Objective: Autologous bone grafting for cranioplasty is associated with a high infection rate and bone absorption. Synthetic implant materials for cranioplasty have been developed. In this study, we evaluated the efficacy of titanium mesh-type patient-specific implants (PSIs) for patients with skull defects using the dice similarity coefficient (DSC), clinical outcomes, and artifacts caused by implants. Methods: This retrospective study included 40 patients who underwent cranioplasty with a titanium mesh PSI at our institution. Based on preoperative and postoperative computed tomography scans, we calculated DSC and artifacts. Results: The calculated DSC of 40 patients was 0.75, and the noise was 13.89% higher in the region of interest (ROI) near the implanted side (average, 7.64 hounsfield unit [HU]±2.62) than in the normal bone (average, 6.72 HU±2.35). However, the image signal-to-noise ratio did not significantly differ between the ROI near the implanted side (4.77±1.78) and normal bone (4.97±1.88). The patients showed no significant perioperative complications that required a secondary operation. Conclusion Titanium mesh-type PSIs for cranioplasty have excellent DSC values with lower artifacts and complication rates.

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.
Adult ; Brain ; Brain Stem ; Brain Stem Hemorrhage, Traumatic ; Contusions ; Craniocerebral Trauma ; Head ; Head Injuries, Closed ; Hematoma ; Hemorrhage ; Humans ; Magnetic Resonance Spectroscopy ; Male ; Paresis ; Prognosis ; Skull ; Skull Fracture, Depressed ; Spinal Cord ; Spine

OBJECTIVE: Recently, the definition of occult osteoporotic vertebral fracture has been established, and its clinical significance has come to our interest. We report the effect of early percutaneous vertebroplasty in occult osteoporotic vertebral fracture. METHODS: From January 2006 to January 2008, we performed percutaneous vertebroplasty for 50 levels in 47 patients. 21 levels (21 patients) of them were classified into occult osteoporotic vertebral fracture group, 29 levels (26 patients) were categorized into control group (not occult osteoporotic vertebral fracture) by the Pham T..s criteria. We obtained VAS score and measured the compression ratio at first hospital day and 1 day, 1 month, 3 months after procedure. RESULTS: There are noticeable improvements in VAS score. The mean VAS score at admission was 6.44 in occult group and 6.15 in control group, which changed 2.23 in occult group and 2.68 in control group after procedure. The compression rate was 1.008, 1.018, 1.016 in occult group and 0.862, 0.891, 0.881 in control group at admission and 1 month, 3 months after procedure. The conservative effect for vertebral height was higher than control group (p=0.011). CONCLUSION: Percutaneous vertebroplasty in occult osteoporotic compression fracture provided significant pain relief and conservative effect for vertebral height. It is probable that it can lower the rate of secondary adjacent vertebral compression fracture.
Fractures, Compression ; Humans ; Vertebroplasty

Vasospasm has been known as one of the most potent causes of delayed ischemic neurologic deficits (DINDs) after aneurysmal subarachnoid hemorrhage (SAH). An established effective therapy for vasospasm has been used in preventing cerebral ischemia. Nevertheless, several reports suggested the possibility that there may be other causes of DINDs from the cases which couldn't be explained by hemodynamic vasospasm. Authors experienced two cases of thromboembolic infarction as a cause of DINDs after aneurysmal SAH. We propose that thromboembolism can be a considerable cause of DINDs independent of hemodynamic vasospasm.
Aneurysm ; Brain Ischemia ; Hemodynamics ; Infarction ; Neurologic Manifestations ; Subarachnoid Hemorrhage ; Thromboembolism

OBJECTIVE: Acute cerebral infarction is often accompanied by transtentorial herniation which can be fatal. The aim of this study is to determine the timing of surgical intervention and prognostic factors in patients who present with acute cerebral infarction. METHODS: We reviewed retrospectively 23 patients with acute cerebral infarction, who received decompressive craniectomy or conservative treatment from January 2002 to December 2004. We divided patients into two groups according to the treatment modalities (Group 1: conservative treatment, Group 2: decompressive craniectomy). In all patients, the outcome was quantified with Glasgow Outcome Scale and Barthel Index. RESULTS: Of the 23 patients, 11 underwent decompressive craniectomy. With decompressive craniectomy at the time of loss of pupillary light reflex, we were able to prevent death secondary to severe brain edema in all cases. Preoperative Glasgow Coma Scale and loss of pupillary light reflex were significant to the clinical outcome statistically. With conservative treatment, 9 of the 12 patients died secondary to transtentorial herniation. The clinical outcomes of remaining 3 patients were poor. CONCLUSION: This study confirms the value of life-saving procedure of decompressive craniectomy after acute cerebral infarction. We propose that the loss of pupillary light reflex should be considered one of the most important factors to determine the timing of the decompressive craniectomy.
Brain Edema ; Cerebral Infarction* ; Decompressive Craniectomy* ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Humans ; Reflex ; Retrospective Studies

