Facial nerve palsy is a common complication of treatment for vestibular schwannoma (VS), so preserving facial nerve function is important. The preoperative visualization of the course of facial nerve in relation to VS could help prevent injury to the nerve during the surgery. In this study, we evaluate the accuracy of diffusion tensor tractography (DTT) for preoperative identification of facial nerve.
We prospectively collected data from 11 patients with VS, who underwent preoperative DTT for facial nerve. Imaging results were correlated with intraoperative findings. Postoperative DTT was performed at postoperative 3 month. Facial nerve function was clinically evaluated according to the House-Brackmann (HB) facial nerve grading system.
Facial nerve courses on preoperative tractography were entirely correlated with intraoperative findings in all patients. Facial nerve was located on the anterior of the tumor surface in 5 cases, on anteroinferior in 3 cases, on anterosuperior in 2 cases, and on posteroinferior in 1 case. In postoperative facial nerve tractography, preservation of facial nerve was confirmed in all patients. No patient had severe facial paralysis at postoperative one year.
This study shows that DTT for preoperative identification of facial nerve in VS surgery could be a very accurate and useful radiological method and could help to improve facial nerve preservation.
Vestibular schwannomas; Facial nerve injury; Diffusion tensor imaging
Recently, the increasing rates of facial nerve preservation after vestibular schwannoma (VS) surgery have been achieved. However, the management of a partially or completely damaged facial nerve remains an important issue. The authors report a patient who was had a good recovery after a facial nerve reconstruction using fibrin glue-coated collagen fleece for a totally transected facial nerve during VS surgery. And, we verifed the anatomical preservation and functional outcome of the facial nerve with postoperative diffusion tensor (DT) imaging facial nerve tractography, electroneurography (ENoG) and House-Brackmann (HB) grade. DT imaging tractography at the 3rd postoperative day revealed preservation of facial nerve. And facial nerve degeneration ratio was 94.1% at 7th postoperative day ENoG. At postoperative 3 months and 1 year follow-up examination with DT imaging facial nerve tractography and ENoG, good results for facial nerve function were observed.
Vestibular schwannoma; Facial nerve injury; Diffusion tensor imaging; Electromyography; Intraoperative monitoring
This study explored the relationships among demographic (DVs) and clinical variables (CVs), neurocognitive (NOs) and functional outcome (FO) that could be used as prognostic factors for old aged patients with traumatic brain injury (TBI) undergoing or appointed disability evaluation (DE) after treatment.
A total of 162 subjects with TBI above the age of 55 years undergoing DE or appointed to do so after treatments were selected. The patients were divided into two subgroups according to age : a junior elderly group 55 to 64 years old and a senior elderly group over the age of 65. NOs and FO were evaluated using the Seoul Neuropsychological Screening Battery and Clinical Dementia Rating scale.
Gender, age, and education level were shown to significantly impact the recovery of NOs after TBI. Other DVs and CVs such as area of residency, occupation, type of injury, or loss of consciousness were not found to significantly affect the recovery of NOs after TBI. Analysis of the relationships among DVs, CVs and NOs demonstrated that gender, age, and education level contributed to the variance of NOs. In FO, loss of consciousness (LOC) was included to prognostic factor.
Gender, age and education level significantly influence the NOs of elderly patients with TBI. LOC may also serve as a meaningful prognostic factor in FO. Unlike younger adult patients with TBI, old aged patients with TBI did not show global faking-bad or malingering attitudes to DE for compensation, but assume that they could faking their performance in a test set available visual feedback.
Advanced age; Traumatic brain injury; Prognosis; Gender; Education
We determined whether the relationship between the neuropsychological performance of patients with mild traumatic brain injury (TBI) and their psychopathological characteristics measured by disability evaluation are interrelated. In addition, we assessed which psychopathological variable was most influential on neuropsychological performance via statistical clustering of the same characteristics of mild TBI.
A total of 219 disability evaluation participants with mild brain injury were selected. All participants were classified into three groups, based on their psychopathological characteristics, via a two-step cluster analysis using validity and clinical scales from the Minnesota Multiphasic Personality Inventory (MMPI) and Symptom Checklist-90-revised (SCL-90-R). The Korean Wechsler Adult Intelligence Scale (K-WAIS), Korean Memory Assessment Scale (K-MAS) and the Korean Boston Naming Test (K-BNT) were used to evaluate the neurocognitive functions of mild TBI patients.
