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Background Most people understand spinal manipulation therapy to be a safe procedure, and in many cases treatment is provided without a diagnosis if there is musculoskeletal pain. Cervical epidural hematoma occurs in extremely rare cases after cervical manipulation therapy. This study reports a case of epidural hematoma that occurred in the anterior spinal cord after cervical massage. Case Description A 38-year-old male patient was admitted to the emergency department for sudden weakness in the lower extremity after receiving a cervical spine massage. No fracture was found using cervical radiographs, and there were no particular findings on performing brain computed tomography or diffusion magnetic resonance imaging. However, using cervical magnetic resonance imaging, an acute epidural hematoma was observed in the anterior spinal cord from the C6 and C7 vertebrae to the T1 vertebra, compressing the spinal cord. There were no fractures or ligament injury. No surgical treatment was required as the patient showed spontaneous improvements in muscle strength and was discharged after just 1 week, following observation of the improvement in his symptoms. Conclusion Although cervical epidural hematoma after cervical manipulation therapy is extremely rare, if suspected, a thorough examination must be performed in order to reduce the chances of serious neurologic sequelae.

Background and purpose Hydrocephalus is a frequent complication following subarachnoid hemorrhage. Few studies investigated the association between laboratory parameters and shunt-dependent hydrocephalus. This study aimed to investigate the variations of laboratory parameters after subarachnoid hemorrhage. We also attempted to identify predictive laboratory parameters for shunt-dependent hydrocephalus. Methods Multiple imputation was performed to fill the missing laboratory data using Bayesian methods in SPSS. We used univariate and multivariate Cox regression analyses to calculate hazard ratios for shunt-dependent hydrocephalus based on clinical and laboratory factors. The area under the receiver operating characteristic curve was used to determine the laboratory risk values predicting shunt-dependent hydrocephalus. Results We included 181 participants with a mean age of 54.4 years. Higher sodium (hazard ratio, 1.53; 95% confidence interval, 1.13–2.07; p = 0.005), lower potassium, and higher glucose levels were associated with higher shunt-dependent hydrocephalus. The receiver operating characteristic curve analysis showed that the areas under the curve of sodium, potassium, and glucose were 0.649 (cutoff value, 142.75 mEq/L), 0.609 (cutoff value, 3.04 mmol/L), and 0.664 (cutoff value, 140.51 mg/dL), respectively. Conclusions Despite the exploratory nature of this study, we found that higher sodium, lower potassium, and higher glucose levels were predictive values for shunt-dependent hydrocephalus from postoperative day (POD) 1 to POD 12–16 after subarachnoid hemorrhage. Strict correction of electrolyte imbalance seems necessary to reduce shunt-dependent hydrocephalus. Further large studies are warranted to confirm our findings.

Myxomas are rare benign tumors that originate from mesenchymal tissue. They usually develop in the atrium of the heart, the skin, subcutaneous tissue, or bone. Involvement of the skull base with an intracranial extension is very rare and not well-described in the literature. We report a rare case of primary intracranial ossifying myxoma arising from the anterior skull base and mimicking a huge chondrosarcoma, and we review the relevant literature.

Objective To evaluate whether subdural hematoma (SDH) volume and other radiologic factors predict deterioration of mental status in patients with acute traumatic SDH. Methods SDH volumes were measured with a semiautomated tool. The area under the receiver operating characteristic curve was used to determine optimal cutoff values for mental deterioration, including the variables midline shift, SDH volume, hematoma thickness, and Sylvian fissure ratio. Multivariate logistic regression was used to calculate the odds ratio for mental deterioration based on several predictive factors. Results We enrolled 103 consecutive patients admitted to our hospital with acute traumatic SDH over an 8-year period. We observed an increase in SDH volume of approximately 7.2 mL as SDH thickness increased by 1 mm. A steeper slope for midline shift was observed in patients with SDH volumes of approximately 75 mL in the younger age group compared with patients in the older age group. When comparing cutoff values used to predict poor mental status at time of admission between the 2 age groups, we observed smaller midline shifts in the older patients. Conclusions Among younger patients, an overall tendency for more rapid midline shift progression was observed in patients with relatively low SDH volumes compared with older patients. Older patients seem to tolerate larger hematoma volumes owing to brain atrophy compared with younger patients. When there is a midline shift, older patients seem to be more vulnerable to mental deterioration than younger patients.

Objective Although many studies have evaluated risk factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage, specific ventricle volume changes after subarachnoid hemorrhage have not been evaluated. We sought to evaluate factors predicting ventricle volume enlargement in patients with aneurysmal subarachnoid hemorrhage by measuring ventricle volume with a validated, semiautomated tool. Methods Uni- and multivariable linear regression analyses were conducted with the follow-up ventricle volume as the dependent variable and the duration between subarachnoid hemorrhage occurrence and follow-up imaging as the independent variable, classified by the use of various predictive factors. A logistic regression model was used to calculate the odds ratio for the greater ventricle volume group compared with the lower ventricle volume group based on predictive factors. Results We included 173 participants with a mean age of 55.5 years. Overall, an approximate increase in ventricle volume of 1.1 mL was observed daily within 60 days of clipping due to subarachnoid hemorrhage. In the multivariate logistic regression analysis, patients in the first and second tertile groups for body mass index showed approximately a 5.9- and 4.1-fold increased risk of greater follow-up ventricle volume, respectively, compared with the third tertile group for body mass index within 60 days of subarachnoid hemorrhage. Conclusions We found that greater body mass index independently predicted suppression of ventricle volume growth, owing to maintenance of subarachnoid trabeculae structures after subarachnoid hemorrhage. Further studies are needed to confirm our findings.

