Cervical Spinal Fracture Caused by Untreated Tourette Syndrome: A Case Report.

Cervical myelopathy can occur in Tourette syndrome patients with severe motor tics showing repetitive and violent neck movements. However, motor tics causing spinal fractures have been rarely reported. A 15-year-old girl presented at our clinic, complaining of recent development of motor weakness of all 4 extremities. She had untreated motor tics involving the neck. Computed tomography and magnetic resonance imaging findings suggested cervical spinal fractures and myelopathy. After diagnosing of Tourette syndrome, medical and psychologic therapies were started. Her motor tics were well controlled, and no complications in the patient's daily life were observed later. Cervical radiography taken at a 9-month follow-up showed bony healings of the fractured cervical spines. Uncontrolled severe motor tics may cause spinal fractures. Conservative treatments would suffice for proper control of these tics and stabilize the spine, and considered as initial treatment in patients with Tourette syndrome.

Anterior Spinal Artery Syndrome Occurring after One Level Segmental Artery Ligation during Spinal Surgery.

In treating the ventral pathology of spine, ligating the segmental vessels is sometimes necessary. This may cause spinal cord ischemia, and concerns of neurologic injury have been presented. However, spinal cord ischemic injury after sacrificing segmental vessels during spine surgery is very rare. Reports of this have been scarce in the literature and most of these complications occur after multi-level segmental vessel ligation. Here we report a case of a patient with postoperative anterior spinal artery syndrome, which occurred after ligating one level segmental vessels during spinal surgery for a T8 vertebral pathologic fracture. Despite its rarity, the risk of spinal cord ischemic injury after segmental vessel ligation is certainly present. Surgeons must keep in mind such risk, and surgery should be planned under a careful risk-benefit consideration.

An investigation of thalamic nuclei volumes and the intrinsic thalamic structural network based on motor subtype in drug naïve patients with Parkinson's disease.

INTRODUCTION: This study aimed to investigate the alterations in thalamic nuclei volumes and the intrinsic thalamic structural network in patients with de novo Parkinson's disease (PD) based on their predominant symptoms. METHODS: We enrolled 65 patients with de novo PD (44 patients with tremor-dominant [TD] subtype and 21 patients with postural instability and gait disturbance [PIGD] subtype) and 20 healthy controls. All subjects underwent three-dimensional T1-weighted magnetic resonance imaging. The thalamic nuclei were segmented using the FreeSurfer program. RESULTS: We obtained volumetric differences in the thalamic nuclei of each subtype of PD in comparison of healthy control. Volumes of the right and left suprageniculate nuclei were significantly increased, whereas that of the left parafascicular nucleus was decreased in patients with the TD subtype. Volumes of the right and left suprageniculate nuclei and right ventromedial nucleus were significantly increased, whereas those of the right and left parafascicular nuclei volumes were decreased in patients with the PIGD subtype. The measures of the intrinsic thalamic global network were not different between patients with TD PD and healthy controls. However, in patients with the PIGD subtype, the global and local efficiencies were significantly increased compared to healthy controls. Moreover, although there were no differences in thalamic volume and intrinsic thalamic global network between patients with the TD and PIGD variants, we identified significant differences in the intrinsic thalamic local network between the two groups. CONCLUSIONS: Alterations in thalamic nuclei volumes and the intrinsic thalamic network in patients with PD differed based on their predominant symptoms. These findings might be related to the underlying pathogenesis and suggest that PD is a heterogeneous syndrome.

Transient neurological deterioration due to watershed shift after STA-MCA bypass surgery in acute atherosclerotic occlusion.

