Search

The article discusses the use of stereotactic radiosurgery to manage brain metastases. It references the study "Stereotactic radiosurgery for treatment of brain metastases," by S.N. Badiyan, W.F. Rehine, and M. Mehta in the same issue. Topics discussed include need for rigorous investigation as total tumor volume is more representative of modern stereotactic radiosurgery application, role of whole-brain radiation therapy, and data extrapolation for physicians doing stereotactic radiosurgery.

The article discusses a study which examines the outcomes after stereotactic radiosurgery (SRS) in patients with ovarian and endometrial carcinoma. It reveals that SRS is an acceptable choice to treat brain metastases that resulted from ovarian and endometrial cancer. It notes that SRS is proven useful in treating deep-seated and metastatic ovarian tumors.

Cyclin-dependent kinases (CDKs) mediate proliferation and neuronal development, while aberrant CDK activity is associated with cancer and neurodegeneration. Consequently, pharmacologic inhibitors, such as 2,6,9-trisubstituted purines, which potently inhibit CDKs 1, 2, and 5, were developed to combat these pathologies. One agent, R-roscovitine (CYC202), has advanced to clinical trials as a potential cancer therapy. In primary neuronal cultures, these agents have been used to delineate the physiologic and pathologic functions of CDKs, and associated signaling pathways. Herein we demonstrate that three 2,6,9-trisubstituted purines: olomoucine, roscovitine, and purvalanol, used at concentrations ascribed by others to potently inhibit CDKs 1, 2, and 5, are powerful triggers of death in maturing cerebellar granule neurons, assessed by loss of mitochondrial reductive capacity and differential staining with fluorescent indicators of living/dead neurons. Based on several criteria, including delayed time course and establishment of an irreversible commitment point of death, pyknotic cell and nuclear morphology, and caspase-3 cleavage, the death process is apoptotic. However, pharmacological and biochemical data indicate that apoptosis is independent of CDK 1, 2, or 5 inhibition. This is based on the pattern of changes in c-jun mRNA, c-Jun protein, and Ca2+/cAMP response element binding protein (CREB) phosphorylation, and also, the ineffectiveness of structurally distinct CDK 1, 2, and 5 inhibitors butyrolactone-1 and PNU112445A to induce apoptosis. Collectively, our results, and those of others, indicate that the CDK regulation of transcription (CDKs 7 and 9) should be examined as a target of these agents, and as an indirect mediator of neuronal fate. [Copyright &y& Elsevier]

An arachnoid web is a pathological formation of the arachnoid membrane. It is a rare phenomenon but is known to lead to syrinx formation in the spinal cord along with pain and neurological deficits. On imaging, the 'scalpel sign' is pathognomonic for an arachnoid web. The etiology of syrinx formation from an arachnoid web is currently unknown. This report documents the only two cases of arachnoid webs with an extensive syrinx in which a likely pathophysiologic mechanism is identified. Both cases presented with motor deficits. The patients had no history of trauma or infection. After extensive workup in both patients and observation of the scalpel sign an arachnoid web was suspected. In both cases, the patients were treated surgically after an arachnoid web was suspected. Intra-operative ultrasound visualized in both cases demonstrates a fenestration in the web that allowed passage of cerebrospinal fluid in a rostral-caudal direction due to a ball-valve effect. [ABSTRACT FROM AUTHOR]

Management of intracranial Langerhans cell histiocytosis generally includes surgical resection. A female patient with a diagnosis of Langerhans cell histiocytosis developed multiple brain lesions. As part of her multimodality treatment, she underwent Gamma Knife stereotactic radiosurgery on 4 occasions over a 20-year period. All tumors showed significant shrinkage on serial imaging after initially demonstrating a transient expansion. No permanent postradiosurgery complications occurred. As part of multimodality management of this recurrent and refractory disease, Gamma Knife stereotactic radiosurgery should be considered an important salvage option that can control local disease and obviate the need for invasive surgery. [ABSTRACT FROM AUTHOR]

