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Haewon Roh, Junwon Kim, Heejin Bae, Kyuha Chong, Jong Hyun Kim, Sang-il Suh, Taek-Hyun Kwon and Wonki Yoon

OBJECTIVE

The safety of the stent-assisted coil embolization (SAC) technique for acutely ruptured aneurysms has not been established yet. SAC is believed to be associated with a high risk of thromboembolic and hemorrhagic complications in acute subarachnoid hemorrhage (SAH). The aim of this study was to evaluate the safety and efficacy of the SAC technique in the setting of acutely ruptured aneurysm.

METHODS

A total of 102 patients who received endovascular treatment for acute SAH between January 2011 and December 2017 were enrolled. The SAC technique was performed in 38 of these patients, whereas the no-stent coil embolization (NSC) technique was performed in 64. The safety and efficacy of the SAC technique in acute SAH was evaluated as compared with the NSC technique by retrospective analysis of radiological and clinical outcomes.

RESULTS

There were no significant differences in clinical or angiographic outcomes between the SAC and NSC techniques in patients with acute SAH. The rate of ventriculostomy-related hemorrhagic complications was higher in the SAC group than that in the NSC group (63.6% vs 12.5%; OR 12.25, 95% CI 1.78–83.94, p = 0.01). However, all these complications were asymptomatic and so small that they were only able to be diagnosed with imaging.

CONCLUSIONS

Ruptured wide-necked aneurysms could be effectively and safely treated with the SAC technique, which showed clinical and angiographic outcomes similar to those of the NSC technique. Hence, the SAC technique with dual-antiplatelet drugs may be a viable option even in acute SAH.

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Jong Won Choi, Byung Moon Kim, Dong Joon Kim, Dong Ik Kim, Sang Hyun Suh, Na-Young Shin and Jin Goo Lee

Object

The purpose of this study was to evaluate the incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of hypoglossal canal dural arteriovenous fistula (HC-dAVF).

Methods

During a 16-year period, 238 patients underwent endovascular treatment for cranial dAVF at a single center. The incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of HC-dAVF were retrospectively evaluated.

Results

The incidence of HC-dAVF was 4.2% (n = 10). Initial symptoms were tinnitus with headache (n = 6), tinnitus only (n = 1), ocular symptoms (n = 1), otalgia (n = 1), and congestive myelopathy (n = 1). Presenting symptoms requiring treatment included ocular symptoms (n = 4), hypoglossal nerve palsy (n = 4), aggravation of myelopathy (n = 1), and aggravation of tinnitus with headache (n = 1). While the affected HC was widened in 4 of 10 patients, hypersignal intensity on source images was conspicuous in all 7 patients who underwent MR angiography (MRA). All ocular symptoms and congestive myelopathy were associated with predominant drainage to superior ophthalmic or perimedullary veins due to antegrade drainage restriction. All patients who underwent transvenous coil embolization (n = 8) or transarterial N-butyl cyanoacrylate (NBCA) embolization (n = 1) improved without recurrence. One patient who underwent transarterial particle embolization had a recurrence 12 months posttreatment and was retreated with transvenous embolization.

Conclusions

The incidence of HC-dAVF was 4.2% of all cranial dAVF patients who underwent endovascular treatment. Source images of MRA helped to accurately diagnose HC-dAVF. More aggressive symptoms may develop as a result of a change in the predominant drainage route due to the development of venous stenosis or obstruction over time. Transvenous coil embolization appears to be the first treatment of choice.

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Taek-Kyun Nam, Jung-Il Lee, Young-Jo Jung, Yong-Seok Im, Hee-Ye An, Do-Hyun Nam, Kwan Park and Jong-Hyun Kim

Object. This study was performed to evaluate the role of gamma knife surgery (GKS) in patients with a large number (four or more) of metastatic brain lesions.

Methods. The authors retrospectively reviewed the outcome in 130 patients who underwent GKS for metastatic lesions. Eighty-four patients presented with one to three lesions (Group A) and 46 presented with four or more lesions (Group B). The overall median survival time after GKS was 35 weeks. The median survival time in Group A (48 weeks) was significantly longer (p = 0.005) than the survival time in Group B (26 weeks). The recursive partitioning analysis (RPA) class was the only significant prognostic factor identified in multivariate analysis. The median survival for patients in RPA Classes I, II, and III was 72, 48, and 19 weeks, respectively, in Group A and 36 and 13 weeks for Classes II and III in Group B. The number of lesions, tumor volume, whole brain radiotherapy, primary tumor site, age, and sex did not affect survival significantly.

Conclusions. It is suggested that GKS provides an increase in survival time even in patients with a large number (four or more) of metastatic lesions. Concerning the selection of patients for GKS, RPA class should be considered as the most important factor and multiplicity of the lesions alone should not be a reason for withholding GKS.

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Doo-Sik Kong, Do-Hyun Nam, Jung-Il Lee, Kwan Park and Jong Hyun Kim

Object

The authors conducted a retrospective study to evaluate the efficacy of Gamma Knife surgery (GKS) followed by radiotherapy for the treatment of unresectable glioblastomas multiforme (GBMs) on patient survival and quality of life.

