Clinical Outcome of Modified Cervical Lateral Mass Screw Fixation Technique

OBJECTIVE: The purpose of this study was 1) to analyze clinically-executed cervical lateral mass screw fixation by the Kim's technique as suggested in the previous morphometric and cadaveric study and 2) to examine various complications and bicortical purchase that are important for b-one fusion. METHODS: A retrospective study was done on the charts, operative records, radiographs, and clinical follow up of thirty-nine patients. One hundred and seventy-eight lateral mass screws were analyzed. The spinal nerve injury, violation of the facet joint, vertebral artery injury, and the bicortical purchases were examined at each lateral mass. RESULTS: All thirty-nine patients received instrumentations with poly axial screws and rod systems, in which one hundred and seventy-eight screws in total. No vertebral artery injury or nerve root injury were observed. Sixteen facet joint violations were observed (9.0%). Bicortical purchases were achieved on one hundred and fifty-six (87.6%). Bone fusion was achieved in all patients. CONCLUSION: The advantages of the Kim's technique are that it is performed by using given anatomical structures and that the complication rate is as low as those of other known techniques. The Kim's technique can be performed easily and safely without fluoroscopic assistance for the treatment of many cervical diseases.

Anomalous Variations of the Origin and Course of Vertebral Arteries in Patients with Retroesophageal Right Subclavian Artery

We present two rare cases of anomalous vertebral artery (VA) with retroesophageal right subclavian artery. One patient had a right VA arising from the right common carotid artery (CCA), and a left VA originating from the third branch off the aorta. Both VAs ascended anteriorly to the transverse foramen of C5 to C6 vertebra and entered the transverse foramen of C4. The other patient had a right VA arising from the right CCA and entering the transverse foramen of C5. The presence of anomalous variations of the origin and course of vertebral artery might have serious implications in angiographic and surgical procedures, and it is of great importance to be aware of such a possibility.

Ruptured Aneurysm of the Ophthalmic Artery

Aneurysms arising from the ophthalmic artery itself are very rare compared with aneurysms originating from the bifurcation of the ophthalmic artery and carotid artery. There was only one reported case of a ruptured aneurysm of the ophthalmic artery itself. We discuss clinical significance of an aneurysm at this site, as well as the role of three dimentional image of multislice computed tomography angiogram(3D-image of MCTA) in determining the cause of subarachnoid hemorrhage(SAH).

Neurological Improvement after Cranioplasty in Patients with Surgical Bony Defects : The Usefulness of Acetazolamide Activated (99m)Tc-HMPAO SPECT

OBJECTIVE: The purpose of this study is to examine the influence of cranioplasty on dynamics of cerebral blood flow(CBF) and cerebrovascular reserve capacity(CVRC), and to investigate the usefulness of single photon emission computed tomography (SPECT) as a prognostic factor for neurological improvement after cranioplasty. METHODS: Between March 2003 and December 2005, a prospective study was performed on 24 patients who had undergone total 25 cranioplasty operations. Cerebral blood flow velocities in the middle cerebral artery(MCA) and internal carotid artery (ICA) were obtained by transcranial Doppler ultrasonography(TCD). The CVRC was assessed by SPECT in the natural state and after stimulation with 1g of acetazolamide. Neurological improvement after cranioplasty was compared between patients who showed hyperactivity to acetazolamide-activated SPECT (Group 1, n=7) and hypoactivity to acetazolamide-activated SPECT (Group 2, n=17). These measurements were obtained two weeks prior to and two weeks after cranioplasty. RESULTS: The blood flow velocities at the opposite site to the cranioplasty as well as at the cranioplasty site were significantly increased (P<0.05). Compared with Group 2, there was significant increase in CBF and neurological imrovement after cranioplasty in Group 1. CONCLUSION: Among patients with surgical bony defects, the patients who had normal reactivity of the CVRC showed a significant increase in CBF and neurological improvement after cranioplasty. The authors suggest that CVRC measurement prior to surgery may be an important prognostic factor for neurological improvement after cranioplasty.

