Massive Hyperostotic Meningioma En Plaque Mimicking Fibrous Dysplasia

The authors report an extremely rare case of a massive hyperostotic meningioma en plaque, which had characteristics of unique bony growth. A 34-year-old man presented with a palpable solid mass in the left cranial region that had gradually grown in size with a broad base on the calvarium for 8 years. Radiologically, the area involved by the mass ranged from the sphenoid bone to the frontal, parietal, temporal, and occipital bones. Three-dimensional CT revealed multiple growing spiculate features on the inner and outer cranial surface. Even though the radiologic features resembled fibrous dysplasia, it was histologically found to be a type of meningioma.

Diagnosis and treatment of trigeminal neuralgia

Trigeminal neuralgia is a sudden and painful facial condition that is triggered by activities of daily living. The pain is debilitating and patients are often unable to perform routine daily tasks such as washing their face, shaving, and brushing their teeth, which in turn has an impact on their social life and mental well-being as they are often anxious and fearful of not knowing when the pain may occur.Current Concepts: Treatment for trigeminal neuralgia involves local nerve destruction surgeries, including neuroblocking, percutaneous ethanol injection therapy, percutaneous radio-frequency rhizotomy, and gamma knife surgery. Although these types of surgeries reduce pain, the side effects are unpleasant and include decreased facial sensation, which originates from the damage to the trigeminal nerve. Furthermore, these surgeries provide insufficient long-term outcomes and symptoms often recur. Microvascular decompression is a radical surgical approach that separates the blood vessels that cause pain from the nerves. In a large-scale study, microvascular decompression significantly reduced the pain in 80–96% of the patients who underwent initial treatment. Of these, 85% experienced significant pain reduction 38 months post-surgery, and 72–85% reported that they were able to manage their pain 5 years post-surgery. Currently, microvascular decompression is the most appropriate surgical approach to control pain in patients with trigeminal neuralgia, as it exhibits the highest rate of pain control and lowest rate of recurrence.Discussion and Conclusion: The accurate diagnosis of trigeminal neuralgia, through clinical symptoms and imaging, is important to obtain good treatment outcomes. Microvascular decompression should be considered when a patient responds poorly to initial treatment approaches, cannot receive surgical treatment due to side effects, or experiences pain recurrence following local nerve destruction.

Clinical Outcome of Percutaneous Trigeminal Nerve Block in Elderly Patients in Outpatient Clinics

Objective@#: Trigeminal neuralgia (TN) is a severe neuropathic condition that affects several elderly patients. It is characterized by uncontrolled pain that significantly impacts the quality of life of patients. Therefore, the condition should be treated as an emergency. In the majority of patients, pain can be controlled with medication; however, other treatment modalities are being explored in those who become refractory to drug treatment. The use of the trigeminal nerve block with a local anesthetic serves as an excellent adjunct to drug treatment. This technique rapidly relieves the patient of pain while medications are being titrated to effective levels. We report the efficacy and safety of percutaneous trigeminal nerve block in elderly patients with TN at our outpatient clinic. @*Methods@#: Twenty-one patients older than 65 years with TN received percutaneous nerve block at our outpatient clinic. We used bupivacaine (1 mL/injection site) to block the supraorbital, infraorbital, superior alveolar, mental, and inferior alveolar nerves according to pain sites of patients. @*Results@#: All patients reported relief from pain, which decreased by approximately 78% after 2 weeks of nerve block. The effect lasted for more than 4 weeks in 12 patients and for 6 weeks in two patients. There were no complications. @*Conclusion@#: Percutaneous nerve block procedure performed at our outpatient clinic provided immediate relief from pain to elderly patients with TN. The procedure is simple, has no serious side effects, and is easy to apply.

