Posterior Cervical Fixation with Nitinol Shape Memory Loop in the Anterior-Posterior Combined Approach for the Patients with Three Column Injury of the Cervical Spine : Preliminary Report

Objective

The authors reviewed clinical and radiological outcomes in patients with three column injury of the cervical spine who had undergone posterior cervical fixation using Nitinol shape memory alloy loop in the anterior-posterior combined approach.

Materials

Nine patients were surgically treated with anterior cervical fusion using an iliac bone graft and dynamic plate-screw system, and the posterior cervical fixation using Nitinol shape memory loop (Davydov™) at the same time. A retrospective review was performed. Clinical outcomes were assessed using the Frankel grading method. We reviewed the radiological parameters such as bony fusion rate, height of iliac bone graft strut, graft subsidence, cervical lordotic angle, and instrument related complication.

Results

Single-level fusion was performed in five patients, and two-level fusion in four. Solid bone fusion was presented in all cases after surgery. The mean height of graft strut was significantly decreased from 20.46±9.97 mm at immediate postoperative state to 18.87±8.60 mm at the final follow-up period (p<0.05). The mean cervical lordotic angle decreased from 13.83±11.84° to 11.37±6.03° at the immediate postoperative state but then, increased to 24.39±9.83° at the final follow-up period (p<0.05). There were no instrument related complications.

Conclusion

We suggest that the posterior cervical fixation using Nitinol shape memory alloy loop may be a simple and useful method, and be one of treatment options in anterior-posterior combined approach for the patients with the three column injury of the cervical spine.     

Analysis of Complications Following Decompressive Craniectomy for Traumatic Brain Injury

Objective

Adequate management of increased intracranial pressure (ICP) is critical in patients with traumatic brain injury (TBI), and decompressive craniectomy is widely used to treat refractory increased ICP. The authors reviewed and analyzed complications following decompressive craniectomy for the management of TBI.

Methods

A total of 89 consecutive patients who underwent decompressive craniectomy for TBI between February 2004 and February 2009 were reviewed retrospectively. Incidence rates of complications secondary to decompressive craniectomy were determined, and analyses were performed to identify clinical factors associated with the development of complications and the poor outcome.

Results

Complications secondary to decompressive craniectomy occurred in 48 of the 89 (53.9%) patients. Furthermore, these complications occurred in a sequential fashion at specific times after surgical intervention; cerebral contusion expansion (2.2 ± 1.2 days), newly appearing subdural or epidural hematoma contralateral to the craniectomy defect (1.5 ± 0.9 days), epilepsy (2.7 ± 1.5 days), cerebrospinal fluid leakage through the scalp incision (7.0 ± 4.2 days), and external cerebral herniation (5.5 ± 3.3 days). Subdural effusion (10.8 ± 5.2 days) and postoperative infection (9.8 ± 3.1 days) developed between one and four weeks postoperatively. Trephined and post-traumatic hydrocephalus syndromes developed after one month postoperatively (at 79.5 ± 23.6 and 49.2 ± 14.1 days, respectively).

Conclusion

A poor GCS score (≤ 8) and an age of ≥ 65 were found to be related to the occurrence of one of the above-mentioned complications. These results should help neurosurgeons anticipate these complications, to adopt management strategies that reduce the risks of complications, and to improve clinical outcomes.     

Simple Decompression of the Ulnar Nerve for Cubital Tunnel Syndrome

Objective

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients.

Methods

According to Dellon''s criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less).

Results

Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbow-below the elbow) was 41.8±15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8±6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8±12.1 m/s to 47.8±12.1 m/s (p<0.05). After an average follow-up of 4.8±5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve.

Conclusion

Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.     

Chronic Subdural Hematoma Treated by Small or Large Craniotomy with Membranectomy as the Initial Treatment

Objective

There are few studies comparing small and large craniotomies for the initial treatment of chronic subdural hematoma (CSDH) which had non-liquefied hematoma, multilayer intrahematomal loculations, or organization/calcification on computed tomography and magnetic resonance imaging. These procedures were compared to determine which would produce superior postoperative results.