The therapeutic outcome for those with malignant glioma is poor, even though diverse therapeutic modalities have been developed. Immunotherapy has emerged as a therapeutic approach for malignant gliomas, making it possible to selectively treat tumors while sparing normal tissue. Here, we review clinical trials of adoptive immunotherapy approaches for malignant gliomas. We also describe a clinical trial that examined the efficacy and safety of autologous cytokine-induced killer (CIK) cells along with concomitant chemoradiotherapy for newly diagnosed glioblastoma. These CIK cells identify and kill autologous tumor cells. This review focuses on the use of adoptive immunotherapy for malignant gliomas and reviews the current literature on the concept of antitumor activity mediated by CIK cells.

Background and purposeLow body mass index (BMI) at presentation has been reported to be associated with higher incidence and mortality of lung cancer, but studies on the relationship between brain metastasis and BMI at presentation are lacking. This study aimed to evaluate the association between brain metastasis and BMI and bone mineral density (BMD) in NSCLC.MethodsWe retrospectively enrolled patients with non-small cell lung cancer who underwent brain magnetic resonance imaging with contrast within 3 months of diagnosis. The BMI was collected, and the BMD was measured in Hounsfield unit (HU) on initial staging computed tomography scans. The independent relationship between BMI and BMD was assessed using multivariable linear regression according to the presence of brain metastasis.ResultsA total of 356 consecutive NSCLC patients were enrolled in the study over a 8-year period in a single institution. Lower BMI with higher BMD was an independent predictive factor for brain metastasis in patients with NSCLC, relative to the other group (HR, 2.03; 95% CI, 1.21 to 3.40; P = 0.007). We also found a significant negative correlation between BMI and BMD among patients with NSCLC with brain metastases (B, -3.343; 95% confidence interval, -6.352 to -0.333; P = 0.030).ConclusionsBrain metastasis may possibly be associated with lower BMI and higher BMD in NSCLC patients. We expect that these results may facilitate future predictions of brain metastases during the clinical course of NSCLC and enhance our understanding of the underlying mechanisms that link brain metastases and lung cancer.

Aims and background Although pituitary adenoma is a primary brain tumor that occasionally accompanies intratumoral hemorrhage, there are little reports about the molecular mechanism of intratumoral bleeding in pituitary adenoma. Vascular endothelial growth factor (VEGF) plays an important role in angiogenesis and vascular permeability of various brain tumors. The authors studied the relationship between intratumoral hemorrhage and the expression of VEGF in human pituitary adenomas. Methods VEGF expression was assessed by reverse transcriptase polymerase chain reaction (RT-PCR) in 71 pituitary adenomas. Clinical factors to investigate were age, gender, hormonal functioning, and radiological findings of pituitary adenomas. Radiological findings which were investigated by magnetic resonance (MR) images were intratumoral hemorrhage, cystic change, tumor size, and cavernous sinus invasion. The relationship between these factors and VEGF expression was statistically analyzed. Results VEGF was expressed in 25 cases (35.2%). Functioning tumors, hemorrhage, cystic change, and cavernous sinus invasion were 32 (45.1%), 18 (25.4%), 12 (16.9%), and 21 (29.6%) respectively. The expression of VEGF showed a significant relationship with the intratumoral hemorrhage of the adenomas (P 0.05). Conclusions This study suggests that VEGF expression may be responsible for intratumoral hemorrhage of pituitary adenomas. Therefore, VEGF can be a novel target to prevent a catastrophic apoplexy in pituitary adenomas and to establish roles in angiogenesis-based therapeutics of pituitary adenomas.

Benign triton tumor (BTT) or neuromuscular hamartoma is an uncommon tumor composed of mature neural and well-differentiated striated muscular elements. Its development is exceptionally rare in the adult and head region. This report describes a case of adulthood BTT that occurred in the orbit. The patient was a 53-year-old woman who presented with right periorbital swelling and pain in eyeball over 2 months. Magnetic resonance imaging revealed a well-enhancing mass surrounding optic nerve and ocular muscles in the right retrobulbar area. The tumor was subtotally removed via transcranial approach. Its pathological diagnosis was confirmed to be a neuromuscular hamartoma. She developed diplopia postoperatively. Adulthood BTT should be considered in the differential diagnosis of head and neck tumors. It is also important to make adequate therapeutic strategy to avoid postoperative neural dysfunction.

