A Rare Case of Pituicytoma Presenting Cystic Formation

Pituicytoma is a rare solid benign tumor of the sellar and/or suprasellar region originating from the pituicytes of the neurohypophysis or infundibulum, which is not differentiated from a pituitary adenoma that is diagnosed mostly in the sellar and/or suprasellar region. In addition, cystic tumors are very rare and have not been reported due to their solid and hypervascular natures. A 33-year-old man presented with a chronic headache which exacerbated recently. MRI was performed and revealed a cystic tumor in the sellar and suprasellar regions with a small parenchymal island in the cyst compressing the optic chiasm. The endoscopic endonasal transsphenoidal approach was used to remove the tumor. Immunohistochemical staining was positive for thyroid transcription factor 1, S-100 protein, and glial fibrillary acidic protein. The pituicytoma was diagnosed based on histologic findings. The authors review herein the literature on clinical presentation, diagnosis, surgical management, and outcome.

Time Course and Characteristics of Astrocyte Activation in the Rat Brain after Injury / 대한신경손상학회지

OBJECTIVE: After injury to the central nervous system (CNS), glial scar tissue is formed in the process of wound healing. This can be is a clinical problem because it interferes with axonal regeneration and functional recovery. It is known that intracellular proteins, including the glial fibrillary acidic protein (GFAP), nestin, and vimentin increase in the astrocytes after an injury to the CNS. By studying the time course and co-expression pattern of these intracellular proteins, this study will attempt to prove that these proteins are involved in the processes of glial scar formation. METHODS: Twenty-five male Sprague-Dawley rats were used in this study. Bregma of the cerebral cortex, an area was incised with a sharp blade, and perfusion was performed. The expressions of the intracellular proteins were assayed, while the co-localization of the intermediate filament (GFAP, nestin, and vimentin) and A2B5 were examined. RESULTS: At 12 hours, the GFAP was expressed in the white matter underlying the lesion, and in the cerebral cortex. Nestin was expressed in the astrocytes in the perilesional area after 3 days, while A2B5 was observed in the edge of the wound at 12 hours post-injury, with its expression reaching a peak at 7 days. Vimentin was detected in the white matter at 12 hours, and in the cortex, reaching a peak at 7 days. CONCLUSION: In the processes of glial scar formation, nestin, vimentin, and A2B5 were revealed in the astrocytes, and these factors may be involved in the division, proliferation, and transportation of the astrocytes.

Spontaneous Spinal Epidural Hematoma on the Ventral Portion of Whole Spinal Canal: A Case Report

Spontaneous spinal epidural hematoma is an uncommon but disabling disease. This paper reports a case of spontaneous spinal epidural hematoma and treatment by surgical management. A 32-year-old male presented with a 30-minute history of sudden headache, back pain, chest pain, and progressive quadriplegia. Whole-spinal sagittal magnetic resonance imaging (MRI) revealed spinal epidural hematoma on the ventral portion of the spinal canal. Total laminectomy from T5 to T7 was performed, and hematoma located at the ventral portion of the spinal cord was evacuated. Epidural drainages were inserted in the upper and lower epidural spaces. The patient improved sufficiently to ambulate, and paresthesia was fully recovered. Spontaneous spinal epidural hematoma should be considered when patients present symptoms of spinal cord compression after sudden back pain or chest pain. To prevent permanent neurologic deficits, early and correct diagnosis with timely surgical management is necessary.

Nail Gun Induced Open Head Injury: A Case Report / 대한신경손상학회지

Increasing use of the nail gun has led to higher injury rates from the use of tools with sequential actuation. Nail gun injury can occur to various parts of the body. Very deep penetration in the brain can have fatal results. A 46-year-old male fired shots from a nail gun into his brain in a suicide attempt. This case demonstrated successful surgical management of the resultant open head injury.

