Delayed cerebral ischemia after meningioma resection: Literature review and illustrative case.

BACKGROUND: Cerebral vasospasm results from arterial vasoconstriction, mainly following aneurysmal subarachnoid hemorrhage, and may cause delayed cerebral ischemia (DCI). DCI rarely occurs after tumor resection. We performed a systematic review of the literature together with a case report of DCI after meningioma resection. LITERATURE REVIEW: METHODS: A systematic literature review was performed following the PRISMA statement, searching the PubMed, Medline and Cochrane databases using keywords and MESH terms related to "vasospasm/DCI and meningioma resection". RESULTS: In the studies retrieved in the literature, 5 cases of DCI after meningioma surgery were identified. The average age of patients was 52 years. The average onset time of DCI was 9.7 days. Clinical presentation was highly variable: hemiparesis (60%), confusion (60%) and/or aphasia (40%). Meningioma location was most frequently sphenoidal (60%). Most patients had vasospasm in multiple cerebral vessels, involving only the anterior circulation. Various management strategies were used: endovascular treatment (33.3%), antiplatelet therapy (50%) and/or nimodipine (40%). In terms of outcome, there were no deaths, but most patients had variable neurological sequelae (80%): aphasia, visual impairment, hemiparesis. CONCLUSION: The systematic literature review and the present case of DCI following resection of an olfactory meningioma suggested that the main etiologic factors causing this rare pathology are: 1) intraoperative subarachnoid hemorrhagic contamination; 2) microvascular manipulation; 3) and possible dysregulation of hypothalamic function.

Aggressive primary scalp lymphoma mimicking an acute epidural hematoma: Case report and review of the literature.

BACKGROUND: Cutaneous Central Follicular Lymphoma (CCFL) is a type B cutaneous lymphoma with a usually indolent course. Scalp localization of CCFL is extremely rare, we report a new case mimicking an epidural hematoma, and showing a rapid progression with aggressive infiltration of skin, calvaria, dura and brain parenchyma. CASE REPORT: A 58-year-old patient with an unlabeled polymalformative syndrome was admitted to the Emergency department following a head injury secondary to a self-resolving tonic-clonic epileptic seizure. The initial CT-scan was interpreted as a minor subcutaneous and epidural hematoma initially deemed for conservative management. Within 4 days, the patient showed a progressive neurological deterioration culminating into a stuporous status which prompted a constrast-enhanced brain MRI. The scan revealed a multilayered solid lesion, extending from the subgaleal compartment to the subdural space, threatening the integrity of overlying skin and causing infiltration of the brain parenchyma. Following emergency neurosurgical excision a definitive histology diagnosis of central follicular lymphoma was made. A focused chemotherapy with high-dose Methotrexate with R-CHOP protocol led to disease control until the latest follow up at 2 years. CONCLUSION: To our knowledge, this case represents the first CCFL invading the brain parenchyma and the second extending to the dura. Although such tumor is usually indolent the aggressive behavior herein reported extend the differential diagnosis to high-grade meningiomas, sarcomas, and metastases. Prognostication and appropriate adjuvant treatment require prompt surgical excision and histological confirmation.

Surgical management of persistent post-traumatic trans-tentorial brain hernia.

INTRODUCTION: Temporal engagement may persist after etiologic surgical treatment of acute subdural hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after surgery for supratentorial ASH and to evaluate clinical outcome. MATERIALS AND METHODS: This was a retrospective analysis of 4 patients undergoing secondary DTLD. Patient data were recorded at admission, pre- and postoperatively and at 6months' follow-up (FU): age, gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP), ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E). RESULTS: At postoperative evaluation 48h after DTLD, we observed a significant improvement in GCS score (initial 6±3, preoperative 7±3, postoperative 14±1; P=0.02), midline shift (initial 16±3mm, preoperative 13±5mm, postoperative 9±2mm; P=0.049) and ONP (P=0.01). In all cases, early postoperative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75% of patients (P=0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related complications or mortality were recorded. CONCLUSIONS: In traumatic brain injury, secondary DTLD may allow simple, effective and safe management of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising, as this technique seems to favorably influence neurological outcome in this selected subgroup of patients with persistent clinical and radiological signs of temporal engagement after etiological treatment with normal ICP values.

