Hydration-induced rapid growth and regression after indirect revascularization of an anterior choroidal artery aneurysm associated with Moyamoya disease: A case report

The prevalence of aneurysm formation in adults with Moyamoya disease (MMD) is higher than that in the general population. The treatment strategy is often individualized based on the patient’s disease characteristics. A 22-year-old man was diagnosed with MMD after presenting a small thalamic intracerebral and subarachnoid hemorrhage in the quadrigeminal cistern. Cerebral angiography revealed a small aneurysm (2.42 mm) in the left anterior choroidal artery. Since the hemodynamics in the left hemisphere was compromised, an indirect bypass surgery was performed. The patient’s condition deteriorated postoperatively because of poor perfusion of the internal carotid artery, and massive hydration was required. During neurocritical care, the aneurysm increased in size (5.33 mm). An observation strategy was adopted because of the distal aneurysmal location and the high risk involved. Subsequently, the patient recovered, and newly developed collateral flow appeared from the external carotid artery. Additionally, a dramatic size reduction of the aneurysm (1.51 mm) was noticed. Our case suggests that MMD-related dissecting aneurysms on a distal cerebral artery, which present a high risk of embolization, could be managed by indirectly reducing the hemodynamic burden. Massive hydration in such cases should be avoided or balanced to avoid the risk of rapid growth and aneurysm rupture.

Recurrence of Rathke’s Cleft Cyst Following Surgery and Histopathological Considerations for Recurrence: A Case Presentation

Recurrence of Rathke’s cleft cysts (RCC) following surgery is not uncommon. We present a 33-yearold male patient with chronic headache and visual disturbances whose MRI showed mostly cystic, suprasellar mass with peripheral enhancement. Endoscopic extended transsphenoidal approach and tumor resection was performed and RCC was pathologically confirmed postoperatively. Early recurrence was first suspected at 3 months following surgery, and his serial MRIs showed a recurred mass without associated clinical symptoms. Upon further histopathological study, extensive squamous metaplasia and high Ki-67 were seen. Also, in this study, we discuss important factors associated with cyst recurrence following surgery.

Arterial Wall Imaging in Angiographically Occult Spontaneous Subarachnoid Hemorrhage : New Insight into the Usual Suspect

Objective@#: The etiology of angiographically occult spontaneous subarachnoid hemorrhage (AOsSAH) is unclear. Threedimensional (3D) high-resolution vessel wall magnetic resonance imaging (HVM) might be useful in detecting the hidden arterial wall angiopathy in patients with AOsSAH. We aimed to demonstrate the feasibility of HVM for detecting the arterial cause of AOsSAH. @*Methods@#: Patients, who were diagnosed with AOsSAH in the first evaluations and underwent HVM, were enrolled. Their clinical and radiologic data were retrospectively reviewed. Especially, focal enhancement of arterial wall on HVM and repetitive catheterized angiograms were precisely compared. @*Results@#: Among 251 patients with spontaneous SAH, 22 patients were diagnosed with AOsSAH in the first evaluations (8.76%). After excluding three patients who did not undergo 3D-HVM, 19 patients were enrolled and classified as convexal (n=2) or perimesencephalic (n=4), and diffuse (n=13) groups. In convexal and perimesencephalic groups, no focal enhancement on HVM and no positive findings on repetitive angiography were noted. In diffuse group, 10 patients showed focal enhancement of arterial wall on HVM (10/13, 76.9%). Repeated angiography with 3D reconstruction revealed four patients of angiographically positive causative arteriopathy and possible lesion in one case in the concordant location of intramural enhancement on 3D-HVM (5/10, 50%). Three of them were treated with endovascular stent insertion. All patients, except one, recovered with good clinical outcome (3-month modified Rankin score, 0 and 1). @*Conclusion@#: 3D-HVM was useful in detecting hidden true arteriopathy in AOsSAH. It may provide new insights into the etiologic investigation of AOsSAH by proving information about the arterial wall status.

Gender differences in adult traumatic brain injury according to the Glasgow coma scale: A multicenter descriptive study / 中华创伤杂志(英文版)

PURPOSE@#Patients' gender, which can be one of the most important determinants of traumatic brain injury (TBI) outcomes, is also likely to interact with many other outcome variables of TBI. This multicenter descriptive study investigated gender differences in epidemiological, clinical, treatment, mortality, and variable characteristics in adult TBI patients.@*METHODS@#The selection criteria were defined as patients who had been diagnosed with TBI and were admitted to the hospital between January 1, 2016 and December 31, 2018. A total of 4468 adult TBI patients were enrolled at eight University Hospitals. Based on the list of enrolled patients, the medical records of the patients were reviewed and they were registered online at each hospital. The registered patients were classified into three groups according to the Glasgow coma scale (GCS) score: mild (13-15), moderate (9-12), and severe (3-8), and the differences between men and women in each group were investigated. The risk factors of moderated and severe TBI compared to mild TBI were also investigated.@*RESULTS@#The study included 3075 men and 1393 women and the proportion of total males was 68.8%. Among all the TBI patients, there were significant differences between men and women in age, past history, and GCS score. While the mild and severe TBI groups showed significant differences in age, past history, and clinical symptoms, the moderate TBI group showed significant differences in age, past history, cause of justice, and diagnosis.@*CONCLUSION@#To the best of our knowledge, this multicenter study is the first to focus on gender differences of adult patients with TBI in Korea. This study shows significant differences between men and women in many aspects of adult TBI. Therefore, gender differences should be strongly considered in TBI studies.

