Cerebellar developmental venous anomalies with associated vascular pathology.

Cerebellar developmental venous anomalies (CDVA) are benign conditions, although sometimes they are associated with haemorrhages and reported to be symptomatic. This is the largest follow-up study to investigate the symptomatology of CDVAs and their association with other malformations. Thirty-two patients were followed for 2 - 9 years. Twenty-eight had isolated asymptomatic CDVA without any neurological condition during follow-up, which might be linked to the CDVA. Four patients had CDVA and an associated vascular pathology: two pontine cavernomas, one asymptomatic arteriovenous malformation (this is the first published case in the literature) and one cerebellar infarct with a developmental variation of the posterior fossa venous circulation. One patient had two CDVAs, while another had a unique draining vein from the upper part of the brainstem too. In conclusion, CDVAs are benign, asymptomatic conditions, but they are sometimes associated with pathogenic malformations requiring detailed neuroradiological investigations.

Combined intraarterial carboplatin, intraarterial etoposide phosphate, and IV Cytoxan chemotherapy for progressive optic-hypothalamic gliomas in young children.

BACKGROUND AND PURPOSE: Optic pathway and/or hypothalamic astrocytomas in children are often quiescent, but in some cases, more aggressive tumors may cause progressive visual, endocrine, and neurologic deterioration. The initial treatment of these gliomas includes surgery and IV chemotherapy. Radiotherapy is not recommended in young children because of its severe adverse effects on cognitive and neuroendocrine function. This report suggests a new approach using combined intraarterial and IV carboplatin-based chemotherapy for patients for whom first line treatment has already failed. METHODS: Six children (mean age, 57 months) with the diagnosis of optic pathway hypothalamic gliomas, who had tumor progression after surgery and underwent IV chemotherapy, were treated monthly with intraarterially administered carboplatin, intraarterially administered etoposide phosphate, and IV administered Cytoxan. Four of the children had histologically verified pilocytic astrocytomas, and in two cases, diagnosis was made on the basis of clinical findings. Administration of the intraarterial chemotherapy required catheter placement in both internal carotid arteries at the level of C2-C3 and into one of the vertebral arteries at the level of C6-C7, with the patient under general anesthesia. RESULTS: Four of six patients had partial radiographic response, one had stable disease, and one had progressive disease after one cycle. Three patients showed clinical improvement. There were no serious complications associated with the angiographic procedures. Toxicities included bronchospasm that resolved after 3 to 4 minutes in one patient. One patient showed mild ototoxicity, and four patients needed platelet transfusion because of hematologic toxicity of drugs. CONCLUSION: These results suggest that this modality of chemotherapy (administered after failure of systemic [ie, IV] chemotherapy), of progressive optic-hypothalamic astrocytomas in young children may be an effective treatment prior to radiotherapy.

Iatrogenic arterial spasm relieved by intraarterial mannitol infusion.

Catheter placement for blood brain-barrier disruption and enhanced chemotherapy delivery can sometimes trigger arterial spasm of moderate-to-severe degree. A slow infusion of a small quantity of intraarterially administered mannitol (10 mL of 25% mannitol) was evaluated as a means to obtain a rapid resolution of catheter placement-induced spasm. We prospectively report 12 consecutive cases of blood brain-barrier disruption among patients who developed catheter placement-induced spasm that was treated by this means without side effects, resulting in rapid resolution of spasm.

Safety and efficacy of a multicenter study using intraarterial chemotherapy in conjunction with osmotic opening of the blood-brain barrier for the treatment of patients with malignant brain tumors.

BACKGROUND: The aim of this study was to determine the safety and efficacy of intraarterial chemotherapy with osmotic opening of the blood-brain barrier (BBB) for the treatment of malignant brain tumors when administered across multiple centers. METHODS: Patients with primary central nervous system lymphoma (PCNSL), primitive neuroectodermal tumor (PNET), germ cell tumor, cancer metastasis to the brain, or low or high grade glioma were eligible. Prior to entry, magnetic resonance imaging or computed tomography brain scan, medical history, neurologic status, and Karnofsky performance status were reviewed at the coordinating center. Standardized anesthesia and intraarterial catheterization guidelines were followed by a multidisciplinary team at each center. Between March 1994 and November 1997, 5 universities treated 221 adult patients with intraarterial chemotherapy with or without osmotic opening of the BBB (2464 procedures). RESULTS: Of evaluable patients with PCNSL, 40 of 53 (75%) achieved complete response (CR). All evaluable patients with PNET (n = 17), metastatic disease (n = 12), or germ cell tumor (n = 4) achieved stable disease (SD) or better. Of 57 evaluable patients with glioblastoma multiforme, 45 (79%) achieved SD or better. Asymptomatic subintimal tear occurred in 11 of 221 patients (5%), pulmonary embolism in 6 of 221 (2.7%), and renal toxicity in 4 of 221 (1.8%). One patient with extensive glioma expired within 48 hours after treatment. CONCLUSIONS: Using standard guidelines and protocols, intraarterial chemotherapy with or without osmotic opening of the BBB is feasible across multiple centers with a low incidence of catheter-related complications. In patients with chemotherapy-sensitive tumors, such as PCNSL, PNET, germ cell tumor, and cancer metastasis to the central nervous system, enhanced delivery results in a high degree of tumor response, with an efficacy profile that is reproducible across multiple centers.

Preoperative history and postoperative survival of supratentorial low-grade astrocytomas.

