Risk Factors of Secondary Lumbar Discectomy of a Herniated Lumbar Disc after Lumbar Discectomy

Objective

To study risk factors of secondary lumbar discectomy (LD) for recurrent herniated lumbar disc (HLD) and identify methods to lower the rate of recurrence.

Methods

Data from 160 patients who underwent primary LD were collected retrospectively. Demographic features, radiologic findings including Pfirrmann disc degeneration, and surgical information were analyzed to compare risks between revision and non-revision patients.

Results

The revision rate was 15% (24 patients), and the mean follow-up was 28.3 months. HLD recurrence was not related to any demographic characteristics. Primary and secondary LD were most common at the L4–5 level, but the level of operation was not significantly associated with revision. Primary LD most commonly had a Pfirrmann disc degeneration grade of 3, followed by 4. For recurrent HLD, Pfirrmann grade 4 was most common and was statistically significant (p<0.05). A body mass index (BMI) over 30 was considered obese and was significantly related with HLD revision (p<0.05).

Conclusion

Patients with high BMI or severe disc degeneration should be informed of HLD revision.

Upper Cervical Subluxation and Cervicomedullary Junction Compression in Patients with Rheumatoid Arthritis

Objective

Rheumatoid arthritis (RA) is known to involve the cervical spine up to 86%. It often causes cervical instability like atlantoaxial subluxation (AAS), subaxial subluxation, and vertical subluxation (VS). In order to find the relation between RA and cord compression, we will evaluate the characteristics and risk factors of basilar invagination (BI) and cervicomedullary junction (CMJ) compression.

Methods

From January 2007 to May 2015, 12667 patients administrated to Hanyang University Medical Center. Four thousand three hundred eighty-six patients took cervical X-ray and 250 patients took cervical computed tomography or magnetic resonance imaging. Radiologic parameters, medication records were obtained from 242 patients. Multivariate logistic regression analysis was performed with correlation of CMJ compression, basin-dental interval (BDI), basin-posterior axial line interval (BAI), pannus formation, BI, and AAS.

Results

In the point of CMJ compression, atlantodental interval (ADI), posterior-atlantodental interval, BAI, AAS, and BI are relatively highly correlated. Patients with BI have 82 times strong possibility of radiologic confirmed CMJ compression, while AAS has 6-fold and pannus formation has the 3-fold possibility. Compared to the low incidence of BI, AAS and pannus formation have more proportion in CMJ compression. Furthermore, wrist joint erosion was correlated with VS and AAS.

Conclusion

BI has a very strong possibility of CMJ compression, while AAS and pannus formation have a high proportion in CMJ compression. Hence bilateral wrist joint erosion can be used as an indicator for the timing of screening test for cervical involvement. We suggest the early recommendation of cervical spine examination for the diagnosis of cervical involvement in order to prevent morbidity and mortality.

Influence of systemic bone mineral density on atlantoaxial subluxation in patients with rheumatoid arthritis

Osteopenia and osteoporosis were independent predictive factors for higher atlantoaxial subluxation occurrence in patients with lower body mass index. Our findings suggest that patients with rheumatoid arthritis with osteopenia or osteoporosis, particularly those with lower body mass index (BMI), should be screened regularly to determine the status of their cervical spines.

INTRODUCTION

Cervical spine involvement in rheumatoid arthritis (RA) patients may cause serious adverse effects on quality of life and overall health. This study aimed to evaluate the association between atlantodental interval (ADI), atlantoaxial subluxation (AAS), and systemic bone mineral density (BMD) based on BMI variations among established patients with RA.

METHODS

The ADI was transformed to the natural log scale to normalize distributions for all analyses. Multivariable linear regression analyses were used to identify independent predictive factors for ADI based on each BMD classification. Multivariate Cox regression analyses were also performed to identify independent predictive factors for the risk of AAS, which were classified by tertile groups of BMI.

RESULTS

A total of 1220 patients with RA who had undergone at least one or more cervical radiography and BMD assessments were identified and enrolled. We found that the association between BMD and ADI (β, -0.029; 95% CI, -0.059 to 0.002; p = 0.070) fell short of achieving statistical significance. However, the ADI showed a 3.6% decrease per 1 BMI increase in the osteoporosis group (β, -0.036; 95% CI, -0.061 to -0.011; p = 0.004). The osteopenia and osteoporosis groups showed about a 1.5-fold and a 1.8-fold increased risk of AAS occurrence among the first tertile of the BMI group.

