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1.  Development of an Ex Vivo Model for the Study of Cerebrovascular Function Utilizing Isolated Mouse Olfactory Artery 
Objective
Cerebral vessels, such as intracerebral perforating arterioles isolated from rat brain, have been widely used as an ex vivo model to study the cerebrovascular function associated with cerebrovascular disorders and the therapeutic effects of various pharmacological agents. These perforating arterioles, however, have demonstrated differences in the vascular architecture and reactivity compared with a larger leptomeningeal artery which has been commonly implicated in cerebrovascular disease. In this study, therefore, we developed the method for studying cerebrovascular function utilizing the olfactory artery isolated from the mouse brain.
Methods
The olfactory artery (OA) was isolated from the C57/BL6 wild-type mouse brain. After removing connective tissues, one side of the isolated vessel segment (approximately -500 µm in length) was cannulated and the opposite end of the vessel was completely sealed while being viewed with an inverted microscope. After verifying the absence of pressure leakage, we examined the vascular reactivity to various vasoactive agents under the fixed intravascular pressure (60 mm Hg).
Results
We found that the isolated mouse OAs were able to constrict in response to vasoconstrictors, including KCl, phenylephrine, endothelin-1, and prostaglandin PGH2. Moreover, this isolated vessel demonstrated vasodilation in a dose-dependent manner when vasodilatory agents, acetylcholine and bradykinin, were applied.
Conclusion
Our findings suggest that the isolated olfactory artery would provide as a useful ex vivo model to study the molecular and cellular mechanisms of vascular function underlying cerebrovascular disorders and the direct effects of such disease-modifying pathways on cerebrovascular function utilizing pharmacological agents and genetically modified mouse models.
doi:10.3340/jkns.2015.57.1.1
PMCID: PMC4323498
Cerebral artery; Vasodilation; Vasoconstriction
2.  Covered Stents for the Endovascular Treatment of a Direct Carotid Cavernous Fistula : Single Center Experiences with 10 Cases 
Objective
Covered stent has been recently reported as an effective alternative treatment for direct carotid cavernous fistulas (DCCFs). The purpose of this study is to describe our experiences with the treatment of DCCF with covered stents and to evaluate whether a covered stent has a potential to be used as the first choice in selected cases.
Methods
From February 2009 through July 2013, 10 patients underwent covered stent placement for a DCCF occlusion. Clinical and angiographic data were retrospectively reviewed.
Results
Covered stent placement was performed for five patients primarily as the first choice and in the other five as an alternative option. Access and deployment of a covered stent was successful in all patients (100%) and total occlusion of the fistula was achieved in nine (90%). Complete occlusion immediately after the procedure was obtained in five patients (50%). Endoleak persisted in five patients and the fistulae were found to be completely occluded by one month control angiography in four. The other patient underwent additional coil embolization by a transvenous approach. Balloon inflation-related arterial dissection during the procedure was noted in two cases; healing was noted at follow-up angiography. One patient suffered an asymptomatic internal carotid artery occlusion noted seven months post-treatment.
Conclusion
Although endoleak is currently a common roadblock, our experience demonstrates that a covered stent has the potential to be used as the first choice in DCCF; this potential is likely to increase as experience with this device accumulates and the materials continue to improve.
doi:10.3340/jkns.2015.57.1.12
PMCID: PMC4323499
Carotid cavernous fistula; Covered stent; Endovascular treatment
3.  A Design for Evaluation of the Trauma Apportionment in Cerebral Infarction after Trauma 
Objective
Posttraumatic cerebral infarction (CI) is a well-known complication of traumatic brain injury (TBI). However, the causation and apportionment of trauma in patients with CI after TBI is not easy. There is a scoring method, so-called trauma apportionment score (TAS) for CI, consisted with the age, the interval, and the severity of the TBI. We evaluated the reliability of this score.
Methods
We selected two typical cases of traumatic CI. We also selected consecutive 50 patients due to spontaneous CI. We calculated TAS in both patients with traumatic and spontaneous CI. To enhance the reliability, we revised TAS (rTAS) adding three more items, such as systemic illness, bad health habits, and doctor's opinion. We also calculated rTAS in the same patients.
Results
Even in 50 patients with spontaneous CI, the TAS was 4 in 44 patients, and 5 in 6 patients. TAS could not assess the apportionment of trauma efficiently. We recalculated the rTAS in the same patients. The rTAS was not more than 11 in more than 70% of the spontaneous CI. Compared to TAS, rTAS definitely enhanced the discriminating ability. However, there were still significant overlapping areas.
Conclusion
TAS alone is insufficient to differentiate the cause or apportionment of trauma in some obscure cases of CI. Although the rTAS may enhance the reliability, it also should be used with cautions.
doi:10.3340/jkns.2015.57.1.19
PMCID: PMC4323500
Cerebral infarction; Causality; Compensation and redress; Craniocerebral trauma
4.  The Influence of Pituitary Adenoma Size on Vision and Visual Outcomes after Trans-Sphenoidal Adenectomy: A Report of 78 Cases 
Objective
The aims of this study were to investigate the quantitative relationship between pituitary macroadenoma size and degree of visual impairment, and assess visual improvement after surgical resection of the tumor.
