Middle Meningeal Artery Embolization in Recurrent Chronic Subdural Hematoma Combined with Arachnoid Cyst / 대한신경손상학회지

Chronic subdural hematoma (CSDH) is a collection of old blood and its breakdown products between the surface of the brain parenchyma and the outermost layer called the dura. The most common treatment option for primary CSDH is burr-hole trephination; however, the treatment method for recurrent CSDH is still widely debated. An arachnoid cyst (AC) is a sac filled with cerebrospinal fluid located between the brain or spinal cord and the arachnoid membrane, which is one of the three meninges covering the brain or spinal cord. Although it is rare, the cyst is associated with CSDH in juveniles, and the recurrence rate of CSDH increases in such cases. Much of the literature has supported the preventive role of middle meningeal artery (MMA) embolization in recurrent CSDH. We report a 13-year-old male patient with recurrent CSDH and AC where the early intervention of MMA embolization was proven effective in preventing the further recurrence of CSDH.

Angiographic Recurrence after Endovascular Coil Embolization for Intracranial Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: We have investigated the risk factors associated with angiographic recurrence of intracranial aneurysms after endovascular coil embolization in a retrospective manner. METHODS: From January 2000 to June 2005, 128 aneurysms in 114 patients were treated with coil embolization. Among them, 54 aneurysms in 51 patients were followed by repeated intraarterial angiography at 6, 12, 18, and 24 months post-embolization. Recurrence was defined when either coil compaction or aneurysm regrowth was identified on follow-up angiography. Patients were divided into stable and recurred groups according to angiographic recurrence. Clinical parameters, anatomical factors, and the degree of occlusion were retrospectively reviewed. RESULTS: The overall recurrence rate was 29% in our study. The diameter of the largest dimension of the fundus was larger in the recurred group of patients as compared to the stable group of patients (7.33+/-2.26 mm vs. 5.87+/-1.93mm, p = 0.048), and a significant rate of recurrence was seen in fundus size of the same or greater than 10 mm (41.7% vs 14.3%, p = 0.038). The coil packing density was significantly smaller in the recurred group of patients (p = 0.002), with a recurrence rate of 47.0% in cases with a coil packing density below 25% (p = 0.017). CONCLUSIONS: Our study showed that maximum aneurysm fundus size and coil packing density had a close correlation to recurrence. However, a larger number of patients with longer observation times may be needed to define the risk factors affecting angiographic recurrence.

The Usefulness of Contrast Extravasation on CT Angiography in Spontaneous Intracerebral Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: The authors investigated the clinical and radiographic characteristics of patients who exhibited contrast extravasation on initial computed tomographic angiography (CTA) and assessed the its association with hematoma expansion. METHODS: Ninety six patients who were diagnosed with intracerebral hemorrhage and who received CTA within 12 hours from initial onset of symptoms and who received a follow up brain CT within 48 hours from the initial CTA between April 2004 and March 2007 were retrospectively assessed. Contrast extravasation was defined as the presence of high-density material within the hematoma. Patients were classified into the extravasation and no extravasation groups. Clinical and radiographic variables were compared between the two groups. RESULTS: Fifteen patients (19%) demonstrated presence of extravasation on initial CTA. A significantly higher rate of hematoma expansion was seen in the extravasation group compared to the non extravasation group (47% vs 17%, p=0.027). Mean time from onset of symptoms to initial CTA was significantly shorter in the extravasation group (3.5+/-1.3 hours vs 7.6+/-2.5 hours, p0.001). CONCLUSIONS: Earlier detection of extravasation using CTA may help in identifying possibly life threatening complications caused by hematoma expansion. However, a larger prospective cohort is warranted to validate this result.

Posttraumatic Carotid-cavernous fistula Combined with Intracavernous False Aneurysm / 대한뇌혈관외과학회지

Posttraumatic high-flow communications between the intracavernous internal carotid artery (ICA) and the cavernous sinus may give rise to two different pathological entities. A connection from the intracavernous ICA system can theoretically connect with two different structures; the vein of the plexus (CCF) or the perivascular bare spaces between the veins (pseudoaneurysm). A CCF and a pseudoaneurysm can be present in the same patient. A 24-year-old man was admitted to our hospital due to sudden mental deterioration. Carotid angiography revealed a CCF, which had occurred after a trauma 5 years earlier, associated with left visual disturbance and skull base fractures. The treatment of choice was permanent coil occlusion of the intracavernous ICA at the level of the lesion. The collateral circulation was evaluated before the endovascular treatment using a balloon test occlusion (BTO). During the BTO, adequate collateral circulation was defined as symmetric angiographic filling of both hemispheres. A continuous neurological examination was performed during the procedure. The follow-up angiography showed a persistent aneurysm occlusion. We report our experience of the successful endovascular treatment of combined lesions with a review of the relevant literature.

