Direct Microsurgical Clipping of Cavernous Carotid Artery Aneurysms

We have recently operated directly on two patients with multiple aneurysms including cavernous carotid artery aneurysms(CCAAS). The pterional extradural transclinoidal and intradural transcavernous approach was used for CCAAS in two patients. Both two CCAAS could be clipped in Dolenc's anteromedial triangle between the optic nerve and the IIIrd nerve. There was no surgical mortality and morbidity was minimal. The combined extradural and intradural transcavernous approach was very useful and safe for direct clipping of CCAAS.

Direct Microsurgical Repair of Traumatic Carotid-Cavernous Fistula

The case of a 55-year-old male developed high flow carotid-cavernous fistula(ccF) after head trauma was successfully treated by a direct microsurgical approach to the cavernous sinus. The cavernous sinus was approached through Dolenc's anteromedial and paramedical triangle by a combined extradural and subdural route. A single tear in the wall of horizontal segment of the cavernous carotid artery was obliterated using Sugita clip while temporary clips were placed on the supraclinoid and the petrous portion of the internal carotid artery.

A Combined Extra and Intradural Direct Microsurgical Approach to Tumors Involving the Cavernous Sinus

A series of seven tumors involving the cavernous sinus operated on from February 1990 to March 1991 is reported. There were 3 meningiomas, 2 neurilemmomas, 1 cavernous hemangioma, and 1 pseudotumor. After a standand pterional craniotomy, bone is removed from the posterior part of the orbital roof, the optic canal, the lesser sphenoid wing, and the anterior clinoid process. Next important step of the extradural stage is unroofing petrous bone over the internal carotid artery, if the proximal control is needed, after the exposure of the foramen rotundum, ovale, and spinosum. Intradural stage is consisted of sectioning of carotid rings and identification of III, IV and V cranial nerves which is associated with removal of tumors through various triangles according to the size and location of the tumor. None of patients died or suffered permenent neurologic deficit postoperatively.

Comparative Analysis of Management of Intracerebral Hematoma

Retrospective analysis of 46 patients with intracerebral hematoma showed that the attack was most frequent in sixth decade and more prevalent in female. The most common cause of the attack was hypertension(80%) and the site of hemorrhage was putamen 32%, thalamic area 15%, subcortical area 7%, cerebellum 17%, ventricle 3%, and brain stem 4%. Mortality of total cases was 36% and there was no difference of mortality in both conservatively or operatively treated group(38% in conservative group, and 35% in operative group). The prognosis of the patient was unfavorable in the group of poor pretreatment Glasgow coma scale(GCS) and those of cases demonstrated more than 30cc of hematoma on computerized tomography(CT) of the brain. The improvement of GCS after management was better in operative group than in the conservative group.

Evaluation of Reversibility of Cerebral Infarction by Somatosensory Evoked Potentials in Experimental Focal Cerebral Ischemia

Somatosensory evoked potentials(SSEP's) are commonly employed to monitor cerebral and spinal cord function in patients with various lesions in the nervous system. In this study, we evaluated SSEP's as a means of measuring not only neurophysiological function but also the alteration of blood folw in the territory of cerebral ischemia. We examined SSEP's and regional cerebral blood flow(rCBF) in the bilateral suprasy1vian gyri following unilateral middle cerebral artery(MCA) occlusion in 15 cats(Group II). The duration of arterial occlusion was 30 minutes followed by 1 hour of recirculation. Five additional cats served as sham-operated groups(Group I). The animals in Group II were divided into 2 subgroups according to the change of the observed rCBF in the ipsilateral hemisphere. Immediately after MCA occlusion, rCBF decreased from around 50 to 14mg/100g/min. Decreased rCBF was remained below 20ml/100g/min throughout the ischemic period in 6 cats(Group IIb), and in the remaining 9 cats, the decreased rCBF was increasing during ischemia although the blood flow was subnormal(Group IIa). The recovery of rCBF during recirculation was faster in Group IIa than in Group IIb. In Group IIa and IIb, there was a significant slowing of the interpeak latency between dorsal column nuclei(Fz) and the major negative deflection(MN) (P<0.05) in the ipsilateral hemisphere and a precipitous decrease in the amplitude of the ipsilateral P1-MN complex immediately after occlusion(P<0.05). In Group IIb the suppressed SSEP's did not show any recovery during ischemia, and recovered late during recirculation. In Group IIa the suppressed SSEP's tended to recover during recirculation. In Group IIa the suppressed SSEP's tended to recover during ischemia and recovered early during recirculation. SSEP's were not completely abolished throughout the experiment in any experimental grup. The relationship between the changes in rCBF and amplitude of SSEP's in the ipsilateral hemisphere was significant(r=0.943, P<0.05) during occlusion of the middle cerebral artery in Group IIa. However there was not any other relationship in the other groups or among other wave components. These results indicate that the suppression of SSEP's and their failure to recover during focal cerebral ischemia correlate with the lack of collateral circulation. Furthermore, SSEP's can be useful means to evaluate the reversibility of cerebral ischemia, which may be decided by existence of collateral circulation. And it appers that the time threshold for abolition of SSEP's is more than 30 minutes in focal cerebral ischemia in the cat.