Endovascular Treatment of Wide-necked Cerebral Aneurysms with an Acute Angle Branch Incorporated into the Sac: Novel methods of Branch Access in 8 Aneurysms / 신경중재치료의학

PURPOSE: The optimal management of geometrically complex aneurysms remains challenging. The aim of this retrospective study was to evaluate the safety and feasibility of branch-selective technique (BT) in wide-necked aneurysms with an acute angle branch incorporated into the sac. MATERIALS AND METHODS: Eight consecutive patients harboring wide-necked cerebral aneurysms with an incorporated, acute angle branch (mean, 30.4degrees) underwent coiling over an 18-month period. Dome-to-neck ratio ranged from 0.9 to 1.8 (mean, 1.2). Every procedure utilized BT, i.e., stent- or catheter-assisted coiling through the incorporated branch. RESULTS: Technical success was achieved in all cases. With the aim to avoid the risk of aneurysmal rupture during struggling intraaneurysmal wire navigation, a 'looping method' and retrograde approach of a preshaped 0.014' microcatheter (C or J) was used for branch access in five cases and a 'looping method' and antegrade approach in one case. In the remaining one, just the C-preshape was enough to directly enter the branch without intraaneurysmal wire navigation. Overall, stent-assisted coiling was performed in seven cases, while catheter-assisted coiling was undertaken in one. The only complication was thrombotic posterior inferior cerebellar artery occlusion in one case, which was recanalized after tirofiban infusion. New neurological deficits were not identified in any cases. CONCLUSION: BT seems safe and feasible for wide-necked aneurysms with an acute angle branch incorporated into the sac. The looping method may offer safe access to the incorporated, acute angle branch and should be considered for replacement of the fearful intra-aneurysmal wire navigation.

A Comparative Result of Ventriculoperitoneal Shunt, Focusing Mainly on Gravity-Assisted Valve and Programmable Valve

OBJECTIVE: Despite rapid evolution of shunt devices, the complication rates remain high. The most common causes are turning from obstruction, infection, and overdrainage into mainly underdrainage. We investigated the incidence of complications in a consecutive series of hydrocephalic patients. METHODS: From January 2002 to December 2009, 111 patients underwent ventriculoperitoneal (VP) shunting at our hospital. We documented shunt failures and complications according to valve type, primary disease, and number of revisions. RESULTS: Overall shunt survival time was 268 weeks. Mean survival time of gravity-assisted valve (GAV) was 222 weeks versus 286 weeks for other shunts. Survival time of programmable valves (264 weeks) was longer than that of pressure-controlled valves (186 weeks). The most common cause for shunt revision was underdrainage (13 valves). The revision rate due to underdrainage in patients with GAV (7 of 10 patients) was higher than that for other valve types. Of 7 patients requiring revision for GAV underdrainage, 6 patients were bedridden. The overall infection rate was 3.6%, which was lower than reported series. Seven patients demonstrating overdrainage had cranial defects when operations were performed (41%), and overdrainage was improved in 5 patients after cranioplasty. CONCLUSION: Although none of the differences was statistically significant, some of the observations were especially notable. If a candidate for VP shunting is bedridden, GAV may not be indicated because it could lead to underdrainage. Careful procedure and perioperative management can reduce infection rate. Cranioplasty performed prior to VP shunting may be beneficial.

Spinal Epidural Metastasis of Cerebral Oligodendroglioma

A 50-year-old male patient with right frontal oligodendroglioma underwent subtotal resection on three separate occasions and, 10 months later, exhibited right frontal oligodendroglioma and extracranial metastasis. Spinal magnetic resonance imaging (MRI) demonstrated the existence of an enhancing mass lesion with evidence of posterior epidural compression at the10th-11th thoracic level, not involving the vertebrae. A bone scan of the spine appeared normal, but showed evidence of hot uptake in the pelvis and femur. This report concerns a patient who developed a fatal and clinically unexplained, pancytopenia 3 months after the removal of a spinal epidural oligodendroglioma. Oligodendroglioma with metastasis outside the central nervous system is extremely rare, and only a few cases have previously been reported. A brief review of the literature with an emphasis on the mechanisms of tumor cell dissemination is presented.

