Anterior Spinal Artery Syndrome Occurring after One Level Segmental Artery Ligation during Spinal Surgery / 대한신경손상학회지

In treating the ventral pathology of spine, ligating the segmental vessels is sometimes necessary. This may cause spinal cord ischemia, and concerns of neurologic injury have been presented. However, spinal cord ischemic injury after sacrificing segmental vessels during spine surgery is very rare. Reports of this have been scarce in the literature and most of these complications occur after multi-level segmental vessel ligation. Here we report a case of a patient with postoperative anterior spinal artery syndrome, which occurred after ligating one level segmental vessels during spinal surgery for a T8 vertebral pathologic fracture. Despite its rarity, the risk of spinal cord ischemic injury after segmental vessel ligation is certainly present. Surgeons must keep in mind such risk, and surgery should be planned under a careful risk-benefit consideration.

Disappearance of a Distal Shunt Catheter: A Case Report of an Unusual Cause of Shunt Malfunction / 대한신경손상학회지

Shunt malfunction is a common complication in patients who undergo ventriculoperitoneal shunt (VPS) placement for the treatment of hydrocephalus. A plethora of reports regarding shunt malfunctions due to distal catheter migration have been demonstrated in the literature. However, to our knowledge, there have been no reports thus far of shunt malfunctions caused by the complete disappearance of a distal catheter. A 70-year-old man was admitted to our hospital for progressive gait disturbance beginning approximately 5 months ago. He received a VPS for posthemorrhagic hydrocephalus and was doing well over the course of 18 months of follow-up. Since no increase in the size of the ventricle was observed on brain computed tomography taken at the outpatient clinic, we tried to readjust the pressure setting of his programmable shunt valve to relieve his symptoms. Without any progression, we discovered later by chance that the distal shunt catheter was missing. Shunt revision surgery was performed. At the 2-year follow-up, a slight improvement in gait was observed. Although it is very rare, the distal catheter can disappear without any noticeable symptoms. If shunt malfunction is suspected, it is important to check whether the entire shunt system is structurally intact.

Spontaneous Disappearance of an Arachnoid Cyst after Burr Hole Drainage of Chronic Subdural Hematoma / 대한신경손상학회지

It is well known that the presence of arachnoid cysts (ACs) in young patients is a risk factor for developing a chronic subdural hematoma (CSDH) after a minor head injury. Although there have been controversies with the treatment, most authors recommend only draining the CSDH if the AC is asymptomatic. This judgement is based on the facts that this surgical approach has shown good clinical outcomes, and the AC usually remains unchanged after the surgery. Our case demonstrates that the AC of a young patient who developed a CSDH after a minor head injury completely disappeared after a burr hole drainage of the CSDH. Although the chances of an AC disappearing are low, this case shows that an AC might disappear after only draining a CSDH when a rupture of the AC membrane is identified. In such cases, we recommend first draining only the CSDH for the treatment of AC-associated CSDHs.

A Thoracolumbar Pure Spinal Epidural Cavernous Hemangioma: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report. OBJECTIVES: We report a case of pure epidural cavernous hemangioma located at the thoracolumbar spine in a 53-year-old woman that mimicked a neurogenic tumor on magnetic resonance imaging (MRI). SUMMARY OF LITERATURE REVIEW: A pure spinal epidural cavernous hemangioma without bony involvement is a very rare lesion about which limited information is available in the literature. MATERIALS AND METHODS: A 53-year-old woman visited our clinic for hypoesthesia with a tingling sensation in the left anterolateral thigh that had begun a month ago. No other neurologic symptoms or signs were present upon a neurologic examination. MRI from an outside hospital showed a 2.0×0.5 cm elongated mass at the T11-12 left neural foramen. The tumor was completely removed in piecemeal fashion. RESULTS: The histopathologic examination revealed a cavernous hemangioma, which was the final diagnosis. The outcome was favorable in that only operation-related mild back pain remained, without any neurologic deficits, after a postoperative follow-up of 2 years and 3 months. No recurrence was observed on MRI at 2 years postoperatively. CONCLUSION: Pure epidural spinal cavernous hemangioma is very rare, and it is very difficult to differentiate from other epidural lesions. However, we believe that it should be included in the differential diagnosis of spinal epidural tumors due to its favorable prognosis.

