Concurrent Surgery of Craniectomy and Splenectomy as Initial Treatment in Severe Traumatic Head Injury: A Case Report / 대한신경손상학회지

It is not a common case for neurosurgery department and the other departments to perform joint operation at the same time. Patients with severe head injury are a condition in which vital signs are unstable due to severe brain swelling and increased intracranial pressure, and emergency surgery is required. A 44-year-old man visited the trauma center with a motorcycle accident. The Glasgow Coma Scale score at the time of emergency department was 3 points, and the pupil was fixed at 6 mm on both sides. His medical history was unknown. His vital signs including blood pressure (BP), heart rate, respiratory rate and oxygen saturation were stable. Associated injuries included multiple fractures of whole body. Brain computed tomography revealed subarachnoid hemorrhage, intraventricular hemorrhage and severe cerebral edema. During the preparation of the craniectomy, abdominal ultrasonography performed because of decreased BP resulted in a large amount of hemoperitoneum. The bi-coronal craniectomy and splenectomy were performed simultaneously for about 4 hours. After fifty days of treatment, he was discharged with Glasgow Outcome Scale-extended 4 points and is undergoing rehabilitation. In severe polytrauma patients, active concurrent surgery is a good method to save their lives.

Continuous Renal Replacement Therapy for Acute Renal Failure in Patients with Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: The purpose of this study was to investigate the impact of continuous renal replacement therapy (CRRT) on survival and relevant factors in patients who underwent CRRT after traumatic brain injury (TBI). METHODS: We retrospectively reviewed the laboratory, clinical, and radiological data of 29 patients who underwent CRRT among 1,190 TBI patients treated at our institution between April 2011 and June 2015. There were 20 men and 9 women, and the mean age was 60.2 years. The mean initial Glasgow Coma Scale score was 9.2, and the mean injury severity score was 24. Kaplan-Meier method and Cox regression were used for analysis of survival and relevant factors. RESULTS: The actuarial median survival time of the 29 patients was 163 days (range, 3-317). Among the above 29 patients, 22 died with a median survival time of 8 days (range, 3-55). The causes of death were TBI-related in 8, sepsis due to pneumonia or acute respiratory distress syndrome (ARDS) in 4, and multi-organ failure in 10. Among the various factors, urine quantity of more than 500 mL for 24-hours before receiving CRRT was a significant and favorable factor for survival in the multivariate analysis (p=0.026). CONCLUSION: According to our results, we suggest that early intervention with CRRT may be beneficial in the treatment of TBI patients with impending acute renal failure (ARF). To define the therapeutic advantages of early CRRT in the TBI patients with ARF, a well-designed and controlled study with more cases is required.

Outcomes of Ultra-Early Decompressive Craniectomy after Severe Traumatic Brain Injury-Treatment Outcomes after Severe TBI / 대한신경손상학회지

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial, but there is no debate that decompression should be performed before irreversible neurological deficit occurs. The aim of our study was to assess the value of ultra-early decompressive craniectomy in patients with severe TBI. METHODS: Total of 127 patients who underwent decompressive craniectomy from January 2007 to December 2013 was included in this study. Among them, 60 patients had underwent ultra-early (within 4 hours from injury) emergent operation for relief of increased intracranial pressure. Initial Glasgow coma scale, brain computed tomography (CT) scan features by Marshall CT classification, and time interval between injury and craniectomy were evaluated retrospectively. Clinical outcome was evaluated, using the modified Rankin score. RESULTS: The outcomes of ultra-early decompressive craniectomy group were not better than those in the comparison group (p=0.809). The overall mortality rate was 68.5% (87 patients). Six of all patients (4.7%) showed good outcomes, and 34 patients (26.8%) remained in a severely disabled or vegetative state. Forty of sixty patients (66.7%) had died, and two patients (3.3%) showed good outcomes at last follow-up. CONCLUSION: Ultra-early decompressive craniectomy for intracranial hypertension did not improve patient outcome when compared with "early or late" decompressive craniectomy for managing severe TBI.

Primary Spinal Cord Melanoma in Thoracic Spine with Leptomeningeal Dissemination and Presenting Hydrocephalus

Primary spinal cord melanoma is a rare central nervous system malignant tumor. Usually it resembles an intradural extramedullary (IDEM) nerve sheath tumor or melanoma. We experienced a patient with upper thoracic primary IDEM spinal cord melanoma who was diagnosed to be with hydrocephalus and without intracranial lesions. Initial symptoms of the patient were related to the hydrocephalus and the primary spinal cord melanoma was diagnosed eight months later. At the first operation, complete resection was impossible and the patient refused additional radiotherapy or chemotherapy. At 22 months after surgery, the patient revisited our institution with recurrent both leg weakness. Leptomeningeal dissemination was present in the whole spinal cord and only partial resection of tumor was performed. The symptoms slightly improved after surgery. Primary spinal cord melanoma is extremely rare but complete resection and additional radiotherapy or chemotherapy can prolong the disease free interval. Hydrocephalus or signs of increased intracranial pressure may be the diagnostic clue of spinal cord malignancy and progression.

