Mask-based immobilization in Gamma Knife stereotactic radiosurgery.

The Gamma Knife Icon (Elekta AB, Stockholm) is a cobalt-based stereotactic radiosurgery (SRS) unit to support the use of a thermoplastic mask in lieu of a rigid frame, using an onboard cone-beam CT (CBCT) and an intrafraction motion management system (IFMM). We retrospectively reviewed 124 patients treated with Gamma Knife SRS from January 2018 to December 2019 at our institution using a mask-based immobilization system. Patient and treatment characteristics were collected and summarized as well as interfraction shifts and treatment-related outcomes. This dataset includes 124 patients with an associated 358 intracranial tumors. Twenty-four patients presented with primary brain tumors, which included 14 meningiomas and 10 other histologies, with 100 patients having brain metastases. Sixty tumors were post-operative, while 298 were intact. The median dose for primary tumors was 25 Gy in 5 fractions. Median doses to metastases were 20 Gy in 1 fraction, 27 Gy in 3 fractions, and 25 Gy in 5 fractions. Median interfraction CBCT shifts were submillimeter. Median patient follow-up was 6.28 months. 91% of patients with metastases maintained local control. Our early clinical experience has demonstrated limited toxicity profiles and high patient tolerance, which suggests that mask-based Gamma Knife SRS provides a safe alternative option for frameless SRS. Patients with large target volumes where fractionation is preferred or with small target volumes in non-eloquent areas can be considered for this approach. Response rates are encouraging, and continued follow-up is necessary to investigate long-term control and survival.

In NPH, setting valve opening pressure close to lumbar puncture opening pressure decreases overdrainage.

BACKGROUND: The management of normal pressure hydrocephalus (NPH) can be difficult, partly because there are frequent treatment complications such as overdrainage which, when serious, may require surgical intervention. We previously reported a correlation between the difference of lumbar puncture opening pressure minus the valve opening pressure setting (LPOP-VOP) (which we refer to as the delta) and increased rates of overdrainage. This led to a modification in our practice, whereby we now set the VOP equal to, or close to, the LPOP, resulting in lower deltas. OBJECTIVE: In this new study, our aim was to compare the rate of overdrainage in our patients with higher and lower deltas and assess the significance of setting the VOP equal, or close, to the patient's LPOP. METHODS: 1. We reproduced the association between delta and overdrainage. 2. We compared the incidence of overdrainage in those whose VOP was set close to LPOP (low delta) versus those with VOP setting distant from the LPOP (higher delta). 3. We compared symptom improvement in those with a low versus higher delta. RESULTS: We confirmed the relation between high delta and an increased rate of overdrainage, lower rates of overdrainage in those whose VOP was set close to the LPOP (Delta Adjusted Practice), and better improvement of symptoms when the VOP was set closer to the LPOP. CONCLUSION: We propose that the initial VOP should be set as close as possible to the patient's LPOP to decrease overdrainage without compromising symptom improvement.

Assessment of unintended shifts during frame-based stereotactic radiosurgery using cone beam computed tomography image guidance.

PURPOSE: To investigate the frequency, magnitude and possible causes of frame-shifts that may occur between treatment planning and treatment delivery when performing Gamma Knife radiosurgery with rigid frame-based immobilization. METHODS: Differences between computed tomography (CT) framed fiducial stereotactic coordinate reference and cone beam computed tomography stereotactic coordinates after image registration were recorded for 49 frame-based GK radiosurgery cases performed using the Gamma Knife Icon. Parameters recorded include rotational shifts, translational shifts, and the GK-computed Maximum Shot Displacement (MSD) between the two stereotactic coordinate spaces. Other patient-specific parameters were collected and linear regression analysis was performed to evaluate predictors of increased displacement. RESULTS: The median values of rotational shifts were: pitch 0.14°, yaw 0.17°, and roll 0.13°. The median absolute values of translational shifts were: left-right 0.39 mm, anteroposterior 0.14 mm, and superior-inferior 0. 22 mm. The median value of MSD was 0.71 mm. Twelve cases (24.5%) had a MSD of greater than 1.0 mm. Male gender was associated with increased MSD (p = 0.013) and translational shifts (root-mean-squared value, p = 0.017). Cases with large differences between right and left sided pin lengths were also associated with increased MSD (p = 0.011). CONCLUSIONS: The use of CBCT image guidance in frame-based GK radiosurgery allows unintended frame shifts to be identified and corrected. A significant fraction (24.5%) of patients had large enough shifts to result in a MSD of greater than 1.0 mm. Male gender and eccentrically placed frames were associated with increased MSD, and particular care should be taken in these cases.

