Jun Young Chung

Paraplegia Caused by an Epidural Hematoma in a Patient With Unrecognized Chronic Idiopathic Thrombocytopenic Purpura Following an Epidural Steroid Injection

Study Design. Case report. Objectives. To report a rare case of complicated paraplegia caused by a spontaneous epidural hematoma following an epidural steroid injection in a patient with unrecognized chronic idiopathic thrombocytopenic purpura (ITP) and to review relevant literature and discuss etiology, pathogenesis, and clinical features. Summary of Background Data. A spinal epidural hematoma is a rare but potentially catastrophic complication, which could develop in patients without any risk factors. Some patients with chronic ITP are asymptomatic. To our knowledge there has been no previous report of such a complication. Methods. This is a retrospective review of a case seen at our institution. Results. The authors present a case of a 67-year-old woman who received an epidural steroid injection following complaints of lower back pain and bilateral buttock and leg pain. One day later, the patient had right leg numbness and weakness extending to her right knee; she was taken for emergency surgery. An emergency magnetic resonance imaging revealed an epidural hematoma with high-signal intensity on T2 imaging in the lumbar spinal cord and spinal cord compression with subdural hematoma. One week later, she was progressively developing lower extremity paraplegia with an L1 motor level and no sensory or sphincter activity. She was taken from the emergency room at our institution to the operating room for emergency decompression. After an uneventful course for 1 year, the patient presented with progressive bilateral lower extremity paralysis. Conclusion. Epidural steroid therapy is a commonly used conservative therapy; however, complications could develop in patients without any risk factors. Clinicians who plan an epidural steroid injection must perform a rigorous evaluation through a detailed physical examination, simple laboratory tests, and history taking to prevent various risks associated with spinal cord compression.

Bedside Prediction of Airway Length in Adults and Children

Background:Malpositioning of the endotracheal tube within the airway leads to serious complications such as endobronchial intubation. Prediction of the correct depth of an endotracheal tube is important and should be individualized. The manubriosternal joint (MSJ) is on the same horizontal plane with the tracheal carina. We compared the straight length from the upper incisor to the MSJ in the fully extended position (incisor-MSJ extension length) with the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in the neutral position (incisor-carina neutral length). Methods:One hundred adults and 50 children were studied. Induction of anesthesia was achieved with 1.5 mg/kg propofol and 0.6 mg/kg rocuronium IV. The incisor-MSJ extension length was measured after adequate mask ventilation. After intubation, the endotracheal tube was positioned properly at the upper incisor teeth, and the incisor-carina neutral length was measured with the fiberoptic bronchoscope at the carina. Results:The correlation between the incisor-MSJ extension length and the incisor-carina neutral length is significant (P < 0.001) in both adults and children. A formula for the regression line in adults (children) can be obtained as the incisor-carina neutral length (cm) = 0.868 (1.009) × the incisor-MSJ extension length (cm) + 4.260 (0.468) with a high coefficient of determination; r2 = 0.88 (0.98). Conclusions:The airway length from the upper incisor to the carina in the neutral position can be predicted by the straight length from the upper incisor to the MSJ in the fully extended position.

Isoflurane induces transient anterograde amnesia through suppression of brain-derived neurotrophic factor in hippocampus

Objective Transient anterograde amnesia is occasionally observed in a number of conditions, including migraine, focal ischemia, venous flow abnormalities, and after general anesthesia. The inhalation anesthetic, isoflurane, is known to induce transient anterograde amnesia. We examined the involvement of brain-derived neurotrophic factor (BDNF) and its receptor tyrosine kinase B (TrkB) in the underlying mechanisms of the isoflurane-induced transient anterograde amnesia. Methods Adult male Sprague-Dawley rats were divided into three groups : the control group, the 10 minutes after recovery from isoflurane anesthesia group, and the 2 hours after recovery from isoflurane anesthesia group (n=8 in each group). The rats in the isoflurane-exposed groups were anesthetized with 1.2% isoflurane in 75% nitrous oxide and 25% oxygen for 2 hours in a Plexiglas anesthetizing chamber. Short-term memory was determined using the step-down avoidance task. BDNF and TrkB expressions in the hippocampus were evaluated by immunofluorescence staining and western blot analysis. Results Latency in the step-down avoidance task was decreased 10 minutes after recovery from isoflurane anesthesia, whereas it recovered to the control level 2 hours after isoflurane anesthesia. The expressions of BDNF and TrkB in the hippocampus were decreased immediately after isoflurane anesthesia but were increased 2 hours after isoflurane anesthesia. Conclusion In this study, isoflurane anesthesia induced transient anterograde amnesia, and the expressions of BDNF and TrkB in the hippocampus might be involved in the underlying mechanisms of this transient anterograde amnesia.

Involvement of tryptophan hydroxylase 2 (TPH2) gene polymorphisms in susceptibility to coronary artery lesions in Korean children with Kawasaki disease.

Kawasaki disease (KD) is an acute vasculitis of childhood that predominantly affects the coronary arteries. We investigated single nucleotide polymorphisms (SNPs) of the tryptophan hydroxylase 2 (TPH2) gene as risk factors for KD with coronary artery lesions (CALs) in Korean children. We genotyped two SNPs [rs7305115 (exon 7) and rs4290270 (exon 9)] using direct sequencing in 101 KD and 256 control subjects. To analyze the genetic data, SNPStats, SNPAnalyzer, and Helixtree programs were used. The genotype analysis of rs7305115 and rs4290270 showed no significant differences between KD and control groups. However, we found a statistically significant association between the two SNPs and the development of CALs in KD (p < 0.05). The minor homozygous genotype (rs7305115, AA genotype and rs42901270, AA genotype) of each SNP showed increased susceptibility to risk of CALs in KD patients. These results suggest that TPH2 may be associated with the development of KD with CALs in Korean children.

