Acute Cholecystitis as a Cause of Fever in Aneurysmal Subarachnoid Hemorrhage / 대한중환자의학회지

BACKGROUND: Fever is a very common complication that has been related to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The incidence of acalculous cholecystitis is reportedly 0.5%–5% in critically ill patients, and cerebrovascular disease is a risk factor for acute cholecystitis (AC). However, abdominal evaluations are not typically performed for febrile patients who have recently undergone aSAH surgeries. In this study, we discuss our experiences with febrile aSAH patients who were eventually diagnosed with AC. METHODS: We retrospectively reviewed 192 consecutive patients who underwent aSAH from January 2009 to December 2012. We evaluated their characteristics, vital signs, laboratory findings, radiologic images, and pathological data from hospitalization. We defined fever as a body temperature of >38.3℃, according to the Society of Critical Care Medicine guidelines. We categorized the causes of fever and compared them between patients with and without AC. RESULTS: Of the 192 enrolled patients, two had a history of cholecystectomy, and eight (4.2%) were eventually diagnosed with AC. Among them, six patients had undergone laparoscopic cholecystectomy. In their pathological findings, two patients showed findings consistent with coexistent chronic cholecystitis, and two showed necrotic changes to the gall bladder. Patients with AC tended to have higher white blood cell counts, aspartame aminotransferase levels, and C-reactive protein levels than patients with fevers from other causes. Predictors of AC in the aSAH group were diabetes mellitus (odds ratio [OR], 8.758; P = 0.033) and the initial consecutive fasting time (OR, 1.325; P = 0.024). CONCLUSIONS: AC may cause fever in patients with aSAH. When patients with aSAH have a fever, diabetes mellitus and a long fasting time, AC should be suspected. A high degree of suspicion and a thorough abdominal examination of febrile aSAH patients allow for prompt diagnosis and treatment of this condition. Additionally, physicians should attempt to decrease the fasting time in aSAH patients.

Acute Cholecystitis as a Cause of Fever in Aneurysmal Subarachnoid Hemorrhage / 대한구급학회지

BACKGROUND: Fever is a very common complication that has been related to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The incidence of acalculous cholecystitis is reportedly 0.5%–5% in critically ill patients, and cerebrovascular disease is a risk factor for acute cholecystitis (AC). However, abdominal evaluations are not typically performed for febrile patients who have recently undergone aSAH surgeries. In this study, we discuss our experiences with febrile aSAH patients who were eventually diagnosed with AC. METHODS: We retrospectively reviewed 192 consecutive patients who underwent aSAH from January 2009 to December 2012. We evaluated their characteristics, vital signs, laboratory findings, radiologic images, and pathological data from hospitalization. We defined fever as a body temperature of >38.3℃, according to the Society of Critical Care Medicine guidelines. We categorized the causes of fever and compared them between patients with and without AC. RESULTS: Of the 192 enrolled patients, two had a history of cholecystectomy, and eight (4.2%) were eventually diagnosed with AC. Among them, six patients had undergone laparoscopic cholecystectomy. In their pathological findings, two patients showed findings consistent with coexistent chronic cholecystitis, and two showed necrotic changes to the gall bladder. Patients with AC tended to have higher white blood cell counts, aspartame aminotransferase levels, and C-reactive protein levels than patients with fevers from other causes. Predictors of AC in the aSAH group were diabetes mellitus (odds ratio [OR], 8.758; P = 0.033) and the initial consecutive fasting time (OR, 1.325; P = 0.024). CONCLUSIONS: AC may cause fever in patients with aSAH. When patients with aSAH have a fever, diabetes mellitus and a long fasting time, AC should be suspected. A high degree of suspicion and a thorough abdominal examination of febrile aSAH patients allow for prompt diagnosis and treatment of this condition. Additionally, physicians should attempt to decrease the fasting time in aSAH patients.

Two Cases of Medical Device-Related Corynebacterium striatum Infection: A Meningitis and A Sepsis / 대한임상미생물학회지

Corynebacterium striatum is a commonly isolated contaminant in the clinical microbiology. However, it can be an opportunistic pathogen in immunocompromised and even immunocompetent hosts. The increasing prevalence of C. striatum infection has been associated with immunosuppression and prosthetic devices. We report a case of meningitis with cerebrospinal fluid drainage and a case of catheter-related bloodstream infection caused by C. striatum. The isolates were identified as nondiphtherial Corynebacterium species by VITEK 2 (bioMérieux, France) anaerobe and Corynebacterium card. The final identification by 16S rRNA gene sequencing analysis was C. striatum with 99.7% identity and 99.6% identity with C. striatum ATCC 6940, respectively. Both strains were sensitive to vancomycin and gentamicin, but multidrug-resistant to ciprofloxacin, penicillin, erythromycin and imipenem.

