Adjuvant Radiotherapy in Stage II Endometrial Cancer: Selective De-intensification of Adjuvant Treatment

AIMS

Risk stratification, including nodal assessment, allows for selective de-intensification of adjuvant radiotherapy in stage II endometrial cancer. Patterns of treatment and clinical outcomes, including the use of reduced volume 'mini-pelvis' radiotherapy fields, were evaluated in a population-based study.

MATERIALS AND METHODS

All patients diagnosed with pathological stage II endometrial cancer between 2000 and 2014, and received adjuvant radiotherapy in a regional healthcare jurisdiction were reviewed. Registry data were supplemented by a comprehensive review of patient demographics, disease characteristics and treatment details. The Charlson Comorbidity Score was calculated. Survival and recurrence data were analysed.

RESULTS

In total, 264 patients met the inclusion criteria. Most patients had endometrioid histology (83%); 41% of patients had International Federation of Gynecologists and Obstetricians grade 1 disease. Half (49%) had surgical nodal evaluation; 11% received chemotherapy. Most patients (59%) were treated with full pelvic radiotherapy fields ± brachytherapy. Seventeen per cent of patients received mini-pelvis radiotherapy ± brachytherapy, whereas 24% received brachytherapy alone. Five-year recurrence-free survival was 87% for the entire cohort, with no significant difference by adjuvant radiotherapy approach. Only one patient receiving mini-pelvis radiotherapy ± brachytherapy recurred in the pelvis but outside of the mini-pelvis field. Recorded late toxicity rates were highest for full pelvis radiotherapy + brachytherapy.

CONCLUSION

Risk stratification in a real-world setting allowed for selective de-intensification of adjuvant radiation with equivalent outcomes for stage II endometrial cancer. Mini-pelvis radiotherapy combined with brachytherapy is effective in highly selected patients, with the potential to decrease toxicity without compromising local control. Brachytherapy should be considered in low-risk stage II patients.

Status of COMPASS RICH-1 Upgrade with MPGD-based Photon Detectors

A Set of new MPGD-based Photon Detectors is being built for the upgrade of COMPASS RICH-1. The detectors cover a total active area of 1.4 m2 and are based on a hybrid architecture consisting of two THGEM layers and a Micromegas. A CsI film on one THGEM acts as a reflective photocathode. The characteristics of the detector, the production of the components and their validation tests are described in detail.

Quantification of diffusion and anisotropy in intracranial epidermoids using diffusion tensor metrics and p: q tensor decomposition

PURPOSE

To quantitatively evaluate the diffusion tensor metrics p, q, L and fractional anisotropy in intracranial epidermoids in comparison with normal white matter in the splenium of the corpus callosum.

METHODS

This retrospective study included 20 consecutive patients referred to our institute. All patients had a magnetic resonance imaging (MRI) study on a 1.5-Tesla MR system. A spin-echo echo-planar DTI sequence with diffusion gradients along 30 non-collinear directions was performed. The eigen values (λ₁, λ₂, λ₃) were computed for each voxel and, using p: q tensor decomposition, the DTI metrics p, q and L-values and fractional anositropy (FA) were calculated. The region of interest (ROI) (6 pixels each) was placed within the lesion in all the cases and in the splenium of the corpus callosum.

RESULTS

The mean FA in the lesion and splenium were 0.50 and 0.88 respectively, with a statistically significant difference between them (P<0.01). On p: q tensor decomposition, the mean p-value in the epidermoid was 1.55±0.24 and 1.35±0.20 in the splenium; the mean q-values in the epidermoid was 0.67±0.13 and 1.27±0.17 in the splenium; the differences were statistically significant (P=0.01 and <0.01 respectively). The significant difference between p- and q-values in epidermoids compared with the splenium of callosum was probably due to structural and orientation differences in the keratin flakes in epidermoids and white matter bundles in the callosum. However, no significant statistical difference in L-values was noted (P=0.44).

CONCLUSION

DTI metrics p and q have the potential to quantify the diffusion and anisotropy in various tissues thereby gaining information about their internal architecture. The results also suggest that significant differences of DTI metrics p and q between epidermoid and the splenium of the corpus callosum are due to the difference in structural organization within them.

