Deep Vein Thrombosis Following Prolonged Prone Position Maintenance after Vitrectomy for Rhegmatogenous Retinal Detachment

Purpose@#We report a rare case of deep vein thrombosis and pulmonary embolism that occurred following 2 weeks in the prone position after a trans pars plana vitrectomy with gas tamponade to treat rhegmatogenous retinal detachment.Case Summary: A 49-year-old man without a remarkable medical history visited our clinic complaining of gradual vision loss on the inferior side of the left eye. In fundus examinations, rhegmatogenous retinal detachment involving the macula with multiple tears was noted. After trans pars plana vitrectomy with gas tamponade, the patient was encouraged to maintain a prone position for retinal reattachment. However, after 2 weeks in the prone position, he complained of right calf pain and swelling. The department of cardiovascular surgery was consulted immediately and deep vein thrombosis and pulmonary embolism were diagnosed. After deep vein thrombectomy and anticoagulation therapy, the lower extremity symptoms improved and the patient was stable during follow-up with a well attached retina. @*Conclusions@#When prolonged prone positioning after retina surgery is necessary, careful monitoring for the possibility of deep vein thrombosis and pulmonary embolism is required, especially in high-risk patients.

Posterior Inferior Cerebellar Artery Infarction Originating at C1-2 after C1-2 Fusion / 대한신경손상학회지

Vertebral artery injuries associated with C1 lateral mass screw insertion rarely occur during C1-2 fusion. The posterior inferior cerebellar artery (PICA) is uncommonly located at the C1 lateral mass insertion position. A 71-year-old woman with atlanto-axial subluxation and cord compression underwent C1-2 fusion. Sixth nerve palsy and diplopia were detected postoperatively, and decreased consciousness occurred on postoperative day 4. Brain magnetic resonance image (MRI) and computed tomography (CT) revealed PICA infarction. In the preoperative CT angiography, the PICA originated between the C1 and C2 level. In the postoperative CT scan, the PICA was not visible. The patient was treated conservatively for two weeks and recovered. PICA originating between the C1 and C2 level comprises 1.1–1.3% of cases. Therefore, vertebral artery anomalies should be evaluated prior to C1-2 fusion to prevent vessel injuries.

Progressive Cervical Spondylotic Myelopathy Caused by Tic Disorders in a Young Adult with Tourette Syndrome / 대한신경손상학회지

Involuntary movement of the cervical spine can cause damage to the cervical spinal cord. Cervical myelopathy may occur at an early age in involuntary movement disorders, such as tics. We report the case of a 21-year-old man with Tourette syndrome, who developed progressive quadriparesis, which was more severe in the upper extremities. The patient had abnormal motor tics with hyperflexion and hyperextension of the cervical spine for more than 10 years. High-signal intensity intramedullary lesions were observed at C3-4-5-6 level on T2 weighted magnetic resonance imaging. Examinations were performed for high-signal intensity intramedullary lesions that may occur at a young age, but no other diseases were detected. Botulinum toxin injection to the neck musculature and medication for tic disorders were administered. However, the myelopathy was further aggravated, as the involuntary cervical movement still remained. Therefore, laminoplasty was performed at C3-4-5-6, with posterior fixation at C2-3-4-5-6-7 to alleviate the symptoms. The neurological signs and symptoms improved dramatically. The management of tic disorders should be the first priority during treatment. However, surgical treatment may be necessary, if symptoms worsen after appropriate treatment.

Tracheal Infection Resulting from High Endotracheal Tube Cuff Pressure in an Unconscious Patient with Brain Trauma / 대한신경손상학회지

Deep neck infections (DNIs) are mainly caused by dental caries, tonsillitis, and pharyngitis; however, DNIs can also occur after head and neck trauma. A 79-year-old male patient underwent a craniectomy due to an acute subdural hematoma. The patient was unconscious and continued to have a fever, but no clear cause was found. On postoperative day 9, he suddenly showed redness and swelling on the anterior neck. Enhanced computed tomography of the pharynx revealed tracheal necrosis and an abscess in the surrounding area. An incision and drainage were performed and Enterobacter aerogenes and E. faecalis were identified. The infection was controlled after antibiotic treatment. High endotracheal tube cuff pressure was suspected as the cause of the tracheal infection. Although DNIs are difficult to predict in patients who cannot report their symptoms due to unconsciousness, prevention and rapid diagnosis are important, as DNIs have serious side effects.

