Multiple Feeding Artery Pedicle Pseudoaneurysms in the Posterior Circulation: Association with Hemorrhage and AVM / 신경중재치료의학

We experienced rare combination of multiple irregular shaped aneurysms along the course of the feeding artery and arteriovenous malformation (AVM) in the posterior circulation. We could not explain which aneurysm was a cause of bleeding because all the aneurysms showed irregular in shape like pseudoaneurysms and location of the aneurysms was very close each other. We report two cases in which multiple irregular shaped aneurysms were related with AVMs and first episode of hemorrhage.

Spontaneous Resolution of Nontraumatic Acute Spinal Subdural Hematoma

Spinal subdural hematoma (SSDH) is an extremely uncommon condition. Causative factors include trauma, anticoagulant drug administration, hemostatic disorders, and vascular disorders such as arteriovenous malformations and lumbar punctures. Of SSDH cases, those that do not have any traumatic event can be considered cases of nontraumatic acute spinal subdural hematoma, which is known to have diverse clinical progress. Treatment typically consists of surgical decompression and cases in which the condition is relieved with conservative treatment are rarely reported. We report two nontraumatic acute spinal subdural hematoma patients who were successfully treated without surgery.

Radiological Analysis of Ponticulus Posticus in Koreans

PURPOSE: Since there has been little reporting on the prevalence or morphologic characteristics of ponticulus posticus in Asians, we retrospectively reviewed cervical 3-dimensional CT scan images and plain radiographs which had been ordered by neurosurgeons or orthopaedic surgeons for evaluation of cervical spine problems to investigate the prevalence and morphologic features of the ponticulus posticus in Koreans. PATIENTS AND METHODS: The presence and types of ponticulus posticus were investigated on 200 consecutive cervical 3-D CT scans. RESULTS: Thirty-one patients, 48 ponticulus posticus, complete or partial, bilateral or unilateral, were identified on the 200 cervical 3-D CT scans; therefore, the prevalence was 15.5% in our patient population. In plain radiographs analysis, the prevalence was 6.95%. CONCLUSION: The ponticulus posticus is a relatively common anomaly in Koreans. Therefore, proper identification of this anomaly on preoperative lateral radiographs should alert surgeons to avoid using the ponticulus posticus as a starting point for a lateral mass screw. Because of its size and shape have wide variation, 3-D CT scanning should be considered before lateral mass screw placement into the posterior arch if its presence is suspected or confirmed on radiographs.

Hydrothorax Due to Migration of Ventriculoperitoneal Shunt Catheter

A cerebrospinal fluid hydrothorax is a very rare complication following ventriculoperitoneal (VP) shunt and usually reported in children. We report a case of 47-year-old woman who developed massive hydrothorax and respiratory distress following intrathoracic migration of distal shunt catheter. After the confirmation of catheter in thoracic cavity using radionuclide shuntogram, the patient was successfully treated with laparoscopic shunt catheter reposition.

Unusual Intracranial Parasagittal Meningioma Extending into the Internal Jugular Vein through the Sinuses

Meningiomas frequently invade cerebral venus sinuses, especially parasagittal meningioma to superior sagittal sinus. However, most invasions do not reach internal jugular vein. We present a case of parasagittal meningioma extending into the internal jugular vein through the sinuses. Radiological investigation revealed that the tumor was invading the sagittal, transverse, sigmoid sinus and junction of the internal jugular vein to subclavian vein, which was filled with tumor. The histopathological examinations revealed that both the cerebral tumor and mass in the internal jugular vein contributed to the transitional meningioma. This is a rare case of a meningioma extending into the internal jugular vein through the sinuses. According to this case, the frontal parasagittal meningioma could invade directly the internal jugular vein. The significance of this association to cerebral venus sinuses and internal jugular vein are discussed.

