Choi Sk

Clinical Factors for the Development of Posttraumatic Hydrocephalus after Decompressive Craniectomy.

OBJECTIVE Earlier reports have revealed that the incidence of posttraumatic hydrocephalus (PTH) is higher among patients who underwent decompressive craniectomy (DC). The aim of this study was to determine the influencing factors for the development of PTH after DC. METHODS A total of 693 head trauma patients admitted in our hospital between March 2004 and May 2007 were reviewed. Among thee, we analyzed 55 patients with severe traumatic brain injury who underwent DC. We excluded patients who had confounding variables. The 33 patients were finally enrolled in the study and data were collected retrospectively for these patients. The patients were divided into two groups: non-hydrocephalus group (Group I) and hydrocephalus group (Group II). Related factors assessed were individual Glasgow Coma Score (GCS), age, sex, radiological findings, type of operation, re-operation and outcome. RESULTS Of the 693 patients with head trauma, 28 (4.0%) developed PTH. Fifty-five patients underwent DC and 13 (23.6%) developed PTH. Eleven of the 33 study patients (30.3%) who had no confounding factors were diagnosed with PTH. Significant differences in the type of craniectomy and re-operation were found between Group I and II. CONCLUSION It is suggested that the size of DC and repeated operation may promote posttraumatic hydrocephalus in severe head trauma patients who underwent DC.

Rapid Expansion of Hypertensive Intracerebral Hemorrhage

We report a series of 10 patients who had a rapid expansion of a hypertensive intracerebral hemorrhage (HICH). It occurred in approximately 3% of 320 patients who sought treatment for HICH during the past 2 years. The site of hemorrhage was the putamen in 6 patients and the thalamus in 4 patients. Neurological deterioration occurred in a mean time of 40 hours after the onset of symptoms (range, 5.5-109 h). Fifty percent of all patients deteriorated within 24 hours. Persistent hypertension was recorded in all patients. Repeat computed tomography showed an increase of hematoma volume that was twice as large in thalamic hemorrhage and about three times as large in putaminal hemorrhage. Six patients died, whereas 3 survived with severe disability and 1 survived with moderate disability. This study indicates that continued or subsequent bleeding can occur in HICH. If those lesions are not detected early and microsurgically evacuated, they are almost always fatal. Early stereotactic evacuation with urokinase irrigation is considered more dangerous than open craniotomy by microsurgical techniques. We stress the need for attention to this problem during the acute phase of HICH.

Morphological study of sinus flow in the confluence of sinuses.

The confluence of sinuses (CS; torcular herophili) is represented by the junction of the superior sagittal (SSS), straight (SS), occipital (OS), and two transverse sinuses (TS). The objective of this study was to interpret sinus flow around the CS by morphological investigation of the sinuses. This study is based on visual examination of dural venous sinuses in the region of the CS in 31 adult cadavers. In the inflow zone, we examined the direction of SSS and SS flow. In the communication zone, we examined the extent to which outflow sinuses communicate with other sinuses. In the outflow zone, we used the diameters of outflow sinuses to determine anatomical dominance. The SSS entered the CS via the right TS in 16 cases (51.6%) and via the center of the CS in 14 cases (45.2%). The SS entered via the center of the CS in 18 cases (58.1%) and via the left TS in 11 cases (35.5%). Outflow sinuses communicated freely in 26 cases (83.8%) and communicated partially in five cases (16.2%). Partial communication was the result of a septate CS. In terms of outflow, the right TS was dominant in 11 cases (35.5%), and in 18 cases (58.1%), outflow was symmetrical. The direction of SSS inflow was different from that of SS inflow, and partial communication was observed in five cases (16.1%). Therefore, the presence of a septum may be considered an anatomical factor, with implications in diagnosis or in the sacrifice of the outflow sinus of the CS. Clin. Anat. 21:294–300, 2008.

Posterior Cervical Inclinatory Foraminotomy for Spondylotic Radiculopathy Preliminary

Posterior cervical foraminotomy is an attractive therapeutic option in selected cases of cervical radiculopathy that maintains cervical range of motion and minimize adjacent-segment degeneration. The focus of this procedure is to preserve as much of the facet as possible with decompression. Posterior cervical inclinatory foraminotomy (PCIF) is a new technique developed to offer excellent results by inclinatory decompression with minimal facet resection. The highlight of our PCIF technique is the use of inclinatory drilling out for preserving more of facet joint. The operative indications are radiculopathy from cervical foraminal stenosis (single or multilevel) with persistent or recurrent root symptoms. The PCIFs were performed between April 2007 and December 2009 on 26 male and 8 female patients with a total of 55 spinal levels. Complete and partial improvement in radiculopathic pain were seen in 26 patients (76%), and 8 patients (24%), respectively, with preserving more of facet joint. We believe that PCIF allows for preserving more of the facet joint and capsule when decompressing cervical foraminal stenosis due to spondylosis. We suggest that our PCIF technique can be an effective alternative surgical approach in the management of cervical spondylotic radiculopathy.

