Sanford P.C. Hsu

Endoscopic hematoma evacuation in patients with spontaneous supratentorial intracerebral hemorrhage.

Background Surgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH. Methods Twenty‐one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kochers, Keens, or Fraziers point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal. Results The median operative time was 120 minutes (range: 90–190 minutes), and the median blood loss was 160 mL (range: 50–300 mL). The median duration of intensive care unit stay was 6 days (range: 2–18 days). The median hematoma evacuation ratio was 90% (range: 60–99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow‐up. Conclusion With the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.

An easy adjustable method of ectatic vertebrobasilar artery transposition for microvascular decompression

BACKGROUND Microvascular decompression (MVD) of trigeminal neuralgia (TN) or hemifacial spasm (HFS) caused by an elongated, tortuous or enlarged vertebral or basilar artery has a higher rate of incomplete cure. OBJECTIVE We used an easily applied and adjustable method of vertebrobasilar artery transposition and fixation to improve the immediate surgical outcome of MVD of TN or HFS due to compression by an ectatic vertebrobasilar artery system. METHODS Vertebral or basilar artery transposition was performed using the vascular sling with a strip of unabsorbable dural tape. The vertebrobasilar artery-sling complex was then fixed to the dura over the petrous bone by aneurysm clip through the dural bridge. The direction and angle of traction on the vertebrobasilar artery was adjustable using different lengths of clip or the horizontal level of the dural bridge. RESULTS The sling and clip fixation method has been applied in 7 cases of MVD associated with vertebral or basilar artery compression. All 3 patients with TN and one with HFS had total remission of symptoms right after the procedure; one patient was completely free of spasm within 1 week after MVD and one had achieved 80% improvement of spasm in his last clinical visit 3 months after MVD. There was no major surgical complication in these 7 patients. Surprisingly, refractory hypertension was unexpectedly cured in one patient with TN following the procedure. CONCLUSION The vertebrobasilar artery transposition and fixation method used in the present study provided surgeons an easy and adjustable way to perform MVD safely and effectively.

Exclusion of histiocytes/endothelial cells and using endothelial cells as internal reference are crucial for interpretation of MGMT immunohistochemistry in glioblastoma.

We evaluated the predictive value of O6-methylguanine-DNA methyltransferase (MGMT) protein expression and MGMT promoter methylation status in glioblastomas (GBM) treated with temozolomide (TMZ) in a Taiwan medical center. Protein expression by immunohistochemical analysis (IHC) and MGMT promoter methylation detected by methylation-specific polymerase chain reaction (MSP) were performed in a series of 107 newly diagnosed GBMs. We used endothelial cells as an internal reference for IHC staining because the staining intensities of the MGMT-expressing cells in different specimens varied considerably; a positive result was defined as the staining intensity of the majority of tumor cells similar to that of the adjacent endothelial cells. Immunostainings for microglial/endothelial markers were included as part of the MGMT IHC evaluation, and in cases that were difficult to interpret, double-labeling helped to clarify the nature of reactive cells. The MGMT protein expression was reversely associated with MGMT promoter methylation status in 83.7% of cases (MSP+/IHC− and MSP−/IHC+; Pearson r=−0.644, P<0.001). Twenty-two of 24 (91.7%) IHC+ tumors did not respond to TMZ treatment. Combining MSP and IHC results, all the 15 MSP−/IHC+ GBMs were TMZ resistant. The MGMT status detected by either IHC or MSP was significantly correlated with the TMZ treatment response (both P<0.001) and survival of GBM patients (both P<0.05).

Malignant transformation of supratentorial ganglioglioma

Gangliogliomas in the central nervous system are usually enign; however, incidences of anaplastic change have been eported. Most malignant transformation is related to radiaion therapy, often occurring several years after treatment [1–3]. his study describes the malignant transformation into anaplastic umors of two well-differentiated gangliogliomas with unique cell ype. These transformations occurred over a period of only eight onths and were not related to radiation. This report examines the linical characteristics, MR images, and histopathological features f these transformed tumors.