Methods

Between 2001 and 2009, 317 consecutive patients were surgically treated for CSDH at our institution. Of these, 16 patients underwent a small craniotomy with partial membranectomy and 42 patients underwent a large craniotomy with extended membranectomy as the initial treatment. A retrospective review was performed to compare the postoperative outcomes of these two techniques, focusing on improvement of neurological status, complications, reoperation rate, and days of post-operative hospitalization.

Results

The mean ages were 69.4±12.1 and 55.6±9.3 years in the small and large craniotomy groups, respectively. The recurrence of hematomas requiring reoperation occurred in 50% and 10% of the small and large craniotomy patients, respectively (p<0.001). There were no significant differences in postoperative neurological status, complications, or days of hospital stay between these two groups.

Conclusion

Among the cases of CSDH initially requiring craniotomy, the large craniotomy with extended membranectomy technique reduced the reoperation rate, compared to that of the small craniotomy with partial membranectomy technique.     

Anterior Interbody Grafting and Instrumentation for Advanced Spondylodiscitis

Objective

To evaluate the surgical outcomes of ventral interbody grafting and anterior or posterior spinal instrumentation for the treatment of advanced spondylodiscitis in patients who had failed medical management.

Methods

A total of 28 patients were evaluated for associated medical illness, detected pathogen, level of involved spine, and perioperative complications. Radiological evaluation including the rate of bony union, segmental Cobb angle, graft- and instrumentation-related complications, and clinical outcomes by mean Frankel scale and VAS score were performed.

Results

There are 14 pyogenic spondylodiscitis, 6 postoperative spondylodiscitis, and 8 tuberculous spondylodiscitis. There were 21 males and 7 females. Mean age was 51 years, with a range from 18 to 77. Mean follow-up period was 10.9 months. Associated medical illnesses were 6 diabetes, 3 pulmonary tuberculosis, and 4 chronic liver diseases. Staphylococcus was the most common pathogen isolated (25%), and Mycobacterium tuberculosis was found in 18% of the patients. Operative approaches, either anterior or posterior spinal instrumentation, were done simultaneously or delayed after anterior aggressive debridement, neural decompression, and structural interbody bone grafting. All patients with neurological deficits improved after operation, except only one who died from aggravation as military tuberculosis. Mean Frankel scale was changed from 3.78±0.78 preoperatively to 4.78±0.35 at final follow up and mean VAS score was improved from 7.43±0.54 to 2.07±1.12. Solid bone fusion was obtained in all patients except only one patient who died. There was no need for prolongation of duration of antibiotics and no evidence of secondary infection owing to spinal instrumentations.

Conclusion

According to these results, debridement and anterior column reconstruction with ventral interbody grafting and instrumentation is effective and safe in patients who had failed medical management and neurological deficits in advanced spondylodiscitis.     

Surgical Results of Selective Median Neurotomy for Wrist and Finger Spasticity

Objective

This study aimed to evaluate the surgical outcomes of selective median neurotomy (SMN) for spastic wrist and fingers.

Methods

We studied 22 patients with wrist and finger spasticity refractory to optimal oral medication and physical therapy. The authors evaluated spasticity of the wrist and finger muscles by comparing preoperative states with postoperative states using the modified Ashworth scale (MAS). We checked patients for changes in pain according to the visual analog scale (VAS) and degree of satisfaction based on the VAS.

