Spontaneous Pneumocephalus Associated with Pneumosinus Dilatans

The majority of cases of pneumocephalus are secondary to trauma or medical intervention. Spontaneous, non-traumatic pneumocephalus is an uncommon condition. Most cases of spontaneous pneumocephalus require surgery. However, if there is no evidence of infection or cerebrospinal fluid leak, bed rest and follow-up imaging is an alternative treatment. Herein, we report a 31-year-old man with spontaneous pneumocephalus associated with pneumosinus dilatans.

Causes of Neurologic Deterioration before Management in the Patients with a Ruptured Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: Although there are many reports describing the risk of rebleeding in hospitalized patients with subarachnoid hemorrhage (SAH), it is common for these patients to deteriorate during transportation or while waiting for surgery. The aim of this study was to estimate the possible causes of neurological deterioration in patients with a ruptured aneurysm prior to hospitalization and management and the effect on patient prognosis. METHODS : Two hundred and thirty patients with aneurysmal SAH that arrived to the hospital within 24 hours after the initial bleeding were recruited. The course of neurological deterioration, age, gender, Hunt and Hess grade, Fisher grade, the arterial blood pressure, the clinical findings when neurological deterioration occurred, aneurysm location and size, treatment and the outcome were analyzed. RESULTS: Among the 230 patients, 32 (13.9%) patients had neurological aggravation prior to management. Fifteen (46.8%) patients had definite rebleeding, 5 (15.6%) acute hydrocephalus and 2 (6.3%) intracerebral hematomas. Two (6.3%) patients had a cardiac arrest, and another 8 (25%) patients likely had rebleeding. Such deterioration occurred in 15 (46.8%) patients within 3 hours after the initial event and in 21 (84%) patients within 6 hours. The patients experiencing neurological deterioration had a more severe Hunt and Hess grade, higher rates of intracerebral hematoma and intraventricular hematoma, reduced operability, and a poorer prognosis. CONCLUSION: The findings showed that neurological deterioration occurred much earlier than expected. Thus, more rapid and careful preoperative management and earlier neurosurgical intervention might prevent neurological deterioration and improve patient outcome.

Lymphocytic Hypophysitis in a Patient with Testicular Feminization Syndrome

Lymphocytic hypophysitis is a rare inflammatory disease of the pituitary gland that is one of the cause of hypopituitarism. The majority of cases occur in women during the peripartum period, and it is rare in men. Testicular feminization syndrome is a genetic disorder presenting a 46XY karyotype, but a normal female phenotype. We report a case of lymphocytic hypophysitis in a 23-year-old woman with testicular feminization syndrome.

Segmental Deformity Correction after Balloon Kyphoplasty in the Osteoporotic Vertebral Compression Fracture

OBJECTIVE: Balloon kyphoplasty can effectively relieve the symptomatic pain and correct the segmental deformity of osteoporotic vertebral compression fractures. While many articles have reported on the effectiveness of the procedure, there has not been any research on the factors affecting the deformity correction. Here, we evaluated both the relationship between postoperative pain relief and restoration of the vertebral height, and segmental kyphosis, as well as the various factors affecting segmental deformity correction after balloon kyphoplasty. METHODS: Between January 2004 and December 2006, 137 patients (158 vertebral levels) underwent balloon kyphoplasty. We analyzed various factors such as the age and sex of the patient, preoperative compression ratio, kyphotic angle of compressed segment, injected PMMA volume, configuration of compression, preoperative bone mineral density (BMD) score, time interval between onset of symptom and the procedure, visual analogue scale (VAS) score for pain rating and surgery-related complications. RESULTS: The mean postoperative VAS score improvement was 4.93+/-0.17. The mean postoperative height restoration rate was 17.8+/-1.57% and the kyphotic angle reduction was 1.94+/-0.38 degrees. However, there were no significant statistical correlations among VAS score improvement, height restoration rate, and kyphotic angle reduction. Among the various factors, the configuration of the compressed vertebral body (p=0.002) was related to the height restoration rate and the direction of the compression (p=0.006) was related with the kyphotic angle reduction. The preoperative compression ratio (p=0.023, p=0.006) and injected PMMA volume (p<0.001, p=0.035) affected both the height restoration and kyphotic angle reduction. Only the preoperative compression ratio was found to be as an independent affecting factor (95% CI : 1.064-5.068). CONCLUSION: The two major benefits of balloon kyphoplasty are immediate pain relief and local deformity correction, but segmental deformity correction achieved by balloon kyphoplasty does not result in additional pain relief. Among the factors that were shown to affect the segmental deformity correction, configuration of the compressed vertebral body, direction of the most compressed area, and preoperative compression ratio were not modifiable. However, careful preoperative consideration about the modifiable factor, the PMMA volume to inject, may contribute to the dynamic correction of the segmental deformity.

