Anterior Craniocervical Junctional Neurenteric Cyst

Intracranial neurenteric cyst at the anterior craniocervical junction is very rare, and its treatment and prognosis have not been established. We report a case of neurenteric cyst at the anterior craniocervical junction and review the relevant literature. A 16-year-old girl presented with a 2-month history of slowly progressive headache. MRI revealed a well-defined intradural extramedullary cyst in the anterior medulla and brain stem with C1 cord compression. We performed gross total resection of the cyst using a far-lateral transcondylar approach. Surgical resection is the treatment of choice for neurenteric cysts at anterior craniocervical junction, the far-lateral transcondylar approach might be the optimal surgical approach.

Re-Irradiation and Its Contribution to Good Prognosisin Recurrent Glioblastoma Patients

Background@#: Radiation therapy, one of the strongest anti-cancer treatments, is already performed totreat primary glioblastoma; however, the effect of repeated radiation therapy for recurrent tumors has notbeen fully explored. The aim of this study was to determine the efficacy of re-irradiation in treating recurrentglioblastoma. @*Methods@#: The study included 36 patients with recurrent glioblastoma treated with repeated radiationtherapy between 2002 and 2016. Stereotactic radiosurgery (SRS) and hypo-fractionated stereotacticradiotherapy (HSRT) were performed in these patients. @*Results@#: Fourteen patients received SRS with a median dose of 25 Gy (range, 20-32 Gy) in1-5 fractions. Twenty-two patients received HSRT with a median dose of 40 Gy (range, 31.5-52 Gy) in6-20 fractions. There were six treatment-related grade 3 adverse events. Survival analysis showed thatre-irradiation significantly prolonged overall survival (OS) and progression-free survival (PFS). The medianOS and one-year OS rate after re-irradiation were 17.2 months and 60.4%, respectively. The medianPFS and 6-month PFS rate after re-irradiation were 4.4 months and 41.9%, respectively. Of the 36 patients,three survived without any progression in their condition. @*Conclusion@#: Re-irradiation for recurrent glioblastoma showed favorable outcomes. Radiation doseand fractionation should be carefully considered to minimize radiation necrosis.

Intensive Rehabilitation Therapy Following Brain Tumor Surgery: A Pilot Study of Effectiveness and Long-Term Satisfaction

OBJECTIVE: To evaluate the effectiveness of intensive rehabilitation to support recovery of neurological function after brain tumor surgery and assess long-term satisfaction. METHODS: This retrospective study included patients with neurological impairment after brain tumor surgery who underwent intensive rehabilitation therapy between December 2013 and May 2017. To assess effectiveness of rehabilitation, functional outcomes (motor, cognition, and activities of daily living [ADL]) were compared between brain tumor group and a control group enrolling stroke patients who received equivalent rehabilitation during the study period. Long-term satisfaction with rehabilitation was evaluated by surveying family caregivers. RESULTS: This study included 21 patients with benign brain tumor, 14 with malignant brain tumor, and 108 with stroke. Significant and similar improvement in motor, cognition, and ADL function were noted in both the brain tumor group and the stroke group. Malignancy status did not influence the extent of functional improvement. According to medical records and surveys, 9 (69.2%) patients with malignant tumor and 2 (11.8%) with benign tumor had expired by the time of the survey. Most family caregivers confirmed that rehabilitation was effective for functional improvement (>60%), expressing overall satisfaction and stating they would recommend such therapy to patients with similar conditions (approximately 70%). CONCLUSION: Intensive rehabilitation may help promote functional improvement following brain tumor surgery regardless of malignancy compared with stroke patients. Family caregivers expressed overall satisfaction with rehabilitation at long-term follow-up. These findings support the provision of intensive rehabilitation therapy for neurologic function recovery following brain tumor surgery.