Does Discharge Destination Matter after Total Knee Arthroplasty? A Single-Institution Korean Experience

PURPOSE: To compare extended care facility (ECF) and home as discharge destination after total knee arthroplasty (TKA) at a single high-volume tertiary center in South Korea. MATERIALS AND METHODS: We retrospectively analyzed 1,120 primary TKAs (614 patients) performed between January 2012 and December 2013. A telephonic survey was conducted to determine discharge destination. The data reviewed included demographic and surgical data, functional outcome at 2 years and complications within 3 months. RESULTS: ECF and home received 316 patients (51%) and 298 patients (49%), respectively. The ECF group had more bilateral TKA patients than the home group (272 vs. 234; p=0.014) and more patients with additional hospital stay (44 vs. 22; p=0.009). A higher tendency of complications was seen at home (n=8, 2.7%) than the ECF (n=2, 0.6%) (p=0.057). No significant differences were found in any functional outcome measure. Home patients had better patient satisfaction than ECF patients (81.9% vs. 54.3%; p < 0.001). CONCLUSIONS: Patients who returned home after discharge had similar functional outcome at 2 years after surgery and higher patient satisfaction than those in the ECF in spite of the higher tendency of complications. Patients need adequate counseling and education regarding advantages and limitations of the two discharge destinations.

A Clinical Analysis of Secondary Surgery in Trigeminal Neuralgia Patients Who Failed Prior Treatment

OBJECTIVE: Although many treatment modalities have been introduced for trigeminal neuralgia (TN), the long-term clinical results remain unsatisfactory. It has been particularly challenging to determine an appropriate treatment strategy for patients who have responded poorly to initial therapies. We analyzed the surgical outcomes in TN patients who failed prior treatments. METHODS: We performed a retrospective analysis of 37 patients with recurrent or persistent TN symptoms who underwent surgery at our hospital between January 2010 and December 2014. Patients with follow-up data of at least one year were included. The prior treatment modalities of the 37 patients included microvascular decompression (MVD), gamma knife radiosurgery (GKRS), and percutaneous procedures such as radiofrequency rhizotomy (RFR), balloon compression, and glycerol rhizotomy (GR). The mean follow-up period was 69.9 months (range : 16–173). The mean interval between the prior treatment and second surgery was 26 months (range : 7–123). We evaluated the surgical outcomes using the Barrow Neurological Institute (BNI) pain intensity scale. RESULTS: Among the 37 recurrent or persistent TN patients, 22 underwent MVD with partial sensory rhizotomy (PSR), 8 received MVD alone, and 7 had PSR alone. Monitoring of the surgical treatment outcomes via the BNI pain intensity scale revealed 8 (21.6%) patients with a score of I, 13 (35.1%) scoring II, 13 (35.1%) scoring III, and 3 (8.2%) scoring IV at the end of the follow-up period. Overall, 91.8% of patients had good surgical outcomes. With regard to postoperative complications, 1 patient had transient cerebrospinal fluid rhinorrhea (2.7%), another had a subdural hematoma (2.7%), and facial sensory changes were noted in 8 (21.1%) patients after surgery. CONCLUSION: Surgical interventions, such as MVD and PSR, are safe and very effective treatment modalities in TN patients who failed initial or prior treatments. We presume that the combination of MVD with PSR enabled us to obtain good short- and long-term surgical outcomes. Therefore, aggressive surgical treatment should be considered in patients with recurrent TN despite failure of various treatment modalities.

Do Trunk Muscles Affect the Lumbar Interbody Fusion Rate?: Correlation of Trunk Muscle Cross Sectional Area and Fusion Rates after Posterior Lumbar Interbody Fusion Using Stand-Alone Cage

OBJECTIVE: Although trunk muscles in the lumbar spine preserve spinal stability and motility, little is known about the relationship between trunk muscles and spinal fusion rate. The aim of the present study is to evaluate the correlation between trunk muscles cross sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion (PLIF) using stand-alone cages. METHODS: A total of 89 adult patients with degenerative lumbar disease who were performed PLIF using stand-alone cages at L4-5 were included in this study. The cross-sectional area of the psoas major (PS), erector spinae (ES), and multifidus (MF) muscles were quantitatively evaluated by preoperative lumbar magnetic resonance imaging at the L3-4, L4-5, and L5-S1 segments, and bone union was evaluated by dynamic lumbar X-rays. RESULTS: Of the 89 patients, 68 had bone union and 21 did not. The MCSAs at all segments in both groups were significantly different (p<0.05) for the PS muscle, those at L3-4 and L4-5 segments between groups were significantly different (p=0.048, 0.021) for the ES and MF muscles. In the multivariate analysis, differences in the PS MCSA at the L4-5 and L5-S1 segments remained significant (p=0.048, 0.043 and odds ratio=1.098, 1.169). In comparison analysis between male and female patients, most MCSAs of male patients were larger than female's. Fusion rates of male patients (80.7%) were higher than female's (68.8%), too. CONCLUSION: For PLIF surgery, PS muscle function appears to be an important factor for bone union and preventing back muscle injury is essential for better fusion rate.

