The revision of the ethical codes and guidelines of the Korean Medical Association

No abstract available.

Importance of writing medical certificate

No abstract available.

Late Spontaneous Recanalization of Chronic Middle Cerebral Artery Occlusion / 신경중재치료의학

Early spontaneous recanalization of the middle cerebral artery in acute ischemic phase artery is not uncommon, whereas the late spontaneous recanalization of chronic occluded artery is a very rare phenomenon and exact incidence and the timing of this event have not been quantified. We present a case in which late spontaneous recanalization of long-lasting middle cerebral artery occlusion occurred in the absence of surgical, endovascular and thrombolytic treatments.

Dissecting Aneurysm Associated with a Double Origin of the Posterior Inferior Cerebellar Artery Causing Subarachnoid Hemorrhage

Two cases of the posterior fossa dissecting aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA) causing subarachnoid hemorrhage are presented. After observing a relationship between the aneurysm and DOPICA on a three dimensional rotational angiogram (3DRA), the dissecting aneurysms were successfully obliterated by surgical trapping and endovascular internal trapping, respectively. This report warrants suspecting DOPICA of an associating anomaly predisposing to dissecting aneurysm in the vertebral artery-posterior inferior cerebellar artery territory and highlights the role of 3DRA in pretreatment evaluation of unusual aneurysms accompanying a particular anatomical variation.

Endovascular or Microsurgical Treatment of Ruptured Distal Anterior Cerebral Artery Aneurysms: Clinical Outcomes and Technical Considerations / 대한뇌혈관외과학회지

OBJECTIVE: To analyze the clinical characteristics and outcomes of ruptured distal anterior cerebral artery (DACA) aneurysms and to discuss optimal treatment strategy. METHODS: Out of 488 patients with ruptured intracranial aneurysms, 24 were treated for DACA aneurysms between February 2001 and January 2009. The medical records, radiological data and outpatient clinic charts of these patients were retrospectively reviewed. RESULTS: The 24 patients (6 men, 18 women) had a mean age of 52 years (range, 30-70). Among the 24 patients, 6 underwent coiling and 17 underwent clipping. Fifteen patients had a Hunt-Hess grade of II, 5 with III, 3 with IV and 1 had a grade of V. Nine patients had a Fisher grade of II, 1 with III and 14 had a grade of IV. Twenty-one (88%) patients had a good clinical course after treatment with endovascular (5 of 6 patients, 83%) or surgical (16 of 18 patients, 89%) treatments. Nineteen of 20 patients (95%) with good preoperative states (Hunt-Hess grade I-III) and 2 of the 4 patients (50%) with poor preoperative states (Hunt-Hess grade IV and V) demonstrated good clinical outcomes with Glasgow Outcome Scale (GOS) scores of 4-5. Two patients (8%) died due to pneumonia or preoperative severe brain damage. CONCLUSIONS: Acceptable and favorable outcomes were achieved in patients with good preoperative states who were treated with either clipping or coiling of ruptured DACA aneurysms. Immediate and active treatment should be mandatory for favorable outcomes.

Characteristics of Computerized Neuropsychologic Test According to the Location of Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: To evaluate characteristics of cognitive impairments according to the location of aneurysmal subarachnoid hemorrhage (SAH) using a computerized neuropsychological test (CNT). METHOD: A total of 211 patients were transferred to our rehabilitation department after becoming neurologically stable following aneurysmal SAH. Twenty four of the 211 patients met the inclusion criteria and participated in a screening test using the mini-mental state examination (MMSE). Twenty patients with a MMSE score <26 were followed prospectively with a CNT and Beck depression inventory (BDI). Eleven patients had anterior communicating artery (ACoA) aneurysms and the other 9 had middle cerebral, internal carotid or posterior communicating artery aneurysms. RESULTS: There were no differences in age, education, Hunt and Hess grade, or Fisher grade between the patients with ACoA aneurysmal SAH compared to patients with other aneurysmal SAH. In patients with ACoA aneurysmal SAH, scores of BDI (p=0.020), verbal learning test were lower than those of other aneurysmal SAH patients. In contrast, patients with non-ACoA aneurysmal SAH took significantly more time in auditory (p=0.025) and visual continuous performance tests (p=0.028). The cognitive deficit following aneurysmal SAH could be characterized by its location using CNT. CONCLUSION: Using CNT in aneurysmal SAH patients could be a useful tool for evaluating the characteristics of cognitive impairment and planning rehabilitation programs according to each characteristic.

