Comparative Analysis of Efficacy and Safety of Multisession Radiosurgery to Single Dose Radiosurgery for Metastatic Brain Tumors

BACKGROUND: The purpose of this study is to compare the efficacy and safety of multisession radiosurgery to those of single dose radiosurgery for metastatic brain tumors. METHODS: Between February 2008 and February 2012, 90 patients with 196 metastatic brain tumors were treated with cyberknife radiosurgery, and we reviewed these patients retrospectively. Among them, 57 patients underwent single dose radiosurgery, and 33 patients multisession radiosurgery. Tumors involving the eloquent area and large tumors (>5 cc) were treated with multisession radiosurgery. The median tumor volume and the median treatment dose of single dose radiosurgery were 2.05+/-0.72 cc and 19.76+/-1.54 Gy respectively, and in the case of multisession radiosurgery, 5.30+/-1.70 cc and 29.6+/-1.70 Gy respectively. The frequency of multisession dose was 3 to 5 times, on average 3.55 times, and 8.91 Gy were given per 1 session on average. RESULTS: The overall survival (OS) of multisession radiosurgery was 16.0 months, whereas that of single dose radiosurgery was 11.5 months. The radiologic tumor response rates were 90% in single dose radiosurgery and 95.4% in multisession radiosurgery, respectively. Over 6-month and 1-year periods, the OS rates of single dose radiosurgery were 71.4% and 44.9%, whereas those of multisession radiosurgery were 69.1% and 58.3%, respectively (p=0.83). Toxicities were seen in 18.1% in the single dose radiosurgery group versus 4% in the multisession radiosurgery group. The difference was significant (p<0.05). CONCLUSION: In this study, the multisession radiosurgery group, despite the location and size constraints, did not differ from the single dose radiosurgery group when comparing the survival and recurrence rates, but complications and toxicity were lower. Thus, multisession radiosurgery is thought to be beneficial for treatment of large tumors and tumors located in the eloquent area.

Crowned Dens Syndrome: A Case Report and Review of the Literature

The crowned dens syndrome (CDS), also known as periodontoid calcium pyrophosphate dehydrate crystal deposition disease, is typified clinically by severe cervical pain, neck stiffness and atlantoaxial synovial calcification which could be misdiagnosed as meningitis, epidural abscess, polymyalgia rheumatica, giant cell arthritis, rheumatoid arthritis, cervical spondylitis or metastatic spinal tumor. Crystalline deposition on cervical vertebrae is less well known disease entity and only a limited number of cases have been reported to date. Authors report a case of CDS and describe the clinical feature.

Minimum 3-Year Outcomes in Patients with Lumbar Spinal Stenosis after Bilateral Microdecompression by Unilateral or Bilateral Laminotomy

OBJECTIVE: Lumbar spine stenosis (LSS) can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Minimally invasive surgery has come to be more commonly used for the treatment of LSS. The current study describes outcomes of bilateral microdecompression by unilateral or bilateral laminotomy (BML) for degenerative LSS after a minimum follow-up period of 3 years and investigates factors that result in a poor outcome. METHODS: Twenty-one patients who were followed-up for at least 3 years were included in this study. For clinical evaluation, the Japanese Orthopedic Association (JOA) scoring system for low back pain was used. The modified grading system of Finneson and Cooper was used for outcome assessment. Radiographic evaluation was also performed for spondylolisthesis, sagittal rotation angle, and disc height. RESULTS: Twenty-one patients (10 men, 11 women) aged 53-82 years (64.1+/-8.9 years) were followed-up for a minimum of 3 years (36-69 months). During follow-up, two patients underwent reoperation. Average preoperative JOA score and clinical symptoms, except persistent low back pain, improved significantly at the latest follow-up. There were no significant differences in radiological findings preoperatively and postoperatively. Thirteen patients (61.9%) had excellent to fair outcomes. CONCLUSION: BML resulted in a favorable and persistent outcome for patients with degenerative LSS without radiological instability over a mid-term follow-up period. Persistent low back pain unrelated to postoperative instability adversely affects mid-term outcomes.

