Ruptured Fusiform Anterior Cerebral Artery Aneurysm in an Infant : Case Report and a Literature Review

Ruptured intracranial aneurysms in infants are rare and infantile fusiform anterior cerebral artery (ACA) aneurysms are much rarer. In this report, we described the case of a 7-month-old infant with a ruptured fusiform ACA aneurysm who presented with seizure and underwent endovascular treatment. The patient was initially in a coma and the neurologic condition did not improve after treatment. The clinical characteristics of the case and literature review were discussed.

Occipital Lobe Metastasis of Hepatocellular Carcinoma Presenting as Homonymous Hemianopia

PURPOSE: To report brain metastasis of hepatocellular carcinoma presenting as homonymous hemianopia. CASE SUMMARY: A 51-year-old female with a history of hepatectomy and diagnosis of hepatocellular carcinoma (HCC) 19 months earlier was referred to our neuro-ophthalmology clinic for evaluation due to headache and decreased visual acuity over the past several months. Best visual acuity was 20/20, and the results of all other aspects of our examination were normal except Humphrey automatic perimetry, which showed complete left homonymous hemianopia. Brain magnetic resonance imaging showed a large mass in the right occipital lobe. Craniotomy and removal of tumor were performed. HCC was confirmed by histopathologic examination. CONCLUSIONS: Metastasis of hepatocellular carcinoma to the occipital lobe is extremely rare but can present as homonymous hemianopia. Therefore, clinicians should be aware of this when examining a patient with a history of HCC.

Epidemiologic Impact of Rapid Industrialization on Head Injury Based on Traffic Accident Statistics in Korea

OBJECTIVE: The aim of the present study is to estimate the incidence trend of head injury and the mortality based on traffic accident statistics and to investigate the impacts of rapid industrialization and economic growth on epidemiology of head injury in Korea over the period 1970-2012 including both pre-industrialized and post-industrialized stages. METHODS: We collected data of head injury estimated from traffic accident statistics and seven hospital based reports to see incidence trends between 1970 and 2012. We also investigated the population structure and Gross National Income (GNI) per capita of Korea over the same period. The age specific data were investigated from 1992 to 2012. RESULTS: The incidence of head injury gradually rose in the 1970s and the 1980s but stabilized until the 1990s with transient rise and then started to decline slowly in the 2000s. The mortality grew until 1991 but gradually declined ever since. However, the old age groups showed rather slight increase in both rates. The degree of decrease in the mortality has been more rapid than the incidence on head injury. CONCLUSION: In Korea during the low income stage, rapid industrialization cause considerable increase in the mortality and the incidence of head injury. During the high income stage, the incidence of head injury gradually declined and the mortality dropped more rapidly than the incidence due to preventive measures and satisfactory medical care. Nevertheless, the old age groups revealed rather slight increase in both rates owing to the large population structure and the declining birth rate.

A Case of Acute Severe Transient Thrombocytopenia Immediately after Cranioplasty using an Artificial Dura Mater / 대한수혈학회지

A four year old boy was admitted to the hospital due to an open skull fracture and severe cerebral contusion with acute subdural hematoma caused by head trauma. The patient underwent emergency operation by craniectomy and duroplasty. Five weeks later, he received a second operation in which autologous cranioplasty and duroplasty was applied using artificial dura mater (Redura), but he experienced transient severe thrombocytopenia immediately after the second operation, necessitating that he receive three platelet transfusions. The patient fully recovered from thrombocytopenia six days after operation. Here, we report a case of abnormal response resulting in acute severe transient thrombocytopenia immediately after cranioplasty using artificial dura mater. The experience of this case suggests that close cooperation with the blood bank is required before a cranioplasty, since severe thrombocytopenia may occur during surgery when employing an absorbable artificial dura mater.

Pyogenic Intradural Abscess of Lumbar Spine: A Case Report / 대한신경손상학회지

We report a case of spinal intradural abscess which shows serial changes on magnetic resonance imaging (MRI). Well-encapsulated, rim-enhancing lesion with mass effect was visualized at ventral side of lumbar spinal canal on 17 days after initial negative MRI, which was thought to be epidural abscess. It was revealed to be intradural in location on operation and successfully treated by drainage and antibiotics. Follow-up MRI showed resolution of abscess. Clinical significance and pathogenesis of this case was briefly discussed.

