Multimodal Treatment of Skull Base Inflammatory Pseudotumor: Case Report

lnflammatory pseudotumor (IPT) is a rare, non-neoplastic inflammatory process. It is most commonly occurs in the orbit, but extension into brain parenchyma is uncommon. In a confirmed case of IPT, most cases show good improvement with steroid theraphy. A 50-year-old man with progressive left-eye visual disturbance and mass lesion was admitted in a hospital. A left orbital mass biopsy revealed what was highly suspected as an inflammatory pseudotumor. Steroid pulse therapy with dexamethasone, radiation therapy, and chemotherapy with amphotericin B were performed, but they were not effective in improving the condition of the patient. Revision open surgery was then performed. A follow-up brain enhancement computerized tomography showed an enlarged mass volume and hydrocephalus with periventricular enhancement. As an additional procedure, ventriculoperitoneal shunt and tuberculosis medication were administered. About 2 weeks later, clinical symptoms and radiologic findings improved. We present a case of intra-cranial IPT and discuss further treatment methods.

Iatrogenic rupture of undiagnosed blood blister-like aneurysm during aneurysmal neck clipping / 대한마취과학회지

No abstract available.

A Case of Multiple Myeloma with Brain Parenchyme Involvement

Multiple myelomas (MM) are characterized by monoclonal proliferation of immunoglobulin (Ig)-secreting plasma cells. Central nervous system involvement is a rare complication of MM, and it can present as either an intraparenchymal or a leptomeningeal lesion. A 77-year-old woman was transferred from the dementia clinic in July 2012. She had a large heterogeneous signal mass with central necrosis and with pial involvement in the left frontal lobe with destruction of the frontal bone that was observed on computed tomography and magnetic resonance imaging. Multiple punched out radiolucent lesions were also noted on the skull X-ray. Serum protein electrophoresis revealed an IgA-kappa monoclonal gammopathy. External lumbar drainage was helpful for treating the fluid collection underneath the scalp after an orbitozygomatic craniotomy with duroplasty.

Desmoid Tumor of the Facet Joint: A Case Report

Desmoid tumors represent a particular type of fibromatosis. The common sites for extra-abdominal desmoid tumors, known as aggressive fibromatosis, are the shoulder, chest wall, and thigh. Desmiod tumors are rare at facet joints of the spine. We describe a patient with a desmoid tumor of a lumbar facet joint.

The Comparative Morphometric Study of the Posterior Cranial Fossa : What Is Effective Approaches to the Treatment of Chiari Malformation Type 1?

OBJECTIVE: The objective of this study was to investigate changes in the posterior cranial fossa in patients with symptomatic Chiari malformation type I (CMI) compared to a control group. METHODS: We retrospectively reviewed clinical and radiological data from 12 symptomatic patients with CMI and 24 healthy control subjects. The structures of the brain and skull base were investigated using magnetic resonance imaging. RESULTS: The length of the clivus had significantly decreased in the CMI group than in the control group (p=0.000). The angle between the clivus and the McRae line (p<0.024), as the angle between the supraocciput and the McRae line (p<0.021), and the angle between the tentorium and a line connecting the internal occipital protuberance to the opisthion (p<0.009) were significantly larger in the CMI group than in the control group. The mean vertical length of the cerebellar hemisphere (p<0.003) and the mean length of the coronal and sagittal superoinferior aspects of the cerebellum (p<0.05) were longer in the CMI group than in the control group, while the mean length of the axial anteroposterior aspect of the cerebellum (p<0.001) was significantly shorter in the CMI group relative to control subjects. CONCLUSION: We elucidate the transformation of the posterior cranial fossa into the narrow funnel shape. The sufficient cephalocaudal extension of the craniectomy of the posterior cranial fossa has more decompression effect than other type extension of the craniectomy in CMI patients.

Simultaneous Multiple Basal Ganglia and Cerebellar Hemorrhage: Case Report

A 35-year-old man presented with simultaneous multiple intracranial hematomas in the right cerebellar dentate nucleus and left basal ganglia. The hematomas were visible by computed tomography performed within two hours of the patient's arrival. The initial computed tomography showed acute hemorrhage in the left basal ganglia and dentate nucleus in cerebellum. The patient then experienced a change of consciousness due to newly developed hydrocephalus, and emergent extra-ventricular drainage was performed. By discharge, fortunately, the patient was fully recovered.

