Resorption of Autogenous Bone Graft in Cranioplasty: Resorption and Reintegration Failure / 대한신경손상학회지

OBJECTIVE: Re-implantation of autologous skull bone has been known to be difficult because of its propensity for resorption. Moreover, the structural characteristics of the area of the defect cannot tolerate physiologic loading, which is an important factor for graft healing. This paper describes our experiences and results with cranioplasty following decompressive craniectomy using autologous bone flaps. METHODS: In an institutional review, the authors identified 18 patients (11 male and 7 female) in whom autologous cranioplasty was performed after decompressive craniectomy from January 2008 to December 2011. We examined the age, reasons for craniectomy, size of the skull defect, presence of bony resorption, and postoperative complications. RESULTS: Postoperative bone resorption occurred in eight cases (44.4%). Among them, two experienced symptomatic breakdown of the autologous bone graft that required a second operation to reconstruct the skull contour using porous polyethylene implant (Medpor(R)). The incidence of bone resorption was more common in the pediatric group and in those with large cranial defects (>120 cm2). No significant correlation was found with sex, reasons for craniectomy, and cryopreservation period. CONCLUSION: The use of autologous bone flap for reconstruction of a skull defect after decompressive craniectomy is a quick and cost-effective method. But, the resorption rate was greater in children and in patients with large skull defects. As a result, we suggest compressive force of the tightened scalp, young age, large skull defect, the gap between bone flap and bone edge and heat sterilization of autologous bone as risk factors for bone resorption.

An Evaluation of the Government's Current Guideline on the Hospitalization of Minor Head Trauma Patients / 대한신경손상학회지

OBJECTIVE: In June 28, 2012, a 'Hospitalization guideline for car accident patients' was announced to mediate the clash of opinions about the hospitalization of minor head trauma patients among doctors, patients and insurance companies. The guideline was issued to describe the patients' symptoms and emotions in detail after the injury. In this paper, evaluation for the guideline and suggestions for modifications was done. METHODS: Thirty-two doctors, 96 patients and 60 employees were each given surveys about the hospitalization guidelines, related personnels' attitude and evaluation of patients' emotional problems. The frequency, ratio and chi-square test were performed. RESULTS: Sixty-eight point eight percent of doctors, 79.8% patients and 91.6% insurance company employees agreed to the need for a guideline. Among the 68.8% doctors that supported the need for a guideline, 18.8% knew that the guideline actually existed. Sixty-nine point two percent of doctors said that they would apply the guideline once they were introduced to it. Among the announced guideline provisions, 'Glasgow coma score less than 15' and 'socially not suitable for discharge' required reevaluation since 40.6% all surveyors consented that these two criteria were not suitable. The consensus supporting the need for emotional evaluation came out to be 78.1%, 58.5%, 50.9% in doctors, patients and insurance employees respectively. CONCLUSION: Although a guideline for hospitalization of minor head injury patients is necessary, some part of it seems to be reevaluated and improved, especially for clauses related to the patient's emotional problems. These changes and revisions to the guideline require further speculation and research.

Content Analysis of Communication between Nurses during Preceptorship / 정신간호학회지

PURPOSE: This study was done to explore communication between nurses during preceptorship. METHODS: A qualitative study, using content analysis was conducted. Semistructured interviews were held with 10 nurses working in urban hospitals. RESULTS: A total of 226 significant statements were selected from the data and classified into 4 categories and 23 subcategories. Communication experiences of new nurses' own performance were responses to reproach - acceptance and apology, and unresponsiveness due to feeling small and uncomfortable; responses to questions - misanswer; responses to directions - unconditional acceptance. Communication experiences of new nurses' performance by nurse preceptors were kindness, stigmatization, talking behind one's back, criticism and reproach, impolite words, and emotional expression. Communication experiences of nurse preceptors's own performance were directives, sympathy, reproach, unkindness, authoritative strictness, and nonverbal expression: being cold, and lessening of tension. Communication experiences of nurse preceptors' performance by new nurses were response to criticism - recognition and apology for mistakes, evasion of responsibility, and excuses; responses to explanations-active acceptance, and difficulty with communication due to lack of comprehension. CONCLUSION: These results provide deep understanding of nurses' communication during preceptorship and should help in developing comprehensive education programs for preceptor nurses and new nurses.