Evaluating Scapular Notching after Reverse Total Shoulder Arthroplasty

BACKGROUND: Scapular notching can happen at diverse location depending on implant design or operative technique, therefore, it is easily misdiagnosed. Thus, this study purposed to suggest a method helpful to assess scapular notching. METHODS: The subjects were 73 cases of reverse shoulder arthroplasty (RSA) for cuff tear arthropathy during the period from May 2009 to April 2014 and followed-up for over a year. There was medialized RSA in 22 cases, bone increased offset RSA (BIO-RSA) in 36 cases, and metal increased offset RSA (metal-RSA) in 15 cases. Scapular notching was not determined by bone defect at the inferior of glenosphere as Sirveaux's classification, but scapular notching at the site where the rotational route of the polyethylene of humeral implant met the scapular neck were examined. The results were compared with conventional method. RESULTS: By conventional method, scapular notching was observed in 10 cases (45.5%) in medialized RSA, 12 cases (33.3%) in BIO-RSA, and none in metal-RSA. By new method, it was observed in 9 cases (40.9%) in medialized RSA, 10 cases (27.8%) in BIO-RSA, and none of metal-RSA. The site of scapular notching was apart from glenoshpere in 18 cases, and at inferior of glenosphere in 1 case. Absorption of bone graft was observed in 4 (11.1%) out of 36 cases of BIO-RSA. CONCLUSIONS: It is hard to distinguish scapular notching from absorption of bone graft in BIO-RSA, and bone absorption at the lateral lower end of glenoid in medialized RSA. Thus, it is considered useful to assess scapular notching at the site where the rotational route of the polyethylene insert meets scapular neck.

Evaluating Scapular Notching after Reverse Total Shoulder Arthroplasty

BACKGROUND: Scapular notching can happen at diverse location depending on implant design or operative technique, therefore, it is easily misdiagnosed. Thus, this study purposed to suggest a method helpful to assess scapular notching. METHODS: The subjects were 73 cases of reverse shoulder arthroplasty (RSA) for cuff tear arthropathy during the period from May 2009 to April 2014 and followed-up for over a year. There was medialized RSA in 22 cases, bone increased offset RSA (BIO-RSA) in 36 cases, and metal increased offset RSA (metal-RSA) in 15 cases. Scapular notching was not determined by bone defect at the inferior of glenosphere as Sirveaux's classification, but scapular notching at the site where the rotational route of the polyethylene of humeral implant met the scapular neck were examined. The results were compared with conventional method. RESULTS: By conventional method, scapular notching was observed in 10 cases (45.5%) in medialized RSA, 12 cases (33.3%) in BIO-RSA, and none in metal-RSA. By new method, it was observed in 9 cases (40.9%) in medialized RSA, 10 cases (27.8%) in BIO-RSA, and none of metal-RSA. The site of scapular notching was apart from glenoshpere in 18 cases, and at inferior of glenosphere in 1 case. Absorption of bone graft was observed in 4 (11.1%) out of 36 cases of BIO-RSA. CONCLUSIONS: It is hard to distinguish scapular notching from absorption of bone graft in BIO-RSA, and bone absorption at the lateral lower end of glenoid in medialized RSA. Thus, it is considered useful to assess scapular notching at the site where the rotational route of the polyethylene insert meets scapular neck.

Modified Stoppa Approach for Surgical Treatment of Acetabular Fracture

BACKGROUND: We analyzed the extent of the comminution in the acetabular weight-bearing area, the clinical and radiographic results, and the complications after a minimum 2-year follow-up of the modified Stoppa approach for the treatment of acetabular fractures, and we attempted to evaluate the efficacy of the operative technique. METHODS: All of the 22 patients, who needed the anterior approach for the treatment of acetabular fractures at our hospital from November 2007 to November 2010, were subjected to surgery via the modified Stoppa approach. Fracture pattern, operative time, blood loss during the operation, quality of reduction, number of bony fragments in the acetabular weight-bearing area, and postoperative complications were assessed by retrospectively analyzing the medical records and the radiographic examinations. The results after the operation were analyzed based on the criteria of Matta. RESULTS: The clinical results were excellent in 3 cases, good in 13 cases, and poor in 4 cases, while the radiographic results were excellent in 5 cases, good in 13 cases, and poor in 2 cases. Although the quality of reduction and the clinical results according to the extent of comminution were statistically significant (p = 0.03 and p = 0.04, respectively), the radiographic results were not statistically significant (p = 0.74). CONCLUSIONS: It can be concluded that the modified Stoppa approach could be used as an alternative to the classic ilioinguinal approach. In addition, comminution of the acetabular fracture was an important factor causing non-anatomic reduction and finally unsatisfactory clinical results.

