Dorsal internal carotid artery aneurysm treated by coil embolization--case report.

A 50-year-old male presented with an extremely rare dorsal wall aneurysm of the internal carotid artery manifesting as intracerebral hemorrhage. Computed tomography demonstrated intracerebral hemorrhage on the frontal base. Magnetic resonance imaging clearly showed the hemorrhage was related to an aneurysm of the internal carotid artery. Cerebral angiography disclosed an elongated aneurysm of the dorsal wall of the internal carotid artery. The aneurysm was packed as fully as possible with Guglielmi detachable coils to achieve complete obliteration. The patient was discharged without neurological deficits. Dorsal internal carotid artery aneurysms have a high risk of premature rupture due to their unusual shape and position, adhesion to the brain tissue, and fragile neck. Direct clipping requires careful brain retraction, necessary exposure of the aneurysm, and gentle neck manipulation. Endovascular treatment is an alternative method for obliteration of the aneurysmal sac.     

Renal biopsy in elderly patients: clinicopathological correlation in 117 Korean patients

AIM: In the elderly with renal disease, the clinical presentations are frequently inconsistent with the pathologic findings. We tried to clarify the differences in pathological findings between the young and the elderly, in Korea and in Western countries, and the usefulness of a percutaneous renal biopsy in the elderly with renal disease. PATIENTS AND METHODS: We analyzed the clinical presentations and spectrums of renal histopathology by reviewing medical records and renal biopsy reports retrospectively in 117 Korean patients aged 60 years or more with renal disease. RESULTS: 85 patients had primary renal disease. The remaining 32 patients had renal diseases associated with systemic conditions. Out of the 85 patients with primary renal disease, 61 cases presented as idiopathic nephrotic syndrome. Compared with renal biopsy results of younger adult patients (age 15-59, n = 1,908), membranous nephropathy, crescentic glomerulonephritis, membranoproliferative glomerulonephritis, amyloidosis, light chain disease, and thrombotic thrombocytopenic purpura were more prevalent, but IgA nephropathy and lupus nephritis were less common in the elderly patients. In clinical presentation, nephrotic syndrome and rapidly progressive renal failure were more prevalent, but asymptomatic urinary abnormality was less common in elderly patients. The responsiveness to treatment was good in elderly patients with minimal-change lesion (complete remission in all patients) but poor in crescentic glomerulonephritis, IgA nephropathy, and membranoproliferative glomerulonephritis. From the above findings, the clinical presentation, patterns of histopathology and responsiveness to treatment of elderly Korean patients were similar to those of the younger Korean control group and the Western elderly group. CONCLUSION: Percutaneous renal biopsy is a useful diagnostic aid and can be used as a therapeutic guideline even in elderly patients with renal disease.     

The outcome of the nonoperated contralateral hand in carpal tunnel syndrome.

It is not well known how the nonoperated contralateral hand behaves in bilateral carpal tunnel syndrome (CTS). The postoperative clinical course of the nonoperated contralateral hand in unilateral CTS is not well documented either. Of 324 CTS patients, the authors studied 37 who had carpal tunnel release on one hand only to evaluate the postoperative outcome of the nonoperated contralateral hand. The other 287 patients had operations on both hands. Seven patients were excluded because of missing data or because they could not be contacted. All 324 patients were subject to clinical and electrodiagnostic studies on both hands. The patients were divided into three groups. Group I was composed of patients who had bilateral CTS, diagnosed clinically and electrophysiologically, but who had surgery done only on the hand with the most pronounced symptoms. The patients in group II showed symptoms of CTS in one hand only. However, the opposite hand was diagnosed with subclinical CTS: Electrodiagnostic studies showed involvement of the median nerve, but without symptoms. Group III was composed of true unilateral CTS patients, diagnosed by symptoms and electrodiagnostic study. The results of the electrodiagnosis were categorized according to the severity of median nerve damage (mild, moderate, severe). The outcome and postoperative clinical course of the nonoperated contralateral hand were evaluated by electromyography and telephone survey. This method of survey was used because of the vast spread of patients throughout the country. Within 1 year, all 30 operated hands showed significant improvement, 20 of which belonged to group I. Regarding progress of the nonoperated contralateral hand, 10 patients showed improvement of one grade whereas 5 patients showed three grades of improvement. In another 5 patients there was no change whatsoever. In addition, from groups II and III there were 5 patients who showed no change in the nonoperated hand. The postoperative electromyographic findings of the nonoperated contralateral hand was not commensurate with the symptoms. However, regardless of electromyographic results, the nonoperated contralateral hand showed significant improvement (p < 0.0001). Patients with unilateral CTS did not experience any symptom development in the nonoperated contralateral hand.     

