Objective: : Spontaneous intracranial hemorrhage is a life-threatening disease, and non-lesional spontaneous intraparenchymal hemorrhage (nIPH) and aneurysmal subarachnoid hemorrhage (aSAH) are the leading causes of spontaneous intracranial hemorrhage. Only a few studies have assessed the association between prior physical activity or triggering events and the occurrence of nIPH or aSAH. The purpose of this study is to investigate the role of specific physical activities and triggering events in the occurrence of nIPH and aSAH. Methods: : We retrospectively reviewed 824 consecutive patients with spontaneous intracranial hemorrhage between January 2010 and December 2018. Among the 824 patients, 132 patients were excluded due to insufficient clinical data and other etiologies of spontaneous intracranial hemorrhage. The medical records of 692 patients were reviewed, and the following parameters were assessed : age, sex, history of hypertension, smoking, history of stroke, use of antiplatelet or anticoagulation agents, season and time of onset, physical activities performed according to the metabolic equivalents, and triggering event at onset. Events that suddenly raised the blood pressure such as sudden postural changes, defecation or urination, sexual intercourse, unexpected emotional stress, sauna bath, and medical examination were defined as triggering events. These clinical data were compared between the nIPH and aSAH groups. Results: : Both nIPH and aSAH most commonly occurred during non-strenuous physical activity, and there was no significant difference between the two groups (p=0.524). Thirty-two patients (6.6%) in the nIPH group and 39 patients (8.1%) in the aSAH group experienced triggering events at onset, and there was a significant difference between the two groups (p=0.034). The most common triggering events were defecation or urination in both groups. Conclusion : Specific physical activity dose no affect the incidence of nIPH and aSAH. The relationship between the occurrence of intracranial hemorrhage and triggering events is higher in aSAH than nIPH.

We describe a case of transvenous embolization through the dilated supraorbital vein to treat a dural carotid cavernous fistula. The approach through the common facial vein or direct access of the superior ophthalmic vein is a commonly used route to the superior ophthalmic vein when the approach via the inferior petrosal sinus is unavailable. In rare cases, the dilated supraorbital vein provides an alternative route and we discuss the technical details.
Fistula ; Veins

OBJECTIVE: Shunt-dependent hydrocephalus (SdHCP) is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). The risk factors for SdHCP have been widely investigated, but few risk scoring systems have been established to predict SdHCP. This study was performed to investigate the risk factors for SdHCP and devise a risk scoring system for use before aneurysm obliteration.METHODS: We reviewed the data of 301 consecutive patients who underwent aneurysm obliteration following SAH from September 2007 to December 2016. The exclusion criteria for this study were previous aneurysm obliteration, previous major cerebral infarction, the presence of a cavum septum pellucidum, a midline shift of >10 mm on initial computed tomography (CT), and in-hospital mortality. We finally recruited 254 patients and analyzed the following data according to the presence or absence of SdHCP : age, sex, history of hypertension and diabetes mellitus, Hunt-Hess grade, Fisher grade, aneurysm size and location, type of treatment, bicaudate index on initial CT, intraventricular hemorrhage, cerebrospinal fluid drainage, vasospasm, and modified Rankin scale score at discharge.RESULTS: In the multivariate analysis, acute HCP (bicaudate index of ≥0.2) (odds ratio [OR], 6.749; 95% confidence interval [CI], 2.843–16.021; p=0.000), Fisher grade of 4 (OR, 4.108; 95% CI, 1.044–16.169; p=0.043), and an age of ≥50 years (OR, 3.938; 95% CI, 1.375–11.275; p=0.011) were significantly associated with the occurrence of SdHCP. The risk scoring system using above parameters of acute HCP, Fisher grade, and age (AFA score) assigned 1 point to each (total score of 0–3 points). SdHCP occurred in 4.3% of patients with a score of 0, 8.5% with a score of 1, 25.5% with a score of 2, and 61.7% with a score of 3 (p=0.000). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the risk scoring system was 0.820 (p=0.080; 95% CI, 0.750–0.890). In the internal validation of the risk scoring system, the score reliably predicted SdHCP (AUC, 0.895; p=0.000; 95% CI, 0.847–0.943).CONCLUSION: Our results suggest that the herein-described AFA score is a useful tool for predicting SdHCP before aneurysm obliteration. Prospective validation is needed.
Aneurysm ; Cerebral Infarction ; Cerebrospinal Fluid Leak ; Diabetes Mellitus ; Hemorrhage ; Hospital Mortality ; Humans ; Hydrocephalus ; Hypertension ; Multivariate Analysis ; Prospective Studies ; Risk Factors ; ROC Curve ; Septum Pellucidum ; Subarachnoid Hemorrhage ; Ventriculoperitoneal Shunt

