Effectiveness of negative pressure isolation stretcher and rooms for SARS-CoV-2 nosocomial infection control and maintenance of South Korean emergency department capacity.

OBJECTIVE: There are growing concerns regarding the lack of COVID-19 pandemic response capacity in already overwhelmed emergency departments (EDs), and lack of proper isolation facilities. This study evaluated the effectiveness of the negative pressure isolation stretcher (NPIS) and additional negative pressure isolation rooms (NPIRs) on the maintenance of emergency care capacity during the COVID-19 outbreak. METHODS: A before and after intervention study was performed between February 27, 2020 and March 31, 2020 at the ED of Chungbuk National University Hospital, Cheongju, South Korea. A total of 2455 patients who visited the ED during the study period were included. Interventions included the introduction of the NPIS and additional NPIRs in the ED. The main outcome of the study was frequency of medical cessation. Secondary outcomes were the average number of ED visits and lengths of stay. RESULTS: After the intervention, average frequency of medical cessation was significantly decreased from 1.6 times per day (range 0-4) in the pre-intervention period to 0.6 times per day (range 0-3) in the post-intervention period (p-value <0.01). On the other hand, the number of patients visiting the ED increased significantly from 67.2 persons per day (range 58-79) pre-intervention to 76.3 persons per day (range 61-88) post-intervention (p value <0.01). However, there were no statistically significant differences in the average ED length of stay across the study phases (p value = 0.50). CONCLUSIONS: This intervention may provide an effective way to prepare and meet the ED response needs of the COVID-19 pandemic.

Comparison of 7T and 3T MRI in patients with moyamoya disease.

Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) are widely used for evaluating the moyamoya disease (MMD). This study compared the diagnostic accuracy of 7Tesla (T) and 3T MRI/MRA in MMD. In this case control study, 12 patients [median age: 34years; range (10-66years)] with MMD and 12 healthy controls [median age: 25years; range (22-59years)] underwent both 7T and 3T MRI/MRA. To evaluate the accuracy of MRI/MRA in MMD, five criteria were compared between imaging systems of 7T and 3T: Suzuki grading system, internal carotid artery (ICA) diameter, ivy sign, flow void of the basal ganglia on T2-weighted images, and high signal intensity areas of the basal ganglia on time-of-flight (TOF) source images. No difference was observed between 7T and 3T MRI/MRA in Suzuki stage, ICA diameter, and ivy sign score; while, 7T MRI/MRA showed a higher detection rate in the flow void on T2-weighted images and TOF source images (p<0.001). Receiver operating characteristic curves of both T2 and TOF criteria showed that 7T MRI/MRA had higher sensitivity and specificity than 3T MRI/MRA. Our findings indicate that 7T MRI/MRA is superior to 3T MRI/MRA for the diagnosis of MMD in point of detecting the flow void in basal ganglia by T2-weighted and TOF images.

Intracerebral Hemorrhagic Infarction after Cranioplasty in a Patient with Sinking Skin Flap Syndrome.

The sinking skin flap syndrome (SSFS) is a rare complication after a large craniectomy. Hemorrhage infarction after a cranioplasty is a very rare complication with only 4 cases to date. We report a case of the patient who underwent an autologous cranioplasty to treat SSFS that developed intracerebral hemorrhage infarction. A 20-year-old male was admitted to our emergency department with stuporous mentality. Emergent decompressive craniectomy (DC) have done. He had suffered from SSFS and fever of unknown origin (FUO) since DC. After 7 months of craniectomy, cranioplasty was done. After 1 day of surgery, acute infarction with hemorrhagic transformation involved left cerebral hemisphere. We controlled increased intracranial pressure by using osmotic diuretics, steroid and antiepileptic drugs. After 14 day of surgery, he improved neurological symptoms and he had not any more hyperthermia. Among several complication of large cranioplasty only 4 cases of intracerebral hemorrhagic infarction due to reperfusion injury has been reported. In this case, unstable autoregulation system made brain hypoxic damage and then reperfusion and recanalization of cerebral vessels resulted in intracerebral hemorrhagic infarction. 7 month long FUO was resolved by cranioplasty.

