Life-threatening hemispheric stroke is associated with a high mortality and morbidity. Decompressive hemicraniectomy has been regarded as an effective treatment option for refractory intracranial hypertension. Here, we reported the clinical course of 5 children with decompressive craniectomy and duroplasty after non-traumatic refractory intracranial hypertension.
Four toddlers and one preschool-girl were included in this study; there were 3 boys and 2 girls with a mean age of 34.6 months (range 17-80). Decompressive craniectomy including duroplasty was performed in cases of dilatation of pupil size after intensified standard medical therapy had proven insufficient. All children had a Pediatric Glasgow Coma Scale score <8 at pre-operation state. The mean time-point of craniectomy after stroke attack was 12 hours (range 4-19).
During the long-term follow-up period (mean 47.6 months), no children died. One year later, when we checked their Glasgow Outcome Scale scores, only one toddler received a score of 4 (moderate disability). But the others had good recoveries although they had minor physical or mental deficits. According to the Pediatric Cerebral Performance Category Scale, 4 children received a score of 2 (mild disability).
Despite our small cases, we suggest that decompressive hemicraniectomy and duroplasty is an acceptable and life-saving treatment for refractory intracranial hypertension after unilateral hemispheric stroke in toddlers and preschool children.
Decompressive craniectomy; Stroke; Pediatric; Outcome
Two-thirds of ependymomas arise in the infratentorial or intraventricles, whereas one-third are located supratentorially. But supratentorial "cortical" ependymomas are very rare. We report a case of a cortical ependymoma in a 21-month-old boy. The patient presented with simple partial seizures. This tumor was located in the postcentral gyrus and he had gross total excision. Microscopy and immunohistochemistry showed grade II differentiation ependymoma.
Ependymoma; Pediatrics; Supratentorial neoplasm; Immunohistochemistry
We present a case of Neuro-Behçet's disease with an unpredictable clinical course. A 47-year-old man was admitted to the neurosurgery department of our hospital with a mild headache. Three days after admission, his consciousness suddenly decreased and respiratory distress progressed rapidly. A brain MRI revealed that the previously observed abnormal signal had extended markedly to both the thalamic areas and the entire brain stem, and the surrounding brain parenchyma were compressed by cerebral edema. Based on the patient's symptoms of recurrent oral and genital ulcers, skin lesions, and uveitis, a rheumatologist made a diagnosis of Behçet's disease with CNS involvement. The patient was treated with high-dose methylprednisolone with respiratory assistance in the intensive care unit for 9 days and his neurologic symptoms improved remarkably. Neuro-Behçet's disease must be considered in the differential diagnosis in rapidly deteriorated young neurological patients along with a stroke, low-grade glioma, multiple sclerosis, and occlusive venous disease.
Behçet's disease; Neuro-Behçet's disease; Central Nerve System manifestation; Neurological deterioration
We report a rare case of petroclival craniopharyngioma with no connection to the sellar or suprasellar region. MRI and CT images revealed a homogenously enhancing retroclival solid mass with aggressive skull base destruction, mimicking chordoma or aggressive sarcoma. However, there was no calcification or cystic change found in the mass. Here, we report the clinical features and radiographic investigation of this uncommon craniopharyngioma arising primarily in the petroclival region.
Craniopharyngioma; skull base; petroclival
Giant lymph node hyperplasia (Castleman's disease) is a nonneoplastic lymphoproliferative disorder of unknown etiology that usually occurs in the chest. Its morphological recognition is based on a composition of various histological features. The mass is often asymptomatic, but it can cause nonspecific thoracic symptoms, such as regional pain. This disease can be found wherever lymph nodes are present, but two-thirds of these tumors are found in the chest, along the tracheobronchial tree in the mediastinum or lung hilus. However, we experienced an unusual case of Castleman's disease as a cause of back pain that was localized in the posterior mediastinum bordering the chest wall.
Castleman's disease; Giant lymph node hyperplasia; Hyaline vascular type; Mediastinum; Back pain
In this study, we investigate the role of adiponectin in the interaction between leukocytes and endothelium in the secondary inflammatory reaction of cerebral ischemia.
