Comparison of the Surgical Approaches for Frontal Traumatic Intracerebral Hemorrhage

PURPOSE@#Recent developments in minimally invasive techniques have the potential to reduce surgical morbidity, promote patient recovery, accelerate surgical procedures, and thus improve cost-effectiveness in case management. In this study, we compared the treatment efficacy and results of supraorbital keyhole approach (SOKA) with those of conventional unilateral frontal craniotomy (CUFC) for traumatic intracerebral hemorrhage (TICH) in the frontal lobe.@*METHODS@#We analyzed the data of 38 patients who underwent CUFC (n=30) and SOKA (n=8) and retrospectively reviewed their medical records and radiological findings. Furthermore, we tried to identify the best surgical method for such lesions by including patients who underwent burr hole aspiration and drainage (BHAD) (n=9) under local anesthesia due to various circumstances.@*RESULTS@#The difference in the initial Glasgow coma scale score, operative time, and length of hospitalization between the CUFC and SOKA were statistically significant. All radiological features between the two groups including associated skull fracture, amount of pre- and postoperative hematoma, percentage of complete hematoma removal, pre- and postoperative midline shifting of the hematoma, and development of postoperative delayed hematoma were not statistically significant. Our experience of 46 patients with TICH in the frontal lobe with any of the three different surgical methods including BHAD enabled us to obtain valuable findings.@*CONCLUSIONS@#Although it is difficult to insist that one particular approach is more useful than the other, we are confident that SOKA will have more advantages over CUFC in carefully selected patients with frontal TICH depending on the surgical experience of a neurosurgeon.

Comparative Analysis between Male and Female Osteoporotic Compression Fractures in Elderly Patients / 대한신경손상학회지

OBJECTIVE: Osteoporosis results in increased fragility of the bone and thereby predisposes the patients to have a fracture with relatively little trauma. Osteoporosis is more common in women, however, its incidence in men is also increasing. Purpose of this article is to assess the clinical difference between male and female patient, and the effects of vertebroplasty or kyphoplasty. METHODS: Between January 2009 and December 2012, total 198 patients have undergone vertebroplasty or kyphoplasty for osteoporotic vertebral compression fractures and we selected 54 patients (27 male and 27 female) in this retrospective study. We investigated the difference of clinical characteristics between male and female osteoporotic vertebral compression fractures. RESULTS: There were no significant differences between the 2 groups in terms of distribution of body mass index, diabetes mellitus, hypertension, stroke, previous vertebroplasty or kyphoplasty. However, bone mineral density and vertebral compression fracture induced by trauma were significantly higher in male group. And preoperative visual analogue scale (VAS) is higher in male group. CONCLUSION: Osteoporotic vertebral compression fracture induced by trauma is more frequent in men. Higher VAS score before operation in men might reflect this difference in etiology. The VAS scores decreased after operation in both men and women, suggesting vertebroplasty or kyphoplasty is effective in osteoporotic compression fracture regardless of etiology.

Comparative Analysis between Male and Female Osteoporotic Compression Fractures in Elderly Patients / 대한신경손상학회지

OBJECTIVE: Osteoporosis results in increased fragility of the bone and thereby predisposes the patients to have a fracture with relatively little trauma. Osteoporosis is more common in women, however, its incidence in men is also increasing. Purpose of this article is to assess the clinical difference between male and female patient, and the effects of vertebroplasty or kyphoplasty. METHODS: Between January 2009 and December 2012, total 198 patients have undergone vertebroplasty or kyphoplasty for osteoporotic vertebral compression fractures and we selected 54 patients (27 male and 27 female) in this retrospective study. We investigated the difference of clinical characteristics between male and female osteoporotic vertebral compression fractures. RESULTS: There were no significant differences between the 2 groups in terms of distribution of body mass index, diabetes mellitus, hypertension, stroke, previous vertebroplasty or kyphoplasty. However, bone mineral density and vertebral compression fracture induced by trauma were significantly higher in male group. And preoperative visual analogue scale (VAS) is higher in male group. CONCLUSION: Osteoporotic vertebral compression fracture induced by trauma is more frequent in men. Higher VAS score before operation in men might reflect this difference in etiology. The VAS scores decreased after operation in both men and women, suggesting vertebroplasty or kyphoplasty is effective in osteoporotic compression fracture regardless of etiology.