Epidemiologic Impact of Rapid Industrialization on Head Injury Based on Traffic Accident Statistics in Korea.

OBJECTIVE: The aim of the present study is to estimate the incidence trend of head injury and the mortality based on traffic accident statistics and to investigate the impacts of rapid industrialization and economic growth on epidemiology of head injury in Korea over the period 1970-2012 including both pre-industrialized and post-industrialized stages. METHODS: We collected data of head injury estimated from traffic accident statistics and seven hospital based reports to see incidence trends between 1970 and 2012. We also investigated the population structure and Gross National Income (GNI) per capita of Korea over the same period. The age specific data were investigated from 1992 to 2012. RESULTS: The incidence of head injury gradually rose in the 1970s and the 1980s but stabilized until the 1990s with transient rise and then started to decline slowly in the 2000s. The mortality grew until 1991 but gradually declined ever since. However, the old age groups showed rather slight increase in both rates. The degree of decrease in the mortality has been more rapid than the incidence on head injury. CONCLUSION: In Korea during the low income stage, rapid industrialization cause considerable increase in the mortality and the incidence of head injury. During the high income stage, the incidence of head injury gradually declined and the mortality dropped more rapidly than the incidence due to preventive measures and satisfactory medical care. Nevertheless, the old age groups revealed rather slight increase in both rates owing to the large population structure and the declining birth rate.

Cerebral-perfusion-based single-photon emission computed tomography (SPECT) staging using NeuroGam® in patients with moyamoya disease.

BACKGROUND AND PURPOSE: Cerebral angiography (CA) is the gold standard for moyamoya disease (MMD) staging and diagnosis, but CA findings are not well correlated with clinical symptoms. The purpose of this study was to establish novel cerebral-perfusion-based staging for MMD that is well correlated with clinical symptoms. MATERIALS AND METHODS: From 2010 to 2015, regional cerebrovascular reserve (rCVR) was examined by single-photon emission computed tomography (SPECT) using NeuroGam® (Segamicorp, Houston, TX, USA) in 30 patients (17 women, 13 men; 60 hemispheres; mean 42.0 years old [range 5-60 years old]) with MMD, which was diagnosed by CA and magnetic resonance angiography (MRA). Brain CT or brain magnetic resonance imaging (MRI) was used to evaluate neurological conditions such as transient ischemic attack (TIA), cerebral hemorrhage, and cerebral infarction. A novel staging system for MMD was developed by combining findings from CA, MRI, and SPECT with NeuroGam®. RESULTS: Our novel staging system was strongly associated with clinical symptoms. Twenty-two hemispheres out of 60 were categorized as stage I, 24 hemispheres were categorized as stage II, and 14 hemispheres were categorized as stage III. Hemispheres with higher scores exhibited a higher incidence of clinical symptoms. These findings indicate that cerebral-perfusion-based staging is predictive of MMD clinical symptoms. CONCLUSION: Perfusion-based SPECT staging correlates well with clinical symptoms and may be a reliable alternative to the Suzuki staging by CA.

Spontaneous Resolution of a Large Chronic Subdural Hematoma Which Required Surgical Decompression.

We report on a case of an 87-year-old woman who showed spontaneous resolution of a large chronic subdural hematoma which required surgical decompression. She had suffered from confused mentality and right side weakness of motor grade II for 10 days. The initial brain CT scan showed a 22 mm thick low density lesion located in the left fronto-temporo-parietal region with midline shift (12 mm) which required emergency decompression. However, because she and her family did not want surgery, she was followed up in the outpatient clinic. Five months later, follow up brain CT showed that the CSDH had disappeared and the patient became neurologically normal. The reasons for spontaneous resolution of CSDH remain unclear. We discuss the possible relation between mechanisms of physio-pathogenesis and spontaneous resolution of a large chronic subdural hematoma (CSH) in an elderly patient.

