Bo-Ra Seo

Spinal Cord Injury Produced by Direct Damage During Cervical Transforaminal Epidural Injection

Objective: Cervical transforaminal epidural steroid injection (TFESI) has become a common treatment for cervical radiculopathy. We describe a case of spinal cord injury caused by direct injection of iohexol into the cervical spinal cord during cervical TFESI. Case Report: A 55‐year‐old male suffered from intractable pain in the neck, radiating to his left arm. After undergoing C6‐7 TFESI under fluoroscopic guidance, the patient reported a shooting pain during needle insertion, and developed quadriparesis shortly after contrast injection. The radiological findings of the contrast medium and air bubble within the cord indicated needle penetration and intracord contrast injection. The paresis of his right arm and both legs recovered within 4 hours after the procedure. At 1‐month follow‐up, his left arm paresis had continued to improve. One year after the event, the motor paresis improved except for grasping with the left hand, resulting in a claw hand deformity. Conclusions: This case report draws attention to this very serious complication of cervical TFESI. It is essential to confirm final needle position using both anteroposterior and lateral fluoroscopy before any injection through the needle.

Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms

OBJECTIVES To describe surgical strategies using cerebral revascularization for complex middle cerebral artery aneurysms unsuitable to microsurgical clipping. MATERIALS AND METHODS In this study, the clinical features, case management, and results in 9 consecutive patients who underwent 10 cerebral revascularization procedures between January 1999 and April 2008 were retrospectively analyzed. The patient population consisted of 6 men and 3 women whose ages ranged from 15 to 71 years (mean, 42.4 years). The size of the aneurysms ranged from 12 to 35 mm (mean, 24.3 mm). Treated aneurysms were located in the M1 segment in 2 patients, the middle cerebral artery (MCA) bifurcation in 3 patients, the distal M3 segment in 3 patients, and the anterior temporal artery (ATA; the early cortical branch of the M1 segment) in 1 patient. A total of 10 revascularizations were performed. Three aneurysms were saccular and six aneurysms were fusiform. For the fusiform aneurysms of the M1 segment in 2 patients, superficial temporal artery (STA) trunk-saphenous vein (SV)-MCA bypasses followed by trapping were performed. For the large saccular MCA bifurcation aneurysms in 3 patients, STA-MCA bypasses followed by complete neck clipping, including the revascularized branch with the preservation of the flow of the other branch, were performed in 2 cases, and a STA trunk-SV-MCA bypass secondary to direct neck clipping with the preservation of both M2 branches was performed in 1 case. For the fusiform distal MCA aneurysms, STA-MCA bypasses in 2 patients and in situ MCA-MCA bypasses in 2 patients were performed. In one case involving distal MCA fusiform aneurysm, STA-MCA bypass and MCA-MCA bypass were performed simultaneously. In a case involving fusiform ATA aneurysm, primary reanastomosis after aneurysm excision was performed in 1 patient. RESULTS The post-operative 3-month Glasgow outcome scales were good recovery in 6 patients, severe disability in 1 patient, a vegetative state in 1 patient, and death in 1 patient. A follow-up angiography was performed in 6 patients and revealed a patent bypass in 5 patients. In one case treated by direct neck clipping secondary to cerebral revascularization, the angiography obtained 2 weeks later showed graft occlusion, but there were no neurologic symptoms. Among the unfavorable outcomes of 3 patients who did not undergo follow-up angiography, surgery-related morbidity secondary to cerebral infarction was due to the size discrepancy between the donor and recipient vessels in 1 patient with severe disability. In the other 2 patients, the preoperative conditions were Hunt and Hess grade V. CONCLUSIONS Cerebral revascularization is a safe and effective technique of treatment for selective cases of complex large or giant aneurysms and unclippable fusiform aneurysms in the MCA.

Recurrent primary spinal subarachnoid neurocysticercosis.

Study Design. Case description. Objective. To describe a patient with a recurrent primary spinal subarachnoid neurocysticercosis (NCC) that was successfully treated with surgical decompression and medical therapy at our center. Summary of Background Data. Spinal subarachnoid NCC is thought to be the secondary result from larval migration through the ventricular system into the spinal subarachnoid space. However, this entity can develop as a primary infection through blood stream or direct larval migration. It can result in high recurrence and severe neurologic morbidity if it is not treated in an appropriate manner. Methods. A 50-year-old woman with treatment history of spinal NCC presented with back pain and radicular pain. The lumbar magnetic resonance imaging showed a cystic lesion with septation and slight rim enhancement after gadolinium administration at the L4–S1 area. We performed surgical removal of this lesion and postoperative medical therapy for complete eradication of the parasite. Results. The histopathology was diagnostic for a cysticercal cyst. Adjuvant medical therapy with albendazole was administered for 30 days after surgery. The patient remained symptom-free for 1 year after surgery without any evidence of recurrence. Conclusion. We report a rare case of recurrent primary spinal subarachnoid NCC at L4–S1 area. In cases of primary spinal subarachnoid NCC can be treated by adequate combined approach with surgery and medical therapy. Spinal subarachnoid NCC should be added to the differential diagnosis of primary spinal intradural cysts, because this lesion can occur primarily.

An intraosseous malignant peripheral nerve sheath tumor of the cervical spine: a case report and review of the literature.

Study Design. Case description. Objectives. To report a rare case of intraosseous malignant peripheral nerve sheath tumors (MPNST), and review the pertinent medical literature. Summary of Background Data. The spinal MPNST that develops from spinal nerve roots and secondary bony erosion is well-known entity. However, primary intraosseous MPNSTs of the spine are extremely rare. Methods. A 41-year-old male presented with a 1-month history of radiating pain to his right shoulder and arm. Magnetic resonance images showed a large extradural mass extending from C6 to T1 with destruction of the posterior elements of C6, C7, and T1. Complete excision of the tumor and posterior stabilization were performed through a posterior approach. The tumor was noted to originate from the posterior element of C7. Results. The histopathology was diagnostic for a MPNST. Adjuvant chemotherapy was administered after surgery. The patient remained symptom-free for 30 months after surgery without local recurrence or metastasis. Conclusion. We report an intraosseous MPNST of the cervical spine. Complete surgical excision and adjuvant chemotherapy resulted in a good functional outcome. MPNST should be added to the differential diagnosis of primary bone tumors causing spinal cord compression.

Surgical Management of Anterior Cerebral Artery Aneurysms of the Proximal (A1) Segment

OBJECTIVE To report a series of 20 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery (ACA. METHODS The medical records of patients who had undergone surgery for intracranial aneurysms at two institutions between January 1, 1989, and February 1, 2009, were reviewed. Mean patient age was 52.15 years (range 39-69 years). All 20 patients underwent direct surgery, with clipping or trapping, via standard pterional craniotomy. RESULTS The incidence of A1 segment aneurysm was 0.59%. There were 16 women and 4 men, showing a strong predominance of this lesion in women. Mean aneurysm size was 6.95 mm (range 3-10 mm). Four patients (20%) had multiple aneurysms, and three patients (15%) had associated vascular anomalies. Among patients whose aneurysms originated from perforating arteries, dissection sacrificed the perforating arteries in two patients, and the perforating arteries occluded postoperatively in three patients. In the patients whose aneurysms did not originate from perforating arteries, no perforating arteries were sacrificed during dissection, and perforating arteries became occluded in two patients postoperatively. There was no statistically significant difference between the two groups of patients regarding the incidence of injury or occlusion. Clinical outcomes were as follows: good recovery in 15 (75%) patients, moderate disability in 2 (10%) patients, severe disability in 2 (10%) patients, and death in 1 (5%) patient. CONCLUSIONS The important consideration in surgery for intracranial aneurysms is preservation of the perforating arteries, through cautious dissection around the neck or dome and avoidance of direct clip compression, even after releasing the retracted frontal lobe.

The role of collagen type I α2 polymorphisms: intracranial aneurysms in Koreans

BACKGROUND The COL1A2 is located on chromosome 7q22.1, and mutations in this gene have been associated with the development of IAs. In this study, we investigated whether the rs42524 and rs2621215 polymorphisms of the COL1A2 gene are associated with the development of cerebral aneurysms in the Korean population. METHODS This was a hospital-based case control study conducted at Chonnam University Hospital, Gwangju, Korea. The study population consisted of 320 patients who had been treated for IA and 189 healthy hospital-based controls (angiographically negative for an IA). Two polymorphic loci were amplified by polymerase chain reaction, namely, rs42524 in exon 28 and rs2621215 in intron 46 of the COL1A2 gene, and analyzed by RFLP using HhaI or BfaI restriction enzymes, respectively. RESULTS The genotype frequencies of rs42524 in cases were 88.0%, 11.4%, and 0.6% for the GG, GC, and CC genotypes, respectively, and in controls were 88.9%, 10.0%, and 1.1%, respectively. Similarly, the genotype frequencies of rs2621515 in cases were 88.0%, 10.1%, and 0.2% for the TT, TG, and GG genotypes, respectively, and among controls were 92.1%, 7.9%, and 0%, respectively. CONCLUSION The rs2621215 SNP in intron 46 of the COL1A2 gene was found to be marginally associated with an increased risk of IA development in the Korean population examined. In contrast, rs42524 showed no association with an increased risk of IA development.