A Comprehensive Model of Factors Affecting Adoption of Clinical Practice Guidelines in Korea

This study aims to investigate the factors related to the adoption of clinical practice guidelines in clinical settings in Korea; it also aims to determine how these factors differ depending on the specific situation of health care system and professional climate. The research sample comprised physicians who are board members of academic societies with experiences in development of clinical practice guidelines using a convenient sampling. We analyzed 324 physicians with pooling two-year sample of 2007 and 2008. From all the respondents, 48.8% stated that they followed Clinical Practice Guidelines, and 93.4% agreed with the content in the Clinical Practice Guidelines. With regard to the item on the self-efficacy of practicing guidelines, 90.3% of the respondents selected 'low level'. In the regression analysis, the factors associated with implementation were level of recognition, agreement and self-efficacy and positive attitude towards practice guidelines. Although the health care system in Korea differs from those in Western countries, our results revealed that the factors related to the adoption of practice guidelines were similar to the research results of Western countries. These results suggest that professionals' attitudes towards clinical practice guidelines are universal, and implementation strategies should be developed globally.

A Case of Ruptured Peripheral Aneurysm of the Anterior Inferior Cerebellar Artery Associated with an Arteriovenous Malformation : A Less Invasive Image-Guided Transcortical Approach

A 47-year-old man presented with a subarachnoid hemorrhage (SAH) and right cerebellar hematoma was referred for evaluation. Cerebral angiography revealed a distal anterior inferior cerebellar artery (AICA) aneurysm associated with an arteriovenous malformation (AVM). Successful obliteration and complete removal of the aneurysm and AVM were obtained using transcortical approach under the guidance of neuronavigation system. The association of a peripheral AICA aneurysm and a cerebellar AVM by the same artery is unique. The reported cases of conventional surgery for this disease complex are not common and their results are variable. Less invasive surgery using image-guided neuronavigation system would be helpful and feasible for a peripheral aneurysm combining an AVM of the posterior fossa in selective cases.

Three-Dimensional Angiographic Demonstration of Plexiform Fenestrations of the Proximal Anterior Cerebral Artery Associated with a Ruptured Aneurysm

A rare case of ruptured aneurysm associated with multiple A1 fenestrations resembling plexiform network was demonstrated by 3D angiography. A 56-year-old female presented with a ruptured aneurysm in the A2 segment of the left distal anterior cerebral artery associated with the right A1 fenestration. The ruptured aneurysm was occluded with surgical neck clipping via interhemispheric approach without neurological deficit. Plexiform fenestrations of the right distal A1, opposite side to the left ruptured A2 aneurysm, were clearly visible on postoperative 3D angiography. Our case may strongly support the theory described by Paget, namely that a remnant of the plexiform anastomosis between the primitive olfactory artery and A1 segment is the source of such fenestration.

Experience of Neuroendovascular Therapy for Peripheral Aneurysm of The Superior Cerebellar Artery: A Case Report / 신경중재치료의학

A case of peripheral superior cerebellar artery aneurysm was treated using neuroendovascular therapy. Not only its rarity but also some specific considerations for diagnostic and therapeutic approach of peripheral superior cerebellar artery aneurysms will be discussed herein.

