• Journal of Korean Neurosurgical Society
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• 제58권6호
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• pp.547-549
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• 2015

Acute subdural hematoma (SDH) of arterial origin is rare, especially SDH associated with an arteriovenous malformation (AVM) is extremely rare. The authors report a case of acute spontaneous SDH due to rupture of a tiny cortical AVM. A 51-year-old male presented with sudden onset headache and mentality deterioration without a history of trauma. Brain CT revealed a large volume acute SDH compressing the right cerebral hemisphere with subfalcine and tentorial herniation. Emergency decompressive craniectomy was performed to remove the hematoma and during surgery a small (5 mm sized) conglomerated aciniform mass with two surrounding enlarged vessels was identified on the parietal cortex. After warm saline irrigation of the mass, active bleeding developed from a one of the vessel. The bleeding was stopped by coagulation and the vessels were removed. Histopathological examination confirmed the lesion as an AVM. We concluded that a small cortical AVM existed at this area, and that the cortical AVM had caused the acute SDH. Follow up conventional angiography confirmed the absence of remnant AVM or any other vascular abnormality. This report demonstrates rupture of a cortical AVM is worth considering when a patient presents with non-traumatic SDH without intracerebral hemorrhage or subarachnoid hemorrhage.

• Journal of Korean Neurosurgical Society
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• 제50권1호
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• pp.6-10
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• 2011

Objective : Spontaneous acute subdural hematomas (aSDH) secondary to ruptured intracranial aneurysms are rarely reported. This report reviews the clinical features, diagnostic modalities, treatments, and outcomes of this unusual and often fatal condition. Methods : We performed a database search for all cases of intracranial aneurysms treated at our hospital between 2005 and 2010. Patients with ruptured intracranial aneurysms who presented with aSDH on initial computed tomography (CT) were selected for inclusion. The clinical conditions, radiologic findings, treatments, and outcomes were assessed. Results : A total of 551 patients were treated for ruptured intracranial aneurysms during the review period. We selected 23 patients (4.2%) who presented with spontaneous aSDH on initial CT. Ruptured aneurysms were detected on initial 3D-CT angiography in all cases. All ruptured aneurysms were located in the anterior portion of the circle of Willis. The World Federation of Neurosurgical Societies grade on admission was V in 17 cases (73.9%). Immediate decompressive craniotomy was performed 22 cases (95.7%). Obliteration of the ruptured aneurysm was achieved in all cases. The Glasgow outcome scales for the cases were good recovery in 5 cases (21.7%), moderate disability to vegetative in 7 cases (30.4%), and death in 11 cases (47.8%). Conclusion : Spontaneous aSDH caused by a ruptured intracranial aneurysm is rare pattern of aneurysmal subarachnoid hemorrhage. For early detection of aneurysm, 3D-CT angiography is useful. Early decompression with obliteration of the aneurysm is recommended. Outcomes were correlated with the clinical grade and CT findings on admission.

• Journal of Korean Neurosurgical Society
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• 제41권5호
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• pp.314-317
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• 2007

Ventriculoperitoneal [VP] shunt is a common treatment for hydrocephalic patients. However, complications, such as shunt tube occlusion, infection, intracranial hemorrhage, seizure can occur. Of these, intracranial hemorrhage may occur due to intracranial vascular injury or a rapid decrease of intracranial pressure [ICP]. Most of these hemorrhages are subdural hematomas [SDH] while a few are epidural hematomas [EDH]. It is extremely rare for an intracranial hemorrhage to occur due to an extension of the bleeding from an injured extracranial vessel. We report two cases of EDH due to occipital artery injury following VP shunt and extraventricular drainage [EVD].

• Journal of Korean Neurosurgical Society
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• 제42권3호
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• pp.228-231
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• 2007

The intracranial hemorrhage in regions remote from the site of initial operations is unusual but may present as fatal surgical complication. We report a rare case of multiple, sequential, remote intracranial hematomas after cranioplasty in a patient who did not have any prior risk factors. A 51-years-old man was transferred to the hospital after a head trauma. The brain computed tomography (CT) revealed acute subdural hemorrhage on the right hemisphere with prominent midline shifting. After performing decompressive craniectomy and hematoma removal, the patient recovered without any complications. However, the patient showed neurological deterioration immediately after cranioplasty, which was done three months after the first surgery. There was extensive hemorrhage in the posterior fossa remote from the site of the initial operation site. The brain CT taken soon after removing this hematoma evacuation displayed large epidural hematoma on the left hemisphere. This case represents posterior fossa hemorrhage after supratentorial procedure and sequential delayed hematoma on the contralateral supratentorial region thus seems very rare surgical complications. Despite several possible pathogenetic mechanisms for such remote hematomas, there are usually no clear cut relationships with each case as in our patient. However, for the successful outcome, prompt evaluation and intensive management seem mandatory.

• Journal of Korean Neurosurgical Society
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• 제57권4호
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• pp.271-275
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• 2015

Objective : Chronic subdural hematoma (CSDH) is a rare complication of unruptured aneurysm clipping surgery. The purpose of this study was to identify the incidence and risk factors of postoperative CSDH after surgical clipping for unruptured anterior circulation aneurysms. Methods : This retrospective study included 518 patients from a single tertiary institute from January 2008 to December 2013. CSDH was defined as subdural hemorrhage which needed surgical treatment. The degree of brain atrophy was estimated using the bicaudate ratio (BCR) index. We used uni- and multivariate analyses to identify risk factors correlated with CSDH. Results : Sixteen (3.1%) patients experienced postoperative CSDH that required burr hole drainage surgery. In univariate analyses, male gender (p<0.001), size of aneurysm (p=0.030), higher BCR index (p=0.004), and the use of antithrombotic medication (p=0.006) were associated with postoperative CSDH. In multivariate analyses using logistic regression test, male gender [odds ratio (OR) 4.037, range 1.287-12.688], high BCR index (OR 5.376, range 1.170-25.000), and the use of antithrombotic medication (OR 4.854, range 1.658-14.085) were associated with postoperative CSDH (p<0.05). Postoperative subdural fluid collection and arachnoid plasty were not showed statistically significant difference in this study. Conclusion : The incidence of CSDH was 3.1% in unruptured anterior circulation aneurysm surgery. This study shows that male gender, degree of brain atrophy, and the use of antithrombotic medication were associated with postoperative CSDH.

