Spontaneous Cerebellar Hemorrhage with the Fourth Ventricular Hemorrhage : Risk Factors Associated with Ventriculoperitoneal Shunt

OBJECTIVE: The purposes of this study are to investigate the factors that may be related to ventriculoperitoneal (VP) shunt in patients with cerebellar hematoma and the effect of severe fourth ventricular hemorrhage, causing obstructive hydrocephalus on subsequent VP shunt performance. METHODS: This study included 31 patients with spontaneous cerebellar hematoma and concomitant fourth ventricular hemorrhage, who did not undergo a surgical evacuation of hematoma. We divided this population into two groups; the VP shunt group, and the non-VP shunt group. The demographic data, radiologic findings, and clinical factors were compared in each group. The location of the hematoma (whether occupying the cerebellar hemisphere or the vermis) and the degree of the fourth ventricular obstruction were graded respectively. The intraventricular hemorrhage (IVH) score was used to assess the IVH severity. RESULTS: Ten out of 31 patients underwent VP shunt operations. The midline location of cerebellar hematoma, the grade of fourth ventricle obstruction, and IVH severity were significantly correlated with that of VP shunt operation (p=0.015, p=0.013, p=0.028). The significant variables into a logistic regression multivariate model resulted in statistical significance for the location of cerebellar hemorrhage [p=0.05; odds ratio (OR), 8.18; 95% confidence interval (CI), 1.00 to 67.0], the grade of fourth ventricle obstruction (p=0.044; OR, 19.26; 95% CI, 1.07 to 346.6). CONCLUSION: The location of the cerebellar hematoma on CT scans and the degree of fourth ventricle obstruction by IVH were useful signs for the selection of VP shunt operation in patients with spontaneous cerebellar hematoma and concomitant acute hydrocephalus.

Simultaneous Vertebral Artery Dissection and Contralateral Posterior Inferior Cerebellar Artery Dissecting Aneurysm

The optimal treatment and appropriate follow-up period for an unruptured vertebral artery (VA) and/or posterior inferior cerebellar artery (PICA) dissection have not been established. Decisions regarding treatment of these vascular lesions are usually based on the manifesting symptoms and changes in radiologic findings during the follow-up period. We experienced a patient who had a simultaneous unruptured VA dissection and a contralateral PICA dissecting aneurysm. We did not find such a case in other literature.

Accuracy and Safety of Bedside External Ventricular Drain Placement at Two Different Cranial Sites : Kocher's Point versus Forehead

OBJECTIVE: External ventricular drain (EVD) is commonly performed with a freehand technique using surface anatomical landmarks at two different cranial sites, Kocher's point and the forehead. The aim of this study was to evaluate and compare the accuracy and safety of these percutaneous ventriculostomies. METHODS: A retrospectively review of medical records and head computed tomography scans were examined in 227 patients who underwent 250 freehand pass ventriculostomy catheter placements using two different methods at two institutions, between 2003 and 2009. Eighty-one patients underwent 101 ventriculostomies using Kocher's point (group 1), whereas 146 patients underwent 149 forehead ventriculostomies (group 2). RESULTS: In group 1, the catheter tip was optimally placed in either the ipsilateral frontal horn or the third ventricle, through the foramen of Monro (grade 1) in 82 (81.1%) procedures, in the contralateral lateral ventricle (grade 2) in 4 (3.9%), and into eloquent structures or non-target cerebrospinal space (grade 3) in 15 (14.8%). Intracerebral hemorrhage (ICH) >1 mL developed in 5 (5.0%) procedures. Significantly higher incidences of optimal catheter placements were observed in group 2. ICH>1 mL developed in 11 (7.4%) procedures in group 2, showing no significant difference between groups. In addition, the mean interval from the EVD to ventriculoperitoneal shunt was shorter in group 2 than in group 1, and the incidence of EVD-related infection was decreased in group 2. CONCLUSION: Accurate and safe ventriculostomies were achieved using both cranial sites, Kocher's point and the forehead. However, the forehead ventriculostomies provided more accurate ventricular punctures.

