Central Sarcopenia, Frailty and Comorbidity as Predictor of Surgical Outcome in Elderly Patients with Degenerative Spine Disease

Objective@#: People are living longer and the elderly population continues to increase. The incidence of degenerative spinal diseases (DSDs) in the elderly population is quite high. Therefore, we are facing more cases of DSD and offering more surgical solutions in geriatric patients. Understanding the significance and association of frailty and central sarcopenia as risk factors for spinal surgery in elderly patients will be helpful in improving surgical outcomes. We conducted a retrospective cohort analysis of prospectively collected data to assess the impact of preoperative central sarcopenia, frailty, and comorbidity on surgical outcome in elderly patients with DSD. @*Methods@#: We conducted a retrospective analysis of patients who underwent elective spinal surgery performed from January 1, 2019 to September 30, 2020 at our hospital. We included patients aged 65 and over who underwent surgery on the thoracic or lumbar spine and were diagnosed as DSD. Central sarcopenia was measured by the 50th percentile of psoas : L4 vertebral index (PLVI) using the cross-sectional area of the psoas muscle. We used the Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight (K-FRAIL) scale to measure frailty. Comorbidity was confirmed and scored using the Charlson Comorbidity Index (CCI). As a tool for measuring surgical outcome, we used the Clavien-Dindo (CD) classification for postoperative complications and the length of stay (LOS). @*Results@#: This study included 85 patients (35 males and 50 females). The mean age was 74.05±6.47 years. Using the K-FRAIL scale, four patients were scored as robust, 44 patients were pre-frail and 37 patients were frail. The mean PLVI was 0.61±0.19. According to the CD classification, 50 patients were classified as grade 1, 19 as grade 2, and four as grade 4. The mean LOS was 12.35±8.17 days. Multivariate stepwise regression analysis showed that postoperative complication was significantly associated with surgical invasiveness and K-FRAIL scale. LOS was significantly associated with surgical invasiveness and CCI. K-FRAIL scale showed a significant correlation with CCI and PLVI. @*Conclusion@#: The present study demonstrates that frailty, comorbidity, and surgical invasiveness are important risk factors for postoperative complications and LOS in elderly patients with DSD. Preoperative recognition of these factors may be useful for perioperative optimization, risk stratification, and patient counseling.

The Influence of Comorbidities on Reoperations Following Primary Surgery of Lumbar Degenerative Diseases : A Nationwide Population-Based Retrospective Cohort Study from 2009–2016

Objective@#: Spinal degeneration is a progressive disease, worsening over time. Lumbar degenerative disease (LDD) is a major spinal disease in elderly patients. Surgical treatment is considered for medically intractable patients with LDD and reoperation after primary surgery is not uncommon. The surgical outcome is occasionally unpredictable because of comorbidities. In the present study, the relationship between comorbidities and the incidence of reoperation for LDD over time was determined. @*Methods@#: The claims data of the health insurance national database were used to identify a cohort of patients who underwent spinal surgery for LDD in 2009. The patients were followed up until 2016. Medical comorbidity was assessed according to the Charlson comorbidity index (CCI). Cox proportional hazard regression modeling was used to identify significant differences in sex, surgery, age, causative disease, and comorbidity. @*Results@#: The study cohort included 78241 patients; 10328 patients (13.2%) underwent reoperation during the observation period. The reoperation rate was statistically higher (p<0.01) in males, patients 55–74 years and 65–74 years of age, and patients with decompression or discectomy. Significant association was found between increasing reoperation rate and CCI score (p<0.01). Based on multivariate analysis of comorbidities, the significantly higher reoperation rates were observed in patients with peripheral vascular disease, pulmonary lung disease, peptic ulcer, diabetes, and diabetes complications (p<0.01). @*Conclusion@#: The study results indicate the reoperation rate for LDD is associated with patient comorbidities. The comorbidities identified in this study could be helpful in future LDD studies.