Intradural Lumbar Disc Herniation

Intradural lumbar disc herniation(ILDH) is a rare pathology. The pathogenesis of ILDH is not known with certainty. Adhesions between the ventral wall of the dura and the posterior longitudinal ligament(PLL) could act as a preconditioning factor. Diagnosis of ILDH is difficult and seldom suspected preoperatively. Prompt surgery is necessary because the neurologic prognosis appears to be closely related to preoperative duration of neurologic symptoms. Despite preoperatively significant neurological deficits, the prognosis following surgery is relatively good. We report on case of ILDH at L3/4 with differential diagnoses, and the possible pathogenic factors are discussed.

Bcl-2 and Bax Expression and Ki-67 Proliferative Index in Astrocytic Tumors: in Relation to Prognosis

OBJECTIVE: We report a retrospective investigation of the prognostic value of bcl-2 and bax expression, and Ki-67 proliferative index in 42 astrocytic tumors. METHODS: We classified the astrocytic tumors and reviewed the clinical information and survival time. The sections were taken from surgically resected paraffin-embedded tissue and performed immunohistochemical stains for bcl-2, bax and Ki-67. RESULTS: The immunohistochemical stain for bcl-2 revealed a positivity in only two(4.76%) among forty-two cases. The immunostain for bax was positive in 35 cases(83.3%). However, the correlation between bcl-2 & bax expression and age, sex, tumor location, size, and histologic grade was not found. By Kaplan-Meier analysis, bcl-2 & bax expression and survival time in astrocytic tumors was no significance in log rank test(p>0.05). There were prognostic values between Ki-67 LI and histologic grade and between Ki-67 LI and survival time, respectively(p<0.05). CONCLUSION: Bcl-2 and bax are not significant, whereas Ki-67 LI is suggested as a significant prognostic factor, associated with histologic grade and survival time of astrocytic tumors.

Complications of Endovascular Detachable Coil Treatment in Cerebral Aneurysms

OBJECTIVE: The purpose of this study is to evaluate complications in 70 patients who had underwent endovascular treatment to occlude cerebral aneurysms. METHODS: From May 1999 to December 2002, we treated 70 patients by endovascular treatment or by combination of endovascular treatment and surgery. Complications have been developed in fifteen patients. Twelve patients had anterior circulation aneurysms: 4 posterior commmuncating artery ; 2 anterior communicating artery ; 2 paraclinoid artery ; 2 anterior choroidal artery ; 1 distal internal carotid artery ; 1 middle cerebral artery ; 1 pericallosal artery and three patients had posterior circulation aneurysms: 3 basilar artery tip. RESULTS: The complications related to the coil embolization were the thromboembolic event in 9 cases, rupture of the aneurysm in 3 cases, coil prolapse in 3 cases and coil migration in 1 case. CONCLUSION: The coil embolization can be a alternative good modality in the treatment of cerebral aneurysms. But careful attention should be required to reduce the various complications of procedures and to improve the prognosis of aneurysmal treatment. Effort to overcome the technical problem and to develop more comfortable device are needed for the better results of endovascular treatment.