Over a quarter (26.9%) experienced severe psychopathological symptoms and 43.4% experienced mild or moderate psychopathological symptoms, and all of the mild TBI patients showed a significant relationship between neurocognitive functions and subjective and/or objective psychopathic symptoms, but the degree of this relationship was moderate. Variances of neurocognitive function were explained by neurotic and psychotic symptoms, but the role of these factors were different to each other and participants did not show intelligence and other cognitive domain decrement except for global memory abilities compared to the non-psychopathology group.
Certain patients with mild TBI showed psychopathological symptoms, but these were not directly related to cognitive decrement. Psychopathology and cognitive decrement are discrete aspects in patients with mild TBI. Furthermore, the neurotic symptoms of mild TBI patients made positive complements to decrements or impairments of neurocognitive functions, but the psychotic symptoms had a negative effect on neurocognitive functions.
Disability evaluation; Mild traumatic brain injury; Neuropsychological performance; Post-concussion syndrome
Intra-cranial aneurysm can be incidental findings in patients with pituitary adenomas, and are usually located outside the pituitary region. However, the coexistence of intrasellar (not intracranial) aneurysms with pituitary adenomas is extremely rare. We report a patient with an incidental superior hypophygeal aneurysm embedded within a non-functional pituitary adenoma which was treated by transsphenoidal surgery after endovascular coil embolization.
Pituitary adenoma; Aneurysm; Therapeutic embolization; Surgical procedure
Meningiomas represent 18-20% of all intracranial tumors and have a 20-50% 10-year recurrence rate, despite aggressive surgery and irradiation. Hydroxyurea, an inhibitor of ribonucleotide reductase, is known to inhibit meningioma cells by induction of apoptosis. We report the long-term follow-up result of hydroxyurea therapy in the patients with recurrent meningiomas.
Thirteen patients with recurrent WHO grade I or II meningioma were treated with hydroxyurea (1000 mg/m2/day orally divided twice per day) from June 1998 to February 2012. Nine female and 4 male, ranging in age from 32 to 83 years (median age 61.7 years), were included. Follow-up assessment included physical examination, computed tomography, and magnetic resonance imaging (MRI). Standard neuro-oncological response criteria (Macdonald criteria) were used to evaluate the follow-up MRI scans. The treatment was continued until there was objective disease progression or onset of unmanageable toxicity.
Ten of the 13 patients (76.9%) showed stable disease after treatment, with time to progression ranging from 8 to 128 months (median 72.4 months; 6 patients still accruing time). However, there was no complete response or partial response in any patients. Three patients had progressive disease after 88, 89, 36 months, respectively. There was no severe (Grade III-IV) blood systemic disorders and no episodes of non-hematological side effects.
This study showed that hydroxyurea is a modestly active agent against recurrent meningiomas and can induce long-term stabilization of disease in some patients. We think that hydroxyurea treatment is well tolerated and convenient, and could be considered as an alternative treatment option in patients with recurrent meningiomas prior to reoperation or radiotherapy.
Meningioma; Chemotherapy; Hydroxyurea; Recurrence
Alveolar soft part sarcoma (ASPS) with skull and brain metastases is extremely rare. A 53-year-old patient diagnosed as skull metastasis of ASPS visited our clinic complaining of an outgrowing scalp mass in spite of radiation therapy. Past medical history revealed that the patient had been diagnosed and treated for ASPS of the thigh 4 years ago. Magnetic resonance imaging revealed a hyperintense ovoid mass on the T2-weighted image, an isointense on the T1-weighted image, and a homogeneous enhanced mass with gadolinium. Another small-sized enhanced mass with mild peritumoral swelling was found at the deep white matter of the left frontal lobe. A gross total resection of the skull lesion with cranioplasty was performed for the surgical defect. A histologic examination of the specimens revealed metastatic ASPS involving the skull. Surgery with a total removal of the lesions may be effective for improving a patient's symptoms especially from neurological dysfunction.
