Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease.

OBJECTIVE: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR). METHODS: A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation. RESULTS: Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications. CONCLUSION: Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Intraoperative Endovascular Embolization of Middle Meningeal Artery and a Pseudoaneurysm by Using N-Butyl 2-Cyanoacrylate for Hemostasis during Operation of Acute Epidural Hemorrhage.

A 21-year-old female presented with acute epidural hemorrhage (EDH) on the left temporal region associated with skull fracture after traffic accident. She was neurologically deteriorated at four-hour after an admission, and follow-up computed tomography revealed increased amount of EDH. Under the general anesthesia, emergency craniotomy was performed. During the surgery, massive bleeding from the base of middle cranial fossa was observed. However, we could not identify an origin of bleeding and foramen spinosum due to brain swelling and obscured surgical field. Consequently, her systolic blood pressure was dropped to 60 mm Hg with >110 beat/min of heart rate. Therefore, we decided to perform an intraoperative angiography after gauze packing into the middle cranial fossa. Intraoperative angiography showed a large pseudoaneurysm with massive contrast leakage of the middle meningeal artery (MMA). Intraoperative endovascular embolization of the pseudoaneurysm and MMA by using n-butyl-2-cyanoacrylate was done. After that, her vital sign became stable, and we could complete the operation after the achievement of adequate hemostasis. Intraoperative angiography and endovascular embolization of MMA was effective in achieving adequate hemostasis in case with brisk bleeding from the middle cranial fossa could not be controlled in an open surgical field.

Delayed improvement after endoscopic carpal tunnel release.

OBJECTIVE: In most patients with carpal tunnel syndrome (CTS), pain and/or paresthesia disappeared or decreased in a month after endoscopic carpal tunnel release (ECTR). However, subpopulation of patients showed delayed improvement following ECTR. We analyzed the delayed improvement hands to investigate the characteristics of those patients and to determine the predictable factors of delayed improvement. METHODS: Single-portal ECTRs were performed in 1194 hands of 793 CTS patients from 2002 to 2011. Five-hundred seventy hands with minimal 1-year postoperative follow-up were included. We divided the 545 satisfied hands into early (group A) and delayed (group B) groups according to improvement period of 1 month. Demographic data, clinical severity and electrodiagnostic abnormality were compared between groups. RESULTS: Group A included 510 hands and group B included 35 hands. In group B, 11 hands improved in 2 months, 15 hands in 3 months and 9 hands in 6 months, respectively. In group A/B, according to clinical severity, 60/1 hands were graded to I, 345/24 hands to II, 105/10 hands to III. In group A/B, based on electrodiagnostic abnormality, 57/3 hands were classified to mild, 221/11 hands to moderate and 222/21 hands to severe group. Statistical analysis between groups did not reach significance but electrodiagnostic or clinical severity had a tendency to affect the delayed response. CONCLUSION: It is difficult to predict the factors contributing to postoperatively-delayed response in subpopulation of CTS patients. However, we recommend that postoperative observation for at least 6 months is necessary in patients without symptomatic improvement.

Clinical and radiological spectrum of posterior reversible encephalopathy syndrome.

OBJECTIVE: Symptoms of posterior reversible encephalopathy syndrome (PRES) include headache, altered mental status, visual disturbances, and seizures. Typical radiological features include edema of the parieto-occipital lobes. The purpose of this study is to review the clinical and radiological findings in patients diagnosed with PRES. METHODS: All patients diagnosed with PRES between January 2006 and December 2012 were retrospectively included in this study. We reviewed demographic and clinical characteristics, and radiological findings. RESULTS: We identified 16 patients with PRES. The most common clinical presentation was seizure (n = 12, 75%). Clinical recovery occurred in all patients within days (mean, 5.7 ± 4.6 days). Comorbid conditions included hypertension (n = 4, 25%), cytotoxic medications (n = 3, 18.8%), sepsis (n = 4, 25%), malignancy (n = 4, 25%), subarachnoid hemorrhage (n = 1, 6.3%), autoimmune disorders (n = 1, 6.3%) and eclampsia (n = 1, 6.3%). The most commonly involved location was the parieto-occipital lobe (n = 13, 81.3%). Atypical radiological findings included significant basal ganglia involvement in 4 episodes; brainstem in 3, cerebellum in 2, and thalamus in 3. Eleven patients (68.8%) underwent diffusion-weighted imaging and apparent diffusion coefficient mapping. Of those, 9 patients (81.8%) had hypo- or isointensity on diffusion-weighted imaging. On the apparent diffusion coefficient map, 10 patients (90.9%) had hyperintensity, and the other had normal values. CONCLUSION: We suggest that PRES may occur in patients with complex systemic conditions. The prognosis of PRES is usually benign. Physicians should be aware of certain atypical radiological findings to avoid a delayed diagnosis of PRES, as delayed diagnosis and treatment can result in permanent neurological sequlae.