A randomized clinical trial comparing fixed vs pro-re-nata dosing of Ozurdex in refractory diabetic macular oedema (OZDRY study)

OBJECTIVE

To compare the clinical effectiveness and safety of 5-monthly fixed dosing vs pro-re-nata (PRN) Ozurdex treatment in patients with refractory diabetic macular oedema (DMO).

DESIGN

Prospective, multicentre, randomized active-controlled non-inferiority clinical trial.

PARTICIPANTS

Participants were 100 patients who attended Medical Retina Clinics for management of centre-involving refractory DMO.

INTERVENTIONS

Participants were randomized 1 : 1 to either 5-monthly fixed dosing or optical coherence tomography (OCT)-guided PRN regimen of Ozurdex therapy for DMO. Data were collected on best-corrected visual acuity (BCVA), patient-reported outcome measures (PROM), macular thickness and morphology, diabetic retinopathy status, number of injections and adverse events from baseline for a period of 12 months.Main outcome measuresThe primary outcome was the difference between arms in change in BCVA from baseline to 12 months. The prespecified non-inferiority margin was five ETDRS letters. Key secondary outcomes included change in PROM scores, change in macular thickness, change in retinopathy and macular morphology, and safety profile.

RESULTS

The mean change in BCVA was +1.48 (SD 14.8) in the fixed arm vs -0.17 (SD 13.1) in the PRN arm, with adjusted effect estimate +0.97, 90% confidence interval (-4.01, +5.95), P=0.02 (per protocol analysis). The conclusions of the ITT analysis were primarily supportive, -0.34 (-5.49, 4.81) P=0.07, but sensitive to an alternative assumption on missing data, +0.28 (-4.72, 5.27) P=0.04.

CONCLUSIONS

The mean change in BCVA with 5-monthly fixed dosing of Ozurdex was non-inferior to OCT-guided PRN Ozurdex therapy for refractory DMO based on a per protocol analysis.

Defining response to anti-VEGF therapies in neovascular AMD

The introduction of anti-vascular endothelial growth factor (anti-VEGF) has made significant impact on the reduction of the visual loss due to neovascular age-related macular degeneration (n-AMD). There are significant inter-individual differences in response to an anti-VEGF agent, made more complex by the availability of multiple anti-VEGF agents with different molecular configurations. The response to anti-VEGF therapy have been found to be dependent on a variety of factors including patient's age, lesion characteristics, lesion duration, baseline visual acuity (VA) and the presence of particular genotype risk alleles. Furthermore, a proportion of eyes with n-AMD show a decline in acuity or morphology, despite therapy or require very frequent re-treatment. There is currently no consensus as to how to classify optimal response, or lack of it, with these therapies. There is, in particular, confusion over terms such as 'responder status' after treatment for n-AMD, 'tachyphylaxis' and 'recalcitrant' n-AMD. This document aims to provide a consensus on definition/categorisation of the response of n-AMD to anti-VEGF therapies and on the time points at which response to treatment should be determined. Primary response is best determined at 1 month following the last initiation dose, while maintained treatment (secondary) response is determined any time after the 4th visit. In a particular eye, secondary responses do not mirror and cannot be predicted from that in the primary phase. Morphological and functional responses to anti-VEGF treatments, do not necessarily correlate, and may be dissociated in an individual eye. Furthermore, there is a ceiling effect that can negate the currently used functional metrics such as >5 letters improvement when the baseline VA is good (ETDRS>70 letters). It is therefore important to use a combination of both the parameters in determining the response.The following are proposed definitions: optimal (good) response is defined as when there is resolution of fluid (intraretinal fluid; IRF, subretinal fluid; SRF and retinal thickening), and/or improvement of >5 letters, subject to the ceiling effect of good starting VA. Poor response is defined as <25% reduction from the baseline in the central retinal thickness (CRT), with persistent or new IRF, SRF or minimal or change in VA (that is, change in VA of 0+4 letters). Non-response is defined as an increase in fluid (IRF, SRF and CRT), or increasing haemorrhage compared with the baseline and/or loss of >5 letters compared with the baseline or best corrected vision subsequently. Poor or non-response to anti-VEGF may be due to clinical factors including suboptimal dosing than that required by a particular patient, increased dosing intervals, treatment initiation when disease is already at an advanced or chronic stage), cellular mechanisms, lesion type, genetic variation and potential tachyphylaxis); non-clinical factors including poor access to clinics or delayed appointments may also result in poor treatment outcomes. In eyes classified as good responders, treatment should be continued with the same agent when disease activity is present or reactivation occurs following temporary dose holding. In eyes that show partial response, treatment may be continued, although re-evaluation with further imaging may be required to exclude confounding factors. Where there is persistent, unchanging accumulated fluid following three consecutive injections at monthly intervals, treatment may be withheld temporarily, but recommenced with the same or alternative anti-VEGF if the fluid subsequently increases (lesion considered active). Poor or non-response to anti-VEGF treatments requires re-evaluation of diagnosis and if necessary switch to alternative therapies including other anti-VEGF agents and/or with photodynamic therapy (PDT). Idiopathic polypoidal choroidopathy may require treatment with PDT monotherapy or combination with anti-VEGF. A committee comprised of retinal specialists with experience of managing patients with n-AMD similar to that which developed the Royal College of Ophthalmologists Guidelines to Ranibizumab was assembled. Individual aspects of the guidelines were proposed by the committee lead (WMA) based on relevant reference to published evidence base following a search of Medline and circulated to all committee members for discussion before approval or modification. Each draft was modified according to feedback from committee members until unanimous approval was obtained in the final draft. A system for categorising the range of responsiveness of n-AMD lesions to anti-VEGF therapy is proposed. The proposal is based primarily on morphological criteria but functional criteria have been included. Recommendations have been made on when to consider discontinuation of therapy either because of success or futility. These guidelines should help clinical decision-making and may prevent over and/or undertreatment with anti-VEGF therapy.

