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1.  Intracranial Atherosclerotic Disease; Current Options for Surgical or Medical Treatment 
Recently, intracranial atherosclerosis has become a major cause of ischemic stroke, appearing more frequently in Koreans than Caucasians. Symptomatic or asymptomatic intracranial atherosclerosis is a disease that could recur readily even during the treatment with anti-platelet agents. When the symptoms develop, ischemic stroke can not be recovered readily. Therefore, aggressive treatments such as endovascular therapy and bypass surgery are required in addition to medical treatment for the intracranial artery stenosis. Recent intracranial stenting and drug eluting stenting have shown as very advanced effective therapeutic modalities. Nevertheless, until now, a randomized controlled study has not been conducted. Regarding bypass surgery, since the failed EC-IC bypass surgery study performed 20 years ago, extensive studies on its efficacy has not been conducted yet, and thus it has to be performed strictly only in hemodynamically compromised patients. Unless breakthrough drugs that suppress the progression of intracranial atherosclerosis and the formation of thrombi, and facilitate the regression of the arterial stenosis, the treatment concept of the recovery of the blood flow of stenotic arterial territory by mechanical recanalization or bypass surgery would be remained for the prevention as well as treatment of ischemic stroke caused by intracranial atherosclerosis.
doi:10.3340/jkns.2007.42.6.427
PMCID: PMC2588182  PMID: 19096584
Angioplasty and stenting; Bypass surgery; Intracranial atherosclerosis
2.  Distal Middle Cerebral Artery M4 Aneurysm Surgery Using Navigation-CT Angiography 
Unruptured non-traumatic dissecting aneurysm in the M4 segment of the middle cerebral artery (MCA) accompanied by complete occlusion of the ipsilateral internal cerebral artery (ICA) has never been reported. A 41-year-old man presented with an infarction manifesting as left-sided weakness and dysarthria. Magnetic resonance angiography revealed a subacute stage infarction in the right MCA territory and complete occlusion of the right ICA. Angiography demonstrated aneurysmal dilatation of the M4 segment of the right MCA. Surgery was performed to prevent hemorrhage from the aneurysm. The aneurysm was proximally clipped guided by Navigation-CT angiography and flow to the distal MCA was restored by superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. We report this rare case with literature review.
doi:10.3340/jkns.2007.42.6.478
PMCID: PMC2588183  PMID: 19096593
Middle cerebral artery aneurysm; Navigation; Dissecting aneurysm
3.  Lumbosacral Plexopathy, Complicating Rhabdomyolysis in a 57-Year-Old Man, Presented with Sudden Weakness in Both Legs 
A 57-year-old man presented with weakness in both legs upon awakening after drinking. Magnetic resonance imaging (MRI) of the lumbar spine did not reveal any intraspinal abnormalities but MRI of the pelvis revealed lesions with abnormal intensities with heterogeneous contrast enhancement in both gluteal muscles. Serum creatine phosphokinase was markedly elevated. A diagnosis of lumbosacral plexopathy, complicating rhabdomyolysis was made. With supportive care he recovered well but mild weakness of the right ankle remained at 6 month-follow-up. Pelvic MRI is a helpful diagnostic tool in localizing rhabdomyolysis. Lumbosacral plexopathy should be included in the differential diagnosis of the such cases, presenting with sudden weakness of legs.
doi:10.3340/jkns.2007.42.6.481
PMCID: PMC2588181  PMID: 19096594
Rhabdomyolysis; Lumbosacral plexopathy; Magentic resonance imaging; Leg weakness
4.  Lumbo-sacro-pelvic Fixation Using Iliac Screws for the Complex Lumbo-sacral Fractures 
Fractures of lumbo-sacral junction involving bilateral sacral wings are rare. Posterior lumbo-sacral fixation does not always provide with sufficient stability in such cases. Various augmentation techniques including divergent sacral ala screws, S2 pedicle screws and Galveston rods have been reported to improve lumbo-sacral stabilization. Galveston technique using iliac bones would be the best surgical approach especially in patients with bilateral comminuted sacral fractures. However, original Galveston surgery is technically demanding and bending rods into the appropriate alignment is time consuming. We present a patient with unstable lumbo-sacral junction fractures and comminuted U-shaped sacral fractures treated by lumbo-sacro-pelvic fixation using iliac screws and discuss about the advantages of the iliac screws over the rod system of Galveston technique.
