Multiloculated Hydrocephalus: Open Craniotomy or Endoscopy?

Multiloculated hydrocephalus (MLH) is a condition in which patients have multiple, separate abnormal cerebrospinal fluid collections with no communication between them. Despite technical advancements in pediatric neurosurgery, neurological outcomes are poor in these patients and the approach to this pathology remains problematic especially given individual anatomic complexity and cerebrospinal fluid (CSF) hydrodynamics. A uniform surgical strategy has not yet been developed. Current treatment options for MLH are microsurgical fenestration of separate compartments by open craniotomy or endoscopy, shunt surgery in which multiple catheters are placed in the compartments, and combinations of these modalities. Craniotomy for fenestration allows better visualization of the compartments and membranes, and it can offer easy fenestration or excision of membranes and wide communication of cystic compartments. Hemostasis is more easily achieved. However, because of profound loss of CSF during surgery, open craniotomy is associated with an increased chance of subdural hygroma and/or hematoma collection and shunt malfunction. Endoscopy has advantages such as minimal invasiveness, avoidance of brain retraction, less blood loss, faster operation time, and shorter hospital stay. Disadvantages are also similar to those of open craniotomy. Intraoperative bleeding can usually be easily managed by irrigation or coagulation. However, handling of significant intraoperative bleeding is not as easy. Currently, endoscopic fenestration tends to be performed more often as initial treatment and open craniotomy may be useful in patients requiring repeated endoscopic procedures.

Craniotomy or Decompressive Craniectomy for Acute Subdural Hematomas: Surgical Selection and Clinical Outcome / 대한신경손상학회지

OBJECTIVE: Craniotomy (CO) and decompressive craniectomy (DC) are two main surgical options for acute subdural hematomas (ASDH). However, optimal selection of surgical modality is unclear and decision may vary with surgeon's experience. To clarify this point, we analyzed preoperative findings and surgical outcome of patients with ASDH treated with CO or DC. METHODS: From January 2010 to December 2014, data for 46 patients with ASDH who underwent CO or DC were retrospectively reviewed. The demographic, clinical, imaging and clinical outcomes were analyzed and statistically compared. RESULTS: Twenty (43%) patients underwent CO and 26 (57%) patients received DC. In DC group, preoperative Glascow Coma Scale was lower (p=0.034), and more patient had non-reactive pupil (p=0.004). Computed tomography findings of DC group showed more frequent subarachnoid hemorrhage (p=0.003). Six month modified Rankin Scale showed favorable outcome in 60% of CO group and 23% of DC group (p=0.004). DC was done in patient with more unfavorable preoperative features (p=0.017). Patients with few unfavorable preoperative features (<6) had good outcome with CO (p<0.001). CONCLUSION: In selective cases of few unfavorable clinical findings, CO may also be an effective surgical option for ASDH. Although DC remains to be standard of surgical modality for patients with poor clinical status, CO can be an alternative considering the possible complications of DC.

The Olfactory Groove Schwannoma Attached to the Cribriform Plate: A Case Report

The olfactory groove schwannoma is a quite rare tumor. We report a case of a 49-year-old woman with an olfactory groove schwannoma attached to the cribriform plate without olfactory dysfunction. She had no specific neurological symptoms other than a headache, and resection of the tumor showed it to be a schwannoma. About 19 months after the operation, a follow-up MRI showed no evidence of tumor recurrence. Surgical resection through subfrontal approach could be one of the curative modality in managing an olfactory groove schwannoma. An olfactory groove schwannoma should be considered in the differential diagnosis of anterior skull base tumors.

Solitary Fibrous Tumor of Central Nervous System: A Case Report

Solitary fibrous tumor (SFT) is a rare neoplasm of mesenchymal origin, especially in the central nervous system (CNS). Reported herein is a case of SFT of CNS in a 63-year-old female patient who had confused mentality, without other neurological deficit. The brain MRI showed an ovoid mass in the right frontal lobe. The tumor was surgically removed grossly and totally, and the pathologic diagnosis was SFT. At 55 months after the surgery, the tumor recurred at the primary site and at an adjacent area. A second operation was thus done, and the tumor was again surgically removed grossly and totally. The pathologic diagnosis was the same as the previous, but the Ki-67 index was elevated. Ten months later, two small recurring tumors in the right frontal skull base were found in the follow-up MRI. It was decided that radiation therapy be done, and MRI was done again 3 months later. In the follow-up MRI, the size of the recurring mass was found to have decreased, and the patient did not manifest any significant symptom. Follow-up will again be done 18 months after the second surgery.

