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Ju Hyung Moon, Eui Hyun Kim, and Sun Ho Kim

OBJECTIVE

Transsphenoidal surgery (TSS) is considered a most effective treatment for pituitary tumors with huge suprasellar extension. However, the chance of developing CSF leakage is relatively high, because tearing of the arachnoid membrane is common and there could be multiple tear points during the dissection of suprasellar tumors from the overlying arachnoid membrane. If there are multiple leaking points in the arachnoid membrane packing methods such as using fat or multilayered fascia graft may not be sufficient to seal off the leaking points. Moreover, the packing material may not provide sufficient tamponade to stop bleeding, and thus generates postoperative hematoma formation in the tumor resection cavity. To prevent these complications, the authors have developed a new technique for remodeling the redundant arachnoid pouch (the so-called snare technique) to reconstruct the diaphragm, seal off the CSF leak points completely, and reduce the dead space in the tumor resection cavity.

METHODS

In 9 patients with huge macroadenomas (> 2.5 cm in diameter) with suprasellar extension, the snare technique was used to remodel the arachnoid pouch after tumor removal via standard TSS between July 2009 and August 2014. Complications were investigated, including postoperative CSF rhinorrhea, postoperative hematoma collection, and visual compromise.

RESULTS

During the resection of the tumor, CSF leakage was encountered in 8 cases, all of which were sealed off using the snare technique. In 1 case without intraoperative CSF leakage, the snare technique was also applied after intentional puncturing of the arachnoid membrane to reduce the volume and tension of the arachnoid pouch. None of the 9 patients experienced postoperative CSF rhinorrhea. Lumbar CSF drainage was not required in any case. Magnetic resonance imaging studies performed 24 hours after surgery revealed a remarkable reduction in the height of the diaphragm in all cases. Visual deficits improved in all patients immediately after surgery.

CONCLUSIONS

Remodeling of the arachnoid pouch using the snare technique is simple and effective for completely sealing off the CSF leak point and preventing hematoma collection in the tumor resection cavity after TSS for huge pituitary tumors with suprasellar extension.

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Ju Hyung Moon, Eui Hyun Kim, and Sun Ho Kim

OBJECTIVE

Endonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects.

METHODS

A retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap.

RESULTS

Thirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery.

CONCLUSIONS

Extended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.

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Eui Hyun Kim, Jung Yong Ahn, and Sun Ho Kim

Object

The transcranial approach has been the standard technique for removal of craniopharyngiomas for several decades. However, many reports of successful suprasellar craniopharyngioma removal accomplished using extended transsphenoidal surgery (TSS) have recently been published. In the present study, the authors describe their technique and the outcomes of removal of suprasellar craniopharyngiomas aided by the use of an operating microscope and an endoscope concurrently during extended TSS.

Methods

Between 1999 and 2008, 18 patients with suprasellar craniopharyngiomas underwent TSS. Tumors that adhered to the optic nerve were safely dissected, and fine perforating vessels were precisely preserved with the aid of a magnified, detailed microscopic view. Portions of the tumor that could not be properly visualized with the microscope were visualized with the endoscope.

Results

Total resection was achieved in all patients, and all visual symptoms improved. Preoperative hypopituitarism improved in 2 patients but persisted postoperatively in 15 patients (hormonal outcome was not available in 1 patient). Diabetes insipidus was present in 16 patients postoperatively. Cerebrospinal fluid leakage developed in 3 patients in the conventional fascia lata graft group, whereas no CSF leakage occurred after the dural suture technique with a fascia lata graft was introduced. This technique could be more precisely applied when using a microscopic view. Tumor recurrence was documented for 1 patient 2 years after surgery.

Conclusions

The authors achieved good results by using extended TSS for the removal of suprasellar craniopharyngiomas. Endoscopy-assisted microscopic extended TSS harnesses the advantages of a microscope as well as those of an endoscope. Surgeons should consider using the advantages of both surgical modalities to achieve the best result possible.

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Min Chul Oh, Eui Hyun Kim, and Sun Ho Kim

Object

The purpose of this study was to assess factors associated with intracranial aneurysm (IA) in patients with pituitary adenoma (PA). In addition, these patients were compared with a control group from the general patient population in terms of the age-matched prevalence rate and the pattern of distribution of IA.

