Salvage pemetrexed for brain metastases from ALK-positive lung cancer after Gamma Knife radiosurgery: illustrative case.

BACKGROUND: Systemic therapy for cancer treatment has improved, and therapeutic options for intracranial lesions are increasing. Combinations of treatment modalities are required in certain difficult cases. Gamma Knife radiosurgery (GKS) is effective for the treatment of brain metastases, especially for lesions that are inoperable because of their anatomical or functional location. OBSERVATIONS: The authors report a case of brain metastases in anaplastic lymphoma kinase (ALK)-positive lung adenocarcinoma initially treated with GKS followed by the combination of repeat GKS and ALK tyrosine kinase inhibitors (ALK-TKIs) for tumor recurrence. During the clinical course, acquired resistance to ALK-TKIs due to the long exposure period was suspected. After a great deal of thought and discussion with the oncologist responsible for the treatment of the pulmonary lesions, the authors successfully controlled the lesion for the next 17 months by salvage pemetrexed administration. LESSONS: This is the first report on the effectiveness of pemetrexed for recurrent brain metastasis from ALK-positive lung adenocarcinoma resistant to both radiosurgery and ALK inhibitors. Salvage pemetrexed showed a favorable therapeutic effect in this specific case.

[Basic and Advanced Techniques of Anastomosis in Deep Surgical Fields:STA-SCA Anastomosis].

This article detailly describes the subtemporal-transtentorial STA-SCA bypass technique. Through temporal base drilling, copious cerebrospinal fluid evacuation before retraction, and sufficient retraction of the temporal lobe preserving the veins of the temporal base would be primodial to obtain an appropriate surgical field. Refrection of the tentrial free edge and identification of recipient SCA posterior to the entry point of the trochlear nerve into the cavernous sinus is a micro-anatomical key. Bilateral bayonet-type needle holders and forceps should be used not to shadow the surgical corridor with one's hands.

Comparing Fractionated and Single-Fraction Gamma Knife Radiosurgery for Brain Metastases From Non-Small-Cell Lung Cancer With a Focus on Driver Alterations.

Background As the overall survival in non-small-cell lung cancer has increased, safer, long-term treatments for brain metastases are increasingly needed. This study aimed to analyze the outcomes of fractionated and single-fraction gamma knife radiosurgery for brain metastases from non-small-cell lung cancer, focusing on driver alteration status. Methodology Patients who underwent gamma knife radiosurgery as their first local treatment for brain metastases from non-small-cell lung cancer between May 2018 and December 2021 at our institution were retrospectively enrolled. Results Among the 98 patients (287 lesions), 45 (130 lesions) harbored driver alterations, including epidermal growth factor receptor mutations in 35 patients and anaplastic lymphoma kinase or ROS1 rearrangement in 10 patients. Overall, 64 and 34 patients underwent single-fraction and fractionated radiosurgery (3-15 fractions), respectively. Large tumor size was a risk factor for recurrence, while fractionated radiosurgery (subdistribution hazard ratio (sHR) = 16.47; confidence interval (CI) = 3.58-75.77; p < 0.001) and small tumor size (sHR = 1.15; CI = 1.04-1.28; p = 0.008) independently protected against radiation necrosis. In the case-matched analyses, the cumulative radiation necrosis rates were significantly lower in the fractionated group than in the single-fraction group among all lesions (p = 0.017) and among those with driver alterations (p = 0.046), whereas no significant difference was confirmed among wild-type lesions (p = 0.382). Conclusions Fractionated gamma knife radiosurgery may be an alternative therapeutic approach for reducing the risk of radiation necrosis, particularly for patients with driver alterations, even when the tumors are small. Further research is necessary to determine the optimal indications for fractionated gamma knife radiosurgery and fractionation methods.

Fractionated versus staged gamma knife radiosurgery for mid-to-large brain metastases: a propensity score-matched analysis.

