Journal of Korean Neurosurgical Society最新文献

Objective: This study investigated the usefulness of somatosensory-evoked potentials (SEPs) and motor-evoked potentials (MEPs) in predicting motor outcomes in patients with intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) extension.

Methods: We retrospectively evaluated 124 patients with ICH and IVH extensions. SEPs of posterior tibial nerve and MEPs of tibialis anterior muscles were evaluated.

Results: About 30% of the patients could walk independently at 6 months from the onset. Patients who exhibited SEP in both bilateral posterior tibial nerves demonstrated better ambulatory function compared to those with SEP in only one unilateral posterior tibial nerve or no SEP in both sides of the posterior tibial nerves. Likewise, patients who displayed MEP in both bilateral tibialis anterior muscles exhibited better ambulatory capacity compared to those with MEP on only one side or no MEP on both sides. In addition, when the posterior tibial nerve SEP was present bilaterally, 54.9% of the patients could walk independently, and when the MEP from the tibialis anterior muscles was present bilaterally, 41.0% of the patients could walk without any assistance.

Conclusion: SEP and MEP could be useful tools for predicting ambulatory function in patients with ICH accompanied by IVH.

Objective: In preclinical research of Parkinson's disease, several rodent models, notably the classical 6-hydroxydopamine (6-OHDA) model and the A53T-alpha-synuclein model, have been widely used, yet their distinct neurochemical characteristics in conjunction with behavioral and histopathological changes have been scarcely documented.

Methods: We examined the two rat models of Parkinson's disease and characterized them using [18F]fluoropropyl-carbomethoxyiodophenyltropane (FP-CIT) animal positron emission tomography (PET) imaging. The 6-OHDA model (n=10) was induced by unilateral injection of 6-OHDA into the middle forebrain bundle, while the A53T-alpha-synuclein model (n=10) was mediated by the adeno-associated viral vectors injected into the substantia nigra. We hypothesized that these models would present differential neurochemical profiles, which could reflect their behavioral and histopathological features and potentially serve as a supplementary tool for evaluating the outcomes of interventions in animal experiments.

Results: The striatum showed decreased PET uptake on the affected side compared to the unaffected control side, which was highly correlated with the stepping behaviors (R=0.854; 95% confidence interval [CI], 0.606 to 0.951). The decrease in striatal PET uptake was more pronounced in the 6-OHDA model than in the A53T-alpha-synuclein model : the 6-OHDA model exhibited a 60% decrease (95% CI, 48% to 65%) in the affected side compared the control side, while the A53T-alpha-synuclein model exhibited a 20% decrease (95% CI, -16% to 47%). Interestingly, PET uptake in the forebrain cortical region, including the motor cortex, was exclusively decreased in the 6-OHDA model (p=1.0×10-4 and p=1.2×10-3, respectively), indicating that 6-OHDA model is affected not only in the nigrostriatal system but also in other cortical regions. Conversely, the A53T-alpha-synuclein model showed no significant alterations in these cortical regions.

Conclusion: Although the A53T-alpha-synuclein model demonstrates less definitive behavioral changes compared to the 6-OHDA model, it presents a more confined pathophysiological representation of Parkinson's disease and may be better suited for evaluating certain therapeutic interventions when utilized with adequate neurochemical characterization.

Objective: This study aimed to evaluate the clinical and radiographic results of patients with adolescent idiopathic scoliosis (AIS) operated by a single neurosurgeon.

Methods: A total of 139 consecutive patients with AIS who underwent corrective surgery by a single neurosurgeon were investigated between January 2011 and January 2024. Segmental instrumentation with pedicle screws was utilized for deformity correction. Demographic information, structural type of curve using Lenke classification, degree of correction achieved, total numbers of fusion levels, complications, and clinical/radiographic results were evaluated.