Predictable Risk Factors for Adjacent Segment Degeneration After Lumbar Fusion

OBJECTIVE: The aim of this study is to investigate predictable risk factors for radiologic degeneration of adjacent segment after lumbar fusion and preoperative radiologic features of patients who underwent additional surgery with adjacent segment degeneration. METHODS: Between January 1995 and December 2002, 201 patients who underwent lumbar fusion for degenerative conditions of lumbar spine were evaluated. We studied radiologic features, the method of operation, the length of fusion, age, sex, osteoporosis, and body mass index. Special attention was focused on, preoperative radiologic features of patients who required additional surgery were studied to detect risk factors for clinical deterioration. RESULTS: Follow-up period ranged from 3 to 11 years. In our study, 61 (30%) patients developed adjacent segment degeneration, and 15 (7%) patients required additional surgery for neurologic deterioration. Age, the postoperative delay, facet volume, motion range, laminar inclination, facet tropism, and preexisting disc degeneration of adjacent segment considered as possible risk factors. Among these, laminar inclination and preexisting disc degeneration of adjacent segment were significantly correlated with clinical deterioration. CONCLUSION: The radiologic degeneration of adjacent segment after lumbar fusion can be predicted in terms of each preoperative radiologic factor, age and the postoperative delay. Laminar inclination and preexisting disc degeneration of adjacent segment have shown as strong risk factors for neurologic deterioration. Thus, careful consideration is warranted when these risk factors are present.

Cerebellar Anaplastic Oligodendroglioma Presenting with Hemorrhage

The authors describe an anaplastic oligodendroglioma of the cerebellum which is distinctly uncommon. The patient presented with sudden onset of decreased consciousness associated with hemorrhage in the cerebellum, which appeared to origin from a vascular malformation or a tumor on a initial computed tomography (CT) scan. Subsequent magnetic resonance (MR) imaging suggested a high grade glioma with abundant vascularity in the right cerebellum. The histological examination revealed the findings compatible with those of an anaplastic oligodendroglioma. A complicated clinical course had led him to a poor outcome.

Analysis of the Effect of Initial External Ventricular Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage on the Late Onset of Hydrocephalus / 대한뇌혈관외과학회지

OBJECTIVE: The incidence and pathophysiologic mechanisms of chronic hydrocephalus requiring shunting after aneurysmal subarachnoid hemorrhage(SAH) is not precisely known. Authors investigated whether the initial external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage can effect on the late onset of shunt-dependent hydrocephalus. METHODS: In this prospective nonrandomized study, 311 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied between Jan 2004 and Dec 2006. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after the subarachnoid hemorrhage. 128 patients underwent perioperative extracranial ventricular drainage to allow brain relaxation and to drain intraventricular hematoma. The occurrence of asymptomatic and shunt-dependent hydrocephalus was analyzed in both treatment groups. Patients clinical grade was evaluated with WFNS (World Federation of Neurosurgical Societies) Grades, and Fisher Grades was used for evaluating radiological condition of the patient. RESULTS: Among 128 patients, who underwent perioperative EVD, total 76 patients diagnosed as hydrocephalus later, and 23 patients needed shunt operation. The occurrence of hydrocephalus was significantly higher in patients underwent perioperative EVD (p<0.001), but there were no statistical significance between the perioperative EVD and the onset of shunt-dependent hydrocephalus (p=0.190). Among variable factors, Fisher grade, WFNS grade, amount of IVH on admission, and site of ruptured aneurysm showed statistical significance in related with the shunt-dependent hydrocephalus. Results of logistic regression analyses, perioperative EVD carried low risk of hydrocephalus (OR 0.408, 95% CI 0.224-0.745), but no statistically significant risk was shown related with the onset of shunt-dependent hydrocephalus. CONCLUSION: As a result of this study, perioperative EVD in patients with aneurysmal SAH identified as a risk factor of the hydrocephalus. But there were no statistical significance as a risk factor of the shuntdependent hydrocephalus. Poor clinical and radiological status showed higher valuable risk of the shunt-dependent hydrocephalus rather than perioperative EVD. No hesitation seems to be needed for the perioperative EVD, especially in patients with poor neurological and radiological condition.

