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1.  Glioma Mimicking a Hypertensive Intracerebral Hemorrhage 
Here, we report a rare case of an anaplastic astrocytoma masquerading as a hypertensive basal ganglia hemorrhage. A 69-year-old woman who had been under medical management for hypertension during the past 3 years suddenly developed right hemiparesis with dysarthria. Brain computed tomography (CT) scans with contrast and CT angiograms revealed an intracerebral hemorrhage (ICH) in the left basal ganglia, without an underlying lesion. She was treated conservatively, but underwent a ventriculoperitoneal shunt operation 3 months after the initial attack due to deteriorated mental status and chronic hydrocephalus. Three months later, her mental status deteriorated further. Magnetic resonance imaging (MRI) with gadolinium demonstrated an irregular enhanced mass in which the previous hemorrhage occurred. The final histological diagnosis which made by stereotactic biopsy was an anaplastic astrocytoma. In the present case, the diagnosis of a high grade glioma was delayed due to tumor bleeding mimicking hypertensive ICH. Thus, a careful review of neuroradiological images including MRI with a suspicion of tumor bleeding is needed even in the patients with past medical history of hypertension.
doi:10.3340/jkns.2013.54.2.125
PMCID: PMC3809438  PMID: 24175027
Basal ganglia; Intracerebral hemorrhage; Tumor bleeding; Brain tumor; Hypertension; Anaplastic astrocytoma
2.  Ruptured Saccular Aneurysm Arising from Fenestrated Proximal Anterior Cerebral Artery : Case Report and Literature Review 
The aneurysm arising from fenestrated proximal anterior cerebral artery (ACA) is considered to be unique. The authors report a case of a 59-year-old woman who presented with a subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm originating from the fenestrated A1 segment of right ACA. The patient had another unruptured aneurysm which was located at the right middle cerebral artery bifurcation. She was successfully treated with surgical clipping for both aneurysms. From the previously existing literatures, we found 18 more cases (1983-2011) of aneurysms associated with fenestrated A1 segment. All cases represented saccular type of aneurysms, and 79% of the patients had SAH. There were three subtypes of the fenestrated A1 aneurysms depending on the anatomical location, relative to the fenestrated segment. The most common type was the aneurysms located on the proximal end of fenestrated artery (82%). Azygos ACA and hypoplastic A1 were frequently accompanied by the aneurysm (33% and 31%, respectively), and multiple aneurysms were shown in three cases (16%). Considering that fenestrated A1 segment is likely to develop an aneurysm, which has high risk of rupture, early management may benefit patients with aneurysms accompanied by fenestrated proximal ACA.
doi:10.3340/jkns.2013.53.5.293
PMCID: PMC3730031  PMID: 23908703
Anterior cerebral artery; Cerebral aneurysm; Fenestration
3.  Customized Cranioplasty Implants Using Three-Dimensional Printers and Polymethyl-Methacrylate Casting 
Objective
The prefabrication of customized cranioplastic implants has been introduced to overcome the difficulties of intra-operative implant molding. The authors present a new technique, which consists of the prefabrication of implant molds using three-dimensional (3D) printers and polymethyl-methacrylate (PMMA) casting.
Methods
A total of 16 patients with large skull defects (>100 cm2) underwent cranioplasty between November 2009 and April 2011. For unilateral cranial defects, 3D images of the skull were obtained from preoperative axial 1-mm spiral computed tomography (CT) scans. The image of the implant was generated by a digital subtraction mirror-imaging process using the normal side of the cranium as a model. For bilateral cranial defects, precraniectomy routine spiral CT scan data were merged with postcraniectomy 3D CT images following a smoothing process. Prefabrication of the mold was performed by the 3D printer. Intraoperatively, the PMMA implant was created with the prefabricated mold, and fit into the cranial defect.
Results
The median operation time was 184.36±26.07 minutes. Postoperative CT scans showed excellent restoration of the symmetrical contours and curvature of the cranium in all cases. The median follow-up period was 23 months (range, 14-28 months). Postoperative infection was developed in one case (6.2%) who had an open wound defect previously.
Conclusion
Customized cranioplasty PMMA implants using 3D printer may be a useful technique for the reconstruction of various cranial defects.
doi:10.3340/jkns.2012.52.6.541
PMCID: PMC3550422  PMID: 23346326
Decompressive craniectomy; Reconstructive surgical procedure; Computer-aided design; Polymethyl-methacrylate
4.  Comparison of cerebrospinal fluid biomarkers between idiopathic normal pressure hydrocephalus and subarachnoid hemorrhage-induced chronic hydrocephalus: A pilot study 
Summary
Background
We examined the cerebrospinal fluid (CSF) markers of subarachnoid hemorrhage (SAH)-induced and idiopathic normal pressure hydrocephalus (INPH) to investigate the pathophysiology and mechanism of communicating hydrocephalus compared to obstructive hydrocephalus.
