Chung Kee Chough

Stereotactic Radiosurgery with the CyberKnife for Pituitary Adenomas

OBJECTIVE In recent years, CyberKnife has emerged as an important treatment modality in the management of pituitary adenomas. Treatment results after performing CyberKnife and the complications of this procedure are reviewed. METHODS Twenty-six patients with pituitary adenomas received stereotactic radiosurgery with the CyberKnife (CKRS). The follow-up periods ranged from 7 months to 47 months (mean+/-SD : 30+/-12.7 months). The patients consisted of 17 with non-functioning adenomas, 3 with prolactinomas and 6 with acromegaly. The change in the tumor volume, visual acuity, hormonal function, and complications by this therapy were analyzed in each case. RESULTS The tumor control rate was 92.3%. Hormonal function was improved in all of the 9 (100%) functioning adenomas. Hormonal normalization was observed in 4 of the 9 (44%) patients with a mean duration of 16 months. In two patients (7.6%), visual acuity worsened due to cystic enlargement of the tumor after CKRS. No other complications were observed. CONCLUSION CyberKnife is considered safe and effective in selected patients with pituitary adenomas. However, longer follow-up is required for a more complete assessment of late toxicity and treatment efficacy.

Giant Anterior Cervical Osteophyte Leading to Dysphagia

Large anterior cervical osteophytes can occur in degeneration of the cervical spine or in diffuse idiopathic skeletal hyperostosis(DISH). Large osteophytes can produce otolaryngological symptoms such as dysphagia, dysphonia, and foreign body sensation. We describe a DISH patient with giant anterior cervical osteophyte causing chronic dysphagia and dysphonia. A 56-year-old man presented with increasing dysphagia, dysphonia, neck pain and neck stiffness. Physical examination of the neck showed a non-tender and hard mass on the left side at the level of C4-5. Radiography showed extensive ossification of anterior longitudinal ligament along the left anterolateral aspect of vertebral bodies from C2 to T1. The ossification was espe cially prominent at the level of C4-5 and linear breakage was noted at same level. Esophagogram revealed a filling defect along the pharynx and lateral displacement of the esophagus. Giant anterior cervical osteophyte was removed through the leftsided anterolateral cervical approach to the spine. Anterior cervical interbody fusion at C4-5 was followed by posterior cervical fixation using lateral mass screws from C3 to C6. After surgery, dysphagia and dysphonia improved immediately. One year later, cervical CT showed bone fusion at C4-5 bodies and no recurrence of osteophyte. DISH is a common cause of anterior cervical osteophyte leading to progressive dysphagia. Keeping this clinical entity in the differential diagnosis is important in patients with progressive neck stiffness, dysphagia or dysphonia. And surgical treatment of symptomatic anterior cervical osteophyte due to DISH should be considered with a solid fusion procedure preventing postoperative instability or osteophyte progress.

Traumatic Atlantoaxial Rotatory Fixation with Accompanying Odontoid and C2 Articular Facet Fracture

Traumatic atlantoaxial rotatory fixation (AARF) with accompanying odontoid and C2 articular facet fracture is a very rare injury, and only one such case has been reported in the medical literature. We present here a case of a traumatic AARF associated with an odontoid and comminuted C2 articular facet fracture, and this was treated with skull traction and halo-vest immobilization for 3 months. After removal of the halo-vest immobilization, his neck pain was improved and his neck motion was preserved without any neurologic deficits although mild torticolis was still observed in closer inspection.

Bow Hunter's Stroke Caused by a Severe Facet Hypertrophy of C1-2

Bow hunters stroke is a rare symptomatic vertebrobasilar insufficiency in which vertebral artery (VA) is mechanically occluded during head rotation. Various pathologic conditions have been reported as causes of bow hunters stroke. However, bow hunters stroke caused by facet hypertrophy of C1-2 has not been reported. A 71-year-old woman presented with symptoms of vertebrobasilar insufficiency. Spine computed tomography showed massive facet hypertrophy on the left side of C1-2 level. A VA angiogram with her head rotated to the right revealed significant stenosis of left VA. C1-2 posterior fixation and fusion was performed to prevent serious neurologic deficit from vertebrobasilar stroke.

Spontaneous Bilateral Supratentorial Subdural and Retroclival Extradural Hematomas in Association with Cervical Epidural Venous Engorgement

We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patients symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.

Microsurgical Anatomy of the Oculomotor nerve

The oculomotor nerve supplies the extraocular muscles. It also supplies the ciliary and sphincter pupillae muscles through the ciliary ganglion. The nerve fibers leave the midbrain through the most medial part of the cerebral peduncle and enter the interpeduncular cistern. After the oculomotor nerve emerges from the interpeduncular fossa, it enters the cavernous sinus slightly lateral and anterior to the dorsum sellae. It enters the orbit through the superior orbital fissure, after exiting the cavernous sinus, to innervate the extraocular muscles. Therefore, knowledge of the detailed anatomy and pathway of the oculomotor nerve is critical for the management of lesions located in the middle cranial fossa and the clival, cavernous, and orbital regions. This review describes the microsurgical anatomy of the oculomotor nerve and presents pictures illustrating this nerve and its surrounding connective and neurovascular structures. Clin. Anat. 30:21–31, 2017.

Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery.

Abstract Objective. Post-operative extradural hematoma (EDH) is a relatively common complication in patients undergoing intracranial operations. The risk factors associated with the occurrence of EDH are not well described in the literature. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy or the craniectomy site. Method. This was a retrospective study of 24 (2.6% of total) patients who underwent extradural hematoma evacuation after primary intracranial supratentorial surgery between January 2005 and December 2011. During this period, 941 intracranial operations were performed. The control group (72 patients) was selected on the basis of having undergone the same pre-operative diagnosis and treatment within 2 months of the operations for the 24 hematoma patients. The Glasgow Coma Scale score and operation character (emergency or elective) of the hematoma and control group were individually matched to minimize pre-operative conditional bias. The ages of both groups were individually matched with similar ages within 10 years of each other to minimize age bias. Result. Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were an intra-operative blood loss of greater than 800 mL (p = 0.007), maximal craniotomy length of greater than or equal to 100 mm (p = 0.001), and craniotomy area of greater than or equal to 71.53 cm2 (p = 0.018). In multivariate analysis, intra-operative blood loss exceeding 800 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH. Conclusion. The data did not examine established risk factors for post-operative hematoma, such as thrombocytopenia, anti-coagulant and anti-platelet therapy, and a history of heavy alcohol consumption and/or tobacco intake. Recognizing the limitations of the study, large intra-operative blood loss and wide craniotomy area are implicated with an increased risk of post-operative EDH after intracranial surgery.

Postlaminectomy Bilateral Lumbar Intraspinal Synovial Cysts

Lumbar intraspinal synovial cysts are included in the difference diagnosis of lumbar radiculopathy. Developing imaging modalities has result in increased reporting about these lesions. However, the case of bilateral new lumbar intraspinal synovial cysts after laminectomy has been rarely reported. We report of a rare case with bilateral lumbar intraspinal synovial cysts after laminectomy, requiring surgical excision.