Preliminary Report of Fully Endoscopic Microvascular Decompression.

Objective: Microscopic microvascular decompression (MVD) has been considered to be a useful treatment modality for medically refractory hemifacial spasm (HFS) and trigeminal neuralgia (TN). But, the advent of the endoscopic era has presented new possibilities to MVD surgery. While the microscope remains a valuable tool, the endoscope offers several advantages with comparable clinical outcomes. Thus, fully endoscopic MVD (E-MVD) could be a reasonable alternative to microscopic MVD. This paper explores the safety and efficacy of the fully E-MVD technique. Methods: A single-center retrospective study was conducted in 25 patients diagnosed with HFS between September 2019 and July 2023. All surgeries were performed by a single neurosurgeon using the fully E-MVD technique without any assistance of a microscope. The study reviewed intraoperative brainstem auditory evoked potentials and disappearance of the lateral spread response. Outcomes were assessed based on the patients' clinical status immediately after surgery and at their last follow-up. Complications, including facial palsy, hearing loss, ataxia, dysphagia, palsy of other cranial nerves, and cerebrospinal fluid (CSF) leakage, were also examined. Results: The most common offending artery was the anterior inferior cerebellar artery (AICA) in 15 cases (60.0%), followed by the posterior inferior cerebellar artery (PICA) in 8 cases (32.0%), vertebral artery (VA) in 1 case (4.0%), tandem lesions involving the AICA and VA in 1 case (4.0%). Ten patients (40.0%) had pre-operative facial palsy on the ipsilateral side, and 8 patients (32.0%) experienced delayed facial palsy on the ipsilateral side, from which they fully recovered by the last follow-up. The median operation time was 105 minutes. All patients were symptom free immediately after surgery and at the last follow-up. One patient experienced a permanent complication, such as high-frequency hearing loss, from which he partially recovered over time. Conclusion: Fully E-MVD demonstrated similar clinical outcomes to microscopic MVD. It offered a similar complication rate, shorter operation time, and a panoramic view with a smaller craniectomy size. Although there is a learning curve associated with fully E-MVD, it presents a viable alternative in the endoscopic era.

Multiple Cerebral Hemorrhages Caused by Paradoxical Reperfusion Injury After Cranioplasty.

Cranioplasty-related reperfusion injury has rarely been reported. Although there are several hypotheses, particularly regarding the mechanisms of the event, clear evidence is lacking. Here, we report the case of an 84-year-old man with traumatic intracranial hemorrhage and subdural hematoma who underwent decompressive craniectomy and hematoma evacuation in the right hemisphere. After 45 days, cranioplasty was performed using titanium. A preoperative perfusion study with 99m-Tc-HMPAO brain single-photon emission tomography revealed diffuse hypoperfusion in the left cerebral hemisphere with decreased vascular reserve. After cranioplasty, multiple cerebral hemorrhages were observed on immediate postoperative computed tomography. Cerebral hemorrhage eventually improved without surgery. Here, we report a case with findings revealed through perfusion studies before and after surgery.

Incidence, mortality, and cardiovascular diseases in pituitary adenoma in Korea: a nationwide population-based study.

PURPOSE: Few nationally representative studies have evaluated the epidemiology of PA (pituitary adenoma). This South Korean study evaluated the incidence of different PA subtypes, cardiovascular disease (CVD), and related mortality. METHODS: This population-based study evaluated 31,898 patients with PA during 2005-2015. The incidence of PA, mortality, and CVD occurrence in PA cases were evaluated during a median follow-up of 5.3 years (range: 0-10 years). Cox regression analysis was used to evaluate the associations between CVD and mortality. RESULTS: The annual incidences (per 100,000 population) were 3.5 for non-functioning pituitary adenoma (NFPA), 1.6 for prolactinoma (PRL), 0.5 for growth hormone-secreting pituitary adenoma (GH), and 0.2 for adrenocorticotropic or thyroid-stimulating hormone-secreting pituitary adenoma (ACTH + TSH). The standardized mortality ratios were 1.9 for ACTH + TSH, 1.7 for NFPA with hypopituitarism, 1.4 for NFPA without hypopituitarism, 1.3 for GH, and 1.1 for PRL. During 2005-2015, the overall incidence of CVD among PA patients was 6.6% (2106 cases), and the standardized incidence ratios were 4.1 for hemorrhagic stroke, 3.0 for ischemic stroke, and 1.7 for acute myocardial infarction. The standardized incidence ratios for stroke were significantly higher in the ACTH + TSH and NFPA groups, which also had higher risks of CVD-related mortality, relative to the PRL and GH groups. CONCLUSION: South Korea had a relatively high incidence of NFPA. The incidence of stroke was highest for ACTH + TSH and NFPA, which was directly related to mortality during long-term follow-up. Patients with these types of PA should receive stroke prevention measures to reduce their risk of mortality.

