Clear cell ependymomas (CCEs) are rare variants of ependymomas. Tumors show anaplastic histological features and behave as an aggressive manner. CCEs have a predilection for extraneural metastases and early recurrence, and they demonstrate characteristic radiographic features. These tumors should be radiologically and pathologically differentiated from oligodendrogliomas. On microscopic examination, CCEs are composed of sheets of cells and resemble oligodendroglioma. However, upon closer examination, the nature of CCEs can be detected earlier, resulting in prompt treatment of the tumor. Although we report only one case, we emphasize the importance of early diagnosis and treatment. Future description of more cases of these rare cancers is necessary to aid in their diagnosis and treatment.
Clear cell; Ependymoma; Oligodendroglioma; Histology; Prognosis
Osteolipoma is an ossified lipoma with distinct components of fat and bone. We present a case of interhemispheric osteolipoma associated with total agenesis of the corpus callosum. A 20-year-old man complained of severe headache, nausea and vomiting. Brain computed tomography showed a low-density mass in an interhemispheric fissure, with high T1 and T2 magnetic resonance signals compatible with fat. The mass measured 4.9 × 2.9 cm in size and showed peripheral calcifications. There was another small piece of same signal mass within the lateral ventricular choroid plexus. The interhemispheric lesion was removed by an interhemispheric approach. Osteolipoma is rare in interhemispheric region, however, it should be a differential diagnosis of lesions with fat intensity mass and calcifications.
Agenesis; Corpus callosum; Intracranial; Lipoma; Osteolipoma
Langerhans' cell histiocytosis (LCH) is a rare immunologic disorder characterized by histiocyte proliferation in multiple organ systems. Eosinophilic granuloma, a benign bone lesion, represents a focal form of LCH. We experienced a case of Langerhans' cell histiocytosis in a patient who presented with intracranial epidural hematoma and cyst on the midline of the frontal skull. A 10-year-old boy presented with a rapidly growing large scalp mass on the midline frontal area after mild head trauma. The scalp mass was painless and immobile. Plain skull x-ray showed a punched-out bone lesion. Computed tomography and magnetic resonance imaging showed a non-enhancing osteolytic lesion presenting with an epidural hematoma and cyst on the midline of the frontal skull. The lesion of the skull was completely resected and the patient's recovery was uneventful. The acute presentation of a solitary eosinophilic granuloma of skull with an epidural hematoma has been described in only five cases in the literature and we report the first case of LCH presenting as an intracranial epidural hematoma on frontal area.
Langerhans' cell histiocytosis; Epidural hematoma; Eosinophilic granuloma; Head trauma
Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. C-reactive protein (CRP) constitutes a highly sensitive inflammatory marker. Elevation of serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between CRP levels in the serum and transcranial Doppler (TCD) and the development of vasospasm in patients with aSAH.
A total of 61 adult patients in whom aSAH was diagnosed were included in the study from November 2008 to May 2011. The patients' demographics, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum CRP measurements were obtained on days 1, 3, 5, 7, 9, 11 and 13 and TCD was measured on days 3, 5, 7, 9, 11 and 13. All patients underwent either surgical or endovascular treatment within 24 hours of their hemorrhagic attacks.
Serum CRP levels peaked on the 3rd postoperative day. There were significant differences between the vasospasm group and the non-vasospasm group on the 1st, 3rd and 5th day. There were significant differences between the vasospasm group and the non-vasospasm group on the 3rd day in the mean middle cerebral artery velocities on TCD.
Patients with high levels of CRP on the 1st postoperative day and high velocity of mean TCD on the 3rd postoperative day may require closer observation to monitor for the development of vasospasm.
Cerebral aneurysms; C-reactive protein; Subarachnoid hemorrhage; Vasospasm
Detection of focal non-hemorrhagic lesion (NHL) has become more efficient in diffuse axonal injury (DAI) patients using an MRI. The aims of this study are to find out the radiological distribution, progress of NHL and its clinical significance.
