Subacute Course of Common Iliac Arterial Laceration in Lumbar Disc Surgery

Vascular injuries in lumbar disc surgery are serious complications which may be overlooked due to a broad range of clinical manifestations. It is important to be aware of the perioperative implications of this rare occurrence to lower mortality risk. A 20-yr-old man with a right L4-5 lumbar disc protrusion was operated on routinely under a surgical microscope. A bloody surgical field was noted temporarily during a discectomy along with a decreased blood pressure. After fluid resuscitation with an ephedrine injection, the bleeding soon stopped spontaneously and his vital signs were stabilized. Fifty hours after the operation, the patient showed signs of hypovolemic hypotension with abdominal distension. The right femoral artery pulsation was absent on palpation. An enhanced CT angiography revealed a retroperitoneal hematoma and obstruction of the left common iliac artery. An urgent laparotomy was done to repair the injured vessel by excision and interposition of a graft. The patient had an uneventful recovery.The subacute course of deterioration might have been due to intermittent blood leakage from the lacerated common iliac artery, which was sealed spontaneously. It is very important to pay close attention to post-surgical clinical manifestations to avoid a potentially fatal outcome in lumbar disc surgery.

Spinal Subarachnoid Hematoma as a Complication of an Intramuscular Stimulation : Case Report and a Review of Literatures

Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.

Isolated Distal Leg Weakness due to a Small Cerebral Infarction Masquerading as a Spinal Lesion

Acute stroke with isolated monoparesis manifesting as distal weakness of a single lower extremity has rarely been described. We report two patients with small cortical infarction who had distal weakness of a single lower extremity. In both cases, diffusion-weighted image (DWI) was used to detect small lesions in the contralateral cortex. These cases illustrate that small cortical infarction can cause isolated monoparesis limited to distal part of the leg and it may be misdiagnosed as spinal lesions, especially when lower back pain and transient sensory symptoms are accompanied. In case of the abrupt onset of weakness limited to one lower limb, the possibility of stroke should be considered and careful attention to identify cortical lesions using magnetic resonance imaging, especially DWI is required.

Ruptured Distal Lenticulostriate Artery Aneurysm Associated with Ipsilateral Middle Cerebral Artery Occlusion : Case Report / 대한뇌혈관외과학회지

A 49-year-old man presented with right basal ganglia hemorrhage due to a ruptured distal lenticulostriate artery aneurysm associated with ipsilateral occlusion of M1 segment of middle cerebral artery with moyamoya-type vessels. Conservative treatment was initially selected. However, the patient suddenly became drowsy with left hemiparesis due to recurrent bleeding 14 days after admission, and excision of the aneurysm was urgently performed via right frontotemporal craniotomy. The follow-up angiography showed successful resolution of the aneurysm. This report describes a rare case of a distal lenticulostriate artery aneurysm associated with ipsilateral middle cerebral artery occlusion with moyamoya-type vessels, which resulted in intracerebral hemorrhage on the right basal ganglia and intraventricular hemorrhage.

A Fatal Intracerebral Hemorrhage Complicated by Compartment Syndrome of the Upper Arm

Compartment syndrome has a wide spectrum from muscle pain to a life-threatening condition, such as acute renal failure and disseminated intravascular coagulation (DIC). Intracerebral hemorrhage (ICH) due to compartment syndrome has not been reported. We report a patient who presented with ICH leading to death. A 25-year-old female with no significant past history developed extensive compartment syndrome followed by rhabdomyolysis, acute renal failure, DIC, and ICH. Although the patient underwent a fasciotomy and hemodialysis and received aggressive resuscitation with massive transfusions of blood and intravenous fluids, she died. This case stresses the importance of early diagnosis and prompt treatment of compartment syndrome to prevent devastating complications.

A Fatal Intracerebral Hemorrhage Complicated by Compartment Syndrome of the Upper Arm

Compartment syndrome has a wide spectrum from muscle pain to a life-threatening condition, such as acute renal failure and disseminated intravascular coagulation (DIC). Intracerebral hemorrhage (ICH) due to compartment syndrome has not been reported. We report a patient who presented with ICH leading to death. A 25-year-old female with no significant past history developed extensive compartment syndrome followed by rhabdomyolysis, acute renal failure, DIC, and ICH. Although the patient underwent a fasciotomy and hemodialysis and received aggressive resuscitation with massive transfusions of blood and intravenous fluids, she died. This case stresses the importance of early diagnosis and prompt treatment of compartment syndrome to prevent devastating complications.

The Influence of Hypoalbuminemia on Neurological Outcome in Patients with Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

Subarachnoid hemorrhages (SAH) result in hemodynamic and metabolic abnormalities. The successful treatment of these abnormalities requires active treatment of neuroprotection. Recently, it has been known that albumin has important roles in neuroprotection as well as in hemodilution. We retrospectively studied 64 patients who were treated surgically for aneurysmal SAH to investigate the relationship between serum albumin levels, severity of disease and neurological outcomes. A high proportion of patients developed hypoalbuminemia after aneurysmal SAH. Patients with poor clinical presentation had significantly lower admission and postoperative albumin values than those with good clinical presentation. Comparison of patients with a favorable outcome and those with an unfavorable outcome revealed a significant difference in postoperative albumin values. In the patients with severe clinical presentation, postoperative albumin levels lower than 3.5 g/dL were associated with an unfavorable outcome. As a result of our analysis, albumin is an important prognostic factor in aneurysmal SAH. Therefore, active albumin replacement therapy might improve neurological outcomes as a neuroprotective agent. We therefore suggest that albumin offers great promise in the therapy of complications of SAH and we propose that it may now be appropriate to consider the initiation of early-phase clinical trials in patients with aneurymal SAH.

The Influence of Hypoalbuminemia on Neurological Outcome in Patients with Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

Subarachnoid hemorrhages (SAH) result in hemodynamic and metabolic abnormalities. The successful treatment of these abnormalities requires active treatment of neuroprotection. Recently, it has been known that albumin has important roles in neuroprotection as well as in hemodilution. We retrospectively studied 64 patients who were treated surgically for aneurysmal SAH to investigate the relationship between serum albumin levels, severity of disease and neurological outcomes. A high proportion of patients developed hypoalbuminemia after aneurysmal SAH. Patients with poor clinical presentation had significantly lower admission and postoperative albumin values than those with good clinical presentation. Comparison of patients with a favorable outcome and those with an unfavorable outcome revealed a significant difference in postoperative albumin values. In the patients with severe clinical presentation, postoperative albumin levels lower than 3.5 g/dL were associated with an unfavorable outcome. As a result of our analysis, albumin is an important prognostic factor in aneurysmal SAH. Therefore, active albumin replacement therapy might improve neurological outcomes as a neuroprotective agent. We therefore suggest that albumin offers great promise in the therapy of complications of SAH and we propose that it may now be appropriate to consider the initiation of early-phase clinical trials in patients with aneurymal SAH.

Effectiveness of Selective Peripheral Denervation for the Treatment of Spasmodic Torticollis

OBJECTIVE: The Bertrand's method of selective peripheral denervation for spasmodic torticollis has already been established as being an effective and safe method. However, such effectiveness has not yet been established in Korea. The authors have performed several cases of selective denervation for the treatment of spasmodic torticollis and we hereby describe the details of the operative method to determine the effectiveness of the method. METHODS: Ten patients who had the selective denervation for the spasmodic torticollis from October 1997 to December 2003, were analyzed. There were 4 rotational and 6 combined types (3 rotational plus retrocollis, 3 rotational plus laterocollis). We performed preoperative electromyograms and neck muscle tonograms in all cases. The technique was used to involve denervation of the ipsilateral posterior paraspinal muscles. Denervation of the sternocleidomastoid muscle was performed on the contralateral side for rotational torticollis and on the ipsilateral side for laterocollis combined type. The surgery was followed by a rigorous physical therapy program. RESULTS: The surgical results were divided into 4 groups labeled excellent, good, fair, and poor. There were 5 excellent patients who showed no detectable abnormal movements, 4 good patients who showed slight residual deviations or slight residual abnormal movements, and 1 fair patient with appreciable residual abnormal movements. Postoperative pain was well tolerated. There was no significant surgical complications. CONCLUSION: The study confirms that selective peripheral denervation for the treatment of spasmodic torticollis is a very useful and safe surgical technique.

Therapeutic Effects of Holmium-166 Chitosan Complex in Rat Brain Tumor Model

This study examined the effectiveness of Holmium-166 (Ho-166) chitosan complex therapy for a malignant glioma. Cultured C6 glioma cells (100, 000 in 5microliter) were injected into the caudate/putamen of 200 - 250 gram Wistar rats. Five days later, a Ho-166 chitosan complex was injected into the same site of the glioma injection. Four injection doses were administered: the control group received PBS 10microliter, group 1 received an injection of 100micro Ci (10microliter), group 2 received an injection of 50microCi (5microliter), and group 3 received an injection of 10micro Ci (1microliter). The average tumor volume for each group was 1.385 mm3 for the control group, 0.036 mm3 for group 1, 0.104 mm3 for group 2, and 0.111 mm3 for group 3. Compared with the control group, the size of the tumors in groups 1, 2 and 3 was reduced by an average of 97.4%, 92.5% and 91.9%, respectively. The Kaplan-Meier survival curve of group 2 was the longest, followed by groups 3, group 1 and the control. The mean survival was 22.8, 59, 60, and 44.6 days for the control group and groups 3, 2 and 1, respectively. H-E staining revealed that group 2 yielded the best results in the destruction of the malignant glioma. TUNEL staining and immunohistochemical studies indicated apoptotic features. The Ho-166 chitosan complex proved to be effective in destroying the malignant glioma.

