Assessment of Cerebrovascular Reserve before and after STA-MCA Bypass Surgery by SPECT and SPM Analysis

OBJECTIVE: The purpose of this study was to objectively assess the efficacy of superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery using Technetium (Tc)-99m-ethyl cysteinate dimer (ECD) single photon emission computed tomography (SPECT) in patients who underwent STA-MCA bypass surgery. MATERIALS AND METHODS: Brain perfusion SPECT images obtained at baseline and after the administration of acetazolamide were reconstructed using statistical parametric mapping in 23 patients, both before and after STA-MCA bypass surgery. The clinical outcomes of the surgery were also recorded and compared with the hemodynamic changes. A voxel with an uncorrected p-value of less than 0.001 was considered to be statistically significant. RESULTS: SPECT images of the territory supplied by the bypass graft showed an increase in both cerebrovascular flow and reserve at baseline, and the increase was significantly higher following the administration of acetazolamide. All patients showed improvement of clinical symptoms and increased blood flow to the left temporal, parietal, and frontal cortices as well as the thalamus. CONCLUSION: Brain SPECT effectively and objectively demonstrated the improved outcomes of STA-MCA bypass surgery, and thus may be used in postoperative analyses.

Efficacy of Intraoperative Facial Electromyographic Monitoring in Patients with Hemifacial Spasm

OBJECTIVE: Hemifacial spasm has characteristic and specific electrophysiological finding, lateral spread response(LSR). We study the correlation between change of lateral spread response during microvascular decompression(MVD) and clinical outcome after MVD. METHODS: Sixty two patients with hemifacial spasm who were treated with microvascular decompression from March 2000 to February 2003 were included in this study. The monitoring of intraoperative facial electromyography(EMG) and brain stem auditory evoked potential were performed. RESULTS: In 28 (44.7%) patients, there was persistence of lateral spread response after vascular decompression in root exit zone of facial nerve. Among these 28 patients, 9 had mild hemifacial spasm at discharge. Three out of 34 patients who had intraoperative disappearance of lateral spread response after MVD had mild hemifacial spasm. But Both groups, disappearance of LSR (Group I), and persistence (Group II) had only 2 patients with mild hemifacial spasm, and 5 patients at 3 months, respectively. CONCLUSION: Although intraoperative EMG monitoring is very useful in assessing the efficacy of MVD, the clinical outcome of MVD in patient with hemifacial spasm does not always correlate with EMG finding. The prognostic value of intraoperative LSR monitoring in the long-term results is questionable.

Radiological Characteristics of Peritumoral Edema in Meningiomas

OBJECTIVES: The purpose of this study is to evaluate the radiological charactersitics related to the formation of peritumoral edema in meningiomas. METHODS: Fifty patients with meningioma were examined by magnetic resonance images and cerebral angiography. The predictive factors associated peritumoral edema, such as, tumor size, peritumoral rim (cerebrospinal fluid cleft), shape of tumor margin, signal intensity of tumor in T2WI, and pial blood supply were evaluated. RESULTS: Tumor size, peritumoral rim and pial blood supply correlated with peritumoral edema on univariate analyses. But in multivariate analyses, pial blood supply was statistically significant as a factor for peritumoral edema in meningioma. CONCLUSION: In our results, pial blood supply is significant contributing factor for peritumoral edema in meningioma.

Hypothermia Effect on Apoptotic Neuronal Death in Traumatic Brain Injury Model

OBJECTIVE: Many researchers believe that the hypothermia shows neuroprotective effect on brain injury. To understand the molecular mechanism of the hypothermic treatment, this study investigated its effects on the expression of cell death or survival related proteins such as p53, Bcl-2 and Bax in the rat traumatic brain injury(TBI) model. METHODS: Twenty rats (Spraque Dawley, 200~250g) were subjected to the brain injury of moderate severity (2.4~2.6atm) using the fluid percussion injury device and five rats were received only same surgery as controls. During 30minutes after the brain injury, the hypothermia group was maintained the body temperature around 34 degrees C while the control group were maintained that of 36 degrees C. Five rats in each group were sacrificed 12h or 24h after brain injury and their brain sections was analyzed for physical damages by H-E stains and the extent of apoptosis by TUNEL assay and immunohistochemical stains. The tissue damage after TBI was mainly observed in the ipsilateral cortex and partly in the hippocampus. RESULTS: Apoptosis was observed by TUNEL assay and the Bax protein was detected in both sample which harvested 12h and 24h after TBI. In the hypothermia treatment group, tissue damage and apoptosis were reduced in HE stains and TUNEL assay. In hypothermia treatment group rat shows more expression of the Bcl-2 protein and shows less expression of the Bax protein, at both 12h and 24h after TBI. CONCLUSION: These results show that the hypothermia treatment is an effective treatment after TBI, by reducing the apoptotic process. Therefore, it could be suggested that hypothermia has a high therapeutic value for treating tissue damages after TBI.