The preoperative history and postoperative course of histologically verified 348 low-grade and 383 anaplastic astrocytomas have been reviewed. In 71.2 and 48.0% of patients epilepsy was the initial symptom of a suspected astrocytoma, and the history was longer than 3 years in 28.1 and 19.5% of cases, respectively. Before the advent of CT, angiography was performed because of a suspected tumour 2-9 years before surgery in 34 cases. The second angiography years later demonstrated the tumour which in 18 cases at surgery proved to be low-grade astrocytoma or anaplastic astrocytoma in 16 cases. During the last 10 years CT or MRI demonstrated a low-density lesion in 21 patients years before surgery. Operation was postponed for different reasons. Ten tumours appeared at 'delayed' surgery as low-grade, but 11 as anaplastic astrocytoma. In the same period 29 further patients were operated on after a history of seizures, longer than 3 years. Histology showed anaplastic astrocytoma in 10 cases also. Malignant transformation occurred nearly in half of the patients during the observation period. This strongly suggests that dedifferentiation is a spontaneous process, an intrinsic feature of astrocytomas and does not depend on any kind of external stimulus. Another 51 patients' surgery was performed following a shorter (1-24 months) history of epilepsy. The 5-year survival rate was 44 and 39.5% Median survival times (53.5 and 51 months) did not show a significant difference between the two groups, but the total survival, including second survivals after reoperation displayed a significant difference (57.5 vs 67.5 months) in favour of patients with a shorter history of seizures. These experiences confirm the difficulties in decision of the time of surgery. Considering the frequent malignant transformation among patients with a long history of seizures, followed by a relatively shorter survival, it may be supposed that an early radical removal in suitable cases might prevent the late dedifferentiation and recurrence.

[The role and importance of CT-guided stereotaxic brain biopsy in neurosurgery. Experiences with 523 cases]. / CT vezérelt stereotaxiás agyi biopszia jelentösége és szerepe az idegsebészetben. Tapasztalataink 523 eset kapcsán.

Between 1989 and 1996, 523 stereotactic biopsies of different intracranial lesions were performed at our institution. In 96.3% of the cases accurate histological diagnosis was made. In 59 cases the drainage of the abscess or cyst was carried out. In 48 cases the lesion was axial, in 27 parasellar, 7 pineal and 37 infratentorial. In the rest of the cases the lesion was in the supratentorial hemispheres. Transient neurological deficits were observed in 3.4% of the cases and craniotomy with haematoma evacuation had to be carried out in one case following the biopsy. There was no mortality associated with the interventions in our material. Our experience supports that CT guided biopsy is a safe and efficient method for obtaining histological diagnosis in different intracranial lesions and showed to be very useful in planning te appropriate treatment for each patient.

Histologically confirmed changes on CT of reoperated low-grade astrocytomas.

During a 15-year period 37 patients with primary low-grade astrocytoma have been operated upon twice in our institute. CT and histological data at the time of the first and second operations were compared. The majority of primary astrocytomas showed as a low-density area without contrast enhancement; minimal, mainly marginal enhancement was present in six cases. At reoperation 10 tumours were histologically unchanged; the corresponding CT studies displayed a nonenhancing lesion, although insignificant contrast uptake could be seen in three cases. There were 18 tumours which had transformed into anaplastic astrocytoma: CT before repeat surgery showed more or less marked enhancement. In all nine cases which progressed into glioblastoma multiforme strong contrast enhancement was seen on CT at the time of recurrence. Although the grade of contrast uptake varied, the appearance of or increase in enhancement was a sign of some degree of anaplastic change, particularly convincing in cases of dedifferentiated glioblastoma multiforme.

[Clinical outcome of stereotaxic radiosurgery of the brain]. / Az agyi stereotaxiás sugársebészet eredményei.

Authors render an account of their four years clinical experiences with linac-based stereotaxic radiosurgery. The first Hungarian stereotaxic radiosurgery team have treated 166 patients between 01. 07. 1991 and 01. 11. 1995: 86 suffered from brain metastases, 13 of them had primary brain tumors 35, benign brain lesions and 32 arteriovenous malformations. The local control rate was found similar to presented in the literature (83, 77, 57 and 82%). During 9 months of median follow up 44% of brain metastatic cases are alive and only 12% died because of cerebral propagation. The primary brain tumors were mostly recurrences (77%) after surgery and/or conventional radiotherapy, 31% died in 11 months of median follow up. Treating benignomas and arteriovenous malformations there was no need for craniotomy at 68 patients. No fatal complications were observed, the rare side-effects seemed to be manageable. The method is an effective possibility for the non-invasive treatment of the above mentioned brain lesions.

Multiple intracranial melanoma metastases treated with surgery and radiosurgery with long term control. A case report.

A case of malignant melanoma with multiplex brain metastases is described, where both surgical and radiosurgical treatment was applied. Due to CNS manifestations the patient was operated on in two sessions. First the symptomatic large tumor was removed, and the other, small lesion which could not be reached from the same approach was operated later. The primary skin lesion was discovered and removed between the two operations. A CT scan three months after the second operation revealed recurrence at the site of the first operation, and the appearance of two new tumors. The intracranial neoplasms were treated in one session by stereotactic radiosurgery using a linear accelerator. Six months after this treatment a new skin lesion was removed and the patient received DTIC therapy. Successive CT scans after the irradiation showed a steady regression of the radiosurgically treated tumors, and more than one year after the irradiation no tumor could be detected on the CT scans.

[The role of CT scan in cases of injury to the inferior orbital muscle]. / A CT vizsgálat szerepe alsó egyenes szemizom becsípödés eseteiben.

Blowout fracture, involving the inferior wall of the orbit, causing the entrapment of the inferior rectus muscle is relatively rare, and is usually seen after traffic or sport accidents. By presenting two cases, the authors draw the attention to the necessity of careful CT scanning of the orbit, when after relatively slight trauma the patients presents with diplopia and inhibited movement of the eye. A correct investigation can establish the diagnosis and early surgery gives a full recovery of the symptoms.