Cerebral cavernous malformation with giant cysts is rare and literature descriptions of its clinical features are few. In this case study, the authors describe the clinical symptoms, radiological findings, and pathological diagnosis of cerebral cavernous malformations with giant cysts, reviewing the relevant literature to clearly differentiate this from other disease entities. The authors present a case of a 19-year-old male with a giant cystic cavernous malformation, who was referred to the division of neurosurgery due to right sided motor weakness (grade II/II). Imaging revealed a large homogenous cystic mass, 7.2×4.6×6 cm in size, in the left fronto-parietal lobe and basal ganglia. The mass had an intra-cystic lesion, abutting the basal portion of the mass. The initial diagnosis considered this mass a glioma or infection. A left frontal craniotomy was performed, followed by a transcortical approach to resect the mass. Total removal was accomplished without post-operative complications. An open biopsy and a histopathological exam diagnosed the mass as a giant cystic cavernous malformation. Imaging appearances of giant cavernous malformations may vary. The clinical features, radiological features, and management of giant cavernous malformations are described based on pertinent literature review.
Cavernous malformation; Giant cyst
Superior sagittal sinus thrombosis (SSST) is an uncommon cause of stroke, whose symptoms and clinical course are highly variable. It is frequently associated with a variety of hypercoagulable states. Coagulation abnormalities are commonly seen in patients with hyperthyroidism. To the best of our knowledge, there are few reports on the association between hyperthyroidism and cerebral venous thrombosis. We report on a 31-year-old male patient with a six-year history of hyperthyroidism who developed seizure and mental deterioration. Findings on brain computed tomography (CT) showed multiple hemorrhages in the subcortical area of both middle frontal gyrus and cerebral digital subtraction angiography (DSA) showed irregular intra-luminal filling defects of the superior sagittal sinus. These findings were consistent with hemorrhagic transformation of SSST. Findings on clinical laboratory tests were consistent with hyperthyroidism. In addition, our patient also showed high activity of factors IX and XI. The patient received treatment with oral anticoagulant and prophylthiouracil. His symptoms showed complete improvement. A follow-up cerebral angiography four weeks after treatment showed a recanalization of the SSS. In conclusion, findings of our case indicate that hypercoagulability may contribute to development of SSST in a patient with hyperthyroidism.
Cerebral venous thrombosis; Superior sagittal sinus; Hyperthyroidism; Hypercoagulability
The purpose of this study was to examine the efficacy and perioperative complications associated with lumbar spinal fusion surgery, focusing on geriatric patients in the Republic of Korea.
We retrospectively investigated 485 patients with degenerative spinal diseases who had lumbar spinal fusion surgeries between March 2006 and December 2010 at our institution. Age, sex, comorbidity, American Society of Anesthesiologists (ASA) class, fusion segments, perioperative complications, and outcomes were analyzed in this study. Risk factors for complications and their association with age were analyzed.
In this study, 81 patients presented complications (16.7%). The rate of perioperative complications was significantly higher in patients 70 years or older than in other age groups (univariate analysis, p=0.015; multivariate analysis, p=0.024). The perioperative complications were not significantly associated with the other factors tested (sex, comorbidity, ASA class, and fusion segments). Post-operative outcomes of lumbar spinal fusion surgeries for the patients were determined on the basis of MacNab's criteria (average follow up period : 19.7 months), and 412 patients (85.0%) were classified as having "excellent" or "good" results.
Increasing age was an important risk factor for perioperative complications in patients undergoing lumbar spinal fusion surgery, whereas other factors were not significant. However, patients' satisfaction or return to daily activities when compared with younger patients did not show much difference. We recommend good clinical judgment as well as careful selection of geriatric patients for lumbar spinal fusion surgery.
Complications; Elderly patients; Lumbar spinal fusion surgery
We investigated the clinical outcome of bone marrow (BM) involvement in patients with diffuse large B-cell lymphoma (DLBCL) who received rituximab-based therapy.
Materials and Methods
A total of 567 consecutive patients with newly diagnosed DLBCL treated with rituximab-CHOP (RCHOP) between November 2001 and March 2010 were included in the current study. All of the patients underwent a BM study at the initial staging and the clinical characteristics and prognosis of these patients with or without BM involvement were analyzed retrospectively.
