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June Ho Lee, Chae-Yong Kim, Dong Gyu Kim and Hee-Won Jung

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Yang Kwon, Jae Sung Ahn, Sang Ryong Jeon, Jeong Hoon Kim, Chang Jin Kim, Jung Kyo Lee, Byung Duk Kwun, Do Hee Lee and Sun Young Kim

Object. The authors evaluated whether gamma knife radiosurgery (GKS) could be a causative factor in intratumoral bleeding in meningiomas.

Methods. Gamma knife radiosurgery was used in the treatment of 173 meningiomas during a 10-year period. Four patients suffered post-GKS intratumoral hemorrhage. The course in these patients was reviewed.

Four of 173 patients suffered an intratumoral hemorrhage during a follow-up period of 1 to 8 years. The risk of intratumoral bleeding after GKS for meningioma was 2.3%. Intracystic hemorrhage occurred in two patients 1 and 5 years, respectively, after radiosurgery. In the other two cases intratumoral bleeding occurred 2 and 8 years, respectively, after radiosurgery. Histological examination in three cases found no specific findings related to the postradiosurgical changes.

Conclusions. Because the reported risk of spontaneous intratumoral bleeding in meningiomas is 1.3 to 2.7%, the incidence in this series was not unduly high. Radiosurgery itself could not be shown to be a significant factor in the development of the intratumoral bleeding.

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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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Myoung Soo Kim, Chang Wan Oh, Dae Hee Han, O-Ki Kwon, Hee-Won Jung and Moon Hee Han

✓ The most common clinical presentations of dural arteriovenous fistulas (DAVFs) are bruit, headache, increased intracranial pressure, and intracranial hemorrhage. In particular locations, such as the cavernous sinus or middle cranial fossa, cranial nerve involvement due to dural arterial steal or venous occlusion may develop. A case in which a DAVF is associated with hearing loss, however, has not previously been reported. The authors report a case in which an intraosseous DAVF and associated hearing loss probably resulted from cochlear nerve or vascular compression caused by the draining vein or nidus of the DAVF.

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Kihwan Hwang, Yong Hwy Kim, Jung Hee Kim, Jung Hyun Lee, Hee Kyung Yang, Jeong-Min Hwang, Chae-Yong Kim and Jung Ho Han

OBJECTIVE

The authors investigated the natural history of asymptomatic nonfunctioning pituitary adenomas (NFPAs) with optic nerve compression.

METHODS

This study retrospectively analyzed the natural history of asymptomatic NFPAs with documented optic nerve compression on MRI diagnosed between 2000 and 2016 from 2 institutions. The patients were followed up with regular endocrinological, ophthalmological, and radiological evaluations, and the endpoint was new endocrinopathy or neurological deficits.

RESULTS

The study comprised 81 patients. The median age at diagnosis was 58.0 years and the follow-up duration was 60.0 months. As the denominator of overall pituitary patients, 2604 patients were treated with surgery after diagnosis at the 2 institutions during the same period. The mean initial and last measured values for tumor diameter were 23.7 ± 8.9 mm and 26.2 ± 11.4 mm, respectively (mean ± SD). Tumor growth was observed in 51 (63.0%) patients; however, visual deterioration was observed in 14 (17.3%) patients. Ten (12.3%) patients experienced endocrine deterioration. Fourteen (17.3%) patients underwent surgery for either visual deterioration (in 12 patients) or endocrine dysfunction (in 2 patients). After surgery, all patients experienced improvements in visual or hormonal function. The actuarial rates of treatment-free survival at 2, 3, and 5 years were 96.1%, 93.2%, and 85.6%, respectively. In the multivariate analysis, initial cavernous sinus invasion (HR 4.985, 95% CI 1.597–15.56; p = 0.006) was the only independent risk factor for eventual treatment.

CONCLUSIONS

The neuroendocrinological deteriorations were not frequent and could be recovered by surgery with early detection on regular follow-up in asymptomatic NFPAs with documented optic nerve compression on MRI. Therefore, conservative management could be an acceptable strategy for these tumors. Careful follow-up is required for tumors with cavernous sinus invasion.

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Hyung-Chul Lee, Hyun-Kyu Yoon, Jung Hee Kim, Yong Hwy Kim and Hee-Pyoung Park

OBJECTIVE

In this double-blind randomized trial, the necessity of preoperative steroid administration in patients without adrenal insufficiency (AI) undergoing endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma was evaluated.

METHODS

Forty patients with and without AI, defined as a peak cortisol level > 18 µg/dl on the insulin tolerance test or rapid adrenocorticotropic hormone (ACTH) test, undergoing ETSS for nonfunctioning pituitary adenomas were randomly allocated to treatment with either 100 mg of preoperative hydrocortisone (group HC, n = 20) or normal saline (group C, n = 20). The patients with pituitary apoplexy, the use of a drug within the last 3 months that could affect the hypothalamic-pituitary-adrenal axis, or a previous history of brain or adrenal surgery were excluded. Intraoperative cortisol and ACTH levels were measured after anesthesia induction, dura incision, and tumor removal, and at the end of surgery. Intraoperative hypotension, early postoperative AI, and postoperative 3-month pituitary function were investigated.

