Solitary fibrous tumor of the pineal region in the elderly: A case report.

INTRODUCTION: Solitary fibrous tumor (SFT) is a mesenchymal tumor with spindle cells that is often detected in the subcutaneous area and rarely in the central nervous system. Intracranial SFTs rarely occur in individuals older than 80 years, and there are only a few cases reports involving the pineal region. PRESENTATION OF CASE: The present case was an 80-year-old man with lightheadedness, headache, and vomiting. Magnetic resonance imaging showed a tumor in the pineal region extending along the falx and tentorium cerebelli with homogenous enhancement. Subtotal resection was performed via the occipital transtentorial approach. A histopathological examination showed the proliferation of oval- to spindle-shaped tumor cells with bland nuclei arranged in a haphazard pattern and accompanied by staghorn-like branching vessels. Immunohistochemically, tumor cells were positive for CD34 (focal), CD99, and STAT6, but negative for epithelial membrane antigen (EMA) and S-100. Based on these findings, the tumor was diagnosed as SFT (WHO grade I). DISCUSSION: Although difficulties are associated with differentiating SFT from meningioma on imaging, recurrence and metastasis are more common with SFT than with meningioma; therefore, histological and immunohistochemical analyses are important. A correlation has been reported between postoperative adjuvant radiotherapy and longer progression-free survival; however, this needs to be confirmed in further studies. CONCLUSION: SFT involving the pineal region is rare in the elderly, but needs to be considered as a preoperative diagnosis. Since high rates of postoperative recurrence and metastasis have been reported, long-term follow-ups are required after surgery.

Cilostazol improves outcome after subarachnoid hemorrhage: a preliminary report.

BACKGROUND: Cerebral vasospasm (VS) is the most common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Reversal of VS by intra-arterial infusion of cyclic adenosine monophosphate (cAMP)-elevating agents has been reported; however, the preventive role in the development of VS is not fully understood. This study is designed to evaluate the possible efficacy of using cilostazol, a selective inhibitor of phosphodiesterase type 3 and a cAMP-elevating agent, in patients with SAH. METHODS: In this prospective randomized study, we enrolled 100 SAH patients who met the following criteria: neck clipping within 72 h after onset, Hunt and Hess (HH) score ≤4, modified Rankin scale (mRS) score ≤2 prior to ictus, and no serious cardiovascular complications. Patients were divided into control and cilostazol groups; we focused on the effects of cilostazol on the decrease in the incidence of symptomatic VS, cerebral infarction, and the mRS score at discharge. RESULT: Patients' age, male/female ratio, mRS score prior to ictus, HH grade, Fisher group, site of the aneurysm, drugs prescribed during the observation period, and length of hospital stay were not different between the groups. Cilostazol did not significantly decrease the incidence of symptomatic VS (37.3% in the control vs. 22.4% in the cilostazol group, p = 0.183) and cerebral infarction (27.5% in control vs. 10.2% in the cilostazol, p = 0.091). However, mRS score was significantly improved at discharge (2.6 in controls vs. 1.5 in the cilostazol group, p = 0.041). Patients' age being ≤65 years (OR = 8.47, 95% CI = 2.45-29.32, p = 0.0007), Fisher group ≤3 (OR = 4.64, 95% CI = 1.00-21.45, p = 0.049), HH grade ≤2 (OR = 4.31, 95% CI = 1.27-14.59, p = 0.019), no hydrocephalus (OR = 8.55, 95% CI = 1.72-19.23, p = 0.0046), and cilostazol use (OR = 5.52, 95% CI = 1.61-18.90, p = 0.0065) were independent predictors of good outcomes (mRS score ≤2). CONCLUSION: Cilostazol may improve outcomes after SAH, but further double-blind, placebo-controlled studies are required for a definitive conclusion.

Gamma Knife surgery for primary central nervous system lymphoma: usefulness as palliative local tumor control.