Relationships between Radiological Change of Fractured Vertebrae and Posterior Ligament Complex Injury in Thoracolumbar Fracture

OBJECTIVE: To investigate the relationships between posterior ligament complex injury and plain radiographic parameters in thoracolumbar spinal fractures. METHODS: Forty patients with thoracolumbar fractures who had operated from Jan 2006 to Dec 2007 were studied. For the evaluation of stability of injured vertebrae, we used the radiographic parameters which were wedge angle, Cobb's angle, compression rate measured on the plain radiographs, and the presence of posterior ligament complex injury on MRI. RESULTS: In the compression fracture group, the compression rate was statistically significant high in the posterior ligament complex injury patient(p=0.03). In the burst fracture group, the wedge angle, Cobb's angle and the compression rate were high in the posterior ligament complex injury patient, which were all statistically significant(p=0.02, 0.01, 0.01). CONCLUSIONS: The presence of a posterior ligament complex injury is important in the treatment of the thoracolumbar spine fracture. The status of the posterior ligament complex should be integrated into future classification schemes of thoracolumbar spine fractures.

Large Ossified Rathke's Cleft Cyst: A Case Report and Review of the Literature

We report a rare case of symptomatic Rathke's cleft cyst with thick calcified wall. Brain CT scans revealed a large cystic mass with round thick calcified wall. In this case, we selected the pterional approach instead of transsphenoidal approach due to the possibility of cystic craniopharyngioma. Histopathologically, it was calcified Rathke's cleft cyst with focal epithelial metaplasia. This case illustrates that calcification of the suprasellar cyst does not always suggest craniopharyngioma and the calcification pattern of Rathke's cleft cyst is different from that of the craniopharyngioma.

Aneurysms of Distal Posterior Inferior Cerebellar Artery

OBJECTIVE: Aneurysms are very rarely encountered in the distal posterior inferior cerebellar artery (PICA). The authors experienced 5 cases with a distal PICA aneurysm among 368 cases of intracranial aneurysms during the period from January 2003 to January 2008. Here, the authors describe their clinical and surgical experiences and include a review of the relevant literature. METHODS: Using radiologic findings and charts, we retrospectively reviewed the surgical results of 5 cases with a distal PICA aneurysm treated from January 2003 to January 2008. RESULTS: The current five cases were composed of four cases of 'Good' and one case of 'Fair'. No postoperative complications occurred other than a ventriculo-peritoneal shunt due to hydrocephalus in Case 2. In all five cases, treatment was successful without neurological deficit. CONCLUSION: Surgical outcome of PICA aneurysms have been reported to be excellent because the amount of intraparenchymal injury is limited. More clinical experience, microsurgical technique developments, and endovascular surgery advancements are certain to improve treatment outcomes.

Identification of Up-Regulated Genes in Malignant Glioma with Subtraction Hybridization: Preliminary Screening Studies

PURPOSE: This investigation is intended to obtain differentially expressed genes related to human malignant glioma using Subtractive hybridization. MATERIALS AND METHODS: Subtractive hybridization is potentially faster methods for identifying differentially expressed genes associated with a particular disease state. We identified 7 over-expressed genes which were not homologous to any of the known genes in the Genbank(TM) database. RESULTS: Using semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR), the mRNA expression levels of these 7 genes were higher in human glioblastomas tissue than in non-tumor brain tissue. In order to learn more about the expression profile of these genes, RT-PCR was performed using various commercially available human carcinoma cell lines. Some of these new genes were over-expressed in human glioma cell line, but not the expressed in other human cancer cell line. CONCLUSION: Theses cloned new genes may play a role in brain tumorigenesis. Further studies including verification of oncogene, cancer protein, and glioblastoma induction in animal model are needed.

