Anticonvulsant effects of gamma surgery in a model of chronic spontaneous limbic epilepsy in rats

Innovative minimally invasive options to treat drug-resistant epilepsies

Despite the regular discovery of new molecules, one-third of epileptic patients are resistant to antiepileptic drugs. Only a few can benefit from resective surgery, the current gold standard. Although effective in 50-70% of cases, this therapy remains risky, costly, and can be associated with long-term cognitive or neurological side effects. In addition, patients are increasingly reluctant to have a craniotomy, emphasizing the need for new less invasive therapies for focal drug-resistant epilepsies. Here, we review different minimally invasive approaches already in use in the clinic or under preclinical development to treat drug-resistant epilepsies. Localized thermolesion of the epileptogenic zone has been developed in the clinic using high-frequency thermo-coagulations or magnetic resonance imaging-guided laser or ultrasounds. Although less invasive, they have not yet significantly improved the outcomes when compared with resective surgery. Radiosurgery techniques have been used in the clinic for the last 20years and have proven efficiency. However, their efficacy is not better than resective surgery, and various side effects have been reported as well as the potential risk of sudden unexpected death associated with epilepsy. Recently, a new strategy of radiosurgery has emerged using synchrotron-generated X-ray microbeams: microbeam radiation therapy (MRT). The low divergence and high-flux of the synchrotron beams and the unique tolerance to MRT by healthy brain tissues, allows a precise targeting of specific brain regions with minimal invasiveness and limited behavioral or functional consequences in animals. Antiepileptic effects over several months have been recorded in animal models, and histological and synaptic tracing analysis suggest a reduction of neuronal connectivity as a mechanism of action. The possibility of transferring this approach to epileptic patients is discussed in this review.

Radiomodulation in Mixed, Complex Cancer Pain by Triple Target Irradiation in the Brain: A Preliminary Experience

Introduction

Up to 30% of terminally ill cancer patients experiencing intense pain might be refractory to opioid treatment. Complex cancer pain can be a mixture of somatic, visceral, and neuropathic pain with few or no effective alternatives to ameliorate pain. Radiosurgery to treat refractory pain in cancer has been reported with different degrees of success. Radiomodulation in pain could be defined as a fast (<72 h), substantial (>50%) pain relief by focal irradiation to a peripheric, and/or central mediated pain circuitry. Based on our previous experience, mixed, refractory cancer pain is usually unresponsive to single target irradiation of the hypophysis. We treated three patients using a multi-target approach.

Methods

Three terminally ill oncological patients experiencing refractory, complex, mixed pain from bone, abdomen, thorax, and brachial plexus were treated with triple target irradiation which consisted of irradiating with a maximum dose (Dmax) of 90 Gy to the hypophysis using either an 8 mm collimator with gamma ray (Infini) (Shenzhen, China: Masep Medical Company) or a 7.5 circular collimator with Cyberknife (Sunnyvale, CA: Accuray Inc.), the other two targets were the mesial structures of the thalamus bilaterally using a 4 mm collimator with Infini and the 5 mm circular collimator with CK delivering 90 Gy Dmax to each region. Patients had a VAS of 10 despite the best medical treatment.

A correlation was made between the 45 Gy and 20 Gy isodose curves of the two different technologies to the Morel stereotactic atlas of the thalamus and basal ganglia for further understanding of dose distribution reconstructions in accordance with the São Paulo-Würzburg atlas of the Human Brain Project were performed. Lastly, a scoping review of the literature regarding radiosurgery for oncological pain was performed.

Results

Radiomodulation effect was achieved in all patients; case 1 had a VAS of five at 72 h, three at 15 days, and three at the time of death (21 days after treatment). Case 2 had a VAS of six at 72 h, five at 15 days, and four at the time of death (29 days after treatment). Case 3 had a VAS of five at 72 h, six at 15 days, and six at the time of death (30 days). Morphine rescues for cases 1 and 2 were reduced to 84%, and 70% for case 3. Overall, there were no adverse effects to treatment although excessive sleepiness was reported by one patient. After reading the title and abstract, only 14 studies remained eligible for full-text evaluation, and only nine studies met inclusion criteria after full-text reading. For most reports (seven), the target was the hypophysis and in two reports, the target was the thalamus either with single or bilateral irradiation.

Conclusions

In complex, for refractory oncological pain of mixed nature (nociceptive, neuropathic, and visceral), very few, if any, treatment alternatives are currently available. We provide a small proof of concept that multitarget intracranial radiosurgery might be effective in ameliorating pain in this population. The doses administered per target are the lowest that have shown effectiveness thus far, a different strategy might be needed as opposed to single target “large” dose approach that has been tried in the past for complex mixed refractory oncological pain. By no means, in our experience, these treatments traduce in elimination of pain, clinical results might make pain to be more bearable and respond better to pain medication.

Non-ablative doses of focal ionizing radiation alters function of central neural circuits

BACKGROUND

Modulation of pathological neural circuit activity in the brain with a minimum of complications is an area of intense interest.

OBJECTIVE

The goal of the study was to alter neurons' physiological states without apparent damage of cellular integrity using stereotactic radiosurgery (SRS).

METHODS

We treated a 7.5 mm-diameter target on the visual cortex of Göttingen minipigs with doses of 40, 60, 80, and 100 Gy. Six months post-irradiation, the pigs were implanted with a 9 mm-wide, eight-shank multi-electrode probe, which spanned the radiation focus as well as the low-exposure neighboring areas.

RESULTS

Doses of 40 Gy led to an increase of spontaneous firing rate, six months post-irradiation, while doses of 60 Gy and greater were associated with a decrease. Subjecting the animals to visual stimuli resulted in typical visual evoked potentials (VEP). At 40 Gy, a significant reduction of the P1 peak time, indicative of higher network excitability was observed. At 80 Gy, P1 peak time was not affected, while a minor reduction at 60 Gy was seen. No distance-dependent effects on spontaneous firing rate, or on VEP were observed. Post-mortem histology revealed no evidence of necrosis at doses below 60 Gy. In an in vitro assay comprising of iPS-derived human neuron-astrocyte co-cultures, we found a higher vulnerability of inhibitory neurons than excitatory neurons with respect to radiation, which might provide the cellular mechanism of the disinhibitory effect observed in vivo.

CONCLUSION

We provide initial evidence for a rather circuit-wide, long-lasting disinhibitory effect of low sub-ablative doses of SRS.

