Delayed Operation of Acute Subdural Hematoma in Subacute Stage by Trephine Drainage using Urokinase / 대한신경손상학회지

OBJECTIVE: The principle operation of acute subdural hematoma (ASDH) is a craniotomy with hematoma removal, but a trephination with hematoma evacuation may be another method in selected cases. Trephine drainage was performed for ASDH patients in subacute stage using urokinase (UK) instillation, and its results were evaluated. METHODS: Between January 2016 and December 2018, the trephine evacuation using UK was performed in 9 patients. The interval between injury and operation was from 1 to 2 weeks. We underwent a burr hole trephination with drainage initially, and waited until the flow of liquefied hematoma stopped, then instilled UK for the purpose of clot liquefaction. RESULTS: The mean age of patients was 71.6 years (range, 38–90 years). The cause of ASDH was trauma in 8 cases, and supposed a complication of anticoagulant medication in 1 case. Four out of 8 patients took antiplatelet medications and one of them was a chronic alcoholism. The range of the Glasgow Coma Scale score before surgery was from 13 to 15. Most of patients, main symptom was headache at admission. The Glasgow Outcome Scale score was 5 in 8 cases and 3 in 1 case. CONCLUSION: It is thought to be a useful operation method in selected patients with ASDH that the subdural drainage in subacute stage with UK instillation. This method might be another useful option for the patients with good mental state regardless of age and the patients with a risk of bleeding due to antithrombotic medications.

Regression of asymptomatic intracranial arterial stenosis by aggressive medical management with a lipid-lowering agent

OBJECTIVE: The incidence rate of stroke as a result of intracranial arterial stenosis (ICAS) is higher in Asian countries than in the West. We aimed to analyze the regression, lack of change, or progression of asymptomatic ICAS after the administration of rosuvastatin and associated factors.METHODS: The patients who had undergone computed tomography angiography (CTA) at our hospital and had been diagnosed with ICAS with no ischemic event in the stenosed vascular territory were included in the study. They were administered 20mg of rosuvastatin per day. After a follow-up period of at least 6 months after treatment, the patients were examined using CTA again and the clinical information and imaging results were analyzed.RESULTS: In total, 48 patients were diagnosed with asymptomatic ICAS. During the final follow-up examination, it was found that the stenotic lesion regressed in 30 patients, whereas it remained unchanged or progressed without any adverse effects in 18 patients. In univariate analysis, the regressed group showed significantly higher differences in the levels of total cholesterol and low-density lipoprotein (LDL) between their initial and final values (both, p=0.031 for both). In the multivariate analysis, a significantly higher difference in the levels of LDL between its initial and final measurement was seen in the regressed group (p=0.035, odds ratio(OR) 3.9).CONCLUSIONS: Rosuvastatin was found to have better lipid-lowering effects for total cholesterol and particularly LDL in patients whose ICAS had regressed. We concluded that rosuvastatin administration can be recommended for the treatment of patients with asymptomatic ICAS.

Multiple Intracranial High Density Foci after Brain Parenchymal Catheterization / 대한신경손상학회지

OBJECTIVE: To report an observational investigation of small high attenuated foci in computed tomography (CT) scan followed by brain parenchymal catheterization. METHODS: From January 2011 to March 2015, we retrospectively reviewed the 381 patients who had undergone brain catheterization in our clinic and enrolled the patients who had newly developed high attenuation foci in the postoperative CT scans. The brain CT scans were reviewed about the lesion location, Hounsfield Unit (HU) and the time of appearance. RESULTS: Twenty seven of 381 patients had high attenuation foci in CT scans after the procedure. The location of high density lesions was as follows: parenchyma in 9 (33.3%) cases, ventricle in 5 (18.5%), combined in parenchyma and ventricle in 13 (48.1%). The lesions were identified in the catheter tract in parenchymal type, and catheter-lodged frontal horn or choroid plexus in ventricular type. We could not find the calcific foci before the catheter removal, and those were found after removal in all cases. The time of appearance after the removal was variable from 0 to 14 days (mean 4.2, median 3). The regular rules of HU change in CT scans were not found as times go on. CONCLUSION: The high attenuation foci in CT scans were bone dust originated from skull during operation. Although these lesions did not make troubles, we should clean the operation field before the insertion of brain catheter and we may use another material, like Surgicel to seal up the burr hole instead of bone dust in the end of operation.