doi:10.3340/jkns.2007.42.6.495
PMCID: PMC2588180  PMID: 19096599
Iliac screw; U-shped sacral fracture; Lumbo-sacro-pelvic fixation
5.  Pneumorrhachis and Paraspinal Air with Vacuum Disc : Case Report and Literature Review 
Air within the spinal canal called pneumorrhachis has been seen rarely. We report a case showing multiple air pockets in the paraspinal and epidural space with vacuum disc and review pathogenesis and treatment of pneumorrhachis.
doi:10.3340/jkns.2007.42.6.490
PMCID: PMC2588178  PMID: 19096597
Intervertebral disc; Air; Spine
6.  The Anatomical Location and Course of the Facial Nerve in Vestibular Schwannomas : A Study of 163 Surgically Treated Cases 
Objective
The aim of this study was to identify the anatomical location and course of the facial nerve (FN) and their relationship to the tumor size in surgically treated vestibular schwannomas.
Methods
A retrospective study was conducted on 163 patients who had been treated by the microsurgical resection for a newly diagnosed vestibular schwannoma between 1995 and 2005 (mean age of 46.1 years; 108 females and 55 males). Surgery was carried out via retrosigmoid approach in all patients with the electromyographic monitoring for the FN function. The anatomical location and course of the FN along the tumor surface were verified in each patient during the microsurgery, and were classified into 4 groups : 1) the FN displaced along the ventral and superior surface of the tumor (VS); 2) the ventral and central (VC); 3) the ventral and inferior (VI); and 4) the dorsal (Do).
Results
The FN displacement was identified as the followings : VS in 91 patients (55.8%); VC in 57 (35.0%); VI in 14 (8.6%); and Do in 1 (0.6%). In the subgroup with tumors less than 2 cm in diameter (n=23), the FN was displaced along the ventral and central surface of the tumor in the majority (65.2%), whereas, in the patients with tumors larger than 2cm (n=140), it was displaced along the ventral and superior surface most frequently (59.3%).
Conclusion
The FN can be displaced variably in vestibular schwannomas, and most frequently along the ventral and superior surface of the tumor, especially in large ones.
doi:10.3340/jkns.2007.42.6.450
PMCID: PMC2588177  PMID: 19096588
Vestibular schwannoma; Facial nerve; Microsurgery
7.  Spinal Drop Metastasis from a Posterior Fossa Choroid Plexus Papilloma 
Choroid plexus papillomas (CPPs) are typically considered as benign tumors, with a favorable long-term prognosis. Drop metastasis of CPP into the spinal subarachnoid space is rare. We report a 42-year-old woman who presented with headache and back pain 6 years after removal of a posterior fossa CPP. Magnetic resonance imaging revealed mass lesions in the lumbosacral subarachnoid space and recurrent intracranial tumor. The lesions were resected and histologically diagnosed was CPP. We consider that CPP can spread via cerebrospinal fluid pathways and cause spinal drop metastasis. Therefore, it is necessary to evaluate the whole spinal axis and to perform periodic follow-up examinations in patients with CPP.
doi:10.3340/jkns.2007.42.6.475
PMCID: PMC2588175  PMID: 19096592
Choroid plexus papilloma; Posterior fossa; Spinal; Metastasis; Cerebrospinal fluid
8.  Complete Cord Injury after Minimal Trauma in a Patient with Forestier's Disease Accompanying Ossification of the Posterior Longitudinal Ligament 
Forestier's disease is a systemic rheumatological abnormality in which exuberant ossification occurs along ligaments throughout the body, but most notably the anterior longitudinal ligament of the spine. This disease is usually asymptomatic; however dysphagia, dyspnea, and peripheral nerve entrapment have all been documented in association with the disorder. We report a rare case of catastrophic neurologic damage caused by Forestier's disease accompanying ossification of the posterior longitudinal ligament.
doi:10.3340/jkns.2007.42.6.487
PMCID: PMC2588174  PMID: 19096596
Forestier's disease; Ossification of the posterior longitudinal ligament
9.  Identification of Novel Metabolic Proteins Released by Insulin Signaling of the Rat Hypothalmus Using Liquid Chromatography-Mass Spectrometry (LC-MS) 
Objective
The brain is dependent on glucose as an energy source. Intricate homeostatic mechanisms have been implicated in maintaining the blood glucose concentration in the brain. The aim of this study is to find the way to identify the metabolic proteins regulating the glucose in rat hypothalamus.
