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Eui Hyun Kim, Jung Yong Ahn and Sun Ho Kim

Object

The transcranial approach has been the standard technique for removal of craniopharyngiomas for several decades. However, many reports of successful suprasellar craniopharyngioma removal accomplished using extended transsphenoidal surgery (TSS) have recently been published. In the present study, the authors describe their technique and the outcomes of removal of suprasellar craniopharyngiomas aided by the use of an operating microscope and an endoscope concurrently during extended TSS.

Methods

Between 1999 and 2008, 18 patients with suprasellar craniopharyngiomas underwent TSS. Tumors that adhered to the optic nerve were safely dissected, and fine perforating vessels were precisely preserved with the aid of a magnified, detailed microscopic view. Portions of the tumor that could not be properly visualized with the microscope were visualized with the endoscope.

Results

Total resection was achieved in all patients, and all visual symptoms improved. Preoperative hypopituitarism improved in 2 patients but persisted postoperatively in 15 patients (hormonal outcome was not available in 1 patient). Diabetes insipidus was present in 16 patients postoperatively. Cerebrospinal fluid leakage developed in 3 patients in the conventional fascia lata graft group, whereas no CSF leakage occurred after the dural suture technique with a fascia lata graft was introduced. This technique could be more precisely applied when using a microscopic view. Tumor recurrence was documented for 1 patient 2 years after surgery.

Conclusions

The authors achieved good results by using extended TSS for the removal of suprasellar craniopharyngiomas. Endoscopy-assisted microscopic extended TSS harnesses the advantages of a microscope as well as those of an endoscope. Surgeons should consider using the advantages of both surgical modalities to achieve the best result possible.

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Sung Kwon Kim, Dong Gyu Kim, Young-Bem Se, Jin Wook Kim, Yong Hwy Kim, Hyun-Tai Chung and Sun Ha Paek

OBJECTIVE

Gamma Knife surgery (GKS) represents an alternative treatment for patients with tumor-related trigeminal neuralgia (TRTN). However, in previous studies, the primary GKS target was limited to mass lesions. The authors evaluated whether GKS could target both the tumor and the trigeminal root exit zone (REZ) in a single session while providing durable pain relief and minimizing radiation dose–related complications for TRTN patients.

METHODS

The authors' institutional review board approved the retrospective analysis of data from 15 consecutive patients (6 men and 9 women, median age 67 years, range 45–79 years) with TRTN who had undergone GKS. In all cases, the radiation was delivered in a single session targeting both the tumor and trigeminal REZ. The authors assessed the clinical outcomes, including the extent of pain relief, durability of the treatment response, and complications. Radiation doses to organs at risk (OARs), including the brainstem and the cranial nerve VII–VIII complex, were analyzed as doses received by 2% or 50% of the tissue volume and the tissue volume covered by a dose of 12 Gy (V12Gy).

RESULTS

The median length of clinical follow-up was 38 months (range 12–78 months). Pain relief with GKS was initially achieved in 14 patients (93.3%) and at the last follow-up in 13 patients (86.7%). The actuarial recurrence-free survival rates were 93%, 83%, and 69% at 1, 3, and 5 years after GKS, respectively. Persistent facial numbness was observed in 3 patients (20.0%). There were no complications such as facial weakness, altered taste function, hearing impairment, and balance difficulties indicating impaired function of the cranial nerve VII–VIII complex. The V12Gy in the brainstem was less than or equal to 0.24 cm3 in all patients. There were no significant differences in any OAR values in the brainstem between patients with and without facial numbness after GKS.

CONCLUSIONS

The strategy of performing GKS for both tumor and trigeminal REZ in a single session is a safe and effective radiosurgical approach that achieves durable pain control for TRTN patients.

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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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Dong-Hun Kang, Woong Yoon, Seul Kee Kim, Byung Hyun Baek, Yun Young Lee, Yong-Won Kim, Yong-Sun Kim, Yang-Ha Hwang, Joon-Tae Kim and Man Seok Park

OBJECTIVE

The optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients.

METHODS

A total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed.

RESULTS

Overall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0–2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094–0.689, p = 0.007).

CONCLUSIONS

Both intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.

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Dong-Hun Kang, Woong Yoon, Byung Hyun Baek, Seul Kee Kim, Yun Young Lee, Joon-Tae Kim, Man-Seok Park, Yong-Won Kim, Yong-Sun Kim and Yang-Ha Hwang

OBJECTIVE

The optimal front-line thrombectomy choice for primary recanalization of a target artery remains unknown for patients with acute large-vessel occlusion (LVO) and an underlying intracranial atherosclerotic stenosis (ICAS). The authors aimed to compare procedural characteristics and outcomes between patients who received a stent-retriever thrombectomy (SRT) and patients who received a contact aspiration thrombectomy (CAT), as the front-line approach for treating LVO due to severe underlying ICAS.

METHODS

One hundred thirty patients who presented with acute LVO and underlying severe ICAS at the occlusion site were included. Procedural characteristics and treatment outcomes were compared between patients treated with front-line SRT (n = 70) and those treated with front-line CAT (n = 60). The primary outcomes were the rate of switching to an alternative thrombectomy technique, time from groin puncture to initial reperfusion, and duration of the procedure. Initial reperfusion was defined as revealing the underlying culprit stenosis with an antegrade flow after thrombectomy.

RESULTS

The rate of switching to an alternative thrombectomy after failure of the front-line technique was significantly higher in the CAT group than in the SRT group (40% vs 4.3%; OR 2.543, 95% CI 1.893–3.417, p < 0.001). The median time from puncture to initial reperfusion (17 vs 31 minutes, p < 0.001) and procedure duration (39 vs 75.5 minutes, p < 0.001) were significantly shorter in the SRT group than in the CAT group. In the binary logistic regression analysis, a longer time from puncture to initial reperfusion was an independent predictor of a 90-day poor (modified Rankin Scale score 3–6) functional outcome (per 1-minute increase; OR 1.029, 95% CI 1.008–1.050, p = 0.006).

CONCLUSIONS

The authors’ results suggest that SRT may be more effective than CAT for identifying underlying culprit stenosis and therefore considered the optimal front-line thrombectomy technique in acute stroke patients with LVO and severe underlying ICAS.

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Jaechan Park, Hyunjin Woo, Dong-Hun Kang, Yong-Sun Kim, Min Young Kim, Im Hee Shin and Sang Gyu Kwak

OBJECT

While the incidence of a recurrent hemorrhage is highest within 24 hours of subarachnoid hemorrhage (SAH) and increases with the severity of the clinical grade, a recurrent hemorrhage can occur anytime after the initial SAH in patients with both good and poor clinical grades. Therefore, the authors adopted a 24-hour-a-day, formal protocol, emergency treatment strategy for patients with ruptured aneurysms to secure the aneurysms as early as possible. The incidences of in-hospital rebleeding and clinical outcomes were investigated and compared with those from previous years when broadly defined early treatment was used (< 3 days of SAH).

METHODS

During an 11-year period, a total of 1224 patients with a ruptured aneurysm were managed using a strategy of broadly defined early treatment between 2001 and 2004 (Period B, n = 423), a mixture of early or emergency treatment between 2005 and 2007, and a formal emergency treatment protocol between 2008 and 2011 (Period A, n = 442). Propensity score matching was used to adjust the differences in age, sex, modified Fisher grade, World Federation of Neurosurgical Societies (WFNS) clinical grade at admission, size and location of a ruptured aneurysm, treatment modality (clip placement vs coil embolization), and time interval from SAH to admission between the two time periods. The matched cases were allotted to Group A (n = 280) in Period A and Group B (n = 296) in Period B and then compared.

RESULTS

During Period A under the formal emergency treatment protocol strategy, the catheter angiogram, endovascular coiling, and surgical clip placement were started at a median time from admission of 2.0 hours, 2.9 hours, and 3.1 hours, respectively. After propensity score matching, Group A showed a significantly reduced incidence of in-hospital rebleeding (2.1% vs 7.4%, p = 0.003) and a higher proportion of patients with a favorable clinical outcome (modified Rankin Scale score 0–3) at 1 month (87.9% vs 79.7%, respectively; p = 0.008). In particular, the patients with good WFNS grades in Group A experienced significantly less in-hospital rebleeding (1.7% vs 5.7%, respectively; p = 0.018) and better clinical outcomes (1-month mRS score of 0–3: 93.8% vs 87.7%, respectively; p = 0.021) than the patients with good WFNS grades in Group B.

