Friday, September 19, 2014

Management of Atypical Cranial Meningiomas, Part 2: Predictors of Progression and the Role of Adjuvant Radiation After Subtotal Resection

Management of Atypical Cranial Meningiomas, Part 2: Predictors of Progression and the Role of Adjuvant Radiation After Subtotal Resection
Neurosurgery - Current Issue

imageBACKGROUND: The efficacies of adjuvant stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) for atypical meningiomas (AMs) after subtotal resection (STR) remain unclear. OBJECTIVE: To analyze the clinical, histopathological, and radiographic features associated with progression in AM patients after STR. METHODS: Fifty-nine primary AMs after STR were examined for predictors of progression, including the impact of SRS and EBRT, in a retrospective cohort study. RESULTS: Twenty-seven patients (46%) progressed after STR (median, 30 months). On univariate analysis, spontaneous necrosis positively (hazard ratio = 5.2; P = .006) and adjuvant radiation negatively (hazard ratio = 0.3; P = .009) correlated with progression; on multivariate analysis, only adjuvant radiation remained independently significant (hazard ratio = 0.3; P = .006). SRS and EBRT were associated with greater local control (LC; P = .02) and progression-free survival (P = .007). The 2-, 5-, and 10-year actuarial LC rates after STR vs STR/EBRT were 60%, 34%, and 34% vs 96%, 65%, and 45%. The 2-, 5-, and 10-year actuarial progression-free survival rates after STR vs STR/EBRT were 60%, 30%, and 26% vs 96%, 65%, and 45%. Compared with STR alone, adjuvant radiation therapy significantly improved LC in AMs that lack spontaneous necrosis (P = .003) but did not improve LC in AMs with spontaneous necrosis (P = .6). CONCLUSION: Adjuvant SRS or EBRT improved LC of AMs after STR but only for tumors without spontaneous necrosis. Spontaneous necrosis may aid in decisions to administer adjuvant SRS or EBRT after STR of AMs. ABBREVIATIONS: AM, atypical meningioma EBRT, external beam radiation therapy GTR, gross total resection LC, local control NTR, near-total resection PFS, progression-free survival RT, radiation therapy SRS, stereotactic radiosurgery STR, subtotal resection

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/10000/Management_of_Atypical_Cranial_Meningiomas,_Part.14.aspx
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Gamma Knife Radiosurgery for Cerebellopontine Angle Meningiomas: A Multicenter Study

Gamma Knife Radiosurgery for Cerebellopontine Angle Meningiomas: A Multicenter Study
Neurosurgery - Current Issue

imageBACKGROUND: Resection of cerebellopontine angle (CPA) meningiomas may result in significant neurological morbidity. Radiosurgery offers a minimally invasive alternative to surgery. OBJECTIVE: To evaluate, in a multicenter cohort study, the outcomes of patients harboring CPA meningiomas who underwent Gamma Knife radiosurgery (GKRS). METHODS: From 7 institutions participating in the North American Gamma Knife Consortium, 177 patients with benign CPA meningiomas treated with GKRS and at least 6 months radiologic follow-up were included for analysis. The mean age was 59 years and 84% were female. Dizziness or imbalance (48%) and cranial nerve (CN) VIII dysfunction (45%) were the most common presenting symptoms. The median tumor volume and prescription dose were 3.6 cc and 13 Gy, respectively. The mean radiologic and clinical follow-up durations were 47 and 46 months, respectively. Multivariate regression analyses were performed to identify the predictors of tumor progression and neurological deterioration. RESULTS: The actuarial rates of progression-free survival at 5 and 10 years were 93% and 77%, respectively. Male sex (P = .014), prior fractionated radiation therapy (P = .010), and ataxia at presentation (P = .002) were independent predictors of tumor progression. Symptomatic adverse radiation effects and permanent neurological deterioration were observed in 1.1% and 9% of patients, respectively. Facial spasms at presentation (P = .007) and lower maximal dose (P = .011) were independently associated with neurological deterioration. CONCLUSION: GKRS is an effective therapy for CPA meningiomas. Depending on the patient and tumor characteristics, radiosurgery can be an adjuvant treatment to initial surgical resection or a standalone procedure that obviates the need for resection in most patients. ABBREVIATIONS: ARE, adverse radiation effect CN, cranial nerve CPA, cerebellopontine angle EBRT, external beam radiation therapy GKRS, Gamma Knife radiosurgery IAC, internal auditory canal NAGKC, North American Gamma knife Consortium PFS, progression-free survival SRS, stereotactic radiosurgery WHO, World Health Organization

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/10000/Gamma_Knife_Radiosurgery_for_Cerebellopontine.19.aspx
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Dose-Volume Analysis of Radiation-Induced Optic Neuropathy After Single-Fraction Stereotactic Radiosurgery

Dose-Volume Analysis of Radiation-Induced Optic Neuropathy After Single-Fraction Stereotactic Radiosurgery
Neurosurgery - Current Issue

imageBACKGROUND: The risk of radiation-induced optic neuropathy (RION) is the primary limitation of single-fraction stereotactic radiosurgery (SRS) for many patients with parasellar lesions. OBJECTIVE: To define the normal tissue complication probability of the anterior visual pathways (AVPs) after single-fraction SRS. METHODS: Retrospective review comparing visual function before and after SRS in 133 patients (266 sides) with pituitary adenomas having SRS between October 2007 and July 2012. Patients with prior radiation therapy or SRS were excluded. The median follow-up after SRS was 32 months. RESULTS: The median maximum point dose to the AVP was 9.2 Gy (interquartile range [IQR], 6.9-10.8). One hundred seventy-four sides (65%) received >8 Gy: the median 8-Gy volume was 15.8 mm3 (IQR, 3.7-36.2). Ninety-four sides (35%) received >10 Gy; the median 10-Gy volume was 1.6 mm3 (IQR, 0.5-5.3). Twenty-nine sides (11%) received >12 Gy; the median 12-Gy volume was 0.1 mm3 (IQR, 0.1-0.6). No patient had a RION after SRS. The chances of developing a RION at the 8-Gy, 10-Gy, and 12-Gy volumes (95% confidence interval) in this series were 0% to 2.6%, 0% to 4.7%, and 0% to 13.9%, respectively. CONCLUSION: The AVP in patients without prior radiation treatments can safely receive radiation doses up to 12 Gy with a low risk of RION. Although additional studies are needed to better delineate the normal tissue complication probability of the AVP, adherence to the AVP radiation tolerance guidelines developed 20 years ago (8 Gy) limits the applicability and potentially the effectiveness of single-fraction SRS for patients with lesions in the parasellar region. ABBREVIATIONS: AVP, anterior visual pathway CI, confidence interval EBRT, external beam radiation therapy IQR, interquartile range RION, radiation-induced optic neuropathy SRS, stereotactic radiosurgery

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/10000/Dose_Volume_Analysis_of_Radiation_Induced_Optic.25.aspx
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Why Brain Death Is Death

Why Brain Death Is Death
Medscape NeurologyHeadlines

The case of a 13-year-old girl declared to be brain-dead but who continues to receive care highlights the need for physicians and other stakeholders to revisit the determination of brain death.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/832001?src=rss
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Saturday, September 13, 2014

Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes

Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes
Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 3, Page 505-510, September 2014.
Object Cavernous sinus (CS) invasion is the most important preoperative predictor of remission in the surgical treatment of growth hormone–producing pituitary adenomas. The purpose of this study was to evaluate the effectiveness of an aggressive technique for removal of tumors invading the CS in patients with acromegaly. Methods The authors retrospectively reviewed the cases of 150 consecutive patients with acromegaly who underwent primary transsphenoidal surgery in 2010 and 2011. The authors reviewed preoperative Knosp grade, intraoperative findings, histology of the medial wall of the CS, and surgical outcome according to the current consensus criteria for acromegaly. Results Cavernous sinus invasion was identified in 55 patients (36.7%): definite CS involvement by the tumor was observed under direct vision in 41 patients (74.5%), while invasion was histologically verified in 39 patients (70.9%). Invasion increased in frequency with the higher Knosp grade but was observed in 14.4% (13 of 90) of Grade 0 and 1 tumors. Overall, the remission rate fulfilling stringent criteria was 84.7% (127 of 150). Although CS invasion was significantly associated with an unfavorable outcome (p < 0.0001), remission was achieved in 69.1% (38 of 55) of patients with invasion. No major complications occurred in this series. Conclusions Cavernous sinus invasion is the most significant, independent predictor of unfavorable outcome. Confirmation of invasion requires direct observation within the CS regardless of the microscope or endoscope used. Particularly in cases in which only the medial wall is involved, histological verification is always necessary to detect the occult invasion. Direct removal of the invading tumor, by sharp excision of the medial wall of the CS, is effective and safe and increases the chance of remission.

Original Article: http://thejns.org/doi/abs/10.3171/2014.3.JNS132214?ai=ru&mi=0&af=R
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Friday, September 12, 2014

Fwd: I Simpósio de Neuro-Oncologia

To: Serviço de Apoio ao Medico <sam@bpsp.org.br>
Subject: I Simpósio de Neuro-Oncologia

 

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Saturday, September 6, 2014

Handheld scanner could make brain tumor removal more complete, reducing recurrence

Handheld scanner could make brain tumor removal more complete, reducing recurrence
Neurology News & Neuroscience News from Medical News Today

Cancerous brain tumors are notorious for growing back despite surgical attempts to remove them - and for leading to a dire prognosis for patients.

Original Article: http://www.medicalnewstoday.com/releases/282033.php
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Tuesday, September 2, 2014

Resection of spinal hemangioblastoma

Resection of spinal hemangioblastoma
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue Suppl2, Page Video 15, September 2014.
Spinal cord hemangioblastomas occur as sporadic lesions or in the setting of Von Hippel-Lindau disease. In this intraoperative video we present a case of sporadic cervical cord hemangioblastoma and illustrate the main surgical steps to achieve safe and complete resection which include: identification and division of the feeding arteries; careful circumferential dissection of the tumor from the surrounding gliotic cord; identification, isolation and division of the main venous drainage and single piece removal of the tumor. The video can be found here: http://youtu.be/I7DxqRrfTxc.

Original Article: http://thejns.org/doi/abs/10.3171/2014.V3.FOCUS14379?ai=rw&mi=3ba5z2&af=R
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Microsurgical technique in excision of intramedullary craniocervical ependymomas. Video report

Microsurgical technique in excision of intramedullary craniocervical ependymomas. Video report
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue Suppl2, Page Video 17, September 2014.
We present the microsurgical technique in excision of intramedullary craniocervical ependymomas. A 27-year-old female came presenting with neck pain and parasthesia in her both arms and hands, where MRI was performed showing intramedullary lesion that extend in the medulla just beyond the foramen magnum to the level of C5–6 disc. Tumor was totally excised using irrigation-dissection microscopic technique with favorable outcome. The video can be found here: http://youtu.be/Yj1yvZOaz58.

Original Article: http://thejns.org/doi/abs/10.3171/2014.V3.FOCUS14391?ai=rw&mi=3ba5z2&af=R
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The natural history of AVM hemorrhage in the posterior fossa: comparison of hematoma volumes and neurological outcomes in patients with ruptured infra- and supratentorial AVMs

The natural history of AVM hemorrhage in the posterior fossa: comparison of hematoma volumes and neurological outcomes in patients with ruptured infra- and supratentorial AVMs
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 3, Page E6, September 2014.
Object Patients with posterior fossa arteriovenous malformations (AVMs) are more likely to present with hemorrhage than those with supratentorial AVMs. Observed patients subject to the AVM natural history should be informed of the individualized effects of AVM characteristics on the clinical course following a new, first-time hemorrhage. The authors hypothesize that the debilitating effects of first-time bleeding from an AVM in a previously intact patient with an unruptured AVM are more pronounced when AVMs are located in the posterior fossa. Methods The University of California, San Francisco prospective registry of brain AVMs was searched for patients with a ruptured AVM who had a pre-hemorrhage modified Rankin Scale (mRS) score of 0 and a post-hemorrhage mRS score obtained within 2 days of the hemorrhagic event. A total of 154 patients met the inclusion criteria for this study. Immediate post-hemorrhage presentation mRS scores were dichotomized into nonsevere outcome (mRS ≤ 3) and severe outcome (mRS > 3). There were 77 patients in each group. Univariate and multivariate logistic regression analyses using severe outcome as the binary response were run. The authors also performed a logistic regression analysis to measure the effects of hematoma volume and AVM location on severe outcome. Results Posterior fossa location was a significant predictor of severe outcome (OR 2.60, 95% CI 1.20–5.67, p = 0.016) and the results were strengthened in a multivariate model (OR 4.96, 95% CI 1.73–14.17, p = 0.003). Eloquent location (OR 3.47, 95% CI 1.37–8.80, p = 0.009) and associated arterial aneurysms (OR 2.58, 95% CI 1.09, 6.10; p = 0.031) were also significant predictors of poor outcome. Hematoma volume for patients with a posterior fossa AVM was 10.1 ± 10.1 cm3 compared with 25.6 ±28.0 cm3 in supratentorial locations (p = 0.003). A logistic analysis (based on imputed hemorrhage volume values) found that posterior fossa location was a significant predictor of severe outcome (OR 8.03, 95% CI 1.20–53.77, p = 0.033) and logarithmic hematoma volume showed a positive, but not statistically significant, association in the model (p = 0.079). Conclusions Patients with posterior fossa AVMs are more likely to have severe outcomes than those with supratentorial AVMs based on this natural history study. Age, sex, and ethnicity were not associated with an increased risk of severe outcome after AVM rupture, but posterior fossa location, associated aneurysms, and eloquent location were associated with poor post-hemorrhage mRS scores. Posterior fossa hematomas are poorly tolerated, with severe outcomes observed even with smaller hematoma volumes. These findings support an aggressive surgical posture with respect to posterior fossa AVMs, both before and after rupture.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14211?ai=rw&mi=3ba5z2&af=R
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