Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management

Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling

Objective@#: Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. @*Methods@#: Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with singlemicrocatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. @*Results@#: Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). @*Conclusion@#: Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling

Objective@#: Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. @*Methods@#: Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with singlemicrocatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. @*Results@#: Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). @*Conclusion@#: Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

Current Status of Neurosurgical and Neurointensive Care Units in Korea : A Brief Report on Nationwide Survey Results

Objective@#: The purpose of this study is identify the operation status of the neurosurgical care units (NCUs) in neurosurgical residency training hospitals nationwide and determine needed changes by comparing findings with those obtained from the Korean Neurosurgical Society (KNS) and Korean Society of Neurointensive Care Medicine (KNIC) survey of 2010.Method : This survey was conducted over 1 year in 86 neurosurgical residency training hospitals and two neurosurgery specialist hospitals and focused on the following areas : 1) the current status of the infrastructure and operating systems of NCUs in Korea, 2) barriers to installing neurointensivist team systems, 3) future roles of the KNS and KNIC, and 4) a handbook for physicians and practitioners in NCUs. We compared and analyzed the results of this survey with those from a KNIC survey of 2010. @*Results@#: Seventy seven hospitals (87.5%) participated in the survey. Nineteen hospitals (24.7%) employed a neurointensivist or faculty member; Thirty seven hospitals (48.1%) reported high demand for neurointensivists, and 62 hospitals (80.5%) stated that the mandatory deployment of a neurointensivist improved the quality of patient care. Forty four hospitals (57.1%) believed that hiring neurointensivist would increase hospital costs, and in response to a question on potential earnings declines. In terms of potential solutions to these problems, 70 respondents (90.9%) maintained that additional fees were necessary for neurointensivists’ work, and 64 (83.1%) answered that direct support was needed of the personnel expenses for neurointensivists. @*Conclusion@#: We hope the results of this survey will guide successful implementation of neurointensivist systems across Korea.

Decompressive Craniectomy in Traumatic Brain Injury: A Review Article / 대한신경손상학회지

The importance of treating traumatic brain injury (TBI) is well known worldwide. Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI. Recently, good randomized controlled trial (RCT) papers about the effectiveness of decompressive craniectomy (DC) in TBI has been published. In this article, we will review the overall contents of the DC (historical base, surgical technic, rationale, complications) and the results of the recently published RCT paper.

Endovascular Treatment of a Fusiform Aneurysm Involving a Premammillary Artery Originating from the Internal Carotid Artery: A Case Report

The premammillary artery (PMA) is a branch of the posterior communicating artery (PCoA). While the PMA is known to originate from the PCoA as demonstrated by most anatomical studies, it originates directly from the internal carotid artery in approximately 1% of patients. Cerebral aneurysms associated with the PMA have rarely been reported. We report an extremely rare case of a ruptured PMA aneurysm that was managed using endovascular treatment.

Chronic Brain-Dead Patients Who Exhibit Lazarus Sign / 대한신경손상학회지

Lazarus sign, a complex reflex movement of the upper limbs after brain death, is a rare occurrence. We report two patients who showed a Lazarus sign following a diagnosis of brain death. It has been accepted that cardiac arrest usually occurs within 1 week after brain death; however, the two patients described herein survived for over 100 days after brain death was diagnosed. This report is intended to examine the relationship between the Lazarus sign and long-term survival after brain death, as well as to share our rare experience.

Clinical, Radiologic, and Pathologic Findings of Subdural Osteoma: A Case Report

We present a case of a subdural osteoma. A 29-year-old female presented with a 3-year history of headaches. Computed tomography scan revealed a homogeneous high-density lesion isolated from the inner table of the frontal bone (a lucent dural line) in the right frontal convexity. Magnetic resonance imaging revealed an extra-axial lesion with a broad base without dural tail sign and punctate enhancement pattern characteristic of abundant adipose tissue. Upon surgical excision, we found a hard bony mass clearly demarcated from the dura. The mass displayed characteristics of an osteoma upon histological examination. The symptom was relieved after operation.

