Among the distal anterior inferior cerebellar artery (AICA) aneurysms, a unique aneurysm at the meatal loop inside the internal auditory meatus is extremely rare. The authors report a case of surgically treated total intrameatal AICA aneurysm. A 62-year-old female patient presenting with sudden bursting headache and neck pain was transferred to our department. Computed tomography and digital subtraction angiography showed subarachnoid hemorrhage at the basal, prepontine cistern and an aneurysm of the distal anterior inferior cerebellar artery inside the internal auditory meatus. Surgery was performed by retrosigmoid craniotomy with unroofing of the internal auditory meatus. The aneurysm was identified between the seventh and eighth cranial nerve in the meatus and was removed from the canal and clipped with a small straight Sugita clip. After operation the patient experienced transient facial paresis and tinnitus but improved during follow up.
Intrameatal AICA aneurysm; Microsurgery; Facial nerve; Vestibular nerve
Although blood contamination of cerebrospinal fluid (CSF) after an intracranial operation can occur, the development of a symptomatic spinal hematoma after craniotomy has been anecdotally reported and it is uncommon reported after a supratentorial meningioma removal operation. We report a case of spinal subdural hematoma following a supratentorial meningioma removal operation and discuss the mechanism of spinal subdural hematoma (SSDH) development. A 54-year-old woman presented with lumbago and radicular pain on both legs 4 days after a right parietooccipital craniotomy for meningioma removal. Only the straight leg raising sign was positive on neurologic examination but the magnetic resonance imaging (MRI) demonstrated a lumbosacral spinal subdural hematoma. The patient received serial lumbar tapping, after which her symptoms showed improvement.
Spinal subdural hematoma; Meningioma; Lumbar tapping
The relationship between abdominal obesity (AO) and mortality in peritoneal dialysis (PD) patients is controversial.
The prevalence of AO in 84 PD patients was assessed in a cross-section manner and followed up for 9 years at a single center. AO was defined as a waist circumference (WC) of more than 90 cm in males or more than 80 cm in females. The patients were classified as either with AO(AO group) or without AO(nAO group).
The AO group was older, contained more diabetics, more females, and had higher Charlson comorbidity index (aCCI) scores, BMI, and triglyceride and lower serum creatinine than the non-AO subjects. The follow-up duration was 53.2±34.4 months. At the end of the follow-up, eighteen patients (21.4%) were dead; 9 died of cardiovascular causes. The five year survival rate was 40.8%. Kaplan-Meier analysis revealed that both all-cause and cardiovascular-cause mortalities were similar in the AO and nAO groups. Multivariate analysis revealed the presence of AO not to be an independent risk factor of all-cause and cardiovascular-cause mortality.
AO itself might not be a risk factor for mortality in PD patients. Nevertheless, further prospective studies with a large number of patients will be needed to prove this.
Abdominal obesity; Continuous ambulatory peritoneal dialysis; Mortality; Risk factors; Chronic kidney failure
Endovascular treatment of wide-necked intracranial aneurysms is a challenge and the durability and the safety of these treated aneurysms remain unknown. The aim of this study was to evaluate the clinical and long-term angiographic results of wide-necked intracranial aneurysms treated with coil embolization.
Between January 2002 and December 2012, 53 wide-necked aneurysms treated with coil embolization were selected. Forty were female, and 13 were male. Twenty eight (52.8%) were ruptured aneurysms, and 25 (47.2%) were unruptured aneurysms. The patents' medical and radiological records were reviewed retrospectively.