PURPOSE: To compare treatment results between fractionated gamma knife radiosurgery (f-GKRS) and staged gamma knife radiosurgery (s-GKRS) for mid-to-large brain metastases (BMs). METHODS: We retrospectively analyzed data of patients with medium (4-10 mL) to large (> 10 mL) BMs who underwent s-GKRS or f-GKRS between March 2008 and September 2022. Patients were treated with (i) s-GKRS before May 2018 and (ii) f-GKRS after May 2018. Patients who underwent follow-up magnetic resonance imaging at least once were enrolled. Case-matched studies were conducted by applying propensity score matching to minimize treatment selection bias and potential confounding. Local control (LC) was set as the primary endpoint and overall survival (OS) as the secondary endpoint. RESULTS: This study included 129 patients with 136 lesions and 70 patients with 78 lesions who underwent s-GKRS and f-GKRS, respectively. Overall, 124 lesions (62 lesions in each group) were selected in the case-matched group. No differences were observed in the 6-month and 1-year cumulative incidences of LC failure between the s-GKRS and f-GKRS groups (15.6% vs. 15.9% at 6 months and 25.6% vs. 25.6% at 1 year; p = 0.617). One-year OS rates were 62.6% (95% confidence interval [CI]: 45.4-75.7%) and 73.9% (95% CI: 58.8-84.2%) in the s-GKRS and f-GKRS groups, respectively. The post-GKRS median survival time was shorter in the s-GKRS group than in the f-GKRS group (17 vs. 36 months), without significance (p = 0.202). CONCLUSIONS: This is the first study to compare f-GKRS and s-GKRS in large BMs. Fractionation is as effective as staged GKRS for treating mid-to-large BMs.

Two adult patients with moyamoya disease presenting with alexia with agraphia limited to kanji: can revascularization improve characteristic symptoms?

Patients with moyamoya disease (MMD) may exhibit higher brain dysfunction due to hypoperfusion, which may be ameliorated by revascularization. However, few studies have examined the relationship between cerebral perfusion and language function or the ameliorating effect of revascularization on language dysfunction. We present two cases with MMD who presented with alexia with agraphia, specifically for Japanese kanji. The patients had impaired perfusion in the left inferior temporal and lateral occipital lobes. Following superficial temporal artery-middle cerebral artery bypass, the symptoms improved dramatically. Thus, correction of hypoperfusion may be effective even in adult patients with MMD presenting with language dysfunction.

VEGFR-TKI treatment for radiation-induced brain injury after gamma knife radiosurgery for brain metastases from renal cell carcinomas.

OBJECTIVE: Antiangiogenic vascular endothelial growth factor receptor tyrosine kinase inhibitors play an essential role in systemic therapy for renal cell carcinoma. Given the anti-edematous effect of bevacizumab, an antiangiogenic antibody targeting vascular endothelial growth factor, vascular endothelial growth factor receptor tyrosine kinase inhibitors should exert therapeutic effects on radiation-induced brain injury after stereotactic radiosurgery. This preliminary study aimed to investigate the therapeutic effect of vascular endothelial growth factor receptor tyrosine kinase inhibitor against radiation-induced brain injury. METHODS: Magnetic resonance images for six patients treated with vascular endothelial growth factor receptor tyrosine kinase inhibitors who were diagnosed with radiation-induced brain injury following gamma knife radiosurgery were retrospectively reviewed. RESULTS: The median brain edema volume and tumour mass volume in the pre-tyrosine kinase inhibitor period were 57.6 mL (range: 39.4-188.2) and 3.2 mL (range: 1.0-4.6), respectively. Axitinib, pazopanib (followed by cabozantinib) and sunitinib were administered in four, one and one cases, respectively. The median brain edema volume and tumour mass volume in the post-tyrosine kinase inhibitor period were 4.8 mL (range: 1.5-27.8) and 1.6 mL (range: 0.4-3.6), respectively. The median rates of reduction in brain edema volume and tumour mass volume were 90.8% (range: 51.9-97.6%) and 57.2% (range: 20.0-68.6%), respectively. The post-tyrosine kinase inhibitor values for brain edema volume (P = 0.027) and tumour mass volume (P = 0.008) were significantly lower than the pre-tyrosine kinase inhibitor values. Changes in volume were correlated with tyrosine kinase inhibitor use. CONCLUSION: This study is the first to demonstrate the therapeutic effects of vascular endothelial growth factor receptor tyrosine kinase inhibitors on radiation-induced brain injury in patients with brain metastases from renal cell carcinoma treated via gamma knife radiosurgery.

