Comparison of the Clinical Effectiveness Between Infrared Thermography and Electrophysiology Tests in Spinal Intradural Extramedullary Schwannoma / 대한신경손상학회지

Objective@#Subjective pain is experienced differently by each patient; therefore, modalities that can objectify subjective symptoms are useful. Electrophysiology tests and infrared (IR) thermography can present subjective symptoms in an objective manner. This study aimed to compare the effectiveness of electrophysiology tests and IR thermography in patients with intradural extramedullary (IDEM) schwannoma and statistically analyze the results to verify the positive relationship between the subjective neurologic symptoms and test results. @*Methods@#We retrospectively analyzed the data from 23 patients, pathologically confirmed to have IDEM spinal schwannoma after surgery between January 2012 and December 2020. All patients were preoperatively examined using IR thermography and an electrophysiology test. IR thermography was conducted again week after operation. The IR thermography results were classified as either positive or negative. @*Results@#Radiculopathy symptoms were reported in 16 cases and myelopathy in 7 cases. Among the radiculopathy patients, 9 out of 16 (56.2%) showed positive electrophysiology test results. Among the myelopathy patients, 2 out of 7 (28.5%) showed positive electrophysiology test results. In the radiculopathy group, 15 out of 16 (93.7%) patients showed positive IR thermography results. In the myelopathy group, 2 out of 7 (28.5%) patients showed positive IR thermography results. The correlation between the IR thermography and electrophysiology test was analyzed. In the radiculopathy group, positive electrophysiology test result was obtained in 8 out of 15 (53.5%) patients with positive IR thermography result. @*Conclusion@#In patients with IDEM schwannoma presenting radiculopathy symptoms, IR thermography is a complementary tool to objectify the neurological symptoms.

Delayed Multiple Intracerebral Hemorrhage After Burr Hole Drainage of Chronic Subdural Hematoma During Failure of Warfarin Resumption in Atrial Fibrillation / 대한신경손상학회지

Many elderly people take warfarin due to underlying disease. Warfarin is a risk factor for developing chronic subdural hematomas and other intracranial hematomas. Our patient was on chronic warfarin treatment for longstanding atrial fibrillation and underwent burr hole trephination due to chronic subdural hematoma. Multiple intracerebral hemorrhages developed 7 days after surgery without resumption of warfarin. Here, we report and review this rare case.

Vertebral Artery Dissecting Aneurysm Causing Central Tapia’s Syndrome: A Case Report / 신경중재치료의학

The central type of Tapia’s syndrome is an extremely rare presentation, characterized by unilateral paralysis of the vagal and hypoglossal nerves, contralateral hemiparesis, or hemihypesthesia. This report describes a case of a middle-aged patient who developed central Tapia’s syndrome due to a right vertebral artery dissecting aneurysm (VADA). The patient complained about swallowing difficulty and odynophagia. Right vocal cord paralysis, mild tongue deviation to the right side, left hypesthesia, and decreased temperature sensation with left hemiparesis were observed in neurologic exams. A right VADA and compression of the medulla oblongata due to the VADA were diagnosed on magnetic resonance imaging. Endovascular flow diversion of the right VADA was performed. After 1 year, all neurological symptoms and vocal cord paralysis were nearly resolved, but left hypesthesia remained with decreased nociception. We present and discuss how a VADA caused those symptoms and propose endovascular flow diversion as a treatment option.

Vertebral Artery Dissecting Aneurysm Causing Central Tapia’s Syndrome: A Case Report / 신경중재치료의학

The central type of Tapia’s syndrome is an extremely rare presentation, characterized by unilateral paralysis of the vagal and hypoglossal nerves, contralateral hemiparesis, or hemihypesthesia. This report describes a case of a middle-aged patient who developed central Tapia’s syndrome due to a right vertebral artery dissecting aneurysm (VADA). The patient complained about swallowing difficulty and odynophagia. Right vocal cord paralysis, mild tongue deviation to the right side, left hypesthesia, and decreased temperature sensation with left hemiparesis were observed in neurologic exams. A right VADA and compression of the medulla oblongata due to the VADA were diagnosed on magnetic resonance imaging. Endovascular flow diversion of the right VADA was performed. After 1 year, all neurological symptoms and vocal cord paralysis were nearly resolved, but left hypesthesia remained with decreased nociception. We present and discuss how a VADA caused those symptoms and propose endovascular flow diversion as a treatment option.

