Young Seob Chung

Atypical and anaplastic meningiomas: prognostic implications of clinicopathological features

Objectives: To evaluate patient outcome and investigate the prognostic factors of high-grade meningiomas by adopting the 2000 World Health Organization (WHO) classification system. Methods: Between 1986 and 2004, 74 patients were diagnosed with high-grade meningioma: 33 with atypical and 41 with anaplastic meningioma. The mean follow-up was 58.5 months. We reclassified all surgical specimens, according to the 2000 WHO classification system, using two expert neuropathologists. Results: Forty of 74 meningiomas were reclassified as atypical meningioma and 24 as anaplastic meningioma. Overall and recurrence-free survivals were significantly longer in patients with atypical than in those with anaplastic meningioma: 142.5 versus 39.8 months and 138.5 versus 32.2 months, respectively (p<0.001). In patients with atypical meningiomas, brain invasion and adjuvant radiotherapy were not associated with survival; however, in the brain invasion subgroup, adjuvant radiotherapy improved patients’ survival. In patients with anaplastic meningioma, the prognostic factors were brain invasion, adjuvant radiotherapy, malignant progression, p53 overexpression and extent of resection. The p53 overexpression was the only factor associated with malignant progression (p = 0.009). Conclusions: The 2000 WHO classification has identified the truly aggressive meningiomas better than did the previous criteria. A precise meningioma grading system may help to avoid over-treatment of patients with an atypical meningioma as, once the tumour has “declared itself” by recurrence and histological features, it becomes a tumour that is poorly amenable to current therapies.

Elective stenting for symptomatic middle cerebral artery stenosis presenting as transient ischaemic deficits or stroke attacks: short term arteriographical and clinical outcome

Background: Although stent assisted angioplasty is an effective treatment for coronary and peripheral arterial disease, its efficacy in intracranial arteriosclerotic disease has not been verified. Objectives: To assess the radiographic and clinical outcome of stent assisted angioplasty for symptomatic middle cerebral artery (MCA) stenosis. Methods: We attempted stent assisted angioplasty in 14 patients with symptomatic high grade stenosis (>60%) on the proximal portion of the MCA, who had experienced either recurrent transient ischaemic attacks (TIAs) resistant to medical therapy or one or more stroke attacks. Patient records were analysed for angiographic characteristics, degree of stenosis, pre-procedural regimen of anti-platelet and/or anti-coagulation agents, use of devices, procedure related complications, pre-operative and post-operative single photon emission computed tomography (SPECT) findings, and clinical and radiographic outcomes. Results: Stent assisted angioplasty was successfully performed in 8 of 14 patients without any serious complications and unsuccessful in 2 of 14 patients due to the tortuous curve of the internal carotid artery siphon. Four patients had complications. Two patients had an arterial rupture; one patient was rescued by an additional stent and balloon tamponade, the other patient died. Complications in the other two patients included thrombotic occlusion and distal thrombosis. Residual stenosis was less than 50% in diameter in all the patients. All eight patients who underwent follow up cerebral angiography had no restenosis. Follow up SPECT showed improved perfusion in the affected MCA territory in all the tested patients with TIA and in one of three stroke patients. Using the modified Rankin Scale at follow up, four of five TIA patients and five of six stroke patients were assessed as functionally improved or having a stable clinical status. Conclusion: Although the re-stenosis rate in stent assisted angioplasty seems to be better than in primary balloon angioplasty as reported previously, the complication rate is still high. Elective stenting is an alternative therapeutic method for the prevention of secondary ischaemic stroke in stroke patients with MCA stenosis, and seems to be a potentially effective but also hazardous therapeutic technique in patients with recurrent TIAs. This study indicates the need for randomised control trial data of this intervention. Additionally, long term follow up data and additional clinical experience are required to assess the durability of this procedure.

Biological behavior and tumorigenesis of subependymal giant cell astrocytomas.

In spite of the benign nature of subependymal giant cell astrocytomas (SEGAs), some show massive hemorrhage, rapid growth, and tumor recurrence. This led us to investigate the biological behavior, cell dynamics, and nobreak tumorigenesis of SEGAs.All patients (4 men and 3 women; age range, 6–27 years; mean, 13.6 years) had features of tuberous sclerosis complex and obstructive hydrocephalus. One patient had intratumoral bleeding. In two patients, sequential neuroimaging showed a subependymal nodule growing to become a SEGA. All underwent surgical resection without radiation therapy. One tumor recurred and was treated surgically. There were no postoperative deaths. The presence of cytologic atypia, mitoses and vascular proliferation had no implication in terms of the clinical course. MIB-1 labeling indices were low (mean, 0.9), indicating low proliferative potential. Unexpectedly, bcl-2 staining was sparse and bax staining predominated in majority of cases. However, the mean value of terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling index was low. Immunohistochemically, tumors were positive for both glial and neuronal markers. In the majority of our cases, the expression of p53 was low. Only one tumor was focally positive for tuberin.SEGAs have low proliferative potential and apoptotic activity, and exhibit features of mixed glial–neuronal differentiation. In contrast to p53, tuberin is suggested to be the tumor suppressor in this tumor.

Thromboembolic complications of elective coil embolization of unruptured aneurysms: the effect of oral antiplatelet preparation on periprocedural thromboembolic complication.

OBJECTIVEWe retrospectively evaluated whether antiplatelet preparation lowered the thromboembolic complication rate during the perioperative period. METHODSWe reviewed 328 elective coil embolization procedures in which only microcatheters were used for coiling. No antiplatelet medication was prescribed before the procedure in 95 cases (29%, group 1), whereas antiplatelet therapy was used in 233 cases (71%, group 2; 61 [18.6%] with a single agent [aspirin or clopidogrel] and 172 [52.4%] with both agents). Antiplatelet agents were not given after coiling unless atherosclerosis, severe coil protrusion, or a thromboembolic complication occurred during the procedure. A thromboembolic complication was defined as a procedural thromboembolic event or transient ischemic attack or stroke occurring within 2 days of embolization. RESULTSThromboembolic complications occurred in 11 cases (3.4%): 6 (6.3%) in group 1 and 5 (2.1%) in group 2 (P = .085). In 195 cases (59.5%) treated by the single microcatheter technique, the risk of thromboembolic complications was low and not affected by antiplatelet preparation (1.8% [no preparation] vs 2.2% [preparation]; P = 1.000). However, in 133 cases (40.5%) treated by the multiple microcatheter technique, antiplatelet preparation significantly reduced the thromboembolic complication risk by 85.2% (12.8% [no preparation] vs 2.1% [preparation]; odds ratio, 0.148; 95% confidence interval, 0.027–0.798; P = .023). The aneurysms treated by the multiple microcatheter technique had more complex configurations for coiling (P < .001). The risk of hemorrhage was not increased by antiplatelet preparation (P = .171). CONCLUSIONAntiplatelet preparation lowered the periprocedural thromboembolic complication rate in unruptured aneurysms treated by the multiple microcatheter technique and did not increase the risk of hemorrhage. Therefore, antiplatelet preparation can help to reduce complications in patients in whom technical difficulties are expected without the risk of hemorrhage.

Clinical experiences with spontaneous intracranial hypotension: A proposal of a diagnostic approach and treatment

OBJECTIVE We analyzed our clinical experience with patients with intracranial hypotension and developed a strategic model for the diagnosis mainly using Radioisotope (RI) cisternography and treatment of spontaneous intracranial hypotension (SIH). METHODS AND MATERIALS We retrospectively analyzed our clinical experiences with 30 cases of SIH from January 2000 through December 2006. All patients had confirmed by magnetic resonance image (MRI). RI cisternography or computed-tomography (CT) myelography was done for disclosing a cerebrospinal fluid leakage point. Initially patients were treated with medication. When patients complained of persistent headache, we performed epidural blood patch (EBP) administration. We performed subdural hematoma evacuation when it grew or worsened neurological status. RESULTS Twenty-one women (70%) and 9 men (30%) were enrolled. The mean age was 40 years (range: 30-58 years). After initial diagnosis with MRI, RI cisternography and CT myelography were helpful in pinpointing the exact leakage site. Four patients were treated only with the medication and 24 patients were treated with the epidural blood patch (EBP). Half of them achieved dramatic relief of symptoms after the initial EBP. A blind EBP was performed in 15 patients. Six patients experienced recurrence of symptoms. Hematoma evacuation was performed in 8 patients. None of diagnostic tools or treatment methods showed distinct superiority in predicting a favorable clinical outcome. CONCLUSION Clinicians should be systematic in their approach to plan a treatment regimen for patients with SIH. We suggest the use of a flow diagram when determining how to best approach and treat patients with SIH.