Results of surgical resection of carotid body tumors: A twenty-year experience.

This study examines whether surgical resection of carotid body tumors (CBTs) is acceptable in light of potential significant neurologic complications. This IRB-approved retrospective study analyzed data from 24 patients undergoing surgical treatment for CBTs between April 1998 and April 2017 at Mayo Clinic (Florida campus only). For patients who underwent multiple CBT resections, only data from the first surgery was used in this analysis. CBT resection occurred in 24 patients with the following demographics: fourteen patients (58.3%) were female, median age was 56.5 years, median BMI was 29. A prior history of neoplasm was found in ten patients (41.7%). A known family history of paraganglioma was present in five patients (20.8%). Two patients were positive for succinate dehydrogenase mutation (8.3%). Multiple paragangliomas were present in seven patients (29.2%). There was nerve sacrifice in three patients (12.5%) during resection. Carotid artery reconstruction and patch angioplasty occurred in one patient (4.2%). Complete resection occurred in 24 patients (100.0%). Postoperatively, one patient (4.2%) suffered stroke. No mortalities occurred within or beyond 30 days of surgery. Persistent cranial nerve injury occurred in two patients (8.3%) with vocal cord paralysis. There was no recurrence of CBT through last follow-up. Five patients (20.8%) were diagnosed with other neoplasms after resection, including basal cell carcinoma, contralateral carotid body tumor, glomus vagale, and glomus jugulare. There was 100% survival at 1 year in patients followed for that time (n = 17). Surgical treatment remains the first-line curative treatment to relieve symptoms and ensure non-recurrence. While acceptable, neurologic complications are significant and therefore detailed preoperative informed consent is mandatory.

Endocrine and Visual Outcomes Following Gross Total Resection and Subtotal Resection of Adult Craniopharyngioma: Systematic Review and Meta-Analysis.

OBJECTIVE: The optimal surgical strategy for management of adult patients with craniopharyngioma remains controversial. To analyze the functional outcomes ofadult patients with gross total resection (GTR) and subtotal resection (STR) of craniopharyngioma. METHODS: MEDLINE, EMBASE, Scopus, and Cochrane databases were searched from inception to July 19, 2018, for articles comparing postoperative endocrine function, vision, complications, and recurrence rates for adult patients with GTR and STR of craniopharyngioma. The articles were analyzed by meta-analysis of proportions using a random-effects model to calculate summary odds ratios (ORs). RESULTS: The initial search resulted in 2468 studies and 540 studies selected for full text review. Seventeen studies were included in the final analyses with 748 patients in the GTR cohort and 559 patients in the STR cohort. GTR resulted in a significantly lower likelihood of recurrence when compared with STR (OR, 0.106; 95% confidence interval [CI], 0.067-0.168; P < 0.001), but a significantly greater likelihood of panhypopituitarism (OR, 2.063; 95% CI, 1.058-4.024; P = 0.034) and permanent diabetes insipidus (OR, 2.776; 95% CI, 1.321-5.832; P = 0.007). There was no significant difference between the groups for postoperative worsened vision (P = 0.868), improved vision (P = 0.876), pathologic weight gain (P = 0.724), cerebrospinal fluid leak (P = 0.788), complications (P = 0.656), or death (P = 0.261). CONCLUSIONS: This is the first systematic review of functional outcomes of adult patients with craniopharyngioma. GTR results in decreased likelihood of recurrence, but increased likelihood of postoperative panhypopituitarsm and permanent diabetes insipidus. Surgeons should be aware of these associations when determining the optimal operative strategy for adult patients with craniopharyngioma.

