Early neurological complications after stereotactic radiosurgery/radiotherapy.

OBJECTIVE: To evaluate the neurological complications after stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT). MATERIAL AND METHOD: The Ramathibodi Radiosurgery Unit started its service in August 1997, using the linear-accelerator based system. There were 144 patients treated from August 1997 to October 1999. Single fraction SRS was performed in 56 cases consisting of 46 arteriovenous malformations (AVMs), 4 cranial nerve (CN) schwannomas, 3 pituitary adenomas, 2 meningiomas, and 1 multiple hemangioblastomas. Eighty eight patients received multifractionated SRT, including 27 meningiomas, 17 pituitary adenomas, 13 benign and malignant gliomas, 8 brain metastasi(e)s, 5 CA nasopharynx, 5 craniopharyngiomas, 5 CN schwannomas, 2 AVMs, 2 chordomas, and 4 others. After treatment the patients were clinically evaluated every 1-6 months and MRI was scheduled at 6 or 12-month interval or when there were abnormal clinical signs/symptoms. The complications included any new neurological complaints or findings during and after treatment. RESULTS: Median follow-up time was 9.5 (0-20) months. Of 138 patients with available follow-up data, there were 23 (13 SRS and 10 SRT) cases who experienced new neurological symptoms at 3 weeks - 20 months (median = 3 months) from the time treatment started. Symptoms included headache, seizure, weakness, decreased vision, vertigo with/without ataxia, diplopia, dizziness, impaired memory, hemifacial spasm, decreased sensation and facial palsy. Three AVM patients had intraventricular hemorrhage from the patent nidi. After symptomatic treatment there were 15 cases with complete recovery (including seizure control) and 6 with partial recovery. There were 2 deaths from ruptured AVM and progressive metastatic brain lesion. There were 79 patients who had at least 1 follow-up MRI, and changes were detected in T2-weighted images in 19 cases at 3-18 months after treatment. Ten cases had symptoms corresponding to the image changes, the other 9 patients were asymptomatic. CONCLUSIONS: Longer follow-up time is needed to fully evaluate the complications after SRS/SRT, however, preliminary results showed that most of the complications were mild and transient. There was a tendency of a higher complication rate in the SRS group. Not all patients with post treatment image changes developed symptoms.

Temporal lobectomy for intractable complex partial seizures in pediatric patients.

Fourteen children, 7 boys and 7 girls, who failed conventional medical treatment for complex partial seizures underwent anterior temporal lobectomy at Ramathibodi Hospital, Bangkok, Thailand, from July 1993 to June 1998. The mean age at onset of patients was 6.7 years old and the mean duration of seizures before surgery was 6.4 years. The age of patients at surgery ranged from 8 to 22 years old. These patients had had limited presurgical evaluation which included video-electroencephalography (EEG), magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT). All patients demonstrated concordant among clinical symptoms, EEG, MRI and SPECT on the same side of the temporal lobe. Ten and 4 patients had unilateral and bilateral temporal lobe lesions respectively. The operations were done on the left in 10 patients and on the right in 4 patients. Seizure free after 1/2-5 years of follow-up was obtained in 70 per cent of patients which included 9 of 10 patients with unilateral temporal lesion and 1 of 4 patients with bilateral temporal lesions. The rest of the patients showed marked reduction of seizures except for one patient with bilateral lesions in whom only 50-70 per cent reduction was obtained. Marked improvement of behaviour was also observed in 70 per cent of patients. Resected brain specimens revealed mesial temporal sclerosis, gliosis, tumors and cavernoma in 6, 5, 2 and 1 patients respectively.

Propofol vs isoflurane for neurosurgical anesthesia in Thai patients.

Sixty Thai patients, ASA class I-II, Glasgow coma score of 15 undergoing elective intracranial surgery were randomly assigned to 2 groups. In group I, 30 patients were induced with thiopental 3-5 mg/kg, intubation with succinylcholine 1-2 mg/kg and then maintained with 60 per cent N2O in O2, isoflurane and vecuronium as a muscle relaxant. In group II, 30 patients received fentanyl 50 micrograms, propofol 1.0-2.5 mg/kg for induction and vecuronium 0.08 mg/kg for intubation then maintained with 60 per cent N2O in O2, continuous infusion of propofol 2-12 mg/kg/h and vecuronium as a muscle relaxant. Controlled ventilation in both groups was set to maintain PET CO2 in the range of 28-35 mmHg. 3 patients (1 in group I and 2 in group II) were excluded from the study due to surgical problems. There was no statistical difference in age, sex, ASA status, weight, duration of anesthesia. Group II had a more stable systolic BP, Diastolic BP and Pulse rate than Group I during induction and emergence from anesthesia. Glasgow coma scores in the recovery period, Group II had higher scores than Group I at 5 and 15 minutes but not at 30 minutes. Mean recovery times (eye opening) was 14.03 +/- 4.85 minutes in group I which is significantly different from 10 +/- 5.17 minutes in group II. The cost of anesthesia in group II was 1.3 times that of group I. In conclusion, although neurosurgical anesthesia for Thai patients with fentanyl-propofol technique produces more stable blood pressure during intubation and emergence, rapid recovery from anesthesia and a higher Glasgow coma score, the cost of anesthesia is more expensive. Furthermore, this technique is more difficult and needs more experience.