Charactersitics and issues of guideline to withdrawal of a life-sustaining therapy

Agenerally accepted consensus of end-of-life (EOL) care decision-making did not appear in Korean medical society until the year 2009. To enhance physician's ethical perception of EOL care, consensus guidelines to withdrawing life-sustaining therapies endorsed by Korean Medical Association, Korean Academy of Medical Science, and Korean Hospital Association, were published on October 13, 2009. In this article, the characteristics and issues with the guidelines are presented to improve understanding by physicians who interact with EOL patients. According to the guidelines, physicians should identify, document, respect, and act on hospitals inpatients' needs, priorities, and preferences for EOL care. The guidelines advocate that competent patients express their right of self-determination in EOL care decisions through advance directives. However, there are barriers to adopting advance directives as a legitimate tool of EOL decision-making in our current society. The guidelines stressed the importance of open communication between care-givers and patients or their surrogates. Through communication, physicians can create a plan regarding how to manage EOL until the patients' last day of life. Concerted actions among the general public, professionals, other stake-holders for EOL care, and governmental organizations to improve EOL care in our society are also stipulated. Physicians, who know the clinical meaning of the treatments available to EOL patients, should play a central role based on the consensus guidelines to help patients and their families make informed decisions about EOL care.

Clinical Factors for the Development of Posttraumatic Hydrocephalus after Decompressive Craniectomy

OBJECTIVE: Earlier reports have revealed that the incidence of posttraumatic hydrocephalus (PTH) is higher among patients who underwent decompressive craniectomy (DC). The aim of this study was to determine the influencing factors for the development of PTH after DC. METHODS: A total of 693 head trauma patients admitted in our hospital between March 2004 and May 2007 were reviewed. Among thee, we analyzed 55 patients with severe traumatic brain injury who underwent DC. We excluded patients who had confounding variables. The 33 patients were finally enrolled in the study and data were collected retrospectively for these patients. The patients were divided into two groups: nonhydrocephalus group (Group I) and hydrocephalus group (Group II). Related factors assessed were individual Glasgow Coma Score (GCS), age, sex, radiological findings, type of operation, re-operation and outcome. RESULTS: Of the 693 patients with head trauma, 28 (4.0%) developed PTH. Fifty-five patients underwent DC and 13 (23.6%) developed PTH. Eleven of the 33 study patients (30.3%) who had no confounding factors were diagnosed with PTH. Significant differences in the type of craniectomy and re-operation were found between Group I and II. CONCLUSION: It is suggested that the size of DC and repeated operation may promote posttraumatic hydrocephalus in severe head trauma patients who underwent DC.

Significance of Aspect Ratio as Predictor of Intracranial Aneurysm Rupture / 대한뇌혈관외과학회지

OBJECTIVE: The size of intracranial aneurysm has been well known as a risk factor of aneurysmal rupture. The aneurysmal shape affects risk of rupture differently even though the size is similar. Aspect ratio corresponds well with morphologic variability. In this study we investigated the significance of aspect ratio as a predictor of intracranial aneurysm rupture. METHODS: The authors reviewed the retrospectively the medical records of consecutive patients with ruptured and unruptured intracranial aneurysms who underwent cerebral angiography from January 2001 to December 2005. A total of 156 patients underwent cerebral angiography and 171 aneurysms were detected. One hundred forty ruptured and 31 unruptured aneurysms were included. We measured aspect ratio which aneurysmal dome distance and neck width on angiographic images. To compare the difference of size and aspect ratio between ruptured and unrupteured aneurysms, we performed statistical analysis of aspect ratio to obtain the odds ratio(OR) for risk of rupture. RESULTS: The mean aspect ratio was 2.33+/-0.96 for ruptured aneurysms, compared with 1.71+/-0.55 for unruptured aneurysms. The difference of the aspect ratios between ruptured and unruptured groups was statistically significant (p<0.001). The odds ratio of rupture was 6.3 fold greater when the aspect ratio was larger than 2.66 compared with an aspect ratio less than 1.54. CONCLUSION: We suggest that aspect ratio is a significant independent predictor for aneurysmal rupture. The rupture risk was increased significantly when aspect ratio increased.

