• Journal of Korean Neurosurgical Society
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• v.55 no.3
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• pp.152-155
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• 2014

Dural ateriovenous fistula (DAVF) at the craniocervical junction is rare. We report a patient presenting with brainstem dysfunction as an uncommon onset. Brainstem lesion was suggested by magnetic resonance image study. Angiogram revealed a DAVF at a high cervical segment supplied by the meningeal branch of the right vertebral artery, with ascending and descending venous drainage. Complete obliteration of the fistula was achieved via transarterial Onyx embolization. Clinical cure was achieved in the follow-up period; meanwhile, imaging abnormalities of this case disappeared. Accordingly, we hypothesize that a brainstem lesion of this case was caused by craniocervical DAVF, which induced venous hypertension. Thus, venous drainage patterns should be paid attention to because they are important for diagnosis and theraputic strategy.

• Journal of Korean Neurosurgical Society
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• v.57 no.1
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• pp.50-53
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• 2015

Usually fungal infections caused by opportunistic and pathogenic fungi had been an important cause of morbidity and mortality among immunocompromised patients. However clinical data and investigations for immunocompetent pathogenic fungal infections had been rare and neglected into clinical studies. Especially Cryptococcal brainstem abscess cases mimicking brain tumors were also much more rare. So we report this unusual case. This 47-year-old man presented with a history of progressively worsening headache and nausea for 1 month and several days of vomituritions before admission. Neurological and laboratory examinations performed demonstrated no abnormal findings. Previously he was healthy and did not have any significant medical illnesses. A CT and MRI scan revealed enhancing $1.8{\times}1.7{\times}2.0$ cm mass lesion in the left pons having central necrosis and peripheral edema compressing the fourth ventricle. And also positron emission tomogram scan demonstrated a hot uptake of fluoro-deoxy-glucose on the brainstem lesion without any evidences of systemic metastasis. Gross total mass resection was achieved with lateral suboccipital approach with neuronavigation system. Postoperatively he recovered without any neurological deficits. Pathologic report confirmed Cryptococcus neoformans and he was successively treated with antifungal medications. This is a previously unreported rare case of brainstem Cryptococcal abscess mimicking brain tumors in immunocompetent host without having any apparent typical meningeal symptoms and signs with resultant good neurosurgical recovery.

• Journal of Korean Neurosurgical Society
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• v.45 no.3
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• pp.176-178
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• 2009

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.

• Journal of Korean Neurosurgical Society
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• v.30 no.sup1
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• pp.20-24
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• 2001

Object : We intended to investigate the relationship between the degree of injury on MRI and the outcome of the patients with diffuse axonal inury. Method : From january, 1995 to march, 1999, 22 patients were supposed to have diffuse axonal injuries by means of their neurologic signs and MRI. We investigated their prognosis according to CT, MRI and initial neurologic findings. Result : 1) The lesions were mainly located at white matter of cerebrum, corpus callosum, brainstem, and basal ganglia. 2) The lesions of white matter were most commonly in the frontal lobe and temporal lobe. 3) The majority of corpus callosal lesions were located in the posterior body and splenium, but anterior corpus callosal lesions combined with posterior lesions were not found. 4) Brainstem lesions, all non-hemorrhagic, were mostly located in the dorsolateral aspect, not be found on CT. 5) The brainstem lesions were found in 10 cases among total 22 cases, and corpus callosal lesions were accompanied with 8 cases of brainstem lesions. 6) The patients with brainstem lesions had worse prognosis. Conclusion : It is important and reasonable to take brain MRI to identify the brainstem lesions in any cases of suspicious diffuse axonal injury, and we should remind that the diffuse axonal injury with stem lesion has worse prognosis.

• Annals of Clinical Neurophysiology
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• v.7 no.2
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• pp.75-79
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• 2005

Vestibular evoked myogenic potentials (VEMP) have been known to useful in documenting abnormality in patients with various vestibular disorders but the studies of VEMP in stroke patients are rare. We recorded VEMP in 17 consecutive patients with acute ischemic stroke in the brainstem lesions. All patients underwent magnetic resonance imaging and we compare VEMP results with the lesion documented by brain imaging. VEMP were defined to be abnormal when they were very asymmetrical (one is 2 times of more as large as the other), or absent in one side. VEMP abnormalities were found in 71%(12/17) of acute infarction patients with brainstem lesions. Most abnormalities found in the ipsilateral side of the lesion(9/12) but abnormalities in contralateral side of lesion were found in 25%(3/12) of patients.VEMP would be considered a useful complementary neurophysiological tool for the evaluation of brainstem dysfunction in acute stroke patients.

