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The purpose of this report is to present the first documented application of GammaTile to an intra-cranial tumor of a patient with a symptomatic radiosensitive connective tissue disorder, a case where there were significant concerns with standard oncologic strategies. We hypothesized that GammaTile® (GT Medical Technologies, Tempe, Arizona, USA) would also be advantageous in the application of intra-cranial tumors in patients with conditions of increased radiosensitivity. We generated a standard external beam radiation therapy (EBRT) plan consisting of an overall 1.5 cm expansion to 59.4 Gy in 1.8 Gy fractions. Also, we developed a CyberKnife (Accuray, Sunnyvale, CA, USA) plan with a 5 mm expansion on the surgical cavity prescribed to 60 Gy in 30 fractions, to make an EBRT comparison using the same prescription volume as GammaTile. We report the first published application of GammaTile® brachytherapy to an intra-cranial malignancy in a patient with limited scleroderma. The dose delivered by GammaTile was compared to the dose that would be delivered with both typical volumes and small volumes of EBRT. The maximum dose delivered to the scar and scalp by GammaTile was reduced to half of that from other external beam techniques (~25 Gy vs. ~55 Gy). MRI imaging at 6 months and 12 months post-resection demonstrated no evidence of disease recurrence nor radiation necrosis. At the 12-month follow-up visit, the surgical scar was well-healed with no skin changes to the surrounding scalp. Dosimetrically and clinically, this report highlights the successful application of GammaTile to an intra-cranial tumor bed in a patient with scleroderma.
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BACKGROUND: Concomitant lung/brain traumatic injury results in significant morbidity and mortality. Lung protective ventilation (Acute Respiratory Distress Syndrome Network [ARDSNet]) has become the standard for managing adult respiratory distress syndrome; however, the resulting permissive hypercapnea may compound traumatic brain injury. Airway pressure release ventilation (APRV) offers an alternative strategy for the management of this patient population. APRV was hypothesized to retard the progression of acute lung/brain injury to a degree greater than ARDSNet in a swine model. METHODS: Yorkshire swine were randomized to ARDSNet, APRV, or sham. Ventilatory settings and pulmonary parameters, vitals, blood gases, quantitative histopathology, and cerebral microdialysis were compared between groups using χ2, Fisher's exact, Student's t test, Wilcoxon rank-sum, and mixed-effects repeated-measures modeling. RESULTS: Twenty-two swine (17 male, 5 female), weighing a mean (SD) of 25 (6.0) kg, were randomized to APRV (n = 9), ARDSNet (n = 12), or sham (n = 1). PaO2/FIO2 ratio dropped significantly, while intracranial pressure increased significantly for all three groups immediately following lung and brain injury. Over time, peak inspiratory pressure, mean airway pressure, and PaO2/FIO2 ratio significantly increased, while total respiratory rate significantly decreased within the APRV group compared with the ARDSNet group. Histopathology did not show significant differences between groups in overall brain or lung tissue injury; however, cerebral microdialysis trends suggested increased ischemia within the APRV group compared with ARDSNet over time. CONCLUSION: Previous studies have not evaluated the effects of APRV in this population. While our macroscopic parameters and histopathology did not observe a significant difference between groups, microdialysis data suggest a trend toward increased cerebral ischemia associated with APRV over time. Additional and future studies should focus on extending the time interval for observation to further delineate differences between groups.
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Lesão Pulmonar Aguda/prevenção & controle , Lesões Encefálicas/prevenção & controle , Pressão Positiva Contínua nas Vias Aéreas/métodos , Lesão Pulmonar Aguda/complicações , Lesão Pulmonar Aguda/patologia , Lesão Pulmonar Aguda/fisiopatologia , Animais , Lesões Encefálicas/complicações , Lesões Encefálicas/patologia , Lesões Encefálicas/fisiopatologia , Hemodinâmica/fisiologia , Complacência Pulmonar/fisiologia , Microdiálise , Projetos Piloto , Distribuição Aleatória , Testes de Função Respiratória , SuínosRESUMO
BACKGROUND: Thermoluminescent dosimeter badges currently utilized to monitor occupational radiation exposures are limited in their ability to provide timely feedback, restricting workers' ability to identify unnecessary exposure. New real time radiation monitoring systems provide an opportunity for workers to immediately identify and alter problematic behaviors in the neuroangiography suite, decreasing unnecessary exposures, lowering risk, and maximizing safety efforts. METHODS: Real time radiation monitoring was performed for 120 diagnostic cerebral angiography procedures. Data were collected in two phases, for procedures performed by two physician participants (30 procedures per physician per phase). Workers were blinded to their real time dose in phase I, and unblinded in phase II. Individual exposures (Sv) and the incidence of red events (exposure rates ≥2.0â mSv/h) were collected for each assigned participating role (physician A, physician B, nurse, scrubbed technologist, and circulating technologist). The dose area product was collected for each procedure to standardize against variations in procedure duration or intensity. RESULTS: In phase II, significant decreased radiation exposure was observed for all roles except physician A. Physician B decreased most from 24.3×10(-8) to 6.9×10(-8) Sv/Gy-cm(2) (p<0.0001). Rates of red events decreased similarly for all roles except physician A, and were significant for all roles except the nurse role. CONCLUSIONS: Real time radiation dose monitoring during diagnostic cerebral angiography may help to reduce occupational radiation exposures for healthcare workers.
