An advantage of surgical treatment over conservative treatment of spontaneous intracerebral hemorrhage (ICH) is controversial. Recent reports suggest that contrast extravasations on CT angiography (CTA) might serve as a crucial predictor of hematoma expansion and mortality. The purpose of this study was aimed at investigating the efficacy of surgical treatment in patients with spot sign positive ICH.
We used our institutional medical data search system to identify all adult patients who admitted for treatment of ICH between January 1, 2007 and January 31, 2012. Patients were classified two groups into a surgical group (n=27) and a conservative treatment group (n=28). Admission criteria were the following: age 20-79 years, spontaneous supratentorial ICH, Glasgow Coma Score Ranging from 9 to 14, ICH volume ≥20 mL, and treatment within 24 hours.
Fifty-five patients were analyzed. There was no significant difference in the ICU stay between the conservative treatment group (7.36±3.66 days) and the surgical treatment group (6.93±2.20 days; p=0.950). There was a significant difference in the in-hospital stay between the conservative treatment group (13.93±8.87 days) and the surgical treatment group (20.33±6.37 days; p=0.001). Overall mortality at day 90 after ICH was 36.4%; this included 16 of 28 patients (57.1%) in the conservative group and 4 of 27 patients (14.8%) in the surgical group. In univariate analysis, there was a positive effect of the surgical treatment in reducing mortality at 90 days (p=0.002), Glasgow Outcome Scale (GOS) at 90-day (p=0.006), and modified Rankin Scale (mRS) at 90-day (p=0.023). In multivariate logistic analysis, there was a significant difference in mortality (odds ratio, 0.211; 95% confidence interval, 0.049-0.906; p=0.036) between the groups at 90-day follow-up. However, there was no significant difference in GOS (odds ratio, 0.371; 95% confidence interval, 0.031-4.446; p=0.434) and mRS (odds ratio, 1.041; 95% confidence interval, 0.086-12.637; p=0.975) between the groups at 90-day follow-up.
In this study of surgical treatment of supratentorial ICH in patients with spot sign positive in CTA was associated with less mortality despite of long duration of in-hospital stay. We failed to show that clinical outcome benefit of surgical treatment compared with conservative treatment in patients with spot sign positive ICH.
Intracerebral hemorrhage; Spot sign; Surgery; Conservative treatment
The purpose of this study was to retrospectively review cases of intracerebral hemorrhage (ICH) medically treated at our institution to determine if the CT angiography (CTA) 'spot sign' predicts in-hospital mortality and clinical outcome at 3 months in patients with spontaneous ICH.
We conducted a retrospective review of all consecutive patients who were admitted to the department of neurosurgery. Clinical data of patients with ICH were collected by 2 neurosurgeons blinded to the radiological data and at the 90-day follow-up.
Multivariate logistic regression analysis identified predictors of poor outcome; we found that hematoma location, spot sign, and intraventricular hemorrhage were independent predictors of poor outcome. In-hospital mortality was 57.4% (35 of 61) in the CTA spot-sign positive group versus 7.9% (10 of 126) in the CTA spot-sign negative group. In multivariate logistic analysis, we found that presence of spot sign and presence of volume expansion were independent predictors for the in-hospital mortality of ICH.
The spot sign is a strong independent predictor of hematoma expansion, mortality, and poor clinical outcome in primary ICH. In this study, we emphasized the importance of hematoma expansion as a therapeutic target in both clinical practice and research.
Intracerebral hemorrhage; Spot sign; Outcome; Mortality
Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.
Endovascular coil embolization; Cerebrovascular complication; Neurosurgical procedure
To examine the synergistic effects of both computer-assisted cognitive rehabilitation (CACR) and transcranial direct current stimulation (tDCS) on cognitive function in patients with stroke.
The current double-blind, sham-controlled study enrolled a total of 11 patients who were newly diagnosed with stroke. The patients of the tDCS group (n=6) completed sessions of the Korean computer-assisted cognitive rehabilitation program five times a week for 30 minutes a session during a mean period of 18.5 days concomitantly with the anodal tDCS over the bilateral prefrontal cortex combined with the CACR. The patients of the control group (n=5) also completed sessions of the sham stimulation during a mean period of 17.8 days. Anodal tDCS over bilateral prefrontal cortex (F3 and F4 in 10-20 EEG system) was delivered for 30 minutes at an intensity of 2 mA. Cathode electrodes were applied to the non-dominant arm. All the patients were evaluated using the Seoul Computerized Neuropsychological Test (SCNT) and the Korean Mini-Mental State Examination.
