Isolated Cerebral Mucormycosis

Isolated cerebral mucoromycosis, without rhino-orbital focus, is an extremely rare but life-threatening infection of central nervous system that most commonly found in intravenous drug abuser. We present a case of isolated cerebral mucormycosis diagnosed by open biopsy and treated with amphotericin B. The patient has returned to independent living.

Clinical Analysis of Video-assisted Thoracoscopic Spinal Surgery in the Thoracic or Thoracolumbar Spinal Pathologies

OBJECTIVE: Thoracoscopic spinal surgery provides minimally invasive approaches for effective vertebral decompression and reconstruction of the thoracic and thoracolumbar spine, while surgery related morbidity can be significantly lowered. This study analyzes clinical results of thoracoscopic spinal surgery performed at our institute. METHODS: Twenty consecutive patients underwent video-assisted thoracosopic surgery (VATS) to treat various thoracic and thoracolumbar pathologies from April 2000 to July 2006. The lesions consisted of spinal trauma (13 cases), thoracic disc herniation (4 cases), tuberculous spondylitis (1 case), post-operative thoracolumbar kyphosis (1 case) and thoracic tumor (1 case). The level of operation included upper thoracic lesions (3 cases), midthoracic lesions (6 cases) and thoracolumbar lesions (11 cases). We classified the procedure into three groups: stand-alone thoracoscopic discectomy (3 cases), thoracoscopic fusion (11 cases) and video assisted mini-thoracotomy (6 cases). RESULTS: Analysis on the Frankel performance scale in spinal trauma patients (13 cases), showed a total of 7 patients who had neurological impairment preoperatively : Grade D (2 cases), Grade C (2 cases), Grade B (1 case), and Grade A (2 cases). Four patients were neurologically improved postoperatively, two patients were improved from C to E, one improved from grade D to E and one improved from grade B to grade D. The preoperative Cobb's and kyphotic angle were measured in spinal trauma patients and were 18.9+/-4.4 degrees and 18.8+/-4.6 degrees, respectively. Postoperatively, the angles showed statistically significant improvement, 15.1+/-3.7 degrees and 11.3+/-2.4 degrees, respectively (P<0.001). CONCLUSION: Although VATS requires a steep learning curve, it is an effective and minimally invasive procedure which provides biomechanical stability in terms of anterior column decompression and reconstruction for anterior load bearing, and preservation of intercostal muscles and diaphragm.

Novalis Radiosurgery of Primary Central Nervous System Lymphoma in Elderly Patients: Preliminary Results

OBJECTIVE: Primary central nervous system lymphoma(PCNSL) is a non-Hodgkin's lymphoma arising in the central nervous system. Combined chemotherapy and radiation therapy is the standard treatment for PCNSL. However, treatment induced neurotoxicity is a major problem especially in elderly patients. METHODS: From May 2001 to April 2004, elderly five patients with PCNSL confirmed via pathological examination were underwent Novalis radiosurgery in authors' institution, who were investigated retrospectively. Of these patients, 2 were male and 3 were female, with a mean age 68 years old (range 65~73). The number of lesions was 1 in 2 patients, 2 in 2, and 3 in 1. The mean follow up period was 12.6 months (range 8~16). RESULTS: Clinical symptoms and signs in all patients markedly improved within 1 weeks after Novalis radiosurgery. The Karnofsky performance status score was also improved from a pre-radiosurgery average of 68 to a post-radiosurgery one of 82. All of treated lesions showed a partial or complete regression of the original mass. There have been no complication following Novalis radiosurgery. CONCLUSION: The preliminary results of our experience indicate that radiosurgery with Novalis provides a safe and effective therapeutic alternative treatment of PCNSL in elderly patients.

Fractionated Stereotactic Radiotherapy in Pediatric Diffuse Intrinsic Brain Stem Gliomas

OBJECTIVE: We treated 10 pediatric diffuse intrinsic brain stem glioma(BSG) patients with Novalis system (linac based radiotherapy unit, Germany) and examined the efficacy of the Fractionated Stereotactic Radiotherapy(FSRT). METHODS: A retrospective review was conducted on 10 pediatric diffuse intrinsic BSG patients who were treated with FSRT between May, 2001 and August, 2004. The mean age of the patient group was 7.7 years old. Male to female ratio was 4 to 1. The mean dose of FSRT was 38.7Gy, mean fractionated dose was 2.6Gy, mean fractionation size was 16.6, and target volume was 42.78cm3. The mean follow up period was 14 months. RESULTS: Four weeks after completion of FSRT, improvements on neurological status and Karnofsky performance scale(KPS) score were recorded in 9/10 (90%) patients and magnetic resonance imaging(MRI) showed decrease in target tumor volume in 8 pediatric patients. The median survival period was 13.5 months after FSRT and treatment toxicity was mild. CONCLUSION: It is difficult for surgeons to choose surgical treatment for diffuse intrinsic BSG due to its dangerous anatomical structures. FSRT made it possible to control the tumor volume to improve neurological symptoms with minimal complications. We expect that FSRT is a feasible treatment modality for pediatric diffuse intrinsic BSG with tolerable toxicities.