Methods
The medical records of patients with pituitary adenoma, who had undergone trans-sphenoidal adenectomy between January 2009 and January 2011, were reviewed. Patients underwent an ocular examination and brain MRI before and after surgery. The visual impairment score (VIS) was derived by combining the scores of best-corrected visual acuity and visual field. The relationship between VIS and tumor size/tumor type/position of the optic chiasm was assessed.
Results
Seventy-eight patients were included (41 male, 37 female). Thirty-two (41%) patients experienced blurred vision or visual field defect as an initial symptom. Receiver operating characteristic curve analysis showed that tumors <2.2 cm tended to cause minimal or no visual impairment. Statistical analysis showed that 1) poor preoperative vision is related to tumor size, displacement of the optic chiasm in the sagittal view on MRI and optic atrophy, and 2) poorer visual prognosis is associated with greater preoperative VIS. In multivariate analysis the only factor significantly related to VIS improvement was increasing pituitary adenoma size, which predicted decreased improvement.
Conclusion
Results from this study show that pituitary adenomas larger than 2 cm cause defects in vision while adenomas 2 cm or smaller do not cause significant visual impairment. Patients with a large macroadenoma or giant adenoma should undergo surgical resection as soon as possible to prevent permanent visual loss.
doi:10.3340/jkns.2015.57.1.23
PMCID: PMC4323501
Ophthalmologic surgical procedures; Pituitary adenoma; Visual fields; Visual impairment
5.  Clinical Analysis of Acute Radiculopathy after Osteoporotic Lumbar Compression Fracture 
Objective
The purpose of this study was to analyze the relationship between fracture pattern and the development of acute radiculopathy after osteoporotic lumbar compression fracture.
Methods
This study included 59 patients who underwent bone cement augmentation for osteoporotic compression fracture below the L2 level, which can lead to radiculopathic radiating pain. The patients were divided into two groups according to the presence of radiculopathy (group A : back pain only; group B : back pain with newly developed radiating pain). We categorized compression fractures into three types by the position of the fracture line. The incidence of newly developed radiculopathy was examined retrospectively for each compression fracture type.
Results
The overall incidence of newly developed leg pain (group B) was 25%, and the frequency increased with descending spinal levels (L2 : 0%, L3 : 22%, L4 : 43%, and L5 : 63%). The back pain-only group (group A) had mostly superior-type fractures. On the other hand, the back pain with radiculopathy group (group B) had mostly inferior-type fractures. Most patients in group B showed significant relief of leg pain as well as back pain after bone cement augmentation.
Conclusion
The incidence of a newly developed, radiating pain after osteoporotic compression fractures increased gradually from the L3 to L5 levels. Most of these fractures were of the inferior type, and the bone cement augmentation procedures seemed to be sufficient for relief of both back and radiating pain.
doi:10.3340/jkns.2015.57.1.32
PMCID: PMC4323502
Fracture; Osteoporosis; Radiculopathy
6.  Outcomes of Secondary Laminoplasty for Patients with Unsatisfactory Results after Anterior Multilevel Cervical Surgery 
Objective
To investigate the causes for failed anterior cervical surgery and the outcomes of secondary laminoplasty.
Methods
Seventeen patients failed anterior multilevel cervical surgery and the following conservative treatments between Feb 2003 and May 2011 underwent secondary laminoplasty. Outcomes were evaluated by the Japanese Orthopaedic Association (JOA) Scale and visual analogue scale (VAS) before the secondary surgery, at 1 week, 2 months, 6 months, and the final visit. Cervical alignment, causes for revision and complications were also assessed.
Results
With a mean follow-up of 29.7±12.1 months, JOA score, recovery rate and excellent to good rate improved significantly at 2 months (p<0.05) and maintained thereafter (p>0.05). Mean VAS score decreased postoperatively (p<0.05). Lordotic angle maintained during the entire follow up (p>0.05). The causes for secondary surgery were inappropriate approach in 3 patients, insufficient decompression in 4 patients, adjacent degeneration in 2 patients, and disease progression in 8 patients. Complications included one case of C5 palsy, axial pain and cerebrospinal fluid leakage, respectively.
Conclusion
Laminoplasty has satisfactory results in failed multilevel anterior surgery, with a low incidence of complications.
doi:10.3340/jkns.2015.57.1.36
PMCID: PMC4323503
Cervical spondylosis; Anterior discectomy and fusion; Anterior corpectomy and fusion; Laminoplasty
7.  Surgical Management with Radiation Therapy for Metastatic Spinal Tumors Located on Cervicothoracic Junction : A Single Center Study 
Objective
The cervicothoracic junction (CTJ) is a biomechanically and anatomically complex region that has traditionally posed problems for surgical access. In this retrospective study, we describe our clinical experiences of the treatment of metastatic spinal tumors at the CTJ and the results.
