Multimodal Treatment of Skull Base Inflammatory Pseudotumor: Case Report.

lnflammatory pseudotumor (IPT) is a rare, non-neoplastic inflammatory process. It is most commonly occurs in the orbit, but extension into brain parenchyma is uncommon. In a confirmed case of IPT, most cases show good improvement with steroid theraphy. A 50-year-old man with progressive left-eye visual disturbance and mass lesion was admitted in a hospital. A left orbital mass biopsy revealed what was highly suspected as an inflammatory pseudotumor. Steroid pulse therapy with dexamethasone, radiation therapy, and chemotherapy with amphotericin B were performed, but they were not effective in improving the condition of the patient. Revision open surgery was then performed. A follow-up brain enhancement computerized tomography showed an enlarged mass volume and hydrocephalus with periventricular enhancement. As an additional procedure, ventriculoperitoneal shunt and tuberculosis medication were administered. About 2 weeks later, clinical symptoms and radiologic findings improved. We present a case of intra-cranial IPT and discuss further treatment methods.

Chronological changes and effects of AMP-activated kinase in the hippocampal CA1 region after transient forebrain ischemia in gerbils.

OBJECTIVES: Adenosine monophosphate-activated kinase (AMPK) is an energy-specific sensor within the central nervous system. In this study, we observed AMPK and its phosphorylated form (pAMPK) in the hippocampal CA1 region after 5 minutes of transient forebrain ischemia. In addition, we also investigated the effects of Compound C, an AMPK inhibitor, against ischemic damage in gerbils. METHODS: Adenosine monophosphate-activated kinase and pAMPK immunoreactivity was observed in the hippocampal CA1 region at various time points after ischemia and Compound C was intraperitoneally administered to gerbils immediately after reperfusion and the animals were sacrificed at 5 days after ischemia/reperfusion. RESULTS: Adenosine monophosphate-activated kinase immunoreactivity was transiently increased in the hippocampal CA1 region 1-2 days after ischemia/reperfusion, while AMPK immunoreactivity was almost undetectable in the stratum pyramidale of the CA1 region 4-7 days after ischemia/reperfusion. The administration of Compound C caused a dose-dependent decrease in the ischemia-induced hyperactive behavior, the depletion of ATP, and lactate accumulation in the hippocampal CA1 region within 24 hours after ischemia/reperfusion. In addition, the administration of Compound C decreased reactive gliosis (astrocytes and microglia) and increased the number of cresyl violet-positive neurons when compared to the vehicle-treated group at 5 days post-ischemia/reperfusion. CONCLUSION: These results suggest that AMPK is transiently phosphorylated following forebrain ischemia in the hippocampal CA1 region and inhibition of AMPK has neuroprotective effects against ischemic damage through the reduction of ATP depletion and lactate accumulation in the hippocampal CA1 region.

Evaluation of vitamin D level in patients from neurosurgical intensive care unit.

Vitamin D plays an important role in maintaining normal bone metabolism. Recent studies have suggested that vitamin D influences many other physiological processes, including muscle function, cardiovascular homeostasis, nerve function, and immune response. Furthermore, accumulated evidence suggests that vitamin D also mediates the immune system response to infection. Critical neurosurgical patients have higher infection and mortality rates. To correlate vitamin D deficiency to the immunological status of neurosurgical intensive care unit patients, we detected serum vitamin D level in 15 patients with clinically suspected infection and 10 patients with confirmed infection. Serum level of 25-hydroxyvitamin D, the primary circulating form of vitamin D, was significantly decreased in patients with suspected or confirmed infection after a 2-week neurosurgical intensive care unit hospitalization, while serum level of 1,25-dihydroxyvitamin D, the active form of vitamin D, was significantly decreased in patients after a 4-week neurosurgical intensive care unit hospitalization. These findings suggest that vitamin D deficiency is linked to the immunological status of neurosurgical intensive care unit patients and vitamin D supplementation can improve patient's immunological status.