Clinical Effects and Radiological Results of Vertebroplasty: Over a 2-year Follow-Up Period

OBJECTIVE: We investigated the association between clinical and radiological results and assessed the radiological changes according to the distribution pattern and amount of injected cement after vertebroplasty. METHODS: Two hundred and one patients underwent vertebroplasty; of these, 15 were follow up for more than 2 years. For radiological analysis, we grouped the patients according to cement distribution as follows: group 1, unilateral, unilateral distribution of cement; group 2, bilateral-uneven, bilateral distribution of cement but separated mass; and group 3, bilateral-even, bilateral single mass of cement. To compare radiologic with clinical results, we assessed the visual analogue scale (VAS) score, amount of injected cement, bone mineral density (BMD), postoperative and follow-up vertebral body compression ratios, and postoperative and follow-up kyphotic angles. RESULTS: There were 4 (26.7%) patients in group 1, 6 (40.0%) in group 2, and 5 (33.3%) in group 3. The mean VAS score was 5.2 preoperatively, 1.8 postoperatively, and 3.2 at 2-year follow-up. The 2-year follow-up compression ratio was better in patients with even distribution of injected cement (group 2 and 3) than group 1. However, it was not statistically insignificant (p>0.05). The follow-up kyphotic angle was more aggravated in the group 1 than in the other groups (p<0.05). CONCLUSION: Our study showed that vertebroplasty had a beneficial effect on pain relief, particularly in the immediate postoperative stage. The augmented spine tended to be more stable in the cases with increased amount and more even distribution of injected cement.

Preliminary Report of Percutaneous Vertebroplasty for the Treatment of the Burst Fractures with Spinal Canal Encroachment / 대한신경손상학회지

OBJECTIVE: Percutaneous vertebroplasty is a minimally invasive procedure to relieve or decrease pain in patients with osteoporotic compression fractures. However, vertebroplasty in the osteoporotic burst fracture patients with preoperative canal encroachment are still being debated, because it can aggravate spinal canal encroachment. The objects of this study is evaluation of the changes in spinal canal narrowing after percutaneous vertebroplasty. METHODS: Inclusion criteria was osteoporotic bursting fracture patients with 5 to 20% canal encroachment (less than 5 mm). Exclusion criteria included pathological fractures, unstable vertebral fractures involving the posterior column, and severe neurological deficit. We measured the changes in spinal canal narrowing by pre- and postoperative computed tomography. Degree of canal encroachment was measured as the distance between the imaginary line along the posterior margin of the bony fragment and the maximal anterior imaginary line of the spinal canal in the axial CT scan. RESULTS: This study was based on 10 patients (1 male and 9 female; age range, 52-89 years; mean age, 75 years). The mean decrease in the compression rate of the vertebral body height was 14.4% (43.4% to 29%). The mean decrease in the kyphotic angle was 4.3degrees (11.7degrees to 7.4degrees). The mean preoperative canal encroachment were 3.5 mm and postoperative canal encroachment was 3.7 mm, respectively. The mean preoperative VAS score was 4.3 and postoperative VAS score was 1.4. CONCLUSION: Vertebroplasty can be a safe treatment option for osteoporotic burst fractures with preoperative minimal canal encroachment.

Risk Factors Associated with Subdural Hygroma after Decompressive Craniectomy in Patients with Traumatic Brain Injury : A Comparative Study

OBJECTIVE: Subdural hygroma (SDG) is a complication occurring after head trauma that may occur secondary to decompressive craniectomy (DC). However, the mechanism underlying SDG formation is not fully understood. Also, the relationship between the operative technique of DC or the decompressive effect and the occurrence and pathophysiology of SDG has not been clarified. Purpose of this study was to investigate the risk factors of SDG after DC in our series. METHODS: From January 2004 to December 2008, DC was performed in 85 patients who suffered from traumatic brain injury. We retrospectively reviewed the clinical and radiological features. For comparative analysis, we divided the patients into 2 groups : one group with SDG after craniectomy (19 patients; 28.4% of the total sample), the other group without SDG (48 patients; 71.6%). The risk factors for developing SDG were then analyzed. RESULTS: The mean Glasgow Outcome Scale (GOS) scores at discharge of the groups with and without SDG were 2.8 and 3.1, respectively (p<0.0001). Analysis of radiological factors showed that a midline shift in excess of 5 mm on CT scans was present in 19 patients (100%) in the group with SDG and in 32 patients (66.7%) in the group without SDG (p<0.05). An accompanying subarachnoid hemorrhage (SAH) was seen in 17 patients (89.5%) in the group with SDG and in 29 patients (60.4%) in the group without SDG (p<0.05). Delayed hydrocephalus accompanied these findings in 10 patients (52.6%) in the group with SDG, versus 5 patients (10.4%) in the group without SDG (p<0.05). On CT, compression of basal cisterns was observed in 14 members (73.7%) in the group with SDG and in 18 members of the group without SDG (37.5%) (p<0.007). Furthermore, tearing of the arachnoid membrane, as observed on CT, was more common in all patients in the group with SDG (100%) than in the group without SDG (31 patients; 64.6%) (p<0.05). CONCLUSION: GOS showed statistically significant difference in the clinical risk factors for SDG between the group with SDG and the group without SDG. Analysis of radiological factors indicated that a midline shifting exceeding 5 mm, SAH, delayed hydrocephalus, compression of basal cisterns, and tearing of the arachnoid membrane were significantly more common in patients with SDG.

