Postoperative Contralateral Hematoma in Patient with Acute Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Head injury is a leading cause of death and disability in subjects who suffer a traumatic accident. Contralateral hematomas after surgery for traumatic brain injury are rare. However, an unrecognized, these hematomas can cause devastating results. We presented our experience of these patients and discussed diagnosis and management. METHODS: This study included 12 traumatic patients with acute traumatic brain injury who developed delayed contralateral hematoma after evacuation of an acute hematoma. Clinical and radiographic data was obtained through review of medical records and radiographs retrospectively. RESULTS: Ten males and two females were included in the study. Ten (83.3%) patients had severe head injury (Glasgow Coma Scale [GCS] score <8). Intraoperative brain swelling during removal of the traumatic subdural hematoma was noted in 10 (83.3%) patients. A skull fracture on the side contralateral to the acute hematoma was noted on computed tomography (CT) scans of nine (75%) patients. Three (33.3%) patients with severe head injury (GCS <8) died. Only (10%) one patient with a severe head injury had less severe disability. CONCLUSION: A postoperative CT scan is essential in patients with acute traumatic brain injury and a contralateral skull fracture or a low GCS score. Our results indicated that it is very important to evaluate this rare but potentially devastating complication.

Serial Brain CT Scans in Severe Head Injury without Intracranial Pressure Monitoring / 대한신경손상학회지

OBJECTIVE: The intracranial pathologies after head trauma should be usually progressed. It is clearly visualized in the non-invasive brain CT. The invasive monitor such as intracranial pressure (ICP) monitoring may be accompanied with the complications. This study aims whether the patients with severe head injury could be managed with serial CT scans. METHODS: The medical records of 113 patients with severe head injury in the prospectively enrolled trauma bank were retrospectively analyzed. After the emergency care, all the patients were admitted to the intensive care unit for the aggressive medical managements. Repeat brain CT scans were routinely taken at 6 hours and 48 hours after the trauma. ICP monitoring was restrictively applied for the uncertain intracranial pressure based on the CT. The surgical intervention and the mortality rate were analyzed. RESULTS: Immediate surgical intervention after the initial CT scan was done in 47 patients. Among the initially non-surgical patients, 59 patients were managed with the serial CT scans and 7 with the ICP monitoring. Surgical interventions underwent eventually for 10 patients in the initially non-surgical patients; 1 in the ICP monitoring and 9 in the serial CT. The mortality rate was 23.7% in the serial brain CT and 28.6% in the ICP monitoring. There was no statistical difference between two groups in the aspect of mortality (p=0.33). CONCLUSION: Serial CT scans in time could be a good way to monitor the intracranial progression in the severe head injury and reduce the implantation of an invasive ICP probe.

Histopathological Findings of Hemorrhagic Ganglion Cyst Causing Acute Radicular Pain: A Case Report

Although juxtafacet cysts of the lumbar spine are being reported with increasing frequency, hemorrhage from a ganglion cyst is rare, and the pathophysiologic mechanism of the hemorrhage from the cyst is still unclear. A 75-year-old male presented with sudden radicular leg pain caused by hemorrhage from the ganglion cyst. Computed tomography revealed bony erosion of vertebral body and multiple punched-out lesions on facets. Magnetic resonance imaging showed the neural structure was compressed by a sharply delineating mass. Capsule and old hematoma with elastic consistency that extended to the epidural space were removed through a paramedian transforaminal approach, which led to the resolution of the patient's symptoms. Histopathologically, chronic inflammation with neovascularization and myxoid degeneration were present in the capsule. Alcian blue staining demonstrated the mixture of mucin and hematoma. The probable pathogenesis of hemorrhage from the cyst was discussed from the unique histopathological findings of surgical specimen.

