ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEWe developed a protocol for a clinical trial of postresection implantation of Gliadel wafers in patients with aggressive, relentlessly recurring pituitary adenomas and craniopharyngiomas.METHODSTen patients, nine with pituitary adenomas and one with a craniopharyngioma, underwent implantation of from two to eight Gliadel wafers.RESULTSNo obvious adverse reactions occurred. Death as a result of disease progression occurred in two patients with malignant adenomas. One patient died as a result of a stroke after undergoing five surgical procedures and prior radiotherapy. The seven living patients have been followed for 5 to 27 months (mean follow-up, 19 mo). Four patients have been free of recurrent or residual tumor, two have stable residual disease, and one has experienced tumor progression.CONCLUSIONThe results of this study suggest a role for Gliadel implantation in patients with recurring aggressive pituitary adenomas and craniopharyngiomas.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEGliomatosis cerebri is an enigmatic diffuse brain neoplasm whose prognosis is grim. We reviewed data for patients with gliomatosis who were treated at the University of California, San Francisco, during a 10-year period. Our focus was on presentation, radiological and pathological features, and outcomes.METHODSWe reviewed hospital and clinic records and magnetic resonance imaging scans for 22 patients with gliomatosis. The diagnosis was based on magnetic resonance imaging findings and tissue confirmation for all patients. Seven patients also underwent magnetic resonance spectroscopy. Eleven patients were male (50%), and the median age at presentation was 49 years (range, 7–79 yr).RESULTSKaplan-Meier analysis demonstrated median lengths of survival as follows: no treatment, 1 month (n = 4); radiotherapy alone, 28 months (95% confidence interval, 5–51 mo; n = 13); radiotherapy followed by chemotherapy, two patients, alive at 28 and 104 months; radiotherapy and chemotherapy simultaneously, three patients, one alive at 18 months and the others dead at 7 and 9 months. There was no significant difference between radiotherapy alone and radiotherapy combined with chemotherapy (P= 0.69). Karnofsky Performance Scale scores of ≥70 and grade were both significantly related to length of survival in univariate analyses (P< 0.05); these correlations were confirmed in the multivariate analysis, although the small numbers of patients and deaths precluded reliable interpretation.CONCLUSIONAlthough the small number of patients in our study and its retrospective nature preclude definitive conclusions regarding the utility of treatment, our findings suggest that biopsies are useful not only for diagnosis but also for prediction of the length of survival.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVETo identify a size cutoff below which it is safe to observe obscure brain lesions suspected of being metastases so that treatment of nonmetastases can be avoided.METHODSMedical records from patients who underwent linear accelerator-based radiosurgery from August 1991 to October 2001 were reviewed. Inclusion criteria were defined as brain metastasis tumor volume less than 5 cm3(diameter, ∼2.1 cm) treated with a dose of 20 Gy or more. One hundred thirty-five patients had 153 evaluable brain metastases with follow-up imaging that met inclusion criteria. Median age was 54 years (range, 18–79 yr). Lesion primaries were non-small-cell lung (n = 39), melanoma (n = 44), renal (n = 37), breast (n = 18), colon (n = 3), sarcoma (n = 5), other (n = 5), and unknown primary (n = 2). Median tumor volume was 0.67 cm3(range, 0.06–4.58 cm3). The minimum peripheral dose was 20 Gy (n = 132) or 21 to 24 Gy (n = 21). At the time of analysis, the median follow-up for all patients was 10 months (range, 0.2–99 mo).RESULTSThe 1- and 2-year actuarial local control rates for all of the lesions were 69 and 46%, respectively. For lesions of 1 cm (0.5 cm3) or less, the corresponding local control rates were 86 and 78%, respectively, which was significantly higher than the corresponding rates of 56 and 24%, respectively, for lesions larger than 1 cm (0.5 cm3) (P= 0.0016).CONCLUSIONA convincing brain metastasis measuring less than 1 cm should be pursued aggressively. If the suspected brain metastasis is ambiguous, observation is proposed up to a diameter of 1 cm. This is the first study in the literature to identify a 1-cm cutoff for radiosurgical control of small brain metastases, and validation by additional studies is required.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEThe results of radiosurgical treatment of acoustic neuromas have improved by reducing the tumor marginal doses. We report relatively long-term follow-up results (>5 yr) for patients who underwent low-dose radiosurgery.METHODSWe treated and followed 51 consecutive patients with unilateral acoustic neuromas who were treated from January 1994 to December 1996 by gamma knife radiosurgery at low doses (≤12 Gy to the tumor margin). The average age of the patients was 55 years (range, 32–76 yr). The treatment volume was 0.7 to 24.9 cm3(median, 3.6 cm3). The marginal radiation dose was 8 to 12 Gy (median, 12 Gy), and the follow-up period ranged from 18 to 96 months (median, 60 mo).RESULTSClinical tumor growth control (without tumor resection) was achieved in 96% of patients, and the 5-year tumor growth control rate was 92%. Hearing was preserved in 59% of those with preradiosurgical hearing preservation (Gardner-Robertson Classes 1–4), and improvements (>20 dB of improvement) were noted in 9% of the patients with any hearing. Hearing was preserved at a useful level (Gardner-Robertson Classes 1 and 2) in 56% of patients. Although preexisting trigeminal neuropathy worsened in 4% of the patients, our patients did not experience new facial palsies or trigeminal neuropathies after radiosurgery. Facial spasm occurred in 6% of the patients, and intratumoral bleeding occurred in 4% of patients.CONCLUSIONLow-dose radiosurgery (≤12 Gy at the tumor margin) can achieve a high tumor growth control rate and maintain low postradiosurgical morbidity (including hearing preservation) for acoustic neuromas.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVETo analyze the treatment options in hemorrhagic intracranial dissections.METHODSThis study involved a retrospective review of 27 patients with 29 dissections treated during a 16-year period, mainly by endovascular treatment (EVT).RESULTSEVT was performed in the acute stage in 12 of the 29 dissections, and occlusion was performed using coils at the dissection site in six dissections and with proximal balloon occlusion in six dissections. Wrapping was performed in one case. In the remaining 16 dissections, which were not treated, mainly for anatomic reasons, three patients died, one from rebleeding. Angiographic follow-up performed in the 13 surviving patients demonstrated an initially misdiagnosed lesion in one and worsening lesions in five that led to delayed EVT in five and surgical clipping in one. One of these dissections, which was located on a dominant vertebral artery, was treated after subsequent rupture using a stent and coils to preserve the patency of the parent vessel. Four ischemic complications related to EVT resulted in a moderate disability in two patients. No rebleeding occurred after EVT, but one patient died because of a poor initial clinical status; the other patients improved. In the 10 patients treated conservatively, four died, three from a poor initial clinical status and one from rebleeding, and six patients had a good clinical outcome. Of the 27 patients, three had rebleeding and one died as a result of that rebleeding. Seventeen patients (63%) had a good recovery, six (22%) had a moderate disability, and four (15%) died.CONCLUSIONEVT provides effective protection against rebleeding. When possible, occlusion with coils at the dissection site is the current method of choice. Another option is parent artery occlusion with balloons, and the use of a stent may preserve vessel permeability in specific cases.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEAlthough the cause of cerebral aneurysms remains unclear, there is clear evidence that genetic predisposition plays a role. Ten percent of patients report an aneurysm in a first-degree family member. However, studies to date have largely involved Caucasian populations. Our goal was to characterize the familial aggregation of intracranial aneurysms in different ethnic groups.METHODSWe began a prospective, single-center study on patients treated for intracranial aneurysms. Consenting subjects completed a detailed questionnaire regarding the medical history of family members. In families with two or more affected members, asymptomatic first-degree relatives were screened using computed tomographic or magnetic resonance angiography.RESULTSIn a 2-year period, 292 patients with intracranial aneurysms were treated and 200 were enrolled; these included 124 Caucasians (62%), 34 African-Americans (17%), 38 Hispanics (19%), and 4 Asian-Americans (2%). Forty patients had a family history (20%). The incidence of family history among the different ethnic groups was similar; it was 19.4% in Caucasians, 20.6% in African-Americans, and 21.6% in Hispanics. One Asian-American patient had a family history. Visual inspection of the pedigrees supported autosomal-dominant inheritance with variable penetrance in all ethnic groups.CONCLUSIONThis study examined the incidence of familial cerebral aneurysms in three ethnic groups common to the United States: Caucasian, African-American, and Hispanic. We noted an equivalent rate of familial aneurysms, a finding that has immediate clinical implications. In families that have two or more members with cerebral aneurysms, screening of asymptomatic members should be recommended, regardless of ethnic background.