Pharmacological Management of Germinal Matrix-Intraventricular Hemorrhage

Germinal matrix-intraventricular hemorrhage (GM-IVH) is among the devastating neurological complications with mortality and neurodevelopmental disability rates ranging from 14.7% to 44.7% in preterm infants. The medical techniques have improved throughout the years, as the morbidity-free survival rate of very-low-birth-weight infants has increased; however, the neonatal and long-term morbidity rates have not significantly improved. To this date, there is no strong evidence on pharmacological management on GM-IVH, due to the limitation of well-designed randomized controlled studies. However, recombinant human erythropoietin administration in preterm infants seems to be the only effective pharmacological management in limited situations. Hence, further high-quality collaborative research studies are warranted in the future to ensure better outcomes among preterm infants with GM-IVH.

Importance of Differential Diagnosis of a Possible Brain Tumor in Patients with Cervical Radiculopathy

Lesions occurring simultaneously in the somatosensory or motor cortex of the brain and the cervical spine are rare. Brain tumors can cause similar symptoms to cervical lesions which can lead to confusion in treatment priorities. Moreover, if cervical disease is noticeably observed in radiologic findings of a patient complaining of cervical radiculopathy with non-specific electromyography results, it is common to no longer perform further evaluation. Here we introduce two cases where the cause of cervical radiculopathy was first considered to be the result of a degenerative cervical disease but was later discovered to be a result of a brain tumor.

Management of Traumatic Cervical Spondyloptosis with an Unsealable Dura Tear: A Case Report / 대한신경손상학회지

Cervical spondyloptosis is defined as dislocation of the spinal column, most often caused by trauma. Due to transection of the spinal cord, severe neurological deficits are common.Here, we reviewed the case of a young man who presented with mental stupor and complete tetraplegia below the level of C5. The patient's left shoulder was sucked into a machine and subjected to strong lateral bending and distraction. Computed tomography (CT) scan and magnetic resonance imaging revealed fracture dislocation and complete transection of the spinal cord at the C5–6 level. Three-dimensional CT scan showed coronal and sagittal spondyloptosis. He underwent open reduction with two surgeries performed via the anterior and posterior approaches: C5–6 anterior cervical discectomy and fusion and lateral mass screw fixation with allograft from C3 to C7. In addition, both ends of the huge dura defect were sutured. We report the clinical history, imaging findings, and surgical management of spondyloptosis with a complete transected spinal cord containing a considerable dura tear.

Analysis According to Characteristics of 18 Cases of Brachial Plexus Tumors : A Review of Surgical Treatment Experience

OBJECTIVE: Because the anatomical structure of the brachial plexus is very complex, surgical treatment of tumors in this region is challenging. Therefore, a lot of clinical and surgical experience is required for successful treatment; however, many neurosurgeons have difficulty accumulating this experience owing to the rarity of brachial plexus tumors. The purpose of this report is to share our surgical experience with brachial plexus tumor with other neurosurgeons. METHODS: The records of 18 consecutive patients with brachial plexus tumors who underwent surgical treatment between January 2010 and December 2017 in a single institution were retrospectively reviewed. The surgical approach was determined according to the tumor location and size, and intraoperative neurophysiological monitoring (IONM) was used in most of cases to prevent iatrogenic nerve injury during surgery. In addition, to evaluate the differences in tumor characteristics according to pathologic diagnosis, the tumors were divided twice into two groups, based on two separate classifications, and statistical analysis was performed. RESULTS: The 18 brachial plexus tumors comprised 15 (83.3%) benign peripheral nerve sheath tumors including schwannoma and neurofibroma, one (5.6%) malignant peripheral nerve sheath tumor, one (5.6%) benign tumor of non-neural sheath origin (neurogenic cyst), and one (5.6%) metastatic tumor (papillary carcinoma). The authors analyzed relationship between tumor size/location and tumor characteristic parameters such as age, size, right-left, and pathology. There were no statistically significant differences except a tendency of bigger tumor size in young age. CONCLUSION: For a successful surgical outcome, an appropriate surgical approach is essential, and the appropriate surgical approach is determined by the location and size of the tumor. Furthermore, applying IONM may prevent postoperative complications and it is favorable option for brachial plexus tumors surgery.

