Association Factors for CT Angiography Spot Sign and Hematoma Growth in Korean Patients with Acute Spontaneous Intracerebral Hemorrhage : A Single-Center Cohort Study

OBJECTIVE: This study was conducted to clarify the association factors and clinical significance of the CT angiography (CTA) spot sign and hematoma growth in Korean patients with acute intracerebral hemorrhage (ICH). METHODS: We retrospectively collected the data of 287 consecutive patients presenting with acute ICH who arrived within 12 hours of ictus. Baseline clinical and radiological characteristics as well as the mortality rate within one month were assessed. A binary logistic regression was conducted to obtain association factors for the CTA spot sign and hematoma growth. RESULTS: We identified a CTA spot sign in 40 patients (13.9%) and hematoma growth in 78 patients (27.2%). An elapsed time to CT scan of less than 3 hours (OR, 5.14; 95% CI, 1.76-15.02; p=0.003) was associated with the spot sign. A CTA spot sign (OR, 5.70; 95% CI, 2.70-12.01; p40 IU (OR, 2.01; 95% CI, 1.01-4.01; p=0.047), and an international normalized ratio > or =1.8 or warfarin medication (OR, 5.64; 95% CI, 1.29-24.57; p=0.021) were independent predictors for hematoma growth. Antiplatelet agent medication (OR, 4.92; 95% CI, 1.31-18.50; p=0.019) was significantly associated with hematoma growth within 6 hours of ictus. CONCLUSION: As previous other populations, CTA spot sign was a strong predictor for hematoma growth especially in hyper-acute stage of ICH in Korea. Antithrombotics medication might also be associated with hyper-acute hematoma growth. In our population, elevated GPT was newly identified as a predictor for hematoma growth and its effect for hematoma growth is necessary to be confirmed through a further research.

The Quality of Life of Patients with Good Outcomes after Anterior Circulation Aneurysm Surgery Assessed by the World Health Organization Quality of Life Instrument-Korean Version

OBJECTIVE: Even in the patients with neurologically good outcome after intracranial aneurysm surgery, their perception of health is an important outcome issue. This study aimed to investigate the quality of life (QOL) and its predictors of patients who had a good outcome following anterior circulation aneurysm surgery as using the World Health Organization Quality of Life instrument-Korean version. METHODS: We treated 280 patients with 290 intracranial aneurysms for 2 years. This questionnaire was taken and validated by 99 patients whose Glasgow Outcome Scale score was 4 and more and Global deterioration scale 3 and less at 6 months after the operation, and 85 normal persons. Each domain and facet was compared between the two groups, and a subgroup analysis was performed on the QOL values and hospital expenses of the aneurysm patients according to the type of craniotomy, approach, bleeding of the aneurysm and brain injury. RESULTS: Aneurysm patients showed a lower quality of life compared with control patients in level of independence, psychological, environmental, and spiritual domains. In the environmental domain, there were significant intergroup differences according to the type of craniotomy and the surgical approach used on the patients (p<0.05). The hospital charges were also significantly different according to the type of craniotomy (p<0.05). CONCLUSION: Despite good neurological status, patients surgically treated for anterior circulation aneurysm have a low quality of life. The craniotomy size may affect the QOL of patients who underwent an anterior circulation aneurysm surgery and exhibited a good outcome.

Bilateral Locked Facets at Lower Lumbar Spine Without Facet Fracture: A Case Report

Bilateral locked facets at L4-5 without facet fracture is a rarely known disease. We present a case of a 37-year-old male patient diagnosed as traumatic L4-5 bilateral facets dislocation without facet fracture. We carried out open reduction, epidural hematoma removal, posterior interbody fusion. After surgery, we attained rapid improvement of the neurologic deficits and competent stabilization.

Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy

OBJECTIVE: The predictors of cranioplasty infection after decompressive craniectomy have not yet been fully characterized. The objective of the current study was to compare the long-term incidences of surgical site infection according to the graft material and cranioplasty timing after craniectomy, and to determine the associated factors of cranioplasty infection. METHODS: A retrospective cohort study was conducted to assess graft infection in patients who underwent cranioplasty after decompressive craniectomy between 2001 and 2011 at a single-center. From a total of 197 eligible patients, 131 patients undergoing 134 cranioplasties were assessed for event-free survival according to graft material and cranioplasty timing after craniectomy. Kaplan-Meier survival analysis and Cox regression methods were employed, with cranioplasty infection identified as the primary outcome. Secondary outcomes were also evaluated, including autogenous bone resorption, epidural hematoma, subdural hematoma and brain contusion. RESULTS: The median follow-up duration was 454 days (range 10 to 3900 days), during which 14 (10.7%) patients suffered cranioplasty infection. There was no significant difference between the two groups for event-free survival rate for cranioplasty infection with either a cryopreserved or artificial bone graft (p=0.074). Intergroup differences according to cranioplasty time after craniectomy were also not observed (p=0.083). Poor neurologic outcome at cranioplasty significantly affected the development of cranioplasty infection (hazard ratio 5.203, 95% CI 1.075 to 25.193, p=0.04). CONCLUSION: Neurologic status may influence cranioplasty infection after decompressive craniectomy. A further prospective study about predictors of cranioplasty infection including graft material and cranioplasty timing is necessary.

Analysis of Incomplete Occlusion of Cerebral Aneurysm by Intraoperative Indocyanine Green Videoangiography / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to investigate factors associated with incomplete occlusion of a cerebral aneurysm detected by indocyanine green videonangiography (ICG-VA) following aneurysm clipping. METHODS: We performed surgery on 135 patients with 151 intracranial aneurysms over a 1-year period. Included was an aneurysm more than 3 mm in size, the dome of which was sufficiently exposed and clipped permanently with one clip. Following ICG-VA, aneurysms were divided into a delayed-filling group and a no-filling group. Retrospective comparisons of the clip force, blade length and width, neck and dome size of the aneurysm, diameter of the parent artery, presence of atherosclerosis in the aneurysm neck, and systolic blood pressure during ICG-VA were made between the two groups. RESULTS: Eight of 31 aneurysms in 29 patients showed delayed filling of contrast. The clip force in the delayed-filling group was lower than in the no-filling group and the atherosclerosis of the aneurysm neck differed between the two groups (P<0.05). Blade width in the delayed-filling group was also significantly lower than in the no-filling group (P<0.05). Following adjustment for atherosclerosis of the aneurysm neck, clip force and blade width in the delayed-filling group was even lower. Incomplete passage of the clip tip was observed in four aneurysms, weak clip force in three, and a slit between clip blades in one. After booster clipping or clip reposition, neither aneurysm regrowth nor recanalization was observed during 6 months of follow-up. CONCLUSION: Closing force, blade width, tip position, and remnant slit are important for incomplete occlusion of an aneurysm.

Cervical Disc Herniation Producing Acute Brown-Sequard Syndrome

Brown-Sequard syndrome may be the result of penetrating injury to the spine, but many other etiologies have been described. This syndrome is most commonly seen with spinal trauma and extramedullary spinal neoplasm. A herniated cervical disc has been rarely reported as a cause of this syndrome. We present a case of a 28-year-old male patient diagnosed as large C3-C4 disc herniation with spinal cord compression. He presented with left hemiparesis and diminished sensation to pain and temperature in the right side below the C4 dermatome. Microdiscectomy and anterior cervical fusion with carbon fiber cage containing a core of granulated coralline hydroxyapatite was performed. After the surgery, rapid improvement of the neurologic deficits was noticed. We present a case of cervical disc herniation producing acute Brown-Sequard syndrome with review of pertinent literature.