The comparative morphometric study of the posterior cranial fossa : what is effective approaches to the treatment of Chiari malformation type 1?

OBJECTIVE: The objective of this study was to investigate changes in the posterior cranial fossa in patients with symptomatic Chiari malformation type I (CMI) compared to a control group. METHODS: We retrospectively reviewed clinical and radiological data from 12 symptomatic patients with CMI and 24 healthy control subjects. The structures of the brain and skull base were investigated using magnetic resonance imaging. RESULTS: The length of the clivus had significantly decreased in the CMI group than in the control group (p=0.000). The angle between the clivus and the McRae line (p<0.024), as the angle between the supraocciput and the McRae line (p<0.021), and the angle between the tentorium and a line connecting the internal occipital protuberance to the opisthion (p<0.009) were significantly larger in the CMI group than in the control group. The mean vertical length of the cerebellar hemisphere (p<0.003) and the mean length of the coronal and sagittal superoinferior aspects of the cerebellum (p<0.05) were longer in the CMI group than in the control group, while the mean length of the axial anteroposterior aspect of the cerebellum (p<0.001) was significantly shorter in the CMI group relative to control subjects. CONCLUSION: We elucidate the transformation of the posterior cranial fossa into the narrow funnel shape. The sufficient cephalocaudal extension of the craniectomy of the posterior cranial fossa has more decompression effect than other type extension of the craniectomy in CMI patients.

Loss of heterozygosity at 1p, 7q, 17p, and 22q in meningiomas.

OBJECTIVE: Allelic losses or loss of heterozygosity (LOH) at many chromosomal loci have been found in the cells of meningiomas. The objective of this study was to evaluate LOH at several loci of different chromosomes (1p32, 17p13, 7q21, 7q31, and 22q13) in different grades of meningiomas. METHODS: Forty surgical specimens were obtained and classified as benign, atypical, and anaplastic meningiomas. After DNA extraction, ten polymorphic microsatellite markers were used to detect LOH. Medical and surgical records, as well as pathologic findings, were reviewed retrospectively. RESULTS: LOH at 1p32 was detected in 24%, 60%, and 60% in benign, atypical, and anaplastic meningiomas, respectively. Whereas LOH at 7q21 was found in only one atypical meningioma. LOH at 7q31 was found in one benign meningioma and one atypical meningioma. LOH at 17p13 was detected in 4%, 40%, and 80% in benign, atypical, and anaplastic meningiomas, respectively. LOH at 22q13 was seen in 48%, 60%, and 60% in benign, atypical, and anaplastic meningiomas, respectively. LOH results at 1p32 and 17p13 showed statistically significant differences between benign and non-benign meningiomas. CONCLUSION: LOH at 1p32 and 17p13 showed a strong correlation with tumor progression. On the other hand, LOH at 7q21 and 7q31 may not contribute to the development of the meningiomas.

Racemose cysticercosis in the cerebellar hemisphere.

Neurocysticercosis is the most common parasitic disease of the central nervous system in humans, caused by infection of the larval stage of the pork tapeworm, Taenia solium. However, cerebellar involvement is rarely reported. We report of a case of racemose cysticercosis in the cerebellar hemisphere. A 44-year-old man presented with headache and dizziness. Magnetic resonance imaging showed hydrocephalus and an ill-defined, multicystic cerebellar mass with hypersignal on T2-weighted images, hyposignal on T1-weighted images and rim enhancement after gadolinium injection. The patient underwent endoscopic third ventriculostomy and the cyst resection was done through a craniotomy. In surgical field, cysts were conglomerated in a dense collagen capsule that were severely adherent to surrounding cerebellar tissue, and transparent cysts contained white, milky fluid. Histological findings confirmed the diagnosis of cysticercosis. He received antiparasitic therapy with praziquantel after surgery. Racemose cysticercosis is rare in the cerebellar hemisphere but neurocysticercosis should be taken into consideration as a differential diagnosis of multiple cystic lesions in the cerebellum.

