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1.  Cerebellar Hemorrhage after Burr Hole Drainage of Supratentorial Chronic Subdural Hematoma 
Cerebellar hemorrhage is an unusual complication of supratentorial neurosurgery. To the best of our knowledge, only three case reports have described the occurrence of cerebellar hemorrhage after burr hole drainage for the treatment of chronic subdural hematoma (SDH). We present the case of a patient with this rare postoperative complication of cerebellar hemorrhage after burr hole drainage of a chronic SDH. Although burr hole drainage for the treatment of chronic SDH is rare complication, it is necessary to be aware of the possibility of cerebellar hemorrhage after supratentorial surgery, even with limited surgery such as burr hole drainage of a chronic SDH.
doi:10.3340/jkns.2009.46.6.592
PMCID: PMC2803280  PMID: 20062580
Cerebral hemorrhage; Subdural hematoma; Craniotomy; Complication; Supratentorial
2.  Brain Magnetic Resolution Imaging to Diagnose Bing-Neel Syndrome 
Radiologic findings of Bing-Neel syndrome, which is an extremely uncommon complication resulting from malignant lymphocyte infiltration into the central nervous system (CNS) in patients with Waldenström's macroglobulinemia (WM), have been infrequently reported due to extreme rarity of the case. A 75-year-old man with WM presented at a neurology clinic with progressive gait and memory disturbances, and dysarthria of 2 months duration. Cerebrospinal fluid and serum protein electrophoresis and immunofixation electrophoresis showed IgM kappa-type monoclonal gammopathy. Brain magnetic resonance imaging revealed multifocal, hyperintense lesions on T2 weighted-images. Brain diffusion-weighted imaging (DWI) demonstrated hyperintensities in cerebral and cerebellar lesions that appeared isointense on apparent diffusion coefficient maps, which were compatible with vasogenic edema. Although histologic analysis is a confirmative study to prove direct cell infiltration into the brain, brain MRI with DWI may be a good supportive study to diagnose Bing-Neel syndrome.
doi:10.3340/jkns.2009.46.6.588
PMCID: PMC2803279  PMID: 20062579
Bing-Neel syndrome; Waldenström's macroglobulinemia; MRI
3.  Contralateral Pedicular Fracture with Unilateral Spondylolysis 
Although most authors regard contralateral pedicular fracture with unilateral spondylolysis as an unstable condition and recommend surgical management when immobilization fails in promoting bony healing of the fracture, few researchers have investigated the natural history of pedicle fracture or the causal relationship between symptoms and the fracture. In addition, there are no detailed guidelines that address the management of this disease. We report a rare case of contralateral pedicular fracture associated with unilateral spondylolysis at the L5 level which was successfully treated by rehabilitation with activity modification.
doi:10.3340/jkns.2009.46.6.584
PMCID: PMC2803278  PMID: 20062578
Lower back pain; Lumbar vertebrae; Spondylolysis; Stress fracture; Guidelines
4.  Abducens Nerve Palsy after Lumbar Spinal Fusion Surgery with Inadvertent Dural Tearing 
Abducens nerve palsy associated with spinal surgery is extremely rare. We report an extremely rare case of abducens nerve palsy after lumbar spinal fusion surgery with inadvertent dural tearing, which resolved spontaneously and completely. A 61-year-old previous healthy man presented with chronic lower back pain of 6 weeks duration and 2 weeks history of bilateral leg pain. He was diagnosed as having isthmic spondylolisthesis at L4-5 and L5-S1, and posterior lumbar interbody fusion was conducted on L4-5 and L5-S1. During the operation, inadvertent dural tearing occurred, which was repaired with a watertight dural closure. The patient recovered uneventfully from general anesthesia and his visual analogue pain scores decreased from 9 pre-op to 3 immediately after his operation. However, on day 2 he developed headache and nausea, which were severe when he was upright, but alleviated when supine. This led us to consider the possibility of cerebrospinal fluid leakage, and thus, he was restricted to bed. After an interval of bed rest, the severe headache disappeared, but four days after surgery he experienced diplopia during right gaze, which was caused by right-side palsy of the abducens nerve. Under conservative treatment, the diplopia gradually disappeared and was completely resolved at 5 weeks post-op.