Surgical Treatment of Hemangioblastoma in the Pituitary Stalk: An Extremely Rare Case

Hemangioblastoma (HBL) in the pituitary stalk is extremely rare. Only 16 such cases have been reported in the past and 5 cases have been treated with surgical procedure. Here, we report surgical case of HBL in the pituitary stalk diagnosed in a 34-year-old woman. The patient underwent a gross-total resection via the modified lateral supra-orbital approach. No recurrence was observed in two years after surgery. To our knowledge, this is the 17th case of HBL in the pituitary stalk and the 6th surgical case. If the tumor is symptomatic and the volume is over 5 cubic centimeters as in our case, we recommend that the surgical resection of the HBL in the pituitary stalk is a more safe and reasonable than radiotherapy.

Clinical Experience of Glioma Surgery Using "Tailed Bullet": Overcoming the Limitations of Conventional Neuro-Navigation Guided Surgery

PURPOSE: Although conventional neuro-navigation is a useful tool for image-guided glioma surgery, there are some limitations, such as brain shift. We introduced our methods using an identifiable marker, a "tailed bullet", to overcome the limitation of conventional neuro-navigation. A tailed bullet is an identifiable tumor location marker that determines the extent of a resection and we have introduced our technique and reviewed the clinical results. MATERIALS AND METHODS: We have developed and used "tailed bullets" for brain tumor surgery. They were inserted into the brain parenchyma or the tumor itself to help identify the margin of tumor. We retrospectively reviewed surgically resected glioma cases using "tailed bullet". Total 110 gliomas included in this study and it contains WHO grade 2, 3, and 4 glioma was 14, 36, and 60 cases, respectively. RESULTS: Gross total resection (GTR) was achieved in 71 patients (64.5%), subtotal resection in 36 patients (32.7%), and partial resection in 3 patients (2.7%). The overall survival (OS) duration of grade 3 and 4 gliomas were 20.9 (range, 1.2-82.4) and 13.6 months (range, 1.4-173.4), respectively. Extent of resection (GTR), younger age, and higher initial Karnofsky Performance Status (KPS) score were related to longer OS for grade-4 gliomas. There was no significant adverse event directly related to the use of tailed bullets. CONCLUSION: Considering the limitations of conventional neuro-navigation methods, the tailed bullets could be helpful during glioma resection. We believe this simple method is an easily accessible technique and overcomes the limitation of the brain shift from the conventional neuro-navigation. Further studies are needed to verify the clinical benefits of using tailed bullets.

Intracranial Hemangiopericytomas : A Retrospective Study of 15 Patients with a Special Review of Recurrence

OBJECTIVE: Although surgical resection is used to treat meningeal hemangiopericytoma (MHPC), there is a high risk of subsequent recurrence. This study investigated factors associated with treatment outcomes and recurrence in patients who had undergone surgical resection of intracranial MHPC. METHODS: Fifteen patients underwent surgical treatments performed by one senior neurosurgeon between 1997 and 2013. Clinical data, radiologic images, surgical outcomes, recurrence, and other relevant characteristics were reviewed and analyzed. RESULTS: Fifteen patients were included in the analysis, 12 (80%) of whom had tumors in the supratentorial region, and 3 (20%) of whom had tumors in the infratentorial region. Complete resection was achieved in all 15 patients, and 3 (20%) patients were administered radiosurgery and conventional radiotherapy after surgery as adjuvant radiotherapy. Three patients developed recurrence, 2 of whom had not received adjuvant radiotherapy. In 1 of the patients who had not received adjuvant radiotherapy, recurrence developed at the original tumor site, 81 months after surgery. The other 2 recurrences occurred at other sites, 78 and 41 months after surgery. The 5- and 10-year overall survival rates were 88.3%, while the 5- and 10-year recurrence-free survival rates were 83% and 52%, respectively. Additionally the mean Ki-67 index differed significantly between patients who did and did not develop recurrence (43% vs. 14%; p=0.001). CONCLUSION: Because of the high risk of MHPC recurrence, MHPC tumors should be completely resected, whenever feasible. However, even when complete resection is achieved, adjuvant radiotherapy might be necessary to prevent recurrence.

