Preliminary Surgical Results of Open Sella Method with Intentionally Staged Transsphenoidal Approach for Patients with Giant Pituitary Adenomas

OBJECTIVE: This study is designed to evaluate the clinical outcome, the safety and the effectiveness of the open sella methods(OSM) with intentionally staged transsphenoidal approach(TSA) for giant pituitary adenomas(GPA). METHODS: Eight patients with GPA were managed by the OSM with intentionally staged TSA. There were 5 nonfunctioning adenomas, 2 prolactin- secreting adenomas, and 1 growth hormone-secreting adenoma. Among them, 6 patients underwent two times of TSA, one patient underwent three times of TSA, and the other patient underwent two times of TSA followed by radiation therapy. The mean time interval between staged operations was 3.9 months except for one case. RESULTS: Seven out of the eight patients with GPA treated with the OSM with intentionally staged TSA showed that the tumors were completely removed on magnetic resonance imaging and that they were free from headache and visual problem suffered previously. Only one patient experienced severe complications including panhypopituitarism, cerebrospinal fluid rhinorrhea and permanent diabetes insipidus. CONCLUSION: With the surgical treatment for 8 cases of GPA, which extended to the suprasellar and parasellar area, we suggest that the OSM with intentionally staged TSA is a safe and effective method in management for GPA.

Surgically Treated Anterior Communicating Artery Aneurysm

OBJECTIVE: The purpose of this study is to assess the factors related to the outcome of 84 patients who underwent surgery for anterior communicating Artery(ACoA) aneurysms. METHODS: The authors review 84 patients who were undertaken from January 1998 to May 2004. In the management of ACoA aneurysms, the outcome was based on several factors: Clinical condition, Distribution of hemorrhage, Time between aneurysmal rupture and surgery, Direction and shape of the aneurysm. RESULTS: The incidence rate of the ACoA aneurysm was 35%. Seventy four patients were classified as those having a good recovery, but 5 patients suffered from some morbidity and 5 patients died. The rate of good outcome for the patients with Hunt and Hess grade was as follows 100% in grade I, 95% in grade II, 80% in grade III, IV and V. The rate of good outcome for the patients with Fisher grade was as follows 98% in grade I, II and 81% in grade III, IV. Nineteen of 22 patients who underwent early surgery were rated as good, while twenty six of 30 patients for whom surgery was delayed showed a favorable result. The unfavorable outcomes were also attributed by vasospasm or other medical problems. CONCLUSION: For further improvement of the overall surgical outcome: First, early surgical intervention is recommended for good grade patients. Second, active management of poor grade patients should be scrutinized with early surgery. Third, it is also important to step up the effort to minimize the risk of medical complications to enhance surgical results on top of the mainstay of prevention efforts for vasospasm and rebleeding.

Cytotoxicity of OKT9 ScFv-Diphtheria Toxin Fusion Immunotoxin on Human Brain Tumor Cell Lines

OBJECTIVE: Immunotoxin therapy is a novel approach for the treatment of tumor, and it has been successfully used in the central nervous system. The purpose of this study is to evaluate the cytotoxicity of OKT9 ScFv-Diphtheria toxin fusion immunotoxin on various human brain tumor cell lines. METHODS: Immunotoxin which was composed of OKT9 ScFv and Diphtheria toxin was made. Its cytotoxicity on glioblastoma cell lines(U87MG, U118MG) and medulloblastoma cell line(TE671) was tested and compared with anti-cancer chemotherapeutic agents. And we also examined the relationship between its cytotoxicity and transferrin receptor expression. RESULTS: It showed most cytotoxicity on U87MG cell line and nearly no effect on U118MG cell line, moderate cytotoxicity on TE671 cell line in sixteen hours exposure experiment. In continuous exposure experiment, it showed moderate cytotoxicity on U118MG cell line, but showed strong cytotoxicity on other cell lines comparable or higher than anti-cancer chemotherapeutic agents. The relationship between its cytotoxicity and transferrin receptor expression was tested using flow cytometry, but no direct relationship could be found. CONCLUSION: Collectively, the result shows the cytotoxic effects of OKT9 ScFv-Diphtheria toxin fusion immunotoxin against various human brain tumor cell lines in continuous exposure experiment. Therefore, we suggest that this immunotoxin could be developed as a potential immunotherapeutic agent in the treatment of various human brain tumor clinically.