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEHyperperfusion syndrome is a rare but potentially devastating complication that can occur after carotid endarterectomy (CEA). The purpose of this study was to determine whether intraoperative transcranial regional cerebral oxygen saturation (rSO2) monitoring via near-infrared spectroscopy could be reliably used to identify patients at risk for post-CEA hyperperfusion.METHODSrSO2was intraoperatively monitored for 50 patients undergoing CEA for treatment of ipsilateral internal carotid artery stenosis (≥70%). Cerebral blood flow (CBF) was also assessed, with single-photon emission computed tomography, before and immediately after CEA.RESULTSPost-CEA hyperperfusion (CBF increase of ≥100%, compared with preoperative values) was observed for six patients. A significant linear correlation was observed between the rSO2increases immediately after declamping of the internal carotid artery and the CBF increases immediately after CEA (r2= 0.247,P= 0.0002). The sensitivity and specificity of the rSO2increases for detection of post-CEA hyperperfusion were 100 and 86.4%, respectively, with a cutoff point of 5%. A strong linear correlation was observed between the rSO2increases at the end of the procedure and the CBF increases immediately after CEA (r2= 0.822,P< 0.0001). Both the sensitivity and the specificity of the rSO2increases for detection of post-CEA hyperperfusion were 100% with a cutoff point of 10%. Hyperperfusion syndrome developed for one patient with post-CEA hyperperfusion, but intracerebral hemorrhage did not occur.CONCLUSIONIntraoperative rSO2monitoring can reliably identify patients at risk for hyperperfusion after CEA.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEThe incidence and severity of venous air embolism (VAE), a potentially fatal complication, among patients undergoing selective peripheral denervation in the sitting position have never been clearly established. We designed this retrospective study to assess the incidence and severity of VAE, the incidence of paradoxical air embolism, and the occurrence of patent foramen ovale, as detected with transesophageal echocardiography, as well as the effects of its detection on patient treatment.METHODSAfter institutional review board approval, data were collected from the charts of all patients who underwent selective peripheral denervation at our institution between 1988 and 2001. The severity of VAE was assessed by using a 5-point scale.RESULTSData for 342 patients were available for analyses. Seven patients exhibited VAE, yielding an incidence of 2%. The severity of VAE was 2/5 for three patients, 3/5 for three patients, and 4/5 for one patient. Air could be aspirated from the central venous catheter for three patients. No deaths occurred. Among the 96 transesophageal echocardiographic examinations performed, 5 cases of patent foramen ovale were detected (5.2%). For those patients, surgery was performed in the prone or park-bench position. No paradoxical air embolism was detected.CONCLUSIONThis is the first large study to directly assess the incidence and severity of VAE among patients undergoing selective peripheral denervation in the sitting position. We recommend that the detection of a patent foramen ovale prompt a change in position for this surgical procedure.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEIn this study, we assessed the feasibility of autotransplantation of carotid body (CB) cell aggregates into the striatum for the treatment of patients with Parkinson’s disease (PD).METHODSSix patients with advanced PD underwent bilateral autotransplantation of CB cell aggregates into the striatum. They were evaluated clinically preoperatively and for 18 months after surgery according to the recommendations of the Core Assessment Program for Intracerebral Transplantation.RESULTSNo major complications or adverse events resulted from the cell implantation or surgical procedures. During the course of the study, there was no significant aggravation of dyskinesia or decline in cognitive function in any of the patients. Five of the six patients who underwent transplantation manifested a measurable degree of clinical improvement evidenced by standardized clinical rating scales for PD. A decrease in the blinded Unified Parkinson’s Disease Rating Scale Part III in the “off” state, the main measure of transplant efficacy in our study, was found to be maximal (between 26 and 74%) at 6 months after surgery. At 1 year, clear reductions in the blinded Unified Parkinson’s Disease Rating Scale Part III were maintained in three patients (24, 38, and 52%, respectively). Modest improvement was seen in two patients (13 and 17%), and the sole patient who showed no improvement had the most fibrosis in the CB. The age of the patient and the state of the CB tissue were adversely correlated with clinical improvement after CB autotransplantation.CONCLUSIONThis pilot study indicates that CB autograft transplantation is a relatively simple, safe, and viable therapeutical approach for the treatment of patients with advanced PD. More studies are needed to optimize the procedure and to assess its general applicability for the treatment of patients with PD.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID