Sung-Kyoo Hwang

Clinical Outcome of Cranial Neuropathy in Patients with Pituitary Apoplexy

OBJECTIVEnPituitary apoplexy (PA) is described as a clinical syndrome characterized by sudden headache, vomiting, visual impairment, and meningismus caused by rapid enlargement of a pituitary adenoma. We retrospectively analyzed the clinical presentation and surgical outcome in PA presenting with cranial neuropathy.nnnMETHODSnTwelve cases (3.3%) of PA were retrospectively reviewed among 359 patients diagnosed with pituitary adenoma. The study included 6 males and 6 females. Mean age of patients was 49.0 years, with a range of 16 to 74 years. Follow-up duration ranged from 3 to 20 months, with an average of 12 months. All patients were submitted to surgery, using the transsphenoidal approach (TSA).nnnRESULTSnSymptoms included abrupt headache (11/12), decreased visual acuity (12/12), visual field defect (11/12), and cranial nerve palsy of the third (5/12) and sixth (2/12). Mean height of the mass was 29.0 mm (range 15-46). Duration between the ictus and operation ranged from 1 to 15 days (mean 7.0). The symptom duration before operation and the recovery period of cranial neuropathy correlated significantly (p = 0.0286). TSA resulted in improvement of decreased visual acuity in 91.6%, visual field defect in 54.5%, and cranial neuropathy in 100% at 3 months after surgery.nnnCONCLUSIONnPA is a rare event, complicating 3.3% in our series. Even in blindness following pituitary apoplexy cases, improvement of cranial neuropathy is possible if adequate management is initiated in time. Surgical decompression must be considered as soon as possible in cases with severe visual impairment or cranial neuropathy.

Nerve atrophy and a small cerebellopontine angle cistern in patients with trigeminal neuralgia.

OBJECTnThe aim of this study was to provide information to help confirm the diagnosis of trigeminal neuralgia (TN) using MR imaging.nnnMETHODSnThe authors evaluated atrophy of the trigeminal nerve, the cross-sectional area of the cerebellopontine angle (CPA) cistern, and the length of the cisternal segment of the trigeminal nerve on the affected side in 26 consecutive patients with TN who were treated using Gamma Knife surgery.nnnRESULTSnThe mean volume of the trigeminal nerve on the affected side was significantly smaller than the mean volume of the trigeminal nerve on the unaffected side (p < 0.001). Nerve atrophy was present in 25 patients (96.2%) on the affected side and in 1 patient on the unaffected side. The mean cross-sectional area of the CPA cistern on the affected side (188.5 mm2) was significantly smaller than the mean volume on the unaffected side (232.8 mm2) in 25 of the 26 patients (p = 0.001). The mean length of the cisternal segment of the trigeminal nerve on the affected side (7.9 mm) was significantly shorter than the mean length on the unaffected side (9.6 mm) in 25 of the 26 patients (p = 0.001).nnnCONCLUSIONSnAmong the patients with TN, there was a statistically significant difference in the MR imaging findings of the affected side compared with the unaffected side of the trigeminal nerve. Atrophy of the trigeminal nerve and a small CPA cistern in patients with TN provides additional markers for the diagnosis of TN and helps confirm the diagnosis based on clinical examination.

Early ventriculoperitoneal shunt placement after severe aneurysmal subarachnoid hemorrhage: role of intraventricular hemorrhage and shunt function.