Effects of MgSO4 on Cerebral Infarction after Permanent Middle Cerebral Artery Occlusion in Rat

OBJECTIVE: This study is aimed to prove the neuroprotective effect of magnesium ion, which is known to have competitive action against calcium influx in the process of neuronal damage. METHODS: One hundred twenty five male Sprague-Dawley rats weighing 300-350gm were divided into control and MgSO4 injected groups. Middle cerebral artery occlusion was induced by nylon insertion near internal carotid artery bifurcation via external carotid artery. Forty rats which were alive for 48 hours after the induction of cerebral infarction were drawn from each group. Thirty minutes after the induction of cerebral infarction, 750mumol/Kg of MgSO4 was intramuscullary injected for the experimental group and same amount of normal saline was injected for the control group. Each group was subdivided into groups of 20 rats 48 hours after the cerebral infarction. Brain-sections of a subgroup were obtained after transcardially perfusion of 2% 2', 3', 5'-triphenyl-tetrazolium chloride and infarction volume was measured using imaging analysis program. Brain-sections of the other subgroup were stained with terminal deoxynucleotidyl-transferase-mediated biotin dUTP nick end labeling(TUNEL) and apoptotic index(AI) was estimated. RESULTS: The volume of cerebral infarction of the control and MgSO4 injected groups were 52.44+/-5.68% and 38.38+/-9.02% respectively, and the infarction volume was significantly reduced in MgSO4 injected group(p<0.001). Brain edema volume were 209.01+/-75.41mm3 in control group and 140.7+/-81.89mm3 in MgSO4 injected group that was a significant reduction in MgSO4 injected group(p<0.001). AI of 53.68+/-6.38 for control group and 29.80+/-6.77 for MgSO4 injected group were estimated and MgSO4 injected groups showed a significant reduction(p<0.001). CONCLUSION: Magnesium ion has neuroprotective effect in reduction of cerebral infarction volume, brain edema volume and AI. In the future, various attempts to prove protecting mechanism of magnesium ion should be made and TUNEL stain is thought to be an effective comparison method in such studies.

Correlation between Activity of Nitric Oxide Synthases and Apoptotic Change in the Closed Head Injury Animal Model

OBJECTIVE: The authors present an investigation of alterations in nitric oxide synthase(NOS) activity and histopathological response after moderate diffuse axonal injury(mDAI). METHODS: A total of 40 anesthetized Sprague-Dawley adult rats were injured utilizing the Marmarou's weight-drop device through a Plexiglas guide tube. These rats were divided into 8 groups(control, 1 hr, 2 hr, 3 hr, 6 hr, 12 hr, 24 hr, 48 hr after trauma). The temporal pattern of apoptosis after mDAI in the adult rat brain was characterized using TUNEL stain and cDNA for NOS activity was amplified using RT-PCR. The PCR products were electrophoresed on a 2% agarose gel and then observed under a UV-transilluminator. The enhanced chemiluminescence method(Pierce, Rockford, IL) was used to visualize the protein bands, and the quantification was performed by using the image analysis soft-ware Bio-1D. RESULTS: eNOS activity was not detected at all groups, but nNOS activity was expressed at 3 hr and continuously by 48 hr after impact , which was especially showed about 2 times larger than control group at 12 and 24 hr(mean value=28314+/-35.07 in injury group, 13386+/-26.14 in control group, p<0.05), followed by being on the decrease at 48 hr. iNOS activity was showed fivetmes larger than control group at 12 hr and 24 hr(mean value=15264+/-38.37 in injury group, 3002+/-31.62 in control group, p<0.05) followed by dramatically decrease below the level of control group(2299+/-14.06). Histologically, significant apoptotic changes after brain injury were occurred from 12 to 24 hr post-injury(AI=24.8%, 27.5%, p<0.001). CONCLUSION: These data indicate that nNOS and iNOS activity are affected after mDAI in a time-dependent manner and there is a close relation between apoptotic changes and NOS activity. nNOS activity is not stronger than iNOS, which lately expressed. However, iNOS activity is markedly reduced by 48 hr compared to nNOS.

