Ealmaan Kim

Intracranial Fusiform Aneurysms: It's Pathogenesis, Clinical Characteristics and Managements

OBJECTIVE The objective of this study is to investigate clinical characteristics, management methods and possible causes of intracranial fusiform aneurysm. METHODS Out of a series of 2,458 intracranial aneurysms treated surgically or endovascularly, 22 patients were identified who had discrete fusiform aneurysms. Clinical presentations, locations, treatment methods and possible causes of these aneurysms were analyzed. RESULTS Ten patients of fusiform aneurysm were presented with hemorrhage, 5 patients with dizziness with/without headache, 4 with ischemic neurologic deficit, and 1 with 6th nerve palsy from mass effect of aneurysm. Two aneurysms were discovered incidentally. Seventeen aneurysms were located in the anterior circulation, other five in the posterior circulation. The most frequent site of fusiform aneurysm was a middle cerebral artery. The aneurysms were treated with clip, and/or wrapping in 7, resection with/without extracranial-intracranial (EC-IC) bypass in 6, proximal occlusion with coils with/without EC-IC bypass in 5, EC-IC bypass only in 1 and conservative treatment in 3 patient. We obtained good outcome in 20 out of 22 patients. The possible causes of fusiform aneurysms were regard as dissection in 16, atherosclerosis in 4 and collagen disease or uncertain in 2 cases. CONCLUSION There is a subset of cerebral aneurysms with discrete fusiform morphology. Although the dissection or injury of internal elastic lamina of the cerebral vessel is proposed as the underlying cause for most of fusiform aneurysm, more study about pathogenesis of these lesions is required.

Spontaneous Intracranial Hypotension: Clinical Presentation, Imaging Features and Treatment

OBJECTIVE In the present study, the authors investigated the clinical and imaging features as well as the therapeutic outcomes of SIH (spontaneous intracranial hypotension) patients. METHODS A retrospective review of 12 SIH patients was carried out. The diagnostic work-up included lumbar tapping and measurement of CSF opening pressure, radioisotope cisternography, brain and spinal magnetic resonance imaging (MRI), and computed tomography (CT) myelography. Autologous epidural blood patching was performed in patients who did not respond to conservative therapies, including analgesics, steroids, hydration and rest. RESULTS Typical postural headache was found in 11 (91%) patients. Nine (75%) patients showed pachymeningeal enhancement on their initial T1-weighted MR images. The CSF opening pressure was less than 60 mmH(2)O in 9 of 11 patients. Autologous epidural blood patching was performed in 7 patients, and all of them showed good responses. CONCLUSION SIH can present with various clinical presentations and neuroimaging findings. Autologous epidural blood patching is thought to be the treatment of choice for patients with SIH.

External decompressive craniectomy including resection of temporal muscle and fascia in malignant hemispheric infarction

Decompressive craniectomy procedures are used for malignant hemispheric infarctions. However, the temporal muscle and fascia are significant limiting factors for external herniation of an edematous brain. Therefore, the authors performed a decompressive craniectomy and expansive duraplasty combined with resection of the temporal muscle and fascia for 15 patients with a malignant hemispheric infarction. The volume of the maximum external herniation that was measured on the basis of a CT volumetry study ranged from 130 to 300 ml (mean +/- standard deviation, 200 +/- 64 ml) on postoperative Day 3.2 +/- 1.5 (range 2-5 days postoperatively). The mean value represented a 2-fold volume expansion in comparison with the conventional decompressive craniectomy, and the greater the external herniation obtained by external decompression, the smaller the midline brain shift after surgery. The mortality rate, favorable outcomes (modified Rankin Scale Scores 1-3), and unfavorable outcomes were 20, 60, and 20%, respectively, and the masticatory function was only minimally affected. Furthermore, a cranioplasty involving reconstruction of the temporal muscle defect performed using a MEDPOR implant resulted in good cosmetic outcomes with no temporal hollow. Resection of the temporal muscle in a decompressive craniectomy was shown to provide greater decompression and better clinical outcomes for malignant hemispheric infarctions at an acceptable cost of minimal masticatory dysfunction and cosmetic disfigurement.