Stent-Assisted Coil Embolization Using Only a Glycoprotein IIb/IIIa Inhibitor (Tirofiban) for Ruptured Wide-Necked Aneurysm Repair

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of stent-assisted coil embolization using only a glycoprotein IIb/IIIa inhibitor (tirofiban). MATERIALS AND METHODS: We retrospectively reviewed patients with a subarachnoid hemorrhage due to ruptured wide-necked intracranial aneurysms who were treated by stent-assisted coil embolization. In all patients, the glycoprotein IIb/IIIa inhibitor tirofiban was administered just before stent deployment. Electronic medical records for these patients were reviewed for peri-procedural complications and extra-ventricular drainage catheter related hemorrhage, as well as Glasgow outcome scale (GOS) at discharge, 3 months, and 6 months follow-up were recorded. RESULTS: Fifty-one aneurysms in 50 patients were treated. The mean patient age was 64.9 years. Eighteen patients (36%) received a World Federation of Neurosurgical Societies grade of 4 or 5. The mean aneurysm size was 9.48 mm and mean dome-to-neck ratio was 1.06. No intraoperative aneurysm ruptures occurred, although five (10%) episodes of asymptomatic stent thrombosis did occur. Three patients experienced a delayed thrombo-embolic event and two a delayed hemorrhagic event. Immediate radiologic assessment indicated a complete occlusion in 29 patients, a residual neck in 19, and a residual sac in 3. Four patients (8%) died. Sixteen patients (32%) experienced a poor GOS (< 4). Two aneurysms were recanalized during the follow-up period (mean, 19 months for clinical and 18 months for angiographic follow-up). CONCLUSION: Treatment of ruptured wide-necked intracranial aneurysms via stent-assisted coil embolization with a glycoprotein IIb/IIIa inhibitor alone was found to be relatively safe and efficient.

Bilateral Infarction of the Recurrent Arteries of Heubner Following Clipping of an Anterior Communicating Artery Aneurysm

A 50-year-old woman reported to the emergency department with thunderclap headache and vomiting. Non-enhanced brain computed tomography (CT) showed a subarachnoid hemorrhage of Hunt-Hess Grade II and Fisher Grade III. Brain angiography CT and transfemoral cerebral angiography (TFCA) revealed an aneurysm of the anterior communicating artery. A direct neck clipping was performed using the pterional approach. The post-operation CT was uneventful. Six days postoperatively, the patient became lethargic. The mean velocity (cm/s) of the middle cerebral artery peaked at 173 cm/s on the right side and 167 cm/s on the left. A TFCA revealed decreased perfusion in both recurrent arteries of Heubner (RAH), but no occlusion in either. Intra-arterial nimodipine injection was administered. On the 7th postoperative day, CT demonstrated a newly developed low-density lesion in the RAH territory bilaterally. The cause of the infarction was attributed to decreased perfusion caused by cerebral vasospasm. The patient was discharged with no definite neurologic deficit except for mild cognitive disorder.

Classification of chronic rhinosinusitis according to a nasal polyp and tissue eosinophilia: limitation of current classification system for Asian population

Chronic rhinosinusitis (CRS) can be classified according to the presence of a nasal polyp (NP): CRS with NP (CRSwNP) and CRS without NP (CRSsNP). CRSwNP has characteristics with high infiltration of tissue eosinophilia with a burst of Th2 inflammatory cytokine. However recent findings in Eastern Asia countries suggest that CRSwNP can be divided according to the presence of tissue eosinophilia. Thus, CRSwNP can be classified into eosinophilic and noneosinophilic. Eosinophilic CRSwNP seems to have different immunological and clinical feature compared to noneosinophilic CRSwNP. From the same point of view, CRSsNP can also be divided according to tissue eosinophilia. However, the meaning of this dichotomous categorization in CRS seems to be not quite clear. This review focus on the limitations in current subclassification of CRS according to the presence of NP and tissue eosinophilia and discuss other factors related to tissue remodeling and NP generation which may provide clues for the further understanding of CRS pathogenesis.