Surgical Technique and Long-term Follow-up of Cervical Laminoplasty using Titanium Miniplates

OBJECTIVE: The authors report a simple and reliable method for cervical open-door laminoplasty secured by titanium miniplate. METHODS: Sixteen patients with cervical myelopathy secondary to multilevel cervical spondylosis or ossification of the posterior longitudinal ligament were treated with an expansive open-door laminoplasty using titanium miniplates to stabilize the posterior elements described by O'Brien et al between February 1998 and June 2002, and all had a minimum of 6 months of follow-up(mean 22.5months) review. Plain radiographs were used to measure sagittal canal diameter and monitor construct integrity. The neurological outcome was evaluated before and after operation using the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. RESULTS: Only 1 titanium miniplate construct was failed out of 69 levels in 16 patients during follow-up period, but decompression was maintained. After surgery, in 15 patients(93.7%) different levels of clinical improvement were demonstrated, and in four of them(25%) full recovery was observed. The sagittal canal diameter and JOA score increased from 13.3+/-2.2mm and 9.19 preoperatively to 20+/-2.4mm and 12.88 postoperatively(p<0.01). CONCLUSION: The use of titanium miniplate to stabilize the posterior elements after laminoplasty is a simple, durable, and effective technique to maintain the increased sagittal canal diameter of the spinal canal and have another advantage of compatability of magnetic resonance imaging.

Intracranial Hemorrhage in Patients with Hematologic Disorders

OBJECTIVE: Spontaneous intracranial hemorrhage is still common cause of death in the hematologic disorder including leukemia. The authors examine laboratory & radiological findings in patients with intracranial hemorrhage caused by hematologic disorder. METHODS: From March 1998 to May 2002, 42 patients with hematologic disease complicated by intracranial hemorrhage were transferred from hematology department. The patients were normotensive and had not trauma history. In all patients, intracranial hemorrhages were diagnosed with the brain computerized tomography. Surgical treatment was performed in one case. RESULTS: Underlying hematologic disorders included aplastic anemia (4), acute myeloblastic leukemia (20), acute lymphoblastic leukemia (6), chronic myeloblastic leukemia (8), myelodysplastic syndrome (2), multiple myeloma (1), and polycythemia vera (1). Intracranial hemorrhage subtypes consisted of intracerebral hemorrhage (39) including mainly subcortical lobar hemorrhage (28), and subarachnoid hemorrhage (3). Twenty (48%) of the 42 patients had multifocal hematomas. Thirty six patients (86%) had moderate and severe thrombocytopenia (less than 100x10(9)/L). Twenty four patients (57%) had moderate and severe leukocytosis (greater than 20x109/L). CONCLUSION: It showed that (1) the risk factors of intracranial hemorrhage in hematologic disorders are thrombocytopenia, leukocytosis and disseminated intravascular coagulopathy ; (2) intracerebral hemorrhage in hematologic disorders occur preferentially in the subcortical portion ; (3) intracranial hemorrhage in hematologic disorders consist of various combinations of subcortical lobar hemorrhage, subarachnoid hemorrhage, subdural hemorrhage and intraventricular hemorrhage ; (4) intracerebral hemorrhage in hematologic disorders tend to be multiple.

