Search

Background Catheter angiography via transradial access (TRA) is better at reducing access site complications and morbidity than via transfemoral access (TFA). The rate of periprocedural complications increases in elderly populations and using a smaller sheath can help reduce access site complications. The aim of this study was to assess the feasibility and safety of 4 F sheath-based TRA cerebral angiography in elderly patients (≥65 years) and compare it to TFA cerebral angiography. Methods The medical records of elderly patients undergoing diagnostic cerebral angiography with a single neurointerventionalist via TRA (57 cases, from July 2019 to December 2020) versus TFA (69 cases, from January 2018 to June 2019) were retrospectively reviewed. All TRA angiographies were performed via right radial artery access with a 4 F sheath and a 4 F Simmons 2 catheter. Results There were no significant differences (TRA vs. TFA) in age (71.1 ± 4.0 vs. 72.1 ± 4.6 years, p = 0.189), accessed vessels (3.9 ± 0.5 vs. 3.9 ± 0.6, p = 0.852), fluoroscopy time (7.1 ± 3.3 vs. 7.6 ± 3.5 min, p = 0.068), and radiation exposure (42.1 ± 15.8 vs. 47.0 ± 13.7 Gy-cm2, p = 0.067). However, the procedure duration was significantly shorter in the TRA group (17.2 ± 3.9 vs. 19.0 ± 6.0 min, p = 0.003). Painful groin hematoma occurred in 2 of the 69 cases (2.9%) in the TFA group. In the TRA group, access site complications were not occurred; however, catheter kinks occurred in 2 of 57 cases (3.5%). Conclusions The 4 F sheath-based TRA is a feasible option for diagnostic cerebral angiography in elderly patients. However, care should be taken during catheter manipulation.

Objective To present values for the dose parameters predictive of alopecia as an adverse effect induced by neuroembolization using a biplane fluoroscopy. Methods This study included a total of 151 patients (52 men, mean age of 55.1 ± 12.2 years) treated for intracranial neuroembolization between 2014 to 2018 with the following criteria: 1) obtainable dose report with digital subtraction angiographic image records, 2) no history of radiation exposure 6 months prior to the first procedure, and 3) and clinical follow-up performed through 12 months following the procedure. Patients were divided into 2 groups according to their presentation of alopecia during the follow-up period. Results Eighteen (11.9%) patients developed alopecia 10 to 30 days after the procedure (average: 18.5 ± 5.3 days). Sixteen (88.9%) patients in the alopecia group were affected by projection of the A-plane fluoroscopy. Area under the receiver operating characteristic analysis curves of 0.865 (P = 0.000) and 0.831 (P = 0.000) were used to compute the optimal A-plane dose area product (255.4 Gy-cm2; sensitivity: 0.875; specificity: 0.805; Youden J = 0.682) and cumulative dose (4437.5 mGy; sensitivity, 0.750; specificity, 0.805; Youden J = 0.556) cutoff values, respectively, capable of distinguishing patients with alopecia (n = 16) from subtotal patients (n = 149). Conclusions The dose area product and the cumulative dose may be useful, intuitive factors for predicting the adverse effects of the neurointerventional radiation. Further multicenter research should be performed to confirm the efficacy and utility of the reference values of dose area product and cumulative dose for preventing excessive irradiation during neurointerventional procedures.

Gold nanoparticles (GNPs) are utilized as diagnostic and therapeutic tools to detect and treat human disease. Researchers in the field of nanotoxicity are working to determine the physicochemical properties of nanoparticles that lead to toxicity in an effort to establish safe design rules. In this study, we performed the MTT and terminal transferase dUTP nick end labeling (TUNEL) assays to verify the cytotoxicity of GNPs on rat brain tissue and human neural progenitor cells (NPCs). As results, we observed that GNPs induced apoptosis in NPCs. NPCs were markedly damaged following the administration of 200 μM and 2 mM GNPs, whereas 2 μM GNPs showed slightly increased damage relative to that of the control. In addition, TUNEL-positive cells were densely distributed at regions surrounding the GNP injection site in the brain 7 days after the GNPs injection. During long-term GNPs exposure, TUNEL-positive cells were rarely observed in the cerebral cortex. In this study, we observed that apoptosis increased in proportion to GNP concentrations in the brain and in cultivated NPCs. These result suggest that large GNPs (

The C1-C2 angle has been shown to correlate with subaxial alignment under various conditions. The aim of this study was to evaluate the correlation between the C1-C2 fixation angle and subaxial sagittal alignment as well as the impact of the sagittal vertical axis (SVA) on functional outcomes in traumatic atlantoaxial (A-A) instabilities. The data of 36 patients who underwent posterior C1-C2 fixation for traumatic A-A instability between December 2005 and September 2015 were retrospectively reviewed. Radiographic parameters, including the C1-C2 angle, occipitocervical angle, C2-C7 angle, and C2-C7 SVA, were measured before surgery and at 1-year follow-up. Clinical outcomes were measured using the visual analogue scale (VAS) and Neck Disability Index (NDI). The preoperative and postoperative relationships between parameters were analyzed. In preoperative and postoperative radiographs, the C1-C2 angle correlated with the C2-C7 angle (r = −0.347, p = 0.038, and r = −0.339, p = 0.043, respectively) and the C2-C7 SVA (r = 0.648, p The postoperative C2-C7 SVA was affected by the preoperative C2-C7 SVA and the postoperative C1-C2 angle and showed significant positive correlation with postoperative NDI. The C1-C2 fixation angle and the preoperative C2-C7 SVA should be carefully considered to avoid postoperative sagittal imbalance.

Background Idiopathic pseudoaneurysms of the external carotid artery (ECA) between the internal maxillary artery and the facial artery are rare. Endovascular covered stenting is an alternative method for surgically challenging cases; however, movable and flexible vessels may prevent the maintenance of the stent. Case Description A 26-year-old woman presented with sudden swelling and pain of the left chin due to a pseudoaneurysm of the proximal ECA trunk. She had undergone endovascular covered stenting and suddenly developed facial palsy at postprocedural 1 week. Regrowth of the aneurysm and slippage of the stent were detected, and additional stenting was performed. Swelling and pain of the chin and neck and subsequently the facial palsy completely resolved, and the patient made a full recovery. Conclusions The ECA aneurysm between the internal maxillary artery and facial artery may be more floating and changeable than any other portions of the ECA, and regrowth of the ECA aneurysm may cause delayed complication. In addition, knowledge of the mechanism is necessary to help in the endovascular treatment.