Mann-Whitney U test revealed a significant difference between the two groups. The patients of the tDCS group achieved a significant improvement in the post/pre ratio of auditory continuous performance test and visual continuous performance test on the SCNT items.
Our results indicate that the concomitant use of the tDCS with CACR to the prefrontal cortex may provide additional beneficial effects in improving the cognitive dysfunction for patients with stroke.
Transcranial direct current stimulation; Brain polarization; Cognitive function; Prefrontal cortex; Computer-assisted cognitive rehabilitation
A 55-year-old female patient presented with lower back pain and neurogenic intermittent claudication and underwent L3-L4 posterolateral fusion. To prepare the bone fusion bed, the transverse process of L3 and L4 was decorticated with a drill. On the 9th post-operative day, the patient complained of a sudden onset of severe abdominal pain and distension. Abdominal computed tomography revealed retroperitoneal hematoma in the right psoas muscle and iatrogenic right L3 transverse process fracture. Lumbar spinal angiography showed the delayed hematoma due to rupture of the 2nd lumbar artery pseudoaneurysm and coil embolization was done at the ruptured lumbar artery pseudoaneusyrm. Since then, the patient's postoperative progress proceeded normally with recovery of the hemodynamic parameters.
Lumbar artery; Spinal fusion; Posterolateral fusion
To compare spinopelvic parameters in young adult patients with spondylolysis to those in age-matched patients without spondylolysis and investigate the clinical impact of sagittal spinopelvic parameters in patients with L5 spondylolysis.
From 2009 to 2012, a total of 198 young adult male patients with spondylolysis were identified. Eighty age-matched patients without spondylolysis were also selected. Standing lateral films that included both hip joints were obtained for each subject. Pelvic incidence (PI), sacral slope (SS), pelvic tilt, lumbar lordosis angle, sacral inclination, lumbosacral angle, and sacral table angle were measured in both groups. A comparative study of the spinopelvic parameters of these two groups was performed using SPSS 15.0 (SPSS Inc., Chicago, IL, USA).
Among the aforementioned spinopelvic parameters, PI, SS and STA were significantly different between patients with spondylolysis and those without spondylolysis. PI and SS were higher in the spondylolysis group than in the control group, but STA was lower in the spondylolysis group than in the control group.
PI and SS were higher in the spondylolysis group than in the control group, but STA was lower in the spondylolysis group than in the control group. Patients with spondylolysis have low STA at birth, which remains constant during growth; a low STA translates into high SS. As a result, PI is also increased in accordance with SS. Therefore, we suggest that STA is an important etiologic factor in young adult patients with L5 spondylolysis.
Spondylolysis; Spondylolisthesis; Spinal curvature
The etiology and pathogenesis of moyamoya disease remain unclear. Furthermore, the definitive diagnostic protein-biomarkers for moyamoya disease are still unknown. The present study analyzed serum proteomes from normal controls and moyamoya patients to identify novel serological biomarkers for diagnosing moyamoya disease.
We compared the two-dimensional electrophoresis patterns of sera from moyamoya disease patients and normal controls and identified the differentially-expressed spots by matrix-assisted laser desorption/ionization-time-of flight mass spectrometry and electrospray ionization quadruple time-of-flight mass spectrometry.
We found and analyzed 22 differently-expressed proteomes. Two proteins were up-regulated. Twenty proteins were down-regulated. Complement C1 inhibitor protein and apolipoprotein C-III showed predominantly changed expressions (complement C1 inhibitor protein averaged a 7.23-fold expression in moyamoya patients as compared to controls, while apolipoprotein C-III averaged a 0.066-fold expression).
Although our study had a small sample size, our proteomic data provide serologic clue proteins for understanding moyamoya disease.