doi:10.3340/jkns.2009.46.6.581
PMCID: PMC2803277  PMID: 20062577
Abducens nerve palsy; Dural tearing; Surgical complication; Lumbar fusion surgery
5.  A Case of Ruptured Peripheral Aneurysm of the Anterior Inferior Cerebellar Artery Associated with an Arteriovenous Malformation : A Less Invasive Image-Guided Transcortical Approach 
A 47-year-old man presented with a subarachnoid hemorrhage (SAH) and right cerebellar hematoma was referred for evaluation. Cerebral angiography revealed a distal anterior inferior cerebellar artery (AICA) aneurysm associated with an arteriovenous malformation (AVM). Successful obliteration and complete removal of the aneurysm and AVM were obtained using transcortical approach under the guidance of neuronavigation system. The association of a peripheral AICA aneurysm and a cerebellar AVM by the same artery is unique. The reported cases of conventional surgery for this disease complex are not common and their results are variable. Less invasive surgery using image-guided neuronavigation system would be helpful and feasible for a peripheral aneurysm combining an AVM of the posterior fossa in selective cases.
doi:10.3340/jkns.2009.46.6.577
PMCID: PMC2803276  PMID: 20062576
Aneurysm; Anterior inferior cerebellar artery; Arteriovenous malformation; Neuronavigation
6.  Endovascular Graft-Stent Placement for Treatment of Traumatic Carotid Cavernous Fistulas 
Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloonexpandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.
doi:10.3340/jkns.2009.46.6.572
PMCID: PMC2803275  PMID: 20062575
Carotid cavernous fistulas; Graft-stent; Endovascular treatment
7.  Saccular Aneurysm at the Anterior Communicating Artery Complex Associated with an Accessory Middle Cerebral Artery : Report of Two Cases and Review of the Literature 
Accessory middle cerebral artery (MCA) is an infrequent vascular anomaly of the brain. Cerebral aneurysms associated with this anomalous artery are also very rare. To our knowledge, there have only been ten previous reports of an aneurysm associated with accessory MCA. The authors present two patients with accessory MCA-related aneurysms. A 38-year-old male and a 59-year-old female both presented with sudden-onset severe headache. In both patients, computed tomography (CT) scan revealed subarachnoid hemorrhage. A subsequent angiogram demonstrated an accessory MCA arising from the anterior cerebral artery (ACA) and a saccular aneurysm at the anterior communicating artery (ACoA) complex associated with an accessory MCA. Surgical clipping allowed for complete exclusion of the aneurysm from the arterial circulation. Based on our review of the ten cases of aneurysms associated with accessory MCA documented in the literature, we suggest that accessory MCA-related aneurysms can be classified according to whether the accessory MCA originates from the proximal A1 segment or from the ACoA complex. We also emphasize the importance of precise interpretation of preoperative angiograms and intraoperative precaution in determining the presence of this anomalous artery prior to temporary clip placement.
doi:10.3340/jkns.2009.46.6.568
PMCID: PMC2803274  PMID: 20062574
Accessory middle cerebral artery; Aneurysm; Anterior communicating artery complex
8.  Rapid Progression of Early Delayed Radiation Effect in Pleomorphic Xanthoastrocytoma 
Early delayed radiation effects are known to occur within several months after completing radiotherapy for brain tumors. We present marked changes of magnetic resonance imaging (MRI) scan that occurred one month after radiotherapy in a patient with a pleomorphic xanthoastrocytoma, which was eventually diagnosed as an early delayed radiation effect. Such an early development of dramatic MRI change has not been reported in patients treated with radiotherapy for pleomorphic xanthoastrocytomas.
doi:10.3340/jkns.2009.46.6.564
PMCID: PMC2803273  PMID: 20062573
Blood brain barrier; Delayed radiation effect; Low grade glioma; Magnetic resonance imaging; Pleomorphic xanthoastrocytoma; Radiation therapy
9.  Association of HLA-DR and -DQ Genes with Familial Moyamoya Disease in Koreans 
Objective
Moyamoya disease (MMD) is an uncommon cerebrovascular disorder, characterized by progressive occlusion at the terminal portion of the internal carotid artery. Incidence of the disease is high in East Asia and familial MMD accounts for about 15% of the disease. Although the pathogenesis is unknown, association of HLA class I or II alleles with MMD has been reported with conflicting results. We investigated whether there is a difference in HLA class II association between familial and non-familial forms of the disease.