Prognostic Factors in Spontaneous Primary Intraventricular Hemorrhage

OBJECTIVE: TA retrospective study is performed on 28 patients with primary intraventricular hemorrhage(PIVH) to examine the outcome and prognostic factors associated with this disorder. METHODS: Clinical data collected between 1998 and 2002 was used in the present study. The outcomes of these patients were compared by age, etiology, initial Glasgow Coma Score(GCS), Graeb's score, ventriculocranial ratio(VCR), hemorrhagic dilation of the third ventricle, and hemorrhagic dilation of the fourth ventricle. The Glasgow Outcome Scale(GOS) at discharge was used for the comparison of outcomes. RESULTS: The mean age of these patients was 48.4+/-17.4 years. The underlying causes of PIVH were hypertension(53.6%), moyamoya disease(17.9%), arteriovenous malformation(10.7%), cerebral aneurysm(7.1%), and unknown(10.7%). The age and etiology were not correlated with outcome. Patients with a GCS of 13-15 showed a good outcome in 90.5%(p or =0.23) showed a poor outcome in 64.3%(p<0.05). Patients with a Graeb's score of 9-12 showed a poor outcome in 87.5%(p<0.05). Those with hemorrhagic dilatation of the third ventricle showed a poor outcome in 80.0%, and those with hemorrhagic dilatation of the fourth ventricle showed a poor outcome in 85.7%(p<0.05). The overall mortality rate was 17.9%. CONCLUSION: Low initial GCS, high Graeb's score, high VCR, and hemorrhagic dilatation of the third ventricle or the fourth ventricle are correlated with poor outcome in PIVH.

A Case of Occult Retroperitoneal Hematoma Associated with Head Trauma

The diagnosis and appropriate management of blunt abdominal trauma including retroperitoneal hematoma associated head injury is difficult. In our case, psoas muscle hematoma was revealed during the evaluation of fever. Psoas muscle hematoma most commonly results secondarily from coagulation defect or from retroperitoneal bleeding into the psoas sheath. The presenting signs and symptoms of this case are hypotension and anemia. Pain is also present in the back or abdomen. If it is associated with head injury and not presented massive hemorrhage, the actual diagnosis is not easy. The appropriate management depends on a careful initial evaluation including suspicion of physician, repetitive physical examination, the timely use of diagnostic procedures.

Endovascualr Treatment for Traumatic Giant Pseudoaneurysm of Internal Carotid Artery

Traumatic pseudoaneurysms of the cavernous portion of the internal carotid artery(ICA) presenting with epistaxis are uncommon and potentially lethal complication of head injury. Because the onset of delayed bleeding from the time of injury is variable, prompt diagnosis and treatment of cavernous ICA pseudoaneurysm is important. A patient with a giant traumatic pseudoaneurysm of the left ICA presented with massive epistaxis 5 months after a head trauma. This patient was treated with occlusion of the opening of pseudoaneurysm and ICA by a detachable balloon and fibered coils.

Endovascualr Treatment for Traumatic Giant Pseudoaneurysm of Internal Carotid Artery

Traumatic pseudoaneurysms of the cavernous portion of the internal carotid artery(ICA) presenting with epistaxis are uncommon and potentially lethal complication of head injury. Because the onset of delayed bleeding from the time of injury is variable, prompt diagnosis and treatment of cavernous ICA pseudoaneurysm is important. A patient with a giant traumatic pseudoaneurysm of the left ICA presented with massive epistaxis 5 months after a head trauma. This patient was treated with occlusion of the opening of pseudoaneurysm and ICA by a detachable balloon and fibered coils.

Penicillin-resistant Aerococcus viridans Bacteremia Associated with Granulocytopenia

Aerococcus viridans, a catalase-negative gram-positive coccus rarely causing bacteremia, was isolated from blood cultures of a 52-yr-old man under the gran-ulocytopenic condition. The isolate showed the typical characteristics of A. viridans, i.e., tetrad arrangements in gram stain, positive pyrrolidonyl aminopeptidase (PYR) and negative leucine aminopeptidase (LAP) reactions, and no growth at 45 degrees C.The isolate was revealed to be highly resistant to penicillin, erythromycin, clindamycin, and ceftriaxone, although most strains of A. viridans isolated from the previously reported patients were susceptible to penicillin and other commonly used antibiotics. Even though A. viridans is rarely associated with human infections, it could be a potential causative agent of bacteremia, especially in immunocompromised patients.