Clipping of Incidental Aneurysm of Middle Cerebral Artery Through Small Temporal Craniotomy and Linear Skin Incision

The authors introduced a new approach for clipping of the incidental aneurysm of the middle cerebral artery (MCA) and reported the clinical results. We retrospectively reviewed 26 patients with 27 incidental MCA aneurysms who were treated from January 2010 to December 2012. All clippings were performed through a small temporal craniotomy and linear skin incision. Follow-up imaging showed complete occlusion of 26 aneurysms (96.3%), residual neck in one (3.7%). In one case, residual neck of the aneurysm did not grow on serial follow up. In one of 26 cases (3.8%), approach-related complication was retraction injury of the temporal cortex. Two patients developed postoperative infarction on the MCA territories due to vasospasm and on the cerebellum due to unknown causes. These were not approach-related complications. Operation time was 95 min-250 min (mean 143 min). There were no complications of temporal muscle atrophy, scar deformity, paresthesia, or pain around the scalp incision and frontalis palsy. This approach offers good surgical possibilities and little approach related morbidity in the clipping of incidental MCA aneurysms.

Factors Related to Catheter-Induced Hemorrhage after Brain Parenchymal Catheterization / 전남의대학술지

This article aimed to investigate the incidence rate and possible risk factors for catheter-induced hemorrhage (CIH) after brain parenchymal catheterization. Between January 2011 and March 2013, 381 patients (572 punctures) who underwent brain parenchymal catheterization were retrospectively evaluated. All patients were checked by computerized tomography scan for the detection of hemorrhage within 48 hours after catheter insertion. CIH was defined as any evidence of new hemorrhage on the post-procedural computerized tomography scan. The incidence rate and the possible risk factors were analyzed by surgeon (4 different surgeons performed the procedures), characteristics of the catheter device, and patient background. Of 381 patients, 572 punctures were performed and CIH developed in 122 puncture cases (122/572, 21.3%). The risk factors related to CIH were Glasgow Coma Scale (GCS) score < or =8 (p<0.01) and prothrombin time international normalized ratio (PT INR) > or =1.3 (p=0.038). The amount of hemorrhage was minimal without additional operations. A low GCS score and high PT INR are implicated as potential risk factors for CIH after brain parenchymal catheterization. Careful and delicate operative technique can help to reduce postoperative complications in these patients.

Factors Related to Catheter-Induced Hemorrhage after Brain Parenchymal Catheterization / 전남의대학술지

This article aimed to investigate the incidence rate and possible risk factors for catheter-induced hemorrhage (CIH) after brain parenchymal catheterization. Between January 2011 and March 2013, 381 patients (572 punctures) who underwent brain parenchymal catheterization were retrospectively evaluated. All patients were checked by computerized tomography scan for the detection of hemorrhage within 48 hours after catheter insertion. CIH was defined as any evidence of new hemorrhage on the post-procedural computerized tomography scan. The incidence rate and the possible risk factors were analyzed by surgeon (4 different surgeons performed the procedures), characteristics of the catheter device, and patient background. Of 381 patients, 572 punctures were performed and CIH developed in 122 puncture cases (122/572, 21.3%). The risk factors related to CIH were Glasgow Coma Scale (GCS) score or =1.3 (p=0.038). The amount of hemorrhage was minimal without additional operations. A low GCS score and high PT INR are implicated as potential risk factors for CIH after brain parenchymal catheterization. Careful and delicate operative technique can help to reduce postoperative complications in these patients.

