Cheong Jh

Visual outcome after transsphenoidal surgery in patients with pituitary apoplexy.

OBJECTIVE Pituitary apoplexy is one of the most serious life-threatening complications of pituitary adenoma. The purpose of this study is to investigate the visual outcome after early transsphenoidal surgery for the patients with pituitary apoplexy. METHODS We retrospectively reviewed the 31 patients with pituitary apoplexy who were admitted due to acute visual acuity or field impairment and treated by transsphenoidal surgery. Five patients were excluded because of the decreased conscious level. The visual acuity of each individual eye was evaluated by Snellens chart. Visual fields were also checked using automated perimetry. To compare the visual outcome according to the surgical timing, we divided the patients into 2 groups. The first group, 21 of the patients have been undertaken transsphenoidal approach (TSA) within at least 48 hours after admission. The second group included 8 patients who have been undertaken TSA beyond 48 hours. All patients were monitored at least 12 months after surgery. RESULTS Patients were 21 males and 8 females (M : F=2.6 : 1) with the mean age of 42.4 years. Among the enrolled 29 patients, 26 patients presented with decreased visual acuity and 23 patients revealed the defective visual field respectively. Postoperatively, improvement in the visual acuity was seen in 15 patients (83.3%) who underwent surgery within the first 48 hours of presentation, as compared to those in whom surgery was delayed beyond 48 hours (n=5; 62.5%) (p=0.014). Improvement in the visual field deficits was observed in 15 (88.2%) of patients who had been operated on within the first 48 hours of presentation, as compared to those in whom surgery was delayed beyond 48 hours (n=3; 50.0%) (p=0.037). CONCLUSION This study suggests that rapid transsphenoidal surgery is effective to recover the visual impairment in patients with pituitary apoplexy. If there are associated abnormalities of visual acuity or visual fields in patients with hemorrhagic pituitary apoplexy, early neurosurgical intervention within 48 hours should be also required to recover visual impairment.

Occludin expression in brain tumors and its relevance to peritumoral edema and survival.

PURPOSE Peritumoral brain edema (PTBE) is a serious causative factor that contributes the morbidity or mortality of brain tumors. The development of PTBE is influenced by many factors, including such tight junction proteins as occludin. We evaluated the PTBE volume and survival time with respect to the occludin expression in various pathological types of brain tumors. MATERIALS AND METHODS Fresh-frozen specimens from sixty patients who had brain tumors were obtained during surgery and the tumors were confirmed pathologically. The occludin expression was investigated by Western blot analysis. The PTBE volume was measured by using preoperative magnetic resonance (MR) imaging, and the survival time in each patient was estimated retrospectively. RESULTS Occludin was detected in 41 (68.3%) of the cases with brain tumors and it was not expressed in the other 19 (31.7%) cases. Although the lowest expression was revealed in high-grade gliomas, its expression was variable according to the pathology of the brain tumors (p>0.05). The difference of PTBE volume between occludin-positive and negative brain tumors was statistically significant (2072.46+/-328.73 mm(3) vs. 7452.42+/-1504.19 mm(3), respectively, p=0.002). The mean survival time was longer in the occludin-positive tumor group than in the occludin-negative group (38.63+/-1.57 months vs. 26.16+/-3.83 months, respectively; p=0.016). CONCLUSIONS This study suggests that the occludin expression is highly correlated to the development of PTBE in brain tumors and it might be a prognostic indicator for patient survival.

Transformation of intracranial anaplastic astrocytoma associated with neurofibromatosis type I into gliosarcoma: Case report

Gliosarcoma is an uncommon malignant brain tumor composed of distinct sarcomatous and malignant glial cell elements. These tumors are defined as a variant of glioblastoma, and it can be developed by progression of the malignant glial cell tumors or primary tumors. We report a rare case with gliosarcomatous recurrence of anaplastic astrocytoma with neurofibromatosis type 1 (NF-1) followed by chemoradiation therapy. A 26-year-old male patient was presented with headache. Five years before admission, he had been diagnosed with NF-1. Magnetic resonance imaging (MRI) showed a well-demarcated, enhanced lesion in the right frontal lobe and multiple enhanced lesions in the scalp, lower cervical, thoracic, and upper lumbar regions. He underwent an osteoplastic craniotomy with total tumor resection. Histopathology of the tumor showed findings corresponding with anaplastic astrocytoma. He was followed by radiotherapy and chemotherapy postoperatively. A month later, his spinal lesion was also resected and confirmed pathologically as plexiform neurofibroma. The subsequent follow-up period of 27 months was uneventful until he developed a generalized tonic-clonic seizure. MRI showed tumor recurrence in the original site of the tumor. Re-exploration was carried out. Pathological examination displayed a biphasic pattern of the glial and sarcomatous components suggesting gliosarcoma.