Management of Tumors Involving the Cavernous Sinus: Experience of 10 Cases

OBJECTIVE: The authors present the complications after resection of the tumors involving the cavernous sinus and the efficacy and role of the adjuvant therapy in the management of the residual or recurrent tumors invading the cavernous sinus. METHODS: From March 1998 to May 2002, ten patients with cavernous sinus tumors were treated in our hospital. The tumors limited to the outer wall of cavernous sinus were excluded in this study. Pathological diagnoses were meningiomas in seven and pituitary adenomas in three patients. RESULTS: Tumors of the extracavernous portion were removed totally except for two cases. Cavernous sinus was opened in seven patients, among which subtotal removal was achieved in four, and partial removal in three patients. In the remaining three patients, the cavernous sinus was neither opened nor exposed. All patients with intracavernous exploration were complicated by ptosis and extraocular muscles paralysis. Radiotherapy was administered to 6 cases. At present, there is no tumor progression except for one patient with malignant meningioma. CONCLUSION: In patients with large tumors involving the cavernous sinus, especially invading the cavernous internal carotid artery, we recommend subtotal or partial resection of the tumor followed by radiation therapy to prevent permanent postoperative sequele.

Sphenoid Dysplasia in the Absence of Neurofibromatosis Type I: Case Report

The authors report a case of a 24-year-old man with unilateral sphenoid dysplasia in the absence of NF-I. Preoperatively, the patient was presented with pulsating exophthalmos and headache. The patient underwent cranioorbital sphenoid wing reconstruction with split calvarial bone graft. Postoperatively, he showed relieved headache and significant reduction of exophthalmos by exophthalmometry. There were no evidence of osteomyelitis and neurologic complication.

Metastatic Mucinous Adenocarcinoma Mimicking Cerebral Hemorrhage

Metastatic adenocarcinoma to the brain usually appears low-to-moderate attenuation on non-enhanced computed tomography. However, metastatic mucinous adenocarcinoma shows strikingly high attenuation, even simulating hemorrhage in some cases. We present a rare case of a mucin-containing metastatic adenocarcinoma of the rectum mimicking cerebral hemorrhage.

Hyperperfusion Syndrome after Extracranial-Intracranial Bypass Surgery

OBJECTIVE: Cerebral hyperperfusion syndrome after extracranial-intracranial(EC-IC) bypass is a rare event but it may be disastrous. It can cause vomiting, confusion, seizure and intracerebral hemorrhage. We report 11 cases of hyperperfusion syndrome after EC-IC bypass surgery for recent 5 years in detail. METHODS: Authors performed EC-IC bypass surgery for augmentation of cerebral blood flow in 60 patients for recent 5 years. In 60 patients of EC-IC bypass procedures, we experienced 11 cases of hyperperfusion syndrome. It was observed that hyperfusion induced headache and vomiting in 2 cases, seizure in 1 case, temporary neurologic deficit in 5 cases, and intracerebral hemorrhage in 3 cases. RESULTS: All patients except three cases of intracerebral hemorrhag recovered completely. Five patients with temporary neurologic deficit improved within maxmum of 10days. In three cases of intracerebral hemorrhage, emergency hematoma removal was performed. Two of them, with moyamoya disease, recovered with minor neurologic deficit. The other, with traumatic intracarotid artery injury died. CONCLUSION: Hyperfusion syndromes may be due to relative hyperperfusion of a cerebral hemisphere in which autoregulation had been impaired because of preoperative chronic hypoperfusion. We strongly recommend that revascularization is deferred to 8 weeks till impaired autoregulation is restored, and meticulous blood pressure control should be done in the postoperative course of EC-IC bypass surgery.

Intracerebral Hematoma after Reperfusion Procedures in Cerebral Ischemia / 대한뇌혈관학회지

Intracerebral hematoma (ICH) after reperfusion procedure in cerebral ischemia is a rare but serious complication. The authors present 4 cases with ICH after reperfusion procedures in cerebral ischemia. First case is ICH after superficial temporal artery-middle cerebral artery anastomosis in moyamoya patient, second case is ICH after graft bypass usuing saphenous vein in traumatic carotid artery injury patient, third case is ICH after intra-arterial urokinase therapy in acute internal carotid artery occlusion and forth case is ICH after temporary clipping to the middle cerebral artery in middle cerebral artery aneurysm surgery. Defective cerebrovascular autoregulation in ischemic brain regions may predispose patients to ICH after reperfusion procedure in cerebral ischemia. The authors suggest reperfusion procedure in ischemia must be executed prudently because of possibility of reperfusion injury including ICH.