The total cohort included 567 patients. The overall incidence of BM involvement was 8.5%. With a median follow-up duration of 33.2 months (range, 0.1 to 80.7 months) for patients who were alive at the last follow-up, the five-year overall survival (OS) and event-free survival (EFS) rate in patients without BM involvement (76.3% and 67.5%, p<0.001) was statistically higher than that in patients with BM involvement (44.3% and 40.1%, p<0.001). In multivariate analysis, among total patients, BM involvement showed a significant association with OS and EFS. In univariate and multivariate analyses, even among stage IV patients, a significant association with worse EFS was observed in the BM involvement group.
BM involvement at diagnosis affected the survival of patients with DLBCL who received RCHOP. Although use of RCHOP can result in significant improvement of the therapeutic effect of DLBCL, BM involvement is still a negative prognostic factor of DLBCL patients in the era of rituximab.
Diffuse large B-cell lymphoma; Bone marrow; Rituximab
We compared the radiological and clinical outcomes between patients who underwent posterior fixation alone and supplemented with fusion following the onset of thoracolumbar burst fractures. In addition, we also evaluated the necessity of posterolateral fusion for patients treated with posterior pedicle screw fixation.
From January 2007 to December 2009, 46 consecutive patients with thoracolumbar burst fracture were included in this study. On the basis of posterolateral fusion, we divided our patients into the non-fusion group and the fusion group. The radiological assessment was performed according to the Cobb's method, and results were obtained at immediately, 3, 6, 12 months after surgery. The clinical outcomes were evaluated using the modified Mcnab criteria at the final follow-up.
The demographic data and the mean follow-up period were similar between the two groups. Patients of both groups achieved satisfactory clinical outcomes. The mean loss of kyphosis correction showed that patients of both groups experienced loss of correction with no respect to whether they underwent the posterolateral fusion. There was no significant difference in the degree of loss of correction at any time points of the follow-up between the two groups. In addition, we also compared the effect of fixed levels (i.e., short versus long segment) on loss of correction between the two groups and there was no significant difference. There were no major complications postoperatively and during follow-up period.
We suggest that posterolateral fusion may be unnecessary for patients with thoracolumbar burst fractures who underwent posterior pedicle screw fixation.
Thoracolumbar burst fracture; Posterior pedicle screw fixation; Posterolateral fusion; Loss of kyphosis correction
We investigated the clinical and radiological advantages of unilateral laminectomy in posterior lumbar interbody fusion (PLIF) procedure comparing with bilateral laminectomy, under the same procedural condition including bilateral instrumentation and insertion of two cages, in patients
with degenerative lumbar disease with unilateral leg symptoms.
We retrospectively reviewed 124 consecutive cases of PLIF via unilateral or bilateral approach between January 2006 and April 2010. In 80 cases (bilateral group), two cages were inserted via bilateral laminectomy, and in 44 cases (unilateral group), via unilateral laminectomy. The average
follow-up duration was 29.5 months. The clinical outcomes were evaluated with the Visual Analogue Scale (VAS) and the Oswestry disability index (ODI). The fusion rates and disc space heights were determined by dynamic standing radiographs and/or computed tomography. Operative times, intra-operative and post-operative blood losses and hospitalization periods were also evaluated.
In clinical evaluation, the VAS and ODI scores showed excellent outcomes in both groups. There were no significant differences in term of fusion rate, but the perioperative blood loss and the operative time of the unilateral group were lower than that of the bilateral group.
Unilateral laminectomy can minimize the operative time and perioperative blood loss in PLIF procedure. However, the different preoperative
disc height between two groups is a limitation of this study. Despite this limitation, solid fusion and satisfactory symptomatic improvement could be achieved uniquely by our surgical method. This surgical method can be an alternative surgical technique in patients with unilateral leg pain.
Posterior lumbar interbody fusion; Iatrogenic root injury; Unilateral approach; Unilateral leg symptoms
This study assessed the efficacy of anterior cervical discectomy and fusion (ACDF) with cage alone compared with ACDF with plate instrumentation for radiologic and clinical outcomes in two-level cervical degenerative disease.
Patients with cervical degenerative disc disease from September 2004 to December 2009 were assessed retrospectively. A total of 42 patients received all ACDF at two-level cervical lesion. Twenty-two patients who underwent ACDF with cage alone were compared with 20 patients who underwent ACDF with plate fixation in consideration of radiologic and clinical outcomes. Clinical outcomes were assessed using Robinson's criteria and posterior neck pain, arm pain described by a 10 point-visual analog scale. Fusion rate, subsidence, kyphotic angle, instrument failure and the degenerative changes in adjacent segments were examined during each follow-up examination.