A Case of Disseminated Multidrug-Resistant Tuberculosis involving the Brain / 감염과화학요법

We report a case of a 23-year-old female immigrant from China who was diagnosed with multidrug-resistant tuberculosis affecting her lung and brain, resistant to the standard first-line therapeutics and streptomycin. She was treated with prothionamide, moxifloxacin, cycloserine, and kanamycin. However, her headache and brain lesion worsened. After the brain biopsy, the patient was confirmed with intracranial tuberculoma. Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response. Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered. To our knowledge, this case is the first multidrug-resistant tuberculosis that disseminated to the brain in Korea.

Granular Cell Tumor in the Pituitary Stalk: A Case Report

Granular cell tumors (GCTs) have been reported in various tissues, especially the skin and subcutaneous soft tissue of the head and neck. We report a 60-year-old man who presented with intermittent headache and dizziness for 3 months, but no other neurological symptoms. Magnetic resonance imaging (MRI) showed the presence of a mass in the pituitary stalk, and contrast-enhanced MRI showed nodular enhancement in this region. The lesion was completely excised microscopically via a frontotemporal (pterional) approach. On pathological examination, a final diagnosis of a typical GCT was made.

Vestibular Schwannoma Atypically Invading Temporal Bone

Vestibular schwannoma (VS) usually present the widening of internal auditory canal (IAC), and these bony changes are typically limited to IAC, not extend to temporal bone. Temporal bone invasion by VS is extremely rare. We report 51-year-old man who revealed temporal bone destruction beyond IAC by unilateral VS. The bony destruction extended anteriorly to the carotid canal and inferiorly to the jugular foramen. On histopathologic examination, the tumor showed typical benign schwannoma and did not show any unusual vascularity or malignant feature. Facial nerve was severely compressed and distorted by tumor, which unevenly eroded temporal bone in surgical field. Vestibular schwannoma with atypical invasion of temporal bone can be successfully treated with combined translabyrinthine and lateral suboccipiral approach without facial nerve dysfunction. Early detection and careful dissection of facial nerve with intraoperative monitoring should be considered during operation due to severe adhesion and distortion of facial nerve by tumor and eroded temporal bone.

Diagnosis and Treatment of Moyamoya Disease / 이화의대지

Moyamoya disease is a cerebrovascular disease of unknown etiology, which is characterized by bilateral stenosis or occlusion at terminal portion of internal carotid artery and at proximal portion of anterior cerebral artery and/or middle cerebral artery and abnormal vascular network in the vicinity of the arterial occlusions. It occurs frequently in Asian countries, particularly in Korea and Japan, but is rare in Western countries. To establish the etiology of moyamoya disease, much about the pathology from autopsies, factors involved in its pathogenesis, and its genetics have been studied. It may occur at any age from childhood to adulthood and in general, initial manifestation is cerebral ischemic symptoms in children and intracranial hemorrhage symptoms in adults. Because it progress and cause recurrent stroke, early diagnosis and proper management has been recognized. Cerebral angiography is essential for definitive diagnosis and treatment plan. Magnetic resonance imaging/magnetic resonance angiography is useful for diagnosis and follow-up tools after revascularization. Evaluation of the cerebral hemodynamics by single photon emission computed tomography and positron emission tomography is useful for diagnosis and assessment of the severity of cerebral ischemia in moyamoya patients. Surgical revascularization is effective for moyamoya disease manifesting as ischemic symptoms, to prevent further ischemia and infarction. In hemorrhagic type moyamoya disease, revascularization can be considered. Direct bypass, indirect synangiosis and combined methods are used. Outcomes of revascularization are excellent in preventing transient ischemic attacks in most patients.

Terson Syndrome Caused by Intraventricular Hemorrhage Associated with Moyamoya Disease

Terson syndrome was originally used to describe a vitreous hemorrhage arising from aneurysmal subrarachnoid hemorrhage. Terson syndrome can be caused by intracranial hemorrhage, subdural or epidural hematoma and severe brain injury but is extremely rare in intraventricular hemorrhage associated with moyamoya disease. A 41-year-old man presented with left visual disturbance. He had a history of intraventicular hemorrhage associated with moyamoya disease three months prior to admission. At that time he was in comatose mentality. Ophthalmologic examination at our hospital detected a vitreous hemorrhage in his left eye, with right eye remaining normal. Vitrectomy with epiretinal membrane removal was performed. After operation his left visual acuity was recovered. Careful ophthalmologic examination is mandatory in patients with hemorrhagic moyamoya disease.