Aneurysmal subarachnoid hemorrhage is uncommon in young adults. The aim of this study was to compare clinical characteristics of ruptured aneurysms between males and females in the third or fourth decade of life. We retrospectively investigated 301 patients who underwent surgery for ruptured cerebral aneurysms over 6 years. Among them, 53 patients were aged between 20–39 years. Clinical characteristics and related variables were compared between genders. In general, there was a favorable outcome in either gender (84.9%). There was a higher incidence of multiplicity and intraoperative rupture in females, as well as a significant difference in aneurysm location between genders (p = 0.030, p = 0.014, and p = 0.027 respectively). Overall outcome was not different between the two groups. These results suggest that aneurysm formation may differ between genders.

Objective: A retrospective study was done on a series of patients in whom authors performed a pedicle subtraction wedge osteotomy within a single vertebral body for deformity correction and decompression. Methods: The authors performed 16 pedicle subtraction osteotomy procedures in patients with thoracolumbar kyphosis after osteoporotic vertebral fracture (OVF). Fourteen cases were available for follow-up 24 months after operation, averaging 33 months (range 27-51 months), are included. Patient examination and interviews, subjective questionnaire, chart reviews, and radiographic measurements were performed. All patients had severe pain and/or deformity; 12 (86%) cases had a preoperative neurologic deficit including two patients with cauda equina syndrome. 6(42%) patients were unable to stand. Their mean age was 66.1 years (range 52-76 years). The mean local kyphotic deformity before surgery was -34.1 degrees (range -58 to -19 degrees). Results: At 24-month follow-up, the mean local kyphotic deformity measured -10.7 degrees (range - 24 to 12 degrees), indicating that the mean surgical correction was 23.5 degrees (range 10 to 36 degrees); All the 12 preoperative neurologic deficit cases improved postoperatively. All patients reported decreased back pain at follow up without narcotic analgesic medication. Complications included two temporary minor neurological injuries and three associated medical complications. There was one case of a neural compression by the dural wrinkling treated conservatively. There were no deaths and prolonged intensive care stay. Conclusion: Pedicle subtraction osteotomy provides both sagittal correction of kyphotic deformity and decompression of spinal cord in the thoracolumbar region. Complications, risks were affordable if patients were carefully selected.

Teratomas of the central nervous system are rare and are frequently found in children and young adults. Cystic teratomas found in infancy is a well-recognized but infrequent entity. Intracranial teratomas,like teratomas in general, tend to arise from midline structures such as the pineal gland, but has rarely been found in the third ventricle. We report a rare case of a 6-month-old infant with a mature cystic teratoma of the third ventricle with a review of literatures.

✓ Intracranial schwannomas are relatively common benign tumors arising from Schwann cells. Among the cranial nerves, the vestibular division of the vestibulocochlear nerve is the site most commonly affected by these lesions, followed by the trigeminal nerve. The authors report a case of bilateral schwannomas arising from both of the pterygoid canals. A 13-year-old girl presented with intermittent headaches and left-sided facial palsy. Preoperative computerized tomography scans and magnetic resonance images revealed nonenhancing round masses within the bilateral vidian canals, bone erosion, and sclerosis. The transnasal transseptal transsphenoidal approach was used to remove the masses. Postoperatively, the patient recovered uneventfully. On histopathological examination, the masses were confirmed as schwannomas. The clinical presentation and probable histogenesis of schwannomas arising in this location are discussed together with a review of the literature.

Telomerase adds telomeric repeats to the ends of telomeres to compensate for their progressive loss. A favorable prognosis is associated with low or no telomerase in some tumors. The authors investigated whether telomerase activity is associated with survival of patients with brain tumors. Sixty-two consecutive patients with brain tumors underwent surgery, and their surgical specimens were investigated. The patients were pathologically categorized as group I (aggressive group) and group II (non-aggressive group). Telomerase activity was examined by the telomeric repeat amplification protocol (TRAP) assay. The median time was calculated in association with overall survival and progression-free survival in each group. The significant difference was noted in telomerase activity between high-grade gliomas and low-grade gliomas (p=0.022). Telomerase activity was significantly associated with the median overall survival and progression-free survival in all tumors of the aggressive group. On the other hand, the median overall survival in the non-aggressive group was not dependent on telomerase activity, while the median progression-free survival was. Our data suggests that telomerase is an important prognostic indicator of survival in patients with brain tumors.

The sinking skin flap syndrome is a rare complication after a large craniectomy. It consists of a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures. In patient with sinking skin flap syndrome, cerebral blood flow and cerebral metabolism are decreased by sinking skin flap syndrome, and it may cause the deterioration of autoregulation of brain. We report a case of a patient with sinking skin flap syndrome who suffered from reperfusion injury after cranioplasty with review of pertinent literature.