Adiponectin knock-out mice group (APN-KO) (n = 8) and wild-type mice group (WT) (n = 8) were prepared. Each group was sub-divided into 2 groups by reperfusion time. One-hour middle cerebral artery occlusion and reperfusion were induced using the intraluminal filament technique. At 6 and 12 hours after the occlusion, the mice were placed on a stereotactic frame to perform craniotomy in the left parietal area. After craniotomy, a straight pial venule was selected as a target vessel. With the fluorescence intravital microscope, the number of rolling leukocytes and leukocytes that adhered to endothelium were counted and documented at 6 and 12 hours after the reperfusion.
At 6 and 12 hours after the reperfusion, more rolling leukocyte and leukocyte adhesion were observed in the APN-KO mice than in the WT mice. The difference in leukocyte numbers between the APN-KO and WT mice was found to be statistically significant (p = 0.029) by Mann-Whitney U-test.
We found that adiponectin inhibits the interaction between the endothelium and leukocytes in cerebral ischemia-reperfusion. Therefore adiponectin might prevent the secondary insult caused by the inflammation reaction.
Adiponectin; Cerebral ischemia; Secondary inflammatory reaction; MCAO-R
Rapidly developed de novo aneurysm is very rare. We present a rapidly developed and ruptured de novo anterior communicating aneurysm 8 days after the rupture of another aneurysm. This de novo aneurysm was not apparent in the initial 3-dimensional computed tomography and digital subtraction angiography. We reviewed the literature and discussed possible mechanisms for the development of this de novo aneurysm.
De novo aneurysm; Subarachnoid hemorrhage; Aneurysm formation; Computed tomography angiography; Digital subtraction angiography
Cerebral aspergillosis is rare and usually misdiagnosed because its presentation is similar to that of a tumor. The correct diagnosis is usually made intra-operatively. Cerebral abscess with fungal infection is extremely rare and few cases have been reported, but it carries a poor prognosis.
A 73 year-old man presented with decreased visual acuity and paresis of the right cranial nerve III. Magnetic resonance imaging (MRI) revealed a mass in the right cavernous sinus, extened to the anterior crainial fossa and the superior orbital fissure. During surgery, a well encapsulated pus pocket was found, and histopathological examination of the mass resulted in the diagnosis of aspergillosis. Despite appropriate anti-fungal treatment, the patient eventually died from fatal cerebral ischemic change and severe brain swelling.
The correct diagnosis of cerebral aspergillosis can only be achieved by histopathological examination because clinical and radiological findings including MRI are not specific. Surgical intervention and antifungal therapy should be considered the optimal treatment. Early diagnosis and aggressive antifungal treatment provide good results.
Aspergillosis; Brain abscess; Neuroaspergillosis; Voriconazole
In an oxygen-depleted environment, endothelial cells initiate an adaptive pattern of synthesis, which may enable them to survive hypoxic crises. Using high-resolution two-dimensional gel electrophoresis in conjunction with mass spectroscopy, we obtained a 24 differential display of proteins in the pancreatic endothelial cell line, MS-1, at four time points following induction of hypoxia. The induction of Wee1 under hypoxia was confirmed both at the mRNA and protein levels. The phosphorylation of cell division cycle 2, which is downstream of Wee1, was also increased after hypoxic exposure. In addition, pre-exposure to hypoxia attenuated a decrease in hydrogen peroxide-induced cell number. The induction of bax (a pro-apoptotic protein) and reduction of bcl (an anti-apoptotic protein) after hypoxia stimulus were also attenuated by hypoxic pre-exposure. Moreover, hydrogen peroxide-induced morphologic damage did not appear in the wild-type Wee1-expressing cells. Taken together, our results suggest that Wee1 may have important role in hypoxia-induced pathophysiological situations in endothelial cells.
cell hypoxia; endothelial cells; hydrogen peroxide; hypoxia inducible factor 1, α subunit; Wee1 protein, human
There is still debate over which method of the surgery is the most appropriate for the treatment of scaphocephalic infants. In addition, change in psychomotor development following these procedures is a very complex issue that has not yet been resolved. In this paper, the authors describe a surgical technique for immediate spontaneous shape correction of infantile scaphocephaly. There were significant differences between pre- and postoperative cephalic index. We also describe an improvement in the developmental quotient following surgery. Therefore, this expantile zigzag craniectomy should be recommended to correct for isolated sagittal craniosynostosis in infants.