EC-IC bypass for cavernous carotid aneurysms: An initial experience with twelve patients

Aims:

Need for performing a bypass procedure prior to parent artery occlusion in patients with good cerebral vascular reserve is controversial. We analyze our experience of 12 giant internal carotid artery aneurysms treated with extracranial-intracranial (EC-IC) bypass and proximal artery occlusion.

Materials and Methods:

Retrospective analysis of the case records of all complex carotid aneurysms operated in our institute since January 2009.

Results:

The study included eleven cavernous carotid aneurysms and one large fusiform cervical carotid aneurysm reaching the skull base. Preoperative assessment of cerebral vascular reserve was limited to Balloon test occlusion with hypotensive challenge. Eleven patients who successfully completed a Balloon test occlusion (BTO) underwent low flow superficial temporal artery to middle cerebral artery (STA-MCA) bypass, while one patient with a failed BTO underwent a high flow bypass using a saphenous vein graft. Parent artery ligation was performed in all patients following the bypass procedure. Check angiogram revealed thrombosis of the aneurysm in all patients with a graft patency rate of 81.8%. We had one operative mortality, probably related to a leak from the anastomotic site. The only patient who had a high flow bypass developed contralateral hemispheric infarcts and remained vegetative. All the other patients had a good recovery and with a Glasgow outcome score of 5 at last follow-up.

Conclusion:

We feel that combining EC-IC bypass prior to parent vessel occlusion helps in reducing the risk of post operative ischemic complications especially in situations where a complete mandated cerebral blood flow studies are not feasible.

Kikuchi-Fujimoto Disease: part of the differential diagnosis of cervical lymphadenopathy in an HIV-positive patient

A 38-year-old HIV-positive Nigerian woman presented with a three-week history of cervical lymphadenopathy, night sweats, weight loss and fever. Provisional diagnoses of tuberculosis and lymphoma were considered; however, a histological diagnosis of Kikuchi-Fujimoto Disease was reached. This rare benign disease has presenting features that mimic more serious conditions commonly occurring in HIV-positive patients. This case report emphasises the importance of Kikuchi-Fujimoto Disease in the differential diagnosis of cervical lymphadenopathy in HIV-positive patients.

Ranibizumab for the treatment of choroidal neovascularisation secondary to pathological myopia: interim analysis of the REPAIR study

AIMS

To evaluate the efficacy and safety of intravitreal ranibizumab in patients with choroidal neovascularisation secondary to pathological myopia (myopic CNV). Data are from a pre-planned, 6-month interim analysis.

METHODS

Phase II, open-label, single arm, multicentre, 12-month study, recruiting patients (aged ≥18 years) with active primary or recurrent subfoveal or juxtafoveal myopic CNV, with a best-corrected visual acuity (BCVA) score of 24-78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the study eye and a diagnosis of high myopia of at least -6 dioptres. Patients received 0.5 mg ranibizumab administered intravitreally to the study eye, followed by monthly injections given as needed (based on a predefined algorithm) for up to 11 months.

RESULTS

At 6 months, mean BCVA improved from baseline by 12.2 letters, as did central macular thickness (in this interim analysis defined as a measure of either central subfield macular thickness or centre point macular thickness) from baseline by 108 μm in the 48 study eyes of 48 patients. Fewer patients had centre-involving intraretinal oedema (13.0% vs 91.5%), intraretinal cysts (10.9% vs 57.4%), or subretinal fluid (13.0% vs 66.0%) at 6 months than at baseline. Patients received a mean of 1.9 retreatments, were satisfied with ranibizumab treatment, and well being was maintained. No new safety signals were identified.

CONCLUSIONS

Results from the planned interim analysis support the role of ranibizumab in the treatment of myopic CNV, with excellent efficacy achieved with a low number of injections and few serious adverse events.

Ranibizumab for the treatment of choroidal neovascularisation secondary to pathological myopia: interim analysis of the REPAIR study

AIMS

To evaluate the efficacy and safety of intravitreal ranibizumab in patients with choroidal neovascularisation secondary to pathological myopia (myopic CNV). Data are from a pre-planned, 6-month interim analysis.

METHODS

Phase II, open-label, single arm, multicentre, 12-month study, recruiting patients (aged ≥18 years) with active primary or recurrent subfoveal or juxtafoveal myopic CNV, with a best-corrected visual acuity (BCVA) score of 24-78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the study eye and a diagnosis of high myopia of at least -6 dioptres. Patients received 0.5 mg ranibizumab administered intravitreally to the study eye, followed by monthly injections given as needed (based on a predefined algorithm) for up to 11 months.

RESULTS

At 6 months, mean BCVA improved from baseline by 12.2 letters, as did central macular thickness (in this interim analysis defined as a measure of either central subfield macular thickness or centre point macular thickness) from baseline by 108 μm in the 48 study eyes of 48 patients. Fewer patients had centre-involving intraretinal oedema (13.0% vs 91.5%), intraretinal cysts (10.9% vs 57.4%), or subretinal fluid (13.0% vs 66.0%) at 6 months than at baseline. Patients received a mean of 1.9 retreatments, were satisfied with ranibizumab treatment, and well being was maintained. No new safety signals were identified.

CONCLUSIONS

Results from the planned interim analysis support the role of ranibizumab in the treatment of myopic CNV, with excellent efficacy achieved with a low number of injections and few serious adverse events.

Bilateral thalamic lesions

OBJECTIVE

Bilateral thalamic lesions are rare and relatively obscure neoplasms. We present our experience with nine cases of bilateral thalamic lesions and attempt to analyse them in the background of available literature.

MATERIALS AND METHODS

Retrospective analyses of the case records of 9 cases of bilateral thalamic lesions treated in our department since January 2002, which have a minimum of 1 year follow-up.

RESULTS

The study group included four males and five females with a mean age of 14.6 years (5 years to 29 years). Seven of these patients had radiological evidence of bilateral thalamic lesions at presentation and 2 patients had involvement of the opposite thalamus at a later stage of the disease. All patients except one presented with raised intracranial pressure symptoms. Focal motor deficits (4/9), behavioral and memory disturbances (3/9) were the other major presenting symptoms. Biopsy confirmation was possible in six patients and histopathology was suggestive of low grade fibrillary astrocytoma in all six patients. Seven patients required CSF diversion procedure for associated hydrocephalus. Eight of our nine patients underwent radiotherapy. On last follow-up, 3 patients were clinically stable with images suggestive of arrested disease, four patients had evidence of progressive disease both clinically and radiologically and there were two recorded cases of mortality.

CONCLUSION

Primary bilateral thalamic lesions have characteristic neuroradiological properties and are distinct from unilateral thalamic tumours with bilateral progression. Almost all of these lesions on histology prove to be gliomas but decompressive surgery is seldom feasible. Surgical intervention is limited to biopsy and CSF diversion for hydrocephalus. Bilateral thalamic lesions remain unresponsive to adjuvant therapy and generally carry a poor prognosis.

X-linked retinoschisis maculopathy treated with topical dorzolamide, and relationship to genotype

PURPOSE

To correlate the response of topical dorzolamide (Trusopt; Merck) in patients with X-linked retinoschisis (XLRS) with genotype.