Methods
A total of 70 Korean children with MMD, including 16 familial cases (10 probands), and 207 healthy controls were studied. Among familial cases, only 10 probands were used for the HLA frequency analysis. High resolution HLA-DRB1 and DQB1 genotyping was performed using polymerase chain reaction (PCR)-sequence specific oligonucleotide hybridization and PCR-single strand conformation polymorphism methods.
Results
The phenotype frequencies of HLA-DRB1*1302 (70.0%) and DQB1*0609 (40.0%) were significantly increased in familial MMD compared to both controls [vs. 15.5%, corrected p (pc) = 0.008, odds ratio (OR) = 12.76; vs. 4.3%, pc = 0.02, OR = 14.67] and non-familial MMD patients (vs. 14.8%, pc = 0.02, OR = 13.42; vs. 1.9%, pc = 0.02, OR = 35.33). The frequencies of DRB1 and DQB1 alleles in non-familial MMD patients were not significantly different from those in controls.
Conclusion
Our findings suggest that the genetic polymorphism of HLA class II genes or other closely linked disease relevant gene(s) could be a genetic predisposing factor for familial MMD.
doi:10.3340/jkns.2009.46.6.558
PMCID: PMC2803272  PMID: 20062572
Moyamoya disease; Familial; HLA-DR; HLA-DQ
10.  Inhibitory Effect of IFN-β, on the Antitumor Activity of Celecoxib in U87 Glioma Model 
Objective
Interferon-β, (IFN-β) has been used in the treatment of cancers. Inhibition of the enzyme cyclooxygenase (COX) with celecoxib had a significantly suppressive effect on tumor growth, angiogenesis, and metastasis in a variety of tumors. The aim of this study was to elucidate the antiglioma effect of combined treatment with IFN-β and celecoxib in U87 glioma model.
Methods
The in vitro effects of IFN-β (50-1,000 IU/mL) and celecoxib (50-250 µM) alone or combination of both on the proliferation and apoptosis of U87 cells were tested using MTT assay, FACS analysis and DNA condensation. To determine the in vivo effect, nude mice bearing intracerebral U87 xenograft inoculation were treated with IFN-β intraperitoneally (2×105 IU/day for 15 days), celecoxib orally (5, 10 mg/kg) or their combination.
Results
IFN-β or celecoxib showed an inhibitory effect on the proliferation of U87 cells. When U87 cells were treated with IFN-β and celecoxib combination, it seemed that IFN-β interrupted the antiproliferative and apoptotic activity of celecoxib. No additive effect was observed on the survival of the tumor bearing mice by the combination of IFN-β and celecoxib.
Conclusion
These results suggest that IFN-β seems to inhibit the antiglioma effect of celecoxib, therefore combination of IFN-β and celecoxib may be undesirable in the treatment of glioma.
doi:10.3340/jkns.2009.46.6.552
PMCID: PMC2803271  PMID: 20062571
Celecoxib; Cyclooxygenase-2 inhibitor; Glioma; Interferon-beta
11.  Sole Stenting Technique for Treatment of Complex Aneurysms 
Objective
Complex aneurysms such as fusiform and very small aneurysms (< 3 mm) are challenging in neurovascular and endovascular surgery. Author reports follow-up results of 9 cases treated by sole stent technique with pertinent literature review.
Methods
A retrospective study was made of 9 patients who were treated by sole stenting technique for cerebral aneurysm between January 2003 and January 2009. Two of them had fusiform aneurysm, 5 had very small aneurysm, and 2 had small saccular aneurysm. Five patients had ruptured aneurysms and four had unruptured aneurysms. Seven aneurysms were located in the internal carotid artery (ICA), 1 in the middle cerebral artery (MCA) and 1 in the basilar artery. Follow-up cerebral angiography was performed at post-procedure 3 months, 6 months, and 12 months. Mean follow-up period is 30 months (ranged from 3 days to 30 months).
Results
Aneurysm size was decreased in 6 of 9 cases on follow-up images and was not changed in 3 cases. Although total occlusion was not seen, patients had stable neurological condition and angiographic result. The procedural complication occurred in 2 cases. One was coil migration and the other was suboptimal deployment of stent, and both were asymptomatic. Re-bleeding and thromboembolic complication had not been occurred.