Role of Multislice Computerized Tomographic Angiography in Vasospasm Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: We evaluate the role of multislice computerized tomographic angiography(MCTA) in the diagnosis of intracranial vasospasm following subarachnoid hemorrhage(SAH) in patients suspected of having vasospasm on clinical ground. METHODS: Between October 2003 and June 2005, patients with ruptured cerebral aneurysms of the anterior circulation clipped within 3 days of the onset were included. We performed follow-up MCTAs in patients who were suspected to have vasospasm on transcranial doppler sonography(TCD) findings and clinical grounds. Based on the clinical presentation of symptomatic vasospasm, we investigated the correlation between clinical, TCD, and MCTA signs of vasospasm and evaluated the role of MCTA in vasospasm. RESULTS: One hundred one patients met the inclusion criteria and symptomatic vasospasm developed in 25 patients (24.8%). We performed follow-up MCTAs in 28 patients. MCTA revealed spasm in the vessels of 26 patients. The sensitivity of MCTA was 100%. Among the 26 patients with MCTA evidence of vasospasm, 3 patients had TCD signs of vasospasm after symptomatic vasospasm presentation. Another 3 patients with symptomatic vasospasm had no TCD signs of vasospasm in daily serial recordings. Six other patients without symptomatic vasospasm showed MCTA evidence of vasospasm (false positive result) but these patients had also positive TCD signs of vasospasm. Volume rendering(VR) images tended to show significantly more exaggerated vasospasm than maximum intensity projection(MIP) images. The mean cerebral blood flow velocity of both proximal segment of the middle cerebral artery (M1) was significantly correlated with each reduced M1 diameter on MCTA (P<0.05). CONCLUSION: MCTA could be a useful tool for evaluation and planning management of critically ill patients suspected of having vasospasm; however, more randomized controlled trials are necessary to assess these points definitively.

In Vitro Proton Magnetic Resonance Spectroscopy Detected a Differential Neurochemical Response in Rabbit Brain Administered Thiopental or Ketamine / 대한마취과학회지

BACKGROUND: Cellular target sites and the neurochemical compounds responsible for anesthetic action remain unclear. This study was designed to detect regional changes in neurochemical compounds by NMR spectroscopy of extracted rabbit brain tissue after anesthetizing with thiopental or ketamine. METHODS: Nine healthy white New Zealand rabbits (2.5-3.0 kg) were studied. A marginal ear vein was punctured for continuous intravenous infusion. Controlled breathing was maintained using a Jackson-Ree circuit after intubation during thiopental (n = 3) or ketamine (n = 3) anesthesia. After maintaining anesthesia for 30 minutes, brains were extracted and placed in liquid nitrogen. Rabbits in the control group (n = 3) were sacrificed using KCl and processed in the same manner. Extracted brain tissues were divided into frontal lobe, temporal lobe, occipital lobe, parietal lobe, pons, midbrain, basal ganglia and spinal cord. The 1H-NMR spectra of extracted regional brain tissues were obtained, and neurochemical compounds such as gamma-aminobutyric acid (GABA), N-acetylaspartate (NAA), choline-containing compounds (Cho), and creatine (Cr) were compared with those of normal control tissues. RESULTS: In the thiopental group, the GABA/Cr and NAA/Cr ratios of brain regions were not significantly different from those of the control group. The Cho/Cr ratios of the frontal lobe, parietal lobe, and basal ganglia were significantly higher than those of the control group. In the ketamine group, the GABA/Cr ratio of the midbrain was significantly lower than that of the control group. However, Cho/Cr ratios of the parietal lobe, temporal lobe, and midbrain were significantly higher than those of the control group, though the NAA/Cr ratio was similar to that of the control. CONCLUSIONS: These results suggest that the anesthetic actions of thiopental, such as, its sedative and hypnotic effects are due to increased GABA activity. Inhibition of acetylcholine induced neurotransmission was observed particularly in the frontal lobe, parietal lobe, and basal ganglia in thiopental anesthesia and in the parietal lobe, temporal lobe and midbrain in ketamine anesthesia. Neurotoxicity was not observed for either drug in anesthetized brain tissue.

Usefulness of Multislice Computerized Tomographic Angiography in Evaluation of Intracranial Aneurysms: Surgical Correlation

