A Rare Intersection of Septic Cavernous Sinus Thrombosis and Subarachnoid Hemorrhage: Insights from the Case of a 70-Year-Old Patient.

We describe a rare and complex case of septic cavernous sinus thrombosis (SCST) in a 70-year-old patient who initially presented with ocular symptoms that rapidly progressed to severe intracranial vascular complications, including subarachnoid hemorrhage (SAH). Despite the use of broad-spectrum antibiotics and anticoagulants, the patient's condition deteriorated. SCST, often caused by sinus infections, presents a significant diagnostic and therapeutic dilemma, with mortality rates exceeding 20%. This report underscores the diversity of clinical presentations, ranging from mild headaches to severe cranial nerve deficits, that complicate diagnosis and treatment. The inability to detect any aneurysms in our patient using magnetic resonance imaging (MRI) and computed tomography angiography (CTA) may indicate an alternative pathogenesis. This could involve venous hypertension and endothelial hyperpermeability. This case illustrates the need for personalized treatment approaches, as recommended by the European Federation of Neurological Societies, and the importance of a multidisciplinary perspective when managing such intricate neurological conditions. Our findings contribute to the understanding of SCST coexisting with SAH.

Adverse Events of Everolimus in Patients with Tuberous Sclerosis Complex Treated for Renal Angiomyolipoma/Subependymal Giant Cell Astrocytoma.

Background: Although regarded as a potentially efficient approach to address tuberous sclerosis complex (TSC)-associated complications, the adverse event profile of everolimus has not yet been fully elucidated. The present study aimed to clarify the adverse event spectrum in patients with TSC who are using everolimus for common indications, in comparison to those who do not use everolimus. Materials and Methods: We recruited patients with TSC who were followed up annually at TSC integrated clinics or referred for medical assistance. Medical reviews and laboratory investigations were performed at baseline and annually by clinical physicians. The adverse events were assessed as per the National Cancer Institute Common Terminology Criteria for Adverse Events. Results: Common adverse events in everolimus users included hypercholesterolemia (55%), gingivostomatitis (50%), proteinuria (50%), and hyperglycemia (40%). Compared with everolimus nonusers, the occurrence of gingivostomatitis and proteinuria was significantly higher in everolimus users (gingivostomatitis, p=0.02; proteinuria, p=0.02). Among the everolimus users, 12 patients had level I CTCAE, and five had level II CTCAE. None of the everolimus users presented with CTCAE level III or higher. Conclusion: Patients with TSC who are everolimus users had a higher tendency to develop gingivostomatitis and proteinuria compared to nonusers. However, no differences were observed in the occurrence of other adverse events between everolimus users and nonusers.

Rare combination of traumatic subarachnoid-pleural fistula and intracranial subdural hygromas: A case report.

BACKGROUND: Subarachnoid-pleural fistula (SPF) is a complex and rare condition characterized by a pathological shunt between the subarachnoid and pleural spaces. It can lead to the accumulation of cerebrospinal fluid (CSF) in the pleural space, pneumocephalus, and the development of central nervous system infection. Trauma or thoracic spinal surgery are common causes of SPF, with symptoms including postural headache, consciousness status changes, and dyspnea. The combination of SPF and subdural hygroma is a severe and rare condition, with little existing literature on its clinical correlation. CASE SUMMARY: We report a case of an 83-year-old male patient with traumatic SPF and bilateral frontal subdural hygroma following a fall from height. The patient initially presented with severe lower back and buttock pain. During admission, the patient developed worsening lower limb weakness and pleural effusion. Further investigation revealed the presence of subdural hygromas with mass effect, requiring emergency bilateral subdural drainage. A multidisciplinary approach was undertaken to manage this complex condition, including intervention for hypovolemic CSF status and subdural hygroma management. The pleural effusion eventually resolved and the patient attained a higher level of consciousness after bilateral hygroma drainage surgery. We also reviewed the present literature relating to this rare combination of medical conditions. CONCLUSION: Traumatic SPF with subsequent subdural hygroma is a rare but serious combination. Although the optimal treatment strategy for this complex condition remains uncertain, our literature review suggested that a multidisciplinary approach, including intervention for hypovolemic CSF and management of the subdural hygroma, is the most beneficial.