Outcome Evaluation of Intravenous Infusion of Urokinase for Acute Ischemic Stroke / 전남의대학술지

The aim of this study was to evaluate the clinical effect of a continuous infusion of urokinase in cerebral stoke patients who were late admitted over 6 hours after onset. From January to December in 2008, acute cerebral stroke patients (n=143) treated with intravenous urokinase infusion (Group I, n=93) or not (Group II, n=50) after 6 hours and within 72 hours of stroke onset were reviewed. Continuous intravenous infusion of urokinase was done for 5 days. The clinical outcome for each patient was evaluated by using the modified National Institutes of Health Stroke Scale (NIHSS) on admission and on the day of discharge. The NIHSS score was decreased at discharge compared with admission in the urokinase treatment group (Group I; from 4.8+/-2.2 to 3.8+/-1.9; p=0.002). There was an improvement in the patients who initiated urokinase treatment within 24 hours from stroke onset in Group I (from 5.1+/-1.9 to 3.9+/-1.5; p=0.04). In patients with initiated urokinase treatment within 24 hours from stroke onset, intravenous urokinase infusion could be an effective modality in acute ischemic stroke patients admitted later than 6 hours after onset.

Intraspinal Ganglion Cyst / 전남의대학술지

The pathogenesis of juxtafacet cysts is closely related to degenerative instability of the lumbar spine and degenerative changes in the ligamentum flavum and the facet joint. A 56-year-old man presented with severe right thigh pain and numbness for 1 month after a laminar fracture of the L4 spine. Magnetic resonance imaging revealed a heterogenous cystic mass surrounding the facet joint between the fourth and fifth lumbar vertebrae on the right side. Conservative therapy was unsuccessful and the lesion was removed by surgical decompression alone without fusion. The histological examination showed a fragmented, cystic wall-like structure composed of myxoid degenerative tissue without lining epithelium. Here we present this case of a ganglion cyst that appeared to be associated with facet joint instability.

Outcome Evaluation of Intravenous Infusion of Urokinase for Acute Ischemic Stroke / 전남의대학술지

The aim of this study was to evaluate the clinical effect of a continuous infusion of urokinase in cerebral stoke patients who were late admitted over 6 hours after onset. From January to December in 2008, acute cerebral stroke patients (n=143) treated with intravenous urokinase infusion (Group I, n=93) or not (Group II, n=50) after 6 hours and within 72 hours of stroke onset were reviewed. Continuous intravenous infusion of urokinase was done for 5 days. The clinical outcome for each patient was evaluated by using the modified National Institutes of Health Stroke Scale (NIHSS) on admission and on the day of discharge. The NIHSS score was decreased at discharge compared with admission in the urokinase treatment group (Group I; from 4.8+/-2.2 to 3.8+/-1.9; p=0.002). There was an improvement in the patients who initiated urokinase treatment within 24 hours from stroke onset in Group I (from 5.1+/-1.9 to 3.9+/-1.5; p=0.04). In patients with initiated urokinase treatment within 24 hours from stroke onset, intravenous urokinase infusion could be an effective modality in acute ischemic stroke patients admitted later than 6 hours after onset.

Intraspinal Ganglion Cyst / 전남의대학술지

The pathogenesis of juxtafacet cysts is closely related to degenerative instability of the lumbar spine and degenerative changes in the ligamentum flavum and the facet joint. A 56-year-old man presented with severe right thigh pain and numbness for 1 month after a laminar fracture of the L4 spine. Magnetic resonance imaging revealed a heterogenous cystic mass surrounding the facet joint between the fourth and fifth lumbar vertebrae on the right side. Conservative therapy was unsuccessful and the lesion was removed by surgical decompression alone without fusion. The histological examination showed a fragmented, cystic wall-like structure composed of myxoid degenerative tissue without lining epithelium. Here we present this case of a ganglion cyst that appeared to be associated with facet joint instability.