The comparative morphometric study of the posterior cranial fossa : what is effective approaches to the treatment of Chiari malformation type 1?

OBJECTIVE: The objective of this study was to investigate changes in the posterior cranial fossa in patients with symptomatic Chiari malformation type I (CMI) compared to a control group. METHODS: We retrospectively reviewed clinical and radiological data from 12 symptomatic patients with CMI and 24 healthy control subjects. The structures of the brain and skull base were investigated using magnetic resonance imaging. RESULTS: The length of the clivus had significantly decreased in the CMI group than in the control group (p=0.000). The angle between the clivus and the McRae line (p<0.024), as the angle between the supraocciput and the McRae line (p<0.021), and the angle between the tentorium and a line connecting the internal occipital protuberance to the opisthion (p<0.009) were significantly larger in the CMI group than in the control group. The mean vertical length of the cerebellar hemisphere (p<0.003) and the mean length of the coronal and sagittal superoinferior aspects of the cerebellum (p<0.05) were longer in the CMI group than in the control group, while the mean length of the axial anteroposterior aspect of the cerebellum (p<0.001) was significantly shorter in the CMI group relative to control subjects. CONCLUSION: We elucidate the transformation of the posterior cranial fossa into the narrow funnel shape. The sufficient cephalocaudal extension of the craniectomy of the posterior cranial fossa has more decompression effect than other type extension of the craniectomy in CMI patients.

A case of multiple myeloma with brain parenchyme involvement.

Multiple myelomas (MM) are characterized by monoclonal proliferation of immunoglobulin (Ig)-secreting plasma cells. Central nervous system involvement is a rare complication of MM, and it can present as either an intraparenchymal or a leptomeningeal lesion. A 77-year-old woman was transferred from the dementia clinic in July 2012. She had a large heterogeneous signal mass with central necrosis and with pial involvement in the left frontal lobe with destruction of the frontal bone that was observed on computed tomography and magnetic resonance imaging. Multiple punched out radiolucent lesions were also noted on the skull X-ray. Serum protein electrophoresis revealed an IgA-kappa monoclonal gammopathy. External lumbar drainage was helpful for treating the fluid collection underneath the scalp after an orbitozygomatic craniotomy with duroplasty.

Simultaneous multiple Basal Ganglia and cerebellar hemorrhage: case report.

A 35-year-old man presented with simultaneous multiple intracranial hematomas in the right cerebellar dentate nucleus and left basal ganglia. The hematomas were visible by computed tomography performed within two hours of the patient's arrival. The initial computed tomography showed acute hemorrhage in the left basal ganglia and dentate nucleus in cerebellum. The patient then experienced a change of consciousness due to newly developed hydrocephalus, and emergent extra-ventricular drainage was performed. By discharge, fortunately, the patient was fully recovered.

Desmoid tumor of the facet joint: a case report.

Desmoid tumors represent a particular type of fibromatosis. The common sites for extra-abdominal desmoid tumors, known as aggressive fibromatosis, are the shoulder, chest wall, and thigh. Desmiod tumors are rare at facet joints of the spine. We describe a patient with a desmoid tumor of a lumbar facet joint.

Radiological and pathological evaluation of the spinal cord in a rat model of electrical injury-induced myelopathy.

BACKGROUND: No study has reported an animal-based experimental model of electrical injury to the spinal cord. This paper presents the first systematic establishment of an animal model of electrical injury to the spinal cord with subsequent pathophysiologic analysis. METHOD: The voltage required for the electrical shock was generated by an electroconvulsive therapy apparatus (57800 ECT unit; UGO BASILE, Italy). We used one side ear as the entry site and the contralateral hind limb as the exit site. Seven electrical shock (frequency, 120 Hz; pulse width, 0.9 ms; duration, 3 s; current, 99 mA) was applied to each rat and used rat showing hind limb weakness. Radiologic and histologic evaluations were performed at one day, one, two and four weeks after injury. RESULTS: Twelve rats showed the hind limb weakness among the total 18 rats. Manganese-enhanced magnetic resonance imaging showed interruption of spinal cord enhancement in the thoracic area. Histological examination showed a greater decrease in the number of neurons in the ventral horn versus the dorsal horn. CONCLUSION: This study demonstrates a novel design and analysis of an animal-based experimental model of spinal cord injury by electrical etiology. This model is useful for experimental studies of injuries to the spinal cord.

