Clinical and Radiologic Outcomes of Single Burr Hole Drainage and Minicraniotomy in the Treatment of Inhomogeneous Chronic Subdural Hematoma: A Retrospective Study / 대한신경손상학회지

Objective@#The optimal treatment for inhomogeneous chronic subdural hematoma (CSH) remains unclear. This study thus aimed to compare single burr hole drainage with minicraniotomy in the treatment of inhomogeneous CSH, including complication and recurrence rates. @*Methods@#The clinical and radiologic data of 240 patients with inhomogeneous CSH who underwent surgery between January 2005 and January 2021 were retrieved. A total of 111 patients were included in this study. Clinical and radiological outcomes were compared between the groups undergoing different surgery types. @*Results@#A total of 102 (91.8%) patients showed clinical improvement after surgery; 81 (93.1%) and 21 (87.5%) patients showed improvements in clinical symptoms in the single burr hole and minicraniotomy groups, respectively. A total of 102 (91.9%) patients showed favorable radiological findings after the surgery, including inhomogeneous CSH disappearance in 64 (73.6%) burr hole and 13 (54.2%) minicraniotomy patients, and inhomogeneous CSH improvement in 17 (19.5%) burr hole and 8 (33.3%) minicraniotomy patients. There were no significant differences in the patient characteristics or surgical outcomes between the groups. @*Conclusion@#Single burr hole drainage showed a slightly better improvement in clinical and radiologic findings and lower recurrence and complication rates than minicraniotomy. There were no statistically significant differences between the two groups.

Clinical Feature and Outcomes of Secondary Hydrocephalus Caused by Head Trauma / 대한신경손상학회지

OBJECTIVE: Post-traumatic hydrocephalus (PTH) is a frequent and serious complication following brain injury. The incidence of PTH varies greatly among studies. The purpose of this study was to investigate the incidence and treatment of PTH in patients with head trauma. METHODS: We examined 956 patients with head trauma who visited our center from January 2012 to December 2015. The hydrocephalus diagnosis was based on radiologic findings and clinical features, and patients were classified into the mild (Group 1, Glasgow Coma Scale score [GCS] 13–15), moderate (Group 2, GCS 9–12), or severe (Group 3, GCS 3–8) brain injury group according to their GCS at admission. To compare these groups, we used age, gender, radiologic findings, PTH developmental period, and postoperative results (Glasgow Outcome Scale). RESULTS: Of the 956 patients, 24 (2.5%) developed PTH. PTH occurred in 11 (1.4%), 3 (5.6%), and 10 (7.0%) patients in Groups 1, 2, and 3, respectively. Of the 24 patients with PTH, 22 (91.7%) developed PTH within 12 weeks post-trauma; the higher the GCS, the later the onset, and the lower the GCS, the earlier the onset (p=0.019). Twenty-one patients underwent ventriculoperitoneal shunting, and 13 had improved symptoms. CONCLUSION: The incidence of PTH cannot be ignored. The possibility of PTH needs to be considered in patients with head trauma and appropriate follow-up should be undertaken. PTH is a treatable complication and patients' quality of life and neurological status can be improved if the appropriate treatment is selected and applied.

Cutaneous Anaplastic Large T-Cell Lymphoma with Invasion of the Central Nervous System: A Case Report

Anaplastic large T-cell lymphoma (ALCL) encompasses different clinical entities that can be aggressive or localized. Scalp anaplastic lymphoma kinase (ALK)-negative ALCL is considered a localized lymphoma, and usually extends to the regional lymph nodes; intracranial invasion is rare. A 74-year-old woman was diagnosed with scalp ALK-negative ALCL, but did not exhibit invasion of the lymph nodes. Computed tomography and magnetic resonance imaging revealed intracranial masses with bony erosions. We treated the patient using CHOP chemotherapy and achieved short-term regression of the scalp and intracranial lesions. However, the patients ultimately died of pneumonia during the pancytopenic period. Therefore, caution must be exercised when treating scalp ALK-negative ALCL with intracranial invasion.

