Dong-Kyu Jang

Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy

Objective The predictors of cranioplasty infection after decompressive craniectomy have not yet been fully characterized. The objective of the current study was to compare the long-term incidences of surgical site infection according to the graft material and cranioplasty timing after craniectomy, and to determine the associated factors of cranioplasty infection. Methods A retrospective cohort study was conducted to assess graft infection in patients who underwent cranioplasty after decompressive craniectomy between 2001 and 2011 at a single-center. From a total of 197 eligible patients, 131 patients undergoing 134 cranioplasties were assessed for event-free survival according to graft material and cranioplasty timing after craniectomy. Kaplan-Meier survival analysis and Cox regression methods were employed, with cranioplasty infection identified as the primary outcome. Secondary outcomes were also evaluated, including autogenous bone resorption, epidural hematoma, subdural hematoma and brain contusion. Results The median follow-up duration was 454 days (range 10 to 3900 days), during which 14 (10.7%) patients suffered cranioplasty infection. There was no significant difference between the two groups for event-free survival rate for cranioplasty infection with either a cryopreserved or artificial bone graft (p=0.074). Intergroup differences according to cranioplasty time after craniectomy were also not observed (p=0.083). Poor neurologic outcome at cranioplasty significantly affected the development of cranioplasty infection (hazard ratio 5.203, 95% CI 1.075 to 25.193, p=0.04). Conclusion Neurologic status may influence cranioplasty infection after decompressive craniectomy. A further prospective study about predictors of cranioplasty infection including graft material and cranioplasty timing is necessary.

Effect of combination therapy with sodium ozagrel and panax ginseng on transient cerebral ischemia model in rats.

Sodium ozagrel (SO) prevents platelet aggregation and vasoconstriction in the cerebral ischemia. It plays an important role in the prevention of brain damage induced by cerebral ischemia/reperfusion. Recently, many animal studies have suggested that the Panax ginseng (PG) has neuroprotective effects in the ischemic brain. In this study, we assessed the neuroprotective effects that come from a combination therapy of SO and PG in rat models with middle cerebral artery occlusion (MCAO). Animals with MCAO were assigned randomly to one of the following four groups: (1) control (Con) group, (2) SO group (3 mg/kg, intravenously), (3) PG group (200 mg/kg, oral feeding), and (4) SO + PG group. The rats were subjected to a neurobehavior test including adhesive removal test and rotarod test at 1, 3, 7, 10, and 15 days after MCAO. The cerebral ischemic volume was quantified by Metamorph imaging software after 2-3-5-triphenyltetrazolium (TTC) staining. The neuronal cell survival and astrocytes expansion were assessed by immunohistofluorescence staining. In the adhesive removal test, the rats of PG or SO + PG group showed significantly better performance than those of the control group (Con: 88.1 ± 24.8, PG: 43.6 ± 11, SO + PG: 11.8 ± 7, P < .05). Notably, the combination therapy group (SO + PG) showed better performance than the SO group alone (SO: 56 ± 12, SO + PG: 11.8 ± 7, P < .05). In TTC staining for infarct volume, cerebral ischemic areas were also significantly reduced in the PG group and SO + PG group (Con: 219 ± 32, PG: 117 ± 8, SO + PG: 99 ± 11, P < .05). Immunohistofluorescence staining results showed that the group which received SO + PG group therapy had neuron cells in the normal range. They also had a low number of astrocytes and apoptotic cells compared with the control or SO group in the peri-infarction area. During astrocytes staining, compared to the SO + PG group, the PG group showed only minor differences in the number of NeuN-positive cells and quantitative analysis of infarct volume. In conclusion, these studies showed that in MCAO rat models, the combination therapy with SO and PG may provide better neuroprotective effects such as higher neuronal cell survival and inhibition of astrocytes expansion than monotherapy with SO alone.

