Seung-Hoon Jung

Tailored surgical approaches for benign craniovertebral junction tumors.

OBJECTIVE We report our surgical experience in the treatment of 16 consecutive patients with benign craniovertebral junction (CVJ) tumor, observed from 2003 to 2008 at our department. METHODS We had treated 6 foramen magnum meningiomas, 6 cervicomedullary hemangioblastomas, 1 accessory nerve schwannoma, 1 hypoglossal nerve schwannoma, 1 C2 root schwannoma, and 1 cavernous hemangioma. Clinical results were evaluated by Karnofsky Performance Scale (KPS) and all patients underwent preoperative neuroradiological evaluation with computed tomography (CT) and magnetic resonance image (MRI). Angiography was performed in 15 patients and preoperative embolization was done in 2 patients. RESULTS Five far-lateral, 1 supracondylar and 10 midline suboccipital approaches were performed. Gross total removal was achieved in 15 cases (94%) and subtotal removal in 1 patient (6%). None of the patients required occipitocervical fusion. Radiological follow-up showed no recurrence in cases totally removed. Postoperative decrease of KPS scores was recorded in only 1 patient. The treatment of cervicomedullary solid hemangioblastoma presented particular issues : by preoperative embolization, we removed tumor totally without an excessive bleeding or brainstem injury. In one of foramen magnum meningioma, we carried out subtotal removal due to hard tumor consistency and encasement of neurovascular structures. CONCLUSION : The choice of surgical approaches and the extent of bone resection should be defined according to the location and size of individual tumors. Moreover, we emphasize that preoperative neuroradiological evaluations on presumptive tumor type could be helpful to the surgeon in tailoring the technique and providing the required exposure for different lesions, without unnecessary surgical steps.

Reconstructive Endovascular Treatment of an Intracranial Infectious Aneurysm in Bacterial Meningitis: A Case Report and Review of Literature

BACKGROUND Intracranial infectious aneurysms (IAs) are rare cerebrovascular lesions that represent only 1%-6% of all intracranial aneurysms. IAs are rare cerebrovascular lesions and pose a significant therapeutic challenge because of their angiographic and pathophysiologic features. We describe a patient with an intracranial IA treated by the use of reconstructive endovascular methods using a balloon-expandable covered stent and discuss the pathophysiologic characteristics of IA based on serial brain imaging findings. CASE DESCRIPTION A 21-year-old man was admitted to our emergency department with headache and vomiting. Neurologic examination, hematologic workup, and cerebrospinal fluid examination confirmed a diagnosis of bacterial meningitis. Initial brain magnetic resonance angiography revealed no significant stenosis lesions or aneurysm. After 4 weeks of antibiotic treatment, follow-up brain magnetic resonance imaging revealed an 8-mm sized aneurysm on the petrous portion of the right internal carotid artery, and 3 months later, follow-up brain magnetic resonance angiography revealed that the aneurysm had increased in size from 8 to 15 mm. Conventional 4-vessel angiography confirmed the presence of a pseudoaneurysm. Endovascular treatment was then planned via the use of a balloon-expandable covered stent. Postoperatively, the patient was discharged without specific neurologic deficit. CONCLUSIONS IAs are rare cerebrovascular lesions and pose a significant therapeutic challenge because of their angiographic and pathophysiologic features. Although endovascular treatment is not performed routinely for infectious aneurysms, the covered stent may represent a safe and effective treatment that achieves complete endoluminal reconstruction of the damaged vessel wall.

Rapid Clinical Course of Cerebral Metastatic Angiosarcoma from the Heart

We report here one case of rapid and aggressive course of cerebral metastatic angiosarcoma from the heart. A 36-year-old man presented with 10-days history of headache. Magnetic resonance imaging demonstrated subacute hemorrhage with a small region of enhancement in right parietal region and the pathological diagnosis was angiosarcoma. Transthoracic echocardiography demonstrated 3.2×3 cm sized mass on right atrial wall. Newly developed lesion was reoperated, three and four weeks later respectively, and whole brain radiotherapy of total 30 Gy was done. With the interval of two months, gamma knife surgery was done for new lesions two times, which were well controlled. Newly developed lesions rapidly happened even in the adjuvant treatment. He died 9 months after the diagnosis because of the aggravation of primary cancer. The cerebral metastatic angiosarcoma from the heart showed the rapid aggressive behavior and the closed follow-up could be needed for the adjuvant treatment.

Traumatic Dural Venous Sinus Injury

Objective The importance of traumatic dural venous sinus injury lies in the probability of massive blood loss at the time of trauma or emergency operation resulting in a high mortality rate during the perioperative period. We considered the appropriate methods of treatment that are most essential in the overall management of traumatic dural venous sinus injuries. Methods We conducted a retrospective review of all cases involving patients with dural venous sinus injury who presented to our hospital between January 1999 and December 2014. Results Between January 1999 and December 2014, 20 patients with a dural venous sinus injury out of the 1,200 patients with severe head injuries who had been operated upon in our clinic were reviewed retrospectively. There were 17 male and 3 female patients. In 11 out of the 13 patients with a linear skull fracture crossing the dural venous sinus, massive blood loss from the injured sinus wall could be controlled by simple digital pressure using Gelfoam. All 5 patients with a linear skull fracture parallel to the sinus over the venous sinus developed massive sinus bleeding that could not be controlled by simple digital pressure. Conclusion When there is a linear skull fracture parallel to the sinus over the dural venous sinus or a depressed skull fracture penetrating the sinus, the surgeon should be prepared for the possibility of potentially fatal venous sinus injury, even in the absence of a hematoma.

Correct Plane of the Sylvian Vein Dissection for Middle Cerebral Artery Aneurysm Using Indocyanine Green Videoangiography

BACKGROUND Preservation of the superficial Sylvian veins (SSVs) is essential to prevent neurologic deficits during Sylvian dissection. We describe an appropriate surgical approach for unruptured middle cerebral artery (MCA) aneurysms to preserve these veins by using indocyanine green videoangiography (ICG-VA). METHODS Between August 2014 and August 2015, we performed microsurgical clipping for 37 unruptured MCA aneurysms in 36 patients. We classified all of the cases into 3 types according to the location between the Sylvian fissure and the SSV. We defined 3 surgical approaches (frontosylvian, intersylvian, and temporo-sylvian) based on the SSV and investigated the proper surgical approach according to the type of case. RESULTS In our study, most SSVs were located above the Sylvian fissure (fissure type, 64.9%). The SSV was located on the temporal lobe in 10 cases (temporal type) and on the frontal lobe in 3 cases (frontal type). The frontosylvian approach (splitting between the SSV and frontal lobe) was performed in all of the patients with temporal type; the temporo-sylvian approach (splitting between the SSV and temporal lobe) was performed in all of the patients with frontal type and single SSV of fissure type. The intersylvian approach (splitting between the frontal and temporal SSV, or among multiple SSVs) was successfully performed in the patients with double or multiple SSVs of fissure type. No venous complications occurred that were related to the surgical approach. CONCLUSIONS Correct dissection strategy using intraoperative ICG-VA is greatly useful to define the optimal surgical approach without vein injury.