Morphometric Relationship between the Cervicothoracic Cord Segments and Vertebral Bodies

OBJECTIVE: The objective of this study was to investigate the morphologic characteristics between the vertebral body and the regions of the cervical and thoracic spinal cords where each rootlets branch out. METHODS: Sixteen adult cadavers (12 males and 4 females) with a mean age of 57.9 (range of 33 to 70 years old) were used in this study. The anatomical relationship between the exit points of the nerve roots from the posterior root entry zone at each spinal cord segment and their corresponding relevant vertebral bodies were also analyzed. RESULTS: Vertical span of the posterior root entry zone between the upper and lower rootlet originating from each spinal segment ranged from 10-12 mm. The lengths of the rootlets from their point of origin at the spinal cord to their entrance into the intervertebral foramen were 5.9 mm at the third cervical nerve root and increased to 14.5 mm at the eighth cervical nerve root. At the lower segments of the nerve roots (T3 to T12), the posterior root entry zone of the relevant nerve roots had a corresponding anatomical relationship with the vertebral body that is two segments above. The posterior root entry zones of the sixth (94%) and seventh (81%) cervical nerve roots were located at a vertebral body a segment above from relevant segment. CONCLUSION: Through these investigations, a more accurate diagnosis, the establishment of a better therapeutic plan, and a decrease in surgical complications can be expected when pathologic lesions occur in the spinal cord or vertebral body.

Indications and Surgical Results of Twist-Drill Craniostomy at the Pre-Coronal Point for Symptomatic Chronic Subdural Hematoma Patients

OBJECTIVE: Twist-drill craniostomy (TDC) with closed-system drainage and burr-hole drainage (BHD) with a closed system are effective treatment options for chronic subdural hematoma (CSDH). The aim of this study was to analyze clinical data and surgical results from symptomatic CSDH patients who underwent TDC with closed-system drainage at the pre-coronal point (PCP). METHODS: We analyzed data for 134 symptomatic CSDH patients who underwent TDC at the PCP with closed-system drainage. We defined the PCP for TDC to be 1 cm anterior to the coronal suture at the level of superior temporal line. TDC at the PCP with closed-system drainage was selected in patients with CSDH that extended beyond the coronal suture, confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed retrospectively. RESULTS: Of the 134 CSDH patients, 114 (85.1%) showed improved clinical performance and imaging findings after surgery. Catheter failures were seen in two cases (1.4%); the catheters were inserted in the epidural space. Recurrent cases were seen in eight patients (5.6%), and they were improved with a second BHD with a closed-system operation. CONCLUSION: TDC at the PCP with closed-system drainage is safe and effective for patients with symptomatic CSDH whose hematomas extend beyond the coronal suture.

Profiles of Spinal Cord Tumors Removed through a Unilateral Hemilaminectomy

OBJECTIVE: To present the profiles of spinal cord tumors that can be removed through a unilateral hemilaminectomy and to demonstrate its usefulness for benign spinal cord tumors that significantly occupy the spinal canal. METHODS: From June 2004 to October 2010, 25 spinal cord tumors were approached with unilateral hemilaminectomy. We calculated the cross-sectional occupying ratio (CSOR) of tumor to spinal canal before and after the operations. RESULTS: The locations of the tumors were intradural extramedullary in 20 cases, extradural in 2, and intramedullary in 3. The levels of the tumors were lumbar in 12, thoracic 9, and cervical 4. In all cases, the tumor was removed grossly and totally without damaging spinal cord or roots. The mean height and width of the lesions we195re 17.64 mm (3-47.5) and 12.62 mm (4-32.7), respectively. The mean CSOR was 69.40% (range, 27.8-96.9%). Postoperative neurological status showed improvement in all patients except one whose neurologic deficit remained unchanged. Postoperative spinal stability was preserved during the follow-up period (mean, 21.5 months) in all cases. Tumor recurrence did not develop during the follow-up period. CONCLUSION: Unilateral hemilaminectomy combined with microsurgical technique provides sufficient space for the removal of diverse spinal cord tumors. The basic profiles of the spinal cord tumors which can be removed through the unilateral hemilaminectomy demonstrate its role for the surgery of the benign spinal cord tumors in various sizes.