Neuroprotective effects of adipose-derived stem cells against ischemic neuronal damage in the rabbit spinal cord.

Transplantation of adipose-derived stem cells (ASCs) is one of the possible therapeutic tools for ischemic damage. In this study, we observed the effects of ASCs against ischemic damage in the ventral horn of L(5-6) levels in the rabbit spinal cord. ASCs were isolated from rabbits, and cell type was confirmed by flow cytometry analysis, labeling with CM-DiI dye and differentiation into adipocytes in adipogenesis differentiation medium. ASCs were administered intrathecally into recipient rabbits (2 × 105) immediately after reperfusion following a 15-min aortic artery occlusion in the subrenal region. Transplantation of ASCs significantly improved functions of the hindlimb and morphology of the ventral horn of spinal cord although CM-DiI-labeled ASCs were not observed in the spinal cord parenchyma. In addition, transplantation of ASCs significantly increased brain-derived neurotrophic factor (BDNF) levels at 72h after ischemia/reperfusion. These results suggest that transplantation of ASCs prevents motor neurons from spinal ischemic damage and reactive gliosis by increasing neurotrophic factors such as BDNF in the spinal cord.

Neuroprotective effects of PEP-1-Cu,Zn-SOD against ischemic neuronal damage in the rabbit spinal cord.

A rabbit model of spinal cord ischemia has been introduced as a good model to investigate the pathophysiology of ischemia-reperfusion (I-R)-induced paraplegia. In the present study, we observed the effects of Cu,Zn-superoxide dismutase (SOD1) against ischemic damage in the ventral horn of L(5-6) levels in the rabbit spinal cord. For this study, the expression vector PEP-1 was constructed, and this vector was fused with SOD1 to create a PEP-1-SOD1 fusion protein that easily penetrated the blood-brain barrier. Spinal cord ischemia was induced by transient occlusion of the abdominal aorta for 15 min. PEP-1-SOD1 (0.5 mg/kg) was intraperitoneally administered to rabbits 30 min before ischemic surgery. The administration of PEP-1-SOD1 significantly improved neurological scores compared to those in the PEP-1 (vehicle)-treated ischemia group. Also, in this group, the number of cresyl violet-positive cells at 72 h after I-R was much higher than that in the vehicle-treated ischemia group. Malondialdehyde levels were significantly decreased in the ischemic spinal cord of the PEP-1-SOD1-treated ischemia group compared to those in the vehicle-treated ischemia group. In contrast, the administration of PEP-1-SOD1 significantly ameliorated the ischemia-induced reduction of SOD and catalase levels in the ischemic spinal cord. These results suggest that PEP-1-SOD1 protects neurons from spinal ischemic damage by decreasing lipid peroxidation and maintaining SOD and catalase levels in the ischemic rabbit spinal cord.

Clinical Effects and Radiological Results of Vertebroplasty: Over a 2-year Follow-Up Period.

