Surgical Management of Unruptured Intracranial Anerysms

Nah, Jong Han,Kim, Jung Hoon,Kim, Chang Jin,Kwon, Yang,Rhim, Seung Chul,Lee, Jung Kyo,Kwun, Byung Duck,Whang, Jin 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.3

새로운 진단방사선기술의 개발에 의한 두 개강내 비파열 뇌동맥류의 발견이 증가함에 따라 이에 대한 치료가 중요하게 되었다. 그러나 여전히 비파열 뇌동맥류에 대한 수술적 치료는 논쟁거리로 남아있어, 특별한 치료없이 경과를 관찰할지, 혈관내색전술을 시행할지, 또는 미세현미경학적 수술을 시행할지 아직 명확한 기준이 뚜렷치 않다. 이에 저자들은 1989년 6월부터 1995년 5월까지 비파열 뇌동맥류로 본원 신경외과에 입원하여 수술적 치료를 받았던 41예에 환자들을 대상으로 수술 결과에 영향을 미칠 수 있는 요인들을 분석하여 보았다. 이들의 발견동기를 incidental, multiple, 그리고 mass effect 등으로 구분하였을 때, 다른 파열 뇌동맥류에 의한 지주막하출혈의 뇌혈관조영술중 발견된 경우(multiple)가 가장 많았으며(19예), incidental하게 발견된 경우 및 mass effect로 발견된 경우가 각각 11예 이었다. 37예의 환자에서 direct neck clipping이 가능하였으며, 2예에서 trapping을 1예에서 wrapping을 시행하였다. 직경이 25㎜이상 되었던 1예의 vertebrobasialr artery aneurysm의 경우 적절한 치료를 시행할 수 없었다. Cranial nerve palsy, hemiparesis, major hemispheric swelling, hematoma 등의 합병증 등을 관찰할 수 있었다. 직경 25㎜ 이상되었던 1예의 proximal internal carotid artery aneurysm 수술후 major hemispheric infarction으로 사망하였으며, 또한 2예의 giant vertebrobasila artery aneurysms 수술후 결과가 불량하였다. 전체적인 수술결과는 양호하여 38예(92.7%)의 환자에서 excellent 또는 good outcome을 얻을 수 있었다. 뇌동맥류의 크기와 수술결과와 상당한 연관성이 관찰되어 직경이 25㎜ 이하인 비파열 뇌동맥류인 경우 100%에서 excellent 또는 good outcome을 얻을 수 있었으나, 직경이 25㎜ 이상인 경우 그 수술결과는 불량하여 75%에서 poor 또는 dead outcome을 관찰할 수 있었다. 저자들은 위험부담이 적은 비파열 뇌동맥류의 수술은 반드시 시행되어져야 한다고 생각하며, 뇌동맥류의 크기 및 위치가 수술결과에 영향을 미칠 수 있는 요인들이라고 생각한다. With the ever-increasing number of intact aneurysms revealed by modern imaging, the options for their management are assuming greater importance. The surgical management of patients with unruptured intracranial aneurysms continues to be controversial, and the criteria for withholding treatment or choosing between endovascular embolization and conventional microsurgery are not will delineated. In order to define the surgical result for unruptured intracranial aneurysms. 41 patients(from June 1989 to May 1995) with surgically treated unruptured aneurysms were analyzed. They were categorized as incidental, multiple or aneurysm with mass effect. Subarachnoid hemorrhage from another aneurysm(multiple) was the most common presentation(19 patients). Eleven patients were presented with incidental findings unrelated to aneurysmal subarachnoid hemorrhage or direct aneurysmal mass effect, and 11 patients were presented with mass effect such as cranial nerve palsy for brain stem compression. We could perform direct neck clipping with/without wrapping in 37 patients, trapping in 2, and wrapping in 1. One patient with giant vertebrobasilar artery aneurysm(greater than 25㎜ in diameter) which was presented with mass effect could not be treated adequately. Instances of morbidity included cranial nerve injury in 4 patients, hemiparesis in 3, hematoma in 2, and major hemispheric infarction in 1. One patient presented with mass effect, died from major hemispheric infarction after surgery of proximal internal carotid artery aneurysm with a size greater than 25㎜ in diameter. Two patients, who underwent surgery for giant vertebrobasilar artery aneurysms presented with mass effect, were in poor state due to persistent cranial nerve palsy and hemiparesis. In general overall outcome was very good. Excellent or good outcome was achieved in 38 patients(92.7%) while 3 patients(7.3%) either died or was/were in poor condition. The aneurysm size was correlated well with the surgical outcome. We have achieved excellent or good out comes in 100% of patients with aneurysms 25㎜ or less in diameter. However, with aneurysms greater than 25㎜ in diameter, the outcomes were very poor with 75% of these patients in poor state or dead. "Surgery in unruptured aneurysms?" The answer was "Yes". We believe the size and location of the aneurysm are the key predictions of risk for surgical morbidity.

