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1.  Surgical Complications of Epilepsy Surgery Procedures : Experience of 179 Procedures in a Single Institute 
Objective
There are a few reports on the complications of surgery for epilepsy. We surveyed our data to present complications of epilepsy surgeries from the neurosurgeon's point of view and compare our results with other previous reports.
Methods
A total of 179 surgical procedures for intractable epilepsy (41 diagnostic, 138 therapeutic) were performed in 92 consecutive patients (10 adults, 82 children) during the last 9.2 years (February. 1997-April. 2006). Their medical records and radiological findings were reviewed to identify and analyze the surgical complications.
Results
The diagnostic procedures encompassed various combinations of subdural grid, subdural strips, and depth electrodes. Four minor transient complications developed in 41 diagnostic procedures (4/41=9.8%). A total of 138 therapeutic procedures included 28 anterior temporal lobectomies, 21 other lobectomies, 6 lesionectomies, 21 topectomies, 13 callosotomies, 20 vagus nerve stimulations, 13 multiple subpial transections, and 16 hemispherectomies. Twenty-six complications developed in therapeutic procedures (26/138=18.8%). Out of the 26 complications, 21 complications were transient and reversible (minor; 21/138=15.2%), and 5 were serious complications (major; 5/138=3.6%). Five major complications were one visual field defect, two mortality cases and two vegetative states. There were 2 additional mortality cases which were not related to the surgery itself.
Conclusion
Our results indicate that complication rate was higher than previous other reports in minor complications and was comparable in major complications. However, our results show relatively high frequency of mortality cases and severe morbidity case compared to other previous reports. The authors would like to emphasize the importance of acute postoperative care in young pediatric patients as well as meticulous surgical techniques to reduce morbidity and mortality in epilepsy surgery.
doi:10.3340/jkns.2008.44.4.234
PMCID: PMC2588306  PMID: 19096683
Epilepsy; Surgery; Intraoperative complication; Morbidity; Mortality
2.  Prognostic Factors and Clinical Outcomes of Acute Intracerebral Hemorrhage in Patients with Chronic Kidney Disease 
Objective
We conducted a retrospective study examining the outcomes of intracerebral hemorrhage (ICH) in patients with chronic kidney disease (CKD) to identify parameters associated with prognosis.
Methods
From January 2001 to June 2008, we treated 32 ICH patients (21 men, 11 women; mean age, 62 years) with CKD. We surveyed patients age, sex, underlying disease, neurological status using Glasgow Coma Scale (GCS), ICH volume, hematoma location, accompanying intraventricular hemorrhage, anti-platelet agents, initial and 3rd day systolic blood pressure (SBP), clinical outcome using the modified Rankin Scale (mRS) and complications. The severity of renal functions was categorized using a modified glomerular filtration rate (mGFR). Multifactorial effects were identified by regression analysis.
Results
The mean GCS score on admission was 9.4±4.4 and the mean mRS was 4.3±1.8. The overall clinical outcomes showed a significant relationship on initial neurological status, hematoma volume, and mGFR. Also, the outcomes of patients with a severe renal dysfunction were significantly different from those with mild/moderate renal dysfunction (p<0.05). Particularly, initial hematoma volume and sBP on the 3rd day after ICH onset were related with mortality (p<0.05). However, the other factors showed no correlation with clinical outcome.
Conclusion
Neurological outcome was based on initial neurological status, renal function and the volume of the hematoma. In addition, hematoma volume and uncontrolled blood pressure were significantly related to mortality. Hence, the severity of renal function, initial neurological status, hematoma volume, and uncontrolled blood pressure emerged as significant prognostic factors in ICH patients with CKD.
doi:10.3340/jkns.2013.54.4.296
PMCID: PMC3841271  PMID: 24294452
Intracerebral hemorrhage; Chronic kidney disease; Renal failure; Modified Rankin Scale; Prognosis; Mortality
3.  The Clinical Efficacy of Decompressive Craniectomy in Patients with an Internal Carotid Artery Territory Infarction 
Objective
To evaluate the surgical efficacy of and factors associated with decompressive craniectomy in patients with an internal carotid artery (ICA) territory infarction.
