Treatment Outcome and Prognostic Factors of Cushing's Disease in Adults

No abstract available.

Intraventricular Pefloxacine Therapy for a Cerebral Ventriculitis by Enterobacter Aerogenes: Case Report

No abstract available.

Expansile Suraplasty for Posttraumatic Syringiomyelia

No abstract available.

The Clinical Significance and Characteristic Shape of Ruptured 'Very Small'Cerebral Aneurysms

The size of unruptured intracranial aneurysms is an important factor that determines their rupture potential; however, the critical threshold size remains to be established. Some useful informations for determining the threshold size have been provided by the reports on the long-term follow-up of previously diagnosed unruptured aneurysms and clinical or autopsy studies on the size of ruptured aneurysms. Among the ninety-eight patients with ruptured cerebral aneurysms the authors managed during the last 4 years and the size of which were identified neuroradiologically and/or intraoperatively, eight cases(8.2%) had very small (maximum diameter less than 5mm) aneurysms. Their clinical features were not remarkably different from the usual aneurysmal SAH. As for the morphology, all of the eight had thin wall and narrow neck; in five cases the aneurysmsal sac had elongated shape. Several clinical reports on the ultimate rupture of previously diagnosed very small unruptured aneurysms and the formidable incidence of very small ruptured aneurysms in such clinical studies as this suggest that very small aneurysms also have a definite risk of rupture. The clinical significance of the narrow neck and elongated sac of the very small ruptured aneurysms observed in the authors' cases seems to be characteristic enough to deserve further investigation.

Spontaneous Fracture of a Lumboperitoneal Shunt Catheter: A Case Report

Spontaneous fracture of the Silastic shunt catheter is a rare complication of lumboperitoneal shunt. A review of the literature revealed only one case in which spontaneous fracture occurred after this procedure. The authors report a case in which fracture of a lumboperitoneal shunt catheter occurred within the interspinous ligament probably due to repeated tension caused by flexion and extension during lumbar motion. The fractured proximal catheter was located entirely within the intrathecal space exclusively from the level of L1 to S1, and caused incomplete cauda equina syndrome.

M1 Fenestration in a Patient with Multiple Cerebral Arterial Aneurysms: Case Report

The authors report an anomalous fenestration at the M1 portion of the middle cerebral artery found incidentally in a patient affected with a ruptured aneurysm at the ipsilateral internal carotid artery(ICA) and unruptured small aneurysms at the contralateral P1 and ICA. The anomaly was confirmed both angiographically and intraoperatively. A review of the literature indicated several reports of this same anomaly, many of which were associated with aneurysms involving either the proximal end of the fenestration or other cerebral arteries. In the interpretation of cerebral angiograms and during intracranial operations, clinical attention should be paid to this rare anomaly.

Putaminal Hemorrhage Associated with Subarachnoid Hemorrhage: Case Report

The preferred site of spontaneous intracerebral hemorrhage(SICH) is the supratentorial area, especially the basal ganglia. Large hematomas frequently spread into the ventricle, and in the case of intraventricular hematomas, varying degrees of fresh blood are found within the subarachnoid space. Cases in which SICH of the basal ganglia ruptures the insular cortex and causes thick subarachnoid hemorrhage(SAH) in the basal cisterns, are, however, rare. The authors report a rare case of putaminal SICH with intraventricular hemorrhage(IVH) and SAH in the basal cisterns. This 58-year-old female was stuporous on admission. Neurological examination revealed Glasgow coma scale score 7, left hemiparesis, positive Babinski's sign and neck stiffness. Brain CT showed a large intracerebral hematoma in the right basal ganglion and associated intraventricular hematoma and SAH in the basal cistern. Cerebral angiography demonstrated a small saccular aneurysm at the right M1. Right pterional and trans-sylvian approach revealed thick SAH in the sylvian fissure and a small unruptured aneurysm at the early bifurcation of the middle cerebral artery. The putaminal hematoma had ruptured into the sylvian fissure through a natural opening at the insular cortex between M2 branches. This case illustrates that hypertensive SICH should be included in the differential diagnosis of basal cistern SAH associated with SICH.

