Pituitary Apoplexy Mimicking Meningitis

Pituitary apoplexy is a rare but life-threatening disorder. Clinical presentation of this condition includes severe headaches, impaired consciousness, fever, visual disturbance, and variable ocular paresis. The clinical presentation of meningeal irritation is very rare. Nonetheless, if present and associated with fever, pituitary apoplexy may be misdiagnosed as a meningitis. We experienced a case of pituitary apoplexy masquerading as a meningitis. A 42-year-old man presented with meningitis associated symptoms and initial imaging studies did not show evidence of intra-lesional hemorrhage in the pituitary mass. However, a follow-up imaging after neurological deterioration revealed pituitary apoplexy. Hereby, we report our case with a review of literatures.

Thromboxane A2 Synthetase Inhibitor Plus Low Dose Aspirin : Can It Be a Salvage Treatment in Acute Stroke Beyond Thrombolytic Time Window

OBJECTIVE: There is no proven regimen to reduce the severity of stroke in patients with acute cerebral infarction presenting beyond the thrombolytic time window. Ozagrel sodium, a selective thromboxane A2 synthetase inhibitor, has been known to suppress the development of infarction. The antiplatelet effect is improved when aspirin is used together with a thromboxane synthetase inhibitor. METHODS: Patients with non-cardiogenic acute ischemic stroke who were not eligible for thrombolysis were randomly assigned to two groups; one group received ozagrel sodium plus 100 mg of aspirin (group 1, n=43) and the other 100 mg of aspirin alone (group 2, n=43). Demographic data, cardiovascular risk factors, initial stroke severity [National Institute of Health Stroke Scale (NIHSS) and motor strength scale] and stroke subtypes were analyzed in each group. Clinical outcomes were analyzed by NIHSS and motor strength scale at 14 days after the onset of stroke. RESULTS: There were no significant differences in the mean age, gender proportion, the prevalence of cardiovascular risk factors, stroke subtypes, and baseline neurological severity between the two groups. However, the clinical outcome for group 1 was much better at 14 days after the onset of stroke compared to group 2 (NIHSS score, p=0.007, Motor strength scale score, p<0.001). There was one case of hemorrhagic transformation in group 1, but there was no statistically significant difference in bleeding tendency between two groups. CONCLUSION: In this preliminary study, thromboxane A2 synthetase inhibitor plus a low dose of aspirin seems to be safe and has a favorable outcome compared to aspirin alone in patients with acute ischemic stroke who presented beyond the thrombolytic time window.

Clinical Characteristics and Outcome Predictor of Hypertensive Intracerebral Hemorrhage in the Very Elderly / 대한뇌혈관외과학회지

OBJECTIVE: We investigated clinical characteristics and independent outcome predictors of hypertensive intracerebral hemorrhage(ICH) in the very elderly patients. METHODS: From January 2001 to December 2005, we analyzed retrospectively 28 very elderly patients(> or = 80 years) with hypertensive ICH admitted to our neurosurgical department. As a control group, 200 younger patients( or = 80 years than in the control group(35.7% vs. 19.0%, respectively, p = 0.005). By multivariate analysis, in ICH patients > or = 80 years, only coma(Glasgow coma scale score < or = 8) was independently associated with 30-day mortality(odds rati[OR]25.5, 95% confidence interva[CI]2.36 - 275.74, p < 0.001). CONCLUSION: Our result suggests that the very elderly patients with hypertensive ICH may present some different clinical characteristics from those in their younger counterparts.

Spinal Cord Compression as Initial Presentation of Follicular Thyroid Carcinoma

Follicular thyroid carcinoma with metastasis rarely manifests as spinal cord compression without any previous symptoms of its malignancy. This report describes a 64-year-old man with follicular thyroid carcinoma who presented initially with left arm motor weakness. Magnetic resonance images demonstrated severe cervical cord compression by a mass with destruction of C4 vertebra. Corpectomy of C4 and anterior interbody fusion was carried out. Histopathological study revealed a metastatic follicular carcinoma of the thyroid. We present our case, especially focused of its possible pathophysiology, with review of pertinent literatures.

Bilateral Traumatic Hemorrhage of the Basal Ganglia

Bilateral traumatic hemorrhage of the basal ganglia is an extremely rare neuropathologic entity. This report describes a 50-year-old man with bilateral basal ganglia hemorrhage with occipital fracture of the skull after head trauma. The mechanism of development of traumatic hemorrhage of the basal ganglia has been not clear. But, it is presumed to be secondary to rupture of the lenticulostriate or anterior choroidal artery by shearing as a result of acceleration/deceleration forces. We briefly summarize our uncommon case and discuss its possible mechanisms.