• Journal of Korean Neurosurgical Society
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• v.29 no.2
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• pp.217-221
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• 2000

Objective : Brainstem hemorrhages usually result in much higher mortality and morbidty than any other intracranial vascular lesions. The purpose of the study is to evaluate the relationship of the radiological classification of the lesions and the clinical outcomes, and to evaluate the value of such classification on the choice of management modality. Method : Thirty seven patients with primary brainstem hemorrhage were managed medically or surgically between Oct. 1995 and Mar. 1998. The lesions were classified as two groups based on radiological findings as follows : Focal subependymal hematoma(group I, n＝7) and diffuse tegmentobasilar hemorrhage(group II, n＝30). The outcomes at discharge were retrospectively reviewed according to such classification. Result : The most common clinical pictures and radiological findings in each group were as followings : 1) Group I : focal compressive lesion which displaces rather than destroys brain tissue. It occurs in a younger age group and causes neurological deficits which are often partially reversible. Operative hematoma evacuation was performed in 43.3%. Their mean improved Glasgow Coma Scale(GCS) score was 4.7. 2) Group II : hypertensive brain stem hemorrhage. It usually causes a diffuse lesion occurring in an older age group and most often associated with profound irreversible neurological deficits which are often fatal. Operative hematoma evacuation was performed in 16.7%. Their mean improved GCS score was 1.4. In both conservatively treated group I and II has no siginificant clinical improvement. Conclusion : Although there is an overlap among them and the size of the group is small, the pathophysiologic classification of this lesion based on clinical features and radiological findings may be useful for decision of treatment method.

• Journal of Korean Neurosurgical Society
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• v.51 no.2
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• pp.109-112
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• 2012

It is rare for low-grade gliomas to disseminate to the leptomeninges. However, low-grade gliomas with dissemination to the leptomeninges have been occasionally reported in children, and have generally been associated with local recurrence. A 16-year-old boy sought evaluation for diplopia and gait disturbance. A brain magnetic resonance imaging (MRI) revealed pontine mass, which was proved to be fibrillary astrocytoma on biopsy, later. Radiation therapy (5400 cGy) was given and the patient's symptoms were improved. He was followed-up radiologically for brain lesion. Seven months after diagnosis he complained of back pain and gait disturbance. A brain MRI showed a newly-developed lesion at the left cerebellopontine angle without an interval change in the primary lesion. A spinal MRI demonstrated leptomeningeal dissemination of the entire spine. Radiation therapy (3750 cGy) to the spine, and adjuvant chemotherapy with a carboplatin plus vincristine regimen were administered. However, he had a progressive course with tumoral hemorrhage and expired 13 months after diagnosis. We report an unusual case of a low-grade brainstem glioma with spinal dissemination, but without local recurrence, and a progressive course associated with hemorrhage.

• Journal of Korean Neurosurgical Society
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• v.52 no.6
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• pp.534-540
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• 2012