Moyamoya disease; Proteome
We compared the survival time between patients with multiple gamma knife radiosurgery (GKRS) and patients with a single GKRS plus whole brain radiation therapy (WBRT), in patients with multiple metachronous brain metastases from lung cancer.
From May 2006 to July 2010, we analyzed 31 patients out of 112 patients who showed multiple metachronous brain metastases. 20 out of 31 patients underwent multiple GKRS (group A) and 11 patients underwent a single GKRS plus WBRT (group B). We compared the survival time between group A and B. Kaplan-Meier method and Cox proportional hazards were used to analyze relationship between survival and 1) the number of lesions in each patient, 2) the average volume of lesions in each patient, 3) the number of repeated GKRS, and 4) the interval of development of new lesions, respectively.
Median survival time was 18 months (range 6-50 months) in group A and 6 months (range 3-18 months) in group B. Only the average volume of individual lesion (over 10 cc) was negatively related with survival time according to Kaplan-Meier method. Cox-proportional hazard ratio of each variable was 1.1559 for the number of lesions, 1.0005 for the average volume of lesions, 0.0894 for the numbers of repeated GKRS, and 0.5970 for the interval of development of new lesions.
This study showed extended survival time in group A compared with group B. Our result supports that multiple GKRS is of value in extending the survival time in patients with multiple metachronous brain metastases, and that the number of the lesions and the frequency of development of new lesions are not an obstacle in treating patients with GKRS.
Survival time; Gamma knife radiosurgery; Whole brain radiation therapy; Metastases; Lung cancer
Intracranial squamous cell carcinoma is extremely rare, with most of the cases arising from malignant transformation of an epidermoid or a dermoid cyst. The patient presented with facial weakness. Initial magnetic resonance imaging revealed a mass in the right cerebellopontine angle. A subtotal resection was performed via right retrosigmoid suboccipital approach. Histopathological findings were consistent with an epidermoid tumor. Five months later, the patient underwent gamma knife radiosurgery due to highly probable recurrent epidermoid tumor. Two years after, the patient's neurological deficit had been newly developed, and follow-up magnetic resonance imaging demonstrated a large contrast-enhancing tumor in the left cerebellopontine angle, which compressed the brainstem. After resection of the tumor, histopathological examinations revealed a squamous cell carcinoma probably arising from an underlying epidermoid cyst. We report a case of an epidermoid tumor in the cerebellopontine angle that transformed into a squamous cell carcinoma.
Epidermoid cyst; Malignancy
Juvenile xanthogranuloma (JXG) is an uncommon histiocytic cutaneous lesion. An 18-month-old girl visited our clinic due to rapid growing orange-yellowish lesion on scalp. Enlarging time from 1 mm to 12 mm was just 8 weeks. We excised the tumor and adjacent normal tissue. Histopathological study showed numerous eosinophils and Touton giant cells within the lesion. Immunohistochemical study revealed positive immunoreactivity for CD68 in most areas. No recurrence was seen during 12 months after resection. We report a case with rapidly growing JXG on scalp with peculiar histopathologic findings.
Juvenile xanthogranuloma; Scalp
D-dimer is a breakdown product of fibrin mesh after factor XIII stabilization. Previously, many authors have demonstrated a relationship between D-dimer level and stroke progression or type. This study aimed to investigate the relationship between D-dimer level and stroke volume.
Between January 2008 and December 2009, we analyzed the D-dimer levels of 59 acute ischemic stroke patients in our neurosurgical department both upon admission and after seven days of initial treatment. Each patient's National Institute of Health Stroke Scale score, modified Rankin Scales score, Glasgow outcome score, and infarction volume were also evaluated.
Mean D-dimer level at admission was 626.6 µg/L (range, 77-4,752 µg/L) and the mean level measured after seven days of treatment was 238.3 µg/L (range, 50-924 µg/L). Mean D-dimer level at admission was 215.3 µg/L in patients with focal infarctions, 385.7 µg/L in patients with multiple embolic infarctions, 566.2 µg/L in those with 1-19 cc infarctions, 668.8 µg/L in 20-49 cc infarctions, 702.5 µg/L in 50-199 cc infarctions, and 844.0 µg/L in >200 cc infarctions (p=0.044). On the 7th day of treatment, the D-dimer levels had fallen to 201.0 µg/L, 293.2 µg/L, 272.0 µg/L, 232.8 µg/L, 336.6 µg/L, and 180.0 µg/L, respectively (p=0.530).
