The concept of rapid rescue radiosurgery in the acute management of critically located brain metastases: A retrospective short-term outcome analysis.

BACKGROUND: Adaptive hypofractionated gamma knife radiosurgery has been used to treat brain metastases in the eloquent regions while limiting the risk of adverse radiation effect (ARE). Ablative responses might be achieved within days to weeks with the goal to preserve the neurological function. The application of this treatment modality in selected acute/subacute settings has been termed Rapid Rescue Radiosurgery (RRR) in our department. We report the expeditious effects of RRR during treatment and 4 weeks after treatment completion. METHODS: In all, 34 patients with 40 brain metastases, each treated over a period of 7 days in three separate gamma knife radiosurgery sessions (GKRS 1-3) between November 2013 and August 2017, were retrospectively analyzed in terms of tumor volume reduction, salvage of organs at risk (OAR), and radiation induced toxicity under the period of treatment (GKRS 1-3 = one week) and at first follow-up magnetic resonance imaging (MRI) (4 weeks after GKRS 3). RESULTS: Mean tumor volume at GKRS 1 was 12.8 cm3. Mean peripheral doses at GKRS 1, GKRS 2, and GKRS 3 were 7.7 Gy, 8.1 Gy, and 8.4 Gy (range: 6.0-9.5 Gy) at the 35% to 50% isodose lines. In the surviving group at first follow-up (n = 28), mean tumor volume reduction was - 10% at GKRS 3 (1 week) and - 48% four weeks after GKRS 3. There was no further clinical deterioration between GKRS 3 and first follow-up in 21 patients. Six patients died prior to first follow-up due to extracranial disease. No ARE was noticed/reported. CONCLUSIONS: In this study, RRR proved effective in terms of rapid tumor volume reduction, debulking, and preservation/rescue of neurological function.

Gamma knife radiosurgery in the management of endolymphatic sac tumors.

BACKGROUND: Although widely regarded as rare epithelial tumors with a low grade of malignancy, endolymphatic sac tumors (ELST) often lead to disabling petrous bone destruction and significantly impairing symptoms at the time of primary diagnosis and/or recurrence. ELST is not uncommon in von Hippel Lindau (VHL) patients. Although open surgery is regarded as the best treatment option, recurrence remains a challenge, particularly when gross tumor resection (GTR) is deemed unachievable due to topographic conditions. Tumor recurrence successfully treated with fractionated radiotherapy and radiosurgery have been reported in selected cases. We present the case of a patient with recurrent ELST treated with salvage gamma knife radiosurgery (GKRS) adding a review of current literature. CASE DESCRIPTION: A 65-year-old patient underwent GKRS of an unresectable, recurrent ELST. Tumor volumetric analysis showed almost 15% increase in tumor volume in the 4 months between the pre-GKRS magnetic resonance imaging (MRI) and the stereotactic MRI (s-MRI) at treatment. Follow-up MRI at 12 and 20 months showed significant decrease in local tumor volume, decreased contrast enhancement and no perifocal edema. The patient's general and neurological status remains stable to the present day. CONCLUSION: In the present case, GKRS was effective in the management of a recurrent ELST over the course of 20 months. Because of ELSTs recurrence potential, long-term follow up is required. The present case as well as previous reports might suggest a possible salvage/adjunctive role of radiosurgery in the management of ELST. Further studies are deemed necessary.

Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series.

BACKGROUND: Oculomotor nerve palsy (ONP) is a common clinical manifestation of ruptured or unruptured posterior communicating artery (PcomA) aneurysms. Although microsurgical clip ligation has been proven a safe and durable treatment, endovascular management is emerging as an increasingly popular alternative. The aim of our study is to compare the recovery rate from ONP and assess the safety and long-term durability of both techniques. METHODS: We have reviewed the retrospective data concerning twenty-two patients treated at our institution between 2004 and 2012 for PcomA aneurysms with ONP. Seven patients were operated on via a standard pterional approach, and fourteen were treated by endovascular occlusion with coils. One patient was managed conservatively. Pre-treatment and post-treatment severity of ONP was recorded, as well as the duration of symptoms before admission and treatment-related complications. RESULTS: All seven patients who underwent surgery improved, with six total recoveries and one partial recovery. Among the fourteen patients treated by embolization, thirteen initially recovered, but long-term follow-up revealed three cases of exacerbation of ONP after refilling of the aneurysms. Two of them were clipped, and one embolized. Also, one partially resolved patient underwent a second embolization. No severe complications occurred in either group. CONCLUSIONS: Despite the small number of patients, our study suggests that both surgical clipping and embolization are safe and effective methods in regards to functional recovery (complete ONP recovery in about 85 % of the cases). However, coiling may lead to delayed recurrence of third cranial nerve (CN) palsy at long-term follow-up, requiring additional treatment.

Two patients with a solitary fibrous tumor of the thoracic spinal cord.

We report two patients with thoracic spinal solitary fibrous tumor (SFT). This report includes a patient with the first secondary SFT arising in the central nervous system from a pleural origin to our knowledge. The diagnosis was confirmed by histological and immunohistochemical analysis. Both patients underwent gross total resection of their tumors and did not show signs of local recurrence. The patient with the secondary lesion later presented with visceral dissemination. We review the reports of spinal SFT and discuss the diagnosis and therapeutic management of this intriguing entity.