Symptomatic Rathke Cleft Cyst: Clinical Features and Surgical Outcomes

OBJECTIVE To depict the clinical, operative, and histological features of Rathke cleft cysts (RCCs) in consideration of therapeutic results and recurrence rates. METHODS This study included 40 patients (29 female; mean age, 41 years) of symptomatic RCCs with pathological verification. The mean length of follow-up was 76 months. The patients were treated by complete cyst evacuation combined with partial wall excision (7 via craniotomy and 33 transsphenoidally). All subjects were examined neurologically, radiologically, and biochemically to ascertain the clinical significance of surgery on endocrine and visual improvement. RESULTS Cysts varied in size from 18 to 43 mm (mean, 19.3 mm); 38 (95.0%) had a suprasellar component. Presenting symptoms included headache (75.0%), chiasmopathy (45.0%), and endocrine dysfunction (37.5%). On magnetic resonance imaging, the signal intensities of the cysts were quite variable, with most commonly hyperintensity (75.0%) on T2-weighted and hypointensity (40.0%) on T1-weighted scans, respectively. Cyst contents were found to be mostly mucoid (52.5%) and watery (30.0%). Squamous epithelium was identified in 18 specimens (45.0%). Headaches and visual symptoms resolved or improved in 76.7% and 78.6% of patients, respectively. Hypothyroidism, hypogonadism, growth hormone deficiency, and hypocortisolemia was resolved in 44.4%, 30.0%, 33.3%, and 56.3% of patients, respectively. Two patients (5%) had repeat surgery for symptomatic relapse. Cerebrospinal fluid leakage (2.5%), new hormone deficit (7.5%), and diabetes insipidus (5.0%) were observed after surgery. CONCLUSIONS When RCCs are recognized intraoperatively, the evacuation of their contents and partial cyst obliteration generally afford dramatic improvements in a patients clinical signs and symptoms, along with low complications and rate of recurrence.

Accuracy and Safety of Bedside External Ventricular Drain Placement at Two Different Cranial Sites : Kocher's Point versus Forehead.

OBJECTIVE External ventricular drain (EVD) is commonly performed with a freehand technique using surface anatomical landmarks at two different cranial sites, Kochers point and the forehead. The aim of this study was to evaluate and compare the accuracy and safety of these percutaneous ventriculostomies. METHODS A retrospectively review of medical records and head computed tomography scans were examined in 227 patients who underwent 250 freehand pass ventriculostomy catheter placements using two different methods at two institutions, between 2003 and 2009. Eighty-one patients underwent 101 ventriculostomies using Kochers point (group 1), whereas 146 patients underwent 149 forehead ventriculostomies (group 2). RESULTS In group 1, the catheter tip was optimally placed in either the ipsilateral frontal horn or the third ventricle, through the foramen of Monro (grade 1) in 82 (81.1%) procedures, in the contralateral lateral ventricle (grade 2) in 4 (3.9%), and into eloquent structures or non-target cerebrospinal space (grade 3) in 15 (14.8%). Intracerebral hemorrhage (ICH) >1 mL developed in 5 (5.0%) procedures. Significantly higher incidences of optimal catheter placements were observed in group 2. ICH>1 mL developed in 11 (7.4%) procedures in group 2, showing no significant difference between groups. In addition, the mean interval from the EVD to ventriculoperitoneal shunt was shorter in group 2 than in group 1, and the incidence of EVD-related infection was decreased in group 2. CONCLUSION Accurate and safe ventriculostomies were achieved using both cranial sites, Kochers point and the forehead. However, the forehead ventriculostomies provided more accurate ventricular punctures.

Osteoplastic pterional craniotomy revisited.

BACKGROUND: A standard pterional approach with a free bone flap to treat brain aneurysms was first introduced and popularized by Yaşargil. OBJECTIVE: To describe a modified pterional craniotomy technique and that mobilizes part of the sphenoid wing and the pterion in a block with the temporalis muscle to enhance cosmetic results. METHODS: A subperiosteal corridor is provided inferiorly by separating the temporalis muscle from the underlying bone in a retrograde dissection. Inferior chisel cuts from the front and back enter the sphenoid wing, enabling removal of part of the sphenoid wing and the pterion in 1 piece, along with the bone flap. Forty patients with aneurysms were treated in this fashion, and the cosmetic outcome was examined at 6 months postoperatively. RESULTS: Thirty-seven patients (92.5%) demonstrated an unremarkable degree of temporalis muscle atrophy. Excellent configuration and fusion of the pterional bone flap were observed on 3-dimensional computed tomography scans. CONCLUSION: With the use of this muscle-preserving and bone-sparing pterional approach and with little additional labor, temporalis muscle function is preserved and improved cosmesis is obtained.

