Clinical Analysis of Risk Factors in Shunt-dependent Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVES: Shunt-dependent hydrocephalus is the major sequela after subarachnoid hemorrhage (SAH) and this continues to be a major source of morbidity for these patients. The prevalence and risk factors are not clear, despite the significant clinical and basic science research that's been done. We analyze the risk factors of shunt-dependent hydrocephalus such as the clinical and radiological parameters, the treatment modality and the peri-operative preparation. METHODS: We collected data on 475 patients with aneurysmal SAH and who were admitted to our hospital between January 1996 and January 2005. We retrospectively analyzed the age, gender, Hunt-Hess grade, Fisher grade, hypertension, intraventricular hemorrhage (IVH), rebleeding, vasospasm, location of aneurysm, treatment modality, timing of surgery, lumbar drainage, external ventricular drainage (EVD) and the prognosis as risk factors. RESULTS: 22.1% (105/475) of the aneurysmal SAH patients developed shunt-dependent hydrocephalus. Univariate analysis revealed that the patient's age, Hunt Hess grade, IVH, rebleeding, vasospasm, location of aneurysm, timing of operation, lumbar drainage, EVD and the prognosis had statistically significant correlation with the development of shunt-dependent hydrocephalus (p<0.05). Through multivariate regression analysis, the aneurysms located in the posterior circulation, use of lumbar drainage and the cases with acute hydrocephalus showed a high prevalence of shunt-dependent hydrocephalus. CONCLUSION: Among the numerous factors, only lumbar drainage was a partially controllable factor. Further analysis of the clinical factors associated with CSF drainage and re-evaluation of the indications for drainage are needed.

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.

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.

Significance of Intra-, Post-operative Electromyography Study and Follow-up Results of Microvascular Decompression for Hemifacial Spasm

OBJECTIVE: The aim of this study is to evaluate of the significance of intraoperative electrophysiologic monitoring and follow up electrophysiologic study at seven days after microvascular decompression(MVD) for hemifacial spasm(HFS). METHODS: Thirty nine patients with hemifacial spasm were included in this study and were treated with MVD of the facial nerve from Jun 1990 to May 2001. The patients were divided into a monitoring group and a non-monitoring group. We compared the surgical outcomes, operation related complications between two groups. The abnormal muscle response(AMR) of preoperative electromyographic recording appeared on the mentalis muscle during stimulation of the zygomatic branch of the facial nerve was compared with those of changed during operation, immediately after operation and at postoperative 7th day(POD 7). The relationship between degree of AMR disappearance and surgical outcome was analyzed. RESULTS: There was no difference in surgical outcomes but significant difference in the incidence of operation-related complications between two groups. The results of electrophysiologic study at POD 7 were significantly correlated with surgical outcome in the monitoring group. CONCLUSION: The electrophysiologic study is helpful for identifying the offenders, determining the adequacy of vascular decompression and decrease of operation-related complications. The clinical and electrophysiologic status of HFS after MVD has continuously changed, and therefore the results of eletrophysiologic study at POD 7 are useful for predicting the surgical outcome.

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.

Clinical Usefulness of Magnetic Resonance Cisternography in Patients Having Hemifacial Spasm

To evaluate the usefulness of MR cisternography fourteen patients that had hemifacial spasm and 20 control patients underwent MR cisternography. All the patients with hemifacial spasm had a confirmed vascular compression after surgery. MR cisternography was performed using a 1.5-tesla superconducting MR magnet in which a 3D (dimensional) heavily T2-weighted turbo spin-echo sequence was used. In 34 randomly selected individuals, we retrospectively determined whether MR cisternography images could be used to evaluat symptoms, and what the benefits of obtaining this image was. The results were correlated with the surgical findings. The sensitivity was 100% and the specificity was 94% in all patients having a hemifacial spasm. The offending vessels were the anterior inferior cerebellar artery (AICA) in six patients cases, the posterior inferior cerebellar artery (PICA) in six, both the vertebral artery and PICA in one, and the vertebral artery in one. All the images showed good resolution and contrast, and also showed the exact correlation between the facial nerve and intracranial vessels in the multiplaner image. The findings of neurovascular compression were well correlated with the surgical findings. We believe that high-resolution 3D MR cisternography is a very useful method for evaluating the neurovascular compression in patients that have hemifacial spasm.

Brain Abscess Associated with Primary Intracerebral Hemorrhage: Case Report

We had experienced a case of hematogenous brain abscess which occurred at the site of spontaneous intracerebral hemorrhage. The 41-year-old patient was admitted with sponetaneous intracerebral hemorrhage on left basal ganglia and sepsis. Brain abscess was incidentally detected by stereotactic aspiration of intracerebral hemorrhage, followed by the gram staining and culture of aspirated material.

