The Predicting Factors for Recurrence of Chronic Subdural Hematoma Treated with Burr Hole and Drainage / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma (CSDH) is common in elderly patients. So, with an increasing number of elderly people in the general population, there is a need to investigate risk factors which increase recurrence rate. In this study, factors affecting the postoperative recurrence are investigated based on the reoperative CSDH cases. METHODS: Total of ninety-seven patients was enrolled in this study who had have operation for CSDH. In all patients, one burr hole trephination and drainage was the method of choice for the initial treatment of CSDH. We retrospectively evaluated several factors which affect to recurrence of CSDH. RESULTS: Retrospective analysis was performed in 97 patients. Sixteen patients experienced reoperation within 3 months (16/97, 16.5%) for recurrence of CSDH. And, when hematoma was divided by internal architecture, heterogeneous density group seems to be have close relationship with recurrence more significantly than homogeneous density group (p=0.002). Hypertension, diabetes mellitus, early removal of drainage tube, bilaterality of hematoma also have significant relationship with recurrence. CONCLUSION: Recurrence rate of CSDH treated with one burr hole drainage is related with some various factors. There was statistically significant difference between recurred group and non-recurred group. Not only demographic factors but also internal architecture on preoperative brain computed tomography is a significant predicting factor of recurrence in CSDH patients who underwent a surgery. In this study, heterogeneous type hematoma have significantly related with recurrence of CSDH. We should give attention to these predicting factors for more effective care.

Posterior Interspinous Fusion Device for One-Level Fusion in Degenerative Lumbar Spine Disease : Comparison with Pedicle Screw Fixation - Preliminary Report of at Least One Year Follow Up

OBJECTIVE: Transpedicular screw fixation has some disadvantages such as postoperative back pain through wide muscle dissection, long operative time, and cephalad adjacent segmental degeneration (ASD). The purposes of this study are investigation and comparison of radiological and clinical results between interspinous fusion device (IFD) and pedicle screw. METHODS: From Jan. 2008 to Aug. 2009, 40 patients underwent spinal fusion with IFD combined with posterior lumbar interbody fusion (PLIF). In same study period, 36 patients underwent spinal fusion with pedicle screw fixation as control group. Dynamic lateral radiographs, visual analogue scale (VAS), and Korean version of the Oswestry disability index (K-ODI) scores were evaluated in both groups. RESULTS: The lumbar spine diseases in the IFD group were as followings; spinal stenosis in 26, degenerative spondylolisthesis in 12, and intervertebral disc herniation in 2. The mean follow up period was 14.24 months (range; 12 to 22 months) in the IFD group and 18.3 months (range; 12 to 28 months) in pedicle screw group. The mean VAS scores was preoperatively 7.16+/-2.1 and 8.03+/-2.3 in the IFD and pedicle screw groups, respectively, and improved postoperatively to 1.3+/-2.9 and 1.2+/-3.2 in 1-year follow ups (p<0.05). The K-ODI was decreased significantly in an equal amount in both groups one year postoperatively (p<0.05). The statistics revealed a higher incidence of ASD in pedicle screw group than the IFD group (p=0.029). CONCLUSION: Posterior IFD has several advantages over the pedicle screw fixation in terms of skin incision, muscle dissection and short operative time and less intraoperative estimated blood loss. The IFD with PLIF may be a favorable technique to replace the pedicle screw fixation in selective case.

Prior Use of 3-Hydroxy-3-Methyl-Glutaryl-Coenzyme A Reductase Inhibitor, Simvastatin Fails to Improve Outcome after Experimental Intracerebral Hemorrhage

OBJECTIVE: Contrary to some clinical belief, there were quite a few studies regarding animal models of intracerebral hemorrhage (ICH) in vivo suggesting that prior use of statins may improve outcome after ICH. This study reports the effect of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG CoA) reductase inhibitor, simvastatin given before experimental ICH. METHODS: Fifty-one rats were subjected to collagenase-induced ICH, subdivided in 3 groups according to simvastatin treatment modality, and behavioral tests were done. Hematoma volume, brain water content and hemispheric atrophy were analyzed. Immunohistochemical staining for microglia (OX-42) and endothelial nitric oxide synthase (eNOS) was performed and caspase-3 activity was also measured. RESULTS: Pre-simvastatin therapy decreased inflammatory reaction and perihematomal cell death, but resulted in no significant reduction of brain edema and no eNOS expression in the perihematomal region. Finally, prior use of simvastatin showed less significant improvement of neurological outcome after experimental ICH when compared to post-simvastatin therapy. CONCLUSION: The present study suggests that statins therapy after ICH improves neurological outcome, but prior use of statins before ICH might provide only histological improvement, providing no significant impact on neurological outcome against ICH.