Of the 53 aneurysms, coiling alone was employed in 45 (84.9%) and stent-assisted coiling was done in 8 (15.1%). The initial angiographic results revealed Raymond class 1 (complete occlusion) in 30 (56.6%) cases, Raymond class 2 (residual neck) in 18 (34.0%) cases, and Raymond class 3 (residual sac) in 5 (9.4%) cases. The mean angiographic follow-up period was 37.9 months (12-120 months). At the last angiographies, Raymond class 1 was seen in 26 (49.1%) cases, Raymond class 2 in 16 (30.2%), and Raymond class 3 in 11 (20.8%). Angiographic recurrence occurred in 22 (41.5%) patients, with minor recurrence in 7 (13.2%) cases and major recurrence in 15 (28.3%). Retreatment was performed in 8 cases (15.1%). A suboptimal result on the initial angiography was a significant predictor of recurrence in this study (p=0.03).
The predictor of recurrence in wide-necked aneurysms is a suboptimal result on the initial angiography. Long-term angiographic follow-up is recommended in wide-necked aneurysms.
Cerebral angiography; Intracranial aneurysm; Recurrence
This retrospective study was performed to determine the ranges of the sodium gradient (SG) between the dialysate sodium concentration (DNa) and serum sodium concentration (SNa) in hemodialysis (HD) patients and to examine the relationships between HD parameters over a 1 year period. Fifty-five clinically stable HD patients, who had been on HD >2 years were enrolled. Monthly HD [ultrafiltration (UF) amount, systolic blood pressure (SBP), frequency of intradialytic hypotension (IDH)] and laboratory data were collected and 12-month means were subjected to analysis. The SG was calculated by subtracting SNa from prescribed DNa. Mean SG values were 1.5±3.3 (range -5.6~9.1). SG was positively related to DNa and the frequency of IDH. A higher SG was associated with larger UF amounts and SBP reduction during HD. The percentages of patients with a SG ≥3mEq/L increased as DNa increased. On the other hand, SG was not found to be associated with SNa or pre-HD SBP. DNa appears to cause a significant increase in SG, and this seems to be related to HD parameters, such as, UF amount and IDH.
Renal dialysis; Dialysis solutions; Sodium
Non-traumatic, spontaneous urinary bladder rupture is a rare complication of urethral stricture. Furthermore, its symptoms are often nonspecific, and misdiagnosis is common. The authors experienced a case of urethral stricture with spontaneous bladder rupture and bilateral hydronephrosis, mimicking obstructive uropathy attributed to cancer metastasis. A 55-year-old woman was admitted with abdominal pain and distension, oliguria, and an elevated serum creatinine level. She had undergone radical hysterectomy for uterine cervical cancer and received post-operative concurrent chemoradiation therapy 13 years previously. Non-contrast enhanced computed tomography showed massive ascites and bilateral hydronephrosis. The initial diagnosis was acute kidney injury due to obstructive uropathy caused by malignant disease. After improvement of her renal function by bilateral percutaneous nephrostomy catheterization, contrast-enhanced computed tomography and a cytologic examination of ascites showed no evidence of malignancy. However, during retrograde pyelography, a severe urethral stricture was found, and subsequent cystography showed leakage of contrast into the peritoneal cavity and cystoscopy revealed a defect of the posterior bladder wall. After urethral dilatation and primary closure of the bladder wall, acute kidney injury and ascites were resolved.
Acute kidney injury; Urinary bladder; Spontaneous rupture; Hydronephrosis; Radiotherapy
Acute kidney injury (AKI) continues to have an exceedingly high mortality rate, despite advances in dialysis technology. Current dialysis therapies replace only the filtration function of the kidney, not the critical transport, metabolic, and endocrine functions of renal tubule cells. Replacement of these additional functions would provide more complete AKI therapy and thereby change the natural history of this disease process. A renal tubule assist device (RAD) containing living renal proximal tubule cells has been successfully engineered and has demonstrated differentiated absorptive, metabolic, and endocrine functions of normal kidney in vitro and ex vivo in animal experiments. The addition of the RAD containing human cells to conventional continuous renal replacement therapy has been shown in preclinical and clinical studies to have the potential to advance AKI treatment, from enhancing renal clearance to providing more complete renal replacement therapy. This “bioartificial kidney” demonstrates metabolic activity with systemic effects and improvement of survival in patients with AKI and multiorgan failure. It also appears to influence systemic leukocyte activation and the balance of inflammatory cytokines, suggesting that cell therapy by use of the RAD may improve morbidity and mortality by altering the proinflammatory state of patients with renal failure. In addition to providing cellular metabolic function, technologies directed toward disrupting systemic inflammatory response may well enhance the clinical outcome of critically ill patients in the future. Innovative approaches to intensive renal care such as the RAD may break the mold of current institutional dialysis therapies and provide numerous opportunities to develop lifesaving technologies.
