The Effect of Microvascular Decompression for Hemifacial Spasm Caused by Vertebrobasilar Dolichoectasia

OBJECTIVE: Hemifacial spasm (HFS) caused by vertebrobasilar dolichoectasia (VBD) is very rare, and in theses cases, it is difficult to decompress the nerve from its vascular compression. The objective of this study was to investigate the outcome of microvascular decompression (MVD) for HFS caused by VBD. METHODS: There were 10 patients of HFS caused by VBD at our hospital between September 1978 and September 2008. We evaluated magnetic resonance angiography (MRA) and time of flight magnetic resonance imaginge (TOF MRI) findings using the criteria for VBD. We compared the clinical outcomes of MVD for the 10 patients with VBD with the overall outcomes of the total 2058 MVDs performed for HFS. RESULTS: The results of MVD for HFS caused by VBD were successful in 90.9% of cases. The postoperative complication rate in VBD was 45.5%. Offending vessels in patients with VBD were identified visually during surgery. Adverse effects after MVD were found in 4 patients. We found that the diameter of VBD was significantly greater in patients with complications than in those with no complications (p=0.028). CONCLUSION: Our data shows that MVD may be a good treatment modality for HFS caused by VBD but care must be taken to avoid adverse effects from the procedure. It is important to detach the dolichoectatic artery from its surrounding structures sufficiently to allow it to be easily movable. In addition, attempts should be made to lessen the retraction of the cerebellum during release of the dolichoectatic artery.

Late Onset Tuberculous Spondylitis Following Kyphoplasty: A Case Report and Review of the Literature

A 76-year-old woman with compression fracture of L1 underwent percutaneous balloon kyphoplasty using polymethyl methacrylate. Three years after kyphoplasty of L1, the patient was readmitted with severe low back pain. Magnetic resonance imaging revealed progressive collapse of L1 vertebra and new compression fracture at T12. There were no signs of infection. As conservative treatment failed, combined surgery consisting of anterior corpectomy of T12 and L1, interposition of a titanium mesh cage filled with autologous rib graft, and anterior instrumentation of T11-L2 was performed. Histologic examination showed granulomatous inflammation surrounding the cement. Polymerase chain reaction and culture of the specimen confirmed the diagnosis of tuberculosis. The anti-tuberculous medications were administered for 10 months, and the patient recovered without any sequelae. Tuberculous spondylitis should be included in the differential diagnosis of spondylitis after cement augmentation. If conservative antibiotic therapy fails, resection of the infected bone-cement complex is indicated.

Association of Methylenetetrahydrofolate Reductase (MTHFR 677C>T and 1298A>C) Polymorphisms and Haplotypes with Silent Brain Infarction and Homocysteine Levels in a Korean Population

PURPOSE: Methylenetetrahydrofolate reductase (MTHFR) is the main regulatory enzyme for homocysteine metabolism. In the present study, we evaluated whether the MTHFR 677C>T and 1298A>C gene polymorphisms are associated with SBI and plasma homocysteine concentration in a Korean population. MATERIALS AND METHODS: We enrolled 264 patients with SBI and 234 healthy controls in South Korea. Fasting plasma total homocysteine (tHcy) concentrations were measured, and genotype analysis of the MTHFR gene was carried out. RESULTS: The plasma tHcy levels were significantly higher in patients with SBI than in healthy controls. Despite a significant association between the MTHFR 677TT genotype and hyperhomocysteinemia, the MTHFR 677C>T genotypes did not appear to influence susceptibility to SBI. However, odds ratios of the 1298AC and 1298AC + CC genotypes for the 1298AA genotype were significantly different between SBI patients and normal controls. The frequencies of 677C-1298A and 677C-1298C haplotypes were significantly higher in the SBI group than in the control group. CONCLUSION: This study demonstrates that the MTHFR 1298A>C polymorphism is a risk factor for SBI in a Korean population. The genotypes of 677C>T and 1298A>C polymorphisms interact additively, and increase the risk of SBI in Korean subjects.