Posterior Reversible Encephalopathy Syndrome after Head Trauma Surgery in Pediatric Patient without Any Underlying Disease / 대한신경손상학회지

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by signs of posterior cerebral edema upon radiographic examination. A 16-year-old girl was involved in motorcycle accident and depressed frontal fracture was presented. She had generalized seizures 3 days after dural repair and fracture reduction. Signal changes was noted on both parietal lobes in the magnetic resonance images and it was completely resolved in 3 months follow-up. We would like to present the case that demonstrated PRES related hypertension after head trauma surgery for cerebrospinal fluid leakage in pediatric patient without any underlying disease.

Stand-Alone Cages for Anterior Cervical Fusion: Are There No Problems?

OBJECTIVE: There are complications in stand-alone cage assisted anterior cervical discectomy and fusion (ACDF), such as cage subsidence and kyphosis. Here we report our clinical result on ACDF, comparing with stand-alone cages and with cervical plate system for degenerative cervical spine diseases. METHODS: Patients with degenerative cervical disease who were diagnosed and treated in Konyang University Hospital between January 2004 and December 2014 were included in this study. Patients who had operation in single level ACDF were selected. Patients scored the degree of pain using visual analog scale before and after the surgery. Subsidence was defined as ≥3-mm decrease of the segmental height, and cervical kyphosis was defined as progression of ≥5° at 12 months after postoperative follow-up compared to that measured at the immediate postoperative period. RESULTS: A total of 81 patients were enrolled for this study. Forty-five patients were included in a cervical plate group and the others were in stand-alone cage group. There was no statistical difference in pain score between the 2 groups. Segmental subsidence was observed in 7 patients (15.6%) in plate-assisted cervical fusion group, and 13 patients (36.1%) in stand-alone cage group. Segmental kyphosis was observed in 4 patients (8.9%) in plate-assisted cervical fusion group, and 10 patients (27.8%) in stand-alone cage group. There was statistical difference between the 2 groups. CONCLUSION: There was no difference in pain between 2 groups. But stand-alone case group showed higher incidence rate than plate-assisted cervical fusion group in segmental subsidence and cervical kyphosis. When designing cervical fusion, more attention should be given selecting the surgical technique.

A Role of Serum-Based Neuronal and Glial Markers as Potential Predictors for Distinguishing Severity and Related Outcomes in Traumatic Brain Injury

OBJECTIVE: Optimal treatment decision and estimation of the prognosis in traumatic brain injury (TBI) is currently based on demographic and clinical predictors. But sometimes, there are limitations in these factors. In this study, we analyzed three central nervous system biomarkers in TBI patients, will discuss the roles and clinical applications of biomarkers in TBI. METHODS: From July on 2013 to August on 2014, a total of 45 patients were included. The serum was obtained at the time of hospital admission, and biomarkers were extracted with centrifugal process. It was analyzed for the level of S-100 beta (S100B), glial fibrillary acidic protein (GFAP), and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1). RESULTS: This study included 33 males and 12 females with a mean age of 58.5 (19-84) years. TBI patients were classified into two groups. Group A was severe TBI with Glasgow Coma Scale (GCS) score 3-5 and Group B was mild TBI with GCS score 13-15. The median serum concentration of S100B, GFAP, and UCH-L1 in severe TBI were raised 5.1 fold, 5.5 fold, and 439.1 fold compared to mild injury, respectively. The serum levels of these markers correlated significantly with the injury severity and clinical outcome (p<0.001). Increased level of markers was strongly predicted poor outcomes. CONCLUSION: S100B, GFAP, and UCH-L1 serum level of were significantly increased in TBI according to severity and associated clinical outcomes. Biomarkers have potential utility as diagnostic, prognostic, and therapeutic adjuncts in the setting of TBI.

