Postoperative Thecal Sac Compression Induced by Hydrogel Dural Sealant after Spinal Schwannoma Removal / 대한신경손상학회지

Cerebrospinal fluid (CSF) leak is a common complication of spinal and cranial surgery, and patients undergoing spinal tumor surgery are probably particularly predisposed due to the presence of an intradural tumor and many other factors. Furthermore, a meticulous dural closure technique does not always result in watertight closure. A number of adjunctive methods have been used to assist with dural closure. Synthetic, absorbable polyethylene glycol hydrogel dural sealants are widely used and have been approved for use as adjuncts for cranial applications requiring sutured dural closure. We report a case of thecal sac compression by DuraSeal ® Dural Sealant used to repair the CSF leak after intentional durotomy during lumbar schwannoma extirpation.

Postoperative Subarachnoid Hemorrhage and Multipunctate Intracerebral Hemorrhages Following Evacuation of Bilateral Chronic Subdural Hematomas / 대한신경손상학회지

Chronic subdural hematoma (CSDH) can be easily treated by burr hole surgery. However, several complications including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and acute subdural hematoma are rare after evacuation of a CSDH. A 77-year-old man was admitted with right hemiparesis and dysarthria. A brain computed tomography (CT) scan revealed a bilateral CSDH with midline shifting toward the right side. The patient got the burr hole trephination with the catheters insertion in the both sides of parietal area under the local anesthesia. After burr hole surgery immediately, he developed left side weakness and decreased level of consciousness. Repeat CT scans detected a diffuse SAH and multiple small ICHs. He was treated conservatively and fully recovered at discharge after 1 month. To avoid these complications, slow and gradual drainage of the CSDH is needed. The authors report a rare case of SAH and multipunctate ICHs in both cerebral hemispheres after evacuation of a bilateral CSDH.

Cellular Neurothekeoma of the Scalp in the Elderly

Cellular neurothekeoma (CNT) is an uncommon variant of neurothekeoma that is composed of pithelioid to spindled cells with variable nuclear atypia or pleomorphism but no myxoid stroma. CNT occurs predominantly in the head and neck or upper trunk of children and young adults, with female predominance. The following case is different from typical CNTs. An 88-year-old female presented with a palpable mass on the scalp, which we excised. Histologically, the tumor was non-encapsulated and composed of spindled and epithelioid cells arranged in fascicles and nodules separated by a collagen-rich stroma. Immunohistochemical analysis showed that the epithelioid and spindle-shaped cells were focally positive for vimentin, neuron-specific enolase, smooth muscle actin, CD68, and CD10 but negative for S-100 protein, HMB-45, epithelial membrane antigen, and CD34. We report a new case of CNT that arose in the scalp of an older patient and that was associated with uncommon clinical, histological, and immunohistochemical profiles.

Cellular Neurothekeoma of the Scalp in the Elderly

Cellular neurothekeoma (CNT) is an uncommon variant of neurothekeoma that is composed of pithelioid to spindled cells with variable nuclear atypia or pleomorphism but no myxoid stroma. CNT occurs predominantly in the head and neck or upper trunk of children and young adults, with female predominance. The following case is different from typical CNTs. An 88-year-old female presented with a palpable mass on the scalp, which we excised. Histologically, the tumor was non-encapsulated and composed of spindled and epithelioid cells arranged in fascicles and nodules separated by a collagen-rich stroma. Immunohistochemical analysis showed that the epithelioid and spindle-shaped cells were focally positive for vimentin, neuron-specific enolase, smooth muscle actin, CD68, and CD10 but negative for S-100 protein, HMB-45, epithelial membrane antigen, and CD34. We report a new case of CNT that arose in the scalp of an older patient and that was associated with uncommon clinical, histological, and immunohistochemical profiles.

