Development of Cloud-Based Telemedicine Platform for Acute Intracerebral Hemorrhage in Gangwon-do : Concept and Protocol

We aimed to develop a cloud-based telemedicine platform for patients with intracerebral hemorrhage (ICH) at local hospitals in rural and underserved areas in Gangwon-do using artificial intelligence and non-face-to-face collaboration treatment technology. This is a prospective and multi-center development project in which neurosurgeons from four university hospitals in Gangwondo will participate. Information technology experts will verify and improve the performance of the cloud-based telemedicine collaboration platform while treating ICH patients in the actual medical field. Problems identified will be resolved, and the function, performance, security, and safety of the telemedicine platform will be checked through an accredited certification authority. The project will be carried out over 4 years and consists of two phases. The first phase will be from April 2022 to December 2023, and the second phase will be from April 2024 to December 2025. The platform will be developed by dividing the work of the neurosurgeons and information technology experts by setting the order of items through mutual feedback. This article provides information on a project to develop a cloud-based telemedicine platform for acute ICH patients in Gangwon-do.

Diagnostic Roots Radiofrequency Sensory Stimulation Looking for Symptomatic Injured Roots in Multiple Lumbar Stenosis / 대한신경손상학회지

Objective@#We present how to perform radiofrequency sensory stimulation (RFSS) and whether RFSS could be helpful in identifying symptomatic injured roots in multilevel lumbar stenosis. @*Methods@#Consecutive patients who underwent RFSS from 2010 to 2012 were enrolled. To identify pathologic lesions, RFSS was performed for suspicious roots, as determined using lumbar magnetic resonance imaging (MRI). The RFSS procedure resembled transforaminal root block. During RFSS of the suspicious root, patients could indicate whether stimulation induced their usual pain and/or sensory changes and could indicate whether the same leg area was affected. The number of possible symptomatic roots on MRI was evaluated before and after RFSS. Based on the RFSS results, we confirmed the presence of symptomatic nerve root(s) and performed surgical decompression. Surgical results, such as numeric rating scale (NRS) scores for low back pain (LBP) and leg pain (LP), and Oswestry disability index (ODI), were evaluated. @*Results@#Ten patients were enrolled in the study. Their mean age was 70.1±9.7 years. Clinically, NRS-LBP, NRS-LP, and ODI before surgery were 5.1%, 7.5%, and 53.2%, respectively. The mean number of suspicious roots was 2.6±0.8. After RFSS, the mean number of symptomatic roots was 1.6±1.0. On average, 1.4 lumbar segments were decompressed. The follow-up period was 35.3±12.8 months. At the last follow-up, NRS-LBP, NRS-LP, and ODI were 3.1%, 1.5%, and 35.3%, respectively. There was no recurrence or need for further surgical treatment for lumbar stenosis. @*Conclusion@#RFSS is a potentially helpful diagnostic tool for verifying and localizing symptomatic injured root lesions, particularly in patients with multilevel spinal stenosis.

A Preliminary Study of the Association between SOX17 Gene Variants and Intracranial Aneurysms Using Exome Sequencing

Objective@#Conflicting results regarding SOX17 genes and the risk of intracranial aneurysms (IA) exist in the Korean population, although significant positive correlations were noted in genome-wide association studies in European and Japanese populations. Therefore, we aimed to investigate an association between SOX17 gene variants and IA using exome sequencing data. @*Methods@#This study included 26 age-gender matched IA patients and 26 control subjects. The SOX17 gene variants identified from whole-exome sequencing data were examined. Genetic associations to estimate odds ratio (OR) and 95% confidence interval (CI) were performed using the software EPACTS. @*Results@#The mean age of the IA and control groups were 51.0±9.3 years and 49.4±14.3 years, respectively (p=0.623). Seven variants of SOX17, including six single nucleotide polymorphisms and one insertion and deletion, were observed. Among these variants, rs12544958 (A>G) showed the most association with IA, but the association was not statistically significant (OR, 1.97; 95% CI, 0.81-4.74; p=0.125). Minor allele frequencies of the IA patients and controls were 0.788 and 0.653, respectively. None of the remaining variants were significantly associated with IA formation. @*Conclusion@#No significant association between SOX17 gene variants and IA were noted in the Korean population. A large-scale exome sequencing study is necessary to investigate any Korean-specific genetic susceptibility to IA.

