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Jung-Hee Lee, Wook-Jae Song and Kyung-Chung Kang

Epidural venous engorgement can result from various lesions, such as arteriovenous malformation, thrombosis or occlusion of the inferior vena cava (IVC), or an abdominal masslike lesion. Most patients with these problems complain of low-back pain, radicular pain, or neurogenic claudication, which are symptoms suggestive of disc herniation or spinal stenosis. However, these patients rarely exhibit neurological deficits or cauda equina syndrome. The authors encountered a case of a 60-year-old man presenting with lower-extremity weakness and voiding difficulty for a period of 1 year. To investigate the patient’s myelopathy-mimicking symptoms, a lumbar spine MRI scan was performed. The MR images exhibited tortuous and dilated spinal vessels compressing the spinal cord and thecal sac at the T11-L3 level, which were concurrent with syringomyelia evidenced by a 22 × 2.5-mm cyst at the T11–12 level. 3D CT scanning of the whole aorta revealed total occlusion and regression of the IVC in the intrahepatic region 3 cm inferior to the right atrium and dilation of multiple collateral veins. The patient was diagnosed with chronic Budd-Chiari syndrome Type I. The authors performed venography, followed by intrahepatic IVC recanalization via stent placement under fluoroscopic and ultra sonographic guidance and without surgical exploration. After this treatment, there was a marked decrease in epidural venous engorgement and the patient’s symptoms resolved almost completely. This case indicates that epidural venous engorgement at thoracolumbar levels may cause symptoms suggestive of myelopathy and can be successfully treated by minimally invasive procedures to eliminate the underlying causes.

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Jae-Sung Ahn, Ho-Jin Lee, Dae-Jung Choi, Ki-young Lee and Sung-jin Hwang

This study was performed to describe the extraforaminal approach of biportal endoscopic spinal surgery (BESS) as a new endoscopic technique for transforaminal decompression and discectomy and to demonstrate the clinical outcomes of this new procedure for the first time. Twenty-one patients (27 segments) who underwent the extraforaminal approach of BESS between March 2015 and April 2016 were enrolled according to the inclusion and exclusion criteria. The operative time (minutes/level) and complications after the procedure were recorded. The visual analog scale (VAS) score was checked to assess the degree of radicular leg pain preoperatively and at the time of the last follow-up. The modified Macnab criteria were used to examine the clinical outcomes at the time of the last follow-up. The mean duration of the follow-up period was 14.8 months (minimum duration 12 months). The mean operative time was 96.7 minutes for one level. The mean VAS score for radicular leg pain dropped from a preoperative score of 7.5 ± 0.9 to a final follow-up score of 2.5 ± 1.2 (p < 0.001). The final outcome according to the modified Macnab criteria was excellent in 5 patients (23.8%), good in 12 (57.2%), fair in 4 (19.0%), and poor in 0. Therefore, excellent or good results (a satisfied outcome) were obtained in 80.9% of the patients. Complications were limited to one dural tear (4.8%). The authors found that the extraforaminal approach of BESS was a feasible and advantageous endoscopic technique for the treatment of foraminal lesions, including stenosis and disc herniation. They suggest that this technique represents a useful, alternative, minimally invasive method that can be used to treat lumbar foraminal stenosis and disc herniation.

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Yang Kwon, Jae Sung Ahn, Sang Ryong Jeon, Jeong Hoon Kim, Chang Jin Kim, Jung Kyo Lee, Byung Duk Kwun, Do Hee Lee and Sun Young Kim

Object. The authors evaluated whether gamma knife radiosurgery (GKS) could be a causative factor in intratumoral bleeding in meningiomas.

Methods. Gamma knife radiosurgery was used in the treatment of 173 meningiomas during a 10-year period. Four patients suffered post-GKS intratumoral hemorrhage. The course in these patients was reviewed.

Four of 173 patients suffered an intratumoral hemorrhage during a follow-up period of 1 to 8 years. The risk of intratumoral bleeding after GKS for meningioma was 2.3%. Intracystic hemorrhage occurred in two patients 1 and 5 years, respectively, after radiosurgery. In the other two cases intratumoral bleeding occurred 2 and 8 years, respectively, after radiosurgery. Histological examination in three cases found no specific findings related to the postradiosurgical changes.

Conclusions. Because the reported risk of spontaneous intratumoral bleeding in meningiomas is 1.3 to 2.7%, the incidence in this series was not unduly high. Radiosurgery itself could not be shown to be a significant factor in the development of the intratumoral bleeding.

