Navigation guided small craniectomy and direct cannulation of pure isolated sigmoid sinus for treatment of dural arteriovenous fistula

Dural arteriovenous fistula (DAVF) is a rare condition affecting approximately 1.5% of 1,000,000 individuals annually. It frequently occurs in the transsigmoid and cavernous sinuses. An isolated sigmoid sinus is extremely rare and is treated by performing transfemoral transvenous embolization along the opposite transverse sinus.A 69-year-old woman presented with asymptomatic Borden type III/Cognard type III DAVF involving an isolated sigmoid sinus. She underwent a staged operation in which a navigation system was used to expose the sigmoid sinus in the operating room before transferring the patient to the angio suite for transvenous embolization.Various modalities have been used to treat DAVF, including surgical disconnection, transarterial embolization, transvenous embolization, and stereotactic radiosurgery. However, treating DAVF cases where the affected sinus is isolated can be challenging because an easily accessible surgical route may not be available. In this case, direct sinus cannulation and transvenous embolization were the most effective treatments.

Long-term outcomes of carotid artery stenting in patients with carotid artery stenosis: A single-center 14-year retrospective analysis

Objective@#Carotid artery stenting (CAS) is currently widely used for the treatment of carotid artery stenosis. The objective of this study was to analyze the outcomes of CAS performed in a single institution. @*Methods@#We retrospectively analyzed 313 CAS cases from January 2007 to December 2020, including 206 (66%) symptomatic and 107 (34%) asymptomatic cases. Procedure-related morbidity and mortality were assessed. Rates of periprocedural (≤30 days after CAS) and postprocedural ipsilateral strokes (>30 days after CAS) were also assessed. Logistic regression analysis was used to identify risk factors for the periprocedural complication, in-stent restenosis (ISR), and ipsilateral stroke. @*Results@#The success rate of CAS was 98%. Among 313 cases, 1 patient died due to hyperperfusion-related intracerebral hemorrhage (ICH). The CAS-related mortality rate was 0.31%. The overall incidence of periprocedural complications is 5.1%. A risk factor for periprocedural complication was a symptomatic carotid artery stenosis (7.3% vs. 0.9%, p=0.016). Twenty cases of ISR occurred during 63.7±42.1 months of follow-up. The overall incidence of ISR was 10.2% (20/196). A risk factors for ISR were diabetes mellitus (17.6% vs. 5.7%, p=0.008) and patients who used Open-cell stents (19.6% vs. 6.9%, p=0.010). The overall incidence of ipsilateral stroke is 5.6%. A risk factors for ipsilateral stroke was ISR (95% CI, p=0.002). @*Conclusions@#CAS is a safe and effective procedure for carotid artery stenosis. Although the incidence of complications is low, fatal complication such as hyperperfusion- related ICH can occur. To prevent hyperperfusion-related ICH, several methods such as strict blood pressure (BP) control, intentional less widening of stenotic segment should be used. To prevent ISR or stroke occurrence, special attention should be paid to patients who have ISR or ipsilateral stroke risk factors.

Multiple Cerebral Hemorrhages Caused by Paradoxical Reperfusion Injury After Cranioplasty / 대한신경손상학회지

Cranioplasty-related reperfusion injury has rarely been reported. Although there are several hypotheses, particularly regarding the mechanisms of the event, clear evidence is lacking. Here, we report the case of an 84-year-old man with traumatic intracranial hemorrhage and subdural hematoma who underwent decompressive craniectomy and hematoma evacuation in the right hemisphere. After 45 days, cranioplasty was performed using titanium. A preoperative perfusion study with 99m-Tc-HMPAO brain single-photon emission tomography revealed diffuse hypoperfusion in the left cerebral hemisphere with decreased vascular reserve. After cranioplasty, multiple cerebral hemorrhages were observed on immediate postoperative computed tomography. Cerebral hemorrhage eventually improved without surgery. Here, we report a case with findings revealed through perfusion studies before and after surgery.