Endoscopic Versus Mini.open Carpal Tunnel Release in Patients with Bilateral Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to determine any differences in outcome and patient satisfaction between endoscopic release (ECTR) and open carpal tunnel release (OCTR) in patients with bilateral carpal tunnel syndrome who underwent both techniques. METHODS: Seven patients with confirmed bilateral idiopathic carpal tunnel syndrome were randomized to undergo endoscopic release using a single portal Agee technique to one hand and a minimal open release to the other. Subsequent assessments were made at 0, 3, and 12 months after operation using a modified Levin scale. We also analyzed subjective and objective outcomes retrospectively, including the time to return to full activity, patient preference, cosmetic satisfaction, scar tenderness, and pillar pain. The pain was assessed using a visual analogue scale from 1 to 10. RESULTS: Based on the Levin scale, there were no significant differences between hands at any follow-up interval. At the three-month follow up, mean scale scores were lower in the ECTR group; however, the differences did not reach statistical significance. Cosmetically, all patients were satisfied with their scar irrespective of the technique. There were no statistical differences in terms of scar tenderness and pillar pain. CONCLUSION:ECTR did not show any significant advantage over short-incision OCTR. Therefore, the operator's experience and skill in using a certain method is important, regardless of which technique is used.

Surgical Treatments for Cervical Spondylotic Myelopathy Associated with Athetoid Cerebral Palsy

OBJECTIVE: To evaluate the clinical characteristics and surgical outcomes of the patients with cervical spondylotic myelopathy associated with athetoid cerebral palsy. METHODS: The authors reviewed the clinical and neurodiagnostic findings, surgical managements and outcomes in six consecutive patients with cervical spondylotic myelopathy associated with athetoid cerebral palsy who had been treated with surgical decompression and fusion procedures between January 1999 and December 2005. The mean age of the 6 patients (four women and two men) at the time of surgery was 42.8 years (range, 31-55 years). The mean follow-up period was 56.5 months (range, 17-112 months). The neurological outcome was evaluated before and after operations (immediately, 6 months after and final follow-up) using grading systems of the walking ability, brachialgia and deltoid power. RESULTS: At immediate postoperative period, after 6 months, and at final follow-up, all patients showed apparent clinical improvements in walking ability, upper extremity pain and deltoid muscle strength. Late neurological deterioration was not seen during follow-up periods. There were no serious complications related to surgery. CONCLUSION: Surgical decompression and stabilization in patients with cervical spondylotic myelopathy associated with athetoid cerebral palsy have been challenging procedure up to now. Our results indicate that early diagnosis and appropriate surgical procedure can effectively improve the clinical symptoms and neurological function in patients with cervical spondylotic myelopathy and athetoid cerebral palsy, even in those with severe involuntary movements.

Analysis of Anterior Cerebralarteriesin Patients with Ruptured Anterior Communicating Artery Aneurysmby Computed Tomography Angiography and Digital Subtraction Angiography / 대한뇌혈관외과학회지

OBJECTIVE: Computed tomography angiography (CTA) has recently been used for detecting cerebral aneurysm because of the accuracy of the images and the large supply of high-resolution CT scanners, and there is no need to perform cerebral digital subtraction angiography (DSA) when performing CTA. In contrast with DSA, CTA is unable to show the realtime cerebral blood flow. The aim of the present study is to find an appropriate aneurysm clipping method to reduce the risk during operation, and we did this by comparing the performance of CTA for detecting ruptured cerebral aneurysm with that of DSA. METHODS: We performed a systemic review of patients suffering from ruptured anterior communicating artery aneurysm. We report here on the results obtained from November 2002 to March 2006. We reviewed a total of 37 patients who had undergone both CTA and DSA before surgery. RESULTS: With performing CTA, 15 patients (40.5%) were observed to have the same thickness of both sides of the A1 (group A); there were 2 patients with right dominance (group B), and 20 patients with left dominance (group C). The total numbers of patients with an anomalous artery was 3 (12.5%). Two of them were in Group A and one of them was in Group B. Two of them (one in Group A and the other in Group B) were accessory A2 patients and the other was an azygous A2 patient. Also, there was no difference between CTA and DSA for the patients with an abnormal artery. CONCLUSION: In the case of observing a severe hypoplastic A1 or an anomalous artery in the patients with anterior communicating artery aneurysm seen on the CTA, it is expected that checking the accurate structure and status of their aneurysm and the surrounding artery through performing DSA and also checking the contralateral carotid artery compression may help prepare the strategy for the operation and reduce the risk during operation.