Surgical Clipping of Intracranial Aneurysm Regrown after Endovascular Coiling

Operative clipping after previous endovascular coiling in an aneurysm is a different problem from primary clipping procedure for neurosurgeons. With the increasing use of coil embolization, neurosurgeons will more and more face the similar situation. We report surgical clipping cases of intracranial aneurysm regrown after endovascular coiling. Three patients with a history of subarachnoid hemorrhage due to ruptured aneurysm underwent endovascular treatment (EVT) with detachable coils. The aneurysms were in the posterior communicating artery, the middle cerebral artery, and distal anterior cerebral artery (DACA). Two near-total occlusions and one partial occlusion were achieved by EVT. After several months, angiographic follow-up revealed regrowth of the aneurysm requiring surgical clipping. Here, we report three cases in which surgical clipping was more difficult than a usual clipping procedure performed several months after EVT, because of adhesion and coil bulging into the aneurysmal neck. The difficulty of the treatment of the residual aneurysm after coiling is discussed, as are the surgical complications and limitations of clipping.

Osteosarcoma of the Skull Resembling Desmoplastic Fibroma: A Case Report

Primary osteosarcoma of the skull is a rare finding. We report here on a pathologically proven case of osteosarcoma that presented as a painless mass in the frontal bone of a 7-year-old boy. This unusual form of osteosarcoma had features of desmoplastic fibroma in a large portion of the tumor. We also include a review of the medical literature related to osteosarcoma.

Clinical Analysis of the Aneurysm of Proximal(A1) Segment of Anterior Cerebral Artery / 대한뇌혈관외과학회지

OBJECTIVES: Aneurysms of the anterior cerebral circulation are usually found on the anterior communicating artery (ACoA) or peripheral portion (A2) of the anterior cerebral artery (ACA). Infrequently, they are found on proximal segment (A1) of the ACA. These are presented 0.88-2.1% of all intracranial aneurysm cases. There are few describing a series of patient with A1 aneurysms. In this report, we present our surgical experience of the 27 A1 aneurysms. MATERIAL AND METHODS: 27 patients with aneurysm of proximal segment of anterior cerebral artery were operated on between January 1983 and September 2004. Retrospective analysis of clinical characteristics, radiologic findings, operation method, clinical outcomes and complications were performed. RESULTS: 27 patients with aneurysm of proximal segment of anterior cerebral artery, male was 11 cases, female was 16 cases. Relatively, predominantly occurred in female. In preoperative Hunt-Hess grade (H-H grade) of the patient, H-H grade I was 10, gradeII in 13, grade III in 3, grade IV in 1 case. In CT findings, 23 cases presented only SAH, SAH and ICH in 4, accompanying hydrocephalus in 3 cases. In angiographics and surgical findings, according to aneurysm site, proximal type was 9 cases, middle type in 8, distal type in 10 cases, and compared with each clinical outcomes. In 9 patients, aneurysms was found in right side and 7 patients of these had favorable outcomes. In left side, 12 of 18 patients had favorable outcomes. Postoperative complication occurred in 8 cases, postoperative infarction in 3 case. vasospasm in 4 cases, hydrocephalus, meningitis in 4 cases. 5 patients had multiple aneurysms. In 2 cases of these, A1 aneurysm was ruptured. In 3 cases, other aneurysm was ruptured and A1 aneurysm was incidental finding. In total 27 patients, 19 patients had favorable outcomes and unfavorable outcomes in 8. CONCLUSION: Aneurysms of proximal segment (A1) of the anterior cerebral artery occur very infrequently and in this report, These are presented 3.9% (27 out of 680) in anterior cerebral artery aneurysms. 19 patients underwent direct surgery had good outcomes after the surgery. As causes of unfavorable outcomes, poor preoperative general condition, injury of perforating artery during operation and vasospasm. Comparison with other aneurysms, relative good outcomes can be obtained by direct surgery.

