Clinical Characteristics of the COVID-19 Patients with Pneumonia Detected by Computerized Tomography but Negative for Infiltration by X-ray.

Coronavirus Disease 2019 (COVID-19) has rapidly spread to all corners of the globe. Different diagnostic tools, such as Chest X-ray (CXR), lung ultrasound (LUS), and computerized tomography (CT), have been used to detect active pneumonic lesions associated with COVID-19 with their varying degrees of sensitivity and specificity. This study was undertaken to investigate the clinical characteristics of COVID-19 patients with a pneumonic lung lesion detected by CT that is not detected by CXR. A total of 156 COVID-19 patients hospitalized at three nationally designated South Korean hospitals with no active lesion detected by CXR but on clinical suspicion of pneumonia underwent the CT examination and were enrolled. Medical records, which included demographic and clinical features, including comorbidity, symptoms, radiological, and laboratory findings on admission, were reviewed and analyzed. The risk factors of pneumonia detected by CT for patients without an active lesion detected by CXR were investigated. Of the 156 patients without an active lesion detected by CXR, 35 (22.44%) patients were found to have pneumonia by CT. The patients with pneumonia defined by CT were older than those without (64.1 years vs. 41.2 years). Comorbidities such as hypertension, diabetes, cardiovascular disease, preexisting stroke, and dementia were more common among patients with pneumonia defined by CT than those without. Serum albumin level, C-reactive protein (CRP), stroke, and age ≥ 70 years were significantly associated with pneumonia defined by CT after adjustment for age. In multivariable regression analysis, serum albumin level (adjusted odds ratio (AOR) = 0.123, 95% CI = (0.035-0.429)) and preexisting stroke (AOR = 11.447, 95% CI = (1.168-112.220)) significantly and independently predicted pneumonia detection by CT. Our results suggest that CT scans should be performed on COVID-19 patients negative for a pneumonic lung lesion by CXR who are suspected to be pneumonic on clinical grounds. In addition, older patients with a lower albumin level and a preexisting stroke should be checked for the presence of pneumonia despite a negative CXR finding for an active lesion.

Postoperative subdural hygroma and chronic subdural hematoma after unruptured aneurysm surgery: age, sex, and aneurysm location as independent risk factors.

OBJECTIVE: This study investigated the incidence and risk factors for the postoperative occurrence of subdural complications, such as a subdural hygroma and resultant chronic subdural hematoma (CSDH), following surgical clipping of an unruptured aneurysm. The critical age affecting such occurrences and follow-up results were also examined. METHODS: The case series included 364 consecutive patients who underwent aneurysm clipping via a pterional or superciliary keyhole approach for an unruptured saccular aneurysm in the anterior cerebral circulation between 2007 and 2013. The subdural hygromas were identified based on CT scans 6-9 weeks after surgery, and the volumes were measured using volumetry studies. Until their complete resolution, all the subdural hygromas were followed using CT scans every 1-2 months. Meanwhile, the CSDHs were classified as nonoperative or operative lesions that were treated by bur-hole drainage. The age and sex of the patients, aneurysm location, history of a subarachnoid hemorrhage (SAH), and surgical approach (pterional vs superciliary) were all analyzed regarding the postoperative occurrence of a subdural hygroma or CSDH. The follow-up results of the subdural complications were also investigated. RESULTS: Seventy patients (19.2%) developed a subdural hygroma or CSDH. The results of a multivariate analysis showed that advanced age (p = 0.003), male sex (p < 0.001), middle cerebral artery (MCA) aneurysm (p = 0.045), and multiple concomitant aneurysms at the MCA and anterior communicating artery (ACoA) (p < 0.001) were all significant risk factors of a subdural hygroma and CSDH. In addition, a receiver operating characteristic (ROC) curve analysis revealed a cut-off age of > 60 years, which achieved a 70% sensitivity and 69% specificity with regard to predicting such subdural complications. The female patients ≤ 60 years of age showed a negligible incidence of subdural complications for all aneurysm groups, whereas the male patients > 60 years of age showed the highest incidence of subdural complications at 50%-100%, according to the aneurysm location. The subdural hygromas detected 6-9 weeks postoperatively showed different follow-up results, according to the severity. The subdural hygromas that converted to a CSDH were larger in volume than the subdural hygromas that resolved spontaneously (28.4 ± 16.8 ml vs 59.6 ± 38.4 ml, p = 0.003). Conversion to a CSDH was observed in 31.3% (5 of 16), 64.3% (9 of 14), and 83.3% (5 of 6) of the patients with mild, moderate, and severe subdural hygromas, respectively. CONCLUSIONS: Advanced age, male sex, and an aneurysm location requiring extensive arachnoid dissection (MCA aneurysms and multiple concomitant aneurysms at the MCA and ACoA) are all correlated with the occurrence of a subdural hygroma and CSDH after unruptured aneurysm surgery. The critical age affecting such an occurrence is 60 years.

