Dual microcatheter coil embolization of acutely ruptured wide-necked intracranial aneurysms.

The dual microcatheter technique is an alternative treatment for stent-assisted coiling in acutely ruptured wide-necked aneurysms because of no antiplatelet therapy. We assessed the safety and efficacy of this technique in ruptured wide-necked aneurysms. Between March 2008 and March 2016, 56 acutely ruptured aneurysms were treated with the dual microcatheter technique. The angiographic results, treatment-related complications, and clinical outcome were documented. Angiographic follow-up was available in 37 patients at a mean of 20.6 months (6 to 81 months). On the postembolization angiograms, 27 (48.2%) aneurysms showed complete occlusion (Raymond 1), 15 (26.8%) showed neck remnant (Raymond 2), and 14 (25.0%) showed body remnant (Raymond 3). Treatment-related complications occurred in seven patients (12.5%) and six patients remained asymptomatic. The permanent complication rate was 1.8% (1/56). A good outcome (modified Rankin Scale (mRS) score, 0-2) was observed in 64.3% of patients at the time of discharge. Five patients had died, all of the sequelae of subarachnoid hemorrhage. The overall mortality rate was 8.9% (5/56); however, the treatment-related mortality rate was 0%. Of the 37 aneurysms for which angiographic follow-up was available, 21 (56.8%) aneurysms demonstrated recanalization. Five aneurysms with recanalization were retreated endovascularly. There was one aneurysm re-rupture on follow-up and it rebled 21 months after the initial procedure. The dual microcatheter technique is a safe and effective treatment for acutely ruptured wide-necked aneurysms due to low treatment-related complication and mortality rate. However, the high rate of postembolization incomplete occlusion and recanalization remains as the main challenge.

Multiloculated Hydrocephalus: Open Craniotomy or Endoscopy?

Multiloculated hydrocephalus (MLH) is a condition in which patients have multiple, separate abnormal cerebrospinal fluid collections with no communication between them. Despite technical advancements in pediatric neurosurgery, neurological outcomes are poor in these patients and the approach to this pathology remains problematic especially given individual anatomic complexity and cerebrospinal fluid (CSF) hydrodynamics. A uniform surgical strategy has not yet been developed. Current treatment options for MLH are microsurgical fenestration of separate compartments by open craniotomy or endoscopy, shunt surgery in which multiple catheters are placed in the compartments, and combinations of these modalities. Craniotomy for fenestration allows better visualization of the compartments and membranes, and it can offer easy fenestration or excision of membranes and wide communication of cystic compartments. Hemostasis is more easily achieved. However, because of profound loss of CSF during surgery, open craniotomy is associated with an increased chance of subdural hygroma and/or hematoma collection and shunt malfunction. Endoscopy has advantages such as minimal invasiveness, avoidance of brain retraction, less blood loss, faster operation time, and shorter hospital stay. Disadvantages are also similar to those of open craniotomy. Intraoperative bleeding can usually be easily managed by irrigation or coagulation. However, handling of significant intraoperative bleeding is not as easy. Currently, endoscopic fenestration tends to be performed more often as initial treatment and open craniotomy may be useful in patients requiring repeated endoscopic procedures.

Craniotomy or Decompressive Craniectomy for Acute Subdural Hematomas: Surgical Selection and Clinical Outcome.

OBJECTIVE: Craniotomy (CO) and decompressive craniectomy (DC) are two main surgical options for acute subdural hematomas (ASDH). However, optimal selection of surgical modality is unclear and decision may vary with surgeon's experience. To clarify this point, we analyzed preoperative findings and surgical outcome of patients with ASDH treated with CO or DC. METHODS: From January 2010 to December 2014, data for 46 patients with ASDH who underwent CO or DC were retrospectively reviewed. The demographic, clinical, imaging and clinical outcomes were analyzed and statistically compared. RESULTS: Twenty (43%) patients underwent CO and 26 (57%) patients received DC. In DC group, preoperative Glascow Coma Scale was lower (p=0.034), and more patient had non-reactive pupil (p=0.004). Computed tomography findings of DC group showed more frequent subarachnoid hemorrhage (p=0.003). Six month modified Rankin Scale showed favorable outcome in 60% of CO group and 23% of DC group (p=0.004). DC was done in patient with more unfavorable preoperative features (p=0.017). Patients with few unfavorable preoperative features (<6) had good outcome with CO (p<0.001). CONCLUSION: In selective cases of few unfavorable clinical findings, CO may also be an effective surgical option for ASDH. Although DC remains to be standard of surgical modality for patients with poor clinical status, CO can be an alternative considering the possible complications of DC.