A Clinical Experience of Massive Transfusion in a Patient with Cardiac Arrest Resulting from Abdominal Aortic Aneurysm Rupture / 대한수혈학회지

We report on a case of successful management of a patient with abdominal aortic rupture requiring massive blood transfusion during the peri-operative period. The patient had fully recovered 19 days after the operation, through intra-operative cardiac arrest and massive transfusion. We analyze a process of blood transfusion and related complications resulting from massive transfusion in order to establish a treatment for peri-operative patients with hypovolemic shock.

Analysis of Transfusion of Packed RBC in Elderly Patients Over 75 Years in Bipolar Hemiarthroplasty / 대한수혈학회지

BACKGROUND: Bipolar hip hemiarthroplasty (BH) was known to require a large amount of transfusion. And, patients who underwent BH were extreme old age and had underlying medical diseases such as hypertension and diabetes mellitus. The aim of this study was to evaluate packed RBC (Red blood cell) transfusion and pre- and intraoperative variables during BH in elderly patients over 75 years in one university hospital. METHODS: A total of 36 patients who underwent BH from September 2013 to August 2014 in our hospital were evaluated through a retrospective study using computerized medical records and archived documents. RESULTS: Average age of patients was 81.5+/-5.3 years and packed RBC transfusion was performed in 41.6% of all enrolled patients. There was no significant difference in age, weight, height, and time of operation between transfused patients and non-transfused patients. Intraoperative volume of packed RBC transfusion was 0.6 (minimum value: 0, maximum value: 4) units. CONCLUSION: Preparation of blood components such as packed RBC is required in elderly patients over 75 years who were planned BH.

The Effects of Preemptive Analgesia to Blood Transfusion in Total Knee Arthroplasty / 대한수혈학회지

BACKGROUND: Total knee arthroplasty (TKA) is associated with moderate to severe postoperative pain. In recent studies, preemptive analgesia was useful for control of postoperative pain in patients undergoing TKA. In particular, cyclooxygenase-2 inhibitor (celecoxib) is recommended for preemptive analgesia. As a large amount of blood is lost during TKA, blood transfusion is often required. In this study, we evaluated the difference of intraoperative blood loss, complications of operation, and hemodynamic change between the celecoxib group and the control group in TKA surgeries. METHODS: A total of 58 patients who underwent TKA from January 2013 to June 2013 in our hospital were evaluated through a retrospective study. Patients in the celecoxib group received 200 mg of oral celecoxib 1 to 2 hours before TKA. Those in the control group received no medication 1 to 2 hours before TKA. Preoperative and postoperative hemoglobin level, estimated blood loss, infused fluid volume, and intraoperative complications (nausea, vomiting) were assessed. Mean blood pressure was recorded immediately, and 30, 60, and 90 minutes after spinal anesthesia, after transfer to the post anesthesia care unit. RESULTS: No significant differences in demographic data (age, height, weight, operation time, nausea, and vomiting) were observed between the two groups. The intraoperative fluid volume of the celecoxib group was lower than that of the control group (782.8+/-240.6 vs 1382.4+/-369.2; P<0.05). No differences in hemodynamic changes (intraoperative blood pressure) were observed between the two groups. CONCLUSION: Perioperative use of an inhibitor of cyclooxygenase 2 is an effective component of multimodal analgesia, which has no effect on hemodynamic change and side effects during TKA.

