Computed Tomography Radiomics for Preoperative Prediction of Spread Through Air Spaces in the Early Stage of Surgically Resected Lung Adenocarcinomas

Purpose@#To assess the added value of radiomics models from preoperative chest CT in predicting the presence of spread through air spaces (STAS) in the early stage of surgically resected lung adenocarcinomas using multiple validation datasets. @*Materials and Methods@#This retrospective study included 550 early-stage surgically resected lung adenocarcinomas in 521 patients, classified into training, test, internal validation, and temporal validation sets (n=211, 90, 91, and 158, respectively). Radiomics features were extracted from the segmented tumors on preoperative chest CT, and a radiomics score (Rad-score) was calculated to predict the presence of STAS. Diagnostic performance of the conventional model and the combined model, based on a combination of conventional and radiomics features, for the diagnosis of the presence of STAS were compared using the area under the curve (AUC) of the receiver operating characteristic curve. @*Results@#Rad-score was significantly higher in the STAS-positive group compared to the STAS-negative group in the training, test, internal, and temporal validation sets. The performance of the combined model was significantly higher than that of the conventional model in the training set {AUC: 0.784 [95% confidence interval (CI): 0.722–0.846] vs. AUC: 0.815 (95% CI: 0.759–0.872), p=0.042}. In the temporal validation set, the combined model showed a significantly higher AUC than that of the conventional model (p=0.001). The combined model showed a higher AUC than the conventional model in the test and internal validation sets, albeit with no statistical significance. @*Conclusion@#A quantitative CT radiomics model can assist in the non-invasive prediction of the presence of STAS in the early stage of lung adenocarcinomas.

Iatrogenic mixed pial and dural arteriovenous fistula after pterional approach for surgical clipping of aneurysm: A case report

Craniotomy is known as a cause of iatrogenic dural cerebral arteriovenous fistula (AVF). However, mixed pial and dural AVFs after craniotomy are extremely rare and require accurate diagnosis and prompt treatment due to their aggressiveness. We present a case of an iatrogenic mixed pial and dural AVF diagnosed 2 years after pterional craniotomy for surgical clipping of a ruptured anterior choroidal aneurysm. The lesion was successfully treated using single endovascular procedure of transvenous coil embolization through the engorged vein of Labbe and the superficial middle cerebral vein. The possibility of the AVF formation after the pterional approach should always be kept in mind because it usually occurs at the middle cranial fossa, which frequently has an aggressive nature owing to direct cortical venous or leptomeningeal drainage patterns. This complication is believed to be caused by angiogenetic conditions due to coagulation, retraction, and microinjuries of the perisylvian vessels, and can be prevented by performing careful sylvian dissection according to patient-specific perisylvian venous anatomy.

Breast Cancer to Meningioma: A Rare Case of Tumor-to-Tumor Metastasis

Tumor-to-tumor metastasis (TTM) is defined as the hematogenous metastasis within a primary host tumor from a donor neoplasm. Since there is insufficient evidence regarding the pathophysiology, clinical course, and management of TTM, there are no precise guidelines for its management. A 73-yearold female patient diagnosed with breast cancer was found to have convexity meningioma. Since the size of tumor and peritumoral brain edema increased during follow-up period, the meningioma was treated with surgical resection. Postoperatively, histopathologic examination confirmed metastasis of invasive ductal carcinoma within a secretory meningioma. The final diagnosis was TTM of breast cancer in meningioma. Here, we report a rare case of intra-meningioma metastasis and a review of literature to provide a better understanding of this rare phenomenon.

Efficacy of 3D-printed simulation models of unruptured intracranial aneurysms in patient education and surgical simulation

Objective@#The purpose of this study was to determine the efficacy of a 3D-printed aneurysm simulation model (3DPM) in educating patients and improving physicians’ comprehension and performance. @*Methods@#This prospective study involved 40 patients who were diagnosed with unruptured intracranial aneurysms (UIAs) and scheduled for surgical clipping or endovascular coiling and randomly divided into two groups (the 3DPM group and the non-3DPM group). The 3DPM was used in preoperative consultation with patients and intraoperatively referenced by surgeons. The patients, 7 neurosurgical residents, and 10 surgeons completed questionnaires (5-point Likert scale) to determine the usefulness of the 3DPM. @*Results@#Patients in the 3DPM group had significantly higher scores in terms of their understanding of the disease (mean 4.85 vs. 3.95, p<0.001) and the treatment plan (mean 4.85 vs. 4.20, p=0.005) and reported higher satisfaction during consultation (5.0 vs. 4.60, p=0.036) than patients in the non-3DPM group. During patient consultation, 3DPMs were most useful in improving doctor–patient communication (mean 4.57, range 4-5). During clipping surgery, the models were most useful in assessing adjacent arteries (mean 4.9, range 4-5); during endovascular coiling, they were especially helpful in microcatheter shaping (mean 4.7, range 4-5). @*Conclusions@#In general, 3DPMs are beneficial in educating patients and improving the physician’s performance in terms of surgical clipping and endovascular coiling of UIAs.