Serious Complication of Cement Augmentation for Damaged Pilot Hole

Polymethl methacrylate (PMMA) screw reinforcement is frequently used in osteoporotic bone as well as in damaged pilot holes. However, PMMA use can be dangerous, since the amount of applied cement is uncontrolled. A 47-year-old male with traumatic cervical spondylolisthesis at C6-7 underwent anterior cervical plate fixation. During repeated drilling and tapping for false trajectory correction, a pilot hole was damaged. Although it was an unconventional method, PMMA augmentation was tried. However, PMMA was accidentally injected to the cervical spinal cord owing to lack of fluoroscopic guidance. The PMMA was surgically removed after corpectomy and durotomy. The patient had left side hemiparesis (Grade 2/5) immediately post operation. The patient improved spontaneously (Grade 4/5) except for 4th and 5th digit extension. Here, we report a rare complication of PMMA extrusion in the spinal cord during a damaged pilot hole injection, which has not previously been described.

Isolated Distal Leg Weakness due to a Small Cerebral Infarction Masquerading as a Spinal Lesion

Acute stroke with isolated monoparesis manifesting as distal weakness of a single lower extremity has rarely been described. We report two patients with small cortical infarction who had distal weakness of a single lower extremity. In both cases, diffusion-weighted image (DWI) was used to detect small lesions in the contralateral cortex. These cases illustrate that small cortical infarction can cause isolated monoparesis limited to distal part of the leg and it may be misdiagnosed as spinal lesions, especially when lower back pain and transient sensory symptoms are accompanied. In case of the abrupt onset of weakness limited to one lower limb, the possibility of stroke should be considered and careful attention to identify cortical lesions using magnetic resonance imaging, especially DWI is required.

Transvenous Coil Embolization of Traumatic Carotid-Cavernous Fistula Associated with a Persistent Primitive Trigeminal Artery / 대한뇌혈관외과학회지

A 45-year-old male presented with left pulsatile tinnitus and left conjunctival chemosis after blunt head trauma. Cerebral angiography demonstrated a left carotid-cavernous sinus fistula associated with a persistent primitive trigeminal artery. The fistula was packed with detachable coils through the transvenous approach and was successfully occluded without complication, while preserving the patency of the persistent primitive trigeminal artery. The patient's symptoms resolved soon after treatment. Persistent primitive trigeminal artery can be associated with a traumatic cavernous sinus fistula and transvenous coil embolization can be a safe and effective method to immediately occlude the fistula.

Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: Long-term follow-up results / 中国神经精神疾病杂志

Background Cingulotomy is alternative lesion treatment to anterior capsulotomy for severe obsessive-compulsive disorder (OCD) which is proved to be beneficial to alleviate the recurrent obsessive thoughts and uncontrollable, compulsive reactions. To investigate the long term efficacy and adverse cognitive effects of stereotactic bilateral anterior cingulotomy as a treatment for refractory obsessive compulsive disorder (OCD) patients,seventeen patients suffering from refractory OCD underwent stereotactic bilateral anterior cingulotomies and were followed for 24 months.Methods The Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Clinical Global Impression (CGI), and other neuropsychological tests were used to assess the efficacy and cognitive changes of cingulotomy.Tests were taken before surgery and 12 and 24 months after surgery.Results The mean improvement rate of the YBOCS score achieved from the baseline was 48%. Eight patients out of 17 met responder criteria. During the 24-month follow-up, there were no significant adverse effects observed after surgery.Conclusions Bilateral anterior cingulotomy for the treatment of refractory OCD was effective, and no other significant adverse cognitive effects on long-term follow-up were found.

A Fatal Intracerebral Hemorrhage Complicated by Compartment Syndrome of the Upper Arm

Compartment syndrome has a wide spectrum from muscle pain to a life-threatening condition, such as acute renal failure and disseminated intravascular coagulation (DIC). Intracerebral hemorrhage (ICH) due to compartment syndrome has not been reported. We report a patient who presented with ICH leading to death. A 25-year-old female with no significant past history developed extensive compartment syndrome followed by rhabdomyolysis, acute renal failure, DIC, and ICH. Although the patient underwent a fasciotomy and hemodialysis and received aggressive resuscitation with massive transfusions of blood and intravenous fluids, she died. This case stresses the importance of early diagnosis and prompt treatment of compartment syndrome to prevent devastating complications.

