Complications Following Burr Hole Craniostomy and Closed-System Drainage for Subdural Lesions / 대한신경손상학회지

OBJECTIVE: Burr hole craniostomy and closed-system drainage (BCD) is a common surgical procedure in the field of neurosurgery. However, complications following BCD have seldom been reported. The purpose of this study was to report our experiences regarding complications following BCD for subdural lesions. METHODS: A retrospective study of all consecutive patients who underwent BCD for presumed subdural lesions at one institute since the opening of the hospital was performed. RESULTS: Of the 395 patients who underwent BCD for presumed subdural lesions, 117 experienced surgical or nonsurgical complications. Acute intracranial hemorrhagic complications developed in 14 patients (3.5%). Among these, 1 patient died and 5 patients had major morbidities. Malposition of the drainage catheter in the brain parenchyma occurred in 4 patients, and opposite-side surgery occurred in 2 patients. Newly developed seizures after BCD occurred in 8 patients (2.0%), five of whom developed the seizures in relation to new brain lesions. Eighty-eight patients (22.3%) suffered from nonsurgical complications after BCD. Pulmonary problems (7.3%) were the most common nonsurgical complications, followed by urinary problems (5.8%), psychologic problems (4.3%), and cognitive impairments (3.8%). CONCLUSION: The incidence of complications after BCD for subdural lesions is higher than previously believed. In particular, catastrophic complications such as acute intracranial hematomas and surgical or management errors occur at rates that cannot be ignored, possibly causing medico-legal problems. Great caution must be taken during surgery and the postoperative period, and these complications should be listed on the informed consent form before surgery.

Ganglioneuroma of the Sacrum

Presacral ganglioneuromas are extremely rare benign tumors and fewer than 20 cases have been reported in the literature. Ganglioneuromas are difficult to be differentiated preoperatively from tumors such as schwannomas, meningiomas, and neurofibromas with imaging modalities. The retroperitoneal approach for resection of presacral ganglioneuroma was performed for gross total resection of the tumor. Recurrence and malignant transformation of these tumors is rare. Adjuvant chemotherapy or radiation therapy is not indicated because of their benign nature. We report a case of a 47-year-old woman with a presacral ganglioneuroma.

Traumatic Pseudoaneurysm Related to Calcified Nodules of Cerebral Convexity Dura Mater in an American College Football Player

Repeated concussion is common among football players; however, these minor blunt head trauma rarely result in serious complications. We report a case of a young college football player who presented acute subdural hematoma, cerebral edema, and seizure due to pseudoaneurysm rupture. The pseudoaneurysm, located at the cortical branch of the middle cerebral artery, was speculated to be formed by dural calcification and adhesion with the underlying brain, possibly due to repeated concussions. Following successful excision of the pseudoaneurysm and control of brain swelling, the patient recovered without sequelae and was discharged after a short while.

Epithelioid Sarcoma in the Cervical Spine: A Case Report

Epithelioid sarcoma is a rare and highly malignant soft tissue neoplasm that most commonly occurs in the long bones. This uncommon tumor has a poor clinical outcome, and the modality of its treatment has not yet been fully established. The authors report an extremely rare presentation of epithelioid sarcoma in the cervical spine, along with its clinical progression, imaging, and pathology. The patient underwent three surgical procedures and adjuvant radiochemical management. He survived for 25 months with a good general condition and adapted well to his social activity. Systemic metastasis was not found, but the patient died of respiratory failure due to direct tracheal invasion of the tumor.

Multiple Spinal Cord Recurrences of an Intracranial Ependymoma after 14 Years

Ependymoma can spread via cerebrospinal fluid, but late spinal recurrences of intracranial tumor are very rare. We describe a case of a 33-year-old male who presented with multiple, delayed, recurrent lesions in the spinal cord from an intracranial ependymoma. The patient underwent gross total resection and postoperative radiation therapy 14 years prior to visit for a low grade ependymoma in the 4th ventricle. The large thoraco-lumbar intradural-extramedullary spinal cord tumor was surgically removed and the pathologic diagnosis was an anaplastic ependymoma. An adjuvant whole-spine radiation therapy for residual spine lesions was performed. After completion of radiation therapy, a MRI showed a near complete response and the disease was stable for three years.