Comparison of Treatment Methods in Lumbar Spinal Stenosis for Geriatric Patient: Nerve Block Versus Radiofrequency Neurotomy Versus Spinal Surgery

OBJECTIVE: The incidence of spinal treatment, including nerve block, radiofrequency neurotomy, instrumented fusions, is increasing, and progressively involves patients of age 65 and older. Treatment of the geriatric patients is often a difficult challenge for the spine surgeon. General health, sociofamilial and mental condition of the patients as well as the treatment techniques and postoperative management are to be accurately evaluated and planned. We tried to compare three treatment methods of spinal stenosis for geriatric patient in single institution. METHODS: The cases of treatment methods in spinal stenosis over than 65 years old were analyzed. The numbers of patients were 371 underwent nerve block, radiofrequency neurotomy, instrumented fusions from January 2009 to December 2012 (nerve block: 253, radiofrequency neurotomy: 56, instrumented fusions: 62). The authors reviewed medical records, operative findings and postoperative clinical results, retrospectively. Simple X-ray were evaluated and clinical outcome was measured by Odom's criteria at 1 month after procedures. RESULTS: We were observed excellent and good results in 162 (64%) patients with nerve block, 40 (71%) patient with radIofrequency neurotomy, 46 (74%) patient with spinal surgery. Poor results were 20 (8%) patients in nerve block, 2 (3%) patients in radiofrequency neurotomy, 3 (5%) patient in spinal surgery. CONCLUSION: We reviewed literatures and analyzed three treatment methods of spinal stenosis for geriatric patients. Although the long term outcome of surgical treatment was most favorable, radiofrequency neurotomy and nerve block can be considered for the secondary management of elderly lumbar spinals stenosis patients.

Clinical Analysis and Surgical Considerations of Atherosclerotic Cerebral Aneurysms: Experience of a Single Center

OBJECTIVE: Atherosclerotic cerebral aneurysms are known to increase occurrence of thromboembolic events and occlusion of perforator vessels intraoperatively due to pathological changes in the vessels themselves. In the current study, we analyzed the points to be considered during surgery for atherosclerotic cerebral aneurysms and the postoperative results. MATERIALS AND METHODS: We retrospectively reviewed the medical records, radiological results, and surgical records, including intraoperative video recordings and photographs, of 262 patients who underwent cerebral aneurysm surgery. We then performed a detailed analysis of aneurysm features, surgical methods, and clinical outcomes. RESULTS: Among 278 aneurysms in 262 patients, 73 aneurysms in 67 patients showed atherosclerotic features (atherosclerotic group, AG), and 205 aneurysms in 195 patients showed no evidence of atherosclerosis (non-atherosclerotic group, NAG). In the AG, clipping with multiple permanent clips was performed in 14 aneurysms, and clip slippage was found in four cases. Six AG cases had a remnant neck after clipping, which was significantly more frequent than in the NAG (p < 0.05). Clinical outcomes and surgery-related complications did not differ significantly between the two groups. CONCLUSION: In the surgical repair of aneurysms, the incidence of ischemia, which is irreversible or severe, might be greater in atherosclerotic than in non-atherosclerotic aneurysms. In addition, multiple clips might be applied to atherosclerotic aneurysms for effective obliteration and an aneurysm neck might be left to avoid a region of atheroma.

