Prediction of Prolonged Hemodynamic Instability During Carotid Angioplasty and Stenting / 신경중재치료의학

PURPOSE: The aim of this study was to assess the risk factors of prolonged hemodynamic instability (HDI) after carotid angioplasty and stenting (CAS). Herein, a simplified predictive scoring system for prolonged HDI is proposed. MATERIALS AND METHODS: Sixty-six patients who had CAS from 2011 to 2016 at a single institution were evaluated. Prolonged HDI was defined as systolic blood pressure >160 mm Hg or <90 mm Hg or heart rate <50 beats/min, lasting over 30 minutes despite medical treatments. For the study, clinical data and radiologic data, including plaque morphology and stenosis were analyzed. RESULTS: Prolonged HDI was observed in 21 patients (31.8%). Multivariable analysis revealed that calcification (OR, 6.726; p=0.006), eccentric stenosis (OR, 3.645; p=0.047) and extensive plaque distribution (OR, 7.169; p=0.006) were related to prolonged HDI. According to these results, a simplified scoring scale was proposed based on the summation of points: 2 points for calcified plaque, 2 points for extensive plaque distribution, and 1 point for eccentric stenosis. The percentages of prolonged HDI according to the total score were as follows: score 0, 8.7%; score 1, 20.0%; score 2, 38.5%; score 3, 72.7%; score 4, 66.7%; score 5, 100%. From the analysis, the total score in patients with prolonged HDI was significantly higher than those without prolonged HDI (p<0.001). CONCLUSION: Prolonged HDI can be associated with calcification of plaque, eccentric stenosis and extensive plaque distribution, and a simplified scoring system enables prediction of prolonged HDI according to our cohort.

Association Factors for CT Angiography Spot Sign and Hematoma Growth in Korean Patients with Acute Spontaneous Intracerebral Hemorrhage : A Single-Center Cohort Study

OBJECTIVE: This study was conducted to clarify the association factors and clinical significance of the CT angiography (CTA) spot sign and hematoma growth in Korean patients with acute intracerebral hemorrhage (ICH). METHODS: We retrospectively collected the data of 287 consecutive patients presenting with acute ICH who arrived within 12 hours of ictus. Baseline clinical and radiological characteristics as well as the mortality rate within one month were assessed. A binary logistic regression was conducted to obtain association factors for the CTA spot sign and hematoma growth. RESULTS: We identified a CTA spot sign in 40 patients (13.9%) and hematoma growth in 78 patients (27.2%). An elapsed time to CT scan of less than 3 hours (OR, 5.14; 95% CI, 1.76-15.02; p=0.003) was associated with the spot sign. A CTA spot sign (OR, 5.70; 95% CI, 2.70-12.01; p40 IU (OR, 2.01; 95% CI, 1.01-4.01; p=0.047), and an international normalized ratio > or =1.8 or warfarin medication (OR, 5.64; 95% CI, 1.29-24.57; p=0.021) were independent predictors for hematoma growth. Antiplatelet agent medication (OR, 4.92; 95% CI, 1.31-18.50; p=0.019) was significantly associated with hematoma growth within 6 hours of ictus. CONCLUSION: As previous other populations, CTA spot sign was a strong predictor for hematoma growth especially in hyper-acute stage of ICH in Korea. Antithrombotics medication might also be associated with hyper-acute hematoma growth. In our population, elevated GPT was newly identified as a predictor for hematoma growth and its effect for hematoma growth is necessary to be confirmed through a further research.

The Quality of Life of Patients with Good Outcomes after Anterior Circulation Aneurysm Surgery Assessed by the World Health Organization Quality of Life Instrument-Korean Version

