Correlation between Symptomatic Vasospasm and Leukocyte, Platelet Count Following Aneurysmal Subarachnoid Hemorrhage: Clinical Research / 대한뇌혈관외과학회지

OBJECTIVE: The mechanisms of vasospasm after subarachnoid hemorrhage (SAH) are still poorly understood. In recent studies, many authors have suggested that platelet aggregation and consumption within the cerebral vessels after SAH is one of the mechanisms of vasospasm. Some authors reported that leukocytosis is a predictive factor of vasospasm. Therefore, we analyzed fever and the leukocyte and platelet counts in patients with aneurismal SAH. Through this analysis, we tried to investigate the predictive factors of symptomatic vasospasm. METHODS: We studied 130 patients who had undergone an aneurysmal neck clipping operation or Guglielmi detachable coil (GDC) embolization within 48 hours after the onset of SAH. Age, gender, hypertension, a history of cerebrovascular accident, aneurysm location, Fisher grade, Hunt-Hess classification, Glasgow coma scale, Glasgow outcome scale, fever, leukocyte, platelet count and the radiologic finding were retrospectively analyzed for both the patients with aneurysmal neck clipping and those with endovascular intervention. RESULTS: One hundred thirty patients were treated for aneurysmal SAH during the review period. Forty nine patients (37.7%) developed symptomatic vasospasm. Symptomatic vasospasm occurred 5.7 days after aneurysmal SAH. During the early hospital period, the Fisher grade (P=0.018), fever (>37.5 degrees C, P=0.029), progressive leukocytosis (WBC>15,000/mm3, P=0.027) and the ratio of thrombocytopenia (platelet count in the hospital/platelet count on admission 37.5 degrees C, odd ratio (OR): 4.022, 95% confidence interval (CI): 1.022-6.866), progressive leukocytosis (WBC>15,000/mm3, OR: 8.182, 95% CI: 1.624-13.417) and the ratio of thrombocytopenia (platelet count in hospital/platelet count on admission < or = 0.67, OR: 11.851, 95% CI: 2.311-21.161) were independent predictors of symptomatic vasospasm on multivariated analysis. CONCLUSION: These results indicated that the Fisher grade, fever and daily monitoring of the leukocyte and platelet counts were important for predicting symptomatic vasospasm after aneurysmal SAH. Especially, fever, leukocytosis and a low platelet count were independent predictors.

Epidural Hematomas due to Occipital Artery Injury Following Ventriculoperitoneal Shunt and Extraventricular Drainage

Ventriculoperitoneal (VP) shunt is a common treatment for hydrocephalic patients. However, complications, such as shunt tube occlusion, infection, intracranial hemorrhage, seizure can occur. Of these, intracranial hemorrhage may occur due to intracranial vascular injury or a rapid decrease of intracranial pressure (ICP). Most of these hemorrhages are subdural hematomas (SDH) while a few are epidural hematomas (EDH). It is extremely rare for an intracranial hemorrhage to occur due to an extension of the bleeding from an injured extracranial vessel. We report two cases of EDH due to occipital artery injury following VP shunt and extraventricular drainage (EVD).

Short-term Coexisting Intracerebral Hemorrhage and Cerebral Infarctions

OBJECTIVE: Short-term coexisting intracerebral hemorrhage and cerebral infarctions defined as the recurrent stroke presented with different type within three weeks. Despite the high recurrence rate of stroke, little attention and insufficient clinical data had been given to short-term coexisting intracerebral hemorrhage and cerebral infarction's features. This study aims to estimate the risk factors and present the clinical features of short-term coexisting intracerebral hemorrhage and cerebral infarctions. METHODS: We investigated 18 patients with short-term coexisting intracerebral hemorrhage and cerebral infarctions who were admitted to our hospital between January 1995 and January 2005. They were subdivided by the recurrence interval such as a group of within one week and another of between one and three weeks as hyperacute and acute respectively. RESULTS: The mean interval between strokes was 6.64 days. Lesional analysis showed that short-term coexisting intracerebral hemorrhage and cerebral infarctions in this study occurred at the other side in 12 cases (66.7%). The abnormality on the electrocardiographic feature (23.5%) and long-term history of hypertension (20.5%) were the most common risk factors. However, short-term history of diabetes was more common in hyperacute group than in acute group (P<0.05). The mean number of risk factors was three in acute group. It is larger than that of hyperacute group (P<0.05). CONCLUSION: If the patients who experienced cerebrovascular attack have many risk factors, they tend to be the cases of acute coexisting intracerebral hemorrhage and cerebral infarctions than hyperacute. Therefore, that cases are required to be vigilant to the change of patients' state up to three weeks in the treatment.