Fibrinogen and D-dimer analysis of chronic subdural hematomas and computed tomography findings: a prospective study.

OBJECTIVE: We investigated the relationship between fibrinolytic factors and computed tomography (CT) findings in patients with chronic subdural hematomas (CSDHs). METHODS: Thirty-one patients with CSDHs were divided on the basis of CT findings into heterogeneous and homogeneous groups. A sample from the subdural hematoma was obtained at surgery to measure the concentrations of fibrinogen and D-dimer. RESULTS: The mean level of fibrinogen in the heterogeneous group, including the layering (n=4) and mixed (n=10) type, was 88.2±121.2 mg/dL, whereas in the homogeneous group, including high density (n=2), isodensity (n=9), and low density (n=6) types, it was <25 mg/dL. The concentration of fibrinogen was significantly higher in the heterogeneous group than in the homogeneous group (p=0.006). The mean level of D-dimer in the heterogeneous group was 35,407.9±16,325.5 µg/L, whereas for the homogeneous group it was 1476.4±2091.4 µg/L. The concentration of D-dimer was significantly higher in the heterogeneous group than in the homogeneous group (p<0.001). CONCLUSIONS: The layering and mixed types of CSDH exhibited higher concentrations of fibrinogen and D-dimer in subdural hematoma than the homogeneous types. These fibrinolytic factors appear to be associated with evolution in CSDHs with heterogeneous density.

Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System.

OBJECTIVE: The amount of hemorrhage observed on a brain computed tomography scan, or a patient's Fisher grade (FG), is a powerful risk factor for development of shunt dependent hydrocephlaus (SDHC). However, the influence of treatment modality (clipping versus coiling) on the rate of SDHC development has not been thoroughly investigated. Therefore, we compared the risk of SDHC in both treatment groups according to the amount of subarachnoid hemorrhage (SAH). METHODS: We retrospectively reviewed 839 patients with aneurysmal SAH for a 5-year-period. Incidence of chronic SDHC was analyzed using each treatment modality according to the FG system. In addition, other well known risk factors for SDHC were also evaluated. RESULTS: According to our data, Hunt-Hess grade, FG, acute hydrocephalus, and intraventricular hemorrhage were significant risk factors for development of chronic SDHC. Coiling group showed lower incidence of SDHC in FG 2 patients, and clipping groups revealed a significantly lower rate in FG 4 patients. CONCLUSION: Based on our data, treatment modality might have an influence on the incidence of SDHC. In FG 4 patients, the clipping group showed lower incidence of SDHC, and the coiling group showed lower incidence in FG 2 patients. We suggest that these findings could be a considerable factor when deciding on a treatment modality for aneurysmal SAH patients, particularly when the ruptured aneurysm can be occluded by either clipping or coiling.

Factors related to the local treatment failure of γ knife surgery for metastatic brain tumors.

