• Journal of Korean Neurosurgical Society
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• v.50 no.2
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• pp.103-108
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• 2011

Objective : There are few studies comparing small and large craniotomies for the initial treatment of chronic subdural hematoma (CSDH) which had non-liquefied hematoma, multilayer intrahematomal loculations, or organization/calcification on computed tomography and magnetic resonance imaging. These procedures were compared to determine which would produce superior postoperative results. Methods : Between 2001 and 2009, 317 consecutive patients were surgically treated for CSDH at our institution. Of these, 16 patients underwent a small craniotomy with partial membranectomy and 42 patients underwent a large craniotomy with extended membranectomy as the initial treatment. A retrospective review was performed to compare the postoperative outcomes of these two techniques, focusing on improvement of neurological status, complications, reoperation rate, and days of post-operative hospitalization. Results : The mean ages were $69.4{\pm}12.1$ and $55.6{\pm}9.3$ years in the small and large craniotomy groups, respectively. The recurrence of hematomas requiring reoperation occurred in 50% and 10% of the small and large craniotomy patients, respectively (p<0.001). There were no significant differences in postoperative neurological status, complications, or days of hospital stay between these two groups. Conclusion : Among the cases of CSDH initially requiring craniotomy, the large craniotomy with extended membranectomy technique reduced the reoperation rate, compared to that of the small craniotomy with partial membranectomy technique.

• Journal of Korean Neurosurgical Society
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• v.39 no.5
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• pp.335-339
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• 2006

Objective : The authors present eight cases of immediate post-operative epidural hematomas[EDHs] adjacent to the craniotomy site, describe clinical details of them, and discuss their pathogenesis. Methods : Medical records of eight cases were retrospectively reviewed and their clinical data, operation records, and radiological findings analyzed. Any risk factors of the EDHs were searched. Results : In 5 of 8 cases, adjacent EDHs developed after craniotomies for the surgical removal of brain tumors. Three cases of adjacent EDHs developed after a pterional approach and neck clipping of a ruptured anterior communicating artery aneurysm, a ventriculoperitoneal shunt, and a craniotomy for a post-traumatic EDH, respectively. In all eight cases, brain computed tomography[CT] scans checked immediately or a few hours after the surgery, revealed large EDHs adjacent to the previous craniotomy site, but there was no EDH beneath the previous craniotomy flap. After emergent surgical removal of the EDHs, 7 cases demonstrated good clinical outcomes, with one case yielding a poor result. Conclusion : Rapid drainage of a large volume of cerebrospinal fluid or intra-operative severe brain collapse may separate the dura from the calvarium and cause postoperative EDH adjacent to the previous craniotomy site. A high-pressure suction drain left in the epidural space may contribute to the pathogenesis. After the craniotomy for brain tumors or intracranial aneurysms, when remarkable brain collapse occurs, an immediate postoperative brain CT is mandatory to detect and adequately manage such unexpected events as adjacent EDHs.

• Journal of Korean Neurosurgical Society
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• v.44 no.6
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• pp.353-357
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• 2008

Objective : Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH. Methods : Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group 8, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A. Results : In Group A. 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group 8, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group 8 (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable. Conclusion : We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.

• Journal of Korean Society for Quality Management
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• v.34 no.4
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• pp.40-50
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• 2006

The authors aimed to analyze the quality improvement efficiency of wound dressing with 2-octyl cyanoacrylate(2-OCA) in stereotactic image guided linear or sigmoid incisions in a cohort of consecutive craniotomy patients, and to compare clinical results with those of iodine-dressing and silk sutured patients underwent conventional craniotomy surgery with large pedicle flap incisions without stereotactic guidance. In methods, 26 patients were involved as the study group at one hospital. We retrospectively compared their results with those of 38 consecutive control patients at the same unit. The suggested new medical material, 2-octyl cyanoacrylate(2-OCA), resultantly decreased or prevented the contaminated fluid influx from scalp outside. The mean infection rate for the control group (7.89%) was relatively higher than that of the study group (3.85%). In addition, the use of stereotactic image guided craniotomy was significant to reduce operation time, to simplify operative procedures and to decrease potential risk factors.