Cerebral Venous Thrombosis Caused by Spontaneous Intracranial Hypotension: A Case Report / 대한신경손상학회지

This case report presents a rare case of cerebral venous thrombosis (CVT) caused by spontaneous intracranial hypotension (SIH). The cause and prognosis of CVT can vary;CVT caused by SIH is uncommon and difficult to diagnose and treat. In this case, magnetic resonance imaging myelography showed definite cerebrospinal fluid leakage, and the patient's symptoms did not improve after conventional treatment. Furthermore, subdural hematoma occurred, causing mental deterioration; however, it improved dramatically after the blood patch procedure and burr hole drainage, which was performed after early cessation of anticoagulant therapy.

Desmoid Fibromatosis in the Multifidus Muscle Misdiagnosed as Intramuscular Schwannoma by Incisional Biopsy: A Case Report / 대한신경손상학회지

Desmoid fibromatosis is a locally aggressive myofibroblastic neoplasm. In this study, we report a case of desmoid fibromatosis in the paraspinal muscle that was misdiagnosed as intramuscular schwannoma through incisional biopsy at another hospital. We performed total excision of the mass lesion with a clear margin. We found that for an accurate diagnosis, magnetic resonance imaging, incisional biopsy and excisional biopsy were required.

Microsurgical treatment for the recurrent cerebral aneurysm initially treated using coil embolization

Objective@#Microsurgical treatment could be a good alternative for the treatment of recurrent cerebral aneurysm after coil embolization. The purpose of this study was to present our experience of microsurgical treatment for recurrent cerebral aneurysm previously treated using coil embolization. @*Methods@#From June 2012 to May 2019, 34 patients consecutively received microsurgical treatment for a recurrent cerebral aneurysm previously treated using coil embolization after it ruptured. @*Results@#Of the 34 patients with aneurysm, 33 had the aneurysm located in the anterior circulation. The most common location was the anterior communicating artery (13 cases). Immediate radiologic outcome at coil embolization was completed (n=6), residual neck (n=26), and residual sac (n=2). The reason for microsurgical treatment included rebleeding (n=12), persistent residual sac (n=1), and recurrence on follow-up study (n=21). Rebleeding occurred within 10 days after coil embolization in 10 cases, and the other 2 were due to regrowth. In the 20 recurred and saccular aneurysms, coil compaction was present in 11 aneurysms and regrowth in 9 aneurysms. Simple neck clipping (n=29) and clipping with coil mass extraction (n=3) was possible in the saccular aneurysms. The blood blister like aneurysm (n=2) were treated using bypass and endovascular internal carotid artery trapping. In the follow-up study group after microsurgical treatment there were no severe complications due to the treatment. Age, cause of retreatment, and modified Rankin Scale before microsurgery were associated with good outcome (p<0.001). @*Conclusions@#Microsurgical treatment may be a viable and effective option for treating recurrent aneurysms previously treated by endovascular techniques.

Acute Quadriplegia after Lumbar Puncture in a Patient with Misdiagnosed Cervical Myelopathy / 대한신경손상학회지

The incidence of quadriplegia following drainage of cerebrospinal fluid by lumbar puncture (LP) below a spinal occupying lesion is rare. We report a case of acute quadriplegia following LP for presumed normal pressure hydrocephalus (NPH) in a 66-year-old man. Acute cervical myelopathy with a herniated cervical disc was subsequently found on magnetic resonance imaging (MRI) at the C5–6 level. After posterior decompression and anterior cervical discectomy and fusion at the C5–6 level with a cervical plate, the patient's motor and sensory functions recovered. Clinicians should be aware that symptoms of NPH and cervical myelopathy may overlap, and that serious complications may occur when performing LP below a spinal lesion. As a safety measure, cervical spine MRI should be performed before LP.

