Jeong-Hyun Hwang

Chronic subdural hematoma preceded by traumatic subdural hygroma.

Patients with traumatic subdural hygroma (SDG) are at an increased risk of developing chronic subdural hematoma (CSDH). However, the mechanism by which this occurs is still not fully understood. The purpose of this paper is to investigate the clinical characteristics and pathogenesis of CSDH, as well as the relationship between CSDH and SDG. We review the pertinent literature and retrospectively examine a series of cases in which CSDH had been preceded by SDG to understand the natural history and developmental mechanisms of these lesions. We discuss the cases of 24 patients in whom CSDH developed from traumatic SDG between 2001 and 2005. Headache was the most common symptom, and the mean Glasgow Coma Scale score was 14.1. Increases in SDG volume were observed in CT scans of 17 patients, and increased density and volume was observed in five patients. The mean interval between the two diseases was 57.6 days, and 13 patients developed new symptoms after the development of CSDH. The most common symptoms at that time were headache and hemiparesis. All patients underwent an operation, which resulted in good recovery in all but one case. The cycle of persistent SDG, rebleeding, coagulation and fibrinolysis contributes to the development of CSDH from SDG. It is important to understand the natural history of CSDH and carefully follow up patients with head injury, especially if it is associated with SDG, and the potential for the development of CSDH should be considered.

Switching Strategy for Mechanical Thrombectomy of Acute Large Vessel Occlusion in the Anterior Circulation

Background and Purpose— We introduce the concept of a switching strategy for mechanical thrombectomy with period-to-period analysis. In period 1, forced arterial suction thrombectomy with a Penumbra reperfusion catheter was performed, even in difficult cases; in period 2, forced arterial suction thrombectomy was initially performed, with switching to Solitaire in difficult cases. Methods— We analyzed 135 consecutive patients treated with mechanical thrombectomy with acute large vessel occlusion in the anterior circulation, 61 from period 1 and 74 from period 2. We defined difficult case for both periods as ≥3 failed attempts at recanalization. Results— Period 2 showed a trend for better angiographic outcome of Thrombolysis in Cerebral Infarction 2b-3 (73.8%, period 1 versus 85.1%, period 2; P=0.10). In interperiod subgroup analysis of difficult cases, switching significantly outperformed nonswitching in Thrombolysis in Cerebral Infarction 2b-3 recanalization (52.7% versus 82.9%; P=0.030). Differences in puncture-to-recanalization time, symptomatic intracranial hemorrhage incidence, and procedure-related complications were not statistically significant. Conclusions— A switching strategy using 2 mechanical thrombectomy techniques (forced arterial suction thrombectomy to Solitaire) may harbor better angiographic outcomes than a 1 technique only strategy (forced arterial suction thrombectomy).

Gamma knife radiosurgery for multiple brain metastases from lung cancer

The aim of this study was to compare the effectiveness of gamma knife radiosurgery (GKS) for the treatment of multiple brain metastases from lung cancer with that of whole brain radiation therapy (WBRT). Patients with multiple (2-20) brain metastases were divided into two groups for initial brain tumor management: a GKS group (14 patients) and a WBRT group (19 patients). The patients were stratified by gender, age, initial Karnofsky performance status score, control of the primary site, known extracranial metastases, number of brain metastases, diameter of the maximal lesion, chemotherapy, and recursive partitioning analysis (RPA) Class. The 6-month and 1-year overall survival rates were 64.3% and 47.7%, respectively, in the GKS group, and 42.1% and 10.5%, respectively, in the WBRT group. The median survival time was 32 weeks in the GKS group and 24 weeks in the WBRT group. The overall survival time in the GKS group was significantly longer than in the WBRT group (p=0.04). The univariate analysis suggests that survival was increased in both patients with a controlled primary tumor site and in the GKS group (p=0.03, 0.04). The use of GKS in patients with multiple brain metastases significantly improved patient survival compared to the employment of WBRT. When we assessed the subgroups, systemic disease control and GKS were significant variables by univariate analysis.

A Retrospective Analysis of Ventriculoperitoneal Shunt Revision Cases of a Single Institute

Objective Ventriculoperitoneal (VP) shunt complication is a major obstacle in the management of hydrocephalus. To study the differences of VP shunt complications between children and adults, we analyzed shunt revision surgery performed at our hospital during the past 10 years. Methods Patients who had undergone shunt revision surgery from January 2001 to December 2010 were evaluated retrospectively by chart review about age distribution, etiology of hydrocephalus, and causes of revision. Patients were grouped into below and above 20 years old. Results Among 528 cases of VP shunt surgery performed in our hospital over 10 years, 146 (27.7%) were revision surgery. Infection and obstruction were the most common causes of revision. Fifty-one patients were operated on within 1 month after original VP shunt surgery. Thirty-six of 46 infection cases were operated before 6 months after the initial VP shunt. Incidence of shunt catheter fracture was higher in younger patients compared to older. Two of 8 fractured catheters in the younger group were due to calcification and degradation of shunt catheters with fibrous adhesion to surrounding tissue. Conclusion The complications of VP shunts were different between children and adults. The incidence of shunt catheter fracture was higher in younger patients. Degradation of shunt catheter associated with surrounding tissue calcification could be one of the reasons of the difference in facture rates.

