Clinical Outcomes of Clipping and Coil Embolization for Ruptured Intracranial Aneurysms Categorized by Region and Hospital Size: A Nationwide Cohort Study in Korea

Background@#To analyze the outcomes of clipping and coiling for ruptured intracranial aneurysms (RIAs) based on data from the National Health Insurance Service in South Korea, with a focus on variations according to region and hospital size. @*Methods@#This study analyzed the one-year mortality rates for patients with RIAs who underwent clipping or coiling in 2018. Coiling was further categorized into non-stent assisted coiling (NSAC) and stent assisted coiling (SAC). Hospitals were classified as tertiary referral general hospitals (TRGHs), general hospitals (GHs), or semi-general hospitals (sGHs) based on size. South Korea’s administrative districts were divided into 15 regions for analysis. @*Results@#In 2018, there were 2,194 (33.1%) clipping procedures (TRGH, 985; GH, 827; sGH, 382) and 4,431 (66.9%) coiling procedures (TRGH, 1,642; GH, 2076; sGH, 713) performed for RIAs treatment. Among hospitals performing more than 20 treatments, the one-year mortality rates following clipping or coiling were 11.2% and 16.0%, respectively, with no significant difference observed. However, there was a significant difference in one-year mortality between NSAC and SAC (14.3% vs. 19.5%, P = 0.034), with clipping also showing significantly lower mortality compared to SAC (P = 0.019). No significant differences in other treatment modalities were observed according to hospital size, but clipping at TRGHs had significantly lower mortality than at GHs (P = 0.042). While no significant correlation was found between the number of treatments and outcomes at GHs, at TRGHs, a higher volume of clipping procedures was significantly associated with lower total mortality (P = 0.023) and mortality after clipping (P = 0.022). @*Conclusion@#Using Korea NHIS data, mortality rates for RIAs showed no significant variation by hospital size due to coiling’s prevalence. However, differences in clipping outcomes by hospital size and volume in TRGH highlight the need for national efforts to improve clipping skills and standardization. Additionally, the higher mortality rate with SAC emphasizes the importance of precise indications for its application.

Microlaryngobronchoscopy Without Tracheostomy in Large Subglottic Cyst Obliterating Airway / 대한이비인후과학회지

Extended endotracheal intubation in infancy causes various complications. Upper airway disruption is very rare but reversible cause of respiratory insufficiency. Tracheostomy may not be avoidable in severe upper respiratory tract lesions especially in large subglottic cysts and severe subglottic stenosis; however, avoiding it is a priority when possible. A 7-month-old child who had a history of newborn respiratory distress syndrome and extended endotracheal intubation developed respiratory symptoms including stridor. A subglottic cyst was found by bronchoscopy and surginally removed with the tubeless anesthesia technique without tracheostomy. This method was successful even on infants. We report this case with a review of literature.

Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea

Background@#We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea. @*Methods@#The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases. @*Results@#A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively). @*Conclusion@#The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.

Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea

Background@#We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea. @*Methods@#The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases. @*Results@#A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively). @*Conclusion@#The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.

Acute Paraplegia as a Result of Hemorrhagic Spinal Ependymoma Masked by Spinal Anesthesia: Case Report and Review of Literature

Ependymomas are the most common intramedullary spinal cord tumors in adults. Although a hemorrhage within spinal ependymoma on imaging studies is not uncommon, it has rarely been reported to bea cause of acute neurological deficit. In the present report, we describe a case of a 24-year-old female patient who developed acute paraplegia as a result of hemorrhagic spinal ependymoma immediately after a cesarean delivery under spinal regional anesthesia. We review the literature of hemorrhagic spinal ependymomas presenting with acute neurological deficit and discuss the most appropriate treatment for a good neurological recovery.

