Nonconvulsive Seizures of Traumatic Brain Injury Patients / 대한신경손상학회지

OBJECTIVE: Seizures are common consequence of traumatic brain injury and have been reported in clinical series as an incidence of 15% to 22%. Among them, nonconvulsive seizures (NCS) are often unrecognized during the early period of neurosurgical hospitalization because their clinical presentations can be misunderstood as consequent symptoms of clinical course, and the diagnosis can be confirmed only by the electroencephalographic (EEG) recording. METHODS: We retrospectively reviewed our clinical database of traumatic brain injury (TBI) patients admitted between March 2008 and September 2012. Twenty one patients with suspicious symptoms of NCS, such as decrease of consciousness, aphasia or irritability, were included. Routine wake and sleep EEG or bedside continuous EEG monitoring were done in all patients. RESULTS: Ten out of twenty-one patients showed abnormal activities on EEG. Ictal discharges were documented on four patients. Based on clinical symptoms and EEG findings, these four patients were diagnosed as NCS. Two out of four NCS patients showed EEG findings of nonconvulsive status epilepticus (NCSE). Another six patients with abnormal EEG activities were considered as 'suspicious NCS' because only interictal activities were recorded on EEG but increasing dose or adding on antiepileptics relieved their symptoms. All NCS/NCSE were successfully controlled by appropriate antiepileptic therapy. CONCLUSION: Our result showed that NCS was diagnosed in about 20% of patients with suspicious symptoms. There's a possibility that actual NCS might have happened more. Because untreated NCS/NCSE might cause worse clinical outcome, careful observation and urgent EEG recordings should be considered in a patient with suspicious NCS symptoms.

Clinical Efficacy of Acute Monitoring Cortical Activity Using Subdural Strip Electrode after Decompressive Craniectomy / 대한신경손상학회지

OBJECTIVE: Decompressive craniectomy is widely used in cases of uncontrolled intracranial hypertension, including traumatic brain injury or acute stroke. Physiological monitorings, such as intracranial pressure or electroenecephalography (EEG) are critical for patients in the acute phase. We retrospectively reviewed our experience of continuous electrocorticography (ECoG) monitoring by subdural strip electrode in patients who performed decompressive craniectomy and assessed its clinical efficacy. METHODS: Patients who underwent decompressive craniectomy because of severe intracranial hypertension were included. 4 Channel strip electrodes were inserted on the frontal cortex before closure. 24-hour continuous monitoring of ECoG was done to identify abnormal electrical activity. The level of consciousness was assessed according to Glasgow Coma Scale (GCS). In patients with malignant intracranial hypertension, barbiturate coma therapy was considered. RESULTS: Fifteen patients (9 men and 6 women) were included and the mean age was 55.7 years (from 17 to 80). The initial mean GCS score was 7.9 (from 3 to 14). In six out of fifteen patients, abnormal spike activities were identified, and one of these six patients was diagnosed as nonconvulsive status epilepticus (NCSE). Cortical spreading depression (CSD) was suspected in five. Three patients underwent barbiturate coma therapy and ECoG monitoring of these patients showed typical burst suppression pattern, which was used for indicator of therapeutic level. The mean duration of strip electrode and ECoG monitoring was 3.5 days, and there was no complication. CONCLUSION: Continuous ECoG monitoring using subdural strip electrode was useful to detect abnormal brain activity in the acute period after decompressive craniectomy.

Clinical Efficacy of Radiofrequency Cervical Zygapophyseal Neurotomy in Patients with Chronic Cervicogenic Headache

The purpose of the present study was to assess the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following the treatment. The results of this study showed that RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. In conclusion, RF cervical zygapophyseal joint neurotomy has shown to provide substantial pain relief in patients with chronic cervicogenic headache when carefully selected.

