Vasa Vasorum Densities in Human Carotid Atherosclerosis Is Associated with Plaque Development and Vulnerability

Objective@#: The extensive vasa vasorum network functions as a conduit for the entry of inflammatory cells or factors that promote the progression of angiogenesis and plaque formation. Therefore, we investigated the correlation between the carotid vasa vasorum activities and carotid plaque vulnerability using indocyanine green video angiography (ICG-VA) during carotid endarterectomy (CEA). @*Methods@#: Sixty-nine patients who underwent CEA were enrolled prospectively from September 2015 to December 2017. During CEA, a bolus of ICG was injected intravenously before and after resecting the atheroma. Additionally, we performed immunohistochemistry using CD68 (a surface marker of macrophages), CD117 (a surface marker of mast cells), and CD4 and CD8 (surface markers of T-cells) antibodies to analyze the resected plaque specimens. @*Results@#: The density of active vasa vasorum was observed in all patients using ICG-VA. The vasa vasorum externa (VVE) and interna (VVI) were seen in 11 (16%) and 57 patients (82.6%), respectively. Macroscopically, the VVE-type patterns were strongly associated with preoperative angiographic instability (81.8%, p=0.005) and carotid plaque vulnerability (90.9%, p=0.017). In contrast, the VVI-type patterns were weakly associated with angiographic instability (31.6%) and plaque vulnerability (49.1%). CD68-stained macrophages and CD117-stained mast cells were observed more frequently in unstable plaques than in stable plaques (p<0.0001, p=0.002, respectively). @*Conclusion@#: The early appearance of VVE, along with the presence of many microvessel channels that provided nutrients to the developing and expanding atheroma during ICG-VA, was strongly associated with unstable carotid plaques. The degree of infiltration of macrophages and mast cells is possibly related to the formation of unstable plaques.

Arachnoid Membrane Suturing for Prevention of Subdural Fluid Collection in Extracranial-intracranial Bypass Surgery

OBJECTIVE: Water-tight closure of the dura in extracranial-intracranial (EC-IC) bypass is impossible because the superficial temporal artery (STA) must run through the dural defect. Consequently, subdural hygroma and subcutaneous cerebrospinal fluid (CSF) collection frequently occur postoperatively. To reduce these complications, we prospectively performed suturing of the arachnoid membrane after STA-middle cerebral artery (STA-MCA) and evaluated the clinical usefulness. MATERIALS AND METHODS: Between Mar. 2005 and Oct. 2010, extracranial-intracranial arterial bypass (EIAB) with/without encephalo-myo-synangiosis was performed in 88 cases (male : female = 53 : 35). As a control group, 51 patients (57 sides) underwent conventional bypass surgery without closure of the arachnoid membrane. Postoperative computed tomography (CT) scan was performed twice in three days and seven days later, respectively, for evaluation of the presence of subdural fluid collection and other mass lesions. RESULTS: The surgical result was excellent, with no newly developing ischemic event until recent follow-up. The additional time needed for arachnoid suture was five to ten minutes, when three to eight sutures were required. Post-operative subdural fluid collection was not seen on follow-up computed tomography scans in all patients. CONCLUSION: Arachnoid suturing is simple, safe, and effective for prevention of subdural fluid collection in EC-IC bypass surgery, especially the vulnerable ischemic hemisphere.

Evaluation of Probability of Survival Using Trauma and Injury Severity Score Method in Severe Neurotrauma Patients

OBJECTIVE: Despite several limitations, the Trauma Injury Severity Score (TRISS) is normally used to evaluate trauma systems. The aim of this study was to evaluate the preventable trauma death rate using the TRISS method in severe trauma patients with traumatic brain injury using our emergency department data. METHODS: The use of the TRISS formula has been suggested to consider definitively preventable death (DP); the deaths occurred with a probability of survival (Ps) higher than 0.50 and possible preventable death (PP); the deaths occurred with a Ps between 0.50 and 0.25. Deaths in patients with a calculated Ps of less than 0.25 is considered as no-preventable death (NP). A retrospective case review of deaths attributed to mechanical trauma occurring between January 1, 2011 and December 31, 2011 was conducted. RESULTS: A total of 565 consecutive severe trauma patients with ISS>15 or Revised Trauma Score<7 were admitted in our institute. We excluded a total of 24 patients from our analysis : 22 patients younger than 15 years, and 2 patients with burned injury. Of these, 221 patients with head injury were analyzed in the final study. One hundred eighty-two patients were in DP, 13 in PP and 24 in NP. The calculated predicted mortality rates were 11.13%, 59.04%, and 90.09%. The actual mortality rates were 12.64%, 61.547%, and 91.67%, respectively. CONCLUSION: Although it needs to make some improvements, the present study showed that TRISS performed well in predicting survival of traumatic brain injured patients. Also, TRISS is relatively exact and acceptable compared with actual data, as a simple and time-saving method.