Efficacy of low dose barbiturate coma therapy for the patients with intractable intracranial hypertension using the bispectral index monitoring.

OBJECTIVE: Barbiturate coma therapy (BCT) is a useful method to control increased intracranial pressure (IICP) patients. However, the complications such as hypotension and hypokalemia have caused conditions that stopped BCT early. The complications of low dose BCT with Bispectral index (BIS) monitoring and those of high dose BCT without BIS monitoring have been compared to evaluate the efficacy of low dose BCT with BIS monitoring. METHODS: We analyzed 39 patients with high dose BCT group (21 patients) and low dose BCT group (18 patients). Because BIS value of 40-60 is general anesthesia score, we have adjusted the target dose of thiopental to maintain the BIS score of 40-60. Therefore, dose of thiopental was kept 1.3 to 2.6 mg/kg/hour during low dose BCT. However, high dose BCT consisted of 5 mg/kg/hour without BIS monitoing. RESULTS: The protocol of BCT was successful in 72.2% and 38.1% of low dose and high dose BCT groups, respectively. The complications such as QT prolongation, hypotension and cardiac arrest have caused conditions that stopped BCT early. Hypokalemia showed the highest incidence rate in complications of both BCT. The descent in potassium level were 0.63 +/- 0.26 in low dose group, and 1.31 +/- 0.48 in high dose group. The treatment durations were 4.89 +/- 1.68 days and 3.38 +/- 1.24 days in low dose BCT and high dose BCT, respectively. CONCLUSION: It was proved that low dose BCT showed less severe complications than high dose BCT. Low dose BCT with BIS monitoring provided enough duration of BCT possible to control ICP.

Changes in abdominal vascular tension associated with various leg positions in the anterior lumbar approach: cadaver study.

STUDY DESIGN: A descriptive cadaveric study measuring arterial tension. OBJECTIVE: Anterior lumbar surgery is technically challenging due to perioperative vascular complications. Many studies suggest approaches based on the anatomy of the abdominal vessel for safe vascular mobilization. However, the tension in the vascular structure is also important for adequate exposure of the target lesion. It has been established that the tension in the lumbar nerve at the root level can be changed by a straight leg raise test and that the structure of the vascular connection is similar to that of the neural connection. Consequently, a change in leg position could affect the tension of lumbosacral vessels. The purpose of this study was to evaluate the effect of leg position on the tension of lumbosacral vessels. METHODS: We dissected 10 unembalmed cadavers using the method described by Gumbs et al, using the Synframe system to expose the abdominal artery and vein. The left iliac artery and the distal abdominal aorta were retracted to the right side at the L4-L5 disc level by a measuring retractor to which a strain gauge was attached. The tension was checked at various angles of the hip joint and the motions of the abdominal arteries were monitored in 4 unembalmed cadavers using a C-arm fluoroscope. RESULTS: The tension in the abdominal aorta at L4-L5 level was decreased by 2.9% to 21.8% in the hip-flexion position, and the motion of the arteries showed proximal displacement of the external iliac artery and the common iliac artery during the hip-flexed position and veins also showed the same pattern of displacement as artery. CONCLUSION: The results of this study would be useful for not only spinal surgery but also other vascular surgeries, particularly, in cases where patients with conditions such as atherosclerosis or stenosis.

Traumatic pseudoaneurysm of the superficial temporal artery in a child: a case report.

