Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy

Objective@#: Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time. @*Methods@#: The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time. @*Results@#: The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively). @*Conclusion@#: The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and doorto- recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.

Changes in Blood Pressure and Heart Rate during Decompressive Craniectomy

Objective@#: Rapid increase in intracranial pressure (ICP) can result in hypertension, bradycardia and apnea, referred to as the Cushing phenomenon. During decompressive craniectomy (DC), rapid ICP decreases can cause changes in mean atrial blood pressure (mABP) and heart rate (HR), which may be an indicator of intact autoregulation and vasomotor reflex. @*Methods@#: A total of 82 patients who underwent DC due to traumatic brain injury (42 cases), hypertensive intracerebral hematoma (19 cases), or major infarction (21 cases) were included in this prospective study. Simultaneous ICP, mABP, and HR changes were monitored in one minute intervals during, prior to and 5–10 minutes following the DC. @*Results@#: After DC, the ICP decreased from 38.1±16.3 mmHg to 9.5±14.2 mmHg (p<0.001) and the mABP decreased from 86.4±14.5 mmHg to 72.5±11.4 mmHg (p<0.001). Conversly, overall HR was no significantly changed in HR, which was 100.1±19.7 rate/min prior to DC and 99.7±18.2 rate/min (p=0.848) after DC. Notably when the HR increased after DC, it correlated with a favorable outcome (p<0.001), however mortality was increased (p=0.032) when the HR decreased or remained unchanged. @*Conclusion@#: In this study, ICP was decreased in all patients after DC. Changes in HR were an indicator of preserved autoregulation and vasomotor reflex. The clinical outcome was improved in patients with increased HR after DC.

Clinical Significance of Decompressive Craniectomy Surface Area and Side

Objective@#: Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side. @*Methods@#: A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side. @*Results@#: DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively). @*Conclusion@#: DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.

Current Status of Neurosurgical and Neurointensive Care Units in Korea : A Brief Report on Nationwide Survey Results

Objective@#: The purpose of this study is identify the operation status of the neurosurgical care units (NCUs) in neurosurgical residency training hospitals nationwide and determine needed changes by comparing findings with those obtained from the Korean Neurosurgical Society (KNS) and Korean Society of Neurointensive Care Medicine (KNIC) survey of 2010.Method : This survey was conducted over 1 year in 86 neurosurgical residency training hospitals and two neurosurgery specialist hospitals and focused on the following areas : 1) the current status of the infrastructure and operating systems of NCUs in Korea, 2) barriers to installing neurointensivist team systems, 3) future roles of the KNS and KNIC, and 4) a handbook for physicians and practitioners in NCUs. We compared and analyzed the results of this survey with those from a KNIC survey of 2010. @*Results@#: Seventy seven hospitals (87.5%) participated in the survey. Nineteen hospitals (24.7%) employed a neurointensivist or faculty member; Thirty seven hospitals (48.1%) reported high demand for neurointensivists, and 62 hospitals (80.5%) stated that the mandatory deployment of a neurointensivist improved the quality of patient care. Forty four hospitals (57.1%) believed that hiring neurointensivist would increase hospital costs, and in response to a question on potential earnings declines. In terms of potential solutions to these problems, 70 respondents (90.9%) maintained that additional fees were necessary for neurointensivists’ work, and 64 (83.1%) answered that direct support was needed of the personnel expenses for neurointensivists. @*Conclusion@#: We hope the results of this survey will guide successful implementation of neurointensivist systems across Korea.

Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients

OBJECTIVE: Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.METHODS: One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.RESULTS: Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).CONCLUSION: The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.

Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients

OBJECTIVE: Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance. METHODS: One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality. RESULTS: Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007). CONCLUSION: The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.

Proper Management of Posttraumatic Tension Pneumocephalus / 대한신경손상학회지

Pneumocephalus is commonly seen after craniofacial injury. The pathogenesis of pneumocephalus has been debated as to whether it was caused by ball valve effect or combined episodic increased pressure within the nasopharynx on coughing. Discontinuous exchange of air and cerebrospinal fluid due to “inverted bottle” effect is assumed to be the cause of it. Delayed tension pneumocephalus is not common, but it requires an active management in order to prevent serious complication. We represent a clinical case of a 57-year-old male patient who fell down from 3 m height, complicated by tension pneumocephalus on 5 months after trauma. We recommend a surgical intervention, but the patient did not want that so we observe the patient. The patient was underwent seizure and meningitis after 7 months after trauma, he came on emergency room on stupor mentality. Tension pneumocephalus may result in a neurologic disturbance due to continued air entrainment and it significantly the likelihood of intracranial infection caused by continued open channel. Tension pneumocephalus threat a life, so need a neurosurgical emergency surgical intervention.

