Multiple Cerebral Hemorrhages Caused by Paradoxical Reperfusion Injury After Cranioplasty / 대한신경손상학회지

Cranioplasty-related reperfusion injury has rarely been reported. Although there are several hypotheses, particularly regarding the mechanisms of the event, clear evidence is lacking. Here, we report the case of an 84-year-old man with traumatic intracranial hemorrhage and subdural hematoma who underwent decompressive craniectomy and hematoma evacuation in the right hemisphere. After 45 days, cranioplasty was performed using titanium. A preoperative perfusion study with 99m-Tc-HMPAO brain single-photon emission tomography revealed diffuse hypoperfusion in the left cerebral hemisphere with decreased vascular reserve. After cranioplasty, multiple cerebral hemorrhages were observed on immediate postoperative computed tomography. Cerebral hemorrhage eventually improved without surgery. Here, we report a case with findings revealed through perfusion studies before and after surgery.

Short and Long-term Outcomes of Subarachnoid Hemorrhage Treatment according to Hospital Volume in Korea: a Nationwide Multicenter Registry

Background@#Subarachnoid hemorrhage is a potentially devastating cerebrovascular attack with a high proportion of poor outcomes and mortality. Recent studies have reported decreased mortality with the improvement in devices and techniques for treating ruptured aneurysms and neurocritical care. This study investigated the relationship between hospital volume and shortand long-term mortality in patients treated with subarachnoid hemorrhage. @*Methods@#We selected subarachnoid hemorrhage patients treated with clipping and coiling from March–May 2013 to June–August 2014 using data from Acute Stroke Registry, and the selected subarachnoid hemorrhage (SAH) patients were tracked in connection with data of Health Insurance Review and Assessment Service to evaluate the short-term and long-term mortality. @*Results@#A total of 625 subarachnoid hemorrhage patients were admitted to high-volume hospitals (n = 355, 57%) and low-volume hospitals (n = 270, 43%) for six months. The mortality of SAH patients treated with clipping and coiling was 12.3%, 20.2%, 21.4%, and 24.3% at 14 days, three months, one year, and five years, respectively. The short-term and long-term mortality in high-volume hospitals was significantly lower than that in low-volume hospitals. On Cox regression analysis of death in patients with severe clinical status, lowvolume hospitals had significantly higher mortality than high-volume hospitals during shortterm follow-up. On Cox regression analysis in the mild clinical status group, there was no statistical difference between high-volume hospitals and low-volume hospitals. @*Conclusion@#In subarachnoid hemorrhage patients treated with clipping and coiling, lowvolume hospitals had higher short-term mortality than high-volume hospitals. These results from a nationwide database imply that acute SAH should be treated by a skilled neurosurgeon with adequate facilities in a high-volume hospital.

Short and Long-term Outcomes of Subarachnoid Hemorrhage Treatment according to Hospital Volume in Korea: a Nationwide Multicenter Registry

Background@#Subarachnoid hemorrhage is a potentially devastating cerebrovascular attack with a high proportion of poor outcomes and mortality. Recent studies have reported decreased mortality with the improvement in devices and techniques for treating ruptured aneurysms and neurocritical care. This study investigated the relationship between hospital volume and shortand long-term mortality in patients treated with subarachnoid hemorrhage. @*Methods@#We selected subarachnoid hemorrhage patients treated with clipping and coiling from March–May 2013 to June–August 2014 using data from Acute Stroke Registry, and the selected subarachnoid hemorrhage (SAH) patients were tracked in connection with data of Health Insurance Review and Assessment Service to evaluate the short-term and long-term mortality. @*Results@#A total of 625 subarachnoid hemorrhage patients were admitted to high-volume hospitals (n = 355, 57%) and low-volume hospitals (n = 270, 43%) for six months. The mortality of SAH patients treated with clipping and coiling was 12.3%, 20.2%, 21.4%, and 24.3% at 14 days, three months, one year, and five years, respectively. The short-term and long-term mortality in high-volume hospitals was significantly lower than that in low-volume hospitals. On Cox regression analysis of death in patients with severe clinical status, lowvolume hospitals had significantly higher mortality than high-volume hospitals during shortterm follow-up. On Cox regression analysis in the mild clinical status group, there was no statistical difference between high-volume hospitals and low-volume hospitals. @*Conclusion@#In subarachnoid hemorrhage patients treated with clipping and coiling, lowvolume hospitals had higher short-term mortality than high-volume hospitals. These results from a nationwide database imply that acute SAH should be treated by a skilled neurosurgeon with adequate facilities in a high-volume hospital.

