Role of Neurosurgeons in the Treatment of Acute Ischemic Stroke in the Emergency Room

Objective@#: With the recent increase in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the role of neurosurgeons in AIS treatment has become increasingly important. This study aimed to assess the outcomes of patients with AIS treated by neurosurgeons and neurologists in the emergency room (ER) of a tertiary hospital in South Korea. @*Methods@#: From January 2020 to June 2021, 536 patients with AIS within 24 hours of symptom onset were admitted to our hospital via the ER. Based on the type of doctors who provided initial care for AIS in the ER, patients were divided into two groups : (a) neurosurgeon group (n=119, 22.2%) and (b) neurologist group (n=417, 77.8%). @*Results@#: Intravenous tissue plasminogen activator (tPA) was administered in 82 (15.3%) of 536 patients (n=17 [14.3%] in the neurosurgeon group and n=65 [15.6%] in the neurologist group). The door-to-tPA time was not significantly different between both groups (median, 53 minutes; interquartile range [IQR], 45–58 vs. median, 54 minutes; IQR, 46–74; p=0.372). MT was performed in 69 patients (12.9%) (n=25, 36.2% in the neurosurgeon group and n=44, 63.8% in the neurologist group). The neurosurgeon group achieved a shorter door-to-puncture time than the neurologist group (median, 115 minutes; IQR, 107–151 vs. median, 162 minutes; IQR, 117–189; p=0.049). Good clinical outcomes (3-month modified Rankin Scale 0–2) did not differ significantly between the two groups (96/119 [80.7%] vs. 322/417 [77.2%], p=0.454). @*Conclusion@#: The neurosurgeon group showed similar door-to-treatment time and clinical outcomes to the neurologist group in patients with AIS in the ER. This study suggests that neurosurgeons have comparable abilities to care for patients with AIS in the ER.

Epigenetic Regulation of the Expression of T Cell Stimulatory and Inhibitory Factors by Histone H3 Lysine Modification Enzymes and Its Prognostic Roles in Glioblastoma

Background@#This study aimed to identify the specific T cell co-stimulatory and co-inhibitory factors that play prognostic roles in patients with glioblastoma. Additionally, the unique histone H3 modification enzymes that regulate the expression levels of these specific costimulatory and co-inhibitory factors were investigated. @*Methods@#The medical records of 84 patients newly diagnosed with glioblastoma at our institution from January 2006 to December 2020 were retrospectively reviewed.Immunohistochemical (IHC) staining for T cell co-stimulatory factors (CD27, CD28, CD137, OX40, and ICOS), T cell co-inhibitory factors (CTLA4, PD1, PD-L1, TIM3, and CD200R), and histone H3 lysine modification enzymes (MLL4, RIZ, EZH1, NSD2, KDM5c, JMJD1a, UTX, and JMJD5) was performed on archived paraffin-embedded tissues obtained by biopsy or resection. Quantitative real time-polymerase chain reaction (qRT-PCR) was performed for specific factors, which demonstrated causal relationships, in order to validate the findings of the IHC examinations. @*Results@#The mean follow-up duration was 27.5 months (range, 4.1–43.5 months). During this period, 76 patients (90.5%) died, and the mean OS was 19.4 months (95% confidence interval, 16.3–20.9 months). Linear positive correlations were observed between the expression levels of CD28 and JMJD1a (R2 linear = 0.982) and those of CD137 and UTX (R2 linear = 1.528). Alternatively, significant negative correlations were observed between the expression levels of CTLA4 and RIZ (R2 linear = −1.746) and those of PD-L1 and EZH1 (R2 linear = −2.118); relationships were confirmed by qRT-PCR. In the multivariate analysis, increased expression levels of CD28 (P = 0.042), and CD137 (P = 0.009), and decreased expression levels of CTLA4 (P = 0.003), PD-L1 (P = 0.020), and EZH1 (P = 0.040) were significantly associated with longer survival. @*Conclusion@#These findings suggest that the expression of certain T cell co-stimulatory factors, such as CD28 and CD 137, and co-inhibitory factors, such as CTLA4 and PD-L1 are associated with prognosis of glioblastoma patients.

