Asymmetry of Medial and Lateral Tempora) Regional Glucose Metabolism in Temporal Lobe Epilepsy by F-18-FDG PET / 대한핵의학회잡지

PURPOSE: We investigated the difference of glucose metabolism of medial and lateral temporal lobes of patients with temporal lobe epilepsy (TLE) utilizing quantitative comparison of regional metabolic activities using asymmetric index. MATERIALS AND METHODS: We studied 19 pathologically proven mesial TLE and 25 lateral TLE patients. Lateral TLE patients were either normal on magnetic resonance imaging (cryptogenic: n=14) or had structural lesions (lesional: n=11). Asymmetric index (ASI) was calculated as [(ipsilateral-contralateral)/(ipsilateral+ contralateral)]x200. RESULTS: ASI of medial and lateral lobes of mesial TLE was decreased (-16.4+/-8.3 and -12.7+/-5.5, respectively). In cryptogenic lateral TLE, ASI of lateral temporal lobe was decreased (-11.8+/-4.7), whereas that of medial temporal lobe was not decreased (-4.6+/-6.3). ASI of medial lobe of lesional lateral TLE was -7.3+/-9.1, which was significantly different from that of mesial TLE (p<0.05). Patients with lesional lateral TLE had evident metabolic defects or decrease (ASI: -22+/-10.5) in lateral temporal lobe. While we could not find the difference of metabolic activity in lateral temporal lobes between cryptogenic lateral TLE and mesial TLE patients, the difference of metabolic activity was significant in medial temporal lobes which was revealed by ASI quantitation. CONCLUSION: Asymmetric decrease of metabolic activity in both medial and lateral temporal lobes indicates medial temporal epilepsy. Symmetry of metabolic activity in medial temporal lobe combined with asymmetry of that in lateral temporal lobe may give hints that the epileptogenic zone is lateral.

Diagnosis of Ictal Hyperperfusion Using Subtraction Image of Ictal and Interictal Brain Perfusion SPECT / 대한핵의학회잡지

A robust algorithm to disclose and display the difference of ictal and interictal perfusion may facilitate the detection of ictal hyperfusion foci. Diagnostic performance of localizing epileptogenic zones with subtracted SPECT images was compared with the visual diagnosis using ictal and interictal SPECT, MR, or PET. Ictal and interictal Tc-99m-HMPAO cerebral perfusion SPECT images of 48 patients(pts) were processed to get parametric subtracted images. Epileptogenic foci of all pts were diagnosed by seizure free state after resection of epileptogenic zones. In subtraction SPECT, we used normalized difference ratio of pixel counts((ictal-interictal)/interictalx100%) after correcting coordinates of ictal and interictal SPECT in semi-automatized 3-dimensional fashion. We found epileptogenic zones in subtraction SPECT and compared the performance with visual diagnosis of ictal and interictal SPECT, MR and PET using post-surgical diagnosis as gold standard. The concordance of subtraction SPECT and ictal-interictal SPECT was moderately good(kappa=0.49). The sensitivity of ictal-interictal SPECT was 73% and that of subtraction SPECT 58%. Positive predictive value of ictal-interictal SPECT was 76% and that of subtraction SPECT was 64%. There was no statistical difference between sensitivity or positive predictive values of subtraction SPECT and ictal-interictal SPECT, MR or PET. Such was also the case when we divided patients into temporal lobe epilepsy and neocortical epilepsy. We conclude that subtraction SPECT we produced had equivalent diagnostic performance compared with ictal-interictal SPECT in localizing epileptogenic zones. Additional value of these subtraction SPECT in clinical interpretation of ictal and interictal SPECT should be further evaluated.