Alveolar soft part sarcoma; Brain metastasis; Sarcoma; Surgery
Cerebellar pilocytic astrocytomas (PAs) are benign gliomas predominantly found in the pediatric population. Intracranial hemorrhages are extremely rare in initial presentations of cerebellar PAs. There are no reports in the medical literature of adult cerebellar PA cases presenting with intratumoral hemorrhage. We report 2 cases of adult cerebellar pilocytic astrocytomas with intratumoral hemorrhage. The first case is a 37-year-old woman presenting with severe headache, nausea, and vomitting. Computed tomography demonstrated an acute hemorrhage adjacent to the right cerebellar hemisphere and hydrocephalus. Magnetic resonance imaging (MRI) revealed a cerebellar vermian tumor with the hemorrhage as a mixed isointense area in the T2-weighted image, and as a mixed hyperintense area in the contrast-enhanced T1-weighted image. The second case is a 53-year-old man presenting with headache for 3 weeks. MRI revealed a cerebellar hemispheric tumor with the hemorrhage as a mixed hyperintense area. It had a cystic mass with a heterogeneous enhanced mural nodule in the gadolinium-enhanced T1-weighted image and a fluid-fluid level within the cyst in the T2-weighted image. Both of them underwent radical resections of their respective lesions. Histological examination of the specimens revealed typical astrocytoma, including a hemorrhagic portion. Both patients recovered postoperatively and continue to do well at present. The medical literature on hemorrhagic cerebellar PAs is also reviewed.
Pilocytic astrocytoma; Hemorrhage; Cerebellum; Adult
The primary objective of this study was to perform a retrospective evaluation of the radiological and pathological features influencing the formation of peritumoral brain edema (PTBE) in meningiomas.
The magnetic resonance imaging (MRI) and pathology data for 86 patients with meningiomas, who underwent surgery at our institution between September 2003 and March 2009, were examined. We evaluated predictive factors related to peritumoral edema including gender, tumor volume, shape of tumor margin, presence of arachnoid plane, the signal intensity (SI) of the tumor in T2-weighted image (T2WI), the WHO histological classification (GI, GII/GIII) and the Ki-67 antigen labeling index (LI). The edema-tumor volume ratio was calculated as the edema index (EI) and was used to evaluate peritumoral edema.
Gender (p=0.809) and pathological finding (p=0.084) were not statistically significantly associated with peritumoral edema by univariate analysis. Tumor volume was not correlated with the volume of peritumoral edema. By univariate analysis, three radiological features, and one pathological finding, were associated with PTBE of statistical significance: shape of tumor margin (p=0.001), presence of arachnoid plane (p=0.001), high SI of tumor in T2WI (p=0.001), and Ki-67 antigen LI (p=0.049). These results suggest that irregular tumor margins, hyperintensity in T2WI, absence of arachnoid plane on the MRI, and high Ki-67 LI can be important predictive factors that influence the formation of peritumoral edema in meningiomas. By multivariate analysis, only SI of the tumor in T2WI was statistically significantly associated with peritumoral edema.
Results of this study indicate that irregular tumor margin, hyperintensity in T2WI, absence of arachnoid plane on the MRI, and high Ki-67 LI may be important predictive factors influencing the formation of peritumoral edema in meningiomas.
Brain edema; Edema index; Intracranial meningioma; Labeling index
We investigated whether Disability Evaluation (DE) situations influence patients' neuropsychological test performances and psychopathological characteristics and which variable play a role to establish an explanation model using statistical analysis.
Patients were 536 (56.6%) brain-injured persons who met inclusion and exclusion criteria, classified into the DE group (DE; n = 300, 56.0%) and the non-DE group (NDE; n = 236, 44.0%) according to the neuropsychological testing's purpose. Next, we classified DE subjects into DE cluster 1 (DEC1; 91, 17.0%), DE cluster 2 (DEC2; 125; 23.3%), and DE cluster 3 (DEC3; 84, 15.7%) via two-step cluster analysis, to specify DE characteristics. All patients completed the K-WAIS, K-MAS, K-BNT, SCL-90-R, and MMPI.
In comparisons between DE and NDE, the DE group showed lower intelligence quotients and more severe psychopathologic symptoms, as evaluated by the SCL-90-R and MMPI, than the NDE group did. When comparing the intelligence among the DE groups and NDE group, DEC1 group performed worst on intelligence and memory and had most severe psychopathologic symptoms than the NDE group did. The DEC2 group showed modest performance increase over the DEC1 and DEC3, similar to the NDE group. Paradoxically, the DEC3 group performed better than the NDE group did on all variables.
The DE group showed minimal "faking bad" patterns. When we divided the DE group into three groups, the DEC1 group showed typical malingering patterns, the DEC2 group showed passive malingering patterns, and the DEC3 group suggested denial of symptoms and resistance to treatment.
Disability evaluation; Brain injury; Malingering
The purpose of this study was to assess memory dysfunction in patients with mild and moderate traumatic brain injury (TBI) with and without frontal lobe injury (FLI).
The subjects were 110 TBI patients, who had recovered from the acute clinical phase, and comprised 20 (18.2%) mild TBI (MTBI) patients with FLI, 16 (14.5%) MTBI patients without FLI, 51 (46.4%) moderate TBI (MOTBI) patients with FLI and 23 (20.9%) MTBI patients without FLI. All patients were administrated the Korean version of the Memory Assessment Scale (K-MAS).
Almost all the Summary Scale scores on the K-MAS failed to show any differences between TBI patients with and without FLI, but differences did emerge by types at severities. TBI patients with FLI showed higher Global Memory ability than TBI patients without FLI if their TBI was only mild, but when their TBI was more severe, this finding was reversed, and TBI patients with FLI showed lower Verbal and Global Memory abilities than TBI patients without FLI.
Different kinds of assessment tools are needed for the measurement of memory abilities in TBI patients with FLI, and that the selection of the appropriate tool depends on the severity of the TBI.
Frontal lobe injury; Memory; Severity
We retrospectively analyzed the surgical outcomes of 42 patients with growth hormone (GH)-secreting pituitary adenoma to evaluate the clinical manifestations and to determine which preoperative factors that significantly influence the remission.
Forty-two patients with GH-secreting pituitary adenoma underwent transsphenoidal surgery (TSS) between 1995 and 2007. The patient group included 23 women and 19 men, with a mean age of 40.2 (range 13-61) years, and a mean follow-up duration of 49.4 (range 3-178) months after the operation. For comparable radiological criteria, we classified parasellar growth into five grades according to the Knosp classification. We analyzed the surgical results of the patients according to the most recent stringent criteria for cure.
The overall rate of endocrinological remission in the group of 42 patients after primary TSS was 64% (26 of 42). The remission rate was 67% (8 of 12) for microadenoma and 60% (18 of 30) for macroadenoma. The remission rate was 30% (3 of 10) for the group with cavernous sinus invasion and 72% (23 of 32) for the group with intact cavernous sinus. Cavernous sinus invasion in Knosp grade III and IV was significantly correlated with the remission rate. There was a significant relationship between preoperative mean GH concentration and early postoperative outcome, with most patients in remission having a lower preoperative GH concentration.
TSS is thought to be an effective primary treatment for GH-secreting pituitary adenomas according to the most recent criteria of cure. Because the remission rate in cases with cavernous sinus invasion is very low, early detection of the tumor before it extends into the cavernous sinus and a long-term endocrinological and radiological follow-up are necessary in order to improve the remission rate of acromegaly.
Growth hormone-secreting pituitary adenoma; Cavernous sinus; Remission induction
Primary intracranial squamous cell carcinoma is extremely rare, with most cases arising from a preexisting benign epidermoid cyst. We report a rare case of primary intracranial squamous cell carcinoma in the brain stem with a cerebellopontine angle (CPA) epidermoid cyst. A 72-year-old female suffered from progressive left hemiparesis, difficulty in swallowing, and right hemifacial numbness. Diffusion-weighted magnetic resonance imaging revealed a high signal intensity (SI) lesion in the CPA region and an intra-axially ring-enhanced cystic mass in the right brain stem with low SI. Whole-body positron emission tomography showed no evidence of metastatic disease. The histological findings revealed a typical epidermoid cyst in the CPA region and a squamous cell carcinoma in the brain stem. We speculate that the squamous cell carcinoma may have been developed due to a chronic inflammatory response by the adjacent epidermoid cyst. The patient underwent a surgical resection and radiotherapy. After 12 months, she had no evidence of recurrence.
