A Comparative Surgical Outcome Study between Below and Above 60 Year-old Patients in Intracranial Aneurysms

OBJECTIVE: The author divide the patients of cerebral aneurysm into two groups, those under and over sixty years of age, and analyze retrospectively how the ages of patients influence the outcome after the operation. METHODS: Among the patients who underwent surgical treatments for aneurysmal rupture at Dankook University Hospital between June, 1994 and June, 1999, the author took 151 cases in which postoperative follow up was possible over 6 months. After dividing them into the young and old aged groups, the author analyzed, clinical characteristics, postoperative results, complications, and the overall prognosis using Glasgow outcome scale of each group. RESULTS: Comparatively young age group to old age group ratio was 84:67, and the old aged group showed higher occurrence in women. Age distribution ranged from 19 to 78 years of age. According to Hunt-Hess grade measured at the time of admission, there was higher proportion of grade II and III in both groups, and according to Fisher grade based on brain CT scan, there was a higher proportion of grade III in both groups. In the young aged group, aneurysm was found in middle cerebral artery(MCA), anterior cerebral artery(ACA) and posterior cerebral artery(PCA) in the order of frequency. In the old aged group, aneurysm of PCA was most common followed by that of ACA and MCA. There was no higher prevalence of post-operative complications among old aged patients except for the occurrence of hydrocephalus. The outcome of patients assessed 6 months after the operation showed that the prognosis depended more on the Hunt - Hess grade and Fisher grade at the time of admission rather than the difference in age. CONCLUSION: Except for the occurrence of hydrocephalus in the old aged group, age did not seem to in-fluence the occurrence of post-operative complications after surgical treatment of aneurysm. Such findings warrant on aggressive surgical treatment for brain aneurysm in older patients.

Symptomatic Vasospasm and Chronic Hydrocephalus in Elderly Patients after Intracranial Aneurysm Rupture-Comparison with Younger Ones / 대한뇌혈관학회지

OBJECTIVE: The purpose of this study is to compare the incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm in elderly patients following intracranial aneurysm rupture with those of younger patients. METHODS: We retrospectively reviewed the medical records of 189 patients who were treated with open surgery between May 1994 and December 2000. They were divided into two groups; elderly (> or =60 yrs) and younger (< or =59 yrs) group. Incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm was analysed in each group during 6 months after surgery. RESULTS: Shunt-dependent chronic hydrocephalus has developed more frequently in the elderly group (27.8%) than in the younger group (7.3%). Incidence of symptomatic vasospasm was not significantly different between two groups, even though poor grade patients were more represented in the elderly group. CONCLUSION: Meticulous clinical long-term follow-up is needed to detect shunt-dependent chronic hydrocephalus as early as possble in the elderly patients with operated ruptured intracranial aneurysms and in that case, shunt operation should be undertaken.

Epidural Steroid Injection for Low Back Pain in Patients with Radicular Pain / 대한마취과학회지

BACKGROUND: This study describes the authors' experience with patients who received an epidural steroid injection (ESI) for lumbosciatica with radicular leg pain as predominant symptom. We analyzed the efficacy of ESI according to duration of pain and history of prior lumbar spine surgery. METHODS: One hundred thirty-six patients who had low back pain with radicular symptoms were included. Each patient was given 10 ml of 1% mepivacaine mixed with 40 mg of methylprednisolone every two weeks until at least a 75% improvement or reduction in pain was seen. We recommended no more than 3 injections within 3 months. RESULTS: Three to six months after the first injection the more favorable results were observed in patients with subacute radicular leg pain (less than 3 months' duration)(87.6 - 75%, good-excellent) and chronic leg pain with no prior surgery (greater than 3 months' duration)(84.8 - 71%, good-excellent) than in patients with chronic leg pain with prior surgery (50 - 40.1%, good-excellent). The efficacy of ESI was decreased after 1 year after the first ESI. CONCLUSIONS: ESI was effective in the management of lumbosacral radicular pain regardless of duration of symptoms. However, patient's who had had prior lumbar spine surgery had the least satisfactory results.

Periventricular Germinoma

Germinomas of the central nervous system are rare embryonal tumors(accounting for less than 1% of intracranial neoplasms) that may be located in the pineal region, in the floor of the third ventricle, or in the suprasellar area. We report a case of germinoma developed in periventricular deep white matter without pineal region tumors or suprasellar masses. The 19-year-old male patient presented with slowly progressing headache, dizziness, photophobia, and dysarthria. Initial brain MRI revealed a irregular and dense enhancement from lateral ventricles to 4th ventricle. The stereotactic biopsy of tumor and histologic examination revealed the germinoma. Craniospinal axis radiation therapy was performed. After radiation therapy patient was improved and no neurologic sequelae was seen at discharge. Periventricular germinomas without pineal or suprasellar lesion are very rare. The radiation therapy, as in our case, is beneficial as with other intracranial germinomas. Stereotactic biopsy of periventricular germinoma provides precise pathologic diagnosis and thus allows more specific management.