A Case of Astroblastoma

An astroblastoma is a rare primary glial tumor occurring preferentially in young adults. It is characterized by a perivascular arrangement of the tumor cells forming perivascular pseudorosettes mimicking ependymomas. The histogenesis of astroblastoma is unclear, despite a number of studies to determine its possible cellular origin. We have experienced a case of astroblastoma located at the temporal lobe. It presented as a large, wellcircumscribed, and highly enhanced mass lesion on magnetic resonance images(MRI). The tumor was well demarcated and did not infiltrate the brain, which made complete removal possible. Here, we report and discuss the characteristic histological and radiological features of this case.

Diffuse Neurofibroma Presenting with Spontaneous Intra-Tumoral Hemorrhage

This report describes a case of diffuse neurofibroma(DNF) that presented with spontaneous intratumoral hemorrhage. A 31-year-old man with cutaneous manifestations typical of neurofibromatosis type 1(NF1) was referred to hospital with a progressively expanding scalp swelling. Magnetic resonance imaging(MRI) showed an acute hematoma surrounded by a dense mass on the parietooccipital scalp. Plain skull radiographs and a computed tomography(CT) scan revealed bony defects in the occipital bone around the lambdoid suture and the skull base, including the sphenoid and petrous bones. The tumor extended to the upper cervical region and infiltrated through the fascia of the musculature. The tumor and adjacent soft tissue were highly vascular, which made surgical resection difficult. We describe the clinical, radiological and pathological features of this patient and discuss the surgical methods used to avoid a life-threatening hemorrhage during surgery.

Acute Aneurysmal Subdural Hematoma: Clinical and Radiological Characteristics

OBJECTIVE: Acute spontaneous subdural hematoma(SDH) secondary to a ruptured intracranial aneurysm is a rare event. The authors present nine cases with aneurysmal SDH. METHODS: We analyzed nine cases of aneurysmal SDH from 337 patients who underwent treatment for a ruptured aneurysm between January 1998 and May 2004. Clinical and radiological characteristics and postoperative course were evaluated by reviewing medical records, surgical charts and intraoperative videos. RESULTS: The nine patients comprised four males and five females with a mean age of 53years (range 15-67years). The World Federation of Neurosurgical Societies grades on admission were I in one patient, II in two patients, III in five patients and V in one patient. With respect to location, there were four internal carotid-posterior communicating artery(ICA-Pcom) aneurysms, one distal anterior cerebral artery(DACA) aneurysm, one anterior communicating artery and three middle cerebral artery aneurysms. CT scans obtained from the four patients with ICA-Pcom aneurysms revealed SDH over the convexity and along the tentorium, and two of these patients presented with pure SDH without subarachnoid hemorrhage(SAH). In three patients with ICA-Pcom aneurysm, the ruptured aneurysm domes adhered to the petroclinoid fold. In the patient with the DACA aneurysm, the domes adhered tightiy to the pia mater and the falx. CONCLUSION: Ruptured intracranial aneurysm may cause SDH with or without SAH. In the absence of trauma, the possibility of aneurysmal SDH should be considered.