OBJECT: Although there is no established treatment for primary central nervous system lymphoma (PCNSL), therapeutic protocols involving high-dose methotrexate therapy followed, in some cases, by whole-brain radiotherapy (WBRT) have generally been adopted, and they have yielded relatively favorable results. Gamma Knife surgery (GKS) is a stopgap measure to treat patients with PCNSL. The authors summarize the results of their cases and evaluate the efficacy and usefulness of GKS. METHODS: Between June 1999, and June 2005, 22 patients suffering from PCNSL were treated with GKS at the authors' institution and were followed up for more than 6 months. Some combination of chemotherapy and/or WBRT and/or microsurgery had been performed in 18 of the 22 patients before GKS. The remaining four patients had not undergone any previous treatment. In these patients, the mean tumor volume was 4.14 cm3, and the tumors were treated with a mean margin dose of 16.5 Gy to the 52.8% isodose line. Magnetic resonance imaging demonstrated the disappearance of the GKS-treated lesions; however, new lesions were observed in other regions of the brain in 10 patients and repeated GKS was performed in some cases. No local recurrences were observed an average of 19.4 months after GKS, and good level of quality of life (QOL) was maintained during this period. CONCLUSIONS: Gamma Knife surgery should be performed only for local tumor control as a stopgap measure in the treatment of PCNSL. It is noninvasive and safe, and its effects occur rapidly. Its use improves prognosis and enhances the patient's quality of life. Gamma Knife surgery should be considered one of the treatment strategies for patients with PCNSLs.

Postoperative adjuvant treatment for pineal parenchymal tumour of intermediate differentiation.

Pineal parenchymal tumour of intermediate differentiation (PPTID) in adults is rare and a treatment strategy for this condition has not yet been established. We present a case of an elderly patient treated with postoperative adjuvant therapy using radio- and chemotherapy. This 60-year-old man presented with a 3-month history of memory disturbance, gait instability and double vision. Computed tomography and magnetic resonance imaging demonstrated a mass in the pineal region that suggested a malignant tumour. Partial removal of the tumour was undertaken via the right occipital transtentorial approach. The histological diagnosis was PPTID. Postoperative radio- and chemotherapy were administered, with a good response. Little is known about the clinical behaviour of PPTID in adults. Our treatment plan indicates one effective option for the management of such tumours.

Tolerance dose in gamma knife surgery of lesions extending to the anterior visual pathway.

OBJECT: The authors performed a retrospective analysis of the radiation dose to the anterior visual pathway (AVP) to assess its tolerance to gamma knife surgery. METHODS: They examined five cases followed for more than 3 years. The AVP was treated with 10-Gy doses or higher. The mean maximum delivered dose to the AVP was 14 Gy. Ten gray or more was delivered to 25.5% of the ipsilateral AVP, 12 Gy or more to 12.5% of the ipsilateral AVP, and 14 Gy or more to 5.7% of the ipsilateral AVP. Although the mean follow-up period was 40.8 months (36-51 months), no cases of visual function deterioration developed. CONCLUSIONS: The tolerance dose of the AVP is considered to be less than 8 to 10 Gy; however, although the delivered dose to the AVP definitely exceeded the tolerance dose in all five cases, no visual disturbance has been identified. Longer follow up is required before any final conclusions may be drawn. Nonetheless, it is suggested that a visual disturbance may be avoided by using careful accurate dose planning even if the dose delivered to the AVP is higher than currently believed to be acceptable.

Anatomic features predictive of complete aneurysm occlusion can be determined with three-dimensional digital subtraction angiography.