Differences in Prevalence and Risk Factors of the Metabolic Syndrome Between Hemorrhagic Stroke and Normal Control / 대한뇌혈관외과학회지

OBJECTIVE: Hemorrhagic stroke is an important cause of mortality after coronary heart disease and cancer, and is a leading cause of disability. Metabolic syndrome causes an increased risk for cardiovascular morbidity and mortality. However, there a few studies on the relationship between hemorrhagic stroke and metabolic syndrome that have been reported in Korea. The purpose of this study is to elucidate the incidence of metabolic syndrome in patients with hemorrhagic stroke and in a control group of subjects. METHODS: A total of 115 patients with hemorrhagic stroke from March 2005 to December 2006 and 120 age- and sex-matched control subjects who undertook a medical examination at our hospital during the same period were studied. Blood pressure, body mass index, fasting blood glucose level, triglyceride level, high-density lipoprotein cholesterol level, total cholesterol level and low-density lipoprotein cholesterol level were checked. We investigated the prevalence and relationship of metabolic syndrome between the hemorrhagic stroke group of patients and normal control group of subjects. RESULTS: The prevalence of metabolic syndrome was 44.35% in the hemorrhagic stroke group of patients as compared to 26.67% in the normal control group of subjects. Among each component of metabolic syndrome, the body mass index, triglyceride level and fasting glucose level were significantly higher in the hemorrhagic stroke group of patients than in the normal control group of subjects. The odds ratio for hemorrhagic stroke by metabolic syndrome was 1.953 (95% CI, 0.781 to 3.245) and if analyzed separately, the presence of hypertension and fasting hyperglycemia showed a significantly increased odds ratio for hemorrhagic stroke among the components. CONCLUSION: Patients with hemorrhagic stroke had higher prevalence of metabolic syndrome as compared with the normal control subjects, and the presence of metabolic syndrome increased the risk for hemorrhagic stroke. Among the metabolic components, fasting hyperglycemia significantly increased the risk for hemorrhagic stroke. This result emphasizes the importance of managing metabolic syndrome in hemorrhagic stroke patients.

Dissecting Aneurysms on Vertebral Artery and its Branches / 대한뇌혈관외과학회지

BACKGROUND: Dissecting aneurysms of the vertebral artery are rare. Diagnosis and treatment of such condition aneurysm has a potentially higher degree of technical difficulty. The authors analyzed the clinical features and treatment modality for dissecting aneurysms arising from vertebral artery and its branches. METHODS: At the authors'institution between April. 2001 and Sep. 2004, 18 patients were diagnosed and treated for dissecting aneurysms of vertebral artery and its branches. The medical records and neuroimaging studies of the patients were reviewed retrospectively. RESULTS: 18 patients were comprised of 8 female and 10 male patients aged from 24~69 year old (mean: 44.2). Of the 18 patients, 8 patients (44.4%) had subarachnoid hemorrhage. 6 patients with subarachnoid hemorrahge were in good neurological status before treatment. Four patients were treated with transcranial surgery and 7 patients with endovascular treatment. the other 7 patient were merely treated with conservative care. All patients were diagnosed with digital subtraction angiography (DSA), but Magnetic resonance angiography (MRA) showed 12 dissecting aneurysms, 2 suspicious cases and 3 normal finding. In the case of anterior inferior cerebellar artery (AICA) dissecting aneurysm, MR angiography showed no visible AICA. Posterior inferior cerebellar artery (PICA) was occluded in postoperative DSA after wrapping of PICA for dissecting aneurysm of proximal protion of AICA. But the patient show no neurologic deficit. One patient developed bilateral vertebral artery dissecting aneurysms. One patient treated only conservative care revealed normal DSA finding on follow-up study. CONCLUSION: DSA is the only accurate diagnostic tool for vertebral dissecting aneurysm. Proximal GDC occlusion of vertebral artery may be a safe and effective therapy for patients with vertebral artery dissecting aneurysm. For proper decision of safe treatment modality, one should consider vertebral artery dominancy, collateral circulation, PICA invasion.