Morphometric Study of the Korean Adult Pituitary Glands and the Diaphragma Sellae

OBJECTIVE To investigate the morphometric characteristics of the pituitary gland and diaphragma sellae in Korean adults. METHODS Using the 33 formaline fixed adult cadavers (23 male, 10 female), the measurements were taken at the diaphragma sellae and pituitary gland. The authors investigated the relationship between dura and structures surrounding pituitary gland, morphometric aspects of pituitary gland and stalk, and morphometric aspect of central opening of diaphragma sellae. RESULTS The boundary between the lateral surface of pituitary gland and the medial wall of cavernous sinus was formed by the thin dural layer and pituitary capsule. The pituitary capsule adherent tightly to the pituitary gland was observed to continue from the diaphragma sellae. Mean width, length, and height of the pituitary gland were 14.3 +/- 2.1, 7.9 +/- 1.3, and 6.0 +/- 0.9 mm in anterior lobes, and 8.7 +/- 1.7, 2.9 +/- 1.1, and 5.8 +/- 1.0 mm in posterior lobes, respectively. Although all dimensions of anterior lobe in female were slightly larger than those in male, statistical significance was noted in only longitudinal dimension. The ratio of posterior lobe to the whole length of pituitary gland was about 27%. The mean thickness of pituitary stalk was 2 mm. The diaphragmal opening was 5 mm or more in 26 (78.8%) of 33 specimen. The opening was round in 60.6% of the specimen, and elliptical oriented in an anterior-posterior or transverse direction in 39.4%. CONCLUSION These results provide the safe anatomical knowledge during the transsphenoidal surgery and may be helpful to access the possibility of the development of empty sella syndrome.

A Morphometric Aspect of the Brachial Plexus in the Periclavicular Region

OBJECTIVE The purpose of this study was to determine the normal morphometric landmarks of the uniting and dividing points of the brachial plexus (BP) in the periclavicular region to provide useful guidance in surgery of BP injuries. METHODS A total of 20 brachial plexuses were obtained from 10 adult, formalin-fixed cadavers. Distances were measured on the basis of the Chassaignac tubercle (CT), and the most lateral margin of the BP (LMBP) crossing the superior and inferior edge of the clavicle. RESULTS LMBP was located within 25 mm medially from the midpoint in all subjects. In the supraclavicular region, the upper trunk uniting at 21 +/- 7 mm from the CT, separating into divisions at 42 +/- 5 mm from the CT, and dividing at 19 +/- 4 mm from the LMBP crossing the superior edge of the clavicle. In the infraclavicular region, the distance from the inferior edge of the clavicle to the musculocutaneous nerve (MCN) origin was 49 +/- 1 mm, to the median nerve origin 57 +/- 7 mm, and the ulnar nerve origin 48 +/- 6 mm. From the lateral margin of the pectoralis minor to the MCN origin the distance averaged 3.3 +/- 10 mm. Mean diameter of the MCN was 4.3 +/- 1.1 mm (range, 2.5-6.0) in males (n = 6), and 3.1 +/- 1.5 mm (range, 1.6-4.0) in females (n = 4). CONCLUSION We hope these data will aid in understanding the anatomy of the BP and in planning surgical treatment in BP injuries.

Morphometric Study of the Upper Thoracic Sympathetic Ganglia

OBJECTIVE Morphometric data for the sympathetic ganglia (SG) of the upper thoracic spine was investigated to identify the exact location of the SG in order to reduce normal tissue injury in the thoracic cavity during thoracoscopic sympathectomy. METHODS In 46 specimens from 23 formalin-fixed adult cadavers, the authors measured the shortest distance from the medial margin of the T1, T2 and T3 SG to the most prominent point and medial margin of the corresponding rib heads, and to the lateral margin of the longus colli muscle. In addition, the distance between the most prominent point of the rib head and the lateral margin of longus colli muscle and the width of each SG were measured. RESULTS The shortest distance from the medial margin of the SG to the prominent point of corresponding rib head was on average 1.9 mm on T1, 4.2 mm, and 4.1 mm on T2, T3. The distance from the medial margin of the SG to the medial margin of the corresponding rib head was 4.2 mm on T1, 5.9 mm, and 6.3 mm on T2, T3. The mean distance from the medial margin of the SG to the lateral margin of the longus colli muscle was 6.7 mm on T1, 8.8 mm, 9.9 and mm on T2, T3. The mean distance between the prominent point of the rib head and the lateral margin of the longus colli muscle was 4.8 mm on T1, 4.6 mm, and 5.9 mm on T2, T3. The mean width of SG was 6.1 mm on T1, 4.1 mm, and 3.1 mm on T2, T3. CONCLUSION We present morphometric data to assist in surgical planning and the localization of the upper thoracic SG during thoracoscopic sympathectomy.