Transient Quadriparesis due to Dysgenesis of the Posterior Arch of the Atlas: Case Report

Acase of 14-year-old student is presented with the complaint of recurrent attack of transient quadriparesis during hyperextension of the neck. On 3-dimensional spinal CT and MRI, the authors confirmed intrusion of posterior tubercle of the atlas with increased signal on T1- and T2- weighted image was found. The clinical manifestations were improved without having cervical instability after a posterior laminectomy of the atlas.

Cerebrovascular Disease during Pregnancy

Cerebrovascular lesions during pregnancy, although uncommon, account for a significant number of maternal deaths. Maternal mortality related to stroke is usually associated with eclampsia complicated by cerebral edema or intracerebral hemorrhage. At times, hypertensive intracerebral hemorrhage, cerebral arteriovenous malformation, and moyamoya disease may also be related. Nine patients with cerebrovascular disease during pregnancy were reviewed. The mean age of pregnancy related hypertensive intracerebral hemorrhage was 32.1+/-6.6years and the time of attack was intrauterine pregnancy(IUP) 27.2+/-13.8 weeks. The basal ganglia hemorrhage was noted in 55.5%(5 ca-ses), followed by intraventricular hemorrhage(IVH)(4 cases) and subcortical hemorrhage(3 cases). The pregnancy related hypertensive intracerebral hemorrhage was developed more often in multigravida(6 out of 9) than in priemiparous woman. Good outcome was expected in patients with subcortical location(p=0.058), primigravida(p=0.058), and high initial GCS score(p=0.056).

Endodermal Sinus Tumor of the Scalp

Endodermal sinus tumors(yolk sac tumors) are malignant germ cell tumors that usually arise in the gonads. We report the first case, to our knowledge, of endodermal sinus tumor of the scalp. The tumor was present in a developmental infant with an abnormal scalp and exhibited histopathologic and immunohistochemical features identical to those of endodermal sinus tumors of gonadal origin. The tumor resolved after surgical excision and chemotherapy, and the patient is at present alive. The purpose of this report is to add a differential diagnosis to neoplasms of the scalp in neonates and review approaches to the management of this rare clinical entity.

Clinical Analysis of Combined Head and Spine Trauma

Among 1350 craniocerebral trauma patients treated between January 1992 and December 1995. The authors analyzed 25 who had suffered combined head and spine trauma and had been subject to follow up. The ratio of males to females was 4 : 1 ; their ages ranged from less than twenty to over sixty. As clinical parameters, we use of the Glasgow Coma Scale(GCS), Revised Trauma Score(RTS) and Glasgow Outcome Scale(GOS) at discharge, and for clinical statistics, used the chi-square test. The results of the study were as follows : 1) Among craniocerebral trauma patients, the incidence of combined head and spine trauma was 2%(25/1350). 2) In cases with combined craniospinal trauma, the incidence of intracranial hemorrhage and cervical spine injury was 76% and 68%, respectively. 3) Among cases with spinal injury, head trauma combined with cervical spine injury showed the worst outcome (p<0.05). 4) Combined high cervical spine injury showed a poorer outcome than did lower cervical spine injury(p<0.05). 5) Initial GCS was significantly related to initial RTS(p<0.05). 6) At discharge, there was a very highly significant correlation between initial GCS and GOS(p<0.01), but not between initial RTS and GOS(p<0.081). 7) Especially in patients who are unconscious because of head trauma, it is important to investigate the possibility of spinal injury other than that of at cervical level.

A Case of Pituitary Abscess

A 35-year-old woman presented with amenorrhea, polydipsia, polyuria, general weakness and intolerance of cold; the duration of these symptoms had been five years. On brain MRI with Gadolinium enhancement, an intrasellar mass protruding above the sella turcica was demonstrated, and the patient was thought to be a pituitary adenoma. The transsphenoid approach(TSA) was employed, and during at surgery, pus was drained. In a culture of this, no microorganism was identified, and on histologic examination, which suggested lymphocytic infiltration with fibrosis and occasional neutrophils were seen, findings which suggested the possibility of capsule of chronic abscess. Transient postoperative polyuria was noted, but this disappreared soon after broad spectrum antibiotics were administered; hormonal therapy was required for anterior and posterior pituitary hypofunction. Clinical features of this condition and its treatment are also discussed, and the literature pertaining to reported cases is reviewed. An enlarged or erosive sella coexisting with bacterial meningitis, sphenoid sinusitis, cavernous sinus thrombophlebitis or bacterial meningitis coincident with a known or suspected pituitary tumor suggests the presence of a pituitary abscess.

