Clinical Outcomes of Coil Embolization for Unruptured Intracranial Aneurysms Categorized by Region and Hospital Size : A Nationwide Cohort Study in Korea

Objective@#: To analyze the outcomes of coil embolization (CE) for unruptured intracranial aneurysm (UIA) according to region and hospital size based on National Health Insurance Service data in South Korea. @*Methods@#: The incidence of complications, including intracranial hemorrhage (ICRH) and cerebral infarction (CI), occurring within 3 months and the 1-year mortality rates in UIA patients who underwent CE in 2018 were analyzed. Hospitals were classified as tertiary referral general hospitals (TRGHs), general hospitals (GHs) or semigeneral hospitals (sGHs) according to their size, and the administrative districts of South Korea were divided into 15 regions. @*Results@#: In 2018, 8425 (TRGHs, 4438; GHs, 3617; sGHs, 370) CEs were performed for UIAs. Complications occurred in 5.69% of patients seen at TRGHs, 13.48% at GHs, and 20.45% at sGHs. The complication rate in TRGHs was significantly lower than that in GHs (p=0.039) or sGHs (p=0.005), and that in GHs was significantly lower than that in sGHs (p=0.030). The mortality rates in TRGHs, GHs, and sGHs were 0.81%, 2.16%, and 3.92%, respectively, with no significant difference. Despite no significant difference in the mortality rates, the complication rate significantly increased as the number of CE procedures per hospital decreased (p=0.001; rho=-0.635). Among the hospitals where more than 30 CEs were performed for UIAs, the incidence of CIs (p=0.096, rho=-0.205) and the mortality rates (3 months, p=0.048, rho=-0.243; 1 year, p=0.009, rho=-0.315) significantly decreased as the number of CEs that were performed increased and no significant difference in the incidence of post-CE ICRH was observed. @*Conclusion@#: The complication rate in patients who underwent CE for UIA increased as the hospital size and physicians’ experience in conducting CEs decreased. We recommend nationwide quality control policies CEs for UIAs.

Difference of Diagnostic Rates and Analytical Methods in the Test Positions of Vestibular Evoked Myogenic Potentials

OBJECTIVE: To compare the differences of diagnostic rates, of the two widely used test positions, in measuring vestibular evoked myogenic potentials (VEMP) and selecting the most appropriate analytical method for diagnostic criteria for the patients with vertigo. METHODS: Thirty-two patients with vertigo were tested in two comparative testing positions: turning the head to the opposite side of the evaluating side and bowing while in seated position, and bowing while in supine positions. Abnormalities were determined by prolonged latency of p13 or n23, shortening of the interpeak latency, and absence of VEMP formation. RESULTS: Using the three criteria above for determining abnormalities, both the seated and supine positions showed no significant differences in diagnostic rates, however, the concordance correlation of the two positions was low. When using only the prolonged latency of p13 or n23 in the two positions, diagnostic rates were not significantly different and their concordance correlation was high. On the other hand, using only the shortened interpeak latency in both positions showed no significant difference of diagnostic rates, and the degree of agreement between two positions was low. CONCLUSION: Bowing while in seated position with the head turned in the opposite direction to the area being evaluated is found to be the best VEMP test position due to the consistent level of sternocleidomastoid muscle tension and the high level of compliance. Also, among other diagnostic analysis methods, using prolonged latency of p13 or n23 as the criterion is found to be the most appropriate method of analysis for the VEMP test.

Difference of Diagnostic Rates and Analytical Methods in the Test Positions of Vestibular Evoked Myogenic Potentials

OBJECTIVE: To compare the differences of diagnostic rates, of the two widely used test positions, in measuring vestibular evoked myogenic potentials (VEMP) and selecting the most appropriate analytical method for diagnostic criteria for the patients with vertigo. METHODS: Thirty-two patients with vertigo were tested in two comparative testing positions: turning the head to the opposite side of the evaluating side and bowing while in seated position, and bowing while in supine positions. Abnormalities were determined by prolonged latency of p13 or n23, shortening of the interpeak latency, and absence of VEMP formation. RESULTS: Using the three criteria above for determining abnormalities, both the seated and supine positions showed no significant differences in diagnostic rates, however, the concordance correlation of the two positions was low. When using only the prolonged latency of p13 or n23 in the two positions, diagnostic rates were not significantly different and their concordance correlation was high. On the other hand, using only the shortened interpeak latency in both positions showed no significant difference of diagnostic rates, and the degree of agreement between two positions was low. CONCLUSION: Bowing while in seated position with the head turned in the opposite direction to the area being evaluated is found to be the best VEMP test position due to the consistent level of sternocleidomastoid muscle tension and the high level of compliance. Also, among other diagnostic analysis methods, using prolonged latency of p13 or n23 as the criterion is found to be the most appropriate method of analysis for the VEMP test.