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Angiografia Cerebral , Sistemas Computacionais , Exposição Ocupacional/prevenção & controle , Médicos , Doses de Radiação , Exposição à Radiação/prevenção & controle , Monitoramento de Radiação/métodos , Angiografia Cerebral/normas , Sistemas Computacionais/normas , Humanos , Exposição Ocupacional/análise , Exposição Ocupacional/normas , Médicos/normas , Exposição à Radiação/análise , Exposição à Radiação/normas , Monitoramento de Radiação/normas , Método Simples-CegoRESUMO
Acute iatrogenic occlusion of cerebral vessels is a risk during the performance of neuroendovascular procedures. Most commonly this is a result of thrombus formation within the vessel, thromboembolism or an acute vasospastic response. There are several options for flow restoration including pharmacological, mechanical and microsurgical. Mechanical flow restoration, usually by thrombectomy, is typically performed in large cerebral vessels. Current mechanical thrombectomy devices have limited utility in smaller vessels that are more difficult to access, such as the anterior cerebral artery (ACA). We present two cases where successful flow restoration of an intraoperative acutely occluded or thrombotic ACA was rapidly achieved by balloon dilation using a new coaxial dual-lumen balloon catheter. The time elapsed from the decision to use the balloon catheter until revascularization for each patient was 5 min and 46 s (case 1) and 10 min and 25 s (case 2).
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Angioplastia com Balão/instrumentação , Artéria Cerebral Anterior/cirurgia , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/cirurgia , Revascularização Cerebral/métodos , Aneurisma Roto/cirurgia , Angiografia Digital , Angioplastia com Balão/métodos , Catéteres , Angiografia Cerebral , Circulação Cerebrovascular , Feminino , Humanos , Doença Iatrogênica , Angiografia por Ressonância Magnética , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Stents , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/cirurgia , Trombectomia , Tromboembolia/etiologia , Tromboembolia/terapia , Resultado do Tratamento , Vasoespasmo Intracraniano/etiologiaRESUMO
OBJECTIVE: We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction. METHODS: We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year. RESULTS: Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome. CONCLUSION: In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.
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Infarto Cerebral/mortalidade , Infarto Cerebral/cirurgia , Craniectomia Descompressiva/mortalidade , Craniectomia Descompressiva/métodos , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/cirurgia , Adulto , Idoso , Artéria Carótida Interna/cirurgia , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/cirurgia , Duração da Cirurgia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Olfactory schwannomas are rare tumors of the anterior skull base that are possibly derived from ectopic Schwann cells, perivascular neural tissue, or sensory nerves of the meninges. The authors report the case of a 14-year-old boy with an olfactory schwannoma that extended inferiorly through the cranial base and superiorly into the frontal lobe. Because of the growth characteristics of the tumor and the significant overlying frontal lobe edema, the lesion was approached via an endonasal endoscopic route, as a strategy to minimize brain retraction. This tumor was characterized radiographically as contrast-enhancing with cystic areas and erosion into bone. The tumor showed immunoreactivity for S100 protein and leukocyte antigen 7 (CD57) but not epithelial membrane antigen, supporting the diagnosis of olfactory schwannoma. A gross-total resection was achieved. This approach represents a novel application of endoscopic endonasal surgery to the pediatric neurosurgical context, as well as a favorable outcome in an extremely unusual tumor type, that should be applicable to other appropriately selected pediatric brain tumors.