OBJECTIVE: The usefulness of multislice computerized tomographic angiography(MCTA) in operating intracranial aneurysms is studied by comparing the features of MCTA with intraoperative findings. METHODS: From December 2001 to February 2003, 74 clippings of aneurysmal neck were carried out based mainly on the aneurysmal features of preoperative MCTA. MCTA studies consisted of four rows(multislice technology), with slice thickness of 1.25mm at 0.6mm reconstruction intervals and pitch of 0.75. Timing was determined using the Smart Prep automatic triggering system. The locations of aneurysms were classified into 3 subgroups: internal carotid artery, middle cerebral artery, and anterior communicating artery and distal anterior cerebral artery. The aneurysmal features on MCTA were compared with their operative findings, using our comparison items, and graded subsequently. RESULTS: A total of 77 intracranial aneurysms were identified among 64 patients on preoperative MCTA, and one of them was false positive. Two angiographically unrecognized microaneurysms were identified on operation. In the detection of intracranial aneurysm, MCTA had 98.4% sensitivity and 96.9% specificity on a perpatient basis. On a per-aneurysm basis, MCTA sensitivity and specificity were 98.6% and 97.3%, respectively. The shapes of aneurysms on MCTA were not related with the grade(chi-square test: X2=1.566, p=0.457), but each grades of simple, bilobulation, and multilobulation were grade 1. Sum of grading scores were related with site of aneurysm(Chi-square test: X2=48.635, p=0.001), In particular, sum of grading scores of MCA aneurysms were 5. Although fine vascular architectures such as hypoplastic A1 and posterior communicating artery, perforating artery of A-COM, and anterior choroidal artery were invisible on MCTA, the MCTA images of ICA and A-COM aneurysms were also found to be valuable in intracranial aneurysm surgery. CONCLUSION: MCTA is useful in planning the surgery of intracranial aneurysm compared to single detector CTA. Postoperative DSA of stabilized patient is mandatory for confirming operative results and any missing unruptured aneurysm after MCTA based cerebral aneurysm surgery.

Pure Acute Subdural Hematoma without Subarachnoid Haemorrhage Caused by Rupture of Distal Anterior Cerebral Artery Aneurysm / 대한뇌혈관외과학회지

A 64-year-old female presented with unconscious state after sudden onset headache, nausea and vomiting. Computed tomography showed acute subdural hematoma (SDH) over the left convexity without subarachnoid hemorrhage. 3D-CT angiogram showed a saccular aneurysm at the junction of A2-A3 of the left anterior cerebral artery. Surgery for decompressive craniotomy and aneurysmal neck clipping was performed. In operative field, the left distal anterior cerebral artery was abnormally elongated toward the frontal pole and located not in the pericallosal cistern but on the cortical surface and the rupturing point was located in the adhesive portion of aneurysmal sac and arachnoid membrane near the falx. Pure acute SDH without subarachnoid hemorrhage (SAH) caused by ruptured aneurysm is extremely rare. Rupture of an aneurysm adhered to either the dura or falx and located in the subdural space may cause pure SDH. In our case, abnormally elongated location of artery may be related to this adhesion and rupture of aneurysm to subdural space. Therefore, ruptured intracranial aneurysm should be considered as a cause of non-traumatic SDH. Immediate removal of the SDH and aneurysmal clipping is recommended in such patients, even those in poor neurological condition.

Coincidental Sphenoid Meningioma and Pituitary Adenoma: Case Report

We report a case of coincidental pituitary adenoma and sphenoid meningioma. Computed tomographic scan had shown a large intrasellar rim enhancing mass and another well-enhancing mass with reactive bony thickening on the medial sphenoidal ridge. Magnetic resonance image revealed a snow-man shaped, expansile intrasellar mass, with small supra-sellar component, and a small enplaque-type enhancing dural thickening on the right medial sphenoidal ridge. Histopathologically, the intrasellar mass was diagnosed as pituitary adenoma and the other mass as secretory meningioma. We present clinical, radiological, and histopathological findings and review the reported cases of coincidental pituitary adenoma and meningioma without irradiation or trauma.

Fenestrate Anomaly of a Vertebral Artery with Repeated Attacks of Ischemic Stroke

In angiographic examinations, abnormalities of vertebral arteries are incidental findings because they are, in most of cases, clinically asymptomatic. We report a case of young woman with a fenestrated anomaly of the left vertebral artery with ischemic strokes. The patient was suffered from repeated attacks of transient ishemic attack(TIA) and cerebral infarction. Vertebral angiography demonstrated a fenestrated anomaly of the left vertebral artery and a large intraluminal thrombus was detected at just proximal of the fenestration. Proximal balloon occlusion of the involved vertebral artery was done and the patient became free from ischemic attack. Follow-up angiography showed well visualization of the posterior circulation through right vertebral artery and the ballooned vertebral artery was well occluded. The left posterior inferior cerebellar artery(PICA) was filled well via collateral circulation from the opposite side.