Between September 2005 and October 2011, 32 individuals with NHLs on brain MRI were enrolled. NHLs were classified by brain location into 4 major districts and 13 detailed locations including cortical and subcortical, corpus callosum, deep nuclei and adjacent area, and brainstem. The severity of NHL was scored from grades 1 to 4, according to the number of districts involved. Fourteen patients with NHL were available for MRI follow-up and an investigation of the changes was conducted.
Thirty-two patients had 59 NHLs. The most common district of NHL was cortical and subcortical area; 15 patients had 20 NHSs. However the most common specific location was the splenium of the corpus callosum; 14 patients had 14 lesions. The more lesions patients had, the lower the GCS, however, this was not a statistically meaningful difference. On follow-up MRI in 14 patients, out of 24 lesions, 13 NHLs resolved, 5 showed cystic change, and 6 showed atrophic changes.
NHLs were located most commonly in the splenium and occur frequently in the thalamus and the mesial temporal lobe. Because most NHS occur concomitantly with hemorrhagic lesions, it was difficult to determine their effects on prognosis. Since most NHLs resolve completely, they are probably less significant to prognosis than hemorrhagic lesions.
Traumatic brain injury; Diffuse axonal injury; Magnetic resonance imaging; Corpus callosum; Non-hemorrhagic
Chronic neck or back pain can be managed with various procedures. Although these procedures are usually well-tolerated, a variety of side effects have been reported. In this study we reviewed cases of unexpected temporary adverse events after blocks and suggest possible causes.
We reviewed the records of patients treated with spinal pain blocks between December 2009 and January 2011. The types of blocks performed were medial branch blocks, interlaminar epidural blocks and transforaminal epidural blocks. During the first eight months of the study period (Group A), 2% mepivacaine HCL and triamcinolone was used, and during the last six months of the study period (Group B), mepivacaine was diluted to 1% with normal saline.
There were 704 procedures in 613 patients. Ten patients had 12 transient neurologic events. Nine patients were in Group A and one was in Group B. Transient complications occurred in four patients after cervical block and in eight patients after lumbar block. Side effects of lumbar spine blocks were associated with the concentration of mepivacaine (p<0.05). The likely causes were a high concentration of mepivacaine in five patients, inadvertent vascular injection in three patients, intrathecal leak of local anesthetics in one, and underlying conversion disorder in one.
Spinal pain blocks are a good option for relieving pain, but clinicians should always keep in mind the potential for development of inevitable complications. Careful history-taking, appropriate selection of the anesthetics, and using real-time fluoroscopy could help reduce the occurrence of adverse events.
Adverse effect; Spinal pain; Conversion disorder; Medial branch blocks; Paralysis; C2 ganglion block
Symptoms of deep cerebral vein thrombosis (DCVT) are variable and nonspecific. Radiologic findings are essential for the diagnoses. In the majority of cases of deep internal cerebral venous thrombosis, the thalamus is affected bilaterally, and venous hypertension by thrombosis causes parenchymal edema or venous infarction and may sometimes cause venous hemorrhage. Intravenous injections of mannitol can be administered or decompressive craniectomy can be performed for reduction of intracranial pressure. The objectives of antithrombotic treatment in DCVT include recanalization of the sinus or vein, and prevention of propagation of the thrombus. Herein, the authors report DCVT which was successfully treated by low molecular weight heparin.
Intracranial thrombosis; Venous thrombosis; Cerebral infarction; Brain edema
Pituitary apoplexy is life-threatening clinical syndrome caused by the rapid enlargement of a pituitary tumor due to hemorrhage and/or infarction. The pathogenesis of pituitary apoplexy is not completely understood. We analyzed the magnetic resonance imaging (MRI) of pituitary tumors and subsequently correlated the radiological findings with the clinical presentation. Additionally, immunohistochemistry was also performed to determine whether certain biomarkers are related to radiological apoplexy.
Thirty-four cases of pituitary adenoma were enrolled for retrospective analysis. In this study, the radiological apoplexy was defined as cases where hemorrhage, infarction or cysts were identified on MRI. Acute clinical presentation was defined as the presence of any of the following symptoms: severe sudden onset headache, decreased visual acuity and/or visual field deficit, and acute mental status changes. Angiogenesis was quantified by immunohistochemical expression of fetal liver kinase 1 (Flk-1), neuropilin (NRP) and vascular endothelial growth factor (VEGF) expression, while microvascular density (MVD) was assessed using Endoglin and CD31.