OBJECTIVE: We investigated the association between clinical and radiological results and assessed the radiological changes according to the distribution pattern and amount of injected cement after vertebroplasty. METHODS: Two hundred and one patients underwent vertebroplasty; of these, 15 were follow up for more than 2 years. For radiological analysis, we grouped the patients according to cement distribution as follows: group 1, unilateral, unilateral distribution of cement; group 2, bilateral-uneven, bilateral distribution of cement but separated mass; and group 3, bilateral-even, bilateral single mass of cement. To compare radiologic with clinical results, we assessed the visual analogue scale (VAS) score, amount of injected cement, bone mineral density (BMD), postoperative and follow-up vertebral body compression ratios, and postoperative and follow-up kyphotic angles. RESULTS: There were 4 (26.7%) patients in group 1, 6 (40.0%) in group 2, and 5 (33.3%) in group 3. The mean VAS score was 5.2 preoperatively, 1.8 postoperatively, and 3.2 at 2-year follow-up. The 2-year follow-up compression ratio was better in patients with even distribution of injected cement (group 2 and 3) than group 1. However, it was not statistically insignificant (p>0.05). The follow-up kyphotic angle was more aggravated in the group 1 than in the other groups (p<0.05). CONCLUSION: Our study showed that vertebroplasty had a beneficial effect on pain relief, particularly in the immediate postoperative stage. The augmented spine tended to be more stable in the cases with increased amount and more even distribution of injected cement.

Clinical outcome of posterior fixation of the C1 lateral mass and C2 pedicle by polyaxial screw and rod.

OBJECTIVE: Because of atlantoaxial complex has a unique and complicated anatomy and instability of this complex is very dangerous. We investigated the clinical results of posterior C1-C2 fixation with a polyaxial screw-rod system. METHODS: Between July 2001 and December 2007, the authors treated 17 patients suffering from atlantoaxial deformity and instability. Atlantoaxial fusion was employed in 9 patients with upper cervical fracture and dislocation, in 6 patients with atlantoaxial subluxation, in 1 patient with pure transverse ligament injury, and in 1 patient with basilar invagination. The mean age at the time of surgery was 40.4 years (range, 15-68 years). RESULTS: Operative times ranged from 165 to 420 min (average 306 min), and the postoperative mean VAS score was 2.4. The mean follow-up period was 26 months. Solid fusion was achieved in 15 patients at the last follow up; no injury of the vertebral artery or spinal cord and no operative mortality occurred in these cases. CONCLUSIONS: We suggest that posterior atlantoaxial fixation using the polyaxial screw-rod system is an effective and relatively safe technique. The navigation guidance system employed during the surgical procedure was helpful methods. Future studies of the feasibility of navigation system-guided surgical procedures will be required.

Risk factors associated with subdural hygroma after decompressive craniectomy in patients with traumatic brain injury : a comparative study.

OBJECTIVE: Subdural hygroma (SDG) is a complication occurring after head trauma that may occur secondary to decompressive craniectomy (DC). However, the mechanism underlying SDG formation is not fully understood. Also, the relationship between the operative technique of DC or the decompressive effect and the occurrence and pathophysiology of SDG has not been clarified. Purpose of this study was to investigate the risk factors of SDG after DC in our series. METHODS: From January 2004 to December 2008, DC was performed in 85 patients who suffered from traumatic brain injury. We retrospectively reviewed the clinical and radiological features. For comparative analysis, we divided the patients into 2 groups : one group with SDG after craniectomy (19 patients; 28.4% of the total sample), the other group without SDG (48 patients; 71.6%). The risk factors for developing SDG were then analyzed. RESULTS: The mean Glasgow Outcome Scale (GOS) scores at discharge of the groups with and without SDG were 2.8 and 3.1, respectively (p<0.0001). Analysis of radiological factors showed that a midline shift in excess of 5 mm on CT scans was present in 19 patients (100%) in the group with SDG and in 32 patients (66.7%) in the group without SDG (p<0.05). An accompanying subarachnoid hemorrhage (SAH) was seen in 17 patients (89.5%) in the group with SDG and in 29 patients (60.4%) in the group without SDG (p<0.05). Delayed hydrocephalus accompanied these findings in 10 patients (52.6%) in the group with SDG, versus 5 patients (10.4%) in the group without SDG (p<0.05). On CT, compression of basal cisterns was observed in 14 members (73.7%) in the group with SDG and in 18 members of the group without SDG (37.5%) (p<0.007). Furthermore, tearing of the arachnoid membrane, as observed on CT, was more common in all patients in the group with SDG (100%) than in the group without SDG (31 patients; 64.6%) (p<0.05). CONCLUSION: GOS showed statistically significant difference in the clinical risk factors for SDG between the group with SDG and the group without SDG. Analysis of radiological factors indicated that a midline shifting exceeding 5 mm, SAH, delayed hydrocephalus, compression of basal cisterns, and tearing of the arachnoid membrane were significantly more common in patients with SDG.

