Optimal Treatment Decision for Brain Metastases of Unknown Primary Origin: The Role and Timing of Radiosurgery

BACKGROUND: Up to 15% of all patients with brain metastases have no clearly detected primary site despite intensive evaluation, and this incidence has decreased with the use of improved imaging technology. Radiosurgery has been evaluated as one of the treatment modality for patients with limited brain metastases. In this study, we evaluated the effectiveness of radiosurgery for brain metastases from unknown primary tumors. METHODS: We retrospectively evaluated 540 patients who underwent gamma knife radiosurgery (GKRS) for brain metastases radiologically diagnosed between August 1992 and September 2007 in our institution. First, the brain metastases were grouped into metachronous, synchronous, and precocious presentations according to the timing of diagnosis of the brain metastases. Then, synchronous and precocious brain metastases were further grouped into 1) unknown primary; 2) delayed known primary; and 3) synchronous metastases according to the timing of diagnosis of the primary origin. We analyzed the survival time and time to new brain metastasis in each group. RESULTS: Of the 540 patients, 29 (5.4%) presented precocious or synchronous metastases (34 GKRS procedures for 174 lesions). The primary tumor was not found even after intensive and repeated systemic evaluation in 10 patients (unknown primary, 34.5%); found after 8 months in 3 patients (delayed known primary, 1.2%); and diagnosed at the same time as the brain metastases in 16 patients (synchronous metastasis, 55.2%). No statistically significant differences in survival time and time to new brain metastasis were found among the three groups. CONCLUSION: Identification of a primary tumor before GKRS did not affect the patient outcomes. If other possible differential diagnoses were completely excluded, early GKRS can be an effective treatment option for brain metastases from unknown primary tumor.ope

Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era

Purpose: The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. Materials and methods: From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017-2019). Results: Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0-106.0), pre-COVID-19; 40.0 min (27.0-98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0-560.0), pre-COVID-19; 184.0 min (134.0-271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID19, 46.7% in pre-COVID-19, p=0.039). Conclusion: During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.ope

병원 수익성 영향요인 분석에 관한 연구

학위논문(석사) --서울대학교 대학원 :보건학과(보건정책관리학전공),2008. 2.Maste

Evaluation of implant failure causes : a 19-Year retrospective study

치의학과/석사[한글]임플란트가 치아 결손 부위의 수복에 있어 예지성 있는 치료가 되어 왔으나 소수의 환자에서 여전히 임플란트 실패가 발생하고 있다. 본 연구의 목적은 임플란트가 실패한 증례에서 임플란트 실패 원인과 위험 인자와의 연관성을 분석함으로써 궁극적으로 임플란트 실패율을 감소시키는데 도움을 주고자 하는데 있다. 1991년2월부터 2009년 5월까지의 기간 동안 연세대학교 치과대학병원에 내원하여 임플란트 식립 및 보철 수복을 받은 임플란트 식립 및 보철 수복을 받은 879명 환자, 2796개의 임플란트 중 1개 이상의 임플란트가 실패한 환자를 대상으로 후향적 연구를 시행하였다. 진료 기록부 및 치과 방사선 사진을 토대로 환자, 임플란트, 수술, 보철 특성에 관한 정보를 수집 후 임플란트 실패 원인을 평가하였으며 위험 인자와 실패 원인간의 상관성을 분석하였다. 연구 결과는 다음과 같다. 1.총 879명의 환자에게 식립된 2796개의 임플란트 중 91명의 환자에서 150개의 임플란트가 실패하였으며 조기 실패는 86개로 57.33%의 비중을 차지하였고 지연 실패는 64개로 42.67%를 차지하였다. 2.조기 실패의 원인은 염증 40개(47%), 골유착 실패 23개(27%), 조기 부하 11개(13%), 숙주 반응 7개(8%), 원인을 알 수 없는 경우 3개(3%), 그리고 여러 원인이 혼합된 경우 2개(2%)의 순으로 나타났다. 3.지연 실패의 원인은 과부하 34개(53%), 임플란트 고정체 파절 11개(17%), 임플란트 주위염 8개(13%), 원인 미상 6개(9%), 숙주 반응 4개(6%), 그리고 염증 1개(2%)의 순서로 나타났다. 4.조기 실패에서 실패 원인이 염증인 경우 상악 전치부, 불량한 초기 안정성, 기계 절삭 임플란트 표면, 15mm이상의 임플란트 길이, 재건적 술식의 동반, 그리고 2단계 술식에서 실패율이 유의성 있게 높았으며 골유착 실패가 원인인 경우는 Type Ⅲ의 골질, 불량한 초기 안정성, 재건적 술식 동반시 실패율이 유의성 있게 높았다. 조기 부하가 원인인 경우는 기계 절삭 임플란트 표면, 재건적 술식 동반시 실패율이 유의성 있게 높았다. 5.지연 임플란트의 실패 원인이 과부하인 경우 기계 절삭 임플란트 표면, 재건적 술식 동반, 2단계 술식 그리고 telescopic denture에서 유의성 있게 높은 실패율을 나타내었다. 실패 원인이 임플란트 고정체 파절인 경우는 남성, 기계 절삭 임플란트 표면, 2단계 술식시에 실패율이 유의성 있게 높았다. [영문]ope

Flow diverter for the treatment of large (> 10 mm) vertebral artery dissecting aneurysms

Objective: To evaluate the outcomes of flow-diverting device (FDD) treatment for large vertebral artery dissecting aneurysms (VADAs). Methods: This retrospective study evaluated 12 patients with 12 VADAs who were treated using FDD between 2013 and 2020. Clinical and radiographic data, including procedure-related complications and clinical outcomes assessed using the modified Rankin Scale (mRS) at the time of the last follow-up, were collected and reviewed. Results: All 12 patients had unruptured aneurysms. There were 3 (25%) female and 9 (75%) male patients, and the mean patient age was 54.6 years. The mean size of the aneurysm was 15.9 ± 4.8 mm. The mean follow-up duration was 15.8 months. Single FDD without additional coils was used in all patients. One patient underwent second-line treatment with FDD for recurrence of large VADA after stent-assisted coiling. Immediate follow-up angiography after placement of the FDD demonstrated intra-aneurysmal contrast stasis. There were 2 (17%) patients who had peri-procedural stroke. Angiography at the 6-month follow-up in 10 patients showed favorable occlusion (OKM grade C3 + D). A total of 11 (92%) patients had good clinical outcome (modified Rankin Scale ≤ 2) at the last follow-up. No re-treatment or delayed aneurysm rupture occurred during the follow-up period. Conclusions: Reconstructive technique with FDD is a feasible and effective modality for the treatment of large VADAs, showing favorable occlusion rate and clinical outcome.restrictio

Ruptured Infundibular dilatation of the posterior communicating artery

Objective: An infundibulum of the posterior communicating artery (PcomA) or infundibular dilatation (ID) is considered to be a benign anatomical variant. However, some evidence suggests that ID is a pre-aneurysmal state. This case series presents cases of ruptured IDs and aneurysms originating from the IDs. Methods: Between April 2002 and June 2020, 1337 patients were treated for aneurysmal subarachnoid hemorrhage (SAH). Among them, 7 patients with ruptured PcomA IDs were identified. Rupture IDs of the PcomA were categorized into 1) direct rupture of IDs, and 2) rupture of aneurysms originating from IDs. The clinical and radiographic factors were retrospectively reviewed. Results: Two patients experienced direct rupture of IDs, while the other 5 patients presented with ruptured aneurysms originating from IDs. The 2 patients with direct rupture of IDs at presentation were relatively younger (< 50 years), while the other 5 patients with ruptured aneurysms originating from IDs were over 70 and had a history of aneurysmal SAH due to other intracranial aneurysms. Ruptured IDs were treated with microsurgery or endovascular treatment. There were no complications related to the procedure for securing ruptured IDs. Five (71.4%) patients showed favorable outcomes. One patient with initial Hunt and Hess grade 4 died due to initial brain damage with cerebral vasospasm and medical complications. Conclusions: ID of the PcomA rarely causes SAH with or without aneurysm formation. Thus, patients with IDs of the PcomA should be carefully followed up for a long period, especially those with a history of aneurysmal SAH.restrictio

Formation, Growth, or Rupture of De Novo Intracranial Aneurysms: Long-Term Follow-up Study of Subarachnoid Hemorrhage Survivors

Background: The survival rate of aneurysmal subarachnoid hemorrhage (aSAH) has gradually increased, leading to more clinical cases of de novo intracranial aneurysms (DNIAs). Objective: To identify the characteristics of patients with DNIA growth or rupture. Methods: We included 1601 patients with aSAH treated by clipping from January 1993 to May 2010. According to the inclusion and exclusion criteria, 233 patients had no DNIAs, and 63 patients had 77 DNIAs. We assessed the incidence rate of DNIAs and risk factors for DNIA formation. After dichotomizing the DNIA group into the heed (patients with DNIA rupture or growth) and stable groups (patients without DNIA growth), we assessed the risk factors for DNIA growth or rupture. Results: The total follow-up period was 4427.9 patient-years. The incidence rate per patient-year was 1.42%. Age ≤50 yr, family history of aneurysm, and multiplicity at initial aSAH were significant risk factors for DNIA formation. Multivariate regression analysis revealed that female sex (odds ratio [OR], 5.566; 95% confidence interval [CI], 1.241-24.952), duration from initial aSAH to DNIA detection <120 mo (OR, 5.043; 95% CI, 1.362-18.668), multiplicity at initial aSAH (OR, 4.859; 95% CI, 1.207-19.563), and maximum DNIA diameter ≥4 mm (OR, 11.104; 95% CI, 2.337-52.772) were significant risk factors for DNIA growth or rupture. Conclusion: DNIAs had a higher incidence rate than expected. Taking into account the presented incidence rate and risk factors, long-term surveillance in aSAH survivors for more than a decade may be worth considering, at least on a case-by-case basis.restrictio

Safety and Efficacy of Stent-Assisted Coiling of Unruptured Intracranial Aneurysms Using Low-Profile Stents in Small Parent Arteries

Background and purpose: Stent-assisted coiling of intracranial aneurysms arising from small vessels (≤ 2.0 mm) is a common procedure. However, data regarding its treatment outcomes are scarce. This study evaluated the clinical and radiologic outcomes of stent-assisted coiling using low-profile stents for aneurysms of small parent arteries. Materials and methods: From November 2015 to October 2020, sixty-four patients with 66 aneurysms arising from parent arteries of ≤2.0 mm were treated with stent-assisted coiling using a Low-Profile Visualized Intraluminal Support Junior (LVIS Jr) or the Neuroform Atlas stent in a single institution. The clinical and radiologic data were retrospectively reviewed, and the risk factors for procedure-related complications were evaluated. Results: The LVIS Jr and Neuroform Atlas stents were used in 22 (33.3%) and 44 (66.7%) cases, respectively. Technical success was achieved in 66 cases (100%). Immediate postprocedural aneurysm occlusion grades assessed by the Raymond-Roy occlusion classification were I (57.6%), II (19.7%), and III (22.7%), respectively. Procedure-related complications occurred in 10 cases (15.2%), with 8 thromboembolic complications (12.1%) and 2 hemorrhagic complications (3.0%). Procedure-related morbidity was 4.5% without mortality. On multivariate analysis, current smoking (odds ratio = 7.1, P = .021) had a statistically significant effect on procedure-related complications. Conclusions: Stent-assisted coiling of intracranial aneurysms with low-profile stents in small vessels (≤ 2.0 mm) had a 100% success rate and a 15.2% overall complication rate with 4.5% morbidity. Current smoking was a significant risk factor associated with procedure-related complications.restrictio

Predictors of Ventriculostomy-Associated Infections: A Retrospective Study of 243 Patients

Objective: Risk factors of ventriculostomy-associated infection (VAI) reported in the literature are variable owing to heterogeneity of external ventricular drainage (EVD) procedures and management. This study aimed to assess the rate of VAI and its risk factors. Methods: The medical records of patients >18 years old who received EVD catheterizations between January 2015 and December 2020 were retrospectively reviewed. Results: Among 243 patients with 355 catheters, 23 VAIs were identified, yielding VIA rates of 9.5% per patient and 6.5% per catheter. VAI was associated with a longer total EVD duration (29.2 days vs. 15.8 days, P < 0.001), a longer procedural time (72 minutes vs. 41 minutes, P < 0.001), intraoperative ventriculostomy (39.1% vs. 9.1%, P < 0.001), craniotomy (87.0% vs. 60.9%, P = 0.014), and other systemic infections (30.4% vs. 8.2%, P = 0.004). On multivariate analysis, a longer total EVD duration (odds ratio 1.086, P < 0.001), intraoperative ventriculostomy (odds ratio 6.119, P = 0.001), and other systemic infections (odds ratio 4.620, P = 0.015) were associated with VAI. There was no statistical difference between the VAI rates of patients with and without prophylactic EVD exchanges at a mean 12.6 days (7.1% vs. 2.2%, P = 0.401). Conclusions: Intraoperative ventriculostomy was independently associated with VAI. Prophylactic EVD exchange at 12.6 days did not lower VAI rate.restrictio