Intramuscular Neural Distribution of Adductor Pollicis Muscle Spasticity in Cadaver Model Regarding Botulinum Neurotoxin Treatment

Purpose@#The adductor pollicis muscle is frequently targeted for botulinum neurotoxin injective treatment for spasticity. However, there are no injective guidelines for delivering injection to the muscle. @*Materials and Methods@#A method known as the modified Sihler’s method was used to stain the adductor pollicis muscle in 16 specimens to reveal intramuscular neural distribution of the muscle. @*Results@#The most intramuscular neural distribution was located on 1/5 to 3/5 of the muscle regarding midline of 3rd metacarpal bone (0) to the base of the 1st proximal phalanx (5/5). The nerve entry point was mostly located on 0 to 1/5 of the muscle. @*Conclusion@#The result suggests that botulinum neurotoxin should be delivered at the middle of second metacarpal bone via deep injection.

Intramuscular Neural Distribution of the Gastrocnemius for Botulinum Neurotoxin Injection:Application to Cosmetic Calf Shaping

Purpose@#Anatomical landmarks can provide vital information on the distribution of nerves in the gastrocnemius muscle. We aimed to provide an anatomical perspective on appropriate locations for botulinum neurotoxin (BoNT) injections in the medial and lateral parts of the gastrocnemius for calf shaping. @*Materials and Methods@#A modified Sihler’s method was applied to both the medial and lateral parts of the gastrocnemius muscles (16 specimens). Intramuscular neural distributions were revealed by dissecting along a transverse line crossing the fibular head and superior margin of the calcaneal tuberosity. @*Results@#The intramuscular neural distribution for the medial and lateral parts of the gastrocnemius had the greatest arborized patterns in the 7/10–8/10 section of the medial head and 7.5/10–8.5/10 section of the lateral part of the gastrocnemius. @*Conclusion@#We propose that BoNT injections should be directed to the 7/10–8/10 section of the medial head and the 7.5/10– 8.5/10 section of the lateral part of the gastrocnemius. Following our guidelines, clinicians can ensure satisfactory results with the use of minimal doses to limit adverse effects, such as gait disturbance, antibody production, and bruising, due to multiple injections. The results can also be altered and applied to electromyography.

Intramuscular neural distribution of the teres minor muscle using Sihler’s stain: application to botulinum neurotoxin injection / 대한해부학회지

The aim of this study was to elucidate the intramuscular arborization of the teres minor muslce for effective botulinum neurotoxin injection. Twelve specimens from 6 adult Korean cadavers (3 males and 3 females, age ranging from 66 to 78 years) were used in the study. The reference line between the 2/3 point of the axillary border of the scapula (0/5), where the muscle originates ant the insertion point of the greater tubercle of the humerus (5/5). The most intramuscular neural distribution was located on 1/5–3/5 of the muscle. The tendinous portion was observed in the 3/5–5/5. The result suggests the botulinum neurotoxin should be delivered in the 1/5–3/5 area of the teres minor muscle.

Unusual insertion of the levator scapulae muscle: a case report / 대한해부학회지

The current case report describes an uncommon insertion of the levator scapulae (LS), which broadly attaches to multiple structures, including the serratus posterior superior, ligamentum nuchae, and the 6th and 7th spinous processes of the cervical vertebrae. The most superior portion of this aponeurosis merged with the ligamentum nuchae at the C7 level. The middle and inferior portions of the head were inserted (or fused) into the tendon of the rhomboid minor as well as the fibers of the serratus posterior superior muscle. Consequently, recognizing this anatomical variation, characterized by an additional slip of the LS attaching to the 7th vertebra and other muscular structures, is crucial not only for anatomists but also for surgeons performing procedures on the posterior neck related to cervical or shoulder pain and cervical dystonia.