Direct Clipping of Paraclinoid Aneurysm in Conjunction with Extradural Anterior Clinoidectomy: Technical Nuance and Functional Outcome.

Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos. Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions. Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A ( p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B ( p = 0.030), respectively. However, it improved in the chronic phase. Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.

Interfractional change of tumor volume during fractionated stereotactic radiotherapy using gamma knife for brain metastases.

PURPOSE: Fractionated stereotactic radiotherapy (FSRT) using gamma knife is useful for brain metastases. However, several uncertainties derived from fractionation pose issues for maintaining high-level accuracy. This study analyzed interfractional tumor change by performing radiological reassessment at the midterm of FSRT with ≥ 10 fractions, and the significance of replanning was evaluated. METHODS: Data of FSRT using gamma knife with ≥ 10 fractions were retrospectively collected. Interfractional volume changes in MRI at the midterm of the irradiation period were analyzed. Radiological changes after FSRT and final outcomes were also investigated. RESULTS: Overall, 114 lesions in 74 treatments from 66 patients were included, with previously irradiated lesions accounting for 46%. The median interval between planning and the interfractional MRI was 7 days. The interfractional change rates of tumor volume ranged from - 48 to + 72%. Significant interfractional enlargement was observed in 16 lesions (14%); evident regression was confirmed in 17 lesions (15%). Predictive factors for interfractional enlargement were small tumor and cystic lesion; high biologically effective dose was associated with regression. After FSRT, most lesions regressed within 6 months despite interfractional change type. The incidences of tumor control and radiation necrosis indicated no differences between interfractionally-regressed lesions and others. CONCLUSION: This is the first study to evaluate interfractional tumor change in FSRT using gamma knife with ≥ 10 fractions, indicating significant volume changes in 29% of the lesions. These preliminary results suggest that interfractional reassessment of a treatment plan in FSRT with irradiation periods exceeding a week is necessary for more adaptive treatment.

Fractionated Gamma Knife radiosurgery after cyst aspiration for large cystic brain metastases: case series and literature review.

Tumor cyst aspiration followed by Gamma Knife radiosurgery (GKRS) for large cystic brain metastases is a reasonable and effective management strategy. However, even with aspiration, the target lesion tends to exceed the dimensions of an ideal target for stereotactic radiosurgery. In this case, the local tumor control rate and the risk of complication might be a critical challenge. This study is aimed to investigate whether fractionated GKRS (f-GKRS) could solve these problems. Between May 2018 and April 2021, eight consecutive patients with nine lesions were treated with f-GKRS in five or ten sessions after cyst aspiration. The aspiration was repeated as needed throughout the treatment course to maintain the cyst size and shape. The patient characteristics, radiologic tumor response, and clinical course were reviewed using medical records. The mean follow-up duration was 10.2 (2-28) months. The mean pre-GKRS volume and maximum diameter were 16.7 (5-55.8) mL and 39.0 (31-79) mm, respectively. The mean tumor volume reduction achieved by aspiration was 55.4%. The tumor volume decreased for all lesions, and symptoms were alleviated in all patients. The median overall survival was 10.0 months, and the estimated 1-year survival rate was 41.7% (95% CI: 10.9-70.8%). The local tumor control rate was 100%. No irradiation-related adverse events were observed. f-GKRS for aspirated cystic brain metastasis is a safe, effective, and less invasive management option for large cystic brain metastases.