A Prospective Observational Study of Return to Work after Single Level Lumbar Discectomy

Objective@#: Lumbar disc herniation (LDH) is a common disease, and lumbar discectomy (LD) is a common neurosurgical procedure. However, there is little previous data on return to work (RTW) after LD. This study investigated the period until the RTW after LD prospectively. Clinically, the pain state at the time of RTW also checked. RTW failure rate 6 months after surgery also investigated. @*Methods@#: Patients with daily/regular jobs undergoing LD between September 2014 and December 2018 were enrolled. Pain was assessed by the Oswestri Disability Index (ODI) and the Numeric Rate Scale (NRS). Employment type was divided into self-employed, regular and contracted. Monthly telephone interviews were conducted to check RTW status and self-estimated work capability after surgery. @*Results@#: Sixty-seven patients enrolled in this study. Three patients failed to RTW, and three others resigned within 6 months after surgery. The preoperative NRS and ODI were 7.2±1.2 and 22.1±7.9, respectively. The average time to RTW was 5.1±6.0 weeks. At RTW, NRS was 1.5±1.8 and ODI was 6.3±3.9. Amongst patients that successfully returned to work were 16 self-employed workers, 42 regular employees, and three contracted workers. The time to RTW of self-employed, regular, and contracted workers were 5.9±8.8, 4.2±4.3 and 13.3±2.3 weeks, respectively (p=0.011). Thirty-six of the patients that returned to work self-reported a 22.8±15.6% reduction in work capability at 6 months. @*Conclusion@#: RTW may vary depending on the employment status. In this study, we found that while employment type may affect the length to RTW, most patients were able to RTW and >40% of patients reported no loss of work capabilities 6 months postoperatively, hopefully alleviating some patient hesitation towards LD.

Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature

OBJECTIVE: To compare peri-operative any symptomatic stroke after carotid angioplasty and stenting (CAS), based on the application or absence of a cerebral protection device.METHODS: A systematic literature review using PubMed, Embase, and the Cochrane Central was done across an online data base from January 1995 to October 2016. Procedures which were performed due to carotid dissection or aneurysm, procedures using covered stents or conducted in an emergency, were excluded. The primary endpoint was perioperative any symptomatic stroke within 30 days after the procedure. A fixed effect model was used in cases of heterogeneity less than 50%.RESULTS: In the 25 articles included in this study, the number of stroke events was 326 (2.0%) in protected CAS and 142 (3.4%) in unprotected CAS. The use of cerebral protection device significantly decreased stroke after CAS (odds ratio [OR] 0.633, 95% confidence interval [CI] 0.479–0.837, p=0.001). In the publication bias analysis, Egger’s regression test disclosed that the intercept was -0.317 (95% CI -1.015–0.382, p=0.358). Regarding symptomatic patients (four studies, 539 CAS procedures), the number of stroke was six (1.7%) in protected CAS and 11 (5.7%) in unprotected CAS. The protective effect against stroke events by cerebral protection device did not have a statistical significance (OR 0.455, 95% CI 0.151–1.366, p=0.160).CONCLUSION: The use of protection device significantly decreased stroke after CAS. However, its efficacy was not demonstrated in symptomatic patients. Routine use of protection device during CAS should be critically assessed before mandatory use.

Endovascular Treatment with Intravenous Thrombolysis versus Endovascular Treatment Alone for Acute Anterior Circulation Stroke : A Meta-Analysis of Observational Studies

