A Giant Aneurysmal Cerebral Arteriovenous Malformation in Childhood: Case Report

A giant aneurysmal cerebral arteriovenous malformation in the left parieto-occipital region is described in a 4 year old child, including resolution of the alternating hemiparesis and left ventricular hypertrophy of the heart following successful removal of the malformation by microsurgical technique. This arteriovenous malformation has a large aneurysmal sac, 6x5x4cm, in size with several feeders from branches of the left middle and posterior cerebral arteries and drains directly into the straight sinus. So we have proposed to call it "a giant aneurysmal cerebral arteriovenous malformation".

Occipito-Cervical Fusion for Atlanto-Axial Subluxation

The authors performed occipito-cervical(C2-3) fusion in a case of atlanto-axial subluxation caused by congenital seperation of dens. At first posterior cervical fusion(C1-2-3) with rib graft was performed, but several days after the operation C1-2 subluxation developed again with cervical cord compression syndrome. In the second operation, the occiput was included in the fusion after removal of the posterior neural arch of atlas which resulted in good reduction and marked improvement in neurologic symptoms.

Osteoplastic Laminotomy for Spinal Canal Surgery in Chilhood

Multiple level laminectomies are a destructive procedure complicating kyphosis, anterior subluxation and instability of the spine in children. The surgical procedure of multiple level osteoplastic laminotomies was proposed as an alternative by Raimondi et al in 1976. The goal is preservation of the normal architecture of the spine in patients who are still developing. We have experienced a case of multiple level laminotomies(T4-T11) for removal of epidural neuroblastoma in a 3-month old baby. The technical points of surgical procedure were discussed.

Clinical Analysis of 158 Surgically Treated Intracranial Aneurysms

The author analyzed 158 cases of intracranial aneurysm surgically treated in the Department of Neurosurgery, Yonsei University Medical College, from Jan. 1965 to Sept. 1976. Of the 158 cases 124 underwent direct intracranial approach (clipping, ligature, coating, wrapping, proximal vessel occlusion, and trapping) for the treatment of the aneurysms, and 33 cases underwent proximal carotid ligation in the neck as the choice of treatment. The aneurysms arising in the posterior communicating artery (46) are most common, followed by anterior communicating artery (43), middle cerebral artery M2 portion (22), and carotid bifurcation (12) in order. We also found cavernous aneurysm (2), ophthalmic artery aneurysms (3), anterior choroidal artery aneurysm (2), anterior cerebral artery A1 portion aneurysm (6), distal anterior cerebral artery aneurysm (2), middle cerebral artery M1 portion aneurysm (8), m3 portion aneurysm (2), posterior cerebral artery aneurysm (1) and basilar artery aneurysm (1). Multiple aneurysms were found in 8 cases. There was no significant difference according to sex. There were 18 cases over 60 years of age, of whom 2 were 75 years old. On this basis, we cannot consider ligation was 18.2%. If patients who were operated on in emergency because of large intracranial hematoma of repeated, or chain rupture of aneurysm are excluded, the mortality rate for purely elective cases using the intracranial approach drops to 4.3%. After introduction of the surgical microscope and newly designed temporary clipping system, 37 patients were operated on with only one death (2.7%), a patient who had repeated ruptures of the posterior communicating artery aneurysm and was operative on only 7 days after the last bleeding. So recently we have not had to pay much attention to the mortality rate of the intracranial attack for the aneurysms. There are instances when imperfection which cannot be seen by the naked eye are noticed only after the aneurysmal neck is magnified from 6 to 40 times with use of microscope. In these cases, it is obvious that correction of clipping as well as coating, which prevents rupture of the aneurysmal sac and reinforces or prevents slipping of the clip are inevitable. Various factors, such as grade of the patient's condition vasospasm, cerebral edema, presence of intracranial hematoma, state of intracranial pressure, preoperative management, timing of surgery, points of operative technique according to the sites of aneurysms, postoperative complications and their management, all of which affect the clinical and postoperative course, are discussed.