CONCLUSIONS

Our study showed a possible association between lower BMD and AAS occurrence in patients with RA with lower BMI. Further studies are needed to confirm our findings.

Comparison of Transarticular Screw Fixation and C1 Lateral Mass-C2 Pedicle Screw Fixation in Patients with Rheumatoid Arthritis with Atlantoaxial Instability

BACKGROUND

Many surgical procedures have been introduced to manage atlantoaxial instability caused by rheumatoid arthritis (RA) to prevent complications and improve fusion rate. We report the surgical outcome between transarticular screw fixation (TAF) and C1 lateral mass-C2 pedicle screw fixation (C1LM-C2P) in patients with atlantoaxial instability from RA.

METHODS

Between 2002 and 2012, 58 patients were enrolled in the study. According to surgical procedures, patients were divided into 2 groups: group I who received TAF (n = 33) and group II who received C1LM-C2P (n = 25). Bony fusion was assessed by radiologic comparison immediately after the operation and 1 year postoperatively. In addition, complications and clinical and functional outcomes were evaluated.

RESULTS

Overall, bone fusion was achieved in 32 patients in group I (97%). In group II, the fusion rate was evaluated in 100% of patients. Complications (regardless of neurologic deterioration) were cable loosening and screw malposition in group I and violation into the vertebral canal and spinal canal in group II. There was no statistical significance in fusion rate, clinical outcomes, or complications. The 12-month atlantodental interval after operation for the C1LM-C2P group was significantly lower than that for the TAF group after adjusting for all variables.

CONCLUSIONS

Two surgical techniques showed a good fusion rate by rigid fixation in the immediate postoperative period and fewer surgery-related complications in patients with RA. Because surgical complications are more likely during the learning curve (as with other surgical techniques), surgeons should carefully evaluate patients before surgery by radiologic and neurologic examinations.

Comparison of Endovascular Treatments of Ruptured Dissecting Aneurysms of the Intracranial Internal Carotid Artery and Vertebral Artery with a Review of the Literature

Objective

Subarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA.

Methods

The authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome.

Results

Fifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability.

Conclusion

Clinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.

Effect of Using Local Intrawound Vancomycin Powder in Addition to Intravenous Antibiotics in Posterior Lumbar Surgery: Midterm Result in a Single-Center Study

Objective

We conducted this study to report the efficacy of local application of vancomycin powder in the setting of surgical site infection (SSI) of posterior lumbar surgical procedures and to figure out risk factors of SSIs.

Methods

From February 2013 to December 2013, SSI rates following 275 posterior lumbar surgeries of which intrawound vancomycin powder was used in combination with intravenous antibiotics (Vanco group) were assessed. Compared with 296 posterior lumbar procedures with intravenous antibiotic only group from February 2012 to December 2012 (non-Vanco group), various infection rates were assessed. Univariate and multivariate analysis to figure out risk factors of infection among Vanco group were done.

Results

Statistically significant reduction of SSI in Vanco group (5.5%) from non-Vanco group (10.5%) was confirmed (p=0.028). Mean follow-up period was 8 months. Rate of acute staphylococcal SSIs reduced statistically significantly to 4% compared to 7.4% of non-Vanco group (p=0.041). Deep staphylococcal infection decreased to 2 compared to 8 and deep methicillin-resistant Staphylococcus aureus infection also decreased to 1 compared to 5 in non-Vanco group. No systemic complication was observed. Statistically significant risk factors associated with SSI were diabetes mellitus, history of cardiovascular disease, length of hospital stay, number of instrumented level and history of previous surgery.

Conclusion

In this series of 571 patients, intrawound vancomycin powder usage resulted in significant decrease in SSI rates in our posterior lumbar surgical procedures. Patients at high risk of infection are highly recommended as a candidate for this technique.

Effects of a Temperature-Sensitive, Anti-Adhesive Agent on the Reduction of Adhesion in a Rabbit Laminectomy Model

OBJECTIVE

A common cause of failure in laminectomy surgery is when epidural, peridural, or perineural adhesion occurs postoperatively. The purpose of this study is to examine the efficacy of a temperature-sensitive, anti-adhesive agent (TSAA agent), Guardix-SG®, as a mechanical barrier for the prevention or reduction of peridural scar adhesion in a rabbit laminectomy model.