A Fatal Intracerebral Hemorrhage Complicated by Compartment Syndrome of the Upper Arm

Compartment syndrome has a wide spectrum from muscle pain to a life-threatening condition, such as acute renal failure and disseminated intravascular coagulation (DIC). Intracerebral hemorrhage (ICH) due to compartment syndrome has not been reported. We report a patient who presented with ICH leading to death. A 25-year-old female with no significant past history developed extensive compartment syndrome followed by rhabdomyolysis, acute renal failure, DIC, and ICH. Although the patient underwent a fasciotomy and hemodialysis and received aggressive resuscitation with massive transfusions of blood and intravenous fluids, she died. This case stresses the importance of early diagnosis and prompt treatment of compartment syndrome to prevent devastating complications.

Effectiveness of Selective Peripheral Denervation for the Treatment of Spasmodic Torticollis

OBJECTIVE: The Bertrand's method of selective peripheral denervation for spasmodic torticollis has already been established as being an effective and safe method. However, such effectiveness has not yet been established in Korea. The authors have performed several cases of selective denervation for the treatment of spasmodic torticollis and we hereby describe the details of the operative method to determine the effectiveness of the method. METHODS: Ten patients who had the selective denervation for the spasmodic torticollis from October 1997 to December 2003, were analyzed. There were 4 rotational and 6 combined types (3 rotational plus retrocollis, 3 rotational plus laterocollis). We performed preoperative electromyograms and neck muscle tonograms in all cases. The technique was used to involve denervation of the ipsilateral posterior paraspinal muscles. Denervation of the sternocleidomastoid muscle was performed on the contralateral side for rotational torticollis and on the ipsilateral side for laterocollis combined type. The surgery was followed by a rigorous physical therapy program. RESULTS: The surgical results were divided into 4 groups labeled excellent, good, fair, and poor. There were 5 excellent patients who showed no detectable abnormal movements, 4 good patients who showed slight residual deviations or slight residual abnormal movements, and 1 fair patient with appreciable residual abnormal movements. Postoperative pain was well tolerated. There was no significant surgical complications. CONCLUSION: The study confirms that selective peripheral denervation for the treatment of spasmodic torticollis is a very useful and safe surgical technique.

The Results of One stage Total Callosotomy in Pediatric Epilepsy / 대한간질학회지

PURPOSE: In the pediatric patients who have medically intractable epilepsy the callosotomy is useful to prevent the propagation of seizure from one hemisphere to the other. The indications of callosotomy are drop attack, life threatening primarily or secondarily generalized seizure, medically refractory mixed seizure types such as Lennox-Gastaut syndrome. In addition, the retarded children are not contraindicated. The anterior callosotomy is used to perform to control medically intractable epilepsy which is believed to have some advantages to total callosotomy. But, we propose that the anterior callosotomy does not seem to be superior to total callosotomy for the prevention of the propagation of seizure or complication. We describe a series of 21 patients with medically intractable epilepsy who underwent total callosotomy in one stage. METHODS: The diagnoses in these patients included Lennox-Gastaut syndrome, atonic seizure, infantile hemiplegia, and no obvious solitary seizure focus on chronic video/EEG monitoring to characterize seizures, electrographic activity, and postictal behaviors. Preoperatively 16 patients suffered from disabling drop attacks or intense head drop seizures which caused frequent physical injuries. Other types of seizures are 12 generalized tonic-clonic seizures, 7 complex partial seizures, 1 absence seizure, and 7 myoclonic seizures. Male:Female=14:7, Age: 2-22 years (Mean: 9.4 years). The follow-up period ranged from 0.8 to 3.8 years (median 2.4 years). Seizure outcome, parental assessment of daily function, and parental satisfaction with outcome were assessed postoperatively. RESULTS: Drop attacks disappeared completely during the entire follow-up period in 13 patients and decreased to less than 10% of baseline in five. The corpus callosum of the one patient were not completely sectioned in Diffusion Tensor Image, tractography. Other types of seizures resolved completely in 14 patients and decreased in 7. 2 patients experienced a transient disconnection syndrome, but completely resolved within four weeks. Overall daily function improved and parents were satisfied with the surgical outcome in all patients except three who experienced recurrent of drop attacks after operation. There was no sign of significant and persistent neurological deficits in any case. CONCLUSION: Results of total callosotomy in patients with medically intractable epilepsy with diffuse epileptic foci were favorable in most cases. The procedure was particularly effective against drop attacks causing physical injuries and impaired quality of life in these patients.

