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: The authors report the various factors which correlated with the intraoperative rupture during aneurysm surgery. METHODS: Retrospective study was done in patients who had been perfomed aneurysmal neck clipping by same surgeon from January 1998 to May 2000. A total of 121 patients were operated by using the microsurgical technique of aneurysmal neck clipping and intraoperative ruptures occurred during dissection in 19 cases and aneurysmal neck clipping in 12 cases. In this study, the incidence of intraoperative rupture was 25.6%. We analyzed the followings: preoperative neurologic status(Hunt-Hess grade), preoperative hemorrhage volume on computed tomography(Fisher grade), timing of operation, aneurysm location, aneurysm size, aneurysm direction, shape of the aneurysmal neck, prescence of atherosclerotic plaque around aneurysmal neck and parent vessel and Glasgow outcome scale score. RESULTS: Hunt-Hess grade, Fisher grade, timing of operation, aneurysm location, aneurysm size and direction of the aneurysm had not associated with intraoperative rupture. However, the incidence of intraoperative aneurysmal rupture during surgery was higher in patients whose anterior communicating artery aneurysm was directed inferiorly and aneurysmal neck was broad. The GOS score and the prescence of atherosclerotic plaque around the aneurysmal neck and parent vessel also correlated with the intraopertive rupture but more closely influenced by neck clipping than dissection. CONCLUSION: Surgeons should keep in mind the use of careful microsurgical sharp dissection especially in cases of inferiorly directed anterior communicating artery, broad-neck aneurysm and presence of atherosclerotic plaque around aneurysmal neck and parent vessels.
Aneurysm* ; Arteries ; Glasgow Outcome Scale ; Hemorrhage ; Humans ; Incidence ; Intracranial Aneurysm ; Neck ; Parents ; Plaque, Atherosclerotic ; Retrospective Studies ; Rupture* ; Subarachnoid Hemorrhage*

OBJECTIVE: Subarachnoid hemorrhage(SAH) is still one of the most serious disease with high morbidity and mortality in the neurosurgical field. Clipping of the aneurysmal neck is the gold standard of the surgical treatment of aneurysmal SAH. The purpose of this study was to investigate the role of the postoperative angiography and to assess the risk factors related to the incomplete clipping. MATERIALS AND METHODS: From July 1995 to June 1998, the pre- and postoperative angiography were performed in 50 patients among total 81 patients who have underwent the aneurysmal surgery. We reviewed the various contributing factors including age, sex, Hunt-Hess grade, Fisher grade and the premature rupture of aneurysm during operation retrospectively. Careful evaluation of pre- and postoperative angiography focusing on the size, shape, and remnant neck of the aneurysms and vasospasm was performed. According to the angiographic findings, the patients were divided into two groups; a complete clipping group and an incomplete clipping group. The data were analyzed by using unpaired independent sample t test after F-test to compare the significance between two groups. RESULTS: Incomplete clipping of aneurysms was found in 6(12%) patients through the evaluation of postoperative angiography. Among them, three cases were located on the middle cerebral artery territory. Whereas the patient age, sex, Hunt-Hess grade, and Fisher grade were not significant(p<0.05), an intraoperative premature rupture had a statistical significance(p<0.05). A severe vasospasm occurred in 24(48%) cases and one patient with anterior communicating aneurysm was reoperated due to residual sac. CONCLUSION: According to our experience, the surgeons' judgement is the most reliable factor in deciding the postoperative angiography. During the aneurysmal surgery, the premature rupture always disturbs a complete clipping of aneurysms. Therefore, the temporary clipping of parent arteries is considered essential for a successful clipping. We believe that the postoperative angiography has a role in decreasing the re-bleeding risk due to clip migration and an inaccurate clipping only in the selected cases.
Aneurysm ; Angiography* ; Arteries ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery ; Mortality ; Neck ; Parents ; Retrospective Studies ; Risk Factors ; Rupture