Fibrinogen and D-dimer analysis of chronic subdural hematomas and computed tomography findings: a prospective study.

OBJECTIVE We investigated the relationship between fibrinolytic factors and computed tomography (CT) findings in patients with chronic subdural hematomas (CSDHs). METHODS Thirty-one patients with CSDHs were divided on the basis of CT findings into heterogeneous and homogeneous groups. A sample from the subdural hematoma was obtained at surgery to measure the concentrations of fibrinogen and D-dimer. RESULTS The mean level of fibrinogen in the heterogeneous group, including the layering (n=4) and mixed (n=10) type, was 88.2±121.2 mg/dL, whereas in the homogeneous group, including high density (n=2), isodensity (n=9), and low density (n=6) types, it was <25 mg/dL. The concentration of fibrinogen was significantly higher in the heterogeneous group than in the homogeneous group (p=0.006). The mean level of D-dimer in the heterogeneous group was 35,407.9±16,325.5 μg/L, whereas for the homogeneous group it was 1476.4±2091.4 μg/L. The concentration of D-dimer was significantly higher in the heterogeneous group than in the homogeneous group (p<0.001). CONCLUSIONS The layering and mixed types of CSDH exhibited higher concentrations of fibrinogen and D-dimer in subdural hematoma than the homogeneous types. These fibrinolytic factors appear to be associated with evolution in CSDHs with heterogeneous density.

Intramedullary Spinal Cord Metastasis in Renal Cell Carcinoma: A Case Report of the Surgical Experience

Intramedullary spinal cord metastasis (ISCM) from renal cell carcinoma (RCC) is rare manifestation and most of them are treated by adjuvant treatment modalities like radiotherapy. Despite the radio-resistance of RCC itself, focal radiotherapy has been preferred as the first-line treatment modality of ISCM from RCC and only a few cases underwent surgical treatment. We describe a case of ISCM from RCC, which underwent surgical excision and pathologically confirmed. A 44-yr-old man was presented with rapid deterioration of motor weakness during focal radiotherapy for ISCM from RCC. After the surgery for removal of the tumor mass and spinal cord decompression, his motor power was dramatically improved to ambulate by himself. We report the first published Korean case of ISCM from RCC confirmed pathologically and describe our surgical experience and his clinical characteristics.

The Role of 18F-Fluorodeoxyglucose Positron Emission Tomography in the Treatment of Brain Abscess

OBJECTIVE The purpose of this study was to evaluate whether (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) can be used to assess the therapeutic response of brain abscess. METHODS A study was conducted on 10 consecutive patients with brain abscess. Magnetic resonance imaging (MRI) with diffuse-weighted imaging (DWI) was performed at 3 and 6 weeks after surgical treatment and intravenous antibiotics therapy and FDG-PET at 6 weeks after treatment. The extent of the abscess, signal changes on MRI, and FDG-PET standardized uptake values were analyzed and correlated with the response to therapy. RESULTS Aspiration or craniotomy with excision of the abscess followed by intravenous antibiotics for 6-8 weeks resulted in good recovery with no recurrence. In 10 patients, two had low signal intensity on the DWI; one had no uptake on FDG-PET imaging after 6 weeks antibiotics and discontinued intravenous treatment, but the other patient had diffuse, increased uptake on FDG-PET imaging after 6 weeks antibiotics and underwent an additional 2 weeks of intravenous antibiotics. The remaining eight patients had high signals on the DWI. Four had no uptake on FDG-PET imaging and the treatment period varied from 6 to 8 weeks (mean, 6.75 weeks). Among the other four patients, FDG was accumulated in a diffuse or local area corresponding to a high signal area within the DWI and 2 weeks of intravenous antibiotics was added. CONCLUSION MRI plus FDG-PET improved the accuracy of assessing therapeutic responses to antibiotics treatment of brain abscess and aided in optimizing therapy.

