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Seong-Hyun Park, Kyu-Yup Lee and Sung-Kyoo Hwang

Object

The purpose of this study was to evaluate the function of the nervus intermedius, the nonmotor component of the facial nerve, following modern Gamma Knife surgery (GKS) for the treatment of vestibular schwannoma.

Methods

Sixty-five consecutive patients at our center underwent GKS as a primary treatment option for vestibular schwannoma between 2005 and 2010. The authors interviewed patients with a functional questionnaire to evaluate the function of the nervus intermedius before and after radiosurgery from their subjective point of view. Data from 50 patients treated using GKS for a unilateral vestibular schwannoma were obtained.

Results

Nine (18%) of 50 patients presented with at least one preradiosurgical disturbance of the nervus intermedius caused by the vestibular schwannoma itself, with dysfunctions of lacrimation, salivation, nasal secretion, and taste. Of the 41 patients without preradiosurgical disturbances, 9 (22%) experienced the onset of at least one new disturbance after GKS. Specifically for each dysfunction, of the 45 patients without a lacrimal disturbance before GKS, 5 (11.1%) had a new lacrimal disturbance after GKS. New onset of a salivary disturbance after GKS was reported in 3 (6.2%) of 48 patients. In 1 patient (2%), increased nasal secretion was noted 1 year after GKS. Five (10.6%) of 47 patients without a preradiosurgical taste disturbance experienced the symptom after GKS. No facial palsy developed in any patient before or after GKS. There was no significant correlation between postradiosurgical nervus intermedius dysfunction and tumor size, margin dose, or patient age.

Conclusions

The authors demonstrated that 22% of patients undergoing modern GKS for vestibular schwannoma experience various disturbances of nonmotor components of the facial nerve as a result of the radiosurgery. Through this study, we can provide useful information about the likelihood of certain postradiosurgical symptoms for vestibular schwannoma.

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Seong-Hyun Park, Sung-Kyoo Hwang, Sun-Ho Lee, Jaechan Park, Jeong-Hyun Hwang and In-Suk Hamm

Object

The aim of this study was to provide information to help confirm the diagnosis of trigeminal neuralgia (TN) using MR imaging.

Methods

The authors evaluated atrophy of the trigeminal nerve, the cross-sectional area of the cerebellopontine angle (CPA) cistern, and the length of the cisternal segment of the trigeminal nerve on the affected side in 26 consecutive patients with TN who were treated using Gamma Knife surgery.

Results

The mean volume of the trigeminal nerve on the affected side was significantly smaller than the mean volume of the trigeminal nerve on the unaffected side (p < 0.001). Nerve atrophy was present in 25 patients (96.2%) on the affected side and in 1 patient on the unaffected side. The mean cross-sectional area of the CPA cistern on the affected side (188.5 mm2) was significantly smaller than the mean volume on the unaffected side (232.8 mm2) in 25 of the 26 patients (p = 0.001). The mean length of the cisternal segment of the trigeminal nerve on the affected side (7.9 mm) was significantly shorter than the mean length on the unaffected side (9.6 mm) in 25 of the 26 patients (p = 0.001).

Conclusions

Among the patients with TN, there was a statistically significant difference in the MR imaging findings of the affected side compared with the unaffected side of the trigeminal nerve. Atrophy of the trigeminal nerve and a small CPA cistern in patients with TN provides additional markers for the diagnosis of TN and helps confirm the diagnosis based on clinical examination.

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Kyoung Soo Ryou, Sun-Ho Lee, Seong-Hyun Park, Jaechan Park, Sung-Kyoo Hwang and In-Suk Hamm

Carney complex is a rare autosomal-dominant familial tumor syndrome that involves the triad of myxoma, mucocutaneous pigmentation, and endocrine overactivity. To the best of the authors' knowledge, there are no reports of multiple fusiform aneurysms coinciding with atrial myxoma.

The authors report the case of a 38-year-old woman with typical Carney complex who had multiple skin myxomas, endocrine abnormalities, and multiple brownish perioral lesions. Multiple fusiform aneurysms were also discovered after the recurrence of atrial myxoma. During a follow-up period of > 10 years, there have been no angiographic changes in the aneurysms and no progression of symptoms.