Antihypertensive Treatment of Acute Intracerebral Hemorrhage by Intravenous Nicardipine Hydrochloride: Prospective Multi-Center Study

The authors performed a multicenter prospective study to evaluate the feasibility and safety of intravenous nicardipine hydrochloride for acute hypertension in patients with intracerebral hemorrhage (ICH). This study included 88 patients (mean age: 58.3 yr, range 26-87 yr) with ICH and acute hypertension in 5 medical centers between August 2008 and November 2010, who were treated using intravenous nicardipine. Administration of nicardipine resulted in a decrease from mean systolic blood pressure (BP) (175.4 +/- 33.7 mmHg) and diastolic BP (100.8 +/- 22 mmHg) at admission to mean systolic BP (127.4 +/- 16.7 mmHg) and diastolic BP (67.2 +/- 12.9 mmHg) in 6 hr after infusion (P or = 2) was observed in 2 (2.2%) of 88 patients during the treatment. Aggressive nicardipine treatment of acute hypertension in patients with ICH can be safe and effective with a low rate of neurological deterioration and hematoma expansion.

Short Term Outcomes of Intervertebral Spike (IS(R)) Cage for Degenerative Lumbar Spinal Disorders

OBJECTIVE: The authors conducted a retrospective study of patients with degenerative lumbar spinal disorders who received a posterior lumbar interbody fusion (PLIF) with the IS(R) cage. METHODS: We assessed 105 patients who underwent on a PLIF with or without pedicle screws using the IS(R) cage in our institute from November 2007 to December 2008. Clinical outcomes were analyzed with a Visual Analog Scale (VAS) for back and leg pain. Radiographs were obtained before and after the surgery. In some cases, a lumbar spinal computed tomography scan was obtained. Radiological outcomes of intercage distance, fusion rate, and intervertebral disc height were assessed. In scoliosis or lateral translation, the extent of correction was examined. RESULTS: The mean VAS score for back pain improved from 6.86 preoperatively to 2.66 at postoperative month 12, and the score for leg pain decreased from 7.92 to 1.78. The mean intervertebral disc height was 8.71+/-2.35mm before the surgery, and it increased to 11.67+/-1.77mm at 7 days postoperative and decreased to 9.57+/-1.90mm at 6 months postoperative. The fusion rate was 95.65%. For scoliosis or lateral translation, thesegmental angle of scoliosis decreased from 11.10+/-5.82degrees before the surgery to 5.61+/-3.71degrees by month 6 postoperative. The extent of the lateral translation changed from 6.04+/-1.73mm before the surgery to 3.56+/-4.99mm at month 6 postoperative. CONCLUSION: There have been low complication rates with the IS(R) cage during the follow-up period, and the results of this study demonstrates a wide fusion area, partial reduction of lateral translation and scoliosis, good clinical success, and a high fusion rate.

Recycling of Cervical Artificial Disc for the Symptomatic Adjacent Segment Disorder Combined with Instability on Total Disc Replacement Area: A Case Report

The authors describe the revision case of a 58-year-old man who presented with pain in the neck and both shoulders after C4-5 cervical total disc replacement (C-TDR) and C5-6 anterior cervical discectomy and fusion (ACDF), and in whom there was evidence of instability with sagittal translation at the C4-5 TDR level and of a herniated cervical disc (HCD) at the left side of C3-4. The revision surgery was performed as follows: previous plate removal at the C5-6 level, artificial disc removal and ACDF at the C4-5 level with cage and previous plate insertion, and TDR at the C3-4 level using the previously implanted C4/5 artificial disc. If instability develops at the level of an artificial disc, we perform additional posterior fusion or anterior removal of the artificial disc and fusion. However, if we encounter combined adjacent segment disc disease, we may reuse the unstable segment artificial disc at the adjacent segment and perform salvage anterior fusion on the unstable segment. This is the first report issued on the management of instability after previous C-TDR involving a switch to ACDF and the use of new TDR at the adjacent level. Furthermore, we conceptually recommend a solution to an emerging problem of adjacent segment disease due to the heterotopic ossification(HO) after C-TDR.

The Surgical Effect of Callosotomy in the Treatment of Intractable Seizure

We evaluated the surgical effects of the callosotomy, particularly with respect to the effect of callosotomy in some seizure types and the extent of surgery. Twenty-one patients with a minimum follow-up of two year were enrolled. The most significant effect of callosotomy was the complete suppression of the generalized seizures associated with drop attack in 12 of 21 patients and seizure reduction of more than 75% in 6 of 21 patients. The surgical effect on the partial seizures was very variable. Transient disconnection syndrome appeared in 4 patients after anterior callosotomy. Total callosotomy by staged operation significantly suppressed generalized seizures associated with drop attack without any disconnection syndrome. Our data show that callosotomy is quite a good approach to the surgical treatment of drop attacks accompanied by disabling generalized seizures.

Microcystic Meningioma - Unusual Variant of Meningiomas

Microcystic meningioma is a rare variant of meningiomas. This unusual variant was originally described by Masson, who labeled it "humid". The computed tomographic scan or magnetic resonance images of these tumors resemble those of a glial or metastatic tumor with cystic or necrotic changes. There is no definitive method for differentiating cystic meningiomas from these more common tumors. But immunohistochemically, they share a similar pattern of positive staining for epithelial membrane antigen and vimentin with other meningiomas. Our case was a 34-year-old woman with a tumor mass on the right frontal area. She was admitted to hospital because of generalized tonic seizure. Grossly all of the tumor could be removed, and histopathologically this tumor was revealed to be a microcystic meningioma.

Primary Intracranial Hemangioendothelioma

Hemangioendothelioma is a recently described uncommon vascular neoplasm, characterized by epithelioid tumor cells and borderline biologic behavior. Its histological features and clinical behavior are intermediate between those of hemangioma and angiosarcoma. Its four principal sites of occurrence are the soft tissue, liver, lung and bone. Its intracranial occurrence is extreamly rare. We report a case of primary cerebral hemangioendothelioma in a 29-year-old male patient

Craniopharyngiomas: Predictive Factors of Recurrence

OBJECTIVE: The authors present a retrospective analysis of the long-term recurrence rate for the 79 craniopharyngima patients surgically treated between Jan 1989 and Dec 1999. METHODS:Tumor recurrence rates were analysed with respect to age of patients, symptom duration, tumor size, localization of tumor, morphology of tumor, the extent of surgical resection, pathologic diagnosis and the other treatment modalities. RESULTS: For 79 patients, with a mean follow-up period of 5 years, the overall recurrence rate was 29%. Factors associated with decreased risk of recurrence was gross total tumor resection(p=0.01). Subtotal resection was associated with increased risk of tumor recurrence. The adjuvant radiation therapy was revealed efficient not in decreasing recurrence rate but in the delay of tumor recurrence time(p=0.05). There were no differences in recurrence rates for other factors. CONCLUSION: A rigorous evaluation of recurrence for craniopharyngima must consider the extent of resection, as judged by postoperative imaging. Adjuvant radiation therapy or Gamma knife surgery could be the effective treatment modalities.

Ganglioglioma of the Brain Stem: Case Report

Ganglioglioma comprises about 2% of all intracranial neoplasm, however, it is rarely originated from the brain stem. We report a case of ganglioglioma arising from the brain stem. A 15-year-old girl presented with gait disturbance and dysarthria. Magnetic resonance image revealed a high signal intensity mass with cystic cavities in the right cerebellum and the brain stem. The patient underwent subtotal resection and microscopic examination revealed a ganglioglioma. It is suggested that ganglioglioma should be included in the differential diagnosis of posterior fossa tumors, even located in the brain stem.

Gangliogioma of Cerebellar Vermis: Case Report

We present a case of ganglioglioma in the cerebellar vermis. A 2-year-old boy presented with symptoms and signs of raised intracranial pressure and the physical examination revealed large head and developmental delay. Magnetic resonance image demonstrated a hypointense mass in the cerebellar vermis on T1-weighted image with heterogeneous enhancement after gadolinium administration, mimicking a malignant tumor. A gross total resection was performed and pathologic findings demonstrated a ganglioglioma. There was no evidence of recurrence of the tumor during 16 months follow up period.

The Role of Basic Fibroblast Growth Factor in Moyamoya Disease

OBJECTIVES AND OMPORTANCE: The present study investigated the levels of basic fibroblast growth factor(bFGF) in the CSF of patients with moyamoya disease and its clinical significance. METHODS: The levels of bFGF in CSF, taken from 26 hemispheres of 14 moyamoya patients and 20 patients without vascular anomaly(control group), were measured by an enzyme-linked immunosorbent assay. We analyzed the correlation between the level of bFGF and the clinical factors such as age, onset pattern, development of neovascularization, and cerebral circulation. RESULTS: The CSF of moyamoya patients contained a high concentration of bFGF to a significant extent. The bFGF level was apparently elevated in the patients in whom neovascularization from indirect revascularization, such as modified encephalo-duro-arterio-synangiosis(EDAS) was well developed. A linear correlation between the values of bFGF and clinical progression was noted. CONCLUSIONS: The elevation of bFGF in moyamoya disease seems to be specific. Clinically, the bFGF level may be considered a useful indicator to predict the efficacy of indirect revascularization.