A Large Ruptured Anterior Communicating Artery Aneurysm Presenting with Bitemporal Hemianopsia

Anterior communicating artery (ACoA) aneurysms sometimes present with visual symptoms when they rupture or directly compress the optic nerve. Giant or large ACoA aneurysms producing bitemporal hemianopsia are extremely rare. Here we present an unusual case of bitemporal hemianopsia caused by a large intracranial aneurysm of the ACoA. A 41-year-old woman was admitted to our neurosurgical department with a sudden-onset bursting headache and visual impairment. On admission, her vision was decreased to finger counting at 30 cm in the left eye and 50 cm in the right eye, and a severe bitemporal hemianopsia was demonstrated on visual field testing. A brain computed tomography scan revealed a subarachnoid hemorrhage at the basal cistern, and conventional cerebral catheter angiography of the left internal carotid artery demonstrated an 18x8 mm dumbbell-shaped aneurysm at the ACoA. Microscopic aneurysmal clipping was performed. An ACoA aneurysm can produce visual field defects by compressing the optic chiasm or nerves. We emphasize that it is important to diagnose an aneurysm through cerebrovascular study to prevent confusing it with pituitary apoplexy.

Outcomes of Stent-assisted Coil Embolization of Wide-necked Intracranial Aneurysms Using the Solitaire(TM) AB Neurovascular Remodeling Device

OBJECTIVE: This retrospective study presents our experience with respect to the clinical and angiographic outcomes of patients treated with stent-assisted coil embolization using Solitaire(TM) AB stents. MATERIALS AND METHODS: From March 2011 to December 2014, 50 patients with 55 wide-necked and/or complex intracranial aneurysms were evaluated. Four patients presented with an acute subarachnoid hemorrhage. Stent deployment was performed with a standard coiling procedure in 49 aneurysms. Three patients underwent bailout stenting, 2 patients were treated by temporary stenting and one patient was treated only by stenting without coiling for dissecting aneurysm. RESULTS: Successful placement of the Solitaire AB stent was achieved in all the cases. Based on the postprocedural angiographic results, a Raymond 1 was obtained in 32 (59%) of 54 aneurysms, excluded by one case of dissecting aneurysm, and a Raymond 2 in 13 (24%), and a Raymond 3 in 9 (17%). There was one thromboembolic (2%) and three hemorrhagic complications (6%). However, procedure-related morbidity or mortality was not found. Annual follow-up angiographic results from the embolization were obtained in 40 (74.1%) of 54 cases. These results were represented as Raymond 1 in 27 (67.5%), class 2 in 9 (22.5%), and class 3 in 4 (10%) cases. Angiographic improvement associated with progressive thrombosis of the aneurysm was obtained in 10 aneurysms. Four aneurysms were recanalized without requiring additional treatment. In-stent stenosis was found in one aneurysm, but stent migration was not seen on follow-up angiography. CONCLUSION: Stent-assisted coil embolization using the Solitaire AB stent for treating wide-necked and/or complex intracranial aneurysms was found to be safe and effective immediately post-embolization and after follow-up. Long-term follow-up will be required to identify the effect of the Solitaire AB stent on recanalization rates.

The Pterional-Transsylvian Approach for Tumor in the Temporal Horn: A Case Report

A variety of surgical approaches to temporal horn tumors of the lateral ventricle have been described. Magnetic resonance imaging (MRI) and angiography are the preferred modalities for preoperative evaluation and provide important information for the choice of surgical approach. A 59-year-old man was referred to our hospital due to confusion and gait disturbance. On enhanced MRI, a homogeneous enhanced solitary mass was observed within the temporal horn of the left lateral ventricle with transependymal extension. The lesion was accompanied by increased hypervascular tumor blush on preoperative cerebral angiography. Subtotal removal of the temporal horn tumor was performed because the lesion was identified as lymphoma during surgery. The postoperative course was un-eventful. The patient was referred to the oncology department for conventional chemotherapy. Adjuvant chemotherapy improved the clinical outcome. The pterional-transsylvian approach was beneficial for partial removal of the tumor and tissue diagnosis in this case.

Rapid Ossification of Epidural Hematoma in a Child: A Case Report / 대한신경손상학회지

The author present a rare case of rapid ossification of epidural hematoma (EDH) in a 5-year-old boy. At admission, the computed tomography (CT) revealed an EDH on left temporoparietal region. On the follow-up CT scan doing 14 days after traffic accident, the expansion of the former hematoma was not visible, but the hematoma accompanied by the thin hyperdense layer on the dura. On follow-up CT scans, the hematoma was decreased but the ossified layer progressing. After 6 months of conservative therapy, the hematoma was fully absorbed and the ossified lesion merged to inner table of the skull. Hence, rapid ossification of an EDH should be considered in children and serial follow-up CT scans must be conducted.

