rate. Of 10 cases who were treated with surgical intervention within 48 hours following ictus, seven cases were succumbed. On the contrary, 0f 12 cases who had received operative treatment after 72 hours following ictus, 9 showed improvement and 3 death. 10. The amount of the hematoma seem to somewhat influence to surgical result.

The Diseases Showing the Abnormal Cerebrovascular Network at the Base of the Brain with Occlusion of the Internal Carotid Arteries

Japanese neurosurgeons have recently reported number of disorder having typical angiographic findings, which showed abnormal cerebrovascular network at the base of the brain related with the occlusion of the internal carotid arteries in Japanese race. Since the authors have observed five cases of the similar vascular abnormalities in Korea by cerebral angiography from 1969 to 1971, the clinical findings and angiographic features of these cases were presented. The results were summarized as follows; 1. Of the 5 patients, 4 cases were over 20 years of age and one 5-year-old child. 4 cases were male and one female. 2. There were considerable differences in the initial symptoms of these patients. Authors classified these as the group of subarachnoidal hemorrhage and non-subarachnoidal hemorrhage. The former was 3 cases and later 2. The most frequent clinical manifestations in the hemorrhagic group was headache, impairment of consciousness and sings of meningeal irritation, while hemiparesis and speech disturbance was mainly seen in the nonhemorrhagic group. Similar clinical pictures were reported in Japanese cases. 3. Characteristic cerebral angiographic findings of these cases were; 1) Narrowing of the cervical portion of both internal carotid arteries. 2) Occlusion or stenosis of bilateral internal carotid arteries at the supraclinoid portion. 3) Abnormal vascular network at the base of the brain around the occlusive area. 4) Anterior and middle cerebral arteries were no visualized in all cases and superficial temporal arteries or ophthaemic artery was prominent in a few cases. The etiological possibility of these disorder, radiological features and symptomatology were discussed.