Results

The preoperative mean MAS score was 3.27±0.46 (mean±SD), and mean MAS scores at 3, 6, and 12 months after surgery were 1.82±0.5, 1.73±0.7, and 1.77±0.81 (mean±SD), respectively. On the last follow-up visit, the mean MAS score measured 1.64±0.9 (mean±SD). Wrist and finger spasticity was significantly decreased at 3, 6, and 12 months after the operation (p<0.01). The preoperative mean pain VAS score was 5.85±1.07 (mean±SD), and the mean pain VAS score on the last follow-up visit after surgery was 2.28±1.8 (mean±SD). Compared with the preoperative mean pain VAS score, postoperative mean pain VAS score was decreased significantly (p<0.01). On the basis of a VAS ranging from 0 to 100, the mean degree of patient satisfaction was 64.09±15.93 (mean±SD, range 30-90).

Conclusion

The authors propose SMN as a possible effective procedure in achieving useful, long-lasting tone and in gaining voluntary movements in spastic wrists and fingers with low morbidity rates.     

Differences in Clinical Features and Disability according to the Frequency of Medication Use in Patients with Chronic Migraine

Background and Purpose

Chronic migraine (CM) has a significant impact on daily activities, and analgesic overuse is a major contributing factor to migraine transformation. Limited information is available on the functional consequences of CM stemming from analgesic overuse. This study evaluated the impact of the frequency of analgesic medication use on headache-related disability and clinical features in patients with CM.

Methods

Patients with CM were enrolled consecutively and classified into two groups according to their frequency of medication use: <15 days/month (CM-ML, n=52) and ≥15 days/month (CM-MH, n=68). All patients completed a structured questionnaire concerning the clinical features of their migraine, a validated version of the Migraine Disability Assessment questionnaire (MIDAS), and the Headache Impact Test-6 (HIT-6).

Results

The pain intensity, as measured by a visual analog scale, was greater in the CM-MH group than in the CM-ML group (8.5±0.2 vs. 7.7±0.3, mean±SD; p<0.05). In the disability domain, the MIDAS scores were significantly higher for CM-MH patients than for CM-ML patients (47.6±4.8 vs. 26.8±4.5, p<0.01). The impact from migraine, as measured by the HIT-6, was greater for CM-MH patients than for CM-ML patients (65.6±1.0 vs. 62.1±1.0, p<0.05).

Conclusions

Our results indicate that the headache pain intensity and disability are greater in patients with CM who use medication frequently.     

Gender Differences in the Functional Recovery after Acute Stroke

Background and Purpose

PurposezzInterest in gender differences in the effects of acute stroke is growing worldwide. However, gender differences in functional recovery after acute stroke in the Korean population have yet to be evaluated. The aim of this investigation was to compare long-term functional outcomes between male and female after acute stroke.

Methods

Patients with acute stroke were enrolled prospectively between January 2005 and January 2009. Baseline characteristics, risk factors, stroke subtypes, time delay from onset to arrival at a hospital, active treatment, and stroke severity were compared between male and female. Differences in mortality and disability at discharge, and at 3 months and 1 year after stroke onset were also investigated. Functional disabilities were categorized into two groups: good outcome (score on modified Rankin scale ≤2) and poor outcome (score on modified Rankin scale >2).

Results

Among 1,055 patients with acute stroke, 575 were male (aged 64.83±11.98 years, mean±SD) and 480 were female (aged 70.09±13.02 years). There were no gender differences in mortality at 3 months and 1 year after stroke. The frequency of poor outcomes was higher in female patients than in male patients at discharge (39.8% versus 30.9%, respectively; p=0.003), the 3 months follow-up (32.3% versus 20.8%, respectively; p<0.001), and the 1 year follow-up (31.1% versus 18.7%, respectively; p=0.001). After adjusting for multiple confounding factors including age and stroke severity, the female gender persisted as a predictor of poor functional outcome at 3 months and 1 year after stroke.

Conclusions

Female patients have greater difficulty than male patients in recovering from a disabled state after acute stroke. Future studies should investigate the causes of this gender difference.     

The Effect of Cognitive Training in Patients with Mild Cognitive Impairment and Early Alzheimer's Disease: A Preliminary Study

Background and Purpose

The objective of this study was to determine the benefits of cognitive training in patients with amnestic mild cognitive impairment (aMCI) and those with early Alzheimer''s disease (AD).

