Paraplegia:An Initial Manifestation of a Ruptured ICA Bifurcation Aneurysm

A case of sudden paraplegia as the first symptom of a ruptured internal carotid artery bifurcation aneurysm is reported. Sudden appearance of paraparesis or paraplegia is an exceptional event in patients with intracranial aneurysms. The various pathogenic mechanisms are briefly discussed. Insufficient blood perfusion of both paracentral areas was the cause of paraplegia in this case.

Intraventricular Cystic Craniopharyngioma: Case Report

Craniopharyngiomas are usually considered to arise from the pituitary stalk and upper aspect of the pituitary gland. However, they very rarely develop from the floor of the third ventricle or the lamina terminalis, and are intrinsically confined to the third ventricle ; about 40 cases have been reported in the literatures. We have recently experienced a case of intrinsic intraventricular craniopharyngioma with the density a little higher than cerebrospinal fluid on the brain CT.

Continuous Free External Ventricular Drainage in Hypertensive Intracerebral Hemorrhage with Ventricular Rupture

There are several methods in the surgical treatment of hypertensive intracerebral hemorrhage, such as craniotomy and hematoma removal, stereotaxic aspiration of hematoma and external ventricular drainage with maintaining physiologic ventricular pressure(over-pressure EVD). In spite of all these methods, surgical treatment yields unsatisfactory results when the patient is comatous and show herniation signs preoperatively. We treated 9 cases of hypertensive intracerebral hemorrhage with ventricular rupture by hematoma removal and continuous free external ventricular drainage instead of over-pressure drainage. In 4 cases, during the drainage, obstruction of the drainage catheter by blood clots or clamping resulted in immediate deterioration of the patient's condition, which was reversed by maintaining the patency suggesting that postoperative control of ICP was essential in treating hypertensive intracerebral hemorrhage in addition to hematoma removal. 7 out of 9 cases regained consciousness and improved gradually with mild to serve neurologic deficit. One patient died of rebleeding in the midbrain and one was discharged by family's will.

Clinical Application Topographic Electroencephalography(Computed Mapping of EEF)

Topographic electroencephalographic study(CME) is a newly developed method using a microcomputer system that displays the scalp topograph as the square roots of the average power spectra over each EEG frequency band on a color television screen. CME were applied to thirty patients, Fifteen patients out of them with focal neurologic deficit were analysed about CT scan and conventional EEG. The results of the study were as follows : 1) Comparing the results of CME and conventional EEG reading, CME revealed to be slightly more sensitive in detecting asymmetrical depression of background activity than the conventional reading of the EEG. 2) Topograph EEG study was more accurate than conventional EEG in lateralization of the lesion. 3) CME is very useful in topographic and objective diagnosis of functional lesion, although the source of the data is the same as that from the conventional EEG.

Long Term Follow-up of Patients with Injuries of the Spinal Cord

184 paraplegics and tetraplegics of Korean male(159 alive and 25 dead) subjected to spinal cord injury during 1950~1976 were followed up for 10~36 years. The 38 patients were interviewed individually and for the other 146 patients, various records of Korean Patriots and Veteran Affairs Agency were analysed. 95.1% out of 1984 patients were service men and 86.9% were second decade. Among 159 living patients, survival rate after injury markedly reduced at 15 years after injury in cervical cord injury group and at 20 years in lumbar cord injury group, thereafter it had gradually reduced in both groups. The changes of survival rate in the thoracic cord injury group showed intermediate form of cervical and lumbar cord group. Of 25 patients dead (thoracic and lumbar cord injuries), survival rate reduced markedly from 20 years after trauma. In 38 patients who were interviewed individually, 55.2% and 76.3 of patients were recovered to get in the wheel-chair within 1 year and 2 year after trauma respectively and in 45.8% the decubitus were not healed after 2 years of trauma. The 39.4% out of 38 patients were able to urinate involuntarily, if any, with voiding desire. And the penile erection and ejaculation were possible or occasionally possible in the 55% and 34% respectively.

