Management of Proximal Iliac Artery Injury during Lumbar Discectomy with Stent Graft

Iatrogenic vascular injuries during lumbar disc surgery may occur rarely but they are serious complications, which can be fatal without appropriate management. Prompt diagnosis and management of these complications are imperative to prevent a desperate outcome. A 72-year-old female with proximal left common iliac artery iatrogenic injury during lumbar discectomy was successfully treated by percutaneous deployment of a stent graft in an emergency setting. Postprocedural angiogram demonstrated complete exclusion of the iliac artery laceration. The patient became hemodynamically stable. Two weeks later she complained of vascular claudication. Follow-up angiography revealed decreased arterial flow in the opposite common iliac artery. An additional kissing stent was inserted into the right common iliac artery and the symptoms of vascular claudication disappeared. Endovascular stenting offers a safe and effective method for the treatment of an iatrogenic arterial laceration, particularly in a critical condition. But, the contralateral iliac arterial flow should be kept intact in case of proximal iliac artery injury. Otherwise, additional treatments may be needed.

Management of Proximal Iliac Artery Injury during Lumbar Discectomy with Stent Graft

Iatrogenic vascular injuries during lumbar disc surgery may occur rarely but they are serious complications, which can be fatal without appropriate management. Prompt diagnosis and management of these complications are imperative to prevent a desperate outcome. A 72-year-old female with proximal left common iliac artery iatrogenic injury during lumbar discectomy was successfully treated by percutaneous deployment of a stent graft in an emergency setting. Postprocedural angiogram demonstrated complete exclusion of the iliac artery laceration. The patient became hemodynamically stable. Two weeks later she complained of vascular claudication. Follow-up angiography revealed decreased arterial flow in the opposite common iliac artery. An additional kissing stent was inserted into the right common iliac artery and the symptoms of vascular claudication disappeared. Endovascular stenting offers a safe and effective method for the treatment of an iatrogenic arterial laceration, particularly in a critical condition. But, the contralateral iliac arterial flow should be kept intact in case of proximal iliac artery injury. Otherwise, additional treatments may be needed.

Spontaneous Resolution of Nontraumatic Acute Spinal Subdural Hematoma

Spinal subdural hematoma (SSDH) is an extremely uncommon condition. Causative factors include trauma, anticoagulant drug administration, hemostatic disorders, and vascular disorders such as arteriovenous malformations and lumbar punctures. Of SSDH cases, those that do not have any traumatic event can be considered cases of nontraumatic acute spinal subdural hematoma, which is known to have diverse clinical progress. Treatment typically consists of surgical decompression and cases in which the condition is relieved with conservative treatment are rarely reported. We report two nontraumatic acute spinal subdural hematoma patients who were successfully treated without surgery.

Broken Mayfield Head Clamp

The Mayfield head clamp is the most frequently used head clamp system in the field of neurosurgery. In many cases, surgery is performed with complete reliance on the safety of the MHC. However, we experienced an extremely rare case in which the MHC accidentally broke while installing this system for immobilization of the head and neck. This is a case report with a brief review of the literature. The patient was a 58-year-old female who was scheduled to undergo cervical laminoplasty under the diagnosis of degenerative spondylotic cervical stenosis. In an attempt to install an MHC, we fixed three pins in the scalp; however, the arm of the MHC system broke when force was applied from both directions. Fortunately, the patient remained in a stable position and did not sustain an injury to the head or neck. Fixation was performed using another MHC, and the surgery was performed successfully. The patient was discharged after surgery with no specific complications related to the MHC system. The authors experienced an extremely rare case of MHC breakage during application and report the importance of properly managing and maintaining the instruments in order to prevent fatal injury.