OBJECTIVE: Survivin is an inhibitor of apoptosis protein(IAP), which inhibits apoptosis through a pathway distinct from the Bcl-2 family members. Overexpression of survivin and Bcl-2 have been commonly reported in human neoplasms. The authors investigate whether there is a synergistic effect on the anti-apoptosis rate of primary brain tumors "in situ" based on the co-expression of survivin and Bcl-2. METHODS: One hundred and two brain tumor patients who had been resected were included in this study. Survivin and Bcl-2 were detected by Western blotting analysis, while apoptosis was examined by DNA fragmentation analysis. An anti-apoptotic rate was assessed in these brain tumor samples based on the expression of survivin and Bcl-2 or co-expression of both. RESULTS: Survivin and Bcl-2 were expressed in 57(55.9%) and 53(52.0%) of 102 brain tumor samples studied respectively, and co-expressed in 31(30.4%). The percentage of astrocytic and meningeal tumors expressing survivin was significantly correlated with histological grades; however, Bcl-2 was not correlated (p=0.106). The anti-apoptotic rate in primary brain tumors with survivin, Bcl-2, and both was detected in 49(86.0%) of 57 samples, 42(79.9%) of 53 samples, and 27(87.1%) of 31 samples, respectively. Their difference in the frequency of anti-apoptosis was not significant. CONCLUSION: Survivin or Bcl-2 is involved in the anti-apoptosis. However, it suggests that co-expression of survivin and Bcl-2, together, have no synergistic effect on the anti-apoptotic properties of the primary brain tumors.
Apoptosis ; Blotting, Western ; Brain Neoplasms* ; DNA Fragmentation ; Humans ; Meningeal Neoplasms

Intracranial arachnoid cyst is presumed to be a developmental anomaly and its natural history is not well defined. Often it is detected incidentally in a asymptomatic patient and hemorrhagic events of arachnoid cyst following head injury are rarely reported. We report hemorrhagic complications including two intracystic hemorrhages, two subdural hematomas, and an epidural hematoma in 5 patients with intracranial arachnoid cyst after minor head injury and review pertinent literatures.
Arachnoid ; Arachnoid Cysts* ; Craniocerebral Trauma* ; Hematoma ; Hematoma, Subdural ; Hemorrhage ; Humans ; Natural History

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.
Adolescent ; Adult ; Aged ; Brain Neoplasms/enzymology/genetics/*pathology ; Child ; Child, Preschool ; Enzyme-Linked Immunosorbent Assay/methods ; Female ; Humans ; Male ; Middle Aged ; Polymerase Chain Reaction/methods ; Prognosis ; Research Support, Non-U.S. Gov't ; Survival Analysis ; Telomerase/genetics/*metabolism

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.
Adult ; Aged ; Female ; Humans ; Hydrocephalus/etiology/*prevention & control ; Hypothalamus/surgery ; Intracranial Aneurysm/complications/*surgery ; Male ; Microsurgery/*methods ; Middle Aged ; Retrospective Studies ; Subarachnoid Hemorrhage/etiology/*surgery ; Treatment Outcome ; Ventriculoperitoneal Shunt/*methods

OBJECTIVE: Acute vertebral burst fractures warrant extensive fixation and fusion on the spine. Osteoplasty (vertebroplasty with high density resin without vertebral expansion) has been used to treat osteoporotic vertebral compression fractures. We report our experiences with osteoplasty in acute vertebral burst fractures. METHODS: Twenty-eight cases of acute vertebral burst fracture were operated with osteoplasty. Eighteen patients had osteoporosis concurrently. Preoperative MRI was performed in all cases to find fracture level and to evaluate the severity of injury. Preoperative CT revealed burst fracture in the series. The patients with severe ligament injury or spinal canal compromise were excluded from indication. Osteoplasty was performed under local anesthesia and high density polymethylmethacrylate(PMMA) was injected carefully avoiding cement leakage into spinal canal. The procedure was performed unilaterally in 21 cases and bilaterally in 7 cases. The patients were allowed to ambulate right after surgery. Most patients discharged within 5 days and followed up at least 6 months. RESULTS: There were 12 men and 16 women with average age of 45.3(28-82). Five patients had 2 level fractures and 2 patients had 3 level fractures. The average injection volume was 5.6cc per level. Average VAS (Visual Analogue Scale) improved 26mm after surgery. The immediate postoperative X-ray showed 2 cases of filler spillage into spinal canal and 4 cases of leakage into the retroperitoneal space. One patient with intraspinal leakage was underwent the laminectomy to remove the resin. CONCLUSION: Osteoplasty is a safe and new treatment option in the burst fractures. Osteoplasty with minimally invasive technique reduced the hospital stay and recovery time in vertebral fracture patients.
Anesthesia, Local ; Female ; Fractures, Compression ; Humans ; Laminectomy ; Length of Stay ; Ligaments ; Magnetic Resonance Imaging ; Male ; Osteoporosis ; Retroperitoneal Space ; Spinal Canal ; Spine ; Vertebroplasty