Analysis of Turnaround Times of Blood Issue at an Island Hospital / 대한수혈학회지

BACKGROUND: Transfusion service, as a task directly affecting the patient's life, must be performed as expeditiously as possible. However, for various reasons, we have experienced difficulty in supplying blood products in a timely manner. In this study, we analyzed the turnaround time (TAT) of blood issue and attempted to find a solution. METHODS: We evaluated the TATs for the request and preparation of blood transfusions in our hospital from January to December 2011. The time of blood issue, from acceptance of the request to preparation in the blood bank, was calculated from computerized medical records. In cases in which the TAT exceeded 24 hours, we investigated the type of blood component and the cause of the delay. RESULTS: A total of 12,856 units of blood were issued during the study year. Of these, 1,333 units (10.4%) had TATs exceeding 24 hours. These units included 148 units of red blood cells (RBC) (2.1%), 49 units of leukocyte-filtered red blood cells (F-RBC) (69.0%), 92 units of fresh frozen plasma (FFP) (3.9%), six units of cryoprecipitates (CRYO) (7.4%), 818 units of platelets (PLT) (27.1%), and 220 units of apheresis platelets (A-PLT) (66.5%). The preparation times for PLT and A-PLT were more delayed. The cause of the delays was lack of inventory at the blood center. CONCLUSION: We recommend that the blood center keep blood products even at the risk that they will be discarded for exceeding the expiration date. In addition, we suggest that testing of donated blood be performed within the region.

Analysis of Turnaround Times of Blood Issue at an Island Hospital / 대한수혈학회지

BACKGROUND: Transfusion service, as a task directly affecting the patient's life, must be performed as expeditiously as possible. However, for various reasons, we have experienced difficulty in supplying blood products in a timely manner. In this study, we analyzed the turnaround time (TAT) of blood issue and attempted to find a solution. METHODS: We evaluated the TATs for the request and preparation of blood transfusions in our hospital from January to December 2011. The time of blood issue, from acceptance of the request to preparation in the blood bank, was calculated from computerized medical records. In cases in which the TAT exceeded 24 hours, we investigated the type of blood component and the cause of the delay. RESULTS: A total of 12,856 units of blood were issued during the study year. Of these, 1,333 units (10.4%) had TATs exceeding 24 hours. These units included 148 units of red blood cells (RBC) (2.1%), 49 units of leukocyte-filtered red blood cells (F-RBC) (69.0%), 92 units of fresh frozen plasma (FFP) (3.9%), six units of cryoprecipitates (CRYO) (7.4%), 818 units of platelets (PLT) (27.1%), and 220 units of apheresis platelets (A-PLT) (66.5%). The preparation times for PLT and A-PLT were more delayed. The cause of the delays was lack of inventory at the blood center. CONCLUSION: We recommend that the blood center keep blood products even at the risk that they will be discarded for exceeding the expiration date. In addition, we suggest that testing of donated blood be performed within the region.

An Experience of Blood Transfusion by Difference of the Count of Fusion Segments in Lumbosacral Spinal Fusion / 대한수혈학회지

BACKGROUND: A large amount of blood is lost during spinal fusion surgery; therefore, a blood transfusion is required. In this study, we analyzed the amount of transfusion and hemodynamic changes in relation to the count of fusion segments in lumbosacral spinal surgeries. METHODS: We analyzed 67 patients who had undergone lumbosacral fusion. They were divided into five groups according to the levels of fusion segments (one level: Group 1, two levels: Group 2, three levels: Group 3, four levels: Group 4 and above three levels: Groups 3+4). Total amounts of transfusion and perioperative hemodynamic changes were compared among each group. RESULTS: Of the total 67 cases, 40 cases were Group 1, 19 cases were Group 2, five cases were Group 3, three cases were Group 4, and eight cases were Groups 3+4. Average volume of Red Blood Cell (RBC) transfusion per operation was 703+/-463 mL (Group 1), 934+/-372 mL (Group 2), 1,677+/-847 mL (Group 3), 1,231+/-412 mL (Group 4), and 1,509+/-669 mL (Group 3+4); and average volume of fresh frozen plasma (FFP) per operation was 55+/-141 mL (Group 1), 108+/-181 mL (Group 2), 306+/-368 mL (Group 3), 567+/-260 mL (Group 4), and 404+/-317 mL (Groups 3+4). Eight patients received transfusion of Platelet Concentrate (PC); each patient received 10 units (400 mL). The preoperative mean level of hemoglobin and platelet was 13.62+/-1.47 g/dL and 245+/-60x10(3)/microliter, postoperatively, 10.26+/-1.14 g/dL and 150+/-46x10(3)/microliter. CONCLUSION: As the fusion segments increase, the need for transfusion of RBC, FFP, and PC increases. Application of the Maximum Surgical Blood Order Schedule (MSBOS) system is required in the planning of spinal fusion, especially in multiple segments.

