Ventriculostomy-Associated Infection : Analysis of Risk Factors and the Venue of External Ventricular Drainage / 대한뇌혈관외과학회지

OBJECTIVE: The purpose of this study is to evaluate the risk factors for ventriculostomy-associated infections (VAI) and to examine the differences among VAI according to the venue of catheter placement in our institute. Materials and METHODS: During a four-year period, 114 patients of the neurosurgical intensive care unit (NICU) who received an external ventricular drainage (EVD), were retrospectively studied. The use of prophylactic systemic antibiotics was not included in the evaluation of the risk factors for VAI, because this was applied to all patients in our trial. RESULTS: One hundred sixty-five catheters were placed, in 114 patients, among whom 7.9% developed ventriculitis. The risk of VAI was not significantly associated with age, intial Glasgow coma scale (GCS) score, indication for the catheter, craniotomy, duration of catheter, DM, hypertension and repeated catheter insertion. Furthermore, EVD catheterization in non-operating places was not associated with a trend toward higher VAI as well. CONCLUSION: Risk factors for an increased incidence of VAI were not observed in our trials. In our study, the risk of VAI was not associated with the venue of catheter placement. These findings suggest that EVD catheter insertion in non-operating places may be a safe procedure without the risk of VAI.

Outcome of Aneurysmal Subarachnoid Hemorrhage Patients with Hunt-Hess Grade III / 대한뇌혈관외과학회지

OBJECT: We designed this study to bring the outcome and the outcome predictors of Hunt-Hess grade III patients to light, and to be aid in determining treatment protocol of such a intermediate group. METHODS: All patients with non-traumatic subarachnoid hemorrhage who visited our hospital between January 1998 and December 2004, were reviewed. We selected 72 Hunt-Hess grade III aneurysmal subarachnoid hemorrhage patients for detailed review. 54 operations and 10 endovacular procedures were performed. The outcome of the patients were evaluated with Glasgow Outcome Scale (GOS). Through univariate and multivariate analysis, several clinical and operative factors were evaluated to determine the significance for the outcome. RESULT: Overall 58 patients were in good outcome group (GOS 4 or 5). overall 6-month mortality was 5.6%. Age, presence of intracerabral hemorrhage(ICH) on the initial computed tomography (CT) scan, and vasospasm were independently important in determining outcome. CONCLUSION: In the Hunt-Hess grade III aneurysmal SAH patient, age, presence of ICH on intial CT scan vasospasm have independent statistical significance to the outcome. More aggressive treatment of vasospasm can improve the outcome.

Spontaneous Intracranial Epidural Hematoma Following Thoracolumbar Schwannoma Removal

We report a case of spontaneous intracranial epidural hematoma following the intraoperative course of a patient who had undergone surgical removal of a thoracolumbar schwannoma in olivo-ponto-cerebellar atrophy. To our knowledge there is no reported case in which the thoracolumbar schwannoma removal was followed by such a complication. Mechanical events leading to this complication are unclear. Abnormal results of a neurological examination in the early postoperative period should suggest this possibility.

Cerebrospinal Fluid Flow Study of Normal Craniocervical Neuraxis Using the Cine Phase Contrast Magnetic Resonance Technique in Korean

OBJECTIVE:To evaluate the normal figure of intracranial and intraspinal cerebrospinal fluid(CSF) dynamics, we report the results of the various parameters of cine phase contrast(PC) magnetic resonance(MR) CSF flow images throughout the whole neuraxis. METHODS: The MR images were obtained with 1.5T unit using the cine PC sequence with cardiac gating and gradient echo imaging in 10 normal persons(mean age, 30.4 years). The temporal velocity information from the anterior and posterior cervical pericord subarachnoid spaces, third and fourth ventricles, aqueduct, and lumbar cistern were plotted as wave forms. The wave forms were analyzed for configurations, amplitude parameters, and temporal parameters. The statistical significance of each parameter was examined with paired t-test. RESULTS: The actual flow of CSF were clearly visible with cine MR images. Throughout the whole neuraxis, the distinct reproducible configuration features were not obtained at ventricular or lumbar cistern, but at aqueduct and cervical pericord spaces. The temporal parameters were more important than the amplitude parameters. CONCLUSION: In this study, the authors demonstrated normal CSF dynamics and obtained further precision by plotting the temporal velocity information from the images as a waveform. This important basic information may be useful for understanding altered physiology in disease states such as syringomyelia and hydrocephalus.

