A Case of Normal Volume Hydrocephalus with Recunent Shunt Obstruction Treated by Subtemporal Decompression

The authors report a case of Normal Volume Hydrocephalus with recuring ventricular catheter obstraction treated by bilateral subtemporal craniectomy. Subtemporal craniectomy provide temporary relief from increased intracranial pressure while the same time encouraging dilatation of ventricle, would protect against further catheter obstruction by prevent trapping of catheter tip between the abutting ventricular wall. The patient had been followed-up for 2 years and postoperative result was excellent.

Effect of Phentolamine on the Lung and Hypothalamic Lesions in the Experimental Neurogenic Ulmonary Edema in Cats

This experiment was performed to define the paricipation of a discrete hypothalamic neural structure in the genesis of pulmonary edema and the effect of alpha adrenergic blockade. Fifty adult cats weighing 2.5 to 4.0 Kg, were used in this study. The components of the pathophysiological systemic changes, lung weight, and histopathological changes of lung and hypothalamus were studied in groups of animals when intracranial pressure(ICP) was raised to 200 mmH2O of 300 mmH2O for 2 hours by intraventricular infusion with normal saline. The animals were divided into 5 groups : The normal control group was comprised in 10 normal cats. Control and phentolamine treated animal groups which had an elevated ICP of up 200 mmH2O consisted of 10 cats each. Control and phentolamine treated animal groups which had an elevated ICP of up to 300 mmH2O consisted of 10 cats each. The results obtained were as follows : 1) In the animal groups of elevated ICP to 200 mmH2O or 300 mmH2O, there were hemodynamic systemic changes which were neurogenically mediated and caused an immediate elevation in blood pressure of 30 mmHg to 60 mmHg. The hemodynamic data of the animals that had an elevated ICP of up to 300 mmH2O were significantly more deviated from normal control values than the 200 mmH2O ICP groups. The hemodynamic responses of the phentolamine treated animal with elevated ICP of up to 200 and 300 mmH2O were less deviated from normal control values. 2) The lung weights of the animals with an elevated ICP of up to 200 and 300 mmH2O were significantly heavier than the normal control value(p<0.05) and the lung weights of the animals with an elevated ICP of 300 mmH2O were significantly heavier than those with an ICP of 200 mmH2O(p<0.01). The lung weights of the phentolamine treated animal groups were significantly lighter than the control group but showed little increase in the lung weight when compared to the normal value. 3) By controlling the elevated ICP above 200 mmH2O in the experimental animals we have confirmed gross and microscopic appearances of hemorrhagic pulmonary edema. Histopathological changes of the phentolamine treated animals were significantly less sever than in the control groups. 4) By elevating ICP above 200 mmH2O in the experimental animals, we have confirmed discrete bilateral hemorrhagic spots of the anterior hypothalamus, preoptic region induced by increased intracranial pressure. Histopathological changes of the phentolamine treated animals with the elevated ICP were significantly less severe than of the control groups. 5) This experimental model may define the specific particification of the hypothalamus in the pathophysiological pathogenesis of neurogenic pulmonary edema. These results suggest that the lungs are directly affected by the intense sympathetic discharge evoked by release phenomenon from the sympathoinhibitory influence of the hypothalamus, and pulmonary edema was effectively eliminated by alpha adrenergic blockade.

A Case of Intramedullary Spinal Neurilemmoma

Intramedullary neurilemmoma of the spinal cord is extremely rare. This is not surprising, since schwann cells, considered the histogenetic source of such a tumor, normally are not present within the spinal cord. A case of intramedullary neurilemmoma in 47-year-old man is reported and the hypotheses as to it's origin are discussed. In a discussion on the origin of the condition, its is concluded that this case might have an origin from the dorsal root entry zone.

A Case of Microgliomatosis of the Brain

A rare case of microgliomatosis(reticulum cell sarcoma) of the brain is reported. The tumor was located in the left parietal lobe and the right cerebellar hemisphere and the vermis. V-P Shunt was performed and left parietal craniotomy was done for removal of tumor. The patient received radiation therapy and chemotherapy for brain tumor with a good result Histogenesis and therapy of the microgliomatosis are briefly discussed.