Unilateral Posterior Atlantoaxial Transarticular Screw Fixation in Patients with Atlantoaxial Instability : Comparison with Bilateral Method

OBJECTIVE: Bilateral C1-2 transarticular screw fixation (TAF) with interspinous wiring has been the best treatment for atlantoaxial instability (AAI). However, several factors may disturb satisfactory placement of bilateral screws. This study evaluates the usefulness of unilateral TAF when bilateral TAF is not available. METHODS: Between January 2003 and December 2007, TAF was performed in 54 patients with AAI. Preoperative studies including cervical x-ray, three dimensional computed tomogram, CT angiogram, and magnetic resonance image were checked. The atlanto-dental interval (ADI) was measured in preoperative period, immediate postoperatively, and postoperative 1, 3 and 6 months. RESULTS: Unilateral TAF was performed in 27 patients (50%). The causes of unilateral TAF were anomalous course of vertebral artery in 20 patients (74%), severe degenerative arthritis in 3 (11%), fracture of C1 in 2, hemangioblastoma in one, and screw malposition in one. The mean ADI in unilateral group was measured as 2.63 mm in immediate postoperatively, 2.61 mm in 1 month, 2.64 mm in 3 months and 2.61 mm in 6 months postoperatively. The mean ADI of bilateral group was also measured as following; 2.76 mm in immediate postoperative, 2.71 mm in 1 month, 2.73 mm in 3 months, 2.73 mm in 6 months postoperatively. Comparison of ADI measurement showed no significant difference in both groups, and moreover fusion rate was 100% in bilateral and 96.3% in unilateral group (p=0.317). CONCLUSION: Even though bilateral TAF is best option for AAI in biomechanical perspectives, unilateral screw fixation also can be a useful alternative in otherwise dangerous or infeasible cases through bilateral screw placement.

Incidence and Risk Factors of Infection Caused by Vancomycin-Resistant Enterococcus Colonization in Neurosurgical Intensive Care Unit Patients

OBJECTIVE: This study was aimed to identify the incidence and risk factors of vancomycin-resistant enterococcus (VRE) colonization in neurosurgical practice of field, with particular attention to intensive care unit (ICU). METHODS: This retrospective study was carried out on the Neurosurgical ICU (NICU), during the period from January. 2005 to December. 2007, in 414 consecutive patients who had been admitted to the NICU. Demographics and known risk factors were retrieved and assessed by statistical methods. RESULTS: A total of 52 patients had VRE colonization among 414 patients enrolled, with an overall prevalence rate of 6.1%. E. faecium was the most frequently isolated pathogen, and 92.3% of all VRE were isolated from urine specimen. Active infection was noticed only in 2 patients with bacteremia and meningitis. Relative antibiotic agents were third-generation cephalosporin in 40%, and vancomycin in 23%, and multiple antibiotic usages were also identified in 13% of all cases. Multivariate analyses showed Glasgow coma scale (GCS) score less than 8, placement of Foley catheter longer than 2 weeks, ICU stay over 2 weeks and presence of nearby VRE-positive patients had a significantly independent association with VRE infection. CONCLUSION: When managing the high-risk patients being prone to be infected VRE in the NICU, extreme caution should be paid upon. Because prevention and outbreak control is of ultimate importance, clinicians should be alert the possibility of impending colonization and infection by all means available. The most crucial interventions are careful hand washing, strict glove handling, meticulous and active screening, and complete segregation.