Vertebral Metastasis from Squamous Cell Carcinoma of the Anal Canal

Distant metastasis of squamous cell carcinoma from the anal canal is an uncommon event. However, hematogenous spread to the vertebrae may occur in the course of this disease. The route of metastasis from the anal canal seems to be Batson's vertebral venous system. A 52-year-old female patient presented with lower back and right leg pain of one-week history. She has undergone radiotherapy and chemotherapy for squamous cell carcinoma of the anal canal and then was followed by surgical resection. Three months later, magnetic resonance images of the lumbar spine disclosed a well-enhanced mass of L5 vertebral body compressing the thecal sac. Surgical decompression and biopsy were performed. Histopathological study confirmed carcinoma of the squamous cell origin. We report a rare case of vertebral metastasis from squamous cell carcinoma of the anal canal with a pertinent review of literature.

An Experience of Management of Homeless Neurosurgical Patients

OBJECTIVE: Homeless patients probably have epidemiologic features that are different from those of general population. However, there have been no published articles about clinical characteristics of neurosurgical homeless patients. The authors tried to assess the clinical characteristics and treatment outcome of homeless neurosurgical patients. METHODS: We retrospectively reviewed the medical records and radiological films of 76 homeless patients and 72 non-homeless patients following head trauma who were admitted to our neurosurgical department between June 2001 and June 2005. We compared two groups of the patients with the demographics, the clinical and laboratory characteristics. Also, 30-day mortality was determined according to Glasgow Coma Scale (GCS) score. RESULTS: Age of homeless patients was younger than that of non-homeless patients. Homeless patients had previous craniotomy evidences in skull x-rays more frequently (10.5% vs. 1.4%). Acute subdural hematoma was the most common type of head injury in the two groups. Moderate and severe head injury, based on GCS score on admission was more frequent in homeless patients (64% vs. 39%). Fifty percent of homeless patients underwent operation for traumatic head injury. However, 30-day mortality according to GCS score was not significantly higher in homeless patients. CONCLUSION: Most homeless neurological patients were relatively young men. Also, moderate or severe brain injuries were observed more frequently. However, mortality rate of homeless patients in neurosurgical field is not significantly higher in the present study.

An Experience of Management of Homeless Neurosurgical Patients

OBJECTIVE: Homeless patients probably have epidemiologic features that are different from those of general population. However, there have been no published articles about clinical characteristics of neurosurgical homeless patients. The authors tried to assess the clinical characteristics and treatment outcome of homeless neurosurgical patients. METHODS: We retrospectively reviewed the medical records and radiological films of 76 homeless patients and 72 non-homeless patients following head trauma who were admitted to our neurosurgical department between June 2001 and June 2005. We compared two groups of the patients with the demographics, the clinical and laboratory characteristics. Also, 30-day mortality was determined according to Glasgow Coma Scale (GCS) score. RESULTS: Age of homeless patients was younger than that of non-homeless patients. Homeless patients had previous craniotomy evidences in skull x-rays more frequently (10.5% vs. 1.4%). Acute subdural hematoma was the most common type of head injury in the two groups. Moderate and severe head injury, based on GCS score on admission was more frequent in homeless patients (64% vs. 39%). Fifty percent of homeless patients underwent operation for traumatic head injury. However, 30-day mortality according to GCS score was not significantly higher in homeless patients. CONCLUSION: Most homeless neurological patients were relatively young men. Also, moderate or severe brain injuries were observed more frequently. However, mortality rate of homeless patients in neurosurgical field is not significantly higher in the present study.

Paradoxical Deterioration of Intramedullary Spinal Tuberculomas during Antituberculous Therapy

"Paradoxical deterioration" during antituberculous therapy is generally defined as the clinical or radiological worsening of pre-existing tuberculous lesions or the development of new lesions in a patient who initially improves. The phenomenon of paradoxical deterioration in intramedullary tuberculoma of the spinal cord is rare and is a less established entity. The authors present an unusual case of paraparesis as a result of paradoxical deterioration of intramedullary tuberculoma despite adequate antituberculous therapy. Here, we review the relevant literatures and discuss its possible pathogenic mechanisms.