The Effect of Continuous Epidural Electrical Stimulation on Neuronal Proliferation in Cerebral Ischemic Rats

OBJECTIVE: To investigate the effect of electrical stimulation (ES) on the recovery of motor skill and neuronal cell proliferation. METHODS: The male Sprague-Dawley rats were implanted with an epidural electrode over the peri-ischemic area after photothrombotic stroke in the dominant sensorimotor cortex. All rats were randomly assigned into the ES group and control group. The behavioral test of a single pellet reaching task (SPRT) and neurological examinations including the Schabitz's photothrombotic neurological score and the Menzies test were conducted for 2 weeks. After 14 days, coronal sections were obtained and immunostained for neuronal cell differentiation markers including bromodeoxyuridine (BrdU), neuron-specific nuclear protein (NeuN), and doublecortin (DCX). RESULTS: On the SPRT, the motor function in paralytic forelimbs of the ES group was significantly improved. There were no significant differences in neurological examinations and neuronal cell differentiation markers except for the significantly increased number of DCX+ cells in the corpus callosum of the ES group (p<0.05). But in the ES group, the number of NeuN+ cells in the ischemic cortex and the number of NeuN+ cells and DCX+ cells in the ischemic striatum tended to increase. In the ES group, NeuN+ cells in the ischemic hemisphere and DCX+ cells and BrdU+ cells in the opposite hemisphere tended to increase compared to those in the contralateral. CONCLUSION: The continuous epidural ES of the ischemic sensorimotor cortex induced a significant improvement in the motor function and tended to increase neural cell proliferation in the ischemic hemisphere and the neural regeneration in the opposite hemisphere.

A Case of Occipital Neuralgia in the Greater and Lesser Occipital Nerves Treated with Neurectomy by Using Transcranial Doppler Sonography: Technical Aspects / 대한통증학회지

Occipital neuralgia is usually defined as paroxysmal stabbing pain in the greater or lesser occipital nerve (GON or LON) distribution. In occipital neuralgia patients, surgical considerations are carefully taken into account if medical management is ineffective. However, identification of the occipital artery by palpation in patients with thick necks or small occipital arteries can be technically difficult. Therefore, we established a new technique using transcranial Doppler (TCD) sonography for more accurate and rapid identification. The patient was a 64-year-old man who had undergone C1-C3 screw fixation and presented with intractable stabbing pain in the bilateral GON and LON distributions. In cases in which pain management was performed using medication, physical therapy, nerve block, or radiofrequency thermocoagulation, substantial pain relief was not consistently achieved, and recurrence of pain was reported. Therefore, we performed occipital neurectomy of the bilateral GON and LON by using TCD sonography, which helped detect the greater occipital artery easily. After the operation, the patient's headache disappeared gradually, although he had discontinued all medication except antidepressants. We believe that this new technique of occipital neurectomy via a small skin incision performed using TCD sonography is easy and reliable, has a short operative time, and provides rapid pain relief.

A Case of Occipital Neuralgia in the Greater and Lesser Occipital Nerves Treated with Neurectomy by Using Transcranial Doppler Sonography: Technical Aspects

Occipital neuralgia is usually defined as paroxysmal stabbing pain in the greater or lesser occipital nerve (GON or LON) distribution. In occipital neuralgia patients, surgical considerations are carefully taken into account if medical management is ineffective. However, identification of the occipital artery by palpation in patients with thick necks or small occipital arteries can be technically difficult. Therefore, we established a new technique using transcranial Doppler (TCD) sonography for more accurate and rapid identification. The patient was a 64-year-old man who had undergone C1-C3 screw fixation and presented with intractable stabbing pain in the bilateral GON and LON distributions. In cases in which pain management was performed using medication, physical therapy, nerve block, or radiofrequency thermocoagulation, substantial pain relief was not consistently achieved, and recurrence of pain was reported. Therefore, we performed occipital neurectomy of the bilateral GON and LON by using TCD sonography, which helped detect the greater occipital artery easily. After the operation, the patient's headache disappeared gradually, although he had discontinued all medication except antidepressants. We believe that this new technique of occipital neurectomy via a small skin incision performed using TCD sonography is easy and reliable, has a short operative time, and provides rapid pain relief.