Accuracy of the Free Hand Placement of an External Ventricular Drain (EVD) / 대한뇌혈관외과학회지

OBJECTIVE: Free hand insertion of an external ventricular drain (EVD) is one of the most common emergency neurosurgical procedures, usually performed on critically ill patients. Complications such as infection and hemorrhage that accompany the placement of an EVD have been studied thoroughly, but few reports have focused on the accuracy of EVD positioning. As a result, the authors of this paper retrospectively studied the accuracy of tip positioning in the placement of an EVD. METHODS: One hundred and thirteen emergency EVDs were performed through Kocher's point during the past 3 years. All patients underwent the following procedures: at least one routine post-EVD computed tomographic (CT) scan that was retrospectively reviewed for accuracy of the EVD tip position, calculation of the Evan's index, and measurement of the intracranial length of the EVD. We divided the EVD tip position into 6 groups as follows:1) ipsilateral frontal horn of the lateral ventricle, 2) contralateral frontal horn of the lateral ventricle, 3) third ventricle, 4) body of the ipsilateral or contralateral lateral ventricle, 5) basal cisterns, or 6) brain parenchyma. Among the 6 groups, only the ipsilateral frontal horn group was considered to be the correct position for the EVD tip. RESULTS: The mean age of the patients was 55.6+/-15.3 years (age range, 12~90 years), and the most common indication for the EVD was supratentorial intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) (57.5%). Forty-five out of a total of 113 EVDs were placed by inexperienced neurosurgical trainees, and the remaining 68 were placed by experienced practitioners. Among 113 post-EVD CT scans, 48 EVD tips (42.5%) were in the ipsilateral frontal horn of the lateral ventricle (considered to be the correct position); 22 (19.5%) were in the third ventricle, 16 (14.1%) in the body of the ipsilateral or contralateral lateral ventricle, 14 (12.4%) in the contralateral frontal horn of the lateral ventricle, 11 (9.7%) within the brain parenchyma and 2 (1.8%) in the basal cistern. The mean estimated EVD length was 57+/-8.4mm. The mean length of EVDs that were positioned in the ipsilateral frontal horn was 55+/-4.3 mm, whereas the mean lengths of EVDs in the parenchyma and basal cistern were 64+/-14mm and 72+/-3.5mm, respectively. In addition, there was no statistically significant relationship between the surgeon's experience and the accuracy of the position of the EVD tip (p > 0.05). CONCLUSION: Emergency free hand placement of an EVD might be an inaccurate procedure. Further multi-institutional prospective studies are required to assess the accuracy and complications of free hand insertion of EVDs in an emergency setting. Studies are also needed on the feasibility of routine use of intra-operative neuro-navigation of other guidance tools, such as ultrasonography.

Angiographic Follow-up Result of Cerebral Aneurysms Treated with Coils Covered with Polyglycolic-Polylactic Acid Copolymer

OBJECTIVE: We evaluate the effect of the copolymer-coated coils on immediate occlusion of the aneurysm, preventing rupture, and decreasing compaction or re-growth. METHODS: Thirty-five aneurysms treated between September 2003 and December 2004 using Matrix detachable coil were reviewed. Study population consisted of 12 men and 23 women ranging in age from 34 to 75 years(mean, 55.1 years). Twentytwo aneurysms were ruptured and 23 aneurysms were located in the anterior circulation. Follow-up angiography was obtained in 16 patients after 6 months from the procedure. RESULTS: Initial complete occlusion was achieved in 17 aneurysms(48.6%), and the others remained as a residual neck in 8 aneurysms(22.8%) and residual sac in 10 aneurysms(28.6%). Among these incompletely occluded aneurysms, 7 aneurysms were performed follow-up angiography. And 6 of them converted into complete occlusion. In the other hands, among 17 aneurysms achieved complete occlusion initially, 9 aneurysms were performed follow-up angiography. Recurrence due to coil compaction occurred in one aneurysm and the others maintained complete occlusion. There was one mortality case due to thromboembolic complication. CONCLUSION: In spite of difficulty in achieving complete occlusion with Matrix coil system, there is no rupture or re-rupture during follow-up period. Follow-up angiography shows many conversions of residual sac into complete occlusion. Embolization using Matrix coil system is safe and effective, but the effects of PGLA copolymer need further investigation.