Analysis of Hyponatremia in Patients with Ruptured Intracranial Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Hyponatremia (Na<135 mEq/L) is associated with cerebral ischemia after subarachnoid hemorrhage (SAH) and the incidence was reported as 9-34% of treated cases of SAH. This study was undertaken to clarify the clinical factors of hyponatremia in ruptured intracranial aneurysms. METHODS: Total 170 consecutive patients with ruptured intracranial aneurysms were included in this study and the incidence and timing of hyponatremia were analyzed retrospectively. Clinical severity quantified by the Hunt and Hess grade and Fisher's grade at admission, location of ruptured aneurysm, presence of vasospasm, onset of hyponatremia, development of hydrocephalus and Glasgow Outcome Scale (GOS) were analyzed in patients with hyponatremia. RESULTS: Hyponatremia occurred in 32 (40.5%) of 79 patients with anterior cerebral artery (ACA) aneurysm group, in 18 (40.0%) of 45 patients with internal cerebral artery (ICA) aneurysm group and in nine (22.5%) of 40 patients with middle cerebral artery (MCA) aneurysm group. Hyponatremia occurred significantly more often in cases with vasospasm and hyrocephalus (p<0.05). Among vasospasm cases, hyponatremia was not associated with the location of aneurysm or hydrocepalus. Respective days of onset for symptomatic vasospasm and for hyponatremia were day 7.2+/-3.3 and day 9.9+/-5.5 following SAH (p<0.05). CONCLUSION: Hyponatremia occurred more frequently in patients with vasospasm and hydrocephalus. The onset of hyponatremia was delayed by 3 days following symptomatic vasospasm. Since careful observation for hyponatremia is required during therapy in patients with vasospasm.

Prospective Follow-up Study of Prenatally Diagnosed Central Nervous System Anomalies

OBJECTIVE: Although advances in neuroradiologic imagings have enabled us to diagnose intrauterine central nervous system(CNS) anomalies, it's management remains difficult because the natural history and postnatal outcome were not well understood. This study is undertaken to clarify the natural history and postnatal outcome of prenatally diagnosed CNS anomaly. METHODS: Between January 1999 and October 2002 there were 18 cases of a fetus with a CNS anomaly prenatally diagnosed by ultrasonography. In six cases, intrauterine magnetic resonance(MR) image was undertaken to confirm the findings when ultrasonography was inconclusive. In this prospective follow-up study the authors have applied the "perspective classification of congenital hydrocephalus(PCCH)" proposed by Oi et al. RESULTS: Hydrocephalus was diagnosed in three cases at PCCH stage I, in six cases at stage II, in 9 cases at stage III. In 8 cases, termination of pregnancy were performed due to severe CNS anomalies. Among these cases, hydrocep halus was diagnosed in 3 cases(100%) at stage I, in 3 cases(50%) at stage II, in 2 cases(22.2%) at stage III. Out of these 8 cases, 5 cases underwent autopsy following parental consent. Of the 10 cases who were delivered, 4(40%) patients were treated. In these 4 cases, hydrocephalus was diagnosed at PCCH stage III(3 fetuses survived, 1 fetus died at 6 months after birth). CONCLUSION: The postnatal outcome is significantly poor in the fetuses with CNS anomaly diagnosed in the early gestation. So it is important to diagnose the fetal CNS anomalies in the early stage of gestation and follow up periodically.

Familial Occurrence of Moyamoya Disease in a Father and a Son

Although moyamoya disease is a clinical entity of unknown cause, considerable evidences suggest that the disease has genetic origins. The disease displays regional and racial differences. Occurrence of the disease within a family suggests that moyamoya disease may have a genetic basis. Familial moyamoya disease involving father and a son is presented and literatures are also reviewed.