Impact of the Coronavirus Disease Pandemic on Patients with Head Injuries in South Korea

Objective@#: The coronavirus disease 2019 (COVID-19) pandemic is affecting the characteristics of patients with head injuries. This study aimed to evaluate the effect of the COVID-19 pandemic on patients with head injuries at a regional emergency medical center in South Korea. @*Methods@#: From April 2019 to November 2020, 350 patients with head injuries were admitted to our hospital. The study period was divided into the pre-COVID-19 (n=169) and COVID-19 (n=181) eras (10 months each). Patients with severe head injuries requiring surgery (n=74) were categorized into those who underwent surgery (n=41) and those who refused surgery (n=33). @*Results@#: Head injuries in pediatric patients (<3 years) were more frequent in the COVID-19 era than in the pre-COVID-19 era (8.8% vs. 3.6%, p=0.048). More patients refused surgery in the COVID-19 era than in the pre-COVID-19 era (57.9% vs. 30.6%, p=0.021). Refusal of surgery was associated with old age (67.7±14.5 vs. 52.4±19.1, p<0.001), marital status (married, 84.8% vs. 61.0%, p=0.037), unemployment (42.4% vs. 68.3%, p=0.034), COVID-19 era (66.7% vs. 39.0%, p=0.021), and lower Glasgow coma scale scores (6.12±3.08 vs. 10.6±3.80, p<0.001). Multivariable logistic regression analysis revealed that refusal of surgery was independently associated with old age (adjusted odds ratio [OR], 1.084; 95% confidence interval [CI], 1.030–1.140; p=0.002), COVID-19 era (adjusted OR, 6.869; 95% CI, 1.624–29.054; p=0.009), and lower Glasgow coma scale scores (adjusted OR, 0.694; 95% CI, 0.568–0.848; p<0.001). @*Conclusion@#: We observed an increased prevalence of head injuries in pediatric patients (<3 years) during the COVID-19 pandemic. Additionally, among patients with severe head injuries requiring surgery, more patients refused to undergo surgery during the COVID-19 pandemic.

Comparative Analysis of the Patients with Spontaneous Thalamic Hemorrhage with Concurrent Intraventricular Hemorrhage and Those without Intraventricular Hemorrhage

Background@#This study aimed to compare the characteristics of patients with spontaneous thalamic hemorrhage (STH) accompanied by intraventricular hemorrhage (IVH) with those of patients without IVH. @*Methods@#The medical records of consecutive patients with STH admitted to our institute between January 2000 and December 2018 were reviewed retrospectively. The laboratory and radiological results, mortality, and functional recovery were compared between the STH patients with IVH and those without IVH. @*Results@#Among 2,389 patients with spontaneous intracerebral hemorrhage, 233 (9.8%) patients were included in this study. Concurrent IVH was detected in 159 (68.2%) patients with STH, and more frequently in those with body mass index ≥ 25, Glasgow Coma Scale score of 3–8, underlying disease, family history of stoke, posterior/medial/global location of hematoma, ventriculomegaly, large volume of hemorrhage, and midline shift ≥ 5 mm. The 3-month mortality was 25.8% and 8.1% (P = 0.039), the rate of good functional recovery at 6 months was 52.2% and 31.0% (P = 0.040), and incidence of delayed normal pressure hydrocephalus (NPH) at 12 months was 10.8% and 24.5% (P = 0.062) in the STH patients with IVH and those without IVH, respectively. At 12 months, delayed NPH developed in 28 of 47 (59.6%) patients who received external ventricular drainage (EVD)-based treatment, 5 of 45 (11.1%) patients who underwent endoscopic evacuation-based treatment, and 8 of 45 (17.8%) patients who underwent other surgeries. @*Conclusion@#Concurrent IVH is strongly associated with mortality in patients with STH. Delayed NPH may develop more frequently in STH patients with IVH who were treated with EVD.

