Clinical outcome of proton therapy for patients with chordomas

PURPOSE: To investigate the clinical outcome of proton therapy (PT) in patients with chordoma. MATERIALS AND METHODS: Fifty-eight patients with chordoma treated with PT between June 2007 and December 2015 at the National Cancer Center, Korea, were retrospectively analyzed. The median total dose was 69.6 cobalt gray equivalent (CGE; range, 64.8 to 79.2 CGE). Local progression-free survival (LPFS), distant metastasis-free survival (DMFS), overall survival (OS), and diseasespecific survival (DSS) rates were calculated by the Kaplan–Meier method. RESULTS: With the median follow-up of 42.8 months (range, 4 to 174 months), the 5-year LPFS, DMFS, OS, and DSS rates were 87.9%, 86.7%, 88.3%, and 92.9%, respectively. The tumor location was associated with the patterns of failure: the LPFS rates were lower for cervical tumors (57.1%) than for non-cervical tumors (93.1%) (p = 0.02), and the DMFS rates were lower for sacral tumors (53.5%) than for non-sacral tumors (100%) (p = 0.001). The total dose was associated with both the LPFS rate and DMFS rate. The initial tumor size was associated with the DMFS rate, but was not associated with the LPFS rate. Three patients had grade 3 late toxicity with none ≥grade 4. CONCLUSION: PT is an effective and safe treatment in patients with chordomas. The tumor location was associated with the patterns of failure: local failure was common in cervical tumors, and distant failure was common in sacral tumors. Further refinement of PT, such as the utilization of intensity modulated PT for cervical tumors, is warranted to improve the outcome.

Temporal augmentation with calvarial onlay graft during pterional craniotomy for prevention of temporal hollowing

BACKGROUND: Atrophy of muscle and fat often contributes to temporal hollowing after pterional craniotomy. However, the main cause is from the bony defect. Several methods to prevent temporal hollowing have been introduced, all with specific limitations. Autologous bone grafts are most ideal for cranial defect reconstruction. The authors investigated the effectiveness of bony defect coverage and temporal augmentation using pterional craniotomy bone flap. METHODS: This study was conducted in 100 patients who underwent brain tumor excision through pterional approach from 2015 to 2016. Group 1 underwent pterional craniotomy with temporal augmentation and group 2 without temporal augmentation. In group 1, after splitting the calvarial bone at the diploic space, the inner table was used for covering the bone defect and as an onlay graft for temporal augmentation. The outcome is evaluated by computed tomography at 1-year follow-up. RESULTS: The mean operative time for temporal augmentation was 45 minutes. The mean follow-up was 12 months. The ratio of temporal thickness of operated side to non-operated side was 0.99 in group 1 and 0.44 in group 2, which was statistically different. The mean visual analogue scale score was 1.77 in group 1 and 6.85 in group 2. CONCLUSION: This study demonstrated a surgical technique using autologous bone graft for successfully preventing the temporal hollowing and improved patient satisfaction.

Hearing Preservation with the Transcrusal Approach to the Skull Base Lesion Combined with Other Transcranial Approach: Results of Consecutive Series of 5 Cases / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: This study reviewed our experience and outcomes of surgery via transcrusal approach to the skull base lesions. SUBJECTS AND METHOD: We performed transcrusal approach technique on five patients with skull base lesions (Cavernous malformation, Petroclival meningioma, Craniopharyngioma, Anaplastic astrocytoma, and Trigerminal epidermoid cyst) aiming at preserving hearing. Pre-and post-operative pure tone audiometry (PTA) and caloric test were performed in all patients. The transcrusal approach technique was performed as reported in the previous references. The approach included trephination of the superior and posterior semicircular canals from the ampullae to the common crus. The main outcome of this study was preserving hearing and the vestibular function after surgery, which was determined by PTA and caloric test. RESULTS: The average diameter of skull base lesion of the five patients was 3.68 cm. The mean follow up period was 114.2 days. The pre-operative mean PTA of five patients was 11 dB. The mean PTA of five patients within seven days after surgery was 28 dB. The last measured mean PTA was 29.8 dB. The pre and post-operative caloric results measured revealed vestibular function deficit in all of the patients after surgery (mean decreased value: 64%). All patients were stable during the surgery. Complications included two cerebrospinal fluid leak (40%) and one cranial VI nerve deficit (20%). CONCLUSION: Transcrusal approach is a method that can simultaneously preserve hearing and afford enough exposure of the skull base lesion if appropriately combined with other transcranial approach. We performed transcrusal approach targeting skull base lesion with hearing preservation, and we found excellent hearing result with this technique.