OBJECTIVE: The aim of this study was to determine outcome of ischemic stroke patients in the anterior circulation treated with endovascular treatment (EVT) with intravenous thrombolysis (IVT) versus EVT alone group.METHODS: A systemic literature review was performed using online database from January 2004 to January 2017. Primary outcomes were successful recanalization seen on finial angiography and good outcome at three months. Secondary outcomes were mortality and the development of symptomatic intracranial hemorrhage (S-ICH) after the procedure. A fixed effect model was used when heterogeneity was less than 50%. Egger’s regression test was used to assess publication bias.RESULTS: Five studies were included for final analysis. Between EVT with IVT and EVT alone group, successful recanalization (odds ratio [OR] 1.467, p=0.216), good clinical outcome at three months (OR 1.199, p=0.385), mortality (OR 0.776, p=0.371), and S-ICH (OR 1.820, p=0.280) did not differ significantly. Egger’s regression intercept with 95% confidence interval (CI) was 1.99 (95% CI -2.91 to 6.89) in successful recanalization and -0.27 (95% CI -6.35 to 5.80) in good clinical outcome, respectively.CONCLUSION: The two treatment modalities, EVT with IVT and EVT alone, could be comparable in treating acute anterior circulation stroke. Studies to find specific beneficiary group for EVT alone, without primary IVT, are needed further.

Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature

OBJECTIVE: To compare peri-operative any symptomatic stroke after carotid angioplasty and stenting (CAS), based on the application or absence of a cerebral protection device. METHODS: A systematic literature review using PubMed, Embase, and the Cochrane Central was done across an online data base from January 1995 to October 2016. Procedures which were performed due to carotid dissection or aneurysm, procedures using covered stents or conducted in an emergency, were excluded. The primary endpoint was perioperative any symptomatic stroke within 30 days after the procedure. A fixed effect model was used in cases of heterogeneity less than 50%.

Endovascular Treatment with Intravenous Thrombolysis versus Endovascular Treatment Alone for Acute Anterior Circulation Stroke : A Meta-Analysis of Observational Studies

OBJECTIVE: The aim of this study was to determine outcome of ischemic stroke patients in the anterior circulation treated with endovascular treatment (EVT) with intravenous thrombolysis (IVT) versus EVT alone group. METHODS: A systemic literature review was performed using online database from January 2004 to January 2017. Primary outcomes were successful recanalization seen on finial angiography and good outcome at three months. Secondary outcomes were mortality and the development of symptomatic intracranial hemorrhage (S-ICH) after the procedure. A fixed effect model was used when heterogeneity was less than 50%. Egger’s regression test was used to assess publication bias.

Osteoblast and Bacterial Culture from Cryopreserved Skull Flap after Craniectomy: Laboratory Study

OBJECTIVE: Cranioplasty using a cryopreserved skull flap is a wide spread practice. The most well-known complications of cranioplasty are postoperative surgical infections and bone flap resorption. In order to find biological evidence of cryopreserved cranioplasty, we investigated microorganism contamination of cryopreserved skulls and cultured osteoblasts from cryopreserved skulls. METHODS: Cryopreserved skull flaps of expired patients stored in a bone bank were used. Cryopreserved skulls were packaged in a plastic bag and wrapped with cotton cloth twice. After being crushed by a hammer, cancellous bone between the inner and outer table was obtained. The cancellous bone chips were thawed in a water bath of 30°C rapidly. After this, osteoblast culture and general microorganism culture were executed. Osteoblast cultures were done for 3 weeks. Microorganism cultures were done for 72 hours. RESULTS: A total of 47 cryopreserved skull flaps obtained from craniectomy was enrolled. Of the sample, 11 people were women, and the average age of patients was 55.8 years. Twenty four people had traumatic brain injuries, and 23 people had vascular diseases. Among the patients with traumatic brain injuries, two had fracture compound comminuted depressed. The duration of cryopreservation was, on average, 83.2 months (9 to 161 months). No cultured osteoblast was observed. No microorganisms were cultured. CONCLUSION: In this study, neither microorganisms nor osteoblasts were cultured. The biological validity of cryopreserved skulls cranioplasty was considered low. However, the usage of cryopreserved skulls for cranioplasty is worthy of further investigation in the aspect of cost-effectiveness and risk-benefit of post-cranioplasty infection.