Cribriform neuroepithelial tumor in the third ventricle: A case report and literature review

Cribriform neuroepithelial tumor (CRINET) is a very rare and recently described entity of INI1‐deficient intraventricular neuroepithelial tumor of primitive non‐rhabdoid cells with distinct cribriform formation and has a relatively favorable prognosis. A 14‐month‐old boy had presented with gait imbalance and was crawling for the last 2 weeks. MRI revealed a large, complex solid and cystic mass with dimensions of 55 × 55 × 50 mm in the vicinity of the third ventricle. Histopathologically, the tumor was composed of relatively small undifferentiated neuroepithelial cells arranged in a cribriform pattern and intervening solid sheets with true rosettes. Immunohistochemically, the tumor cells showed complete loss of nuclear INI1 expression and distinct expression of epithelial membrane antigen (EMA) along the luminal borders of the tubules or glands. The typical rhabdoid feature of tumor cells was absent. Ultrastructurally, the tumor cells were neuroepithelial cells that contained short linear rough endoplasmic reticula and distinct intercellular junctions. Here, we describe a new case of CRINET and also discuss its clinicopathological, immunohistochemical, and ultrastructural features.

Expression of Cancer-Testis Genes in Brain Tumors

OBJECTIVE Cancer-testis (CT) genes are considered promising candidates for immunotherapeutic approaches. The aim of this study was to investigate which CT genes should be targeted in immunotherapy for brain tumors. METHODS We investigated the expression of 6 CT genes (MAGE-E1, SOX-6, SCP-1, SSX-2, SSX-4, and HOM-TES-85) using reverse-transcription polymerase chain reaction in 26 meningiomas and 32 other various brain tumor specimens, obtained from the patients during tumor surgery from 2000 to 2005. RESULTS The most frequently expressed CT genes of meningiomas were MAGE-E1, which were found in 22/26 (85%) meningioma samples, followed by SOX-6 (9/26 or 35%). Glioblastomas were most frequently expressed SOX-6 (6/7 or 86%), MAGE-E1 (5/7 or 71%), followed by SSX-2 (2/7 or 29%) and SCP-1 (1/7 or 14%). However, 4 astrocytomas, 3 anaplastic astrocytomas, and 3 oligodendroglial tumors only expressed MAGE-E1 and SOX-6. Schwannomas also expressed SOX-6 (5/6 or 83%), MAGE-E1 (4/6 or 67%), and SCP-1 (2/6 or 33%). CONCLUSION The data presented here suggest that MAGE-E1 and SOX-6 genes are expressed in a high percentage of human central nervous system tumors, which implies the CT genes could be the potential targets of immunotherapy for human central nervous system tumors.

Rare variant of persistent primitive hypoglossal artery in magnetic resonance angiography

We present an extremely rare case of a variant of persistent primitive hypoglossal artery, which was found incidentally in magnetic resonance angiography during an examination for dizziness. This anastomotic vessel arose from the external carotid artery (ECA), not internal carotid artery, and entered the hypoglossal canal to basilar artery. To our knowledge, this is the fourth reported case of the persistent hypoglossal artery arising from the ECA. The possible clinical implications of this anomalous vessel are discussed.

Isolated oculomotor nerve palsy following minor head trauma : case illustration and literature review.

Isolated oculomotor nerve palsy (ONP) attributable to mild closed head trauma is a distinct rarity. Its diagnosis places high demands on the radiologist and the clinician. The authors describe this condition in a 36-year-old woman who slipped while walking and struck her face. Initial computed tomography did not reveal any causative cerebral and vascular lesions or orbital and cranial fractures. Enhancement and swelling of the cisternal segment of the oculomotor nerve was seen during the subacute phase on thin-sectioned contrast-enhanced magnetic resonance images. The current case received corticosteroid therapy, and then recovered fully in 13 months after injury. Possible mechanism of ONP from minor head injury is proposed and previous reports in the literature are reviewed.