Giant Fusiform Aneurysm by Circumferential Wrapping with Sutures-Reinforcement

Adirect intracranial operative approach with clipping the neck of the aneurysm is generally considered to be the ideal treatment for the intracranial arterial aneurysms. Several strategies exist for treating unclippable aneurysms. Intravascular techniques, proximal occlusion of the parent artery or trapping of the aneurysm, microsurgical bypass of the involved arterial segment, and reinforcement or wrapping of the aneurysmal wall are frequently used. The authors report a case with long term(6 years) follow-up results of the circumferential wrapping with sutures-reinforcement for giant fusiform aneurysm of the internal carotid artery. The giant fusiform aneurysm and ideal wrapping materials were discussed with review of literature.

Morphometric Study of the Pedicles of Lumbar Vertebrae in Koreans

OBJECTIVE: This study was undertaken to study pedicle morphology in Koreans to provide a reference guide in transpedicular screw fixation. METHODS: Pedicle measurements were obtained from 35 dried human lumbar columns(175 lumbar vertebrae). Anatomic evaluation was focused on pedicle transverse diameter, pedicle axis length and the distance from the pedicle axis point to the midline of the transverse process. Pedicle angle and vertebral body length also were measured. RESULT: In the transverse plan, pedicle diameter increased from L1(7.8mm) to L5(15.5mm). But in 20.0% of L1 and L2, its diameters was under 6.0mm. In the sagittal plan, it was not as constant and had similar diameter from L1 to L5. In the transverse plan, the pedicle angle increased from L1 to L5. But in the sagittal plan it decreased from L1 to L5. Also, the pedicle axis length did not show concordant change, but rather had similar length in lumbar vertebrae. In 15%, its length was under 45mm. CONCLUSION: These results suggest that using above 6mm diameter and 45mm length of screw for L1 and L2 can violate the pedicle and vertebrae. Above L4, the pedicle axis point was superior to the midline of the transverse process, below L4, it was inferior to the midline of the transverse process. This information may prove to be helpful when contemplating the placement of screws to the lumbar pedicles.

Clinical Analysis of Surgically Managed Cervical Spondylosis by Anterior Approach

Microsurgical anterior foraminodiscectomy was developed to improve the surgical result of cervical radiculopathy. We reviewed 40 patients with cervical spondylosis after anterior foraminodiscectomy with or without bony fusion over 5 years. The tunnel of anterior foraminodiscectomy was made at lateral one-third of the disc trajectory to intersect the uncinate process at the level of neuroforamen. The compressed nerve root and spinal cord were decompressed by removing the spondylotic spur and disc. The most common presenting symtom was radiating pain to upper extremity. The most frequent site of involvement was the C5-6. Operation of one level was performed in 57% of cases, 2 levels in 40% of cases and three levels in 3%. Of the 40 cases, interbody fusion was performed in 45% of cases. In 92.5% of the patient, the outcome was excellent or good based on Odom's criteria. Postoperative complications were encountered in 7.5%. The correlation between the clinical factors and postoperative results was assessed. As to age, duration of symtoms, herniation of soft and hard disc, number of the operative levels and with and without bony fusion, the clinical results were not stastistically significant.

Giant Serpentine Aneurysm of the Anterior Communicating Artery: Case Report

Giant serpentine aneurysm(GSA) is a giant aneurysm containing a serpentine channel which enters and exits at separate sites and is continuous with the parent vessel. This 33-year-old man with a two-year history of frontal headache presented with bitemporal hemianopsia three months before admission. Suprasellar mass of computed tomography revealed a giant(3X2.5X2cm) mixed density, mimicking a brain tumor. Cerebral magnetic resonance images showed a flow void within the mass, and this was consistent with the serpentine vascular channel demonstrated by angiography. The aneurysm was revealed by surgery involving the frontobasal interhemispheric approach, left A1 & A2 were clipped and the mass of the aneurysm was removed in toto an aneurysmorrhaphy was constructed, and to preserve the distal blood flow to the left A2, the patient made an unevenful recovery.