A Novel Association between Lysyl Oxidase Gene Polymorphism and Intracranial Aneurysm in Koreans

PURPOSE: Lysyl oxidase (LOX) controls the cross-linking and maturation of elastin and collagen fibers. In this study, we investigated the association between LOX gene polymorphisms and intracranial aneurysm (IA) formation in a homogeneous Korean population. MATERIALS AND METHODS: This cross-sectional study involved 80 age-sex matched patients with IA and controls. Fisher's exact test was performed to analyze allelic associations between ten single nucleotide polymorphisms (SNPs) and IA, including 41 ruptured and 39 unruptured cases. Haplotype-specific associations were analyzed using the omnibus test estimating asymptotic chi-square statistics. RESULTS: Of ten SNPs, three SNPs (rs2303656, rs3900446, and rs763497) were significantly associated with IA (p<0.01). The C allele of rs3900446 was significantly related to increased IA risk with a significant threshold [odds ratio (OR)=20.15, p=4.8×10⁻⁵]. Meanwhile, the A allele of rs2303656 showed a preventive effect against IA formation (p=8.2×10⁻⁴). Seventeen of 247 haplotype structures showed a suggestive association with IA (asymptotic p<0.001). Of ten SNP haplotype combinations, the CG combination of rs3900446 and rs763497 reached Bonferroni-adjusted significant threshold in IA patients (minor haplotype frequency=0.113, asymptotic p=1.3×10⁻⁵). However, there was no association between aneurysm rupture and the LOX gene. CONCLUSION: This preliminary study indicated that LOX gene polymorphisms, such as rs2303656, rs3900446, and rs763497, may play crucial roles in IA formation in the Korean population. Our novel findings need to be validated in a large-scale independent population.

Prediction of Prolonged Hemodynamic Instability During Carotid Angioplasty and Stenting / 신경중재치료의학

PURPOSE: The aim of this study was to assess the risk factors of prolonged hemodynamic instability (HDI) after carotid angioplasty and stenting (CAS). Herein, a simplified predictive scoring system for prolonged HDI is proposed. MATERIALS AND METHODS: Sixty-six patients who had CAS from 2011 to 2016 at a single institution were evaluated. Prolonged HDI was defined as systolic blood pressure >160 mm Hg or <90 mm Hg or heart rate <50 beats/min, lasting over 30 minutes despite medical treatments. For the study, clinical data and radiologic data, including plaque morphology and stenosis were analyzed. RESULTS: Prolonged HDI was observed in 21 patients (31.8%). Multivariable analysis revealed that calcification (OR, 6.726; p=0.006), eccentric stenosis (OR, 3.645; p=0.047) and extensive plaque distribution (OR, 7.169; p=0.006) were related to prolonged HDI. According to these results, a simplified scoring scale was proposed based on the summation of points: 2 points for calcified plaque, 2 points for extensive plaque distribution, and 1 point for eccentric stenosis. The percentages of prolonged HDI according to the total score were as follows: score 0, 8.7%; score 1, 20.0%; score 2, 38.5%; score 3, 72.7%; score 4, 66.7%; score 5, 100%. From the analysis, the total score in patients with prolonged HDI was significantly higher than those without prolonged HDI (p<0.001). CONCLUSION: Prolonged HDI can be associated with calcification of plaque, eccentric stenosis and extensive plaque distribution, and a simplified scoring system enables prediction of prolonged HDI according to our cohort.

Delayed Consecutive Contralateral Thalamic Hemorrhage after Spontaneous Thalamic Hemorrhage

Simultaneous or subsequent bilateral thalamic hemorrhagic events have ranged from 12 to 19 in prior reports, with a time lag between bilateral thalamic hemorrhage of up to two days. Herein, we report the first case of delayed (17 days) consecutive contralateral thalamic hemorrhage after spontaneous first thalamic hemorrhage. A 65-year-old female initially presented with a drowsy mentality with a left-side motor weakness (grade II/III). Brain computed tomography (CT) demonstrated right side thalamic and intraventricular hemorrhage. She regained alertness with mild residual motor weakness (grade III/IV) under medical management. Seventeen days later, a sudden and generalized tonic-clonic seizure developed. Brain CT scans revealed a new contralateral thalamic hemorrhage coincident with microbleeds. Neurologic status remained unchanged, consisting of a stuporous mentality with quadriparesis of grade II/II. We report the first case of delayed consecutive contralateral thalamic hemorrhage up to 17 days after first thalamic hemorrhage. The case highlights the need for close monitoring of patients with thalamic hemorrhage who experience microbleeds on the contralateral side, due to the possibility of delayed hemorrhage.