Clinical and Angiographic Features and Stroke Types in Adult Moyamoya Disease

DSA was used to study patients with Moyamoya disease with acute stroke. Advanced Suzuki angiographic stages, aneurysms, arterial occlusions, and collateral flow including transdural anastomoses were present more often in patients with hemorrhage than in those with only ischemia. These findings are the main contributors to the development of hemorrhagic strokes in patients with Moyamoya disease. BACKGROUND AND PURPOSE: This study was conducted to elucidate the association between clinical and angiographic characteristics and stroke types in adult Moyamoya disease that has been rarely evaluated. MATERIALS AND METHODS: We analyzed the clinical and radiologic data obtained from a retrospective adult Moyamoya disease cohort with acute strokes, which were classified into 7 categories: large-artery infarct, hemodynamic infarct, perforator infarct, deep intracerebral hemorrhage, lobar intracerebral hemorrhage, intraventricular hemorrhage, and SAH. With conventional angiography, which was performed in the hemispheres with acute strokes, the Suzuki angiographic stage, intracranial aneurysm, major artery occlusion, and collateral vessel development were confirmed within 1 month of stroke onset. RESULTS: This study included 79 patients with acute ischemic stroke and 96 patients with acute hemorrhagic stroke. The angiographic stage had a strong tendency to be more advanced in the hemorrhagic than the ischemic patients (P = .061). Intracranial aneurysms were more frequently found in the hemorrhagic than ischemic or control hemispheres (P = .002). Occlusions of the anterior cerebral artery and development of fetal-type posterior cerebral artery were more frequently observed in the hemorrhagic than the ischemic (P = .001 and .01, respectively) or control hemispheres (P = .011 and .013, respectively). MCA occlusion (P = .039) and collateral flow development, including the ethmoidal Moyamoya vessels (P = .036) and transdural anastomosis of the external carotid artery (P = .022), occurred more often in the hemorrhagic than the ischemic hemispheres. Anterior cerebral artery occlusion occurred more frequently in patients with deep intracerebral hemorrhage or intraventricular hemorrhage than with lobar intracerebral hemorrhage (P = .009). CONCLUSIONS: In adult Moyamoya disease, major artery occlusion and collateral compensation occurred more often in the hemorrhagic than in the ischemic hemispheres. Thus, anterior cerebral artery occlusion with or without MCA occlusion and intracranial aneurysms may be the main contributing factors to hemorrhagic stroke in adult patients with Moyamoya disease.

A Pilot Study for the Neuroprotective Effect of Gongjin-dan on Transient Middle Cerebral Artery Occlusion-Induced Ischemic Rat Brain

In this study, we investigated whether gongjin-dan improves functional recovery and has neuroprotective effects on reducing the infarct volume after transient middle cerebral artery occlusion (MCAo). Infarct volume was measured using TTC staining and glucose utilization by F-18 FDG PET. Functional improvement was evaluated with the Rota-rod, treadmill, Garcia score test, and adhesive removal test. At 14 days after MCAo, neuronal cell survival, astrocytes expansion, and apoptosis were assessed by immunohistofluorescence staining in the peri-infarct region. Also, the expression of neurotrophic factors and inflammatory cytokines such as VEGF, BDNF, Cox-2, TNF-α, IL-1β, and IL-1α was measured in ischemic hemisphere regions. The gongjin-dan-treated group showed both reduced infarct volume and increased glucose utilization. Behavior tests demonstrated a significant improvement compared to the control. Also in the gongjin-dan treated group, NeuN-positive cells were increased and number of astrocytes, microglia, and apoptotic cells was significantly decreased compared with the control group in the ischemic peri-infarct area. Furthermore, the expression of VEGF and BDNF was increased and level of Cox-2, TNF-α, IL-1β, and IL-1α was decreased. These results suggest that gongjin-dan may improve functional outcome through the rapid restoration of metabolism and can be considered as a potential neuroprotective agent.

Motor-Evoked Potential Confirmation of Functional Improvement by Transplanted Bone Marrow Mesenchymal Stem Cell in the Ischemic Rat Brain

This study investigated the effect of bone marrow mesenchymal stem cells (BMSCs) on the motor pathway in the transient ischemic rat brain that were transplanted through the carotid artery, measuring motor-evoked potential (MEP) in the four limbs muscle and the atlantooccipital membrane, which was elicited after monopolar and bipolar transcortical stimulation. After monopolar stimulation, the latency of MEP was significantly prolonged, and the amplitude was less reduced in the BMSC group in comparison with the control group (P < .05). MEPs induced by bipolar stimulation in the left forelimb could be measured in 40% of the BMSC group and the I wave that was not detected in the control group was also detected in 40% of the BMSC group. Our preliminary results imply that BMSCs transplanted to the ischemic rat brain mediate effects on the functional recovery of the cerebral motor cortex and the motor pathway.

Ischaemic stroke after acute intracranial haemorrhage in patients with moyamoya disease: six new cases and a short literature review

BackgroundWe report six new cases of ischaemic stroke after cerebral haemorrhage in patients with moyamoya disease (MMD) and analyse their clinical and radiological characteristics, together with cases reported in the literature, to deduce the mechanism of cerebral infarct.MethodsSix (2%) of 246 patients with MMD who were admitted to our hospitals between 1993 and 2009 suffered cerebral infarct after intracranial haemorrhage. Ten patients identified in the literature with the PubMed search engine were also included in this study. All the ischaemic lesions in these 16 patients were analysed according to their location, size, and number and were compared according to the spatial relationship between the haemorrhage and infarct, as follows: (1) anterior vs posterior involvement, (2) cortical vs subcortical involvement, (3) watershed vs non-watershed infarct, (4) small vs large infarct, (5) single vs multiple infarct, and (6) adjacent vs distant involvement.ResultsAcute synchronous multiple brain infarcts occurred in six (38%) patients and recurrent infarcts in three patients (19%). Cerebral infarcts had mainly cortical (72%), anterior (66%), and distant involvement (75%) and were large (69%) and non-watershed (66%). Adjacent infarct had significantly anterior involvement (P < 0.05), and distant infarcts tended to have cortical involvement. Non-watershed infarcts had significantly cortical involvement (P < 0.05). Watershed infarcts tended to be large. Vasospasm was confirmed either pathologically or angiographically in two patients with large cerebral infarcts.ConclusionsWe suggest that thromboembolism or vasospasm plays a crucial role in the pathogenesis of cerebral infarction after acute intracranial haemorrhage in patients with MMD.