Real-time PCR assay compared with antigenemia assay for detecting cytomegalovirus infection in kidney transplant recipients

Human cytomegalovirus (CMV) infection is a major cause of morbidity and mortality among kidney transplant recipients. The CMVpp65 antigenemia assay has been used for preemptive therapy. Real-time polymerase chain reaction (PCR) technology for CMV DNA quantification in blood has demonstrated a good correlation with the currently employed CMV antigenemia assay. In this study, 90 renal transplant recipients were prospectively enrolled from July 2004 and May 2005. Monitoring of CMV infection was routinely performed with CMV antigenemia and real-time PCR assays. Real-time plasma PCR and CMV antigenemia assays were assessed on 797 samples. CMV antigenemia correlated with a positive CMV PCR (chi(2) = 78.05; P < .0001). Not only the positive rate but also the number of positive cells correlated with the number of PCR DNA copies (F = 26.07, r(2) = .25, P < .0001). To define an optimal cutoff value of CMV DNA load to initiate treatment in kidney transplant patients, we considered a CMV antigenemia titer of >50 positive cells per 400,000 leukocytes as the gold standard in our previous study. The optimal cutoff value for the quantitative real-time PCR assay was predicted to be 86 copies/microL. Thus, we observed that CMV real-time PCR assay would not completely replace antigenemia assay in kidney transplant recipients, but can be used complementarily to screen antigenemia and monitor preemptive therapy.     

Elbow arthritis

Patients with elbow arthritis typically present with complaints of pain and stiffness. Rheumatoid arthritis is the most common cause of elbow arthritis, followed by posttraumatic arthritis and primary osteoarthritis. Nonoperative management consisting of oral analgesics, intra-articular steroid injections, physical therapy, and splinting may provide symptomatic relief in the majority of patients. If these modalities fail, operative treatment is guided by the severity of disease as well as several patient-related factors such as age, activity level, and expectations. Total elbow arthroplasty can provide satisfactory results in the majority of patients with significant degeneration of the elbow. However, due to issues regarding prosthesis longevity, this procedure is generally avoided in young active patients. Other operative treatment options for such patients include arthroscopic or open synovectomy, debridement arthroplasty, and interpositional arthroplasty. As all of these operations may provide a satisfactory outcome for the appropriate patient, a thorough preoperative evaluation is essential in choosing the suitable surgical procedure for each individual patient.     

Endovascular coil embolization of unruptured intracranial aneurysms: a Korean multicenter study

Background and objective

Endovascular coil embolization has been a major treatment modality for unruptured intracranial aneurysms (UIAs) in South Korea. However, there are still few reports on the outcomes of this procedure. We performed a retrospective, multicenter study to determine how safe and effective coiling for UIA has been over the most recent 3 years in South Korea.

Materials and methods

We analyzed a total of 2,180 UIAs in 2,035 patients who were treated by coiling from January 2007 to December 2009 at 22 centers in South Korea, with a focus on patient characteristics, the location and size of the aneurysms, procedural complications, and angiographic and clinical outcomes.