Methods
Seventeen patients (8 men and 9 women, average age 61.53 years, range 53-77 years) were treated by decompressive craniectomy for an ICA territory infarction at our institute. We retrospectively reviewed medical records, radiological findings, and National Institutes of Health Stroke Scale (NIHSS) at presentation and before surgery. Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS).
Results
Of the 17 patients, 15 (88.24%) achieved a poor outcome (Group A, GOS 1-3) and 2 (11.76%) a good outcome (Group B, GOS 4-5). The mortality rate at one month after surgery was 52.9%. Average preoperative NIHSS was 27.6±10.88% in group A and 10±4.24% in group B. Mean cerebral infarction fraction at the septum pellucidum level before surgery in group A and B were 33.67% and 23.72%, respectively. Mean preoperative NIHSS (p=0.019) and cerebral infarction fraction at the septum pellucidum level (p=0.017) were found to be significantly associated with a better outcome. However, no preexisting prognostic factor was found to be of statistical significance.
Conclusion
The rate of mortality after ICA territory infarction treatment is relatively high, despite positive evidence for surgical decompression, and most survivors experience severe disabilities. Our findings caution that careful consideration of prognostic factors is required when considering surgical treatment.
doi:10.3340/jkns.2012.52.4.293
PMCID: PMC3488635  PMID: 23133715
Cerebral infarction; Decompressive craniectomy; Surgical efficacy
4.  The Unusual Origin of the Sternocleidomastoid Artery from the Lingual Artery 
The sternocleidomastoid (SCM) artery supplying blood to the SCM muscle has different origins according to its anatomical segment. The authors performed cadaveric neck dissection to review the surgical anatomy of neurovascular structures surrounding the carotid artery in the neck. During the dissection, an unusual finding was cited in which the SCM artery supplying the middle part of the SCM muscle originated from the lingual artery (LA); it was also noted that it crossed over the hypoglossal nerve (HN). There have been extremely rare reports citing the SCM artery originated from the LA. Though the elevation of the HN over the internal carotid artery was relatively high, the vascular loop crossing over the HN was very close to the carotid bifurcation. Special anatomical consideration is required to avoid the injury of the HN during carotid artery surgery.
doi:10.3340/jkns.2012.51.1.44
PMCID: PMC3291706  PMID: 22396843
Lingual artery; Carotid artery surgery; SCM artery; Hypoglossal nerve
5.  Clinical Outcomes of Halo-Vest Immobilization and Surgical Fusion of Odontoid Fractures 
Objective
In the present study, authors retrospectively reviewed the clinical outcomes of halo-vest immobilization (HVI) versus surgical fixation in patients with odontoid fracture after either non-surgical treatment (HVI) or with surgical fixation.
Methods
From April 1997 to December 2008, we treated a total of 60 patients with upper cervical spine injuries. This study included 31 (51.7%) patients (22 men, 9 women; mean age, 39.3 years) with types II and III odontoid process fractures. The average follow-up was 25.1 months. We reviewed digital radiographs and analyzed images according to type of injury and treatment outcomes, following conservative treatment with HVI and surgical management with screw fixation.
Results
There were a total of 31 cases of types II and III odontoid process fractures (21 odontoid type II fractures, 10 type III fractures). Fifteen patients underwent HVI (10 type II fractures, 5 type III fractures). Nine (60%) out of 15 patients who underwent HVI experienced successful healing of odontoid fractures. The mean period for bone healing was 20.2 weeks. Sixteen patients underwent surgery including anterior screw fixation (6 cases), posterior C1-2 screw fixation (8), and transarticular screw fixation (2) for healing the odontoid fractures (11 type II fractures, 5 type III fractures). Fifteen (93.8%) out of 16 patients who underwent surgery achieved healing of cervical fractures. The average bone healing time was 17.6 weeks.
Conclusion
The overall healing rate was 60% after HVI and 93.8% with surgical management. Patients treated with surgery showed a higher fusion rate and shorter bony healing time than patients who received HVI. However, prospective studies are needed in the future to define better optimal treatment and cost-effective perspective for the treatment of odontoid fractures.
doi:10.3340/jkns.2011.50.1.17
PMCID: PMC3159875  PMID: 21892399
Cervical fracture; Odontoid fracture; Operation; Halovest; Bony healing
6.  Optimal Use of the Halo-Vest Orthosis for Upper Cervical Spine Injuries 
Yonsei Medical Journal  2010;51(5):648-652.