수술전 임상등급이 좋은 뇌동맥류의 치료결과와 나쁜 예후의 원인

김창희,허승곤,정남,신문수,이광수 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.4

We analyzed the overall surgical results in 100 patients with intracranial aneurysms operated in Presbyterian. Medical Center during the period from June 1990 to December 1993. Preoperatively, all patients were in Hunt and Hess grades Ⅰ-Ⅲ. Overall outcomes revealed 83 patients(83%) of good outcome. 10 patients(10%) of fair outcome. 3 patients(3%) of poor outcoms. and 4 patients(4%) of dead outcome. The outcome was worse if surgery was performed in the 4 to 10 day post-bleed interval(P<0.05) and there was no statistical difference of the rate of good outcome between the patients operated at 0 to 3 days. and 11 day and more after subarachnoid hemorrhage. In good grade patients. surgical trauma rather than delayed ischemic deficit was considered as the major cause of unfavorable outcome of aneurysm surgery Intermediate period operation increased the chance of postoperative do-layed ischemic deficit Systemic complications and vasospasm were 4he major causes of dead outcome in the oldaged patients.

Anterior Choroidal Artery Aneurysm Surgery : Ischemic Complications and Clinical Outcomes Revisited

Lee, Young-Sup,Park, Jaechan The Korean Neurosurgical Society 2013 Journal of Korean neurosurgical society Vol.54 No.2

Objective : Surgical results for anterior choroidal artery (AChA) aneurysms have previously been reported as unsatisfactory due to inadvertent occlusion of the AChA, while the low incidence of AChA aneurysms hampers the accumulation of surgical experience. The authors reviewed their related surgical experience to document the ischemic complications and surgical outcomes. Methods : Identification of the AChA at its origin by rigorous visual scrutiny, careful microdissection, and meticulous clip placement to avoid the AChA origin are all crucial surgical maneuvers. A retrospective review of a surgical series of 62 consecutive cases of an AChA aneurysm between 2004 and 2012 was performed. Results : All patients, except for five (8.1%) with a small residual neck, showed complete aneurysm obliteration in postoperative angiographic evaluations. There was no incidence of procedure-related permanent AChA syndrome or oculomotor nerve palsy, while three (4.8%) patients suffered from transient AChA syndrome. The clinical outcomes [the 3-month modified Rankin Scale (mRS)] of the patients were related to their preoperative World Federation of Neurologic Surgeons (WFNS) grade. As regards the 3-month mRS, significant differences were found between patients with an unruptured aneurysm (WFNS grade 0; n=20), good-grade subarachnoid hemorrhage (WFNS grade 1-3; n=30), and poor-grade subarachnoid hemorrhage (WFNS grade 4-5; n=4). Conclusion : In surgical treatment of AChA aneurysms, a risk of AChA insufficiency can be minimized by taking every precaution to preserve the AChA patency and intraoperative monitoring. In addition, the surgical outcome is primarily determined by the preoperative clinical state.

Cervical Spondylotic Amyotrophy: Case Series and Review of the Literature

Toshiyuki Takahashi,Junya Hanakita,Manabu Minami,Yosuke Tomita,Tomoki Sasagasako,Ryo Kanematsu 대한척추신경외과학회 2019 Neurospine Vol.16 No.3