Radioneuromodulation by Dual-Target Irradiation in Pain Crisis From Trigeminal Neuralgia

Background Radioneuromodulation (RNM) can explain the immediate pain relief experienced by a subgroup of patients after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). In this study, our main objective was to demonstrate that a minimum of a 50% reduction in TN pain can be achieved consistently in under 72 hours by targeting the affected nerve, the contralateral centromedian nucleus, and parafascicular complex in patients experimenting a prolonged refractory pain crisis. Methodology We treated eight patients experiencing severe TN pain crisis in whom percutaneous procedures had failed or were unwanted with SRS with an intention to procure pain relief in under 72 hours. The affected trigeminal nerve was targeted using a 4-mm collimator with an 80 to 90-Gy dose; an additional target was defined in the mesial portions of the thalamus and irradiated using the 4-mm collimator with a 120 to 140-Gy dose. Results The median duration of TN was 60 months, the median duration of pain crisis was 10.7 weeks despite the best medical treatment, and the mean presenting visual analogue score (VAS) was 10 at the time of treatment. The median follow-up was 135 days (range, 65-210). Twenty-four hours after treatment, two (25%) patients had no pain (VAS 0), three (37.5%) had mild pain (VAS 1 to 3), and three (37.5%) had moderate pain (VAS 4 to 7). Forty-eight hours after treatment, all patients reported pain relief, seven (87.5%) reported >50%, and one (12.5%) patients reported 30% relief. The three-month median VAS score was 3 (range, 0 to 5). At the last follow-up, there were no adverse events to report. Conclusions Dual irradiation to the affected trigeminal nerve and contralateral mesial structures of the thalamus may provide fast pain relief for patients experiencing a prolonged pain crisis from TN, which veers away from the concept that the SRS pain relief effect is generally delayed and holds no place in the management of such patients. Although this is a small series with a limited follow-up duration, no adverse effects were noted. RNM can be defined as the capacity to alter neuronal activity through targeted delivery of a stimulus of radiation at a duration too brief to be explained by the development of a focal lesion. The immediate pain relief and its habitual oscillatory nature of lesser pain recurrence in most patients until enough time elapses for pain stabilization clinically demonstrates that the pain circuitry is altered and remains functional, thus accomplishing a neuromodulation effect even at the face of an apparent doses suspected to be ablative. Further research is needed to understand if this clinical effect is achieved with a suspected sub-ablative dose.

Neuromodulation via Focal Radiation: Radiomodulation Update

When radiation is focally delivered to brain tissue at sub-ablative doses, neural activity may be altered. When done at a specific brain circuit node or connection, this is referred to as “radiomodulation.” Radiation-induced effects on brain tissue, basic science, and clinical research that supports the radiomodulation hypothesis are reviewed in this article. We review progress in defining the necessary parameters in terms of dose, volumes, and anatomical location. It may be possible to deliver therapeutic neuromodulation that is non-invasive, non-destructive, and durable.

Effects of Focal Ionizing Radiation of the Squid Stellate Ganglion on Synaptic and Axonal Transmission in the Giant-Fiber Pathway

Ionizing radiation is clinically used to treat neurological problems and reduce pathological levels of neural activity in the brain, but its cellular-level mechanisms are not well understood. Although spontaneous and stimulated synaptic activity has been produced in rodents by clinically and environmentally relevant doses of radiation, the effects on basic excitability properties of neurons have seldom been reported. This study examined the effects of focused ionizing radiation on synaptic transmission and action potential generation in the squid giant-fiber system, which includes the giant synapse between a secondary interneuron and the tertiary giant motor axons. Radiation of 140-300 Gy was delivered to a stellate ganglion of a living squid over several minutes, with the contralateral stellate ganglion serving as an internal control. No qualitative changes in the efficacy of synaptic transmission were noted in conjunction with stimulation of the input to the giant synapse, although in one irradiated ganglion, the refractory period increased from about 5 ms to more than 45 seconds. Small but significant changes in the action potential recorded from the giant motor axon in response to electrical stimulation were associated with an increased maximum rate of fall and a shortened action potential duration. Other action-potential parameters, including resting potential, overshoot, the maximum rate of the rise, and the refractory period were not significantly changed. Attempts to account for the observed changes in the action potential were carried through a Hodgkin-Huxley model of the action potential. This approach suggests that an increase in the maximum voltage-gated potassium conductance of about 50% mimics the action potential shortening and increased rate of fall that was experimentally observed. We propose that such an effect could result from phosphorylation of squid potassium channels.

Effects of Focal Radiation on [18 F]-Fluoro-D-Glucose Positron Emission Tomography in the Brains of Miniature Pigs: Preliminary Findings on Local Metabolism

OBJECTIVES

It would be a medically important advance if durable and focal neuromodulation of the brain could be delivered noninvasively and without ablation. This ongoing study seeks to elucidate the effects of precisely delivered ionizing radiation upon focal brain metabolism and the corresponding cellular integrity at that target. We hypothesize that focally delivered ionizing radiation to the brain can yield focal metabolic changes without lesioning the brain in the process.

MATERIALS AND METHODS

We used stereotactic radiosurgery to deliver doses from 10 Gy to 120 Gy to the left primary motor cortex (M1) of Lee Sung miniature pigs (n = 8). One additional animal served as a nonirradiated control. We used positron emission tomography-computed tomography (PET-CT) to quantify radiation dose-dependent effects by calculating the ratio of standard uptake values (SUV) of 2-deoxy-2-[¹⁸ F]-fluoro-D-glucose (¹⁸ F-FDG) between the radiated (left) and irradiated (right) hemispheres across nine months.

RESULTS

We found that the FDG-PET SUV ratio at the targeted M1 was significantly lowered from the pre-radiation baseline measurements for animals receiving 60 Gy or higher, with the effect persisting at nine months after radiosurgery. Only at 120 Gy was a lesion suggesting ablation visible at the M1 target. Animals treated at 60-100 Gy showed a reduced signal in the absence of an identifiable lesion, a result consistent with the occurrence of neuromodulation.

CONCLUSION

Focal, noninvasive, and durable changes in brain activity can be induced without a magnetic resonance imaging (MRI)-visible lesion, a result that may be consistent with the occurrence of neuromodulation. This approach may provide new venues for the investigation of neuromodulatory treatments for disorders involving dysfunctional brain circuits. Postmortem pathological analysis is needed to elucidate whether there have been morphological changes not detected by MRI.

