Migraine is a disabling headache that can occur with or without aura. We present here a case of migraine that was effectively managed by a series of cervical epidural blocks. A 41-year-old woman who had suffered from severe headache on her left temporal area for 12 years visited our pain clinic. Her 11-point numeric pain rating scale was 10 out of 10 at the first visit and the symptoms were associated with homonymous visual disturbances, paresthesia on the left face, shoulder and arm, and general weakness. For the first 5 years after the headaches began, her headache was relatively well controlled by acetaminophen; after then, the acetaminophen wasn't effective. After wandering from this hospital to the next one in search of relief, she managed to visit our pain clinic. We tried several blocks including cervical epidural block, and she was continuously medicated with sumatriptan. Her headache was gradually relieved. Now, her 11-point numeric rating scale is 1-2 out of 10 at the most during her headache attacks.
Acetaminophen ; Adult ; Arm ; Epilepsy ; Female ; Headache ; Humans ; Migraine Disorders* ; Pain Clinics ; Paresthesia ; Shoulder ; Sumatriptan

BACKGROUND: Adequate evaluation and monitoring for pre-eclamptic paturient and capable assistance before induction for anesthesiologist, must be taken to avoid sudden severe maternal hypertension with intubation during a Rapid Sequence intravenous induction. Such event predispose the paturient to intracranial hemorrhage and pulmonary hypertension with pulmonary edema. To diminish danger of hypertension that can be developed during general anesthesia and facilitate control of blood pressure, 24 women presenting for cesarean section were studied. METHODS: All received 17.9+/-2.6ml of 0.5% bupivacaine, including 3ml of test dose, through the epidural catheter inserted in T12-L1 interspace using 18 gauge Tuohy needle to the patients with a lateral decubitus position. We measured blood pressure and heart rate in 5, 10, 15, 20, 30, 45, and 60 minutes after injection of 0.5% bupivacaine and 15 minutes after transferred to recovery room. RESULTS: The blood pressure of the patients started to decrease in 5 minutes and most decreased in 20 minutes after injection, the heart rate had little change but decreased significantly in 45 minutes. Apgar Scores of the neonates at 1 and 5 minutes were 7.3+/-2.0 and 9.2+/-1.5. The patients used ephedrine and crystalloid solution for correction of hypotension were 6 of 24 women and had no any systemic toxicity or neurologic symptoms by local anesthetics(bupivacaine). CONCLUSION: Continuous epidural anesthesia for cesarean section in preeclamptic patients is recommended for safe anesthesia.
Anesthesia ; Anesthesia, Epidural* ; Anesthesia, General ; Blood Pressure ; Bupivacaine ; Catheters ; Cesarean Section* ; Ephedrine ; Female ; Heart Rate ; Humans ; Hypertension ; Hypertension, Pulmonary ; Hypotension ; Infant, Newborn ; Intracranial Hemorrhages ; Intubation ; Needles ; Neurologic Manifestations ; Pregnancy ; Pulmonary Edema ; Recovery Room

Cranial mononeuropathies, manifesting particulary as opthalmoplegia or facial palsy, are common entities in the dia-betic population. However, sequential multiple cranial neuropathies due to diabetes are much less common. It is often associated with other conditions such as a brain tumor or head trauma. A 61-year-old diabetic man presented with ptosis, opthalmoplegia, and facial palsy which were manifestations of multiple cranial neuropathies involving the left 3rd, 4th, 6th, and 7th cranial nerves throughout five weeks. The pupils were not involved. The neurologic evaluation included a CSF study and a brain MRI with MRA. None of them produced any significant results. Blink reflexes revealed evidence of a left facial nerve lesion. The blood glucose was strictly controlled and steroid therapy was administered. The ptosis of the patientanjx left eyelid improved during treatment and he was discharged after 13 days. In a follow-up examination 3 months after onset, focal neurological deficits including opthalmoplegia and facial palsy on the left side were greatly improved and barely noticeable.
Blinking ; Blood Glucose ; Brain ; Brain Neoplasms ; Cranial Nerve Diseases* ; Cranial Nerves ; Craniocerebral Trauma ; Diabetes Mellitus* ; Eyelids ; Facial Nerve ; Facial Paralysis ; Follow-Up Studies ; Humans ; Magnetic Resonance Imaging ; Middle Aged ; Mononeuropathies ; Pupil

