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Zhijun Yang, Bo Wang, Chungcheng Wang, and Pinan Liu

Object

The authors aim to identify the characteristics of primary spontaneous CSF rhinorrhea and propose a hypothesis for its pathogenesis.

Methods

Between 2003 and 2009, 21 patients diagnosed with primary spontaneous CSF rhinorrhea underwent surgery in the authors' hospital. The clinical aspects were retrospectively reviewed, and their characteristics were analyzed.

Results

There were 18 women and 3 men, whose ages ranged from 37 to 74 years (mean 53 years). Body mass index (BMI) ranged from 22 to 58.8 kg/m2 (mean 31.2 kg/m2). Eighteen patients (85.7%) were overweight, and 18 (85.7%) suffered from headache or tinnitus before rhinorrhea. Radiological images revealed fully or partially empty sellae in 14 patients (66.7%). The preoperative intracranial pressure (ICP) ranged from 11 to 28 cm H2O (mean 17.6 cm H2O), while the postoperative ICP ranged from 21 to 32 cm H2O (mean 25.5 cm H2O, p < 0.01). An endoscopeassisted transnasal approach was chosen for the repair. Postoperatively, in 95.2% of patients a cure was achieved. Rhinorrhea recurred in only 1 patient, and a leakage from a new defect occurred in another patient 4 years after the operation. Both patients underwent additional surgery, which was successful. The follow-up period varied from 5 to 75 months with a mean of 34 months.

Conclusions

All patients had direct or indirect evidence of elevated ICP, most patients presented with symptoms of idiopathic intracranial hypertension (IIH), and most patients were women and obese. Primary spontaneous CSF rhinorrhea may be due to IIH, and it is a rare symptom of IIH. When treating or monitoring these patients during follow-up, ICP should be controlled, and other symptoms of IIH should be noted.

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Anant Naik, Darrion Bo-Yun Yang, Frank J. Bellafiore, Muhamad A. Amine, and Wael Hassaneen

BACKGROUND

Allergic fungal sinusitis (AFS) is an immunoglobulin E–mediated reaction to fungal organisms in the sinonasal region and can be categorized as acute or chronic. Acute infection is typical in immunocompromised patients, while chronic infection is classically seen in immunocompetent patients. Spread of infection to the skull base is a rare and potentially lethal complication of prolonged infection. Surgical management is frequently augmented with steroid therapy to prevent recurrence.

OBSERVATIONS

The authors present a case of a 20-year-old African American male with prolonged headaches and blurred vision who was diagnosed with chronic invasive fungal sinusitis resulting in invasion of fungal burden into the anterior skull base and the posterior aspect of the clivus, in addition to complete obliteration of the maxillary sinus. The patient was managed surgically without complication and with gradual improvement in vision.

LESSONS

Early management and detection of AFS should be a focus to prevent erosion of the fungal burden into the skull base. Neurosurgery and ear, nose, and throat surgery have a multidisciplinary role in the management of advanced AFS cases.

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Liang Xu, Xu Sun, Muyi Wang, Bo Yang, Changzhi Du, Qingshuang Zhou, Zezhang Zhu, and Yong Qiu

OBJECTIVE

The objective of this study was to investigate the incidence and risk factors of coronal imbalance (CI) in patients with early-onset scoliosis (EOS) who underwent growing rod (GR) treatment.

METHODS

A consecutive series of 61 patients with EOS (25 boys and 36 girls, mean age 5.8 ± 1.7 years) who underwent GR treatment was retrospectively reviewed. Postoperative CI was defined as postoperative C7 translation on either side ≥ 20 mm. Patients were divided into an imbalanced and a balanced group. Coronal patterns were classified into three types: type A (C7 translation < 20 mm), type B (C7 translation ≥ 20 mm with C7 plumb line [C7PL] shifted to the concave side of the curve), and type C (C7 translation ≥ 20 mm and a C7PL shifted to the convex side of the curve).

RESULTS

Each patient had an average of 5.3 ± 1.0 lengthening procedures and was followed for an average of 6.2 ± 1.3 years. Eleven patients (18%) were diagnosed with CI at the latest distraction, 5 of whom graduated from GRs and underwent definitive fusion. However, these patients continued to present with CI at the last follow-up evaluation. The proportion of preoperative type C pattern (54.5% vs 16.0%, p = 0.018), immediate postoperative apical vertebral translation (30.4 ± 13.5 mm vs 21.2 ± 11.7 mm, p = 0.025), lowest instrumented vertebra tilt (11.4° ± 8.2° vs 7.3° ± 3.3°, p = 0.008), and spanned obliquity angle (SOA) (9.7° ± 10.5° vs 4.1° ± 4.5°, p = 0.006) values in the imbalanced group were significantly higher than in the balanced group. Multiple logistic regression demonstrated that a preoperative type C pattern and immediate postoperative SOA > 11° were independent risk factors for postoperative CI.