Novalis Shaped Beam Radiation Treatment for Craniopharyngiomas

OBJECTIVE: To evaluate the effectiveness of Novalis shaped beam radiation treatment as an adjuvant treatment in patients with craniopharyngiomas. METHODS: We reviewed 8 patients with craniopharyngiomas who had recurring tumors during follow-up or had residual lesions after primary surgery. Three of 8 patients were found to have recurrence after gross total excision of the tumor and 5 patents had residual lesions after subtotal resection. All patients were treated with fractionated stereotactic radiation treatment(FSRT) using Novalis system. The mean age of patients was 28 years (range 16~52). The median irradiation dose per fraction was 1.7Gy (range 1.7~2.0). The median fraction number was 23 (range 15~25), and the median total dose was 39.1Gy (range 25.5~42.5). Follow-up included MR imaging, and ophthalmologic and endocrine examinations. RESULTS: The median follow-up period was 23 months (range 12~43). The local tumor control rate was 87.5%. One patient had a recurring tumor, in which cystic change developed 2 months after FSRT. Four patients showed a decrease in size of their tumor, while 3 patients remained stable. Seven out of 8 patients had hormonal dysfunction that remained unchanged after initial surgery. No further progression of visual impairment was observed. CONCLUSION: FSRT using Novais system is effective and safe for the treatment of recurring or residual craniopharyngiomas without toxicity like optic neuropathy.

Metastatic Spinal Tumors: MR Findings after Novalis Radiosurgery

PURPOSE: To assess the therapeutic effect of Novalis radiosurgery for metastatic spinal tumors and evaluate the changes after treatment using MR imaging. MATERIALS AND METHODS: Between November 2003 and June 2005, 21 patients with metastatic spinal tumors underwent Novalis radiosurgery. Of these patients, the 7 with 13 metastatic spinal tumors who had undergone follow-up MR imaging were included in this study. The tumor locations were cervical spine in three, thoracic spine in four, lumbar spine in five and sacrum in one. During the first three months after Novalis radiosurgery, follow-up MRI was performed monthly and subsequently at 3-6-month intervals. On MR imaging, the volume of the tumors, the changes of their signal intensities and any changes in adjacent spinal cord were evaluated. RESULTS: Among the 13 lesions, 9 were decreased in volume (69.2%), 2 were stable (15.4%) and 2 were slightly increased. Seven of 9 lesions showed decreased signal intensity on T2 weighted images and 4 had compressive deformity. Two of 9 lesions had increased T2 signal intensity and tumor necrosis were detected on contrast-enhanced MR imaging. No changes in spinal cord were noted in any of the lesions. Those changes were detected on MRI obtained 1 month after Novalis surgery and the lesion sizes were gradually changed up to 3 months. CONCLUSION: Novalis radiosurgery was effective for the treatment of metastatic spinal tumor and the suppression of tumor growth. The estimation of therapeutic effect and detecting complication were precisely evaluated on MR imaging.

Huge Size Intracranial Plasmacytoma Treated with Surgery and Fractionated Stereotactic Radiotherapy

Surgery and radiotherapy are mainly used for plasma cell neoplasm which constitutes about 1~2% of human malignancy. The authors carried out Fractionated Stereotactic Radiotherapy(FSRT) on the residual tumor after the subtotal removal of intracranial plasmacytoma. A huge mass lesion was observed on MRI (magnetic resonance image) in the left anterior and middle cranial fossa of a 63-year-old man with left exophthalmus which lasted for a month, and was suspected as a meningioma with strong contrast enhancement. Extramedullary plasmacytoma was diagnosed on histopathological examination. After the surgery, FSRT was also carried out on the residual tumor which invaded the skull base. One-year follow up after FSRT showed contrast enhancement only in the left sphenoid bone on MRI, which indicated significant decrease in the size of the tumor without any abnormal neurologic deficits. We treated intracranial plasmacytoma which invaded left anterior and middle cranial fossa and surrounded cavernous sinus without cranial nerve deficit through subtotal tumor removal and FSRT.