Acute Paraplegia as a Result of Hemorrhagic Spinal Ependymoma Masked by Spinal Anesthesia: Case Report and Review of Literature

Ependymomas are the most common intramedullary spinal cord tumors in adults. Although a hemorrhage within spinal ependymoma on imaging studies is not uncommon, it has rarely been reported to bea cause of acute neurological deficit. In the present report, we describe a case of a 24-year-old female patient who developed acute paraplegia as a result of hemorrhagic spinal ependymoma immediately after a cesarean delivery under spinal regional anesthesia. We review the literature of hemorrhagic spinal ependymomas presenting with acute neurological deficit and discuss the most appropriate treatment for a good neurological recovery.

Parasellar Extension Grades and Surgical Extent in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas : A Single Surgeon's Consecutive Series with the Aspects of Reliability and Clinical Validity

OBJECTIVE: The inter-rater reliability of the modified Knosp's classification was measured before the analysis. The clinical validity of the parasellar extension grading system was evaluated by investigating the extents of resection and complication rates among the grades in the endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas. METHODS: From November 2008 to August 2015, of the 286 patients who underwent EETS by the senior author, 208 were pituitary adenoma cases (146 non-functioning pituitary adenomas, 10 adrenocorticotropic hormone-secreting adenomas, 31 growth hormone-secreting adenomas, 17 prolactin-secreting adenomas, and 4 thyroid-stimulating hormone-secreting adenomas; 23 microadenomas, 174 macroadenomas, and 11 giant adenomas). Two neurosurgeons and a neuroradiologist independently measured the degree of parasellar extension on the preoperative sellar MRI according to the modified Knosp's classification. Inter-rater reliability was statistically assessed by measuring the intraclass correlation coefficient. The extents of resection were evaluated by comparison of the pre- and post-operative MR images; the neurovascular complications were assessed by reviewing the patients' medical records. The extent of resection was measured in each parasellar extension grade; thereafter, their statistical differences were calculated. RESULTS: The intraclass correlation coefficient value of reliability across the three raters amounted to 0.862. The gross total removal (GTR) rates achieved in each grade were 70.0, 69.8, 62.9, 21.4, 37.5, and 4.3% in Grades 0, 1, 2, 3A, 3B, and 4, respectively. A significant difference in the extent of resection was observed only between Grades 2 and 3A. In addition, significantly higher complication rates were observed in the groups above Grade 3A. CONCLUSION: Although the modified Knosp's classification system appears to be complex, its inter-rater reliability proves to be excellent. Regarding the clinical validity of the parasellar extension grading system, Grades 3A, 3B, and 4 have a negative predictive value for the GTR rate, with higher complication rates.

A Case of Pituitary Metastasis of Lung Cancer Presenting as Cavernous Sinus Syndrome / 대한이비인후과학회지

The cavernous sinus contains significant structures such as the internal carotid artery and cranial nerves III to VI. Cavernous sinus lesions may cause ophthalmoplegia, proptosis, and diplopia. We report a 56-year-old woman who presented with throbbing headache and associated right-sided ocular pain. While awaiting imaging studies, she suddenly developed opthalmoplegia and ptosis of the right eye. She had ipsilateral palsy of the third and fourth cranial nerves, while the sixth nerve remained intact. Magnetic resonance imaging revealed a pituitary gland mass extending into the right cavernous sinus with associated sphenoid sinusitis. The patient underwent endoscopic sinus surgery and subsequent pituitary tumor removal by transsphenoidal approach. During preoperative evaluation, a mass was found protruding in her left bronchus. The pituitary tumor pathologic examination revealed metastatic adenocarcinoma of the lung. In this patient, the initial symptoms of lung cancer were headache and cavernous sinus syndrome, which had metastasized to the pituitary gland.

A Case of Posterior Inferior Cerebellar Artery Infarction Presenting with Sudden Hearing Loss and Vertigo / 대한평형의학회지

Sudden hearing loss and vertigo are the typical presentation of anterior inferior cerebellar artery infarction, but may rarely occur in posterior inferior cerebellar artery (PICA) infarction. Here we describe a 65-year-old man who presented with sudden hearing loss in his left ear and severe vertigo. The diffusion-weighted magnetic resonance imaging revealed acute infarction in the territory of PICA and cerebral angiography showed non-visualization of left vertebral artery. Sudden hearing loss and vertigo may be a presentation of PICA infarction.