Background and purpose Although the effect of weather and air pollution on the occurrence of subarachnoid hemorrhage (SAH) has been investigated, results have remained inconsistent. The present study aimed to determine the seasonality of aneurysmal subarachnoid hemorrhage occurrence and mortality. Methods We used the National Inpatient Sample database to evaluate the effect of meteorological factors and air pollutants on patients with subarachnoid hemorrhage in Korea between 2011 and 2014. Monthly variations in SAH occurrence and mortality were analyzed using locally weighted scatter plot smoothing curves. Multivariate Poisson generalized linear regression models were used to evaluate potential independent meteorological and pollutant variables associated with SAH occurrence and mortality. Results In total, 21,407 patients who underwent clip or coil treatment owing to aneurysmal SAH in Korea from January 1, 2011, to December 31, 2014, were included. The crude incidence rate of SAH in Korea was 10.5 per 100,000 people per year. An approximately 0.5% lower risk of SAH was observed per 1°C increase in mean monthly temperature (relative risk, 0.995; 95% confidence interval [CI], 0.992–0.997; p < 0.001), while an approximately 2.3% higher risk of SAH was observed per 1°C increase in mean monthly diurnal temperature. Conclusions We showed distinct patterns of seasonal and monthly variation in the occurrence and mortality of SAH. Our findings suggest that meteorological factors may play an important role in monthly variations in the occurrence of aneurysmal SAH.

Objective The aims of current study are to compare complications following cranioplasty (CP) using either sterilized autologous bone or polymethyl methacrylate (PMMA), and to identify the risk factors for two of the most common complications: bone flap resorption (BFR) and surgical site infection (SSI). Methods Between January 2004 and December 2013, 127 patients underwent CP and were followed at least 12 months. Variables, including sex, age, initial diagnosis, time interval between decompressive craniectomy (DC) and CP, operation time, size of bone flap, and presence of ventriculo-peritoneal shunt, were analyzed to identify the risk factors for BFR and SSI. Results A total of 97 (76.4%) patients underwent CP using PMMA (Group I) and 30 (23.6%) underwent CP using autologous bone (Group II). SSI occurred in 8 (8.2%) patients in Group I, and in 2 (6.7%) in Group II; there was no statistically significant difference between the groups (p=1.00). No statistically significant risk factors for SSI were found in either group. In Group I, there was no reported case of BFR. In Group II patients, BFR developed in 18 (60.0%) patients at the time of CP (Type 1 BFR), and at 12-month follow up (Type 2 BFR) in 4 (13.3%) patients. No statistically significant risk factors for BFR were found in Group II. Conclusion CP using sterilized autologous bone result in a significant rate of BFR. PMMA, however, is a safe alloplastic material for CP, as it has low complication rate.

Background and purpose This study is to investigate the actual using patterns and clinical effects of topiramate in patients with neurosurgical disease as antiepileptic drugs (AEDs) in 94 korean multicenters. Methods A total of 7,152 patients who had taken topiramate for at least 3 months between August 2008 and February 2009 were eligible to participate in this study. We evaluated demographic data, disease entities, duration of topiramate administration, initial and subsequent dosage adjustment, concomitant AEDs, the frequency of seizure reduction, and adverse events. Results Topiramate was commonly prescribed in stroke (38%) and head trauma group (36%). In the dosage of topiramate, the mean initial dosage was 65 mg/day, and the mean maintenance dosage was adjusted into 105 mg/day. The mean duration of the initial dosage for topiramate administration was 24 days, and the mean duration of the maintenance dosage was 125 days, respectively. Among groups with prophylactic administration, 98% did not develop convulsion and among groups with therapeutic administration, 2% was ineffective to control seizure. After taking topiramate, 2% patients showed adverse events, that sensory aberration was the most common. Conclusions These results suggest that topiramate prescribe widely in diverse neurosurgical disorders, and effective in reduction of seizure frequency, and does not cause serious adverse effects comparable with old AEDs.

Hemorrhagic metastatic brain tumors of hepatocellular carcinoma (HCC) are rare and have been mostly presented as intracranial hemorrhage (ICH). A 51-year-old male patient presented with sudden altered level of consciousness. He suffered from HCC since 2010 and transarterial chemoembolization was performed three times for HCC. The brain computed tomography (CT) scans revealed subdural hematoma (SDH) in the right fronto-temporal area and 6.0×3.5 cm sized ICH in the right parieto-occipital lobe. Brain angiographic CT scans demonstrated that the hemorrhagic lesions did not include any enhancing lesions and vascular abnormalities. We undertook a decompressive craniectomy and evacuation of the acute SDH and ICH. During evacuation of ICH, the yellowish mass was observed in the cortical surface of the right occipital lobe. Pathological examination displayed the findings of metastatic brain tumor from HCC. Metastatic brain tumors should be considered in the differential diagnosis as a cause of spontaneous SDH with ICH.

Objective: Resorption of autologous bone flap grafts is a known long-term complication of cranioplasty following decompressive craniectomy (DC). We analyzed our data to identify risk factors for bone flap resorption (BFR) following cranioplasty. Methods: A total of 162 patients who underwent cranioplasty following DC due to life-threatening elevated intracranial pressure between October 2003 and December 2012, were included in our investigation. Follow-up exceeded one year. Results: BFR occurred as a long-term complication in 9 of the 162 patients (5.6%). The affected patients consisted of individuals who had undergone DC for traumatic brain injury (TBI; n=4), for subarachnoid hemorrhage (SAH; n=3), for cerebral infarction (n=1), and intracerebral hemorrhage (n=1). Logistic regression analysis identified no significant risk factors for BFR. Conclusion: TBI and SAH as initial diagnoses are more often associated with BFR than other diagnoses. This finding may influence future surgical decision making, especially in patients with possible risk factors for BFR. A prospective study with a large number of patients is needed to identify potential predictors of BFR such as bone flap sterilization and preservation.