METHODS

We carried out a retrospective evaluation of four patients (seven eyes) with XLRS, treated with topical dorzolamide. The change in best-corrected visual acuity (VA) and central macular thickness (CMT; central 1 mm subfield thickness) from optical coherence tomography (OCT) was analysed over the follow-up period, using Student's t-test. Each patient also had genetic analysis for mutations in the retinoschisisgene (RS1).

RESULTS

The mean age at the start of treatment was 14.7±11 years, and mean follow-up duration was 21.7±7.7 months. Mean CMT at the final follow-up was significantly better than at baseline (291±123 vs 352±119 μm, P=0.007); however, mean VA was worse (0.38±0.25 vs 0.31±0.24 logMAR score, P=0.041). All four patients had a mutation in the RS1gene; there was no apparent association between the type of mutation and the response to topical dorzolamide.

CONCLUSION

Topical dorzolamide may have some effect in reducing central macular thickness in patients with XLRS, but this does not necessarily correlate with improvement in VA. In our case series, genotypic information did not predict the response to this treatment.

Advanced magnetic resonance imaging with histopathological correlation in papillary tumor of pineal region: report of a case and review of literature

Papillary tumors of the pineal region are recently described as rare mass lesions with limited literature available on their natural history and imaging features. Magnetic resonance imaging (MRI) including perfusion, diffusion, and spectroscopic features were described in an 18-year-old girl with papillary tumor of pineal region. A well-defined, T1 hyperintense and contrast-enhancing mass lesion was noted in pineal region with few cystic spaces within. Solid portion of lesion showed minimal diffusion restriction with average apparent diffusion coefficient of 0.812 Χ 10 -3 mm 2 /s; on MR spectroscopy elevated myo-inositol peak with reduced N-acetylaspartate and elevated choline in the tumor. On perfusion study there was significantly high relative cerebral blood volume (rCBV) (6-9 times) and relative cerebral blood flow (rCBF). Our findings agree with previous descriptions of cystic areas with T1 hyperintense appearance of this tumor but very high level of tumor perfusion, diffusion restriction, and presence of myo-inositol peak are important imaging findings and may correlate with the recent reports of high tumor recurrence in these cases.

A Comparative Study of GaN Films Grown on Different Faces of Sapphire by ECR-Assisted MBE

GaN films were grown on c-plane (0001), a-plane (1120) and r-plane (1102) sapphire substrates by the ECR-assisted MBE method. The films were grown using a two-step growth process, in which a GaN buffer is grown first at relatively low temperatures and the rest of the film is grown at higher temperatures. RHEED studies indicate that this growth method promotes lateral growth and leads to films with smooth surface morphology. The epitaxial relationship to the substrate, the crystalline quality and the surface morphology were investigated by RHEED, X-ray diffraction and SEM studies.

Kissing anterior communicating artery aneurysms: diagnostic dilemma and management issues

Kissing aneurysms are unusual and relatively rare types of multiple intracranial arterial aneurysms. When located on the anterior communicating artery (ACoA), kissing aneurysms pose considerable diagnostic difficulty on preoperative conventional angiogram. Special angiographic views or 3D rotational angiogram are needed to make the correct diagnosis and to avoid interpreting them as multilobed or bilobed saccular aneurysms on preoperative conventional angiogram. Treatment of these aneurysms, either by clipping or coiling, needs to be individualized. Unique problems which need to be addressed during surgical clipping are high risk of rupture due to dense adhesions between the kissing aneurysms, requirement of at least two clips in a narrow working area, the aneurysm that needs to be clipped first and interference of the first clip with application of subsequent clips. The authors present a case of a 63-year-old male who had kissing ACoA aneurysms managed successfully by clipping.

Regionally acquired intestinal failure data suggest an underestimate in national service requirements

OBJECTIVES, SETTING AND PATIENTS: With complete case referral for prolonged parenteral nutrition (PN) beyond term equivalent, serving a stable population of 1.25 million people, we describe the long-term outcome and survival of patients referred to an intestinal failure (IF) nutrition support team over the first 8 years of existence at a regional paediatric centre, and extrapolate to potential numbers of national home parenteral nutrition (HPN) cases and intestinal transplantation data.

