Requirements for Cerebrovascular Surgery in Comprehensive Stroke Centers in South Korea

OBJECTIVE: Cerebrovascular disease (CVD) was the third most common cause of death in South Korea in 2014. Evidence from abroad suggests that comprehensive stroke centers play an important role in improving the mortality rate of stroke. However, surgical treatment for CVD is currently slightly neglected by national policy, and there is still regional imbalance in this regard. For this reason, we conducted a survey on the necessity of, and the requirements for, establishing regional comprehensive cerebrovascular surgery centers (CCVSCs). METHODS: This investigation was performed using the questionnaire survey method. The questionnaire was consisted with two sections. The first concerned the respondent’s opinion regarding the current status of demand and the regional imbalance of cerebrovascular surgery in South Korea. The second section asked about the requirements for establishing regional CCVSCs. We sent the questionnaire to 100 board members of the Korean Society of Cerebrovascular Surgeons. RESULTS: Most experts agreed that cerebrovascular surgery patients were concentrated in large hospitals in the capital area, and 83.6% of respondents agreed that it was necessary to alleviate the regional imbalance of cerebrovascular surgery. With regards to personnel, over 90% of respondents answered that at least two neuro-vascular surgeons and two neuro-interventionists are necessary to establish a CCVSC. Regarding facilities, almost all respondents stated that each CCVSC would require a neuro-intensive care unit and hybrid operating room. The survey asked the respondents about 13 specific neurovascular surgical procedures and whether they were necessary for a regional CCVSC. In the questions about the necessity of cerebrovascular surgical equipment, all seven pieces of equipment were considered essential by all respondents. A further five pieces of equipment were considered necessary on site: computed tomographic angiography, magnetic resonance angiography, conventional angiography, surgical microscope, and surgical navigation. Our results may provide a basis for future policy regarding treatment of cerebrovascular disease, including surgery. CONCLUSION: Raising the comprehensiveness of treatment at a regional level would lower the national disease burden. Policies should be drafted regarding comprehensive treatment including surgery for cerebrovascular disease, and related support plans should be implemented.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Requirements for Cerebrovascular Surgery in Comprehensive Stroke Centers in South Korea

OBJECTIVE: Cerebrovascular disease (CVD) was the third most common cause of death in South Korea in 2014. Evidence from abroad suggests that comprehensive stroke centers play an important role in improving the mortality rate of stroke. However, surgical treatment for CVD is currently slightly neglected by national policy, and there is still regional imbalance in this regard. For this reason, we conducted a survey on the necessity of, and the requirements for, establishing regional comprehensive cerebrovascular surgery centers (CCVSCs).METHODS: This investigation was performed using the questionnaire survey method. The questionnaire was consisted with two sections. The first concerned the respondent’s opinion regarding the current status of demand and the regional imbalance of cerebrovascular surgery in South Korea. The second section asked about the requirements for establishing regional CCVSCs. We sent the questionnaire to 100 board members of the Korean Society of Cerebrovascular Surgeons.RESULTS: Most experts agreed that cerebrovascular surgery patients were concentrated in large hospitals in the capital area, and 83.6% of respondents agreed that it was necessary to alleviate the regional imbalance of cerebrovascular surgery. With regards to personnel, over 90% of respondents answered that at least two neuro-vascular surgeons and two neuro-interventionists are necessary to establish a CCVSC. Regarding facilities, almost all respondents stated that each CCVSC would require a neuro-intensive care unit and hybrid operating room. The survey asked the respondents about 13 specific neurovascular surgical procedures and whether they were necessary for a regional CCVSC. In the questions about the necessity of cerebrovascular surgical equipment, all seven pieces of equipment were considered essential by all respondents. A further five pieces of equipment were considered necessary on site: computed tomographic angiography, magnetic resonance angiography, conventional angiography, surgical microscope, and surgical navigation. Our results may provide a basis for future policy regarding treatment of cerebrovascular disease, including surgery.CONCLUSION: Raising the comprehensiveness of treatment at a regional level would lower the national disease burden. Policies should be drafted regarding comprehensive treatment including surgery for cerebrovascular disease, and related support plans should be implemented.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

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.