Clinical Applications of Cine MR

Evaluation of intracranial CSF flow was accomplished by the use of cine MR technique. In the cine MR, there were two methods of evaluation in CSF flow pattern. Qualitative and quantitative methods were called magnitude reconstruction and phase contrast mapping method, respectively. The image of magnitude reconstruction method can demonstrate areas of decreased CSF flow and help explain the cause of hydrocephalus. The image of phase contrast mapping method is more sensitive to fluid motion and may increase utility in the future for analysis of fluid flow. Cine MR is capable of showing both normal and abnormal intracranial CSF flow. Such a study can be easily added as an extra pulse sequence at the end of a routinely acquired MR examination. We evaluated 2 cases of the normal pattern of pulsatile flow within subarachnoid space and 3 cases of abnormal patterns of CSF flow(communicating hydrocephalus: 2 cases, arachnoid cyst in posterior fossa: 1 case). These observations were compared with pre- and post-operative CSF flow state. In conditions which result in alterations of flow, cine MR shows either obstruction or excessively turbulent flow within the CSF pathways. In our studies, the most distinctive pathological finding was bulk flow in the aqueduct of Sylvius. The authors suggest that this technique can be applied in a wide range of conditions where CSF pathway is altered including hydrocephalus, evaluation of the function of the shunt system and communication between arachnoid cyst and subarachnoid space . Moreover correct diagnosis is possible in patients with hydrocephalus, in whom the exact level of CSF obstruction can be determined. We believe that surgical decisions can be aided by careful analysis of these CSF cine MR studies. We discuss the normal and abnormal CSF flow findings and indications of cine MR CSF flow technique with literature review.

Comparative Study of the Proliferating Cell Nuclear Antigen and Clinicopathological Features in Intracranial Meningiomas

The PC10, a monoclonal antibody(mAb) to proliferating cell nuclear antigen(PCNA), is known to show immunoreactivity in paraffin embedded tissue. The authors present the relation between PCNA expression and clinicopathological features such as patient's age and sex, tumor size and location, histological types, and recurrence in 18 intracranial meningiomas. PCNA scores were obtained by immunostaining of the paraffin embedded surgical specimens using a streptoavidin/peroxidase method with PC10 mAb, which recognized an epitope on the PCNA. Univariate analysis showed that high PC10 scores were associated with old age(>or=50 years old), male, recurrent tumor and meningothelial type. However, these high scores did not reach statistical significance(p>0.05). PC10 scores of basal meningioma tended to be higher than that of hemispheric meningioma(p<0.05). The staining intensity of PCNA was markedly increased in basal meningiomas. It is suggested that the proliferative potential is higher in basal meningiomas than in hemispheric meningiomas, however, the number of patients in this study is too small to draw a statistical conclusion.

Clinical Analysis of the Sellar and Parasellar Lesions using the Bifrontal Basal Interhemispheric Approach

The authors describe the use of the bifrontal basal interhemispheric approach in the clinical analysis of sellar and parasellar lesions. This approach is a more basal modification of the conventional anterior interhemispheric approach extended to the nasion, and most bridging veins are preserved. After dividing the falx at its anterior end, frontal lobes are retracted bilaterally and olfactory nerves are dissected from the frontal lobe to the olfactory trigon. This approach was used ffor operationsinvolving ten patients : in seven, in whom a parasellar tumor had been detected, gross or near-total removal of this large mass was achieved, and three, with aneurysm of the anterior communicating artery aneurysm underwent clipping and aneurysmorrhapy. In one patient with a huge retrochiasmatic tumor, division of the anterior communicating artery was performed. After cutting the anterior communicating artery, no side effects were detected. Visual improvement and preservation of the pituitary stalk was achieved in 86% and 57% of cases, respectively. This approach, progressing from the midline, provided better orientation of the mass and its surrounding structures such as the hypothalamus, optic chiasm, pituitary stalk and perforating arteries. The authors discuss the indications, advantages and disadvantages of the bifrontal basal interhemispheric approach, and include a review of the literature.

