The Clinical Experience of Computed Tomographic-Guided Navigation System in C1-2 Spine Instrumentation Surgery

OBJECTIVE: To identify the accuracy and efficiency of the computed tomographic (CT)-based navigation system on upper cervical instrumentation, particularly C1 lateral mass and C2 pedicle screw fixation compared to previous reports. METHODS: Between May 2005 and March 2014, 25 patients underwent upper cervical instrumentation via a CT-based navigation system. Seven patients were excluded, while 18 patients were involved. There were 13 males and five females; resulting in four degenerative cervical diseases and 14 trauma cases. A CT-based navigation system and lateral fluoroscopy were used during the screw instrumentation procedure. Among the 58 screws inserted as C1-2 screws fixation, their precise positions were evaluated by postoperative CT scans and classified into three categories : in-pedicle, non-critical breach, and critical breach. RESULTS: Postoperatively, the precise positions of the C1-2 screws fixation were 81.1% (47/58), and 8.6% (5/58) were of non-critical breach, while 10.3% (6/58) were of critical breach. Most (5/6, 83.3%) of the critical breaches and all of non-critical breaches were observed in the C2 pedicle screws and there was only one case of a critical breach among the C1 lateral mass screws. There were three complications (two vertebral artery occlusions and a deep wound infection), but no postoperative instrument-related neurological deteriorations were seen, even in the critical breach cases. CONCLUSION: Although CT-based navigation systems can result in a more precise procedure, there are still some problems at the upper cervical spine levels, where the anatomy is highly variable. Even though there were no catastrophic complications, more experience are needed for safer procedure.

Anterior Cervical Discectomy and Fusion Using a Double Cylindrical Cage versus an Anterior Cervical Plating System with Iliac Crest Autografts for the Treatment of Cervical Degenerative Disc Disease

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is often complicated by subsidence, pseudoarthrosis, kyphosis, and graft donor site morbidities. To decrease the occurrence of these complications, various types of cages have been developed. We designed this retrospective study to analyze and compare the efficacy and outcomes of ACDF using double cylindrical cages (DCC) (BK Medical, Seoul, Korea) versus an anterior cervical plating system with autogenous iliac crest grafts. METHODS: Forty-eight patients were treated with autograft and plating (plate group), and 48 with DCC group from October 2007 to October 2011. We analyzed construct length, cervical lordotic curvarture, the thickness of the prevertebral soft tissue, segmental instability, and clinical outcomes. RESULTS: There were no significant differences between the two groups with regard to the decrease in construct length or cervical lodortic curvature at the 3-, 6-, and 12-month follow-ups. The prevertebral soft tissue was thinner in the DCC group than the plate group immediately after surgery and at the 3-, 6-, and 12-month follow-ups. The difference in interspinous distance on flexion-extension was shorter in the plate group than the DCC group at the 3- and 6-month follow-ups. However, there was no significant difference in this distance between the two groups at the 12-month follow-up. CONCLUSION: A double cylindrical cage is a good alternative for fusion in patients with cervical degenerative diseases; the surgical method is relatively simple, allows good synostosis, has less associated prevertebral soft tissue swelling, and complications associated with autografting can be avoided.

Optochiasmatic Cavernous Angioma with Rapid Progression after Biopsy Despite Radiation Therapy

We present a rare case of optochiasmatic cavernous angioma (CA) that progressed despite radiation therapy. A 31-year-old female patient presented with sudden loss of left visual acuity and right homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed a suprasellar mass and findings compatible with a craniopharyngioma or an optic glioma with bleeding. An open biopsy was conducted using the transcranial approach, and histological examination revealed gliosis. During the one-year follow-up period, imaging suggested intratumoral bleeding and the mass continued to grow. We recommended re-operation, but the patient refused due to fear of surgery. Consequently, the patient received fractionated radiation therapy (3,000 cGy) to the parasellar area. Despite the radiotherapy, the mass continued to grow for the following 6 years. The final MRI before definitive treatment revealed a multilobulated, multistage hematoma with calcification in the parasellar area, extending into the third ventricle and midbrain. The patient ultimately underwent reoperation due to the growth of the tumor. The mass was completely removed with transcranial surgery, and the pathologic findings indicated a cavernous angioma (CA) without evidence of glioma. As shown in our case, patients may suffer intratumoral hemorrhage after biopsy and radiotherapy. This case places the value of biopsy and radiotherapy for a remnant lesion into question. It also shows that reaching the correct diagnosis is critical, and complete surgical removal is the treatment of choice.

