Radiosurgery for Trigeminal Neuralgia Secondary to Dolichoectatic Vessels: Case Series and Review of Literature.

Even for seasoned neurosurgeons who have mastered the microvascular decompression (MVD) techniques, trigeminal neuralgia (TGN) secondary to vertebrobasilar dolichoectatic vessels remains a challenge. Often, patient is either medically infirm or unwilling for invasive surgical interventions. Alternative treatment options including Gamma Knife radiosurgery (GKRS) are considered in such a situation with variable success. This study aimed to evaluate the role of GKRS in patients with trigeminal neuralgia with dolichoectatic vessels and severe cross compression. We prospectively managed three male patients of intractable TGN secondary to dolichoectatic vascular compression with single-session GKRS. The cisternal component of the trigeminal nerve was targeted with 90 Gy radiation at 100% isodose with a single 4-mm collimator. The patients were regularly evaluated on clinical parameters for pain relief (Barrow Neurological Institute (BNI) score), sensory complaints, and outcome. All patients had satisfactory pain control (BNI I-IIIa) at 3 months of interval only to get recurrent pain (BNI IV-V) after 6 months. The treatment was eventually considered a failure after 6-month duration and one patient needed MVD for pain control. Post-GKRS pain control remains inferior in patients with dolichoectasia compared with typical TGN. GKRS should be offered only as a salvage or rescue procedure and should not be used as an alternative treatment of MVD in patient population with dolichoectatic vessels.

Primary Hypofractionated Gamma Knife Radiosurgery for Giant Cavernous Sinus Hemangiomas.

Cavernous sinus hemangioma (CSH) are notoriously difficult to excise because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures. Radiosurgery offers an alternative treatment modality in cases of small and medium-sized CSH. However, no reports are available in the world literature detailing gamma knife radiosurgery (GKRS) in large (3-4 cm) and giant (>4 cm) CSH. Two patients with giant CSH (Tumor volume was 72.2 and 99.8 cm3, respectively) were treated with frame-based fractionated GKRS (5 Gy × 5 #). The treatment was done with Leksell Perfexion with frame in situ and interfraction interval of 24 h. The tumor was engulfing the optic apparatus, and chiasma could not be separated delineated. The patients were followed at 3 months interval with clinic-radiologic evaluation. Following GKRS, both patients showed remarkable clinical improvement in presenting complaints of headache and visual deterioration. Sixth nerve paresis recovered completely in case no. 1. Significant reduction in tumor volumes (85.1 and 75.6% respectively) was noticed in both the patients at 6 months follow-up radiology. Transient alopecia was noted in case 1 at 3 months follow-up that completely resolved by the 6 months. There was no complication till the last follow-up of 9 months. We report the first account of five fraction frame-based hypo fractionated GKRS for giant CSH. At an interval as short as 3 months, giant CSH shows remarkable clinical improvement. Primary hypofractionated GKRS may be considered an alternative effective modality in these difficult lesions with a favorable safety profile.

Successful Transplant of Two Kidneys Harvested from a Young Brain-Dead Liver Transplant Recipient.

Efforts to increase the dismal deceased renal transplantation (DRT): live renal transplantation (LRT) ratio in our country have gathered momentum recently, with governmental and non-governmental projects focussing on building public awareness and capacity-building, and appropriate legislation. Worldwide, efforts at increasing the number of organs from the deceased pool have focussed on the use of 'expanded criteria donors', including deceased cardiac donors (DCD). 'Reuse' transplant, where an organ is transplanted after removal from the first recipient, is a rare strategy, used more commonly in liver than in kidney transplantation. Exceptional circumstances, where other organs have been harvested from transplant recipients, are rare. We describe the successful transplants of two renal grafts obtained from a 19-year-old brain-dead liver transplant recipient; this is probably the second case in English-language literature. A 19-year-old male patient with hepatitis E-induced fulminant hepatic failure underwent live-related liver transplantation. On postoperative day 2, cerebral edema set in, and the patient was declared brain-dead. Despite the economical and emotional trauma, the family opted for donation of the well-perfused kidneys. The kidneys were transported in HTK solution (histidine-tryptophan-ketoglutarate) to our centre. Recipient 1 was a 32-year-old woman (B positive) and recipient 2 was a 29-year-old man (also B positive); the kidneys were placed extraperitoneally and anastomosed end-to-side to the external iliac artery and vein. Recipient 2 experienced delayed graft function; however, both are doing well 15 months posttransplant.