Lysis of Intracerebral Hematoma with Thrombolytic Agents in a Rabbit Model

The lysing capability urokinase(UK) and streptokinase (SK) in intracerebral hematoma were examined in vitro and in a rabbit model. Intracerebral-intraventricular(IC-IV) hematomas were created by stereotaxically injecting 0.2ml of clotted human blood into the frontal lobe and lateral ventricle of a total of 87 house rabbits(weighing 1.5-2.7kg). Control animals received 0.2ml of physiologic saline infused into the clot, and the experimental group received an equal volume of UK solution(50,000units/ml), SK solution(50,000units/ml), UK-SK mixture(0.1ml of UK solution, 0.1ml of SK solution) respectively after the clot infusion. Forty two animals were sacrificed at 3 hours and 45 animals at 24 hours after infusion, The results obtained were as follows: 1) At 3 hours, clot lysis had been achieved in 8(67%) of 12 UK-infused animals, 5(36%) of 14 SK-infused animals and 6(60%) of 10 UK-SK-infused animals as compared to zero of 6 controls. 2) At 24 hours, clots had been lysed in 11(73%) of 15 UK-infused animals, 8(67%) of 12 SK-infused animals, 8(67%) of 12 UK-SK-infused animals and in 2(33%) of 6 controls. 3) There was mild inflammatory reaction by the clotted blood, but no additional histologic abnormality by thrombolytic agents(UK,SK) on microscopic examination. 4) Therefore we suggest that UK, SK or UK-SK mixture may be effectively used for the lysis of clotted intracerebral hematoma in the rabbit model and UK, UK-SK mixture are more effective than SK at 3 hours.

Delayed Epidural Hematoma

Four cases of delayed post-traumatic epidural hematoma which had not been present on initial CT scan were found on repeated CT scan. The delayed epidural hematoma was developed after evacuation of a hematoma in all cases. And a skull fracture was present at the site of the delayed hematoma in two cases. The neurologic deterioration heralded the onset of delayed epidural hematoma after decompressive therapy by either surgical or medical means. Repeated CT scan is indicated if anticapated improvement from does not occur after decompression by either surgical or medical means, recovery from shock, or whenever there is evidence of even minimal bleeding under a skull fracture on the initial CT scan.

The Change of Total Ascorbic Acid Level in the Experimental Spinal Cord Injury

The changes of total ascorbic acid level in the spinal cord tissues following experimental spinal cord injury were observed in the 20 cats. Three small areas (2x1.5cm sized) in the thoracic cord following laminectomy were made and the specimens were removed in one control and the other two areas after 5 & 30 minutes following impact injury respectively in each cat. The significant decrease of the total ascorbic acid level after 5 & 30 minutes following experimental spinal cord injury was found.

Fracture of the Dorsum Sella

Fracture involving the sella turcica is a rare complication of head injury but draws attention of neurosurgeon because it can result in serious neurological, vascular and endocrine complications. Anatomically the sella being located central within the extensive basal dural attachments to the cranial vault, shearing force is transmitted directly to this structure and results in isolated complications. We recently experienced a case of fractured dorsum sellae complicated with cranial nerve palsy and report here with some references.

The Effect of Naloxone on the Na+ K+ ATPase Activity Changes Following Experimental Spinal Cord Injury