The Clinical Outcome of Hydroxyurea Chemotherapy after Incomplete Resection of Atypical Meningiomas

BACKGROUND: The aim of this study is to investigate the clinical results of adjuvant chemotherapy with hydroxyurea and to compare those with the results of postoperative radiotherapy after incomplete resection of atypical meningiomas (ATMNGs). METHODS: We retrospectively reviewed the medical records of 84 patients with ATMNGs diagnosed in the period from January 2000 to December 2014. Clinical data included patient sex and age at the time of surgery, presenting symptoms at diagnosis, location and size of tumor, extent of surgery, use of postoperative radiotherapy or hydroxyurea chemotherapy, duration of follow-up, and progression. In terms of the extent of surgical resection, incomplete resection was defined as Simpson grade II–V. RESULTS: Among the 85 patients, 55 (65.5%) patients underwent incomplete resection; 24 (43.6%) were treated with adjuvant hydroxyurea (group A), and 20 (36.4%) with postoperative radiotherapy (group B), and 11 (20.0%) underwent conservative treatment after surgery (group C). Twenty-five (45.5%) patients experienced the progression of tumors during the follow-up period (mean 47.7 months, range 12.4-132.1 months); 8 of 24 (33.3%) patients in group A, 7 of 20 (35.0%) patients in group B, and 10 of 11 (90.9%) patients in group C. The mean progression-free survival (PFS) was 30.9 months (range 6.4-62.3 months); 46.2 months in group A, 40.4 months in group B, and 11.9 months in group C (p=0.041). Multivariate analysis showed that Simpson grade (p=0.040), adjuvant treatment after surgery (p<0.001), increased Ki67 (p=0.017), mitotic index (p=0.034), and overexpression of p53 (p=0.026) predicted longer PFS. CONCLUSION: This investigation suggested that adjuvant treatment after incomplete resection of ATMNGs are associated with longer PFS than conservative treatment, and that there is no difference of PFS between hydroxyurea chemotherapy and radiotherapy after surgery. Therefore, hydroxyurea chemotherapy can be considered as another adjuvant tool for the ATMNGs if the postoperative adjuvant radiotherapy cannot be applicable.

Stent-assisted Coil Embolization of Petrous ICA in a Teenager with Neurofibromatosis

We herein report on a patient with a cerebral aneurysm located at the petrous portion of the internal carotid artery (ICA). An 18-year-old male, previously diagnosed with neurofibromatosis, was referred to our emergency service complaining of severe headache, pulsatile tinnitus, nausea, and vomiting which occurred suddenly. Neuro-radiological studies including computed tomography and magnetic resonance imaging of the cerebral artery showed a large aneurysm arising from the petrous segment of the left ICA. He was treated with a neuro-interventional technique such as intra-arterial stenting and coil embolization for the aneurysm. Several days after the interventional treatment, his symptoms were resolved gradually except for a mild headache. Symptomatic unruptured aneurysm at the petrous portion of the ICA is rare, and our patient was treated successfully using a neuro-intervention technique. Therefore, we describe a case of a petrous aneurysm treated with endovascular coils without compromising the ICA flow, and review the literature.

Cervical Myelopathy Secondary to Atlanto-occipital Assimilation: The Usefulness of the Simple Decompressive Surgery

Atlanto-occipital assimilation is one of the most common osseous anomalies observed at the craniocervical junction. Most patients with atlas assimilation show no symptom, but some have neurological problems such as myelopathy that may require surgical treatment. Occipitocervical fusion may be required if atlato-occipital assimilation is accompanied by occipito-axial instability. However, in cases of symptomatic atlas assimilation with minor cord compression without instability, simple decompressive surgery may be the treatment modality. This report describes a case of successful treatment of a patient with myelopathy secondary to atlanto-occipital assimilation without instability, using posterior simple decompressive surgery.