Co-existence of Lipoma and Myxopapillary Ependymoma in a Filum Terminale Tumor

A 65-year-old woman presented with a history of severe lower back pain on forward-flexion for 2 months duration. Magnetic resonance imaging revealed a high signal mass with a tail on T1-weighted images at the L3 level. A total surgical resection was performed via a posterior approach with the aid of a microscope. Histopathological examination of the tumor revealed two pathological components: lipoma and myxopapillary ependymoma. The presence of dual histological components in one spinal cord tumor is rare. There are no prior reports of both types of cells (adipose and ependymal) grown simultaneously in a single tumor of the filum terminale in the medical literature. We report a unique case of the co-existence of lipoma and myxopapillary ependymoma within the same tumor located at the filum terminale and review related literature.

A Case of Idiopathic Localized Hypertrophic Pachymeningitis Presented with Partial Seizures / 대한간질학회지

Idiopathic hypertrophic pachymeningitis is a clinical disorder caused by a localized or diffuse thickening of the dura mater, with an associated chronic inflammation. This can be diagnosed when there is no evidence of other etiologies such as trauma, infection, tumors, and Wegener's disease. Clinical manifestations are chronic headache with or without neurological manifestations such as cranial nerve palsies, cerebellar ataxia, neuro-ophthalmologic complications, and rarely clinical seizures. We described a patient with simple partial seizures with focal sensory and motor symptoms in the right hand as an initial and the only clinical manifestation, accompanied by a tumor-like lesion in the left parietal convexity on brain MRI. The patient underwent a lesionectomy, and the seizures have been well controlled so far without immunosuppressant treatment.

Long-term Result of Circumferential Stabilization for Spondylolytic Spondylolisthesis by One Stage Posterior Approach

OBJECTIVE: The purpose of this study is to evaluate the efficacy of circumferential fusion with PLIF(posterior lumbar interbody fusion) using fusion cages and pedicle screw fixation by one stage posterior approach in the patients with spondylolytic spondylolisthesis. METHODS: Total 254 patients with spondylolytic spondylolisthesis underwent circumferential fusion during last 10 years. Among them, 117 patients could be followed for more than two years (mean follow up period: 27.4+/-5.5 months). The clinical and radiographic data were reviewed retrospectively. RESULTS: The clinical success rate according to Prolo's scale was achieved in 86.3% of patients and the solid bony fusion was occurred in 92.3%. The anterior slipping was reduced from 9.54+/-3.89mm to 3.26+/-2.46mm(p<0.001, paired t-test). Angular instability in lateral dynamic X-ray was improved in all case immediately after surgery. There were 3 cases of instrument-related complication (2.6%) such as loosening, disconnection, and cage retropulsion. CONCLUSION: The circumferential stabilization with PLIF using fusion cages and pedicle screw fixation by one stage posterior approach has been found to be an effective and safe procedure, demonstrating a high fusion rate and clinical success with a rare complications.

Diagnostic Efficacy of Digital Infrared Thermographic Imaging in Carpal Tunnel Syndrome

OBJECTIVE: Electromyography(EMG) has been very helpful in establishing the diagnosis of carpal tunnel syndrome(CTS). But invasive procedure of EMG makes patients discomfort, who are suffering from consistent numbness. The authors investigate the diagnostic efficacy of Digital Infrared Thermographic Imaging(DITI) in CTS by comparing thermal changes between normal control group and patients group. METHODS: Among 31 patients who had operated due to CTS from march 1984 to February 2002 at the Spine Center, both EMG & DITI were used for diagnostic method in 24 patients. Authors have measured thermal differences(deltaT, degrees C) of symptomatic site between forearm and palm in 20 patients, and 30 normal controls. Authors have analyzed thermal differences(deltaT, degrees C) statistically using T-test. RESULTS: Average thermal difference(deltaT, degrees C) in symptomatic site was statistically higher than that of normal control group. Average thermal difference(deltaT, degrees C) is+0.984+/-0.342 degrees C in symptomatic site, +0.323+/-0.296 degrees C in normal control group, respectively. Significant thermal difference(deltaT, degrees C) was seen between two groups(p<0.005). Average thermal difference(deltaT, degrees C) in CT S was statistically higher than normal group, significantly. Average thermal difference(deltaT, degrees C) greater than 1 degrees C can be suspicious of CTS. CONCLUSION: Diagnostic usefulness of DITI in CTS is very high especially for the screening purpose.