Spontaneous Partial Regression of Cerebral Arteriovenous Malformation

Arteriovenous malformation (AVM) of the brain is one of the important pathologic conditions which cause intracerebral or subarachnoid hemorrhage, epilepsy, or chronic cerebral ischemia. The spontaneous regression of cerebral AVM is reported to be very rare and more likely to occur when the AVM is small, is accompanied by hemorrhage, and has fewer arterial feeders. We report a case of right occipital AVM which at follow-up angiography performed four years later showed near-complete spontaneous regression.

Tension Pneumocephalus after Shunting for Hydrocephalus: Case Report

Pneumocephalus is exceedingly rare in the absence of trauma or recent surgery. It is most commonly seen after severe head injury, with disruption of the dura and subsequent cerebrospinal fluid leakage. Intracranial air has also been reported as a complication of shunting. This may be secondary to intermittent shunt failure or a persistent communication between the extracranial and intracranial space that permits the entrance of air. In the present case, air appeared to enter the ventricular system through the fistula that connected the frontal sinus. This air replaced the CSF being drained into the peritoneal cavity by the shunt. The decrease of intracranial pressure after a shunt might play a role in causing pneumocephalus. We report a case of tension pneumocephalus after shunting for hydrocephalus as a life-threatning complication.

Neurovascular Morphometric Aspect in the Region of Cranio-Cervical Junction

OBJECTIVE: During the trans-condylar or trans-jugular approach for the lesion of cranio-cervical junction(CCJ), its necessary to identify the accurate locations of vertebral artery(VA), internal jugular vein(IJV) and its related lower cranial nerves. These neurovascular structures can also be damaged during the operation for vascular tumor or traumatic aneurysm around extra-jugular foramen, because of their changed locations. To reduce the neurovascular injury at the operation for CCJ, morphometric relationship of its surrounding neurovascular structures based on the tip of the transverse process of atlas(C1 TP), were studied. MATERIALS AND METHODS: Using 10 adult formalin fixed cadavers, tip of mastoid process(MT) and TPs of atlas and axis were exposed bilaterally after removal of occipital and posterior neck muscles. Using standard caliper, the distances were measured from the C1 TP to the following structures: 1) exit point of VA from C1 transverse foramen, 2) branching point of muscular artery from VA, 3) entry point of VA into posterior atlanto-occipital membrane(AOM), 4) branching point of C-1 nerve. In addition, the distances were measured from the mid-portion of the posterior arch of atlas to the entry point of the VA into AOM and to the exit point of the VA from C1 transverse foramen. After removal of the ventrolateral neck muscles, neurovascular structures were exposed in the extra-jugular foraminal region. Distances were then measured from the C1 TP to the following structures: 1) just extra-jugular foraminal IJV and lower cranial nerves, 2) MT and branching point of facial nerve in parotid gland. In addition, distance between MT and branching point of facial nerve was measured. RESULTS: The VA was located at the mean distance of 12mm(range, 10.5-14mm) from the C1 transverse foramen and entered into the AOM at the mean distance of 24mm(range, 22.8-24.4mm) from the C1 TP. The mean distance from the mid portion of the C1 posterior arch was 20.6mm(range, 19.1-22.3mm) to the entry point of the VA into AOM and 38.4mm(range, 34-42.4mm) to the exit point of the VA from C1 transverse foramen. Muscular artery branched away from the posterior aspect of the transverse portion of VA below the occipital condyle at the mean distance of 22.3mm(range, 15.3-27.5mm) from the C1 TP. The C-1 nerve was identified in all specimens and ran downward through the ventroinferior surface of the transverse segment of VA and branched at the mean distance of 20mm(range, 17.7-20.3mm) from the C1 TP. The IJV was located at the mean distance of 6.7mm(range, 1-13.4mm) ventromedially from the lateral surface of the C1 TP. The XI cranial nerve ran downward on the lateral surface of the IJV at the mean distance of 5mm(range, 3-7.5mm) from the C1 TP. Both IX and X cranial nerves were located in the soft tissue between the medial aspect of the internal carotid artery(ICA) and the medial aspect of the IJV at the mean distance of 15.3mm(range, 13-24mm) and 13.7mm(range, 11-15.4mm) from the C1 TP, respectively. The IX cranial nerve ran downward ventroinferiorly crossing the lateral aspect of the ICA. The X cranial nerve ran downward posteroinferior to the IX cranial nerve and descended posterior to the ICA. The XII cranial nerve was located between the posteroinferior aspect of the IX cranial nerve and the posterior aspect of the ICA at the mean distance of 13.3mm(range, 9-15mm) ventromedially from the C1 TP. The distance between MT and C1 TP was 17.4mm(range, 12.5-23.9mm). The VII cranial nerve branched at the mean distance of 10.2mm(range, 6.8-15.3mm) ventromedially from the MT and at the mean distance of 17.3mm(range, 13-21mm) anterosuperiorly from the C1 TP. CONCLUSION: This study facilitates an understanding of the microsurgical anatomy of CCJ and may help to reduce the neurovascular injury at the surgery around CCJ.