A Pathophysiological Approach to Reduce Peritumoral Edema with Gamma Knife Radiosurgery for Large Incidental Meningiomas.

BACKGROUND: Peritumoral edema may be a prohibitive side effect in treating large incidental meningiomas with stereotactic radiosurgery. An approach that limits peritumoral edema and achieves tumor control with SRS would be an attractive management option for large incidental meningiomas. METHODS: This is a retrospective cohort study of patients with large incidental meningiomas (≥2 mL in volume and/or 2 cm in diameter) treated with gamma knife radiosurgery (GKRS) between 2000 and 2019 in Taiwan and followed up for 5 years. The outcomes of a pathophysiological approach targeting the dural feeding artery site with a higher marginal dose (18-20 Gy) to enhance vascular damage and the parenchymal margin of the tumor with a lower dose (9-11 Gy) to reduce parenchymal damage were compared with those of a conventional approach targeting the tumor center with a higher dose and tumor margin with a lower dose (12-14 Gy). RESULTS: A total of 53 incidental meningiomas were identified, of which 23 (43.4%) were treated with a pathophysiological approach (4 cases underwent a two-stage approach) and 30 (56.7%) were treated with a conventional approach. During a median follow-up of 3.5 (range 1-5) years, tumor control was achieved in 19 (100%) incidental meningiomas that underwent a single-stage pathophysiological approach compared with 29 (96.7%) incidental meningiomas that underwent a conventional approach (log-rank test: p = 0.426). Peritumoral edema developed in zero (0%) incidental meningiomas that underwent a single stage pathophysiological approach compared to seven (23.3%) incidental meningiomas that underwent a conventional approach (log-rank test: p = 0.023). CONCLUSIONS: Treatment of large incidental meningiomas with a pathophysiological approach with GKRS achieves similar rates of tumor control and reduces the risk of peritumoral edema. GKRS with a pathophysiological approach may be a reasonable management strategy for large incidental meningiomas.

Dumbbell-shaped meningioma of Meckel's cave mimicking trigeminal schwannoma: A case report.

INTRODUCTION AND IMPORTANCE: Several meningioma cases arising through Meckel's cave (MC) at the middle and posterior fossa have been reported. However, few relevant meningiomas have been observed with a dumbbell shape. PRESENTATION OF CASE: We report a rare case of a 36-year-old woman with a meningioma of MC with a typical dumbbell-shaped, schwannoma-like presentation on magnetic resonance imaging (MRI), resulting in a misleading differential diagnosis. CLINICAL DISCUSSION: In this case report, we discuss the characteristics of meningioma of MC observed on MRI and our surgical approach to this condition. CONCLUSION: This tumor was able to mimic a trigeminal schwannoma both clinically and radiographically. This case report has been reported in line with the SCARE 2020 criteria [1].

Lumboperitoneal Shunt: A New Modified Surgical Technique and a Comparison of the Complications with Ventriculoperitoneal Shunt in a Single Center.

Background and objectives: Hydrocephalus remains a disease requiring surgical treatment even in the modern era. Ventriculoperitoneal (VP) shunt placement is the most common treatment, whereas lumboperitoneal (LP) shunts are less commonly used due to initial reports of very high rates of complications. In the present study, we retrospectively reviewed our experience of the new two-stage procedure with LP shunt implantation to assess the complications and the results of this procedure versus VP shunt insertion. Materials and Methods: All patients from a single center who had received LP shunts using a Medtronic Strata device or VP shunts in the past six-year interval were retrospectively reviewed. The LP shunt insertion was a new two-stage procedure. We compared the three major complications and shunt revisions between the two groups, including shunt malfunction, infection, and subdural hematoma. Results: After matching the age and sex of both groups, we included 96 surgery numbers of LP shunts and 192 surgery numbers of VP shunts for comparison. In the LP shunt group, one patient (1.0%) underwent revision of the shunt due to shunt infection. In the VP shunt group, 26 surgeries (13.5%) needed revision, and 11 surgeries (5.7%) had shunt infection. Shunt malfunction occurred in 14 patients (7.3%) and all needed revisions. The revision rate showed statistically significant differences between the LP and VP shunt groups (p < 0.001). Conclusions: The recent improvements in the quality of the LP shunt device and the proficiency of the procedure has made the LP shunt a safer procedure than the VP shunt. The programmable valve can avoid overdrainage complications and reduce the revision rate. With our procedural steps, the LP shunt can be used to decrease the complications and revision rates.