Epidural Metastasis in Malignant Thymoma Mimicking Epidural Abscess: Case Report and Literature Review

Thymoma and thymic carcinoma are rare epithelial tumors that originate from the thymus gland. Extrathoracic metastases occur in the liver, kidney, and bone in 1% to 15% of patients. Although thymoma and thymic carcinoma exhibit highly aggressive biological behavior, spinal metastasis is rare. We describe a 78-year-old man with left wrist and grasp weakness that occurred 7 days before admission. The patient underwent thymoma surgery 7 years ago and was cured. Magnetic resonance images showed a rim-enhanced mass in the C6–7–T1 epidural space. C6–7–T1 laminectomy was performed and the mass was removed. Histological examination was performed and patient was diagnosed with metastatic thymoma. The previous reported case occurred with involvement of the vertebral body or posterior element, but our case was mostly rim-enhanced and appeared as an abscess and intradural extramedullary tumor.

Endovascular Treatments for Ruptured Intracranial Vertebral Artery Dissecting Aneurysms: Experience in 16 Patients

OBJECTIVE: Intracranial vertebral artery dissecting aneurysms are rare lesions that are considered an important cause of spontaneous subarachnoid hemorrhage. We report our decade-long experience in treating ruptured intracranial vertebral artery dissecting aneurysms. MATERIALS AND METHODS: This retrospective single-center study included 21 consecutive patients between February 2005 and March 2015. Their clinical features included radiologic finding at the initial examination, treatment modality, functional outcome at the last follow-up, mortality, and radiologic outcome at more than 6 months after the initial treatment. RESULTS: All 16 aneurysms were treated endovascularly; aneurysm trapping was performed in 9 patients and vascular reconstruction was performed in 7 patients. For 6 aneurysms involving the posterior inferior cerebellar artery (PICA), the modalities of treatment were aneurysm trapping in 3 patients and vascular reconstruction in 3 patients. The mean duration of follow-up was 29 months (range, 6–70 months). Five patients expired, indicating a mortality rate of 31%. In surviving patients, the unfavorable outcome rate (modified Rankin Scale [mRS] > 2) was 36%. The overall mean mRS for survivors was 1.8. Angiographic follow-up in 11 survivors at 13 months, (range, 6–46 months) revealed recanalization of the aneurysm in one patient. CONCLUSIONS: Ruptured intracranial vertebral artery dissecting aneurysm is associated with poor functional outcome and high mortality. More immediate treatments are needed due to the high rebleeding rate in this disease condition. Endovascular treatment may be a useful option for ruptured intracranial vertebral artery dissecting aneurysms.

Clinical Features and Outcomes of a Rare Nasal Cavity Tumor Glomangiopericytoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Glomangiopericytoma falls within the category of borderline low-malignant-potential soft tissue tumors of the nose and paranasal sinuses. It is a rare tumor arising from the pericytes surrounding capillaries, and accounts for less than 0.5% of all sinonasal tumors. The aim of this study was to analyze the clinical manifestation and surgical outcomes of the glomangiopericytoma in the nasal cavity. SUBJECTS AND METHOD: Medical records of eight patients who were surgically managed for glomangiopericytoma of the nose and paranasal sinuses from 2000 to 2015 were retrospectively reviewed. Clinical features, size, Immunohistochemical staining, extent of surgery, adjuvant treatment, and recurrence were evaluated. RESULTS: Eight patients, 3 males and 5 females, were enrolled, with the mean age of 54.7 years old. The most common symptom of glomangiopericytoma was ipsilateral nasal obstruction. All patients got surgical treatment, and one patient received radiation to the surgical site, whose margin of resection was positive. The mean follow-up period was 39.5 months (3-176 months). During the follow-up period, one patient was found to have a positive resection margin. CONCLUSION: The surgical outcome shows that complete initial excision is important to prevent recurrence. Furthermore, adjuvant radiation therapy may also be a reasonable option for some patients with margin involvement.

A Viewpoint on Treatment of Traumatic Bilateral Basal Ganglia Hemorrhage in a Child: Case Report / 대한신경손상학회지

Traumatic basal ganglia hemorrhage (TBGH) is a rare presentation of head injuries. Bilateral lesions are extremely rare. The pathophysiologic mechanism of bilateral TBGH seems to be the same as diffuse axonal injury. However, limited information about childhood bilateral TBGH is available in the literature. We report the case of a child with bilateral TBGH treated with stereotactic aspiration of hemorrhage and periodic urokinase irrigation.