Short and Long-term Outcomes of Subarachnoid Hemorrhage Treatment according to Hospital Volume in Korea: a Nationwide Multicenter Registry

Background@#Subarachnoid hemorrhage is a potentially devastating cerebrovascular attack with a high proportion of poor outcomes and mortality. Recent studies have reported decreased mortality with the improvement in devices and techniques for treating ruptured aneurysms and neurocritical care. This study investigated the relationship between hospital volume and shortand long-term mortality in patients treated with subarachnoid hemorrhage. @*Methods@#We selected subarachnoid hemorrhage patients treated with clipping and coiling from March–May 2013 to June–August 2014 using data from Acute Stroke Registry, and the selected subarachnoid hemorrhage (SAH) patients were tracked in connection with data of Health Insurance Review and Assessment Service to evaluate the short-term and long-term mortality. @*Results@#A total of 625 subarachnoid hemorrhage patients were admitted to high-volume hospitals (n = 355, 57%) and low-volume hospitals (n = 270, 43%) for six months. The mortality of SAH patients treated with clipping and coiling was 12.3%, 20.2%, 21.4%, and 24.3% at 14 days, three months, one year, and five years, respectively. The short-term and long-term mortality in high-volume hospitals was significantly lower than that in low-volume hospitals. On Cox regression analysis of death in patients with severe clinical status, lowvolume hospitals had significantly higher mortality than high-volume hospitals during shortterm follow-up. On Cox regression analysis in the mild clinical status group, there was no statistical difference between high-volume hospitals and low-volume hospitals. @*Conclusion@#In subarachnoid hemorrhage patients treated with clipping and coiling, lowvolume hospitals had higher short-term mortality than high-volume hospitals. These results from a nationwide database imply that acute SAH should be treated by a skilled neurosurgeon with adequate facilities in a high-volume hospital.

Short and Long-term Outcomes of Subarachnoid Hemorrhage Treatment according to Hospital Volume in Korea: a Nationwide Multicenter Registry

Background@#Subarachnoid hemorrhage is a potentially devastating cerebrovascular attack with a high proportion of poor outcomes and mortality. Recent studies have reported decreased mortality with the improvement in devices and techniques for treating ruptured aneurysms and neurocritical care. This study investigated the relationship between hospital volume and shortand long-term mortality in patients treated with subarachnoid hemorrhage. @*Methods@#We selected subarachnoid hemorrhage patients treated with clipping and coiling from March–May 2013 to June–August 2014 using data from Acute Stroke Registry, and the selected subarachnoid hemorrhage (SAH) patients were tracked in connection with data of Health Insurance Review and Assessment Service to evaluate the short-term and long-term mortality. @*Results@#A total of 625 subarachnoid hemorrhage patients were admitted to high-volume hospitals (n = 355, 57%) and low-volume hospitals (n = 270, 43%) for six months. The mortality of SAH patients treated with clipping and coiling was 12.3%, 20.2%, 21.4%, and 24.3% at 14 days, three months, one year, and five years, respectively. The short-term and long-term mortality in high-volume hospitals was significantly lower than that in low-volume hospitals. On Cox regression analysis of death in patients with severe clinical status, lowvolume hospitals had significantly higher mortality than high-volume hospitals during shortterm follow-up. On Cox regression analysis in the mild clinical status group, there was no statistical difference between high-volume hospitals and low-volume hospitals. @*Conclusion@#In subarachnoid hemorrhage patients treated with clipping and coiling, lowvolume hospitals had higher short-term mortality than high-volume hospitals. These results from a nationwide database imply that acute SAH should be treated by a skilled neurosurgeon with adequate facilities in a high-volume hospital.

Staged hybrid treatment for giant thrombosed fusiform aneurysm

Partially thrombosed intracranial aneurysm was difficult to treat because of higher recurrence rate compared to non-thrombosed saccular aneurysm. The author reports a case of partially thrombosed intracranial aneurysm causing transient ischemic symptom. A 40-year-old man presented with transient right hemiparesis. Brain magnetic resonance imaging (MRI) depicted low-signal intensity target-like mass lesion on left sylvian fissure, and magnetic resonance angiography (MRA) showed aneurysm on left middle cerebral artery bifurcation (MCBF), suggested thrombosed aneurysm. On operative finding, aneurysm wall had thick and atherosclerotic change, and it was fusiform aneurysm not saccular type. We initially planned direct clip for the aneurysm, but it was failed due to collapse of parent artery after clipping on aneurysm neck. To prevent ischemia, extracranial-intracranial bypass was performed and then thrombectomy with clip reconstruction. To remodeling the fusiform aneurysm, stent-assisted coiling was performed for remnant portion of aneurysm. With staged hybrid technique, giant thrombosed fusiform aneurysm was completely obliterated and the patient did not suffer any neurologic symptoms no longer.