Spinal Cord Stimulation Improves the Microvascular Perfusion Insufficiency Caused by Critical Limb Ischemia.

OBJECTIVE: This retrospective case-controlled study intended to identify the benefits and efficacy of spinal cord stimulation (SCS) as a therapeutic strategy for patients with perfusion problems caused by critical limb ischemia (CLI). The outcomes of patients who received SCS were compared with those of patients who did not receive SCS. METHODS: This study recruited 78 patients who were diagnosed with perfusion problems over the period of 2003-2011. Lower-limb Thallium-201 (201 Tl) scintigraphy revealed that the patients exhibited a perfusion difference of <0.95. Thirty-seven of the recruited patients received SCS treatment and 41 did not receive SCS treatment. All patients received the same medication: 100 mg aspirin once a day and 500 mg paracetamol thrice a day. The outcomes of walking distance, walking time, and sleeping quality were measured and recorded. Pain intensities were evaluated using the visual analog scale (VAS) scoring system. RESULTS: Prior to SCS implantation, patients in the SCS treatment group had worse walking distance (64.86 ± 40.80 vs. 613.70 ± 535.00, p < 0.001), walking time (2.65 ± 1.64 vs. 13.90 ± 11.91, p < 0.001), and sleep quality (1.70 ± 0.78 vs. 3.32 ± 1.17, p < 0.001) than patients in the non-SCS treatment group. At the one-year follow-up, however, patients in the SCS treatment group had significantly better walking distance (1595.00 ± 483.60, p < 0.001), walking time (48.92 ± 14.10, p < 0.001), and sleep quality (4.65 ± 0.92, p < 0.001) than patients in the non-SCS treatment group. Moreover, the VAS score of patients in the SCS treatment group improved one week (8.63 ± 0.54 vs. 4.48 ± 0.59, p < 0.001) and one year after SCS implantation (2.35 ± 0.62, p < 0.001). By contrast, at the one-year follow-up, the walking distance (277.60 ± 374.80, p = 0.002), walking time (9.44 ± 10.73, p = 0.078), sleep quality (2.20 ± 1.10, p < 0.001), and VAS score (7.98 ± 0.43, p = 0.020) of patients in the non-SCS treatment group worsened. Furthermore, lower-limb 201 Tl scintigraphy revealed that microcirculation intensity increased in the lower extremities of patients in the SCS treatment group after SCS implantation relative to that before SCS implantation. Most importantly, 10 of the 41 patients in the non-SCS treatment group required the use of wheelchairs, whereas none of the patients in the SCS treatment group required the use of wheelchairs. CONCLUSION: Treatment of CLI patient with SCS improved patient's walking ability, pain severity, and sleep quality. SCS should be considered as an effective treatment toward limb salvage in CLI.

Gamma Knife radiosurgery for large vestibular schwannomas greater than 3 cm in diameter.

OBJECTIVE Stereotactic radiosurgery (SRS) is an important alternative management option for patients with small- and medium-sized vestibular schwannomas (VSs). Its use in the treatment of large tumors, however, is still being debated. The authors reviewed their recent experience to assess the potential role of SRS in larger-sized VSs. METHODS Between 2000 and 2014, 35 patients with large VSs, defined as having both a single dimension > 3 cm and a volume > 10 cm3, underwent Gamma Knife radiosurgery (GKRS). Nine patients (25.7%) had previously undergone resection. The median total volume covered in this group of patients was 14.8 cm3 (range 10.3-24.5 cm3). The median tumor margin dose was 11 Gy (range 10-12 Gy). RESULTS The median follow-up duration was 48 months (range 6-156 months). All 35 patients had regular MRI follow-up examinations. Twenty tumors (57.1%) had a volume reduction of greater than 50%, 5 (14.3%) had a volume reduction of 15%-50%, 5 (14.3%) were stable in size (volume change < 15%), and 5 (14.3%) had larger volumes (all of these lesions were eventually resected). Four patients (11.4%) underwent resection within 9 months to 6 years because of progressive symptoms. One patient (2.9%) had open surgery for new-onset intractable trigeminal neuralgia at 48 months after GKRS. Two patients (5.7%) who developed a symptomatic cyst underwent placement of a cystoperitoneal shunt. Eight (66%) of 12 patients with pre-GKRS trigeminal sensory dysfunction had hypoesthesia relief. One hemifacial spasm completely resolved 3 years after treatment. Seven patients with facial weakness experienced no deterioration after GKRS. Two of 3 patients with serviceable hearing before GKRS deteriorated while 1 patient retained the same level of hearing. Two patients improved from severe hearing loss to pure tone audiometry less than 50 dB. The authors found borderline statistical significance for post-GKRS tumor enlargement for later resection (p = 0.05, HR 9.97, CI 0.99-100.00). A tumor volume ≥ 15 cm3 was a significant factor predictive of GKRS failure (p = 0.005). No difference in outcome was observed based on indication for GKRS (p = 0.0761). CONCLUSIONS Although microsurgical resection remains the primary management choice in patients with VSs, most VSs that are defined as having both a single dimension > 3 cm and a volume > 10 cm3 and tolerable mass effect can be managed satisfactorily with GKRS. Tumor volume ≥ 15 cm3 is a significant factor predicting poor tumor control following GKRS.

