Subdural Empyema from Streptococcus suis Infection, South Korea.

In Jeju Island, South Korea, a patient who consumed raw pig products had subdural empyema, which led to meningitis, sepsis, and status epilepticus. We identified Streptococcus suis from blood and the subdural empyema. This case illustrates the importance of considering dietary habits in similar clinical assessments to prevent misdiagnosis.

Delayed Unilateral Facet Interlocking After a Stable Superior Articular Process Fracture of the Cervical Spine: A Case Report.

A 42-year-old man presented with neck pain after a fall from a tree. Spine computed tomography (CT) illustrated the right C5 superior articular process fracture without displacement. Magnetic resonance imaging (MRI) confirmed the fracture and injury of the posterior ligament complex. Initially he was managed conservatively with a neck brace as there were no signs of instability or vertebral body misalignment. However, three days after discharge, right shoulder weakness and numbness of the right upper arm became prominent. X-rays and CT showed anterior slippage of the C4 vertebral body and locked C4/5 facet ??a fractured bony fragment of the C5 superior articular process was pushed forward by the locked inferior articular process of C4 and invaded the neural foramen. Anterior cervical discectomy and fusion (ACDF) was performed using allograft and plate/screws fixation. Although initial imaging showed no evidence of subluxation, surgeons should be aware of occult instability and the possibility of delayed dislocation associated with the unilateral cervical facet fracture.

Ruptured Fusiform Anterior Cerebral Artery Aneurysm in an Infant : Case Report and a Literature Review.

Ruptured intracranial aneurysms in infants are rare and infantile fusiform anterior cerebral artery (ACA) aneurysms are much rarer. In this report, we described the case of a 7-month-old infant with a ruptured fusiform ACA aneurysm who presented with seizure and underwent endovascular treatment. The patient was initially in a coma and the neurologic condition did not improve after treatment. The clinical characteristics of the case and literature review were discussed.

Expression of neuronal antigens and related ventral and dorsal proteins in the normal spinal cord and a surgically induced open neural tube defect of the spine in chick embryos: an immunohistochemical study.

OBJECTIVE: The aims of this study were to elucidate the processes of neuronal differentiation and ventrodorsal patterning in the spinal cord of the chick embryo from embryonic day (E) 3 to E17 and to study the effect of a prenatal spinal open neural tube defect (ONTD) on these processes. METHOD: Expression patterns of neuronal antigens (neuronal nuclear antigen, neurofilament-associated protein (NAP), and synaptophysin) and related ventral markers [sonic hedgehog, paired box gene (PAX)6, and islet-1], and dorsal markers (bone morphogenetic protein, Notch homolog 1, and PAX7) were investigated in the normal spinal cord and in a surgically induced spinal ONTD in chick embryos. Four normal and ONTD chick embryos were used for each antigen group. RESULT & CONCLUSION: There were no differences in the expression of neuronal and ventrodorsal markers between the control and ONTD groups. NAP and synaptophysin were useful for identifying dorsal structures in the distorted anatomy of the ONTD chicks.

Expression of neuronal markers in the secondary neurulation of chick embryos.

OBJECTIVE: The goal of our study was to evaluate the expression patterns of neuronal antigens during the process of secondary neurulation. MATERIALS AND METHODS: Chick embryos of Hamburger and Hamilton stages 16, 18, 20, 22, 24, 26, 30, 35, 40, and 45 were harvested, and tail sections were processed for neuronal antigen studies. RESULTS AND CONCLUSIONS: The areas and periods showing positive reactions for each antigen are as follows: neuronal cell adhesion molecule (N-CAM): the secondary neural tube and notochord from stages 18 to 26 and the germinal and mantle layers from stages 30 to 45; synaptophysin: the caudal cell mass, secondary neural tube, and notochord from stages 22 to 26, the germinal and mantle layers from stages 30 to 45, and the marginal layer at the later stages of development; neurofilament-associated protein (3A10): the dorsal white matter, dorsal root ganglion, and scattered cells around the germinal layer from stages 35 to 45; and neuronal nuclear-specific protein (NeuN): the mantle layer at stage 35, which shows decreased reaction at stages 40 and 45; islet-1: no remarkable staining on the caudal cell mass or on the other neural structures at all stages. Our results indicate that neuronal markers of the secondary neurulation in chick embryos have their own chronological patterns of expression. At early stages of secondary neurulation, N-CAM and synaptophysin are thought to modulate the differentiation of structures derived from the caudal cell mass. At later stages, N-CAM, synaptophysin, 3A10, and NeuN seem to be involved in the maturation of the caudal spinal cord.