The Current Analysis of the Risk Factors for Bone Graft Infection after Cranioplasty / 대한신경손상학회지

OBJECTIVE: The aim of this study is to investigate the factors that may be related to bone graft infection and to contribute to lower the infection rate. According to current studies, the rate of bone graft infection after cranioplasty was reported up to 15.9% and this is significantly high. There are many analyses of the factors influencing bone graft infection, but this issue may need to be reconsidered in that the current medical environment is ever-changing. METHODS: We retrospectively reviewed the demographic, clinical data of 130 patients who underwent cranioplasty following decompressive craniectomy from January 2004 to December 2011. We analyzed several factors influencing bone graft infection and divided them into three categories of clinical, operation-related and hematological factors including white blood cell count, erythrocyte sedimentation rate, C-reactive protein and albumin. Statistical significance was done by chi-square test, Fisher's test and Mann-Whitney U test. RESULTS: The infection occurred in 12 patients in 130 cranioplasties (9.2%). There was no difference in infection rate between each group of early and later surgery, graft material, cause of craniectomy. Among many factors, low Glasgow Coma Scale (GCS< or =8) and combined ventriculoperitoneal (VP) shunt were significantly correlated with bone graft infection (p=0.025, p=0.025, respectively). There was no statistically significant difference in hematological analysis between groups. CONCLUSION: Low GCS and combined VP shunt with cranioplasty may increase the risk of bone graft infection.

Risk Factors for Reoperation after Traumatic Intracranial Hemorrhage / 대한신경손상학회지

OBJECTIVE: Progression after operation in traumatic brain injury (TBI) is often correlated with morbidity and poor outcome. We have investigated to characterize the natural course of traumatic intracranial hemorrhage and to identify the risk factors for postoperative progression in TBI. METHODS: 36 patients requiring reoperation due to hemorrhagic progression following surgery for traumatic intracranial hemorrhage were identified in a retrospective review of 335 patients treated at our hospital between 2001 and 2010. We reviewed the age, sex, Glasgow Coma Scale, the amount of hemorrhage, the type of hemorrhage, rebleeding site, coagulation profiles, and so on. Univariate statistics were used to examine the relationship between the risk factors and reoperation. RESULTS: Acute subdural hematoma was the most common initial lesion requiring reoperation. Most patients had a reoperation within 24-48 hours after operation. Peri-lesional edema (p=0.002), and initial volume of hematoma (p=0.013) were the possible factors of hemorrhagic progression requiring reoperation. But preoperative coagulopathy was not risk factor of hemorrhagic progression requiring reoperation. CONCLUSION: Peri-lesional edema and initial volume of hematoma were the statistical significant factors requiring reoperation. Close observation with prompt management is needed to improve the outcome even in patient without coagulopathy.

An Ideal Method of Calculating the Approved Period of Disability / 대한신경손상학회지

OBJECTIVE: In 1980s, so-called approved period of disability was imported to Korea from Japan to control the excess of compensation which was caused by an inappropriate rule for disability evaluation. However, there were neither objective criteria nor established area for the approved period of disability. Now, the objectivity and credibility of the disability evaluation become a serious problem. We tried to solve this problem. METHODS: We examined the time of import and background of the approved period of disability. We also investigated the status and problems of deciding the approved period of disability. We used an internet search using the keywords the approved period of disability in the Korean Supreme Court (http://glaw.scourt.go.kr/jbsonw/jbson.do). RESULTS: We found 11 precedents with full text. The approved period of disability was applied only for the disability from spinal injuries at first. The application area became wider. It was used as an expedient to negotiate the indemnities. In 2010, the Korean Academy of Medical Sciences made a new guideline as an appropriate rule for disability evaluation. A new method is necessary for calculating the average or acceptable period of disability instead of the approved period of disability. CONCLUSION: We proposed an ideal method of compensation according to the age and the degree of disability, i.e., (Disability Rate+Age)/5. This formula can be applied when the age was between 21-49 years old and the disability rate was less than 50%.