Risk Factors of Postoperative Hematomas after Surgery for Intracranial Meningiomas

OBJECTIVE: Meningioma is a benign tumor which has a high occurrence rate of postoperative hematomas. The purpose of this study is to analyze risk factors for postoperative hemorrhages after meningioma surgery. METHODS: One hundred and fifty three patients with intracranial meningiomas, operated at the Department of Neurosurgery, National Medical Center, between January 1995 and December 2003 were included in this retrospective study. Risk factors considered to be related with postoperative hematomas were age, sex, preoperative pharmacological anticoagulants for medical co-morbidity, tumor location, histological type of the meningioma, infiltration of dural sinus and arachnoid, removal range of tumors, and the perioperative coagulation status including prothrombin time, partial thromboplastin time, and platelet count. RESULTS: Patients' aged more than 70 years with a platelet count of less than 150 x 10(9) l(-1) after surgery had statistically significant relations to the occurrence rate of postoperative hematomas. The other factors had no statistical significance. CONCLUSION: Various and intensive preoperative examinations for coagulation factors of patients, especially of older age, and proper transfusion before meningioma surgery are necessary for preventing postoperative hematoma.

Observation between Clinical Outcomes and the Size of the Syrinx with Magnetic Resonance Image

OBJECTIVE: This study was conducted to examine the correlation between clinical outcomes and the size of the syrinx in post-operative magnetic resonance imaging(MRI) and symptom duration. METHODS: The authors investigated twelve patients who underwent various operations for syringomyelia from January 1995 to December 2003. The authors retrospectively analyzed medical records, pre- and post-operative MRI findings, features and durations of symptoms, and the method of surgical treatments. The clinical outcomes were assessed on Prolo scale at 6 months of post-operative period. RESULTS: Neurologic symptoms did not promptly disappear after the shrinkage of syrinx, but post-operative MRI demonstrated most patients showed reductions in the size of the syrinx. There is no statistical relationship between clinical improvements and decrements of the syrinx size. However, patients who underwent surgical treatment within 2 years from the symptom onset had more favorable outcome than those who had operations after 2 years from the onset of symptoms. CONCLUSION: Change in the size of the syrinx in post-operative MRI is not directly proportional to favorable clinical outcomes. However, symptom duration before surgical treatment has considerable impact on the clinical outcomes.

Respiratory Arrest due to Tension Pneumoperitoneum and Pneumomediastinum without Pneumothorax: Complication of the Lumbar Spinal Surgery

The authors present a case of respiration arrest after posterior lumbar interbody fusion. This rare complication occurred because of the tension pneumoperitoneum and pneumomediastinum. We report the pathophysiology and treatments.

Clinical Results of Radiofrequency Dorsal Root Entry Zone Coagulation for Paraplegic Pain

OBJECTIVE: Dorsal root entry zone(DREZ) operation has been the most common surgical treatment for paraplegic pain in the past, but the results differ according to the patients. In this study, we attempt to analyze the results from the patients by the different patterns of the pain before the surgery. METHODS: A total of twelve paraplegic patients have undergone a total of thirteen radiofrequency DREZ coagulation procedures between April 1994, and March 2003. The patients were divided depending on patients' subjective description on the character, frequency, and range of pain. RESULTS: The patients were divided into the two groups, postoperatively: improvement of more than 75% of pain was defined as treatment success, and any level less than 75% of improvement was defined as treatment failure. Eight of the ten mechanical pain group cases were regarded as treatment success, and remaining two cases with thermal type of pain as treatment failure. Also, one case with combined pain failed to obtain any favorable outcome. Intermittent pain group (6 of 7 cases), continuous pain group (2 of 6 cases), and localized pain group (7 of 11 cases) showed treatment success, respectively. However, diffuse pain group (1 of 2 cases) resulted in poor outcome. CONCLUSION: Radiofrequency DREZ coagulation is more effective in managing intermittent and/or mechanical pain than continuous and/or thermal pain in the paraplegic patients following spinal cord injury.

Surgical Outcome and Prognostic Factors of Hypertensive Putaminal Hemorrhage in the Elderly Patients