PURPOSE: Radiosurgery (RS) is regarded as a standard therapy for metastatic brain tumors, but local failure requiring repeated therapy for the same lesion remains an unsolved problem. The authors analyzed outcomes of gamma knife surgery (GKS) for metastatic lesions to identify factors of local treatment failure. MATERIALS AND METHODS: The hospital records of 103 patients with a metastatic brain tumor and monitored for more than 6 months were analyzed. Lesion response to RS was analyzed in 77 patients with available gamma plan data. Local treatment failure was defined as lesion regrowth or repeat GKS within 6 months. In cases with multiple lesions, largest masses were evaluated. Primary sites, metastatic location, Karnofsky scale, tumor size, number of metastatic lesions, and various radiosurgical prescription parameters, namely, Paddick's conformity index (CI), Radiation Therapy Oncology Group (RTOG)-CI, and gradient index, were analyzed. RESULTS: Of the 103 study subjects, 58 were male and 45 were female. Primary sites were lung (n = 58), breast (n = 12), colon (n = 6), kidney (n = 7), rectum (n = 6), and others (n = 14). Median survival duration from the diagnosis of brain metastasis was 25 months. Local treatment failure occurred in 14 of 77 the patients (77 lesions) with available gamma plan data. A lung cancer primary site was found to have a lower GKS failure rate than a breast or a renal site (p < 0.05). Lesions with a high Paddicks' CI or a low RTOG-CI had a higher rate of treatment failure (p < 0.05). Multivariate analysis revealed that primary tumor site and Paddick's CI were related to treatment failure (p < 0.05). CONCLUSION: Brain metastases from renal and breast cancers had higher rates of local GKS treatment failure than those from lung cancer. Furthermore, high Paddick's CI revealed higher rate of local recurrence, and was not contributory to prevent local treatment failure. However, the enlargement of the diameter of the tumor after RS in the early follow-up period does not necessarily represent the poor outcome or need of retreatment.

Early ventriculoperitoneal shunt placement after severe aneurysmal subarachnoid hemorrhage: role of intraventricular hemorrhage and shunt function.

OBJECTIVE: This study investigated the outcome of early shunt placement in patients with poor-grade subarachnoid hemorrhage and the effect of intraventricular hemorrhage (IVH) and high proteinaceous cerebrospinal fluid (CSF) on subsequent shunt performance. METHODS: This study included 33 consecutive patients with initial Fisher grade (3/4) subarachnoid hemorrhage who had undergone conversion from external ventricular drainage (EVD) to a ventriculoperitoneal (VP) shunt and whose computed tomography scan showed IVH at the time of shunt placement. Early weaning from an EVD and conversion to a VP shunt was performed irrespective of IVH or high protein content in the CSF. RESULTS: The mean interval from EVD to VP shunt placement was 6.4 days. The mean volume of IVH was 9.44 mL, and the mean value of IVH/whole ventricle volume ratio (ie, percentage of blood suspension in the CSF) was 9.81%. The mean perioperative protein level in the CSF was 149 mg/dL. During the follow-up period, 2 patients (6.1%) required VP shunt placement, and no patients experienced complications of ventriculitis or shunt-related infection. CONCLUSION: Based on our data, earlier EVD weaning and shunt placement can effectively treat subarachnoid hemorrhage-induced hydrocephalus in patients with severe subarachnoid hemorrhage. This procedure resulted in no shunt-related infections and a 6.1% revision rate. There were fewer adverse effects of IVH and protein on shunt performance. Therefore, weaning from an EVD and conversion to a permanent VP shunt need not be delayed because of IVH or proteinaceous CSF.

Acute serious rebleeding after angiographically successful coil embolization of ruptured cerebral aneurysms.