Clinical Results of the Intra-Arterial Thrombolysis with Stent Retriever Device Weather Perfusion Diffusion Mismatching and Intravenous Tissue Plasminogen Activator Administration

OBJECTIVE: Intraarterial thrombolysis (IA-Tx) with stent retriever is accepted as an additional treatment for selected patients and the clinical benefit is well reported. Each intravenous tissue plasminogen activator administration (IV-tPA) and perfusion diffusion mismatching (P/D-mismatching) is well known the beneficial effects for recanalization and clinical outcomes. In this report, authors analyzed the clinical outcomes of additional IA-Tx with retrieval stent device, according to the combined IV-tPA and P/D-mismatching or not. METHODS: Eighty-one treated IA-Tx with the Solitaire stent retriever device, diagnosed as anterior circulation larger vessel occlusion were included in this study. Computed tomography-angiography (CTA) was done as an initial diagnostic image and acute stroke magnetic resonance image (MRI) followed after the IV-tPA. Forty-two patients were in the tPA group and 39 patients were in the non-tPA group. Recanalization rate, clinically significant hemorrhagic (sICH) and clinical outcomes were recorded according to the IV-tPA and P/D-mismatching. RESULTS: Recanalization rate was 81.0% in IV-tPA group, and it was 69.2% in non-tPA group (p = 0.017). While sICH were 19.9% and 25.6%, respectively (p = 0.328). Neurologic outcomes did not influence by IV-tPA administration or not. But according to the P/D-mismatching, the recanalization rate and sICH were 91.9% and 16.7% in the mismatched group and 46.7% and 46.7% in the matched group (p = 0.008 and p = 0.019, respectively). CONCLUSION: For patients treated with IA-Tx with retrieval stent, IV-tPA infusion does not influence on the sICH, recanalization rate and neurologic outcomes. But P/D-mismatching was correlated well with sICH, recanalization rate and clinical outcomes.

Brain Metastases of Papillary Thyroid Carcinoma with Horner's Syndrome

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy and has relatively favorable prognosis. Blood-borne metastases of PTC are very rare among the thyroid malignancies. Moreover a case of blood-borne central nervous system metastasized PTC with only unilateral Horner's syndrome, and without any abnormalities in laboratory or physical examinations has not been described before. A 53-year-old female patient had been managed in ophthalmologic clinic due to vague symptoms of right monocular blurred vision with eye dryness for 3 months, but showed no signs of improvement. So it was performed a magnetic resonance imaging and magnetic resonance angiography to evaluate the possibilities of cerebral lesion. And a left frontal mass was incidentally found, and the tumor turned out to be a PTC that had metastasized to brain, regional lymph node, cervical, thoracic spine, and lung. We describe a PTC with extraordinary initial symptoms that metastasized to an unusual site. We recommend that if a papillary thyroid tumor with unusual symptoms or at an advanced stage is found, further investigation should be performed for distant metastasis.

Hinge Fracture during Cervical Open-door Laminoplasty: Does it Affect Clinical and Radiographic Outcomes?

OBJECTIVE: The purpose of this study was to determine whether the status of the hinge gutter affected clinical and radiographic outcomes of cervical open door laminoplasty. METHODS: We retrospectively analyzed 43 patients who had undergone cervical open door laminoplasty. 23 CT scans were performed at 2 days post-operation. The number of CT scans at 3, 6, 12 and 24 months were 16, 12, 21 and 11, respectively. We collected perioperative and follow-up data, including clinical and radiographic results. RESULTS: There were 7 patients without a hinge fracture and 16 patients with one or more hinge fractures at 2 days postoperation. There were 90 hinges, and the rate of ideal greenstick deformation of the hinge was 63% on 2-day-postoperative CT scans. Postoperative VAS scores of neck pain (p=0.012) in patients without a hinge fracture were higher than in patients with hinge fractures. The hinge healing rates were 37% at 3 months, 57.4% at 6 months, 86.4% at 12 months, and 85.4% at 24 months. Among the patients, 14 patients had healed hinges, and 7 patients had one or more hinge(s) that was/were not healed at 12 months post-operation. However, in clinical and radiographic outcomes, there was no difference between these patients. CONCLUSION: Cervical open door laminoplasty was safe and provided stable reconstruction of laminar expansion. In radiographs, the difference between hinges that had healed and hinges that had not healed was statistically negligible. Hinge fractures might not influence the clinical and radiographic outcomes of cervical open door laminoplasty.

