Updated Korean Clinical Practice Guidelines on Decompressive Surgery for Malignant Middle Cerebral Artery Territory Infarction / 대한뇌졸중학회지

No abstract available.

Clinical Practice Guidelines for the Medical and Surgical Management of Primary Intracerebral Hemorrhage in Korea

The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.

Review of Evidences and Updates of the Korean Clinical Practice Guidelines for Stroke in 2013

The first edition of Korean Clinical Practice Guidelines for Stroke, which was published in 2009, reflected evidence published prior to June 2007. Since then, many clinical trials and well-designed observational studies provided new evidence that may be pertinent to clinical practice. Accordingly, investigators of the Clinical Research Center for Stroke have timely updated the guidelines. This article summarizes the recent evidence and updated guidelines regarding the use of aspirin for primary stroke prevention, the management of asymptomatic carotid stenosis, the use of antithrombotics in atrial fibrillation for stroke prevention, the diagnosis and management of unruptured aneurysm, intravenous and intra-arterial thrombolysis in acute ischemic stroke, antiplatelet therapy for secondary stroke prevention in patients with non-cardioembolic stroke or transient ischemic attack, and the management of symptomatic carotid stenosis for secondary stroke prevention.

Endovascular Treatment of Wide-necked Cerebral Aneurysms with an Acute Angle Branch Incorporated into the Sac: Novel methods of Branch Access in 8 Aneurysms / 신경중재치료의학

PURPOSE: The optimal management of geometrically complex aneurysms remains challenging. The aim of this retrospective study was to evaluate the safety and feasibility of branch-selective technique (BT) in wide-necked aneurysms with an acute angle branch incorporated into the sac. MATERIALS AND METHODS: Eight consecutive patients harboring wide-necked cerebral aneurysms with an incorporated, acute angle branch (mean, 30.4degrees) underwent coiling over an 18-month period. Dome-to-neck ratio ranged from 0.9 to 1.8 (mean, 1.2). Every procedure utilized BT, i.e., stent- or catheter-assisted coiling through the incorporated branch. RESULTS: Technical success was achieved in all cases. With the aim to avoid the risk of aneurysmal rupture during struggling intraaneurysmal wire navigation, a 'looping method' and retrograde approach of a preshaped 0.014' microcatheter (C or J) was used for branch access in five cases and a 'looping method' and antegrade approach in one case. In the remaining one, just the C-preshape was enough to directly enter the branch without intraaneurysmal wire navigation. Overall, stent-assisted coiling was performed in seven cases, while catheter-assisted coiling was undertaken in one. The only complication was thrombotic posterior inferior cerebellar artery occlusion in one case, which was recanalized after tirofiban infusion. New neurological deficits were not identified in any cases. CONCLUSION: BT seems safe and feasible for wide-necked aneurysms with an acute angle branch incorporated into the sac. The looping method may offer safe access to the incorporated, acute angle branch and should be considered for replacement of the fearful intra-aneurysmal wire navigation.

Bilateral Approach for Stent-assisted Coiling of Posterior Inferior Cerebellar Artery Aneurysms: Two Cases

Aneurysms of the posterior inferior cerebellar artery (PICA) are rarely encountered. In particular, due to frequent anatomic complexity and the presence of nearby critical structures, PICA origin aneurysms are difficult to treat. However, recent reports of anecdotal cases using advanced endovascular instruments and skills have made the results of endovascular treatment rather outstanding. PICA preservation is the key to a successful endovascular treatment, based on the premise that a PICA origin aneurysm is well occluded. To secure PICA flow, stenting into the PICA would be the best method, however, it is nearly impossible technically via the ipsilateral vertebral artery (VA) if the PICA arose at an acute angle from the sac. In such a case, a bilateral approach for stent-assisted coiling can be a creative method for achievement of two goals of both aneurysm occlusion and PICA preservation: ipsilateral approach for coil delivery and contralateral cross-over approach for stent delivery via a retrograde smooth path into the PICA.