Extensive Spinal Epidural Abscess: The Usefulness of Minimal Invasive Surgical Technique using Epidural Irrigation Catheter

Spinal epidural abscess (SEA) is a rare infection but may be devastating and fatal. We describe a case of a42-year-old male who presented with a posteriorly located SEA extending from C2 to the sacrum with severe neurologic deficits. We had the emergency surgery with the minimal invasive technique using epidural irrigation catheter, and then obtained an excellent recovery. The purpose of this report introduces the usefulness of minimal invasive surgical technique for extensive SEA.

Clinical Analysis of Patients who Survived for Less than 3 Months After Brain Metastatectomy

In the patients with brain metastasis (BM), it is impossible to determine who will benefit from surgery because of limited survival. In an attempt to identify optimal candidates for brain metastatectomy, we analyzed patients who survived for <3 months after craniotomy for a single BM lesion. Between January 1st, 1997 and July 31st, 2007, 83 patients with a single BM underwent craniotomy. Of these patients, 25 patients (30.1%) died within 3 months of craniotomy. The primary lesions were non-small call lung cancer in 15, colon cancer in 6, and breast cancer, renal cell carcinoma, ovarian cancer, or esophageal cancer in one apiece. Of the 25 patients, 19 (79%) were of tumor stage IV and had extra-cranial metastasis. Eleven (44%) of the 25 primary cancers had a well-controlled status. Twelve patients (48%) had a Karnofsky Performance Scale (KPS) score of <70, and 13 (52%) were of Recursive Partitioning Analysis (RPA) class 3. Primary cancer status, RPA class, and functional status were found to be critical factors for consideration when selecting surgical candidates. In addition, adjuvant therapy was found to have an important role on survival.

Predictors for Functional Recovery and Mortality of Surgically Treated Traumatic Acute Subdural Hematomas in 256 Patients

OBJECTIVE: The purpose of this study was to investigate the reliable factors influencing the surgical outcome of the patients with traumatic acute subdural hematoma (ASDH) and to improve the functional outcome of these patients. METHODS: A total of 256 consecutive patients who underwent surgical intervention for traumatic ASDH between March 1998 and March 2008 were reviewed. We evaluated the influence of perioperative variables on functional recovery and mortality using multivariate logistic regression analysis. RESULTS: Functional recovery was achieved in 42.2% of patients and the overall mortality was 39.8%. Age (OR=4.91, p=0.002), mechanism of injury (OR=3.66, p=0.003), pupillary abnormality (OR=3.73, p=0.003), GCS score on admission (OR=5.64, p=0.000), and intraoperative acute brain swelling (ABS) (OR=3.71, p=0.009) were independent predictors for functional recovery. And preoperative pupillary abnormality (OR=2.60, p=0.023), GCS score (OR=4.66, p=0.000), and intraoperative ABS (OR=4.16, p=0.001) were independent predictors for mortality. Midline shift, thickness and volume of hematoma, type of surgery, and time to surgery showed no independent association with functional recovery, although these variables were correlated with functional recovery in univariate analyses. CONCLUSION: Functional recovery was more likely to be achieved in patients who were under 40 years of age, victims of motor vehicle collision and having preoperative reactive pupils, higher GCS score and the absence of ABS during surgery. These results would be helpful for neurosurgeon to improve outcomes from traumatic acute subdural hematomas.

Endoscopic Endonasal Transsphenoidal Resection of Solitary Extramedullary Plasmacytoma in the Sphenoid Sinus with Destruction of Skull Base

