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

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Isaac Yang, Won Kim, Antonio De Salles and Marvin Bergsneider

Object

Stereotactic radiosurgery (SRS) has emerged as an adjuvant radiation-based therapy for pituitary adenomas. Here, the authors present a systematic analysis of SRS for growth hormone–secreting adenomas to characterize the efficacy of SRS in the treatment of acromegaly.

Methods

A comprehensive search of the English language literature revealed 970 patients with new, recurrent, or persistent acromegaly that had been treated using SRS along with assessable and quantifiable outcome data. Articles published between June 1998 and September 2009 were included in the analysis. Patient outcome data were aggregated and investigated based on tumor size, radiosurgery dose, and clinical outcomes both with and without medication.

Results

The overall disease control rate without medication was 48%–53%, and the overall disease control rate with or without medication was 73%. The overall mean duration of the reported follow-up was 48.5 ± 25.8 months. The mean overall tumor volume in this analysis was 2.11 ± 1.16 cm3. The Pearson product-moment correlation coefficient for tumor volume and cure rate was not significant (r = 0.0668, p = 0.8546).

Conclusions

Data from this analysis suggest that tumor size may not be a significant prognostic factor in disease control after radiosurgery for acromegaly. The overall disease control rate was approximately 48% without suppressive medications after radiosurgery for acromegaly. With the advancement of increasingly sophisticated stereotactic planning and tumor targeting, the precision of radiosurgery may continue to improve in the treatment of acromegaly.

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Sun-Chul Hwang, Soo-Bin Im, Bum-Tae Kim and Won-Han Shin

Object

Twist-drill craniostomy (TDC) with closed-system drainage is an effective treatment option for chronic subdural hematoma (CSDH). Because the entry point for TDC has not been described in a definitive area, the aim of this study was to define the optimal twist-drill entry point for CSDH.

Methods

The authors selected 40 random cases involving selective catheter angiography of the external carotid artery, regardless of study purpose, to evaluate the course of the middle meningeal artery. Furthermore, 50 skull radiographs were reviewed to assess the relation of the vascular groove to the coronal suture. On the basis of the radiological anatomical study, the authors propose that the normal TDC entry point should be 1 cm anterior to the coronal suture at the level of the superior temporal line (STL). Thirty patients with symptomatic CSDH were treated using TDC with closed-system drainage at the proposed entry point. The thicknesses of the hematoma and the skull were measured at the proposed entry point. The congruence between the proposed entry point and postoperative craniostomy was estimated and complications were evaluated.

Results

In the radiological study, all the branches of the middle meningeal artery ran posterior to the coronal suture and the vascular grooves were also located posterior to the coronal suture at the level of the STL. The average distance of the vascular grooves was 8.0 ±5.8 mm. Thirty-five procedures were performed. The coronal suture and the STL could be identified clearly on brain CT scans. The mean thickness of the skull and the CSDH at the proposed point was 8 mm (range 5–13 mm) and 20 mm (range 10–28 mm), respectively. All the TDCs except 1 were congruent with the preoperative brain CT scans. One CSDH recurred 1 month after the first operation and was revised using the same procedure. No other complications occurred.

Conclusions

One centimeter anterior to the coronal suture at the level of the STL is suitable as the normal entry point of the TDC for symptomatic CSDH. The thickness of the CSDH can be measured at this point on a preoperative brain CT scan. Furthermore, the entry point on the scalp can be accurately estimated using surface landmarks.

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Seong-eun Park, Ju-seong Kim, Eun Kyung Park, Kyu-Won Shim and Dong-Seok Kim

OBJECTIVE

For patients with moyamoya disease (MMD), surgical intervention is usually required because of progressive occlusion of the internal carotid artery. The indirect bypass method has been widely accepted as the treatment of choice in pediatric patients. However, in adult patients with MMD, the most effective treatment method remains a matter of debate. Here, the authors compared the clinical outcomes from MMD patients treated with either extracranial-intracranial arterial bypass (EIAB; 43 hemispheres) or modified encephaloduroarteriosynangiosis (mEDAS; 75 hemispheres) to investigate whether mEDAS is an effective surgical method for treating adults with symptomatic MMD.

METHODS

A comparative analysis was performed in patients treated using either mEDAS or EIAB. Collateral grading, collateral vein counting, and symptom analysis were used to assess the outcome of surgery.

RESULTS

Seventy-seven percent (58/75) of mEDAS cases and 83.7% (36/43) of EIAB cases in the analysis experienced improvement in their symptoms after surgery. Furthermore, patients in 98.7% (74/75) of mEDAS cases and those in 95.3% (41/43) of EIAB cases exhibited improved collateral grades. Increases in regions of perfusion were seen after both procedures.