Choroid Plexus Carcinoma in an Adult

Choroid plexus carcinomas are extremely rare in adults. They can behave aggressively and their optimal management is uncertain. A 35-year-old woman was admitted with an episode of loss of consciousness. Magnetic resonance imaging showed a homogeneously enhancing mass in the trigone of the right lateral ventricle. Detailed examinations found no evidence of an extraneural primary focus. She underwent total removal of the tumor. Pathological diagnosis was confirmed as a choroid plexus carcinoma. She is doing well eight months after surgery.

Spinal Metastases from Supratentorial Glioblastoma

The tendency of glioblastoma multiforme(GBM) to metastasize to the cerebrospinal fluid is well documented. However, symptomatic intradural extramedullary metastasis of GBM in the spinal cord are rarely reported. A 31-year-old female with a previously treated supratentorial GBM presented with back pain and lower extremities weakness. Magnetic resonance imaging of the thoracic spine demonstrated an intradural extramedullary mass at levels of T2-T4 and arachnoid membrane enhancement. The patient underwent an operation. Pathologic diagnosis was confirmed as spinal metastases of GBM. We present a case of spinal metastases from supratentorial GBM presented with paraparesis.

Distal Middle Cerebral Artery Aneurysm: Case Report / 대한뇌혈관외과학회지

OBJECTIVE: Middle cerebral artery (MCA) aneurysm, which takes up about 25% of all intracranial aneurysms, usually occurs in MCA bifurcation, and 10% occurs in proximal MCA, and about 1% occurs in distal MCA. For that reason, it is rare to find an understanding and report on distal MCA aneurysm in its clinical aspect and radiological characteristics. In this class, four people experienced distal MCA aneurysm with subarachnoid hemorrhage (SAH), and it was reported along with document research. METHODS: Among the 214 intracranial aneurysm operations carried out in this class from May 2001 to May 2004, We report four ruptured distal MCA aneurysms. RESULTS: Distal MCA aneurysm was equal male to female ratio, and manifested in M2 segment mainly. In the case of ruptured distal MCA aneurysm, intracerebral hematoma (ICH) is usually accompanied, showing poor pre-operation grade, and no intracranial aneurysm was found on other regions. Except one case of mycotic aneurysm, all were saccular types. Aneurysm clipping was carried out in trans-sylvian approach, and except one case of Glasgow Coma Scale (GCS) of 3 points before operation, all showed good recovery. CONCLUSION: Distal MCA aneurysm is usually accompanied by ICH and shows poor preoperative grade, but early surgery draws favorable outcome. Distal aneurysm is not anatomically well known and has problems in dissection, therefore intraoperative angiography can be helpful to the surgery, and in case distal MCA aneurysm should be discovered, it is wise to carry out an evaluation on the possibility of mycotic aneurysm.

Intradural Invasion of Extradural Clival Chordoma

Most chordomas show extradural extension and bone destruction. A 32-year-old man presented with neck pain and progressive paraparesis. He had been diagnosed a clival chordoma and underwent an operation seven years ago. Radiological studies revealed that the tumor was recurred in a retroclival area and invaded into intradural region. We removed the tumor by two staged operations. After surgery, satisfactory resluts were achieved.

Intradural Invasion of Extradural Clival Chordoma

Most chordomas show extradural extension and bone destruction. A 32-year-old man presented with neck pain and progressive paraparesis. He had been diagnosed a clival chordoma and underwent an operation seven years ago. Radiological studies revealed that the tumor was recurred in a retroclival area and invaded into intradural region. We removed the tumor by two staged operations. After surgery, satisfactory resluts were achieved.

Aneurysmal Bone Cyst of a Thoracic Vertebra

The authors describe a case of aneurysmal bone cyst of a thoracic vertebra. A 34-year-old woman presented with posterior neck and upper back pain. Radiological examination demonstrated an aneurysmal bone cyst involving the posterior elements of the second thoracic vertebra. The spinal cord was compressed severely also. Satisfactory results were obtained after complete resection of the lesion.

Giant Serpentine Intracranial Aneurysm Treated with Wrapping under the Extracorporeal Circulation and Hypothermia

The giant serpentine aneurysm(GSA) is an entity defined on radiological and pathological grounds as a giant, partially thrombosed aneurysm containing tortuous vascular channel which usually supplies the territory distal to the aneurysm. GSAs belong to the subgroup of giant aneurysms, however, they are distinct from giant saccular and fusiform aneurysms. We present a case of giant serpentine aneurysm of a middle cerebral artery treated with wrapping under the extracorporeal circulation and hypothermia.