A 59-year-old patient with a history of hepatocellular carcinoma presented with decreased consciousness and left hemiparesis. A rim-enhanced mass lesion without diffusion restriction was observed in contrast-enhanced MRI including diffusion-weighted imaging. Based on these findings, metastatic brain tumor was suspected. However, brain abscess (BA) was diagnosed after multiple bacterial colonies were observed in aspiration biopsy. Initial conventional antibiotic treatment including vancomycin had failed, so linezolid was used as second-line therapy. As a result, infection signs and clinical symptoms were resolved. We report a case with atypical imaging features and antibiotic susceptibility of a BA in an immunocompromised patient undergoing chemotherapy.
Biopsy, Needle ; Brain Abscess* ; Brain Neoplasms ; Brain* ; Carcinoma, Hepatocellular ; Consciousness ; Diffusion Magnetic Resonance Imaging ; Diffusion* ; Drug Therapy ; Humans ; Immunocompromised Host ; Linezolid* ; Magnetic Resonance Imaging ; Middle Aged ; Paresis ; Vancomycin

OBJECTIVE: To quantitatively measure the degree of bone flap resorption (BFR) following autologous bone cranioplasty and to investigate factors associated with BFR. METHODS: We retrospectively reviewed 29 patients who underwent decompressive craniectomy and subsequent autologous bone cranioplasty between April 2005 and October 2014. BFR was defined as: 1) decrement ratio ([the ratio of initial BF size/craniectomy size]–[the ratio of last BF/craniectomy size]) >0.1; and 2) bone flap thinning or geometrical irregularity of bone flap shape on computed tomographic scan or skull plain X-ray. The minimal interval between craniectomy and cranioplasty was one month and the minimal follow-up period was one year. Clinical factors were compared between the BFR and no-BFR groups. RESULTS: The time interval between craniectomy and cranioplasty was 175.7±258.2 days and the mean period of follow up was 1364±886.8 days. Among the 29 patients (mean age 48.1 years, male: female ratio 20: 9), BFR occurred in 8 patients (27.6%). In one patient, removal of the bone flap was carried out due to severe BFR. The overall rate of BFR was 0.10±0.11 over 3.7 years. Following univariate analysis, younger age (30.5±23.2 vs. 54.9±13.4) and longer follow-up period (2204.5±897.3 vs. 1044.1±655.1) were significantly associated with BFR (p=0.008 and 0.003, respectively). CONCLUSION: The degree of BFR following autologous bone cranioplasty was 2.7%/year and was associated with younger age and longer follow-up period.
Autografts ; Bone Resorption ; Decompressive Craniectomy ; Female ; Follow-Up Studies ; Humans ; Male ; Retrospective Studies ; Skull

OBJECTIVE: Although subdural hematoma (SDH) is commonly treatable by burr hole surgery in the late subacute or chronic stage, there is no clear consensus regarding appropriate management and exact predictive factors for postoperative recurrence also remain unclear. The aim of this study was to evaluate risk factors associated with recurrence of SDH that requires burr hole surgery in the late subacute or chronic stage. We also identified the appropriate timing of surgery for reducing the recurrence. METHODS: We retrospectively reviewed 274 patients with SDH in the late subacute or chronic stage treated with burr hole surgery in our hospital between January 2007 and December 2014. Excluding patients with acute intracranial complications or unknown time of trauma onset left 216 patients included in the study. RESULTS: Of 216 patients with SDH in the late subacute or chronic stage, recurrence was observed in 36 patients (16.7%). The timing of the operation in patients with late subacute stage (15–28 days) resulted in a significant decrease in recurrence (RR, 0.33; 95% CI, 0.17–0.65; p=0.001) compared to chronic stage (>28 days). Otherwise, no significant risk factors were associated with recurrences including comorbidities and surgical details. CONCLUSION: The results indicated that time from trauma onset to burr hole surgery may be important for decreasing the risk of recurrence. Therefore, unless patients can be treated conservatively without surgery, prompt surgical management is recommended in patients diagnosed as having late subacute or chronic subdural hematoma treatable by burr hole surgery, even when neurological deficits are unclear.
Comorbidity ; Consensus ; Hematoma, Subdural ; Hematoma, Subdural, Chronic* ; Humans ; Recurrence* ; Retrospective Studies ; Risk Factors

BACKGROUND: Few clinical studies have clarified the prognostic factors that affect clinical outcomes for patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) after immunochemotherapy. METHODS: A total of 158 patients with relapsed or refractory DLBCL were enrolled. All patients underwent positron emission tomography/computed tomography (PET/CT) before and after salvage therapy. All enrolled patients previously received the ifosfamide, carboplatin, and etoposide regimen. Clinical outcomes were compared according to several factors (age > or = 65 years, low age-adjusted International Prognostic Index [aa-IPI], maximum standardized uptake value [SUVmax] <6.0 on PET/CT, time to relapse > or =12 months, complete response after salvage therapy). A low aa-IPI, SUVmax <6.0, and time to relapse > or = 12 months were independent prognostic factors for survival. RESULTS: In univariate analysis and multivariate analysis, SUVmax below 6.0 (P<0.001 for progression-free survival (PFS), P<0.001 for overall survival (OS)) and low aa-IPI (P<0.001 for PFS, P<0.001 for OS) were independent prognostic factors associated with favorable outcome. CONCLUSION: The aa-IPI and initial SUVmax were powerful prognostic factors in patients with relapsed or refractory DLBCL.
Carboplatin ; Disease-Free Survival ; Electrons* ; Etoposide ; Humans ; Ifosfamide ; Lymphoma, B-Cell* ; Multivariate Analysis ; Positron-Emission Tomography ; Positron-Emission Tomography and Computed Tomography ; Recurrence ; Salvage Therapy