Post-traumatic diabetes insipidus (DI) is a relatively common complication after head injury. The authors report a fatal case of refractory DI, which developed in a patient with chronic subdural haematoma.A 38-year-old woman presented to the emergency room with a headache for over a week. She was alert and neurological examination demonstrated no significant deficits or external wounds in her head. Brain computed tomography (CT) scans revealed a small amount of chronic subdural haematoma bilaterally. She was treated conservatively and her hospital course was uneventful until she developed a convulsive seizure and mental change on the 3rd day after admission. Immediate follow-up CT scans showed no significant change in the amount of haemorrhage except effacement of gyral marking. Bilateral trephination and drainage of the haematoma were performed immediately. Post-operatively, she developed a refractory DI and was managed in the intensive care unit. However, she died on the 6th day after the operation ultimately.The authors emphasize the importance of timely drainage of chronic subdural haematoma to prevent a fatal endocrinologic complication after head injury. This study also discusses the possible mechanism of DI after head injury, management and review of the pertinent literatures.

Lhermitte-Duclos disease (LDD) is a rare cerebellar disorder characterized by diffuse or focal enlargement of cerebellar folia. Clinical manifestations are usually related to a mass effect and secondary obstructive hydrocephalus. Increased intracranial pressure symptoms and cerebellar symptoms are the most frequent patient complaints. We describe the case of a patient with LDD who developed secondary obstructive hydrocephalus. A 68-year-old woman was brought to the emergency room for sudden vertigo following several bouts of vomiting and headache. There were no external signs of trauma, serious illness or infection. On admission, the patient was alert and had no neurological deficits. Brain computed tomography (CT) and magnetic resonance imaging (MRI) showed hydrocephalus and a cerebellar mass in the right cerebellar hemisphere compressing the fourth ventricle. Suboccipital craniotomy and subtotal removal of the mass was performed. Pathological study of the surgical specimen showed abnormal ganglionic neurons and an enlarged molecular layer compatible with dysplastic gangliocytoma. Cytoreduction can achieve improvement in symptoms caused by mass effect, but postoperative swelling may aggravate obstructive hydrocephalus. Therefore, if symptoms still remain after removal of the mass, an additional shunting procedure may be needed as a further management option.

Colpocephaly is an abnormal enlargement of the occipital horns, i.e., the posterior or rear portions of the lateral ventricles of the brain, and is associated with several other brain abnormalities. Colpocephaly is occasionally misdiagnosed as hydrocephalus, and various etiologies have been postulated, including genetic disorders and errors of morphogenesis. Meanwhile, chromosomal losses including 22q and rarely 21q are observed in malignant and atypical meningiomas. We report an uncommon case of a 67-year-old woman with colpocephaly and an atypical meningioma in the posterior fossa. There were no neurological deficits or family history of hereditary neuropsychiatric disorders. Brain magnetic resonance (MR) images showed bilateral enlarged occipital horns, agenesis of corpus callosum, and a cerebellar mass in the right cerebellar hemisphere. Right suboccipital craniotomy was performed, and the tumor was resected totally. Pathological study of the surgical specimen showed findings of atypical meningioma, and the postoperative course was uneventful until hydrocephalus developed. At 36th day after tumor removal, the patient undertook an external ventricular drainage followed by replacement of the ventriculoperitoneal shunt. We discuss the importance of colpocephaly in terms of the differential diagnosis for hydrocephalus and review the pertinent literature.

Colpocephaly is an abnormal enlargement of the occipital horns, i.e., the posterior or rear portions of the lateral ventricles of the brain, and is associated with several other brain abnormalities. Colpocephaly is occasionally misdiagnosed as hydrocephalus, and various etiologies have been postulated, including genetic disorders and errors of morphogenesis. Meanwhile, chromosomal losses including 22q and rarely 21q are observed in malignant and atypical meningiomas. We report an uncommon case of a 67-year-old woman with colpocephaly and an atypical meningioma in the posterior fossa. There were no neurological deficits or family history of hereditary neuropsychiatric disorders. Brain magnetic resonance (MR) images showed bilateral enlarged occipital horns, agenesis of corpus callosum, and a cerebellar mass in the right cerebellar hemisphere. Right suboccipital craniotomy was performed, and the tumor was resected totally. Pathological study of the surgical specimen showed findings of atypical meningioma, and the postoperative course was uneventful until hydrocephalus developed. At 36th day after tumor removal, the patient undertook an external ventricular drainage followed by replacement of the ventriculoperitoneal shunt. We discuss the importance of colpocephaly in terms of the differential diagnosis for hydrocephalus and review the pertinent literature.

