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.

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 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.

A Reconstructive Transbasal Approach to Tumors Involving the Anterior Skull Base

An en bloc bilateral osteotomy of the orbital roofs and frontal sinus for large or deeply situated anterior skull base tumors offers less brain retraction and a wide exposure. The authors describe en bloc bilateral osteotomy of the orbital roofs and frontal sinus, with skull base reconstruction using inner table of the patient's own frontal bone flap. The approach in this report offers the advantage of wide exposure, one-site operation and short operation time.

Long Term Follow-up of SAH Patients with Conservative Treatment

Two hundreds and four consecutive patients who sustained proven spontaneous subarachnoid hemorrhage with conservative treatment were studied retrospectively. The reasons for conservative treatment were poor condition for surgery, difficulties in surgery and operation refusal. Comparative study was done in proven 47 cases of aneurysmal SAH, 27 cases of SAH with negative angiography and 130 cases of SAH without angiography about age, aneurysm site & size, neurologic grade mortality & morbidity, etc. Death had occurred in 2 weeks after attack predominantly. Rebleeding was most common cause of mortality(64%, 68/107). Survivals had good quality of life(73%, 19/26).

Traumatic False Aneurysm: Two Cases of Traumatic False Aneurysm of the Superficial Temporal Artery

Two cases of iatrogenically induced false aneurysm of the superficial temporal artery are presented. One patient showed partially filled aneurysmal sac, 1x1 cm sized, on the main trunk of left superficial temporal artery by external carotid artery angiography. Another patient showed aneurysmal dilatation, 3x2 cm sized, of the superficial temporal artery with direct injection of Urograffin into the pulsatile mass. Aneurysm excision is indicated to reduce the risk of hemorrhage from the subsequent head trauma, to relieve headache, and for any cosmetic defect. The authors have reviewed the literature and discussed the incidence, classification, pathogenesis, clinical and angiographic diagnosis, differential diagnosis, and treatment.

Ischemic and Hemorrhagic Cerebral Lesion of the Newborn

Stroke in infant was relatively rare. But recently, development of diagnostic tools and infantile intensive care unit were introduced. So, early detection and follow up study were easily performed and the motality of infant stroke was improved. The pathophysiologic factor was multiple such as structural, development and physiological aspects of brain circulation and cardiorespiratory perinatal accidents, which are the cause of several neuropathology. So, preventable secondary factors such as perinatal asphyxia, respiratory manipulation during daily care should be removed thus, mortality and morbidity were decreased. Therefore, the anthors analysized 16 patient, with storke whom age were younger less than 1 year for searching of preventable secondary factors.

Clinical Analysis of Chronic Subdural Hematoma

The authors have experienced 62 cases of chronic subdural hematoma from Jan. 1987 to May 1992 at National Medical Center. In these cases, 58 cases of chronic subdural hematoma were treated with burr hole and closed draninage, 4 cases were managed with conservative management. Male was predominant to female with the ratio of 6:1 and common age was 50-60 years old. Most common causes was head injury and there was cases of chronic subdural hematoma developed after shunt operation. Common symptom was mental change and headache. Brain expansion was delayed in old age group(over 50 years old), Brain CT was available in diagnosis but brain MRI was useful in diagnosis of scantly chronic subdural hematoma. Surgical outcome was related to preoperative neurologic grade and time interval of diagnosis. In this study, clinical improvement rates was 88% in surgically treated cases.

Intracranial Arteriovenous Malformation Associated Intracranial Aneurysms

The simultaneous occurrence of one or more intracranial aneurysm and an intracranial arteriovenous malformation(AVM) in a patient is unusual. Four cases of intracranial aneurysm associated with cerebral arteriovenous malformation(AVM) were found in a total of 67 patients with cerebral malformation(AVM). The site of aneurysm was related anatomically to the arterial supplying arteriovenous malformation(AVM) in 3 cases and the bleeding source was aneurismal rupture in all four cases(100%). It is generally accepted that aneurysm is caused by hemodynamic stress result from the presence of an arteriovenous malformation(AVM). The management of the unusual problem is controversial which are surgical obliteration of both vascular lesion in one stage(2 cases) and surgical obliteration of both vascular lesion in two stages(1 case) were accomplinished with good surgical result.

Dissecting Aneurysm of Intracranial Vertebral Artery: A Case Report

Rupture of an intracranial dissecting aneurysm is a rare but dangerous event and are difficult to diagnosis and manage, and carry a high morbidity and mortality. The angiographic features typically showed fusiform dilatation and proximal and/or distal dilatation of the affected artery. Depending of location of dissection, surgical options are;ligation, trapping, or reenforcement of exposed abnormal portion of vessels. The authors report a case of nontraumatic dissecting aneurysm, stroke with subarachnoid hemorrhage(SAH) and the proximal porton of origin of PICA was treated with dlipping of vertebral artery proximal to dissecting aneurysm.

Clinical Analysis of the Brain Abscess

The authors reviewed 24 patients with brain abscess from January 1986 to December 1990. The male to female ratio was 16:8 and most frequently developed at second decades. The commonest cause was chronic ear infection with abscess in the temporal lobe, and common organism was proteus species. All patients received a total of 6 weeks of antiobiotic therapy. Surgery was performed in 24 patients, Drainage of drainage and later capsulectomy may offer a simple, safe and easy removal of capsule. There was no postoperative death or empyema. The most important predictor of outcome was the patients condition when first seen. Early specialist care, computerized tomography, correct choice and dosage of antibiotics, and the surgical methods in present use should make this a benign disease.

