Endovascular treatment for elderly patients with ruptured aneurysm.

We report our results of endovascular treatment for elderly patients with ruptured aneurysm and discuss the indication for treatment. One hundred and thirty four consecutive patients with ruptured aneurysm treated in our institute during the last 4 years were retrospectively evaluated. Fifty eight patients were included in group A (over 70 years old), and 76 patients in group B (under 69 years old). In both groups, the outcome was strongly related to the preoperative Hunt & Kosnik grade. However, significant risk factors (i.e. pneumonia, rupture of extracranial aneurysm) which make prognosis poor were more common in group A. Group A showed poor outcome in grade III patients, although there were no outcome differences between the two groups in patients of other grades. Endovascular treatment for elderly patients with ruptured aneurysms seemed to be useful. Their outcome was strongly related to their preoperative condition. General risk factors should be evaluated before treatment, especially in elderly patients. Patients with low Hunt & Kosnik grade seem to be most suitable for endovascular treatment. On the other hand, outcome of patients with poor preoperative grade was worse despite the less invasive nature of endovascular treatment. An improvement of outcome in grade III patients is desirable.

Combined brachytherapy and external beam radiotherapy in normal monkey brains--experimental radiation necrosis evaluated by sequential magnetic resonance imaging.

Radiation-induced brain damage was evaluated using sequential magnetic resonance (MR) imaging in monkeys more than 1 year after either brachytherapy or combined brachytherapy and external beam radiotherapy (EBRT). MR images were obtained 1 week, 1 month, 3 months, and subsequently every 3 months after brachytherapy, and the volume of the lesions was measured. In all four monkeys receiving only brachytherapy and three of the four animals receiving combined brachytherapy and EBRT, MR imaging revealed only transient extensive edema 1 week after treatment and ring enhancement, which was maximal 3 months after treatment, surrounding the implantation site. In one of the four animals undergoing combined brachytherapy and EBRT, MR images obtained 9 months after treatment showed an irregularly extending enhanced lesion with edema. MR images obtained 15 months after brachytherapy in this monkey showed the lesion extended into the contralateral hemisphere through the corpus callosum. Necropsy revealed severe radiation necrosis. This animal developed a very similar MR imaging presentation to that often encountered in human brains after combined brachytherapy and EBRT.

Stereotactic brachytherapy for a cystic metastatic brain tumor in the midbrain. Case report.

The authors report a rare case of a cystic metastasis in the midbrain that was successfully treated by brachytherapy following stereotactic biopsy and aspiration of the intratumoral cyst. Stereotactic aspiration of cystic lesions can lead to clinical improvement and brachytherapy prevents cyst recurrence. A 46-year-old man was referred to the authors' institution with a 2-month history of a left hemisensory disturbance and a 1-month history of progressive hemiparesis. Magnetic resonance (MR) imaging revealed a ring-enhancing cystic mass in the midbrain. On the basis of this imaging study, a differential diagnosis that included brainstem abscess, glioma, and metastatic tumor was made. Magnetic resonance imaging-guided stereotactic biopsy and aspiration of the intratumoral cyst were performed, yielding 5 ml of yellowish-white fluid. Histological examination provided a diagnosis of adenocarcinoma. During the surgery, a catheter through which brachytherapy would be delivered was inserted at a predetermined target. The patient's left hemiparesis and sensory disturbance were markedly improved and brachytherapy was begun 2 days postoperatively. Three radioactive isotopes composed of iridium-192 were implanted to irradiate the tumor tissue. The total dose at the tumor periphery was 30 Gy, which was administered over 100 hours. External-beam radiotherapy (20 Gy) was added after completion of the brachytherapy. At discharge from the hospital, the patient was alert and all his neurological symptoms had resolved. Follow-up MR imaging revealed stabilization of the cyst and no recurrence of the tumor. The patient is alive and well 18 months following the brachytherapy. This case suggests that brachytherapy can delay cyst recurrence, suppress tumor growth, and prolong survival in patients with cystic brainstem metastasis.

Primary brain tumors in children under age 3 years.

During the period from 1966 to 1996 the authors analyzed the clinicopathological characteristics of 46 cases of histologically verified primary brain tumors with symptomatic onset during the first 3 years of life. The patient group included 27 males and 19 females. There were 14 patients during the first year, 13 during the second year, and 19 during the third year. Supratentorial tumors (60.9%) were more common than infratentorial tumors. Histologically, neuroepithelial tumors predominated. The incidence of ependymal tumors, particularly malignant ones, and of neuronal/mixed neuronal-glial tumors was higher than in previous reports. Congenital brain tumors, those occurring within 2 months after birth, or tumors of dysplastic origin comprised 42.9% of the tumors that developed within 1 year of birth. At the onset, macrocephaly, failure to thrive, and seizures were prominent symptoms or signs in the younger patients. Focal neurological deficits and increased intracranial pressure predominated in the older patients. All but one patient underwent surgical treatment, and 17 patients received adjuvant therapy after surgery. The prognosis was mainly related to the histology of the malignancy. The outcome of medulloblastomas was poor. The quality of life of surviving patients was relatively good, 77.8% having better performance status (PS) than the Eastern Cooperative Oncology Group PS 2.

Primary intracranial germinoma involving the midbrain.

To our knowledge, this is the first reported case of a germinoma involving the midbrain without the demonstrable coexistence of any common midline tumors. A 27-year-old man was referred to our institution for evaluation and treatment of diplopia persisting for 5 years. Magnetic resonance imaging (MRI) showed the mass in the midbrain to be of iso intensity on T1-weighted images, and of high intensity on T2-weighted images with homogeneous enhancement. MRI-guided stereotactic biopsy was performed, and the histologic diagnosis was germinoma. Following biopsy, external beam radiotherapy of 50 Gy (whole brain 30 Gy: local 20 Gy) was performed. At the time of discharge, the patient's neurological symptoms had resolved. Follow-up MRI revealed disappearance of the tumor. These findings suggest the diagnostic value of magnetic resonance image-guided stereotactic biopsy in the differential diagnosis of adult brainstem lesions, which should now include germinoma.

[Stereotactic brachytherapy for clival chordoma].

There has recently been interest in the use of high-dose radiation with methods such as radiosurgery and brachytherapy for skull base tumors. Brachytherapy is believed to be effective for clival chordomas, but technical difficulties exist in stereotactic insertion of catheters into the clivus. We assessed the usefulness following improvement of implantation techniques in three patients with clival chordomas. All tumors were larger than 50 mm in diameter. Removable iridium-192 sources were held in catheters which were implanted through a transnasal approach under general anesthesia using a CT-guided stereotactic system in one patient and a CRW stereotactic system adapted to a magnetic resonance imaging (MRI) scanner in 2 patients. The implantation array was designed based on results of stereotactic 3-D MRI scanning, and coordinates were calculated for stereotactic implantation through twist drill holes. These catheters were introduced through the nares and directed into the clival chordoma under endoscopic visualization and X-ray fluoroscopy. No complications such as CSF liquorrhea, hemorrhage or infection were observed. Brachytherapy with a total dose of 43.2-58.0 Gy at the tumor periphery was administered for 7 to 10 days, and serial follow-up imaging studies demonstrated reduction in tumor size in two patients and no tumor growth in the other. Our results suggested that stereotactic brachytherapy is potentially useful for the control of clival chordomas and that computer-guided transnasal stereotactic insertion enables implantation of catheters less invasively and more accurately than does X-ray fluoroscopic guidance alone.