This study was aimed at finding out the changes in cognitive dysfunction in patients with traumatic brain injury (TBI) and investigating the factors limiting their cognitive improvement.
Between January 2010 and March 2014, 33 patients with TBI participated in serial mini-mental status examination (MMSE). Their cognitive functions were statistically analyzed to clarify their relationship with different TBI status. Patients who developed hydrocephalus were separately analyzed in regards to their cognitive function depending on the placement of ventriculoperitoneal shunt (VPS).
Bi-frontal lobe injury (β=-10.441, p<0.001), contre-coup injury (β=-6.592, p=0.007), severe parenchymal injury (β=-7.210, p=0.012), temporal lobe injury (β=-5.524, p=0.027), and dominant hemisphere injury (β=-5.388, p=0.037) significantly lowered the final MMSE scores. The risk of down-grade in the prognosis was higher in severe parenchymal injury [odds ratio (OR)=13.41, 95% confidence interval (CI)=1.31-136.78], temporal lobe injury (OR=12.3, 95% CI=2.07-73.08), dominant hemisphere injury (OR=8.19, 95% CI=1.43-46.78), and bi-frontal lobe injury (OR=7.52, 95% CI=1.31-43.11). In the 11 post-traumatic hydrocephalus patients who underwent VPS, the final MMSE scores (17.7±6.8) substantially increased from the initial MMSE scores (11.2±8.6).
Presence of bi-frontal lobe injury, temporal lobe injury, dominant hemisphere injury, and contre-coup injury and severe parenchymal injury adversely influenced the final MMSE scores. They can be concluded to be poor prognostic factors in terms of cognitive function in TBI patients. Development of hydrocephalus aggravates cognitive impairment with unpredictable time of onset. Thus, close observation and routine image follow-up are mandatory for early detection and surgical intervention for hydrocephalus.
Brain injuries; Cognition disorders; Mini-mental status examination; Neuropsychological tests
Therapeutic approaches to brain metastases include surgery, whole-brain radiotherapy, stereotactic radiosurgery (SRS), and combination therapy. Recently, postoperative or preoperative SRS draws more attention to reduce postoperative recurrence in brain metastases. The goal of this study is to review surgical outcome of patients who had been treated by SRS, and to discuss the effectiveness of preoperative SRS.
From 2009 to 2015, 174 patients were treated by SRS for brain metastases, and among these 50 patients underwent surgery. Eighteen patients underwent surgery after SRS, and 14 had oligometastases. The patients' median age at the time of surgery was 56 years (range, 34–84 years). The median follow-up duration was 16.5 months (range, 4–47 months). Pathological findings were classified as follows; radiation necrosis (Group I, n=3), mixed type (Group II, n=2), and tumor-dominant group (Group III, n=9). We compared surgical outcome in respect of steroid, mannitol dosage, Karnofsky performance scale, and pathological subgroups.
The median overall survival was 11 months (range, 2–40 months). Six, 12 and 24 months survival rate was 64.3, 42.9, and 28.6%, respectively. Improvement of Karnofsky performance score was achieved in 50% after surgery. The overall survival of Group I (26.6 months) was longer than the other groups (11.5 months). Additionally the patients were able to be weaned from medications, such as steroid administration after surgery was reduced in 10 cases, and mannitol dosage was reduced in 6 cases. Time interval within 3 months between SRS and surgery seemed to be related with better local control.
Surgical resection after radiologically and symptomatically progressed brain metastases previously treated with SRS seems to be effective in rapid symptom relief and provides an improvement in the quality of life. A short time interval between SRS and surgical resection seems to be associated with good local tumor control.
Metastases; Stereotactic radiosurgery; Necrosis; Radiation; Surgery
Intracranial hemangiopericytoma (HPC) is a rare brain tumor with aggressive biologic behavior associated with high recurrence rate and often with extracranial metastasis. The most common sites of extracranial metastasis of the intracranial HPC are the long bones, lung, liver and abdominal cavity in the order of frequencies. Extracranial metastases usually occur long after the initial diagnosis of the primary tumor. Metastatic intracranial HPC to the vertebra has been rarely reported. We present a case of intracranial HPC metastasized to the L2 vertebral body 13 years after multiple surgical resections and radiotherapy of the primary intracranial HPC.
Hemangiopericytoma; Metastasis; Surgery; Lumbar vertebrae
The gyrus rectus (GR) is known as a non-functional gyrus; hence, its resection is agreed to be a safe procedure frequently practiced to achieve a better surgical view during specific surgeries. This study aimed at comparing the cognitive outcomes following GR resection in patients who underwent surgery for ruptured anterior communicating artery (ACoA) aneurysms.