Novel anatomical proposal for botulinum neurotoxin injection targeting depressor anguli oris for treating drooping mouth corner / 대한해부학회지

The depressor anguli oris (DAO) muscle is a thin, superficial muscle located below the corner of the mouth. It is the target for botulinum neurotoxin (BoNT) injection therapy, aimed at treating drooping mouth corners. Hyperactivity of the DAO muscle can lead to a sad, tired, or angry appearance in some patients. However, it is difficult to inject BoNT into the DAO muscle because its medial border overlaps with the depressor labii inferioris and its lateral border is adjacent to the risorius, zygomaticus major, and platysma muscles. Moreover, a lack of knowledge of the anatomy of the DAO muscle and the properties of BoNT can lead to side effects, such as asymmetrical smiles. Anatomical-based injection sites were provided for the DAO muscle, and the proper injection technique was reviewed. We proposed optimal injection sites based on the external anatomical landmarks of the face. The aim of these guidelines is to standardize the procedure and maximize the effects of BoNT injections while minimizing adverse events, all by reducing the dose unit and injection points.

Complications of Cranioplasty Following Decompressive Craniectomy: Risk Factors of Complications and Comparison Between Autogenous and Artificial Bones / 대한신경손상학회지

Objectives@#Craniectomy is widely performed to lower the intracranial pressure in various conditions, such as traumatic brain injury, stroke, or brain swelling. Several complications can occur after craniectomy and cranioplasty, which significantly affect the prognosis of the patients after surgery. We studied the complications of craniectomy and cranioplasty and the factors affecting prognosis after the operation. @*Methods@#Patients who underwent cranioplasty after craniectomy at Daejeon St. Mary’s Hospital from 2015 to 2021 were included. We retrospectively reviewed their medical records and images. All patients were classified according to their sex, age, clinical grade, and diagnosis. Complications after craniectomy and cranioplasty were investigated for 1 year after surgery. The complications included postoperative hemorrhage, infection, hydrocephalus, and bone resorption. @*Results@#This study included 104 patients. Complications after decompressive craniectomy were significantly frequent in patients with hypertension history (p=0.03). In contrast, complications of cranioplasty were significantly frequent in patients with history of diabetes mellitus, hepatic failure, or trauma (p=0.03, p<0.01, and p=0.01, respectively). Artificial bones were used more frequently than autologous bones in patients with trauma (p=0.03); however, there was no difference in the incidence of complications between them (p=0.64). @*Conclusion@#Hypertension is a significant risk factor for decompressive craniectomy complications, especially rebleeding. Diabetes, hepatic failure, and trauma are significant risk factors for cranioplasty complications. There was no statistical difference in the incidence of complications between the use of autologous and artificial bones.

Prognostic Factors of Patients with Stercoral Perforation of the Colon / 대한소화기학회지

Background/Aims@#The incidence of stercoral perforation of the colon (SPC) is expected to rise, given the increased life expectancy and the aging population. On the other hand, the prognostic factors of mortality after surgery for SPC remain unclear. This study examined the prognostic factors of patients with SPC after surgery. @*Methods@#The medical records of 145 patients who underwent surgery for colonic perforation between April 2010 and May 2019 were reviewed retrospectively. In 145 patients, 22 patients who underwent SPC surgery were categorized into the following two groups according to in-hospital survival after surgery: alive (group A, n=15) and dead (group B, n=7). @*Results@#In all enrolled patients, the mean age was 75.7±9.0 years, with a female predominance (female patients, n=19, 86.4%). Sixteen patients (72.7%) had chronic constipation with medications, and five patients (22.7%) were bedridden. The rate of preoperative bedridden status was significantly higher in group B than group A (6.7% vs. 57.1%; p=0.021). Univariate analysis revealed immobility, a sequential organ failure assessment (SOFA) score, and lactate levels of more than 2.0 mmol/L to be factors associated with increased mortality rates in the postoperative period. Multivariate analysis revealed abnormal lactate levels to be the only factor related to mortality (hazard ratio 16.50, 95% CI 1.48-183.07, p=0.022). @*Conclusions@#Preoperative abnormal serum lactate levels may be a risk factor for mortality after surgery in patients with stercoral perforation. Further research will be needed to identify the postoperative prognostic SPC factors.