Current state of benefits of Enhanced Recovery After Surgery (ERAS) in spinal surgeries: A systematic review of the literature.

INTRODUCTION: Recent years have been characterized by a great technological and clinical development in spine surgery. In particular, enhanced recovery after surgery (ERAS) programs, started to gain interest also in this surgical field. Here we tried to analyse the current state of art of ERAS technique in spine surgery. MATERIAL AND METHOD: A systematic review of the literature has been performed in order to find all the possible inclusions. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, Medline databases was conducted to identify all full-text articles in the English-language literature describing the use of ERAS programs or techniques for spine surgery in adult patients. RESULTS: Out of the 827 studies found, only 21 met the inclusion criteria has been retained to be included in the present study. The most frequently benefits of ERAS protocols were shorter hospitalisations (n=15), and decreased complication rates (n=8) lower postoperative pain scores (n=4). These benefits were seen in the 3 main categories considered: lumbar spine surgeries, surgeries for correction of scoliosis or deformity, and surgeries of the cervical spine. CONCLUSION: There are an arising amount of data showing that the use of ERAS programs could be helpful in reducing the days of hospitalizations and the number of complications for certain spinal procedures and in a highly selected group of patients. Despite the large interest on the topic; there is an important lack of high level of scientific evidences. Because of that, there is the need to encourage the design and creation of new randomized clinical trials that will validate the present findings.

Is physical activity a trigger factor for subarachnoid hemorrhage?

INTRODUCTION: Subarachnoid hemorrhage (SAH) is a serious pathology, associated with 43% mortality and significant disability. In the absence of relevant guidelines, some teams advocate that patients harboring an unruptured intracranial aneurysm (ICA) abstain from all sports activity, as a prophylactic precaution. The aim of the present study was to evaluate the impact of physical activity as a risk factor for SAH, through a review of the literature. METHOD: A systematic literature review was performed for the period 2000 to 2020 in accordance with the PRISMA guidelines. Prospective and retrospective articles reporting more than 50 patients whose physical activity was associated with onset of SAH were included. The main end-point was prevalence of SAH occurring after physical activity. For comparison purposes, the prevalences of other circumstances were calculated to establish a range of frequency. RESULTS: Physical activity appeared to be quite rarely associated with onset of SAH, with a prevalence of 3%, compared to 30% at rest, 7.3% in association with defecation and 4.5% in association with sexual activity. Age under 60 years, male gender (M/F ratio 1.38) and smoking (67.1%) were associated with onset of SAH during physical activity. CONCLUSION: Physical activity appears to be a rare trigger factor for SAH. These results are in contrast to the idea that physical activity should, as a precaution, be avoided in patients with unruptured ICA. There is at present no scientific evidence of an association with aneurysmal SAH.

Interventional magnetic-resonance-guided cryotherapy combined with microsurgery for recurrent glioblastoma: An innovative treatment?

BACKGROUND: Glioblastoma invariably recurs after primary Stupp tumor therapy and portends a poor prognosis. Cryoablation is a well-established treatment strategy for extra-cranial tumors. The safety and efficacy of interventional MR-guided cryoablation (iMRgC) has not been explored in recurrent glioblastoma. METHODS: A retrospective analysis of data collected over a period of 24 months was performed. The inclusion criteria were: (I) recurrent glioblastoma despite Stupp protocol; (II) MRI followed by histological confirmation of recurrent glioblastoma; (III) location allowing iMRgC followed by microsurgical resection; and (IV) patient's consent. The primary objective was to assess feasibility in terms of complications. The secondary objective was to analyze progression-free survival (PFS), post-iMRgC survival and overall survival (OS). RESULTS: The study included 6 patients, with a mean age of 67±7.6 years [range, 54-70 years]. No major complications were observed. Median PFS was 7.5 months [IQR 3.75-9.75] and 6-month PFS was 50%. Median post-iMRgC survival was 9 months [IQR 7.5-15.25] and 6-month post-iMRgC survival was 80%. Median OS was 22.5 months [IQR 21.75-30]. CONCLUSION: iMRgC for recurrent glioblastoma demonstrated a good safety profile, with no major complications. Our data suggest improved PFS and OS. TRIAL REGISTRATION NUMBER: No. IRB00011687 retrospectively registred on July 7th 2021.

Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Cervical myelopathy caused by ventrally located atlanto-axial synovial cysts: An open quest for the safest and most effective surgical management. Case series and systematic review of the literature.

OF BACKGROUND DATA: Despite a good understanding of the natural history of spinal synovial cysts (SCs), a widespread agreement regarding their optimal management is still lacking. This is particularly true for SCs occurring at the C1-C2 level, which are rare, but oftentimes lead to a rapidly evolving cervical myelopathy. METHODS: We report a series of 4 patients (M:F ratio=1:1; mean age 63.5 years) presenting with progressive cervical myelopathy secondary to ventrally located C1-C2 SCs. All patients underwent a postero-lateral facet-sparing intradural approach with total excision of the SCs. Functional status was assessed pre- and postoperatively with Nurick scale and the modified Japanese Orthopaedic association grading. Furthermore we conducted a systematic review, following PRISMA guidelines of pertinent literature to contextualize the options for surgical management of such lesions. RESULTS: Complete excision of the SCs was confirmed radiologically and on histological analysis. All measures of functional status improved post-operatively, and no cyst recurrence or need for instrumented fusion were noted during follow up (range from 22 to 88 months). CONCLUSION: Our experience suggests that the facet-sparing intradural approach provides excellent clinical outcomes without causing any C1-C2 instability. This is in keeping with the take home message emerging from our literature review, which confirms that treatment should aim at radical resection of SCs while minimizing the risk of postoperative instability.

Relapsing-Remitting Hepatic Pseudo-Cyst: A great simulator of malfunctioning ventriculoperitoneal shunt. Case report and proposal of a new classification.

BACKGROUND: Ventriculoperitoneal shunt is the most common treatment to manage hydrocephalus; it is unfortunately burdened by up to 25% of complications. The peritoneal approach may expose patients to many complications, however the formation of a liver pseudocyst is a rare occurrence, and its mechanisms are still largely unknown. CASE REPORT: We report the case of a 69-year-old woman with ventriculoperitoneal shunt, inserted for the management of post aneurysmal subarachnoid hemorrhage hydrocephalus, presenting to the Accident and Emergency for acute cholecystitis. Besides confirming the diagnosis, an ultrasound investigation revealed the presence of a hepatic cyst. Conservative treatment with antibiotics and non-steroidal anti-inflammatory drugs was performed with favorable outcome and resorption of the cyst. Interestingly the patient kept on presenting several similar episodes managed well by non-steroidal anti-inflammatory drugs alone, each of them associated with transient symptoms and signs of ventriculoperitoneal shunt malfunction. Computerized Tomography brain and lumbar puncture were normal, whereas CT abdomen showed the ventriculoperitoneal shunt distal catheter passing through the hepatic cyst. Given the ventriculoperitoneal shunt malfunction, in the context of an infective/inflammatory process a conversion of the ventriculoperitoneal shunt into a ventriculo-atrial shunt was carried out with successful clinical outcome. CONCLUSION: Based on current literature we propose a clinical and radiological classification of such pseudocysts related to ventriculoperitoneal shunt. Clinical presentation, diagnostic findings and management options are proposed for each type: purely infective, spurious (infective/inflammatory) and purely inflammatory. In the absence of system infection, a simple replacement of the distal catheter seems to be the best solution.

[What is the place of surgery in the management of brain metastases in 2020?] / Quelle est la place de la chirurgie dans la prise en charge des métastases cérébrales en 2020 ?

Brain metastases are the most common intracranial tumors and are associated with a dismal prognosis. The management of patients with brain metastases has become more important because of the increased incidence of these tumours, the better treatment of the systemic disease and the improvement of surgical techniques. The treatment requires multidisciplinary approaches and become complex because of new emerging systemic therapy and advancements in neurosurgery and radiation oncology. The surgical treatment has an indispensable role to obtain a tissue diagnosis, in relieving intracranial effect mass and improving neurological status by improving induced encephalopathy. An understanding of the role and indications of the surgery in patients with metastatic brain lesions is essential for the effective management of this growing population.

Impact of discontinuation of antithrombotic therapy after surgery for chronic subdural hematoma.