Scaphocephaly; Cephalic index; Developmental quotient; Expantile zigzag craniectomy
Radiofrequency (RF) medial branch neurotomy is an effective management of lumbar facet syndrome. However, pain may recur after period of time. When pain recurs, it can be repeated, but the successful outcome and duration of relief from repeated procedures are not clearly known. The objective of this study was to determine the success rate and duration of pain relief from repeated radiofrequency medial branch neurotomy for lumbar facet syndrome.
A retrospective review of medical records was done on 60 consecutive patients, from March of 2006 to February of 2009, who had an initial successful RF neurotomy but subsequently underwent repeated procedures due to recurrence of pain. All procedures were done in carefully selected patients after at least two responsive medial branch nerve blocks. C-arm fluoroscopic guide, impedance, sensory and motor threshold monitoring tools were used for the precise placement of electrodes. Responses of repeated procedures were compared with initial radiofrequency neurotomy for success rates and duration of pain relief.
There were 48 females and 12 males. Mean age was 52.4 years (range, 26-83). RF medial branch neurotomy was done on one side in 38 and both sides in 22 patients, each covering at least three segments. Average visual analog scale at last procedure was 6.8. Twelve patients had previous lumbar operations, including 4 patients with instrumentations. Fifty-five patients had two procedures and five patients had three procedures. Mean duration of successful pain relief (> 50% of previous pain for at least 3 months period) after initial radiofrequency neurotomy was 10.9 months (range, 3-28) in 51 (85%) patients. From repeated procedures, successful pain relief was seen in 50 (91%) patients with average duration of 10.2 months (range, 3-24). Five patients had third procedure, which was successful in 4 (80%) patients with mean duration of 9.8 months (range, 5-16). This was not statistically different from initial results. There were no permanent neurological complications from the procedures.
Results of this study indicate that the frequency of success and durations of relief from repeated RF medial branch neurotomy for lumbar facet syndrome are similar to initial results that provided relatively prolonged period of pain relief without major side effects. Each procedure seems to provide successful pain relief for about 10 months in more than 85% of carefully selected patients when properly done.
Facet syndrome; Zygapophyseal joint denervation; Radiofrequency neurotomy; Repeat operation; Outcome
Aim of study was to find a proper method for assessing subsidence using a radiologic measurement following anterior cervical discectomy and fusion (ACDF) with stand-alone polyetheretherketone (PEEK), Solis™ cage.
Forty-two patients who underwent ACDF with Solis™ cage were selected. With a minimum follow-up of 6 months, the retrospective investigation was conducted for 37 levels in 32 patients. Mean follow-up period was 18.9 months. Total intervertebral height (TIH) of two fused vertebral bodies was measured on digital radiographs with built-in software. Degree of subsidence (ΔTIH) was reflected by the difference between the immediate postoperative and follow-up TIH. Change of postoperative disc space height (CT-MRΔTIH) was reflected by the difference between TIH of the preoperative mid-sagittal 2D CT and that of the preoperative mid-sagittal T1-weighted MRI.
Compared to preoperative findings, postoperative disc height was increased in all cases and subsidence was observed only in 3 cases. For comparison of subsidence and non-subsidence group, TIH and CT-MRΔTIH of each group were analyzed. There was no statistically significant difference in TIH and CT-MRΔTIH between each group at 4 and 8 weeks, but a difference was observed at the last follow-up TIH (p=0.0497).
ACDF with Solis™ cage was associated with relatively good radiologic long-term results. Fusion was achieved in 94.5% and subsidence occurred in 8.1% by the radiologic assessment. Statistical analysis reveals that the subsidence seen later than 8 weeks after surgery and the development of subsidence does not correlate statistically with the change of the postoperative disc space height.
Cervical PEEK cage; Radiologic assessment; subsidence; Fusion rate; Anterior cervical discectomy and fusion
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.
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).
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.
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.
Cerebral infarct; Brain edema; Decompression; Surgery; Craniectomy
The purpose of the present study was to assess the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following the treatment. The results of this study showed that RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. In conclusion, RF cervical zygapophyseal joint neurotomy has shown to provide substantial pain relief in patients with chronic cervicogenic headache
when carefully selected.
Cervicogenic Headache; Zygapophyseal Joint; Radiofrequency Neurotomy