Jin Woo Chang

Interictal epileptiform discharges relate to 1H-MRS-detected metabolic abnormalities in mesial temporal lobe epilepsy.

Summary: u2002Purpose: To examine whether the distribution of interictal epileptiform discharges (IEDs) recorded from foramen ovale electrodes (FOEs) correlates with metabolite levels in medial structures of the temporal lobes in patients with mesial temporal lobe epilepsy (MTLE).

Neurocutaneous Melanosis Presenting as Chronic Partial Epilepsy

Background Neurocutaneous melanosis (NCM) is a rare neurocutaneous syndrome characterized by the presence of multiple congenital melanocytic nevi (CMN) and the proliferation of melanocytes in the central nervous system, usually involving the leptomeninges. Chronic partial epilepsy as a sole manifestation is rare in NCM. Case Report A 32-year-old man suffering from chronic partial epilepsy presented with multiple CMN on his trunk and scalp. Brain MRI demonstrated a focal lesion in the right amygdala that was consistent with interictal epileptiform discharges in the right temporal region on electroencephalography (EEG). An anterior temporal lobectomy was performed, and the pathology investigation revealed numerous melanophages in the amygdala. The patient was seizure-free after surgery. Conclusions We report a patient with NCM presenting as chronic partial epilepsy who was successfully treated by anterior temporal lobectomy.

Balloon cells and dysmorphic neurons in the hippocampus associated with epileptic amnesic syndrome: a case report.

Recently, we encountered a 39‐year‐old woman with typical epileptic amnesic syndrome. The patient underwent right anterior temporal lobectomy, which removed the right hippocampus. The patients resected hippocampus showed typical histological features of Ammons horn sclerosis (AHS) with dysmorphic neurons. In addition, the prominent balloon cells, admixed with dysmorphic neurons, were noted in the hippocampus. To our knowledge, this is the first reported case showing AHS with balloon cells. The presence of balloon cells reinforces the hypothesis that AHS itself might be a maldevelopment disorder.

Radiosurgery for Radiosurgery-induced Cavernous Malformation

BACKGROUNDnThis report describes the use of radiosurgery for the treatment of a radiosurgery-induced cavernous malformation (CM).nnnMETHODSnA 21-year-old woman underwent stereotactic biopsy of a pineocytoma and subsequent gamma knife radiosurgery (marginal 14.5 Gy, 50%) for the lesion. A T1-weighted enhanced magnetic resonance imaging one year later showed that the tumor had disappeared. After two years, she developed facial palsy and experienced mental status changes. It was found that she experienced repeated hemorrhages in that radiation field, and magnetic resonance imaging showed a CM.nnnRESULTSnThe area where the CM developed had been exposed to 5.0 ± 3.7 Gy. This value was calculated using the fused dose planning image using Leksell GammaPlan. We used gamma knife radiosurgery to treat this lesion (marginal 12.5 Gy, 50%), and believe that it is a radiation-induced CM. Five years after gamma knife radiosurgery for the CM, the CM has controlled without any new hemorrhages.nnnCONCLUSIONSnGamma knife radiosurgery-induced CMs are very rare, and the use of another gamma knife radiosurgery to treat this lesion has not yet been reported. We report a case of radiosurgery for CM that was induced by gamma knife radiosurgery for a pineocytoma. This report suggests that radiosurgery is a reasonable option for treating radiation-induced CM to prevent repeated hemorrhage.

Planned stereotactic biopsy of a bilateral thalamic glioma in a patient presenting with unilateral tremor