Cryptococcal Brainstem Abscess Mimicking Brain Tumors in an Immunocompetent Patient

Usually fungal infections caused by opportunistic and pathogenic fungi had been an important cause of morbidity and mortality among immunocompromised patients. However clinical data and investigations for immunocompetent pathogenic fungal infections had been rare and neglected into clinical studies. Especially Cryptococcal brainstem abscess cases mimicking brain tumors were also much more rare. So we report this unusual case. This 47-year-old man presented with a history of progressively worsening headache and nausea for 1 month and several days of vomituritions before admission. Neurological and laboratory examinations performed demonstrated no abnormal findings. Previously he was healthy and did not have any significant medical illnesses. A CT and MRI scan revealed enhancing 1.8x1.7x2.0 cm mass lesion in the left pons having central necrosis and peripheral edema compressing the fourth ventricle. And also positron emission tomogram scan demonstrated a hot uptake of fluoro-deoxy-glucose on the brainstem lesion without any evidences of systemic metastasis. Gross total mass resection was achieved with lateral suboccipital approach with neuronavigation system. Postoperatively he recovered without any neurological deficits. Pathologic report confirmed Cryptococcus neoformans and he was successively treated with antifungal medications. This is a previously unreported rare case of brainstem Cryptococcal abscess mimicking brain tumors in immunocompetent host without having any apparent typical meningeal symptoms and signs with resultant good neurosurgical recovery.

Late Onset Tuberculous Spondylitis Following Kyphoplasty: A Case Report and Review of the Literature

A 76-year-old woman with compression fracture of L1 underwent percutaneous balloon kyphoplasty using polymethyl methacrylate. Three years after kyphoplasty of L1, the patient was readmitted with severe low back pain. Magnetic resonance imaging revealed progressive collapse of L1 vertebra and new compression fracture at T12. There were no signs of infection. As conservative treatment failed, combined surgery consisting of anterior corpectomy of T12 and L1, interposition of a titanium mesh cage filled with autologous rib graft, and anterior instrumentation of T11-L2 was performed. Histologic examination showed granulomatous inflammation surrounding the cement. Polymerase chain reaction and culture of the specimen confirmed the diagnosis of tuberculosis. The anti-tuberculous medications were administered for 10 months, and the patient recovered without any sequelae. Tuberculous spondylitis should be included in the differential diagnosis of spondylitis after cement augmentation. If conservative antibiotic therapy fails, resection of the infected bone-cement complex is indicated.

Development of a contralateral acute subdural hematoma during awake craniotomy for glial tumor in a 12-year-old boy: A case report

Contralateral acute subdural hematomas that occur during removal of brain tumors under general anesthesia are extremely rare, and there are no reports of this developing during awake craniotomy for brain tumors. We report a case of a 12-year-old boy who complained of sudden and severe headache and nausea around the completion of removal of a glial tumor of the frontal lobe under awake anesthesia. Postoperative computerized tomography scan revealed the presence of contralateral acute minimal subdural hematoma. We suggest that during craniotomy with awake anesthesia for brain tumors, contralateral acute subdural hematoma may occur, even in the absence of brain bulging or changes in vital signs. Sudden intra-operative headache and nausea should be investigated by immediate postoperative computerized tomography scans to ascertain diagnosis.

Development of a contralateral acute subdural hematoma during awake craniotomy for glial tumor in a 12-year-old boy: A case report

Contralateral acute subdural hematomas that occur during removal of brain tumors under general anesthesia are extremely rare, and there are no reports of this developing during awake craniotomy for brain tumors. We report a case of a 12-year-old boy who complained of sudden and severe headache and nausea around the completion of removal of a glial tumor of the frontal lobe under awake anesthesia. Postoperative computerized tomography scan revealed the presence of contralateral acute minimal subdural hematoma. We suggest that during craniotomy with awake anesthesia for brain tumors, contralateral acute subdural hematoma may occur, even in the absence of brain bulging or changes in vital signs. Sudden intra-operative headache and nausea should be investigated by immediate postoperative computerized tomography scans to ascertain diagnosis.

Middle Cerebral Artery Infarction Caused by Cerebral Vasospasm After Brain Tumor Surgery by Pterional Approach

No abstract available.