Modified encephaloduroarteriosynangiosis with bifrontal encephalogaleoperiosteal synangiosis for the treatment of pediatric moyamoya disease. Technical note.

The authors describe a modified technique of encephaloduroarteriosynangiosis (EDAS) with bifrontal encephalogaleoperiosteal synangiosis (EGPS) and present the preliminary results of the procedure. Between January 2004 and June 2005 the authors performed modified EDAS with bifrontal EGPS in 17 patients with moyamoya disease. Surgical results were evaluated in terms of clinical outcomes, changes visible on neuroimages, extent of revascularization noted on angiograms, and hemodynamic changes demonstrated on single-photon emission computed tomography (SPECT) scans. The follow-up period ranged from 6 to 21 months (mean 11.5 months). The overall clinical outcomes were excellent or good in 15 patients (88.2%) and poor in two (11.8%). The overall morbidity rate was 5.9% (one of 17 patients). Based on changes in the anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories after surgery, as shown on SPECT scans following administration of acetazolamide, 14 patients (82.4%) exhibited an improved vascular reserve capacity in both the ACA and MCA territories. It is the authors' opinion that wide covering of the cortex is necessary for sufficient revascularization. In the present study they demonstrate that modified EDAS with bifrontal EGPS is a safe and efficient surgical approach that covers not only the MCA territory but also the ACA territory.

Identification of patients with childhood moyamoya diseases showing temporary hypertension after anesthesia by preoperative multifractal Hurst analysis of heart rate variability.

OBJECTIVE: This study was performed to determine whether the preoperative multifractal Hurst analysis of heart rate variability might identify and characterize childhood patients with moyamoya disease (MMD) who showed temporary postoperative hypertension. METHODS: We studied 59 childhood patients with MMD. Thirty were classified as hypertensive group when the mean arterial pressure in the postoperative recovery room was 120% or greater than that during the preoperative period and 29 were classified as normotensive group. The 2 groups were compared with respect to preoperative indices of heart rate variability including frequency-domain measures, approximate entropy, and very short-term multifractal Hurst exponents of RR intervals (RRI). Using preoperative indices that showed significant differences, discriminant analysis was performed to identify postoperative hypertensive patients. RESULTS: Only exponents of the order > or =3 (H3alpha, H4alpha, and H5alpha) were significantly lower in the hypertensive group than in the normotensive group. Frequency-domain measures, approximate entropy, and the exponents of the order < or =2 were not significantly different in the 2 groups. Discriminant analysis using all of the three exponents correctly identified 27/30 (90%) of the postoperative hypertensive patients. CONCLUSIONS: Preoperative very short-term multifractal Hurst analysis of RRI variability identified 90% of childhood MMD patients who developed postoperative hypertension. The preoperative characteristic of RRI variability was the reduced smoothness at the 8-second-long, local RRI regions within which a very large change of RRI occurs.

Acute Cervical Spontaneous Spinal Epidural Hematoma Presenting with Minimal Neurological Deficits: A Case Report.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) is an uncommon but potentially fatal condition. The increased bleeding tendency associated with anticoagulant medications has been proven to increase the risk of SSEH. The symptoms of SSEH usually begin with sudden severe neck or back pain and are followed by neurological deficits. However, some cases present with only axial pain or with radicular pain similar to herniated disc disorders. CASE PRESENTATION: A 28-year-old healthy man developed a sudden onset of severe neck and right shoulder pain with mild arm weakness. The MRI revealed an SSEH that was compressing his spinal cord in the right posterolateral epidural space from C2-C6. On the second hospital day, his symptoms suddenly improved, and most of the hematoma had spontaneously resolved. CONCLUSIONS: Currently, the incidence of SSEH is expected to increase. Pain physicians must include SSEH in their differential diagnosis for patients with axial pain or radicular symptoms alone, particularly when risk factors are present.

