A Simplified Skull Base Approaches for Anterior Circulation Aneurysms: Superolateral Orbital Craniotomy and Orbital Roof Craniotomy viaan Eyebrow Incision

OBJECTIVE: Previous standard surgical approaches for aneurysms of anterior circulation are concerned with possible injury to the normal brain by cerebral retraction. Simplified skull base approaches have been introduced to fulfill the ideal goals of skull base surgery, brain protection and technical minimalism. Superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offered sufficient working space for aneurysmal neck clipping of anterior circulaton and have advantages of minimal brain retraction and rapid recovery. METHODS: The concept and technique of the superolateral orbital craniotomy and orbital roof craniotomy are presented in detail. We conducted a retrospective study in which we evaluated the technical aspect of the superolateral orbital craniotomy and orbital roof craniotomy considering the indications, limitations, and complications of these approaches. RESULTS: The superolateral orbital craniotomy and orbital roof craniotomy provide an ample space to access the neurovascular structure of the anterior skull base without using brain retractors, enable rapid anatomical reconstruction for closure and acceptable cosmetic results. CONCLUSION: The superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offer better surgical possibilities and approach related morbidity than conventional approaches in the treatment of anterior circulation aneurysms.

A Simplified Skull Base Approaches for Anterior Circulation Aneurysms: Superolateral Orbital Craniotomy and Orbital Roof Craniotomy viaan Eyebrow Incision

OBJECTIVE: Previous standard surgical approaches for aneurysms of anterior circulation are concerned with possible injury to the normal brain by cerebral retraction. Simplified skull base approaches have been introduced to fulfill the ideal goals of skull base surgery, brain protection and technical minimalism. Superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offered sufficient working space for aneurysmal neck clipping of anterior circulaton and have advantages of minimal brain retraction and rapid recovery. METHODS: The concept and technique of the superolateral orbital craniotomy and orbital roof craniotomy are presented in detail. We conducted a retrospective study in which we evaluated the technical aspect of the superolateral orbital craniotomy and orbital roof craniotomy considering the indications, limitations, and complications of these approaches. RESULTS: The superolateral orbital craniotomy and orbital roof craniotomy provide an ample space to access the neurovascular structure of the anterior skull base without using brain retractors, enable rapid anatomical reconstruction for closure and acceptable cosmetic results. CONCLUSION: The superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offer better surgical possibilities and approach related morbidity than conventional approaches in the treatment of anterior circulation aneurysms.

Intracranial Hemorrhage Developed from Patient Who Had Been Preeclampsia at Five Days Postpartum

Intracranial hemorrhage due to preeclampsia in the postpartum woman is rarely documented. Generally, the incidence of stroke is increased during pregnancy and early postpartum. Preeclampsia is considered a main cause of both nonhemorrhagic and hemorrhagic stroke. We present a 32-year-old woman who had intracranial hemorrhage at 5 days postpartum. At admission, her consciousness was semicomatose with elevated blood pressure. Computerized tomography revealed intracranial hemorrhage on right frontal lobe. Additional angiography did not reveal abnormal vascular lesion. Emergency craniectomy with hematoma removal was done. However, the patient showed no recovery and died 2 weeks later. We conclude that postpartum care of preeclampsia is important to prevent intraparenchymal hemorrhage. Relative high risk of stroke during the postpartum period suggests a causal roles for the large decrease in blood volume or the rapid changes in hormonal status that follow a live birth or stillbirth, perhaps by means of hemodynamics, coagulative, or vessel wall changes.

Syringo-Pleural Shunt for Failed Syringosubarachnoid Shunt in Posttraumatic Syringomyelia

The authors report a case of syringo-pleural shunt for recurrent distal obstruction of syringosubarachnoid shunt in a 23-year-old woman. She complained of tingling sensation and dysesthesia on the left upper extremity. Neuroradiologic imaging studies revealed syringomyelia in the left lateral side of the cord from medulla to 7th thoracic cord level. We identified intraoperatively high internal pressure of the syrinx cavity due to distal shunt tube obstruction. Syringo-pleural shunt was performed and cavity size was markedly decreased at later follow up MRI. In conclusion, the posttraumatic syrinx, especially in cases with previous syringosubarachnoid shunt or diffuse subarachnoid scarring, can be successfully managed with syringo-pleural shunt.