Diagnostic Agreement between Magnetic Resonance Image and Computed Tomography in Degenerative Cervical Diseases

OBJECTIVE: This study is aimed to estimate the equality of two diagnostic modalities of computed tomography(CT) and magnetic resonance image in herniated intervertebral disc and other degenerative cervical diseases. METHODS: Retrospective study was carried out on 37 patients who have undergone surgery for degenerative cervical diseases from December 1996 to February 2001. Mean age was 49.7 years. Twenty eight patients were male(mean age : 48.4 years) and 9 patients female(mean age : 53.7 years). Magnetic resonance image and CT of the patients were evaluated blindly about 5 items as bony spur, existence of ossification of posterior longitudinal ligament(OPLL), intradiscal calcification, herniated intervertebral disc and spinal stenosis. RESULTS: While comparing radiologic results, bony spur was found in CT of 25 patients and magnetic resonance image of 20 patients, OPLL was seen in CT of six and magnetic resonance image of four and herniated intervertebral disc was seen in CT of 32 patients and MRI of 33 patients. These three diagnosis were considered to be concordant between CT and magnetic resonance image(p<0.01). Intradiscal calcification was seen in CT of 6 patients and magnetic resonance imge of one patient that the diagnosis was not considered statistically concordant(p=0.023). Although spinal stenosis was positive in CT of 16 patients and magnetic resonance image of 13 patients, diagnostic concordance could not be stated(p=0.345). CONCLUSION: Bony spur, OPLL and the herniated intervertebral disc may be diagnosed by any of the radiologic method because both magnetic resonance image and CT have shown statistically significant diagnostic concordance. Since intradiscal calcification and spinal stenosis have not shown diagnostic concordance, it is thought that either diagnostic method alone may not be sufficient confirmative diagnosis.

A New Scale(NS) Score System to Predict Outcome of Intracranial Aneurysm Using TCD

OBJECTIVE: By conducing a review of clinical outcomes for patients with aneurysm treated using current microneurosurgical techniques and intensive care unit management, we speculated that grading systems based only on clinical condition or CT finding after admission failed to provide a significant stratification of outcome between individual grades of patients, because these systems did not include the factor for postoperative vasospasm. We hypothesized that postoperative blood flow velocity could have a significant impact on outcome prediction for patients surgically treated for intracranial aneurysms. METHODS: We conducted a analysis on patient- and lesion-specific factors that might have been associated with outcome in a series of 55 aneurysm operations performed with measurements of blood-flow velocity with transcranial Doppler ultrasonography(TCD). In the new scale(NS) score system, 1 point is assigned additionally for the case with Hunt and Hess(H-H)/World Federation of Neurological Surgeons(WFNS) Grade IV or V, Fisher Scale(FS) score 3 or 4, aneurysm size greater than 10mm, patient age older than 60 years, blood-flow velocity higher than 120cm/sec, and posterior circulation lesion. By adding the total points, a 6-point scale score(score 0-6) is obtained. RESULTS: Age of patient, size of aneurysm, clinical condition(H-H grade and WFNS), FS score, and blood flow velocity(TCD 1day after operation) were independently and strongly associated with long-term outcome. When NS scores were applied to 55 patients with at least 6 months follow-up, the correlation of individual scores with outcome was strongly validated the retrospective findings. CONCLUSION: It was speculated that TCD could be used to assess postoperative vasospasm and to monitor noninvasively the patients with aneurysmal SAH. This NS score system is easy to apply, divide patients into groups with different outcome, and is comprehensive, allowing for more accurate prediction of surgical outcome.

