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Cheng-Chia Lee and David Hung-Chi Pan

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Ta-Jen Lee, Po-Hung Chang, Chi-Che Huang and Chi-Cheng Chuang

Object

Basal encephaloceles are rare entities that can present as congenital diseases; however, traumatic lesions due to head injuries or iatrogenic causes have been described in the literature. In this study the authors aimed to define placement techniques for free grafts in repairing traumatic basal encephaloceles and to describe the long-term effectiveness of endoscopic treatment.

Methods

Between September 1997 and December 2006, 8 patients with traumatic encephaloceles underwent endoscopic surgery. A free graft following an underlay (2 cribriform plate and 4 ethmoid fovea defects) or obliteration (2 sphenoid defects) procedure was used as the repair material.

Results

All traumatic basal encephaloceles with the associated skull base defects and cerebrospinal fluid (CSF) leakage were successfully treated via the endoscopic approach. There were no major complications or recurrence of meningitis or leakage of CSF encountered after an average follow-up of 77 months.

Conclusions

Long-term follow-up results demonstrated that endoscopic surgery was suitable for the treatment of traumatic basal encephaloceles. The underlay procedure is more appropriate than the overlay procedure in repairing large defects of the anterior skull base. Meticulous manipulations of the endoscope following precise autograft placement are mandatory for the successful repair of traumatic basal encephaloceles.

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Da Li and Jun-Ting Zhang

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I-Chang Su, Chi-Cheng Yang, Wei-Han Wang, Jing-Er Lee, Yong-Kwang Tu and Kuo-Chuan Wang

The authors present a rare case of an infarction complication 15 days following acute intraventricular bleeding due to moyamoya disease. Before the infarction occurred, perfusion CT imaging disclosed early but reversible ischemic injury on the day of hemorrhage. Dehydration and hypotension are both possibly contributing factors of progressive injury from reversible ischemia due to infarction. Although the patient underwent successful bypass surgery, 1 month after the ictus the neurobehavior evaluation still showed marked executive dysfunction. The authors address that, in hemorrhagic-type moyamoya disease, early perfusion CT scanning is not only a powerful tool to identify the high-risk group of patients who could experience subacute infarction, but also alarms neurosurgeons to eliminate any predisposing factors when it shows reversible ischemic injuries.

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Ching-Chang Chen, Shao-Wei Chen, Po-Hsun Tu, Yin-Cheng Huang, Zhuo-Hao Liu, Alvin Yi-Chou Wang, Shih-Tseng Lee, Tien-Hsing Chen, Chi-Tung Cheng, Shang-Yu Wang and An-Hsun Chou

OBJECTIVE

Burr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown.

METHODS

A nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed.

RESULTS

The in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC.

CONCLUSIONS

Even for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.

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Mun-Chun Yeap, Ching-Chang Chen, Zhuo-Hao Liu, Po-Chuan Hsieh, Cheng-Chi Lee, Yu-Tse Liu, Alvin Yi-Chou Wang, Yin-Cheng Huang, Kuo-Chen Wei, Chieh-Tsai Wu and Po-Hsun Tu

OBJECTIVE

Cranioplasty is a relatively simple and less invasive intervention, but it is associated with a high incidence of postoperative seizures. The incidence of, and the risk factors for, such seizures and the effect of prophylactic antiepileptic drugs (AEDs) have not been well studied. The authors’ aim was to evaluate the risk factors that predispose patients to postcranioplasty seizures and to examine the role of seizure prophylaxis in cranioplasty.

METHODS

The records of patients who had undergone cranioplasty at the authors’ medical center between 2009 and 2014 with at last 2 years of follow-up were retrospectively reviewed. Demographic and clinical characteristics, the occurrence of postoperative seizures, and postoperative complications were analyzed.

RESULTS

Among the 583 patients eligible for inclusion in the study, 247 had preexisting seizures or used AEDs before the cranioplasty and 336 had no seizures prior to cranioplasty. Of these 336 patients, 89 (26.5%) had new-onset seizures following cranioplasty. Prophylactic AEDs were administered to 56 patients for 1 week after cranioplasty. No early seizures occurred in these patients, and this finding was statistically significant (p = 0.012). Liver cirrhosis, intraoperative blood loss, and shunt-dependent hydrocephalus were risk factors for postcranioplasty seizures in the multivariable analysis.

CONCLUSIONS

Cranioplasty is associated with a high incidence of postoperative seizures. The prophylactic use of AEDs can reduce the occurrence of early seizures.

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Cheng-Chia Lee, Hideyuki Kano, Huai-Che Yang, Zhiyuan Xu, Chun-Po Yen, Wen-Yuh Chung, David Hung-Chi Pan, L. Dade Lunsford and Jason P. Sheehan

Object

Nonfunctioning pituitary adenomas (NFAs) are the most common type of pituitary adenoma and, when symptomatic, typically require surgical removal as an initial means of management. Gamma Knife radiosurgery (GKRS) is an alternative therapeutic strategy for patients whose comorbidities substantially increase the risks of resection. In this report, the authors evaluated the efficacy and safety of initial GKRS for NFAs.

