Jong-Myong Lee

Surgical Management of Anterior Cerebral Artery Aneurysms of the Proximal (A1) Segment

OBJECTIVE To report a series of 20 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery (ACA. METHODS The medical records of patients who had undergone surgery for intracranial aneurysms at two institutions between January 1, 1989, and February 1, 2009, were reviewed. Mean patient age was 52.15 years (range 39-69 years). All 20 patients underwent direct surgery, with clipping or trapping, via standard pterional craniotomy. RESULTS The incidence of A1 segment aneurysm was 0.59%. There were 16 women and 4 men, showing a strong predominance of this lesion in women. Mean aneurysm size was 6.95 mm (range 3-10 mm). Four patients (20%) had multiple aneurysms, and three patients (15%) had associated vascular anomalies. Among patients whose aneurysms originated from perforating arteries, dissection sacrificed the perforating arteries in two patients, and the perforating arteries occluded postoperatively in three patients. In the patients whose aneurysms did not originate from perforating arteries, no perforating arteries were sacrificed during dissection, and perforating arteries became occluded in two patients postoperatively. There was no statistically significant difference between the two groups of patients regarding the incidence of injury or occlusion. Clinical outcomes were as follows: good recovery in 15 (75%) patients, moderate disability in 2 (10%) patients, severe disability in 2 (10%) patients, and death in 1 (5%) patient. CONCLUSIONS The important consideration in surgery for intracranial aneurysms is preservation of the perforating arteries, through cautious dissection around the neck or dome and avoidance of direct clip compression, even after releasing the retracted frontal lobe.

Malignant Transformation of an Epidermoid Cyst in the Cerebellopontine Angle

Intracranial squamous cell carcinoma is extremely rare, with most of the cases arising from malignant transformation of an epidermoid or a dermoid cyst. The patient presented with facial weakness. Initial magnetic resonance imaging revealed a mass in the right cerebellopontine angle. A subtotal resection was performed via right retrosigmoid suboccipital approach. Histopathological findings were consistent with an epidermoid tumor. Five months later, the patient underwent gamma knife radiosurgery due to highly probable recurrent epidermoid tumor. Two years after, the patients neurological deficit had been newly developed, and follow-up magnetic resonance imaging demonstrated a large contrast-enhancing tumor in the left cerebellopontine angle, which compressed the brainstem. After resection of the tumor, histopathological examinations revealed a squamous cell carcinoma probably arising from an underlying epidermoid cyst. We report a case of an epidermoid tumor in the cerebellopontine angle that transformed into a squamous cell carcinoma.

Hemimasticatory spasm treated with microvascular decompression of the trigeminal nerve

Hemimasticatory spasm is a very rare disorder of the trigeminal nerve characterized by paroxysmal involuntary contraction of the jaw-closing muscles. The mechanisms leading to hemimasticatory spasm are still unclear. Recently, injection of botulinum toxin has become the treatment of choice due to its excellent results. We report a case of a successful treatment of hemimasticatory spasm via microvascular decompression of the motor branch of the trigeminal nerve.

Surgery versus Conservative Treatment for Spontaneous Supratentorial Intracerebral Hemorrhage in Spot Sign Positive Patients.

