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Dong Gyu Kim, Chul-Kee Park, and Sun Ha Paek

✓ Bo Sung Sim (1924–2001) stands as a prominent figure in the history of Korean neurosurgery. His devoted contributions have led to the fruitful development of modern neurosurgery in Korea. Sim practiced advanced neurosurgical techniques, undertook basic research, was passionate about education in the early years of neurosurgery in Korea, and played an essential role in founding the Korean Neurosurgical Society. Sim was a true neurosurgeon—a teacher, a scientist, and a superb pioneer in Korean neurosurgery.

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Chul-Kee Park

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Chul-Kee Park, Dong-Chul Kim, Sung-Hye Park, Jeong Eun Kim, Sun Ha Paek, Dong Gyu Kim, and Hee-Won Jung

Object

Cystic vestibular schwannoma (VS) is a unique subgroup of VSs characterized by unpredictable expansion of the cyst component. Little is known, however, about the mechanism of cyst formation. In this study the authors compared neuroimaging and histological characteristics of cystic with solid VS to determine the pathogenesis of the cystic subgroup.

Methods

Two cohorts, one comprising 10 patients with cystic VS and the other comprising 10 patients with solid VS, were studied. Surgery was chosen as the primary treatment in all patients, with no other modality applied. Preoperative magnetic resonance images and histological characteristics of the tumor in patients with cystic VSs were evaluated and compared with those in the group with solid VSs. Differences between the two groups were assessed using the chi-square test. Neuroimaging findings revealed that either fluid-fluid level or hemosiderin deposit was present in all cystic VSs. Histological evidence of microhemorrhage, such as hemosiderinladen macrophages (p = 0.069), hemosiderin deposits (p = 0.019), thrombotic vessels (p = 0.008), and abnormal vessel proliferation (p = 0.006) were more prominent in cystic VSs compared with solid ones. There was no difference in Antoni type dominance and Ki-67 proliferative index between the two groups.

Conclusions

Intratumoral microhemorrhage is a possible mechanism of pathogenesis in cystic VS.

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Jung Ho Han, Dong Gyu Kim, Hyun-Tai Chung, Chul-Kee Park, Sun Ha Paek, Jeong Eun Kim, Hee-Won Jung, and Dae Hee Han

Object

In this paper the authors analyzed the clinical and neuroimaging outcomes of patients with cerebral arteriovenous malformations (AVMs) after Gamma Knife surgery (GKS), focusing on the analysis of the radiation injury rate depending on the AVM volume.

Methods

Between 1997 and 2004, 277 consecutive patients with cerebral AVMs were treated with GKS. Of these patients, 218 were followed up for ≥ 2 years. The mean age was 31 ± 15 years, the median AVM volume was 3.4 cm3 (range 0.17–35.2 cm3), the median marginal dose was 18.0 Gy (range 10.0–25.0 Gy), and the mean follow-up duration was 44 ± 20 months. The authors reduced the prescription dose by various amounts, depending on the AVM volume and location as prescribed in the classic guideline to avoid irreversible radiation injuries.

Results

The angiographic obliteration rate was 66.4% overall, and it was 81.7, 53.1, and 12.5% for small, medium, and large AVMs, respectively. The overall annual bleeding rate was 1.9%. The annual bleeding rate was 0.44 and 4.64% for small and large AVMs, respectively. Approximately 20% of the patients showed severe postradiosurgery imaging (PRI) changes. The rate of PRI change was 11.4, 33.3, and 9.5% for small, medium, and large AVM volume groups, respectively, and a permanent radiation injury developed in 5.1% of patients.

Conclusions

By using the reduced dose from what is usually prescribed, the authors were able to obtain outcomes in small AVMs that were comparable to the outcomes described in previous reports. However, medium AVMs appear to still be at risk for adverse radiation effects. Last, in large AVMs, the authors were able to attain a tolerable rate of radiation injury; however, the clinical outcomes were quite disappointing following administration of a reduced dose of GKS for large AVMs.

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Jin Wook Kim, Hee-Won Jung, Yong Hwy Kim, Chul-Kee Park, Hyun-Tai Chung, Sun Ha Paek, Dong Gyu Kim, and Sang Hyung Lee

OBJECTIVE

A thorough investigation of the long-term outcomes and chronological changes of multimodal treatments for petroclival meningiomas is required to establish optimal management strategies. The authors retrospectively reviewed the long-term clinical outcomes of patients with petroclival meningioma according to various treatments, including various surgical approaches, and they suggest treatment strategies based on 30 years of experience at a single institution.

METHODS

Ninety-two patients with petroclival meningiomas were treated surgically at the authors’ institution from 1986 to 2015. Patient demographics, overall survival, local tumor control rates, and functional outcomes according to multimodal treatments, as well as chronological change in management strategies, were evaluated. The mean clinical and radiological follow-up periods were 121 months (range 1–368 months) and 105 months (range 1–348 months), respectively.