The Na+ K+ ATPase activity, whose disturbance have been implicated in the pathophysiology of a variety of disease processes, have been shown to be reduced in traumatized spinal cord and in ischemic brain made by decapitation or carotid artery occlusion by many authors, but MacMillan contrary documented the increase of this ferment in ischemic rat brain following the electrocautery of the bilateral vertebral arteries and carotid arteries. This experiment was intended to study the cause of the above two contradictory results and the effect of Naloxone to the Na+ K+ ATPase activity following experimental spinal cord injury. Thirty cats were divided to 3 groups : Control No. 1, control No.2 and Naloxone groups. The Na+ K+ ATPase activity was measured by variation of Kang & Lee method and the experimental spinal cord injury was made by falling 20 gm. of iron bar from 20 cm height to exposed thoracic cord. 1) In control No. 1 group the Na+ K+ ATPase activity increased 21.4% after 30 minutes of trauma showing significant difference(p<0.05). 2) In control No. 2 group it increased 13.8%(p<0.01) after 5 minutes, 11.6%(p<0.05) after 30 minutes showing significant difference. 3) In Naloxone group (10 mg/kg was injected I.V. before 30 minutes of trauma) it did not show any significant change after 5 and 30 minutes of trauma. 4) Discussion was made upon above experimental results with literature review.

A Clinical Analysis of Spontaneous Cerebral & Cerebellar Hematoma

The Clinical analysis of 130 spontaneous intracebral & cerebellar hematoma confirmed by brain CT & admitted to this neurosurgical clinic past years & 5 months were made with literature review. 1) The age incidence showed increase over fourth decade and male to female ratio was 56.1:43.9. 2) 50.4% of total patients showed hypertension but 40.3% did not checked their B.P. & 9.3% had normal B.P. before cerebral hemorrhage. Among 50.4% of hypertension cases, 72% received antihypertensive treatment intermittently, 2.9% regularly and the rest 24.3% did not. 3) 69.7% of hematoma located in basal ganglia & thalamus. In nonoperated patients, the morbidity & mortality showed no marked difference in their location except pontine & cerebellar hematomas. In operated patients the morbidity & mortality was prominent in putaminal hemorrhage than in thalamus and cerebellum. Most of putaminal hematoma had semicomatose or comatose mental state and ventricular hemorrhage in 87.5%. 4) The morbidity & mortality increased in proportion to size of hematomas, grade of unconsciousness in admisson and state of intraventricular hemorrhage. 5) About time interval from ictus to operation, the patients within first 24 hours are 29 cases(51.1%) and the next 24 hours are 13 cases(26.5%). The mortality rate of two groups were 55.1% & 53.8% respectively but no death in the patients with operation performed after 48 hours. 6) The morbidity & mortality rate were as follows. In the non operated patients (90 patients), no or mild neurological deficits:22.2% moderate:21.1% severe:20% and moribund or death:36.6%. In the operated patients no or mild neurological deficits:16.3% moderate:18.4% severe:18.4% and moribund or death:46.9%. The results of total patients showed no or mild neurological deficits:20.1%, moderate:20.1%, severe:19.4% and moribund or death:40.2%.

A Case of Ependymoblastoma in the Posterior Fossa

We have recently experienced a case of ependymoblastoma arising in the posterior fossa. 8 years old Korean boy suffered from headache, vomiting, diplopia and ataxic gait since 4 months prior to admission revealed drowsy mental state papilledema of both eyes, left abducens nerve paralysis, mild cerebellar syndrome in the neurologic examination. The radiological findings of skull revealed increased intracranial pressure and brain CT scan showed calcified round high density mass in the posterior fossa. After 3 weeks of V-P shunt operation, relatively well demarcated grayish-pink mass between the vermis of cerebellum and right cerebellar hemisphere was removed. The histological finding had a pattern of solid cord aroused thin walled blood vessel and typical ependymal rosette. The patient died at 6th postoperative day due to brain stem swelling.

A Case of Cerebral Rete Mirabile with Intracranial Aneurysm

The cerebral rete mirabile with intracranial aneurysm is rare. The authors presented a cerebral rete mirabile with aneurysm which was experienced by us recently and the literature review about 38 cerebral rete mirabile with intracranial aneurysms which were reported until 1981 in the whole world were made. A 22 years old Korean female was admitted due to sudden onset of severe headache and vomiting. Neurological finding revealed positive neck stiffness with Kernig' sign. The carotid angiogram narrowed internal carotid artery and distinct occlusion of middle cerebral artery with vascular network in the base of the brain and small aneurysm in the anterior choroidal artery. The patient was discharged following conservative treatment.