Squamous cell carcinoma; Epidermoid cyst; Brain stem; Cerebellopontine angle
Premorbid demographic backgrounds of injured individuals are likely to reflect more accurately the status of patients with traumatic brian injury (TBI) than clinical factors. However, the concrete study about the relationship between the demographic factors and neurocognitive function in TBI patients has not been reported. The object of this study was to evaluate the effect of premorbid demographic factors on the recovery of neurocognitive function following TBI.
From July 1998 to February 2007, 293 patients (male: 228, female: 65) with a history of head injury, who had recovered from the acute phase, were selected from our hospital to include in this study. We analyzed the effect of premorbid demographic factors including age, sex, educational level and occupation on the recovery of neurocognitive function in each TBI subgroup as defined by Glasgow Coma Scale (GCS) score. Intelligence and memory are components of neurocognitive function, and the Korean Wechsler Intelligence Scale (K-WAIS) and the Korean memory assessment scale (K-MAS) were used in this study. The results were considered significant at p<0.05.
The higher level of education was a good prognostic factor for intelligence regardless of GCS score and younger age group showed a better result for memory with an exception of severe TBI group. In the severe TBI group, the meaningful effect of demographic factors was not noted by the cause of influence of severe brain injury.
The demographic factors used in this study may be helpful for predicting the precise prognosis and developing an appropriate rehabilitation program for TBI patients.
Traumatic brain injury; Premorbid demographic factors; Prognosis
The purpose of the present study is to assess the long-term results of microsurgical dorsal root entry zonotomy (MDT) for the treatment of medically intractable upper-extremity spasticity.
The records of nine adult patients who underwent MDT by one operating neurosurgeon from March 1999 to June 2004 were retrospectively reviewed by another investigator who had no role in the management of these patients. In all patients, MDT was performed on all roots of the upper limb (from C5 to T1) for spasticity of the upper extremity. The degree of spasticity was measured by the Modified Ashworth Scale (grade 0-4). Severity of the pain level was determined using the Numeric Rating Scale (NRS, score 0-10). Also, patient satisfaction of the post-operative outcome was assessed.
Comparing the preoperative and postoperative spasticity using the Modified Ashworth Scale, we observed improvement in all patients, particularly in five of the nine patients (55.6%) who improved by three grades over an average of 66.4 months (range, 40-96). Regarding patient satisfaction, seven patients (77.8%) had affirmative results. None of the patients experienced severe, life-threatening, postoperative complications. We observed a decrease in the intensity of painful spasms to less than three scores as measured by NRS in all four patients with associated pain.
This study shows that MDT provides significant, long-term reduction of harmful spasticity and associated pain in the upper limbs.
Muscle spasticity; Upper extremity; Spinal cord; DREZ operation; Long-term effect
The purpose of this study is to identify the factors affecting the failure of trials (<50% pain reduction in pain for trial period) to improve success rate of spinal cord stimulation (SCS) trial.
A retrospective review of the failed trials (44 patients, 36.1%) among the patients (n=122) who underwent SCS trial between January 1990 and December 1998 was conducted. We reviewed the causes of failed trial stimulation, age, sex, etiology of pain, type of electrode, and third party support.
Of the 44 patients, 65.9% showed unacceptable pain relief in spite of sufficient paresthesia on the pain area with trial stimulation. Four of six patients felt insufficient paresthesia with stimulation had the lesions of the spinal cord. Seventy five percent of the patients experienced unpleasant or painful sensation during stimulation had allodynia dominant pain. Third-party involvement, sex, age and electrode type had no influence on the outcome.
We conclude that SCS trial is less effective for patients with neuropathic pain of cord lesions, postherpetic neuropathy or post-amputation state. Further, patients with allodynia dominant pain can feel unpleasant or painful during trial stimulation.
Spinal cord stimulation; Cord lesion; Allodynia; Paresthesia; Chronic pain