Conclusion
Sole stenting technique is relatively effective and safe as an alternative treatment for fusiform and very small aneurysms.
doi:10.3340/jkns.2009.46.6.545
PMCID: PMC2803270  PMID: 20062570
Sole stenting technique; Fusiform aneurysm; Very small aneurysm
12.  Clinical Results of Cyberknife® Radiosurgery for Spinal Metastases 
Objective
Primary treatment of spinal metastasis has been external beam radiotherapy. Recent advance of technology enables radiosurgery to be extended to extracranial lesions. The purpose of this study was to determine the clinical effectiveness and safety of stereotactic radiosurgery using Cyberknife in spinal metastasis.
Methods
From June, 2002 to December, 2007, 129 patients with 167 spinal metastases were treated with Cyberknife. Most of the patients (94%) presented with pain and nine patients suffered from motor deficits. Twelve patients were asymptomatic. Fifty-three patients (32%) had previous radiation therapy. Using Cyberknife, 16-39 Gy in 1-5 fractions were delivered to spinal metastatic lesions. Radiation dose was not different regarding the tumor pathology or tumor volume.
Results
After six months follow-up, patient evaluation was possible in 108 lesions. Among them, significant pain relief was seen in 98 lesions (91%). Radiological data were obtained in 83 lesions. The mass size was decreased or stable in 75 lesions and increased in eight lesions. Radiological control failure cases were hepatocellular carcinoma (5 cases), lung cancer (1 case), breast cancer (1 case) and renal cell carcinoma (1 case). Treatment-related radiation injury was not detected.
Conclusion
Cyberknife radiosurgery is clinically effective and safe for spinal metastases. It is true even in previously irradiated patients. Compared to conventional radiation therapy, Cyberknife shows higher pain control rate and its treatment process is more convenient for patients. Thus, it can be regarded as a primary treatment modality for spinal metastases.
doi:10.3340/jkns.2009.46.6.538
PMCID: PMC2803269  PMID: 20062569
Spinal metastasis; Radiosurgery; Cyberknife
13.  Surgical Outcome of Cervical Arthroplasty Using Bryan® 
Objective
Recently, motion preservation has come to the forefront of emerging technologies in spine surgery. This is the important background information of the emergence of cervical arthroplasty as an alternative to arthrodesis that offers the promise of restoring normal spinal movement and reduces a kinematic strain on adjacent segments. The study was designed to evaluate early surgical outcome and radiological effects of Bryan® cervical disc prosthesis.
Methods
The authors retrospectively reviewed radiographic and clinical outcomes in 52 patients who received the Bryan® Cervical Disc prosthesis, for whom follow-up data were available. Static and dynamic radiographs were measured by computer to determine the angles formed by the endplates of the natural disc preoperatively, those formed by the shells of the implanted prosthesis, the angle of functional spine unit (FSU), and the C2-7 Cobb angle. The range of motion (ROM) was also determined radiographically, whereas clinical outcomes were assessed using Odom's criteria, visual analogue pain scale (VAS) and neck disability index (NDI).
Results
A total of 71 Bryan® disc were placed in 52 patients. A single-level procedure was performed in 36 patients, a two-level procedure in 13 patients, and a three-level procedure in 3. Radiographic and clinical assessments were made preoperatively. Mean follow-up duration was 29.2 months, ranging from 6 to 36 months. All of the patients were satisfied with the surgical results by Odom's criteria, and showed significant improvement by VAS and NDI score (p < 0.05). The postoperative ROM of the implanted level was preserved without significant difference from preoperative ROM of the operated level (p < 0.05). 97% of patients with a preoperative lordotic sagittal orientation of the FSU were able to maintain lordosis. The overall sagittal alignment of the cervical spine was preserved in 88.5% of cases at the final follow up. Interestingly, preoperatively kyphotic FSU resulted in lordotic FSU in 70% of patients during the late follow up, and preoperatively kyphotic overall cervical alignment resulted in lordosis in 66.6% of the patients postoperatively.
Conclusion
Arthroplasty using the Bryan® disc seemed to be safe and provided encouraging clinical and radiologic outcome in our study. Although the early results are promising, this is a relatively new approach, therefore long-term follow up studies are required to prove its efficacy and its ability to prevent adjacent segment disease.
doi:10.3340/jkns.2009.46.6.532
PMCID: PMC2803268  PMID: 20062568
Arthroplasty; Cervical disc; Artificial disc; Bryan®
14.  Enhancing Box Sign : Enhancement Pattern of Acute Osteoprotic Compression Fracture 
Objective
Although gadolinium enhancement of compression fractures is well known, the enhancement pattern of the acute stage of a fracture is not completely understood. Here, we investigated the enhancement pattern of acute vertebral compression fractures (VCFs).