Solitary Fibrous Tumor of Central Nervous System: A Case Report.

Solitary fibrous tumor (SFT) is a rare neoplasm of mesenchymal origin, especially in the central nervous system (CNS). Reported herein is a case of SFT of CNS in a 63-year-old female patient who had confused mentality, without other neurological deficit. The brain MRI showed an ovoid mass in the right frontal lobe. The tumor was surgically removed grossly and totally, and the pathologic diagnosis was SFT. At 55 months after the surgery, the tumor recurred at the primary site and at an adjacent area. A second operation was thus done, and the tumor was again surgically removed grossly and totally. The pathologic diagnosis was the same as the previous, but the Ki-67 index was elevated. Ten months later, two small recurring tumors in the right frontal skull base were found in the follow-up MRI. It was decided that radiation therapy be done, and MRI was done again 3 months later. In the follow-up MRI, the size of the recurring mass was found to have decreased, and the patient did not manifest any significant symptom. Follow-up will again be done 18 months after the second surgery.

The olfactory groove schwannoma attached to the cribriform plate: a case report.

The olfactory groove schwannoma is a quite rare tumor. We report a case of a 49-year-old woman with an olfactory groove schwannoma attached to the cribriform plate without olfactory dysfunction. She had no specific neurological symptoms other than a headache, and resection of the tumor showed it to be a schwannoma. About 19 months after the operation, a follow-up MRI showed no evidence of tumor recurrence. Surgical resection through subfrontal approach could be one of the curative modality in managing an olfactory groove schwannoma. An olfactory groove schwannoma should be considered in the differential diagnosis of anterior skull base tumors.

Antihypertensive treatment of acute intracerebral hemorrhage by intravenous nicardipine hydrochloride: prospective multi-center study.

The authors performed a multicenter prospective study to evaluate the feasibility and safety of intravenous nicardipine hydrochloride for acute hypertension in patients with intracerebral hemorrhage (ICH). This study included 88 patients (mean age: 58.3 yr, range 26-87 yr) with ICH and acute hypertension in 5 medical centers between August 2008 and November 2010, who were treated using intravenous nicardipine. Administration of nicardipine resulted in a decrease from mean systolic blood pressure (BP) (175.4 ± 33.7 mmHg) and diastolic BP (100.8 ± 22 mmHg) at admission to mean systolic BP (127.4 ± 16.7 mmHg) and diastolic BP (67.2 ± 12.9 mmHg) in 6 hr after infusion (P < 0.001, mixed-effect linear models). Among patients who underwent follow-up by computed tomography, hematoma expansion at 24 hr (more than 33% increase in hematoma size at 24 hr) was observed in 3 (3.4%) of 88 patients. Neurological deterioration (defined as a decrease in initial Glasgow coma scale ≥ 2) was observed in 2 (2.2%) of 88 patients during the treatment. Aggressive nicardipine treatment of acute hypertension in patients with ICH can be safe and effective with a low rate of neurological deterioration and hematoma expansion.

Risk factors for postoperative ischemic complications in patients with moyamoya disease.

OBJECT: The aim of this study was to determine the risk factors associated with the development of postoperative ischemic complications after surgical revascularization used to treat pediatric patients with ischemic moyamoya disease. METHODS: The clinical, imaging, and perioperative data from 170 procedures in 90 children who underwent indirect revascularization surgery were retrospectively reviewed. To clarify the risk factors, cases with identified ischemic complications and those without such events were compared. For this study, a postoperative ischemic complication was defined as a newly developed infarction within 2 weeks after surgery, which was confirmed by follow-up imaging studies. CONCLUSIONS: The higher ischemic risks from surgical treatment should be considered for patients with moyamoya disease who are younger than 3 years of age and have a preoperative cerebral infarction. It is also recommended that the revascularization surgery be delayed for at least 6 weeks after the development of the previous cerebral infarction.

Endoscopic disconnection for hypothalamic hamartoma with intractable seizure. Report of four cases.

Although intractable epilepsy associated with hypothalamic hamartoma (HH) can be controlled by microsurgical resection of the lesion, excision of deep-seated lesions is often associated with morbidity and mortality. Endoscopic disconnection is less invasive and seems to be well suited for this indication. The authors discuss the role of endoscopic-assisted surgery in the management of HH-induced seizures. Four patients with HH-related intractable gelastic seizure underwent endoscopic disconnection surgery. Postoperatively, all patients exhibited improvement. Two patients became seizure free immediately after endoscopic disconnection surgery, one patient with a widespread seizure focus involving the motor strip continued to experience rare complex partial seizures but gelastic seizures ceased, and one experienced a reduced frequency of seizures but persistence of some generalized seizures. Three patients suffered postoperative disconnection-like syndrome, which continued 3 to 7 days and spontaneously disappeared. The authors advocate the endoscopic disconnection surgery as a safe and effective treatment for HH-related epilepsy by blocking the spread of epileptic discharges from the lesion.

