Cerebral Aneurysms in Judicial Precedents

OBJECTIVE: From November 30, 2016, the Korean Government carried the revised Medical Dispute Mediation and Arbitration Act into effect. Mediation will start automatically without agreements of the defendant, when the outcome of the patient was death, coma more than a month or severe disability. Cerebral aneurysm has a definite risk of bad outcome, especially in the worst condition. Any surgical intervention to this lesion has its own high risk of complications. Recently, Seoul central district court decided 50% responsibility of the doctors who made a rupture of the aneurysm during coiling (2015Ga-Dan5243104). We reviewed judicial precedents related to cerebral aneurysms in lawsuit using a web search. METHODS: We searched judicial precedents at a web search of the Supreme Court, using the key words, "cerebral aneurysm". RESULTS: There were 15 precedents, six from the Supreme Court, seven from the High Court, and two from district courts. Seven precedents were related to the causation analysis, such as work-relationship. Five precedents were malpractice suits related bad results or complications. Remaining three precedents were related to the insurance payment. In five malpractice precedents, two precedents of the Supreme Court reversed former two precedents of the High Court. CONCLUSION: Judicial precedents on the cerebral aneurysm included not only malpractice suits, but also causation analysis or insurance payment. Attention to these subjects is needed. We also need education of the independent medical examination. To avoid medical disputes, shared decision making seems to be useful, especially in cases of high risk condition or procedures.

Cerebral Aneurysms in Judicial Precedents

OBJECTIVE: From November 30, 2016, the Korean Government carried the revised Medical Dispute Mediation and Arbitration Act into effect. Mediation will start automatically without agreements of the defendant, when the outcome of the patient was death, coma more than a month or severe disability. Cerebral aneurysm has a definite risk of bad outcome, especially in the worst condition. Any surgical intervention to this lesion has its own high risk of complications. Recently, Seoul central district court decided 50% responsibility of the doctors who made a rupture of the aneurysm during coiling (2015Ga-Dan5243104). We reviewed judicial precedents related to cerebral aneurysms in lawsuit using a web search.METHODS: We searched judicial precedents at a web search of the Supreme Court, using the key words, "cerebral aneurysm".RESULTS: There were 15 precedents, six from the Supreme Court, seven from the High Court, and two from district courts. Seven precedents were related to the causation analysis, such as work-relationship. Five precedents were malpractice suits related bad results or complications. Remaining three precedents were related to the insurance payment. In five malpractice precedents, two precedents of the Supreme Court reversed former two precedents of the High Court.CONCLUSION: Judicial precedents on the cerebral aneurysm included not only malpractice suits, but also causation analysis or insurance payment. Attention to these subjects is needed. We also need education of the independent medical examination. To avoid medical disputes, shared decision making seems to be useful, especially in cases of high risk condition or procedures.

Procedure-related Complications during Endovascular Treatment of Intracranial Saccular Aneurysms

OBJECTIVE: We evaluate the rates and outcomes of major procedure-related complications during coiling. MATERIALS AND METHODS: Between 2007 and 2015, 436 intracranial saccular aneurysms were treated. Complications are categorized as three types: intraprocedural aneurysm rupture (IAR), thromboembolism (TE), and post-procedural early rebleeding (PER). And we evaluated the risk factors of procedure related complications by multivariate analysis. RESULTS: Complications occurred in 61 aneurysms (14%). The overall incidence of complications in subarachnoid hemorrhage (SAH) was significantly higher than in unruptured intracranial aneurysm (UIA) (20% vs. 6%). The incidence of IAR and TE were higher in SAH than in UIA (IAR 12% vs. 4%, TE 7% vs. 3%, p 0.05). All 7 patients who had IAR during BAC had good recovery. In multiple logistic regression analysis, female gender, SAH, and intraventricular hemorrhage were associated with procedure related complication (p < 0.05). CONCLUSION: Endovascular coil embolization is a minimally invasive procedure, but incidence of its complication is not low, especially in SAH. BAC can be a good tool to avoid poor outcome from unexpected IAR during coiling. While IA tirofiban injection is a useful therapy in TE during coiling, sometimes we are aware of the risk of the early rebleeding in SAH patients.

Clinical Features of Interhemispheric Subdural Hematomas / 대한신경손상학회지

OBJECTIVE: Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively. METHODS: From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes. RESULTS: The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment. CONCLUSION: IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.

Chronic Low Back Pain in Young Korean Urban Males: The Life-Time Prevalence and Its Impact on Health Related Quality of Life

OBJECTIVE: We assessed the life-time prevalence (LTP) of chronic low back pain (LBP) in young Korean males. We also evaluated the relationship between lumbar spinal lesions and their health related quality-of-life (HRQOL). METHODS: A cross-sectional, self-reported survey was conducted in Korean males (aged 19-year-old) who underwent physical examinations for the conscript. We examined 3331 examinees in November 2014. We included 2411 subjects, who accepted to participate this study without any comorbidities. We interviewed using simple binary questions for their LBP experience and chronicity. HRQOL was assessed by Short-Form Health-Survey-36 (SF-36) in chronic LBP and healthy control groups. Radiological assessment was performed in chronic LBP group to determine whether there were any pathological causes of their symptoms. RESULTS: The LTP of chronic LBP was 13.4%. Most (71.7%) of them didn't have any lumbar spinal lesions (i.e., non-specific chronic LBP). The SF-36 subscale and summary scores were significantly lower in subjects with chronic LBP. Between specific and non-specific chronic LBP group, all physical and mental subscale scores were significantly lower in specific chronic LBP group, except mental health (MH) subscale score. In MH subscale and mental component summary score, statistical significant differences didn't appear between two groups (p=0.154, 0.126). CONCLUSION: In Korean males 19 years of age, the LTP of chronic LBP was 13.4%, and more than two-thirds were non-specific chronic LBP. Chronic LBP had a significant impact on HRQOL. The presence of lumbar spinal pathoanatomical lesions affected mainly on the physical aspect of HRQOL. It influenced little on the mental health.