Methods
From June 2006 to December 2011, 23 patients who underwent surgery for spinal tumors involving the CTJ were enrolled in our study. All of the patients were operated on through the posterior approach, and extent of resection was classified as radical, debulking, and simple neural decompression. Adjuvant radiation therapy (RT) was also considered. Visual analog scale score for pain assessment and Medical Research Council (MRC) grade for motor weakness were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG).
Results
Almost all of the patients were operated using palliative surgical methods (91.3%, 21/23). Ten complications following surgery occurred and revision was performed in four patients. Of the 23 patients of this study, 22 showed significant pain relief according to their visual analogue scale scores. Concerning the aspect of neurological and functional recovery, mean MRC grade and ECOG score was significantly improved after surgery (p<0.05). In terms of survival, radiation therapy had a significant role. Median overall survival was 124 days after surgery, and the adjuvant-RT group (median 214 days) had longer survival times than prior-RT (63 days) group.
Conclusion
Although surgical procedure in CTJ may be difficult, we expect good clinical results by adopting a palliative posterior surgical method with appropriate preoperative preparation and postoperative treatment.
doi:10.3340/jkns.2015.57.1.42
PMCID: PMC4323504
Metastatic spinal tumor; Cervicothoracic junction; Treatment
8.  The Neuromodulation of Neuropathic Pain by Measuring Pain Response Rate and Pain Response Duration in Animal 
Objective
Neuropathic pain causes patients feel indescribable pain. Deep Brain Stimulation (DBS) is one of the treatment methods in neuropathic pain but the action mechanism is still unclear. To study the effect and mechanism of analgesic effects from DBS in neuropathic pain and to enhance the analgesic effect of DBS, we stimulated the ventral posterolateral nucleus (VPL) in rats.
Methods
To observe the effect from VPL stimulation, we established 3 groups : normal group (Normal group), neuropathic pain group (Pain group) and neuropathic pain+DBS group (DBS group). Rats in DBS group subjected to electrical stimulation and the target is VPL.
Results
We observed the behavioral changes by DBS in VPL (VPL-DBS) on neuropathic pain rats. In our study, the pain score which is by conventional test method was effectively decreased. In specific, the time of showing withdrawal response from painful stimulation which is not used measuring method in our animal model was also decreased by DBS.
Conclusion
The VPL is an effective target on pain modulation. Specifically we could demonstrate changes of pain response duration which is not used, and it was also significantly meaningful. We thought that this study would be helpful in understanding the relation between VPL-DBS and neuropathic pain.
doi:10.3340/jkns.2015.57.1.6
PMCID: PMC4323508
Neuropathic pain; Deep brain stimulation; Ventral poterolateral nucleus; Neuromodulation
9.  A New Measure for Monitoring Intraoperative Somatosensory Evoked Potentials 
Objective
To propose a new measure for effective monitoring of intraoperative somatosensory evoked potentials (SEP) and to validate the feasibility of this measure for evoked potentials (EP) and single trials with a retrospective data analysis study.
Methods
The proposed new measure (hereafter, a slope-measure) was defined as the relative slope of the amplitude and latency at each EP peak compared to the baseline value, which is sensitive to the change in the amplitude and latency simultaneously. We used the slope-measure for EP and single trials and compared the significant change detection time with that of the conventional peak-to-peak method. When applied to single trials, each single trial signal was processed with optimal filters before using the slope-measure. In this retrospective data analysis, 7 patients who underwent cerebral aneurysm clipping surgery for unruptured aneurysm middle cerebral artery (MCA) bifurcation were included.
Results
We found that this simple slope-measure has a detection time that is as early or earlier than that of the conventional method; furthermore, using the slope-measure in optimally filtered single trials provides warning signs earlier than that of the conventional method during MCA clipping surgery.
Conclusion
Our results have confirmed the feasibility of the slope-measure for intraoperative SEP monitoring. This is a novel study that provides a useful measure for either EP or single trials in intraoperative SEP monitoring.
doi:10.3340/jkns.2014.56.6.455
PMCID: PMC4303719  PMID: 25628803
Intraoperative neurophysiological monitoring; Somatosensory evoked potentials; Slope-measure; Single trials; Temporary clipping
10.  Unexpected Detachment of Solitaire Stents during Mechanical Thrombectomy 
Objective
Unexpected Solitaire stent detachment can occur during mechanical Solitaire thrombectomy. The purpose of this study was to retrospectively evaluate the influencing factors causing unexpected Solitaire stent detachment and the clinical outcomes.
Methods
Between October 2011 to December 2013, 232 cases of mechanical Solitaire thrombectomy for acute ischemic stroke were performed in 3 stroke centers. During this period, we encountered unexpected Solitaire stent detachments during mechanical Solitaire thrombectomies in 9 cases.
Results
Solitaire stents unexpectedly detached in 9 cases (3.9%) during the retrieval of Solitaire stents. The median patient age was 76 years. The occlusion sites of the unexpected stent detachment were the proximal middle cerebral artery (MCA) in 7 cases and the internal carotid artery in 2 cases. The sizes of the stents that unexpectedly detached were 6×30 mm in 7 cases, 5×30 mm in 1 case, and 4×20 mm in 1 case. Four patients had unexpected detachment at the first retrieval, 1 patient at the second, 3 patients at the third, and 1 patient at the fifth. In all of the cases of unexpected detachment at the first retrieval, the stent deployment site was the proximal MCA. After detachment, a proximal marker of the Solitaire stent was observed in 3 patients. However, no marker was visible in the remaining 6 patients.