Focused Update of 2009 Korean Clinical Practice Guidelines for the Surgical or Interventional treatment of Extracranial Carotid Artery Stenosis in Secondary Prevention of Stroke / 대한뇌졸중학회지

Since the publication of the first edition of Korean clinical practice guidelines of secondary stroke prevention, encouraging data from recent large clinical trials and meta-analysis have led us to consider many therapeutic options in the treatment of symptomatic extracranial carotid stenosis. Accordingly, the writing group of Clinical Research Center for Stroke decided to provide recent views on the therapeutic revascularization of extracranial carotid stenosis, and timely evidence-based recommendations. In this updated version, new evidences about carotid angioplasty/stenting, treatment timing, and perioperative preparation are given, and qualifying conditions for operator are elucidated. This refinement was based on current consensus between Korean Society of Intravascular Neurosurgery, Korean Society of Interventional Neuroradiology, and Korean Society of Cerebrovascular Surgery and approved by Korean Stroke Society, Korean Neurological Association, and Korean Society of Geriatric Neurology. These recommendations are subject to future correction based on new evidences from ongoing and future studies.

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.

Thoracic Intraspinal Synovial Cyst Causing Myelopathy: A Case Report

Intraspinal synovial cysts are commonly found in the lumbar spine and occur less commonly in the cervical spine. Occurrence of a cyst in the thoracic spine causing myelopathy is extremely rare. We report here the radiological findings of a case of a thoracic intraspinal synovial cyst that caused myelopathy at the T2-3 level with an accompanying review of the clinical literature.

Spontaneous Recanalization from Traumatic Internal Carotid Artery Occlusion

The incidence of spontaneous recanalization after traumatic internal carotid artery occlusion is very rare. We have experienced a case of spontaneous recanalization after a traumatic internal carotid artery occlusion. A 5-year-old boy developed contra-lateral hemiparesis and dysphasia after a blunt injury on the head and neck. He had a complete left internal carotid artery occlusion which was diagnosed through angiography. We treated the patient with an antiplatelet agent and rehabilitation. Six months later, he regained motor power of right extremities, language ability, and revisualization of internal carotid artery on the follow-up magnetic angiography. We confirmed a recanalization of injured internal carotid artery on the conventional cerebral angiography which was performed one year later. We suggest conservative treatment with serial angiographic studies as a possible option of traumatic internal carotid artery occlusion even though there is hemodynamic instability.

Technical Modification and Comparison of Results with Hirabayashi's Open-door Laminoplasty

OBJECTIVE: Hirabayashi's open-door laminoplasty is a good procedure to use to treat patients with myelopathy of the cervical spine; however, the authors have experienced problems in maintaining an open-window in cervical spines after the surgery. The authors developed a modified method of the expanded open-door laminoplasty and compared the radiological and clinical results with those of the classical method. METHODS: In the modified method, wiring fixation with lateral mass screws on the contra lateral-side instead of fixing the paraspinal muscle or facet joint, as in the classical methods, was used in the open window of the cervical spine. Fifteen patients with cervical myelopathy were treated using the classical method and 12 patients were treated using the modified method. Preoperative and postoperative clinical conditions were assessed according to the Japanese Orthopedic Association (JOA) score. The radiological results were compared with the preoperative and postoperative computed tomography (CT) findings. RESULTS: In both methods, the clinical results revealed a significant improvement in neurological function (p<0.001). Image analysis revealed that the cervical canals were continuously expanded in patients treated using the modified methods. However, authors have observed restenosis during the follow-up periods in 4 patients treated using the original method. Progression to deformity and spinal instability were not observed in any of the patients in the radiological results. CONCLUSION: Although analysis with a larger population and a longer follow-up period needs to be undertaken, our modified open-door laminoplasty has shown an advantage in better maintaining an open window in comparison with the Hirabayashi's open-door laminoplasty.