The Effect of Ethanol and Microwave Treated into the Feline Brain on Brain MRI

OBJECTIVE: The purpose of this study is to ascertain whether magnetic resonance(MR) images taken after ethanol injection or microwave irradiation into feline brain can verify changes within the brain and offer valuable information about the spatial extent of the induced lesion. METHODS: In the ethanol injection experiment, nine male cats were divided into three groups including group I(n =3) treated with 0.1cc ethanol injection, group II(n=3) 0.2cc ethanol, and group III(n=3) 0.3cc ethanol into the feline brains. In the microwave irradiation experiment, twelve male cats were divided into four groups including group I(n=3) irradiated with 30 watt electrical power with 10 sec duration, group II(n=3) same power with 30 sec duration, group III(n=3) irradiated with 60 watt power with 10 sec duration, and group IV irradiated with 60 watt power with 30 sec duration. MR images were obtained in both ethanol injection and microwave irradiation experiments. Pathologic examinations were done after completion of MR imagings. RESULTS: Contrast-enhanced T1-weighted MR images showing nodular or rim enhancement were most reliable in delineating the extent of the necrosis induced by ethanol injection and microwave irradiation. The contrast enhancement corresponded with gliosis in normal brain surrounding the necrotic area and hypervascularity in ongoing necrotic area and adjacent normal brain. There were various enhancement patterns after ethanol injection with reflux of ethanol. In case of microwave irradiation, round or oval enhancements were shown with clear margin. The size of the enhancement was well correlated with the amount of injected ethanol and the amount of electrical power. Application time was not correlated with the size of enhancement in high electrical power group. The feature of the edema after ethanol injection was unpredictable and predictable in case of microwave irradiation. CONCLUSION: It is easy to predict the result in case of microwave irradiation, and the achieved results can be used as basic information in performing these procedures.

Intraoperative Aneurysmal Rupture and Management

OBJECTIVE: The rupture of an aneurysm during operation is an event that can be considered grave. The authors present the retrospective analysis of 10 cases of intraoperative rupture in 145 consecutive aneurysm procedure. METHODS: Of 10 cases of intraoperative rupture, two cases were ruptured at predissection period, six cases during dissection and two cases during clip application. RESULTS: The causes of intraoperative aneurysm rupture in our 10 cases were forceful and blunt dissection(4 cases), excessive brain retraction(2 cases), poor exposure of aneurysm neck(1 case), poor clip application(1 case), excessive removal of aneurysmal intracerebral hematoma(1 case), unknown(1 case that was ruptured during anesthesia or craniotomy). Methods of management of nine intraoperative rupture except one of rupture during craniotomy were temporary clipping to the parent artery(3 cases), tentative aneurysm clipping(2 cases), temponade with cottonid and suction(2 cases), and induced hypotension(2 cases). The final outcome of 10 cases of intraoperative aneurysmal rupture was good in 5, fair in 1, poor in 1 and dead in 2 cases. Especially cases that were ruptured during predissection period and case that were managed with induced hypotension were poor result. CONCLUSION: The use of meticulous microsurgical technique with sharp dissection around the aneurysm, a systematic contingency plan for dealing with sudden hemorrhage and the judicious use of temporary clips should serve to minimize the adverse effect of intraoperative rupture on overall management morbidity and mortality.

Syringostomy Using Myringostomy Tube in Syringomyelia Associated Type I Chiari Malformation

We describe a case of syringomyelia associated with type I Chiari malformation treated with syringostomy using myringostomy tube. The syrinx was found at C2 to C5 level, and the patient presented with quadriparesis and both shoulder pain. We performed extensive suboccipital craniectomy, C1 laminectomy, duroplasty, and then syringostomy using myringostomy tube. Postoperatively, the clinical and neurological improvement was noted and MRI showed reduced size of syrinx.