Ventriculo-peritoneal Shunting with One Piece Spring Catheter Technical Note

Shunting of cerebrospinal fluid into the peritoneal cavity is a well established procedure which has, over the years, enjoyed increasing popularity. A slit valve at the distal end elminated the insinuation of the omentum into the shunting tube and a spring catheter prevented kinking of the shunt tubing. However, the most common cause of failure of the shunting is from the separation, or pulling apart, of the various components of the shunt system with subsequent infection. A one piece spring catheter is sufficient to the necessity. Surgical details are illustrated for installing a one piece spring catheter for hydrocephalus. Four basic steps of surgical procedure using a subcutaneous guide, a leader, a cannula and a cuff are described; firstly passing the guide and the one piece shunt from McBurney's point to the supraclavicular space, secondly passing the guide from the parietal eminence to the supraclavicular space to thread the one piece shunt cephalad. Thirdly, inserting the cannula into the lateral ventricle and threading the ventricular end of the one piece shunt through the cuff into the lateral ventricle and fourthly inserting the peritoneal end into the peritoneal cavity.

Critical Review of Shunting Procedures for Hydrocephalus

The authors analyzed 174 consecutive shunting procedures for hydrocephalus at Severance Hospital, Yonsei University. There were a total of 65 complications (48.5%) among 134 patients. The most common complications were blockage of the catheters (26.2%) and shunt-related infections (15.4%). Among the different types of shunting technique ventriculoatrial, ventriculoperitoneal and ventriculocisternal routes were most commonly used. The ventriculoatrial route had a greater complication rate (40%) than ventriculoperitoneal shunting (21.8%). Flushing devices are critically reviewed and the disadvantages are discussed. The authors suggested a need for a standardized prospective national data collection system where Procedures and compilations may be assembled in a comparable form.

Orbital Venography in Parasellar Lesions

Five cases of various parasellar lesions ; unclassified malignant tumor, neurofibroma, microglioma, granuloma and metastatic carcinoma from the lung, were determined by orbital venography while the plane skull X-ray, tomogram and carotid angiogram failed to demonstrate and lesions. The technique was described and the usefullness discussed along with a review of literature. It is emphasized the orbital venogram seemed to valuable not only for the determination of the extent of the lesions but also as a good surgical guide to the region where the anatomical complexity can easily confuse the surgeon.

Orbital Venography in Parasellar Lesions

Five cases of various parasellar lesions ; unclassified malignant tumor, neurofibroma, microglioma, granuloma and metastatic carcinoma from the lung, were determined by orbital venography while the plane skull X-ray, tomogram and carotid angiogram failed to demonstrate and lesions. The technique was described and the usefullness discussed along with a review of literature. It is emphasized the orbital venogram seemed to valuable not only for the determination of the extent of the lesions but also as a good surgical guide to the region where the anatomical complexity can easily confuse the surgeon.

Microsurgical Transsphenoidal Approach for Pituitary Denomas

3 cases of pituitary adenomas, two hormone-secreting adenomas, and one non-secreting chromophobe adenoma, were treated surgically by the sublabial transsphenoidal approach with use of surgical microscope and radiofluroscopic image intensification at the Dept. of Neurosurgery, Yonsei University Medical College. The 2 cases of hormone secreting adenomas were an eosinophilic microadenoma manifestating gigantism and a prolaction secreting adenoma with amenorrhea and galactorrhea. The simplicity of this technique, criteria for the treatment of the hormone secreting and non-secreting adenomas and their biologic behaviors were described and discussed with review of literatures.

Microsurgical Transsphenoidal Approach for Pituitary Denomas

3 cases of pituitary adenomas, two hormone-secreting adenomas, and one non-secreting chromophobe adenoma, were treated surgically by the sublabial transsphenoidal approach with use of surgical microscope and radiofluroscopic image intensification at the Dept. of Neurosurgery, Yonsei University Medical College. The 2 cases of hormone secreting adenomas were an eosinophilic microadenoma manifestating gigantism and a prolaction secreting adenoma with amenorrhea and galactorrhea. The simplicity of this technique, criteria for the treatment of the hormone secreting and non-secreting adenomas and their biologic behaviors were described and discussed with review of literatures.

Spinal Cysticercosis Minicking Lumbar Disc Herniation

Two cases of lumbar subarachnoid cysticercosis were surgically treated. Both of them developed low back pain and radiating pain in one or both legs. The diagnostic myelogram for lumbar disc herniation showed a movable oval cyst-like filling defect in the lumbar subarachnoid space in one case, and multiple fixed round filling defects in the other. The cystic lesions were successfully removed through laminectomy. In one case, as the cyst was movable, a radiofluoroscopic image intensifier was of considerable assistance. Following surgery the patients' symptoms cleared up and the pathological specimens revealed cysticerci cellurosae.