Acute Shunt Malfunction after Cesarean Section Delivery: A Case Report

Shunt malfunctions that require surgical intervention during pregnancy and the postpartum period are rare. Furthermore, no study has reported on an acute shunt malfunction immediately after cesarean section. Here, we describe the case of a 32-yr-old woman who became drowsy 12 hr after cesarean section delivery of her second child. She had a ventriculoperitoneal shunt placed to treat hydrocephalus associated with meningitis at 26 yr of age. Marked ventriculomegaly was seen on brain computed tomography and her consciousness recovered temporarily after aspirating cerebrospinal fluid from the flushing device. At surgery, the distal catheter tip was plugged by a blood clot. We believe that the blood spilled over during the cesarean section. The clogged catheter end was simply cut off and the remaining catheter was repositioned in the peritoneal cavity. Her consciousness recovered fully.

Erratum: Figure Correction

We found an error in our published article: Park KW, Im SB, Kim BT, Hwang SC, Park JS, Shin WH. Neurotoxic manifestations of an overdose intrathecal injection of gadopentetate dimeglumine. J Korean Med Sci 2010; 25: 505-8. The published Fig. 2 C and D are identical with Fig. 2 A and B on page 506 of above article. It was a mistake that occurred during editing process of figures by the publishing company. We have attached a corrected version of the Fig. 2.

Neurotoxic Manifestations of an Overdose Intrathecal Injection of Gadopentetate Dimeglumine

The intravenous administration of gadopentetate dimeglumine (GD) is relatively safe and rarely causes systemic toxicity in the course of routine imaging studies. However, the general safety of intrathecal GD has not been established. We report a very rare case of an overdose intrathecal GD injection presenting with neurotoxic manifestations, including a decreased level of consciousness, global aphasia, rigidity, and visual disturbance.

Surgical Findings of a Lumbar Mature Teratoma Accompanying the Preoperative Intracranial Dissemination of Fatty Droplets

There are several mechanisms for the dissemination of lipid material from a mature teratoma into the subarachnoid space or ventricles, including iatrogenic or traumatic rupture, but spontaneous rupture of a mature teratoma is rare. We report the spontaneous rupture of a spinal mature teratoma into the subarachnoid space and ventricles. However, at surgery, there was no definite evidence of rupture into the perimedullary cerebrospinal fluid. We postulate that the central canal could be a migration pathway for ruptured material into the brain.

Application of Neuronavigation System for the side Selection of Pterional Approach in Anterior Type of Anterior Communicating Artery aAneurysm / 대한뇌혈관외과학회지

OBJECTIVE: The purpose of this study is to evaluate the feasibility of neuronavigation system for side selection of pterional approach in anterior type anterior communicating aneurysm. METHODS: Forty six anterior type aneurysms were evaluated with neuronavigation system based on computed tomography angiography from October 2005 to September 2008. According to neuronavigation system images the approach were subdivided into two groups. The approach in open standing group defined as the craniotomy was done in the A2 of the approach side located more posteriorly than the contralateral A2. The approach in closed standing group was defined as craniotomy was done in the ipsilateral A2 located more anteriorly than the contralateral A2. We analyzed operation time, premature rupture rate, temporary clipping time, perforator injury on postoperative CT scan and Glasgow outcome scale (GOS) of two groups. RESULTS: Thirty-three cases of approaches in open standing group and thirteen cases of approaches in closed standing group were evaluated. In operation time, premature rupture rate, temporary clipping time and GOS, no significant difference was observed between approaches in closed standing group and open standing group. But, in closed standing group, the perforator injury on CT scan was occurred more frequently than open standing group (p=0.001) in postoperative 7 days. CONCLUSION: With the neuronavigation system, three dimensional angiographic images were reconstructed by the operator and actively used to side selection of pterional approach for the aneurysm neck clipping. The perforator injury could be avoided with this policy.

Hemifacial Spasm Caused by a Huge Tentorial Meningioma

A rare case of hemifacial spasm caused by an ipsilateral tentorial meningioma is described. Magnetic resonance imaging showed a huge tumor in the right cerebellar hemisphere, distant to the cerebello-pontine cistern. The facial-vestibulocochlear nerve complex was stretched by the shift of the brainstem and the right cerebello-pontine cistern was effaced. After removing the tumor, the hemifacial spasm resolved completely. We review our case with the pertinent literature regarding the etiological mechanism.