Cytotoxicities of Tumor-specific T Lymphocytes Primed by Glioma Apoptotic Body-or Glioma Cell Lysate-pulsed Dendritic Cells

OBJECTIVE: The choice of tumor antigen for dendritic cell(DC)-loading has still been an unresolved problem in the DC-based vaccine strategies against malignant gliomas that has not been found well-characterized tumor specific antigens. In this study, we compare tumor-specific T cell response induced by glioma apoptotic body(GAB)-pulsed DCs to response induced by glioma cell lysate-pulsed ones quantitatively. METHODS: DCs generated in the presence of granulocyte macrophage-colony stimulating factor and interleukin(IL)-4 from peripheral blood mononuclear cells(PBMCs) of HLA-A2 positive healthy donors were cultured. Each GABs and glioma cell lysate generated from HLA-A2 positive T98G glioblastoma cells were co-incubated with DCs. CD8+ T lymphocytes isolated from PBMCs of same donors were cultured in media containing IL-2 and either stimulated by GAB- or lysate-pulsed DCs three times at a weekly interval. The interferon(IFN)-gamma concentrations of each cell culture supernate were measured by enzyme immunoassay technique. Cytolytic activity of the generated cytotoxic CD8+ T cells either stimulated with GAB- or lysate-pulsed DCs was determined by a standard 4-h 51Cr-release assay. RESULTS: IFN-gamma production and cytolytic activity of effector T cells stimulated by GAB-pulsed DCs were significantly higher than those of T cells stimulated by lysate-pulsed ones. CONCLUSION: These results indicate the choice of antigen is a critical determinant in the induction of antitumor immunity against malignant glioma. Antigen preparations from GABs represent a promising alternative to glioma cell lysate in DC-based glioma vaccine strategies.

Intraosseous Lipoma of the Lumbar Spine

Intraosseous lipoma is one of the rarest benign primary tumors of the bone, especially of the spine, but has been reported at increasing frequency. Only a few cases of intraosseous lipoma originating primarily in the spine were reported. Twenty one-year old male with intraosseous lipoma located in lamina and spinous process of the 4th lumbar vertebra, who presented with lower back pain is reported. And the clinical features, natural courses and treatments of this rare tumor are discussed with literature review.

Induction of Cellular Immune Response by Dendritic Cells Pulsed with Glioma Apoptotic Bodies

OBJECTIVE: The aim of this study is to verify the hypothesis that human dendritic cells(DCs) can process antigens from glioma cell apoptotic bodies and induce antigen-specific effector T cells. METHODS: DCs generated in the presence of granulocyte macrophage-colony stimulating factor(GM-CSF) and interleukin-4(IL-4) from peripheral blood mononuclear cells(PBMCs) of healthy donors with human leucocyte antigen(HLA) A*0201 were cultured for 7 days. Glioma apoptotic bodies(GABs) from T98G glioblastoma cells following 18 hour-actinomycin D treatment were co-incubated with DCs for 3 days. CD8 T cells isolated from peripheral blood of same donors were cultured in media containing IL-2 and were stimulated by GAB-pulsed DCs three times at a weekly interval. The interferon-gamma(IFN-gamma), a cytokine related to cytotoxicity, concentrations of cell culture supernates were measured by enzyme immunoassay technique. RESULTS: Induced DCs had DC's own phenotypic characteristics such as highly expressed major histocompatibility complex(MHC) class II, CD1a and CD86 molecules. They also had high endocytotic activity. Preteatment of T98G glioma cells with actinomycin D resulted in 53% of cells undergoing apoptosis. IFN-gamma production of effector T cells stimulated by GAB-pulsed DCs was significantly higher than that of T cells stimulated by non-pulsed DCs. CONCLUSION: Naive CD8 T cells can be activated by human GAB-pulsed DCs to become antigen-specific effector T cells. Using GABs as a antigen source may be a novel approach in future DC-based immunotherapeutic trials for malignant glioma.

