Seul-Kee Kim

The clinical experience of recurrent central nervous system hemangioblastomas

OBJECTIVEnHemangioblastomas (HBLs) of the central nervous system are benign vascular tumors that may occur sporadically or in von Hippel-Lindau disease (VHLD). We analyzed the clinical and radiological findings of HBLs focusing on recurrence.nnnMATERIAL AND METHODSnFrom 1998 to 2012, 36 patients with HBLs were treated. Twenty nine patients (80.6%, mean age 46.7 years) had sporadic HBLs and seven (19.4%, mean age 39 years) had HBLs associated with VHLD. Initially, the mass was totally removed in 32 patients, subtotally in one and partially in one, and gamma knife radiosurgery was done in two patients. The mean duration of follow-up was 48.4 months. We retrospectively analyzed the clinical and radiologic findings.nnnRESULTSnThe location of cerebellum and brainstem was common. The HBLs of spinal cord and cerebral hemisphere were related with VHLD. The common radiologic findings of sporadic HBLs showed a cyst with a mural nodule in 15 patients (51.7%) and pure solid lesion in eight (27.6%). In HBLs related with VHLD, five of seven patients had multiple lesions and pure solid mass was common. Three (10.3%) and two (28.6%) patients showed recurrence in sporadic and VHLD-related HBLs, respectively. Two totally resected mural nodules on the cyst showed recurrence with similar radiologic findings 3 years later in sporadic HBLs. In recurred HBLs related with VHLD, one pure solid mass and one mural nodule on cyst showed the local recurrences after the total resection 8 years later and associated with distant recurrence.nnnCONCLUSIONSnAll patients should be more specifically followed to detect local and distant recurrence, even if the clinical course was benign and mass was totally removed.

The effect of a Foley catheter balloon on cervical ripening

The Foley catheter balloon may affect cervical ripening through changes in biochemical mediators by immunoassay and immunohistochemistry, when it is used for pre-induction cervical ripening. The aim of the study was to evaluate the changes in the biochemical mediators from the extra-amniotic space and immunohistochemistry in ripened cervical tissue after the insertion of a Foley catheter balloon (FCB) for pre-induction cervical ripening. A total of 18 pregnant women with a Bishops score < 6, who were undergoing labour induction, were evaluated in this prospective study. The FCB was irrigated with 10 ml of phosphate buffered saline and the irrigant was collected 0, 2, 4 and 8 h after placement of the FCB or until spontaneous expulsion of the FCB occurred. Irrigant specimens were also collected from 10 spontaneous labouring (SL) women in the active phase of labour. The levels of interleukin (IL)-6, IL-8, matrix metalloproteinase (MMP)-8 and NO were measured. Cervical specimens were obtained from 12 women, including four undergoing induction; four SL and four non-pregnant (NP) women. Immunohistochemical staining was performed to localise hyaluronic acid synthase (HAS)-1, IL-6, IL-8, MMP-8, endothelial nitric oxide synthase (eNOS) and inducible NOS (iNOS). Results showed that the levels of IL-6, IL-8, and MMP-8 significantly increased over time in FCB group (p < 0.01). In the immunohistochemical analysis of cervical tissues, immunoreactivity of HAS-1 in the after FCB group was stronger than any of the other groups. The protein expressions of IL-6, IL-8, MMP-8, eNOS and iNOS were more prominent in the after FCB and SL groups than in the NP and the before FCB groups. iNOS was only observed in the after FCB and SL groups. It was concluded that FCB may affect cervical ripening through changes in biochemical mediators by immunoassay and immunohistochemistry, when it is used for pre-induction cervical ripening.