A Ruptured Dermoid Cyst of the Cavernous Sinus Extending into the Posterior Fossa

Supratentorial dermoid cysts are uncommon to develop in the cavernous sinus. We present a ruptured dermoid cyst of the cavernous sinus extending into the posterior fossa. The patient was a 32-year-old female who complained occipital headache, blurred vision, and tinnitus over 4 years. Brain magnetic resonance (MR) imaging revealed an enhanced tumor in the right cavernous sinus extending into the right temporal base and the posterior fossa with findings of ruptured cyst. Surgical resection was performed, and pathological findings were confirmed to be a dermoid cyst. We report a second case with ruptured dermoid cyst of the cavernous sinus extending into the posterior fossa.

Valproic Acid-Induced Hyperammonemic Encephalopathy as a Cause of Neurologic Deterioration after Unruptured Aneurysm Surgery

Neurological deficits after brain surgery are not uncommon, and correct and prompt differential diagnosis is essential to initiate appropriate treatment. We describe a patient suffering from loss of consciousness due to hyperammonemia, following valproic acid treatment after surgery for an unruptured cerebral aneurysm. A 57-year-old female patient underwent successful aneurysmal neck clipping to correct an unruptured aneurysm. Her postoperative course was good, and she received anti-epileptic therapy (valproic acid) and a soft diet. Within a few days the patient experienced mental deterioration. Her serum valproic acid reached toxic levels (149.40 mg/L), and serum ammonia was fifteen times the upper normal limit (553 mmol/L; normal range, 9-33 mmol/L). After discontinuation of valproic acid and with conservative treatment, the patient recovered without any complications. Valproate-induced hyperammonemic encephalopathy is an unusual but serious neurosurgical complication, and should not be disregarded as a possible cause of neurological deficits after neurovascular surgery. Early diagnosis is crucial, as discontinuation of valproic acid therapy can prevent serious complications, including death.

Radiologic Factors Predicting Deterioration of Mental Status in Patients with Acute Traumatic Subdural Hematoma

OBJECTIVE To evaluate whether subdural hematoma (SDH) volume and other radiologic factors predict deterioration of mental status in patients with acute traumatic SDH. METHODS SDH volumes were measured with a semiautomated tool. The area under the receiver operating characteristic curve was used to determine optimal cutoff values for mental deterioration, including the variables midline shift, SDH volume, hematoma thickness, and Sylvian fissure ratio. Multivariate logistic regression was used to calculate the odds ratio for mental deterioration based on several predictive factors. RESULTS We enrolled 103 consecutive patients admitted to our hospital with acute traumatic SDH over an 8-year period. We observed an increase in SDH volume of approximately 7.2 mL as SDH thickness increased by 1 mm. A steeper slope for midline shift was observed in patients with SDH volumes of approximately 75 mL in the younger age group compared with patients in the older age group. When comparing cutoff values used to predict poor mental status at time of admission between the 2 age groups, we observed smaller midline shifts in the older patients. CONCLUSIONS Among younger patients, an overall tendency for more rapid midline shift progression was observed in patients with relatively low SDH volumes compared with older patients. Older patients seem to tolerate larger hematoma volumes owing to brain atrophy compared with younger patients. When there is a midline shift, older patients seem to be more vulnerable to mental deterioration than younger patients.

Increased Short-Term Mortality in Patients with Spontaneous Intracerebral Hemorrhage and its Association with Admission Glucose Levels and Leukocytosis

OBJECTIVE Spontaneous intracerebral hemorrhage (ICH) can be a devastating event. An increased glucose level in patients with ICH is known to be related to poor outcomes, including acute leukocytosis, which is a well-established response to ICH. The purpose of this study was to evaluate the association between admission laboratory factors and 3-month mortality in patients with spontaneous supratentorial ICH. METHODS We performed a Kaplan-Meier analysis to evaluate the risk factors for 3-month mortality in patients with ICH. We used univariate and multivariate Cox regression analyses to calculate hazard ratios with 95% confidence intervals for short-term mortality based on clinical and laboratory factors. The area under the receiver operating characteristic curve was used to determine the laboratory risk factors that predicted mortality. RESULTS In total, 538 patients from our hospital admitted with primary spontaneous supratentorial ICH over an 8-year period were enrolled in this study. Higher leukocyte counts (hazard ratio, 1.019; 95% confidence interval, 1.012-1.027; P < 0.001) and glucose levels on admission were associated with higher 3-month mortality. The receiver operating characteristic curve analysis showed that the areas under the curve of ICH volume, glucose, and leukocyte counts were 0.696 (cutoff value, 41.63), 0.687 (cutoff value, 134), and 0.642 (cutoff value, 9.4), respectively. CONCLUSIONS Higher admission white blood cell counts and glucose levels were associated with higher 3-month mortality in patients with spontaneous ICH. These data show that an altered glucose metabolism and inflammatory state after ICH may be related to early deterioration after an ICH.