Common Carotid Artery Dissection in Multiple Extracranial Injury: A Case Report / 대한신경손상학회지

Traumatic common carotid artery dissection (CCAD) is rare. To our knowledge, only 14 case reports have described traumatic CCAD previously. Here, we report a case of CCAD in a patient with severe trauma. A 50-year-old man was lying on the road after drinking alcohol when a car drove over him. Computed tomography (CT) revealed multiple rib fractures with hemopneumothorax, lung contusion, flail chest, large amount of hematoma with bladder rupture, and fractures on the C6 spinous process, sacral ala, iliac bone, and pubic ramus. Repair of the bladder rupture, exploratory thoracotomy, and open reduction of multiple rib fractures were performed. Right side hemiparesis was observed on hospital day 4. Brain CT showed a large acute left middle cerebral artery infarction. CT angiography showed focal carotid dissection at the left common carotid artery with intimal flap. The CCAD was located at the C6 level. Clexane (enoxaparin sodium) treatment was initiated. An abdominal CT scan revealed a huge retroperitoneal hematoma and increased amount of hematoma in the prevesical and perivesical space, 10 days later. The patient died two days later. Although traumatic CCAD is rare, this case report provides useful information for trauma surgeons regarding the treatment and diagnosis of similar cases.

Intermediate Pilomyxoid Astrocytoma in the Cerebellum of a 5-Year-Old Boy

Intermediate pilomyxoid tumors (IPTs) were defined by the presence of some features typical of pilomyxoid astrocytoma (PMA) in combination with features that could be considered more consistent with pilocytic astrocytoma (PA). PMA is rare in the cerebellum. And, IPT in the cerebellum is rarer than PMA. To our knowledge, only 2 reports have described IPT in the cerebellum. A 5-year-old boy had nausea and vomiting. Computed tomography revealed a large, round, low-density tumor in the cerebellar vermis area. On enhanced magnetic resonance imaging (MRI), the tumor showed inhomogeneous diffuse enhancement; the central portion showed homogenous enhancement, while the peripheral portion showed inhomogeneous enhancement. The patient underwent a midline suboccipital craniotomy, and gross total resection was performed. The tumor was gray-colored, rubbery hard, and severely hemorrhagic with a clear boundary. On pathologic examination, the combined features of both PA and PMA were retrospectively indicative of an IPT. The patient was symptom-free for 18 months, with no evidence of tumor recurrence on MRI. More observation and further studies on PMA and IPT are required to determine the most appropriate treatment for these tumors.

Posterior Epidural Herniation of a Lumbar Disk Fragment at L2–3 That Mimicked an Epidural Hematoma

Lumbar disk herniation is common. Because of the posterior longitudinal ligament, migration usually occurs into the ventral epidural space. Rarely, fragments migrate into the dorsal epidural space. A 57-year-old man presented with lower back pain and weakness on right hip flexion and right knee flexion. He had lower back pain 1 day previously and received a transforaminal epidural block at a local hospital. The next day, he reported weakness of the right lower extremity. Lumbar spine magnetic resonance imaging revealed a dorsal epidural lesion with compression of the thecal sac at L2–3. Initial differential diagnoses included epidural hematoma after the block, neoplasm, and a sequestrated disk. Posterior lumbar decompression was performed. The lesion was identified intraoperatively as a large herniated disk fragment. Posterior epidural herniation of a lumbar disk fragment is rare and may be difficult to diagnose preoperatively. It may present as a variety of clinical scenarios and, as in this case, may mimic epidural hematoma.