Value of Indocyanine Green Videoangiography in Deciding the Completeness of Cerebrovascular Surgery

Objective Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. Methods Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. Results Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. Conclusion ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery.

Post-Traumatic Cerebral Infarction : Outcome after Decompressive Hemicraniectomy for the Treatment of Traumatic Brain Injury

OBJECTIVE Posttraumatic cerebral infarction (PTCI), an infarction in well-defined arterial distributions after head trauma, is a known complication in patients with severe head trauma. The primary aims of this study were to evaluate the clinical and radiographic characteristics of PTCI, and to assess the effect on outcome of decompressive hemicraniectomy (DHC) in patients with PTCI. METHODS We present a retrospective analysis of 20 patients with PTCI who were treated between January 2003 and August 2005. Twelve patients among them showed malignant PTCI, which is defined as PTCI including the territory of Middle Cerebral Artery (MCA). Medical records and radiologic imaging studies of patients were reviewed. RESULTS Infarction of posterior cerebral artery distribution was the most common site of PTCI. Fourteen patients underwent DHC an average of 16 hours after trauma. The overall mortality rate was 75%. Glasgow outcome scale (GOS) of survivors showed that one patient was remained in a persistent vegetative state, two patients were severely disabled and only two patients were moderately disabled at the time of discharge. Despite aggressive treatments, all patients with malignant PTCI had died. Malignant PTCI was the indicator of poor clinical outcome. Furthermore, Glasgow coma scale (GCS) at the admission was the most valuable prognostic factor. Significant correlation was observed between a GCS less than 5 on admission and high mortality (p<0.05). CONCLUSION In patients who developed non-malignant PTCI and GCS higher than 5 after head injury, early DHC and duroplasty should be considered, before occurrence of irreversible ischemic brain damage. High mortality rate was observed in patients with malignant PTCI or PTCI with a GCS of 3-5 at the admission. A large prospective randomized controlled study will be required to justify for aggressive treatments including DHC and medical treatment in these patients.

Vertebral artery injury after cervical spine trauma: A prospective study using computed tomographic angiography.

Background: Although the vertebral artery injuries (VAI) associated with cervical spine trauma are usually clinically occult, they may cause fatal ischemic damage to the brain stem and cerebellum. Methods: We performed a prospective study using computed tomographic angiography (CTA) to determine the frequency of VAI associated with cervical spine injuries and investigate the clinical and radiological characteristics. Between January 2005 and August 2007, 99 consecutive patients with cervical spine fractures and/or dislocations were prospectively evaluated for patency of the VA, using the CTA, at the time of injury. Results: Complete disruption of blood flow through the VA was demonstrated in seven patients with unilateral occlusion (7.1%). There were four men and three women with a mean age of 43 (range, 33-55 years). Unilateral occlusion of the right vertebral artery occurred in four patients and of the left in three. Regarding the cervical injury type, two cases were cervical burst fractures (C6 and C7), two had C4-5 fracture/dislocations, two had a unilateral transverse foraminal fracture, and one had dens type III fracture. All patients presented with good patency of the contralateral VA. None of the patients developed secondary neurological deterioration due to vertebrobasilar ischemia during the follow-up period with a mean duration of 23 months. Conclusions: VAI should be suspected in patients with cervical trauma that have cervical spine fractures and/or dislocations or transverse foramen fractures. CTA was useful as a rapid diagnostic method for ruling out VAI after cervical spine trauma.

Traumatic subluxation associated with absent cervical pedicle: case report and review of the literature.

Study Design. Case description. Objectives. To describe a case of traumatic subluxation in association with a congenitally absent cervical pedicle, and review the pertinent medical literature. Summary of Background Data. The congenital absence of a cervical pedicle is a relatively uncommon developmental anomaly that is frequently mistaken for a unilateral facet fracture-dislocation in the context of acute trauma. Because there is little evidence of recovery after surgery, and the symptoms are usually not disabling, surgery is not recommended for most cases. Methods. A 62-year-old man presented with severe neck and right shoulder pain after falling. Plain radiographs and computed tomography of the cervical spine showed the typical features of a congenitally absent pedicle at C6 with anterolisthesis of C6 on C7. We performed anterior interbody fusion at C6–C7 because of persistent neck pain and progressive instability. Results. Complete restoration of the C6–C7 subluxation was achieved with resolution of the presenting symptoms. At 18 months follow-up, flexion and extension dynamic radiographs demonstrated good alignment with solid fusion at C6–C7. Conclusion. Although conservative treatment is the primary treatment for this clinical entity, surgery is an alternative option for those patients who fail to achieve recovery after conservative treatment or exhibit instability.