Oocyte maturity in repeated ovarian stimulation / 대한생식의학회지

OBJECTIVE: During stimulated IVF cycles, up to 15% of oocytes are recovered as immature. The purpose of this study was to investigate the trend of oocyte maturity in repeated ovarian stimulation for IVF. METHODS: One hundred forty-eight patients were selected who underwent two consecutive IVF cycles using same stimulation protocol during 2008 to 2010. Ovarian stimulation was performed with FSH and human menopausal gonadotropin and flexible GnRH antagonist protocol in both cycles. Oocyte maturity was assessed according to presence of germinal vesicle (GV) and the first polar body. Immature oocyte was defined as GV stage or metaphase I oocyte (GV breakdown with no visible polar body) and cultured up to 48 hours. If matured, they were fertilized with ICSI. RESULTS: Percentages of immature oocytes were 30.8% and 32.9% (p=0.466) and IVM rates of immature oocytes were 36.2% and 25.7% (p=0.077), respectively. A significant correlation was noted between percentage of immature oocytes in the two cycles (R=0.178, p=0.03). Women with >40% immaturity in both cycles (n=21) showed lower fertilization rate of in vivo matured oocytes (56.4% vs. 72.0%, p=0.005) and lower pregnancy rate (19.0% vs. 27.1%, p=0.454) after the second cycle when compared with women with <40% immaturity (n=70). In both groups, female age, number of total retrieved oocyte and embryos transferred were similar. CONCLUSION: In repeated ovarian stimulation cycles for IVF, the immature oocyte tended to be retrieved repetitively in consecutive IVF cycles.

Primary Thoracic Epidural Melanoma : A Case Report

A 68-year-old woman with progressive paraparesis and altered sensation lasting approximately five days was admitted to our clinic. Magnetic resonance imaging (MRI) revealed an advanced stage T7-8 epidural mass ventral to the spinal cord, which was believed to be a metastatic tumor considering the patient's age. A highly enhanced epidural mass and pedicle appeared during the MR scan. However, the pathologic findings were compatible with the diagnosis of a primary meningeal melanocytic tumor. Primary epidural melanomas are extremely rare lesions. This case was finally diagnosed as a primary thoracic spinal epidural melanoma.

Is Transradial Cerebral Angiography Feasible and Safe? A Single Center's Experience

OBJECTIVE: Although a transradial angiography is accepted as the gold standard for cardiovascular procedures, cerebral angiography has been performed via transfemoral approach in most institutions. The purpose of this study is to present our experience concerning the feasibility, efficacy, and safety of a transradial approach to cerebral angiography as an alternative to a transfemoral approach. METHODS: Between February 2007 and October 2009, a total of 1,240 cerebral angiographies were performed via a transradial approach in a single center. The right radial approach was used as an initial access route. The procedure continued only after the ulnar artery was proven to provide satisfactory collateral perfusion according to two tests (a modified Allen's test and forearm angiography). RESULTS: The procedural success rate was 94.8% with a mean duration of 28 minutes. All supra-aortic vessels were successfully catheterized with a success rate of 100%. The success rates of selective catheterization to the right vertebral artery, right internal carotid artery, left internal carotid artery, and left vertebral artery were 96.1%, 98.6%, 82.6% and 52.2%, respectively. The procedure was performed more than twice in 73 patients (5.9%), including up to 4 times in 2 patients. The radial artery occlusion was found in 4 patients (5.4%) on follow-up cerebral angiography, but no ischemic symptoms were observed in any of the cases. CONCLUSION: This study suggests that cerebral angiography using a transradial approach can be performed with minimal risk of morbidity. In particular, this procedure might be useful for follow-up angiographies and place less stress on patients.