The Brain C.T. Analysis of the Patients with Convulsive Seizure

The pathological manifestation of the patient with convulsive seizures has not been clearly proved mostly until the clinical use of brain computerized tomography. The brain C.T. findings, anamnesis, clinical diagnosis in the 133 consecutive patients who admitted to this hospital because of convulsive seizures from Oct. 1981 to Feb. 1983 were analyzed and literature review was made. 1) The C.T. scan revealed structural abnormalities in 46% of patients with seizure disorders, and cortical atrophy non-specific granuloma etc. 2) The older patients had a high rate of abnormal findings in the brain C.T. than younger patients. 3) The patients having short duration of disease history had higher rate of abnormal C.T. findings. 4) The patients with focal seizure had higher abnormal findings than generalized seizure. 5) The patients with seizure only showed C.T. abnormalities in 22% of cases inspite of patients with positive neurological findings showing C.T. abnormalities in 80% of cases. 6) The patients with temporal lobe lesion showed focal seizures usually in higher rate in compare with the patients with lesion in other part of brain.

Clinical Analysis of Lumbar Myelography with Metrizamide

Metrizamide lumbar myelography were performed in 150 patients with suspected herniated lumbar disc. The examination is easier to perform than with gas or iophendylate. The advantage of metrizamide over gas or iophendylate are the improved root sleeve visualization and examination of small structure such as root, root pocket and blood vessel. And then this is a higher percentage of diagnostic accuracy than can be obtained with other myelogram. Most of adverse reactions during and after myelography are mild and transitory, and no serious adverse reactions occured. It probably has a lower neurotoxicity than any other water soluble contrast agent.

Change of the Ventricular System Following Intraventricular Injection of the Blood

The authors attempted to make experimental intraventricular hemorrhage by injection of autogenous whole blood into the lateral ventricle through a small burr hole and to observe the outcome of the intraventricular hematoma and the consequent change of the ventricular system in the rabbits. 1) The maximum duration of remaining hematoma was 4 days in the ventricular system and 28 days in the subarachnoid space. 2) In the ventricular hemorrhage group, the ventricular began to dilate after 1 day of hemorrhage. 3) The degree of the ventricular dilatation related to the amount of the injected blood into the lateral ventricle. 4) In the microscopic findings of the ventricular dilatation, flattening of the periventricular white matter fiber were more prominent in acute phase and subsided thereafter. Hemosiderin or siderophage observed before 1 week at the ventricular wall and after 1 week at the leptomeninges. The meningeal fibrosis or thickening was almost constantly presented throughout the 4 weeks. 5) The gross and microscopic changes were milder in the steroid therapy group than the others.

Superior Facet Syndrome: Case Report

The intense radicular pain of sciatica caused by a herniated disc is familiar. That similar symptoms may result from nerve root entrapment in a stenotic lateral vertebral recess without discal herniation is less well known and its possibility should be considered in the patients with root pain. We recently experienced a case of superior facet syndrome in a 57 years old female with intense sciatic pain. On operation, the right L-5 root was found to be entrapped in a stenotic lateral recess beneath the superior articular facet of the L-5 vertebra. There was no evidence of a herniated disc. The result was clinically excellent with surgical unroofing of the lateral recess with removal of the overhanging horizontal portion of the superior facet, L-5 vertebra of right.