Multiple Hemangioblastomas on Cerebellum and Spinal Cord in a Patient of Von Hippel-Lindau Disease

Hemangioblastomas are rare benign tumor of the central nervous system that commonly occur in the posterior fossa around the 4th ventricle. In case of von Hippel-Lindau disease, hemangioblastomas involve multiple regions such as cerebellum, spinal cord and brainstem but, rarely show simultaneous involvement of cerebellum and spinal cord. We have experienced a case of multiple hemangioblastomas that were located at the cerebellum, cervical cord and conus medullaris and also had multiple lesions that a part of von Hippel-Lindau disease;retinal angioma, syringomyelia, multiple cyst on kidney and pancreas, renal cell carcinoma on left kidney. Hemangioblastomas on cerebellum and spinal cord were removed totally, retinal angioma was treated with laser photocoagulation and renal cell carcinoma was also totally excised. The authors report a case of von Hippel-Lindau disease had multiple located hemangioblastomas on cerebellum, cervical cord and conus medullaris with review of literature.

A Clinical Analysis of Pediatric Head Injuries

OBJECTIVES: With the advancement of a social life, the pediatric head injuries(PHI) occur greater than ever. Since the PHI differs from adult head injury with regards to mechanism of trauma, prognosis, and mortality, it is important to identify the characteristics of the PHI for its proper treatments and prognosis. METHODS: For this study, a series of 365 PHI patients under 15 years of age who were admitted to our hospital, were evaluated from January 1991 to December 1996. The clinical variable studied were age, sex, Glasgow coma score(GCS), causes of trauma, diagnosis, symptoms, associated injuries and Glasgow outcome score (GOS). The characteristics of PHI were evaluated according to presentations of skull fractures, intracranial hemorrhages, associated injuries, GCS at admission and GOS. RESULTS: Mean age of the studied patients was 6.51 years of age. The majority of PHI patients were under the 7 years of age(66.7%). The ratio of male to female was 2.2:1. Seasonally, PHI occurred more frequently during March to August(61.6%). The main causes of the injuries were accidental falls and traffic accidents(47.1% and 46.3%). One hundred ninety seven(54%) patients suffered from skull fractures and 110(30.1%) patients were developed intracranial hemorrhages and acute epidural hematomas(17.8%) which were the most common intracranial hemorrhages. There was statistical significance between skull fractures and intracranial hemorrhage (p=0.032) and between GCS and GOS(p=0.001). However, there was no statistical significance between skull fractures and intracranial hemorrhage(epidural hematomas, subdural hematomas, and intracerebral, intraventricular and subarachnoid hemorrhage)(p=0.061, 0.251 and 0.880). Also there were no significance of prognosis between under the seven and over the 8 years of age(p=0.349). CONCLUSIONS: The core management for PHI is prevention from its occurrences. However, when unexpected accident occurs, early diagnosis and treatment for PHI by through examination for associated injuries and other damages even if there is no skull fracture are essential in managing patient's outcome.

Hunt-Hess and Fisher Grades as Predicting Factors for Chronic Hydrocephalus in Surgically Treated Ruptured Aneurysm