RESULTS

A posterior transpetrosal approach was most frequently selected and was followed in 44 patients (48%); a simple retrosigmoid approach, undertaken in 30 patients, was the second most common. The initial extent of resection and following adjuvant treatment modality were classified into 3 subgroups: gross-total resection (GTR) only in 13 patients; non-GTR treatment followed by adjuvant radiosurgery or radiation therapy (non-GTR+RS/RT) in 56 patients; and non-GTR without adjuvant treatment (non-GTR only) in 23 patients. The overall progression-free survival rate was 85.8% at 5 years and 81.2% at 10 years. Progression or recurrence rates according to each subgroup were 7.7%, 12.5%, and 30.4%, respectively.

CONCLUSIONS

The authors’ preferred multimodal treatment strategy, that of planned incomplete resection and subsequent adjuvant radiosurgery, is a feasible option for the management of patients with large petroclival meningiomas, considering both local tumor control and postoperative quality of life.

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Kyung-Chung Kang, Chong-Suh Lee, Seung-Kee Shin, Se-Jun Park, Chul-Hee Chung, and Sung-Soo Chung

Object

Thoracic ossification of the ligamentum flavum (OLF), a main cause of thoracic myelopathy, is an uncommon disease entity. It is seen mostly in East Asia, although the majority of reports have issued from Japan. In the present study, the clinical features and prognostic factors of thoracic OLF were examined in a large number of Korean patients.

Methods

Data from 51 consecutive patients who underwent decompressive laminectomy with or without fusion for thoracic OLF between 1998 and 2008 were retrospectively analyzed. Patients were evaluated pre- and postoperatively using the modified Japanese Orthopedic Association (JOA) scale (maximum total score of 11). Patient age, sex, preoperative symptoms, duration of initial symptoms, number of involved segments, duration of follow-up, presence of dural adhesion (dural tearing), intramedullary high signal intensity, morphological classification of OLF (axial or sagittal), coexisting disease, and fusion or no fusion were also evaluated. Surgical outcomes were assessed using JOA recovery rate/outcome scores, and patient satisfaction grades and prognostic factors were analyzed.

Results

There were 18 men and 33 women with a mean age of 60.9 years (range 38–80 years). A mean preoperative JOA score of 5.5 improved to a mean score of 7.4 at the last follow-up (mean 52 months after surgery). The mean duration of the initial symptoms was 34.5 months (range 0.1–240 months) prior to surgery. The most common symptoms were motor dysfunction (80%); sensory deficit (67%); and pain, numbness, and claudication (59%) in the lower extremities. Knee hyperreflexia appeared in 69% of the patients. There were a total of 130 ossified segments, and the mean number of segments per patient was 2.6. Ninety-two (71%) of 130 segments were located below T-8. Recovery outcomes were good (18 patients), fair (16 patients), unchanged (11 patients), or worse (6 patients). Thirty-one patients (61%) were satisfied with their operations. Patients with a beak type of OLF on sagittal MR images experienced a higher recovery rate and a better satisfaction grade than did those with a round OLF. The patients with higher preoperative JOA scores demonstrated significantly higher JOA scores postoperatively (p < 0.001), and the preoperative JOA score had a significant correlation with the recovery rate in patients exhibiting mainly motor dysfunction (p = 0.040, r = 0.330).

Conclusions

Of the thoracic OLF studies published to date, the present analysis involves the largest Korean population. The most common symptoms of thoracic OLF were motor dysfunction and sensory deficit in the lower extremities, although pain, numbness, and claudication were observed in some patients and were notably accompanied by knee hyperreflexia. At a minimum of 2 years after surgery for thoracic OLF, operative outcomes were generally good, and the prognostic factors affecting good surgical outcomes included a beak type of OLF and a preoperative JOA score > 6.

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Chul-Jin Kim, Kee-Won Kim, Jin-Woo Park, Jung-Chung Lee, and John H. Zhang

Object. This study was undertaken to explore whether erythrocyte lysate, a proposed cause of vasospasm, produces vasoconstriction by activation of tyrosine kinase in rabbit cerebral arteries.

Methods. Isometric tension was used to monitor contractions in rabbit basilar arteries induced by erythrocyte lysate, 5-hydroxytryptamine (5-HT), or KCl in the absence or presence of tyrosine kinase inhibitors. Erythrocyte lysate, 5-HT, or KCl produced concentration-dependent contractions in rabbit basilar arteries. Preincubation with the tyrosine kinase inhibitors tyrphostin A23 and genistein (30 and 100 µM), but not diadzein, an inactive analog of genistein, attenuated significantly the contraction induced by erythrocyte lysate (p < 0.05). Tyrphostin A23, genistein, and diadzein (30 µM) failed to reduce the contraction caused by 5-HT. Genistein, but not tyrphostin A23 or diadzein (30 µM), attenuated significantly the contraction induced by KCl (p < 0.05). In another series, arterial rings were initially contracted with erythrocyte lysate, 5-HT, or KCl and the relaxant effect of genistein was then tested. Genistein relaxed rabbit basilar arteries that had been contracted by exposure to erythrocyte lysate, 5-HT, or KCl (30–100 µM; p < 0.05).