Navigation-guided K eyhole Approach for Unruptured Intracranial Aneurysms / 대한뇌혈관외과학회지

OBJECTIVES: In vascular neurosurgery, the pterional approach has primarily been used in the treatment of a wide variety of diseases. However, there has been an increasing interest in minimally invasive procedures or keyhole approaches for treating cerebral aneurysms. We report our experience with a neuronavigation-guided keyhole approach in the treatments of various intracranial aneurysms. METHODS: Between December 2008 and December 2010, 32 patients with unruptured intracranial aneurysms were treated by direct surgical neck clipping through the neuronavigation-guided keyhole approach. A 4 to 5 cm-sized skin incision and a small 2.5 x 4 cm craniotomy was performed around the sylvian fissure. The remainder of the aneurysm surgery was performed using conventional microsurgical techniques. RESULTS: The enrolled patients comprised 15 men and 17 women, with a mean age of 63.06 years (range, 47 to 79 years). Of these, 21 aneurysms were in the middle cerebral artery (MCA) bifurcation; 3, in the M1; 5, in the posterior communicating artery segment; 2, in the anterior communicating artery; and 1, in the anterior choroidal artery segment. The size of the aneurysms ranged from 3.5 to 4.8 mm. Mean operation time was 2.19 hours (range, 100 to 150 minutes). All patients were clipped successfully. There were no procedure related complications. CONCLUSION: We suggest that the navigation-guided keyhole approach is useful for the treatment of anterior circulation aneurysms in selected cases. It has the advantages of less operative time, fewer days of hospitalization, and cosmetic results.

Navigation-guided K eyhole Approach for Unruptured Intracranial Aneurysms / 대한뇌혈관외과학회지

OBJECTIVES: In vascular neurosurgery, the pterional approach has primarily been used in the treatment of a wide variety of diseases. However, there has been an increasing interest in minimally invasive procedures or keyhole approaches for treating cerebral aneurysms. We report our experience with a neuronavigation-guided keyhole approach in the treatments of various intracranial aneurysms. METHODS: Between December 2008 and December 2010, 32 patients with unruptured intracranial aneurysms were treated by direct surgical neck clipping through the neuronavigation-guided keyhole approach. A 4 to 5 cm-sized skin incision and a small 2.5 x 4 cm craniotomy was performed around the sylvian fissure. The remainder of the aneurysm surgery was performed using conventional microsurgical techniques. RESULTS: The enrolled patients comprised 15 men and 17 women, with a mean age of 63.06 years (range, 47 to 79 years). Of these, 21 aneurysms were in the middle cerebral artery (MCA) bifurcation; 3, in the M1; 5, in the posterior communicating artery segment; 2, in the anterior communicating artery; and 1, in the anterior choroidal artery segment. The size of the aneurysms ranged from 3.5 to 4.8 mm. Mean operation time was 2.19 hours (range, 100 to 150 minutes). All patients were clipped successfully. There were no procedure related complications. CONCLUSION: We suggest that the navigation-guided keyhole approach is useful for the treatment of anterior circulation aneurysms in selected cases. It has the advantages of less operative time, fewer days of hospitalization, and cosmetic results.

Spontaneous Regression of Lumbar Herniated Intervertebral Disc

Although the spontaneous regression of herniated intervertebral disc(HIVD) is well documented, the most useful and effective treatment protocol for symptomatic HIVD remains controversial. Here, we present a rare case of spon- taneous regression of lumbar HIVD. A 43-year-old woman presented with a pain in her lower back and right lower limb radiating from the buttock to the calf. Straight-leg raising test was positive at 30 degrees on the right side. Magnetic resonance imaging(MRI) revealed right-sided extrusion of an L5-S1 disc fragment with caudal migration; the disc fragment compressed the dural sac and nerve root at this level. The patient refused surgery and was, therefore, managed with conservative therapy comprising bed rest, epidural block, muscle relaxants, and nonsteroidal anti- inflammatory drugs(NSAIDs) for 45 days. At a follow-up after 45 days of this therapy, all the initial symptoms of the patient disappeared completely and a follow-up MRI showed regression of the disc fragment. The exact mecha- nism that prompted this regression is still unclear. However, as shown in our case, lumbar HIVD may spontaneously regress, implying that conservative treatment should be given additional importance in the treatment of HIVD.