Clinicoepidemiological Features of Asymptomatic Moyamoya Disease in Adult Patients

OBJECTIVE: The aim of this study was to document the natural course of asymptomatic adult moyamoya disease (MMD) and the factors related to disease progression to aid in treatment decisions. MATERIALS AND METHODS: Among 459 adult MMD patients (aged > or = 20 years), 42 patients were included in this retrospective cohort study. Clinical records of adult asymptomatic MMD patients (n = 42) and follow-up data from September 2013 were reviewed to determine the factors related to disease progression. RESULTS: The mean age of patients at the time of diagnosis was 41.2 years (range, 23-64 years), and the mean follow-up period was 37.3 months (range, 7.4-108.7 months). Of the 42 patients and 75 hemispheres, there were 12 patients (28.6%) and 13 hemispheres (17.3%) with disease progression. There were four hemispheres (5.3%) with symptomatic progression (three hemorrhage, one transient ischemic attack) and nine hemispheres (12.0%) with asymptomatic radiographic progression. There were no relationships with sex, diabetes, hypertension, thyroid disease, family history of MMD, or family history of stroke. However, reduced initial cerebrovascular reserve capacity was observed in seven hemispheres (9.3%) in patients with disease progression. A relationship was found between disease progression and initial cerebrovascular reserve capacity (p = 0.05). None of the patients underwent bypass surgery during the follow-up period. CONCLUSION: It appears that asymptomatic adult MMD is not a permanent stable disease. In particular, reduced cerebrovascular reserve capacity is an indication of MMD progression, so close regular observation is needed.

Sacral Nerve Stimulation for Treatment of Intractable Pain Associated with Cauda Equina Syndrome

Sacral nerve stimulation (SNS) is an effective treatment for bladder and bowel dysfunction, and also has a role in the treatment of chronic pelvic pain. We report two cases of intractable pain associated with cauda equina syndrome (CES) that were treated successfully by SNS. The first patient suffered from intractable pelvic pain with urinary incontinence and fecal incontinence after surgery for a herniated lumbar disc. The second patient underwent surgery for treatment of a burst fracture and developed intractable pelvic area pain, right leg pain, excessive urinary frequency, urinary incontinence, voiding difficulty and constipation one year after surgery. A SNS trial was performed on both patients. Both patients' pain was significantly improved and urinary symptoms were much relieved. Neuromodulation of the sacral nerves is an effective treatment for idiopathic urinary frequency, urgency, and urge incontinence. Sacral neuromodulation has also been used to control various forms of pelvic pain. Although the mechanism of action of neuromodulation remains unexplained, numerous clinical success reports suggest that it is a therapy with efficacy and durability. From the results of our research, we believe that SNS can be a safe and effective option for the treatment of intractable pelvic pain with incomplete CES.

Selective Musculocutaneous Neurotomy for Spastic Elbow

OBJECTIVE: The purpose of this study was to investigate the effectiveness and outcome of selective musculocutaneous neurotomy (SMcN) for spastic elbow. METHODS: We retrospectively reviewed the medical records of 14 patients with spasticity of their elbows. The patients were selected using clinical and analytical scales, as well as nerve block tests, for assessment. Their mean age was 37.29 years (range, 19-63 years). SMcN was performed for these patients, and the mean follow-up period was 30.71 months (range, 19-54 months). RESULTS: The modified Ashworth scale (MAS) scores recorded before and after the SMcN showed that the patients' mean preoperative MAS score of 3.28 +/- 0.12 was improved to 1.71 +/- 0.12, 1.78 +/- 0.18, 1.92 +/- 0.16 and 1.78 +/- 0.18 at postoperative 3, 6, 12 months and last follow-up, respectively. On the basis of a visual analogue score ranging from 0-100, the patients' mean degree of satisfaction score was 65.00 +/- 16.52 (range, 30-90). CONCLUSION: We believe that SMcN can be a good and effective treatment modality with low morbidity in appropriately selected patients who have localized spastic elbow with good antagonist muscles and without joint contracture.

A peripheral tremor associated with intractable pain after traffic accident: case report / 영남의대학술지

There are debates about whether peripherally induced movement disorders exist. We report a case of upper limb tremor induced by peripheral nerve injury. A 25-year-old male patient presented with pain and tremor of the left upper extremity, 2 days after a car accident. Magnetic resonance images of the brain and cervical spine were normal. His past medical history was unremarkable and there were no family members with symptoms of movement disorders. He suffered from an aggravating tremor for about 10 minutes, four to six times a day. We treated the patient with medication, epidural infusion, cervical nerve root block and trigger point injection of the trapezius muscle. The pain subsided 50% and the incidence of tremor attacks was reduced to once or twice a day. The role of peripheral trauma in the genesis of movement disorders has not been generally accepted. It is unclear whether peripheral trauma can induce dystonia and other movement disorders. It has been proposed that peripheral trauma can alter sensory input and induce cortical and subcortical reorganization that generates a movement disorder. Some studies provide evidence for central reorganization following peripheral injury.

Long Term Results of Microsurgical Dorsal Root Entry Zonotomy for Upper Extremity Spasticity

OBJECTIVE: The purpose of the present study is to assess the long-term results of microsurgical dorsal root entry zonotomy (MDT) for the treatment of medically intractable upper-extremity spasticity. METHODS: The records of nine adult patients who underwent MDT by one operating neurosurgeon from March 1999 to June 2004 were retrospectively reviewed by another investigator who had no role in the management of these patients. In all patients, MDT was performed on all roots of the upper limb (from C5 to T1) for spasticity of the upper extremity. The degree of spasticity was measured by the Modified Ashworth Scale (grade 0-4). Severity of the pain level was determined using the Numeric Rating Scale (NRS, score 0-10). Also, patient satisfaction of the post-operative outcome was assessed. RESULTS: Comparing the preoperative and postoperative spasticity using the Modified Ashworth Scale, we observed improvement in all patients, particularly in five of the nine patients (55.6%) who improved by three grades over an average of 66.4 months (range, 40-96). Regarding patient satisfaction, seven patients (77.8%) had affirmative results. None of the patients experienced severe, life-threatening, postoperative complications. We observed a decrease in the intensity of painful spasms to less than three scores as measured by NRS in all four patients with associated pain. CONCLUSION: This study shows that MDT provides significant, long-term reduction of harmful spasticity and associated pain in the upper limbs.

Arachnoid Cyst with Spontaneous Intracystic Hemorrhage and Chronic Subdural Hematoma

We report a case of arachnoid cyst in which subdural hematoma and intracystic hemorrhage developed spontaneously. Usually, arachnoid cysts are asymptomatic, but can become symptomatic because of cyst enlargement or hemorrhage, often after mild head trauma. Although they are sometimes combined with subdural hematoma, intracystic hemorrhage has rarely been observed. Our patient had a simultaneous subdural hematoma and intracystic hemorrhage without evidence of head trauma.