Purpose
Upper cervical fractures can heal with conservative treatments such as halo-vest immobilization (HVI) and Minerva jackets without surgery. The most rigid of these, HVI, remains the most frequently used treatment in many centers despite its relatively high frequency of orthosis-related complications. We conducted this study to investigate the clinical outcome, effectiveness, patient satisfaction, and associated complications of HVI.
Materials and Methods
From April 1997 to December 2008, we treated 23 patients for upper cervical spinal injuries with HVI. For analysis, we divided high cervical fractures into four groups, including C1 fracture, C2 dens fracture, C2 hangman's fracture, and C1-2 associated fracture. We evaluated the clinical outcome, complications, and patient satisfaction through chart reviews and a telephone questionnaire.
Results
The healing rate for upper cervical fracture using HVI was 60.9%. In most cases, bony healing occurred within 16 weeks. Older patients required longer fusion time. We observed a 39.1% failure rate, and 60.9% of patients experienced complications. The most common complications were frequent pin loosening (34.8%; 8/23) and pin site infection (17.4%; 4/23). The HVI treatment failed in 66.7% of patients with pin site problems. The patient approval rate was 31.6%.
Conclusion
The HVI produced frequent complications and low patient satisfaction. Bony fusion succeeded in 60.9% of patients. Pin site complications showed a tendency to influence the outcome of HVI, and would be promptly addressed to prevent treatment failure if they develop. The decision to use HVI requires an explanation to the patient of potential complications and constant vigilance to prevent such complications and unsatisfactory outcomes.
doi:10.3349/ymj.2010.51.5.648
PMCID: PMC2908866  PMID: 20635437
Halo-vest; cervical trauma; bony healing; complication
7.  Decompressive Surgery in a Patient with Posttraumatic Syringomyelia 
Posttraumatic syringomyelia may result from a variety of inherent conditions and traumatic events, or from some combination of these. Many hypotheses have arisen to explain this complex disorder, but no consensus has emerged. A 28-year-old man presented with progressive lower extremity weakness, spasticity, and decreased sensation below the T4 dermatome five years after an initial trauma. Magnetic resonance imaging (MRI) revealed a large, multi-septate syrinx cavity extending from C5 to L1, with a retropulsed bony fragment of L2. We performed an L2 corpectomy, L1-L3 interbody fusion using a mesh cage and screw fixation, and a wide decompression and release of the ventral portion of the spinal cord with an operating microscope. The patient showed complete resolution of his neurological symptoms, including the bilateral leg weakness and dysesthesia. Postoperative MRI confirmed the collapse of the syrinx and restoration of subarachnoid cerebrospinal fluid (CSF) flow. These findings indicate a good correlation between syrinx collapse and symptomatic improvement. This case showed that syringomyelia may develop through obstruction of the subarachnoid CSF space by a bony fracture and kyphotic deformity. Ventral decompression of the obstructed subarachnoid space, with restoration of spinal alignment, effectively treated the spinal canal encroachment and post-traumatic syringomyelia.
doi:10.3340/jkns.2010.47.3.228
PMCID: PMC2851081  PMID: 20379479
Syringomyelia; Magnetic resonance imaging; Trauma; Subarachnoid space; Obstruction
8.  Early Dorsal Midbrain Syndrome Mimicking an Adie's Tonic Pupil 
Background
While tonic pupils have been attributed to various diseases, including syphilis, herpes zoster, orbital trauma, temporal arteritis, endometriosis, and paraneoplastic syndromes, obstructive hydrocephalus has not been implicated.
Case Report
A 36-year-old woman visited a neurology department with a 7-day history of throbbing headache and blurred vision in both eyes. She had early dorsal midbrain syndrome mimicking an Adie's tonic pupil, and cholinergic supersensitivity was demonstrated using topical 0.125% pilocarpine. Brain MRI revealed obstructive hydrocephalus at the level of the aqueduct of Sylvius, and her symptoms resolved 4 days after surgery.