Trevo Provue stent retriever with visible struts under fluoroscopy may be useful in identifying the optimal position and expansion of the stent during the procedure. This study aimed to demonstrate and analyze changes in the segmental diameter of a radio-opaque stent retriever after deployment according to recanalization results, and its relationship with the angle of the occluded segment of the middle cerebral artery (MCA). Forty-one patients who underwent mechanical thrombectomy using a Trevo stent retriever were divided into two groups according to Thrombolysis in Cerebral Infarction (TICI) score (TICI 0-2a and TICI 2b/3). The proximal (Pt), middle (Mt), and distal diameter (Dt) of the deployed stent, at three post-deployment waiting times (t = 0, 3, and 5 min), were measured, and ratios of Mt to Pt (Mt/Pt) and of Mt to Dt (Mt/Dt) were calculated. TICI 2b/3 was achieved in 31 patients (75.6%) and TICI 0-2a in 10 patients (24.4%). In the TICI 2b/3 group, both changes of Mt/Pt (P

Background: The aim of this study was to retrospectively evaluate and analyze the relationships between head circumference percentile (HCP), lumbar puncture pressure (LPP), and cerebrospinal fluid (CSF) space. Methods: The 88 patients were divided into 3 age groups (group 1, up to 12 months; group 2, 12–36 months; group 3, 36–72 months). Results: In group 1 (n = 40), there was a significant positive correlation of the HCP with the LPP (r =0.414, p =0.008), Evans ratio (r =0.365, p =0.021), and thickness of subdural hygroma (SDHG; r =0.403, p =0.010). Group 2 (n = 29) revealed a significant positive correlation between the LPP and the thickness of SDHG (r =0.459, p =0.012). Group 3 (n = 19) showed no significant correlation among these factors. Overall, age was related with SDHG thickness both in infants and toddlers, while HCP was related with LPP, Evans ratio, and SDHG thickness only in infants, and LPP was related with SDHG thickness only in toddlers. Conclusion: We suggest that increased cerebrospinal space and pressure may result in compensatory enlargement of head circumference only in the infant period, and the SDHG thickness decreases with age during the infant and toddler phases.

Patients with brain metastases (BM) can benefit from radiotherapy (RT), although the long-term benefits of RT remain unclear. We searched a Korean national health insurance claims database and identified 135,740 patients with newly diagnosed BM during 2002–2017. Propensity score matching (PSM) was used to evaluate survival according to RT modality, which included whole-brain radiotherapy (WBRT) and/or stereotactic radiosurgery (SRS). The 84,986 eligible patients were followed for a median interval of 6.6 months, and 37,046 patients underwent RT (43.6%). After the PSM, patients who underwent RT had significantly better overall survival after 1 year (42.4% vs. 35.3%, P

Carbon nanotubes (CNTs) are used in batteries, nano-electronic devices, fuel cells, and biosensors as they can be used to make these devices more biocompatible; moreover, various compounds can be attached to these CNTs. Although multi-walled carbon nanotubes (MWCNTs) have been used in biosensors for the detection of specific proteins and neurotransmitters, they are not well understood. The present study addressed the difference between the cytotoxic effects of different types of MWCNTs by testing them on two dimensional (2D) and 3D-cultivated human neural precursor cells (hNPCs). We also evaluated the apoptotic damage caused by these MWCNTs using rat brain slices. Our results confirmed that there was significant cytotoxic effect of MWCNT, as shown by the damage caused to the 2D cultured cells. However, the cell death seen in the 3D cultured cells treated with MWCNT was significantly lower than that of the 2D cultivated cells. Furthermore, the 3D cell cytotoxicity assay showed similar results after MWCNT 1/2 treatment and decreased slightly after MWCNT 3/4 treatment, except when treated with 10 ng/ml of MWCNT 3 and 1 g/ml of MWCNT 4. Western blot results using brain slices treated with MWCNTs showed that the expressions of SAPK/JNK, Caspase 3, and Caspase 8 were not significantly different compared to those in the control. In conclusion, MWCNTs had a stable effect on the 3D cultured cells or brain slices, consistent with the results seen in the in vivo system, but caused remarkable damage to the 2D cultured cells that were observed as a flat structure

AIM To describe and demonstrate the close analogy between dual volume reconstruction images derived using three-dimensional digital subtraction angiography (3D-DSA) and surgical microscopic images. MATERIAL AND METHODS From 2013 to 2018, 12 patients with spinal vascular malformation (SVM) underwent preoperative 3D-DSA with dual volume reconstruction followed by surgery for the SVM without prior endovascular treatment. Two spinal neurosurgeons involved in each operation were surveyed regarding the similarity between the dual volume images of 3D-DSA and the surgical microscopic images with respect to the following four aspects: (1) relationship between bony structures and the entry artery going to the feeder; (2) feeding artery; (3) shunting point or nidus location; and (4) draining vein. RESULTS The patients were diagnosed with spinal dural arteriovenous fistulas (n=8) and spinal arteriovenous malformations (n=4). Two, six, and four lesions showed cervical, thoracic, and lumbar area distribution, respectively. All operations were successful and without complications. The correspondence between dual volume images and intraoperative microscopic images, with respect to bony structure and entry artery, showed perfect reliability (k=1.000; p=0.000) and a high level of similarity in all cases. With respect to the feeding artery, shunt point/nidus location, and draining vein, there was substantial reliability between the operator and the observer (k=0.750; p=0.045). CONCLUSION Images obtained using the dual volume reconstruction technique of the 3D-DSA exhibit a reliable similarity to real microscopic images and are useful in the surgical treatment of SVMs with respect to surgical planning, targeting, and orientation.