Authors' Reply to Letter to the Editor: Influence of Gender on Occurrence of Chronic Subdural Hematoma; Is It an Effect of Cranial Asymmetry? (Korean J Neurotrauma 2014;10:82–85) / 대한신경손상학회지

No abstract available.

Efficacy of Balloon-Guiding Catheter for Mechanical Thrombectomy in Patients with Anterior Circulation Ischemic Stroke

OBJECTIVE: To evaluate the efficacy of balloon guiding catheter (BGC) during thrombectomy in anterior circulation ischemic stroke. METHODS: Sixty-two patients with acute anterior circulation ischemic stroke were treated with thrombectomy using a Solitaire stent from 2011 to 2016. Patients were divided into the BGC group (n=24, 39%) and the non-BGC group (n=38, 61%). The number of retrievals, procedure time, thrombolysis in cerebral infarction (TICI) grade, presence of distal emboli, and clinical outcomes at 3 months were evaluated. RESULTS: Successful recanalization was more frequent in BGC than in non-BGC (83% vs. 66%, p=0.13). Distal emboli occurred less in BGC than in non-BGC (23.1% vs. 57.1%, p=0.02). Good clinical outcome was more frequent in BGC than in non-BGC (50% vs. 16%, p=0.03). The multivariate analysis showed that use of BGC was the only independent predictor of good clinical outcome (odds ratio, 5.19: 95% confidence interval, 1.07–25.11). More patients in BGC were successfully recanalized in internal carotid artery (ICA) occlusion with small retrieval numbers (<3) than those in non-BGC (70% vs. 24%, p=0.005). In successfully recanalized ICA occlusion, distal emboli did not occur in BGC, whereas nine patients had distal emboli in non-BGC (0% vs. 75%, p=0.001) and good clinical outcome was superior in BGC than in non-BGC (55.6% vs. 8.3%, p=0.01). CONCLUSION: A BGC significantly reduces the number of retrievals and the occurrence of distal emboli, thereby resulting in better clinical outcomes in patients with anterior circulation ischemic stroke, particularly with ICA occlusion.

Clinical Features of Interhemispheric Subdural Hematomas / 대한신경손상학회지

OBJECTIVE: Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively. METHODS: From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes. RESULTS: The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment. CONCLUSION: IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.

Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty?

OBJECTIVE: Decompressive craniectomy is an effective therapy to relieve high intracranial pressure after acute brain damage. However, the optimal timing for cranioplasty after decompression is still controversial. Many authors reported that early cranioplasty may contribute to improve the cerebral blood flow and brain metabolism. However, despite all the advantages, there always remains a concern that early cranioplasty may increase the chance of infection. The purpose of this retrospective study is to investigate whether the early cranioplasty increase the infection rate. We also evaluated the risk factors of infection following cranioplasty. METHODS: We retrospectively examined the results of 131 patients who underwent cranioplasty in our institution between January 2008 and June 2015. We divided them into early (≤90 days) and late (>90 days after craniectomy) groups. We examined the risk factors of infection after cranioplasty. We analyzed the infection rate between two groups. RESULTS: There were more male patients (62%) than female (38%). The mean age was 49 years. Infection occurred in 17 patients (13%) after cranioplasty. The infection rate of early cranioplasty was lower than that of late cranioplasty (7% vs. 20%; p=0.02). Early cranioplasty, non-metal allograft materials, re-operation before cranioplasty and younger age were the significant factors in the infection rate after cranioplasty (p<0.05). Especially allograft was a significant risk factor of infection (odds ratio, 12.4; 95% confidence interval, 3.24–47.33; p<0.01). Younger age was also a significant risk factor of infection after cranioplasty by multivariable analysis (odds ratio, 0.96; 95% confidence interval, 0.96–0.99; p=0.02). CONCLUSION: Early cranioplasty did not increase the infection rate in this study. The use of non-metal allograft materials influenced a more important role in infection in cranioplasty. Actually, timing itself was not a significant risk factor in multivariate analysis. So the early cranioplasty may bring better outcomes in cognitive functions or wound without raising the infection rate.