OBJECTIVE: The aim of this study is to describe the surgical outcome and determine prognostic factors of hypertensive putaminal hemorrhage in the elderly patients. METHODS: In a retrospective study, we analyzed the surgical outcome of 61 patients under 50 year-old (the younger group) and 57 patients over 70 year-old (the older group) with hypertensive putaminal hemorrhage treated from April 1998 to May 2002 in our institution. Neurological condition, brain computed tomography characteristics, and previous disease were analysed to select prognostic factors. The Glasgow Outcome Scale after six months was used for comparison of outcome. RESULTS: Of 16 patients with an initial GCS of 3-6, six of the younger group (86%) and nine of the older group (100%) had poor outcomes (p=0.062). Of 64 patients with an initial GCS of 7-11, 24 of the younger group (73%) and 23 of the older group (74%) had good outcomes. Of 38 patients with an initial GCS of 12-15, 20 of the younger group (95%) and 16 of the older group (94%) had good outcomes. Of 58 patients with moderate hematoma (30-50ml), 23 of the younger group (79%) and 22 of the older group (76%) had good outcomes. Of 30 patients with large hematoma (>50ml), 6 of the younger group (40%) and 5 of the older group (33%) had good outcomes (P=0.144). Of 21 patients with intraventricular hemorrhage, 6 of the younger group (60%) and 10 of the older group (91%) had poor outcomes (2.6 versus 1.8: p=0.016). Of 13 patients with hydrocephalus, 4 of the younger group (67%) and 7 of the older group (100%) had poor outcomes (2.5 versus 1.4: p=0.006). The surgical outcome of hypertensive putaminal hemorrhage showed no significant difference in the older group compared with the younger group. Outcome was worse in the older group with intraventricular hemorrhage or hydrocephalus. CONCLUSION: We conclude that surgical treatment for hypertensive putaminal hemorrhage in the elderly patients without intraventricular hemorrhage or hydrocephalus is needed. Poor prognosis in elderly patients is significantly associated with intraventricular hemorrhage and hydrocephalus.

Spinal Epidural Cavernous Hemangioma of the Upper Thoracic Vertebrae: Case Report

Primary spinal epidural cavernous hemangioma has been rarely reported in the literature. The authors report a case of spinal epidural cavernous hemangioma on C7-T3 in a 46-year-old man suffered from sensoirmotor impairment and gait disturbance. Based on the imaging characteristics and review of literatures, the roles of preoperative neuroradiological diagnosis and the need for complete surgical resection are discussed.

Clinical Experience of Anterior Cervical Interbody Fusion with the PCB System

OBJECTIVE: The purpose of the study was to evaluate the clinical and radiological results after discectomy and Lubboc bone graft in the surgical management of the cervical diseases with a new titanium interbody implant and integrated screw fixation(PCB) by anterior approach. METHODS: The authors retrospectively analyzed 28 cases of anterior cervical fusion with PCB system and Lubboc bone(xeno graft) from september 1998 to december 2000. Twenty-eight patients with cervical diseases underwent decompression cervical lesion and followed from 5 to 27 months with a mean follow-up of 14 months. There patients were evaluated with clinically and radiologically at immediate postoperative period and at 3, 6, 9, and 12 months. RESULT: The authors investigated the pre- and postoperative intervertebral disc space, clinical outcomes, radiography fusion rate, and Cobb angle in the fixed segments by anterior approach. The lordotic angles and height of disc space were increased after the operation. The clinical outcome of patients follow-up was good or excellent result based on Odom's criteria with improvement of clinical symptom in about 92.9% of the cervical diseases. Two patients showed loosening of the lower and upper cervical screw of PCB instruments, and two patients showed swallowing difficulty and wound infection. CONCLUSION: The PCB system is a new implant for anterior cervical interbody fusion in the degenerative cervical disease and disc herniations. It provides immediate stability and segment distraction. The results of this study indicate that the PCB system is safe, easy handling of hardware, less complications, high fusion rate, and has provide the keeping the intervertebral disc space height and lordotic angles.

Clinical Analysis of Stereotactic Aspiration and Conservative Management in Spontaneous Thalamic Hematoma

OBJECTIVES: The purpose of this study is to review our experience with spontaneous thalamic hemorrhage. Clinical outcome of patients was brought about by comparing stereotactic aspiration and conservative medical therapy. METHODS: The study consists of seventy-three cases with spontaneous thalamic hemorrhage which were treated from the period of Jan. 1993 to Dec. 1999. Thirty-eighty patients were treated with computed tomography (CT) guided stereotactic aspiration and thirty-five patients were treated conservatively. We compared the factors affecting treatment and the factors are as follows: age and sex, conscious level on admission, hematoma volume, hematoma sites, presence of ventricular penetration. RESULTS: The results in the thirty eight stereotactic aspirated cases for the 6 months from oneset are as follows: good recovery or moderate disability in 43%, severe disability in 32%, vegitative state in 11%, dead in 13% respectively. The clinical result was more favorable in stereotactic aspiration, with 11-30cc hematoma volume, extend to internal capsule of hematoma, poor conscious level on admission than conservative medical therapy. But age and sex, conscious level on admission, presence of ventricular penetration were not influential in the statistical outcome between stereotactic aspiration and conservative medical therapy. CONCLUSION: Treatment modality of spontaneous thalamic hemorrhage is still controversial. But stereotactic aspiration is more recommended for improvement therapeutic results than conservative treatment or open craniotomy in case of 11-30cc hematoma volume, extend to internal capsule of hematoma and poor conscious level on admission.