Conclusion
Unexpected Solitaire stent detachment should be considered in the first instance of stent retrieval for a relatively large-diameter stent, especially in elderly patients with MCA occlusions.
doi:10.3340/jkns.2014.56.6.463
PMCID: PMC4303720  PMID: 25628804
Stroke; Thrombectomy; Stents
11.  Comparison of Transforaminal Lumbar Interbody Fusion with Direct Lumbar Interbody Fusion: Clinical and Radiological Results 
Objective
The use of direct lumbar interbody fusion (DLIF) has gradually increased; however, no studies have directly compared DLIF and transforaminal lumbar interbody fusion (TLIF). We compared DLIF and TLIF on the basis of clinical and radiological outcomes.
Methods
A retrospective review was performed on the medical records and radiographs of 98 and 81 patients who underwent TLIF and DLIF between January 2011 and December 2012. Clinical outcomes were compared with a visual analog scale (VAS) and the Oswestry disability index (ODI). The preoperative and postoperative disc heights, segmental sagittal/coronal angles, and lumbar lordosis were measured on radiographs. Fusion rates, operative time, estimated blood loss (EBL), length of hospital stay, and complications were assessed.
Results
DLIF was superior to TLIF regarding its ability to restore disc height, foraminal height, and coronal balance (p<0.001). As the extent of surgical level increased, DLIF displayed significant advantages over TLIF considering the operative time and EBL. However, fusion rates at 12 months post-operation were lower for DLIF (87.8%) than for TLIF (98.1%) (p=0.007). The changes of VAS and ODI between the TLIF and DLIF were not significantly different (p>0.05).
Conclusion
Both DLIF and TLIF are less invasive and thus good surgical options for treating degenerative lumber diseases. DLIF has higher potential in increasing neural foramina and correcting coronal balance, and involves a shorter operative time and reduced EBL, in comparison with TLIF. However, DLIF displayed a lower fusion rate than TLIF, and caused complications related to the transpsoas approach.
doi:10.3340/jkns.2014.56.6.469
PMCID: PMC4303721  PMID: 25628805
Transforaminal lumbar interbody fusion; Direct lumbar interbody fusion; Segmental balance; Coronal balance; Fusion rate
12.  Anatomic Feasibility of Posterior Cervical Pedicle Screw Placement in Children: Computerized Tomographic Analysis of Children Under 10 Years Old 
Objective
To evaluate the anatomical feasibility of 3.5 mm screw into the cervical spine in the pediatric population and to establish useful guidelines for their placement.
Methods
A total of 37 cervical spine computerized tomography scans (24 boys and 13 girls) were included in this study. All patients were younger than 10 years of age at the time of evaluation for the period of 2007-2011.
Results
For the C1 screw placement, entry point height (EPH) was the most restrictive factor (47.3% patients were larger than 3.5 mm). All C2 lamina had a height larger than 3.5 mm and 68.8% (51/74) of C2 lamina had a width thicker than 3.5 mm. For C2 pedicle width, 55.4% (41/74) of cases were larger than 3.5 mm, while 58.1% (43/74) of pedicle heights were larger than 3.5 mm. For pedicle width of subaxial spine, 75.7% (C3), 73% (C4), 82.4% (C5), 89.2% (C6), and 98.1% (C7, 1/54) were greater than 3.5 mm. Mean lamina width of subaxial cervical spine was 3.1 (C3), 2.7 (C4), 2.9 (C5), 3.8 (C6), and 4.0 mm (C7), respectively. Only 34.6% (127/370) of subaxial (C3-7) lamina thickness were greater than 3.5 mm. Mean length of lateral mass for the lateral mass screw placement was 9.28 (C3), 9.08 (C4), 8.81 (C5), 8.98 (C6), and 10.38 mm (C7).
Conclusion
C1 lateral mass fixation could be limited by the morphometrics of lateral mass height. C2 trans-lamina approach is preferable to C2 pedicle screw fixation. In subaxial spines, pedicle screw placement was preferable to trans-lamina screw placement, except at C7.
doi:10.3340/jkns.2014.56.6.475
PMCID: PMC4303722  PMID: 25628806
Anatomical morphometrics; Cervical spine; Pediatric population; Screw placement
13.  Chronic Low Back Pain in Young Korean Urban Males: The Life-Time Prevalence and Its Impact on Health Related Quality of Life 
Objective
We assessed the life-time prevalence (LTP) of chronic low back pain (LBP) in young Korean males. We also evaluated the relationship between lumbar spinal lesions and their health related quality-of-life (HRQOL).
Methods
A cross-sectional, self-reported survey was conducted in Korean males (aged 19-year-old) who underwent physical examinations for the conscript. We examined 3331 examinees in November 2014. We included 2411 subjects, who accepted to participate this study without any comorbidities. We interviewed using simple binary questions for their LBP experience and chronicity. HRQOL was assessed by Short-Form Health-Survey-36 (SF-36) in chronic LBP and healthy control groups. Radiological assessment was performed in chronic LBP group to determine whether there were any pathological causes of their symptoms.