Sustained somatostatin gene expression reverses kindling-induced increases in the number of dividing Type-1 neural stem cells in the hippocampi of behaviorally responsive rats

Neurogenesis persists throughout life in the hippocampi of all mammals, including humans. In the healthy hippocampus, relatively quiescent Type-1 neural stem cells (NSCs) can give rise to more proliferative Type-2a neural progenitor cells (NPCs), which generate neuronal-committed Type-2b NPCs that mature into Type-3 neuroblasts. Many Type-3 neuroblasts survive and mature into functionally integrated granule neurons over several weeks. In kindling models of epilepsy, neurogenesis is drastically upregulated and many new neurons form aberrant connections that could support epileptogenesis and/or seizures. We have shown that sustained vector-mediated hippocampal somatostatin (SST) expression can both block epileptogenesis and reverse seizure susceptibility in fully kindled rats. Here we test whether adeno-associated virus (AAV) vector-mediated sustained SST expression modulates hippocampal neurogenesis and microglial activation in fully kindled rats. We found significantly more dividing Type-1 NSCs and a corresponding increased number of surviving new neurons in the hippocampi of kindled versus sham-kindled rats. Increased numbers of activated microglia were found in the granule cell layer and hilus of kindled rats at both time points. After intrahippocampal injection with either eGFP or SST-eGFP vector, we found similar numbers of dividing Type-1 NSCs and -2 NPCs and surviving BrdU⁺ neurons and glia in the hippocampi of kindled rats. Upon observed variability in responses to SST-eGFP (2/4 rats exhibited Grade 0 seizures in the test session), we conducted an additional experiment. We found significantly fewer dividing Type-1 NSCs in the hippocampi of SST-eGFP vector-treated responder rats (5/13 rats) relative to SST-eGFP vector-treated non-responders and eGFP vector-treated controls that exhibited high-grade seizures on the test session. The number of activated microglia was upregulated in the GCL and hilus of kindled rats, regardless of vector treatment. These data support the hypothesis that sustained SST expression exerts antiepileptic effects potentially through normalization of neurogenesis and suggests that abnormally high proliferating Type-1 NSC numbers may be a cellular mechanism of epilepsy.

Synchrotron-generated microbeams induce hippocampal transections in rats

Synchrotron-generated microplanar beams (microbeams) provide the most stereo-selective irradiation modality known today. This novel irradiation modality has been shown to control seizures originating from eloquent cortex causing no neurological deficit in experimental animals. To test the hypothesis that application of microbeams in the hippocampus, the most common source of refractory seizures, is safe and does not induce severe side effects, we used microbeams to induce transections to the hippocampus of healthy rats. An array of parallel microbeams carrying an incident dose of 600 Gy was delivered to the rat hippocampus. Immunohistochemistry of phosphorylated γ-H2AX showed cell death along the microbeam irradiation paths in rats 48 hours after irradiation. No evident behavioral or neurological deficits were observed during the 3-month period of observation. MR imaging showed no signs of radio-induced edema or radionecrosis 3 months after irradiation. Histological analysis showed a very well preserved hippocampal cytoarchitecture and confirmed the presence of clear-cut microscopic transections across the hippocampus. These data support the use of synchrotron-generated microbeams as a novel tool to slice the hippocampus of living rats in a minimally invasive way, providing (i) a novel experimental model to study hippocampal function and (ii) a new treatment tool for patients affected by refractory epilepsy induced by mesial temporal sclerosis.

Seizure outcomes after stereotactic radiosurgery for the treatment of cerebral arteriovenous malformations

OBJECTIVE

Patients with cerebral arteriovenous malformations (AVMs) commonly present with seizure. Seizure outcomes in patients treated with stereotactic radiosurgery (SRS) are poorly defined. A case series of patients with cerebral AVMs treated with SRS is presented to evaluate long-term seizure outcome.

METHODS

A retrospective review of the medical record was performed, identifying 204 consecutive patients with AVMs treated with SRS between January 1991 and June 2012. Clinical and radiographic data were evaluated. Seizure outcome was measured using the Engel Epilepsy Surgery Outcome Scale. Mean duration of follow-up was 37.1 months (SD 38.3 months) with a minimum follow-up period of 1 month.

RESULTS

Of the 204 patients with cerebral AVMs treated with SRS, 78 patients (38.2%) presented with seizures and 49 of those patients were treated with antiepileptic drugs (AEDs). Following SRS, 63 (80.8%) of the 78 patients who had had seizures prior to SRS were seizure-free at a mean follow-up time of 37.2 months (SD 41.3 months). Of the 49 patients who had been treated with AEDs, 17 were still taking AEDs at last follow-up. Of the 126 patients who did not present with seizures prior to treatment with SRS, only 5 patients (4.0%) had seizures in the post-SRS period. There was no significant correlation between post-SRS seizure status and patient demographic features, comorbidities, AVM characteristics, history of operative intervention, pre- or posttreatment hemorrhage, or radiographic degree of AVM resolution.

CONCLUSIONS

Stereotactic radiosurgery for treatment of cerebral AVMs is effective at providing long-term control of seizures. A substantial number of patients who were treated with SRS were not only seizure free at their last follow-up, but had been successfully weaned from antiepileptic medications.

Gene expression variance in hippocampal tissue of temporal lobe epilepsy patients corresponds to differential memory performance

Temporal lobe epilepsy (TLE) is a severe brain disorder affecting particularly young adults. TLE is frequently associated with memory deterioration and neuronal damage of the hippocampal formation. It thereby reveals striking parallels to neurodegenerative disorders including Alzheimer's disease (AD). TLE patients differ with respect to their cognitive performance, but currently little is known about relevant molecular-genetic factors. Here, we correlated differential memory performance of pharmacoresistant TLE patients undergoing neurosurgery for seizure control with in-vitro findings of their hippocampal tissues. We analyzed mRNA transcripts and subsequently promoter variants specifically altered in brain tissue of individuals with 'very severe' memory impairment. TLE patients (n=79) were stratified according to preoperative memory impairment using an established four-tiered grading system ranging from 'average' to 'very severely'. Multimodal cluster analyses revealed molecules specifically associated with synaptic function and abundantly expressed in TLE patients with very impaired memory performance. In a subsequent promoter analysis, we found the single nucleotide polymorphism rs744373 C-allele to be associated with high mRNA levels of bridging integrator 1 (BIN1)/Amphiphysin 2, i.e. a major component of the endocytotic machinery and located in a crucial genetic AD risk locus. Using in vitro luciferase transfection assays, we found that BIN1 promoter activation is genotype dependent and strongly increased by reduced binding of the transcriptional repressor TGIF. Our data indicate that poor memory performance in patients with TLE strongly corresponds to distinctly altered neuronal transcript signatures, which - as demonstrated for BIN1 - can correlate with a particular allelic promoter variant. Our data suggest aberrant transcriptional signaling to significantly impact synaptic dynamics in TLE resulting in impaired memory performance and may serve as basis for future therapy development of this severe comorbidity.