Surgical Approaches to the Middle Cranial Base Tumors

OBJECTIVE: We analysed various surgical approaches and surgical results of 28 middle cranial base tumors for the purpose of selecting optimal surgical approach to the middle cranial base tumor. METHODS: In this retrospective review, 28 patients, including 16 meningioma, 6 trigeminal neurinoma, 2 pituitary adenoma, 2 craniopharyngioma, 1 facial neurinoma, and 1 metastatic tumor, underwent surgical treatment using skull base technique. Of theses, 16 tumors were mainly confined to middle cranial fossae, 5 tumors with extension into both anterior and middle fossa, and 7 tumors with extension into both middle and posterior fossa. Tumors that confined to the middle cranial fossa or extended into the anterior cranial fossa were operated with modified pterional, orbitozygomatic or Dolen'c approach, and tumors that extended into the posterior cranial fossa were operated with anterior, posterior or combined transpetrosal approach. Completeness of tumor resection, surgical outcome, postoperative complication, and follow up result were studied. RESULTS: Total tumor removal was achieved in 9 tumors of 10 tumors that did not extended to the cavernous sinus, and was achieved in 7 tumors of 8 tumors that extended to the lateral wall of the cavernous sinus. Of 10 tumors that extended to the venous channel of the cavernous sinus, only 2 were removed totally. Surgical outcome was excellent in 14 patients, good in 10, fair in 2 and poor in 2. There were no death in this series. Dumbell type tumor which extended into both middle and posterior fossae showed tendency of poor prognosis as compared with tumors that confined middle cranial fossa and extended into both anterior and middle cranial fossa. Postoperative dysfunctions were trieminal hypesthesia in 3, oculomotor nerve palsy in 2, abducens nerve palsy in 2, hemiparesis in 2, cerebellar sign in 1, facial palsy in 1 and hearing impairment in 1. CONCLUSION: Based on our findings and a review of the literature, we conclude that, when selecting the surgical approach to the middle cranial fossa tumors, the most important factors to be considered were exact location of the tumor mass and existence of the cavernous sinus invasion by tumor mass. We recommend modified pterional or orbitozygomatic approach in cases with tumors located anterior and middle cranial base, without cavernous sinus invasion. In cases with tumors invading into cavernous sinus, we recommend Dolen'c or orbitozygomatic approach. And in lateral wall mass and the cavernous sinus, it is preferred to approach the tumor extradurally. For the tumor involing with middle fossa and posterior fossa(dumbell type) a combined petrosal approach is necessary. In cases with cavernous sinus invasion and internal carotid artery encasement, we recommend subtotal resection of the tumor and radiation therapy to prevent permanent postoperative sequele.

Efficacy of Unilateral Pallidotomy for Parkinson's Diesease

OBJECTIVES: For Parkinsonian patients who had not reacted favorably on drug therapy are good candidate for ventroposterolateral pallidotomy, although not curative. We studied these patients after unilateral pallidotomy, to confirm the effectiveness and safety of this procedure. METHODS: We evaluated the 17 patients with idiopathic Parkinson's diesease who had undergone unilateral posteroventral pallidotomy. All patients responded to levodopa initially. Mean age was 55 years(38-75years), and mean duration of disease was 9.8 years(3-20years). Pre-and postoperative evaluation at 3 month intervals included Unified Parkinson's Disease Rating scale(UPDRS) scoring, Hoehn and Yahr(H and Y) staging, and neuropsychological examinations. RESULTS: Pallidotomy significantly improved parkinsonian symptom(tremor, rigidity, bradykinesia, dyskinesia, sensory symptom). Nine of 10 patients who showed dyskinesia preoperatively significant improvement. The mean dose of levodopa in 9 patients was lowered. The mean H and Y score and UPDRS score were improved in on and/or off time in 15 patients. Among patients who were not improved, one patient worsened, and the others showed no change. The mean overall UPDRS off score changed from 76 preoperatively to 44(33%) at 6 months and from 70 to 52(25%) at 1 year. Transient surgical morbidity was showen in four patients and included dysarthria, hypotonia and confusion. CONCLUSION: We conclude that pallidotomy is safe and effective in patients who have levodopa-reponsive parkinsonism with severe symptom fluctuation. Unilateral pallidotomy also considered helpful to ipsilateral symptom. Unilateral pallidotomy can improve all of parkinsonian's symptom and allow to reduce the levodopa medication. Most of patients show satisfactory results.

Surgical Management of Trigeminal Neurinoma

No abstract available.