Spinal cord stimulation (SCS) was first attempted by Shearly et al for the relief of intractable pain. A spinal cord stimulator has traditionally been used for failed back surgery syndrome (FBSS) angina pectoris, complex regional pain syndrome (CRPS) and ischemic pain in the extremity. However, the complications associated with the use of a spinal cord stimulator, such as wound infection, hematoma, lead migration and device malfunction; make its long term application difficult. Here, our experience of an interesting case, in which intractable right leg pain was controlled using a spinal cord stimulator placed in the left epidural space, is reported, with a review of the literature.
Angina Pectoris ; Epidural Space* ; Extremities ; Failed Back Surgery Syndrome ; Hematoma ; Leg* ; Pain, Intractable ; Spinal Cord Stimulation ; Spinal Cord* ; Wound Infection

BACKGROUND: Although a magnetic resonance imaging (MRI) is highly sensitive for changes associated with ischemic stroke, the detection of an acute ischemic lesion is usually impossible within 6 hours of the stroke onset on a conventional MRI. The perfusion MRI is a new imaging technique for diagnosing acute ischemic stroke. We evaluate the clinical usefulness of the perfusion MRI in predicting the final infarct extent in 18 patients with acute middle cerebral artery (MCA) territory ischemic stroke. METHOD: The perfusion MRI was performed within 6 hours after the stroke onset in all patients with a single-section dynamic contrast-enhanced T2*-weighted imaging in conjunction with a conventional routine MRI and MR angiography. Time-concentration curves and cerebral blood volume (CBV) maps were calculated from the dynamic MR imaging data by using numerical integration techniques. We compared findings of CBV maps with infarction on a follow-up CT or MRI. RESULTS: In 14 of 18 patients, the CBV in the occluded MCA territory were decreased. In the remaining 4 patients with a reversible ischemic neurologic deficit (RIND) or transient ischemic attack (TIA), the CBV were increased in 3 and normal in 1. Out of 14 patients with a decreased CBV, two had focal regions of increased CBV within the affected territory, indicating reperfusion hyperemia. The regions of increased or decreased CBV were eventually converted to infarction on follow-up images in all 14 patients. Out of 4 patients with RIND or TIA, one showed focal infarction in centrum semiovale on a follow-up image. CONCLUSIONS: The perfusion MRI was useful for the assessment of hemodynamic change about cerebral perfusion and may predict the extent of final infarction in acute MCA territory ischemic stroke. These results suggest that the perfusion MRI may play an important role in the diagnosis and management of acute ischemic stroke.
Angiography ; Blood Volume ; Diagnosis ; Follow-Up Studies ; Hemodynamics ; Humans ; Hyperemia ; Infarction ; Ischemic Attack, Transient ; Magnetic Resonance Imaging* ; Middle Cerebral Artery* ; Neurologic Manifestations ; Perfusion* ; Reperfusion ; Stroke*

BACKGROUND: Electroconvulsive therapy (ECT) still remains a place in modern psychiatric practice. The anesthetic agent for ECT should provide smooth and rapid induction, rapid recovery and attenuation of the physiologic effects of ECT as well as minimal antagonistic effects on seizure activity. We performed a study to assess the comparative effects of propofol and thiopental sodium on seizure activity, hemodynamic stability, and recovery after ECT. METHODS: Ten patients scheduled for maintenance ECT participated in this prospective, randomized, crossover study. The induction dose was 1.5 mg.kg 1 of propofol and 3 mg.kg 1 of thiopental sodium. The lengths of motor and EEG seizure were measured after each electric stimuli. Mean arterial pressure, heart rate and recovery time were also compared between two groups. RESULTS: Both propofol and thiopental sodium were associated with mean motor and EEG seizure durations above thirty seconds. However, the improved hemodynamic stability associated with propofol and recovery time of propofol (8.1 +/- 2.8 min) was shorter than thiopental sodium (13.0 +/- 9.3 min). CONCLUSIONS: Compared with thiopental sodium, the use of propofol was associated with a clinically insignificant decrease in seizure duration and improved hemodynamic stability, recovery time. We conclude that propofol may be a useful alternative to thiopental sodium for ECT therapy.
Anesthetics* ; Arterial Pressure ; Cross-Over Studies ; Electroconvulsive Therapy* ; Electroencephalography ; Heart Rate ; Hemodynamics* ; Humans ; Propofol* ; Prospective Studies ; Seizures* ; Thiopental*

