Clinical Analysis of Results of Shunt Operation for Hydrocephalus Following Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Ventricular enlargement following head injury is a frequent finding but cases requiring shunt operation are rare. The incidence and developing factors of post-traumatic hydrocephalus (PTH) have been variously reported, but studies for factors influencing outcomes of shunt operation for PTH are rare. The incidence of PTH requiring shunt operation, causing injuries, and factors influencing outcome of shunt operation need to be identified. METHODS: In total, 1,142 patients suffering from traumatic brain injury (TBI) between January 2007 and December 2012 were admitted to our department. Of them, 23 patients underwent shunt operation for diagnosed PTH. In this clinical study, we reviewed retrospectively our TBI database and in the 23 patients, we evaluated outcomes with Glasgow Outcome Score just before the operation, at 14 days, 3 months, and 6 months according to initial Glasgow Coma Scale (GCS) score, interval time between shunt operation and trauma, and lumbar cerebrospinal fluid (CSF) pressure. RESULTS: The incidence of PTH treated with shunt operation was 2.01%. Subdural hematoma (SDH) was the most common preceding head injury. The outcomes of shunt operation were not related with lumbar CSF pressure or interval time from trauma, but initial GCS score correlated with the outcome. CONCLUSION: In present study, 2.01% of TBI patients underwent shunt operation. SDH was the most common preceding injury. Admission GCS score was related to the outcome of shunt operation. However, there were no correlation between the outcome of shunt operation and initial lumbar CSF pressure or interval time of shunt operation after the trauma.

FSL-1, a Toll-like Receptor 2/6 Agonist, Induces Expression of Interleukin-1alpha in the Presence of 27-hydroxycholesterol

We investigated the question of whether cholesterol catabolite can influence expression of inflammatory cytokines via Toll-like receptors (TLR) in monocytic cells. Treatment of THP-1 monocytic cells with 27-hydroxycholesterol (27OHChol) resulted in induction of gene transcription of TLR6 and elevated level of cell surface TLR6. Addition of FSL-1, a TLR6 agonist, to 27OHChol-treated cells resulted in transcription of the IL-1alpha gene and enhanced secretion of the corresponding gene product. However, cholesterol did not affect TLR6 expression, and addition of FSL-1 to cholesterol-treated cells did not induce expression of IL-1alpha . Using pharmacological inhibitors, we investigated molecular mechanisms underlying the expression of TLR6 and IL-1alpha. Treatment with Akt inhibitor IV or U0126 resulted in significantly attenuated expression of TLR6 and IL-1alpha induced by 27OHChol and 27OHChol plus FSL-1, respectively. In addition, treatment with LY294002, SB202190, or SP600125 resulted in significantly attenuated secretion of IL-1alpha . These results indicate that 27OHChol can induce inflammation by augmentation of TLR6-mediated production of IL-1alpha in monocytic cells via multiple signaling pathways.

Combined Atlantoaxial Rotatory Fixation and Unilateral Counter Occipitoatlantal Subluxation after Minor Trauma / 대한신경손상학회지

Rotatory fixation of the atlantoaxial joint is relatively rare in adults but somewhat more common in children. Most of them are reduced spontaneously or after traction. However, combined rotatory injury of atlantoaxial joint and unilateral occipitoatlantal subluxation is a rare disease, and it is often difficult to diagnose accurately. Because the craniovertebral junction is complex and patients with combined atlantoaxial rotatory fixation (AARF) and occipitoatlantal subluxation has a less rotated head than patients with pure AARF. And injury of the occipitoatlantal and atlantoaxial joint can often result upper cervical instability, so early diagnosis is very important. We present a case of the combined AARF and unilateral counter occipitoatlantal subluxation after minor trauma.

Comparative Study between a Curved and a Wedge PEEK Cage for Single-level Anterior Cervical Discectomy and Interbody Fusion

OBJECTIVE: This study evaluated the efficiency of a curved polyetheretherketone (PEEK) cage in comparison with a wedge PEEK cage according to radiologic and clinical outcomes in patients with cervical degenerative disease. METHODS: A total of 37 patients who suffering from cervical disc disease with radiculopathy or myelopathy were reviewed retrospectively. Seventeen patients were underwent anterior cervical discectomy and interbody fusion with a curved shape PEEK cage (curved cage group), and twenty patients with wedge shape PEEK cage (wedge cage group). Clinical assessment was graded using Odom's criteria, NDI score and VAS score. For radiologic analysis, disc height (DH), segmental angle (SA), subsidence were measured at the preoperative and last follow up. RESULTS: A comparison of the preoperative and postoperative results revealed improvements after the surgery in the DH and SA in both cage groups. The change of postoperative DH between the preoperative and the last follow-up in wedge cage group and curved cage group was 6.85% and 25.5%, respectively. The change of postoperative SA was 1.75degrees and 0.95degrees, respectively. There was no statistically significant difference in the DH and SA between the 2 groups. The subsidence rate in the wedge cage group and curved cage group was 20% and 6%, respectively. CONCLUSION: The 2 different cage groups showed significant improvements in the disc height, segmental angle and clinical outcomes. However, the shape of PEEK Cage influences the tendency for subsidence. Increasing contact surface area and fitting into two adjacent vertebral body prevent significant subsidence.

