Ching-Yi Lee

High cervical spinal cord stimulation after failed dorsal root entry zone surgery for brachial plexus avulsion pain.

BACKGROUND Many patients had intractable pain after brachial plexus avulsion. This article describes a feasible method of high cervical SCS for a patient who failed in DREZ surgery to treat the pain. CASE DESCRIPTION A 70-year-old man had right brachial plexus avulsion after a car accident 15 years ago. He complained of chronic spontaneous pain over his right upper limb since then. Two DREZ surgeries failed to relieve the pain. The pain was successfully controlled by high cervical SCS. CONCLUSION Stimulating the high cervical spinal cord is effective for treating intractable pain after brachial plexus avulsion, which the DREZ surgery failed to relieve.

Low and High Frequency Hippocampal Stimulation for Drug-Resistant Mesial Temporal Lobe Epilepsy.

Electrical stimulation of the hippocampus offers the possibility to treat patients with mesial temporal lobe epilepsy (MTLE) who are not surgical candidates. We report long‐term follow‐up results in five patients receiving low or high frequency hippocampal stimulation for drug‐resistant MTLE.

Successful Treatment of Refractory Status Epilepticus Using Anterior Thalamic Nuclei Deep Brain Stimulation

BACKGROUND Refractory status epilepticus (RSE) is considered a medical emergency in neurology and is related to high mortality. We report a successfully treated case of RSE using deep brain stimulation (DBS) at the anterior thalamic nuclei (ATN) in a 17-year-old woman. RESULTS This patient developed RSE as a result of progressive seizure activity. RSE with generalized tonic-clonic seizures was noted 2 weeks before admission. Video electroencephalography monitoring showed continuous 3-Hz generalized spike-and-wave complexes with higher amplitude over bilateral frontal. Four weeks after RSE onset, bilateral DBS of the ATN was started. This treatment was immediately followed by the disappearance of tonic-clonic seizures and spike-and-wave complexes, suggesting resolution of the RSE. Significant clinical improvement was noted 1 week after DBS implantation. CONCLUSIONS DBS at the ATN significantly improved both the electroencephalography and clinical presentation in the patient with RSE. DBS at the ATN should be considered as a possible treatment choice once a patient develops RSE.

Indications and Outcomes of Prophylactic and Therapeutic Extracranial-to-intracranial Arterial Bypass for Cerebral Revascularization

Background: Extracranial-to-intracranial (EC-IC) arterial bypass is a technically demanding procedure used to treat complex cerebral artery diseases. The indications, proper surgical techniques, and outcomes of this procedure have been under debate over the recent decades. Methods: Between January 2004 and December 2012, 28 patients, including patients with cerebral artery occlusion, intracranial aneurysm, cranial base tumor, and Moyamoya disease, underwent EC-IC bypass. Patients’ records were retrospectively reviewed for demography, indications, complications, high-flow versus low-flow bypass, patency rate of bypass, and neurological outcome. The patients were sorted into prophylactic (n = 16) and therapeutic (n = 12) groups based on the preoperative presentation of their neurological symptoms. Follow-up evaluation was performed at a mean of 32.7 ± 24.3 months. Results: The overall patency rate of bypass was 100%, the postoperative stroke rate was zero, and the surgical complication rate was 14.3%. There was no significant difference in the bypass patency rate between the 2 groups or between the high-flow and low-flow bypass patients. Patients who underwent prophylactic bypass had minimal surgical and total complications (P = 0.03 and P < 0.01, respectively) and a better neurological outcome. Surgical complications were more common in patients who underwent therapeutic bypass (25%). Conclusions: The collaboration of neurosurgeons and plastic surgeons in performing EC-IC bypass can result in excellent outcomes with a high bypass patency rate and few complications, particularly for prophylactic EC-IC bypass.