Methods

Eleven patients with aMCI and nine with early AD (stage 4 on the Global Deterioration Scale) participated in this study. Six participants with aMCI and six with AD were allocated to the cognitive training group, while five participants with aMCI and three with AD were allocated to a wait-list control group. Multicomponent cognitive training was administered in 18 weekly, individual sessions. Outcome measures were undertaken at baseline, and at 2 weeks and 3 months of follow-up.

Results

In the trained MCI group, there were significant improvements in the delayed-recall scores on the Seoul Verbal Learning Test at both the 2-week and 3-month follow-ups compared with baseline (baseline, 1.6±1.5; 2 weeks, 4.4±1.5, p=0.04; 3 months, 4.6±2.3, p=0.04). The phonemic fluency scores (1.0±0.8 vs. 5.0±1.8, p=0.07) and Korean Mini-Mental State Examination scores (18.8±0.5 vs. 23.8±2.2, p=0.07) also showed a tendency toward improvement at the 2-week follow-up compared to baseline in the trained AD group.

Conclusions

This study provides evidence of the effectiveness of cognitive training in aMCI and early AD. The efficacy of cognitive training programs remains to be verified in studies with larger samples and a randomized design.     

Ischemic complications occurring in the contralateral hemisphere after surgical treatment of adults with moyamoya disease

Objective

Direct revascularization surgery is regarded as the most effective method of treatment of adults with moyamoya disease. These patients, however, have a higher risk of perioperative ischemic complications than do patients with atherosclerotic stroke, and are at risk for ischemic complications in the hemisphere contralateral to the one operated on. We investigated the incidence and risk factors for ischemic stroke in the contralateral hemisphere after surgical treatment of adults with moyamoya disease.

Methods

We retrospectively reviewed the medical records and results of neuroimaging studies on 79 hemispheres of 73 consecutive patients with adult moyamoya disease (mean±SD age, 37.96±11.27 years; range, 18-62 years) who underwent direct bypass surgery over 6 years.

Results

Ischemic complications occurred in 4 of 79 (5.1%) contralateral hemispheres, one with Suzuki stage 3 and three with Suzuki stage 4. Three patients showed posterior cerebral artery (PCA) involvement by moyamoya vessels. Advanced stage of moyamoya disease (Suzuki stages 4/5/6; p=0.001), PCA involvement (p=0.001) and postoperative hypotension (mean arterial blood pressure <80% of preoperative mean arterial blood pressure) on the first (p<0.0001) and second (p=0.003) days after surgery were significantly correlated with postoperative contralateral ischemic complications.

Conclusion

In patients with advanced moyamoya disease and involvement of the PCA, intentional hypotension can result in ischemic stroke in the hemisphere contralateral to the one operated on. Careful control of perioperative blood pressure is crucial for good surgical results.     

Surgical Results of Unruptured Intracranial Aneurysms in the Elderly : Single Center Experience in the Past Ten Years

Objective

As medical advances have increased life expectancy, it has become imperative to develop specific treatment strategies for intracranial aneurysms in the elderly. We therefore analyzed the clinical characteristics and outcomes of the treatment of unruptured intracranial aneurysms in patients older than 70 years.

Methods

We retrospectively reviewed the medical records and results of neuroimaging modalities on 54 aneurysms of 48 consecutive patients with unruptured intracranial aneurysms. (mean±SD age, 72.11±1.96 years; range, 70-78 years) who underwent surgical clipping over 10 years (May 1999 to June 2010).

