• Journal of Korean Neurosurgical Society
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• v.56 no.2
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• pp.86-90
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• 2014

Objective : The spot sign is related with the risk of hematoma expansion in spontaneous intracerebral hemorrhage (ICH). However, not all spot sign positive patients undergo hematoma expansion. Thus, the present study investigates the specific factors enhancing the spot sign positivity in predicting hematoma expansion. Methods : We retrospectively studied 316 consecutive patients who presented between March 2009 to March 2011 with primary ICH and whose initial computed tomography brain angiography (CTA) was performed at our Emergency Department. Of these patients, 47 primary ICH patients presented spot signs in their CTA. We classified these 47 patients into two groups based on the presence of hematoma expansion then analyzed them with the following factors : gender, age, initial systolic blood pressure, history of anti-platelet therapy, volume and location of hematoma, time interval from symptom onset to initial CTA, spot sign number, axial dimension, and Hounsfield Unit (HU) of spot signs. Results : Of the 47 spot sign positive patients, hematoma expansion occurred in 26 patients (55.3%) while the remaining 21 (44.7%) showed no expansion. The time intervals from symptom onset to initial CTA were $2.42{\pm}1.24$ hours and $3.69{\pm}2.57$ hours for expansion and no expansion, respectively (p=0.031). The HU of spot signs were $192.12{\pm}45.97$ and $151.10{\pm}25.14$ for expansion and no expansion, respectively (p=0.001). Conclusions : The conditions of shorter time from symptom onset to initial CTA and higher HU of spot signs are the emphasizing factors for predicting hematoma expansion in spot sign positive patients.

• Journal of Korean Neurosurgical Society
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• v.54 no.3
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• pp.159-163
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• 2013

Objective : Cerebral hyperperfusion syndrome (CHS) is a serious complication after carotid endarterectomy (CEA). However, the prevalence of CHS has decreased as techniques have improved. This study evaluates the role of strict blood pressure (BP) control for the prevention of CHS. Methods : All 18 patients who received CEA from February 2009 through November 2012 were retrospectively reviewed. All patients were routinely managed in an intensive care unit by a same protocol. The cerebral perfusion state was evaluated on the basis of the regional cerebral blood flow (rCBF) study by perfusion computed tomography (pCT) and mean velocity by transcranial doppler (TCD). BP was strictly controlled (<140/90 mm Hg) for 7 days. When either post-CEA hyperperfusion (>100% increase in the rCBF by pCT or in the mean velocity by TCD compared with preoperative values) or CHS was detected, BP was maintained below 120/80 mm Hg. Results : TCD and pCT data on the patients were analyzed. Ipsilateral rCBF was significantly increased after CEA in the pCT (p=0.049). Post-CEA hyperperfusion was observed in 3 patients (18.7%) in the pCT and 2 patients (12.5%) in the TCD study. No patients developed clinical CHS for one month after CEA. Furthermore, no patients developed additional neurological deficits related to postoperative cerebrovascular complications. Conclusion : Intensive care with strict BP control (<140/90 mm Hg) achieved a low prevalence of post-CEA hyperperfusion and prevented CHS. This study suggests that intensive care with strict BP control can prevent the prevalence of post-CEA CHS.

• Journal of Korean Neurosurgical Society
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• v.63 no.5
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• pp.640-648
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• 2020

