Acute Pontine Infarction due to Basilar Artery Dissection from Strenuous Physical Effort: One from Sexual Intercourse and Another from Defecation

A basilar artery dissection (BAD) is an extremely rare disease. It can lead to hemorrhage or infarction involving the brain stem, and is often associated with grave outcome. However, little is known about the pathophysiology of BAD, and its proper managements are yet in controversy. Herein, we report on two rare cases of basilar artery dissection from strenuous physical effort; one from sexual intercourse and another from defecation. The treatment modalities and the outcomes are also discussed.

Acute Pontine Infarction due to Basilar Artery Dissection from Strenuous Physical Effort: One from Sexual Intercourse and Another from Defecation

A basilar artery dissection (BAD) is an extremely rare disease. It can lead to hemorrhage or infarction involving the brain stem, and is often associated with grave outcome. However, little is known about the pathophysiology of BAD, and its proper managements are yet in controversy. Herein, we report on two rare cases of basilar artery dissection from strenuous physical effort; one from sexual intercourse and another from defecation. The treatment modalities and the outcomes are also discussed.

Lytic Complications after Skull Reconstruction Using GeneX(R) / 대한신경손상학회지

Multiple methods and materials are available for bone defect reconstruction. Bone graft substitute is one of the materials used for reconstruction of bone defect and have been widely used recently. This report describes some cases about complications related to GeneX(R) which is introduced as mixture of calcium sulfate and beta-tricalcium phosphate at manufacturer's official web site. It informed of 3 patients who suffered wound inflammation, serous cyst after using GeneX(R) for reconstructing skull defect.

A Simple Method for Reconstruction of the Temporalis Muscle Using Contourable Strut Plate after Pterional Craniotomy: Introduction of the Surgical Techniques and Analysis of Its Efficacy

OBJECTIVE: Pterional craniotomy (PC) using myocutaneous (MC) flap is a simple and efficient technique; however, due to subsequent inferior displacement (ID) of the temporalis muscle, it can cause postoperative deformities of the muscle such as depression along the inferior margin of the temporal line of the frontal bone (DTL) and muscular protrusion at the inferior portion of the temporal fossa (PITF). Herein, we introduce a simple method for reconstruction of the temporalis muscle using a contourable strut plate (CSP) and evaluate its efficacy. MATERIALS AND METHODS: Patients at follow-ups between January 2014 and October 2014 after PCs were enrolled in this study. Their postoperative deformities of the temporalis muscle including ID, DTL, and PITF were evaluated. These PC cases using MC flap were classified according to two groups; one with conventional technique without CSP (MC Only) and another with reconstruction of the temporalis muscle using CSP (MC + CSP). Statistical analyses were performed for comparison between the two groups. RESULTS: Lower incidences of ID of the muscle (p < 0.001), DTL (p < 0.001), and PITF (p = 0.001) were observed in the MC + CSP than in the MC Only group. The incidence of acceptable outcome was markedly higher in the MC + CSP group (p < 0.001). ID was regarded as a causative factor for DTL and PITF (p < 0.001 in both). CONCLUSION: Reconstruction of the temporalis muscle using CSP after MC flap is a simple and efficient technique, which provides an outstanding outcome in terms of anatomical restoration of the temporalis muscle.

Two Cases of Subarachnoid Hemorrhage from Spontaneous Anterior Cerebral Artery Dissection : A Case of Simultaneous Hemorrhage and Ischemia Without Aneurysmal Formation and Another Case of Hemorrhage with Aneurysmal Formation

Spontaneous anterior cerebral artery (ACA) dissection, although extremely rare, is often associated with severe morbidity and mortality. It could lead to cerebral hemorrhage, ischemic stroke, or, rarely, combination of hemorrhage and ischemia due to hemodynamic changes. Prompt and accurate diagnosis is essential for determining the appropriate management. However, the optimal treatment for ACA dissection remains controversial. Herein, we report on two rare cases of subarachnoid hemorrhage (SAH) caused by ACA dissection; a case presenting with simultaneous SAH and infarction without aneurysmal formation and another case presenting with SAH with fusiform aneurysmal formation. A review of the related literature is provided, and optimal treatments for each type of dissection are suggested.