Clinical Analysis of the Aneurysm of Proximal(A1) Segment of Anterior Cerebral Artery / 대한뇌혈관외과학회지

OBJECTIVES: Aneurysms of the anterior cerebral circulation are usually found on the anterior communicating artery (ACoA) or peripheral portion (A2) of the anterior cerebral artery (ACA). Infrequently, they are found on proximal segment (A1) of the ACA. These are presented 0.88-2.1% of all intracranial aneurysm cases. There are few describing a series of patient with A1 aneurysms. In this report, we present our surgical experience of the 27 A1 aneurysms. MATERIAL AND METHODS: 27 patients with aneurysm of proximal segment of anterior cerebral artery were operated on between January 1983 and September 2004. Retrospective analysis of clinical characteristics, radiologic findings, operation method, clinical outcomes and complications were performed. RESULTS: 27 patients with aneurysm of proximal segment of anterior cerebral artery, male was 11 cases, female was 16 cases. Relatively, predominantly occurred in female. In preoperative Hunt-Hess grade (H-H grade) of the patient, H-H grade I was 10, gradeII in 13, grade III in 3, grade IV in 1 case. In CT findings, 23 cases presented only SAH, SAH and ICH in 4, accompanying hydrocephalus in 3 cases. In angiographics and surgical findings, according to aneurysm site, proximal type was 9 cases, middle type in 8, distal type in 10 cases, and compared with each clinical outcomes. In 9 patients, aneurysms was found in right side and 7 patients of these had favorable outcomes. In left side, 12 of 18 patients had favorable outcomes. Postoperative complication occurred in 8 cases, postoperative infarction in 3 case. vasospasm in 4 cases, hydrocephalus, meningitis in 4 cases. 5 patients had multiple aneurysms. In 2 cases of these, A1 aneurysm was ruptured. In 3 cases, other aneurysm was ruptured and A1 aneurysm was incidental finding. In total 27 patients, 19 patients had favorable outcomes and unfavorable outcomes in 8. CONCLUSION: Aneurysms of proximal segment (A1) of the anterior cerebral artery occur very infrequently and in this report, These are presented 3.9% (27 out of 680) in anterior cerebral artery aneurysms. 19 patients underwent direct surgery had good outcomes after the surgery. As causes of unfavorable outcomes, poor preoperative general condition, injury of perforating artery during operation and vasospasm. Comparison with other aneurysms, relative good outcomes can be obtained by direct surgery.

Neuroprotective Effect of N-nitro-L-arginine Methylester Pretreatment on the Early Stage of Kainic Acid Induced Neuronal Degeneration in the Rat Brain

OBJECTIVE: Kainic acid(KA) enhances the expression of nitric oxide synthase, increases nitric oxide(NO), and thus evokes epileptic convulsion, which results in neuronal damage in the rat brain. NO may stimulate cyclooxygenase type-2 (COX-2) activity, thus producing seizure and neuronal injury, but it has also been reported that KA-induced seizure and neurodegeneration are aggravated on decreasing the COX-2 level. This study was undertaken to investigate whether the suppression of NO using the NOS inhibitor, N-nitro-L-arginine methyl ester(L-NAME), suppresses or enhances the activity of COX-2. METHODS: Silver impregnation and COX-2 immunohistochemical staining were used to localize related pathophysiological processes in the rat forebrain following KA-induced epileptic convulsion and L-NAME pretreatment. Post-injection survival of the rat was 1, 2, 3days and 2months, respectively. RESULTS: After the systemic administration of KA in rats, neurodegeneration increased with time in the cornu ammonis (CA) 3, CA 1 and amygdala, as confirmed by silver impregnation. On pretreating L-NAME, KA-induced neuronal degeneration decreased. COX-2 enzyme activities increased after KA injection in the dentate gyrus, CA 3, CA 1, amygdala and pyriform cortex, as determined by COX-2 staining. L-NAME pretreatment prior to KA-injection, caused COX-2 activities to increase compared with KA- injection only group by 1day and 2days survival time point. CONCLUSION: These results suggest that L-NAME has a neuroprotective effect on KA-induced neuronal damage, especially during the early stage of neurodegeneration.