Congenital Cleft of Anterior Arch and Partial Aplasia of the Posterior Arch of the C1

Congenital anomalies in arches of the atlas are rare, and are usually discovered incidentally. However, a very rare subgroup of patients with unique radiographic features is predisposed to transient quadriparesis after minor cervical or head trauma. A 46-year-old male presented with a 2-month history of tremor and hyperesthesia of the lower extremities after experiencing a minor head trauma. He said that he had been quadriplegic for about 2 weeks after that trauma. Radiographs of his cervical spine revealed bilateral bony defects of the lateral aspects of the posterior arch of C1 and a midline cleft within the anterior arch of the atlas. A magnetic resonance imaging revealed an increased cord signal at the C2 level on the T2-weighted sagittal image. A posterior, suboccipital midline approach for excision of the remnant posterior tubercle was performed. The patient showed significant improvement of his motor and sensory functions. Since major neurologic deficits can be produced by a minor trauma, it is crucial to recognize this anomaly.

Magnetic Resonance Imaging in Patients with Low Back Pain

OBJECTIVE: The objective of this study was to analyze lumbar spine MRI findings and investigate their association factors with lumbar spinal degeneration. METHODS: Between March 2008 and December 2008, we retrospectively analyzed lumbar spine MRI scans of 246 patients with LBP. We used a modified MRI score for evaluation of spinal degeneration, which was obtained by modifying the Meyerding classical system. We performed Mantel Haenszel chi-square tests to compare the MRI score and associated factors. RESULTS: The mean MRI score was 12.05. The main level at which the pathological condition existed was L4-5 in 123 patients (50.2%). Statistical analysis showed that an age of over 40 years (p-value <0.0001) and symptom duration of over 5 years (p=0.0122, which is <0.05) were significantly related to a high MRI score. Annular tear, irregular nucleus shape, and reduced disc height in the lumbar spine were strongly associated with LBP. CONCLUSION: Annular tear, irregular nucleus shape, and reduced disc height in the lumbar spine were strongly associated with LBP. Especially, MRI finding in patients aged over 40 years and who experienced symptoms for 5 years or more showed higher MRI score.

A Case of Hypoglycemic Brain Injuries with Cortical Laminar Necrosis

We report a case of 68-yr-old male who died from brain injuries following an episode of prolonged hypoglycemia. While exploring controversies surrounding magnetic resonance imaging (MRI) findings indicating the bad prognosis in patients with hypoglycemia-induced brain injuries, we here discuss interesting diffusion-MRI of hypoglycemic brain injuries and their prognostic importance focusing on laminar necrosis of the cerebral cortex.

The Change of Adjacent Segment and Sagittal Balance after Thoracolumbar Spine Surgery

OBJECTIVE: To characterize perioperative biomechanical changes after thoracic spine surgery. METHODS: Fifty-eight patients underwent spinal instrumented fusions and simple laminectomies on the thoracolumbar spine from April 2003 to October 2008. Patients were allocated to three groups; namely, the laminectomy without fusion group (group I, n = 17), the thoracolumbar fusion group (group II, n = 27), and the thoracic spine fusion group (group III, n = 14). Sagittal (ADS) and coronal (ADC) angles for adjacent segments were measured from two disc spaces above lesions at the upper margins, to two disc spaces below lesions at the lower margins. Sagittal (TLS) and coronal (TLC) angles of the thoracolumbar junction were measured from the lower margin of the 11th thoracic vertebra body to the upper margin of the 2nd lumbar vertebra body on plane radiographs. Adjacent segment disc heights and disc signal changes were determined using simple spinal examinations and by magnetic resonance imaging. Clinical outcome indices were determined using a visual analog scale. RESULTS: The three groups demonstrated statistically significant differences in terms of angle changes by ANOVA (p < 0.05). All angles in group I showed significantly smaller angles changes than in groups II and III by Turkey's multiple comparison analysis. Coronal Cobb's angles of the thoracolumbar spine (TLC) were not significantly different in the three groups. CONCLUSION: Postoperative sagittal balance is expected to change in the adjacent and thoracolumbar areas after thoracic spine fusion. However, its prevalence seems to be higher when the thoracolumbar spine is included in instrumented fusion.