Outcome of Gamma Knife radiosurgery for trigeminal neuralgia associated with neurovascular compression.

We reviewed 130 patients from 1999 to 2012 to evaluate whether neurovascular compression (NVC) has prognostic value for pain relief in idiopathic trigeminal neuralgia (TN) treated by Gamma Knife radiosurgery (GKRS). Patients were assigned to one of the following groups based on NVC identified by MRI: no NVC, small vessel NVC, and large vessel (defined as part of the vertebrobasilar arterial system) NVC. Follow-up ranged from 4 to 14years. Primary outcome was pain graded by the Barrow Neurological Institute (BNI) pain scale. Successful pain control was defined asa score within Grade I-IIIb. Among the 130 patients, 53 had no neurovascular compression (group 1), 60 had a small vessel NVC (group 2), and 17 had a large vessel NVC (group 3). Successful pain control was 85% in group 1, 75% in group 2, and 88% in group 3 (X2=2.480, p=.289). Secondary outcome was new onset facial numbness which was 21% in group 1, 28% in group 2, and 35% in group 3 (X2=1.683, p=.431). NVC did not affect pain outcome for TN patients treated by GKRS. The lack of poorer response with large vessel NVC that has been reported in literature may be explained by treatment of multiple 4mm shots (as opposed to a single shot in 11/17 patients) to cover a larger compression area of the nerve root by a tortuous vessel.

Increase in gray matter volume and white matter fractional anisotropy in the motor pathways of patients with secondarily generalized neocortical seizures.

PURPOSE: Convulsive motor activity is a clinical manifestation of secondarily generalized seizures evolving from different focal regions. The way in which the motor seizures present themselves is not very different from most of the generalized seizures in and between epilepsy patients. This might point towards the involvement of motor-related cortices and corticospinal pathway for wide spread propagation of epileptic activity. Our aim was to identify changes in the cerebral structures and to correlate clinical variables with structural changes particularly in the motor-related cortices and pathway of patients with generalized convulsions from different seizure foci. METHODS: Sixteen patients with focal onset and secondarily generalized seizures were included, along with sixteen healthy volunteers. Structural differences were analysed by measuring grey matter (GM) volume and thickness via T1-weighted MRI, and white matter (WM) fractional anisotropy (FA) via diffusion tensor imaging. GM and WM microstructural properties were compared between patients and controls by voxel- and surface- based analyses. Next, morphometric findings were correlated with seizure severity and disease duration to identify the pathologic process. KEY FINDINGS: In addition to widely reduced GM and WM properties, increased GM volume in the bilateral precentral gyri and paracentral lobules, and elevated regional FA in the bilateral corticospinal tracts adjacent to these motor -related GM were observed in patients and with higher statistical difference in the sub-patient group with drug-resistance. SIGNIFICANCE: The increment of GM volume and WM FA in the motor pathway positively correlated with severity and duration of epilepsy. The demonstrated microstructural changes of motor pathways imply a plastic process of motor networks in the patients with frequent generalization of focal seizures.

Management of Deep Infection after Instrumentation on Lumbar Spinal Surgery in a Single Institution.