The Safety and Decision Making of Instrumented Surgery in Infectious Spondylitis

OBJECTIVE: Infectious spondylitis is mostly managed by appropriate antibiotic treatment options, and some patients may require surgical interventions. However, surgical interventions that use spinal instrumentation to correct the mechanical instability may be associated with the risk of an increase in the recurrence rate. In this study, we investigated whether spinal instrumentation effects on recurrence of infectious spondylitis. METHODS: The study was conducted as a retrospective study by dividing the subjects into the noninstrumentation surgery and instrumentation surgery groups among a total of 95 patients who had received surgical interventions in infectious spondylitis from 2009 to 2014. The study investigated patient variables such as underlying illness, presumed source of infection, clinical data, laboratory and radiological data, and ultimate outcome, and compared them between the 2 groups. RESULTS: In the 95 patients, instrumentation was not used in 21 patients but it was used in 74 patients. When the disease involved ≥3 vertebral bodies, lumbosacral level and epidural part, noninstrumentation surgery was mainly conducted, but when the disease involved the thoracic level and psoas muscle part, instrumentation surgery was mainly conducted. However, there were no differences between the 2 groups in terms of the recurrence rate and the incidence of primary failure. CONCLUSION: The use of instrumentation in treating infectious spondylitis was determined by the level of involvement and part of the infection, but the use of instrumentation did not cause any increases in the recurrence rate and the incidence of primary failure.

Comparison of the Effectiveness between Sampling Methods for Protein Analysis of Tear Fluids

PURPOSE: Although various sampling methods of tears from conjunctival sac have been reported, no previous study compared their effectiveness or efficiency based on protein extraction. By comparing the compliance, volume and protein concentration of each tear sampling method, we searched for the most efficient tear collection method. METHODS: Resting tear samples of 14 eyes of normal subjects were collected using Schirmer paper, capillary tube, cellolose acetate rod and 3 different ophthalmic sponges made of different materials and density (Merocel(R), KeraCel(R) and Weck-Cel(R)). After centrifugation of the collected tear samples, the tear volume and protein concentration were measured for each method. Additionally, the compliance of each tear sampling method was analyzed by numerically representing the amount of discomfort experienced during resting tear collection. RESULTS: The average volume retrieved by each tear sampling method was 9.0 +/- 1.1 microL with no significant differences between groups. The average concentration of protein retrieved by each tear sampling method was 5.3 +/- 1.2 microg/microL. Merocel(R) retrieved 7.6 +/- 0.61 microg/microL, which was significantly higher than other sampling methods (p < 0.05). The compliance of Merocel(R) and the capillary tube were the highest, while KeraCel(R) showed the lowest compliance. CONCLUSIONS: Merocel(R) retrieved the highest amount of protein and showed high compliance and may be the most effective and easily applicable tear sampling method in clinical settings.

Relationship Between Snoring Intensity and Severity of Obstructive Sleep Apnea

OBJECTIVES: The aim of this study was to determine the relationship between the intensity of snoring and severity of sleep apnea using Watch-PAT (peripheral arterial tone) 100. METHODS: A total of 404 patients (338 males and 66 females) who underwent home-based portable sleep study using Watch-PAT 100 for obstructive sleep apnea (OSA) from January 2009 through December 2011 were included in this study. Subjects were divided into 4 groups; no OSA (PAT apnea hypopnea index [pAHI] or =30/hour). Mean snoring intensity and percent sleep time with snoring intensity greater than 40, 50, and 60 dB were measured by Watch-PAT 100. Correlations of these parameters with apnea hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index were assessed. RESULTS: The mean age and body mass index were 46.5+/-14.8 years and 24.7+/-3.4 kg/m2, respectively. Mean AHI and RDI were 16.5+/-15.3/hour and 20.8+/-14.3/hour, respectively. The mean snoring intensity in the no, mild, moderate, and severe OSA groups was 44.0+/-2.7, 45.4+/-6.0, 47.7+/-5.0, and 50.5+/-5.6 dB, respectively (P<0.001). There was a positive correlation between snoring intensity and pAHI or PAT RDI (pRDI) (r=0.391 and r=0.385, respectively, both P<0.001). There was also a positive correlation between percent sleep time with the snoring intensity greater than 50 dB and pAHI or pRDI (r=0.423 and r=0.411, respectively, both P<0.001). CONCLUSION: This study revealed that the intensity of snoring increased with the severity of sleep apnea, which suggests that the loudness of snoring might be an indicator of the severity of OSA.

