The intracranial pathologies after head trauma should be usually progressed. It is clearly visualized in the non-invasive brain CT. The invasive monitor such as intracranial pressure (ICP) monitoring may be accompanied with the complications. This study aims whether the patients with severe head injury could be managed with serial CT scans.
The medical records of 113 patients with severe head injury in the prospectively enrolled trauma bank were retrospectively analyzed. After the emergency care, all the patients were admitted to the intensive care unit for the aggressive medical managements. Repeat brain CT scans were routinely taken at 6 hours and 48 hours after the trauma. ICP monitoring was restrictively applied for the uncertain intracranial pressure based on the CT. The surgical intervention and the mortality rate were analyzed.
Immediate surgical intervention after the initial CT scan was done in 47 patients. Among the initially non-surgical patients, 59 patients were managed with the serial CT scans and 7 with the ICP monitoring. Surgical interventions underwent eventually for 10 patients in the initially non-surgical patients; 1 in the ICP monitoring and 9 in the serial CT. The mortality rate was 23.7% in the serial brain CT and 28.6% in the ICP monitoring. There was no statistical difference between two groups in the aspect of mortality (p=0.33).
Serial CT scans in time could be a good way to monitor the intracranial progression in the severe head injury and reduce the implantation of an invasive ICP probe.
CT; Severe head injury; Intracranial pressure monitoring; Mortality
Although juxtafacet cysts of the lumbar spine are being reported with increasing frequency, hemorrhage from a ganglion cyst is rare, and the pathophysiologic mechanism of the hemorrhage from the cyst is still unclear. A 75-year-old male presented with sudden radicular leg pain caused by hemorrhage from the ganglion cyst. Computed tomography revealed bony erosion of vertebral body and multiple punched-out lesions on facets. Magnetic resonance imaging showed the neural structure was compressed by a sharply delineating mass. Capsule and old hematoma with elastic consistency that extended to the epidural space were removed through a paramedian transforaminal approach, which led to the resolution of the patient's symptoms. Histopathologically, chronic inflammation with neovascularization and myxoid degeneration were present in the capsule. Alcian blue staining demonstrated the mixture of mucin and hematoma. The probable pathogenesis of hemorrhage from the cyst was discussed from the unique histopathological findings of surgical specimen.
Ganglion cyst; Hemorrhage; Lumbar vertebrae; Mucins; Radiculopathy; Zygapophyseal joint
The objective of this study was to investigate the morphologic characteristics between the vertebral body and the regions of the cervical and thoracic spinal cords where each rootlets branch out.
Sixteen adult cadavers (12 males and 4 females) with a mean age of 57.9 (range of 33 to 70 years old) were used in this study. The anatomical relationship between the exit points of the nerve roots from the posterior root entry zone at each spinal cord segment and their corresponding relevant vertebral bodies were also analyzed.
Vertical span of the posterior root entry zone between the upper and lower rootlet originating from each spinal segment ranged from 10-12 mm. The lengths of the rootlets from their point of origin at the spinal cord to their entrance into the intervertebral foramen were 5.9 mm at the third cervical nerve root and increased to 14.5 mm at the eighth cervical nerve root. At the lower segments of the nerve roots (T3 to T12), the posterior root entry zone of the relevant nerve roots had a corresponding anatomical relationship with the vertebral body that is two segments above. The posterior root entry zones of the sixth (94%) and seventh (81%) cervical nerve roots were located at a vertebral body a segment above from relevant
Through these investigations, a more accurate diagnosis, the establishment of a better therapeutic plan, and a decrease in surgical complications can be expected when pathologic lesions occur in the spinal cord or vertebral body.
Spinal; Cord; Nerve root; Cervical spine; Thoracic spine; Cadaveric study
Twist-drill craniostomy (TDC) with closed-system drainage and burr-hole drainage (BHD) with a closed system are effective treatment options for chronic subdural hematoma (CSDH). The aim of this study was to analyze clinical data and surgical results from symptomatic CSDH patients who underwent TDC with closed-system drainage at the pre-coronal point (PCP).