Value of Indocyanine Green Videoangiography in Deciding the Completeness of Cerebrovascular Surgery

OBJECTIVE: Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. METHODS: Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. RESULTS: Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. CONCLUSION: ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery.

The Usefulness of Electromagnetic Neuronavigation in the Pediatric Neuroendoscopic Surgery

OBJECTIVE: Neuroendoscopy is applied to various intracranial pathologic conditions. But this technique needs informations for the anatomy, critically. Neuronavigation makes the operation more safe, exact and lesser invasive procedures. But classical neuronavigation systems with rigid pinning fixations were difficult to apply to pediatric populations because of their thin and immature skull. Electromagnetic neuronavigation has used in the very young patients because it does not need rigid pinning fixations. The usefulness of electromagnetic neuronavigation is described through our experiences of neuroendoscopy for pediatric groups and reviews for several literatures. METHODS: Between January 2007 and July 2011, nine pediatric patients were managed with endoscopic surgery using electromagnetic neuronavigation (AxiEM, Medtronics, USA). The patients were 4.0 years of mean age (4 months-12 years) and consisted of 8 boys and 1 girl. Totally, 11 endoscopic procedures were performed. The cases involving surgical outcomes were reviewed. RESULTS: The goal of surgery was achieved successfully at the time of surgery, as confirmed by postoperative imaging. In 2 patients, each patient underwent re-operations due to the aggravation of the previous lesion. And one had transient mild third nerve palsy due to intraoperative manipulation and the others had no surgery related complication. CONCLUSION: By using electromagnetic neuronavigation, neuroendoscopy was found to be a safe and effective technique. In conclusion, electromagnetic neuronavigation is a useful adjunct to neuroendoscopy in very young pediatric patients and an alternative to classical optical neuronavigation.

Rapid Progression of Unilateral Moyamoya Disease

The detailed clinical characteristics of unilateral moyamoya disease (MMD) have not been fully elucidated. It has been reported that some patients with unilateral MMD progress to bilateral involvement, while others remain with the unilateral variant. In this series, we present a case of unilateral MMD that progressed to bilateral involvement over the course of just one month.

Laminotomy with Continuous Irrigation in Patients with Pyogenic Spondylitis in Thoracic and Lumbar Spine

OBJECTIVE: Pyogenic spondylitis often results in acute neurological deterioration requiring adequate surgical intervention and appropriate antibiotic treatment. The purpose of this study was to conduct an analysis of the clinical effect of continuous irrigation via laminotomy in a series of patients with pyogenic spondylitis in thoracic and lumbar spine. METHODS: The authors conducted a retrospective investigation of 31 consecutive patients with pyogenic thoracic and lumbar spondylitis who underwent continuous irrigation through laminotomy from 2004 to 2008. The study included 22 men and 9 women, ranging in age from 38 to 78 years (mean 58.1 years). The average follow-up duration was 13.4 months (range, 8-34 months). We performed debridement and abscess removal after simple laminotomy, and then washed out epidural and disc space using a continuous irrigation system. Broad spectrum antibiotics were administered empirically and changed according to the subsequent culture result. Clinical outcomes were based on the low back outcome scale (LBOS), visual analogue scale (VAS) score, and Frankel grade at the last follow-up. Radiological assessment involved plain radiographs, including functional views. RESULTS: Common predisposing factors included local injection for pain therapy, diabetes mellitus, chronic renal failure, and liver cirrhosis. Causative microorganisms were identified in 22 cases (70.9%) : Staphylococcus aureus and Streptococcus spp. were the main organisms. After surgery, LBOS, VAS score, and Frankel grade showed significant improvement in most patients. Spinal stability was maintained during the follow-up period, making secondary reconstructive surgery unnecessary for all patients, except one. CONCLUSION: Simple laminotomy with continuous irrigation by insertion of a catheter into intervertebral disc space or epidural space was minimally invasive and effective in the treatment of pyogenic spondylitis. This procedure could be a beneficial treatment option in patients with thoracolumbar spondylitis combined with minimal or moderate destructive change of vertebrae.