Clinical Analysis and Treatment Result in Posterior Inferior Cerebellar Artery Aneurysms / 대한뇌혈관학회지

OBJECTIVE: The purpose of this study is to characterize the Posterior Inferior Cerebellar Artery aneurysm distribution (location, age, sex, multiplicity and associated vascular anomalies), clinical presentation, neuroradiological findings and surgery outcome. MATERIALS AND METHODS: From Jul. '96 to Jun. '99, the admission chart and radiologic study material of 24 cases of angiographically confirmed PICA aneurysm patients were reviewed, retrospectively. RESULTS: Mean age of the patients was 53.4 years (ranged from 24 to 75), and majority of these aneurysms occurred in females (20 of 24). 22 of 24 patients presented with subarachnoid hemorrhage. The most common subarachnoid hemorrhage observed at ambient cistern, crural cistern, and the forth ventricular hemorrhage. In 19 of 24 cases the aneurysm size was 5+/-2 mm, and 23 cases show saccular aneurysm. PICA aneurysm patients have many associated intracranial vascular diseases (multiple aneurysm: 5, arteriovenous malformation: 2, abnormal vasculature: 4) and concomitant medical diseases (diabetes mellitus and tuberosclerosis). Direct surgical approaches were attempted in 22 cases (lateral suboccipital approach: 10, far lateral approach: 8, midline suboccipital: 2, pre-sigmoidal and combined approach in each case) and the surgical result was acceptable (favorable outcome: 19, unfavorable: 5). CONCLUSIONS: Based on this study, the incidence of PICA aneurysm was 1.3% and shows female predominance. In 46%, intracranial vascular abnormality was associated. On brain CT examination, subarachnoid hemorrhage at peimesencephalic cistern and intraventricular hemorrhage at the forth ventricle were most frequent CT finding. In most surgical cases, lateral or farlateral suboccipital approach was a good surgical approach enough to reach the PICA aneurysm and the surgical result was acceptable.

Crossed Cerebellar Diaschisis : Comparison of SPECT, MRI, Clinical Sign

No abstract available.

Early Change of Intracranial Pressure, Regional Cerebral Blood Flow and Cerebral Edema Depending on the Occlusion Site of the Superior Sagittal Sinus in Cats

OBJECTIVE: Although it is well known that cerebral sinus thrombosis or resection of large cerebral veins during surgery may cause venous hypertension, often leading to brain edema and intracerebral hemorrhage and the outcome is widely variable with symptoms from headache to coma, the pathophysiology of cerebral venous circulatory disturbance is poorly understood. The purpose of this study was to investigate the pathophysiological change of cerebral venous circulatory disturbance by measurement of intracranial pressure, regional cerebral blood flow and cerebral water content, and histological examination for extravasation of Evans blue dye and cerebral edema for 2 hours after occlusion of the superior sagittal sinus and diploic veins in cats. METHODS: Thirty five cats were divided into 4 groups: (1) control group, 5 cats with sham operation, (2) experiment group I, 10 cats with occlusion at the anterior 1/3 of the superior sagittal sinus, (3) experiment group II, 10 cats with occlusion at the middle 1/3 of the superior sagittal sinus, (4) experiment group III, 10 cats with occlusion at the posterior 1/3 of the superior sagittal sinus. RESULTS: The results were as follows: 1) After occlusion of the superior sagittal sinus, intracranial pressure was elevated with increased cerebral water content and regional cerebral blood flow was reduced in all experiment groups. The degree of their changes was the least in experiment group I, the most in experiment group III, and intermediate in experiment group II. 2) Extravasation of the Evans blue dye was not observed in any experiment groups 120 minutes after occlusion of the superior sagittal sinus. 3) On the histological examination, pericellular edematous change of the brain was observed in all experiment groups 120 minutes after occlusion of the superior sagittal sinus. The degree of edema also showed similar pattern in magnitude to that of changes of other parameters. CONCLUSION: These results suggest that occlusion of the middle or posterior 1/3 of the superior sagittal sinus could bring a significant harmful effect to the cerebral hemodynamics, leading to secondary brain injury and the hydrostatic edema is responsible for the cerebral swelling in early stage after occlusion of the superior sagittal sinus.