Results
The LTP of chronic LBP was 13.4%. Most (71.7%) of them didn't have any lumbar spinal lesions (i.e., non-specific chronic LBP). The SF-36 subscale and summary scores were significantly lower in subjects with chronic LBP. Between specific and non-specific chronic LBP group, all physical and mental subscale scores were significantly lower in specific chronic LBP group, except mental health (MH) subscale score. In MH subscale and mental component summary score, statistical significant differences didn't appear between two groups (p=0.154, 0.126).
Conclusion
In Korean males 19 years of age, the LTP of chronic LBP was 13.4%, and more than two-thirds were non-specific chronic LBP. Chronic LBP had a significant impact on HRQOL. The presence of lumbar spinal pathoanatomical lesions affected mainly on the physical aspect of HRQOL. It influenced little on the mental health.
doi:10.3340/jkns.2014.56.6.482
PMCID: PMC4303723  PMID: 25628807
Chronic low back pain; Public health; Quality of life; Health surveys
14.  Cortical Neuronal Loss after Chronic Prenatal Hypoxia: A Comparative Laboratory Study 
Objective
The purpose of this study was to investigate the prenatal hypoxic effect on the fetal brain development.
Methods
We used the guinea pig chronic placental insufficiency model to investigate the effect of hypoxia on fetal brain development. We ligated unilateral uterine artery at 30-32 days of gestation (dg : with term defined as -67 dg). At 50 dg, 60 dg, fetuses were sacrificed and assigned to either the growth-restricted (GR) or control (no ligation) group. After fixation, dissection, and sectioning of cerebral tissue from these animals, immunohistochemistry was performed with NeuN antibody, which is a mature neuronal marker in the cerebral cortex.
Results
The number of NeuN-immunoreactive (IR) cells in the cerebral cortex did not differ between the GR and control groups at 50 dg. However, the number of NeuN-IR cells was lesser in GR fetuses than in controls at 60 dg (p<0.05).
Conclusion
These findings show that chronic prenatal hypoxia affect the number of neuron in the cerebral cortex of guinea pig fetus at 60 dg. The approach used in this study is helpful for extending our understanding of neurogenesis in the cerebral cortex, and the findings may be useful for elucidating the brain injury caused by prenatal hypoxia.
doi:10.3340/jkns.2014.56.6.488
PMCID: PMC4303724  PMID: 25628808
Hypoxia; Cerebral cortex; Neuron
15.  Intra-Spinal Bone Marrow Mononuclear Cells Transplantation Inhibits the Expression of Nuclear Factor-κB in Acute Transection Spinal Cord Injury in Rats 
Objective
To assess the effect of bone marrow mononuclear cells (BMMNCs) transplantation in the expression of nuclear factor-κB (NF-κB) in spinal cord injury (SCI) in rats.
Methods
BMMNCs were isolated from tibia and femur by a density gradient centrifugation. After establishment of acute transection SCI, rats were divided into experiment (BMMNCs), experiment control (0.1 M PBS infused) and sham surgery groups (laminectomy without any SCI). Locomotor function was assessed weekly for 5 weeks post-injury using BBB locomotor score and urinary bladder function daily for 4 weeks post-injury. Activity of NF-κB in spinal cord was assessed by immunohistochemistry and reverse transcriptase polymerase chain reaction.
Results
At each time point post-injury, sham surgery group had significantly higher Basso, Beattie, Bresnahan locomotor and urinary bladder function scores than experiment and experiment control group (p<0.05). At subsequent time interval there were gradual improvement in both experiment and experiment control group, but experiment group had higher score in comparison to experiment control group (p<0.05). Comparisons were also made for expression of activated NF-κB positive cells and level of NF-κB messenger RNA in spinal cord at various time points between the groups. Activated NF-κB immunoreactivity and level of NF-κB mRNA expression were significantly higher in control group in comparison to experiment and sham surgery group (p<0.05).
Conclusion
BMMNCs transplantation attenuates the expression of NF-κB in injured spinal cord tissue and thus helps in recovery of neurological function in rat models with SCI.
doi:10.3340/jkns.2014.56.5.375
PMCID: PMC4272994  PMID: 25535513
Cell transplantation; Inflammation; Mononuclear cells; Neuroprotective agent; NF-κB; Spinal cord injury
16.  Enhanced Efficacy of Human Brain-Derived Neural Stem Cells by Transplantation of Cell Aggregates in a Rat Model of Parkinson's Disease 
Objective
Neural tissue transplantation has been a promising strategy for the treatment of Parkinson's disease (PD). However, transplantation has the disadvantages of low-cell survival and/or development of dyskinesia. Transplantation of cell aggregates has the potential to overcome these problems, because the cells can extend their axons into the host brain and establish synaptic connections with host neurons. In this present study, aggregates of human brain-derived neural stem cells (HB-NSC) were transplanted into a PD animal model and compared to previous report on transplantation of single-cell suspensions.
