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.

Optimal Treatment in Patients with Ruptured Middle Cerebral Artery Aneurysms and Intracranial Hematoma According to Hematoma Distribution / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to determine the clinical courses and optimal treatments for patients suffering from ruptured middle cerebral artery (MCA) aneurysms with either intracerebral (ICHs) or sylvian hematomas (SylH), based on hematoma distribution. METHODS: We grouped 49 patients with Fisher grade III or IV subarachnoid hemorrhages, who underwent aneurysmal neck clipping and hematoma evacuation within 24 hours of developing an intracranial hematoma, according to hematoma distribution. Group A comprised 21 patients who had ICHs<30 ml, while group B comprised 28 patients with dense SylHs<30 ml. Result: Immediate postoperative brain computerized tomography findings showed residual hematomas in 3 group A patients (14.3%) and 20 group B patients (71.7%). We noted post-operative brain edema in 5 group A (23.8%) and 15 group B patients (53.6%). Vasospasm developed in 4 group A (19.0%) and 20 group B patients (71.4%; p<0.05). In group A, 12 patients (57.1%) had focal neurologic deficits upon discharge, while 5 patients died. In group B, 9 patients (32.1%) had focal neurologic deficits upon discharge, while 8 died (p<0.05). Normal pressure hydrocephalus developed in 1 patient (4.8%) in group A and 5 in group B (17.9%). Favorable outcomes were achieved in 9 patients (42.9%) in group A and 4 (14.3%) in group B. CONCLUSION: Patients who experienced ruptured MCA aneurysms with SylHs had more severe clinical courses and poorer outcomes than patients with ICHs did. The SylH patients had a higher incidence of both vasospasm and brain edema. Therefore, physicians must consider differences in clinical features based on hematoma distribution when choosing an appropriate therapeutic approach for patients with ruptured MCA aneurysms and intracranial hematomas.

Chronic Subdural Hematomas : A Comparative Study of Three Types of Operative Procedures

OBJECTIVE: Several surgical procedures have been reported for the treatment of chronic subdural hematoma (CSDH). We compared the results of treatments for CSDH obtained from one burr-hole craniostomy with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation, and small craniotomy with irrigation and closed-system drainage. METHODS: Eighty-seven patients with CSDH underwent surgery at our institution from January 2004 to December 2008. Our patients were classified into three groups according to the operative procedure; group I, one burr-hole craniostomy with closed system drainage with or without irrigation (n = 25), group II, two burr-hole craniostomy with closed system drainage with irrigation (n = 32), and group III, small craniotomy with irrigation and closed-system drainage (n = 30). RESULTS: Age distribution, male and female ratio, Markwalder's grade on admission and at the time of discharge, size of hematoma before and after surgery, duration of operation, Hounsfield unit of hematoma before and after surgery, duration of hospital treatment, complication rate, and revision rate were categories that we compared between groups. Duration of operation and hospitalization were only two categories which were different. But, when comparing burr hole craniostomy group (group I and group II) with small craniotomy group (group III), duration of post-operative hospital treatment, complication and recurrence rate were statistically lower in small craniotomy group, even though operation time was longer. CONCLUSION: Such results indicate that small craniotomy with irrigation and closed-system drainage can be considered as one of the treatment options in patients with CSDH.

Remote Cerebellar Hemorrhage After Supratentorial Aneurysm Surgery: Report of 2 Cases / 대한뇌혈관외과학회지

Remote cerebellar hemorrhage is a rare complication of supratentorial neurosurgical surgery occurring in approximately 0.3~0.6%, and it is same with the supratentorial aneurysm surgery. Although remote cerebellar hemorrhage is a rare complication of supratentorial neurosurgical surgery, this is often related with significant morbidity and mortality. In spite of its lethal character, the precise mechanism is uncertain. In this article, we present clinical details of two patients with cerebellar hemorrhage after supratentorial aneurysm surgery, and discuss about possible mechanism of this rare complication. In reported articles, seven predisposing factors are correlated with remote cerebellar hemorrhage after supratentorial aneurysm surgery; hypertension, cerebrovasular anomaly, anti-coagulation treatment, coagulopathy, head positioning during surgery, over drainage via epidural closed drainage system with negative pressure, and excessive CSF drainage during or after the surgery. By reporting these two cases, we want to alert neurosurgeons about this rare but lethal complication, and tell about that there are several ways to minimize the possibility of remote cerebellar hemorrhage.