Microsurgical Decompression for Lumbar Stenosis via Unilateral Laminotomy

No abstract available.

A Case of Primary Multiple Intracerebral spergillosis Abscess in Neonate:Treatment with Amphotericin B, Flucytosine and Itraconazole

Fungal infection of the central nervous system tends to occur mostly in immunosuppressed patients. In the pediatric population, it is usually seen in severely immunocompromised patients, particulary in children with chronic granulomatous disease and hematopoietic malignancies. Although aspergillosis is considered one of the most frequent agents of mycotic infection of the brain, it is especially rare in the neonatal period, and overwhelming multisystem infection is usually diagnosed postmortem. Manifestations include meningitis, meningoencephalitis, granulomata formation, brain abscess, vasculitis, aneurysm formation, infarct and intracranial hemorrhage. We present a neonate who had brain abscess diagnosed by MRI, and aspergillus was found at surgical exploration. There are very few reported survivors of neonatal aspergillosis. We reported a case of primary multiple brain abscess caused by aspergillus associated with severe hypernatremic dehydration and prerenal azotemia. The patient was treated with amphotericin B combined with flucytosine and itraconazole.

Endoscopic Third Ventriculostomy for Adult Aqueduct Stenosis: Double Fenestration: A Case Report and Technical Note

No abstract available.

Posterior Transvertebral Extension Osteotomy: A Case Report

No abstract available.

Cerebral Salt Wasting Syndrome Associated with Pseudomonas Meningitis ccurred after Removal of Pituitary Adenoma: A Case Report

The authors report a case of cerebral salt wasting(CSW) syndrome followed by diabetes insipidus and meningitis after transsphenoidal approach for pituitary adenoma. Fluid and electrolyte imbalance occurs occasionally in neurosurgical patients due to DI or SIADH, however, CSW is different disease entity and the methods of treatment are different from those of DI or SIADH. A number of studies in recent years have shown that hyponatremia in many patients with intracranial disease might actually be caused by CSW in which a renal loss of sodium leads to hyponatremia and massive urinary water loss. CSW of this patient was resolved by fluid and salt replacement after 6 months.

Congenital Insensitivity to Pain with Anhidrosis: Follow-up of 1 case

Congenital insensitivity to pain with anhidrosis (CIPA: a hereditary sensory and autonomic neuropathy, HSAN IV) is a rare disease characterized by the self-mutilation, bone fracture, multiple scars, osteomyelitis, joint deformities and anhidrosis. The pathophysiologic mechanism remains unknown. This is the report of a twelve years old boy who had been diagnosed as the CIPA at his age of five. Loss of unmyelinated and small myelinated nerve fibers have been noted in an abdominal skin biopsy. On follow up studies, no significant changes were noted in the clinical manifestations and in the findings of laboratory, radiologic and electrophysiologic studies when compared to the initial studies except for the minimally progressed neuropathic ankle joints. Long term follow up study including the sequential electrophysiologic examination and biopsy of nerve and muscle might be necessary to establish the natural course of the disease. Prevention of the injury should be emphasized for the good prognosis.

The Clinical Significance of Residual Latency in Diagnosis of Diabetic Neuropathy

OBJECTIVE: To determinate the reference values of residual latencies of motor nerves and to evaluate the early diagnostic value of residual latency. METHOD: The subjects were 129 diabetes mellitus patients and 60 controls with no known neurological disorders. The patients were divided into two groups based on the conventional nerve conduction study: Group 1, 75 patients without neuropathy; Group 2, 54 patients with neuropathy. The group 2 patients were subdivided into 4 sub- groups on the basis of conduction velocity and residual latency of the median nerve. Residual latencies were measured in all subjects and glycosylated hemoglobin percentages (HbA1c) were measured in the diabetes patients. In group 2, each nerve conduction parameter was correlated with the duration of diabetes and HbA1c. The duration of diabetes, HbA1c, and amplitude of median nerve response were compared between the subgroups of group 2 patients. RESULTS: Motor residual latencies obtained from the controls were 1.93+/-0.28 msec, 1.53+/-0.24 msec, 2.46+/-0.43 msec, 2.21+/-0.53 msec in median, ulnar, deep peroneal and posterior tibial nerves, respectively. In group 1, motor residual latencies of median & deep peroneal nerves were significantly delayed compared with those of the controls. In group 2, motor residual latencies of median, ulnar, deep peroneal and posterior tibial nerves were significantly delayed more than those of the controls and group 1. In group 2, increased HbA1c correlated to the decreased conduction velocities of median, deep peroneal, posterior tibial nerves but not to the residual latencies. In the subgroup of group 2 (2-D), the nerve involved more distally showing lower compound muscle action potential and higher HbA1c. CONCLUSION: Residual latency measurement can be a useful diagnostic method for the early detection of diabetic neuropathy.