The Influence of Hypoalbuminemia on Neurological Outcome in Patients with Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

Subarachnoid hemorrhages (SAH) result in hemodynamic and metabolic abnormalities. The successful treatment of these abnormalities requires active treatment of neuroprotection. Recently, it has been known that albumin has important roles in neuroprotection as well as in hemodilution. We retrospectively studied 64 patients who were treated surgically for aneurysmal SAH to investigate the relationship between serum albumin levels, severity of disease and neurological outcomes. A high proportion of patients developed hypoalbuminemia after aneurysmal SAH. Patients with poor clinical presentation had significantly lower admission and postoperative albumin values than those with good clinical presentation. Comparison of patients with a favorable outcome and those with an unfavorable outcome revealed a significant difference in postoperative albumin values. In the patients with severe clinical presentation, postoperative albumin levels lower than 3.5 g/dL were associated with an unfavorable outcome. As a result of our analysis, albumin is an important prognostic factor in aneurysmal SAH. Therefore, active albumin replacement therapy might improve neurological outcomes as a neuroprotective agent. We therefore suggest that albumin offers great promise in the therapy of complications of SAH and we propose that it may now be appropriate to consider the initiation of early-phase clinical trials in patients with aneurymal SAH.

The Influence of Hypoalbuminemia on Neurological Outcome in Patients with Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

Subarachnoid hemorrhages (SAH) result in hemodynamic and metabolic abnormalities. The successful treatment of these abnormalities requires active treatment of neuroprotection. Recently, it has been known that albumin has important roles in neuroprotection as well as in hemodilution. We retrospectively studied 64 patients who were treated surgically for aneurysmal SAH to investigate the relationship between serum albumin levels, severity of disease and neurological outcomes. A high proportion of patients developed hypoalbuminemia after aneurysmal SAH. Patients with poor clinical presentation had significantly lower admission and postoperative albumin values than those with good clinical presentation. Comparison of patients with a favorable outcome and those with an unfavorable outcome revealed a significant difference in postoperative albumin values. In the patients with severe clinical presentation, postoperative albumin levels lower than 3.5 g/dL were associated with an unfavorable outcome. As a result of our analysis, albumin is an important prognostic factor in aneurysmal SAH. Therefore, active albumin replacement therapy might improve neurological outcomes as a neuroprotective agent. We therefore suggest that albumin offers great promise in the therapy of complications of SAH and we propose that it may now be appropriate to consider the initiation of early-phase clinical trials in patients with aneurymal SAH.

Comparison of Thalamotomy with Deep Brain Stimulation in Essential Tremor

OBJECTIVE: Thalamic lesioning and deep brain stimulation(DBS) have proved to be beneficial to the treatment of essential tremor(ET). The authors compared the effects and complications of two modalities. METHODS: A total of 34 patients with ET were treated with ventral intermediate(Vim) nucleus thalamotomy or Vim DBS from May 1999 to May 2003. The procedure of lesioning or stimulation were performed as usual manner with or without microelectrode recording. Postoperatively, utilizing the various combinations of frequency, voltage and pulse width optimized the stimulation. The degree of improvements of tremor and the occurrence of the complications were evaluated postoperatively and at follow-up. RESULTS: There were 38 procedures, including 27 with Vim thalamotomy and 11 with DBS, in 34 patients. Of the thalamotomy group, left Vim lesioning is 25 and right one is 2. Follow-up duration ranged from 12 to 57 months. In the thalamotomy group, the rate of overall good outcome was 88.9% but 12 patients (44.4%) showed permanent adverse effects. In the cases of stimulation, the rate of overall good outcome was 90.9% and two patients had acceptable dysarthria. CONCLUSION: Both Vim thalamotomy and Vim DBS were effective for the treatment of ET, although perioperative adverse effects tended to be higher in patients who had thalamotomy. In cases of DBS, adjustments of stimulation parameters enabled an acceptable position to be achieved with tremor control and unwanted effects.