INTRODUCTION: The management of antithrombotic therapy (AT) after surgery for chronic subdural hematoma (cSDH) requires taking account of the balance of risk between hemorrhage recurrence (HR) and the prophylactic thromboembolic effect (TE). The goal of the present study was to evaluate the prevalence of vascular events (VE: TE and/or HR) in the first 3 postoperative months after cSDH evacuation in patients previously treated by AT. The impact of AT resumption was also evaluated. PATIENTS AND METHODS: This observational prospective multicenter collaborative study (14 French neurosurgery centers) included patients with cSDH treated by AT and operated on between May 2017 and March 2018. Data collection used an e-CRF, and was principally based on an admission questionnaire and outcome/progression at 3 months. RESULTS: In this cohort of 211 patients, VE occurred in 58 patients (27.5%): HR in 47 (22.3%), TE in 17 (8%), with mixed event in 6 cases (2%). Median overall time to onset of complications 26 days±31.5, and specifically 43.5 days±29.25 for HR. Non-resumption of AT significantly increased the relative risk of VE [OR: 4.14; 95% CI: 2.08 - 8.56; P <0.001] and especially of TE [OR: 7.5; 95% CI: 1.2 - 42; P<0.001]. The relative risk of HR was significantly increased when AT was resumed at less than 30 days (P=0.015). CONCLUSION: The occurrence of VE in patients operated on for cSDH and previously treated by AT was statistically significant (27.5%). HR was the most common event (22.3%), whereas TE accounted for only the 8%, although with shorter time to onset. In order to prevent TE risk, AT should be restarted after 30 days, as HR risk is greatly decreased beyond this time.

Diagnostic value of fusion of metabolic and structural images for stereotactic biopsy of brain tumors without enhancement after contrast medium injection.

BACKGROUND: The heterogeneous nature of glioma makes it difficult to select a target for stereotactic biopsy that will be representative of grade severity on non-contrast-enhanced lesion imaging. The objective of this study was to evaluate the benefit of fusion of metabolic images (PET 18F-DOPA) with magnetic resonance imaging (MRI) morphological images for cerebral biopsy under stereotactic conditions of glioma without contrast enhancement. PATIENTS AND METHODS: This single-center prospective observational study conducted between January 2016 and April 2018 included 20 consecutive patients (mean age: 45±19.5 years; range, 9-80 years) who underwent cerebral biopsy for a tumor without MRI enhancement but with hypermetabolism on 18F-FDOPA PET (positron emission tomography). Standard 18F-FDOPA uptake value (SUVmax) was determined for diagnosis of high-grade glioma, with comparison to histomolecular results. RESULTS: Histological diagnosis was made in all patients (100%). Samples from hypermetabolism areas revealed high-grade glial tumor in 16 patients (80%). For a SUVmax threshold of 1.75, sensitivity was 81.2%, specificity 50%, PPV 86.7% and VPN 40% for diagnosis of high-grade glioma. No significant association between SUVmax and histomolecular mutation was found. CONCLUSION: 18F-FDOPA metabolic imaging is an aid in choosing the target to be biopsied under stereotactic conditions in tumors without MR enhancement. Nevertheless, despite good sensitivity, 18F-FDOPA PET is insufficient for definitive diagnosis of high-grade tumor.

Biopsying a spinal cord lesion: A diagnostic dilemma. Case report and review of literature.

Spinal cord biopsy is a difficult procedure fraught with the risk of false-negative results or even misdiagnosis in up to 30% of cases. Differential diagnoses of spinal cord lesions include a wide range of inflammatory, infectious and neoplastic diseases. Given the importance of correctly managing these pathologies, it is crucial to avoid delays in making the correct diagnosis in order to improve the patient's outcome. We present here the case of a 21-year-old male with rapidly progressing sphincter and lower limb motor dysfunctions up to complete paraplegia with evidence of thoracic spinal cord lesion on magnetic resonance imaging. None of the blood and cerebrospinal fluid tests pointed to a diagnosis, while a first spinal cord biopsy revealed an inflammatory necrotic process. After several weeks of empirical treatments and clinical stability, the patient started having focal structural seizures that became generalized with local progression of the lesion and diffuse leptomeningeal spread on magnetic resonance imaging. A second spinal cord biopsy found a grade IV glioblastoma with H3 K27M histone mutation. Unfortunately the patient passed away before any treatment could be initiated. In this report, the authors analyze the difficulty of making the rapid, correct diagnosis of a highly malignant intrinsic spinal cord lesion, discussing also possible strategies to avoid diagnostic delays and to improve the outcome of these difficult patients.