Objective : This study aimed to assess the relationship between increased intracranial pressure (ICP) and mastoid effusions (ME). Methods : Between January 2015 and October 2018, patients who underwent intracranial surgery and had ICP monitoring catheters placed were enrolled. ICP was recorded hourly for at least 3 days. ME was determined by the emergence of opacification in mastoid air cells on follow-up brain imaging. C-reactive protein (CRP) levels, presence of endotracheal tube (ETT) and nasogastric tube (NGT), duration of intensive care unit (ICU) stay, duration of mechanical ventilator application, diagnosis, surgical modalities, and presence of sinusitis were recorded. Each factor's effect on the occurrence of ME was analyzed by binary logistic regression analyses. To analyze the independent effects of ICP as a predictor of ME a multivariable logistic regression analysis was performed. Results : Total of 61 (53%) out of 115 patients had ME. Among the patients who had unilateral brain lesions, 94% of subject (43/50) revealed the ipsilateral development of ME. ME developed at a mean of 11.1±6.2 days. The variables including mean ICP, peak ICP, age, trauma, CRP, ICU stays, application of mechanical ventilators and presence of ETT and NGT showed statistically significant difference between ME groups and non-ME groups in univariate analysis. Sex and the occurrence of sinusitis did not differ between two groups. Adding the ICP variables significantly improved the prediction of ME in multivariable logistic regression analysis. Conclusion : While multiple factors affect ME, this study demonstrates that ICP and ME are probably related. Further studies are needed to determine the mechanistic relationship between ICP and middle ear pressure.

• Journal of Korean Neurosurgical Society
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• v.40 no.3
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• pp.154-158
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• 2006

Objective : We treated 10 pediatric diffuse intrinsic brain stem glioma[BSG] patients with Novalis system [linac based radiotherapy unit, Germany] and examined the efficacy of the Fractionated Stereotactic Radiotherapy[FSRT]. Methods : A retrospective review was conducted on 10 pediatric diffuse intrinsic BSG patients who were treated with FSRT between May, 2001 and August, 2004. The mean age of the patient group was 7.7 years old. Male to female ratio was 4 to 1. The mean dose of FSRT was 38.7Gy, mean fractionated dose was 2.6Gy, mean fractionation size was 16.6, and target volume was $42.78cm^3$. The mean follow up period was 14 months. Results : Four weeks after completion of FSRT, improvements on neurological status and Karnofsky performance scale[KPS] score were recorded in 9/10 (90%] patients and magnetic resonance imaging[MRI] showed decrease in target tumor volume in 8 pediatric patients. The median survival period was 13.5 months after FSRT and treatment toxicity was mild. Conclusion : It is difficult for surgeons to choose surgical treatment for diffuse intrinsic BSG due to its dangerous anatomical structures. FSRT made it possible to control the tumor volume to improve neurological symptoms with minimal complications. We expect that FSRT is a feasible treatment modality for pediatric diffuse intrinsic BSG with tolerable toxicities.

• Journal of Korean Neurosurgical Society
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• v.48 no.4
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• pp.347-353
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• 2010

Objective : Iliac screw fixation has been used to prevent premature loosening of sacral fixation and to provide more rigid fixation of the sacropelvic unit. We describe our technique for iliac screw placement and review our experience with this technique. Methods : Thirteen consecutive patients who underwent spinopelvic fixation using iliac screws were enrolled. The indications for spinopelvic fixation included long segment fusions for spinal deformity and post-operative flat-back syndrome, symptomatic pseudoarthrosis of previous lumbosacral fusions, high-grade lumbosacral spondylolisthesis, lumbosacral tumors, and sacral fractures. Radiographic outcomes were assessed using plain radiographs, and computed tomographic scans. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and questionnaire about buttock pain. Results : The median follow-up period was 33 months (range, 13-54 months). Radiographic fusion across the lumbosacral junction was obtained in all 13 patients. The average pre- and post-operative ODI scores were 40.0 and 17.5, respectively. The questionnaire for buttock pain revealed the following : 9 patients (69%) perceived improvement; 3 patients (23%) reported no change; and 1 patient (7.6%) had aggravation of pain. Two patients complained of prominence of the iliac hardware. The complications included one violation of the greater sciatic notch and one deep wound infection. Conclusion : Iliac screw fixation is a safe and valuable technique that provides added structural support to S1 screws in long-segment spinal fusions. Iliac screw fixation is an extensive surgical procedure with potential complications, but high success rates can be achieved when it is performed systematically and in appropriately selected patients.