Zygomatic Temporopolar Approach to High Placed P1 Aneurysm

The authors describe the case of a 57-year-old female who developed subrachnoid hemorrhage secondary to rupture of posteriorly projecting, high placed aneurysm of the proximal posterior cerebral artry. This aneurysm was treated easily and successfully with the zygomatic temporopolar approach which was modification of the temporopolar approach proposed by Sano by detaching the zygomatic arch to get a wide and flexible operating field.

Microsurgical Endarterectomy for Symptomatic Carotid Artery Stenosis

Five patients with symptomatic carotid artery stenosis were treated with microsurgical carotid endarterectomy from January 1988 to December 1990. All patients but one case with major stroke have been improved remarkably after surgery. During the surgery, the use of surgical microscope and electroencephalographic recording seemed to be very useful and beneficial not only for meticulous surgical procedure but also for monitoring of cerebral tolerance in carotid artery cross clamping.

Two Cases of Intraventricular Arachnoid Cyst

Two rare cases of intraventricular arachnoid cyst locating in the posterior portion of the third ventricle are presented. A diagnosis was based on the radiological and operative findings and the microscopic features. Cyst wall fenestration by a direct approach resulted in good outcome. The orgin and the management of arachnoid cyst are discussed.

Two Cases of Intraventricular Arachnoid Cyst

Two rare cases of intraventricular arachnoid cyst locating in the posterior portion of the third ventricle are presented. A diagnosis was based on the radiological and operative findings and the microscopic features. Cyst wall fenestration by a direct approach resulted in good outcome. The orgin and the management of arachnoid cyst are discussed.

The Effect of Radiation Therapy on Oligodendrogliomas / 대한치료방사선과학회지

From April, 1983 through April, 1989, we have treated histologically proven 21 patients with oligodendroglima using 6 MV linear accelerator at the Division of Radiation Therapy, Kangnam St. Mary's Hospital Catholic University Medical College. These are 8% of the irradiated 246 primary brain tumors during the same period. To investigate influencing factors on the survival of irradiated 21 patients with oligodendroglioma, we analyzed the cerebral location of the nvolvements, initial symptoms, CT findings and survival rates, retrospectively. One case was lost to flow up and excluded from survival data. Of the 21 patients, thirteen were male and 8 female. Ages ranged from 5 to 68 years with a median age of 38 years. Radiation doses varied from 3960 cGy to 6480 cGy and were given for 5 to 8 weeks. All but one were supratentorial. The involvement of the frontal and parietal lobes were 10 (48%) patients in each and temporal lobe in 8 (38.1%). Histological diagnosis was made by stereotactic biopsy in 3 and postoperatively in 18. The type of surgery was divided into partial, subtotal and total resection in 7,9 and 2 cases respectively. In 6 cases, chemotherapy was also tried during or after radiation therapy. Major presenting respectively in decreasing order. In CT analysis, low density (62%), cystic mass (33%), calcification (66%) and positive contrast enhancement (42.8%) were observed as the highest frequency. Mean survival duration after radiation therapy was 38 months (K-M methods). We could not achieve statistically significant factors influencing on the survival rate after radiation therapy for oligodendrogliomas by one or two tail test.

Brain Tumor Immunology: Part II : Immunotherapy of Malignant Brain Tumors

The prognosis of patients with malignant brain tumors has improved only slightly despite the combined use of surgery, radiation therapy, and chemotherapy. Immunotherapy offers some possibilities and hopes as a fourth modality for the treatment of cancers although it is still in the early stages of development. It is possible to classify immunotherapy within four generally accepted modalities : 1) restorative or nonspecific immunotherapy 2) adoptive immunotherapy 3) passive immunotherapy 4) active immunotherapy. The techniques of recombinant DNA, genetic engineering, cell fusion and hybridoma production, and molecular biology will make these therapeutic approaches more successful and as the clinical applications expand the skillful cancertherapist will become increasingly familiar with these treatments and the problems associated with their use.