DESIGN AND OUTCOME MEASURES

Retrospective analysis detailing patient demographics, interventions, use of HPN, occurrence of intestinal failure-associated liver disease (IFALD), and outcomes of enteral adaptation, survival, and referral for and receipt of organ transplantation.

RESULTS

23 patients were referred over 8 years, 20 being PN dependent within the neonatal period. Diagnoses included short bowel syndrome (SBS) (18), neuromuscular abnormalities (4) and congenital enterocyte disorder (1). 12 696 days of PN were delivered with 314 confirmed episodes of sepsis at a median of 12 episodes per patient. 144 central venous catheters (CVCs) were required at a median of four per patient. IFALD occurred in 17 (73%) patients, with 10 (44%) referred for transplant assessment. Thirteen (56%) children received HPN. Overall mortality was 44%. A significant predictor for survival in the SBS group was residual bowel >40 cm (82% vs 28%, p = 0.049).

CONCLUSIONS

Survival for IF at 56% was lower than reported from non-UK supra-regional centres, and nationally collected data, possibly reflecting pre-selected referral populations. Data from regional centres with complete ascertainment may be important both when counselling parents and when planning regional and national HPN and IF specialist services.

New paradigms in the treatment of wet AMD: the impact of anti-VEGF therapy

The incidence of age-related macular degeneration (AMD) in the United Kingdom is increasing with the ageing population. The wet form of this progressive and potentially blinding disease can develop very rapidly and lead to severe loss of central vision and reduction in quality of life, sometimes in just a matter of weeks. Recent advances in the treatment of wet AMD with the licensing of anti-vascular endothelial growth factor therapies, coupled with current guidance from the Scottish Medicines Consortium and the National Institute of Health and Clinical Excellence have led to a subsequent increase in workload at AMD clinics due to the increased number of patients now eligible for treatment. In addition, the Royal College of Ophthalmologists recommend a 2-week diagnosis to treatment schedule due to the aggressive nature of the disease. The role of the retinal specialist is thus changing, and business management skills are becoming increasingly necessary to obtain the necessary resources to implement the guidance. Through prior experience and formal external evaluation of services at Frimley Park and Harrogate District Hospitals, a number of critical success factors have been developed for optimising treatment pathways in efficient wet AMD clinics.

Subfrontal gangliocytoma masquerading as olfactory groove meningioma

We describe a rare case of an unusually located gangliocytoma. The conventional magnetic resonance imaging (MRI) appearance was suggestive of an olfactory groove meningioma. However, advanced MRI sequences (diffusion-weighted imaging--DWI; perfusion MRI; susceptibility-weighted imaging--SWI; MR spectroscopy--MRS) revealed features more consistent with a glial neoplasm.

Morphine analgesia and gastrointestinal morbidity in preterm infants: secondary results from the NEOPAIN trial

OBJECTIVE

To investigate the influence of morphine therapy and other factors on the attainment of full enteral feeds and on acquired gastrointestinal pathology in preterm infants.

DESIGN

Secondary data analysis from a randomised, placebo controlled trial.

SETTING

16 neonatal intensive care units in USA, Sweden, France and UK.

PATIENTS

898 infants (treatment group 449, control 449). Gestation (median (range)): 27 (23-32) weeks; birth weight (median (range)): 985 (420-2440) g.

INTERVENTIONS

Morphine (M) or placebo (Pl) given pre-emptively by intravenous loading dose (100 microg/kg of morphine) and infusion (10-30 microg/kg/h depending on gestation) while infants were ventilated, for up to 14 days. "Open-label" morphine (A) could be given if clinically indicated.

MAIN OUTCOME MEASURES

Age at full enteral feeds and major acquired gastrointestinal pathology.

RESULTS

The group randomised to morphine was later in attaining full feeds (median days (quartiles): M 20 (13-29), Pl 17 (12-26); p = 0.003), and in starting feeds (median days (quartiles): M 5 (3-8), Pl 4 (2-7)). In a linear regression model, age at full feeds was independently associated with birth weight, a score of neonatal morbidities, neonatal dexamethasone use and cumulative morphine dose. There was no relationship between morphine use and acquired gastrointestinal pathology (M 9/449, Pl 8/449; chi2 p = 0.81).

CONCLUSIONS

Morphine delays the attainment of full enteral feeds, partly by delaying the start of feeding, but does not discernibly increase gastrointestinal complications. The attainment of full feeds is influenced by morphine dose, but other factors seem to be important, including birth weight and neonatal morbidity.