Spinal Cysticercosis Minicking Lumbar Disc Herniation

Two cases of lumbar subarachnoid cysticercosis were surgically treated. Both of them developed low back pain and radiating pain in one or both legs. The diagnostic myelogram for lumbar disc herniation showed a movable oval cyst-like filling defect in the lumbar subarachnoid space in one case, and multiple fixed round filling defects in the other. The cystic lesions were successfully removed through laminectomy. In one case, as the cyst was movable, a radiofluoroscopic image intensifier was of considerable assistance. Following surgery the patients' symptoms cleared up and the pathological specimens revealed cysticerci cellurosae.

Trigeminal Neurinomas: Report of 2 Cases

No abstract available.

On the Surgical Treatment of Ruptured Intracranial Aneurysms with Deliberate Hypotensive Anesthesia

13 cases of intracranial Aneurysm were obliterated intracranially with Heifetz clip under Halothane /O2 Deliberate Hypotensive anesthesia. Deliberate hypotension in the surgery of intracranial aneurysm is used to diminish bleeding and render an aneurysmal sac slack to make clipping easy. Herein is presented a review of clinical experience of deliberate hypotension in conjunction with postural drainage. Clinical investigation has shown that this method offers a wider margin of safety. All factors stressed again the needs for careful, adequate and ideal clippage of the neck of aneurysm preferably with the use of Heifetz clip. Deliberate hypotension and adequate clippage of the neck of aneurysm subsequently allowed a favorable clinical result with an operative mortality by 7.7%.

A Case of Trigeminal Neuralgia Treated with Percutaneous Radiofrequency Lesions

The radiofrequency has been used for percutaneous cordotomy in patient having intractable pain. Recently the use of this radiofrequency has been extended to include other neurosurgical procedures, which in the past were done with chemical agents or mechanical methods etc. We treated one case of trigeminal neuralgia with the radiofrequency. The gasserian ganglion was punctured through the foramen ovale using a modified Hartel technique and the radiofrequency lesion was made in the second and third branches of the right trigeminal nerve selectively. The postoperative result was satisfactory. We reviewed the literature and described the technical procedures and complications.

A Clinical Experience of Induced Hypotension for Intracranial Aneurysm Surgery / 대한마취과학회지

Deliberate hypotension in the surgery of intracranial aneurysm's used to diminish bleeding and render an aneurysmal sac slack to make clipping easy. It has been reported by Murtagh (1960) and Schettini et al. (1967) that deliberate hypotension induced with halothane anesthesia is a useful method. We are reporting clinical experience of halothane induced hypotension in 13 cases of intracranial aneurysm surgery. The results of clinical observation were as follows: 1. On the average, the systolic blood pressure lay between 60 and 80 mmHg. Hypctension by halothane was readily controllable by increasing and decreasing the inspired concentration of halothane. The use of vasopressors was not necessary to raise the blood pressure. Recovery from anesthesia was rapid. The mean of Mean Arterial Blood Pressure of 13 cases was 56.077 mmHg during the .hypotensive phase. The rate of fall of the mean arterial blood pressure was 1.862 mmHg per minute. 2. The common EKG finding was bradycardia associated with hypotension, but the pulse rate increased by raising the blood pressure. 3. The serum electrolytes, Na, K, Cl, and CO₂ combining power, checked in the pre and posto-perative period, showed no significant change. 4. Arterial blood gas study showed increased values for PaCO₂ and oxygen saturation during the hypotensive phase. The PaCO₂ was slightly lowered during hypotension. The pH was within normal limits. 5. The Hb and Hct, checked pre and postop ratively, showed lowered values in the postopertive period. During surgical clipping of the aneurysm, there were two cases of aneurysmal rupture, requiring blood transfusion; the amount of whole blood transfused was 500 ml to 1, 000 ml. 6. Urinary excretion, observed during hypoension, showed a decreased urine output at a systolic blood pressure of about 70 mmHg. 7. Postoperatively there was one death at the end of second week and the cause was thought to be cerebral infarction, not directly relnted to anesthesia.