Glomus Tumor in the Femoral Nerve

The glomus tumor of the peripheral nerve is one of the mesenchymal tumors originating in the epineurium, and is extremely rare. A 56-year-old man presented complaining of lancinating pain on the left thigh, which was provoked by pressure or exercise. Subsequent image study revealed a mass in the femoral nerve. Total surgical excision with the aid of intraoperative ultrasonography was performed and the pain was successfully controlled. The authors report an unusual case of a patient diagnosed with glomus tumor in peripheral nerve, with a review of the clinical features, imaging, and pathological findings.

Endovascular Management of Great Vessel Injury Following Lumbar Microdiscectomy

Great vessel injury is a rare but well-known complication of lumbar disc surgery, which may result in acute or fatal outcomes of delayed diagnosis. Thus, early detection and proper management is vital. The authors report a case of retroperitoneal hemorrhage with arteriovenous fistula and pseudoaneurysm after lumbar microdiscectomy. The patient was successfully managed by endovascular intervention using a stent graft. Endovascular repair is a minimally invasive and efficient treatment modality with considerably low morbidity and mortality.

Eosinophilic Myelitis in the Cervical Cord Mimicking Intramedullary Cord Tumor

Eosinophilic myelitis (EM) or atopic myelitis is a rare disease characterized by a myelitic condition in the spinal cord combined with allergic process. This disease has specific features of elevated serum IgE level, active reaction to mite specific antigen and stepwise progression of mostly the sensory symptoms. Toxocariasis can be related with a form of EM. This report describes two cases of cervical eosinophilic myelitis initially considered as intramedullary tumors. When a differential diagnosis of the intramedullary spinal cord lesion is in doubt, evaluation for eosinophilic myelitis and toxocariasis would be beneficial.

Preliminary Report on Usefulness of Adjacent Interspinous Stabilization using Interspinous Spacer Combined with Posterior Lumbosacral Spinal Fusion in Degenerative Lumbar Disease

OBJECTIVE: Posterior lumbar or lumbosacral spinal fusion in degenerative lumbar disease has the problems of adjacent level disease as well as surgical complications. An interspinous device used for dynamic stabilization can also be applied to the adjacent segment for spinal fusion to reduce the severity of these problems. The authors reviewed the adjacent interspinous stabilization using an interspinous spacer(CoflexTM paradigm spine,Germany) combined with posterior lumbar or lumbosacral spinal fusion in degenerative lumbar disease. Method: From January 2007 to July 2008, ten patients with degenerative lumbar disease underwent posterior lumbar or lumbosacral spinal fusion with adjacent interspinous stabilization using CoflexTM. The indications for this type were adjacent segmental disc protrusion, adjacent segmental degenerative changes or high surgical risk groups, such as elderly patients or osteoporotic patients undergoing multiple leveled fusions. CoflexTM was inserted into the adjacent segmental interspinous space. The control group consisted of fifteen patients, who underwent posterior lumbar or lumbosacral spinal fusion without interspinous stabilization. The radiological parameters and clinical outcomes were compared. All patients were followed-up for more than twelve months. RESULTS: The visual analogue scale(VAS) in both groups postoperatively and at the twelve month follow-up were improved. In the CoflexTM group, the postoperative and twelve month follow-up X-ray showed no significant change in posterior disc height, interpedicular height, segmental lordotic angle, flextion-extension angulation and translation and no significant segmental instability. The control group showed a higher level of segmental lordotic angle, translation and a lower posterior disc height, interpedicular height, flextion-extension angulation and three patients showed adjacent segmental instability. CONCLUSION: CoflexTM can be used to stabilize the adjacent segment of spinal fusion in degenerative lumbar disease and might be effective in preventing adjacent segmental degeneration. However, further study will be needed to confirm this observation.

Traumatic Entrapment of the Vertebrobasilar Junction Due to a Longitudinal Clival Fracture: A Case Report

Vertebrobasilar junction entrapment due to a clivus fracture is a rare clinical observation. The present case report describes a 54-yr-old man who sustained a major craniofacial injury. The patient displayed a stuporous mental state (Glasgow Coma Scale [GCS]=8) and left hemiparesis (Grade 3). The initial computed tomography (CT) scan revealed a right subdural hemorrhage in the frontotemporal region, with a midline shift and longitudinal clival fracture. A decompressive craniectomy with removal of the hematoma was performed. Two days after surgery, a follow-up CT scan showed cerebellar and brain stem infarction, and a CT angiogram revealed occlusion of the left vertebral artery and entrapment of vertebrobasilar junction by the clival fracture. A decompressive suboccipital craniectomy was performed and the patient gradually recovered. This appears to be a rare case of traumatic vertebrobasilar junction entrapment due to a longitudinal clival fracture, including a cerebellar infarction caused by a left vertebral artery occlusion. A literature review is provided.

