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1.  Spinal Dural Arteriovenous Fistulas: Clinical Experience with Endovascular Treatment as a Primary Therapeutic Modality 
Objective
The aim of this study was to evaluate the efficacy of endovascular therapy as a primary treatment for spinal dural arteriovenous fistula (DAVF).
Methods
The authors reviewed 18 patients with spinal DAVFs for whom endovascular therapy was considered as an initial treatment at a single institute between 1993 and 2006. NBCA embolization was considered the primary treatment of choice, with surgery reserved for patients in whom endovascular treatment failed.
Results
Surgery was performed as the primary treatment in one patient because the anterior spinal artery originated from the same arterial pedicle as the artery feeding the fistula. Embolization was used as the primary treatment modality in 17 patients, with an initial success rate of 82.4%. Two patients with incomplete embolization had to undergo surgery. One patient underwent multiple embolizations, which failed to completely occlude the fistula but relieved the patient's symptoms. Spinal DAVF recurred in two patients (one collateral development and one recanalization) during the follow-up period. The collateral development was obliterated by repeated embolization, but the patient with recanalization refused further treatment. The overall clinical status improved in 15 patients (83.3%) during the follow-up period.
Conclusion
Endovascular therapy can be successfully used as a primary treatment for the majority of patients with spinal DAVFs. Although it is difficult to perform in some patients, endovascular embolization should be the primary treatment of choice for spinal DAVF.
doi:10.3340/jkns.2008.44.6.364
PMCID: PMC2615139  PMID: 19137080
Spine; Dural arteriovenous fistula; Therapeutic embolization
2.  Gamma Knife Radiosurgery for Ten or More Brain Metastases 
Objective
This study was performed to assess the efficacy of GKS in patients with ten or more brain metastases.
Methods
From Aug 2002 to Dec 2007, twenty-six patients (13 men and 13 women) with ten or more cerebral metastatic lesions underwent GKS. The mean age was 55 years (32-80). All patients had Karnofsky performance status (KPS) score of 70 or better. According to recursive partitioning analysis (RPA) classification, 3 patients belonged to class I and 23 to class II. The location of primary tumor was lung (21), breast (3) and unknown (2). The mean number of the lesions per patient was 16.6 (10-37). The mean cumulated volume was 10.9 cc (1.0-42.2). The median marginal dose was 15 Gy (9-23). Overall survival and the prognostic factors for the survival were retrospectively analyzed by using Kaplan Meier method and univariate analysis.
Results
Overall median survival from GKS was 34 weeks (8-199). Local control was possible for 79.5% of the lesions and control of all the lesions was possible in at least 14 patients (53.8%) until 6 months after GKS. New lesions appeared in 7 (26.9%) patients during the same period. At the last follow-up, 18 patients died; 6 (33.3%) from systemic causes, 10 (55.6%) from neurological causes, and 2 (11.1%) from unknown causes. Synchronous onset in non-small cell lung cancer (p=0.007), high KPS score (≥80, p=0.029), and controlled primary disease (p=0.020) were favorable prognostic factors in univariate analysis.
Conclusion
In carefully selected patients, GKS may be a treatment option for ten or more brain metastases.
doi:10.3340/jkns.2008.44.6.358
PMCID: PMC2615138  PMID: 19137079
Multiple; Brain metastases; Gamma knife radiosurgery; Prognostic factor
3.  Emergent Clipping without Prophylactic Decompressive Craniectomy in Patients with a Large Aneurysmal Intracerebral Hematoma 
Objective
Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH.
Methods
Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group B, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A.
Results
In Group A, 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group B, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group B (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable.
Conclusion
We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.
doi:10.3340/jkns.2008.44.6.353
PMCID: PMC2615137  PMID: 19137078
Clipping; Craniectomy; Aneurysm; Intracerebral hematoma
4.  Radiologic Assessment of Subsidence in Stand-Alone Cervical Polyetheretherketone (PEEK) Cage 
Objective
Aim of study was to find a proper method for assessing subsidence using a radiologic measurement following anterior cervical discectomy and fusion (ACDF) with stand-alone polyetheretherketone (PEEK), Solis™ cage.