Ovulation induction: an up-to-date knowledge / 대한산부인과학회지

Ovulation induction is to make ovulation occur in a woman with ovulatory problems by giving her medical or surgical treatment. The method of ovulation induction varies depends on the cause and classification. In group I of WHO classification, gonadotropins should be used, and in group V or VI which shows hyperprolactinemia, dopamine agonist such as bromocriptine can be used to lower the serum level of prolactin. Group III is not an indication of ovulation induction and ovum donation should be recommended. In group II which is clinically most common, the first choice of treatment is clomiphene. If the initial treatment doesn't work, glucocorticoids, insulin sensitizers such as metformin, or gonadotropins can be added to induce ovulation. Aromatase inhibitor or gonadotropin alone can be an alternative treatment. In patients with polycystic ovary syndrome, ovarian electrocautery, diathermy or laser vaporization can be helpful. In patients with prolactinoma, transsphenoidal pituitary adenomectomy is available.

Clinical Experience with Double Cylindrical Cages for Anterior Cervical Interbody Fusion

OBJECTIVE: We performed the surgery using titanium double cylindrical cage for anterior cervical discectomy and interbody fusion in various degenerative cervical diseases. We compared the clinical results and radiologic results in cervical anterior disectomy. Method: From October 2007 to October 2008, 19 patients diagnosed with degenerative disease underwent anterior cervical disectomy and interbody fusion. The postsurgical clinical results were analyzed retrospectively by classifying them into four levels based on Odom's criteria(excellent, good, fair, and poor) after a more than 6-month follow-up period. RESULTS: In all cases, a single segment was involved, and surgery was performed for 19 segments. The C5-C6 inter-vertebral disc was the most commonly affected(9 cases). The clinical outcome was excellent, good, and fair in 5(26.3 %), 10(52.6%), and 4(21.0%) cases, respectively. An excellent or good outcome was considered as a successful result, showing an approximately 78.9% cure rate. No patient had aggravated symptoms compared with their preoperative status. CONCLUSION: Relatively satisfactory clinical and radiographic results were obtained with double cylindrical cages. The surgical method is relatively simple, allows good synostosis, and prevents many complications associated with autografting. It is also less traumatic to the spinal cord during cage insertion. Therefore, double cylindrical cages are generally more recommended for treating cervical spondylosis accompanied with flat cages.

The Expansion of Cervical Synovial Cyst after Trauma : A Case Report and Literature Review

We report a rare case that showed aggravation of neurological symptoms due to expansion of the synovial cyst at C7/T1 after several month of trauma and present the consideration of proper prevention and management. A 64-year old male was admitted by right arm weakness(GIV+) after a pedestrian traffic accident. According to computed tomography(CT) scan and electromyography(EMG), a brachial plexus injury was diagnosed and he was treated conservatively. After 7 months, he was re-admitted by the left side weakness(GIV-) with severe pain and magnetic resonance image(MRI) revealed the expanded cystic lesion at C7/T1 level which compressed the cord from left side. After administration of steroid, surgical resection was performed via posterior approach and partial laminectomy. The dural expansion was observed after total removal of cyst which was diagnosed as a pathologist and symptoms were completely recovered. Because of its possibility of expansion of the synovial cyst and critical myelopathic symptoms can be induced in cervical spine, immobilization should be in consideration for acute period of post-trauma, especially, in old-aged patients with degenerative facet joints. And surgical procedure should not be delayed if symptoms developed.

An Unexpected Huge Hematoma after Iliac Artery Injury as a Rare Complication at an Anterior Iliac Bone Graft Donor Site: A Case Report

Even through there are many reported complications of the iliac bone donor site during anterior cervical spine surgery, vascular injuries are very rare, especially deep circumflex iliac artery(DCIA) injury encountered after harvesting of a bone graft. A 68-year-old female was presented with neck pain and recent progressive weakness due to dislocation and instability of C5/6 with cord compression. Corpectomy and inter-body fusion from C5 to 7 was done without any definite perioperative complications including the iliac donor site. On the 2nd post-operative day, a huge hematoma and active bleeding at the retroperitoneal site was found by computed tomography and angiography revealed bleeding from DCIA. The authors report a case of massive bleeding due to DCIA injury that was difficult to control and managed by selective arterial embolization.

Embolization through the Ophthalmic Artery with Onyx in Bilateral Ethmoidal Dural Arteriovenous Fistula: A Case Report / 대한뇌혈관외과학회지

Endovascular treatment of ethmoidal dural arteriovenous fistula (DAVF) has not been widely performed because of the technical difficulty of the procedure and the potential risk of central retinal artery occlusion. We report the case of a patient who underwent Onyx embolization through the ophthalmic artery in bilateral ethmoidal DAVF; to our best knowledge this is the first report.