Morphological changes after radiosurgery for mesial temporal lobe epilepsy

Background

To review our experience with morphological developments during the long-term follow-up of patients treated by Gamma Knife radiosurgery for mesial temporal lobe epilepsy.

Method

Between 1995 and 1999, we treated 14 patients with marginal doses of 24 Gy (n = 6) and 18–20 Gy (n = 8). Nine of these were operated on for insufficient seizure control. We reviewed seizure outcome and magnetic resonance images in both operated and unoperated patients and also re-examined histopathology specimens.

Results

Of the nine operated patients, two were Engel IIIA, one was IVA, five were IVB, and one was Engel IVC prior to surgery. At their final visit, five cases had become Engel class IA, one patient was ID, and two were IIC. In one patient the follow-up was not long enough for classification. Of the five unoperated patients, one was Engel class IB, one was IIIA, one IIB and one IVB at their final visit. Radionecrosis developed in 11 patients, occurring more often and earlier in those treated with higher doses. Collateral edema reached outside the temporal lobe in six patients, caused uncal herniation in two and intracranial hypertension in three. During longer follow-up, postnecrotic pseudocysts developed in 9 patients, and postcontrast enhancement persisted for 2.5–16 years after GKRS in all 14 patients. In five of them we detected its progression between 2 and 16 years after treatment. Signs of neoangiogenesis were found in two patients and microbleeds could be seen in five. Histopathology revealed blood vessel proliferation and macrophage infiltration.

Conclusions

Early delayed complications and morphological signs suggesting a risk of development of late delayed complications are frequent after radiosurgery for mesial temporal lobe epilepsy. Together with its unproven antiseizure efficacy, these issues should be taken into account when planning future studies of this method.

Electronic supplementary material

The online version of this article (doi:10.1007/s00701-015-2525-2) contains supplementary material, which is available to authorized users.

Minimally invasive techniques for epilepsy surgery: stereotactic radiosurgery and other technologies

Minimally invasive surgical techniques for the treatment of medically intractable epilepsy, which have been developed by neurosurgeons and epileptologists almost simultaneously with standard open epilepsy surgery, provide benefits in the traditional realms of safety and efficacy and the more recently appreciated realms of patient acceptance and costs. In this review, the authors discuss the shortcomings of the gold standard of open epilepsy surgery and summarize the techniques developed to provide minimally invasive alternatives. These minimally invasive techniques include stereotactic radiosurgery using the Gamma Knife, stereotactic radiofrequency thermocoagulation, laser-induced thermal therapy, and MRI-guided focused ultrasound ablation.

Visual field defects after radiosurgery for mesial temporal lobe epilepsy

PURPOSE

Gamma knife radiosurgery (RS) may be an alternative to open surgery for mesial temporal lobe epilepsy (MTLE), but morbidities and the anticonvulsant mechanisms of RS are unclear. Examination of visual field defects (VFDs) after RS may provide evidence of the extent of a postoperative fixed lesion. VFDs occur in 52-100% of patients following open surgery for MTLE.

METHODS

This multicenter prospective trial of RS enrolled patients with unilateral hippocampal sclerosis and concordant video-electroencephalography (EEG) findings. Patients were randomized to low (20 Gy) or high (24 Gy) doses delivered to the amygdala, hippocampal head, and parahippocampal gyrus. Postoperative perimetry were obtained at 24 months after RS. Visual field defect ratios (VFDRs) were calculated to quantify the degree of VFDs. Results were contrasted with age, RS dose and 50% isodose volume, peak volume of radiation-induced change at the surgical target, quality of life measurements, and seizure remission.

KEY FINDINGS

No patients reported visual changes and no patients had abnormal bedside visual field examinations. Fifteen (62.5%) of 24 patients had postoperative VFDs, all homonymous superior quadrantanopsias. None of the VFDs were consistent with injury to the optic nerve or chiasm. Clinical diagnosis of VFDs correlated significantly with VFDRs (p = 0.0005). Patients with seizure remission had smaller (more severe) VFDRs (p = 0.04). No other variables had significant correlations.

SIGNIFICANCE

VFDs appeared after RS in proportions similar to historical comparisons from open surgery for MTLE. The nature of VFDs was consistent with lesions of the optic radiations. The findings support the hypothesis that the mechanism of RS involves some degree of tissue damage and is not confined entirely to functional changes in neuromodulation.

Image-defined resolution following radiosurgery for hypothalamic hamartoma

The authors present the rare case of complete image-defined resolution of a hypothalamic hamartoma (HH) following Gamma Knife surgery (GKS). A 9-month-old girl presented with an episode of generalized tonic-clonic seizures. Magnetic resonance imaging revealed a left-sided HH, which remained radiologically stable. By 3 years of age the patient had a development delay of 12 months, and experienced 8 gelastic seizures per day while on 2 antiepileptic medications. Thirty-one months after presentation, the patient underwent elective GKS to treat the HH. She has since been seizure free for 22 months, while receiving 3 antiepileptic medications. Twelve months after radiosurgery, MRI revealed complete radiological resolution of the lesion. The authors discuss alternative management options for HH, including microsurgical resection, endoscopic disconnection, stereotactic radiofrequency thermocoagulation, and interstitial radiosurgery. Gamma Knife surgery is a minimally invasive procedure associated with a lower morbidity rate than that of published surgical results. The present case demonstrates the potential for complete image-defined resolution of an HH post-GKS, without long-term neurological sequelae, emphasizing the safety and efficacy of this therapeutic option for the control of epileptic seizures produced by small-volume, surgically inaccessible HHs.

Synchrotron X-ray interlaced microbeams suppress paroxysmal oscillations in neuronal networks initiating generalized epilepsy

Radiotherapy has shown some efficacy for epilepsies but the insufficient confinement of the radiation dose to the pathological target reduces its indications. Synchrotron-generated X-rays overcome this limitation and allow the delivery of focalized radiation doses to discrete brain volumes via interlaced arrays of microbeams (IntMRT). Here, we used IntMRT to target brain structures involved in seizure generation in a rat model of absence epilepsy (GAERS). We addressed the issue of whether and how synchrotron radiotherapeutic treatment suppresses epileptic activities in neuronal networks. IntMRT was used to target the somatosensory cortex (S1Cx), a region involved in seizure generation in the GAERS. The antiepileptic mechanisms were investigated by recording multisite local-field potentials and the intracellular activity of irradiated S1Cx pyramidal neurons in vivo. MRI and histopathological images displayed precise and sharp dose deposition and revealed no impairment of surrounding tissues. Local-field potentials from behaving animals demonstrated a quasi-total abolition of epileptiform activities within the target. The irradiated S1Cx was unable to initiate seizures, whereas neighboring non-irradiated cortical and thalamic regions could still produce pathological oscillations. In vivo intracellular recordings showed that irradiated pyramidal neurons were strongly hyperpolarized and displayed a decreased excitability and a reduction of spontaneous synaptic activities. These functional alterations explain the suppression of large-scale synchronization within irradiated cortical networks. Our work provides the first post-irradiation electrophysiological recordings of individual neurons. Altogether, our data are a critical step towards understanding how X-ray radiation impacts neuronal physiology and epileptogenic processes.