Hyperprolactinemia After Severe Head Trauma

Patients of head injury may manifest neurohypophyseal dysfunction during the early post-traumatic period. A case of hyperprolactinemia and low prolactin response to thyrotrophin-releasing hormone in a woman 7 months after severe head injury is presented and literatures are also reviewed.

In Vitro Effect of Liposome-mediated Combined p16 and p53 Gene Transfer to the Human Glioblastoma Cell Lines

OBJECTIVE: To overcome the limitations of the single gene transfer, the authors present the results of wild-type p16 and p53 combined genes transfer in vitro to the U251MG and U373MG cell lines using cationic liposome as a vector. METHODS: To compare the therapeutic effect of the combined p16 and p53 genes transfer with the single p16 and p53 gene transfer, full length of wild-type human p16 and p53 gene, and combined p16-p53 genes were transferred in vitro to the U251MG and U373MG cell lines using cationic liposome as a vector. As the U251MG and U373MG cell lines are devoid of p16 and p53 genes, the therapeutic effect of the three groups of gene transfer could be evaluated by the growth suppression or percentage of the viable cells. Reverse transcription polymerase chain reaction(RT-PCR), flow cytometry, and electron microscopy(EM) were used for evaluation of the growth suppression or apoptosis of the tumor cells. RESULTS: p16 gene, p53 gene and the combined p16-p53 genes were effectively transferred to the cell lines using cationic liposome as a vector resulting in dramatic decrease of the viable tumor cells in comparison to the control group(p=0.004). The cytotoxic effect of the gene transfer in the U251MG cell line was the most significant in the combined p16-p53 group. However, in the U373MG cell line p53 single gene transfer group showed more significant effect than the combined gene transfer group. Apoptosis was confirmed by EM in the combined p16-p53 genes group. The G1 phase arrest effect, confirmed by the flow cytometry was more prevalent in the p16 gene transfer group than the other groups. CONCLUSION: Cationic liposome-mediated transfer of combined p16-p53 genes to the human glioblastoma cell lines is proven effective. However, the therapeutic effect of the combined p16-p53 genes transfer was not consistently superior to the single p16 or p53 gene transfer.

The Usefulness of T2* Weighted Magnetic Resonance Image in the Diagnosis of Minute Traumatic Intracerebral Hemorrhage

OBJECTIVE: This study is performed in order to compare T2* weighted magnetic resonance(T2*W MR) image to computerized tomography(CT) and conventional magnetic resonance(MR) image for the detection of minute traumatic intracerebral hemorrhage. METHODS: A series of 40 patients with head trauma underwent CT and MR image including T2*W MR sequnence. The authors compared T2*W MR image to CT and conventional MR image in the diagnosis of traumatic intracerebral hemorrhage. RESULTS: Thirty five of 40 patients(88%) were revealed the hemorrhagic foci in the T2*W MR image, whereas 30 patients(75%) were revealed in the conventional MR image, 18 patients(45%) in the CT. Therefore it is concluded that T2*W MR image is more sensitive than CT or conventional MR image in the diagnosis of minute traumatic intracerebral hemorrhage in patients with head trauma. CONCLUSION: If headache is persisted in the head trauma patients with negative CT and MR image finding, We recommend T2*W MR image.

Subperiosteal Orbital Extension of Subgaleal Hematoma: A Case Report

No abstract available.

The Magnetic Resonance Images and Clinical Features of the Asymptomatic Pineal Cysts

No abstract available.

Rhinocerebral Mucormycosis with Intracerebral Hemorrhage

No abstract available.

Comparision of the Two Groups between Autologous Bone Chips and Cage as Posterior Lumbar Interbody Fusion in Spondylolisthesis Patients

No abstract available.