Outcomes of Cranioplasty Using Autologous Bone or 3D-Customized Titanium Mesh Following Decompressive Craniectomy for Traumatic Brain Injury: Differences in Complications

PURPOSE@#Cranioplasty (CP) is often required for survival after decompressive craniectomy. Several materials, including autologous bone and various artificial materials, have been introduced for CP, but it remains unclear which material is best for CP. This study aimed to explore differences in complications between patients who underwent CP using an autologous bone flap versus a three-dimensional (3D) titanium mesh and to identify significant risk factors for post-CP complications.@*METHODS@#In total, 44 patients were enrolled in this study and divided into two groups (autologous bone vs. 3D titanium mesh). In both groups, various post-CP complications were evaluated. Through a comparative analysis, we aimed to identify differences in complications between the two groups and, using binary logistic analysis, to determine significant factors associated with complications after CP.@*RESULTS@#In the autologous bone flap group, there were three cases of surgical infection (3/24, 12.5%) and 11 cases of bone flap resorption (BFR) (11/24, 45.83%). In the 3D titanium mesh group, there was only one case of surgical infection (1/20, 5%) and 11 cases of various complications, including mainly cosmetic issues (11/20, 55%). A subgroup risk factor analysis of CP with an autologous bone f lap showed no risk factors that predicted BFR with statistical significance, although a marginal association was found between larger bone flaps and BFR (odds ratio [OR]=1.037, p=0.090). In patients treated with a 3D titanium mesh, multivariate analysis revealed that only the existence of a ventriculo-peritoneal shunt system was strongly associated with overall post-CP complications (OR=18.66, p=0.021).@*CONCLUSIONS@#Depending on which material was used, different complications couldoccur, and the rate of complications was relatively high in both groups. Hence, thematerial selected for CP should be selected based on individual patients' conditions.

Progression of Ossification of the Posterior Longitudinal Ligament after Cervical Total Disc Replacement / 대한신경손상학회지

OBJECTIVE: Total disc replacement (TDR) is frequently performed anterior approaching method for the patients diagnosed with cervical disc herniation. This study aimed to assess the degree of ossification of the posterior longitudinal ligament (OPLL) progression after cervical TDR. METHODS: Twenty-two male soldiers who underwent cervical TDR surgery from 2009 to 2016 and were followed-up for more than 12 months were enrolled. The enrolled patients were classified as; 1) patients with pre-existing OPLL and without; and 2) patient showing progression of OPLL or not. RESULTS: Twenty-two men were included in the analysis. The mean follow-up period from the surgery was 41.4 months (range, 12–114 months). The mean age of all patients was 40.7 years (range, 31–52 years). TDR-only was used in 7 cases, and the hybrid surgery (TDR+ACDF) was used in 15 cases. The incidence of progression or newly development of OPLL was significantly higher in pre-existing OPLL group (p=0.01). In 11 cases showing the progression of the OPLL, the mean size of OPLL progression was 4.16 mm (range, 0.34–18.87 mm) in the longitudinal height and 1.57 mm (range, 0.54–3.91 mm) in thickness. CONCLUSION: The progression of OPLL after cervical TDR was more frequent in patients with pre-existing OPLL than in patients without OPLL. Even though TDR is a major alternative to the treatment of cervical lesions to preserve vertebral segmental motion, careful attention should be paid to whether TDR should be used in patients with OPLL and this should be fully explained to the patient.

How to Escape Stentriever Wedging in an Open-cell Carotid Stent during Mechanical Thrombectomy for Tandem Cervical Internal Carotid Artery and Middle Cerebral Artery Occlusion

We present 2 cases of complicated mechanical thrombectomy involving tandem cervical internal carotid artery and middle cerebral artery occlusion using the Solitaire FR stent and simultaneous carotid stent angioplasty. During the procedures, the Solitaire stents containing the thrombus were wedged into the open-cell carotid stents, which were already deployed for proximal flow restoration. We describe the methods used to avoid and overcome such complications.

The Relationship between Neck Pain and Cervical Alignment in Young Female Nursing Staff

OBJECTIVE: Degenerative changes in the cervical spine are commonly accompanied by cervical kyphosis which can cause neck pain. This study examined the relationship between neck pain and cervical alignment. METHODS: A total of 323 female nursing staff from our hospital were enrolled. Sagittal radiographs of the cervical spine, Body Mass Index (BMI), Visual Analogue Scale (VAS) measures of neck and arm pain, Neck Disability Index (NDI) and the Short Form (36) Health Survey (SF-36 scores) were obtained and reviewed retrospectively. Global lordosis (GL) of the cervical spine was measured on radiograph images. Correlations between GL and questionnaire scores were investigated using the following three methods : 1) correlation between GL and questionnaire scores among the entire sample; 2) subgroup analysis of patients with "kyphosis (KYP) : GL scores0" on questionnaire measures; and 3) subgroup analysis of patients with pain vs. those without pain, on GL and questionnaire measures. RESULTS: There was no significant correlation between GL and any questionnaire measure. There was a significant difference between the mean GLs of the KYP and LOR groups, but there were no group differences in BMI, age or any questionnaire measures. There was no difference between the pain (n=92) and pain-free (n=231) groups in age, BMI or GL, but there were differences in neck, and arm pain, and physical function and NDI scores. CONCLUSIONS: Our data suggest that kyphotic deformity was not associated with neck pain.