PURPOSE: The present study investigated the incidence of acute rebleeding after successful coil embolization of a ruptured cerebral aneurysm, including clinical outcomes, and possible mechanisms of the events other than coil compaction and/or incomplete embolization. MATERIALS AND METHODS: This study included 591 consecutive patients who presented with aneurysmal subarachnoid hemorrhage, were treated with coil embolization, and whose post-procedural angiography revealed successful embolization. Data were collected retrospectively from six patients who showed acute rebleeding despite that angiographically successful coil embolization was achieved. All clinical, radiological data and intraoperative videos were reviewed to identify causative factors which could have contributed to the occurrence of rebleeding. RESULTS: Incidence of acute rebleeding after successful coil embolization of ruptured cerebral aneurysm was 1.0% (6/591). In all of these six patients, complete angiographic occlusion was achieved except in one case where a small residual neck was intentionally left to avoid compromise of the parent artery. Four of the six patients showed poor clinical courses, either died or recovered with severe disability. Whenever possible, we performed an immediate craniotomy for exploration and additional clipping. Based on intraoperative findings, we hypothesized that uneven distribution of the coil masses and spontaneous resolution of thrombus among the strands of coil (inter-coil-loop thrombolysis) could be possible mechanisms of rebleeding. CONCLUSION: Acute rebleeding is extremely rare, but is possible as a complication of coil embolization of a ruptured cerebral aneurysm even when a case is angiographically successful. The higher degree of morbidity and mortality is a major concern. Therefore, further investigation to discover risk factors and causative mechanisms for such a complication is sorely needed.

Remote cerebellar hemorrhage complicated after supratentorial surgery: retrospective study with review of articles.

OBJECTIVE: Remote cerebellar hemorrhage (RCH) is one of the rare complications occurring after supratentorial surgery, and its pathomechanism is poorly understood. We report 10 cases of RCH from our institution and review 154 cases from a database in order to delineate incidence, common presentation, risk factors, and outcomes of this complication. In addition, the means of prevention are discussed. METHODS: We reviewed the medical records of 10 patients who experienced RCH after undergoing supratentorial surgery at our institution between 2001 and 2008. A database search in Medline revealed 154 cases of RCH in the English literature. Characteristic features were analyzed and compared. RESULTS: There were 10 cases of RCH among 3307 supratentorial surgery cases, indicating a 0.3% incidence. All patients had characteristic imaging features of RCH, namely a streaky bleeding pattern in the superior folia of the cerebellum. Seven patients had a history of preoperative hypertension. Four cases were related to cerebral aneurysms, and other four developed after the removal of brain tumors. Cerebrospinal fluid (CSF) drainage apparatuses were installed postoperatively in all cases. Outcomes according to modified Rankin scale (mRS) were good in 7 patients, with 1 fatal case. CONCLUSION: RCH is a rare complication after supratentorial surgery, and the exact etiology still remains uncertain. Hypertension and perioperative loss of CSF seem positively correlated with RCH, but no single risk factor is totally responsible. Patients with RCH should be closely observed to improve their prognosis.

Does non-perimesencephalic type non-aneurysmal subarachnoid hemorrhage have a benign prognosis?

We reviewed and compared the clinical course and long-term prognosis of patients with non-aneurysmal subarachnoid hemorrhage (SAH) with and without a perimesencephalic pattern of hemorrhage on CT scan. In 876 patients with spontaneous SAH, 52 (5.9%) were diagnosed with non-aneurysmal SAH. Based on their CT scans, the SAH was classified as perimesencephalic non-aneurysmal SAH (PNSH) in 23 patients and non-perimesencephalic (non-PNSH) in 29 patients. The patients in the non-PNSH group were further divided into diffuse type (19 patients) and localized type (10 patients). We performed follow-up three-dimensional-CT angiography (3D-CTA) in all possible patients at least 1 year after the attack. The PNSH group had a lower rate of acute hydrocephalus (8.7%) and angiographic vasospasm (0%) complications than the non-PNSH group (37.9% and 27.6%, respectively). Only one case of rebleeding occurred in the non-PNSH group. No demonstrable source of bleeding was found on follow-up 3D-CTA, which was performed 1 year after the attack. All patients with non-aneurysmal SAH had similarly favorable long-term functional outcomes. Based on our study, patients with non-PNSH have a more complicated clinical course than those with PNSH. However, the long-term prognosis was similarly favorable for both the PNSH and non-PNSH in limited circumstances when they showed normal findings on a series of two-dimensional and 3D angiographic work-ups.