The Efficacy of Titanium Burr Hole Cover for Reconstruction of Skull Defect after Burr Hole Trephination of Chronic Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Although burr hole trephination is a safe and effective surgical option to treat patients with chronic subdural hematoma (CSDH), it often results in a small but undesirable scalp depression from burr hole defect. This study is to evaluate the efficacy of titanium burr hole cover (BHC) for reconstruction of skull defects in these patients. METHODS: A hundred and ninety-six cases of burr hole trephinations for CSDHs between January 2009 and December 2013 were assigned into two groups; Gelfoam packing only (GPO) and reconstruction using titanium BHC group, according to the modalities of burr hole reconstructions. The incidences and depths of scalp depressions and incidences of postoperative complications such as infections or instrument failures were analyzed in both groups. We also conducted telephone surveys to evaluate the cosmetic and functional outcomes from patient's aspect. RESULTS: Significantly lower incidence (p<0.0001) and smaller mean depth (p<0.0001) of scalp depressions were observed in BHC than GPO group. No statistical differences were seen in postoperative infection rates (p=0.498) between the two groups. There were no instrument failures in BHC group. According to the telephone surveys, 73.9% of respondents with scalp depressions had cosmetic inferiority complexes and 62.3% experienced functional handicaps during activities of daily life. CONCLUSION: Titanium BHC is highly effective for reconstruction of skull defect after burr hole trephination of CSDH, and provides excellent cosmetic and functional outcomes without significant complications.

Clinical Outcomes of Patients with Good Neurological Scores in Spite of Significant Amounts of Acute Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Acute subdural hematoma (ASDH) with good initial Glasgow Coma Scale (GCS) score 13-15 is generally regarded as a mild head injury. However, the risk increases when significant amount of hematoma with midline shift exists. This study is to evaluate the clinical outcomes of patients with good neurological scores in spite of significant amounts of ASDH, and to compare the outcomes according to the treatment modalities. METHODS: Sixty patients with initial GCS score 13-15 in spite of significant amounts of ASDH and midline shifts were enrolled. They were divided into groups according to age, sex, side of location, initial GCS score, midline shift, and hematoma thickness. According to the therapeutic modalities, early craniotomy and initially conserved groups were identified, and initially conserved group was further classified into persistently conserved and delayed operation groups. The outcomes were measured by Glasgow Outcome Scale. RESULTS: Initial GCS score was a significant factor that influenced the final outcome (p=0.001). The outcomes were good in both early craniotomy and initially conserved groups without significant differences (p=0.268). Fifteen of initially conserved 49 patients underwent delayed operations from neurological deteriorations, but the outcomes were good without significant differences from persistently conserved group (p=0.481). CONCLUSION: Initial GCS score is an important factor that influences the clinical outcome. These patients can be conserved under close observations without early preventive craniotomies if no deteriorations are seen in the acute stage. Only those with delayed deteriorations may require simple operations such as burr hole trephinations which still guarantee good outcomes.

Comparative Analysis of the Mini-pterional and Supraorbital Keyhole Craniotomies for Unruptured Aneurysms with Numeric Measurements of Their Geometric Configurations

OBJECTIVE: Keyhole craniotomy is a modification of pterional craniotomy that allows for use of a minimally invasive approach toward cerebral aneurysms. Currently, mini-pterional (MPKC) and supraorbital keyhole craniotomies (SOKC) are commonly used. In this study, we measured and compared the geometric configurations of surgical exposure provided by MPKC and SOKC. METHODS: Nine patients underwent MPKC and four underwent SOKC. Their postoperative contrast-enhanced brain computed tomographic scans were evaluated. The transverse and longitudinal diameters and areas of exposure were measured. The locations of the anterior communicating artery, bifurcation of the middle cerebral artery (MCAB), and the internal carotid artery (ICA) terminal were identified, and the working angles and depths for these targets were measured. RESULTS: No significant differences in the transverse diameters of exposure were observed between MPKC and SOKC. However, the longitudinal diameters and the areas were significantly larger, by 1.5 times in MPKC. MPKC provided larger operable working angles for the targets. The angles by MPKC, particularly for the MCAB, reached up to 1.9-fold of those by SOKC. Greater working depths were required in order to reach the targets by SOKC, and the differences were the greatest in the MCAB by 1.6-fold. CONCLUSION: MPKC provides larger exposure than SOKC with a similar length of skin incision. MPKC allows for use of a direct transsylvian approach, and exposes the target in a wide working angle within a short distance. Despite some limitations in exposure, SOKC is suitable for a direct subfrontal approach, and provides a more anteromedial and basal view. MCAB and posteriorly directing ICA terminal aneurysms can be good candidates for MPKC.