RESULTS

Intraoperative serum cortisol levels were significantly higher in the HC group than in the C group after anesthesia induction (median 69.0 µg/dl [IQR 62.2–89.6 µg/dl] vs 12.7 µg/dl [IQR 8.4–18.2 µg/dl], median difference 57.5 µg/dl [95% CI 33.0–172.9 µg/dl]), after dura incision (median 53.2 µg/dl [IQR 44.9–63.8 µg/dl] vs 6.4 [IQR 4.8–9.2 µg/dl], median difference 46.6 µg/dl [95% CI 13.3–89.2 µg/dl]), after tumor removal (median 49.5 µg/dl [IQR 43.6–62.4 µg/dl] vs 9.2 µg/dl [IQR 5.75–16.7 µg/dl], median difference 39.4 µg/dl [95% CI 0.3–78.1 µg/dl]), and at the end of surgery (median 46.9 µg/dl [IQR 40.1–63.4 µg/dl] vs 16.9 µg/dl [IQR 12.1–23.2 µg/dl], median difference 32.2 µg/dl [95% CI −42.0 to 228.1 µg/dl]). Serum ACTH levels were significantly lower in group HC than in group C after anesthesia induction (median 3.9 pmol/L [IQR 1.7–5.2 pmol/L] vs 6.9 pmol/L [IQR 3.9–11.9 pmol/L], p = 0.007). No patient showed intraoperative hypotension due to AI. Early postoperative AI was observed in 3 and 5 patients in groups HC and C, respectively. The postoperative 3-month pituitary hormone outcomes including ACTH deficiency were not different between groups.

CONCLUSIONS

Preoperative steroid administration may be unnecessary in patients without AI undergoing ETSS for nonfunctioning pituitary adenomas. However, a further large-scale study is needed to determine whether preoperative steroid administration has a significant impact on clinically meaningful events such as perioperative AI and postoperative 3-month ACTH deficiency in these patients.

Korean Clinical Trial Registry no.: KCT0002426 (https://cris.nih.go.kr/cris/).

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Dae Hee Han, Dong Gyu Kim, Je G. Chi, Sung Hye Park, Hee-Won Jung and Young Gyu Kim

✓ The authors present the clinical, radiological, pathological features, and autopsy findings of a patient with malignant triton tumor of the acoustic nerve, which probably arose from a pre-existing acoustic schwannoma. The term “malignant triton tumor” is applied to malignant schwannomas with rhabdomyoblastic differentiation. A cerebellopontine angle tumor with spinal drop metastasis occurred in this patient 10 months after near-total removal of the original tumor.

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Jung-Hee Lee, Ki-Tack Kim, Kyung-Soo Suk, Sang-Hun Lee, Bi-O Jeong, Hyun-Seok Oh, Chul-Hee Lee and Myung-Seo Kim

Intraspinal cystic lesions with different pathogeneses have been reported to cause neurological deficits; however, no one has focused on the intraspinal extradural cysts that develop after osteoporotic compression fracture. The reported case features a 66-year-old woman presenting with progressive neurological deficit, back pain, and no history of additional trauma after undergoing conservative treatment for an osteoporotic fracture of L-1. The authors present serial radiographs and MR images demonstrating an epidural cyst successfully treated via a single posterior approach. This appears to be the first such case reported in the literature.

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Dong Gyu Kim, Chi Heon Kim, Hyun-Tai Chung, Sun Ha Paek, Sang Soon Jeong, Dae Hee Han and Hee-Won Jung

Object. The authors analyzed tumor control rates and complications in patients with superficially located meningiomas after gamma knife surgery (GKS).

Methods. Between 1998 and 2003, GKS was performed in 23 patients with 26 lesions in whom follow-up imaging for 1 year or more was available. The male/female ratio was 1:22. The mean age was 59 years. The median tumor volume was 4.7 cm3, and the mean margin dose was 16 Gy at the 50% isodose line. Peritumoral edema was revealed on magnetic resonance (MR) imaging in four patients before GKS. Magnetic resonance imaging and clinical examinations were performed every 6 months after GKS. The mean follow-up duration was 32 months.

The tumor shrank in eight cases, was stable in 17, and enlarged in one; thus 25 (95%) of 26 tumors were controlled. A peritumoral high signal on T2-weighted MR images was found in eight lesions and preexisting edema was aggravated in three lesions after GKS. Ten of these 11 patients complained of severe headache, and three patients experienced neurological deficits at the same time after a mean latency of 3 months; however, high signal was not demonstrated on imaging before 6 months on average. Steroid agents, when required, gave relief to all patients. The complication rate was 43% (10 of 23 cases). High signal disappeared in nine patients and decreased in the remaining two. High signal was associated with a high integral dose and a large tumor volume. Tumor shrinkage at the last follow-up examination was more prominent in the patients with symptomatic high signal (p = 0.03).

Conclusions. There was a good tumor control rate with a high complication rate. Longer follow up of more patients is needed. Adjusting the dose—volume relationship should be considered to reduce complications.