Multidisciplinary management of an intra-sellar cavernous hemangioma: Case report and review of the literature.

Extra-axial cavernous hemangiomas (ECH) are rare vascular lesions with a tendency to grow within the medial structures of the middle cranial fossa. This pathological entity lacks specific symptoms, and falls into the category of differential diagnosis of space occupying lesions in the cavernous sinus (CS) with or without sellar involvement, including those of tumoral, vascular and inflammatory nature. Of note, ECH can also be indolent, and is at times discovered incidentally during autopsy investigations. On radiological studies, ECH with sellar extension are frequently mistaken at first for pituitary adenomas. Total removal of intrasellar-CS ECH is technically demanding and burdened by remarkable morbidity and mortality rates, mostly related to the complex neuroanatomy of the CS-sellar region (i.e., peri and postoperative bleeding, and transitory or permanent nerve palsies, hormonal deficits). Consequently, only a few cases of successful total removal have been reported so far in the literature. Surgical debulking with cranial nerve decompression followed by stereotactic radiosurgery is currently considered the best alternative to total removal when the latter carries excessive perioperative risks. We present a rare case of a mainly located intrasellar ECH extending to the left CS discussing its clinical features and focusing on the most relevant aspects of the surgical management along with a review of the pertinent literature.

Pure Endoscopic Management of Fourth Ventricle Arachnoid Cyst: Case Report and Literature Review.

Arachnoid cysts (ACs) within the fourth ventricle are rare, and only a few cases have been reported in the literature. These are benign lesions within the arachnoid membrane, and they have been reported to occur in almost all locations where arachnoid is present. Different procedures have been performed to restore a normal cerebrospinal fluid dynamic and/or pressure, including shunting and partial or complete excision of the cyst by open microsurgery or endoscopic fenestration. We report the case of a fourth ventricle AC successfully treated using only endoscopic anterior trans-frontal cyst fenestration/marsupialization and standard third ventriculostomy. Clinical and technical features are discussed, along with the pertinent literature.

Spinal adhesive arachnoiditis following the rupture of an Adamkiewicz aneurysm: Literature review and a case illustration.

BACKGROUND: The rupture of an isolated spinal aneurysm is an exceptional occurrence. It might be responsible for a spinal subarachnoid haemorrhage (SSAH) that in rare cases can be complicated by arachnoiditis. Among the former the adhesive type is the most severe leading to the formation of a cyst and/or a syrinx. PATIENTS AND METHODS: The literature review was performed via a PubMed search using the following keywords. Adhesive arachnoiditis; spinal subarachnoid haemorrhage; spinal arachnoiditis; spinal arachnoid cyst; arachnoid cyst .Thesearch yielded 24 articles. Given the fact that only a few studies had been reported on the subject, we decided to include all studies regarding adhesive arachnoiditis after SAH leading to a descriptive literature review. Furthermore, a case illustration of a 57 year old man harbouring this type of rare pathology is described. RESULTS: Twenty-four case reports were found regarding spinal adhesive arachnoiditis (SAA) following SSAH. Posterior cerebral circulation bleeding (66.7%) most often occurred followed by spinal (9.1%) and anterior cerebral circulation (9.1%) respectively. The mean time between the haemorrhage and the SAA onset was 10 months. A higher predominance of symptomatic thoracic SAA was found. Including the present case, 80% of patients had a laminectomy, 72% had a micro adhesiolysis, and 56% a shunt placement. Cervical and upper thoracic involvement appeared to have a better outcome. CONCLUSION: Although most authors suggested surgical treatment, the long-term outcome remains unclear. Early stage diagnosis and management of this rare and disabling pathology may lead to a better outcome. Larger co-operative studies remain essential to obtain a better understanding of such a rare and complex disease.

Intracranial solitary fibrous tumor/hemangiopericytoma: Report of two cases and literature review.