The Results of Extraventricular Drainage Combined with Intraventricular Injection of Urokinase for Intraventricular Hematomas

The authors applied extraventricular drainage combined with intermittent intraventricular injection of urokinase to 21 patients with intraventricular hemtoma and ventricular dilatation. Ten-thousand IU of urokinase was injected every 12 hours for 3 days. Follow-up CT on day 4 after the treatment showed complete disappearance of the hematoma in the 3rd and 4th ventricles and a small residual hematoma in the occipital horns of lateral ventricles in the majority(14 patients) of the patients. Obstruction of the drainage catheter did not occur in any case, but transient pleocytosis in CSF study, ventriculitis, and rebleeding complicated 6,4, and 4 cases, respectively. The duration of extraventricular drainage in the 17 patients without major complications was 3-17 days. The clinical and death in 7 cases. The decisive events that were thought to have caused vegetative states or death in the 13 case. The method of extraventricular drainage combined with intermittent intraventricular injection of urokinase seems useful in revoving intraventricular hematomas, futher investigation including prospective studies is necessary to determine whether the intraventricular injection of urokinase significantly improves the final outcomes of those patients with severe intraventricular hematomas.

Experimentally induced Chiari-like malformation with myeloschisis in chick embryos

Though several pathogenetic theories concerning the frequent association of Chiari malformation and hydrocephalus with myeloschisis have been suggested, none of them explains all the aspects of the disorder. To investigate whether myeloschisis is the direct cause of Chiari malformation and hydrocephalus or these conditions are the results of another basic event, we observed the morphological changes of the posterior cranial fossa and its components in the chick embryos with surgically induced myeloschisis. To make myeloschistic lesions, we opened the neural tube for a length of 9-11 somites in Hamburger and Hamilton stage 16-19 chick embryos. They were divided into cervicothoracic (C-T) and lumbosacral(L-S) groups according to the area of incision. The embryos were re-incubated until postoperative day 11. In the control group, embryos were incubated with the eggshell window open as their experimental counterparts. The survival rates of each group were as follows; 11% (9 survivors/85 operated embryos), 8% (7/83), and 17% (10/60) in the C-T, L-S and control groups, respectively. Myeloschisis positive rates were 100% in the operated groups and 0% in the control group. The heads of embryos were sectioned along the sagittal plane to observe the morphological changes in the posterior cranial fossa and its components. Of the survivors, five in the C-T group, two in the L-S group and six in the control group were available for light microscopic inspection. In the majority of embryos with myeloschisis, without difference between the C-T and L-S groups, the fourth ventricles were smaller than those of the control group and the subarachnoid spaces in the posterior cranial fossa were also narrower. In embryos with severe changes, the cerebellum displaced downward comparing with that of the control embryos. No evidence of hydrocephalus was present Though not always typical, morphological changes similar to Chiari malformation were observed in chick embryos with surgically induced myeloschisis. It suggests a strong direct causal relationship between the two conditions and supports the theories of derangements in cerebrospinal fluid dynamics rather than those of primary mesenchymal or neural origin as a pathogenetic mechanism of Chiari malformation.

Experimentally induced Chiari-like malformation with myeloschisis in chick embryos

Though several pathogenetic theories concerning the frequent association of Chiari malformation and hydrocephalus with myeloschisis have been suggested, none of them explains all the aspects of the disorder. To investigate whether myeloschisis is the direct cause of Chiari malformation and hydrocephalus or these conditions are the results of another basic event, we observed the morphological changes of the posterior cranial fossa and its components in the chick embryos with surgically induced myeloschisis. To make myeloschistic lesions, we opened the neural tube for a length of 9-11 somites in Hamburger and Hamilton stage 16-19 chick embryos. They were divided into cervicothoracic (C-T) and lumbosacral(L-S) groups according to the area of incision. The embryos were re-incubated until postoperative day 11. In the control group, embryos were incubated with the eggshell window open as their experimental counterparts. The survival rates of each group were as follows; 11% (9 survivors/85 operated embryos), 8% (7/83), and 17% (10/60) in the C-T, L-S and control groups, respectively. Myeloschisis positive rates were 100% in the operated groups and 0% in the control group. The heads of embryos were sectioned along the sagittal plane to observe the morphological changes in the posterior cranial fossa and its components. Of the survivors, five in the C-T group, two in the L-S group and six in the control group were available for light microscopic inspection. In the majority of embryos with myeloschisis, without difference between the C-T and L-S groups, the fourth ventricles were smaller than those of the control group and the subarachnoid spaces in the posterior cranial fossa were also narrower. In embryos with severe changes, the cerebellum displaced downward comparing with that of the control embryos. No evidence of hydrocephalus was present Though not always typical, morphological changes similar to Chiari malformation were observed in chick embryos with surgically induced myeloschisis. It suggests a strong direct causal relationship between the two conditions and supports the theories of derangements in cerebrospinal fluid dynamics rather than those of primary mesenchymal or neural origin as a pathogenetic mechanism of Chiari malformation.