Delayed Consecutive Contralateral Thalamic Hemorrhage after Spontaneous Thalamic Hemorrhage

Simultaneous or subsequent bilateral thalamic hemorrhagic events have ranged from 12 to 19 in prior reports, with a time lag between bilateral thalamic hemorrhage of up to two days. Herein, we report the first case of delayed (17 days) consecutive contralateral thalamic hemorrhage after spontaneous first thalamic hemorrhage. A 65-year-old female initially presented with a drowsy mentality with a left-side motor weakness (grade II/III). Brain computed tomography (CT) demonstrated right side thalamic and intraventricular hemorrhage. She regained alertness with mild residual motor weakness (grade III/IV) under medical management. Seventeen days later, a sudden and generalized tonic-clonic seizure developed. Brain CT scans revealed a new contralateral thalamic hemorrhage coincident with microbleeds. Neurologic status remained unchanged, consisting of a stuporous mentality with quadriparesis of grade II/II. We report the first case of delayed consecutive contralateral thalamic hemorrhage up to 17 days after first thalamic hemorrhage. The case highlights the need for close monitoring of patients with thalamic hemorrhage who experience microbleeds on the contralateral side, due to the possibility of delayed hemorrhage.

Radiologic Determination of Corpus Callosum Injury in Patients with Mild Traumatic Brain Injury and Associated Clinical Characteristics

OBJECTIVE: To investigate the incidence of corpus callosum injury (CCI) in patients with mild traumatic brain injury (TBI) using brain MRI. We also performed a review of the clinical characteristics associated with this injury. METHODS: A total of 356 patients in the study were diagnosed with TBI, with 94 patients classified as having mild TBI. We included patients with mild TBI for further evaluation if they had normal findings via brain computed tomography (CT) scans and also underwent brain MRI in the acute phase following trauma. As assessed by brain MRI, CCI was defined as a high-signal lesion in T2 sagittal images and a corresponding low-signal lesion as determined by axial gradient echo (GRE) imaging. Based on these criteria, we divided patients into two groups for further analysis : Group I (TBI patients with CCI) and Group II (TBI patients without CCI). RESULTS: A total of 56 patients were enrolled in this study (including 16 patients in Group I and 40 patients in Group II). Analysis of clinical symptoms revealed a significant difference in headache severity between groups. Over 50% of patients in Group I experienced prolonged neurological symptoms including dizziness and gait disturbance and were more common in Group I than Group II (dizziness : 37 and 12% in Groups I and II, respectively; gait disturbance : 12 and 0% in Groups I and II, respectively). CONCLUSION: The incidence of CCI in patients with mild TBI was approximately 29%. We suggest that brain MRI is a useful method to reveal the cause of persistent symptoms and predict clinical prognosis.

Sensory Complications in Patients after Scalp Mass Excision and Its Anatomical Considerations

OBJECTIVE: To evaluate the incidence of postsurgical sensory complications in patients with scalp masses and classify the locations of them from a surgical standpoint according to anatomical considerations. METHODS: A total of 121 patients who underwent surgery for scalp mass were included in this study. The authors reviewed medical records and preoperative radiologic images. We investigated the complications related to sensory changes after procedure. Enrolled patients have been divided into three groups. Group A included patients with tumors above the superior nuchal line (SNL), Group B with tumors within the trapezius muscle area and patients who had tumors on the lateral trapezius muscle area were assigned to Group C. We compared the incidence related to postoperative sensory complications and summarized their additional treatments for these with clinical outcome. RESULTS: There were 12 patients (10%) with sensory complications related on the mass excision site (Group A: 1 patient, Group B: 2 patients, Group C: 9 patients). Six patients were affected with lesser occipital nerve (LON), 2 patients on greater occipital nerve (GON) and 4 patients on GON and LON. Over 6 months after surgery, two of the twelve patients with sensory complications did not have complete recovered pain in spite of proper medications and local chemical neurolysis with 1.0% lidocaine and dexamethasone. CONCLUSION: Occipital neuropathy should be considered as a complication related excision of scalp mass. The sensory complications are more frequent in Group C because of the anatomical characteristics of the occipital nerves and there were no statistical difference for other variables.