Pituitary Macroincidentaloma - Report of 3 Cases -

With improvements in diagnostic imaging techniques for the brain, pituitary tumors without neurological signs or symptoms have occasionally been found. To evaluate therapeutic strategy for incidentally found pituitary tumors ("pituitary incidentaloma"), we analyzed the result of magnetic resonance imaging findings and of ophthalmological and endocrinological studies in 3 cases with follow up. Incidentally found functioning tumors were excluded. All of 3 cases is greater than 10mm in tumor size("pituitary macroincidentaloma"). The follow-up period was 49 months, 16 months and 6 months(mean, 25.3 months) in each case. There was no evidence of tumor enlargement, endocrinological problems and visual field defect during follow-up period. Patients with pituitary incidentalomas usually follow a benign course and neurosurgical intervention is not initially required in the management even those greater than 10mm in diameter. Observation over time may be good approach to the patient with a pituitary macroincidentaloma to avoid the unnecessary risk for surgery in a patients with a stable mass.

Acute Paraplegia Following Lumbar Puncture in a Patient with Cervical Disc Herniation

The incidence of paraplegia following drain of cerebrospinal fluid(CSF) by lumbar puncure below a spinal block is rare, and most of them occurred in spinal tumor. We report a case of acute paraplegia following lumbar puncture for computed tomography myelography(CTM) in a 42-year-old man who sustained a cervical disc herniation. Four hours after lumbar puncture for CTM, sudden paraplegia was developed. After emergent anterior cervical discectomy and fusion with cervical plating, the patient recovered completely. To the authors' knowledge, this is the first case of spinal shock complicating lumbar puncture for routine myelography in a patient with cervical disc herniation. The prompt recognition of this unusual complication of lumbar puncture may lead to good clinical outcome. Instead of CTM requiring lumbar puncture, MRI should be considered as the initial diagnostic procedure in a patient of cervical disc herniation associated with myelopathy. We discuss the possible mechanisms of acute paraplegia following lumbar puncture with literature review.

Correlation between Angiographic Vasospasm and Clinical Vasospasm following Aneurysmal Subarachnoid Hemorrhage

No abstract available.

Intradural Extramedullary Spinal Metastasis: A Case Report

No abstract available.

Prognosis and Clinical Significance of Traumatic Subarachnoid Hemorrhage

No abstract available.

Using Blood Donating Set for the Treatment of Subgaleal Hematoma: Technical Note

No abstract available.