Observations on the Activation of Chronic Compensated Hydrocephalus in Adult Patients / 대한신경손상학회지

OBJECTIVE: There is a broad spectrum of compensated hydrocephalus. Various terms such as long-standing overt ventriculomegaly in adult (LOVA) has been coined, however, even such terms leave diverse aspect of this condition out of account. We have experienced compensated hydrocephalus cases which were considered to be activated after a long time period of quiescent state, and tried to compare their clinical characteristics with the relatively well described entity of LOVA. METHODS: We conducted a retrospective review of 206 patients who underwent ventriculoperitoneal shunt (VPS) between February 2001 and May 2012. Of these, 6 patients had chronic compensated hydrocephalus. The clinical and radiological characteristics are evaluated. RESULTS: Definite triventriculomegaly was observed in two patients. Macrocephaly was observed in two cases, one with aqueductal stenosis (AS), the other with unknown status of aqueduct. All of the cases with triventriculomegaly were normocephalic. Spinal causes were thought as aggravating factor in two. Two endoscopic third ventriculostomy and eight VPS were performed in five patients. Four patients responded well but one took a very complicated course. CONCLUSION: The relationships between macrocephaly, triventriculomegaly, and AS suggested in other studies were inconsistent. Blockage or narrowing of cerebrospinal fluid pathways were observed at various sites. Disturbances of spinal arachnoid pathways were related to the activation in some cases. Treatment is to be tailored individually considering various reigniting event. It is suggested that this entity is to be evaluated for better nomenclature reflecting diverse aspects of this condition. Further study is needed to elucidate underlying pathophysiology and effective management.

Comparative Clinical Results of Vertebroplasty Using Jamshidi(R) Needle and Bone Void Filler for Acute Vertebral Compression Fractures

OBJECTIVE: Percutaneous vertebroplasty (PVP) is an effective treatment modality for management of osteoporotic compression fracture. However physicians sometimes have problems of high pressure in cement delivery and cement leakage when using Jamshidi(R) needle (JN). Bone void filler (BVF) has larger lumen which may possibly diminish these problems. This study aims to compare the radiologic and clinical outcome of JN and BVF for PVP. METHODS: One hundred twenty-eight patients were treated with PVP for osteoporotic vertebral compression fracture (VCF) where 46 patients underwent PVP with JN needle and 82 patients with BVF. Radiologic outcome such as kyphotic angle and vertebral body height (VBH) and clinical outcome such as visual analog scale (VAS) scores were measured after treatment in both groups. RESULTS: In JN PVP group, mean of 3.26 cc of polymethylmethacrylate (PMMA) were injected and 4.07 cc in BVF PVP group (p<0.001). For radiologic outcome, no significant difference in kyphotic angle reduction was observed between two groups. Cement leakage developed in 6 patients using JN PVP group and 2 patients using BVF group (p=0.025). No significant difference in improvement of VAS score was observed between JN and BVF PVP groups (p=0.43). CONCLUSION: For the treatment of osteoporotic VCF, usage of BVF for PVP may increase injected volume of cement, easily control the depth and direction of PMMA which may reduce cement leakage. However, improvement of VAS score did not show difference between two groups. Usage of BVF for PVP may be an alternative to JN PVP in selected cases.

Therapeutic Effects and Prognostic Factors of Kyphoplasty for Thoracolumbar Osteoporotic Burst Fracture Patients

OBJECTIVE: There are few studies of osteoporotic burst fractures with spinal canal compromise that were treated with kyphoplasty. The purpose of this study was to assess the efficacy and the safety of kyphoplasty for the treatment of thoracolumbar spine osteoporotic burst fractures without neurological deficits and to investigate predictors that can improve the effectiveness of this treatment. METHODS: From October 2004 until December 2010, 79 osteoporotic burst fracture patients with asymptomatic spinal canal compromise were treated by kyphoplasty. Kyphoplasty involved injecting polymethylmethacrylate (PMMA) from the anterior one-third of the vertebral body into the posterior one-third of the vertebral body. PMMA powder and liquid were mixed in a ratio of 1:3 at 21-23degrees C. Preoperative and postoperative visual analog scores (VAS), kyphotic angles, the heights of the vertebral body, and the degrees of spinal canal compromise were analyzed. The relationships between the factors and the VAS difference between the preoperative and postoperative states were analyzed. RESULTS: The mean postoperative VAS, the postoperative kyphotic angle, the vertebral body height measurement from the anterior and the middle of the body were significantly improved after kyphoplasty (p<0.05). Postoperatively, the mean VAS was restored from 7.35 to 2.11, the postoperative kyphotic angle was restored from 18.21degrees to 12.08degrees, the vertebral body height measurement from the anterior of the body was from 18.56mm to 23.54mm and the middle of the body was from 24.81mm to 27.90mm. Among the variables, only the duration of symptoms before surgical treatment was implicated as a factor in the outcome (p<0.01). CONCLUSION: Kyphoplasty is a very effective and safe therapeutic modality for the treatment of osteoporotic burst fractures without neurological deficits. The standardization of this procedure helps to avoid complications. In the acute stages, early treatment is more effective for the reduction of pain. Further investigation is warranted in order to assess the effectiveness of early surgery in improving outcome.