We analyzed data for 134 symptomatic CSDH patients who underwent TDC at the PCP with closed-system drainage. We defined the PCP for TDC to be 1 cm anterior to the coronal suture at the level of superior temporal line. TDC at the PCP with closed-system drainage was selected in patients with CSDH that extended beyond the coronal suture, confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed retrospectively.
Of the 134 CSDH patients, 114 (85.1%) showed improved clinical performance and imaging findings after surgery. Catheter failures were seen in two cases (1.4%); the catheters were inserted in the epidural space. Recurrent cases were seen in eight patients (5.6%), and they were improved with a second BHD with a closed-system operation.
TDC at the PCP with closed-system drainage is safe and effective for patients with symptomatic CSDH whose hematomas extend beyond the coronal suture.
Chronic subdural hematoma; Craniostomy; Coronal suture
To present the profiles of spinal cord tumors that can be removed through a unilateral hemilaminectomy and to demonstrate its usefulness for benign spinal cord tumors that significantly occupy the spinal canal.
From June 2004 to October 2010, 25 spinal cord tumors were approached with unilateral hemilaminectomy. We calculated the cross-sectional occupying ratio (CSOR) of tumor to spinal canal before and after the operations.
The locations of the tumors were intradural extramedullary in 20 cases, extradural in 2, and intramedullary in 3. The levels of the tumors were lumbar in 12, thoracic 9, and cervical 4. In all cases, the tumor was removed grossly and totally without damaging spinal cord or roots. The mean height and width of the lesions we195re 17.64 mm (3-47.5) and 12.62 mm (4-32.7), respectively. The mean CSOR was 69.40% (range, 27.8-96.9%). Postoperative neurological status showed improvement in all patients except one whose neurologic deficit remained unchanged. Postoperative spinal stability was preserved during the follow-up period (mean, 21.5 months) in all cases. Tumor recurrence did not develop during the follow-up period.
Unilateral hemilaminectomy combined with microsurgical technique provides sufficient space for the removal of diverse spinal cord tumors. The basic profiles of the spinal cord tumors which can be removed through the unilateral hemilaminectomy demonstrate its role for the surgery of the benign spinal cord tumors in various sizes.
Laminectomy; Microsurgery; Spinal cord neoplasms; Unilateral hemilaminectomy; Spinal ligaments
Shunt malfunctions that require surgical intervention during pregnancy and the postpartum period are rare. Furthermore, no study has reported on an acute shunt malfunction immediately after cesarean section. Here, we describe the case of a 32-yr-old woman who became drowsy 12 hr after cesarean section delivery of her second child. She had a ventriculoperitoneal shunt placed to treat hydrocephalus associated with meningitis at 26 yr of age. Marked ventriculomegaly was seen on brain computed tomography and her consciousness recovered temporarily after aspirating cerebrospinal fluid from the flushing device. At surgery, the distal catheter tip was plugged by a blood clot. We believe that the blood spilled over during the cesarean section. The clogged catheter end was simply cut off and the remaining catheter was repositioned in the peritoneal cavity. Her consciousness recovered fully.
Ventriculoperitoneal Shunt; Prosthesis Failure; Hydrocephalus; Cesarean Section
The intravenous administration of gadopentetate dimeglumine (GD) is relatively safe and rarely causes systemic toxicity in the course of routine imaging studies. However, the general safety of intrathecal GD has not been established. We report a very rare case of an overdose intrathecal GD injection presenting with neurotoxic manifestations, including a decreased level of consciousness, global aphasia, rigidity, and visual disturbance.
Neurologic Manifestations; Injections, Spinal; Gadolinium DTPA
There are several mechanisms for the dissemination of lipid material from a mature teratoma into the subarachnoid space or ventricles, including iatrogenic or traumatic rupture, but spontaneous rupture of a mature teratoma is rare. We report the spontaneous rupture of a spinal mature teratoma into the subarachnoid space and ventricles. However, at surgery, there was no definite evidence of rupture into the perimedullary cerebrospinal fluid. We postulate that the central canal could be a migration pathway for ruptured material into the brain.