Clinical Analysis of Prognostic Factors for Hypertensive Intracerebral Hemorrhage

The authors reviewed medical records of 219 patients who were admitted due to the hypertensive intracerebral hemorrhage(HICH) between January 1993 and December 1994. The relationship between the patient's age and sex, Glasgow Coma Scale(GCS) on the admission, location and volume of intracerebral hematoma, Graeb score, ventriculocranial ratio(VCR) and the maximum transverse diameter of fourth ventricle were analyzed. The neurological outcome for survivors was determined two years after admission. Forty normal brain scans were obtained to determine the normal range of VCR and the maximum transverse diameter of fourth ventricle. From reviewing the cases, the authors found; the most common age group of HICH was 7th and 8th decades with slight male preponderance(1:0.75); VCR of the lateral ventricle and maximum transverse diameter of the 4th ventricle were 0.16 and 1.14 cm in 40 normal brain scans, respectively; basal ganglia(42%) and thalamus(29.2%) were the most common sites of HICH hemorrhage in 219 patients followed by subcortex(13.7%), pons(7.3%) and cerebellum(4.6%); the fourth ventricular dilation(>1.35cm in diameter) and increased VCR(>0.24) were the most significant predictors for poor outcome.

A Case of Intradural Epidermoid Tumor of the Lumbar Spine

Histologically, epidermoid tumors are composed only of dermal epithelium and associated connective tissue. They arise from the epithelial tissue displaced during the closure of the neural tube between the third and fifth weeks of gestation. This tumor accounts for 0.6 to 1.1% of all spinal cord tumors; intradural and extramedullary epidermoid tumors are rarely found within the spinal canal. The authors describe a case of intradural epidermoid tumor, in which The patient presented with low back pain and weakness of the lower extremities. On axial and sagittal T1-weighted magnetic resonance imaging of the lumbar spine, a round, high signal intensity response revealed the presence of an intradural tumor at L3-4; it was totally removed. The pathological and clinical characteristics of epidermoid tumors are discussed.

Multiple Intracranial Meningiomas: Case Report

Meningioma is the third most common intracranial tumor and different from meningiomatosis and multiple meningiomas. Multiple meningiomas without the stigma of Von Recklinghausen's disease are rare. The incidence of multiple meningiomas has been reported in 1-8.9% of all intracranial meningiomas. Although the pathogenic factors related to the multiple meningiomas are unknown, various theories have been studied and reported. The authors report two cases with multiple meningiomas without evidence of the Von Recklinghausen's diseases treated successfully by staged operation. The clinical, radiological and histopathological features of these lesions are discussed.

Postoperative Visual Results on Sellar and Parasellar Tumors

We reviewed the records of 28 patients who underwent transcranial(20 cases) or transsphenoidal(8 cases) surgery sellar and parasellar tumors. Both pre-and postoperative visual status(visual acuity and field) of each eye were analyzed under the rating system of Cohen, et al. The average duration of follow-up 3 months. The lesions encountered consisted of pituitary adenoma in 14 cases, craniopharyngioma in 5 cases, meningioma in 4 cases, chordoma in 3 cases, a dermoid cyst in 1 case, and an unspecified tumor in another case. All patients had objective signs of visual acuity or field defects preoperatively. Overall postoperative visual acuity and visual fields were normalized or improved in 73% and 71% of the eyes, respectively. The visual outcome of postoperative visual acuity was better in cases of craniopharyngioma(80%) than the other tumors. Visual evoked potentials(VEP) showed all postoperative improvement and was as helpful as visual fields in determining visual status. The visual outcome was better in patients with a shorter duration of symptoms and those with smaller tumors. Patients with lesser compromise of preoperative visual acuity had better outcome of postoperative visual acuity. However, the severity of preoperative visual field defects did not seem to influence postoperative field outcome. There also was no relationship between the presence of endocrine activity of the tumor and visual outcome. Patients who underwent transsphenoidal approach had either better visual acuity or field improvement than patients with transcranial approach.