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery is considered not the primary but the last treatment option for acute atherosclerotic occlusions refractory to medical treatment. We retrospectively evaluated patients who underwent STA-MCA bypass surgery for acute atherosclerotic occlusion intractable to other treatments. From June 2010 to May 2014, 10 patients underwent STA-MCA bypass surgery for acute atherosclerotic occlusion at our hospital. The sites of occlusion were the internal carotid artery (n = 5) and the proximal MCA (n = 5). All 10 patients showed good patency in the anastomosis after bypass surgery, and postoperative cerebral angiography showed a newly formed border zone between the existing collateral blood flow and bypass graft blood flow. Transient neurological deterioration (TND) developed in 4 patients after STA-MCA bypass surgery (40%). All 4 patients showed worsened hemiparesis or aphasia 2-3 days after bypass surgery and improvement in neurological deficits within 1 week after bypass surgery. Diffusion MRI in patients with TND showed new cerebral infarctions near the newly formed border zone. In our series of bypass surgeries for acute atherosclerotic occlusion, postoperative changes in hemodynamic status, also called watershed zone shift, may be one of the causes of new cerebral infarctions near the newly formed border zone.

Angiographic and clinical outcomes of non-patent anastomosis after bypass surgery in adult moyamoya disease.

BACKGROUND: The clinical and radiologic outcomes of symptomatic adult moyamoya disease (MMD) patients who have an occluded anastomosis immediately after bypass surgery are poorly studied. The clinical and angiographic outcomes of non-patent anastomosis in symptomatic adult MMD patients were retrospectively reviewed. METHODS: From August 2011 to November 2016, 31 revascularization surgeries, consisting of direct and indirect bypass, were performed on 29 adult MMD patients. Primary outcomes were evaluated based on the frequency of transient ischaemic attack (TIA) incidence and the recurrence of cerebral infarction and were assessed as improvement or worsening. RESULTS: Among 31 cases, computed tomography angiography (CTA) on the first day after surgery showed patent anastomosis in 20 hemispheres and non-patent anastomosis in 11 hemispheres. Follow-up conventional angiographies showed spontaneous recanalization of non-patent anastomosis in all occlusion cases. The incidence of TIA decreased in both the non-patent and the patent groups. Two newly developed cerebral infarctions were observed, which occurred in the patent group. Patients in the non-patent group also showed clinical improvement after surgery (p = 0.04), and no significant relationship was found between immediate postoperative patency and the primary outcome (p = 0.53). CONCLUSIONS: In our series, regardless of patency immediately after bypass surgery, delayed recanalization and clinical improvement can be expected after bypass surgery for adult MMD.

Sudden Paraplegia Caused by Nontraumatic Cervical Disc Rupture: A Case Report.

A 38-year-old man visited our Emergency Department for sudden onset paraplegia that occurred 1 hour ago. He felt a piercing pain in the posterior neck and became paraplegic while he was watching television, lying down on a sofa. Neurological examination showed motor power grades II-III in both arms and grade 0 in both legs. His cervical magnetic resonance imaging (MRI) showed a large ruptured disc at the C5-6 level, severely compressing the spinal cord. Emergency anterior cervical discectomy and fusion at C5-6 were performed. Because extensive cord swelling was observed on postoperative MRI, laminoplasty from C3 to C6 was performed 3 days after the initial operation. At a postoperative 8-month follow-up, the motor power was improved to grade III-IV- for both hands and grade IV- for both legs. Nontraumatic cervical disc rupture causing acute paraplegia is a very rare but possible event. Immediate neurologic assessment and thorough imaging studies to allow accurate diagnosis are crucial. Emergency surgical decompression is important and may lead to good neurological outcomes.

A 20-Year-Old Retained Surgical Gauze Mimicking a Spinal Tumor: A Case Report.

A 79-year-old man visited our clinic complaining of lower back and left leg radiating pain that began 1 month prior to his presentation. He underwent surgery for lumbar disc herniation 20 years ago at another hospital. Magnetic resonance imaging revealed left-sided foraminal stenosis at L4-5. In addition, a paraspinal mass occupying the L4 spinous process and left lamina was observed. We subsequently performed an L4-5 decompression and fusion. During the operation, retained surgical gauze with granulation tissue was found. The term gossypiboma is used to define a mass lesion consisting of retained surgical gauzes and an adjacent foreign body reaction. Gossypibomas are uncommon in the paraspinal area and are mostly asymptomatic in chronic cases. Because there are no specific clinical or radiological signs, they can be confused with other tumorous conditions. Gossypibomas should be included in the differential diagnosis of paraspinal soft-tissue masses detected in patients with a history of prior spinal surgery.

The Interference Phenomenon of Microcatheters in the Jailing Treatment for Internal Carotid Artery Side Wall Aneurysms with an Open Cell Stent System.

OBJECTIVE: Excelsior XT-27 (Stryker Neurovascular, Fremont, CA, USA) or Rebar 27 (eV3 Covidien, Irvine, CA, USA) microcatheters have recently been used to overcome the limitations of the Renegade Hi-Flo microcatheter such as interference between two microcatheters (one for stent delivery and the other for cerebral aneurysm coiling) during the jailing technique. We evaluated differences and influential factors related to the interference phenomenon according to these two microcatheters group. MATERIALS AND METHODS: Between June 2011 and September 2013, the jailing technique was applied to 94 internal cerebral artery (ICA) aneurysms. The jailing technique with the Neuroform EZ stent system was performed using Renegade (n = 22), Rebar (n = 35), and XT-27 microcatheters (n = 37). In the Renegade Hi-Flo microcatheter group, the jailing technique was successful in 19/22 patients (86.4%) and interference between the two microcatheters occurred in 6/21 patients (28.6%). In the Rebar and XT-27 microcatheter group, the jailing technique was successful in 71/72 patients (98.6%) and interference between the two microcatheters occurred in 1/72 patients (1.4%). RESULTS: There was a significant difference in the interference between the two delivered microcatheters group (p-value < 0.000) and the carotid siphon angle (p-value: 0.004) in the univariate analysis. In the multiple logistic regression analysis, the Rebar and XT-27 microcatheter group (odds ratio [OD] [95% confidence interval (CI)]; 31.277 [3.138-311.729], p-value: 0.003) and the carotid siphon angle (OD [95%CI]; 0.959 [0.922-0.997], p-value: 0.035) were found to be influential factors in the interference phenomenon. CONCLUSION: The Rebar 27 and XT-27 microcatheters were more successful and exhibited less interference between the two microcatheters than the Renegade Hi-Flo microcatheter.

Intra-arterial Thrombolysis for Central Retinal Artery Occlusion after the Coil Embolization of Paraclinoid Aneurysm.

The most common complication of coil embolization for cerebral aneurysms is thrombo-embolic stroke; in rare cases, these strokes, can present with central retinal artery occlusion. At our institution, a 53-year-old woman underwent stent-assisted coiling of the aneurysm. The patient's vision was improved immediately after intra-arterial thrombolysis and had further improved 8 months later. This report describes our experience of a rare case of central retinal artery occlusion after coil embolization that was successfully treated by intra-arterial thrombolysis.

Salvage STA-MCA bypass surgery in an adult moyamoya patient after failed indirect revascularization surgery.

A 39-year-old female moyamoya disease patient underwent a salvage direct bypass surgery involving anastomosis of the superficial temporal artery or STA and middle cerebral artery or MCA. This report describes a rare case of moyamoya disease that was revascularized after the previous indirect bypass surgery failed to restore collateral blood flow.

Idiopathic Spontaneous Intramedullary Hemorrhage: A Report of a Rare Case of Repeated Intramedullary Hemorrhage with Unknown Etiology.