CONCLUSIONS

Patients with ruptured aneurysms may benefit from a strategy of emergency application of surgical clip placement or endovascular coiling due to the reduced incidence of recurrent bleeding and improved clinical outcomes.

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Dong-Hun Kang, Byung Moon Kim, Ji Hoe Heo, Hyo Suk Nam, Young Dae Kim, Yang-Ha Hwang, Yong-Won Kim, Yong-Sun Kim, Dong Joon Kim, Hyo Sung Kwak, Hong Gee Roh, Young-Jun Lee and Sang Heum Kim

OBJECTIVE

The role of the balloon guide catheter (BGC) has not been evaluated in contact aspiration thrombectomy (CAT) for acute stroke. Here, the authors aimed to test whether the BGC was associated with recanalization success and good functional outcome in CAT.

METHODS

All patients who had undergone CAT as the first-line treatment for anterior circulation intracranial large vessel occlusion were retrospectively identified from prospectively maintained registries for six stroke centers. The patients were dichotomized into BGC utilization and nonutilization groups. Clinical findings, procedural details, and recanalization success rates were compared between the two groups. Whether the BGC was associated with recanalization success and functional outcome was assessed.

RESULTS

A total of 429 patients (mean age 68.4 ± 11.4 years; M/F ratio 215:214) fulfilled the inclusion criteria. A BGC was used in 45.2% of patients. The overall recanalization and good outcome rates were 80.2% and 52.0%, respectively. Compared to the non-BGC group, the BGC group had a significantly reduced number of CAT passes (2.6 ± 1.6 vs 3.4 ± 1.5), shorter puncture-to-recanalization time (56 ± 27 vs 64 ± 35 minutes), lower need for the additional use of thrombolytics (1.0% vs 8.1%), and less embolization to a distal or different site (0.5% vs 3.4%). The BGC group showed significantly higher final (89.2% vs 72.8%) and first-pass (24.2% vs 8.1%) recanalization success rates. After adjustment for potentially associated factors, BGC utilization remained independently associated with recanalization (OR 4.171, 95% CI 1.523–11.420) and good functional outcome (OR 2.103, 95% CI 1.225–3.612).

CONCLUSIONS

BGC utilization significantly increased the final and first-pass recanalization rates and remained independently associated with recanalization success and good functional outcome.

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Sook Young Sim, Yong Sam Shin, Kyung Gi Cho, Sun Yong Kim, Se Hyuk Kim, Young Hwan Ahn, Soo Han Yoon and Ki Hong Cho

Object

The clinical features of blood blister–like aneurysms (BBAs) that arise at nonbranching sites of the internal carotid artery (ICA) differ from those of saccular aneurysms. In this study, the authors attempt to describe optimal treatments for BBAs, which have yet to be clearly established.

Methods

Ten of 483 patients with aneurysmal subarachnoid hemorrhage who had been seen at the authors’ institution between March 2001 and June 2005 had intraoperatively confirmed BBAs at nonbranching sites of the ICA. All ten patients were women between the ages of 37 and 64 years (mean age 49.3 years); five had a history of hypertension. The BBAs were localized to the right side of the ICA in seven cases. All patients were successfully treated; clipping was undertaken in six, clipping combined with wrapping in three, and trapping in one. These methods were used in conjunction with various other surgical techniques such as brain relaxation by draining cerebrospinal fluid, anterior clinoidectomy, exposing the cervical ICA, gentle subpial dissection (for aneurysms that adhered to the frontal lobe), complete trapping of the ICA before clipping, and protecting the brain. Clip slippage occurred at the end of dural closing in two cases; the aneurysm was completely obliterated using multiple clips combined with ICA stenosis in one of these cases and ICA trapping with good collateral flow in the other. An excellent clinical outcome was achieved in eight patients, whereas two patients were disabled from massive vasospasm. The authors retrospectively reviewed radiological and surgical data in all cases to determine which treatment methods produced a favorable outcome.

Conclusions

Blood blister–like aneurysms located at nonbranching sites of the ICA are difficult to treat. Preoperative awareness and careful consideration of these lesions during surgery can prevent poor clinical outcomes.