Results

Coiling was successful in 98.0 % of the cases (2,137/2,180 aneurysms). Immediate post-procedural angiography demonstrated complete occlusion in 62.6 % (1,337/2,137 aneurysms), residual neck in 32.4 % (692/2,137), and residual sac in 5.0 % (108/2,137) of the cases. The rate of any procedure-related adverse event was 6.9 % (148/2,137 aneurysms). The rates of permanent morbidity and mortality were 1.8 % (39/2,137 aneurysms) and 0.1 % (2/2,137 aneurysms), respectively. Follow-up conventional angiography or MRA at ≥6 months was performed in 85.7 % (1,832/2,137 aneurysms) of cases. Among the eligible aneurysms for follow-up angiographic analysis, major recanalization was noted in 3.9 % (72/1,832 aneurysms, mean follow-up interval, 12 months). Among these, 68 aneurysms (3.7 %) were re-treated. An aneurysm of the middle cerebral artery (MCA) was a risk factor for incomplete occlusion (P?=?0.049) and major recanalization (P?=?0.046). During follow-up, no aneurysmal rupture occurred.

Conclusions

Endovascular coil embolization of UIAs has been an effective preventive modality with low procedure-related morbidity in South Korea.     

Re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms

Background

Unplanned re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms (UIAs) is sometimes required, but the underlying causes and rates of these procedures are seldom reported. This study retrospectively analyzed the causes of such re-explorations to identify methods for decreasing their necessity.

Method

From January 2000 to December 2011, 1,720 patients with a total of 1,938 UIAs underwent surgical treatment at our institution. From this cohort, 26 patients (1.5 %) with 38 UIAs required re-exploration. Clinical data, aneurysm characteristics, treatment methods, and the incidence and causes of re-exploration of the craniotomy were analyzed for these 26 patients.

Results

Several causes of re-exploration were identified: compromised distal blood flow (eight patients, 0.47 %), hemorrhagic venous infarction (four patients, 0.23 %), brain retraction injury (three patients, 0.17 %), newly identified aneurysms (three patients, 0.17 %), bleeding from an incompletely clipped aneurysm (two patients, 0.12 %), epidural hematoma (two patients, 0.12 %), failed aneurysm clipping (two patients, 0.12 %) and other causes (two patients, 0.12 %). Annual re-exploration incidence rates ranged from 0 to 3.1 %. Annual incidence rates gradually decreased following the introduction of several intraoperative monitoring systems.

Conclusions

Precise surgical planning and careful operative techniques can reduce the incidence of unplanned re-exploration of the craniotomy. The introduction of various intraoperative monitoring systems can also contribute to a reduction in this incidence.     

Comparison of the outcomes for laparoscopic gastrectomy performed by the same surgeon between a low-volume hospital and a high-volume center

Background

The volume–outcome relationship in laparoscopic surgery is controversial. This study was designed to identify differences in laparoscopic gastrectomy outcomes between a low-volume hospital and a high-volume center and to provide guidelines for overcoming the problems associated with a low-volume hospital.

Methods

From April 2009 to November 2012, one surgeon performed 134 totally laparoscopic distal gastrectomies (TLDGs) at a high-volume center (HVC; ASAN Medical Center) and at a low-volume hospital (LVH; Hanyang University Guri Hospital). All laparoscopically assisted gastrectomies were excluded from this study. During the early period of laparoscopic gastrectomy at the low-volume hospital, TLDG with Roux-en-Y gastrojejunostomy (RYGJ) was performed according to the surgeon’s choice. The reconstruction method was classified as gastroduodenostomy (GD) or RYGJ. Early surgical outcomes achieved at the LVH were investigated and compared with those obtained at the HVC.

Results

The early surgical outcomes differed significantly between the two hospitals. In particular, the postoperative complication rate for the patients who underwent TLDG RYGJ at the LVH was higher than at the HVC (LVH 15.4 % vs. HVC 0 %; p = 0.037). Furthermore, significant differences were observed in the mean operation time (TLDG GD: LVH 141.0 min vs. HVC 117.4 min, p = 0.001; TLDG RYGJ: LVH 186.3 min vs. HVC 134.6 min, p = 0.009) and length of hospital stay (TLDG GD: LVH 8.1 days vs. HVC 7.2 days, p = 0.044; TLDG RYGJ: LVH 11.5 day vs. HVC 6.8 day, p = 0.009).