Bypass surgery versus medical treatment for symptomatic moyamoya disease in adults

OBJECTIVE In this study the authors evaluated whether extracranial-intracranial bypass surgery can prevent stroke occurrence and decrease mortality in adult patients with symptomatic moyamoya disease (MMD). METHODS The medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups. RESULTS The bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27-0.86, p = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43-2.66, p = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06-0.49, p = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; p = 0.524, p = 0.828, and p = 0.616, respectively). CONCLUSIONS During the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.

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.

Monoplane 3D Overlay Roadmap versus Conventional Biplane 2D Roadmap Technique for Neurointervenional Procedures

Purpose We investigated whether a 3D overlay roadmap using monoplane fluoroscopy offers advantages over a conventional 2D roadmap using biplane fluoroscopy during endovascular aneurysm treatment. Materials and Methods A retrospective chart review was conducted for 131 consecutive cerebral aneurysm embolizations by three neurointerventionalists at a single institution. Allowing for a transition period, the periods from January 2012 to August 2012 (Time Period 1) and February 2013 to July 2013 (Time Period 2) were analyzed for radiation exposure, contrast administration, fluoroscopy time, procedure time, angiographic results, and perioperative complications. Two neurointerventionalists (Group 1) used a conventional 2D roadmap for both Time Periods, and one neurointerventionalist (Group 2) transitioned from a 2D roadmap during Time Period 1 to a 3D overlay roadmap during Time Period 2. Results During Time Period 2, Group 2 demonstrated reduced fluoroscopy time (p<0.001), procedure time (P=0.023), total radiation dose (p=0.001), and fluoroscopy dose (P=0.017) relative to Group 1. During Time Period 2, there was no difference of immediate angiographic results and procedure complications between the two groups. Through the transition from Time Period 1 to Time Period 2, Group 2 demonstrated decreased fluoroscopy time (p< 0.001), procedure time (p=0.022), and procedure complication rate (p=0.041) in Time Period 2 relative to Time Period 1. Conclusion The monoplane 3D overlay roadmap technique reduced fluoroscopy dose and fluoroscopy time during neurointervention of cerebral aneurysms with similar angiographic occlusions and complications rate relative to biplane 2D roadmap, which implies possible compensation of limitations of monoplane fluoroscopy by 3D overlay technique.

Association of apolipoprotein E gene polymorphism with small-vessel lesions and stroke type in moyamoya disease: a preliminary study

OBJECT The present study was conducted to investigate whether microbleeds or microinfarcts are associated with apolipoprotein E (APOE) gene polymorphisms in patients with moyamoya disease (MMD), and if so, whetherAPOE gene polymorphisms are also associated with stroke type in patients with MMD. METHODS This cross-sectional, multicenter study included 86 consecutive patients with MMD who underwent T2*-weighted gradient echo or susceptibility-weighted MR imaging and 83 healthy control volunteers. Baseline clinical and radiological characteristics were recorded at diagnosis, and inter- and intragroup differences in the APOE genotypes were assessed. Multivariate binary logistic regression models were used to determine the association factors for small-vessel lesions (SVLs) and hemorrhagic presentation in patients with MMD. RESULTS There was no difference in APOE gene polymorphism and the incidence of SVLs between patients with MMD and healthy controls (p > 0.05). In the MMD group, 7 (8.1%) patients had microbleeds and 32 (37.2%) patients had microinfarcts. Microbleeds were more frequently identified in patients with hemorrhagic-type than in nonhemorrhagictype MMD (p = 0.003). APOE genotypes differed according to the presence of microbleeds (p = 0.024). APOE ε2 or ε4 carriers also experienced microbleeds more frequently than APOE ε3/ε3 carriers (p = 0.013). In the multivariate regression analysis in patients with MMD, microbleeds were significantly related to APOE ε2 or ε4 carrier status (OR 7.86; 95% CI1.20-51.62; p = 0.032) and cerebral aneurysm (OR 17.31; 95% CI 2.09-143.57; p = 0.008). Microinfarcts were independently associated with hypertension (OR 3.01; 95% CI 1.05-7.86; p = 0.007). Hemorrhagic presentation was markedly associated with microbleeds (OR 10.63; 95% CI 1.11-102.0; p = 0.041). CONCLUSIONS These preliminary results did not show a difference in APOE gene polymorphisms between patients with MMD and healthy persons. However, they imply that APOE gene polymorphisms may play certain roles in the presence of microbleeds but not microinfarcts in patients with MMD. A further confirmatory study is necessary to elucidate the effect of APOE gene polymorphisms and SVLs on the future incidence of stroke in patients with MMD.