Surgical Treatment for Vertebral Artery and Posterior Inferior Cerebellar Artery Aneurysms Via Transcondylar Approach or Transcondylar Fossa Approach / 대한뇌혈관외과학회지

OBJECTIVE: Since posterior circulation vascular lesions are adjacent to important structures such as the brain stem and lower cranial nerves, the acquisition of anatomical information and the careful selection of approaches are essential for the surgical treatment of these lesions. We examined the characteristics and the indications of the far lateral suboccipital approach which exposes lesions without retraction of the brain stem for the treatment of either a vertebral artery (VA) or posterior inferior cerebellar artery (PICA) aneurysm. We present the best diagnostic tool to determine the approaches. METHODS: We have reviewed 11 patients who received surgical treatments between 2005 and 2011 for VA or PICA aneurysms. All of the patients had 3-dimensional computed tomography (3DCT) angiography performed to investigate the relation of the location between the aneurysm and hypoglossal canal. RESULTS: Eight of the 11 patients were treated with the transcondylar fossa approach (TCFA) as their lesions were located proximal to the hypoglossal canal, while three were treated with the transcondylar approach (TCA) as their lesions were located distal to the hypoglossal canal. Of the three patients treated with the TCA, one had temporary palsy of the 11th cranial nerve and the others recovered without any neurological defects. 3DCT angiography showed the relation of the location between the aneurysm and hypoglossal canal. CONCLUSION: The TCFA and TCA are good approaches to expose lesions without retraction of the brain stem. To determine the approaches for the surgery of VA or PICA aneurysms, using 3DCT before surgery is advantageous in understanding the positional relations between the hypoglossal canal and the lesions. During the actual surgery, the posterior condylar canal through which the posterior condylar emissary vein passes can be used as an anatomical landmark for TCFA. With this approach, craniocervical instability can be avoided.

A Perforator Originating from the Aneurysmal Dome : Image Artifact of 3D Digital Subtraction Angiogram / 신경중재치료의학

3D DSA has been introduced recently and was known to be useful for evaluating aneurysmal shapes and relations to neighboring arteries. However, there are some problems related to image acquisition and reconstruction of 3D DSA, such as artifacts. We present two cases showing perforators to arise from the aneurysmal dome on 3D DSA, which is probably associated with artifacts.

Unusual Intracranial Parasagittal Meningioma Extending into the Internal Jugular Vein through the Sinuses

Meningiomas frequently invade cerebral venus sinuses, especially parasagittal meningioma to superior sagittal sinus. However, most invasions do not reach internal jugular vein. We present a case of parasagittal meningioma extending into the internal jugular vein through the sinuses. Radiological investigation revealed that the tumor was invading the sagittal, transverse, sigmoid sinus and junction of the internal jugular vein to subclavian vein, which was filled with tumor. The histopathological examinations revealed that both the cerebral tumor and mass in the internal jugular vein contributed to the transitional meningioma. This is a rare case of a meningioma extending into the internal jugular vein through the sinuses. According to this case, the frontal parasagittal meningioma could invade directly the internal jugular vein. The significance of this association to cerebral venus sinuses and internal jugular vein are discussed.

Hydrothorax Due to Migration of Ventriculoperitoneal Shunt Catheter

A cerebrospinal fluid hydrothorax is a very rare complication following ventriculoperitoneal (VP) shunt and usually reported in children. We report a case of 47-year-old woman who developed massive hydrothorax and respiratory distress following intrathoracic migration of distal shunt catheter. After the confirmation of catheter in thoracic cavity using radionuclide shuntogram, the patient was successfully treated with laparoscopic shunt catheter reposition.

Aneurysms of Distal Posterior Inferior Cerebellar Artery

OBJECTIVE: Aneurysms are very rarely encountered in the distal posterior inferior cerebellar artery (PICA). The authors experienced 5 cases with a distal PICA aneurysm among 368 cases of intracranial aneurysms during the period from January 2003 to January 2008. Here, the authors describe their clinical and surgical experiences and include a review of the relevant literature. METHODS: Using radiologic findings and charts, we retrospectively reviewed the surgical results of 5 cases with a distal PICA aneurysm treated from January 2003 to January 2008. RESULTS: The current five cases were composed of four cases of 'Good' and one case of 'Fair'. No postoperative complications occurred other than a ventriculo-peritoneal shunt due to hydrocephalus in Case 2. In all five cases, treatment was successful without neurological deficit. CONCLUSION: Surgical outcome of PICA aneurysms have been reported to be excellent because the amount of intraparenchymal injury is limited. More clinical experience, microsurgical technique developments, and endovascular surgery advancements are certain to improve treatment outcomes.