A Thoracolumbar Pure Spinal Epidural Cavernous Hemangioma: A Case Report

OBJECTIVES@#We report a case of pure epidural cavernous hemangioma located at the thoracolumbar spine in a 53-year-old woman that mimicked a neurogenic tumor on magnetic resonance imaging (MRI).SUMMARY OF LITERATURE REVIEW: A pure spinal epidural cavernous hemangioma without bony involvement is a very rare lesion about which limited information is available in the literature.@*MATERIALS AND METHODS@#A 53-year-old woman visited our clinic for hypoesthesia with a tingling sensation in the left anterolateral thigh that had begun a month ago. No other neurologic symptoms or signs were present upon a neurologic examination. MRI from an outside hospital showed a 2.0×0.5 cm elongated mass at the T11-12 left neural foramen. The tumor was completely removed in piecemeal fashion.@*RESULTS@#The histopathologic examination revealed a cavernous hemangioma, which was the final diagnosis. The outcome was favorable in that only operation-related mild back pain remained, without any neurologic deficits, after a postoperative follow-up of 2 years and 3 months. No recurrence was observed on MRI at 2 years postoperatively.@*CONCLUSION@#Pure epidural spinal cavernous hemangioma is very rare, and it is very difficult to differentiate from other epidural lesions. However, we believe that it should be included in the differential diagnosis of spinal epidural tumors due to its favorable prognosis.

Considerations in Treating Neonatal and Infantile Patients with a Retrocerebellar Arachnoid Cyst: in the Perspective of Different CSF Dynamics

Arachnoid cysts found under the age of 1 year are more likely to grow in size, relatively short term follow-up is required. Retrocerebellar location predicts a high risk of hydrocephalus, and the time window until irreversible neuronal damage is often narrow if the arachnoid cyst increases in size and becomes symptomatic. However, when and how to treat a neonatal or infantile patient with a retrocerebellar arachnoid cyst is still a controversial subject. We recently experienced 3 differently treated very young pediatric patients with retrocerebellar arachnoid cysts. One patient was treated two weeks after birth by a cystoperitoneal shunt. This patient showed normal development after the surgery. The other patient was treated by a ventriculoperitoneal shunt and subsequent cystoventriculostomy at the age of 4 months because of his mother's refusal on 14th day after birth. This one showed developmental delay despite of decreasing size of ventricles after the surgery. The last patient was treated with microscopic fenestration, which failed in its initial attempt. A revision operation by cyst excision succeeded and had no problem after the surgery. Therefore, we suggest that early surgical intervention for retrocerebellar arachnoid cyst can be considered. Although there are concerns of long term complications related to shunts, a cystoperitoneal shunt would be a feasible treatment if we consider the minor cerebrospinal fluid pathway which is the dominant cerebrospinal fluid dynamic at this age.

Sudden Paraplegia Caused by Nontraumatic Cervical Disc Rupture: A Case Report

A 38-year-old man visited our Emergency Department for sudden onset paraplegia that occurred 1 hour ago. He felt a piercing pain in the posterior neck and became paraplegic while he was watching television, lying down on a sofa. Neurological examination showed motor power grades II–III in both arms and grade 0 in both legs. His cervical magnetic resonance imaging (MRI) showed a large ruptured disc at the C5–6 level, severely compressing the spinal cord. Emergency anterior cervical discectomy and fusion at C5–6 were performed. Because extensive cord swelling was observed on postoperative MRI, laminoplasty from C3 to C6 was performed 3 days after the initial operation. At a postoperative 8-month follow-up, the motor power was improved to grade III–IV- for both hands and grade IV- for both legs. Nontraumatic cervical disc rupture causing acute paraplegia is a very rare but possible event. Immediate neurologic assessment and thorough imaging studies to allow accurate diagnosis are crucial. Emergency surgical decompression is important and may lead to good neurological outcomes.

A 20-Year-Old Retained Surgical Gauze Mimicking a Spinal Tumor: A Case Report

A 79-year-old man visited our clinic complaining of lower back and left leg radiating pain that began 1 month prior to his presentation. He underwent surgery for lumbar disc herniation 20 years ago at another hospital. Magnetic resonance imaging revealed left-sided foraminal stenosis at L4-5. In addition, a paraspinal mass occupying the L4 spinous process and left lamina was observed. We subsequently performed an L4-5 decompression and fusion. During the operation, retained surgical gauze with granulation tissue was found. The term gossypiboma is used to define a mass lesion consisting of retained surgical gauzes and an adjacent foreign body reaction. Gossypibomas are uncommon in the paraspinal area and are mostly asymptomatic in chronic cases. Because there are no specific clinical or radiological signs, they can be confused with other tumorous conditions. Gossypibomas should be included in the differential diagnosis of paraspinal soft-tissue masses detected in patients with a history of prior spinal surgery.