Measurement of Regional Tissue Water and Ionic Concentrations During the Evolution of Infraction and the Therapeutic Value of Nimodipine in Rat Middle Cerebral Artery Occlusion Model of Ischemia

The evolution of infarction in the rat middle cerebral artery(MCA) occlusion model was examined by atomic absorption spectrometric measurements of Na, K and Ca concentrations in brain tissue sample. At 2, 4, 6, 8, and 24 hours after MCA occlusion and sham occlusion the brain tissue samples were obtained. Tissue water concentrations were estimated from dry-wet weight measurement. The effects of nimodipine(2 microgram/kg/min for 10 min) administered intra-venously at 4 hours(Group A), 6 hours(Group B), and 9 hours(Group C) after MCA occlusion were investigated on both the size of infarction and tissue water, Na, K, Ca concentrations at 24 hours. The result were as follows : 1) Normal concentrations of water, Na, K, and Ca averaged 0.793+/-0.009ml, 54.06+/-4.18 micromole, 81.04+/-3.44 micromole, and 3.578+/-0.712 micromole/gm wet weight. At the infarct site by 24 hours, the changes of tissue water and ionic concentrations were conspicuously evident so that water increased by more than 10%(p<0.005), Na increased by more than 120%(p<0.005), K decreased by more than 75%(p<0.005), and Ca increased by more than 200%(p<0.005). 2) The remarkable shifts of Na, K, and Ca concentrations occurred at 4-6 hours so that 60-85% of the ionic shifts developed by 6 hours. This characteristics of chronological ionic changes correlated well with the findings of 2% TTC staining during the evolution of infarction. Water concentrations increased rapidly at 2-4 hours so that nearly 80% of water shift developed by 4 hours. 3) In group A(administered at 4 hours), nimodipine treatment significantly reduced both the ionic shifts at the infarct site and the size of infarction compared with non-treated rats(p<0.05). 4) In group B(administered at 6 hours), nimodipine treatment did not significantly reduce the ionic shifts but did reduce the size of infarction compared with non-treated rats(p<0.05). In group C(administered at 8 hours), nimodipine treatment significantly reduce neither the ionic shifts nor the size of infarction. In summary it was concluded that the progressive changes in tissue water and ionic concentrations developed at the infarct sites and the critical period of the changes was between 4 and 6 hours, and nimodipine treatment was effective when administered within 4 hours. The results suggested that measurement of tissue ionic concentrations could be used as an alternative method for assessing tissue damage and a reliable method to quantify the tissue damage. This method may be useful for determining the time window for therapeutic protocol, as well as for evaluating therapeutic effects.

Preoperative treatment of acromegaly with long-acting somatostatin analog octreotide / 대한내분비학회지

No abstract available.

Surgical Management of Chronic Subdural Hematoma:The Outcome and Factors Relating to The Brain Expansion

Ninety-seven patients with chronic subdural hematoma were treated surgically between 1983 and 1992. The case records and radiological findings on computerized tomography(CT) scan were studied with regard to surgical outcome and postoperative brain expansion after burr hole craniostomy and closed system drainage. Male:Female ratio was 3.6:1 and the peak incidence was in the sixth decade of life. The patients were graded according to the scale used by Markwalder et al. and 56% were in Grade 0 and 1. The CT scan demonstrated the brain expansion and resolution of subdural space within 2 weeks in 53% of patients. Risk factors causing poor postoperative brain expansion were poor intraoperative brain expansion, too young(below 20 years) or too old(more than 71 years) age, and underlying disease. Following surgery, most of the patients improved. Whereas at the time of admission only 7% were neurologically normal(Grade 0), 67% of the patients fell into this category during the postoperative phase and 90% of the patients were postoperatively in Grade 0 and 1. Four patients died in the hospital, for a mortality rate of 4.1%. The most important factor influencing outcome was preoperative neurologic state.

Primary Third Ventricular Tumors

Intrathird ventricular tumors that mainly occupy the ventricle cavity without extending to the neighbouring structures are rare. These tumors are developed from the choroids plexus, tela, ependyma, subjacent neuroglia and embryonic cell rest. The authors experienced 11 cases of rare intrathird ventricular tumors during the past 10 years. During the same period, number of surgically proven brain tumors were 990 and intrathird ventricular tumors comprised 1.1%. These are two cases of choroids plexus papillomas, three craniopharyngiomas, two germ cell tumors, one meningioma, one glioependymal cyst, one ependymoma, one astrocytoma. Suprasellar craniopharyngiomas, thalamic gliomas, optic and hypothalamic gliomas were excluded. The age distribution was from 6 years old to 59 years old. The clinical manifestation was characteristic in that they usually had the sudden intermittent headache without specific localizing signs. Surgical approach to this area is by transcallosal or transcortical approach. Surgical total removal was quite feasible by either approach and outcome was rather favorable.

