Stereotactic Radiosurgery for Trigeminal Neuralgia Caused by Vertebrobasilar Compression: A Report of Four Cases.

BACKGROUND: Microvascular decompression (MVD) of the trigeminal nerve is an effective procedure for treating patients with trigeminal neuralgia (TGN). However, vertebrobasilar decompression involves technical difficulties and demonstrates a higher risk of minor trigeminal hypesthesia/hypalgesia, transient diplopia, and hearing loss. Stereotactic radiosurgery (SRS) has been an effective alternative treatment for TGN. Few studies reported the treatment results of SRS for TGN caused by vertebrobasilar compression. This report presents the treatment results of SRS using gamma knife (GK) in four TGN cases. MATERIALS AND METHODS: GK-SRS was performed for TGN due to vertebrobasilar compression in four patients, including two males and two females, aged 67-90 years. The maximum dose of 80 Gy was delivered at the retrogasserian portion (RGP) of the ipsilateral trigeminal nerve root. RESULTS: All four cases with TGN achieved relief in four to 10 months after GK-SRS. However, TGN recurred 41 months after GK-SRS in one of the four cases. A second GK-SRS at the root entry zone (REZ) at a maximum dose of 70 Gy relieved pain again 10 days later. TGN in another case among the four partially recurred in three years but did not deteriorate until the patient died from old age 62 months after GK-SRS. The other three cases, including the one with repeat GK-SRS, were alive with complete TGN remission at the end of follow-up of 20-52 months. GK-SRS-related adverse effects were not observed in any case. CONCLUSIONS: GK-SRS was a safe and effective treatment in all four TGN cases due to vertebral artery (VA)-basilar artery (BA) compression, although a second treatment session was added again for pain recurrence in one of the four cases.

Cerebellar Hemangioblastoma Associated With a Vascular Malformation: A Case Report Treated With Surgery and Radiosurgery.

Hemangioblastoma is well known as an essentially benign cystic and/or solid tumor classified WHO grade I, mainly originated in the posterior fossa. One of the characteristics of this tumor is very rich vasculature in and around the tumor. We have encountered a case of hemangioblastoma in association with a vascular anomaly near the tumor, though they were located separately by the tentorium. A vascular anomaly with arteriovenous (AV) shunting flow in the left occipital lobe was verified at angiography, which received a blood supply from left occipital artery and drained to occipital cortical veins. Successful removal of the cerebellar tumor and pathological diagnosis of hemangioblastoma was made. The second angiography in our hospital demonstrated the same vascular anomaly above the tentorium with feeding artery of posterior cerebral artery, a small nidus, and cortical draining veins, which were less obviously stained. Only the arteriovenous malformation (AVM) nidus in sigmoid vein was targeted for radiosurgery and 20 Gy at the margin was delivered. Since AV shunting was less remarkable on the second angiography than that on the first angiography may be because of a decreased vascular supply to the supratentorial AVM after surgical resection of the infratentorial hemangioblastoma and might indicate an indirect connection between the two lesions.

Neuroendocrine Carcinoma of Uterine Cervix: Stereotactic Radiotherapy for Brain Metastasis and Stereotactic Body Radiotherapy for Renal and Pancreatic Metastases.

A case of cervical neuroendocrine carcinoma (NEC) of the uterine cervix (NECUC) was presented. After total hysterectomy with bilateral salpingo-oophorectomy and adjuvant chemotherapy, a left renal tumor and a pancreatic lesion developed and were both diagnosed on pathological examination as metastases from NEC. In addition, a brainstem metastasis causing neurologic signs developed. The brain lesion was treated by stereotactic radiotherapy (SRT) and the renal and pancreatic lesions by stereotactic body radiotherapy (SBRT). Despite control of the renal and pancreatic lesions, multiple small lung metastases developed later. Recurrence and newly developed brain metastases were treated by repeat stereotactic radiosurgery (SRS)/SRT successfully. Chemotherapy was continued and controlled the lung metastases until three and a half years after the initial operation of the uterus.

Stereotactic Radiosurgery and Stereotactic Radiotherapy for Malignant Skull Base Tumors.