Cerebral Infarction due to Mucormycosis in the Cavernous Sinus / 대한뇌혈관외과학회지

Rhinocerebral mucormycosis is the most common fungal infection and is frequently seen in patients with poorly controlled diabetes mellitus. We report a rare case of cavernous sinus mucormycosis in a 70-year-old man with insulin-dependent diabetes mellitus. An endoscopic surgical removal of the mucocele was performed. The histopathologic examination revealed characteristic aseptate branching hyphae with invasion of blood vessels, which is consistent with zygomycosis. The patient was administered high-dose amphotericin B therapy. While undergoing amphotericin-B treatment, the patient developed a left-sided hemiparesis. Magnetic resonance imaging and magnetic resonance angiography revealed acute infarction in the right hemisphere and occlusion of the right internal carotid artery in the right cavernous sinus. The patient was managed with conventional medical treatment for acute cerebral infarction and additional amphotericin B infusion. The patient survived, but with severe neurologic sequelae despite extensive medical therapy, including complete-visual loss, leftsided hemiparesis, impairment of cognitive function, dysphagia, and neuropathic pain on the left side of the body. We report herein the clinical course and treatment of a patient with cerebral complications due to mucormycosis and also present a brief literature review.

Is Extravasation of Radiographic Contrast a Predictor of Hematoma Enlargement in Spontaneous Supratentorial Intracerebral Hemorrhage? / 대한뇌혈관외과학회지

BACKGROUND AND PURPOSE: The enlargement of a hematoma occurs commonly in patients with spontaneous intracerebral hemorrhage (ICH) after hospitalization and can worsen the clinical outcome. We conducted this study to determine whether extravasation of a radiographic contrast agent is a predictor of hematoma enlargement occurring after admission in patients with spontaneous ICH. METHODS: We reviewed the clinical records and computerized tomography (CT) scan findings of 384 patients with spontaneous ICH admitted within 24 hours of ictus from 2002 to 2005. Only 71 patients with primary ICH in the basal ganglia or thalamus were included in the study. The first CT scan was preformed within 24 hours of onset and the second CT scan was preformed within 72 hours of onset. We compared patients with and without hematoma enlargement according to the radiological findings, clinical characteristics and laboratory data. RESULTS: Seventeen patients (23.9%) showed hematoma enlargement after admission. Extravasation of the radiographic contrast agent on a CT scan was seen in 23 patients (32.4%). The presence of contrast extravasation on a CT scan closely correlated with evidence of hematoma enlargement, as seen on a follow-up CT scan (p = 0.000). Other variables did not reach statistical significance for the independent association with hematoma enlargement. CONCLUSIONS: Due to a high risk for hematoma enlargement, patients with spontaneous ICH in the basal ganglia and thalamus, especially those with evidence of contrast extravasation on a CT scan, should be closely observed. Short term followup radiological studies are needed for the verification of hematoma enlargement.

Recanalization Rate and its Associated Factors after Intravenous Tissue Plasminogen Activator Thrombolysis for Acute Major Cerebral Arterial Occlusion / 대한뇌혈관외과학회지

PURPOSE: To investigate the recanalization rate after intravenous administration of recombinant tissue plasminogen activator (IV-tPA) for acute major arterial occlusion of the anterior cerebral circulation and to investigate the relationship between atrial fibrillation and recanalization. METHODS: From April 2005 to April 2006, 16 patients with acute major arterial occlusion of the anterior cerebral circulation were treated with IV-tPA. Recanalization was classified as good (as compared with an unoccluded contralateral vessel; thrombolysis in myocardial infarction (TIMI) classification grade II and III) and poor (TIMI grade 0 and I). The clinical and radiological parameters associated with recanalization were analyzed. The clinical outcomes were evaluated by use of the National Institute of Health Stroke Scale (NIHSS) at 3 months after treatment. RESULTS: Of all of the 16 patients, 11 patients (68.8%) showed good recanalization. Among these 11 patients, nine patients survived (81.8%). However, only one patient survived (20%, p = 0.036) of the other five patients who showed poor recanalization. The pretreatment NIHSS score and atrial fibrillation were significantly correlated with the recanalization rate. Atrial fibrillation was found in 8 of 16 patients (50.0%) as the cause of the cerebral embolic infarction. Among the patients with atrial fibrillation only three patients showed good recanalization (37.5%); patients without atrial fibrillation showed good recanalization (100%, p = 0.026). CONCLUSIONS: I.-tPA appears to be effective and safe as a recanalization method for acute major cerebral arterial occlusion in patients that do not have atrial fibrillation. Good recanalization was associated with a good clinical result. Atrial fibrillation is a significant associated factor of poor recanalization and high mortality.

