Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.

Development of an Offline Based Internal Organ Motion Verification System during Treatment Using Sequential Cine EPID Images / 의학물리

Verification of internal organ motion during treatment and its feedback is essential to accurate dose delivery to the moving target. We developed an offline based internal organ motion verification system (IMVS) using cine EPID images and evaluated its accuracy and availability through phantom study. For verification of organ motion using live cine EPID images, a pattern matching algorithm using an internal surrogate, which is very distinguishable and represents organ motion in the treatment field, like diaphragm, was employed in the self-developed analysis software. For the system performance test, we developed a linear motion phantom, which consists of a human body shaped phantom with a fake tumor in the lung, linear motion cart, and control software. The phantom was operated with a motion of 2 cm at 4 sec per cycle and cine EPID images were obtained at a rate of 3.3 and 6.6 frames per sec (2 MU/frame) with 1,024x768 pixel counts in a linear accelerator (10 MVX). Organ motion of the target was tracked using self-developed analysis software. Results were compared with planned data of the motion phantom and data from the video image based tracking system (RPM, Varian, USA) using an external surrogate in order to evaluate its accuracy. For quantitative analysis, we analyzed correlation between two data sets in terms of average cycle (peak to peak), amplitude, and pattern (RMS, root mean square) of motion. Averages for the cycle of motion from IMVS and RPM system were 3.98+/-0.11 (IMVS 3.3 fps), 4.005+/-0.001 (IMVS 6.6 fps), and 3.95+/-0.02 (RPM), respectively, and showed good agreement on real value (4 sec/cycle). Average of the amplitude of motion tracked by our system showed 1.85+/-0.02 cm (3.3 fps) and 1.94+/-0.02 cm (6.6 fps) as showed a slightly different value, 0.15 (7.5% error) and 0.06 (3% error) cm, respectively, compared with the actual value (2 cm), due to time resolution for image acquisition. In analysis of pattern of motion, the value of the RMS from the cine EPID image in 3.3 fps (0.1044) grew slightly compared with data from 6.6 fps (0.0480). The organ motion verification system using sequential cine EPID images with an internal surrogate showed good representation of its motion within 3% error in a preliminary phantom study. The system can be implemented for clinical purposes, which include organ motion verification during treatment, compared with 4D treatment planning data, and its feedback for accurate dose delivery to the moving target.

A Case of Docetaxel Induced Subacute Cutaneous Lupus Erythematosus / 결핵및호흡기질환

Drug-induced subacute cutaneous lupus erythematosus (SCLE) is associated with use of the following classes of medications: anti-hypertensives, anti-cholesterolemia, anti-psychotics, and anti-inflammatory drugs. Docetaxel is an anti-neoplastic agent, which is widely used for treatment of non-small cell lung cancer. Few cases of docetaxel-induced SCLE have been reported in the medical literature. Here, we report the case of a 58-year-old female patient who developed drug-induced SCLE after administration of docetaxel. After 4 cycles of chemotherapy with docetaxel and cisplatin, erythematous skin eruptions developed on the patient's face. Skin biopsies of the eruptions were remarkable for interfacing dermatitis with basement membrane thickening. Immunofluorescent study revealed characteristic features of SCLE, including granular deposition of IgM, C3, and apoptotic bodies along the basement membrane. The skin eruptions resolved gradually after cessation of drug and with the use of topical corticosteroids.

A case of nephrotic syndrome in a patient with scleroderma / 대한내과학회지

Scleroderma is a connective tissue disorder characterized by fibrosis of the skin, vessels and internal organs (gastrointestinal tract, lung, heart, and kidney etc.). Renal involvement in scleroderma has a clinical manifestation from subnephrotic proteinuria to renal crisis accompanied by hypertension, and shows a typical histology of intimal proliferation and fibrinoid necrosis of blood vessel without primary glomerular pathology. We experienced a case of nephrotic syndrome in a 31-old-female patient with sclerodema. But the patient has not showed a clinical feuture of hypertension or renal crisis, moreover, renal biopsy of the patient showed global sclerosis and crescent formation in the glomeruli without vessel involvement. We report this case with a brief review of literature.