Methods
Forty-two patients who underwent ACDF with Solis™ cage were selected. With a minimum follow-up of 6 months, the retrospective investigation was conducted for 37 levels in 32 patients. Mean follow-up period was 18.9 months. Total intervertebral height (TIH) of two fused vertebral bodies was measured on digital radiographs with built-in software. Degree of subsidence (ΔTIH) was reflected by the difference between the immediate postoperative and follow-up TIH. Change of postoperative disc space height (CT-MRΔTIH) was reflected by the difference between TIH of the preoperative mid-sagittal 2D CT and that of the preoperative mid-sagittal T1-weighted MRI.
Results
Compared to preoperative findings, postoperative disc height was increased in all cases and subsidence was observed only in 3 cases. For comparison of subsidence and non-subsidence group, TIH and CT-MRΔTIH of each group were analyzed. There was no statistically significant difference in TIH and CT-MRΔTIH between each group at 4 and 8 weeks, but a difference was observed at the last follow-up TIH (p=0.0497).
Conclusion
ACDF with Solis™ cage was associated with relatively good radiologic long-term results. Fusion was achieved in 94.5% and subsidence occurred in 8.1% by the radiologic assessment. Statistical analysis reveals that the subsidence seen later than 8 weeks after surgery and the development of subsidence does not correlate statistically with the change of the postoperative disc space height.
doi:10.3340/jkns.2008.44.6.370
PMCID: PMC2615140  PMID: 19137081
Cervical PEEK cage; Radiologic assessment; subsidence; Fusion rate; Anterior cervical discectomy and fusion
5.  Intraventricular Glioblastoma Multiforme with Previous History of Intracerebral Hemorrhage : A Case Report 
GBM is the most common primary brain tumor, but intraventricular GBM is rare and only few cases have been reported in the literature. The authors report a case of 64-year-old man who had a remote history of previous periventricular intracerebral hemorrhage. Brain computed tomography (CT) and magnetic resonance (MR) imaging showed an intraventricular lesion with inhomogeneous enhancement, infiltrative borders and necrotic cyst, and obstructive hydrocephalus. The patient underwent surgical removal through transcortical route via the bottom of previous hemorrhage site and the final pathologic diagnosis was GBM. We present a rare case of an intraventricular GBM with detailed clinical course, radiological findings, and pathological findings, and the possible origin of this lesion is discussed.
doi:10.3340/jkns.2008.44.6.405
PMCID: PMC2615149  PMID: 19137090
Glioblastoma multiforme; Intraventricular tumor; Intracerebral hemorrhage; Obstructive hydrocephalus
6.  Primary Intracranial Squamous Cell Carcinoma in the Brain Stem with a Cerebellopontine Angle Epidermoid Cyst 
Primary intracranial squamous cell carcinoma is extremely rare, with most cases arising from a preexisting benign epidermoid cyst. We report a rare case of primary intracranial squamous cell carcinoma in the brain stem with a cerebellopontine angle (CPA) epidermoid cyst. A 72-year-old female suffered from progressive left hemiparesis, difficulty in swallowing, and right hemifacial numbness. Diffusion-weighted magnetic resonance imaging revealed a high signal intensity (SI) lesion in the CPA region and an intra-axially ring-enhanced cystic mass in the right brain stem with low SI. Whole-body positron emission tomography showed no evidence of metastatic disease. The histological findings revealed a typical epidermoid cyst in the CPA region and a squamous cell carcinoma in the brain stem. We speculate that the squamous cell carcinoma may have been developed due to a chronic inflammatory response by the adjacent epidermoid cyst. The patient underwent a surgical resection and radiotherapy. After 12 months, she had no evidence of recurrence.
doi:10.3340/jkns.2008.44.6.401
PMCID: PMC2615148  PMID: 19137089
Squamous cell carcinoma; Epidermoid cyst; Brain stem; Cerebellopontine angle
7.  Hemifacial Spasm Caused by Fusiform Aneurysm at Vertebral Artery-Posterior Inferior Cerebellar Artery Junction 
Hemifacial spasm induced by intracranial aneurysm is a rare clinical condition. A 45-year-old male patient presented with a 3-year history of progressive involuntary twitching movement on right face. On radiological study, a dilated vascular lesion compressing the brain stem was found at the junction of vertebral artery and posterior inferior cerebellar artery. On operative field, we found the posterior inferior cerebellar artery and the fusiform aneurysm compressing root exit zone of facial nerve. Microvascular decompression was performed and the facial symptom was relieved without complications.
