Efficacy of anti-epileptic drugs in patients with gliomas and seizures.

Although seizures in brain tumor patients are common, the knowledge on optimal anti-seizure therapy in this patient group is limited. An observational study was carried out using a database of all patients from the neuro-oncology service during the period 2000-2005, with data on seizure characteristics, therapy with AEDs, the underlying brain tumor and its treatment. A total of 140 brain tumor patients were studied of whom 23.6% had a low-grade glioma, 53.6% a high-grade glioma, and 22.8% belonged to a mixed group existing of ependymoma, meningioma, and brain metastasis. Epilepsy as the presenting sign was more frequent in low-grade vs. high-grade gliomas (69.7 vs. 52%, P = 0.087), and a total of 75.8% of patients developed seizures with low-grade and of 80.0% with high-grade gliomas. Of all 99 patients with seizures, 80.1% received valproic acid (VPA) as first choice, and either levetiracetam (LEV), carbamazepine (CBZ) or lamotrigine (LMT) as the most frequent next choice. Patients treated with a combination of VPA and LEV showed the highest percentage of responders (81.5%), with a decline in seizure frequency of more than two categories in 55.6% and seizure freedom in 59%. No correlation was found between the use of VPA and survival. A combination of VPA and LEV seems effective, if seizure control cannot be achieved by VPA alone. This indicates that adding levetiracetam may be preferable over sequential trials of AED monotherapy in treatment-resistant seizures in patients with brain tumors.

Intracranial compartment volumes in normal pressure hydrocephalus: volumetric assessment versus outcome.

BACKGROUND AND PURPOSE: Although enlargement of the cerebral ventricles plays a central role in the diagnosis of normal pressure hydrocephalus (NPH), there are no reports on the use of volumetric assessment to distinguish between patients who respond to ventriculoperitoneal shunt surgery and those who do not. The purpose of this study is to explore the association between preoperative intracranial compartment volumes and postoperative improvement. METHODS: Twenty-six patients (17 men; mean age, 75 years [range, 54-87 years]) with a clinical or radiologic suspicion of NPH were included in the study. Gait, cognition, and bladder function were evaluated by clinical rating. MR imaging of the brain was acquired at 0.5 T and 1.5 T. Total intracranial volume, ventricular volume, brain volume, and pericerebral CSF volume were determined by volumetric assessment. Four imaging variables were determined: ventricular volume ratio, brain volume ratio, pericerebral CSF volume ratio, and the ratio of ventricular volume to pericerebral CSF volume. All patients underwent ventriculoperitoneal shunt surgery. RESULTS: Clinical follow-up was assessed 1 year after shunt surgery. No difference in the mean ventricular volume ratio, the mean brain volume ratio, the mean pericerebral CSF volume ratio, and the mean ratio between ventricular and pericerebral CSF volume was found between subjects who improved on gait or cognition or bladder function and those who did not. CONCLUSION: Volumetric assessment has no predictive value in differentiating between NPH patients who respond to ventriculoperitoneal shunt surgery and those who do not.

The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus.

OBJECTIVE: It has been reported that temporary external lumbar CSF drainage (ELD) is a very accurate test for predicting the outcome after ventricular shunting in patients with normal pressure hydrocephalus (NPH). However, only a limited number of patients have been studied for assessing the predictive accuracy of ELD. Therefore, the value of ELD in predicting the outcome after a ventriculoperitoneal shunt in patients with presumed NPH was assessed. METHODS: All patients with presumed NPH were invited to participate in this study. Clinical assessment, MRI, and neuropsychological evaluation were followed by a lumbar CSF tap test consisting of removing 40 ml CSF. When this test resulted in marked clinical improvement of gait impairment, mental disturbances, or both, the patient was shunted without further tests. In patients with either questionable or no improvement after the CSF tap test, ELD was carried out. The value of ELD for predicting the outcome after shunting was calculated by correlating the results of ELD with that of ventriculoperitoneal shunting. RESULTS: Between January 1994 and December 2000, 49 presumed NPH patients from three institutes were included. Forty three had idiopathic, and the remaining six had secondary NPH. Forty eight patients were shunted; 39 had an ELD of whom 38 completed the test. After 2 months 35 of the 48 (73%) shunted patients had improved. The predictive value of a positive ELD was 87% (95% confidence interval (95% CI) 62-98) and that of a negative ELD 36% (95% CI 17-59). In two patients serious test related complications (meningitis) occurred without residual deficit. CONCLUSION: The study suggests that although the predictive value of a positive ELD is high, that of a negative ELD is deceptively low because of the high rate of false negative results. The costs and invasiveness of the test and the possibility of serious test related complications further limits its usefulness in managing patients with presumed NPH.

Cine phase-contrast MR imaging in normal pressure hydrocephalus patients: relation to surgical outcome.

Phase-contrast cine MR flow imaging through the aqueduct was used to establish the diagnosis of normal pressure hydrocephalus (NPH), and to predict outcome after shunting. From 1990-1994 16 patients, who were participants in the Dutch Normal Pressure Hydrocephalus Study [3], were studied. The patients included in this study met clinical and CT-scan criteria as described in this study, underwent cine phase-contrast MR imaging prior to placement of a CSF shunt, and had a follow-up 12 months after the operation. Claustrophobic patients, patients with a pacemaker or extremely agitated patients were excluded. Normal Flux was calculated in each patients, as the average difference in caudal and rostral flux (Fdiff) +2 times standard deviation (0.97 cc/sec) [2]. The clinical outcome was measured with a modified scale of activities of daily living (ADL) as described by Rankin. Of the 16 patients, 8 could not be evaluated due to restlessness during MR measurements, disabling cerebral vascular accidents or death before the end of the follow-up period. Of the remaining 8 patients, 5 had a normal flux, of which only one improved. Two patients had a Fdiff twice the normal range, which improved in both patients. One patient had no measurable flux, consistent with an aqueduct stenosis; he too improved. Overall, there was a concordance of MR findings with final outcome after shunting in 7 out of 8 patients. This pilot study, therefore, support the need to further evaluate flow with MR imaging techniques to select patients with shunt responsive NPH.

Microvascular decompression for trigeminal neuralgia: a critical reappraisal.

The results of posterior fossa explorations for trigeminal neuralgia over the period 1980-1990 in 58 patients and in 59 procedures were studied retrospectively. In 51 procedures vascular compression was treated by microvascular decompression (MVD). In the absence of such a compression, partial sensory rhizotomy (PSR) was performed in 5 cases and only adhesiolysis of thickened arachnoidea in 2 cases. In one additional case the procedure was terminated prematurely due to the development of cerebellar edema. Two months postoperatively a good or fair result was obtained in 80% of the procedures. At long-term follow-up (mean 77.3 months, range 8-146 months), a good or fair result was maintained in 71%. There was no significant difference in outcome between the MVD group and the other procedures, or between the three groups formed according to the type of vascular compression. However, in the group of 10 patients with a history of a procedure affecting the trigeminal ganglion or nerve root the result was worse. In the group of 41 MVD patients rendered free of pain at 2 months postoperatively, 8 patients perceived a recurrence. The annual recurrence rate was calculated to be 2.6%. There was no mortality in this series but the morbidity rate was 22% including 1.7% persistent neurological deficit. Compared to the literature results of percutaneous controlled differential thermocoagulation (PCDT), the recurrence and failure rates in the present series appear to be more or less the same. As neither of the two is an unequivocally more effective treatment, we are of the opinion that the less invasive procedure should be preferred.(ABSTRACT TRUNCATED AT 250 WORDS)