Frame-Based and Mask-Based Stereotactic Radiosurgery: The Patient Experience, Compared.

INTRODUCTION: Noninvasive frameless modalities have become increasingly utilized for stereotactic radiosurgery (SRS) for benign and malignant pathologies. There is minimal comparison in the literature of frame-based (FB) and mask-based (MB) SRS. With the dual capabilities of the Elekta Gamma Knife® Icon™, we sought to compare patient perceptions of FB and MB SRS with respect to comfort and pain and to examine effects of lesion type on the patient experience of SRS. METHODS: Over a 1-year period, patients who underwent single fraction, fractionated or hypofractionated FB or MB Gamma Knife SRS at our institution were given an 8-question survey about their experience with the procedure immediately after treatment was completed. Descriptive statistics were applied. RESULTS: A total of 117 patients completed the survey with 65 FB and 52 MB SRS treatments. Mean pain for FB SRS (5.64 ± 2.55) was significantly greater than mean pain for MB SRS (0.92 ± 2.24; t114 = 10.46, p < 0.001). Patient comfort during the procedure was also higher for those having MB SRS (p < 0.001). Mixed results were obtained when investigating if benign versus malignant diagnosis affected patient experience of SRS. For the purposes of this study, malignant diagnoses were almost entirely metastatic lesions. Diagnosis played no role on pain levels when all patients were analyzed together. The treatment technique had no effect on patient comfort in patients with benign diagnoses, while patients with malignant diagnoses treated with MB SRS were more likely to be comfortable (p < 0.001). Among patient's receiving FB treatments, diagnosis played no role on patient comfort. When only MB treatments were analyzed, patients were more likely to be comfortable if they had a malignant lesion (p < 0.01). CONCLUSIONS: Patients treated with MB SRS experience the procedure as more comfortable and less painful compared to those treated using a FB modality. Overall, this difference was not affected by a benign versus a malignant diagnosis and the treatment type is more indicative of the patient experience during SRS. A more homogenous sample between modalities and diagnoses and further follow-up with the patient's input on their experience would be beneficial.

Efficacy and safety of cilostazol-nimodipine combined therapy on delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a prospective, randomised, double-blinded, placebo-controlled trial protocol.

INTRODUCTION: Delayed cerebral ischaemia (DCI) due to cerebral vasospasm (cVS) remains the foremost contributor to morbidity and mortality following aneurysmal subarachnoid haemorrhage (aSAH). Past efforts in preventing and treating DCI have failed to make any significant progress. To date, our most effective treatment involves the use of nimodipine, a calcium channel blocker. Recent studies have suggested that cilostazol, a platelet aggregation inhibitor, may prevent cVS. Thus far, no study has evaluated the effect of cilostazol plus nimodipine on the rate of DCI following aSAH. METHODS AND ANALYSIS: This is a multicentre, double-blinded, randomised, placebo-controlled superiority trial investigating the effect of cilostazol on DCI. Data concerning rates of DCI, symptomatic and radiographic vasospasm, length of intensive care unit stay, and long-term functional and quality-of-life (QoL) outcomes will be recorded. All data will be collected with the aim of demonstrating that the use of cilostazol plus nimodipine will safely decrease the incidence of DCI, and decrease the rates of both radiographic and symptomatic vasospasm with subsequent improvement in long-term functional and QoL outcomes when compared with nimodipine alone. ETHICS AND DISSEMINATION: Ethical approval was obtained from all participating hospitals by the Ascension Providence Hospital Institutional Review Board. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04148105.

Major complications from radiotherapy following treatment for atypical meningiomas.

OBJECTIVEComplications from radiotherapy (RT), in a primary or adjuvant setting, have overall been described as uncommon, with few detailed descriptions of major complications. The authors present two cases involving significant complications and their management in their review of patients undergoing RT for treatment of atypical meningioma.METHODSThe authors conducted a retrospective review of all patients with pathologically confirmed atypical meningioma (WHO grade II) treated with primary or adjuvant RT from February 2011 through February 2019. They identified two patients with long-term, grade 3 toxicity. The cases of these patients are described in detail.RESULTSTwo patients had major complications associated with postoperative RT. Patients 1 and 2 both were treated with postoperative RT for pathologically confirmed atypical meningioma. Patient 1 experienced worsening behavioral changes, cognitive decline, and hydrocephalus following treatment. This required cerebrospinal fluid diversion. Patient 2 developed radiation necrosis with mass effect and cognitive decline. Neither patient returned to his/her initial post-RT status after steroid therapy, and each remained in need of supportive care. Both patients remained free of tumor progression at 52 and 38 months following treatment.CONCLUSIONSThe postoperative management of patients with atypical meningioma continues to be defined, with questions remaining regarding timing of RT, dose, target delineation, and fractionation. Both of the patients in this study received fractionated RT, which included a greater volume of normal brain than more focal treatment options such as would be required by stereotactic radiosurgery (SRS). Further research is needed to compare SRS and fractionated RT for the management of patients with grade II meningiomas. The more focused nature of SRS may make this a preferred option in certain cases of focal recurrence.

Rapidly Expanding Pediatric Post Radiation Brainstem Cavernoma Presenting with Singultus.

Here we present a pediatric patient status post resection of a primitive neuroectodermal tumor (PNET) with cranial/spinal radiation and development of a medullary cavernoma seven years after radiation therapy. The patient's cavernoma demonstrated rapid symptomatic growth in six weeks resulting in the presentation of intractable hiccups (singultus). The patient underwent resection of the cavernoma with cessation of the hiccups. We also review the pathology and possible mechanisms of such rapid growth of this post-radiation cavernoma as well as advise surveillance for patients with such lesions, as their course may be different from that of sporadic cavernomas.