A 48-year-old woman presented with acute voiding difficulty, numbness and weakness of both lower extremities. Magnetic resonance imaging (MRI) showed an intramedullary hemorrhagic mass that extended from T9 to T10. T8-T10 laminotomy and surgical removal of the hemorrhagic mass was performed. The pathological diagnosis was hematoma. Her neurological status remained the same after the operation. At 5 days post-operation, the patient suddenly became paraplegic, and MRI that was immediately performed revealed a recurrent intramedullary hemorrhage. Emergent surgical evacuation was performed. Again, histological examination showed only hematoma, without any evidence of abnormal vessels or a tumor. A postoperative MRI revealed no abnormal lesions other than those resulting from postoperative changes. At a 9-month follow up, the patient could walk a short distance with the aid of a walker. Because spontaneous intramedullary hemorrhage with unknown etiology is very rare, it is essential to perform a meticulous inspection of the hemorrhagic site to find the underlying cause. Repeated hemorrhage can occur; therefore, close observation of patients after surgery is important in cases without an apparent etiology. Urgent surgical evacuation is important to improve outcomes in these cases.

Vascular changes caused by deep brain stimulation using double-dose gadolinium-enhanced brain MRI.

We retrospectively analyzed the clinical data of 32 patients with medically intractable idiopathic Parkinson's disease who had undergone staged bilateral deep brain stimulation of the subthalamic nuclei from January 2007 to May 2011. The vascularture of the patients who received two deep brain stimulations was detected using double-dose gadolinium-enhanced brain MRI. The dimensions of straight sinus, superior sagittal sinus, ipsilateral internal cerebral vein in the thalamic branch and ipsilateral anterior caudate vein were reduced. These findings demonstrate that bilateral deep brain stimulation of the subthalamic nuclei affects cerebral venous blood flow.

Analysis on bilateral hindlimb mapping in motor cortex of the rat by an intracortical microstimulation method.

Intracortical microstimulation (ICMS) is a technique that was developed to derive movement representation of the motor cortex. Although rats are now commonly used in motor mapping studies, the precise characteristics of rat motor map, including symmetry and consistency across animals, and the possibility of repeated stimulation have not yet been established. We performed bilateral hindlimb mapping of motor cortex in six Sprague-Dawley rats using ICMS. ICMS was applied to the left and the right cerebral hemisphere at 0.3 mm intervals vertically and horizontally from the bregma, and any movement of the hindlimbs was noted. The majority (80%± 11%) of responses were not restricted to a single joint, which occurred simultaneously at two or three hindlimb joints. The size and shape of hindlimb motor cortex was variable among rats, but existed on the convex side of the cerebral hemisphere in all rats. The results did not show symmetry according to specific joints in each rats. Conclusively, the hindlimb representation in the rat motor cortex was conveniently mapped using ICMS, but the characteristics and inter-individual variability suggest that precise individual mapping is needed to clarify motor distribution in rats.

The pterional approach and extradural anterior clinoidectomy to clip paraclinoid aneurysms.

OBJECTIVE: The surgical clipping of paraclinoid segment internal carotid artery aneurysms is considered difficult because of the complex anatomical location and important neighboring structures. Our experiences of pterional craniotomy and extradural anterior clinoidectomy (EAC) to clip paraclinoid aneurysms are reported herein. METHODS: We present two patients with paraclinoid aneurysms who underwent surgical clipping using pterional craniotomy and EAC. The clinical results and operative techniques were reviewed from the patients' medical records. RESULTS: EAC improves the surgical field in the suprasellar and periclinoid regions. Clinically, a good outcome was obtained in both cases. No surgical complications directly resulting from the EAC were observed. CONCLUSION: Favorable surgical results can be obtained with pterional craniotomy and EAC for the clipping of paraclinoid aneurysms. EAC is advocated for the clipping of paraclinoid aneurysms.

Antithrombotic effects of aspirin on 1- or 2-level lumbar spinal fusion surgery: a comparison between 2 groups discontinuing aspirin use before and after 7 days prior to surgery.