Natural course of chronic subdural hematoma following surgical clipping of unruptured intracranial aneurysm by pterional approach

Objective@#Chronic subdural hematoma (CSDH) is a neurological complication following clipping surgery. However, the natural course and ideal approach for the treatment of clipping-related-CSDH (CR-CSDH) have not been clearly established. We aimed to investigate the course of CR-CSDH using chronological radiological findings. @*Methods@#We performed a retrospective analysis of 28 (3.8%) patients who developed CSDH among 736 patients who underwent surgical clipping using pterional approach for unruptured aneurysms at our institution between December 2010 and December 2018. Patients underwent follow-up CT scan 6–8 weeks after clipping surgery and decision to pursue surgical intervention rests upon the patient’s symptom based on the Markwalder’s grading scale (MGS) and numeric rating scale (NRS). @*Results@#Of the 28 patients, 3 patients (10.7%) underwent surgery, while 25 (89.2%) showed spontaneous resolution of CR-CSDH. Eighteen patients (64.2%) had mild headache with MGS of 0–1. The mean maximum hematoma volume was 41.9±30.9 ml (5.8–135 ml), and 26 patients (92.8%) had homogeneous hematoma. The mean time to hematoma resolution was 126.7±52.9 days (46–228 days). Comparing group of CR-CSDH volume ≥43 ml or a midline shift ≥5 mm, the difference in presence of linear low-density area (p=0.002) and age (p=0.026) between the conservative and operative groups were found to be statistically significant. @*Conclusions@#Most CR-CSDH cases spontaneously resolved within 4 months. Therefore, we suggest that close observation should be performed if patient’s symptoms are mild and special radiologic findings are present, despite its relatively large volume and midline shifting.

The Role of Adjuvant Therapy Following Surgical Resection of Small Cell Lung Cancer: A Multi-Center Study / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This multi-center, retrospective study was conducted to evaluate the long-term survival in patients who underwent surgical resection for small cell lung cancer (SCLC) and to identify the benefit of adjuvant therapy following surgery. @*Materials and Methods@#The data of 213 patients who underwent surgical resection for SCLC at four institutions were retrospectively reviewed. Patients who received neoadjuvant therapy or an incomplete resection were excluded. @*Results@#The mean patient age was 65.29±8.93 years, and 184 patients (86.4%) were male. Lobectomies and pneumonectomies were performed in 173 patients (81.2%), and 198 (93%) underwent systematic mediastinal lymph node dissections. Overall, 170 patients (79.8%) underwent adjuvant chemotherapy, 42 (19.7%) underwent radiotherapy to the mediastinum, and 23 (10.8%) underwent prophylactic cranial irradiation. The median follow-up period was 31.08 months (interquartile range, 13.79 to 64.52 months). The 5-year overall survival (OS) and disease-free survival were 53.4% and 46.9%, respectively. The 5-year OS significantly improved after adjuvant chemotherapy in all patients (57.4% vs. 40.3%, p=0.007), and the survival benefit of adjuvant chemotherapy was significant in patients with negative node pathology (70.8% vs. 39.7%, p=0.004). Adjuvant radiotherapy did not affect the 5-year OS (54.6% vs. 48.5%, p=0.458). Age (hazard ratio [HR], 1.032; p=0.017), node metastasis (HR, 2.190; p < 0.001), and adjuvant chemotherapy (HR, 0.558; p=0.019) were associated with OS. @*Conclusion@#Adjuvant chemotherapy after surgical resection in patients with SCLC improved the OS, though adjuvant radiotherapy to the mediastinum did not improve the survival or decrease the locoregional recurrence rate.