Risk Factors Predicting Unfavorable Neurological Outcome during the Early Period after Traumatic Brain Injury

OBJECTIVE: We aimed to identify clinico-radiological risk factors that may predict unfavorable neurological outcomes in traumatic brain injury (TBI), and to establish a guideline for patient selection in clinical trials that would improve neurological outcome during the early post TBI period. METHODS: Initial clinico-radiological data of 115 TBI patients were collected prospectively. Regular neurological assessment after standard treatment divided the above patients into 2 groups after 6 months : the Favorable neurological outcome group (GOS : good & moderate disability, DRS : 0-6, LCFS : 8-10) and the Unfavorable group (GOS : severe disability-death, DRS : 7-29 and death, LCFS : 1-7 and death). RESULTS: There was a higher incidence of age > or =35 years, low initial GCS score, at least unilateral pupil dilatation, and neurological deficit in the Unfavorable group. The presence of bilateral parenchymal lesions or lesions involving the midline structures in the initial brain CT was observed to be a radiological risk factor for unfavorable outcome. Multivariate analysis demonstrated that age and initial GCS score were independent risk factors. The majority of the Favorable group patients with at least one or more risk factors showed improvement of GCS scores within 2 months after TBI. CONCLUSION: Patients with the above mentioned clinico-radiological risk factors who received standard treatment, but did not demonstrate neurological improvement within 2 months after TBI were deemed at risk for unfavorable outcome. These patients may be eligible candidates for clinical trials that would improve functional outcome after TBI.

Histological and Functional Changes after Transplantation of Human Mesenchymal Stem Cell in the Ischemic Rat Model / 대한뇌혈관외과학회지

OBJECTIVES: Brain transplantation has emerged as an effective treatment for patients suffering from neurodegenerative diseases, including Parkinson's disease, Huntingtons disease and Stroke. We evaluated that cytokine inducted human mesenchymal stem cells (Ci-hMSCs) transplanted in brain differentiated into neural cells and improved neurological functions after stroke in rats. MATERIALS AND METHODS: In the adult female Sprague-Dawley rats, ischemic lesion was induced by transient MCA occlusion lasted for 2 hours. One day later, Ci-hMSCs carrying LacZ gene were implanted via tail vein. The animals were assessed for sensorymotor function and sacrificed for Immunohistochemical staining at 7, 14, 28, 56 days after transplantation. RESULTS: A large number of X-gal positive hMSCs were observed in the ischemic core and ischemic boundary zone. Some hMSCs were reactive for the astrocytic marker - glial fibrillary acidic protein (GFAP) and neuronal marker - neuronal nuclear antigen (NeuN). The ischemic rats that were transplanted with Ci-hMSCs exhibited better functional improvement than control groups and the rats with hMSCs, which was statistically significant. CONCLUSION: The neuronal differentiation of CihMSCs suggested that transplantation of the Ci-hMSCs may provide the possibility of the clinical implication for cerebral stroke.

Analysis of Treatment Results of Vertebral Artery Dissecting Aneurysms Presented with Various Clinical Manifestations

OBJECTIVE: The dissecting aneurysms of vertebral artery with various clinical manifestations have been increasingly reported with recent advent of diagnostic tools such as 3-Dimension computed tomography angiogram, magnetic resonance image and conventional angiogram. The authors analyzed the various treatment modalities according to their clinical presentations of vertebral artery dissecting aneurysms. METHODS: At the author's institution between March 2001 and February 2004, 28 patients were managed under diagnose of vertebral artery dissection. The medical record and neuroimaging studies of patients were reviewed retrospectively. RESULTS: Seven patients were presented with subarchnoid hemorrhage and 2 patients with mass effect. The other 12 patients were presented with ischemic stroke and 7 patients with headache or neck pain. 19 patients were treated with endovascular coils or stent. The other 8 patients were treated conservatively. and one patient was treated with operation. We had no endovascular treatment-related complications. Sixteen patients who underwent endovascular treatment survived with good recovery. but one patient died and 2 patients were in poor neurological status. Among patients with mass effect, one patient was treated with operation. and the other one patient with endovascular coils. We obtained optimal treatment results with improvement of myelopathy in both patients. CONCLUSION: The choice of the treatment of vertebral artery dissecting aneurysm of patients, clinical characteristics, and relation with posterior inferior cererebellar artery. The endovascular treatment using stent with/without coiling could be the treatment of choice if preservation of the vertebral artery is necessory.