Induction of Apoptosis by a Novel Bcl-2 Protein, Bak-like without a BH3 Domain

OBJECTIVE: In a variety of physiologic settings, cells are eliminated by apoptosis, a genetically encoded process of cellular suicide. Bak, a member of the Bcl-2 protein family, accelerates apoptosis by an unknown mechanism. Here, we describe the identification and characterization of a complementary DNA that encodes a previously unknown Bcl-2 homologue designated Bak-like. METHODS: We identified a splicing variant of Bak with a lacked BH3 domain from human full-length cDNA bank. The expression of Bak-like was examined by northern blot analysis and polymerase chain reaction. To investigate whether Bak-like might arise from alternative splicing of mRNA of Bak, Southern blot analysis was executed. Apoptosis in transfected HeLa cells was analyzed by direct counting of viable cells. We examined the location of Bak-like in individual living cells by using EGFP fusion constructs and confocal microscope. RESULTS: Bak-like cDNA coded a protein consisting of 101 amono acid, and conserved BH1 and BH2 domains like Bak but not BH3 domain. Bak-like mRNA was about 2.4kb similar to bak. Bak-like was assumed to be an alternative splicing variant of Bak and to concern with promotion of apoptosis. GFP-bak-like markedly changed its intracellular distribution, relocating within cells during apoptosis from a diffuse to a punctate pattern. CONCLUSION: Our results define a novel splicing form of the bak gene and demonstrate that this variant without a conserved BH3 domain appears to contain the BH1 and BH2 domains and the transmembrane sequence for apoptosis induction by channel-forming Bcl-2 proteins. Like Bak, Bak-like gene product primarily enhanced apoptotic cell death following an appropriate stimulus.

Endovascular Treatments of Traumatic Carotid and Vertebral Vascular Injuries

OBJECTIVE: The purpose of this report is to determine the safety and efficacy of endovascular therapy in the management of craniocervical vascular injuries. METHODS: Fifteen patients with traumatic carotid and vertebral lesions were treated using therapeutic endovascular methods. In 13 patients with blunt trauma, five patients had a carotid-cavernous fistula, 8 had a dissecting pseudoaneurysm or arterial dissection. One of two penetrating patients had complete transection of the vertebral artery, and the other had an internal carotid artery-internal jugular vein fistula with two pseudoaneurysms. Endovascular therapy was accomplished by implanting the balloons, porous or polytetrafluoroethylene covered stent, and/or embolic materials including coils or glue. RESULTS: All fistulas and pseudoaneurysms were successfully embolized with coils, glue, or stents. Most of all parent arteries except two patients were preserved. Sacrifice of the parent artery was inevitable in cases of thrombus formation due to coil migration into the parent artery and the existing transaction of the parent artery. No additional surgical procedures for vascular lesions were required. There were no delayed neurological or vascular complications. Additionally, no lesions recurred during follow-up periods (mean 26.9 months). CONCLUSION: From the author's experiences, the endovascular therapy using stents, balloons, and coils is both feasible and safe in treatment of the traumatic vascular injuries. Long-term follow-up review of these repairs will be requisite to provide a full evaluation of the safety and efficacy of these devices.

Molecular Genetics of Primary Intracerebral Hemorrhage / 대한뇌혈관외과학회지

Intracerebral hemorrhage (ICH) is more deadly than ischemic stroke but is also rarer and more difficult to study. Genetic and environmental risk factors likely play a role in the occurrence of ICH. The genetics of cerebral amyloid angiopathy like mutation at beta-amyloid peptide positions 22 and 23, cystatin C, presenilin 1 and 2 or apolipoprotein E have been studied for both familial and sporadic forms. In addition, genetic variation in the hemostasis pathway likewise might affect the likelihood of sporadic ICH. Furthermore, polymorphisms of candidate genes such as endoglin, cytochrome P450 enzyme, lipoproteins, or proteolytic enzyme are all known to be risk factors of ICH. Recent advances in molecular biology provide evidence that genetic variants of different candidate genes are associated with the occurrence of ICH. The aim of this review is to expose the current status of these various hypotheses and their contribution to the pathogenesis of ICH in order to provide a basis for future investigations in this field.