Disappearance of Arachnoid Cyst after Burrhole Trephination: Case Series / 대한신경손상학회지

We report 3 cases of arachnoid cysts (ACs) that completely disappeared after burr hole drainage, without cyst fenestration into the subarachnoid space or cystoperitoneal shunt. The first patient was a 21-year-old female with an AC of the right cerebral convexity, found incidentally. After endoscopic AC fenestration was performed, the patient complained of persistent headache. Two-month postoperative brain imaging revealed reaccumulated AC and associated multi-stage subdural hematoma. Burr hole drainage was performed to resolve the chronic subdural hematoma (CSDH). Three months later, brain computed tomography showed that the CSDH and the AC had disappeared. The second patient was an 11-year-old male who had a history of trauma 1 month prior to presentation at the clinic. Brain magnetic resonance imaging revealed an AC in the left sylvian fissure with CSDH. We performed burr hole drainage to treat the CSDH first. Subsequently, the AC as well as the CSDH disappeared. The third case was an AC of the right parietal convexity, found incidentally. Only burr hole drainage was performed, following which, the AC disappeared. This case series shows that an AC can disappear naturally after rupture into the subdural space by trauma or the burr hole procedure.

Calcium pyrophosphate dihydrate deposition disease in the temporomandibular joint: diagnosis and treatment / 대한악안면성형재건외과학회지

BACKGROUND: Calcium pyrophosphate dihydrate deposition disease (CPDD) is a rare disease in the temporomandibular joint (TMJ) space. It forms a calcified crystal mass and induces a limitation of joint movement. CASE PRESENTATION: The calcified mass in our case was occupied in the left TMJ area and extended to the infratemporal and middle cranial fossa. For a complete excision of this mass, we performed a vertical ramus osteotomy and resected the mass around the mandibular condyle. The calcified mass in the infratemporal fossa was carefully excised, and the segmented mandible was anatomically repositioned. Scanning electronic microscopy (SEM)/energy-dispersive X-ray spectroscopy (EDS) microanalysis was performed to evaluate the calcified mass. The result of SEM/EDS showed that the crystal mass was completely composed of calcium pyrophosphate dihydrate. This result strongly suggested that the calcified mass was CPDD in the TMJ area. CONCLUSIONS: CPDD in the TMJ is a rare disease and is difficult to differentially diagnose from other neoplasms. A histological examination and quantitative microanalysis are required to confirm the diagnosis. In our patient, CPDD in the TMJ was successfully removed via the extracorporeal approach. SEM/EDS microanalysis was used for the differential diagnosis.

Predictors of Reoperation after Microdecompression in Lumbar Spinal Stenosis

OBJECTIVE: The risk factors of reoperation after microdecompression (MD) for lumbar spinal stenosis (LSS) are unclear. In this study, we presented the outcomes of MD for degenerative LSS and investigated the risk factors associated with reoperation. METHODS: A retrospective review was conducted using the clinical records and radiographs of patients with LSS who underwent MD. For clinical evaluation, we used the Japanese Orthopedic Association (JOA) scoring system for low back pain, body mass index, and Charlson comorbidity index. For radiological evaluation, disc height, facet angle, and sagittal rotation angle were measured in operated segments. Also the Modic change and Pfirrmann grade for degeneration in the endplate and disc were scored. RESULTS: Forty-three patients aged 69±9 years at index surgery were followed for 48±25 months. The average preoperative JOA score was 6.9±1.6 points. The score improved to 9.1±2.1 points at the latest follow-up (p0.1. Patients with Pfirrmann grade IV and lower lumbar segment had a 29.1% rate of reoperation (p=0.001), whereas patients without these factors had a 0% rate of reoperation. CONCLUSION: Moderate disk degeneration (Pfirrmann IV) in lower lumbar segments is a risk factor of disk herniation or foraminal stenosis requiring reoperation after MD in LSS.

Long-Term Outcome of Posterior Cervical Inclinatory Foraminotomy

OBJECTIVE: A modified surgical technique of posterior cervical foramintomy called posterior cervical inclinatory foraminotomy (PCIF) was introduced in previous preliminary article. PCIF allows better preservation of facet joint and capsule than conventional techniques. The authors conducted a study to investigate long-term outcomes of PCIF. METHODS: We retrospectively reviewed demographic, radiologic, and clinical data from the patients who underwent PCIFs at our institution. Criteria included a minimum of 48 month follow-up and PCIFs for patients with radiculopathy from foraminal stenosis (C2-T1; single or multilevel) with persistent or recurrent root symptoms despite conservative treatment for more than 3 months. Patients who had undergone previous cervical operation were excluded. The visual analogue scale (VAS) score was used for clinical follow-up, and radiologic follow-up was performed to compare the changes of cervical sagittal alignment, focal angle and disc-space height of treated segment. RESULTS: The PCIFs were performed between April 2007 and March 2011 on 46 patients (32 males and 14 females) with a total of 73 levels affected. The average duration of follow-up was 74.4 months. Improvements in radiculopathic pain were seen in 39 patients (84.7%), and VAS score decreased from 6.82±1.9 to 2.19±1.9. Posterior neck pain also improved in 25 patients (71.4%) among 35 patients, and VAS score decreased from 4.97±2.0 to 2.71±1.9. The mean disc-space heights of treated segment were 5.41±1.03 mm preoperatively and decreased to 5.17±1.12 mm postoperatively. No statistically significant changes in cervical sagittal alignment, focal angle were seen during the follow-up period (Cox proportional hazards analysis and Student t-test, p>0.05). CONCLUSION: The PCIF is highly effective in treating patients with cervical spondylotic radiculopathy, leading to long-lasting relief in pain. Long-term radiologic follow-up showed no significant spinal angular imbalance.

