The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique

Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt "spinal cord" dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Feasibility and accuracy of a voxel-based neuronavigation system with 3D image rendering in preoperative planning and as a learning tool for young neurosurgeons, exemplified by the anatomical localization of the superior sagittal sinus

It is essential for a neurosurgeon to know individual anatomy and the corresponding anatomical landmarks before starting a surgery. Continuous training, especially of young neurosurgeons, is crucial for understanding complex neuroanatomy. In this study, we used a neuronavigation system with 3D volumetric image rendering to determine the anatomical relationship between the sagittal suture and the superior sagittal sinus (SSS) in patients with intracranial lesions. Furthermore, we discussed the applicability of such system in preoperative planning, residency training, and research. The study included 30 adult patients (18 female/12 male) who underwent a cranial computed tomography (CT) scan combined with venous angiography, for preoperative planning. The position of the sagittal suture in relation to the SSS was assessed in 3D CT images using an image guidance system (IGS) with 3D volumetric image rendering. Measurements were performed along the course of the sagittal sinus at the bregma, lambda, and in the middle between these two points. The SSS deviated to the right side of the sagittal suture in 50% of cases at the bregma, and in 46.7% at the midpoint and lambda. The SSS was displaced to the left of the sagittal suture in 10% of cases at the bregma and lambda and in 13% at the midpoint. IGSs with 3D volumetric image rendering enable simultaneous visualization of bony surfaces, soft tissue and vascular structures and interactive modulation of tissue transparency. They can be used in preoperative planning and intraoperative guidance to validate external landmarks and to determine anatomical relationships. In addition, 3D IGSs can be utilized for training of surgical residents and for research in anatomy.

Lethal outcome after pelvic salvage radiotherapy in a patient with prostate cancer due to increased radiosensitivity : Case report and literature review

BACKGROUND

In general, late side effects after salvage radiotherapy (RT) for prostate cancer are below 10%. Patients with impaired DNA repair ability and genetic instability can have significantly increased reactions after RT.

CASE, CLINICAL FOLLOW-UP, AND EXAMINATION

We present a patient who experienced severe side effects after additive RT for prostate cancer and died from the complications 25 months after RT. Imaging (MR) is shown as well as three-color fluorescence in situ hybridization. The blood sample testing revealed that radiosensitivity was increased by 35-55%. We undertook a review of the literature to give an overview over the tests established that are currently considered useful.

CONCLUSION

This case highlights that the identification of patients with increased radiosensitivity is an important task in radiation protection. Groups of patients who should be screened have to be found and corresponding research facilities have to be set up.

Planning strategies and practical implementation of the cardiac dose reduction in the left-side breast irradiation with the deep inspiration breath-hold (DIBH) method

Background: Despite of the use of tangential beam directions during the irradiation of mammary carcinomas, a dose reduction of the heart cannot always be achieved. This is decivise for the increased risk of heart diseases and the associated mortality. Especially affected is the cardiac apex. However, by using respiratory gated treatment techniques, like the deep inspiration breath-hold (DIBH), a dose sparing of this area can be reached.

Material and Methods: The Elekta ABC system was used to control the respiratory stop of early staged breast cancer patients. The treatment planning was implemented by a 3D and VMAT technique. The focus was the optimization of irradiation plans and the evaluation of the respective dose exposure to the heart, the left ventricle and the left anterior descending coronary artery (LAD artery). A planning concept of 28 x 2,25 Gy in the SIB and 28 x 1,8 Gy in the left breast was used.

Results: The results showed that a dose reduction of 30-40% in mean and maximal in all structures is possible by using the VMAT technique in combination with the ABC system. In the case of 3D irradiation planning, a substantial relief can only be seen at the mean dose exposure of approximately 50%. Also, only a maximum dose reduction of 13% could be achieved.

Conclusion: The mean dose reduction was mainly achieved by the increased distance between the heart and the thorax wall. The maximum dose was reduced by the volumentric optimization algortihm of the VMAT and the resulting steeper dose fall-off at the inner thoracic wall. Due to the lack of this optimization and thus the greater dose drop, the maximum dose of the 3D plans could only reduced by 13%.