Co-Existence of Dual Spinal Cord Tumor: Schwannoma and Meningioma

A 49-year-old woman was admitted to the authors' institution with a history of progressive paraparesis. Magnetic resonance imaging revealed two enhancing intradural extramedullary tumors with different signal intensity at T10-11 and L1. Surgical resection was performed via the posterior approach under microscope and the two lesions were completely removed. Histopathologic examination showed schwannoma with cystic change and meningothelial meningioma respectively. In spinal cord tumor, dual cord tumors in one patient are very rare. We report our surgical experience and review of the related literature on two spinal cord tumors in one patient.

Surgical Treatment of Intramedullary Spinal Cord Cavernous Malformation

OBJECTIVE: Comparing to cerebral cavernoma, spinal intramedullary cavernoma is rare. But, spinal intramedullary cavernomas are increasingly recognized after introduction of magnetic resonance image. The purpose of this study is to define the spectrum of presenting symptoms and signs in patients with intramedullary cavernomas and to analyze the role of surgery as a treatment for these lesions. METHODS: The authors reviewed retrospectively the cases of 13 patients who underwent surgery for intramedullary cavernomas from 1983 to 2001. We investigated demographic findings, history, onset of clinical manifestation, neurological status, radiological findings, operation, and clinical outcome. RESULTS: The mean age was 47 years(range: 29-68 years). Among 13 patients, male were 7 cases(54%) and female were 6 cases(46%). Mean duration of symptom were 3.7 years(range: 1-20 years). Patients presented three clinical manifestation types. One was acute onset of neurological compromise, the second type was slowly progressive neurological decline, and the third was acute exacerbation during chronic slow decline. Complete surgical removal of the cavernoma was possible in all cases. Mean duration of follow-up was 14.5 months. The surgical outcome were improved(9 cases, 69.2%), same(2 cases, 15.4%), and worse(2 cases, 15.4%). CONCLUSION: Surgical resection is the therapeutic method to restore aggravated neurological status and to halt acute rebleedng and chronic deterioration.

Spontaneous Cervical Epidural Hematomas in Healthy Young Adults: Case Report

There have been seldom described about acute spontaneous spinal epidural hematomas in young adults without coagulation disorder or trauma. We report two cases of spontaneous cervical epidural hematomas in young adults diagnosed with magnetic resonance image. We tried to point out the necessity of early detection and prompt surgical decompression of hematoma, with thorough description of cases and review of various literatures.

Post-Traumatic Basal Gangliar Ischemia in Children

The authors reviewed the cases of 12 children with unilateral motor weakness after minor head injury who were treated between 1990 and 1996. Eight were boys and four were girls, and all were less than seven years old (range, 8 month to 6years) ; unilateral weakness developed immediately after an apparently minor head injury. Computed tomography and MR scanning disclosed an ischemic lesion at one side of the basal ganglia. Most children recovered. The mechanism by which this ischemic lesion develops at the basal ganglia is not known. In children, however the angle between the middle cerebral artery and lateral perforating vessels is more acute than in the adult, and we believe that after minor head injury, stretching and distorting the angle of these perforating branches may lead to'unknown vessel change', with a consequent decrease in local blood flow. The end result is an ischemic lesion in the basal ganglia.

Three Cases of Spinal Mesenchymal Chondrosarcoma

Mesenchymal chondrosarcoma arising in the central nervous system is extremely rare and most of case described are intracranial. During the last ten years, the authors have encountered three cases of spinal mesenchymal chondrosarcoma; These involved a four-year-old boy, a 29-year-old man, and a 36-year women. Their location was lumbosacral, at the cervicothoracic junction, and in the midcervical area, respectively. The three patients underwent surgery, and microscopic examination revealed mesenchymal chondrosarcoma. The postoperative result was good. The related literature is also reviewed.