Clinical Analysis of Pituitary Apoplexy

OBJECTIVES: Pituitary apoplexy is a well-described clinical syndrome resulting from pituitary hemorrhage, hemorrhagic infarction, or infarction, almost invariably occurring in the presence of an adenoma. We analyzed pituitary apoplexy with an emphasis on clinical presentation, pathology and predisposing factors. METHODS: We reviewed 35 histologically proven pituitary adenomas, operated from January 1995 to August 1999, to select 8 cases which showed clinical or operative findings compatible with pituitary apoplexy. These patients were analyzed in terms of symptom and sign, hormonal status, and predisposing factors, pathologic findings. RESULTS: Among 35 surgically treated tumors of the pituitary gland, 8 cases(23%) were diagnosed as pituitary apoplexy. The pathologic findings revealed hemorrhage(7 cases) and infarction(1 case) of pituitary adenomas. One case had predisposing factor of appendectomy. The most common presenting symptom and sign were sudden severe headache and visual disturbance. CONCLUSION: We treated pituitary apoplexy surgically and obtained good outcomes. Pituitary apoplexy due to massive infarction of the pituitary gland is very rare condition but surgical treatment by trans-spheniodal surgery showed a good result.

Multiple Spinal Intradural Schwannomas in the Absence of Neurofibromatosis Type 2 Manifestations: A Case Report

No abstract available.

GDC(Guglielmi Detachable Coil) Embolization for Carotid Cavernous Fistula - by Percutaneous Puncture of Superior Ophthalmic Vein -

OBJECTIVE: For the treatment of carotid cavernous fistula(CCF), transarterial detachable balloon occlusion(DBO) is the method of choice. When it has failed to occlude the fistula, various embolization methods are used to treat the fistula. Transvenous embolization through the superior ophthalmic vein(SOV) is another method of treatment. The venous approach through the SOV after surgical dissection and exposure of this vein has been recommended by some delete, but(here) delete delete(an) alternative treatment method by percutaneous puncture of the SOV without surgical dissection(is described). METHODS: A 19-year-old woman admitted to our hospital two months after accident, presented with proptosis, chemosis, occulomotor and abducens nerve palsies, and bruit of the right eye. The authors tried DBO via transarterial route in initial treatment and the fistula was occluded with subsequent disapearance of bruit. However, 2 weeks later, she complained of recurence of bruit. Transarterial approach was attempted again, but the fistula hole was too small for this approach. The venous approach via SOV by percutaneous puncture was then tried. Puncture was made at the medial one third of the superior orbital rim and the fistula was embolized with Guglielmi detachable coils (GDCs). RESULTS: The fistula was completely occluded and no early and late complications noted. The patient's clinical symptoms were improved within a few days. CONCLUSION: Treatment of CCF by percutaneous puncture of the SOV is an alternative and effective method when other approaches are not feasible.

Multiple Metastases of the Adenoid Cystic Carcinoma Associated with Intracranial Metastasis

OBJECTIVE: Adenoid cystic carcinoma is a relatively slowly growing malignant tumor. Probably at least 40-50% of patients eventually develop distant metastases. We present the natural history and treatment modality of this malignancy from our experience and review of literature. METHODS: We report a case of a 30-year-old man who complained of a headache, facial pain and hearing disturbance in the right ear. Physical examination revealed soft, protruded mass and narrowed external auditory canal. The cranial MRI showed a well defined mass in the extradural middle cranial fossa. RESULTS: The patient underwent subtotal resection of the lesion after tumor embolization was performed. The pathological diagnosis was adenoid cystic carcinoma. The patient received postoperative radiation therapy(56Gy) resulting in a complete neurological recovery. Fifteen months later, the patient was readmitted for severe back pain. Bone scan disclosed hot uptakes at the upper cervical spine, the 4th lumbar vertebra, and the pelvic area. These areas were irradiated(40Gy) and the presenting symptoms were relieved. Twenty months later, he complained of respiratory difficulty and was found to have a multiple nodule(s) in the lung. He was given 10 cycles of chemotherapy but discharged because of unresponsivencess and development of new lesions. Brain MRI and bone scan were checked 10 months after his discharge due to more aggravated lung metastasis although local tumor was controlled. Adjuvant radiation therapy(18Gy) was performed and he continued to be functional independently, although he was no longer working as a registered nurse. Two months later, dyspnea and hemoptysis were more improved and chest X-ray showed decreased mass. During the follow up period, he complained of intercostal pain, chest X-ray showed more aggregated lung mass. Chest CT scan showed multiple lung metastases and liver metastasis. In spite of adjuvant radiotherapy, the patient died of multiple systemic metastases 47 months after the first operation. CONCLUSION: Surgery is essential in the treatment of adenoid cystic carcinoma. Radiotherapy has gained acceptance as a palliative therapy, as it reduces tumor bulk and relieves symptoms. The combined treatment do not, however, prevent further recurrence and distance metastasis.