Complications of Stenting for Symptomatic Middle Cerebral Artery Stenosis and Their Rescue: Case Report

Intravascular stents are being used with increasing frequency in interventional neuroradiology. We present two cases of arterial rupture and subarachnoid hemorrhage during middle cerebral artery stenting. Extravasation of contrast material and massive subarachnoid hemorrhage during stenting in one case resulted in mortality. In the other case, overlapping stenting and balloon tamponade on the dissected vessel, however, were performed emergently. Thereafter, thrombotic occlusion of the middle cerebral artery was managed by intraarterial abciximab administration. Serial angiography showed that normal vessel patency was reestablished within 20 min. We discuss complications of stenting for symptomatic middle cerebral artery stenosis and their rescue work.

Medial Trunk Aneurysm of the Distal Posterior Inferior Cerebellar Artery in the Fourth Ventricle: Case Report

We present a case of a ruptured aneurysm of the medial trunk of the right posterior inferior cerebellar artery(PICA) in the fourth ventricle. A 52-year-old man presented with sudden onset of headache, followed by an abrupt decline in consciousness. Angiographic studies revealed that the aneurysm arose from the medial trunk of the right PICA, distal to the choroidal point and associated with the stenosis of the basilar artery and the hypoplasia of the right anterior inferior cerebellar artery and superior cerebellar artery. The patient underwent a midline suboccipital craniotomy and aneurysmectomy after clipping of the parent artery. A postoperative angiogram confirmed complete obliteration of the aneurysm, but demonstrated occlusion of the vermian branch of the right PICA. The pathogenesis of this lesion could be due to hemodynamic stress.

Endovascular Treatment of a Traumatic Carotid-Jugular Fistula by Using Stent-Graft

Traumatic arteriovenous fistulas following carotid artery injuries are rare. Treatment of carotid artery-to-jugular vein fistula requires direct closure of the fistula or occlusion of the carotid artery above and below the level of the fistula, by a surgical or endovascular approach. A 32-year-old man presented with right-sided pulsatile neck swelling and left-sided limb weakness 2 days following a stab wound. Neck computed tomography demonstrated a vascular mass protruding the anterior neck. Digital subtraction arteriography demonstrated a bilobular large internal carotid artery pseudoaneurysm just distal to its bifurcation. There was simultaneous opacification of a dilated left internal jugular vein indicating a high-flow internal carotid-internal jugular fistula. A balloon-expandable stent-graft was delivered and successfully positioned across the fistula. The arteriovenous fistula and pseudoaneurysm were completely disappeared and the right internal carotid artery was preserved well. The stent-graft is a promising technology to obliterate the fistula and preserve the parent artery with relative safety.

Ascertainment of Clinical Usefulness of Neurosurgery Simulator(R) in Stereotactic & Functional Neurosurgery

OBJECTIVE: An usefulness and an accuracy of Neurosurgery Simulator(R)(NSS(R)) is evaluated for the clinical applications. The NSS(R) is a surgical planning tool for stereotactic and functional neurosurgery, recently developed in Korea. METHODS: Thirty-four surgical cases, performed with the NSS(R) from October 1999 to April 2002, were analyzed. The accuracy was examined by comparing the actual lesion with the planned target. The usefulness was discussed with time consuming factor and convenience for surgical steps. Results of surgical outcome were also reviewed. RESULTS: The precise coordinates of surgical target is directly acquired by designating an anatomical lesion on the magnetic resonance image with NSS(R) due to auto recognition algorithm of the fiducials on the MRI image. The correctness is confirmed again by examining the anatomical lesion with superimposing the Schaltenbrand-Wahren atlas on the image directly. Among eleven cases of the thalamotomy for tremors, five cases resulted in complete resolution, the remaining five patients showed significant reduction of tremors. Improvement of ADL and UPDRS was recorded in all 6 Parkinson's disease patients who had undergone pallidotomy. Seventy five percent of patient in pain and psychosurgery resulted in improvements. The NSS(R) achieved 100% accuracy in calculating stereotactic biopsy coordinates. There was no deviation in guiding surgical trajectory. There was no significant surgical complication. CONCLUSION: Stereotactic and functional neurosurgery performed with the assistance of the NSS(R) is relatively safe and accurate.