How do I: Venous reconstruction of accidentally injured superficial sylvian vein during the clipping of an unruptured cerebral aneurysm.

BACKGROUND: The transsylvian approach is a versatile treatment method for aneurysms of the anterior circulatory system. Studies have shown that sylvian veins run in various patterns, suggesting the need for dissection between veins to obtain appropriate surgical corridor. In case of inadvertent sylvian vein injury, serious complications such as venous congestion may occur. METHOD: We herein describe the "side-to-side anastomosis reconstruction technique" of the resected superficial sylvian vein. CONCLUSION: This technique can be effective for the reconstruction of other cortical veins, and indocyanine green videoangiography was effective in determining the indications for venous reconstruction.

Vein-related Trigeminal Neuralgia: How to Determine the Treatment Method of the Causative Vein: A Technical Note.

Trigeminal neuralgia (TN) is often caused by various vein forms. Herein, we report two cases of vein-related TN. In the first case, the vein of the cerebellopontine fissure (VCPF), along with the thickened surrounding arachnoid, clung to the trigeminal nerve. As the perfusion range of this vein was expected to be wide and its injury might cause extensive venous infarction, the anchor between the trigeminal nerve and the vein was carefully dissected and the vein was successfully transposed. In the second case, the involvement of the vein of the middle cerebellar peduncle (VMCP), which penetrates the nerve bundle of the trigeminal nerve, was suspected. Because vein transposition was impossible, the vein was transected at the nerve penetration site after confirming that there was sufficient collateral venous outflow. The superior petrosal vein and its tributaries are the primary causative veins of vein-related TN, and their contact patterns are infinite. Moreover, their perfusion range and the presence or absence of collateral venous outflow vary from case to case. Therefore, it is necessary to judge the perfusion range as well as collateral venous outflow based on preoperative images and intraoperative findings and to determine the appropriate treatment method for each case.

Comparison of postoperative temporalis muscle atrophy between the muscle-preserving pterional approach and the mini-pterional approach in the treatment of unruptured intracranial aneurysms.

This study aimed to compare the muscle-preserving pterional approach (modified classic pterional approach, mCP) and the mini-pterional approach (mPA) with respect to postoperative temporalis muscle atrophy.From November 2013 to April 2020, 78 patients with unruptured intracranial aneurysm of the anterior circulation underwent surgery using mCP or mPA in our institution. Patients' background characteristics, postoperative complications, and temporalis muscle volume (MV) rates (operative side/healthy side) were retrospectively investigated. In 64 patients (n = 31, mCP group; n = 33, mPA group), excluding 14 patients with missing imaging data from 6 to 24 months after surgery, associations between the MV rate and clinical variables were assessed. A multiple regression model was used to examine the association between the MV rate and the surgical method, which is a predictor of postoperative atrophy.The mCP group had a significantly higher mean MV rate than the mPA group (0.955 ± 0.040 and 0.915 ± 0.070, respectively; p = 0.008). Based on the results of the univariate analysis, a multiple regression model was established using sex, age, follow-up period, and the presence of diabetes in addition to the surgical method. Patients who underwent mCP had a higher MV rate than those who underwent mPA (t value = 2.33, p = 0.023).The present result suggested that mCP has a preventive effect on postoperative temporalis muscle atrophy. However, further studies are needed in order to prove that mCP is also effective in terms of postoperative aesthetic and functional outcomes.

Revascularization to the ACA: effectiveness and variation of the STA-RAG-A3 bonnet bypass.