Endovascular or Microsurgical Treatment of Intracranial Aneurysms: Single Center Analysis / 고신대학교의과대학학술지

OBJECTIVES: The objective of this study was to assess effectiveness and outcomes of endovascular versus microsurgical treatment for intracranial aneurysms in single hospital. METHODS: This was a retrospective study, using data collected during 4 year (between 2008 and 2011) from single hospital(Kosin University Gospel Hospital). A total of 274 treated, intracranial aneurysm cases were evaluated. The measurements used were effectiveness as measured by hospital discharge outcomes: 1) mortality (in-hospital death), 2) clinical outcomes(modified Ranking Scale: mRS). RESULTS: Among total of 274 cases, unruptured intracranial aneurysm cases were 132 cases and ruptured cases were 142 cases. Among unruptured 132 cases, 65 cases were treated by microsurgical treatment and 67 cases were treated by endovascular treatment. Among ruptured 142 cases, 61 cases were treated by microsurgical treatment and 81 cases were treated by endovascular treatment. In unruptured cases, there was not any fatal complication and same adverse outcomes (3% versus 3%). In ruptured case, in regards of treatment modality (i.e., endovascular versus microsurgical treatment), each clinical outcomes were as followings; good clinical outcome was 53.1% (43/81) versus 41.0% (25/61), moderate clinical outcome was 13.6% (1/81) versus 9.8% (6/61), severe clinical outcome was 18.5% (15/81) versus 22.9% (29/142) and fatal outcome was 14.8 (12/81) versus 26.2% (16/61). CONCLUSIONS: This analysis of single hospital data indicates that endovascular therapy is associated with significantly less morbidity, less mortality, compared with conventional microsurgical treatment for all intracranial aneurysms. Endovascular therapy, as a treatment alternative to microsurgical clipping, should be offered as a viable therapeutic option for all patients considering treatment of an intracranial aneurysm.

Efficacy of Transradial Cerebral Angiography in the Elderly

OBJECTIVE: Transradial angiography has become popular among many cardiologists as a diagnostic and therapeutic tool. However, transradial cerebral angiography is not utilized to the same extent. The purpose of this study is to present our experience regarding the usefulness of transradial cerebral angiography, especially in elderly patients. METHODS: Between May 2011 and February 2012, a total of 126 cerebral angiographies were performed via a transradial approach in a single center. Of them, only 47 patients were over 60 years old. In our institution, we shifted the initial access from the right femoral artery to the right radial artery in all patients requiring cerebral angiography in 2011. We did not attempt radial access in 40 cases for variable reasons. RESULTS: The procedural success rate was 92.2%. We have four failures of transradial angiography; two because of loop formations of the radial and brachial artery and two due to multiple puncture failures. All supra-aortic vessels were successfully catheterized. However, the selective catheterization rates of the left side distal vessels were lower, as success rates were 89.7% for the right internal carotid artery and 75% for the left internal carotid artery. Procedure-related vascular complications, such as puncture site hematoma, hand ischemia, pseudoaneurysm, arteriovenous fistula and arterial dissection were not observed in our series. However, intraprocedural thrombosis developed in one patient, which was resolved completely by intraarterial thrombolytic agents. CONCLUSION: With advancing patient's age, we believe that transradial cerebral angiography is a useful tool to decrease patient's discomfort and more effectively manage the vessel tortuosity.

Fatal Septic Internal Jugular Vein-Sigmoid Sinus Thrombosis Associated with a Malpositioned Central Venous Catheter

Septic internal jugular vein-sigmoid sinus thrombosis (IJV-SST) associated with a malpositioned central venous catheter is a rare condition. It is potentially life-threatening and necessitates early diagnosis and rapid administration of appropriate medications. Unfortunately, it is difficult to diagnose due to vague clinical presentations. Several studies such as CT, MRI, and cerebral angiography should be performed and carefully examined to help make the diagnosis. We report a case of septic IJV-SST due to a malpositioned central venous catheter.

Successful Treatment of Tracheoinnominate Artery Fistula Following Tracheostomy in a Patient with Cerebrovascular Disease

Tracheoinnominate artery fistula is a critical complication of tracheostomy. The most important factors influencing patient outcome are prompt diagnosis, immediate control of bleeding with a patent airway, and emergency operation with or without interruption of the innominate artery. Here, we report a case of tracheoinnominate artery fistula in a 40-year-old woman with cerebrovascular accident who was successfully managed with an aorta-axillary artery bypass.