Silent Corticotropic Adenomas of the Pituitary Gland: Cases Report

This is our report of two cases of pituitary adenoma containing immunoreactive adrenocorticotropic hormone(ACTH) in tumor specimens but unassociated with Cushing's disease. The first case is a 39-year-old male with visual disturbance for 3 years. He was in a eucorticoid state clinically and biochemically. A large size pituitary tumor was found and removed by trans-sphenoidal approach. The tumor specimen was confirmed as adenoma with hematoxylin and eosin(H & E) staining;and immunohistochemical study demonstrated strong positivity for ACTH. The second case is a 61-year-old female with progressive deterioration of visual function and headache. She had no signs of symptoms of hormonal excess and was found to have a pituitary macroadenoma which was then removed by the trans-sphenoidal route. Surgical specimen also showed findings of adenoma;and immunohistochemical study revealed the presence of ACTH in biopsy. Since silent corticotropic adenoma of the pituitary gland is rarely encountered, the authors therefore report these 2 cases and causes of endocrinologic silence with review of literatures.

Microsurgical Study on the Circle of Willis in Korean Adults

Anatomical information of the circle of Willis is important in evaluating the various cerebrovascular diseases and surgical procedures. In this study, we present the anatomical structures of the circle of Willis in 54 Korean adults. The authors observed the morphological characteristics of the vasculature, the incidence of deficiency or incompleteness in the circle and clinical considerations. Measurements of the outer diameter and the length of each arterial segments were performed. Number and the origin of perforators from individual arteries were also oserved. Results of this study were as followings. Normal circles of Willis was oserved in 35 cases(64.81%) and abnormal circles in 19 cases(35.9%). 2) Incidental detection of aneurysms occurred in 5 cases(9.26%). 3) Frequency of anomalies were most commonly observed in the anterior communicating arteries(N=16, 20.37%). 4) A string-like artery was most frequently observed in te post-erior communicating artery(N=11, 20.37%). 5) Anomalous origin of the P1 segment of the posterior cerebral artery was observed, fetal type was in 12 cases(22.2%) and transitional typ was in 3 cases(5.55%) respectively. 6) The longest artery was the A1 segmnt of the anterior cerebral artery;the second, posterior communicating artery;the third, P1 segment of the posterior cerebral artery;and the shortest, anterior communicating artery. 7) The outer diameters of the basilar artery and internal carotid artery were almost, equal, A1 segment was half of ICA, AcoA was two thirds of A1 segment, PcoA was half of P1 segment and P1 segment was two thirds of the basilar artery. There were difference the anterior and posterior portion of the circle Willis. In the anterior communicating arteries, duplicated structure were frequently found. And also, inequality in the outer diameter of both A1 segmnts was observed. String-like arteries were often revealed in the posterior communicating arteries. Anomalous origin of P1 segments that may be persistant embryonic derivatives were frequently demonstrated in posterior cerebral arteries.

Intracranial Chordomas:Clinical Review and Therapeutic Outcome

Chordomas are uncommon tumors arising from the embryonic remnants of the fetal notochord. The spheno-occipital region accounts for 36 percent of chordomas. The authors are presenting four cases of intracranial chordomas with clinical manifestation was analyzed. All patients were men and their mean age was 37 years old. The presenting complaints were diplopia in 2 patients and decreased visual acuity in the order two. Radiologic studies demonstrated extensive bony destruction of the skull base and soft mass with punctate calcification in all 4 cases. Treatment consisted of subtotal removal of tumor and subsequent radiotherapy. Histopathologically, three of the four patients had typical chordomas and the remaining case was confirmed as chondroid chordoma. The three typical chordomas recurred after initial treatment. 2 of these three were reoperated but died in the 10 months and 33 months, respectively after initial diagnosis. The patient with chondroid chordoma remained well for 46 months after initial treatment without significant neurological deficits. In conclusion, therapeutic outcome of intracranial chordomas are grim because of their aggressive that, frequent recurrence and inability to remove tumors completely. With the exception, chondroid chordoma had good prognosis and long term survival.