Analysis According to Characteristics of 18 Cases of Brachial Plexus Tumors : A Review of Surgical Treatment Experience

OBJECTIVE: Because the anatomical structure of the brachial plexus is very complex, surgical treatment of tumors in this region is challenging. Therefore, a lot of clinical and surgical experience is required for successful treatment; however, many neurosurgeons have difficulty accumulating this experience owing to the rarity of brachial plexus tumors. The purpose of this report is to share our surgical experience with brachial plexus tumor with other neurosurgeons.METHODS: The records of 18 consecutive patients with brachial plexus tumors who underwent surgical treatment between January 2010 and December 2017 in a single institution were retrospectively reviewed. The surgical approach was determined according to the tumor location and size, and intraoperative neurophysiological monitoring (IONM) was used in most of cases to prevent iatrogenic nerve injury during surgery. In addition, to evaluate the differences in tumor characteristics according to pathologic diagnosis, the tumors were divided twice into two groups, based on two separate classifications, and statistical analysis was performed.RESULTS: The 18 brachial plexus tumors comprised 15 (83.3%) benign peripheral nerve sheath tumors including schwannoma and neurofibroma, one (5.6%) malignant peripheral nerve sheath tumor, one (5.6%) benign tumor of non-neural sheath origin (neurogenic cyst), and one (5.6%) metastatic tumor (papillary carcinoma). The authors analyzed relationship between tumor size/location and tumor characteristic parameters such as age, size, right-left, and pathology. There were no statistically significant differences except a tendency of bigger tumor size in young age.CONCLUSION: For a successful surgical outcome, an appropriate surgical approach is essential, and the appropriate surgical approach is determined by the location and size of the tumor. Furthermore, applying IONM may prevent postoperative complications and it is favorable option for brachial plexus tumors surgery.

Spontaneous Resolution of Chronic Subdural Hematoma : Close Observation as a Treatment Strategy

OBJECTIVE: Chronic subdural hematoma (cSDH) is common condition in neurosurgical field. It is difficult to select the treatment modality between the surgical method and the conservative method when patients have no or mild symptoms. The purpose of this study is to provide a suggestion that the patients could be cured with conservative treatment modality. METHODS: We enrolled 16 patients who had received conservative treatment for cSDH without special medications which could affect hematoma resolution such as mannitol, steroids, tranexamic acid and angiotensin converting enzyme inhibitors. The patients were classified according to the Markwalder's Grading Scale. RESULTS: Among these 16 patients, 13 (81.3%) patients showed spontaneously resolved cSDH and 3 (18.7%) patients received surgery due to symptom aggravation and growing hematoma. They were categorized into two groups based on whether they were cured with conservative treatment or not. The first group was the spontaneous resolution group. The second group was the progression-surgery group. The mean hematoma volume in the spontaneous resolution group was 43.1 mL. The mean degree of midline shift in the spontaneous resolution group was 5.3 mm. The mean hematoma volume in the progression-surgery group was 62.0 mL. The mean degree of midline shift in the second group was 6 mm. CONCLUSION: We suggest that the treatment modality should be determined according to the patient's symptoms and clinical condition and close observation could be performed in patients who do not have any symptoms or in patients who have mild to moderate headache without neurological deterioration.

