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Jae-Sang Oh, Dong-Sung Kim, Jai-Joon Shim, and Seok-Mann Yoon

Endovascular occlusion via the transvenous route is the favored treatment for indirect carotid-cavernous fistulas (CCFs). However, transarterial embolization can be used as an alternative method in patients with an inaccessible venous route. The authors present the case of a 49-year-old woman with a 2-month history of chemosis and proptosis in her right eye. Angiography demonstrated a Barrow Type D CCF. Transarterial Onyx embolization through the accessory meningeal artery was performed after an unsuccessful transvenous approach. Unexpected Onyx migrations to the cerebral arteries were detected while injecting the embolic material. Three hours after failed attempts to retrieve the Onyx cast endovascularly, it was microsurgically removed from the right middle cerebral artery. To the authors' knowledge, this is the first report of the surgical removal of Onyx from a normal cerebral artery.

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Ziev B. Moses, Seok Yoon Oh, Ricardo B. V. Fontes, Harel Deutsch, John E. O’Toole, and Richard G. Fessler

OBJECTIVE

The modified frailty index (mFI) is a simple tool that measures physiological reserve based on a thorough history and physical examination. Its use has been validated in several surgical specialties, including spinal deformity surgery. Prior research has suggested no significant differences in clinical outcomes between elderly and nonelderly patients undergoing posterior lumbar interbody fusion. The authors sought to investigate the use of the mFI in patients undergoing transforaminal lumbar interbody fusion (TLIF) and the relationship between frailty scores and clinical outcomes.

METHODS

A retrospective chart review was conducted on 198 patients who underwent a single-level TLIF over a 60-month period at a single institution. For all patients, an mFI score was computed incorporating a set of 11 clinical factors to assess preexisting comorbidities and functional status. Clinical follow-up and health-related quality-of-life (HRQOL) scores were obtained at baseline and regular intervals of 6 weeks, 6 months, and 1 year following surgery.

RESULTS

Patients were grouped according to their level of frailty: no frailty (mFI = 0), mild frailty (mFI = 0.09), moderate frailty (mFI = 0.18), and severe frailty (mFI ≥ 0.27). One-way ANOVA revealed increasing levels of frailty to be associated with an increased rate of complications, from 10.3% to 63.6%. In addition, increasing levels of frailty were associated with longer hospital length of stay (LOS), from 3.1 days to 6.5 days, and lower rates of disposition to home. At the 1-year follow-up, increased levels of frailty were associated with worse HRQOL measures.

CONCLUSIONS

Increasing mFI score was associated with higher morbidity, longer inpatient LOS, and a lower probability of discharge to home in patients undergoing single-level TLIF. Consideration of the mFI may help surgeons improve decision-making across the spectrum of patients who are at risk from frailty.

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Eui Hyun Kim, Jihwan Yoo, In-Ho Jung, Ji Woong Oh, Ju-Seong Kim, Jin Sook Yoon, Ju Hyung Moon, Seok-Gu Kang, Jong Hee Chang, and Tae Hoon Roh

OBJECTIVE

The insula is a complex anatomical structure. Accessing tumors in the insula remains a challenge due to its anatomical complexity and the high chance of morbidity. The goal of this study was to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the insular region based on a cadaveric study.

METHODS

One cadaveric head was used to study the anatomy of the insula and surrounding vessels. Then, anatomical dissection was performed in 4 human cadaveric heads using a dedicated endoscopic system with the aid of neuronavigation guidance. To assess the extent of resection, CT scanning was performed before and after dissection. The insular region was directly exposed by a classic transcranial approach to check the extent of resection from the side with a classic transcranial approach.

RESULTS

The entire procedure consisted of two phases: an extradural orbital phase and an intradural sylvian phase. After eyelid incision, the sphenoid bone and orbital roof were extensively drilled out with exposure of the frontal and temporal dural layers. After making a dural window, the anterior ramus of the sylvian fissure was opened and dissected. The M2 segment of the middle cerebral artery (MCA) was identified and traced posterolaterally. A small corticectomy was performed on the posterior orbital gyrus. Through the window between the lateral lenticulostriate arteries and M2, the cortex and medulla of the insula were resected in an anteroposterior direction without violation of the M2 segment of the MCA or its major branches. When confirmed by pterional craniotomy, the sylvian fissure and the MCA were found to be anatomically preserved. After validation of the feasibility and safety based on a cadaveric study, the ETOA was successfully performed in a patient with a high-grade glioma (WHO grade III) in the right insula.

CONCLUSIONS

The transorbital route can be considered a potential option to access tumors located in the insula. Using an ETOA, the MCA and its major branches were identified and preserved while removal was performed along the long axis of the insula. In particular, lesions in the anterior part of the insula are most benefited by this approach. Because this approach was implemented in only one patient, additional discussion and further verification is required.