Lhermitte–Duclos disease (LDD) is a rare cerebellar disorder characterized by diffuse or focal enlargement of cerebellar folia. Clinical manifestations are usually related to a mass effect and secondary obstructive hydrocephalus. Increased intracranial pressure symptoms and cerebellar symptoms are the most frequent patient complaints. We describe the case of a patient with LDD who developed secondary obstructive hydrocephalus. A 68-year-old woman was brought to the emergency room for sudden vertigo following several bouts of vomiting and headache. There were no external signs of trauma, serious illness or infection. On admission, the patient was alert and had no neurological deficits. Brain computed tomography (CT) and magnetic resonance imaging (MRI) showed hydrocephalus and a cerebellar mass in the right cerebellar hemisphere compressing the fourth ventricle. Suboccipital craniotomy and subtotal removal of the mass was performed. Pathological study of the surgical specimen showed abnormal ganglionic neurons and an enlarged molecular layer compatible with dysplastic gangliocytoma. Cytoreduction can achieve improvement in symptoms caused by mass effect, but postoperative swelling may aggravate obstructive hydrocephalus. Therefore, if symptoms still remain after removal of the mass, an additional shunting procedure may be needed as a further management option.

Isolated hypoglossal nerve paresis due to mechanical compression from a vascular lesion is very rare. We present a case of a 32-year-old man who presented with spontaneous abrupt-onset dysarthria, swallowing difficulty and left-sided tongue atrophy. Brain computed tomographic angiography and magnetic resonance imaging of the brainstem demonstrated an abnormal course of the left vertebral artery compressing the medulla oblongata at the exit zone of the hypoglossal rootlets that was relieved by microvascular decompression of the offending intracranial vertebral artery. This case supports the hypothesis that hypoglossal nerve palsy can be due to nerve stretching and compression by a pulsating normal vertebral artery. Microvascular decompression of the intracranial nerve and careful evaluation of the imaging studies can resolve unexpected isolated hypoglossal nerve palsy.

Minocycline, a second-generation tetracycline-class antibiotic, has been well established to exert a neuroprotective effect in animal models and neurodegenerative disease through the inhibition of microglia. Here, we investigated the effects of minocycline on motor recovery and neuropathic pain in a rat model of spinal cord injury.To simulate spinal cord injury, the rats' spinal cords were hemisected at the 10th thoracic level (T10). Minocycline was injected intraperitoneally, and was administered 30 minutes prior surgery and every second postoperative day until sacrifice 28 days after surgery. Motor recovery was assessed via the Basso-Beattie-Bresnahan test. Mechanical hyperalgesia was measured throughout the 28-day post-operative course via the von Frey test. Microglial and astrocyte activation was assessed by immunohistochemical staining for ionized calcium binding adaptor molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP) at two sites: at the level of hemisection and at the 5th lumbar level (L5).In rats, spinal cord hemisection reduced locomotor function and induced a mechanical hyperalgesia of the ipsilateral hind limb. The expression of Iba1 and GFAP was also increased in the dorsal and ventral horns of the spinal cord at the site of hemisection and at the L5 level. Intraperitoneal injection of minocycline facilitated overall motor recovery and attenuated mechanical hyperalgesia. The expression of Iba1 and GFAP in the spinal cord was also reduced in rats treated with minocycline.By inhibiting microglia and astrocyte activation, minocycline may facilitate motor recovery and attenuate mechanical hyperalgesia in individuals with spinal cord injuries.

The granulins, a novel class of peptides from leukocytes, are growth factors that mediate cycle progression and the motility of epithelial and mesenchymal cells. They are also involved in tissue repair and tumorigenesis. We investigated granulin expression in intracranial meningiomas by reverse transcription-polymerase chain reaction and correlated its expression to clinical parameters. Seventy-nine patients who underwent tumor removal for intracranial meningiomas were included in this study. Granulin expression was analyzed in respect to clinical parameters including age, gender, tumor size and peritumoral brain edema (PTBE). Granulin was expressed in the tumors of 29 of 79 (36.7%) patients with intracranial meningiomas, and its presence or absence was correlated to tumor size and PTBE volume. However, granulin expression did not vary significantly according to patient age or gender. Our data provide improved understanding about the clinical implications of granulin expression in intracranial meningiomas. Additionally, our information suggests a potential role for granulin as a molecular target in the management of meningiomas.

s Background We investigate cases of low-lying IC-PC artery aneurysms with the aim to demonstrate an easy and less laborious technique of APF resection in lieu of AC in cases involving difficult aneurysmal neck clipping. Methods Among a total 117 IC-PC artery aneurysms, 15 low-lying IC-PC artery aneurysms (13 ruptured and 2 unruptured) were obliterated between January 1996 and December 2006. We retrospectively investigated patients who have been treated by simple resection of APF (APF group) compared with patients treated by AC (AC group) in the surgery of the communicating segment of the ICA aneurysms. Clinical, radiological, and operative data were analyzed; and the 2 groups were compared. Results Among 15 cases, 7 cases were included in the AC group and 8 cases were included in the APF group. One case was treated by a combination of AC and APF resection simultaneously. There was no difference in the clinical outcome between the 2 groups. No operative complications were encountered in any patients treated by the simple APF resection. Conclusions Simple APF resections improve the visualization of the proximal neck of aneurysms, allowing for accurate clip placement and also facilitating the use of proximal vascular control as an adjunct to low-lying IC-PC artery aneurysms surgery.