Gamma knife radiosurgery for multiple brain metastases from lung cancer.

The aim of this study was to compare the effectiveness of gamma knife radiosurgery (GKS) for the treatment of multiple brain metastases from lung cancer with that of whole brain radiation therapy (WBRT). Patients with multiple (2-20) brain metastases were divided into two groups for initial brain tumor management: a GKS group (14 patients) and a WBRT group (19 patients). The patients were stratified by gender, age, initial Karnofsky performance status score, control of the primary site, known extracranial metastases, number of brain metastases, diameter of the maximal lesion, chemotherapy, and recursive partitioning analysis (RPA) Class. The 6-month and 1-year overall survival rates were 64.3% and 47.7%, respectively, in the GKS group, and 42.1% and 10.5%, respectively, in the WBRT group. The median survival time was 32 weeks in the GKS group and 24 weeks in the WBRT group. The overall survival time in the GKS group was significantly longer than in the WBRT group (p=0.04). The univariate analysis suggests that survival was increased in both patients with a controlled primary tumor site and in the GKS group (p=0.03, 0.04). The use of GKS in patients with multiple brain metastases significantly improved patient survival compared to the employment of WBRT. When we assessed the subgroups, systemic disease control and GKS were significant variables by univariate analysis.

Nerve atrophy and a small cerebellopontine angle cistern in patients with trigeminal neuralgia.

OBJECT: The aim of this study was to provide information to help confirm the diagnosis of trigeminal neuralgia (TN) using MR imaging. METHODS: The authors evaluated atrophy of the trigeminal nerve, the cross-sectional area of the cerebellopontine angle (CPA) cistern, and the length of the cisternal segment of the trigeminal nerve on the affected side in 26 consecutive patients with TN who were treated using Gamma Knife surgery. RESULTS: The mean volume of the trigeminal nerve on the affected side was significantly smaller than the mean volume of the trigeminal nerve on the unaffected side (p < 0.001). Nerve atrophy was present in 25 patients (96.2%) on the affected side and in 1 patient on the unaffected side. The mean cross-sectional area of the CPA cistern on the affected side (188.5 mm2) was significantly smaller than the mean volume on the unaffected side (232.8 mm2) in 25 of the 26 patients (p = 0.001). The mean length of the cisternal segment of the trigeminal nerve on the affected side (7.9 mm) was significantly shorter than the mean length on the unaffected side (9.6 mm) in 25 of the 26 patients (p = 0.001). CONCLUSIONS: Among the patients with TN, there was a statistically significant difference in the MR imaging findings of the affected side compared with the unaffected side of the trigeminal nerve. Atrophy of the trigeminal nerve and a small CPA cistern in patients with TN provides additional markers for the diagnosis of TN and helps confirm the diagnosis based on clinical examination.

Saccular aneurysm at the anterior communicating artery complex associated with an accessory middle cerebral artery : report of two cases and review of the literature.

Accessory middle cerebral artery (MCA) is an infrequent vascular anomaly of the brain. Cerebral aneurysms associated with this anomalous artery are also very rare. To our knowledge, there have only been ten previous reports of an aneurysm associated with accessory MCA. The authors present two patients with accessory MCA-related aneurysms. A 38-year-old male and a 59-year-old female both presented with sudden-onset severe headache. In both patients, computed tomography (CT) scan revealed subarachnoid hemorrhage. A subsequent angiogram demonstrated an accessory MCA arising from the anterior cerebral artery (ACA) and a saccular aneurysm at the anterior communicating artery (ACoA) complex associated with an accessory MCA. Surgical clipping allowed for complete exclusion of the aneurysm from the arterial circulation. Based on our review of the ten cases of aneurysms associated with accessory MCA documented in the literature, we suggest that accessory MCA-related aneurysms can be classified according to whether the accessory MCA originates from the proximal A1 segment or from the ACoA complex. We also emphasize the importance of precise interpretation of preoperative angiograms and intraoperative precaution in determining the presence of this anomalous artery prior to temporary clip placement.