A Case of Hypoglossal Neurilemmoma Resected Via Burr-hole Craniectomy

Hypoglossal neurilemmoma is extremely rare. Intracranial hypoglossal neurilemmoma has been reported to the present most commonly as a space-occupying lesion with symptoms of raised intracranial pressure. A 68-year-old women presented with deviation of the tongue to the left on protrusion. Preoperative radiological images revealed an extra-axial mass in and around the hypoglossal canal. The tumor was totally resected via retrosigmoid suboccipital approach with burrhole craniectomy. Histopathological examination verified a neurilemmoma. She had no neurologic abnormality except hypoglossal palsy which recovered completely in six months. Retrosigmoid suboccipital approach with burrhole craniectomy can be an useful approach in intracranial hypoglossal neurilemmoma without extracranial extension or with minimal extracranial extension into the hypoglossal canal.

Myelopathy Caused by Soft Cervical Disc Herniation: Surgical Results and Prognostic Factors

OBJECTIVE: The purpose of this study was to investigate the surgical results and prognostic factors for patients with soft cervical disc herniation with myelopathy. METHODS: During the last 7 years, 26 patients with cervical discogenic myelopathy were undertaken anterior discectomy and fusion. Clinical and radiographic features were reviewed to evaluate the surgical results and prognostic factors. The clinical outcome was judged using two grading systems (Herkowitz's scale and Nurick's grade). RESULTS: Male were predominant (4:1), and C5-6 was the most frequently involved level. Gait disturbance, variable degree of spasticity, discomfort in chest and abdomen, hand numbness were the most obvious signs. Magnetic resonance(MR) images showed that central disc herniation was revealed in 16 cases, and accompanying cord signal changes in 4. Postoperatively, 23 patients showed favorable results (excellent, good and fair) according to Herkowitz's scale. CONCLUSION: Anterior cervical discectomy and fusion effectively reduced myelopathic symptoms due to soft cervical disc herniation. The authors assured that the shorter duration of clinical attention, the lesser the degree of myelopathy and better outcome in discogenic myelopathy.

Co-expression of Survivin and Bcl-2 in Primary Brain Tumors: Their Potential Effect on Anti-apoptosis

OBJECTIVE: Survivin is an inhibitor of apoptosis protein(IAP), which inhibits apoptosis through a pathway distinct from the Bcl-2 family members. Overexpression of survivin and Bcl-2 have been commonly reported in human neoplasms. The authors investigate whether there is a synergistic effect on the anti-apoptosis rate of primary brain tumors "in situ" based on the co-expression of survivin and Bcl-2. METHODS: One hundred and two brain tumor patients who had been resected were included in this study. Survivin and Bcl-2 were detected by Western blotting analysis, while apoptosis was examined by DNA fragmentation analysis. An anti-apoptotic rate was assessed in these brain tumor samples based on the expression of survivin and Bcl-2 or co-expression of both. RESULTS: Survivin and Bcl-2 were expressed in 57(55.9%) and 53(52.0%) of 102 brain tumor samples studied respectively, and co-expressed in 31(30.4%). The percentage of astrocytic and meningeal tumors expressing survivin was significantly correlated with histological grades; however, Bcl-2 was not correlated (p=0.106). The anti-apoptotic rate in primary brain tumors with survivin, Bcl-2, and both was detected in 49(86.0%) of 57 samples, 42(79.9%) of 53 samples, and 27(87.1%) of 31 samples, respectively. Their difference in the frequency of anti-apoptosis was not significant. CONCLUSION: Survivin or Bcl-2 is involved in the anti-apoptosis. However, it suggests that co-expression of survivin and Bcl-2, together, have no synergistic effect on the anti-apoptotic properties of the primary brain tumors.

Aneurysmal Subarachnoid Hemorrhage Associated with Achondroplasia: Case Report / 대한뇌혈관외과학회지

Patients with achondroplasia manifest various neurologic symptoms including megaencephaly, hydrocephalus, and progressive myelopathy or radiculopathy secondary to spinal stenosis. However, only anecdotal postmortem reports proved ruptured aneurysm or vascular malformation as a source of intracranial hemorrhage. We herein report a case of a 26-year-old woman with achondroplasia who underwent uneventful surgical treatment for the aneurysmal subarachnoid hemorrhage. In this literature, we review the pathophysiologic mechanism and emphasize the necessity of considering the possibility of sudden mental deterioration in achondroplastic patient.