Methods
In this study, we analysed the secretome from rat hypothalamus in vivo. We introduced 500 nM of insulin into the rat hypothalamus. The chromatographic patterns of the secretome were identified, after which Mass Spectrometry-Mass Spectrometry (MS-MS) analysis was performed.
Results
In Liquid Chromatography-Mass Spectrometry (LC-MS) analysis, 60 proteins were identified in the secretome. Among them, 8 novel proteins were unveiled and were associated with the energy metabolism of insulin signaling in mitochondria of rat hypothalamic neuron. Nineteen other proteins have unknown functions. These ligands were confirmed to be secreting from the rat hypothalmus on insulin signaling by western blotting.
Conclusion
The hypothalamus is the master endocrine gland responsible for the regulation of various physiological and metabolic processes. Proteomics using LC-MS analysis offer a efficient means for generating a comprehensive analysis of hypothalamic protein expression by insulin signaling.
doi:10.3340/jkns.2007.42.6.470
PMCID: PMC2588169  PMID: 19096591
Insulin; Energy metabolism; Hypothalamus; Liquid chromatography; Mass spectrometry
10.  Radiculopathy Caused by Internal Iliac Artery Pseudoaneurysm Managed with Endovascular Embolization 
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.
doi:10.3340/jkns.2007.42.6.484
PMCID: PMC2588168  PMID: 19096595
Pseudoaneurysm; Internal iliac artery; Radiculopathy; Endovascular embolization
11.  Spinal Cord Hemangioblastoma : Diagnosis and Clinical Outcome after Surgical Treatment 
Objective
Spinal cord hemangioblastoma is an uncommon vascular neoplasm with a benign nature and is associated with von Hippel-Lindau (VHL) disease in 20-30% of patients. Total removal of these tumors without significant neurological deficit remains a great challenge. The purpose of this study was to investigate the efficacy of VHL mutation analysis and to evaluate surgical outcome of patients with spinal cord hemangioblastomas.
Methods
This study included nine patients treated for spinal cord hemangioblastomas at our institute between December 1994 and March 2006. There were four male and five female patients. Mean age was 37.8 years. The mean follow-up period was 22.4 months. Magnetic resonance imaging (MRI) of the complete neuraxis was done in all cases and VHL mutation analysis was performed in three cases for a definite diagnosis.
Results
Six patients had intramedullary tumor, and the remaining patients had intradural extramedullary lesions. Five patients were associated with VHL disease. The von Hippel-Lindau mutation analysis was done in three patients and two of them showed VHL gene abnormality. Tumors were located in the cervical cord in five cases and in the thoracic cord in four cases. All patients underwent surgical intervention, and total removal was achieved in six cases. All patients showed improvement or, at least, clinically stationary state. Surgical complications did not develop in any cases.
Conclusion
Spinal hemangioblastoma in this series has been safely and effectively removed via a posterior approach. Postoperatively, clinical outcome was excellent in the majority of cases. The VHL mutation analysis was useful in patients with family history and in those with multiple hemangioblastomas.
doi:10.3340/jkns.2007.42.6.436
PMCID: PMC2588179  PMID: 19096585
Hemangioblastoma; Von Hippel-Lindau disease; Mutation analysis
12.  Myelopathy Caused by Soft Cervical Disc Herniation : Surgical Results and Prognostic Factors 
Objective
The purpose of this study was to investigate the surgical results and prognostic factors for patients with soft cervical disc herniation with myelopathy.
Methods
During the last 7 years, 26 patients with cervical discogenic myelopathy were undertaken anterior discectomy and fusion. Clinical and radiographic features were reviewed to evaluate the surgical results and prognostic factors. The clinical outcome was judged using two grading systems (Herkowitz's scale and Nurick's grade).