Conclusions

Although all the operations were performed by one experienced surgeon, the early surgical outcomes differed significantly between the low- and high-volume hospitals. Low-volume hospitals often lack well-trained surgical professionals such as first assistants and scrub nurses. Therefore, the authors recommend that a surgeon who works at an LVH should assess potential personnel shortages and find a solution before operating.     

Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial

Background contextThoracolumbar burst fractures have good outcomes when treated with early ambulation and orthosis (TLSO). If equally good outcomes could be achieved with early ambulation and no brace, resource utilization would be decreased, especially in developing countries where prolonged bed rest is the default option because bracing is not available or affordable.PurposeTo determine whether TLSO is equivalent to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures with respect to their functional outcome at 3 months.Study designA multicentre, randomized, nonblinded equivalence trial involving three Canadian tertiary spine centers. Enrollment began in 2002 and 2-year follow-up was completed in 2011.Patient sampleInclusion criteria included AO-A3 burst fractures between T11 and L3, skeletally mature and older than 60 years, 72 hours from their injury, kyphotic deformity lower than 35°, no neurologic deficit. One hundred ten patients were assessed for eligibility for the study; 14 patients were not recruited because they resided outside the country (3), refused participation (8), or were not consented before independent ambulation (3).Outcome measuresRoland Morris Disability Questionnaire score (RMDQ) assessed at 3 months postinjury. The equivalence margin was set at δ=5 points.MethodsThe NO group was encouraged to ambulate immediately with bending restrictions for 8 weeks. The TLSO group ambulated when the brace was available and weaned from the brace after 8 to 10 weeks. The following competitive grants supported this work: VHHSC Interdisciplinary Research Grant, Zimmer/University of British Columbia Research Fund, and Hip Hip Hooray Research Grant. Aspen Medical provided the TLSOs used in this study. The authors have no financial or personal relationships that could inappropriately influence this work.ResultsForty-seven patients were enrolled into the TLSO group and 49 patients into the NO group. Forty-six participants per group were available for the primary outcome. The RMDQ score at 3 months postinjury was 6.8±5.4 (standard deviation [SD]) for the TLSO group and 7.7±6.0 (SD) in the NO group. The 95% confidence interval (?1.5 to 3.2) was within the predetermined margin of equivalence. Six patients required surgical stabilization, five of them before initial discharge.ConclusionsTreating these fractures using early ambulation without a brace avoids the cost and patient deconditioning associated with a brace and complications and costs associated with long-term bed rest if a TLSO or body cast is not available.     

Outcome analysis of arthroscopic treatment of partial thickness rotator cuff tears

Background:

Partial thickness rotator cuff tears occupy an important position in the spectrum of rotator cuff disease. The development of a more comprehensive classification has been sought to address both the tear location and extent, which may influence clinical results. The purpose of this study is to classify partial thickness rotator cuff tears according to the arthroscopic findings and to evaluate the clinical outcomes after arthroscopic repair of partial thickness tears.

Materials and Methods:

One hundred and two patients had arthroscopic treatment of partial thickness rotator cuff tears. The inclusion criterion for the study was a partially torn supraspinatus tendon involving articular or bursal side, verified by direct arthroscopic visualization. Outcome analysis was exclusively applied to patients who underwent transtendon repair, using the shoulder index of American Shoulder and Elbow Society and the University of California Los Angeles (UCLA) rating system.

Results:

Partial thickness rotator cuff tears were divided into five groups according to arthroscopic findings. There was significant improvement after surgery in all parameters of clinical evaluation in the tears that warranted repair. Arthroscopic repair in situ (transtendon technique) may be the preferred option in unstable partial thickness tear.

Conclusion:

The proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears.