While stereotactic biopsy increases the accuracy of obtaining appropriate tissue for precise diagnosis, inconclusive diagnostic lesions can still be observed frequently. We present a review of 43 patients with inconclusive diagnostic samples in stereotactic biopsy between June 1989 and June 1994. inconclusive diagnostic lesions were found in 43 patients(17.9%); the biopsy of these patients showed reactive gliosis in 22, foam cell infiltration and/or demyelination with coagulation necrosis in 8, chronic inflammatory cell infiltration with necrosis, fibrosis in 6, no evidence of tumor in 5, and ganglioglial lesion in 2. The final diagnosis was based on histological findings of permanent paraffin sections after rebiopsy or open surgery, close follow-up CT/MRI scan findings, clinical features and/or history, and serological studies;neoplasm 16, infarction/leukodystrophy 8, infection/inflammation 4, granuloma 1, and no confirmative diagnosis 4, In conclusion, rebiopsy or open surgery is recommended if the lesion is suspected to be a neoplasm, and the patient is closely observed with repeated radiological studies if the lesion is suspected to be benign. This study provides evidence that in some cases an accurate histopathological diagnosis can not be made with stereotactic biopsy and therefore, further investigations are needed in such inconclusive cases.
Biopsy* ; Demyelinating Diseases ; Diagnosis ; Fibrosis ; Foam Cells ; Follow-Up Studies ; Gliosis ; Granuloma ; Humans ; Necrosis ; Paraffin

The treatment of choice for symptomatic pituitary adenomas varies according to the hormone secreting types of the adenoma and can include pharmacology, surgery, or radiotherapy. The recent development of radiological imaging and microsurgery has made surgery the treatment of choice for most pituitary tumors. However, the long-term tumor control rate after microsurgery varies from 50% to as high as 80%. During the last 38 months(1990. 5-1990. 9., 1991. 5-1994. 2), 34 cases of pituitary adenomas were treated by gamma knife at Asan Medical Center. There were 11 cases of prolactinomas, 9 cases of acromegaly, 8 cases of ACTH-secreting tumors and 6 cases of non-functioning tumors. Seventeen patients underwent gamma knife radiosurgery for recurrent or remaining tumors after resective surgery. Another 17 patients were treated primarily with gamma knife. In microadenomas, the mean tumor volume was 221 cumm and the mean marginal dose was 33.1 Gy. In microadenomas, the mean tumor volume was 2690 cumm and the mean marginal dose was 2.6 Gy. Twenty-seven patients have had an average follow-up period of 26 months with a range from 3 to 48 months. As a result, five out of eight prolactinoma patients had normalization of prolactin hypersecretion and seven patients showed clinical cure. On follow-up imaging studies, five out of seven tumors showed no changes in their size, while two showed marked reduction. Two out of four ACTH-producing tumor patients showed normalization of 24 hour urine cortisol levels. On follow-up imaging studies of the two cases, the tumor of one patient disappeared and the other one showed no change. Three out of six acromegalic patients showed clinical responses. Two out of five non-functiong tumors showed reduction in size and three showed no changes. In conclusion, gamma knife radiosurgery seems to be effective as adjuvant therapy for the treatment of remaining or recurrent pituitary adenomas after surgery and primary treatment modality in selective patients.
Acromegaly ; Adenoma ; Chungcheongnam-do ; Follow-Up Studies ; Humans ; Hydrocortisone ; Microsurgery ; Pharmacology ; Pituitary Neoplasms* ; Prolactin ; Prolactinoma ; Radiosurgery* ; Radiotherapy ; Tumor Burden

Between May 1990, and June 1994, 79 patients with malignant tumors were treated radiosurgically using a Leksell gamma unit at Asan Medical Center. Of these patients, 57 were metastatic brain tumor, 12 were glioblastoma multiforme (GM), 4 were primitive neuroectodermal tumor, 3 were malignant germ cell tumor, 2 were recurrent lymphoma, and 1 was adenoid cystic carcinoma of the orbit. Among 57 patients with metastatic tumors, 28 patients harboring 60 tumors were followed clinically and radiographically. The median marginal dose for these tumors was 30 Gy and the median survival rate was 15 months. Twenty-one tumors disappeared and 32 tumors decreased in size during 2 to 6 months after radiosurgery on computed tomographic or magnetic resonance imaging scans. All 12 patients with GM were treated with conventional radiation (6,240 approximately 6,500 cGy) after surgical resection or biopsy prior to radiosurgery (13 approximately 15 Gy to margin). The results were varied. Radiosurgical treatment of two recurrent lymphomas and three recurrent mixed germ cell tumors after radiation and chemotherapy provided rapid clinical improvement with disappearance of the tumor. However, new lesions appeared in two lymphomas and one mixed germ cell tumor within 3 to 4 months. One patient with adenoid cystic carcinoma of the orbit, who was treated radiosurgically prior to resection, is alive without recurrence 31 months after the treatment. Gamma knife radiosurgery appears to be the best alternative method to surgical excision plus radiation therapy for single and multiple cerebral metastases. It also provides rapid palliation of symptoms due to recurrent malignant tumors. And it may have an adjuvant role in the treatment of some tumors delaying local recurrence, if given prior to resection. However, the preliminary results for the malignant gliomas were inconclusive.
Adult ; Aged ; Brain Neoplasms/secondary/*surgery ; Female ; Follow-Up Studies ; Human ; Male ; Middle Age ; *Radiosurgery