Predictors of Outcome of Spontaneous Cerebellar Hemorrhage

It is generally agreed that a small hematoma can be treated conservatively, whereas a larger one requires aggressive surgery; the surgical indication for those that are medium-sized remains controversial. To determine the criteria for conservative or surgical management, the authors analyzed 64 cases of spontaneous cerebellar hemorrhage diagnosed by CT scan between January 1990 and May 1996. An assessment was made of the relationship of initial GCS(Glasgow Coma Scale) score and GOS(Glasgow Outcome Scale) to hypertension, the location and size of the hematoma, obstructive hydrocephalus, intraventricular hemorrhage and the CT appearance of the quadrigeminal cistern. The results may be summarized as follows: 1) The incidence of spontaneous cerebellar hemorrhage was 6.37%(64/1005 spontaneous intracerebral hemorrhage). 2) The location of hematoma and hypertension did not correlated with initial GCS and GOS(p>0.05, p>0.05). 3) Obstructive hydrocephalus, intraventricular hemorrhage and obliteration of the quadrigeminal cistern correlated with intial GCS and GOS(p<0.01, p<0.001). 4) In case of spontaneous cerebellar hemorrhage, the mortality rate was 17.2%(11/64). 5) Poor prognostic factors were initial GCS score of less than 10(p<0.05), hematoma volume greater than 15 ml (p<0.01), the occurrance of intraventricular hemorrhage(p<0.05), and obliteration of the quadrigeminal cistern(p<0.001).

Prognostic Factors in Head-injured Patients with Traumatic Subarachnoid Hemorrhage

The presence of traumatic subarachnoid hemorrhage on the initial computerized tomographic scans has been known to be associated with worse results. By means of a simple and reliable computerized tomographic grade system proposed by Greene and his colleagues, prognostic factors of the traumatic subarachnoid hemorrhage was significantly related to clinical outcome at the time of discharge from acute hospitalization. Between February 1992 and August 1995, 3975 patients were admitted to our department of neurosurgery due to head injury. Clinical data were retrospectively reviewed to ascertain the relationship of the thickness of traumatic subarachnoid hemorrhage, its location, evidence of mass lesion(s), midline shift, obliteration of the basal cistern, and cortical sulcal effacement to outcome. Additionally, initial Glasgow coma scale score, arterial gas study, systemic blood pressure and prothrombin time were also analyzed for the same purpose. Among 3975 head-injured patients, 213 patients were identified to h ave traumatic subarachnoid hemorrhage on the initial computerized tomographic scan. Among 213 traumatic subarachnoid hemorrhage patients, the patients treated with calcium channal blocker(32 patients) and 3 patients lost to follow-up were excluded from this study for a total of 178. The computerized tomographic scan findings were divided into a 3 grade system;Grade 1 indicating only traumatic subarachnoid hemorrhage, Grade 2 indicating traumatic subarachnoid hemorrhage with mass lesion(s) , Grade 3 indicating traumatic subarachnoid hemorrhage with mass lesion(s) and midline shift. All these data were compared to Glasgow outcome scale on discharge, and arbitrarily these were divided into the good(good recovery and moderate disability) and the bad(severe disability, vegetative state and death). The authors conclude that the contributing factors to outcome at discharge were as follows:1. midline shift(p=0.002), PT< or =70%(p<0.001), obliteration of the basal cistern(p=0.001) and cortical sulcal effacement(p=0.001) were shown to the statistically significant. 2. initial computerized tomographic grade contributed to outcome at discharge.

Aneurysmal Bone Cyst(ABC) Secondary to Eosinophilic Granuloma of the Skull: Case Report

A case of aneurysmal bone cyst(ABC) secondary to eosinophilic granuloma of the skull is reported. In the skull, the presence of ABC secondary to eosinophilic granuloma is rare. We reviewed the clinicopathological- and radiological features of this type of eocinophilic granuloma at the cranium.

Miliary Tuberculosis Involving the Central Nervous System

In recent times, central nervous system(CNS) tuberculosis has been rare and the prevalence of the focal form, the tuberculoma, varies from 1 per 20 to 1 per 1000. CNS tuberculosis occurs as a result of hematogenous sparead from a primary focus, mostly pulmonary tuberculosis. It can be diffuse exudative leptomeningitis or a localized tuberculoma; the former is more common. We report a case of military cerebral tuberculosis in a 24-year-old female who had been having headaches for 4 months. Magnetic resonance imaging showed numerous small round Gadolinium-enhanced supratentorial and infratentorial lesions scattered throughtout the brain. Histologic examination confirmed well-defined tuberculous granulomas with central caseous necrosis in open biopsy, containing several acid-fast bacilli, the patient was treated with isoniazid, rifampin, ethambutol, pyrazinamide in combination with prednisolone.