An Experimental Study of Effects of Nitric Oxide Synthase on Rat Anterior Pituitary Gland

OBJECTIVE: The nitric oxide synthases(NOS) are a group of isoenzymes that convert L-arginine to L-citrulline and generate nitric oxide(NO). The constitutive form of NOS is present in endothelium, adrenal gland, brain, and platelets, while the inducible form of NOS is present in macrophages, hepatocytes, vascular smooth muscle cell and endothelial cells. To determine whether NO has a role in anterior pituitary cell function, immunohistochemistry and molecular techniques were used to study NOS expression in rat pituitary gland. MATERIALS AND METHODS: We treated the rats with two NOS inhibitors: N-mono-methyl amine(NMMA), which is an inhibitor of NOS activity, and aminoguanidine, which a selective inhibitor of the inducible NOS isoform and two NO donors; sodium nitroprusside(SNP), s-nitro-acetyl-penicillamine(SNAP) as well as L-arginine. Rat growth hormone was measured in the serum using radioimmunoassay and NOS producing cells in the anterior lobe of the pituitary was detected by immunohistochemical stains. Also mRNA was extracted from the pituitary and performed RT-PCR using inducible NOS primer. RESULTS: Serum growth hormone levels were increased significantly by administration of NOS inhibitors, such as NMMA and aminoguanidine. Immunohistochemical stains for neuronal and inducible NOS showed strong positivity in the folliculostellate cells and weak positivity in the anterior pituitary cells in the control and various experimental groups. RT-PCR in inducible NOS showed more brighter band in the 222 base pairs in the aminoguanidine treated group than normal control group. CONCLUSION: These data suggest that pituitary NOS may play a pivotal role in the control of growth hormone secretion.

Prognostic Factors of Lumboperitoneal Shunt in Communicating Hydrocephalus

OBJECTIVE: A 10-year retrospective lumboperitoneal(LP) shunt surgery was reviewed in order to verify the several prognostic factors including the etiology, the findings of brain computed tomography(CT) and/or magnetic resonance imaging(MRI), and the effect of lumbar drainage which have been implicated in the result of LP shunt. PATIENTS AND MEHTODS: A series of 32 patients who underwent LP shunt surgery between March 1988 and May 1998 for the management of communicating hydrocephalus was reviewed. RESULTS: The etiology of communicating hydrocephalus was subarachnoid hemorrhage(SAH) in 19 cases(59.4%), head trauma in 10 cases(31.2%), intracerebral hemorrhage in 2 cases(6.3%), meningitis in 1 case(3.1%), tumor in 1 case(3.1%), and idiopathic in 2 cases(6.3%). The mean follow-up period was 1.2 years(range, 2 week to 8.5 year). Among them, twenty four patients(75%) were clinically improved after shunt operation. The result of LP shunt was not related to the etiologies and many findings of brain CT/MRI such as ventricular index, Evan's index, periventricular low density, obliteration of cerebral sulci and cortical atrophy. However, the result of LP shunt was significantly related to the effect of preoperative lumbar drainage(p=0.0184). CONCLUSION: This result suggests that the effect of preoperative lumbar drainage has a significant role in predicting the result of LP shunt in patients with communicating hydrocephalus.

Clinical Analysis of Metastatic Brain Tumors

Several prognostic factors have been implicated in survival prolongation in patients with metastatic brain tumors. Among these, surgery has been regarded as very significant one with respect to life prolongation and improving the quality of survival in such patients. From August 1982 through July 1996, a series of 31 patients with metastatic brain tumors among 785 patients with operated brain tumors, whose medical records, X-rays and follow-ups were avilable, was studied retrospectively to evaluate the beneficial effects of surgery. Despite the limitations inherent to the retrospective study and limited number of patients, we divided these patients into two groups to find out any statistical differences in terms of survival and quality of survival among them: 1) Conservative group(8 nonoperated patients: 5 patients with biopsy or partial resection): 13, and 2) Surgical treatment group(17 totally resected patients: one patient with subtotal resection): 18. The quality of survival was assessed by Karnofsky performance(KP) scale before and after each treatment. The survival of the patients in the surgical treatment group was longer than the conservative treatment group(14.5 months/10 months), but this was not statistically significant(p value: 0.3305). However, improvement of quality of survival, in terms of KP scale, was significantly higher in the surgical treatment group(p value: 0.0027). Although confounded by the lack of controlled, randomized study and limitations of retrospective study, aggressive surgery can be regarded to have a significant role in improving the quality of survival in patients with metastatic brain tumors.