Idiopathic Spontaneous Intramedullary Hemorrhage: A Report of a Rare Case of Repeated Intramedullary Hemorrhage with Unknown Etiology

A 48-year-old woman presented with acute voiding difficulty, numbness and weakness of both lower extremities. Magnetic resonance imaging (MRI) showed an intramedullary hemorrhagic mass that extended from T9 to T10. T8-T10 laminotomy and surgical removal of the hemorrhagic mass was performed. The pathological diagnosis was hematoma. Her neurological status remained the same after the operation. At 5 days post-operation, the patient suddenly became paraplegic, and MRI that was immediately performed revealed a recurrent intramedullary hemorrhage. Emergent surgical evacuation was performed. Again, histological examination showed only hematoma, without any evidence of abnormal vessels or a tumor. A postoperative MRI revealed no abnormal lesions other than those resulting from postoperative changes. At a 9-month follow up, the patient could walk a short distance with the aid of a walker. Because spontaneous intramedullary hemorrhage with unknown etiology is very rare, it is essential to perform a meticulous inspection of the hemorrhagic site to find the underlying cause. Repeated hemorrhage can occur; therefore, close observation of patients after surgery is important in cases without an apparent etiology. Urgent surgical evacuation is important to improve outcomes in these cases.

Correlation between Bone Mineral Density Measured by Dual-Energy X-Ray Absorptiometry and Hounsfield Units Measured by Diagnostic CT in Lumbar Spine

OBJECTIVE: Use of quantitative computed tomography (CT) to evaluate bone mineral density was suggested in the 1970s. Despite its reliability and accuracy, technical shortcomings restricted its usage, and dual-energy X-ray absorptiometry (DXA) became the gold standard evaluation method. Advances in CT technology have reduced its previous limitations, and CT evaluation of bone quality may now be applicable in clinical practice. The aim of this study was to determine if the Hounsfield unit (HU) values obtained from CT correlate with patient age and bone mineral density. METHODS: A total of 128 female patients who underwent lumbar CT for back pain were enrolled in the study. Their mean age was 66.4 years. Among them, 70 patients also underwent DXA. The patients were stratified by decade of life, forming five age groups. Lumbar vertebrae L1-4 were analyzed. The HU value of each vertebra was determined by averaging three measurements of the vertebra's trabecular portion, as shown in consecutive axial CT images. The HU values were compared between age groups, and correlations of HU value with bone mineral density and T-scores were determined. RESULTS: The HU values consistently decreased with increasing age with significant differences between age groups (p<0.001). There were significant positive correlations (p<0.001) of HU value with bone mineral density and T-score. CONCLUSION: The trabecular area HU value consistently decreases with age. Based on the strong positive correlation between HU value and bone mineral density, CT-based HU values might be useful in detecting bone mineral diseases, such as osteoporosis.

Supratentorial Intracerebral Schwannoma : Its Fate and Proper Management

Intracerebral schwannomas are rare and there have been none reported in Korea. We present the case of a 25-year-old man with newly developed right-side weakness and recent seizure aggravation. His seizures started approximately 9 years prior to admission. At that time, a 1 cm diameter intra-axial enhancing mass at the left precentral gyrus was found on magnetic resonance image (MRI). After 9 years of observation and treatment with antiepileptic medication, an MRI taken due to symptom aggravation revealed peri-tumoral cyst formation with tumor enlargement. The tumor was surgically removed. Subsequently, right-side weakness diminished and there was good seizure control. Pathologic diagnosis was schwannoma. Schwannoma is a very rare tumor and there are no pathognomonic findings on radiologic images; thus, it is challenging to make a correct diagnosis. However, considering the natural course and excellent prognosis after surgical treatment of this kind of intra-axial mass with benign features, early surgery for diagnosis and proper treatment is highly recommended.

Hypertensive Encephalopathy with Reversible Brainstem Edema

Presented here is a 36-year-old male with arterial hypertension who developed brainstem edema and intracranial hemorrhage. Magnetic resonance scan revealed diffuse brainstem hyperintensity in T2-weighted and fluid-attenuated inversion-recovery images, with an increase in apparent diffusion coefficient values. After a reduction in blood pressure, rapid resolution of the brainstem edema was observed on follow-up. The patient's condition was thus interpreted as hypertensive brainstem encephalopathy. While many consider this a vasogenic phenomenon, induced by sudden, severe hypertension, the precise mechanism remains unclear. Prompt recognition and aggressive antihypertensive treatment in such patients are essential to prevent permanent or life-threatening neurologic injury.

Desmoplastic Fibroma of the Cranium in a Young Man

Desmoplastic fibroma, which develops predominantly in long bones and the mandible, is a rare and benign but locally aggressive tumor. Desmoplastic fibroma of the cranium is extremely rare. We report a case of desmoplastic fibroma of the frontal bone in a young man. Because of its locally aggressive behavior, complete surgical excision with a safety margin is essential.