The Preferred Learning Styles of Neurosurgeons, Neurosurgery Residents, and Neurology Residents: Implications in the Neurosurgical Field

OBJECTIVE To delineate the learning style that best defines a successful practitioner in the field of neurosurgery by using a validated learning style inventory. METHODS The Kolb Learning Style Inventory, a validated assessment tool, was administered to all practicing neurosurgeons, neurosurgical residents, and neurology residents employed at Chang Gung Memorial Hospital, an institution that provides primary and tertiary clinical care in 3 locations, Linkou, Kaohsiung, and Chiayi. There were 81 participants who entered the study, and all completed the study. RESULTS Neurosurgeons preferred the assimilating learning style (52%), followed by the diverging learning style (39%). Neurosurgery residents were slightly more evenly distributed across the learning styles; however, they still favored assimilating (32%) and diverging (41%). Neurology residents had the most clearly defined preferred learning style with assimilating (76%) obtaining the large majority and diverging (12%) being a distant second. CONCLUSIONS The assimilating and diverging learning styles are the preferred learning styles among neurosurgeons, neurosurgery residents, and neurology residents. The assimilating learning style typically is the primary learning style for neurosurgeons and neurology residents. Neurosurgical residents start off with a diverging learning style and progress toward an assimilating learning style as they work toward becoming practicing neurosurgeons. The field of neurosurgery has limited opportunities for active experimentation, which may explain why individuals who prefer reflective observation are more likely to succeed in this field.

Correlations between clinical hormone change and pathological features of pituicytoma

Abstract Purpose: Pituicytoma is a rare low-grade glioma arising from the pituicytes of the posterior pituitary. To date, the clinical and pathological correlates of pituicytoma have not been investigated. This study was thus designed to examine the correlation between pituicytoma and the normal pituitary gland. Methods: The records of patients who underwent pituitary surgery at Chang Gung Memorial Hospital in Linkou, Taiwan between 2000 and 2016 were reviewed. Patients who received a pathological diagnosis of pituicytoma were included; however, those with inadequate specimens for pathological study were excluded. Clinical information, including patients’ presenting symptoms, serum hormone levels, neuroimages, and specimens, were collected. Hematoxylin and eosin stains and immunohistochemical (IHC) stains were performed for differential diagnosis. Results: Among the 1532 patients who underwent pituitary surgery, nine (0.59%) received a pathological diagnosis of pituicytoma. Two patients were excluded due to inadequate specimens. Among the seven remaining patients, six presented with hormone changes. The IHC stains revealed that pituicytoma has no secretory function; however, the resected pituitary glands showed positive results for hormone change. Coexisting pituicytoma and adrenocorticotropic hormone adenoma were identified in one patient with a diagnosis of Cushing disease. Conclusions: Pituicytoma revealed a negative endocrine secretory function through IHC staining. Additionally, pituicytoma is associated with hypersecretion of the pituitary gland both clinically and pathologically. Diagnosing pituicytoma before pathological confirmation is difficult because the tumour may present with hormone dysfunction. Therefore, IHC staining of specimens is useful to exclude the possibility of coexisting pituicytoma and pituitary adenoma.

The Intracranial Volume Pressure Response in Increased Intracranial Pressure Patients: Clinical Significance of the Volume Pressure Indicator.

Background For patients suffering from primary brain injury, monitoring intracranial pressure alone is not enough to reflect the dynamic intracranial condition. In our previous study, a segment of the pressure-volume curve can be expressed by the parabolic regression model with single indicator “a”. The aim of this study is to evaluate if the indicator “a” can reflect intracranial conditions. Methods Patients with traumatic brain injury, spontaneous intracranial hemorrhage, and/or hydrocephalus who had external ventricular drainage from January 2009 to February 2010 were included. The successive volume pressure response values were obtained by successive drainage of cerebral spinal fluid from intracranial pressure 20–25 mm Hg to 10 mm Hg. The relationship between withdrawn cerebral spinal fluid volume and intracranial pressure was analyzed by the parabolic regression model with single parameter “a”. Results The overall mean for indicator “a” was 0.422 ± 0.046. The mean of “a” in hydrocephalus was 0.173 ± 0.024 and in severe intracranial mass with slender ventricle, it was 0.663 ± 0.062. The two extreme intracranial conditions had a statistical significant difference (p<0.001). Conclusion The indicator “a” of a pressure-volume curve can reflect the dynamic intracranial condition and is comparable in different situations. A significantly larger indicator “a” with increased intracranial pressure is always observed in severe intracranial mass lesions with cerebral edema. A significantly smaller indicator “a” with increased intracranial pressure is observed in hydrocephalus. Brain computed tomography should be performed early if a rapid elevation of indicator “a” is detected, as it can reveal some ongoing intracranial pathology prior to clinical deterioration. Increased intracranial pressure was frequently observed in patients with intracranial pathology. The progression can be differentiated using the pattern of the volume pressure indicator.