Angiographically Progressive Change of Traumatic Pseudoaneurysm Arising from the Middle Meningeal Artery

Traumatic pseudoaneurysms of the middle meningeal artery (MMA) are rare phenomenon, which are usually associated with head trauma such as an underlying skull fracture. They were usually known to cause acute or delayed epidural hematomas but can be associated with subdural, subarachnoid, or even intracerebral hemorrhage. Sometimes, a high mortality rate was reported in these circumferences. But the natural course of these pseudoaneurysms is not well recognized. The indication and guideline of treatment for pseudoaneurysm are also unclear. This report describes a rare case of angiographically progressive change of traumatic pseudoaneurysm of the middle meningeal artery for one week, which was treated with endovascular embolization.

Ganglioglioma in Brainstem : Case Report and a Review of Literatures

Ganglioglioma is an infrequent tumor of the central nervous system (CNS); mostly supratentorial region. But, they can occur anywhere in the central nervous system such as brainstem, cerebellopontine angle (CPA), thalamus, optic nerve and spinal cord. Although it occurs rarely, ganglioglioma should be included in the differential diagnosis of a posterior fossa mass because early recognition is important for treatment and patient counseling.

Cervical Cord Decompression Using Extended Anterior Cervical Foraminotomy Technique

OBJECTIVE: At present, gold-standard technique of cervical cord decompression is surgical decompression and fusion. But, many complications related cervical fusion have been reported. We adopted an extended anterior cervical foraminotomy (EACF) technique to decompress the anterolateral portion of cervical cord and report clinical results and effectiveness of this procedure. METHODS: Fifty-three patients were operated consecutively using EACF from 2008 to 2013. All of them were operated by a single surgeon via the unilateral approach. Twenty-two patients who exhibited radicular and/or myelopathic symptoms were enrolled in this study. All of them showed cervical cord compression in their preoperative magnetic resonance scan images. RESULTS: In surgical outcomes, 14 patients (64%) were classified as excellent and six (27%), as good. The mean difference of cervical cord anterior-posterior diameter after surgery was 0.92 mm (p<0.01) and transverse area was 9.77 mm2 (p<0.01). The dynamic radiological study showed that the average post-operative translation (retrolisthesis) was 0.36 mm and the disc height loss at the operated level was 0.81 mm. The change in the Cobb angle decreased to 3.46, and showed slight kyphosis. The average vertebral body resection rate was 11.47%. No procedure-related complications occurred. Only one patient who had two-level decompression needed anterior fusion at one level as a secondary surgery due to postoperative instability. CONCLUSIONS: Cervical cord decompression was successfully performed using EACF technique. This procedure will be an alternative surgical option for treating cord compressing lesions. Long-term follow-up and a further study in larger series will be needed.

Results of Combined 360-Degree Fusion versus Posterior Fixation Alone for Thoracolumbar Burst Fractures / 대한신경손상학회지

OBJECTIVES: To identify the better option of treatment, we compared the surgical results and efficacy of combined anterior-posterior approach versus posterior fixation alone. METHODS: During a 10 years period from 2002 to 2011, 111 patients with thoracolumbar burst fracture was surgically managed at our institute. 25 patients were managed by a combined anterior-posterior surgery and 86 patients were managed by posterior fusion alone. Radiographs were repeated at 3, 6, 12 and 24 months after operation. Radiologic outcome was evaluated by measuring Kyphotic angulation and vertebral height and the clinical outcome was evaluated by visual analogue scale (VAS) score comparison. RESULTS: The average Cobb's angle difference between immediate post operative and last follow up was 15.0degrees in combined 360-degree fusion group and 7.5degrees in posterior surgery alone group. A corrections of vertebral body height between immediate post operative and last follow up was 2.27 mm in 360-degree fusion group while 0.59 mm in posterior fixation group. The VAS score decreased from 8.4 to 2.2 after post operation 24 months in 360-degree fusion group and the posterior surgery alone group decreased 9.3 to 6.2 after post operation 24 months. CONCLUSION: The combined anterior-posterior approach resulted in less deterioration of the kyphotic angle postoperatively and improvement of vertebral height (sagittal index). Clinical outcome was also better in the combined group.