An Experience of Blood Transfusion by Difference of the Count of Fusion Segments in Lumbosacral Spinal Fusion / 대한수혈학회지

BACKGROUND: A large amount of blood is lost during spinal fusion surgery; therefore, a blood transfusion is required. In this study, we analyzed the amount of transfusion and hemodynamic changes in relation to the count of fusion segments in lumbosacral spinal surgeries. METHODS: We analyzed 67 patients who had undergone lumbosacral fusion. They were divided into five groups according to the levels of fusion segments (one level: Group 1, two levels: Group 2, three levels: Group 3, four levels: Group 4 and above three levels: Groups 3+4). Total amounts of transfusion and perioperative hemodynamic changes were compared among each group. RESULTS: Of the total 67 cases, 40 cases were Group 1, 19 cases were Group 2, five cases were Group 3, three cases were Group 4, and eight cases were Groups 3+4. Average volume of Red Blood Cell (RBC) transfusion per operation was 703+/-463 mL (Group 1), 934+/-372 mL (Group 2), 1,677+/-847 mL (Group 3), 1,231+/-412 mL (Group 4), and 1,509+/-669 mL (Group 3+4); and average volume of fresh frozen plasma (FFP) per operation was 55+/-141 mL (Group 1), 108+/-181 mL (Group 2), 306+/-368 mL (Group 3), 567+/-260 mL (Group 4), and 404+/-317 mL (Groups 3+4). Eight patients received transfusion of Platelet Concentrate (PC); each patient received 10 units (400 mL). The preoperative mean level of hemoglobin and platelet was 13.62+/-1.47 g/dL and 245+/-60x10(3)/microliter, postoperatively, 10.26+/-1.14 g/dL and 150+/-46x10(3)/microliter. CONCLUSION: As the fusion segments increase, the need for transfusion of RBC, FFP, and PC increases. Application of the Maximum Surgical Blood Order Schedule (MSBOS) system is required in the planning of spinal fusion, especially in multiple segments.

Outcome of Decompressive Hemicraniectomy for Treating Malignant Cerebral Infarction / 대한뇌혈관외과학회지

OBJECTIVE: This study is aimed to describe our experience with performing hemicraniectomy for treating patients with malignant cerebral infarction. This study also aimed at describing the difference between our experience and that of the published articles. METHODS: Ten patients who had anterior circulation territory cerebral infarction underwent decompressive hemicraniectomy for treating their life threatening brain swelling between August 2004 and October 2007. We retrospectively analyzed the patients' medical records and radiological films and we described the patients' clinical and radiological details. The outcomes were measured according to the case fatality rate at 2 weeks and the modified Rankin scale (mRS) at 9 months. We compared our institution's outcomes with the pooled analysis result of three randomized controlled trials (DESTINY, DECIMAL, HAMLET trial). RESULTS: Nine men and one woman were included in this study. Their mean age was 61.5 +/- 11.9 years, and the mean National Institute of Health Stroke Scale (NIHSS) score on admission was 17.3 +/- 6.0. Five patients died within 2 weeks after operation. Four patients had a mRS of 5 and one had a mRS of 4 at 9 months. Our series included elder patients (mean difference : 9.9~18.3 years) who had a low NIHSS score on admission (mean difference : -4.8~-6.8) as compared to that of the pooled analysis group. Our series revealed a higher proportion of an unfavorable outcome (mRS > or = 4) compared to that of the pooled analysis results (p=0.01). No patient in our series would have been eligible, according to the inclusion criteria, for inclusion in the pooled analysis studies. CONCLUSION: We think that the higher proportion of an unfavorable outcome in our series was a consequence of the elder age of our patients.