OBJECTIVE: The clinical uses of screws are increasing with broader applications in spinal disorders. When screws are inserted repeatedly to achieve optimal position, tips of screw pitch may become damaged during insertion even though there are significant differences in the moduli of elasticity between bone and titanium. The effect of repeated screw insertion on pullout resistance was investigated. METHODS: Three different titanium screws(cortical lateral mass screw, cancellous lateral mass screw and cervical vertebral body screw) were inserted into the synthetic cancellous material and then extracted axially at a rate of 2.4mm/min using Instron(Model TT-D, Canton, MA). Each set of screws was inserted and pulled out three times. There were six screws in each group. The insertional torque was measured with a torque wrench during insertion. Pullout strength was recorded with a digital oscilloscope. RESULTS: The mean pullout force measurements for the cortical lateral mass screws(185.66N+/-42.60, 167.10N+/-27.01 and 162.52 N+/-23.83 for first, second and third pullout respectively: p=0.03) and the cervical vertebral body screws(386.0N+/-24.1, 360.2N+/-17.5 and 330.9N+/-16.7: p=0.0024) showed consecutive decrease in pullout resistance after each pullout, whereas the cancellous lateral mass screws did not(194.00N+/-36.47, 219.24N+/-26.58 and 199.49N(36.63: p=0.24). The SEM after insertion and pullout three times showed a blunting in the tip of the screw pitch and a smearing of the screw surface. CONCLUSIONS: Repetitive screw insertion and pullout resulted in the decrease of pullout resistance in certain screws possibly caused by blunting the screw tip. This means screw tips suffer deformations during either repeated insertion or pullout. Thus, the screws that have been inserted should not be used for the final construct.
Elasticity ; Titanium ; Torque

No abstract available.

No abstract available.

Interests in the microanatomy of the proximal segment of the internal carotid artery(ICA) have been increased due to the anatomical complexity of this region and the potential sites of the aneurysmal formation. In this study, microanatomical dissections were performed in 70 specimens obtained from 35 formalin-fixed human cadaveric heads to examine the superior hypophyseal arteries(SHAs), ophthalmic artery, and the carotid cave. In our study, 54(77%) carotid caves were presented in 70 specimens. Twenty-five(71%, 50 caves) cadavers harbored the carotid caves on both sides, 4(11%, 4 caves) cadavers only on the one side and the remaining 6(17%) didn't have the caval structure. Total of 162 SHAs which have showen to arise from the medial or posterior aspect of the ophthalmic(C6) segment of the ICA in all cases were identified: 108(67%) arose from the proximal half of the C6 segment and 54(33%) from the distal half. Interestingly, in 54 specimens which had the carotid caves, one to four SHAs arose from the part of the C6 segment within the cave in the 43(80%) specimens. Total number of the SHAs originated within the carotid cave were 51. Sixty-four(91%) of ophthalmic arteries have shown to arise just distal to the distal dural ring on C6 segment, whereas 4(6%) from the clinoid(C5) segment and in 2(3%) cases, the ophthalmic artery arose just at the insertion of the distal dural ring level. The authors describe the microanatomical relationships between the SHA and the carotid cave, and the origin of the SHA and the ophthalmic artery. We hope to get better knowledge of the vascular relationship and the possible mechanism of the SHA aneurysm.
Aneurysm ; Arteries* ; Cadaver ; Caves ; Head ; Hope ; Humans ; Ophthalmic Artery

Epidural abscess of the spine is an uncommon disorder. However, this condition can cause irriversible neurologic injury or death if it is not recognized and treated early. The constellation of presenting symptoms is frequently nondiagnostic and may be especially confusing in patients with chronic neck or back pain. The most important source of infection is, via hematogenous spread, the furuncle and abscess of the skin. The most frequent site of infection is thoracolumbar region(50%), and the most common cause of pathogen is Staphylococcus The pathogenesis o f the associated spinal cord dysfunction remains unresolved, but histopathological data from a previous study suggested that a mechanical mass effect rather than vascular thrombosis or vasculitis was responsible for the initial neurological deficit. MRI offered the advantage of noninvasive early recognition and anatomical localization, which made it the imaging modality of choice. Rim enhancement indicates abscess and diffuse enhancement indicates granulation tissue and fibrosis. Tuberculous epidural abscess usually spreads to ventral epidural space whereas pyogenic epidural abscess encircles entire epidural space. The treatment of choice of the spinal epidural abscess is early surgical decompression and drainage. Rapid diagnosis and treatment of this disease is essential for neurologic recovery and even for preservation of life. The author report a case of spinal epidu ral abscess, which involved continuously from the second cervical vertebra to the forth lumbar vertebra. The patients neurological conditions were improved following emergent decompression.
Abscess ; Back Pain ; Decompression ; Decompression, Surgical ; Diagnosis ; Drainage ; Epidural Abscess* ; Epidural Space ; Fibrosis ; Furunculosis ; Granulation Tissue ; Humans ; Laminectomy ; Magnetic Resonance Imaging ; Neck ; Skin ; Spinal Cord ; Spine ; Staphylococcus ; Thrombosis ; Vasculitis