Solitary extramedullary plasmacytomas are isolated plasma cell tumors of soft tissue that typically do not metastasize. They are rare and account for 4% of all plasma cell tumors. To our knowledge, only 14 cases of solitary extramedullary plasmacytomas in the sphenoid sinus have been reported. A 32-year-old man presented to our department with complaint of ocular pain in the right eyeball and diplopia. Physical and neurological examinations revealed intact and prompt direct and indirect light reflexes in both pupils and limitation of extraocular muscle movement seen with the lateral gaze of the right eyeball. Magnetic resonance imaging suggested the presence of mucocele or mycetoma, therefore surgical resection was performed with endoscopic endonasal transsphenoidal approach. Histopathology was consistent with plasmacytoma. Systemic work-up did not show any evidence of metastasis and the sphenoid sinus was the sole tumor site, and therefore the diagnosis of solitary extramedullary plasmacytoma was confirmed. We report a rare case of solitary extramedullary plasmacytoma in the sphenoid sinus with successful treatment using the endoscopic endonasal transsphenoidal resection and adjuvant radiotherapy.

A case of ulcerative duodenitis accompanying ulcerative colitis / 대한내과학회지

Ulcerative colitis (UC) is a chronic inflammatory disorder of the colonic mucosa that characteristically affects the rectum and involves the large bowel in a contiguous distribution. Upper gastrointestinal inflammation was not believed to be present in UC, but a few recent studies have reported a high incidence of gastroduodenal inflammation in patients with UC, although such occurrences are apparently rare and the stomach and duodenum are not generally considered target organs in UC. Here, we present the case of a 29.year.old man with UC who was found to have diffuse ulcerative duodenitis with endoscopic and histologic features identical to UC

Predictors of 30-Day Mortality and 90-Day Functional Recovery after Primary Intracerebral Hemorrhage : Hospital Based Multivariate Analysis in 585 Patients

OBJECTIVE: The purpose of this study was to identify independent predictors of mortality and functional recovery in patients with primary intracerebral hemorrhage (PICH) and to improve functional outcome in these patients. METHODS: Data were collected retrospectively on 585 patients with supratentorial PICH admitted to the Stroke Unit at our hospital between 1st January 2004 and the 31st July 2008. Using multivariate logistic regression analysis, the associations between all selected variables and 30-day mortality and 90-day functional recoveries after PICH was evaluated. RESULTS: Ninety-day functional recovery was achieved in 29.1% of the 585 patients and 30-day mortality in 15.9%. Age (OR=7.384, p=0.000), limb weakness (OR=6.927, p=0.000), and hematoma volume (OR=5.293, p=0.000) were found to be powerful predictors of 90-day functional recovery. Furthermore, initial consciousness (OR=3.013, p=0.014) hematoma location (lobar, OR=2.653, p=0.003), ventricular extension of blood (OR=2.077, p=0.013), leukocytosis (OR=2.048, p=0.008), alcohol intake (drinker, OR=1.927, p=0.023), and increased serum aminotransferase (OR=1.892, p=0.035) were found to be independent predictors of 90-day functional recovery after PICH. On the other hand, a pupillary abnormality (OR=4.532, p=0.000) and initial unconsciousness (OR=3.362, p=0.000) were found to be independent predictors of 30-day mortality after PICH. CONCLUSION: The predictors of mortality and functional recovery after PICH identified during this analysis may assist during clinical decision-making, when advising patients or family members about the prognosis of PICH and when planning intervention trials.

Even in Patients with a Small Hemorrhagic Volume, Stereotactic-Guided Evacuation of Spontaneous Intracerebral Hemorrhage Improves Functional Outcome

OBJECTIVE: The decision to adopt a conservative or surgical modality for a relatively small volume of spontaneous intracerebral hemorrhage (SICH) is difficult and often controversial, especially when consciousness is tolerable. The authors examined the results of stereotactic-guided evacuation of SICH for relatively small volumes with respect to functional outcome. METHODS: This prospective study was performed on 387 patients with SICH who underwent stereotactic-guided evacuation (n = 204, group A) or conservative treatment (n = 183, group B) during the past 8 years. The primary end-point was recovery of functional status, which was estimated using the Modified Barthel Index (MBI) and the modified Rankin Scale (mRS). RESULTS: All patients had a Glasgow coma scale (GCS) score of > or = 13 and unilateral hemiparesis of less than motor power grade 3. Group demographic characteristics and initial neurological statuses were similar. In all cases, the volume of SICH involved was < 30 cm3 and location was limited to basal ganglia and thalamus. At 6-month follow-ups, MBI was 90.9 in group A and 62.4 in group B (p < 0.05), and MRS was 1.2 in group A and 3.0 in group B (p < 0.05). Better motor function and stereotactic-guided evacuation had a significant effect on a functional recovery in regression analyses. CONCLUSION: Even in patients with a small volume of SICH, stereotactic-guided evacuation improved functional recovery in activities in daily life than conservative treatment did.