The effect of brain atrophy on outcome after a large cerebral infarction

Purpose We retrospectively evaluated the effect of brain atrophy on the outcome of patients after a large cerebral infarct. Methods Between June 2003 and Oct 2008, 134 of 2975 patients with stroke were diagnosed as having a large cerebral infarct. The mean age of the patients was 70 (21–95) y. The mean infarct volume was 223.6±95.2 cm3 (46.0–491.0). The inter-caudate distance (ICD) was calculated as an indicator of brain atrophy by measuring the hemi-ICD of the intact side and then multiplying by two to account for brain swelling at the infarct site. The mean ICD was 18.0±4.8 mm (9.6–37.6). Results Forty-nine (36.6%) patients experienced a malignant clinical outcome (MCO) during management in the hospital. Thirty-one (23.1%) patients had a favourable functional outcome (FO) (modified Rankin scale (mRS) ≤3) and 49 (36.6%) had an acceptable functional outcome (AO) (mRS≤4) at 6 months after stroke onset. In the multivariate analysis, brain atrophy (ICD≥20 mm) had a significant and independent protective effect on MCO (p=0.003; OR=0.137; 95% CI 0.037 to 0.503). With respect to FO, the age and infarct volume reached statistical significance (p<0.001, OR=0.844, 95% CI 0.781 to 0.913; p=0.006, OR=0.987, 95% CI 0.977 to 0.996, respectively). Brain atrophy (ICD≥20 mm) was negatively associated only with AO (p=0.022; OR=0.164; 95% CI 0.035 to 0.767). Conclusions Brain atrophy may have an association with clinical outcome after a large stroke by a trend of saving patients from an MCO but also by interfering with their functional recovery.

Palliatively treated cerebral arteriovenous malformations: follow-up results

The purpose of this study was to evaluate the benefits of palliative embolisation of patients with inoperable intracranial AVMs. It involved the analysis of the long-term clinical follow-up results of 27 patients with inoperable intracranial AVMs. Sixteen patients were treated medically and 11 patients received partial embolisation. The mean size of the lesions was 7.2 +/- 2.6 cm, and the mean follow-up period was 99 +/- 44 months (range 52-192 months). There were no significant statistical differences in the sex, age, size, venous drainage pattern, location of the lesions or presented symptoms. The analysis of the long-term clinical follow-up results showed no significant difference in either the risk of haemorrhage or clinical status of the patients in the two treatment groups. Of the 16 patients in the medical treatment group, 8 (50%) showed a clinical improvement, 3 no improvement and 5 (31%) deterioration. Of the 11 patients in the embolisation group, 5 (45.5%) showed clinical improvement, 3 no improvement and 3 (27.3%) deterioration (P = 0.871). Twenty-five percent (4 cases) of patients in the medical group and 45.5% (5 cases) of patients in the embolisation group suffered from haemorrhage during the follow-up period (P = 0.270). Complications related to embolisation occurred in three cases. This comparative study shows that palliative partial embolisation of intracranial AVMs, in all probability does not produce better clinical results than medical treatment.

The natural clinical course of hemodynamically stable adult moyamoya disease.

OBJECT Moyamoya disease (MMD) is a rare cerebrovascular disease and its natural history is still unclear. The authors aimed to investigate the natural course of hemodynamically stable cases of adult MMD, with the analysis of stroke risk factors. METHODS Two hundred forty-one patients were included in this retrospective study. One hundred sixty-six (68.9%) were female, and mean age (± SD) at first visit was 41.3 ± 12.0 years (range 18-69 years). Unilateral involvement was identified in 33 patients, and 19 patients (7.9%) had a family history of MMD. According to the clinical presentations, patients were classified into hemorrhagic (n = 62, 25.7%), ischemic (n = 144, 59.8%), and asymptomatic (n = 35, 14.5%) groups. The mean duration of follow-up was 82.5 ± 62.9 months (range 7.3-347.0 months). RESULTS The annual stroke risk was 4.5%, and the annual risks of rebleeding in the hemorrhagic group and recurrent ischemic events in the ischemic group were 4.3% and 3.0%, respectively. There was no significant difference in cumulative stroke risk between the 3 groups (p = 0.461). Risk factors included thyroid disease for overall strokes (HR 2.56, 95% CI 1.16-5.67), initial hemorrhagic presentation for hemorrhagic strokes (HR 2.53, 95% CI 1.24-5.17), and initial ischemic presentation for ischemic strokes (HR 2.69, 95% CI 1.15-6.27). Familial MMD was a common risk factor for all types of stroke. Among the 3 clinical groups, the hemorrhagic group showed the worst clinical status at discharge and at most recent follow-up. Twenty-three patients (9.5%) eventually underwent revascularization surgery. CONCLUSIONS There was no statistically significant difference in the incidence of stroke in the different clinical groups; clinical status, however, was most severe in patients with hemorrhagic presentation. In patients who experienced stroke during the follow-up period, the stroke type tended to correspond to their initial presentation. Close follow-up is needed in patients with thyroid disease and a family history of MMD.

Little Response of Cerebral Metastasis from Hepatocellular Carcinoma to Any Treatments

OBJECTIVE We retrospectively evaluated the survival outcome of patients with brain metastasis from hepatocellular carcinoma (HCC). METHODS Between 1991 and 2007, a total of 20 patients were diagnosed as having brain metastasis from HCC. The mean age of the patients was 55 +/- 13 years, and 17 (85.0%) were men. Seventeen (85.0%) patients had already extracranial metastases. The median time from diagnosis of HCC to brain metastasis was 18.5 months. Fourteen (70.0%) patients had stroke-like presentation due to intracerebral hemorrhage (ICH). Ten (50.0%) patients had single or solitary brain metastasis. Among a total of 34 brain lesions, 31 (91.2%) lesions had the hemorrhagic components. RESULTS The median survival time was 8 weeks (95% CI, 5.08-10.92), and the actuarial survival rates were 85.0%, 45.0%, 22.5%, and 8.4% at 4, 12, 24, and 54 weeks. Age < 60 years, treatment of the primary and/or extracranial lesions, and recurrent ICH were the possible prognostic factors (p = 0.044, p < 0.001, and p = 0.111, respectively). The median progression-free survival (PFS) time was 3 months (95% CI, 0.95-5.05). CONCLUSION The overall survival of the patients with brain metastasis from HCC was very poor with median survival time being only 8 weeks. However, the younger patients less than 60 years and/or no extracranial metastases seem to be a positive prognostic factor.

A risk factor analysis of prospective symptomatic haemorrhage in adult patients with cerebral cavernous malformation

Objective The purpose of this study was to assess the risk factors of prospective symptomatic haemorrhage in a large series of adult patients with cerebral cavernous malformation (CM). Methods Three hundred twenty-six patients >18 years of age with 410 CMs were evaluated retrospectively. Symptomatic haemorrhage was defined as new clinical symptoms with radiographic features of haemorrhage. Clinical data and the characteristics of CM were analysed. MR appearance was divided into three groups according to Zabramskis classification. Results The overall haemorrhage rate of CM was 4.46% per lesion-year. The overall annual haemorrhage rate according to MR appearance was as follows: type I, 9.47%; type II, 4.74%; and type III, 1.43%. A multivariate analysis revealed that prior symptomatic haemorrhage (p<0.001) and MR appearance (p<0.001) were statistically significant. After multiple comparisons, type I (p<0.001) and type II (p=0.016) showed higher haemorrhage risk than type III. However, no significant difference in haemorrhage rate was observed between type I and type II (p=0.105). Other variables including female gender, age, location, multiplicity, hypertension, size and associated venous angioma were not significant. The haemorrhage rates based on risk factors were estimated at 3 years as follows: 33.77% in patients with prior haemorrhage versus 7.54% in patients without prior haemorrhage (p<0.001); type I, 27.62% vs type II, 15.44% vs type III, 5.38% (p<0.001). Conclusions Prior symptomatic haemorrhage and MR appearance could be related to prospective symptomatic CM haemorrhage in adults. A prospective multicentre observational study is necessary to confirm our results.