INTRODUCTION: Pseudoaneurysm of the superficial temporal artery (STA) is usually caused by head or facial injury and is rarely reported in children. It is frequently discovered as a pulsatile cystic mass in the temple, and its diagnosis can be made with ultrasound or computerized tomography angiogram (CTA). Treatment modalities consist of surgical excision and endovascular embolization. CASE REPORT: A 14-year-old boy presented with a pulsatile, cystic, and painless mass in the left anterior temporal region, developed 6 weeks after head injury from a traffic accident. The mass was 15 mm in diameter and compressible, and disappeared after manual compression of the proximal STA. Bruit was audible over the mass with a stethoscope. CTA showed a pseudoaneurysm of the anterior division of the left STA. The mass was resected with ligation of the proximal and distal ends of the STA. CONCLUSION: A pseudoaneurysm of the STA should be suspected in a child presented with a pulsatile, cystic mass in the temple, developed after head injury. It can be easily diagnosed with history and physical examination with the aid of imaging modalities such as Doppler ultrasonography and CTA. Pseudoaneurysms are usually successfully treated with excision.

Simple oblique lumbar magnetic resonance imaging technique and its diagnostic value for extraforaminal disc herniation.

STUDY DESIGN: Prospective study evaluating the oblique lumbar magnetic resonance imaging (MRI). OBJECTIVE: To present the technique of oblique lumbar MRI and assess the clinical efficacy of this technique for diagnosis of extraforaminal disc herniation. SUMMARY OF BACKGROUND DATA: Herniated lumbar discs are traditionally diagnosed using conventional lumbar axial and sagittal MRI. However, conventional lumbar MRI might not reveal nerve root compression in the extraforaminal area. Oblique lumbar MRI can provide clear visualization of the dorsal root ganglion and lumbar nerve root in the foraminal and extraforaminal areas. METHODS: Ten patients diagnosed with extraforaminal disc herniations underwent bilateral oblique lumbar MRIs before surgery (turbo spin-echo T2-weighted sequence). We compared the side with symptomatic extraforaminal disc herniation to the asymptomatic contralateral side. RESULTS: Oblique lumbar MRI succeeded in depicting pedicles, dorsal root ganglions, and lumbar nerve roots of the foraminal and extraforaminal areas. In 9 of 10 patients (90.0%), nerve root compression by the herniated disc in the extraforaminal area was clearly demonstrated when compared with the asymptomatic contralateral side (P < 0.05). In 1 patient with scoliosis and spinal stenosis, oblique MRI could not clearly display foraminal or extraforaminal anatomy due to spinal deformity. CONCLUSION: In light of this data, we suggest that oblique lumbar MRI can precisely demonstrate nerve roots in foraminal and extraforaminal areas. This technique is a simple and useful diagnostic tool for extraforaminal lumbar disc herniations.

Metastatic choriocarcinoma with multiple neoplastic intracranial microaneurysms: case report.

The authors report on a case of a metastatic choriocarcinoma that mimicked systemic necrotizing vasculitis on a cerebral angiogram. A 35-year-old woman presented with right hemiplegia and a drowsy mental state. A computed tomography (CT) scan revealed an intracerebral hemorrhage in the left frontal region. A cerebral angiogram showed multiple microaneurysms arising from the bilateral anterior cerebral arteries and middle cerebral arteries, and the renal angiogram showed multiple microaneurysms arising from the left distal renal artery. A chest CT scan revealed multiple metastatic lesions in the left lower lung field. The hematoma and microaneurysms were surgically removed. Choriocarcinoma was diagnosed after histological examination. Despite receiving postoperative chemotherapy, the patient died 1 month after the operation.

Multivariate analysis of risk factors of hematoma expansion in spontaneous intracerebral hemorrhage.

BACKGROUND: We focused on the cause of hematoma expansion after admission because the volume of hematoma after S-ICH plays a crucial role in the cause of mortality and morbidity. METHODS: In a retrospective review, 51 patients with hematoma expansion of S-ICH were identified among 880 cases of S-ICH treated between 2001 and May 2006. We divided cases into 2 groups according to the time of hematoma expansion. An enlargement of hematoma within 2 weeks after hospitalization was categorized as the acute stage group and after 2 weeks was categorized as the chronic stage group. Spontaneous intracerebral hemorrhage without hematoma expansion group (100 cases) had been consecutively selected as a control group. We analyzed the risk factors of hematoma expansion in patients with S-ICH especially in the acute stage group. RESULTS: Fifty-one of 880 patients had the enlargement of hematoma (5.8%). Forty-three (84%) of 51 cases were acutely developed and 8 cases (16%) were developed chronically. On univariate analysis there were significant differences in BP within the initial 48 hours (P < .0001), GOS (P < .0001), and previously taking anticoagulant agents (P = .0053). Especially the difference in SBP and DBP within 48 hours between groups was 19 (11%) and 13 mm Hg (14%), respectively. The DBP within the initial 24 hours had a meaningful odds ratio (1.06) on logistic regression analysis. CONCLUSION: A reduction of BP by 15% (SBP < or =140 mm Hg, DBP < or =80 mm Hg) is necessary at acute stage in S-ICH.