Purpose: Traditionally, the transcranial approach has been used to remove tuberculum sellae (TS) meningiomas. However, the trans-sphenoidal route has recently been adopted for removal of parasellar tumors. The authors describe use of the trans-sphenoidal supradiaphragmatic intradural approach (TSIA) for removal of presellar and/or suprasellar TS meningiomas. Methods: Six women, aged from 37 to 69 years (average, 59.5 yrs), presented with headaches and visual disturbances. All cases underwent the TSIA via the transnasal trans-septal routes. After removal of tumors, the surgical dural and bony defects were repaired with autologous abdominal fat and silicone plate substitutes. Results: The extents of tumor removal were gross total in 3 patients and subtotal in 3. There was 1 postoperative cerebrospinal fluid leak and 1 aggravation of the visual function. The mean follow-up period was 49.3 months (from 92 to 14 mos). Conclusions: The major advantage of this technique is that it is easily applicable through a minor modification of the standard trans-sphenoidal approach. Although we used this TSIA in a limited number of cases, it can be concluded that TSIA makes it possible to remove TS meningiomas safely in selected cases. However, the transcranial approach is preferred whenever the surgeon aims for complete removal of the tumor.

Background CT angiography has been widely used for the detection of cerebral aneurysm. However, there are still limitations despite improving CT angiographic techniques. We describe the unusual case of the detection of a false-positive aneurysm on CT angiography. Case Description A 64-year-old man presented with a 14-day history of severe headache and nuchal rigidity. Brain CT demonstrated no subarachnoid hemorrhage, but cerebrospinal fluid appeared xanthochromic in 3 successive tubes after lumbar puncture. Subsequent CT angiography suggested an aneurysm at the bifurcation of the left MCA. However, at operation, prominent sylvian vein superimposed on the bifurcation of the left MCA, and there was no aneurysm. Follow-up monitoring with conventional angiography at 2 weeks showed no abnormal findings. The patient recovered uneventfully. Conclusion The case demonstrates that although CT angiography has a reportedly high specificity and sensitivity for the detection of intracranial aneurysm, careful interpretation is required to diagnose intracranial aneurysms.

Congenital supratentorial hemangioblastomas are extremely rare tumors even in pediatric population. A 57-day-old female neonate presented with a pure motor seizure. On imaging studies, intracranial hemorrhagic lesions containing multiple cystic components in the cerebral and cerebellar areas were revealed, simultaneously. After the emergency surgical evacuation only to a fatal supratentorial lesion, an infratentorial lesion also regressed spontaneously. The authors report a case of full-term neonate presenting with supra- and infratentorial hemorrhagic lesions, which occurred as a result of congenital supratentorial hemangioblastoma bleeding.

Objective The epidural fluid collection (EFC) as a complication of cranioplasty is not well-described in the literature. This study aimed to identify the predictive factors for the development of EFC as a complication of cranioplasty, and its outcomes. Methods From January 2004 to December 2012, 117 cranioplasty were performed in our institution. One-hundred-and-six of these patients were classified as either having EFC, or not having EFC. The two groups were compared to identify risk factors for EFC. Statistical significance was tested using the t-test and chi-square test, and a logistic regression analysis. Results Of the 117 patients undergoing cranioplasty, 59 (50.4%) suffered complications, and EFC occurred in 48 of the patients (41.0%). In the t-test and chi-test, risk factors for EFC were size of the skull defect (p=0.003) and postoperative air bubbles in the epidural space (p

Meningioma is a common primary tumor of central nervous system. However, extracranial extension of the intracranial meningioma is unusual, and mostly accompanied the osteolytic change of the skull. We herein describe an atypical meningioma having extracranial extension with hyperostotic change of the skull. The patient was a 72-year-old woman who presented a large mass in the right frontal scalp and left hemiparesis. Brain magnetic resonance imaging and computed tomography scans revealed an intracranial mass, diffuse meningeal thickening, hyperostotic change of the skull with focal extension into the right frontal scalp. She underwent total removal of extracranial tumor, bifrontal craniectomy, and partial removal of intracranial tumor followed by cranioplasty. Tumor pathology was confirmed as atypical meningioma, and she received adjuvant radiotherapy. In this report, we present and discuss a meningioma en plaque of atypical histopathology having an extracranial extension with diffuse intracranial growth and hyperostotic change of the skull.

PC10, a monoclonal antibody (mAb) to proliferating cell nuclear antigen (PCNA) is known to show immunoreactivity in paraffin-embedded specimens. The authors present the relation between PCNA expression and clinicopathological features in 38 intracranial meningiomas. PCNA scores were obtained by immunohistochemical staining of the paraffin-embedded sections using a streptoavidin-biotin immunoperoxidase method with PC10 mAb. Univariate analysis showed that high PC10 scores were associated with old age (≥ 50 years old), male, recurrent tumours, and meningothelial type. However, these high scores did not reach a statistical significance (P> 0.05). PC10 scores of the basal meningioma tended to be higher than that of the hemispheric meningioma (P< 0.05). The staining intensity of PCNA was also markedly increased in basal meningiomas. It is suggested that the proliferative potential is higher in basal meningiomas than in hemispheric meningiomas. Moreover, these results could reflect high recurrence and difficulty in management of the skull base meningiomas.