Relationship Between Leukocytosis and Vasospasms Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: Percutaneous approach to the middle thoracic vertebra through the transpedicular route for the patients with osteoporotic vertebral compression fractures is difficult due to the small size of the pedicle and parasagittally oriented vertebral body anatomy. The percutaneous vertebral body access (PVBA) technique utilizing the posterolateral extrapedicular approach avoids the pedicle and provides direct access to the vertebral body. The objective of this study is to evaluate the efficacy of the vertebroplasty utilizing PVBA technique for osteoporotic vertebral compression fractures in the middle thoracic vertebrae. METHODS: A retrospective review was done on 20 patients who underwent vertebroplasty utilizing PVBA technique performed for painful osteoporotic compression fracture in the middle thoracic vertebrae at 22 levels from May 2003 to June 2006. The average amount of the injected cement was 1.5-2.5ml. The postprocedural outcome was assessed using a visual analogue scale (VAS). RESULTS: The treated vertebrae were T5 (1 level), T6 (5 levels), T7 (7 levels), and T8 (9 levels). The compression rate and kyphotic angle were improved after procedure from 18%+/-13.4 to 16%+/-13.8 (p>0.05) and from 6.9degrees+/-6.7 to 6.6degrees+/-6.2 (p>0.05), respectively. Preprocedural VAS was 8.2+/-0.70 and was decreased to 2.1+/-1.02 (p<0.01) after treatment. Postprocedural cement leakage was noted in 3 levels (13.7%). There were no cases of leakage to epidural space or neural foramen, segmental artery injury, and pneumothorax. CONCLUSION: These results suggest that the complication rates are low and good results can be achieved with vertebroplasty utilizing PVBA technique for the osteoporotic vertebral compression fractures especially in the middle thoracic vertebrae.

Treatment Outcomes in Patients with a Vertebral Artery Dissecting Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: The vertebral artery dissecting aneurysms have been increaslingly reported with recent advent of diagnostic tools. The authors analyzed the various therapeutic modalities according to the patient's clinical presentation. METHODS: The clinical characteristics of vertebral artery dissecting aneurysm including clinical presentation, therapeutic modalities and outcomes were reviewed in eleven patients between March 2001 and August 2005. RESULTS: Six patients were presented with subarachnoid hemorrhage and five patients with ischemia. Four patients were treated with endovascular coils or stent and one patient was treated with craniotomy and aneurysmal wrapping. The other six patients were treated conservatively. Clinical outcomes were relatively good (Glawsgow outcome scale > or = 4) except one patient (Glawsgow oucome scale = 3). CONCLUSIONS: The treatment of a vertebral artery dissecting aneurysm must be choosed by characteristics of an aneurysm and the patient's clinical presentations. The patients with hemorrhage must be candidates for aggressive attempts to prevent rebleeding. On the other hand, the patients with ischemia may be good candidates for conservative treatment, and follow-up angiography is mandatory within three weeks after the symptom onset.