Methods
We conducted a retrospective study of patients with acute osteoporotic VCFs admitted to hospital between January 2004 and December 2005. The demographic details, stage of the fracture, management data, and results were analyzed. There were nine men and 22 women, and the mean age was 71 years (range, 53-92 years). According to the onset of pain, patients were divided into the following four groups : Group I (less than 3 days), Group II (4-7 days), Group III (8-14 days), and Group IV (14-30 days).
Results
All patients had central low-signal intensity of the nonenhancing part of vertebral bodies on T1 images. Enhancing box sign (EBS) was seen 7 days of VCF development. After 7 days of onset (Groups III and IV), patch or Kummell's enhancements occurred. EBS has been statistically correlated with stage of compression fracture (Pearson's correlation = -0.774). However, EBS had no statistically significant correlation with prognosis in our study (Pearson's correlation = 0.059).
Conclusion
EBS represents a characteristic sign 7 days of VCF development.
doi:10.3340/jkns.2009.46.6.528
PMCID: PMC2803267  PMID: 20062567
Compression fracture; Magnetic resonance imaging; Gadolinium
15.  The Incidence and Clinical Implications of Congenital Defects of Atlantal Arch 
Objective
Atlantal arch defects are rare. Few cadaveric and imaging studies have been reported on the variations of such anomalies. Our goal in this study was to examine the incidence and review the clinical implications of this anomaly.
Methods
A retrospective review of 1,153 neck or cervical spine computed tomography (CT) scans was performed to identify patients with atlantal arch defects. Neck CT scans were performed in 650 patients and cervical spine CT scans were performed in 503 patients. Posterior arch defects of the atlas were grouped in accordance with the classification of Currarino et al. In patients exhibiting this anomaly, special attention was given to defining associated anomalies and neurological findings.
Results
Atlantal arch defects were found in 11 (11/1153, 0.95%) of the 1,153 patients. The type A posterior arch defect was found in nine patients and the type B posterior arch defect was found in two patients. No type C, D, or E defects were observed. One patient with a type A posterior arch defect had an anterior atlantal-arch midline cleft (1/1153, 0.087%). Associated cervical spine anomalies observed included one C6-7 fusion and two atlantal assimilations. None of the reviewed patients had neurological deficits because of atlantal arch anomalies.
Conclusion
Most congenital anomalies of the atlantal arch are found incidentally during investigation of neck mass, neck pain, radiculopathy, and after trauma.
doi:10.3340/jkns.2009.46.6.522
PMCID: PMC2803266  PMID: 20062566
Arch; Atlas; Incidence; Congenital defect
16.  Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Recurrent Disc Herniation 
Objective
The purpose of this study was to compare clinical and radiological outcomes of percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM) for recurrent disc herniation.
Methods
Fifty-four patients, who underwent surgery, either PELD (25 patients) or repeated OLM (29 patients), due to recurrent disc herniation at L4-5 level, were divided into two groups according to the surgical methods. Excluded were patients with sequestrated disc, calcified disc, severe neurological deficit, or instability. Clinical outcomes were assessed using Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI). Radiological variables were assessed using plain radiography and/or magnetic resonance imaging.
Results
Mean operating time and hospital stay were significantly shorter in PELD group (45.8 minutes and 0.9 day, respectively) than OLM group (73.8 minutes and 3.8 days, respectively) (p < 0.001). Complications occurred in 4% in PELD group and 10.3% in OLM group in the perioperative period. At a mean follow-up duration of 34.2 months, the mean improvements of back pain, leg pain, and functional improvement were 4.0, 5.5, and 40.9% for PELD group and 2.3, 5.1, and 45.0% for OLM group, respectively. Second recurrence occurred in 4% after PELD and 10.3% after OLM. Disc height did not change after PELD, but significantly decreased after OLM (p = 0.0001). Neither sagittal rotation angle nor volume of multifidus muscle changed significantly in both groups.