Prevalence and Epidemiological Features of Moyamoya Disease in Korea

OBJECTIVE: The objectives of the present study were to investigate the annual detection rate of patients with Moyamoya disease (MMD) and to describe the prevalence and epidemiological features of the Moyamoya patients in Korea. MATERIALS AND METHODS: The authors analyzed the epidemiological data of Korean patients taken from the National Health Insurance Corporation in Korea among Moyamoya patients who were treated from 2004 until 2008. RESULTS: Based on 2004 data, 2,539 MMD patients were treated in Korea and the prevalence rate was 5.2 per 100,000 people. There were 2,987 in 2005, 3,429 in 2006, 4,051 in 2007, and 4,517 cases in 2008, and the prevalence rates per 100.000 people were 6.3, 7.0, 8.6, and 9.1, for those respective years. This represents an annual increase of 15% of new cases during this period. In 2008, 466 people were newly diagnosed with MMD, representing an incidence rate of 1 per 100,000 persons. The gender ratio was 1,547 men (34%) and 2,970 women (66%). Women had a higher incidence rate than men (1.94 times). There were two age peaks: teenagers and those in their forties. CONCLUSION: The present study shows that the number of Moyamoya patients in Korea is increasing. This increase could partly be explained by a recent increase in newly diagnosed cases, suggesting that a more careful consideration of the disease and better diagnostic techniques should be promoted among clinicians.

Erratum to "Prevalence and Epidemiological Features of Moyamoya Disease in Korea" (JCEN vol.14, no.2, 2012)

In the article, name of the first author, "Sang Hyuk Im", was printed mistakenly as "Sang Hyuk Yim" by negligence of the authors. Additionally, the correspondence author's address has been also corrected as follow at their request: Department of Neurosurgery, Catholic Neuroscience Center, Yeouido St. Mary's Hospital, College of Medicine, Catholic University, 82 Yeouido-dong, Yeongdeungpo-gu, Seoul, 150-713, Korea.

Analysis of Risk Factors for the Development of Post-Operative Epidural Hematoma after Intracranial Surgery / 대한신경손상학회지

OBJECTIVE: Patients undergoing intracranial operations often suffer from post-operative epidural hematoma (EDH). The incidence and risk factors for with the occurrence of EDH after intracranial operations are not well described previously. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy. METHODS: This was a retrospective study of 23 (2.4%) patients, between January 2005 and December 2011, who underwent epidural hematoma evacuation after primary intracranial during this period, 941 intracranial operations were performed. The control group (46 patients) and hematoma group (23 patients) were categorized on the basis of having undergone the same pre-operative diagnosis and treatment within 3 months of their operations. The ages of the hematoma and control group were individually matched to similar ages within 10 years of each other to minimize bias of age. RESULTS: Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were a pre-operative Glasgow Coma Scale (GCS) scored 1.0 (p=0.014), prothrombin time (PT) >11.3 sec (p=0.008), intra-operative blood loss >650 mL (p=0.003) and craniotomy size >7,420 mm2 (p=0.023). In multivariate analysis, intra-operative blood loss exceeding 650 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH. CONCLUSION: Recognizing the limitations of the study, large intra-operative blood loss, wide craniotomy area, prolonged PT and a pre-operative GCS <8 are presented implicated with an increased risk of post-operative EDH after intracranial surgery.

Polyetheretherketone Cage filled with Beta-Tricalcium Phosphate versus Autogenous Tricortical Iliac Bone Graft in Anterior Cervical Discectomy and Fusion