Clinical Evaluationnof Monovision Induced by Laser Thermal Keratoplasty (LTK)

PURPOSE: To evaluate clinical effects of laser thermal keratoplasty (LTK), LTK was performed in patients with presbyopia or hyperopia. METHODS: LTK was performed in 38 patients who was older than 45 between May and December 2001. Preoperative contact lens fitting and wearing for patients to experience the monovision was tried in all patients for one week. With LTK, we intended patients used dominant eyes for distance vision and nondominant eyes for near vision. Patients' satisfaction, refractive change and near visual acuity were evaluated for least 3 months after surgery. RESULTS: The mean improvement of near vision was 5.16 lines by test with Korean near vision chart. 79% (30 of 38) of patients were satisfied with the results of LTK. CONCLUSIONS: Monovision with LTK is thought to be a good option in patients with presbyopia.

The clinical outcomes of Occlusion for Monocular Amblyopia in Children More than 8 years

PURPOSE: We schemed to help the therapeutic plan in amblyopic children of old age group by analyzing the clinical outcomes of occlusion therapy in amblyopic children more than 8 years old. METHODS: In 104 unilateral amblyopic children whose occlusion therapy had been finished, the retrospective study was performed. The average age at the beginning of treatment was 5.9 years (1.2~15.2 years). We divide the patients into three groups on the basis of age at the beginning of treatment: below 4 years (group 1, N=41), 5~7 years (group 2, N=44), more than 8 years (group 3, N=19). The success rate of occlusion therapy in group 3 was compared with the success rate of other groups, and the clinical features of group 3 were analyzed. RESULTS: The success rate of occlusion therapy in group 3 (68.4%) was significantly low compared with other groups (p<0.05). In group 3, the success rate of anisometropic amblyopia (90.0%) was significnatly higher compared with the success rate of strabismic amblyopia (44.4%)(P<0.05), and it was similar to the success rate of anisometropic amblyopia of other groups. CONCLUSIONS: The success rate of occlusion therapy in amblyopic children more than 8 years old was significantly lower compared with other groups. But the clinical outcomes were fair, especially in anisometropic amblyopia. We suggest to enforce occlusion therapy in amblyopic children more than 8 years old.

A Case of Refractory Hepatic Hydrothorax That Was Not Treated by Transjugular Intrahepatic Portosystemic Shunt / 대한간학회지

Refractory hepatic hydrothorax has been treated by conservative methods: salt and water restriction, diuretics, thoracentesis, thoracostomy, and pleurodesis. The results, however, havebeen disappointing. Recently, TIPS has emerged as a new method for refractory hepatic hydrothorax, but it may lead to fatal complications. We report a case of refractory hepatic hydrothorax that was not treated by TIPS despite of successful control of ascitest.

A case of Von Meyenburg Complex associated with calculous cholecystitis, cerebral aneurysm and renal cortical cyst / 대한내과학회지

Von Meyenburg complexes (VMC) have many synonyms such as bile duct hamartomas and biliary hamartoma. These rare benign disorders are considered as congenital diseases caused by malformed differentiation of ductal plate. The diagnosis of VMC by common radiologic modality such as ultrasound and computed tomography was nearly impossible until the emergence of cholangiopancreatography by magnetic resonance imaging (MRCP) and the pathologic examination was the only way to confirm the diagnosis of VMC. But MRCP is now considered as most accurate noninvasive method for diagnosis of VMC. We report a histologically proven case of VMC associated with calculous cholecystitis, cerebral aneurysm and renal cortical cyst. To our knowledge, no comparable case has been reported and this would be the only second reported case of VMC, which was diagnosed by MRCP.