Immunohistochemical Study of Glucose Transporters 1 and 3 in the Mouse Hippocampus after Kainic Acid Treatment / 대한해부학회지

Seizure activity increases glucose utilization within the brain in response to neuronal injury. In this study, we investigated the expression of two brain glucose transporter (GLUT) proteins, GLUT1 and GLUT3, in the mouse hippocampus after kainic acid (KA) treatment. Forty-eight hours after KA (30 mg/kg) injection, mice were sacrificed and a histological evaluation of KA-treated hippocampus revealed cell death using cresyl violet staining and immunohistochemistry for caspase-3. In KA-treated hippocampus, reactive astrocytic changes were confirmed by increased immunoreactivity of glial fibrillary acidic protein (GFAP). Enhanced GLUT1-positive endothelial cells were present in the hippocampus after KA treatment. However, GLUT3-positive neurons were not localized to the KAtreated hippocampus. In particular, although GLUT-3 was not expressed in the hippocampus, pronounced GLUT3- positive cells were observed in the hypothalamic paraventricular nucleus (PVN), which controls energy metabolism. Thus, these results indicate that changes in endothelial GLUT1 and neuronal GLUT3 levels in response to neural injury may play important roles in neuroprotection against brain excitotoxicity.

Non-invasive Doppler ultrasonography for assessment of the portal hypertension of liver cirrhosis: A prospective study / 대한내과학회지

BACKGROUND/AIMS: Portal hypertension occurs as a consequence of liver cirrhosis and is responsible for serious complications such as variceal bleeding, ascites and hepatic encephalopathy. The hepatic venous pressure gradient (HVPG) is the gold standard for assessment of portal hypertension. However, use of the HVPG is limited by being an invasive test. This prospective study evaluated whether the parameters identified by the non-invasive Doppler ultrasonography reflect the HVPG and could potentially be used for the assessment of the severity of portal hypertension in patients with liver cirrhosis. METHODS: HVPG and Doppler ultrasonographic parameters, including the damping index (DI) of the hepatic vein waveform, the portal venous velocity and flow, the splenic venous velocity and flow, the pulsatility and the resistive index of the hepatic, splenic and renal arteries were measured in 114 patients with liver cirrhosis and compared. RESULTS: The DI of the Doppler hepatic vein waveform was significantly correlated with the grade of the HVPG, i.e. with a higher HVPG, an increase in the DI was observed (p<0.01). The other Doppler parameters did not correlate with the HVPG grade. CONCLUSIONS: The results of this study showed that the DI measurements of the hepatic vein waveform by Doppler ultrasonography might provide a noninvasive assessment of the severity of portal hypertension.

The Relationship between Brachial Ankle Pulse Wave Velocity andAtherosclerotic Risk Factors