Methods

The authors retrospectively reviewed 800 patients who received transsphenoidal surgery for PA and 3850 control patients from the general patient population who were evaluated for routine health care at the authors' institution between 2004 and 2010. All patients underwent MR imaging and MR angiography. Hormone assessment and pathological examination performed using immunohistochemical (IHC) staining were completed for patients with PA.

Results

Coexistence of IA in patients with PA was detected in 18 patients (2.3%). Multivariate analysis showed that age (p = 0.04) and cavernous sinus invasion (p < 0.001) were correlated with the increased incidence of IA, but hormone type, IHC staining, and sex were not associated. An age-matched comparison of the prevalence of IA showed an increased prevalence in patients with PA compared with the controls (p = 0.014), and when categorized according to age by decade, the 6th decade was significantly different (p = 0.039). However, the intracranial distribution pattern of IA did not demonstrate a significant difference.

Conclusions

Older age and the existence of a cavernous sinus invasion were correlated with increased incidence of IA in patients with PA. An age-matched comparison showed an increased incidence of IA in patients with PA than in the controls.

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Eui Hyun Kim, Se Hoon Kim, Jin Mo Cho, Jung Yong Ahn, and Jong Hee Chang

The authors report a case of IgG4-related hypertrophic pachymeningitis that involved cerebral parenchyma. The mass was removed surgically. Histopathological studies showed diffuse infiltration of lymphoplasmacytic cells without evidence of Langerhans histiocytes or meningothelial cells. Immunoglobulin G4 was strongly positive on immunohistochemical staining. The Gd-enhanced lesion deep inside brain parenchyma was completely resolved after 3 months of oral corticosteroid medication. A nodular type of hypertrophic pachymeningitis that mimics a meningioma is rare. Nevertheless, preoperative presumption is very important, and immunohistochemical studies for IgG4 may be helpful in the differential diagnosis.

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Ji Woong Oh, Kyoung Su Sung, Ju Hyung Moon, Eui Hyun Kim, Won Seok Chang, Hyun Ho Jung, Jin Woo Chang, Yong Gou Park, Sun Ho Kim, and Jong Hee Chang

OBJECTIVE

This study investigated long-term follow-up data on the combined pituitary function test (CPFT) in patients who had undergone transsphenoidal surgery (TSS) for nonfunctioning pituitary adenoma (NFPA) to determine the clinical parameters indicative of hypopituitarism following postoperative Gamma Knife surgery (GKS).

METHODS

Between 2001 and 2015, a total of 971 NFPA patients underwent TSS, and 76 of them (7.8%) underwent postoperative GKS. All 76 patients were evaluated with a CPFT before and after GKS. The hormonal states were analyzed based on the following parameters: relevant factors before GKS (age, sex, extent of resection, pre-GKS hormonal states, time interval between TSS and GKS), GKS-related factors (tumor volume; radiation dose to tumor, pituitary stalk, and normal gland; distance between tumor and stalk), and clinical outcomes (tumor control rate, changes in hormonal states, need for hormone-related medication due to hormonal changes).

RESULTS

Of the 971 NFPA patients, 797 had gross-total resection (GTR) and 174 had subtotal resection (STR). Twenty-five GTR patients (3.1%) and 51 STR patients (29.3%) underwent GKS. The average follow-up period after GKS was 53.5 ± 35.5 months, and the tumor control rate was 96%. Of the 76 patients who underwent GKS, 23 were excluded due to pre-GKS panhypopituitarism (22) or loss to follow-up (1). Hypopituitarism developed in 13 (24.5%) of the remaining 53 patients after GKS. A higher incidence of post-GKS hypopituitarism occurred in the patients with normal pre-GKS hormonal states (41.7%, 10/24) than in the patients with abnormal pre-GKS hormonal states (10.3%, 3/29; p = 0.024). Target tumor volume (4.7 ± 3.9 cm3), distance between tumor and pituitary stalk (2.0 ± 2.2 mm), stalk dose (cutoffs: mean dose 7.56 Gy, maximal dose 12.3 Gy), and normal gland dose (cutoffs: maximal dose 13.9 Gy, minimal dose 5.25 Gy) were factors predictive of post-GKS hypopituitarism (p < 0.05).

CONCLUSIONS

This study analyzed the long-term follow-up CPFT data on hormonal changes in NFPA patients who underwent GKS after TSS. The authors propose a cutoff value for the radiation dose to the pituitary stalk and normal gland for the prevention of post-GKS hypopituitarism.