Intracranial solitary fibrous tumors (ISFTs) are rare mesenchymal neoplasms originating in the meninges and constitute a heterogeneous group of rare spindle cell tumors that include benign and malignant neoplasms of which hemangiopericytoma is nowadays considered a cellular phenotypic variant. ISFT usually shows benign or indolent clinical behavior. We describe two cases of ISFT managed in our institution along with a review of pertinent literature.

[Risk of radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases]. / Risque de radionécrose après radiothérapie hypofractionnée en conditions stéréotaxiques du lit opératoire de métastases cérébrales.

PURPOSE: To investigate the factors that potentially lead to brain radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases. METHODS AND MATERIALS: A retrospective analysis conducted in two French centres, was performed in patients treated with trifractionated stereotactic radiotherapy (3×7.7Gy prescribed to the 70% isodose line) for resected brain metastases. Patients with previous whole-brain irradiation were excluded of the analysis. Radionecrosis was diagnosed according to a combination of criteria including clinical, serial imaging or, in some cases, histology. Univariate and multivariate analyses were performed to determine the predictive factors of radionecrosis including clinical and dosimetric variables such as volume of brain receiving a specific dose (V8Gy-V22Gy). RESULTS: One hundred eighty-one patients, with a total of 189 cavities were treated between March 2008 and February 2015. Thirty-five patients (18.5%) developed radionecrosis after a median follow-up of 15 months (range: 3-38 months) after hypofractionated stereotactic radiotherapy. One third of patients with radionecrosis were symptomatic. Multivariate analysis showed that infra-tentorial location was predictive of radionecrosis (hazard ratio [HR]: 2.97; 95% confidence interval [95% CI]: 1.47-6.01; P=0.0025). None V8Gy-V22Gy was associated with appearance of radionecrosis, even if V14Gy trended toward significance (P=0.059). CONCLUSION: Analysis of patients and treatment variables revealed that infratentorial location of brain metastases was predictive for radionecrosis after hypofractionated stereotactic radiotherapy for postoperative resection cavities.

Pure endoscopic management of epileptogenic hypothalamic hamartomas.

Hypothalamic hamartomas (HH) are rare congenital malformations located in the region of the tuber cinereum and third ventricle. Their usual clinical presentation is characterized by gelastic/dacrystic seizures which often become pharmaco-resistant and progress to secondary focal/generalized intractable epilepsy causing mostly in children cognitive and behavioral problems (particularly in cases of progressive epileptic encephalopathy) and precocious puberty. Whereas gelastic seizures can be surgically controlled either by resection of the lesion or disconnection (tissue-destructive) procedures, aimed at functionally prevent the spreading of the epileptic burst; generalized seizures tend to respond better to HH excision rather than isolated neocortical resections, which generally fail to control them. Prospective analysis of 14 consecutive patients harboring HH treated in an 8-year period; 12 patients had unilateral and two bilateral HH. All patients were managed by pure endoscopic excision of the HH. The mean operative time was 48 min and mean hospital stay was 2 days; perioperative blood loss was negligible in all cases. Two patients showed a transient diabetes insipidus (DI); no transient or permanent postoperative neurological deficit or memory impairment was recorded. Complete HH excision was achieved in 10/14 patients. At a mean follow-up of 48 months, no wound infection, meningitis, postoperative hydrocephalus, and/or mortality were recorded in this series of patients. Eight patients became seizure free (Engel class I), 2 other experienced worthwhile improvement of disabling seizures (Engel class II); 2 patients were cured from gelastic attacks while still experiencing focal dyscognitive seizures; and 2, having bilateral HH (both undergoing unilateral HH excision), did not experience significant improvement and required later on a temporal lobectomy coupled to amygdalohyppocampectomy. Overall, the followings resulted to be predictive factors for better outcomes in terms of seizure control: (1) cases of unilateral, Delalande class B, HH, (2) shorter history of epilepsy. Endoscopic resection of HH proved, in our series, to be effective in achieving complete control or in reducing the frequency of seizures. Furthermore, this approach has confirmed its minimally invasive nature with a very low morbidity rate: of note, it allowed to better preserve short-term memory and hypothalamic function.