Postoperative surgical site infections (SSIs) are more common complications after spinal surgery. SSIs often require extended hospitalisation and may worsen overall clinical outcomes. A retrospective database review of consecutive patients with traditional open lumbar spinal surgery was performed. SSIs patients were identified and reviewed for clinically relevant details, and postoperative SSIs' incidence was calculated for the entire cohort as well as for subgroups with or without spinal implants. In 15 years, 1,176 patients underwent open lumbar spinal surgery with spinal implants and 699 without. Thirty-eight developed postoperative SSIs. Total SSI rate for the entire group was 2.03%. The incidence of postoperative SSIs in the nonimplant group was relatively low. Patients received antibiotics, hyperbaric oxygen therapy, and wet dressing. We provided the precise rates of postoperative SSIs in traditional open spinal surgery obtained from a single-centre data. Patients with spinal implants had higher SSIs' incidence than those without.

Insights Into Microcirculation Underlying Critical Limb Ischemia by Single-Photon Emission Computed Tomography.

Perfusion difference is used as a parameter to evaluate microcirculation. This study aims to differentiate lower-limb perfusion insufficiency from neuropathy to prevent possible occurrence of failed back surgery syndrome (FBSS).Patients were retrospectively gathered from 134 FBSS cases diagnosed in the past 7 years. Up to 82 cases that were excluded from neuralgia by radiologic imaging, electrodiagnostic electromyography, and nerve conduction velocity were enrolled in this study. Perfusion difference was evaluated by single-photon emission computed tomography, and pain intensities were recorded via visual analog scale (VAS) score.Lower perfusion at the left leg comprises 51.2% (42 of 82) of the patients. The mean perfusion difference of the 82 patients was 0.86 ±â€Š0.05 (range: 0.75-0.93). Patients with systemic vascular diseases exhibited significantly higher perfusion difference than that of patients without these related diseases (P < 0.05), except for renal insufficiency (P = 0.134). Significant correlation was observed between perfusion difference and VAS score (r = -0.78; P < 0.0001; n = 82).In this study, we presented perfusion difference as a parameter for evaluating microcirculation, which cannot be detected by ultrasonography or angiography.

Long-term follow-up study of osteoporotic vertebral compression fracture treated using balloon kyphoplasty and vertebroplasty.

OBJECT: Long-term follow-up study is required for verifying whether the clinical outcomes of kyphoplasty and vertebroplasty are altered. The authors' findings showed only subtle differences between these operations within a 5-year period. However, they still suggest the use of vertebroplasty over kyphoplasty in view of the treatment costs. In their previous study, the authors performed a short-term prospective comparison between vertebroplasty and kyphoplasty. Vertebroplasty was recommended instead of kyphoplasty for the treatment of vertebral compression fractures (VCFs) because of the subtle differences between this procedure and kyphoplasty and the treatment costs. To determine whether these clinical outcomes persist in the long term, they continued to observe the patients from their short-term study over a longer-term period. METHODS :One hundred cases of VCF were assigned randomly to either the kyphoplasty or the vertebroplasty group. In cement augmentation, the authors used polymethylmethacrylate as bone filler. Pain was assessed by using a visual analog scale (VAS). For each patient, vertebral body height and wedge angle were measured from reconstructed CT images. RESULTS: The duration of the follow-up period was 5 years. Vertebral body height, kyphotic wedge angle, and VAS score were not evidently altered. Eight patients in the kyphoplasty group had an adjacent fracture after the procedure, whereas 7 patients in the vertebroplasty group had an adjacent fracture after the procedure. These adjacent fractures occurred within 1 year of surgery in both treatment groups except in 1 kyphoplasty-treated patient in whom the adjacent fracture was noted 16 months after treatment. Three patients in the vertebroplasty group had a nonadjacent fracture, and 4 patients in the kyphoplasty group had a nonadjacent fracture. The link between angular correction and the occurrence of adjacent fracture was statistically significant in the vertebroplasty group. CONCLUSIONS: Excessive angular correction is a critical concern in the risk of adjacent fracture after vertebroplasty. Given the subtle differences between vertebroplasty and kyphoplasty observed over the course of 5 years, vertebroplasty remains the preferred option in view of the costs.

Lower limb pain caused by insufficient muscular microcirculation.