OBJECTIVE: To compare clinical and radiologic results of two graft materials for anterior cervical discectomy and fusion (ACDF) with rigid plate fixation for cervical spinal disorder. METHODS: Twenty-eight patients treated with single-level ACDF with rigid plate fixation were retrospectively reviewed. They were divided into twogroups: Polyetheretherketone (PEEK) cage filled with beta-tricalcium phosphate (beta-TCP) in Group A (n=15); and autogenous tricortical iliac bone graft in group B (n=13). The average follow-up durations were 16.3 months and 19.90 months for group A and group B, respectively. Clinical outcomes were graded using the visual analogue scale (VAS) score and neck disability index (NDI). Interbody height, segmental kyphotic angle and overall kyphotic angle were used as parameters to evaluate radiographic change in the 2 treatment groups. RESULTS: Clinically, VAS scores and NDI significantly improved after the surgery in both groups (p0.05). The fusion rates after 12 months in group A and B were 93.3% and 100%, respectively. One case of cage subsidence which resulted in pseudoarthrosis occurred in group A. However, statistical analysis did not show difference in fusion rate between the two groups (p>0.05). CONCLUSION: ACDF using PEEK cage filled with alpha-TCP showed comparable clinical and radiologic results with the standard of autogenous iliac bone graft. However, pseudoarthrosis did occur even with rigid plate and screw fixation in ACDF using PEEK cage filled with beta-TCP. There is high likelihood of emerging pseudoarthrosis, especially when there is a sign of chronic and progressive cage subsidence.

Hemorrhagic Complications Induced by External Ventricular Draining Catheters / 대한뇌혈관외과학회지

BACKGROUND: External ventricular drainage (EVD) is one of the most frequently performed operative procedures in neurosurgery. A retrospective analysis was conducted for patients who underwent EVD to determine the incidence rate of post-procedural intracranial hemorrhage and to identify underlying risk factors. METHODS: Patients who underwent EVD between January 2003 and January 2011 were selected. Catheter-induced hemorrhage (CIH) was defined as any evidence of new hemorrhage on the post-procedural computerized tomography (CT) scan obtained within 24 hours of catheter insertion. The rate of hemorrhage was calculated, and the possible risk factors were statistically analyzed. RESULTS: The data of 229 patients were analyzed. Twenty-one patients developed CIH, for an incidence rate of 9.17%. The factors that increased the rate of CIH were age > or =60 years, bilateral catheter insertion, and pre-existing heart disease. The patients > or =60 years of age had a 2.8-fold increased risk of CIH. A history of heart disease contributed to a 20-fold increased risk of CIH (p or =60 years, bilateral catheter insertion, and a history of heart disease are the three most significant risk factors for CIH. Since these risk factors are not modifiable, all possible contributors should be considered to minimize the risk such as skilled maneuvers and techniques or high blood pressure.

Hemorrhagic Complications Induced by External Ventricular Draining Catheters / 대한뇌혈관외과학회지

BACKGROUND: External ventricular drainage (EVD) is one of the most frequently performed operative procedures in neurosurgery. A retrospective analysis was conducted for patients who underwent EVD to determine the incidence rate of post-procedural intracranial hemorrhage and to identify underlying risk factors. METHODS: Patients who underwent EVD between January 2003 and January 2011 were selected. Catheter-induced hemorrhage (CIH) was defined as any evidence of new hemorrhage on the post-procedural computerized tomography (CT) scan obtained within 24 hours of catheter insertion. The rate of hemorrhage was calculated, and the possible risk factors were statistically analyzed. RESULTS: The data of 229 patients were analyzed. Twenty-one patients developed CIH, for an incidence rate of 9.17%. The factors that increased the rate of CIH were age > or =60 years, bilateral catheter insertion, and pre-existing heart disease. The patients > or =60 years of age had a 2.8-fold increased risk of CIH. A history of heart disease contributed to a 20-fold increased risk of CIH (p or =60 years, bilateral catheter insertion, and a history of heart disease are the three most significant risk factors for CIH. Since these risk factors are not modifiable, all possible contributors should be considered to minimize the risk such as skilled maneuvers and techniques or high blood pressure.

Traumatic Atlantoaxial Rotatory Fixation with Accompanying Odontoid and C2 Articular Facet Fracture

Traumatic atlantoaxial rotatory fixation (AARF) with accompanying odontoid and C2 articular facet fracture is a very rare injury, and only one such case has been reported in the medical literature. We present here a case of a traumatic AARF associated with an odontoid and comminuted C2 articular facet fracture, and this was treated with skull traction and halo-vest immobilization for 3 months. After removal of the halo-vest immobilization, his neck pain was improved and his neck motion was preserved without any neurologic deficits although mild torticolis was still observed in closer inspection.