Complication of the Augmented Vertebral Body after Percutaneous Vertebroplasty in Patients with Osteoporotic Compression Fracture: Hammer Effect: Preliminary Report

OBJECTIVE: Percutaneous vertebroplasty has been known to be one of the most effective procedure for the treatment of osteoporotic vertebral compression fractures, providing immediate relief of the pain and early mobilization. The goal of this study is to find out the influence of the augmented vertebral body on the adjacent bodies after percutaneous vertebroplasty. METHODS: One hundred and thirty-two patients with osteoporotic vertebral compression fractures were treated with percutaneous vertebroplasty from 1998 to 2000. 10 patients were suffered from severe back pain without any obvious traumatic event during the follow-up period and underwent magnetic resonance(MR) images. RESULTS: Despite of absence of the traumatic events, MR imagies showed compression fracture of the adjacent vertebral body with low signal on T1WI. Among 10 patients, percutaneous vertebroplasty was repeated in 8 patients, One case was treated with conservative treatment and 1 case with refusal of vertbroplasty. All patients result in good relief of the pain except refusal case. CONCLUSION: Our preliminary results suggest that the spontaneous vertebral compression fracture might be developed due to'Hammer effect'without any obvious traumatic event after percutaneous vertebroplasty in osteoporosis.

Expression of mRNAs for Neurotrophic Factors in Human Neural Stem Cells Derived from Fetal Telencephalon

OBJECTIVE: Cellular diversity in the mammalian central nervous system is originated from precursor cells present in the neural ectoderm. The multipotent neural stem cells(NSCs) rapidly proliferate to give rise to transiently dividing progenitors that eventually differentiate into several cell types of neural cells. The authors investigate whether NSCs could differentiate neurons and glia and express neurotrophic factor. METHODS: To establish human neural cell lines, we isolated neural stem cells from human fetal telencephalon. Secondly, to investigate the expression of neurotrophic factor, basic fibroblast growth factor(bFGF), brain-derived neurotrophic factor(BDNF) and glial derived neurotrophic factor(GDNF) in rat and human cell, mRNA expressions of bFGF, BDNF and GDNF were detected by the reverse transcripted polymerase chain reaction(RT-PCR) analysis. RESULTS: In the NSCs cultures of embryonic rat striata and human fetal telencephalon, we demonstrated that bFGF induces the proliferation of stem cell, which give rise to spheres of undifferentiated cell that generate neurons and glia. Also, neurotrophic factor transcripts were identified using PCR in rat and human NSCs. CONCLUSION: These results demonstrate that human NSCs derived from human fetal telencephalon could differentiate neurons and glia and express neurotrophic factors. Therefore, NSCs may be an important key for the therapeutic application of neurotrophic factors.