Clinical, Radiologic, and Pathologic Findings of Subdural Osteoma: A Case Report

We present a case of a subdural osteoma. A 29-year-old female presented with a 3-year history of headaches. Computed tomography scan revealed a homogeneous high-density lesion isolated from the inner table of the frontal bone (a lucent dural line) in the right frontal convexity. Magnetic resonance imaging revealed an extra-axial lesion with a broad base without dural tail sign and punctate enhancement pattern characteristic of abundant adipose tissue. Upon surgical excision, we found a hard bony mass clearly demarcated from the dura. The mass displayed characteristics of an osteoma upon histological examination. The symptom was relieved after operation.

Fusiform Superior Cerebellar Artery Aneurysm Treated with Endovascular Treatment

An aneurysm of the distal superior cerebellar artery (SCA) is a highly rare disease. Fusiform aneurysms of the distal SCA are particularly challenging to treat. Clipping, trapping with or without bypass using microsurgery or endovascular treatment (EVT) were used to treat this condition. We describe the case of fusiform distal SCA aneurysms treated successfully with endovascular coiling with a 3-month follow-up. A 39 year-old male was presented with subarachnoid hemorrhage (SAH) and a 15 mm fusiform aneurysm of the ambient segment of the left distal SCA. EVT for parent artery occlusion and packing of the aneurysm was done. Left sixth nerve palsy appeared after 1 day of EVT. The symptom completely recovered within 1 week of the post-procedural period. No neurological deficit was seen during the clinical 3-month follow-up. EVT of fusiform distal SCA aneurysms with coils is a safe and feasible option to manage this rare condition. However, the treatment options must be carefully selected depending on the neurologic condition, development of collateral circulation, and configuration of the dissection.

Therapeutic Hypothermia in Traumatic Brain injury; Review of History, Pathophysiology and Current Studies / 대한중환자의학회지

The fact that therapeutic hypothermia (TH) has lowered intracranial pressure and protected brain in severe traumatic brain injury (TBI) is well known throughout past sources and experimental data. In this paper, the result of TH in TBI needs to be confirmed. The result of North American Brain Injury Study; Hypothermia (NAVIS-H) 1 and 2, Eurotherm3235, Japan trauma society study was reviewed throughout randomized controlled study which performed recently. The prognosis was not confirmed throughout TH in NAVIS-H1; however, there was statistical significance among the group of 45 years or less and below 35 degree in celcius which checked when he or she visited initially. Hence, NAVIS-H2 study was preceded. In patient who had surgically removed hematoma, the effects of TH were proved compared to diffuse brain damage in NAVIS-H2 study. This was found in the result of Japan neurotrauma data bank. Eurotherm study has been doing, which leads to collect many data later on. The TBI of TH makes them better prognosis in patients who had surgically removed hematoma and lowered initial body temperature. Later on, it is considered further study is necessary.

Therapeutic Hypothermia in Traumatic Brain injury; Review of History, Pathophysiology and Current Studies / 대한구급학회지

The fact that therapeutic hypothermia (TH) has lowered intracranial pressure and protected brain in severe traumatic brain injury (TBI) is well known throughout past sources and experimental data. In this paper, the result of TH in TBI needs to be confirmed. The result of North American Brain Injury Study; Hypothermia (NAVIS-H) 1 and 2, Eurotherm3235, Japan trauma society study was reviewed throughout randomized controlled study which performed recently. The prognosis was not confirmed throughout TH in NAVIS-H1; however, there was statistical significance among the group of 45 years or less and below 35 degree in celcius which checked when he or she visited initially. Hence, NAVIS-H2 study was preceded. In patient who had surgically removed hematoma, the effects of TH were proved compared to diffuse brain damage in NAVIS-H2 study. This was found in the result of Japan neurotrauma data bank. Eurotherm study has been doing, which leads to collect many data later on. The TBI of TH makes them better prognosis in patients who had surgically removed hematoma and lowered initial body temperature. Later on, it is considered further study is necessary.

Head Injury by Pneumatic Nail Gun: A Case Report / 대한신경손상학회지

A 56-year-old man had five nail gun-shots on his skull due to attempted suicide and was transferred to the emergency room. Because the nail head played a role as a brake, the launched nail made a hole in the skull but did not entirely pass through it. If major artery or sinuses are not involved, cautious retrieval after a small scalp incision can be performed and prophylactic antibiotics be administered for treatment.

Superficial Siderosis in Central Nervous System: A Case Report and Literature Review / 대한신경손상학회지

Superficial siderosis (SS) in central nervous system is a rare, slowly progressive disease and usually misdiagnosed or diagnosed too late when the patient is chronically devastated. A 55-year-old man with deafness and gait disturbance for ten years was referred from otorhinologist for evaluation of brain. Magnetic resonance image (MRI) showed symmetric hypointense rim partially delineated the bilateral hemisphere on gradient-recalled-echo T2-weighted image, and it was diagnosed as hemosiderin deposition in subarachnoid and subpial meningeal layer. The correct diagnosis of cerebral superficial siderosis can be achieved by careful neurological examination and MRI because computed tomography findings and symptoms are ambiguous. Serial follow-up of imaging study and education for patient are necessary to prevent progression of SS.

Superficial Siderosis in Central Nervous System: A Case Report and Literature Review / 대한신경손상학회지

Superficial siderosis (SS) in central nervous system is a rare, slowly progressive disease and usually misdiagnosed or diagnosed too late when the patient is chronically devastated. A 55-year-old man with deafness and gait disturbance for ten years was referred from otorhinologist for evaluation of brain. Magnetic resonance image (MRI) showed symmetric hypointense rim partially delineated the bilateral hemisphere on gradient-recalled-echo T2-weighted image, and it was diagnosed as hemosiderin deposition in subarachnoid and subpial meningeal layer. The correct diagnosis of cerebral superficial siderosis can be achieved by careful neurological examination and MRI because computed tomography findings and symptoms are ambiguous. Serial follow-up of imaging study and education for patient are necessary to prevent progression of SS.

Slip Reduction Rate between Minimal Invasive and Conventional Unilateral Transforaminal Interbody Fusion in Patients with Low-Grade Isthmic Spondylolisthesis

OBJECTIVE: To compare the slip reduction rate and clinical outcomes between unilateral conventional transforaminal lumbar interbody fusion (conventional TLIF) and unilateral minimal invasive TLIF (minimal TLIF) with pedicle screw fixation for treatment of one level low-grade symptomatic isthmic spondylolisthesis. METHODS: Between February 2008 and April 2012, 25 patients with low-grade isthmic spondylolisthesis underwent conventional TLIF (12 patients) and minimal TLIF (13 patients) in single university hospital by a single surgeon. Lateral radiographs of lumbar spine were taken 12 months after surgery to analyze the degree of slip reduction and the clinical outcome. All measurements were performed by a single observer. RESULTS: The demographic data between conventional TLIF and minimal TLIF were not different. Slip percentage was reduced from 15.00% to 8.33% in conventional TLIF, and from 14.15% to 9.62% in minimal TLIF. In both groups, slip percentage was significantly improved postoperatively (p=0.002), but no significant intergroup differences of slip percentage in preoperative and postoperative were found. The reduction rate also not different between conventional TLIF (45.41+/-28.80%) and minimal TLIF (32.91+/-32.12%, p=0.318). CONCLUSION: Conventional TLIF and minimal TLIF with pedicle screw fixation showed good slip reduction in patients with one level low-grade symptomatic isthmic spondylolisthesis. The slip percentage and reduction rate were similar in the conventional TLIF and minimal TLIF.

Preliminary Efficacy of Combination Decompressive Surgery, Stabilization and Cyberknife Radiosurgery: A New Treatment Paradigm for Metastatic Spinal Tumors with Cord Invasion

OBJECTIVE: The goal of this retrospective study was to assess clinical and radiographic outcomes of posterior surgical decompression with stabilization followed by image-guided robot Cyberknife radiosurgery for encircling malignant tumors of the spine. METHODS: From August 2008 to December 2009, 14 consecutive patients with a malignant spinal metastatic lesion with cord compression were treated at the author's institute. Patients underwent on a decompressive surgery by the posterior approach, and latent unstable spines were stabilized with instrumentation. After recovery, radiosurgery was administered at doses ranging from 16 to 26 Gy (mean 20.1Gy) prescribed to the 75-85% isodose line that encompassed at least 95% of tumor volumes. Visual Analogue Scale, American spine injury association grades, and MRI with gadolinium enhancement were used to monitor pain, neurology, and radiological outcomes, respectively, after the radiosurgery. RESULTS: No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (mean 4.5 months). Axial pain improved in 10 out of the 14 patients. No hardware failure was encountered. At 3-6 months after the Cyberknife radiosurgery, local control and effective therapeutic rates were both 80%(8/10) and no lesion enhancement on vertebral bodies or pedicles was visualized by MRI. CONCLUSION: Posterior decompression with stabilization followed by radiosurgery of residual tumor in the anterolateral region is useful in cases where an anterior approach or a circumferential approach is not an option due to medical condition. Longer term follow-up is required to evaluate survival and late toxicities.