Inflammation and echocardiographic parameters of ventricular hypertrophy in a cohort with preserved cardiac function

OBJECTIVE

To investigate the association between inflammation and selective echocardiographic parameters (EP) characteristic for ventricular hypertrophy in cross-sectional and longitudinal population-based analyses.

METHODS

Baseline (711 men, 659 women: 45-83 years) and 4-year follow-up data (622 men, 540 women) of the prospective, population-based CARdio-vascular disease, Living and Ageing in Halle (CARLA)study after exclusion of participants with cardiacvascular diseases were analysed. Inflammation parameters: soluble tumour necrosis factor receptor 1 (sTNF-R1), high-sensitivity C reactive protein (hsCRP) and interleukin 6 (IL-6). EPs: left ventricular mass (LVM), left atrial systolic dimension (LADS), interventricular septum diameter (IVSD), posterior wall dimension (PWD), left ventricular diastolic diameter (LVDD), ejection fraction according to Teichholz (EF). For the longitudinal analyses baseline to follow-up differences were considered. Effect sizes were determined by using multiple linear regression and mixed models. Missing values were replaced by means of multiple imputations.

RESULTS

Men had higher sTNF-R1 levels; means of hsCRP and IL-6 were similar in men and women. In multiple regression models, sTNF-R1 was associated with LADS (1.4 mm/1000 pg/mL sTNF-R1, 95% CI 0.6 to 2.1) in men. Respecting confounder hsCRP was associated with LVM (5.2 g/10 mg/L hsCRP, 95% CI 1.6 to 8.8), IVSD (0.2 mm/10 mg/L hsCRP, 95% CI 0 to 0.3) and PWD (0.2 mm/10 mg/L hsCRP, 95% CI 0.1 to 0.3) in women, while there were no relevant effects in analysis of IL-6 in both sexes. The baseline to follow-up change in EPs was not relevantly associated with sTNF-R1, hsCRP or IL-6.

CONCLUSIONS

STNF-R1, hsCRP and IL-6 were inadequate predictors for structural changes of the heart at follow-up, while weak cross-sectional associations are restricted to certain EPs and depend on sex.

Radiochemotherapy for lung cancer with cisplatin and vinorelbine orally and shrinking field radiotherapy: Effectivity and feasibility in a nonselected patient collective

e17516

Background: To explore the side effects and effectivity of simultaneous radiochemotherapy (sim RCT) with cisplatin (Cis-DDP) and vinorelbine orally (VRBo) in pts. with NSCLC. Methods: From 2009 and 2011, a total of 20 pts. (5 female, 15 male) aged between 46 and 82 yrs. with NSCLC stage IIIA/B were irradiated with a median dose of 66.6 Gy to the primary and 45 Gy to the involved nodes as neoadjuvant or palliative treatment. Treatment volumes were adapted to tumor shrinkage after 19.8, 30.6, 45 and 59.4 Gy. Cis-DDP (20 mg/qm d1-4, d29-32) and VRBo (50 mg/qm d1,8,15,22,36,43) were administered simultaneously. Comorbidity was scored by the Charlson Index and nutritional status was monitored. Results: Toxicity rates: thrombopenia 3° 10%, 4° 0%, leucopenia 3° 15%, 4° 20%, haemoglobin 0% 3°/4°, esophagitis 3° 5%, 4° 0%, pneumonitis 3° 0%, 4° 5%. No reduction of planned RT-dose. Chx reduction was done due to hematologic toxicity in 35%. Response rates: CR 10%, PR 75%, SD 10%, PD 5%. 11pts. (55%) are alive after a median FU of 19 months. Conclusions: Sim RCT with Cis-DDP and VRBo results in good tumor response rates and is feasible with acceptable side effects. Shrinking treatment volumes allow adequate dose escalation without the risk for early locoregional recurrence.