Clinical Analysis of Diffuse Axonal Injury(DAI) Diagnosed with Magnetic Resonance Image(MRI)

Atotal of 26 patients diagnosed as diffuse axonal injury(DAI) between Nov. 1993 and Dec. 1995, were evaluated retrospectively with special attention given to MRI findings. In clinical aspects, there was male predominance(1.9:1) with the mean age of 28.5 years. The clinical grades based on the Glasgow coma scale(GCS) score were classified as mild(13-15), moderate(9-12) and severe(3-8). The duration of hospitalization and loss of consciousness(LOC) at admission were well correlated with the severity of clinical status. As regards the outcome of patients, twenty patients(77%) recovered as alert, but three patients(12%) died of sepsis. Short duration of LOC less than one day and young age of less than 10 years were good prognostic factors. The MRI findings of DAI were divided into three grades; in grade 1, there was small scattered lesions in the white matter of the cerebral hemisphere, in grade 2, focal lesion in the corpus callosum, and in grade 3, there was an additional focal lesion in the brain stem. The final outcome of grade 3 was poor, but in grade 2, there was wide spectrum between initial clinical status from alertness to semicoma and relative good result.

Acute Epidural Hematoma Following Ventriculo-Peritoneal(V-P) shunt Operation

Ventriculo-peritoneal(V-P) shunt operation has been accepted as the most effective and safe procedure for the relief of increased intracranial pressure in hydrocephalic patients of various etiologies. A variety of complications have been reported in association with these relatively easy surgical procedures. Overdrainage induced effusions occur commonly in the subdural and rarely in the epidural spaces. Six cases of epidural hematoma(EDH) have been reported thus far in the literature following shunt operation remote from the catheter implantation. We report another case of this extremely rare complication of such procedures in a 16-year-old girl.

Surgical Treatment of Intracranial Arachnoid Cysts

Eighteen patients with symptomatic intracranial arachnoid cysts underwent 27 surgical procedures between January 1990 and December 1995. These were analysed with respect to their surgical procedures and results, complications and prognosis retrospectively, with an attempt assess the efficacy of each surgical procedure. Thirteen patients underwent excision of the inner and outer membranes with fenestration procedures to the basal cisterns(primary excision group), resulting in excellent or good outcomes in 12 cases, of which three patients were subjected to secondary shunt procedures due to symptom recurrence in two and persistence of the cyst in one during follow-up radiological study. There were no significant complications in this primary excision group. Four patients out of five in the primary shunt group had good or excellent results. But shunt revisions had to be performed in two patients;of these two patients, one died from subdural empyema and sepsis while the outcome of the other one was satisfactory. The results of this study suggested that excision and fenestration should be considered as the primary procedure in patients with symptomatic intracranial arachnoid cyst, especially in the pediatric age group.

Expression of bFGF and VEGF in brain astrocytoma

Neovascularization is an important factor in the prognosis of brain tumor and many angiogenetic factors have been evaluated for prognostic significance. Among them, basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) are known as potent angiogentic factors and mitogens. We evaluated seven cases of grade II brain astrocytoma. Four, group A, was diagnosed as anaplastic progression at their second operation, and three, group B, did not. Using monoclonal antibodies to bFGF and VEGF in paraffin embedded tissue from first operation, their immunoreactivity and differences between two groups were examined. The growth fractions of these tumor were also measured by Ki-67 monoclonal antibodies (MIB1). Immunostaining for bFGF in tumor cells were observed in both nuclei and cytoplasm, and for VEGF, mainly observed in the cytoplasm. Mean cell count number +/- standard deviation per high power field in each were as follows: 1) for bFGF, 20.08 +/- 6.38 in group A and 0.87 +/- 0.90 in group B (p< 0.01), 2) for VEGF, 43.75 +/- 17.09 in group A, and 0.8 +/- 1.06 in group B (p< 0.05) and 3) for the proliferation index with Ki-67 antibodies, 3.20 +/- 0.81 in group A and 0.77 +/- 1.03 in group B (p< 0.05). This data supports the assertion that angiogenetic factor such as bFGF and VEGF may contribute to progressive change of astrocytoma by tumor angiogenesis.