The Effectiveness of Gelfoam Technique before Percutaneous Vertebroplasy: Is It Helpful for Prevention of Cement Leakage? A Prospective Randomized Control Study

OBJECTIVE: Preinjection gelfoam embolization during percutaneous vertebroplasty (PVP) has been thought alternative technique to prevent the leakage of bone cement. The goal of this study was to evaluate whether the gelfoam techniques are useful to reduce bone cement leakage. METHODS: Total 100 PVPs of osteoporotic spine compression fractures were performed by 1 spine surgeon who experienced more than 500 PVP cases under prospective control study. Operation was done in T-L junction (T10-L2) fractures with bi-transpedicular approach. Preinjection gelfoam PVP was done in the 50 levels. As control group, PVP without gelfoam was done in the 50 levels. We did not perform preoperative venography. We inserted normal saline-mixed gelfoam to the anterior third of vertebral body via PVP needle, and then 3mL of polymethylmetacrylate (PMMA) was injected. We prospectively evaluated the incidence and leakage pattern of PMMA by postoperative computed tomography. RESULTS: Between gelfoam and control groups, there were 11 leaks (22%) versus 12 leaks (26%). The mean operation time was 7.00 minutes versus 6.30 minutes. In gelfoam group, there were 6 spinal canal leaks, 4 paravertebral venous leaks, and 1 soft tissue leaks. In control group, there were 4 spinal canal leaks, 8 paravertebral venous leaks, and 1 disc space leak. In spite of cement leakage, there was no symptomatic case in both groups. Statistically, gelfoam technique was not related to decrease the incidence of leakage (p=0.64). CONCLUSION: Our prospective study showed that it did not significantly decrease cement leakage when vertebroplasty is performed by experienced spine surgeon.

Leading a Patient of Ankylosing Spondylitis to Death by Iatrogenic Spinal Fracture

Fractures in ankylosing spondylitis (AS) are often difficult to identify and treat. If combined with osteoporosis, the spine becomes weaker and vulnerable to minor trauma. An 83-year-old woman with a history of chronic AS and severe osteoporosis developed paraparesis and voiding difficulty for 4 days prior. She had been placed in the lateral decubitus position in a bedridden state in a convalescent hospital due to the progressive paraparesis. The laboratory findings showed CO₂ retention in the arterial blood gas analysis. After the patient was transferred to the computed tomography (CT) room, a CT was taken in the supine position. Approximately half an hour later, the resident in our neurosurgical department checked on her, and the neurological examination showed a complete paraplegic state. She was treated conservatively and finally expired 20 days later.