Results: Most patients were adolescent girls (105 vs. 34) with an average age of 15.9 vs. 16.0, respectively. The average duration of follow-up was 4.5 years (0.1-13.0). Nine patients (6.6%) had levoscoliosis, and the remaining 130 had dextroscoliosis. Chiari malformation with syringomyelia was incidentally diagnosed in four patients (2.8%). Of the patients having Chiari malformation, two (50%) had levoscoliosis. The mean number of fused levels was 11.2. The mean value of the Cobb angle of the major structural curvature was 63.4° (43°-125°). The major structural curve's average percentage of correction was 78.8%. The final postoperative SRS-22 average score significantly improved to 4.3±0.4 compared with the preoperative score of 3.8±0.5 (p<0.001). After the surgery, there were no observed cases of neurological deficits or need for screw repositioning. Revision fusion extension surgery was performed on one patient to treat postoperative shoulder imbalance.

Conclusion: Patients with AIS treated by a neurosurgeon had acceptable clinical and radiographic results. However, AIS surgery necessitates a fundamental comprehension of pediatric spinal deformities, which is crucial. Furthermore, spine surgeons should be careful with patients who have levoscoliosis.

Objective: The Leksell Gamma Knife (LGK) Icon™ facilitates frameless (mask-based) fixation through its high-definition motion management (HDMM) system. However, the HDMM only records the intra-fractional motion values of patient marker without specifying changes along the X, Y, and Z axes. This study investigates the coordinate shifts in patient markers using the HDMM system during frameless gamma knife radiosurgery (GKRS) in patients with meningioma and metastases.

Methods: We conducted a retrospective study of patients diagnosed with meningioma or metastases who underwent frameless GKRS using the LGK Icon™ between January and September 2023. All patients were immobilized using a Nanor thermoplastic mask (Orfit Industries, Wijnegem, Belgium) for frameless fixation. Sequential data of the patients' nose marker coordinates (X, Y, Z) were imported into the LGK system, and subsequent coordinate changes were analyzed.

Results: We evaluated patients with meningiomas (n=30) and metastases (n=30) who underwent GKRS with frameless fixation. None of the patients exhibited cognitive impairment or compliance issues. The median beam-on time was 44.2 minutes in patients with meningioma and 93.75 minutes in patients with metastases. In patients with meningioma, no significant intra-fractional displacements were found along the X (0.07±0.06 mm), Y (0.08±0.46 mm), and Z (0.08±0.04 mm) axes. However, in patients with metastases, the Y axis (0.57±0.37 mm, p<0.05) exhibited significantly greater intra-fractional displacements compared with the X axis (0.33±0.23 mm). No significant differences in intra-fractional displacement were observed between the X and Z (0.43±0.31 mm) axes or between the Y and Z axes. An analysis of movement over time revealed a significant increase in Y axis displacement after 30 minutes.

Conclusion: Y axis movement, as indicated by the HDMM, was most prominent in patients with metastases. We recommend pressing the forehead when securing a mask to minimize nose marker movement. Additionally, when creating treatment plans for managing patients with metastases using the LGK Icon™, we suggest adding a 0.5 mm margin to the Y axis.

Objective: To identify the ideal timing for resuming oral or injectable anticoagulants therapy after spontaneous intracranial hemorrhage (sICH).

Methods: We conducted a retrospective cohort study involving 90 patients from a tertiary hospital in Korea, between June 2000 and May 2022, who had experienced sICH while receiving anticoagulant therapy and who resumed treatment within six months. Exclusions were made for trauma-induced hemorrhages and early post-ictus fatalities. The interval between sICH occurrence and anticoagulant resumption was the main exposure variable. We evaluated hemorrhagic and thromboembolic events as outcomes. Multivariate analysis was used to determine the risk factors for post-resumption complications. Receiver operating characteristic (ROC) and locally estimated scatterplot smoothing (LOESS) were used to identify optimal timing.

Results: The median patient age was 71 years, with 56.7% male. Warfarin was the most commonly used anticoagulant prior to sICH (63.3%), and non-vitamin K antagonist oral anticoagulants (NOACs) were used in 22.2%. Within six months of resuming anticoagulants, 9 patients experienced hemorrhagic and 13 experienced ischemic complications. Age ≥80 years was significantly associated with ischemic events (OR 4.29, p=0.048), while NOAC use was strongly associated with hemorrhagic complications (OR 16.59, p=0.003). ROC analyses suggested possible cut-off points for anticoagulants resumption at day 30 for ischemic risk and day 7.5 for hemorrhagic risk, though AUC values were not statistically significant. Risk modeling using LOESS curves indicated that the combined complication risk was lowest when anticoagulants were resumed between days 20 and 22 after ictus.

Conclusion: The findings suggest that approximately 3 weeks after sICH is the optimal time to resume anticoagulants, minimizing the risk of rebleeding or thromboembolic events. These findings may inform clinical decision-making in a broad patient population, though individualized assessment remains essential.

Objective: Partially thrombosed intracranial aneurysms (PTIAs) are known to occur for both large and small aneurysms; however, standardized treatment guidelines remain undefined. This study aimed to evaluate and compare the efficacy of surgical and endovascular strategies for managing PTIAs to identify the optimal treatment approach.

Methods: A retrospective analysis was performed on patients diagnosed with PTIAs who underwent surgical or endovascular treatment at our institution from January 2005 to December 2022. Patients with intraluminal thrombi confirmed via brain imaging were categorized based on the treatment modality. A total of 45 patients were included. Clinical outcomes, including preoperative and postoperative modified Rankin scale scores, complication rates, and recurrent or remnant aneurysm rates, were reviewed to analyze the treatment results.

Results: Of the 45 enrolled patients, 31 patients (68.9%) underwent surgical treatment, and 14 patients (31.1%) received endovascular treatment. Surgical approaches included direct clipping, trapping with bypass, and aneurysm wrapping. Multivariate analysis revealed a statistically significant association between the treatment modality and recurrent or remnant aneurysms (p<0.001). However, no significant differences were identified between the two treatment groups in terms of complication rates or functional outcomes.

Conclusion: In comparison to endovascular treatment, surgical management of PTIAs demonstrated superior efficacy in minimizing recurrent and remnant aneurysms. Considering the comparable rates of postoperative complications and functional outcomes, surgical treatment may be the preferred treatment strategy, particularly for younger patients with longer follow-up periods or for cases requiring decompression.

Endoscopic spine surgery is the perfect culmination of the concept of minimally invasive spine surgery. Among the various endoscopic spine procedures, full-endoscopic spine surgery (FESS) is an endoscopic technique characterized by the performance of the entire spinal procedure via the percutaneous approach using a uniportal working-channel endoscope with continuous saline perfusion. FESS effectively decompresses the tissues and allows for instrumentation while preserving the normal musculoskeletal structures. It also has fewer complications and enables quicker return to work. However, potential disadvantages include its steep learning curves and limited indications. Previously, the indications for endoscopic procedures had been limited to soft disc herniations or focal neural impingement, with most degenerative spinal diseases other than disc herniation being considered contraindications. However, owing to the remarkable advancements in endoscopic technology, nearly all degenerative spinal diseases, including spinal stenosis and instability, can currently be treated using FESS. Furthermore, the application of spinal endoscopes has expanded to other spinal disorders, including infections, traumas, and tumors. Unfortunately, the steep learning curve and technical limitations of FESS cannot be overlooked by most standard spine surgeons. To ensure the clinical success of endoscopic procedures in actual clinical practice, a comprehensive understanding of the core properties of working channel endoscopes is necessary to facilitate the learning process. With the ongoing development of endoscopic technology, endoscopic surgery can be expected to become the standard treatment approach for all degenerative spinal diseases in the near future.

Objective: Primary intraventricular hemorrhage (PIVH) is a rare type of neurologic disorder and remains a challenge for cerebrovascular surgeons. This study intended to investigate the factors associated with neurosurgical intervention and its impact on outcome after PIVH.

Methods: We retrospectively included consecutive patients with PIVH admitted to at a single tertiary academic medical center in China. Conservative treatment or neurosurgical intervention options (including endovascular therapy, craniotomy, stereotactic radiotherapy, endoscopic surgery or external ventricular drain) were assessed. Multivariable logistic regression was applied to determine associations.

Results: In total, 174 patients with PIVH were included in our analysis. There were 79 patients (45.4%) underwent surgery, which was associated with younger age (p=0.004), higher baseline Graeb score (p=0.001), acute hydrocephalus (p=0.02) and underlying cerebrovascular diseases (p<0.001) in an adjusted model. In multivariable logistic regression analysis, significant predictors of external ventricular drain after PIVH were higher baseline Graeb score (p=0.04), and acute hydrocephalus (p<0.001). Furthermore, after adjustment for confounders, our analysis showed that neurosurgical intervention could decrease 90-day mortality after PIVH (p=0.04).

Conclusion: After PIVH, younger patients with higher baseline Graeb score, acute hydrocephalus and underlying cerebrovascular diseases were more likely to undergo neurosurgical intervention. Surgical treatment of PVIH patients should be optimized to decrease mortality. However, further clinical trials are still needed to determine which patients would benefit from neurosurgical intervention.

Objective: This retrospective study aims to analyze hemorrhage complications in patients undergoing deep brain stimulation (DBS) surgery, focusing on the impact of imaging modalities and trajectory planning.

Methods: We conducted a retrospective review of patients who underwent DBS at a single institution from September 2018 to February 2023. Surgical planning data were analyzed using a combination of 1.5 Tesla (T) and 3.0 T magnetic resonance image (MRI) for trajectory planning. Trajectories were classified into four types (type 1-4) based on the proximity of vascular structures within 2 mm on preoperative MRI scans, as defined in this study. Hemorrhage presence was evaluated through postoperative computed tomography scans.

Results: Out of 200 patients analyzed, type 1 trajectories (no vascular structures within 2 mm on both MRIs) accounted for 72.70% of cases with the lowest hemorrhage rate. Significant differences in hemorrhage rates were observed among the types, with higher risks associated with type 4 trajectories. Additionally, significant variations in vascular structure types were noted across DBS targets, with subthalamic nucleus showing the highest risk.

Conclusion: Meticulous trajectory planning using both 1.5 T and 3.0 T MRI is crucial in minimizing hemorrhagic complications in DBS. The study underscores the need for precise imaging and planning to enhance patient safety and surgical outcomes.

Objective: The Leksell Gamma Knife (LGK) is one of the most precise radiosurgical tools available. However, the quality assurance (QA) practices for LGK vary considerably across institutions in Korea. In this study, we aim to identify and standardize key QA items, categorized into daily, monthly, biannual, and annual protocols, based on a nationwide survey conducted at 16 medical centers. Additionally, the tolerance values for each QA items were reviewed, comparing them with the American Association of Physicists in Medicine Task Group (TG-178), and tailored to establish distinct Korean Gamma Knife Radiosurgery (GKRS) tolerances reflecting local standards and regulatory requirements.

Methods: The survey focused on QA practices for the LGK Icon™/Esprit™ and Perfexion™ systems. The QA items were categorized into daily, monthly, biannual, and annual tasks in accordance with the guidelines set by TG-178. Sixteen participating institutions were asked to rate the importance of each QA item on a scale of 0 (not important) to 5 (extremely important). Items rated 4 or 5 were selected to create a national priority list.

Results: Eleven daily, six monthly, and three annual QA items were identified as high priority. Daily QA tasks primarily focused on radiation and patient safety, whereas the monthly tasks were largely related to dosimetric validation. Annual QA emphasizes mechanical and dosimetric checks. Biannual evaluations were not prioritized as they were routinely performed by the manufacturer's maintenance service (Elekta AB, Stockholm, Sweden).

Conclusion: We succeeded in making recommendations for Gamma Knife QA standardization in Korea. Continuous QA updates are essential to ensure treatment safety, particularly with the introduction of new LGK models. These findings may contribute to the development of unified national QA guidelines for GKRS.