Intracapsular and paraarticular chondroma is a rare benign lesion of the large joints (mostly the knee). We report a case of intracapsular and paraarticular chondroma in the infrapatellar Hoffa's fat pad that presented as a painful palpable mass in 15-yearold woman. A physical examination revealed a firm, movable and tender mass in the infrapatellar area. Magnetic resonance images showed an ovoid, well-defined, soft tissue mass with focal calcification in the infrapatellar fat pad. The final pathology revealed an intracapsular and paraarticular chondroma.
Adipose Tissue ; Chondroma ; Female ; Humans ; Joints ; Knee ; Lower Extremity ; Magnetic Resonance Imaging ; Magnetic Resonance Spectroscopy ; Physical Examination

Rupture of the trachea as a result of external trauma is well documented. But, rupture of the membranous trachea following tracheal intubation has been infrequently noted. Risk factors associated with tracheobronchial rupture include inexperienced endoscopists, intubating stylets, multiple vigorous attempts at intubation, tracheal abnormalities, overdistension of tracheal or bronchial cuff with high pressure, low volume cuffs, and old age. We report a case of tracheal rupture occurred during one lung ventilation using Robertshaw double-lumen endotracheal tube for right upper lobe lobectomy. The etiology and treatment are discussed and the recent literature is reviewed.
Intubation ; One-Lung Ventilation* ; Risk Factors ; Rupture* ; Trachea

OBJECTIVE: Intraoperative monitoring using somatosensory evoked potential (SEP) study has been used increasingly to monitor neurological function during scoliosis surgery and other high-risk spinal surgeries. However, there are few studies related to this intraoperative monitoring, particularly in severe spinal deformity surgery, in Korea. So we evaluated the clinical efficacy of intraoperative SEP monitoring and considered the risk factors related to spinal surgery. METHOD: We performed a posterior tibial nerve somatosensory evoked potential study for intraoperative monitoring during surgical procedures in 101 patients (male 46, female 55). RESULTS: Neurologic damage occurred in 16 patients (10 congenital scoliosis cases, 5 tuberculous kyphosis cases, and 1 degenerative spondylosis case) after surgical procedures. Delayed postoperative neurologic damage occurred in 4 patients (2 mild damage cases, 2 severe damage cases) among 85 cases which showed normal responses during surgical procedures. Sensitivity of this study was 75%, and specificity was 95.3%. CONCLUSION: Somatosensory evoked potential study for intraoperaive monitoring is a sensitive and very useful method to detect iatrogenic lesions during spinal deformity surgery with satisfactory specificity. However, to improve the sensitivity and specificity of the intraoperative monitoring, combination of motor evoked potentials is recommended.
Congenital Abnormalities* ; Evoked Potentials, Motor ; Evoked Potentials, Somatosensory* ; Female ; Humans ; Korea ; Kyphosis ; Monitoring, Intraoperative* ; Risk Factors ; Scoliosis ; Sensitivity and Specificity ; Spondylosis ; Tibial Nerve

Purpose: Urinary tract infections (UTIs) are the most common and serious bacterialinfections in children. Therefore, early diagnosis of vesicoureteral reflux (VUR)for treatment planning and the identification of noninvasive markers that canpredict renal injury are important in patients with UTIs. We analyzed the clinicalfeatures of pediatric UTIs commonly encountered by general practitioners and reinterpretedthe blood tests and imaging findings to identify the important clinicalpredictive markers of VUR in order to selectively perform VCUG. Methods: This retrospective study was performed among 183 children diagnosedwith a UTI or acute pyelonephritis. Results: The most significant predictor of high grade and bilateral VUR identifiedusing area under the curve analyses was hydronephrosis on kidney ultrasoundimages with renal cortical defects on dimercaptosuccinic acid (DMSA) kidney scansimultaneously, followed by hydronephrosis only on kidney ultrasound. Conclusion The presence of hydronephrosis on kidney ultrasound images or corticaldefects or asymmetric kidneys on the DMSA kidney scans can be predictivemarkers of VUR, reducing the need for VCUG. Our study can thus help minimizethe exposure to radiation among patients through selective VCUG.