A Huge Neurilemmoma of the Cauda Equina

We are report a case of surgically treated a huge neurilemmoma in the lower thoracic and lumbosacral areas. A 57-year-old women presented with low back pain, motor weakness of the both lower extremities and urination difficulty. Magnetic resonance imaging revealed a huge enhancing lesion at the L3-S1 levels and isolated two small enhancing lesions at the T12 and L1 level respectively. This case was treated with extensive laminectomy from T12 through S1 level and total resection. The pathological findings were consistent with neurilemmoma. The patient's preoperative neurologic deficit has been recovered and no postoperative complications developed.

Surgical Treatment of Distal Anterior Cerebral Artery Aneurysms

The incidence of the distal anterior cerebral artery(DACA) aneurysm comprises about 2-6% of all intracerebral aneurysms. Because of the low incidence, unique anatomies of the distal anterior cerebral arteries and some technical difficulties in surgery, these aneurysms present such challenge to neurosurgeons. Presently, early surgery using interhemispheric approach is preferred. The auhtors experienced six patients with DACA aneurysms in 130 consecutive intracerebral aneurysms surgically treated between May. 1994 and Dec. 1997. The patients received operations within five days from the ictus, except one patient because of symptomatic vasospasm. The surgical approaches were all unilateral interhemispheric approaches. During the operations, infusion of large amount of mannitol and CSF volume removal were applied, although there were few difficulties in the interhemispheric dissections, the outcomes of the patients were excellent in three, good in three. The authors suggest that early operative interventions using unilateral interhemispheric approach without generous craniotomy can improve the outcomes of the patients with ruptured DACA aneurysm.

Deep Hypothermia and Circulatory Arrest in the Giant MCA Aneurysm Surgery

Despite significant advances in neurosurgical and neuroanesthetic techniques, certain lesions such as giant aneurysms still present significant challenge to neurosurgoens. The authors experienced a case of giant MCA bifurcation aneurysm surgery using a technique of deep hypothermia and circulatory arrest with excellent outcome. Cannulation for cardiopulmonary bypass can be done either centrally through a sternotomy(aortic-right atrial), or peripherally through a small inguinal incision(femoral-femoral). In our case, femoral-femoral cannulation was done which can eliminate many serious complications following the sternotomy. The rationale for the application of the deep hypothermia and circulatory arrest in the complex intaracranial aneurysm surgery and the benefits of the femoral cannulation are disccused.

Early Pathological Changes after Stereotactic Radiosurgery for AVM

The effects of radiosurgery on the arteriovenous malformation(AVM) nidus are documented in some studies as endothelial hypertrophy followed by obliteration of the vascular lumen with thrombosis. According to the literature total angiographic obliteration of the AVM nidus after radiosurgery takes about two years, but few reports of the histologic changes after radiosurgery for AVM are found. The authors encountered a case in which AVM surgery was performed after three months of LINAC radiosurgery because of the AVM bleeding. Histologic changes seen in the AVM nidus after three months of radiosurgery were the endothelial hypertrophy and the perivascular inflammation as early features of obliteration.

GDC(Guglielmi Detachable Coil) Embolization Used in Carotid-Cavernous Fistula Incompletely Occluded by Detachable Balloon

For the treatment of carotid-cavernous fistula, detachable balloon occlusion(DBO) is the method of choice. When it fails, or when the fistula is incompletely occluded, alternative treatment methods include direct surgery and internal carotid artery occlusion at the proximal and distal portion of the fistula. Before ligation or occlusion of the internal carotid artery, however, coil embolization should be considered, as this preserves patent internal carotid artery. The authors used DBO in a 22-year-old male patient with carotid-cavernous fistula which developed after head injury. During the procedures the fistula was partially obstructed by one detachable balloon. In spite of several attempted occlusions with a second balloon, this could not be introduced into the small remnant fistula hole. The second stage of intervention involved embolization with a Guglielmi detachable coil(GDC) ; this was successfully introduced into the partially obstructed fistula, which was thus completely occluded, and the patient's clinical symptoms improved. In this case, GDC emboization was an effective tool for the treatment of carotid-cavernous fistula incompletely occluded by a detachable balloon.