Brainstem auditory evoked potential monitoring and neuro-endoscopy: Two tools to ensure hearing preservation and surgical success during microvascular decompression

Background: The effectiveness of microvascular decompression (MVD) has made trigeminal neuralgia (TN), hemifacial spasm (HFS), glossopharyngeal neuralgia, and other cranial nerve rhizopathy diseases treatable by surgery. To ensure hearing preservation and surgical success, we have presented our experience in the application of brainstem auditory evoked potential (BAEP) monitoring and neuro‐endoscopy during MVD. Methods: From July 2007 to October 2012, a total of 93 patients in our institution received MVD for cranial nerve rhizopathies. Among these patients, 43 had both BAEP monitoring and endoscope‐assisted microsurgery for their MVD. None of the patients had undergone previous surgical treatment. Postoperative outcomes were assessed based on the medical records and clinical follow‐up. Results: This study included 32 women and 11 men. There were 36 HFS cases and seven TN cases, and the median patient age at the time of MVD was 48 years. The median duration of symptoms before MVD was 4.2 years, and the median follow‐up duration was 3.5 years (range 1.5 months–5 years). All of the patients had either immediate or delayed complete relief from the symptoms after MVD. One TN patient underwent gamma knife radiosurgery 3 years after MVD, and two HFS cases had recurrent slight spasms, which warranted no further treatment. There was no surgical mortality. The major complications included one HFS patient with delayed and permanent hearing loss and facial palsy, which occurred 1 week after MVD. The surgical success rate was 100%, and the hearing complication rate was 2%. Conclusion: The results of this retrospective study emphasized the importance of BAEP monitoring and neuro‐endoscopy during MVD. It is well known that BAEP monitoring can preserve hearing function, and the endoscope offers neurosurgeons a second look to identify the nerve root entry zone and confirms the position of the Teflon felt. These two tools are especially useful in difficult cases.

Outcomes after Stroke in Patients with Previous Pressure Ulcer: A Nationwide Matched Retrospective Cohort Study

BACKGROUND Factors associated with poststroke adverse events were not completely understood. The purpose of this study was to investigate whether stroke patients with previous pressure ulcers had more adverse events after stroke. METHODS Using the claims data from Taiwans National Health Insurance Research Database, we conducted a retrospective cohort study matched by propensity score. Three thousand two first-ever stroke patients with previous pressure ulcer and 3002 first-ever stroke patients without pressure ulcer were investigated between 2002 and 2009. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of complications and 30-day mortality after stroke associated with previous pressure ulcer were calculated in the multivariate logistic regressions. RESULTS Patients with pressure ulcer had significantly higher risk than control for poststroke urinary tract infection (OR: 1.56, 95% CI: 1.38-1.78), pneumonia (OR: 1.35, 95% CI: 1.16-1.58), gastrointestinal bleeding (OR: 1.31, 95% CI: 1.04-1.66), and epilepsy (OR: 1.84, 95% CI: 1.83-1.85). Stroke patients with pressure ulcer had increased 30-day poststroke mortality (OR: 2.01, 95% CI: 1.55-2.61), particularly in those treated with debridement (OR: 2.87, 95% CI: 1.85-4.44) or high quantity of antibiotics (OR: 4.01, 95% CI: 2.10-7.66). Pressure ulcer was associated with poststroke mortality in both genders and patients aged 60 years or older. CONCLUSIONS This study showed increased poststroke complications and mortality in patients with previous pressure ulcer, which suggests the urgent need for monitoring stroke patients for pressure ulcer history.