Ruptured Intracranial Bacterial Aneurysms: Report of Two Cases

Two Cases of ruptured bacterial aneurysms involving the distal branches of the middle cerebral artery associated with an intracerebral hematoma are reported. Both patients presented with a medical history of valvular heart disease and subacute bacterial endocarditis. The mortality of ruptured intracranial bacterial aneurysms has been reported to be very. High and a proper treatment strategy for such aneurysms still remains controversial. Most authors have recommended aggressive antimicrobial therapy, serial antiographic follow-up studies, and surgery for aneurysm's that do not resolve or enlarge even after medical treatment. Both of the reported patients were treated with antibiotics and underwent surgical evacuation for huge-sized intracerebral hematomas, and in one patient, the aneurysm was completely resected.

Cerebral Aeurysms Associated with Brain Tumor: Report of Three Cases

The authors present three cases of intracranial aneurysm associated with brain tumors. Two cases were unruptured intracranial aneurysms(one was located at the origin of anterior choroidal artery of right internal carotid artery and the other at the bifurcation of right middle cerebral artery). Which were found incidentally during the transcranial approaches to pituitary adenoma and right frontal glioblastoma multiforme respectively. As preoperative angiography was not performed in those cases, there was some difficulty in clipping the neck of the aneurysms. The third case presented with sudden headache and vomiting, and her brain computed tomography, magnetic resonance imaging and cerebral angiography showed subarachnoid hemorrhage, five anterior and one posterior circulation aneurysms as well as a pituitary adenoma. The patient refused the operation. It is well known that some brain tumors, such as pituitary adenoma, glioma, meningioma, are often associated with intracranial aneurysms. In planning the treatment of those brain tumors, preoperative angiography seems essential to know the status of the vessels adjacent to the tumors and to rule out incidental aneurysms.

Thoracic Myelopathy Caused by Ossified Ligamentum Flavum: Case Report

A rare case of thoracic myelopathy caused by the ossification of hypertrophied ligamentum flavum is presented. A fourty-year old male complained of decreased pain, temperature, touch sense at right lower limb, weak urinary stream, poor penile erection, and constipation. CT revealed an ovoid, homogeneously high density at the site of left T10-11 ligamentum flavum, which compressed the spinal cord posterolaterally. MR imaging showed significant spinal cord compression on the left posterolateral aspect at T10-11 level by a well-defined purely low-intensity signal lesion. Simple spine X-rays did not show any abnormality. T10 total laminectomy and removal of the ossified ligamentum flavum resolved his neurological dysfunction. Clinical summary of the case is presented and the corresponding literature are reviewed.

Intracranial Intradural Chondroma: Case Report

Solitary chondroma is a benign tumor which rarely involves the intracranial cavity. Most of them are originated from and attached to the skull base. Very rarely they occur intradurally. The authors experienced a female case of a chondrome located at fromtal interhemispheric fissure and connected to the inferior margin of the falx by a thin pedicle. Her clinical , radiologic, operative, and pathologic findings are reported and the pertinent literatures are reviewed.

MRI of the Posttraumatic Cerebral Parenchymatous Injuries

The authors retrospecitviely analyzed the MRI findings of the 8 head-injured patiens who had showed persistent unconsciousness and severe neurologic deficite after trauma. T2-weighted MR images disclosed high signal intensity lesions of various size and shape at lobar white matter and corpus callosum, subcortical gray matter, brain stem, and cerebral cortex, and assisted greatly in understanding the neurologic deficits of the corresponding patients. The lesions were mostly multiple and involved multiple structures. CT's revealed in those patients only small hemorrhages, suspicious low densities, such nonspecific findings as slit ventricles and diffuse brain atrophy, or no abnormality at all. Post-traumatic parenchymatous lesions detected by MR images were either missed or quite underestimated on CT's. MRI was very supeior to CT in the detection and anatomic localization of nonhemorrhagic intraaxial cerebral injuries. especially in the cases of small corical contusions, brainstem and white matter injuries. For the evaluation of the acute posttraumatic patients, CT ios indicated in order to fastly detect intracranial hemagomas which may need emergent surgical evacuation. If CT findings does not explain the neurologic degicits of the patients, especially in the late stage. MRI is indicated. MRI is expected to play a major role in the diagnosis of shear injuries involoving white matter and brainstem where CT has been of little contribution or misleading.