Clinical Results of Penetrating Keratoplasty after Glaucoma Surgery

PURPOSE: We retrospectively reviewed the medical records of the patients who had undergone penetrating keratoplasty after glaucoma surgery, to evaluate the surgical outcome of penenetrating keratoplasty associated with glaucoma surgery. METHODS: Twelve patients, 12 eyes were reviewed. Graft status and postoperative intraocular pressure were main outcome measures. And success was defined as thin, clear corneal graft and IOP control between 6 and 21 mmHg after at least 6 month follow-up. RESULTS: The mean age of the patients was 40 year old and male to female ratio was 9 to 3. Mean postoperative follow up time was 12 months for Penetrating keratoplasty and the mean period between glaucoma surgery and penetrating keratoplasty was 12 months. Seventy five percent(9 eyes) maintained clear corneal graft and 67%(8 eyes) showed successful IOP control and both clear graft and IOP control in 58%(7 eyes). CONCLUSIONS: Fifty-eight percent(58%) of our cases showed successful outcome. With the knowledge of better timing for a surgical intervention and an improvement of surgical techniques, there will be an increased success rate.

Regression of nodules on cranial computerized tomography (CCT) scans in focal epileptic patients

Epilepsy can be defined as a paroxysmal, neuronal discharge within the brain originating from either corticalor sugcortical regions. The incidence of epilepsy is increasing possibly due to the survival of persons who shouldhave died of brain injuries or other cerebral abnormalities acquired in earlylife. the use of abtibiotics andimprovement in the medical care have saved many children who might have died of meningitis, brain abscess,encephalitis, severe head injuries, etc. CCT scan is new radiologic procedure for defining cranial andintracranial structures and also an useful procedure for evaluation and follow-up(FU) of patient with focalseizure disorder. Recently we experienced nodules which were isodense or hypodense on initial noncontrasted CT(NECT) and scans became hyperdense of the enhancement in 4 cases of focal epileptic seizures. Nearly completedisappearance or regression of the epileptic foci occurred on the FU CT scans in 2 cases. Operation was performedin 2 cases. The tissue specimen obtianed from the CT nodule revealed cerebral edema in one case and localizedgliosis and congestion in the other. All the patients showed marked clinical improvement when the CT noduleimporved. Review of literature failed to disclose any previous report on such observation.

Regional Cerebral Blood Flow on Cerebral Reperfusion after Occlusion of Bilateral Common Carotid Arteries : An Experimental Cat Model

The microvasculature of the brain is also quite susceptible to ischemic insult, and substantial portions of the brain are not reperfused after restoration of the blood supply following overtime of critical ischemic periods. The purpose of this series of experiments was to determine the effects of ischemia on subsequential regional cerebral blood flow measurements and cortical electric activities following reperfusion after ischemia and also to define the proper time of vascular occlusion without irreversible neural damage. Cerebral ischemia was induced in cat by bilateral common carotid occlusions for periods of 10, 30, to 60 minutes, and the blood flow(rCBF) was measured by hydrogen clearance technique following ischemia, restoration of blood supply and electroencephalogram recovery could be predicted according to the rCBF. Forty adult cats weighing 2.7 to 4.0kg were used in this study. The animals were divided into 4 groups of 10 cats each : normal control, 10 min-clamped, 30 min-clamped, and 60 min-clamped groups. The results obtained were as follows : 1) The mean rCBF was 24.6+/-7.0ml/100g/min in control group. 2) Bilateral carotid occlusions resulted in a reduction of the rCBF (12.4+/-4.1ml/100g/min) to 50% of control flow on both hemispheres. 3) Sequential changes of the rCBF after reperfusion. (1) There was restored the rCBF(21.3+/-5.1ml/100g/min) to control flow in the 10 minutes-clamped group. (2) There was a 85% recovery of control flow in the 30 minutes-clamped group. (3) There was a only 25% recovery of control flow in the 60 minutes-clamped group. 4) A close correlation was found between cortical electrical activity and rCBF suggesting a threshold relationship. (1) The changes of cortical electric activity began to notice at rCBF less than 17.4+/-4.7ml/100g/min. (2) The changes of cortical electric activity noted at rCBF more than 10.2+/-2.3ml/100g/min. 5) There was no evidence of ischemic involvement at the cortex, white matter and basal ganglia in the 10 minutes clamped group, but demonstrated a dense wedge shaped infarct at the cortex and uncus herniation in the 60 minutes clamped group. The rCBF and cortical electric activity restorted to normal values in reperfusion within 10 minutes after occlusion of both common carotid arteries.