Five Aneurysms Arising from the Ipsilateral Internal Carotid Artery : Case Report / 대한뇌혈관외과학회지

Although the incidence of intracranial multiple aneurysms are not low, the occurrence of multiple aneurysms more than three developing on the ipsilateral carotid artery is quite rare. We present a patient with five aneurysms on the left internal carotid artery. Four aneurysms arising from the left internal carotid artery underwent microsurgical clipping and wrapping, and remnant superior hypophyseal artery aneurysm was treated by using coil embolization. Incidence and risk factors for management of multiple aneurysms were investigated with the literature review.

Incidence rate of Aneurysmal SAH in Gwangju City and Jeollanamdo Province in 2007

OBJECTIVE: The incidence of subarachnoid hemorrhage (SAH) worldwide varies considerably. In spite of many reports about the incidence of SAH, there has been no report about the incidence of SAH on the basis of the Korean population. The purpose of this hospital-based study was to assess the actual incidence rates of aneurysmal SAH in Gwangju city and Jeollanamdo province. METHODS: All cases of SAH confirmed by computerized tomography (CT) between January 2007 and December 2007 were selected for analysis. For the data collection, three major training hospital and ten general hospitals working the CT in Gwangju city and four major general hospitals in Jeollanamdo province participate in this study. RESULTS: According to the official census of Korea, the population was 1,413,444 in Gwangju city and 1,929,836 in Jeollanamdo province in 2007. There were 163 patients in Gwangju city and 266 patients in Jeollanamdo province confirmed SAH by CT in 2007. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages in Gwangju city were 11.5 and 12.4 for aneurysmal SAH and in Jeollanamdo province were 13.8 and 10.8. The incidence was higher in women and increased with age. The gender distribution varied with age. At young ages, the incidence was higher in men while after the age of 40 years, the incidence was higher in women. CONCLUSION: In the present study, the age- and sex-adjusted annual incidence rates is 11.8 in Gwangju city and Jeollanamdo province. The incidence was higher in women and increased with age.

Cerebral Infarction after Transfemoral Carotid Angiography : Report of 2 Cases / 대한뇌혈관외과학회지

Computerized tomography angiography (CTA) and magnetic resonance angiography (MRA) have been frequently used as non-invasive methods for the evaluation of cerebral vessels. The use of an invasive therapeutic method, transfemoral carotid angiography (TFCA), has also recently increased. The complication rate after TFCA is reported to be 0.9 % to 4%, and it is continuously decreasing. We experienced 2 patients who underwent TFCA as a diagnostic tool. The embolic type of cerebral infarction, which occurred within 30 hours, was diagnosed with performing diffusion weighted MRI (DW-MRI). One patient developed temporary dysphasia and motor weakness, but the patient improved after 2 days. The other patient presented with an altered mentality and motor weakness with some permanent deficits. TFCA is a less invasive method for treating cerebral vessels, and because this is a popular therapeutic modality, the frequency of complications will increase. Clinicians should bear in mind that complications may occur when performing TFCA and so they should be prepared to deal with them.

Effect of Continuous External Ventricular Drainage on Delayed Ischemic Neurologic Deficits after Aneurysmal Clipping in Spontaneous Subarachnoid Hemorrhage

OBJECTIVE: The purpose of this reports is to describe the influence of continuous external ventricular drainage (EVD) on delayed ischemic neurologic deficit (DIND) after early surgery in ruptured aneurysmal patients. METHODS: The authors reviewed 229 patients with aneurysmal subarachnoid hemorrhage (SAH) who had been treated with clipping at a single institution between 1998 and 2004. Of these, 121 patients underwent continuous EVD (Group A) postoperatively, whereas 108 patients did not (Group B). EVD was performed at ipsilateral Kocher's point and maintained 2 to 14 days postoperatively. RESULTS: DIND occurred in 15.7% (19 cases) of patients in Group A, 25% (27 cases) from Group B (P value=0.112). Compared with Group A, Group B was more likely to suffer acute symptom of DIND and showed poor response to 3- H therapy. Major symptoms of DIND in Group A were mild confusion (36.8%) and mild deterioration of mental state (26.3%), contrary to weakness of extremities (59.2%) in Group B. At discharge, Glasgow Outcome Scales (GOS) of Group A were: good recovery (63.2%), moderately disabled (21%), severely disabled (10.5%), dead (5.3%) and Group B : good recovery (48.1%), moderately disabled (37%), severely disabled (14.8%) and dead (0%). Of 121 patients from group A, 35 patients (28.9%) suffered ventriculitis. CONCLUSION: Continuous EVD after aneurysmal clipping in patients with SAH reduced the risk of DIND and its sequelae, relieved its symptoms, and improved the outcome.