Therapeutic Effects of Holmium-166 Chitosan Complex in Rat Brain Tumor Model

This study examined the effectiveness of Holmium-166 (Ho-166) chitosan complex therapy for a malignant glioma. Cultured C6 glioma cells (100, 000 in 5microliter) were injected into the caudate/putamen of 200 - 250 gram Wistar rats. Five days later, a Ho-166 chitosan complex was injected into the same site of the glioma injection. Four injection doses were administered: the control group received PBS 10microliter, group 1 received an injection of 100micro Ci (10microliter), group 2 received an injection of 50microCi (5microliter), and group 3 received an injection of 10micro Ci (1microliter). The average tumor volume for each group was 1.385 mm3 for the control group, 0.036 mm3 for group 1, 0.104 mm3 for group 2, and 0.111 mm3 for group 3. Compared with the control group, the size of the tumors in groups 1, 2 and 3 was reduced by an average of 97.4%, 92.5% and 91.9%, respectively. The Kaplan-Meier survival curve of group 2 was the longest, followed by groups 3, group 1 and the control. The mean survival was 22.8, 59, 60, and 44.6 days for the control group and groups 3, 2 and 1, respectively. H-E staining revealed that group 2 yielded the best results in the destruction of the malignant glioma. TUNEL staining and immunohistochemical studies indicated apoptotic features. The Ho-166 chitosan complex proved to be effective in destroying the malignant glioma.

Alterations of Spontaneous Behaviors and the Neuronal Activities of the Deep Cerebral Nuclei by Subthalamic Lesion with Kainic Acid in Rat Parkinsonian Models with 6-hydroxydopamine

OBJECTIVE: The purpose of this study is to investigate the effect of ipsilateral subthalamic nucleus(STN) lesioning on the spontaneous behavioral changes and the alteration of neuronal activities of deep cerebral nuclei in the rat parkinsonian model with 6-hydroxydopamine(6-OHDA). METHODS: To identify the spontaneous behavioral changes, apomorphine-induced rotational test and forepaw adjusting step were performed. We subsequently investigated the alteration of neuronal activities in the substantia nigra pars reticulata(SNpr) and globus pallidus(GP), in order to compare them with the behavioral changes in rat parkinsonian models. RESULTS: The STN lesioning in the rat parkinsonian model clearly improved behavioral changes. Compared to the normal control rats, rat PD models exhibited a significant increase in mean firing rates and the percentage of bursting neurons in the STN and SNpr. In the STN-lesioned rat PD models, mean firing rates and the percentage of bursting neurons in the SNpr were reduced and those in the GP increased. CONCLUSION: STN lesioning induced behavior improvement in rat parkinsonian models seems to be consistent with the surgical outcomes of the STN stimulation therapy in advanced Parkinsonn's disease(PD). The alteration of the neuronal activities in the SNpr and GP suggests that these sites are responsible for the improvement of parkinsonian motor symptoms observed following STN lesioning in rat parkinsonian models. The significance of bursting activity in the SNpr and GP remains obscure. Further study is necessary to elucidate the pathophysiological mechanism of PD.

Induction of Apoptosis by a Novel Bcl-2 Protein, Bak-like without a BH3 Domain

OBJECTIVE: In a variety of physiologic settings, cells are eliminated by apoptosis, a genetically encoded process of cellular suicide. Bak, a member of the Bcl-2 protein family, accelerates apoptosis by an unknown mechanism. Here, we describe the identification and characterization of a complementary DNA that encodes a previously unknown Bcl-2 homologue designated Bak-like. METHODS: We identified a splicing variant of Bak with a lacked BH3 domain from human full-length cDNA bank. The expression of Bak-like was examined by northern blot analysis and polymerase chain reaction. To investigate whether Bak-like might arise from alternative splicing of mRNA of Bak, Southern blot analysis was executed. Apoptosis in transfected HeLa cells was analyzed by direct counting of viable cells. We examined the location of Bak-like in individual living cells by using EGFP fusion constructs and confocal microscope. RESULTS: Bak-like cDNA coded a protein consisting of 101 amono acid, and conserved BH1 and BH2 domains like Bak but not BH3 domain. Bak-like mRNA was about 2.4kb similar to bak. Bak-like was assumed to be an alternative splicing variant of Bak and to concern with promotion of apoptosis. GFP-bak-like markedly changed its intracellular distribution, relocating within cells during apoptosis from a diffuse to a punctate pattern. CONCLUSION: Our results define a novel splicing form of the bak gene and demonstrate that this variant without a conserved BH3 domain appears to contain the BH1 and BH2 domains and the transmembrane sequence for apoptosis induction by channel-forming Bcl-2 proteins. Like Bak, Bak-like gene product primarily enhanced apoptotic cell death following an appropriate stimulus.