Our study shows that D-dimer level has the positive correlation with infarction volume and can be use to predict infarction-volume.
D-dimer; Acute ischemic stroke; Volume
An effective intervention has not yet been established for patients with acute occlusion of the internal carotid artery (ICA). The aim of our study was to investigate the feasibility, safety, and efficacy of emergent stent placement of carotid artery to improve neurologic symptoms and clinical outcome.
Of 84 consecutive patients with severe ICA stenosis who were admitted to our institution from March 2006 to May 2009, 10 patients with acute ICA occlusion (11.9%) underwent emergency carotid artery stent placement. We reviewed their records for neurologic outcome using the National Institutes of Health Stroke Scale (NIHSS) score, before and at 7 days after stent placement; clinical outcome using the modified Rankin Scale score (mRS) and Glasgow Outcome Scale (GOS); frequency of procedure-related complications; and recurrence rate of ipsilateral ischemic stroke within 90 days.
Carotid lesions were dilated completely in all patients. Median NIHSS scores before emergency stent placement and at 7 days were 16.6 and 6, respectively, showing significant improvement. Eight patients (80%) had favorable outcomes (mRS score 0-2 and GOS 4-5). Complications occurred in two patients (20%): stent insertion failed in one and an intracerebral hemorrhage occurred in the other. Ipsilateral ischemic stroke did not recur within 3 months.
Emergency carotid artery stent placement can improve the 7-day neurologic outcome and the 90-day clinical outcome in selected patients with acute cerebral infarction.
Cerebral infarction; Carotid stenosis; Stent
The objectives of this study were to analyze the outcome and hemorrhagic risk of intravenous (IV) argatroban in patients with acute ischemic stroke presenting beyond six hours of ischemic symptom onset.
Eighty patients with acute ischemic stroke who were admitted to the hospital beyond six hours from ischemic symptom onset were retrospectively analyzed. We could not perform IV thrombolysis or intra-arterial thrombolysis because of limited time window. So, IV argatroban was performed to prevent recurrent thrombosis and progression of infarcted area. The outcome was assessed by the National Institute of Health Stroke Scale (NIHSS) score and related hemorrhagic risk was analyzed. Also, each outcome was analyzed according to the initial stroke severity, subtype, and location.
The median NIHSS was 8.0 at admission, 4.1 upon discharge, and 3.3 after three months. A good outcome was achieved in 81% of patients upon discharge and 88% after three months. Symptomatic hemorrhage occurred in only two patients (3%). IV argatroban was effective regardless of initial stroke severity, subtype, and location.
IV argatroban may be an effective and safe treatment modality for acute ischemic stroke presenting beyond six hours of ischemic symptom onset.
Acute ischemic stroke; Intravenous argatroban
Multiplex PCR analyses of DNAs from genotypically unique Escherichia coli strains isolated from the feces of 138 humans and 376 domesticated animals from Jeonnam Province, South Korea, performed using primers specific for the chuA and yjaA genes and an unknown DNA fragment, TSPE4.C2, indicated that none of the strains belonged to E. coli phylogenetic group B2. In contrast, phylogenetic group B2 strains were detected in about 17% (8 of 48) of isolates from feces of 24 wild geese and in 3% (3 of 96) of isolates obtained from the Yeongsan River in Jeonnam Province, South Korea. The distribution of E. coli strains in phylogenetic groups A, B1, and D varied depending on the host examined, and there was no apparent seasonal variation in the distribution of strains in phylogenetic groups among the Yeongsan River isolates. The distribution of four virulence genes (eaeA, hlyA, stx1, and stx2) in isolates was also examined by using multiplex PCR. Virulence genes were detected in about 5% (38 of 707) of the total group of unique strains examined, with 24, 13, 13, and 9 strains containing hlyA, eaeA, stx2, and stx1, respectively. The virulence genes were most frequently present in phylogenetic group B1 strains isolated from beef cattle. Taken together, results of these studies indicate that E. coli strains in phylogenetic group B2 were rarely found in humans and domesticated animals in Jeonnam Province, South Korea, and that the majority of strains containing virulence genes belonged to phylogenetic group B1 and were isolated from beef cattle. Results of this study also suggest that the relationship between the presence and types of virulence genes and phylogenetic groupings may differ among geographically distinct E. coli populations.