Spontaneous Regression of Lumbar Herniated Intervertebral Disc

Although the spontaneous regression of herniated intervertebral disc(HIVD) is well documented, the most useful and effective treatment protocol for symptomatic HIVD remains controversial. Here, we present a rare case of spon- taneous regression of lumbar HIVD. A 43-year-old woman presented with a pain in her lower back and right lower limb radiating from the buttock to the calf. Straight-leg raising test was positive at 30 degrees on the right side. Magnetic resonance imaging(MRI) revealed right-sided extrusion of an L5-S1 disc fragment with caudal migration; the disc fragment compressed the dural sac and nerve root at this level. The patient refused surgery and was, therefore, managed with conservative therapy comprising bed rest, epidural block, muscle relaxants, and nonsteroidal anti- inflammatory drugs(NSAIDs) for 45 days. At a follow-up after 45 days of this therapy, all the initial symptoms of the patient disappeared completely and a follow-up MRI showed regression of the disc fragment. The exact mecha- nism that prompted this regression is still unclear. However, as shown in our case, lumbar HIVD may spontaneously regress, implying that conservative treatment should be given additional importance in the treatment of HIVD.

Comparative Analysis of Usefulness of Vertebral Venography on the Percutaneous Vertebroplasty for Osteoporotic Compression Fracture

BACKGROUND: Percutaneous vertebroplasty (PV) is a minimally invasive, image-guided therapy used to relieve pain from osteoporotic vertebral compression fractures. Venography before injection of bone cement has been advocated as a means of identifying sites of potential venous leakage during the procedure. However, venography has been used only in selected situations, and its need is debatable. We aimed to analyze the usefulness of venography with percutaneous vertebroplasties for osteoporotic compression fractures and to report our recent experiences in treating such patients. METHODS: One hundred PVs performed on 93 patients were evaluated. To identify the usefulness of venography, our cases were divided into 2 groups. Group A patients had venographies before the PVs, whereas Group B patients were treated without venography. We analyzed their clinical status, pain status, and complications linked to leakage of bone cement. RESULTS: There were no significant differences in any of the collected data for the two groups. CONCLUSION: Our results indicate that PVs can be performed safely without venography beforehand. However, venography may be beneficial for less experienced physicians or trainees.

Comparative Analysis of Usefulness of Vertebral Venography on the Percutaneous Vertebroplasty for Osteoporotic Compression Fracture

BACKGROUND: Percutaneous vertebroplasty (PV) is a minimally invasive, image-guided therapy used to relieve pain from osteoporotic vertebral compression fractures. Venography before injection of bone cement has been advocated as a means of identifying sites of potential venous leakage during the procedure. However, venography has been used only in selected situations, and its need is debatable. We aimed to analyze the usefulness of venography with percutaneous vertebroplasties for osteoporotic compression fractures and to report our recent experiences in treating such patients. METHODS: One hundred PVs performed on 93 patients were evaluated. To identify the usefulness of venography, our cases were divided into 2 groups. Group A patients had venographies before the PVs, whereas Group B patients were treated without venography. We analyzed their clinical status, pain status, and complications linked to leakage of bone cement. RESULTS: There were no significant differences in any of the collected data for the two groups. CONCLUSION: Our results indicate that PVs can be performed safely without venography beforehand. However, venography may be beneficial for less experienced physicians or trainees.

Effect of Cerebral Motor Cortex Stimulation in Amyotrophic Lateral Sclerosis Model: A Preliminary Controlled Study

OBJECTIVE: To observe the effect of the depolarizing stimulation in amyotrophic lateral sclerosis (ALS) mouse model on the survival and behavioral performance. METHOD: Transgenic male mouse model of ALS at the age of 9~11 weeks were divided into sham control group (n=10) and stimulation group (n=9). Electrode was implanted in the motor cortex in left hemisphere. Movement thresholds (MT) were regularly checked. Half threshold of MT, unipolar, and continuous electrical stimulation (frequency, 50 Hz; pulse duration, 220micron s) was delivered through implanted electrode. Behavioral tests including Rota-rod and Paw-grip endurance were checked every day. RESULTS: Induction of symptom was delayed in 8 days in stimulation than sham control group. However, there was no significant difference in survival in both groups. Behavioral tests showed that stimulation group is significantly better than sham group in Rota-rod (11~15 weeks) and in grip endurance (11~14, 16 weeks). MT was always between 1.0 volt and 3.2 volt in sham group, however, MT was between 0.8 volt and 2.8 volt in stimulation group. MT was jumped up around the time of death in both groups. CONCLUSION: Electrical stimulation is considered to be one of possible trial methods in ALS model. However, parameters of the stimulation in the experiment should be modified for better results.