Necessity of Whole Spine Standing Lateral Radiograph in Adults over 50 Years Old Who Have Degenerative Lumbar Disease: Comparison with Supine Lumbar Lateral Radiograph

STUDY DESIGN: Cross-sectional study. OBJECTIVES: Sagittal imbalance cannot be predicted depending on the degree of lumbar lordosis. Thus, we tried to evaluate the necessity of whole spine standing lateral radiograph through comparison of the spinal and pelvic parameter between supine lumbar lateral radiograph and whole spine standing lateral radiograph. SUMMARY OF LITERATURE REVIEW: No studies in the literature compare supine lumbar lateral radiograph and whole spine standing lateral radiograph. MATERIALS AND METHODS: We randomly selected 50 males and 50 females among the patients over the age of 50 who visited our hospital for outpatient due to degenerative lumbar disease. Lumbar lordosis (sLL/wLL), sacral slope (sSS/wSS), and pelvic tilt (sPT/wPT) were measured and compared respectively by supine lumbar lateral radiograph and whole spine standing lateral radiograph. We categorized as group AI (sLL or =30degrees) by supine lumbar lateral radiograph and analyzed them. We also categorized as group BI (SVA5 cm) by whole spine standing lateral radiograph and analyzed them. RESULTS: There were no statistical difference in lumbar lordosis (sLL/wLL: 35.1degrees/37.7degrees) and pelvic parameter (sSS/wSS: 32degrees/31.7degrees, sPT/wPT: 24.3degrees/24.2degrees. sPI/wPI: 56.3degrees/58.2degrees) between supine lumbar lateral radiograph and whole spine standing lateral radiograph, and there were also no statistical difference between two groups (group AI & AII) in SVA, lumbar lordosis and pelvic parameter. Pelvic parameter compared by supine lumbar lateral radiograph and whole spine standing lateral radiograph based on sagittal balance was no significant difference, but lumbar lordosis appeared statistical difference. CONCLUSION: Sagittal imbalance appears quite a lot in patients with degenerative lumbar disease and supine lateral radiograph can't reflect the whole sagittal imbalance. So, whole spine standing lateral radiograph should be performed routinely to analyze the sagittal alignment.

Trigeminal Neuralgia Caused by Persistent Primitive Trigeminal Artery

A 66-year-old man presented with typical trigeminal neuralgia (TN). Magnetic resonance angiography (MRA) revealed a primitive trigeminal artery (PTA) that came into contact with the trigeminal nerve. Based on MRA, we performed microvascular decompression (MVD). In the operational field, we confirmed the PTA location and performed MVD successfully. Postoperatively, the patient's pain subsided without any complications.

Trigeminal Neuralgia Caused by Persistent Primitive Trigeminal Artery

A 66-year-old man presented with typical trigeminal neuralgia (TN). Magnetic resonance angiography (MRA) revealed a primitive trigeminal artery (PTA) that came into contact with the trigeminal nerve. Based on MRA, we performed microvascular decompression (MVD). In the operational field, we confirmed the PTA location and performed MVD successfully. Postoperatively, the patient's pain subsided without any complications.

Ceramic-on-Ceramic Total Hip Arthroplasty: Minimum of Six-Year Follow-up Study

BACKGROUND: This study examines the clinical and radiologic results of ceramic-on-ceramic total hip arthroplasties with regard to wear, osteolysis, and fracture of the ceramic after a minimum follow-up of six years. METHODS: We evaluated the results of a consecutive series of 148 primary ceramic-on-ceramic total hip arthroplasties that had been performed between May 2001 and October 2005 in 142 patients. The mean age was 57.2 years (range, 23 to 81 years). The mean follow-up period was 7.8 years (range, 6.1 to 10.1 years). Preoperative diagnosis was avascular necrosis in 77 hips (52%), degenerative arthritis in 36 hips (24.3%), femur neck fracture in 18 hips (12.2%), rheumatoid arthritis in 15 hips (10.1%), and septic hip sequelae in 2 hips (1.4%). Clinical results were evaluated with the Harris hip score, and the presence of postoperative groin or thigh pain. Radiologic analysis was done with special attention in terms of wear, periprosthetic osteolysis, and ceramic failures. RESULTS: The mean Harris hip score improved from 58.3 (range, 10 to 73) to 92.5 (range, 79 to 100) on the latest follow-up evaluation. At final follow-up, groin pain was found in 4 hips (2.7%), and thigh pain was found in 6 hips (4.1%). Radiologically, all femoral stems demonstrated stable fixations without loosening. Radiolucent lines were observed around the stem in 25 hips (16.9%), and around the cup in 4 hips (2.7%). Endosteal new bone formation was observed around the stem in 95 hips (64.2%) and around the cup in 88 hips (59.5%). No osteolysis was observed around the stem and cup. There were 2 hips (1.4%) of inclination changes of acetabular cup, 2 hips (1.4%) of hip dislocation, 1 hip (0.7%) of ceramic head fracture, and 1 hip (0.7%) of squeaking. The Kaplan-Meier survival rate of the prostheses was 98.1% at postoperative 7.8 years. CONCLUSIONS: The ceramic-on-ceramic total hip arthroplasty produced excellent clinical results and implant survival rates with no detectable osteolysis on a minimum six-year follow-up study. The ceramic-on-ceramic couplings could be a reasonable option of primary total hip arthroplasty for variable indications.