Risk Factors for Ischemic Lesions on Computed Tomography in Aneurysmal Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: The aim of this study was to investigate predictive risk factors for permanent ischemic lesions visible on follow-up computerized tomography scans obtained after subarachnoid hemorrhage (SAH). METHODS: A hundred and two patients who were treated with surgery for aneurysmal SAH from November 2002 to February 2005 were retrospectively analyzed. The predictive risk factors for permanent ischemic lesions used in this study were as follows ; age, sex, obesity, preoperative clinical condition, amount of SAH (Fisher grade), location of aneurysm, intracerebral hemorrhage (ICH), intraventricular hemorrhage, symptomatic vasospasm, duration of temporary artery occlusion, transfusion, hypertension, diabetes mellitus, cigarette smoking and time of SAH. RESULTS: Permanent ischemic lesions developed in 55 (60%) patients. The presence of lesions correlated highly with preoperative clinical condition (p=0.032), amount of subarachnoid blood (p=0.007), middle cerebral artery aneurysms (p=0.041), ICH (p=0.039), symptomatic vasospasm (p=0.027), duration of temporary artery occlusion during surgery (p=0.004), diabetes mellitus (p=0.043), excessive alcohol drinking (p=0.040), cigarette smoking (p=0.037) and nocturnal occurrence of SAH (that is, between 12:01 a.m. and 8:00 a.m., p=0.044). Hypertension, obesity and other factors were not associated with the lesions. CONCLUSION: The presence of ischemic lesions can be predicted by preoperative clinical condition, amount of SAH, the location of aneurysm, ICH, symptomatic vasospasm, duration of temporary artery occlusion, diabetes mellitus, excessive alcohol drinking, cigarette smoking and time of aneurysm rupture.

Effect on Varying the Impact Velocity in the Controlled Cortical Impact Injury Model: Injury Severity and Impact Velocity

OBJECTIVE: A study of the histopathologic and neurobehavioral correlates of cortical impact injury produced by increasing impact velocity using the controlled cortical impact(CCI) injury model is studied. METHODS: Twenty-four Sprague-Dawley rats (200~250g) were given CCI injury using a pneumatically driven piston. Effect of impact velocity on a 3mm deformation was assessed at 2.5m/sec (n=6), 3.0m/sec (n=6), 3.5m/sec (n=6), and no injury (n=6). After postoperative 24hours the rats were evaluated using several neurobehavioral tests including the rotarod test, beam-balance performance, and postural reflex test. Contusion volume and histopathologic findings were evaluated for each of the impact velocities. RESULTS: On the rotarod test, all the injured rats exhibited a significant difference compared to the sham-operated rats and increased velocity correlated with increased deficit (P<0.001). Contusion volume increased with increasing impact velocity. For the 2.5, 3.0, and 3.5m/sec groups, injured volumes were 18.8+/-2.3mm3, 26.8+/-3.1mm3, and 32.5+/-3.5mm3, respectively. In addition, neuronal loss in the hippocampal sub-region increased with increasing impact velocity. In the TUNEL staining, all the injured groups exhibited definitely positive cells at pericontusional area. However, there were no significant differences in the number of positive cells among the injured groups. CONCLUSION: Cortical impact velocity is a critical parameter in producing cortical contusion. Severity of cortical injury is proportional to increasing impact velocity of cortical injury.

p53 Protein Expression Area as a Molecular Penumbra of Focal Cerebral Infarction in Rats

OBJECTIVE: The authors investigate the spatial characteristics of apoptotic genes expressed around the focal cerebral infarction, and attempted to explain the penumbra with them. METHODS: A delayed focal cerebral infarction was created in twelve adult Sprague-Dawley rats. We performed the immunohistochemical staining for the apoptosis, bcl-2 and p53 proteins and measured the local cerebral blood flow (CBF) at the infarction core area and peri-infarct area pre- and intra-operatively. The peri-infarct area was divided into six sectors by distance from the infarction border. RESULTS: The size (mm2) of apoptosis, bcl-2, and p53 areas were 3.1+/-1.2, 4.7+/-2.1, and 6.8+/-2.4, respectively. Apoptosis, bcl-2 or p53 positive cells were concentrated at the peri-infarct area adjacent to the infarction core. Their numbers reduced peripherally, which was inversely proportional to the local CBF. The p53 area seems to overlap with and larger than the ischemic penumbra. CONCLUSION: The p53 positive area provides a substitutive method defining the penumbra under the molecular base of knowledge.