Assessment of Autonomic Function in Diabetic Patients

Dysfunction of the autonomic nervous system is reported to occur at an incidence of 20% to 40% in diabetes. The clinical symptoms include orthostatic hypotension, vomiting, diarrhea, bladder dysfunction, male impotence, sweating, etc. Two simple noninvasive tests, sympathetic skin response (SSR) and R-R interval variation (RRIV), were used to assess autonomic functions. We performed SSR and RRIV on the diabetic patients and controls. The patients were classified into 4 groups (group I: without peripheral neuropathy or dysautonomia, group II: with dysautonomia only, group III: with peripheral neuropathy only, group IV: with both peripheral neuropathy and dysautonomia). We also tried to correlate their clinical dysautonomic symptoms and the results of nerve conduction studies (NCS) and of SSR and RRIV. The subjects of this study were 82 diabetic patients, 20 to 73 years old with the mean age of 53, and 12 controls. Latency, amplitude, and loss of SSR all showed a significant difference in relation to the dysautonomic symptoms. The loss of SSR in the foot showed a remarkable difference in group I. In groups III and IV, three RRIVs (Valsalva ratio, E:I ratio, 30 : 15 ratio) showed a significant decrease compared with the control group, and in group II, only the 30:15 ratio showed a statistically significant decrease. In conclusion, the changes in SSR and RRIV were significantly associated with the dysautonomia. Among these, loss of SSR in the foot and decrease in the 30 : 15 ratio were useful parameters for early detection of diabetic autonomic neuropathy without peripheral neuropathy.

Findings of Semiquantitative Analysis of 99mTc-HMPAO Brain SPECT in Cerebral Palsy

It is often difficult, on the basis of clinical examination and conventional investigations, to evaluate the functional impairment of brain in children with cerebral palsy in which early detection remains a challenge. This study was designed to know the usefulness of single photon emission tomography(SPECT) of the brain with technetium-99 m hexamethylpropyleneamineoxime (99mTc-HMPAO) as a semiquantitative method of determination of right-left asymmetries in tracer uptake and a change in antero-posterior regional cerebral blood flow(rCBF) distribution. We investigated 33 children with cerebral palsy aged from 4 months to 48 months(mean 19.3 months). The results were as follows: right to left ratio and regional index of a transverse view were useful to quantify the decrease of tracer uptake in left hemiplegia, but not in right hemiplegia who were all mild in severity, and in tetra- and diplegia in which cerebral lesions were found bilaterally; cortico-cerebellar ratios of a sagittal view were found useful to detect a decrease of rCBF distribution in tetra- and diplegia ,which was not distinct by means of right to left ratio and regional index on transverse view. The results suggest that semiquantitative analysis of 99mTc-HMPAO Brain SPECT would be a valuable complementary tool for determination of topographical involvement in cerebral palsy.

Clinical Evaluation of Salvage Surgery for Patients with Failed Anterior Cervical Surgery

Although anterior cervical fusion provides an excellent choice for variable cervical pathologic conditions. However the potential risk of complications involved with its use have been the reason for its being less then universally accepted. The authors experienced 10 cases(5.8%) of failed anterior cervical surgery among the total of 171 during the past 5 years. The patients in our series averaged 52.9 years of age(range 26-75), consisted of 9 men and 1 woman. The clinical presentations were nuchal pain(80%), radiculopathy(50%), myelopathy(10%) and dysphagia (10%). The causes of failed anterior cervical surgery included 6 hardware failures and 4 graft failures. Salvage procedures included 9 anterior approach and 1 posterior approach. The mean follow up period was 15 months. All patients had achieved solid bony fusion in addition to marked symtomatic improvements of 70%(in 7 cases). The results of our study indicates that in order to reduce the need for salvage operations, accurate diagnosis, skillful surgical techniques are necessary.