OBJECTIVE: The goal of this study was to assess the effect of high-dose simvastatin on cerebral vasospasm and its clinical outcome after aneurysmal subarachnoid hemorrhage (SAH) in Korean patients. METHODS: This study was designed as a prospective observational cohort study. Its subjects were aneurysmal SAH patients who had undergone aneurysm clipping or coiling. They were assigned to 1 of 3 groups : the 20 mg, 40 mg, and 80 mg simvastatin groups. The primary end-point was the occurrence of symptomatic vasospasm. The clinical outcome was assessed with the modified Rankin Scale (mRS) score after 1 month and 3 months. The risk factors of the development of vasospasm were assessed by logistic regression analysis. RESULTS: Ninety nine patients with aneurysmal SAH were treated and screened. They were sequentially assigned to the 20 mg (n=22), 40 mg (n=34), and 80 mg (n=31) simvastatin groups. Symptomatic vasospasm occurred in 36.4% of the 20 mg group, 8.8% of the 40 mg group, and 3.2% of the 80 mg group (p=0.003). The multiple logistic regression analysis showed that poor Hunt-Hess grades (OR=5.4 and 95% CI=1.09-26.62) and high-dose (80 mg) simvastatin (OR=0.09 and 95% CI=0.1-0.85) were independent factors of symptomatic vasospasm. The clinical outcomes did not show a significant difference among the three groups. CONCLUSION: This study demonstrated that 80 mg simvastatin treatment was effective in preventing cerebral vasospasm after aneurysmal SAH, but did not improve the clinical outcome in Korean patients.
Aneurysm* ; Cohort Studies* ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Logistic Models ; Prospective Studies* ; Risk Factors ; Simvastatin* ; Subarachnoid Hemorrhage* ; Vasospasm, Intracranial*

Cancer-related facial pain refractory to pharmacologic management or nondestructive means is a major indication for destructive pain surgery. Stereotactic mesencephalotomy can be a valuable procedure in the management of cancer pain involving the upper extremities or the face, with the assistance of magnetic resonance imaging (MRI) and electrophysiologic mapping. A 72-year-old man presented with a 3-year history of intractable left-sided facial pain. When pharmacologic and nondestructive measures failed to provide pain alleviation, he was reexamined and diagnosed with inoperable hard palate cancer with intracranial extension. During the concurrent chemoradiation treatment, his cancer-related facial pain was aggravated and became medically intractable. After careful consideration, MRI-based stereotactic mesencephalotomy was performed at a point 5 mm behind the posterior commissure, 6 mm lateral to and 5 mm below the intercommissural plane using a 2-mm electrode, with the temperature of the electrode raised to 80degrees C for 60 seconds. Up until now, the pain has been relatively well-controlled by intermittent intraventricular morphine injection and oral opioids, with the pain level remaining at visual analogue scale 4 or 5. Stereotactic mesencephalotomy with the use of high-resolution MRI and electrophysiologic localization is a valuable procedure in patients with cancer-related facial pain.
Aged ; Analgesics, Opioid ; Electrodes ; Facial Pain* ; Humans ; Magnetic Resonance Imaging ; Morphine ; Palate, Hard ; Upper Extremity

OBJECTIVE: Early decompressive craniectomy (DC) has been used as the first stage treatment to prevent secondary injuries in cases of severe traumatic brain injury (TBI). Postoperative management is the major factor that influences outcome. The aim of this study is to investigate the effect of postoperative management, using intracranial pressure (ICP) monitoring and including consecutive DC on the other side, on the two-week mortality in severe TBI patients treated with early DC. METHODS: Seventy-eight patients with severe TBI [Glasgow Coma Scale (GCS) score <9] underwent early DC were retrospectively investigated. Among 78 patients with early DC, 53 patients were managed by conventional medical treatments and the other, 25 patients were treated under the guidance of ICP monitoring, placed during early DC. In the ICP monitoring group, consecutive DC on the other side were performed on 11 patients due to a high ICP of greater than 30 mm Hg and failure to respond to any other medical treatments. RESULTS: The two-week mortality rate was significantly different between two groups [50.9% (27 patients) and 24% (6 patients), respectively, p=0.025]. After adjusting for confounding factors, including sex, low GCS score, and pupillary abnormalities, ICP monitoring was associated with a 78% lower likelihood of 2-week mortality (p=0.021). CONCLUSION: ICP monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death.
Brain Injuries* ; Coma ; Decompressive Craniectomy* ; Humans ; Intracranial Pressure* ; Mortality ; Retrospective Studies