Radiologic Changes of Anterior Cervical Discectomy and Fusion Using Allograft and Plate Augmentation: Comparison of Using Fixed and Variable Type Screw

OBJECTIVE: To evaluate radiologic result of anterior cervical discectomy and fusion with allobone graft and plate augmentation, and the change of radiologic outcome between screw type and insertion angle. METHODS: Retrospective review of clinical and radiological data of 29 patients. Segmental angle, height and screw angles were measured and followed. The fusion rate was assessed by plain radiography and CT scans. We divided the patients into two groups according to screw type and angles. Group A: fixed screw, Group B: variable screw. Interscrew angle was measured between most upper and lower screws with Cobb's methods. RESULTS: Overall fusion rate was 86.2% on plain radiography. Fusion was also assessed by CT scan and Bridwell's grading system. There was no difference in fusion and subsidence rates between two groups. Subsidence was found in 5 patients (17.2%). Segmental lordotic angle was increased from preoperative status and maximized at the immediate postoperative period and then reduced at 1 year follow up. Segmental height showed similar increase and decrease values. CONCLUSION: ACDF with allograft and plate showed favorable fusion rates, and the screw type and angle did not affect results of surgery.

Posterior C2-C3 Fixation for Unstable Hangman's Fracture

OBJECTIVE: This is a retrospective review of 13 unstable Hangman's fractures who underwent posterior C2-3 fixation to describe clinical outcomes with a literature review. METHODS: Thirteen patients for unstable Hangman's fracture were enrolled between July 2007 and June 2010 were included in this study. The medical records of all patients were reviewed. Concurrently, clinical outcomes were evaluated using Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores during preoperative and postoperative follow up period. Plain radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months. CT was done at postoperative 12 months in all patients for evaluation of bone fusion. The mean period of clinical follow-up was 17 months. RESULTS: Mean age were 43 years old. Bone fusion was recognized in all cases at the final follow-up. The average preoperative VAS score for neck pain was 8.3+/-1.1, while the final follow-up VAS score was 2.07+/-0.8 (p<0.001). The average immediate postoperative NDI was 84% points and final NDI was 22% points (p<0.001). There were one case of infection and 1 case of screw loosening. CONCLUSION: In the treatment of the patients with unstable Hangman's fracture, posterior C2-C3 fusions is effective and curative treatments to achieve cervical spinal stability.

Navigation-assisted Aspiration and Thrombolysis of Deep Intracerebral Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: Frame-based stereotatic catheter placement and subsequent thrombolysis is one treatment option for the management of a deep intracerebral hemorrhage. Recently, frameless stereotactic surgery with a navigation system has been introduced to reduce the hematoma volume. This study was designed to evaluate the effectiveness of frameless stereotactic ICH catheterization using a navigation system. METHODS: From January 2006 to November 2006, we identified 27 patients who were diagnosed with deep ICH and underwent navigationassisted frameless stereotactic catheter insertion with/without thrombolysis by urokinase irrigation. RESULTS: The mean length between the center of the hematoma and the tip of the catheter was 6.8 mm (range between 0 and 15 mm). The catheter tip and target matched in 8 patients (29.6%). In cases of an inappropriately located catheter tip (70.4%), most of the hematomas were thalamic in location due to the long trajectory (9 of 10 thalamic locations). The preoperative hematoma volume showed a statistically significant correlation with the final hematoma volume. There was no mortality reported. Multiple regression analysis showed a statistically significant correlation between the initial Glasgow coma scale score and the outcome. CONCLUSIONS: Navigation-assisted frameless stereotactic ICH catheterization has limited accuracy but is effective in reducing the ICH volume reduction.

Long Term Magnetic Resonance Angiography Follow-up in Moyamoya Disease / 대한뇌혈관외과학회지

OBJECTIVE: Revascularization is an effective treatment for the ischemic symptom of moyamoya disease. Indirect revascularization is also effective. Magnetic resonance angiography (MRA) has the ability for collateral formation that is equivalent to conventional angiography. This study analyzed the results of indirect revascularization by MRA. METHODS: A total of 25 patients underwent bilateral EDAS for the management of moyamoya disease. All patients underwent MRA after surgery more than 24 months later. The collateral formation was graded as Good, Fair, and Poor. The clinical outcome was assessed as Excellent, Good, Fair, and Poor. RESULTS: Good collateral formation was 32 sides of the EDAS, and fair was 18. An excellent clinical outcome was obtained in 15 patients, Good in 8, Fair in 1, and Poor in 1. There was a significant correlation between the preoperative symptom, gender, and the clinical outcome. CONCLUSION: In the management of ischemic moyamoya disease, indirect revascularization has been the golden standard with remarkably low morbidity and mortality. Moreover, and MRA can replace conventional angiography in the follow-up of moyamoya patients.