BackgroundDecompressive craniectomy is an important surgical treatment for patients with severe traumatic brain injury (TBI). Several reports have been published on the efficacy of non-watertight sutures in duraplasty performed in decompressive craniectomy. This study aims to evaluate the effectiveness of dura closure without sutures (non-suture duraplasty) in decompressive craniectomy for TBI.MethodsOne hundred and six patients were enrolled at a single trauma center between January 2017 and December 2018. We retrospectively collected the data and classified the patients into non-suture and suture duraplasty craniectomy groups. We compared the characteristics of patients and their intra/post- operative findings such as operative time, blood loss, imaging findings, complications, and Glasgow outcome scale.ResultsThere were 37 patients in the non-suture group and 69 in the suture craniectomy group. There were no significant differences between the two groups with regard to general characteristics. The operative time was 205 min for the suture duraplasty group and 150 min for the non-suture duraplasty group, and that for the non-suture duraplasty group was significantly lesser (p=0.002). Blood loss was significantly lesser in the non-suture duraplasty group (1000 mL) than in the suture duraplasty group (1500 mL, p=0.028). There were no other significant differences.ConclusionNon-suture duraplasty involved shorter operative time and lesser blood loss when compared to suture duraplasty. Other complications and prognosis were similar in both groups. Therefore, it can be concluded that decompressive craniectomy with non-suture duraplasty is a safe and useful surgical technique in patients with TBI.

Objective To evaluate the efficacy of fractionated stereotactic radiosurgery (FSRS) performed using the Novalis Tx® system (BrainLAB AG, Feldkirchen, Germany; Varian Medical Systems, Palo Alto, CA, USA) for brain metastases. Methods Between March 2013 and July 2016, 23 brain metastases patients were admitted at a single institute. Twenty-nine lesions too large for single session stereotactic radiosurgery or located in the vicinity of eloquent structures were treated by FSRS. Based on the results obtained, we reviewed the efficacy and toxicity of FSRS for the treatment of brain metastases. Results The most common lesion origin was lung (55%) followed by breast (21%). Median overall survival was 10.0 months (95% confidence interval [CI], 4.9-15.0), and median progression-free survival was 10.0 months (95% CI, 2.1-13.9). Overall survival rates at 1 and 2 years were 58.6% and 36.0%, respectively. Local recurrence and neurological complications affecting morbidity each occurred in two cases. Conclusion FSRS using the Novalis-Tx® system would appear to be an effective, safe noninvasive treatment modality for large and eloquently situated brain metastases. Further investigation is required on a larger number of patients.

Gastrointestinal stromal tumors (GISTs) are rare, but are the most common mesenchymal neoplasm of the gastrointestinal tract. The most common sites of metastasis are liver and peritoneum, while bone metastasis is rare. We report on a patient with skull metastasis after seven years of treatment with imatinib for metastatic GIST. She underwent metastasectomy consisting of craniectomy with excision of the mass, and cranioplasty and continued treatment with imatinib and sunitinib, without evidence of cranial recurrence. She died of pneumonia sepsis one year after metastasectomy. Skull metastasis of GIST is a very rare presentation, and an aggressive multidisciplinary approach should be considered whenever possible.

The aim of this study was to investigate the regional cerebral metabolism related to growth hormone deficiency (GHD) after traumatic brain injury (TBI) using F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) images.Twenty-three patients with diffuse axonal injury following TBI were enrolled. They underwent brain F-18 FDG PET study and an insulin tolerance test (ITT). According to the results of ITT, they were divided into two groups: patients with GHD and subjects with TBI but normal Growth Hormone (GH). Voxel-based statistical analysis was performed and the regional cerebral glucose metabolism shown on F-18 FDG PET from 10 patients with GHD was compared with those from 13 patients without GHD. Analysis was performed using SPM2 to identify regions where decreased changes in regional cerebral glucose metabolism were significantly related to GHD.Compared with subjects with TBI but normal GH, patients with GHD after TBI showed decreased cerebral glucose metabolism in the Left superior frontal gyrus, Right angular gyrus, Right superior temporal gyrus, Left inferior temporal gyrus, Left anterior and middle cingulate gyrus and Right anterior and middle cingulate gyrus. (pThe findings are suggestive of the brain region influenced by GHD. These cortical areas are involved in regulation of intellectual function, executive function and working memory.

Background Pathologic diagnosis of central nervous system (CNS) neoplasms is made by comparing light microscopic, immunohistochemical, and molecular cytogenetic findings with clinicoradiologic observations. Intraoperative frozen cytology smears can improve the diagnostic accuracy for CNS neoplasms. Here, we evaluate the diagnostic value of cytology in frozen diagnoses of CNS neoplasms. Methods Cases were selected from patients undergoing both frozen cytology and frozen sections. Diagnostic accuracy was evaluated. Results Four hundred and fifty-four cases were included in this retrospective single-center review study covering a span of 10 years. Five discrepant cases (1.1%) were found after excluding 53 deferred cases (31 cases of tentative diagnosis, 22 cases of inadequate frozen sampling). A total of 346 cases of complete concordance and 50 cases of partial concordance were classified as not discordant cases in the present study. Diagnostic accuracy of intraoperative frozen diagnosis was 87.2%, and the accuracy was 98.8% after excluding deferred cases. Discrepancies between frozen and permanent diagnoses (n = 5, 1.1%) were found in cases of nonrepresentative sampling (n = 2) and misinterpretation (n = 3). High concordance was observed more frequently in meningeal tumors (97/98, 99%), metastatic brain tumors (51/52, 98.1%), pituitary adenomas (86/89, 96.6%), schwannomas (45/47, 95.8%), high-grade astrocytic tumors (47/58, 81%), low grade astrocytic tumors (10/13, 76.9%), non-neoplastic lesions (23/36, 63.9%), in decreasing frequency. Conclusions Using intraoperative cytology and frozen sections of CNS tumors is a highly accurate diagnostic ancillary method, providing subtyping of CNS neoplasms, especially in frequently encountered entities.