GDC(Guglielmi Detachable Coil) Embolization Used in Carotid-Cavernous Fistula Incompletely Occluded by Detachable Balloon

For the treatment of carotid-cavernous fistula, detachable balloon occlusion(DBO) is the method of choice. When it fails, or when the fistula is incompletely occluded, alternative treatment methods include direct surgery and internal carotid artery occlusion at the proximal and distal portion of the fistula. Before ligation or occlusion of the internal carotid artery, however, coil embolization should be considered, as this preserves patent internal carotid artery. The authors used DBO in a 22-year-old male patient with carotid-cavernous fistula which developed after head injury. During the procedures the fistula was partially obstructed by one detachable balloon. In spite of several attempted occlusions with a second balloon, this could not be introduced into the small remnant fistula hole. The second stage of intervention involved embolization with a Guglielmi detachable coil(GDC) ; this was successfully introduced into the partially obstructed fistula, which was thus completely occluded, and the patient's clinical symptoms improved. In this case, GDC emboization was an effective tool for the treatment of carotid-cavernous fistula incompletely occluded by a detachable balloon.

Malignant Schwannoma of the Scalp in Type I Neurofibromatosis: Case Report

It has been reported that malignant transformation of neurofibroma occurs in about 5 to 10 per cent of type I neurofibromatosis patients. This 68 year old female patient presented with a huge fungating mass lesion in the right parietal scalp, which had recently grown rapidly. She had multiple neurofibromas of varying sizes on the entire trunk, extremities, and face. On the basis of family history and opthalomologic examination, type I neurofibromatosis was diagnosed. The mass was totally removed and the pathologic report revealed malignant transformation of the benign neurofibroma to malignant schwannoma. According to the literature, the incidence of head and neck sarcomas is very low, in particular malignant schwannoma occurring in the scalp is extremely rare. This case was, then, a rare event associated with type I neurofibromatosis.

Cerebellar Botryomycosis: Case Report

A 60 year old male patient with a medical history of pulmonary tuberculosis presented with severe headaches and general weakness. Radiological studies revealed mass lesions both in the right using and the right cerebellar hemisphere. Clinically metastatic brain tumor and tuberculoma were highly suspected. The cerebella mass was totally excised and an unusual pathologic result was reported as botryomycosis. According to literatures reviewed, botryomycosis is a chronic bacterial infectious lesion resembling actinomycosis and mycotic abscess and it has been frequently reported in the skin, subcutaneous lesions and other visceral organs, but the cases of brain involvement were extremely rare. This article is a case report of a cerebellar botryomycosis. The pathologic characteristics and the differential diagnosis of botryomycosis are discussed.

Internal Carotid Artery Aneurysms Arising Remote from Arterial Divisions: Dorsal and Medical ICAA

Aneurysms arising remote from arterial divisions are rare. From January 1981 to December 1993, We operated on 271 internal carotid artery aneurysms(ICAA). Among them, we found nine of such unusual aneurysms protruding from the dorsal(six cases) or medical wall(three cases) of the internal carotid artery. Angiographically, they were often misdiagnosed as the posterior communicating artery aneurysms or carotid artery bifurcation aneurysm due to small size and flat shape with broad neck. On operation, all three medical wall aneurysms showed severe atherosclerosis. and moderate to minimal atherosclerosis was found in four dorsal wall aneurysms. In four cases, we experienced intraoperative premature rupture of the aneurysm, one during retraction of the frontal lobe due to adhesion of the aneurysmal dome to the base of frontal lobe, two during aneurysmal neck dissection and the other one during clip application. These aneurysms were difficult to operate on because of their fragility(thin or atherosclerotic wall) and relatively board aneurysmal neck. In conclusion, these aneurysms presented with difficulties in preoperative diagnosis by angiography due to small size and flat shape. In operation, special care should be taken to avoid premature rupture of the aneurysm due to thin or atherosclerotic fragile wall.

Role of Endovascular Treatment in the Management of Intracranial Arteriovenous Malformations: Experience of 15 Cases

The authors report the results of treatment in 15 patients with intracranial arteriovenous malformations(AVM's) who underwent embolization with n-butyl cyanoacrylate(NBCA) and poly vinyl alcohol(PVA) particle between March, 1990 and August, 1992 at Seoul National University Hospital and discuss about role of endovascular treatment in the management of intracranial AVM's. Seven patients(46.7%) had pre-operative embolization, microsurgery was done in six patients and radiosurgery was done in one patient. In patients with pre-operative embolization, endovascular treatment had helped microsurgery in dissection, diminution of blood transfusion, and shorter time of surgery. AVM's of two patients(12.5%) were totally occluded by embolization alone. But they had morbidity after embolization due to inadvertent occlusion. AVM's of six patients(40%) were partially occluded and recurrence of previous symptoms, bleeding, revascularization, increase of AVM nidus developed during follow up. It is concluded that role of endovascular treatment is in intracranial AVM's adjuvant, definite, palliative. Except surgical resection after embolization, embolization alone should be done very cautiously indefinite and palliative treatment.