Cerebral Hemorrhage after Endovascular Treatment of Bilateral Traumatic Carotid Cavernous Fistulae with Covered Stents

Bilateral traumatic carotid-cavernous fistulae (TCCFs) is rarely encountered neurovascular disease. For treatment of TCCF, detachable balloons have been widely used. Nowadays, transarterial and/or transvenous coil embolization with placement of covered stents is adopted as another treatment method. We experienced a patient with a bilateral TCCFs who was successfully treated with covered stents. However, cerebral hemorrhage occurred in the bed of previous infarction one day after treatment. Hyperperfusion syndrome was considered as a possible cause of the hemorrhage, so that barbiturate coma therapy was started and progression of hemorrhage was stopped. We emphasize that cerebral hyperperfusion hemorrhage can occur even after successful endovascular treatment of TCCF.

Guidelines for the Management of Unruptured Intracranial Aneurysm / 대한뇌혈관외과학회지

Intracranial aneurysmal rupture causes subarachnoid hemorrhage which usually leads to fatality or severe disability. Treatment of unruptured intracranial aneurysms (UIAs) can substantially reduce the risk of rupture and prevent the grave consequences, but the risk of prophylactic treatment cannot be ignored. UIAs have diverse characteristics and management strategy needs to be tailored according to their location, size and clinical status. In the absence of level I evidence, the treatment guidance often relied on expert's opinions and experience. Knowledge of the natural course and management risks of individual aneurysms can help to guide treatment decision, but the natural history is still controversial and risks are not clearly defined. The Korean Society of Cerebrovascular Surgeons (KSCVS) decided to issue a Korean version of UIA management guideline as a framework for the treatment decision and as a basis for future studies, following 'Guideline Development Manual' of the Clinical Research Center for Stroke (CRCS). The organized committee systematically reviewed relevant literature and major guidelines published between January 2000 and July 2010 and took a developmental strategy of adaptation rather than de novo methods. On the basis of interpretation of the published evidences, recommendations were synthesized, and the level of evidence and the grade of recommendation were determined using the methods adapted from those of the US Agency for Healthcare Policy and Research and CRCS. The current guideline focuses on three domains of natural history, diagnosis and treatment of UIAs. The hierarchy of evidence and the recommendation grading indicate the current level by the literature and do not indicate the necessity or the prohibition of a certain clinical practice. Accordingly, this guideline cannot provide the answer for every clinical situation and should not take precedence over the clinical judgment of responsible physicians for individual patients. The final judgment regarding the care of a particular patient must be made by the physician and patient in light of circumstances specific to that patient. This is the first version of the UIA management guideline in Korea and new evidences will be timely and continuously updated in the future guidelines.

A Comparative Result of Ventriculoperitoneal Shunt, Focusing Mainly on Gravity-Assisted Valve and Programmable Valve

OBJECTIVE: Despite rapid evolution of shunt devices, the complication rates remain high. The most common causes are turning from obstruction, infection, and overdrainage into mainly underdrainage. We investigated the incidence of complications in a consecutive series of hydrocephalic patients. METHODS: From January 2002 to December 2009, 111 patients underwent ventriculoperitoneal (VP) shunting at our hospital. We documented shunt failures and complications according to valve type, primary disease, and number of revisions. RESULTS: Overall shunt survival time was 268 weeks. Mean survival time of gravity-assisted valve (GAV) was 222 weeks versus 286 weeks for other shunts. Survival time of programmable valves (264 weeks) was longer than that of pressure-controlled valves (186 weeks). The most common cause for shunt revision was underdrainage (13 valves). The revision rate due to underdrainage in patients with GAV (7 of 10 patients) was higher than that for other valve types. Of 7 patients requiring revision for GAV underdrainage, 6 patients were bedridden. The overall infection rate was 3.6%, which was lower than reported series. Seven patients demonstrating overdrainage had cranial defects when operations were performed (41%), and overdrainage was improved in 5 patients after cranioplasty. CONCLUSION: Although none of the differences was statistically significant, some of the observations were especially notable. If a candidate for VP shunting is bedridden, GAV may not be indicated because it could lead to underdrainage. Careful procedure and perioperative management can reduce infection rate. Cranioplasty performed prior to VP shunting may be beneficial.

