Magnetic Resonance Spectroscopy of Patients with Acute Cerebral Infarction / 대한뇌혈관외과학회지

OBJECTIVE: MR spectroscopy is a noninvasive method of monitoring in vivo metabolite concentration changes over time. In this study we evaluated the usefulness of combined magnetic resonance imaging and spectroscopy on the diagnosis of cerebral infarction. METHODS: Combined magnetic resonance imaging and spectroscopy investigations were carried out with 1.5-T system in 18 volunteers, 10 patients with acute infarction (< 8 hours). RESULTS: Acute ischemic infarctions were characterized by decreased N-acetyl aspartate and elevation of lactate. CONCLUSION: Metabolic alterations in ischemic tissue can be monitored.

Surgical Experiences for Intracranial Aneurysms(3,000 Cases)

OBJECTIVE: The present study evaluated overall surgical results for 3,000 patients with intracranial aneurysms, operated on in Busan Paik Hospital institution. METHODS: Three thousand aneurysm cases, operated on in Busan Paik Hospital between January 1980 to June, 15th, 2005, were evaluated based on the following criteria;aneurysm form, aneurysm location, surgical results, postoperative complications, and seasonsonality of occuence. 957 cases were anterior communicating artery aneurysms, 776 were internal carotid artery(ICA) aneurysms, 755 were middle cerebral artery(MCA) aneurysms, 96 were anterior cerebral artery(ACA) aneurysms, 128 were vertebro-basilar artery(VBA) aneurysms and 288 were multiple aneurysms. The male to female ratio was 0.7 to 1. Surgical methods included 2,738 clippings, 219 coating and wrappings, 23 aneurysmoraphies, 20 proximal ligations. RESULTS: Rebleeding occured in 5.1% of the early operation group and 16% of the late operation group respectively. Incidence of clinical vasospasm was 16.6% and angiographic vasospasm was 24.1%. The percentage of the multiple aneurysms was 9.5%, the percentage of the dissecting aneurysm was 6 cases (0.2%), 6 of the total (0.2%);De Novo" aneurysm, the percentage of lobectomies with clipping cases was 9 cases (0.3%), the percentage were incidental aneurysms;164 (5.5%). 88.1% had overall favorable surgical results with a 5.5 % mortality rate. Calcium-channel blocker and "Triple H" therapy did not improve mortality but did significantly improve morbidity. In the old age group, early operation reduced vasospasm, rebleeding and medical complications. The early surgery group exhibited a 86.2% favorable outcome with a 8.1% mortality rate. Intraoperative angiography reduced residual or remained aneurysms in large, giant aneurysm, especially in A.com artery aneurysm. CONCLUSION: The surgical results for the early surgery group according to surgical timming was better, but there were not statistically significant. ntraoperative angiography was especially useful on large aneurysms of the anterior communicating artery.

Thalamotomy without Microelectrode Recording

OBJECTIVE: Tremor, either essential tremor or Parkinsonian tremor, has been effectively and safely treated by lesioning the ventral intermediate(Vim) nucleus of the thalamus with or without mircroelectrode recording. The authors evaluate the treatment outcome of sixteen tremor patients who had been treated with thalamotomy without microelectrode. METHODS: Between September, 2001, and December, 2003, sixteen tremor patients were treated with thalamotomy without microelectrode recording. Twelve patients suffered from Parkinsonian tremor and four patients were essential tremor patients. The male to female ratio was 1.6 to 1 with median age of 59.6 years (range; 39-74 years). Under local anesthesia, a 3mm hole was made using a hand-held twist drill, and the dura mater was penetrated with a 1.2mm sharp drill beat. Radiofrequency(RF) electrode was placed in the Vim nucleus of thalamus. With intraoperative macrostimulation, RF lesion was made. Postoperative CT scan and/or MR imaging was performed to confirm the localization of the target lesioned. Preoperative and postoperative tremor was evaluated with simple tremor severity scale and the development of complications related with the procedure was closely reviewed at the immediate postoperative period and the last follow-up. RESULTS: It produces immediate relief in up to 98.4% of the patients. There were no development of complications related with procedure, all patients discharged one or two days after surgery. CONCLUSION: Vim thalamotomy without microelectrode recording is a safe and effective procedure to control the tremor with minimal morbidity. Intraoperative macroelectrode stimulation safely localizes the Vim nucleus target of the thalamus for the treatment of patients with tremor.

