[show abstract][hide abstract] ABSTRACT: Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications.
Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography.
Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely.
The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.
Journal of Korean Neurosurgical Society 12/2013; 54(6):477-83. · 0.56 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose: To investigate the efficacy and safety of intra-arterial thrombolysis (IAT) for acute central retinal artery occlusion (CRAO). Methods: Records from 101 CRAO patients treated with either IAT (n = 57) or standard treatment (ST, n = 44) were retrospectively reviewed. ST consisted of ocular massage and intraocular pressure-lowering agents. Using fundoscopic and angiographic findings, CRAO was categorized as incomplete (diminished visual acuity [VA] with slight retinal edema, slight cherry-red spot), subtotal (severe VA reduction, cherry-red spot, distinct retinal edema), or total (massive edema, occluded perimacular arterioles, additional choroidal blood flow interruption). One-month and final best-corrected VA (BCVA) were compared between the IAT and ST groups. Early (≤3 days) and final (1 month) reperfusion (improvement of retinal perfusion) rates were compared between groups. Subgroup analyses were performed according to CRAO stage. Results: Overall VA did not significantly differ between groups, but early reperfusion was greater in the IAT group (74.1% vs. 42.9%, P = 0.005). In incomplete CRAO, the IAT group exhibited greater visual improvement after 1 month (1.08 ± 0.21 vs. 0.23 ± 0.26 logMAR, P <0.001) and at the final visit (1.08 ± 0.53 vs. 0.08 ± 0.57 logMAR, P <0.001). However, in subtotal and total CRAO, no significant differences in visual outcomes were observed between groups. IAT resulted in clinically insignificant cerebral infarcts, detectable on brain imaging, in 8% of patients. Hemorrhagic transformation was not noted. Conclusions: The IAT treatment may provide early restoration of retinal perfusion and offer functional benefits in the management of incomplete CRAO.
[show abstract][hide abstract] ABSTRACT: We report two cases of surgical removal of a retained subfoveal perfluorocarbon liquid (PFCL) bubble through a therapeutic macular hole combined with intravitreal PFCL injection and gas tamponade. Two patients underwent pars plana vitrectomy with PFCL injection for rhegmatogenous retinal detachment. In both cases, a retained subfoveal PFCL bubble was noticed postoperatively by funduscopy and optical coherence tomography. Both patients underwent surgical removal of the subfoveal PFCL through a therapeutic macular hole and gas tamponade. The therapeutic macular holes were completely closed by gas tamponade and the procedure yielded a good visual outcome (best-corrected visual acuity of 20 / 40 in both cases). In one case, additional intravitreal PFCL injection onto the macula reduced the size of the therapeutic macular hole and preserved the retinal structures in the macula. Surgical removal of a retained subfoveal PFCL bubble through a therapeutic macular hole combined with intravitreal PFCL injection and gas tamponade provides an effective treatment option.
Korean Journal of Ophthalmology 10/2013; 27(5):392-395.
[show abstract][hide abstract] ABSTRACT: Abstract Background: Post-traumatic diabetes insipidus (DI) is a relatively common complication after head injury. The authors report a fatal case of refractory DI, which developed in a patient with chronic subdural haematoma. Case history: A 38-year-old woman presented to the emergency room with a headache for over a week. She was alert and neurological examination demonstrated no significant deficits or external wounds in her head. Brain computed tomography (CT) scans revealed a small amount of chronic subdural haematoma bilaterally. She was treated conservatively and her hospital course was uneventful until she developed a convulsive seizure and mental change on the 3rd day after admission. Immediate follow-up CT scans showed no significant change in the amount of haemorrhage except effacement of gyral marking. Bilateral trephination and drainage of the haematoma were performed immediately. Post-operatively, she developed a refractory DI and was managed in the intensive care unit. However, she died on the 6th day after the operation ultimately. Conclusion: The authors emphasize the importance of timely drainage of chronic subdural haematoma to prevent a fatal endocrinologic complication after head injury. This study also discusses the possible mechanism of DI after head injury, management and review of the pertinent literatures.
[show abstract][hide abstract] ABSTRACT: The introduction and development of the embolic protecting device (EPD) has resulted in a decreased rate of stroke after carotid artery stenting (CAS). The authors performed a retrospective study to investigate the risk factors for developing large emboli after CAS which can lead to ischemic events.
A total of 35 consecutive patients who underwent CAS between January 2009 and March 2012 were included in this study. Patients were divided into two groups including those with small emboli (group A; grade 1, 2) and those with large emboli (group B; grade 3, 4). The size and number of emboli were assigned one of four grades (1=no clots, 2=1 or 2 small clots, 3=more than 3 small clots, 4=large clots) by microscopic observation of the EPD after CAS. We compared demographic characteristics, medical history, and angiographic findings of each group.