Primary Third Ventricular Tumors

Intrathird ventricular tumors that mainly occupy the ventricle cavity without extending to the neighbouring structures are rare. These tumors are developed from the choroids plexus, tela, ependyma, subjacent neuroglia and embryonic cell rest. The authors experienced 11 cases of rare intrathird ventricular tumors during the past 10 years. During the same period, number of surgically proven brain tumors were 990 and intrathird ventricular tumors comprised 1.1%. These are two cases of choroids plexus papillomas, three craniopharyngiomas, two germ cell tumors, one meningioma, one glioependymal cyst, one ependymoma, one astrocytoma. Suprasellar craniopharyngiomas, thalamic gliomas, optic and hypothalamic gliomas were excluded. The age distribution was from 6 years old to 59 years old. The clinical manifestation was characteristic in that they usually had the sudden intermittent headache without specific localizing signs. Surgical approach to this area is by transcallosal or transcortical approach. Surgical total removal was quite feasible by either approach and outcome was rather favorable.

Microsurgical Approach to Cerebellopontine Angle Tumors

The authors reviewed one hundred and twenty cases of cerebellopontine angle(CPA) tumors that were operated upon at the department of neurosurgery of Seoul National University Hospital between 1977 and 1987. The pathologic diagnosis of the tumors were acoustic neurinoma(66%), meningioma(13%), epidermoid(5%) and trigeminal neurinoma(5%). The age incidence was most frequent in the 5th and the 6th decades and 6.7% of cases occurred at the pediatric ages. Acoustic neurinomas were frequent in the 5th decade and on admission more than half of patients were poor clinical grades with large tumors more than 3cm in diameter(78.5%). There was good correlation between the clinical grade and tumor size on admission. All of the acoustic tumors were operated through the suboccipital transmeatal approach and total removal was possible in 73% with 5% of motality rate. Facial nerve was preserved in 62% of total removal-cases and the size of tumor was the important factor for the total removal of tumor with preservation of facial nerve. Cerebellopontine angle meningioma comprised 13% of all CPA tumors and incidence of male to female ratio was 2:13. Operations were performed either through retromastoid suboccipital approach or combined supra-infratentorial approach. Total temoval was possible in 67% without mortality. Six trigeminal neurinomas were located:one in the middle fossa, one in the posterior fossa and the other four cases appearing as dumbbell shape. Total removal was possible in two cases and subtotal removal in four cases and the outcome was rather good in all cases. Pediatric CPA tumors were two each of medulloblastomas and ependymomas and one each of astrocytoma, primitive neuroectodermal tumor(PNET) and trigeminal neurinoma, Masson's hemagioendothelioma. Total removal was possible in four cases and the outcome was good in all cases.

Surgical Management of Syringomyelia

Twelve patients were operated upon and diagnosed as syringomyelia at the Department of Neurosurgery of Seoul National University Hospital from July 1983 to June 1987. The etiologies were Chiari malformation(3 cases), arachnoiditis(2 cases), trauma(2 cases), neoplasm(2 cases) and idiopathic(3 cases). Four patients had foramen magnum decompression with 4th ventricle spinal subarachnoid space shunt and/or syringosubarachnoid shunt, and 7 patients underwent syringotomy or syringosubarachnoid shunt. In one case, only tumor removal was done. Functional improvement of the motor disturbance was noted only in 3 cases, in one of whom the result might be the effect of tumor removal. Pain and sensory disturbance responded well with surgery, but sphincter disturbance did not. The clinical, radiological and operative findings were correlated with theories of its pathogenesis. And the results of surgical treatment and some problems in the management of this disease entiry were discussed.