Prevalence and Insight of Scoliosis among Korean Male Adolescents by Chest Radiographs

OBJECTIVE: We applied chest radiographs to scoliosis screening for conscription. Prevalence, types of scoliosis, and insight of examinees with scoliosis were investigated. METHODS: In this study, chest radiographs of 2417 males, who had been given an examination for conscription at the Seoul Regional Military Manpower Administration from April 2009 to May 2009, were analyzed. The prevalence of scoliosis more than a 10 degrees Cobb angle was calculated. The insight of scoliosis was investigated in every examinee and thoracolumbar radiographs were checked in those examinees with more than a 20 degree Cobb angle. RESULTS: Among 1904 males, 477 (19.7%) exhibited scoliosis involving more than a 5 degrees Cobb angle were and 131 (5.4%) exhibitedmore than a 10 degree Cobb angle. In those 131 cases, 18 (13.7%) had a known history of problems with scoliosis. Among the group measuring less than a 10 degree Cobb angle, 1.7% of them misunderstood scoliosis. Insight of scoliosis increased according to the severity of spinal curvature; however, nearly half of the cases with a 20 degree or greater Cobb angle had no insight with respect to their scoliosis. CONCLUSION: In male adolescents, the prevalence of scoliosis with a greater than 10 degree Cobb angle was 5.4% and there was a low insight with respect to scoliosis.

Comparison of Bony Fusion Between the Hollow Cage Group and the Cage with Bone Substitutes Group in One-level Cervical Spinal Disorders

OBJECTIVE: The aim of this study was to assess the clinical outcomes and bone fusion rates after insertion of hollow cages or cages with bone substitutes for treatment of disc protrusion in the cervical spine. METHODS: We performed a retrospective review of 93 patients who had undergone cage-assisted anterior cervical spine fusion. Patients were treated with hollow cages (N=52) or with cages with bone substitutes (N=41). Initial and follow up radiologic data were analyzed using Vavruch bone fusion criteria. RESULTS: Clinical outcomes including preoperative and postoperative pain and functional scores were not significantly different between the two patient groups. The over-all fusion rates differed between the two groups: patients treated with hollow cages demonstrated an average fusion rate of 84.6%, while patients treated with cages with bone substitutes demonstrated an average fusion rate of 87.8%, but these differences were not significant 24 months after surgery. At 18 months after surgery, the fusion rates of patients treated with cages with bone substitutes were significantly different from those of patients treated with hollow cages. Among patients who received bone substitutes, patients who received DBM exhibited better fusion outcomes than patients treated with other bone materials after 18 months of follow-up. CONCLUSION: Patients who are surgically treated with anterior cervical spine fusion for disc protrusion using cages with bone substitutes may achieve earlier fusion than patients treated with hollow cages, although both groups show similar final fusion rates.

A Occluded Posterior Communicating Artery Mimicking a Cerebral Aneurysm: A Case Report / 대한뇌혈관외과학회지

A 47-year-old man was admitted to the emergency department due to a sudden onset of headache during exercise. Brain computed tomography (CT) and CT angiography showed a subarachnoid hemorrhage (SAH) with a small sac in the left posterior communicating (pcom) artery and total obstruction in the proximal portion of the right middle cerebral artery (MCA). Catheter angiography revealed a protruding lesion in the left p-com artery and a total obstruction in the right MCA. It was difficult to differentiate the aneurysm from the occlusion of the pcom artery. We planned to confirm whether or not the protruded lesion was an aneurysm. Intraoperatively, the aneurysmal opacification seen on the preoperative catheter angiography proved it to be the occluded p-com artery filled with thrombus. The possibility of a vascular stump should be considered when diagnosing a protruding vascular lesion at the p-com artery.