Idiopathic Hypertrophic Spinal Pachymeningitis with Spinal Cord Lesion: A Case Report / 대한신경손상학회지

Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare, diffuse inflammatory fibrosis of the dura mater that can lead to spinal cord compression. Though the optimal treatment is controversial, some reports recommend decompressive surgery and postoperative steroid therapy. However, we encountered a case of pachymeningitis that worsened after decompressive surgery. A 79-year-old woman presented with gait disturbance and bilateral lower extremity weakness that began 6 months prior. She had radiating pain on the C5 and T1 dermatomes and clumsiness in both hands. Magnetic resonance imaging (MRI) revealed diffuse thickening of the posterior longitudinal ligament of C6 to T4/5 and ligamentum flavum of C3/4 to T4/5, causing central canal stenosis and compressive myelopathy. She underwent posterior decompressive laminectomy from C4 to T1 total (T2 subtotal) and cervicothoracic screw fixation. During surgery, we found severe adhesion of the posterior longitudinal ligament and ligamentum flavum to the dura mater. Chronic inflammation with fibrosis and lymphoplasmacytic infiltration were present. After surgery, the patient's motor weakness worsened. Despite steroid treatment, her symptom severity fluctuated. Follow-up MRI obtained 3 months postoperation revealed high signal intensity from C5 to T2, possibly indicating aggravated compressive myelopathy. Thus, in this case, decompressive surgery and steroid therapy were detrimental.

Multimodal Treatment of Skull Base Inflammatory Pseudotumor: Case Report

lnflammatory pseudotumor (IPT) is a rare, non-neoplastic inflammatory process. It is most commonly occurs in the orbit, but extension into brain parenchyma is uncommon. In a confirmed case of IPT, most cases show good improvement with steroid theraphy. A 50-year-old man with progressive left-eye visual disturbance and mass lesion was admitted in a hospital. A left orbital mass biopsy revealed what was highly suspected as an inflammatory pseudotumor. Steroid pulse therapy with dexamethasone, radiation therapy, and chemotherapy with amphotericin B were performed, but they were not effective in improving the condition of the patient. Revision open surgery was then performed. A follow-up brain enhancement computerized tomography showed an enlarged mass volume and hydrocephalus with periventricular enhancement. As an additional procedure, ventriculoperitoneal shunt and tuberculosis medication were administered. About 2 weeks later, clinical symptoms and radiologic findings improved. We present a case of intra-cranial IPT and discuss further treatment methods.

A Case of Multiple Myeloma with Brain Parenchyme Involvement

Multiple myelomas (MM) are characterized by monoclonal proliferation of immunoglobulin (Ig)-secreting plasma cells. Central nervous system involvement is a rare complication of MM, and it can present as either an intraparenchymal or a leptomeningeal lesion. A 77-year-old woman was transferred from the dementia clinic in July 2012. She had a large heterogeneous signal mass with central necrosis and with pial involvement in the left frontal lobe with destruction of the frontal bone that was observed on computed tomography and magnetic resonance imaging. Multiple punched out radiolucent lesions were also noted on the skull X-ray. Serum protein electrophoresis revealed an IgA-kappa monoclonal gammopathy. External lumbar drainage was helpful for treating the fluid collection underneath the scalp after an orbitozygomatic craniotomy with duroplasty.

Simultaneous Multiple Basal Ganglia and Cerebellar Hemorrhage: Case Report

A 35-year-old man presented with simultaneous multiple intracranial hematomas in the right cerebellar dentate nucleus and left basal ganglia. The hematomas were visible by computed tomography performed within two hours of the patient's arrival. The initial computed tomography showed acute hemorrhage in the left basal ganglia and dentate nucleus in cerebellum. The patient then experienced a change of consciousness due to newly developed hydrocephalus, and emergent extra-ventricular drainage was performed. By discharge, fortunately, the patient was fully recovered.