The role of stereotactic radiosurgery/stereotactic radiotherapy (SRS/SRT) for malignant skull base tumors was summarized and discussed. The treatment of skull base tumors remains challenging. Their total resection is often difficult. SRS/SRT is one useful treatment option for residual or recurrent tumors after surgical resection in cases of primary skull base tumors. If skull base metastasis and skull base invasion are relatively localized, they can be candidates for SRS/SRT. Low rates of cervical lymph node involvement in early-stage (N0M0, no lymph node involvement or distant metastasis) nasal and paranasal carcinomas (NpNCa) and external auditory canal carcinomas (EACCa) have been reported in the literature. Such cases might be good candidates for SRS/SRT as the initial therapy. We previously reported the results of SRS/SRT for various malignant extra-axial skull base tumors. In addition, treatment results of early-stage head and neck carcinomas were summarized. Those of our data and those of other reported series were reviewed here to clarify the usefulness of SRS/SRT for malignant extra-axial skull base tumors.

One-Day Two-Fraction Radiosurgery for Brain Metastases Using Gamma Knife.

OBJECTIVE: We aimed to evaluate the feasibility of a one-day two-fraction Gamma Knife radiosurgery (GKRS) for brain metastases. CASES AND METHODS: Ten cases with ten brain metastases (four cases of lung adenocarcinoma, one small cell lung carcinoma (SCLC), two renal cell carcinoma, one breast cancer, one esophageal carcinoma, and one bile duct carcinoma) were treated by one-day two-fraction (with an interval of more than six hours) GKRS under rigid skull frame fixation. Of the ten brain metastases, five lesions were in the frontal lobe, one in temporal, one in occipital, and three in the cerebellar hemisphere. The mean planning target volume (PTV) of the ten brain tumors was 7.8 ml (median, 8.0; range, 3.8 - 11.8). The ten targets of the mean prescription isodose volume (PIV) of 10.1 ml (median, 10.1; range, 4.4 - 15.9) were treated with a mean margin dose of 20.4 Gy (median, 20.5; range, 16.4 - 22) in two fractions. In five cases, other small brain metastases (one to seven tumors) were also treated simultaneously in a single fraction GKRS. The indication of two-fraction radiosurgery was large lesion size in eight, retreatment in three, the proximity of the motor area in three, and pre-existing perifocal edema symptom of dysarthria in two, nausea and vomiting in one, and dementia in one. RESULTS: Eight cases were alive at the end of the follow-up period of one to nine months (median, 6). One patient with SCLC died four and a half months after GKRS, from aggressive regrowth of the treated frontal lesion after transient marked shrinkage. Another patient died four months after GKRS due to the progression of other brain tumors treated by single fraction GKRS at the same time. In nine of 10 cases, the size of the treated tumors was controlled until the end of the follow-up period or the patient's death. In two cases, an additional GKRS was performed for newly developed brain metastases at distant locations at six months and five months after one-day two-fraction GKRS, respectively, and controlled at the end of the follow-up period. CONCLUSIONS: A relatively high dose may be safely delivered to large lesions, to those close to the important structures, or those with perifocal edema by one-day two-fraction radiosurgery. Local control was good except for a relapsed SCLC metastasis case. Evaluation in more cases with a longer follow-up period is necessary to determine definite indications and optimal prescription doses.

[Spontaneous extra-cranial vertebral artery dissection accompanied with multiple cerebral infarctions due to re-canalization].

In this paper we report a case of vertebral artery occlusion caused by spontaneous extra-cranial vertebral artery dissection accompanied with cerebellar and thalamic infarctions due to recanalization. Furthermore, after a nine-week time lapse we performed PTA/stenting. A 62-year-old man with vertigo, dysarthria and nuchal pain without injury was admitted to our hospital. Emergent cerebral angiography revealed an occlusion of the right vertebral artery and the right PICA. The patient's symptoms gradually improved owing to local-fibrinolysis with urokinase for the right PICA via the left vertebral artery. Follow-up angiography (2 weeks later) showed re-canalization and dissection of the right vertebral artery. Treatment for spontaneous extra-cranial vertebral artery dissection is chosen, depending on whether there is co-lateral circulation or not. We obtained a good result using PTA/Stenting in this case of spontaneous extra-cranial vertebral artery dissection within nine weeks after onset.

[A case of treatment on traumatic pseudoaneurysm of internal carotid artery occurred epistaxis].

We reported a case of traumatic pseudoaneurysm of internal carotid artery accompanied by skull base fracture, for which Guglielmi detachable coil(GDC) embolization surgery was very effective for recovery. A 53-year-old man met a traffic accident and was admitted to our hospital with blindness and epistaxis accompanied with shock. Balloon occlusion test showed a positive sign of traumatic pseudoaneurysm of internal carotid artery, and under the diagnosis GDC embolization surgery was performed on six days after the onset. The patient has completely recovered and keeps his wellness untill now after six months from the surgery except for loss of left eye vision. We believe that the endovascular surgery using stents will become the prime modality for treatment of traumatic pseudoaneurysm in the future.