The Role of digital subtraction angiography in the ventricular spot sign on the computed tomography angiography

OBJECTIVE: The spot sign on computed tomography angiography is little known about the relationship between the spot sign and the results of cerebral angiography We retrospectively analyzed the spot sign, digital subtraction angiography results, and other factors.MATERIAL AND METHODS: From December 2009 to May 2014, DSA was performed in 52 ICH patients with non-specific location or abnormalities on CTA findings. 26 of those patients, whose initial CTA showed the spot sign, were analyzed. Two groups, one with the spot sign in the ventricle (Group A) and others with the spot sign in another location (Group B) were statistically compared.RESULTS: The mean age of the study subjects was 46.9 years (range, 15 to 80 years) and the percentage of males was 53.8%. Thirteen of 26 patients had ICH without intraventricular hemorrhage, and 6 patients had co-existing IVH. In 17 cases, the DSA results were negative. Seven patients were diagnosed with pseudoaneurysms, and two cases showed developmental venous anomalies. Group A consisted of the 8 patients (30.8%) who showed the spot sign in a ventricle. The number of pseudoaneurysms was statistically significantly higher in Group A than in Group B (71.4% versus 28.6%; OR, 13.3; 95% CI, 1.7-103.8 P = 0.014). All three patients who underwent endovascular treatment were members of Group A (P = 0.022), whereas most (92.3%) of those in Group B underwent surgical evacuation. (P = 0.030).CONCLUSION: When CTA shows the spot sign in a ventricle, it is a clue that an existing underlying vascular lesion requires endovascular treatment.

Successful Mechanical Thrombectomy Using Solumbra Technique In a 35-year-old Man With Achondroplasia: a case report

BACKGROUND: Achondroplasia is one of the most common types of dwarfism and is inherited as an autosomal dominant disease. The patients with achondroplasia suffer from various complications such as craniofacial, central nervous system, spinal, respiratory and cardiac anomalies.CASE DESCRIPTION: We report a case of a 35-year-old man with achondroplasia who visited the emergency room with right hemiplegia and aphasia within 6 hours after onset. An Initial CT angiography showed the total occlusion of a left internal cerebral artery due to the thrombus. We treated the patient with endovascular thrombectomy using “Solumbra technique” with balloon guiding catheter. The procedure was successful and result was completely recanalized with Thrombolysis in Cerebral Infarction (TICI) scale 3 and the weakness also improved from grade II to grade IV.CONCLUSION: Acute ischemic stroke patients with achondroplasia could be treated with mechanical thrombectomy.

Does Retaining Ligament Exist in the Neck? / 체질인류학회지

The goal of this study was to determine the characteristics of the horizontal cervical wrinkle and to investigate histological feature, especially with respect to elastin and collagen fiber. Histologic sample were harvested from two fresh adult cadavers where the cervical wrinkle is in the neck. The tissue sections were stained with hematoxylin and eosin (HE) or Masson's Trichrome. In sections of neck skin, keratinization was observed in the epidermis, and many collagen fibers were observed in the dermis layer as in other skin. Specifically, a lot of short and curly elastic fiber were observed between the collagen fibers in the dermis. These elastic fibers were not stained with eosin and observed in gray. This long ligament-like structures were observed in the dermis. The ligament-like structures were stained with dark red by trichrome. These results indicate that these ligament-like structures are neither typical ligament nor typical smooth muscles. The results obtained from present study showed a ligamentous structure originating from the fascial layer (platysma muscle or investing layer). The results may help to understand the reasons about the formation of horizontal cervical wrinkle.