Objective To evaluate the efficacy of fractionated stereotactic radiosurgery (FSRS) performed using the Novalis Tx® system (BrainLAB AG, Feldkirchen, Germany; Varian Medical Systems, Palo Alto, CA, USA) for brain metastases. Methods Between March 2013 and July 2016, 23 brain metastases patients were admitted at a single institute. Twenty-nine lesions too large for single session stereotactic radiosurgery or located in the vicinity of eloquent structures were treated by FSRS. Based on the results obtained, we reviewed the efficacy and toxicity of FSRS for the treatment of brain metastases. Results The most common lesion origin was lung (55%) followed by breast (21%). Median overall survival was 10.0 months (95% confidence interval [CI], 4.9–15.0), and median progression-free survival was 10.0 months (95% CI, 2.1–13.9). Overall survival rates at 1 and 2 years were 58.6% and 36.0%, respectively. Local recurrence and neurological complications affecting morbidity each occurred in two cases. Conclusion FSRS using the Novalis-Tx® system would appear to be an effective, safe noninvasive treatment modality for large and eloquently situated brain metastases. Further investigation is required on a larger number of patients.

Objective The aim of this study was to assess the benefit of using a prophylactic surgical site closed suction drain in pterional craniotomy. Materials and Methods A retrospective review was conducted on 607 consecutive patients who underwent a pterional craniotomy for treatment of intracranial anterior circulation aneurysms over a 5-year period. Between January 2000 and December 2004, 607 patients were divided into two groups, those who had a prophylactic suction drain during closure of the surgical site (drain group, DG) and those who did not (non-drain group, NDG). Head computed tomography (CT) was taken routinely on postoperative day (POD) 1, 7, and 14. Patients' demographics, incidence of surgical site complications, and courses of surgical site healing which were evaluated radiologically by the thickness of the surgical site myocutaneous layer, were analyzed between DG and NDG. Results Patients' demographics and characteristics did not differ significantly between the two groups. The head CT showed that the degree of changes in the postoperative surgical site thickness was 148% at POD 1, 209% at POD 7, and 198% at POD 14 in DG, and 118% at POD 1, 152% at POD 7, and 158% at POD 14 in NDG compared to the preoperative value. Postoperative surgical site hematoma was 7.9% (22/274) in DG and 2.4% (8/333) in NDG. Conclusion Prophylactic use of an epidural and/or subgaleal closed suction drain does not appear to be necessary for prevention of postoperative surgical site hematoma as well as for promotion of surgical site healing in pterional craniotomy.

The approach to ethmoidal dural arteriovenous fistulas (eDAVFs) is usually via a pterional or a frontal craniotomy. However, the transfrontal sinus is a more direct route to the fistula. The aim of this report is to describe our experience and associated complications occurring as a result of flow diversion in the transfrontal sinus approach for eDAVFs. In this report, we discuss visual field defects occurring after a transfrontal sinus operation. This approach is most direct for surgical treatment of an eDAVF, enabling preservation of neural structures with minimal to no negative effects on the brain. Although the surgery was uneventful, the patient presented with a left side visual field defect. An ophthalmologic exam detected an arterial filling delay in the choroidal membrane and ischemic optic neuropathy was highly suspected. The patient is currently recovering under close observation with no special treatment. The transfrontal sinus approach provides the most direct and shortest route for eDAVFs, while minimizing intraoperative bleeding. However, complications, such as visual field defects may result from a sudden flow diversion or eyeball compression due to scalp traction.

AIM Surgical procedures for aneurysmal subarachnoid hemorrhage (SAH) are increasing among the elderly as the population ages. Chronic shunt-dependent hydrocephalus is a recognized complication of SAH. The aim of this study was to identify predictive factors for the development of shunt-dependent hydrocephalus among elderly patients with SAH. MATERIAL AND METHODS We retrospectively studied 878 patients, including 275 patients ? 65 years old, with SAH treated between 2005 and 2015 to identify factors contributing to the development of shunt-dependent hydrocephalus. The relationships between shunt-dependent hydrocephalus and the causative factors were analyzed using univariate and multivariate analysis; the causative factors were based on the results of previous studies. RESULTS In the 878 patients with SAH, there was a significant difference in the incidence of shunt-dependent hydrocephalus between patients < 65 years old and those ? 65 years old (p=0.021). In the 275 patients ? 65 years old, the following were associated with shunt-dependent hydrocephalus on univariate analysis: 1) Hunt and Hess grade (p=0.005), 2) Fisher grade (p < 0.001), 3) intraventricular hemorrhage (p < 0.001), 4) acute hydrocephalus (p=0.003), 5) aneurysm location (p=0.001), and 6) external ventricular drain placement (p < 0.001). On multivariate analysis, only 1) intraventricular hemorrhage (p < 0.001) and 2) a ruptured aneurysm located in the distal posterior circulation (p=0.014) were related to an increased risk for the development of shunt-dependent hydrocephalus. CONCLUSION Evaluating risk factors can help identify patients at high risk of developing shunt-dependent hydrocephalus. Identifying these risk factors may help neurosurgeons to provide optimal therapy and improve outcomes in patients with SAH.

Objective: To evaluate the efficacy of fractionated stereotactic radiosurgery (FSRS) to large or eloquent area cerebral metastases. Methods: A retrospective analysis of 16 patients who had received FSRS (less than 3 fractions) for cerebral metastases from Mar. 2013 to Mar. 2016 was performed. All tumors were treated with the frameless LINAC-based, Novalis -Tx system. Patients who underwent single session of SRS to the tumors were excluded. All patients were treated with 3 fractions. The mean planning target volume was 20.68 cm3 (6.9 - 53.9 cm3). The mean dose was 10 Gy per day at 90% isodose line with 3 fractions for three consecutive days. Results: Primary origin was lung, G-I tract and breast in order. Four patients were dead during follow up period. The mean survival time was 14.8 months and local tumor control rate was 87.5%. Radiation necrosis was developed in 1 patient. Conclusions: Limited number of patients and short follow up period is not enough to conclude the efficacy of fractionated stereotactic radiosurgery (FSRS). However, FSRS might be a good treatment modality for the patients had large or eloquent area cerebral metastases.