Blood Transfusion in Brain Surgery: A Comparison of Elective versus Emergency Operations / 대한수혈학회지

BACKGROUND: Blood transfusion is often performed to support successful brain surgery. In this study, we looked at two groups of surgery patients to analyze the transfusion requirements for patients undergoing brain surgery in our hospital. Group A patients received elective surgery, whereby blood products were prepared in advance, and Group B patients required emergency surgery which is often accompanied massive bleeding, and therefore adequate transfusion blood may not be available in advance. METHODS: During a one year period, patients who received brain surgery were classified as requiring either elective (Group A) or emergency (Group B) surgery. In each group, operation time and blood transfusion requirements were compared. RESULTS: Of the 35 total patients included in this study, 14 cases were Group A and 21 cases were group B. Average operation time was 4 hours and 13 minutes (253 minutes), and 2 hours and 50 minutes (170 minutes), respectively for Groups A and B. Red Blood Cell (RBC) transfusion was conducted in more than 90% of all patients. Average volume of RBC transfusion per operation was 2.5 units (Group A) and 3.1 units (Group B). Fresh frozen plasma (FFP) was transfused in 21% of Group A patients and in 38% of Group B patients. Platelet Concentrate (PC) was transfused in 19% of Group B patients, only. CONCLUSION: FFP and PC were more frequently transfused in patients who received emergency surgery than those who received elective surgery. Preparation of, not only RBC, but FFP and PC is required for emergency brain surgery. Therefore, efforts to retain adequate amounts of blood are needed to support emergency brain surgery.

Spinal Cavernous Hemangioma Causing Sudden Paraplegia in a 23-Month-Old Kid

Although cavernous angioma itself is not rare, the epidural spinal localization is uncommon and makes preoperative differential diagnosis difficult. An extraordinary case of a thoracic epidural cavernous angioma in very young age, causing sudden paraplegia is presented. Only 79 cases have been reported in the literatures and among them, this kid was the youngest. A 23-month-old boy was referred to us with a 2-day history of sudden both lower limb weakness. Two days before admission, he got up at morning and was unable to stand and even to move the legs. MRI revealed an epidural mass surrounding spinal cord associated with cord compression at the level of the C5 through T3. Through posterior approach with exposure of C6 to T3 level, the hematomatous mass was removed subtotally due to intraoperative bleeding and its ventral location. After the first operation, the weakness of bilateral lower extremities was improved so as to move against the gravity. But the next day, the limb weakness was aggravated as same as preoperative status due to mass effect of new hematoma. The second operation was performed to remove the hematoma and to control the bleeding focus. Several weeks later, the limb weakness was improved and he was able to walk. The literatures about spinal cavernous angioma are reviewed.

Re-closure by the Skin Graft of the Surgically Induced Spinal Open Neural Tube Defect in Chick Embryos

OBJECTIVE: To investigate a re-closure capacity and chronological changes of re-closure, the histologic findings are observed after skin graft on surgically induced spinal open neural tube defect(ONTD) in chick embryos. METHODS: Embryos were divided into two groups: graft and control. In the embryos of the graft, a skin fragment from another chick embryo of embryonic day 7 was grafted on the ONTD immediately after neural tube incision. Embryos were re-incubated in ovo, up to postoperative days(PODs) 3, 5, 7, 10 and sacrificed. Rate of re-closure was compared according to the group of the embryo and the observation time point. Serial changes in histological appearance were observed to investigate whether the re-closured ONTDs regain normal shape. Statistical analysis was performed using the SAS and x2 test. RESULTS: On PODs 3, 5, 7, and 10, re-closure rates of the graft were 87, 60, 53 and 88%, and those of the control were 13, 0, 0 and 20%, respectively. They showed more frequent re-closure of ONTDs by the skin allograft in the graft than control. There was no statistical difference between the closure rates of adjacent POD subgroups. Some embryos of the closed groups revealed complete closure of the neural tube and there was no difference from the normal neural tube. CONCLUSION: Skin graft on the surgically induced ONTD in the embryonic period has a protective effect on the spinal cord. It is suggested that the prenatal skin graft on the lesions of fetal myelomeningocele might prevent repeated spinal cord damage.