An Idiopathic Hypertrophic Tentorial Pachymeningitis Presented as an Alternating Recurrent Painful Ophthalmoplegia

Alternating recurrent painful ophthalmoplegia is caused by various neurological conditions including Tolosa-Hunt syndrome, sellar mass, and parasagittal meningioma. We experienced a rare case of recurrent painful ophthalmoplegia occurring on the contralateral side as a manifestation of idiopathic hypertrophic tentorial pachymeningitis. We propose that idiopathic hypertrophic pachymeningitis should be considered in the differential diagnosis of alternating recurrent painful ophthalmoplegia.

Two Siblings with Adolescent/Adult Onset Niemann-Pick Disease Type C in Korea

Niemann-Pick disease, type C (NP-C), is caused by NPC1 or NPC2 gene mutations. Progressive neurological, psychiatric, and visceral symptoms are characteristic. Here, we present cases of a brother (Case 1) and sister (Case 2) in their mid-20s with gait disturbance and psychosis. For the Case 1, neurological examination revealed dystonia, ataxia, vertical supranuclear-gaze palsy (VSGP), and global cognitive impairment. Case 2 showed milder, but similar symptoms, with cortical atrophy. Abdominal computed tomography showed hepatosplenomegaly in both cases. NPC1 gene sequencing revealed compound heterozygote for exon 9 (c.1552C>T [R518W]) and exon 18 (c.2780C>T [A927V]). Filipin-staining tests were also positive. When a young patient with ataxia or dystonia shows VSGP, NP-C should be considered.

Development of an Ex Vivo Model for the Study of Cerebrovascular Function Utilizing Isolated Mouse Olfactory Artery

OBJECTIVE: Cerebral vessels, such as intracerebral perforating arterioles isolated from rat brain, have been widely used as an ex vivo model to study the cerebrovascular function associated with cerebrovascular disorders and the therapeutic effects of various pharmacological agents. These perforating arterioles, however, have demonstrated differences in the vascular architecture and reactivity compared with a larger leptomeningeal artery which has been commonly implicated in cerebrovascular disease. In this study, therefore, we developed the method for studying cerebrovascular function utilizing the olfactory artery isolated from the mouse brain. METHODS: The olfactory artery (OA) was isolated from the C57/BL6 wild-type mouse brain. After removing connective tissues, one side of the isolated vessel segment (approximately -500 microm in length) was cannulated and the opposite end of the vessel was completely sealed while being viewed with an inverted microscope. After verifying the absence of pressure leakage, we examined the vascular reactivity to various vasoactive agents under the fixed intravascular pressure (60 mm Hg). RESULTS: We found that the isolated mouse OAs were able to constrict in response to vasoconstrictors, including KCl, phenylephrine, endothelin-1, and prostaglandin PGH2. Moreover, this isolated vessel demonstrated vasodilation in a dose-dependent manner when vasodilatory agents, acetylcholine and bradykinin, were applied. CONCLUSION: Our findings suggest that the isolated olfactory artery would provide as a useful ex vivo model to study the molecular and cellular mechanisms of vascular function underlying cerebrovascular disorders and the direct effects of such disease-modifying pathways on cerebrovascular function utilizing pharmacological agents and genetically modified mouse models.

The Risk Factors for Hydrocephalus and Subdural Hygroma after Decompressive Craniectomy in Head Injured Patients