• Journal of Korean Neurosurgical Society
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• v.47 no.3
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• pp.174-179
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• 2010

Objective : Cricothyrotomy and tracheostomy are performed by physicians in various disciplines. It is important to know the comprehensive anatomy of the laryngotracheal region. Hemorrhage, esophageal injury, recurrent laryngeal nerve injury, pneumothorax, hemothorax, false passage of the tube and tracheal stenosis after decannulation are well known complications of the cricothyrotomy and tracheostomy. Cricothyrotomy and tracheostomy should be performed without complications and as quickly as possible with regards the patients' clinical condition. Methods : A total of 40 cadaver necks were dissected in this study. The trachea and larynx and the relationship between the trachea and larynx and the surrounding structures was investigated. The tracheal cartilages and annular ligaments were counted and the relationship between tracheal cartilages and the thyroid gland and vascular structures was investigated. We performed cricothyrotomy and tracheostomy in eleven cadavers while simulating intensive care unit conditions to determine the duration of those procedures. Results : There were 11 tracheal cartilages and 10 annular ligaments between the cricoid cartilage and sternal notch. The average length of trachea between the cricoid cartilage and the suprasternal notch was 6.9 to 8.2 cm. The cricothyroid muscle and cricothyroid ligament were observed and dissected and no vital anatomic structure detected. The average length and width of the cricothyroid ligament was 8 to 12 mm and 8 to 10 mm, respectively. There was a statistically significant difference between the surgical time required for cricothyrotomy and tracheostomy (p < 0.0001). Conclusion : Tracheostomy and cricothyrotomy have a low complication rate if the person performing the procedure has thorough knowledge of the neck anatomy. The choice of tracheostomy or cricothyrotomy to establish an airway depends on the patients' clinical condition, for instance; cricothyrotomy should be preferred in patients with cervicothoracal injury or dislocation who suffer from respiratory dysfunction. Furthermore; if a patient is under risk of hypoxia or anoxia due to a difficult airway, cricothyrotomy should be preferred rather than tracheostomy.

• Journal of Korean Neurosurgical Society
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• v.29 no.12
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• pp.1634-1641
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• 2000

Objective : The cerebrospinal fluid(CSF) pulsates within the craniospinal axis in response to rhythmic cerebral blood volume variation during the cardiac cycle. The aim of this study is to characterize the normal and abnormal CSF flow and its waveforms in the cervical spinal subarachnoid space. Methods : The magnetic resonance(MR) images were obtained with 1.5 T(GE Signa, GE Medical Systems, Milwaukee, USA) unit using the 2 dimensional cine PC(phase contrast) sequence with cardiac gating and gradient recalled echo imaging. This pulse sequence yielded 16 quantitative flow-encoded images per cardiac cycle. Sagittal and axial images of the cervical spinal CSF space were obtained, and target sites were analyzed for characteristic CSF flow (TR=50ms, TE=12.5-15ms). The region of interest(ROI) was 1mm 3 in volume. Twenty six persons were included in this study : 10 healthy volunteers and 16 patients with cervical myelopathy. The post-operative cine MR study were also done in five patients. Results : The normal CSF pulsation dynamics in the cervical spine showed discrete systolic and diastolic components. The CSF flow revealed a sine wave pattern, in which the systolic phase was shorter than the diastolic phase(ratio=2 : 3). The patient group revealed decreased amplitudes of the CSF flow and irregularly distored flow waves. The systolic phase was elongated in the ROI above the stenotic level, whereas the diastolic phase was lengthened below the level. In the postoperative images, the abnormal pattern and amplitude were found to be corrected. Conclusion : From these results, the authors believe that the CSF flow study provides valuable informations regarding the extent of cervical stenosis and may be useful for the surgical planning and post-operative evaluation.