Clinical application of dual-phase F-18 sodium-fluoride bone PET/CT for diagnosing surgical site infection following orthopedic surgery.

F-18 sodium-fluoride (NaF) bone positron emission tomography (PET/CT) has been used for diagnosing various bone and joint diseases, and, with using dual-phase scan protocol, it could give the same information obtained by the 3-phase bone scintigraphy. The present study aimed to evaluate the diagnostic ability of dual-phase F-18 NaF bone PET/CT in detecting surgical site infection after orthopedic surgery.Twenty-three patients who underwent dual-phase F-18 NaF bone PET/CT under clinical suspicion of surgical site infection of the bone following orthopedic surgery were enrolled in this study. Dual-phase bone PET/CT consisted of an early phase scan performed immediately after radiotracer injection and a conventional bone-phase scan. All dual-phase PET/CT images were visually assessed, and, for quantitative analysis, 6 parameters of dual-phase PET/CT (lesion-to-blood pool uptake ratio, lesion-to-bone uptake ratio, and lesion-to-muscle uptake ratio on both early phase and bone-phase scans) were measured.Surgical site infection was diagnosed in 14 patients of the 23 patients. The sensitivity, specificity, and accuracy of visual analysis of dual-phase F-18 NaF bone PET/CT for diagnosing surgical site infection of the bone were 92.9%, 100.0%, and 95.7%, respectively. Among the 6 parameters, the lesion-to-blood pool uptake ratio on early phase scan showed the highest area under the receiver operating characteristic curve value (0.857, 95% confidence interval, 0.649-0.966), with the cut-off value of 0.88 showing sensitivity, specificity, and accuracy of 85.7%, 88.9%, and 87.0%, respectively.Our study showed the high diagnostic ability of dual-phase F-18 NaF bone PET/CT for detecting surgical site infection following orthopedic surgery. Further studies are needed to compare the diagnostic ability of dual-phase bone PET/CT with other imaging modalities.

Clinical Features of Interhemispheric Subdural Hematomas.

OBJECTIVE: Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively. METHODS: From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes. RESULTS: The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment. CONCLUSION: IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.

Tailgut cyst accompanied with bony defect.

Retro-rectal cystic hamartoma (tailgut cyst), is an uncommon congenital developmental lesion, generally located in the retro-rectal space. Its diagnosis and approach is challenging because the retropelvic space is not familiar. We report a 51-year-old woman who presented with paresthesia and pain in perianal area. The magnetic resonance image showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image of the retropelvic space and CT showed sacral bony defect. We chose the posterior approach for removal of the tailgut cyst. Histopathology exam of the retropelvic cyst revealed a multiloculated cyst containing abundant mucoid material lined by both squamous and glandular mucinous epithelium. The patient has recovered nicely with no recurrence. Tailgut cyst needs complete surgical excision for good prognosis. So, a preoperative high-resolution image and co-operation between neurosurgen and general surgeon would help to make safe and feasible diagnosis and surgical access.

Open Surgical Evacuation of Spontaneous Putaminal Hematomas: Prognostic Factors and Comparison of Outcomes between Transsylvian and Transcortical Approaches.

OBJECTIVE: The purpose of this study was to investigate the factors affecting the surgical outcome and to compare the surgical results between transsylvian and transcortical approaches in patients with putaminal hematomas. METHODS: Retrospective review of charts and CT scan images was conducted in 45 patients (20 transsylvian and 25 transcortical approaches) who underwent open surgical evacuation of putaminal hematomas. Mean Glasgow coma scale (GCS) score and hematoma volume were 7.5+/-3.2 and 78.1+/-29.3 cc, respectively. The factors affecting the functional mortality were investigated using a multivariate logistic regression analysis. In addition, surgical results between transsylvian and transcortical approaches were compared. RESULTS: None of the patients had a good recovery after the surgery. Overall functional survival rate and mortality were 37.7% and 31%, respectively. The only risk factor for functional mortality was GCS motor score after controlling age, history of hypertension, side of hematoma, hematoma amount, midline shift, presence of intraventricular hemorrhage and surgical approach (p=0.005). Even though a transcortical approach was shorter in operative time (4.4 versus 5.1 hour) and showed a higher mortality rate (40% versus 20%) and lower functional survival (45% versus 35%) compared to the transsylvian approach, the differences were not statistically significant between the two groups. CONCLUSION: In patients who have large amounts of hematoma and require open surgical evacuation, the only significant risk factor for functional survival is the preoperative GCS score. Cortical incision methods such as transsylvian and transcortical approaches have no influence on the surgical outcome. To decompress the swollen brain rapidly, transcortical approach seems to be more suitable than transsylvian approach.