Radiosurgery for epilepsy: clinical experience and potential antiepileptic mechanisms

Stereotactic radiosurgery, well established in the noninvasive treatment of focal lesions that are otherwise difficult to access through open surgery, is an emerging technology in the treatment of focal epileptic lesions. Recent studies suggest that seizures from hypothalamic hamartomas and mesial temporal lobe epilepsy remit at clinically significant rates with radiosurgery, but large variations among different studies have raised questions about appropriate treatment protocols and mechanisms. Proposed anticonvulsant mechanisms include neuromodulatory effects or ischemic necrosis of epileptic tissue. An ongoing trial that directly compares efficacy, morbidities, and cost of radiosurgery versus open surgery for mesial temporal lobe epilepsy is underway.

Predictors of efficacy after stereotactic radiosurgery for medial temporal lobe epilepsy

BACKGROUND

Stereotactic radiosurgery (RS) is a promising treatment for intractable medial temporal lobe epilepsy (MTLE). However, the basis of its efficacy is not well understood.

METHODS

Thirty patients with MTLE were prospectively randomized to receive 20 or 24 Gy 50% isodose RS centered at the amygdala, 2 cm of the anterior hippocampus, and the parahippocampal gyrus. Posttreatment MRI was evaluated quantitatively for abnormal T2 hyperintensity and contrast enhancement, mass effect, and qualitatively for spectroscopic and diffusion changes. MRI findings were analyzed for potential association with radiation dose and seizure remission (Engel Ib or better outcome).

RESULTS

Despite highly standardized dose targeting, RS produced variable MRI alterations. In patients with multiple serial imaging, the appearance of vasogenic edema occurred approximately 9-12 months after RS and correlated with onset of seizure remission. Diffusion and spectroscopy-detected alterations were consistent with a mechanism of temporal lobe radiation injury mediated by local vascular insult and neuronal loss. The degree of these early alterations at the peak of radiographic response was dose-dependent and predicted long-term seizure remission in the third year of follow-up. Radiographic changes were not associated with neurocognitive impairments.

CONCLUSIONS

Temporal lobe stereotactic radiosurgery resulted in significant seizure reduction in a delayed fashion which appeared to be well-correlated with structural and biochemical alterations observed on neuroimaging. Early detected changes may offer prognostic information for guiding management.

Gamma knife radiosurgery treatment planning for small animals using high-resolution 7T micro-magnetic resonance imaging

Gamma Knife stereotactic radiosurgery is capable of providing small, high gradient dose distributions to a target with a high level of precision, which makes it an excellent choice for studies of focal irradiations with small animals. However, the Gamma Knife stereotactic radiosurgery process makes use of a human-sized fiducial marker system that requires a field of view of at least 200 mm(2) to relate computed tomography and magnetic resonance images to the Gamma Knife treatment planning software. Thus the Gamma Knife fiducial marker system is five to six times larger than a typical small animal subject. The required large field of view limits the spatial resolution and structural detail available in the animal treatment planning image set. In response to this challenge we have developed a custom-designed stereotactic jig and miniature fiducial marking system that allow small bore high-resolution micro-imaging techniques, such as 7T MR and micro-CT, to be used for treatment planning of Gamma Knife stereotactic radiosurgery focal irradiation of small animals.

Treatment modality for intractable epilepsy in hypothalamic hamartomatous lesions

OBJECTIVE

Hypothalamic hamartomas (HHs) are often associated with early-onset gelastic seizures, thus configuring a well recognized and usually severe case of childhood epilepsy syndrome. We present a treatment modality for intractable epilepsy in hypothalamic hamartomatous lesions.

METHODS

This study presents 14 patients with medically refractory seizure associated with HHs treated between 1995 and 2005. The HHs were diagnosed on the basis of magnetic resonance imaging, except in the case of one patient in whom hamartoma was confirmed histologically. There were seven boys and seven girls in this study. The most frequent clinical presentations were seizures. To identify the epileptic focus, we performed comprehensive epilepsy investigations, including electroencephalographic recording using a depth electrode into the hamartoma.

RESULTS

To control the seizure, we performed surgical resection in one patient, gamma knife radiosurgery in four patients, and endoscopic disconnection in 11 patients. Seizure outcome was scored according to Engel's classification throughout a mean follow-up period of 27.4 months (range, 3-54 mo). Of the 11 patients who underwent endoscopic disconnection, six were seizure-free immediately after surgery. Two patients were already diagnosed as having an HH and underwent gamma knife radiosurgery, but seizure control was not achieved. Their gelastic seizure disappeared after endoscopic disconnection.

CONCLUSION

We confirmed that HHs are intrinsically epileptogenic. Therefore, we suggest that HH-related seizures may be controlled by blocking the seizure propagation from epileptogenic HHs through simple disconnection, regardless of the treatment modality, and the endoscopic disconnection of HHs is safer and more effective than other modalities.

[Radiosurgery for drug-resistant epilepsies: state of the art, results and perspectives]

BACKGROUND

There is growing interest in the use of radiosurgery in epilepsy. We analyzed our experience in this field in an attempt to define the potential of radiosurgery in epileptology.

MATERIAL AND METHODS

[corrected] Our local clinical experience (134 patients), accumulated over the last 15 years, mainly includes treatment of temporal lobe epilepsy without space-occupying lesions (59 patients), including 53 with pure MTLE, 61 cases of hypothalamic hamartoma, two cases of callosotomy, and 12 other types of epilepsy.

RESULTS

The analysis of our material, as well as other clinical and experimental data, suggest that the use of radiosurgery is beneficial only to patients in whom a strict preoperative definition of the extent of the epileptogenic zone (or network) has been achieved and strict rules of dose planning have been applied. As soon as these principles are not observed, the risk of treatment failure and/or side effects increases dramatically. Long-term outcome data are now available and published for MTLE but not yet for other types of epilepsy. Long-term safety and efficacy in MTLE are comparable to surgical resection but radiosurgery has the advantage of sparing verbal memory in patients operated by Gamma Knife (GK) on the dominant side. In small hamartomas, the efficacy is comparable to microsurgery but with a dramatic reduction in risk.