Clinically, fourteen patients presented with acute symptoms and 20 for mild or none clinical symptoms. Radiologically, fifteen patients met the criteria for radiological apoplexy. Of the fifteen patients with radiologic apoplexy, 9 patients presented acute symptoms whereas of the 19 patient without radiologic apoplexy, 5 patients presented acute symptoms. Of the five biomarkers tracked, only VEGF was found to be positively correlated with both radiological and nonradiological apoplexy.
While pituitary apoplexy is currently defined in cases where clinical symptoms can be histologically confirmed, we contend that cases of radiologically identified pituitary hemorrhages that present with mild or no symptoms should be designated subacute or subclinical apoplexy. VEGF is believed to have a positive correlation with pituitary hemorrhage. Considering the high rate of symptomatic or asymptomatic pituitary tumor hemorrhage, additional studies are needed to detect predictors of the pituitary hemorrhage.
Pituitary adenoma; Pituitary apoplexy; Pituitary hemorrhage; Angiogenesis; Microvascular density; VEGF
Spontaneous acute subdural hematomas (aSDH) secondary to ruptured intracranial aneurysms are rarely reported. This report reviews the clinical features, diagnostic modalities, treatments, and outcomes of this unusual and often fatal condition.
We performed a database search for all cases of intracranial aneurysms treated at our hospital between 2005 and 2010. Patients with ruptured intracranial aneurysms who presented with aSDH on initial computed tomography (CT) were selected for inclusion. The clinical conditions, radiologic findings, treatments, and outcomes were assessed.
A total of 551 patients were treated for ruptured intracranial aneurysms during the review period. We selected 23 patients (4.2%) who presented with spontaneous aSDH on initial CT. Ruptured aneurysms were detected on initial 3D-CT angiography in all cases. All ruptured aneurysms were located in the anterior portion of the circle of Willis. The World Federation of Neurosurgical Societies grade on admission was V in 17 cases (73.9%). Immediate decompressive craniotomy was performed 22 cases (95.7%). Obliteration of the ruptured aneurysm was achieved in all cases. The Glasgow outcome scales for the cases were good recovery in 5 cases (21.7%), moderate disability to vegetative in 7 cases (30.4%), and death in 11 cases (47.8%).
Spontaneous aSDH caused by a ruptured intracranial aneurysm is rare pattern of aneurysmal subarachnoid hemorrhage. For early detection of aneurysm, 3D-CT angiography is useful. Early decompression with obliteration of the aneurysm is recommended. Outcomes were correlated with the clinical grade and CT findings on admission.
Acute subdural hematoma; Subarachnoid hemorrhage; Intracranial aneurysm; CT angiography
Lumbar spinal stenosis (LSS) is a common spinal disease in the elderly. The cardinal symptom of LSS is neurogenic claudication, but not all patients present with such typical symptom. The clinical symptoms are often confused with symptoms of peripheral neuropathy, musculo-skeletal disease and other medical conditions in elderly patients. In particular, LSS presenting with rapid progression of leg weakness must be distinguished from other combined diseases. We report a case of rapid progressive leg weakness in a patient with LSS and iatrogenic adrenal insufficiency that was induced by obscure health supplement.
Leg weakness; Lumbar spinal stenosis; Adrenal insufficiency
The majority of cases of pneumocephalus are secondary to trauma or medical intervention. Spontaneous, non-traumatic pneumocephalus is an uncommon condition. Most cases of spontaneous pneumocephalus require surgery. However, if there is no evidence of infection or cerebrospinal fluid leak, bed rest and follow-up imaging is an alternative treatment. Herein, we report a 31-year-old man with spontaneous pneumocephalus associated with pneumosinus dilatans.