Quantitative anatomy of the endplate of the middle and lower cervical vertebrae in Koreans.

STUDY DESIGN: Assessment of the size and shape of cervical vertebral endplates in Koreans. OBJECTIVE: To obtain data regarding cervical vertebrae and propose an appropriate size for artificial discs in Koreans. SUMMARY OF BACKGROUND DATA: The use of various types of cervical artificial discs has increased in recent years; hence, it is important to develop endplate implants of appropriate size. In this study, we determined the quantitative anatomy of cervical endplates in Koreans and proposed a new angular parameter. METHODS: This study details the quantitative surface anatomy of the middle and lower cervical vertebral endplates based on the study of 272 cervical vertebrae in Korean cadavers. Computed tomographic images were obtained from 57 Korean cadavers (28 males and 29 females). The mean age and height were 51.14 years (range, 21-60 years) and 161 cm (range, 146-175 cm), respectively. The images were reconstructed, and linear parameters (EPWu, upper endplate width; EPDu, upper endplate depth; EPWl, lower endplate width; and EPDl, lower endplate depth) and an angular parameter (AUA, anterior wall to uncovertebral joint angle) were measured. RESULTS.: The width and depth of both the upper and lower endplates increased from C3 through C7. The EPDu, EPWl, and EPDl values of Koreans were similar to those reported in whites, while the EPWu value in this study were smaller than those reported in whites. The AUA for C4 differed significantly between the sexes. The linear parameter values obtained using Korean cadavers were compared with those obtained using white and Singaporean subjects. The EPWu values of Koreans were smaller than those reported in whites, while the values for all the parameters were considerably larger than those reported in Singaporeans. The AUA indicated the existence of various relationships between the endplate and the uncovertebral joint. CONCLUSIONS: This data can be used to develop cervical devices for Koreans. The AUA should be studied in other populations.

Delayed diagnosis of cerebellar hemangioblastoma after intracerebellar hemorrhage.

BACKGROUND: Cerebellar hemorrhage caused by cerebellar hemangioblastoma is not a frequent case. We report a case of solid, cerebellar hemangioblastoma, diagnosed 4 years after cerebellar hemorrhage. CASE DESCRIPTION: A 69-year-old man presented with dizziness and gait disturbance. He had a 4-year history of evacuation of cerebellar hemorrhage. Gadolinium-enhanced MRI revealed a well-enhancing mass in the left cerebellar hemisphere, and vertebral angiography revealed hypervascularity. Radiotherapy was given to the tumor bed. He remained stable for more than a year after radiation. CONCLUSION: In cases of spontaneous cerebellar hemorrhage, particularly in the patient without hypertension or other underlying diseases related to bleeding from tumor, cerebellar hemangioblastoma should be suspected as a rare cause of hemorrhage, and computed tomography and/or MRI with contrast administration is mandatory for differential diagnosis.

Surgical experience of the ruptured distal anterior cerebral artery aneurysms.