METHODS

Twenty-six mature rabbits were used for this study. Each rabbit underwent two separate laminectomies at lumbar vertebrae L3 and L6, left empty (the control group) and applied 2 mL of the TSAA agent (the experimental group), respectively. Invasive scar formation or inflammation after laminectomy was quantitatively evaluated by measuring the thickness of the dura, the distance from the surface of dura to the scar tissues, the number of inflammatory cells in the scar tissues at the laminectomy site, and the concentration of collagen in histological sections.

RESULTS

At 6 weeks postsurgery, the dura was significantly thinner and the distance from the surface of dura to the scar tissues was greater in the experimental group than in the control group (p=0.04 and p=0.01). The number of inflammatory cells was not significantly different in the two groups (p=0.08), although the mean number of inflammatory cells was relatively lower in the experimental group than in the control group.

CONCLUSION

The current study suggests that the TSAA agent, Guardix-SG®, could be useful as an interpositional physical barrier after laminectomy for the prevention or reduction of adhesion.

Unilateral C1 Lateral Mass and C2 Pedicle Screw Fixation for Atlantoaxial Instability in Rheumatoid Arthritis Patients: Comparison with the Bilateral Method

OBJECTIVE

Bilateral C1 lateral mass and C2 pedicle screw fixation (C1LM-C2P) is an ideal technique for correcting atlantoaxial instability (AAI). However, the inevitable situation of vertebral artery injury or unfavorable bone structure may necessitate the use of unilateral C1LM-C2P. This study compares the fusion rates of the C1 lateral mass and C2 pedicle screw in the unilateral and bilateral methods.

METHODS

Over five years, C1LM-C2P was performed in 25 patients with AAI in our institute. Preoperative studies including cervical X-ray, three-dimensional computed tomography (CT), CT angiogram, and magnetic resonance imaging were performed. To evaluate bony fusion, measurements of the atlanto-dental interval (ADI) and CT scans were performed in the preoperative period, immediate postoperative period, and postoperatively at 1, 3, 6, and 12 months.

RESULTS

Unilateral C1LM-C2P was performed in 11 patients (44%). The need to perform unilateral C1LM-C2P was due to anomalous course of the vertebral artery in eight patients (73%) and severe degenerative arthritis in three patients (27%). The mean ADI in the bilateral group was 2.09 mm in the immediate postoperative period and 1.75 mm in 12-months postoperatively. The mean ADI in the unilateral group was 1.82 mm in the immediate postoperative period and 1.91 mm in 12-months postoperatively. Comparison of ADI measurements showed no significant differences in either group (p=0.893), and the fusion rate was 100% in both groups.

CONCLUSION

Although bilateral C1LM-C2P is effective for AAI from a biomechanical perspective, unilateral screw fixation is a useful alternative in patients with anatomical variations.

The Predicting Factors for Recurrence of Chronic Subdural Hematoma Treated with Burr Hole and Drainage

Objective

Chronic subdural hematoma (CSDH) is common in elderly patients. So, with an increasing number of elderly people in the general population, there is a need to investigate risk factors which increase recurrence rate. In this study, factors affecting the postoperative recurrence are investigated based on the reoperative CSDH cases.

Methods

Total of ninety-seven patients was enrolled in this study who had have operation for CSDH. In all patients, one burr hole trephination and drainage was the method of choice for the initial treatment of CSDH. We retrospectively evaluated several factors which affect to recurrence of CSDH.

Results

Retrospective analysis was performed in 97 patients. Sixteen patients experienced reoperation within 3 months (16/97, 16.5%) for recurrence of CSDH. And, when hematoma was divided by internal architecture, heterogeneous density group seems to be have close relationship with recurrence more significantly than homogeneous density group (p=0.002). Hypertension, diabetes mellitus, early removal of drainage tube, bilaterality of hematoma also have significant relationship with recurrence.

Conclusion

Recurrence rate of CSDH treated with one burr hole drainage is related with some various factors. There was statistically significant difference between recurred group and non-recurred group. Not only demographic factors but also internal architecture on preoperative brain computed tomography is a significant predicting factor of recurrence in CSDH patients who underwent a surgery. In this study, heterogeneous type hematoma have significantly related with recurrence of CSDH. We should give attention to these predicting factors for more effective care.

Cerebral Infarction after Traumatic Brain Injury: Incidence and Risk Factors

Objective

Post-traumatic cerebral infarction (PTCI) is one of the most severe secondary insults after traumatic brain injury (TBI), and is known to be associated with poor outcome and high mortality rate. We assessed the practical incidence and risk factors for the development of PTCI.