Terminal Myelocystocele: A Skin-Covered Lumbosacral Cystic Mass

OBJECTIVE: Terminal myelocystocele(TMC) is a closed form of neural tube defect, presenting a large, fully epithelialized, cystic lumbosacral mass containing fat, cerebrospinal fluid and neural tissue. This report demonstrates the clinical manifestation, surgical management, and the outcome of TMC patients. METHODS: The medical records of the six patients(male/female=3/3) with surgically and histologically proven TMC, registered between 1991 to 2001, were retrospectively reviewed. The initial presentation, features of the lumbosacral mass, urodynamic study, motor function of the lower extremity, the age at the repair and postoperative status were investigated. RESULTS: Initial symptoms and signs were low back mass, urinary/fecal incontinence, and lower limb deformity. One patient was associated with cloacal exstrophy, one patient had imperforated anus, and three patients had foot anomalies. All patients had urological problems on urodynamic study. Neurosurgical correction of the TMC was undertaken at the median age of three months. The mean follow-up period was 71 months(range: 9-136 months). Four patients voided with clean intermittent catheterization postoperatively. One patient underwent augmentation ileocystoplasty and Malone operation. One patient had orthopedic operation. CONCLUSION: Understanding about the characteristic features of TMC and its embryogenesis is necessary for the diagnosis of this entity. For the management of the TMC, early prophylactic surgical intervention is recommended to prevent secondary deterioration in neurological function. Postoperatively all patients must be followed-up long-termly on urological function and lower extremity status.

Effect of Surgery in Pediatric Neuroblastoma with Spinal Involvement

OBJECTIVE: Neuroblastoma is a very common pediatric malignant tumor and sometimes involves the spinal cord to result in neurological deficits. The authors perform a retrospective analysis of the 12 cases of pediatric neuroblastoma with spinal involvement to assess the characteristics and surgical outcome. METHODS: We retrospectively reviewed the 12 cases of pediatric neuroblastoma with spinal involvement which underwent surgery from 1988 to 2002 in our hospital. All the cases were confirmed by pathologic diagnosis and reviewed about initial presentation, the location of tumor, treatment, outcome and complication. RESULTS: The ratio of male to female was 1: 2 and mean age was 3.5 years(0.3-13.6). The chief complaint was motor weakness in 7 cases, mass in 2, urinary incontinence in one and 2 cases were asymptomatic. The tumor involved thoracic level in 5 cases, thoracolumbar level in 3, cervicothoracic level in 2, cervical and lumbar levels in one case each. All the cases underwent surgery, four had chemotherapy and four had both chemotherapy and radiotherapy. After 33.9 months of mean follow up, in all of the 4 cases whose intraspinal tumor was gross-totally resected, neurological status improved. Of the 4 cases with subtotal resection, all except one showed progression or no neurologic improvement. Postoperative spinal deformity has developed in 5 cases. Three cases expired because of chemotherapy complication and tumor progression. CONCLUSION: Active surgery about the spinal involvement of pediatric neuroblastoma shows neurological improvement regardless of the survival. It seems to be helpful to the quality of life in pediatric patients.

Primary Intracranial Atypical Teratoid/Rhabdoid Tumor in a Child: A Case Report

Rhabdoid tumors of the central nervous system are rare malignancies. Primary central nervous system atypical teratoid/rhabdoid tumors (ATT/RhTs) mostly occur during early childhood and are almost invariably fatal. These tumors show similar histological and radiological features to primitive neuroectodermal tumor-medulloblastoma (PNET-MB) but have different biological behaviors. We report a case of primary intracranial ATT/RhT in the posterior cranial fossa of a child. Preoperative radiological diagnosis was PNET-MB, but pathological diagnosis is ATT/ RhT. The case involved a 16-month-old baby boy who presented with severe headache, vomiting, and gait disturbance. He was treated by surgical resection, chemotherapy, and radiotherapy. Despite aggressive therapy, he died 19 months after diagnosis. Clinical, radiological, and histopathological features of primary intracranial ATT/RhT are discussed with a special emphasis on the differential diagnosis from PNET-MB.

Shaken Baby Syndrome

Head injury in the youngest age group is distinct from that occurring in older children or adults because of differences in mechanisms, injury thresholds, and the frequency with which the question of child abuse is encountered. "Shaken baby syndrome" has results in intracranial and introcular hemorrhages with no evidence of external trauma. The cause of these injuries is vigorous shaking of an infant being held by the chest, shoulders, or extremities. Severe head injuries commonly diagnosed as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome. "Shaken impact syndrome" has the advantage of being more inclusive of verifiable impact mechanisms and of reflecting the extreme forces that appear to be necessary to produce these often devastating injuries. All clinicians must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation. And physicians play an important role in diagnosis, management and prevention of child abuse and shaken baby syndrome.