Analysis of Mortality and Epidemiology in 2617 Cases of Traumatic Brain Injury : Korean Neuro-Trauma Data Bank System 2010–2014

OBJECTIVE: The aims of the Korean Neuro-Trauma Data Bank System (KNTDBS) are to evaluate and improve treatment outcomes for brain trauma, prevent trauma, and provide data for research. Our purpose was to examine the mortality rates following traumatic brain injury (TBI) in a retrospective study and to investigate the sociodemographic variables, characteristics, and causes of TBI-related death based on data from the KNTDBS. METHODS: From 2010 to 2014, we analyzed the data of 2617 patients registered in the KNTDBS. The demographic characteristics of patients with TBI were investigated. We divided patients into 2 groups, survivors and nonsurvivors, and compared variables between the groups to investigate variables that are related to death after TBI. We also analyzed variables related to the interval between TBI and death, mortality by region, and cause of death in the nonsurvivor group. RESULTS: The frequency of TBI in men was higher than that in women. With increasing age of the patients, the incidence of TBI also increased. Among 2617 patients, 688 patients (26.2%) underwent surgical treatment and 125 patients (4.7%) died. The age distributions of survivors vs. nonsurvivor groups and mortality rates according the severity of the brain injury, surgical treatment, and initial Glasgow Coma Scale (GCS) scores were statistically significantly different. Among 125 hospitalized nonsurvivors, 70 patients (56%) died within 7 days and direct brain damage was the most common cause of death (80.8%). The time interval from TBI to death differed depending on the diagnosis, surgical or nonsurgical treatment, severity of brain injury, initial GCS score, and cause of death, and this difference was statistically significant. CONCLUSION: Using the KNTDBS, we identified epidemiology, mortality, and various factors related to nonsurvival. Building on our study, we should make a conscious effort to increase the survival duration and provide rapid and adequate treatment for TBI patients.

Large Intracranial Aneurysm after Transsphenoidal Surgery for Pituitary Macroadenoma

Uncontrolled cerebrospinal fluid (CSF) leakage after transsphenoidal surgery (TSS) for pituitary adenoma can lead to meningitis. Intracranial mycotic pseudoaneurysm is a rare complication in central nervous system infection. Large single pseudoaneurysm is more uncommon. Most mycotic aneurysms occur due to endocarditis. The present patient had no heart problem and was infected by CSF leakage after transsphenoidal surgery. We present a case of large ruptured mycotic pseudoaneurysm as a complication of cerebral infection after TSS for pituitary macroadenoma.

Primary Osteolytic Intraosseous Atypical Meningioma with Soft Tissue and Dural Invasion: Report of a Case and Review of Literatures

Primary intraosseous meningioma is a rare tumor, and atypical pathologic components both osteolytic lesion and dura and soft tissue invasion is extremely rare. A 65-year-old woman presented with a 5-month history of a soft mass on the right frontal area. MR imaging revealed a 4 cm sized, multilobulated, strongly-enhancing lesion on the right frontal bone, and CT showed a destructive skull lesion. The mass was adhered tightly to the scalp and dura mater, and it extended to some part of the outer and inner dural layers without brain invasion. The extradural mass and soft tissue mass were totally removed simultaneously and we reconstructed the calvarial defect with artificial bone material. The pathological study revealed an atypical meningioma as World Health Organization grade II. Six months after the operation, brain MR imaging showed that not found recurrence in both cranial and spinal lesion. Here, we report a case of primary osteolytic intraosseous atypical meningioma with soft tissue and dural invasion.

Microsurgical Excision of Symptomatic Sacral Perineurial Cyst with Sacral Recapping Laminectomy : A Case Report in Technical Aspects

Perineurial cysts (Tarlov cysts) are lesions of the nerve root that are often observed in the sacral area. There is debate about whether symptomatic perineurial cysts should be treated surgically. We presented three patients with symptomatic perineurial cyst who were treated surgically, and introduced sacral recapping laminectomy. Patients complained of low back pain and hypesthesia on lower extremities. We performed operations with sacral recapping technique for all three. The outcome measure was baseline visual analogue score and post operative follow up magnetic resonance images. All patients were completely relieved of symptoms after operation. Although not sufficient to address controversies, this small case series introduces successful use of a particular surgical technique to treat sacral perineural cyst, with resolution of most symptoms and no sequelae.