A Ruptured Aneurysm at the Infraoptic Azygous Anterior Cerebral Artery with the Contralateral Internal Carotid Artery Agenesis Treated by Y-stent Assisted Coil Embolization

Infraoptic anterior cerebral artery (ACA) is an extremely rare congenital anomaly. This anomalous artery usually arises from the intradural internal carotid artery (ICA) near the level of the ophthalmic artery (OA) or rarely from the extradural ICA. This anomaly frequently harbors a cerebral aneurysm, and may involve other coexisting vascular anomalies. In the case of this anomaly, surgical treatment of the aneurysm at the proximal ACA or anterior communicating artery (ACoA) may sometimes be difficult, because the veiled proximal ACA by the optic nerve would make proximal control inconvenient and the vertical midline segment of the proximal ACA would frequently form a superiorly directing aneurysm with a relatively high position. We report on an extremely rare case of a ruptured aneurysm at the infraoptic azygous ACA, possibly having an extradural origin, accompanied by contralateral ICA agenesis, and also introduce a feasible method for treatment by Y-stent assisted coil embolization.

Mechanical Thrombolysis Using Coil in Acute Occlusion of Fenestrate M1 Segment

A fenestrated middle cerebral artery (MCA) is a rare congenital anomaly, and is related to interference in the normal embryonic development of the MCA. Fenestrated MCA has been regarded to have no clinical significance other than a rare event of hemorrhage from associated aneurysm. However, the fenestration within the arterial trunk can be an obstacle against thrombus migration and may be associated with a major cerebral infarction. Moreover, the presence of this anomaly can be hardly detected prior to thrombolytic procedures, and emergent treatments are proceeded without any information of anatomical configurations. Therefore, the recanalization procedures would carry a high risk of intraprocedural complications. We report a rare case of MCA territory infarction from occlusion of fenestrated M1 segment, and also introduce a safe method of mechanical thrombolysis using coil.

Cavernous Sinus Thrombophlebitis: Case Report and Literature Review / 대한뇌혈관외과학회지

Cavernous sinus thrombophlebitis is characterized by edema of the eyelids and the conjunctivae, and paralysis of the cranial nerves. It is rare, often misdiagnosed or underestimated by neurosurgeons, and is generally related with high rates of mortality and morbidity. High rate of suspicion is required for early diagnosis, and aggressive managements can lead to better outcomes. With recent advancements in antibiotic therapies, the mortality rate has been decreased to less than 30%. However, the morbidity remains high and complete recovery is rare. A 69-year-old woman presented with headache and right ocular pain with sixth cranial nerve palsy for one week. Under the suspicion of Tolosa-Hunt syndrome, steroid treatment was done. On discharge, there was improvement in right ocular pain, but the cranial nerve palsy remained. Subsequently, the patient returned with left ocular pain, lid swelling, redness, ecchymosis of conjunctiva, and ptosis. Enhanced brain magnetic resonance imaging revealed an asymmetrically enlarged left cavernous sinus with heterogeneously enhancing contour. Intravenous antibiotics and oral steroids along with anticoagulant medications were administered.

Sinus Pericranii: A Case Report and the Literature Review / 대한뇌혈관외과학회지

Sinus pericranii is a rare vascular anomaly that's characterized by an extracranial vascular mass with anastomotic connections between the intracranial and extracranial systems via the diploic veins of the skull. Preoperative evaluations for making the diagnosis are important to help prevent unexpected intraoperative bleeding. We report here on a case of surgically treated sinus pericranii in a 20-year-old female following minor head trauma. The clinical manifestations, pathogenesis and managements are discussed, and we also review the relevant literature.

Endovascular Treatment of "Kissing Aneurysms" at the Anterior Communicating Artery

Kissing aneurysms are the rare type of multiple aneurysms. They are adjacent aneurysms of different origin arteries in the same region, which require great care in diagnosis and treatment. We report a case of kissing aneurysms at the anterior communicating artery (AcomA) which were treated by endovascular coil embolization.