CONCLUSIONS

Modified EDAS and EIAB both result in positive outcomes for symptomatic adults with MMD. However, when considering the benefit of both surgeries, the authors propose mEDAS, a simpler and less strenuous surgery with a lower risk of complications, as a sufficient and safe treatment option for symptomatic adults with MMD.

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Jun-Yeong Seo, Kee-Yong Ha, Tae-Hyok Hwang, Ki-Won Kim and Young-Hoon Kim

Object

In this paper the authors' goal was to determine the factors associated with the progression of degenerative lumbar scoliosis (DLS).

Methods

Twenty-seven patients (3 men and 24 women; mean age 64.9 years) with more than 10° of lumbar scoliosis at baseline were monitored for a mean period of 10 years. The radiological evaluation included measurement of the scoliosis angle using the Cobb method, the direction of the scoliosis, the relationship between the intercrest line and the L-5 vertebra, lateral listhesis, segmental angle, distance from the center of the sacral line to the apical vertebra, degenerative listhesis anteriorly or posteriorly or both, and lordosis angle. In addition, the lateral osteophyte difference, disc index, and severity of osteoporosis were measured. The pain and disability outcomes were assessed using the visual analog scale and the Oswestry Disability Index (ODI) relative to severity of the angle of scoliosis.

Results

The mean initial and final scoliosis angles were 14° ± 5.4° and 25° ± 8.5°, respectively. The initial disc index at the L-3 vertebra (Spearman ρ = 0.7, p < 0.001), the sum of the segmental wedging angles above and below the L-3 vertebra (ρ = 0.6, p < 0.001), and the initial disc index at the apical vertebra (ρ = 0.6, p < 0.001) were correlated with the last follow-up angle of the scoliosis. By contrast, there was no statistically significant correlation between the initial segmental angles at L2–3 and L3–4 and the final follow-up scoliosis angle (ρ = 0.2, p = 0.67; and ρ = 0.1, p = 0.22; respectively). When the authors separated the patients into 3 groups according to the sum of the segmental angles above and below L-3 (< 5°, 5° to 10°, and > 10°), they found that 3 (42.9%) of 7, 8 (66.7%) of 12, and 6 (75.0%) of 8 patients in the 3 groups showed increases of greater than 10° in scoliosis angle. The mean distance from the center of the sacral line to the apical vertebra was 36.0 ± 9.7 mm, and the distance correlated with the measurement of the last follow-up angle of the scoliosis (ρ = 0.6, p < 0.001). The mean angle of the scoliosis was significantly greater when the intercrest line passed through the L-5 or L4–5 disc space than when the line passed through the L-4 vertebral body (31.4° ± 7.9° vs 21.8° ± 6.7°, p = 0.01). The ODI correlated with the measurement of the angle of the scoliosis (ρ = 0.6, p < 0.001). Age, sex, osteoporosis, the direction of the scoliosis, listhesis of coronal and sagittal planes, the lateral osteophyte difference, and the vertebral body index did not correlate with curve progression.

Conclusions

The findings of this study demonstrated that the progression of DLS was affected by the relationship between the intercrest line and the L-5 vertebra. When L-5 was deep seated, progression of DLS was found. Asymmetrical change in the disc space above and below the L-3 or apical vertebra may also be an important predictor of curve progression.

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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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Won-Ki Yoon, Young-Woo Kim, Sang-Don Kim, Ik-Seong Park, Min-Woo Baik and Seong-Rim Kim

The authors report on a case of intravascular ultrasonography (IVUS)-guided stent angioplasty for iatrogenic extracranial vertebral artery (VA) dissection in a 49-year-old man after coil embolization for an unruptured aneurysm of the right posterior inferior cerebellar artery. Insignificant dissections occurred during the procedure. Postoperatively, the patient experienced gradually worsening posterior neck pain and headache, and follow-up angiography 8 months after the coil embolization revealed expansion of the dissection. The patient underwent stent angioplasty with IVUS guidance and his symptoms improved.

To the authors' knowledge, this is the first report of IVUS-guided stent angioplasty of an extracranial VA dissection. It was safe and feasible to treat extracranial VA dissections with stent placement under IVUS guidance. Intravascular environments are in real time with IVUS, and this technique is useful in the confirmation of a true lumen and evaluation of appropriate stent apposition. More clinical experience with this technique is necessary and mandatory, and devices with smaller diameters with improved trackability are essential for further introduction of IVUS into the field of endovascular neurosurgery.