Effectiveness of Temporal Augmentation Using a Calvarial Onlay Graft during Pterional Craniotomy

Temporal hollowing occurs to varying degrees after pterional craniotomy. The most common cause of temporal hollowing is a bony defect of the pterional and temporal regions due to the resection of the sphenoid ridge and temporal squama for adequate exposure without overhang. The augmentation of such bony defects is important in preventing craniofacial deformities and postoperative hollowness. Temporal cranioplasty has been performed using a range of materials, such as acrylics, porous polyethylene, bone cement, titanium, muscle flaps, and prosthetic dermis. These methods are limited by the risk of damage to adjacent tissue and infection, a prolonged preparation phase, the possibility of reabsorption, and cost inefficiency. We have developed a method of temporal augmentation using a calvarial onlay graft as a single-stage neurosurgical reconstructive operation in patients requiring craniotomy. In this report, we describe the surgical details and review our institutional outcomes. The patients were divided into pterional craniotomy and onlay graft groups. Clinical temporal hollowing was assessed using a visual analog scale (VAS). Temporal soft tissue thickness was measured on preoperative and postoperative computed tomography (CT) studies. Both the VAS and CT-based assessments were compared between the groups. Our review indicated that the use of an onlay graft was associated with a lower VAS score and left-right discrepancy in the temporal contour than were observed in patients undergoing pterional craniotomy without an onlay graft.

Transfacial Surgical Approaches to Secure Wide Exposure of the Skull Base

BACKGROUND: Treatment of skull base tumors is challenging due to limited access and presence of important neurovascular structures nearby. The success of a complete tumor resection depends on the extent of tumor exposure and secure field of view. While these tumors are often removed by transcranial endoscopic access, transfacial approach is sometimes required depending on the location and size of the tumor. This study describes various transfacial approaches in patients undergoing skull base tumor resection. METHODS: From March to November 2013, 15 patients underwent skull base tumor resection via transfacial accesses at a tertiary institution. Data were reviewed for patient demographics, type of access used, completeness of tumor resection, surgical outcome, and postoperative complications. RESULTS: Two clivus tumor patients underwent transmaxillary approach; three tuberculum- sellae and suprasellar-hypothalamus tumor patients underwent transbasal approach; three clinoid and retrobulbar intraconal orbital tumor patients underwent orbitozygomatic approach; and seven petroclival-area, pons, cavernous sinus, and lateral-sphenoid-wing tumor patients underwent zygomatic approach. In all cases, the upper and lower margins of the tumor were visible. Complete tumor removal consisted of 10 cases, and partial tumor removal in 5. There were no immediate major complications observed for the transfacial portion of the operations. The overall cosmetic results were satisfactory. CONCLUSION: Plastic surgeons can use various transfacial approaches according to the location and size of skull base tumors to secure a sufficient field of view for neurosurgeons.

Two Indices Affecting the Directions of the Sylvian Fissure Dissection in Middle Cerebral Artery Bifurcation Aneurysms

OBJECTIVE: This study proposes more objective methods for deciding the appropriate direction of the sylvian fissure dissection during surgical clipping in middle cerebral artery (MCA) bifurcation aneurysms. METHODS: We reviewed data of 36 consecutive patients with MCA bifurcation aneurysms. We measured 2 indices preoperatively on 3-dimensional computed tomography angiography (3D-CTA). Analysis of the calculated data allowed us to select the appropriate direction of sylvian fissure dissection for ease of proximal control of M1. Statistically, Mann-Whitney test was used. RESULTS: We classified subjects into 2 groups based on the technical level of M1 exposure during surgical clipping. When it was difficult to expose M1, subjects were assigned to Group I, and Group II were subjects in whom M1 exposure was easy. The mean difference between the distances extending from the limbus sphenoidale (LS) line to the internal carotid artery bifurcation and extending from the LS line to the MCA bifurcation was 1.00 +/- 0.42 mm in group I and 4.39 +/- 2.14 mm in group II. The mean M1 angle was 9.36 +/- 3.73degrees in the group I and 34.05 +/- 16.71degrees in the group II (M1 slope gap p < 0.05, M1 angle p < 0.05). CONCLUSION: We have found an objective method for preoperatively verifying ease of exposure of M1 artery during surgical clipping. Therefore, we suggest use of the preoperative M1 slope gap and M1 angle as indicators in 3D-CTA selecting the direction of sylvian fissure dissection for easy proximal control of M1.