Comparative Analysis of Efficacy and Safety of Multisession Radiosurgery to Single Dose Radiosurgery for Metastatic Brain Tumors

BACKGROUND: The purpose of this study is to compare the efficacy and safety of multisession radiosurgery to those of single dose radiosurgery for metastatic brain tumors. METHODS: Between February 2008 and February 2012, 90 patients with 196 metastatic brain tumors were treated with cyberknife radiosurgery, and we reviewed these patients retrospectively. Among them, 57 patients underwent single dose radiosurgery, and 33 patients multisession radiosurgery. Tumors involving the eloquent area and large tumors (>5 cc) were treated with multisession radiosurgery. The median tumor volume and the median treatment dose of single dose radiosurgery were 2.05+/-0.72 cc and 19.76+/-1.54 Gy respectively, and in the case of multisession radiosurgery, 5.30+/-1.70 cc and 29.6+/-1.70 Gy respectively. The frequency of multisession dose was 3 to 5 times, on average 3.55 times, and 8.91 Gy were given per 1 session on average. RESULTS: The overall survival (OS) of multisession radiosurgery was 16.0 months, whereas that of single dose radiosurgery was 11.5 months. The radiologic tumor response rates were 90% in single dose radiosurgery and 95.4% in multisession radiosurgery, respectively. Over 6-month and 1-year periods, the OS rates of single dose radiosurgery were 71.4% and 44.9%, whereas those of multisession radiosurgery were 69.1% and 58.3%, respectively (p=0.83). Toxicities were seen in 18.1% in the single dose radiosurgery group versus 4% in the multisession radiosurgery group. The difference was significant (p<0.05). CONCLUSION: In this study, the multisession radiosurgery group, despite the location and size constraints, did not differ from the single dose radiosurgery group when comparing the survival and recurrence rates, but complications and toxicity were lower. Thus, multisession radiosurgery is thought to be beneficial for treatment of large tumors and tumors located in the eloquent area.

Crowned Dens Syndrome: A Case Report and Review of the Literature

The crowned dens syndrome (CDS), also known as periodontoid calcium pyrophosphate dehydrate crystal deposition disease, is typified clinically by severe cervical pain, neck stiffness and atlantoaxial synovial calcification which could be misdiagnosed as meningitis, epidural abscess, polymyalgia rheumatica, giant cell arthritis, rheumatoid arthritis, cervical spondylitis or metastatic spinal tumor. Crystalline deposition on cervical vertebrae is less well known disease entity and only a limited number of cases have been reported to date. Authors report a case of CDS and describe the clinical feature.

Review of Stereotactic Radiosurgery for Intramedullary Spinal Lesions

Stereotactic radiosurgery (SR) represents an increasingly utilized modality in the treatment of intracranial and extracranial pathologies. Stereotactic spine radiosurgery (SSR) uses an alternative strategy to increase the probability of local control by delivering large cumulative doses of radiation therapy (RT) in only a few fractions. SSR in the treatment of intramedullary lesions remains in its infancy - this review summarizes the current literature regarding the use of SSR for treating intramedullary spinal lesions. Several studies have suggested that SSR should be guided by the principles of intracranial radiosurgery with radiation doses placed no further than 1-2mm apart, thereby minimizing exposure to the surrounding spinal cord and allowing for delivery of higher radiation doses to target areas. Maximum dose-volume relationships and single-point doses with SSR for the spinal cord are currently under debate. Prior reports of SR for intramedullary metastases, arteriovenous malformations, ependymomas, and hemangioblastomas demonstrated favorable outcomes. In the management of intrame- dullary spinal lesions, SSR appears to provide an effective and safe treatment compared to conventional RT. SSR should likely be utilized for select patient-scenarios given the potential for radiation-induced myelopathy, though high-quality literature on SSR for intramedullary lesions remains limited.

