Dural arteriovenous fistulas (AVFs) are uncommon, representing only 10% to 15% of all intracranial AVFs. Here we present the case of a patient with cerebral infarction who experienced a dural AVF after craniotomy for superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery. A 48-year-old man presented with dysarthria and right side hemiparesis. A brain magnetic resonance imaging scan revealed multiple acute infarctions and severe stenosis of the left MCA. Therefore, STA-MCA bypass surgery was performed. A follow-up angiography performed 2 weeks after the surgery showed an abnormal vascular channel from the left middle meningeal artery (MMA) to the middle meningeal vein (MMV) just anterior to the border of the craniotomy margin. This fistula originated from a screw used for cranial fixation. The screw injured the MMA and MMV, and this resulted in the formation of a fistula. The fistula was successfully treated with transarterial embolization. Surgeons should be careful when fixing bones with screws and plates as fistulas can develop if vessels are injured.
Angiography ; Brain ; Central Nervous System Vascular Malformations* ; Cerebral Infarction ; Cerebral Revascularization ; Constriction, Pathologic ; Craniotomy ; Dysarthria ; Fistula ; Follow-Up Studies ; Humans ; Infarction ; Magnetic Resonance Imaging ; Meningeal Arteries ; Middle Aged ; Middle Cerebral Artery* ; Paresis ; Temporal Arteries* ; Veins

BACKGROUND: Cardiogenic shock is the most common cause of in-hospital mortality after acute myocardial infarction. Despite improvement in coronary care, the in-hospital mortality rate of cardiogenic shock is very high in conventional conservative therapy. Recently, it was suggested that coronary angioplasty may reduce the mortality associated with cardiogenic shock. METHOD: Thirteen consecutive patients with cardiogenic shock who underwent coronary angioplasty were studied. Shock was not induced by mechanical complications, arrhythmia, hypovolemia and other reversible cause. We collected and analyzed the clinical, hemodynamic survivor groups. RESULTS: Of 13 patients, 11 had successful reperfusion of the infarct-related coronary artery and 2 had unsuccessful reperfusion. Of 11 patients with successful angioplasty, 8 survived at the time of hospital discharge. All patents with unsuccessful angioplasty died in the hospital. Therefore overall hospital survival rate was 62% and the rate increased to 73% in patients with successful reperfusion. Survivor and non-survivor groups in clinical, hemodynamic and angiographic variables were similar except systolic blood pressure and the presence of successful reperfusion. CONCLUSION: In patients with cardiogenic shock, the patency of infarct-related coronary artery was strongly associated with in-hospital mortality. This findings support aggressive interventional strategy in patient with cardiogenic shock complicating acute myocardial infarction.
Angioplasty ; Angioplasty, Balloon, Coronary* ; Arrhythmias, Cardiac ; Blood Pressure ; Coronary Vessels ; Hemodynamics ; Hospital Mortality ; Humans ; Hypovolemia ; Mortality ; Myocardial Infarction* ; Reperfusion ; Shock ; Shock, Cardiogenic* ; Survival Rate ; Survivors

BACKGROUND: Cardiogenic shock is the most common cause of in-hospital mortality after acute myocardial infarction. Despite improvement in coronary care, the in-hospital mortality rate of cardiogenic shock is very high in conventional conservative therapy. Recently, it was suggested that coronary angioplasty may reduce the mortality associated with cardiogenic shock. METHOD: Thirteen consecutive patients with cardiogenic shock who underwent coronary angioplasty were studied. Shock was not induced by mechanical complications, arrhythmia, hypovolemia and other reversible cause. We collected and analyzed the clinical, hemodynamic survivor groups. RESULTS: Of 13 patients, 11 had successful reperfusion of the infarct-related coronary artery and 2 had unsuccessful reperfusion. Of 11 patients with successful angioplasty, 8 survived at the time of hospital discharge. All patents with unsuccessful angioplasty died in the hospital. Therefore overall hospital survival rate was 62% and the rate increased to 73% in patients with successful reperfusion. Survivor and non-survivor groups in clinical, hemodynamic and angiographic variables were similar except systolic blood pressure and the presence of successful reperfusion. CONCLUSION: In patients with cardiogenic shock, the patency of infarct-related coronary artery was strongly associated with in-hospital mortality. This findings support aggressive interventional strategy in patient with cardiogenic shock complicating acute myocardial infarction.
Angioplasty ; Angioplasty, Balloon, Coronary* ; Arrhythmias, Cardiac ; Blood Pressure ; Coronary Vessels ; Hemodynamics ; Hospital Mortality ; Humans ; Hypovolemia ; Mortality ; Myocardial Infarction* ; Reperfusion ; Shock ; Shock, Cardiogenic* ; Survival Rate ; Survivors