Conclusions
We report a patient with early dorsal midbrain syndrome that was initially believed to represent a tonic pupil on the basis of pharmacologic testing. The findings in our patient suggested that early dorsal midbrain syndrome mimicking an Adie's tonic pupil can be caused by obstructive hydrocephalus compressing the Edinger-Westphal nucleus.
doi:10.3988/jcn.2010.6.1.38
PMCID: PMC2851291  PMID: 20386642
dorsal midbrain syndrome; cholinergic supersensitivity; Adie's tonic pupil
9.  Anterior Communicating Artery Aneurysm Related to Visual Symptoms 
Objective
Intracranial aneurysms are sometimes presented with visual symptoms by their rupture or direct compression of the optic nerve. It is because their prevalent sites are anatomically located close to the optic pathway. Anterior communicating artery is especially located in close proximity to optic nerve. Aneurysm arising in this area can produce visual symptoms according to their direction while the size is small. Clinical importance of visual symptoms presented by aneurysmal optic nerve compression is stressed in this study.
Methods
Retrospective analysis of ruptured anterior communicating artery aneurysms compressing optic apparatus were carried out. Total 33 cases were enrolled in this study. Optic nerve compression of the aneurysms was confirmed by the surgical fields.
Results
In 33 cases among 351 cases of ruptured anterior communicating artery aneurysms treated surgically, from 1991 to 2000, the dome of aneurysm was compressed in optic pathway. In some cases, aneurysm impacted into the optic nerve that deep hollowness was found when the aneurysm sac was removed during operation. Among 33 cases, 10 cases presented with preoperative visual symptoms, such as visual dimness (5), unilateral visual field defect (2) or unilateral visual loss (3), 20 cases had no visual symptoms. Visual symptoms could not be checked in 3 cases due to the poor mental state. In 6 cases among 20 cases having no visual symptoms, optic nerve was deeply compressed by the dome of aneurysm which was seen in the surgical field. Of 10 patients who had visual symptoms, 8 showed improvement in visual symptoms within 6 months after clipping of aneurysms. In 2 cases, the visual symptoms did not recover.
Conclusion
Anterior communicating artery aneurysm can cause visual symptoms by compressing the optic nerve or direct rupture to the optic nerve with focal hematoma formation. We emphasize that cerebral vascular study is highly recommended to detect intracranial aneurysm before its rupture in the case of normal CT findings with visual symptoms and frequent headache.
doi:10.3340/jkns.2009.46.3.232
PMCID: PMC2764022  PMID: 19844624
Anterior communicating artery; Intracranial aneurysm; Optic pathway; Visual Symptoms
10.  Surgical Management of Massive Cerebral Infarction 
Objective
The aim of this study was to analyze the treatment results and prognostic factors in patients with massive cerebral infarction who underwent decompressive craniectomy.
Methods
From January 2000 to December 2005, we performed decompressive craniectomy in 24 patients with massive cerebral infarction. We retrospectively reviewed the medical records, radiological findings, initial clinical assessment using the Glasgow Coma Scale, serial computerized tomography (CT) with measurement of midline and septum pellucidum shift, and cerebral infarction territories. Patients were evaluated based on the following factors : the pre- and post-operative midline shifting on CT scan, infarction area or its dominancy, consciousness level, pupillary light reflex and Glasgow Outcome Scale.
Results
All 24 patients (11 men, 13 women; mean age, 63 years; right middle cerebral artery (MCA) territory, 17 patients; left MCA territory, 7 patients) were treated with large decompressive craniectomy and duroplasty. The average time interval between the onset of symptoms and surgical decompression was 2.5 days. The mean Glasgow Coma Scale was 12.4 on admission and 8.3 preoperatively. Of the 24 surgically treated patients, the good outcome group (Group 2 : GOS 4-5) comprised 9 cases and the poor outcome group (Group1 : GOS 1-3) comprised 15 cases.
Conclusion
We consider decompressive craniectomy for large hemispheric infarction as a life-saving procedure. Good preoperative GCS, late clinical deterioration, small size of the infarction area, absence of anisocoria, and preoperative midline shift less than 11mm were considered to be positive predictors of good outcome. Careful patient selection based on the above-mentioned factors and early operation may improve the functional outcome of surgical management for large hemispheric infarction.
doi:10.3340/jkns.2007.42.4.331
PMCID: PMC2588216  PMID: 19096565
Acute cerebral infarction; Brain edema; Brain herniation; Decompressive craniectomy; Intracranial pressure
11.  Vagus Nerve Stimulation in Intractable Childhood Epilepsy: a Korean Multicenter Experience 
Journal of Korean Medical Science  2007;22(3):442-445.
