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Ryuta Suzuki, Jun-ichiro Asai, Goro Nagashima, Hiroshi Itokawa, Chih-Wei Chang, Masayuki Noda, Michio Fujimoto and Tsukasa Fujimoto

Object. Transsphenoidal surgery for the removal of macroadenomas has some disadvantages, including the risk of performing procedures without adequate visualization, difficulties in estimating the amount of residual tumor, and the risk of injuring major vessels. To overcome these disadvantages, the authors have developed transcranial echo-guided transsphenoidal surgery.

Methods. Three patients with large macroadenomas and two patients with irregularly shaped macroadenomas were selected for this operation. In addition to standard preparations for transsphenoidal surgery, in each case the right frontal bone was trephined and an echo probe was inserted transdurally through the trephination hole. During tumor removal, brightness-mode echo images and Doppler color flow images were obtained. The echo images allowed for real-time visualization of the tumor and surrounding brain structures including major arteries and the cisterns; histological heterogeneities of the tumor could also be appreciated. The tumors were removed safely and maximal tumor removal was achieved.

Conclusions. Transcranial echo-guided transsphenoidal surgery provides real-time visualization of tumor removal. The method enhances the safety of this surgery, maximizes the removal of the tumor, and is inexpensive.

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G. Evren Keles, Edward F. Chang, Kathleen R. Lamborn, Tarik Tihan, Chih-Ju Chang, Susan M. Chang and Mitchel S. Berger

Object

To investigate the prognostic significance of the volumetrically assessed extent of resection on time to tumor progression (TTP), overall survival (OS), and tumor recurrence patterns, the authors retrospectively analyzed preoperative and postoperative tumor volumes in 102 adult patients from the time of the initial resection of a hemispheric anaplastic astrocytoma (AA).

Methods

The quantification of tumor volumes was based on a previously described method involving computerized analysis of magnetic resonance (MR) images. Analysis of contrast-enhancing tumor volumes on T1-weighted MR images was conducted for 67 patients who had contrast-enhancing tumors. Measurements of T2 hyperintensity were obtained for all 102 patients in the study.

The presence or absence of preresection enhancement, actual volume of this enhancement, and the percentage of preoperative enhancement as it relates to the total T2 tumor volume did not have a statistically significant relationship to TTP or OS. In addition to age, the volume of residual disease measured on T2-weighted MR images was the most significant predictor of TTP (p < 0.001), and residual contrast-enhancing tumor volume was the most significant predictor of OS (p = 0.003) on multivariate analysis. In contrast to low-grade gliomas, there was no statistically significant relationship between the extent of resection and histological characteristics at the time of recurrence, that is, tumor Grade III compared with Grade IV.

Conclusions

Data from this retrospective analysis of a histologically uniform group of hemispheric AAs treated in the MR imaging era suggest that residual tumor volumes, as documented on postoperative imaging studies, may be a prognostic factor for TTP and OS for this patient population.

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Chih-Chuan Yang, Hung-Chang Chen and Chien-Min Chen

✓Presacral tumors are rarely found in adults. Resections via open abdominal or sacral approaches have been advocated traditionally as the preferred treatment for these tumors. The endoscopic surgical technique provides direct visualization of the presacral or retroperitoneal space. The authors report on a 67-year-old man who experienced difficulty in defecation off and on for 5 weeks, and recently he had suffered indistinct pain in the lower abdomen. The abdominal computed tomography scan revealed a 5.1 × 4.2–cm, homogeneous, low-density, well-defined mass arising from the left sciatic nerve abutting the left piriformis muscle, favoring a diagnosis of benign neurogenic tumor. Endoscopically guided resection was applied, with a favorable outcome. This procedure represents a less invasive approach that may be useful for benign retroperitoneal pelvic tumors.

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Chih-Lung Lin, Aaron S. Dumont, Yu-Feng Su, Yee-Jean Tsai, Jih-Hui Huang, Kao-Ping Chang, Shen-Long Howng, Aij-Lie Kwan, Neal F. Kassell and Cheng-Hsing Kao

Object

Cerebral vasospasm remains a major complication in patients who have suffered a subarachnoid hemorrhage (SAH). Previous studies have shown that 17β-estradiol (E2) attenuates experimental SAH–induced cerebral vasospasm. Moreover, E2 has been shown to reduce neuronal apoptosis and secondary injury following cerebral ischemia. Adenosine A1 receptor (AR-A1) expression is increased following ischemia and may represent an endogenous neuroprotective effect. This study was designed to evaluate the efficacy of E2 in preventing cerebral vasospasm and reducing secondary injury, as evidenced by DNA fragmentation and AR-A1 expression, following SAH.