A long-term survival case of a primary malignant intracerebral nerve sheath tumor.

We report a long-term survival case of a primary malignant intracerebral nerve sheath tumor (MINST) occurring in the right frontal lobe of a 13-year old boy. After the gross total resection (GTR), we have performed radiation therapy but it recurred 50 months after the surgery, so the second GTR was performed. Later, second tumor recurrence was found 4 months after the second surgery. Subsequently the third GTR, radiotherapy, and chemotherapy were carried out. At present, the patient has been remaining alive for 77 months without evidence of tumor recurrence. According to the previous reports, the primary MINST is very rare : there are only 8 cases reported. It is also a fast-growing, invasive tumor with poor outcome. This is the first case that had no recurrence for 50 months after the surgery among the reported cases that had been followed up for more than 5 years. It is supposed that a period of recurrence free survival after GTR and low mitotic activity are associated with the patient's prognosis. A GTR followed by adjuvant radiation therapy and chemotherapy will be recommended to patients of MINST.

Recent changes in risk factors of chronic subdural hematoma.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a typical disease that is encountered frequently in neurosurgical practice. The medications which could cause coagulopathies were known as one of the risk factors of CSDH, such as anticoagulants (ACs) and antiplatelet agents (APs). Recently, the number of patients who are treated with ACs/APs is increasing, especially in the elderly population. With widespread use of these drugs, there is a need to study the changes in risk factors of CSDH patients. METHODS: We retrospectively reviewed 290 CSDH patients who underwent surgery at our institute between 1996 and 2010. We classified them into three groups according to the time of presentation (Group A : the remote period group, 1996-2000, Group B : the past period group, 2001-2005, and Group C : the recent period group, 2006-2010). Also, we performed the comparative analysis of independent risk factors between three groups. RESULTS: Among the 290 patients, Group A included 71 patients (24.5%), Group B included 98 patients (33.8%) and Group C included 121 patients (41.7%). Three patients (4.2%) in Group A had a history of receiving ACs/APs, 8 patients (8.2%) in Group B, and 19 patients (15.7%) in Group C. Other factors such as head trauma, alcoholism, epilepsy, previous neurosurgery and underlying disease having bleeding tendency were also evaluated. In ACs/APs related cause of CSDH in Group C, significantly less proportion of the patients are associated with trauma or alcohol compared to the non-medication group. CONCLUSION: In this study, the authors concluded that ACs/APs have more importance as a risk factor of CSDH in the recent period compared to the past. Therefore, doctors should prescribe these medications carefully balancing the potential risk and benefit.

Unpredictable postoperative global cerebral infarction in the patient of williams syndrome accompanying moyamoya disease.

We report a rare case of Williams syndrome accompanying moyamoya disease in whom postoperative global cerebral infarction occurred unpredictably. Williams syndrome is an uncommon hereditary disorder associated with the connective tissue abnormalities and cardiovascular disease. To our knowledge, our case report is the second case of Williams syndrome accompanying moyamoya disease. A 9-year-old boy was presented with right hemiparesis after second operation for coarctation of aorta. He was diagnosed as having Williams syndrome at the age of 1 year. Brain MRI showed left cerebral cortical infarction, and angiography showed severe stenosis of bilateral internal carotid arteries and moyamoya vessels. To reduce the risk of furthermore cerebral infarction, we performed indirect anastomosis successfully. Postoperatively, the patient recovered well, but at postoperative third day, without any unusual predictive abnormal findings the patient's pupils were suddenly dilated. Brain CT showed the global cerebral infarction. Despite of vigorous treatment, the patient was not recovered and fell in brain death one week later. We suggest that in this kind of labile patient with Williams syndrome accompanying moyamoya disease, postoperative sedation should be done with more thorough strict patient monitoring than usual moyamoya patients. Also, we should decide the revascularization surgery more cautiously than usual moyamoya disease. The possibility of unpredictable postoperative ischemic complication should be kept in mind.