Solitary intraventricular hemorrhage without subarachnoid hemorrhage due to aneurysmal rupture: a case report.

The presence of primary intraventricular hemorrhage (IVH) without vascular lesion is very rare. We experienced solitary IVH without subarachnoid hemorrhage due to aneurysmal rupture in a 58-year-old man treated with coil embolization, which contributed to his good prognosis. After 33 days of hospitalization, he had mild right hemiplegic symptoms remaining, and he was transferred to a rehabilitation institute for further treatment. In cases of primary IVH, computed tomography angiography seems worthwhile for making a differential diagnosis, although the possibility of IVH due to cerebral aneurysmal rupture is very low. Endovascular intervention is a good option for diagnosis and treatment.

Computational simulation of sacral-alar-iliac (S2AI) screw fixation of pelvis and implications for fluoroscopic procedure: A cadaver study.

PURPOSE: To determine an easy and convenient method of sacral-alar-iliac (S2AI) screw fixation and introduce the surgical landmarks for fluoroscopic procedure by analyzing 3-D models of pelvis and virtual implantation in a 3-D model. MATERIALS AND METHODS: Eighty-two cadavers underwent computed tomography scans and the images imported into Mimics® software to make the 3-D pelvis model. The pedicle screw (Ø 8.5 mm/length 115 mm) was processed into a 3-D model using a 3-D-sensor (Comet5®) at the actual size and virtually placed as the S2AI screw. The ideal screw position was defined as the maximal intraosseous length without cortical perforation along the entire path. The ideal entry point and screw trajectory were verified and assessed to introduce the surgical landmark for fluoroscopic procedure. RESULTS: There was no cortical violation around nerve root canal and greater sciatic notch through the entry point between first and second dorsal sacral foramen. There was no impossible model of S2AI screws. The average screw length was 99.8 mm (range, 59.8-115 mm; standard deviation, 16.1) and just one model had shorter than 65 mm S2AI screw. The factors limiting the intra-iliac screw length were sex ( p = 0.000) and the iliac groove around the sacroiliac joint ( p = 0.000). A free 360° rotation with magnification revealed that the screw trajectory was consistently directed toward the anteroinferior iliac spine (AIIS) in any plane. CONCLUSION: The ideal entry point of S2AI screw showed a wide range of tolerance between the first and second dorsal sacral foramen; and thus, there was no need for deep dissection to identify the first dorsal sacral foramen. Considering the tendency to shift the pilot hole laterally and the ideal screw trajectory was consistently directed toward AIIS, the entry point is better to be located with a medial shift.

Risk Factor Analysis of Change in Intraoperative Neurophysiologic Monitoring During Cervical Open Door Laminoplasty.

OBJECTIVE: The aim of this study is to determine the risk factors affecting intraoperative neurophysiologic monitoring (IONM) changes, when such changes take place, and clinical outcomes associated with IONM change during cervical open door laminoplasty (COL) for cervical compressive myelopathy. METHODS: Between 2010 and 2015, 79 patients who underwent COL with IONM recording were studied. Changes in motor evoked potentials or somatosensory evoked potentials over an alarm criterion were defined as IONM change. Patients with IONM change were assigned to the alarm group, and the others were classified as the control group. Baseline data and radiographic measurements were compared between the 2 groups. Radiologic parameters including maximal compression level (MCL), area and diameter of the spinal canal and ventral compressive lesion, stenosis grade, and occupying ratio of area (ORA) and length at the MCL were measured with magnetic resonance imaging. RESULTS: Thirteen patients were assigned to the alarm group and 66 patients were assigned to the control group. Multivariate analysis identified ORA at the MCL (odds ratio, 1.520; 95% confidence interval, 1.192-1.37; P = 0.001) as an independent risk factor for IONM change. Immediately after decompression, the IONM change occurred. One of 4 patients who did not fully recover from the IONM change had postoperative motor deficits. CONCLUSIONS: IONM change during COL occurred immediately after decompression, and a risk factor of IONM change was ORA at the MCL. If the IONM change was not fully recovered, a new motor deficit occurred after COL.

Cystic Meningiomas: Correlation between Radiologic and Histopathologic Features.