Methods

A total of 19 patients with unresectable GBMs located in eloquent areas of the brain were eligible for this study. Beginning in January 2002, 10 patients underwent GKS followed by fractionated radiotherapy. Nine patients who had undergone radiotherapy alone after biopsy-proven diagnosis served as the control group. The mean patient ages were 53 years and 56 years, respectively. Preoperative Karnofsky Performance Scale (KPS) scores were 80 (range 60–100) and 90 (range 50–100), respectively. The median margin dose for GKS was 12 Gy (9–16 Gy), and the total dose for radiotherapy was 60 Gy in 30 fractions. The mean follow-up duration was 7.2 months, the median patient survival time was 52 weeks (95% confidence interval [CI] 22–110.6 weeks) in the GKS group, and the median overall survival time was 28 weeks (95% CI 22.5–33.5 weeks) in the control group. The difference was not statistically significant (p = 0.0758). The estimated progression-free survival rate at 3 months was 75% in the GKS group and 45% in the control group (p = 0.082). The posttreatment KPS scores were either unchanged or improved in the GKS group, whereas it deteriorated by 20 or more points in six of nine patients of the control group (p = 0.004).

Conclusions

Gamma Knife surgery prior to radiotherapy may be helpful in preserving patients' daily activities in the adjuvant management of unresectable GBM.

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Jung-Il Lee, Do-Hyun Nam, Jong Soo Kim, Seung-Chyul Hong, Hyung-Jin Shin, Kwan Park, Whan Eoh, Yeon-Lim Suh and Jong Hyun Kim

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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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Hong Joo Moon, Bong-Kyung Shin, Joo Han Kim, Jong-Hyun Kim, Taek-Hyun Kwon, Hung-Seob Chung and Youn-Kwan Park

Intramedullary teratomas, particularly adult cervicothoracic lesions, are extremely rare. Up to now only 6 cases of intramedullary cervical teratomas have been reported in adults, and all of these were histologically mature. The authors present the case of a 35-year-old man with progressive myelopathic symptoms who was admitted through an outpatient clinic and was surgically treated. The characteristics, diagnosis, epidemiology, and treatment of cervical intramedullary teratomas in adults are also reviewed. Postoperative MR imaging showed that the tumor had been near totally removed, and severely adherent tissue remained ventrocranially with tiny focal enhancement on follow-up MR imaging. Pathological examinations revealed immature teratoma without any malignant component. Adjuvant therapy was not performed. Although no change in neurological findings and symptoms was apparent postoperatively, lesion regrowth was demonstrated on MR imaging 4 months after surgery. At 8 months postoperatively, myelopathic symptoms had developed and a huge intramedullary tumor recurred according to MR imaging. This case is the seventh reported instance of intramedullary cervical teratoma in an adult, and the first case report of the immature type with malignant features.

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Seung-Chyul Hong, Kwan-Soo Kang, Dae Won Seo, Seung Bong Hong, Munhyang Lee, Do-Hyun Nam, Jung-Il Lee, Jong Soo Kim, Hyung-Jin Shin, Kwan Park, Whan Eoh, Yeon-Lim Suh and Jong-Hyun Kim

Object. Surgical treatment of cortical dysplasia (CD) together with intractable seizures is challenging because both visualization and localization of the lesion are difficult, correlation with seizure foci requires comprehensive study, and the surgical outcomes reported thus far are unsatisfactory. The authors report their experience in the surgical treatment of CD classified according to a surgical point of view.

Methods. The definition of CD used in this study was a dysplastic lesion visible on magnetic resonance (MR) images or a lesion that, although not visible on MR images, was diagnosed as moderate-to-severe dysplasia by using pathological analysis. During the last 4.5 years, the authors treated 36 patients with intractable epilepsy accompanied by CD. They divided the 36 cases of CD into four characteristic groups: Group A, diffuse bilateral hemispheric dysplasia; Group B, diffuse lobar dysplasia; Group C, focal dysplasia; and Group D, a moderate to severe degree of CD with a normal appearance on MR images. All but one patient in Group C were monitored in the epilepsy monitoring unit by using subdural electrodes for seizure localization and functional mapping.

The incidence of CD among a cohort of 291 patients who had undergone epilepsy surgery at the authors' center during the study period was 12.4%. The mean age of the 36 patients was 21.3 years and the mean age at seizure onset was 8.5 years. The mean follow-up period was 26 months. Twenty-six patients (72.2%) belonged to Engel Class I or II (20 and six, respectively). There were five cases in Group A, nine in Group B, nine in Group C, and 13 in Group D. Patients in Groups A and B were significantly younger at seizure onset and had significantly poorer surgical outcomes compared with patients in Groups C and D (p < 0.05). If outcome is compared on the basis of the extent of removal of CD, patients in whom CD was completely removed had significantly better outcomes than those in whom CD was only partially removed (p < 0.001).

Conclusions. The authors conclude that intractable epilepsy accompanied by CD can be treated surgically using comprehensive preoperative approaches. Deliberate resective procedures aimed at complete removal of dysplastic tissue ensure excellent seizure control without permanent neurological deficit.

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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.