Results

Of the 54 aneurysms, 22 were located in the internal carotid artery, 19 in the middle cerebral artery, 12 in the anterior cerebral artery, and 1 in the superior cerebellar artery. Six patients had multiple aneurysms. Aneurysm size ranged from 3 mm to 17 mm (mean±SD, 6.82±3.07 mm). Fifty of the 54 aneurysms (92.6%) were completely clipped. Three-month outcomes were excellent in 50 (92.6%) aneurysms and good and poor in 2 each (3.7%), with 1 death (2.0%). Procedure-related complications occurred in 7 aneurysms (13.0%), with 2 (3.7%) resulting in permanent neurological deficits, including death. No postoperative subarachnoid hemorrhage occurred during follow-up. The cumulative rates of stroke- or death-free survival at 5 and 10 years were 100% and 78%, respectively.

Conclusion

Surgical clipping of unruptured intracranial aneurysms in elderly group could get it as a favorable outcome in well selected cases.     

Automated Pressure-Controlled Discography with Constant Injection Speed and Real-Time Pressure Measurement

Objective

This study was designed to investigate automated pressure-controlled discography (APCD) findings, to calculate the elastance of intervertebral discs, and to assess the relationship between the calculated elastance and disc degeneration.

Methods

APCD was performed in 19 patients. There were a total of 49 intervertebral discs treated. Following intradiscal puncture, a dye was constantly injected and the intradiscal pressure was continuously measured. The elastance of the intervertebral disc was defined as unit change in intradiscal pressure per fractional change in injected dye volume. Disc degeneration was graded using a modified Dallas discogram scale.

Results

The mean elastance was 43.0 ± 9.6 psi/mL in Grade 0, 39.5 ± 8.3 psi/mL in Grade 1, 30.5 ± 22.3 psi/mL in Grade 2, 30.5 ± 22.3 psi/mL in Grade 3, 13.2 ± 8.3 psi/mL in Grade 4 and 6.9 ± 3.8 psi/mL in Grade 5. The elastance showed significant negative correlation with the degree of degeneration (R² = 0.529, p = 0.000).

Conclusion

APCD liberates the examiner from the data acquisition process during discography. This will likely improve the quality of data and the reliability of discography. Elastance could be used as an indicator of disc degeneration.     

Minimum 2-Year Follow-Up Result of Degenerative Spinal Stenosis Treated with Interspinous U (Coflex?)

Objective

Clinical and radiological results of posterior dynamic stabilization using interspinous U (ISU, Coflex™, Paradigm Spine Inc.®, NY, USA) were analyzed in comparison with posterior lumbar interbody fusion (PLIF) in degenerative lumbar spinal stenosis (LSS).

Methods

A retrospective study was conducted for a consecutive series of 61 patients with degenerative LSS between May 2003 and December 2005. We included only the patients completed minimum 24 months follow up evaluation. Among them, 30 patients were treated with implantation of ISU after decompressive laminectomy (Group ISU) and 31 patients were treated with wide decompressive laminectomy and posterior lumbar interbody fusion (PLIF; Group PLIF). We evaluated visual analogue scale (VAS) and Oswestry Disability Index (ODI) for clinical outcomes (VAS, ODI), disc height ratio disc height (DH), disc height/vertebral body length ×100), static vertebral slip (VS) and depth of maximal radiolucent gap between ISU and spinous process) in preoperative, immediate postoperative and last follow up.

Results

The mean age of group ISU (66.2 ± 6.7 years) was 6.2 years older than the mean age of group PLIF (60.4 ± 8.1 years; p = 0.003 ). In both groups, clinical measures improved significantly than preoperative values (p < 0.001). Operation time and blood loss was significantly shorter and lower in group ISU than group PLIF (p < 0.001). In group ISU, the DH increased transiently in immediate postoperative period (15.7 ± 4.5% → 18.6 ± 5.9%), however decreased significantly in last follow up (13.8 ± 6.6%, p = 0.027). Vertebral slip (VS) of spondylolisthesis in group ISU increased during postoperative follow-up (2.3 ± 3.3 → 8.7 ± 6.2, p = 0.040). Meanwhile, the postoperatively improved DH and VS was maintained in group PLIF in last follow up.

Conclusion

According to our result, implantation of ISU after decompressive laminectomy in degenerative LSS is less invasive and provides similar clinical outcome in comparison with the instrumented fusion. However, the device has only transient effect on the postoperative restoration of disc height and reduction of slip in spondylolisthesis. Therefore, in the biomechanical standpoint, it is hard to expect that use of Interspinous U in decompressive laminectomy for degenerative LSS had long term beneficial effect.     

Balloon Kyphoplasty through Extrapedicular Approach in the Treatment of Middle Thoracic Osteoporotic Compression Fracture : T5-T8 Level

Objective

Kyphoplasty performed in the middle thoracic spine presents technical challenges that differ from those in the lower thoracic or lumbar region due to small pedicle size and angular severity for thoracic kyphosis. The purpose of this study was to evaluate the efficacy of balloon kyphoplasty through extrapedicular approach for the treatment of intractable osteoporotic compression fractures in the middle thoracic spine.

Methods

The patients who were performed with one level balloon kyphoplasty through extrapedicular approach due to painful osteoporotic compression fractures at T5-T8 from June 2003 to July 2005 were retrospectively analyzed. Imaging and clinical features were analyzed including involved vertebrae level, vertebral height, injected cement volume, clinical outcome and complications.

Results

Eighteen female patients (age ranged from 60 to 77 years old) were included in this study. The average amount of the implanted cement was 4.2±1.5 cc. The mean cobb angle and compression rate were improved from 12.1±6.5° to 8.5±7.2° and from 30% to 15%, respectively. The mean pain score (visual analogue scale) prior to kyphoplasty was 7.9 and it decreased to 3.0 after the procedure. Cement leakage to the adjacent disc (2 cases) and paravertebral soft tissues (1 case) were seen but there were no major complications such as pneumothorax, segmental artery injury, pulmonary embolism, or epidural leakage.

Conclusion

Balloon kyphoplasty through extrapedicular approach is considered as a safe and effective in treating the middle thoracic regions with low complication rate.     

Prehospital Notification from the Emergency Medical Service Reduces the Transfer and Intra-Hospital Processing Times for Acute Stroke Patients

Background and Purpose

There is little information available about the effects of Emergency Medical Service (EMS) hospital notification on transfer and intrahospital processing times in cases of acute ischemic stroke.

Methods

This study retrospectively investigated the real transfer and imaging processing times for cases of suspected acute stroke (AS) with EMS notification of a requirement for intravenous (IV) tissue-type plasminogen activator (t-PA) and for cases without notification. Also we compared the intra-hospital processing times for receiving t-PA between patients with and without EMS prehospital notification.

Results

Between December 2008 and August 2009, the EMS transported 102 patients with suspected AS to our stroke center. During the same period, 33 patients received IV t-PA without prehospital notification from the EMS. The mean real transfer time after the EMS call was 56.0±32.0 min. Patients with a transfer distance of more than 40 km could not be transported to our center within 60 min. Among the 102 patients, 55 were transferred via the EMS to our emergency room for IV t-PA. The positive predictive value for stroke (90.9% vs. 68.1%, p=0.005) was much higher and the real transfer time was much faster in patients with an EMS t-PA call (47.7±23.1 min, p=0.004) than in those without one (56.3±32.4 min). The door-to-imaging time (17.8±11.0 min vs. 26.9±11.5 min, p=0.01) and door-to-needle time (29.7±9.6 min vs. 42.1±18.1 min, p=0.01) were significantly shorter in the 18 patients for whom there was prehospital notification and who ultimately received t-PA than in those for whom there was no prehospital notification.

Conclusions

Our results indicate that prehospital notification could enable the rapid dispatch of AS patients needing IV t-PA to a stroke centre. In addition, it could reduce intrahospital delays, particularly, imaging processing times.     

The Effect of Barbiturate Coma Therapy for the Patients with Severe Intracranial Hypertension: A 10-Year Experience

Objective

Barbiturate coma therapy (BCT) has been known to be an useful method to control increased intracranial pressure (IICP) refractory to medical and surgical treatments. We have used BCT for patients with severe IICP during the past 10 years, and analyzed our results with review of literatures.

