Long-term Complications of Arteriovenous Malformation Treated by Gamma Knife Radiosurgery: A 10-Year Experience

OBJECTIVE: The authors conduct a retrospective study to analyze long-term complications of Gamma knife radiosurgery for cerebral arteriovenous malformation(AVM). METHODS: We performed a detailed long-term follow-up study of 100 patients, who could be followed more than 2 years, with AVMs treated by Gamma knife radiosurgery during the last 10 years. At the time of radiosurgery, the mean age was 31.6 years(range : 7-65). The mean follow-up period after radiosurgery was 63.7 months(range : 24-116) except one mortality related with rebleeding. Mean target volume was 5039.2mm3(range : 105-38400). In all of the patients, AVMs were completely covered with a 40-80% isodose profile. The selected target dose delivered by the Gamma Knife was 7.2 to 33 Gy(mean : 22.2 Gy) at the periphery. RESULTS: Angiographic complete obliteration rate was 80% at 2 years after radiosurgery. Rebleeding occur in 4 cases at 4, 8, 44, 98 months after radiosurgery, respectively. Annual bleeding rate was 0.6%. Among them, one patient died. Postradiosurgical complications consisted of adverse radiation effects (ARE) in 19 patients, cyst formation in three, and asymptomatic vascular stenosis in one. Symptomatic ARE was 8% and the mean time from the last radiosurgery to ARE was 12.4 months(1-29) on follow-up images. Three patients, who have been verified angiographically complete obliteration, developed cyst formation within previous irradiated area at 48, 102, 115 months after radiosurgery respectively. Two of them underwent cystic aspiration with catheter drainage. CONCLUSION: The individual incidence of postradiosurgical complication was approximately from 3 to 19%, which is higher than expected. Long-term follow-up is mandatory even after complete nidus obliteration.

Intracerebral Hemorrhage in Geriatric Patients / 대한뇌혈관학회지

There are so many differences between the elderly patients and the younger patients in the aspects of a causes and the clinical course of spontaneous intracerebral hemorrage (ICH). As the mean life-time of a general population goes longer, the incidence of spontaneous ICH increases but the aggressive support in ICH is withdrawn more commonly and a prognosis of ICH becomes poor. Therefore, a prevention of ICH and a strict control of hypertension is very very important.

Comparative Study of Angiography and Magnetic Resonance Image in Verifying Obliteration of Arteriovenous Malformation after Gamma Knife Radiosurgery

OBJECTIVE: The purpose of this study is that magnetic resonance(MR) imaging can substitute for conventional angiography in verifying obliteration of arteriovenous malformation(AVM) after Gamma Knife radiosurgery. METHODS: Among the patients of AVM treated with Gamma Knife between 1992 and 1997, all of 40 patients who had been followed up more than 2 years(range 24-101 months) had no AVM on follow-up MR images. Follow-up imaging was performed every 6 months or when clinically warranted. Conventional angiography was performed when the AVM was no longer seen on MR images. RESULTS: Among 40 patients who had shown total obliteration on MR images, thirty one patients(77.5%) showed complete obliteration of the lesion on angiography. However, subtotal obliteration was shown in five patients(12.5%) and partial obliteration in four patients(10.0%). CONCLUSION: The conventional angiography is absolutely needed for verifying obliteration of AVMs and to eliminate the misunderstanding of follow-up MR images.

A Case of Turcot's Syndrome Combined with Colon Cancer in a 15-year-old Girl

Turcot's syndrome is a rare hereditary disease marked by the association of central nervous system neuroepithelial tumor with colonic polyposis. Authors report herein a case of a 15-year-old girl diagnosed as having Turcot's syndrome, otherwise known as brain tumor-polyposis syndrome, combined with sigmoid colon cancer. The patient was carried out craniostomy and brain tumor removal. The tumor was confirmed histologically to be oligodendroglioma. The patient visited the department of internal medicine for bloody diarrhea during 6 months. Colonoscopy and biopsy was done. The patient was diagnosed as having Turcot's syndrome combined with sigmoid colon cancer, and was then transferred to the department of surgery for treatment of sigmoid colon cancer. Total proctocolectomy and IPAA (ileal pouch-anal anastomosis) was carried out. Multiple polyps were found in the colon, two large masses were confirmed histologically to be adenocarcinoma. The remaining polyps were adenomas. This case report describes the characteristic features of Turcot's syndrome presented by this patient.