Redundant Nerve Roots of Cauda Equina Mimicking Intradural Disc Herniation: A Case Report

Redundant Nerve Roots (RNRs) is an uncommon clinical condition characterized by a tortuous, serpentine, large and elongated nerve root of the cauda equina. To our knowledge, most cases of RNRs are associated with lumbar stenosis, and RNRs associated with lumbar disc herniation has not been reported until now. Here we present a rare case of unusual RNRs associated with lumbar disc herniation mimicking intradural disc herniation.

The Current Analysis of the Risk Factors for Bone Graft Infection after Cranioplasty / 대한신경손상학회지

OBJECTIVE: The aim of this study is to investigate the factors that may be related to bone graft infection and to contribute to lower the infection rate. According to current studies, the rate of bone graft infection after cranioplasty was reported up to 15.9% and this is significantly high. There are many analyses of the factors influencing bone graft infection, but this issue may need to be reconsidered in that the current medical environment is ever-changing. METHODS: We retrospectively reviewed the demographic, clinical data of 130 patients who underwent cranioplasty following decompressive craniectomy from January 2004 to December 2011. We analyzed several factors influencing bone graft infection and divided them into three categories of clinical, operation-related and hematological factors including white blood cell count, erythrocyte sedimentation rate, C-reactive protein and albumin. Statistical significance was done by chi-square test, Fisher's test and Mann-Whitney U test. RESULTS: The infection occurred in 12 patients in 130 cranioplasties (9.2%). There was no difference in infection rate between each group of early and later surgery, graft material, cause of craniectomy. Among many factors, low Glasgow Coma Scale (GCS< or =8) and combined ventriculoperitoneal (VP) shunt were significantly correlated with bone graft infection (p=0.025, p=0.025, respectively). There was no statistically significant difference in hematological analysis between groups. CONCLUSION: Low GCS and combined VP shunt with cranioplasty may increase the risk of bone graft infection.

Risk Factors for Reoperation after Traumatic Intracranial Hemorrhage / 대한신경손상학회지

OBJECTIVE: Progression after operation in traumatic brain injury (TBI) is often correlated with morbidity and poor outcome. We have investigated to characterize the natural course of traumatic intracranial hemorrhage and to identify the risk factors for postoperative progression in TBI. METHODS: 36 patients requiring reoperation due to hemorrhagic progression following surgery for traumatic intracranial hemorrhage were identified in a retrospective review of 335 patients treated at our hospital between 2001 and 2010. We reviewed the age, sex, Glasgow Coma Scale, the amount of hemorrhage, the type of hemorrhage, rebleeding site, coagulation profiles, and so on. Univariate statistics were used to examine the relationship between the risk factors and reoperation. RESULTS: Acute subdural hematoma was the most common initial lesion requiring reoperation. Most patients had a reoperation within 24-48 hours after operation. Peri-lesional edema (p=0.002), and initial volume of hematoma (p=0.013) were the possible factors of hemorrhagic progression requiring reoperation. But preoperative coagulopathy was not risk factor of hemorrhagic progression requiring reoperation. CONCLUSION: Peri-lesional edema and initial volume of hematoma were the statistical significant factors requiring reoperation. Close observation with prompt management is needed to improve the outcome even in patient without coagulopathy.

Minimum 3-Year Outcomes in Patients with Lumbar Spinal Stenosis after Bilateral Microdecompression by Unilateral or Bilateral Laminotomy

OBJECTIVE: Lumbar spine stenosis (LSS) can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Minimally invasive surgery has come to be more commonly used for the treatment of LSS. The current study describes outcomes of bilateral microdecompression by unilateral or bilateral laminotomy (BML) for degenerative LSS after a minimum follow-up period of 3 years and investigates factors that result in a poor outcome. METHODS: Twenty-one patients who were followed-up for at least 3 years were included in this study. For clinical evaluation, the Japanese Orthopedic Association (JOA) scoring system for low back pain was used. The modified grading system of Finneson and Cooper was used for outcome assessment. Radiographic evaluation was also performed for spondylolisthesis, sagittal rotation angle, and disc height. RESULTS: Twenty-one patients (10 men, 11 women) aged 53-82 years (64.1+/-8.9 years) were followed-up for a minimum of 3 years (36-69 months). During follow-up, two patients underwent reoperation. Average preoperative JOA score and clinical symptoms, except persistent low back pain, improved significantly at the latest follow-up. There were no significant differences in radiological findings preoperatively and postoperatively. Thirteen patients (61.9%) had excellent to fair outcomes. CONCLUSION: BML resulted in a favorable and persistent outcome for patients with degenerative LSS without radiological instability over a mid-term follow-up period. Persistent low back pain unrelated to postoperative instability adversely affects mid-term outcomes.