Material/Methods
We obtained CSF samples from 8 INPH, 10 SAH-induced hydrocephalus, and 6 unmatched patients with non-hemorrhagic obstructive hydrocephalus during their ventriculoperitoneal shunt operations. Transforming growth factor (TGF)-β1, tumor necrosis factor (TNF)-α, vascular endothelial growth factor (VEGF), and total tau in the CSF were analyzed via enzyme-linked immunosorbent assay.
Results
The mean VEGF levels in the CSF of patients with SAH-induced hydrocephalus, INPH, and obstructive hydrocephalus were 239±131, 239±75, and 163±122 pg/mL, respectively. The total tau concentrations in the CSF of the groups were 1139±1900, 325±325, and 1550±2886 pg/mL, respectively. TNF-α values were 114±34, 134±38, and 55±16 pg/mL, respectively. TGF-β1 values were 953±430, 869±447, and 136±63 pg/mL, respectively. A significant difference in TNF-α and TGF-β1 levels was observed only between SAH-induced and chronic obstructive hydrocephalus, and between INPH and chronic obstructive hydrocephalus (p<0.01).
Conclusions
No significant differences in the 4 CSF biomarker levels were observed between INPH and SAH-induced hydrocephalus, whereas CSF TNF-α and TGF-β1 levels were increased compared to those in patients with chronic obstructive hydrocephalus. Post-SAH hydrocephalus and INPH are probably more destructive to neural tissues, and then stimulate the inflammatory reaction and healing process, compared with obstructive hydrocephalus.
doi:10.12659/MSM.883586
PMCID: PMC3560808  PMID: 23197244
cerebrospinal fluid; subarachnoid hemorrhage; normal pressure hydrocephalus; transforming growth factor-β1; tumor necrosis factor-α; vascular endothelial growth factor; total tau
5.  Angiographic Features and Clinical Outcomes of Intra-Arterial Nimodipine Injection in Patients with Subarachnoid Hemorrhage-Induced Vasospasm 
Objective
The aim of this study was to determine the role of intra-arterial (IA) nimodipine injections for cerebral vasospasm secondary to ruptured subarachnoid hemorrhage (SAH) and to investigate the factors that influence vasodilation and clinical outcomes.
Methods
We enrolled 29 patients who underwent aneurysm clipping for ruptured cerebral aneurysms between 2009 and 2011, and who received IA nimodipine after subsequently presenting with symptomatic vasospasm. The degree of vasodilation shown in angiography was measured, and the correlation between the degree of vasodilation and both the interval from SAH to cerebral vasospasm and the interval from clipping to cerebral vasospasm was determined. The change in blood flow rate after IA injection was assessed by transcranial Doppler ultrasound. Multiple clinical parameters were completed before and after IA nimodipine injection to evaluate any improvements in clinical symptoms.
Results
For eight patients, Glasgow Coma Scale (GCS) scores increased by two or more points. The regression analysis demonstrated a positive correlation between the change in GCS scores after IA nimodipine injection and the change in blood vessel diameter (p=0.025). A positive correlation was also observed between the interval from SAH to vasospasm and the change in diameter (p=0.040); and the interval from clipping to vasospasm and the change in diameter (p=0.022).
Conclusion
IA nimodipine injection for SAH-induced vasospasm led to significant vasodilation in angiography and improvement in clinical symptoms without significant complications. Our findings suggest that IA nimodipine injection should be utilized when intractable vasospasm develops despite rigorous conservative management.
doi:10.3340/jkns.2012.52.3.172
PMCID: PMC3483315  PMID: 23115657
Cerebral angiograms; Intra-arterial injection; Nimodipine; Ruptured aneurysm; Subarachnoid hemorrhage; Vasospasm
6.  Increased Vascular Endothelial Growth Factor in the Ventricular Cerebrospinal Fluid as a Predictive Marker for Subsequent Ventriculoperitoneal Shunt Infection : A Comparison Study among Hydrocephalic Patients 
Objective
The aim of this study is to determine the association between the cerebrospinal fluid (CSF) biomarkers and inflammation, and the predictive value of these CSF biomarkers for subsequent shunt associated infection.
