1.Revisiting the Role of Surgical Resection for Brain Metastasis
Brain Tumor Research and Treatment 2023;11(1):1-7
Brain metastasis (BM) is the most common type of brain tumor in adults. The contemporary management of BM remains challenging. Advancements in systemic cancer treatment have increased the survival of patients with cancer. Although the treatment of BM is still complicated, advances in radiotherapy, including stereotactic radiosurgery and chemotherapy, have improved treatment outcomes. Surgical resection is the traditional treatment for BM and its role in the surgical resection of BM has been well established. However, refinement of the surgical resection technique and strategy for BM is needed.Herein, we discuss the evolving role of surgery in patients with BM and the future of BM treatment.
3.A Rare Case of Metastatic Brain Tumor From Classic Biphasic Pulmonary Blastoma Presented as Intracerebral Hemorrhage
Sanghyeok PARK ; Joonho BYUN ; Sang Woo SONG ; Young-Hoon KIM ; Chang-Ki HONG ; Jeong Hoon KIM
Brain Tumor Research and Treatment 2021;9(2):81-86
Pulmonary blastoma is a rare type of primary lung cancer that accounts for only 0.25%-0.5% of all lung malignancies. Pulmonary blastoma consists of three subgroups: classic biphasic pulmonary blastoma (CBPB), pleuropulmonary blastoma, and well-differentiated fetal adenocarcinoma. Due to the rarity of the tumor, metastatic brain tumor from CBPB is extremely rare, and only 13 cases, including our case, have been reported. A 60-year-old woman who underwent left upper lobectomy of the lung because of pathologically diagnosed as CBPB 5 months ago, suddenly lost consciousness and presented with stupor mental status. The emergent CT scan showed a large, 51 mL, intracerebral hemorrhage on left parieto-occipital lobe with midline shifting. The patient underwent emergent craniotomy, and a hypervascular tumor was identified during the operation. Histopathologic examination reported metastatic pulmonary blastoma, CBPB. The patient has been in a vegetative state, but there has been no evidence of recurrence over a 6-month follow-up period. We report a rare case of brain metastasis from CBPB presenting with altered mentality due to massive tumor bleeding. This is the only reported case of brain metastasis from CBPB presenting with acute intracerebral hemorrhage.
4.Extraventricular Neurocytoma: Clinical Investigation of Heterogenous Prognosis
Joonho BYUN ; Moinay KIM ; Sang Woo SONG ; Young-Hoon KIM ; Chang Ki HONG ; Jeong Hoon KIM
Brain Tumor Research and Treatment 2022;10(1):22-28
Background:
Extraventricular neurocytoma (EVN) is an extremely rare neuronal neoplasm that arises outside the ventricle. The clinical implication of the heterogenous prognosis of this rare tumor has not yet been clarified. Herein, we analyzed our institutional series of EVN.
Methods:
A total of eight consecutive cases were enrolled and investigated. The prognosis of EVN was analyzed and compared to that of central neurocytoma (CN).
Results:
There were two male and six female patients, and the median age was 36.5 years. The median tumor size was 38 mm, and the most common location of the tumor was the frontal lobe (3, 37.5%), followed by the parietal and temporal lobes. In brain imaging, four (50%) tumors showed peritumoral edema and three (37.5%) tumors showed calcification. All patients underwent gross total resection, and two (25%) underwent adjuvant radiotherapy. The 5-year overall survival (OS) was 55.6%, and the 2-year progression-free survival (PFS) was 42.9%. The OS and PFS of EVN were poor compared to those of CN. Although EVN is a single disease entity, individual patients showed varying prognosis. One patient showed no recurrence during the 7-year follow-up period; however, another patient had a recurrence 4 months after surgery and died 2 years later.
Conclusion
EVN may be a heterogenous disease entity. Additional cases with long-term followup are needed to develop optimal management protocols.
5.Microsurgical treatment of lateral cavernous sinus wall dural arteriovenous fistula with large venous aneurysm: A case report
Dong Jin KIM ; Wonhyoung PARK ; Jung Cheol PARK ; Jae Sung AHN ; Deok Hee LEE ; Joonho BYUN
Journal of Cerebrovascular and Endovascular Neurosurgery 2021;23(1):41-48
We report a case of lateral cavernous sinus wall dural arteriovenous fistula (DAVF) accompanied large venous aneurysm which is presented intracerebral hemorrhage (ICH). A 58-year-old male patient came to emergency department for acute onset of headache and dysarthria. In brain computed tomography scan, large left temporal lobe ICH was noted. In transfemoral cerebral angiography, multiple arteries from external carotid artery and left internal carotid artery (ICA) fed arteriovenous shunt. This shunt was drained through cavernous sinus with enlarged multiple cortical veins. One large venous aneurysm was estimated as bleeding focus for ICH. Considering ICH and high flow shunt, we planned urgent treatment to reduce flow of arteriovenous shunt. However, transvenous embolization was failed due to tortuous venous anatomy. Therefore, we planned craniotomy and microsurgical treatment. There was engorged small vessel in lateral wall of cavernous sinus and vascular trunk which is fistulous connection was noted. Fistula connection was obliterated and disconnected after coagulation. In postoperative image, fistula was completely disappeared and there was no cortical venous reflux, also large venous aneurysm was disappeared. Patient recovered very well without new neurological deficits. We reported successfully treated lateral cavernous sinus wall DAVF by combined endovascular and transcranial-microsurgical treatment.