Lumbar spinal surgery is a common procedure to treat low back pain. To remark that lower limb perfusion insufficiency may induce the similar syndrome as neuropathic pain, 1,076 cases of postspinal surgery was surveyed within 5 years, in which 51 cases had no obvious improvement 3 months after surgery; 27 cases received second operation because of instability, inadequate decompression, and wrong level; and the other 27 cases including 3 cases after twice spinal surgeries were enrolled. Physical examinations were presented with atypical neuropathic pain and muscle wasting at single lower limbs which deteriorated with long-distance walking. Computed tomography or magnetic resonance imaging scan was studied including the neural structure and lower limb angiography. The report showed degenerative change without definite neural structural compression or vascular occlusion. There was also no significant finding of electrodiagnostic study. The rest radionuclide study of lower limb muscle and myocardium was performed in these 27 cases using Thallium-201. All patients presented 9-24 % (~14%) muscle perfusion difference compared with two legs. Most of peripheral arterial occlusion disease cases presented the symptoms with ischemic pain and vascular claudication. In the study, the patients presented not only ischemic limb but also the bizarre symptoms, such as low back pain with or without radiating root pain and sensory disturbance. Physicians should be aware of the possibility of lower limb pain caused by lower perfusion syndrome.

Use of apparent diffusion coefficients in evaluating the response of vestibular schwannomas to Gamma Knife surgery.

OBJECT: Cellular density is a major factor responsible for changes in apparent diffusion coefficients (ADCs). The authors hypothesized that loss of tumor cells after Gamma Knife surgery (GKS) might alter ADC values. Magnetic resonance imaging, including diffusion-weighted (DW) imaging, was performed to detect cellular changes in brain tumors so that the authors could evaluate the tumor response to GKS as well as the efficacy of the procedure. METHODS: The authors conducted a prospective trial involving 31 patients harboring solid or cystic vestibular schwannomas (VSs) that were treated with GKS. The patients underwent serial MR imaging, including DW imaging, before GKS and at multiple intervals following the procedure. The authors observed the patients over time, evaluating MR imaging findings and clinical outcomes at 6-month intervals. The ADCs were calculated from echo-planar DW images, and mean ADC values were compared at each follow-up. RESULTS: The mean follow-up period was 36.5 months (range 18-60 months). Imaging studies showed a reduction in tumor volume in 19 patients (61.3%) and tumor growth arrest in 9 patients (29%). In the remaining 3 patients (9.7%), tumor enlargement was documented at 18, 36, and 42 months. The mean ADC value before GKS for all solid VSs was 1.06 ± 0.17 × 10(-3) mm(2)/second, which significantly increased 6 months after GKS and continued to increase with time (p = 0.0086). The mean ADC value for treated solid tumors as of the last mean follow-up of 36 months (range 18-60 months) was 1.72 ± 0.26 × 10(-3) mm(2)/second (range 1.50-2.09 × 10(-3) mm(2)/second), which was significantly higher than that before GKS (p = 0.0001). Tumor volumes were positively related to ADC values (p = 0.03). The mean ADC value before GKS for all cystic VSs was 2.09 ± 0.24 × 10(-3) mm(2)/second (range 1.80-2.58 × 10(-3) mm(2)/second). The mean ADC value for treated cystic tumors as of the last mean follow-up of 38 months (range 18-48 months) was 1.89 ± 0.22 × 10(-3) mm(2)/second. In 3 patients harboring solid VSs, the tumor enlarged after GKS but the ADC values were higher than those before GKS. The authors considered these tumors to be controlled and continued follow-up in the patients. CONCLUSIONS: Apparent diffusion coefficient values may be useful for evaluating treatment results before any definite volume change is detected on imaging studies and for distinguishing radiation-induced necrosis from tumor recurrence in cases in which other imaging results are not definitive, as in cases of increased tumor volume or no volume change. The authors suggest that ADC measurements be included during routine MR imaging examinations for the evaluation of GKS results.

Gamma Knife surgery for hemifacial spasm related to cerebellopontine angle tumors.

