• 대한두개안면성형외과학회지
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• 제12권2호
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• pp.107-110
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• 2011

Purpose: There have been few case reports regarding treatment plans for long-term, neglected scalp defects and calvarial defects with subdural abscess. The purpose of this case report is to present our experience with a free latissimus dorsi musculocutaneous flap for scalp and calvarial defects and to discuss flap options in comparison with a literature review. Methods: A 60-year-old man who fell down from a four-story-height that resulted in a craniotomy in 1979; he visited our outpatient clinic for a chronic, purulent scalp and calvarial defects with unidentified artificial bone. The artificial bone was removed by a neurosurgeon and reconstructed with a free latissimus dorsi musculocutaneous flap. The deep temporal artery was used as a recipient artery. The postoperative flap status was excellent until the 6th day post-operation when the patient experienced a seizure, and an arterial insufficiency occurred at the flap probably due to an arterial spasm. Emergency exploration with arterial re-anastomosis was performed and the flap status was stabilized. Results: Complete wound healing was achieved after 3 weeks without infectious and systemic postoperative complications. During the 6 month follow-up period, there were no complications. Conclusion: We suggest the latissimus dorsi myocutaneous free flap as a good treatment option for a chronic, purulent, complicated scalp with calvarial defect, as a well as treatment for an acute traumatic defect.

• Journal of Korean Neurosurgical Society
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• 제65권4호
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• pp.582-590
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• 2022

Objective : Hydrocephalus after intracerebral hemorrhage (ICH) is known to be related to poor prognosis and mortality. We analyzed predictors of permanent hydrocephalus in the patients with surgically treated supratentorial ICH. Methods : From 2004 to 2019, a total of 414 patients with surgically treated primary supratentorial ICH were included. We retrospectively analyzed age, sex, preexisting hypertension and diabetes, location and volume of ICH, presence and severity of intraventricular hemorrhage (IVH), and type of surgery. Results : Forty patients (9.7%) required shunt surgery. Concomitant IVH was higher in the 'shunt required' group (92.5%) than in the 'shunt not required' group (67.9%) (p=0.001). IVH severity was worse in the 'shunt required' group (13.5 vs. 7.5, p=0.008). Craniectomy (47.5%) was significantly high in the 'shunt required' group. According to multivariable analysis, the presence of an IVH was 8.1 times more frequent and craniectomy was 8.6 times more frequent in the 'shunt required' group. In the comparison between craniotomy and craniectomy group, the presence of an IVH was related with a 3.9 times higher (p=0.033) possibility and craniectomies rather than craniotomies with a 7-times higher possibility of shunt surgery (p<0.001). Within the craniectomy group, an increase in the craniectomy area by 1 cm² was correlated with a 3.2% increase in the possibility of shunt surgery (odds ratio, 1.032; 95% confidence interval, 1.005-1.061; p=0.022). Conclusion : Presence of IVH, the severity of IVH and decompressive craniectomy were related to the development of shunt dependent hydrocephalus in the patients with ICH. The increasing size of craniectomy was related with increasing rate of shunt requirement.

• 대한두개안면성형외과학회지
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• 제23권4호
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• pp.178-182
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• 2022

Postoperative temporal hollowing is a common complication of craniotomy. Damage and repositioning of the temporalis muscle can lead to a depression in the temporal side of the skull with inferior bulging, worsening aesthetic outcomes. We report a case of cranioplasty with three-dimensional (3D) printed mesh involving an additional correction using a temporalis muscle sling to help address this problem. A 3D-printed bioabsorbable mesh was prepared based on preoperative facial computed tomography, and was fixed to the hollowed area for tissue augmentation. The temporalis muscle was elevated and fanned out to its original position, and a sling was attached to a screw that was fixed to the mesh. For reinforcement, an additional sling was attached to another screw fixed to the mesh 2-3 cm vertically above the first screw. Aesthetic results were confirmed immediately after surgery and later during outpatient follow-up. Both depression and lateral bulging were resolved, and there was no delayed drooping of the temporalis muscle on 6-month follow-up. There were no complications, and the patient was satisfied with the appearance. This is a simple yet effective technique with a low risk of complications, and should be considered for postoperative temporal hollowing patients, especially those with severe lateral bulging.

