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1.  Multiple Gamma Knife Radiosurgery for Multiple Metachronous Brain Metastases Associated with Lung Cancer : Survival Time 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2012.52.4.334
PMCID: PMC3488641  PMID: 23133721
Survival time; Gamma knife radiosurgery; Whole brain radiation therapy; Metastases; Lung cancer
2.  Rapid-Growing Juvenile Xanthogranuloma on the Scalp in 18-Month-Old Girl 
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.
doi:10.3340/jkns.2011.50.3.271
PMCID: PMC3218193  PMID: 22102964
Juvenile xanthogranuloma; Scalp
3.  Correlation between Serum D-Dimer Level and Volume in Acute Ischemic Stroke 
Objective
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.
Methods
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.
Results
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).
Conclusion
Our study shows that D-dimer level has the positive correlation with infarction volume and can be use to predict infarction-volume.
doi:10.3340/jkns.2011.50.2.89
PMCID: PMC3206284  PMID: 22053225
D-dimer; Acute ischemic stroke; Volume
4.  Emergency Carotid Artery Stent Insertion for Acute ICA Occlusion 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2010.47.6.428
PMCID: PMC2899029  PMID: 20617087
Cerebral infarction; Carotid stenosis; Stent
5.  Language Lateralization in Patients with Temporal Lobe Epilepsy : A Comparison between Volumetric Analysis and the Wada Test 
Objective
Determining language lateralization is important for the presurgical evaluation of patients with medically intractable epilepsy. The Wada test has been the gold standard for lateralization of language dominance before epilepsy surgery. However, it is an invasive test with risk, and have some limitations.
Methods
We compared the volumetric analysis with Wada test, and studied the clinical potential of volumetric analysis to assess language laterality in large surgical candidates with temporal lobe epilepsy (TLE). To examine the efficacy of volumetric analysis to determine language lateralization during presurgical evaluation, we compared the volumetric analysis of the bilateral planum temporale with the results of Wada test in 59 patients with chronic intractable TLE (rTLE, n=32; lTLE, n=27) who underwent epilepsy surgery. We measured the gray matter volumes of planum temporale (PT) of each patients using the VoxelPlus2 program (Mevisys, Daejeon, Korea).
Results
Overall congruence of the volumetric analysis with the Wada test was 97.75% in rTLE patients and 81.5% in lTLE patients. There were more significant leftward asymmetry of the PT in rTLE patients than lTLE patients. In lTLE patients, relatively high proportion (37%) of the patients showed bilateral or right hemispheric language dominance.
Conclusion
These results provide evidence that the volumetric analysis of the PT could be used as an alternatives in language lateralization. Also, the results of the Wada test suggested that there was considerable plasticity of language representation in the brains of patients with intractable TLE and it was associated with an earlier age of brain injury.
doi:10.3340/jkns.2009.45.6.329
PMCID: PMC2711229  PMID: 19609415
Cerebral dominance; Temporal lobe epilepsy; Wada; Volume
6.  Effect of Vagus Nerve Stimulation in Post-Traumatic Epilepsy and Failed Epilepsy Surgery : Preliminary Report 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2008.44.4.196
PMCID: PMC2588308  PMID: 19096676
Vagus nerve; Electric stimulation; Epilepsy; Post-traumatic
7.  Midline Glioblastoma Multiforme With Bilateral Symmetric Cysts 
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.
doi:10.3340/jkns.2008.43.2.105
PMCID: PMC2588232  PMID: 19096613
Glioblastoma multiforme; Cyst; Prognosis
8.  The Spot Sign Predicts Hematoma Expansion, Outcome, and Mortality in Patients with Primary Intracerebral Hemorrhage 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2014.56.4.303
PMCID: PMC4219187  PMID: 25371779
Intracerebral hemorrhage; Spot sign; Outcome; Mortality
9.  Surgical Recanalization of Distal Middle Cerebral Artery Occlusion Due to a Coil Migration During Endovascular Coil Embolization: A Case Report 
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.
doi:10.7461/jcen.2014.16.3.287
PMCID: PMC4205257  PMID: 25340033
Endovascular coil embolization; Cerebrovascular complication; Neurosurgical procedure
10.  Cerebral Infarction Presenting with Unilateral Isolated Foot Drop 
Weakness of the dorsiflexor muscles of the ankle or toe, referred to as foot drop, is a relatively common presentation. In most cases, foot drop is caused by a lower motor neuron disease such as peroneal peripheral neuropathy, L4-5 radiculopathic sciatic neuropathy, or polyneuropathy. Although upper motor neuron lesions can present as foot drop, the incidence is very rare. Here, we report an extremely rare case in which foot drop was the only presenting symptom of cerebral infarction.
doi:10.3340/jkns.2014.56.3.254
PMCID: PMC4217064  PMID: 25368770
Foot drop; Cerebral infarction; Upper motor neuron
11.  A Double-Blind, Sham-Controlled, Pilot Study to Assess the Effects of the Concomitant Use of Transcranial Direct Current Stimulation with the Computer Assisted Cognitive Rehabilitation to the Prefrontal Cortex on Cognitive Functions in Patients with Stroke 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2013.54.6.484
PMCID: PMC3921275  PMID: 24527190
Transcranial direct current stimulation; Brain polarization; Cognitive function; Prefrontal cortex; Computer-assisted cognitive rehabilitation
12.  Comparative Analysis of Serum Proteomes of Moyamoya Disease and Normal Controls 
Objective
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.
Methods
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.
Results
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).
Conclusion
Although our study had a small sample size, our proteomic data provide serologic clue proteins for understanding moyamoya disease.
doi:10.3340/jkns.2010.48.1.8
PMCID: PMC2916155  PMID: 20717506
Moyamoya disease; Proteome
13.  Treatment for Patients with Acute Ischemic Stroke Presenting beyond Six Hours of Ischemic Symptom Onset : Effectiveness of Intravenous Direct Thrombin Inhibitor, Argatroban 
Objective
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.
Methods
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.
Results
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.
Conclusion
IV argatroban may be an effective and safe treatment modality for acute ischemic stroke presenting beyond six hours of ischemic symptom onset.
doi:10.3340/jkns.2010.47.4.258
PMCID: PMC2864817  PMID: 20461165
Acute ischemic stroke; Intravenous argatroban
14.  Multimodal Therapy for Patients with Acute Ischemic Stroke : Outcomes and Related Prognostic Factors 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2009.45.6.360
PMCID: PMC2711234  PMID: 19609420
Acute ischemic stroke; Mechanical thrombolysis; Balloon angioplasty; Stenting; Prognostic factors

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