Congenital cleft of anterior arch and partial aplasia of the posterior arch of the c1.

Congenital anomalies in arches of the atlas are rare, and are usually discovered incidentally. However, a very rare subgroup of patients with unique radiographic features is predisposed to transient quadriparesis after minor cervical or head trauma. A 46-year-old male presented with a 2-month history of tremor and hyperesthesia of the lower extremities after experiencing a minor head trauma. He said that he had been quadriplegic for about 2 weeks after that trauma. Radiographs of his cervical spine revealed bilateral bony defects of the lateral aspects of the posterior arch of C1 and a midline cleft within the anterior arch of the atlas. A magnetic resonance imaging revealed an increased cord signal at the C2 level on the T2-weighted sagittal image. A posterior, suboccipital midline approach for excision of the remnant posterior tubercle was performed. The patient showed significant improvement of his motor and sensory functions. Since major neurologic deficits can be produced by a minor trauma, it is crucial to recognize this anomaly.

A case of hypoglycemic brain injuries with cortical laminar necrosis.

We report a case of 68-yr-old male who died from brain injuries following an episode of prolonged hypoglycemia. While exploring controversies surrounding magnetic resonance imaging (MRI) findings indicating the bad prognosis in patients with hypoglycemia-induced brain injuries, we here discuss interesting diffusion-MRI of hypoglycemic brain injuries and their prognostic importance focusing on laminar necrosis of the cerebral cortex.

The change of adjacent segment and sagittal balance after thoracolumbar spine surgery.

OBJECTIVE: To characterize perioperative biomechanical changes after thoracic spine surgery. METHODS: Fifty-eight patients underwent spinal instrumented fusions and simple laminectomies on the thoracolumbar spine from April 2003 to October 2008. Patients were allocated to three groups; namely, the laminectomy without fusion group (group I, n = 17), the thoracolumbar fusion group (group II, n = 27), and the thoracic spine fusion group (group III, n = 14). Sagittal (ADS) and coronal (ADC) angles for adjacent segments were measured from two disc spaces above lesions at the upper margins, to two disc spaces below lesions at the lower margins. Sagittal (TLS) and coronal (TLC) angles of the thoracolumbar junction were measured from the lower margin of the 11th thoracic vertebra body to the upper margin of the 2nd lumbar vertebra body on plane radiographs. Adjacent segment disc heights and disc signal changes were determined using simple spinal examinations and by magnetic resonance imaging. Clinical outcome indices were determined using a visual analog scale. RESULTS: The three groups demonstrated statistically significant differences in terms of angle changes by ANOVA (p < 0.05). All angles in group I showed significantly smaller angles changes than in groups II and III by Turkey's multiple comparison analysis. Coronal Cobb's angles of the thoracolumbar spine (TLC) were not significantly different in the three groups. CONCLUSION: Postoperative sagittal balance is expected to change in the adjacent and thoracolumbar areas after thoracic spine fusion. However, its prevalence seems to be higher when the thoracolumbar spine is included in instrumented fusion.

Inter-racial, gender and aging influences in the length of anterior commissure-posterior commissure line.