Usefulness of Ultrasound for Detecting Suspected Peripheral Nerve Lesions in Diagnosis of Peripheral Neuropathy : Case Report and Brief Review of the Literature

Ultrasound scanning of a peripheral nerve along its expected course is a simple and useful method for determining the cause of peripheral neuropathy. We present 3 cases of peripheral neuropathy in which the pathology was detected by simple ultrasound scanning of the affected nerve. There were 2 cases of entrapment neuropathy due to mucoid cyst and 1 case of nerve sheath tumor. All lesions were visualized by simple ultrasound scanning of the involved peripheral nerve. Our results suggest that if a lesion affecting the peripheral nerve is suspected after history and physical examination or electrophysiologic studies, ultrasound scanning of the peripheral nerve of interest throughout its course is very helpful for identifying the causative lesion.

The Diagnostic Value of Ultrasonography in Korean Carpal Tunnel Syndrome Patients / 대한신경손상학회지

OBJECTIVE: The purpose of this study was to assess the diagnostic utility of the wrist ultrasonography (USG) in patients with and without carpal tunnel syndrome (CTS). METHODS: Individuals with electrodiagnostically proven CTS patients and healthy control subjects were enrolled prospectively. USG was done 60 wrists of 48 patients with CTS and 36 wrists of 18 controls. The USG analysis included median nerve cross sectional area (CSA) at the level of carpal tunnel inlet. We also evaluated the relationship between median nerve CSA at the level of carpal tunnel inlet and severity grade of nerve conduction test in CTS patients. RESULTS: The median nerve CSA at the level of carpal tunnel inlet was significantly larger in CTS patients (13.6 mm2 versus 7.7 mm2, p<0.0001). And there was an association between median nerve CSA and severity grade of nerve conduction studies (p=0.036). Receiver operating characteristics (ROC) analysis yielded sensitivity of 86.7% and specificity of 88.9% using a cut-off value of 9 mm2. But the specificity was increased to 97.2%, although sensitivity was decreased to 78.3%, when using cut-off value at 10.1 mm2. CONCLUSION: Ultrasonographic measurement of the median nerve CSA at carpal tunnel inlet was useful in diagnosis of CTS. According to ROC analysis, USG is used as a complementary test for electrodiagnostic test.

Analysis of Precedents Related to the Medical Accidents of Neurosurgery / 대한신경손상학회지

OBJECTIVE: The Korean government has legislated for Medical Dispute Mediation Act in 2011. As a member of medical accident appraisal board, the medical doctor should have well-balanced mind along with the thorough knowledge and experiences on his specialty. METHODS: We evaluated precedents related to the medical accidents of neurosurgery in Korea. We searched precedents in the Korean Supreme Court web site. There were 60 suits of damages in 108 precedents related to the neurosurgery from 1978 to 2010. We found 23 precedents related to neurosurgical treatment. RESULTS: Doctors or medical institutions were liable for damages in 12 precedents including 4 cases of partial responsibility such as solatium. In 11 precedents, liability for damages was disclaimed. The judgment was unrelated to the level of court, dead or disabled, main issue (11 medical error, 7 explanation, 5 negligence and others), or methods of treatment. Liability for damages was usually disclaimed (6 : 2) in 1980s, more frequently claimed (1 : 7) in 1990s, and it became almost same (4 : 3) in 2000s. CONCLUSION: Medical accident appraisal board should be fair in explorations of the accidents. We should prepare to get an expert medical investigator, who has balanced mind, knowledge on the law, and specialized knowledge with experiences on his specialty.

A Case of Intraosseous Dural Arteriovenous Fistulas Involving Diploic Vein Treated with Transarterial Onyx Embolization

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous connections that lie within the dura. Intraosseous DAVFs involving diploic venous system are extremely rare. A 46-year-old woman presented with headache and right pulsatile tinnitus for three weeks. The tinnitus started after yelling. Digital subtraction angiography revealed DAVF within the basal portion of right parietal bone along the middle meningeal artery (MMA) groove. The fistula was fed by frontal branch of right MMA and drained into right transverse sigmoid sinus junction through dilated middle meningeal vein. The intraosseous DAVF involving diploic vein was successfully obliterated with Onyx embolization via transarterial route.

Intradural Extramedullary Capillary Hemangioma in Thoracic Area

Spinal hemangioma is the uncommon, slowly growing benign tumor that arises from the blood vessels and commonly located in thoracic spine. We have recently experienced a caseof capillary Hemangioma in intradural extramedullary space of thoracic spine level. The patient presented with a slowly progressive weakness of both lower extremities and hypesthesia below T6 dermatome. The plain X-ray films, thoracic spine myelography and CT scan disclosed an intradural mass at T5 level. The mass was surgically removed and conformed by histological examination.