VAS was checked during each follow-up and Robinson's criteria were compared in both groups. Both groups showed no significant difference. Fusion rates were 90.9% (20/22) in ACDF with the cage alone group, 95% (19/20) in ACDF with the plate fixation group (p = 0.966). Subsidence rates of ACDF with cage alone were 31.81% (7/22) and ACDF with plate fixation were 30% (6/20) (p = 0.928). Local and regional kyphotic angle difference showed no significant difference. At the final follow-up, adjacent level disease developed in 4.54% (1/22) of ACDF with cage alone and 10% (2/20) of ACDF with plate fixation (p = 0.654).
In two-level ACDF, ACDF with cage alone would be comparable with ACDF with plate fixation with regard to clinical outcome and radiologic result with no significant difference. We suggest that the routine use of plate and screw in 2-level surgery may not be beneficial.
ACDF with cage alone; ACDF with plate fixation; Fusion rate; Subsidence; Adjacent level degeneration
We experienced a rare case of solitary syphilitic osteomyelitis of the skull without any other clinical signs or symptoms of syphilis. A 20-year-old man was referred due to intermittent headache and mild tenderness at the right parietal area of the skull with a palpable coin-sized lesion of softened cortical bone. On radiological studies, the lesion was a radiolucent well enhanced mass (17 mm in diameter). The erythrocyte sedimentation rate (52 mm/h) and C-reactive protein (2.24 mg/dL) were elevated on admission. Serum venereal disease research laboratory (VDRL) and Treponema pallidum haemagglutination assay (TPHA) tests were positive. There were no clinical signs or symptoms of syphilis. After treatment with benzathine penicillin, we removed the lesion and performed cranioplasty. The pathologic finding of the skull lesion was fibrous proliferation with lymphoplasmocytic infiltration forming an osteolytic lesion. In addition, a spirochete was identified using the Warthin-starry stain. The polymerase chain reaction study showed a positive band for Treponema pallidum. Solitary osteomyelitis of the skull can be the initial presenting pathological lesion of syphilis.
Infectious osteomyelitis; Syphilis; Skull; Treponema pallidum
This study was conducted to investigate the correlation between the degrees of injury on brain magnetic resonance imaging (MRI) and the time interval to recovery of consciousness in patients with diffuse axonal injury.
From January 2004 to December 2008, 25 patients with diffuse axonal injury were treated at our hospital. We retrospectively investigated the patients' medical records and radiological findings. We divided the patients into three groups according to the grade of MRI finding : grade I, small scattered lesions on the white matter of the cerebral hemisphere; grade II, focal lesions on the corpus callosum; and grade III, additional focal lesions on the brain stem.
Seven patients belonged to the grade I group; 10 to the grade II group; and 8 to the grade III group. The mean Glasgow Coma Scale (GCS) score of all patients at the time of admission was 7.28. Recovery of consciousness was observed in 23 of the 25 patients; the remaining two patients never regained consciousness. The time interval to recovery of consciousness (awake status) ranged from 1 day to 125 days (mean 22.1 days) : grade I group patients, within approximately 1 week (mean 3.7 days); grade II group patients, within approximately 2 weeks (mean 12.5 days); and grade III group patients, within approximately 2 months (mean 59.5 days).
Our study results suggest a correlation between the mean time interval to recovery of consciousness in patients with diffuse axonal injuries and the degrees of brain injuries seen on MRI. Patients with grade I and II diffuse axonal injuries recovered consciousness within 2 weeks, while patients with grade III injuries required approximately 2 months.
Brain stem; Consciousness; Diffuse axonal injury; MRI
Spontaneous spinal epidural hematoma (SSEH) is a relatively rare but significant spinal condition. Urgent surgical evacuation of a hematoma is generally indicated to prevent serious permanent neurological deficits. We encountered three cases of spontaneous spinal epidural hematomas associated with motor weakness that were treated successfully by surgical intervention.
Spinal epidural hematana; Laminectomy
No definitive recommendation is available concerning optimal antithrombotic therapy in pregnant women with a mechanical heart valve. The purpose of the current study was to evaluate the clinical results of nadroparin treatment with respect to pregnancy outcome and maternal complications. From 1997 to 2005, 31 pregnancies were reviewed in 25 women. Nadroparin (7,500 U, twice daily) was used in 23 pregnancies between 6 and 12 weeks of gestation and close-to-term only, and coumarin derivatives were used with aspirin at other times. Eight pregnant women treated with coumarin derivatives throughout pregnancy were compared to evaluate the safety and efficacy of nadroparin. No maternal death or bleeding complication occurred in either of the two groups, and frequencies of maternal thromboembolism including valve thrombosis (8.7% vs. 12.5%, p>0.05) were similar. However, the frequencies of live born (91.3% vs. 50%, p=0.01) and healthy babies (90.4% vs. 25%, p<0.01) were significantly higher, and the fetal loss rate was significantly lower (8.7% vs. 50%, p=0.01) in the nadroparin-treated group. Regarding the efficacy and safety of antithrombotic treatment in pregnant women with prosthetic heart valves, nadroparin treatment during the first trimester is an acceptable regimen and produces better results than coumarin derivatives.