Effects of the Rheomacrodex and Alteration of Blood Pressure after Experimental Occlusion of the Middle Cerebral Artery

An experiment was planned to observe the histopathological alteration with administration of the Rheomacrodex and blood pressure changes in induced cerebral infarct after occlusion. Eighty well developed cats, weighing 2.3 to 3.5kg, were used in this experiment. The right MCA was exposed through temporal approach and the proximal part of the MCA was occluded with a silver clip. The animals were divided into 4 groups: The control group was comprised of 20 cats with occlusion of the right MCA alone, Rheomacrodex-treated group was comprised of 20 cats after occlusion of right MCA, induced hypotension and hypertension groups consisted in each 20 cats following occlusion of the MCA. The animals were sacrificed at intervals of 3 hours, 6 hours, 24 hours, 1 week and 2 weeks respectively after occlusion of the MCA. The animals were studied for clinical deficits and histopathological changes of the cerebral infarct according to the time courses. The results obtained were as follows: 1) In the control group, severe contralateral hemiplegia was developed in the early stage following the MCA occlusion, however the neurological deficits were progressively improved to the state of abnormal walking in 24 hours to 2 weeks. The hemorrhagic infarct was involving the basal ganglia, internal capsule and extending to the cortex with mild brain edema in the early stage and the area of the infarct was gradually enlarged from 6 hours to 24 hours following the MCA occlusion. Although the brain edema of surrounding area of the lesion was remained unchanged, the size and distribution of the infarct were decreased in one week to 2 weeks. Extensive ischemic neuronal damage was observed in the control group. 2) In the Rheomacrodex-treated group, mild to moderate neurological deficit was developed in the early stage after MCA occlusion and the deficit was less severe than control group. The clinical deficit was improving in the time course and one case had shown completely normal activity in 2 weeks. The distribution of the infarct was well defined and it was smaller than control group. The infarct mainly involved the basal ganglia and internal capsule. The area of the infarct was gradually enlarged from 6 hours to one week after MCA occlusion, then the extent of the infarct was decreased in 2 weeks. The ischemic neuronal change in this group was less severe than control group. 3) In the induced hypotension group, the early neurological deficit was worse than that of the control group and severe hemiplegia was developed in one week. There was minimal improvement of the neurological deficit in 2 weeks. The area of the infarct was ill-defined and hemorrhagic extending a large portion of the brain with severe brain edema. The infart was involving the basal ganglia, internal capsule, claustrum and the cortex from 3 hours to 24 hours after the occlusion and the area of the infarct was not changed during the observation. Severe ischemic nerve cell change or resolution of the cells was oserved in this group. 4) In the induced hypertension group, the neurological deficit was mild and it was better than that of the control group. The distribution of the infarct was well localized and minimum in extent. The extent of the infarct was not changed during the observation. There was no observable gross brain edema and the ischemic nerve cell changes were not severe.

Surgical Treatment and Analysis of Pituitary Hormone with Serial Hormonal: Radioimmunoassay in Pituitary Tumor

There were 11 cases of pituitary tumors and 2 cases of craniopharyngiomas, who were admitted to the Department of Neurosurgery of the Catholic Medical Center from July 1976 to April 1977. The authors analyzed changes of the hormone related with the hypophyses before and after surgery, and radiation using the radioimmunoassay according to Schalch and Parker's double antibody method. The hormonal assays were performed as follows : 5 samplings of growth hormones were given at a fasting state, at 8 AM, 8:30 AM, 10 AM and 11 AM, also the oral glucose tolerance test simulataneously after the patients were given 100 gm of surgar, associated with the insulin tolerance test (0.15 unit/kg). Two specimens of blood for the prolactin were withdrawn at 8 AM and 4 PM on that day. A specimen for LH, FSH, TSH, T3, T4 and cortisol was taken at 8 AM. The 8 surgery cases of the pituitary tumors associated with post-operative radiation underwent 3 transsphenoidal approaches, 3 transfrontal and 2 transtemporal approaches, and all of the surgery cases were alive. The transtemporal approach was for all craniopharyngiomas, and all of them died following surgery. One patient in this chromophile adenoma group had radiation therapy only. Following the clinical improvement after the treatment, the endocrinological symptoms, i. e. diminished libido and amenorrhea, were improved in the acromegalic group. The visual disturbance in the chromophobe adenoma group was markedly improved and the menstruation had started in one case. In inoperative patients, the visual disturbance and the endocrinological disarrangements were aggravated. In the chromophile adenoma group accompanying the acromegaly, the mean value of the plasma growth hormone was markedly increased to 61.3 ng/ml and greatly decreased to 36.8 ng/ml after the surgery and radiation, but increased rather than before radiation in the one case of radiation only. The mean prolactine value was also increased to 60.6 ng/ml and not changed after the therapy. The gonadotropin was within normal limits and tended to decrease slightly after the treatment. The TSH, T3, T4 cortisol were within normal values. In the chromophobe adenoma group, the mean growth hormone values were within normal limits, 7.27 ng/ml, and not altered after the therapy. The mean prolactin value was increased to 57.8 ng/ml and not changed after the treatment. The gonadotropin, TSH, T4 and cortisol were within normal limits before and after the treatment, but the T3 value was slightly higher than normal. In the craniopharyngioma group, the mean growth hormone value was within normal limits, 7.4 ng/ml and not altered after the surgery. The mean prolactin gonadotropin, TSH, T3 and T4 were within normal limits but the cortisol value was increased to 13.7 ng/ml after the surgery.