Methods

We conducted retrospective study on 986 consecutive patients with TBI from the period May 2005 to November 2012 at our institution. The definition of PTCI was made on non-enhanced CT scan based on a well-demarcated or fairly discernible region of low attenuation following specific vascular territory with normal initial CT. Clinical and radiological findings that related to patients' outcome were reviewed and statistically compared.

Results

PTCI was observed in 21 (2.1%) patients. Of various parameters, age (p=0.037), initial Glasgow coma scale score (p<0.01), brain herniation (p=0.044), and decompressive craniectomy (p=0.012) were significantly higher in patients with PTCI than patients who do not have PTCI. Duration between accident and PTCI, patterns of TBI and vascular territory of PTCI were not specific. The mortality rates were significantly higher in patients with PTCI than without PTCI.

Conclusion

The development of PTCI is rare after TBI, but it usually results in serious outcome and high mortality. Early recognition for risks and aggressive managements is mandatory to prevent PTCI.

Posterior interspinous fusion device for one-level fusion in degenerative lumbar spine disease : comparison with pedicle screw fixation - preliminary report of at least one year follow up

Objective

Transpedicular screw fixation has some disadvantages such as postoperative back pain through wide muscle dissection, long operative time, and cephalad adjacent segmental degeneration (ASD). The purposes of this study are investigation and comparison of radiological and clinical results between interspinous fusion device (IFD) and pedicle screw.

Methods

From Jan. 2008 to Aug. 2009, 40 patients underwent spinal fusion with IFD combined with posterior lumbar interbody fusion (PLIF). In same study period, 36 patients underwent spinal fusion with pedicle screw fixation as control group. Dynamic lateral radiographs, visual analogue scale (VAS), and Korean version of the Oswestry disability index (K-ODI) scores were evaluated in both groups.

Results

The lumbar spine diseases in the IFD group were as followings; spinal stenosis in 26, degenerative spondylolisthesis in 12, and intervertebral disc herniation in 2. The mean follow up period was 14.24 months (range; 12 to 22 months) in the IFD group and 18.3 months (range; 12 to 28 months) in pedicle screw group. The mean VAS scores was preoperatively 7.16±2.1 and 8.03±2.3 in the IFD and pedicle screw groups, respectively, and improved postoperatively to 1.3±2.9 and 1.2±3.2 in 1-year follow ups (p<0.05). The K-ODI was decreased significantly in an equal amount in both groups one year postoperatively (p<0.05). The statistics revealed a higher incidence of ASD in pedicle screw group than the IFD group (p=0.029).

Conclusion

Posterior IFD has several advantages over the pedicle screw fixation in terms of skin incision, muscle dissection and short operative time and less intraoperative estimated blood loss. The IFD with PLIF may be a favorable technique to replace the pedicle screw fixation in selective case.

Long-term follow-up radiologic and clinical evaluation of cylindrical cage for anterior interbody fusion in degenerative cervical disc disease

Objective

Various procedures have been introduced for anterior interbody fusion in degenerative cervical disc disease including plate systems with autologous iliac bone, carbon cages, and cylindrical cages. However, except for plate systems, the long-term results of other methods have not been established. In the present study, we evaluated radiologic findings for cylindrical cervical cages over long-term follow up periods.

Methods

During 4 year period, radiologic findings of 138 patients who underwent anterior cervical fusion with cylindrical cage were evaluated at 6, 12, 24, and 36 postoperative months using plain radiographs. We investigated subsidence, osteophyte formation (anterior and posterior margin), cage direction change, kyphotic angle, and bone fusion on each radiograph.

Results

Among the 138 patients, a minimum of 36 month follow-up was achieved in 99 patients (mean follow-up : 38.61 months) with 115 levels. Mean disc height was 7.32 mm for preoperative evaluations, 9.00 for immediate postoperative evaluations, and 4.87 more than 36 months after surgery. Osteophytes were observed in 107 levels (93%) of the anterior portion and 48 levels (41%) of the posterior margin. The mean kyphotic angle was 9.87° in 35 levels showing cage directional change. There were several significant findings : 1) related subsidence [T-score (p=0.039) and anterior osteophyte (p=0.009)], 2) accompanying posterior osteophyte and outcome (p=0.05).

