Sinking skin flap syndrome, resulting from decompressive craniectomy, is defined as a series of neurologic symptoms with skin depression at the site of cranial defect. A 61-year-old male was hospitalized with high fever and operative site swelling. He underwent decompressive craniectomy on his left side for treatment for acute subdural hematoma and traumatic intracerebral hematoma 5 years ago. Four months later, a ventriculoperitoneal shunt was performed for treatment for hydrocephalus and cranioplasty was also performed. We suspected infection at the previous operative site and proceeded with craniectomy and epidural abscess removal. Following the procedure, the depression of the sinking flap became significant, and he has suffered from right hemiparesis. We performed a shunt catheter tie at the level of the right clavicle under local anesthesia, and the patient recovered his health to his baseline. We present a patient who was successfully managed with a tie of the shunt catheter for sinking skin flap syndrome.
Anesthesia, Local ; Catheters ; Clavicle ; Decompressive Craniectomy ; Depression ; Epidural Abscess ; Fever ; Hematoma ; Hematoma, Subdural, Acute ; Humans ; Hydrocephalus ; Male ; Neurologic Manifestations ; Paresis ; Skin ; Ventriculoperitoneal Shunt

Isolated unilateral abducens nerve palsies associated with spontaneous subarachnoid hemorrhage have rarely been reported, and their association with anterior communicating artery is even rarer. We report two cases of unilateral abducens nerve palsies following rupture of anterior communicating artery aneurysms. The aneurysms were successfully clipped, and abducens nerve palsies were gradually recovered.
Abducens Nerve ; Abducens Nerve Diseases ; Aneurysm ; Arteries ; Intracranial Aneurysm ; Rupture ; Subarachnoid Hemorrhage

OBJECTIVE: There is a broad spectrum of compensated hydrocephalus. Various terms such as long-standing overt ventriculomegaly in adult (LOVA) has been coined, however, even such terms leave diverse aspect of this condition out of account. We have experienced compensated hydrocephalus cases which were considered to be activated after a long time period of quiescent state, and tried to compare their clinical characteristics with the relatively well described entity of LOVA. METHODS: We conducted a retrospective review of 206 patients who underwent ventriculoperitoneal shunt (VPS) between February 2001 and May 2012. Of these, 6 patients had chronic compensated hydrocephalus. The clinical and radiological characteristics are evaluated. RESULTS: Definite triventriculomegaly was observed in two patients. Macrocephaly was observed in two cases, one with aqueductal stenosis (AS), the other with unknown status of aqueduct. All of the cases with triventriculomegaly were normocephalic. Spinal causes were thought as aggravating factor in two. Two endoscopic third ventriculostomy and eight VPS were performed in five patients. Four patients responded well but one took a very complicated course. CONCLUSION: The relationships between macrocephaly, triventriculomegaly, and AS suggested in other studies were inconsistent. Blockage or narrowing of cerebrospinal fluid pathways were observed at various sites. Disturbances of spinal arachnoid pathways were related to the activation in some cases. Treatment is to be tailored individually considering various reigniting event. It is suggested that this entity is to be evaluated for better nomenclature reflecting diverse aspects of this condition. Further study is needed to elucidate underlying pathophysiology and effective management.
Adult ; Arachnoid ; Humans ; Hydrocephalus ; Macrocephaly ; Numismatics ; Retrospective Studies ; Ventriculoperitoneal Shunt ; Ventriculostomy