BACKGROUND: Tumors with cysts often correlate with gliomas, metastatic tumors, or hemangioblastomas, which require differentiation. METHODS: Thirty-eight cases of cyst associated-meningioma based on preoperative radiologic studies and histologic confirmations were reviewed from November 1998 to July 2017. RESULTS: A total of 395 cases of meningioma were observed in the 20 years, and surgical treatment of intracranial meningioma was performed in 120 cases. Thirty-eight (9.6%) cases of cyst associated meningiomas were analyzed. Nauta type I was the most common type of cyst (39.5%) and the most frequent histopathological subtype was meningothelial type (36.8%). CONCLUSION: Statistically there were no significant associations between meningioma histopathological type and associated cysts; however, the rate of World Health Organization grade II was higher in cyst associated meningiomas than in unrelated meningiomas. This correlation was weak, in accordance with the meningioma grade.

Cilostazol attenuates kainic acid-induced hippocampal cell death.

Cilostazol is a selective inhibitor of type 3 phosphodiesterase (PDE3) and has been widely used as an antiplatelet agent. Cilostazol mediates this activity through effects on the cyclic adenosine monophosphate (cAMP) signaling cascade. Recently, it has attracted attention as a neuroprotective agent. However, little is known about cilostazol's effect on excitotoxicity induced neuronal cell death. Therefore, this study evaluated the neuroprotective effect of cilostazol treatment against hippocampal neuronal damage in a mouse model of kainic acid (KA)-induced neuronal loss. Cilostazol pretreatment reduced KA-induced seizure scores and hippocampal neuron death. In addition, cilostazol pretreatment increased cAMP response element-binding protein (CREB) phosphorylation and decreased neuroinflammation. These observations suggest that cilostazol may have beneficial therapeutic effects on seizure activity and other neurological diseases associated with excitotoxicity.

Association between bicortical screw fixation at upper instrumented vertebra and risk for upper instrumented vertebra fracture.

OBJECTIVE The aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery. METHODS A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9-L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV. RESULTS The mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence-LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02). CONCLUSIONS Bicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.

Radiographic and Clinical Results of Freehand S2 Alar-Iliac Screw Placement for Spinopelvic Fixation: An Analysis of 45 Consecutive Screws.

STUDY DESIGN: This was a retrospective clinical case series. OBJECTIVE: The purpose of this study was to evaluate mid-term outcomes of S2 ala-iliac (S2AI) screw fixation in patients who underwent multilevel posterior spinal fusion surgery. SUMMARY OF BACKGROUND DATA: There have been few reports on radiographic and clinical outcomes in patients who underwent spinopelvic reconstruction surgery using S2AI screw installation. MATERIALS AND METHODS: Twenty-three patients were treated by a single spinal surgeon between September 2013 and June 2014 utilizing segmental instrumentation with pedicle and S2AI screw. Instrumentation including S2AI screw was performed by a freehand technique. Surgical, radiographic, clinical outcomes and complications were evaluated to determine surgical results of S2AI screw fixation. RESULTS: The mean follow-up period was 16.9 months (ranged, 13-22 mo). The average number of fusion levels was 7.9 vertebral bodies. There were no cases of neurological deficit and violation of acetabulum or sciatic notch. A peri-screw halo was found in 1 patient and cortical wall violation was observed in 4 patients. The number of lateral and medial breaches was 2 and 3, respectively. All of them were asymptomatic. One patient experienced sacroiliac joint pain after S2AI screw installation. There was no case of screw/rod fracture and revision surgery for S2AI screw. CONCLUSIONS: Radiographic and clinical outcomes of freehand S2AI screw fixation was acceptable. Sacroiliac joint irritation symptoms after S2AI screw fixation were rare. S2AI screw instrumentation can be a good alternative for spinopelvic fixation. LEVEL OF EVIDENCE: Level 4.

Multi-channel motor evoked potential monitoring during anterior cervical discectomy and fusion.

OBJECTIVES: Anterior cervical discectomy and fusion (ACDF) surgery is the most common surgical procedure for the cervical spine with low complication rate. Despite the potential prognostic benefit, intraoperative neurophysiological monitoring (IONM), a method for detecting impending neurological compromise, is not routinely used in ACDF surgery. The present study aimed to identify the potential benefits of monitoring multi-channel motor evoked potentials (MEPs) during ACDF surgery. METHODS: We retrospectively reviewed 200 consecutive patients who received IONM with multi-channel MEPs and somatosensory evoked potentials (SSEPs). On average, 9.2 muscles per patient were evaluated under MEP monitoring. RESULTS: The rate of MEP change during surgery in the multi-level ACDF group was significantly higher than the single-level group. Two patients from the single-level ACDF group (1.7%) and four patients from the multi-level ACDF group (4.9%) experienced post-operative motor deficits. Multi-channel MEPs monitoring during single and multi-level ACDF surgery demonstrated higher sensitivity, specificity, positive predictive and negative predictive value than SSEP monitoring. CONCLUSIONS: Multi-channel MEP monitoring might be beneficial for the detection of segmental injury as well as long tract injury during single- and multi-level ACDF surgery. SIGNIFICANCE: This is first large scale study to identify the usefulness of multi-channel MEPs in monitoring ACDF surgery.