Clinical Observation in the Narrow Spinal Canal

Authors analysed 25 cases of the narrow spinal canal in cervical and lumbar region, who admitted to the Catholic Medical Center, Seoul from Jan. 1970 to August 1976. Correlation between neurologic feature and radiologic finding was attempted and compared the measurements of narrow cervical and lumbar spinal canal with that of the healthy Korean. The mean anterioposterior diameter of the cervical canal in healthy Korean was 16.2mm at C4, 16.4mm. at C5, 16.6mm. at C6, and 16.4mm. at C7. The ratio of canal to vertebral body in the plain lumbar spine was 1 : 3.9 at L3, 1 : 3.8 at L4 and 1 : 3.8 at L5. The measurements of 25 cases of narrow spinal canal were significantly reduced comparing with the healthy one. The clinical symptoms were closely related to the severity of the narrow spinal canal while there was intermittent or insidious course of symptom in the group of mild narrow spinal canal. Symptom of root compression or neurogenic claudication is frequent manifestation in the severe narrow spinal canal. and the symptom is correlated to the severity of the narrowing. Urinary disturbance and pyramidal tract sign were evident in the cervical narrow canal. The characteristic myelographic feature was multiple constrictive defect at the level of the narrow canal. Common findings in laminectomy were the thickened laminae and hypertrophied ligamentum flavum in the narrow canal. Herniated disc was not found but in one case in the cervical narrow canal at surgery. The recovery of the symptom was better in the group of the narrow canal who had mild degree of narrowing or who had the symptom in short duration rather than prolonged course.

Effect of Steroid and Alpha Adrenergic Blockade in Experimental Spinal Cord Trauma

To evaluate the effect of steroid and alpha adrenergic blockade in experimental spinal cord trauma, pathological change was observed after 500 gm-cm force was impacted on the exposed cord of the 30 Mongoreal adult dogs. The progression of the pathological changes was compared in time lag with the groups of steroid adminstered and phenoxybenzamine treatment. In the group of the spinal cord trauma without treatment, histopathological findings were classical evolution namely from the central hemorrhage and necrosis to peripheral involvement up to amorphous necrotic pattern of entire cord at 24 hours preparation. In the steroid therapy group after the trauma, the pathological changes were confined in the gray matter around and posterior portion of the central canal in all intervals. Moreover the edematous changes and hemorrhagic necrosis were far less severe than the group without treatment. Although the pathologic change was somewhat less severe in the group which received phenoxybenzamine prior to the trauma than the group administered phenoxybenzamine afterward, these group revealed much severe edema and hemorrhagic necrosis than steroid therapy group. The pathologic change, however, in the groups which received phenoxybenzamine was less severe than the group of the spinal cord trauma without treatment.