Change of Radiologic Indicators during Putting Foot Orthosis on Flatfoot in Children with Cerebral Palsy

OBJECTIVE: To identify change of the radiologic indicators known to reflect height of medial longitudinal arch between with and without foot orthosis on flatfoot in children with cerebral palsy. METHOD: 15 children with cerebral palsy, which were diagnosed as pes planus by bio-mechanical examination and foot print test, were participated in this study. Initial radiologic study (foot anteroposterior and lateral view with standing position) had been done with shoe only and then second radiologic study with shoe and foot orthosis as same method. 3 months after, third radiologic study were performed with shoe only. Radiologic indicators were measured at each radiologic studies. Radiologic indicators measured at intial study were compared with both second and third study. RESULTS: In comparing initial radiologic study with second, consistently changed radiologic indicators toward corrective direction were calcaneometatarsal angle, navicular height, arch height ratio, arch height angle, talometatarsal angle in anteroposterior view. The other five indicators were variable in increase or decrease of change. There were no interval changes of radiologic indicators comparing at initial study with third study. CONCLUSION: Calcaneometatarsal angle, arch height ratio, arch height angle, and talometatarsal angle were consistently changed, simply measurable radiologic indicators for evaluation of pes planus in children with cerebral palsy.

Effect of Radiofrequency Lesioning on Peripheral Nerve Conductivity in Relation to Distance between Lesioning Electrode and Target Tissue in Rats

OBJECTIVE: To investigate neurophysiologic changes of peripheral nerves, which were injured by radiofrequency thermocoagulation and evaluate an effective distance between the lesioning electrode and target nerve tissue. METHOD: Thirty Sprague-Dawley rats were used and divided into three groups by the distance between the lesioning electrode and the sciatic nerve: 2 mm, 4 mm, 6 mm for each group (10 rats for each group). Radiofrequency lesioning was performed with 1.5 Volt, 1 MHz-frequency and 1 ms duration current for 90 sec. On the first and the fifth day after radiofrequency lesioning, latencies and amplitudes of compound muscle action potential were compared with the baseline values. RESULTS: No statistically significant latency change was observed on the first and the fifth day after lesioning. The amplitude was significantly reduced in group I and II on the first and the fifth day after lesioning, in contrast that, there was no significant change in the group III. CONCLUSION: There was significant decrement in the amplitude after effective radiofrequency lesioning to the sciatic nerve with the distance of 4 mm or less. However, changes of the latencies was not significant. It was suggested that effective distance between raidiofrequency lesioning electrode and target peripheral nerve was 4 mm or less.

A Familial Case of Choreoacanthocytosis

We have experienced a family case of 3 sisters in whom the proband showed a complete form of the choreo-acanthosytosis. 439-year-old female proband was admitted because of frequent seizures. She was alert, well-oriented, and had no gross memory defects. She had slurred speech, choreic movements of chin. Deep tendon reflexes on the both lower extremities were decreased. Laboratory examination showed acanthocytes in her peripheral red blood cells, normal serum lipid values, increased creatine-phosphokinase levels and bilateral caudate atrophy on her brain CT scan. Electrophysiological data were consistent with lower motor neuron dysfunction. Another 33-year-old sister with frequent seizures and psychic problems also showed acanthocytosis. The other 36-year-old sister has been treated under the diagnosis of schizophrenia for 10 years, not showing acanthocytosis.