• Journal of Korean Neurosurgical Society
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• 제59권3호
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• pp.310-313
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• 2016

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M.tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema.

• Journal of Korean Neurosurgical Society
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• 제29권6호
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• pp.748-753
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• 2000

Objectives : A 10-year retrospective clinical study was undertaken to determine the differences between two groups according to age at presentation(group A, under 50 ; B, over 50). Methods : We analyzed 468 cases with chronic subdural hematoma admitted to the department of neurosurgery in our hospital from January 1987 to December 1996. The patients were divided into two groups according to age at presentation(group A, under 50 ; B, over 50). Results : 1) The number of group A was 126 cases(26.9%) and that of group B was 342 cases(73.1%), respectively. Males were more frequently involved than females in each group. 2) There noted a history of head trauma in 88.9% of group A and 92.4% of group B. Forty-nine patients(38.9%) of group A and 103 cases(30.1%) of group B revealed a history of alcoholism. 3) Group A patients presented with symptoms of increased intracranial pressure such as headache(75.% ), nausea and vomiting(68.0%). However, Group B patients had more frequent mental changes(84.0%) and focal neurological deficits such as hemiparesis(76.5%). 4) Onset of symptom and its duration was shorter in group A than group B. 5) Six patients among 441 cases(1.4%) treated with burr hole drainage and two patients of 27 cases(5.4%) with craniotomy died, and all of these were group B patients. The two cases among six patients with burr hole drainage developed huge intracerebral hemorrhage and brain stem hemorrhage, respectively. Conclusion : In treating patients with chronic subdural hematoma, distinguishing between two age groups is quite helpful to determine treatment strategies.

• Journal of Korean Neurosurgical Society
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• 제54권3호
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• pp.211-219
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• 2013

Objective : The objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression. Methods : Retrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors. Results : No significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG. Conclusion : A large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging.

• Journal of Yeungnam Medical Science
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• 제29권1호
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• pp.42-44
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• 2012

Plasma cell myelomas generally manifest as bone or soft-tissue tumors with variable mass effects, pain, and infiltrative behavior. Extramedullary involvement occurs most commonly in the spleen, liver, lymph nodes, and kidneys, but intracranial involvement in plasma cell myeloma is a rare extramedullary manifestation. These authors recently encountered a case of intracranial involvement of plasma cell myeloma. A 69-year-old man was hospitalized for headache and mental changes. Brain CT showed subdural hemorrhage caused by plasma cell myeloma. Plasma cell myeloma with intracranial involvement has poor prognosis, and the patient in this case died from acute complications, such as subdural hemorrhage. Based on this case report, it is suggested that more effective treatment regimens of plasma cell myeloma with intracranial involvement be developed. Moreover, a screening method and decision on the appropriate time for intracranial involvement are needed for plasma cell myeloma patients.

• Investigative Magnetic Resonance Imaging
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• 제19권2호
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• pp.107-113
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• 2015

Purpose: Susceptibility weighted imaging (SWI) is a new magnetic resonance technique that can exploit the magnetic susceptibility differences of various tissues. Intracranial hemorrhage (ICH) looks a dark blooming on the magnitude images of SWI. However, the pattern of ICH on phase images is not well known. The purpose of this study is to characterize hemorrhagic lesions on the phase images of SWI. Materials and Methods: We retrospectively enrolled patients with ICH, who underwent both SWI and precontrast CT, between 2012 and 2013 (n = 95). An SWI was taken, using the 3-tesla system. A phase map was generated after postprocessing. Cases with an intracranial hemorrhage were reviewed by an experienced neuroradiologist and a trainee radiologist, with 10 years and 3 years of experience, respectively. The types and stages of the hemorrhages were determined in correlation with the precontrast CT, the T1- and T2-weighted images, and the FLAIR images. The size of the hemorrhage was measured by a one- directional axis on a magnitude image of SWI. The phase values of the ICH were qualitatively evaluated: hypo-, iso-, and hyper-intensity. We summarized the imaging features of the intracranial hemorrhage on the phase map of the SWI. Results: Four types of hemorrhage are observed: subdural and epidural; subarachnoid; parenchymal hemorrhage; and microbleed. The stages of the ICH were classified into 4 groups: acute (n = 34); early subacute (n = 11); late subacute (n = 15); chronic (n = 8); stage-unknown microbleeds (n = 27). The acute and early subacute hemorrhage showed heterogeneous mixed hyper-, iso-, and hypo-signal intensity; the late subacute hemorrhage showed homogeneous hyper-intensity, and the chronic hemorrhage showed a shrunken iso-signal intensity with the hyper-signal rim. All acute subarachnoid hemorrhages showed a homogeneous hyper-signal intensity. All parenchymal hemorrhages (> 3 mm) showed a dipole artifact on the phase images; however, microbleeds of less than 3 mm showed no dipole artifact. Larger hematomas showed a heterogeneous mixture of hyper-, iso-, and hypo-signal intensities. Conclusion: The pattern of the phase value of the SWI showed difference, according to the type, stage, and size.