OBJECTIVES: To investigate the pattern of subclinical hypothyroidism (SCH) in patients with bipolar disorders managed by lithium or valproic acid. METHODS: The study participants were 106 patients with DSM-IV bipolar disorders receiving planned maintenance treatment at the Mood Disorders Clinic of Seoul National University Bundang Hospital (aged between 17 and 64, mean duration of follow-up = 875.65 days). Using the bipolar disorder registry, thyroid function data were analyzed to assess the frequency of and the risk factors for SCH in patients managed by lithium (n = 64) or valproic acid (n = 42) for more than 5 months. RESULTS: Overall frequencies of SCH were 20.3% (13/64) in the lithium group, 14.3% (6/42) in the valproic acid group, and between the two groups there is no difference (p = 0.43). No differences were observed in the potential risk factors for SCH between the two groups including age, sex, subtype of bipolar disorder, baseline TSH, and concomitant antipsychotic use. In cases with SCH, thyroid-stimulating hormone (TSH) showed a tendency to increase at 3 month after the initiation of lithium or valproic acid. A gradual increase in the number of patients showing SCH was found within the first 3 years of medication. CONCLUSIONS: With regular monitoring and careful assessment, there was no difference in the risk of SCH between lithium and valproic acid maintenance. The risk of mood stabilizer-associated SCH may gradually increase within 3 years following the commencement of medication, thereby mandating close monitoring for the first 3 years of treatment. Further studies with large sample size would be needed to confirm these findings.
Bipolar Disorder* ; Diagnostic and Statistical Manual of Mental Disorders ; Follow-Up Studies ; Humans ; Hypothyroidism* ; Lithium* ; Mood Disorders ; Risk Factors ; Sample Size ; Seoul ; Thyroid Gland ; Thyrotropin ; Valproic Acid*