Clinical Analysis of Acute Epidural Hematoma

The authors have analyzed the factors influencing the outcome of the 168 patients with acute epidural hematoma who had been managed in our hospital for 3 years from July 1986 to June 1989. 1) Sex incidence showed that male patients were 4.8 times more commonly affected than females, and the most commonly affected age group was the 3rd decade. 2) The most common cause of injury was motor vehicle accidents. The patients with unknown cause of injury which probably suggested significant delay in starting the clinical managements had a higher mortality rate. 3) The most common site of hematoma was the FTP convexity(63.6%). The patients with diffuse hematoma in the fronto-temporo-parietal region had a high mortality and deteriorated level of consciousness. 4) Skull fractures were not seen only in 9.5% of the patients with acute epidural hematoma. 5) The main factors associated with the higher mortality rate were rapid development of hematoma, pupillary dilatation, low score in Glasgow Coma Scale on arrival, and more midline shifting on brain CT. 6) The patients with concomitant intracranial lesions had a high mortality rate(25.8%), and the patients with acute epidural hematoma alone had a low rate(2%), and the overall mortality rate of the patients with acute epidural hematoma was 11.3%.

Clinical Survey of Intracranial Acute Subdural Hematoma

One Hundred and eight patients received operation for acute subdural hematoma were evaluated in prognostic factors. They were admitted to the Neurosurgical Department in S.R.C.H during the 3 years from January, 1986 to December, 1988. The results were as follows ; 1) The patients were consist of 85 male patients and 23 female patients with the sex ratio 3.7 : 1. 2) Evaluated prognostic factors were age and sex, preoperative Glasgow coma scale(GCS), preoperative pathological physical findings, time interval from injury to operation, type of injury, midline shift, location of hematoma, thickness of hematoma, and operative procedure. 3) On the statistical analysis, factors of GCS and midline shift were considerable significant factors. 4) In the overall results of 108 patients, 47 patients(43.5%) had good recovery, 9 patients(8.3%) had moderate disabled state, 2 patients(1.9%) were severe disabled state, 4 patients(3.7%) were vegetative state, and 46 patients(42.6%) died.

A Case of Intracranial Meningeal Mesenchymal Chondrosarcoma: A Case Report

Recently, the authors have experienced a case of intracranial meningeal mesenchymal chondrosarcoma. Mesenchymal chondrosarcoma is a rare tumor of the bone and soft tissue. It has been reported that the most common site of their extra-osseous origin is the central nervous system. Precise differential diagnosis should be done because of 1) its similarity to angioblastic meningioma or hemangiopericytoma in pathological aspect, 2) much more malignant tendency. We present one case of intracranial meningeal mesechymal chondrosarcoma with a brief review of the relevant literature.

Sacral Spinal Meningeal Cyst(Perineurial Cyst): A Case Report

We experienced a rare case of sacral meningeal cyst so called sacral perineurial cyst(Tarlov cyst). A 15 years old girl was admitted to the hospital because of sudden severe low back pain and Lt. sciatica for about one week. We performed delayed myelography and spinal computeized tomographic myelography(C.T.M) for differential diagnosis. Delayed filling of contrast media in the cyst was significant in diagnosis of sacral meningeal cyst type II. Laminectomy of sacrum(S1) was performed for partial excision of cystic wall and plastic suture. Operative finding was typical sacral perineurial cyst(Tarlov cyst) which was recently clssified as sacral meningeal cyst type II. The classification of spinal meningeal cysts in the literature was indistinct and confused. We also agree with Nabors et. al, in current classificcation of spinal meningeal cysts, in which the spinal meningeal cysts, in which the spinal meningeal cysts were divided into 3 groups as extradural spinal Mcs Type I(Diverticulum), Type II(perineurial cyst), intradural spinal Mcs(arachnoid cyst).

A Case of Left Temporal Gliosarcoma

A case of left temporal gliosarcoma is reported. The patient was a 40-year old man who had headache, behavior change, dysphasia, and mental confusion for about 2 months duration. On brain CT, a large partially cystic mass with homogeneous enhancement was located at left temporal lobe and associated with remarkable peritumoral edema and mass effect. Angiographic tumor vascularity was faintly visualized. Surgical subtotal resection of the tumor and post-operative radiotherapy offered transient symptomatic improvement, being followed within several months by clinical deterioration and regrowth of the tumor on brain CT. Light microscopic studies of the H & E and special stained specimens showed two different components within the tumor in a mixed fashion, i.e. intermingled glioblastoma multiforme and fibrosarcoma. Electron microscopic study of the sarcomatous cells disclosed intracytoplasmic Weibel-Palade-like bodies, a specific marker of endothelial cells. The fibrosarcomatous component of gliosarcoma is believed to be originated from malignant transformation of the hyperplastic endothelial cells within the anaplastic glioma. Literature concerned with gliosarcoma is reviewed.