Severe Cerebral Vasospasm in Patients with Hyperthyroidism

Cerebral vasospasm associated with hyperthyroidism has not been reported to cause cerebral infarction. The case reported here is therefore the first of cerebral infarction co-existing with severe vasospasm and hyperthyroidism. A 30-year-old woman was transferred to our hospital in a stuporous state with right hemiparesis. At first, she complained of headache and dizziness. However, she had no neurological deficits or radiological abnormalities. She was diagnosed with hyperthyroidism 2 months ago, but she had discontinued the antithyroid medication herself three days ago. Magnetic resonance imaging and angiography showed cerebral infarction with severe vasospasm. Thus, chemical angioplasty using verapamil was performed two times, and antithyroid medication was administered. Follow-up angiography performed at 6 weeks demonstrated complete recovery of the vasospasm. At the 2-year clinical follow-up, she was alert with mild weakness and cortical blindness. Hyperthyroidism may influence cerebral vascular hemodynamics. Therefore, a sudden increase in the thyroid hormone levels in the clinical setting should be avoided to prevent cerebrovascular accidents. When neurological deterioration is noticed without primary cerebral parenchyma lesions, evaluation of thyroid function may be required before the symptoms occur.

Tailgut cyst accompanied with bony defect

Retro-rectal cystic hamartoma (tailgut cyst), is an uncommon congenital developmental lesion, generally located in the retro-rectal space. Its diagnosis and approach is challenging because the retropelvic space is not familiar. We report a 51-year-old woman who presented with paresthesia and pain in perianal area. The magnetic resonance image showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image of the retropelvic space and CT showed sacral bony defect. We chose the posterior approach for removal of the tailgut cyst. Histopathology exam of the retropelvic cyst revealed a multiloculated cyst containing abundant mucoid material lined by both squamous and glandular mucinous epithelium. The patient has recovered nicely with no recurrence. Tailgut cyst needs complete surgical excision for good prognosis. So, a preoperative high-resolution image and co-operation between neurosurgen and general surgeon would help to make safe and feasible diagnosis and surgical access.

Endovascular Treatment of Dural Arteriovenous Fistulas: Single Center Experience

OBJECTIVE: Treatment of intracranial dural arteriovenous fistulas (dAVFs) remains a challenge. However, after introduction of Onyx, transarterial approach is the preferred treatment option in many centers. We report our experience of dAVFs embolization with special emphasis on transarterial approach. METHODS: Seventeen embolization procedures were performed in 13 patients with dAVFs between Jan 2009 and Oct 2014. Clinical symptoms, location and type of fistulas, embolization methods, complications, radiological and clinical outcomes were evaluated using charts and PACS images. RESULTS: All 13 patients had symptomatic lesions. The locations of fistulas were transverse-sigmoid sinus in 6, middle fossa dura in 4, cavernous sinus in 2, and superior sagittal sinus in 1 patient. Cognard types were as follows : I in 4, IIa in 2, IIa+IIb in 5, and IV in 2. Embolization procedures were performed > or =2 times in 3 patients. Nine patients were treated with transarterial Onyx embolization alone. One of these required direct surgical puncture of middle meningeal artery. Complete obliteration of fistulas was achieved in 11/13 (85%) patients. There were no complications except for 1 case of Onyx migration in cavernous dAVF. Modified Rankin scale score at post-operative 3 months were 0 in 11, and 3 in 2 patients. CONCLUSION: Transarterial Onyx embolization can be a first line therapeutic option in patients with dAVFs. However, transvenous approach should be tried first in cavernous sinus dAVF because of the risk of intracranial migration of liquid embolic materials. Furthermore, combined surgical endovascular approach can be considered as a useful option in inaccessible route.

Ruptured Dermoid Cyst in the Conus Medullaris Detected by Susceptibility Weighted Imaging of the Brain

No abstract available.

Iatrogenic Carotid-Cavernous Fistula after Stent Assisted Coil Embolization of Posterior Communicating Artery Aneurysm

Stent assisted coiling (SAC) is a useful technique for the treatment of wide necked complex aneurysm. As the frequency of SAC increases, stent-related complications such as thromboembolism, aneurysm rupture, and vessel rupture have been reported. However, to the best of our knowledge, carotid-cavernous fistula (CCF) after SAC has never been reported. The authors experienced a case of direct CCF after a SAC procedure for treatment of a complex posterior communicating artery (PCoA) aneurysm regrowth, which was treated by clip ligation 12 years before. The patient was managed conservatively and angiograms performed three months after the procedure showed the complete obliteration of the left PcoA aneurysm and the spontaneous disappearance of CCF. Navigation of Solitaire stent lumen with microcatheter can cause unexpected arterial injury, especially when the proximal tip is placed in the curved portion. It seems to be desirable to place the proximal tip of Solitaire stent in the straight portion whenever possible to reduce the risk of inadvertent arterial injury which might be caused by future navigation of stent lumen.