Clinical Analysis of the Delayed Post-Traumatic Epidural Hematoma after Hematoma Evacuation

OBJECTIVE: The authors analyze the incidence, etiological and prognostic factors between contralateral and ipsilateral delayed epidural hematoma after evacuation of initial hematoma and to formulate recommendations for early detection of evolving hematoma and improvement of outcome. METHODS: Between July 1997 and December 1999, 417 patients underwent craniotomy at department of neurosurgery to evacuate an acute posttraumatic intracranial hematoma. Analysis of these clinical and neuroradiologic data showed that we underwent a second operation on 24 patient(5.8%) for removal of delayed epidural hematoma. In 10(2.4%) of these patients the second operation was undertaken to evacuate a new hematoma that had developed at a contralateral side from the initial hematoma. In 14 patients(3.4%), the second operation was to remove a epidural hematoma at the same site as the first craniotomy. RESULTS: 24 patients were divided into two groups. In Group A, 10 patients who developed contralateral delayed epidural hematoma were 31.5 years(11-61) of age and had skull fracture at the site of delayed epidual hematoma formation. Two of these patients revealed severe brain swelling during the evacuation of acute subdural hematoma. Eight of them were diagnosed within 24 hours after craniotomy through immediately postoperative computed tomography scan. In Group B, 14 patients who developed ipsilateral epidural hematoma were 56.1 years(27-75) of age. Six of them had hemorrhagic tendency related to past medical history. Eleven of these patients were associated with thrombocytopenia and consumptive coagulopathy when required second operation. Twelve patients were diagnosed within 48-72 hours after craniotomy due to clinical deterioration or failure to improve. There was no significant difference in outcome between two groups. CONCLUSION: The authors sought differential factors between contralateral and ipsilateral delayed epidural hematoma. Delayed epidural hematoma after craniotomy may need an urgent operation or lead to serious complication or disability. Postoperative computed tomography scan, intracranial pressure monitoring and repeat computed tomography scan within 72 hours of injury are strongly recommended in these cases, especially after decompression of cranial cavity.

Clinical Characteristics and Prognosis of Mild Head Injury in the Elderly559

OBJECTIVE: The elderly population is rapidly growing, and the population over age 65 is expected to increase. To evaluate factors that determine recovery in this population, we report a clinical analysis of 77 elder patients of mild head trauma over 65 years of age. METHODS: The medical records were reviewed retrospectively for 77 head-injured patients aged 65 to 85 years who were admitted to our institution between March, 1995 and December, 1999. The outcome was compared with age, sex, Glasgow Coma Scale score, and radiologic characteristics. RESULTS: As in all age groups, males predominated and motor vehicle accidents accounted for a highest proportion(35%). Of the traffic accidents, pedestrian injuries were more common. The single most common lesion was subdural hematoma. The initial radiologic findings were not correlated with outcome. The GCS score was statistically correlated with prognosis. Sixty-one patients(79.2%) had favorable outcome. Ten of seventy-seven patients(13%) died whereas cerebral injury accounted for 5 deaths. Non-cerebral causes of death were composed of pneumonia, multi-organ failure and sepsis. The mean hospitalization was 52.3+/-12.6 days. CONCLUSION: The mortality rate after injury is higher in elderly patients. It is therefore the factors of intracranial and extracranial cause which influence survival and outcome be carefully treated. Neurologic deficits, even though mild, are the risk factor of poor prognosis in the elderly. Earlier identification of risk and aggressive support may be needed for decreasing the morbidity and the mortality in the elderly.

An assessment on cross-sectional view of the mandible by linear tomogram of panorama / 대한구강악안면방사선학회지

PURPOSE: To evaluate the precision of measurements of distances and angle in the cross-sectional views of linear tomogram of panorama and to assess the technique for visualizing the mandibular canal. METHODS: Ten dry mandibles were radiographically examined with 3 continuous cross-sectional views of linear tomogram of panorama and 4 continuous computed tomograms. The distance between the superior border of canal and alveolar crest and the bucco-lingual width of alveolar bone at the level of the superior border of canal and the angle between the two lines above were measured. Measurements were performed by radiologist and implantologist group and compared with measurements on computed radiograms of the same areas. RESULTS: The measurements differences for the distance of alveolar bone height between in panorama and in CT showed 0.9mm+/-0.6mm by radiologists and 1.3mm+/-0.8mm by implantologists. There was no statistically significant difference between two groups' measurements. The differences in measurements for the distance of alveolar bone width between in panorama and in CT showed 0.5mm+/-0.8mm by radiologists and 2.5mm+/-1.4 mm by implantologists. There was significant difference (p<0.05) between two groups' measurements. The average bucco-lingual inclination of alveolar bone above mandibular canal was average 95.8degrees in CT. The difference of measurements between two groups was average 1+/-0.9degrees. Three cross-sectional views of panorama could show that the mandibular canal crosses antero-lingually and slopes inferiorly from the posterior segment of the mandible. Conclusions : The measurements in the linear tomogram of panorama by radiologists gave the accurate values of the distances and the angle compared with the values in computed tomograms.