Axial Neck Pain after Cervical Laminoplasty

OBJECTIVE: It has been demonstrated that cervical laminoplasty is an effective and safe method of treating multi-level cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. However, recent reports have suggested that axial neck pain is frequently encountered after cervical laminoplasty. The aim of the present study was to determine clinical significance of the C7 spinous process on axial neck pain after cervical laminoplasty. METHODS: A total of 31 consecutive patients that underwent cervical laminoplasty between March 2002 and December 2008 were reviewed. The authors evaluated and compared axial neck pain and lordotic angle in patients that underwent C7 spinous process preserving surgery (group 1, n = 16) and in patients in which the C7 spinous process was sacrificed (group 2, n = 15). RESULTS: Severe or moderate early axial pain occurred in 56.2% of patients in group 1 and in 86.6% in group 2. Severe or moderate late axial pain occurred in 12.5% in group 1 and in 73.3% in group 2. Eighty-Six percent of patients in group 2 and 43% in group 1 experienced aggravation of their axial neck pain during the early postoperative period. Aggravation of axial neck pain during early postoperative period was less common in group 1 but not statistically significant (p = 0.073). Sixty-six percent of patients in group 2 and 12% in group 1 had aggravated axial neck pain at late postoperative period and aggravation of late axial neck pain was significantly less common in group 1 (p = 0.002). CONCLUSION: The present study demonstrates that C7 spinous process preserving laminoplasty decreases the incidence of aggravated axial neck pain after cervical laminoplasty.

Causative analysis of cases with permanent complication following extracranial-entracranial bypass surgery in patients with hemodynamic ischemia / 대한뇌혈관외과학회지

OBJECTIVE: Extracranial-intracranial(EC-IC) bypass procedures have proved to be useful and safe in selected patients for revascularization. We have performed EC-IC bypass procedures in 170 patients with atherosclerotic cerebral ischemia and moyamoya disease. We analyzed the cases that had permanent complications after performing EC-IC bypass procedures in these 170 patients. METHODS: We performed ECIC bypass surgery during the recent 10 years for augmenting the cerebral blood flow in 170 patients with atherosclerotic cerebral ischemia and moyamoya disease. Of the 170 patients, the pathologic lesions were atherosclerotic cerebral ischemia in 125 and moyamoya in 45. All the patients were symptomatic and in a hemodynamic cerebral ischemic state, as diagnosed by the acetazolamide loading test. Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 158 cases and graft bypass with using the saphenous vein or radial artery was done in 12 cases. RESULTS: Of 170 patients who underwent bypass surgery, twenty four patients had postoperative neurologic deficits. Of these 24 patients, the neurologic deficits of 17 patients resolved completely within 3 weeks, but the remaining 7 patients (moyamoya in 5 patients and 2 patients were atherosclerotic) had permanent deficits. The probable causes of the permanent neurologic deficits were that bypass was done too soon after an ischemic attack or hemorrhage (3 cases), intracerebral steal phenomenon during anesthesia (2 case), postbypass thrombotic occlusion of the prebypass stenotic artery (1 case) and postbypass thromboembolism (1 case) CONCLUSION: Permanent neurologic deficits could complicate some cases following bypass surgery. The suggested causes of neurologic deficit were hypoperfusion and inappropriate CO2 tension in the blood and fluctuation of the blood pressure during the perioperative period. To prevent complications, maintain an appropriate perfusion pressure and blood pressure control and follow this with antiplatelet or anticoagulation therapy as soon as possible.

Stereotactic Radiosurgery with the CyberKnife for Pituitary Adenomas

OBJECTIVE: In recent years, CyberKnife has emerged as an important treatment modality in the management of pituitary adenomas. Treatment results after performing CyberKnife and the complications of this procedure are reviewed. METHODS: Twenty-six patients with pituitary adenomas received stereotactic radiosurgery with the CyberKnife (CKRS). The follow-up periods ranged from 7 months to 47 months (mean+/-SD : 30+/-12.7 months). The patients consisted of 17 with non-functioning adenomas, 3 with prolactinomas and 6 with acromegaly. The change in the tumor volume, visual acuity, hormonal function, and complications by this therapy were analyzed in each case. RESULTS: The tumor control rate was 92.3%. Hormonal function was improved in all of the 9 (100%) functioning adenomas. Hormonal normalization was observed in 4 of the 9 (44%) patients with a mean duration of 16 months. In two patients (7.6%), visual acuity worsened due to cystic enlargement of the tumor after CKRS. No other complications were observed. CONCLUSION: CyberKnife is considered safe and effective in selected patients with pituitary adenomas. However, longer follow-up is required for a more complete assessment of late toxicity and treatment efficacy.