Histopathological Studies of Chronic Nerve Compression

Recently nerve entrapments or nerve root compressions are common clinical symdromes. However, a clear understanding of both pathophysiological and morphological changes is lacking and it may not be completely established in the experimental model for chronic nerve compression, compared with a surprising review of peripheral nerve exposed to various acute damage. Adult Sprague-Dawley rats weighing 250 to 300g were used as the experimental model to elucidate histopathological changes in chronic nerve compression, which were produced by banding the sciatic nerve(normally 1.2mm in diameter) with the length of 1cm silastic tubings with inner diameter, 0.6mm(Group I), 0.9mm(Group II) and 1.5mm(Group III) in each. Specimens were obtained for light and electron microscopic studies postoperatively at 1 and 3 months following by nerve conduction study. Grossly in group I, the sciatic nerve was compressed to approximately 50% of its normal in cuff area and in thin strand on distal part at 1 month and more progressed at 3 months. The sciatic nerve of group II demonstrated 75% of control and distal part in 50% compression at 1 month, but the nerve seemed not to be affected by tubing. Light microscopic findings revealed Wallerian degeneration and diminished large myelinated fiber particularly in the periphery of nerves with 34% of transverse nueral percentage in group I at postoperative 1 month. Above findings were progressed to epineurial scarring and fibrosis at 3 months. There were marked diminution and deformity in large myelinated fiber in group II, but it was not more severe than the ones of group I. Electron microscopic findings in this group revealed the appearance of small regenerating unit clusters and thinly myelinated fibers. In group III, histological findings were not much different from that of normal nerve. Nerve conduction study revealed the decrease in conduction velocity to mean 10 M/sex in group I at 1 month and no electrical conduction at 3 months. In group II, diminution of conduction velocity in 73% of normal range at 1 month was noted, and 82% at 3 months. These findings explain correspondingly the histopathological changes in part of chronic nerve entrapment syndromes and appeal the need of further investigation in this experimental model.

Large Aneurysm of Azygos Anterior Cerebral Artery: Case Report

A case of large aneurysm of azygos anterior cerebral artery(Azygos ACA) is reported. This 52-year-old male patient became unconscious suddenly on working. The CT scan demonstrated small amount of hemorrhage in the interhemispheric fissure and basal cistern and huge intraventricular hematoma with marked dilatation of all ventricles. Emergency external ventricular drainage was done and his consciousness recovered to the level of possible spontaneous eye opening. 4-vessels angiography done a month later revealed a large revealed a large fusiform aneurysm at the bifurcation of distal end of azygos ACA. Authors preferred interhemispheric approach and clipped the aneurysmal neck uneventfully. Despite the successful clipping of the aneurysm confirmed by postoperative angiography, preoperative mutism, spastic weakness of lower extremities and urinary incontinence didn't recovered. This case suggests that preoperative neurological status is no less critical to the postoperative outcome than surgical technique. This is the first case of large aneurysm at this site so far as we know.

3 Cases of Coincidental Cerebral Aneurysm with Pituitary Tumor

We report three cases of coincidental cerebral aneurysm with pituitary tumor. In our hospital the incidence of such cases was 4.4% of 68 patients with pituitary tumors from March, 1970 to October, 1990. Cases No. 1 was a 47-year-old female suffering from progressive loss of visual acuity. Preoperative brain C-T scan and angiographies revealed unruptured posterior communicating aneurysm with pituitary tumor. Case No. 2 was a 39-year-old male suffering from headache after head trauma with acromegaly. Preoperative brain C-T scan and angiographies appeared unruptured anterior communicating aneurysm and pituitary tumor. Case No. 3 was a 62-year-old female suffering progressive loss of visual acuity and headache. Left middle cerebral artery aneurysm and pituitary tumor were found by preoperative brain C-T scan and angiographies. All cases were operated by transcranial route and performed tumor removal after primary clipping of aneurysm. Postoperatively remained tumor of all cases was treated by radiosurgery successfully.

Motor and Sensory Evoked Potential in the Evaluation of Increased Intracranial Pressure in Cats

Motor evoked potential(MEP) and sensory evoked potential(SEP) were recorded in 30 experimental cats in accordance with change of intracranial pressure. MEP was obtained on the thoracic cord after electric stimulation through a ball electrode directly installed on the cerebral motor cortex. SEP was elicited on the cerebral cortex after stimulation of thoracic cord. Experimental animals were composed of control group(10 cats) and raised intracranial pressure (ICP) group(20 cats) which included a group of 10 cats with 30 mmHg increased ICP and another group of 10 cats with 50 mmHg elevated ICP. Each evoked potential according to changes in ICP was obtained and the results were as follows: 1) MEP in control group showed that latency was 14.8+/-0.8 msec and amplitude was 24.4+/-2.1 microV. MEP after elevation of ICP showed more profound change in 50 mmHg increased ICP group than in 30 mmHg increased ICP group. Latency was prolonged by 152%(37.4+/-1.8 msec) of control group and amplitude was reduced to 82%(4.58+/-1.2 microV) of control group in the 50 mmHg increased ICP group. Recovery of MEP changes from increased ICP by reduction of the pressure was more prominent in 30 mmHg elevated group than 50 mmHg elevated group. 2) In control group SEP showed that latency was 25.38+/-1.5 msec and amplitude was 22.8+/-1.4 microV. SEP after elevation of ICP showed more profound change in 50 mmHg increased ICP group than 30 mmHg increased ICP group. Latency of SEP in 50 mmHg increased ICP group was prolonged by 54%(39.18+/-2.2 msec) of control group and amplitude reduced by 47%(10.98+/-0.9 microV) of control group was more prominent in 30 mmHg elevated group than 50 mmHg elevated group. changes in MEP after raised ICP were more remarkable than that of SEP. The degree of Recovery from raised ICP was more prominent in 30 mmHg group than 50 mmHg group. This study indicates that because change of MEP is more sensitive than that of SEP in the evaluation of cerebral function in case of increased ICP, MEP might be a paramount indicator in the evaluation of cerebral injury. Recording of MEP as well as ICP monitoring system might be a new method for the early detection of changes in cerebral function.