Repeated Spontaneous Intracranial Epidural Hemorrhage After Hysterical Crying

BACKGROUND Spontaneous epidural hemorrhage (EDH) is a rare occurrence that may be caused by vascular anomalies, infections, coagulopathies, or tumors. Spontaneous EDH occurring in patients without specific underlying disease has been reported only as intraspinal lesion but has never been demonstrated in the intracranial area. This study presents a 19-year-old patient with repeated spontaneous intracranial EDH caused twice by hysterical crying. CASE DESCRIPTION The patient had spontaneous left frontal EDH after hysterical crying. Two years later, she had a similar episode after crying and a new spontaneous right frontal EDH was revealed. There was no obvious risk factor revealed by laboratory and radiologic survey. We postulated that hyperventilation during crying resulted in a sudden decrease in intracranial pressure. The intracranial hypotension induced detachment of the dura from the skull and spontaneous EDH occurred. CONCLUSIONS Crying or hyperventilation may trigger spontaneous EDH and should be suspected when there are signs of persisting headache and increased intracranial pressure. The prognosis is excellent if early diagnosis and surgical decompression are achieved.

Does one size fit all? Examining the Application of Neurosurgery Residency Milestones Developed in the USA to a Taiwanese Culture

BACKGROUND The Milestone Project was launched in 2009, charging specialties to develop specific educational accomplishments required to establish clinical competency. The milestone assessment method was first introduced to Taiwan in 2013 and before applying milestone assessments to our medical education system, the validity and reliability of these questionnaires needed to be evaluated. METHODS Twenty neurosurgical faculty members representing 3 clinical divisions and all 4 branch institutes completed milestone questionnaires for 26 residents semiannually, resulting in 435 resident assessments being collected and analyzed. RESULTS Cronbachs α, Kuder-Richardson Formula 20, and Kendalls W were used to show acceptable reliability and validity. Rater consistencies for nonskilled parts found that rater consistency progressively improved with time. Not all raters were able to assess the residents for the skilled parts resulting in nonassessable rates ranging from 9.5%-89.4%. For nonskilled and skilled items, milestone level as assessed by the staff improved as the resident progressed from residency year 3 (R3) to R6 in the residency program and showed that the milestone achievement level for an R3 was lower than that of an R6. CONCLUSIONS Milestone assessments have high reliability and may be a helpful assessment tool. Although milestone assessment can provide thorough feedback concerning performance and the content of the training program, they may not perfectly suit all residency-training programs, especially in different countries or different cultures. Modifications should be done before applying milestones to different areas; therefore the results can truly reflect the progress and condition of the training and learning process.

Seizure Freedom After Limited Hippocampal Radiofrequency Thermocoagulation

BACKGROUND Surgical interventions are often used for freedom from seizure in patients with drug-resistant mesial temporal lobe epilepsy. A patient with seizure foci in the left mesiotemporal region underwent limited-size stereotactic radiofrequency thermocoagulation (RF-TC) over the left hippocampus. CASE DESCRIPTION A 37-year-old woman with febrile convulsion in her childhood was admitted to our neurologic department with complex partial seizure with secondary generalization. Electroencephalography showed epileptogenic focus mainly from the left mesiotemporal region, and magnetic resonance imaging confirmed a left hippocampal atrophy. Because of failure to control seizure after use of several antiepileptic drugs, drug-resistant mesial temporal lobe epilepsy was diagnosed. RF-TC was done in the left hippocampus. Unique features of our technique include intraoperative electroencephalography recordings directly from electrodes on the left hippocampus, an aura sensation provoked during the low-temperature test thermocoagulation, and therapeutic thermocoagulation performed via a Radionics radiofrequency lead. In the 16-week period following the surgery, the patient experienced no seizure attacks and no significant postoperative adverse effects or memory impairments. Compared with other reports using RF-TC, our case demonstrates a 1-step minimally invasive surgery that reduces hippocampal volume loss, shortens the length of hospital stay, decreases the occurrence of postoperative infection, and achieves good outcomes for epilepsy control. CONCLUSIONS Favorable seizure control was achieved with minimally invasive RF-TC. Further use of this technique is warranted in cases of drug-resistant mesial temporal lobe epilepsy.