Multiple Intradural Disc Herniations Masquerading as Intradural Extramedullary Tumors: A Case Report and Review of the Literature.

Intradural disc herniation is a very rare condition, and multiple intradural disc herniations have not been reported to date. The latter may be confused with intradural extramedullary (IDEM) spinal tumors. Here, we report a case of multiple intradural disc herniations masquerading as multiple IDEM tumors and review the relevant literature. We retrospectively reviewed the patient's medical chart, reviewed the intraoperative microscopic findings, and reviewed of PubMed articles on intradural disc herniation. The masses considered to be IDEM tumors were confirmed to be multiple intradural disc herniations. A nonenhancing mass was found to have migrated along the intra-arachnoid space. Two enhancing masses could not migrate because of adhesion and showed peripheral neovascularization. We report an extremely rare case of multiple intradural lumbar disc herniations showing diverse enhancing patterns and masquerading as multiple IDEM tumors. In case of multiple enhancing IDEM masses suspected preoperatively, surgeons should consider the possibility of intradural disc herniation.

Differences in Multimodality Intraoperative Neurophysiological Monitoring Changes Between Spinal Intramedullary Ependymoma and Hemangioblastoma.

INTRODUCTION: Intraoperative neurophysiological monitoring using transcranial muscle motor evoked potentials (MEPs) and somatosensory evoked potentials is an established method for intramedullary spinal cord tumor surgery. Ependymomas and hemangioblastomas arise in different anatomic locations and require different surgical techniques. The aim of our study was to assess differences in intraoperative neurophysiological monitoring findings between ependymoma and hemangioblastoma. METHODS: Fifty-six limbs from 16 patients diagnosed with ependymoma and 18 limbs from six patients with hemangioblastoma were included. The alarm criterion for MEPs was a 50% decrease in amplitude, whereas for somatosensory evoked potentials, it was a 50% decrease in amplitude and/or a 10% delay in latency. RESULTS: We found that 14 of the 56 ependymoma limbs (25.9%) and 8 of the 18 hemangioblastoma limbs (44.4%) showed MEP decrement during surgery. Eight limbs of patients with ependymoma (57.1%) and one limb of a patient with hemangioblastoma (12.5%) did not show recovery of MEPs at the end of surgery. Among those who showed recovery of MEPs, six ependymoma (10.7%) and six hemangioblastoma (33.3%) limbs did not show postoperative motor deficits (P = 0.04). Finally, 11 limbs of patients with ependymoma and one limb of a patient with hemangioblastoma showed postoperative weakness. CONCLUSIONS: In our study, the incidence of transient changes in MEPs was higher in hemangioblastoma than in ependymoma. Our data suggest that it may be necessary to consider tumor features and the type of surgical technique used, particularly when interpreting intraoperative neurophysiologic monitoring profiles of intramedullary spinal cord tumors such as ependymomas and hemangioblastomas.

Posterior Spinal Reconstruction with Pedicle Screws, Multiple Iliac Screws and Wisconsin Spinal Wires in a Patient with Neurofibromatosis Scoliosis: A Case Report.

A 54-year-old female with neurofibromatosis type 1 presented with progressing truncal shift owing to spinal deformity. On plain radiograph, the Cobb angle was 54 degree in coronal plane. Radiological examinations showed severe dystrophic change with dysplastic pedicles, bony scalloping, neural foraminal widening from dural ectasia. The patient underwent deformity correction and reconstruction surgery from the T9 to the pelvis using multiple iliac screws and Wisconsin interspinous segmental instrumentation by wiring due to maximize fixation points. The postoperative course was uneventful. One-year follow-up radiographs showed a successful curve correction with solid fusion. We report a case of pedicle dysplasia and dystrophic change treated by posterior segmental spinal instrumentation and fusion with help of multiple iliac screws and modified Wisconsin interspinous segmental wiring.

Adolescent Idiopathic Scoliosis Treatment by a Korean Neurosurgeon: The Changing Role for Neurosurgeons.