Neuroprotective Effect of Ginseng Total Saponins in Experimental Traumatic Brain Injury

In the present study, we investigated whether ginseng total saponins (GTSs) protect hippocampal neurons after experimental traumatic brain injury (TBI) in rats. A moderate-grade TBI was made with the aid of a controlled cortical impact (CCI) device set at a velocity of 3.0 m/sec, a deformation of 3.0 mm, and a compression time of 0.2 sec at the right parietal area for adult male Sprague-Dawley rats. Shamoperated rats that underwent craniectomy without impact served as controls. GTSs (100 and 200 mg/kg) or saline was injected intraperitoneally into the rats immediately post-injury. Twenty-four hours after the injury, the rats underwent neurological evaluation. Contusion volume and the number of hippocampal neurons were calculated with apoptosis evaluated by TUNEL staining. 24 hr post-injury, salineinjected rats showed a significant loss of neuronal cells in the CA2 region of the right hippocampus (53.4%, p<0.05) and CA3 (34.6%, p<0.05) compared with contralateral hippocampal region, a significant increase in contusion volume (34 +/-8microliter), and significant increase in neurologic deficits compared with the GTSs groups. Treating rats with GTSs seemed to protect the CCI-induced neuronal loss in the hippocampus, decrease cortical contusion volume, and improve neurological deficits.

Development of a Rat Model of Graded Contusive Spinal Cord Injury Using a Pneumatic Impact Device

An animal model of spinal cord trauma is essential for understanding the injury mechanisms, cord regeneration, and to aid the development of new therapeutic modalities. This study focused on the development of a graded experimental contusion model for spinal cord injury (SCI) using a pneumatic impact device made in Korea. A contusive injury was made to the dorsal aspect of the cord. Three trauma groups were defined according to the impact velocity (IV). A control group (n=6), received laminectomy only. Group 1 (n=10), 2 (n=10), and 3 (n=10) had IVs of 1.5 m/sec, 2.0 m/sec, and 3.5 m/sec respectively. Functional assessments were made up to the 14th day after injury. The cord was removed at the 14th post-injury day and prepared for histopathologic examination. Significant behavioral and histopathological abnormalities were found in control and each trauma group. All trauma groups showed severe functional impairment immediately after injury but following different rates of functional recovery (Fig. 5). As the impact velocity and impulse increased, the depth of contusive lesion revealed to be profound the results show that the rat model reproduces spinal cord lesions consistently, has a distinctive value in assessing the effects of impact energy.

Coexistence of Cerebral Amyloid Angiopathy and an Arteriovenous Malformation in a Young Adult

The prevalence and cerebral hemorrhage of cerebral amyloid angiopathy(CAA) are age-related. It is rare in young adults. The authors report on CAA coexisting with an arteriovenous malformation(AVM) in a 30-year-old male, who present with the sudden onset of headache and vomiting. Magnetic resonance imaging revealed a cerebral hemorrhage with an AVM. The AVM was completely removed through the hematoma and the histological section obtained from the periphery of the hematoma showed the typical findings of CAA. The epsilon4 allele of apoprotein E(apoE) was identified in genotype determination.

Esthesioneuroblastoma Treated by Craniofacial Resection: Case Report

The authors report a case of esthesioneuroblastoma with intracranial extension treated by craniofacial resection. The tumor was resected by transbasal approach and repaired the dural defect using pericranial flap. The defect of floor of anterior cranial fossa was repaired with splitted calvarium and pericranial flap. Otorhinolaryngologist removed the residual tumor mass located at paranasal sinuses using lateral rhinotomy. Using cranifacial resection, the authors could remove the mass completely. The patient was referred to hemato-oncologist for chemotherapy.

Differences in Biomechanical Factors for Fusion Transition Syndrome of Lumbar Spine between Pedicle Screw Fixation and Posterior Lumbar Interbody Fusion Groups