Morphometric Aspect of Juxta-Clinoidal Cranial Nerves / 대한뇌혈관학회지

OBJECTIVE: During anterior clinoidectomy for aneurysms of ophthalmic artery or paraclinoidal lesions, not only optic nerve but also cranial nerves passing through the superior orbital fissure (SOF) can be damaged by mechanical or thermal injury. Particularly, revision for paraclinoidal lesions can give further damage to the cranial nerves because of the obscure anatomical structure resulting from the tight fibrous adhesion. Thus, to reduce the damage of the cranial nerves passing through the SOF during the anterior clinoidectomy or optic canal decompression via the extradural or intradural route, morphometric relationship of juxta-clinoidal cranial nerves were studied. MATERIALS AND METHODS: Using 15 adult formalin fixed cadavers, the anatomical landmarks for measurements were chosen as follows: lateral entry point of optic nerve into the optic canal (LON), tip of anterior clinoid process (ACP), tip of posterior clinoid process (PCP), upper border of lesser wing of sphenoid bone, and lateral end of SOF. The measurements were carried out as follows: 1) distance from the LON to the dural entry point (DEP) of the third (III), fourth (IV), and ophthalmic branch of the fifth (V1) nerves into the tentorium, 2) distance from the tip of PCP to the DEP of III and VI cranial nerves, 3) distance from the LON to the cranial nerves within intradural space before passing through SOF, 4) The shortest depth from the tip of ACP and the edge of lesser wing to the cranial nerves passing through the cavernous sinus, 5) distance from the lateral end of SOF to the cranial nerves just before passing through the annular tendon. RESULTS: The mean distance from the LON to the DEP of the III, IV, and V1 cranial nerves were 10.4 mm, 18.8 mm, and 23.4 mm, respectively. The mean distance from the tip of PCP to the DEP of the III and VI cranial nerves were 5.4 mm and 18.6 mm, respectively. DEP of the III cranial nerve was corresponded with the just anterior coronal plane of PCP. The mean distance from the LON to the III, IV, and V1 cranial nerves passing through the SOF were 7.2 mm, 10.0 mm, 10.5 mm and 10.6 mm, respectively. The III cranial nerve located at a mean depth of 3.4 mm from the tip of ACP. The IV, V1 , and VI cranial nerves located at a mean depth of 2.1 mm, 2.4 mm and 7.4 mm from the upper border of lesser wing of sphenoid bone, respectively. The III cranial nerve splitted into superior and inferior divisions at a mean distance of 1.51 mm from the lateral end of SOF, just before where it passes through the SOF. The mean distance from the lateral end of SOF to the lateral margins of the III, IV and frontal nerves of V1 were 12.5 mm, 11.0 mm and 10.2 mm, respectively. CONCLUSION: DEP of the III cranial nerve was corresponded with the just anterior coronal plane of PCP and was about a half distance from PCP than from LOP. DEP of the IV cranial nerve looks like same site as that of V1 cranial nerve, but IV cranial nerve located at just superior to V1. From the LON, III, IV, V1 , and VI CNs latero-inferiorly passed through the SOF. The III cranial nerve located at the most medial portion of SOF with a mean distance of 7 mm, and the IV, V1 and VI cranial nerves were arranged in the same order as vertical arrangement with a mean distance of 10 mm. The cranial nerves just before passing through SOF were located at a range of 7.8 to 20 mm from the lateral end of SOF. This study facilitates an understanding of the anatomy of juxta-sellar region and may help to reduce the cranial nerve injury at the surgery around juxta-clinoidal CNs.

anterior Spinal Epidural Hematoma after posterior Approach in Cervical Meningioma

No abstract available.

Surgical Pitfall

Authors report two cases of central neurocytoma with unusual surgical pitfall. The one of these presented with postoperative intraventricular hemorrhage with hydrocephalus. The other case developed motor aphasia and hemiplegia due to brain retration during operation. We describe peripoerative courses of these cases and discuss possible causes of postoperative complications.

Analysis of Inpatients by Standardization for Disease and Surgical Procedure / 대한의료정보학회지

BACKGROUND: It is not so reasonable international classification of disease and surgical procedure to clinicians. Authors made a more comprehensive standardization for neurological disease and neurosurgical procedures and have been used for the analysis of the inpatients. METHODS: For making the standardization of disease, we modified the mane of disease according to that used for daily report during 10 years, textbook of neurosurgery, but kept the fields of international coding system in each. Neurosurgical procedures were made and modified according to Current Procedure Terminology 96. Client-server system was used for networking and database software was applied. The neurosurgical patients admitted at Soonchunhyuna University Hospital from January o December, 1998 were analysed with this system. RESULTS: Diseases were classified as 14 large categories and 379 small categories. Neurosurgical procedures were did also 20 large and 202 small categories. Futhermore, international coding system such as ICD-10 and ICD-9CM maintained for the disease and procedures in each. The number of patients for admission and operation during 1 year were 834 and 412 patients. The accurate and rapid interpretation of the disease and surgical procedures was identified. CONCLUSIONS: It could be possibel to make database of patients management with the resonable standardization of disease and neurosurgical procedures.

Thoracic Compression Fracture Following Electro-Convulsive Therapy

Spine fractures occur less than 1% after electro-convulsive therapy(ECT). We report a rare case of thoracic compression fracture due to seizure after ECT. The patient was a 37-year-old female who suffered from major depression disorder. She received ECT six times in total. She complained of back pain after fifth ECT. There was no history of trauma. On thoracic CT and MRI, compression fracture of T4 body was clearly shown, but cord injury was not evident. After one month of bed rest, her back pain was improved. We discuss the mechanism of vertebral fracture after ECT with literature review.