A Comparative Analysis of C-arm Fluoroscopic Guided and Computed Tomography-guided Stereotactic Catheter Drainage of Hypertensive Intracerebral Hematoma

OBJECTIVE: For the treatment of the hypertensive intracerebral hemorrhage, stereotactic catheter drainage of hematoma has been widely used as a less invasive and effective therapeutic modality. However stereotactic catheter drainage method occasionally can not be available. Here, we introduce C-arm fluoroscopic guided catheter drainage of hematoma as an alternative method. The authors compared the two methods and report the result with review of the literatures. METHODS: A total of 62 patients with hypertensive intracerebral hemorrhage who underwent catheter drainage between February 1996 and December 1999 were reviewed. The patients were divided into two groups according to the method of catheter insertion. The two groups were compared with respect to pre- and post-operative changes of hematoma volume and neurological deficit, hematoma drainage rate, duration of catheter placement, complication, and short term prognosis. RESULTS: The pre-operative hematoma volume was slightly large in the C-arm fluoroscopic guided method group. But post-operative hematoma volume, pre- and post-operative neurological deficit, hematoma drainage rate, duration of catheter placement, post-operative complication and short term prognosis were not different statistically between the two groups. The preparation time for operation was short in C-arm fluoroscopic guided group. CONCLUSION: C-arm fluoroscopic guided catheter drainage of intracerebral hematoma can be an alternative to the stereotactic guided method in the urgent situation or when the stereotactic system is not available

Cervical Epidural Hematoma Caused by Ruptured Arteriovenous Malformation: Case Report

No abstract available.

A Case of Penetrating Head Injury by a Western-Style Arrow: A Case Report

No abstract available.

Endoscopic Surgery of a Subependymal Giant Cell Astrocytoma Associated with Tuberous Sclerosis: Case Report

No abstract available.

Intra-aneurysmal Pressure Changes according to Clippings on the Parent Artery and Aneurysm in Experimental Model of Rabbits: a Preliminary Study

Temporary clipping on parent artery is widely accepted as a useful method to prevent intraoperative aneurysmal rupture, to dissect the aneurysm safely, and to obtain the clear operation field during intraoperative aneyrysm rupture. However, the exact role and adequate technique of the temporary clipping has yet to be determined. The authors performed an experimental study to investigate the effect of temporary clipping on intra-aneurysmal pressure. The experimental aneurysms, using side-to-side anastomosis between common carotid artery and the jugular vein, were made in 24 rabbits. The intra-aneurysmal pressure was monitored through a catheter inserted in the aneurysm. The intra-aneurysmal pressure was significantly decreased to 31.8+/-4.39mmHg after temporary clipping on the proximal common carotid artery(p<.05). On the contrary, intra-aneurysmal pressure was increased to 73.3+/-4.39mmHg after the distal parent temporary clipping. In case of the temporary clipping on both proximal and distal parent artery, the intra-aneurysmal pressure was markedly increased to 81. 0+/-11.7mmHg(p=0.0036 on t-test). In conclusion, the temporary clipping on the parent artery should be performed only on the proximal site of the aneurysm. Temporary clipping on both proximal and distal site would be rather dangerous since it causes sharp increase in intra-aneurysmal pressure during the clipping of aneurysm itself.

Intra-aneurysmal Pressure Changes according to Clippings on the Parent Artery and Aneurysm in Experimental Model of Rabbits: a Preliminary Study

Temporary clipping on parent artery is widely accepted as a useful method to prevent intraoperative aneurysmal rupture, to dissect the aneurysm safely, and to obtain the clear operation field during intraoperative aneyrysm rupture. However, the exact role and adequate technique of the temporary clipping has yet to be determined. The authors performed an experimental study to investigate the effect of temporary clipping on intra-aneurysmal pressure. The experimental aneurysms, using side-to-side anastomosis between common carotid artery and the jugular vein, were made in 24 rabbits. The intra-aneurysmal pressure was monitored through a catheter inserted in the aneurysm. The intra-aneurysmal pressure was significantly decreased to 31.8+/-4.39mmHg after temporary clipping on the proximal common carotid artery(p<.05). On the contrary, intra-aneurysmal pressure was increased to 73.3+/-4.39mmHg after the distal parent temporary clipping. In case of the temporary clipping on both proximal and distal parent artery, the intra-aneurysmal pressure was markedly increased to 81. 0+/-11.7mmHg(p=0.0036 on t-test). In conclusion, the temporary clipping on the parent artery should be performed only on the proximal site of the aneurysm. Temporary clipping on both proximal and distal site would be rather dangerous since it causes sharp increase in intra-aneurysmal pressure during the clipping of aneurysm itself.