Nontraumatic Spinal Epidural Hematoma - An Analysis of The Etiology -

Spontaneous spinal epidural hematoma is a rare entity. Various definitions for spontaneous epidural hematoma have been reported in the literature. The expression of nontraumatic spinal epidural hematoma seems to be less ambiguous and includes idiopathic hematomas and hematomas secondary to coagulopathy, vascular malformations, and tumors. We report three cases of nontraumatic spinal epidural hematomas observed from 1991 to 2000. The causes of the spinal epidural hematomas were not clear in two cases among them, but in the another one case, the cause was determined to be an acquired coagulopathy. We reviewed 24 cases reported in the Korean Journal of Neurosurgery and our three cases with particular emphasis on the various causes such as coagulopathy, vascular malformations and tumors. Among the 27 cases, numerous causes were detected such as three cases of vascular malformation, one case of anticoagulant treatment, five cases of combined lumbar disc herniation, two cases associated with pregnancy and postpartum, one case associated with hypertension, and one case associated with ossification of ligamentum flavum. No causes were detected in the ten cases. The authors reviewed the literature.

Agenesis of Right Internal Carotid Artery Associated with Intracranial Aneurysm: Case Report

The authors present a case of unilateral agenesis of internal carotid artery associated with an aneurysm at the unusual site. A 22-years old female was admitted with sudden headache and nausea. She was alert on admission and no focal neurologic deficit was detected. Brain computed tomography(CT) scan showed subarachnoid hemorrhage. In the cerebral angiography, right internal carotid artery was absent and an aneurysm was arisen from the junction of the right middle cerebral artery and posterior communicating artery. The blood supply of the right anterior cerebral artery was maintained from the left internal carotid artery via the anterior commuicating artery. The territory of the right middle cerebral artery was supplied from the basilar artery through enlarged right posterior communicating artery. Direct clipping of the aneurismal neck was performed through right pterional approach. In the postoperative high resolution CT scan, there was no carotid canal in the right skull base suggesting agenesis of the right internal carotid artery.

Solitary Schwannoma in the Psoas Muscle

The vast majority of schwannomas occur on cranial nerves, and rarely in the retroperitoneum. Solitary schwannoma in the psoas muscle is extremely rare. The authors present a case of retroperitoneal neoplasm in the psoas muscle identified as schwannoma which is not associated with von Recklinghausen's disease. A 68 years old female patient was admitted because of low back pain and weakness at the left leg. CT and MRI revealed a large cystic mass with well-defined margin and multiple internal septation within the left psoas muscle. The tumor was totally extirpated and histologically confirmed as a schwannoma.

Clinical Roles of Continuous Lumbar Drainage in Acute Hydrocephalus Patients

No abstract available.

Primary Osteosarcoma of the Sphenoid Bone: Case Report

No abstract available.

Carcinogenesis of Murine Astrocytes in Culture

Astrocytes play important roles in normal brain development and the physiological processes. In particular, 30% of the brain volume consists of astrocytes, and they are the primary target cell in the brain for cellular injuries from chemical exposures. The present study attempts to establish an immortalized murine astrocyte cell line to study the mechanisms of chemical-induced carcinogenesis of astrocytes. Primary astrocytes isolated from mice were transfected with plasmid carrying the SV40 T antigen. Clonal cells obtained after G418 selection were continuously subcultured to establish an immortalized astrocyte cell line. The cell line was positive on GFAP expression and was sensitive to exposure to such chemicals as MNNG. Cells were treated with MNNG for 5 days, with doses ranging from 0.001ug/ml to 1ug/ml. Dose-dependent cellular transformations of astrocytes were observed. Treatments at 0.01ug/ml showed the most distinct characteristics of neoplastic transformation. Subsequent treatment with TPA produced higher levels of neoplastic cell transformation than MNNG treatment alone, as evidenced by increases of saturation density, soft-agar colony formation and cell aggregation. Promotional effects of TPA on cell transformation was further demonstrated by the shortening duration of foci appearance. Addition of hydrocortisone to the culture media resulted in further promotion of cell transformation in astrocytes treated with MNNG and TPA, suggesting that glucocortocoid also plays a role in the promotion of chemical-induced astrocyte transformation. The present study demonstrates that astrocytes are susceptible to chemical-induced carcinogenicity and subject to mechanisms of multistage carcinogenesis. Analysis of MNNG-transformed astrocytes showed that, while the expression of TGF-beta was decreased, expression of GFAP, IL-1betaand fibronectin were increased. The results suggest that these factors are associated with mechanisms of MNNG-induced astrocyte transformation and may be used as potential candidates for biomarkers representing astrocyte-related tumors and cell toxicities. The study showed scientific evidence that growth factors, cytokine and the extracellular matrix are involved in processes of chemical-induced transformation of astrocytes. In addition, the present work provided an excellent opportunity to develop an immortalized astrocyte cell line that can be used for studying mechanisms of astrocyte-related diseases.