The Mechanism on the Glutamate-evoked Release of 3H) norepinephrine in Rat Cortex Slices

Glutamate Is the predominant excitatory neurotransmitter in the mammalian CNS. To elucidate the influence of glutamate on the noradrenergic neurotransmission in rat cortex, we examined the effects of agents that act in several steps of neurotransmission on [3H]norepinephrine ([3H])NE) release evoked by glutamate. Glutamate (1 mM) evoked significant release of [3H]NE from rat cortex slices in the absence of Mg2+in the incubation media. This effect was attenuated by cromakalime (10 nM) and lemakalime (10 nM), and the inhibitory effect of cromakalime was abolished by glipizide. Inhibitory effect of muscimol (30 uM) and baclofen (3 uM, 30 uM) was antagonized by biccuculine (3 uM), respectively. Nipecotic acid(10 uM), DABA(300 uM), and beta-alanine(100 uM) attenuated the glutamate-induced release of [3H]NE. Dihydrokinate (300 uM) PDC (100 nM) increased the glutamate-induced release of [3H]NE. Ifenprodile (10 nM) and arcaine (1 uN), blockers of polyamine site, attenuated the release of ("H)NE. The stimulatory effect of spermine was abolished by arcaine. CPA(100 nM) and CPCA(100 nM), EHNA(30 uN) and NBTI(1 uN) attenuated the release of ("H)NE. Verapamil(S uN), nitredipine(10 uN), u- conotoxin (100 nM) and flunarizine (5 uM) attenuated the release of (3H)NE. Dantrolene(30 uM), KT-362(3 uM), and ryanodine(10 nM), attenuated the glutamate-induced release of [3H]NE. Glycine (10 uM) increased the release of [3H]NE. DCQX (30 uN) attenuated the release of [3H]NE. These results suggest that glutamate-evoked release of norepinephrine can be modulated by GABAergic, adenosinergic neurotransmitters, and by various drugs which modulate ion channel activities in rat cortex.

Henoch-schonlein Purpura Involving Cerebral Hemisphere

Henoch-Schonlein Purfrura is a generalized small vessel vasculitis of hypersensitivity type characterized primarily by a purpuric skin lesion, renal involvementwith hematuria and proteinuria, arthralgia, and colicky abdominal pain. A possible neurologic involvement was recognized in 1914 by Osler. A case of a 7 1/2-year-old male patient with Henoch-Schonlein purpura developed neurologic manifestations including seizure and mental status change. The cranial CT demonstrated a occipital hemorrhage of right side and cerebral edema with contrast enhancing scattered dilated vessels. The EEGchanges were slow wave activities in acute stage. The follow-up EEG shows that the slow wave activities were more improved than previous and that multiple spike waves were recorded at bothfronto-temporo-parietal areas with phase reversals. The vasculitis of HenochSch6nlein purpura can involve the nervous system.

Ischemia-Induced Release of (3H) norepinephrine from Rat Cerebral Cortex Slices

OBJECTIVE & BACKGROUND: It has been shown that cerebral ischemia alters brain monoamine metabolism. In an attempt to elucidate the. Mechanism for ischen-iiainduced release of neurotransmitters in vitro, we examined the ischemia-induced release of (3H) norepinephrine (NE) from cerebral cortex of the rat. RESULTS: Ischemia, deprivation of oxygen and glucose, induced significant (about 12% of total tissue content) release of (3H)NE from cerebral cortex in vitro. This ischemia-induced release of (3H)NE from cerebral cortex was significantly attenuated by 1 mM TTX (tetrodotoxin), 1. 2 mM Mg2+, 10 mM MK-801, 10 mM ketamine, NMDA receptor antagonist, 30 mM DNQX, a kainate/AMPA receptor antagonist, or a 30 mM carbetapentane, an inhibitor of glutarnate release Dantrolene(30 mM) and ryanodine (100 nM), inhibitors of intraceuular Ca2+ release, flunarizine(5 mM) and w-conotoxin (100 nM), inhibitors of N-type Ca2+ channels, significantly attenuated the ischeniiainduced release of (3H)NF, but verapamil (5mM), an inhibitor of L-type Ca2+ channels, did not. Nisoxetine(100 nM), a relative NE transporter blocker, significantly inhibited the ischemia-induced release of (3H) NE. Removal of Ca2+ from the incubation media potently increased ischemia-induced (3H)NE release. CONCLUSION: These results suggest that ischemia-evoked release of norepienphrine was caused by release of glutamate via activation of NMDA and non-NMDA receptors, and that Ca2+-dependent and -independent release processes are underlying in this phenomenon.