Cervical radiculopathy and cervicalgia are commonly managed with spinal epidural steroid injections in the outpatient setting. Although cervical epidural injections are routinely performed, there is potential for significant complications if proper technique and safety measures are not followed. Spinal cord infarction and stroke following transforaminal injection have been described in the literature, whereas interlaminar injections have been associated with both epidural hematomas and direct cord injury. Here we describe a case of pneumomyelia after cervical interlaminar epidural steroid injection resulting in acute quadriparesis. The patient's symptoms were caused by an inadvertent puncture of the cervical cord and injection of air present in the needle or syringe via an interlaminar approach. The initial computed tomography imaging showed a slit-like lesion at C7-T2 with density consistent with air that migrated rostrally on a follow-up scan. Epidural steroid injections are often the treatment of choice in management of neck pain and cervical radiculopathy. Devastating complications can ensue if proper safety measures and technique are not used during the procedure regardless of the approach used. [ABSTRACT FROM AUTHOR]

The current pandemic crisis, caused by a novel human coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has forced a dramatic change in our society. A key portion of the medical work force on the frontline is composed of resident physicians. Thus, it becomes imperative to create an adequate and effective action plan to restructure this valuable human resource amid the SARS-CoV2 pandemic. We sought to describe a comprehensive approach taken by a Neurosurgery Department in quaternary care academic institution in the United States of America amid the SARS-CoV2 pandemic focused in resident training and support. To describe a comprehensive approach taken by a Neurosurgery Department in quaternary care academic institution in the United States of America amid the SARS-CoV2 pandemic focused on resident training and support. A restructuring of the Neurosurgery Department at our academic institution was performed focused on decreasing their risk of infection/exposure and transmission to others, while minimizing negative consequences in the training experience. An online academic platform was built for resident education, guidance, and support, as well as continue channel for pandemic update by the department leadership. The SARS-CoV2 pandemic constitutes a global health emergency full of uncertainty. Treatment, scope, duration, and economic burden forced a major restructuring of our medical practice. In this regard, academic institutions must direct efforts to diminish further negative impact in the training and education of the upcoming generation of physicians, including those currently in medical school. Perhaps the only silver lining in this terrible disruption will be greater appreciation of the role of current health care providers and educators, whose contributions to our society are often neglected or unrecognized. [ABSTRACT FROM AUTHOR]

The number of metastases that can be treated safely and effectively with Gamma Knife stereotactic radiosurgery (SRS) remains controversial despite continuing evidence to support its expanded utilization. We endeavored to elucidate the survival outcomes for patients who presented with ≥15 brain metastases at the time of initial SRS. This retrospective analysis reviewed patients treated for ≥15 brain metastases originating from breast cancer, lung cancer, or melanoma. Ninety-three patients met the inclusion criteria. In this study, 3016 tumors were treated. The median number of tumors at the first SRS procedure was 23 (range, 15–67) for breast cancer, 21 (range, 15–48) for lung cancer, and 21 (range, 15–67) for melanoma. The mean aggregate metastases volume was 8.75 cm3 for breast, 6.89 cm3 for lung, and 9.98 cm3 for melanoma. Patients with breast cancer, lung cancer, and melanoma had a median survival after diagnosis of brain metastases of 18.0, 9.4, and 6.3 months, respectively. The survival after SRS was 16 months for breast cancer, 4.6 months for lung cancer, and 3.1 months for melanoma. Patients with breast cancer had significantly longer survival than patients with lung cancer and melanoma after SRS (P = 0.001). A higher Karnofsky Performance Status score was associated with an increase in survival across all tumor types. Repeat SRS for local or distant progression was performed in 56% of patients with breast cancer, 35% of patients with lung cancer, and 24% of patients with melanoma. SRS is an effective means of managing extensive brain metastases, particularly in patients with breast cancer. The primary tumor type, systemic disease, and performance status heavily influence survival outcomes. [ABSTRACT FROM AUTHOR]