6.Microsurgical treatment of lateral cavernous sinus wall dural arteriovenous fistula with large venous aneurysm: A case report
Dong Jin KIM ; Wonhyoung PARK ; Jung Cheol PARK ; Jae Sung AHN ; Deok Hee LEE ; Joonho BYUN
Journal of Cerebrovascular and Endovascular Neurosurgery 2021;23(1):41-48
We report a case of lateral cavernous sinus wall dural arteriovenous fistula (DAVF) accompanied large venous aneurysm which is presented intracerebral hemorrhage (ICH). A 58-year-old male patient came to emergency department for acute onset of headache and dysarthria. In brain computed tomography scan, large left temporal lobe ICH was noted. In transfemoral cerebral angiography, multiple arteries from external carotid artery and left internal carotid artery (ICA) fed arteriovenous shunt. This shunt was drained through cavernous sinus with enlarged multiple cortical veins. One large venous aneurysm was estimated as bleeding focus for ICH. Considering ICH and high flow shunt, we planned urgent treatment to reduce flow of arteriovenous shunt. However, transvenous embolization was failed due to tortuous venous anatomy. Therefore, we planned craniotomy and microsurgical treatment. There was engorged small vessel in lateral wall of cavernous sinus and vascular trunk which is fistulous connection was noted. Fistula connection was obliterated and disconnected after coagulation. In postoperative image, fistula was completely disappeared and there was no cortical venous reflux, also large venous aneurysm was disappeared. Patient recovered very well without new neurological deficits. We reported successfully treated lateral cavernous sinus wall DAVF by combined endovascular and transcranial-microsurgical treatment.
7.Clinical Outcomes of Large (>10 mm) Unruptured Posterior Circulation Aneurysms and Their Predictors
Joonho BYUN ; Wonhyoung PARK ; Jung Cheol PARK ; Jae Sung AHN
Journal of Korean Neurosurgical Society 2021;64(1):39-50
Objective:
: The treatment of large aneurysms of the posterior circulation is complicated and remains challenging. We here analyzed our institutional clinical outcomes of large unruptured aneurysms of the posterior circulation.
Methods:
: This study included 56 patients who presented with a large (>10 mm) unruptured aneurysm of the posterior circulation between 2002 and 2018.
Results:
: There were 18 (32.1%) male and 38 (67.9%) female patients, with a mean age of 53.4 years. The most common location was the vertebral artery, followed by the basilar tip and posterior cerebral artery. The median follow-up duration was 29 months. Eighteen patients (32.1%) were treated by transcranial surgery and 38 (67.9%) were treated by endovascular treatment (EVT). Posttreatment complications occurred in 16 patients (28.6%), with there being no significant difference between the transcranial surgery and EVT groups. Complete obliteration was achieved in 30 patients (53.6%), with there being no statistically significant difference between the transcranial surgery and EVT groups. Recurrence occurred in 17 patients (30.4%), and the rate of recurrence was higher in the EVT group than in the transcranial surgery group (39.5% vs. 11.1%, p=0.03). Forty-four (84%) of 56 patients showed a favorable functional outcome. In saccular aneurysm, EVT was negative predictor of worsening of functional status.
Conclusion
: Treatment of these aneurysms harbors an inherent high risk of morbidity. No superiority was found between transcranial surgery and EVT in terms of complications and complete obliteration, but transcranial surgery showed a higher treatment durability than EVT.
8.Middle meningeal artery embolization for chronic subdural hematoma in elderly patients at high risk of surgical treatment
Jin Hoo SEOK ; Jong Hyun KIM ; Taek Hyun KWON ; Joonho BYUN ; Won Ki YOON
Journal of Cerebrovascular and Endovascular Neurosurgery 2023;25(1):28-35
Objective:
The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate.
Methods:
We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated.
Results:
The mean follow-up period was 160 days (range, 46−311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case.
Conclusions
MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.
9.Pseudoaneurysm formation or dural arteriovenous fistula formation at the middle meningeal artery following revascularization surgery in Moyamoya disease
Dongok SEO ; Byul Hee YOON ; Joonho BYUN ; Wonhyoung PARK ; Jung Cheol PARK ; Jae Sung AHN
Journal of Cerebrovascular and Endovascular Neurosurgery 2023;25(1):87-92
Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation—has been identified in rare cases after the surgical intervention for revascularizations.
We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation.
In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia.
Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery
10.Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM
Joonho BYUN ; Do Hoon KWON ; Do Heui LEE ; Wonhyoung PARK ; Jung Cheol PARK ; Jae Sung AHN
Journal of Korean Neurosurgical Society 2020;63(4):415-426
Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.