Measurement of Normal Distribution of Vertebrobasilar System on Vertebral Angiogram

Angiographic diagnosis of lesions of the posterior fossa requires detailed knowledge of the normal anatomy of both arteries and veins of the brainstem and cerebellum. For this perfuse we measured normal distribution of the vertebrobasilar vessels from three base lines namely clival line, Twining line and foramen magnum line. In the measurement are also included some of the methods which were published in the past. This paper is based on the results of the measurements on 18 cases of normal vertebral angiogram among 77 cases of serial vertebral angiography performed at Catholic Medical center from October 1972 to August 1975. The result obtained were as follows: 1) Distance from the most posterior portion of the pericallosal artery to the clival line is 6.55+/-0.68 cm. 2) Distance from the most posterior portion of the arcuate portion of the lateral posterior choroidal artery to the clival line is 5.16+/-0.61 cm. 3) Distance from the posterior portion of the quadrigeminal portion of the medial posterior choroidal artery to the clival line is 4.87+/-0.67 cm. 4) Distance from the most posterior portion of the distal segment of the medial posterior choroidal artery to the clival line is 4.47+/-0.49 cm. 5) Distance from the bifurcation portion of the basilar artery to the clival line is 1.22+/-0.26 cm. 6) Distance from the forward convexity of the basilar artery to the clival line is 0.15+/-0.11 cm. 7) Distance from the choroidal point to the clival line is 2.99+/-0.51 cm. 8) Distance from the posterior medullary portion of the PICA to the clival line is 2.58+/-0.45 cm. 9) Distance from the tuberculum sellae to the Torcular Herophilli(Twining line) is 10.96+/-0.52 cm. 10) Distance between the tuberculum sellae to the point on the Twining line crossed by a perpendicular line drawn from the choroidal point is 6.61+/-0.40 cm. 11) Distance from the superior portion of the anterior culminate segment of the superior cerebellar artery to the Twining line is 3.28+/-0.48 cm. 12) Distance from the supratonsilar portion of the PICA to the Twining line is 0.97+/-0.42 cm. 13) Distance from the colliculocentral point to the clival line is 3.74+/-0.37 cm. 14) Distance from the crural portion of the anterior pontomesencephalic vein to the clival line is 1.65+/-0.33 cm. 15) Distance from the crural portion of the anterior pontomesencephalic vein to the colliculocentral point is 2.51+/-0.35 cm. 16) Distance from the copular point to the clival line is 3.99+/-0.51 cm. 17) Distance from the copular point to the line drawn from the anterior margin of the foramen magnum is 1.63+/-0.38 cm. 18) Distance from the highest point of the lateral posterior choroidal artery to the Twining line is 4.74+/-0.37 cm. 19) Distance from the highest point of the medial posterior choroidal artery to the Twining line is 4.35+/-0.34 cm. 20) Distance between two bisected points of the anterior culminate segment of the superior cerebellar artery by a line drawn parallel to the Twining line at 1cm from the top of the anterior culminate segment is 2.86+/-0.29 cm.

An Analysis of the Result of Surgical Treatment of Anterior Communicating Aneurysms

The authors attempted to analyse the factors influencing the mortality involved in aneurysm surgery based on 38 cases of intracranial surgery for anterior communicating aneurysms, and obtained the following conclusion. 1. The surgical results are much better when the aneurysm surgery is delayed over one week after the occurrence of aneurysmal rupture, if there is no evidence of intracerebral hematoma. Administration of a massive dosage of epsilon aminocaproic acid in the waiting period prior to aneurysm surgery seems to be effective for preventing recurrence of bleeding from the aneurysm. 2. The direction of the anterior communicating aneurysm should be clearly visualized on a cerebral angiogram so that the most effective aneurysmal approach can be selected in surgery. 3. Microsurgery and hypotension in aneurysm surgery minimize brain damage in the exposure of aneurysm and provide accurate isolation of the aneurismal neck from the parent vessel in aneurysmal neck ligation. 4. Proximal ligation of the anterior cerebral artery is also an effective procedure to prevent recurrent hemorrhage from anterior communicating aneurysm.