doi:10.3340/jkns.2008.44.6.399
PMCID: PMC2615147  PMID: 19137088
Hemifacial spasm; Microvascular decompression; Fusiform aneurysm
8.  Delayed Bilateral Abducens Nerve Palsy after Head Trauma 
Although the incidence of unilateral abducens nerve palsy has been reported to be as high as 1% to 2.7% of head trauma cases, bilateral abducens nerve palsy following trauma is extremely rare. In this report, we present the case of a patient who developed a bilateral abducens nerve palsy and hypoglossal nerve palsy 3 days after suffering head trauma. He had a Glasgow Coma Score (GCS) of 15 points. Computed tomography (CT) images demonstrated clivus epidural hematoma and subarachnoid hemorrhage on the basal cistern. Herein, we discuss the possible mechanisms of these nerve palsies and its management.
doi:10.3340/jkns.2008.44.6.396
PMCID: PMC2615146  PMID: 19137087
Abducens nerve palsy; Hypoglossal nerve palsy; Epidural hematoma; Clivus
9.  Congenital Absence of a Cervical Spine Pedicle : Report of Two Cases and Review of the Literature 
Congenital absence of a cervical spine pedicle is a rare clinical entity, and it is usually found incidentally on radiological studies performed after trauma in patients with cervical pain. We report two cases of congenital absence of a cervical spine pedicle and present a review of the literature.
doi:10.3340/jkns.2008.44.6.389
PMCID: PMC2615144  PMID: 19137085
Congenital defects; Cervical vertebrae; Radiography
10.  Lumbar Periradicular Abscess Mimicking a Fragmented Lumbar Disc Herniation : An Unusual Case 
We herein describe the case of a focal spontaneous spinal epidural abscess who was initially diagnosed to have a free fragment of a lumbar disc. A 71-year-old woman presented with history of low back and right leg pain. Magnetic resonance imaging suggested a peripherally enhancing free fragment extending down from S1 nerve root axilla. Preoperative laboratory investigation showed elevation of c-reactive protein (CRP), erythrocyte sedimentation rate (ESR) levels. She was taken for surgery and a fluctuating mass at the axilla of S1 nerve was found. When the mass was probed with a dissector, a dark yellow, thick pus drained out. Pus cultures were negative. Patients who present with extreme low back plus leg pain and increased leucocyte count, ESR and CRP levels should raise the suspicion of an infection of a vertebral body or spinal epidural space.
doi:10.3340/jkns.2008.44.6.385
PMCID: PMC2615143  PMID: 19137084
Abscess; Disc; Periradicular; Spinal
11.  Prone Position-Related Meralgia Paresthetica after Lumbar Spinal Surgery : A Case Report and Review of the Literature 
Lateral femoral cutaneous neuropathy occurring during spinal surgery is frequently related to iliac bone graft harvesting, but meralgia paresthetica (MP) can result from the patient being in the prone position. Prone position-related MP is not an uncommon complication after posterior spine surgery but there are only few reports in the literature on this subject. It is usually overlooked because of its mild symptoms and self-limiting course, or patients and physicians may misunderstand the persistence of lower extremity symptoms in the early postoperative period to be a reflection of poor surgical outcome. The authors report a case of prone position-related MP after posterior lumbar interbody fusion at the L3-4 and reviewed the literature with discussion on the incidence, pathogenesis, and possible risk factors related to this entity.
doi:10.3340/jkns.2008.44.6.392
PMCID: PMC2615145  PMID: 19137086
Meralgia paresthetica (MP); Lateral femoral cutaneous nerve (LFCN); Prone position; Posterior spinal surgery
12.  Gas-Forming Brain Abscess Caused by Klebsiella Pneumoniae 
Gas forming brain abscess is a rare disease caused by Klebsiella pneumoniae occurring in patients with impaired host defense mechanism such as diabetes mellitus or liver cirrhosis. A 59-year-old man with 2-year history of diabetes mellitus and 20-year history of liver cirrhosis presented to the hospital with headache. On the day after admission, severe headache was developed and he deteriorated rapidly. Brain CT showed a non-enhanced mass including multiple air density as well as surrounding edema seen in the right occipital lobe, and isodensity air-fluid level seen in the right lateral ventricle. Despite emergent ventricular drainage and intraventricular and intravenous administration of antibiotics, his condition progressively worsened to sepsis and to death after 5 days. Bacterial culture of blood and ventricular fluids disclosed a Gram (-) rod, Klebsiella pneumoniae. In this report we review the pathogenic mechanism and its management.