Conclusion

Cage subsidence and osteophyte formation were radiologically observed in most cases. Low T-scores may have led to subsidence and kyphosis during bone fusion although severe neurologic aggravation was not found, and therefore cylindrical cages should be used in selected cases.

Perioperative risk factors related to lumbar spine fusion surgery in korean geriatric patients

Objective

Life expectancy for humans has increased dramatically and with this there has been a considerable increase in the number of patients suffering from lumbar spine disease. Symptomatic lumbar spinal disease should be treated, even in the elderly, and surgical procedures such as fusion surgery are needed for moderate to severe lumbar spinal disease. However, various perioperative complications are associated with fusion surgery. The aim of this study was to examine perioperative complications and assess risk factors associated with lumbar spinal fusion, focusing on geriatric patients at least 70 years of age in the Republic of Korea.

Methods

We retrospectively investigated 489 patients with various lumbar spinal diseases who underwent lumbar spinal fusion surgery between 2003 and 2007 at our institution. Three fusion procedures and the number of fused segments were analyzed in this study. Chronic diseases were also evaluated. Risk factors for complications and their association with age were analyzed.

Results

In this study, 74 patients experienced complications (15%). The rate of perioperative complications was significantly higher in patients 70 years of age or older than in other age groups (univariate analysis, p=0.001; multivariate analysis, p=0.004). However, perioperative complications were not significantly associated with the other factors tested (sex, comorbidities, operation procedures, fusion segments involved).

Conclusion

Increasing age was an important risk factor for perioperative complications in patients undergoing lumbar spinal fusion surgery whereas other factors were not significant. We recommend good clinical judgment and careful selection of geriatric patients undergoing lumbar spinal fusion surgery.

The safety and efficacy of cadaveric allografts and titanium cage as a fusion substitutes in pyogenic osteomyelitis

OBJECTIVE

The safety and efficacy of various fusion substitutes in pyogenic osteomyelitis has not been investigated. We evaluated and compared the cadaveric allograft and titanium cages used to reconstruct, maintain alignment and achieve fusion in the management of pyogenic spinal infection.

METHODS

There were 33 patients with pyogenic osteomyelitis underwent fusion in this study. Fifteen of the 33 patients were operated on by fusion with allografts (cadaveric patella bones) and 18 of those were operated with titanium mesh cages filled with autologous cancellous iliac bone. After the affected disc and vertebral body resection with pus drainage, cadaveric allograft or titanium cages were inserted into the resected space. Posterior transpedicular screw fixation and rod compression in resected space, where cadaveric allograft or titanium cages were inserted, was performed to prevent the malposition in all patients except in 1 case. Recurrent infection was identified by serial erythrocyte sedimentation rate and cross reactive protein follow-up. Osseous union and recurred infection available at a minimum of 2 years following operation was identified. The amount of kyphosis correction and the subsidence were measured radiographically.

RESULTS

Spinal fusion was achieved in 29 of 33 patients. In the cadaveric allograft group, 93.3% of patient (14 of 15) showed the osseous union while 83.3% of patient (15 of 18) in the titanium cage group showed union. Subsidence was noted in 12 of the patients. Twelve patients (36.3%) showed unsettling amounts of subsidence postoperatively whereas 46.6% of patients in the cadaveric allograft group and 37.7% of patients in the titanium cage group showed similar subsidence, respectively. There were statistical difference in the fusion rate (p=0.397) and subsidence rate (p=0.276) between the two groups. There was significant statistical difference in the postoperative improvement of segmental kyphosis between the two groups (p=0.022), that is the improvement in sagittal alignment was greater in the titanium cage group than in the cadaveric allograft group. There was no case of recurred infection.

CONCLUSION

The cadaveric allograft and titanium cages are effective and safe in restoring and maintaining sagittal plane alignment without increased incidence in infection recurrence in pyogenic osteomyelitis. The postoperative improvement of segmental kyphosis was better in the cage group.

Rod migration into the posterior fossa after harms operation : case report and review of literatures

C1 lateral mass and C2 pedicle (C1LM-C2P) fixation is a relatively new technique for atlantoaxial stabilization. Complications from C1LM-C2P fixation have been rarely reported. The authors report unilateral rod migration into the posterior fossa as a rare complication after this posterior C1-C2 stabilization technique. A 23-year-old man suffered severe head trauma and cervical spine injury after vehicle accident. He was unconscious for 2 months and regained consciousness. He underwent C1LM-C2P fixation for stabilization of type II odontoid process fracture described by Harms. The patient recovered without a major complication. Twenty months after operation, brain computed tomogram performed at psychology department for disability evaluation showed rod migration into the right cerebellar hemisphere. The patient had mild occipital headache and dizziness only regarding the misplaced rod. He refused further operation for rod removal. To our knowledge, this complication is the first report regarding rod migration after Harms method. We should be kept in mind the possibility of rod migration, and C1LM-C2P fixation should be performed with meticulous technique and long-term follow-up.

