Fulminant meningitis after radiotherapy for clival chordoma.

The best treatment for clival chordoma is obtained with total surgical excision, sometimes combined with adjuvant radiotherapy. A cerebrospinal fluid (CSF) fistula is a fatal complication that may occur following extended transsphenoidal surgery (TSS) and adjuvant radiotherapy. We report a case of fulminant meningitis without a CSF fistula in a 57-year-old woman who underwent TSS and multiple radiotherapies for a clival chordoma. She presented to our emergency room with copious epistaxis and odor inside her nasal cavity and had an unexpected fatal outcome. She was diagnosed with meningitis based on CSF culture and blood culture. While treating clival chordomas with adjuvant radiotherapy, clinicians should be aware of the possibility of fulminant meningitis.

Intracranial dural arteriovenous fistulas: clinical characteristics and management based on location and hemodynamics.

OBJECTIVE: A dural arteriovenous fistula (DAVF) generally refers to a vascular malformation of the wall of a major venous sinus. These lesions have diverse symptoms according to the location and venous drainage, and require multidisciplinary treatment. We report on our experience and analyze the treatment outcome of intracranial DAVFs for a nine-year period. METHODS: Between January 2000 and December 2008, 95 patients with intracranial DAVFs were enrolled in this study. A retrospective review of clinical records and imaging studies of all patients was conducted. Endovascular embolization, surgical interruption, gamma knife stereotactic radiosurgery (GKS), or combinations of these treatments were performed based on clinical symptoms, lesion location, and venous drainage pattern. RESULTS: Borden type I, II, and III were 34, 48, and 13 patients, respectively. Aggressive presentation was reported in 6% of Borden type I, 31% of Borden type II, and 77% of Borden type III DAVFs, respectively, and DAVFs involving transverse, sigmoid, and superior sagittal sinus. Overall, the rate of complete obliteration was 68%. The complete occlusion rates with a combination treatment of endovascular embolization and surgery, surgery alone, and endovascular embolization were 89%, 86%, and 80%, respectively. When GKS was used with embolization, the obliteration rate was 83%, although it was only 54% in GKS alone. Spontaneous obliteration of the DAVF occurred in three patients. There were a few complications, including hemiparesis (in microsurgery), intracranial hemorrhage (in endovascular embolization), and facial palsy (in GKS). CONCLUSION: The hemorrhagic risk of DAVFs is dependent on the location and hemodynamics of the lesions. Strategies for treatment of intracranial DAVFs should be decided according to the characteristic of the DAVFs, based on the location and drainage pattern. GKS can be used as an optional treatment for intracranial DAVFs.

Surgical results and risk factors for recurrence of lumbar disc herniation.

OBJECTIVE: Recurrent lumbar disc herniation has been defined as disc herniation at the same level, regardless of ipsilateral or contralateral herniation, with a pain-free interval greater than 6 months. The aim of this study is to analyze outcomes and identify the potential risk factors for recurrent lumbar disc herniation. METHODS: The authors retrospectively reviewed the cases of 178 patients who underwent open discectomy for single-level lumbar disc herniation. Visual analogue scales and modified Macnab criteria were used to compare the clinical outcomes between the recurrent group and the non-recurrent group. Sex, age, discectomy level, degree of disc degeneration, type of disc herniation, pain-free interval after first-operation, smoking status, and trauma were investigated as potential recurrence risk factors. RESULTS: Of the 178 patients for whom the authors were able to definitely assess symptomatic recurrence status, 18 patients (10.1%) underwent revision surgery for recurrent disc herniation. The most common level involved was L4-L5 (61%) and the mean period of time to recurrence was 18.7 months (6-61 months). There were 17 cases of ipsilateral herniation and 1 case of contralateral herniation. The types of herniation for which revision surgery was done were protrusion (3 cases), and transligamentous extrusion (14 cases). There were five excellent, eight good, and two fair results. CONCLUSION: Repeated discectomy for recurrent disc herniation produced unsatisfactory outcomes. Factors such as sex, type of disc herniation and traumatic events were found to be significant risk factors.

Long-term patient monitoring for clozapine-induced agranulocytosis and neutropenia in Korea: when is it safe to discontinue CPMS?

OBJECTIVES: This study documents the incidences of agranulocytosis and neutropenia, and the patterns of incidence of the side effects of long-term clozapine treatment in order to determine an appropriate time to stop the Clozaril Patient Monitoring System (CPMS). METHODS: Hematological, demographic, and other data from the CPMS for 6782 patients who took clozapine for the past 11 years in the Republic of Korea has been analyzed. RESULTS: Twenty-nine (53.7%) of fifty-four agranulocytosis cases occurred within the first 18 weeks. The cumulative incidence of agranulocytosis was 1.64% between 6 and 11 years and the crude incidence was 0.8%. Neutropenia occurred in 697 patients, and 365 (52.4%) of these cases occurred within the first 18 weeks. The cumulative incidence of neutropenia was 19.8% between 8 and 11 years, and the crude incidence was 10.3%. There were no cases of agranulocytosis or neutropenia after the 9th year of clozapine treatment. CONCLUSIONS: The incidence of agranulocytosis in the Republic of Korea was similar to those in the rest of the world. While agranulocytosis began several years after clozapine treatment, long-term monitoring of white blood cells is necessary. We suggest that the CPMS should be stopped or less frequently after the 9th year of treatment.