Continuous Monitoring of Jugular Venous Oxygen Saturation in Severe Head-injured Patients

The continuous measurement of jugular venous oxygen saturation(SjvO2) with a fibroptic catheter is evaluated as a method of detecting cerebral ischemia after head injury. Fifty patients admitted to the hospital who were unconscious after severe head injuries had continuous and simultaneous monitoring of SjvO2, intracranial pressure, arterial oxygen saturation, arterial blood pressure. Whenever SjvO2 dropped to less than 50%, a standardized protocol was followed to confirm the validity of the desaturation and to elucidate its cause. A total of 72 episodes of jugular venous oxygen desaturation occurred in 45 patients, possibly due to intracranial hypertension in 39 episodes, arterial hypoxia in 13, combinations of the above in 9, systemic hypotension in 7, and anemia in 4. Two episodes of hyp-eremia, SjvO2 more than 90%, occurred in 2 patients with carotid-cavernous fistula. The incidence of jugular venous oxygen desaturation found in this study suggests that continuous monitoring of SjvO2 may be of clinical value in patients with head injury.

Transaqueductal Migration of the Neurocysticercus Cyst: Two Case Report

The authors report two cases of radiologically documented transaqueductal migration of intraventricular neurocysticercus cysts. The patients had suffered from symptomatic hydrocephalus caused by neurocysticercosis. The migration of the cysts from third to forth ventricle and cisterna magna were clearly demonstrated on serial radiological studies. Since the exact route of the subarachnoid type of the neurocysticercosis has not been defined, these cases may provide a valuable clue in verifying the pathogenic pathway. The possibility of the cyst migration before surgery also should be kept in mind. The radiological appearance and the clinical significance of this condition are discussed with brief review of literatures.

The Efficacy of the Unicortical Screw in the Anterior Cervical Fusion of the Degenerative Cervical Spine Disease

Anterior cervical fusion without internal fixation destabilizes an already unstable spine and can result in tenuous bone graft stability and potential for incorporation. Anterior fusion of cervical spine with screw-plates is gaining in popularity in the management of anterior cervical spine instability. Eighty six cases that underwent anterior fusion with or without internal fixation and autogenous iliac bone graft were compared and analyzed. The pathologies included 40 cases of cervical disc disease, 43 of cervical spondylosis and 3 of ossification of posterior longitudinal ligament. Changes in the alignment of the total cervical spine and of the fused segment were evaluated in both groups. Dislodgement of the grafted bone, which was observed in 2 of 11 cases in the nonplate group, was not seen in the plate group. Hardware failure was developed in 3 of 24 cases in the bicortical group, but not in 51 cases in the unicortical group. Alignment of the cervical spine was corrected and relatively well manintained in the plate group compared with the nonplate group. We concluded that a unicortical screw fixation was superior than a bicortical screw and a fusion without plating system could not keep a cervical lordotic curve in the treatment of the degenerative cervical disease.

A Case of Orbital Cavernous Angioma Associated with Intracranial Venous Anomalies

The authors present a rare case of orbital cavernous malformation associated with intracranial venous anomalies. A 7-year-old female patient was admitted to our hospital complaining of headache and progressive diplopia. Neurologic examination revealed a painful proptosis and limited movement of right eye. Magnetic resonance images demonstrated a cavernous malformation in the right orbit, intracerebral cystic cavernous malformation, and well-enhancing vascular marking in the right temporal lobe. On the cerebral angiography, dilated vein of Labb and duplicated transverse sinus were noted. The patient showed marked improvement of her vision after the total removal of the orbital lesion. We believe this is an another evidence that cavernous malformation may be derived from increased burden of cerebral blood flow and/or venous pressure.

Clinical Study of the Serial Changes of Fixed Segmental Height and Cobb Angle in Anterior Cervical Fusion

The authors investigated the serial changes of height and Cobb angle in the fused segments in the anterior cervical fusion. Patients who underwent anterior cervical fusion and fixation were investigated from September 1993 to August 1997. Total of 52 cases who met the following entry criteria were included in this study: (a) no history of prior cervical spine surgery or concomittent posterior fusion, (b) an anatomic radiculopathy or myelopathy that correlated with a radiographic study at the corresponding level, and(c) the clinical follow-up period of at least ten months. The radiographic data were obtained retrospectively from routine clinical radiographs, which included neutral radiographs preoperatively, immediate-postoperatively, and at 4-6 months postoperatively. The heights of the fixed segment were increased significantly after the operation(p<0.05 on Oneway ANOVA on ranks), and then decreased to preoperative value at last follow-up. The lordotic angles were increased after the operation and maintained throughout the study period(p<0.05 on Oneway ANOVA). In conclusion, on the contrary to the general belief that plate fixation can prevent the decrease in the segmental height, we found that the gain of height lasted only temporarily. Despiter this, postoperatively increased lordotic curve was maintained through the study period in spite of height loss. Therefore, we think that the lordosis of the cervical spine may reflects most of functional status of the whole cervical spine rather than height gain of the fused segment.