OBJECT: Most cases of tumor-related hemifacial spasm (HFS) are treated by open surgery. The authors report the effects of Gamma Knife surgery (GKS) on benign tumor-related HFS at a mean follow-up time of 84 months. METHODS: Between 2000 and 2011, 6 patients (5 women and 1 man) harboring single tumors of the cerebellopontine angle (4 meningiomas and 2 vestibular schwannomas [VSs]) and experiencing HFS underwent GKS as a primary treatment. The mean age of the patients at the time of radiosurgery was 52.7 years (range 45-60 years). The patients' tumors lay within the radiosurgical target area. In the 4 cases of meningioma, the mean radiosurgical treatment volume was 5.3 cm(3) (range 1.2-9.6 cm(3)), and the mean radiosurgical tumor margin dose was 14.1 Gy (range 12-18 Gy); in the 2 cases of VS, the treatment volume was 2.5 cm(3) in 1 patient and 11.2 cm(3) in the other, and the margin doses were 11.5 and 12 Gy, respectively. The mean duration of HFS symptoms was 15.5 months (range 3-36 months). RESULTS: The mean follow-up period was 84 months (range 40-110 months). Overall, 4 (66%) of the 6 patients experienced complete relief from HFS without medication after GKS and 1 patient obtained a good outcome. The mean time for improvement to be realized was 12.6 months (range 3-24 months). Only 1 patient failed to experience relief from HFS, and coincidentally, the tumor did not shrink in that case. In all 6 patients (100%), tumor growth was controlled at a mean follow-up of 56 months after GKS: in 5 patients the tumor had decreased in size and in the other patient the tumor size remained unchanged. No new neurological deficit was noted after GKS, and 1 patient with facial numbness reported improvement after tumor shrinkage. CONCLUSIONS: Gamma Knife surgery appears to be effective in treating benign tumor-related HFS and in controlling tumor growth. A reduction in tumor volume is related to spasm improvement. Although a time latency for spasm relief is associated with GKS, minimal side effects are expected.

Stereotactic radiosurgery of essential trigeminal neuralgia using Leksell Gamma Knife model C with automatic positioning system: technical nuances and evaluation of outcome in 130 patients with at least 2 years follow-up after treatment.

The objective of the present study was the evaluation of outcome in 130 patients with essential trigeminal neuralgia, who were treated using Leksell Gamma Knife model C with automatic positioning system and followed at least 24 months thereafter. Radiosurgery was guided by fused thin-sliced magnetic resonance (MR) and "bone window" computed tomographic (CT) images. In all cases, retrogasserian part of the trigeminal nerve at the level of trigeminal incisura was selected as a target, and one 4-mm collimator was used for delivery of the maximum irradiation dose of 90 Gy. The coordinates of the isocenter were adjusted for positioning of the nerve in the center of 80% isodose area, and were corrected in each individual case with regard to presence of distortion artifacts on MR images. Initial relief of the typical paroxysmal facial pain was marked in 127 patients (98%) within a median interval of 3 weeks after treatment. However, in 23 patients the pain re-appeared later on. Overall, at the time of the last follow-up 112 patients (86%) were pain-free, including 86 who remained both pain- and medication-free after initial radiosurgery. In 31 cases (24%), treatment was complicated by facial hypesthesia and/or paresthesia. In conclusion, radiosurgery of essential trigeminal neuralgia results in a high rate of initial pain relief, but pain recurrences and associated complications are not uncommon. The outcome may be influenced by various technical nuances; therefore, treatment should be preferably done in specialized clinical centers with sufficient expertise in the management of this disorder.

Endoscopic surgery for spontaneous basal ganglia hemorrhage: comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients.