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Sung Soo Ahn, Na-Young Shin, Jong Hee Chang, Se Hoon Kim, Eui Hyun Kim, Dong Wook Kim, and Seung-Koo Lee

Object

The methylation status of the methylguanine methyltransferase (MGMT) promoter has been associated with treatment response in glioblastoma. The authors aimed to assess whether MGMT methylation status can be predicted by dynamic contrast-enhanced (DCE) MRI and diffusion tensor imaging (DTI).

Methods

This retrospective study included 43 patients with pathologically diagnosed glioblastoma who had undergone preoperative DCE-MRI and DTI and whose MGMT methylation status was available. The imaging features were qualitatively assessed using conventional MR images. Regions of interest analyses for DCE-MRI permeability parameters (transfer constant [Ktrans], rate transfer coefficient [Kep], and volume fraction of extravascular extracellular space [Ve]) and DTI parameters (apparent diffusion coefficient [ADC] and fractional anisotropy [FA]) were performed on the enhancing solid portion of the glioblastoma. Chi-square or Mann-Whitney tests were used to evaluate relationships between MGMT methylation and imaging parameters. The authors performed receiver operating characteristic curve analysis to find the optimal cutoff value for the presence of MGMT methylation.

Results

MGMT methylation was not significantly associated with any imaging features on conventional MR images. Ktrans values were significantly higher in the MGMT methylated group (median 0.091 vs 0.053 min−1, p = 0.018). However, Kep, Ve, ADC, and FA were not significantly different between the 2 groups. The optimal cutoff value for the presence of MGMT methylation was Ktrans > 0.086 min−1 with an area under the curve of 0.756, a sensitivity of 56.3%, and a specificity of 85.2%.

Conclusions

Ktrans may serve as a potential imaging biomarker to predict MGMT methylation status preoperatively in glioblastoma; however, further investigation with a larger cohort is necessary.

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Hun Ho Park, Min Chul Oh, Eui Hyun Kim, Chan Yun Kim, Sun Ho Kim, Kyu-Sung Lee, and Jong Hee Chang

OBJECT

The authors investigated the value of retinal nerve fiber layer (RNFL) thickness in predicting visual outcome after surgery for parachiasmal meningioma.

METHODS

Forty-nine eyes of 25 patients who underwent craniotomy and resection of a parachiasmal meningioma were analyzed retrospectively. Visual parameters including visual field (VF) (recorded as the mean deviation [MD]), visual acuity (VA), and RNFL thickness (via optical coherence tomography) were measured before and 1 week, 6 months, and 1 year after surgery. Postoperative visual outcome was compared among the patients with a thin or normal RNFL. A separate analysis of data pertaining to 22 eyes of 13 patients with severe VF defects (MD ≤ −10 dB) was performed to compare visual outcome for those with a thin or normal RNFL.

RESULTS

Of the 23 eyes that showed VF improvement, 22 (95.7%) had normal RNFL thickness. The positive predictive value of normal RNFL thickness for VF improvement was 78.6%. The VF of patients with normal RNFL thickness improved in 6 months and continued improving 1 year after surgery (MD −5.9 dB before surgery, −5.5 dB 1 week after surgery, −2.8 dB 6 months after surgery [p < 0.01], and −1.1 dB 1 year after surgery [p < 0.01]). In contrast, those with a thin preoperative RNFL showed deterioration at first and then slower, worse visual recovery after surgery (MD −18.1 dB before surgery, −22.4 dB 1 week after surgery, −21.2 dB 6 months after surgery, and −19.1 dB 1 year after surgery). VA also showed significant progress 6 months after surgery in patients with normal RNFL thickness (0.6 before surgery, 0.7 one week after surgery, 0.9 six months after surgery [p = 0.025], and 0.9 one year after surgery [p = 0.050]) compared to those with a thin RNFL (0.3 before surgery, 0.2 one week after surgery, 0.3 six months after surgery, and 0.4 one year after surgery). Preoperative differences in VF MD and VA were noted between the 2 groups (p < 0.01). Even patients with severe VF defects and normal RNFL thickness improved by 11.1 dB by 1 year after surgery compared with patients with a thin RNFL (−0.01 dB) (p < 0.01). Patients with normal RNFL thickness also did better in VA improvement (from 0.7 to 1.1) than those with a thin RNFL (from 0.2 to 0.3), but these results were not statistically significant.

