Clinical Analysis of Chronic Subdural Hematomas: Review of 69 Operated Cases

The authors analysed retrospectively, 69 cases of chronic subdural hematoma admitted to the Department of Neurological Surgery, from January 1992 to February 1995. All hematomas were operated on by one burr hole trephination and continuous closed-system cather drainage system. The results were as follows: 1) Male was more frequently involved than female with ratio of 5.3:1 and the incidence was prredominent in the patients whose ages were over 50. 2) History of head trauma was found in 52 cases(75.4%), among which habitual alcoholism was found in 6 cases(8.7%). 3) The major symptoms and signs at admission were headache(55.1%), hemiparesis(44.9%), and mental changes(30.4%). 4) On the brain CT scan, hematoma showed low, iso, mixed, and high in density, and the shapes of hematoma were crescenteric, biconvex, planoconvex, and concave in order of frequency. 5) We have found a significant relationship between the neurological grade at admission and the prognosis, and noted full recovery in 45 cases(65.2%) and no d eath as a result of 1-burr hole trephination.

A Case of Intradural Spinal Lipoma

Intradural spinal lipomas are rare, primary genign tumor of the spinal canal. A case of intradural spinal lipoma with intramedullary extension is presented. Clinical feature was slowly progressing paraparesis. A subtotal excision was performed, and pathological studies confirmed the diagnosis.

A Case of Extradural Spinal Tuberculoma

Extraosseous extradural tuberculosis of the spine is rare entity. A 21-year-old man with low back pain, left-sided sciatica & motor weakness was admitted. Simple X-ray were normal. At operation, extradural, extraosseous granuation tissue were removed, which proved upon histologic examination to be tuberculous granulomas. The authors report a rare case of extraosseous tuberculoma in the posterior extradural space of whole lumbar region with review of literatures.

Acute Expanding Venous Extradural Hematoma: Pitfall of Early Brain CT Scan

A case of a acute expanding venous extradural hematoma was treated. Initial CT scan was favorable, but delayed bleeding & its expansion was developed. The bleeding points were left transverse sinus and superior petrosal sinus. Serial neurologic examination & serial CT scan in patients with head injuries are recommended.

Delayed Post-traumatic Extradural Hematomas: Delayed Bleeding & Delayed Expansion

Delayed traumatic extradural hematoma is a new pathological dimension. Thirteen patients with delayed traumatic extradural hematoma were seen 70 treated cases of extradural hematomas for a frequency of 18.6%. The hematomas were insignificant or not present on the initial CT scanning. All patients had a skull fracture at the site of delayed extradural hematoma formation. Ten hematomas were surgically evacuated and three were reabsorbed spontaneously. Repeated CT scanning was performed if the patient has any new focal neurological deficits or clinical status was not improved despite of minimal extradural hematoma after head injury. Delayed extradural hematoma were classified into two groups based on the presence of hematoma in initial CT scan : delayed bleeding type(newly formed xtradural hematoma/4 cases : 5.7%) & delayed expansion type(enlargement of initial thin hematoma/9 cases : 12.6%).

Air Bubble in Acute Extradural Hematomas

During 3-year period, fourteen patients with air bubble in acute extradural hematomas were seen among 84 consecutively cases of extradural hematomas for a frequency of 16.7%. Extradural air were classified into 3 groups based on the location of air bubble ;frontal type(4 cases), temporal type(8 cases) & occipital type(2 cases). A skull fracture was seen in all cases & the air entrance was considered to frontobasal or laterobasal skull fractere. In patients with 4 cases of CSF leak & multiple air bubbles, delayed expansion of extradural hematoma was seen. The clinical significance of air bubble in acute extradural hematoma is disscussed.

Intraoperative Development of Contralateral Subdural Hematoma during Evacuation of Acute Subdural Hematoma: Case Report

A case of traumatic acute bilateral subdural hematoma with different times is expierenced. The contralateral shbural hematoma was developed during the evacuation of an acute subdural hematoma. The reduction of intracranial pressure after removal of subdural hematoma was postulated to be contributing factor to formation of the contralateral subdural hematoma.

Albendazole Therapy for Multiple Neurocysticercosis

Albendazole is a new drug for the treatment of cerebral cysticercosis. We have recently experience a case that had shown poor therapeutic response to praziquantel. The patient have multiple parenchymal cysts. She was treated with 15mg/kg/day of albendazole for 1 month to confirm healing of the intracranial lesion by the follow up brain CT scan and CSF-ELISA associated with marked clinical improvement.