OBJECTIVE: The length of anterior-posterior commissure (AC-PC) in racial groups, age, gender of patients with deep brain stimulation (DBS) and pallidotomy were investigated. METHODS: From January 1996 to December 2003, 211 patients were treated with DBS and pallidotomy. There were 160 (76%) Caucasians, 35 (17%) Hispanics, 12 (5%) Asians and 4 Blacks (2%). There were 88 males and 52 females in DBS-surgery group and 44 males, 27 females in pallidotomy group. Mean age was 58 year-old. There were 19 males and 19 females and mean age was 54.7 years in the control group. Measurements were made on MRI and @Target software. RESULTS: The average AC-PC distance was 24.89 mm (range 32 to 19), which increased with aging until 75 years old in Caucasian and also increased with aging in Hispanic, but the AC-PC distance peaked at 45 years old in Hispanic. The order of AC-PC distance were 25.2+/-2 mm in Caucasian, 24.6+/-2.24 mm in Asian, 24.53 mm in Black, 23.6+/-1.98 mm in Hispanic. The average AC-PC distance in all groups was 24.22 mm in female who was mean age of 56.35, 25.28 mm in male who was mean age of 60.19 and 24.5+/-2 mm in control group that was excluded because of the difference of thickness of slice. According to multiple regression analysis, the AC-PC distance was significantly correlated with age, race, and gender. CONCLUSION: The AC-PC distance is significantly correlated with age, gender, and race. The atlas of functional stereotaxis would be depended on the variation of indivisual brain that can influenced by aging, gender, and race.

Spinal schwannoma; analysis of 40 cases.

OBJECTIVE: This study is to report our experience of 40 cases of spinal schwannoma. METHODS: From 1995 to 2006, medical records were retrospectively reviewed in 40 cases of spinal schwannoma. RESULTS: We treated 40 spinal schwannomas in 38 (22 male and 16 female) patients. The mean age was 50.2. Four cases were sited in the cervical spine, 11 cases in the thoracic spine, and 25 cases in the lumbar spine. Two patients showed recurrences. Thirty-eight cases were intradural-extramedullary type and 2 cases were extradural. Two cases (5%) including 1 recurred case had no postoperative motor improvement. Ninety-five percents of patients improved on postoperative motor grade. CONCLUSION: Spinal schwannoma is mostly benign and extramedullary tumor. There were 2 recurred cases (5%) that had history of previous subtotal removal at first operation and had shown worse prognosis compared with the cases without recurrence. To reduce the recurrence of spinal schannoma, total excision of tumor mass should be done.

Multivariate analysis of risk factors of hematoma expansion in spontaneous intracerebral hemorrhage.

BACKGROUND: We focused on the cause of hematoma expansion after admission because the volume of hematoma after S-ICH plays a crucial role in the cause of mortality and morbidity. METHODS: In a retrospective review, 51 patients with hematoma expansion of S-ICH were identified among 880 cases of S-ICH treated between 2001 and May 2006. We divided cases into 2 groups according to the time of hematoma expansion. An enlargement of hematoma within 2 weeks after hospitalization was categorized as the acute stage group and after 2 weeks was categorized as the chronic stage group. Spontaneous intracerebral hemorrhage without hematoma expansion group (100 cases) had been consecutively selected as a control group. We analyzed the risk factors of hematoma expansion in patients with S-ICH especially in the acute stage group. RESULTS: Fifty-one of 880 patients had the enlargement of hematoma (5.8%). Forty-three (84%) of 51 cases were acutely developed and 8 cases (16%) were developed chronically. On univariate analysis there were significant differences in BP within the initial 48 hours (P < .0001), GOS (P < .0001), and previously taking anticoagulant agents (P = .0053). Especially the difference in SBP and DBP within 48 hours between groups was 19 (11%) and 13 mm Hg (14%), respectively. The DBP within the initial 24 hours had a meaningful odds ratio (1.06) on logistic regression analysis. CONCLUSION: A reduction of BP by 15% (SBP < or =140 mm Hg, DBP < or =80 mm Hg) is necessary at acute stage in S-ICH.