OBJECTIVE: Chronic subdural hematoma is a common disorder observed in neurosurgical care and the recurrence rate is relatively high. In this report, we evaluated the relationship between the recurrence rate of chronic subdural hematoma and the postoperative head position of the patient. METHODS: We conducted a retrospective study of 72 patients with unilateral chronic subdural hematoma treated by burr hole surgery with closed system drainage from October 2009 to May 2011. In group A, there was no restriction in head position for days keeping the catheter. In group B, the patients were placed with the lesion side of the head downward after the operation. We analyzed the recurrence rate, amount of postoperative drainage and changes in computed tomography finding of group A and B. RESULTS: Group A and group B consisted of 36 cases, respectively. The mean amount of total postoperative drainage was 248.8+/-127.2 mL in group A and 176.3+/-98.9 mL in group B (p=0.01). The improvement rates of midline shifting before and after surgery showed 60.5+/-25.6% in group A and 73.4+/-26.3% in group B (p=0.039). The total recurrence rate in group A was 11.1% and 5.6% in group B. CONCLUSION: By facing the lesion downward after surgical treatment, chronic subdural hematoma is thought to help reexpand the brain and to prohibit cerebrospinal fluid from flowing into subdural space and to decrease the recurrence rate better than having a free position.
Brain ; Catheters ; Diphtheria Toxoid ; Drainage ; Haemophilus Vaccines ; Head ; Hematoma, Subdural ; Hematoma, Subdural, Chronic ; Humans ; Recurrence ; Retrospective Studies ; Subdural Space

OBJECTIVE: Intracranial pressure (ICP) is one of the critical parameter for the patients of severe traumatic brain injury (TBI) to determine the treatment modalities and predict clinical outcomes. Hence, the ICP monitoring with accuracy and safety is essential for the TBI patients. The purpose of this study is to compare its safety and clinical usefulness of intraventricular ICP monitoring method to the parenchymal type. METHODS: We retrospectively reviewed the medical records and imaging data of 18 severe TBI patients. We used intraventricular ICP monitoring in 10 patients and parenchymal 8 patients. We compared the clinical findings of the two type ICP monitoring methods including procedure time, neurological status, outcome, complications and mortality. RESULTS: The initial Glasgow Coma Scale of intraventricular ICP monitoring and parenchymal ICP monitoring patients were 5.8 (range: 4-7) and 6.5 (range: 3-7) respectively. The Glasgow Outcome Scale after 6 months was a little higher in intraventricular monitoring patients than parenchymal monitoring patients (2.8 vs. 2.0, p=0.25). We could not find any intraventricular catheter related complication in intraventricular ICP monitoring patients. There was no difference in mortality in both groups (p=0.56). CONCLUSION: Our results suggest that intraventricular catheter insertion for ICP monitoring is relatively a safe procedure in the severe TBI patients. We could not demonstrate the significant benefit of intraventricular type ICP monitoring compared with parenchymal type ICP monitoring. Considering intraventricular type ICP monitoring have advantages of the accuracy and extraventricular drainage, intraventricular type ICP monitoring could be considered for severe TBI patients, regardless of hydrocephalus.
Brain Injuries ; Catheters ; Drainage ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Humans ; Hydrocephalus ; Intracranial Pressure ; Medical Records ; Retrospective Studies

OBJECTIVE: Considerable recurrence rates have been reported for chronic subdural hematoma (CSDH) following surgical evacuation. The aim of this study was to determine the independent factors and features of CSDH that are associated with postoperative recurrence. METHODS: Retrospective analysis of 136 consecutive patients diagnosed with CSDH who were surgically treated from September 2005 to December 2011 was performed. The demographic data, clinical characteristics, radiologic features were analyzed to clarify the correlation between independent variables and postoperative recurrence of CSDH. RESULTS: CSDH was resolved within 1 month following surgery in 51 patients (37.5%), between 1 to 3 months in 59 patients (43.4%), and past 3 months in 14 patients (10.3%). A total of 12 patients (8.8%) experienced recurrence of CSDH, and reoperation was performed in all recurred cases. The average duration between initial surgery and reoperation was 20.1 days. Delayed resolution and recurrence were more commonly presented in bilateral CSDH, but this data was not statistically significant. Large hematomas with maximum thickness over 20 mm were significantly correlated with higher recurrence rates of CSDH (p=0.032). In addition, the incidence of recurrence was significantly higher in the cases with high-density and mixed-density hematomas according to brain computed tomography (CT) findings (p=0.0026). CONCLUSION: The thickness and density of the hematoma is significantly correlated with higher recurrence rates of CSDH. Discerning these risk factors could be beneficial in predicting the postoperative recurrence of CSDH.
Brain ; Hematoma ; Hematoma, Subdural, Chronic ; Humans ; Incidence ; Recurrence ; Reoperation ; Retrospective Studies ; Risk Factors