Methods

An international group of three academic Gamma Knife centers retrospectively reviewed outcome data in 569 patients with NFAs.

Results

Forty-one patients (7.2%) underwent GKRS as primary management for their NFAs because of an advanced age, multiple comorbidities, or patient preference. The median age at the time of radiosurgery was 69 years. Thirty-seven percent of the patients had hypopituitarism before GKRS. Patients received a median tumor margin dose of 12 Gy (range 6.2–25.0 Gy) at a median isodose of 50%. The overall tumor control rate was 92.7%, and the actuarial tumor control rate was 94% and 85% at 5 and 10 years postradiosurgery, respectively. Three patients with tumor growth or symptom progression underwent resection at 3, 3, and 96 months after GKRS, respectively. New or worsened hypopituitarism developed in 10 patients (24%) at a median interval of 37 months after GKRS. One patient suffered new-onset cranial nerve palsy. No other radiosurgical complications were noted. Delayed hypopituitarism was observed more often in patients who had received a tumor margin dose > 18 Gy (p = 0.038) and a maximum dose > 36 Gy (p = 0.025).

Conclusions

In this study, GKRS resulted in long-term control of NFAs in 85% of patients at 10 years. This experience suggests that GKRS provides long-term tumor control with an acceptable risk profile. This approach may be especially valuable in older patients, those with multiple comorbidities, and those who have endocrine-inactive tumors without visual compromise due to mass effect of the adenoma.

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Cheng-Chia Lee, David Hung-Chi Pan, Wen-Yuh Chung, Kang-Du Liu, Huai-Che Yang, Hsiu-Mei Wu, Wan-Yuo Guo and Yang-Hsin Shih

Object

The authors retrospectively reviewed the efficacy and safety of Gamma Knife surgery (GKS) in patients with brainstem cavernous malformations (CMs). The CMs had bled repeatedly and placed the patients at high risk with respect to surgical intervention.

Methods

Between 1993 and 2010, 49 patients with symptomatic CMs were treated by GKS. The mean age in these patients was 37.8 years, and the predominant sex was female (59.2%). All 49 patients experienced at least 2 instances of repeated bleeding before GKS; these hemorrhages caused neurological deficits including cranial nerve deficits, hemiparesis, hemisensory deficits, spasticity, chorea or athetosis, and consciousness disturbance.

Results

The mean size of the CMs at the time of GKS was 3.2 cm3 (range 0.1–14.6 cm3). The mean radiation dose directed to the lesion was 11 Gy with an isodose level at 60.0%. The mean clinical and imaging follow-up time was 40.6 months (range 1.0–150.7 months). Forty-five patients participated in regularly scheduled follow-up. Twenty-nine patients (59.2%) were followed up for > 2 years, and 16 (32.7%) were followed up for < 2 years. The pre-GKS annual hemorrhage rate was 31.3% (69 symptomatic hemorrhages during a total of 220.3 patient-years). After GKS, 3 episodes of symptomatic hemorrhage were observed within the first 2 years of follow-up (4.29% annual hemorrhage rate), and 3 episodes of symptomatic hemorrhage were observed after the first 2 years of follow-up (3.64% annual hemorrhage rate). In this study of 49 patients, symptomatic radiation-induced complications developed in only 2 patients (4.1%; cyst formation in 1 patient and perifocal edema with neurological deficits in the other patient). There were no deaths in this group.

Conclusions

Gamma Knife surgery is effective in reducing the rate of recurrent hemorrhage. In the authors' experience, it was possible to control bleeding using a low-dose treatment. In addition, there were few symptomatic radiation-induced complications. As a result, the authors believe that GKS is a good alternative treatment for brainstem CMs.

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Cheng-Chia Lee, Hsiu-Mei Wu, Wen-Yuh Chung, Ching-Jen Chen, David Hung-Chi Pan and Sanford P. C. Hsu

Object

Resection of vestibular schwannoma (VS) after Gamma Knife surgery (GKS) is infrequently performed. The goals of this study were to analyze and discuss the neurological outcomes and technical challenges of VS resection and to explore strategies for treating tumors that progress after GKS.

Methods

In total, 708 patients with VS underwent GKS between 1993 and 2012 at Taipei Veterans General Hospital. The post-GKS clinical courses, neurological presentations, and radiological changes in these patients were analyzed. Six hundred patients with imaging follow-up of at least 1 year after GKS treatment were included in this study.

Results

Thirteen patients (2.2%) underwent microsurgery on average 36.8 months (range 3–107 months) after GKS. The indications for the surgery included symptomatic adverse radiation effects (in 4 patients), tumor progression (in 6), and cyst development (in 3). No morbidity or death as a result of the surgery was observed. At the last follow-up evaluation, all patients, except 1 patient with a malignant tumor, had stable or near-normal facial function.

Conclusions

For the few VS cases that require resection after radiosurgery, maximal tumor resection can be achieved with modern skull-based techniques and refined neuromonitoring without affecting facial nerve function.