Fahr's Disease(=Idiopathic Strio-Pallido-Dentate Calcinosis): A Case Report

The authors present a case of Fahr's disease which is characterized by idiopathic symmetrical calcifications in the basal ganglia and the dentate nuclei. Computerized tomographic scans of the brain demonstrated bilateral calcified lesions recognized in the region of the dentate nuclei of both cerebellar hemispheres and the basal ganglia. A review of the literature on several cases of intracranial ferrocalcinosis is presented.

Assessment of Visual Outcome Following Optic Canal Decompression in Traumatic Optic Nerve Injuries

Nine patients with traumatic optic nerve injury were treated with optic canal decompression via transcranial approach. Postoperative visual function evaluated by visual in all patients and monitoring of visual evoked potential in 3 patients. 4 of 8 patients showed improvement in visual acuity and 2 of 3 patients also improved in the results of visual evoked potential monitoring. The mean duration between injury and operation of whom showed postoperative improvement of visual function was 6.8 days but 13 days in 5 unimproved or deteriorated patients. These findings indicate that optic canal decompression is recommended for patients with traumatic optic nerve injury who show no neurological improvement by conservative management. And also, the preoperative duration, the better visual outcome postoperatively.

Mucopyocele Involving Sphenoid Sinus: Case Report

A rare case of sphenoid sinus mucopyocele with visual impairment and opthalmoplegia is presented. Clinical presentations including headache, opthalmoplegia, visual disturbance and ptosis are caused by local extension of the mucopyocele of the sphenoid sinus. The authors report a mucrpyocele involving the sphenoid sinus with a brief review of the literature.

Treatment of Fusiform Intracranial Aneurysm by Wrapping with Suture-Reinforcement: Technical Note

Several strategies exit for treating unclippable aneurysm, including intravascular techniques, proximal occlusion of the parent artery or trapping of the aneurysm, microsurgical bypass of the involved arterial segment and reinforcement of the aneurysmal wall. Reinforcement or wrapping is frequently used when the other techniques are thought to be unsafe. We report a technical modification of the traditional wrapping technique for treatment of the fusiform aneurysm of the internal carotid artery, which includes reinforced Daron-patch with traction sutures to the adjacent to prevent aneurysmal rupture and further expansion.

Inteacerebral and Brain Stem Hemorrhage Following Evacuation of Chronic Subdural Hematoma and Hygroma

Two cases of intracerebral and brain stem hemorrhage occurring after evacuation of chronic subdural hematoma and subdural hygroma are reported. A patient who had undergone craniotomy with closed drainage for subdural hygroma had intracerbral and fatal brain stem hemorrhage in the immediate postoperative period. Despite rapid and intensive treatment, he died. The other patient had intracerebral hematoma following drainage of chronic subdural hematoma and left with severe disability. Possible pathogenic mechanisms leading to development of the postoperative intraparenchymal hemorrhage are suggested. Sudden increase in cerebral blood flow combined with defective autoregulation seemed the most likely pathogenic mechanism to be responsible for the postoperative hemorrhage. If close neurosurgical observation of patients and clinical awareness for the intraparenchymal hemorrhage after evacuation of chronic extracerebral fluid collections given, this devastating complication may be avoided.

Two Cases of Intracerebral Tuberculoma

It is believed that differentiating tuberculoma, abscess, metastatic tumor and glioma is often difficult without exisional biopsy. The authers report two cases of tuberculoma in the cerebral hemisphere which were treated surgically. Differentiating characteristics of intracerebral tuberculoma in MR imaging and CT scans are also discussed. With the references reviewed, the MR imaging features of the tuberculoma were found to be distinct from those of abscess, metastatic tumor, glioma and cysticercus granuloma.