Expression of mRNAs for BDNF and NT-3 in Reactive Astrocytes

OBJECTIVE: Astrocytes secrete various neurotrophic factors which act to support the survival and growth of neurons. Reactive astrocytes express an increased level of neurotrophic factors in response to central nervous system injury. We demonstrate that reactive astrocytes could express neurotrophic factors to promote neuronal rescue and generate functional recovery. METHODS: To investigate the correlation of neurotrophic factor, brain-derived neurotrophic factor(BDNF) and neurotrophin-3(NT-3) to glutamate-induced reactive gliosis, mRNA expression of BDNF and NT-3 were detected by the RT-PCR technique. RESULTS: Exposure of cultured astrocytes to L-glutamate(1, 100, 200 and 500 microM) and scraped astrocytes for 1 day resulted in significant cell damage and we observed mRNA expression of BDNF and NT-3. The maximal expression of BDNF was observed in the control, scraped and L-glutamate treated astrocytes(1 microM). The basal expression of BDNF mRNA in astrocytes treated with L-glutamate(100, 200 and 500 microM) decreased relative to that of control, scraped and L-glutamate treated astrocytes(1 microM). Reactive gliosis, treatment of control astrocytes with glutamate, showed similar pattern for NT-3 mRNA expression. In a word, the basal content of NT-3 mRNA in scrape and L-glutamate(1, 100, 200 and 500 microM) expressed similar to that of control astrocytes. CONCLUSION: This study indicates that the reactive astrocytes also expressed mRNA of BDNF and NT-3 as normal astrocytes.

Effects of Deletions in the Regulatory Domain on the Stability and Enzymatic Characteristics of Tyrosine Hydroxylase

BACKGROUND: Various vectors have been developed and tried for the delivery of tyrosine hydroxylase (TH) in order to supplement dopamine, which is severely deficient in Parkinson's disease, however, none of the protocols tried have yielded fruitful results that can be applied directly to humans. One of the problems revealed from previous trials was a short duration of expression of the delivered gene, that is, tyrosine hydroxylase. METHODS: To extend the stability and to improve the enzymatic characteristics of the protein, part of the regulatory domain was deleted via PCR technique. The cDNA for regulatory domain-deleted THs (dTH) were sub-cloned into a retroviral vector and the resulting recom-binant retrovirus was used to infect NIH-3T3. After selection, expression levels of TH were determined by Western blot analysis and the enzymatic characteristics were examined. RESULTS: The deletion increased steady state expression level of TH protein by 7-fold for d19TH (TH with amino acids #2-19 are deleted) and 3-fold for d31TH (TH with amino acids #2-31 are deleted. The elevated expression level of d19TH is likely due to the enhanced stability of the protein as determined by a treatment of cycloheximide. The activity of d19TH was also increased approximately by 3-fold but no increase of the L-dopa production was observed. However, the production of L-dopa was dramatically increased when GTP cyclohydrolase I (GTPCH I) was co-transfected suggesting that the activity of d19TH is dependent on the presence of cofactor. d19TH seem to be free of feedback inhibition at low concentration of dopamine (10 nM~1 nM) but more sensitive to the inhibition at high concentration of dopamine (10 mM). CONCLUSIONS: The deletion of 18 amino acids on the regulatory domain increases the stability of the protein, reduces the activity, and frees it from the feedback inhibi-tion by the end product.

Ventral Foramen Magnum Meningioma: Case Report

We report a case of a ventral foramen magnum meningioma in a 73-year-old woman presenting with swallowing difficulty, posterior neck pain, gaiting difficulty, progressive motor and sensory deficits in all extemities, and intrinsic muscle atrophy in both hands. Magnetic resonace imaging revealed a huge mass, 4x4x4.5cm in size, located in anterior foramen magnum. We removed the mass by partial condylectomy via far lateral transcondylar approach without neurological deficit and postoperative craniovertebral instability.

Intraabdominal Aortic Obstruction with Severe Low Back Pain and Acute Paraplegia: Case Report

Acute intraabdominal aortic obstruction ends in progressive fatal course or severe permanent disability unless it is diagnosed and treated promptly. However, the incidence of such disease is very rare, so there is very little chance for a neurosurgeon to encounter a patient with acute intraabdominal aortic obstruction. The authors present a case of 62-year-old man with severe low back pain and acute paraplegia caused by acute intraabdominal aortic obstruction.

Intradural Lumbar Disc Rupture

The intradural lumbar disc herniation which was first described by Dandy in 1942 is unusual. The pathogenesis is obscure and preoperative diagnosis is not easy. The patient usually have more severe neurologic deficits than those found in the much more common extradural disc herniations. We experienced two cases of the intradural lumbar disc herniation who had previous disc operations and the symptoms and neurologic signs were improved after removal of the intradural sequestration of disc fragments.