Acute kidney injury; systemic inflammatory response syndrome; bioartificial kidney; cell therapy; renal replacement therapy
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.
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.
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.
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.
Type I Arnold-Chiari malformation; Posterior cranial fossa; Decompressive craniectomy; Embryology; Congenital abnormality
Septic shock has a clinical mortality rate approaching fifty percent. The major clinical manifestations of sepsis are due to the dysregulation of the host's response to infection rather than the direct consequences of the invading pathogen. Central to this initial immunologic response is the activation of leukocytes and microvascular endothelium resulting in cardiovascular instability, lung injury and renal dysfunction. Due to the primary role of leukocyte activation in the sepsis syndrome, a synthetic biomimetic membrane, called a selective cytopheretic device (SCD), was developed to bind activated leukocytes. The incorporation of the SCD along an extracorporeal blood circuit coupled with regional anticoagulation with citrate to lower blood ionized calcium was devised to modulate leukocyte activation in sepsis.
University of Michigan Medical School.
Pigs weighing 30-35 kg.
To assess the effect of the SCD in septic shock, pigs were administered 30×1010 bacteria/kg body weight of Escherichia coli into the peritoneal cavity and within 1 hr were immediately placed in an extracorporeal circuit containing SCD.
Measurements and Main Results
In this animal model, the SCD with citrate compared to control groups without the SCD or with heparin anticoagulation ameliorated the cardiovascular instability and lung sequestration of activated leukocytes, reduced renal dysfunction and improved survival time compared to various control groups. This effect was associated with minimal elevations of systemic circulating neutrophil activation.
These preclinical studies along with two favorable exploratory clinical trials form the basis of an FDA-approved investigational device exemption for a pivotal multicenter, randomized control trial currently underway.
Although current dialysis techniques have transformed acute and chronic renal failure from uniformly fatal clinical disorders into treatable diseases, these therapies replace only the water and solute clearance function of the kidney and have reached a point where little further therapeutic improvement can be anticipated. In addition to their metabolic and endocrine functions, renal tubule cells presumably play an important role in the systemic inflammatory balance by participating in the complex and dynamic network of leukocyte action and pro- and anti-inflammatory cytokines. Loss of this function may result in a propensity to develop systemic inflammatory response syndrome (SIRS), multiorgan dysfunction, and a high risk of death in acute kidney injury (AKI), and may relate to chronic inflammatory state in end-stage renal disease (ESRD). A renal tubule cell assist device (RAD) containing animal and human renal tubule cells has been recently developed with the purpose of integrating the functions of tubule cells with the filtration function of current dialysis to offer a more complete renal replacement therapy. The viability and functionality of this device were confirmed in in vitro experiments and large-animal studies, and recently the RAD’s clinical therapeutic benefit was demonstrated with a series of FDA-approved human trials. Another novel synthetic membrane extracorporeal device that binds and inhibits circulating leukocytes has been developed with the purpose of reducing microvascular damage promoted primarily via activated circulating leukocytes in AKI and SIRS. This device, called a selective cytopheretic inhibitory device (SCD), mimics immunomodulation and duplicates RAD efficiency in preliminary studies. Both devices may become comprehensive treatments, replacing full renal function and correcting inflammatory imbalance in patients with acute and chronic renal disorders.