Materials and Methods
From 2012 to 2015, 39 patients underwent surgical clipping for ruptured ACoA aneurysms. Mini-mental state examinations (MMSE) were performed in 2 different periods. The statistical relationship between GR resection and MMSE results was evaluated, and further analysis of MMSE subgroup was performed.
Twenty-five out of the 39 patients (64.19%) underwent GR resection. Mean initial and final MMSE scores in the GR resection group were 16.3 ± 9.8 and 20.8 ± 7.3, respectively. In the non-resection group, the mean initial and final MMSE scores were 17.1 ± 8.6 and 21.9 ± 4.5, respectively. Neither group's scores showed a significant change. Subgroup analysis of initial MMSE showed a significant difference in memory recall and language (p = 0.02) but not in the final MMSE scores.
There was no significant relationship between the GR resection and cognitive outcomes in terms of total MMSE scores after surgery for ruptured ACoA aneurysm. However, subgroup analysis revealed a temporary negative effect of GR resection in the categories of language and memory recall. This study suggests that GR resection should be executed superficially, owing to its close anatomical relationship with the limbic system.
Anterior communicating artery; Gyrus rectus; MMSE
Meningiomas are typically diagnosed by their characteristic appearance on conventional magnetic resonance imaging (MRI). However, detailed image findings regarding peri- and intra-tumoral anatomical structures, tumor consistency and vascularity are very important in pre-surgical planning and surgical outcomes. At the 7.0 T MRI achieving ultra-high resolution, it could be possible to obtain more useful information in surgical strategy. Four patients who were radiologically diagnosed with intracranial meningioma in 1.5 T MRI underwent a 7.0 T MRI. Three of them underwent surgery afterwards, and one received gamma knife radiosurgery. In our study, the advantages of 7.0 T MRI over 1.5 T MRI were a more detailed depiction of the peri- and intra-tumoral vasculature and a clear delineation of tumor-brain interface. In the safety issues, all patients received 7.0 T MRI without any adverse event. One disadvantage of 7.0 T MRI was the reduced image quality of skull base lesions. 7.0 T MRI in patients with meningiomas could provide useful information in surgical strategy, such as the peri-tumoral vasculature and the tumor-brain interface.
7.0 T MRI; Meningioma
The purpose of this study was to evaluate the clinical utility and validity of using a pupillometer to assess patients with acute brain lesions.
Pupillary examinations using an automated pupillometer (NeurOptics®NPi™-100 Pupillometer) were performed every 4 hours and were simultaneously assessed using the Glasgow Coma Scale (GCS) and for intracranial pressure (ICP), from admission to discharge or expire in neuro-intensive care unit (NICU). Manual pupillary examinations were also recorded for comparison. By comparing these data, we evaluated the validity of using automated pupillometers to predict clinical outcomes.
The mean values of the Neurologic Pupillary index (NPi) were different in the groups examined manually. The GCS correlated well with NPi values, especially in severe brain injury patients (GCS below 9). However, the NPi values were weakly correlated with intracranial pressure (ICP) when the ICP was lower than 30 cm H2O. The NPi value was not affected by age or intensity of illumination. In patients with a "poor" prognosis who had a Glasgow Outcome Scale (GOS) of 1 or 2, the mean initial NPi score was 0.88±1.68, whereas the value was 3.89±0.97 in patients with a "favorable" prognosis who had a GOS greater than 2 (p<0.001). For predicting clinical outcomes, the initial NPi value of 3.4 had the highest sensitivity and specificity.
An automated pupillometer can serve as a simple and useful tool for the accurate measurement of pupillary reactivity in patients with acute brain lesions.
Pupillometer; Light reflex; Neurologic Pupillary Index
The purpose of our study was to determine the frequency and severity of intracerebral hemorrhages and T2 hyperintense white matter lesions (WMLs) following radiation therapy for brain tumors in adult patients. Of 648 adult brain tumor patients who received radiation therapy at our institute, magnetic resonance (MR) image data consisting of a gradient echo (GRE) and FLAIR T2-weighted image were available three and five years after radiation therapy in 81 patients. Intracerebral hemorrhage was defined as a hypointense dot lesion appearing on GRE images after radiation therapy. The number and size of the lesions were evaluated. The T2 hyperintense WMLs observed on the FLAIR sequences were graded according to the extent of the lesion. Intracerebral hemorrhage was detected in 21 (25.9%) and 35 (43.2) patients in the three- and five-year follow-up images, respectively. The number of intracerebral hemorrhages per patient tended to increase as the follow-up period increased, whereas the size of the intracerebral hemorrhages exhibited little variation over the course of follow-up. T2 hyperintense WMLs were observed in 27 (33.3%) and 32 (39.5) patients in the three and five year follow-up images, respectively. The age at the time of radiation therapy was significantly higher (p < 0.001) in the patients with T2 hyperintense WMLs than in those without lesions. Intracerebral hemorrhages are not uncommon in adult brain tumor patients undergoing radiation therapy. The incidence and number of intracerebral hemorrhages increased over the course of follow-up. T2 hyperintense WMLs were observed in more than one-third of the study population.