doi:10.3340/jkns.2008.44.6.382
PMCID: PMC2615142  PMID: 19137083
Brain abscess; Klebsiella pneumoniae; Air
13.  Effect of Single Growth Factor and Growth Factor Combinations on Differentiation of Neural Stem Cells 
Objective
The effects on neural proliferation and differentiation of neural stem cells (NSC) of basic fibroblast growth factor-2 (bFGF), insulin growth factor-I (IGF-I), brain-derived neurotrophic factor (BDNF), and nerve growth factor (NGF) were assessed. Also, following combinations of various factors were investigated : bFGF+IGF-I, bFGF+BDNF, bFGF+NGF, IGF-I+BDNF, IGF-I+NGF, and BDNF+NGF.
Methods
Isolated NSC of Fisher 344 rats were cultured with individual growth factors, combinations of factors, and no growth factor (control) for 14 days. A proportion of neurons was analyzed using β-tubulin III and NeuN as neural markers.
Results
Neural differentiations in the presence of individual growth factors for β-tubulin III-positive cells were : BDNF, 35.3%; IGF-I, 30.9%; bFGF, 18.1%; and NGF, 15.1%, and for NeuN-positive cells was : BDNF, 34.3%; bFGF, 32.2%; IGF-1, 26.6%; and NGF, 24.9%. However, neural differentiations in the absence of growth factor was only 2.6% for β-tubulin III and 3.1% for NeuN. For β-tubulin III-positive cells, neural differentiations were evident for the growth factor combinations as follows : bFGF+IGF-I, 73.1%; bFGF+NGF, 65.4%; bFGF+BDNF, 58.7%; BDNF+IGF-I, 52.2%; NGF+IGF-I, 40.6%; and BDNF+NGF, 40.0%. For NeuN-positive cells : bFGF+IGF-I, 81.9%; bFGF+NGF, 63.5%; bFGF+BDNF, 62.8%; NGF+IGF-I, 62.3%; BDNF+NGF, 56.3%; and BDNF+IGF-I, 46.0%. Significant differences in neural differentiation were evident for single growth factor and combination of growth factors respectively (p<0.05).
Conclusion
Combinations of growth factors have an additive effect on neural differentiation. The most prominent neural differentiation results from growth factor combinations involving bFGF and IGF-I. These findings suggest that the combination of a mitogenic action of bFGF and postmitotic differentiation action of IGF-I synergistically affects neural proliferation and NSC differentiation.
doi:10.3340/jkns.2008.44.6.375
PMCID: PMC2615141  PMID: 19137082
Neuron; Single growth factor; Combination of growth factors; Synergistic effect
14.  Intraventricular Cavernous Malformation Radiologically Mimicking Meningioma 
We report a case of trigonal cavernous malformation (CM) radiologically mimicking meningioma. The computed tomographic (CT) head angiography and magnetic resonance imaging (MRI) showed a partially calcified lesion with slight contrast enhancement located in the area of the left atrium of lateral ventricle. The lesion was completely removed using microsurgery with a parieto-occipital transcortical approach. The resected mass was histologically confirmed as CM. CM should be considered as differential diagnosis in case of the atrial mass lesion due to lack of hemosiderin ring characteristically seen other seated CM.
doi:10.3340/jkns.2008.44.5.345
PMCID: PMC2612575  PMID: 19119474
Cavernous malformation; Meningioma; Trigone; Atrium
15.  Disseminated Intravascular Coagulation in a Patient Undergoing Removal of Metastatic Brain Tumor 
The authors present a case of 68-year-old woman who underwent resection of a metastatic adenocarcinoma in the left parietooccipital area. The intraoperative course was uneventful; however, after closure of the scalp incision, increased bleeding from the suture line was noted. A computerized tomography scan that was performed immediately after operation revealed acute epidural hemorrhage with mass effect under the bone flap. The patient developed disseminated intravascular coagulation and immediate re-exploration was performed. This patient was successfully treated owing to early recognition of the condition and immediate treatment with transfusion. Neurosurgeons should be alert that hypercoagulabe state is common in cancer patients and consumptive coagulopathy can occur after resection of metastatic brain tumor.
doi:10.3340/jkns.2008.44.5.341
PMCID: PMC2612574  PMID: 19119473
Disseminated intravascular coagulation; Brain tumor; Blood transfusion; Hemostasis
16.  Three-Dimensional Angiographic Demonstration of Plexiform Fenestrations of the Proximal Anterior Cerebral Artery Associated with a Ruptured Aneurysm 
A rare case of ruptured aneurysm associated with multiple A1 fenestrations resembling plexiform network was demonstrated by 3D angiography. A 56-year-old female presented with a ruptured aneurysm in the A2 segment of the left distal anterior cerebral artery associated with the right A1 fenestration. The ruptured aneurysm was occluded with surgical neck clipping via interhemispheric approach without neurological deficit. Plexiform fenestrations of the right distal A1, opposite side to the left ruptured A2 aneurysm, were clearly visible on postoperative 3D angiography. Our case may strongly support the theory described by Paget, namely that a remnant of the plexiform anastomosis between the primitive olfactory artery and A1 segment is the source of such fenestration.
doi:10.3340/jkns.2008.44.5.338
PMCID: PMC2612573  PMID: 19119472
Anterior cerebral artery fenestration; Aneurysm; Three-dimensional angiography
17.  Spinal Intradural Extramedullary Mature Cystic Teratoma in an Adult 
Spinal intradural extramedullary teratoma is a rare condition that develops more commonly in children than in adults and may be associated with spinal dysraphism. We report a rare case of adult-onset intradural extramedullary teratoma in the thoracolumbar spinal cord with no evidence of spinal dysraphism and without the history of prior spinal surgery. The patient was a 38-year-old male whose chief complaint was urinary incontinence. X-ray images of the thoracolumbar spine showed the widening of the interpedicular distance and posterior marginal erosion of the vertebral bodies and pedicles at the T11, T12, and L1 level. Magnetic resonance imagings of the lumbar spine showed a lobulated inhomogeneous high signal intradural mass (87×29×20 mm) between T11 and L1 and a high signal fluid collection at the T11 level. Laminectomy of the T11-L1 region was performed, and the mass was subtotally excised. The resected tumor was histopathologically diagnosed as a mature cystic teratoma. The patient's symptom of urinary incontinence was improved following the surgery.
doi:10.3340/jkns.2008.44.5.334
PMCID: PMC2612572  PMID: 19119471
Spinal cord neoplasm; Mature teratoma
18.  Contralateral Reherniation after Open Lumbar Microdiscectomy : A Comparison with Ipsilateral Reherniation 
Objective
To evaluate the risk factors that may be responsible for the development of contralateral reherniations from ipsilateral ones after open lumbar microdiscectomy (OLM), and to compare surgical outcomes of revision OLM for contralateral reherniations with those for ipsilateral ones.
Methods
Seventeen patients who underwent revision OLM for contralateral reherniation were enrolled into Group I, and 35 patients who underwent revision OLM for ipsilateral reherniation were enrolled into Group II. Using medical charts and imaging study results, the differences in the clinical and radiological factors were evaluated between the two groups. Clinical outcomes of each group were compared between the two groups.
Results
Significant differences were found in the interval to reherniation from initial surgery (33 months for Group I and 18.6 months for Group II, p=0.009), as well as in the incidences of both protruded disc (35.3% for Group I and 8.6% for Group II, p=0.045) and mild disc degeneration (29.4% for Group I and 5.7% for Group II, p=0.031) at initial surgery. On binary multi-logistic regression analysis, significant differences were found in the interval to reherniation (p=0.027, Odds ratio=1.051) and incidence of mild disc degeneration (p=0.025, Odds ratio=12.03) between the two groups. There were no significant differences in the improvement of clinical outcomes after revision OLM between the two groups.
