A therapeutic experience of diffuse cerebellopontine angle meningioma through combined translabyrinthine, infratemporal fossa, and suboccipital craniotomy approach

Meningioma is a slow growing tumor that mainly originates from the intracranial region, but rarely occurs at extracranial region. Once the extracranial meningioma shows diffuse and extensive involvement along the cranial nerves, surgical extirpation of the tumor becomes extremely difficult, and surgical morbidity often follows. We present a single case of en plaque meningioma extended to temporal area and parapharyngeal space, and reviewed the surgical technique for manipulation of facial nerve and postoperative cranial nerve palsy.ope

Recurrent Giant Cell Tumor of Skull Combined with Multiple Aneurysms

Giant cell tumors are benign but locally invasive and frequently recur. Giant cell tumors of the skull are extremely rare. A patient underwent a surgery to remove a tumor, but the tumor recurred. Additionally, the patient developed multiple aneurysms. The patient underwent total tumor resection and trapping for the aneurysms, followed by radiotherapy. We report this rare case and suggest some possibilities for treating tumor growth combined with aneurysm development.ope

Multiple Separate Aneurysms on Anterior Communicating Artery

Multiple cerebral aneurysms reportedly account for 14-33 % of all cerebral aneurysms. The incidence of multiple aneurysms has been increasing with development of radiological diagnostic tools such as magnetic resonance angiography, digital subtraction angiography and three dimension computed tomography. However, multiple aneurysms arising from same parent artery are uncommon. We have found only a few references as to diagnosis and surgical treatment of such lesions in the literature. Multiple separate aneurysms on same parent artery have been found most frequently on internal carotid artery 2, and then from middle cerebral artery (MCA). Those lesions arising from anterior communicating artery (ACoA) are rare. We report 7 cases (5.21%) of multiple aneurysms developed separately on ACoA and describe angiographic and operative finding of these rare lesions. One hundred and thirty four ACoA aneurysms were operated in our hospital from May 1997 to November 2004. There were only 7 patients with multiple aneurysms on ACoA. Out of 7 cases, four were diagnosed preoperatively and the other 2 were found intraoperatively. Multiple aneurysms may be associated with familiar aneurysms or arteriovenous malformations, however, there was no such case in our series. All patients were treated successfully with single or multiple clippings. Despite the advanced technology in radiological examinations, these lesions may not be detected on preoperative study. Close proximity or smaller size of the lesion may be responsible for the preoperative false negative angiographic findings. It is recommended to keep this possibility in mind during aneurysm surgery. Careful dissection is mandatory to ensure the completeness of aneurysm surgery.ope

Stent angioplasty for intracranial vertebral dissections:Single stent versus double stent placement

Objective : The reduced stent porosity caused by a double stent may accelerate the intraaneurysmal thrombosis and be helpful in achieving a more rapid complete occlusion compared with that achieved by single stent placement. This study examined the safety and efficacy of stent angioplasty according to two different stent techniques (single versus double stent placement). Methods : Twenty two patients who underwent stent angioplasty for vertebral dissections were reviewed retrospectively. Results : n the 22 patients, 23 intracranial vertebral artery dissections were treated using stent placement. Among them, 12 dissections were treated with single stent placement. The immediate and follow-up angiography showed a complete occlusion in only one case(8.3%). Eleven dissections were treated using a double stent method. Although an immediate complete occlusion was performed in only one case, the follow-up angiography revealed a complete occlusion in six cases(54.6%). Complications were encountered in only one case (4.3%, acute thrombosis) in the double stent placement group. On the modified Rankin scale applied in the follow-up, all the patients were assessed as being functionally improved or of a stable clinical status in both groups except for one patient with a severe subarachnoid hemorrhage who underwent a double stent placement. Conclusions : Intracranial vertebral artery dissections can be treated alternatively using an endovascular method with a stent. Double stent placement is superior to the single stent method. However, there are some limitations and complications associated with stent angioplasty.ope

Anterior skull base reconstruction using nasoseptal flap: cadaveric feasibility study and clinical implication [SevEN-001]

Background: Pedicled nasoseptal flap (PNSF) has significantly improved the surgical outcomes of endoscopic endonasal approach (EEAs) by reducing cerebrospinal fluid (CSF) leakage. The purpose of this study is to assess the feasibility of using a PNSF for anterior skull base (ASB) reconstruction and to describe a method to compensate for a short flap based on our results. Methods: In this cadaveric study, ASB dissection without sphenoidotomy was performed using 10 formalin-fixed and 5 fresh adult cadaver specimens, and the sufficiency of the PNSF to cover the ASB was assessed. After the sphenoidotomy, the length by which the PNSF fell short in providing coverage at the posterior wall of the frontal sinus (CPFS), and the extent of the anterior coverage from the limbus (CL) of the sphenoid bone was measured. Results: Without sphenoidotomy, the mean length of the remaining PNSF after the coverage of the posterior wall of the frontal sinus was 0.67 cm. After sphenoidotomy, the PNSF fell short by a mean length of 2.10 cm, in providing CPFS. The CL was 1.86 cm. Based on these findings, defects resulting from an endoscopic resection of ASB tumors were reconstructed using PNSF without total sphenoidotomy in 3 patients. There were no postoperative CSF leaks or complications. Conclusions: The use of PNSF for ASB reconstruction may be insufficient to cover the entire ASB defect after removal of large lesions which need total sphenoidotomy. When possible, by leaving some portion of the anterior sphenoid wall for supporting the PNSF, successful ASB reconstruction could be achieved in endoscopic resection of ASB tumors. Additional methods might be needed in some cases of large ASB lesions wherein the anterior sphenoid wall should be removed totally and the ASB defect is too large.ope

The Effects of High Fat Formula on the Blood Glucose Control of Brain-injured Patients: A Pilot Study

Purpose: Hyperlycemia after brain injury is known to be a risk factor that is correlated with hospital infection, mortality and the length of the hospital stay. There have been some reports about the use of a reduced-carbohydrate, modified high fat enteral formula for improving the blood glucose control and clinical outcomes of patients with type 2 diabetes. This pilot study evaluated the glucose control of brain-injured patients who were admitted into the neurointensive care unit (NCU) and they received either standard formula or high fat formula. Methods: Fourteen subjects were collected and they were divided into the experimental (high fat formula) and the control (standard formula) groups. We investigated the blood glucose levels, the total dose of insulin used, the number of patients who received insulin, the rate of hospital infection, the number of hospital days, the number of NCU days, the days of mechanical ventilation, the body mass index and the mental status of the subjects. Results: The hospital infection rate of the control group was higher than that of the experimental group, but the daily blood glucose level, the number of patients who received insulin and the total dose of insulin used were not statistically different between the two groups. The number of hospital days, the number of NCU days and the days on mechanical ventilation or the number of patients on mechanical ventilation were lower in the experimental group than that in the control group, but there were no statistically significant differences. Conclusion: These results suggest that the use of high fat enteral formula as compared to standard formula may decrease the hospital infection rate in critically ill patients after brain injury. But high fat formula did not have beneficial effects on the blood sugar level and insulin dosage.ope

Characteristics and management of residual or slowly recurred intracranial aneurysms

OBJECTIVE: Residual aneurysm from incomplete clipping or slowly recurrent aneurysm is associated with high risk of subarachnoid hemorrhage. We describe complete treatment of the lesions by surgical clipping or endovascular treatment. METHODS: We analyzed 11 patients of residual or recurrent aneurysms who had undergone surgical clipping from 1998 to 2009. Among them, 5 cases were initially clipped at our hospital. The others were referred from other hospitals after clipping. The radiologic and medical records were retrospectively analyzed. RESULTS: All patients presented with subarachnoid hemorrhage at first time, and the most frequent location of the ruptured residual or recurrent aneurysm was in the anterior communicating artery to posterior-superior direction. Distal anterior cerebral artery, posterior communicating artery, and middle cerebral artery was followed. Repositioning of clipping in eleven cases, and one endovascular treatment were performed. No residual aneurysm was found in postoperative angiography, and no complication was noted in related to the operations. CONCLUSION: These results indicate the importance of postoperative or follow up angiography and that reoperation of residual or slowly recurrent aneurysm should be tried if such lesions being found. Precise evaluation and appropriate planning including endovascular treatment should be performed for complete obliteration of the residual or recurrent aneurysmope

Progressively Enlarged Intracerebral Ependymal Cyst Presenting with Movement Disorder

Ependymal cysts are neuroepithelial cysts, typically found in the central white matter of the temporoparietal and frontal lobes. Clinical symptoms usually result from neurological deficits referable to these regions, from seizures, and chronic headaches associated with increased intracranial pressure. We describe here a case of ependymal cyst on the right fronto-parietal lobe, presenting with tremor and weakness. The cyst was resected surgically and presurgical neurological abnormalities were improved. An exploratory surgery with establishment of an adequate route of drainage and histological examination of the cyst wall are mandatory in the management of patients with a progressive and symptomatic intraparenchymal cyst.ope

아래가쪽동맥 외상성 손상에 의한 눈정맥의 경질막동정맥루: 얼굴정맥을 통한 경정맥 코일 색전술 사례

A 31-year-old man was admitted with exophthalmos. He suffered from progressive exophthalmos, bruit and conjunctival chemosis 7 days after head trauma caused by falling down. Cerebral angiography showed a dural arteriovenous fistula (DAVF) draining into the ophthalmic vein caused by tear in the inferolateral trunk, which is a rare presentation of traumatic DAVF. Selective transvenous coil embolization was performed via the facial vein without neurologic complications.ope

Rescue Therapy for Acute Thromboembolic Occulsion During Endovascular Treatment of Cerebral Aneurysms

Background and Purpose：One of the most common complications that occurrs during the treatment of cerebral aneurysm is acute thromboembolic occlusion. With the advent of endovascular devices and techniques, various recanalization methods have been introduced. We report our experience with rescue therapies for acute thromboembolic occlusions during endovascular treatment of cerebral aneurysms. Materials and Methods：From March 2009 to February 2011, acute thromboembolic events occurred in 7 patients during endovascular coil embolization of cerebral aneurysms. We performed rescue treatment for these 7 patients using endovascular methods. Our protocol for recanalization includes intra-arterial chemical and/or mechanical thrombolysis. Urokinase, glycoprotein IIb-IIIa inhibitor (Tirofiban) and self-expandable stents were used for recanalization. We assessed the recanalization results with a TICI grading system immediately after the rescue therapy, and clinical outcomes were reviewed. Results：Two men and 5 women (age range 49-69, mean age 56 years) were treated with rescue therapy. All 7 patients presented with subarachnoid hemorrhage; intra-arterial chemical thrombolysis was successful in 3, and their TICI grades were 2a (n=3). In the other 4 patients, successful recanalization was achieved with a self-expandable stent, and 3 of them had favorable outcomes as TICI grades were 2b (n=1) or 3 (n=2). Emergency bypass surgery was performed in one patient after a failed endovascular recanalization procedure. Conclusions：With these rescue treatments, we can minimize permanent neurological deficits from thromboembolic complications after endovascular procedures. Stent-assisted revascularization with concomitant administration of IIb-IIIa inhibitors contributed to the achievement of increased recanalization rates.ope