BACKGROUND AND PURPOSE: Complete occlusion of intracranial aneurysms is the goal of endovascular treatment and is influenced by several aneurysm-related anatomic factors. The anatomic features of aneurysms can be characterized by three-dimensional reconstructed images by use of rotational digital subtraction angiography (3D-DSA). The purpose of this study was to determine the anatomic factors that could help predict complete endosaccular packing of cerebral aneurysms by use of 3D-DSA and to design a simple scoring system to predict the difficulty of achieving complete occlusion of the aneurysm. METHODS: Forty-seven patients with 47 intracranial berry (<12 mm) aneurysms underwent 3D-DSA. Aneurysms were subsequently treated by endosaccular packing with coils. The following aneurysm-related anatomic parameters were measured on 3D-DSA images: largest diameter, neck size, dome-to-neck ratio, shape, and relationship to the neighboring artery. The relationship between each parameter and the rate of successful treatment was determined, and a score used to rate difficulty of attaining occlusion (ie, difficulty score) was developed on the basis of the identified predictors of successful treatment. Subsequently, we assessed the correlation between the score and the rate of successful occlusion. RESULTS: Four anatomic parameters correlated significantly with the rate of successful occlusion: neck size (P =.014), shape (P=.042), dome-to-neck ratio (P <.01), and relationship to neighboring artery (P=.025). The difficulty score based on two parameters (dome-to-neck ratio and relationship to neighboring artery) significantly correlated with the occlusion rate (r = 0.63, P <.01). CONCLUSION: In this population, the difficulty score based on 3D-DSA findings provides useful information for prediction of successful endovascular treatment for intracranial aneurysms.

3.3F catheter/sheath system for use in diagnostic neuroangiography.

BACKGROUND AND PURPOSE: Although neuroangiography remains the criterion standard standard for the detection of and surgical/interventional planning for cerebrovascular diseases, it usually requires that patients be confined to bed rest for several hours after angiography to prevent local complications. Decreasing catheter size has reduced the risk of hemorrhagic complications associated with early ambulation after angiography. For this study, we prospectively evaluated the clinical feasibility of a 3.3F catheter/sheath system for selective neuroangiography. METHODS: One hundred seventeen consecutive patients (49 men, 68 women; age range, 18-83 years; mean age, 56.9 years) underwent selective neuroangiography using 3.3F catheters. The exclusion criteria for this study included a subsequent surgical/neurointerventional procedure performed within 18 hours and necessity of arch aortography, which is routinely performed for the first examination of patients with ischemic cerebrovascular diseases. The procedure was evaluated prospectively in terms of success rate, compression time of the arterial puncture site, and periprocedural complications. RESULTS: Selective catheterization of the intended arteries was performed in 99% of the carotid arteries and 97.4% of the vertebral arteries. No neurologic complications or local hemorrhagic complications were observed. Manual compression time after the procedure ranged from 3 to 7 minutes (mean, 3.7 minutes), and patient bed rest after the procedure ranged from 2 to 3 hours (mean, 2.04 hours). CONCLUSION: Selective neuroangiography with a 3.3F catheter/sheath system is feasible and enables early ambulation in selected patients.

Detection of the residual lumen of intracranial aneurysms immediately after coil embolization by three-dimensional digital subtraction angiographic virtual endoscopic imaging.

OBJECTIVE: Detection of a small residual lumen after coil embolization is often difficult because of the coil mass and the overlap of the cerebral arteries. The purpose of this study was to assess the usefulness of virtual endoscopic (VE) analysis of three-dimensional digital subtraction angiographic (DSA) images for evaluation of aneurysmal occlusion immediately after the procedure. METHODS: Twenty-seven intracranial aneurysms were treated with coil embolization using a three-dimensional DSA system. Biplane and rotational DSA scanning was performed before and immediately after the procedures. VE images were obtained at a separate workstation, after transfer of the rotational images. Two-dimensional (2D) DSA images and VE images obtained after the procedure were assessed with respect to aneurysmal occlusion. Morphological outcomes and other factors, including location, size, volumetric ratio (coil volume/aneurysm volume), and residual sites, were also evaluated. RESULTS: Seven aneurysms were evaluated as complete occlusion (CO) on both 2D DSA images and VE images. Twelve aneurysms exhibited residual lumina on both 2D DSA images and VE images. Five aneurysms were evaluated as CO on 2D DSA images and as incomplete occlusion on VE images. There were no recurrences among the aneurysms that were evaluated as CO on VE images. Two of five aneurysms that were evaluated as CO on 2D DSA images and as incomplete occlusion on VE images demonstrated regrowth in follow-up examinations. Residual sites and volumetric ratios were correlated with aneurysmal regrowth. CONCLUSION: VE imaging can demonstrate a residual lumen more frequently than can 2D DSA imaging and is useful for evaluating aneurysmal occlusion after coil embolization.