Conclusion
The interval to reherniation from initial surgery and the grade of disc degeneration at initial surgery were key factors that distinguished the development of contralateral reherniations from ipsilateral ones. Surgical outcomes of revision OLM were similar in both groups.
doi:10.3340/jkns.2008.44.5.320
PMCID: PMC2612570  PMID: 19119469
Reherniation; Discectomy; Lumbar spine
19.  Multimodal Treatment for Complex Intracranial Aneurysms: Clinical Research 
Objective
For patients with giant or dissecting aneurysm, multimodal treatment consisting extracranial-intracranial bypass surgery plus clip or coil for parent artery occlusion may be necessary. In this study, the safety and efficacy of multimodal treatment in 15 patients with complex aneurysms were evaluated retrospectively.
Methods
From January 1995 to June 2007, the authors treated 15 complex aneurysms that were unable to be clipped or coiled. Among them, nine patitents had unruptured aneurysms and 6 had ruptured aneurysms. Aneurysms were located in the internal cerebral artery (ICA) in 11 patients (4 in the dorsal wall, 4 in the terminal ICA, 1 in the paraclinoid, and 2 in the cavernous ICA), in the middle cerebral artery (MCA) in 2, and in the posterior circulation in two patients
Results
Fifteen patients with complex aneurysms were treated with bypass surgery previously. Thirteen patients were treated with external carotid middle cerebral artery (ECA-MCA) anastomosis, and one patient with superficial temporal to posterior cerebral artery (STA-PCA) and another patient with occipital artery to posterior inferior cerebellar artery (OA-PICA) anastomosis. Parent artery occlusion was then performed with a clip in 9 patients, with a coil in 4, with balloon plus coil in one patient. All 15 aneurysms were successfully treated with clip or coil combined with bypass surgery. Follow-up angiograms showed good patency of anastomotic site in 10 out of 11 patients, and perfusion study showed sufficient perfusion in 6 out of 9 patients.
Conclusion
These findings indicate that for patients with complex aneurysms, clip or coil for parent vessel occlusion with additive bypass surgery can successfully exclude the aneurysm from the neurovascular circulatory system.
doi:10.3340/jkns.2008.44.5.314
PMCID: PMC2612569  PMID: 19119468
Aneurysm; Clip; Coil; Bypass
20.  Posterior Cervical Fixation with Nitinol Shape Memory Loop in the Anterior-Posterior Combined Approach for the Patients with Three Column Injury of the Cervical Spine : Preliminary Report 
Objective
The authors reviewed clinical and radiological outcomes in patients with three column injury of the cervical spine who had undergone posterior cervical fixation using Nitinol shape memory alloy loop in the anterior-posterior combined approach.
Materials
Nine patients were surgically treated with anterior cervical fusion using an iliac bone graft and dynamic plate-screw system, and the posterior cervical fixation using Nitinol shape memory loop (Davydov™) at the same time. A retrospective review was performed. Clinical outcomes were assessed using the Frankel grading method. We reviewed the radiological parameters such as bony fusion rate, height of iliac bone graft strut, graft subsidence, cervical lordotic angle, and instrument related complication.
Results
Single-level fusion was performed in five patients, and two-level fusion in four. Solid bone fusion was presented in all cases after surgery. The mean height of graft strut was significantly decreased from 20.46±9.97 mm at immediate postoperative state to 18.87±8.60 mm at the final follow-up period (p<0.05). The mean cervical lordotic angle decreased from 13.83±11.84° to 11.37±6.03° at the immediate postoperative state but then, increased to 24.39±9.83° at the final follow-up period (p<0.05). There were no instrument related complications.
Conclusion
We suggest that the posterior cervical fixation using Nitinol shape memory alloy loop may be a simple and useful method, and be one of treatment options in anterior-posterior combined approach for the patients with the three column injury of the cervical spine.
doi:10.3340/jkns.2008.44.5.303
PMCID: PMC2612567  PMID: 19119466
Nitinol; Shape memory loop; Posterior cervical surgery; fracture fixation
21.  The Jugular Foramen Schwannomas: Review of the Large Surgical Series 
Objective
Jugular foramen schwannomas are uncommon pathological conditions. This article is constituted for screening these tumors in a wide perspective.
Materials
One-hundred-and-ninty-nine patients published in 19 articles between 1984 to 2007 years was collected from Medline/Index Medicus.