Morphometric Study of Hypoglossal Nerve and Facial Nerve on the Submandibular Region in Korean

OBJECTIVE: This study was performed to determine the anatomical landmarks and optimal dissection points of the facial nerve (FN) and the hypoglossal nerve (HGN) in the submandibular region to provide guidance for hypoglossal-facial nerve anastomosis (HFNA). METHODS: Twenty-nine specimens were obtained from 15 formalin-fixed adult cadavers. Distances were measured based on the mastoid process tip (MPT), common carotid artery bifurcation (CCAB), and the digastric muscle posterior belly (DMPB). RESULTS: The shortest distance from the MPT to the stylomastoid foramen was 14.1+/-2.9 mm. The distance from the MPT to the FN origin was 8.6+/-2.8 mm anteriorly and 5.9+/-2.8 mm superiorly. The distance from the CCAB to the crossing point of the HGN and the internal carotid artery was 18.5+/-6.7 mm, and that to the crossing point of the HGN and the external carotid artery was 15.1+/-5.7 mm. The distance from the CCAB to the HGN bifurcation was 26.6+/-7.5 mm. The distance from the digastric groove to the HGN, which was found under the DMPB, was about 35.8+/-5.7 mm. The distance from the digastric groove to the HGN, which was found under the DMPB, corresponded to about 65.5% of the whole length of the DMPB. CONCLUSION: This study provides useful information regarding the morphometric anatomy of the submandibular region, and the presented morphological data on the nerves and surrounding structures will aid in understanding the anatomical structures more accurately to prevent complications of HFNA.

A Case of Intraosseous Dural Arteriovenous Fistulas Involving Diploic Vein Treated with Transarterial Onyx Embolization

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous connections that lie within the dura. Intraosseous DAVFs involving diploic venous system are extremely rare. A 46-year-old woman presented with headache and right pulsatile tinnitus for three weeks. The tinnitus started after yelling. Digital subtraction angiography revealed DAVF within the basal portion of right parietal bone along the middle meningeal artery (MMA) groove. The fistula was fed by frontal branch of right MMA and drained into right transverse sigmoid sinus junction through dilated middle meningeal vein. The intraosseous DAVF involving diploic vein was successfully obliterated with Onyx embolization via transarterial route.

Significance of an Early Clinical Course during the External Ventricular Drainage in Thalamic Hemorrhage

OBJECTIVE: The purpose of this study is to investigate the significance of an early clinical course during the external ventricular drainage(EVD) in patients with thal amic hemorrhage. METHODS: During the last 11 years(1990-2000), a hundred patients with thalamic hemorrhage who underwent EVD were studied. Thirty-four patients underwent temporary closing of EVD at the mean interval of 4.5 days after EVD. The clinical course was divided into 3 groups according to change of Glasgow Coma Scale(GCS) scores of 2 or more within 3 days after EVD compared with those just before EVD: deteriorated, unchanged, and improved. RESULTS: The factors affecting mortality were unchanged(odds ratio [OR] 0.05, 95% confidence interval [CI]0.01-0.38, p=0.0028) and deteriorated clinical course(OR 0.06, 95% CI 0.01-0.38, p=0.0033), GCS scores at the time of admission(OR 1.3, 95% CI 1.02-1.66, p=0.0346), amount of hematoma(OR 0.91, 95% CI 0.83-1.00, p=0.0461) and hematoma enlargement(OR 0.06, 95% CI 0.01-0.65, p=0.0198). The factor affecting the early clinical deterioration was the hematoma enlargement(OR 0.11, 95% CI 0.03-0.38, p=0.0005). The shunt operation was predicted in patients who showed the clinical improvement after EVD followed by the clinical deterioration within 48 hours after temporary closing of EVD. CONCLUSION: It is suggested that an early clinical course during the maintenance of EVD is important to predict mortality and necessity of shunt operation.

Persistent Trigeminal Artery Aneurysm Treated with Guglielmi Detachable Coils

A persistent trigeminal artery(PTA) is a rare embryonic channel between internal carotid artery and basilar artery. It can be frequently associated with intracranial aneurysms. But an aneurysm arising from the junction of PTA and internal carotid artery(ICA) is extremely rare. The authors report a case of unruptured right ICA-PTA aneurysm treated with Guglielmi detachable coils successfully. Pathogenesis for the aneurysm formation at the junction of ICA and PTA is discussed.