OBJECTIVE In June 28, 2012, a 'Hospitalization guideline for car accident patients' was announced to mediate the clash of opinions about the hospitalization of minor head trauma patients among doctors, patients and insurance companies. The guideline was issued to describe the patients' symptoms and emotions in detail after the injury. In this paper, evaluation for the guideline and suggestions for modifications was done. METHODS Thirty-two doctors, 96 patients and 60 employees were each given surveys about the hospitalization guidelines, related personnels' attitude and evaluation of patients' emotional problems. The frequency, ratio and chi-square test were performed. RESULTS Sixty-eight point eight percent of doctors, 79.8% patients and 91.6% insurance company employees agreed to the need for a guideline. Among the 68.8% doctors that supported the need for a guideline, 18.8% knew that the guideline actually existed. Sixty-nine point two percent of doctors said that they would apply the guideline once they were introduced to it. Among the announced guideline provisions, 'Glasgow coma score less than 15' and 'socially not suitable for discharge' required reevaluation since 40.6% all surveyors consented that these two criteria were not suitable. The consensus supporting the need for emotional evaluation came out to be 78.1%, 58.5%, 50.9% in doctors, patients and insurance employees respectively. CONCLUSION Although a guideline for hospitalization of minor head injury patients is necessary, some part of it seems to be reevaluated and improved, especially for clauses related to the patient's emotional problems. These changes and revisions to the guideline require further speculation and research.

A Solitary Fibrous Tumor (Sft) Is A Rare Neoplasm Originated From The Pleura, But They Can Occur In A Variety Of Extrathoracic Regions. Although Many Cases Of Primary Sft Have Been Reported, There Are Extremely Rare Repots To Date Of A Malignant Sft In The Spine Or Skull. A 54-year-woman Visited Our Hospital Due To Low Back Pain And Both Leg Radiating Pain. Several Imaging Studies Including Magnetic Resonance Imaging And Computed Tomography Revealed Expansive Enhanced Lesions In The Occipital Bone, T8, S1-2, And Ilium, With Neural Tissue Compression. We Performed Surgical Resection Of The Tumor In Each Site, And Postoperative Radiosurgery And Chemotherapy Were Performed. However, After Six Months, Tumors Were Recurred And Metastasized In Multiple Regions Including Whole Spine And Lung. The Authors Report Here The First Case Of Patient With Malignant Sft Of Tandem Lesions In The Various Bony Structures, Including Skull, Thoracic Spine, And Sacral Spine, With A Rapid Recurrence And Metastasis. Although Malignant Sft Is Extremely Rare, It Should Be Considered In The Differential Diagnosis And Carful Follow-up Is Needed.

Objective : The objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression. Methods : Retrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors. Results : No significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG. Conclusion : A large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging.

Objective : Although there is no consensus on the ideal treatment of the craniocervical instability, biomechanical stabilization and bone fusion can be induced through occipito-cervical fusion (OCF). The authors conducted this study to evaluate efficacy of OCF, as well as to explore methods in re ducing complications. Methods : A total of 16 cases with craniocervical instability underwent OCF since the year 2002. The mean age of the patients was 51.5 years with a mean follow-up period of 34.9 months. The subjects were compared using lateral X-ray taken before the operation, after the operation, and during last follow-up. The Nurick score was used to assess neurological function pre and postoperatively. Results : All patients showed improvements in myelopathic symptoms after the operation. The mean preoperative Nurick score was 3.1. At the end of follow-up after surgery, the mean Nurick score was 2.0. After surgery, most patients’ posterior occipito-cervical angle entered the normal range as the pre operation angle decresed from 121 to 114 degree. There were three cases with complications, such as, vertebral artery injury, occipital screw failure and wound infection. In two cases with cerebral palsy, occipital screw failures occurred. But, reoperation was performed in one case. Conclusion : OCF is an effective method in treating craniocervical instability. However, the complication rate can be quite high when performing OCF in patients with cerebral palsy, rheumatoid arthritis. Much precaution should be taken when performing this procedure on high risk patients.

Background Spinal subdural hematoma (SDH) secondary to intracranial aneurysmal subarachnoid hemorrhage (SAH) occurs rarely and can cause neurologic deficits. Case Description A 52-year-old man was diagnosed with SAH caused by rupture of an anterior communicating artery aneurysm. The aneurysm was treated by coil embolization on the day of admission. After embolization, the patient's left lower extremity strength had decreased and a spinal magnetic resonance imaging showed subarachnoid hematoma and SDH with severe thecal sac compression at L4-S2. On postbleed day 6, L4-S1 laminectomy was performed, and the strength in all muscle of the left leg improved. Conclusions Rupture of an intracranial aneurysm may cause symptomatic SDH in the lumbosacral spine as well as subarachnoid hematoma.

Lower extremity ischemia following deployment of a vascular closure device for access site closure after a transfemoral endovascular procedure rarely occurs. A 68-year-old woman diagnosed with subarachnoid hemorrhage due to a ruptured anterior communicating aneurysm was treated by endovascular coil embolization. The StarClose SE device was deployed for right femoral arteriotomy closure. After 2 days, critical ischemia occurred on her right lower leg due to total occlusion of the popliteo-tibial artery. Emergent surgical embolectomy was performed and the nitinol clip of the StarClose device was captured in the lumen of the tibioperoneal trunk. Although StarClose is an extravascular closure system, intravascular deployment, distal migration, and resultant critical limb ischemia can occur.