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Seong-Hyun Park, Hideyuki Kano, Ajay Niranjan, John C. Flickinger and L. Dade Lunsford

Object

To assess the long-term outcomes of stereotactic radiosurgery (SRS) for cerebellopontine angle (CPA) meningiomas, the authors retrospectively reviewed data from a 20-year experience. They evaluated progression-free survival as well as improvement, stabilization, or deterioration in clinical symptoms.

Methods

Seventy-four patients with CPA meningiomas underwent SRS involving various Gamma Knife technologies between 1990 and 2010. The most common presenting symptoms were dizziness or disequilibrium, hearing loss, facial sensory dysfunction, and headache. The median tumor volume was 3.0 cm3 (range 0.3–17.1 cm3), and the median radiation dose to the tumor margin was 13 Gy (range 11–16 Gy). The median follow-up period was 40 months (range 4–147 months).

Results

At last imaging follow-up, the tumor volume had decreased in 46 patients (62%), remained stable in 26 patients (35%), and increased in 2 patients (3%). The progression-free survival after SRS was 98% at 1 year, 98% at 3 years, and 95% at 5 years. At the last clinical follow-up, 23 patients (31%) showed neurological improvement, 43 patients (58%) showed no change in symptoms or signs, and 8 patients (11%) had worsening symptoms or signs. The neurological improvement rate after SRS was 16% at 1 year, 31% at 3 years, and 40% at 5 years. The post-SRS deterioration rate was 5% at 1 year, 10% at 3 years, and 16% at 5 years. A multivariate analysis demonstrated that trigeminal neuralgia was the symptom most likely to worsen after SRS (HR 0.08, 95% CI 0.02–0.31; p = 0.001). Asymptomatic peritumoral edema occurred in 4 patients (5%) after SRS, and symptomatic adverse radiation effects developed in 7 patients (9%).

Conclusions

Stereotactic radiosurgery for CPA meningiomas provided a high tumor control rate and relatively low risk of ARE. Tumor compression of the trigeminal nerve by a CPA meningioma resulted in an increased rate of facial pain worsening in this patient experience.

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Jae Hyo Park, Park In Sung, Dae Hee Han, Seong Hyun Kim, Chang Wan Oh, Jeong-Eun Kim, Hyun Jib Kim, Moon Hee Han and O-Ki Kwon

Object

Because of its thin wall, an aneurysm arising from the posterior wall of the internal carotid artery (ICA), the so-called blood blister–like aneurysm (BBA), is difficult to manage surgically and is often associated with high morbidity and mortality rates. The authors treated these aneurysms endovascularly. In this paper, they present angiographic and clinical results obtained in patients with ICA BBAs treated endovascularly.

Methods

In seven patients with ICA BBAs who presented with subarachnoid hemorrhage, a total number of 12 endovascular treatments were performed, including seven endosaccular coil embolizations (four conventional, two stent-assisted and one balloon-assisted procedure) in four patients and five endovascular ICA trapping procedures in five patients. Repeated endovascular treatments were undertaken in four patients. In two patients, the endovascular treatment was performed after failure of surgical treatment (one case of rebleeding after clip placement and one aneurysmal regrowth after wrapping). A balloon occlusion test (BOT) was performed in all patients prior to ICA trapping.

All four patients treated by endosaccular coil embolization showed aneurysmal regrowth. Neither stents nor balloons helpfully prevented aneurysmal regrowth. Of these four patients, two experienced rebleeding. These two patients remained vegetative at the last follow-up examination. After the BOT, ICA trapping was performed with coils and balloons without complication in five patients; excellent outcomes were achieved in all cases but one in which the patient had been in poor neurological condition due to rebleeding after surgical clip therapy.

Conclusions

All ICA BBAs that were treated by endosaccular coil embolization exhibited regrowth of the aneurysm. Some of the lesions rebled. The majority of patients who underwent ICA trapping experienced excellent outcomes. Based on the authors' experiences, they suggest that ICA trapping including the lesion segment should be considered as a first option for definitive treatment if a BOT reveals satisfactory results. Regarding trapping methods, endovascular treatment may be preferred because of its convenience and safety.