Surgical Outcome of Cervical Arthroplasty Using Bryan(R)

OBJECTIVE: Recently, motion preservation has come to the forefront of emerging technologies in spine surgery. This is the important background information of the emergence of cervical arthroplasty as an alternative to arthrodesis that offers the promise of restoring normal spinal movement and reduces a kinematic strain on adjacent segments. The study was designed to evaluate early surgical outcome and radiological effects of Bryan(R) cervical disc prosthesis. METHODS: The authors retrospectively reviewed radiographic and clinical outcomes in 52 patients who received the Bryan(R) Cervical Disc prosthesis, for whom follow-up data were available. Static and dynamic radiographs were measured by computer to determine the angles formed by the endplates of the natural disc preoperatively, those formed by the shells of the implanted prosthesis, the angle of functional spine unit (FSU), and the C2-7 Cobb angle. The range of motion (ROM) was also determined radiographically, whereas clinical outcomes were assessed using Odom's criteria, visual analogue pain scale (VAS) and neck disability index (NDI). RESULTS: A total of 71 Bryan(R) disc were placed in 52 patients. A single-level procedure was performed in 36 patients, a two-level procedure in 13 patients, and a three-level procedure in 3. Radiographic and clinical assessments were made preoperatively. Mean follow-up duration was 29.2 months, ranging from 6 to 36 months. All of the patients were satisfied with the surgical results by Odom's criteria, and showed significant improvement by VAS and NDI score (p < 0.05). The postoperative ROM of the implanted level was preserved without significant difference from preoperative ROM of the operated level (p < 0.05). 97% of patients with a preoperative lordotic sagittal orientation of the FSU were able to maintain lordosis. The overall sagittal alignment of the cervical spine was preserved in 88.5% of cases at the final follow up. Interestingly, preoperatively kyphotic FSU resulted in lordotic FSU in 70% of patients during the late follow up, and preoperatively kyphotic overall cervical alignment resulted in lordosis in 66.6% of the patients postoperatively. CONCLUSION: Arthroplasty using the Bryan(R) disc seemed to be safe and provided encouraging clinical and radiologic outcome in our study. Although the early results are promising, this is a relatively new approach, therefore long-term follow up studies are required to prove its efficacy and its ability to prevent adjacent segment disease.

Ventriculostomy-Associated Infection : Analysis of Risk Factors and the Venue of External Ventricular Drainage / 대한뇌혈관외과학회지

OBJECTIVE: The purpose of this study is to evaluate the risk factors for ventriculostomy-associated infections (VAI) and to examine the differences among VAI according to the venue of catheter placement in our institute. Materials and METHODS: During a four-year period, 114 patients of the neurosurgical intensive care unit (NICU) who received an external ventricular drainage (EVD), were retrospectively studied. The use of prophylactic systemic antibiotics was not included in the evaluation of the risk factors for VAI, because this was applied to all patients in our trial. RESULTS: One hundred sixty-five catheters were placed, in 114 patients, among whom 7.9% developed ventriculitis. The risk of VAI was not significantly associated with age, intial Glasgow coma scale (GCS) score, indication for the catheter, craniotomy, duration of catheter, DM, hypertension and repeated catheter insertion. Furthermore, EVD catheterization in non-operating places was not associated with a trend toward higher VAI as well. CONCLUSION: Risk factors for an increased incidence of VAI were not observed in our trials. In our study, the risk of VAI was not associated with the venue of catheter placement. These findings suggest that EVD catheter insertion in non-operating places may be a safe procedure without the risk of VAI.

Fatal Aortic Tumor Embolism Presenting as Acute Paraplegia

We report a case of fatal aortic tumor embolism presenting as acute paraplegia. A four-year-old girl was referred from a local hospital with sudden paraplegia and a poor medical condition. A neighbor had noticed her fall from a bike, and she could not walk. She had no previous illness. Emergency spine MRI revealed no remarkable findings. During the process of evaluation, her general condition deteriorated progressively. Chest and abdominal CT showed a large mass in the left lung field, and a diagnosis of aortic occlusion was made. An emergency transfemoral embolectomy was attempted. However, the patency of the aorta was not recovered. On pathological examination of tissues taken from the embolectomy, a pleuro-pulmonary blastoma was found. The patient died 22 hours after the onset of her symptoms. We describe a possible mechanism for the tumor embolism. To the best of our knowledge, this is the first case report of aortic occlusion caused by an embolic malignancy, presenting as acute paraplegia.

Outcome of Aneurysmal Subarachnoid Hemorrhage Patients with Hunt-Hess Grade III / 대한뇌혈관외과학회지

OBJECT: We designed this study to bring the outcome and the outcome predictors of Hunt-Hess grade III patients to light, and to be aid in determining treatment protocol of such a intermediate group. METHODS: All patients with non-traumatic subarachnoid hemorrhage who visited our hospital between January 1998 and December 2004, were reviewed. We selected 72 Hunt-Hess grade III aneurysmal subarachnoid hemorrhage patients for detailed review. 54 operations and 10 endovacular procedures were performed. The outcome of the patients were evaluated with Glasgow Outcome Scale (GOS). Through univariate and multivariate analysis, several clinical and operative factors were evaluated to determine the significance for the outcome. RESULT: Overall 58 patients were in good outcome group (GOS 4 or 5). overall 6-month mortality was 5.6%. Age, presence of intracerabral hemorrhage(ICH) on the initial computed tomography (CT) scan, and vasospasm were independently important in determining outcome. CONCLUSION: In the Hunt-Hess grade III aneurysmal SAH patient, age, presence of ICH on intial CT scan vasospasm have independent statistical significance to the outcome. More aggressive treatment of vasospasm can improve the outcome.

Feasibility, Safety and Prognostic Factors for Computed Tomography Guided Aspiration and Thrombolysis of Intracerebral Hematoma - Clinical Analysis - / 대한뇌혈관외과학회지

OBJECTIVE: The authors reviewed experience with patients harboring intracerebral hematoma (ICH) treated by stereotactic computed tomography (CT) guided thrombolysis and aspiration and evaluated feasibility, safety and prognostic factors of this procedure. METHODS: One hundred and ten patients with supratentorial ICH >25 ml without underlying structural etiology or coagulopathy were recruited. The patients with Glasgow Coma Scale (GCS) or =4) and bad (GOS<4) prognosis group, and performed comparative analysis between two groups. RESULTS: Mean age was 59.8 years. The baseline hematoma size ranged from 15 to 72 mL. ICH volume reduced by an average of 74.2%. At 6 months after the procedure, 56 patients had achieved a good recovery, 29 patients were dependent, and 10 remained vegetative. Fifteen patients died in hospital. The main good prognostic factors were young age, small ICH volume, high GCS, absence of rebleeding, underlying disease and complications. CONCLUSION: CT-guided thrombolysis and aspiration appears safe and effective in the reduction of ICH volume. Patients of ICH presenting with bad prognostic factors should require frequent radiological investigation and more meticulous procedure. Further studies are needed to assess optimal thrombolytic dosage and must include controlled comparisons of mortality, and disability outcome.

Urokinase Thrombolysis for Nonaneurysmal Spontaneous Intraventricular Hemorrhage

OBJECTIVE: The authors report our experience of urokinase thrombolysis in treating patients harboring nonaneurysmal spontanesous intraventricular hemorrhage(IVH) and evaluated complications, safety and feasibility of this procedure retrospectively. METHODS: Fifty-three patients with nonaneurysmal IVH>15mL without underlying structural etiology or coagulopathy were recruited. The patients with Glasgow Coma Scale(GCS) or =3) and bad (GOS<3) prognosis group, and performed comparative analysis between two groups. RESULTS: Mean age was 60.2 years. The baseline hematoma size ranged 16 to 72mL. IVH volume reduction was done by an average of 74.2%. As complications, there were 3cases of rebleeding and 2cases of ventriculitis. No intracranial adverse effects were observed during thrombolytic theraphy. At 6months after the procedure, 29patients had achieved a good recovery, 15remained vegetative. 9patients died in hospital. The main good prognostic factors were young age, small IVH volume, and high GCS. CONCLUSION: The results of this study suggest that this relatively easy and safe method of treatment will improve the prognosis. However, further clinical studies also must assess optimal thrombolytic dosage, frequency, and timing of urokinase instillation for safety and effectiveness and must include controlled comparisons of mortality, disability outcome, quality of life, time until convalescence, and cost of care in treated and untreated patients.