OBJECTIVE: Even in the patients with neurologically good outcome after intracranial aneurysm surgery, their perception of health is an important outcome issue. This study aimed to investigate the quality of life (QOL) and its predictors of patients who had a good outcome following anterior circulation aneurysm surgery as using the World Health Organization Quality of Life instrument-Korean version. METHODS: We treated 280 patients with 290 intracranial aneurysms for 2 years. This questionnaire was taken and validated by 99 patients whose Glasgow Outcome Scale score was 4 and more and Global deterioration scale 3 and less at 6 months after the operation, and 85 normal persons. Each domain and facet was compared between the two groups, and a subgroup analysis was performed on the QOL values and hospital expenses of the aneurysm patients according to the type of craniotomy, approach, bleeding of the aneurysm and brain injury. RESULTS: Aneurysm patients showed a lower quality of life compared with control patients in level of independence, psychological, environmental, and spiritual domains. In the environmental domain, there were significant intergroup differences according to the type of craniotomy and the surgical approach used on the patients (p<0.05). The hospital charges were also significantly different according to the type of craniotomy (p<0.05). CONCLUSION: Despite good neurological status, patients surgically treated for anterior circulation aneurysm have a low quality of life. The craniotomy size may affect the QOL of patients who underwent an anterior circulation aneurysm surgery and exhibited a good outcome.

Analysis of Incomplete Occlusion of Cerebral Aneurysm by Intraoperative Indocyanine Green Videoangiography / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to investigate factors associated with incomplete occlusion of a cerebral aneurysm detected by indocyanine green videonangiography (ICG-VA) following aneurysm clipping. METHODS: We performed surgery on 135 patients with 151 intracranial aneurysms over a 1-year period. Included was an aneurysm more than 3 mm in size, the dome of which was sufficiently exposed and clipped permanently with one clip. Following ICG-VA, aneurysms were divided into a delayed-filling group and a no-filling group. Retrospective comparisons of the clip force, blade length and width, neck and dome size of the aneurysm, diameter of the parent artery, presence of atherosclerosis in the aneurysm neck, and systolic blood pressure during ICG-VA were made between the two groups. RESULTS: Eight of 31 aneurysms in 29 patients showed delayed filling of contrast. The clip force in the delayed-filling group was lower than in the no-filling group and the atherosclerosis of the aneurysm neck differed between the two groups (P<0.05). Blade width in the delayed-filling group was also significantly lower than in the no-filling group (P<0.05). Following adjustment for atherosclerosis of the aneurysm neck, clip force and blade width in the delayed-filling group was even lower. Incomplete passage of the clip tip was observed in four aneurysms, weak clip force in three, and a slit between clip blades in one. After booster clipping or clip reposition, neither aneurysm regrowth nor recanalization was observed during 6 months of follow-up. CONCLUSION: Closing force, blade width, tip position, and remnant slit are important for incomplete occlusion of an aneurysm.

In vivo Tracking of Transplanted Bone Marrow-Derived Mesenchymal Stem Cells in a Murine Model of Stroke by Bioluminescence Imaging

OBJECTIVE: This study was designed to validate the cell trafficking efficiency of the in vivo bioluminescence image (BLI) study in the setting of transplantation of the luciferase expressing bone marrow-derived mesenchymal stem cells (BMSC), which were delivered at each different time after transient middle cerebral artery occlusion (MCAO) in a mouse model. METHODS: Transplanting donor BMSC were prepared by primary cell culture from transgenic mouse expressing luciferase (LUC). Transient focal infarcts were induced in 4-6-week-old male nude mice. The experiment mice were divided into five groups by the time of MSC transplantation : 1) sham-operation group, 2) 2-h group, 3) 1-day group, 4) 3-day group, and 5) 1- week group. BLI for detection of spatial distribution of transplanted MSC was performed by detecting emitted photons. Migration of the transplanted cells to the infarcted area was confirmed by histological examinations. Differences between groups were evaluated by paired t-test. RESULTS: A focal spot of bioluminescence was observed at the injection site on the next day after transplantation by signal intensity of bioluminescence. After 4 weeks, the mean signal intensities of 2-h, 1-day, 3-day, and 1-week group were 2.6x10(7) +/- 7.4x10(6), 6.1x10(6) +/- 1.2x10(6), 1.7x10(6) +/- 4.4x10(5), and 8.9x10(6) +/- 9.5x10(5), respectively. The 2-h group showed significantly higher signal intensity (p < 0.01). The engrafted BMSC showed around the infarct border zones on immunohistochemical examination. The counts of LUC-positive cells revealed the highest number in the 2-h group, in agreement with the results of BLI experiments (p < 0.01). CONCLUSION: In this study, the results suggested that the transplanted BMSC migrated to the infarct border zone in BLI study and the higher signal intensity of LUC-positive cells seen in 2 hrs after MSC transplantation in MCAO mouse model. In addition, noninvasive imaging in real time is an ideal method for tracking stem cell transplantation. This method can be widely applied to various research fields of cell transplantation therapy.