Dysembryoplastic Neuroepithelial Tumor in the Cerebellum: Case Report

Dysembryoplastic neuroepithelial tumor(DNT) is described by Daumas-Duport in 1988 and it was interpreted as low grade astrocytoma, oligodendroglioma, and mixed oligoastrocytoma previously. In recently revised World Health Organization classification of brain tumors, DNT is classified under 'neuronal and mixed neuronalglial tumor'. DNT is clinicopathologically unique tumor and commonly located in the temporal lobe associated with intractable complex partial seizure in young patients. We report a rare case of DNT located in the cerebellum.

Intradural Lipoma in the Lower Thoracic Spinal Cord

Intradural spinal lipoma is a rare benign tumor in the spinal cord and a case of intradural lipoma in the lower thoracic region is presented. In our case, subtotal resection was done due to the severe fibrous adhesion to surrounding neural tissue. We conclude that the role of surgery in intradural spinal lipoma should be a decompressive procedure to stop the progression of neurological deficit.

Treatment Outcome of Gamma Knife Radiosurgery for GH-Secreting Pituitary Tumors

OBJECTIVE: As for growth hormone(GH) secreting pituitary adenoma, it's remission should be declared on the basis of satisfactory controlling of the tumor, normalization of hormonal level, and symptomatic improvement of the patient. Several modalities of treatment have been applied and administered, and yet, this disease still remains as inveterate one to be fully treated. The purpose of this study is to evaluate the outcome of gamma knife radiosurgery(GKRS) for GH secreting pituitary adenoma, and to identify various factors affecting the outcome of the treatment. METHOD: A group of 24 out of 35 patients, treated by Leksell gamma knife unit during the period of March of 1992 through October of 1997, had been observed for more than two years. The mean target volume of microadenoma was 449.3mm3(range 216-880mm3), and that of macroadenoma was 3183.1mm3(range 1456-13125mm3). The tumor margin was covered with 50% isodose profile, and mean marginal dose was 25.2Gy(range 15-32.4Gy). The mean number of isocenter was 4.3(range 1-6). The exposed dose to the optic apparatus was less than 8Gy. The mean follow-up period was 37.8months(range 24-102months). RESULT: No patients showed any increase in the tumor volume during the follow-up period. And definite shrinkage of tumor volume(tumor volume reduction rate, TVRR: more than 50%) was obtained in 10 patients(41.7%). Twenty one patients(87.5%) had reduced hormonal level compared than pre-treatment level. Among them, normalization of the hormonal level was achieved in 12 patients(50%). Clinicoendocrinological remission was seen in 3 patients (12.5%). According to the results of statistical analysis, tumor volume(p=0.016),duration of symptoms(p=0.046), initial GH level(p=0.017), and the invasion of cavernous sinus(p=0.036) were significantly favorable to post-radiosurgical outcome. The TVRR was significantly related to post-radiosurgical reduction of serum GH level. Permanent complication was not seen. CONCLUSION: The authors concluded that GKRS is a safe and effective treatment modality for acromegaly. To otain the better outcome of GKRS in GH secreting pituitary adenoma, more careful and sophisticated treatment-planning is recommended.

Management Outcome and Clinical Manifestation of Posterior Circulation Aneurysms VS. Anterior Circulation Aneurysm