Results
Male were predominant (4:1), and C5-6 was the most frequently involved level. Gait disturbance, variable degree of spasticity, discomfort in chest and abdomen, hand numbness were the most obvious signs. Magnetic resonance(MR) images showed that central disc herniation was revealed in 16 cases, and accompanying cord signal changes in 4. Postoperatively, 23 patients showed favorable results (excellent, good and fair) according to Herkowitz's scale.
Conclusion
Anterior cervical discectomy and fusion effectively reduced myelopathic symptoms due to soft cervical disc herniation. The authors assured that the shorter duration of clinical attention, the lesser the degree of myelopathy and better outcome in discogenic myelopathy.
doi:10.3340/jkns.2007.42.6.441
PMCID: PMC2588176  PMID: 19096586
Cervical vertebrae; Intervertebral disc; Myelopathy
13.  A Case of Myelopathy after Intrathecal Injection of Fluorescein 
We present a case with seizure, confusion, hypesthesia and paraplegia after intrathecal injection of fluorescein. A 41-year-old man was admitted to our institution for the management of the CSF leakage. Intrathecal injection of fluorescein was performed and he complained of severe pain and numbness in the lower extremities at the end of the injection. Four hours later, he exhibited confusion, paraparesis and two episodes of generalized seizures. Two days later, he showed paraplegia and all sensory modalities below the T12 level were absent. Spine magnetic resonance imaging revealed myelopathic change in the lower thoracic spinal cord. There was no improvement of weakness and sensory deficits in lower extremity even 14 days after fluorescein injection. We speculated that thoracic myelopathy was associated with the intrathecal injection of fluorescein. In spite of its rarity, the complication after intrathecal injection of fluorescein could be serious. Thus, obtaining an informed consent with discussion with patient before the procedure is mandatory.
doi:10.3340/jkns.2007.42.6.492
PMCID: PMC2588173  PMID: 19096598
Fluorescein; Intrathecal; Myelopathy
14.  Persistent Trigeminal Artery Variant Detected by Conventional Angiography and Magnetic Resonance Angiography-Incidence and Clinical Significance- 
Objective
Persistent trigeminal artery variant (PTAV) is an anastomosis between the internal carotid artery (ICA) and the cerebellar artery without any interposing basilar artery segment. We discuss its probable embryological origin and emphasize clinical implications.
Methods
Retrospectively 1250 conventional cerebral angiograms and 2947 cranial magnetic resonance angiographies (MRAs) were evaluated for the patients with PTAV.
Results
Five patients (four men and one woman, 23 to 76 years of age, median age 65 years) had a PTAV. Three patients who underwent MRA had a PTAV (3/2947=0.1%). Four of the patients who underwent cerebral angiography had a PTAV (4/1250=0.32%). Two of 143 patients who underwent both conventional angiography and cranial MRA showed PTAV. The PTAV was an incidental finding in all five patients. The PTAV originated from the cavernous segment of the left ICA in four patients and from the cavernous segment of the right ICA in one patient. The terminal branch of the PTAV was the anterior inferior cerebellar artery (AICA) and superior cerebellar artery (SCA) in two patients and the AICA only in the other three patients.
Conclusion
Neurosurgeons should be aware of possible presence of PTAV. Manipulation of this vessel during a surgical approach to the parasellar region and percutaneous gasserian ganglion procedure may result in hemorrhage or ischemia.
doi:10.3340/jkns.2007.42.6.446
PMCID: PMC2588172  PMID: 19096587
Persistent trigeminal artery variant; Incidence; Clinical implication
15.  The VR1-Positive Primary Afferent-Mediated Expression of pERK in the Lumbosacral Neurons in Response to Mechanical and Chemical Stimulation of the Urinary Bladder in Rats 
Objective
This study characterized the neurons in the lumbosacral cord that express phospho ERK (pERK) after distension or irritation of the bladder, and their relation to the vanilloid receptor 1 (VR1) positive primary afferents.
Methods
Mechanical distension and chemical irritation of the bladder were induced by intravesical injection of the saline and mustard oil, respectively. Spinal neurons expressing pERK and the primary afferent fibers were characterized using multiple immunofluorescence for neurokinin 1 (NK1), neuronal nitric oxide synthetase (nNOS) and VR1.