Endoscopic Versus Mini.open Carpal Tunnel Release in Patients with Bilateral Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to determine any differences in outcome and patient satisfaction between endoscopic release (ECTR) and open carpal tunnel release (OCTR) in patients with bilateral carpal tunnel syndrome who underwent both techniques. METHODS: Seven patients with confirmed bilateral idiopathic carpal tunnel syndrome were randomized to undergo endoscopic release using a single portal Agee technique to one hand and a minimal open release to the other. Subsequent assessments were made at 0, 3, and 12 months after operation using a modified Levin scale. We also analyzed subjective and objective outcomes retrospectively, including the time to return to full activity, patient preference, cosmetic satisfaction, scar tenderness, and pillar pain. The pain was assessed using a visual analogue scale from 1 to 10. RESULTS: Based on the Levin scale, there were no significant differences between hands at any follow-up interval. At the three-month follow up, mean scale scores were lower in the ECTR group; however, the differences did not reach statistical significance. Cosmetically, all patients were satisfied with their scar irrespective of the technique. There were no statistical differences in terms of scar tenderness and pillar pain. CONCLUSION:ECTR did not show any significant advantage over short-incision OCTR. Therefore, the operator's experience and skill in using a certain method is important, regardless of which technique is used.

Analysis of Anterior Cerebralarteriesin Patients with Ruptured Anterior Communicating Artery Aneurysmby Computed Tomography Angiography and Digital Subtraction Angiography / 대한뇌혈관외과학회지

OBJECTIVE: Computed tomography angiography (CTA) has recently been used for detecting cerebral aneurysm because of the accuracy of the images and the large supply of high-resolution CT scanners, and there is no need to perform cerebral digital subtraction angiography (DSA) when performing CTA. In contrast with DSA, CTA is unable to show the realtime cerebral blood flow. The aim of the present study is to find an appropriate aneurysm clipping method to reduce the risk during operation, and we did this by comparing the performance of CTA for detecting ruptured cerebral aneurysm with that of DSA. METHODS: We performed a systemic review of patients suffering from ruptured anterior communicating artery aneurysm. We report here on the results obtained from November 2002 to March 2006. We reviewed a total of 37 patients who had undergone both CTA and DSA before surgery. RESULTS: With performing CTA, 15 patients (40.5%) were observed to have the same thickness of both sides of the A1 (group A); there were 2 patients with right dominance (group B), and 20 patients with left dominance (group C). The total numbers of patients with an anomalous artery was 3 (12.5%). Two of them were in Group A and one of them was in Group B. Two of them (one in Group A and the other in Group B) were accessory A2 patients and the other was an azygous A2 patient. Also, there was no difference between CTA and DSA for the patients with an abnormal artery. CONCLUSION: In the case of observing a severe hypoplastic A1 or an anomalous artery in the patients with anterior communicating artery aneurysm seen on the CTA, it is expected that checking the accurate structure and status of their aneurysm and the surrounding artery through performing DSA and also checking the contralateral carotid artery compression may help prepare the strategy for the operation and reduce the risk during operation.

Assessment of Cerebrovascular Reserve before and after STA-MCA Bypass Surgery by SPECT and SPM Analysis

OBJECTIVE: The purpose of this study was to objectively assess the efficacy of superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery using Technetium (Tc)-99m-ethyl cysteinate dimer (ECD) single photon emission computed tomography (SPECT) in patients who underwent STA-MCA bypass surgery. MATERIALS AND METHODS: Brain perfusion SPECT images obtained at baseline and after the administration of acetazolamide were reconstructed using statistical parametric mapping in 23 patients, both before and after STA-MCA bypass surgery. The clinical outcomes of the surgery were also recorded and compared with the hemodynamic changes. A voxel with an uncorrected p-value of less than 0.001 was considered to be statistically significant. RESULTS: SPECT images of the territory supplied by the bypass graft showed an increase in both cerebrovascular flow and reserve at baseline, and the increase was significantly higher following the administration of acetazolamide. All patients showed improvement of clinical symptoms and increased blood flow to the left temporal, parietal, and frontal cortices as well as the thalamus. CONCLUSION: Brain SPECT effectively and objectively demonstrated the improved outcomes of STA-MCA bypass surgery, and thus may be used in postoperative analyses.

