Ko Y

Role of angiogenic growth factors and inflammatory cytokine on recurrence of chronic subdural hematoma

BACKGROUND Chronic subdural hematoma, a benign illness with established surgical treatment, occasionally presents as an annoying recurrence. In this paper, we assess the role of local inflammation and angiogenesis on the recurrence of CSH by measuring relevant biochemical factors from surgical specimens. METHODS During a 2-year period, a prospective comparative study was conducted on 66 consecutive patients with CSH who underwent the same one burr-hole drainage procedure. In the initial operation, the subdural fluid and outer membrane were collected and stored. In the subdural fluid, concentrations of VEGF, bFGF, and IL-6 were measured by the ELISA technique. And semiquantitative analyses were performed with the outer membrane, which was stained by an immunohistochemical method. All data were compared between patients with and without recurrence. RESULTS The mean concentrations of IL-6, VEGF, and bFGF in subdural fluid in 52 nonrecurrent patients were 1980.2 +/- 229.1, 8262.1 +/- 971.9, and 8.6 +/- 1.4 pg/mL, whereas those in 14 recurrent patients were 2411.3 +/- 446.7, 8646.0 +/- 793.3, and 9.8 +/- 2.6 pg/mL, respectively. Concentration of IL-6 was significantly higher in recurrent patients than in nonrecurrent patients, but no significant differences were found in VEGF and bFGF concentrations. Immunohistochemical staining of the outer membrane showed significantly stronger staining of the VEGF and bFGF in recurrent patients than in those without recurrence, but not of the IL-6. CONCLUSIONS When patients with CSH exhibit higher concentrations of IL-6 in the subdural fluid, or enhanced expression of VEGF and bFGF in the outer membrane at the initial operation, recurrence is more likely to occur and a precautious follow-up evaluation is mandated. With regard to the recurrence, local inflammation seems to be responsible for continuous bleeding by capillary exudation in the earlier phase, whereas angiogenesis appears to render maturation of the outer membrane by sprouting vascular networks in the later phase.

Seizures and Epilepsy following Aneurysmal Subarachnoid Hemorrhage : Incidence and Risk Factors

OBJECTIVE Although prophylactic antiepileptic drug (AED) use in patients with aneurysmal subarachnoid hemorrhage (SAH) is a common practice, lack of uniform definitions and guidelines for seizures and AEDs rendered this prescription more habitual instead of evidence-based manner. We herein evaluated the incidence and predictive factors of seizure and complications about AED use. METHODS From July 1999 to June 2007, data of a total of 547 patients with aneurysmal SAH who underwent operative treatments were reviewed. For these, the incidence and risk factors of seizures and epilepsy were assessed, in addition to complications of AEDs. RESULTS Eighty-three patients (15.2%) had at least one seizure following SAH. Forty-three patients (7.9%) had onset seizures, 34 (6.2%) had perioperative seizures, and 17 (3.1%) had late epilepsy. Younger age (< 40 years), poor clinical grade, thick hemorrhage, acute hydrocephalus, and rebleeding were related to the occurrence of onset seizures. Cortical infarction and thick hemorrhage were independent risk factors for the occurrence of late epilepsy. Onset seizures were not predictive of late epilepsy. Moreover, adverse drug effects were identified in 128 patients (23.4%) with AEDs. CONCLUSION Perioperative seizures are not significant predictors for late epilepsy. Instead, initial amount of SAH and surgery-induced cortical damage should be seriously considered as risk factors for late epilepsy. Because AEDs can not prevent early postoperative seizures (< 1 week) and potentially cause unexpected side effects, long-term use should be readjusted in high-risk patients.

Factors associated with survival and neurological outcome after cardiopulmonary resuscitation of neurosurgical intensive care unit patients.

OBJECTIVE:We investigated predictors of survival and the neurological outcomes of neurosurgical patients who experienced cardiac arrest and received cardiopulmonary resuscitation after being admitted to the neurosurgical intensive care unit. METHODS:A retrospective study was conducted of adult patients in the neurosurgical intensive care unit who had experienced cardiac arrest and received cardiopulmonary resuscitation. Factors relevant to the cardiac arrest (before and after arrest) were used to study association with survival (immediate or short-term) and neurological outcome (unconscious or conscious) via statistical methods. RESULTS:Immediate survival was seen in 105 patients (49%), 19 survived until hospital discharge, and 11 were still alive at the conclusion of this study. Of the immediate survivors, 41 patients were conscious and 64 were unconscious. Multivariate analysis showed increased mortality in patients with infection, asystole, or resuscitation time exceeding 30 minutes (P < 0.05). Additional factors associated with high in-hospital mortality included lack of spontaneous respiration, no caloric-vestibular reflex, and unconsciousness after resuscitation (P < 0.05). In addition, neurological recovery was poor in patients with infection, asystole, no caloric-vestibular reflex, conscious recovery, or resuscitation lasting more than 30 minutes (P < 0.05). CONCLUSION:Even after initially successful resuscitation, survival and neurological recovery is quite dismal in patients with cerebral lesions. Prognostic factors for neurosurgical patients should be assessed on an individual basis to determine medical futility in the early post-resuscitation period.