Post-Traumatic Cerebral Infarction : Outcome after Decompressive Hemicraniectomy for the Treatment of Traumatic Brain Injury

OBJECTIVE: Posttraumatic cerebral infarction (PTCI), an infarction in well-defined arterial distributions after head trauma, is a known complication in patients with severe head trauma. The primary aims of this study were to evaluate the clinical and radiographic characteristics of PTCI, and to assess the effect on outcome of decompressive hemicraniectomy (DHC) in patients with PTCI. METHODS: We present a retrospective analysis of 20 patients with PTCI who were treated between January 2003 and August 2005. Twelve patients among them showed malignant PTCI, which is defined as PTCI including the territory of Middle Cerebral Artery (MCA). Medical records and radiologic imaging studies of patients were reviewed. RESULTS: Infarction of posterior cerebral artery distribution was the most common site of PTCI. Fourteen patients underwent DHC an average of 16 hours after trauma. The overall mortality rate was 75%. Glasgow outcome scale (GOS) of survivors showed that one patient was remained in a persistent vegetative state, two patients were severely disabled and only two patients were moderately disabled at the time of discharge. Despite aggressive treatments, all patients with malignant PTCI had died. Malignant PTCI was the indicator of poor clinical outcome. Furthermore, Glasgow coma scale (GCS) at the admission was the most valuable prognostic factor. Significant correlation was observed between a GCS less than 5 on admission and high mortality (p<0.05). CONCLUSION: In patients who developed non-malignant PTCI and GCS higher than 5 after head injury, early DHC and duroplasty should be considered, before occurrence of irreversible ischemic brain damage. High mortality rate was observed in patients with malignant PTCI or PTCI with a GCS of 3-5 at the admission. A large prospective randomized controlled study will be required to justify for aggressive treatments including DHC and medical treatment in these patients.

Early Surgical Results of Carotid Endarterectomy / 대한뇌혈관외과학회지

OBJECTIVES: In this study, we evaluated early surgical results including 30 days early stroke and death rate and complications in 168 cases carotid endarterectomy (CEA). METHODS: A retrospective review of patients who underwent CEA at our institute between September 1999 and August 2010 was done. Preoperative symptoms were stroke in 72 cases, transient ischemic stroke or reversible ischemic neurologic deficit in 56 cases and asymptomatic in 40 cases. Most of the patients had conventional cerebral angiography or neck computed tomography angiography (CTA) for preoperative evaluation. Immediate radiological follow up was performed by neck CTA 1 week postoperatively. RESULTS: The overall postoperative stroke rate including transient ischemic attack within 30 days of the treatment was 1.7%. Major stroke rate with morbidity and death rate within 30 days was 0.6% (1 : major stroke, 1 : death). The cause of death was airway occlusion due to wound hematoma. Cranial nerve palsy developed in two patients (1.1%) and neck hematoma in six patients (3.5%). Neck CTA revealed total occlusion of internal carotid artery in one patient with acute cerebral infarction and then recovered fully. Intracranial hemorrhage relating to the hyperperfusion syndrome developed in one patient. Radiological patency rate was 98.7%. The comparison of 30 days morbidity and mortality rate between CEA and carotid angioplasty and stenting were each 0.6% and 1.5%, but there was no statistical significance. CONCLUSIONS: Carotid endarterectomy provides considerable future risk prevention against stroke in patients with symptomatic and asymptomatic carotid stenosis.