There have been controversies in the treatment of elderly patients with glioblastoma. We introduce the outcome of the treatment of elderly patients with glioblastoma comparing with younger patients.
The author's hospital database was used to identify patients with histologically confirmed glioblastoma after surgery between January 2006 and December 2013. Forty-eight patients (control group) were under age 65 and 16 patients (elderly group) were aged 65 years or over at the time of surgery.
The median age of the elderly group was 71 years and control group was 50 years. Mean number of medical comorbidities was 1.8 in the elderly group vs. 0.5 in the control group. The median progression free survival (PFS) was 5.6 months and the median overall survival (OS) was 19.9 months in all patients. The elderly group had a median PFS of 4.2 months vs. 8 months for the control group (log-rank test, p=0.762). Median OS was 8.2 months in the elderly group vs. 20.9 months in the control group (log-rank test, p=0.457). Major complications occurred in 5 cases (7.8%) for all patients. The ratio of completion of concomitant chemo-radiotherapy (CCRT) was 81.3% and was the same between the two groups. In multivariable analysis, extent of resection (p=0.034) and completion of CCRT (p=0.023) were statistically significant, independent prognostic factors only for PFS in all patients by Cox proportional hazards model. Age was not an independent prognostic factor. As for OS, there was no significant factor.
Surgical resection and CCRT were well tolerated in elderly patients with glioblastoma, and maximal safe resection followed by timely CCRT could improve clinic-oncologic outcomes.
Elderly, outcome; Glioblastoma; Prognosis; Concomitant chemoradiotherapy
We investigated the effect of propofol and fentanyl on microelectrode recording (MER) and its clinical applicability during subthalamic nucleus (STN) deep brain stimulation (DBS) surgery. We analyzed 8 patients with Parkinson's disease, underwent bilateral STN DBS with MER. Their left sides were done under awake and then their right sides were done with a continuous infusion of propofol and fentanyl under local anesthesia. The electrode position was evaluated by preoperative MRI and postoperative CT. The clinical outcomes were assessed at six months after surgery. We isolated single unit activities from the left and the right side MERs. There was no significant difference in the mean firing rate between the left side MERs (38.7±16.8 spikes/sec, n=78) and the right side MERs (35.5±17.2 spikes/sec, n=66). The bursting pattern of spikes was more frequently observed in the right STN than in the left STN. All the electrode positions were within the STNs on both sides and the off-time Unified Parkinson's Disease Rating Scale part III scores at six months after surgery decreased by 67% of the preoperative level. In this study, a continuous infusion of propofol and fentanyl did not significantly interfere with the MER signals from the STN. The results of this study suggest that propofol and fentanyl can be used for STN DBS in patients with advanced Parkinson's disease improving the overall experience of the patients.
Parkinson Disease; Microelectrodes; Propofol; Fentanyl; Subthalamic Nucleus; Deep Brain Stimulation
Primary intracranial fibrosarcomas (PIFs) are extremely rare and the origin of these tumors is still controversial. The rarity of primary intracranial fibrosarcomas makes it difficult to diagnose them correctly and establish a standard treatment. The pathologic diagnosis is made by distinguishing findings from light microscopic and immunohistochemistry analysis. PIFs have been known to be very aggressive neoplasms. The extra-axial location of the tumor could provide an opportunity to perform a total resection even if it does not mean a cure. We present a case of PIFs mimicking a falx meningioma in a 17-year-old man.
Fibrosarcoma; Primary CNS origin; Differential diagnosis
Brain metastasis occurs in 3.9-24% of patients with renal cell carcinoma (RCC), with an average interval from nephrectomy to brain metastasis of 1 to 3 years. A few cases have been reported where brain metastasis occurred after a delay of more than 10 years from the initial onset of renal cell carcinoma. This long interval for central nervous system metastasis from the primary cancer has been recognized as an indicator of better prognosis. Histopathological confirmation and aggressive treatment must be considered in these delayed brain metastases cases, since the patients usually show long survival and good prognosis. We present a case of a 76-year-old woman who developed extremely late multiple brain metastases 18 years after a nephrectomy for RCC.
Renal cell carcinoma; Brain metastasis; Recurrence
Postoperative subgaleal cerebrospinal fluid (CSF) collection is considered as one of the common minor surgical complication which can lead to prolonged hospitalization. We introduce "galeal tack-up suture" to prevent postoperative subgaleal CSF collection.