Swallowing Difficulty in Diffuse Idiopathic Skeletal Hyperostosis with Metabolic Syndrome / 대한신경손상학회지

Diffuse idiopathic skeletal hyperostosis (DISH) is a disease of unknown etiology developing following ossification of the antero-lateral ligaments of the spine. Mostly, prevailing elderly adult males, it is an uncommon cause of dysphagia and dysphonia. We report three cases of DISH with metabolic syndrome. They were complained of neck movement restriction and dysphagia. At first, They all visited ear, nose, and throat outpatient department. The initial impression was gastroesophageal reflux, and an endoscopy excluded esophageal lesion.Cervical spine radiologic imaging revealed ossification of the cervical anterior longitudinal ligament with large, conspicuous osteophytes from cervical spine lesion, producing compression of pharyngoesophagus and upper airway; these images corresponded to DISH. Cervical osteophyte surgical removal resulted in a complete alleviation from dysphagia for the patient. DISH should be considered in the differential diagnosis of dysphagia.

Burr Hole Drainage versus Small Craniotomy of Chronic Subdural Hematomas / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma drainage is one of the most common procedures performed in neurosurgical practice. Not only burr hole drainage but also small craniotomy (diameter 3–5 cm) is frequently used neurosurgical treatment of chronic subdural hematomas. We assessed to compare the postoperative recurrence rates between burr hole drainage versus small craniotomy with closed-system drainage for chronic subdural hematomas. METHODS: From January 2016 to December 2018, 75 patients who were treated with burr hole drainage and small craniotomy with closed system drainage for the symptomatic chronic subdural hematoma were enrolled. Pre and postoperative computed tomography (CT) were used for radiologic evaluation. The choice of procedure was decided by preoperative CT images. RESULTS: 60 patients out of 75 patients underwent burr hole drainage, whereas 15 patients underwent small craniotomy. The overall postoperative recurrence rate was 16%. The recurrence occurred in 8 patients out of 60 patients in burr hole drainage group (13.3%) and 7 patients out of 15 patients in small craniotomy group (46.7%). The number of days of hospitalization was 10.3 days in burr hole drainage group and 15.7 days in small craniotomy group. CONCLUSION: Burr hole drainage would be sufficient to evacuate chronic subdural hematoma with lower recurrence rate, but small craniotomy was also needed in some cases such as hematoma has solid portion or multiple septum.

Trigeminal Neuralgia Resulting from Delayed Cervical Cord Compression after Acute Traumatic Fracture of Odontoid Process / 대한신경손상학회지

Trigeminal neuralgia is caused by compression of trigeminal nerve root and it leads to demyelination gradually. It was almost idiopathic and occurred unexpected. The upper cervical spinal cord contains the spinal trigeminal tract and nucleus. Fibers with cell bodies in the trigeminal ganglion enter in the upper pons and descend caudally to C2 level. We experienced a rare patient with facial pain, which was paroxysmal attack with severe pain after a clear event, cervical spinal injury (C2). So, this case reminds us of a possible cause of trigeminal neuralgia after a trauma of the head and neck.

Cervicothoracic Junction Approach using Modified Anterior Approach: J-type Manubriotomy and Low Cervical Incision / 대한신경손상학회지

Spinal surgery of the anterior aspect of the cervicothoracic junction is difficult and has technological challenges because of the kyphotic alignment of the upper thoracic spine. This approach requires knowledge of the cervicothoracic regional anatomy. Surgery in this region is rare because of its indications; despite this rarity, surgeons must be prepared to expose this region. In addition, surgery in this region demands extensive opening of the surgical field and results in severe postoperative pain. Therefore, a less invasive procedure must be considered. Six cases of cervicothoracic lesion operation have been reported. The patients were successfully treated using an anterior modified approach (J-type manubriotomy). Anterior reconstruction and instrumentation of the cervicothoracic junction offers a distinct advantage of a stable anterior implant bone construction while preserving the posterior osseo-ligamentous tension band. Moreover, the modified anterior approach (J-type manubriotomy) provides the same exposure of the cervicothoracic junction without a full median sternotomy and avoids injury to subclavian vessels during resection of the clavicle or sternoclavicular junction. Therefore, the anterior cervical approach combined with J-type manubriotomy allows extensive exposure of the cervicothoracic junction and causes less complications. We performed preoperative radiological evaluation to identify the cases in which J-type manubriotomy was necessary.