Somatosensory Evoked Potential Responses in Focal Brain Lesions

Cerebral somatosensory evoked potentials(SEPs) produced by stimulation of peripheral nerves provide a useful diagnostic index of conduction in somatosensory pathways to the cortex. Thus the integrity of both the dorsal column-medial lemniscus pathway and primary sensorimotor area has been considered an essential requirement to record a normal SEP. There are suggestions that SEPs contain several components arising from different neuronal sources, the early short latency potentials corresponding to the lemniscus-mediated responses and the late waves to the diffuse spino-thalamic projections. The present work analyses the influence on SEPs of focal brain lesions, using the computerized tomography in detecting and localizing brain lesions. Somatosensory evoked potentials were recorded in 20 patients with focal brain lesions recognized by computerized tomography. 1) Patients with primary sensorimotor area(PSMA) damages(group I) had a very abnormal of the early component(No, Po, Nl, Pl) in 100% on the lesion side. 2) Patients presented supratentorial lesions, sparing PSMA(group II), 87.5% showing abnormal SEPs in early components and characterized by increment of amplitude in late components. 3) Brainstem damage(group III) produced a distortion of the early components especially N11, N20msec in latency. 4) In incomplete spinal cord injuries, the SEPs is indeed signal of functional recovery, of posterior column, and incorrespondance with clinical improvement.

Basal Ganglia Calcification and Hypoparathyroidism: Case Report

Microscopic calcification within the basal ganglia was reported by Virchow and Bamberger in 1855. The description of symmetrical cerebral calcification, particularly of the basal ganglia and often of the dentate nuclei, associated with hypoparathyrodism as related by Eaton, Camp and Love(1939) was a significant development in the field of calcification. Calcification of the basal ganglia has been visualized by skull radiography and computed tomography(CT) scan, and in two-third of cases, it has been associated with metabolic and endocrine abnormalities. Computed tomography is more sensitive to detect the intracranial calcification than plain skull radiography. The purpose of our report was evaluate the significance of basal ganglia calcification as visualized by CT, discusses on pathogensis of calcification, clinical significance and management under the hypocalemia.

Effect of the Thiopental in Acute Focal Cerebral Infarction after Experimental Occlusion of the Middle Cerebral Artery