Angiographic Pattern of Space Occupying Lesions in the Anterior Cranial Fossa

Although reports have been assessed to locate lesions in the frontal lobe or anterior cranial fossa, the exact localization of the lesion is invariably difficult in neurological examination. However angiographic pattern is one of the most significant clue to the diagnosis of this area. For the past 2 years, from may in 1968 to December in 1970, we have analyzed angiographic patterns of space occupying lesion in the frontal lobe and anterior cranial fossa in a total of subsequent 100 cases. It is suggested that these lesions be classified into four groups according to their characteristic patterns and, for accurate localization and practical feasibility, their surgical approach. The characteristic angiographic patterns of each group are summarized as follows: (Frontal-pole) A-P view: 1. Round shift of A.C.A. 2. Flattening of carotid fork. 3. Elongation of AI. 4. No chekrein effect. 5. Sylvian point & M.C.A.... normal / (Fronto-central) A-P view: 1. Round shift of A.C.A.-mild. 2. Checkrein effect. 3. Depression of M1. 4. Flattening or mushroom appearance of carotid-fork. 5. Sylvian point... normal. / Lateral view: 1. Posterior displacement of A.C.A. 2. Vertical stretching of A2-A3. 3. Stretching of frontopolar artery. 4. Downward displacement of M2. 5. Depression of candelabra artery. 6. Closing of carotid siphon. 7. Ophthalmic artery... normal. / Lateral view: 1. Rectangular erection of C1-M1. 2. Right angle of C1-C2. 3. Elevation of M2-M3. 4. P.C.A. & ant. Choroidal artery... better. / (Fronto-lateral) A-P view: 1. Round shift of A.C.A. 2. Infrequent checkrein effect. 3. Flattering of carotid fork. 4. Vertical stretching of C1. 5. Sylvian point... normal. / Lateral view: 1. Mild stretching of A2-A3. 2. Continuous line of C2-M2. 3. Depression of M2. 4. Stretching of candelabra artery. / (Fronto-basal) A. subfrontal; A-P view: 1. Round or angular shift of A.C.A. 2. Flattening of carotid bifurcation. 3. No checkrein effect. 4. Sylvian point... normal. / Lateral view: 1. Bowing and downward convexity of A.C.A. 2. Closing of carotid siphon. 3. Depression of sylvian artery group. 4. Enlargement of ophthalmic artery. B. Inferior frontal; A-P view and lateral view: 1. Same as subfrontal lesions. 2. Relative preservation of A.C.A. branches. 3. Enlarged ophthalmic artery... mild. 4. Depression or elevation of M2.

A Case of Ependymoblastoma

We have seen a primitive glioma which can be regarded as ependymoblastoma arising at the left frontal lobe of four-year-old boy. He has complained of excitement, hyperesthesia, mild incomplete paralysis of the left lower extremity for 1 1/2 months, and also incontinence of urine and stool was complained. The signs of increased intracranial pressure such as papilledema and separation of suture line were noted. Brain scanning showed tumor mass at the left frontal lobe, and which was revealed to be vascular tumor on carotid angiogram and delta wave was found at those area by electroencephalogram. Operative findings were that the tumor was hemorrhagic vascular mass showing partly cystic and necrotic in appearance, not bulged above outer surface and not connected with ventricle. The tumor mass measured 6x5x4cm which cut surface was pinkish white and focal necrotic areas were also seen. On microscopic examination the tumor was composed of relatively uniform primitive glial cells and the tumor cells arranged in perivascular area forming multiple layers while other region showed well formed tubules. Fibrillated cytoplasmic process between central vessel and glial cells that could be seen in matured ependymoma was not identified.

Spinal Paragonimiasis

Spinal paragonimiasis is an uncommon ectopic manifestation of the lung fluke. In this paper eight cases of spinal paragonimiasis treated in the Severance Hospital are reported and the literature is reviewed. Differantial diagnosis is usually difficult because of the similarity of symptoms and signs with benign spinal cord tumors. positive chest X-ray findings, positive skin test and pleocytosis of the spinal fluid, especially of eosinsphils, are valuable findings in the diagnosis. The extradural space in the 1ower thoracic region is the most frequently affected area. Laminectomy with excision of the lesion supported by chemotherapy is the treatment of choice. When treated early, prognosis of this type of manfestation is usually favorable.