CONCLUSION

The vast amount of clinical materiel and long-term evaluation now support the use of GK surgery in small hypothalamic hamartomas and MTLE when the patient is at risk of verbal memory loss.

Lesion evolution after gamma knife irradiation observed by magnetic resonance imaging

PURPOSE

Our study is focused on the magnetic resonance imaging (MRI) observation of lesion development and hippocampus related functional impairments in rats after irradiation with a Leksell Gamma knife (LGK).

MATERIALS AND METHODS

We exposed 32 three-month-old Long-Evans rats to various radiation doses (25 Gy, 50 Gy or 75 Gy). The rats were scanned by a 4.7 T magnetic resonance (MR) spectrometer at several timepoints (1 - 18 months) after irradiation. The lesion size was evaluated by manual segmentation; the animals were behaviorally tested in a Morris water maze and examined histologically.

RESULTS

We found that a dose of 25 Gy induced no edema, necrosis or behavioral change. The response of the rats to higher doses was not uniform; the first occurrence of lesions in the rat brains irradiated with 50 and 75 Gy was detected six months post-irradiation. Functional impairment correlated well with the lesion size and histology.

CONCLUSIONS

Rat brains showed the development of expanding delayed lesions after 50 or 75 Gy doses from the LGK during the first year after irradiation.

Radiosurgical posterior corpus callosotomy in a child with Lennox–Gastaut syndrome

The authors report the successful use of radiosurgery in a child for posterior corpus callosotomy; the early results are good and the patient has not suffered any morbid conditions. The relevant literature pertaining to the use of radiosurgery for treating epilepsy is reviewed. Details of the radiosurgical techniques and prescription dose used are presented, along with 1-year serial neuroimaging results.

Gamma knife radiosurgery targeting protocols for the experiments with small animals

BACKGROUND/AIMS

Manipulation of brain functions via Gamma Knife (GK) irradiation would have numerous applications in clinical and experimental neurology.

METHODS

Alteration of brain functions in the unilaterally irradiated striatum was indexed through monitoring freely moving rat behaviors. Spontaneous activity and rotations on the apomorphine test, which can detect dopaminergic function imbalance, were indexed employing our behavior tracking system. The spatial distribution of necrotic lesions was explored using serial sections, and was assumed to represent the real foci of the GK target.

RESULTS

Distinct behavioral alterations corresponded to the precise locations of the lesions in various areas of the basal ganglia. Displacement of the irradiation sites in the anteromedial direction increased spontaneous activity, and posterolateral shift provoked circling behavior on the apomorphine test.

CONCLUSION

Accurate positioning of the target is crucial for experimental GK irradiation locally focused on domains of a small brain such as that of the rat. Here, we propose a protocol for converting the 'intended' focus, based on brain map coordinates, to a 'planned' focus on the MR imaging coordinate system with the Régis-Valliccioni stereotactic frame.

Radiosurgery for epilepsy

Radiosurgery is an emerging therapeutic approach for the treatment of medically intractable epileptogenic foci. A favourable seizure outcome was first reported in studies of the effects of radiosurgery in the treatment of arteriovenous malformations and tumours. Radiosurgery has since been applied to the treatment of complex partial seizures with mesial-temporal-lobe onset. Nearly simultaneously, experimental evidence supporting the usefulness of radiosurgery to improve or abolish seizures has confirmed that stereotactic irradiation can preferentially affect epileptogenic versus normal cortex. Further work is clearly needed, but this technique might become an important approach in the management of mesial-temporal and extratemporal epilepsy, especially if refractory seizures arise from eloquent cortex or surgically challenging regions of brain.

Influence of ionizing radiation on the course of kindled epileptogenesis

Several clinical and experimental reports suggest that low-dose irradiation of an established epileptic focus can reduce the occurrence of spontaneous seizures. Conversely, some recent reports suggest that under some conditions low-dose irradiation may have disinhibitory effects on seizure expression. Here, we have investigated mechanistic aspects of this phenomenon in the kindling model of epilepsy by applying focal irradiation at various points during kindling development. Rats were kindled to stage 5 by afterdischarge-threshold electrostimulation of the left amygdala. Treatment groups were irradiated using a collimated X-ray beam (18 MV) either prior to kindling, at kindling stage 3, or at kindling stage 5, by exposure of the left amygdala to a single-fraction central-axis dose of 25 Gy. Generalized seizure thresholds (GSTs) were subsequently assayed at weekly intervals for 10 weeks and at monthly intervals for an additional 3 months, along with the severity of the evoked seizures. Irradiation produced no significant effects on seizure threshold, but did produce persistent changes in seizure severity which varied as a function of the timing of irradiation. Relative to sham irradiated controls, the occurrence of stage 6 seizures was significantly increased by irradiation prior to kindling, but was unaffected by irradiation at kindling stage 3, and significantly reduced by irradiation at kindling stage 5. Quantitative immunohistochemical assays for neuron and astrocyte densities within the amygdala and hippocampus revealed only subtle changes in neuronal density within the dentate granule cell layer. These results are discussed in relation to mechanisms of seizure- and radiation-induced plasticity.

The effect of gamma knife irradiation on functions of striatum in rats

Object. An animal model has been developed to study the effect of gamma knife surgery(GKS) on cerebral function.

Methods. A rat was fixed in a newly developed Régis—Valliccioni frame that enables the target region to be planned directly on the magnetic resonance images. The left striatum was irradiated with 150 Gy via a 4-mm collimator of the Leksell gamma knife. Apomorphine (dopamine agonist) was administered to elicit a circling behavior (apomorphine test) after the GKS so as to examine the time course of the changes in dopaminergic functions of irradiated striatum. After a series of behavioral analyses, irradiated brains were subjected to histological examination.

Necrosis was observed in the irradiated area surrounded by hemorrhage and gliosis. The distance between the histologically estimated and planned centers of the irradiation areas was 1.0 ± 0.5 mm. The extent of the distance was due to errors along dorsoventral axis. The distribution of the irradiation areas influenced the activity and the circling behaviors in apomorphine test, which was suggestive of involvement of the nigrostriatal pathway.

Conclusions. Targeting by using the Régis—Valliccioni frame was very accurate compared with targeting with coordinates based on brain maps used hitherto. Although targeting improved the accuracy, further effort will still be necessary to reduce errors along dorsoventral axis. The apomorphine test indicated a reduced dopaminergic function of the irradiated area including striatum, which accompanied histological changes after a high dose of irradiation (150 Gy).

The effect of gamma knife irradiation on functions of striatum in rats

Object.An animal model has been developed to study the effect of gamma knife surgery(GKS) on cerebral function.