Cutoff Value of Pharyngeal Residue in Prognosis Prediction After Neuromuscular Electrical Stimulation Therapy for Dysphagia in Subacute Stroke Patients

OBJECTIVE: To determine the cutoff value of the pharyngeal residue for predicting reduction of aspiration, by measuring the residue of valleculae and pyriformis sinuses through videofluoroscopic swallowing studies (VFSS) after treatment with neuromuscular electrical stimulator (VitalStim) in stroke patients with dysphagia. METHODS: VFSS was conducted on first-time stroke patients before and after the VitalStim therapy. The results were analyzed for comparison of the pharyngeal residue in the improved group and the non-improved group. RESULTS: A total of 59 patients concluded the test, in which 42 patients improved well enough to change the dietary methods while 17 did not improve sufficiently. Remnant area to total area (R/T) ratios of the valleculae before treatment in the improved group were 0.120, 0.177, and 0.101 for solid, soft, and liquid foods, respectively, whereas the ratios for the non-improved group were 0.365, 0.396, and 0.281, respectively. The ratios of the pyriformis sinuses were 0.126, 0.159, and 0.121 for the improved group and 0.315, 0.338, and 0.244 for the non-improved group. The R/T ratios of valleculae and pyriformis sinus were significantly lower in the improved group than the non-improved group in all food types before treatment. The R/T ratio cutoff values were 0.267, 0.250, and 0.185 at valleculae and 0.228, 0.218, and 0.185 at pyriformis sinuses. CONCLUSION: In dysphagia after stroke, less pharyngeal residue before treatment serves as a factor for predicting greater improvement after VitalStim treatment.

VATER Syndrome: A Case Report

VATER syndrome is defined as the combinations of three or more of the followings; Vertebral defect, Anal atresia, Esophageal atresia and/or Tracheo-Esophageal fistula, Renal dysplasia, and Radial-ray limb anomalies. A 21-month old female patient was admitted. She had the history of anastomosis of trcheo-esophageal fistula, V-P shunt operation due to hydrocephalus, and spina bifida. Upon admission, physical examinations showed increased deep tendon reflexes of all four extremities with grade 1 spasticity and popliteal angle being 45 degrees, bilaterally. The overall development of the patient was delayed. The imaging study showed hydrocephalus, periventricular leukomalatic change, underdevelopment of the cerebral cortex, atrophy of corpus callosum, Arnold-Chiary malformation, a vascular malformation along the intradural space from lower cervical to nearly entire thoracic vertebral level, multiple vertebral anomalies, and the fusion of multiple ribs. Furthermore hydronephrosis of the left kidney was detected. Follow-up of natural history and management of the patient is needed.

Parkinson's Syndrome Caused by Organophosphate Intoxication: A case report

Organophosphate intoxication causing the extrapyramidal symptom is not frequent. A case of Parkinson's syndrome caused by organophosphate intoxication was observed, of which is reported with the quantitative measurement of tremor using Tri-axial accelerometry. A fifty nine year-old male was admitted to Wonju Christian Hospital after the intake of organophosphate for the purpose of suicide and three days after the accident, involuntary movements were detected. The encephalography and MRI showed no abnormality. With Tri-axial accelerometry, we detected less than 4 Hz resting tremor. The tremor did not response to L-dopa, and in the follow up examination performed 149 days after the accident, an increase in amplitude was detected. Gait disturbance and dysarticulation became more severe. In a case of the organophosphate intoxication patient, very rare Parkinson's syndrome findings were detected, and the tremor during the resting period was measured quantitatively by electromyography and Tri-axial accelerometry.

Correlation between VEMP (Vestibular Evoked Myogenic Potentials) and Vestibular Ratio of Posturography in Patients with Vertigo

OBJECTIVE: To find out whether there is correlation between result of VEMP and vestibular ratio of posturography, and also to investigate if VEMP can show diagnostic efficiency in patients with vertigo. METHOD: Thirty-two patients whose BAEP test showed normal latency were included after patients whose somatosensory ratio and visual ratio from posturography showed abnormality were excluded. Ten healthy participants were set up as control group. We made comparison between P13 latency in VEMP and vestibular ratio posturography among these participants. RESULTS: Among the participants 47% showed normal P13 latency, and 53% showed abnormal P13 latency. In normal P13 latency group, 86.7% of patients showed normal vestibular ratio, and in abnormal P13 latency group, 70.6% of patients showed abnormal vestibular ratio. CONCLUSION: VEMP showed high correlation between vestibular ratio of posturography. VEMP can be used in screening test and clinically complementary diagnostic method of vestibular function test for patients with vertigo.