Clinical and Angiographic Results after Treatment with Combined Clipping and Wrapping Technique for Intracranial Aneurysm

OBJECTIVE: There have been numerous follow-up studies of patients who had ruptured or unruptured intracranial aneurysms treated by wrapping technique using various materials have been reported. Our objective was to ascertain whether our particular wrapping technique using the temporalis muscle provides protection from rebleeding and any aneurysm configuration changes in follow-up studies. METHODS: Clinical presentation, the location and shape of the aneurysm, outcomes at discharge and last follow-up, and any aneurysm configuration changes on last angiographic study were analyzed retrospectively in 21 patients. Reinforcement was acquired by clipping the wrapped temporalis muscle. Wrapping and clipping after incomplete clipping was also done. Follow-up loss and non-angiographic follow-up patient groups were excluded in this study. RESULTS: The mean age was 53 years (range 29-67), and 15 patients were female. Among 21 patients, 10 patients had ruptured aneurysms (48%). Aneurysms in 21 patients were located in the anterior circulation. Aneurysm shapes were broad neck form (14 cases), fusiform (1 case), and bleb to adjacent vessel (6 cases). Five patients were treated by clipping the wrapped temporalis, and 16 patients by wrapping after partial clipping. The mean Glasgow coma scale (GCS) at admission was 14.2. The mean Glasgow outcome scale (GOS) at discharge was 4.8, and 18 patients were grade 5. The mean period between initial angiography and last angiography was 18.5 months (range 8-44). Aneurysm size was not increased in any of these patients and configuration also did not change. There was no evidence of rebleeding in any of these treated aneurysms. CONCLUSION: Our study results show that wrapping technique, using the temporalis muscle and aneurysm clip(s), for intracranial aneurysm treatment provides protection from rebleeding or regrowth.

Efficacy and Safety of Balloon Kyphoplasty in the Treatment of Osteoporotic Vertebral Body Compression Fractures: Compared with Vertebroplasty

OBJECTIVE: Kyphoplasty and vertebroplasty are two minimally invasive procedures for osteoporotic vertebral compression fractures. The purpose of this retrospective study was to compare the radiological findings and clinical outcomes between two procedures. METHODS: Osteoporotic vertebral fractures were treated in 76 vertebrae, using kyphoplasty (n=35 vertebrae) and using vertebroplasty (n=41 vertebrae). Fractured vertebral bodies were diagnosed by correlating the clinical symptoms with radiologic study. The responses of pain symptoms were measured by a self-reported Visual Analog Scale (VAS) score. Plain X-rays were checked preoperatively and postoperatively at admission and 6 months. The vertebral body height and kyphotic angle were measured to assess the reduction of the sagittal alignment. RESULTS: The mean pain scores were decreased significantly for both procedures postoperatively, but there were no significant differences between two groups. Kyphoplasty led to a significant reduction of the vertebral body height and improvement of kyphotic angle. There were no neurological deficits after kyphoplasty, but one patient experienced paraparesis after vertebroplasty. During the 6 months follow-up both procedures provided stabilization of the sagittal alignment. CONCLUSION: Kyphoplasty and vertebroplasty are considered effective minimally invasive techniques for the stabilization of osteoporotic vertebral body fractures, leading to a statistically significant reduction in pain. Kyphoplasty significantly restore sagittal alignment. Also, complications and the incidence of bone cement leakage are significantly lesser than vertebroplasty. Therefore, kyphoplasty seems to be reasonable procedure for osteoporotic vertebral body compression fractures when medical treatment fail.

The Efficacy of Microvascular Decompression in Hemifacial Spasm over the Course of Time

OBJECTIVE: Microvascular decompression(MVD) at root exit zone(REZ) of the facial nerve has been largely popularized and it has become the standard treatment for patients with hemifacial spasm(HFS). This sturdy is performed to evaluate the efficacy of MVD over the course of time. METHODS: From 1994 to 2003, 50 patients with HFS who underwent MVD were followed up for more than 6 months. We retrospectively analyzed results with medical records and telephone researches. RESULTS: The mean age of patients at the time operation was 57.6 years and 84% of the patients were female. The mean duration of follow-up after operation was 3.4 years (range 0.5~7.8 years). One day after MVD, 54% of patients had complete relief of spasm immediately. Continuous improvements of HFS were observed during the follow-up period and these improvements were statistically significant with time (P<0.05). Until 6 months after operation, complete relief of spasm was observed in 84% of patients. The delayed relief of spasm was observed in 35.7% of our patients who experienced complete relief. CONCLUSION: The efficacy of MVD in HFS is improves with time. Continuous follow-up evaluations for the duration of more than at least 6 months after MVD are important for the decision of its clinical results because delayed relief of spasms occurs.