CONCLUSIONS

The incidence of CI in patients with EOS who underwent GR treatment was 18%. This complication could only be slightly improved after definitive spinal fusion because of the autofusion phenomenon. A preoperative type C pattern and immediate postoperative SOA > 11° were found to be the risk factors for CI occurrence at the latest follow-up.

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Peng Li, Fu Zhao, Jing Zhang, Zhenmin Wang, Xingchao Wang, Bo Wang, Zhijun Yang, Jun Yang, Zhixian Gao, and Pinan Liu

OBJECT

The aim of this study was to evaluate the clinical features of spinal schwannomas in patients with schwannomatosis and compare them with a large cohort of patients with solitary schwannomas and neurofibromatosis Type 2 (NF2).

METHODS

The study was a retrospective review of 831 patients with solitary schwannomas, 65 with schwannomatosis, and 102 with NF2. The clinical, radiographic, and pathological data were extracted with specific attention to the age at onset, location of tumors, initial symptoms, family history, and treatment outcome.

RESULTS

The male-to-female ratio of patients with schwannomatosis (72.3% vs 27.7%) was significantly higher than that of patients with solitary schwannomas (53.3% vs 46.7%) and NF2 (54.0% vs 46.0%), respectively (chi-square test, p = 0.012). The mean age at the first spinal schwannoma operation of patients with NF2 (24.7 ± 10.2 years) was significantly younger than that of patients with solitary schwannomas (44.8 ± 13.2 years) and schwannomatosis (44.4 ± 14.1 years; 1-way ANOVA, p < 0.001). The initial symptoms were similar among the 3 groups, with pain being the most common. The distribution of spinal tumors among the 3 groups was significantly different. The peak locations of spinal schwannomas in patients with solitary schwannomas were at C1–3 and T12–L3; in schwannomatosis, the peak location was at T12-L5. A preferred spinal location was not evident for intradural-extramedullary tumors in NF2. Only a slight prominence in the lumbar area could be observed. The patients in the 3 groups obtained similar benefits from the operation; the recovery rates in the patients with solitary schwannomas, NF2, and schwannomatosis were 50.1%, 38.0%, and 53.9%, respectively. The prognosis varied among spinal schwannomas in the patients with schwannomatosis. Up until the last date of follow-up, most patients with schwannomatosis (81.5%) had undergone a single spinal operation, but 12 patients (18.5%) had undergone multiple spinal operations. Patients with nonsegmental schwannomatosis or those with early onset disease seemed to have a poor prognosis; they were more likely to undergo multiple spinal operations. Small cauda equina nodules were common in patients with schwannomatosis (46.7%) and NF2 (86.9%); these small schwannomas appeared to have relatively static behavior. Two patients suspicious for schwannomatosis were diagnosed with NF2 with the detection of constitutional NF2 mutations; 1 had unilateral vestibular schwannoma, and the other had suspicious bilateral trigeminal schwannomas.

CONCLUSIONS

The clinical features of spinal schwannomas vary among patients with solitary schwannomas, NF2, and schwannomatosis. Spinal schwannomas of patients with NF2 appear to be more aggressive than those in patients with solitary schwannomas and schwannomatosis. Spinal schwannomas of schwannomatosis predominate in the lumbar area, and most of them can be treated successfully with surgery. The prognosis varies among spinal schwannomas of schwannomatosis; some patients may need multiple operations due to newly developed schwannomas. Sometimes, it is difficult to differentiate schwannomatosis from NF2 based on clinical manifestations. It is prudent to perform close follow-up examinations in patients with undetermined schwannomatosis and their offspring.

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Cheng-Tsung Yang, Bo-Siang Fu, Hsun-Yen Wang, Huey-Kang Sytwu, and Dueng-Yuan Hueng

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Michael W. Groff, David C. Adams, Ronald A. Kahn, Uday M. Kumbar, Bo-Yi Yang, and Joshua B. Bederson

✓ Advances in anesthetic and surgical management, such as induced deep hypothermic circulatory arrest and application of temporary clips, have improved outcome for patients with basilar artery aneurysms. Nonetheless, these techniques are associated with significant risks. The authors report a case in which three transient periods of cardiac asystole were induced during basilar artery aneurysm surgery. Adenosine-induced asystole facilitated the safe clipping of the aneurysm by producing consistent periods of profound hypotension and collapse of the aneurysm without the need for temporary clipping. This technique provided unencumbered identification of perforating arteries, precise definition of the local anatomy, and an ideal environment for the safe placement of the aneurysm clip.