Bortezomib (Velcade, Millennium Pharmaceuticals, Inc.), a potent proteasome inhibitor, is a boronic acid dipeptide that induce cancer cell death. It is an effective drug for both newly diagnosed or relapsed multiple myeloma (MM) patients and is widely used in the treatment of various kinds of lymphomas and other diseases. Peripheral nerve damage is one of the most significant nonhematologic toxicities of bortezomib. The reported incidence of bortezomib-induced peripheral neuropathy (BIPN) ranges from 25 to 75 % . When it occurs, the painful sensory neuropathy can interfere with quality of life (QOL) and with performance of activities of daily living, and it may also adversely affect clinical outcomes by forcing dose modification and/or premature treatment discontinuation. Therefore there are many efforts to improve multiple symptoms associated with BIPN. But there are no reports on amelioration of neurotoxicity which occurred in patients with treatment of bortezomib .Therefore control of this toxicity by the concomitant use of other safe candidates can make it a better option for the cancer therapy with bortezomib. Glutathione (GSH) is a substance produced naturally by the liver and it is also found in fruits, vegetables, and meats. GSH is an important antioxidant and capable of preventing damage to important cellular components caused by reactive oxygen species (ROS) such as free radicals, peroxides, lipid peroxides, and heavy metals. Several small randomized trials have addressed the protective effect of GSH against chemotherapy induced peripheral neuropathy (CIPN )with a platinum agent . In this study we observed that treatment of GSH either in the pre-treatment or in the post treatment inhibited the bortezomib -induced neuronal cell death in both mouse neuronal cells (N2a) as well as dopaminergic neuron of human origin (SHSY5Y). Bortezomib treatment at the concentration of 100 and 200 µg/ml significantly increased the cell death with increased lactate dehydrogenase activity (LDH) and increased apoptotic proteins expressions in the 24 h of treatment of both cells. GSH treatment (1 mg/ml) not only inhibited the bortezomib -induced cell death but also inhibited the LDH activity, suggesting that GSH ameliorates bortezomib -induced neuronal toxicity. A clear activation of the autophagy was also observed in the bortezomib treatment that was lowered by the GSH treatment. In addition to this inhibition of the apoptotic proteins specially Cleaved caspase 3 was observed in the neuronal cells and also the increased Bcl2 and NRF2 protein which are responsible for the cell survival was upregulated with GSH treatment suggesting that GSH increase the cell survival against bortezomib -induced neurotoxicity. Inhibition of the cleaved caspase-3, Bax and LC3 protein are prominent in SHSY5Y cells while activation of the BCL2 and NRF2 is more significant in N2a cells. To elucidate the role of GSH in the development and maintenance of bortezomib -induced neurotoxicity, we will additionally assess ROS and antioxidant enzyme activity levels in the cellular system. This research suggests that GSH ameliorates BIPN and thus can improve the QOL and increase the survival rate of patients treated with bortezomib. Disclosures No relevant conflicts of interest to declare.

Purpose: The purpose of this study was to evaluate the implementation of problem-based learning (PBL), in combination with team-based learning (TBL), in an integrated curriculum at Gachon University School of Medicine. Methods: The study methods included in-depth interviews and an open questionnaire. The subjects of the study comprised 5 faculty members and 38 second-year graduate students. Results: PBL, combined with TBL, was not helpful in enhancing student ability with regard to reasoning and self-directed learning. This program also had negative effects, increasing student tension and interfering with the dynamics of discussions due to frequent tutor intervention. Conclusion: Overall, PBL that is combined with TBL was a less useful method than PBL only. We recommended understanding the characteristics of each program and attempting to develop better programs that mix the positive aspects of TBL and PBL.

After spinal cord injury (SCI), a loss of myelinating oligodendrocytes and neurons occurs. The functional recovery of injured spinal cords is the principal objective of SCI repair. Cell transplantation may prove beneficial to help replace lost myelin and spinal cord circuitry. In this study, we demonstrated that neural precursor cells (hNPCs) from human fetal spinal cord express three types of proteoglycan proteins—chondroitin sulfate, keratan sulfate, and cartilage proteoglycan (an extracellular matrix detected in normal spinal cord), and non-proteoglycan matrix collagen. Both proteoglycan and collagen evidenced profound immunoreactivity in double-stained cell clusters. In addition, whether or not hNPCs were capable of differentiating into a variety of cells, including GABAergic and cholinergic neurons, were assessed. The differentiated cells of eight passages grown on a monolayer expressed the human nuclear protein (HNu), the progenitor marker nestin, GAD, ChAT, TJU, and MAP-2. These results indicate that hNPCs may prove to be candidate cells for therapeutic SCI strategies.

OBJECTIVE To select a surgical approach for aneurysm clipping by comparing 2 approaches. MATERIALS AND METHODS 204 patients diagnosed with subarachnoid hemorrhage treated by the same neurosurgeon at a single institution from November 2011 to October 2013, 109 underwent surgical clipping. Among these, 40 patients with Hunt and Hess or Fisher grades 2 or lower were selected. Patients were assigned to Group 1 (supraorbital keyhole approach) or Group 2 (modified supraorbital approach). The prognosis according to the difference between the two surgical approaches was retrospectively compared. RESULTS Supraorbital keyhole approach (Group 1) was performed in 20 aneurysms (50%) and modified supraorbital approach (Group 2) was used in 20 aneurysms. Baseline characteristics of patients did not differ significantly between two groups. Total operative time (p = 0.226), early ambulation time (p = 0.755), length of hospital stay (p = 0.784), Glasgow Coma Scale at discharge (p = 0.325), and Glasgow Outcome Scale scores (p = 0.427) did not show statistically significant differences. The amount of intraoperative hemorrhage was significantly lower in the supraorbital keyhole approach (p < 0.05). CONCLUSION The present series demonstrates the safety and feasibility of the two minimal invasive surgical techniques for clipping the intracranial aneurysms. The modified supraorbital keyhole approach was associated with more hemorrhage than the previous supraorbital keyhole approach, but did not exhibit differences in clinical results, and provided a better surgical view and convenience for surgeons in patients with Hunt and Hess or Fisher grades 2 or lower.