OBJECTIVE: The present study aims to investigate 1) the risk factors for hydrocephalus and subdural hygroma (SDG) occurring after decompressive craniectomy (DC), and 2) the association between the type of SDG and hydrocephalus. METHODS: We retrospectively reviewed the clinical and radiological features of 92 patients who underwent DC procedures after severe head injuries. The risk factors for developing post-traumatic hydrocephalus (PTH) and SDG were analyzed. Types of SDGs were classified according to location and their relationship with hydrocephalus was investigated. RESULTS: Ultimately, 26.09% (24/92) of these patients developed PTH. In the univariate analyses, hydrocephalus was statically associated with large bone flap diameter, large craniectomy area, bilateral craniectomy, intraventricular hemorrhage, contralateral or interhemisheric SDGs, and delayed cranioplasty. However, in the multivariate analysis, only large craniectomy area (adjusted OR=4.66; p=0.0239) and contralateral SDG (adjusted OR=6.62; p=0.0105) were significant independent risk factors for developing hydrocephalus after DC. The incidence of overall SDGs after DC was 55.43% (51/92). Subgroup analysis results were separated by SDG types. Statistically significant associations between hydrocephalus were found in multivariate analysis in the contralateral (adjusted OR=5.58; p=0.0074) and interhemispheric (adjusted OR=17.63; p=0.0113) types. CONCLUSION: For patients who are subjected to DC following severe head trauma, hydrocephalus is associated with a large craniectomy area and contralateral SDG. For SDGs after DC that occur on the interhemispherical or controlateral side of the craniectomy, careful follow-up monitoring for the potential progression into hydrocephalus is needed.

Tentorial Dural Arteriovenous Fistula Treated Using Transarterial Onyx Embolization

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which has high risk of intracranial hemorrhage. We present two cases of tentorial DAVF which were successfully treated with single trial of transarterial embolization using Onyx. We briefly reviewed the types of the tentorial DAVF and strategies of treatment.

Assessment of the Optimal Site of Femoral Artery Puncture and Angiographic Anatomical Study of the Common Femoral Artery

OBJECTIVE: The purpose of this study was to evaluate demographic and clinical factors affecting the common femoral artery diameter and length, and anatomical relationship between the femoral head and the common femoral artery during angiography. METHODS: We retrospectively reviewed 109 femoral angiograms. We collected the clinical data of the patients and estimated the common femoral artery diameter and length. We divided the areas in the angiogram from cephalic to caudal direction (zone 0 to 5). The lowest levels of the inferior epigastric artery loop and points of the common femoral artery bifurcation were checked. RESULTS: The luminal diameter of the common femoral artery was 6.19+/-1.20 mm. Height, weight, body surface area, as well as common femoral artery diameter were significantly greater in men than in women (p<0.005). The length of the common femoral artery was 27.59+/-8.87 mm. Height, weight and body surface area showed strong positive relationships with common femoral artery diameter. All of the inferior epigastric artery loops were located above the center of the femoral head. The point of common femoral artery bifurcation was above the center of the femoral head in 4.59% of femoral angiograms. CONCLUSIONS: Males and patients with a high body surface area have a larger common femoral artery diameter. The cumulative probability of optimal targeting between the lowest margin of the inferior epigastric artery loop and the common femoral artery bifurcation is the highest in zone 3 puncture.

A Case of Insulinoma Presenting as Repetitive Abnormal Behavior with Amnesia

Insulinomas are very rare tumors. Diagnosis of insulinoma is often delayed or misdiagnosed because of its various symptoms. We report a patient with hypoglycemic encephalopathy who had repetitive behavior changes, diagnosed as a pancreatic insulinoma. A 52 years old man was referred to a memory and dementia clinic for evaluation of his repetitive abnormal behavior changes. He has threatened his wife with violent acts and showed aggressive behaviors, but he couldn't remember when he was recovered to normal state. During the hospitalization, we noticed that his repetitive abnormal behaviors were correlated to severe hypoglycemia. After we corrected glucose level, his symptoms were disappeared. We performed an abdomen-pelvis CT scan, revealing pancreatic head tumor. After he took surgical treatment, His symptoms were fully recovered. Our case demonstrates that various neurological symptoms, such as abnormal behavior, rarely occur due to recurrent hypoglycemia in patient with insulinoma.