Clinical Analysis of Poor grade Subarachnoid Hemorrhage Patients / 대한뇌혈관외과학회지

PURPOSE: Subarachnoid hemorrhage (SAH) resulting from aneurysmal rupture carries a high rate of morbidity and mortality despite of intensive care. Owing to the advance in surgical techniques, the management results of good grade patients have shown better outcomes than the past, but those of poor grade patients have been still unsatisfactory. The aim of this study is to determine the treatment and the prognostic factors in the poor grade SAH patients. METHOD: We have analyzed 43 patients of Hunt & Hess (H&H) grade IV and V among 438 SAH patients treated between 1998 and 2004. The patients were divided into two groups (Good outcome group and Poor outcome group) according to the management outcomes. Each group was analyzed about the various prognosis factors; age, sex, H&H grade, Fisher grade, location and size of aneurysm, timing of operation, and complications. RESULTS: Among the various factors evaluated, the preoperative H&H grade only showed statistical significance (P value=0.0173). The better H&H grade seemed to show the more favorable outcome, especially surgically treated cases. CONCLUSIONS: An aggressive treatment including early surgery seems to contribute to a better outcome of poor grade SAH patients, especially H&H grade IV. But further clinical study should be researched to improve clinical outcomes in H&H grade V patients.

Meningeal Hemangiopericytoma: Study of 6 Cases and Review of the Literatures

OBJECTIVE: Hemangiopericytoma is known as a malignant tumor originating from pericytes and rarely occurs in the central nervous system. We present 6 cases of pathologically confirmed meningeal hemangiopericytoma. METHODS: Retrospective study was done based on patient's recordings including radiological studies. Each case of tumors was treated surgically and postoperative radiotherapy was done. RESULTS: There were 5 cases of intracranial and 1 case of spinal hemangiopericytomas. Three of 5 intracranial hemangiopericytomas were located at tentorial region. Total tumor removal was done in 4 cases and postoperative local recurrence (or regrowth) was noted in 3 cases despite of postoperative external radiation therapy, 2 of which had died. CONCLUSION: Our cases show more frequent tentorial locations and poor clinical outcomes of hemangiopericytomas compared with meningiomas.

Cranioplasty with the Porous Polyethylene Implant(Medpor) for Large Cranial Defect

OBJECTIVE: This paper describes our experience and implant technique for cranioplasty of a large cranial defects using a porous polyethylene implant(Medpor) and compares the results with polymethylmethacrylate(PMMA). METHODS: Sixteen cranioplasties were performed using Medpor(n=10) and PMMA(n=6) implants between June 2003 and January 2005. The criterion for patient enrollment was a defect larger than 10cm in diameter. This study compared the operation times and complications. RESULTS: The operation times ranged from 105 to 250minutes(Mean 180 degrees +/-44minutes) in Medpor and from 185 to 460minutes (mean 128minutes) in PMMA. The absolute operation times were shorter using the Medpor implant and the differences were statistically significant(P=0.030). Satisfactory cosmetic results were obtained in all cases using the Medpor implant and with no implant-related complications. Bone ingrowth to the medpor implant was presumed to be the result on an increase in Houndsfield units of the implant, particularly at the marginal areas in the serial follow-up brain computed tomography images. CONCLUSION: It is believed that the properties of a Medpor implant make this implant an good alternative to the existing methods of a cranial contour correction. However, a further follow-up study will be needed.

Evaluation of Syringo-Subarachnoid Shunt for Syringomyelia

OBJECTIVE: The aim of this study is to evaluate the effectiveness of the syringo-subarachnoid shunt for the syringomyelia, according to the clinical outcome and radiological changes. METHODS: Ten patients who underwent syringo-subarachnoid shunt during last 5 years were included in this analysis. The average age at the presentation was 32.6(range 7 to 51) years. Chiari I malformation was found in four patients, Post-infectious syringomyelia was in three patients, and posttraumatic syringomyelia in two patients. The most common presenting symptoms were motor weakness and pain. Radiological diagnosis was made by magnetic resonance image in all patients. All patients underwent syringo-subarachnoid shunt, and in five patients with Chiari I malformation or achondroplasia, foramen magnum decompression was done as well. RESULTS: Eight showed the significant clinical improvement. Remaining two patients showed stabilization of the symptom. The postoperative magnetic resonance image, performed in seven cases, showed the reduction of the syrinx size in all case. There was no shunt malfunction or infection in our series. The transient cerebospinal fluid leakage was noted in three cases. CONCLUSION: It appears that the syringo-subarachnoid shunt is beneficial surgical method for the syringomyelia of various etiologies.