Tapia's Syndrome after Posterior Cervical Spine Surgery under General Anesthesia

We present a case report to remind surgeons of this unusual complication that can occur in any surgery, even posterior cervical spine surgery under general anesthesia and discuss its causes, treatment methods, and the follow-up results in the literature. The peripheral Tapia's syndrome is a rare complication of anesthetic airway management. Main symptoms are hoarseness of voice and difficulty of tongue movement. Tapia's syndrome after endotracheal general anesthesia is believed to be due to pressure neuropathy of the vagus nerve and the hypoglossal nerve caused by the endotracheal tube. To our knowledge, no report has been published or given an explanation for Tapia's syndrome after posterior cervical spine surgery. Two patients who underwent posterior cervical surgery complained hoarseness and tongue palsy postoperatively. There is no direct anatomical relation between the operation, the vagus nerves and the hypoglossal nerves, and there is no record of displacement or malposition of the endotracheal tube. After several months, all symptoms are resolved. To avoid this problem in posterior cervical spine surgery, we suggest paying special attention to the position of the endotracheal tube to avoid excessive neck flexion before and during the positioning of the patient.

Central Nervous System Infection Related to Intracranial Indwelling Catheters / 대한뇌혈관외과학회지

OBJECTIVE: Infection of the intracranial catheter remains the main morbidity and mortality associated with this procedure. In this retrospective study we have collected the information regarding the occurrence of this disease in order to find ways to reduce the incidence of central nervous system (CNS) infection related to an intracranial indwelling catheter. METHOD: In a six-year retrospective study we selected and reviewed the records of 242 patients (with a total of 314 catheters). We analyzed the incidence of infection, etiologic bacteria and factors affecting the risk of infection: catheter duration, catheter sequence, concurrent craniotomy, subcutaneous tunneling of catheter, cerebrospinal fluid (CSF) draining catheter, urokinase irrigation. RESULTS: Nineteen patients were infected. the infection rate was thus 8%. Staphylococcus aureus and Coagulase-Negative Staphylococcus are the most frequently-involved pathogens. The onset of infection ranged from 6 days to 38 days (with a mean of 14 days). There was a significant association between infection and a CSF draining catheter, a concurrent craniotomy, no subcutaneous tunneling, the duration of the catheter and multiple sequential catheters in the univariate logistic regression model. There was, however, no significant association between a CSF draining catheter and infection in the multivariate logistic regression model. CONCLUSION: The result of this study suggests that long catheter duration, no subcutaneous tunneling, multiple sequential catheters, concurrent craniotomy increase the incidence of CNS infection related to an intracranial indwelling catheter. An intracranial catheter must be placed using aseptic procedures with subcutaneous tunneling and maintenance of a strict closed system alsoshort duration as possible as.

Use of Prophylactic Decompressive Craniectomy in Middle Cerebral Artery Aneurysmal Subarachnoid Hemorrhage Patients Presenting with Associated Large Hematoma / 대한뇌혈관외과학회지