OBJECTIVEThis study investigated the outcome of early shunt placement in patients with poor-grade subarachnoid hemorrhage and the effect of intraventricular hemorrhage (IVH) and high proteinaceous cerebrospinal fluid (CSF) on subsequent shunt performance. METHODSThis study included 33 consecutive patients with initial Fisher grade (3/4) subarachnoid hemorrhage who had undergone conversion from external ventricular drainage (EVD) to a ventriculoperitoneal (VP) shunt and whose computed tomography scan showed IVH at the time of shunt placement. Early weaning from an EVD and conversion to a VP shunt was performed irrespective of IVH or high protein content in the CSF. RESULTSThe mean interval from EVD to VP shunt placement was 6.4 days. The mean volume of IVH was 9.44 mL, and the mean value of IVH/whole ventricle volume ratio (ie, percentage of blood suspension in the CSF) was 9.81%. The mean perioperative protein level in the CSF was 149 mg/dL. During the follow-up period, 2 patients (6.1%) required VP shunt placement, and no patients experienced complications of ventriculitis or shunt-related infection. CONCLUSIONBased on our data, earlier EVD weaning and shunt placement can effectively treat subarachnoid hemorrhage–induced hydrocephalus in patients with severe subarachnoid hemorrhage. This procedure resulted in no shunt-related infections and a 6.1% revision rate. There were fewer adverse effects of IVH and protein on shunt performance. Therefore, weaning from an EVD and conversion to a permanent VP shunt need not be delayed because of IVH or proteinaceous CSF.

Multiple fusiform myxomatous cerebral aneurysms in a patient with Carney complex

Carney complex is a rare autosomal-dominant familial tumor syndrome that involves the triad of myxoma, mucocutaneous pigmentation, and endocrine overactivity. To the best of the authors knowledge, there are no reports of multiple fusiform aneurysms coinciding with atrial myxoma. The authors report the case of a 38-year-old woman with typical Carney complex who had multiple skin myxomas, endocrine abnormalities, and multiple brownish perioral lesions. Multiple fusiform aneurysms were also discovered after the recurrence of atrial myxoma. During a follow-up period of > 10 years, there have been no angiographic changes in the aneurysms and no progression of symptoms.

Unilateral hearing loss following shunt placement for normal pressure hydrocephalus with a unilateral patent cochlear aqueduct.

Hearing loss in patients who have undergone shunt placement for a hydrocephalus is perhaps an underestimated complication rather than a rare event. There appears to be a correlation between the occurrence of hearing loss and patient characteristics consistent with excessive drainage of cerebrospinal fluid (CSF) and patent cochlear aqueduct (CA). We present the case of a 77-year-old man with unilateral dominant sensorineural hearing loss after a shunt placement for normal pressure hydrocephalus (NPH) combined with a patent cochlear aqueduct. Based on our experience and a review of the literature, we suggest an early restoration of the reduced CSF pressure using a programmable valve as a treatment strategy, which might prevent the persistent hearing loss.

Intramedullary clear cell meningioma

SummaryIntramedullary clear cell meningioma (CCM), which is more aggressive than other meningioma variants, is extremely rare. To date, only one case of such a spinal tumour has been documented. We report the first case of an intramedullary CCM originating in the thoracic region of the spinal cord.

Isolated recurrence of intracerebral granulocytic sarcoma in acute lymphoblastic leukemia: a case report.

Intracranial granulocytic sarcoma (chloroma) may occur rarely in leukemia. A 27-year-old male presented with an isolated recurrence of granulocytic sarcoma manifesting as an intraaxial mass 27xa0months after complete remission of acute lymphoblastic leukemia. He was admitted due to a severe headache and blurred vision. Brain magnetic resonance imaging demonstrated an enhanced mass which was initially interpreted as an extraaxial tumor in the right temporal region. Because of increased intracranial pressure and the mass effect, open biopsy with surgical resection was performed. The biopsy result indicated that intraaxial lymphoblastic leukemia infiltration had caused CNS relapse.Although granulocytic sarcoma occurs primarily in patients with acute myelogenous leukemia, the authors report a rare case of intraparenchymal granulocytic sarcoma in acute lymphoblastic leukemia.