Surgical Treatment of Intractable Epilepsy with Benign Brain Lesion / 대한간질학회지

Epilepsy surgery can be a safe, effective treatment for individuals with intractable partial epilepsy. There is increasing evidence that brain abnormalities in focal epilepsy are not restricted to a single area. The longstanding debate around the relationship between structural lesions and the epileptic zone remains unresolved. Patients with DNT (dysembryoplastic neuroepithelial tumor), which is an essentially benign tumor, can be cured by epilepsy surgery-oriented approach. Cortical dysplasia is frequently associated with DNT and seems to contribute to epileptogenic activity of DNT. Surgical treatment should be aimed at removal of the associated cortical dysplasia as well as DNT itself for ideal treatment of the disease. Simple lesionectomy of cavernous angioma would relieve seizures significantly, but not always. The concept of epilepsy surgery needs to be recruited in the treatment of cavernous angioma with seizures because diffusion of hemosiderin into the surrounding brain tissue and formation of cortical scars can make epileptogenic areas. Cortical dysplasia is a highly epileptogenic lesion constituting an important cause of medically intractable epilepsy and surgery is a treatment of choice in a selected group of patients. Identification and complete resection of the lesion and ictal onset zone are necessary to achieve a good surgical results. Intractable epilepsy accompanied by benign brain lesions can be treated surgically using the entire armamentarium of presurgical investigations. Deliberate resective procedures aimed at complete removal of dysplastic tissue and epiletogenically active areas on and around the lesion ensure excellent seizure control without permanent neurologic deficit.

A Case of Wernicke's Encephalopathy in a Patient with Multiple System Atrophy

A 41-year-old man was admitted due to altered mentality and confusion. He had showed progressive cerebellar ataxia, dysarthria, gait disturbance from his age of 33 years old. Brain MRI revealed high signal lesions in periaqueductal gray matter, mammillary bodies, median thalami and postcentral gyri bilaterally on T2-weighted images. Severe cerebellar atrophy was noted, too. We report a case of Wernicke's encephalopathy in a patient with probable multiple system atrophy. As far as we know, there have been no published report on this kind of case.

Protracted Perihematomal Edema after Fibrinolysis Therapy with Urokinase / 대한뇌혈관외과학회지

There is increasing evidence that thrombin is directly involved in the pathogenesis of cerebral edema after intracerebral hemorrhage. Some authors emphasize that early removal of hematoma using plasminogen activator can be an effective intervention that interrupts the cascade of events leading to increasing edema formation and white matter injury. Recently, there are many reports of the edema intensification following plasminogen activator-induced lysis of the intracerebral clot. The author reports a case who showed protracted perihematomal edema after hematoma evacuation and fibrinolysis therapy with urokinase. Considering that the benefit obtained from fibrinolysis therapy may be offset by an accentuation of its toxic edematous effect, further investigation into the use of urokinase for hematoma evacuation should be undertaken.

Treatment of Cerebral AVM's with Surgery, Radiosurgery and Embolization: Clinical Experiences in 74 Patients

OBJECTIVE: With the greater availability of alternative techniques, different management strategies are evolving for the treatment of arteriovenous malformations(AVM's) and individual management decision became more complex. The purpose of this study is to report our experiences in treatment of AVM's. METHODS: We retrospectively studied the result of 74 patients with cerebral AVM's treated in 1995-1999 at our hospital. RESULTS: Of the 74 patients, 38 patients had hemorrhage as presenting symptom. Surgery was done in 47 patients. Preoperative embolization was performed in 28 patients. In 44 of these patients(93.6%), the lesions were totally removed. Postoperative radiosurgery was done in two cases with partial removal. Radiosurgery was used as a primary treatment modality in 19 patients, in four of them preradiosurgical embolization was performed. In 15 patients who were followed over 12 months, complete obliteration of the nidus was confirmed in four cases(27.6%) and partial obliteration in six cases. Embolization was performed in eight patients as a primary treatment with complete obliteration verified in only one case. There were seven fatal cases. CONCLUSION: We conclude that microsurgical resection is the most effective treatment and surgical indication can be extended by embolization and functional evaluations. Radiosurgery may be a useful treatment modality for small, deep-seated, or inoperable lesions. Embolization facilitates surgery and radiosurgery, but should be used very carefully because of high complication rate.