Endovascular Treatment of Incompletely Clipped Cerebral Aneurysm

Residual aneurysm is a challenging problem after clipping procedure for the aneurysms. The anthors describe one patient in whom endovascular treatment was sucessfully done to treat residual aneurysm after surgical clipping. We discussed the role of endovascular coil occlusion in case of incomplete surgical obliteration of aneurysms.

Effects of MK-801, CNQX, Cycloheximide and BAPTA-AM on Anoxic Injury of Hippocampal Organotypic Slice Culture

No abstract available.

Hemangioblastoma of the Conus Medullaris : Case Report

No abstract available.

Hemangioblastoma of the Conus Medullaris : Case Report

No abstract available.

Intracranial Magnetic Resonance Angiography-Its Role in the Approach to Ischemic Stroke

No abstract available.

Intracranial Aneurysm Associated with Moyamoya Disease

It is well known that moyamoya disease is often accompanied by an intracranial aneurysm. We present 3 patients, among total 40 patients with moyamoya disease over a recent 4-year period, in whom moyamoya disease and an intracranial saccular aneurysm were discovered simultaneously. In 2 of the 3 patients, the aneurysms were occluded endovascularly by Guglielmi detachable coils(GDC). Here, with review of pertinent literature, we discuss the clinical characteristics of an intracranial aneurysm associated with moyamoya disease and the benefits and drawbacks between two therapeutic options- direct surgery and endovascular treatment.

The Protective Effect of Preconditioning Ischemia on Subsequent Cerebral Ischemic Insults

A brief period of cerebral ischemia produces neuronal damage in the vulnerable regions of the brain, such as the CA1 area of the hippocampus. However, mild ischemic episodes may limit damage from subsequent ischemic insults, the phenomenon known as ischemic tolerance or preconditioning. We used hippocampal slices as an experimental model to investigate the possible utilization of ischemic tolerance, and to determine the effects of various drugs acting on glutamate and adenosine receptors following a conditioned ischemic insult. Preconditioning ischemic insult was induced in hippocampal slices of 450nm thickness for 60-70 seconds. Glutamate and adenosine receptors were pretreated 1 hour later with D,L-2-amino-5-phosphonovaleric acid(AP-5, 50nM), propentofylline(PPF, 200nM), 6-cyano-7-nitroquinoxaline-2,3-dione(CNQX, 10nM), 8-cyclopentyl-3,7-dihydro-1,3-dipropyl-1H-purine-2,6-dione(DPCPX, 1, 10nM) and 2-chloro-N6-cyclopentyl-adenosine (CCPA, 1, 10, 50nM). The slices were reoxygenated for 3 hours, after then a second ischemic insult was induced by substituting 95% O2, 5% CO2 and glucose for 95% N2, 5% CO2 and sucrose for 10 minutes. Population spikes(PS) were estimated from extracellular electrophysiological recordings of the hippocampal CA3-CA1 synaptic conduction 1 hour following the second ischemic insult. The PS(mV) was 2.69+/-0.06 in the normal hippocampal slice, while it was reduced to 1.21+/-0.05 in the hippocampal slice induced with 10 minutes of ischemia. The effects of the A1 selective agonist CPPA revealed a reduction of PS to 0.98+/-0.06 with low concentration(1nM), similar PS as the control group with a concentration of 10nM, and an increase in ischemic tolerance of 1.78+/-0.05 at a higher concentration(50nM). The selective A1 antagonist DPCPX(1nM) showed minimal reduction in PS of 1.10+/-0.04, while the NMDA antagonist AP-5(5nM) had a more profound weakening effect(1.05+/-0.04). The adenosine uptake inhibitor profentophylline(200nM) augmented the PS to 1.56+/-0.06; this effect was not influenced by 1nM DPCPX(1.60+/-0.07), but was abolished by a higher concentration of 10nM(1.36+/-0.05). These results confirmed ischemic tolerance in the hippocampal experimental model. We conclude that adenosine plays an important role in ischemic tolerance as activation of adenosine receptors or adenosine uptake inhibition enhances ischemic tolerance.