Porencephalic Cyst Associated with Shunt Malfunction

When hydrocephalus develops, excessive cerebrospinal fluid accumulation usually occurs within the ventricular system, leading to a ventriculomegaly caused by increased intracranial pressure. Shunt malfunction, a common complication after a shunt operation, usually occurs, together with recurring ventricular dilatation. The authors report a case of shunt malfunction which manifested as a porencephalic cyst along the proximal catheter. The cyst subsided after the replacement of the shunt system, and this led to the patient's clinical improvement. We postulate that although the region around a catheter is an unusual site for cerebrospinal fluid collection, this finding should be considered as a shunt obstruction. The possible mechanism of reversible porencephaly is discussed and the literature is briefly reviewed.

Sequestered Disc Mimicking Benign Neurogenic Tumor: Report of 2 Cases

We describe two rare cases of sequestered disc herniation which mimicked benign nerve sheath tumors radiologically. It is often quite difficult to differentiate a sequesterded disc from an extradural tumor when the discal fragments are migrated away from the origin. Distinguishable features of clinical and radiological characteristics between sequestered discs and benign intraspinal tumors were disscused. Although a well enhancing spherical mass in the spinal canal is routinely diagnosed as tumors, a free sequestered disc fragment also should be taken into consideration if the mass shows peripheral enhancement accompanied with degenerative spinal changes on MRI.

The Prognostic Implications of Radiological Findings after Laminoplasty in Cervical Myelopathy Patients

In order to define the prognostic implications of cervical myelopathy, we conducted a morphometrical analysis of spinal cords in patients suffering from this condition. Twenty patients who had undergone laminoplasty for their cervical myelopathy were the subject of this study. Cervical spondylosis was diagnosed in 14 patients and ossification of the posterior longitudinal ligament in six. Signal change of the spinal cord, its anteroposterior diameter, and the number of stenotic segments were determined by pre- and postoperative magnetic resonance imaging and simple X-ray. The patients' neurological status before and after surgery was evaluated by the Neurosurgical Cervical Scale. Patients whose cord revealed no signal change had better recovery rates than those who showed change (77.5% vs. 60.5%). The wider the diameter of the cord, the better the outcome of surgery(p<0.05 on one-way ANOVA). The number of stenotic segments was not significantly related to recovery rate. In conclusion, focal morphological changes of the spinal cord, regardless of the general stenotic area, are the main factors determining the outcomes of surgery.

Cavernous Angioma Associated with Developmental Venous Anomaly

Owing to the development of high resolution-imaging modalities, cavernous angiomas and developmental venous anomalies are no longer uncommon clinical entities. The simultaneous occurrence of cavernous angioma and venous anomaly, however, is rare. In this paper we describe our clinical experience of 13 cavernous angiomas associated with venous anomaly, as well as the clinical and radiological characteristics, and surgical result; We report a retrospective series of cases in our four hospitals between July, 1990 and September, 1996. Seven patients were men and six were women; cavernous angiomas were classified into three pathophysiologic patterns, and venous anomalies were detected by either or a combination of these. In three cases, the MRI, MR angiography, cerebral angiography, venous anomaly was not in the vicinity of the cavernous angioma. Removal of the lesion aimed to eradicate the risk of recurrent bleeding and alleviate the patients' symptoms; no death occured, but patient deteriorated after surgery, showing a postoperative hemiparesis resulting from hemorrhagic venous infarction. In conclusion, the simultaneous occurrence of cavernous angioma and venous malformation is not rare. For the safe removal of a cavernous angioma, preoperative plans should involve considerations of venous anomaly; We believe that for successful surgery, the identification and preservation of venous malformation, which should be left undisturbed during the operation, is essential.

Surgical Management of Cervical Spondylotic Myelopathy

Patients admitted with the clinical symptomatology of a progressive myelopathy associated with radiologic findings compatible with spondylotic degeneration of the cervical spine and who manifest appropriate neurophysiological abnormalities should be considered as candidates for surgical treatment. The authors have undertaken a study of 20 patients who had received decompressive surgical procedures and possible follow up studies for CSM, which was defined as a myelopathy related to osteophytic overgrowth and ossification of posterior longitudinal ligament(OPLL) in the cervical spinal canal causing impingement upon the spinal cord from Sep.93. To Aug. 1995. It was concluded with the following results. 1) man was exclusively prevalent in most cases. 2) age at surgery: There was a signigicant negative correlation between the age at surgery and the recovery rate. 3) Original cause of compression: There was no signigicant difference between the CSM and OPLL. 4) The involved level : three level involvement was the most common(8cases), followed by two level(6 cases), four level(3 cases), and single level(2 cases). There was no correlation between the preoperative Harsh scale and the number of the involved level. 5) Recovery rate: excellent(Grade O.I). 12 cases(60%), good(Grade II, IIIA), 4 cases(20%), poor(Grade IIIc, IV, V), 4 cases(20%).