The Effect of Continuous Epidural Electrical Stimulation on Synapse and Neuronal Cell in Rat with Focal Ischemia

OBJECTIVE: To evaluate the effects of continuous epidural electrical stimulation (ES) on the behavioral recovery, and the molecular proliferation of synapse and neural cell in rats with photothrombotic stroke. METHOD: The male Sprague-Dawley rats were pre-trained on a single pellet reaching task (SPRT), and then received the photothrombotic infarction on dominant sensorimotor cortex (SMC) and implantation of electrode over the peri-lesion SMC surface. All rats were randomly assigned to one of two groups: anodal ES on infarcted SMC (ES group) and no ES on infarcted SMC (control group). Rats received daily SPRT and neurological examinations for 14 days. After the rats had been sacrificed, brain sections were immunostained for quantification of infarct volumes and evaluation of the structural remodeling markers (MAP2, synaptophysin and GFAP). RESULTS: The functional improvement of SPRT was significantly increased in the ES group compared to control group. There were no significant group differences in the infarct volumes, neurological examinations, structural remodeling markers. But, in the ES group, MAP2 and synaptophysin in affected peri-infarct area tended to increase compared with unaffected hemisphere. In affected hemisphere of ES group, many structural remodeling markers tended to increase compared with unaffected hemisphere. Especially, the staining of synaptophysin and GFAP in peri-infarct area showed more increased uptake than unaffected hemisphere in ES group and control group, respectively (p<0.05). CONCLUSION: The ES improved greatly the behavioral motor function after SMC infarction and induced the significant synaptogenesis with the widespread neuronal proliferation in peri-infarct area. Postischemic astrogliosis was not remarkable in ES group.

Relevance of Behavioral Test in the Photothrombotic Stroke Rat Model

OBJECTIVE: The purpose of this study was to find reliable behavioral measures for the evaluation of motor dysfunction in photothrombotic ischemia rat model. METHOD: Male Sprague-Dawley rats were trained for behavioral test including tray reaching task (TRT), single pellet reaching task (SPRT), and rotarod task (RRT) for more than 2 weeks. Photothrombotic ischemia was induced in a stereotactically held rats using Rose Bengal dye (20 mg/kg) and cold light. Rats were assigned to either control (n=10) or experimental ischemic group (n=10). Post-lesional behavioral tests were performed for 4 weeks after confirmation of lesion by magnetic resonance imaging (MRI), followed by histological examination. RESULTS: RRT showed no difference between control and experimental group. SPRT and TRT showed significant difference between control and experimental group (p<0.05). SPRT could well demonstrate the recovery of motor dysfunction after over time. CONCLUSION: SPRT could be the most reliable test to measure not only motor dysfunction but also motor recovery in unilateral motor cortex lesion of photothrombotic ischemia rat model.

Chronological Changes in Cerebral Infarction of Photochemical Thrombosis Model: Magnetic Resonance Imaging and Histopathological Correlation

OBJECTIVE: Authors investigated magnetic resonance imaging (MRI) and histological characteristics of photothrombotic infraction rat model (PIRM) on long term basis to provide a basis for further research. METHOD: Photothrombotic ischemia was induced in male Sprague-Dawley rats using Rose-bengal dye (20 mg/kg) and cold light. MRI was performed 1, 6, 12, 24 hours, 3, 7 days, 2, 3, 4, 6, and 8 weeks after photothrombosis and obtained T1- & T2-weighted and contrast-enhanced images. Also, T2* images were obtained after superparamagnetic iron oxide injection. After MRI, animals were sacrificed and the brain sections were stained for routine immunohistopathology. RESULTS: MRI and histological analysis revealed well induced lesion in the cortex and showed biological course of infarction. However, PIRM showed rapid development of infarction lacking collateral circulation. Infarction size reached maximum 12 hours after induction, progressively decreasing over 4 weeks. Interstitial and cytotoxic edema were evident at 6, 12, 24 hours, but decreasing afterwards. Neurogenic inflammation appeared on 3rd day and reached maximum on 5~7th day. Arachnoid membrane was characteristically invaded with inflammatory cells and later thickened with fibrosis. CONCLUSION: This study showed PIRM is ideal model to study subacute and chronic stages of cerebral infarction.