Anterior Cervical Interbody Fusion Using a Plate Cage System in Degenerative Cervical Disease

OBJECTIVE: The plate cage system is an intradiscal cage combining with an integrated plate. To evaluate its suitability for an clinical application, the authors present a retrospective analysis of outcome assessment of our series. METHODS: From March 1998 to November 2001, fifty three patients with degenerative cervical disease underwent anterior cervical interbody fusion with the PCB(R)(PCB(R) instrument, SCIENT'X, Paris, France). Single level fusion was accomplished in 31 patients, two levels in 19 patients, and three levels in two patients. RESULTS: All patients were improved without intraoperative complications ; excellent in 28(52.9%), good in 15(28.3%), and satisfactory in 10(18.8%). Four cases of screw loosening were identified, however, there was no cage backout, worsening of symptom or reoperation due to screw loosening. The bony fusion was confirmed in all patients by cervical flexion and extension X-ray and computed tomography during follow-up. CONCLUSION: The design of this plate cage system appears to prevent bone-graft recipient site and donor site complications, provides immediate stability, and restores height and lordosis.

Stent-Assisted Angioplasty for Symptomatic Middle Cerebral Artery Stenosis: Short-term Arteriographic and Clinical Outcome

OBJECTIVE: Stent-assisted angioplasty is an effective treatment modality in the coronary and peripheral arterial disease, however, its efficacy for intracranial atherosclerotic disease has not been verified. We assess the treatment outcome of stent-assisted angioplasty for symptomatic middle cerebral artery (MCA) stenosis. METHODS: We performed stent-assisted angioplasty in 12 patients with symptomatic high-grade stenosis(>60%) on the proximal portion of the MCA, who had either recurrent transient ischemic attacks (TIAs) resistant to medical therapy or perfusion problems. Patient records were analyzed for angiographic characteristic, degree of stenosis, preprocedural regimen of antiplatelet and/or anticoagulation agents, used devices, procedure-related complications, and clinical and radiographic outcomes. RESULTS: Stent-assisted angioplasty was successfully performed in 8 patients without any serious complications. Two patients had arterial rupture. One of two patients was rescued by an additional stenting and balloon tamponade, and the other patient was dead. Another complications among the 2 patients included thrombotic occlusion and distal thrombosis. Residual stenosis was less than 50% in diameter in all the patients. During follow-up period (mean, 11 months), stroke attacks including TIAs did not recur in 9 of 11 patients who had experienced intractable TIAs or strokes. All of 8 patients who underwent follow-up cerebral angiography had no restenosis. CONCLUSION: Stent-assisted angioplasty for refractory and symptomatic MCA stenosis is a relatively safe and effective procedure. It can be used to prevent recurrent TIAs or strokes in selected patients.

Management of Elderly Patients Older than 80 Years with Ruptured Intracranial Aneurysm / 대한뇌혈관학회지

OBJECTIVES: The aim of this investigation is to provide the strategy of management and to improve the outcomes of elderly patients older than 80 years with the ruptured intracranial aneurysm. METHODS: 18 patients over 80 years old with aneurysmal subarachnoid hemorrhage who are admitted to our institute between Jan. 1996 and Nov. 2001 were included. Mean age was 81.6 years and female was predominant (89%). Hunt and Hess grade (HHG) and Fisher grade (FG) on admission, specific management components, and clinical outcomes were recorded. RESULTS: HHG I to III on admission were in 11 patients (61.1%) and FG III to IV on admission were in 15 patients (83.3%). The 4-vessel angiography was performed in 13 patients and 18 aneurysms were detected with the highest percentage of posterior communicating artery aneurysm (22.8%). Aneurysm repair was performed in 12 patients; 7 patients underwent surgical repair, 5 patients underwent Guglielmi detachable coil (GDC) embolization but 1 patient failed because of tortuous vessel. Preexisting medical conditions, such as hypertension (33.8%), diabetes (16.7%), myocardial disease (11.1%), cerebrovascular disease (11.1%), bronchial asthma (5.6%), were related with poor outcomes. Overall Glasgow outcome scale (GOS) were death 6 (33.3%), vegetative state and severe disability 5 (27.8%), moderate disability 0 (0%), and good recovery 7 (38.9%). Favorable outcomes of active management were 6 (50%), and favorable outcomes of GDC embolization were 3 (60%). 3 patients who had favorable clinical grade refused treatment and discharged. CONCLUSION: Elderly patients with subarachnoid hemorrhage can be treated successfully and results are still improving. The development of GDC embolization may have contributed to the improved outcome. So we think that elderly patients of favorable clinical grade would have a chance of returning to an active, independent life, if treated actively.