The Comparision of Histologic & Electrophysiologic Changing Area after Monopolar Coagulation in the Rabbit Brain

Lesions with controlled monopolar coagulation were generated in the cerebral cortex of 20 healthy rabbits. With 28 watts monopolar coagulation, average diameter of histologically changed area around lesion was aout 7.5mm with using Evans blue dye technique. At same time, EEGs in three points, which were 5mm, 10mm & 15mm distant from the coagulated lesion site, were cheched before and just after coagulation. In results, the frequency of EEG was slightly decreased after coagulation, but there were no relation with distance from lesion. But the amplitudes of EEG were decreased as 51.2 micro v(61.2%), 42.9 micro v(3.9) and 34.0 micro v(25.3%) after coagulation, which depended on the distance from site of coagulation. That means electrophysiologically changed area after coaguation was far beyond the histologically changed area.

The Comparision of Histologic & Electrophysiologic Changing Area after Monopolar Coagulation in the Rabbit Brain

Lesions with controlled monopolar coagulation were generated in the cerebral cortex of 20 healthy rabbits. With 28 watts monopolar coagulation, average diameter of histologically changed area around lesion was aout 7.5mm with using Evans blue dye technique. At same time, EEGs in three points, which were 5mm, 10mm & 15mm distant from the coagulated lesion site, were cheched before and just after coagulation. In results, the frequency of EEG was slightly decreased after coagulation, but there were no relation with distance from lesion. But the amplitudes of EEG were decreased as 51.2 micro v(61.2%), 42.9 micro v(3.9) and 34.0 micro v(25.3%) after coagulation, which depended on the distance from site of coagulation. That means electrophysiologically changed area after coaguation was far beyond the histologically changed area.

A Case of Cryptococcal Ventriculitis / 영남의대학술지

Cryptococcosis of central nervous system in uncommon, but fatal if untreated. We experienced a case of cryptococcal ventriculitis with hydrocephalus. The symptom was an increased intracranial pressure without meningeal irritation sign. It was confirmed by pathology and cytology taken from fibrous material, which caused an obstruction of shunt catheter in the lateral ventricle. We report a case of cryptococcal ventriculitis in 6 years old male child.

A Case of Multiple Mendingiomas / 영남의대학술지

The incidence of multiple meningiomas found prior to the introduction of CT was 1~2%, the incidence since the introduction of CT was 8.9%. The authors report a case of multiple meningiomas without evidence of von Recklinghausen's disease. The possible presence of more than 1 tumor in a patient with an intracranial meningiomas must always be kept in mind. The pathogenetic factors related to true multiple meningiomas in unknown. We report a patient with multiple meningiomas which was confirmed by operation.

A Case of Cerebral Sparganosis Operated by BRW Stereotaxic System / 영남의대학술지

A patient of cerebral sparganosis is reported: The patient, a 47-year-old female complained of frequent seizures and headache. The disease was involved on right frontal lobe, and the lesion was successfully removed by BRW stereotaxic system. The characteristic features of sparganosis are reviewed.

Stereotactic Management of Spontaneous Infratenorial Hemorrhage: Part I:Stereotactic Evacuation and Gradual Urokinase Irigation for Spontaneous Brain Stem Hemorrhage

In spontaneous brain stem hemorrhage, efforts are being made to treat the hemorrhage by means of active medical treatment of intricate suboccipital craniectomy. But these efforts are still unsatisfactory in decreasing the high mortality and morbidity. Our recent efforts have got good results in the 11 cases of brain stem hemorrhage by removing the hemorrhage through the application of R.R.W. stereotactic system and gradual urokinase irrigation. The residual hemorrhage following the initial aspiration was completely evacuated by gradual urokinase irrigation through stereotactically placed catheter. Also this catheter was used for monitoring of intrahematomal intracranial pressure for an early stoppage of the increased intracranial pressure or early detecting of rebleeding. This kind of stereotactic evacuation and gradual irrigation with urokinase could remove the brain stem hemorrhage accurately and easily in a short time under the local anesthesia. Mean-while the normal brain tissue is subjected to less surgical trauma by this procedure, which can be interpreted as having a wide indication, a definite advantage, with a low mortality of 27.3%.

Experiences of Stereotaxic Endoscopy

Recently we experienced stereotaxic endoscopic biopsy and resection of intracranial tumors using the Brown-Robert-Wells system. Surgical exploration was undertaken under the local anesthesia:1 germinoma in pineal region, 1 arachnoid cyst in basal cistern. The method is described, and the its potential clinical applications is discussed.

A Study of Influencing Factors of Intracranial Pressure and Prognosis with Continuous Intracranial Pressure Monitoring in Severe Inreacranial Lesions

The cranium can be thought of a as shallow, rigid sphere of contrast volume. There are three main components within the intracranial space : brain, cerebrospinal fluid and blood. Intracranial volume and pressure are maintained constantly by Monroe-Kellie doctrine. Also intracranial pressure is influenced by a number of physiologic factors and it will be changed with intracranial lesion. Now we were look for the possible factors that influence the intracranial pressure with continuous intracranial pressure monitoring. At the same time we studied the possibility of the relationship between factors that influence ICP and ADL(Ability of Daily Life) in 43 severe brain lesions(33 cases ; intracerebral hematoma, 10 cases ; head injury). In cases of higher GCS, smaller hematoma, lower amplitude of ICP, lesser frequency of A-wave and lower elastance, the ICP were lowed. Ninety percent of cases that GCS is over 12 was belong to ADL I and II, but only nineteen percent of cases that GCS is under 7 was belong to ADL I and II. No case of internal capsule involved group was belong to ADL I but forty-eight percent of cases whose hematoma volume is under 10ml was belong to ADL I. Fifty percent of cases whose hematoma volume is under 10ml was belong to ADL I and no case that hematoma volume is over 20ml was belong to ADL I. Cases that PCO2 is in the range of 25mmHg-29mmHg were not belong to ADL I. In cases of higher amplitude of ICP, higher frequency of A-wave and higher elastance, the patient's ADL was grave. And in cases of ICP was progressively increased, the prognosis was also grave. Consequently we are able to guess that patient's prognosis will be influenced by initial GCS, internal capsule involvement, hematoma volume, PCO2, amplitude of ICP, frequency of A-Wave, brain elastance and curve of ICP.

Transtentorial BRW Stereotactic Approach for Cerebellar Lesions: Technical Note

We previoulsy reported the successful performances of the BRW stereotactic biopsy and aspiration of supratentorial and brain stem lesions. The BRW system has disadvantage of less accessibility to the cerebellar lesions by suboccipital approach. To overcome this disadvantage, we have tried to treat four patients having a cerebellar lesions, a case of hemangioblastoma, two cerebellar hemorrhages and acoustic neuroma, by transtentorial BRW stereotactic approach. This approach has been used successfully under the local anesthesia with satisfactory postoperative neurological results. We present a detailed technique of this approach.

Comparison of Intracranial Pressure on Different Monitoring Sites

To compare intrahematomal pressure(IH) with epidural pressure(EP), lumbar subarachnoid pressure(LP) and intraventricular pressure(IV), 34 intracerebral hemorrhage patients from Dec. 1986 to Aug. 1987 were selected. We measured IH via stereotacically placed catheter and at the same time, we measured EP with fiberoptic sensor, LP by lumbar puncture and IV via stereotactically placed catheter during communication between hematoma and ventricle. The results obtained were as follows : 1) IH was the highest in most cases and IH, IV, LP and EP in orders by mean values. 2) In distribuion of EP, LP and IV compared with IH, EP had wide range of distribution(17~500%) compared to LP and IV. 3) There was a tendency of increased rate of higher IH than EP according to increased size of hematoma. 4) There was a tendency of increased rate of higher IH than EP in thalamic hemorrhage than putaminal hemorrhage. 5) ICP curves showed abrupt increase or decrease in cases of rebleeding or communication between hematoma and ventricle. 6) In analysis of low IH compared with EP and LP, the causes were due to checking of IH just after aspiration of large amount of hematoma(3 cases) and normal variations(6 cases). 7) In analysis of failed monitoring, EP was 5 cases(19%) and IH was 3 cases(8.8%) so more failed monitoring were found in EP than IH and there was no failed cases in LP and IV. From above results, we concluded that IH was the highest in most cases and EP was less reliable than other pressures.

Impedance on the Lesions and Parenchyma of the Brain: With Brain Stereotaxis

From Nov. 1986 to Sep. 1987, we operated 63 cases of intracerebral hemorrhage and brain tumor with B.R.W. stereotaxic method. Among them, the impedance was checked in 40 cases. Results are as followings. 1) In 89.3% of patients, the impedance of hematoma was 1.5 times higher than the mean cortical impedance, in 57.1% of patients it was 2 times higher, and in 32.1% of patients, it was 3 times higher. 2) In the relationship between impedance and nature of hematoma, the impedance of liquified hematoma was higher than clot. 3) In the relationship between impedance and glasgow coma scale, the impedance of patients who were below 9 in score was higher and who were above 10 in score was lower than the mean cortical impedance. 4) The impedance of the low density area surrounding the lesion was lower than the mean cortical impedance by 73%. 5) In the relationship between impedance of the hematoma lapsed over 12 hours was lower than hematoma before 12 hours. 6) In the impedance of the brain tumor, the impedance of the solid lesion was decreased to 85.7% and cystic lesion was decreased 48.3% of the cortical impedance.

The Application and Effect of the Brown-Roberts-Wells Stereotactic System in the Management of Intracranial Lesions / 영남의대학술지

In the past 10 years, modern technology has made deep seated obscure lesions visible. With development of computer technology and various stereotaxic techniques, many new procedures, refinement of old procedures, and development of new applications are possible. The authors are intended to provide a detailed description of our experience with the Brown-Roberts-Wells (BRW) stereotactic system in the evaluation and management of 90 patients with intracranial lesions, and to provide cases presentation of various inaccessible intracranial lesions.