Prognostic Implication of Telomerase Activity in Patients with Brain Tumors

Telomerase adds telomeric repeats to the ends of telomeres to compensate for their progressive loss. A favorable prognosis is associated with low or no telomerase in some tumors. The authors investigated whether telomerase activity is associated with survival of patients with brain tumors. Sixty-two consecutive patients with brain tumors underwent surgery, and their surgical specimens were investigated. The patients were pathologically categorized as group I (aggressive group) and group II (non-aggressive group). Telomerase activity was examined by the telomeric repeat amplification protocol (TRAP) assay. The median time was calculated in association with overall survival and progression-free survival in each group. The significant difference was noted in telomerase activity between high-grade gliomas and lowgrade gliomas (p=0.022). Telomerase activity was significantly associated with the median overall survival and progression-free survival in all tumors of the aggressive group. On the other hand, the median overall survival in the non-aggressive group was not dependent on telomerase activity, while the median progression-free survival was. Our data suggests that telomerase is an important prognostic indicator of survival in patients with brain tumors.

Occludin Expression in Brain Tumors and its Relevance to Peritumoral Edema and Survival / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Peritumoral brain edema (PTBE) is a serious causative factor that contributes the morbidity or mortality of brain tumors. The development of PTBE is influenced by many factors, including such tight junction proteins as occludin. We evaluated the PTBE volume and survival time with respect to the occludin expression in various pathological types of brain tumors. MATERIALS AND METHODS: Fresh-frozen specimens from sixty patients who had brain tumors were obtained during surgery and the tumors were confirmed pathologically. The occludin expression was investigated by Western blot analysis. The PTBE volume was measured by using preoperative magnetic resonance (MR) imaging, and the survival time in each patient was estimated retrospectively. RESULTS: Occludin was detected in 41 (68.3%) of the cases with brain tumors and it was not expressed in the other 19 (31.7%) cases. Although the lowest expression was revealed in high-grade gliomas, its expression was variable according to the pathology of the brain tumors (p>0.05). The difference of PTBE volume between occludin-positive and negative brain tumors was statistically significant (2072.46+/-328.73 mm3 vs. 7452.42+/-1504.19 mm3, respectively, p=0.002). The mean survival time was longer in the occludin-positive tumor group than in the occludin-negative group (38.63+/-1.57 months vs. 26.16+/-3.83 months, respectively; p=0.016). CONCLUSIONS: This study suggests that the occludin expression is highly correlated to the development of PTBE in brain tumors and it might be a prognostic indicator for patient survival.

Surgical Treatment of Lumbar Spinal Stenosis in Geriatric Population: Is It Risky?

OBJECTIVE: Lumbar spinal stenosis is increasingly recognized as a common cause of low back pain in elderly patients. Conservative treatment has been initially applied to elderly patients, however, surgical treatment is sometimes indispensable to relieve severe pain. We retrospectively examine the age-related effects on the surgical risk, and results following general anesthesia and operative procedure in geriatric patients for two different age groups of at least 65years old. METHODS: Consecutive 51patients (> or = 65years), who underwent open surgical procedure for degenerative lumbar spinal stenosis, were selected in the study. Patients were divided into two groups. Group A included all patients who were between 65 and 69years of age at the time of surgery. Group B included all patients who were at least 70years of age at the time of surgery. We reviewed medical history including preoperative American Society of Anesthesiologists(ASA) classification of physical status, anesthetic risk factor, operative time, estimated blood loss, transfusion requirements, hospital stay, operated level, and clinical outcome to look for comparisons between two age groups (65~69 and over 70years). RESULTS: In preoperative evaulation, mean anesthetic risk factor of patients was numerically similar between the groups. The American Society of Anesthesiologists classification of physical status was similar between two groups. There was no difference in operated level, operative time, estimated blood loss, hospital stay, and anesthetic risk factor between the two groups. The clinical successful outcome showed 82.7% for Group A and 81.8% for group B. The overall postoperative complication rates were similar for both group A and B. CONCLUSION: We conclude that advanced age per se, did not increase the associated morbidity and mortality in surgical decompression for spinal stenosis.