• 대한두개안면성형외과학회지
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• 제23권2호
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• pp.59-63
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• 2022

Background: Deformational plagiocephaly is usually managed conservatively, as it tends to improve over time and with the use of conservative measures. However, before the year 2017 we operated on patients with severe plagiocephaly and neurological symptoms at the Helsinki Cleft Palate and Craniofacial Center. Methods: Of the 20 infants with severe deformational plagiocephaly and neurological symptoms referred to us between 2014 and 2016, 10 underwent cranioplasty open reshaping of the posterior cranial vault. The parents of the last 10 patients were given information on the natural history of the condition and the patients were followed up with an outpatient protocol. The aim of this study was to gain information on the brain electrophysiology and recovery of patients after total cranial vault reconstruction by measuring the electroencephalogram (EEG) somatosensory evoked potentials (SEP; median nerve). Results: Of the 10 participants in the operation arm, six had abnormal SEP at least on the affected cerebral hemisphere and all SEPs were recorded as normal when controlled postoperatively. In the follow-up arm, eight out of 10 participants had abnormal SEP at the age of approximately 24 months, and all had normalized SEPs at control visits. Conclusion: Our data suggest that cranioplasty open reshaping of the posterior cranial vault did not affect abnormal SEP-EEG recordings. We have abandoned the operations in deformational plagiocephaly patients due to findings suggesting that expanding cranioplasty is not beneficial for brain function in this patient group.

• Journal of Korean Neurosurgical Society
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• 제65권3호
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• pp.457-468
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• 2022

Objective : The clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. Methods : We retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. Results : Among the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. Conclusion : The EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.

• Pediatric Infection and Vaccine
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• 제30권3호
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• pp.159-164
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• 2023

뇌농양은 생명을 위협할 수 있는 심각한 중추신경계 감염으로 특히 소아에서는 증상이 모호하여 시의적절한 진단이 이루어지지 않는 경우가 종종 발생한다. 저자들은 면역력이 정상인 소아에서 드문 병원체에 의한 중추신경계 감염을 진단 및 치료하여 보고하는 바이다. 7년 전 심방중격결손을 진단받았고, 1달 전부터 충치 치료를 받은 과거력이 있는 10세 여아가 10일 전 발생한 두통을 주소로 입원하였다. 뇌자기공명영상에서 4.2 cm 크기의 뇌농양이 오른쪽 두정엽에서 발견되어 두개골절개술과 농양 흡인을 시행하였다. 흡인된 농과 조직에서 Aggregatibacter aphrophilus가 배양되었고, 16S rRNA sequencing에서 Actinomyces georgiae가 확인되어 ampicillin-sulbactam을 8주간 투여하였다. 수술 및 항균요법으로 환자의 증상이 호전되었고, 추적한 뇌자기공명영상에서 농양과 부종도 호전되어 치료를 종료하였다.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제25권4호
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• pp.380-389
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• 2023

Objective: Middle meningeal artery embolization (MMAe) has burgeoned as a treatment for chronic subdural hematoma (cSDH). This study evaluates the safety and short-term outcomes of MMAe patients relative to traditional treatment approaches. Methods: In this retrospective large database study, adult patients in the National Inpatient Sample from 2012-2019 with a diagnosis of cSDH were identified. Cost of admission, length of stay (LOS), discharge disposition, and complications were analyzed. Propensity score matching (PSM) was utilized. Results: A total of 123,350 patients with cSDH were identified: 63,450 without intervention, 59,435 surgery only, 295 MMAe only, and 170 surgery plus MMAe. On PSM analysis, MMAe did not increase the risk of inpatient complications or prolong the length of stay compared to conservative management (p>0.05); MMAe had higher cost ($31,170 vs. $10,768, p<0.001) than conservative management, and a lower rate of nonroutine discharge (53.8% vs. 64.3%, p=0.024). Compared to surgery, MMAe had shorter LOS (5 vs. 7 days, p<0.001), and lower rates of neurological complications (2.7% vs. 7.1%, p=0.029) and nonroutine discharge (53.8% vs. 71.7%, p<0.001). There was no significant difference in cost (p>0.05). Conclusions: MMAe had similar LOS and decreased odds of adverse discharge with a modest cost increase compared to conservative management. There was no difference in inpatient complications. Compared to surgery, MMAe treatment was associated with decreased LOS and rates of neurological complications and nonroutine discharge. This nationwide analysis supports the safety of MMAe to treat cSDH.

• Journal of Korean Neurosurgical Society
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• 제30권11호
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• pp.1340-1344
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• 2001

뇌로 전이한 악성 섬유성 조직구종 1례를 문헌 고찰과 함께 보고하고자 한다. 환자는 62세 남자로 다발성 전이성 뇌종양 의증하에 개두술 및 종양 제거술을 시행받았다. 술전 검사상 두개강외 원발 부위를 의심할만한 병변은 발견하지 못하였다. 수술과 전뇌 방사선 치료후 6개월째에 성장하는 우측 견부 종양이 발견되어 적출술을 시행하였다. 뇌와 견부 조직 표본에서 악성 섬유성 조직 세포종에 부합되는 일치된 병리 소견을 보였으나 GFAP-양성 세포들은 뇌병변의 조직 표본에서만 발견되었다. 이후에 발생한 척추 등의 골격계 전이성 병변에 대하여서는 고식적 방사선 치료를 행하였다. 최초 진단 후 12개월째 우측 견부 종양이 재발하여 항암 화학 치료 중이다. 이 증례에서 특이한 점은 원발 부위 발견전 전이성 뇌종양이 진단된 것인데, 악성 섬유성 조직구종으로부터 뇌로 전이한 경우가 드물거니와 특히 원발부위가 확인되기 전에 뇌로 전이한 병변이 먼저 발견된 경우는 보고된 바가 없다. 또 하나의 중요한 소견은 GFAP 발현이 뇌병변에서만 나타나며 원발부위인 견부 종양에서는 관찰되지 않은 점이다. 원발성 두개강내 악성 섬유성 조직구종에서 GFAP-양성 세포의 존재는 중요한 조직학적 특성의 하나로 알려져 있으나, 본 증례의 소견은 원발성 두개강내 악성 섬유성 조직구종에 존재하는 GFAP-양성 세포들도 악성 섬유성 조직구종에 의해 이차적으로 생성된 비종양성 성상 세포들이라는 가설을 뒷받침하고 있다.