Large Ossified Rathke's Cleft Cyst: A Case Report and Review of the Literature

We report a rare case of symptomatic Rathke's cleft cyst with thick calcified wall. Brain CT scans revealed a large cystic mass with round thick calcified wall. In this case, we selected the pterional approach instead of transsphenoidal approach due to the possibility of cystic craniopharyngioma. Histopathologically, it was calcified Rathke's cleft cyst with focal epithelial metaplasia. This case illustrates that calcification of the suprasellar cyst does not always suggest craniopharyngioma and the calcification pattern of Rathke's cleft cyst is different from that of the craniopharyngioma.

Differences in Prevalence and Risk Factors of the Metabolic Syndrome Between Hemorrhagic Stroke and Normal Control / 대한뇌혈관외과학회지

OBJECTIVE: Hemorrhagic stroke is an important cause of mortality after coronary heart disease and cancer, and is a leading cause of disability. Metabolic syndrome causes an increased risk for cardiovascular morbidity and mortality. However, there a few studies on the relationship between hemorrhagic stroke and metabolic syndrome that have been reported in Korea. The purpose of this study is to elucidate the incidence of metabolic syndrome in patients with hemorrhagic stroke and in a control group of subjects. METHODS: A total of 115 patients with hemorrhagic stroke from March 2005 to December 2006 and 120 age- and sex-matched control subjects who undertook a medical examination at our hospital during the same period were studied. Blood pressure, body mass index, fasting blood glucose level, triglyceride level, high-density lipoprotein cholesterol level, total cholesterol level and low-density lipoprotein cholesterol level were checked. We investigated the prevalence and relationship of metabolic syndrome between the hemorrhagic stroke group of patients and normal control group of subjects. RESULTS: The prevalence of metabolic syndrome was 44.35% in the hemorrhagic stroke group of patients as compared to 26.67% in the normal control group of subjects. Among each component of metabolic syndrome, the body mass index, triglyceride level and fasting glucose level were significantly higher in the hemorrhagic stroke group of patients than in the normal control group of subjects. The odds ratio for hemorrhagic stroke by metabolic syndrome was 1.953 (95% CI, 0.781 to 3.245) and if analyzed separately, the presence of hypertension and fasting hyperglycemia showed a significantly increased odds ratio for hemorrhagic stroke among the components. CONCLUSION: Patients with hemorrhagic stroke had higher prevalence of metabolic syndrome as compared with the normal control subjects, and the presence of metabolic syndrome increased the risk for hemorrhagic stroke. Among the metabolic components, fasting hyperglycemia significantly increased the risk for hemorrhagic stroke. This result emphasizes the importance of managing metabolic syndrome in hemorrhagic stroke patients.

Dissecting Aneurysms on Vertebral Artery and its Branches / 대한뇌혈관외과학회지

BACKGROUND: Dissecting aneurysms of the vertebral artery are rare. Diagnosis and treatment of such condition aneurysm has a potentially higher degree of technical difficulty. The authors analyzed the clinical features and treatment modality for dissecting aneurysms arising from vertebral artery and its branches. METHODS: At the authors'institution between April. 2001 and Sep. 2004, 18 patients were diagnosed and treated for dissecting aneurysms of vertebral artery and its branches. The medical records and neuroimaging studies of the patients were reviewed retrospectively. RESULTS: 18 patients were comprised of 8 female and 10 male patients aged from 24~69 year old (mean: 44.2). Of the 18 patients, 8 patients (44.4%) had subarachnoid hemorrhage. 6 patients with subarachnoid hemorrahge were in good neurological status before treatment. Four patients were treated with transcranial surgery and 7 patients with endovascular treatment. the other 7 patient were merely treated with conservative care. All patients were diagnosed with digital subtraction angiography (DSA), but Magnetic resonance angiography (MRA) showed 12 dissecting aneurysms, 2 suspicious cases and 3 normal finding. In the case of anterior inferior cerebellar artery (AICA) dissecting aneurysm, MR angiography showed no visible AICA. Posterior inferior cerebellar artery (PICA) was occluded in postoperative DSA after wrapping of PICA for dissecting aneurysm of proximal protion of AICA. But the patient show no neurologic deficit. One patient developed bilateral vertebral artery dissecting aneurysms. One patient treated only conservative care revealed normal DSA finding on follow-up study. CONCLUSION: DSA is the only accurate diagnostic tool for vertebral dissecting aneurysm. Proximal GDC occlusion of vertebral artery may be a safe and effective therapy for patients with vertebral artery dissecting aneurysm. For proper decision of safe treatment modality, one should consider vertebral artery dominancy, collateral circulation, PICA invasion.