Posterior Cervical Fixation with Nitinol Shape Memory Loop in the Anterior-Posterior Combined Approach for the Patients with Three Column Injury of the Cervical Spine : Preliminary Report

OBJECTIVE: The authors reviewed clinical and radiological outcomes in patients with three column injury of the cervical spine who had undergone posterior cervical fixation using Nitinol shape memory alloy loop in the anterior-posterior combined approach. MATERIALS: Nine patients were surgically treated with anterior cervical fusion using an iliac bone graft and dynamic plate-screw system, and the posterior cervical fixation using Nitinol shape memory loop (Davydov(TM)) at the same time. A retrospective review was performed. Clinical outcomes were assessed using the Frankel grading method. We reviewed the radiological parameters such as bony fusion rate, height of iliac bone graft strut, graft subsidence, cervical lordotic angle, and instrument related complication. RESULTS: Single-level fusion was performed in five patients, and two-level fusion in four. Solid bone fusion was presented in all cases after surgery. The mean height of graft strut was significantly decreased from 20.46+/-9.97 mm at immediate postoperative state to 18.87+/-8.60 mm at the final follow-up period (p<0.05). The mean cervical lordotic angle decreased from 13.83+/-11.84degrees to 11.37+/-6.03degrees at the immediate postoperative state but then, increased to 24.39+/-9.83degrees at the final follow-up period (p<0.05). There were no instrument related complications. CONCLUSION: We suggest that the posterior cervical fixation using Nitinol shape memory alloy loop may be a simple and useful method, and be one of treatment options in anterior-posterior combined approach for the patients with the three column injury of the cervical spine.

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.

Vertebroplasty Utilizing Percutaneous Vertebral Body Access (PVBA) Technique for Osteoporotic Vertebral Compression Fractures in the Middle Thoracic Vertebrae

OBJECTIVE : Percutaneous approach to the middle thoracic vertebra through the transpedicular route for the patients with osteoporotic vertebral compression fractures is difficult due to the small size of the pedicle and parasagittally oriented vertebral body anatomy. The percutaneous vertebral body access (PVBA) technique utilizing the posterolateral extrapedicular approach avoids the pedicle and provides direct access to the vertebral body. The objective of this study is to evaluate the efficacy of the vertebroplasty utilizing PVBA technique for osteoporotic vertebral compression fractures in the middle thoracic vertebrae. METHODS : A retrospective review was done on 20 patients who underwent vertebroplasty utilizing PVBA technique performed for painful osteoporotic compression fracture in the middle thoracic vertebrae at 22 levels from May 2003 to June 2006. The average amount of the injected cement was 1.5-2.5ml. The postprocedural outcome was assessed using a visual analogue scale (VAS). RESULTS : The treated vertebrae were T5 (1 level), T6 (5 levels), T7 (7 levels), and T8 (9 levels). The compression rate and kyphotic angle were improved after procedure from 18%+/-13.4 to 16%+/-13.8 (p>0.05) and from 6.9degrees+/-6.7 to 6.6degrees+/-6.2 (p>0.05), respectively. Preprocedural VAS was 8.2+/-0.70 and was decreased to 2.1+/-1.02 (p<0.01) after treatment. Postprocedural cement leakage was noted in 3 levels (13.7%). There were no cases of leakage to epidural space or neural foramen, segmental artery injury, and pneumothorax. CONCLUSION : These results suggest that the complication rates are low and good results can be achieved with vertebroplasty utilizing PVBA technique for the osteoporotic vertebral compression fractures especially in the middle thoracic vertebrae.

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).

Simple Decompression of the Ulnar Nerve for Cubital Tunnel Syndrome

OBJECTIVE: Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients. METHODS: According to Dellon's criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less). RESULTS: Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbowbelow the elbow) was 41.8+/-15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8+/-6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8+/-12.1 m/s to 47.8+/-12.1 m/s (p<0.05). After an average follow-up of 4.8+/-5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve. CONCLUSION: Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.

Solitary Subdural Osteoma

Osteomas are benign neoplasms consisting of mature normal osseous tissue. They are common on the long bones of the extremities and found in the sinuses, facial bones, skull and madible in the head and neck region. Much rarer, however, are osteomas arising from subdural space with displacement of the underlying brain. A 42-year-old woman presented with a history of intermittent left frontal headache that was proved to be due to an intracranial lesion. After surgical removal, it was found to be an subdural osteoma. We report this case with pertinent literatual reviews.

Congenital Hypoplasia of the Bilateral Internal Carotid Artery: A Case Report

Congenital agenesis, aplasia or hypoplasia of the internal carotid artery is rare vascular disease and usually combine with intracranial aneurysm, subarachnoid hemorrhage, or intracerebral hemorrhage. We report a case of bilateral congenital hypoplasia of internal carotid artery in a 36 year-old woman presented with semicomatose mentality. The brain computed tomography(CT) revealed intracerebral hemorrhage with intraventricular hemorrhage, and cerebral angiography showed hypoplasia of bilateral internal carotid artery without narrowing of the bony carotid canal on the temporal bone CT.