Intracranial Occlusion of Internal Carotid Artery in Acute Closed Head Injury: Case Report

A case of traumatic intracranial occlusion of the right internal carotid artery is reported, and the mechanism and management of occlusion is reviewed to make realize the importance of vascular lesions in patients with head injury. Considering that CT became the principal diagnostic method in head injured patients, it is important to realize the possibility of vascular injury in patients with head injury who have unexplained neurological deficits and to pursue the evaluation of the patients with an angiography.

Two Cases of Intraventricular Arachnoid Cyst

Two cases with intraventricular arachnoid cysts are reported and a brief review of the relevant literature is presented. Arachnoid cysts are benign developmental cysts that occur in the cerebrospinal axis in relation to the arachnoid membrane. They are usually extracerbral or extraventricular. Intraventricular arachnoid cysts are rare: except the two cases reported here, only five cases have been described. The following characteristics were noted in these patients: all were young; headache was the initial symptom; the cyst was in the body of a lateral ventricle.

Management of Intracranial Arachnoid Cysts in Children

14 supratentorial and 6 infratentorial arachnoid cysts, diagnosed and treated at Kangnam St Mary's Hospital from 1983 to 1988, are reported. The most common presenting symptoms in children were craniomegaly, delayed development, increased ICP and neurological focal signs. Neuroradiological examination included plain skull X-ray, brain CT and metrizamide CT or isotope study. Therapeutic criteria according to the clinical and radiological findings were reviewed. The results were as follows; 1) The patient below age of 2 yrs who's brain had a potent ability of growth should be operated in any cases for reducing mass effect. 2) In sylvian lesion, Type II and III according to the classification of Galassi were well treated with C-P snunt. 3) In infratentorial lesion, all patients had hydrocephalus and the patient who had communicated with subarachnoid space in metrizamide CT were well treated with V-P shunt and who not communicated with subarachnoid space was well treated with Y-shunt. 4) We had good results by fenestration above the age of 3 yrs and by C-P shunt under the age of 2 yrs in supratentorial lesion.

Efficacy and Tolerability of Nimodipine in Patients with Organic Brain Syndrome

The nimodipine, calcium-channel blocker, is known to specific to brain tissue and effect on the ischemic stroke. To evaluate the efficacy and tolerability of nimodipine, we studied the 37 patients with Organic Brain Syndrome(OBS) who admitted to St. Mary's Hospital from January to August, 1989. We followed up for 12 weeks of their 18 items of neurologic outcome. The results and conclusion were as follows: 1) The pretreatment SCAG(Sandoz Clinical Assessment-Geriatric Scale) was used as a base-line measurement and the efficacy of the therapy was evaluated entirely in terms of changes in SCAG after 3, 6, 9 and 12 weeks of treatment. The total score was changed with meaningful improvement(p<0.01). 2) Among the 18 items of symptoms, the confusion, the level of alertness, the memory and the orientation were the area that have showed the most improvement. 3) No effect on heart, blood chemistry or other side effect was noted during medication. 4) We also found that those improvement has no specific relation to age, sex and causes of OBS. These result indicate that nimodipine has a possible therapeutic benefit in patients with OBS, especially who have the symptoms of confusion and impaired recent memory. These result should encouraged us to do further study such as double blind placebo in order to clarify the genuine pharmacological efficacy.

The Clinical Analysis of Surgical Treatment in the Medically Intractable Seizure

We performed callosotomy and amygdalo-hippocampectomy in medically intractable seizure patients. Symptom duration of these patients was over 2 years and seizure was not controlled with anticonvulsants in spite of high level in drug monitoring according to their seizure type. 7 patients with generalized epilepsy were treated by anterior callosotomy and 8 patients with temporal lobe epilepsy were treated by amygdalo-hippocampectomy. Anyone of these patients were not dead and discovered permanent complications. And so these methods, anterior callostomy and amygdalo-hippocampectomy seems to be relatively safety and effective methods in treatment of medically intractable seizure.