Conclusions. These data indicate that tyrosine kinase may play a role in the regulation of cerebral arterial contraction and tyrosine kinase inhibitors may be useful in the management of cerebral vasospasm.

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Ji Hoon Phi, Sun Ha Paek, Hyun-Tai Chung, Sang Soon Jeong, Chul-Kee Park, Hee-Won Jung, and Dong Gyu Kim

Object

The current study was undertaken to evaluate the tumor control rate and functional outcome after Gamma Knife surgery (GKS) in patients with a trigeminal schwannoma. The conditions associated with the development of cranial neuropathies after radiosurgery were scrutinized.

Methods

The authors reviewed the clinical records and radiological data in 22 consecutive patients who received GKS for a trigeminal schwannoma. The median tumor volume was 4.1 ml (0.2–12.0 ml), and the mean tumor margin dose was 13.3 ± 1.3 Gy at an isodose line of 49.9 ± 0.6% (mean ± standard deviation). The median clinical follow-up period was 46 months (range 24–89 months), and the median length of imaging follow-up was 37 months (range 24–79 months).

Results

Tumor growth control was achieved in 21 (95%) of the 22 patients. Facial pain responded best to radio-surgery, with two thirds of patients showing improvement. However, only one third of patients with facial hypesthesia improved. Six patients (27%) experienced new or worsening cranial neuropathies after GKS. Ten patients (46%) showed tumor expansion after radiosurgery, and nine of these also showed central enhancement loss. Loss of central enhancement, tumor expansion, and a tumor in a cavernous sinus were found to be significantly related to the emergence of cranial neuropathies.

Conclusions

The use of GKS to treat trigeminal schwannoma resulted in a high rate of tumor control and functional improvement. Cranial neuropathies are bothersome complications of radiosurgery, and tumor expansion in a cavernous sinus after radiosurgery appears to be the proximate cause of the complication. Loss of central enhancement could be used as a warning sign of cranial neuropathies, and for this vigilant patient monitoring is required.

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Dong Hyun Yoo, Chul-Ho Sohn, Young Dae Cho, Hyun-Seung Kang, Chul-Kee Park, Jin Wook Kim, and Jae Hyoung Kim

OBJECTIVE

Superselective pseudocontinuous arterial spin labeling (ss-pCASL) is an MRI technique in which individual vessels are labeled to trace their perfusion territories. In this study, the authors assessed its merit in defining feeding vessels and gauging preoperative embolization feasibility for patients with meningioma, using digital subtraction angiography (DSA) as the reference method.

METHODS

Thirty-one consecutive patients with meningiomas were prospectively recruited, each undergoing DSA (and embolization, if feasible) before resection. All ss-pCASL imaging studies were performed 1 day prior to DSA. Two neuroradiologists independently reviewed ss-pCASL images, rating the contribution of each labeled vessel to tumor blood supply as none, minor, or major. Two neuroradiologists also gauged the feasibility of embolization in each patient, based on ss-pCASL images. Interobserver and intermodality agreement were determined using Cohen’s kappa statistic. The diagnostic performance of ss-pCASL was assessed in terms of discerning tumor blood supply and the potential for embolization.

RESULTS

Interobserver agreement in the rating of blood supply by ss-pCASL was very good (κ = 0.817, 95% CI 0.771–0.863), and intermodality agreement (consensus ss-pCASL readings vs DSA findings) was good (κ = 0.688, 95% CI 0.632–0.744). In delineating tumor blood supply, ss-pCASL showed high sensitivity (87.1%) and specificity (87.2%). The positive and negative predictive values for embolization feasibility were 85.2% and 100%, respectively.

CONCLUSIONS

In patients with meningiomas, feeding vessels are reliably predicted by ss-pCASL. This noninvasive approach, involving no iodinated contrast or radiation exposure, is particularly beneficial if there are no prospects of embolization.

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Hyungseok Seo, Eugene Kim, Haesun Jung, Young-Jin Lim, Jin Wook Kim, Chul-Kee Park, Young-Bem Se, Young-Tae Jeon, Jung-Won Hwang, and Hee-Pyoung Park

OBJECTIVE

Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. The authors sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects.

METHODS

A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration.

RESULTS

The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ < 130 mmol/L) was significantly higher in Group D than in other groups (38.7% vs 0.0%, 9.7%, and 12.9% in Groups A, B, and C; p < 0.001, p = 0.008, and p = 0.020, respectively). Hyperkalemia (K+ > 5.0 mmol/L) was observed in 12.9% of patients in Group D only.

CONCLUSIONS

The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects.

Clinical trial registration no.: NCT02168075 (clinicaltrials.gov)