Technical Modification and Comparison of Results with Hirabayashi's Open-door Laminoplasty

OBJECTIVE: Hirabayashi's open-door laminoplasty is a good procedure to use to treat patients with myelopathy of the cervical spine; however, the authors have experienced problems in maintaining an open-window in cervical spines after the surgery. The authors developed a modified method of the expanded open-door laminoplasty and compared the radiological and clinical results with those of the classical method. METHODS: In the modified method, wiring fixation with lateral mass screws on the contra lateral-side instead of fixing the paraspinal muscle or facet joint, as in the classical methods, was used in the open window of the cervical spine. Fifteen patients with cervical myelopathy were treated using the classical method and 12 patients were treated using the modified method. Preoperative and postoperative clinical conditions were assessed according to the Japanese Orthopedic Association (JOA) score. The radiological results were compared with the preoperative and postoperative computed tomography (CT) findings. RESULTS: In both methods, the clinical results revealed a significant improvement in neurological function (p<0.001). Image analysis revealed that the cervical canals were continuously expanded in patients treated using the modified methods. However, authors have observed restenosis during the follow-up periods in 4 patients treated using the original method. Progression to deformity and spinal instability were not observed in any of the patients in the radiological results. CONCLUSION: Although analysis with a larger population and a longer follow-up period needs to be undertaken, our modified open-door laminoplasty has shown an advantage in better maintaining an open window in comparison with the Hirabayashi's open-door laminoplasty.

Posterior Epidural Migration of Lumbar Ruptured Disc: Report of Two Cases

Disc fragment migration occurs in 35%-72% of lumbar disc herniations. Most of the herniated disc fragments migrate in the rostal, caudal and lateral directions. Posterior epidural disc fragment migration is a rare finding and posterior migration causing Cauda Equina syndrome is exceptionally rare. We report here on two cases of L4-5 disc fragment posterior epidural migration that caused Cauda Equina syndrome, and this was diagnosed by performing radiological examination, and we also include a review of the related literature.

Chronic Lumbar Epidural Hematoma in a Patient Suffering With Spondylolytic Spondylolisthesis at the L4-5 Level: A Case Report

Nontraumatic spinal epidural hematoma (SEH) is a rare condition and the exact cause of the hemorrhage in SEH has never been established. However, there have been a few recent reports on some types of the epidural hematoma with a detectable origin of hemorrhage. We encountered a case of chronic SEH in a patient who had spondylolytic spondylolisthesis, which is also a rare condition to be associated with SEH. We report here on the radiologic findings of a case of chronic epidural hematoma in a patient who had spondylolytic spondylolisthesis at the L4-5 level, and we include a review of the related literatures.

Lumbar Internal Disc Derangement in Patients with Chronic Low Back Pain: Diagnostic Value of the MR Imaging Findings as Compared with Provoked Discography as the Standard