The annual incidence rate of spontaneous vertebral artery dissection (VAD) has been reported at about 1 to 1.5 per 100000. However, the natural history of spontaneous unruptured VAD is not completely understood. The primary presentation of spontaneous unruptured VAD is severe headache only or focal neurologic deficits caused by vertebrobasilar artery ischemia. Unruptured VAD tends not to follow an aggressive clinical course, and because the prognosis tends to be favorable, conservative treatment of these lesions has been advocated. However, if there is the event of aneurysmal rupture, it might lead to be fatal. Therefore, complete understanding of mechanism and pathogenesis of VAD is needed, and patients with VAD need a careful follow-up. In this retrospective review, we investigated the clinical outcomes of unruptured VAD and discuss strategies for their treatment with review of literatures.

Objective The introduction and development of the embolic protecting device (EPD) has resulted in a decreased rate of stroke after carotid artery stenting (CAS). The authors performed a retrospective study to investigate the risk factors for developing large emboli after CAS which can lead to ischemic events. Methods A total of 35 consecutive patients who underwent CAS between January 2009 and March 2012 were included in this study. Patients were divided into two groups including those with small emboli (group A; grade 1, 2) and those with large emboli (group B; grade 3, 4). The size and number of emboli were assigned one of four grades (1=no clots, 2=1 or 2 small clots, 3=more than 3 small clots, 4=large clots) by microscopic observation of the EPD after CAS. We compared demographic characteristics, medical history, and angiographic findings of each group. Results Thirty-five patients underwent CAS, and technical success was achieved in all cases. Twenty-three patients were included in group A and 12 patients in group B. Our results demonstrated that advanced age [odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.52; p=0.044] and smoking (OR 42.06; CI 2.828-625.65, p=0.006) were independent risk factors for developing large emboli after CAS. Conclusion In patients with carotid artery stenosis treated with CAS, advanced age and smoking increased the number and size of emboli. Although use of an EPD is controversial, it may be useful in CAS in patients with risk factors for large emboli in order to reduce the risk of ischemic events.

The pin-type headrest is one of the most common equipment for the skull fixation for stereotactic neurosurgical procedures. This device clamps the patient’s skull to rigid structure, and holds the patient’s head and neck in a particular position during surgical procedures. Pin headrest device has brought conveniences and favorable outcomes in neurosurgical fields, but can develop hazardous complications. Particularly in pediatric patients, a case with skull penetration has been reported. However, a skull perforation and depressed fracture has uncommonly complicated in adults. We report a case with skull perforation and depressed fracture following skull fixation by pin headrest in an adult.

Traumatic intracranial aneurysms are rare, comprising 1% or less of all cerebral aneurysms. The majority of these aneurysms arise at the skull base or in the distal anterior and middle cerebral arteries or their branches following direct mural injury or acceleration-induced shearing force. We present a 50-year-old patient in whom subarachnoid hemorrhage (SAH) was developed as a result of traumatic aneurysm rupture after a closed craniofacial injury. Through careful evaluation of the three-dimensional computed tomography and conventional angiographies, the possible mechanism of the traumatic internal carotid artery trunk aneurysm is correlated with a hit injury by the bony protuberances on the anterior and posterior clinoid processes. This traumatic aneurysm was successfully obliterated with clipping and wrapping technique. The possibility of a traumatic intracranial aneurysm should be considered when patient with SAH demonstrates bony protuberances on the clinoid process as a traumatic aneurysm may result from mechanical injury by the sharp bony edges.

Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system. Most cases of NCC are to related and/or associated with inflammation within the cerebral parenchyma. A 71-year-old woman presented with a 4-year history of visual disturbance. This symptom had become aggravated 4 weeks earlier. Her visual acuity gradually decreased and superior hemianopsia was noted. Magnetic resonance imaging (MRI) revealed an enhanced and thickened pituitary stalk accompanying a suspicious mass. The provisional diagnoses were lymphoma, glioma, or other inflammatory conditions. Laboratory studies, including blood and hormonal studies, showed normal findings. Surgical resection was performed. In the pathological examination, degenerated parasitic wall structure was seen and its contents were composed of completely degenerated focal globular structures suggesting the scolex of cysticercus. We report an unusual case of NCC involving the pituitary stalk which was presented with a juxtasellar tumor. The possible underlying mechanisms are discussed with a review of pertinent literature.

Subdural hygromas are characterized by a subdural collection of cerebrospinal fluid (CSF). Although its pathogenic mechanism is uncertain, it develops by the tearing of the arachnoid membrane and subsequent accumulation of CSF in the subdural space. The surgical procedures for subdural hygromas include drainage through burr holes or twist drills, subduroperitoneal shunt, and craniotomy. Reaccumulation of fluid, infection, seizure, and hydrocephalus are common complications after surgery. The incidence of intracerebral hemorrhage after drainage of the subdural hygroma is as low as 1 to 5%. This report presents a patient who had rapid neurological deterioration caused by massive intracerebral hemorrhage after drainage of the subdural hygroma.