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There is no standard therapy for elderly patients with high-grade glioma. We have adopted short course radiotherapy for such patients since 2005. The efficacy of this therapy was assessed retrospectively.This study reviewed 16 newly diagnosed high-grade glioma patients aged 75 years or older who were treated with short course radiotherapy (focal radiation in daily fraction of 3 Gy given 5 days per week, for a total dose of 39 Gy).All patients received 100% of the planed radiation dose. No patients received prior or concomitant chemotherapy. Thirteen patients had died and median follow-up period was 9 months at the time of analysis. The median age at surgery was 79 years (range 75-86). The estimated median overall survival was 9.6 months. The median Karnofsky Performance Status on admission was 60% (range 40-90) and at discharge was 60% (range 40-80). The median length of hospital stay was 38 days (range 19-61). There is no severe adverse events related to radiation therapy. The rate of discharge to home was 69%.Short course radiotherapy can reduce the treatment time and adverse events of conventional radiotherapy without decrement in survival. This therapy seems to be a considerable treatment option for elderly patients with high-grade glioma.

Here, we report a case of cerebrospinal fluid hypovolemia caused by lumbar puncture for implantation of an Ommaya reservoir. A 55-year-old man with central nervous system lymphoma developed meningeal dissemination. He was treated by spinal radiotherapy, and had an Ommaya reservoir implanted for intrathecal injection of anticancer drugs. After one month, he complained of orthostatic neck pain. MRI revealed bilateral subdural effusion and diffuse meningeal enhancement. He was diagnosed as having cerebrospinal fluid hypovolemia. Because no improvement in symptoms was seen after 2 weeks of conservative treatment, he was treated by a lumbar epidural blood patch. Subsequently symptoms improved markedly, and bilateral subdural effusion and diffuse meningeal enhancement disappeared on follow-up MRI.

Cytoreductive surgery is accepted by many neurosurgeons to be the best treatment for patients with malignant gliomas. Resection of a contrast-enhancing lesion on a CT or MR image is a particularly common treatment, because observation of such lesions indicates the presence of viable tumor cells. We have used intravenous injection of fluorescein Na (0.2 cc/kg body weight) as a chemical probe for resection of malignant gliomas. Following this injection, the yellow-stained tumor is visible to the naked eye. For tumors located in an eloquent area, resection is performed at the surface of the yellow-stained tumor, or tumor debulking within the yellow-colored lesion is conducted until the resection surface becomes pale yellow. For tumors located in non-eloquent regions, suction of peritumoral white matter is also required. This procedure requires no special equipment and has wide applicability in resection of malignant gliomas.

Progress in imaging techniques has contributed to improvements in reliable diagnosis and surgical decision making in neurosurgery. From the viewpoint of neurosurgeons, there are two major needs in the development of imaging techniques. One is greater accuracy in demonstrating the anatomy of the brain at microscopic resolutions and the other is visualization of function or metabolism that is invisible on surgical views. Use of 3.0 T magnetic resonance imaging (MRI) in clinical patients has revealed anatomy appropriate for microsurgery at high resolution, and three-dimensional reconstruction of MRI on high-specification computers helps neurosurgeons to understand the anatomy of the brain in individual patients. Functional imaging methods such as functional MRI, positron emission tomography, and magnetoencephalography have provided new insights in brain surgery, visualizing various cerebral functions on anatomic images. Recently, diffusion tensor imaging is used to visualize neural tracts passing through subcortical white matter and MR spectroscopy is used to show the metabolic status of lesions. These tools are also forms of functional imaging. New noninvasive imaging techniques are still being developed to visualize function more easily. Here, we summarize the roles of recent imaging techniques in our previous studies and discuss the future of imaging in neurosurgery.

Brain tumors are frequently treated with steroids due to the presence of peritumoral edema. However, in Japan it is not widely recognized that primary brain tumor patients who are receiving steroid therapy become susceptible to Pneumocystis carinii pneumonia (PCP). We reviewed the clinical features and risk factors for PCP in brain tumor patients treated at our institution between 1994 and 2002. The treated cases consisted of 6 men and 6 women ranging in age from 47 to 78 yr (mean age 65.3). Underlying diseases included malignant glioma in 9 patients, malignant lymphoma in 2 patients and meningioma in one patient. All were diagnosed by respiratory disease specialists using bronchial washings and bronchoalveolar lavage or chest X ray/CT image. Radiation therapies were administered with 20 to 60 Gy (mean 52.9 Gy) except in one patient. Chemotherapy was performed with ranimustine in 4 malignant glioma patients and with methotrexate in 2 malignant lymphoma patients. Prednisone, begun perioperatively, was reduced gradually from a mean initial dosage of 38.3 mg/day orally. The duration of steroid treatment at the onset of PCP in these patients ranged from 41 to 79 days (mean 61.4 days). Six patients (50%) died of PCP despite appropriate antibiotic therapy and 2 patients needed intensive therapy with a respirator. For early diagnosis of PCP, periodic serological (e.g.; the level of lactate dehydrogenase and beta-D-glucan) and radiological examination (e.g.; chest X ray and CT image) is indicated in patients with brain tumors, and prophylaxis against PCP might be needed for patients with intracranial neoplasms and who are also receiving high-dose and long-term steroid treatment.

The purpose of this study was to assess the complication risk rate and diagnostic yield in a series of 211 procedures performed by a consistent method at one institute.Two hundred and one patients underwent 211 stereotactic biopsy procedures for diagnosis of malignant brain tumor at Niigata University between 1987-2001. Indication for stereotactic biopsy is decided on the following factors: 1) the patient is elderly or unsuitable for craniotomy; 2) the tumor location is in a deep, diffusing, multiple, eloquent site; 3) cytoreductive surgery is not needed to treat the suspected pathology. The specimen was obtained from the target point of CT scan by the aspiration method under local anesthesia except for in six patients who were children or needed operation for a VP shunt under general anesthesia. The lesion was located in 114 cases of cerebral hemisphere, in 44 cases of basal ganglia, in 11 cases of cerebellum and in 11 cases of spreading site.Histological diagnosis was obtained in 188 of 211 procedures and the diagnostic yield was 93.5%. There were 104 high grade gliomas, 16 low grade gliomas, 5 germ cell tumors, 37 malignant lymphomas, 19 metastatic tumors and 13 negative/inconclusive biopsies. Sixteen patients incurred complications (7.6%). Four patients (1.6%) suffered intratumoral hemorrhage. Emergency craniotomy was performed in three patients and stereotactic aspiration of hematoma was carried out in one patient. Furthermore, of 12 complications, 9 occurred with the patient showing symptoms of worsening neurological deficit, 2 occurred with general convulsion and 1 occurred with severe facial pain.This study provided evidence that stereotactic biopsy was a safe and reliable tool for patients with unresectable malignant brain tumors.