Efficacy of Laparoscopy Guided Ventriculo-Peritoneal Shunt : Analysis of Data in 102 Consecutive Patients / 대한뇌혈관외과학회지

OBJECTIVE: This study compare outcomes in patients with laparoscopic guided ventriculo-peritoneal shunt placement with the nonlaparoscopic approach (conventional mini-laparotomy technique) in patients with hydrocephalus. METHODS: The study enrolled 102 adult patients who had undergone surgery between August 2005 and May 2008 for the treatment of hydrocephalus at our department. Seventy-six patients (38 men and 38 women) received laparoscopy-assisted distal catheter placement, and 26 patients (14 men and 12 women) received shunt surgery by a conventional mini-laparotomy approach. The median follow-up period of the non-laparoscopic group was 26 months (14-33 months) and laparoscopic group was 12 months (1-30 months). We analyzed age, sex, cause of hydrocephalus, type of shunt valve, operation time, shunt infection rate, and shunt distal catheter malfunction during follow-up. RESULTS: There was no statistically significant difference in age, sex, cause of hydrocephalus, or type of shunt valve. Shunt infections were observed in 10 cases (13.2%) in the laparoscopic group and in 4 cases (15.4%) in the mini-laparotomy group, which was not statistically significant. Distal shunt malfunction rates were significantly lower in the laparoscopic group (1.3%) compared to the mini-laparotomy group (11.5%, P<0.05). The mean operation time was also shorter in the laparoscopic group (108 min, 45-190 min) than of the mini-laparotomy group (146 min, 75-255 min, P<0.005). CONCLUSION: Laparoscopic guided placement of the VP shunt in hydrocephalus patients reduces shunt distal catheter malfunction and operation time.

CT Angiography in Acute Ischemic Stroke: Clinical Research / 대한뇌혈관외과학회지

OBJECTIVE: This study was designed to evaluate the feasibility and clinical implications of CT angiography (CTA) in patients with acute ischemic stroke. METHODS: From August 2004 to July 2005, 24 cases of acute ischemic stroke were prospectively included in this study. We checked location of ischemic parenchymal lesion, location of vascular occlusion, degree of collateral supply, and presence of other accompanying vascular lesions on CT and CTA, and assessed the usefulness of CTA by comparing the findings with those of diffusionweighted MR imaging and digital subtraction angiography. RESULTS: Average time required for performing CT and CTA and getting reconstructed images was 30 minutes. Location of the parenchymal lesions and the corresponding occluded or stenosed artery could be clarified in 16 cases (67%) and 20 cases (83%), respectively. There were 13 cases of severe stenosis and 7 cases of occlusion. In 7 cases of major arterial occlusion, degree of collateral circulation could be assessed as good in 5, and moderate in 2. Incidental unruptured intracranial aneurysms were identified in 5 cases. CONCLUSION: CTA could provide valuable information regarding locations of parenchymal lesion and vascular occlusion, degree of collateral supply, and presence of accompanying intracranial aneurysm in cases of acute ischemic stroke without significant time delay, thereby guiding therapeutic plan.

Persistent Hypoglossal Artery

The persistent hypoglossal artery(PHA) is a rare anomaly that belongs to the group of embryonic carotid-basilar artery anastomoses that may occur in adults. The most commonly reported type of such an anastomosis is the primitive trigeminal artery, followed by the PHA. We report a 35-year old man, hospitalized because of an intraventricular hemorrhage, who was found to have a right persistent PHA. Three-dimensional computed tomography(CT) angiography provided excellent anatomical topology of the anomaly. To our knowledge, this patient is the first case of a PHA identified by this means in Korea.

Cerebral Vasospasm after Surgical Clipping Versus GDC Embolization in Ruptured Intracranial Aneurysm

OBJECTIVE: The purpose of this study is to analyze the influence of the treatment modality(surgical cilpping versus GDC embolization) on development of cerebral vasospasm in a non-randomized retrospective analysis of 93 patients of aneurysmal subarachnoid hemorrhage. METHODS: The following parameters were retrospectively reviewed in our institution's data base and analyzed in association with vasospasm-related ischemic infarctions: 1) Hunt and Hess(H&H) grade, 2) Fisher group, 3) location of aneurysm, 4) treatment modality(surgical cilpping versus endovascular treatment). RESULTS: Of the 93 patients, 39 (41.9%) patients suffered delayed ischemic infarctions. The incidence of delayed ischemic infarctions were increased as higher H&H grade and Fisher group but was not related with the location of aneurysms and the treatment modalities. CONCLUSION: Even with vigorous removal of the subarachnoid blood clots in the surgical clipping group, there is no statistical differences in the incidence of cerebral vasospasm between the two treatment modalities.