Results
The series consist of 83 male and 98 female. The mean age of 199 operated patients was 40.4 years. The lesion located on the right side in 32 patients and on the left side in 60 patients. The most common presenting clinical symptoms were hearing loss, tinnitus, disphagia, ataxia, and hoarseness. Complete tumor removal was achieved in 159 patients. In fourteen patients tumor reappeared unexpectedly. The tumor was thought to originate from the glossopharyngeal nerve in forty seven cases; vagal nerve in twenty six cases; and cranial accessory nerve in eleven cases. The most common postoperative complications were lower cranial nerve palsy and facial nerve palsy. Cerebrospinal fluid leakage, meningitis, aspiration pneumonia and mastoiditis were seen as other complications.
Conclusion
This review shows that jugular foramen schwannomas still have prominently high morbidity and those complications caused by postoperative lower cranial nerve injury are life threat.
doi:10.3340/jkns.2008.44.5.285
PMCID: PMC2612565  PMID: 19119464
Cranial nerve; Schwannoma; Skull base tumors; Surgery; Jugular foramen
22.  Rabbit Model for in vivo Study of Intervertebral Disc Degeneration and Regeneration 
Objective
The purpose of this study is to verify the usefulness of the rabbit model for disc degeneration study.
Materials
The L1-L2, L2-L3, L3-L4, or L4-L5 lumbar intervertebral disc (IVD) of 9 mature male New Zealand White rabbits were injured by inserting a 16-gauge needle to a depth of 5 mm in the left anterolateral annulus fibrosus while leaving L5-L6 IVD uninjured. Three other rabbits also received intradiscal injections of rabbit disc cells transfected with adenovirus and bone morphogenetic protein-2 (ad-BMP-2) at L4-L5 in addition to injury by 16-gauge needle at the L1-L2 level. Using digitized radiographs, measurements of IVD height were made and analyzed by using the disc height index (DHI). Magnetic resonance imaging (MRI) scans of the injured discs, injected discs, and uninjured L5-L6 discs were performed at 15 weeks post surgery and compared with preoperative MRI scans.
Results
All twelve rabbits showed consistent results of disc degeneration within 15 weeks following annular puncture. DHIs of injured discs were significantly lower than that of the uninjured L5-L6 discs (p<0.05). The mean value of disc degeneration grade of injured discs was significantly higher than that of uninjured discs (p<0.05). The injection of disc cell transfected with ad-BMP-2 did not induce disc regeneration at 15 weeks after injection.
Conclusion
This study showed that the injured disc had a significant change in DHI on simple lateral radiograph and disc degeneration grade on MRI scans within 15 weeks in all rabbits. Rabbit annular puncture model can be useful as a disc degeneration model in vivo.
doi:10.3340/jkns.2008.44.5.327
PMCID: PMC2612571  PMID: 19119470
Intervertebral disc; Animal model; Rabbit; Disc degeneration; in vivo
23.  Prognostic Value of Serum S100 Protein by Elecsys S100 Immunoassay in Patients with Spontaneous Subarachnoid and Intracerebral Hemorrhages 
Objective
The serum S100 protein has been known to reflect the severity of neuronal damage. The purpose of this study was to assess the prognostic value of the serum S100 protein by Elecsys S100 immunoassay in patients with subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) and to establish reference value for this new method.
Methods
Serum S100 protein value was measured at admission, day 3 and 7 after bleeding in 42 consecutive patients (SAH : 20, ICH : 22) and 74 healthy controls, prospectively. Admission Glasgow coma scale (GCS) score, Hunt & Hess grade and Fisher grade for SAH, presence of intraventricular hemorrhage, ICH volume, and outcome at discharge were evaluated. Degrees of serum S100 elevation and their effect on outcomes were compared between two groups.
Results
Median S100 levels in SAH and ICH groups were elevated at admission (0.092 versus 0.283 µg/L) and at day 3 (0.110 versus 0.099 µg/L) compared to healthy controls (0.05 µg/L; p<0001). At day 7, however, these levels were normalized in both groups. Time course of S100 level in SAH patient was relatively steady at least during the first 3 days, whereas in ICH patient it showed abrupt S100 surge on admission and then decreased rapidly during the next 7 days, suggesting severe brain damage at the time of bleeding. In ICH patient, S100 level on admission correlated well with GCS score (r=-0.859; p=0.0001) and ICH volume (r=0.663; p=0.001). A baseline S100 level more than 0.199 µg/L predicted poor outcome with 92% sensitivity and 90% specificity. Logistic regression analyses showed Ln (S100) on admission as the only independent predictor of poor outcome (odd ratio 36.1; 95% CI, 1.98 to 656.3).