Late Spontaneous Recanalization of Chronic Middle Cerebral Artery Occlusion / 신경중재치료의학

Early spontaneous recanalization of the middle cerebral artery in acute ischemic phase artery is not uncommon, whereas the late spontaneous recanalization of chronic occluded artery is a very rare phenomenon and exact incidence and the timing of this event have not been quantified. We present a case in which late spontaneous recanalization of long-lasting middle cerebral artery occlusion occurred in the absence of surgical, endovascular and thrombolytic treatments.

Dissecting Aneurysm Associated with a Double Origin of the Posterior Inferior Cerebellar Artery Causing Subarachnoid Hemorrhage

Two cases of the posterior fossa dissecting aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA) causing subarachnoid hemorrhage are presented. After observing a relationship between the aneurysm and DOPICA on a three dimensional rotational angiogram (3DRA), the dissecting aneurysms were successfully obliterated by surgical trapping and endovascular internal trapping, respectively. This report warrants suspecting DOPICA of an associating anomaly predisposing to dissecting aneurysm in the vertebral artery-posterior inferior cerebellar artery territory and highlights the role of 3DRA in pretreatment evaluation of unusual aneurysms accompanying a particular anatomical variation.

Total Occlusion of the Internal Carotid Artery by Subacute In-Stent Thrombosis and Subsequent Spontaneous Recanalization After Stent-Assisted Coil Embolization / 신경중재치료의학

We present a 61-year-old female with an unruptured intracranial aneurysm on the left superior hypophyseal artery. The patient was treated with endovascular management, stent-assisted coil embolization. Multiple embolic infarction and total occlusion of the left internal carotid artery (ICA) was occurred one day later. At 14 days of heparinization, complete recanalization of the ICA and full recovery of neurologic symptoms were achieved. Stent-assisted coil embolization is not without risk of instent thrombosis and the subsequent embolism. The cause of subacute in-stent thrombosis and natural course were uncertain; however, the clinical course may potentially be fatal. Therefore, rapid diagnosis and proper treatment are recommended.

Endovascular Management of the Wide-neck Aneurysms: the Applications of the Coils and Catheter / 신경중재치료의학

The endovascular treatment of aneurysms with wide-neck or the incorporated branch can be technically very challenging. Various neck protecting devices, such as temporary balloons or self-expanding stents are effective for management of the wide-neck aneurysm. However, these devices are not amenable to successful management of aneurysms with unfavorable configurations, because the introduction of additional devices into small intracranial vessels is technically demanding. Without the support of these neck protecting devices, the use of three-dimensional (3D) coils or coil delivery technique with the application of microcatheter can help to overcome the unfavorable configuration of the aneurysm. This article presents 3D coils, double catheter method, and catheter-assisted method for coil embolization of the wide-neck aneurysm independently with neck protecting device. These methods are considered as viable alternatives for management of wide-neck aneurysms. To make the strategy of the endovascular treatment of the wide-neck aneurysm, neurointerventionists should consider the aneurysm configuration, relationship between the aneurysm and parent artery, the presence of incorporated branch, proximal approach route, technical availability, the risk of thromboembolic complications, and antiplatelet therapy.

Clinical Analysis of the Aneurysm of Proximal(A1) Segment of Anterior Cerebral Artery / 대한뇌혈관외과학회지