The objectives of this study were to analyze the recanalization rates and outcomes of multimodal therapy that consisted of sequential intravenous (IV)/intra-arterial (IA) thrombolysis, mechanical thrombolysis including mechanical clot disruption using microcatheters and microwires, balloon angioplasty, and stenting for acute ischemic stroke, and to evaluate the prognostic factors related to the outcome.
Fifty patients who were admitted to the hospital within 8 hours from ischemic symptom onset were retrospectively analyzed. Initial IV thrombolysis and subsequent cerebral angiography were performed in all patients. If successful recanalization was not achieved by IV thrombolysis, additional IA thrombolysis with mechanical thrombolysis, including balloon angioplasty and stenting, were performed. The outcomes were assessed by the National Institute of Health Stroke Scale (NIHSS) change and modified Rankin scale (mRS) and prognostic factors were analyzed.
Successful recanalization was achieved in 42 (84%) of 50 patients, which consisted of 8 patients after IV thrombolysis, 19 patients after IA thrombolysis with mechanical clot disruption, and 15 patients after balloon angioplasty or stenting. Symptomatic hemorrhage occurred in 4 (8%) patients. Good outcomes were achieved in 76% and 70% of patients upon discharge, and 93% and 84% of patients after 3 months according to the NIHSS change and mRS. The initial clinical status, recanalization achievement, and presence of symptomatic hemorrhage were statistically related to the outcomes.
Multimodal therapy may be an effective and safe treatment modality for acute ischemic stroke. Balloon angioplasty and stenting is effective for acute thrombolysis, and produce higher recanalization rates with better outcomes.
Acute ischemic stroke; Mechanical thrombolysis; Balloon angioplasty; Stenting; Prognostic factors
Vagus nerve stimulation (VNS) has been used in epilepsy patients refractory to standard medical treatments and unsuitable candidates for resective or disconnective surgery. In this study, we investigated the efficacy of VNS to patients who had refractory result to epilepsy surgery and patients with post-traumatic epilepsy.
We analyzed the effect of VNS in 11 patients who had undergone previous epilepsy surgery and patients with intractable post-traumatic epilepsy associated with brain injury. All patients underwent VNS implantation between October 2005 and December 2006.
We evaluated seizure frequency before and after implantation of VNS and maximum follow up period was 24 months. In the first 6 months, 11 patients showed an average of 74.3% seizure reduction. After 12 months, 10 patients showed 85.2% seizure reduction. Eighteen months after implantation, 9 patients showed 92.4% seizure reduction and 7 patients showed 97.2% seizure reduction after 24 months. Six patients were seizure-free at this time.
We conclude that the VNS is a helpful treatment modality in patients with surgically refractory epilepsy and in patients with post-traumatic epilepsy due to severe brain injury.
Vagus nerve; Electric stimulation; Epilepsy; Post-traumatic
Cystic glioblastoma multiforme (GBM) is a rare disease. Its exact prevalence has not yet been reported. Also, the mechanism of cyst formation remains to be elucidated. We report a case of GBM with a large peripheral cyst. A 43-year-old woman visited our clinic with a 3-month history of severe headache, memory impairment and general weakness. T1-weighted gadolinium-enhanced magnetic resonance (MR) image revealed a midline enhanced solid mass and bilateral symmetric banana-shaped peripheral cysts. A centrally enhanced mass was measured 2×4 cm in size and both mass and cysts as 7×7 cm. Both the frontal lobe and the frontal horn were severely compressed inferiorly and posteriorly. We resected a midline solid tumor and cysts via the bilateral interhemispheric transcortical approach. Histopathologic examination revealed GBM. The patient was subsequently treated with fractionated conventional brain radiation therapy, followed by temozolomide chemotherapy. Eighteen months later, there was no tumor recurrence and no neurological deficits were noted. Our patient showed no tumor recurrence and a long survival at a long follow-up.
Glioblastoma multiforme; Cyst; Prognosis