PURPOSE: The aim of this study was to evaluate the diagnostic value of the MR Imaging findings with provoked discography used as the standard for painful lumbar disc derangement. MATERIALS AND METHODS: Two hundred patients (412 discs), (age range: 21-77 years), with chronic low back pain underwent MRI and provoked discography. We evaluated the MRI T2-WI findings such as disc degeneration, high-Intensity zones and endplate abnormalities. Subsequently, provocative discography was independently performed with using MR imaging, and a painful disc was defined when moderate to severe and concordant pain was provoked. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the MRI findings with using provoked discography as the standard. RESULTS: 400 discs showed abnormal findings such as disc degeneration, HIZ and endplate abnormalities on the T2-WI images. 12 discs showed normal findings. HIZ or endplate abnormalities were always combined with disc degeneration. The prevalence of each findings were disc degeneration (400 discs: 97.1%), HIZ (111 discs: 26.9%), type I endplate abnormalities (34 discs: 8.3%), type II endplate abnormalities (75 discs: 18.2%), the combined findings of HIZ and type I endplate abnormalities (2 discs: 0.5%) and the combined findings of HIZ and type II endplate abnormalities (7 discs: 1.7%). The disc degeneration showed high sensitivity (99.5%) and low specificity (5.0%), so only the NPV (91.7%) was significant, and not the PPV (47.8%). Each findings of HIZ (sensitivity, 36.5%; specificity, 81.4%; PPV, 63.18%; NPV, 59.5%), type I endplate abnormalities (11.0%, 94.1%, 61.8% and 54.8%, respectively), type II endplate abnormalities (19.8%, 83.2%, 50.7% and 54.3%, respectively), the combined findings of HIZ and type I endplate abnormalities (0.5%, 99.6%, 50.0% and 53.4%, respectively) and the combined findings of HIZ and type II endplate abnormalities (26.0%, 99.1%, 71.4% and 53.8%, respectively) show high specificity, but low sensitivity, so the PPV and NPV were also not significant. CONCLUSION: For diagnosing painful lumbar disc derangement, the MR imaging findings seem to be inadequate as predictive factors when provoked discography was used as the standard.

Symptomatic Spinal Epidural Gas-Containing Cystic Lesions: Reports of 2 Cases

Symptomatic spinal epidural gas-containing cystic lesion is a rare clinical disease entity. We recently experienced two cases of symptomatic epidural gas-containing cysts that were the main cause of the patients?radiculopathy and the cysts were removed surgically. These lesions were actually gas containing ruptured disc herniations from the vacuum discs at the same level. We report herein on the radiological findings along with conducting a review of the related literature.

Capillary Hemangioma of the Cauda Equina: Case Report

Capillary hemangioma of the cauda equina is extremely rare. We present the MR imaging and histologic findings of a case of this disease. The tumor was well demarcated, 0.9x1.3 cm in diameter and 1.2 cm in length. On the MR images, the tumor showed isointensity relative to the spinal cord on the T1-weighted images, hyperintensity on the T2-weighted images, and strong homogeneous enhancement on the contrast-enhanced T1-weighted images. Capillary hemangioma should be included in the differential diagnosis of a spinal tumor of the cauda equina.

En Plaque Meningioma in Thoracic Spine: Case Report

Spinal en plaque meningioma is rarely found in the spinal canal, although lateral sphenoid wing meningioma displays a propensity for growth en plaque. We encountered a case of completely circumferential spinal en plaque meningioma, which is an even rarer condition. Herein, we report the CT & MRI findings along with a review of the related literature.

The Results and Complications of the C1-C2 Transarticular Screw Fixation Methods

OBJECTIVE: To evaluate the accuracy and safety of C1-C2 transarticular screw insertion, we retrospectively review surgical records and postoperative radiological findings. METHODS: From January 2001 to October 2003, the C1-C2 transarticular screw fixation and posterior wiring with iliac bone grafts was performed in 16 pateints. 6 patients had rheumatoid arthritis which caused cervical instability, 3 patients had os odontoideum, 3 patients had type 2 odontoid process fracture, 3 patients had traumatic transverse ligament injury and 1 patients who had been managed with C1-C2 wire fixation had psoriatic arthritis. RESULTS: Osseous fusion was documented in 15 patients(93.8%). Only one patient was recorded screw loosening because of postoperative infection. One patient had only one screw placed because of abnormal anatomical structure, one patients was breakage of a Kirschner wire, and one screw was medial location to lateral mass of C1, but clinical results was excellent and radiological instability was not noted. CONCLUSION: The author's experience demonstrates that C1-C2 transarticular screw fixation with wired bone graft is a safe procedure with higher fusion rate but precaution is needed to avoid the neural damage, vertebral artery injury, and hardware failure.