Analysis of the Risk Factors Affecting the Surgical Site Infection after Cranioplasty Following Decompressive Craniectomy / 대한신경손상학회지

OBJECTIVE: The risk factors for surgical site infections (SSIs) after cranioplasty following decompressive craniectomy remain unclear. The goal of this study was to analyze the risk factors related to developing SSIs after cranioplasty and to suggest valuable predictors. METHODS: A retrospective review was conducted of patients who underwent cranioplasty following decompressive craniectomy at our institution from January 2011 to December 2014, a total of 78 patients who underwent 78 cranioplasties. Univariate and multivariate logistic regression analyses were carried out to determine possible risk factors related to developing SSIs. We analyzed both patient-specific and surgery-specific factors. RESULTS: The overall rate of SSIs was 9.0% (7/78). SSIs after cranioplasty were significantly related to being female, having the primary etiology of traumatic brain injury (TBI) and having had a bilateral cranioplasty in the univariate analysis. Multivariate logistic regression analysis showed that being female [odds ratio (OR) 5.98, p=0.000] and having had a bilateral cranioplasty (OR 4.00, p=0.001) significantly increased the risk of SSIs. CONCLUSION: Based on our data, cranioplasty following decompressive craniectomy is associated with a high incidence of SSI. Being female, having a primary etiology of TBI and having had a bilateral cranioplasty may be risk factors for surgical site infections after cranioplasty.

An Unruptured Cerebral Aneurysm at the Origin of the Duplicated Middle Cerebral Artery

A variety of cerebral vascular anomalies are widely applied, however anomalies of the middle cerebral artery (MCA) are relatively infrequent. The duplicated MCA (DMCA) is a MCA anomaly. Aneurysm arising from the origin of the DMCA is rare. Cerebral angiography in a 61-year-old female demonstrated a small (about 3 mm) saccular aneurysm located at the origin of the DMCA in the anterior direction. Considering the unusual location, the lesion was treated, regardless of the size. Aneurysmal characteristics of a broad neck and small size limited the endovascular approach, necessitating open surgery. Her postoperative course was uneventful and postoperative angiography showed complete obliteration of the aneurysm. The patient was discharged without neurologic deficit.

Selection of Treatment for Large Non-Traumatic Subdural Hematoma Developed during Hemodialysis / 대한구급학회지

A 49-year-old man with end-stage renal disease was admitted to the hospital with a severe headache and vomiting. On neurological examination the Glasgow Coma Scale (GCS) score was 15 and his brain CT showed acute subdural hematoma over the right cerebral convexity with approximately 11-mm thickness and 9-mm midline shift. We chose a conservative treatment of scheduled neurological examination, anticonvulsant medication, serial brain CT scanning, and scheduled hemodialysis (three times per week) without using heparin. Ten days after admission, he complained of severe headache and a brain CT showed an increased amount of hemorrhage and midline shift. Emergency burr hole trephination and removal of the hematoma were performed, after which symptoms improved. However, nine days after the operation a sudden onset of general tonic-clonic seizure developed and a brain CT demonstrated an increased amount of subdural hematoma. Under the impression of persistent increased intracranial pressure, the patient was transferred to the intensive care unit (ICU) in order to control intracranial pressure. Management at the ICU consisted of regular intravenous mannitol infusion assisted with continuous renal replacement therapy. He stayed in the ICU for four days. Twenty days after the operation he was discharged without specific neurological deficits.