PURPOSE: Aging and atherosclerotic changes enhance the stiffness of the arterial wall, and the pulse wave travels faster in stiffer vessel. Measurement of the brachial ankle pulse wave velocity (baPWV) is a non-invasive method for evaluating the stiffness of the vessel wall. We investigated the relation between the baPWV and risk factors for atherosclerosis. METHOD: We studied 180 subjects (38 male and 142 female; mean age 46 years, range 24 to 76 years). The instrument used for evaluating the baPWV was a Vasoguard (VIASYS Healthcare, Dublin, Ohio, USA), and measurements were performed in the right arm and in both ankles. Data were analyzed using Pearson correlation, t-test, and multiple regression analysis. Multiple regression analysis was performed for age, sex, smoking, hypertension, height, weight, body mass index (BMI), total cholesterol, LDL, HDL, TG, and HbA1c. RESULT: Right and left baPWVs were significantly increased (P<0.05) in subjects with the following risks: older age, high body weight, high BMI, high total cholesterol, high LDL, high TG, high HbA1c, and low HDL. Right and left baPWVs were also significantly increased (P<0.05) in male subjects with a history of smoking and hypertension. Multiple regression analysis showed that age, sex, and LDL were independent determinants of the right and left baPWVs. CONCLUSION: This study provides evidence that increased age, male gender, and high serum LDL levels are risk factors that contribute to arterial stiffness. Measurement of the baPWV may be a useful method for evaluating vascular status.

Skull Base Invasion of Adenoid Cystic Carcinoma of the Lacrimal Gland : A Case Report

Although adenoid cystic carcinoma (ACC) of the lacrimal gland is a rarely encountered orbital tumor, it invades intracranially more frequently than carcinomas of other glands in the head and neck. A 52-year-old man underwent orbital exenteration and resection of intracranially extended tumor via a fronto-orbito-zygomatic approach in combination with a transfacial approach. Histopathologically, the tumor showed perineural, vascular, and lymphatic invasion. Additionally, he received radiotherapy (60 Gy) and adjuvant systemic cisplatin and 5-fluorouracil chemotherapy due to residual tumor in the orbit and systemic metastases (lung, ribs, and spines). He was free of progression and recurrence at 6 months after treatment. The authors report a case of skull base invasion by an ACC of the lacrimal gland to remind neurosurgeons planning intervention that this disease shows a tendency to invade intracranially.

Clinical Comparison between Simple Craniectomy and Lesionectomy in the Patients with Acute Cerebral Infarction / 대한뇌혈관외과학회지

OBJECTIVE: Life-threatening middle cerebral artery infarction may be accompanied by severe post-ischemic brain swelling due to cytotoxic vasogenic edema. The resultant progressive mass effect may prove fatal, owing to increased intracranial pressure and herniation. Recent studies have shown that early decompressive craniectomy decreases mortality, but no comparison has been performed between the outcomes achieved with simple craniectomy and those achieved with craniectomy combined with lesionectomy. This study was performed to compare the outcomes achieved after simple craniectomy and after craniectomy combined with lesionectomy. MATERIALS AND METHODS: We prospectively reviewed the records of 59 patients who presented with acute middle cerebral infarction between January 2001 and October 2007. Thirty-one patients (Group A) underwent simple decompressive craniectomy, and 28 patients (Group B) underwent lesionectomy with craniectomy. In all patients, lesion volume and mid-line shift were measured radiologically. Outcomes were quantified using the Glasgow Outcome Scale. RESULT: Patient factors (age, sex), Glasgow Coma Scale, radiologic findings, and lobe involvement were the same for the two groups. However, the outcomes for the two groups were different. At 6 months after surgery, the mean Glasgow Outcome Scale for Group A was 2.71 and that for Group B was 3.39 (p<0.05). CONCLUSION: Surgical treatment, especially decompressive craniectomy combined with lesionectomy, was beneficial in the setting of malignant cerebral infarction.

A Case of Afferent Loop Syndrome Treated by Endoscopic Drainage Procedure using Nasogastric Tube / 대한소화기학회지

Afferent loop syndrome is an uncommon complication which occurs in patients with Billroth II partial gastrectomy. Clinically, the diagnosis of afferent loop syndrome may be difficult to establish and thus, depends on the finding of computed tomography, abdominal ultrasound, barium studies and hepatobiliary scan. When the diagnosis is made, most of the cases are treated by surgical operation. We present a case of 67-year-old male patient with afferent loop syndrome associated with acute pancreatitis which was treated by endoscopic drainage procedure using a nasogastric tube.