Brachytherapy in the treatment of recurrent solitary brain metastases.

Conventional therapy for solitary brain metastases includes radiotherapy and surgical resection in selected cases. Often, however, the metastasis recurs and limits the quality of life and survival of the patient. Once the metastasis recurs, therapeutic options are limited. Brachytherapy delivers a high total dose of radiation to a localized area, allowing reirradiation at the time of recurrence. Three patients with recurrent brain metastases treated with iridium-192 implants are presented; two of these patients had breast carcinoma and one had malignant melanoma. The implants allowed long term survival in the two patients with recurrent metastatic breast carcinoma. Unfortunately, the patient with melanoma did not respond to the brachytherapy and died within 7 months of implantation. The approaches to treatment to metastatic brain tumors and the rationale for using brachytherapy are discussed.

Thoracic cord compression in Scheuermann's disease.

A 29-year-old man with spastic paraparesis of insidious onset was discovered to have thoracic cord compression by a combination of kyphosis and thoracic disc herniation. Radiologic evaluation showed evidence of Scheuermann's disease, of which thoracic kyphosis is one manifestation. Neurologic signs are uncommon in Scheuermann's disease and few cases have been successfully managed with resolution of neurologic deficit. This patient made a virtually complete recovery after thoracic cord decompressions by costrotransversectomy and transthoracic approaches.

Patterns of recurrence in glioma patients after interstitial irradiation and chemotherapy: report of three cases.

Three patients with malignant gliomas who developed dissemination of tumor at the time of recurrence are presented. All three patients received combination therapy including conventional radiotherapy and interstitial radiation therapy followed by systemic BCNU chemotherapy. A review of the literature on the development of glioma metastases and an analysis of the possible mechanisms of this uncommon growth pattern are presented.

Selective delivery of chemotherapeutic agents with a new catheter system.

A new catheter system was used in ten patients (16 infusions) for infusion of chemotherapeutic agents to the sites of malignant gliomas. Thirteen infusions to the supraophthalmic region were successful, as were three infusions to the posterior cerebral region. There were no complications after the infusions. A neurologic complication occurred in one patient in whom two successful supraophthalmic infusions were previously carried out. In this patient the guide wire separated during catheter placement into the posterior cerebral artery.

Intracarotid chemotherapy with 1,3-bis-(2-chloroethyl)-1-nitrosourea (BCNU) in 5% dextrose in water in the treatment of malignant glioma.

After radiotherapy, 20 patients, 18 with documented progression of malignant glioma and 2 with Grade II astrocytoma, received a total of 52 courses of intracarotid 1,3-bis-(2-chloroethyl)-1-nitrosourea (BCNU) at a dose of 150 mg/m2 dissolved in 5% dextrose in water. The patients were treated at 6-week intervals for a maximum of five courses of chemotherapy per patient. Response to treatment was analyzed on computed tomographic scans by measuring the volume of the enhancing tumor and any central low density. From these data, tumor doubling times ranging from 110 to 968 days were obtained. An 11 to 60% reduction in enhancing tumor volume was noted in 8 patients, 2 of whom had a greater than 50% decrease in tumor volume. One patient had no change in tumor volume 110 weeks after the initiation of BCNU chemotherapy. Four patients had tumor in more than one vascular territory; tumor growth was arrested in the perfused territory, but continued in the nonperfused area. In 1 of the 4 patients, tumor also grew along a shunt catheter tract and spread over the surface of the ipsilateral hemisphere. One patient developed clinically asymptomatic leukoencephalopathy after five courses of BCNU. Two patients had postradiation leukoencephalopathy before BCNU treatment. Seventeen patients had peritumoral low density with mass effect after BCNU; thus, the true incidence of BCNU-related leukoencephalopathy could not be determined. All patients experienced transient unilateral orbital pain during the infusion and scleral erythema that lasted for several hours afterward. Loss of vision was noted in 2 patients, although it seemed to be related to the therapy in only 1 patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Staggered stable isotope administration technique for study of drug distribution.

By infusing intravenously a series of different stable isotope labeled forms of a drug at different times prior to performing a single collection of a body fluid via puncture (or tissue via biopsy), one can obtain the same information about a drug's distribution as would be obtained by infusing a single dose of drug and performing serial collections of fluid (or tissue). Application of this technique of "staggered stable isotope administration" is illustrated with a study of entry of phenobarbital into the cerebrospinal fluid of a dog. Advantages and disadvantages of this technique are discussed.