Spontaneous Intracranial Hemorrhage Caused by Brain Tumor

919 consecutive brain tumor cases and 665 consecutive spontaneous intracranial hemorrhage cases were reviewed for the analysis of cases in which spontaneous intracranial hemorrhage caused by brain tumor was confirmed with gross operative findings. Authors analyzed their incidence, patients' demography, tumor histology, clinical symptoms and signs, predisposing factor, tumor vascularity, type of hemorrhage, relations between the clinical symptoms and signs and the type of hemorrhage, relations between the location of tumor and the type of hemorrhage and the outcome of treatment. The conclusions are as follow; 1) The proportion of the hemorrhage caused by brain tumor to the total spontaneous intracranial hemorrhage was 5.1%(34/665). 2) The proportion of the spontaneous intracranial hemorrhage caused by brain tumor to the total brain tumor was 3.7%(34/919) and the proportion of that excluding pituitary adenoma was 2.5%(18/729). 3) Compared with the other brain tumors, oligodendroglioma and pituitary adenoma had significant tendency of hemorrhage(p<0.05, p<0.01, respectively) and meningioma had a significantly low incidence of hemorrhage(p<0.05). 4) The hemorrhage brought about major symptoms in 13 cases(72%), minor symptoms in 2 cases(11%). These cases showed no symptoms related to the hemorrhage. 5) Among the 18 cases of spontaneous intracranial hemorrhage caused by brain tumor, one case with the major attack died of postoperative pneumonia. There were additional 2 motalities which were not related to the preoperative hemorrhage. And most of the symptoms associated with the preoperative hemorrhage stabilized or improved with operative treatment.

A Case of Pleomorphic Xanthoastrocytoma

The pleomorphic xanthoastrocytoma has been known as a very rare type of glioma, which occurs mainly in the temporal lobe of the brain in young ages. It has distinctive characteristics regarding age, symptoms and signs, gross and microscopic features and relatively favorable prognosis despite of pleomorphism and bizarre giant cells in microscopic picture. The authors report a case of plemorphic xanthoastrocytoma presented with generalized seizure and review the past literatures.

An Experimental Study on the Effect of Reperfusion on Changes of rCBF in Focal Cerebral Ischemia

Reperfusion into focal ischemia using a transorbital snare ligature was studied in 20 unanesthetized cats following middle cerebral artery(MCA) occlusion of 1 to 6 hours duration. Changes of a regional cerebral flow(rCBF) were investigated upon with a hydrogen clearance method in the center and periphery of the MCA territory, which were correlated with the size of infarct delineated by a 2% triphenyl tetrazolium chloride solution and with the occurrence of severe brain edema or hemorrhagic infarct. The results were as followings: 1) Post-ischemic hyperperfusion was usually found after 1 hour occlusion of MCA followed by 2 hours recirculation. Final rCBF, however, reached pre-occlusion value and little or no infarct was found. 2) In the 2 hours occlusion-reperfusion group, hypoperfusion after reopening of MCA was regularly found in both the center and the periphery of ischemia, which was well contrasted with hyperperfusion in the 1 hour occlusion group and was accompained by evident but mild infarcts. 3) After 4 and 6 hours occlusion, there was usually evident post-ischemic hyperperfusion soon followed by development of severe hypoperfusion and a higher grade of infarct and hemispheric swelling was found. 4) Final hypoperfusion after transient MCA occlusion was observed only after ischemic periods lasting 2 hours or more irrespective of preceding post-ischemic hyperperfusion and was only related to the duration of the occlusion and not to the degree of blood flow disturbance. 5) Spontaneous hyperemia during occlusion was found in 3 of the 5 cats used in each of the 4 and 6 hours occlusion groups, in which there was marked hyperperfusion after reopening of MCA followed by severe hypoperfusion and transtentorial herniation associated with resulting extensive hemorrhagic infarct and marked hemispheric swelling. 6) Hemorrhagic infarcts were found in one cat of the 4 hour-occlusing group and two of the 6 hour-occlusion group, all of whom showed early hyperemia before reperfusion predictable of such a detrimental result. 7) These data indicate that potential hazard for surgical early revascularization in the acute stage of ischemic stroke should be considered in case profound ischemia had already progressed for 4 hours or more and especially when hyperemia during the initial stage of severe ischemia is observed at the center and the periphery of the ischemic area expected.