Prognostic role of copeptin after stroke: A systematic review and meta-analysis of observational studies

Copeptin, the C-terminal part of provasopressin, has emerged as a novel prognostic marker after hemorrhagic or ischemic stroke. The aim of this study was to quantitatively assess the prognostic significance of plasma copeptin level on functional outcome and mortality in patients with acute stroke using a meta-analysis of the available evidence. Thirteen relevant studies from 2,746 patients were finally included in our study. An elevated plasma copeptin level was associated with an increased risk of unfavorable outcome and mortality after stroke (OR 1.77; 95% CI, 1.44–2.19 and OR 3.90; 95% CI 3.07–4.95, respectively). The result of the pooled measure on standardized mean difference (SMD) was that plasma copeptin levels were found to be significantly higher in patients who died compared to survivors (SMD 1.70; 95% CI, 1.36–2.03). A stratified analysis by study region showed significant differences in SMD of copeptin, and the heterogeneity among studies was significantly decreased. However, the positive association of copeptin with poor prognosis after stroke was consistent in each stratified analysis. The present meta-analysis suggests that early measurement of plasma copeptin could provide better prognostic information about functional outcome and mortality in patients with acute stroke.

Incidence and Risk Factors of Infection Caused by Vancomycin-Resistant Enterococcus Colonization in Neurosurgical Intensive Care Unit Patients

OBJECTIVE This study was aimed to identify the incidence and risk factors of vancomycin-resistant enterococcus (VRE) colonization in neurosurgical practice of field, with particular attention to intensive care unit (ICU). METHODS This retrospective study was carried out on the Neurosurgical ICU (NICU), during the period from January. 2005 to December. 2007, in 414 consecutive patients who had been admitted to the NICU. Demographics and known risk factors were retrieved and assessed by statistical methods. RESULTS A total of 52 patients had VRE colonization among 414 patients enrolled, with an overall prevalence rate of 6.1%. E. faecium was the most frequently isolated pathogen, and 92.3% of all VRE were isolated from urine specimen. Active infection was noticed only in 2 patients with bacteremia and meningitis. Relative antibiotic agents were third-generation cephalosporin in 40%, and vancomycin in 23%, and multiple antibiotic usages were also identified in 13% of all cases. Multivariate analyses showed Glasgow coma scale (GCS) score less than 8, placement of Foley catheter longer than 2 weeks, ICU stay over 2 weeks and presence of nearby VRE-positive patients had a significantly independent association with VRE infection. CONCLUSION When managing the high-risk patients being prone to be infected VRE in the NICU, extreme caution should be paid upon. Because prevention and outbreak control is of ultimate importance, clinicians should be alert the possibility of impending colonization and infection by all means available. The most crucial interventions are careful hand washing, strict glove handling, meticulous and active screening, and complete segregation.

Effectiveness of papaverine cisternal irrigation for cerebral vasospasm after aneurysmal subarachnoid hemorrhage and measurement of biomarkers

Cisternal irrigation with thrombolytic agents was used to prevent post-SAH vasospasm, but its role remained inconclusive. To verify effectiveness of papaverine (PPV) in preventing vasospasm, we studied relationship between inflammatory biologic markers and vasospasm. This prospective study included 121 patients with clipped anterior circulation aneurysms that had ruptured, and 372 control patients. Patients were divided into three groups according to cisternal irrigation method: simple drain, papaverine group, and urokinase (UK) group. Intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were determined in CSF and serum on days 3 and 7 after SAH. The PPV group showed similar incidence of vasospasm with UK group, but lower incidence than the simple drain group. The levels of ICAM-1 and VCAM-1 were significantly higher in the SAH group than in the control group. CSF and serum levels were more elevated on day 7 than day 3, and the degree of elevation were more marked when measured in the CSF than in the serum. However, there was no statistical difference between measured levels of ICAM-1 and VCAM-1, and vasospasm development. PPV cisternal irrigation was similarly effective as UK at preventing vasospasm. Although neither PPV nor UK irrigation could reduce the concentration of adhesion molecules compared with simple drain, we found levels of ICAM-1 and VCAM-1 were specifically elevated in the CSF. Therefore, further research should focus on anti-inflammation as a therapeutic target against cerebral vasospasm and on the CSF as the optimum place where such inflammatory action practically brought about.

Perioperative Risk Factors Related to Lumbar Spine Fusion Surgery in Korean Geriatric Patients

Objective Life expectancy for humans has increased dramatically and with this there has been a considerable increase in the number of patients suffering from lumbar spine disease. Symptomatic lumbar spinal disease should be treated, even in the elderly, and surgical procedures such as fusion surgery are needed for moderate to severe lumbar spinal disease. However, various perioperative complications are associated with fusion surgery. The aim of this study was to examine perioperative complications and assess risk factors associated with lumbar spinal fusion, focusing on geriatric patients at least 70 years of age in the Republic of Korea. Methods We retrospectively investigated 489 patients with various lumbar spinal diseases who underwent lumbar spinal fusion surgery between 2003 and 2007 at our institution. Three fusion procedures and the number of fused segments were analyzed in this study. Chronic diseases were also evaluated. Risk factors for complications and their association with age were analyzed. Results In this study, 74 patients experienced complications (15%). The rate of perioperative complications was significantly higher in patients 70 years of age or older than in other age groups (univariate analysis, p=0.001; multivariate analysis, p=0.004). However, perioperative complications were not significantly associated with the other factors tested (sex, comorbidities, operation procedures, fusion segments involved). Conclusion Increasing age was an important risk factor for perioperative complications in patients undergoing lumbar spinal fusion surgery whereas other factors were not significant. We recommend good clinical judgment and careful selection of geriatric patients undergoing lumbar spinal fusion surgery.