Vertebral Artery Dissection : Natural History, Clinical Features and Therapeutic Considerations

When a tear occurs in one of the major cervicocerebral arteries and allows blood to enter the wall of the artery and split its layers, the result is either stenosis or aneurysmal dilatation of the vessel. Vertebral artery dissection (VAD) is an infrequent occurrence but is a leading cause of stroke in young and otherwise healthy patients. This article discusses recent developments in understanding of the epidemiology and pathogenesis of VAD and the various clinical manifestations, methods of diagnosis, and approaches to treatment.

A Morphometric Study on Cadaveric Aortic Arch and Its Major Branches in 25 Korean Adults : The Perspective of Endovascular Surgery

Objective: To understand the anatomic characteristics of the aortic arch (AA) and its major branches to build a foundation toward performing endovascular surgery safely. Methods: A total of 25 formalin fixed Korean adult cadavers were used. The authors investigated : anatomical variations of the AA and its major branches; curvature of the AA; distance from the mid-vertebrae line to the origin of the major branches; distances from the origin of the major branches of AA to the origin of its distal branches; and the angle of the three major branches, the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSCA) arising from AA. Results: The three major branches directly originated from AA in 21 (84%) of the cadavers. In two (8%) of remaining four cadavers, orifice of LCCA was slightly above the stem of BCT. In remaining two (8%) cadavers, the left vertebral artery (LVA) was directly originated from AA. Average angle of AA curvature to the coronal plane was 62.2 degrees. BCT originated 0.92 mm on the right of the mid-vertebrae line. LCCA and LSCA originated from 12.3 mm and 22.8 mm on the left of the mid-vertebrae line. Mean distance from the origin of the BCT to the origin of the RCCA was 32.5 mm. Mean distance from the origin of the LSCA to the origin of the LVA was 33.8 mm. Average angles at which the major branches arise from the AA were 65.3, 46.9 and 63.8 degrees. Conclusion: This study may provides a basic anatomical information to catheterize AA and its branches for safely performing endovascular surgery.

Pathogenesis of Cerebral Aneurysm / 대한뇌혈관외과학회지

Cerebral aneurysms are common lesions. In most populations, the incidence of subarachnoid hemorrhage (SAH) is 10 per 100,000 personyears. The case fatality rate of SAH is about 50 percent in population-based studies, with a trend toward gradual improvement. Associated conditions include autosomal dominant polycystic kidney disease, fibromuscular dysplasia, Marfan's syndrome, Ehlers-Danlos syndrome, and arteriovenous malformations of the brain. The risk factors for the rupture of cerebral aneurysms include increasing size, specific site, smoking, and hypertension. Cerebral aneurysms can be divided into two different categories: saccular (atherosclerotic) and dissecting (nonatherosclerotic). The most common histologic finding in saccular aneurysms is a decrease in the tunica media, the middle muscular layer of the artery, causing structural defects. These defects combined with hemodynamic factors, lead to aneurysmal outpouchings at arterial branch points in the subarachnoid space at the base of the brain. Dissecting aneurysms are characterized by widespread disruption of the internal elastic lamina that leads to mural thrombus formation and causes ischemic or hemorrhagic symptoms. Ultimately, therapeutic strategies should be based on the epidemiology, natural history, and pathogenesis of the cerebral aneurysms.

Delayed Cerebral Abscess as a Shunt Complication and Endoscopic Removal of the Ventricular Catheter and Abscess

Shunt infections are a common complication of ventriculoperitoneal (VP) shunts, but the formation of a brain abscess related to a shunt system is very rare. A 44-year-old woman had a VP shunt inserted for hydrocephalus secondary to a subarachnoid hemorrhage. She suffered an episode of meningitis and sepsis 8 months after the shunt operation. After recovering from the meningitis, she complained of a loss of cognitive function. An enhancing mass was found in the frontal lobe, around the frontal horn of the lateral ventricle, and the ventricular catheter was embedded inside the mass. The ventricular catheter and cerebral abscess were removed using neuroendoscopy. We present an interesting case of a shunt-related brain abscess which illustrates the usefulness of neuroendoscopy.