Methods
Rats received an injection of 6-OHDA into the right medial forebrain bundle to generate the PD model and followed by injections of PBS only, or HB-NSC aggregates in PBS into the ipsilateral striatum. Behavioral tests, multitracer (2-deoxy-2-[18F]-fluoro-D-glucose ([18F]-FDG) and [18F]-N-(3-fluoropropyl)-2-carbomethoxy-3-(4-iodophenyl)nortropane ([18F]-FP-CIT) microPET scans, as well as immunohistochemical (IHC) and immunofluorescent (IF) staining were conducted to evaluate the results.
Results
The stepping test showed significant improvement of contralateral forelimb control in the HB-NSC group from 6-10 weeks compared to the control group (p<0.05). [18F]-FP-CIT microPET at 10 weeks posttransplantation demonstrated a significant increase in uptake in the HB-NSC group compared to pretransplantation (p<0.05). In IHC and IF staining, tyrosine hydroxylase and human β2 microglobulin (a human cell marker) positive cells were visualized at the transplant site.
Conclusion
These results suggest that the HB-NSC aggregates can survive in the striatum and exert therapeutic effects in a PD model by secreting dopamine.
doi:10.3340/jkns.2014.56.5.383
PMCID: PMC4272995  PMID: 25535514
Parkinson's disease; Cell transplantation; Human brain-derived neural stem cells; Cell aggregates; Rat model; [18F]-FP-CIT microPET
17.  Delayed Improvement after Endoscopic Carpal Tunnel Release 
Objective
In most patients with carpal tunnel syndrome (CTS), pain and/or paresthesia disappeared or decreased in a month after endoscopic carpal tunnel release (ECTR). However, subpopulation of patients showed delayed improvement following ECTR. We analyzed the delayed improvement hands to investigate the characteristics of those patients and to determine the predictable factors of delayed improvement.
Methods
Single-portal ECTRs were performed in 1194 hands of 793 CTS patients from 2002 to 2011. Five-hundred seventy hands with minimal 1-year postoperative follow-up were included. We divided the 545 satisfied hands into early (group A) and delayed (group B) groups according to improvement period of 1 month. Demographic data, clinical severity and electrodiagnostic abnormality were compared between groups.
Results
Group A included 510 hands and group B included 35 hands. In group B, 11 hands improved in 2 months, 15 hands in 3 months and 9 hands in 6 months, respectively. In group A/B, according to clinical severity, 60/1 hands were graded to I, 345/24 hands to II, 105/10 hands to III. In group A/B, based on electrodiagnostic abnormality, 57/3 hands were classified to mild, 221/11 hands to moderate and 222/21 hands to severe group. Statistical analysis between groups did not reach significance but electrodiagnostic or clinical severity had a tendency to affect the delayed response.
Conclusion
It is difficult to predict the factors contributing to postoperatively-delayed response in subpopulation of CTS patients. However, we recommend that postoperative observation for at least 6 months is necessary in patients without symptomatic improvement.
doi:10.3340/jkns.2014.56.5.390
PMCID: PMC4272996  PMID: 25535515
Carpal tunnel syndrome; Endoscopy; Surgical decompression; Delayed improvement
18.  Are Blood Blister-Like Aneurysms a Specific Type of Dissection? A Comparative Study of Blood Blister-Like Aneurysms and Ruptured Mizutani Type 4 Vertebral Artery Dissections 
Objective
Blood blister-like aneurysms (BBAs) resemble arterial dissections. The purpose of this study was to investigate the relationship between these two disease entities and highlight commonalities and distinct features.
Methods
Among 871 consecutive patients with aneurysmal subarachnoid hemorrhage, 11 BBAs of internal carotid artery and seven vertebral artery dissections (VADs) with a short segmental eccentric dilatation (Mizutani type 4), which is morphologically similar to a BBA, were selected. The following clinical factors were studied in each group : age, gender, risk factors, Hunt and Hess grade (HHG), Fisher grade (FG), vasospasms, hydrocephalus, perioperative rebleeding rate, and treatment outcome.
Results
The mean age was 47.9 years in the BBAs group and 46.4 years in the type 4 VADs group. All the BBA patients were female, whereas there was a slight male predominance in the type 4 VAD group (male : female ratio of 4 : 3). In the BBA and type 4 VAD groups that underwent less aggressive treatment to save the parent artery, 29% (n=2/7) and 66.6% (n=2/3), respectively, eventually required retreatment. Perioperative rebleeding occurred in 72.7% (n=8) and 28.6% (n=2) of patients in the BBA and type 4 VAD groups, respectively. There was no statistical difference in the other clinical factors in both groups, except for the male dominancy in the type 4 VAD group (p=0.011).