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Gwanhee Ehm, Han-Joon Kim, Ji-Young Kim, Jee-Young Lee, Hee Jin Kim, Ji Young Yun, Young Eun Kim, Hui-Jun Yang, Yong Hoon Lim, Beomseok Jeon and Sun Ha Paek

OBJECTIVE

For patients with highly asymmetrical Parkinson’s disease (PD), unilateral subthalamic nucleus (STN) deep brain stimulation (DBS) has been suggested as a reasonable treatment. However, the results of a previous 2-year follow-up study involving patients with prominently asymmetrical PD who had unilateral STN DBS suggested that simultaneous bilateral surgery should be performed. In the present study, the authors analyze 7-year follow-up data from the same patient group to examine changes in motor benefit from unilateral STN DBS over time and the interval between initial unilateral surgery and a second (contralateral) STN DBS surgery.

METHODS

Eight patients with highly asymmetrical parkinsonism who underwent unilateral STN DBS were evaluated. The factors measured were scores on the motor part of the Unified Parkinson’s Disease Rating Scale (UPDRS III), Hoehn and Yahr (HY) stage, and levodopa equivalent daily dose (LEDD). Evaluations occurred at 3, 6, and 12 months after the initial surgery and annually thereafter.

RESULTS

The mean follow-up period was 91.5 months (range 36–105 months). Three years after the initial unilateral surgery, motor benefits on the contralateral side continued; however, an aggravation of the ipsilateral parkinsonism attenuated the improvement in total UPDRS III scores, which reverted to baseline. Axial motor score, LEDD, and HY stage did not differ from the baseline. Seven of 8 patients (87.5%) were considered candidates for a second surgery to offer additional motor benefits. Of the 7 candidates, 4 patients (50% of total patients) underwent the second surgery at 58.5 ± 11.6 (mean ± SD) months after the initial surgery. Three patients were not able to have the second surgery: one patient died of gastric cancer, one patient was severely immobilized by an accident, and one patient could not afford the second surgery. One patient remained content with the initial unilateral surgery throughout the follow-up period.

CONCLUSIONS

Seven of 8 patients with unilateral STN DBS became candidates for second surgery before battery replacement surgery of the first implanted device. Baseline asymmetry alone may not predict appropriate candidates for unilateral STN DBS. This study provides further evidence that, from a long-term perspective, initial simultaneous bilateral STN DBS should be considered for PD patients with prominently asymmetrical motor symptoms.

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Dong-Hun Kang, Duck-Ho Goh, Seung-Kug Baik, Jaechan Park and Yong-Sun Kim

Object

This study aimed to investigate morphological predictors of intraprocedural rupture (IPR) during coil embolization of ruptured cerebral aneurysms.

Methods

A retrospective analysis was conducted in 322 consecutive patients with ruptured cerebral aneurysms who were treated with coil embolization over an 8-year period from January 2005 to December 2012. The authors analyzed all available data with emphasis on morphological characteristics of the aneurysm as shown on baseline angiography in relation to IPR. Regarding aneurysm morphology, the authors classified patients according to multilobulation, presence of a daughter sac, and presence of a small basal outpouching (SBO).

Results

The incidence of IPR was 4.8% (16 of 332). In terms of aneurysm configuration, the presence of multilobulation (100.0% [16 of 16] in the IPR group vs 89.2% [282 of 316] in the non-IPR group, p = 0.388) and daughter sac (75.0% [12 of 16] in the IPR group vs 59.2% [187 of 316] in the non-IPR group, p = 0.208) were not significantly associated with IPR. However, SBO, found in 9% (30 of 332) of the study population, was significantly associated with IPR (56.3% [9 of 16] in the IPR group vs 6.7% [21 of 316] in the non-IPR group, OR 18.06, p < 0.0001).

Conclusions

Based on the authors' data, the more general groups of multilobulation and daughter sac were not significantly associated with IPR, although the more specific subgroup with an SBO was. More confirmation studies on these results are required, but they point to the possibility that SBO (with its possible connection to basal rupture) is an important morphological risk factor for IPR during coiling. In addition, future comparison of coiling and clipping treatment for ruptured aneurysms associated with an SBO seems necessary.