Angiographic Results of Indirect and Combined Bypass Surgery for Adult Moyamoya Disease

OBJECTIVE: The aim of this study was to compare the efficacy of indirect and combined bypass surgery for treatment of adult moyamoya disease (MMD). The definition of combined bypass surgery is a combination of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect anastomosis. Development of collateral circulation after surgery was investigated. METHODS: Forty three patients (58 hemispheres) with MMD were followed by cerebral angiography for at least six months after surgery, between May 2002 and July 2011. Indirect and combined revascularization surgeries were performed in 33 and 25 cases, respectively. Good outcome was defined as more than group B, in accordance with the method suggested by Matsushima. RESULTS: Development of collateral circulation was not affected by sex (p = 0.493), clinical features (p = 0.206), or Suzuki stage (p = 0.428). Based on postoperative cerebral angiography, the combined bypass surgery group showed a better angiographic outcome, than the encephaloduroarteriomyosynangiosis (EDAMS) group (p = 0.100, odds ratio [OR] 4.107, 95% confidence interval [CI] 0.700 - 24.096). The combined bypass group showed a better response than the encephaloduroarteriogaleosynangiosis (EDAGS) group (p = 0.088, OR 4.600, 95% CI 0.721 - 29.332). Similar responses were observed for EDAGS and EDAMS (p = 0.886, OR 1.120, 95% CI 0.239 - 5.251). The combined bypass group showed a better response than the indirect group (p = 0.064, OR 4.313, 95% CI 0.840 - 22.130). CONCLUSION: Results of this study demonstrate that combined bypass results in better revascularization on angiographic evaluation in adult MMD. Therefore, among surgical procedures, combined bypass is a choice that can be recommended.

Posterior Cervical Inclinatory Foraminotomy for Spondylotic Radiculopathy Preliminary

Posterior cervical foraminotomy is an attractive therapeutic option in selected cases of cervical radiculopathy that maintains cervical range of motion and minimize adjacent-segment degeneration. The focus of this procedure is to preserve as much of the facet as possible with decompression. Posterior cervical inclinatory foraminotomy (PCIF) is a new technique developed to offer excellent results by inclinatory decompression with minimal facet resection. The highlight of our PCIF technique is the use of inclinatory drilling out for preserving more of facet joint. The operative indications are radiculopathy from cervical foraminal stenosis (single or multilevel) with persistent or recurrent root symptoms. The PCIFs were performed between April 2007 and December 2009 on 26 male and 8 female patients with a total of 55 spinal levels. Complete and partial improvement in radiculopathic pain were seen in 26 patients (76%), and 8 patients (24%), respectively, with preserving more of facet joint. We believe that PCIF allows for preserving more of the facet joint and capsule when decompressing cervical foraminal stenosis due to spondylosis. We suggest that our PCIF technique can be an effective alternative surgical approach in the management of cervical spondylotic radiculopathy.

Idiopathic Thoracic Epidural Lipomatosis with Chest Pain

Spinal epidural lipomatosis (SEL) is an overgrowth of the normally encapsulated adipose tissue in the epidural space around the spinal cord in the thoracic and lumbar spine causing compression of the neural components. Idiopathic SEL in non-obese patients is exceptional. Idiopathic SEL can result in thoracic myelopathy and lumbar radiculopathy. A thoracic radiculopathy due to idiopathic SEL has not been reported yet. We report a case of idiopathic SEL with intractable chest pain and paresthesia. We suggest that idiopathic SEL should be considered as a cause of chest pain.