• Journal of Korean Neurosurgical Society
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• v.30 no.3
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• pp.366-370
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• 2001

Objective : The authors present three cases of brain tumors in which epidural hematomas(EDHs) were developed postoperatively in the remote areas from craniotomy sites. The preventive tactics as well as possible mechanisms of development of remote EDH are discussed. Material and Methods : The magnetic resonance imagings of three patients revealed a left lateral ventricular mass located just aside of foramen Monro in a 27-year-old male, a large cystic mass in the temporal lobe in a 35-year-old male, and a partially calcified pineal mass in a 27-year-old male patient. The surgical removals of these tumors were performed without any noticeable events during surgery via left frontal transcortical transventricular approach for lateral ventricular tumor, left temporal craniotomy for cystic temporal tumor, and right occipital transtentorial approach for pineal tumor. Results : Postoperative EDHs remote from the sites of craniotomy were detected by the immediate postoperative computerized tomographic scans. We obtained good outcomes without any morbidity in all three patients with emergent evacuation of the hematoma. The pathologic diagnoses were lateral ventricular ependymoastrocytoma, temporal craniopharyngioma and mixed germinoma of the pineal region. Conclusion : It is postulated that a sudden reduction of intracranial pressure(ICP) at the time of tumor removal may strip the dura from the inner table of the skull to cause EDH from the remote site of craniotomy. Gradual reduction of ICP with slow drainage of cerebrospinal fluid before tumor removal as well as lowering the head position of patient during surgery might be helpful for preventing this unusual complication.

• Journal of Korean Neurosurgical Society
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• v.55 no.6
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• pp.348-352
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• 2014

Objective : Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia. Methods : In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated. Results : The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived. Conclusion : Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy.

• Journal of Korean Neurosurgical Society
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• v.41 no.6
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• pp.403-407
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• 2007

The authors encountered a case of simultaneous radiation-induced multiple meningiomas and ventriculoperitoneal [VP] shunt-related pneumocephalus. A 35-year-old man, who had undergone surgery for medulloblastoma 21 years previously and subsequently received high dose craniospinal irradiation with adjuvant chemotherapy and later underwent a VP shunt because of hydrocephalus, presented with a severe headache and weakness of both lower extremities. Computed tomography showed an air pocket lesion in the left temporal lobe and a large amount of pneumocephalus with a bony defect of the left tegmen tympani. In addition, a 3 cm sized well enhancing mass was noted in the in the right middle cranial fossa and additional small enhancing nodule in the left frontal pole. He was treated by left temporal craniotomy and repair of the bony and dural defects of the left tegmentum tympanum through extradural and intradural approaches, respectively. Afterwards, he underwent right temporal craniotomy and gross total removal of a rapidly growing right middle fossa mass and a left frontal mass. The histological examination was consistent with atypical meningioma, WHO grade II. In conclusion, physicians have to consider the serious long term complications of high dose radiation therapy and VP shunt placement and need to perform the neuroradiologic follow-up after such treatments for several decades.

• Journal of Korean Neurosurgical Society
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• v.58 no.3
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• pp.301-303
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• 2015

We report on a case of an 87-year-old woman who showed spontaneous resolution of a large chronic subdural hematoma which required surgical decompression. She had suffered from confused mentality and right side weakness of motor grade II for 10 days. The initial brain CT scan showed a 22 mm thick low density lesion located in the left fronto-temporo-parietal region with midline shift (12 mm) which required emergency decompression. However, because she and her family did not want surgery, she was followed up in the outpatient clinic. Five months later, follow up brain CT showed that the CSDH had disappeared and the patient became neurologically normal. The reasons for spontaneous resolution of CSDH remain unclear. We discuss the possible relation between mechanisms of physio-pathogenesis and spontaneous resolution of a large chronic subdural hematoma (CSH) in an elderly patient.

• Journal of Korean Neurosurgical Society
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• v.54 no.6
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• pp.477-483
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• 2013

Objective : Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. Methods : Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. Results : Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. Conclusion : The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.

• Journal of Korean Neurosurgical Society
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• v.48 no.2
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• pp.166-169
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• 2010

Spontaneous intracranial epidural hematoma (EDH) due to dural metastasis of hepatocellular carcinoma is very rare. A 53-year-old male patient with hepatocellular carcinoma, who was admitted to the department of oncology, was referred to department of neurosurgery because of sudden mental deterioration to semicoma with papillary anisocoria and decerebrate rigidity after transarterial chemoembolization for hepatoma. Brain computed tomography (CT) revealed large amount of acute EDH with severe midline shifting. An emergent craniotomy and evacuation of EDH was performed. Active bleeding from middle cranial fossa floor was identified. There showed osteolytic change on the middle fossa floor with friable mass-like lesion spreading on the overlying dura suggesting metastasis. Pathological examination revealed anaplastic cells with sinusoidal arrangement which probably led to spontaneous hemorrhage and formation of EDH. As a rare cause of spontaneous EDH, dural metastasis from malignancy should be considered.