LINAC-Based Radiosurgery of Arteriovenous Malformation involving Visual Pathway: A Report of Two Cases / 대한뇌혈관외과학회지

The authors present two cases of arteriovenous malformation (AVM) involving the visual pathway following linear accelerator (LINAC) stereotactic radiosurgery. Both patients were treated with 18 Gy (marginal dose, 70-80% isodose line, 3 isocenter) delivered to the malformed vascular mass involving the optic tract on the right side. For both patients, however, less than 8 Gy were irradiated onto the ipsilateral optic chiasm and optic nerve, and 4.5 Gy were irradiated onto the contralateral optic nerve (20% isodose line). On the five-year follow-up MRI scan and angiogram, the AVM was totally obliterated in one patient and the AVM was markedly decreased in size in the other patient. Their visual fields were well preserved and visual acuities were even improved for both patients. We report here with on two cases of AVM involving the visual pathway that were effectively and safely treated with 18 Gy using LINAC-based radiosurgery, and we also attempt to define the safe and effective radiation dosage for the patients with AVM involving visual apparatus.

Therapeutic Results of Dissecting Aneurysms of Vertebral Artery

OBJECTIVE: We present a retrospective analysis of clinical characteristics of vertebral artery dissecting aneurysms and efficacy of treatment outcome according to the various treatment modalities. METHODS: From March 2001 to February 2002, seven patients with dissecting aneurysm of vertebral artery were diagnosed by cerebral angiography. Five patients presented with subarchnoid hemorrhage and two patients with mass effect. Five patients were treated endovascularly using Guglielmi detachable coils and a patient with severe brainstem compression underwent direct surgery. Another patient rebled before treatment and subsequently died. RESULTS: We had no endovascular procedure-related complications. Four patients with subarachnoid hemorrhage who underwent endovascular treatment survived with good recovery. One of them rebled after initial treatment and was treated by additional endovascular procedure. Among patients with mass effect, one patient was treated with proximal occlusion of vertebral artery and another underwent complete excision of aneurysm, with anastomosis of the PICA into the dissecting aneurysm proximal portion. We obtained a good treatment results with improvement of myelopathy in both patients, however, the patients who had underwent bypass surgery suffered from transient lower cranial nerve palsy. CONCLUSION: The endovascular treatment for vertebral artery dissecting aneurysm could be the treatment of choice for these lesions to prevent early rebleeding and obtain optimal results. However, the choice for the treatment modality in such lesions should be determined according to the individual lesions considering the status of patients, clinical characteristics, and relation with posterior inferior cerebellar artery.

Clinical Characteristics of Aneurysm Rupture with the Focus of Hypertension and Smoking as Predisposing Factors

OBJECTIVE: The purpose of this study is to identify risk factors for subarachnoid hemorrhage(SAH) in Korea. METHODS: The clinical record and environmental data of 250 patients who had admitted our hospital between September 2001 and May 2003 were reviewed retrospectively by the neurosurgical nursing practitioners. RESULTS: In this study, the peak age for presentation with ruptured intracranial aneurysm was around 5th decade which is most active period of his or her life. The peak time of aneurysm rupture was from 6 to 12 A.M.(34.8%) and the onset of SAH occurred the most frequently at work(30.4%). The prevalence of hypertension in SAH patients was 42.8%, That of cigarette smoking in men and in women were 81.7% and 15.8% respectively. Hypertension was significantly corrected with the amount of hemorrhage based on Fisher Grading system(P<0.05). The consumption of smoking and the amount of hemorrhage was closely correlated also(P<0.05). CONCLUSION: Hypertension and cigarette smoking may be closely related to aneurysmal SAH. Undoubtedly, they are significantly related to massive, fatal SAH with poor neurologic condition. To prevent reduce aneurysmal SAH, cessation of smoking, anti-hypertensive medication and stress control are most important basic step in promotion of public health.