BACKGROUND: This prospective study aimed to evaluate the safety, neurological outcomes, and cost-effectiveness of 3 surgical procedures for spontaneous basal ganglia hemorrhage. METHODS: Ninety noncomatose patients with basal ganglia hemorrhages were randomized into 3 groups. Group A (n = 30) underwent endoscopic surgery, group B (n = 30) underwent stereotactic aspiration, and group C (n = 30) underwent craniotomy. Waiting time of surgery, length of operation time, and blood loss were compared between all groups. On the second operative day, we evaluated the amount of residual hematoma and the hematoma evacuation rate by computed tomography scan. Surgical mortality and complications were recorded 3 months after the procedure. Neurological outcomes were evaluated by functional independence measure (FIM) score, Barthel index score, and muscle power (MP) of affected limbs 6 months after surgery. We also evaluated the cost-effectiveness of each procedure. RESULTS: There was significant delay in waiting timing of the stereotactic aspiration (172.56 +/- 93.18 minutes; P < .001). Craniotomy had the longest operation time (229.96 +/- 50.57 minutes; P < .001). Blood loss was most significant in the craniotomy (236.13 +/- 137.45 mL; P < .001). The highest hematoma evacuation rate was seen in the endoscopic surgery (87% +/- 8%; P < .01). The mortality rate was 0% in group A, 6.7% in group B, and 13.3% in group C (P = .21). The complication rate was 3.3% in group A, 10% in group B, and 16.6% in group C (P = .62). The most major complications were rebleeding and infection. The FIM score was higher in the endoscopic surgery (79.90 +/- 36.64) than in the craniotomy (33.84 +/- 18.99; P = .001). The Barthel index score was also significantly better in the endoscopic surgery (50.45 +/- 28.59) than in the craniotomy (16.39 +/- 20.93; P = .006). There was more improvement in MP of affected limbs in endoscopic surgery than in craniotomy (P = .004). Endoscopic surgery was more cost-effective than craniotomy using FIM and Barthel index (P < .02 and P < .05, respectively). CONCLUSIONS: Both endoscopic surgery and stereotactic aspiration are minimally invasive and are effective procedures with low complication and mortality rates; however, the waiting timing of stereotactic aspiration is usually longer. Endoscopic surgery may be an appropriate substitute for stereotactic aspiration. It produces good neurological outcomes and aids in rapid hematoma evacuation. Craniotomy may be used for emergency decompression of enlarged hematoma if endoscopic surgery or stereotactic aspiration is not available.

Socioeconomic costs of open surgery and gamma knife radiosurgery for benign cranial base tumors.

OBJECTIVE: The aim of this study was to evaluate the relative socioeconomic costs of benign cranial base tumors treated with open surgery and gamma knife radiosurgery. METHODS: In a retrospective study, we studied 174 patients with benign cranial base tumors, less than 3 cm in diameter (or volume less than 30 ml), admitted in the past 5 years. Group A (n = 94) underwent open surgery for removal of the tumors, whereas Group B (n = 80) underwent gamma knife radiosurgery. The socioeconomic costs were evaluated by both direct and indirect cost. The direct costs comprised intensive care unit cost, ward cost, operating room cost, and outpatient visiting cost. The indirect costs included loss of workdays and mortality. The length of hospital stay, the number of lost workdays, surgical complications, mortality, and cost-effectiveness analysis were calculated as well. Student t test and chi test were used for statistical analysis. RESULTS: The mean length of hospital stay for open surgery was 18.2 +/- 30.4 days including 5.0 +/- 14.7 days of intensive care unit stay and 13.0 +/- 15.2 days of ward stay, P < 0.01. The mean hospital stay for gamma knife was 2.2 +/- 0.9 days with no need of intensive care unit stay, P < 0.01. The mean loss of workdays for open surgery was 160 +/- 158 days and 8.0 +/- 9.0 days for gamma knife, P < 0.01. The gamma knife cost per hour (1435 US dollars) is higher than the open surgery cost per hour (450 US dollars), P < 0.01. The direct cost for gamma knife (9677 US dollars +/- 6700 US dollars) is higher than that for open surgery (5837 US dollars +/- 6587 US dollars), P < 0.01. Open surgery had more complication rates (31.2%) than gamma knife (3.8%). Open surgery had a mortality rate of 5.3%; there was no mortality for gamma knife. The indirect costs, including loss of workdays and mortality, were significantly higher for open surgery than for gamma knife, P < 0.01. Finally, the socioeconomic cost (34,453 US dollars +/- 97,277 US dollars) is higher for open surgery than for gamma knife (10,044 US dollars +/- 7481 US dollars), P < 0.01. The CEA is significantly higher in gamma knife (3762 US dollars/quality-adjusted life year) than in open surgery (8996 US dollars/quality-adjusted life year), P < 0.01. CONCLUSION: Most of the socioeconomic loss with open surgery for benign cranial base tumors comes from the indirect costs of workdays lost and mortality. Gamma knife radiosurgery is a worthwhile treatment to our patients and to our society because it may shorten hospital stays and workdays lost and reduce complications, mortality, socioeconomic loss, and achieve better cost-effectiveness.