Protective Effects of Potassium Ion on Rotenone-Induced Apoptosis in Neuronal (Neuro 2A) Cells

OBJECTIVE: The authors investigated whether rotenone induces cellular death also in non-dopaminergic neurons and high concentration of potassium ion can show protective effect for non-dopaminergic neuron in case of rotenone-induced cytotoxicity. METHODS: Neuro 2A cells was treated with rotenone, and their survival as well as cell death mechanism was estimated using 3-(4, 5-Dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium(MTT) assay, Lactate dehydrogenase(LDH) release assay, fluorescence microscopy, and agarose gel electrophoresis. The changes in rotenone-treated cells was also studied after co-treatment of 50mM KCl. And the protective effect of KCl was evaluated by mitochondrial membrane potential assay and compared with the effects of various antioxidants. RESULTS: Neuro 2A cells treated with rotenone underwent apoptotic death showing chromosome condensation and fragmentation as well as DNA laddering. Co-incubation of neuro 2A cells with 50mM KCl prevented it from the cytotoxicity induced by rotenone. Intracellular accumulation of reactive oxygen species(ROS) resulting by rotenone were significantly reduced by 50mM KCl. Potassium exhibited significantly similar potency compared to the antioxidants. CONCLUSION: The present findings showed that potassium attenuated rotenone-induced cytotoxicity, intracellular accumulation of ROS, and fragmentation of DNA in Neuro 2A cells. These findings suggest the therapeutic potential of potassium ion in neuronal apoptosis, but the practical application of high concentration of potassium ion remains to be settled.

Multiple Intracerebral Hemorrhages Associated with Cardiac Myxoma

The authors report a case of cardiac myxoma with simultaneous multiple intracranial hemorrhages. A 45-year-old man presenting with hemiparesis and seizure was found on brain computerized tomography(CT) scan to have intracranial hemorrhagic regions in both frontoparietal areas. Chest CT scan for searching primary focus of metastasis showed a mass in the heart, and subsequent echocardiogram showed a myxoma in the left atrium. Total resection of the brain lesions was carried out after cardiac operation. Although myxoma cells could not be found in specimens of the intracerebral lesions, coincidental hemorrhages were suspected to have occurred due to metastasis of cardiac myxoma.

Effects of Acute and Chronic Treatment of Olanzapine and Risperidone on the Extracellular Dopamine Concentrations of the Prefrontal Cortex in Rats / 신경정신의학

OBJECT: It is reported that the effect of antipsychotics on the extracellular dopamine levels in the prefrontal cortex is related to the their effect on the negative symptoms. Therefore, we investigated the acute and chronic effects of olanzapine and risperidone on the extracellular dopamine concentrations in the prefrontal cortex of rat. Samples were obtained using in vivo brain microdialysis. METHOD: Dopamine levels in the samples were measured by high pressure liquid chromatography with electrochemical detection. RESULTS: 1) Both the acute treatment of olanzapine and risperidone increased the extracellular dopamine concentrations in the prefrontal cortex, dose-dependently. 2) There was a no significant difference in the maximal change of the extracellular dopamine concentrations in the prefrontal cortex induced by the acute treatment of olanzapine and risperidone. 3) Both the chronic treatment of olanzapine and risperidone also increased the extracellular dopamine concentrations in the prefrontal cortex, but they showed the tolerance effect that the degree of increase was smaller than that of the acute treatment. 4) As for the maximal changes of the extracellular dopamine concentrations in the prefrontal cortex induced by the chronic treatment of olanzapine and risperidone, the effect of the former was greater than that of the latter. CONCLUSION: These results suggest that the effects of olanzapine and risperidone on the negative symptoms are related to the increased extracellular dopamine concentrations in the prefrontal cortex induced by these drugs.