OBJECTIVE: The current understanding reveals that chronic subdural hematoma (CSDH) is mostly the results of direct or indirect head trauma. Other factors such as alcoholism, medication (such as anticoagulants or antiplatelet agents), liver cirrhosis, chronic renal failure and hematologic disease are also well known as causes of CSDH. Of them, the authors attempted to identify the risk factors of CSDH by focusing on the age with a view point of recent increase in the elderly population. METHODS: We retrospectively reviewed 216 consecutive CSDH patients who underwent surgery at our institute between 2002 and 2011. We classified them into two groups according to the patients' age (Group A: <65 years old, Group B: > or =65 years old). Various factors were investigated for risk factor of CSDH, such as head trauma, chronic alcoholism, epilepsy, previous shunt surgery, underlying disease having bleeding tendency or medication affecting blood coagulation. And these factors were compared between the two groups for statistical significance. RESULTS: Among the 216 patients, group A included 81 patients (37.5%), group B included 135 patients (62.5%). The medication of group B had significantly more proportion than group A, comparing to the result that group B had relatively less proportion of head trauma and alcoholism (p<0.05). And medication was more associated with non-traumatic CSDH, especially in group B. CONCLUSION: As previously reported, head trauma or alcoholism are also most important causes as a risk factor of CSDH of all ages in our study. But medication is more closely related to the incidence of CSDH in group A, than group B.
Aged ; Alcoholism ; Anticoagulants ; Blood Coagulation ; Craniocerebral Trauma ; Epilepsy ; Hematologic Diseases ; Hematoma, Subdural, Chronic ; Hemorrhage ; Humans ; Incidence ; Kidney Failure, Chronic ; Liver Cirrhosis ; Retrospective Studies ; Risk Factors

OBJECTIVE: The goal of this study was to assess the incidence and risk factors for post-traumatic hydrocephalus (PTH) following decompressive craniectomy (DC). An additional objective was to investigate the relationship between hydrocephalus and subdural hygroma (SDG) after DC. METHODS: We conducted a retrospective study of 94 patients who were admitted to our department between 2007 and 2010 with severe head injury requiring DC. Post-traumatic hydrocephalus was defined as: frontal horn index (FHI) > or =0.4 or modified FHI > or =0.33 accompanying transependymal edema; the presence of either clinical worsening or failure to make neurological improvement over time; and clinical improvement after ventriculoperitoneal shunt. Post-traumatic SDG was defined as the presence of low density at computerized tomography (CT) of more than 5mm thickness. RESULTS: Among the 94 patients, we could follow up more than 3 months and obtain more than 4 serial CT scans in 41 patients. PTH developed in 29.3% (12/41) and SDG developed in 48.8% (20/41) of these patients. The development of PTH was significantly associated with delayed craniplasty after DC and with interhemispheric SDG. No relationship was found between PTH and age, sex, Glasgow Coma Scale (GCS) score, intraventricular hemorrhage, subarachnoid hemorrhage, midline shift, basal cistern effacement, or cortical opening during DC. CONCLUSION: Hydrocephalus occurred in 29.3% of the patients with severe traumatic brain injury who required DC. Delayed cranioplasty and interhemispheric SDG after DC were risk factors for the development of PTH.
Animals ; Brain Injuries ; Craniocerebral Trauma ; Decompressive Craniectomy ; Follow-Up Studies ; Glasgow Coma Scale ; Hemorrhage ; Horns ; Humans ; Hydrocephalus ; Incidence ; Retrospective Studies ; Risk Factors ; Subarachnoid Hemorrhage ; Subdural Effusion ; Ventriculoperitoneal Shunt