Nervus intermedius dysfunction following Gamma Knife surgery for vestibular schwannoma

OBJECTnThe purpose of this study was to evaluate the function of the nervus intermedius, the nonmotor component of the facial nerve, following modern Gamma Knife surgery (GKS) for the treatment of vestibular schwannoma.nnnMETHODSnSixty-five consecutive patients at our center underwent GKS as a primary treatment option for vestibular schwannoma between 2005 and 2010. The authors interviewed patients with a functional questionnaire to evaluate the function of the nervus intermedius before and after radiosurgery from their subjective point of view. Data from 50 patients treated using GKS for a unilateral vestibular schwannoma were obtained.nnnRESULTSnNine (18%) of 50 patients presented with at least one preradiosurgical disturbance of the nervus intermedius caused by the vestibular schwannoma itself, with dysfunctions of lacrimation, salivation, nasal secretion, and taste. Of the 41 patients without preradiosurgical disturbances, 9 (22%) experienced the onset of at least one new disturbance after GKS. Specifically for each dysfunction, of the 45 patients without a lacrimal disturbance before GKS, 5 (11.1%) had a new lacrimal disturbance after GKS. New onset of a salivary disturbance after GKS was reported in 3 (6.2%) of 48 patients. In 1 patient (2%), increased nasal secretion was noted 1 year after GKS. Five (10.6%) of 47 patients without a preradiosurgical taste disturbance experienced the symptom after GKS. No facial palsy developed in any patient before or after GKS. There was no significant correlation between postradiosurgical nervus intermedius dysfunction and tumor size, margin dose, or patient age.nnnCONCLUSIONSnThe authors demonstrated that 22% of patients undergoing modern GKS for vestibular schwannoma experience various disturbances of nonmotor components of the facial nerve as a result of the radiosurgery. Through this study, we can provide useful information about the likelihood of certain postradiosurgical symptoms for vestibular schwannoma.

Pituitary carcinoma with fourth ventricle metastasis: treatment by excision and Gamma-knife radiosurgery

AbstractPituitary carcinomas, which are rare, generally present with craniospinal and systemic metastases. Although several treatments exist, the prognoses of patients with pituitary carcinomas are extremely poor to date. In this report, the authors describe the case of a 23-year-old male who had undergone trans-sphenoidal surgery and radiotherapy for an invasive prolactinoma. Seven years later, he presented with a new 4th ventricle metastasis from the pituitary lesion, and it was diagnosed with a pituitary carcinoma. He underwent resection and Gamma-knife radiosurgery (GKRS). The tumor has been well controlled for over 3xa0years. To our knowledge, there have been no reports of the effects of GKRS in patients with pituitary carcinomas. GKRS might have considerable effects in the treatment of pituitary carcinomas.n

Stereotactic radiosurgery for dural carotid cavernous sinus fistulas

OBJECTIVEnWe reviewed our 7-year experience to assess the efficacy of stereotactic radiosurgery (SRS) for dural carotid cavernous fistulas (DCCFs). We analyzed the clinical outcome, complications, and angiographic results.nnnMETHODSnWe performed a retrospective analysis of 18 consecutive patients with DCCFs treated by SRS alone using Gamma Knife between 2009 and 2015. Median target volume was 2.6 cm3 (range, 0.6-11.6 cm3), and median radiation dose to the target was 17 Gy (range, 14-19 Gy). Median follow-up period was 30 months (range, 6-65 months).nnnRESULTSnFifteen patients (83%) achieved total obliteration of the DCCF, and a subtotal obliteration of the DCCF was achieved in 3 patients (17%). Total obliteration rates after SRS were 53% at 1 year and 90% at 2 years. Twelve patients (67%) showed complete recovery from symptoms or signs, and 6 patients (33%) showed incomplete recovery. Improvement rates of neurologic function after SRS were 56% at 1 month, 72% at 3 months, and 94% at 6 months. None of the patients experienced radiation-related complications. A univariate analysis revealed that absence of hypertension (Pxa0= 0.025), seizure (Pxa0= 0.025), and cortical venous drainage (Pxa0= 0.013) were significantly associated with symptoms improvement.nnnCONCLUSIONSnSRS for DCCFs offered a high obliteration rate with low risk of radiation-induced complications. In patients with benign DCCFs that are not amenable to embolization or microsurgery, SRS is a safe and effective treatment for complete obliteration of the arteriovenous shunt and for improving quality of life.