Low Molecular Weight Heparin; Heart Valve Prosthesis; Pregnant Women
The current phase II study was conducted to evaluate the response rate and safety of a combination regimen of biweekly irinotecan plus cisplatin in pretreated patients with advanced gastric cancer. Patients with previously treated metastatic or recurrent gastric cancer received intravenous irinotecan 70 mg/m2 and cisplatin 30 mg/m2 on day 1 and 15 every 4-week cycle. Thirty-two patients were enrolled in the current study. Of these, 31 patients were assessable for efficacy and all for toxicity. No complete response and 5 partial responses were confirmed, giving an overall response rate of 15.6% (95% CI; 2.3-28.9%). The median time to progression and median overall survival for all patients was 113 days and 184 days, respectively. Grade 3/4 neutropenia occurred in 6 patients (18.8%), yet no febrile neutropenia was observed. In addition, grade 3 anorexia was observed in 4 patients (12.5%) and grade 3 diarrhea occurred in 2 patients (6.2%). The combination chemotherapy of biweekly irinotecan and cisplatin was found to be moderately effective and well tolerated in pretreated patients with advanced gastric cancer. Accordingly, this regimen can be regarded as an important second-line treatment option for advanced gastric cancer.
irinotecan; Cisplatin; Drug Therapy; Stomach Neoplasms
Although many treatments for advanced gastric cancer have been developed, only poor treatment results have generally been obtained. We performed a prospective study on the combination chemotherapy of paclitaxel and cisplatin (PC). The primary objectives of the study were elucidating the disease response and evaluating the drug regimen's safety.
Patients with metastatic or recurrent gastric cancer received intravenous paclitaxel 175 mg/m2, and cisplatin 70 mg/m2 on day 1. This cycle was repeated every 3 weeks.
From January 2000 to March 2004, 37 patients from 3 different hospitals were enrolled in this study. A total of 135 treatment cycles (median: 3 cycles) were administered. The responses were evaluable in 34 patients; 24 patients received this regimen as their first-line treatment for metastatic cancer and the other patients received it as their second-line treatment for recurrent cancer. The objective response rate (RR) was 26.5% (95% CI: 11.7-41.3) with two complete responses, and stable disease was observed in 41.1% of the patients. Importantly, an RR of 33.3% (95% CI: 0.6-66.0) was achieved for the eight patients who received this regimen as a first-line treatment. The median follow up duration was 14 months for all the patients, and the median time to progression was 6 months (95% CI: 1.9-10.2). The overall survival time was 8.9 months (95% CI: 7.0-11.0) with a 1-year survival rate of 18.7% (95% CI: 5.6-31.8). The most common toxicity was neutropenia.
PC exhibited promising activity against gastric cancer for the previously untreated patients as a first-line treatment with an acceptable toxicity profile.
Stomach Neoplasms; Paclitaxel
There are debatable claims in the optimal approach for clipping of the anterior communicating artery (AcomA) aneurysm. The authors invented the superior orbital rim approach (SORA) as an alternative and minimally invasive approach for the treatment of AcomA aneurysm. The authors reviewed retrospectively all the medical records of 27 patients of subarachnoid hemorrhage due to ruptured AcomA aneurysm. who were admitted to Kosin University Gospel Hospital for last 2 yr. Fourteen women (51.9%) and 13 men (48.1%) were from 29 to 79 yr in age. The mean aneurysm size was 6.2 mm ranging from 4 to 12 mm. A favorable Glasgow outcome scale (GOS) of 4 or 5 was achieved in 92.6%, a GOS score of 3 in 3.7%, and 1 death (GOS 1) occurred in 3.7% of the patients. During the follow-up between 4 and 28 months (mean, 17.5 months) after the surgery, the prognosis of the patients and the cosmetic results were favorable compared with conventional approach. We became to believe that it was an alternative, effective and minimally invasive approach to the surgical treatment of AcomA aneurysm.