Temporary ventricular drainage and emergency radiotherapy in the management of hydrocephalus associated with germinoma

OBJECT

The authors used an alternative strategy to avoid shunt placement for hydrocephalus associated with germinoma, and the ensuing complications.

METHODS

Between 1998 and 2000, five patients presenting with germinomas of the pineal area and symptomatic obstructive hydrocephalus were treated with a novel strategy. On arrival, they underwent ventriculostomy placement and one of several surgical procedures to obtain tissue for diagnosis. Within several days of the initial diagnosis, stereotactically guided fractionated radiotherapy was started. All patients experienced rapid tumor shrinkage and resolution of hydrocephalus, allowing discontinuation of external ventricular drainage without the need for permanent shunting of cerebrospinal fluid. To date, follow up reveals 100% radiographically and clinically confirmed tumor control.

CONCLUSIONS

Prompt resolution of hydrocephalus and absence of complications make this a potentially valuable therapy for control of germinomas and their symptoms.

Prognostic significance of 111indium-DTPA CSF flow studies in leptomeningeal metastases

We assessed the clinical significance of interruption of CSF flow documented by radionuclide ventriculography (111Indium-DTPA CSF flow study) in patients with leptomeningeal metastases. Forty patients (25 men and 15 women) ranging in age from 6 to 70 years (median 38.5 years) with cytologically documented leptomeningeal metastases were demonstrated to have interruption of CSF flow by radionuclide ventriculography. All patients were treated with radiotherapy (30 Gy in 10 fractions) to the site of CSF obstruction after which intra-CSF chemotherapy (methotrexate or cytarabine followed by cytarabine or thio-TEPA if clinically indicated) was administered. Twenty patients (group 1) after radiotherapy to the site of CSF flow block demonstrated reestablishment of normal CSF flow. By contrast, 20 patients (group 2) treated in a similar manner had persistent CSF flow obstruction. All patients were treated with intraventricular chemotherapy. Median survival was 6 months in group 1 (range 3 to 15 months) compared with 1.75 months in group 2 (range 1 to 4 months) (p < 0.0001). Cause of death differed between groups with 20% of group 1 patients dying of progressive leptomeningeal disease compared with 70% of group 2 patients (p < 0.0006). In patients with leptomeningeal metastases and CSF flow obstruction, 111Indium-DTPA CSF flow studies predict patient survival and are useful in determining which patients would be candidates for intra-CSF chemotherapy administration.

Interstitial irradiation of a large, low grade ependymoma with stereotactically implanted iodine-125 seeds. Case report

In this case report a patient with a large intraventricular benign ependymoma is presented. The tumour was treated with stereotactically implanted Iodine-125 seeds and interstitial irradiation. Extension (diameter: 6.5 cm) and volume (112.5 ml) of the lesion caused the application of an unusually low dose (tumour surface dose: 40 Gy). The tumour shrank significantly within a few weeks. Follow-up at nearly 5 years shows the patient to be tumour free.

[A case with postoperative calcified epidural hematoma]

In the literature, postoperative calcified epidural hematoma is not common. The authors report a case of calcified epidural hematoma after ventriculoperitoneal shunt, and radiotherapy for pinealoma. A 14-year-old boy was admitted to author's department on December 9, 1983, complaining of headache. He underwent a ventriculoperitoneal shunt on August 28, 1980 under the diagnosis of hydrocephalus caused by pinealoma. After the operation hydrocephalus improved. The patient had radiotherapy of 5090 rad. CT scan taken after the irradiation revealed reduction of the size of the tumor. On August 30, 1983, a ring calcification of epidural hematoma in the right parietal region was noticed on CT and plain skull X-rays. He was readmitted because of headache. There was no history of head injury. The calcified epidural hematoma was totally removed on December 12, 1983. The extirpated calcified epidural hematoma was 7.0 X 7.5 cm and 2.5 cm in thickness. Capsule formation was observed and ossification was also seen at dural side. No inflammatory finding was seen on histological examination. The postoperative course was uneventful. Etiology of calcified intracranial hematoma was discussed in relation to the present report, the relevant literature reviewed.

[Diagnostic and therapeutic problems in the treatment of tumors of the epiphyseal region of the brain]

The case is described of a 17 year-old male, who was treated because of a large tumour in the region of the pineal gland. The diagnostic and therapeutic problems are presented and discussed.

Selective radionecrosis of the choroid plexus for control of experimental hydrocephalus

✓ Hydrocephalic dogs treated with intraventricular radioactive colloidal gold showed a sustained decrease in cerebrospinal fluid flow and intraventricular pressure associated with a reversal of progressive hydrocephalus. Gamma scanning and isotopic sampling, however, indicated a more diffuse distribution of the isotope than previously thought, although pathological changes up to 7 weeks post-instillation of the radioactive colloid appeared confined to the choroid plexus.

Radioactive tissue changes induced to control experimental hydrocephalus

✓ Hydrocephalic animals were given an intraventricular infusion of radioactive colloidal gold and then sacrificed up to 7 weeks after infusion. Histological evaluation revealed progression from a marked hemorrhagic necrosis of choroid plexus vessels and stroma to eventual replacement by fibrous connective tissue, sclerosis, and fibrinous degeneration of stromal vessels. Particulate colloid was found engulfed in perivascular spaces in the subependymal periventricular tissues, but there was no evidence of vascular damage, gliosis, or demyelination. These findings may play a role in decreasing cerebrospinal fluid production.