Pulsed Doppler echocardiography was performed before and five to fifteen days (mean, 9.3 days) after mitral valve surgery to evaluate the change of pulmonary arterial pressure in 80 patients (29 males and 51 females) with mitral valve disease by preejection period (PEP)/acceleration time (AT) ratio at the right ventricular outflow tract. In 13 patients with pulmonary hypertension (mean pulmonary arterial pressure equal to or greater than 20mmHg), Doppler echocardiography was followed three to twelve months after operation. In 76 patients with a mitral valve prosthesis (15 patients with the Bjork-Shiley valve, 28 patients with the Ionescu-Shiley valve, and 33 patients with the St. Jude valve), mean transmitral pressure gradient and pressure-half time were estimated by continuous wave Doppler echocardiography five to fifteen days after operation. 1) PEP/AT Ratio by pulsed Doppler echocardiography correlated well with the mean pulmonary arterial pressure gradient by cardiac catheterization (r=0.83, p<0.001). 2) After mitral valve surgery, PEP/AT ratio decreased significantly (p<0.001). In group with mean pulmonary arterial pressure equal to or greater than 40mmHg, immmediate postoperative PEP/AT ratio was greater (P<0.05) than that in group with mean pulmonary arterial pressure less than 20 mmHg, but, difference between the preoperative and postoperative PEP/AT ratio was much greater (P<0.001) than that in group with mean pulmonary arterial pressure between 20 and 39 mmHg. 3) In 13 patients, on whom repeated Doppler echocardiography performed, PEP/AT ratio decreased immediately after mitral valve surgery (p<0.001). After then, it decreased further, but, the amount of the decrease was much smaller than immediate one (p<0.001). 4) There was no significant difference in postoperative PEP/AT ratio among the different prosthesis. Mean transmitral pressure gradient and pressure half-time of the Bjork-Shiley, Ionescu-Shiley, and St, jude valves were 3.1 mmhg and 67.3 msec, 2.9 mmHg and 65.3 msec, and 2.7 mmhg and 60.2 msec, repectively. The St.Jude valve had somewhat smaller mean transmitral pressure gradient and pressure half-time, but there was no statistical significance. In conclusion, elevated pulmonary arterial pressure in patients with mitral valve disease decreased greatly within 15 days after operation, and Doppler echocardiography was a useful method in the follow-up of prosthetic mitral valve function.
Arterial Pressure ; Cardiac Catheterization ; Cardiac Catheters ; Echocardiography* ; Echocardiography, Doppler ; Echocardiography, Doppler, Pulsed ; Follow-Up Studies ; Humans ; Hypertension, Pulmonary ; Male ; Mitral Valve* ; Prostheses and Implants

OBJECTIVE: Detection of intracranial multiple aneurysms, including mirror-image aneurysms, have recently been increasing with the development of diagnostic techniques. However, studies of mirror-image aneurysms have been rare in South Korea. Thus, we intend to report our hospital's experience with mirror-image aneurysms during the past 20 years along with a review of relevant literature. METHODS: We analyzed medical records and image data from patients with cerebral aneurysms who had been admitted to our institution from January 1988 to June 2007. We divided the patients into three groups and investigated the clinical patterns of mirror-image aneurysms (Group 1). We then compared them with patients exhibiting non-mirror multiple aneurysms (Group 2) and the patients with solitary aneurysms (Group 3). We also statistically analyzed the age, sex, smoking habits, medical histories, and prognoses of the patients. RESULTS: Mirror-image aneurysms were found in 62 (5.1%) of the 1,209 patients admitted for cerebral aneurysms over the past 20 years. Of the mirror-image aneurysms, 48% were located in the posterior communicating artery (PcoA), and 40% were in the middle cerebral artery (MCA). Ruptures of aneurysms occurred slightly more frequently on the right side and when the aneurysm was larger and its shape was more irregular. Women, particularly menopausal women aged 50 and older, were shown to be at higher risk. Smoking was also a risk factor. However, there were no significant differences in prognoses among the three groups. CONCLUSION: We should pay attention to the possibility of mirror-image or multiple aneurysms when diagnosing and treating menopausal women and smokers, particularly if the cerebral aneurysm is located in the MCA or PcoA.
Aged ; Aneurysm ; Arteries ; Female ; Humans ; Intracranial Aneurysm ; Medical Records ; Middle Cerebral Artery ; Prognosis ; Republic of Korea ; Risk Factors ; Rupture ; Smoke ; Smoking

A 65-year-old woman presented with a history of severe lower back pain on forward-flexion for 2 months duration. Magnetic resonance imaging revealed a high signal mass with a tail on T1-weighted images at the L3 level. A total surgical resection was performed via a posterior approach with the aid of a microscope. Histopathological examination of the tumor revealed two pathological components: lipoma and myxopapillary ependymoma. The presence of dual histological components in one spinal cord tumor is rare. There are no prior reports of both types of cells (adipose and ependymal) grown simultaneously in a single tumor of the filum terminale in the medical literature. We report a unique case of the co-existence of lipoma and myxopapillary ependymoma within the same tumor located at the filum terminale and review related literature.
Aged ; Cauda Equina* ; Ependymoma* ; Female ; Humans ; Lipoma* ; Low Back Pain ; Magnetic Resonance Imaging ; Spinal Cord Neoplasms