Epidemiologic Impact of Rapid Industrialization on Head Injury Based on Traffic Accident Statistics in Korea.

OBJECTIVE: The aim of the present study is to estimate the incidence trend of head injury and the mortality based on traffic accident statistics and to investigate the impacts of rapid industrialization and economic growth on epidemiology of head injury in Korea over the period 1970-2012 including both pre-industrialized and post-industrialized stages. METHODS: We collected data of head injury estimated from traffic accident statistics and seven hospital based reports to see incidence trends between 1970 and 2012. We also investigated the population structure and Gross National Income (GNI) per capita of Korea over the same period. The age specific data were investigated from 1992 to 2012. RESULTS: The incidence of head injury gradually rose in the 1970s and the 1980s but stabilized until the 1990s with transient rise and then started to decline slowly in the 2000s. The mortality grew until 1991 but gradually declined ever since. However, the old age groups showed rather slight increase in both rates. The degree of decrease in the mortality has been more rapid than the incidence on head injury. CONCLUSION: In Korea during the low income stage, rapid industrialization cause considerable increase in the mortality and the incidence of head injury. During the high income stage, the incidence of head injury gradually declined and the mortality dropped more rapidly than the incidence due to preventive measures and satisfactory medical care. Nevertheless, the old age groups revealed rather slight increase in both rates owing to the large population structure and the declining birth rate.

Pyogenic Intradural Abscess of Lumbar Spine: A Case Report.

We report a case of spinal intradural abscess which shows serial changes on magnetic resonance imaging (MRI). Well-encapsulated, rim-enhancing lesion with mass effect was visualized at ventral side of lumbar spinal canal on 17 days after initial negative MRI, which was thought to be epidural abscess. It was revealed to be intradural in location on operation and successfully treated by drainage and antibiotics. Follow-up MRI showed resolution of abscess. Clinical significance and pathogenesis of this case was briefly discussed.

Elevation of CRABP-I in the cerebrospinal fluid of patients with Moyamoya disease.

BACKGROUND AND PURPOSE: The etiology of moyamoya disease (MMD) remains obscure. This study was undertaken to identify specific proteins associated with the pathogenesis of MMD. METHODS: We studied cerebrospinal fluid (CSF) from 20 patients with angiographically confirmed MMD (4 boys and 16 girls; age range, 3 to 13 years; mean, 7.5 years) and 4 control patients with cerebral palsy who underwent selective dorsal rhizotomy (2 boys and 2 girls; age range, 5 to 10 years; mean, 7.3 years). CSF proteins were analyzed by 2-dimensional polyacrylamide gel electrophoresis, and protein identification was performed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The presence of specific CSF protein in patients with MMD was confirmed by Western blotting. In addition, cerebral CSF was also tested in 7 patients who had other brain diseases but no MMD (2 boys and 5 girls; age range, 1 to 12 years; mean, 6.9 years). RESULTS: We identified 1 polypeptide spot (Mr of 13 to 15 kDa and isoelectric point of 5 to 5.5) that was differentially expressed in the CSF samples of MMD patients (mean optical density intensity, 0.36+/-0.24; range, 0.05 to 0.92) and control spinal CSF samples (mean, 0.03+/-0.04; range, 0 to 0.08; P=0.002). This polypeptide was identified as cellular retinoic acid-binding protein (CRABP)-I. High levels of expression of CRABP-I in the CSF from 17 MMD children were confirmed by Western blotting. CONCLUSIONS: The analysis of the CSF of MMD patients reveals high CRABP-I expression. The present study suggests that the elevation of CRABP-I in CSF may be a candidate for pathogenesis of MMD.