Radiculopathy Caused by Internal Iliac Artery Pseudoaneurysm Managed with Endovascular Embolization

The authors describe a case of pseudoaneurysm arising from internal iliac artery presented with radiculopathy mimicking the symptoms of lumbar disc disease or spinal cord tumor. Among the several preoperative evaluation including CT, MRI, electrophysiologic study and ultrasonography, important diagnostic clue was obtained by ultrasonographic findings of turbulence flow at the core of partially enhanced mass in the pelvic cavity. The patient was managed with endovascular coil embolization successfully. The current case makes us remind that assessment of neurological symptoms on lower extremity should include consideration of extraspinal cause in pelvis.

Surveillance in the Cerebral Aneurysm Surgery / 대한뇌혈관외과학회지

Intraoperative monitoring has been a valuable part in the cerebral aneurysm surgery. Insight into the nervous system and the relationship of the aneurysm to the adjacent structure during the surgery provide critical information to the surgeon allowing reversal or avoidance of neural insults and the complete clipping of the aneurysm. The goal of cerebral aneurysm surgery is to eliminate the risk of hemorrhage but not disrupt the surrounding vascular and neural structures. Several techniques including microvascular doppler ultrasonography, monitoring cerebral blood flow, evoked potentials, intraoperative angiography, endoscope assisted aneurysm surgery and neuronavigator system are used for the surveillance in the aneurysm surgery. The abnormal findings in these procedures can change surgical management during the surgery such as removal or readjustment of temporary or permanent clips and a decrease in brain retraction or manipulation. The additional feedback provided by intraoperative monitoring promises to improve the safety and efficacy of aneurysm surgery.

Pathophysiology of Spontaneous Intracerebral Hemorrhage / 대한뇌혈관외과학회지

Chronic hypertension causes pathologic changes within the tunica media, termed lipohyalinosis. The most prominent changes were seen at bifurcation point within the vessels and middle and distal portion of the vessels. The role of microaneursyms in spontaneous intracerebral hemorrhage (ICH) secondary to hypertension is not well understood. A cerebral amyloid angiopathy is associated with fibrinoid necrosis and affects the small to medium sized vessels and it may account for a higher percentage of spontaneous ICH in the elderly. Neurologic dysfunction secondary to ICH is caused by initial hemorrhage with its associated mass effect, and tissue destruction with hematoma enlargement. Consequently, the further deterioration may be due to cerebral edema. The exact role of CBF changes is not unproved in the pathogenesis of neuronal injury. However, much has been learned about the mechanisms involved the brain edema formation after ICH. A number of components of blood are capable of inducing brain injury and brain edema formation. The hematoma exerts its effects not only by mechanical but also by chemical influences.

Treatment Results of Twist-drill Craniostomy with Closed-system Drainage for the Symptomatic Chronic Subdural Hematoma Patients

OBJECTIVE: Symptomatic chronic subdural hematoma(CSDH) is a well-known neurosurgical entity and most of the lesion is managed by surgical treatment. The authors analyze the surgical indication and the treatment results of twist drill craniostomy with closed-system drainage(TDD) for the symptomatic CSDH. METHODS: From March 2001 through December 2003, 31patients who were treated with TDD for the symptomatic CSDH and followed more than 6months were included. The radiologic criteria of TDD in this study were 1) homogeneous density of hematoma on computed tomography(CT), 2) no septation of hematoma on magnetic resonance imaging(MRI), and 3) thicker hematoma more than twice thickness of skull. Surgical procedures were performed on the maximum thickness of hematoma on CT/MRI. Short and long Steinman pins were used to penetrate the skull and hematoma membrane. As the 5L catheter was inserted through the drill hole, it was kept for 1-7days for the drainage of CSDH. The patients of CSDH were followed with clinical symptoms and CT studies. RESULTS: Most of all the 31 patients were improved. However, one patient was suffered from postoperative epidural hematoma and the other patients have received the secondary operation because of the recurrence of CSDH on 3 months after initial surgery. CONCLUSION: TDD is safe procedure for the symptomatic CSDH if the patients are selected appropriately.