Conclusion
Both PELD and repeated OLM showed favorable outcomes for recurrent disc herniation, but PELD had advantages in terms of shorter operating time, hospital stay, and disc height preservation.
doi:10.3340/jkns.2009.46.6.515
PMCID: PMC2803265  PMID: 20062565
Reherniation; Discectomy; Lumbar spine
18.  Cervical Disc Herniation as a Cause of Brown-Séquard Syndrome 
The possible causes of Brown-Séquard Syndrome (BSS) have been frequently observed with spinal trauma and extramedullary spinal tumors, but the cervical disc herniation to cause BSS is rare. The authors present five cases of patients who were diagnosed with BSS resulting from cervical disc herniation, and the results of the literature in view of their distinctive symptoms and clinical outcomes. Postoperatively, the patients showed complete or almost complete recovery from their motor and sensory deficits. On the basis of our cases, it is important to diagnose it early by cervical magnetic resonance imaging, especially in the absence of the typical symptoms of cervical disc herniation or other obvious etiology of extremity numbness. Immediate surgical treatment is also essential for a favorable functional neurological recovery.
doi:10.3340/jkns.2009.46.5.505
PMCID: PMC2796362  PMID: 20041066
Brown-Séquard Syndrome; cervical disc herniation; anterior cervical discectomy and fusion
19.  Remote Cerebellar Hemorrhage after Lumbar Spinal Surgery 
Remote cerebellar hemorrhage (RCH) is rare but potentially lethal as a complication of spinal surgery. We recently experienced a case of RCH in a 61-year-old man who showed mental deterioration after lumbar spinal surgery. There was dural tearing with subsequent cerebrospinal fluid (CSF) loss during the surgery. Brain computed tomography scan revealed cerebellar hemorrhage, 3rd and 4th ventricular hemorrhage and pneumocephalus. He underwent suboccipital craniectomy and hematoma removal. The most important pathomechanism leading to RCH after spinal surgery has been known to be venous bleeding due to caudal sagging of cerebellum by rapid leak of large amount of CSF which seems to be related with this case. Dural repair and minimizing CSF loss after intraoperative dural tearing would be helpful to prevent postoperative RCH.
doi:10.3340/jkns.2009.46.5.501
PMCID: PMC2796361  PMID: 20041065
Remote cerebellar hemorrhage; Spinal surgery; Dural tear; Cerebrospinal fluid leakage
20.  Concomitant Dual Origin and Fenestration of the Left Vertebral Artery Resembling Dissection 
Dual origin and fenestration of the vertebral artery (VA) are very rare anomalies. Understanding of these variations, however, is important because they can be misdiagnosed as a VA dissection. A 42-year-old woman presented with motor weakness and sensory disturbance of the right upper extremity. Radiologic evaluations showed ectatic change in the right VA and an arteriovenous fistula between the right VA and the vertebral vein. We decided on endovascular occlusion of the proximal right VA and its fistulous portion. During the endovascular procedure, we had misunderstood the dual origin and fenestration of the VA as a dissection. Thus, failure to recognize these anomalies might result in unnecessary anticoagulation or therapeutic intervention. Clinicians should be alert to such VA variations when making a diagnosis and when planning any intervention or surgery involving the proximal VA.
doi:10.3340/jkns.2009.46.5.498
PMCID: PMC2796360  PMID: 20041064
Dissection; Dual origin; Fenestration; Vertebral artery
21.  Delayed Carotid Wallstent Shortening Resulting in Restenosis Following Successful Carotid Artery Angioplasty and Stenting 
Carotid angioplasty and stenting (CAS) for carotid stenosis has been increasingly used as an alternative treatment in patients not eligible for surgery. Even though CAS can be performed relatively simply in many cases, various complications can occur. We report four cases of CAS using the Carotid Wallstent, which were complicated by delayed shortening of the stent, resulting in restenosis after successful CAS.
doi:10.3340/jkns.2009.46.5.495
PMCID: PMC2796359  PMID: 20041063
Carotid angioplasty and stenting; Stent shortening; Restenosis
22.  Recurrent Subarachnoid Hemorrhage after Complete Obliteration of Intracranial Aneurysm 
The authors report a case of recurrent subarachnoid hemorrhage (SAH) after complete occlusion of an intracranial aneurysm. It is known that regrowth of an aneurysm after the complete clipping is a rare event. For detection of recurrence, however, it may be necessary to follow up with the patient regularly after the initial operation for intracranial aneurysms, because re-rupture of an aneurysm can cause a fatal result, and the cumulative risk of a recurrent SAH is thought to be not low over time.
doi:10.3340/jkns.2009.46.5.492
PMCID: PMC2796358  PMID: 20041062
Subarachnoid hemorrhage; Complete occlusion; Recurrence; Intracranial aneurysm
23.  External Carotid Artery Angioplasty and Stenting Followed by Superficial Temporal Artery to Middle Cerebral Artery Anastomosis 
A 31-year-old man presented with right hemiparesis, and magnetic resonance imaging revealed a small infarct at left basal ganglia. Digital subtraction angiography showed left cervical internal carotid artery (ICA) occlusion and severe stenosis of the ipsilateral external carotid artery (ECA) with collateral cerebral circulation fed by ECAs. Based on the results of a functional evaluation of cerebral blood flow, we performed preventive ECA angioplasty and stenting for advanced ECA stenosis to ensure sufficient blood flow to the superficial temporal artery. Eight weeks later, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was performed. His postoperative course was uneventful and no additional transient ischemic attacks have occurred. To our knowledge, this is the first report of preventive angioplasty and stenting for advanced narrowing of an ECA before STA-MCA anastomosis for ipsilateral ICA occlusion.
doi:10.3340/jkns.2009.46.5.488
PMCID: PMC2796357  PMID: 20041061
Angioplasty; External carotid artery; Internal carotid artery; Middle cerebral artery
24.  A Case of Calvarial Hemangioma in Cranioplasty Site 
It is not uncommon for hemangiomas to occur in the calvarium, accounting for about 10% of the benign skull tumors. A 46-year-old man was presented with a palpable scalp mass on the left parietal region. Past medical history indicated that he had undergone cranioplasty 25 years prior due to a depressed skull fracture suffered from a traffic accident. Magnetic resonance imaging revealed mixed signal intensity mass on T1 -and T2-weighted images pushing a linear signal void lesion outward in the left parietal region. After total surgical removal along with cranioplasty, he was discharged without neurological deficits. Histological examination of the surgical specimen revealed a cavernous hemangioma. A skull hemangioma occurring at the site of a cranioplasty has not yet been reported. Therefore, authors report this case in combination with a pertinent literature review.
doi:10.3340/jkns.2009.46.5.484
PMCID: PMC2796356  PMID: 20041060
Cavernous hemangioma; Calvarium; Cranioplasty
25.  A Mouse Model of Photochemically Induced Spinal Cord Injury 
Objective
A mouse model of spinal cord injury (SCI) could further increase our basic understanding of the mechanisms involved in injury and repair of the nervous system. The purpose of this study was to investigate whether methods used to produce and evaluate photochemical graded ischemic SCI in rats, could be successfully adapted to mice, in a reliable and reproducible manner.
Methods
Thirty female imprinting control region mice (weighting 25-30 g, 8 weeks of age) were used in this study. Following intraperitoneal injection of Rose bengal, the translucent dorsal surface of the T8-T9 vertebral laminae of the mice were illuminated with a fiber optic bundle of a cold light source. The mice were divided into three groups; Group 1 (20 mg/kg Rose bengal, 5 minutes illumination), Group 2 (20 mg/kg Rose bengal, 10 minutes illumination), and Group 3 (40 mg/kg Rose bengal, 10 minutes illumination). The locomotor function, according to the Basso-Beattie-Bresnahan scale, was assessed at three days after the injury and then once per week for four weeks. The animals were sacrificed at 28 days after the injury, and the histopathology of the lesions was assessed.
Results
The mice in group 1 had no hindlimb movement until seven days after the injury. Most mice had later recovery with movement in more than two joints at 28 days after injury. There was limited recovery of one joint, with only slight movement, for the mice in groups 2 and 3. The histopathology showed that the mice in group 1 had a cystic cavity involving the dorsal and partial involvement of the dorsolateral funiculi. A larger cavity, involving the dorsal, dorsolateral funiculi and the gray matter of the dorsal and ventral horns was found in group 2. In group 3, most of the spinal cord was destroyed and only a thin rim of tissue remained.
Conclusion
The results of this study show that the photochemical graded ischemic SCI model, described in rats, can be successfully adapted to mice, in a reliable and reproducible manner. The functional deficits are correlated an increase in the irradiation time and, therefore, to the severity of the injury. The photothrombotic model of SCI, in mice with 20 mg/kg Rose bengal for 5 minutes illumination, provides an effective model that could be used in future research. This photochemical model can be used for investigating secondary responses associated with traumatic SCI.
doi:10.3340/jkns.2009.46.5.479
PMCID: PMC2796355  PMID: 20041059
Photochemical; Spinal cord Injury; Mouse

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