Spontaneous Bilateral Basal Ganglia Hemorrhage: Case Report / 대한뇌혈관외과학회지

A 39-year old man presented with comatose mentality. Brain computerized tomography revealed bilateral basal ganglia hemorrhage. The amount of hematoma was 35 cc each. He had no hypertension history through out regular health examination. Emergenct hematoma evacuation was performed. Histopathologic study disclosed no evidence of amyloid angiopathy or infection. He died 4 days after the operation due to myocardiac infarction. This report describe a rare case of simultaneous bilateral cerebral hemorrhages without history of hypertension.

Clinical Efficacy of Body Mass Index as Predictor of In Vitro Fertilization and Embryo Transfer Outcomes

The aim of this study was to evaluate the clinical efficacy of body mass index (BMI) as a predictor of in vitro fertilization and embryo transfer (IVF-ET) outcomes. Two hundred twenty-three IVF-ET cycles in 164 patients under 37 yr using GnRH agonist long protocols were included in this retrospective study. All of the selected cases were divided into two groups by a cutoff of 24 kg/m2 and these two groups were compared in regard to the outcomes of IVF-ET. There were no significant differences between group 1 (BMI or = 24 kg/m2) in age, basal serum FSH level, estradiol (E2) level and endometrial thickness on hCG day, number of retrieved oocytes and transferred embryos. However, higher doses of gonadotropins were used in group 2 (30.8+/-12.7 ampoules vs. 35.4+/-15.3 ampoules, p=0.051). The clinical pregnancy rate was significantly lower in group 2 (25.9% vs. 10.5%, p=0.041) and implantation rate tended to be lower in group 2 (12.7% vs. 6.8%, p=0.085). BMI > or = 24 kg/m2 can be a candidate prognosticator of IVF-ET outcomes.

The clinical efficacy of body mass index as a predictor of in vitro fertilization and embryo transfer outcomes / 대한산부인과학회지

OBJECTIVE: To evaluate the clinical efficacy of body mass index (BMI) as a predictor of in vitro fertilization and embryo transfer (IVF-ET) outcomes. METHODS: Two hundred twenty-three IVF-ET cycles in 164 patients under 37 years using GnRH agonist long protocol were included in this retrospective study. All of the selected cases were divided into two groups by BMI of 24 kg/m2 and these two groups were compared in regard to the outcomes of IVF-ET. RESULTS: There were no significant differences between Group 1 (BMI or =24 kg/m2) in age, basal serum FSH level, estradiol (E2) level and endometrial thickness on hCG day, number of retrieved oocytes and transferred embryos. However, more gonadotropins were used in Group 2 with borderline significance (30.8+/-12.7 ampules vs. 35.4+/-15.3 ampules, p=0.051). The clinical pregnancy rate was significantly lower in Group 2 (25.9% vs. 10.5%, p=0.041) and implantation rate tended to be lower in Group 2 with borderline significance (12.7% vs. 6.8%, p=0.085). CONCLUSION: BMI> or =24 kg/m2 may have a detrimental effect on the IVF-ET outcomes in Korean infertile women, and BMI may be a candidate predictor for IVF outcomes.