The Efficacy of P2Y12 Reactive Unit to Predict the Periprocedural Thromboembolic and Hemorrhagic Complications According to Clopidogrel Responsiveness and Safety of Modification of Dual Antiplatelet Therapy : A Meta-Analysis

The efficacy of P2Y12 reaction unit (PRU) of VerifyNow still remains as a controversial issue in neurointervention. So we investigated the usefulness of PRU of VerifyNow to predict the peri-procedural thromboembolic events (TE) and hemorrhagic events (HE). And we evaluated the safety of modified dual antiplatelet therapy (DAPT) or triple antiplatelet therapy (TAPT) for clopidogrel hyporesponders. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus on August 19 2018. Data was collected the 1) incidence of TE between clopidogrel responder and clopidogrel hypo-responder, 2) incidence of HE between clopidogrel hyper-responder and clopidogrel responder and hypo-responder, and 3) incidence of TE and HE between modified DAPT or TAPT and standard DAPT in clopidogrel hypo-responder. High cut-off value of PRU was defined as PRU >40% or 0.05). The incidence of periprocedural HE after changing regimen of DAPT for clopidogrel hypo-responder was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). PRU is a useful tool as a predictor of peri-procedural TE or HE on neurointervention. PRU has a threshold effect of cut-off value to predict the peri-procedural TE. Modified DAPT or TAPT to prevent TE in clopidogrel hypo-responders could not reduce the incidence of TE. We should investigate the further research about modification of regiment on neurointervention.

Long-term Prognosis of Patients Who Contraindicated for Intravenous Thrombolysis in Acute Ischemic Stroke

BACKGROUND: As intravenous thrombolysis (IVT) has very restricted inclusion criteria, eligible patients of IVT constitute a very small proportion and studies about their mortality are rare. The long-term mortality in a patients with contraindication of ineligible patients of IVT still under the debate. So, we investigated the proportion of patients with contraindication of IVT and the short and long-term mortality of them in AIS on emergency department comparing with the long-term effect of IVT in patients with moderate-to-severe stroke.METHODS: Using acute stroke assessment indication registry & Health Insurance Review and Assessment Service database, a total of 5,407 patients with NIHSS≥5 were selected from a total of 169 acute stroke care hospital nationwide during October-December 2011 and March-June 2013. We divided AIS patients into two groups: 1) IVT group who received IVT within 4.5 hours, and 2) non-IVT group who did not receive the IVT because of contraindications. And we divided the subgroups according to the reason of contraindication of IVT. The 5-year survival rate of each group was assessed using Kaplan-Meyer survival analysis.RESULTS: Of the 5,407 patients, a total of 1,027 (19%) patients who received IVT using r-tPA within 4.5 h after onset. Compared with the IVT group, hazard ratios of non-IVT group were 1.33 at 3 months, 1.53 at 1 year and 1.47 at 5 years (p<.001). A total of 4,380 patients did not receive IVT because of the following contraindications to IVT. 1) Time restriction: 3,378 (77.1 %) patients were admitted after 4.5 h following stroke onset, and 144 (3.3%) patients failed to determine the stroke onset time. 2) Mild symptoms:137 (3.1%) patients had rapid improvement or mild stroke on emergency room, 3) Bleeding diathesis or non-adjustable hypertension: 53 (1.2%) patients showed a bleeding tendency or severe hypertension. Compared with the IVT group, the subgroups of non-IVT group showed consistently high mortality during short and long term follow up. Mild symptom and bleeding diathesis or non-adjustable hypertension subgroup in the non-IVT group consistently showed the higher mortality than time restriction subgroup during the short and long-term follow-up (log-rank p<.001). Patients who had rapid improvement or mild stroke on emergency department had the higher mortality than time restriction group in short and long term follow up.CONCLUSION: The AIS patients with rapid improvement or mild stroke on emergency room had higher mortality than ineligible patients of IVT due to time restriction during the short and long-term follow-up. A further management and special support on emergency department is needed for these patients with initially mild stroke and rapid improvement in AIS to reduce the poor outcome.

Authors' Reply to Letter to the Editor: Influence of Gender on Occurrence of Chronic Subdural Hematoma; Is It an Effect of Cranial Asymmetry? (Korean J Neurotrauma 2014;10:82–85) / 대한신경손상학회지

No abstract available.