Spontaneous pneumocephalus; Hyperpneumatization; Pneumosinus dilatans
Arteriovenous malformations (AVM) are generally considered to be cured following angiographically proven complete resection. However, rare instances of AVM recurrence have been reported in both children and adults with negative findings on postoperative angiography. The authors present the case of a 12-year-old boy with recurrent AVM. The AVM was originally fed by the pericallosal arteries on both sides, and it showed changing patterns of supply at recurrence. The authors concluded that a negative postoperative angiogram is not necessarily indicative of a cure. Repeat angiography and regular follow-up examinations should be performed to exclude the possibility of recurrence, especially in children.
Arteriovenous malformations; Cerebral angiography; Recurrence
Malignant peripheral nerve sheath tumors (MPNSTs) are very rare tumors. We experienced a case of MPNST in the cervical paraspinal space which was not associated with neurofibromatosis. The tumor located in left C6-7 foramen and compressed C7 root. The tumor was removed through the occipital triangle. We report a case of the primary cerivcal MPNST in a patient who did not have neurofibromatosis-1.
Malignant peripheral nerve sheath tumor; Cervical paraspinal space; Occipital triangle
Balloon kyphoplasty can effectively relieve the symptomatic pain and correct the segmental deformity of osteoporotic vertebral compression fractures. While many articles have reported on the effectiveness of the procedure, there has not been any research on the factors affecting the deformity correction. Here, we evaluated both the relationship between postoperative pain relief and restoration of the vertebral height, and segmental kyphosis, as well as the various factors affecting segmental deformity correction after balloon kyphoplasty.
Between January 2004 and December 2006, 137 patients (158 vertebral levels) underwent balloon kyphoplasty. We analyzed various factors such as the age and sex of the patient, preoperative compression ratio, kyphotic angle of compressed segment, injected PMMA volume, configuration of compression, preoperative bone mineral density (BMD) score, time interval between onset of symptom and the procedure, visual analogue scale (VAS) score for pain rating and surgery-related complications.
The mean postoperative VAS score improvement was 4.93±0.17. The mean postoperative height restoration rate was 17.8±1.57% and the kyphotic angle reduction was 1.94±0.38°. However, there were no significant statistical correlations among VAS score improvement, height restoration rate, and kyphotic angle reduction. Among the various factors, the configuration of the compressed vertebral body (p=0.002) was related to the height restoration rate and the direction of the compression (p=0.006) was related with the kyphotic angle reduction. The preoperative compression ratio (p=0.023, p=0.006) and injected PMMA volume (p<0.001, p=0.035) affected both the height restoration and kyphotic angle reduction. Only the preoperative compression ratio was found to be as an independent affecting factor (95% CI : 1.064-5.068).
The two major benefits of balloon kyphoplasty are immediate pain relief and local deformity correction, but segmental deformity correction achieved by balloon kyphoplasty does not result in additional pain relief. Among the factors that were shown to affect the segmental deformity correction, configuration of the compressed vertebral body, direction of the most compressed area, and preoperative compression ratio were not modifiable. However, careful preoperative consideration about the modifiable factor, the PMMA volume to inject, may contribute to the dynamic correction of the segmental deformity.
Balloon kyphoplasty; Compression fracture; Deformity; Restoration
In this study, we compared the paramedian interfascial approach (PIA) and the traditional midline approach (MA) for lumbar fusion to determine which approach resulted in the least amount of postoperative back muscle atrophy. We performed unilateral transforaminal posterior lumbar interbody fusion via MA on the symptomatic side and pedicle screw fixation via PIA on the other side in the same patient. We evaluated the damage to the paraspinal muscle after MA and PIA by measuring the preoperative and postoperative paraspinal muscle volume in 26 patients. The preoperative and postoperative cross-sectional area, thickness, and width of the multifidus muscle were measured by computed tomography. The degree of postoperative paraspinal muscle atrophy was significantly greater on the MA side than on the contralateral PIA side (-20.7% and -4.8%, respectively, p<0.01). In conclusion, the PIA for lumbar fusion yielded successful outcomes for the preservation of paraspinal muscle in these 26 patients. We suggest that the success of PIA is due to less manipulation and retraction of the paraspinal muscle and further studies on this technique may help confirm whether less muscle injury has positive effects on the long-term clinical outcome.