Treatment of Cerebral Aneurysms and Aneurysm Surgery under Hypotension

Authors have experienced 104 cases of the intracranial aneurysms with subarachnoid hemorrhage, who were proved to have aneurysms by cerebral angiography for past 8 years. Aneurysms surgery under controlled hypotension has shown far better result than that of surgery under hypothermia, carotid ligation or conservative treatment. Of the 104 cases, the site distribution of aneurysms and the result of various treatment are analyzed. Followings are the results. 1. Anterior communication aneurysm was 44 per cent of the cases and it was most common site of the intracranial aneurysms. 19 per cent of aneurysms located on internal carotid artery at the posterior communicating artery, and middle cerebral artery aneurysm was 16%. The site distribution of aneurysms in Korean has shown marked difference from the reports of other countries. 2. Of 40 cases, who received conservative therapy, 15 cases (375% ) were expired, and most of them were dead due to rebleeding from aneurysms. 3. The direct attack of aneurysms through intracranial approach was performed under moderate hypothermia till 1970, and controlled hypotension was introduced thereafter. In 19 cases of intracranial aneurysm surgery, 7(14.2%) were expired following surgery. 4. Mortality of the carotid ligation for 15 cases of the intracranial aneurysms was 40 per cent. Cerebral ischemia or rebleeding was cause of death. 5. Intracranial aneurysm surgery under hypotension was carried out in 16 cases, and one cases (6.2%) was expired. Induced hypotension and careful identification of aneurysm and neighbouring structures by magnify operating glasses promoted operative result in aneurysm surgery.

Clinical Observation and Surgical Treatment of Cerebral Arterioveous Malformations

We have experienced 19 patients of the cerebral arteriovenous malformation with subarachnoid hemorrhage, who were admitted to the Presbyterian Hospital, Daegu from January 1966 to July 1968, and to the Catholic Medical Center, Seoul from August 1968 to August 1971. All of the patients, who have the cerebral arteriovenous malformation, were proved by cerebral angiography. Since the site of lesions were considered to have close relation to the neurologic deficit and the result of surgery, various analysis of the clinical manifestations and the cerebral angiographic findings were attempted. Of the 19 patients, surgery was performed on 12 patients and its results were analyzed correlating to various types of surgical procedure. Following are the results. 1. From January 1966 to August 1971, there were 100 cases of cerebral vascular anomalies which were proved by cerebral angiography. Among the 100 cases, there were 71 intracranial aneurysms, 19 cerebral arteriovenous malformations, one cavernous angioma, 2 telangiectasis, 5 cerebral rete mirabile, and s Sturge Weber-Dimitris disease. The ratio of arteriovenous malformatons to aneurysms was 1: 3.7. 2. Age distribution of the bleeding arteriovenous malformations was ranged from 8 to 54, and 42 per cent of them were in the third decade. 73 percent of the group had bleeding from the cerebral arteriovenous malformation before the age of 40. The ratio of male to female was 1.9:1. 3. The parietal region was most commonly involved by the malformations. There were 8 parietal lesion, 4 temoroparietal lesions, one temporal lesion, one occipital lesion, and one tela chorioidea lesion. Simultaneous involvement of the both hemispheres occurred in one case. In lesions involving the cerebral hemisphere, there was a predominance of the left side. 4. In the past history, convulsive seizure was recorded in two cases and recurrent hemorrhages were reported in two. One patient was recorded to have suffered fourth hemorrhage and the other have sufferd third hemorrhge. 5. Meningeal irritation signs were most frequently observed in bleeding arteriovenous malformations. The incidence of weakness of extremities was higher in lesions involving the parietal area. Unconsciousness was occurred in 6 patients at the onset of symptom, of which transient loss of consciousness was seen in 3 patients. Transient hypertension at the onset was observed in two patients. 6. The feeding arteries of the malformations were most frequently seen from the middle cerebral artery and the draining veins from the malformations were into the superior sagittal sinus and internal cerebral vein in many cases. It was evident that the carotid artery of the sites of arteriovenous malformations was markedly dilated in 5 patients. 7. Ligation of the vessels feeding the arteriovenous malformations was carried out in 8 patients. One patient had neurologic deficit after the operation. Evacuation of intracerebral hematoma, resection of the anomaly or carotid ligation were carried out in 4 patients. Of the 12 patients who underwent various types of surgery, there was one death after evacuation of a large intracereral hematoma. 8. In our opinion, the ligation of feeding artery a choice of procedure to reduce the incidence of rebleeding, if the resection of the lesion was considered to have operative risk by the location of malformations.