Objective An advantage of surgical treatment over conservative treatment of spontaneous intracerebral hemorrhage (ICH) is controversial. Recent reports suggest that contrast extravasations on CT angiography (CTA) might serve as a crucial predictor of hematoma expansion and mortality. The purpose of this study was aimed at investigating the efficacy of surgical treatment in patients with spot sign positive ICH. Methods We used our institutional medical data search system to identify all adult patients who admitted for treatment of ICH between January 1, 2007 and January 31, 2012. Patients were classified two groups into a surgical group (n=27) and a conservative treatment group (n=28). Admission criteria were the following: age 20-79 years, spontaneous supratentorial ICH, Glasgow Coma Score Ranging from 9 to 14, ICH volume ≥20 mL, and treatment within 24 hours. Results Fifty-five patients were analyzed. There was no significant difference in the ICU stay between the conservative treatment group (7.36±3.66 days) and the surgical treatment group (6.93±2.20 days; p=0.950). There was a significant difference in the in-hospital stay between the conservative treatment group (13.93±8.87 days) and the surgical treatment group (20.33±6.37 days; p=0.001). Overall mortality at day 90 after ICH was 36.4%; this included 16 of 28 patients (57.1%) in the conservative group and 4 of 27 patients (14.8%) in the surgical group. In univariate analysis, there was a positive effect of the surgical treatment in reducing mortality at 90 days (p=0.002), Glasgow Outcome Scale (GOS) at 90-day (p=0.006), and modified Rankin Scale (mRS) at 90-day (p=0.023). In multivariate logistic analysis, there was a significant difference in mortality (odds ratio, 0.211; 95% confidence interval, 0.049-0.906; p=0.036) between the groups at 90-day follow-up. However, there was no significant difference in GOS (odds ratio, 0.371; 95% confidence interval, 0.031-4.446; p=0.434) and mRS (odds ratio, 1.041; 95% confidence interval, 0.086-12.637; p=0.975) between the groups at 90-day follow-up. Conclusion In this study of surgical treatment of supratentorial ICH in patients with spot sign positive in CTA was associated with less mortality despite of long duration of in-hospital stay. We failed to show that clinical outcome benefit of surgical treatment compared with conservative treatment in patients with spot sign positive ICH.

Cerebral Infarction Presenting with Unilateral Isolated Foot Drop

Weakness of the dorsiflexor muscles of the ankle or toe, referred to as foot drop, is a relatively common presentation. In most cases, foot drop is caused by a lower motor neuron disease such as peroneal peripheral neuropathy, L4-5 radiculopathic sciatic neuropathy, or polyneuropathy. Although upper motor neuron lesions can present as foot drop, the incidence is very rare. Here, we report an extremely rare case in which foot drop was the only presenting symptom of cerebral infarction.

Surgical Recanalization of Distal Middle Cerebral Artery Occlusion Due to a Coil Migration During Endovascular Coil Embolization: A Case Report

Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.

Visualization of a Traumatic Pseudoaneurysm at Internal Carotid Artery Bifurcation due to Blunt Head Injury: A Case Report

Traumatic intracranial pseudoaneurysms occurring after blunt head injuries are rare. We report an unusual case of subarachnoid hemorrhage (SAH) caused by rupturing of the traumatic pseudoaneurysm of the internal carotid artery (ICA) bifurcation that resulted from a non-penetrating injury. In a patient with severe headache and SAH in the right sylvian cistern, which developed within 7 days after a blunt-force head injury, a trans-femoral cerebral angiogram (TFCA) showed aneurysmal sac which was insufficient to confirm the pseudoaneurysm. We obtained a multi-slab image of three dimensional time of flight (TOF) of magnetic resonance angiography (MRA). The source image of the gadolinium-enhanced MRA revealed an intimal flap within the intracranial ICA bifurcation, providing a clue for the diagnosis of a dissecting pseudoaneurysm at the ICA bifurcation due to blunt head trauma. We performed direct aneurysmal neck clipping, without neurological deficit. A follow-up TFCA did not show either aneurysm sac or luminal narrowing. We suggest that in the patient with a history of blunt head injury with SAH following shortly, multi-slab image of 3D TOF MRA can give visualization of the presence of a pseudoaneurysm.

Spontaneous Spinal Epidural Hematoma With Hemiparesis Masquerading as Acute Cerebral Infarction: A Case Report

Acute onset hemiparesis is a common initial presentation of cerebral ischemic stroke. However, other possibilities should be considered as well before final diagnosis. Motor deficits resulting from spontaneous spinal epidural hematoma (SSEH) are usually paraparesis or quadriparesis, but a few cases of SSEH that presented hemiparesis have been documented and misdiagnosed as cerebral ischemic stroke. Herein, we present a rare case of SSEH with acute hemiparesis, which was initially misdiagnosed.

Gamma Knife radiosurgery in steroid-intolerant Tolosa-Hunt syndrome: case report

Tolosa-Hunt syndrome is a rare cause of painful ophthalmoplegia due to idiopathic chronic granulomatous inflammation in the cavernous sinus. Usually clinical manifestations are well controlled by corticosteroid therapy, but steroid dependency or resistance is common. We report a case of marked improvement of Tolosa-Hunt syndrome without symptom relapse after Gamma Knife radiosurgery in a patient with steroid intolerance.