A prospective study of radiofrequency rhizotomy in the treatment of posttraumatic spasticity.

Posttraumatic spasticity severely impedes rehabilitation potential and nursing care. Treatment of severe spasticity has included medical therapy, spinal cord ablative procedures, anterior and posterior root lesions and peripheral denervations, and tendon releases. Open rhizotomy and percutaneous radiofrequency rhizotomy have achieved good results. We prospectively studied 25 patients with severe spasticity to assess the efficacy of percutaneous radiofrequency rhizotomy. All or most of the prospectively identified goals were accomplished in 24 of the 25 patients, with improvement persisting during an average follow-up period of 12 months. The improvement due to decreased tone was much greater than the improvement due to increased range of motion.

Sclerosing orbital pseudotumor.

We report two patients who underwent orbital exploration yielding the diagnosis of sclerosing orbital pseudotumor. The presenting symptoms were exophthalmos, visual loss, abnormal ocular mobility, and ocular pain. Computed tomographic (CT) scans showed masses in the orbital apex. Steroids were ineffective. Orbital pseudotumor is a heterogeneous diagnostic category of lymphoid infiltrations of the orbit with a wide spectrum of pathological conditions and intraorbital locations. The clinical presentation typically includes the sudden onset of pain, diplopia, lid edema, and exophthalmos. Visual loss is uncommon. Most cases resolve spontaneously or respond to steroid treatment. Although fibrosis may be a prominent histological finding, the literature contains little information concerning its significance. We discuss the evidence for considering the sclerosing pseudotumors to be a significant variant with unique clinical behavior. Although features suggestive of pseudotumor were present in our case, the presence of visual loss and an apical mass shown on the CT scan led to the presumptive diagnosis of tumor and exploratory operation. Neurosurgeons should be aware of this entity as a cause of visual loss and orbital mass. Proper suspicion may in some cases permit transorbital biopsy and avoid craniotomy, inasmuch as operation is of no therapeutic benefit in this disease.

Aphasia in subdural hematoma.

The occurrence of aphasia as the only or dominant symptom of subdural hematoma (SDH) has not been emphasized in the literature. The possible confusion of traumatic aphasia with transient ischemic attacks or stroke has been the object of most recent investigations. Four patients with subacute SDH had aphasia as an initial symptom; the relevant pathophysiologic characteristics were noted in each. These patients had a rapid response to decompression with marked resolution of the aphasia irrespective of immediate or delayed drainage.

Recurrent central cord injury: a case report.

A case of multiple episodes of central cord injury after minor trauma is reported. Cervical films showed a canal diameter of 11 mm at C-3, C-4 and minor instability with a canal diameter of 9 mm in extension. Anterior cervical fusion resulted in a stable spine and the prevention of further symptoms. The mechanism of central cord injury is reviewed, and it is suggested that in some cases careful evaluation will reveal remediable cord compression. Operative treatment may be indicated in central cord injury.

Metastatic brain tumor from the prostate: two unusual cases.

Metastasis to the brain from prostatic cancer is very rare. Two cases are reported with additional unusual features, 1 with no other metastatic disease, and the other with repeated episodes of subarachnoid and intraventricular hemorrhage.

Cranial fasciitis: nodular fasciitis of the head.

An infant was noted at birth to have a lesion over the left coronal suture fixed to both the skin and periosteum, which was identical histologically to nodular fasciitis. This lesion has been described in the literature in various locations, but rarely in the scalp, and not in newborns.

Bilateral interhemispheric subdural hematomas.

Interhemispheric subdural hematomas are rare. Bilateral interhemispheric subdural hematomas in a patient with a ventriculoperitoneal shunt for hydrocephalus were diagnosed by computerized tomographic (CT) scan after mild head trauma. The value of CT scanning, the clinical presentation and treatment, and a review of the literature are presented.

Congenital lumbar ridge causing spinal claudication in adolescents. Report of two cases.

Two adolescent boys had classic histories and findings of spinal claudication. Their plain x-ray films were read as normal and myelograms demonstrated a ventral defect at L4-5. Surgical exploration revealed ventral bony ridges in both cases. Laminectomy initially provided substantial relief, but spinal fusion was necessary for complete abolition of symptoms.