Clinical Analysis of the Brain Abscess

The authors reviewed 24 patients with brain abscess from January 1986 to December 1990. The male to female ratio was 16:8 and most frequently developed at second decades. The commonest cause was chronic ear infection with abscess in the temporal lobe, and common organism was proteus species. All patients received a total of 6 weeks of antiobiotic therapy. Surgery was performed in 24 patients, Drainage of drainage and later capsulectomy may offer a simple, safe and easy removal of capsule. There was no postoperative death or empyema. The most important predictor of outcome was the patients condition when first seen. Early specialist care, computerized tomography, correct choice and dosage of antibiotics, and the surgical methods in present use should make this a benign disease.

Cervical Cord Injury Associated with Osteochondroma Involving Cervical Lamina: Case Report

Osteochondroma of long bone are common lesions : however spinal involvement may occur in 2.5% to 7% of all, and usually occurs from the neural arch of spinous process. Neurological complications are rare, occurring in less than 1% of patients of them. The authors report a solitary osteochondroma occurring in the lamina of C5, causing spinal cord compression.

Multiple Thoracic Disc Herniations: Report of 2 Cases

The authors describe 2 cases of multiple thoracic disc herniations in the level of T5~6, T6~T7, T7~8 and T8~9, T9~10, T10~11. Thoracic disc herniations is rare and occurs in less than 4% of all diseases. Moreover, multiple thoracic disc herniations is very rare and only 7 cases were reported in the literatures, which occurred at two levels in 6 cases and five levels in one case. The lesions were determined by thoracic CT myelogram and MRI study. A microsurgical posterolateral approach made them curative. Surgical instruments such as downbite curette and surgical microscope were essential for successful treatment.

Surgical Management of the Distal Anterior Cerebral Artery Aneurysms

The authors described different type of aneurysms in the distal anterior cerebral artery(DACA), which is difficult to approach surgically. there are anomalies of distal anterior cerebral artery in about one fourth and narrow space, which made more careful surgical dissection. We experienced 7 cases of DACA aneurysm, 6 cases of which were treated surgically through the interhemispheric approach via the unilateral frontal paramedian craniotomy on the non-dominant side. Surgical results were anatomical complexities, modern microsurgical technique aided by microscope make the approach more exactly and safely.

CT-guided Stereotaxic Brain Tumor Biopsy

The authors have performed simple CT-guided free-hand tumor biopsy. CT images and C-arm fluroscopy were taken to determine the coordinates of the target point, which was the center of the tumorous CT findings. This CT-guide stereotaxic approach for biopsy of intracranial tumors have the following advantages: 1) The procedure is simple and safe. 2) The operation can be performed under local anesthesia. 3) The operation can be performed without stereotaxic frame. 4) Tissue biopsy was taken on various sites of tumors. The authors have performed 4 cases as follow: 3 cases of anaplastic astrocytoma, 1 case of metastatic tumor. Neither mortality nor morbidity was noted.

Cerebellar Nocardiosis: Case Report

The authors report a extemely rare case of primary cerebellar nocardial abscess. Cerebral nocardiosis is arare disease and often fatal, and commonly spreaded from nocardiosis of lung or skin. Total excision of abscess and medication with sulfonamide is the treatment of choice. The patient was treated by continuous external dirainage with intermittent irrigation of abscess cavity by sulfonamide and given with sulfonamide for 10 months.

Management of Cervical Spine Injuries without Fracture or Dislocation

The authors analized the 98 cases of cervical spine injuries without fracture or dislocation by hyperflexion/hyperextension of the neck. The peak incidence of the age was in the second to fourth decades(69.4%). There was a male preponderance with a sex ratio of. 1.8 : 1. Sources of trauma were motor vehicle accident, object falling on and motorcycle accident in the order of frequency. The common mechanisms of injury were flexion-extension, extension and flexion injury in the order of frequency. There were 10 cases of cervical cord injury without fracture or dislocation and operative management was given in 6 cases of them. The most common preexisting disease was congenital cervical stenosis. Surgical modality such as laminectomy, laminoplasty and anterior decompressive procedure made them improved. The authors discuss the mechanism of injury and surgical management of the patients with cervical cord injury in the absence of concomittent fracture or dislocation.

Low Back Pain Syndrome in Pregnancy

The authors surveyed one-hundred women within 24-36 hours after delivary for the evaluation of low back pain in pregnancy. It showed that 55% of them suffered from low back pain during pregnancy. Low back pains mostly started form 6-9 months of gestational age. Low back pains were tolerable at 84% of them. And low back pains were not aggravated during pregnancy among the 67% of low back pain pregnant women. Leg pains were noted at 34% of low back pain group.

Microsurgical Posterolateral Approach for a Thoracic Disc Herniation

The authors describe the case of a man who presented with T2-T3 disc herniation. The lesion was successfully identified by computed tomography with iopamidol myelogram and other radiological examinations. A posterolateral approach was tried and made successful result by the aids of microsurgical divices.