Convexity Meningioma En Plaque Presenting with Diffuse Hyperostosis of the Skull

Although meningioma is a common and benign intracranial tumor, meningioma en plaque is a rare tumor, especially in the cranial vault. Meningioma en plaque(MEP) usually occurs in the area of the sphenoid wing, and it causes cosmetic and visual problems, as well as the problems that are due to its mass effect. The authors present here a case of convexity meningioma en plaque that involved the skull and scalp with diffuse hyperostosis as the presenting salient radiological findings, which caused marked intraoperative bleeding.

Efficacy of Intraoperative Facial Electromyographic Monitoring in Patients with Hemifacial Spasm

OBJECTIVE: Hemifacial spasm has characteristic and specific electrophysiological finding, lateral spread response(LSR). We study the correlation between change of lateral spread response during microvascular decompression(MVD) and clinical outcome after MVD. METHODS: Sixty two patients with hemifacial spasm who were treated with microvascular decompression from March 2000 to February 2003 were included in this study. The monitoring of intraoperative facial electromyography(EMG) and brain stem auditory evoked potential were performed. RESULTS: In 28 (44.7%) patients, there was persistence of lateral spread response after vascular decompression in root exit zone of facial nerve. Among these 28 patients, 9 had mild hemifacial spasm at discharge. Three out of 34 patients who had intraoperative disappearance of lateral spread response after MVD had mild hemifacial spasm. But Both groups, disappearance of LSR (Group I), and persistence (Group II) had only 2 patients with mild hemifacial spasm, and 5 patients at 3 months, respectively. CONCLUSION: Although intraoperative EMG monitoring is very useful in assessing the efficacy of MVD, the clinical outcome of MVD in patient with hemifacial spasm does not always correlate with EMG finding. The prognostic value of intraoperative LSR monitoring in the long-term results is questionable.

Selective Peripheral Denervation for the Treatment of Spasmodic Torticollis

OBJECTIVE: Various methods of treatment for idiopathic cervical dystonia have been tried in the past with unsatisfactory results. The authors report cases of five patients who underwent selective peripheral denervation for spasmodic torticollis. METHODS: Between July 2002 and December 2003, 5 patients underwent surgery at St. Mary's Hospital for spasmodic torticollis. Age of the patient at the onset of symptoms ranged from 29 to 56years (mean 43.75years). Selective peripheral denervation(SPD) was performed at 7 to 11months after the onset of symptoms (mean 8.75 months). A patient was considered to be the candidate for surgery if conservative methods were unsuccessful and symptoms persisted for longer than 7months. In addition, 2patients who refused treatment with botulinum toxin were also enrolled in this study. RESULTS: Although one patient underwent reoperation, all of the five patients' symptoms were improved after the operation. Clinically, patients with retrocollis showed better improvement than laterocollis patients. CONCLUSION: Although injection of botulinum toxin is the first-choice in treatment modality, when surgery is required, selective peripheral denervation provides good results with minimum side effects.

Chordoid Meningioma

A case of chordoid meningioma occurring in a 61-year-old woman who did not have a Castleman's disease is presented. The patient had suffered from headache and motor dysphasia. Laboratory findings are normal. The tumor, located in the left frontal region and associated with peritumoral edema, was totally resected. Surgical specimen revealed a solid mass with irregular surface that measured 3.5 x 4.5 x 4cm. Immunohistochemical staining revealed that the tumor cells expressed epithelial membrane antigen(EMA) focally, but not S-100 protein and glial fibrillary acid protein (GFAP), and the Ki-67 proliferative index of the tumor was 9%. The neoplasm was diagnosed chordoid meningioma of the World Health Organization(WHO) grade II. After total resection, her preoperative headache and dysphasia were disappeared.