Endovascular Treatments of Traumatic Carotid and Vertebral Vascular Injuries

OBJECTIVE: The purpose of this report is to determine the safety and efficacy of endovascular therapy in the management of craniocervical vascular injuries. METHODS: Fifteen patients with traumatic carotid and vertebral lesions were treated using therapeutic endovascular methods. In 13 patients with blunt trauma, five patients had a carotid-cavernous fistula, 8 had a dissecting pseudoaneurysm or arterial dissection. One of two penetrating patients had complete transection of the vertebral artery, and the other had an internal carotid artery-internal jugular vein fistula with two pseudoaneurysms. Endovascular therapy was accomplished by implanting the balloons, porous or polytetrafluoroethylene covered stent, and/or embolic materials including coils or glue. RESULTS: All fistulas and pseudoaneurysms were successfully embolized with coils, glue, or stents. Most of all parent arteries except two patients were preserved. Sacrifice of the parent artery was inevitable in cases of thrombus formation due to coil migration into the parent artery and the existing transaction of the parent artery. No additional surgical procedures for vascular lesions were required. There were no delayed neurological or vascular complications. Additionally, no lesions recurred during follow-up periods (mean 26.9 months). CONCLUSION: From the author's experiences, the endovascular therapy using stents, balloons, and coils is both feasible and safe in treatment of the traumatic vascular injuries. Long-term follow-up review of these repairs will be requisite to provide a full evaluation of the safety and efficacy of these devices.

Molecular Genetics of Primary Intracerebral Hemorrhage / 대한뇌혈관외과학회지

Intracerebral hemorrhage (ICH) is more deadly than ischemic stroke but is also rarer and more difficult to study. Genetic and environmental risk factors likely play a role in the occurrence of ICH. The genetics of cerebral amyloid angiopathy like mutation at beta-amyloid peptide positions 22 and 23, cystatin C, presenilin 1 and 2 or apolipoprotein E have been studied for both familial and sporadic forms. In addition, genetic variation in the hemostasis pathway likewise might affect the likelihood of sporadic ICH. Furthermore, polymorphisms of candidate genes such as endoglin, cytochrome P450 enzyme, lipoproteins, or proteolytic enzyme are all known to be risk factors of ICH. Recent advances in molecular biology provide evidence that genetic variants of different candidate genes are associated with the occurrence of ICH. The aim of this review is to expose the current status of these various hypotheses and their contribution to the pathogenesis of ICH in order to provide a basis for future investigations in this field.

Radiological and Hormonal Responses of Functioning Pituitary Adenomas after Gamma Knife Radiosurgery

In this study, we examined patients with functioning pituitary adenoma that underwent Gamma Knife radiosurgery (GKS). In particular, we assessed the effects of GKS on the growth and endocrinological response of the functioning pituitary adenoma. Forty-two cases of functioning pituitary adenoma treated with GKS were analyzed. The mean follow-up duration was 42.5 months (range 6 - 98), and the mean tumor volume was 1.4 cm3 (range 0.1 - 3.8). Multiple isocenters, ranging from 1 to 6 in number (mean 2.7), were used. The tumor margin was covered by an isodose ranging from 50 to 90%. The margin dose was 18 to 40 Gy (mean 28.5) and the maximum dose varied from 35 to 80 Gy (mean 54.1). Tumor growth was controlled in 96.9% of the cases and tumor shrinkage occurred in 40.6% of the cases. Hormonal response was observed in 35 of the 42 (83.3%) patients after GKS, with a mean duration of 6.8 months. Sixteen of the 42 (38.1%) patients showed hormonal normalization, with a mean duration of 21 months. In our multivariate analysis, high integral dosage (p=0.005) and maximum dosage (p=0.001) correlated significantly with hormonal normalization. For patients with functioning pituitary adenoma, GKS can be effective in controlling tumor growth and inducing hormonal normalization, especially if patients are reluctant to undergo surgical resection, or are not able to undergo microsurgery under general anesthesia. It appears that early hormonal normalization can be induced by high maximum dosage (at least 50 Gy) and broad coverage of the target volume within the isodose curve, while keeping the maximum dose to the visual pathways below 9 Gy.