Preliminary Report of Percutaneous Vertebroplasty for the Treatment of the Burst Fractures with Spinal Canal Encroachment / 대한신경손상학회지

OBJECTIVE: Percutaneous vertebroplasty is a minimally invasive procedure to relieve or decrease pain in patients with osteoporotic compression fractures. However, vertebroplasty in the osteoporotic burst fracture patients with preoperative canal encroachment are still being debated, because it can aggravate spinal canal encroachment. The objects of this study is evaluation of the changes in spinal canal narrowing after percutaneous vertebroplasty. METHODS: Inclusion criteria was osteoporotic bursting fracture patients with 5 to 20% canal encroachment (less than 5 mm). Exclusion criteria included pathological fractures, unstable vertebral fractures involving the posterior column, and severe neurological deficit. We measured the changes in spinal canal narrowing by pre- and postoperative computed tomography. Degree of canal encroachment was measured as the distance between the imaginary line along the posterior margin of the bony fragment and the maximal anterior imaginary line of the spinal canal in the axial CT scan. RESULTS: This study was based on 10 patients (1 male and 9 female; age range, 52-89 years; mean age, 75 years). The mean decrease in the compression rate of the vertebral body height was 14.4% (43.4% to 29%). The mean decrease in the kyphotic angle was 4.3degrees (11.7degrees to 7.4degrees). The mean preoperative canal encroachment were 3.5 mm and postoperative canal encroachment was 3.7 mm, respectively. The mean preoperative VAS score was 4.3 and postoperative VAS score was 1.4. CONCLUSION: Vertebroplasty can be a safe treatment option for osteoporotic burst fractures with preoperative minimal canal encroachment.

Bromocriptine for Control of Hyperthermia in a Patient with Mixed Autonomic Hyperactivity after Neurosurgery: A Case Report

Mixed autonomic hyperactivity disorder (MAHD) among patients with acquired brain injury can be rare. A delayed diagnosis of MAHD might exacerbate the clinical outcome and increase healthcare expenses with unnecessary testing. However, MAHD is still an underrecognized and evolving disease entity. A 25-yr-old woman was admitted the clinic due to craniopharyngioma. After an extensive tumor resection, she complained of sustained fever, papillary contraction, hiccup, lacrimation, and sighing. An extensive evaluation of the sustained fever was conducted. Finally, the cause for MAHD was suspected, and the patient was successfully treated with bromocriptine for a month.

Clinical Effects and Radiological Results of Vertebroplasty: Over a 2-year Follow-Up Period

OBJECTIVE: We investigated the association between clinical and radiological results and assessed the radiological changes according to the distribution pattern and amount of injected cement after vertebroplasty. METHODS: Two hundred and one patients underwent vertebroplasty; of these, 15 were follow up for more than 2 years. For radiological analysis, we grouped the patients according to cement distribution as follows: group 1, unilateral, unilateral distribution of cement; group 2, bilateral-uneven, bilateral distribution of cement but separated mass; and group 3, bilateral-even, bilateral single mass of cement. To compare radiologic with clinical results, we assessed the visual analogue scale (VAS) score, amount of injected cement, bone mineral density (BMD), postoperative and follow-up vertebral body compression ratios, and postoperative and follow-up kyphotic angles. RESULTS: There were 4 (26.7%) patients in group 1, 6 (40.0%) in group 2, and 5 (33.3%) in group 3. The mean VAS score was 5.2 preoperatively, 1.8 postoperatively, and 3.2 at 2-year follow-up. The 2-year follow-up compression ratio was better in patients with even distribution of injected cement (group 2 and 3) than group 1. However, it was not statistically insignificant (p>0.05). The follow-up kyphotic angle was more aggravated in the group 1 than in the other groups (p<0.05). CONCLUSION: Our study showed that vertebroplasty had a beneficial effect on pain relief, particularly in the immediate postoperative stage. The augmented spine tended to be more stable in the cases with increased amount and more even distribution of injected cement.

Magnetic Resonance Imaging in Patients with Low Back Pain

OBJECTIVE: The objective of this study was to analyze lumbar spine MRI findings and investigate their association factors with lumbar spinal degeneration. METHODS: Between March 2008 and December 2008, we retrospectively analyzed lumbar spine MRI scans of 246 patients with LBP. We used a modified MRI score for evaluation of spinal degeneration, which was obtained by modifying the Meyerding classical system. We performed Mantel Haenszel chi-square tests to compare the MRI score and associated factors. RESULTS: The mean MRI score was 12.05. The main level at which the pathological condition existed was L4-5 in 123 patients (50.2%). Statistical analysis showed that an age of over 40 years (p-value <0.0001) and symptom duration of over 5 years (p=0.0122, which is <0.05) were significantly related to a high MRI score. Annular tear, irregular nucleus shape, and reduced disc height in the lumbar spine were strongly associated with LBP. CONCLUSION: Annular tear, irregular nucleus shape, and reduced disc height in the lumbar spine were strongly associated with LBP. Especially, MRI finding in patients aged over 40 years and who experienced symptoms for 5 years or more showed higher MRI score.

Cortisol Awakening Response and Nighttime Salivary Cortisol Levels in Healthy Working Korean Subjects

PURPOSE: Cortisol awakening response (CAR) and nighttime cortisol levels have been used as indices of adrenocortical activity. However, population-based statistical information regarding these indices has not been provided in healthy subjects. This study was carried out to provide basic statistical information regarding these indices. MATERIALS AND METHODS: Cortisol levels were measured in saliva samples collected immediately upon awakening (0 min), 30 min after awakening and in the nighttime on two consecutive days in 133 healthy subjects. RESULTS: We determined the mean [standard deviation (SD)], median (interquartile range) and 5th-95th percentile range for each measure and auxiliary indices for CAR, i.e., the secreted cortisol concentration within 30 min of awakening (CARscc) and absolute and relative increases in cortisol level within 30 min of awakening (CARi and CARi%, respectively). We also determined these values for auxiliary indices derived from nighttime cortisol level, i.e., the ratio of cortisol level 30 min after awakening (CA30 min) to nighttime level (CA30 min/NC), as well as absolute and relative decreases in cortisol levels from CA30 min to nighttime (DCd and DCd%, respectively). We found no significant differences in cortisol level for any time point or in auxiliary indices between collection days, genders and ages. CONCLUSION: The provided descriptive information and statistics on the CAR and nighttime cortisol level will be helpful to medical specialists and researchers involved in hypothalamus-pituitary-adrenal axis assessment.

Intracranial Dissemination from Spinal Cord Anaplastic Astrocytoma

We report a case of intracranial dissemination developing approximately 4 months after partial removal of a spinal cord anplastic astrocytoma in a 22-year-old male. He presented with paraplegia on initial admission at a local hospital. Spinal magnetic resonance (MR) images disclosed multiple intramedullary lesions at the T3-11. The tumor was partially removed. The final histologic diagnosis was anaplastic astrocytoma. Four months after the operation, he was admitted with the symptoms of headache and deterioration of consciousness. MR images showed enhanced lesions in the anterior horn of the left lateral ventricle, and septum pellucidum. He underwent computed tomography-guided stereotactic biopsy and histological appearance was consistent with anaplastic astrocytoma. The clinical course indicates that the tumor originated in the spinal cord and extended into the subarachnoid space, first the spinal canal and later intracranial.

Successful Treatment of a Case with Rhino-Orbital-Cerebral Mucormycosis by the Combination of Neurosurgical Intervention and the Sequential Use of Amphotericin B and Posaconazole

Rhino-orbital-cerebral (ROC) mucormycosis is an uncommon, acute and aggressive fungal infection. It remains a challenging problem to clinicians despite aggressive debridement surgery and antifungal therapy. The authors describe a case of ROC mucormycosis with pericranial abscess occurring in a female patient with uncontrolled diabetes mellitus. The infection initially developed in the right-sided nasal sinus and later progressed through the paranasal sinuses with the invasion of the peri-orbital and frontotemporal region, due to the delayed diagnosis and treatment. Numerous non-septate hyphae of the zygomycetes were identified by a punch biopsy from the nasal cavity and by an open biopsy of the involved dura. The patient was treated successfully with extensive debridement of her necrotic skull and surrounding tissues, drainage of her pericranial abscess and antifungal therapy, including intravenous amphotericin B for 61 days and oral posaconazole for the following 26 days. She returned to a normal life and has had no recurrence since the end of her treatment 15 months ago.

Effects of Mindfulness Based Stress Reduction Program on Depression, Anxiety and Stress in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: In this study, the Mindfulness Based Stress Reduction (MBSR) program was applied to patients presenting with depression and anxiety after surgery from spontaneous subarachnoid hemorrhage (SAH) and the effects were assessed. METHODS: The subjects were patients admitted for cerebral aneurysm rupture and treated by means of surgery from March to December, 2007. More than 6 months had passed after surgery, without any special lesions showing up on computed tomography (CT), and the Glasgow outcome scale (GOS) was 5 points. Among patients with anxiety and depression symptoms, 11 patients completed the program. The MBSR program was conducted once a week, 2.5 hours each, for 8 weeks. The evaluation criteria were : 1) the Beck Depression Inventory (BDI): it measures the type and level of depression, 2) the State-Trait Anxiety Inventory : the anxiety state of normal adults without mental disorder, and 3) Heart Rate Variability (HRV) : the influence of the autonomous nervous system on the sinoarterial node varies continuously in response to the change of the internal/external environment. RESULTS: The BDI value was decreased from 18.5 +/- 10.9 to 9.5 +/- 7.1 (p = 0.013) : it was statistically significant, and the depression level of patients was lowered. The state anxiety was decreased from 51.3 +/- 13.9 to 42.3 +/- 15.2; the trait anxiety was reduced from 50.9 +/- 12.3 to 41.3 +/- 12.8, and a borderline significant difference was shown (p = 0.091, p = 0.056). In other words, after the treatment, although it was not statistically significant, a decreased tendency in anxiety was shown. In the HRV measurement, standard deviation normal to normal (SDNN), square root of the square root of the mean sum of squared differences between adjacent normal to normal intervals (RMSSD), and total power (TP) showed significant increase, Physical Stress Index (PSI) showed a significant reduction, and thus an improvement in the homeostatic control mechanism of the autonomic nervous system was ween. CONCLUSION: The MBSR program was applied to the patients showing anxiety and depression reaction after SAH treatment, and a reduction in depression symptoms and physiological reactions were observed. The application of the MBSR program may be considered as a new tool in improving the quality of life for patients after surgery.

Clinical Analysis of Spontaneous Subarachnoid Hemorrhage with Negative Angiography / 대한뇌혈관외과학회지

OBJECTIVE: Most cases of spontaneous subarachnoid haemorrhage (SAH) are due to a ruptured cerebral aneurysm, yet sometimes the cause of bleeding can be obscure. We report here on the results of a retrospective single-center study to determine the role of the hemorrhage patterns for the patients with a negative angiogram on admission. METHODS : A total of 480 patients with spontaneous subarachnoid hemorrhage (SAH) were admitted from January 2004 to September 2008. Of these, 44 patients were included in this study because of their negative findings on their initial angiography. SAH was diagnosed by a computed tomographic scan or lumbar puncture. The clinical grade was assessed using the Hunt-Hess grading system, Fisher's grading system and the modified Rankin scale. RESULT : The overall incidence of an initially negative angiogram for patients with a spontaneous SAH was 10.2%. Based on the hemorrhage pattern on the admission CT, the most common pattern was the diffuse type (52.3%), followed by the perimesencephalic type (29.5%), the CT negative type (11.4%) and the localized non-perimesencephalic type (6.8%). The repeat angiogram revealed an aneurysm in 3 (7.7%) patients and exploration revealed a dissecting aneruysm of the vertebral artery in 1 patient. The patients with the diffuse type SAH significantly differed from the perimesencephalic group with regard to the Fisher grade (p = 0.002), the outcome at discharge (p = 0.004) and the need for EVD. CONCLUSION : Patients with SAH of an unknown cause, especially with perimesencephalic SAH, have an excellent prognosis and low mortality. We believe that digital subtraction angiogram is still the gold standard for making the diagnosis of aneurysm in patients with spontaneous SAH. A repeat angiogram is recommended for all the patients with initially angionegative SAH. For those patients with perimesencephalic SAH and a positive CSF study with a negative CT, we suggest to perform a CT angiogram as a less invasive follow-up study.

Clinical Analysis of Cerebral Aneurysms of Posterior Circulation / 대한뇌혈관외과학회지

OBJECTIVES: We sought to examine the diverse factors associated with aneurysms of the posterior circulation. In addition, the results of conventional craniotomy were compared with those of endovascular treatment. METHODS: One hundred and one patients with posterior circulation aneurysms were selected for study inclusion. The factors that might affect the clinical outcomes were studied , such as the initial Hunt-Hess (H-H) grade, aneurysm location, size of the aneurysm, and therapeutic modalities. In addition, the morbidity and mortality rates were analyzed. The treatment outcomes were evaluated using the Glasgow Outcome Scale (GOS) 6 months after the initial insult. RESULTS: The patient population consisted of 67 women and 34 men, with a mean age of 52 (range 28-81 years). The overall morbidity and mortality rates at 6 months were 13.9% (14/101) and 17.8% (18/101), respectively. Sixty-one operations (60.3%) were performed, and 32 patients were treated with endovascular therapy. Forty-two (85.7%) of the 49 patients that had initial H-H grades of I and II had a better prognosis (GOS more than 4) than those with poor H-H grades (P<0.001). Patients that underwent endovascular treatment had better outcomes than those that had clipping (P=0.032). There was no significant difference in outcome according to the size of the aneurysm, location of the aneurysm, or the age of the patients. CONCLUSIONS: The results of this study showed that the factors affecting the prognosis were the initial HH grade and treatment modality. Considering the very high mortality rate in patients with rebleeding, early management may help improve the prognosis of patients with posterior circulation aneurysms. Endovascular therapy should be considered the primary treatment modality in patients with posterior circulation aneurysms.

A Morphometric Study on Cadaveric Aortic Arch and Its Major Branches in 25 Korean Adults : The Perspective of Endovascular Surgery

Objective: To understand the anatomic characteristics of the aortic arch (AA) and its major branches to build a foundation toward performing endovascular surgery safely. Methods: A total of 25 formalin fixed Korean adult cadavers were used. The authors investigated : anatomical variations of the AA and its major branches; curvature of the AA; distance from the mid-vertebrae line to the origin of the major branches; distances from the origin of the major branches of AA to the origin of its distal branches; and the angle of the three major branches, the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSCA) arising from AA. Results: The three major branches directly originated from AA in 21 (84%) of the cadavers. In two (8%) of remaining four cadavers, orifice of LCCA was slightly above the stem of BCT. In remaining two (8%) cadavers, the left vertebral artery (LVA) was directly originated from AA. Average angle of AA curvature to the coronal plane was 62.2 degrees. BCT originated 0.92 mm on the right of the mid-vertebrae line. LCCA and LSCA originated from 12.3 mm and 22.8 mm on the left of the mid-vertebrae line. Mean distance from the origin of the BCT to the origin of the RCCA was 32.5 mm. Mean distance from the origin of the LSCA to the origin of the LVA was 33.8 mm. Average angles at which the major branches arise from the AA were 65.3, 46.9 and 63.8 degrees. Conclusion: This study may provides a basic anatomical information to catheterize AA and its branches for safely performing endovascular surgery.

Posterior Cerebral Artery Aneurysm: Surgical Result of 11 Patients

OBJECTIVE: Eleven patients treated with posterior cerebral artery(PCA) aneurysm during 6.3-years period are retrospectively reviewed to determine treatment outcome. METHODS: Eleven patients with PCA aneurysm were treated from January 1998 to May 2004. Their medical records and radiologic studies were reviewed retrospectively. The records of these patients were analysed with particular reference to their demographic details, mode of presentation, and treatment outcome. RESULTS: Of the 11 patients, 8 patients presented with symptoms related aneurysmal bleeding. Three patients had unruptured PCA aneurysms. Open or endovascular surgery was performed in 9 patients; None of these patients exhibited a third nerve palsy, visual field deficit, or hemiparesis at the time of presentation. Postoperatively, 2 made a good recovery, 2 had a moderate disability because of cerebral infarction after surgery, and 5 had a severe disability because of cerebral infarction after surgery. Of 2 conservatively treated patients, 1 was doing well but the other died as a result of brain swelling. CONCLUSION: The treatment of the PCA aneurysms is difficult regardless of the aneurysmal size, site, and treatment modality. All reasonable treatment to reduce the risk of associated morbidity should be considered.

Clinical Experiences with Vagus Nerve Stimulation for Medically Intractable Epilepsy / 대한간질학회지

PURPOSE: Recently, Vagus nerve stimulation (VNS) has been reported to show promising results as an adjunctive therapy for medically intractable seizures. We report early experiences with VNS for medically intractable epilepsy in young adults and pediatric patients. METHODS: Eleven patients ages ranging from 7 years to 29 years underwent implantation of vagal nerve stimulators (Cyberonics, Houston, TX) from September 1999 to April 2003. We reviewed clinical findings in 11 patients and recorded changes of seizure frequency, quality of life (QOL), and antiepileptic drug (AED). RESULTS: The mean age of seizure onset was 4.5 years old (range:3 months-11 years). The seizure duration before VNS was mean 8.7 years (range:1.5-19 years). Seven patients had symptomatic partial epilepsies, and one had cryptogenic partial epilepsy. Unclassified patients had 2 Lennox-Gastaut syndrome and 1 reflex epilepsy. Two patients received total callosotomy for reducing drop attack, but refractory. One patient, who underwent a temporal lobectomy, failed to obtain desirable results. One implantation was performed with total callosotomy, simultaneously. All of implantations were successful, except for one wound revision due to a subcutaneously protruded anchoring device of electrode. About two weeks after the implantation, programming of the stimuli was started and increased the output current to the levels, at which patients was tolerated. The most common adverse effect was hoarseness or voice alteration (44%). Mean reduction of seizure frequency compared with baseline before VNS was 23.6% after 3 months, 33.5% after 6 months, 41.3% after 1 year, and 46.6% at latest follow-up. Three patients had no response to VNS. One patient was added 1 one new AED after VNS. Two patients were reduced 1 or 2 drugs. But there was no correlation between VNS effect and AED change. Six patients had some improvement of QOL. Mean follow-up period, which was 28 months (range:12-48 months). CONCLUSIONS: We concluded that VNS has a role of adjunctive therapy for medically intractable epilepsy and the further studies should be focused on the prediction of unresponsiveness and the adjustment of VNS parameters for maximal efficacy in patients with various backgrounds.

Incidence and Pathophysiology of Cerebral Hemorrhagic Stroke in the Elderly / 대한뇌혈관학회지

As the number of elderly people increases, the incidence of stroke, especially the hemorrhagic stroke, is increasing. A large-scale survey of the entire country pertaining to the incidence and demographic characteristics of hemorrhagic stroke in elderly is necessary. Through information garnered from a basic survey and clinical study, we must design a treatment program to reduce the mortality of elderly people through elucidating the specific properties of stroke pathophysiology.

Intradural Extramedullary Spinal Metastasis: A Case Report

No abstract available.