Methods

We analyzed 92 semicomatose or comatose patients with Glasgow coma scale (GCS) of 7 or less with severe IICP due to cerebral edema secondary to parenchymal damages irrespective of their causes. Forty patients who had received BCT with ICP monitoring from January 1997 to December 2006 were included in BCT group, and fifty-two patients who had been managed without BCT from January 1991 to December 1995 were divided into control group. We compared outcomes with Glasgow outcome scale (GOS) and survival rate between the two groups.

Results

Good outcome (GOS=4 and 5) rates at 3-month after insult were 27.5% and 5.8% in BCT and control group, respectively (p<0.01). One-year survival rates were 35.9% and 12.5% in BCT and control group, respectively (p<0.01). In BCT group, the mean age of good outcome patients (37.1 ± 14.9) was significantly lower than that of poor outcome patients (48.1 ± 13.5) (p<0.05).

Conclusion

With our 10-year experience, we suggest that BCT is an effective treatment method for severe IICP patients for better survival and GOS, especially for younger patients.     

Difference of Sagittal Spinopelvic Alignments between Degenerative Spondylolisthesis and Isthmic Spondylolisthesis

Objective

The purpose of this study was to analyze the differences of spinopelvic parameters between degenerative spondylolisthesis (DSPL) and isthmic spondylolisthesis (ISPL) patients.

Methods

Thirty-four patients with DSPL and 19 patients with ISPL were included in this study. Spinopelvic parameters were evaluated on whole spine X-rays in a standing position. The following spinopelvic parameters were measured : pelvic incidence (PI), sacral slope, pelvic tilt (PT), lumbar lordosis (LL), and sagittal vertical axis from C7 plumb line (SVA). The population of patients was compared with a control population of 30 normal and asymptomatic adults.

Results

There were statistically significant differences in LL (p=0.004) and SVA (p=0.005) between the DSPL and ISPL group. The LL of DSPL (42±13°) was significantly lower than that of the control group (48±11°; p=0.029), but that of ISPL (55±6°) was significantly greater than a control group (p=0.004). The SVA of DSPL (55±49 mm) was greater than that of a control group (<40 mm), but that of ISPL (21±22 mm) was within 40 mm as that of a control group. The PT of DSPL (24±7°) and ISPL (21±7°) was significantly greater than that of a control group (11±6°; p=0.000).

Conclusion

Both symptomatic DSPL and ISPL patients had a greater PI than that of the asymptomatic control group. In conclusion, DSPL populations are likely to have global sagittal imbalance (high SVA) compared with ISPL populations because of the difference of lumbar lordosis between two groups.     

Angio-Seal? Evolution? versus Manual Compression for Common Femoral Artery Puncture in Neurovascular Diagnostic Angiography : A Prospective,Non-Randomized Study

Objective

This prospective, non-randomized study compared the safety and efficacy of the Angio-Seal™ Evolution™ to that of manual compression for common femoral artery punctures in neurovascular diagnostic angiography.

Methods

From June 2009 to September 2009, we performed 169 diagnostic trans-femoral cerebral angiographies, using either the Angio-Seal™ Evolution™ or manual compression to achieve hemostasis. We included 60 patients in this study, 30 in each group. We defined minor complications as those requiring no further treatment such as hematoma size less than 6 cm and bruise size less than 25 cm. Major complications were those requiring surgery of the femoral artery pseudoaneurysm and/or the second line increase of hospital stay even without further treatment.

Results

Mean time to hemostasis was 0.42±0.04 minutes for the angioseal and 15.83±1.63 minutes for manual compression (p<0.001). Overall complication rate did not differ between the 2 groups. After the patients were fully mobile, at 24 hours, the rate of onset of new complication differed significantly between the 2 groups (p=0.032). In the angioseal group, 5 (16.7%) of the 30 patients experienced the onset of a new complication after 24 hours, including 3 (60.0%) of the 5 who experienced major complications.