Pedicle Screw Fixation of the Thoracic Spine

Pedicle screw instrumentation has proven to be reliable and effective in the surgical management of lumbosacral disorders, yet the appropriateness in the thoracic spine is not known. To evaluate the accuracy of the pedicle screw placement in the surgical management of the thoracic spinal disorders and to establish its risks and benefits, a prospective study was designed. One hundred and two thoracic pedicle screws in 22 consecutively treated patients were investigated after surgery by computed tomography scans. Twenty-one(20.5%) screws penetrated the pedicle cortex or the vertebral body anterior cortex. Three screws penetrated the medial cortex of the pedicle by the averages of 2mm to a maximum 4mm. Fifteen screws(14.7%) penetrated laterally by an average of 1.5mm. There were 3 screws of caudal penetration. The screws inserted at T1-T8 revelaed a higher penetration rate than those inserted at T9-T12(35.7% versus 14.7%)(p<0.05). Hardware failures causing the preoperative defor-mity were seen in a patient to whom half the cephalad screws were laterally misplaced. However, there were no major neurologic complications. Although segmental pedicle screw fixation of the thoracic spine requires meticulous measures and considerable experience, it was therefore can be considered as a safe and effective method for stabilizing the thoracic spine.

Paraspinal Retroperitoneal Ganlioneuroma

Ganglioneuroma is a rare benign neurogenic tumor arising from sympathetic ganglia. A case of paraspinal retro-peritoneal ganglioneuroma in a 39-year-old woman is described here. The patient underwent surgery with gross total removal of the tumor and relief of her initial chief complaint of backache and leg pain. We review the literature and discuss the clinical features and the histogenesis of ganglioneuroma.

A Case of Intracranial Infectious Aneurysm with Embolic Cerebral Infarction

Infectious intracranial aneurysm, so-called mycotic aneurysm, has been rarely reported after era of antibiotics. Infective endocarditis is the most common cause. It is commonly occurs in patients with valvular heart disease. The authors report a case of infectious intracranial aneurysm in the distal branch of the right middle cerebral artery with embolic cerebral infarction in the contralateral middle cerebral artery territory. The patient underwent surgical excision of the aneurysm after six weeks of antibiotics therapy. The pathological findings demonstrated severe inflammatory change in the adventitial layer but intact intimal layer. The clinical features and the pathogenesis is discussed with review of pertinent literature.

Peripheral Cerebral Arterial Aneurysm: Case Report and Review of the Literature

Aneurysms arising from the peripheral distribution of the cerebral arteries are very rare, and those aneurysms are mostly mycotic in origin. We have experienced a rare case of non-mycotic, peripheral aneurysm of the middle cerebral artery. A clinical description of our case as well as a review of the literature about possible etiologies contributing to the peripheral aneurysmal formation is presented.

Unlateral Moyamoya Disease Associated with Brain Tumor

A 51-year-old female patient with right lower motor weakness and left side motor weakness is presented. MRI signal revealed a butterfly brain mass. Angiography showed stenosis of left side internal carotid artery at the supraclinoid portion and Moyamoya vessel, collateral circulation to mass via posterior circulation and contralateral was observed.

ICA Bifurcation Aneurysm: Clinical Features and Surgical Outcome

OBJECTIVE: Aneurysms at the internal carotid artery(ICA) bifurcation are uncommon and account for about 3 to 5% of all intracranial aneurysms. Moreover, the surgical treatment of these aneurysms has been discussed in detail only by a few authors. In this report, we present our experienced cases, and discuss the clinical features and surgical outcome of these aneurysms. METHOD: In the last eight years, out of total of 672 patients operated for intracranial aneurysms at our hospital, 17 patients(2.5%) had aneurysms at the ICA bifurcation. The direction of aneurysms were distinguished based upon DaPian's classification; superior, anterior, or posterior. RESULT: There were female preponderance(M:F=1:1.8) and the left side predominance(11 of 17 cases). Nine patients had multiple aneurysms, and in that cases ICA bifurcation aneurysms were responsible for hemorrhage in most cases. All aneurysms were clipped via the standard pterional approach. Thirteen out of 17 patients had good results and 2 patients fair results; the surgical outcome was favorable in 88.2% of cases. One who had rebleeding before surgery died. CONCLUSION: It is presumed that the perforator occlusion and intraoperative aneurysmal rupture were the main factors aggravating the surgical outcome. In cases with anteriorly- or posteriorly-projecting aneurysm, more careful cautions would be necessary.