Factor Affecting Recurrence of Chronic Subdural Hematoma after Burr-Hole Drainage / 대한신경손상학회지

OBJECTIVE: A variety of factors are known to have an influence on the recurrence of chronic subdural hematoma (CSDH). In this study, the authors investigated the influential factors for recurrence of CSDH after burr hole drainage. METHODS: 45 patients with unilateral CSDH were treated with one-burr hole trephination and closed drainage in our hospital during last 6 years, whom the drainage catheter tip was randomly located and checked on postoperative computed tomography (CT). The clinical status of patients, thickness of hematoma, midline displacement of before and after surgery, amount of subdural air collection, drainage catheter tip location were estimated and the relationship of those factors with the recurrence was analyzed. RESULTS: Patients with located catheter tip in frontal had a better clinical and radiological result. And the recurrence of CSDH was lower who has lesser amount of subdural air collection in postoperative CT. CONCLUSION: The recurrence rate of unilateral CSDH is influenced by the location of drainage catheter tip and the amount of subdural air collection.

Spine Fractures in Patients with Ankylosing Spondylitis : Three Cases Report

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease. Pathologic changes occurred in patients with AS result in a weakened vertebral column with increased susceptibility to fractures, even though a trivial injury. Fractures usually tends to involve the lower cervical spine, but rarely, they are also occurred in thoracolumbar spine. We present our experiences of three cases of spinal fracture in patients with AS, cervical, thoracic, and lumbar spine, with a review of literatures.

Clinical Analysis of Prognostic Factors in Primary Intraventricular Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: This study was conducted to evaluate the prognostic factors of primary intraventricular hemorrhage. METHODS: We retrospectively reviewed 26 patients who suffered from primary intraventricular hemorrhage between 2003 and 2007. We analyzed the various factors that might influence the prognosis and these included the patient age, the disease etiology, the initial Glasgow Coma Scale(GCS) score, the pupil reflex, Evan's ratio, Graeb's score, the ventriculocranial ratio (VCR) and dilatation of the fourth ventricle. The clinical outcomes were evaluated for each patient by using the Glasgow Outcome Scale (GOS) three months after the hemorrhage. RESULTS: The overall mortality rate was 38.5%. The factors correlated with a poor clinical outcome are an initial GCS score below 12 (p0.05). Dilatation of the fourth ventricle showed a poor outcome in 10 patients (83.3%), but this was without clinical significance (p>0.05). CONCLUSION: A low initial GCS score, a high Graeb's score, the absence of a pupil reflex, a high VCR and the presence of obstructive hydrocephalus are associated with a poor outcome in patients with primary intraventricular hemorrhage.

Preliminary Radiological Outcomes of Cervical Arthroplasty with Bryan and Prestige LP Cervical Disc Prosthesis

OBJECTIVE: Postoperative motion preservation and prevention of adjacent segment degeneration is well recognized after placing artificial cervical disc prosthesis in patients with degenerative cervical disc disease. The authors investigated postoperative changes in motion dynamics in two different types of artificial cervical disc prosthesis, Bryan and Prestige LP cervical disc prosthesis, and compared them. METHODS: Twenty five patients underwent anterior cervical discectomy and implantation of artificial cervical disc prosthesis: 10 with Bryan and 15 with Prestige LP. Radiological assessments, including overall sagittal alignment angle, range of motion (ROM) of overall sagittal, functional spine unit (FSU) angle, segmental ROM of FSU and ROM of adjacent segment (Upper and Lower level) using static and dynamic lateral radiographs, were performed preoperatively and postoperatively. The mean postoperative follow up period was 18.6 months (range 10.4~28.5) in Bryan and 9.2 months (range 6.5~12.6) in Prestige LP. RESULTS: The overall sagittal alignment angle was decreased 2.9degrees in Bryan group (p=0.033) and increased 5.7degrees in Prestige LP group (p=0.017). The FSU angle at treated level was decreased 0.4degrees in Bryan group (p=0.929) and increased 2.9degrees in Prestige LP group (p=0.008). The ROM of overall sagittal was decreased in both groups (Bryan: 8.6degrees p=0.075, Prestige LP: 2.9degrees p=0.182). The segmental ROM of FSU was increased 1.0degrees in Prestige LP group (p=0.191) but, decreased 0.6degrees in Bryan group (p=0.929). The ROM of adjacent segment was decreased in both groups (Bryan: upper p=0.023 lower p=0.050, Prestige LP: upper p=0.570 lower p=0.132). The postoperative radiological results of comparison between two different artificial disc showed that overall sagittal alignment angle and FSU angle were more increased in Prestige LP (p=0.005, p=0.026, respectively). CONCLUSION: The segmental ROM of FSU was preserved and ROM of adjacent segment was decreased in both groups. This means that postoperative adjacent segment disease may be prevented regardless of types of implants. On comparison study, postoperative cervical curvature was more lordotic in Prestige LP. Therefore, Prestige LP is more suitable to maintain postoperative cervical lordosis. The limitation of our study is small number of case and short and unequal follow up period between two types of implants. Further long term study will be needed.