Primary diffuse leptomeningeal gliomatosis

A 20-year-old woman with a history of seizures presented symptoms of walking difficulties for the past six months. Clinical examination was suggestive of a craniovertebral junction anomaly. A cerebrospinal fluid study showed mild protein elevation with no evidence of an infective pathology. Craniospinal MRI revealed diffuse nodular leptomeningeal enhancement of the brain and spinal cord. Histopathological examination was suggestive of a low-grade glioma, and the patient was diagnosed with primary diffuse leptomeningeal gliomatosis. So far, the patient has survived for more than 110 months without aggressive therapy.

Dissecting intracranial aneurysms presenting as subarachnoid haemorrhage: report of two cases and review of literature

Subarachnoid haemorrhage due to intracranial non-traumatic dissecting aneurysms is rare. Most of the published reports refer to dissecting aneurysms in the vertebrobasilar territory. Anterior circulation dissecting aneurysms are rare and their pathogenesis, clinical features, angiographic findings and management are a matter of debate. Management of patients with intracranial arterial dissection is unclear. Unlike the well-established proximal occlusion and trapping approaches to vertebral artery dissections, choices of interventions for anterior circulation and basilar dissecting aneurysms are limited, and most reports have been limited to wrapping techniques for arterial wall reinforcement. The role of anticoagulation therapy in the presence of subarachnoid haemorrhage is also a matter of debate. As no clear-cut guidelines are available, treatment should be tailored to the individual patient. We describe two cases of intracranial dissecting aneurysms, which presented as subarachnoid haemorrhage (SAH) and discuss the management issues.

Symptomatic granular cell tumour of the pituitary

Granular cell tumours (GCT) and pituicytomas are rare tumours seen in the sellar suprasellar region which are believed to arise from either the infundibulum or the posterior lobe of the pituitary gland. Whether they are two distinct lesions or represent one single pathological entity remains a matter of debate. We report the case of a 42-year-old male with a granular cell neoplasm of the sellar suprasellar region and attempt to discuss the controversies shrouding this distinct clinicopathological entity.

Intratumoral microhemorrhages on T2*-weighted gradient-echo imaging helps differentiate vestibular schwannoma from meningioma

BACKGROUND AND PURPOSE

Vestibular schwannomas (VS) may be difficult to differentiate from cerebellopontine angle (CPA) meningiomas. Demonstration of microhemorrhages in VS on T2*-weighted gradient-echo (GRE) sequences may have potential value to differentiate VS from CPA meningiomas.

MATERIALS AND METHODS

In this prospective study of 20 patients, MR imaging was performed with T2*-weighted GRE in addition to all basic sequences. Histopathologic examination was performed after surgery. Intratumoral hemosiderin was confirmed by pigment staining.

RESULTS

There were 15 patients in the VS group with 16 VS and 5 in the meningioma group with 5 posterior fossa meningiomas. Fourteen of the 16 VS and all 5 meningiomas were treated surgically and were confirmed on histopathologic examination. T2*-weighted GRE identified microhemorrhages on T2*-weighted sequence in 15 (93.75%) of the 16 VS. CT excluded calcification in all VS. T2-weighted turbo spin-echo (TSE) and fluid-attenuated inversion recovery (FLAIR) images recognized microhemorrhages in 2 cases. Pigment staining confirmed hemosiderin in all 14 surgically treated VS, and none of the meningiomas showed microhemorrhages on MR imaging. For the detection of microhemorrhages, T2*-weighted GRE showed a sensitivity of 93.8%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 83.3%. The sensitivity of T2 TSE and FLAIR for microhemorrhage was 12.5%. The Fisher exact test showed a statistically significant difference in the differentiation of VS from meningioma on the basis of detection of microhemorrhages (P < .01).

CONCLUSION

Most VS demonstrate microhemorrhages on T2*-weighted GRE. This finding is useful to differentiate VS from CPA meningiomas. T2*-weighted GRE should be used as a basic sequence to evaluate CPA tumors. Identification of microhemorrhages may have the potential to assess the aggressive biologic behavior of VS.