Continuous Intratumoral Delivery of Chemotherapeutic Agent by Convection-enhanced Technique: Preliminary Clinical Study

OBJECTIVE: Because of the limited penetration into the central nervous system after systemic administration of numerous therapeutic compounds, intratumoral chemotherapy for brain tumors has also been used. However, the efficacy of intratumoral drug administration is restricted by the poor diffusion of drug through tumor and brain interstitium. In order to enhance the diffusion of chemotherapeutic agent and increase the cytotoxicity with minimal dose, the authors report the results of convection-enhanced delivery(CED) of chemotherapeutic agent to the malignant brain tumor as a method of enhancing cerebral drug delivery. METHODS: Authors used "CADD-Micro(R) ambulatory infusion pump" from Deltec, which can be programmed for continuous infusion. Intratumoral injection of chemotherapeutic drug using the pump was applied to eight patients with glioma and one patient with lymphoma. Surgery was done and tumor was removed as much as possible. The tip of catheter was placed in the center of tumor cavity. Adriamycin (0.16~0.32mg) was put in the reservoir which was connected to the proximal catheter and fixed in the pump device. Twenty-four hours after surgery, Adriamycin was infused. RESULTS: There was no adverse reaction of CED technique. Compared with current delivery techniques, the improvement of survival rate has been observed(5 patients: alive, 3 patients: dead, 1 patient: lost(alive to 5 mo.)). CONCLUSION: CED can be useful method for distributing therapeutic molecules in the interstitial space of tumor and can be utilized for chemotherapeutic agents, immunotoxins, and gene etc..

Intracerebral Hemorrhage Secondary to Ruptured Middle Cerebral Artery Aneurysms: Therapeutic Consideration and Prognostic Factors Related to the Site of Hemorrhage

OBJECTIVE: The purpose of this study is to investigate the prognostic factors and appropriate treatment in patients with intracerebral hemorrhage secondary to ruptured middle cerebral artery(MCA) aneurysms. METHODS: Among 120 cases with ruptured MCA aneurysms during last 9 years from 1993 to 2002, 85 cases was analyzed according to hematoma distribution. All cases were included in one of three groups Group A(15 cases) having an intraparenchymal hematoma(IPH) larger than 5cc with or without subarachnoid hemorrhage(SAH). Group B(25 cases) having an intrasylvian hematoma(ISH) with or without SAH. Group C(45 cases) having a diffuse SAH without localized hematoma. Prognosis was evaluated postoperatively by applying Glasgow Outcome Scale(GOS) at discharge. RESULTS: In Group A, hypertension and Hunt-Hess(H-H) grade on admission, hematoma volume larger than 15cc and postoperative edema were corrleated with poor outcome. In Group B, old age, postoperative edema and delayed ischemic neurologic deficit(DIND) were related to poor outcome. Group C revealed better consciousness on admission and favourable outcome than Group A and B. CONCLUSION: We suggest that therapeutic consideration in Group A is focused on postoperative edema after early surgical intervention and in Group B is focused on postoperative edema with DIND after removal of residual clot in sylvian fisssure as much as possible by irrigation and suction.

Cerebellar Ectopia Associated with Unilateral Agenesis of Posterior Arch of Atlas

Chiari type I malformation(CM-I) is a congenital disorder recognized by caudal displacement of the cerebellar tonsils through the foramen magnum and into the cervical canal. Though bony anomalies associated with CM including platybasia, small posterior fossa and occipitalization, are relatively frequent, but the incidence rate associated with agenesis of posterior arch of atlas is very low. We report our experience of surgical treatment for patient who had CM-I with unilateral agenesis of posterior arch of atlas.

Malignant Variant of the Central Neurocytoma

Central neurocytoma is a rare, well-differentiated neuronal tumor and is usually located in the lateral or third ventricle of young adults. Its overall prognosis is excellent with a low proliferative index. The majority of previously reported malignant variants rarely did recurred after tumor removal and regarded as benign tumor despite of histopathological malignant feature. Nevertheless, we experienced a case of malignant variant of the central neurocytoma with high proliferative index(Ki-67 labeling index >30%), which showed recurrence immediately after surgery and died within 3 months POD. Here, we describe the case with a review of the literatures.