Cerebral Aneurysms in Judicial Precedents

OBJECTIVE: From November 30, 2016, the Korean Government carried the revised Medical Dispute Mediation and Arbitration Act into effect. Mediation will start automatically without agreements of the defendant, when the outcome of the patient was death, coma more than a month or severe disability. Cerebral aneurysm has a definite risk of bad outcome, especially in the worst condition. Any surgical intervention to this lesion has its own high risk of complications. Recently, Seoul central district court decided 50% responsibility of the doctors who made a rupture of the aneurysm during coiling (2015Ga-Dan5243104). We reviewed judicial precedents related to cerebral aneurysms in lawsuit using a web search.METHODS: We searched judicial precedents at a web search of the Supreme Court, using the key words, "cerebral aneurysm".RESULTS: There were 15 precedents, six from the Supreme Court, seven from the High Court, and two from district courts. Seven precedents were related to the causation analysis, such as work-relationship. Five precedents were malpractice suits related bad results or complications. Remaining three precedents were related to the insurance payment. In five malpractice precedents, two precedents of the Supreme Court reversed former two precedents of the High Court.CONCLUSION: Judicial precedents on the cerebral aneurysm included not only malpractice suits, but also causation analysis or insurance payment. Attention to these subjects is needed. We also need education of the independent medical examination. To avoid medical disputes, shared decision making seems to be useful, especially in cases of high risk condition or procedures.

Causes and Trauma Apportionment Score of Chronic Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: The pathophysiology of chronic subdural hematoma (CSH) is not yet clear. Trauma alone is not sufficient to result in CSH in young individuals, while a trivial injury can result in CSH in older adults. Although the causality and apportionment of trauma are important issues in CSH, especially in terms of insurance, it is too obscure to solve all struggles. METHODS: There are three key factors for producing CSH. First, CSH necessitates a potential subdural reservoir. Other important precipitating factors are trauma and coagulopathy. However, these factors are not sufficient to cause CSH development. The trauma apportionment score (TAS) can be used to compare the relative importance of these three factors. Here, we applied the TAS to 239 consecutive cases of CSH. We retrospectively obtained the patients' history and laboratory results from their medical records. RESULTS: The TAS ranged from −5 to 5. The most common score was 0. If we defined the cause of CSH as being combined when the TAS was 0, then the cause was combined in 30 cases (12.6%). If we extended the criteria for a combined cause from 0 to −1 to 1, the cause was combined in 107 cases (44.8%). Regardless of the criteria used, traumatic CSHs were more common than were spontaneous CSHs. Spontaneous CSHs were more common in older than in younger patients (p < 0.01, Fisher's exact test). CONCLUSION: The TAS is a useful tool for differentiating the causality of CSH.

Gliosarcoma of Cerebello-Pontine Angle: A Case Report and Review of the Literature

Gliosarcoma (GS), known as variant of glioblastoma multiforme, is aggressive and very rare primary central nervous system malignant neoplasm. They are usually located in the supratentorial area with possible direct dural invasion or only reactive dural thickening. However, in this case, GS was located in lateral side of left posterior cranial fossa. A 78-year-old man was admitted to our hospital with 3 month history of continuous dizziness and gait disturbance without past medical history. A gadolinium-enhanced MRI demonstrated 5.6×4.8×3.2 cm sized mass lesion in left posterior cranial fossa, heterogeneously enhanced. The patient underwent left retrosigmoid craniotomy with navigation system. The tumor was combined with 2 components, whitish firm mass and gray colored soft & suckable mass. On pathologic report, the final diagnosis was GS of WHO grade IV. In spite of successful gross total resection of tumor, we were no longer able to treat because of the patient's rejection of adjuvant treatment. The patient survived for nine months without receiving any special treatment from the hospital.

Delayed Monocular Blindness after Coil Embolization of Large Paraclinoid Aneurysm

Treatment of paraclinoid aneurysms weather by surgery, or endovascular embolization has a risk of visual loss due to optic neuropathy, or diplopia due to cranial nerve palsies. Visual complications occur immediately after the clipping, whereas they can occur variable time after endovascular coiling. Recently, endovascular coiling for paraclinoid aneurysm is regarded as a safe and feasible treatment. But it still has risks of acute thromboembolic complication, or cranial nerve palsies. A 45-year-old woman was referred from local hospital to our hospital due to ruptured large ICA dorsal wall aneurysm. A total of 12 coils (195 cm) were used for obliteration of aneurysm. Postoperative diffusion weighted image showed no abnormal signal intensity lesion and magnetic resonance angiography demonstrated no sign of vasospasm, or vessel narrowing. But, she complained visual problem 23 days after coil embolization. Ophthalmologist confirmed the left optic disc atrophy on fundoscopy. Although steroid was started, but monocular blindness did not recover completely. The endovascular embolization of paraclinoid aneurysm, especially projecting superiorly with large irregular shape, has the risk of progressive visual loss because of the proximity to optic nerve.