Given the emergence of nanotherapeutics and nanodiagnostics as key tools in today's medicine, it has become of critical importance to define the interactions of nanomaterials with biological systems. The biomedical applications of nanoparticles (NPs) in chemical sensing, biological imaging, drug delivery, photothermal therapy and cancer treatment have been demonstrated. Gold NPs as new biomedical tools are the focus of research due to their ease of synthesis, chemical stability and unique optical properties. Therefore, there is a need to establish the toxicity, side effects and safety of gold NPs for human applications. To study the in vitro cytotoxicity of gold NPs, we performed MTT assay using two types of gold NPs such as gold nanorods (GNRs) and gold nanowires (GNWs). The percentage cytotoxicity of damaged neural precursor cells (NPCs) that were treated with 100 mg GNRs was 97.5±3.9%; and proportion of damaged NPCs following the administration of the same dose of GNWs was 98.8±0.3%. The cytotoxicity of 10 mg GNRs in NPCs was 54.4±8.3%, whereas it was 98.7±0.6% for the same dose of GNWs. Then, to verify that gold NPs induced apoptotic cell death in NPCs, the LIVE/DEAD Viability/Cytotoxicity assay was performed. We observed that cell death of NPCs increased with an increase in quantity of both types of gold NPs. Cell viability assessed the overall dose-dependent toxicity of NPs in cultured cells. As the results suggest, this study demonstrated that treatment with gold NPs resulted in cellular toxicity in a dose-dependent manner in cultured NPCs.

Nanoparticles are promising tools for the advancement of drug delivery, medical imaging, and as diagnostic sensor. Medical nanodevices should develop miniaturization, because it would be injected into a human body. Gold nanoparticles (GNPs) with different sizes and shapes have therapeutic potential as a result of their small size, robust nature, excellent biocompatibility and optical properties. However, the application of GNPs as medical nanodevices it is necessary to know the biodegradation, biocompatibility, and development of surface coating which avoid the accumulation of nanoparticles. In this study, we carry out an in vitro toxicity and in vivo gene expression study using two kinds of GNPs. We found that GNPs toxicity is dependent on the dose or size administrated after the injected GNPs into the brain, and small particle size GNPs appeared more nestin expression compared to large particle size at short term implantation. These findings of toxicity of GNPs may play an important role in development of in vivo tools for the safety of GNPs.

Object Parkinson disease (PD) is a well-known degenerative disease resulting in the depletion of dopamine-producing neurons in the pars compacta of the substantia nigra. Adenoviral vector delivery of neurotrophic factors may provide a potential therapy for PD. The authors examined whether glial cell line–derived neurotrophic factor (GDNF) delivered via adenoviral vector (Ad-GDNF) could promote functional recovery in a rat model of PD. Additionally, they examined whether neural precursor cells (NPCs) provide the therapeutic potential of cultured neural cells for cell regeneration and replacement in PD. Methods All animals underwent stereotactic injection of 6-hydroxydopamine into the right substantia nigra. Eight weeks later, the rats were tested for apomorphine-induced rotational asymmetry and evaluation of explanted grafts infected with the complementary DNA for GDNF containing NPCs and NPCs alone. In the NPC cultures of embryonic rat striata, the authors found that basic fibroblast growth factor induced the proliferation of stem cells, which give rise to spheres of undifferentiated cells that generate neurons and glia. Conclusions In this study the authors found that the reduction of apomorphine-induced rotation was more prominent in parkinsonian rats that received Ad-GDNF-treated grafts containing NPCs (61%) than in those that received grafts of NPCs alone (16%).

OBJECTIVE Re-implantation of autologous skull bone has been known to be difficult because of its propensity for resorption. Moreover, the structural characteristics of the area of the defect cannot tolerate physiologic loading, which is an important factor for graft healing. This paper describes our experiences and results with cranioplasty following decompressive craniectomy using autologous bone flaps. METHODS In an institutional review, the authors identified 18 patients (11 male and 7 female) in whom autologous cranioplasty was performed after decompressive craniectomy from January 2008 to December 2011. We examined the age, reasons for craniectomy, size of the skull defect, presence of bony resorption, and postoperative complications. RESULTS Postoperative bone resorption occurred in eight cases (44.4%). Among them, two experienced symptomatic breakdown of the autologous bone graft that required a second operation to reconstruct the skull contour using porous polyethylene implant (Medpor®). The incidence of bone resorption was more common in the pediatric group and in those with large cranial defects (>120 cm(2)). No significant correlation was found with sex, reasons for craniectomy, and cryopreservation period. CONCLUSION The use of autologous bone flap for reconstruction of a skull defect after decompressive craniectomy is a quick and cost-effective method. But, the resorption rate was greater in children and in patients with large skull defects. As a result, we suggest compressive force of the tightened scalp, young age, large skull defect, the gap between bone flap and bone edge and heat sterilization of autologous bone as risk factors for bone resorption.

OBJECTIVE In Korea, early vertebroplasty (EVP) or delayed vertebroplasty (DVP, which is performed at least 2 weeks after diagnosis) were performed for the treatment of acute osteoporotic compression fracture (OCF) of the spine. The present study compared the outcomes of two surgical strategies for the treatment of single-level acute OCF in the thoracolumbar junction (T12-L2). METHODS From 2004 to 2010, 23 patients were allocated to the EVP group (EVPG) and 27 patients to the DVP group (DVPG). Overall mean age was 68.3±7.9 and minimum follow-up period was 1.0 year. Retrospective study of clinical and radiological results was conducted. RESULTS No significant differences in baseline characteristics were observed between the two groups. As expected, mean duration from onset to vertebroplasty and mean duration of hospital stay were significantly longer in the DVPG (17.1±2.1 and 17.5±4.2) than in the EVPG (3.8±3.3 and 10.8±5.1, p=0.001). Final clinical outcome including visual analogue scale (VAS), Oswestry Disability Index, and Odom's criteria did not differ between the two groups. However, immediate improvement of the VAS after vertebroplasty was greater in the EVPG (5.1±1.3) than in the DVPG (4.0±1.0, p=0.002). The proportion of cement leakage was lower in the EVPG (30.4%) than in the DVPG (59.3%, p=0.039). In addition, semiquantitative grade of cement interdigitation was significantly more favorable in the EVPG than in the DVPG (p=0.003). Final vertebral body collapse and segmental kyphosis did not differ significantly between the two groups. CONCLUSION Our findings suggest that EVP achieves a better immediate surgical effect with more favorable cost-effectiveness.