Sacral insufficiency fracture is a debilitating injury not easily found in general radiologic examinations and is rarely diagnosed, since its symptoms are obscure. It is known to frequently occur in patients with osteoporosis, but the treatment has not yet been established and various kinds of treatment methods are being attempted. Sacroplasty is sometimes performed by applying percutaneous vertebroplasty which is known to be a less invasive treatment. Since the course of diagnosis of sacral insufficiency fracture is difficult and clear guidelines for treatments have not yet been established, many spine surgeons fail to diagnose patients or speculate on treatment methods. We report our experience in diagnosing a sacral insufficiency fracture in a 54-year-old healthy female patient using MRI and treating her with sacroplasty. From a therapeutic point of view, we then cover the usefulness, effects and characteristics relating to the complications of sacroplasty, along with literature review.
Sacroplasty; Sacrum; Insufficiency fracture; Vertebroplasty; Kyphoplasty
To evaluate the anatomical parameters that must be considered when performing thoracic transpedicular or extrapedicular screw fixation.
We selected 958 vertebrae (1,916 pedicles) from 98 patients for analysis. Eight parameters were measured from CT scans : the transverse outer pedicular diameter, transverse inner pedicular diameter, length, angle, chord length of the pedicles and the transverse width, angle, and chord length of the pedicle-rib units.
The age of the patients ranged from 21 to 82 years (mean : 48.2 years) and there were 57 men and 41 women. The narrowest transverse outer pedicular diameter was at T5 (4.4 mm). The narrowest pedicle length was at T1 (15.9 mm). For pedicle angle, T1 was 31.6 degrees, which was the most convergent angle, and it showed the tendency of the lower the level, the lesser the convergent angle. The chord length showed a horizontal pattern with similar values at all levels. For the PRU width, T5 showed a similar pattern to the pedicle width at 13.4 mm. For the PRU angle, T1 was the largest angle at 46.2 degrees and the tendency was the lower the level, the narrower the angle. For chord length, T1 was the shortest at 46.9 mm and T8 was the longest at 60.1 mm.
When transpedicular screw fixations carried out at the mid-thoracic level, special care must be taken because there is a high chance of danger of medial wall violation. In these circumstances, extrapedicular screw fixation may be considered as an alternative treatment.
Pedicle screws; Extrapedicular screws; Thoracic spine; Pedicle morphology; Spine fixation; Morphology
Ligamentum flavum hematoma is a rare condition. Twenty cases including present case have been reported in English-language literature. Among them, only one case reported in pure thoracic spine. A 72-year-old man presented with thoracic myelopathy without precedent cause. Magnetic resonance images revealed a posterior semicircular mass which was located in T7 and T8 level compressing the spinal cord dorsally. T7-8 total laminectomy and extirpation of the mass was performed. One month later following surgery, the patient fully recovered to normal state. Pathologic result was confirmed as ligamentum flavum hematoma. Ligamentum flavum hematoma of rigid thoracic spine is a very rare disease entity. Most reported cases were confined to mobile cervical and lumbar spine. Surgeons should be aware that there seems to be another different pathogenesis
other than previously reported cases of mobile cervical and lumbar spine.
Ligamentum flavum; Hematoma; Thoracic spine; Myelopathy
Equations are frequently used to estimate resting energy expenditure (REE) in a clinical setting. However, few studies have examined their accuracy in end-stage renal disease (ESRD) patients.
Materials and Methods
To investigate agreement between indirect calorimetry and several REE estimating equations in 38 ESRD patients on peritoneal dialysis, we performed indirect calorimetry and compared the results with REEs estimated using 5 equations [Harris-Benedict (HBE), Mifflin, WHO, Schofield, and Cunningham].
Measured REE was 1393.2 ± 238.7 kcal/day. There were no significant differences between measured and estimated REEs except Mifflin (1264.9 ± 224.8 kcal/day). Root mean square errors were smallest for HBE, followed by Schofield, Cunningham, and WHO, and largest for Mifflin (171.3, 171.9, 174.6, 175.3, and 224.6, respectively). In Bland-Altman plot, correlation coefficients between mean values and differences were significant for HBE (r = 0.412, p = 0.012) and tended to be significant for Cunningham (r = 0.283, p = 0.086). In DM patients and patients with overhydration, HBE showed significant underestimation when REE increased.