Differential Expression of the Tight Junction Protein, Occludin, in Brain Tumors

OBJECTIVE: Cerebral edema develops in the brain tumors by loosening of the endothelial tight junction. Tight junction(TJ) proteins, such as occludin and claudin bind adjacent cells tightly. Authors examine the expression rate of occludin in human brain tumors to evaluate the effect of altered expression of occludin on cerebral edema. METHODS: Seventy surgical specimens stored at -70degrees C were used. It included 14 astrocytic tumors, 27 meningiomas, 12 scwannomas, 7 pituitary adenomas, 6 hemangioblastomas, and 4 craniopharyngiomas. After protein extraction, expression of occludin was investigated by Western blot analysis. The tumors were classified according to World Health Organization(WHO) classification. RESULTS: The expression rates of occludin in brain tumors were: glioma (8/14=57.1%), meningioma (16/27=59.3%), schwannoma (10/12=83.3%), pituitary adenoma (6/7=85.7%), hemangioblastoma (6/6=100%), and craniopharyngioma (3/4=75.0%). The expression rate in glioma and meningioma was lower than other brain tumors. In gliomas, high grade tumor (1/4=25.0%) exhibited lower expression rate of occludin than low grade one (7/10=70.0%). CONCLUSION: These results suggest that the expression of occludin is different among the various kinds of brain tumors. In gliomas, its expression is correlated with the histological grade. It may indicate that occludin plays a role in the development of edema in the brain tumors.

Cystic Non-enhancing Vestibular Schwannoma with Unusual Clinical Presentation

We present a case of large cystic vestibular schwannoma in a 60-year-old woman who complained of facial palsy and tinnitus. Magnetic resonance images revealed signals of long T1 and T2, suggesting its cystic architectures. Enhanced images showed marginal enhancement at the peripheral wall and multiple internal septa, but not at the intracanalicular portion. An epidermoid cyst was presumed owing to its insinuating growth and lack of enhancement, but cystic degeneration of vestibular schwannoma was confirmed histopathologically. She had an unremarkable postoperative course. After thorough review of our case together with pertinent literatures, we emphasise the importance of differential diagnosis of cystic lesions in the cerebellopontine angle.

Hemorrhagic Cerebral Metastases from Hepatocellular Carcinoma: Presumptive Role of Minor Head Trauma

We report two cases of cranial metastasis hepatocellular carcinomas in young adults of their early 30s, with intracerebral hemorrhage. Both patients experienced minor head trauma several days before the onset of neurological deterioration. Detailed description of cases and review of the relevant literatures are presented with emphasis on the presumptive role of minor head trauma and pertinent magnetic resonance features.

Intraventricular Vancomycin Instillation for Postcraniotomy Ventriculitis

OBJECTIVE: To evaluate the efficiencies, shortcomings and complications of intraventricular(IVT) vancomycin instillation for controlling the postcraniotomy ventriculitis, the authors retrospectively studied clinical, radiological and microbiological profiles of such patients. METHODS: We reviewed medical records and radiological findings of eleven patients with postcraniotomy ventriculitis managed between 1995 and 1999. External ventricular drainage(EVD) was performed for the purpose of retrieving cerebrospinal fluid(CSF) and instilling vancomycin. RESULTS: The mean duration for maintaining EVD elapsed 17.8 days and IVT instillation elapsed 11.9 days. The causative pathogens were revealed in eight patients ; methicillin-resistant Staphylococcus aureus(MRSA) in five, coagulase-negative Staphylococcus epidermidis(CNSE) in three. Vancomycin was instilled to patients with MRSA and CNSE. Empirical vancomycin was instilled to three patients with negative bacterial culture. Seizure was seen in one patient. Except one deceased patient, all showed clinical and laboratory improvement. Therapeutic drug monitoring(TDM) did not show any confidential relationship in three patients' status. CONCLUSION: Intraventricular instillation of vancomycin is an effective and safe method in treatment of the postcraniotomy ventriculitis. Complication is negligible and outcome is favorable in general. However, more refined TDM is required to attain steady CSF antibiotic concentration and prudent antibiotic selection is prerequisite to prevent formidable bacterial drug resistance.