Methods
We obtained CSF samples from the patients with hydrocephalus during ventriculoperitoneal (VP) shunt operations. Twenty-two patients were enrolled for this study and divided into 3 groups: subarachnoid hemorrhage (SAH)-induced hydrocephalus, idiopathic normal pressure hydrocephalus (INPH) and hydrocephalus with a subsequent shunt infection. We analyzed the transforming growth factor-β1, tumor necrosis factor-α, vascular endothelial growth factor (VEGF) and total tau in the CSF by performing enzyme-linked immunosorbent assay. The subsequent development of shunt infection was confirmed by the clinical presentations, the CSF parameters and CSF culture from the shunt devices.
Results
The mean VEGF concentration (±standard deviation) in the CSF of the SAH-induced hydrocephalus, INPH and shunt infection groups was 236±138, 237±80 and 627±391 pg/mL, respectively. There was a significant difference among the three groups (p=0.01). Between the SAH-induced hydrocephalus and infection groups and between the INPH and infection groups, there was a significant difference of the VEGF levels (p<0.01). However, the other marker levels did not differ among them.
Conclusion
The present study showed that only the CSF VEGF levels are associated with the subsequent development of shunt infection. Our results suggest that increased CSF VEGF could provide a good condition for bacteria that are introduced at the time of surgery to grow in the brain, rather than reflecting a sequel of bacterial infection before VP shunt.
doi:10.3340/jkns.2012.51.6.328
PMCID: PMC3424171  PMID: 22949960
Cerebrospinal fluid; Shunt infection; Biomarkers; Vascular endothelial growth factor; Hydrocephalus
7.  Successful and safe treatment of hemangioma with oral propranolol in a single institution 
Korean Journal of Pediatrics  2012;55(5):164-170.
Purpose
Dramatic improvement of hemangioma to propranolol has been recently reported; however, details on dose and duration of treatment, potential risks, and monitoring have not been determined. The objective of this study is to describe and analyze the use of propranolol as a first-line treatment or as a single therapy in management of complicated hemangioma.
Methods
A retrospective chart review of eight patients diagnosed with hemangioma and treated with propranolol in Kangbuk Samsung Hospital from February 2010 to April 2011 was performed.
Results
Eight patients with hemangioma with functional impairment, cosmetic disfigurement, or rapid growth were treated with propranolol. Five patients had solitary facial hemangioma. The mean age of symptoms at onset was 5 weeks. The median age for starting propranolol treatment was 5.5 months. Propranolol at 2 mg/kg/day was finally administered in divided doses with a gradual increase. Significant regression was observed in seven patients, and shrinkage in size, softening in consistency, and decrease in redness were evident within 4 weeks. Among them, six patients were still taking propranolol, and one patient had stopped after 12 months. Other one patient did not show significant improvement with satisfactory result after 3 months of propranolol use. Treatment with propranolol was well tolerated and had few side effects. No rebound growth was observed in any of the patients.
Conclusion
We observed that use of propranolol was very effective in treatment of hemangioma without obvious adverse effects or relapse.
doi:10.3345/kjp.2012.55.5.164
PMCID: PMC3362730  PMID: 22670151
Hemangioma; Propranolol; Treatment
8.  Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review 
We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.
doi:10.7461/jcen.2012.14.1.44
PMCID: PMC3471248  PMID: 23210029
Coil embolization; Bilateral proximal internal carotid artery occlusion; Basilar tip aneurysms; Ruptured; Subarachnoid hemorrhage; Collateral circulation
9.  Tuning photoluminescence of organic rubrene nanoparticles through a hydrothermal process 
Nanoscale Research Letters  2011;6(1):405.
Light-emitting 5,6,11,12-tetraphenylnaphthacene (rubrene) nanoparticles (NPs) prepared by a reprecipitation method were treated hydrothermally. The diameters of hydrothermally treated rubrene NPs were changed from 100 nm to 2 μm, depending on hydrothermal temperature. Photoluminescence (PL) characteristics of rubrene NPs varied with hydrothermal temperatures. Luminescence of pristine rubrene NPs was yellow-orange, and it changed to blue as the hydrothermal temperature increased to 180°C. The light-emitting color distribution of the NPs was confirmed using confocal laser spectrum microscope. As the hydrothermal temperature increased from 110°C to 160°C, the blue light emission at 464 to approximately 516 nm from filtered-down NPs was enhanced by H-type aggregation. Filtered-up rubrene NPs treated at 170°C and 180°C exhibited blue luminescence due to the decrease of intermolecular excimer densities with the rapid increase in size. Variations in PL of hydrothermally treated rubrene NPs resulted from different size distributions of the NPs.
doi:10.1186/1556-276X-6-405
PMCID: PMC3211500  PMID: 21711925
10.  Acute Treatment With Herbal Extracts Provides Neuroprotective Benefits in In Vitro and In Vivo Stroke Models, Characterized by Reduced Ischemic Cell Death and Maintenance of Motor and Neurological Functions 
Cell medicine  2010;1(3):137-142.