Galeal tack-up suture consists of various surgical techniques which aim to fix galea to cranium in order to prevent CSF pooling in subgaleal space. A total of 87 patients who underwent craniotomy were divided into two groups while closing the wound : group A with galeal tack-up suture and group B with routine wound closure without galeal tack-up suture. The patients were observed for postoperative subgaleal CSF collection.
Among 87 cranitomy cases, galeal tack-up suture was performed in 32 cases and routine wound closure was done in 55 cases. Postoperative subgaleal CSF collection occurred in 13 cases (15%) in which 12 cases occurred in group B patients and 1 case occurred in group A patients (p=0.026).
Galeal tack-up suture is an easy and effective technique in wound closure to prevent postoperative CSF collection.
Cerebrospinal fluid leak; Craniotomy; Scalp; Sutures
Extraventricular neurocytomas are rare brain tumors that have a diverse range of clinical characteristics. We describe two cases involving fluorescence-guided resection of extraventricular neurocytoma using 5-aminolevulinic acid (5-ALA) and evaluate the efficacy of the technique. We found that the tumor reactions to 5-ALA differed depending on the histologic grade. This finding shows that the 5-ALA fluorescence reaction may potentially be used as a biomarker of the clinical behavior of these tumors. To our knowledge, this is the first report in which fluorescence-guided resection was utilized for the resection of extraventricular neurocytomas.
Extraventricular neurocytoma; Fluorescence guided surgery; 5-aminolevulinic acid
The 5-aminolevulinic acid (5-ALA)-induced tumor fluorescence is a useful intraoperative marker for the diagnosis and the detection of various malignancies, but its use in meningioma is only reported infrequently. In meningioma, a complete resection of the tumor mass is crucial for the prevention of recurrence and postoperative morbidities. Deep sylvian meningioma is a rare type of meningioma where complete tumor removal is complicated by its deep anatomical location and close involvement with the middle cerebral artery. From our experience, 5-ALA-mediated fluorescence facilitated a safe excision whilst preserving critical neurovascular structures. To our best knowledge, this is first report from use of 5-ALA in a deep sylvian meningioma.
5-aminolevulinic acid; Resection; Deep sylvian meningioma; Meningioma without dural attachment
To evaluate the mechanism of the development of therapeutic resistance after temozolomide treatment, we focused on changes in O6-methylguanine DNA methyltransferase (MGMT) and mismatch repair (MMR) between initial and recurrent glioblastomas. Tissue samples obtained from 24 paired histologically confirmed initial and recurrent adult glioblastoma patients who were initially treated with temozolomide were used for MGMT and MMR gene promoter methylation status and protein expression analysis using methylation-specific multiplex ligation probe amplification (MS-MLPA), methylation-specific polymerase chain reaction (MSP), and immunohistochemical staining. There was a significant decrease in the methylation ratio of the MGMT promoter determined by MS-MLPA, which was not detectable with MSP, and MGMT protein expression changes were not remarkable. However, there was no epigenetic variability in MMR genes, and a relatively homogeneous expression of MMR proteins was observed in initial and recurrent tumors. We conclude that the development of reduced methylation in the MGMT promoter is one of the mechanisms for acquiring therapeutic resistance after temozolomide treatment in glioblastomas.
A spinal epidural hemangioma is rare. In this case, a 51 year-old female patient had low back pain and right thigh numbness. She was initially misdiagnosed as having a ruptured disc with possible sequestration of granulation tissue formation due to the limited number of spinal epidural hemangiomas and little-known radiological findings. Because there are no effective diagnostic tools to verify the hemangioma, more effort should be put into preoperative imaging tests to avoid misdiagnosis and poor decisions).
Spinal hemangioma; Indocyanine green videoangiography; Spinal cavernous; Hemangioma; Spinal epidural hemangioma
Ga-doped ZnO [GZO] thin films were employed for the transparent electrodes in dye-sensitized solar cells [DSSCs]. The electrical property of the deposited GZO films was as good as that of commercially used fluorine-doped tin oxide [FTO]. In order to protect the GZO and enhance the photovoltaic properties, a TiO2 blocking layer was deposited on the GZO surface. Then, TiO2 nanoparticles were coated on the blocking layer, and dye was attached for the fabrication of DSSCs. The fabricated DSSCs with the GZO/TiO2 glasses showed an enhanced conversion efficiency of 4.02% compared to the devices with the normal GZO glasses (3.36%). Furthermore, they showed better characteristics even than those using the FTO glasses, which can be attributed to the reduced charge recombination and series resistance.