Fractionated Stereotactic Radiosurgery(FSRS) for Sella and Parasella Tumors Adjacent to Optic Apparatus

OBJECTIVE: Compared with other neural structures, optic apparatus are particularly sensitive to radiation. If tumors are adjacent to or in contact with optic apparatus, a number of limitations need to be addressed for planning radiosurgery. To avoid radiation induced optic neuropathy, we treated these lesions with fractionated stereotactic radiosurgery (FSRS). This study is undertaken to assess the efficacy of FSRS for sella and parasella tumors adjacent to or in contact with optic apparatus. METHODS: We treated 19 sellar region tumors located adjacent to or in contact with optic apparatus with fractionated stereotactic radiosurgery using the Novalis system. Seventeen patients who could be followed were included in this study. They consisted of 8 pituitary adenomas, 4 optic gliomas, 3 meningiomas, 2 craniopharyngiomas. The mean tumor volume was 16.1cc(range 1-61.1). When planning FSRS, the prescribed fractionation dose to optic apparatus below 200cGy. Follow up examinations consisted of neurological, neuroradiological, and neuroopthalmological evaluations. RESULTS: Follow-up ranged from 2 to 34 months(mean 15 months). Serial magnetic resonance imaging revealed no increase in volume of tumor in all 17 patients. No patients had radiation induced optic neuropathy. CONCLUSION: Fractionated stereotactic radiosurgery is proper innovative treatment modality for sella or parasella tumors adjacent to or in contact with optic apparatus to avoid radiation induced optic neuropathy. We need further follow-up and clinical experiences.

Intracranial Erdheim-Chester Disease

Erdheim-Chester disease is a rare form of non-Langerhans cell histiocytosis consisting of disseminated xanthogranulomatous infiltration and fibrosis that involves the long bones, visceral organs, orbital, retroperitoneal and soft tissues. Intracranial involvement is very rare, although the most common site is extra axial if it occurs. In our case study, a 53-year-old woman with one-month history of left hemianopsia was examined and treated. Her initial T2-weighted MRI revealed increase in signal intensity and an irregularly enhanced mass following gadolinium injection in the right temporal lobe. Stereotactic biopsy was done, and histopathological diagnosis was Erdheim- Chester disease, consist of sheets of foamy histiocytes with abundant cytoplasm. The patient was treated with oral corticosteroid for 4 weeks. During next 6 months, the clinical picture and the MRI showed improvements.

Intracranial Plasma Cell Granuloma: Case Report

We report a case of intracranial plasma cell granuloma which is a rare intracranial tumor showing plasma cell infiltration. It mimics meningioma or solitary plasmacytoma clinically and radiologically. Clinical presentation and diagnostic investigations are discussed and pertinent literatures are reviewed.

A Case of Cauda Equina Schwannoma Presenting as Normal Pressure Hydrocephalus

A 61-year-old man presented with cognitive dysfunction and an 8-month history of progressive gait disturbance. Brain MRI revealed communicating hydrocephalus. Under the impression of normal pressure hydrocephalus, cerebrospinal fluid (CSF) study was done and showed unusually increased opening pressure (40 cm H2O) and protein concentration (650 mg/dl). Spine MRI was performed to rule out the possibility of intraspinal tumor. It revealed cauda equina mass, which was confirmed to be schwannoma pathologically. Intraspinal tumor should be suspected in patients with abnormally increased CSF opening pressure and/or CSF protein who presented as normal pressure hydrocephalus.

Dysplastic Gangliocytoma of Cerebellum(Lhermitte-Duclos Disease): Relation to Cowden Disease

We report a case of dysplastic gangliocytoma of the cerebellum(Lhermitte-Duclos disease) that can cause progressive mass effect in the posterior fossa. Cowden disease is a rare autosomal dominant disorder characterized by mucocutaneous hamartoma and high incidences of systemic malignancies. The patient had no mucocutaneous lesions indicating Cowden disease. With recent advances in molecular genetics, the association between Lhermitte-Duclos disease and Cowden disease has been recognized, it is considered that Cowden disease is a new phakomatosis. Recognition of this association has direct clinical relevance and long term follow up may lead to the early detection of malignancy.

Clinical Application of Image Guided Surgery: Zeiss SMN System

No abstract available.