Giant Intracranial Aneurysm with Blind Sac on Middle Cerebral Artery: Case Report / 대한뇌혈관외과학회지

A case of a giant intracranial aneurysm (GIA) with a blind sac on the left middle cerebral artery (MCA) accompanied by mural thrombosis is described. A 62-year-old male presented with headache and motor dysphasia. Magnetic resonance imaging and digital subtraction angiography revealed a GIA that arose from the proximal MCA. The M2 segment of the MCA was not visualized due to intramural thrombosis. The patient was treated with an extracranial-intracranial arterial bypass and trapping of the aneurysm. Literature relevant to the management of this rare lesion is reviewed and discussed.

Angiographic and Clinical Results of Indirect Bypass Surgery for Moyamoya Disease / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to verify the validity and effectiveness of indirect bypass surgery as a treatment for Moyamoya disease. The development of post-surgical collateral circulation was investigated, and the clinical effectiveness of the surgery was confirmed. METHODS: Of 45 patients (66 hemispheres) with Moyamoya disease, 28 (42 hemispheres) were followed by cerebral angiography for at least 6 months after surgery, between May 2002 and May 2009. There were eight men (13 hemispheres) and 20 women (29 hemispheres) with an average age of 24 +/- 17.1 years (range, 2-62 years) at the time of diagnosis. The average follow-up period was 23 +/- 18.6 months (range, 6-67 months). Indirect revascularization surgery was performed as encephaloduroarteriomyosynangiosis (EDAMS) in 39 cases, encephaloduroarteriosynangiosis (EDAS) in three cases, and bifrontal encephalogaleoperiosteal synangiosis (BEGPS) in 21 cases. The development of collateral circulation was assessed by cerebral angiography at least 6 months after surgery to evaluate the results of the indirect revascularization surgery. For the classification, good indicated collateral circulation of more than two-thirds of the middle cerebral artery distribution; fair between one- and two-thirds; and poor very weak or no collateral circulation. The development of collateral circulation was compared according to age, gender, clinical feature, surgical method, and Suzuki stage. RESULTS: Cerebral infarction was the most frequent clinical feature at the time of incidence (27 cases; 64.4%), and Suzuki stage 3 was most common (15 cases; 35.7%). Based on cerebral angiography, 85.7% of patients showed good or fair development of collateral circulation, which was better among pediatric patients (15-years-of-age; p = 0.0344). Compared with EDAS, EDAMS tended to show better surgical results, but the difference was not statistically significant. Gender, clinical feature, or Suzuki stage did not influence the results. Among 21 patients in whom BEGPS was performed, 15 (71.4%) showed good or fair development of collateral circulation. CONCLUSION: Among the Moyamoya disease patients who received indirect bypass surgery, about 85% showed good or fair results, with collateral circulation involving more than one-third of the middle cerebral artery area. In addition to its effect in pediatric patients younger than 15-years-of-age, indirect bypass surgery also resulted in the development of collateral circulation in adults. EDAMS showed better effectiveness than EDAS as a surgical method. It is speculated that multiple, open arachnoid membranes stimulate the development of collateral circulation. One shortcoming of indirect bypass surgery for Moyamoya disease is that several months are required for the development of collateral circulation. One advantage is that it enables sufficient collateral circulation to develop in those who cannot endure direct bypass surgery. More effective results are expected with BEGPS.

A case of Tangier disease with two novel mutations in the ATP-binding cassette transporter A1 gene / 대한내과학회지

Tangier disease (TD) is a rare autosomal recessive disorder of lipoprotein metabolism characterized by extremely low levels of high-density lipoprotein cholesterol (HDL-C) and apolipoprotein (apo) A-I resulting in accumulation of cholesterol esters in various organs. TD is caused by mutations in the ATP-binding cassette transporter A1 (ABCA1) gene. Here, we present the first case report of a Korean patient with TD. A 45-year-old man had corneal opacity, intestinal mucosa abnormalities, and extremely low levels of HDL-C (1.8 mg/dL) and apo A-I (T (p.G1050X) nonsense mutation and c.3202C>T (p.R1068C) missense mutation. The c.3202C>T mutation was not found in 192 normal control alleles.

Sudden Migration of a Thalamic Hemorrhage into the Ventricles

Spontaneous intracerebral hemorrhage (ICH) is a common condition that often leads to death or disability. Accurate prediction of the outcome and decisions regarding the treatment of ICH patients are important issues. We report a case of thalamic hemorrhage with an intraventricular hemorrhage that was suddenly migrated into the third and fourth ventricles in its entirety 8 hours after symptom onset. To our knowledge, this case is the first report of spontaneous migration of thalamic ICH into ventricles, and we suggest a possible mechanism for this case with a brief review of the literature.