Cerebral Aneurysms in Judicial Precedents

OBJECTIVE: From November 30, 2016, the Korean Government carried the revised Medical Dispute Mediation and Arbitration Act into effect. Mediation will start automatically without agreements of the defendant, when the outcome of the patient was death, coma more than a month or severe disability. Cerebral aneurysm has a definite risk of bad outcome, especially in the worst condition. Any surgical intervention to this lesion has its own high risk of complications. Recently, Seoul central district court decided 50% responsibility of the doctors who made a rupture of the aneurysm during coiling (2015Ga-Dan5243104). We reviewed judicial precedents related to cerebral aneurysms in lawsuit using a web search. METHODS: We searched judicial precedents at a web search of the Supreme Court, using the key words, "cerebral aneurysm". RESULTS: There were 15 precedents, six from the Supreme Court, seven from the High Court, and two from district courts. Seven precedents were related to the causation analysis, such as work-relationship. Five precedents were malpractice suits related bad results or complications. Remaining three precedents were related to the insurance payment. In five malpractice precedents, two precedents of the Supreme Court reversed former two precedents of the High Court. CONCLUSION: Judicial precedents on the cerebral aneurysm included not only malpractice suits, but also causation analysis or insurance payment. Attention to these subjects is needed. We also need education of the independent medical examination. To avoid medical disputes, shared decision making seems to be useful, especially in cases of high risk condition or procedures.

Procedure-related Complications during Endovascular Treatment of Intracranial Saccular Aneurysms

OBJECTIVE: We evaluate the rates and outcomes of major procedure-related complications during coiling. MATERIALS AND METHODS: Between 2007 and 2015, 436 intracranial saccular aneurysms were treated. Complications are categorized as three types: intraprocedural aneurysm rupture (IAR), thromboembolism (TE), and post-procedural early rebleeding (PER). And we evaluated the risk factors of procedure related complications by multivariate analysis. RESULTS: Complications occurred in 61 aneurysms (14%). The overall incidence of complications in subarachnoid hemorrhage (SAH) was significantly higher than in unruptured intracranial aneurysm (UIA) (20% vs. 6%). The incidence of IAR and TE were higher in SAH than in UIA (IAR 12% vs. 4%, TE 7% vs. 3%, p 0.05). All 7 patients who had IAR during BAC had good recovery. In multiple logistic regression analysis, female gender, SAH, and intraventricular hemorrhage were associated with procedure related complication (p < 0.05). CONCLUSION: Endovascular coil embolization is a minimally invasive procedure, but incidence of its complication is not low, especially in SAH. BAC can be a good tool to avoid poor outcome from unexpected IAR during coiling. While IA tirofiban injection is a useful therapy in TE during coiling, sometimes we are aware of the risk of the early rebleeding in SAH patients.

Clinical Features of Interhemispheric Subdural Hematomas / 대한신경손상학회지

OBJECTIVE: Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively. METHODS: From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes. RESULTS: The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment. CONCLUSION: IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.

Efficacy of Balloon-Guiding Catheter for Mechanical Thrombectomy in Patients with Anterior Circulation Ischemic Stroke

OBJECTIVE: To evaluate the efficacy of balloon guiding catheter (BGC) during thrombectomy in anterior circulation ischemic stroke. METHODS: Sixty-two patients with acute anterior circulation ischemic stroke were treated with thrombectomy using a Solitaire stent from 2011 to 2016. Patients were divided into the BGC group (n=24, 39%) and the non-BGC group (n=38, 61%). The number of retrievals, procedure time, thrombolysis in cerebral infarction (TICI) grade, presence of distal emboli, and clinical outcomes at 3 months were evaluated. RESULTS: Successful recanalization was more frequent in BGC than in non-BGC (83% vs. 66%, p=0.13). Distal emboli occurred less in BGC than in non-BGC (23.1% vs. 57.1%, p=0.02). Good clinical outcome was more frequent in BGC than in non-BGC (50% vs. 16%, p=0.03). The multivariate analysis showed that use of BGC was the only independent predictor of good clinical outcome (odds ratio, 5.19: 95% confidence interval, 1.07–25.11). More patients in BGC were successfully recanalized in internal carotid artery (ICA) occlusion with small retrieval numbers (<3) than those in non-BGC (70% vs. 24%, p=0.005). In successfully recanalized ICA occlusion, distal emboli did not occur in BGC, whereas nine patients had distal emboli in non-BGC (0% vs. 75%, p=0.001) and good clinical outcome was superior in BGC than in non-BGC (55.6% vs. 8.3%, p=0.01). CONCLUSION: A BGC significantly reduces the number of retrievals and the occurrence of distal emboli, thereby resulting in better clinical outcomes in patients with anterior circulation ischemic stroke, particularly with ICA occlusion.