Traumatic Intraventricular Hemorrhage(TIVH)

Intraventricular hemorrhage after blunt head trauma, which reflects the severity of head injury, is uncommon. A retrospective study of 109 traumatic intraventricular hemorrhage(TIVH) patients who were admitted between January 1, 1988 and December 31, 1993 was conducted. The results are as follows: 1) Incidence of TIVH and its associated mortality were 2.45% and 28.4%, respectively. 2) TIVH-associated radiological abnormalities were traumatic intracerebral hematoma(62.7%), skull fracture(42.7%), and traumatic subarachnoid hemorrhage(34.5%). 3) Amount of TIVH was related to traumatic intracerebral hematoma(p=0.0003) and traumatic subarachnod hemorrhage(p=0.0385). 4) The poorest prognostic indicator was associated abnormalities, especially corpus callosum or brainstem hemorrhage(p=0.0099). 5) TIVH-associated hydrocephalus was not related to the amount of TIVH(p=0.42), and poor prognosis(p=0.12). 6) Patients with TIVH showed better Glasgow coma scale and Glasgow outcome scale than TIVH-associated abnormalities.

Immunohistochemical Study of p53 Gene Expression in Astrocytic Neoplasms

Nineteen astrocytic neoplasms, such as 9 cases of glioblastoma multiforme, 6 cases of anaplastic astrocytoma and 4 cases of low grade astrocytoma, were analysed in view of the relationship between histopathologic grade, nuclear pleomorphism, grade of mutant p53 gene expression and mean survival time after operation. The histopathologic classification by Ringertz and immunohistochemical stain for mutant p53 gene with the DO-7 anti-p53 oncoprotein mouse monoclonal antibody were applied, and the results obtained were as follows; 1) Among 19 cases, 18 cases were located in the supratentorium, where 13 cases(42%) were located in the left and 17 cases(55%) in the right. 2) The p53 gene expression was detected in 12(63.2%) of the cases, as revealed by positive nuclear staining. All cases of glioblastoma multiforme showed p53 gene expression, compared with two(33.3%) cases of anaplastic astrocytoma and one(25%) case of low grade astrocytoma. The frequency and degree of histopathologic grade(p=0.03). 3) The mean survival time after operation was 29.49+/-4.08 months in cases with p53-negative tumors and 12.93+/-3.14 months in cases with p53-positive tumors(p<0.05). 4) Both histopathological classification and p53 gene expression showed a significant influence on servival(p=0.02 and p=0.03, respectively). 5) The relative risk for survival time was the highest in p53 gene expression. In conclusion, p53 gene expression appears to be one of the recommendable prognosticators among astrocytic neoplasms.

Granulocytic Sarcoma in the Cerebellum

Granulocytic sarcoma, a rare extramedullary solid tumor arising from early myeloid precursors, is capable of invading the meninges or the rain parenchyma. The tumor may occur during or after the onset of systemic myelogenous leukemia. On rare occasions, the tumor may evolve before the onset of systemic myelogenous leukemia. Children are affected more often than adults, but sex is not related. Although no definite target area of the brain can be demonstrated, there may be some predilection of the tumor for the posterior fossa. The authors report a case of 4-year-old-boy with granulocytic sarcoma occurring in the posterior fossa presenting with gait disturbance and torticollis. The patient was treated by surgical removal of the tumor, there by avoiding the potentially lethal complication of a posterior fassa mass. This rare case is reported together a review of the literature.

Stereotactic Removal of Spontaneous Intracerebral Hematoma Using Hematome and Urokinase

We had tried to perform mechanical aspiration using Hematoma and fibrinolytic drainage with Urokinase for treatment of spontaneous intracerebral hematoma(SICH) in 24 patients. Mean initial volume of SICH was 53.65+/-26.34 ml, mean evacuated amount of SICH after Hematoma procedure was 46.25+/-23.64%, and mean evacuated amount of SICH after fibrinolytic drainage after Urokinase was 74.15+/-20.89%, compared with pre-operative status. We could aspirate more than 50% of hematoma if the Hematoma procedure had been performed within 18 hours after ictus(p=0.0306). The rebleeding rate after Hematoma procedure was 8.3%, and overall mortality rate was 12.5%. There results seem to indicate mechanical aspiration using Hematoma and fibrinolytic drainage with Urokinase might be one of the useful method for treatment of SICH.