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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]

Objective: The purpose of this study was to retrospectively analyze the outcomes of stereotactic radiosurgery for patients suffering from medically refractory Parkinson disease (PD) tremor. Methods: We retrospectively studied the outcomes of 33 patients who were treated with gamma knife thalamotomy (GKT) over a 19-year period. Twelve patients were ≥80 years. A median dose of 140 Gy (range, 130-150 Gy) was delivered to the nucleus ventralis intermedius through a single 4-mm isocenter. We used the Fahn-Tolosa-Marin clinical tremor rating scale to score tremor, handwriting, drawing, and ability to drink fluids. The median time to the last follow-up was 23 months (range, 9-144 months). Results: After GKT, 31 patients (93.9%) experienced improvement in tremor. Twenty-three patients (70.0%) had complete or nearly complete tremor arrest. Nine patients (27.2%) noted tremor arrest and resolution of impairment in writing, drawing, and ability to drink fluids. One patient (3%) improved in bradykinesia, 3 patients (9%) improved in rigidity, and 3 patients (9%) decreased their dosage of dopa after GKT. Tremor relief was fully maintained in the last follow-up for 96.8% of responding patients. Two patients (6%) experienced temporary adverse radiation effects. Conclusions: GKT is a safe and effective treatment for medically refractory PD tremor, especially for the elderly or those not suitable for deep brain stimulation or thermal thalamotomy. [ABSTRACT FROM AUTHOR]

Object: In this report, we discuss the development of a new, comprehensive, Health Insurance Portability and Accountability Act-compliant electronic quality assurance (QA) registry for Gamma Knife (GK) radiosurgery patients. This registry can be used to query outcomes, link with current hospital electronic medical records, and share data with future corporate or national professional society registries under development. Methods: A clinical task force comprising physicians and regulatory, legal, and information technology (IT) experts was created to define the nomenclature, regulatory requirements, hosting site, and required capabilities of the proposed system. A team of physicians and IT experts defined the clinical parameters and designed the query functions for the registry. Results: The UPMC GK Registry was established as a QA registry exempt from Institutional Review Board oversight. In order to facilitate subsequent query functions (analytics), data entry was created for 3 main categories: brain tumors, vascular malformations, and functional disorders. A Microsoft SQL-based database infrastructure was employed. Conclusions: We developed a new UPMC GK QA registry and successfully migrated our previous data on 13,000 patients into the registry. This simplified and user-friendly registry offers clinicians the opportunity to participate in national registries and to contribute to multicenter evidence-based outcome analyses. [ABSTRACT FROM AUTHOR]

Background: Trigeminal neuralgia (TN) is mostly caused by vascular compression of the nerve's root entry zone due to an ectatic artery. Rarer causes include compression from tumors, vascular malformations or multiple sclerosis plaques. Developmental venous anomalies (DVAs) are benign, aberrantly appearing venous structures that drain normal cerebral tissue. DVAs are a rare etiology of TN. The management of TN caused by a DVA is controversial as disruption of the DVA can be catastrophic. Methods: We report a case of a young man with severe medically refractory TN related to a brachium pontis DVA who was successfully treated by gamma knife stereotactic radiosurgery (GKSR) to the trigeminal nerve. Results: Within 2 weeks of GKSR, the patient reported experiencing 60% pain relief; 5 years postoperatively, he remains completely pain free with some mild sensory loss in the V2 and V3 areas. Conclusions: GKSR has an established role in the management of TN. This is the first reported case of using GKSR to treat TN caused by a DVA. In the setting of a DVA, GKSR should be an initial consideration for TN therapy after medical failure because of the high surgical risk related to disrupting the DVA. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Repeat Gamma Knife stereotactic radiosurgery (GKSR) procedures are becoming common, especially for brain metastases. It is important to identify tumors requiring treatment at repeat GKSR and it can be challenging to distinguish treated tumors, tumor progression and new tumors. Using the image co-registration tool within the Leksell Gamma Plan software, we developed a technique to aid in the identification of tumors needing treatment. Objectives: The objective was to explore a new co-registration technique to identify tumors requiring treatment at repeat GKSR procedures. Methods: Ten patients who underwent repeat GKSR for brain metastases were identified. Contrast-enhanced volumetric T1 magnetic resonance images (MRI) from the previous GKSR were co-registered with the new images and the resulting two-color format image was used to evaluate tumor status. Results: Using the co-registered images, tumors were characterized as: resolved, regressed, stable, larger or new. Overall, 13.6% of tumors completely resolved, 26.2% regressed, 13.1% remained stable, while 7.9% progressed. Thirty-nine percent of tumors were new. Conclusions: The co-registration technique makes clinically relevant changes conspicuous on MRI. It distinguishes between tumors potentially requiring treatment and those that have been treated successfully. It can be used with tumors other than metastases and for evaluating tumor response at follow-up. © 2014 S. Karger AG, Basel [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]

Intracranial metastatic prostate carcinoma is rare. We sought to determine the clinical outcomes after Gamma Knife® stereotactic radiosurgery (GKSRS) for patients with intracranial prostate carcinoma metastases. We studied data from 10 patients who underwent radiosurgery for 15 intracranial metastases (9 dural-based and 6 parenchymal). Six patients had radiosurgery for solitary tumors and four had multiple tumors. The primary pathology was adenocarcinoma (eight patients) and small cell carcinoma (two patients). All patients received multimodality management for their primary tumor (including resection, radiation therapy, androgen deprivation therapy) and eight patients had evidence of systemic disease at time of radiosurgery. The mean tumor volume was 7.7 cm3 (range 1.1–17.2 cm3) and a median margin dose of 16 Gy was administered. Two patients had progressive intracranial disease in spite of fractionated partial brain radiation therapy (PBRT) prior to SRS. A local tumor control rate of 85% was achieved (including patients receiving boost, upfront and salvage SRS). New remote brain metastases developed in three patients (33%) and one patient had repeat SRS for tumor recurrence. The median survival after radiosurgery was 13 months and the 1-year survival rate was 60%. SRS was a well tolerated and effective therapy either alone or as a boost to fractionated radiation therapy in the management of patients with intracranial prostate carcinoma metastases. [ABSTRACT FROM AUTHOR]

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.

Background: Cerebrospinal fluid (CSF) leakage into the epidural space following lumbar puncture (LP) has been documented in pediatric patients, but there have been no reported cases in adults. Case Description: We report an epidural CSF leak in an adult who presented with back pain, positional headache, urinary retention, and constipation following an LP performed as a part of a research study. The patient's magnetic resonance (MR) scan showed an extensive epidural CSF collection. Following placement in a recumbent position for 72 h, the collection fully resolved along with his neurological complaints. Conclusion: Symptomatic epidural CSF collections rarely occur in adults following LPs. Nevertheless, the management remains the same as for pediatric patients; bed rest for 72 h results typically in full resolution of symptoms/signs and regression of the collection on MR studies. [ABSTRACT FROM AUTHOR]