Sung-Pil Joo

Endovascular embolization of iatrogenic vertebral artery injury during anterior cervical spine surgery: report of two cases and review of the literature.

Study Design. Case description. Objectives. To report 2 cases of vertebral artery injury (VAI) during anterior cervical decompression surgery and review the pertinent medical literature. Summary of Background Data. The incidence of VAI during an anterior surgical approach to the cervical spine is rare but potentially lethal. The spine surgeon should be aware of the detailed surgical anatomy and be prepared to manage an inadvertent injury to the vertebral artery. Methods. In the first case presented, infection was the cause of VAI. During aggressive irrigation and pus drainage, massive bleeding was encountered. For the second case, the vertebral artery was injured during decompression of cervical spondylosis while drilling the neural foramen. Intraoperative direct packing with hemostatic agents provided effective control of hemorrhage. Results. Ten days after surgery, sudden neck swelling and mental deterioration occurred because of rebleeding from a pseudoaneurysm in the first case. In the second case, a pseudoaneurysm was detected by angiography, obtained 4 days after surgery. Both pseudoaneurysms were successfully occluded by an endovascular technique without any neurologic sequelae. Conclusions. In case of bleeding control by hemostatic packing, there remains a risk of delayed hemorrhage from pseudoaneurysm. Postoperative vertebral angiography is helpful to avoid life-threatening complications. Endovascular treatment can be a good alternative in the treatment of VAI.

Endothelial nitric oxide gene T-786C polymorphism and subarachnoid hemorrhage in Korean population.

We aimed to elucidate whether the eNOS T-786C mutant allele is implicated in subarachnoid hemorrhage (SAH) susceptibility or vasospasm after SAH, and whether the mutant allele is differentially expressed in those with small and large ruptured aneurysms in Korean population. 136 consecutive patients diagnosed with aneurismal SAH and 113 controls were recruited. Polymerase chain reaction and direct sequencing of both strands were performed to determine genotypes with respect to the eNOS T-786C mutation. No significant difference was found between cases and controls with respect to the distributions of the two eNOS T-786C single nucleotide polymorphism (SNP) genotypes. No significant differences in the distributions of the eNOS T-786C SNP genotypes were found with regard to the sizes of ruptured aneurysms or the occurrence of vasospasm after SAH. Multiple logistic regression analysis after controlling for age and sex showed the eNOS T-786C SNP T/C genotype was independently associated with an unfavorable outcome (GOS grade 3-5) of SAH (Exp (β)=4.27, 95% CI 1.131-16.108, p=0.032). In conclusion, the eNOS T-786C mutation was not found to be associated with either a susceptibility to SAH or vasospasm after SAH, or with aneurysm size in Korean population. The eNOS T-786C SNP T/C genotype could be used as a prognostic marker in individuals with SAH.

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.

Rutin improves functional outcome via reducing the elevated matrix metalloproteinase-9 level in a photothrombotic focal ischemic model of rats

BACKGROUND Blood-brain barrier (BBB) disruption mediated by proteases plays a pivotal role in neural tissue damage after acute ischemic stroke. In an animal stroke model, the activation of matrix metalloproteinases (MMPs), especially MMP-9, was significantly increased and it showed potential association with blood-brain barrier (BBB) disruption and cerebral edema. Theoretically, it is expected that early blockade of expression and activation of MMP-9 after ischemic stroke provides neuroprotective effects from secondary neural tissue damage. This study was aimed to determine the ability of rutin to influence MMP-9 expression, activity and BBB disruption using a photothrombotic focal ischemic model in rats. METHODS Adult male Sprague-Dawley rats, weighing between 250 and 300 g (aged 8 weeks) received focal cerebral ischemia by photothrombosis using Rose Bengal (RB) and cold light. Injured animals were divided into two groups; one group received 50mg/kg of rutin intraperitoneally, starting 1h after injury and at 12h intervals for 3 days, while animals in the control group received weight-adjusted doses of saline vehicle over the same period. In each group, the expressions and activities of MMP-9 were assessed by Western blot and gelatin zymography at 6, 24, 48, and 72 h after photothrombotic insult. The effects of rutin on BBB disruption and functional outcomes were also determined. RESULTS Western blot and zymographic analysis showed up-regulated MMP-9 expression and activity in the ischemic cortex. The expression and activity of MMP-9 were significantly elevated at 6h after photothrombotic insult, which remained up-regulated for at least until 72 h after injury. In the rutin-treated group, MMP-9 expression and activity were significantly attenuated at 6, 24, and 48 h compared to the control group. Relative to the control group, BBB permeability was significantly reduced in the rutin-treated group. The results of the rotarod test revealed that rutin treatment significantly improved functional outcomes. CONCLUSIONS Rutin treatment starting 1h after injury attenuated BBB disruption during photothrombotic focal ischemia, which was partly, at least, achieved through inhibitory effects on MMP-9 expression and activity. The results of this study suggest that rutin might be useful in clinical trials aimed to improve the outcome of patients suffering from acute ischemic stroke.

