Adaptive Staged-Dose Gamma Knife Radiosurgery for the Treatment of Large Brain Metastases: Report of 40 Consecutive Cases and Analysis of Literature.

Background: Brain metastases are the most common brain tumors, being one of the most frequent neurological complications of systemic cancer and an important cause of morbidity and mortality. Stereotactic radiosurgery is efficacious and safe in the treatment of brain metastases, with good local control rates and low adverse effects rate. Large brain metastases present some issues in balancing local control and treatment-related toxicity. Objective: Demonstrating adaptive staged-dose Gamma Knife radiosurgery (ASD-GKRS) being a safe and effective treatment for large brain metastases. Materials and Methods: We retrospectively analyzed our series of patients treated with two-stage Gamma Knife radiosurgery for large brain metastases in [BLINDED], between February 2018 and May 2020. Results: Forty patients with large brain metastases underwent adaptive staged-dose Gamma Knife radiosurgery, with median prescription dose of 12 Gy and a median interval between stages of 30 days. At three-month follow-up, the survival rate was 75.0% with a local control rate of 100%. At six-month follow-up, the survival rate was 75.0% with a local control rate of 96.7%. The mean volume reduction was 21.81 cm3 (16.76-26.86; 95% CI). The difference between baseline volume and six-month follow-up volume was statistically significant. Conclusions: Adaptive staged-dose Gamma Knife radiosurgery is a safe, non-invasive and effective treatment for brain metastases, with a low rate of side effects. Large prospective trials are needed to strengthen data obtained about the effectiveness and safety of this technique in managing large brain metastases.

Gamma Knife Radiosurgery for Treatment of Brain Metastases during the COVID-19 Outbreak.

INTRODUCTION: The WHO declared 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a public health emergency of international concern. The National and Regional Health System has been reorganized, and many oncological patients died during this period or had to interrupt their therapies. This study summarizes a single-centre experience, during the COVID-19 period in Italy, in the treatment of brain metastases with Gamma Knife stereotactic radiosurgery (GKRS). METHODS: We retrospectively analysed our series of patients with brain metastases who underwent GKRS at the Niguarda Hospital from February 24 to April 24, 2020. RESULTS: We treated 30 patients with 66 brain metastases. A total of 22 patients came from home and 8 patients were admitted to the emergency room for urgent neurological symptoms. Duration of stay was limited to 0-1 day in 17 patients. We chose to treat a cluster of 9 patients, whose greater lesion exceeded 10 cm3, with 2-stage modality GKRS to minimize tumour recurrence and radiation necrosis. CONCLUSION: Due to the COVID-19 pandemic, the whole world is at a critical crossroads about the use of health care resources. During the COVID-19 outbreak, the deferral of diagnostic and therapeutic procedures and a work backlog in every medical specialty are the natural consequences of reservation of resources for COVID-19 patients. GKRS improved symptoms and reduced the need for open surgeries, allowing many patients to continue their therapeutic path and sparing beds in ICUs. Neurosurgeons have to take into account the availability of stereotactic radiosurgery to reduce hospital stay, conciliating safety for patients and operators with the request for health care coming from the oncological patients and their families.

Torcular Meningioma with Multi-Venous Sinus Invasion: Compensatory Drainage Veins and Surgical Strategy.

BACKGROUND: Torcular meningiomas involving major dural venous sinuses are rare entities and a great challenge for neurosurgeons. The deep knowledge of the patency of occlusion of the sinuses, the extent of the occlusion and potentially new developing of extra and intracranial collateral venous drainage as compensatory venous channels, are at the base of a correct operative strategy. CASE DESCRIPTION: A 45-year-old woman presented with persistent headache. Magnetic resonance imaging of the brain and digital subtraction angiography demonstrated a huge torcular meningioma with complete multi-venous sinus occlusion and a wide venous network for brain and tumor drainage. In these rare cases, we have hypothesized the presence of venous drainage shared by the brain and the tumor, which could generate undesirable venous occlusion during operative resection. This could be a cause of the well-known surgical complications, such as brain swelling and hemorrhagic infarction. CONCLUSIONS: We report our experience with a huge torcular meningioma with multi-venous sinus invasion and a literature review, with a special emphasis on compensatory drainage veins and surgical strategy.