An experimental ischemic model in cats is described in which we have attempted to produce acute cerebral ischemia by occlusion of the middle cerebral artery(MCA) through the orbit. The main objectives of this experiment were:to observe the effect of thiopental in the tophographic distribution of infarct;the size of the infarct;histological changes of ischemic nerve cells following occlusion of a major cerebral artery;to investigate the best timing of the administration and dosage of thiopental after the occlusion. 80 adult cats weighing 2.7 to 4.0kg, were used in this study. The components of the pathophysiological responses, systemic changes, cerebral infarct size and histopathological ischemic neuronal changes were studid in these groups of animals. We observed the protective effect of the thiopental on acute focal cerebral ischemia in 40 cats by effecting permanent occlusion of MCA. The EEG was monitored continuously using bifrontal electrodes from the time of administration of thiopental(10mg/kg). The animals were divided into 4 groups of 20 cats each. The 4 different groups were used to investigate the effects of thiopental on focal ischemia according to different time interval. The time intervals were 6 hours, 24 hours, 48 hours, and 72 hours after occlusion of MCA. Each animal group were divided into two groups, which one was control(n=10) the other, thiopental treated group(n=10). The results obtained were as follows: 1) Blood gases, artrial pressure, body temperature, and intracranial pressure differed among groups only as follows: (a) Normal blood pressure was maintained but pulse rate was slightly fast in each control group. (b) Blood pressure and pulse rate in the thiopental treated groups were significantly lower than in the control groups. In the thiopental treated groups, the value of PaO2 was significantly higher than control groups, however, PaCO2 was not significantly higher in the thiopental treated groups as compared to the control group. 2) In the control groups, severe contralateral hemiplegia(grade III) developed in the early stage of MCA occlusion, however the neurological deficit progressively improved to the state of abnormal climbing(neurological grade II) 48 hours to 72 hours after the occlusion. In the thiopental treated groups, minimum to mild neurological deficit significantly developed in the early stage of MCA occlusion and in one case walking ability was regained. 3) The size and distribution of the infarct significantly decreased to 60% in the thiopental treated groups(p<0.01). The value of the size of the size of the infarct in the thiopental treated groups 72 hours after occlusion was minimized to 0.3+/-0.6%(p<0.01). In 80 percent of the control group cases severe extensive ischemic neuronal damage(score 3 or 4), was observed, 70 percent in the thiopental treated groups showed mild ischemic nerve cell changes(score 1 or 2) when the histological examination was given. Although the severity of the ischemic neuronal damage was gradually improved from 6 hours to 72 hours after occlusion of the MCA in the control, the thiopental treated group was not significantly affected to the time factor. 4) Significantly reduction of experimentally induced acute focal cerebral ischemia was associated in the cat model with the administration of thiopental at 5 minute, 30 minute, and one hour postocclusion. Also we have defined the best barbiturate, best does, and best timing of administration to protect the acute focal ischemia.

A Case of Congenital Dermal Sinus with Dermoid Cyst of Posterior Fossa

Congenital dermal sinuses are dermal tubes which extended inward from the surface for varying distances and frequently connect the central nervous system or its covering with the surface of the body. The inner end of the sinus may be expanded to form a dermoid or epidermoid cyst. They are the results of incomplete separation of the epithelial ectoderm from the neuroectoderm at the fourth week of fetal development. As cystic expansion of a congenital sinus which is located within the cranium or spinal canal may act as any other mass lesion to interrupt neurologic function by local compression or it may obstruct the normal circulation of spinal fluid. In addition, because of its persistent communication with the skin surface, it serves as a constant potential port of entry for infection into the central nervous system. Since the first report in 1926 by Moise of staphyloccus meningitis secondary to a congenital sacral sinus, numerous reports have appeared of infection secondary to congenital sinuses along the craniospinal axis, particulary in the suboccipital region. Authors report a case of congenital dermal sinus associated with dermoid cyst of posterior fossa which was successfully removed and discuss the pathegenesis of it in embryology, and surgical management of it's complications.

The Mega Cisterna Magna: Report of 4 Cases

The size of the cisterna magna is still detatable. Robertson13) stated that the cisterna magna varies greatly in capacity and described the large cisterna magna as a separate entity. He also found that in most cases the cisterna magna extended approximately 2.5cm above the foramen magnum and was usually 5mm deep with a variable width. Liliequist8) proposed a mean heigh of 28mm for the normal cisterna magna with a wide variation of 15 to 60mm, and a depth of 6mm at the foramen magnum with a variation of 2 to 10mm:however, he did not quote measurements for the width. Gonsette, et al.5) reported 28 cases of enlarged cisterna magna diagnosed by ventriculography and coined the phrase "mega grande citerne" or mega cisterna magna. All of these cases, however, had symptoms of posterior fossa disease. Our study of the syndrome of the mega cisterna magna without specific syndrome is presented nystagmus, transient syncope in the first & third cases were operated under suboccipital craniectomy and was confimed the large cisterna magna. This paper presents the clinical diagnosis with vertebral angiogrraphy, pneumoencephalography and computed tomography.