OBJECTIVE: We present the investigation of the biomechanical factors of the degeneration process after lumbar fusion. METHODS: Thirty-five patients underwent L4-5 fusion operation. We measured radius(cm), top angle(TA)(degree), and flexion-extension angle(FEA) at L3-4 joint in pedicle screw fixation(PSF)(n=27) and posterior lumbar interbody fusion(PLIF)(n=8)groups. They were divided into early(3 to 6 months) and late(over 1 year) groups according to post-operative period. RESULTS: The pre-operative radius, TA and FEA in PSF were 6.2+/-0.4, 9.0+/-0.8, and 8.2+/-0.8. The early and late post-operative radius, TA and FEA in PSF were 6.4+/-0.5, 6.9+/-0.8, 6.8+/-0.8, and 5.5+/-0.7, 12.1+/-0.9, 11.0+/-0.9, respectively. The pre-operative radius, TA and FEA in PLIF were 5.4+/-0.5, 8.9+/-0.8, and 9.5+/-1.2. The early and late post-operative Radius, TA and FEA in PLIF were 5.0+/-0.4, 5.8+/-0.9, 5.2+/-0.7, and 5.0+/-0.5, 8.4+/-0.9, 7.6+/-0.8, respectively. In late PSF, TA and FEA were significantly increased(p<0.05)but radius was significantly decreased (p<0.05) compared with pre-operative ones. But in late PLIF, all the factors were decreased compared with pre-operative ones. CONCLUSION: Biomechanical factors of chronic complications were different between PSF and PLIF. Increased FEA seems to be an important factor for post-operative degeneration in PSF, whereas increased stiffness and stress seems more important in PLIF.

The Level of Cerebral Blood Flow, p53 and p21 Expression at the Penumbric Area of Cerebral Infarction in Rats

OBJECTIVE: We report an investigation of cerebral blood flow(CBF) and the expression of p53 and p21 at peri-infarct area of focal cerebral infarction in rats. METHODS: Adult Sprague-Dawley male rats were used for the experiment. In Group 1(n=7), the right middle cerebral artery(MCA) was coagulated. In Group 2(n=11), the right MCA and common carotid artery(CCA) were coagulated, and the left CCA was occluded for 30 minutes. Cerebral blood flow was measured at two areas, 2mm and 8mm distal to the MCA coagulation site. The rats were killed after 24 hours. After immunohistochemical staining, the width of the p53 or p21 positive area was measured. The p53 and p21 positive glial cells were counted at the peri-infarct area adjacent to the infarction core in Group 2. RESULTS: A focal infarction was found invariably in Group 2. CBF's at 2 mm and 8 mm areas were 8.3+/-2.1, 36.4+/-4.2 in Group 1 and 0.0+/-0.0, 6.7+/-1.5ml/100g/min in Group 2, respectively. All of the measured CBF's except that of the 8mm site in Group 1 were significantly lower than preoperative level(p<0.001), which were between 20.8+/-4.5% and 16.3+/-3.3% of preoperative CBF. The ratio of p21 and p53 positive cells was 1.0+/-0.1. CONCLUSION: We could note that the expression of p53 and p21 was the highest at an adjacent peri-infarct area. The degree of CBF reduction is more responsible for infarction than CBF itself.

Spontaneous Resolution of Dissecting Aneurysm of the Vertebral Artery / 대한뇌혈관외과학회지

Although dissecting aneurysm of vertebral artery were once thought to be extremely rare, they are now recognized with increasing frequency by dint of aggressive work-up using sophisticated imaging techniques. Vertebral dissection most commonly result from cervical hyperextension and lateral cervical rotation. Our two cases followed suit respectively and presented with ischemic symptoms. The vertebral angiogram demonstrated a pseudoaneurysm at the site of dissection in both cases. Presence or absence of SAH, size of dissection and incorporation of the PICA into dissection greatly have influence upon the outcome after treatment. The authors report two cases of dissecting aneurysm of vertebral artery, in which complete resolution of the pseudoaneurysm was spontaneously achieved following conservative management.

Pleomorphic Xanthoastrocytoma: Report of 3 Cases

Pleomorphic xanthoastrocytoma(PXA) is a rare neoplasm with favorable prognosis despite of its aggressive histological features. The authors report three cases of pleomorphic xanthoastrocytomas. The masses were in the temporal or parietal lobe of children or adolscence and presented as complex partial seizures. Total removal of mass was performed in all three cases and the seizure was abscent postoperatively. It is important to differentiate of pleomorphic xanthoastrocytoma from other malignant brain tumors and identify this type of glioma as a distinct entity.