Chronic Spinal Epidural Hematoma due to Repeated Epidural Block: A Case Report

A case of a patient diagnosed as the chronic spinal epidural hematoma in the lumbar region is reported. There was no history of trauma except the repeated epidural block for controlling the lower back pain at the pain clinic. The symptoms were occurred after epidural block and were exaggerated by repeated injections. Magnetic resonance imaging showed a spinal epidural mass located dorsolaterally at the level of L3-L4. After removal of the hematoma, the symptoms were completely relieved. The diagnosis of a chronic spinal epidural hematoma was confirmed with both operative and histological findings.

Prognostic factors influencing outcomes in elderly patients with aneurysmal subarachnoid hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: This study evaluated the prognostic factors that influence the surgical outcomes of elderly patients older than 65 years old with an aneurysmal subarachnoid hemorrhage. METHODS: Ninety-two patients older than 65 years old, who were operated in our hospital between 1998 and 2005, were reviewed retrospectively. The clinical outcomes were evaluated using the modified Rankin Scale three months after surgery. RESULTS: The preoperative neurological status, such as the Hunt-Hess grade (p<0.001), World Federation of Neurological Surgeons (WFNS) grade (p<0.001), and the Fisher grade (p=0.001), was significantly associated with the surgical outcomes in this series. The vasospasm (0.016) and ventriculostomy (0.039) are factors influencing the surgical outcomes. However, the other factors including hypertension (0.831), smoking (0.228), accompanying disorder (0.706), size of aneurysms (0.177), location of aneurysms (0.755), shunt operation (0.356), and timing of surgery (0.194) had no influence on the surgical outcome. CONCLUSION: In elderly patients with intracranial aneurysms, the preoperative neurological status, vasospasm, and ventriculostomy are the most significant prognostic factors.

Surgical Experiences of Unruptured Intracranial Aneurysms / 대한뇌혈관외과학회지

Object : This study was conducted to evaluate the surgical results of the active treatment of unruptured intracranial aneurysms (UIAs) and to suggest treatment indications. METHODS: Operations were performed on 49 patients with 52 UIAs between 1999 and 2005. Medical records and radiologic studies of the patients with UIAs were retrospectively reviewed. The clinical outcomes were evaluated in each patient by the modified Glasgow Outcome Scale (m-GOS) one month after operation. RESULTS: UIAs had a high frequency of a middle cerebral artery (MCA) and an internal carotid artery (ICA) aneurysm. Forty-four UIAs (84.6%) ranged between 5 mm to 15 mm in diameter. Fortysix UIAs were treated by clipping, 2 by wrapping, and coil embolization was used in 3 UIAs. In one patient, which had only one UIA, one procedure and one operation was performed. There was no surgical mortality. In most patients, surgical complications or neurological deteriorations were not found. In three patients, minor neurological deficits of ptosis (2 patients) and spinal subdural hematoma (1 patient) were newly developed after operation. However the patients completely recovered within 3 months after operation. Finally, the surgical mortality and morbidity rate was 0%. CONCLUSION: If the UIAs are larger than 5 mm in diameter and located in a susceptible area for rupture, surgical treatment should be considered for the UIAs. If operation is performed by an expert neurosurgeon, surgical clipping is one of the best treatment modalities with or without endovascular treatment.