Cerebral Sparganosis with Apoplectic Presentation

Cerebral sparganosis is a rare parasitic infestation of the brain, usually presenting with seizure associated with chronic recurrent inflammatory reaction. Recently we have treated a very unusual form of this parasitic disease, of which clinical onset was apoplectic. A 60-year-old man was transferred to our emergency room complaining of sudden onset of right hemiparesis and speech impairment. Computed tomography(CT) of the brain demonstrated high density lesion, suggestive of a hematoma in the left parietal subcortical region. Unusual location and shape of the hematoma made us took CT angiogram to confirm any vascular abnormalities in or around the hematoma. We performed an explorative craniotomy and evacuation of the hematoma under the guidance of stereotactic system. At surgery, a live parasite, a larva of a tapew (Spirometra mansoni) was found and removed with the hematoma.

The Apoptosis and Expression of p53, Bcl-2 in Graded Contusion Injury of Rat Spinal Cord

OBJECTIVE: This study is designed to investigate how apoptosis is presented and how the genes of p53 and bcl-2 are expressed depending on graded injury in experimental spinal cord injury. METHODS: Experimental spinal cord injury was made on rats with weight drop method. Two different amounts of impact were applied on rat spinal cord. Rats were categorized into three groups (control; five rats, mild injury; five rats, severe injury; five rats). Fourty eight hours following cord injury, cord specimen was harvested from injury epicenter. TUNEL staining was done for apoptotic detection and immunohistochemical staining for p53 and bcl-2 expression. Positively stained cells were counted and mean values were compared among three groups. RESULTS: TUNEL positive cells increased depending on injury severity(p=0.027). The p53 positive cells increased in both injury groups compared to control group(p=0.001). Bcl-2 positive cells decreased as injury amount increased(p=0.002). The p53 expression increased in proportion to TUNEL staining in correlation curve in white matter(correlation coefficient, 0.387). The bcl-2 expression was inversely proportional to TUNEL staining and steeper decrease was found in gray matter than in white matter (correlation coefficient, -0.875). CONCLUSION: Apoptosis increases as the injury grading elevated within 20gm-cm of impact. The p53 seems to promote apoptosis in white matter, but do not show proportional relationship with injury amount. Bcl-2 appeared to be protective to cell death due to apoptosis.

Effect of Intraarterially Administered Abciximab(Glycoprotein IIb-IIIa Inhibitor) in the Acute Cerebral Vascular Occlusion

OBJECTIVE: The authors report the safe recanalization after intraarterial injection of abciximab(glycoprotein IIb-IIIa inhibitor) in the acute cerebral vascular occlusion from the thromboembolism. METHODS: Eight patients with acute occlusion of cerebral arteries were treated by using an intraarterial infusion of urokinase and abciximab(Reopro(R)). Six patients had acute thromboembolic complication of endovascular therapy and two patients had acute basilar artery occlusion. Authors used mean 428, 000 units of the urokinase, and mean 6.2mg of the abciximab. In six cases, intraarterial urokinase and abciximab were infused shortly after the event of thrombosis duration endovascular procedure. RESULTS: In all cases, successful recanalization of thrombotic artery was achieved by using intraarterial abciximab and urokinase without bleeding complication. Seven patients recovered without neurologic deficit and one patient remained in locked-in neurological state. CONCLUSION: The authors believe that the intraarterial infusion of abxicimab even in small dose is effective and safe recanalization method in acute thrombotic occlusion of cerebral arteries, but further evaluation and study are needed.