ACDF Using the Solis Cage with Iliac Bone Graft in Single Level: Clinical and Radiological Outcomes in Average 36 months Follow-up

OBJECTIVE: To evaluate the utility of anterior cervical discectomy and fusion (ACDF) with polyetheretherketone (PEEK) cage and autograft through long term(average 36 months) follow-up. METHODS: Thirty selected patients (male:20/female:10) who suffered from cervical radiculopathy, myelopathy or radiculomyelopathy underwent a single level ACDF with PEEK cage and autograft from iliac crest from March 2006 to July 2008 in single institute. We followed patients for an average 36.4+/-8.1 months (ranged from 23 to 49 months). The Japanese Orthopedic Association (JOA) score for evaluation of myelopathy and visual analogue scale (VAS) for radiating pain was used to estimate postoperative clinical outcome. Plain x-ray on true lateral standing flexion, extension and neutral position view and 3D CT scan were used every 6 months after surgery during follow-up period. RESULTS: The mean VAS and JOA scoring improved significantly after the surgery and radiological fusion rate was accomplished by 100% 36 months after the surgery. We had no complication related with the surgery except one case of osteomyelitis. There was one case of Grade I fusion, four cases of grade II, and 25 cases of grade III by radiologic evaluation. CONCLUSION: This long term follow-up study for ACDF with PEEK cage shows that this surgical method is comparable with other anterior cervical fusion methods in terms of clinical outcomes and radiologic fusion rate.

Neuromyelitis Optica Mimicking Intramedullary Tumor

Neuromyelitis optica (NMO) is considered to be a rarer autoimmune disease than multiple sclerosis. It is very difficult to make a diagnosis of MNO for doctors who are not familiar with its clinical features and diagnostic criteria. We report a case of a young female patient who had been suffering motor weakness and radiating pain in both upper extremities. Cervical MRI showed tumorous lesion in spinal cord and performed surgery to remove lesion. We could not find a tumor mass in operation field and final diagnosis was NMO. NMO must be included in the differential diagnosis of lesions to rescue the patient from invasive surgical interventions. More specific diagnostic tools may be necessary for early diagnosis and proper treatment.

Understandings and Key Elements of Trauma Data Bank System / 대한신경손상학회지

Understanding the components of a Trauma Data Bank System (TDBS) is important, whether one is to use registry data for research or administrative purposes by an institution or a nation. TDBS has been designed to serve a number of purposes, including quality of life improvement, injury prevention, clinical research, and policy development. This review describes the history of trauma registry in the world and key components of TDBS. A detailed review of english-language articles on trauma registry was performed using MEDLINE searches. In addition, relevant articles from non-indexed journals were identified with Google Scholar. Since their beginning over 30 years ago, trauma registries have not fully been established in most developing countries. The following elements play key roles in the creation of trauma data bank: 1) study design, 2) inclusion and exclusion criteria, 3) collected variables, 4) registry software, 5) registry staff and training, and 6) data management strategies. By reviews in the articles, guidelines for the design and implementation of trauma registries are given. The final goal of this review is to make an application to establishment the futures of Korean Trauma Data Bank System.

A Case of Neurotoxicity Induced by Valaciclovir in a Continuous Ambulatory Peritoneal Dialysis Patient / 영남의대학술지

Valaciclovir is metabolized to acyclovir after ingestion and thereafter exerts its antiviral activity. Because of its superior pharmacokinetic profile, it has quickly replaced acyclovir in the treatment of herpesvirus infection. Neurotoxicity caused by valaciclovir has been reported, however, among patients with pre-existing impaired renal function. This paper reports a case of neurotoxicity of valaciclovir in a patient with end-stage renal disease who was undergoing continuous ambulatory peritoneal dialysis (CAPD). A 67-year-old female on CAPD took 500 mg of valaciclovir twice for herpes zoster. After she took her second dose orally, she developed confusion and disorientation, along with involuntary movements. Her mental confusion progressed to a coma. Discontinuation of valaciclovir showed no rapid improvement. There- fore, hemodialysis was started. After two sessions of hemodialysis, the patient became alert; and after four sessions of hemodialysis, her neurological abnormalities were completely reversed. In conclusion, valaciclovir can induce life-threatening neurotoxicity, especially in CAPD patients, even with appropriate dose reduction, which can be effectively managed by hemodialysis.