Delayed Facial Palsy Following Microvascular Decompression in Hemifacial Spasm Patients

OBJECTIVE: Microvascular decompression(MVD) for hemifacial spasm(HFS) is well established. However delayed postoperative facial palsy has not been substantially reported. The authors reviewed patients with HFS who underwent MVD in our institution to evaluate the post-operative courses with special attention to the development of delayed facial palsy. METHODS: Records of 144 cases(137 patients) from 1988 to 1997 were reviewed. Of these patients, 12(8.3%) developed delayed facial palsy. Follow-ups via chart and phone records were available for 10 of 12 patients. RESULTS: Reviews of these 12 cases demonstrated that 3 men, 9 women of with average age of 53(range 45-60) had delayed facial palsy. Among them, 2 had repeated operation. The preoperative duration of symptoms averaged 12 years(range 1-30) and 4 patients had mild preoperative weakness. All were improved their HFS within 7 days after MVD. Offending vessels were anterior inferior cerebellar artery(AICA) in 7. Five of these were meatal branches and 2 were sandwich type compressions. One case was combined compression of AICA and posterior inferior cerebellar artery. Three to 7 pieces of Teflon felt were necessary for the decompression of offender. The onset of weakness occurred invariably between postoperative day 6 and 11. Two cases had associated complications. The one was hearing loss and the other was meningitis accompanied by cerebrospinal fluid otorrhea. Ten cases received steroids following the onset of their facial palsies. Duration of follow up of 10 cases was 21months(3months-5years). Three cases showed complete recovery at 4, 8 and 12 weeks, respectively. Four patients have improved to House Grade II at 5 weeks and remaining three showed continuing improvement until last follow-up. CONCLUSIONS: Delayed facial palsy following MVD in HFS patients is not uncommon, being 8.3% in our series. It occurs consistently 1-2 weeks postoperatively. Possible causes include facial nerve exit zone injury with Teflon felt or delayed facial nerve edema. Spontaneous recovery usually occur within several weeks.

Bilateral Large Thoracic Neuofibromas in Type I Neurofibromatosis

Type 1 Neurofibromatosis(von Recklinghausen's disease) characterized by cafe-au-lait spot and multiple skin nodules, may involve any part of the body. The incidence of multiple spinal neurofibromas is about 15% of all spinal neurofibromas and the majority of them are located in cauda equina. However, thoracic spine is uncommon site of multiple spinal neurofibrmas in type 1 neurofibromatosis. The authors describe a case of bilateral large neurofibromas of the thoracic spine associated with type 1 neurofibromatosis in a 27-year-old man.

Surgical Indications of Decompressive Craniectomy for Middle Cerebral Artery Infarction

OBJECTIVES: A significant number of acute hemispheric infarctions are associated with severe cerebral edema and even herniation as a cause of early mortality. In clinically acute hemispheric infarction, it is estimated that 7% to 15% of patients have severe cerebral edema with herniation syndromes, with 50% to 75% of mortality. This study was performed to determine clinical and radiologic factors which might affect the clinical course and the timing of surgical decompression in cerebral infarction with severe edema. PATIENTS AND METHODS: The authors prospectively studied 33 consecutive patients with acute middle cerebral artery infarction from January 1996 to December 1997. Of these, 9 patients underwent decompressive craniectomy, and 24 patients were treated conservatively. They were divided into GroupI(n=15), surgically treated patients and clinically deteriorated and died, and GroupII(n=18), clinically stable patients. Patients were evaluated and compared between groups based on following factors: age, sex, consciousness level, pupillary light reflex, outcome, midline shift, enlargement of contralateral temporal horn, the maximum diameter of infarct area and the ratio of infarct area. RESULTS: In GroupI, the mean interval of the time elapsed for changing of consciousness was 2.29 day after attack. The majority of deterioration was seen on day 2 after attack. Four patients underwent decompressive craniectomy, and 5 patients decompressive craniectomy with removal of infarct area or temporal lobectomy. The method of surgery did not affect the outcome(p>0.05). The change of consciousness, preservation of pupillary light reflex, midline shift, enlargement of contralateral temporal horn, the maximum diameter of infarct area, and the ratio of infarct area were related with outcome after acute middle cerebral infarction(p10cm) and ratio(>30% of brain volume) of infarct area.