Early Surgical Results of Carotid Endarterectomy / 대한뇌혈관외과학회지

OBJECTIVES: In this study, we evaluated early surgical results including 30 days early stroke and death rate and complications in 168 cases carotid endarterectomy (CEA). METHODS: A retrospective review of patients who underwent CEA at our institute between September 1999 and August 2010 was done. Preoperative symptoms were stroke in 72 cases, transient ischemic stroke or reversible ischemic neurologic deficit in 56 cases and asymptomatic in 40 cases. Most of the patients had conventional cerebral angiography or neck computed tomography angiography (CTA) for preoperative evaluation. Immediate radiological follow up was performed by neck CTA 1 week postoperatively. RESULTS: The overall postoperative stroke rate including transient ischemic attack within 30 days of the treatment was 1.7%. Major stroke rate with morbidity and death rate within 30 days was 0.6% (1 : major stroke, 1 : death). The cause of death was airway occlusion due to wound hematoma. Cranial nerve palsy developed in two patients (1.1%) and neck hematoma in six patients (3.5%). Neck CTA revealed total occlusion of internal carotid artery in one patient with acute cerebral infarction and then recovered fully. Intracranial hemorrhage relating to the hyperperfusion syndrome developed in one patient. Radiological patency rate was 98.7%. The comparison of 30 days morbidity and mortality rate between CEA and carotid angioplasty and stenting were each 0.6% and 1.5%, but there was no statistical significance. CONCLUSIONS: Carotid endarterectomy provides considerable future risk prevention against stroke in patients with symptomatic and asymptomatic carotid stenosis.

Incidence rate of Aneurysmal SAH in Gwangju City and Jeollanamdo Province in 2007

OBJECTIVE: The incidence of subarachnoid hemorrhage (SAH) worldwide varies considerably. In spite of many reports about the incidence of SAH, there has been no report about the incidence of SAH on the basis of the Korean population. The purpose of this hospital-based study was to assess the actual incidence rates of aneurysmal SAH in Gwangju city and Jeollanamdo province. METHODS: All cases of SAH confirmed by computerized tomography (CT) between January 2007 and December 2007 were selected for analysis. For the data collection, three major training hospital and ten general hospitals working the CT in Gwangju city and four major general hospitals in Jeollanamdo province participate in this study. RESULTS: According to the official census of Korea, the population was 1,413,444 in Gwangju city and 1,929,836 in Jeollanamdo province in 2007. There were 163 patients in Gwangju city and 266 patients in Jeollanamdo province confirmed SAH by CT in 2007. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages in Gwangju city were 11.5 and 12.4 for aneurysmal SAH and in Jeollanamdo province were 13.8 and 10.8. The incidence was higher in women and increased with age. The gender distribution varied with age. At young ages, the incidence was higher in men while after the age of 40 years, the incidence was higher in women. CONCLUSION: In the present study, the age- and sex-adjusted annual incidence rates is 11.8 in Gwangju city and Jeollanamdo province. The incidence was higher in women and increased with age.

Synovial Sarcoma of the Posterior Neck : A Case Report and Review of Literature

We recently experienced a case of synovial sarcoma in the posterior neck, which involved adjacent bony structures. Synovial sarcoma is rare, malignant soft tissue tumor that occur predominantly in the lower extremities. Wide surgical excision with involved tissue is the treatment of first choice, because most synovial sarcomas reveal aggressive features. We removed the tumor with involved bony structures and patient was given postoperative radiation therapy. Despite these treatment options, the patient died 1 year after surgery. We report this case with a review of the literature.

Surgical Experience of Distal Middle Cerebral Artery Aneurysm Rupture / 대한뇌혈관외과학회지

OBJECTIVE: Distal middle cerebral artery (MCA) aneurysms are the least frequent aneurysms of the MCA, and they represent about 1.1 to 5% of all MCA aneurysms. Patients with ruptured distal MCA aneurysms generally have a poor clinical outcome. The purpose of this article is to review the characteristics of distal MCA aneurysms to avoid the complications of microsurgical dissection and clipping of distal MCA aneurysms. METHODS: A total of 1187 patients with ruptured aneurysms were treated at our hospital between January 1997 and May 2008. All patients underwent surgical procedures. Computed tomography (CT) revealed rupture of distal MCA aneurysms in 15 (1.26%) patients. The location of the aneurysm were the M2 (insular) segment in seven patients, the M2-3 junction in three and the M3 (opercular) segment in five. Brain CT images revealed the presence of both subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH) in 11 of 15 (77.3%) patients, with a mean ICH volume of 14.5 cc (range : 5 to 32 cc). Rebleeding occurred in 7 out of the 15 (46.7%) patients. RESULTS: All the patients underwent early surgical procedures, including clipping in seven, trapping in two, bypass surgery in four, Guglielmi detachable coil embolization in one and exploratory craniotomy in one patient. The aneurysm had a fusiform appearance in 9 out of 15 cases (60%), and the mean size of the aneurysm was 10.4 mm (range : 2 to 35 mm). Three patients died due to severe brain swelling (20%). CONCLUSION: In this study, distal MCA aneurysms had a relatively fusiform shape as well as high rates of rebleeding and ICH. A good clinical outcome was associated with early surgery for adequately controlling brain swelling and preventing rebleeding.