Clinical Review of Cerebral Subdural Empyema

OBJECTIVE: The purpose of this study was to review our experience with subdural empyema. Clinical presentation, methods of diagnosis, results of microbiological tests, types of therapy, and outcome of patients are presented and compared with previous reports. METHODS: The study consists of 10 patients with subdural empyema treated from January 1988 to December 1997. Clinical records and radiologic studies were reviewed retrospectively. The patient population consisted of 8 men and 2 women, whose ages ranged from 12 to 65 years(mean 49.1 years). Diagnosis of subdural empyema was confirmed with contrastenhanced CT scanning or Gadoliniumenhanced MR imaging. Seven patients received surgical treatments and three patients were treated with a multiple antibiotics only. RESULTS: The subdural empyema have been found to occur most commonly after paranasal sinusitis and postoperative infection in four cases respectively, otitis media and mastoiditis in one case respectively. The organism were found to be staphylococci in three cases, streptococci in two cases, anaerobic streptococci in one case, sterile in one case, and unknown in three cases. Relative frequency of signs and symptoms revealed fever in eight cases, headache in seven cases, vomiting in five cases, hemiparesis in three cases, and epilepsy in two cases. The outcome was revealed good in eight cases, poor in two cases. CONCLUSION: Although subdural empyema is considered a rare condition, it constitutes between 13 and 23 per cent of all intracranial infectin. It usually presents as a fulminant clinical picture and rapid neurological deterioration. In this sense, it constitutes a true neurosurgical emergency. Diagnosis of subdural empyema is best made by either CT with contrast or by MRI. Both of these tests are also helpful in establishing the presence or absence of sinusitis. Subsequently, surgery along with antibiotics help to lower mortality rate. Antibiotics therapy should be selected according to final culture results and continued for 4 to 6 weeks. The general consensus is in favour of early drainage to reduce the mortality and clinical deterioration. In our study, the overall mortality rate was 0%, and 20% of patients had neurological deficiencies at the time of discharge from the hospital. It is very important for clinician to detect this condition early to keep low mortality and morbidity.

Factors Affecting Brain Re-expansion after Simple Burr Hole Drainage in Chronic Subdural Hematoma

Delayed brain re-expansion is one of the most frequent problems on the chronic subdural hematoma. The aim of this study is to determine the factors affecting brain re-expansion. The study consists of 76 patients with the chronic subdural hematoma treated primarily by simple burr-hole drainage from January 1992 to December 1996. Clinical records and radiologic studies were reviewed retrospectively. The age distribution ranged from 22 to 82 years(mean 64 years), the male-to-female ratio was 1.8:1(49:27). At the 2nd, 4th, 6th and 12th week after surgery, the follow-up study was performed with computed tomography or magnetic resonance image. Complete brain reexpansion was defined as that the subdural space was 5mm or less without midline shift on computed tomography or magnetic resonance image. The factors interfering the brain re-expansion are as follows; d age, low Glasgow Coma Scale(GCS) score on admission, history of chronic alcohol consumption, hypodense hematoma on computed tomography, bilateral hematoma, disappearance of intraoperative brain pulsation, and long duration after trauma. The results of this study may be helpful to predict the brain re-expansion after simple burr-hole drainage. If the complete brain re-expansion is not observed immediately, it should be waited for 6 weeks to conduct the follow-up study. Patient's position and sufficient hydration are important for brain expansion. Further investigations on other factors related to promotion of the brain re-expansion should be followed.

Treatment of Aneurysmal SAH with CRF

There are several difficulties in treating aneurysmal subarachnoid hemorrhage(SAH) with chronic renal failure(CRF). First, fluid therapy is not feasible especially in vasospasm. Second, hypertonic solution therapy used to reduce intracranial pressure(ICP) is restricted. Third, hemorrhage2) and disequilibrium syndrome1)2)9) associated hemodialysis can occur. In this article, the authors experienced two cases of aneurysmal SAH with CRF. The first patient was a 57-year old man who suffered from CRF for 8 years. Magnetic resonance angiography had demonstrated a middle cerebral artery(MCA) bifurcation aneurysm on right side. He was treated with early surgery and recovered without neurological deficits. The second patient was a 43-year old woman who suffered from CRF for 5 years. Posterior communicating artery(P-Com) aneurysm was identified on the left side and delayed surgery was performed. After operation, vasospasm occurred and she died of brain swelling from infraction on the left MCA territory. It is noteworthy that the most important factor in aneurysmal SAH with CRF is the prevention vasospasm, because the use of fluid and hypertonic solution therapy is not feasible. To prevent vasospasm, early operation is warranted for the removal of SAH during operation. Non-anticoagulant agent hemodialysis is used during pre and post operative period.