• Journal of Korean Neurosurgical Society
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• v.52 no.5
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• pp.435-440
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• 2012

Objective : The purpose of this study is to find the optimal stiffness and volume of bone cement and their biomechanical effects on the adjacent vertebrae to determine a better strategy for conducting vertebroplasty. Methods : A three-dimensional finite-element model of a functional spinal unit was developed using computed tomography scans of a normal motion segment, comprising the T11, T12 and L1 vertebrae. Volumes of bone cement, with appropriate mechanical properties, were inserted into the trabecular core of the T12 vertebra. Parametric studies were done by varying the volume and stiffness of the bone cement. Results : When the bone cement filling volume reached 30% of the volume of a vertebral body, the level of stiffness was restored to that of normal bone, and when higher bone cement exceeded 30% of the volume, the result was stiffness in excess of that of normal bone. When the bone cement volume was varied, local stress in the bony structures (cortical shell, trabecular bone and endplate) of each vertebra monotonically increased. Low-modulus bone cement has the effect of reducing strain in the augmented body, but only in cases of relatively high volumes of bone cement (>50%). Furthermore, varying the stiffness of bone cement has a negligible effect on the stress distribution of vertebral bodies. Conclusion : The volume of cement was considered to be the most important determinant in endplate fracture. Changing the stiffness of bone cement has a negligible effect on the stress distribution of vertebral bodies.

• Journal of Korean Neurosurgical Society
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• v.46 no.3
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• pp.210-214
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• 2009

Objective : Several surgical procedures have been reported for the treatment of chronic subdural hematoma (CSDH). We compared the results of treatments for CSDH obtained from one burr-hole craniostomy with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation, and small craniotomy with irrigation and closed-system drainage. Methods : Eighty-seven patients with CSDH underwent surgery at our institution from January 2004 to December 2008. Our patients were classified into three groups according to the operative procedure; group I, one burr-hole craniostomy with closed system drainage with or without irrigation (n=25), group II, two burr-hole craniostomy with closed system drainage with irrigation (n=32), and group III, small craniotomy with irrigation and closed-system drainage (n=30). Results : Age distribution, male and female ratio, Markwalder's grade on admission and at the time of discharge, size of hematoma before and after surgery, duration of operation, Hounsfield unit of hematoma before and after surgery, duration of hospital treatment, complication rate, and revision rate were categories that we compared between groups. Duration of operation and hospitalization were only two categories which were different. But, when comparing burr hole craniostomy group (group I and group II) with small craniotomy group (group III), duration of post-operative hospital treatment, complication and recurrence rate were statistically lower in small craniotomy group, even though operation time was longer. Conclusion : Such results indicate that small craniotomy with irrigation and closed-system drainage can be considered as one of the treatment options in patients with CSDH.

• Journal of Korean Neurosurgical Society
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• v.45 no.6
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• pp.341-349
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• 2009

Objective : The purpose of this study was to identify independent predictors of mortality and functional recovery in patients with primary intracerebral hemorrhage (PICH) and to improve functional outcome in these patients. Methods : Data were collected retrospectively on 585 patients with supratentorial PICH admitted to the Stroke Unit at our hospital between 1st January 2004 and the 31st July 2008. Using multivariate logistic regression analysis, the associations between all selected variables and 30-day mortality and 90-day functional recoveries after PICH was evaluated. Results : Ninety-day functional recovery was achieved in 29.1% of the 585 patients and 30-day mortality in 15.9%. Age (OR=7.384, p=0.000), limb weakness (OR=6.927, p=0.000), and hematoma volume (OR=5.293, p=0.000) were found to be powerful predictors of 90-day functional recovery. Furthermore, initial consciousness (OR=3.013, p=0.014) hematoma location (lobar, OR=2.653, p=0.003), ventricular extension of blood (OR=2.077, p=0.013), leukocytosis (OR=2.048, p=0.008), alcohol intake (drinker, OR=1.927, p=0.023), and increased serum aminotransferase (OR=1.892, p=0.035) were found to be independent predictors of 90-day functional recovery after PICH. On the other hand, a pupillary abnormality (OR=4.532, p=0.000) and initial unconsciousness (OR=3.362, p=0.000) were found to be independent predictors of 30-day mortality after PICH. Conclusion : The predictors of mortality and functional recovery after PICH identified during this analysis may assist during clinical decision-making, when advising patients or family members about the prognosis of PICH and when planning intervention trials.