Methods.A rat was fixed in a newly developed Régis—Valliccioni frame that enables the target region to be planned directly on the magnetic resonance images. The left striatum was irradiated with 150 Gy via a 4-mm collimator of the Leksell gamma knife. Apomorphine (dopamine agonist) was administered to elicit a circling behavior (apomorphine test) after the GKS so as to examine the time course of the changes in dopaminergic functions of irradiated striatum. After a series of behavioral analyses, irradiated brains were subjected to histological examination.

Necrosis was observed in the irradiated area surrounded by hemorrhage and gliosis. The distance between the histologically estimated and planned centers of the irradiation areas was 1.0 ± 0.5 mm. The extent of the distance was due to errors along dorsoventral axis. The distribution of the irradiation areas influenced the activity and the circling behaviors in apomorphine test, which was suggestive of involvement of the nigrostriatal pathway.

Conclusions.Targeting by using the Régis—Valliccioni frame was very accurate compared with targeting with coordinates based on brain maps used hitherto. Although targeting improved the accuracy, further effort will still be necessary to reduce errors along dorsoventral axis. The apomorphine test indicated a reduced dopaminergic function of the irradiated area including striatum, which accompanied histological changes after a high dose of irradiation (150 Gy).

Metabolite and diffusion changes in the rat brain after Leksell Gamma Knife irradiation

Our study describes the time course of necrotic damage to the rat brain resulting from Leksell Gamma Knife (LGK) irradiation at a dose that was previously considered to be subnecrotic. A lesion induced in the rat hippocampus by 35 Gy irradiation was monitored by MRI, MRS, and DW-MRI for 16 months. T2-weighted images revealed a large hyperintense area with an increased apparent diffusion coefficient of water (ADCw), which occurred 8 months after irradiation, accompanied by metabolic changes (increase of lactate (Lac) and choline (Cho), and decrease of creatine (Cr) and N-acetyl aspartate (NAA), as determined by MRS) that indicated an edema. In two animals, the hyperintensity persisted and a postnecrotic cavity connected to enlarged lateral ventricles developed. In the rest of the animals, the hyperintensity started to decrease 9 months post-irradiation (PI), revealing hypointense areas with a decreased ADCw. Histology confirmed the MRI data, showing either scar formation or the development of a postnecrotic cavity.

Effects of kindling and irradiation on neuronal density in the rat dentate gyrus

Low-dose radiosurgery is presently in use as a treatment modality for focal epilepsy, but the mechanisms underlying the associated changes in seizure expression are poorly understood. We investigated whether total and parvalbumin expressing (PV+) neuronal densities within the hippocampus and amygdala are affected by analogous focal irradiation in amygdala-kindled rats. Adult rats were kindled by electrical stimulation through 10 stage 5 seizures. The kindled amygdala was then focally irradiated at 18 or 25 Gy, and generalized seizure thresholds were subsequently monitored for approximately 6 months. Histological and immunohistochemical assays of total and PV+ neuronal densities were performed bilaterally throughout the hippocampus and within the basolateral amygdala. PV+ neuronal densities were unaffected by kindling or irradiation in these regions. Kindling selectively reduced neuronal densities in the dentate granule cell layer, and medial CA3 pyramidal cell layer. Irradiation at 25 Gy, but not at 18 Gy, prevented or reversed this kindling-associated reduction in density.

Influence of penicillin-induced epileptic activity during pregnancy on postnatal hippocampal nestin expression in rats: light and electron microscopic observations

OBJECTS

Current data concerning the effects of maternal epileptic phenomena on newborns are limited. In clinical practice, therefore, it is difficult to suggest proper guidelines on this issue. This study was carried out to investigate the morphological changes in the hippocampus of newborn pups of rats subjected to experimental epilepsy during pregnancy.

METHODS

Eighteen Swiss Albino rats were randomly divided into three groups (n=6): experimental group, saline-injected sham surgery group, and intact control group. In the experimental group of rats, an acute grand mal epileptic seizure was induced by 400 IU penicillin-G administration into their intra-hippocampal CA3 region with a stereotaxic device during the 13th day of their pregnancy. On the first neonatal day, pups were perfused with intracardiac fixative solution under anesthesia, and newborn hippocampi were dissected surgically for light and electron microscopic examinations. In an immunohistochemical study using Rat-401 mono-clonal antibody and peroxidase, nestin expression was analyzed in the developing hippocampal tissue.

RESULTS

Histologically, normal migration and hippocampal maturation were determined in the newborn rat hippocampus in the control and the sham-operated groups. It was observed that the morphological structure of hippocampus in the experimental group corresponded to the early embryonal period. Most importantly, it was found that nestin (+)cell density was increased in the experimental epilepsy group in contrast to the control and sham groups.

CONCLUSION

It has been concluded that epileptic seizures during embryonic life may cause impaired hippocampal neurogenesis and maturation,explaining the potentially harmful effects of epileptic seizures on the embryo at the early stage of neuronal differentiation. This is the first report regarding the alterations in nestin expression in newborn rat hippocampus. In the light of such findings, it will also be necessary to evaluate the functional consequences of a va-riety of epileptic seizures on learning and memory in neonates.

Novel surgical treatments for epilepsy

The surgical treatment of epilepsy is expanding in an exciting and unprecedented way. This review highlights some of the recent advances in neuroimaging that have improved epilepsy surgery. In addition, novel therapies currently being evaluated in clinical trials, including gamma knife radiosurgery, deep brain stimulation, and responsive stimulation, are discussed. Further surgical developments that will be ready for human application in the near future are highlighted.

FAILURE OF GAMMA KNIFE RADIOSURGERY FOR MESIAL TEMPORAL LOBE EPILEPSY: REPORT OF FIVE CASES

OBJECTIVE

We sought to determine the efficacy of gamma knife radiosurgery (GKRS) in controlling mesial temporal lobe epilepsy.

METHODS

From August 1999 to January 2001, five patients with drug-resistant mesial temporal lobe epilepsy due to hippocampal sclerosis underwent GKRS amygdalohippocampectomy. All of the patients underwent standard epilepsy preoperative evaluation at the comprehensive epilepsy center of the Cleveland Clinic Foundation. A marginal dose of 20 Gy to the 50% isodose line was delivered to the mesial temporal structures in all patients. Postoperative follow-up included serial neurological examinations, neuroimaging studies, and neuropsychological evaluations.

RESULTS

None of the patients were seizure-free after GKRS. Two patients died, 1 month and 1 year after the procedure, as a result of complications related to recurrent seizures. At 1 year, T2-weighted magnetic resonance imaging changes were noted in all three patients, which suggested radiational changes. None of the three surviving patients had any seizure reduction, so 18, 20, and 22 months after GKRS, they underwent temporal lobectomy, which resulted in complete seizure control in all patients.