OBJECT: With the recent variable treatment modalities and the development of microsurgical techniques, outcomes of surgical and medical management of aneurysm have shown much progress in the last 10 years. However, the management of posterior circulation aneurysm is still a debatable due to its difficulty in limited surgical approach, complicated anatomical structure and many small perforators to vital structure. The purpose of this study is to compare the results of clinical manifestation and outcome of surgery with respect to anterior and posterior circulation aneurysms. MATERIAL AND METHODS: We evaluated the 33 patients with PCAs(posterior circulation aneurysm) and 359 patients with ACAs(anterior circulation aneurysm) treated between 1994 and 1999, retrospectively. RESULTS: Posterior circulation aneurysms showed higher tendency(5 cases, 14.7%) to have unusual shapes, such as dissecting or fusiform compared with anterior circulation aneurysm(15 cases, 4.2%). There were more multiple aneurysms in posterior circulation aneurysm(8 cases, 26.5%) than anterior circulation aneurysm(59 cases, 16.2%). The number of patients with Hunt-Hess grade III or IV on admission were 91(25.3%) in anterior circulation aneurysms, and 14(42.4%) in posterior circulation aneurysms. There were higher incidences of vasospasm and acute hydrocephalus in patients with posterior circulation aneurysm. In cases of anterior circulation aneurysm, neck clipping was possible in 97%. But, in posterior circulation aneurysm, neck clipping was possible only in 67.7% of each. Two hundred forty four cases(85.0%) of all anterior circulation aneurysms and 22 cases(78.6%) of all posterior circulation aneurysms showed good recovery(GR) or moderate disability(MD). The postoperative mortality rates of anterior and posterior circulation aneurysms were 4.9% and 10.7%, respectively. CONCLUSION: These results indicate that there exist substantial differences with respect to that there were few difference in the aspect of surgery and management outcome between posterior circulation aneurysms and anterior circulation aneurysms.

A Vestibular Schwannoma Associated with Massive Intratumoral Hemorrhage

The report of massive intratumoral hemorrhage from vestibular schwannoma is rare. A 66-year-old female who had suffered from disturbance of hearing for one year developed severe headache and dizziness. Brain MRI showed crescent shaped mass in the left cerebellopontine angle. A left suboccipital approach revealed an 3X3cm-sized encapsulated mass. The tumor was totally extirpated together with clot. Histologically the tumor was schwannoma with massive hemorrhage. Postoperative course was uneventful. The authors report the rare case of vestibular schwannoma presenting with intratumoral hemorrhage with review of possible pathophysiology and associated factor.

Meningioma with Intratumoral Hemorrhage

Meningioma associated with intratumoral hemorrhage is rarely reported. We present two patients with intratumoral hemorrhage. One 70-year-old man was admitted to our department with a decreased level of consciousness and left hemiparesis. CT scan and MRI scan revealed huge tumor with intratumoral hemorrhage in the frontal lobe. After surgical removal of the tumor, histopathological diagnosis was a meningotheliomatous meningioma. The other seemed patients was 56-year-old woman with headache and vomiting. She showed no specific neurological deficit. CT and MRI scan revealed large size tumor with intratumoral hemorrhage that looks like meningioma. The patient died suddenly before surgery. We reviewed the relevant literature and discussed the possible mechanism of hemorrhage in the meningioma.

The Role of Gamma Knife Radiosurgery for Essential and Secondary Trigeminal Neuralgia: vs Microsurgery

No abstract available.

Distal Superior Cerebellar Artery Aneurysm: Case Report

No abstract available.

The Role of Gamma Knife Radiosurgery for Prolactin Secreting Pituitary Adenomas

No abstract available.

The Clinical Analysis of Patients with Carpal Tunnel Syndrome Underwent Surgery: Comparison Between Conventional and Endoscopic Surgery

No abstract available.

A Clinical Analysis of Chronic Subdural Hematoma according to Age Factor

No abstract available.

Prognosis of Aneurysmal Subarachnoid Hemorrhage in the Elderly Patients / 대한뇌혈관학회지

The purpose of this study is to investigate the overall management outcome and surgical outcome for the elderly patients with aneurysmal subarachnoid hemorrhage (SAH) as compared with that of younger patients. To address the question of managing SAH in the elderly patients, 52 consecutive patients aged 65 or older (elderly patients group: EPG) and 312 patients aged 64 or younger (younger patients group: YPG) who admitted to Kyung-Hee university medical center during recent three years (from Jan. 1996 to Dec. 1998) were analyzed and compared with each other. The managemnet mortality was 17.0% in YPG and 44.2% in EPG, and favorable management outcome (including good recovery: GR and moderate disability: MD in the grade of Grascow outcome scale) was achieved in 65.0% in YPG and 38.5% in EPG (p0.05). The surgical outcomes according to the preoperative clinical grade (Hunt-Hess grade: HHG) were recorded as follows; 1) In the patients with good preoperative clinical grade (HHG I or II), favorable surgical outcome (including GR and MD) was achieved in 86.5% in YPG and 79.7% in EPG, and the surgical mortality was 2.9% in YPG and 6.7% in EPG (p>0.05). 2) In the patients with poor preoperative clinical grade (HHG III or IV), favorable surgical outcome was achieved in 62.8% in YPG and 57.2% in EPG, and the surgical mortality was 11.8% in YPG and 28.6% in EPG (p>0.05). 3) The favorable outcome achieved in patients with good preoperative clinical grade (86.5% in YPG, 79.7% in EPG) was superior to that of patients with poor preoperative grade (62.8% in YPG, 57.2% in EPG)(p<0.05). We conclude that the surgical treatment of an intracranial aneurysms are advisable not only in younger patients but also in patients aged 65 years or more with good neurological grade following SAH.