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Letter to the Editor

Small cerebellopontine angle cisterns in patients with trigeminal neuralgia

Maud Parise, Carlos Telles Ribeiro, Maurice Vincent and Emerson Gasparetto

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Greg Bowden, Hideyuki Kano, Ellen Caparosa, Seong-Hyun Park, Ajay Niranjan, John Flickinger and L. Dade Lunsford

OBJECT

Non–small cell lung cancer (NSCLC) is the most frequent cancer that metastasizes to brain. Stereotactic radiosurgery (SRS) has become the management of choice for most patients with such metastatic tumors. Therefore, the authors endeavored to elucidate the survival and SRS outcomes for patients with NSCLC metastasis at their center.

METHODS

In this single-institution retrospective analysis, the authors reviewed their experience with NSCLC metastasis during a 10-year period from 2001 to 2010. Seven hundred twenty patients underwent Gamma Knife radiosurgery. A total of 1004 SRS procedures were performed, and 3143 tumors were treated. The NSCLC subtype was adenocarcinoma in 386 patients, squamous cell carcinoma in 111 patients, and large cell carcinoma in 34 patients. The median aggregate tumor volume was 4.5 cm3 (range 0.1–88 cm3).

RESULTS

The median survival time after diagnosis of brain metastasis from NSCLC was 12.6 months, and the median survival after SRS was 8.5 months. The 1-, 2-, and 5-year survival rates after SRS were 39%, 21%, and 10%, respectively. Postradiosurgery survival was decreased in patients treated with prior whole-brain radiation therapy compared with SRS alone (p = 0.003). Aggregate tumor volume was inversely related to survival after SRS (p < 0.001), and the histological subgroups demonstrated significant survival differences (p = 0.023). The overall local tumor control rate in the entire group was 92.8%. One hundred seventy-four patients (24%) underwent repeat SRS for new or resistant metastatic deposits.

CONCLUSIONS

Stereotactic radiosurgery is an effective means of providing local control for NSCLC metastases. Neurological function and survival benefit from serial patient monitoring and repeat SRS for new tumors.

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Seong-Cheol Park, Seung-Ki Kim, Byung-Kyu Cho, Hyun Jib Kim, Jeong Eun Kim, Ji Hoon Phi, In-One Kim and Kyu-Chang Wang

Object

Sinus pericranii (SP) is a rare venous varix in an extracranial location connected to the intracranial venous system. The aim of this retrospective study was to report on 16 pediatric cases of SP with consideration of the preoperative evaluation of surgical risk.

Methods

The study population consisted of 10 patients who had undergone surgery for SP and 6 patients with concomitant craniosynostosis and SP. The mean age of the patients at presentation was 3.7 years. To identify characteristics of SP with high operative risk, 8 cases in this report and 11 previously reported cases of SP with sufficient information were categorized on the basis of the number and size of SP, the number and size of transcranial channels, the venous drainage type, and the amount of blood loss. Hemorrhage amounts were classified into 3 grades based on the description of intraoperative blood loss.

Results

Sinus pericranii not associated with craniosynostosis were resected without any postoperative morbidity. Sinus pericranii associated with craniosynostosis were preserved. After craniofacial reconstruction, 2 cases of SP with craniosynostosis regressed, completely in one patient and partially in another. These 2 patients with SP were confirmed to have compromised intracranial sinus before craniofacial reconstruction. Among a total of 19 patients, multiplicity or size (> 6 cm) of SP (p = 0.036) and multiplicity (> 3) or size (> 3 mm) of transcranial channels (p = 0.004) was associated with more severe hemorrhage grade. Sinus pericranii with peripheral venous drainage (drainer type) was not associated with hemorrhage grade after classification into 3 grades (p = 0.192). However, all 3 cases of SP with massive Grade 3 hemorrhage were the drainer type. Hemorrhage grade was correlated with the number of risk factors for SP (r = 0.793, p < 0.001).

Conclusions

Three risk factors of SP and the presence of compromised intracranial sinus are markers for highrisk SP. “Squeezed-out sinus syndrome” is suggested as a concept for SP associated with compromised intracranial sinus, mainly caused by craniosynostosis. Sinus pericranii in squeezed-out sinus syndrome probably serves as a crucial alternative to venous drainage of the brain with intracranial venous compromise. Conservative treatment for such patients with SP is recommended.