Methods

A double-hemorrhage model of SAH in rats was used, and the degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after the first SAH. A cell death assay was used to detect apoptosis. Changes in the protein expression of AR-A1 in the cerebral cortex, hippocampus, and dentate gyrus were compared with levels in normal controls and E2-treated groups (subcutaneous E2, 0.3 mg/ml).

Results

The administration of E2 prevented vasospasm (p < 0.05). Seven days after the first SAH, DNA fragmentation and protein levels of AR-A1 were significantly increased in the dentate gyrus. The E2 treatment decreased DNA fragmentation and prevented the increase in AR-A1 expression in the dentate gyrus. There were no significant changes in DNA fragmentation and the expression of AR-A1 after SAH in the cerebral cortex and hippocampus in the animals in the control and E2-treated groups.

Conclusions

The E2 was effective in attenuating SAH-induced cerebral vasospasm, decreasing apoptosis in the dentate gyrus, and reducing the expression of AR-A1 in the dentate gyrus after SAH. Interestingly, E2 appears to effectively prevent cerebral vasospasm subsequent to SAH as well as attenuate secondary injury by reducing both apoptosis and a compensatory increase in AR-A1 expression in the dentate gyrus.

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Chih-Lung Lin, Aaron S. Dumont, Yu-Feng Su, Zen-Kong Dai, Juei-Tang Cheng, Yee-Jean Tsai, Jih-Hui Huang, Kao-Ping Chang and Shiuh-Lin Hwang

Object

Apoptosis is implicated in vasospasm and long-term sequelae of subarachnoid hemorrhage (SAH). The authors observed that 17β-estradiol (E2) can attenuate cerebral vasospasm, lower endothelin-1 production, and preserve normal endothelial nitric oxide synthase expression by reduction of inducible NO synthase expression in experimental SAH. The authors investigated the potential antiapoptotic effects of E2 in an experimental rat model of SAH.

Methods

The authors examined the antiapoptotic effects of E2 in a double-hemorrhage SAH model in male Sprague-Dawley rats. The rats underwent subcutaneous implantation of a Silastic tube containing corn oil either with or without E2, and some E2-treated animals also received ICI 182,780 (a nonselective estrogen receptor [ER] antagonist) for 7 days after SAH. The degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after SAH. The expression of apoptotic indicators, including TNF-α, caspase 3, Bcl-2, Bax, terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick end labeling (TUNEL), and cell death assays were used for detection of apoptosis.

Results

Treatment with E2 significantly attenuated SAH-induced vasospasm. Seven days after the induction of SAH, positive TUNEL-staining was seen, and DNA fragmentation was increased in the dentate gyrus. Increased TNF-α and cleaved caspase-3 protein expression and decreased Bcl-2 protein expression in the dentate gyrus were also observed. These changes were reversed with E2-treatment but not in the presence of ICI 182,780. However, the expression of Bax did not change after SAH either with or without E2 treatment.

Conclusions

The authors found that E2 appears to confer an antiapoptotic effect that reduces secondary brain injury after SAH via estrogen receptor–dependent mechanisms. This finding provides support for possible future applications of E2 treatment for the reduction of secondary injury after SAH in patients.

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Oral Presentations

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

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Chih-Chen Chang, Hong-Shiu Chang and Cheng Hong Toh

The authors report a case in which intravitreous silicone oil migrated into the ventricles. They note that intraventricular silicone oil can be misdiagnosed as intraventricular hemorrhage and neurosurgeons should be aware of this possibility.

This 58-year-old woman with a history of Type II diabetic mellitus and retinal detachment (resulting from diabetic retinopathy), which had been treated with intravitreous silicone tamponade, presented with dizziness and headache approximately 10 years after the intravitreous silicone treatment. Over the next 6 years she underwent 2 non–contrast-enhanced brain CT studies and 1 MRI study for evaluation of her symptoms. On CT scan, extension of the intraocular silicone along the optic nerve was evident. Two hyperdense nodules were observed freely floating in the right lateral and fourth ventricles, remaining in the nondependent portion of ventricles in both supine and prone positions. On T2-weighted MRI, the left orbital content and the intraventricular nodules all demonstrated chemical shift artifacts typically associated with silicone. The imaging findings were characteristic for intraventricular silicone after silicone oil tamponade. The patient's dizziness and headache were treated symptomatically and she was followed up at the outpatient department.