Correlation of Neuropeptide Y Neuron and its Size with Nitric Oxide Synthase in Cerebral Cortex of Aged Rats

No abstract available.

Frontosupraorbital Approach and Orbitozygomatic Temporopolar Approach for High Basilar Aneurysms

Surgery of aneurysms around the basilar bifurcation artery is still one of the most difficult and challenging operations in the field of neurosurgery, because of their rare occurrences, unfamiliar anatomy and deeply located lesions. Two major surgical approaches, pterional approach and subtemporal approach, are conventionally used for upper basilar artery aneurysm. Neither approach, however, ensures easy treatment of high basilar bifurcation aneurysm, because there is always the chance of excessive retraction of the brain, nerves and vessels. In order to gain sufficient exposure of highly placed basilar bifurcation aneurysms, the surgical approach needs to be in the direction in which the surgeon can see the interpeduncular fossa from below. In an attempt to gain better exposure of these lesions, neurosurgeons have used a variety of surgical approaches. We have used forntosupraorbital(FSO) approach and orbitozygomatic temporopolar(OZTP) approach for seven cases of high basilar aneurysm including basilar bifurcation artery-SCA aneurysm. The advantage of these approaches are multidirectional view, wide operative field, less brain retraction and easy application of temporary clip. Therefore, authors would like to recommended these approaches in case of for high basilar aneurysm as a effective method of aneurysmal neck clipping.

Treatment Results of the New Microsurgery in Hemifacial Spasm

Hemifacial spasm is painless uncommon disorder characterized by involuntary paroxysmal movement of one side of face. Microvascular decompression at root exit zone of the facial nerve has become the standard treatment for hemifacial spasm. An alternative hypothesis, proposed for the relieve of hemifacial spasm with microvascular decompression, actually result from minor trauma or circumferential fibrosis to a sensitive zone of the facial nerve. Upon the base of this hypothesis, author have treated patient with hemifacial spasm with surgical manipulation in addition to microvascular decompression. During last fifteen years, 250 patients with hemifacial spasm underwent this operation. The age at operation ranged from 18 to 71 years, with mean over 45.7 years and the duration of symptoms averaged 5.8 years. The spasms occurred predominantly right side, 5 cases were bilateral. The common offending vessels were AICA in 127 cases(50.8%) and PICA in 50 cases(20%). The remainder were 17 cases in vertebral artery, 9 cases in labyrin-thine artery(3.6%) and multiple offending vessels were found in 29 cases(11.6%). In two hundred fifteen cases, the spasm was completely relieved within 5 days after operation. Among 25 cases whose spasm unrelieved initially after surgery, 19 cases was relieved within 3 weeks and 6 cases within 3 months. Complications following surgery is approximately 22.8%: the most commonly encountered deficit is facial weakness(16 cases) followed by CSF leak (12 cases), and some degree of hearing loss(12 cases). Other complications include wound infection, ataxia, pneumocephalus and focal hemorrhage. Surgical manipulation in addition to microvascular decompression for hemifacial spasm(a new combined approach) produces better results of improvement approximately up to 96%.

Symptomatic Arachnoid Cyst in the Sellar Region: Case Report

A case of a large symptomatic intrasellar arachnoid cyst with suprasellar extension is reported. A 59-year-old woman was admitted because of headache and visual field defect caused by optic nerve compression. Magnetic resonance imaging showed a large intrasellar cyst extending into the suprasellar cistern, with compression of optic nerves. Transsphenoidal approach with cystectomy was performed. Histological study revealed that the cyst wall was composed of dense collagenous fibrous tissue and epithelial cells. The pathophysiology and the MRI finding of intrasellar arachnoid cysts are discussed.