BACKGROUND: The effectiveness of bypass surgery in patients with atherothrombotic ischemia in the anterior cerebral artery (ACA) domain remains unclear. In this study, three cases with ischemia in the ACA territory underwent revascularization surgery using superficial temporal artery (STA)-radial artery graft (RAG)-A3 (pericallosal artery) bonnet bypass. Herein, we discuss the effectiveness and variations of this approach. METHODS: Among 182 consecutive patients with atherothrombotic ischemic stroke admitted to the NTT Medical Center, Tokyo, from April 2017 to May 2021, three patients with hemodynamic insufficiency in the extensive ACA territory beyond the recent infarct area were treated using STA-RAG-A3 bonnet bypass. RESULTS: One patient with bilateral severe cerebral blood flow (CBF) deficiency required additional A3-A3 and STA-middle cerebral artery single bypass in conjunction with STA-RAG-A3 bypass. There were no complications associated with the surgical procedure. The patients' hemodynamic study results and neurocognitive performances improved dramatically after surgery. CONCLUSION: Our results suggest the efficacy of STA-RAG-A3 bypass for atherothrombotic ACA ischemia. However, because the number of cases was too small to generalize our results, more cases and thorough pre- and postoperative hemodynamic studies are necessary to prove the validity of the approach.

Acute surgery for a case of superior vermian arteriovenous malformation producing raised venous pressure coexisting with basilar-superior cerebellar artery aneurysm presenting subarachnoid hemorrhage; Case report.

BACKGROUND: Superior vermian subtype of arteriovenous malformation (AVM) coexisting with proximal feeder aneurysm on basilar-superior cerebellar artery (BA-SCA) junction is an extremely rare situation. We experienced a case of this rare entity presenting with subarachnoid hemorrhage (SAH), and herein, introduce the outline and clinical features of this experience together with the actual surgical video. CASE DESCRIPTION: A 54-year-old man SAH patient with severe headache, disturbance of consciousness, and left oculomotor palsy was urgently admitted to our hospital. Imaging examination demonstrated superior vermian AVM with BA-SCA aneurysm, and both lesions were treated through two different approaches (left pterional craniotomy in conjunction with zygomectomy, and left posterior interhemispheric occipital transtentorial approach) in acute phase of SAH. Both lesions were completely disappeared postoperatively and the patient's postoperative course was favorable, without symptomatic cerebral vasospasm. Although slight oculomotor palsy remained, the patient recovered well and was transferred to a rehabilitation hospital for further improvement. CONCLUSION: In the cases of AVM coexisting with proximal feeder aneurysm, presenting with SAH, disorders of intracranial venous return associated with an AVM can be a vital hindrance to managing cerebral vasospasm; therefore, treating both lesions in the acute phase may lead to good outcomes.

Management of brain metastasis from eccrine porocarcinoma: illustrative case.

BACKGROUND: Eccrine porocarcinoma (EP) is a rare malignant skin neoplasm, and there are still many unknowns regarding its natural history and treatment. Due to its scarcity, associated brain metastasis is a far rarer condition. OBSERVATIONS: A 71-year-old-woman with a history of EP was diagnosed with brain metastasis. In her clinical course, the patient underwent tumor removal surgery twice and Gamma Knife radiosurgery (GKRS) four times. The tumor showed a good response to radiotherapy. The histopathological findings of the brain tumor were consistent with those of the primary skin tumor. LESSONS: There are only a few case reports referring to the detailed treatment, especially with GKRS, of brain metastasis from EP. Few reports have presented a detailed histopathological comparison between the primary skin lesion and the metastatic brain lesion. Herein, the authors have described the clinical course, histological features, and results of multidisciplinary treatment for brain metastasis of EP.

Surgical management for IgG4-related ophthalmic disease by a transcranial biopsy combined with extraorbital decompression: illustrative case.