Noninvasive Reduction of Fractures of Pubis and Separation of Symphysis Pubis by Circumferential Pelvic Belt: A case report

Early reduction and stabilization of the pelvic bone after traumatic unstable pelvic bone fracture is the most effective method to control life-threatening bleeding and reduce late complication. In this study, we compared the effect of the non-invasive pelvic belt on various positions, and studied the effects of weight bearing and shifting during walking on pelvic belt position. Case 1) separation of symphysis pubis; Case 2) fracture of the superior and inferior ramus of the right pubis; Case 3) fractures of the superior and inferior ramus of both pubis and separation of symphysis pubis. Pelvic belt was prescribed in all three cases. Pelvic belt reduction reduced the distance between fracture line by 40~60% at all levels. Therefore, pelvic belt reduction is recommended as a non-invasive, safe and effective rehabilitative treatment for pelvic bone fracture patients to restore function without pain or secondary injury.

The Comparison of Hallux Valgus Angles between Plain Radiography and Footprint Test

OBJECTIVE: To find out whether the footprint test was significant as a screening test in hallux valgus (HV) patients. METHOD: The standing AP radiography and the static footprint were performed on 26 general patients, 52 feet total, ranging in age from 15~70 years. As markers of the footprint test, the angles that we want to measure were designated as H and H' angles. RESULTS: The HV angle on plain radiography correlated significantly to the H angle of the footprint test (r=0.75), and presented as HV angle=1.012H+2.723. The HV angle on plain radiography inversely correlated significantly to the H' angle (r=-0.56) and presented as HV angle=-0.731H' +90.953. CONCLUSION: The footprint test could be used as a screening test for hallux valgus prior to plain radiography. HV angle in standing AP radiograph could be predicted by measuring the H and H' angle on the static footprint. Supplement studies on variable factors such as age, gender, etc. are required for further study.

Rehabilitation for Ambulation of Triple Amputee: A case report

Triple amputee is an uncommon impairment and has been rarely reported. We reported a case of success in independent bipedal ambulation of a triple amputee with bilateral lower limb prostheses. We selected a thirty five-year-old male who underwent a left shoulder disarticulation and a left very short transfemoral amputation and a right transfemoral amputation due to trauma. After program of gait training for eight weeks, he could walk independently, donning right hip disarticulation prosthesis and left transfemoral prosthesis and left shoulder disarticulation prosthesis with right Lofstrand forearm orthosis. We measured the amountof oxygen consumption of the patient before and after rehabilitation program done, of which all parameters including oxygen consumption were more improved than before that program. The patient preferred to walk by himself and got a feeling of full achievement. Nevertheless higher energy consumption, young active triple amputees need fitting prostheses with intensive rehabilitation training program for bipedal ambulation to prevent deterioration of physical function and mental health due to immobilization.

Two Cases of Xp21 Contiguous Gene Deletion Syndrome

On chromosome Xp21 region, several genes such as glycerol kinase (GK) gene, adrenal hypoplasia congenita gene and Duchenne muscular dystrophy gene are located contiguously. Xp21 contiguous gene deletion syndrome involves the glycerol kinase gene deletion together with the adrenal hypoplasia congenita and/or Duchenne muscular dystrophy gene. The clinical features of a patient with a Xp21 contiguous gene deletion syndrome are sum of each disease,psychomotor retardation and lethargy for glycerol kinase deficiency, hyperpigmentation and salt wasting dehydration for congenital adrenal hypoplasia and muscular weakness and hypotonia for Duchenne muscular dystrophy. We experienced and reviewed two cases of Xp21 contiguous gene deletion syndrome with literatures.