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Jin Wook Kim, Hee-Won Jung, Yong Hwy Kim, Chul-Kee Park, Hyun-Tai Chung, Sun Ha Paek, Dong Gyu Kim and Sang Hyung Lee

OBJECTIVE

A thorough investigation of the long-term outcomes and chronological changes of multimodal treatments for petroclival meningiomas is required to establish optimal management strategies. The authors retrospectively reviewed the long-term clinical outcomes of patients with petroclival meningioma according to various treatments, including various surgical approaches, and they suggest treatment strategies based on 30 years of experience at a single institution.

METHODS

Ninety-two patients with petroclival meningiomas were treated surgically at the authors’ institution from 1986 to 2015. Patient demographics, overall survival, local tumor control rates, and functional outcomes according to multimodal treatments, as well as chronological change in management strategies, were evaluated. The mean clinical and radiological follow-up periods were 121 months (range 1–368 months) and 105 months (range 1–348 months), respectively.

RESULTS

A posterior transpetrosal approach was most frequently selected and was followed in 44 patients (48%); a simple retrosigmoid approach, undertaken in 30 patients, was the second most common. The initial extent of resection and following adjuvant treatment modality were classified into 3 subgroups: gross-total resection (GTR) only in 13 patients; non-GTR treatment followed by adjuvant radiosurgery or radiation therapy (non-GTR+RS/RT) in 56 patients; and non-GTR without adjuvant treatment (non-GTR only) in 23 patients. The overall progression-free survival rate was 85.8% at 5 years and 81.2% at 10 years. Progression or recurrence rates according to each subgroup were 7.7%, 12.5%, and 30.4%, respectively.

CONCLUSIONS

The authors’ preferred multimodal treatment strategy, that of planned incomplete resection and subsequent adjuvant radiosurgery, is a feasible option for the management of patients with large petroclival meningiomas, considering both local tumor control and postoperative quality of life.

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Won Heo, June Sic Kim, Chun Kee Chung and Sang Kun Lee

OBJECTIVE

In this study, the authors investigated long-term clinical and visual outcomes of patients after occipital lobe epilepsy (OLE) surgery and analyzed the relationship between visual cortical resection and visual function after OLE surgery.

METHODS

A total of 42 consecutive patients who were diagnosed with OLE and underwent occipital lobe resection between June 1995 and November 2013 were included. Clinical, radiological, and histopathological data were reviewed retrospectively. Seizure outcomes were categorized according to the Engel classification. Visual function after surgery was assessed using the National Eye Institute Visual Functioning Questionnaire 25. The relationship between the resected area of the visual cortex and visual function was demonstrated by multivariate linear regression models.

RESULTS

After a mean follow-up period of 102.2 months, 27 (64.3%) patients were seizure free, and 6 (14.3%) patients had an Engel Class II outcome. Nineteen (57.6%) of 33 patients had a normal visual field or quadrantanopia after surgery (normal and quadrantanopia groups). Patients in the normal and quadrantanopia groups had better vision-related quality of life than those in the hemianopsia group. The resection of lateral occipital areas 1 and 2 of the occipital lobe was significantly associated with difficulties in general vision, peripheral vision, and vision-specific roles. In addition, the resection of intraparietal sulcus 3 or 4 was significantly associated with decreased social functioning.

CONCLUSIONS

The authors found a favorable seizure control rate (Engel Class I or II) of 78.6%, and 57.6% of the subjects had good visual function (normal vision or quadrantanopia) after OLE surgery. Lateral occipital cortical resection had a significant effect on visual function despite preservation of the visual field.

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Young Soo Kim, Sang Won Lee, Jeong A Yeom, Chang Hyo Yoon and Seung Kug Baik

OBJECT

Stent-assisted coil embolization for the treatment of intracranial aneurysms has been used widely. This study aimed to investigate the effect of stent implantation in the nonatherosclerotic parent artery with cerebral aneurysms. The authors evaluated luminal changes and the related factors following stent-assisted coil embolization.

METHODS

This study included 97 patients harboring a total of 99 unruptured aneurysms of the distal internal carotid artery (ICA) who underwent single-stent implantation and more than 1 session of conventional angiography during follow-up (midterm follow-up only, n = 70; midterm and long-term follow-up, n = 29) between January 2009 and April 2014. The luminal narrowing point was measured using a local thickness map (ImageJ plug-in).

RESULTS

Stent-assisted coil embolization caused dynamic luminal narrowing of approximately 82% of the parent artery diameter on average after 8 months, which was reversed to 91% after 25 months. In addition, luminal narrowing greater than 40% was noticed in 2 (7%) of the 29 patients who experienced spontaneous reversion without additional management during follow-up. Most luminal narrowing changes seen were diffuse.

CONCLUSIONS

Luminal narrowing after aneurysm stent-assisted coil embolization is a dynamic process and appears to be a spontaneously reversible event. Routine management of luminal narrowing may not cause adverse events that require additional treatment.