A rare case of hemifacial spasm caused by an ipsilateral tentorial meningioma is described. Magnetic resonance imaging showed a huge tumor in the right cerebellar hemisphere, distant to the cerebello-pontine cistern. The facial-vestibulocochlear nerve complex was stretched by the shift of the brainstem and the right cerebello-pontine cistern was effaced. After removing the tumor, the hemifacial spasm resolved completely. We review our case with the pertinent literature regarding the etiological mechanism.
Hemifacial spasm; Posterior fossa tumor; Meningioma
When a tear occurs in one of the major cervicocerebral arteries and allows blood to enter the wall of the artery and split its layers, the result is either stenosis or aneurysmal dilatation of the vessel. Vertebral artery dissection (VAD) is an infrequent occurrence but is a leading cause of stroke in young and otherwise healthy patients. This article discusses recent developments in understanding of the epidemiology and pathogenesis of VAD and the various clinical manifestations, methods of diagnosis, and approaches to treatment.
Stenosis; Aneurysmal dilatation; Vertebral artery dissection; Diagnosis; Treatment
To understand the anatomic characteristics of the aortic arch (AA) and its major branches to build a foundation toward performing endovascular surgery safely.
A total of 25 formalin fixed Korean adult cadavers were used. The authors investigated : anatomical variations of the AA and its major branches; curvature of the AA; distance from the mid-vertebrae line to the origin of the major branches; distances from the origin of the major branches of AA to the origin of its distal branches; and the angle of the three major branches, the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSCA) arising from AA.
The three major branches directly originated from AA in 21 (84%) of the cadavers. In two (8%) of remaining four cadavers, orifice of LCCA was slightly above the stem of BCT. In remaining two (8%) cadavers, the left vertebral artery (LVA) was directly originated from AA. Average angle of AA curvature to the coronal plane was 62.2 degrees. BCT originated 0.92 mm on the right of the mid-vertebrae line. LCCA and LSCA originated from 12.3 mm and 22.8 mm on the left of the mid-vertebrae line. Mean distance from the origin of the BCT to the origin of the RCCA was 32.5 mm. Mean distance from the origin of the LSCA to the origin of the LVA was 33.8 mm. Average angles at which the major branches arise from the AA were 65.3, 46.9 and 63.8 degrees.
This study may provides a basic anatomical information to catheterize AA and its branches for safely performing endovascular surgery.
Aorta; Cadaver; Brachiocephalic trunk; Common carotid artery; Subclavian artery; Atherectomy
Shunt infections are a common complication of ventriculoperitoneal (VP) shunts, but the formation of a brain abscess related to a shunt system is very rare. A 44-year-old woman had a VP shunt inserted for hydrocephalus secondary to a subarachnoid hemorrhage. She suffered an episode of meningitis and sepsis 8 months after the shunt operation. After recovering from the meningitis, she complained of a loss of cognitive function. An enhancing mass was found in the frontal lobe, around the frontal horn of the lateral ventricle, and the ventricular catheter was embedded inside the mass. The ventricular catheter and cerebral abscess were removed using neuroendoscopy. We present an interesting case of a shunt-related brain abscess which illustrates the usefulness of neuroendoscopy.
Brain Abscess; Ventriculoperitoneal shunt; Endoscopy
The authors describe a case of pseudoaneurysm arising from internal iliac artery presented with radiculopathy mimicking the symptoms of lumbar disc disease or spinal cord tumor. Among the several preoperative evaluation including CT, MRI, electrophysiologic study and ultrasonography, important diagnostic clue was obtained by ultrasonographic findings of turbulence flow at the core of partially enhanced mass in the pelvic cavity. The patient was managed with endovascular coil embolization successfully. The current case makes us remind that assessment of neurological symptoms on lower extremity should include consideration of extraspinal cause in pelvis.
Pseudoaneurysm; Internal iliac artery; Radiculopathy; Endovascular embolization