Dear editor, Thalamic tumors account for 1-1.5% of all brain neoplasms, and primary bilateral thalamic glioma (BTG) is exceedingly rare [1–6, 9]. The epidemiology of BTG has not been definitively characterized, and the age of onset is variable. In most of the reported cases, the presenting symptoms were cognitive impairment, abnormal behavior, and changes in motor and sensory function [7]. Stereotactic biopsy has become a standard diagnostic tool used in areas in which operation is difficult or in cases requiring a definitive diagnosis to determine the appropriate treatment. The patient we describe here presented to our institution with a progressive resting tremor. She was diagnosed with a bilateral thalamic tumor based on preoperative magnetic resonance imaging (MRI) findings. We were unsure as to which target would be the safest and most effective, so we experimentally applied deep brain stimulation (DBS) targeting based on our previous experience with essential tremor (ET) patients treated using stereotactic biopsy. We hypothesized that using stereotactic biopsy as a lesioning technique similar to thalamotomy would be effective in this case of diffuse infiltrated glioma limited to the thalamus by controlling abnormal motor circuits through tissue destruction. To date, there have been no reports of unilateral tremor control in a BTG patient who underwent stereotactic biopsy of the ventralis intermedius nucleus (Vim) and the ventralis oralis anterior (Voa)-ventralis oralis posterior (Vop) complex. A 46-year-old woman presented to our institution with a progressive resting tremor of the left hand aggravated by intentional movement of 1 month’s duration. Her neurocognitive function was normal, and her sensory function and visual fields were normal. A brain MRI revealed a bilateral thalamic diffuse homogenous lesion that was isointense on T1-weighted images and hyperintense on T2weighted images (Fig. 1a). Fluid attenuation inversion was observed in recovery images (Fig. 1b) without enhancement after administration of the contrast agent (Fig. 1c). Electromyography characterized the hand tremor as rhythmic at 3 Hz. After Leksell frame fixation, brain MRIs were taken using a 1.5-T machine using continuous 1-mm-thick slices. After data acquisition, all images were transferred to a Surgiplan workstation (Elekta, Sweden). Based on the literature and my personal experience with electrode placement in VIM, the target coordinates should be: 28.5% of the ACPC line anterior to the PC, X013 mm lateral, Y00, and Z00 (Fig. 1d, e and f). The Voa-Vop complex target coordinates were 6 mm superiolaterally within the same trajectory from the Vim target. A stereotactic biopsy was performed with tissue removal from the right Vim and the Voa-Vop complex under general anesthesia. We used a side-cutting brain biopsy needle with aspiration accomplished using negative vacuum pressure. We obtained six specimens from the Vim area and six from the Voa-Vop complex. Postoperative J. P. Kim : J. W. Chang :Y. G. Park Department of Neurosurgery, Severance Hospital, Brain Korea 21 Project for Medical Science, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea

Surgical Management of Hemifacial Spasm and Meige Syndrome

Publisher Summary This chapter focuses on the surgical management of hemifacial spasm (HFS) and meige syndrome. HFS is a benign, chronic, involuntary movement of one side of the face, characterized by twitching, tonic spasm, and synkinesis of the muscles innervated by the facial nerve. It typically starts with intermittent twitches in the orbicularis oculi muscle. The symptoms usually progress gradually in frequency and severity, and spread downward to the other facial muscles of the affected side. HFS is seen almost exclusively in middle-aged and older patients, with a female predominance. In most patients, the spasm of HFS begins at the lower eyelid, gradually progressing to involve the entire orbicularis oculi muscle and then moving on to the orbicularis oris or perioral muscles. In advanced cases, the platysma and, less frequently, the frontalis muscle of the forehead can also be affected. The occurrence in childhood and adolescence is extremely rare. The symptoms of HFS can be aggravated or induced by emotional stress, psychological tension and/or fatigue. MVD is now considered the treatment of choice for HFS because of its low morbidity and its long-term benefit of symptom relief. The term “Meige syndrome” was used by Paulson to describe spontaneous, involuntary spasm involving the facial muscles. This syndrome is now considered a variant of adult-onset torsion dystonia or idiopathic cranialcervical dystonia, which is considered as a segmental dystonia. There are several recent reports of bilateral pallidal deep brain stimulation (DBS) effectively controlling symptoms in medication refractory Meige syndrome. There are only a few cases of Meige syndrome, either isolated or advanced, that have been treated with bilateral GPi DBS. Some adverse effects that have been reported include worsening of handwriting, typing, balancing, and walking. But these adverse effects were mild and not evident on objective examination.

Magnetic Resonance-Guided High Intensity Focused Ultrasound for Treating Movement Disorders

Transcranial magnetic resonance-guided focused ultrasound (MRgFUS) surgery has recently gained favor as a novel, noninvasive alternative to conventional neurosurgery. In contrast to traditional ablative interventions, transcranial MRgFUS surgery is entirely imaging-guided and uses continuous temperature measurements at the target and surrounding tissue taken in real-time. Unlike Gamma Knife radiosurgery, MRgFUS surgery can make a lesion immediately and does not use ionizing radiation. Moreover, since no metallic device is implanted, MR imaging-based diagnosis is not restricted throughout life. An additional strength of transcranial MRgFUS surgery is its ability to focus acoustic energy through the intact skull onto deep-seated targets, while minimizing adjacent tissue damage. Even though the established indications of MRgFUS include bone metastases, uterine fibroids, and breast lesions, several promising preclinical and phase I clinical trials of neuropathic pain, essential tremor, Parkinsons disease (PD), and obsessive-compulsive disorder have demonstrated that the delivery of focused ultrasound energy promises to be a broadly applicable technique. For instance, this technique can be used to generate focal intracranial thermal ablative lesions of brain tumors, or to silence dysfunctional neural circuits and disrupt the blood-brain barrier for targeted drug delivery and the modulation of neural activity. Here we review the general principles of MRgFUS and its current applications, with a special focus on movement disorders such as essential tremor and PD, and discuss controversies and limitations of this technique.