Comparative Study of Cerebral Vasospasm between Endovascular Treatment and Conventional Surgery of Acutely Ruptured Aneurysms: Clinical Study / 대한뇌혈관외과학회지

OBJECT: Generally, it seems like that the incidence of vasospasm of vasospasm in endovascular coil embolization is higher than clipping in aneurysmal subarachnoid hemorrhage. But endovascular coil embolization in our study group was not associated with higher incidence of symptomatic vasospasm than direct clipping and we made an analysis of that cause. METHODS: The authors reviewed 220 patients with aneurysmal subarachnoid hemorrhage who had been treated with either neck clipping or coil embolization by a single surgeon between January 1997 and December 2002. Poor initial grade (Hunt & Hess grade IV & V) patients were excluded. Finally 171 patients were enrolled in this study. 126 patients(74%) underwent direct surgical clipping and 45 patients (26%) underwent endovascular treatments of their aneurysms. RESULTS: Overall symptomatic vasospasm occurred in 32 (19%) patients, 4 of 45 patients (9%) were coiling group and 28 of 126 (22%) were surgically treated group. There was no difference between two groups in age, initial Hunt & Hess grade, Glasgow coma scale, operation time, treatment initiation time, patient's medical status. CONCLUSIONS: Patients who underwent coil embolization were not more likely to suffer from symptomatic vasospasm than aneurysm neck clipping in better clinical grades (Hunt & Hess grade of I to III) patients in our institute.

Usefulness of Drug-Eluting Stents in Angioplasty and Stenting of the Vertebral Artery Origin : Comparison with Bare Stents: Clinical Research / 대한뇌혈관외과학회지

OBJECT: In the treatment of coronary atherosclerosis, drug-eluting stents are effective in decreasing the rate of major adverse cardiac events and angiographic restenosis compared with bare metal stents. However, the benefits and safety of using these new devices in the cerebral vasculature have not been evaluated. To assess the effectiveness of drug-eluting stents in the cerebral vasculature, the authors analyzed clinical and angiographic results after percutaneous transluminal angioplasty and stenting in patients with vertebral artery origin stenosis. METHODS: Ninety-one patients with 99 vertebral origin stenoses treated with percutaneous endovascular balloon angioplasty and stent placement during a period of 5.1 years (September 1999-October 2004). Follow-up angiograms were obtained from 38 patients with 42 lesions (24 men, 14 women ; mean age, 61.9 yrs ; mean follow-up period, 9.1 months). We reviewed the clinical and radiological records of these patients. RESULTS: Bare stents were implanted in 30 lesions, while drug-eluting stents were implanted in 12 lesions, with a mean residual stenosis of 5.1 %. The overall rate of moderate-to-severe restenosis (> or =50%) was 31.0 % (13 of 42 cases). The restenosis rate in the bare stent group was 36.7 %, compared with 16.7 % in the drug-eluting stent group (p=0.282). Comparing the restenosis rate in stented lesions with reference diameters less than 3.5 mm (11 with bare stents, 12 with drug-eluting stents), the restenosis rates were 63.6 % in the bare stent-group and 16.7 % in the drug-eluting stent-group (p=0.029). CONCLUSION: Drug-eluting stents placed in vertebral artery origin stenosis have lower restenosis rate than bare stents, particularly in small-sized vessels.

Comparative Study of Cerebral Vasospasm between Endovascular Treatment and Conventional Surgery of Acutely Ruptured Aneurysms: Clinical Study / 대한뇌혈관외과학회지

OBJECT: Generally, it seems like that the incidence of vasospasm of vasospasm in endovascular coil embolization is higher than clipping in aneurysmal subarachnoid hemorrhage. But endovascular coil embolization in our study group was not associated with higher incidence of symptomatic vasospasm than direct clipping and we made an analysis of that cause. METHODS: The authors reviewed 220 patients with aneurysmal subarachnoid hemorrhage who had been treated with either neck clipping or coil embolization by a single surgeon between January 1997 and December 2002. Poor initial grade (Hunt & Hess grade IV & V) patients were excluded. Finally 171 patients were enrolled in this study. 126 patients(74%) underwent direct surgical clipping and 45 patients (26%) underwent endovascular treatments of their aneurysms. RESULTS: Overall symptomatic vasospasm occurred in 32 (19%) patients, 4 of 45 patients (9%) were coiling group and 28 of 126 (22%) were surgically treated group. There was no difference between two groups in age, initial Hunt & Hess grade, Glasgow coma scale, operation time, treatment initiation time, patient's medical status. CONCLUSIONS: Patients who underwent coil embolization were not more likely to suffer from symptomatic vasospasm than aneurysm neck clipping in better clinical grades (Hunt & Hess grade of I to III) patients in our institute.