Brain Tumors in Which Lactate and Lipid Have Been Detected: A Proton Magnetic Resonance Spectroscopy Study

To determine the spectral pattern of metabolites in 31 brain tumors in which the presence of lipids, lactate and additional intermediary metabolites had been detected, in vivo 1H-MR spectroscopy was performed. Metastasis (n=3), meningioma(n=7), astrocytic tumors of different grades(n=11), postop recurrent tumors(n=2) and other tumors(n=10) were examined using the stimulated echo(STEAM, TE=30ms) or double spin echo technique(PRESS, TE=272ms) with CHESS pulse for water suppression. The detection of lactate in astrocytic tumors correlated with a higher grade of malignancy, and lipid was observed in most glioblastomas. Elevated lactate levels in tumors do not simply originate in the necrotic region, but are related to the high glycolytic activity of adequately perfused, viable neoplastic cells. Lipid signals were detected in high grade, late stage brain tumors, indicating the need for enhanced phospholipid metabolism and membrane degradation, respectively. The absence of lactate and presence of alanine, glutamate/glutamine in most meningiomas distinguished them from schwannomas and other glial tumors. Observation of the spectral pattern of metabolites in brain tumors in which lipid and lactate has been detected might play an important prognostic role in the management and differentiation of metastasis, glial tumors, tumor recurrence, and other non-neoplastic diseases.

Malignant Transformation and Extracranial Metastasis of a Meningioma

Since its earliest description in the 18th century, meningioma has been considered a relatively indolent benign tumor which can be completely removed. Some grow very quickly, however, recur more frequently and with each recurrence, may change their biology to a more malignant form. A meningioma rarely metastasizes to the extracranium; the most frequent extracranial metastatic sites include the lung, musculoskeletal system and lymph node. The authors report a rare case of meningotheliomatous meningioma which occurred in the left parasagittal area and invaded the superior sagittal sinus; after surgery, it showed multiple recurrences and regrowth, and finally metastasized to the left thoracic cage. The authors also reviw the literature.

Central Neurocytoma: A Case Report

A rare case of intraventricular central neurocytoma in 17-year-old male is reported. The patient had diffuse headache and diplopia. Radiologic findings displayed obstructive hydrocephalus and a large, well-demarcated intraventricular mass lesion obstructing the foramen of Monroe. The tumor arouse from the splenium of corpus callosum. It was removed successfully using two different approaches after extraventricular drainage of the cerebrospinal fluid(CSF). Histologically, the tumor showed pathological features as that of oligodengroglioma on the light microscope. In immunohistochemical examination, glial fibrillary acidic protein(GFAP) was negative and synaptophysin, positive. Numerous neurosecretory granules were found and no typical synapsis was noticed on the electron microscope. No shunt operation was needed. Postoperative radiotherapy or chemotherapy was not performed and no tumor recurrence was detected during the one year follow-up period. We present the case together with a review of the literatures.

Remote Intracerebral Hematoma after Supratentorial Graniotomy

Four cases of intracerebral hemorrhage remote from the site of initial supratentorial craniotomy are presented. Traumatic cases are excluded in this report and all cases developed after uneventful elective craniotomy. Two patients had ruptured aneurysm and the other two had giant supratentorial tumors, one craniophayrngioma and one ependymoma. All patients were operated on supine position and no patient had preoperative hypertension. Two had hematoma in the sucortical white matter, one in the cerebellar hemisphere and the other one showed hematoma both in the cerebellar hemisphere and the supratentorial subcortical area. The size of hematoma ranged from 8-20cc in volume. No definite cause could be found except one in which the blood pressure was transiently elevated during induction of anesthesia. A possible cause might be the sudden changes of blood pressure during induction and recovery from anesthesia, overdrainage of CSF, continuous CSF drainage and sudden changes in intracranial dynamics by removal of a huge intracranial mass. One patient with intracerebellar hemorrhage needed emergency suboccipital craniectomy for removal of the hematoma. One patient shows no improvement due to aspiration pneumonia and subsequent lung abscess. Although rare, these conditions may occur after any craniotomy and surgeons should always be alert to the possibilities of such comlication, especially when intracranial pressure(ICP) was elevated.