An assessment on cross-sectional view of the mandible by linear tomogram of panorama / 대한구강악안면방사선학회지

PURPOSE: To evaluate the precision of measurements of distances and angle in the cross-sectional views of linear tomogram of panorama and to assess the technique for visualizing the mandibular canal. METHODS: Ten dry mandibles were radiographically examined with 3 continuous cross-sectional views of linear tomogram of panorama and 4 continuous computed tomograms. The distance between the superior border of canal and alveolar crest and the bucco-lingual width of alveolar bone at the level of the superior border of canal and the angle between the two lines above were measured. Measurements were performed by radiologist and implantologist group and compared with measurements on computed radiograms of the same areas. RESULTS: The measurements differences for the distance of alveolar bone height between in panorama and in CT showed 0.9mm+/-0.6mm by radiologists and 1.3mm+/-0.8mm by implantologists. There was no statistically significant difference between two groups' measurements. The differences in measurements for the distance of alveolar bone width between in panorama and in CT showed 0.5mm+/-0.8mm by radiologists and 2.5mm+/-1.4 mm by implantologists. There was significant difference (p<0.05) between two groups' measurements. The average bucco-lingual inclination of alveolar bone above mandibular canal was average 95.8degrees in CT. The difference of measurements between two groups was average 1+/-0.9degrees. Three cross-sectional views of panorama could show that the mandibular canal crosses antero-lingually and slopes inferiorly from the posterior segment of the mandible. Conclusions : The measurements in the linear tomogram of panorama by radiologists gave the accurate values of the distances and the angle compared with the values in computed tomograms.

A Case of Spinal Cord Compression Caused by Rhabdomyosarcoma of the Mediastinum Associated with Type I Neurofibromatosis(NF Type I)

A 12-years-old female admitted to the hospital with the complaint of pain on the right upper chest area which persisted about 1 month prior to admission. Cafe-au-lait spots of various size laying on a whole body and freckling on the axilla were found on physical examination. A huge mass was found on the plain chest X-ray and on chest MRI. The mass encroached thoracic spine, posterior rib, back muscles, and then into the neural canal and compressed thoracic spinal cord. On the 5th day of hospitalization, the patient complained tingling on the both legs and 2 days later, monoparesis on the right leg. Open thoracotomy and decompressive laminectomy was done to remove mass. Pathologic reports confirmed rhabdomyosarcoma, embryonal type.

Dural Arteriovenous Malformation on the Anterior Cranial Fossa

Dural arteriovenous malformations(AVM) are not uncommon. Reports of intracranial dural AVM have been increasing but most of them deal with dural AVM in the region of the cavernous sinus, posterior fossa and tentorium, but those of the anterior cranial fossa are very rare. Recently, we experienced two cases of right frontal dural arteriovenous malformation fed mainly by both ethmoidal arteries. The angiographic appearance in these two cases is quite uniform. The nidus was located in the frontal dura, although their main feeders were dural arteries. They were drained through an intracerebral cortical vein associated with aneurysmal dilatation of proximal portion into superior sagittal sinus. Spontaneous intracerebral hematoma was the cause of the clinical symptoms. We report two cases of intracerebral hematoma, caused by dural AVM, which was successfully managed by surgical treatment.

Tic convulsif caused by cerebellopontine angle schwannoma

A case is presented of painful tic convulsif caused by schwannoma in the cerebellopontine angle (CPA), with right trigeminal neuralgia and ipsilateral hemifacial spasm. Magnetic resonance images showed a 4 cm round mass displacing the 4th ventricle and distorting the brain stem in the right CPA. The schwannoma, which compressed the fifth and seventh cranial nerves directly, was subtotally removed by a suboccipital craniectomy. Postoperatively, the patient had a complete relief from the hemifacial spasm and marked improvement from trigeminal neuralgia. The painful tic convulsif in this case was probably produced by the tumor compressing and displacing the anterior cerebellar artery directly.

Clinical Features of the Patients with Fracture on the Frontal Bone

No abstract available.