Cervical Epidural Abscess: Rare Complication of Bacterial Endocarditis with Streptococcus Viridans: A Case Report

Although many patients with infective endocarditis (IE) complain of joint, muscle, and back pain, infections at these sights are rare. The incidence of spinal abscess in cervical spine complicating endocarditis is very rare. Although the surgical management is the mainstay of treatment, conservative treatment can get success in selected patients. We report a patient with cervical epidural abscess due to Streptococcus viridans endocarditis. Both epidural abscess and IE were managed conservatively with intravenous antibiotics for 8 weeks, with recovery. It is important to remind spinal epidural abscess can occur in those patients with bacterial endocarditis.

Transcranial Direct Middle Meningeal Artery Puncture for the Onyx Embolization of Dural Arteriovenous Fistula Involving the Superior Sagittal Sinus

A 66-year-old woman presented with intermittent paraparesis and generalized tonic-clonic seizure. Cerebral angiography demonstrated dural arteriovenous fistula (AVF) involving superior sagittal sinus (SSS), which was associated with SSS occlusion on the posterior one third. The dural AVF was fed by bilateral middle meningeal arteries (MMAs), superficial temporal arteries (STAs) and occipital arteries with marked retrograde cortical venous reflux. Transfemoral arterial Onyx embolization was performed through right MMA and STA, but it was not successful, which resulted in partial obliteration of dural AVF because of tortuous MMA preventing the microcatheter from reaching the fistula closely enough. Second procedure was performed through left MMA accessed by direct MMA puncture following small decortications of cranium overlying the MMA using diamond drill one week later. Microcatheter could be located far distally to the fistula through 5 F sheath placed into the MMA and complete obliteration of dural AVF was achieved using 3.9 cc of Onyx.

Thromboembolic Event Detected by Diffusion Weighted Magnetic Resonance Imaging After Coil Embolization of Cerebral Aneurysms

OBJECTIVE: The purpose of this study was to evaluate the occurrence rate of diffusion positive lesions (DPLs), and to assess the peri-procedural risk factors for the occurrence of DPLs in patients who underwent coil embolization of cerebral aneurysms. MATERIALS AND METHODS: A total of 304 saccular aneurysms were embolized during a seven-year period from Jan 2007 to Dec 2013. Of these, postoperative diffusion-weighted images were obtained in 186 procedures. There were 100 ruptured aneurysm and 86 unruptured aneurysms. The coiling procedures were as follows: simple coiling in 96, balloon assisted coiling (BAC) in 39, and stent assisted coiling (SAC) in 51 aneurysms. Clinical, angiographic and procedural factors were analyzed in relation to the occurrence of DPLs. RESULTS: Overall, DPLs were observed in 50.5%. In unruptured aneurysms, DPLs occurred in 23.5% of BAC, 41.9% of SAC and 57.7% of simple coiling (p = 0.08). Among ruptured aneurysms, DPLs occurred in 63.6% of BAC, 62.5% of SAC and 54.3% of simple coiling (p = 0.71). DPLs had a tendency to increase in ruptured aneurysms compared with unruptured aneurysms (57% vs. 43%, p = 0.077). Logistic regression analysis revealed that age > 55 years was the only independent risk factor for the occurrence of DPLs. CONCLUSION: DPLs occured more frequently in ruptured aneurysm and at an older age. Although most DPLs are asymptomatic, careful manipulation of cerebral or extracerebral arteries using various endovascular devices is important to reducing the occurrence of DPLs. BAC appeared to reduce occurrence of TE events in patient with unruptured aneurysm.