Objective : Brainstem arteriovenous malformation (AVM) is rare and radiosurgical management is complicated by the sensitivity of the adjacent neurological structures. Complete obliteration of the nidus is not always possible. We describe over 20 years of radiosurgical procedures for brainstem AVMs, focusing on clinical outcomes and radiosurgical techniques. Methods : Between 1992 and 2011, the authors performed gamma knife radiosurgery (GKRS) in 464 cerebral AVMs. Twenty-nine of the 464 patients (6.3%) reviewed had brainstem AVMs. This series included sixteen males and thirteen females with a mean age of 30.7 years (range : 5-71 years). The symptoms that led to diagnoses were as follows : an altered mentality (5 patients, 17.3%), motor weakness (10 patients, 34.5%), cranial nerve symptoms (3 patients, 10.3%), headache (6 patients, 20.7%), dizziness (3 patients, 10.3%), and seizures (2 patients, 6.9%). Two patients had undergone a previous nidus resection, and three patients had undergone a previous embolization. Twenty-four patients underwent only GKRS. With respect to the nidus type and blood flow, the ratio of compact type to diffuse type and high flow to low flow were 17 : 12 and 16 : 13, respectively. In this series, 24 patients (82.8%) had a prior hemorrhage. The mean target volume was 1.7 $cm^3$ (range 0.1-11.3 $cm^3$). The mean maximal and marginal radiation doses were 38.5 Gy (range 28.6-43.6 Gy) and 23.4 Gy (range 18-27 Gy), and the mean isodose profile was 61.3% (range 50-70%). Results : Twenty-four patients had brainstem AVMs and were followed for more than 3 years. Obliteration of the AVMs was eventually documented in 17 patients (70.8%) over a mean follow-up period of 77.5 months (range 36-216 months). With respect to nidus type and blood flow, the obliteration rate of compact types (75%) was higher than that of diffuse types (66.7%), and the obliteration rate of low flow AVMs (76.9%) was higher than that of high flow AVMs (63.6%) (p<0.05). Two patients (6.9%) with three hemorrhagic events suffered a hemorrhage during the follow-up period. The annual bleeding rate of AVM after GKRS was 1.95% per year. No adverse radiation effects or delayed cystic formations were found. Conclusion : GKRS has an important clinical role in treatment of brainstem AVMs, which carry excessive surgical risks. Angiographic features and radiosurgical techniques using a lower maximal dose with higher isodose profiles are important for lesion obliteration and the avoidance of complications.

• Korean Journal of Radiology
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• v.24 no.3
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• pp.247-258
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• 2023

Objective: To localize the neuroanatomical substrate of rapid eye movement sleep behavior disorder (RBD) and to investigate the neuroanatomical locational relationship between RBD and α-synucleinopathy neurodegenerative diseases. Materials and Methods: Using a systematic PubMed search, we identified 19 patients with lesions in different brain regions that caused RBD. First, lesion network mapping was applied to confirm whether the lesion locations causing RBD corresponded to a common brain network. Second, the literature-based RBD lesion network map was validated using neuroimaging findings and locations of brain pathologies at post-mortem in patients with idiopathic RBD (iRBD) who were identified by independent systematic literature search using PubMed. Finally, we assessed the locational relationship between the sites of pathological alterations at the preclinical stage in α-synucleinopathy neurodegenerative diseases and the brain network for RBD. Results: The lesion network mapping showed lesions causing RBD to be localized to a common brain network defined by connectivity to the pons (including the locus coeruleus, dorsal raphe nucleus, central superior nucleus, and ventrolateral periaqueductal gray), regardless of the lesion location. The positive regions in the pons were replicated by the neuroimaging findings in an independent group of patients with iRBD and it coincided with the reported pathological alterations at post-mortem in patients with iRBD. Furthermore, all brain pathological sites at preclinical stages (Braak stages 1-2) in Parkinson's disease (PD) and at brainstem Lewy body disease in dementia with Lewy bodies (DLB) were involved in the brain network identified for RBD. Conclusion: The brain network defined by connectivity to positive pons regions might be the regulatory network loop inducing RBD in humans. In addition, our results suggested that the underlying cause of high phenoconversion rate from iRBD to neurodegenerative α-synucleinopathy might be pathological changes in the preclinical stage of α-synucleinopathy located at the regulatory network loop of RBD.

• Journal of Korean Neurosurgical Society
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• v.55 no.6
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• pp.379-382
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• 2014

A case of intractable hiccup developed by cavernous hemangioma in the medulla oblongata is reported. There have been only five previously reported cases of medullary cavernoma that triggered intractable hiccup. The patient was a 28-year-old man who was presented with intractable hiccup for 15 days. It developed suddenly, then aggravated progressively and did not respond to any types of medication. On magnetic resonance images, a well-demarcated and non-enhancing mass with hemorrhagic changes was noted in the left medulla oblongata. Intraoperative findings showed that the lesion was fully embedded within the brain stem and pathology confirmed the diagnosis of cavernous hemangioma. The hiccup resolved completely after the operation. Based on the presumption that the medullary cavernoma may trigger intractable hiccup by displacing or compression the hiccup arc of the dorsolateral medulla, surgical excision can eliminate the symptoms, even in the case totally buried in brainstem.