Clinical Aspect of Spontaneous Pontine Hemorrhage / 대한뇌혈관외과학회지

OBJECT: Spontaneous pontine hemorrhage can be diagnosed by CT or MRI, but the clinical course is variable according to the location of the hemorrhage. MATERIALS AND METHODS: Author attempted to analyse 39 cases of spontaneous pontine hemorrhage, considering factors to influence their prognosis, admitted in Inje University Busan Paik Hospital from 1998 to 2002. RESULT: Pontine hemorrhage was classified according to the finding of CT scan;4 cases of Type I (hematoma, localized in the tegmentum), 18 cases of Type II (those in the tegmentolaterally), 16 in Type III (those in the basis pontis mainly with tegmentum and midbrain). Male to female ratio was 31:8, mean age was 48.2 years (9-76 years). Initial Glascow Coma scale was 7.6 (3-14), and mean follow-up period was 5.1 months (0.1-52 months). Associated diseases were as follows;hypertension;20, pulmonary tuberculosis;2, hypertension with D.M;1. Treatment modality was consisted of 36 conservative treatment, 1 stereotactic hematoma aspiration, 2 Gamma-Knife radiosurgery for associated cavernous malformations. Prognosis was good at following order of the tegmentotectal, tegmentolateral type. CONCLUSION: The prognosis of tegmentotectal, tegmentolateral type hemorrhage was better than basis pontis. The little volume of the hematoma, the better prognosis.

Intracranial Chloroma(Granulocytic Sarcoma) by Lymphocytic Leukemia

Intracranial chloroma may occur in leukemia, although they are rare. A 23-year-old female complained diplopia. Brain magnetic resonance MR imaging showed tumors in the both cavernous sinus , both tentorial and anterior falx. Gamma-Knife radiosurgery was performed with maximal dose; 20Gy, marginal dose; 10Gy. Peripheral blood smear revealed leukemia, and bone marrow aspiration biopsy showed acute lymphocytic leukemia. Two weeks later, MR image for the stereotactic biopsy noticed markedly decreased tumor size. Biopsy result was lymphocytic leukemia. She received conventional radiation therapy, chemotherapy, and bone marrow transplantation. Brain involvement by acute lymphocytic leukemia is very rare. Even though chloroma are sensitive to radiation therapy, prognosis is poor because of the gravity of the underlying disease and association with impending blast transformation. The authors reports a intracranial chloroma by acute lymphocytic leukemia.

Treatment of Intracranial Unruptured Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Treatment decisions in patients with unruptured aneurysms required detail assessment of the risk. The most important things to prevent the subarachnoid hemorrhage (SAH) are the measuring of risk of rupture of intracranial aneurysm and the decreasing of operation risk at aneurysm neck clipping. METHODS: Between January, 1994, and April, 2003, data regarding a series of 1586 aneurysm operations performed by a single neurosurgeon (J.H.S). Among them 158 patients with unruptured intracranial aneurysm (UIA) were analyzed retrospectively from the medical records and radiological findings (CT, CT angiography, MR angiography & angiography). The type of aneurysm was classified by three categories : Group 1 : incidental (asymptomatic, unruptured), Group 2 : symptomatic unruptured, Group 3 : UIA with SAH from a separate aneurysm. Unoperated cases were excluded. RESULTS: The treated aneurysms were 91 patients with 103 UIAs. Group 1 : 41 patients with 49 UIAs, Group 2 : 5 patients and Group 3 : 45 patients with 49 UIAs. In Group 1 the results of treatment were 0 mortality and below 4% morbidity. The cases with morbidity were a giant aneurysm, old age patient and the UIAs of posterior circulation. CONCLUSION: The UIA with SAH should be treated surgically and/or endovascular therapy. The treatment of the unruptured, asymptomatic incidental intracranial aneurysm was recommended but the patient's age, size and lcoation of aneurysm, and the skill and experience of neurosurgeon were considered honestly and carefully.

Gamma-Knife Radiosurgery of Upper Cervical Spinal Cord Tumor

OBJECTIVE: The lower limit of gamma knife radiosurgery is considered as foramen magnum. The head is long and narrow in western people, however, the head is short and wide in oriental people. In microcephalic oriental person, gamma knife radiosurgery is tried for the upper cervical cord tumor. METHODS: We have treated seven patients of upper cervical cord tumor with Gamma-plan during the last 8 years. The seven patients consisted of one man and six women, and ages ranging from 25 to 67 years. The histologic diagnoses were cervicomedullary hemangioblastoma in two, meningioma in two, brain stem glioma extending to C2 in one, hemangioma in one, glomus jugulare tumor in one. Preradiosurgical surgical intervention was performed in three patients. Mean marginal dose was 10.8Gy. RESULTS: The median follow-up period was 40 months (12-51 months). Four tumor had markedly decreased in size on follow-up magnetic resonance image. The remaining four cases were stationary in size. There was no complication. CONCLUSION: In microcehalic or normocephalic oriental person, the lower limit of gamma knife radiosurgery is level of second cervical spine.