Middle temporal vein access for transvenous embolization of Cavernous sinus dural arteriovenous fistula: A case report and review of literature

Transvenous endovascular treatment is the first choice for treating most cavernous sinus dural arteriovenous fistulas (CDAVFs). Among several available venous routes, the inferior petrosal sinus is the most commonly used. We report a case of CDAVF treated with endovascular treatment via the middle temporal vein (MTV). A 65-year-old man presented with unilateral chemosis and exophthalmos for approximately two months. Digital subtraction angiography showed a right CDAVF with predominant venous drainage toward the right superior ophthalmic vein. The superior ophthalmic vein primarily drained into the dilated MTV. Both sides of the inferior petrosal sinus were occluded; therefore, transvenous embolization was performed via the MTV route. The fistula was completely obliterated. The patient’s symptoms improved and the postoperative course was uneventful. The transfemoral approach via the MTV to treat CDAVF provides a crucial alternative when other venous routes are difficult or impossible to navigate with a catheter.

The effectiveness of systemic and endovascular intra-arterial thrombectomy protocol for decreasing door-to-recanalization time duration

Objective@#Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization. @*Methods@#A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration. @*Results@#Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p＞0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p＜0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p＞0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p＜0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p＜0.05), and 79.1±47.5 vs. 58.4±75.3 (p＜0.05) in three steps, respectively. @*Conclusions@#We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.

Rapid-Growing Intracranial Immature Teratoma Presenting Obstructive Hydrocephalus and Abducens Nerve Palsy: A Case Report and Literature Review

Intracranial immature teratoma is an extremely rare disease with poor prognosis and requires complicated treatment. Owing to the deep midline location of the tumor, total surgical resection of the tumor is challenging. We present our experience with a fast-growing pineal gland immature teratoma in a 4-year-old boy, who presented with obstructive hydrocephalus and abducens nerve palsy, which was treated with total surgical resection of the tumor. In addition, we aimed to determine the appropriate treatment modality for intracranial immature teratomas by reviewing the literature and investigating the prognosis.

Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency

Objective@#The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms. @*Methods@#A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. @*Results@#Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy. @*Conclusions@#We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

Cervical spinal extradural arteriovenous fistula successfully treated using transarterial balloon-assisted coil embolization

We present the case of a patient who developed compressive radiculopathy that was found to be associated with a spinal extradural arteriovenous fistula. The fistula was successfully obliterated with transarteiral balloon-assisted coiling, after which the patient was symptom-free. Although spinal extradural arteriovenous fistula is rare, this pathology should be considered in the differential diagnosis of spinal radiculopathy or myelopathy. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

Factors Affecting the Number of Stapler Cartridges in Complete Video-Assisted Thoracoscopic Surgery Lobectomy for Non-small Cell Lung Cancer

Background@#Video-assisted thoracoscopic surgery (VATS) lobectomy has become the major surgical option for the treatment of non-small cell lung cancer (NSCLC). Endoscopic instruments such as stapler cartridges are essential for VATS procedures. In this study, we investigated the factors that affect the number of stapler cartridges used in VATS lobectomy. @*Methods@#A retrospective analysis was conducted of patients who underwent complete VATS lobectomy for NSCLC from January 2013 to December 2015. @*Results@#In total, 596 patients underwent complete VATS lobectomy. The average number of stapler cartridges used for VATS lobectomy was 5.3±1.9. The number of stapler cartridges used for VATS lobectomy was higher in men (5.5±1.9 vs. 5.0±18, p=0.006), those aged older than 70 years (5.5±2.1 vs. 5.1±1.7, p=0.038), those who underwent upper or middle lobectomy procedures (5.7±1.9 vs. 4.1±1.2, p<0.001), those with a higher fissure sum average (p<0.001), and those in whom surgery was performed by a surgeon with a preference for staplers (5.6±2.0 vs. 4.9±1.6, p<0.001). @*Conclusion@#The number of stapler cartridges required to perform VATS lobectomy in NSCLC patients appears to be influenced by sex, age, the location of the tumor, the degree of fissure development, and the surgeon’s preference.