The Predicting Factors for Recurrence of Chronic Subdural Hematoma Treated with Burr Hole and Drainage

Objective Chronic subdural hematoma (CSDH) is common in elderly patients. So, with an increasing number of elderly people in the general population, there is a need to investigate risk factors which increase recurrence rate. In this study, factors affecting the postoperative recurrence are investigated based on the reoperative CSDH cases. Methods Total of ninety-seven patients was enrolled in this study who had have operation for CSDH. In all patients, one burr hole trephination and drainage was the method of choice for the initial treatment of CSDH. We retrospectively evaluated several factors which affect to recurrence of CSDH. Results Retrospective analysis was performed in 97 patients. Sixteen patients experienced reoperation within 3 months (16/97, 16.5%) for recurrence of CSDH. And, when hematoma was divided by internal architecture, heterogeneous density group seems to be have close relationship with recurrence more significantly than homogeneous density group (p=0.002). Hypertension, diabetes mellitus, early removal of drainage tube, bilaterality of hematoma also have significant relationship with recurrence. Conclusion Recurrence rate of CSDH treated with one burr hole drainage is related with some various factors. There was statistically significant difference between recurred group and non-recurred group. Not only demographic factors but also internal architecture on preoperative brain computed tomography is a significant predicting factor of recurrence in CSDH patients who underwent a surgery. In this study, heterogeneous type hematoma have significantly related with recurrence of CSDH. We should give attention to these predicting factors for more effective care.

Unilateral Posterior Atlantoaxial Transarticular Screw Fixation in Patients with Atlantoaxial Instability : Comparison with Bilateral Method

OBJECTIVE Bilateral C1-2 transarticular screw fixation (TAF) with interspinous wiring has been the best treatment for atlantoaxial instability (AAI). However, several factors may disturb satisfactory placement of bilateral screws. This study evaluates the usefulness of unilateral TAF when bilateral TAF is not available. METHODS Between January 2003 and December 2007, TAF was performed in 54 patients with AAI. Preoperative studies including cervical x-ray, three dimensional computed tomogram, CT angiogram, and magnetic resonance image were checked. The atlanto-dental interval (ADI) was measured in preoperative period, immediate postoperatively, and postoperative 1, 3 and 6 months. RESULTS Unilateral TAF was performed in 27 patients (50%). The causes of unilateral TAF were anomalous course of vertebral artery in 20 patients (74%), severe degenerative arthritis in 3 (11%), fracture of C1 in 2, hemangioblastoma in one, and screw malposition in one. The mean ADI in unilateral group was measured as 2.63 mm in immediate postoperatively, 2.61 mm in 1 month, 2.64 mm in 3 months and 2.61 mm in 6 months postoperatively. The mean ADI of bilateral group was also measured as following; 2.76 mm in immediate postoperative, 2.71 mm in 1 month, 2.73 mm in 3 months, 2.73 mm in 6 months postoperatively. Comparison of ADI measurement showed no significant difference in both groups, and moreover fusion rate was 100% in bilateral and 96.3% in unilateral group (p=0.317). CONCLUSION Even though bilateral TAF is best option for AAI in biomechanical perspectives, unilateral screw fixation also can be a useful alternative in otherwise dangerous or infeasible cases through bilateral screw placement.

Myelopathy Caused by Soft Cervical Disc Herniation : Surgical Results and Prognostic Factors

OBJECTIVE The purpose of this study was to investigate the surgical results and prognostic factors for patients with soft cervical disc herniation with myelopathy. METHODS During the last 7 years, 26 patients with cervical discogenic myelopathy were undertaken anterior discectomy and fusion. Clinical and radiographic features were reviewed to evaluate the surgical results and prognostic factors. The clinical outcome was judged using two grading systems (Herkowitzs scale and Nuricks grade). RESULTS Male were predominant (4:1), and C5-6 was the most frequently involved level. Gait disturbance, variable degree of spasticity, discomfort in chest and abdomen, hand numbness were the most obvious signs. Magnetic resonance(MR) images showed that central disc herniation was revealed in 16 cases, and accompanying cord signal changes in 4. Postoperatively, 23 patients showed favorable results (excellent, good and fair) according to Herkowitzs scale. CONCLUSION Anterior cervical discectomy and fusion effectively reduced myelopathic symptoms due to soft cervical disc herniation. The authors assured that the shorter duration of clinical attention, the lesser the degree of myelopathy and better outcome in discogenic myelopathy.