The Efficacy of Titanium Mesh Cage in Tuberculous Spondylitis Treated with Anterior Intervertebral Fusion

OBJECTIVE: The maintenance of the correction of kyphotic deformity is one of the difficult problem in tuberculous spondylitis after anterior debriment and fusion with tricortical bone graft. The goal of this study is to find out the efficacy of titanium mesh cage impacted with autogenous bone chip in tuberculous spondylitis treated with anterior intervertebral fusion. MATERIALS AND METHODS: Twelve patients were treated with anterior intervertebral fusion using titanium mesh cage for tuberculous spondylitis from January 1996 to June 1999. We analized the changes in the correction of kyphotic deformity, changes of ESR and CRP, fusion state and recurrence after anterior intervertebral fusion with titanium mesh cage. RESULTS: Clinical symptoms were improved in all twelve patients without any neurologic complications. The mean kyphotic angle corrected was 7.3 degrees immediately after operation, but the loss of correction of kyphotic angle was 2.2 degrees after 3 months and 2.6 degrees after 6 months. We found that the loss of correction of kyphotic deformity occurred mainly within the first 3 months after surgery. Only one patient, suffered from acute hepatic failure after first operation and had an insufficient anti-tuberculous medication therapy, showed recurrence of tuberculous spondylitis after 6 months. The patient underwent a second operation with posterior fixation procedure with good outcome. The changes of ESR and CRP were not specifically important factor to reveal recurrence of tuberculosis of the spine in our series. CONCLUSION: The surgical procedure of tuberculous spondylitis using titanium mesh cage with bone chip seems to be an effective procedure to minimize loss of the correction of kyphotic deformity without any aggravating inflammatory change and recurrence with titanium mesh cage, when sufficient debridement and anti-tuberculous chemotherapy are achieved.

Effects of Cofactor Tetrahydrobiopterin and Deletions on the Regulatory Domain of Tyrosine Hydroxylase on the Expression of Tyrosine Hydroxylase

BACKGROUND: For the treatment of Parkinson's disease, dopamine-producing cells or genes involved in producing dopamine or supporting neurons have been tested to replace conventional chemical therapies. Of these, tyrosine hydroxylase (TH) was the most widely used gene for the therapy. Trials using TH via various vectors yielded behavioral improvements in animal models but the effectiveness did not last long enough. As one of the approaches for solving this problem, the regulation of expression of the protein and mRNA of TH was studied. METHODS: Two approaches for a higher and/or more stable expression of TH were pursued. First, the effect of cofactor tetrahydrobiopterin (BH4) on the expression level of TH and second, the effect of deletion which enables TH protein to escape from protease attack, were examined. RESULTS: Cells producing BH4 showed an approximately 10-fold higher TH expression than cells expressing TH alone. When the in vitro modified TH was expressed in NIH-3T3, mutant THs showed elevated protein (17.5 ~68.6 fold) and mRNA (1.8 ~4.6 fold) expression levels at a steady state. CONCLUSIONS: Results suggest that an addition of BH4 has a more positive effect on mRNA expression levels than protein. However, the deletions seem to have a tremen-dous effect on the translation and/or protein stability, but a small effect on the mRNA level. (J Korean Neurol Assoc 19(5):514~519, 2001)

The Implementation of the Moral Education Program in a Medical School Using Dilemma Discussion / 한국의학교육