Analysis of Circulating Endostatin and Vascular Endothelial Growth Factor in Patients with Pituitary Adenoma Treated by Stereotactic Radiosurgery: A Preliminary Study

Background The purpose of this study was to investigate plasma levels of endostatin and vascular endothelial growth factor (VEGF) in normal subjects and in patients with pituitary adenoma and to evaluate change in these levels following stereotactic radiosurgery (SRS) for pituitary adenoma. Methods Peripheral venous blood was collected from five patients with pituitary adenoma before SRS using Gamma Knife and at the 1 week and 1 month follow-up visits. Plasma endostatin and VEGF levels were measured using commercially available enzyme-linked immunosorbent assay kits. Peripheral blood samples were obtained from 10 healthy volunteers as controls. Results Mean baseline plasma endostatin level (105.3 ng/mL, range, 97.0-120.2 ng/mL) in patients with pituitary adenoma was higher than that of the healthy controls (86.6 ng/mL, range, 71.3-98.2 ng/mL) (p=0.001). Mean plasma VEGF level was 89.5 pg/mL (range, 24.1-171.8 pg/mL) in patients with pituitary adenoma at baseline and 29.3 pg/mL (range, 9.2-64.3 pg/mL) in the control group (p=0.050). Plasma endostatin level changed to 106.6 ng/mL 1 week after SRS and decreased to 95.9 ng/mL after 1 month. Plasma VEGF level following SRS decreased to 74.1 pg/mL after 1 week and 79.0 pg/mL after 1 month. There was a trend toward decreased plasma endostatin and VEGF concentrations 1 month after SRS compared to baseline levels (p=0.195, p=0.812, respectively). Conclusion Plasma endostatin and VEGF levels in patients with pituitary adenoma were significantly elevated over controls at baseline, which decreased from baseline to 1 month after SRS for pituitary adenomas.

Traumatic Brain Injury in Children under Age 24 Months : Analysis of Demographic Data, Risk Factors, and Outcomes of Post-traumatic Seizure

Objective Traumatic brain injury (TBI) in children under age 24 months has characteristic features because the brain at this age is rapidly growing and sutures are opened. Moreover, children this age are completely dependent on their parents. We analyzed the demographic data and risk factors for outcomes in TBI patients in this age group to elucidate their clinical characteristics. Methods We retrospectively reviewed the medical records and radiological films of children under 24 months who were admitted to Kyungpook National University Hospital from January 2004 to December 2013 for TBI. Specifically, we analyzed age, cause of injury, initial Glasgow coma scale (GCS) score, radiological diagnosis, seizure, hydrocephalus, subdural hygroma, and Glasgow outcome scale (GOS) score, and we divided outcomes into good (GOS 4–5) or poor (GOS 1–3). We identified the risk factors for post-traumatic seizure (PTS) and outcomes using univariate and multivariate analyses. Results The total number of patients was 60, 39 males and 21 females. Most common age group was between 0 to 5 months, and the median age was 6 months. Falls were the most common cause of injury (n=29, 48.3%); among them, 15 were falls from household furniture such as beds and chairs. Ten patients (16.7%) developed PTS, nine in one week; thirty-seven patients (61.7%) had skull fractures. Forty-eight patients had initial GCS scores of 13–15, 8 had scores of 12–8, and 4 had scored 3–7. The diagnoses were as follows: 26 acute subdural hematomas, 8 acute epidural hematomas, 7 focal contusional hemorrhages, 13 subdural hygromas, and 4 traumatic intracerebral hematomas larger than 2 cm in diameter. Among them, two patients underwent craniotomy for hematoma removal. Four patients were victims of child abuse, and all of them had PTS. Fifty-five patients improved to good-to-moderate disability. Child abuse, acute subdural hematoma, and subdural hygroma were risk factors for PTS in univariate analyses. Multivariate analysis found that the salient risk factor for a poor outcome was initial GCS on admission. Conclusion The most common cause of traumatic head injury in individuals aged less than 24 months was falls, especially from household furniture. Child abuse, moderate to severe TBI, acute subdural hematoma, and subdural hygroma were risk factors for PTS. Most of the patients recovered with good outcomes, and the risk factor for a poor outcome was initial mental status.

Delayed Perilesional Ischemic Stroke after Gamma-knife Radiosurgery for Unruptured Deep Arteriovenous Malformation: Two Case Reports of Radiation-induced Small Artery Injury as Possible Cause

Radiation-induced vasculopathy is a rare occurrence, however, it is one of the most serious complications that can occur after gamma-knife radiosurgery (GKRS). The authors present two cases of incidentally found deep cerebral arteriovenous malformation (AVM), which were treated by GKRS, where subsequently there occurred delayed-onset cerebral infarction (11 and 17 months after GKRS) at an area adjacent to the AVM. In both cases, perforators of the M1 segment of the middle cerebral artery were included in the radiation field and delayed injury to these is suggested to be the mechanism of the ischemic event.