Cavernous hemangioma of the third ventricle: a case report and review of the literature

BackgroundAlthough cavernous hemangiomas (CHs) can be found anywhere in the central nervous system, CHs of the third ventricle have been reported in only 29 patients (including our case). In the current case report, we discuss the clinical characteristics and surgical outcome of CHs of the third ventricle.Case presentationA 64-year-old female was admitted to our emergency room with a sudden decreased level of consciousness. Brain imaging studies demonstrated a multi-lobulated hemorrhagic mass in the third ventricle. The lesion was removed via the transcallosal-interforniceal approach and pathologically diagnosed as CH. Postoperatively, the patient had a transient neurological deficit due to hypothalamic injury and recovered to the normal status at 2xa0months after the operation. In the review of 29 cases, the mean age of the patients was 40xa0years with a slight female preponderance (female/male, 17/12). The majority of the patients complained of a mass effect with signs of increased intracranial pressure; only one case was asymptomatic. Gross total resection was achieved in 81% of the cases. Around 80% of the patients were asymptomatic or improved from the initial symptoms. Mortality rate was 6.9% and the most common complication was hydrocephalus.ConclusionsAs demonstrated in the review of the previous reports, the outcome is favorable after surgical excision for CH of the third ventricle. Hence, surgical excision appears to be the treatment of choice for CH located in the third ventricle, which tends to grow rapidly resulting in a mass effect.

Destructive Radiologic Development of Intravascular Papillary Endothelial Hyperplasia on Skull Bone

Intravascular papillary endothelial hyperplasia (IPEH) is a rare vascular benign lesion that rarely involves the central nervous system with or without skull invasion. We report a rare case of IPEH on the skull bone, which displayed destructive radiologic development associated with hemorrhage. A 14-year-old male presented with an incidentally detected a small enhancing, left frontal osteolytic lesion. Previously, he underwent operation and received adjuvant chemoradiation therapy for cerebellar medulloblastoma. Follow-up magnetic resonance imaging revealed a left frontal bone lesion, which expanded to an approximately 2 cm-sized well-circumscribed osteolytic lesion associated with hemorrhage for 20 months. Frontal craniectomy and cranioplasty were performed. Destructive change was detected on the inner table and diploic space of the skull. The mass had a cystic feature with hemorrhagic content without dural attachment. Pathologic examination showed the capsule consisted of parallel collagen lamellae representing a vascular wall, vascular lumen, which was pathognomonic for IPEH. Immunohistochemical staining revealed that the capsule was positive for CD34 and factor VIII, which favor the final diagnosis of IPEH. This was the first case of intracalvarial IPEH.

Predictive factors for surgical outcome in anterior clinoidal meningiomas: Analysis of 59 consecutive surgically treated cases

Abstract Despite the advances in the microsurgical technique and anatomical understanding of the anterior and middle skull base, anterior clinoidal meningiomas are still challenging lesions to resect completely and safely due to their intimate relationship with vital neurovascular structures. We report predictive factors for tumor recurrence and postoperative complications based on surgical outcome of patients with anterior clinoidal meningiomas treated at our institution. Fifty-nine consecutive patients with anterior clinoidal meningioma who were surgically treated between March, 1993, and July, 2015, were reviewed retrospectively. For microsurgical tumor removal, orbitocranial or orbitozygomatic (78.0%), extended pterional (15.3%) and subfrontal approach (6.8%) were performed. The median follow-up duration was 54.1 months. Gross total resection (GTR, Simpsons grade I or II) was achieved in 38 patients (64.4%). The overall recurrence rate (new lesion in GTR cases and re-growth in non-GTR cases) was 18.6%. GTR (Hazard ratio [HR] 0.014, 95% confidence interval [CI] 0.001–0.256; Pu200a=u200a.004), absence of internal feeder (HR 0.058, 95% CI 0.004–0.759; Pu200a=u200a.030) and benign pathology (WHO grade I, HR 0.056, 95% CI 0.005–0.674; Pu200a=u200a.023) were independent prognostic factors for recurrence-free. Fourteen patients (23.7%) developed permanent complications. The most common complication was cranial nerve injury (nu200a=u200a6; 10.2%), followed by postoperative hemorrhage/infarction, hydrocephalus and infection. Larger size (≥ 40u200amm) was significant as an independent predictive factor for permanent complication (HR 0.139, 95% CI 0.030–0.653; Pu200a=u200a.012). Old age (≥60 years, Pu200a=u200a.056) and peritumoral edema (thickness ≥ 5u200amm, Pu200a=u200a.303) did not reach statistical significance in multivariate analysis. In surgical resection of anterior clinoidal meningiomas, various clinicoradiological factors were related with resection degree, complication, and progression rate. Although our results showed acceptable resection degree and morbidity, mortality, and recurrence rate, compared to the results of past, anterior clinoidal meningioma remain as neurosurgical challenges because of their close contact to critical vascular and neural structures.