Restoration of Vasoreactivity in Patients with Symptomatic ICA Occlusion after Extracranial-Intracranial Bypass Surgery / 대한뇌혈관학회지

OBJECTIVE: The purpose of this study is to investigate changes of vasoreactivity after STA-MCA anastomosis in patients who develop hemodynamic cerebral ischemia associated with ICA or MCA occlusion. METHODS: Twenty-five patients with hemodyamic infarction due to symptomatic ICA or MCA occlusion were treated with extracranial-intracranial bypass surgery (EIAB). Of these, we enrolled 17 patients who underwent follow-up SPECT and follow-up angiogram. To test vasomotor reactivity, we measured relative regional cerebral blood flow (rrCBF) with SPECT both at rest and after diamox infusion. rrCBF were calculated using the following equation: (lesional radioactivity/contralateral radioactivity) x100. We performed EIAB in patients with impaired vasomotor reactivity. To evaluate changes in vasomotor reactivity after surgery, follow-up brain SPECT was performed 1-6 months after surgery and compared rrCBF before and after surgery. RESULTS: Base line radioactivity ratios did not change after surgery. These ratios after diamox challenge were 59.8+/-4.2%, however, 1-6 months after surgery, ratios increased to 77.7+/-.6% (p<0.05, Paired T-test). Preoperative degree of angiographic collateral circulation did not influence the restoration of vasoreactivity. All but two patients showed good collateral circulation through the bypass. There were no cerebral accidents in any these patients at 6 months to 2 years follow-up. CONCLUSION: These results demonstrate the restoration of vasomotor reactivity distal to the occluded ICA or MCA after EIAB, and also show that measurement of rrCBF using SPECT are useful indicators of the clinical and hemodynamic improvement.

Relaxation of Subarachnoid Hemorrhage-Induced Spasm by Eicosapentanoic Acid

OBJECTIVE: There is increasing evidence that the omega-3 polyunsaturated fatty acid, eicosapentanoic acid(EPA), induces relaxation in vessels from various animal models as cardiovascular protective nutrients. In vivo study was undertaken to investigate the potential therapeutic application of EPA to resolve vasospasm. METHODS: The basilar artery was visualized using transclival exposure, and its diameter monitored using videomicroscopy. Rabbits were divided randomly into seven groups:1) normal rabbits basilar artery treated with topical application of 100nM/L EPA only;2) normal rabbits basilar artery treated with 20nM/L phorbol dibutyrate(PDB), then 20 nM/L PDB+100nM/L EPA;3) normal rabbits basilar artery treated with 80mM/L KCL, then 80mM/L KCL+100nM/L EPA;4) normal rabbits basilar artery treated with 20nM/L endothelin 1(ET-1) only;5) normal rabbits basilar artery treated with 20nM/L ET-1, then 20nM/L ET-1+100nM/L EPA;6) subarachnoid hemorrhage(SAH) rabbits basilar artery treated with artificial CSF only;7) SAH rabbits basilar artery treated with 100nM/L EPA. RESULTS: In normal(non-SAH) rabbits, EPA:1) had no effect on basal tone;2) did not reverse KCL or PDB-induced constriction;and 3) substantially reversed ET-1-induced constriction. The diameter of normal rabbit basilar artery was 779.1+/-17.9nm(mean+/-standard error). After SAH, the mean diameter was 521.0+/-32.5nm. The addition of EPA reversed this SAH-induced constriction to 80.4% of baseline diameter. CONCLUSION: These results suggest that EPA induces relaxation in cerebrovascular arteries constricted with ET-1, and that it prevents and partially reverses SAH-induced vasoconstriction.

Cholesterol Granuloma in the Sphenoid Sinus: A Case Report

The authors report a case of cholesterol granuloma in the sphoid sinus in 54-year old woman, which is probably the first report of cholesterol granuloma arising primarily in the sphenoid sinus apart from the petrous bone. The initial clinical presentations were unilateral decreased visual acuity and facial sensory change. The mass was removed totally via transsphenoidal route and the pathological examination revealed cholesterol clefts and chronic granulomatous changes. The differences between the present case and the previous reports are discussed.

Expression of Vascular Endothelial Growth Factor in Astrocytic Tumors: Correlation to Peritumoral Brain Edema and Microvasculature

No abstract available.