OBJECTIVE: Patients who present with a poor Hunt-Hess grade (IV or V) after aneurysmal subarachnoid hemorrhage (SAH) often have a poor prognosis. However, there may be subgroups of these patients for whom the sustained increased intracranial pressure predominates due to a large sylvian hematoma and for which rapid decompression of these predominant pathological processes may result in an improved outcome. We report here on the use of prophylactic decompressive craniectomy in patients who present in a poor neurological condition or they have a focal neurologic deficit, such as motor aphasia, after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. METHODS: Twelve patients (mean age: 52yr, age range: 13-71yr) presented with middle cerebral artery (MCA) aneurysmal SAH (one with Hunt-Hess grade III, five with Hunt-Hess grade IV and six Hunt-Hess grade V). They all had large hematomas (mean hematoma volume: 70ml, range: 30-120ml). All the patients underwent emergency operation. One patient whose Hunt-Hess grade was III underwent decompressive craniectomy because she had motor aphasia due to a focal mass effect of the hematoma. Five of them underwent operation without conventional angiography. All the patients were treated with large craniectomy and duraplasty. RESULTS: All patients underwent craniectomy without operative complications. The results for this study demonstrated that craniectomy patients had a remarkably high rate of good recovery or they had moderately disabled outcomes. The outcomes of the craniectomy patients were three grade 5s, four grade 4s, one grade 3 and four grade 1s for the GOS. CONCLUSION: The data in this study showed that decompressive craniectomy can be performed safely as part of the initial management for patients with SAH and who also present with large hematomas. We suggest decompressive craniectomy when patients with a large hematoma present not only with deteriorated mentality due to the increased intracranial pressure, but also with focal neurologic deficits such as motor aphasia due to the local mass effect.

Cavernous Hemangioma in the Middle Cranial Fossa & Cavernous Sinus

Extracerebral cavernous hemangiomas are rare vascular tumors that are very difficult to remove because of severe intraoperative bleeding. We report a case of 57-year-old male with extracerebral cavernous hemangioma with review of 126 cases in the literature. Patient presented with blurred vision, diplopia, numbness on the left side of his face. Magnetic resonance imaging revealed a well defined mass of 3 x 4 x 3 cm size with heterogenous iso-or hypointensity on T1-weighted image showing strong homogenous contrast enhancement and marked hyperintensity on T2-weighted image. Digital subtraction angiography(DSA) revealed a faint tumor blush by feeders from the left internal carotid artery(ICA) and left external carotid artery(ECA) in the delayed phase. Even with profuse intratumoral bleeding, near total removal was achieved. In addition to preoperative neurologic deficits such as ophthalmoplegia, facial numbness in the V1-2 dermatomes, ptosis appeared postoperatively.

Does ST-segment depression combined with R wave amplitude change improve the test accuracy of the EKG during exercise testing? / 대한내과학회지

BACKGROUND: Exercise electrocardiogram is the most widely used non-invasive test in those patients suspected of having coronary artery disease. However, sensitivity and specificity of this test are not satisfactory, especially when the exercise induced ST-segment depression is used as a single criterion of myocardial ischemia. Although many investigators have tried to improve diagnostic accuracy with R-wave amplitude change in addition to ST-segment depression, controversy exists whether this new criteria improve the test accuracy for coronary artery disease or not. The purpose of this study is to determine the test accuracy of R-wave amplitude change induced by exercise combined with the conventional ST-segment criterion for myocardial ischemia. METHODS: We reviewed our records of patients who visited to Korea University Anam Hospital with chest pain from January, 1998 to July, 1999. We included 130 patients with chest pain who had a tredmill test followed by a coronary angiography within 2 months. Patients with change in ST-segment depression (delta STD)> or = 1.00 mm and delta STD> or = 1.00 mm with R wave amplitude decrease (-delta R)> or = 1.00 mm in the same lead in any of 12 leads and delta STD> or = 1.00 mm with R wave amplitude increase (+delta R)> or = 1.00 mm in the same lead in any of 12 leads were compared. According to the findings of coronary angiograms, patients were divided into 4 groups ; normal coronary artery group, mild coronary artery stenosis group (> or = 30% to or = 50% to or = 70%). RESULTS: Fifty three patients (40.7%) had normal coronary angiograms and 77 patients (59.3%) had coronary artery stenosis. There was no significant difference in gender and age. But, patients with coronary artery stenosis had more diabetes mellitus, hyperlipidemia, smoking, previous myocardial infarction history and angina during exercise testing than those without coronary artery stenosis. The sensitivity of exercise EKG is significantly decreased when combined with delta R (delta STD, 74.0%, delta STD with -delta R, 45.5%, delta STD with +delta R, 30.0%, p<0.01), but the The test accuracy is delta STD; 73.7%, delta STD with -delta R; 61.5%, delta STD with +delta R; 57.7%. CONCLUSION: When ST-segment depression is combined with R-wave amplitude change as a marker for myocardial ischemia, the specificity is increased, but the test accuracy of exercise EKG is not improved.