Comparison of the clinical and quality-of-life outcomes after the inside-out TVT-O procedure with or without concomitant transvaginal gynaecological surgery

The study was undertaken to compare the clinical and quality-of-life (QoL) outcomes of the inside-out transobturator vaginal tape (TVT-O)-only procedures and TVT-O procedures with concomitant transvaginal gynaecological surgery for the treatment of stress urinary incontinence (SUI). A review of charts from January 2006 to March 2010 identified 305 patients with urodynamic stress incontinence for whom we performed the TVT-O. Of the initial 305 patients, 272 (89.2%) were re-examined for complications 1 month, 4 months, 1 year and 2–4 years postoperatively (122 TVT-O only; 150 TVT-O + other transvaginal gynaecological surgery). They were also evaluated with the Urogenital Distress Inventory Questionnaire (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) 1–4 years after the procedure. The median follow-up was 37.3 months. The success rate was 89.3% in the TVT-O-only group vs 93.3% in the TVT-O with concomitant gynaecological surgery group (p =0.729). The QoL score was quite good for 91.8% of the TVT-O-only patients and for 96.7% of the TVT-O with concomitant gynaecologic surgery patients (p =0.405). In conclusion, gynaecological operations performed concomitantly with the TVT-O procedure do not affect the clinical and QoL outcomes of the TVT-O procedure.

Gliomatosis cerebri having a poor performance status without recurrence after radiotherapy: a single institutional experience.

OBJECTIVEnRadiotherapy (RT) has been advocated for gliomatosis cerebri (GC) to delay tumor progression. However, patients with GC may experience poor performance status without recurrence after RT. Herein, we reviewed the responses of patients with GC treated with RT.nnnMATERIALS AND METHODSnSeventeen patients with diffuse radiologic infiltration of more than two cerebral lobes and diagnosed as having grade II (N=12) or III (N=5) glioma were treated with a mean radiation dose of 51.8 Gy (range, 42-59.4 Gy). The mean radiation volume to a mean marginal dose of 42.8 Gy (range, 36-45 Gy) was 693.4 cc (range, 316.5-1279.6 cc), which was 45.3% of the mean whole brain volume. We reviewed the clinical prognostic factors related to progression-free survival (PFS) and overall survival (OS) in all patients and described characteristics of patients with poor performance (Eastern Cooperative Oncology Group performance scale 3-4) without recurrence.nnnRESULTSnIn all patients, the median PFS was 12.3 months, and oligodendroglial pathology (p=0.002) and non-enhanced tumor (p=0.002) were associated with an improved PFS. The median OS was 39.3 months, and young age and adjuvant chemotherapy were associated with improved OS (p=0.022 and 0.002, respectively). Based on multivariate analysis, adjuvant chemotherapy was significantly associated with a longer OS (p=0.012; hazard ratio=0.099; 95% CI, 0.016-0.596). Five patients (29.4%) showed poor performance without recurrence. The median age of these 5 patients was 65 years (range, 60-75 years). The mean radiation volume to a mean marginal dose of 41 Gy (range, 36-45 Gy) was 539.9 cc (range, 255.5-983.1 cc). The pathologic diagnosis was grade II glioma in 2 patients and grade III in 3 patients. The median OS was 10.0 months (range, 8.2-45.9 months).nnnCONCLUSIONSnSome GC patients, especially the elderly, might have a poor performance status without recurrence after RT of a larger radiation field.