Cyst Formation after Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation

OBJECTIVE: The authors present cases of cyst formation after gamma knife radiosurgery for arteriovenous malformation. METHODS: One hundred seventy eight arteriovenous malformation patients were treated with Gamma knife radiosurgery from October, 1994 to October, 2002. Six patients developed cyst after Gamma knife radiosurgery after a mean of 46.5 months(range, 11-62 months). Male to female ratio was 5: 1 and mean age was 19.7 years(range, 15-24 years). RESULTS: The mean marginal dose was 22.7Gy(range, 10-25Gy) and mean volume was 22.4cm3(range, 1.9-80.3cm3). Initial symptoms were hemorrhage in three, seizure in two and headache in one. Symptom after cyst formation was motor weakness in three patients, asymptome in three patients. The locations of the cyst were basal ganglia in two, parietal in two, occipital in one, parietooccipital in one. Ventriculoperitoneal shunt was performed in one, Ommaya's reservoir insertion in one, craniotomy and removal of cyst and then Ommaya's reservoir insertion after 8 months in one and no treatment was given in three. CONCLUSION: Cyst formation after Gamma knife radiosurgery for arteriovenous malformation may occur. However, symptomatic cysts can be effectively treated with Ommaya's reservoir insertion, or cystoperitoneal shunt and in some cases, excision is needed.

Familial Multiple Endocrine Neoplasia, Type I, in Identical Twins

We report of case of one monozygotic twin sister with pituitary tumor and multiple endocrine neoplasia, type 1.The older sister, 31-year-old woman, had undergone Gamma Knife radiosurgery for prolactin producing pituitary microadenoma. Four years later, pancreatic insulinoma was detected, distal pancreatectomy and splenectomy were done. The younger sister, 31-year-old woman, had been operated for pancreatic insulinoma, 12 years ago. One year ago, hyperparathyroidism and pituitary macroadenoma were detected. Tumor removal was followed by Gamma Knife radiosurgery for residual tumor.

Familial Occurrence of Cerebellar Gliomas

Several cases of familial occurrence of gliomas have been reported, but little has been known on the importance of genetic factors, which indeed remains controversial. In establishing the genetic basis for cancer susceptibility, the evaluation of a single family is perhaps the most satisfactory and meaningful approach. We report a family in which the 47-year-old father had glioblastoma in cerebellar vermis and his 14-year-old daughter developed pilocytic astrocytoma in cerebellar hemisphere. Karyotypic analysis of this family showed no abnormal findings in chromosomes.

Surgical Experiences of 2,178 Cases of Intracranial Aneurysms

OBJECTIVE: The present study is conducted to evaluate the overally surgical results in 2,178 patients with intracranial aneurysms operated in our institution from January 1980 to December 30th, 2000. METHODS: The anterior communicating artery aneurysms was 720 case, internal carotid artery aneurysms 576, middle cerebral artery aneurysms 588, anterior cerebral artery aneurysms 57 and vertebro-basilar artery aneuryms was 78 case. The male to female ratio was 0.7 to 1. Surgical methods were 1,968 clippings, 170 coatings and wrappings, 22 aneurysmorraphy, 18 proximal ligations. RESULTS: Incidence of the rebleeding was 5.6% of the early operation group, 17% of the late operation group. Incidence of the clinical vasospasm was 18.6%, angiographic vasospasm was 26.2%. The multiple aneurysms was 8.6%, dissecting aneurysm 4 cases(0.2%), "De Novo" aneurysm 4 cases(0.19%), lobectomy cases 7 cases(0.32%), and incidental aneurysms 108 cases(5.01%) respectively. Overall surgical result was favorble outcome in 86% and mortality in 7%. In early surgery group, favorable outcome was 88%, mortality was 6%. The calcium-channel blocker and "Triple-H" therapy improved the post-operative morbidity significantly. In old age group, favorable outcome was 85.5% and 8.5% mortality rate in early operation group, favorable outcome 69.8%, mortality 11.3% in late operation group. Intraoperative angiography reduced residual aneurysm or remained aneurysm in large, giant aneurysm, and complicated aneurysm especially in anterior communication artery aneurysm. CONCLUSION: It is important to know our own statisticts about the cerebrovascular disease in Korea. We present the large series of aneurysm surgery in one institute.