Validation of histologic changes induced by external irradiation in mandibular bone. An experimental animal model

The present experimental study sought to determine the effect of high-dose irradiation on the rat mandible in order to establish an experimental model of radiogenic bone damage. The left mandibles of 20 adult Wistar rats were irradiated (single fraction 1500cGy, total dose 60Gy) by means of a hypofractionated stereotactic radiotherapy (hfSRT) over a period of 6 weeks. Follow-up was 6 weeks (group 1, n=10) and 12 weeks (group 2, n=10). The contralateral mandibles as well as 5 non-irradiated animals served as controls. Primary endpoints were fibrosis, loss of cell count, decreased immunohistochemical labelling for bone morphogenetic protein-2 (BMP-2) and osteocalcin as well as increased expression of transforming growth factor (TGF-beta). Cell loss, progressive fibrosis, and focal necrosis were detected in all irradiated sites. Quantitative measurement revealed 32.0+/-8.7% and 37.3+/-9.5% empty osteocyte lacunae for groups 1 and 2 resp., compared to 16.3+/-4.7% and 18.9+/-4.9% on the contralateral side and 7.9+/-1.7% for unirradiated controls (Mann-Whitney U test; p<.01). BMP-2 and osteocalcin labelling showed a marked decrease in irradiated and contralateral sides while TGF-beta was expressed strongly in irradiated sites only (for all p<.05). External hypofractionated irradiation with a total dose of 60Gy is feasible in rats and yields all histologic changes attributed to osteoradionecrosis (ORN) after a follow-up of 6 weeks. The irradiation protocol is suitable for an assessment of regenerative options in severe radiogenic bone damage. As a split mouth design entails major inaccuracies healthy animals have to be used as controls.

Stereotactic radiotherapy for the treatment of nonacoustic schwannomas

OBJECTIVE

Nonacoustic schwannomas are rare tumors in contrast to the most common neuromas of Cranial Nerve VIII. The current treatment of choice in these cases is microsurgical resection, but the risk of postoperative complications is high, especially in cavernous sinus-invading tumors. In many of these cases, it is not possible to achieve complete tumor removal, resulting in the probability of recurrences. For those patients, radiosurgery (RS) or stereotactic radiotherapy (SRT) can offer an alternate treatment.

METHODS

Within a 5-year period (2000-2005), 19 intracranial nonacoustic neuromas were treated with SRT-13 trigeminal neuromas, five neuromas of the lower cranial nerves (jugular foramen), and one located in the orbital region. Of these cases, there were nine women and 10 men who were, on average, 54 years of age (range, 33-83 yr). Eight patients had previously undergone surgery elsewhere and showed progressive tumor growth. All 19 patients were treated with SRT: 15 with normal fractions of 1.8-2 Gy single dose up to 54-59.4 Gy. Their irregular tumor volume ranged from 4.2 to 43.1 ccm (average: 14.1 ccm). Hypofractionation with 6 to 7 x 5 Gy was applied in four cases with an average tumor volume of 4.1 ccm (2.2-6.2 ccm). Clinical results and the efficacy for tumor control with an average follow-up of 35 months (11-63 mo) were evaluated.

RESULTS

Local tumor control rate was 95% (18 of 19 cases): one patient previously operated on had a recurrence of tumor progression after SRT, followed by a second subtotal resection. A tumor regression was proved in 11 cases (one neuroma disappeared and four patients had tumor shrinkage of more than 50%, the other six experienced shrinkage between 20% and 40%). Within the first 6 months, two patients developed temporarily increased tumor volume as well as a confirmed reaction to irradiation. In one of these two cases, there were mild side effects according to CTC Grade I. No patient experienced a new or increased neurological deficit. Improvement of their cranial nerve disturbances was achieved in 11 of 19 patients and the other eight showed no clinical changes. The mostly moderate trigeminal pain decreased slowly.

CONCLUSION

SRT is a low-risk and effective treatment option for intracranial neuromas. Particularly in cases of sinus cavernous-invading trigeminal and in jugular foramen tumors, SRT can be the treatment of choice. Concerning tumor regression, SRT is as effective as RS.

Hemorrhage into cystic vestibular schwannoma following stereotactic radiation therapy

The occurrence of a hemorrhage into a vestibular schwannoma is a rare phenomenon. Several reports, however, indicate a risk profile for a subgroup of patients with vestibular schwannoma which show hypervascularity in the histopathological examination. Cystic formation, large size, mixed Antoni type and anticoagulation therapy seem to enhance the risk of tumor hemorrhage. We report on a patient with a large cystic vestibular schwannoma who died from fatal bleeding into the tumor 15 months following stereotactic radiation therapy. Since hemorrhage seems to be a relevant risk in large cystic vestibular schwannomas, a surgical treatment should be preferred whenever possible.