Migration of intravitreous silicone oil into the cerebral ventricles is a rare complication. Intraventricular silicone oil can mimic intraventricular hemorrhage. Radiographically, intraventricular silicone oil can be distinguished from hemorrhage as silicone oil tends to stay in the nondependent portion of the ventricle. Chemical shift artifacts on MRI may help establishing the diagnosis of intraventricular silicone oil. Currently, there is no consensus on surgical removal of intraventricular silicone oil, and in the majority of cases reported in the literature, the patients were asymptomatic.

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Chih-Hsiang Liao, Jau-Ching Wu, Wen-Cheng Huang, Wei-Hsin Wang, Peng-Yuan Chang, Henrich Cheng and Yang-Shih

Surgical treatment of thoracic disc herniation is technically challenging from anterior, lateral or posterior approaches. Because of the deeply located thoracic discs and non-retractable thoracic thecal sac, standard anterior and lateral procedures for discectomy require extensive tissue dissection causing prolonged lengths of stay in hospital. In this video, the authors present a case of calcified disc herniation at the level of T10/11 causing paraplegia and voiding difficulty. The patient was operated on via an endoscope-assisted minimally invasive transforaminal thoracic interbody fusion (EA-TTIF). The herniated disc and calcification were removed through a 26-mm tubular retractor, under microscopes via a unilateral transpedicular approach. The endoscopes were used for direct visualization of the ventral thecal sac and confirmation of complete decompression. After the operation, the patient's neurological function completely recovered. Minimally invasive EA-TTIF is a viable and effective option for the surgical management of thoracic disc herniation. Thoracic interbody fusion can be achieved through a minimally invasive approach from the back.

The video can be found here: http://youtu.be/54rRMtvSyCM.

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Chang-Po Kuo, Li-Li Wen, Chun-Mei Chen, Billy Huh, Chen-Hwan Cherng, Chih-Shung Wong, Wen-Jinn Liaw, Chun-Chang Yeh, Bo-Feng Lin and Ching-Tang Wu

Object

Baicalein has been shown to offer neuroprotection in the ischemic brain, but its effect in subarachnoid hemorrhage (SAH) is unknown. The authors used a double-hemorrhage model to study the role of early baicalein treatment in SAH.

Methods

Subarachnoid hemorrhage was induced in male Wistar rats through a repeat injection of autologous blood at a 48-hour interval. Rats subjected or not subjected to SAH received a 30-mg/kg baicalein injection 3 hours after SAH and daily for 6 consecutive days, and results were compared with those obtained in vehicle-treated control rats. Mortality of the rats was recorded. Neurological outcome was assessed daily. Cerebrospinal fluid dialysates were collected and examined for glutamate concentrations. Cerebral vasospasm (CVS), brain water content, neuron variability, expression of glutamate transporter–1 (GLT-1), immunoreactivity of astrocyte, and level of malondialdehyde, activities of superoxide dismutase (SOD), and catalase in brain tissues content were determined on post-SAH Day 7.

Results

Mortality rate, neuronal degeneration, brain water content, and CVS were decreased and neurological function improved in the baicalein-treated rats. Baicalein increased astrocyte activity and preserved GLT-1, which attenuated the glutamate surge after SAH. Baicalein also provided antioxidative stress by preserving activities of SOD and catalase and decreased malondialdehydelevel after SAH. The glutamate, body weight, neurological scores, and glial fibrillary acidic protein activity were significantly correlated. The CVS was correlated with neuronal degeneration, and GLT-1 was correlated with oxidative stress.

Conclusions

Early baicalein treatment attenuated CVS and limited neurological injury following SAH. These data may indicate clinical utility for baicalein as an adjunct therapy to reduce brain injury and improve patient outcomes.

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Hsuan-Kan Chang, Jau-Ching Wu, Diego Shih-Chieh Lin, Chih-Chang Chang, Tsung-Hsi Tu, Wen-Cheng Huang and Henrich Cheng