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Jung-Ho Yun, Do Hoon Kwon, Eun Jung Lee, Do Heui Lee, Jae Sung Ahn and Byung Duk Kwun

New nidi are rarely found adjacent to the resection margin following treatment for an arteriovenous malformation (AVM), especially in adults. In addition, there are no reports in adults of new nidus formation adjacent to the targeted site of an AVM that angiography has verified to be completely obliterated by radiosurgery. The authors present their experience with recurrent AVMs following AVM radiosurgery in 3 patients whose ages were 9 years, 10 years, and 33 years. None of the patients had been treated with embolization before radiosurgery. Two patients had a history of intracerebral hemorrhage before radiosurgery. New lesions developed around the obliterated nidi in all 3 cases. Angiography performed after the first radiosurgery confirmed complete removal of the nidus in all 3 patients, and new nidus formation was detected 31, 132, and 36 months after the initial GKS. The new lesions were also treated by GKS. Occasionally, in patients with recurrent AVMs, such as those described in this paper, long-term clinical and angiographic follow-up may be required, even if complete occlusion is originally shown on angiograms.

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Jung Cheol Park, Deok Hee Lee, Jae Kyun Kim, Jae Sung Ahn, Byung Duk Kwun, Dae Yoon Kim and Choong Gon Choi

OBJECT

The incidence and risk factors of microembolic lesions on MR diffusion-weighted imaging (DWI) were analyzed after the endovascular coiling of unruptured intracranial aneurysms (UIAs).

METHODS

Data obtained from 271 consecutive patients (70 men and 201 women; median age 57 years; range 23–79 years) who presented with UIA for coil embolization between July 2011 and June 2013 were analyzed. Two independent reviewers examined the DWI and apparent diffusion coefficient maps obtained the following day for the presence of restrictive diffusion spots and counted the number of spots. Multivariate analysis was then performed to identify independent risk factors for developing microembolism following the coiling of an aneurysm.

RESULTS

Microembolic lesions were noted in 101 of 271 patients (37.3%). The results of the multivariate analysis showed that the following factors significantly influenced the risk for microembolism: age, diabetes, previous history of ischemic stroke, high-signal FLAIR lesions in the white matter, multiple aneurysms, and the insertion of an Enterprise stent (all ORs > 1.0 and all p values < 0.05). Previously known risk factors such as prolonged procedure duration, aneurysm size, and decreased antiplatelet function did not show any significant influence.

CONCLUSIONS

The incidence of microembolism after endovascular coiling of UIA was not low. Lesions occurred more frequently in patients with vascular status associated with old age, diabetes, and previous stroke. Aneurysm multiplicity and the type of stent used for treatment also influenced lesion occurrence.

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Hyoung-Sub Kim, Jong Beom Lee, Jong Hyeok Park, Ho Jin Lee, Jung Jae Lee, Shumayou Dutta, Il Sup Kim and Jae Taek Hong

OBJECTIVE

Little is known about the risk factors for postoperative subaxial cervical kyphosis following craniovertebral junction (CVJ) fixation. The object of this study was to evaluate postoperative changes in cervical alignment and to identify the risk factors for postoperative kyphotic change in the subaxial cervical spine after CVJ fixation.

METHODS

One hundred fifteen patients were retrospectively analyzed for postoperative subaxial kyphosis after CVJ fixation. Relations between subaxial kyphosis and radiological risk factors, including segmental angles and ranges of motion (ROMs) at C0–1, C1–2, and C2–7, and clinical factors, such as age, sex, etiology, occipital fixation, extensor muscle resection at C2, additional C1–2 posterior wiring, and subaxial laminoplasty, were investigated. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for postoperative kyphotic changes in the subaxial cervical spine.

RESULTS

The C2–7 angle change was more than −10° in 30 (26.1%) of the 115 patients. Risk factor analysis showed CVJ fixation combined with subaxial laminoplasty (OR 9.336, 95% CI 1.484–58.734, p = 0.017) and a small ROM at the C0–1 segment (OR 0.836, 95% CI 0.757–0.923, p < 0.01) were related to postoperative subaxial kyphotic change. On the other hand, age, sex, resection of the C2 extensor muscle, rheumatoid arthritis, additional C1–2 posterior wiring, and postoperative segmental angles were not risk factors for postoperative subaxial kyphosis

CONCLUSIONS

Subaxial alignment change is not uncommon after CVJ fixation. Muscle detachment at the C2 spinous process was not a risk factor of kyphotic change. The study findings suggest that a small ROM at the C0–1 segment with or without occipital fixation and combined subaxial laminoplasty are risk factors for subaxial kyphotic change.