Conclusion
Brain damage in ICH patient seems to develop immediately after bleeding, whereas in SAH patients it seems to be sustained for few days. Degree of brain damage is more severe in ICH compared to SAH group based on the S100 level. S100 level is considered an independent predictor of poor outcome in patient with spontaneous ICH, but not in SAH. Further study with large population is required to confirm this result.
doi:10.3340/jkns.2008.44.5.308
PMCID: PMC2612568  PMID: 19119467
S100 protein; Prognosis; Subarachnoid hemorrhage; Elecsys S100 immunoassay; Intracerebral hemorrhage
24.  The Effect of Premorbid Demographic Factors on the Recovery of Neurocognitive Function in Traumatic Brain Injury Patients 
Objective
Premorbid demographic backgrounds of injured individuals are likely to reflect more accurately the status of patients with traumatic brian injury (TBI) than clinical factors. However, the concrete study about the relationship between the demographic factors and neurocognitive function in TBI patients has not been reported. The object of this study was to evaluate the effect of premorbid demographic factors on the recovery of neurocognitive function following TBI.
Methods
From July 1998 to February 2007, 293 patients (male: 228, female: 65) with a history of head injury, who had recovered from the acute phase, were selected from our hospital to include in this study. We analyzed the effect of premorbid demographic factors including age, sex, educational level and occupation on the recovery of neurocognitive function in each TBI subgroup as defined by Glasgow Coma Scale (GCS) score. Intelligence and memory are components of neurocognitive function, and the Korean Wechsler Intelligence Scale (K-WAIS) and the Korean memory assessment scale (K-MAS) were used in this study. The results were considered significant at p<0.05.
Results
The higher level of education was a good prognostic factor for intelligence regardless of GCS score and younger age group showed a better result for memory with an exception of severe TBI group. In the severe TBI group, the meaningful effect of demographic factors was not noted by the cause of influence of severe brain injury.
Conclusion
The demographic factors used in this study may be helpful for predicting the precise prognosis and developing an appropriate rehabilitation program for TBI patients.
doi:10.3340/jkns.2008.44.5.295
PMCID: PMC2612566  PMID: 19119465
Traumatic brain injury; Premorbid demographic factors; Prognosis
25.  Stereotactic Multiplanar Reformatted Computed Tomography-Guided Catheter Placement and Thrombolysis of Spontaneous Intracerebral Hematomas 
Objective
The authors present their experiences with stereotactic multiplanar reformatted (MPR) computed tomography (CT)-guided catheter placement for thrombolysis of spontaneous intracerebral hematoma (sICH) and their clinical results.
Methods
In 23 patients with sICH, MPR CT-guided catheter placement was used to select the trajectory and target point of hematoma drainage. This group was comprised of 11 men and 12 women, and the mean age was 57.5 years (range, 31-79 years). The patients' initial Glasgow Coma Scale scores ranged from 7 to 15 with a median of 11. The volume of the hematoma ranged from 24 mL to 86 mL (mean 44.5 mL). A trajectory along the main axis of the hematoma was considered to be optimal for thrombolytic therapy. The trajectory was calculated from the point of entry through the target point of the hematoma using reformatted images.
Results
The hematoma catheter was left in place for a median duration of 48.9 hours (range 34 to 62 hours). In an average of two days, the average residual hematoma volume was 6.2 mL (range 1.4 mL to 10.2 mL) and was reduced by an average of 84.7% (range 71.6% to 96.3%). The residual hematoma at postoperative seven days was less than 5 mL in all patients. There was no treatment-related death during hospitalization.
Conclusion
The present study indicates that stereotactic MPR CT-guided catheter placement for thrombolysis is an accurate and safe procedure. We suggest that this procedure for stereotactic removal of sICH should be considered for the optimization of the trajectory selection in the future.
doi:10.3340/jkns.2008.44.4.185
PMCID: PMC2588315  PMID: 19096674
Intracerebral hematoma; Stereotactic aspiration; Surgical treatment; Thrombolysis

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