Fluorescence-assisted visualization of facial nerve during mastoidectomy: A novel technique for preventing iatrogenic facial paralysis

OBJECTIVE Mastoidectomy can be risky due to the chance of iatrogenic facial nerve dysfunction. Avoiding injuries to the mastoid segment of the facial nerve is mandatory when drilling the bone. With advancements in intraoperative near-infrared indocyanine green (ICG) video angiography, we describe the application of a novel fluorescent guidance technique during mastoidectomies to identify the facial canal with safety. METHODS Mastoidectomies were performed as the key step in the presigmoid, petrosal or translabyrinthine approaches in 16 patients with different pathologies located at the cerebellopontine angle or petroclival region. After the facial canal was drilled to paper thin, ICG was injected via the central venous catheter. Compared with the dark bony portion, the vessels inside the vasa nervorum were highlighted as a result. The fluorescence guides the operator through the course of the facial nerve and facilitates opening of the internal auditory canal and the dissection of tumors. RESULTS All 16 facial nerves were recognized during mastoidectomies under fluorescence guidance for varied periods of enhancing time (range, 23-50s). In all, one to four attempts after repeated drilling works to enhance the facial nerve were required before these nerves could be clearly seen. The tumor resection procedure yielded the following results: grossly total removal in seven patients, near total removal in five, and subtotal removal in three. Complete obliteration of a giant vertebral artery aneurysm in one patient was seen in the follow-up angiogram. The post-mastoidectomy facial nerve function, examined by triggered EMG, was preserved in all 16 patients, and no patients had postoperative facial palsy worse than House-Brackmann grade IV after 6 months of follow-up. CONCLUSION With this novel technique, the course of the facial nerve can be confirmed during mastoidectomy, which reduces the possibility of iatrogenic facial nerve dysfunction. This fluorescence technique is especially helpful in establishing confidence and shortening the learning curve for beginners at mastoidectomies.

Microsurgery for vestibular schwannoma after Gamma Knife surgery: challenges and treatment strategies

OBJECT Resection of vestibular schwannoma (VS) after Gamma Knife surgery (GKS) is infrequently performed. The goals of this study were to analyze and discuss the neurological outcomes and technical challenges of VS resection and to explore strategies for treating tumors that progress after GKS. METHODS In total, 708 patients with VS underwent GKS between 1993 and 2012 at Taipei Veterans General Hospital. The post-GKS clinical courses, neurological presentations, and radiological changes in these patients were analyzed. Six hundred patients with imaging follow-up of at least 1 year after GKS treatment were included in this study. RESULTS Thirteen patients (2.2%) underwent microsurgery on average 36.8 months (range 3-107 months) after GKS. The indications for the surgery included symptomatic adverse radiation effects (in 4 patients), tumor progression (in 6), and cyst development (in 3). No morbidity or death as a result of the surgery was observed. At the last follow-up evaluation, all patients, except 1 patient with a malignant tumor, had stable or near-normal facial function. CONCLUSIONS For the few VS cases that require resection after radiosurgery, maximal tumor resection can be achieved with modern skull-based techniques and refined neuromonitoring without affecting facial nerve function.

Primary large B-cell lymphoma of the fourth ventricle

We present a patient with an isolated primary central nervous system lymphoma (PCNSL) of the fourth ventricle. A 77-year-old man had a 1 week history of intermittent vertigo, nausea, vomiting, and progressively unsteady gait. CT scans of the brain showed a fourth ventricle tumor. MRI revealed a 2.5 cm dumbbell-shaped avidly-enhancing tumor in the fourth ventricle. Metastasis or high-grade glioma was suspected. The neuropathological findings were compatible with a diffuse large B-cell lymphoma. A slit lamp examination, bone marrow biopsy, and imaging studies for extracranial lesions were unremarkable. We suggest that PCNSL be listed in the differential diagnosis of fourth ventricle tumors with well-circumscribed margins and homogenous contrast enhancement.

Rhabdoid glioblastoma: a recently recognized subtype of glioblastoma

BackgroundRhabdoid glioblastoma is a rare type of recently described malignant brain tumor. It is characterized by a glioblastoma associated with rhabdoid components.MethodsHere we report two cases of rhabdoid glioblastoma and a brief literature review. The first patient was a 19-year-old boy who initially presented with a foul-smelling odor and progressive right-side weakness. The second case was a 29-year-old male patient who presented only with a severe headache.ResultsBoth of these patients were young, and the disease progression was quick despite optimal treatment.ConclusionThe diagnosis of rhabdoid glioblastoma was confirmed after microscopic and immunohistochemical findings.