Biochemical Alterations of Jungular Venous Blood after the Complete Cerebral Ishemia: Lactate and Latate/Pyruvate Ratios of Canine Jugular Venous Blood following Complete Cerebral Bloody-ischemia

If in the aneurysmal rupture patients the brain metabolic parameters obtained from blood chemistry were significant and useful in clinical practice, it cannot be overstimated. Hansdorfer er al.(1973) reported that lactate, pyruvate, uric acid and alpha-HBDH of central venous blood obtained form the patients with brain contusion in basal metabolic state were significantly increased and they were useful in evaluating the prognosis of the patients. Zooping(1970) and Broderson(1974) also had tried to evaluate the prognosis and brain metabolic status of the comatous patients with blood gas analysis and CSF biochemistry. They encouraged us to estimate lactate and lactate/pyruvate ratios of canine jugular venous blood combined with gas analysis. Complete cerebral bloody-ischemia similar with initial stage of aneurysmal rupture was induced by the instanteneous elevation of intracranial pressure 30 mmHg above systemic arterial pressure by infusion of blood and mock CSF mixture into the cisterna arrest or pulmonary hypertension were discarded. At the end of the 5 minutes ischemic period, the needle tip which was inserted in to cisterna magna was removed without decreasing intracranial pressure. At 3 hours, 24 hours, 48 hours and 72 hours after ischemic period jugular venous and arterial blood were sampled for determination of lactate and pyruvate, and blood gas analysis. The following results were obtained. ie ; 1. Both lactate and pyruvate of canine jugular venous blood were increased from 3 hours and reached peak level at 24 hours after insult. Standard value of lactate and pyruvate were 1.416mM and 0.075mM and peak values were 2.429 and 0.165mM(P<0.05). 2. The more severe the neurological deficits of the animals, the highest levels of lactate and pyruvate were observed. 3. The lactate concentrations in 48 hours and 72 hours sample slopped down from 24 hours peak level but were significantly higher than those of standard. 4. Pyruvate returned to the normal range within 48 hours after insult. 5. L/P ratios were not changed significantly until 48 hours after insult but steeply elevated in 72 hours sample. 6. In gas analysis all the animals show respiratory alkalosis after insult. 7. In arterial boundary zones multiple focal ischemia were found in necropsy which was thought as reflecting no-reflow phenomenon. We concluded that elevation of lactate and pyruvate in early stage must be due to the hyperventilation after insult and lactate of late stage reflected CSF lactic acidosis.

A Case of Hemispherectomy for the Treatment of Infantile Hemiplegia with Uncontrolled Epilepsy

Infantile hemiplegia is the end state of various pathological conditions affecting the cerebral hemisphere before or during birth, or in first few years of life. In 1950, Krynauw first reported that total hemispherectomy could be carried out with beneficial results for infantile hemiplegia with uncontrollable convulsion, temper tantrum and mental deficiency. Hemispherectomy is not suitable for all cases of infantile hemiplegia, but is seems clear that it should be undertaken in any case of established infantile hemiplegia with fits which cannot be controlled by drugs, or in which there is backwardness or deterioration in the patient's intellectual or emotional state. We have recently experienced a 8-year-old boy who was suffering left hemiplegia with intractable epilepsy. Both carotid angiogram and pneumoencephalogram showed right cerebral hemiatrophy. After right hemispherectomy intractable seizure was controlled and personality disorder disappeared completely. But left hemiplegia wasn't definitely improved.

A Case of Craniopharyngioma in Adult

The craniopharyngima has been known to be congenital origin and primary tumor of childhood. The craniopharyngioma may be found at all ages, though nearly one half in the first twenty years of life and equally in either sex. Important differences exist between younger and older patients. In children, signs of increased intracranial pressure, endocrine Abnormality and radiological calcification are common. In adults, mental disturbance becomes of increasing importance as well as remaining visual failure and endocrine disturbance. Because of slow growing rate of tumor in adult, subtotal excision is recommended. A 39-year-old male patient, suffering from agitation memory disturbance and almost total blindness, was diagnosed craniopharyngioma by neuroradiologic examinations. After surgical treatment, mental symptoms and visual acuity improved much more than before operation.