Results
Neurons in lamina I, medial dorsal horn (MDH), dorsal gray commissure (DGC) and sacral parasympathetic nucleus (SPN) were immunoreactive for pERK after either mechanical or chemical stimulation. The majority of pERK positive cells were positive for NK1 in lamina I and SPN, but not in the DGC. Most of pERK positive cells are not stained for nNOS except in a small population of the cells in the SPN and DGC. Contacts between perikarya and dendrites of pERK-positive cells and terminals of primary afferents expressing VR1 were identified in lamina I, lateral collateral path (LCP) and SPN.
Conclusion
In this study, the lumbosacral neurons activated by mechanical and chemical stimulation of the urinary bladder were identified with expression of the pERK, and also provided the evidence that VR1-positive primary afferents may mediate the activation of these neurons.
doi:10.3340/jkns.2007.42.6.462
PMCID: PMC2588171  PMID: 19096590
Spinal cord; Visceral sense; Primary afferent; pERK; NK1; VR1
16.  Lesion of Subthalamic Nucleus in Parkinsonian Rats : Effects of Dopamine D1 and D2 Receptor Agonists on the Neuronal Activities of the Substantia Nigra Pars Reticulata 
Objective
It was hypothesized that dopamine agonist administration and subthalamic nucleus (STN) lesion in the rat might have a synergistic effect on the neuronal activities of substantia nigra pars reticulata (SNpr) as observed in patients with Parkinson's disease. The effects of SKF38393 (a D1 receptor agonist) and Quinpirole (a D2 receptor agonist) were compared in parkinsonian rat models with 6- hydroxydopamine (6-OHDA) after STN lesion.
Methods
SKF38393 and Quinpirole were consecutively injected intrastriatally. SNpr was microrecorded to ascertain the activity of the basal ganglia output structure. The effect of SKF38393 or Quinpirole injection on the firing rate and firing patterns of SNpr was investigated in medial forebrain bundle (MFB) lesioned rats and in MFB+STN lesioned rats.
Results
The administration of SKF38393 decreased SNpr neuronal firing rates and the percentage of burst neurons in the MFB lesioned rats, but did not alter them in MFB+STN lesioned rats. The administration ofQuinpirole significantly decreased the spontaneous firing rate in the MFB lesioned rats. However, after an additional STN lesion, it increased the percentage of burst neurons.
Conclusion
This study demonstrated that dopamine agonists and STN lesion decreased the hyperactive firing rate and the percentage of burst neurons of SNpr neurons in 6-OHDA lesioned rats, respectively. Quinpirole with STN lesion increased a percentage of burst neurons. To clear the exact interactive mechanism of D1 and D2 agonist and the corresponding location, it should be followed a study using a nonselective dopamine agonist and D1, D2 selective antagonist.
doi:10.3340/jkns.2007.42.6.455
PMCID: PMC2588170  PMID: 19096589
6-hydroxydopamine; Substantia nigra pars reticulate; Kainic acid; Subthalamic nucleus; Dopamine agonist; Parkinson's disease
17.  Subsidence of Cylindrical Cage (AMSLU™ Cage) : Postoperative 1 Year Follow-up of the Cervical Anterior Interbody Fusion 
Objective
There are numerous reports on the primary stabilizing effects of the different cervical cages for cervical radiculopathy. But, little is known about the subsidence which may be clinical problem postoperatively. The goal of this study is to evaluate subsidence of cage and investigate the correlation between radiologic subsidence and clinical outcome.
Methods
To assess possible subsidence, the authors investigated clinical and radiological results of the one-hundred patients who underwent anterior cervical fusion by using AMSLU™ cage during the period between January 2003 and June 2005. Preoperative and postoperative lateral radiographs were measured for height of intervertebral disc space where cages were placed. Intervertebral disc space was measured by dividing the sum of anterior, posterior, and midpoint interbody distance by 3. Follow-up time was 6 to 12 months. Subsidence was defined as any change in at least one of our parameters of at least 3 mm.