Two Indices Affecting the Directions of the Sylvian Fissure Dissection in Middle Cerebral Artery Bifurcation Aneurysms

OBJECTIVE: This study proposes more objective methods for deciding the appropriate direction of the sylvian fissure dissection during surgical clipping in middle cerebral artery (MCA) bifurcation aneurysms. METHODS: We reviewed data of 36 consecutive patients with MCA bifurcation aneurysms. We measured 2 indices preoperatively on 3-dimensional computed tomography angiography (3D-CTA). Analysis of the calculated data allowed us to select the appropriate direction of sylvian fissure dissection for ease of proximal control of M1. Statistically, Mann-Whitney test was used. RESULTS: We classified subjects into 2 groups based on the technical level of M1 exposure during surgical clipping. When it was difficult to expose M1, subjects were assigned to Group I, and Group II were subjects in whom M1 exposure was easy. The mean difference between the distances extending from the limbus sphenoidale (LS) line to the internal carotid artery bifurcation and extending from the LS line to the MCA bifurcation was 1.00 +/- 0.42 mm in group I and 4.39 +/- 2.14 mm in group II. The mean M1 angle was 9.36 +/- 3.73degrees in the group I and 34.05 +/- 16.71degrees in the group II (M1 slope gap p < 0.05, M1 angle p < 0.05). CONCLUSION: We have found an objective method for preoperatively verifying ease of exposure of M1 artery during surgical clipping. Therefore, we suggest use of the preoperative M1 slope gap and M1 angle as indicators in 3D-CTA selecting the direction of sylvian fissure dissection for easy proximal control of M1.

An Early Comparative Analysis of the Use of Autograft Versus Allograft in Anterior Cervical Discectomy and Fusion

OBJECTIVE: The purpose of this study is to verify the usefulness of autograft versus allograft in the radiographic and clinical outcome in early period after the surgery. METHODS: We performed a retrospective review of 38 patients who had undergone one- or two-level anterior cervical discectomy and fusion (ACDF) with rigid anterior plate fixation from March 2006 to May 2009. Interbody graft materials were iliac autograft (n=17) or with allograft (n=21). Fusion rate and graft collapse rate were assessed by radiographic analysis and clinical outcome was based on Odom's criteria. RESULTS: In autograft group, 13 patients achieved successful bone fusion (65%), whereas 7 patients (31.8%) in allograft group. There was statistically significant between two groups (p0.05), but statistically significant in allograft group (p<0.05). Clinical outcome was excellent or good in 94.1% in autograft group, and 90.5% in allograft group. CONCLUSION: In study, anterior cervical interbody fusion with an allograft got a result of lower fusion rate and higher collapse rate compared with autograft in early period after surgery, and clinical outcome showed similar results in both groups.

Surgical Results and Risk Factors for Recurrence of Lumbar Disc Herniation

OBJECTIVE: Recurrent lumbar disc herniation has been defined as disc herniation at the same level, regardless of ipsilateral or contralateral herniation, with a pain-free interval greater than 6 months. The aim of this study is to analyze outcomes and identify the potential risk factors for recurrent lumbar disc herniation. METHODS: The authors retrospectively reviewed the cases of 178 patients who underwent open discectomy for single-level lumbar disc herniation. Visual analogue scales and modified Macnab criteria were used to compare the clinical outcomes between the recurrent group and the non-recurrent group. Sex, age, discectomy level, degree of disc degeneration, type of disc herniation, pain-free interval after first-operation, smoking status, and trauma were investigated as potential recurrence risk factors. RESULTS: Of the 178 patients for whom the authors were able to definitely assess symptomatic recurrence status, 18 patients (10.1%) underwent revision surgery for recurrent disc herniation. The most common level involved was L4-L5 (61%) and the mean period of time to recurrence was 18.7 months (6-61 months). There were 17 cases of ipsilateral herniation and 1 case of contralateral herniation. The types of herniation for which revision surgery was done were protrusion (3 cases), and transligamentous extrusion (14 cases). There were five excellent, eight good, and two fair results. CONCLUSION: Repeated discectomy for recurrent disc herniation produced unsatisfactory outcomes. Factors such as sex, type of disc herniation and traumatic events were found to be significant risk factors.

Effectiveness of Nicardipine for Blood Pressure Control in Patients with Subarachnoid Hemorrhage

OBJECTIVE: The purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH). METHODS: We prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure. RESULTS: The blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications. CONCLUSION: Nicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.