Predictive Value of Sensory Nerve Conduction in Carpal Tunnel Syndrome

OBJECTIVE: Electrodiagnostic test has shown diagnostic sensitivity and specificity in carpal tunnel syndrome(CTS). This study was to evaluate the correlation between clinical outcome of endoscopic carpal tunnel ligament release(ECTR) and the predictive value of sensory nerve conduction. METHODS: From January 1998 to December 2004, 87 patients (44 right hand, 37 left hand, 6 bilateral hands) with CTS who underwent ECTR were followed up in our hospital for an average of 2.4 months. We retrospectively analyzed the results with previous medical records. All patients underwent electrodiagnostic test and ECTR. The patients were divided into three groups according to the electrodiagnostic test results. Group (A) was normal sensory nerve response, Group (B) was slowing sensory response and Group (C) was no sensory response. Improvement of the symptom after ECTR was assessed using a visual analogue scale(VAS) score. RESULTS: Differences between the three groups on the correlation of severity of sensory potential and duration of preoperative symptoms were significant. The mean value of improved VAS scores for the three groups were 6.0+/-0.96 in the Group A, 6.11+/-0.48 in the Group B and 6.14+/-0.53 in the Group C. There was no statistically significant difference between the severity of sensory nerve response and improvement in VAS score after ECTR. Complications included a wound infection, a case of skin necrosis, and two patients with persistent symptoms without any improvement. CONCLUSION: Although electrodiagnostic test has been known to be useful, sensory nerve response is considered not to be a good prognostic value for carpal tunnel syndrome after ECTR.

Instrument Failure in Anterior Cervical Plate Fixation

OBJECTIVE: Anterior cervical fusion is widely used with many kinds of plate systems. The purpose of this study is to evaluate the rate and influencing factor of instrument failure. METHODS: The authors reviewed 101 consecutive patients who underwent anterior interbody fusion used Caspar, PCB(Cervical Plate Cage System), Orion and Atlantis plate system during the period of January 1991 to December 2000. The cases of trauma were 49, tumor 2 and degenerative disorder 50. The average length of follow up was 12.2 months. RESULTS: There were 10 cases of instrument related complications and 18 cases of non-instrument related complications. Among 10 cases of instrument related complication, eight patients showed screw loosening and two patients showed bone graft displacement. The nine cases of hardware failure occurred within 3 months. The rate of instrument failure was higher in trauma, unlocking plate and multi-level than non-trauma, locking plate and one-level. There were no injuries to tracheoesophageal or neurovascular structures as a results of instrument failure. CONCLUSION: We conclude that anterior cervical plating can be carried out with acceptable complication rate. The incidence of prominent instrument failure that endangers tracheoesophageal structures is minimal.

Percutaneous Endoscopic Discectomy Compared to Microsurgical Discectomy: Preliminary Results

To help clarify the comparative effects of percutaneous endoscopic discectomy and microsurgical discectomy in the treatment of lumbar disc herniation, the authors studied 37 consecutive patients with discogenic symptoms who had not responded to conservative treatment. Their indications are restricted to discogenic root compression with"contained"or small"noncontained"lumbar disc. Patients with sequestrated disc, spinal stenosis, or spondylolisthesis were excluded. All patients underwent magnetic resonance imaging and if the radiological interpretation was confused with extruded migrated disc, a discogram was also obtained. Of the 37 patients, 18 underwent percutaneous endoscopic discectomy and 19, microsurgical discectomy. In order to compare the efficacy of the two methods, both groups were investigated. Disc herniations were located at L4-5(24 patients), L5-S1(11 patients), or L4-5 and L5-S1(2 patients). With regard to age and sex distribution, preoperative complaints, and clinical symptoms, there were no differences between the two groups. At the last follow-up evaluation after percutaneous endoscopic discectomy, low back pain had disappeared in three patients(17.6%), sciatica in nine(50.0%), sensory deficits in two(16.7%), motor deficits in three(42.5%), and reflex differences in one (50%). After microsurgical discectomy, low back pain had disappeared in one patient(5.6%), sciatica in nine(47.4%), sensory deficits in five(33.3%), motor deficits in six(66.7%), and reflex differences in three(75.0%). In 83.3% of patients in the percutaneous endoscopic discectomy group, the outcome was successful(excellent or good result), compared with 78.9% of those who had undergone microsurgical discectomy. One patient in the percutaneous endoscopic discectomy group suffered from discitis. For patients with"contained"or slight subligamentous lumbar disc herniations, percutaneous endoscopic discectomy offers a surgical alternative.

Congenital Cystic Supratentorial Hemangioblastoma Associated with Intracystic Hemorrhage: Case Report

Supratentorial hemangioblastomas are rare tumors. The first documented case of congenital cystic supratentorial hemangiblastoma associated with intracystic hemorrhage is presented; it occurred in a 38-day-old male infant.