Immunoglobulin G4-related disease (IgG4-RD) is an autoimmune disorder associated with fibroinflammatory conditions that can affect multiple organs. Hallmark histopathological findings of IgG4-RD include lymphocytic infiltration of IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. However, little is known about central nervous system involvement of IgG4-RD.Hypertrophic pachymeningitis (HP) has recently been reported as a manifestation of IgG4-RD, which may have previously been demonstrated in a significant percentage of idiopathic cases. Herein, we report a rare case of a 63-year-old male who presented with a scalp mass that mimicked a brain tumor. He was diagnosed with IgG4-related HP (IgG4-RP) after surgery. This case suggests that awareness of a possibility of IgG4-RP in patients with isolated scalp masses, even in the absence of systemic symptoms, is crucial. A combination of careful history taking, evaluation of serum IgG4-levels and imaging as an initial work-up, followed by tissue biopsy, is important for the differential diagnosis of IgG4-RP, malignancy, and other infectious diseases.

Background: Brain metastases of peri-Rolandic area is crucial as it directly impacts the quality of life for cancer patients. Surgery or stereotactic radiosurgery (SRS) is considered for peri-Rolandic brain metastases as for other brain metastases. However, the benefit of each treatment modality on functional outcome has not been clearly defined for this tumor. The purpose of this study is to compare the functional course of each treatment and to suggest an effective treatment for patients’ quality of life. Methods: Fifty-two patients who had undergone SRS or surgery for brain metastasis confirmedby enhanced MRI were enrolled retrospectively. Overall survival (OS), progression free survival (PFS), and functional outcomes were estimated using the Kaplan-Meier method, univariate, multivariate analysis, and Cox proportional hazards regression. Results: Median OS and PFS were 13.3 months and 8.9 months in our study population.Treatment modalities were not significant factors for OS and PFS. Extracranial systemic cancer progression was significant factor for both parameters (p=0.030 for OS and p=0.040 for PFS). Median symptom improvement (improvement of at least 1 grade after surgery compared to preoperative state) time was significantly shorter in surgery group than in the SRS group (10.5 days vs. 37.5 days, p=0.034). Conclusion Surgery for brain metastases can contribute to a positive quality of life for the remain-ing duration of the patient’s life.

Objective: : Deep learning is a machine learning approach based on artificial neural network training, and object detection algorithm using deep learning is used as the most powerful tool in image analysis. We analyzed and evaluated the diagnostic performance of a deep learning algorithm to identify skull fractures in plain radiographic images and investigated its clinical applicability. Methods: : A total of 2026 plain radiographic images of the skull (fracture, 991; normal, 1035) were obtained from 741 patients. The RetinaNet architecture was used as a deep learning model. Precision, recall, and average precision were measured to evaluate the deep learning algorithm’s diagnostic performance. Results: : In ResNet-152, the average precision for intersection over union (IOU) 0.1, 0.3, and 0.5, were 0.7240, 0.6698, and 0.3687, respectively. When the intersection over union (IOU) and confidence threshold were 0.1, the precision was 0.7292, and the recall was 0.7650. When the IOU threshold was 0.1, and the confidence threshold was 0.6, the true and false rates were 82.9% and 17.1%, respectively. There were significant differences in the true/false and false-positive/false-negative ratios between the anteriorposterior, towne, and both lateral views (p=0.032 and p=0.003). Objects detected in false positives had vascular grooves and suture lines. In false negatives, the detection performance of the diastatic fractures, fractures crossing the suture line, and fractures around the vascular grooves and orbit was poor. Conclusion : The object detection algorithm applied with deep learning is expected to be a valuable tool in diagnosing skull fractures.

Objective: To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL). Methods: We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into “good” and “poor” outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups. Results: Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH. Conclusions Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

Objective: We aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms. Methods: We retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant. Results: We enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis. Conclusions POP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

OBJECTIVE: To evaluate the efficacy of fractionated stereotactic radiosurgery (FSRS) performed using the Novalis Tx® system (BrainLAB AG, Feldkirchen, Germany; Varian Medical Systems, Palo Alto, CA, USA) for brain metastases.METHODS: Between March 2013 and July 2016, 23 brain metastases patients were admitted at a single institute. Twenty-nine lesions too large for single session stereotactic radiosurgery or located in the vicinity of eloquent structures were treated by FSRS. Based on the results obtained, we reviewed the efficacy and toxicity of FSRS for the treatment of brain metastases.RESULTS: The most common lesion origin was lung (55%) followed by breast (21%). Median overall survival was 10.0 months (95% confidence interval [CI], 4.9–15.0), and median progression-free survival was 10.0 months (95% CI, 2.1–13.9). Overall survival rates at 1 and 2 years were 58.6% and 36.0%, respectively. Local recurrence and neurological complications affecting morbidity each occurred in two cases.CONCLUSION: FSRS using the Novalis-Tx® system would appear to be an effective, safe noninvasive treatment modality for large and eloquently situated brain metastases. Further investigation is required on a larger number of patients.
Brain Neoplasms ; Brain ; Breast ; Disease-Free Survival ; Germany ; Humans ; Lung ; Neoplasm Metastasis ; Radiosurgery ; Recurrence ; Survival Rate

OBJECTIVE: This study aimed to investigate the rates, types, and risk factors of surgical site infection (SSI) following intracranial neurosurgical procedures evaluated by a Korean SSI surveillance system.METHODS: This was a prospective observational study of patients who underwent neurosurgical procedures at 29 hospitals in South Korea from January 2017 to June 2017. The procedures included craniectomy, craniotomy, cranioplasty, burr hole, and ventriculoperitoneal shunt. Univariate and multivariate logistic regression analyses were performed.RESULTS: Of the 1576 cases included, 30 showed infection, for an overall SSI rate of 1.9%. Organ/space infection was the most common, found in 21 out of the 30 cases (70%). Staphylococcus aureus was the most common (41%) of all bacteria, and Serratia marcescens (12%) was the most common among gram-negative bacteria. In univariate analyses, the p-values for age, preoperative hospital stay duration, and over T-hour were <0.2. In a multivariate analysis of these variables, only preoperative hospital stay was significantly associated with the incidence of SSI (p < 0.001), whereas age and over T-hour showed a tendency to increase the risk of SSI (p=0.09 and 0.06).CONCLUSION: Surveillance systems play important roles in the accurate analysis of SSI. The incidence of SSI after neurosurgical procedures assessed by a national surveillance system was 1.9%. Future studies will provide clinically useful results for SSI when data are accumulated.
Bacteria ; Craniotomy ; Gram-Negative Bacteria ; Humans ; Incidence ; Korea ; Length of Stay ; Logistic Models ; Multivariate Analysis ; Neurosurgery ; Neurosurgical Procedures ; Observational Study ; Prospective Studies ; Risk Factors ; Serratia marcescens ; Staphylococcus aureus ; Surgical Wound Infection ; Ventriculoperitoneal Shunt

OBJECTIVE: This study aimed to investigate the rates, types, and risk factors of surgical site infection (SSI) following spinal surgery using data from a Korean SSI surveillance system that included diagnoses made by surgeons.METHODS: This was a prospective observational study of patients who underwent spinal surgeries at 42 hospitals in South Korea from January 2017 to December 2017. The procedures included spinal fusion, laminectomy, discectomy, and corpectomy. Univariate and multivariate logistic regression analyses were performed.RESULTS: Of the 3080 cases included, 30 showed infection, and the overall SSI rate was 1.0% (an incidence of 1.2% in spinal fusion and 0.6% in laminectomy). Deep incisional infections were the most common type of SSIs (46.7%). Gram-positive bacteria caused 80% of the infections, and coagulase-negative staphylococci, including Staphylococcus epidermidis, accounted for 58% of the gram-positive bacteria. A longer preoperative hospital stay was significantly associated with the incidence of SSI after both spinal fusion and laminectomy (p=0.013, p < 0.001). A combined operation also was associated with SSI after laminectomy (p=0.032).CONCLUSION: An SSI surveillance system is important for the accurate analysis of SSI. The incidence of SSI after spinal surgery assessed by a national surveillance system was 1.0%. Additional data collection will be needed in future studies to analyze SSI in spinal surgery.
Data Collection ; Diagnosis ; Diskectomy ; Gram-Positive Bacteria ; Humans ; Incidence ; Korea ; Laminectomy ; Length of Stay ; Logistic Models ; Observational Study ; Prospective Studies ; Risk Factors ; Spinal Fusion ; Spine ; Staphylococcus epidermidis ; Surgeons ; Surgical Wound Infection

Craniopharyngiomas exhibiting histologic malignancy are extremely rare. Herein, we report the case of a 26-year-old male patient who underwent suprasellar mass excision via an interhemispheric transcallosal approach. Histopathological examination indicated that the craniopharyngioma was of the adamantinomatous subtype. The patient received postoperative medical treatment for endocrine dysfunction and diabetes mellitus without radiation treatment. Two years after the operation, he presented with progressive visual disturbance and altered mentality. Magnetic resonance imaging revealed a huge mass in the suprasellar cistern and third ventricle. He underwent a second operation via the same approach. The histopathological examination showed an adamantinomatous craniopharyngioma with sheets of solid proliferation in a spindled pattern, indicating malignant transformation. Malignant transformation of craniopharyngioma in the absence of radiation therapy has been reported in only five cases, including this one. We present a case of malignant transformation of craniopharyngioma with a brief review of relevant literature.
Adult ; Craniopharyngioma* ; Diabetes Mellitus ; Humans ; Magnetic Resonance Imaging ; Male ; Radiotherapy ; Third Ventricle

Low-grade myofibroblastic sarcoma (LGMS) is a rare sarcoma with myofibroblastic differentiation. LGMS has a propensity for local recurrence and is associated with a low risk of metastatic spread. A 26-year-old man presented with a 12-month history of a slow growing palpable hard mass in the right parietal scalp. Enhanced CT scan of head showed a 3x4 cm sized well-defined and heterogeneously enhancing scalp mass. The patient underwent excision of the tumor. The histological and immunohistochemical features were consistent with a LGMS. We performed re-operation for remnant tumor removal after diagnosis. After 14 months of surgery, the patient was well-being state.
Adult ; Diagnosis ; Head ; Humans ; Myofibroblasts* ; Rabeprazole ; Recurrence ; Sarcoma* ; Scalp* ; Tomography, X-Ray Computed