The Safety and Feasibility of Urokinase Thrombolysis for Nonaneurysmal Intraventricular Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVES: The authors report experience with patients harboring nonaneurysmal intraventricular hemorrhage treated urokinase thrombolysis and evaluated safety and feasibility of this procedure. METHODS: Fifty-three patients with nonaneurysmal IVH >25 ml without underlying structural etiology or coagulopathy were recruited. The patients with Glasgow Coma Scale (GCS) or =3) and bad (GOS<3) prognosis group, and performed comparative analysis between two groups. RESULTS: Mean age was 60.2 years .The baseline hematoma size ranged 16 to 72 ML. IVH volume reduction was done by an average of 74.2%. At 6 months after the procedure, 29 patients had achieved a good recovery, 15 remained vegetative. 9 patients died in hospital. The main good prognostic factors were young age, small IVH volume, high GCS, underlying disease and associated complications. CONCLUSION: The results of this study suggest that this relatively easy and safe method of treatment will improve the prognosis. However, further clinical studies also must assess optimal thrombolytic dosage, frequency, and timing of urokinase instillation for safety and effectiveness and must include controlled comparisons of mortality, disability outcome, quality of life, time until convalescence, and cost of care in treated and untreated patients.

Multiple Lumbar Intradural Dermoid Cysts without Spinal Dysraphism

We report a rare case of lumbar intradural dermoid cysts. A 19 year-old male presented with low back pain for 3years. Physical examination revealed no abnormalities including skin lesions. On the magnetic resonance images, multiple intradural extramedullary cystic lesions were found in the lumbar region. These lesions were removed surgically. Histologically, the mass turned out to be a dermoid cyst. We think those were unusual intraspinal dermoid cysts because they were not associated with other congenital spinal malformation, and located in the intradural extramedullary region. We report this case of lumbar dermoid cysts with a review of literatures.

Sellar Chordoma Mimicking Pituitary Adenoma

Most chordomas involving the sellar region are parasellar or suprasellar, and largely or entirely sellar lesions are very rare. The authors report a case which chordoma involve pituitary fossa and surrounding structures and presented as nonfunctioning pituitary adenoma. Successful surgical removal was conducted via endonasal endoscopic approach. The pathology exhibited the typical histological patterns and immunophenotype of chordoma. The authors present a rare case of sellar chordoma and review the literature on that.

Surgical Removal of a Huge Atypical Choroid Plexus Papilloma

The authors present a case of huge atypical choroid plexus papilloma in both lateral and third ventricles. A 2-year-old girl presented with lethargy and vomiting. Magnetic resonance images disclosed a huge enhancing mass, which probably arose from the left lateral ventricle and extended to the right lateral and the third ventricles. Total removal of the mass via the interhemispheric transcallosal approach was done. Histologically, an atypical choroid plexus papilloma was identified. Second operative treatment, subduro-peritoneal shunt, was performed due to postoperative subdural effusion. The patient was discharged two weeks after the second surgical procedure without a neurological deficit.

Clinical Significance of Preoperative Cine Magnetic Resonance Study in Communicating Hydrocephalus

OBJECTIVE: To evaluate the changes of intracranial cerebrospinal fluid(CSF) dynamics in communicating hydrocephalus, the authors present an analysis of various parameters of cine magnetic resonance(MR) CSF flow images in case of progressive communicating hydrocephalus. METHODS: The MR images were obtained with 1.5T(GE Signa, GE Medical Systems, Milwaukee, USA) unit using the 2 dimensional cine phase contrast sequence with cardiac gating and gradient recalled echo imaging in 10 communicating hydrocephalus and 10 controls. Various parameters of the aqueduct and cervicomedullary subarachnoid space were plotted as wave forms. The wave forms were analyzed for configurations, amplitude parameters(Vmax, Vmin, Vdif), and temporal parameters(R-MSV, R-D, R-MDV, R-S). The statistical significance of each parameter examined with paired t-test. RESULTS: Distinct reproducible configuration features were obtained at both ROIs. We could determine the statistically significant differences between control and communicating hydrocephalus in temporal parameters at the aqueduct level. There was no significant differences at the cervicomedullary subarachnoid space level. In communicating hydrocephalus, the graph showed R-MDV(p=0.005) and R-S(p=0.001) shortening at the aqueduct. CONCLUSION: The analysis of cine MR CSF flow study may be helpful for diagnosing the communicating hydrocephalus and even deciding the necessity of shunting procedures. The temporal parameters are more important than amplitude parameters for diagnosing communicating hydrocephalus.