Multiple fusiform myxomatous cerebral aneurysms in a patient with Carney complex.

Carney complex is a rare autosomal-dominant familial tumor syndrome that involves the triad of myxoma, mucocutaneous pigmentation, and endocrine overactivity. To the best of the authors' knowledge, there are no reports of multiple fusiform aneurysms coinciding with atrial myxoma. The authors report the case of a 38-year-old woman with typical Carney complex who had multiple skin myxomas, endocrine abnormalities, and multiple brownish perioral lesions. Multiple fusiform aneurysms were also discovered after the recurrence of atrial myxoma. During a follow-up period of > 10 years, there have been no angiographic changes in the aneurysms and no progression of symptoms.

Chronic subdural hematoma preceded by traumatic subdural hygroma.

Patients with traumatic subdural hygroma (SDG) are at an increased risk of developing chronic subdural hematoma (CSDH). However, the mechanism by which this occurs is still not fully understood. The purpose of this paper is to investigate the clinical characteristics and pathogenesis of CSDH, as well as the relationship between CSDH and SDG. We review the pertinent literature and retrospectively examine a series of cases in which CSDH had been preceded by SDG to understand the natural history and developmental mechanisms of these lesions. We discuss the cases of 24 patients in whom CSDH developed from traumatic SDG between 2001 and 2005. Headache was the most common symptom, and the mean Glasgow Coma Scale score was 14.1. Increases in SDG volume were observed in CT scans of 17 patients, and increased density and volume was observed in five patients. The mean interval between the two diseases was 57.6 days, and 13 patients developed new symptoms after the development of CSDH. The most common symptoms at that time were headache and hemiparesis. All patients underwent an operation, which resulted in good recovery in all but one case. The cycle of persistent SDG, rebleeding, coagulation and fibrinolysis contributes to the development of CSDH from SDG. It is important to understand the natural history of CSDH and carefully follow up patients with head injury, especially if it is associated with SDG, and the potential for the development of CSDH should be considered.

Occluded vascular stump mimicking middle cerebral artery bifurcation aneurysm: report of 2 cases.

BACKGROUND: An intracranial stump of an occluded vessel is a rare but important aneurysm mimic. We present 2 cases of middle trunk atresia of the trifurcated MCA, in which the proximal stump of the atretic vessel mimics an MCA bifurcation aneurysm in angiograms. CASE DESCRIPTION: Both patients were referred to the authors with a presumptive diagnosis of an unruptured asymptomatic aneurysm at the MCA bifurcation that was found in an MR angiogram. The aneurysmal shape was conical in one case and in the other case, globoid and saccular. Careful examination of the catheter angiograms allowed us to notice the fine moyamoya phenomenon localized at adjacent M2 segments, in addition to the aneurysmal lesions. Surgical exploration revealed an MCA trifurcation instead of a bifurcation. The middle trunk of the MCA was atretic, showing a thin and white cordlike appearance, and its proximal end was a vascular stump instead of a true aneurysm. Adjacent M2 segments emitted fine perforating vessels in accordance with the moyamoya phenomenon at angiography. CONCLUSION: In angiographic examinations, when an aneurysmal lesion is present at the MCA bifurcation in association with the moyamoya phenomenon at adjacent M2 trunks, the proximal stump of an atretic middle trunk of the MCA instead of a true aneurysm should be suspected and treated appropriately.

Revision of Paine's technique for intraoperative ventricular puncture.

