Outcome of Gamma Knife Radiosurgery for Trigeminal Neuralgia

전상룡,이동준,김정훈,김창진,권양,이정교,권병덕,Jeon, Sang Ryong,Lee, Dong Joon,Kim, Jeong Hoon,Kim, Chang Jin,Kwon, Yang,Lee, Jung Kyo,Kwun, Byung Duk The Korean Neurosurgical Society 2000 Journal of Korean neurosurgical society Vol.29 No.9

목 적 : 본 연구는 삼차신경통에 대한 감마나이프 방사선 수술을 한 경우에 있어서 그 장기추적 결과를 분석하고자 하였다. 방 법 : 총 증례수는 11례였고 신경근 입구부(nerve root entry zone)에 수술의 목표점으로 최대량 67~85Gy를 조사하였다. 4mm collimator를 사용하였고 목표점은 뇌교의 표면으로부터 1~6mm 원위부 신경근에 위치하였다. 초기 3례에 있어서는 신경근과 뇌교가 만나는 접합부를 방사선수술의 목표점으로 삼았다. 이들 증례에서는 뇌교에 56 혹은 60Gy가 조사되었다. 후반 8례에서는 목표점을 다소 신경근의 원위부로 이동하여 뇌교의 가장자리가 최대량의 20% 이하로 조사되도록 계획하였다. 결 과 : 평균추적 기간은 25개월(13~50개월)이었다. 통증감소의 시작시점은 수술후 일주일내에서부터 길게는 5개월째였다. 통증의 치료결과는 삼례에서 완전소실, 3례에서 현격히 감소(80~90%)하였고 4례에서는 의미있게 감소하였다. 단 한례에서 최종추적결과 수술전과 같은 정도의 통증재발이 있었다. 전례에서 감마나이프 방사선수술과 관련된 의미있는 정도의 부작용은 관찰되지않았다. 결 론 : 장기추적 결과 감마나이프 방사선 수술이 삼차신경통의 치료에 효과적임이 관찰되었고 향후 이 질환에 대한 일차적 치료법으로 정하기 위하여 좀더 많은 치료경험이 필요할 것으로 사료된다. Objective : This study was undertaken to analysis gamma knife radiosurgery(GKR) effect for trigeminal neuralgia after long term follow-up. Methods : There were 11 trigeminal neuralgia patients. The authors irradiated 67-85 Gy maximally to the nerve root entry zone(NREZ) using single 4mm collimator, just 1-6mm lateral side from the junction of the trigeminal nerve and pons. For the first 3 cases, we targeted the junction between the nerve and the pons. In theses cases, the pons was irradiated 56 or 60 gray in the surface. In the later 8 cases, the isocenter is positioned more distal side so that the brain stem surface would receive less than the 20% isodose. Results : The average follow-up duration was 25 months(13-50 months). Pain relief was noticed within a week to 5 months. In 3 patients, pain was relieved completely and in other 3 patients, mark improvement was achieved(80-90%). Remaining 4 patients showed significant improvement(30-50%). There was recurrence in only one case and she complained with similar intensity of pain at the last follow-up. There was no significant complication related to GKR. Conclusion : GKR is considered effective for trigeminal neuralgia based on the long term follow-up evaluation, but more clinical experience is needed to evaluate the efficacy of GKR for trigeminal neuralgia as a primary treatment modality.

두개강내 상의세포종 환자 30례에 있어서 재발에 영향을 주는 예후 인자

이해일,안재성,전상룡,김정훈,나영신,김창진,권병덕,Rhee, Hae Il,Ahn, Jae Sung,Jeon, Sang Ryong,Kim, Jeong Hoon,Rha, Young Shin,Kim, Chang Jin,Kwun, Byung Duk 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.2

Objective : The goal of this study was to identify variables that were predictive of recurrence in primary intracranial ependymomas. Methods : We analyzed variables affecting recurrence in 30 patients with primary intracranial ependymomas. Age, location, CSF cytology, seeding on neuroimaging study, tumor grade, extent of surgery, use of chemotherapy, chemotherapy regimen, use of radiotherapy, and radiotherapy field were entered to test their impacts on recurrence. Results : Follow-up ranged from 2 to 110 months. Tumors were recurred at the primary tumor site only in 13 patients (43.3%). The overall average recurrence free period was 55 months, with overall recurrence free rates at 3 and 6 years of 61.0% and 20.9%, respectively. Extent of surgery was the strongest variable affecting recurrence. The median recurrence free period and 3-year recurrence free rate were 72 months and 78.4% for patients having complete excision and 33 months and 0% for those having incomplete excision(p=0.05). Other prognostic variables like age, location, tumor grade, use of chemotherapy, and use of radiotherapy did not affect recurrence(p=0.2848, 0.7899, 0.1714, 0.2157, 0.7076, respectively). Conclusions : Intracranial ependymomas have a propensity to recur after treatment, and recurrence at the primary site is still the main obstacle to cure. Among various variables, only extent of resection had the strongest impact on recurrence. Additional studies may still be needed to precisely define the prognostic variables on recurrence in intracranial ependymomas.

성인에서 천막상부, 두개엽에 위치한 원발성 교모세포종의 치료에서 종양 절제의 역할

이종주,안재성,전상룡,김정훈,나영신,김창진,이정교,권병덕,Rhee, Jong Joo,Ahn, Jae Sung,Jeon, Sang Ryong,Kim, Jeong Hoon,Ra, Young Shin,Kim, Chang Jin,Lee, Jung Kyo,Kwun, Byung Duk 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.2

Objective : The therapeutic impact of tumor resection in glioblastomas is poorly defined and still questionable. Therefore, we conducted the current study to verify the role of tumor resection in the treatment of these highly malignant tumors. Methods : A retrospective study was performed(1990-1999) to compare the treatment results of surgical resection plus radiotherapy(130 patients) with those of stereotactic biopsy plus radiotherapy(19 patients) in glioblastomas. Only adult patients with supratentorial, de novo glioblastoma located in one lobe were included. Survival time/rate was analysed with Kaplan-Meier method, and prognostic variables were obtained from the univariate log-rank test and the multivariate Cox's proportional hazards model. Results : The resection group and the biopsy group did not differ in terms of age, gender, duration of symptoms, presenting symptoms, tumor location, tumor side, tumor size, and the frequency of midline shift. Patients in the biopsy group more often were found to have worse preoperative Karnofsky performance status(KPS)(p=0.001). On univariate analysis, age, KPS, and tumor side were associated with survival(p=0.0053, 0.0001, and 0.0331 respectively). Median survival time and 1-year survival rate were also statistically improved by tumor resection ; resection group - 13 months and 61.2%, and biopsy group - 8 months and 19.7%, respectively(p=0.0001). In patients with midline shift of the tumor, resection was highly effective comparing to biopsy(p=0.0001), but in patients without midline shift, external beam radiation alone was as effective as tumor resection(p=0.0605). Other prognostic variables did not affect survival. On multivariate analysis after variable selection, survival was independently associated with KPS(p=0.001), but not the surgical resection(p=0.2837). Even in biopsy group with midline shift of the tumor, survival rate was not different from that seen after tumor resection(p=0.3505). Conclusions : Radiotherapy alone was as effective as tumor resection plus radiotherapy in patients without midline shift of the tumor. Although there was not statistically significant, tumor resection looked like effective in patients with midline shift. For supratentorial, lobar glioblastoma patients without mass effect of the tumor, biopsy with radiotherapy is one of rational treatment strategies. We consider that tumor resection should be performed in patients with pretreatment midline shift.

내시경적 경접형동 접근술에 의한 뇌하수체 종양의 수술

안영상,전영일,안재성,전상룡,김정훈,나영신,노성우,김창진,권양,임승철,이정교,권병덕,Ahn, Young Sang,Chun, Young Il,Ahn, Jae Sung,Jeon, Sang Ryong,Kim, Jeong Hoon,Ra, Young Shin,Roh, Sung Woo,Kim, Chang Jin,Kwon, Yang,Rhim, Seung Chul,Lee 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.5

Objective : Transseptal or sublabial transsphenoidal surgery has been standard teatment for pituitary tumors for decades. However, as an alternative to this surgery endonasal endoscopic technique has been reported with encouraging results. We have started endoscopy-assisted transsphednoidal surgery from May 1998. In this paper we analyzed the methods, outcome, advantage and disadvantage of this surgical approach for the purpose of planning optimal treatment of pituitary tumors. Methods : This study consisits of 13 cases of pituitary tumors who were treated by endoscopy-assisted transsphenoidal surgery using one nostril from May 1998 to July 1999. Mean follow up period was 12.9 months. Results : There was no septal or sublabial incision and little surgical damage to nasal structure. With this technique, rapid surgical approach and short hospital day were possible, being 3-6 days in patients without CSF leakage. Using various angled endoscope, good surgical view was obtained. Initially it was difficult to use various instruments in narrow nasal cavity, but became feasible after several procedures. Among 13 cases, total removal was possible in 11 cases. One of two cases in whom tumor was incompletely removed underwent gamma-knife radiosurgery and second underwent reoperation through subfrontal approach. There were 6 cases of hormone secreting tumors and hormonal remission was achived in all of these cases. Postoperative complications were CSF leakage(6 cases), diabetes insipidus(2 cases) and panhypopituitarysm(1 case). Lumbar drainage was done in all cases of CSF leakage. Conclusion : The advantage of endoscopy-assisted transsphenoidal surgery are rapid surgical approach, low postoperative morbidity, short hospital day and good surgical view. The disadvantage of this appoach are difficulty in manupulating various instruments in narrow nostril and difficulty in distance perception but these problems can be overcome by practice and using stereoscopic endoscope.

측두엽내 공간 점유 병소와 동반된 난치성 간질의 수술적 치료 성적

박준범,이완수,이정교,전상룡,김정훈,노성우,나영신,김창진,권양,임승철,권병덕,강중구,이상암,고태성,Park, Jun Bum,Lee, Wan Su,Lee, Jung Kyo,Jeon, Sang Ryong,Kim, Jeong Hoon,Roh, Sung Woo,Ra, Young Shin,Kim, Chang Jin,Kwon, Yang,Rhim, Seung Chul 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.1

Objective : The increasing use of sensitive neuroimaging techniques has demonstrated that significant percentage of patients with intractable complex partial seizures have brain masses, especially in temporal lobe. The optimal surgical solution for these patients is still open to debate. The purpose of our investigation is to evaluate the surgical outcome of patient with lesion-related temporal lobe epilepsy with respect to the types of surgery and the location of lesion. Patients and Methods : From DEC. 1993 to Dec. 1997, 35 patients with intractable epilepsy and space occupying temporal lobe lesion identified in preoperative MRI were included in this study. The types of surgery were lesionectomy, anterior temporal lobectomy with or without hippocampectomy. The location of lesion was divided as anteromedial group and lateral cortical group. The postoperative seizure outcomes according to the type of surgery and location of the lesion were compared. Results : Twenty-six of 34 patients(76.5%) were seizure-free after surgery. The Engel's class was favorable after anterior temporal lobectomy with or without hippocampectomy(p=.044) Conclusion : It is favorable to perform anterior temporal lobectomy for the treatment of intractable epilepsy with space-occipying lesion in temporal lobe. The resection of the hippocampus can be individualized.

두개강내압 상승 환자에서 저체온법의 유용성 - 임 상 연 구 -

이종무,안재성,김정훈,김창진,권양,이정교,권병덕,전상룡,Lee, Jong Moo,Ahn, Jae Sung,Kim, Jeong Hoon,Kim, Chang Jin,Kwon, Yang,Lee, Jung Kyo,Kwun, Byung Duk,Jeon, Sang Ryong 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.2

Objectives : The goal of this study is to evaluate the usefulness of mild hypothermia treatment in patients with increased intracranial pressure(ICP). Material and Method : From November 1999 to May 2001, 11 patients were treated with mild hypothermia ($32-34^{\circ}C$) in whom ICP maintained at higher than 20mmHg in spite of decompressive surgery and high dose barbiturate therapy. The patient's rectal temperature were lowered by external cooling. Hypothermia was maintained for not more than 7 days and then the patients were rewarmed slowly for 24 hours. If increased ICP persisted for 2 days of hypothermia, this treatment was continued for several days. The functional outcome of each patient was assessed according to Glasgow Outcome Scale(GOS). Results : All cases except two cases showed decrease of ICP after hypothermia therapy. In 1 case which was right middle cerebral artery(MCA) infarct, ICP re-increased after 24 hours and in another 1 case, ICP was not controlled initially. Among 11 cases, 3 cases showed favorable outcome. Conclusion : Mild hypothermia treatment in patients with increased ICP was effective in controlling ICP and mortality was so decreased. More clinical experience and controlled study was need to determine the effectiveness.

두개인두종의 감마나이프 치료 후 장기 추적 결과

김윤석,이도희,라동숙,전영일,안재성,전상룡,김정훈,노성우,나영신,김창진,권양,임승철,이정교,권병덕,Kim, Yun Sok,Lee, Do Heui,Ra, Dong Suk,Chun, Young Il,Ahn, Jae Sung,Jeon, Sang Ryong,Kim, Jeong Hoon,Roh, Sung Woo,Ra, Young Shin,Kim, Chang Jin 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.2

Objectives : The optimal treatment of craniopharyngioma is controversial. Despite recent advances in microsurgical management, complete surgical removal of craniopharyngioma remains very difficult. Radiation added to surgery is effective, but radiation therapy resulted in untoward side effect in young patient. Gamma knife radiosurgery offers the theoretical advantage of a reduced radiation dose to surrounding structures during the treatment of residual or recurrent craniopharyngioma compared with fractionated radiotheraphy. We described retrospective analysis of tumor size and clinical symptoms of patients after gamma knife radiosurgery in residual or recurrent craniopharyngioma were performed. Material and Methods : From September 1990 to January 2000, 18 patients of craniopharyngioma were treated by gamma knife radiosurgery. All patient had undergone surgery, but residual or recurrent tumor was found and all of them treated postoperative gamma knife radiosurgery. The mean age was 19(from 6 to 66) and male to female ratio was 10 to 8 and 8 patients were below 15 years old. In young age group(below age 15), the average volume of the tumor was $2904.8mm^3$ and mean maximal gamma knife dose was 34.9Gy. In old age group(older than 15), the average volume of the tumor was $2590.4mm^3$ and mean maximal gamma knife dose was 45.2Gy. The size of the tumor was average $2730.1mm^3$($88-12000mm^3$), mean average radiation dose was 40.7Gy and the mean prescription dose was 17.6 Gy(4-35Gy) delivered to a median prescription 50.7% isodose. Results : The follow up was from 1 year to 9 years(mean 59.1 months) after gamma knife radiosurgery. The tumor was controlled in 13(72.2%) patients. The tumor decreased in 9 patients and not changed in 4 patients. The tumor size increased in 4(22.2%) patients during follow up period. In two cases the tumor size increased because of its cystic portion was increased, but their solid portion of the tumor was not changed. In another two patients, the solid portion of the tumor was increased. So, one patient underwent reoperation and the other patient underwent operation and repeated gamma knife radiosurgery. The tumor recurred in one case(5.6%) that is a outside of irradiated site. The presenting symptoms were improved in 4 patients(improved visual acuity in 1, controlled increased intracranial presure sign in 3 patients). In one case, visual acuity decreased after gamma knife radiosurgery. The endocrine symptoms were not influenced by gamma knife radiosurgery. Conclusion : Craniopharyngioma can be treated successfully by gamma knife radiosurgery. Causes of the tumor regrowth are inadequate dose planning because of postoperatively poor margination of the tumor, close approximation of optic nerve and residual tumors outside the target lesion. Recurrence can develop 4 years after gamma knife radiosurgery. Volume is important, but the accurate targeting is more important to prevent tumor recurrence. If the tumor definition is not clear during planning gamma knife surgery, long-term image follow up is required.

라스케씨 열낭종과 동시에 발생한 뇌하수체 선종

김정훈 ( Jeong Hoon Kim ),권순찬 ( Soon Chan Kwon ),안재성 ( Jae Sung Ahn ),전상룡 ( Sang Ryong Jeon ),나영신 ( Young Shin Ra ),김창진 ( Chang Jin Kim ),이정교 ( Jung Kyo Lee ) 대한뇌종양학회 2003 대한뇌종양학회지 Vol.2 No.2

Objective:The goal of this study was to characterize the clinical, radiological, surgical, and pathological findings in patients with both pituitary adenoma and Rathke`s cleft cyst. Methods:We conducted a retrospective study of patients with concomitant pituitary adenoma and Rathke`s cleft cyst operated on from 1991 through 2001 at our institution. Three patients were identified with this diagnosis. The medical records, neuroradiologic studies, and histologies were reviewed. Results:There were 771 patients with pituitary adenoma and 46 with Rathke`s cleft cyst in the same period. The frequency of the combination was 0.39 % of pituitary adenoma and 6.5% of Rathke`s cleft cyst. One case was associated with hyperprolactinemia. Preoperative diagnosis on the basis of CT/MRI was pituitary adenoma in all three cases. Transsphenoidal approaches were done for these three patients, and postoperative courses were uneventful. Hormonal and visual symptoms were improved. Histologically, the tumor was composed of typical pituitary adenoma and component compatible with Rathke`s cleft cyst. Conclusion:When a non-enhancing cyst-like structure is demonstrated in a patient with pituitary adenoma, the possibility of a coexisting Rathke`s cleft cyst should be considered. Patients with this kind of pituitary tumor can be managed in the same fashion as patients with other types of pituitary adenoma.

척추 경막외 출혈에 대한 수술적 치료성적 분석

조영현 ( Young Hyun Cho ),박진훈 ( Jin Hoon Park ),김지훈 ( Ji Hoon Kim ),노성우 ( Sung Woo Roh ),김창진 ( Chang Jin Kim ),전상룡 ( Sang Ryong Jeon ) 대한외상학회 2010 大韓外傷學會誌 Vol.23 No.2

Purpose: Spinal epidural hematoma (EDH) is a rare condition requiring an urgent diagnosis and management. We describe here the clinical features, magnetic resonance image (MRI) findings, and outcomes of surgery in six patients with spinal EDH. Methods: We retrospectively analyzed six patients who underwent surgery for spinal EDH between April 2004 and May 2010. Preoperative MRI findings within 48 hours of symptom occurrence were analyzed for cord compression, extent of EDH, and presence of vascular abnormalities. Pre- and postoperative neurological status was also assessed comparatively. Results: Our six patients consisted of three men and three women, with a mean age of 70 years (range: 54-88 years), who presented with the back pain or motor weakness. The mean follow-up period was 34 months (range: 2-72 months). Two patients had cardiovascular disease and were taking warfarin, but the others had no history of medical comorbidity. Those two patients taking warfarin had a history of trauma, another one experienced symptoms during a strenuous effort, and the others developed spontaneously. Before surgery, motor power was grade III in three patients, grade 0 in two patients, and normal in one patient. Preoperative MRI showed no vascular abnormalities except for the EDH in any patient. At the last follow-up, all those five patients with motor weakness showed neurological improvement compared to their preoperative status. There were no complications related to surgery. All six patients were able to ambulate with or without an assistive device. Conclusion: Spinal EDH can occur in patients without trauma, bleeding diathesis, or combined vascular pathology. The surgical outcomes of spinal EDH seem to be satisfactory, even in quadriplegic patients. (J Korean Soc Traumatol 2010;23:163-169).

해면정맥동 부위 거대동맥류에 있어서 외경동맥과 중대뇌동맥간 복재정맥 우회 이식술 : 증례보고

전상룡,장웅규,정천기,한대희 대한신경외과학회 1994 Journal of Korean neurosurgical society Vol.23 No.5

The authors report a case of giant internal carotid artery aneurysm at the cavernous portion which was treated by trapping of internal carotid artery(1CA) after external carotid artery(ECA) to middle cerebral artery(MCA) bypass by long saphenous vein graft. It was impossible to clip the aneurysm because of its position and size. The patient suffered from progressive extraocular movement disturbance and decreased visual acuity. She was intolerant to balloon occlusion test. The size of the aneurysm was 3.5 X 25X 2cm. ECA to MCA bypass was done with saphenous vein graft successfdly. However, computerized tomography shows hemorrhagic infarction at left temporal lobe postoperatively. Two days later, left temporal lobectomy was done because of uncontrollable increased intracranial pressure. Internal carotid artery was trapped with pmxb mal ligation and distal clipping at the supraclinoid segment.