Spinal Cord Tumors : An Analysis of 175 Cases(1973-1986)

The authors analyzed 175 cases of spinal cord tumor who had been operated upon at the Department of Neurosurgery of the Seoul National University Hospital from 1973 to 1986. The tumor was most common in the 5th decade of age(47 cases, 26.9%) and 24 cases(13.7%) were children. And the ratio of male to female was 1.2:1. The pathologic diagnosis was neurogenic tumor in 73 cases(41.7%), metastatic tumor in 29 cases(16.6%), glial tumor in 24 cases(13.7%), and meningeal tumor in 23 cases(13.1%) in the order of frequency, and the tumors of dysembryogenesis were only 2 cases(1.1%). The tumors were located most frequently in the thoracic area(79 cases, 45.1%) and I the intradural extramedullary space(79 cases, 45.1%). The most common initial presentation was pain(86 cases, 49.1%) and the mean duration of presentation was 20.6 months. On admission 70 cases(40.0%) were in the 'paraparesis stage'. The mean value of the CSF protein was 741mg%. The rate of positivity of the plain spinal radiologic study was 55.7% and the most common positive findings was the increased interpedicular distance(46 cases, 29.1%). the total or gross total removal was possible in 105 cases (60.0%). The surgical result within the postoperative one month was recovery in 52 cases(29.7%), improvement in 76 cases(43.4%), stationary state in 36 cases (20.6%), progression in 11 cases(6.3%). After 20.1 months of the mean follow-up duration in 109 cases(62.3%), the result was recovery in 69 cases(63.3%), improvement in 16 cases(14.7%), stationary state in 8 cases(7.3%), progression in 16 cases(14.7%). As a major complication, there was a spinal deformity in 6 cases(3.4%), pulmonary embolism in 2 cases(1.1%), postoperative hematoma and meningitis in 1 case(0.6%) each. Ten cases(5.7%) were followed up to their deaths. And the authors discussed the clinical features of the spinal cord tumors reported in the literatures and the results of the present study with a more detailed consideration on each of major pathologies, neurogenic tumors, meningeal tumors, glial tumors, and metastatic tumors.

Occpital Lobe Arteriovenous Malformation

There were 13 cases of occipital lobe arteriovenous malformation(AVM) in a series of 100 intracranial arteriovenous malformations from Jan. 1981 to May 1987. Occipital lobe AVM's which encompass medial occipital, parieto-occipital, temporo-occipital AVM have distinct clinical and anatomic features. They usually present with bleeding, often accompanied by homonymous visual field deficit or with migrainous headache and seizure is very infrequent. However 4 cases out of 13 cases of our series had the seizure. The malformations were supplied principally by branches of posterior cerebral artery(PCA) but middle cerebral artery(MCA), anterior cerebral artery(ACA) and middle meningeal artery(MMA) were also contributed to the supply in some cases. The goal of surgery is to remove the conglomerated mass without disturbing the visual field. On considering the surgical approach, preservation of the visual field should be always kept in mind. We also discuss the surgical approaches.

Hypothalamic Tumors Causing Precocious Puberty

Various types CNS lesions bring about precocious puberty and mostly these lesions involve the hypothalamus. We experienced two cases of hypothalamic hamartomas and a case of hypothalamic astrocytoma, presenting sexual precocity as the initial symptom. Other clinical findings included gelastic seizure, behavioral disturbance, accelerated bony growth. MRI of the hamartoma showed high signal intensities on T2 weighted spin echo image. The two hypothalamic hamartomas were partially removed and the patients showed some improvements endocrinologically and clinically one month after the operation. Literatures about the hypothalamic hemartoma were reviewed and the problems especially in the extent of surgical removal in the hypothalamic hamartomas were discussed.