Inter-Racial, Gender and Aging Influences in the Length of Anterior Commissure-Posterior Commissure Line

OBJECTIVE: The length of anterior-posterior commissure (AC-PC) in racial groups, age, gender of patients with deep brain stimulation (DBS) and pallidotomy were investigated. METHODS: From January 1996 to December 2003, 211 patients were treated with DBS and pallidotomy. There were 160 (76%) Caucasians, 35 (17%) Hispanics, 12 (5%) Asians and 4 Blacks (2%). There were 88 males and 52 females in DBS-surgery group and 44 males, 27 females in pallidotomy group. Mean age was 58 year-old. There were 19 males and 19 females and mean age was 54.7 years in the control group. Measurements were made on MRI and @Target software. RESULTS: The average AC-PC distance was 24.89 mm (range 32 to 19), which increased with aging until 75 years old in Caucasian and also increased with aging in Hispanic, but the AC-PC distance peaked at 45 years old in Hispanic. The order of AC-PC distance were 25.2+/-2 mm in Caucasian, 24.6+/-2.24 mm in Asian, 24.53 mm in Black, 23.6+/-1.98 mm in Hispanic. The average AC-PC distance in all groups was 24.22 mm in female who was mean age of 56.35, 25.28 mm in male who was mean age of 60.19 and 24.5+/-2 mm in control group that was excluded because of the difference of thickness of slice. According to multiple regression analysis, the AC-PC distance was significantly correlated with age, race, and gender. CONCLUSION: The AC-PC distance is significantly correlated with age, gender, and race. The atlas of functional stereotaxis would be depended on the variation of indivisual brain that can influenced by aging, gender, and race.

Spinal Schwannoma; Analysis of 40 Cases

OBJECTIVE: This study is to report our experience of 40 cases of spinal schwannoma. METHODS: From 1995 to 2006, medical records were retrospectively reviewed in 40 cases of spinal schwannoma. RESULTS:We treated 40 spinal schwannomas in 38 (22 male and 16 female) patients. The mean age was 50.2. Four cases were sited in the cervical spine, 11 cases in the thoracic spine, and 25 cases in the lumbar spine. Two patients showed recurrences. Thirty-eight cases were intradural-extramedullary type and 2 cases were extradural. Two cases (5%) including 1 recurred case had no postoperative motor improvement. Ninety-five percents of patients improved on postoperative motor grade. CONCLUSION: Spinal schwannoma is mostly benign and extramedullary tumor. There were 2 recurred cases (5%) that had history of previous subtotal removal at first operation and had shown worse prognosis compared with the cases without recurrence. To reduce the recurrence of spinal schannoma, total excision of tumor mass should be done.

A Case of Postoperative Herpes Simplex Pneumonia

Herpes simplex virus (HSV) esophagitis is a rare disease and most of cases are reported in the immunocompromised patients2,3,11,15,17,18). We report a case of fatal HSV infection started from herpes labialis and esophagitis. She had initially suffered from perioral ulcer, esophagitis, and interstitial pneumonitis later and eventually died of respiratory insufficiency one month later after the aneurysmal surgery. She did not have any immunocompromised medical history and also had no evidence of herpes encephalitis in laboratory study and magnetic resonance image (MRI). With the availability of effective agents for the treatment of HSV infection, early recognition of HSV esophagitis is important because it may be clinically confused with Cushing ulcer and may be complicated with a fatal pneumonitis.

Surgical Treatment of Squamous cell Carcinomas Arising in Scalp Burn Wounds: Two Case Reports

Marjolin's ulcer is a rare and often-aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. We experienced two cases after burns. Case I involved a forty eight year-old man who had suffered from a flame burn at the parietal scalp area, where had been initially described three years earlier as a full-thickness wound including the pericranium. The man consulted us for a persistent ulcerative and infected wound on the burned lesion during the last 24 months, which turned out on the contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) to be the squamous cell carcinoma with involving the skull and the dura mater. Although the posterior auricular lymph node was enlarged on the ipsilateral side, recent positron emission tomography (PET) CT did not show any metastatic lesion. It was impossible for us to resect the intracranial involvement of the tumor radically, and the postoperative PET CT still showed a focal fluorodeoxyglucose (FDG) uptake around the wall of the superior sagittal sinus. We think that an aggressive combined approach is essential for treatment in early stages for a high success rate, before the intracranial structures are involved because there is no consensus on the treatment for advanced disease, and the results are generally poor. Case 1 also did not involve a radical resection because of the intracranial invasion to the wall of superior sagittal sinus and the possibility of damage to the major cortical veins. He received adjuvant radiotherapy and must be followed periodically. Case 2 involved an eighty six year-old women who suffered from a painful scalp ulcer lesion after flame burns three years earlier. Unlike case 1, neither tumor infiltration into the dura nor lymph node enlargement was observed on the contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) CT. We did a radical resection of the tumor, including the involved bone, and a cranioplasty with bone cement.

Bilateral Cortical Blindness Caused by Tentorial Herniation due to Brain Tumor

Two patients, one with glioblastoma multiforme (GM) in the right thalamus and the other with meningioma at the right frontal convexity, had suffered bilateral cortical blindness after transtentorial herniation. On one of those patients, bilateral cortical blindness had occurred due to acute obstructive hydrocephalus caused by GM and on the other patient, cortical blindness had developed after acute hemorrhage from meningioma. Bilateral occipital lobes of those patients showed signal change on the brain magnetic resonance image (MRI). There were no ophthalmologic abnormalities on fundoscopy and ophthalmologic examination. After recovery of consciousness, cortical blindness was detected in both patients, and during gradual recovery period, visual function was slowly recovered. The pattern of visual evoked potential (VEP) at 7 weeks and 12 weeks after herniation was normalized gradually. Cortical blindness due to herniation was reversible, even though the high signals of bilateral visual cortex still existed on MRI 16 months later in case 2.

Blindness Caused by Wrapping of the ICA Aneurysm

The incidence of blindness after aneurysm surgery is very rare. We experienced a case of unilateral blindness after internal carotid artery(ICA) aneurysm wrapping. A 43-year-old male immediately developed ipsilateral ocular pain and visual loss in his left eye after the treatment of a lateral ICA aneurysm by wrapping with muscle pieces. He had also multiple aneurysms, which were multilobulated anterior communicating artery (A-com), middle cerebral artery(MCA) and posterior communicating artery (P-com) aneurysms. Coilings were done for a part of A-com artery aneurysm and P-com artery aneurysm on admission. The remaining A-com artery aneurysm was clipped and ICA aneurysm was wrapped with temporal muscle piece. A retrobulbar optic neuropathy might have resulted from either direct injury or damage to small dural vessels of the posterior optic nerve. Actually, the optico-carotid space was tight and the optic nerve was compressed by swollen muscle piece. Despite releasing of compression of the optic nerve on second day, his visual loss was irreversible.

Mortality and Morbidity of Aneurysmal Neck Clipping during the Learning Curve

OBJECTIVE: Young neurosurgeons need to focus on the mortality and morbidity of aneurysmal neck clipping to develop a personal experience with an initial series. METHODS: Total 88 aneurysms from 75 patients who underwent neck clipping by the same operator from 2001 to 2004 were reviewed. Patients were divided into three groups: first year (Group I), second year (Group II), and third year (Group III) in each group. Location of aneurysm, age, Fisher grade, Hunter-Hess grade (H-H grade), postoperative Glasgow outcome scale (GOS), and complications related to surgical procedures were evaluated with Chi-square and logistic regression analyses. RESULTS: Fourteen patients had complications related to surgery (18.7%). The major causes of mortality and morbidity related to surgery were cerebral infarction, hemorrhage and brain swelling due to intraoperative rupture, brain retraction and vasospasm. Among the 4 cases of mortality were 2 patients in Group I, 1 patient in Group II and 1 patient in Group III, and location of aneurysms were 2 internal carotid artery(ICA) and 2 posterior communicating artery(PCoA) aneurysms. There were 4 morbidity and new neurological deficits in Group I, 4 in Group II and 2 in Group III. Although mortality and morbidity during the learning curve had a statistical significance in H-H grade, age (>60 years old), and aneurysm location (especially ICA aneurysm) as variables, mortality mainly occurred in ICA and PCoA aneurysms. CONCLUSION: Experienced supervision or endovascular approach should be considered for the treatment of ICA and PCoA aneurysms during the learning curve.