The present study explored the prophylactic and restorative benefits of cacao and red sage using both in vitro and in vivo models of stroke. For the in vitro study, we initially exposed primary rat cells to the established oxygen-glucose deprivation (OGD) stroke model followed by reperfusion under normoxic conditions, then added different cacao and sage concentrations to the cell culture media. Trypan blue cell viability results revealed specific cacao and sage dosages exerted significant therapeutic effects against OGD-induced cell death compared to cultured cells treated with extract vehicle. We next embarked on testing the therapeutic effects of cacao and sage in an in vivo model of stroke when extract treatment commenced either prior to or after transient middle cerebral artery occlusion (MCAo). Significant reduction in ischemic cell death within the peri-infarct area coupled with better performance in routine motor and neurological tasks were demonstrated by stroke animals that received cacao or sage extracts prior to MCAo compared to those that received the extracts or vehicle after MCAo. In summary, the present results demonstrate that neuroprotective effects were afforded by plant extract treatment, and that the in vitro stroke paradigm approximates in vivo efficacy when considering prophylactic treatment for stroke.
doi:10.3727/215517910X552818
PMCID: PMC3048457  PMID: 21379315
Oxygen-glucose deprivation (OGD); Stroke; Prophylactic; Middle cerebral artery occlusion (MCAo); Plant extracts
11.  Surgical Treatment for Acute, Severe Brain Infarction 
Objective
Stroke is the most prevalent disease involving the central nervous system. Since medical modalities are sometimes ineffective for the acute edema following massive infarction, surgical decompression may be an effective option when medical treatments fail. The present study was undertaken to assess the outcome and prognostic factors of decompressive surgery in life threatening acute, severe, brain infarction.
Methods
We retrospectively analyzed twenty-six patients (17 males and 9 females; average age, 49.7yrs) who underwent decompressive surgery for severe cerebral or cerebellar infarction from January 2003 to December 2006. Surgical indication was based on the clinical signs such as neurological deterioration, pupillary reflex, and radiological findings. Clinical outcome was assessed by Glasgow Outcome Scale (GOS).
Results
Of the 26 patients, 5 (19.2%) showed good recovery, 5 (19.2%) showed moderate disability, 2 (7.7%) severe disability, 6 (23.1%) persistent experienced vegetative state, and 8 (30.8%) death. In this study, the surgical decompression improved outcome for cerebellar infarction, but decompressive surgery did not show a good result for MCA infarction (30.8% overall mortality vs 100% mortality). The dominant-hemisphere infarcts showed worse prognosis, compared with nondominant-hemisphere infarcts (54.5% vs 70%). Poor prognostic factors were diabetes mellitus, dominant-hemisphere infarcts and low preoperative Glasgow Coma Scale (GCS) score.
Conclusion
The patients who exhibit clinical deterioration despite aggressive medical management following severe cerebral infarction should be considered for decompressive surgery. For better outcome, prompt surgical treatment is mandatory. We recommend that patients with severe cerebral infarction should be referred to neurosurgical department primarily in emergency setting or as early as possible for such prompt surgical treatment.
doi:10.3340/jkns.2007.42.4.326
PMCID: PMC2588211  PMID: 19096564
Cerebral infarct; Brain edema; Decompression; Surgery; Craniectomy
12.  Outcome of postoperative intratumoral bleomycin injection for cystic craniopharyngioma. 
Journal of Korean Medical Science  2002;17(2):254-259.
Total excision is a treatment of choice in preventing the relapse of craniopharyngioma, but for tumors involving an extensive area, it is often associated with an increased risk of complications. We have performed a partial or subtotal tumor removal followed by repeated injection of bleomycin into the remaining tumor through a subcutaneous reservoir as postoperative adjuvant therapy. A retrospective review of clinical, radiological, and surgical data was performed for 10 patients (5 males and 5 females; age, 3-65 yr; follow-up duration, 12-79 months) with cystic craniopharyngiomas. The measurements of lactate dehydrogenase (LDH) level at each aspiration were performed. The shrinkage and/or stabilization of tumor was initially noted in all cases. The recurrence of tumor was seen in 4 cases (40%). The decreased or increased level of LDH was interpreted as tumor shrinkage or recurrence, respectively. The transient toxic reactions were observed in 3 patients (30%). Our study demonstrates that postoperative bleo-mycin injection for cystic craniopharyngioma, although does not appear to eradicate the tumor, decreases and stabilizes the tumor size, when used as an adjuvant therapy in young patients.
PMCID: PMC3054855  PMID: 11961313

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