The surgical effect of callosotomy in the treatment of intractable seizure.

We evaluated the surgical effects of the callosotomy, particularly with respect to the effect of callosotomy in some seizure types and the extent of surgery. Twenty-one patients with a minimum follow-up of two year were enrolled. The most significant effect of callosotomy was the complete suppression of the generalized seizures associated with drop attack in 12 of 21 patients and seizure reduction of more than 75% in 6 of 21 patients. The surgical effect on the partial seizures was very variable. Transient disconnection syndrome appeared in 4 patients after anterior callosotomy. Total callosotomy by staged operation significantly suppressed generalized seizures associated with drop attack without any disconnection syndrome. Our data show that callosotomy is quite a good approach to the surgical treatment of drop attacks accompanied by disabling generalized seizures.

Posterior atlantoaxial dislocation without fracture. Case report.

Posterior dislocation of the atlas onto the axis without related fracture of the odontoid process is a very rare traumatic condition of which five cases have been previously reported. The authors present a sixth case in which management was different from the others. The patient was successfully treated by open reduction of the dislocation and C1-2 transarticular screw fixation. The rarity of the lesion, the differences in diagnostic studies, and the successful treatment by safe intraoperative reduction and fixation are factors of interest in this case.

Optic sheath schwannomas: report of two cases.

INTRODUCTION: Schwannomas are benign tumors that arise from Schwann cells in the peripheral nervous system. The vestibular division of the VIIIth cranial nerve is the nerve segment most commonly affected, the trigeminal nerve root being the next most frequently affected. Although schwannomas of other cranial nerves are very rare, these nerves do have myelinated sheaths composed of Schwann cells and are potential sites for intracranial schwannomas. However, previous studies have suggested that the term 'schwannoma' should not be applied in the case of optic nerve pathology, although two cases of optic nerve sheath schwannoma have been reported to our knowledge. PURPOSE: The purpose of this paper is to report two cases of the exceedingly rare entity of optic sheath schwannoma and to discuss its histopathogenesis.

The reversible focal MRI abnormalities in complex partial seizure: technical instruction.

CASE REPORT: A 17-month-old infant girl was admitted with complex partial seizures and right side hemiparesis. Five days after the last seizure, MR signal changes were observed in the left hemisphere with a cavernous hemangioma in the middle temporal gyrus. However, these MR signal changes had normalized 11 days after the last seizure, except for the cavernous hemangioma. The scalp EEG findings revealed that the epileptic focus was on the mid-temporal gyrus. The patient underwent lesionectomy only. Two months after this operation the MR showed no signal abnormality. Throughout a 12-month follow-up after surgery the patient remained seizure free. DISCUSSION: MR signal changes in seizure patients do not always indicate the structural region concerned, but can be transient signal changes. They may be due to the propagation of epileptic discharge along the association fiber from the seizure focus. However, transient signal changes after seizure must be followed up to allow exclusion of a tumor and other diseases.

Selective posterior rhizotomy for lower extremity spasticity: how much and which of the posterior rootlets should be cut?

BACKGROUND: It is well known that selective posterior rhizotomy is effective for relieving spasticity associated with cerebral palsy. However, there is significant variation between surgeons in terms of how much and which of the posterior rootlets should be cut for the improvement of ambulatory function without causing adverse effects. METHODS: The study population was composed of 200 CP patients who underwent SPR more than 1 year before this study. The children were divided into 4 groups (Group A had their L1-S2 roots cut, Group B had the L2-S2 roots cut, Group C had the L2-S1 roots cut, and Group D had the L2-S1 roots and the unilateral S2 root cut). We assessed lower limb spasticity, passive range of motion, ambulatory function, and gait pattern in each group. RESULTS: Inclusion of L1 and S2 in the lesioning process of SPR was more effective at relieving spasticity in terms of hip adduction and ankle dorsiflexion respectively and improving ambulatory function (p < 0.01). Although lesioning of S2 carried a greater risk of urinary dysfunction, resection of less than 50% of S2 significantly improved ambulatory function without urinary complications (p < 0.01). Unilateral lesioning of S2 was an alternative option in selected cases with different amounts of spasticity in the ankles for the same purpose. CONCLUSIONS: We propose that L1 and S2 roots should be included in the lesioning process of SPR for effective improvement of gross motor function, but that resection of these roots should be less than 50% to prevent complications.