Petrous Carotid Aneurysm Causing Pulsatile Tinnitus: Case Report and Review of the Literature

We present the case of a patient who developed pulsatile tinnitus that was found to be associated with a petrous carotid aneurysm. The aneurysm was successfully obliterated using stent-assisted coiling, after which the patient was symptom-free. Although aneurysms arising from the petrous segment of the internal carotid artery are rare, this pathology must be considered as a causative factor in patients with pulsatile tinnitus. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

Predisposing Factors and Clinical Impact of Linear Intracrania l Calcification Following External Ventricular Drainage / 계명의대학술지

External ventricular drainage (EVD) is a common procedure performed in neurosurgical field. The purpose of this study was to introduce the linear intracranial calcification formed along EVD tract and to investigate its incidence, predisposing factors, and clinical impact. A total of 59 patients who underwent EVD insertion over a 1-year period were included in this study. The clinical factors and radiographic features between the occurrence and the non-occurrence groups were analyzed to investigate the predisposing factors and clinical impact related to the linear intracranial calcification in EVD tract. The linear intracranial calcification following EVD insertion occurred in 7 patients (11.9%). Among various risk factors assessed, only usage of bone dust (p =0.003) had contributed to linear intracranial calcification with statistical significance in univariate logistic regression analysis. Housefield unit (HU) scale was different between calcification (872.57 ± 46.15 HU) and EVD catheter (169.00 ± 61.35 HU). This study indicates that using bone dust for sealing a burr hole is the only predisposing factor for linear intracranial calcification formed in EVD tract.

Kissing Aneurysms at Fenestrated Proximal Basilar Artery: Double-barrel Stent-assisted Coiling Using Dual Closed-cell Stents

Kissing aneurysms associated with a proximal basilar artery fenestration are an exceedingly rare and unique therapeutic challenge due to anatomical complexity. This report describes double-barrel stent-assisted technique with dual closed-cell stents for the successful endovascular coiling of kissing aneurysms from a proximal basilar artery fenestration.

Surgical Repair of a Traumatic Tracheobronchial Injury in a Pediatric Patient Assisted with Venoarterial Extracorporeal Membrane Oxygenation

Tracheobronchial rupture due to blunt chest trauma is a rare but life-threatening injury in the pediatric population. Computed tomography (CT) is not always reliable in the management of these patients. An additional concern is that ventilation may be disrupted during surgical repair of these injuries. This report presents the case of a 4 -year-old boy with an injury to the lower trachea and carina due to blunt force trauma that was missed on the initial CT scan. During surgery, he was administered venoarterial extracorporeal membrane oxygenation (ECMO). Although ECMO is not generally used in children, this case demonstrated that the short-term use of ECMO during pediatric surgery is safe and can prevent intraoperative desaturation.

Surgical Repair of a Traumatic Tracheobronchial Injury in a Pediatric Patient Assisted with Venoarterial Extracorporeal Membrane Oxygenation

Tracheobronchial rupture due to blunt chest trauma is a rare but life-threatening injury in the pediatric population. Computed tomography (CT) is not always reliable in the management of these patients. An additional concern is that ventilation may be disrupted during surgical repair of these injuries. This report presents the case of a 4 -year-old boy with an injury to the lower trachea and carina due to blunt force trauma that was missed on the initial CT scan. During surgery, he was administered venoarterial extracorporeal membrane oxygenation (ECMO). Although ECMO is not generally used in children, this case demonstrated that the short-term use of ECMO during pediatric surgery is safe and can prevent intraoperative desaturation.

Predicting Factors of Chronic Subdural Hematoma Following Surgical Clipping in Unruptured and Ruptured Intracranial Aneurysm

OBJECTIVE: The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA). METHODS: We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data. RESULTS: The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ≥5 mm and male sex in the UIA and A high HF unit for SFC and SFC ≥5 mm without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05). CONCLUSION: There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ≥5 mm were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ≥5 mm at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.

Combined Bilateral Lung Transplantation and Off-Pump Coronary Artery Bypass

Coronary artery disease has historically been a contraindication to lung transplantation. We report a successful combined bilateral lung transplantation and off-pump coronary artery bypass in a 62-year-old man. The patient had a progressive decline in lung function due to idiopathic pulmonary fibrosis and a history of severe occlusive coronary artery disease.

Successful Management of Delayed Esophageal Rupture with T-Tube Drainage Using Video-Assisted Thoracoscopic Surgery

Spontaneous perforation of the esophagus after forceful vomiting is known as Boerhaave syndrome, a rare and life-threatening condition associated with a high rate of mortality. The management of Boerhaave syndrome is challenging, especially when diagnosed late. Herein, we report the successful management of late-diagnosed Boerhaave syndrome with T-tube drainage in a 55-year-old man. The patient was transferred to our institution 8 days after the onset of symptoms, successfully managed by placing a T-tube, and was discharged on postoperative day 46 without complications.