Primary Cranial Ewing's Sarcoma: Case Report

We present a case of primary Ewing's sarcoma involved the cranium in a young child. The tumor originated in the temporal bone. The patient was acutely compromised by signs and symptoms of raised intracranial pressure. Radiographic studies including brain magnetic resonance image showed a huge mass affecting the temporal bone. Systemic examination found no evidence of other primary site or metastasis. Following aggressive surgical resection, the patient received intensive chemotherapy without radiotherapy. Nine months after surgery, there has been no recurrence of the tumor. The principles of the management in children with primary cranial Ewing's sarcoma are discussed.

Extraskeletal Cervical Epidural Ewing's Sarcoma: Case Report and Review of the Literature

A patient with extraskeletal cervical epidural Ewing's sarcoma who presented with cervical radiculopathy is reported. A 58-year-old woman presented with right posterolateral neck pain and upper extremity radiculopathy. The computed tomography myelography showed epidural and paravertebral masses on right side, with widening of the ipsilateral neural foramina at the C2-C3 level. On magnetic resonance images, the mass was isointense to soft tissue on T1-weighted images, hyperintense on T2-weighted images, and showed diffuse enhancement on GdTA enhanced T1-weighted images. The staged, combined posterior and anterior approach were done and the tumor mass was subtotally removed. During postoperative adjuvant chemotherapy with Cytoxane, Adriamycin, Vincristine, Prednisolone regimen, the patient died of severe compression of upper cervical cord by recurrent, extended tumor mass in the spinal canal.

Clinical Analysis and Treatment Result in Posterior Inferior Cerebellar Artery Aneurysms / 대한뇌혈관학회지

OBJECTIVE: The purpose of this study is to characterize the Posterior Inferior Cerebellar Artery aneurysm distribution (location, age, sex, multiplicity and associated vascular anomalies), clinical presentation, neuroradiological findings and surgery outcome. MATERIALS AND METHODS: From Jul. '96 to Jun. '99, the admission chart and radiologic study material of 24 cases of angiographically confirmed PICA aneurysm patients were reviewed, retrospectively. RESULTS: Mean age of the patients was 53.4 years (ranged from 24 to 75), and majority of these aneurysms occurred in females (20 of 24). 22 of 24 patients presented with subarachnoid hemorrhage. The most common subarachnoid hemorrhage observed at ambient cistern, crural cistern, and the forth ventricular hemorrhage. In 19 of 24 cases the aneurysm size was 5+/-2 mm, and 23 cases show saccular aneurysm. PICA aneurysm patients have many associated intracranial vascular diseases (multiple aneurysm: 5, arteriovenous malformation: 2, abnormal vasculature: 4) and concomitant medical diseases (diabetes mellitus and tuberosclerosis). Direct surgical approaches were attempted in 22 cases (lateral suboccipital approach: 10, far lateral approach: 8, midline suboccipital: 2, pre-sigmoidal and combined approach in each case) and the surgical result was acceptable (favorable outcome: 19, unfavorable: 5). CONCLUSIONS: Based on this study, the incidence of PICA aneurysm was 1.3% and shows female predominance. In 46%, intracranial vascular abnormality was associated. On brain CT examination, subarachnoid hemorrhage at peimesencephalic cistern and intraventricular hemorrhage at the forth ventricle were most frequent CT finding. In most surgical cases, lateral or farlateral suboccipital approach was a good surgical approach enough to reach the PICA aneurysm and the surgical result was acceptable.

Primary Pituitary Aspergillosis: Case Report

No abstract available.

Lumbar Spinal Stenosis in Vertebral Ankylosing Hyperostosis: A Case Report

Vertebral ankylosing hyperostosis is a systemic rheumatological abnormality of unknown etiology whose hallmark is luxurious flowing ossification of the anterior longitudinal ligament. It has been regarded as asymptomatic ankylosis requiring no medical or surgical treatment. However, dyspnea, dysphagia, spinal cord compression, and peripheral nerve entrapment have all been documented in association with this disorder. On the other hand, reports on spinal stenosis at lumbar level are extremely rare. We present a case of spinal stenosis assosiated with vertebral ankylosing hyperostosis.