Transoral Approach to Lower Third of a Clival Meningioma

Midline lesion at the base of skull have been considered in the past to be inoperable, partially respectable, and even when respectable, unpleasant difficult. According for the above has been the poor visulization of minimal surgical exposure, copious bleeding and lack of adequate fluoroscopic depth monitoring. These built-in difficulties may prove to be a fertile ground for microsurgery. Presently the use of the surgical dissecting microscope, portable image intensifiers and specifically designed microinstruments has enabled to permit approach of clival area for removal of the clival tumor. Authors had experience of transoral approach for removal of lower third of clival meningioma, and reviewed surgical approachs to midline lesion at the base of the skull.

The Effect of THIOPENTAL and MANNITOL of Acute Intracranial Hypertension in Severe Head Injury and the Other Comatous Patients

Laboratory and clinical evidence indicates a potentially important role for barbiturates in the management of brain injury and intracranial hypertension. The present report describes our experience with the thiopental and mannitol therapy in 30 consecutive patients who were over 20mmHg of intracranial pressure(ICP) in severe head injuries and the other comatous conditions. The anothers have analyzed the effects of thiopental on outcome in comatous 30 patients by continuous monitoring of ICP. High dose barbiturate therapy was induced with an intravenous bolus of thiopental, 40mg/kg and the infusion of barbiturates intermittently continued until control of the ICP(below 20mmHg) was obtained. In those patients responding to thiopental, the daily mannitol requirement was reduced from 3.5 to 0.5mg/kg/day. Our overall results are presented; 1) In patients with intracranial mass lesions only very high ICP(>40mmHg) on barbiturate management was significantly associated with a poor neurological deficit and outcome from injury, while the patients with any increased in ICP above 20 to 29mmHg was associated with a moderate neurological disability and better outcome with thiopental and mannitol treatment. 2) In patients with surgical mass lesion ICP between 20 to 29mmHg was significantly associated good neurological picture and outcome, but the patients in ICP above 40mmHg, had a 75% motality. 3) Decreases in ICP over 20mmHg were seen in 75%of the patient who had managed with thiopental and mannitol. 4) Thiopental responders have returned to a good recovered and minimal deficit, but thiopental nonresponsiveness was associated with a completely unfavorable outcome:5 deaths, 1 vegetative survior.

Total Excision of an Arterio-Venous Malformation of the Corpus Callosum: Case Report

The arteriovenous malformations(AVMs) of the corpus callosum are distinct anatomical and surgical entities. The AVMs of the corpus callosum are supplied by the pericallosal arteries if the malformations are located in the anterior and middle portion of the callosum and the AVMs of the splenium are usually fed by the pericallosal and posterior cerebral arteries. Radical excision of the callosal AVMs became successful with microsurgical techniques since a few years ago. The authors report a case of the callosal AVM, who had subarachnoid hemorrhage twice prior to this admission, and the studies with angiography and computed tomography revealed an AVM involing the middle portions of the corpus callosum. Radical excision of the AVM was accomplished by microsurgical techniques without neurologic sequela.

Aneurysm of the Great Vein of Galen: Case Report

Aneurysms of the great vein of Galen are rare and the authors report a case of primary type aneurysm of the great vein of Galen. Clinicaly aneurysm of great vein of Galen give rise to different symptoms and signs at different age. New born infants have intractable heart failure, infancy have hydrocephalus, and adolescents have headache and syncope. The diagnosis rests upon angiography, especially four-vessel angiography is mandatary to delineate all of the feeding arteries. The posterior cerebral arteries supply most of the blood to the aneurysm. The only effective treatment is ligation of the feeding vessels at the point of entry into the vein of Galen.