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Qiao Zuo, Pengfei Yang, Nan Lv, Qinghai Huang, Yu Zhou, Xiaoxi Zhang, Guoli Duan, Yina Wu, Yi Xu, Bo Hong, Rui Zhao, Qiang Li, Yibin Fang, Kaijun Zhao, Dongwei Dai, and Jianmin Liu

OBJECTIVE

The authors compared the contemporary perioperative procedure-related complications between coiling with stent placement and coiling without stent placement for acutely ruptured aneurysms treated in a single center after improvement of interventional skills and strategy.

METHODS

In an institutional review board–approved protocol, 133 patients who underwent coiling with stent placement and 289 patients who underwent coiling without stent placement from January 2012 to December 2014 were consecutively reviewed retrospectively. Baseline characteristics, procedure-related complications and mortality rate, angiographic follow-up results, and clinical outcomes were compared between the two groups. Univariate analysis and logistic regression analysis were performed to determine the association of procedure-related complications of coiling with stent placement with potential risk factors.

RESULTS

The coiling/stent group and coiling/no-stent group were statistically comparable with respect to all baseline characteristics except for aneurysm location (p < 0.001) and parent artery configuration (p = 0.024). The immediate embolization results and clinical outcomes between the two groups showed no significant differences (p = 0.807 and p = 0.611, respectively). The angiographic follow-up results of the coiling in stent group showed a significant higher occlusion rate and lower recurrence rate compared with the coiling/no-stent group (82.5% vs 66.7%, 3.5% vs 14.5%, p = 0.007). Procedure-related intraoperative rupture and thrombosis, postoperative early rebleeding and thrombosis, and external ventricular drainage–related hemorrhagic event occurred in 3.0% (4 of 133), 2.3% (3 of 133), 1.5% (2 of 133), 0.7% (1 of 133), and 0.8% (1 of 133) of the coiling/stent group compared with 1.0% (3 of 289), 1.4% (4 of 289), 1.4% (4 of 289), and 0.7% (2 of 289) of the coiling/no-stent group, respectively (p = 0.288, p = 0.810, p = 1.000, p = 0.315, and p = 1.000, respectively). One patient presented with coil protrusion in the group of coiling without stent. The procedure-related mortality was 1.5% (2 of 133) in the coiling/stent group and 0.7% in the coiling/no-stent group (p = 0.796). Multivariable analysis showed no significant predictors for the total perioperative procedure-related complications, hemorrhagic complications, or ischemic complications.

CONCLUSIONS

The perioperative procedure-related complications and mortality rate did not differ significantly between the coiling/stent group and the coiling/no-stent group for patients with acutely ruptured aneurysms. Considering the better angiographic follow-up results, coiling with stent placement might be a feasible, safe, and promising option for treatment in the acute phase of selected wide-necked ruptured intracranial aneurysms.

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Lennart Riemann, Daphne C. Voormolen, Katrin Rauen, Klaus Zweckberger, Andreas Unterberg, Alexander Younsi, and the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Investigators and Participants

OBJECTIVE

The aim of this paper was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life (HRQOL) in pediatric and adolescent patients with mild traumatic brain injury (mTBI) who received head CT imaging during initial assessment.

METHODS

Patients aged between 5 and 21 years with mTBI (Glasgow Coma Scale scores 13–15) and available Rivermead Post Concussion Questionnaire (RPQ) at 6 months of follow-up in the multicenter, prospectively collected CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) study were included. The prevalence of postconcussive symptoms was assessed, and the occurrence of postconcussive syndrome (PSC) based on the ICD-10 criteria, was analyzed. HRQOL was compared in patients with and without PCS using the Quality of Life after Brain Injury (QOLIBRI) questionnaire.

RESULTS

A total of 196 adolescent or pediatric mTBI patients requiring head CT imaging were included. High-energy trauma was prevalent in more than half of cases (54%), abnormalities on head CT scans were detected in 41%, and admission to the regular ward or intensive care unit was necessary in 78%. Six months postinjury, 36% of included patients had experienced at least one moderate or severe symptom on the RPQ. PCS was present in 13% of adolescents and children when considering symptoms of at least moderate severity, and those patients had significantly lower QOLIBRI total scores, indicating lower HRQOL, compared with young patients without PCS (57 vs 83 points, p < 0.001).

CONCLUSIONS

Adolescent and pediatric mTBI patients requiring head CT imaging show signs of increased trauma severity. Postconcussive symptoms are present in up to one-third of those patients, and PCS can be diagnosed in 13% 6 months after injury. Moreover, PCS is significantly associated with decreased HRQOL.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010