Surgical Experiences of 2,178 Cases of Intracranial Aneurysms

OBJECTIVE: The present study is conducted to evaluate the overally surgical results in 2,178 patients with intracranial aneurysms operated in our institution from January 1980 to December 30th, 2000. METHODS: The anterior communicating artery aneurysms was 720 case, internal carotid artery aneurysms 576, middle cerebral artery aneurysms 588, anterior cerebral artery aneurysms 57 and vertebro-basilar artery aneuryms was 78 case. The male to female ratio was 0.7 to 1. Surgical methods were 1,968 clippings, 170 coatings and wrappings, 22 aneurysmorraphy, 18 proximal ligations. RESULTS: Incidence of the rebleeding was 5.6% of the early operation group, 17% of the late operation group. Incidence of the clinical vasospasm was 18.6%, angiographic vasospasm was 26.2%. The multiple aneurysms was 8.6%, dissecting aneurysm 4 cases(0.2%), "De Novo" aneurysm 4 cases(0.19%), lobectomy cases 7 cases(0.32%), and incidental aneurysms 108 cases(5.01%) respectively. Overall surgical result was favorble outcome in 86% and mortality in 7%. In early surgery group, favorable outcome was 88%, mortality was 6%. The calcium-channel blocker and "Triple-H" therapy improved the post-operative morbidity significantly. In old age group, favorable outcome was 85.5% and 8.5% mortality rate in early operation group, favorable outcome 69.8%, mortality 11.3% in late operation group. Intraoperative angiography reduced residual aneurysm or remained aneurysm in large, giant aneurysm, and complicated aneurysm especially in anterior communication artery aneurysm. CONCLUSION: It is important to know our own statisticts about the cerebrovascular disease in Korea. We present the large series of aneurysm surgery in one institute.

A Dumbbell-shaped Thoraco-lumbar Extradural Ganglioneuroma: Case Report

Ganglioneuromas commonly arise from sympathetic ganglia. These neoplasm may be located wherever ganglion cells are normally found from skull base to pelvis including adrenal gland. Ganglioneuromas in spinal cord are very rare. We report a case of dumbbell-shaped extradural spinal ganglioneuroma. A 7-year-old boy was admitted to our hospital with a 20 day-history of both leg pain and a 10 day-history of progressive paraparesis. On magnetic resonance image, there was a dumbbell-shaped extradural spinal cord tumor in T11-L4 level. Two stage operation(First : Laminoplastic laminotomy of T11-L4 to remove the extradural portion of the tumor in the spinal canal, Second : Right retroperitoneal approach for the removal of paraspinal tumor located in L2-3 level) was performed. Pathologic diagnosis was a ganglioneuroma and paraparesis improved postoperatively.

Dysphagia associated with Jugular Foramen Syndrome due to Traumatic Brain Injury

OBJECTIVE: To present one case of dysphagia associated with jugular foramen syndrome (Vernet syndrome) by trauma. The jugular foramen syndrome refers to paralysis of the IX, X and XI cranial nerves. Dysphagia due to jugular foramen syndorme without pseudobular palsy is rare in traumatic brain injury. CASE SUMMARY: A 16-year-old boy with the left occipital skull fracture and skull base fracture was not able to take any food by mouth. There was no other significant symptom without dysphagia. Physical examination, laryngoscopic examination and electromyography revealed paralysis of the left IX, X and XI cranial nerves. Videofluoroscopic examination demonstrated atonic ballooned pyriformis sinus and closed upper esophageal sphincter. Brain CT and MRI showed fracture line in the left jugular foramen without brain stem or diffuse cortical lesion. Feeding gastrostomy was performed. CONCLUSION: We report an unusual case of dysphagia due to jugular foramen syndrome in traumatic brain injury patient.

Epidemiology and Natural History of Cavernous Malformations / 대한뇌혈관학회지

Cavernous malformations are well demarcated mulberry-like lesions composed of thin-walled sinusoidal channels. Thanks to introduction of magnetic resonance imaging (MRI), vascular malformations are being diagnosed with increasing frequency. Cavernous malformations constitute about 10% of all cerebrovascular malformations and are present in about 0.5% of the population. There is no sex predominance, with the highest incidence occuring in fourth decade. The most common symptom is seizure, followed by focal neurological deficits, headache and hemorrhage. The annualized bleeding rate is 0.7%, with the significantly greater risk of overt hemorrhage in females. The lesion is asymptomatic in about 16% of patients. Cavernous malformations usually are sporadic but multiple lesions are common in the familial form (50% to 73%). Symptom presentation is strongly related to the size of lesion greater than 1 cm in diameter.