What Causes Severe Myelopathy Resulting in Acute Quadriplegia after a Surgery for Atlantoaxial Subluxation due to Os Odontoideum? A Case Report / 대한신경손상학회지

A case of acute quadriplegia resulting from reduction of atlantoaxial subluxation due to os odontoideum is rare. Patient with os odontoideum are at a greater risk for atlantoaxial instability and resultant spinal cord compression. In our case, the patient exhibited mild myelopathic symptoms before the onset of acute quadriplegia. Owing to the clinical presentations, the spinal cord not only seemed to suffer a mechanical compression but also an insufficiency of blood supply to the spinal artery and its branches. No other report has described the findings from magnetic resonance imaging before and after the onset of acute myelopathy after surgery. The aim of our case report is to highlight the pathophysiology and appropriate management strategy of a patient with severe progressive spinal cord myelopathy after surgery, secondary to chronic atlantoaxial subluxation due to os odontoideum. This case depicts the presence of this rare yet possible complication, and emphasizes the importance of preoperative evaluation in cases with chronic progressive myelopathy. Moreover, urgent postoperative treatment and rehabilitation are important for the recovery of neurological symptoms.

Advantages and disadvantages of the ENVOY 6F distal access guiding catheter in endovascular coiling for anterior circulation aneurysms

OBJECTIVE: Selecting an appropriate guiding catheter to provide both sufficient supportability for working devices and sufficient distal navigability is essential for ensuring the success of a procedure. This study aimed to evaluate the advantages and disadvantages of using the ENVOY 6F distal access (DA) guiding catheter in coil embolization of anterior circulation cerebral aneurysms.METHODS: We included 98 patients (72 [73.5%] women, median age: 63 [range: 25–84] years) who underwent endovascular coiling with the ENVOY 6F DA guiding catheter from May to November 2016. We analyzed data on patient demographics and the number of co-axial techniques to position the guiding catheter, initial and final location of the catheter, and complications related to the catheter.RESULTS: The co-axial technique was used to position the ENVOY 6F DA guiding catheter in the internal carotid artery (ICA) in 20 cases (20.41%). The initial position of the ENVOY 6F DA guiding catheter involved the cervical ICA (79.6%), horizontal petrous ICA (17.3%), and vertical petrous ICA (3.1%). Final control angiograms after endovascular coiling showed proximal change in the final, compared to the initial, position of the ENVOY 6F DA guiding catheter in 25 cases (25.51%). Procedure-related complications were observed in nine patients (9.18%), involving vasospasm in all cases; however, there was no symptomatic case.CONCLUSION: The ENVOY 6F DA guiding catheter had relatively sufficient distal navigability without symptomatic procedural complications. However, the change in the catheter position after endovascular coiling denoted insufficient supportability.

Stimulation in Supplementary Motor Area Versus Motor Cortex for Freezing of Gait in Parkinson's Disease

BACKGROUND AND PURPOSE: Freezing of gait (FOG) is a frustrating problem in Parkinson's disease (PD) for which there is no effective treatment. Our aim was to find brain stimulation areas showing greater responses for reducing FOG. METHODS: Twelve PD patients with FOG were selected for inclusion. We explored the therapeutic effect of repetitive transcranial magnetic stimulation (rTMS) in the supplementary motor area (SMA) and the motor cortex (MC). We measured the number of steps, completion time, and freezing episodes during the stand-walk-sit test before and after rTMS treatment. We also tested freezing episodes in two FOG-provoking tasks. RESULTS: There was a trend for a greater reduction in freezing episodes with SMA stimulation than MC stimulation (p=0.071). FOG was significantly improved after SMA stimulation (p < 0.05) but not after MC stimulation. CONCLUSIONS: Our study suggests that the SMA is a more-appropriate target for brain stimulation when treating PD patients with FOG. This study provides evidence that stimulating the SMA using rTMS is beneficial to FOG, which might be useful for future developments of therapeutic strategies.

Superficial Temporal Artery-Sparing Mini-Pterional Approach for Cerebral Aneurysm Surgery

OBJECTIVE: The purposes of this study were to introduce a superficial temporal artery (STA)-sparing mini-pterional approach for the treatment of cerebral aneurysms and review the surgical results of this approach. METHODS: Between June 2010 and December 2015, we performed the STA-sparing mini-pterional approach for 117 patients with 141 unruptured intracranial aneurysms. We analyzed demographic, radiologic, and clinical variables including age, sex, craniotomy size, aneurysm location, height of STA bifurcation, and postoperative complications. RESULTS: The mean age of patients was 58.4 years. The height of STA bifurcation from the superior border of the zygomatic arch was 20.5 mm±10.0 (standard deviation [SD]). The craniotomy size was 1051.6 mm²±206.5 (SD). Aneurysm neck clipping was possible in all cases. Intradural anterior clinoidectomy was performed in four cases. Contralateral approaches to aneurysms were adopted for four cases. Surgery-related complications occurred in two cases. Permanent morbidity occurred in one case. CONCLUSION: Our STA-sparing mini-pterional approach for surgical treatment of cerebral aneurysms is easy to learn and has the advantages of small incision, STA sparing, and a relatively wide surgical field. It may be a good alternative to the conventional pterional approach for treating cerebral aneurysms.