Traumatic brainstem hemorrhage presenting with hemiparesis

Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.

Simple anterior petroclinoid fold resection in the treatment of low-lying internal carotid-posterior communicating artery aneurysms

BACKGROUND

We investigate cases of low-lying IC-PC artery aneurysms with the aim to demonstrate an easy and less laborious technique of APF resection in lieu of AC in cases involving difficult aneurysmal neck clipping.

METHODS

Among a total 117 IC-PC artery aneurysms, 15 low-lying IC-PC artery aneurysms (13 ruptured and 2 unruptured) were obliterated between January 1996 and December 2006. We retrospectively investigated patients who have been treated by simple resection of APF (APF group) compared with patients treated by AC (AC group) in the surgery of the communicating segment of the ICA aneurysms. Clinical, radiological, and operative data were analyzed; and the 2 groups were compared.

RESULTS

Among 15 cases, 7 cases were included in the AC group and 8 cases were included in the APF group. One case was treated by a combination of AC and APF resection simultaneously. There was no difference in the clinical outcome between the 2 groups. No operative complications were encountered in any patients treated by the simple APF resection.

CONCLUSIONS

Simple APF resections improve the visualization of the proximal neck of aneurysms, allowing for accurate clip placement and also facilitating the use of proximal vascular control as an adjunct to low-lying IC-PC artery aneurysms surgery.

Aneurysmal subarachnoid hemorrhage in young adults: a gender comparison study

Aneurysmal subarachnoid hemorrhage is uncommon in young adults. The aim of this study was to compare clinical characteristics of ruptured aneurysms between males and females in the third or fourth decade of life. We retrospectively investigated 301 patients who underwent surgery for ruptured cerebral aneurysms over 6 years. Among them, 53 patients were aged between 20-39 years. Clinical characteristics and related variables were compared between genders. In general, there was a favorable outcome in either gender (84.9%). There was a higher incidence of multiplicity and intraoperative rupture in females, as well as a significant difference in aneurysm location between genders (p=0.030, p=0.014, and p=0.027 respectively). Overall outcome was not different between the two groups. These results suggest that aneurysm formation may differ between genders.

Venous loop mimicking middle cerebral artery bifurcation aneurysm on computed tomographic angiography—case report

BACKGROUND

CT angiography has been widely used for the detection of cerebral aneurysm. However, there are still limitations despite improving CT angiographic techniques. We describe the unusual case of the detection of a false-positive aneurysm on CT angiography.

CASE DESCRIPTION

A 64-year-old man presented with a 14-day history of severe headache and nuchal rigidity. Brain CT demonstrated no subarachnoid hemorrhage, but cerebrospinal fluid appeared xanthochromic in 3 successive tubes after lumbar puncture. Subsequent CT angiography suggested an aneurysm at the bifurcation of the left MCA. However, at operation, prominent sylvian vein superimposed on the bifurcation of the left MCA, and there was no aneurysm. Follow-up monitoring with conventional angiography at 2 weeks showed no abnormal findings. The patient recovered uneventfully.

CONCLUSION

The case demonstrates that although CT angiography has a reportedly high specificity and sensitivity for the detection of intracranial aneurysm, careful interpretation is required to diagnose intracranial aneurysms.

Bilateral vidian nerve schwannomas associated with facial palsy. Case report and review of the literature

Intracranial schwannomas are relatively common benign tumors arising from Schwann cells. Among the cranial nerves, the vestibular division of the vestibulocochlear nerve is the site most commonly affected by these lesions, followed by the trigeminal nerve. The authors report a case of bilateral schwannomas arising from both of the pterygoid canals. A 13-year-old girl presented with intermittent headaches and left-sided facial palsy. Preoperative computerized tomography scans and magnetic resonance images revealed nonenhancing round masses within the bilateral vidian canals, bone erosion, and sclerosis. The transnasal transseptal transsphenoidal approach was used to remove the masses. Postoperatively, the patient recovered uneventfully. On histopathological examination, the masses were confirmed as schwannomas. The clinical presentation and probable histogenesis of schwannomas arising in this location are discussed together with a review of the literature.

Prognostic implication of telomerase activity in patients with brain tumors

Telomerase adds telomeric repeats to the ends of telomeres to compensate for their progressive loss. A favorable prognosis is associated with low or no telomerase in some tumors. The authors investigated whether telomerase activity is associated with survival of patients with brain tumors. Sixty-two consecutive patients with brain tumors underwent surgery, and their surgical specimens were investigated. The patients were pathologically categorized as group I (aggressive group) and group II (non-aggressive group). Telomerase activity was examined by the telomeric repeat amplification protocol (TRAP) assay. The median time was calculated in association with overall survival and progression-free survival in each group. The significant difference was noted in telomerase activity between high-grade gliomas and lowgrade gliomas (p=0.022). Telomerase activity was significantly associated with the median overall survival and progression-free survival in all tumors of the aggressive group. On the other hand, the median overall survival in the non-aggressive group was not dependent on telomerase activity, while the median progression-free survival was. Our data suggests that telomerase is an important prognostic indicator of survival in patients with brain tumors.

Influence of lamina terminalis fenestration on the occurrence of the shunt-dependent hydrocephalus in anterior communicating artery aneurysmal subarachnoid hemorrhage

Recently, it was reported that fenestration of the lamina terminalis (LT) may reduce the incidence of shunt-dependent hydrocephalus in aneurysmal subarachnoid hemorrhage (SAH). The authors investigated the efficacy of the LT opening on the incidence of shunt-dependent hydrocephalus in the ruptured anterior communicating artery (ACoA) aneurysms. The data of 71-ruptured ACoA aneurysm patients who underwent aneurysmal clipping in acute stage were reviewed retrospectively. Group I (n=36) included the patients with microsurgical fenestration of LT during surgery, Group II (n=35) consisted of patients in whom fenestration of LT was not feasible. The rate of shunt-dependent hydrocephalus was compared between two groups by logistic regression to control for confounding factors. Ventriculo-peritoneal shunts were performed after aneurysmal obliteration in 18 patients (25.4%). The conversion rates from acute hydrocephalus on admission to chronic hydrocephalus in each group were 29.6% (Group I) and 58.8% (Group II), respectively. However, there was no significant correlation between the microsurgical fenestration and the rate of occurrence of shunt-dependent hydrocephalus (p>0.05). Surgeons should carefully decide the concomitant use of LT fenestration during surgery for the ruptured ACoA aneurysms because of the microsurgical fenestration of LT can play a negative role in reducing the incidence of chronic hydrocephalus.

Congenital supratentorial hemangioblastoma as an unusual cause of simultaneous supra- and infratentorial intracranial hemorrhage: case report

Congenital supratentorial hemangioblastomas are extremely rare tumors even in pediatric population. A 57-day-old female neonate presented with a pure motor seizure. On imaging studies, intracranial hemorrhagic lesions containing multiple cystic components in the cerebral and cerebellar areas were revealed, simultaneously. After the emergency surgical evacuation only to a fatal supratentorial lesion, an infratentorial lesion also regressed spontaneously. The authors report a case of full-term neonate presenting with supra- and infratentorial hemorrhagic lesions, which occurred as a result of congenital supratentorial hemangioblastoma bleeding.

Metachronous germinoma after total removal of mature teratoma in the third ventricle: a case report

A rare case of intraventricular germinoma in the third ventricle, which occurred 30 months after total removal of mature teratoma on the same location in a 29- yr-old man is presented. Recurrence is supposed to represent an acceleration of localized dysplastic processes of totipotent germ cells present in the midline neuraxis or a growth of unidentified microscopic residue of germinoma component in mature teratoma. Although the radiation therapy after total removal of mature teratoma is still controversial, careful follow-up is warranted for evaluating a possible recurrence of other germ cell tumors.

Expression of the proliferating cell nuclear antigen and clinicopathological features in intracranial meningiomas

PC10, a monoclonal antibody (mAb) to proliferating cell nuclear antigen (PCNA) is known to show immunoreactivity in paraffin-embedded specimens. The authors present the relation between PCNA expression and clinicopathological features in 38 intracranial meningiomas. PCNA scores were obtained by immunohistochemical staining of the paraffin-embedded sections using a streptavidin-biotin immunoperoxidase method with PC10 mAb. Univariate analysis showed that high PC10 scores were associated with old age (> or = 50 years old), male, recurrent tumours, and meningothelial type. However, these high scores did not reach a statistical significance (P> 0.05). PC10 scores of the basal meningioma tended to be higher than that of the hemispheric meningioma (P< 0.05). The staining intensity of PCNA was also markedly increased in basal meningiomas. It is suggested that the proliferative potential is higher in basal meningiomas than in hemispheric meningiomas. Moreover, these results could reflect high recurrence and difficulty in management of the skull base meningiomas.

