Ching-Chang Chen, Shao-Wei Chen, Po-Hsun Tu, Yin-Cheng Huang, Zhuo-Hao Liu, Alvin Yi-Chou Wang, Shih-Tseng Lee, Tien-Hsing Chen, Chi-Tung Cheng, Shang-Yu Wang and An-Hsun Chou
Burr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown.
A nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed.
The in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC.
Even for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.
Chih-Hsiang Liao, Jui-To Wang, Chun-Fu Lin, Shao-Ching Chen, Chung-Jung Lin, Sanford P. C. Hsu and Min-Hsiung Chen
Despite the advances in skull base techniques, large petroclival meningiomas (PCMs) still pose a challenge to neurosurgeons. The authors’ objective of this study was to describe a pretemporal trans–Meckel’s cave transtentorial approach for large PCMs and to report the surgical outcomes.
From 2014 to 2017, patients harboring large PCMs (> 3 cm) and undergoing their first resection via this procedure at the authors’ institute were included. In combination with pretemporal transcavernous and anterior transpetrosal approaches, the trans–Meckel’s cave transtentorial route was created. Surgical details are described and a video demonstrating the procedure is included. Retrospective review of the medical records and imaging studies was performed.
A total of 18 patients (6 men and 12 women) were included in this study, with mean age of 53 years. The mean sizes of the preoperative and postoperative PCMs were 4.36 cm × 4.09 cm × 4.13 cm (length × width × height) and 0.83 cm × 1.08 cm × 0.75 cm, respectively. Gross-total removal was performed in 7 patients, near-total removal (> 95%) in 7 patients, and subtotal removal in 4 patients (> 90% in 3 patients and > 85% in 1 patient). There were no surgical deaths or patients with postoperative hemiplegia. Surgical complications included transient cranial nerve (CN) III palsy (all patients, resolved in 3 months), transient CN VI palsy (2 patients), CN IV palsy (3 patients, partial recovery), hydrocephalus (3 patients), and CSF otorrhea (1 patient). Temporal lobe retraction–related neurological deficits were not observed.
A pretemporal trans–Meckel’s cave transtentorial approach offers large surgical exposure and multiple trajectories to the suprasellar, interpeduncular, prepontine, and upper-half clival regions without overt traction, which is mandatory to remove large PCMs. To unlock Meckel’s cave where a large PCM lies abutting the cave, pretemporal transcavernous and anterior transpetrosal approaches are prerequisites to create adequate exposure for the final trans–Meckel’s cave step.
Cheng-Chia Lee, Ching-Jen Chen, Shao-Ching Chen, Huai-Che Yang, Chung Jung Lin, Chih-Chun Wu, Wen-Yuh Chung, Wan-Yuo Guo, David Hung-Chi Pan, Cheng-Ying Shiau and Hsiu-Mei Wu
Clival epidural-osseous dural arteriovenous fistula (DAVF) is often associated with a large nidus, multiple arterial feeders, and complex venous drainage. In this study the authors report the outcomes of clival epidural-osseous DAVFs treated using Gamma Knife surgery (GKS).
Thirteen patients with 13 clival epidural-osseous DAVFs were treated with GKS at the authors’ institution between 1993 and 2015. Patient age at the time of GKS ranged from 38 to 76 years (median 55 years). Eight DAVFs were classified as Cognard Type I, 4 as Type IIa, and 1 as Type IIa+b. The median treatment volume was 17.6 cm3 (range 6.2–40.3 cm3). The median prescribed margin dose was 16.5 Gy (range 15–18 Gy). Clinical and radiological follow-ups were performed at 6-month intervals. Patient outcomes after GKS were categorized as 1) complete improvement, 2) partial improvement, 3) stationary, and 4) progression.
All 13 patients demonstrated symptomatic improvement, and on catheter angiography 12 of the 13 patients had complete obliteration and 1 patient had partial obliteration. The median follow-up period was 26 months (range 14–186 months). The median latency period from GKS to obliteration was 21 months (range 8–186 months). There was no intracranial hemorrhage during the follow-up period, and no deaths occurred. Two adverse events were observed following treatment, and 2 patients required repeat GKS treatment with eventual complete obliteration.
Gamma Knife surgery offers a safe and effective primary or adjuvant treatment modality for complex clival epidural-osseous DAVFs. All patients in this case series demonstrated symptomatic improvement, and almost all patients attained complete obliteration.
Hsi-Kai Tsou, Shao-Ching Chao, Chao-Jan Wang, Hsien-Te Chen, Chiung-Chyi Shen, Hsu-Tung Lee and Yuang-Seng Tsuei
The authors assessed the effectiveness of percutaneous pulsed radiofrequency treatment for providing pain relief in patients with chronic low-back pain with or without lower-limb pain.
Data were obtained in 127 patients who had chronic low-back pain with or without lower-limb pain due to a herniated intervertebral disc or previous failed back surgery and who underwent pulsed radiofrequency treatment. Their conditions were proven by clinical features, physical examination, and imaging studies. Low-back pain was treated with pulsed radiofrequency applied to the L-2 dorsal root ganglion (DRG) and lower-limb pain was treated with pulsed radiofrequency applied to the L3–S1 DRG. Patients underwent uni- or bilateral treatment depending on whether their low-back pain was unilateral or bilateral. A visual analog scale was used to assess pain. The patients were followed up for 3 years postoperatively.
In patients without lower-limb pain (Group A), 27 (55.10%) of 49 patients had initial improvement ≥ 50% at 3-month follow-up. At 1-year follow-up, 20 (44.44%) of 45 patients in Group A had pain relief ≥ 50%. An analysis of patients with pain relief ≥ 50% for at least 1 month showed that the greatest effect was at 3 months after treatment. In patients with low-back pain and lower-limb pain (Group B), 37 (47.44%) of 78 patients had initial improvement ≥ 50% at 3-month follow-up. At 1-year follow-up, 34 (45.95%) of 74 patients had pain relief effect ≥ 50%. An analysis of patients in Group B with pain relief ≥ 50% for at least 1 month showed that the greatest effect was at 1 month after treatment.
The results of this prospective analysis showed that treatment with pulsed radiofrequency applied at the L-2 DRG is safe and effective for treating for chronic low-back pain. Satisfactory pain relief was obtained in the majority of patients in Group A with the effect persisting for at least 3 months. The results indicate that pulsed radiofrequency provided intermediate-term relief of low-back pain. Further studies with long-term follow-up are necessary.