The comparison of monitored anesthesia care with dexmedetomidine and spinal anesthesia during varicose vein surgery

Purpose The purpose of this study was to investigate the effectiveness and safety of monitored anesthesia care (MAC) using dexmedetomidine for its sedative and analgesic effect during varicose vein surgery. Methods Forty-two patients, who underwent varicose vein surgery, were divided into the MAC group (n = 20) or the spinal anesthesia group (n = 22) for randomized clinical trial. In the MAC group, dexmedetomidine was administered by a loading dose of 1 µg/kg for 10 minutes, followed by a maintenance infusion of 0.2-1.0 µg/kg/hr. Ketamine was used for intermittent injection. In the spinal anesthesia group, midazolam was used for sedation. Intraoperative vital signs, the number of adverse events, and the satisfaction of patients and surgeons concerning the anesthetic condition were compared between the two groups. Results Systolic blood pressure was intraoperatively significantly different over time between the two groups. The groups had statistical differences in the change in heart rate with regard to time. In the postanesthetic care unit, patients and surgeons in the MAC group had a lower satisfaction score, compared to patients and surgeons in the spinal anesthesia group. However, in the recovery period, patients had a positive perception concerning MAC anesthesia. In addition, without significant adverse events, the MAC group had a shorter time to possible ambulation, which indicated an early recovery. Conclusion We believe that MAC using dexmedetomidine in combination with ketamine may be an alternative anesthetic technique for varicose vein surgery with regard to a patients preference and medical condition.

Comparison of two topographical airway length measurements in adults

Background A correct estimate of the tracheal tube insertion depth can prevent complications, including endobronchial intubation and vocal cord trauma. We evaluated a new topographical method for endotracheal tube positioning relative to the carina, using a well-known prior topographical method for comparison. Methods One hundred adult (male 50, female 50) patients were studied. The comparison topographic length (in cm) was measured by adding the distance between the right mouth corner and the right mandibular angle to the distance between the right mandibular angle and the center of the sternal manubrium. The new endotracheal tube insertion depth (in cm) was determined by adding the distance between the right mouth corner and the vocal cords, measured with the endotracheal tube itself, to the distance between the thyroid prominence and the manubriosternal joint, and then subtracting 4 cm. After intubation, the endotracheal tube was positioned properly at the right mouth corner and the endotracheal tube tip was evaluated using a fiberoptic bronchoscope at the carina. Results The distances from the tip of the endotracheal tube to the carina were not significantly different between the methods in the same gender. However, our method allowed endotracheal tube tip placement between 3 cm and 5 cm, above the carina more frequently than the prior method in males. Conclusions The new topographical method can be used as a guide to positioning the endotracheal tubes.

Changes in gene expression in the rat hippocampus after focal cerebral ischemia.

OBJECTIVE The rat middle cerebral artery thread-occlusion model has been widely used to investigate the pathophysiological mechanisms of stroke and to develop therapeutic treatment. This study was conducted to analyze energy metabolism, apoptotic signal pathways, and genetic changes in the hippocampus of the ischemic rat brain. METHODS Focal transient cerebral ischemia was induced by obstructing the middle cerebral artery for two hours. After 24 hours, the induction of ischemia was confirmed by the measurement of infarct size using 2,3,5-triphenyltetrazolium chloride staining. A cDNA microarray assay was performed after isolating the hippocampus, and was used to examine changes in genetic expression patterns. RESULTS According to the cDNA microarray analysis, a total of 1,882 and 2,237 genes showed more than a 2-fold increase and more than a 2-fold decrease, respectively. When the genes were classified according to signal pathways, genes related with oxidative phosphorylation were found most frequently. There are several apoptotic genes that are known to be expressed during ischemic brain damage, including Akt2 and Tnfrsf1a. In this study, the expression of these genes was observed to increase by more than 2-fold. As energy metabolism related genes grew, ischemic brain damage was affected, and the expression of important genes related to apoptosis was increased/decreased. CONCLUSION Our analysis revealed a significant change in the expression of energy metabolism related genes (Atp6v0d1, Atp5g2, etc.) in the hippocampus of the ischemic rat brain. Based on this data, we feel these genes have the potential to be target genes used for the development of therapeutic agents for ischemic stroke.

Anesthesia for liver transplantation from a maastricht category 4 non-heart-beating donor -A case report-

Great improvements in patient selection, surgical techniques, perioperative care, and immunosuppression have been made for the optimization of liver transplantation. To increase the number of organs available for liver transplantation, transplant centers have used marginal donors, split livers, living donors, or non-heart-beating donors (NHBDs). Despite recent enthusiasm for NHBDs in liver transplantation, warm ischemic injury to recovered organs has been an obstacle for the wide acceptance of NHBD. In the present case, we have conducted a liver transplantation from a Maastricht Category 4 NHBD. Warm ischemic time was 20 minutes and cold ischemic time was 5 hour 43 minutes. Consequently, the liver was successfully transplanted into the recipient.