OBJECT: It is well known that infratentorial surgery is more difficult to approach to the lesion and may result in poorer outcome than supratentorial surgery. The prognostic factors and outcome were analyzed for one hundred forty-five consecutive patients who underwent surgical treatment for infratentorial tumor between 1989 and 1997. METHODS: Neurilemmoma was the most common tumor(41 cases), followed by astrocytoma(19 cases), hemangioblastoma(19 cases), medulloblastoma(18 cases), meningioma(17 cases) respectively. We studied the relationship between postoperative outcome known various factors retrospectively: age at surgery, pathology, duration of symptoms, tumor size, location of tumor, presence of hydrocephalus, and extent of resection. A statistical analysis of clinical characteristics was conducted to evaluate the significance of associations by student t-test. Surgical results were evaluated by Ojemann's method. RESULTS: Of 145 cases, excellent were in 25 patients, good in 60 patients, fair in 41 patients, poor in 9 patients, and dead in 10 patients. Large size of tumor(p<0.01) and presence of hydrocephalus(p<0.05) were factors that indicate poor outcome. Surgical results of tumors in the cerebellopontine angle(CPA) or clival area were poorer than those in cerebellum(p<0.05). Age, duration of symptom, pathology, and extent of resection did not influence postoperative outcome significantly. The most common postoperative complication was facial palsy(21 cases). The operative mortality was 6.9% and sepsis was the leading cause of death. CONCLUSION:Large size(p<0.01), presence of hydrocephalus(p<0.05), and location in CPA and clival region(p<0.05) were factors that indicate poor outcome after infratentorial tumor surgery.
Cause of Death ; Humans ; Hydrocephalus ; Infratentorial Neoplasms* ; Mortality ; Neurilemmoma ; Pathology ; Postoperative Complications ; Retrospective Studies ; Sepsis

OBJECTIVE: Growth of cerebral gliomas depends on their neovascularization and invasion into the adjacent neural tissue. There are several extracellular and intracellular factors affecting its growth. Tenascin(TN) is a type of extracellular matrix(ECM) protein which may be responsible for the migration of neoplastic cells and tumor angiogenesis, but its exact role has not been established. We studied the relation between the expression of TN and the histological grade of the glial cell tumors as well as to determine the expression of TN-C in tumor vessel. PATIENTS AND METHODS:In the fifty-six patients with glial cell tumors, we characterized the expression of tenascin-C(TN-C) in the neoplastic vessel, intercellular network, and tumor cell by immunohistochemistry using monoclonal antibody. The relationship between the histological malignancy and TN-C expression was evaluated. In addition, TN-C expression of the tumor vessels was also examined. RESULTS: The tumors included 32 glioblastomas, 13 astrocytomas, 4 pilocytic astrocytoma, 3 anaplastic astrocytoma, 1 pleomorphic xanthoastrocytoma, 1 oligodendroglioma, 1 anaplastic oligodendroglioma, and 1 mixed oligoastrocytoma. TN-C expression in intercellular network of glioblastoma, anaplastic astrocytoma, and astrocytoma was 87. 5%, 66.7%, and 61.5%, respectively. There was a close relationship between the TN-C expression and histological grade of the glial cell tumors. In 28(87.5%) of 32 glioblastomas, TN-C was significantly expressed in the tumor vessels(p<0.05). CONCLUSION: Present results demonstrate that TN-C in the glial cell tumors may be identified as a one of the related factors contributing to malignant progression. And also, enhanced expression of TN-C in the tumor vessels of glioblastoma indicate the possibility that TN-C could be involved in neoplastic angiogenesis.
Astrocytoma ; Glioblastoma ; Glioma* ; Humans ; Immunohistochemistry ; Neuroglia* ; Oligodendroglioma ; Tenascin*