Detection of Intracranial Aneurysms Using Multi-detector Row CT 3D-Angiography: Comparison with Operative Findings

PURPOSE: To assess the efficacy of three-dimensional CT angiography (3D-CTA) using multi-detector row computed tomography (MDCT) in the evaluation of intracranial aneurysms in patients with non-traumatic acute subarachnoid hemorrhage and to describe those aneurysms which were not found 3D-CTA. MATERIALS AND METHODS: 3D-CTA was done in 40 patients with non-traumatic subarachnoid hemorrhage by using a 16-slice MDCT; conventional digital subtraction angiography (DSA) was done in 36 of those patients within 12 hours. The CT and DSA images were reviewed by two radiologists and the site, size and neck of the aneurysms were evaluated. The results from these two modalities were then compared with the operative findings. We calculated the detection rates by 3D-CTA and DSA and evaluated the size differences of aneurysms dignosed with 3D-CTA and those found at surgery. We also analyzed the locations and sizes of aneurysms missed by 3D-CTA and attempted to explain these false negatives. RESULTS: A total of 55 aneurysms were surgically confirmed in 40 patients. 48 of these were detected pre-operatively by 3D-CTA. Thus, the detection rate by 3D-CTA was 87%. The size difference of aneurysms as calculated by 3-D CTA and found operatively was as follows: less than 1 mm in 17 cases, within 1-2 mm in 15 cases, and more than 2 mm in 16 cases. Seven aneurysms were not detected by 3D-CTA. The major cause of these missed aneurysms was their small size. The undetected aneurysms were less than 2 mm in size, except for 2 instances of PCoA aneurysms. One case was not detected due to difficult image evaluation. A possible explanation of the one remaining missed aneurysm was the filling of the aneurismal sac by thrombosis. CONCLUSION: Though there were some limitations in the detection of aneurysms, 3D-CTA using 16-channel MDCT may provide sufficient pre-operative information for the management of patients with intracranial aneurysms in cases of emergency operations or DSA-failure.

Multiple Lumbar Intradural Dermoid Cysts without Spinal Dysraphism

We report a rare case of lumbar intradural dermoid cysts. A 19 year-old male presented with low back pain for 3years. Physical examination revealed no abnormalities including skin lesions. On the magnetic resonance images, multiple intradural extramedullary cystic lesions were found in the lumbar region. These lesions were removed surgically. Histologically, the mass turned out to be a dermoid cyst. We think those were unusual intraspinal dermoid cysts because they were not associated with other congenital spinal malformation, and located in the intradural extramedullary region. We report this case of lumbar dermoid cysts with a review of literatures.

Clear Cell Meningioma: Case Report

We report a case of clear cell meningioma in the petroclival area, occurring in a 39-year old woman. She complained of dizziness, right facial pain and ataxia. Magnetic resonance imaging performed after first operation in other hospital showed a 6x8x8cm sized slightly enhancing mass in the right petroclival area. The tumor was totally removed with petrosal approach. The clinical, radiological, histopathological, and surgical points of view are discussed.

Two Primary Intracranial Tumors of Different Histology: Report of a Case with a Choroid Plexus Papilloma and a Concurrent Vestibular Schwannoma in the Cerebellopontine Angle

A very rare case of multiple primary intracranial tumors is reported. A 41-year-old female patient was referred for surgery with a cerebellopontine angle (CPA) tumor. Medical history and MRI study showed typical findings of a right acoustic neuroma with a hydrocephalus. Neurological, dermatological, and ocular examinations revealed no evidence of neurofibromatosis. During surgery, a red-colored cauliflower like mass was found in the right CPA. The roof of the fourth ventricle could be seen through the lateral recess after removal of the tumor. Another mass, a 1.5-cm sized schwannoma protruding through the right internal auditory meatus, was removed by the transmeatal approach. Although the tumor masses were in contact and compressed against each other, there was a clear demarcation between them. Histological examination confirmed that the first mass was a typical choroid plexus papilloma with fibrovascular core, and that the second was a schwannoma. The patient recovered without any new neurological deficit. Result of a Medline search indicated that this rare combination of multiple primary tumors has not been reported previously.