Epileptogenic Properties of Balloon Cells in Cortical Tubers of Tuberous Sclerosis: Upregulation of Drug Resistance Proteins

OBJECTIVES: Balloon cells and dysplastic neurons are histopathological hallmarks of the cortical tubers of tuberous sclerosis complex (TSC) and focal cortical dysplasia (FCD) of the Taylor type. They are believed to be the epileptogenic substrate and cause therapeutic drug resistant epilepsy in man. P-glycoprotein (P-gp) is the product of multidrug resistance gene (MDR1), and it maintains intracellular drug concentration at a relatively low level. The authors investigated expression of P-gp in balloon cells and dysplastic neurons of cortical tubers in patients with TSC. METHODS: An immunohistochemical study using the primary antibody for P-gp, as an indicative of drug resistance, was performed in the cortical tuber tissues in two patients of surgical resection for epilepsy and six autopsy cases. RESULTS: Balloon cells of each lesion showed different intensity and number in P-gp immunopositivity. P-gp immunopositivity in balloon cells were 28.2%, and dysplastic neurons were 22.7%. These immunoreactivities were more prominent in balloon cells distributed in the subpial region than deeper region of the cortical tubers. Capillary endothelial cells within the cortical tubers also showed P-gp immunopositivity. CONCLUSION: In this study, the drug resistance protein P-glycoprotein in balloon cells and dysplastic neurons might explain medically refractory epilepsy in TSC.

Epidemiology and Characteristics of Recurrent Stroke: The Occurrence Type of Restroke is Similar as Previous Stroke

OBJECTIVE: Despite improvement of therapeutic regimen, incidence of stroke increases and it remains a leading cause of death. Our study aims at offering variable data on recurrent strokes. METHODS: There were 59 patients who admitted from Jan. 2002 to Dec. 2004 due to recurrent strokes. A retrospective longitudinal cohort study was done. RESULTS: Four-hundred-seventy five patients, diagnosed with acute stroke, experienced 491 strokes in 3 years, and there were 75 recurrent strokes (15.3%) in 59 patients. These 59 patients were included in the study. First hemorrhagic cases (H) were 19 (32%), and the first infarction cases (I) were 40 (68%). Subsequent strokes after first stroke were as follows : H-->H 14 (23.7%)cases, H-->I 5 (8.5%), I-->H 8 (13.6%), I-->I 32 (54.2%). A Cox regression analyses showed that the first type of stroke was a significant factor to the second stroke as follows : if one has had a hemorrhagic stroke, the possibility of second hemorrhagic attack (H-->H attack) increase 3.2 times than ischemic type and in ischemic stroke (I-->I attack) 3.6 times increased incidence of second ischemic attack. CONCLUSION: The recurrence rate of stroke was 12.4% (59 of 475 patients). If the first stroke is hemorrhage or infarction, the next stroke would have high potentiality of hemorrhage, or infarction. The possibility of same type in second stroke increase over 3 times. In H-->H group, the time interval between first and second stroke was shorter and the age of onset was earlier than in I-->I group. Moreover, the infarction was more frequent than hemorrhage in multiple strokes. There was a correlation in lacunar type infarction between first and second attack.