OBJECTIVE: The purpose of this study was to evaluate radiographic/clinical outcomes of adolescent idiopathic scoliosis (AIS) patients treated by a Korean neurosurgeon. METHODS: Ten AIS patients were treated by a single neurosurgeon between January 2011 and September 2013 utilizing segmental instrumentation with pedicle screws. Basic demographic information, curve pattern by Lenke classification, number of levels treated, amount of correction achieved, radiographic/clinical outcomes [by Scolisis Resarch Society (SRS-22r) questionnaire] and complications were evaluated to determine the surgical results. Pulmonary function test was utilized to assess forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before and after surgery. RESULTS: The average percentage of correction of the major structural curve was 73.6% (ranged from 64% to 81.5%). Preoperative and final postoperative absolute FVC averaged 3.03 L and 3.76 L (0.73 L increase, p=0.046), and absolute FEV1 averaged 2.63 L and 3.49 L (0.86 L increase, p=0.021). Preoperative and final postoperative average self-image and function scores of SRS-22r were, 2.6±0.5, 3.3±0.1, 4.0±0.5, and 4.6±0.0, respectively. There was a significant improvement of the self-image and function scores of SRS-22r questionnaires before and after surgery (p<0.05). There was no case of neurological deficit, infection and revision for screw malposition. One patient underwent a fusion extension surgery for shoulder asymmetry. CONCLUSION: Radiographic/clinical outcomes of AIS patients treated by a Korean neurosurgeon were acceptable. Fundamental understanding of pediatric spinal deformity is essential for the practice of AIS surgery.

Plasmacytoma to the Axis Mimicking Metastatic Paraganglioma: Circumferential Reconstruction via Posterior Approach.

Plasmacytoma is a malignant plasma cell tumor growing within soft tissue or the axial skeleton. Here, we present the case of a patient with plasmacytoma of the axis vertebra who underwent decompressive surgery with reconstruction via a posterior approach. The patient was referred because of quadriparesis with severe neck pain. Magnetic resonance imaging revealed a relatively demarcated, highly enhanced mass lesion in a destructed axis, with spinal cord compression. Computed tomography revealed a 5.6×4.3 cm adrenal mass at the left retroperitoneal space. We suspected the axis lesion to be a metastatic paraganglioma from the adrenal mass. The patient underwent total excision of the tumor under an operative microscope with occipitocervical fixation. Histopathologically, the tumor was shown to be a plasmacytoma. Following the operation, the patient recovered without significant complications. This was a rare case of plasmacytoma in the axis, mimicking metastatic paraganglioma.

Laparotomy versus Laparoscopic Placement of Distal Catheter in Ventriculoperitoneal Shunt Procedure.

OBJECTIVE: Traditionally, peritoneal catheter is inserted with midline laparotomy incision in ventriculoperitoneal (V-P) shunt procedures. Complications of V-P shunt is not uncommon and have been reported to occur in 5-37% of cases. The aim of this study is to compare the clinical outcomes and the operation time between laparotomy and laparoscopic groups. METHODS: A total of 155 V-P shunt procedures were performed to treat hydrocephalic patients of various origins in our institute between June 2006 to January 2010; 95 of which were laparoscopically guided and 65 were not. We reviewed the operation time, surgery-related complications, and intraoperative and postoperative problems. RESULTS: In the laparoscopy group, the mean duration of the procedure (52 minutes) was significantly shorter (p < 0.001) than the laparotomy group (109 minutes). There were two cases of malfunctions and one incidence of diaphragm injury in the laparotomy group. In contrast, there were neither malfunction nor any internal organ injuries in the laparoscopy group (p = 0.034). There were total of two cases of infections from both groups (p = 0.7). CONCLUSION: Laparoscopically guided insertions of distal shunt catheter is considered a fast and safe method in contrast to the laparotomy technique. This method allows the exact localization of the peritoneal catheter and a confirmation of its patency.

Posterior atlantoaxial screw-rod fixation in a case of aberrant vertebral artery course combined with bilateral high-riding vertebral artery.

We present a case of posterior atlantoaxial screw-rod fixation in a patient with an aberrant vertebral artery (VA) course combined with bilateral high-riding VA. An aberrant VA which courses below the posterior arch of the atlas (C1) that does not pass through the C1 transverse foramen and without an osseous anomaly is rare. However, it is important to consider an abnormal course of the VA both preoperatively and intraoperatively in order to avoid critical vascular injuries in procedures which require exposure or control of the VA, such as the far-lateral approach and spinal operations.