Results
Subsidence was found in 22 patients (22%). The mean value of subsidence was 2.21 mm, and mean subsidence rate was 22%. There were no cases of the clinical status deterioration during the follow-up period. No posterior or anterior migration was observed.
Conclusion
The phenomenon of subsidence is seen in substantial number of patients. Nevertheless, clinical and radiological results of the surgery were favorable. An excessive subsidence may result in hardware failure. Endplate preservation may enables us to control subsidence and reduce the number of complications.
doi:10.3340/jkns.2007.42.5.367
PMCID: PMC2588192  PMID: 19096571
Subsidence; AMSLU™ cage; Anterior cervical fusion
18.  Segmental Deformity Correction after Balloon Kyphoplasty in the Osteoporotic Vertebral Compression Fracture 
Objective
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.
Methods
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.
Results
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).
Conclusion
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.
doi:10.3340/jkns.2007.42.5.371
PMCID: PMC2588189  PMID: 19096572
Balloon kyphoplasty; Compression fracture; Deformity; Restoration
19.  Hemifacial Spasm: A Neurosurgical Perspective 
Hemifacial spasm (HFS) is characterized by tonic clonic contractions of the muscles innervated by the ipsilateral facial nerve. Compression of the facial nerve by an ectatic vessel is widely recognized as the most common underlying etiology. HFS needs to be differentiated from other causes of facial spasms, such as facial tic, ocular myokymia, and blepharospasm. To understand the overall craniofacial abnormalities and to perform the optimal surgical procedures for HFS, we are to review the prevalence, pathophysiology, differential diagnosis, details of each treatment modality, usefulness of brainstem auditory evoked potentials monitoring, debates on the facial EMG, clinical course, and complications from the literature published from 1995 to the present time.
doi:10.3340/jkns.2007.42.5.355
PMCID: PMC2588188  PMID: 19096569
Hemifacial spasm; Microvascular decompression; Craniofacial abnormalities
20.  Occlusion of the Middle Cerebral Artery Branch Mimicking Aneurysm 
A 26-year-old man was admitted to our department due to intermittent left hemiparesis for 3 months. Magnetic resonance image showed subacute infarction in the right precentral gyrus. Digital subtraction angiography and magnetic resonance angiography revealed an aneurysmal protrusion at the right middle cerebral artery (MCA) bifurcation. It was difficult to differentiate the aneurysm from the occlusion of the middle trunk of the MCA trifurcation. Brain single photon emission computerized tomography showed a decrease in perfusion in the right posterior frontal lobe without vascular reserve. Therefore, we planned a superficial temporal artery-MCA anastomosis with an exploration of the right MCA bifurcation. Intraoperatively, the aneurysmal opacification on preoperative angiography proved to be the proximal stump of the occluded middle trunk of the MCA trifurcation. An aneurysmal protrusion at the MCA bifurcation does not always indicate an aneurysm. In diagnosing protruding vascular lesions at the MCA bifurcation, the possibility of a vascular stump should be considered according to their angioanatomical appearance and the history of the patient.
doi:10.3340/jkns.2007.42.5.413
PMCID: PMC2588198  PMID: 19096581
Middle cerebral artery; Aneurysm; Occlusion
21.  Extraordinarily Long-Term Posttraumatic Cerebrospinal Fluid Fistula 
Most posttraumatic cerebrospinal fluid (CSF) leakage is noticed by the patients with the first symptom, rhinorrhea. A 38-year-old woman presented with frequent clear continuous rhinorrhea and otorrhea for 5 years after basilar skull fracture. After this, meningitis was developed with subsequent CSF fistula. Her clinical symptom was improved by medical treatment. The dural defect and CSF leakage were not detected by computerized tomography (CT) cisternography. We report a rare case of persistent posttraumatic CSF fistula that continued for five years.
doi:10.3340/jkns.2007.42.5.403
PMCID: PMC2588196  PMID: 19096578
Traumatic CSF fistula; Meningitis; CT cisternography
22.  Clipping of the Anterior Communicating Artery Aneurysm without Sylvian Fissure Dissection 
Objective
The focus of aneurysm surgery is eliminating unnecessary operative manipulations and preparing the surgeon for any crises that might arise. With this concept in mind, we have tried resection of the gyrus rectus without routine sylvian fissure dissection in selected patients with anterior communicating artery (ACom) aneurysms, and compared these results with those from the conventional transsylvian approach.
Methods
This retrospective study included 231 surgically treated patients with ACom aneurysms from March, 1997 to May, 2005. The patients were divided into two groups : Group A (96 with sylvian fissure dissection, March, 1997-December, 2000) and Group B (135 without sylvian fissure dissection, January, 2001-May, 2005). Overall surgical outcomes were compared, and operative times have been prospectively recorded since January, 04 to evaluate how this maneuver affected the length of surgical procedures.
Results
All aneurysms were satisfactorily clipped, and there was no evidence of increased number of procedure-related retraction injuries in group B. Overall outcome was good in 186 (80.5%); 76 (79.2%) in group A, and 110 (81.5%) in group B (x2 test, p=0.79). In good clinical grade of group A, good outcome was observed in 60 patients (89.6%) and in group B, 97 patients (94.2%) (Fisher's exact test, p=0.38) (Fig. 2).
Conclusion
In this study, eliminating the step of sylvian fissure dissection by gentle lateral basal-frontal retraction to the side of the sylvian fissure did not increase morbidity and mortality. However, we do not intend to modify the standard approach to the ACom aneurysm that is familiar to and has been mastered by many others. Rather, we report our experience on the basis of our anatomic understanding of the technique and its results.
doi:10.3340/jkns.2007.42.5.388
PMCID: PMC2588195  PMID: 19096575
Anterior communicating artery; Aneurysm; Sylvian fissure; Dissection
23.  Simple Decompression of the Ulnar Nerve for Cubital Tunnel Syndrome 
Objective
Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients.
Methods
According to Dellon's criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less).
Results
Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbow-below the elbow) was 41.8±15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8±6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8±12.1 m/s to 47.8±12.1 m/s (p<0.05). After an average follow-up of 4.8±5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve.
Conclusion
Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.
doi:10.3340/jkns.2007.42.5.382
PMCID: PMC2588194  PMID: 19096574
Cubital tunnel syndrome; Ulnar nerve; Simple decompression
24.  Pleomorphic Xanthoastrocytoma with an Intracystic Hemorrhage : A Case Report and Literature Review 
Pleomorphic xanthoastrocytoma (PXA) has been considered as a low grade tumor of adolescents and young adults. Although this tumor often shows cystic component, the hemorrhage within the cyst is extremely rare. The authors report a rare case of cystic PXA with a hemorrhage within the cyst and the mural nodule in the left frontal lobe. A 64-year-old male presented with a week history of the right side hemiparesis. After gross total resection of the tumor, the patient was fully recovered from neurological deficit. It is suggested that this typically benign tumor could be presented with hemorrhage, causing a rapid neurological deterioration. Prompt surgical intervention, especially total removal of the tumor can provide an excellent functional recovery.
doi:10.3340/jkns.2007.42.5.410
PMCID: PMC2588191  PMID: 19096580
Pleomorphic xanthoastrocytoma (PXA); Cyst; Hemorrhage; Mural nodule
25.  Intracerebral Hematoma Caused by Ruptured Traumatic Pseudoaneurysm of the Middle Meningeal Artery : A Case Report 
Hematomas caused by ruptured traumatic pseudoaneurysms of the middle meningeal artery (MMA) usually present with extradural hematomas, whereas intradural intraparenchymal hematomas are extremely rare. We report a case of traumatic pseudoaneurysm of the MMA giving rise to an intracerebral hematoma after head trauma. A 70-year-old man suffered a massive intracerebral temporoparietal hemorrhage after a head injury. CT angiogram of the brain revealed a large hematoma in the right middle cranial fossa extending to the right sylvian fissure. Cerebral angiogram also revealed a pseudoaneurysm of the MMA, which was successfully treated surgically. Although traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare, it should be considered as a possible cause of intracerebral hematoma.
doi:10.3340/jkns.2007.42.5.416
PMCID: PMC2588190  PMID: 19096582
Traumatic pseudoaneurysm; Middle meningeal artery (MMA); Intracerebral hematoma

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