Pseudoaneurysm Formed by Slippage of Aneurysmal Clip

We report a case of pseudoaneurysm formation after aneurysmal clipping. An aneurysm, which was located on the beginning of orbitofrontal artery, was clipped and wrapped with Surgicel(R) and fibrin glue. Four weeks later, an enlarged aneurysm was detected at the same site on postoperative angiography. We could not find a new aneurysm in the second operation except inflated wrapping region. And clip had been slipped from the original aneurysmal neck. So we concluded that a new aneurysm was a pseudoaneurysm made with surgicel and fibrin glue. And it had been formed from continuous minor leakage caused by slipped clip.

Clinical Evaluation of Spinal Tuberculosis Treated with Hemilaminectomy

OBJECTIVE: The variable operative methods are underwent as a treatment of tuberculous spondylitis. We propose hemilaminectomy and debridement as a one of operative method at a certain circumstance. METHODS: From July 1998 to June 2002, 13 consecutive patients with spinal tuberculosis were treated surgically in our institution. Among them, the authors analysed 7 patients in whom posterior approach were performed. The lumbar spine was involved in 6 patients, the thoracic in 1. The hemilaminectomy with debridement was done in all cases. The changes in the Kyphotic angle and the height of involved vertebras retrospectively measured from lateral spinal radiographs obtained preoperatively and postoperatively. Mean follow up periods were 16 months. RESULTS: Clinical symptoms and signs were improved in all cases. One patient (14%) was needed anterior fusion because of aggravation of lesion. Another one needed reoperation because of relapse of epidural abscess. The arithmethical average of kyphotic angle was worsened about 2 degrees and that of height loss was lesser than 5% postoperatively. CONCLUSION: The hemilaminectomy with debridement for spinal spondylitis can be a first therapeutic modality in a mild neurologic deficit and minor lesions with extended epidural abscess and granulation tissue to the adjacent vertebras in radiologic finding. Especially if epidural abscess and granulation tissue involve the multiple vertebras, we recommend this operative method.

Clinicopathologic Findings of Atypical Teratoid/Rhabdoid Tumor of the Central Nervous System

OBJECTIVE: Atypical teratoid/rhabdoid tumor(AT/RT) is a new entity among malignant pediatric brain tumors, and shows variable histopathologic features. The authors investigate the clinicopathologic and cytogenetic features of the tumor. METHODS: Five cases were included in this study ; three of them were primarily diagnosed, and two cases were reclassified from primitive neuroectodermal tumor/medulloblastoma to AT/RT. Mean age of patients at diagnosis was 5.6 years. The tumors were located in infratentorial or supratentorial areas. Maximum survival period was 13 months. RESULTS: Histopathologically, the tumors were mainly composed of modified rhabdoid cells and undifferentiated small cells, and mixed with epithelial, mesenchymal components, and other features mimicking glioma and chordoma. The histopathologic features were supported by polyphenotypic immunoreactivity, including epithelial membrane antigen, cytokeratin, vimentin, smooth muscle actin, and glial fibrillary acidic protein. Cytogenetic studies for karyotype analysis and fluorescent in situ hybridization revealed monosomy of chromosome 22 in two cases out of three cases of the tumor. CONCLUSION: Atypical teratoid/rhabdoid tumor may be an unique clinicopathologic entity, and histopathologic diagnosis should be made carefully by differentiating other polymorphous tumors of the brain.

The Operation of Acute Epidural Hematoma Through Small Craniotomy: Technical Note

We introduce a new operative method for acute epidural hematoma(AEDH) through small craniotomy. Between January 1999 and December 2001, 63 patients underwent craniotomy in our hospital to evacuate an acute posttraumatic epidural hematoma. Among these, we operated 18 patients with linear scalp incision and about 4 X 4cm sized small craniotomy. After operation, neurological symptoms were improved and there were no significant postoperative complications in all patients. This operative method is simple and less time consuming. It can be done under the local anesthesia and may be useful to all AEDH without severe brain swelling, subdural hematoma and intracerebral hematoma.