Objective: Cervical spondylotic amyotrophy (CSA) is a relatively rare entity caused by cervical degenerative spinal diseases and characterized by motor weakness accompanied by remarkable muscle atrophy in the upper extremities without significant sensory deficits or spastic paraparesis in the lower extremities. Postoperative outcomes and predictive prognostic factors vary among previous reports. In the present report, we describe the surgical results in patients who were surgically treated for CSA and present a literature review. Methods: In total, 33 patients with CSA were retrospectively analyzed. Correlations between the surgical outcome and the following factors were statistically analyzed: age, sex, type of impaired muscle, preoperative severity of motor weakness, number of levels of cord or root compression, presence of a T2 high-intensity area in the spinal cord, cervical kyphosis, and methods of surgical procedure. Results: On postoperative neurological evaluation, 25 patients (75.8%) had favorable outcomes and 8 had unfavorable outcomes (proximal type, 72.2%; distal type, 78.6%). Patients with favorable outcomes were significantly younger than those with unfavorable outcomes (p=0.013). Patient’s characteristics except for age and radiological factors were not correlated to surgical outcome. Conclusion: The present study focused on the surgical results in patients who were surgically treated for CSA along with updated information from a literature review. Improvement of motor weakness is expected with acceptable prevalence although higher age can be a negative factor. Surgical outcomes and predictive factors related to a poor prognosis were determined and compared with those of previous articles.

피질이형성증으로 인한 난치성 간질의 가지공명영상, 침습적 뇌파 및 병리소견과 간질수술결과의 비교연구

서대원,홍승봉 대한신경과학회 1999 대한신경과학회지 Vol.17 No.6

Surgical Outcomes of Kommerell Diverticulum

권영건,박성준,주석중,윤태진,이재원,김준범 대한흉부외과학회 2020 Journal of Chest Surgery (J Chest Surg) Vol.53 No.6

Background: We aimed to assess the clinical outcomes of patients who underwent sur- gical repair of Kommerell diverticulum (KD) with individualized surgical methods. Methods: A retrospective analysis was performed of adult patients (aged ≥17 years) who underwent surgery to treat KD between June 2008 and October 2019. Results: Nine patients (median age, 45 years; range, 19–67 years; 7 men) underwent sur- gical repair. The indications for surgical therapy were acute aortic dissection in 2 patients, the presence of compressive symptoms due to dilated KD in 4 patients, and aneurysm growth in 3 patients. Various surgical techniques were used: (1) resection of the divertic- ulum stump and revascularization of the aberrant subclavian artery (n=3), (2) one-stage total-arch replacement including the diverticulum segment (n=3), and (3) hybrid repair (n=3). Early mortality occurred in 1 case of hybrid repair. Transient paraparesis occurred in a patient who underwent total arch repair as part of complicated acute aortic dissection. During follow-up (median duration, 30 months; range, 7–130 months), no late death or associated aortic complications were documented. All survivors were free from symptoms and had no abnormal findings on follow-up computed tomography. Conclusion: With a customized surgical approach and appropriate consideration of pa- tient-specific anatomy and associated comorbidities, KD can be repaired with favorable outcomes.

임상 : 측뇌실 종양의 수술적 치료 결과 및 합병증

유남훈 ( Nam Hoon Yoo ),한성록 ( Seong Rok Han ),윤상원 ( Sang Won Yoon ),이기택 ( Gi Taek Yee ),최찬영 ( Chan Young Choi ),손문준 ( Moon Jun Sohn ),황충진 ( Choong Jin Whang ) 대한뇌종양학회 2005 대한뇌종양학회지 Vol.4 No.2

Object￡ºLateral ventricular tumors are rare lesion of the central nervous system. We conducted a retrospective study of patients with these lesion treated on surgically. Methods￡ºTotal 9 cases of lateral ventricular tumors, who underwent operative removal between 2001 and 2004 at our hospital were reviewed. There were 3 cases located in the trigone, 3 in the frontal horn, and 3 in the ventricular body. Tumors were removed by various surgical approaches according to the location of tumors. Transcortical approach was used in 7 patients, and transcallosal approach was used in 2 patients. Results￡ºTotal resection was performed in 6 patients. Surgical complications included epidural hematoma, subdural hygroma, intracranial hemorrhage, and seizure. Seven patients were achieved good recovery. Conclusion￡ºTo improve surgical outcome and to avoid complications, proper knowledge of intraventricular anatomy and selection of an appropriate surgical approach are needed.