Asymptomatic Fracture of a Distal Shunt Catheter after Ventriculoperitoneal Shunt for Post-traumatic Hydrocephalus

A fracture of a distal shunt catheter is a rare complication. In many cases of shunt failure, shunt revision should be performed to prevent the development of hydrocephalus. However, the question of whether to operate on asymptomatic patients remains to be answered. Our patient received a ventriculoperitoneal shunt due to post-traumatic hydrocephalus, and his symptoms improved. Abdominal x-ray revealed a fracture of the distal shunt catheter at the 5- year follow-up. However, the patient was asymptomatic. In this case, the patient improved without shunt revision during the year after the fracture of the distal shunt catheter.

Stent-Assisted Coil Trapping in a Manual Internal Carotid Artery Compression Test for the Treatment of a Fusiform Dissecting Aneurysm

Internal carotid artery (ICA) trapping can be used for the treatment of giant intracranial aneurysms, blood blister-like aneurysms, and fusiform dissecting aneurysms. Fusiform dissecting aneurysms are challenging to treat surgically and endovascularly because of no definite neck and critical perforators. Surgical or endovascular trapping of the ICA with or without an extracranial-intracranial bypass has commonly been used as an effective method to treat these lesions, but balloon test occlusion (BTO) must be performed. Here, we report a case of a ruptured fusiform dissecting aneurysm of the distal ICA, which was successfully treated using an endovascular ICA trapping with a manual ICA compression test instead of BTO.

Treatment Results for Basilar Artery Aneurysms / 고신대학교의과대학학술지

OBJECTIVES: We report our recent treatment results of ruptured and unruptured basilar artery aneurysms during the last 2 years. METHODS: A retrospective analysis was performed on 21 patients with basilar artery aneurysms managed with endovascular and microsurgical treatments from January 2007 to December 2008. Successful embolization was defined as more than 90% occlusion. Clinical outcome was evaluated using the Glasgow Outcome Scale (GOS) at 6 months, and follow-up angiography was obtained at 6 to 12 months. RESULTS: Based on the Hunt and Hess grading scale, the patient population included 8 patients (38.1%) with unruptured aneurysms, 3 patients with grade II, 6 with grade III, 2 with grade IV, and 2 with grade V. Microsurgical clipping was done in 3 patients with ruptured aneurysms, and the other patients were treated by the endovascular method. Clinical outcome was revealed 5 patients (38.5%) with GOS 5, 1 (7.7%) with GOS 4, 3 (23.1%) with GOS 3, and 2 patients (15.4%) died. Of all the patients that underwent endovascular treatment, 10 patients (55.6%) had successful embolization. On angiographic follow-up, recanalizations developed in 3 patients (17.6%) and these patients were treated by repeat embolizations. CONCLUSIONS: Endovascular coil embolization is a safe and effective method in basilar artery aneurysms although occasionally require repeat embolizations. Surgical treatment was indicated in restricted number of ruptured cases.

Clival Cystic Chordoma in Children with Confused Magnetic Resonance Imaging

There are some kinds of neoplasms to be differentiated in the clival area, such as chordoma, invasive pituitary adenoma, craniopharyngioma, trigeminal neuroma, epidermoid cyst, and epidermoid tumor. A 12-year-old girl had admitted with a chief complaint of diplopia. On computed tomography and magnetic resonance(MR) image , cystic mass of about 4cm in diameter which partially destroyed bony structure at posterior part of the clivus was compressing brainstem slightly at anterior direction. This mass showed hyperintensity on T2-weighted MR image, hypointensity on T1-weighted MR image and especially hyperintensity on diffusion image, but no contrast enhancement. So, We suspected a epidermoid cyst and planned biopsy through a transsphenoidal approach. Fortunately, tumor was removed completely. This tumor was considered as epidermoid cyst on MR image. But, it was confirmed as chordoma in pathologic diagnosis. Therefore, we report this case and it may be helpful to make a differential diagnosis in clival cystic chordoma preoperatively that has multilobulation, bony erosion, and calcification on radiologic findings.