BACKGROUND: Immunoglobulin G4-related ophthalmic disease (IgG4-ROD) accounts for 22% of Japanese lymphoproliferative orbital disease and occurs in 4%-34% of patients with IgG4-related disease, according to the largest case series published to date. Because the optic nerve mass often appears as a tumor-like lesion, it is important, although difficult, to differentiate IgG4-ROD from other orbital tumors and diseases, and biopsy is essential for diagnosis. Here, the authors describe the surgical management of an IgG4-ROD case. OBSERVATIONS: A 63-year-old man presented to the authors' hospital with proptosis and visual impairment. Ophthalmic examination revealed intraocular hypertension. IgG4-related disease with an ophthalmic lesion was suspected on the basis of a blood test and imaging studies. Transcranial biopsy with extraorbital decompression was performed. The patient's symptoms, including visual impairment, improved 3 days after operation, and his IgG4-related disease resolved after corticosteroid treatment. LESSONS: The standard treatment for IgG4-related disease is systemic corticosteroid therapy. However, this treatment should not be administered to patients with IgG4-ROD who a high risk of blindness. In this case, the authors completed a diagnostic and symptom-relieving transcranial biopsy without affecting the patient's aesthetic characteristics. This is the first study, to our knowledge, to report extraorbital decompression via a transcranial approach as a surgical option for IgG4-ROD.

The efficacy of temporary clamping of V3 with a suboccipital far-lateral approach in microvascular decompression for Hemifacial spasm associated with the vertebral artery.

Hemifacial spasm (HFS) is often caused by compression of the vertebral artery (VA) directly or indirectly as a result of other intervening vessels, so VA-associated HFS is difficult to treat. Recently, we have achieved good surgical outcomes using a far lateral approach and temporary clamping of V3 for VA-associated HFS. Herein, we present our method with an accompanying surgical video. From April 2018 to March 2019, 5 patients with VA-associated HFS underwent surgery, and pre-and postoperative symptoms and postoperative complications were evaluated. In the procedure, the suboccipital muscles were dissected and reflected layer by layer, and the extracranial VA (V3) was secured within the suboccipital triangle. A lateral suboccipital craniotomy followed by far lateral drilling was made to widen the surgical field from the caudolateral side. After reducing the VA flow pressure by temporary clamping of V3, the VA was transposed using a Teflon sling via two triangular space above and below the lower cranial nerves (LCNs). Causative vessels included direct VA compression in two cases and intervening vessels in three cases. The symptoms disappeared in four cases and improved satisfactorily in one case. One patient had mild hearing loss (approximately 10 dB) and hoarseness, but both improved 9 months after surgery. There was no postoperative cerebrospinal fluid leakage in any cases. A wide surgical field via the far lateral approach and the temporary clamping of V3 contributed to thorough observation of the REZ and safe and complete VA transposition.

Surgical removal using V3-radial artery graft-V4 bypass and occipital artery-posterior inferior cerebellar artery bypass for a giant thrombosed aneurysm of vertebral artery compressing brain stem: Case report.

BACKGROUND: Giant thrombosed vertebral artery aneurysms (GTVAs) are difficult disease to treat. Here, we are reporting a case of GTVA successfully treated with excluding the pathological segment and restoring the anterograde blood flow of the parent artery, highlighting the reliable surgical procedure. CASE DESCRIPTION: A 55-year-old man with a left GTVA complained of right hemiparesis (manual muscle testing 4/5) represented by hand clumsiness and gait disturbance, in addition to severe left-sided dysesthesia, was referred to our hospital. The posterior inferior cerebellar artery (PICA) was incorporated into the GTVA segment, and the contralateral vertebral artery showed atherosclerotic change. Thus, we decided to treat the aneurysm with aneurysm trapping and thrombectomy, in conjunction with V3-radial artery graft (RAG)-V4 bypass and occipital artery (OA)-PICA bypass through a suboccipital transcondylar approach. The distal end of the dilated segment was meandering and deflecting outwardly to the vicinity of the internal auditory canal and was stretched in an axial direction. Thus, the V4 stump can be transposed to the triangle space made by the medulla, lower cranial nerves, and sigmoid sinus, and we could perform a safe and reliable anastomosis through the corridor. After the surgery, the compression of the brain stem was released, and right hemiparesis was improved completely after rehabilitation. The patient was discharged with a modified Rankin Scale score of 1. CONCLUSION: Trapping of the aneurysm and thrombectomy are the most radical treatment for GTVA, and if possible, reconstruction of anterograde blood flow with V3-RAG-V4 bypass and OA-PICA bypass is desirable.