Lupus Cystitis and Azathioprine-iIduced Pure Red Cell Aplasia in a Patient with Systemic Lupus Erythematosus / 대한신장학회지

We report a case of lupus cystitis as the manifestation of lupus flare, and pure red cell aplasia resulting from the use of azathioprine in a patient with systemic lupus erythematosus (SLE). A 30-year-old female with a nine-year history of SLE was admitted to our hospital with complaint of anemia and azotemia. Eighteen and three months before, she had two episodes of lupus enteritis treated with high dose steroid. She had serologic evidence of an SLE flare at admission. Abdominal computed tomography revealed bilateral hydronephrosis and hydroureter with marked diffuse thickening of the urinary bladder wall, suggesting lupus cystitis. Treatment with corticosteroid led to prompt normalization of her renal function. Use of azathioprine may lead to severe anemia. The bone marrow examination revealed a decrease of erythropoiesis, suggesting pure red cell aplasia. Serologic tests for hepatitis B and parvovirus B19 were negative. There was immediate hemoglobin recovery after complete azathioprine discontinuation.

The Need for the Introduction of Assessment Program of Good Animal Care and Use Facility / 한국실험동물학회지

The humane care and use of animals should be the prime concern and responsibility of all those individuals using animals for research, teaching or testing. The use of animals as experimental subjects in the 20th century has contributed to many important advances in scientific and medical knowledge. Although scientists have also developed non-animal models for research, these models often cannot completely mimic the complex human or animal body. Nevertheless, efforts to develop and use scientifically valid alternatives, adjuncts, and refinements to animal research should continue. Laboratory Animal Law that was prepared to improve the reliability and reproducibility of research data using laboratory animals also required an institutes to care and use animal in ways judged to be scientifically, technically, and humanely appropriate. The law introduced Assessment Program of Good Animal Care and Use Facility. The primary goal of the Assessment Program is to provide quality assurance for the care and use of experimental animals on a national basis. Although, an effective surveillance protects animals, promotes animal welfare and ensures the quality of science that uses animals, it is the responsibility of investigators to conduct animal experiment on the basis of the highest scientific, humane, and ethical principles. It is expected that the Program will accelerate the introduction of mind concerning humane and ethical animal experiment and will enhance animal well-being, the quality of biomedical research, and the advancement of biologic knowledge that is relevant to humans or animals.

A Case of Plasmodium vivax Malaria Complicated with Acute Renal Failure, Jaundice and Thrombocytopenia / 대한신장학회지

Malaria is caused by four species of the genus Plasmodium. Plasmodium vivax malaria is the most common malarial infection in Korea and usually has benign clinical course. However, serious complications such as severe anemia, pulmonary edema, acute renal failure are reported in Plasmodium vivax malaria. We report a case of Plasmodium vivax malaria complicated with acute renal failure, jaundice and thrombocytopenia. A 56-year-old male was transferred to our hospital with acute renal failure, jaundice and thrombocytopenia. 10 days before admission, he had intermittent fever, chill, myalgia, and was treated with some medications under the impression of URI. Laboratory findings showed that hemoglobin was 11.5 g/dL, platelet 44,000/mm3, blood urea nitrogen 73 mg/dL, creatinine 4.0 mg/dL, total bilirubin 5.2 mg/dL, direct bilirubin 4.0 mg/dL. Serologic tests for leptospirosis, rickettsia, EB virus and CMV were negative. Ring form trophozoites were found in red blood cells, suggesting Plasmodium vivax malaria. Following anti-malarial therapy, acute renal failure, jaundice and thrombocytopenia were recovered to normal. From this case, malarial infection should be included as a differential diagnosis in a febrile patient with acute renal failure, jaundice and thrombocytopenia.