Spinal Epidural Cavernous Hemangioma Simulating a Disc Protrusion: A Case Report

The authors present a case of solitary pure epidural cavernous angioma. A 47-year-old man was admitted our department due to acute back pain and left lower extremity radicular pain. Lumbar spine magnetic resonance(MR) image revealed a mass, 1x0.8x0.8cm in size, located in L4/5 intervertebral disc space. We performed surgical excision and it was confirmed cavernous angioma, histologically. Postoperatively, patient has no neurological deficit and no specific complication. Follow-up MR imaging six months later showed no residual mass. The solitary pure spinal epidural cavernous angiomas are exceedingly rare. It is suggested that spinal epidural cavernous angioma should be included in the differential diagnosis of epidural mass and simple herniated disc.

The Outcome of Anterior Microforaminotomy for Single Level Cervical Radicular Disease

OBJECTIVE: Anterior cervical microforaminotomy has become one of surgical options to treat cervical rad iculopathy. The goal of this study is to evaluate the effectiveness of anterior cervical microforaminotomy for single-level cervical radicular disease. METHODS: We performed a prospective review of radiological data and clinical records only in patients whom the patients met the inclusion criteria for this study. Among 53 patients who underwent anterior cervical microforaminotomy between June 2000 and May 2002, 36 patients were evaluated in this study. RESULTS: Male to female rate was 2: 1 and mean age was 46.1(28-63) years. Compressive pathological lesions included disc herniation in 24 cases(66.7%), spondylosis 10 cases(27.8%), and a combined of the two in 2 cases(5.5%). Twenty eight patients(77.8%) experienced excellent results, six patients(16.7%) experienced good results, and two patients(5.5%) experienced fair results. No patient demonstrated a poor or unchanged outcome. All patients showed adequate decompression in their postoperative computed tomography or magnetic resonance images. There were no complications. Mean hospital stay was 3.9(3-12) days. CONCLUSION: Patients treated with the anterior cervical microforaminotomy procedure for single-level cervical radicular disease have good outcomes. It appears to be a good alternative procedure for cervical radicular disease. But this procedure have complications such as vertebral artery injury. And long term follow up should be analyzed for instability or recurrence of disc herniation.

Clinical Study of the Serial Changes of Fixed Segmental Height and Cobb Angle in Anterior Cervical Fusion

The authors investigated the serial changes of height and Cobb angle in the fused segments in the anterior cervical fusion. Patients who underwent anterior cervical fusion and fixation were investigated from September 1993 to August 1997. Total of 52 cases who met the following entry criteria were included in this study: (a) no history of prior cervical spine surgery or concomittent posterior fusion, (b) an anatomic radiculopathy or myelopathy that correlated with a radiographic study at the corresponding level, and(c) the clinical follow-up period of at least ten months. The radiographic data were obtained retrospectively from routine clinical radiographs, which included neutral radiographs preoperatively, immediate-postoperatively, and at 4-6 months postoperatively. The heights of the fixed segment were increased significantly after the operation(p<0.05 on Oneway ANOVA on ranks), and then decreased to preoperative value at last follow-up. The lordotic angles were increased after the operation and maintained throughout the study period(p<0.05 on Oneway ANOVA). In conclusion, on the contrary to the general belief that plate fixation can prevent the decrease in the segmental height, we found that the gain of height lasted only temporarily. Despiter this, postoperatively increased lordotic curve was maintained through the study period in spite of height loss. Therefore, we think that the lordosis of the cervical spine may reflects most of functional status of the whole cervical spine rather than height gain of the fused segment.

A Case of Orbital Cavernous Angioma Associated with Intracranial Venous Anomalies

The authors present a rare case of orbital cavernous malformation associated with intracranial venous anomalies. A 7-year-old female patient was admitted to our hospital complaining of headache and progressive diplopia. Neurologic examination revealed a painful proptosis and limited movement of right eye. Magnetic resonance images demonstrated a cavernous malformation in the right orbit, intracerebral cystic cavernous malformation, and well-enhancing vascular marking in the right temporal lobe. On the cerebral angiography, dilated vein of Labb and duplicated transverse sinus were noted. The patient showed marked improvement of her vision after the total removal of the orbital lesion. We believe this is an another evidence that cavernous malformation may be derived from increased burden of cerebral blood flow and/or venous pressure.