Lumbar Disc Herniation Presenting Cauda Equina Syndrome

OBJECTIVE: To determine the relationship between the clinical outcome and the extent of surgical laminectomy for adequate decompression on the cases of cauda equina syndrome, the authors review and analyze their cases and compared with those of literatures. METHODS: The authors reviewed 655 patients retrospectively who had underwent surgery on the cases of lumbar disc herniation from January 2000 to December 2004. There were 19 patients (2.9%) who presented for clinical cauda equina syndrome. Among them, we selected and analyzed 15 patients who were treated by unilateral partial hemilaminectomy with discectomy or bilateral partial laminectomy with discectomy, and they had been followed from 5 weeks to 47 months postoperatively (mean, 13.47 months). The levels of the disc herniations were L4-5 in 8 patients, following L5-S1 in 4 patients and 2 levels(L4-5 and L5-S1) in 3 patients. Motor and sensory recoveries were recorded. Postoperative urinary function recovery was defined according to Gleave and Macfarlane7). RESULTS: In 12 months postoperatively, the bladder function was obtained in 14 of 15 patients(93%) with regaining urinary continence. Thirteen of 15 patients(86%) with preoperative motor weakness of lower extremities were recovered. Sensory deficit of lower extremities, perianal and saddle anesthesia were all recovered. Patients had recovered on lumbosciatic pain and saddle hypesthesia, in turn, motor function and urinary incontinence. CONCLUSION: In treating cauda equina syndrome, the authors did less extensive surgery, such as unilateral partial hemilaminectomy with discectomy or bilateral partial laminectomy with discectomy for adequate decompression. The outcome is satisfactory and comparable with those of subtotal or total laminectomy.

Spinal Subdural Hematoma: A Complication of Intracranial Surgery

Spinal subdural hematoma(SSDH) is rare disease. Furthermore, it rarely occurs as a complication of intracranial surgery. There are few case reports which describing SSDH after craniotomy. Although the exact pathogenetic mechanism is obscure, some investigators propose that downward migration of intracranial hematoma by the effect of gravity is one of the cause of SSDH, and which is commonly suggested. But others propose that cerebrospinal fluid(CSF) hypotension is an another possible mechanism. In this paper, we report two cases of SSDH after clipping of an aneurysmal neck.

Primary Leptomeningeal Malignant Melanoma

Primary leptomeningeal malignant melanoma is rare entity. We present a case of primary leptomeningeal malignant melanoma of 66-year-old male, who had suffered severe headache, confusion, and right hemiparesis. The brain computed tomography and magnetic resonance image revealed a well enhancing mass with hemorrhage in the left fronto-parietal region. Total surgical removal of the lesion was performed without neurological deficit. He died at home 6 months after operation. Probably, it seems that the cause of death was poor general condition due to obtunded mentality or brain herniation due to increased intracranial pressure. The literature on this subject is briefly reviewed.

The Advantages of Rectangular Titanium Cage(RABEA) Fusion after Anterior Cervical Discectomy: Comparative Study of Fibula Allograft

OBJECTIVE: To study the safety and efficacy of using rectangular titanium cage(RABEA) for anterior cervical fusion, we have compared the results of fusion performed by using fibula allograft and RABEA cage. METHODS: Total of 74 patients with single level cervical discectomy were included in this study. Allogenic fibula bone graft alone was done in 38 patients and RABEA cage was inserted in 36 patients. Retrospective clinical analysis was based on review the symptoms and radiological findings on both two groups at postoperative 12 months. RESULTS: Solid fusion was achieved in 95% of patients who received rectangular titanium cage and 74% of patients who received fibula allograft. According to Odom's criteria, 92% of patients were found to have excellent or good results in the RABEA cage group and 68% of patients in allograft group. Functional outcome was assessed according to Odom's criteria and patient's postoperative satisfaction index(PSI). Better clinical outcome and solid fusion could be achieved by rectangular titanium cage fusion than allogenic fibula graft after single level anterior cervical discectomy. CONCLUSION: We believe that RABEA cage is an effective and safe cervical fusion substitute for single level cervical fusion after discectomy.

Surgical Treatment of Posterior Circulation Aneurysms in Mother and Son: Report of Two Cases

Familial intracranial aneurysm is rare. We have clipped two posterior circulation intracranial aneurysms in mother and son. Mother was 48 years old and presented with severe headache and drowsy mentality. A basilar artery bifurcation aneurysm was found on DSA(digital subtraction angiography) and successfully clipped with transsylvian pterional approach. Her son was 24-year-old and presented with seizure and drowsy mentality. An aneurysmal sac was found on the bifurcation of vertebral artery and posterior inferior cerebellar artery. We have clipped it successfully with far lateral suboccipital approach. The authors recommended the use of screening test, such as MRIand high resolution CT, on the group of patients with the characteristic features of familial intracranial aneurysm.