OBJECTIVE: Distal anterior cerebral artery (DACA) aneurysms are fragile and known to have high risks for intraoperative premature rupture and a relatively high associated morbidity. To improve surgical outcomes of DACA aneurysms, we reviewed our surgical strategy and its results postoperatively. METHODS: A total of 845 patients with ruptured cerebral aneurysms were operated in our hospital from January 1991 to December 2005. Twenty-three of 845 patients had ruptured DACA aneurysms which were operated on according to our surgical strategy. Our surgical strategy was as follows; early surgery, appropriate releasing of CSF, appropriate surgical approach, using neuronavigating system, securing the bridging veins, using temporary clipping and/or tentative clipping, meticulous manipulation of aneurysm, and using micro-Doppler flow probe. Twenty of 23 patients who had complete medical records were studied retrospectively. We observed the postoperative radiographic findings and checked Glasgow Outcome Scale score sixth months after the operation. RESULTS: Nineteen DACA aneurysms were clipped through a unilateral interhemispheric approach and one DACA aneurysm was clipped through a pterional approach. Postoperative radiographic findings revealed complete clipping of aneurysmal neck without stenosis or occlusion of parent arteries. In two patients, a residual neck of aneurysm was visualized. Seventeen patients showed good recovery, one patient resulted in moderate disability, while 2 patients died. CONCLUSION: With our surgical strategy it was possible to achieve acceptable surgical morbidity and mortality rates in patients with DACA aneurysms. Appropriate use of tentative clipping, temporary clipping and neuro-navigating systems can give great help for safe approach and clipping of DACA aneurysm.

Lumbosacral plexopathy, complicating rhabdomyolysis in a 57-year-old man, presented with sudden weakness in both legs.

A 57-year-old man presented with weakness in both legs upon awakening after drinking. Magnetic resonance imaging (MRI) of the lumbar spine did not reveal any intraspinal abnormalities but MRI of the pelvis revealed lesions with abnormal intensities with heterogeneous contrast enhancement in both gluteal muscles. Serum creatine phosphokinase was markedly elevated. A diagnosis of lumbosacral plexopathy, complicating rhabdomyolysis was made. With supportive care he recovered well but mild weakness of the right ankle remained at 6 month-follow-up. Pelvic MRI is a helpful diagnostic tool in localizing rhabdomyolysis. Lumbosacral plexopathy should be included in the differential diagnosis of the such cases, presenting with sudden weakness of legs.

The pattern of E2F1 and c-myb immunoreactivities in the CA1 region is different from those in the CA2/3 region of the gerbil hippocampus induced by transient ischemia.

In this study, we examined transient ischemia-induced changes in transcription factor E2F1 and c-myb expressions in the gerbil hippocampus after 5 min of transient forebrain ischemia. E2F1 immunoreactivity significantly increased in the CA1 region 6-12 h after ischemia/reperfusion. c-myb immunoreactivity increased mainly in CA1 pyramidal cells with time by 12 h after ischemia. Thereafter, E2F1 and c-myb immunoreactivities significantly decreased compared to those in the 12 h post-ischemic group. Four days after ischemia/reperfusion, E2F1 and c-myb immunoreactivities were detected in non-pyramidal cells. Ten days after ischemia, c-myb immunoreactivity increased again: at this time, astrocytes as well as non-pyramidal cells showed E2F1 and c-myb immunoreactivities. In the CA2/3 region, E2F1 and c-myb immunoreactivities mainly changed in non-pyramidal cells, and 10 days after ischemia, c-myb immunoreactivity was not expressed in astrocytes. In conclusion, E2F1 and c-myb significantly alter in pyramidal cells and express in astrocytes in the gerbil hippocampal CA1 region after transient ischemia. These results indicate that E2F1 and c-myb in the CA1 region after ischemic damage may be associated with delayed neuronal death.

Head injuries from falls in preschool children.

Falls are a leading cause of morbidity and mortality among children. We performed a retrospective analysis of pediatric patients under 7 years of age admitted to our department after a fall from January 1994 through December 1999 to describe the characteristics of fall-related head injury and to determine the clinical parameters influencing outcome. The patients were divided into two groups according to age: group I (babies and toddlers, 0-3 years) and group II (preschool children, 4-6 years). Falls were classified as low and high level. Sixty-eight cases were identified and falls accounted for 35.2% of head injuries. There were more boys than girls, and more low-level falls(LLF) than high-level falls (HLF), particularly in group I. Although more common in HLF, significant intracranial injuries were also sustained from LLF. Calvarial fractures were the most frequent type of head injury and were more common in LLF than HLF. Admission Glasgow Coma Scale score, types of head injury and hypoxia on admission were significantly correlated with Glasgow Outcome Scale score, but age, sex, extracranial injury and height of fall did not influence clinical outcome. From this study, we concluded that the height of fall should not limit the evaluation of patients and that aggressive management is mandatory to improve outcome even in patients with poor prognostic factors.