Intradural Retroclival Chordoma

A 43-year-old woman presented with dizziness, ataxia and right hearing difficulty. Her magnetic resonance images demonstrated an inhomogeneously contrast-enhanced large tumor growing into right cavernous sinus and Meckel's cave located totally within intradural retroclival region. She underwent retromastoid suboccipital craniotomy to resect the tumor mass and adjuvant gamma knife radiosurgery for remnant tumor at 1 month after operation. Adjuvant radiosurgery after surgical excision seems to be effective for the treatment of intradural extraosseous chordomas.

What Is the Significance of a Large Number of Ruptured Aneurysms Smaller than 7 mm in Diameter?

OBJECTIVE: The International Study of Unruptured Intracranial Aneurysms (ISUIA) reported that the 5-year cumulative rupture rate of small unruptured aneurysms less than 7 mm in diameter is very low depending on the aneurysm's location. However, we have seen a large number of ruptured aneurysms less than 7 mm in clinical practice. The purpose of this study was to review our experience and to measure the size and location at which aneurysms ruptured in our patient population. METHODS: We reviewed the characteristics of aneurysms, such as size and location, from the original angiograms of patients who were admitted to our hospital between January 2004 and December 2007. All aneurysms were treated surgically or through endovascular procedures. RESULTS: Interventional or surgical treatment was given to a total of 889 patients, including 568 females and 321 males. At the time of our study, 627 cases were ruptured aneurysms and 262 cases were unruptured aneurysms. Of the ruptured cases, the mean diameter of the aneurysm was 6.28 mm. We found that 71.8% of ruptured aneurysms were smaller than 7 mm in diameter, and 87.9%, were smaller than 10 mm. Based on location, the data show that anterior communicating artery aneurysms most often presented with rupture sizes less than 7 mm (76.8%) and 10 mm (92.1%) in diameter. Most ruptured aneurysms were less than 7 mm in size, although recent studies have noted that small aneurysms are less likely to rupture. CONCLUSION: Although the natural history of unruptured intracranial aneurysms remains controversial, the aneurysm size and location play a signigicant role in determining the risk of rupture. Larger sample sizes and a long term study are needed to reveal the natural history and the rupture risk of unruptured intracranial aneurysms because the size of most ruptured aneurysms was less than 7 mm in diameter in our series.

Removal of Intradural-Extramedullary Spinal Cord Tumors with Unilateral Limited Laminectomy

Total laminectomy for the removal of intradural-extramedullary spinal cord tumors has been used widely, but postoperative complications often develop, such as kyphosis, spinal instability, and persistent back pain. In this study, we evaluated seven patients with intradural-extramedullary spinal cord tumors with respect to the value of unilateral limited laminectomy. Our cases included six schwannomas, and one meningioma. The cervical region was involved in four cases, the thoracolumbar region in two cases, and the lumbar region in one case. The rationale for choosing a unilateral approach is to preserve musculoligamentous attachments and posterior bony elements as much as possible. The patients were mobilized on the third postoperative day and preoperative neurological symptoms were recovered within a few weeks. We did not observe any complication relating to unilateral limited laminectomy and at follow-up evaluation (at 3 and 12 months postoperatively), none of the patients showed spinal deformity or spinal instability. We think that the unilateral limited laminectomy is a safe and efficient technique for the treatment of intradural-extramedullary spinal cord tumors. We suggest that this technique is one of the best treatments for these tumors.

Therapeutic Strategies of the Intracranial Meningioma in Elderly Patients

OBJECTIVE: The apparent increase in the incidence of the intracranial meningiomas in the elderly is due in part to improved diagnostic tools and improved span of life. The authors carried out a retrospective study to validate the use of the Clinical-Radiological Grading System (CRGS) as a clinical tool to orientate surgical decision making in elderly patients and to explore prognostic factors of survival. METHODS: From January 1997 to January 2006, the authors consecutively recruited and surgically treated 20 patients older than 65 years of age with radiologic findings of intracranial meningiomas and a preoperative evaluation based on the CRGS. RESULTS: High CRGS score was associated with a higher probability of good outcome (p=0.004) and a lower probability of postoperative complications (p=0.049). Among the different subset items of the CRGS score, larger maximum tumor diameters (D> or =4cm) and the presence of a severe peritumoral edema were associated with incidence rate of postoperative poor outcome and complications (p<0.05). Additionally, the critical location of the tumor was also correlated with poor outcome (p<0.05). CONCLUSION: A CRGS score higher than 13 is a good prognostic indication of survival. The CRGS score is a useful and practical tool for the selection of elderly patients affected by intracranial meningiomas as surgical candidates.

Does Age Influence the Poor Prognosis after Aneurysmal SAH Surgery in Elderly Patients?

OBJECTIVE: The incidence of aneurysmal subarachnoid hemorrhage has been increasing. At the same time, surgical results for elderly patients are unsatisfactory and no guidelines of treatment are available. We carried out a study comparing variable factors and surgical results between young and old age groups to find ways to improve prognosis. METHODS: A retrospective study was carried out on 754 patients who were operated on between 1990 and 2004 by the same surgeon in our hospital. The patients were divided into seven groups according to age: 93 patients below 40 years of age (Group I), 419 patients aged 40~59 (Group II), 115 patients aged 60~64 (Group III), 82 patients aged 65~69 (Group IV), 28 patients aged 70~74 (Group V), 12 patients aged 75~79 (Group VI) and 5 patients over the age of 80 (Group VII). We then checked their medical history, Fisher's grade, Hunt-Hess grade, postoperative complications, and Glasgow Outcome Scale. RESULTS: Age was not a statistically significant factor among patients below 70 years of age (P value> or =0.05). But for those aged 70 and older, the age factor had a statistical value (P value< or =0.001). In addition, there was a close correlation between Hunt-Hess grade IV and V patients, and those with vasospasm, and hydrocephalus after surgery, with poor prognosis in elderly patients as well as young patients (P value< or =0.001). CONCLUSION: Advanced age (under the age of 70) dose not precluded adequate surgical treatment in patient with AN SAH, and we should be also alert to preventable causes of delayed neurological deterioration for improving the outcome in all elderly groups.