Demographic and Clinical Characteristics of Patients with Restless Legs Syndrome in Spine Clinic

OBJECTIVE: The restless legs syndrome (RLS) is a common disorder affecting up to 5% to 15% of the general population, in which the incidence increases with age, and includes paresthesia in the legs. The purpose of this study is to investigate the incidence of RLS in spine center and to review clinical manifestations of this syndrome and its current treatments. METHODS: Over a period of a year, retrospective medical record review and lumbar magnetic resonance images were performed on 32 patients with RLS in spine clinic who were diagnosed by National Institutes of Health criteria. Affected limbs were classified as five. Two grading systems were used in the evaluation of neural compromises. RESULTS: The incidence of RLS was 5.00% (32/639). There were 16 males (50%) and 16 females (50%). The median age at diagnosis was 55.4 years (range, 25-93 years). There are no correlation between the affected limbs of RLS and neural compromises on the lumbar spine. CONCLUSION: The RLS is a clearly common neurologic disorder of the limbs, usually the legs. The awareness of this syndrome can help reduce diagnostic error; thereby, avoiding the morbidity and expense associated with unnecessary studies or inappropriate treatments in RLS patients.

Coil Embolization in Ruptured Inferior Thyroid Artery Aneurysm with Active Bleeding

We present a unique experience of urgent parent arterial embolization for treatment of an aneurysm of the inferior thyroid artery (ITA) that bled during tracheostomy. The event happened to a 69-year-old female patient with subarachnoid hemorrhage and hospital-acquired pneumonia that required tracheostomy. Abrupt and massive bleeding developed during the procedure, and the source could not be identified. Under manual compression, angiography revealed an 8-mm aneurysm that arose from the inferior thyroid artery. The superselected parent artery of the aneurysm was successfully occluded with a single pushable coil. The patient's postoperative course was uneventful.

Trigeminal Neuralgia Caused by Persistent Primitive Trigeminal Artery

A 66-year-old man presented with typical trigeminal neuralgia (TN). Magnetic resonance angiography (MRA) revealed a primitive trigeminal artery (PTA) that came into contact with the trigeminal nerve. Based on MRA, we performed microvascular decompression (MVD). In the operational field, we confirmed the PTA location and performed MVD successfully. Postoperatively, the patient's pain subsided without any complications.

Trigeminal Neuralgia Caused by Persistent Primitive Trigeminal Artery

A 66-year-old man presented with typical trigeminal neuralgia (TN). Magnetic resonance angiography (MRA) revealed a primitive trigeminal artery (PTA) that came into contact with the trigeminal nerve. Based on MRA, we performed microvascular decompression (MVD). In the operational field, we confirmed the PTA location and performed MVD successfully. Postoperatively, the patient's pain subsided without any complications.

Clinical Features of Wrist Drop Caused by Compressive Radial Neuropathy and Its Anatomical Considerations

OBJECTIVE: Posture-induced radial neuropathy, known as Saturday night palsy, occurs because of compression of the radial nerve. The clinical symptoms of radial neuropathy are similar to stroke or a herniated cervical disk, which makes it difficult to diagnose and sometimes leads to inappropriate evaluations. The purpose of our study was to establish the clinical characteristics and diagnostic assessment of compressive radial neuropathy. METHODS: Retrospectively, we reviewed neurophysiologic studies on 25 patients diagnosed with radial nerve palsy, who experienced wrist drop after maintaining a certain posture for an extended period. The neurologic presentations, clinical prognosis, and electrophysiology of the patients were obtained from medical records. RESULTS: Subjects were 19 males and 6 females. The median age at diagnosis was 46 years. The right arm was affected in 13 patients and the left arm in 12 patients. The condition was induced by sleeping with the arms hanging over the armrest of a chair because of drunkenness, sleeping while bending the arm under the pillow, during drinking, and unknown. The most common clinical presentation was a wrist drop and paresthesia on the dorsum of the 1st to 3rd fingers. Improvement began after a mean of 2.4 weeks. Electrophysiologic evaluation was performed after 2 weeks that revealed delayed nerve conduction velocity in all patients. CONCLUSION: Wrist drop is an entrapment syndrome that has a good prognosis within several weeks. Awareness of its clinical characteristics and diagnostic assessment methods may help clinicians make diagnosis of radial neuropathy and exclude irrelevant evaluations.