Kernohan’s notch phenomenon in chronic subdural hematoma: MRI findings

We report two cases of Kernohans notch phenomenon secondary to chronic subdural hematoma detected by MRI. In the first case, the patient was drowsy with an oculomotor palsy and a hemiparesis ipsilateral to the chronic subdural hematoma. MRI in the post-operative period showed no abnormal signal or deformity of the crus cerebri. The neurological signs immediately resolved after trephination. In the second case, the patient was admitted with progressive decrease in their level of consciousness and ipsilateral hemiparesis with the chronic subdural hematoma. MRI on admission revealed an abnormal signal in the contralateral crus cerebri against the chronic subdural hematoma. After surgery, the mental state gradually recovered to normal with some degree of residual hemiparesis. In patients with chronic subdural hematoma, a compressive deformity of the crus cerebri, without abnormal signal on MRI, may predict a better neurological recovery in patients with Kernohans notch phenomenon.

Osteochondroma of the Cervical Spine Extending Multiple Segments with Cord Compression

Involvement of the cervical spinal cord by a solitary osteochondroma is rare. We describe a case of cervical osteochondroma extending from C5 to C7 in a 16-year-old male. The tumor, arising from the inner aspect of the C6 spinous process, projected longitudinally into the spinal canal and compressed the spinal cord; this caused clinical symptoms associated with myelopathy and radiculopathy. Total excision of the tumor by C5–C7 hemilaminectomy resulted in a good functional recovery.

Characteristics and management of ruptured distal middle cerebral artery aneurysms

SummaryObjective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding.

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.

Aortic aneurysm complicated with pyogenic spondylitis following vertebroplasty.

Percutaneous vertebroplasty is a commonly used procedure for the treatment of painful vertebral fractures induced by osteoporosis or metastatic disease. It is generally considered to be safe and effective. However, infectious complications can be serious. We present a patient in whom pyogenic spondylitis developed 3 months after vertebroplasty. During the debridement, profuse bleeding was encountered from injury to the aorta and the patient was managed with primary closure. Two months after the initial surgery, an aortic aneurysm was detected. A wide resection of all infected tissue, including the bony lesion and aortic aneurysm was performed, and the descending thoracic aorta was replaced with a vascular graft. A titanium mesh cage filled with bone graft was employed for anterior reconstruction. Our patient illustrates that a life-threatening aortic aneurysm can indeed occur as an infectious complication of this minimally invasive procedure due to the proximity of the aorta to the thoracolumbar vertebra. The spine surgeon should be aware of the possibility of aortic wall erosion caused by long-standing spondylitis, and be prepared to manage an inadvertent injury to the aorta during surgical debridement.

Intracerebral Hematoma Caused by Ruptured Traumatic Pseudoaneurysm of the Middle Meningeal Artery : A Case Report

Hematomas caused by ruptured traumatic pseudoaneurysms of the middle meningeal artery (MMA) usually present with extradural hematomas, whereas intradural intraparenchymal hematomas are extremely rare. We report a case of traumatic pseudoaneurysm of the MMA giving rise to an intracerebral hematoma after head trauma. A 70-year-old man suffered a massive intracerebral temporoparietal hemorrhage after a head injury. CT angiogram of the brain revealed a large hematoma in the right middle cranial fossa extending to the right sylvian fissure. Cerebral angiogram also revealed a pseudoaneurysm of the MMA, which was successfully treated surgically. Although traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare, it should be considered as a possible cause of intracerebral hematoma.