Progressive Multiple Cavernous Angiomas after Radiotherapy in a Pediatric Patient with Medulloblastoma: A Case Report

Background: We report a case of progressive multiple cavernous angiomas. Patient and Method: A 16-year-old boy presented with a 2-month history of headache and dizziness. Six years earlier, he underwent surgery for cerebellar medulloblastoma and subsequent chemoradiotherapy according to the M-051 protocol of the Korean Society of Pediatric Neuro-Oncology. Follow-up brain magnetic resonance imaging (MRI) revealed a tiny hemorrhage on the cerebellum 3 months after 23.4-Gy craniospinal and 32.4-Gy boost radiotherapy. Result: The multiple hemorrhagic lesions had progressively developed on the whole brain without any symptoms for 6 years. On admission, MRI revealed a 1.5-cm enlarged mass with subacute hemorrhage on the right frontal area. The mass was totally removed and diagnosed as cavernous angioma. However, 5 months later, the patient complained of a headache. MRI revealed 1.4- and 0.7-cm enlarged masses on the left frontal and right temporal areas with internal hemorrhage, respectively. The left frontal mass was totally removed, and the histopathological finding was suggestive of cavernous angioma. Conclusion: This case showed early-developed multiple hemorrhagic lesions after radiotherapy, which had been progressive and were associated with some symptomatic cavernous angiomas. Pediatric patients with brain radiotherapy should undergo radiological check-up to identify vascular lesions, especially symptomatic patients.

Metabolic alterations in a rat model of hepatic ischaemia reperfusion injury: In vivo hyperpolarized 13C MRS and metabolic imaging

Despite a number of studies addressing the pathophysiology of hepatic IRI, a gold standard test for early diagnosis and evaluation of IRI remains elusive. This study investigated the metabolic alterations in a rat model of hepatic IRI using the in vivo hyperpolarized ¹³C MRS and metabolic imaging.

Visual outcome after endoscopic third ventriculostomy for hydrocephalus

PurposeHydrocephalus-related symptoms are mostly improved after successful endoscopic third ventriculostomy (ETV). However, visual symptoms can be different. This study was focused on visual symptoms. We analyzed the magnetic resonance images (MRI) of the orbit and visual outcomes.MethodsFrom August 2006 to November 2016, 50 patients with hydrocephalus underwent ETV. The male-to-female ratio was 33:17, and the median age was 61xa0years (range, 5–74xa0years). There were 18 pediatric and 32 adult patients. Abnormal orbital MRI findings included prominent subarachnoid space around the optic nerves and vertical tortuosity of the optic nerves. We retrospectively analyzed clinical symptoms, causes of hydrocephalus, ETV success score (ETVSS), ETV success rate, ETV complications, orbital MRI findings, and visual impairment score (VIS).ResultsThe median duration of follow-up was 59xa0months (range, 3–113xa0months). The most common symptoms were headache, vomiting, and gait disturbance. Visual symptoms were found in 6 patients (12%). The most common causes of hydrocephalus were posterior fossa tumor in 13 patients, pineal tumor in 12, aqueductal stenosis in 8, thalamic malignant glioma in 7, and tectal glioma in 4. ETVSS was 70 in 3 patients, 80 in 34 patients, and 90 in 13 patients. ETV success rate was 80%. ETVSS 70 showed the trend in short-term survival compared to ETVSS 90 and 80. ETV complications included epidural hematoma requiring operation in one patient, transient hemiparesis in two patients, and infection in two patients. Preoperative abnormal orbital MRI findings were found in 18 patients and postoperative findings in 7 patients. Four of six patients with visual symptoms had abnormal MR findings. Three patients did not show VIS improvement, including two with severe visual symptoms.ConclusionsPatients with severe visual impairment were found to have bad outcomes. The visual symptoms related with increased intracranial pressure should be carefully monitored and controlled to improve outcomes.