Gachon Medical School has developed and implemented a medical ethics course entitled, "Life and Society II". The course uses dilemma discussion based on medical case studies to allow students to develop their moral reasoning ability in both clinical and hospital settings. The course was developed by the faculty of medicine during the 1998-1999 academic years. The program was designed in a four-stage process: 1) learning objectives were identified, 2) contemporary controversies and relevant ethical issues were chosen based on relevance to modern medical practice, 3) a syllabus was drafted based on the aforementioned ethical issues and teaching methods appropriate for each issue were integrated into the syllabus, and 4) tutorial manuals were produced. The course was taught to 41 second-year premedical students and evaluated by student surveys. The learning goals were identified through both a literature survey of contemporary issues in medical ethics and an in-house survey of important content to teach in a medical ethics course. The curriculum was designed based on the identification of specific learning objectives per ethical issue, selection of appropriate materials and content, organization of dilemma scenarios and formulation of questions for discussion. The course was taught using a variety of teaching formats: dilemma discussions, seminars, tutorials, lectures, assigned readings and student presentations. Positive results were obtained from the student surveys: it was discovered that most students thought that the course's learning objectives were achieved. Furthermore, of all the teaching methods employed, most of our students felt that discussing dilemmas was the most effective method for developing moral reasoning ability.

Identification of M-1, S-1 Cortex Using Combined Intraoperative SEP and Cortical Stimulation: A Case Report

No abstract available.

Analysis of Mitochondrial DNA in Patients with Essential Tremor

No abstract available.

The Analysis of Mitochondrial DNA in the Patients with Essential Tremor and Parkinson's Disease

No abstract available.

Simultaneous Ipsilateral Posteroventral Pallidotomy and Ventrolateral Thalamotomy for Advanced Parkinson's Disease

Stereotactic thalamotomy has traditionally provided good relief of tremor for patients with intractable tremor dominant in Parkinson's disease. However bradykinesia, dyskinesia and rigidity are less reliably treated with this technique. Although posteroventral pallidotomy(PVP) can alleviate dyskinesias appendicular bradykinesia and rigidity, tremor may not be completely ameliorated. Between January 1993 and May 1997, the authors performed posteroventral pallidotomy(PVP) on 69 patients with Parkinson's disease who had bradikinesia, rigidity, drug induced dyskinesia and tremor. Of these patients who had only PVPs 17(25%) patients had severe tremor, 20(29%) patients moderate tremor and 32(46 %) patients mild or no tremor after the surgery. We have combined ventrolateral thalamotomy(VLT ) and PVP in 37 patients with moderate to severe tremor. Of the 37 patients, who had both PVP and VLT, 27(73%) patients showed good improvement, and fair improve-ment in 10(27%). Except for 6 cases with transient dysarthria we did not encounter any other operative complications from the ipsilateral combined PVP and VLT. The combination of the two procedures appear to provide excellent relief for the majority of symptoms in patients suffering from advanced Parkinsons disease with rigidity bradykinesia, dyskinesia and tremor.

The Deletion Analysis of Mitochondrial Multicomplexes in Parkinson's Disease

Arkinson's disease(PD) is a neurodegenerative disease involving mainly the loss of dopaminergic neurons in substantia nigra by several factors. The cause of dopaminergic cell death is unknown. Recently, it has been focused on that Parkinson's disease resulting from mitochondrial dysfunction. In the previous studies, it was found that a 5 kilobase(kb) deletion derived from mtDNA dysfunction. And this result leads to a reduction of ATP production, which ultimately causes result in cell death. Blood samples were collected from 6 positive control(PC) and 9 PD patients. Total DNA was extracted twice with phenol followed by chloroform:isoamylalcohol(24: 1). For the analysis of mtDNA, polymerase chain reaction(PCR) and long and accurate polymerase chain reaction(LA PCR) were performed by mitochondrial specific primers. As a result, a deletions of large quantity was detected within several regions of mtDNA in PD patients. The analysis of the partial sequence of the mitochondrial D-loop gene and restriction fragment length polymorphism(RFLP) technique were performed to investigate the point mutation and nucleotide sequence variations between PC and PD patients. Fragment variations between PC and PD were seen in the fragment digested by Hin d III, Eco R V. These variations are attributed to the presence or absence of recognition site by base substitution. Point mutation was observed in the D-loop region. Patients 1 and 2 had one point mutation. Patient 1 had a transition from T to C at 195, and patient 2 had a transversion from A to T. In addition to point mutation, the deletion of mtDNA occurred complexI, III, IV and V subunits in PD patients.