Conclusion

The Angio-Seal™ Evolution™ is effective at decreasing mean time to hemostasis, like other closing devices. However, it may not be effective at producing early ambulation and discharge, compared to manual compression, because delayed complications may occur significantly after 24 hours.     

Accumulated Mannitol and Aggravated Cerebral Edema in a Rat Model of Middle Cerebral Artery Infarction

Objective

Repeated administration of mannitol in the setting of large hemispheric infarction is a controversial and poorly defined therapeutic intervention. This study was performed to examine the effects of multiple-dose mannitol on a brain edema after large hemispheric infarction.

Methods

A middle cerebral artery was occluded with the rat suture model for 6 hours and reperfused in 22 rats. The rats were randomly assigned to either control (n=10) or the mannitol-treated group (n=12) in which intravenous mannitol infusions (0.8 g/kg) were performed six times every four hours. After staining a brain slice with 2,3,5-triphenyltetrazolium chloride, the weight of hemispheres, infarcted (IH) and contralateral (CH), and the IH/CH weight ratio were examined, and then hemispheric accumulation of mannitol was photometrically evaluated based on formation of NADH catalyzed by mannitol dehydrogenase.

Results

Mannitol administration produced changes in body weight of -7.6±1.1%, increased plasma osmolality to 312±8 mOsm/L. It remarkably increased weight of IH (0.77±0.06 gm versus 0.68±0.03 gm : p<0.01) and the IH/CH weight ratio (1.23±0.07 versus 1.12±0.05 : p<0.01). The photometric absorption at 340 nm of the cerebral tissue in the mannitol-treated group was increased to 0.375±0.071 and 0.239±0.051 in the IH and CH, respectively from 0.167±0.082 and 0.162±0.091 in the IH and CH of the control group (p<0.01).

Conclusion

Multiple-dose mannitol is likely to aggravate cerebral edema due to parenchymal accumulation of mannitol in the infarcted brain tissue.     

Aggressive Glucose Control for Acute Ischemic Stroke Patients by Insulin Infusion

Background and Purpose

Hyperglycemia after acute ischemic stroke (AIS) is associated with poor outcomes. However, there is no consensus as to the optimal method for glycemic control. We designed an insulin infusion protocol for aggressive glucose control and investigated its efficacy and safety.

Methods

We applied our protocol to patients within 48 hours after AIS or transient ischemic attack (TIA) with an initial capillary glucose level of between 100 and 399 mg/dL (5.6-22.2 mmol/L). An insulin solution comprising 40 or 50 U of human regular insulin in 500 mL of 5% dextrose was administered for 24 hours. Capillary glucose was measured every 2 hours and the infusion rate was adjusted according to a nomogram with a target range of 80-129 mg/dL (4.4-7.2 mmol/L). Changes in glucose and overall glucose levels during insulin infusion were analyzed according to the presence of diabetes or admission hyperglycemia (admission glucose >139 mg/dL or 7.7 mmol/L) by the generalized estimating equation method.

Results

The study cohort comprised 115 consecutive patients. Glucose was significantly lowered from 160±57 mg/dL (8.9±3.2 mmol/L) at admission to 93±28 mg/dL (5.2±1.6 mmol/L) during insulin infusion (p<0.05). Laboratory hypoglycemia (capillary glucose <80 mg/dL or 4.4 mmol/L) occurred in 91 (71%) patients, 11 (10%) of whom had symptomatic hypoglycemia. Although glucose levels were significantly lowered and maintained within the target range in all patients, overall glucose levels were significantly higher in patients with diabetes or hyperglycemia (p<0.05).

Conclusions

Our insulin-infusion protocol was effective in glycemic control for patients with AIS or TIA. Further modification is needed to improve the efficacy and safety of this procedure, and tailored intervention should be considered according to glycemic status.