Pituitary Apoplexy Presenting as Isolated Third Cranial Nerve Palsy with Ptosis : Two Case Reports

Pituitary apoplexy is a clinical syndrome caused by an acute ischemic or hemorrhagic vascular accident involving a pituitary adenoma or an adjacent pituitary gland. Pituitary apoplexy may be associated with a variety of neurological and endocrinological signs and symptoms. However, isolated third cranial nerve palsy with ptosis as the presenting sign of pituitary apoplexy is very rare. We describe two cases of pituitary apoplexy presenting as sudden-onset unilateral ptosis and diplopia. In one case, brain magnetic resonance imaging (MRI) revealed a mass in the pituitary fossa with signs of hemorrhage, upward displacement of the optic chiasm, erosion of the sellar floor and invasion of the right cavernous sinus. In the other case, MRI showed a large area of insufficient enhancement in the anterior pituitary consistent with pituitary infarction or Sheehan's syndrome. We performed neurosurgical decompression via a transsphenoidal approach. Both patients showed an uneventful recovery. Both cases of isolated third cranial nerve palsy with ptosis completely resolved during the early postoperative period. We suggest that pituitary apoplexy should be included in the differential diagnosis of patients presenting with isolated third cranial nerve palsy with ptosis and that prompt neurosurgical decompression should be considered for the preservation of third cranial nerve function.

Clinical Results of in situ Vascular Reconstruction for the Treatment of Complex Intracranial Aneurysms / 대한뇌혈관외과학회지

CONCLUSION: Vascular reconstruction is an important part of the treatment of complex intracranial aneurysms. We report our clinical experience using vascular reconstruction techniques without an extracranial arterial stump for the treatment of complex intracranial aneurysms. METHODS: We conducted a retrospective review of five patients who underwent in situ bypasses and two patients who underwent direct neck suture secondary to clip reinforcement for the treatment of complex intracranial aneurysms between January 1999 and May 2008. RESULTS: Five of the aneurysms were fusiform and the other two were blood blister-like aneurysms (BBAs). Fusiform aneurysms were located at the anterior cerebral artery (ACA) in two patients and the middle cerebral artery (MCA) in three patients. The aneurysms were treated with end-to-side anastomosis after aneurysm excision in three cases and end-to-end anastomosis after aneurysm excision in two cases. Two cases of BBA on the dorsal intracranial artery (ICA) wall were treated by direct suture secondary to the wrapping-clipping method. Follow-up angiography was performed in five patients and revealed patent bypasses in four patients. Follow-up angiography was not performed in two patients due to their poor postoperative condition, and it revealed delayed occlusion due to granuloma formation in one patient with BBA. The patient outcomes were excellent in five patients and poor in two patients whose clinical condition was Hunt- Hess grade V preoperatively. CONCLUSION: In situ bypass is an effective alternative to extracranial-intracranial bypass for distally located fusiform aneurysms. In addition, arterial suturing followed by the wrapping-clipping method is a useful technique for fragile aneurysms unamenable to direct clip or encircled clip for true ICA trunk aneurysms. Although technically challenging, this technique of vascular reconstruction without extracranial arterial graft should be considered for appropriate candidates.

Successful Endovascular Treatment of Ruptured Superior Cerebellar Artery Aneurysm Associated with Moyamoya Disease : A Case Report and Review of the Literature / 대한뇌혈관외과학회지

We present a patient with moyamoya disease and a ruptured superior cerebellar artery aneurysm that was managed by endovascular embolization. A 53-year-old man with sudden onset severe headache and altered mental status was referred to our hospital. Computed tomography revealed a subarachnoid hemorrhage. Cerebral angiography showed evidence of moyamoya disease and a 7 mm saccular aneurysm at the origin of the right superior cerebellar artery. Endovascular coil embolization was performed successfully without posterior cerebral artery and superior cerebellar artery obliteration. Endovascular treatment with microcoils appear particularly safe for moyamoya patients with cerebral saccular aneurysms.