Malignant(papillary) Meningioma of the Petrous Bone Extending to Cerebellopontine Angle and Infratemporal Fossa: Case Report

The authors present a case of malignant papillary meningioma of the petrous bone involving the whole petrous bone which extended to the left cerebellopontine angle and internal jugular vein extracranially. A 46-year-old male patient was presented with a 3-years history of the left otalgia and subsequent deafness with left facial nerve palsy. Neurological examination revealed a complete palsy of the left eighth nerve, and incomplete palsies of the left 7th, 9th, 11th, and 12th cranial nerves. Magnetic resonance imaging and computerized tomographic scan demonstrate a huge mass in cerebellopontine angle which involved the whole petrous bone, suboccipital bone and internal jugular vein. The tumor was totally resected using the transjugular approach with modified petrous bone resection. Neuropathologic examination revealed a papillary meningioma.

Transarticular Screw Fixation in Atlantoaxial Instability

Atlantoaxial joint is a complex and unique structure which promotes rotation of head. Disruption of the transverse ligament and odontoid process fracture caused by trauma result in atlantoaxial instability. The instability must be corrected to relieve pain and to reduce the risk of neural damage and possibility of sudden death. The most recent and technologically advanced fixation method of C1-2 instability is the use of C1-2 transarticular screw fixation. The transarticular screw fixation augmented with interspinous wiring technique provide immediate multidirectional rigid fixation and increase the fusion rate of atlantoaxial instability. It can be employed in situations where the posterior arch of C1 is absent or fractured and in situations where standard wiring techniques pose risky posterior subluxation of C1 on C2, or for congenital odontoid anomalies. Twenty-one patients with atlantoaxial instability were operated with posterior transarticular screw fixations augmented with interspinous C1-2 strut graft and posterior wire fixation technique. All patients restored C1-2 stability without complication. This technique seems to be superior biomechanically when compared with other posterior fixation methods. Precaution is needed to avoid the vertebral artery injury.

Iatrogenic Pseudomeningomyelocele after Lumbar Laminectomies: Report of Cases

Two unique cases of delayed nerve root herniation and entrapment into the pseudomeningocele through an unrepaired dural laceration at lumbar laminectomy were reported. Both patients presented with recurred radiculopathy, 3 and 6 years after first operation respectively. Lumbar myelography showed an extradural pseudomeningocele pouch in case 1 while showing no abnormality in case 2. Lumbar MRI in case 1 showed tangled herniated nerve root in the pouch of pseudomeningocele. Lumbar myelographic CT of case 2 showd delayed partial filling of the pseudomeningocele pouch only. Herniation through dural defect and entrapment of nerve root in the pseudomeningocele was nosted during surgery. Surgical correction of the herniated nerve root and dural repair was performed and this correction completely relieved the pain in both patients. These cases demonstrate even a small tear in the spinal dura during laminectomies requires surgical closure to prevent late nerve root herniation. Finally, the possible mechanism of this condition was also discussed.

Iatrogenic Pseudomeningomyelocele after Lumbar Laminectomies: Report of Cases

Two unique cases of delayed nerve root herniation and entrapment into the pseudomeningocele through an unrepaired dural laceration at lumbar laminectomy were reported. Both patients presented with recurred radiculopathy, 3 and 6 years after first operation respectively. Lumbar myelography showed an extradural pseudomeningocele pouch in case 1 while showing no abnormality in case 2. Lumbar MRI in case 1 showed tangled herniated nerve root in the pouch of pseudomeningocele. Lumbar myelographic CT of case 2 showd delayed partial filling of the pseudomeningocele pouch only. Herniation through dural defect and entrapment of nerve root in the pseudomeningocele was nosted during surgery. Surgical correction of the herniated nerve root and dural repair was performed and this correction completely relieved the pain in both patients. These cases demonstrate even a small tear in the spinal dura during laminectomies requires surgical closure to prevent late nerve root herniation. Finally, the possible mechanism of this condition was also discussed.