Young-Jin Song

Predisposing factors related to shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage.

OBJECTIVE Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion. METHODS Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (>/=14 days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography. RESULTS Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence on the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not correlate with the development of shunt-dependent chronic hydrocephalus. CONCLUSION Hydrocephalus after aneurysmal SAH seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.

Olfactory Schwannoma-Case Report-

Intracranial schwannomas preferentially arise from the vestibular branch of the eighth nerve, and rarely from the trigeminal nerve, facial nerve, and lower cranial nerves. Anterior cranial fossa schwannomas are extremely uncommon and few details about them have been reported. The patient was a 39-year-old woman whose chief complaints were anosmia and frontal headache for 2 years. The gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) showed an extra-axial mass from ethmoid sinus to right frontal base region near the midline, with solid enhancement in lower portion and multicystic formation in upper portion. The tumor was totally resected via basal subfrontal approach. At operation, the tumor had cystic portion with marginal calcification and the anterior skull base was destructed by the tumor. The olfactory bulb was involved, and the tumor capsule did not contain neoplastic cells. The histopathological diagnosis was schwannoma. We report a rare case of anterior cranial fossa schwannoma with literature review.

Removal of Intradural-Extramedullary Spinal Cord Tumors with Unilateral Limited Laminectomy

Total laminectomy for the removal of intradural-extramedullary spinal cord tumors has been used widely, but postoperative complications often develop, such as kyphosis, spinal instability, and persistent back pain. In this study, we evaluated seven patients with intradural-extramedullary spinal cord tumors with respect to the value of unilateral limited laminectomy. Our cases included six schwannomas, and one meningioma. The cervical region was involved in four cases, the thoracolumbar region in two cases, and the lumbar region in one case. The rationale for choosing a unilateral approach is to preserve musculoligamentous attachments and posterior bony elements as much as possible. The patients were mobilized on the third postoperative day and preoperative neurological symptoms were recovered within a few weeks. We did not observe any complication relating to unilateral limited laminectomy and at follow-up evaluation (at 3 and 12 months postoperatively), none of the patients showed spinal deformity or spinal instability. We think that the unilateral limited laminectomy is a safe and efficient technique for the treatment of intradural-extramedullary spinal cord tumors. We suggest that this technique is one of the best treatments for these tumors.

Multiple Tuberculoma Involving the Brain and Spinal Cord in a Patient with Miliary Pulmonary Tuberculosis

Although tuberculosis of the central nervous system is well known, the incidence of intramedullary tuberculomas is low and a combination of intramedullary with intracranial tuberculomas is extremely rare. We report a case of disseminated tuberculoma involving brain and spine with miliary pulmonary tuberculosis in a 66-year-old woman initially presenting with fever, general weakness, back pain and motor weakness of both lower extremities. Despite medical therapy, she developed progressive motor weakness of both lower extremities with muscle strength 1/5 in both lower extremities. Urgent surgical intervention was followed and her muscle power and motor functions were improved gradually. The anti-tuberculous drugs were continued and the follow-up magnetic resonance imaging (MRI) of brain and spine showed that the lesions had become smaller or disappeared.

Spinal Intradural Extramedullary Mature Cystic Teratoma in an Adult

Spinal intradural extramedullary teratoma is a rare condition that develops more commonly in children than in adults and may be associated with spinal dysraphism. We report a rare case of adult-onset intradural extramedullary teratoma in the thoracolumbar spinal cord with no evidence of spinal dysraphism and without the history of prior spinal surgery. The patient was a 38-year-old male whose chief complaint was urinary incontinence. X-ray images of the thoracolumbar spine showed the widening of the interpedicular distance and posterior marginal erosion of the vertebral bodies and pedicles at the T11, T12, and L1 level. Magnetic resonance imagings of the lumbar spine showed a lobulated inhomogeneous high signal intradural mass (87x29x20 mm) between T11 and L1 and a high signal fluid collection at the T11 level. Laminectomy of the T11-L1 region was performed, and the mass was subtotally excised. The resected tumor was histopathologically diagnosed as a mature cystic teratoma. The patients symptom of urinary incontinence was improved following the surgery.

Spontaneous intraorbital hemorrhage: a case report.