Thoracolumbar Paraspinal Myonecrosis after Aortic Dissection / 대한신경손상학회지

Thoracolumbar paraspinal myonecrosis can be developed with various etiologies. It can induce compartment syndrome of spinal muscles and cause elevated pressure on back muscles, resulting in severe back pain. Thoracolumbar paraspinal myonecrosis is a very rare disease. There are only a few studies about paraspinal myonecrosis. Here we report a case of a spontaneous thoracolumbar paraspinal myonecrosis in a patient who had asymptomatic abdominal aortic dissection. Through this case, etiologies, clinical features, radiologic findings, and treatment options for thoracolumbar paraspinal myonecrosis are discussed.

The Effectiveness of Infrared Thermography in Patients with Whiplash Injury

OBJECTIVE: This study aims to visualize the subjective symptoms before and after the treatment of whiplash injury using infrared (IR) thermography. METHODS: IR thermography was performed for 42 patients who were diagnosed with whiplash injury. There were 19 male and 23 female patients. The mean age was 43.12 years. Thermal differences (DeltaT) in the neck and shoulder and changes in the thermal differences (DeltadT) before and after treatment were analyzed. Pain after injury was evaluated using visual analogue scale (VAS) before and after treatment (DeltaVAS). The correlations between DeltadT and DeltaVAS results before and after the treatment were examined. We used Digital Infrared Thermal Imaging equipment of Dorex company for IR thermography. RESULTS: The skin temperature of the neck and shoulder immediately after injury showed 1-2degrees C hyperthermia than normal. After two weeks, the skin temperature was normal range. DeltaT after immediately injuy was higher than normal value, but it was gradually near the normal value after two weeks. DeltadT before and after treatment were statistically significant (p<0.05). VAS of the neck and shoulder significantly reduced after 2 week (p=0.001). Also, there was significant correlation between DeltadT and reduced DeltaVAS (the neck; r=0.412, p<0.007) (the shoulder; r=0.648, p<0.000). CONCLUSION: The skin temperature of sites with whiplash injury is immediately hyperthermia and gradually decreased after two weeks, finally it got close to normal temperature. These were highly correlated with reduced VAS. IR thermography can be a reliable tool to visualize the symptoms of whiplash injury and the effectiveness of treatment in clinical settings.

Predominant proximal upper extremity involvement in Hirayama disease

Hirayama disease usually selectively involves lower cervical myotomes (C8, T1). Thus, patients usually manifest with atrophy and weakness of small hand muscle. Predominant isolated involvement of proximal arm is rarely reported in Hirayama disease. Here, we report a case of Hirayama disease who had focal weakness and wasting, mainly confined to right biceps brachii muscle, with prominent shifting of dural sac in C4-5 segment by dynamic flexion magnetic resonance imaging (dfMRI), which may explain this unusual distribution of the disease.

Usefulness of Intraoperative Monitoring during Microsurgical Decompression of Cervicomedullary Compression Caused by an Anomalous Vertebral Artery

We report a case of cervicomedullary compression by an anomalous vertebral artery treated using microsurgical decompression with intraoperative monitoring. A 68-year-old woman presented with posterior neck pain and gait disturbance. MRI revealed multiple abnormalities, including an anomalous vertebral artery that compressed the spinal cord at the cervicomedullary junction. Suboccipital craniectomy with C1 laminectomy was performed. The spinal cord was found to be compressed by the vertebral arteries, which were retracted dorsolaterally. At that time, the somatosensory evoked potential (SSEP) changed. After release of the vertebral artery, the SSEP signal normalized instantly. The vertebral artery was then lifted gently and anchored to the dura. There was no other procedural complication. The patient's symptoms improved. This case demonstrates that intraoperative monitoring may be useful for preventing procedural complications during spinal cord microsurgical decompression.