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Kyung-Hwa Lee, Kyung-Sub Moon, Sook Jung Yun, Young Ho Won, Jae-Hyuk Lee, Min-Cheol Lee and Shin Jung

Leprosy has a predilection for peripheral nerves and is not considered to involve the CNS. The idea that the CNS is exempt from Mycobacterium leprae bacilli has been suspected from a clinical perspective or CSF study in leprosy patients. However, there has been no direct evidence for CNS involvement by leprosy in a living patient. To the best of the authors' knowledge, the present case is the first report providing histopathological and molecular evidence for CNS involvement by leprosy in a living patient. Brain MRI revealed a 2-cm cystic lesion in the right frontal lobe of the patient. The medical history revealed that the patient had been receiving multidrug therapy for borderline lepromatous leprosy. Neuronavigation-guided craniotomy and lesion removal were performed due to a presumptive diagnosis of low-grade glioma. The brain specimen demonstrated variably thickened blood vessels and densely scattered foamy macrophages in the perivascular spaces and parenchymal stroma. Fite acid-fast stain displayed red granular inclusions that were suggestive for fragmented M. leprae. M. leprae-specific nested polymerase chain reaction amplification showed positive bands, and DNA sequencing also demonstrated homology with the M. leprae genome. This case supports the notion that M. leprae can involve the cerebral cortex regardless of cranial nerve engagement.

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Young-Hoon Kim, Young Jin Lee, Jung Ho Han, Soyeon Ahn, Jaebong Lee, Jae Hyoung Kim, Byung Se Choi, Jae Seung Bang, Chae-Yong Kim, Gyojun Hwang, O-Ki Kwon and Chang Wan Oh

OBJECT

The authors aimed to assess whether the prevalence of intracranial aneurysms in patients with intracranial meningiomas was higher than that in a healthy population.

METHODS

The authors performed a hospital-based case-control study of 300 patients with newly diagnosed intracranial meningiomas and 900 age- and sex-matched controls without a history of brain tumors to evaluate any associations between intracranial aneurysms and intracranial meningiomas. Unconditional multivariate logistic regression models were used for case-control comparisons.

RESULTS

Intracranial aneurysms were identified in 23 patients (7.7%) and 24 controls (2.7%; p < 0.001). There was a significant association between intracranial aneurysms and intracranial meningiomas (OR 2.913, 95% CI 1.613–5.261) and hypertension (OR 1.905, 95% CI 1.053–3.446). In a subgroup analysis of the patients with newly diagnosed intracranial meningiomas, there was a significant association between intracranial aneurysms and hypertension (OR 2.876, 95% CI 1.125–7.352) and tumor volume (OR 1.012, 95% CI 1.001–1.024). These patients were also more likely than controls to have other intracranial vascular diseases (p < 0.001), such as isolated occlusion of the intracranial vessels, excluding intracranial aneurysms.

CONCLUSIONS

The prevalence of intracranial aneurysms was higher in patients with intracranial meningiomas. Hypertension and tumor volume appear to be associated with the formation of intracranial aneurysms in these patients.

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Yang Kwon, Jun Seok Bae, Jae Myung Kim, Do Hee Lee, Soon Young Kim, Jae Sung Ahn, Jeong Hoon Kim, Chang Jin Kim, Byung Duk Kwun and Jung Kyo Lee

✓ Tumors involving the optic nerve (optic glioma, optic nerve sheath meningioma) are benign but difficult to treat. Gamma knife surgery (GKS) may be a useful treatment. The authors present data obtained in three such cases and record the effects of GKS.

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Hae-Won Koo, Wonhyoung Park, Kuhyun Yang, Jung Cheol Park, Jae Sung Ahn, Sun Uck Kwon, Changmo Hwang and Deok Hee Lee

Although extremely rare, retention of foreign bodies such as microcatheters or micro guidewires can occur during various neurovascular procedures due to gluing of the microcatheter tip or entanglement of the micro guidewire tip with intravascular devices. The authors have experienced 2 cases of irresolvable wire retention, one after flow diverter placement for a left cavernous internal carotid artery aneurysm and the other after intracranial stenting for acute basilar artery occlusion. The first patient presented 6 weeks after her procedure with right lung parenchymal hemorrhage due to direct piercing of the lung parenchyma after the retained wire fractured and migrated out of the aortic arch. The second patient presented 4 years after his procedure with pneumothorax due to migration of the fractured guidewire segment into the right thoracic cavity. In this report, the authors discuss the possible mechanisms of these unusual complications and how to prevent delayed consequences from a retained intravascular metallic wire.