Thirty-five patients underwent CAS, and technical success was achieved in all cases. Twenty-three patients were included in group A and 12 patients in group B. Our results demonstrated that advanced age [odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.52; p=0.044] and smoking (OR 42.06; CI 2.828-625.65, p=0.006) were independent risk factors for developing large emboli after CAS.
In patients with carotid artery stenosis treated with CAS, advanced age and smoking increased the number and size of emboli. Although use of an EPD is controversial, it may be useful in CAS in patients with risk factors for large emboli in order to reduce the risk of ischemic events.
Journal of Korean Neurosurgical Society 03/2013; 53(3):155-60. · 0.56 Impact Factor
[show abstract][hide abstract] ABSTRACT: To describe an ultrasonography-guided technique for cubital tunnel injection.
The ulnar nerves from 12 elbows of 6 adult cadavers were scanned, and the cross-sectional areas of the ulnar nerves, cubital tunnel inlets and outlets were measured by using ultrasonography. All elbows were dissected after an ultrasonography-guided dye injection at the inlet of the cubital tunnel. The dissectors evaluated the spread of dye and the coloration of the nerve and remeasured the cross-sectional areas of the cubital tunnel inlets and outlets.
After a real-time visualization of an ultrasonography-guided injection, the ulnar nerves were seperated from the medial groove for the ulnar nerve. All the ulnar nerves of the cadavers were successfully colored with the dye, from the inlet to oulet of the cubital tunnel. The post-injection cross-sectional areas were significantly larger than the pre-injection cross-sectional areas. No significant differences were detected in the post-injection cross-sectional areas of the cubital tunnel outlet and the ulnar nerve as compared with the pre-injection areas.
Clinicians should consider real-time visualization of ultrasonography for guided injection around the ulnar nerve at the inlet of the cubital tunnel.
Annals of rehabilitation medicine. 08/2012; 36(4):496-500.
[show abstract][hide abstract] ABSTRACT: The sinking skin flap syndrome is a rare complication after a large craniectomy. It consists of a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures. In patient with sinking skin flap syndrome, cerebral blood flow and cerebral metabolism are decreased by sinking skin flap syndrome, and it may cause the deterioration of autoregulation of brain. We report a case of a patient with sinking skin flap syndrome who suffered from reperfusion injury after cranioplasty with review of pertinent literature.
Journal of Korean Neurosurgical Society 02/2012; 51(2):117-9. · 0.60 Impact Factor
[show abstract][hide abstract] ABSTRACT: Lhermitte-Duclos disease (LDD) is a rare cerebellar disorder characterized by diffuse or focal enlargement of cerebellar folia. Clinical manifestations are usually related to a mass effect and secondary obstructive hydrocephalus. Increased intracranial pressure symptoms and cerebellar symptoms are the most frequent patient complaints. We describe the case of a patient with LDD who developed secondary obstructive hydrocephalus. A 68-year-old woman was brought to the emergency room for sudden vertigo following several bouts of vomiting and headache. There were no external signs of trauma, serious illness or infection. On admission, the patient was alert and had no neurological deficits. Brain computed tomography (CT) and magnetic resonance imaging (MRI) showed hydrocephalus and a cerebellar mass in the right cerebellar hemisphere compressing the fourth ventricle. Suboccipital craniotomy and subtotal removal of the mass was performed. Pathological study of the surgical specimen showed abnormal ganglionic neurons and an enlarged molecular layer compatible with dysplastic gangliocytoma. Cytoreduction can achieve improvement in symptoms caused by mass effect, but postoperative swelling may aggravate obstructive hydrocephalus. Therefore, if symptoms still remain after removal of the mass, an additional shunting procedure may be needed as a further management option.
[show abstract][hide abstract] ABSTRACT: Colpocephaly is an abnormal enlargement of the occipital horns, i.e., the posterior or rear portions of the lateral ventricles of the brain, and is associated with several other brain abnormalities. Colpocephaly is occasionally misdiagnosed as hydrocephalus, and various etiologies have been postulated, including genetic disorders and errors of morphogenesis. Meanwhile, chromosomal losses including 22q and rarely 21q are observed in malignant and atypical meningiomas. We report an uncommon case of a 67-year-old woman with colpocephaly and an atypical meningioma in the posterior fossa. There were no neurological deficits or family history of hereditary neuropsychiatric disorders. Brain magnetic resonance (MR) images showed bilateral enlarged occipital horns, agenesis of corpus callosum, and a cerebellar mass in the right cerebellar hemisphere. Right suboccipital craniotomy was performed, and the tumor was resected totally. Pathological study of the surgical specimen showed findings of atypical meningioma, and the postoperative course was uneventful until hydrocephalus developed. At 36th day after tumor removal, the patient undertook an external ventricular drainage followed by replacement of the ventriculoperitoneal shunt. We discuss the importance of colpocephaly in terms of the differential diagnosis for hydrocephalus and review the pertinent literature.
[show abstract][hide abstract] ABSTRACT: Although pituitary adenoma is a primary brain tumor that occasionally accompanies intratumoral hemorrhage, there are little reports about the molecular mechanism of intratumoral bleeding in pituitary adenoma. Vascular endothelial growth factor (VEGF) plays an important role in angiogenesis and vascular permeability of various brain tumors. The authors studied the relationship between intratumoral hemorrhage and the expression of VEGF in human pituitary adenomas.
VEGF expression was assessed by reverse transcriptase polymerase chain reaction (RT-PCR) in 71 pituitary adenomas. Clinical factors to investigate were age, gender, hormonal functioning, and radiological findings of pituitary adenomas. Radiological findings which were investigated by magnetic resonance (MR) images were intratumoral hemorrhage, cystic change, tumor size, and cavernous sinus invasion. The relationship between these factors and VEGF expression was statistically analyzed.
VEGF was expressed in 25 cases (35.2%). Functioning tumors, hemorrhage, cystic change, and cavernous sinus invasion were 32 (45.1%), 18 (25.4%), 12 (16.9%), and 21 (29.6%) respectively. The expression of VEGF showed a significant relationship with the intratumoral hemorrhage of the adenomas (P <0.001). However, age, gender, tumor size, hormonal functioning, cyst formation, and cavernous sinus invasion had no relationship with VEGF expression (P >0.05).
This study suggests that VEGF expression may be responsible for intratumoral hemorrhage of pituitary adenomas. Therefore, VEGF can be a novel target to prevent a catastrophic apoplexy in pituitary adenomas and to establish roles in angiogenesis-based therapeutics of pituitary adenomas.
[show abstract][hide abstract] ABSTRACT: Isolated hypoglossal nerve paresis due to mechanical compression from a vascular lesion is very rare. We present a case of a 32-year-old man who presented with spontaneous abrupt-onset dysarthria, swallowing difficulty and left-sided tongue atrophy. Brain computed tomographic angiography and magnetic resonance imaging of the brainstem demonstrated an abnormal course of the left vertebral artery compressing the medulla oblongata at the exit zone of the hypoglossal rootlets that was relieved by microvascular decompression of the offending intracranial vertebral artery. This case supports the hypothesis that hypoglossal nerve palsy can be due to nerve stretching and compression by a pulsating normal vertebral artery. Microvascular decompression of the intracranial nerve and careful evaluation of the imaging studies can resolve unexpected isolated hypoglossal nerve palsy.
Journal of Korean Neurosurgical Society 03/2011; 49(3):167-70. · 0.60 Impact Factor
[show abstract][hide abstract] ABSTRACT: Minocycline, a second-generation tetracycline-class antibiotic, has been well established to exert a neuroprotective effect in animal models and neurodegenerative disease through the inhibition of microglia. Here, we investigated the effects of minocycline on motor recovery and neuropathic pain in a rat model of spinal cord injury.
To simulate spinal cord injury, the rats' spinal cords were hemisected at the 10th thoracic level (T10). Minocycline was injected intraperitoneally, and was administered 30 minutes prior surgery and every second postoperative day until sacrifice 28 days after surgery. Motor recovery was assessed via the Basso-Beattie-Bresnahan test. Mechanical hyperalgesia was measured throughout the 28-day post-operative course via the von Frey test. Microglial and astrocyte activation was assessed by immunohistochemical staining for ionized calcium binding adaptor molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP) at two sites: at the level of hemisection and at the 5th lumbar level (L5).
In rats, spinal cord hemisection reduced locomotor function and induced a mechanical hyperalgesia of the ipsilateral hind limb. The expression of Iba1 and GFAP was also increased in the dorsal and ventral horns of the spinal cord at the site of hemisection and at the L5 level. Intraperitoneal injection of minocycline facilitated overall motor recovery and attenuated mechanical hyperalgesia. The expression of Iba1 and GFAP in the spinal cord was also reduced in rats treated with minocycline.
By inhibiting microglia and astrocyte activation, minocycline may facilitate motor recovery and attenuate mechanical hyperalgesia in individuals with spinal cord injuries.
Journal of Korean Neurosurgical Society 02/2011; 49(2):83-91. · 0.60 Impact Factor
[show abstract][hide abstract] ABSTRACT: Traumatic intracranial aneurysms are rare, comprising 1% or less of all cerebral aneurysms. The majority of these aneurysms arise at the skull base or in the distal anterior and middle cerebral arteries or their branches following direct mural injury or acceleration-induced shearing force. We present a 50-year-old patient in whom subarachnoid hemorrhage (SAH) was developed as a result of traumatic aneurysm rupture after a closed craniofacial injury. Through careful evaluation of the three-dimensional computed tomography and conventional angiographies, the possible mechanism of the traumatic internal carotid artery trunk aneurysm is correlated with a hit injury by the bony protuberances on the anterior and posterior clinoid processes. This traumatic aneurysm was successfully obliterated with clipping and wrapping technique. The possibility of a traumatic intracranial aneurysm should be considered when patient with SAH demonstrates bony protuberances on the clinoid process as a traumatic aneurysm may result from mechanical injury by the sharp bony edges.
Journal of Korean Neurosurgical Society 01/2011; 49(1):49-52. · 0.60 Impact Factor
[show abstract][hide abstract] ABSTRACT: To evaluate the visual outcomes of retinoblastoma in the posterior pole (RBPP) treated with chemotherapy plus local treatments and to address the prognostic factors that influence such outcomes.
The medical records of patients with RBPP diagnosed at the Department of Pediatric Ophthalmology, Seoul National University Children's Hospital between August 1987 and September 2007 were reviewed retrospectively. Only those patients treated via primary chemotherapy plus local treatments were included. The presence of foveal involvement and tumors in the posterior pole before and after treatment, the type of regression pattern and the best corrected visual acuity (BCVA) of each patient were evaluated.
A total of 13 eyes in 12 patients were included. The mean final BCVA for treated RBPP was 20/210 (range, hand motion to 20/16). However, eight eyes (61.5%) had an acuity of 20/200 or better and seven eyes (53.8%) had an acuity of 20/50 or better. The mean final BCVA was significantly better in cases with negative foveal involvement; however, four eyes (37.5%) with positive foveal involvement had an acuity of 20/200 or better. Tumors area in the posterior pole and the type of regression pattern were not significantly related to final BCVA.
Over one half of the studied RBPP patients had working vision. Although the eyes had RBPP with positive foveal involvement, about one-third of the patients had working vision. Vision preservation should be considered when deciding on RBPP treatment.
Korean Journal of Ophthalmology 12/2010; 24(6):347-52.
[show abstract][hide abstract] ABSTRACT: The glenohumeral joint can be accessed by anterior, posterior, or superior approach. Blind shoulder injections using anterior or posterior approach have been often inaccurate and infiltrated untargeted structures. The aim of this study was to investigate the success rate of injections in the glenohumeral joint using the superior approach.
Nineteen shoulders from 12 adult cadavers were anatomically dissected after a dye injection had been performed, with cadavers in the supine position. A clinician rated injection confidence scores. The dissectors rated injection accuracy scores and investigated untargeted structures penetrated.
The clinician's confidence scores were the highest in 18 of 19 shoulders. Superior glenohumeral injections were successful in 18 of 19 (94.7%) shoulders; however, in 3 of these 18 shoulders, the long heads of biceps tendons were penetrated.
The glenohumeral joint injection using the superior approach is accurate and clinically useful, but caution for the likelihood of penetrating the long head of biceps tendon should be considered.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 09/2010; 89(9):755-8. · 1.56 Impact Factor
[show abstract][hide abstract] ABSTRACT: Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system. Most cases of NCC are to related and/or associated with inflammation within the cerebral parenchyma. A 71-year-old woman presented with a 4-year history of visual disturbance. This symptom had become aggravated 4 weeks earlier. Her visual acuity gradually decreased and superior hemianopsia was noted. Magnetic resonance imaging (MRI) revealed an enhanced and thickened pituitary stalk accompanying a suspicious mass. The provisional diagnoses were lymphoma, glioma, or other inflammatory conditions. Laboratory studies, including blood and hormonal studies, showed normal findings. Surgical resection was performed. In the pathological examination, degenerated parasitic wall structure was seen and its contents were composed of completely degenerated focal globular structures suggesting the scolex of cysticercus. We report an unusual case of NCC involving the pituitary stalk which was presented with a juxtasellar tumor. The possible underlying mechanisms are discussed with a review of pertinent literature.
Journal of Korean Neurosurgical Society 07/2010; 48(1):91-3. · 0.60 Impact Factor