The Change of Skin Temperature after Thoracic Sympathectomy in Patients with Palmar Hyperhidrosis

OBJECTIVE: The purposes of this study were to evaluate the change of temperature before and after thoracic sympathectomy in patients with palmar hyperhidrosis and to find the usefulness of infrared thermography for the assessment of effects of thoracic sympathectomy. METHOD: The skin temperature was measured before, one day and 30 days after sympathectomy in 28 patients with palmar hyperhidrosis. Temperature was recorded on forehead, cheek, neck, axilla, umbilicus and 6 sites of each hand and foot by infrared thermography and thermometer. Patient's satisfaction with operation was assessed by 10 point scale. RESULTS: All patient who had undergone sympathectomy showed significantly decreased discomfort owing to hyperhidrosis by 10 point scale (p<0.05). The temperature significantly elevated on postoperative 1 day and 30 days on both palms as compared with preoperative state, bilaterally (p<0.05). There were no significant differences of sole temperatures among preoperative, postoperative 1 day and postoperative 30 days, bilaterally. CONCLUSION: We proved significant effect of thoracic sympathectomy to the patients with palmar hyperhidrosis objectively, and we also quantified the elevation of palm temperature after sympathectomy.

Surface Anatomical Landmark and Optimal Insertion Angle in Cervical Epidural Block

OBJECTIVE: The aim of this study is to evaluate the surface anatomical landmark for the cervical epidural block by investigating the proportion of patient's prominence in the 7th cervical vertebra. And the most optimal insertion angle over the mid point between the 6th and the 7th cervical spinous process is also measured. METHOD: Patients who did a plane x-ray examination of cervical spine were selected. We performed plane x-ray after marking on cervical vertebra prominence that was assumed as the spinous process of the 7th cervical vertebra by inspection and palpation. We identified where the marker were located on the spinous process. Moreover, we measured optimal insertion angle in the plane x-ray of cervical spine lateral. RESULTS: A total 100 cases were identified. The vertebra prominence was on the 7th cervical vertebra in 62 cases and the 6th cervical vertebra in 29 cases. The 1st thoracic vertebra was in the 2 cases and the 6th and 7th cervical vertebra in the 7 cases. CONCLUSION: The vertebra prominence was identified as the spinous process of the 7th cervical vertebra in sixty two percent of the cases. And the most optimal insertion angle is a -25.28 degree angle from the perpendicular line of the skin.

Three Newly Designed Arm Slings for the Stroke Patient with Shoulder Subluxation: A case report

We reported three types of newly designed arm slings (the "V" strap pouch arm sling, the Modified hemisling, the Tripod arm sling). The three slings and the conventional hemisling were all tested by a single stroke patient for the correction of shoulder subluxation. Sling effectiveness was evaluated by simple shoulder AP X-rays, quantitative electromyography (root mean square; RMS), strap tension, and preference of the patient. Of the four types, the "V" strap pouch arm sling reduced the vertical displacement the most. RMS values of the supraspinatus muscle tended decrease and strap tension was also lower after using the "V" strap pouch arm sling compared with others. The patient also preferred the "V" strap pouch arm sling to the other slings. We suggested that "V" strap pouch arm sling was the most effective among four types of arm slings (including conventional hemisling) for the correction of shoulder subluxation, and patient's preference.

The Effect of the Suspension, Electrical Stimulation and Treadmill Training in the Hindlimb Muscle of the Rats

OBJECTIVE: The purposes of this study were to investigate the effect of suspension, the electrical stimulation and full weight bearing treadmill training on the muscle atrophy and transformation of muscle fibers. METHOD: Forty Spraque-Dawley rats were divided into control and 3 intervention groups: suspension control (n= 10), suspension with weight bearing treadmill (n=10), and suspension with electrical stimulation (n=10). After 4 weeks intervention, both gastrocnemius and soleus were dissected and the muscle weight and transformation of muscle fibers were analyzed. RESULTS: In suspension control and suspension electrical stimulation groups, muscle to body weight ratio of gastro-cnemius was decreased compared to control group (p<0.05). In all intervention groups, muscle to body weight ratio of soleus was decreased compared to control group (p<0.05). In suspension electrical stimulation group, type I muscle fiber ratio of gastrocnemius was increased compared to control and suspension control groups (p<0.05). In suspension electrical stimulation group, type IIa muscle fiber ratio of gastrocnemius was increased compared to suspension control group (p<0.05). CONCLUSION: It is suggested that muscle atrophy induced by disuse and transformation of muscle fiber can be prevented by electrical stimulation intervention.