BACKGROUND: The aim of this study was to determine the ideal point for a ventricular puncture in pterional craniotomies. METHODS: Using a circle that had its center around the junction of the columns of the fornix and conforming to the surface of the frontal lobe on an axial computed tomography scan 2.5 cm superior to the lateral orbital roof, we simulated the introduction of a catheter perpendicular to the cortex by drawing the radii of the circle in 70 patients with an acute subarachnoid hemorrhage. The cortical point at which perpendicular puncture provides the best trajectory for ventricular access, traversing the least brain tissue and avoiding important brain structures, such as the head of the caudate nucleus, anterior limb of the internal capsule, and Broca's cortex in the dominant hemisphere, was measured. RESULTS: The new landmark was located at the point 44 +/- 4 mm anterior to the sylvian fissure on the level of 2.5 cm superior to the lateral orbital roof and was consistent regardless of the ventricular dimensions and sex. Clinical trial of the ventriculostomy in 32 patients with a ruptured aneurysm approved the new landmark. CONCLUSIONS: An intraoperative ventriculostomy can be performed safely and reliably using the new landmark 2.5 cm superior to the lateral orbital roof and 4.5 cm anterior to the sylvian fissure in aneurysm surgery using a pterional craniotomy.

Eosinophilic granuloma of the skull: a retrospective analysis.

BACKGROUND: The authors describe 9 cases of children with eosinophilic granuloma (EG) of the skull and report on their clinical manifestations, treatment, and prognosis. METHOD: Nine consecutive patients were diagnosed as EG of the skull and confirmed pathologically between 1996 and 2005. In the present study, multi- and single-system Langerhans' cell histiocytosis without skull involvement were excluded. Patients with EG of the skull were divided into two groups: (1) those with only a single bone lesion and those with (2) multiple bone lesions. Surgical removal was performed between 2 and 10 years of age (mean, 4.2 years). RESULTS: Eight (88.9%) of the study subjects were found to have a single bone lesion at diagnosis, and 1 had multiple bone lesions. Seven patients had a painless skull mass and 2 patients had a painful skull mass. Total removal was performed in all 9 patients. Eight patients received postoperative chemotherapy or indomethacin as adjuvant therapy. Of the 8 patients who received adjuvant therapy, 4 were treated with indomethacin and the remaining 4 received methotrexate-based chemotherapy. Eight patients did not experience EG recurrence, however, 1 patient developed additional lesions 2 years after surgical excision. CONCLUSIONS: EG of the skull is a clinicopathological entity with a good outcome. However, therapies and prognoses are dependent on age at diagnosis and the number of bony involvements.

Cortical osteotomy technique for mobilizing the temporal muscle in pterional craniotomies. Technical note.

Although many procedures have already been performed to mobilize and reconstruct the temporal muscle for pterional craniotomies, the authors described a novel cortical osteotomy technique for creating and mobilizing a cortical bone slat along the superior temporal line with the temporal muscle attached to it. Screw fixation of the cortical bone slat then provides secured temporal muscle reconstruction. As such, this new technique minimized damage to the temporal muscle and prevented the formation of an anterior temporal hollow. In addition, key hole and parietal burr hole defects were covered by the cortical bone slat.

Aneurysm rupture at an anomalous collateral artery that extended from the proximal A2 segment to the middle of the M1 segment, bypassing atresia of the internal carotid artery bifurcation. Case report.

The authors report the first known case in which an anomalous collateral artery was found to connect the proximal A2 segment with the middle of the M1 segment. This rarity was associated with atresia of the T-shaped internal carotid artery bifurcation. Two aneurysms had developed on a tortuous and tangled portion of the anomalous artery; one of them had ruptured, producing a subarachnoid hemorrhage and an intracerebral hematoma in the area of the putamen. The aneurysms were clipped and the intracerebral hematoma was removed via an emergency craniotomy. Possible causes of the anomaly and the differences between it and accessory and duplicated middle cerebral arteries are reviewed.