OBJECTIVES: Aneurysms of the anterior cerebral circulation are usually found on the anterior communicating artery (ACoA) or peripheral portion (A2) of the anterior cerebral artery (ACA). Infrequently, they are found on proximal segment (A1) of the ACA. These are presented 0.88-2.1% of all intracranial aneurysm cases. There are few describing a series of patient with A1 aneurysms. In this report, we present our surgical experience of the 27 A1 aneurysms. MATERIAL AND METHODS: 27 patients with aneurysm of proximal segment of anterior cerebral artery were operated on between January 1983 and September 2004. Retrospective analysis of clinical characteristics, radiologic findings, operation method, clinical outcomes and complications were performed. RESULTS: 27 patients with aneurysm of proximal segment of anterior cerebral artery, male was 11 cases, female was 16 cases. Relatively, predominantly occurred in female. In preoperative Hunt-Hess grade (H-H grade) of the patient, H-H grade I was 10, gradeII in 13, grade III in 3, grade IV in 1 case. In CT findings, 23 cases presented only SAH, SAH and ICH in 4, accompanying hydrocephalus in 3 cases. In angiographics and surgical findings, according to aneurysm site, proximal type was 9 cases, middle type in 8, distal type in 10 cases, and compared with each clinical outcomes. In 9 patients, aneurysms was found in right side and 7 patients of these had favorable outcomes. In left side, 12 of 18 patients had favorable outcomes. Postoperative complication occurred in 8 cases, postoperative infarction in 3 case. vasospasm in 4 cases, hydrocephalus, meningitis in 4 cases. 5 patients had multiple aneurysms. In 2 cases of these, A1 aneurysm was ruptured. In 3 cases, other aneurysm was ruptured and A1 aneurysm was incidental finding. In total 27 patients, 19 patients had favorable outcomes and unfavorable outcomes in 8. CONCLUSION: Aneurysms of proximal segment (A1) of the anterior cerebral artery occur very infrequently and in this report, These are presented 3.9% (27 out of 680) in anterior cerebral artery aneurysms. 19 patients underwent direct surgery had good outcomes after the surgery. As causes of unfavorable outcomes, poor preoperative general condition, injury of perforating artery during operation and vasospasm. Comparison with other aneurysms, relative good outcomes can be obtained by direct surgery.

Clinical Analysis of the Aneurysm of Proximal(A1) Segment of Anterior Cerebral Artery / 대한뇌혈관외과학회지

OBJECTIVES: Aneurysms of the anterior cerebral circulation are usually found on the anterior communicating artery (ACoA) or peripheral portion (A2) of the anterior cerebral artery (ACA). Infrequently, they are found on proximal segment (A1) of the ACA. These are presented 0.88-2.1% of all intracranial aneurysm cases. There are few describing a series of patient with A1 aneurysms. In this report, we present our surgical experience of the 27 A1 aneurysms. MATERIAL AND METHODS: 27 patients with aneurysm of proximal segment of anterior cerebral artery were operated on between January 1983 and September 2004. Retrospective analysis of clinical characteristics, radiologic findings, operation method, clinical outcomes and complications were performed. RESULTS: 27 patients with aneurysm of proximal segment of anterior cerebral artery, male was 11 cases, female was 16 cases. Relatively, predominantly occurred in female. In preoperative Hunt-Hess grade (H-H grade) of the patient, H-H grade I was 10, gradeII in 13, grade III in 3, grade IV in 1 case. In CT findings, 23 cases presented only SAH, SAH and ICH in 4, accompanying hydrocephalus in 3 cases. In angiographics and surgical findings, according to aneurysm site, proximal type was 9 cases, middle type in 8, distal type in 10 cases, and compared with each clinical outcomes. In 9 patients, aneurysms was found in right side and 7 patients of these had favorable outcomes. In left side, 12 of 18 patients had favorable outcomes. Postoperative complication occurred in 8 cases, postoperative infarction in 3 case. vasospasm in 4 cases, hydrocephalus, meningitis in 4 cases. 5 patients had multiple aneurysms. In 2 cases of these, A1 aneurysm was ruptured. In 3 cases, other aneurysm was ruptured and A1 aneurysm was incidental finding. In total 27 patients, 19 patients had favorable outcomes and unfavorable outcomes in 8. CONCLUSION: Aneurysms of proximal segment (A1) of the anterior cerebral artery occur very infrequently and in this report, These are presented 3.9% (27 out of 680) in anterior cerebral artery aneurysms. 19 patients underwent direct surgery had good outcomes after the surgery. As causes of unfavorable outcomes, poor preoperative general condition, injury of perforating artery during operation and vasospasm. Comparison with other aneurysms, relative good outcomes can be obtained by direct surgery.