We evaluated the long-term outcome of vagus nerve stimulation (VNS) in 28 children with refractory epilepsy. Of these 28 children, 15 (53.6%) showed a >50% reduction in seizure frequency and 9 (32.1%) had a >75% reduction. When we compared seizure reduction rates according to seizure types (generalized vs. partial) and etiologies (symptomatic vs. cryptogenic), we found no significant differences. In addition, there was no correlation between the length of the stimulation period and treatment effect. The seizure reduction rate, however, tended to be inversely related to the seizure duration before VNS implantation and age at the time of VNS therapy. VNS also improved quality of life in this group of patients, including improved memory in 9 (32.1%), improved mood in 12 (42.9%), improved behavior in 11 (39.3%), improved altertness in 12 (42.9%), improved achievement in 6 (21.4%), and improved verbal skills in 8 (28.6%). Adverse events included hoarseness in 7 patients, dyspnea at sleep in 2 patients, and wound infection in 1 patient, but all were transient and successfully managed by careful follow-up and adjustment of parameters. These results indicate that VNS is a safe and effective alternative therapy for pediatric refractory epilepsy, without significant adverse events.
doi:10.3346/jkms.2007.22.3.442
PMCID: PMC2693635  PMID: 17596651
Vagus Nerve Stimulation; Epilepsy; Child
12.  Effects of Methylprednisolone on the Neural Conduction of the Motor Evoked Potentials in Spinal Cord Injured Rats 
Journal of Korean Medical Science  2005;20(1):132-138.
Methylprednisolone (MP), a glucocorticoid steroid, has an anti-inflammatory action and seems to inhibit the formation of oxygen free radicals produced during lipid peroxidation in a spinal cord injury (SCI). However, the effects of MP on the functional recovery after a SCI is controversial. The present study was conducted to determine the effects of MP on the recovery of neural conduction following a SCI. A SCI was produced using the NYU spinal cord impactor. A behavioral test was conducted to measure neurological disorders, and motor evoked potentials (MEPs) were recorded. According to the behavioral test, using BBB locomotor scaling, MP-treated animals showed improved functional recoveries when compared to salinetreated animals. MEP latencies in the MP-treated group were shortened when compared to those in the control group. Peak amplitudes of MEPs were larger in the MP-treated group than those in the control group. The thresholds of MEPs tended to be lower in the MP-treated group than those in the control group. These results suggest that MP may improve functional recovery after a SCI.
doi:10.3346/jkms.2005.20.1.132
PMCID: PMC2808560  PMID: 15716618
Spinal Cord Injuries; Methylprednisolone; Behavior; Evoked Potentials; Recovery of Function
14.  Cloning and Analysis of a DNA Fragment Stimulating Avermectin Production in Various Streptomyces avermitilis Strains 
To isolate a gene for stimulating avermectin production, a genomic library of Streptomyces avermitilis ATCC 31267 was constructed in Streptomyces lividans TK21 as the host strain. An 8.0-kb DNA fragment that significantly stimulated actinorhodin and undecylprodigiosin production was isolated. When wild-type S. avermitilis was transformed with the cloned fragment, avermectin production increased approximately 3.5-fold. The introduction of this fragment into high-producer (ATCC 31780) and semi-industrial (L-9) strains also resulted in an increase of avermectin production by more than 2.0- and 1.4-fold, respectively. Subclones were studied to locate the minimal region involved in stimulation of pigmented-antibiotic and avermectin production. An analysis of the nucleotide sequence of the entire DNA fragment identified eight complete and one incomplete open reading frame. All but one of the deduced proteins exhibited strong homology (68 to 84% identity) to the hypothetical proteins of Streptomyces coelicolor A3(2). The orfX gene product showed no significant similarity to any other protein in the databases, and an analysis of its sequence suggested that it was a putative membrane protein. Although the nature of the stimulatory effect is still unclear, the disruption of orfX revealed that this gene was intrinsically involved in the stimulation of avermectin production in S. avermitilis.
doi:10.1128/AEM.69.2.1263-1269.2003
PMCID: PMC143579  PMID: 12571055

Results 1-14 (14)