Survivin Expression in Brain Tumors: Relevance of Apoptosis and Histological Malignancy

OBJECTIVE: Survivin is one of the inhibitor of apoptosis protein family proteins, which inhibits apoptosis through pathway different from that involving the Bcl-2 family. Overexpression of survivin has been reported in the most common human cancers. The purpose of this study is to investigate survivin expression and its relevance to histological malignancy and apoptosis of brain tumors. METHODS: Seventy-eight consecutive patients with brain tumor, who underwent operation, were included in this study. Pathological types of brain tumor were classified by World Health Organizaton classification. Survivin expression was detected by Western blot analysis and apoptosis was examined by DNA fragmentation. RESULTS: Survivin was expressed in 32(41.0%) of 78 patients with brain tumor and apoptosis was detected in 14(21.9%) patients. Histological malignancy of brain tumors was not correlated with survivin expression or apoptosis(p>0.05). However, survivin-positive tumors were strongly associated with anti-apoptosis(p=0.000) and apoptosis was significantly relevant to survivin-negative tumors(p=0.006). CONCLUSION: These results suggest that survivin expression is strongly related to the apoptosis of brain tumors, but not associated with biological malignancy. Therefore, survivin may be a potential target for brain tumor therapy based on apoptosis.

3-Dimensional Computed Tomography Angiography in Early Operation for Poor Grade Aneurysms

OBJECTIVE: The authors studied the feasibility of 3-Dimensional computed tomographic angiography(3-D CTA) in early surgery for poor grade patients with aneurysmal subarachnoid hemorrhage(SAH), therefore intended to verify the eligibility of this diagnostic tool in these special clinical settings. METHODS: During the period between July 1997 and December 2000, we studied 31 patients diagnosed as aneurysmal SAH that were classified as the Hunt-Hess grade IV or V and Fisher group III or IV. As the conventional angiography could not be conducted because of the patients' poor clinical conditions, we carried out early surgery on the same day of SAH solely based on the 3-D CTA. We compared the 3-D CTA features with intraoperative findings. RESULTS: Total of 33 aneurysms were found in preoperative 3-D CTA and, of them, all 31 ruptured aneurysms and additional another two unruptured ones were also. Undetected three aneurysms were found in the operative field(2 cases) and postoperative digital subtraction angiography(1 case). The sensitivity of 3-D CTA was 94.7% and specificity was 100%. CONCLUSION: According to our results, 3-D CTA might be sufficient for early surgery of intracranial aneurysms in poor grade SAH patients in urgent conditions.

A Common Peroneal Nerve Palsy Following Anterior Cervical Discectomy: Case Report

We describe an immediately developed common peroneal nerve palsy in a 53-year-old slender man who underwent anterior cervical discectomy. Cause of the palsy is uncertain, however, it is presumed to be stretching injury with regard to the patient positioning rather than to be direct compression in operative procedure. He suffered incomplete common peroneal nerve injury for about 8 months. He undertook two times of electromyographic examination suggesting demyelinating injury and received conservative treatment, finally made a favorable although not complete recovery. In this report, we suggest the possible risk factors, preventive measures, therapeutic options and relevant outcome of this unwanted result.

Telomerase Activity and Correlation with Histological Malignancy and Prognosis in Brain Tumors

OBJECTIVE: Telomerase, a ribonucleoprotein adds telomeric sequences repeatedly to the ends of telomeres to compensate for the progressive loss. A favorable prognosis might be associated with low or no telomerase activity in some tumors. We present the correlation of the telomerase activity and the prognosis of patients with brain neoplasms. METHODS: Between March 1998 and December 1999, 62 patients with brain tumors underwent surgery and their surgical specimens were studied. Telomerase activity was investigated by telomeric repeats amplification protocol assay and the survival time was analyzed, retrospectively. The significance and the correlation of data were also assessed statistically. RESULTS: There was no significant difference in the expression of telomerase activity among histological types. However, a significant difference was noted in the expression of telomerase activity between high-grade gliomas and low-grade gliomas(p=0.022). The overall mean survival time of telomerase-positive and telomerase-negative groups in 11 dead patients were 11.4+/-6.6 months and 15.0+/-8.4 months respectively, and its difference was statistically significant(p=0.038). CONCLUSION: Our data suggests that telomerase may play a role in biological malignancy of the gliomas and also can be used as a prognostic indicator for the survival time of brain tumors.