Intraorbital hemorrhage is a rare clinical condition caused by orbital trauma, surgery around the orbit, intraorbital vascular abnormalities, and neoplasm. It was reported to occur spontaneously without any known causes and in association with orbital pseudotumor in a very few cases. A 59-year-old, female patient admitted with sudden onset of severe exophthalmos and pain on the left eye. Orbital CT and MR imaging suggested hemorrhage in the upper part of retrobulbar area of the left orbit. Cerebral angiography was taken to rule out any possible vascular abnormalities. On the left carotid cerebral angiography, the run-off of the distal ophthalmic artery was not seen and the engorgement of the supraophthalmic artery was noted. Systemic administration of corticosteroid did not improve the clinical status and craniectomy was done and retrobulbar hematoma was removed, and the clinical symptoms and signs were improved. Authors report a case of spontaneous intraorbital hemorrhage with the clinical features similar to those of orbital pseudotumor, requiring surgical decompression.

Measurement of Critical Structures around Paraclinoidal Area : A Cadaveric Morphometric Study.

Objective Although removal of the anterior clinoid process (ACP) is essential surgical technique, studies about quantitative measurements of the space broadening by the anterior clinoidectomy are rare. The purposes of this study are to investigate the dimension of the ACP, to quantify the improved exposure of the parasellar space after extradural anterior clinoidectomy and to measure the correlation of each structure around the paraclinoidal area. Methods Eleven formalin-fixed Korean adult cadaveric heads were used and frontotemporal craniotomies were done bilaterally. The length of C6 segment of the internal carotid artery on its lateral and medial side and optic nerve length were checked before and after anterior clinoidectomy. The basal width and height of the ACP were measured. The relationships among the paraclinoidal structures were assessed. The origin and projection of the ophthalmic artery (OA) were investigated. Results The mean values of intradural basal width and height of the ACP were 10.82 mm and 7.61 mm respectively. The mean length of the C6 lateral and medial side increased 49%. The mean length of optic nerve increased 97%. At the parasellar area, the lengths from the optic strut to the falciform liament, distal dural ring, origin of OA were 6.69 mm, 9.36 mm and 5.99 mm, respectively. The distance between CN III and IV was 11.06 mm. Conclusion With the removal of ACP, exposure of the C6 segments and optic nerve can expand 49% and 97%, respectively. This technique should be among a surgeons essential skills for treating lesions around the parasellar area.

Oculomotor Nerve Schwannoma: A Case Report

Schwannomas account for about 8% of intracranial tumors and 90% are vestibular schwannomas. Oculomotor schwannoma without neurofibromatosis is extremely rare. A 41-year-old female presented with complaints of blurred vision, and the neurologic examination revealed afferent pupillary defect and decreased visual acuity of the left side. Brain magnetic resonance image showed an extra axial mass in the left superior orbital fissure. The patient underwent major surgery via the fronto-temporal approach. The tumor originated from the oculomotor nerve and was subtotally removed under microscopic surgery. The pathological findings confirmed the tumor as a schwannoma. After surgery, ptosis and medial gaze limitation of the left eye was detected, but the symptoms improved gradually.

Meningioma in a 20-Month-Old Boy

A 20-month-old boy presented with a intraparenchymal mass in the right frontoparietal area manifesting as complex partial seizure, secondary generalization and left hemiparesis. Magnetic resonance images (MRI) of the brain showed inhomogeneously enhancing mass in the right frontoparietal area which has irregular margin and perilesional edema. Based on the radiological findings, a preoperative diagnosis was an intraaxial tumor, such as pilocytic astrocytoma or dysembryoplastic neuroepithelial tumor. The patient underwent a surgery including frontal craniotomy. The tumor had a partially extreme adherence to the surrounding brain tissue but it showed no dural attachment. Gross-total resection of the tumor was achieved. Postoperative follow-up computed tomography scans showed no residual tumor. The pathological findings confirmed the tumor as a WHO grade I meningioma, transitional type. Nine months after the surgery, follow-up brain MRI showed no recurrence of the tumor, porencephaly in site where the tumor was resected; the patients symptoms had fully recovered. We report the case of a meningioma in a 20-month-old boy.

Neurocutaneous Melanosis in Association with Dandy-Walker Complex with Extensive Intracerebral and Spinal Cord Involvement

Neurocutaneous melanosis (NCM) is a rare congenital syndrome consisting of benign or malignant melanotic tumors of the central nervous system with large or numerous cutaneous melanocytic nevi. The Dandy-Walker complex (DWC) is characterized by an enlarged posterior fossa with high insertion of the tentorium, hypoplasia or aplasia of the cerebellar vermis, and cystic dilatation of the fourth ventricle. These each two conditions are rare, but NCM associated with DWC is even more rare. Most patients of NCM with DWC present neurological symptoms early in life such as intracranial hemorrhage, hydrocephalus, and malignant transformation of the melanocytes. We report a 14-year-old male patient who was finally diagnosed as NCM in association with DWC with extensive intracerebral and spinal cord involvement.