Device for Catheter Placement of External Ventricular Drain

To introduce a new device for catheter placement of an external ventricular drain (EVD) of cerebrospinal fluid (CSF). This device was composed of three portions, T-shaped main body, rectangular pillar having a central hole to insert a catheter and an arm pointing the tragus. The main body has a role to direct a ventricular catheter toward the right or left inner canthus and has a shallow longitudinal opening to connect the rectangular pillar. The arm pointing the tragus is controlled by back and forth movement and turn of the pillar attached to the main body. Between April 2012 and December 2014, 57 emergency EVDs were performed in 52 patients using this device in the operating room. Catheter tip located in the frontal horn in 52 (91.2%), 3rd ventricle in 2 (3.5%) and in the wall of the frontal horn of the lateral ventricle in 3 EVDs (5.2%). Small hemorrhage along to catheter tract occurred in 1 EVD. CSF was well drained through the all EVD catheters. The accuracy of the catheter position and direction using this device were 91% and 100%, respectively. This device for EVD guides to provide an accurate position of catheter tip safely and easily.

Severe Cerebral Vasospasm in Patients with Hyperthyroidism

Cerebral vasospasm associated with hyperthyroidism has not been reported to cause cerebral infarction. The case reported here is therefore the first of cerebral infarction co-existing with severe vasospasm and hyperthyroidism. A 30-year-old woman was transferred to our hospital in a stuporous state with right hemiparesis. At first, she complained of headache and dizziness. However, she had no neurological deficits or radiological abnormalities. She was diagnosed with hyperthyroidism 2 months ago, but she had discontinued the antithyroid medication herself three days ago. Magnetic resonance imaging and angiography showed cerebral infarction with severe vasospasm. Thus, chemical angioplasty using verapamil was performed two times, and antithyroid medication was administered. Follow-up angiography performed at 6 weeks demonstrated complete recovery of the vasospasm. At the 2-year clinical follow-up, she was alert with mild weakness and cortical blindness. Hyperthyroidism may influence cerebral vascular hemodynamics. Therefore, a sudden increase in the thyroid hormone levels in the clinical setting should be avoided to prevent cerebrovascular accidents. When neurological deterioration is noticed without primary cerebral parenchyma lesions, evaluation of thyroid function may be required before the symptoms occur.

The Effectiveness of Gelfoam Technique before Percutaneous Vertebroplasy: Is It Helpful for Prevention of Cement Leakage? A Prospective Randomized Control Study

OBJECTIVE: Preinjection gelfoam embolization during percutaneous vertebroplasty (PVP) has been thought alternative technique to prevent the leakage of bone cement. The goal of this study was to evaluate whether the gelfoam techniques are useful to reduce bone cement leakage. METHODS: Total 100 PVPs of osteoporotic spine compression fractures were performed by 1 spine surgeon who experienced more than 500 PVP cases under prospective control study. Operation was done in T-L junction (T10-L2) fractures with bi-transpedicular approach. Preinjection gelfoam PVP was done in the 50 levels. As control group, PVP without gelfoam was done in the 50 levels. We did not perform preoperative venography. We inserted normal saline-mixed gelfoam to the anterior third of vertebral body via PVP needle, and then 3mL of polymethylmetacrylate (PMMA) was injected. We prospectively evaluated the incidence and leakage pattern of PMMA by postoperative computed tomography. RESULTS: Between gelfoam and control groups, there were 11 leaks (22%) versus 12 leaks (26%). The mean operation time was 7.00 minutes versus 6.30 minutes. In gelfoam group, there were 6 spinal canal leaks, 4 paravertebral venous leaks, and 1 soft tissue leaks. In control group, there were 4 spinal canal leaks, 8 paravertebral venous leaks, and 1 disc space leak. In spite of cement leakage, there was no symptomatic case in both groups. Statistically, gelfoam technique was not related to decrease the incidence of leakage (p=0.64). CONCLUSION: Our prospective study showed that it did not significantly decrease cement leakage when vertebroplasty is performed by experienced spine surgeon.