CONCLUSION

GKRS at the 20-Gy dose level did not lead to seizure control in patients with mesial temporal lobe epilepsy due to hippocampal sclerosis.

Gamma Knife Surgery in Mesial Temporal Lobe Epilepsy: A Prospective Multicenter Study

PURPOSE

This article is the first prospective documentation of the efficacy and safety of gamma knife surgery (GKS) in the treatment of drug-resistant epilepsies of mesial temporal lobe origin.

METHODS

From July 1996 to March 2000, three European centers selected 21 patients with mesial temporal lobe epilepsy (MTLE) for a temporal lobectomy. The preoperative investigations included video-EEG with foramen ovale electrodes, magnetic resonance imaging, neuropsychological testing, and the ESI-55 quality-of-life questionnaire. In place of a cortectomy, radiosurgical treatment was performed by using the Leksell Gamma Knife (LGK) at a dose of 24 +/- 1 Gy at the margin. The target included the anterior parahippocampal cortex and the basal and lateral part of the amygdala and anterior hippocampus (head and body). One patient (a heavy smoker) died of a myocardial infarction. Twenty patients were available for prospective evaluation. A minimum 2-year follow-up period included clinical, neuropsychological, and radiologic evaluations.

RESULTS

At each 6-month follow-up evaluation, the frequency of seizures was significantly smaller than that at the previous visit. The median seizure frequency of 6.16 the month before treatment was reduced to 0.33 at 2 years after treatment. At 2 years, 65% of the patients (13 of 20) were seizure free. Five patients had transient side effects, including depression, headache, nausea, vomiting, and imbalance. There was no permanent neurological deficit reported except nine visual field deficits. No neuropsychological deterioration was observed 2 years after treatment. The quality of life was significantly better than that before surgery.

CONCLUSIONS

The safety and efficacy of the radiosurgical treatment of MTLEs appears good in this group of patient over short-to-middle term. Delay of the seizure cessation was the major disadvantage of GKS. A longer follow-up period is required for confirmation of these results.

The effect of experimental epilepsy induced by penicillin administration during pregnancy on nestin expression in the immature rat cerebellum. A light, electron microscopic, and immunohistochemical study

INTRODUCTION

Recent knowledge regarding the effect of epileptic seizures in pregnant women on newborns was limited and, therefore, it was difficult to suggest the proper clinical guidelines and to take precautions against it. Studies evaluating the morphological effects of epileptic seizure during pregnancy on newborns in various experimental models are valuable. Therefore, the current study was designed to investigate the morphological changes in the cerebellum of newborn pups of rats subjected to experimental epilepsy during pregnancy.

MATERIALS AND METHODS

Swiss Albino rats were divided into three groups (six animals in each). In the first group (experimental group) an acute grand mal epileptic seizure was induced by 400 IU penicillin-G administration into their intrahippocampal CA3 region with a stereotaxic device during the 13th day of their pregnancy. The second group (intrahippocampal saline-injected sham group) and the third group (untreated animals) were the control groups. On the 1st neonatal day, pups were perfused with intracardiac fixative solution under anesthesia, and newborn cerebellums were dissected surgically for light and electron microscopic studies.

RESULTS

In an immunohistochemical study using Rat-401 monoclonal antibody and peroxidase, the intermediate filament nestin was detected in the developing cerebellar tissue. Histologically, normal migration and cerebellar maturation were determined in the newborn rat cerebellum in the control and sham-operated groups. It was observed that the morphological structure of the cerebellar cortex in the experimental group was compromised in the early embryonal period. In contrast to the control and sham groups, it was found that nestin (+) cell density was increased in the experimental epilepsy group.

CONCLUSIONS

It has been concluded that epileptic convulsions during embryonic life may cause early neurogenesis and delayed maturation, which explains the harmful effects of epileptic grand mal seizures, hypoxia, and obstetric trauma to the embryo at the early stage of neuronal differentiation. However, further studies are necessary to investigate epileptic pregnant phenomena and to characterize the possible relationship between epilepsy and congenital malformations as well as mental retardation.

Delayed radiation necrosis with extensive brain edema after gamma knife radiosurgery for multiple cerebral cavernous malformations--case report

A 39-year-old man presented with multiple intracranial cavernous malformations manifesting as intractable seizures persisting for more than 20 years. He underwent gamma knife radiosurgery (GKRS) for right frontal and left temporal cavernous malformations. He began to suffer from progressive left hemiparesis and inattention 2 years 5 months after the GKRS. Magnetic resonance imaging showed abnormal ring enhancement and extensive brain edema around the right frontal lesion. Conservative therapies such as external decompression, low-dose barbiturates, and mild hypothermia had no effect on his clinical status. Stereotactic biopsy of the ring-enhanced area demonstrated gliosis. Signs of cerebral herniation appeared, so we performed partial resection of the right frontal lobe. His symptoms recovered immediately. Subsequent hyperbaric oxygen (HBO) therapy significantly improved the extensive brain edema. Delayed radiation necrosis associated with potentially fatal brain edema may occur after GKRS for cavernous malformations. Internal decompression and subsequent HBO therapy were very effective for the treatment of these lesions.

Leksell gamma knife lesioning of the rat hippocampus: the relationship between radiation dose and functional and structural damage

Object. The goals of the study were to determine at what dosage and after what interval impairment of hippocampal function occurs after Leksell gamma knife radiosurgery (GKS) of the rat hippocampus and to assess the associated structural changes.

Methods. Long—Evans rats were irradiated with maximum doses of 25, 50, 75, 100, and 150 Gy, and four 4-mm isocenters were used to cover the hippocampus bilaterally. The impairment of hippocampal function, which is associated with a loss of memory, was measured by testing the impairment of the rats' orientation in a Morris water maze. Changes in the irradiated tissue were measured using magnetic resonance imaging (Bruker 4.7/20 experimental spectrometer). The data were compared with histologically demonstrated changes.

Significantly higher incidences of edema, necrosis, and behavioral changes were observed following administration of doses higher than 50 Gy. No edema, necrosis, or behavioral changes were observed when doses were 25 Gy.

Conclusions. It would seem that rats can be used for experiments involving the induction of complex brain lesions by using four 4-mm isocenters. Testing retention memory for behavioral changes after bilateral GKS of the whole hippocampus proved insensitive; acquisition memory should be tested to assess functional changes of hippocampus. Significantly higher incidences of edema, necrosis, and behavioral changes were observed for doses higher than 50 Gy. There seems to be a therapeutic window during which doses may affect epilepsy without impairing the memory of the rat.