Intracranial Dural Arteriovenous Fistulas: Clinical Characteristics and Management Based on Location and Hemodynamics

OBJECTIVE: A dural arteriovenous fistula (DAVF) generally refers to a vascular malformation of the wall of a major venous sinus. These lesions have diverse symptoms according to the location and venous drainage, and require multidisciplinary treatment. We report on our experience and analyze the treatment outcome of intracranial DAVFs for a nine-year period. METHODS: Between January 2000 and December 2008, 95 patients with intracranial DAVFs were enrolled in this study. A retrospective review of clinical records and imaging studies of all patients was conducted. Endovascular embolization, surgical interruption, gamma knife stereotactic radiosurgery (GKS), or combinations of these treatments were performed based on clinical symptoms, lesion location, and venous drainage pattern. RESULTS: Borden type I, II, and III were 34, 48, and 13 patients, respectively. Aggressive presentation was reported in 6% of Borden type I, 31% of Borden type II, and 77% of Borden type III DAVFs, respectively, and DAVFs involving transverse, sigmoid, and superior sagittal sinus. Overall, the rate of complete obliteration was 68%. The complete occlusion rates with a combination treatment of endovascular embolization and surgery, surgery alone, and endovascular embolization were 89%, 86%, and 80%, respectively. When GKS was used with embolization, the obliteration rate was 83%, although it was only 54% in GKS alone. Spontaneous obliteration of the DAVF occurred in three patients. There were a few complications, including hemiparesis (in microsurgery), intracranial hemorrhage (in endovascular embolization), and facial palsy (in GKS). CONCLUSION: The hemorrhagic risk of DAVFs is dependent on the location and hemodynamics of the lesions. Strategies for treatment of intracranial DAVFs should be decided according to the characteristic of the DAVFs, based on the location and drainage pattern. GKS can be used as an optional treatment for intracranial DAVFs.

Endoscope-Assisted Microsurgical Removal of an Epidermoid Tumor within the Cavernous Sinus

Epidermoid tumor of the cavernous sinus is rare. The aim of this case report is to discuss the role of neuroendoscopes in the removal of such lesions. A 21-year-old man presented with 6-year history of progressive headache, diplopia, and visual disturbance. Work-up revealed an epidermoid tumor located in the right cavernous sinus. An extradural transcavernous approach was utilized via a traditional frontotemporal craniotomy with endoscopic assistance. The postoperative course was uneventful with immediate improvement of the patient's headache. Postoperative magnetic resonance imaging demonstrated complete removal of the tumor. There were no signs of recurrence during a 2-year follow-up period. The endoscope is a useful tool for removing epidermoid tumors from the cavernous sinus and enhances visualization of areas that would otherwise be difficult to visualize with microscopes alone. Endoscopes also help minimize the retraction of neurovascular structures.

Meningeal Layers Around Anterior Clinoid Process as a Delicate Area in Extradural Anterior Clinoidectomy : Anatomical and Clinical Study

OBJECTIVE: Removal of the anterior clinoid process (ACP) is an essential process in the surgery of giant or complex aneurysms located near the proximal internal carotid artery or the distal basilar artery. An extradural clinoidectomy must be performed within the limits of the meningeal layers surrounding the ACP to prevent morbid complications. To identify the safest method of extradural exposure of the ACP, anatomical studies were done on cadaver heads. METHODS: Anatomical dissections for extradural exposure of the ACP were performed on both sides of seven cadavers. Before dividing the frontotemporal dural fold (FTDF), we measured its length from the superomedial apex attached to the periorbita to the posterolateral apex which connects to the anterosuperior end of the cavernous sinus. RESULTS: The average length of the FTDF on cadaver dissections was 7 mm on the right side and 7.14 mm on the left side. Cranial nerves were usually exposed when cutting FTDF more than 7 mm of the FTDF. CONCLUSION: The most delicate area in an extradural anterior clinoidectomy is the junction of the FTDF and the anterior triangular apex of the cavernous sinus. The FTDF must be cut from the anterior side of the triangle at the periorbital side rather than from the dural side. The length of the FTDF incision must not exceed 7 mm to avoid cranial nerve injury.