In ESRD patients on continuous ambulatory peritoneal dialysis (CAPD), REE-estimating equations have no significant differences from indirect calorimetry, except Mifflin. However, HBE showed greater bias than others when REE was high.
Energy metabolism; chronic kidney failure; continuous ambulatory peritoneal dialysis
Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients.
According to Dellon's criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less).
Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbow-below the elbow) was 41.8±15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8±6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8±12.1 m/s to 47.8±12.1 m/s (p<0.05). After an average follow-up of 4.8±5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve.
Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.
Cubital tunnel syndrome; Ulnar nerve; Simple decompression
Protein-calorie malnutrition is prevalent in hemodialysis (HD) patients. The prevalence of obesity in healthy Korean adults has increased rapidly during the last 10 years. However, there are few large scale data collections available about the current weight status of Korean HD patients. The weight statuses of 10,304 HD patients (data from the Insan Memorial Dialysis Registry 2002, Korean Society of Nephrology) were compared to those of 12,436 control subjects (age > 18) by using body mass index (BMI). Weight status was assessed by WHO classification for Asian-Pacific region [underweight (UW): < 18.5; normal weight (NW): 18.5-22.9; overweight (OW): 23-24.9; obese (OB): 25-29.9; and extremely obese (EOB): > 30 kg/m2] in both the control and HD patients. HD patients had significantly lower body weight and BMI than the controls in all age groups and in both sexes. For the male controls, the proportions of OW and OB showed a reversed U-shape, peaking at the 5th and 6th decades. of the numbers of those classified as NW and UW were relatively small. For the female controls, the proportions of OW and OB progressively increased with age. On the contrary, in HD patients, the proportions of NW and UW were large, up to more than 70%, and those of OW and OB were small in both sexes. In each age group, UW was seen significantly more in the HD group than in the control group. The 6th decade age group showed the highest prevalence ratio for UW in the HD group for both sexes, compared to the controls (Male: 17.33, Female: 17.68). The percentages of UW were related to HD duration and age in both sexes. In conclusion, Korean HD patients seem to have small proportions of OW and OB, compared to the general population, and protein-calorie malnutrition may still be an important nutritional condition.
Body mass index; chronic kidney failure; anthropometry; renal dialysis
For developing race-specific anthropometry-based total body water (TBW) equations, we measured TBW using bioelectrical impedance analysis (TBWBIA) in 2,943 healthy Korean adults. Among them, 2,223 were used as a reference group. Two equations (TBWK1 and TBWK2) were developed based on age, sex, height, and body weight. The adjusted R2 was 0.908 for TBWK1 and 0.910 for TBWK2. The remaining 720 subjects were used for the validation of our results. Watson (TBWW) and Hume-Weyers (TBWH) formulas were also used. In men, TBWBIA showed the highest correlation with TBWH, followed by TBWK1, TBWK2 and TBWW. TBWK1 and TBWK2 showed the lower root mean square errors (RMSE) and mean prediction errors (ME) than TBWW and TBWH. On the Bland-Altman plot, the correlations between the differences and means were smaller for TBWK2 than for TBWK1. On the contrary, TBWBIA showed the highest correlation with TBWW, followed by TBWK2, TBWK1, and TBWH in females. RMSE was smallest in TBWW, followed by TBWK2, TBWK1 and TBWH. ME was closest to zero for TBWK2, followed by TBWK1, TBWW and TBWH. The correlation coefficients between the means and differences were highest in TBWW, and lowest in TBWK2. In conclusion, TBWK2 provides better accuracy with a smaller bias than the TBWW or TBWH in males. TBWK2 shows a similar accuracy, but with a smaller bias than TBWW in females.
Body Water; Electric Impedance; Anthropometry; Body Composition