Ruptured Intracranial Aneurysm Successfully Treated by Clipping in a Patient with Idiopathic Thrombocytopenic Purpura: A Case Report / 대한뇌혈관외과학회지

We report here on a case of a ruptured left posterior communicating artery (P-com) aneurysm that was treated by clipping in a patient with idiopathic thrombocytopenic purpura (ITP) and steroids were used to control the platelet count during the perioperative period. A 34-year-old female who had been suffering from ITP for four years experienced the sudden onset of a headache and vomiting while showering. She was referred to our hospital as a case of subarachnoid hemorrhage (SAH) due to a ruptured P-com aneurysm. Aneurysmal neck clipping was performed via the left pterional approach 6 hours after the ictus. The aneurysmal clipping was successful without an increased bleeding tendency during the operation. Intravenous steroid injection was given after aneurysmal clipping for 7 days and then it was tapered off. It is important to maintain an adequate platelet count in SAH patients with chronic ITP in order to avoid hemorrhagic diathesis during surgery. Intravenous steroid injection is a helpful method for maintaining an adequate platelet count in these patients during surgery.

Clinical Analysis of Risk Factors Related to Recurrent Chronic Subdural Hematoma

OBJECTIVE: Burr hole drainage has been widely used to treat chronic subdural hematoma (CSDH). However, the incidence of recurrent CSDH varies from 3.7 to 30% after surgery. The authors attempted to elucidate the risk factors associated with the recurrence of CSDH in one burr hole drainage technique. METHODS: A total of 255 consecutive cases who underwent one burr hole drainage for CSDH were included in this study. Twenty-four patients (9.4%) underwent a repeated operation because of the recurrence of CSDH. We analyzed retrospectively the demographic, clinical and radiologic factors associated with the recurrence of CSDH. RESULTS: In this study, two risk factors were found to be independently associated with the recurrence of CSDH. The incidence of CSDH recurrence in the high- and mixed-density groups was significantly higher than those in the low- and iso-density groups (p<0.001). Bleeding tendency such as in leukemia, liver disease and chronic renal failure was also significantly associated with recurrence of CSDH (p=0.037). CONCLUSION: These results suggest that high- and mixed-density shown on computed tomographic scan was closely relates with a high incidence of recurrence. Therefore, the operation could be delayed in those cases unless severe symptoms or signs are present. Reoperation using the previous burr hole site is a preferred modality to treat the recurrent CSDH.

Syringomyelia Associated with Posterior Fossa Tumor: Case Report

The authors describe three patients of syringomyelia associated with posterior fossa tumor. The lesions were diagnosed by magnetic resonance imaging. Total removal of tumor without decompression of foramen magnum was done and regression of syringomyelia and improvement of symptoms were demonstrated. It is suggested that the blockage of cerebrospinal fluid flow at the foramen magnum by tonsilar herniation may play an important role in syrinx formation.

Outcome of Endoscopic Third Ventriculostomy

OBJECTIVE: The authors review 17 cases of obstructive hydrocephalus treated with endoscopic third ventriculostomy to elucidate the adequate age, indication, surgical technique and radiologic criteria. METHODS: From March 1998 to August 2002, 17 endoscopic third ventriculostomies were performed(11 male and 6 female patients). The operation records and neuroimaging studies of the patients were reviewed retrospectively. RESULTS: The age of the patients ranged from 2 months to 70 years(mean age 21 years). Hydrocephalus was caused by aqueductal stenosis in 8 patients, tumor in 8(pineal mass: 5, cystic mass in third ventricle: 2 cerebellar mass: 1), cavernous angioma in 1. The overall success rate was 64.7%(11/17). In the present study, the preoperative increased intracranial pressure symptom was a reliable indicator of surgical outcome. The lateral ventricular size and the III ventricle width reduction, the presence of a signal void on the third ventricle floor appeared to correlate with clinical success. But the cystic mass in the third ventricle was less likely to benefit. Complications were bleeding in 3, infections in 2 and transient III and VI nerve palsy in one case, but there was no permanent morbidity or mortality. CONCLUSION: Endoscopic third ventriculostomy is a safe, simple, effective alternative treatment option of obstructive hydrocephalus in appropriate patient selection.