Surgical Treatment of Unruptured Intracranial Middle Cerebral Artery Aneurysms: Angiographic and Clinical Outcomes in 143 Aneurysms

Seung Won Choi,안재성,Jung Cheol Park,권도훈,Byung Duk Kwun,김창진 대한뇌혈관외과학회 2012 Journal of Cerebrovascular and Endovascular Neuros Vol.14 No.4

Objective:The purpose of this study was to determine the outcomes of surgical clipping in patients with unruptured middle cerebral artery (MCA) aneurysms. Methods:A retrospective single-center database of 125 consecutive patients with 143 small MCA aneurysms (< 10 mm) who underwent surgical clipping was reviewed from January 2007 to December 2010. Clinical outcomes were assessed based on surgery-related complications and follow-up (mean: 17 months) using the modified Rankin scale (mRS). Angiographic outcomes were evaluated by conventional angiography (N = 96) or computed tomography angiography (N = 29) at postoperative weeks 1 and 6. Results:There were no cases of mortality. There were three surgery-related complications (intracranial hemorrhage, meningitis and wound infection, respectively). The hemorrhagic event caused transient neurological deficits. All patients showed good clinical outcomes during follow-up (mRS 0-1). There was angiographic evidence of complete occlusion in 137 aneurysms (95.8%), a small residual neck in three aneurysms (2.2%) and partial for three aneurysms. In the three cases with partial clipping, the decision was made preoperatively to leave the residual sac to maintain distal flow, and muscular wrapping was performed. Conclusion:Our study demonstrates that surgical clipping of unruptured small MCA aneurysms yields favorable clinical and angiographic outcomes. Aneurysmal clipping can be safely recommended for patients with small unruptured MCA aneurysms.

성장호르몬분비 뇌하수체 선종 80예의 수술성적 및 예후 인자의 분석

김정은,정희원,곽호신,백선하,김동규,최길수,Kim, Jeong Eun,Jung, Hee-Won,Gwak, Ho-Shin,Paek, Sun Ha,Kim, Dong Gyu,Choi, Kil Soo 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.6

Objectives : The surgical results of 80 patients with growth hormone(GH)-producing pituitary adenoma were analyzed retrospectively to evaluate the clinical manifestations and to determine which preoperative factors significantly influenced the surgical outcome. Patients and Methods : The patients consisted of 39 men and 41 women and the age of patients at the time of initial operation ranged from 17 to 67 years(mean age, 40.5 years) Between January 1990 and June 1996, 77 patients underwent transsphenoidal surgery and 3 patients underwent craniotomy for GH-producing pituitary adenoma at our institution. Preoperative administration of octreotide was performed in 18 patients. Surgical control was defined as a postoperative serum basal level of GH less than 5ng/ml. A logistic regression model was used for univariate and multivariate analysis. Probability value of less than 0.05 was considered as statistically significant. Results : The most common presenting symptom was acromegaly, followed by headache, visual disturbance, and fatigability. Visual symptoms were present in 39% of the patients. Diabetes mellitus was associated in 24 patients and hypertension in 12. Preoperative mean basal level of GH was 93.2ng/ml(range 72-500ng/ml) which was closely related with tumor size(p<0.05). Grade II by Hardy's classification was the most common radiological type. Preoperative octreotide treatment significantly reduced the level of GH(p<0.05), but not enough to induce endocrinological remission. One patient died of cerebral infarction after craniotomy. The most common surgical complication was transient diabetes insipidus. The symptom of the earliest improvement after surgery was paresthesia and tightness of the hand and foot, followed by headache and easy fatigability. The preoperative visual symptom was improved in all patients. The patients who had hypertension or DM experienced alleviated symptoms in 67% and 92%, respectively. The overall rate of endocrinological remission was 44%. By multivariate logistic regression analysis, the size of tumor, extrasellar extension, and extent of removal were significant prognostic factors for endocrinologial remission. Conclusion : Early detection of a small tumor without extrasellar extension followed by a complete resection is highly recommended in order to achieve endocrinological cure of GH-producing pituitary adenomas.

Surgical Strategy for Skull Base Chordomas : Transnasal Midline Approach or Transcranial Lateral Approach

Wang, Benlin,Li, Qi,Sun, Yang,Tong, Xiaoguang The Korean Neurosurgical Society 2022 Journal of Korean neurosurgical society Vol.65 No.3

Objective : The clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. Methods : We retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. Results : Among the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. Conclusion : The EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.