Conclusion
BBAs and ruptured type 4 VADs have a similar morphological appearance but there is a distinct clinical feature in gender and perioperative rebleeding rates. Complete isolation of an aneurysm from the parent artery might be the most important discipline for the treatment of these diseases.
doi:10.3340/jkns.2014.56.5.395
PMCID: PMC4272997  PMID: 25535516
Aneurysm; Dissection; Internal carotid artery; Subarachnoid hemorrhage; Vertebral artery
19.  Quantitative Analysis of Factors Affecting Cobalt Alloy Clip Artifacts in Computed Tomography 
Objective
Clip artifacts limit the visualization of intracranial structures in CT scans from patients after aneurysmal clipping with cobalt alloy clips. This study is to analyze the parameters influencing the degree of clip artifacts.
Methods
Postoperative CT scans of 60 patients with straight cobalt alloy-clipped aneurysms were analyzed for the maximal diameter of white artifacts and the angle and number of streak artifacts in axial images, and the maximal diameter of artifacts in three-dimensional (3-D) volume-rendered images. The correlation coefficient (CC) was determined between each clip artifact type and the clip blade length and clip orientation to the CT scan (angle a, lateral clip inclination in axial images; angle b, clip gradient to scan plane in lateral scout images).
Results
Angle b correlated negatively with white artifacts (r=-0.589, p<0.001) and positively with the angle (r=0.636, p<0.001) and number (r=0.505, p<0.001) of streak artifacts. Artifacts in 3-D images correlated with clip blade length (r=0.454, p=0.004). Multiple linear regression analysis revealed that angle b was the major parameter influencing white artifacts and the angle and number of streak artifacts in axial images (p<0.001), whereas clip blade length was a major factor in 3-D images (p=0.034).
Conclusion
Use of a clip orientation perpendicular to the scan gantry angle decreased the amount of white artifacts and allowed better visualization of the clip site.
doi:10.3340/jkns.2014.56.5.400
PMCID: PMC4272998  PMID: 25535517
Artifacts; Clip; Intracranial aneurysm; Multidetector computed tomography
20.  Outcome of Endoscopic Transsphenoidal Surgery in Combination with Somatostatin Analogues in Patients with Growth Hormone Producing Pituitary Adenoma 
Objective
To determine the efficacy of endoscopic surgery in combination with long-acting somatostatin analogues (SSAs) in treating patients with growth hormone (GH)-secreting pituitary tumor.
Methods
We performed retrospective analysis of 133 patients with GH producing pituitary adenoma who underwent pure endoscopic transsphenoidal surgery in our center from January 2007 to July 2012. Patients were followed up for a range of 3-48 months. The radiological remission, biochemical remission and complication were evaluated.
Results
A total of 110 (82.7%) patients achieved radiological complete resection, 11 (8.2%) subtotal resection, and 12 (9.0%) partial resection. Eighty-eight (66.2%) patients showed nadir GH level less than 1 ng/mL after oral glucose administration. No mortality or severe disability was observed during follow up. Preoperative long-acting SSA successfully improved left ventricle ejection fraction (LVEF) and blood glucose in three patients who subsequently underwent success operation. Long-acting SSA (20 mg every 30 days) achieved biochemical remission in 19 out 23 (82.6%) patients who showed persistent high GH level after surgery.
Conclusion
Endoscopic transsphenoidal surgery can biochemically cure the majority of GH producing pituitary adenoma. Post-operative use of SSA can improve biochemical remission.
doi:10.3340/jkns.2014.56.5.405
PMCID: PMC4272999  PMID: 25535518
GH producing pituitary adenoma; Endoscopic transsphenoidal surgery; Somatostatin analogue
21.  Clinical Analysis of Epidural Fluid Collection as a Complication after Cranioplasty 
Objective
The epidural fluid collection (EFC) as a complication of cranioplasty is not well-described in the literature. This study aimed to identify the predictive factors for the development of EFC as a complication of cranioplasty, and its outcomes.
Methods
From January 2004 to December 2012, 117 cranioplasty were performed in our institution. One-hundred-and-six of these patients were classified as either having EFC, or not having EFC. The two groups were compared to identify risk factors for EFC. Statistical significance was tested using the t-test and chi-square test, and a logistic regression analysis.
Results
Of the 117 patients undergoing cranioplasty, 59 (50.4%) suffered complications, and EFC occurred in 48 of the patients (41.0%). In the t-test and chi-test, risk factors for EFC were size of the skull defect (p=0.003) and postoperative air bubbles in the epidural space (p<0.001). In a logistic regression, the only statistically significant factor associated with development of EFC was the presence of postoperative air bubbles. The EFC disappeared or regressed over time in 30 of the 48 patients (62.5%), as shown by follow-up brain computed tomographic scan, but 17 patients (35.4%) required reoperation.
Conclusion
EFC after cranioplasty is predicted by postoperative air bubbles in the epidural space. Most EFC can be treated conservatively. However, reoperation is necessary to resolve about a third of the cases. During cranioplasty, special attention is required when the skull defect is large, since EFC is then more likely.
doi:10.3340/jkns.2014.56.5.410
PMCID: PMC4273000  PMID: 25535519
Cranioplasty; Epidural fluid collection; Size of skull defect
22.  Clinical Characteristics of Cerebral Venous Thrombosis in a Single Center in Korea 
Objective
The purpose of this study is to investigate the clinical characteristics of cerebral venous thrombosis (CVT) in a single center in Korea.