Tear lipid layer thickness and ocular comfort with a novel device in dry eye patients with and without Sjögren's syndrome

BACKGROUND

To measure changes in tear-film lipid-layer thickness (LLT) and symptoms in patients with dry eye symptoms with and without Sjögren's syndrome after using a novel device. The device is designed to promote release of meibomian sebum into the tear film by delivering latent heat to the eyelids.

STUDY DESIGN

Two prospective, controlled, randomised, observer-masked, single-intervention studies.

METHODS

Two independent studies were conducted in a major university hospital in the South West of England. The first study involved 24 patients with dry eye symptoms without Sjögren's [the PDE study] and the second study involved 31 patients with dry eye symptoms and Sjögren's syndrome (the SS study). The PDE study was randomised into two groups. Group I (12 patients) underwent 10 min of treatment with the activated device and Group II (12 patients) had no treatment. The SS study was similarly randomised into Group I (17 patients) and Group II (14 patients). The LLT and subjective alterations in ocular comfort of each subject were assessed prior and immediately after 5 and 30 min subsequent to the 10-min period. In the SS study, a further assessment was carried out at 60 min.

RESULTS

In the PDE study, treated patients exhibited a bilateral increase of LLT at 5 min (right eyes, 1.2 levels, p<0.0005; left eyes, 1.0 levels, p<0.0005, Mann-Whitney) and at 30 min (right eyes, 0.7 levels, p<0.005; left eyes, 0.6 levels, p<0.005). Mean symptom scores improved in the treated group compared with the control group at 5 min (treatment group, +2.0; control group, +0.2; p<0.05) and 30 min (treatment group, +2.8; control group, +0.4; p<0.015). In the SS study, treated patients exhibited a bilateral increase of LLT, 5 min (right eyes, 0.5 levels, p<0.009; left eyes, 0.5 levels, p<0.005, Monte Carlo 2-tailed), 30 min (right eyes, 0.5 levels, p<0.007; left eyes 0.5 levels, p<0.002) and 60 min (right eyes, 0.3 levels, p<0.1; left eyes, 0.3 levels, p<0.05). There was no change in any of the control patients in any of the assessments. With regard to symptom scores, the mean change at 5 min measured +0.8 in the treatment group and remained relatively unchanged at +0.1 in the control group (p<0.1). At 30 min, this change measured +1.3 in the treatment group and +0.1 in the control group (p<0.03) and at 60 min, the change measured +1.5 in the treatment group and remained at +0.1 in the control group (p<0.02).

CONCLUSION

Meibomian therapy with this novel device increases LLT and ocular comfort in patients with dry eye symptoms with and without Sjögren's syndrome.

Telovelar approach: technical issues for large fourth ventricle tumors

OBJECTS

Fourth ventricle is conventionally accessed via resection of the part of the vermis for total excision of the tumors at the expense of significant morbidity. Numerous avenues have been identified to minimize the morbidity; some of which include transforaminal, subtonsillar, telovelar approaches, etc. These approaches are devised on the basis that accurate dissection along the natural avascular planes will avoid injury to the important structures in this area minimizing morbidity. We attempt to emphasize the technique of telovelar approach and the problems encountered while employing this technique for excision of large fourth ventricle tumors.

MATERIALS AND METHODS

Fifteen patients with fourth ventricle tumors were operated during January to September 2005 at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Fourteen of these cases were medulloblastomas, and one was ependymoma. All the patients were operated in prone oblique position via telovelar approach.

CONCLUSION

Clear understanding of the normal anatomy will help in meticulous dissection and will result in reduced morbidity. Significant incidence of postoperative ataxia and mutism is seen with this approach in large tumors, and this can be avoided by staged dissection of the uvulotonsillar cleft.

Alanine peak in central neurocytomas on proton MR spectroscopy

INTRODUCTION

We present three consecutive patients with central neurocytoma in whom proton MRS demonstrated the presence of alanine.

MATERIALS AND METHODS

Three patients in the age range 24 to 30 years underwent MRI and proton MRS using a 1.5-T system. MRS was performed with the multivoxel PRESS sequence. All three patients underwent surgery and the diagnosis of central neurocytoma was established by histopathological examination and immunostaining.

RESULTS

With an echo time of 135 ms glycine, high choline, small NAA and alanine were observed in all three patients.

CONCLUSION

Alanine may be observed in central neurocytomas as it is in meningiomas. Other spectral peaks such as those for glycine and NAA should help to identify this tumor correctly.