Spontaneous Cervical Epidural Hematoma Causing Brown-Sequard Syndrome

Spontaneous cervical epidural hematoma (SCEH) is a rare clinical entity and has a varied etiology. Urgent surgical decompression should be done to prevent serious permanent neurologic deficits. We describe a 59-year-old female who presented with Brown-Sequard syndrome due to spontaneous cervical epidural hematoma. Initially, she was misdiagnosed as cerebrovascular accident. Cervical magnetic resonance imaging revealed epidural hematoma to the right of the spinal cord extending from C3 to C6. She later underwent surgical evacuation and had complete restoration of neurologic function. The outcome in SCEH is essentially determined by the time taken from onset of the symptom to operation. Therefore, early and precise diagnosis such as careful history taking and MRI evaluation is mandatory.

Transcavernous Approach for Invasive Pituitary Adenoma

OBJECTIVE: Surgical management of invasive pituitary tumor is challengeable with conventional transsphenoidal approach(TSA) or pterional intradural approach alone. Gross total resection of pituitary adenoma influences its prognosis favorably, so transcavernous approach(TCA) is essential in invasive pituitary tumor. This study is performed to evaluate and analyze the surgical results of TCA in cases of invasive pituitary adenoma. METHODS: From November 1995 to May 2002, nine cases of invasive pituitary adenoma were treated. The authors reviewed medical records and radiological findings. Pterional transzygomatic or orbitozygomatic transcavernous approach was selected for tumors extended below or above the third ventricle floor respectively and intradural removal of tumor with suprasellar extension was combined. Surgical results including hormonal function, recurrence, completeness of tumor resection, and postoperative complications were evaluated and analyzed. RESULTS: Eight patients were treated with TSA followed by TCA and one with TCA alone. Total resection was achieved in seven cases, subtotal resection in one, and partial resection in one. Postoperative complications included temporary third nerve palsy in four cases and facial paresthesia in two. There was no recurrence during follow-up period. CONCLUSION: Transcavernous approach alone or combined with TSA is essential surgical procedure for total removal of invasive pituitary adenomas with acceptable morbidities.

Selection of the Surgical Approach of the Aneurysms around the Vertebrobasilar Junction: New Surgical Option Based on Angiogram / 대한뇌혈관외과학회지

No abstract available.

Multiple Dissecting Aneurysms of the PICA Trunk: Case Report

A patient with multiple dissecting aneurysms of a posterior inferior cerebellar artery trunk who presented with SAH is reported. A 58-year-old woman presented with sudden occipital headache, dizziness and vomiting. The intial vertebral angiography revealed a suspicious pearl and string sign at the proximal posterior inferior cerebellar artery(PICA) segment. After 2 weeks , follow up angiography showed a progression of the proximal PICA dissection and newly developed dissecting aneurysm of the distal PICA segment. A far lateral suboccipital transcondylar appoach confirmed two dissecting aneurysms at distant sites of the PICA trunk. The dissection segments were wrapped with muslin wrap , which preserved the flow through the PICA and brain stem perforators. The angiographys at 3 weeks and 6 months after operation revealed serial disappearance of the dissecting aneurysms which is distal to proximal. The diagnosis , course and treatment of the dissecting aneurysms of the PICA are discussed with literature review.

Far Lateral Approaches for Intracranial Aneurysms / 대한뇌혈관학회지

Surgical approaches to the posterior circulation aneurysms are difficult and still remained as a matter of debate. Many skull base approaches has been developed to overcome the inadequate exposure of these aneurysm by conventional surgical approaches. Far lateral approaches are an extension of suboccipital approach to expose neurovascular structures around the lower clivus. Aneurysms locating at the vertebral arteries, vertebrobasilar junction and lower basilar artery could be exposed by these approach. However, it is not still evident which kind of far lateral approach is most appropriate for the aneurysms of various locations at these vascular territory. Among the 3 kinds of far lateral approaches, such as far lateral, far lateral transcondylar and extreme lateral transcondylar approach, far lateral approach is not recently used frequently. Far lateral transcondylar approach is good far the aneurysm at the origin of posterior inferior cerebellar artery and the extreme lateral transcondylar approach is useful to expose aneurysms around vertebrobasilar junction. For an appropriate selection of surgical approaches, useful surgical guidelines are mandatory. The recent use of "intermeatal line" and "K lines" and others are of many help for the lower basilar and vertebral artery aneurysms. Surgical approach itself needs knowledge and experience for an adequate performance. Once exposed appropriately manipulation of aneurysms at these locations are not very complicated. Microsurgical anatomy of each surgical step is essential for the sucessful management of aneurysms locating at the lower clivus.

Non-Watertight Intermittent Dural Closure in Neurological Surgery

No abstract available.

Hypothalamic Ganglioglioma: Case Report

No abstract available.