• Journal of Korean Neurosurgical Society
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• 제30권1호
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• pp.60-65
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• 2001

Objective : The popular grading systems in use, such as Hunt-Hess grade and Fisher scale score, are based primarily on the patient's clinical conditions or computerized tomography score after aneurysmal subarachnoid hemorrhage(SAH). The author investigated whether the need for ventriculoperitoneal(VP) shunt for chronic hydrocephalus and outcome can be predicted by Hunt-Hess grade and Fisher scale. Methods : A series of 146 patients admitted to our hospital from August 1991 to July 1999, who presented with SAH and underwent craniotomy for aneurysm clipping were studied retrospectively. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after initial hemorrhage which required shunting. Patients were evaluated based on following factors : Hunt-Hess grade, Fisher scale, age, sex, hypertension, aneurysm location, and intervals from aneurysm rupture to operation. Results : The overall mortality rate of the study group was 8.2%. Hunt-Hess grade(p=0.001) or Fisher scale (p=0.001) at all pretreatment times was significantly correlated with outcome. In addition, there was an increased risk of poor outcome in older age(65<). However, there were statistically no significant relationship between outcome and sex, location of aneurysm, hypertension, and interval from aneurysmal rupture to operation(p>0.05). Of 134 surviving patients, 16 patients(12%) underwent VP shunt placement secondary to chronic hydrocephalus. Hunt-Hess grade(p=0.001) is more predictive of chronic hydrocephalus than Fisher scale(p=0.146). Aneurysm location was significantly correlated with development of chronic hydrocephalus (p<0.05), without significant correlations in sex, age, hypertension. IVH, and ICH. Conclusion : This study suggests that there is a high clinical correlation between outcome and Hunt-Hess grades and Fisher scales on admission, but Hunt-Hess grade is more predictive for chronic hydrocephalus than Fisher scale. In addition, age(<65 yrs) is the significant factor for prediction of outcome. There was a trend of increasing risk for chronic hydrocephalus according to aneurymal location.

• Journal of Korean Neurosurgical Society
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• 제29권5호
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• pp.668-674
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• 2000

Objective : The classic and accepted surgical method of compound comminuted depressed skull fractures (FCCD) involves total resection of all the contaminated bone and fragments at the fracture site. A second operation for cranioplasty is then performed at a later date. However, we have believed that primary repair of these bony defects can be achieved by the replacement of bone fragments at the time of the initial debridement, and this can be accomplished without danger to patient. The authors retrospectively reviewed the surgical results to assess the advantages and disadvantages, and also propose the selection criteria of replacement of fractured bone fragments as a primary procedure in FCCD. Materials and Methods : The authors analyzed the data extracted from medical records, and radiological findings in 22 of 71 patients with FCCD, who underwent immediate replacement of fractured bone fragments between April 1993 and October 1998. The mean follow-up period was 13.7 months. The selection criteria for the operation included the patients with mild to moderate severity, regardless of the degree of contamination or dural violation, which presented in hospital within 24 hours of injury. Results : The ages of the patients varied from 4 to 63 years, and there were 20 males and 2 females. Seventeen of 22 patients were fully conscious on admission and the others also had relatively good Glasgow coma scales. Sixteen fractures were located in the frontal area, 9 with involvement of the frontal sinuses, and 6 in the parietal and temporoparietal areas. Of the 22 patients, 8(36.3%) had dural lacerations with 3 of these requiring patching with pericranium, and 12(54.5%) had intracranial hematoma requiring wide craniotomy. The degree of wound contamination was also variable. Fifteen patients had relatively clean wounds, while seven(31.8%) had seriously contaminated wounds with soil, sand, hair, and wood. Only one patient(4.5%) developed infection, and the bone fragments were removed. All wounds healed primarily without pulsatile defect, the skull has remained solid, and no complications have occurred, except the infected case. Conclusion : It is proposed that bone fragments removal for FCCD, regardless of the degree of contamination or dural violation, is not necessary and that primary bone fragments replacement avoids a second operation for cranioplasty.