Gamma Knife Radiosurgery for Growth Hormone-secreting Pituitary Adenoma following Trans-sphenoidal Approach

OBJECTIVE: The results of gamma knife radiosurgery(GKRS) for growth hormone(GH)-secreting pituitary adenoma are investigated to identify the role of adjuvant GKRS for remnant or recurrent tumor following transsphenoidal approach(TSA). METHODS: From March 1992 to December 2001, 20 patients treated by GKRS for GH-secreting pituitary adenoma following TSA were followed up more than 3 years and evaluated their symptomatic, hormonal and radiological changes after radiosurgery. RESULTS: There were 6 men and 14 women and the mean age was 40.2 years (range 24-58 years). The maximal dose was 32 to 60Gy (mean 46.2Gy) and the marginal dose was 12.8 to 36Gy (mean 25.5Gy). The mean follow-up time was 5.9 years (range 3-10years). Normalization of GH level (below 2ng/ml) was achieved in 10 of 20 patients (50.0%), and the normalization of IGF-I was in 8 of 15 patients (53.3%). On follow up MR imaging, the tumor control rate was 100% and the tumor volume reduction rate was 25~50% in 4 patients, 50~75% in 13 patients and 75~100% in 3 patients. CONCLUSION: In the treatment of GH-secreting pituitary adenoma, tumor control rate and improvement of clinical symptom show good outcome without major complication after adjuvant GKRS following TSA, though the rate of normalization of GH level is unsatisfactory. The optimal marginal dose for GH-secreting pituitary adenoma is more than 25Gy, and secondary GKRS can be considered in the failed cases to achieve effective hormonal normalization after the first adjuvant GKRS.

Preliminary Experiences with Interbody Titanium Cage(RABEA(TM)) Fusion in Patients with Degenerative Cervical Disease

OBJECTIVE: The purpose of this study is to evaluate the safety and efficacy of cervical interbody fusion with implantable titanium cage(RABEA(TM)). The authors retrospectively analysis the result of application of cervical hollow cage(RABEA(TM)) without bone graft to the patients of degenerative cervical disease. METHODS: 78 patients with radiculopathy with or without myelopathy due to degenerative cervical diseases were underwent anterior cervical discectomy and interbody fusion with titanium cages(RABEA(TM)) which were not filled with autogenous bone from June 1999 to December 2002. Among them, 33 patients could be followed-up for at least 6 months. Mean follow-up period was 13.3 months(ranged 6-30 months). RESULTS: Good or excellent results were found in approximately 82.0%. Preoperatively, the mean height of the disc space was 4.27mm(range 3~6mm), and at 1 day postoperatively it was 7.87mm(range 7~9mm). The mean height of the disc space after 1 year was 6.07mm(range 1~8mm). Due to subsidence of cage, 7 patients showed decrease of disc space height to preoperative disc space height. Among them, 1 patients showed poor results. A solid fusion was achieved in all patients. In this context, causes of subsidence are represented by osteoporosis and degree of cage recess. CONCLUSION: Titanium cages appear safe and effective in the treatment of degenerative cervical disease. But subsidence of cage, so far limited in number, appeared to be important risk factor for recurrence of the symptoms.