Paraspinal Muscle; Paramedian Approach; Muscle Atrophy; Lumbar Spine
In the present study, we investigated whether ginseng total saponins (GTSs) protect hippocampal neurons after experimental traumatic brain injury (TBI) in rats. A moderate-grade TBI was made with the aid of a controlled cortical impact (CCI) device set at a velocity of 3.0 m/sec, a deformation of 3.0 mm, and a compression time of 0.2 sec at the right parietal area for adult male Sprague-Dawley rats. Sham-operated rats that underwent craniectomy without impact served as controls. GTSs (100 and 200 mg/kg) or saline was injected intraperitoneally into the rats immediately post-injury. Twenty-four hours after the injury, the rats underwent neurological evaluation. Contusion volume and the number of hippocampal neurons were calculated with apoptosis evaluated by TUNEL staining. 24 hr post-injury, saline-injected rats showed a significant loss of neuronal cells in the CA2 region of the right hippocampus (53.4%, p<0.05) and CA3 (34.6%, p<0.05) compared with contralateral hippocampal region, a significant increase in contusion volume (34±8 µL), and significant increase in neurologic deficits compared with the GTSs groups. Treating rats with GTSs seemed to protect the CCI-induced neuronal loss in the hippocampus, decrease cortical contusion volume, and improve neurological deficits.
Brain Injuries; Panax; Saponins; Neuroprotective Agents; Hippocampus
An animal model of spinal cord trauma is essential for understanding the injury mechanisms, cord regeneration, and to aid the development of new therapeutic modalities. This study focused on the development of a graded experimental contusion model for spinal cord injury (SCI) using a pneumatic impact device made in Korea. A contusive injury was made to the dorsal aspect of the cord. Three trauma groups were defined according to the impact velocity (IV). A control group (n=6), received laminectomy only. Group 1 (n=10), 2 (n=10), and 3 (n=10) had IVs of 1.5 m/sec, 2.0 m/sec, and 3.5 m/sec respectively. Functional assessments were made up to the 14th day after injury. The cord was removed at the 14th post-injury day and prepared for histopathologic examination. Significant behavioral and histopathological abnormalities were found in control and each trauma group. All trauma groups showed severe functional impairment immediately after injury but following different rates of functional recovery (Fig. 5). As the impact velocity and impulse increased, the depth of contusive lesion revealed to be profound the results show that the rat model reproduces spinal cord lesions consistently, has a distinctive value in assessing the effects of impact energy.
Models, Animal; Spinal Cord Injuries; Equipment and Supplies; Equipment Design
Neural stem cells in the brain have been shown to be ‘cells of origin’ of certain brain cancers, most notably astrocytomas and medulloblastoma. In particular, in a mouse model, the targeting of genetic modifications for astrocytoma-relevant tumor suppressors to neural stem cells causes malignant astrocytoma to arise, thereby suggesting that astrocytoma is derived from neural stem cells. However, it remains to be determined whether this important finding is reproducible in humans. Herein, we generated cancerous neural stem cells by introducing a set of oncogenes to human fetal neural stem cells (hfNSCs). Serial genetic modification with v-myc for immortalization and consequent H-Ras for oncogenic stimulation with viral gene delivery proved sufficient to induce the transformation of hfNSCs. The resultant F3.Ras cells evidenced a variety of the hallmarks of brain cancer stem cells and most importantly were tumorigenic, forming brain cancers consisting of both a large number of differentiated and a very few undifferentiated populations of cells in an in vivo mouse model. On the contrary, oligodendrocytes derived from the v-myc expressing parent neural stem cells were not transformed by H-Ras, which suggests that neural stem cells may be more susceptible to cancerous transformation by a combination of oncogenes. We also determined that v-myc expressing fetal neural stem cells were defective in p53 response upon the introduction of H-Ras; this finding suggests that an insufficient p53-dependent tumor suppressive mechanism would be associated with high oncogenic susceptibility to H-Ras introduction.
Human neural stem cells; v-myc; H-Ras; Cancerous stem cells; p53; Glial tumor