Renal Subcapsular Hematoma after Percutaneous Transfemoral Angiography

Vascular complications after percutaneous angiography include hematoma, pseudoaneurysm, arteriovenous fistula, thromboembolism, arterial laceration and infection. Hematomas may occur in the groin, thigh, retroperitoneal, intraperitoneal, or abdominal wall. A 54-year-old female underwent percutaneous transfemoral angiography for the evaluation of cerebral aneurysm. Renal subcapsular hematoma developed 3 hours after the procedure. Renal subcapsular hematoma after percutaneous angiography is very rare. We investigated the possible causes of renal subcapsular hematoma. To avoid this rare complication, we need to perform guide-wire passage carefully from the beginning of the procedure under full visual monitoring.

Identification of MicroRNAs with Altered Expression Profiles in a Rat Model of Experimentally Induced Early Cerebral Aneurysms / 대한신경손상학회지

OBJECTIVE: Structural adaptation of the vascular wall may occur due to various factors, such as shear stress, pressure, injury or inflammation. The role of microRNAs (miRNAs) in the development of vascular remodeling has been investigated in several studies. Recently, the authors reported altered expression profiles of miRNAs in late stage of experimentally induced giant cerebral aneurysm (CA) in rat models. But, early biologic roles of miRNAs in CA formation have not been explained yet. We employed microarrays analysis to identify miRNA expression profiles in early stage of CA in rat model and to compare with those in late stage of giant CA. METHODS: Seventy, 7-week-old male Sprague-Dawley rats underwent a CA induction procedure. The control animals (n=11) were fed a regular diet, and the experimental animals (n=59) were fed a regular diet with 1% normal saline for two months. Then, the rats were killed, their cerebral arteries were dissected, and the 13 regions of early aneurysmal change on the right olfactory artery-anterior cerebral artery bifurcation were cut for miRNA microarrays analysis. Six miRNAs (miRNA-1, miRNA-448, miRNA-352, miRNA-551b, miRNA-431, and miRNA-485) were randomly chosen for validation using real-time quantitative polymerase chain reaction. RESULTS: Among a set of differentially expressed miRNAs, 15 miRNAs were up-regulated more than 200% and five miRNAs were down-regulated less than 50% in the early CA tissues. CONCLUSIONS: This study provides an overall view of miRNA expression profiles in experimentally induced early CAs and strongly supports the idea that some miRNAs, such as miR-31 and miR-27a, play an important role in pathological processes in early CA formation. Further investigations to detect their exact roles of these miRNAs in the pathogenesis of CA are needed.

Rat Peripheral Nerve Regeneration Using Nerve Guidance Channel by Porcine Small Intestinal Submucosa

OBJECTIVE: In order to develop a novel nerve guidance channel using porcine small intestinal submucosa (SIS) for nerve regeneration, we investigated the possibility of SIS, a tissue consisting of acellular collagen material without cellular immunogenicity, and containing many kinds of growth factors, as a natural material with a new bioactive functionality. METHODS: Left sciatic nerves were cut 5 mm in length, in 14 Sprague-Dawley rats. Grafts between the cut nerve ends were performed with a silicone tube (Silicon group, n=7) and rolled porcine SIS (SIS group, n=7). All rats underwent a motor function test and an electromyography (EMG) study on 4 and 10 weeks after grafting. After last EMG studies, the grafts, including proximal and distal nerve segments, were retrieved for histological analysis. RESULTS: Foot ulcers, due to hypesthesia, were fewer in SIS group than in Silicon group. The run time tests for motor function study were 2.67 seconds in Silicon group and 5.92 seconds in SIS group. Rats in SIS group showed a better EMG response for distal motor latency and amplitude than in Silicon group. Histologically, all grafts contained some axons and myelination. However, the number of axons and the degree of myelination were significantly higher in SIS group than Silicon group. CONCLUSION: These results show that the porcine SIS was an excellent option as a natural biomaterial for peripheral nerve regeneration since this material contains many kinds of nerve growth factors. Furthermore, it could be used as a biocompatible barrier covering neural tissue.