Clinical Analysis of Spinal Cord Hemangioblastoma

OBJECTIVES: The authors present a retrospective analysis of 14 patients treated for spinal cord hemangioblastoma (SCH) between Dec. 1986 and Mar. 2000. This study was conducted to evaluate and compare the difference of the functional outcomes associated with the extent of surgical removal of SCH. METHODS: Eleven patients were male and three patients were female. Their mean age was 37.2 years that ranged from 19 to 62 years. Preoperative magnetic resonance(MR) imaging of the spine was performed in all cases, and preoperative angiography in eleven cases. They were followed from 15 months to 161 months(median follow-up period, 47 months), and we investigated the change of neurological symptoms and functional outcomes with radiological features, especially on MR imaging. RESULTS: Six patients were accompanied by von Hippel-Lindau disease, and three of them had multiple CNS tumors. Thirteen patients had intramedullary tumor, and the remaining one had extradural. Syringomyelia around the tumor was observed in ten cases. All patients underwent surgical removal, and gross total removal(GTR) was achieved in ten cases. Preoperative embolization was performed in four cases. In four patients who were treated with preoperative embolization, intraoperative loss of blood was minimal and GTR was possible. One patient developed a transient swallowing difficulty postoperatively without permanent postoperative neurological deficits. In three of four patients in whom GTR was not possible, their functional outcomes were worsened postoperatively. The functional status at discharge was improved in seven patients, stationary in four patients, and worse in three. At the last follow-up(15-161 months), one of four patients who had been stationary at discharge showed improvement but, the rest did not show any change. All patients who showed neurological improvement were patients with GTR, and the patients with GTR had significant better outcome than those without GTR(p=0.015). CONCLUSION: Surgical treatment, and especially, GTR is considered as treatment of choice for spinal cord hemangioblastoma. Preoperative embolization may prevent intraoperative bleeding and improve surgical outcome.

Spinal Cord Tumors: An Analysis of 654 Cases(1973-1999)

OBJECTIVE: The spinal cord tumors(including vertebral tumors) are increasingly diagnosed and operated due to development of refined diagnostic and therapeutic tools. It is necessary to re-evaluate clinical features and surgical results of spinal cord tumors with increasing cases and developing treatment modalities. The authors reviewed the spinal cord tumor cases to evaluate their clinical characteristics. MATERIALS AND METHODS: The retrospective review of 654 cases of spinal cord tumors between 1973 and 1999 was done. The clinical features, pathological analysis and surgical results were analyzed and compared to the literature. The results of the study are analyzed with a more detailed consideration of each of major pathologies: neurogenic tumors, meningeal tumors, neuroepithelial tumors, and metastatic tumors. RESULTS AND CONCLUSION: The spinal cord tumor was most common in the 5th decade of age(145 cases, 22.1%) and 78 cases(11.9%) were found in children under 15 years of age. The ratio of male to female was 1.2:1. The pathologic diagnosis was neurogenic tumor in 266 cases(40.7%), neuroepithelial tumor in 131(20.0%), metastatic tumor in 118(18.0%), and meningeal tumor in 94(14.4%) in the order of frequency. The tumor was located most frequently in the thoracic area(36.5%) and in the intradural extramedullary space(38.1%). The most common initial presentation was pain(40.1%) and the mean duration for presentation to operation was 14.8 months. The total or gross total removal was possible in 404 cases(61.7%) and the surgical result on the postoperative one month was recovery or improvement in 424 cases(64.8%), stationary in 188(28.7%), progression in 42(6.4%). As a surgical complication, there was a spinal deformity(12 cases), wound infection(5 cases), aspiration pneumonia(5 cases) etc. Neurogenic tumors and menigiomas showed good surgical results, whereas neuroepithelial tumors(except ependymoma) and metastatic tumors showed relatively poor prognosis.

Management of Intracranial Small AVM / 대한뇌혈관학회지

For the management of small intracranial arteriovenous malformation(AVM), various methods were proposed and their clinical outcomes have been analyzed. Microsurgery, radiosurgery, and embolization can be effective for the treatment of small AVM. Small AVM is known to be at a higher risk of bleeding. Therefore, the aim of treatment should be the prevention of neurological deterioration from bleeding. Microsurgery has the advantage of prompt elimination of the risk of rebleeding by complete excision with single procedure. With the advance of microsurgical techniques, small AVM can be cured with minimal neurological deficit. Outcome of microsurgery depends on location, size, and numbers and patterns of draining veins, which mean Spetzler-Martin grades. Stereotactic device guided surgery, preoperative careful evaluation, intraoperative electrophysiological and hemodynamic monitoring, and experienced surgical skills can greatly reduce adverse brain injury and help complete and exact excision of malformations. Radiosurgery has its unique role for the deep seated AVM, but long term outcome remains to be evaluated. In the management of small AVM, surgery should be considered as the first line of treatment, and radiosurgery can be an alternative for the surgically inaccessible lesions.