STUDY DESIGN: Retrospective clinical analysis. OBJECTIVE: To study proper discontinuation date of aspirin in spinal fusion surgery. SUMMARY OF BACKGROUND DATA: It is thought that excess bleeding can be normalized if aspirin intake is discontinued approximately 7 days before surgery; however, the average life span of a platelet is generally regarded to be 7 to 10 days. METHODS: From January 2004 to December 2009, a single surgeon performed 182 cases of 1- or 2-level lumbar fusion surgical procedures. Patients who were aspirin users (n = 86) were divided into 2 groups according to the number of days prior to surgery that they discontinued their aspirin use: the aspirin 1 group discontinued their aspirin use 3 to 7 days before surgery and the aspirin 2 group discontinued their aspirin use 7 to 10 days before surgery. Ninety-six patients who did not use aspirin before surgery were selected for the control group. We retrospectively compared the several hematological parameters among the 2 aspirin groups and the control group. RESULTS: Both the total amount of drained blood and the duration of indwelling of the drainage catheter were significantly less in the control group than in the aspirin 1 group in patients who underwent either type of 1-level fusion surgery. However, those were not significantly different between aspirin 2 group and control group in patients who underwent either type of 1-level fusion surgery. Only drainage catheter was significantly less in the control group than in the aspirin 1 group in patients who underwent 2-level fusion surgery. CONCLUSION: Only the aspirin 1 group, wherein patients discontinued aspirin use 3 to 7 days before surgery, showed a greater drained blood and drainage catheter than the control group. If aspirin was discontinued 7 days or longer before surgery, there was no difference in the study parameters, compared with the control group. LEVEL OF EVIDENCE: 3.

Usefulness of an additional mattress suture for the extracranial drainage catheter.

In most intracranial surgery cases, a drain catheter is inserted to prevent the collection of the wound hematoma or seroma. A drain catheter is also inserted to drain the hematoma or the cerebrospinal fluid. The drain catheter itself does not cause complications; but many complications occur during its removal, such as hematoma, seroma, air collection and pseudomeningocele formation. To prevent these complications, neurosurgeons perform a suture on the catheter to remove the site. In this study, an additional horizontal mattress suture and an anchoring suture to the drainage catheter are proposed. This method maintains negative pressure in the catheter insertion site during the catheter removal, compresses the catheter tunnel site and attaches the external wounds strongly. The technique is easy and safe to perform, and does not require an additional suture to remove the catheter.

Long-term outcomes after an arterial switch operation for simple complete transposition of the great arteries.

BACKGROUND AND OBJECTIVES: Although coronary artery obstruction, aortic insufficiency (AI), and pulmonary stenosis (PS) have been reported after arterial switch operation (ASO), limited long-term studies on ASO exist. Our study aimed to examine long-term outcomes after ASO for simple complete transposition of the great arteries (TGA). SUBJECTS AND METHODS: All 108 patients with simple complete TGA who underwent ASO at Seoul National University Children's Hospital between 1987 and 2004 were enrolled. We retrospectively reviewed the patients' medical records and the results of various functional and imaging studies. RESULTS: Among 108 cases of ASO for simple TGA, 96 have been followed-up through the present time (mean follow-up duration was 11.7+/-8.6 years: range= 4 to 23 years). The 20-year rates of freedom from significant AI, PS, and coronary obstruction were 78.6%, 67.8%, and 95.8%, respectively. AI showed a tendency to progress as follow-up time increased in 21.4% of the population studied (p=0.014); however, AS, PS, and PI showed no such progression. Late coronary artery occlusion was not associated with the initial coronary arterial pattern. Re-operations were done for 13 patients (13.5%) at an average of 8+/-4.3 years after ASO. The survival rate was 96%, while the re-operation-free was 90% at 10 years and 83% at 20 years. Most patients showed normal physical growth with good activity {98%; New York Heart Association (NYHA) class 1 activity} and normal development (96%). CONCLUSION: Although most patients showed normal physical growth and development after successful ASO, meticulous long-term follow-up is necessary because of progressive AI and coronary complications.