Objective We have observed, anecdotally, that the incidence of primary spontaneous intracerebral hemorrhage (sICH), as well as spontaneous subarachnoid hemorrhage, varies in accordance with seasonality and meteorological conditions. This retrospective single-hospital-based study aimed to determine the seasonality of sICH and the associations, if any, between the occurrence of sICH and meteorological parameters in Incheon city, which is a northwestern area of South Korea. Methods Electronic hospital data on 708 consecutive patients admitted with primary sICH from January 2008 to December 2010 was reviewed. Traumatic and various secondary forms of ICHs were excluded. Average monthly admission numbers of sICH were analyzed, in relation with the local temperature, atmospheric pressure, humidity, and daily temperature range data. The relationships between the daily values of each parameter and daily admission numbers of sICH were investigated using a combination of correlation and time-series analyses. Results No seasonal trend was observed in sICH-related admissions during the study period. Furthermore, no statistically significant correlation was detected between the daily sICH admission numbers and the meteorological parameters of temperature, atmospheric pressure and humidity. The daily temperature range tended to correlate with the number of daily sICH-related admissions (p = 0.097). Conclusion This study represents a comprehensive investigation of the association between various meteorological parameters and occurrence of spontaneous ICH. The results suggest that the daily temperature range may influence the risk of sICH.

Objective : Anterior cervical corpectomy with fusion (ACF) or laminoplasty may be associated with substantial number of complications for treating multilevel cervical ossification of the posterior longitudinal ligament (OPLL) with significant cord compression. For more safe decompression and stabilization in multilevel cervical OPLL with prominent cord compression, we propose circumferential cervical surgery (selective ACF and laminoplasty) based on our favorable experience. Methods : Twelve patients with cervical myelopathy underwent circumferential cervical surgery and all patients showed multilevel OPLL with signal change of the spinal cord on magnetic resonance imaging (MRI). A retrospective review of clinical, radiological, and surgical data was conducted. Results : There were 9 men and 3 women with mean age of 56.7 years and a mean follow up period of 15.6 months. The average corpectomy level was 1.16 and laminoplasty level was 4.58. The average Japanese Orthopedic Association score for recovery was 5.1 points and good clinical results were obtained in 11 patients (92%) (p < 0.05). The average space available for the cord improved from 58.2% to 87.9% and the average Cobb’s angle changed from 7.63 to 12.27 at 6 months after operation without failure of fusion (p < 0.05). Average operation time was 8.36 hours, with an estimated blood loss of 760 mL and duration of bed rest of 2.0 days. There were no incidences of significant surgical complications, including wound infection. Conclusion : Although the current study examined a small sample with relatively short-term follow-up periods, our study results demonstrate that circumferential cervical surgery is considered favorable for safety and effectiveness in multilevel OPLL with prominent cord compression.

Chronic subdural hematoma (CSDH) is one of the most common types of traumatic intracranial hemorrhage, usually occurring in the older patients, with a good surgical prognosis. Burr hole craniostomy is the most frequently used neurosurgical treatment of CSDH. However, there have been only few studies to assess the role of the number of burr holes in respect to recurrence rates. The aim of this study is to compare the postoperative recurrence rates between one and two burr craniostomy with closed-system drainage for CSDH.From January 2002 to December 2006, 180 consecutive patients who were treated with burr hole craniostomy with closed-system drainage for the symptomatic CSDH were enrolled. Pre- and post-operative computed tomography (CT) scans and/or magnetic resonance imaging (MRI) were used for radiological evaluation. The number of burr hole was decided by neurosurgeon's preference and was usually made on the maximum width of hematoma. The patients were followed with clinical symptoms or signs and CT scans. All the drainage catheters were maintained below the head level and removed after CT scans showing satisfactory evacuation. All patients were followed-up for at least 1 month after discharge.Out of 180 patients, 51 patients were treated with one burr hole, whereas 129 were treated with two burr holes. The overall postoperative recurrence rate was 5.6% (n = 10/180) in our study. One of 51 patients (2.0%) operated on with one burr hole recurred, whereas 9 of 129 patients (7.0%) evacuated by two burr holes recurred. Although the number of burr hole in this study is not statistically associated with postoperative recurrence rate (p0.05), CSDH treated with two burr holes showed somewhat higher recurrence rates.In agreement with previous studies, burr hole craniostomy with closed drainage achieved a good surgical prognosis as a treatment of CSDH in this study. Results of our study indicate that burr hole craniostomy with one burr hole would be sufficient to evacuate CSDH with lower recurrence rate.

This study characterized the neurons in the lumbosacral cord that express phospho ERK (pERK) after distension or irritation of the bladder, and their relation to the vanilloid receptor 1 (VR1) positive primary afferents.Mechanical distension and chemical irritation of the bladder were induced by intravesical injection of the saline and mustard oil, respectively. Spinal neurons expressing pERK and the primary afferent fibers were characterized using multiple immunofluorescence for neurokinin 1 (NK1), neuronal nitric oxide synthetase (nNOS) and VR1.Neurons in lamina I, medial dorsal horn (MDH), dorsal gray commissure (DGC) and sacral parasympathetic nucleus (SPN) were immunoreactive for pERK after either mechanical or chemical stimulation. The majority of pERK positive cells were positive for NK1 in lamina I and SPN, but not in the DGC. Most of pERK positive cells are not stained for nNOS except in a small population of the cells in the SPN and DGC. Contacts between perikarya and dendrites of pERK-positive cells and terminals of primary afferents expressing VR1 were identified in lamina I, lateral collateral path (LCP) and SPN.In this study, the lumbosacral neurons activated by mechanical and chemical stimulation of the urinary bladder were identified with expression of the pERK, and also provided the evidence that VR1-positive primary afferents may mediate the activation of these neurons.

We found an error in our published article. Author name should be corrected as the following: Before Suyoung Kim1, Kang Lock Lee1, Dong Min Lee1, Ji Hun Jeong2, Song Mi Moon1, Yiel-Hae Seo2, Chan Jong Yoo3, Dongki Yang4, Yong Kyun Cho1, and Yoon Soo Park1 After Su Young Kim1, Kang Lock Lee1, Dong Min Lee1, Ji Hun Jeong2, Song Mi Moon1, Yiel-Hae Seo2, Chan Jong Yoo3, Dongki Yang4, Yong Kyun Cho1, and Yoon Soo Park1