Gene Expression Profiling of Meningioma by cDNA Chip

OBJECTIVE: The current progress of the molecular biological study is in the situation of documentation of relation between the tumor development and the gene mutation. We report an analysis of gene expression profiling of meningioma by cDNA chip. METHODS: Meningioma, tumor attached dura and normal dura were obtained during surgery. RNA was extracted from each specimen and cDNA microarray was done. After that, we confirmed the reliability of results from the microarray technique by RT-PCR. RESULTS: We examined the expression of the tumor related gene by cDNA chip. The genes showing two fold changes in the expression were analyzed to find the difference between two groups. The analysis of the tumor and tumor attached dura indicated that the expression of twenty four genes were increased and seventeen genes were decreased in the tumor. The analysis of the gene expression of tumor and normal dura showed increase in twenty seven genes and decrease in thirty one genes. Nine genes in the tumor showed more increase than those in the tumor attached dura and the normal dura. We performed RT-PCR using cytokines to confirm the reliability of the microarray result. CONCLUSION: The cDNA chip contributes as a good laboratory method to check various gene expression of the meningioma and the dura. In the future, the relationship between the expression of IL-1beta, IL-4, IL-6, IL-8, and the function of each gene are required to investigate.

Post-treatment Bleeding of Cerebral Arteriovenous Malformations after Gamma Knife Radiosurgery

OBJECTIVE: This study is designed to assess the cause of post-treatment bleeding after gamma knife radiosurgery(GKRS) for cerebral arteriovenous malformation(AVM). METHODS: We experienced post-treatment bleeding in seven cases out of 214 AVM patients group before complete obliteration and analyzed their clinical characteristics, angiographic architecture and radiosurgical dosimetry. RESULTS: Hemorrhage rate was 3.2% (7/214) and the bleeding occurred individually at 4, 8, 9, 20, 44, 44 and 115 months after GKRS. Annual bleeding rate was 0.6% (7 episodes of bleeding / 1131 patient years). Three patients presented with hemorrhage as initial symptom upon admission and four patients were admitted with other symptom rather than hemorrhage. AVM was deep-seated in 4 cases, and at motor cortex in three patients. Average marginal dose was 18.9Gy (range;10-25Gy). Most of patients showed angiographic risk factor for bleeding such as venous aneurysm, multiple venous drainage, dual arterial supply and shunt type. Upon bleeding incidence, emergency operation was performed in 5 cases and two patients received second GKRS. Two patients were expired after emergency operation. CONCLUSION: The risk of hemorrhage from GKRS for AVMs is inevitable, even if patients are in non-hemorrhagic group before complete obliteration. In order to minimize hemorrhage rate, intensive follow-up is strongly suggested after radiosurgery, and the retreatment for a residual nidus is recommended at early point after the latency period.

Gamma Knife Radiosurgery for Hemorrhagic Cavernous Malformations

OBJECTIVE: In patients with hemorrhagic cavernous malformation(CMs) located in critical brain region that were thought to pose an excessive risk for microsurgical resection, Gamma Knife radiosurgery(GKRS) has been used as an alternative management option for these lesions. The purpose of this study is to evaluate the efficacy of GKRS for hemorrhagic CMs. METHODS: Among the patients of hemorrhagic CMs who had been treated by using Leksell Gamma Knife, 20 patients who had been followed up more than 2 years were analysed for their postradiosurgical results. RESULTS: Mean target volume was 3199mm3(224-9300mm3). Mean maximal dose was 28.9Gy(15-50Gy) and mean marginal dose was 16.5Gy(9-25Gy). 50% isodose or greater was used for the margins of the lesions. Mean follow-up period after GKRS was 51 months(24-112months). During the follow-up period, 3 patients suffered from rebleeding at 5, 6, and 28 months after radiosurgery, respectively. Two cases had a rebleeding in latency period(time interval from GKRS to its maximal effect on vascular obliteration, usually 2-4 years in case of CMs) and another one case after latency period. The annual rebleeding rate was 3.1%(first 2 years after radiosurgery 5%, thereafter 1.7%). Delayed radiation-induced complications occurred in 4 cases at 4, 7, 15 and 18 months after radiosurgery. CONCLUSION: The use of GKRS as an alternative management strategy to the hemorrhagic CMs which located in critical brain region and so had potential risk for microsurgical resection is thought to be available. And the GKRS would reduce the rate of rebleeding of CMs, especially after 2-3 years of latency periods.