CONCLUSIONS

RNFL thickness measured by optical coherence tomography has significant value as a prognostic factor of postoperative visual recovery for parachiasmal meningioma. Patients with normal RNFL thickness before surgery are more likely to have visual improvement after surgery than patients with a thin RNFL.

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Soo Heon Kim, Cheol Ryong Ku, Minkyun Na, Jihwan Yoo, Woohyun Kim, In-Ho Jung, Kyung Won Kim, Ju Hyung Moon, Daham Kim, Eun Jig Lee, Sun Ho Kim, and Eui Hyun Kim

OBJECTIVE

Thyroid-stimulating hormone (TSH)–secreting pituitary adenoma (TSHoma) is a rare type of pituitary adenoma; thus, little is known about TSHomas. The purpose of this study was to analyze clinical characteristics and therapeutic outcomes of TSHomas based on a single-center experience. The authors also searched for reliable preoperative and early postoperative factors that could predict long-term endocrinological remission.

METHODS

The clinical, radiological, and pathological characteristics and surgical and endocrinological outcomes of 31 consecutive cases of TSHomas that were surgically treated between 2005 and 2017 were reviewed retrospectively. Preoperative factors were evaluated for their ability to predict long-term remission by comparing remission and nonremission groups. TSH and free thyroxine levels were measured at 2, 6, 12, 18, and 24 hours after surgery to determine whether they could predict long-term remission.

RESULTS

Gross-total removal of tumor was achieved in 28 patients (90.3%), and 26 patients (83.9%) achieved endocrinological remission by surgery alone based on long-term endocrinological follow-up (median 50 months, range 32–81 months). The majority of the tumors were solid (21/31, 67.7%), and en bloc resection was possible in 16 patients (51.6%). Larger tumor size and tumor invasion into cavernous sinus and sphenoid sinus were strong predictors of lower rates of endocrinological remission. Immediate postoperative TSH level at 12 hours after surgery was the strongest predictor, with a 0.62 μIU/mL cutoff. Postoperative complications included CSF rhinorrhea in one patient and epistaxis in another patient, who underwent additional surgical treatment for the complications.

CONCLUSIONS

Tumor size and extent are major prognostic factors for both extent of resection and endocrinological remission. The consistency of TSHomas was more likely to be solid, which makes extracapsular dissection more feasible. Long-term remission of TSHomas could be predicted even during the early postoperative period.

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Soo Heon Kim, Cheol Ryong Ku, Minkyun Na, Jihwan Yoo, Woohyun Kim, In-Ho Jung, Kyung Won Kim, Ju Hyung Moon, Daham Kim, Eun Jig Lee, Sun Ho Kim, and Eui Hyun Kim

OBJECTIVE

Thyroid-stimulating hormone (TSH)–secreting pituitary adenoma (TSHoma) is a rare type of pituitary adenoma; thus, little is known about TSHomas. The purpose of this study was to analyze clinical characteristics and therapeutic outcomes of TSHomas based on a single-center experience. The authors also searched for reliable preoperative and early postoperative factors that could predict long-term endocrinological remission.

METHODS

The clinical, radiological, and pathological characteristics and surgical and endocrinological outcomes of 31 consecutive cases of TSHomas that were surgically treated between 2005 and 2017 were reviewed retrospectively. Preoperative factors were evaluated for their ability to predict long-term remission by comparing remission and nonremission groups. TSH and free thyroxine levels were measured at 2, 6, 12, 18, and 24 hours after surgery to determine whether they could predict long-term remission.

RESULTS

Gross-total removal of tumor was achieved in 28 patients (90.3%), and 26 patients (83.9%) achieved endocrinological remission by surgery alone based on long-term endocrinological follow-up (median 50 months, range 32–81 months). The majority of the tumors were solid (21/31, 67.7%), and en bloc resection was possible in 16 patients (51.6%). Larger tumor size and tumor invasion into cavernous sinus and sphenoid sinus were strong predictors of lower rates of endocrinological remission. Immediate postoperative TSH level at 12 hours after surgery was the strongest predictor, with a 0.62 μIU/mL cutoff. Postoperative complications included CSF rhinorrhea in one patient and epistaxis in another patient, who underwent additional surgical treatment for the complications.

CONCLUSIONS

Tumor size and extent are major prognostic factors for both extent of resection and endocrinological remission. The consistency of TSHomas was more likely to be solid, which makes extracapsular dissection more feasible. Long-term remission of TSHomas could be predicted even during the early postoperative period.