Spinal cord herniation is a rare condition that has become increasingly recognised in the last few years. The authors report a case of idiopathic spinal cord herniation in a 33 year old woman performed with progressive Brown-Sequard syndrome. The diagnosis was made on MR imaging. After repairing the herniation, the patient made a gradual improvement. Potential causes are discussed, including a possible role of dural defect. In conclusion, idiopathic spinal cord herniation is a potentially treatable condition that should be more readily diagnosed that increasing awareness and improved imaging techniques.
Brown-Sequard Syndrome* ; Diagnosis ; Female ; Humans ; Magnetic Resonance Imaging ; Spinal Cord*

OBJECTIVE: Among pediatric injury, brain injury is a leading cause of death and disability. To improve outcomes, many developed countries built neurotrauma databank (NTDB) system but there was not established nationwide coverage NTDB until 2009 and there have been few studies on pediatric traumatic head injury (THI) patients in Korea. Therefore, we analyzed epidemiology and outcome from the big data of pediatric THI. METHODS: We collected data on pediatric patients from 23 university hospitals including 9 regional trauma centers from 2010 to 2014 and analyzed their clinical factors (sex, age, initial Glasgow coma scale, cause and mechanism of head injury, presence of surgery). RESULTS: Among all the 2617 THI patients, total number of pediatric patients was 256. The average age of the subjects was 9.07 (standard deviation±6.3) years old. The male-to female ratio was 1.87 to 1 and male dominance increases with age. The most common cause for trauma were falls and traffic accidents. Age (p=0.007), surgery (p<0.001), mechanism of trauma (p=0.016), subdural hemorrhage (SDH) (p<0.001), diffuse axonal injury (DAI) (p<0.001) were statistically significant associated with severe brain injury. CONCLUSION: Falls were the most common cause of trauma, and age, surgery, mechanism of trauma, SDH, DAI increased with injury severity. There is a critical need for effective fall and traffic accidents prevention strategies for children, and we should give attention to these predicting factors for more effective care.
Accidental Falls ; Accidents, Traffic ; Brain Injuries* ; Cause of Death ; Child ; Craniocerebral Trauma ; Developed Countries ; Diffuse Axonal Injury ; Epidemiology* ; Female ; Glasgow Coma Scale ; Hematoma, Subdural ; Hospitals, University ; Humans ; Korea ; Male ; Mortality* ; Pediatrics ; Republic of Korea ; Trauma Centers

Various surgical procedures for the treatment of post-traumatic syringomyelia have been introduced recently, but most surgical strategies have been unreliable. We introduce the concept and technique of a new shunting procedure, syringo-subarachnoid-peritoneal shunt. A 54-year-old patient presented to our hospital with a progressive impairment of motion and position sense on the right side. Sixteen years before this admission, he had been treated by decompressive laminectomy for a burst fracture of L1. On his recent admission, magnetic resonance (MR) imaging studies of the whole spine revealed the presence of a huge syrinx extending from the medulla to the L1 vertebral level. We performed a syringo-subarachnoid-peritoneal shunt, including insertion of a T-tube into the syrinx, subarachnoid space and peritoneal cavity. Clinical manifestations and radiological findings improved after the operation. The syringo-subarachnoid-peritoneal shunt has several advantages. First, fluid can communicate freely between the syrinx, the subarachnoid space, and the peritoneal cavity. Secondly, we can prevent shunt catheter from migrating because dural anchoring of the T-tube is easy. Finally, we can perform shunt revision easily, because only one arm of the T-tube is inserted into the intraspinal syringx cavity. We think that this procedure is the most beneficial method among the various shunting procedures.
Arm ; Catheters ; Humans ; Laminectomy ; Magnetic Resonance Spectroscopy ; Middle Aged ; Peritoneal Cavity ; Proprioception ; Spinal Cord Injuries ; Spine ; Subarachnoid Space ; Syringomyelia