Background We evaluated clinical outcomes in patients with symptomatic brainstem cavernous malformations (CMs) treated by stereotactic radiosurgery (SRS). Methods Between 1988 and 2016, Gamma Knife SRS was performed in 76 evaluable patients with solitary symptomatic brainstem CMs. Forty-nine (66%) were intrinsic (not reaching a pial or ependymal surface). Most patients (91%) had experienced 2 or more hemorrhages associated with new neurologic deficits. Fourteen patients (18%) underwent resection before radiosurgery. The median CM volume was 0.66 cm3 (range, 0.05–6.8), and the median margin dose was 15.0 Gy. Results After SRS, 15 patients (20%) had an imaging confirmed new hemorrhage at a median follow-up of 48 months. The hemorrhage-free survival after SRS for brainstem CMs was 92% at 1 year, 87% at 3 years, and 85% at 5 years. The annual hemorrhage rate was 31% before and 4% after SRS. In univariate analysis, CM volume, previous surgical resection, and increased number of hemorrhages before SRS were significantly associated with a higher rate of hemorrhage after SRS. In multivariate analysis, only number of previous hemorrhages was significant (P < 0.0005; hazard ratio, 1.51, 95% confidence interval, 1.23–1.85). Symptomatic adverse radiation effects developed in 7 patients (9%). The rate of symptom deterioration related to hemorrhage or symptomatic adverse radiation effects was 10% at 1 year, 18% at 3 years, and 20% at 5 years. Conclusions Patients with an increased rate of hemorrhage before SRS had an increased risk of repeat hemorrhage and symptom deterioration rate after SRS. Intrinsic CM location did not significantly affect rates of symptom deterioration or rebleeding. [ABSTRACT FROM AUTHOR]

• Neoadjuvant SRS is associated with decreased radiation dosage and improved conformality profile due to enhanced target delineation. • Pre-operative SRS can decrease delivery of radiation to important structures such as optic apparatus, hippocampal cortex and brain stem. • These findings better characterize the role of neoadjuvant SRS in brain metastatic disease and could support further clinical trials. Stereotactic radiosurgery (SRS) after maximal safe resection is an accepted treatment strategy for patients with cerebral metastatic disease. Despite its high conformality profile, the incidence of radionecrosis (RN) remains high. SRS delivered pre-operatively could be associated with a reduced incidence of RN. We sought to evaluate whether neoadjuvant SRS could reduce radiotherapy doses in a cohort of patients treated with post-operative SRS. A cohort of 47 brain metastases (BM) treated at 2 academic institutions was retrospectively analyzed. Subjects underwent surgical extirpation of BMs and subsequent SRS to surgical bed. Post-operative volumetric and dosimetric data was collected from records or recreations of delivered plans; pre-operative data were derived from hypothetical radiotherapy courses and compared using Wilcoxon signed-rank tests. Higher planned tumor volume post-operatively (median[IQR] 12.28 [6.54, 18.69]cc vs 10.20 [4.53, 21.70]cc respectively, p = 0.4150) was observed. The median prescribed radiotherapy dose (DRx) was 16 Gy pre-operatively and 24 Gy post-operatively (p < 0.0001). Further investigations revealed improved pre-operative conformity index (1.23[1.20, 1.29] vs 1.29[1.23, 1.39], p = 0.0098) and gradient index (2.72[2.59, 2.98] vs 2.94[2.69, 3.47], p = 0.0004). A significant difference was found in normal brain tissue exposed to 10 Gy (12.97[6.78, 25.54]cc vs 32.13[19.42, 48.40]cc, p < 0.0001), 12 Gy (9.31[4.56, 17.43]cc vs 23.80[14.74, 36.56]cc, p < 0.0001), and 14 Gy (5.62[3.23, 11.61]cc vs 17.47[9.00, 28.31]cc, p < 0.0001), favoring pre-operative SRS. Neoadjuvant SRS is associated reduced DRx, better conformality profile and decreased radiation to normal tissue. These findings could support the use of neoadjuvant SRS for the treatment of BMs. [ABSTRACT FROM AUTHOR]

Background Infectious intracranial aneurysms (IIAs) are rare and potentially devastating. First-line management involves intravenous antibiotics, with surgical or endovascular management reserved for cases of failed medical treatment or aneurysmal rupture. Endovascular therapy has become the primary approach for treating these small, distally located aneurysms. Liquid embolic agents are well suited for use because of their ability to fill the aneurysm and parent vessel. We present our experience in treating these aneurysms via Onyx embolization and review the literature. Methods We retrospectively reviewed the endovascular treatment of IIAs at our institution from 2010 to 2012. Eight patients with 16 IIAs ranging in size from 1 to 16 mm underwent treatment. Seven of the patients initially presented after aneurysmal rupture. Onyx was pushed until the aneurysm and parent artery were filled. Confirmation of aneurysmal occlusion was made by repeat cerebral angiography. Results One symptomatic stroke occurred after embolization. Fourteen of the 16 aneurysms have been evaluated with follow-up angiography and remain occluded. Conclusions Treatment of IIAs using an endovascular approach with Onyx is safe and effective. [ABSTRACT FROM AUTHOR]