Skin graft on the surgically induced spinal open neural tube defects does not induce lipomatous malformation but enhances re-closure to the normal state in chick embryos.

To determine the effect of skin allograft on open neural tube defects (ONTDs), the neural tube was incised open using Hamburger and Hamilton stage 18 or 19 chick embryos for a length of six somites. Embryos were divided into two groups: graft and control (with and without skin allograft). On postoperative day 5, closure of ONTDs was more frequent in the graft group than in the control group (9/15 versus 0/15), and healing was nearly complete. However, typical lipomatous features were not observed. These results suggest that simple mechanical attachment of skin allograft on ONTDs does not lead to lipomatous malformation in chick embryos. On the other hand, our results support a potential role of skin allograft in the management of prenatal spinal ONTDs.

Enhancement of re-closure capacity by the intra-amniotic injection of human embryonic stem cells in surgically induced spinal open neural tube defects in chick embryos.

To evaluate the re-closure promoting capacity of human embryonic stem (hES) cells injected into the amniotic cavity on spinal open neural tube defects (ONTDs) of chick embryos, neural tubes were opened at Hamburger and Hamilton stage 18 or 19 and the embryos were divided into three groups: a control group (no injection), a vehicle group, and a hES cell group (injection of 20,000 hES cells immediately after neural tube incision). On postoperative days 3, 5, and 7, ONTDs were significantly more re-closed in the hES cell group than in the other two groups. hES cells were present at the area in the process of re-closure, and covered ONTDs, but were not found in the re-closed area, suggesting indirect effects rather than cell replacement on the neural tissue.

Gene expression profile analyses of cortical dysplasia by cDNA arrays.

Cortical dysplasia (CD) is a well-recognized cause of intractable epilepsy, especially in children and is characterized histologically by derangements in cortical development and organization. The objective of this study was to expand the current knowledge of altered gene expression in CD as a first step towards in the identification of additional genes operative in the evolution of CD. Surgical specimens were obtained from eight patients (4 males and 4 females; age range 2-38 years; mean 15 years) with a pathologic diagnosis of CD. Nondysplastic temporal neocortex was obtained from a 2-year-old boy with intractable epilepsy and medial temporal lobe ganglioglioma. After total RNA isolation from frozen brain tissues, we carried out gene expression profiling using a cDNA expression array. Differences in gene expressions between CD and the nondysplastic neocortex were confirmed by semi-quantitative conventional reverse transcription-PCR. Three genes (recombination activating gene 1 (RAG1), heat shock 60 kDa protein 1 (HSP-60), and transforming growth factor beta1 (TGF beta1)) were found to be up-regulated more than two-fold in CD, whereas four genes (phosphoinositide-3-kinase regulatory subunit polypeptide 1 [p85 alpha] (PI3K), frizzled homolog 2 [Drosophila], Bcl-2/adenovirus E1B 19 kDa interacting protein (NIP3), and glia maturation factor beta (GMF beta)) were down-regulated to less than 50% of their normal levels. Interestingly, the majority of genes showing altered expression were associated with apoptosis. Our study demonstrates diverse changes in gene expression in CD. However, it remains to be shown which of these are causally related to the evolution of CD.

Adenoviral p16/CDKN2 gene transfer to malignant glioma: role of p16 in growth, invasion, and senescence.

In gliomas, a high frequency of homozygous p16 gene deletions have been demonstrated, which are believed to be linked with malignant progression. The aim of this study was to assess the role of p16 in growth, invasion, and senescence. The human glioma cell lines U87 MG and U373 MG were transduced with Ad-p16, and cell viability was assessed by trypan blue staining. To examine the mechanism of cell growth inhibition, cell cycle analyses and annexin assays were performed. The invasive potential of Ad-p16 transduced cells was evaluated using a Matrigel invasion assay, and trimolecular complex (MMP-2/MT1-MMP/TIMP-2) synthesis was proven by zymography and Western blotting. To establish the link between p16 and cell senescence, we stained for Senescence-Associated beta-galactosidase activity. A cell proliferation assay demonstrated that Ad-p16 treatment significantly inhibits cell growth. Moreover, this cell growth inhibition was induced by cell cycle arrest, not by apoptosis. In vitro treatment of malignant glioma cells with Ad-p16 significantly decreased their invasive potential by Matrigel invasion assay. However, we were unable to demonstrate any differences in the constitutive productions and secretions of MMP-2, MT1-MMP, and TIMP-2, among the mock-treated, Ad-lacZ-transduced, and Ad-p16-transduced cells. p16 expression caused an enlargement of all cells, and these were morphologically similar to senescent cells. Staining for Senescence-Associated beta-galactosidase activity showed that the enlarged cells stained positively. Taken together these data strongly suggest that the anti-cancer effect of p16 is modulated by p16-mediated cell cycle arrest and by the induction of senescence.

Effects of human neural stem cell transplantation in canine spinal cord hemisection.

OBJECTIVES: Previous works have reported that the transplantation of neural stem cells (NSCs) may improve functional recovery after spinal cord injury (SCI), but these results have been mainly obtained in rat models. In the present work, the authors sought to determine whether the transplantation of human NSCs improves functional outcome in a canine SCI model and whether transplanted NSCs survive and differentiate. METHODS: Human NSCs (HB1. F3 clone) were used in this work. Lateral hemisection at the L2 level was performed in dogs and either (1) Matrigel (200 microl) alone as a growth-promoting matrix or (2) Matrigel seeded with human NSCs (10(7) cells/200 microl) were transplanted into hemisected gaps. Using a canine hind limb locomotor scale, functional outcomes were assessed over 12 weeks. Immunofluorescence staining was performed to examine cell survival, differentiation and axonal regeneration. RESULTS: Compared with dogs treated with Matrigel alone, dogs treated with Matrigel + human NSCs showed significantly better functional recovery (10.3 +/- 0.7 versus 15.6 +/- 0.7, respectively, at 12 weeks; p<0.05). Human nuclei-positive cells were found mainly near hemisected areas in dogs treated with Matrigel + NSCs. In addition, colocalization of human nuclei and neuronal nuclei or myelin basic protein was clearly observed. Moreover, the Matrigel + NSC group showed more ascending sensory axon regeneration. CONCLUSIONS: The transplantation of human NSCs has beneficial effects on functional recovery after SCI, and these NSCs were found to differentiate into mature neurons and/or oligodendrocytes. These results provide baseline data for future clinical applications.

Optic pathway glioma: outcome and prognostic factors in a surgical series.

OBJECTS: The goals of this study were to evaluate the surgical outcomes of optic pathway glioma (OPG) and to analyze the prognostic factors related to the progression-free survival. MATERIALS AND METHODS: A retrospective review was conducted on 33 patients who underwent surgery for OPG; these included 15 male and 18 female patients with a mean age of 8.3 years. The mean duration of follow-up was 52 months. RESULTS AND CONCLUSIONS: The preservation rate of ipsilateral vision was 25%, while that of contralateral vision was 83% (P<0.001). There was no remarkable endocrine improvement after surgery. The overall and progression-free survival rates at 5 years were 93.6 and 52.4%, respectively. In our study, the predictors for tumor progression were children younger than 5 years of age (p=0.023) and of female gender (p=0.022). Because of the variable course of OPG, treatment policy should be optimized individually according to patient's status.

Encephaloduroarteriosynangiosis with bifrontal encephalogaleo(periosteal)synangiosis in the pediatric moyamoya disease: the surgical technique and its outcomes.

METHODS: To increase the blood flow of the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) territories, we modified the "ribbon" procedure in combination with encephaloduroarteriosynangiosis (EDAS). This is referred to as "EDAS with bifrontal encephalogaleo(periosteal)synangiosis (EGS)." The surgical technique, clinical outcomes, complications, extent of revascularization, and changes in CBF in 67 pediatric MMD patients were retrospectively reviewed. RESULTS: The excellent and good clinical recovery rates were 57% and 31%. The rate for complete disappearance of TIA was 63%. All the bifrontal EGS made abundant collateral vessels in the ACA territory. When the EDAS with bifrontal EGS was performed in the first operation, collaterals of EGS sites developed more on the contralateral side of the EDAS. The arachnoid opening of the medial frontal lobe in the EGS site had no effect on the results. There was a positive correlation between the clinical outcome and the extent of angiographic revascularization. Improvements in the CBF and the reserve in ACA territory were observed in 57%. CONCLUSIONS: EDAS with bifrontal EGS resulted in excellent revascularization in both the MCA and ACA territories. The clinical and hemodynamic results were also excellent. This procedure may be an effective and safe surgical modality for the prevention of ischemia in the whole territory of the anterior circulation of the brain in pediatric MMD.

Shunt dependency in shunted arachnoid cyst: a reason to avoid shunting.

Cystoperitoneal (CP) shunting is minimally invasive and achieves a high rate of resolution on neuroimaging. However, in the absence of definite symptoms, shunting should be reconsidered, because some patients can experience shunt dependency after CP shunting. In this study, the risk of shunt dependency in patients with arachnoid cysts treated with CP shunting and the management of these patients are described. Eight patients (7 boys and 1 girl) were diagnosed as shunt dependent following CP shunting. At the time of the first operation (mean age at first shunting 6.1 years, range 1-11 years), a causal relationship between symptoms and the arachnoid cyst was evident in only 2 cases. Clinical manifestations, neuroimaging (computed tomography and/or magnetic resonance imaging) and intracranial pressure (ICP) data were reviewed retrospectively. The mean age of the patients at the time of shunt dependency was 9.8 years (range 6-13 years), and the mean time between the first shunt operation and shunt dependency was 41 months (range 17-80 months). Although neuroimaging demonstrated a collapsed cyst and small ventricles in most patients, ICP monitoring revealed significant intracranial hypertension. The release of shunt ligation, revision or additional shunting, such as ventriculoperitoneal shunting or lumboperitoneal shunting, resulted in the complete resolution of symptoms except in one patient who lost vision. This study shows that shunt dependency after CP shunting is a real problem and requires more attention. ICP monitoring can demonstrate the presence of intracranial hypertension when clinical and radiological analyses do not.

Transsphenoidal microsurgery for pediatric craniopharyngioma: special considerations regarding indications and method.

Although the transsphenoidal approach offers a narrow operative field and poor visual control through a small sellar opening, this approach has the advantage of being associated with minimal surgical trauma, especially in children. We share our experience of good surgical outcome achieved by the transsphenoidal approach in selected craniopharyngiomas in childhood, and report on our pediatric series of transsphenoidal complete removals of six relatively large craniopharyngiomas and one Rathke's cleft cyst. The most common presenting symptom was visual dysfunction (6/7). All tumors were 'prechiasmatic' cystic masses with moderate to marked suprasellar extensions and elevated diaphragm sellae. The tumors measured from 25 to 37 mm in maximum diameter in the midsagittal plane (median 33 mm). In 5 of the 7 tumors, the suprasellar portion (range 11-27 mm) was larger than the intrasellar portion (range 8-14 mm). Gross total resection was achieved in all patients. Special attention should be paid to multicystic craniopharyngiomas to prevent the possibility of incomplete tumor resection. The 'bone in a fat pocket' method was useful for preventing postoperative cerebrospinal fluid leakage. Vision was improved in all six patients who had preoperative visual disturbances. Hypopituitarism was provoked by radical tumor removal in all patients and managed by hormonal supplementation therapy. Transsphenoidal surgery is an appropriate approach for the radical excision of intrasellar-suprasellar 'prechiasmatic' craniopharyngiomas, even in children, and even if the tumor has a relatively large suprasellar component.