OBJECTIVE: The popular grading systems in use, such as Hunt-Hess grade and Fisher scale score, are based primarily on the patient's clinical conditions or computerized tomography score after aneurysmal subarachnoid hemorrhage(SAH). The author investigated whether the need for ventriculoperitoneal(VP) shunt for chronic hydrocephalus and outcome can be predicted by Hunt-Hess grade and Fisher scale. METHODS: A series of 146 patients admitted to our hospital from August 1991 to July 1999, who presented with SAH and underwent craniotomy for aneurysm clipping were studied retrospectively. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after initial hemorrhage which required shunting. Patients were evaluated based on following factors: Hunt-Hess grade, Fisher scale, age, sex, hypertension, aneurysm location, and intervals from aneurysm rupture to operation. RESULTS: The overall mortality rate of the study group was 8.2%. Hunt-Hess grade(p=0.001) or Fisher scale (p=0.001) at all pretreatment times was significantly correlated with outcome. In addition, there was an increased risk of poor outcome in older age(650.05). Of 134 surviving patients, 16 patients(12%) underwent VP shunt placement secondary to chronic hydrocephalus. Hunt-Hess grade(p=0.001) is more predictive of chronic hydrocephalus than Fisher scale(p=0.146). Aneurysm location was significantly correlated with development of chronic hydrocephalus (p<0.05), without significant correlations in sex, age, hypertension. IVH, and ICH. CONCLUSION: This study suggests that there is a high clinical correlation between outcome and Hunt-Hess grades and Fisher scales on admission, but Hunt-Hess grade is more predictive for chronic hydrocephalus than Fisher scale. In addition, age(<65 yrs) is the significant factor for prediction of outcome. There was a trend of increasing risk for chronic hydrocephalus according to aneurymal location.

Cerebral Arteriovenous Malformation Associated with Intracranial Meningioma and Aneurysm: Case Report

The cerebral arteriovenous malformation(AVM) rarely coexists with primary intracranial tumor. The authors experienced a patient with intracerebral hematoma due to AVM rupture in whom intracranial meningioma and intracranial aneurysms coexisted. The meningioma was located at convexity of right frontal lobe, and arteriovenous malformation at temporo-occipital lobe of same hemisphere with feeding from right middle cerebral artery, and three intracranial aneurysms exist at the cavernous portion of right internal carotid artery, AVM feeding artery, and intranidal of the AVM. The authors report a rare case of coexisted intracranial AVM, meningioma and aneurysms with review of literatures.

Change of the Intervertebral Foraminal Pressure after Removal of the Disc Material

OBJECTIVES: Spinal nerve root compression occurs commonly in conditions, such as herniated nucleus pulposus, spinal stenosis, intervertebral foraminal stenosis, and trauma. However, the pathophysiolosy of the symptoms and signs related to spinal nerve root compression is poorly understood. The purpose of the present study was to assess and compare the changes of various pressures of intervertebral foraminal pressure before and after decompression. METHOD: After laminetomy without foraminotomy was performed, pressure sensor tip of Camino parenchymal type was located at the middle-central portion of the intervertebral foramen and anterior portion of nerve root for the foraminal pressure before decompression of the intervertebral foramen. After laminectomy with foraminotomy, the same method was used for the foraminal pressure after decompression. The authors studied 40 consecutive patients (57 disc spaces) with severe constant root pain to the lower leg, pain unrelived by bed rest, and minimal tension signs, diagnosed by MRI. RESULTS: In patients with intervertebral foraminal stenosis, the intraforaminal pressure was decreased from 86+/-2.23mmHg to 17.1+/-1.51mmHg and in patients without stenosis, from 55.9+/-1.08mmHg to 11.9+/-1.25mmHg. All patients below 20mmHg after decompression showed good outcome, but 4 cases who showed poor outcome had foraminal stenosis, posterolateral type of the herniated disc, and above 30mmHg of foraminal pressure after decompression. CONCLUSION: These findings suggest that if the foraminal pressure falls below 20mmHg after decompression, good outcome can be anticipated. Central type of the herniated disc shows better outcome compared to the posterolateral type.

A Case of Aneurysmal Bone Cyst on the Thoracic Spine: A Case Report

No abstract available.

Effects of Posttraumatic Hypothermia in an Animal Model of Traumatic Brain Injury(TBI): Immunohistochemical Stain by TUNEL & beta-APP

No abstract available.

Traumatic Spinal Subdural Hematoma : Value of MRI(Fat Suppression Technique) and Spinal Puncture : 2 Cases Report

No abstract available.

Effects of Posttraumatic MgSO4 Injection and Hypothermia an Animal Model of Traumatic Brain Injury(TBI)

No abstract available.