Gamma Knife Radiosurgery on Uveal Melanoma

Uveal melanoma is uncommon but life-threatening intraocular malignancy and has been treated by irradiation, local excision and enucleation. Gamma-Knife radiosurgery allows a high dose of radiation to be delivered to an intracranial target with a very high spatial accuracy and has been used for the treatment of ocular melanomas. We have treated two cases of uveal melanoma between October 1994 and December 1999. They include one man and one woman(34, 62 years, respectively). They were followed up for 12 momths. Mean maximal dose was 65Gy. In one case, the tumor disappeared 7 months after gamma-knife radiosurgery. In another case, multiple tumors (uveal, suprasellar and cerebellar tumor) had decreased in size. These results show that single and high dose gamma-knife radiosurgery is may be an option in the local control of uveal melanoma which can spare the eyeball and vision.

Gamma-Knife Radiosurgery for Vestibular Schwannoma

OBJECT: The goals of radiosurgery include preservation of neurological function and prevention of tumor growth. We document the results of gamma-knife radio-surgery for vestibular schwannoma. METHOD AND OBJECT: Eighty-two patients underwent stereotactic radiosurgery for an vestibular schwannoma from October, 1994 to December, 2000. Sixty-five of these patients were followed up for radiological and clinical evaluation. As pregamma-knife modality, surgical resection were done in 23 patients,and V-P shunt in 2 patients. Initial symptoms were headache(n=45), dizziness(n=16), tinnitus(n=17). While normal facial function(House-Brackmann grade 1) was present in 48 patients(73.8%), other patients showed grade 2 function in 8, grade 3 function in 7,and grade 4 function in 2. The Gardner/Robertson scale was used to code hearing function. Male to female ratio was 1:3. Mean tumor volume was 7.98cm3. Mean dose delivered to the tumor margin was 14.2Gy,and mean maximal dose was 28.3Gy. RESULTS: Mean follow-up duration of 19.9 months. Thirty-five showed decrease(53.8%) in size, 19 patients(29.2%) stationary, 3(4.6%) initial decrease follow up increase, 5(7.6%) initial increase follow up decrease,and 59 patients (90.8%) were well controlled. Two patients experienced transient facial neuropathy, one transient trigeminal neuropathy, and one transient hearing deterioration. After gamma-knife radiosurgery, ventriculoperitoneal shunt was done in 4 patients. CONCLUSIONS: Gamma-knife radiosurgery can be used to treat postoperative residual tumors as well as in patients with concomitant medical problems in patients with preserved hearing function. Gamma-knife radiosurgery is safe and effective method to treat small, medium sized(less than 3cm in extracanalicular diameter), intracanalicular vestibular schwannoma, associated with low rate of cranial neuropathy.

Multiple External Carotid Artery Aneurysms with Neurofibromatosis: Case Report

No abstract available.

Preliminary Report of Gamma Knife Radiosurgery for the Movement Disorders

No abstract available.

Modified Transsylvian Approach with Orbitozygomatic Resection for Distal Basilar Artery Aneurysms / 대한뇌혈관학회지

Aneurysms arising from the distal basilar artery(BA) and relating to the origin of the superior cerebellar artery (SCA), posterior cerebral artery (PCA) account for more than 15% of all intracranial aneurysms and more than one-half of all aneurysms occurring in the vertebrobasilar circulation. The anatomic complexity of the interpeduncular cistern is directly related to the dangers of surgical manipulation in this region and it is undoubtedly difficult to operate on a distal basilar aneurysm which located deep in a very narrow operative field restricted by unremovable neural and vascular architectures. Although we can not choose no single operative approach suitable to this area because the indivisual patient's vascular, neural and bony anatomy is widly variable, using the modified transsylvian approach with orbitozygomatic resection the distal basilar artery aneurysms could be seen and clipped easily by upward and oblique viewing from below through the wide operative space consisting of the less retracted intracarotid artery, middle cerebral artery and oculomotor nerve. We have operated 64 distal basilar artery aneuysms. Among them, 27 patients were approached using the modified transsylvian approach with orbitozygomatic resection. The operative procedure is presented in detail and compared with other surgical approaches.