Pediatric Cerebellopontine Angle Tumors

From 1957 to Jun 1987, authors experienced 8 cases of pediatric brain tumor located in the cerebellopontine angle(CPA) which were operated upon at the Department of Neurosurgery of Seoul National University Hospital. The proportion of the pediatric CPA tumors in the total pediatric brain tumors was 4% (8/197), and that in the pediatric posterior fossa tumors was 8% (8/100). The pathologic diagnoses of the 8 cases were ependymoma (2 cases), medulloblastoma (2 cases), astrocytoma ( 1 case), primitive neuroectodermal tumor (1 case), trigeminal schwannoma (1 case) and Masson's hemangioendothelioma (1 case). The proportion of CPA location in the posterior fossa ependymomas was 13% (2/16), and those of the posterior fossa medulloblastomas and astrocytomas were 4% (2/50 and 1/28, respectively). The initial presentations were symptoms of increased intracranial pressure in 5 cases, and those of cranial nerve dysfunction in 3 cases. On admission, all of 8 cases showed signs of increased intracranial pressure and among the cranial nerve dysfunctions, facial nerve dysfunction was most common (5 cases). It seemed that it was due to close relationship between these tumors and fourth ventricle, and the patients' age which was too young to complain of subtle subjective sensory dysfunctions. The operative findings showed medial displacement and compression of the cerebellum, brain stem and cranial nerves, enlargement of surrounding subarachnoid space or arachnoid cyst formation, tumor growth into the cranial nerve canals, and encasement of nerves or vessels by the tumor. The sites of origin were lateral recess of fourth ventricle in 4 cases (2 ependymomas and 2 medulloblastomas), and surrounding brain tissue in the other 2 glioma cases. And a representative case was presented.

Clinical Study on Myelomeningocele

Myelomengocele is one of the most common congenital anomalies. The exact incidence of myelomeningocele is not known, but it is about one to three per 1000 live births. The long term results of treatment of infants born with myelomeningocele are disappointing. So many factors must be considered in deciding the treatment of the patients, such as clinical state of the patients, family's attitude, socioeconomic factors, and ethical and moral aspects. Authors performed clinical study of 71 cases of spina bifida cystica for past 10 years and the results are as follows : 1) Of the 71 cases, 51 cases(71.8%) were myelomeningocele and 20(28.2%) were meningocele. There was no sexual difference. 2) Admissions within 24 hours after birth were only 21 cases(29.5%). 3) Familial tendency and the relation to the number of childbearings were not observed. Majority of the cases were born in the families of low socioeconomic state. 4) Of the 71 cases, 17 cases(23.9%) were associated with hydrocephalus and 3(4.2%) with Arnold-Chiari malformation. 5) 39 cases(76.5%) of myelomeningocele showed definite neurological deficit but all cases of meningocele were quite normal neurologically. 6) Operation was performed in only 24 cases(47.1%) of 51 myelomeningocele.

So-called Inflammatory Granuloma on CT Scan

Authors report 10 cases of intracranial inflammatory granulomatous lesions which were identified on CT scan and proven pathologically after surgical excision. They were composed of three cases of tuberculoma, three cases of degenerated cysticercus, two cases of healed abscess and two cases of non-specific inflammatory lesions. Most patients were children or young adults. Seizure was the most frequent presenting symptom. All cases had characteristic CT findings in common : a small nodular or ring-like lesion with strong enhancement surrounded by irregular-shaped low density area. Surgical exploration is of value in that specific diagnosis would not be possible with clinical and radiological findings only.

A Case Report of Syringomyelia

No abstract available.

Intramedullary Glioblastoma Multiforme: Report of 3 Cases

The authors report 3 cases of primary intramedullary glioblastoma multiforme which is relatively rare among spinal cord tumors. They were located at the thoracolumbar, cervical and conus medullaris region respectively. Clinical, radiographic and pathological material are presented and the literature is discussed.