High dose hyperfractionated radiotherapy for adults with glioblastomas.

From 1989 to 1991, 27 patients with glioblastoma multiforme or anaplastic astrocytoma of the brain were treated with radiotherapy. Fifteen of twenty-seven patients were treated through limited volume fields, with a thrice-a-day (1.1 Gy/f) or twice-a-day (1.4 Gy/f) hyperfractionated regimen to a total physical dose of 62-92 Gy (median dose 76 Gy). The remaining 12 were treated with whole brain irradiation (40 Gy of total conventionally fractionated dose) and a localised boost to a total dose of 60 Gy. The hyperfractionated regimen was well tolerated and there was no sign of increased brain oedema to indicate the insertion of a split. Of six patients who received a NTD10 (normalised total dose for alpha/beta = 10) higher than 71 Gy, five showed CR (83% CR rate) versus three of 21 patients who received a lower NTD10 (14% CR rate). For 13 patients who received a NTD10 higher than 66 Gy, the 18-months survival was 61% (8/13) versus 28% (4/14) for 14 patients who received a NTD10 less than 66 Gy. As far as the late morbidity is concerned, of six patients treated with 76-92 Gy of physical dose, none died because of radiation-induced brain necrosis within 18-42 months of follow-up, and three of them are without evidence of disease 18-31 months after the end of radiation treatment. None of our 15 patients who received less than whole brain irradiation relapsed outside the radiation portals. The present study strongly suggests the use of limited volume hyperfractionated radiotherapy schemes, so as to increase the local tumor dose (NTD10) to values higher than 79 Gy, at the same time keeping the NTD2 (NTD for alpha/beta = 2) below 68 Gy.

[Diffuse intracranial arterectasias: megadolichocarotids, megadolichovertebrals]. / Les artérectasies diffuses intracrâniennes: mégadolichocarotides, mégadolichovertébrales.

Intracranial diffuse arteriectasis may be located to the carotid and vertebral arteries and their branches separately or concomitantly and associated with saccular aneurysms and generalized arteriectasis. The principle clinical aspects of intracranial arteriectasis are cranial nerve palsies, particularly of the cerebellopontine region in association or not with cerebellar disorders and transient or permanent motor deficiencies. Arterial hypertension exists in a high proportion of cases. The some times complex clinical picture may be due to pressure of nervous structures by the ectatic vessels, ischemia or hemorrhagy. Mostly affected are men over 50 years of age although arteriectasis has been observed in younger patients including children and infants. The disease can be suspected clinically but is generally diagnosed after neuroradiological studies, mostly angiography and/or computerized tomography. Initially arteriectasis was supposed to be the result of arteriosclerosis but histopathology has shown that it may be independent of arteriosclerosis and appears to be the result of a congenital abnormality in the elastic component of the vessel wall. On the basis of our six observations and those already published it becomes apparent that diffuse intracranial arteriectasis represents a specific disease.

[Orbital and intracranial complications of paranasal osteomata (author's transl)]. / Complications orbitaires et endocraniennes des ostéomes des sinus paranasaux.

Osteomata of the paranasal frontal and ethmoidal sinuses are benign, slow growing tumors generally asymptomatic. Complications due to orbital or intracranial development of the osteoma are rare and demand neurosurgical treatment. The authors report two cases. In the first a fronto-ethmoidal osteoma first caused exophtalmos and later ophtalmoplegia due to compression of the superior ophtalmic vein. In the second case the posterior development of an osteoma of the frontal sinus resulted in pneumocephalus with epileptic fits and headache and initially homolateral hemiparesis. In both cases CT Scan showed the extent of the osteoma and in the second case the gap in the wall of the sinus. Both osteomata were radically removed through frontal craniectomy. The literature is reviewed, 12 other cases of pneumocephalus due to posterior development of paranasal osteomata have been published during the last 50 years.

[Tumoral forms of tuberous sclerosis. The clinical and therapeutic importance of concomitant hydrocephalus (author's transl)]. / Formes tumorales de la sclérose tubéreuse de Bourneville. L'importance de l'hydrocéphalie dans la symptomatologie et le traitement.

In a young man and a pregnant young woman presenting since childhood of tuberous sclerosis without epilepsy or mental disorders severe intracranial hypertension developped secondary to obstructive hydrocephalus. Ventriculo-peritoneal shunting unilateral in the first case, bilateral in the second, releaved the patients of all their symptoms. Angiographic studies in both cases showed the existence of extracerebral visceral lesions. After a short review of similar published cases and the proposed treatments the authors suggest as only treatment a shunting procedure without attempt of removal of intracerebral nodules.