OBJECTIVE: Surgical site infection (SSI) is a problem constantly uppermost in the minds of all surgeons, although the actual rate of occurrence is only 1-5% in general surgery. In neurosurgical fields, there have been a few papers published about efficacy of post-operative antimicrobial prophylaxis (PAMP) to prevent SSI, compared to well known effectiveness of pre-operative antibiotics. Thus, infection rates of short-term PAMP groups and those of long-term PAMP groups were investigated to evaluate the effectiveness of PAMP and the efficacy of short-term PAMP compared to long-term PAMP for prevention of SSI. METHODS: Between April 2010 and April 2012, we retrospectively analyzed the data of 35 patients in the aneurysmal neck clipping groups (short-term PAMP group: PAMP for 3 days and fewer, long-term PAMP group: PAMP for 10 days and more) and 79 patients in the microdiscectomy groups (short-term PAMP group: 3 days and fewer, long-term PAMP group: PAMP for 6 days and more). RESULTS: In aneurysmal neck clipping groups, SSI occurred 23.1% of short-term PAMP group and 9.1% of long-term PAMP group (p=0.3370). And in microdiscectomy groups, SSI occurred 6.7% of short-term PAMP group and 4.1% of long-term PAMP group (p=0.9840). CONCLUSION: There is no significant difference between the short-term PAMP group and the long-term PAMP group in terms of SSI, regardless of operation type. We therefore suggest that short-term PAMP usage could be an appropriate therapy for preventing SSI in clean neurosurgical operations.
Aneurysm ; Anti-Bacterial Agents ; Antibiotic Prophylaxis ; Humans ; Neck ; Neurosurgical Procedures ; Retrospective Studies ; Surgical Wound Infection

OBJECTIVE: To show the effect of dual monitoring including cardiac output (CO) and intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI) patiens. We hypothesized that meticulous treatment using dual monitoring is effective to sustain maintain minimal intensive care unit (ICU) complications and maintain optimal ICP and cerebral perfusion pressure (CPP) for severe TBI patiens. METHODS: We included severe TBI, below Glasgow Coma Scale (GCS) 8 and head abbreviation injury scale (AIS) >4 and performed decompressive craniectomy at trauma ICU of our hospital. We collected the demographic data, head AIS, injury severity score (ISS), initial GCS, ICU stay, sedation duration, fluid therapy related complications, Glasgow Outcome Scale (GOS) at 3 months and variable parameters of ICP and CO monitor. RESULTS: Thirty patients with severe TBI were initially selected. Thirteen patients were excluded because 10 patients had fixed pupillary reflexes and 3 patients had uncontrolled ICP due to severe brain edema. Overall 17 patients had head AIS 5 except 2 patients and 10 patients (58.8%) had multiple traumas as mean ISS 29.1. Overall complication rate of the patients was 64.7%. Among the parameters of CO monitoring, high stroke volume variation is associated with fluid therapy related complications (p=0.043) and low cardiac contractibility is associated with these complications (p=0.009) statistically. CONCLUSION: Combined use of CO and ICP monitors in severe TBI patients who could be necessary to decompressive craniectomy and postoperative sedation is good alternative methods to maintain an adequate ICP and CPP and reduce fluid therapy related complications during postoperative ICU care.
Brain Edema ; Brain Injuries* ; Cardiac Output* ; Cerebrovascular Circulation* ; Decompressive Craniectomy ; Fluid Therapy ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Head ; Humans ; Injury Severity Score ; Intensive Care Units ; Intracranial Pressure* ; Monitoring, Physiologic ; Multiple Trauma ; Reflex, Pupillary ; Stroke Volume