Methods
A total of 36 patients were diagnosed with CVT from August 2005 to May 2013. The patient data regarding age, sex, disease stage, pathogenesis, location, laboratory findings, radiological findings, and treatment modalities were retrospectively collected. The results were compared with those of previous studies in other countries.
Results
The patient group comprised 21 men and 15 women with a mean age of 46.9 years (ranging from three months to 77 years). The most common cause was a prothrombotic condition (8 patients, 22.2%). Within the patient group, 13 patients (36.1%) had a hemorrhagic infarction, whereas 23 (63.9%) had a venous infarction without hemorrhage. By location, the incidence of hemorrhagic infarction was the highest in the group with a transverse and/or sigmoid sinus thrombosis (n=9); however, the proportion of hemorrhagic infarction was higher in the cortical venous thrombosis group (75%) and the deep venous thrombosis group (100%). By pathogenesis, the incidence of hemorrhagic infarction was the highest in the prothrombotic group (n=6), which was statistically significant (p=0.016).
Conclusion
According to this study, CVT was more prevalent in men, and the peak age group comprised patients in the sixth decade. The most common cause was a prothrombotic condition. This finding was comparable with reports from Europe or America, in which CVT was more common in younger women. Hemorrhagic infarction was more common in the prothrombotic group (p=0.016) than in the non-prothrombotic group in this study.
doi:10.3340/jkns.2014.56.4.289
PMCID: PMC4219185  PMID: 25371777
Cerebral venous thrombosis; Hemorrhagic infarction; Prothrombotic condition
23.  Association Factors for CT Angiography Spot Sign and Hematoma Growth in Korean Patients with Acute Spontaneous Intracerebral Hemorrhage : A Single-Center Cohort Study 
Objective
This study was conducted to clarify the association factors and clinical significance of the CT angiography (CTA) spot sign and hematoma growth in Korean patients with acute intracerebral hemorrhage (ICH).
Methods
We retrospectively collected the data of 287 consecutive patients presenting with acute ICH who arrived within 12 hours of ictus. Baseline clinical and radiological characteristics as well as the mortality rate within one month were assessed. A binary logistic regression was conducted to obtain association factors for the CTA spot sign and hematoma growth.
Results
We identified a CTA spot sign in 40 patients (13.9%) and hematoma growth in 78 patients (27.2%). An elapsed time to CT scan of less than 3 hours (OR, 5.14; 95% CI, 1.76-15.02; p=0.003) was associated with the spot sign. A CTA spot sign (OR, 5.70; 95% CI, 2.70-12.01; p<0.001), elevated alanine transaminase (GPT) level >40 IU (OR, 2.01; 95% CI, 1.01-4.01; p=0.047), and an international normalized ratio ≥1.8 or warfarin medication (OR, 5.64; 95% CI, 1.29-24.57; p=0.021) were independent predictors for hematoma growth. Antiplatelet agent medication (OR, 4.92; 95% CI, 1.31-18.50; p=0.019) was significantly associated with hematoma growth within 6 hours of ictus.
Conclusion
As previous other populations, CTA spot sign was a strong predictor for hematoma growth especially in hyper-acute stage of ICH in Korea. Antithrombotics medication might also be associated with hyper-acute hematoma growth. In our population, elevated GPT was newly identified as a predictor for hematoma growth and its effect for hematoma growth is necessary to be confirmed through a further research.
doi:10.3340/jkns.2014.56.4.295
PMCID: PMC4219186  PMID: 25371778
Intracerebral hemorrhage; CT angiography; Spot sign; Hematoma growth; Antithrombotics; Alanine transaminase
24.  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
25.  Anterior Lumbar Interbody Fusion for the Treatment of Postoperative Spondylodiscitis 
Objective
To analyze the clinical courses and outcomes after anterior lumbar interbody fusion (ALIF) for the treatment of postoperative spondylodiscitis.
Methods
A total of 13 consecutive patients with postoperative spondylodiscitis treated with ALIF at our institute from January, 1994 to August, 2013 were included (92.3% male, mean age 54.5 years old). The outcome data including inflammatory markers (leukocyte count, C-reactive protein, erythrocyte sedimentation rate), the Oswestry Disability Index (ODI), the modified Visual Analogue Scale (VAS), and bony fusion rate using spine X-ray were obtained before and 6 months after ALIF.
Results
All of the cases were effectively treated with combination of systemic antibiotics and ALIF with normalization of the inflammatory markers. The mean VAS for back and leg pain before ALIF was 6.8±1.1, which improved to 3.2±2.2 at 6 months after ALIF. The mean ODI score before ALIF was 70.0±14.8, which improved to 34.2±27.0 at 6 months after ALIF. Successful bony fusion rate was 84.6% (11/13) and the remaining two patients were also asymptomatic.
Conclusion
Our results suggest that ALIF is an effective treatment option for postoperative spondylodiscitis.
doi:10.3340/jkns.2014.56.4.310
PMCID: PMC4219188  PMID: 25371780
Anterior lumbar interbody fusion; Postoperative spondylodiscitis

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