Endovascular Treatment for Ruptured Distal Anterior Inferior Cerebellar Artery Aneurysm

A 42-year-old woman presented with Hunt and Hess grade (HHG) III subarachnoid hemorrhage (SAH) caused by a ruptured left distal anterior inferior cerebellar artery (AICA) aneurysm. Computed tomography showed a thin SAH on the cerebellopontine angle cistern, and small vermian intracerebral hemorrhage and intraventricular hemorrhage in the fourth ventricle. Digital subtraction angiography revealed the aneurysm on the postmeatal segment of left distal AICA, a branching point of rostrolateral and caudomedial branch of the left distal AICA. Despite thin caliber, tortuous running course and far distal location, the AICA aneurysm was obliterated successfully with endovascular coils without compromising AICA flow. However, the patient developed left side sensorineural hearing loss postoperatively, in spite of definite patency of distal AICA on the final angiogram. She was discharged home without neurologic sequela except hearing loss and tinnitus. Endovascular treatment of distal AICA aneurysm, beyond the meatal loop, is feasible while preserving the AICA flow. However, because the cochlear hair cell is vulnerable to ischemia, unilateral hearing loss can occur, possibly caused by the temporary occlusion of AICA flow by microcatheter during endovascular treatment.

Influence of Gender on Occurrence of Chronic Subdural Hematoma; Is It an Effect of Cranial Asymmetry? / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma (CSDH) is a condition mostly present in older people. Men are more commonly affected than women. Several theories about male predominance could not enough to explain the reason for male predominance on CSDH. The purpose of this study is to find out whether there were any differences in the anatomy of cranium, which may contribute the pathogenesis or risk factors of CSDH. METHODS: The study population was consisted of 87 patients with CSDH and 100 patients with transient ischemic attack (TIA) from 2006 to 2013. We classified into four groups; group A (CSDH male 47), group B (CSDH female 40), group C (TIA male 50), and group D (TIA female 50). We measured the size of the cranium in the computed tomography scans, retrospectively. We define the difference of cranium (Dc), which is difference between the right and left radiuses. RESULTS: The Dc was significantly higher in patients with CSDH (group A and B)(p=0.03). The mean Dc was 3.49 mm in CSDH group (group A and B) and 2.14 mm in TIA group (group C and D). The mean Dc of CSDH group was significantly larger than that of TIA group (by t-test, p<0.01). CONCLUSION: Size and asymmetry of the cranium may be a risk factor of CSDH. Gender differences in the anatomy of cranium may contribute pathogenesis of CSDH.

The Diagnostic Value of Ultrasonography in Korean Carpal Tunnel Syndrome Patients / 대한신경손상학회지

OBJECTIVE: The purpose of this study was to assess the diagnostic utility of the wrist ultrasonography (USG) in patients with and without carpal tunnel syndrome (CTS). METHODS: Individuals with electrodiagnostically proven CTS patients and healthy control subjects were enrolled prospectively. USG was done 60 wrists of 48 patients with CTS and 36 wrists of 18 controls. The USG analysis included median nerve cross sectional area (CSA) at the level of carpal tunnel inlet. We also evaluated the relationship between median nerve CSA at the level of carpal tunnel inlet and severity grade of nerve conduction test in CTS patients. RESULTS: The median nerve CSA at the level of carpal tunnel inlet was significantly larger in CTS patients (13.6 mm2 versus 7.7 mm2, p<0.0001). And there was an association between median nerve CSA and severity grade of nerve conduction studies (p=0.036). Receiver operating characteristics (ROC) analysis yielded sensitivity of 86.7% and specificity of 88.9% using a cut-off value of 9 mm2. But the specificity was increased to 97.2%, although sensitivity was decreased to 78.3%, when using cut-off value at 10.1 mm2. CONCLUSION: Ultrasonographic measurement of the median nerve CSA at carpal tunnel inlet was useful in diagnosis of CTS. According to ROC analysis, USG is used as a complementary test for electrodiagnostic test.