Increased Viability by Over-Expression of Bcl-XL in a Human Neural Progenitor Cell Line

OBJECTIVE: This study is aimed whether bcl-xl could protect C4 cells from the cell death induced by serum deprivation. METHODS: The transient transfection of the bcl-xl gene was made with a LipofectAMINE reagent. An immunohistocytochemical assay and Western-blotting were performed to examine the bcl-xl transfection into the C4 cells. In order to analyze the effect of the bcl-xl transfection, the number of cells on the well plate were serially counted each day, for 5 days, from the 2nd to the 6th day after transfection. The number of GFP-positive cells in the defined fields, following serum deprivation, was counted using fluorescence microscopy, and the total number of viable cells, including transfected cells, were also assessed. RESULTS: Immunocytochemical staining showed positive cells in 52% of nestin staining, 60% of GFAP and 20% of MAP-2. The number of cells decreased after transfection using the LipofectAMINE in the serum free medium (p<0.001). Western blotting using an anti-human bcl-xl antibodies showed that bcl-xl was expressed in both the non-transfected and bcl-xl transfected C4 cells. Cell death in the C4 cells, and the number of cells, were serially monitored each day for 5 days. In the bcl-xl transfected cells, the cell death induced by serum deprivation was significantly inhibited and delayed compared to that in the control cells (p<0.001). CONCLUSION: It is suggested that the bcl-xl transfected human neural progenitor cells might improve the survival of the grafted cells, and may be an alternative source of cells for neural transplantation in degenerative diseases.

Clinical Analysis of Aneurysmal Subarachnoid Hemorrhage Patients with Vasospasm on Admission

OBJECTIVE: The purpose of this preliminary study is to evaluate the influence of the treatment time(early surgery versus delay surgery) on outcome in a series of 14 patients with the aneurysmal subarachnoid hemorrhage presenting clinical and angiographic vasospasm on admission. METHODS: The authors have reviewed retrospectively the clinical characteristics of 14 patients presenting vasospasm at admission among 430 patients admitted from January 1998 to December 2001. The patients were divided into two groups based on their preoperative time: in 7 days (early treated group): over 7 days from the hemorrhage(delayed treated group). RESULTS: There were no clinical differences between the two groups in age and sex distribution, preoperative Hunt-Hess scale and Fisher grade except anterior communicating artery aneurysm predominance in delayed treated group. The early treated group had a better outcome than the delayed treated group by Glasgow Outcome Scale(p<0.05): 6 good recovery in early treated group(100%, n=6) versus 3 good recovery, 3 moderate Disability, 1 severe disability and 1 death in delayed treated group(n=8). The latter group had high complication rates such as a hemiparesis, meningitis and hydrocephalus(n=6, 78%) CONCLUSION: The early treated group has a good outcome in spite of vasospasm period by early medical treatment for vasospasm. The authors suggest that active early treatment regardless of vasospasm would be one of the treatment choice which contribute to improve the clinical result for subarachnoid hemorrhage presenting vasospasm.

A Case of Parkinsonism Associated with Secondary Hydrocephalus following Aneurysmal Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

A case of parkinsonism caused by hydrocephalus after aneurysmal subarachnoid hemorrhage is reported. A 42-year-old man was admitted with typical symptoms of hydrocephalus, including deteriorated mental status, poor oral intake, gait disturbance and urinary incontinence. He had a past history of aneurysmal subarachnoid hemorrhage clipped one month before. Computed tomographic (CT) scan of the brain revealed dilatation of ventricles with periventricular low densities. He underwent a shunt operation and the symptoms of hydrocephalus were dramatically improved. However, new symptoms just like cogwheel rigidity, masked face, dysarthria and sialorrhea were developed. Levodopa was administrated and the patient showed marked improvement in above symptoms and discharged with independent daily activities. We report this rare clinical presentation and successful management with dopaminergic agent in parkinsonism induced by hydrocephalus after aneurysmal subarachnoid hemorrhage.