Comparison of Drug-Eluting Stent and Bare Metal Stent in Reducing Adverse Cardiac Event after Coronary Stenting in Hemodialysis Patients / 대한신장학회지

PURPOSE: The patients treated with hemodialysis have been known to have a high 1-year mortality rate after percutaneous coronary intervention (PCI). We evaluated the clinical benefits of drug-eluting stent (DES), compared to bare-metal stent (BMS) in Korean hemodialysis patients. METHODS: We studied 72 hemodialysis patients (M:F=49:23, age 60+/-11 years) treated with percutaneous coronary intervention (PCI) from January, 1999 to February, 2006. Forty four patients (M:F=28: 16, age 60+/-11 years) treated with DES and 28 patients (M:F=21:7, age 60+/-12 years) with BMS were enrolled. A composite of major adverse cardiac and cerebral endpoints (MACCE) was defined as all-cause death, myocardial infarction, stroke, and target-vessel revascularization (TVR). We compared the incidence of MACCE between DES and BMS group. RESULTS: A composite of MACCE occurred in none in DES group (n=44) and 4 in BMS group (n=28) within 3 months after coronary stenting (Kaplan-Meier survival analysis: 0% vs 14%, respectively, p= 0.02). After 3 months, there was no difference in the incidence of primary end points between two groups. Multi-vessel disease (OR 2.47, 95% CI 1.02-6.11, p<0.05) was associated with a significant increase in the incidence of MACCE within 18 months after coronary artery stenting CONCLUSION: DES may be superior to BMS in reducing adverse cardiac outcome at early period after coronary stenting in HD patients. However, this study showed no significant difference with the lapse of time.

The Mildly Elevated Serum Bilirubin Level is Negatively Associated with the Incidence of End Stage Renal Disease in Patients with IgA Nephropathy

Oxidative stress plays various roles in the development and progression of IgA nephropathy, while bilirubin is known as a potent antioxidant. We therefore hypothesized that serum bilirubin would be associated with renal prognosis in IgA nephropathy. The study subjects comprised 1,458 adult patients with primary IgA nephropathy in Korea. We grouped patients according to the following quartile levels of bilirubin: 0.8 mg/dL (Q4). The outcome data were obtained from the Korean Registry of end-stage renal disease (ESRD). Eighty patients (5.5%) contracted ESRD during a mean follow-up period of 44.9 months. The ESRD incidences were 10.7% in Q1, 8.2% in Q2, 2.8% in Q3, and 2.8% in Q4 (p<0.001). The relative risk of ESRD compared to that in Q1 was 0.307 (95% confidence interval [CI], 0.126-0.751) in Q3 and 0.315 (95% CI, 0.130-0.765) in Q4. The differences of ESRD incidence were greater in subgroups of males and of patients aged 35 yr or more, with serum albumin 4.0 g/dL or more, with normotension, with eGFR 60 mL/min/1.73 m2 or more, and with proteinuria less then 3+ by dipstick test. In conclusion, higher bilirubin level was negatively associated with ESRD incidence in IgA nephropathy.

Induction of Animal Model of Scleroderma with Repeated Injection of Bleomycin / 대한류마티스학회지

OBJECTIVE: To induce a mouse model of scleroderma with repeated bleomycin injections for research into human scleroderma at our research laboratory. METHODS: The protocol of Yamamoto et al. was replicated to establish the bleomycin-induced mouse model of scleroderma. RESULTS: A mouse model of scleroderma was induced by repeated subcutaneous injections of bleomycin. The dermal thickness increased with homogeneous and thickened collagen bundles. Semiquantitative measurements of dermal fibrosis were prominent in bleomycin-treated mice. CONCLUSION: A mouse model of scleroderma was induced with repeated injections of bleomycin at our laboratory.