Cortical Magnetic Resonance Imaging Findings in Patients With Posttraumatic Olfactory Dysfunction: Comparison According to the Interval Between Trauma and Evaluation

OBJECTIVES: Patients with smell loss after craniocerebral trauma are known to have some brain abnormalities, but there was no study to analyze the findings according to the time interval between injury and evaluation. We aimed to identify whether the time interval may influence on the findings in the brain. METHODS: Medical records of 19 patients with posttraumatic olfactory dysfunction were reviewed. All of them underwent a magnetic resonance imaging and olfactory function tests. The patients were divided into early (n=10) and delayed (n=9) groups according to the time interval. RESULTS: Magnetic resonance imaging was taken at a mean time of 2.2 and 59.6 months after trauma in the early and delayed groups, respectively. Abnormal findings in the brain were found in 6 and 8 patients in the early and delayed groups, respectively. The olfactory bulb and orbitofrontal cortex were commonly affected olfactory pathways in both groups. In the early group, the abnormalities were brain tissue defect, hemorrhage, and focal edema whereas tissue defect was the only finding in the delayed group. In the early group, 5 of 6 patients with severe olfactory dysfunction showed brain abnormality while 1 of 4 patients with mild dysfunction had abnormality. In the delayed group, all the patients had severe dysfunction and 8 of 9 patients showed brain abnormality. CONCLUSION: Most patients with traumatic olfactory dysfunction had abnormality in the brain, and brain abnormality might be different according to the timing of evaluation. Furthermore, there might be an association between the severity of olfactory dysfunction and radiological abnormalities.

Tension Band Wiring for Distal Clavicle Fracture: Radiologic Analysis and Clinical Outcome

PURPOSE: The purpose of this study is to evaluate the radiologic and clinical outcomes after tension band wire fixation of Neer type II distal clavicle fractures. MATERIALS AND METHODS: Twenty-six patients with Neer type II distal clavicle fractures who underwent tension band wire fixation from March 2002 to May 2011 were included in the study. Fifteen cases were classified as Neer type IIa and 11 cases as type IIb. The postoperative mean follow-up period was 14.3 months. Clinical and radiologic evaluation was performed at two weeks, six weeks, three months, six months, and 12 months postoperatively. RESULTS: Bony union on X-rays was observed at an average of 11.7 weeks (range 8-20 weeks) postoperatively. The overall visual analogue scale score for pain was 1.23+/-2.75 postoperatively. The overall postoperative University of California at Los Angeles score increased to 33.5+/-2.15 from the preoperative score of 21.6+/-1.91 (p<0.05). CONCLUSION: Among various methods of treatment for Neer type II distal clavicle fracture, K-wire and tension band fixation was used and relatively satisfactory radiological and clinical results were obtained. This surgical method yields excellent clinical results, owing to its relatively easy technique, fewer complications, and allowance of early rehabilitation.

Surgical Treatment of Pyogenic Spondylitis with the Use of Freeze-Dried Structural Allograft

OBJECTIVE: Radical debridement and reconstruction is necessary for surgical treatment of pyogenic spondylitis to control infection and to provide segmental stability. The authors identified 25 patients who underwent surgery for pyogenic spondylitis using freeze-dried structural allograft for reconstruction. This study aimed to evaluate and demonstrate the effectiveness and safety of a freeze-dried structural allograft during the surgical treatment of pyogenic spondylitis. METHODS: From January 2011 to May 2013, we retrospectively reviewed 25 surgically treated patients of pyogenic spondylitis. Surgical techniques used were anterior radical debridement and reconstruction with a freeze-dried structural allograft and instrumentation. In these 25 patients, we retrospectively examined whether the symptoms had improved and the infection was controlled after surgery by evaluating laboratory data, clinical and radiological outcomes. The average follow-up period was 15.7 months (range, 12.2-37.5 months). RESULTS: The infection resolved in all of the patients and there were no cases of recurrent infection. The mean Visual Analog Scale score was 6.92 (range, 5-10) before surgery and 1.90 (range, 0-5) at the time of the last follow-up. Preoperatively, lower extremity motor deficits related to spinal infection were noted in 10 patients, and they improved in 7 patients after surgery. Follow-up computed tomographic scans were obtained from 10 patients, and osseous union between the vertebral body and the structural allograft was achieved in 2 patients. CONCLUSION: The freeze-dried structural allograft can be a safe and effective alternative for surgical treatment of pyogenic spondylitis, and another option for vertebral reconstruction instead of using the other materials.