A retrospective study of 29 cases of brain-stem gliomas(BSG's) from 1989 to 1993, was performed to determine prognostic factors. Our study also analyzed clinical features, growth patterns, pathologic findings and modalities of treatment in patients with brain-stem gliomas. The patients ranged in age from 6 to 65 years, most commonly in the first decade. The symptom duration prior to diagnosis was 1/2 to 6 months(mean 1 1/2 months). The most common symptom and sign were cranial nerve palsies, especially 6th or 7th cranial nerve. The growth patterns of BSG's were classified into diffuse tumors(7 patients), exophytic(9 patients), focal(2 patients) and cervicomedullary(1 patient). Twenty three of 29 patients were diagnosed pathologically by means of stereotactic biopsy(13 patients) and ope surgery(10 patients). The Pathologic findings were low grade astrocytoma in 9 patients, oligodendroglioma(3 patients), malignant astrocytoma(7 patients), and glioblastoma mulitiforme(4 patients). A significant correlation between diffuse growth pattern and malignant pathologic finding could be obtained(P=0.05). The methods of radiation therapy for BSG's were conventional(10 patients), hyperfractionated(13 patients), and Gamma knife radiosurgery(6 patients). The median survival time was 12 months. The Poor prognostic factors determined in our study were 1) short symptom duration prior to diagnosis(< or = 2 months), 2) diffuse growth pattern, 3) malignant pathologic finding, 4) tumor without cystic portion, and 5) tumor without hydrocephalus.
Astrocytoma ; Cranial Nerve Diseases ; Cranial Nerves ; Diagnosis ; Glioblastoma ; Glioma ; Humans ; Hydrocephalus ; Magnetic Resonance Imaging ; Pathology* ; Prognosis* ; Retrospective Studies

Between May, 1992 and April, 1993, four patients with paraclinoid aneurysms were treated by a direct operative approach. Two patients had large aneurysms, all of which had ruptured, presented with subarachnoid hemorrhage(SAH). The other two patients had giant aneurysms, causing visual symptoms by optic nerve compression. All patients were treated by a combined extradural and intradural approach. All the aneurysms were successfully clipped and collapsed or resected, eliminating the risk of rebleeding and decompressing the visual system immediately and effectively, while preserving the blood flow of the carotid artery and its branches. Removal of the individual bony structure including anterior clinoid process(ACP) and orbital roof at the skull base extradurally provides a better and safer exposure of the aneurysm, and of the ophthalmic segment of the carotid artery than does excessive retraction of the brain. This technique also affords exposure of the internal carotid artery proximal to the lesion and ophthalmic artery, which is important in securing safe and complete occlusion of the aneurysm. Authors present operative technique, summary of cases, and literature review.
Aneurysm* ; Brain ; Carotid Arteries ; Carotid Artery, Internal ; Humans ; Ophthalmic Artery ; Optic Nerve ; Orbit ; Skull Base

Brain stem hematomas, expecially due to ruptured angiographically occult vascular malformation(AOVM), are of great interest because they are potentially curable. Preoperative diagnosis has been difficult due to poor resolution of CT scans in the posterior fossa region. The advent of MRI has made the identification of the angiographically occult vascular malformation possible before surgical excision. We preset 3 cases of brainstem hematoma due to vascular malformations which wre not visualized by angiography but were diagnosted by MRI. The patients were treated surgically and vascular malformations were confirmed.
Angiography ; Brain Stem* ; Diagnosis ; Hematoma* ; Humans ; Magnetic Resonance Imaging ; Tomography, X-Ray Computed ; Vascular Malformations

Among various approaches to midline skull base tumors, anterior approaches can provide excellent visualization of the lesion. Since June 1989, 12 anterior procedures have been carried out on 9 consecutive patients presenting with midline skull base tumors(four transsphenodal approches, three Le Fort I osteotomies. Two lateral rhinotomies, two facial translocation approaches, and one craniofacial approach). These anterior procedures allowed good access to the lesions. Wound healing was rapid, with little discomfort to the patients. Cosmetic results were also excellent, and there were no significant problems related to malocclusion in the cases of Le Fort I osteotomy. Patients who underwent facial translocation approach developed nasolacrimal duct obstruction and small area hypesthesia on the cheek. Postoperatively, two patients died from tumor progression and meningitis secondary to CSF leakage, respectively. Although the number of cases and follow-up period are limited in our series, we think that anterior approaches may be useful in the surgical treatment to midline skull base tumors.
Cheek ; Follow-Up Studies ; Humans ; Hypesthesia ; Malocclusion ; Meningitis ; Nasolacrimal Duct ; Osteotomy ; Skull Base* ; Skull* ; Wound Healing