European consensus conference on unruptured brain AVMs treatment (Supported by EANS, ESMINT, EGKS, and SINCH).

In December of 2016, a Consensus Conference on unruptured AVM treatment, involving 24 members of the three European societies dealing with the treatment of cerebral AVMs (EANS, ESMINT, and EGKS) was held in Milan, Italy. The panel made the following statements and general recommendations: (1) Brain arteriovenous malformation (AVM) is a complex disease associated with potentially severe natural history; (2) The results of a randomized trial (ARUBA) cannot be applied equally for all unruptured brain arteriovenous malformation (uBAVM) and for all treatment modalities; (3) Considering the multiple treatment modalities available, patients with uBAVMs should be evaluated by an interdisciplinary neurovascular team consisting of neurosurgeons, neurointerventionalists, radiosurgeons, and neurologists experienced in the diagnosis and treatment of brain AVM; (4) Balancing the risk of hemorrhage and the associated restrictions of everyday activities related to untreated unruptured AVMs against the risk of treatment, there are sufficient indications to treat unruptured AVMs grade 1 and 2 (Spetzler-Martin); (5) There may be indications for treating patients with higher grades, based on a case-to-case consensus decision of the experienced team; (6) If treatment is indicated, the primary strategy should be defined by the multidisciplinary team prior to the beginning of the treatment and should aim at complete eradication of the uBAVM; (7) After having considered the pros and cons of a randomized trial vs. a registry, the panel proposed a prospective European Multidisciplinary Registry.

Arterial and venous aneurysms associated with arteriovenous malformations.

OBJECTIVE: To identify prioritization based on hemorrhagic risk and indications for treatment of arterial and venous aneurysms associated with arteriovenous malformation (AVM). METHODS: From a global series of 400 consecutively treated AVMs, 34 patients (8.5%) with 45 arterial or venous aneurysms were extrapolated. These 45 lesions were classified as unrelated aneurysms (n = 5 cases; 11.%), flow-related aneurysms (n = 18 cases; 40%), and intranidal and postnidal venous aneurysms (n = 22; 49.%). The 18 flow-related aneurysms were further divided into remote (n = 6 cases) and adjacent (n = 12 cases) types. Of 45 aneurysms associated with AVMs, 15 were unruptured with a 5-year mean follow-up. Various possible risk indicators were considered and measured by univariate and multivariate analyses. RESULTS: During the follow-up period, 1 of 15 unruptured aneurysms bled, and the patient died. A significantly different bleeding incidence was found between unrelated aneurysm and flow-related aneurysm types (P = 0.002). Bleeding was significantly less probable in flow-related remote aneurysm type than in venous and flow-related adjacent aneurysm types (P = 0.007). The location of the aneurysm was the only true risk factor for bleeding; the other parameters had no influence on bleeding. CONCLUSIONS: In this series, different subtypes of aneurysms associated with AVMs had different clinical behaviors. The bleeding risk of the unrelated aneurysm and the flow-related remote aneurysm types should be considered almost the same as any other unruptured aneurysm. In other words, bleeding risk should be considered taking into account the parameters established by the International Study of Unruptured Intracranial Aneurysms (location, size, and morphology). Conversely, flow-related adjacent aneurysm and venous aneurysm types have significantly higher bleeding potentials.

Molecular screening test in familial forms of cerebral cavernous malformation: the impact of the Multiplex Ligation-dependent Probe Amplification approach.

Object The purpose of this study was to underline the effectiveness of molecular analysis in cerebral cavernous angioma, with special attention to the familial forms. Methods Multiplex Ligation-dependent Probe Amplification analysis integrates the consecutive sequence analysis of the 3 genes (Krit1/CCM1, MGC4607/CCM2, and PDCD10/CCM3) known to be responsible for cerebral cavernous malformation lesions. Results The Multiplex Ligation-dependent Probe Amplification analysis revealed a new mutation, a heterozygous exon 9/10 deletion of Krit1, in the proband and in all affected family members. Conclusions The identification of the molecular defect allows physicians to screen family members at risk and to identify affected individuals before the onset of clinical symptoms caused by the presence of lesions.