Multiple intracranial aneurysms associated with branchio-oto-dysplasia

Branchio-oto-dysplasia is characterized by abnormalities of embryonic branchial arch system and deafness inherited as autosomal dominant with variable gene expression. We present a rare case of multiple intracranial aneurysms associated with branchio-oto-dysplasia. A 40-yr-old man with severe headache presented as spontaneous subarachnoid hemorrhage on brain computed tomographic scan. The patient also manifested clinical features of branchio-oto-dysplasia and right hemifacial hypoplasia. Carotid angiogram confirmed an aneurysm in the anterior communicating artery. Intraoperative findings demonstrated multiple aneurysms in the anterior communicating artery and in the left posterior communicating artery, which were clipped successfully. Postoperative course was uneventful. This condition has not been reported previously. We also reviewed literatures to discuss whether the intracranial aneurysm was as a coincidental finding or a part of this malformation.

Expression of tenascin-C in astrocytic tumors: its relevance to proliferation and angiogenesis

BACKGROUND

The expression and distribution of the extracellular matrix protein tenascin-C (TN-C) may be enhanced in human astrocytomas. The purpose of this study is to evaluate the expression of TN-C according to histological malignancy of tumor cells and its relevance to neoplastic angiogenesis in human astrocytic tumors.

METHODS

Between 1994 and 1998, 52 astrocytic tumor specimens including 4 pilocytic astrocytomas, 13 astrocytomas, 3 anaplastic astrocytomas, and 32 glioblastomas were used in this study. A retrospective analysis was performed to evaluate a statistical correlation between TN-C expression and proliferative indices. We characterized the expression of TN-C in neoplastic vessels, around individual tumor cells as a tumor network, and in tumor cells by immunohistochemistry using antibodies against human TN-C. The proliferative indices were also investigated by immunostaining with the MIB-1 antibody against the Ki-67 proliferation antigen.

RESULTS

TN-C immunoreactivity was found to be enhanced in tumor vessels and tumor networks of high-grade astrocytic tumors. The vascular TN-C deposition was greater in high-grade than in low-grade astrocytic tumors (p < 0.05). Its expression was the most intense in glioblastomas. Proliferation indices increased with tumor grade and MIB-1 labeling index (LI) was highest in glioblastomas. Moreover, expression of TN-C in tumor vessels was correlated with proliferative indices.

CONCLUSIONS

Our data show that TN-C in human astrocytic tumors may be identified as a factor contributing to malignant progression. And also, enhanced expression of TN-C in tumor vessels having a high proliferative index indicates that TN-C could be involved in neoplastic angiogenesis.

Metastatic tumors in the sellar and parasellar regions: clinical review of four cases

Metastatic tumors in the sellar and parasellar regions are uncommon and rarely detected in clinical practice. We present four cases of sellar and parasellar metastatic tumors, which metastasized from distant organ in one case and extended directly from adjacent structures in three. Common presenting symptoms were cranial neuropathies, headache and facial pain. Invasion into the cavernous sinus was noted in all cases. We report rare cases of sellar and parasellar metastases. Also, we should consider the possibility of metastasis in these regions for patients who showed the above clinical presentations in systemic cancer patients. In extensive diseases, transient symptomatic relief could be obtained by direct surgical management, even in restricted degree.

Symptomatic sacral extradural arachnoid cyst associated with lumbar intradural arachnoid cyst

A case of sacral extradural arachnoid cyst associated with lumbar intradural arachnoid cyst in a 35-year-old male is reported. The patient presented with a history of severe sacrococcygeal pain, constipation, and dysuria for several months. Computed tomographic (CT) myelograms and magnetic resonance imaging (MRI) scans showed a huge sacral cyst without neural components. A favorable outcome could be achieved by decompression of the cyst, obliteration of the fistulous channel between the cyst and the thecal sac, and fenestration of the arachnoid cyst into the subarachnoid space. The relevant literatures are also reviewed.