Improved access to lesions at the medial end of the sphenoid ridge, in the cavernous sinus, or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study described out experience with 23 patients who underwent the zygomatic osteotomy for skull base tumors in the past 6 years. The follow-up period ranged from 5 months to 49 months. The patient' age range was 11 to 75 years, with an average age of 45 years. This zygomatic osteotomy was used from eleven patients with medial sphenoid ridge lesions, six with lesions arising in or involving the cavernous sinus, three with clival lesions, two with sellar/parasellar lesions, and one with temporal lobe lesions. The histology of these patients showed fourteen meningiomas, two pituitary adenomas, two chordomas, one neurinoma, one chondrosarcoma, one osteochondroma, one malignant lymphoma, and one dermoid cyst. Surgical treatment consisted of total removal in ten patients, subtotal removal in twelve, and partial removal in one. Instances of morbidities associated with basic lesions included cranial nerve injury in five patients, hemorrhage/infarction in three, hemiparesis in two, and transient aphasia in one. There were no significant problems related to zygomatic osteotomy. One patient who underwent zygomatic osteotomy for medial sphenoid ridge meingioma developed a frontalis nerve injury. No patient experienced a detachment of zygomatic arch in our series. Postoperatively, one patient with parasellar malignant lymphoma died 14 months after surgery from tumor progression. Our cases treated via this zygomatic osteotomy are as yet insufficient to determine whether the method offers definite adventages, in terms of patient mortality and morbidity, over conventional operative approaches, but we suggest that this procedure has some advantages such as minimal brain retraction, exposure of lesion in shortest distance, multidirectional viewing of the lesions, and can serve as an alternative approach to a usual pterional approach when cranial base pathologies are large or complex.
Aphasia ; Brain ; Cavernous Sinus ; Chondrosarcoma ; Chordoma ; Cranial Nerve Injuries ; Dermoid Cyst ; Follow-Up Studies ; Humans ; Lymphoma ; Meningioma ; Mortality ; Neurilemmoma ; Osteochondroma ; Osteotomy ; Paresis ; Pathology ; Pituitary Neoplasms ; Skull Base* ; Skull* ; Temporal Lobe ; Zygoma*

Idiopathic hypertrophic pachymeningitis (IHP) is a rare, chronic nonspecific and granulomatous inflammatory disorder of the dura with unknown etiology. The diagnosis can be established by open biopsy and exclusion of all other specific granulomatous and infectious diseases. We report a typical case of spinal IHP occurring in a long segment of cervical and thoracic dura from C6 to T8. The patient was 56-yr-old female, who had been suffered from pain on her upper back and both arms for 3 months and recent onset motor weakness of both legs. During the 9 months of follow-up period, she experienced the improvement of her neurologic symptoms with combined therapy of partial excision and corticosteroid medication. Since early surgical intervention and subsequent pulse ste-roid therapy are mandatory for this disease to avoid irreversible damage of nervous system, the identification of this unique disease entity is essential on frozen diagnosis. A few cases have been reported in Korean literature.
Case Report ; Female ; Follow-Up Studies ; Human ; Magnetic Resonance Imaging ; Meningitis/diagnosis/*pathology/therapy ; Middle Age ; Spinal Diseases/diagnosis/*pathology/therapy

In order to define the surgical result for ruptured anterior circulation aneurysms in the elderly, 59 patients(from June 1989 to May 1994) whose age was 66 years of age or older were analyzed. The factors which might influence the outcome were statistically compared between those aged 66 years or older(elderly patients group:59 patients:12.5%) and those aged 65 years or younger(younger patients group :413 patients;87.5%);the clinical grading, the location of aneurysms, the multiplicity, the presence of the angiographic vasospasm, the development of the symptomatic vasospasm, the presence of the hypertension. Fisher's grade IV(intracerebral hemorrhage or intraventricular hemorrhage), and the timing of surgery. Overall outcome between two groups was not different significantly, and many factors did not affect the outcome except the location. Surgical outcome in good grade patients(Hunt and Hess Grade I, II) was excellent regardless of age and timing of surgery. "Early surgery in the elderly?" The answer was Yes especially in good grade patients. We conclude that surgical outcome for ruptured anterior circulation aneurysms in the elderly does not seem to be directly affected by age, so elderly patients need not therefore be excluded from the benefits of surgery just because of their chronological age. It is principally the patient's condition during the acute stage that determine the surgical outcome.
Aged* ; Aneurysm* ; Hemorrhage ; Humans ; Hypertension