Treatment of Cerebral AVM's with Surgery, Radiosurgery and Embolization: Clinical Experiences in 74 Patients

OBJECTIVE: With the greater availability of alternative techniques, different management strategies are evolving for the treatment of arteriovenous malformations(AVM's) and individual management decision became more complex. The purpose of this study is to report our experiences in treatment of AVM's. METHODS: We retrospectively studied the result of 74 patients with cerebral AVM's treated in 1995-1999 at our hospital. RESULTS: Of the 74 patients, 38 patients had hemorrhage as presenting symptom. Surgery was done in 47 patients. Preoperative embolization was performed in 28 patients. In 44 of these patients(93.6%), the lesions were totally removed. Postoperative radiosurgery was done in two cases with partial removal. Radiosurgery was used as a primary treatment modality in 19 patients, in four of them preradiosurgical embolization was performed. In 15 patients who were followed over 12 months, complete obliteration of the nidus was confirmed in four cases(27.6%) and partial obliteration in six cases. Embolization was performed in eight patients as a primary treatment with complete obliteration verified in only one case. There were seven fatal cases. CONCLUSION: We conclude that microsurgical resection is the most effective treatment and surgical indication can be extended by embolization and functional evaluations. Radiosurgery may be a useful treatment modality for small, deep-seated, or inoperable lesions. Embolization facilitates surgery and radiosurgery, but should be used very carefully because of high complication rate.

Therapeutic Results of Posterior Fossa Tumors with Hydrocephalus

OBJECTIVE: This study is designed to identify the clinical characteristics and the optimal treatment modality of hydrocephalus in posterior fossa tumors. METHODS: The authors reviewed 154 infratentorial tumor patients. Age, sex, clinical symptoms, types of treatment, and surgical results of posterior fossa tumor patients with hydrocephalus were analyzed, retros-pectively. Factors which might predict the need for external ventricular drainage(EVD) or ventriculo-peritoneal shunt were analyzed statistically. RESULTS: Hydrocephalus was noted in 86 cases(56%), and it was associated with medulloblastoma in 16 cases(89%), hemangioblastoma in 12(63%) and brain stem glioma in three(33%). The surgical results of the posterior fossa tumors with hydrocephalus were poorer than those without hydrocephalus(p<0.05). A large tumor(p<0.05) and an incomplete removal(p<0.05) were factors predicting the need for EVD or shunt. Complications of intraoperative EVD or shunt developed in four cases. They were infection, he-morrhage at puncture site, and obstruction. Five patients in whom intraoperative EVD or shunt had not been performed developed a fatal hydrocephalic attack at immediate postoperative period, and the pos-toperative computed tomography scan revealed intraventricular hemorrhages in three cases cerebellar swellings in two cases. CONCLUSION: Intraoperative EVD or shunt is a safe, effective treatment modality especially in large size tumor and/or incomplete tumor resection. Intraventricular hemorrhages or cerebellar swellings during immediate postoperative period might cause fatal hydrocephalic attack, therefore EVD or shunt might be recommended in selected cases.

Analysis of Radiologic Factors Affecting Longterm Surgical Results of Anterior Cervical Fusion Patients

OBJECTIVE: Anterior cervical discectomy and fusion is accepted as appropriate surgical intervention for disease processes of the ventral cervical spine. In some cases, however, improvement of symptom following operation develop myelopathy or rhizopathy at longterm follow-up. We studied to clarify the correlation between clinical results and plain radiologic findings at long term follow-up. METHODS: A total of 86 patients who underwent anterior cervical discectomy and fusion were grouped into deteriorated and good recovery group. These two groups were compared in lateral functional roentgenograms on the cervical kyphosis and disc height at fused level, sagittal plane rotation and dynamic sagittal canal diameter at adjacent level. RESULTS: The presence of cervical kyphosis and disc height at fused level do not correlate with long term follow-up results. Sagittal plane rotation of more than 20 degrees were identified in 36% of the cases in deteriorated group, whereas the same findings were identified in 15% of the cases in good group. Sagittal diameter of less than 12mm were identified in 48% of the cases in deteriorated group, whereas the same finding were identified in 8% of the cases in good group. Preoperatively, sagittal plane rotation of more than 20 degrees at adjacent level were identified in 28% of the cases in deteriorated group, whereas the same findings were identified in 13% of the cases in good group. Preoperatively sagittal diameter of less than 12mm at adjacent level were identified in 40% of the cases in deteriorated group, whereas the same finding were identified in 7% of the cases in good group. CONCLUSION: Large sagittal plane rotation and small dynamic sagittal diameter at adjacent level were factors that might be associated with later clinical deterioration after cervical anterior fusion.

Lacrimal Gland Adenoid Cystic Carcinoma: Case Report

No abstract available.