Complex Regional Pain Syndrome after Wedge Resection of Apex of Lung / 대한흉부외과학회지

Complex regional pain syndrome is pain disorder which is characterized by aching pain, marked painful sensation, hypothermesthesia, vasomotor dysfunction, hyperhidrosis, impairment of motor function, trophic changes of distal part of not-operated extremity after trauma and operation. Pain produce increased sensitivity to catecholamine and diagnosed by infra red thermography and Treatment consists of pain relief and rehabilitational therapy for functional restoration of affected limb. We experienced a case of complex regional pain syndrome in a 16-year-old man after wedge resection of pulmonary apex for bullae and report this case with a review of the literature.

Effects of Therapeutic Electrical Stimulation of Sensory Dermatome on Spasticity in Patients with Brain Lesion

OBJECTIVE: The purpose of this study was to investigate the immediate and delayed effects of electrical stimulation of sensory nerve pathway on spasticity in patients with brain lesions. METHOD: Sixteen stroke and traumatic brain injured subjects participated in this study. Electrical stimulation on the der matome of spastic muscles was applied for 30 minutes a day for 4 weeks. Spasticity was quantified through the use of a relaxation index obtained from pendulum test and a amplitude and latency from knee tendon reflex test. The measurements were performed 6 times in treatment period. The data were analyzed by repeated measures one way ANOVA. RESULTS: Relaxation index was significantly increased in treatment period (p<0.05). In each therapeutic stimulation session, relaxation index of post-stimulation was increased in comparison with that of pre-stimulation (p<0.01). The amplitude of post-stimulation was significantly decreased in comparison with pre-stimulation status in each measurement session (p<0.01). The latency of tendon reflex was not changed after stimulation. CONCLUSION: These results showed that the electrical stimulation was useful method to decrease spasticity in patients with brain lesions. Further studies are needed to explore the effects of functional improvement and the long-lasting carry over effects on spasticity in electrical stimulation.

A Case of Pharyngoesophageal Diverticulum (Zenker's Diverticulum) Following Anterior Cervical Spine Screw or Plate Fixation / 대한소화기내시경학회지

As a complication following anterior cervical spine screw or plate fixation, a pharyngoesophageal diverticulum (Zenker's diverticulum) is rare in comparison with iatrogenic esophageal perforation or tracheo-esophageal fistula. Esophageal perforation or fistula usually develop abrupt and severe symptoms such as fever, dyspnea, coughing or swelling on the cervical area. However. there is no definite symptoms except mild and chronic dysphagia in case of pharyngoesophageal diverticulum. Therefore, it is very likely that the diagnosis will be delayed and serious complication will be occurred. We report a case of 58-year-old spinal cord injured man with a Zenker's diverticulum following anterior cervical plate fixation.

The Changes of Skin Temperature and Sympathetic Skin Response after Thoracic Sympathectomy in Patients with Palmar Hyperhidrosis

OBJECTIVE: The purposes of these study were to evaluate the changes of temperature and sympathetic skin response (SSR) before and after sympathectomy in patients with palmar hyperhidrosis and to quantify long standing effect of sympathectomy. METHOD: The SSR and skin temperature were measured before, one day and 30 days after thoracoscopic sympathectomy. SSR was recorded from palm and sole bilaterally. Temperature was recorded on 9 sites of each hand and 11 site of each sole. Patient's satisfaction with operation was assessed by 10-point scale. RESULTS: One day after sympathectomy, the amplitude of SSR was significantly decreased and latency of SSR was delayed in all cases on bilateral palm and sole. However, after sympathectomy 30 days, the amplitude of SSR was normalized in all cases on bilateral sole. All patients who had undergone sympathectomy showed significant clinical improvement. The temperature increased dramatically over 3degrees C on postoperation 1 day and maintained 1.72degrees C higher in post-operation 30 days than pre-operation on both hands. There was no significant difference of temperature among pre-operation and post-operation 1 day and post-operation 30 days on sole. CONCLUSION: Our study proved effect of thoracoscopic sympathectomy to the patients with palmar hyperhidrosis objectively and quantified the decrement of sympathetic tone. Further study is needed for long term follow up over 2 months or more.

Endovascualr Treatment for Traumatic Giant Pseudoaneurysm of Internal Carotid Artery

Traumatic pseudoaneurysms of the cavernous portion of the internal carotid artery(ICA) presenting with epistaxis are uncommon and potentially lethal complication of head injury. Because the onset of delayed bleeding from the time of injury is variable, prompt diagnosis and treatment of cavernous ICA pseudoaneurysm is important. A patient with a giant traumatic pseudoaneurysm of the left ICA presented with massive epistaxis 5 months after a head trauma. This patient was treated with occlusion of the opening of pseudoaneurysm and ICA by a detachable balloon and fibered coils.