Clinical Outcome of Endovascular Treatment of Cerebral Aneurysms in Elderly Patients / 대한뇌혈관외과학회지

OBJECTIVE: Subarachnoid hemorrhage (SAH) is known to have a high mortality rate and increase incidence by aging process. To old aged patients, treatment of cerebral aneurysm is controversial due to multiple factors, regarding underlying disease, life expectancy and treatment risk. We reviewed treatment outcome of the patients older than 65 years who had cerebral aneurysm (s) by using endovascular technique. METHODS: Between 2000 and 2009, 177 patients who aged over 65 years were treated by endovascular management. Among them, 116 patients were presented with SAH and 61 patients were unruptured aneurysm. In SAH group, treatment outcome was evaluated by Glasgow Outcome Scale (GOS) at discharge and modified Rankin Scale (mRS) at 3 months. In unruptured aneurysm group, procedure complication and recurrence of the cerebral aneurysm were evaluated. RESULTS: 177 patients harbored 209 aneurysms in total. GOS for the patients with SAH at discharge was good recovery (n=82, 71%), mild disability (n=7, 6%), severe disability (n=18, 15%), vegetative (n=3, 3%) and death (n=6, 5%). Three months mRS was good condition (mRS 0-2) in 83 patients, poor condition (mRS 3-5) in 26 and death in 1. Regarding the factors related with good recovery in SAH groups, initial Hunt and Hess grade showed statistical significance. In the group of unruptured aneurysm, only 1 patient (1.6%) had a procedure rupture and related in symptomatic intracerebral hemorrhage. CONCLUSION: Based upon our data, coil embolization of cerebral aneurysm was relatively safe and effective to older patients.

Clinical Outcome of Cranial Neuropathy in Patients with Pituitary Apoplexy

OBJECTIVE: Pituitary apoplexy (PA) is described as a clinical syndrome characterized by sudden headache, vomiting, visual impairment, and meningismus caused by rapid enlargement of a pituitary adenoma. We retrospectively analyzed the clinical presentation and surgical outcome in PA presenting with cranial neuropathy. METHODS: Twelve cases (3.3%) of PA were retrospectively reviewed among 359 patients diagnosed with pituitary adenoma. The study included 6 males and 6 females. Mean age of patients was 49.0 years, with a range of 16 to 74 years. Follow-up duration ranged from 3 to 20 months, with an average of 12 months. All patients were submitted to surgery, using the transsphenoidal approach (TSA). RESULTS: Symptoms included abrupt headache (11/12), decreased visual acuity (12/12), visual field defect (11/12), and cranial nerve palsy of the third (5/12) and sixth (2/12). Mean height of the mass was 29.0 mm (range 15-46). Duration between the ictus and operation ranged from 1 to 15 days (mean 7.0). The symptom duration before operation and the recovery period of cranial neuropathy correlated significantly (p = 0.0286). TSA resulted in improvement of decreased visual acuity in 91.6%, visual field defect in 54.5%, and cranial neuropathy in 100% at 3 months after surgery. CONCLUSION: PA is a rare event, complicating 3.3% in our series. Even in blindness following pituitary apoplexy cases, improvement of cranial neuropathy is possible if adequate management is initiated in time. Surgical decompression must be considered as soon as possible in cases with severe visual impairment or cranial neuropathy.

Solitary Lumbar Spinal Osteochondroma Presenting with Sciatic Pain: A Case Report

Osteochondroma is one of the most common benign bone tumors, but only 1-4% involve the spine. They make up 0.4% of intraspinal tumors. Herein, we report on a solitary osteochondroma of the lumbar spine presenting with sciatica. A 54-year-old male patient visited our institution, complaining of right leg pain of 2 months duration. His neurological examination revealed a limited right straight-leg-raising test result, motor weakness of right great toe dorsiflexion, and L4-L5 hypoesthesia. Lumbar computerized tomographic (CT) scan and magnetic resonance (MR) imaging studies revealed a tumor mass arising from the inferior articular process of the L3. There was marked improvement of the symptoms after surgical removal of the lesion. Symptoms showed marked improvement after surgical removal of the lesions. Histopathologic examination confirmed the diagnosis of benign osteochondroma.