Primary histiocytic sarcoma of the central nervous system: a case report with platelet derived growth factor receptor mutation and PD-L1/PD-L2 expression and literature review.

BACKGROUND: Histiocytic sarcoma (HS) is an aggressive malignant neoplasm. HS in the central nervous system is exceptionally rare and associated with a poor prognosis. This report documents a case of primary HS of the central nervous system with treatment including surgery, radiotherapy, and chemotherapy. CASE PRESENTATION: Our patient was a 47 year old female presenting with progressive ataxia, headaches, imbalance, nausea, vomiting, and diplopia. MRI showed a heterogeneously enhancing lesion approximately 2.9 × 3.0 × 2.3 cm centered upon the cerebellar vermis with mild surrounding vasogenic edema and abnormal enhancement of multiple cranial nerves. The patient underwent surgical debulking, which revealed histiocytic sarcoma with grossly purulent drainage. Staging revealed diffuse leptomeningeal involvement, primarily involving the brain and lower thoracic and lumbar spine. She underwent adjuvant radiotherapy to the brain and lower spine and was started on high dose methotrexate. However, she experienced progressive disease in the cervical and thoracic spine as well as pulmonary involvement. Genomic sequencing of her tumor showed a mutation in the platelet-derived growth factor receptor A (p.V0681) which could be targeted with Dasatinib. However, she did not tolerate Dasatinib and she succumbed to progressive disseminated disease eight months from original diagnosis. Our pathologic evaluation also revealed expression of PD-L1 and PD-L2 by tumor cells raising the potential therapeutic role for immune checkpoint inhibition. CONCLUSIONS: This case provides an example of effective CNS control with resection and moderate doses of radiation therapy. A review of the literature confirms aggressive multidisciplinary treatment is the most effective treatment against this disease. In addition, genomic sequencing may play an important role in determining new therapeutic options. However, CNS histiocytic sarcoma remains an aggressive disease with a propensity for early widespread dissemination and few long term survivors.

Surgical treatment of bilateral glossopharyngeal neuralgia.

Glossopharyngeal neuralgia (GPN) is a condition characterised by sudden, severe pain in the distribution of the glossopharyngeal nerve. It can be triggered by talking, yawning, coughing and swallowing. Classically, patients experience a unilateral lancinating and excruciating pain described as electrical shock-like pain in the areas around the ear, tongue, or the mandibular angle. Uncommon manifestations include cardiac arrhythmias and syncope during pain episodes. Surgery is indicated in refractory cases. Bilateral GPN is rare, and definitive surgical treatment for bilateral GPN has not yet been reported. In this case report, a young woman with bilateral GPN who underwent staged surgery bilaterally is described. She did not develop life-threatening cardiac abnormalities postoperatively.

Results of Percutaneous Balloon Compression in Trigeminal Pain Syndromes.

OBJECTIVE: To investigate initial pain relief and subsequent recurrence after percutaneous balloon compression (PBC) and describe its association with the nature of trigeminal pain, previous procedures, or other clinical factors. METHODS: A total of 222 patients with medically refractory trigeminal pain treated with PBC at Mayo Clinic Florida between 1998 and 2017 were enrolled into this study. Patients were divided into those with typical trigeminal neuralgia (TN) and those with atypical trigeminal pain. The postprocedural rate of pain recurrence and associations between patient characteristics and recurrence were studied. RESULTS: One hundred fifty-two patients had TN and 70 patients had atypical pain. At the last follow-up, 158 patients had excellent pain relief, 37 had good pain relief, 11 had fair pain relief, and 16 had poor pain relief. The median duration of follow-up was 31.1 months. Patients with atypical pain were less likely to have an excellent result compared with patients with typical pain (61.4% vs. 82.9%; P < 0.001). Recurrence was observed in 103 patients (46.4%) and was associated with previous procedures (hazard ratio, 1.658; 95% confidence interval, 1.09-2.49; P = 0.017). Other clinical factors were not significant. CONCLUSIONS: Our study demonstrates the safety and efficacy of PBC, with 88% of patients pain-free at last follow-up. Patients with atypical pain have worse outcomes, and patients with previous procedures have a higher risk of recurrence. Repeat surgery does not decrease efficacy. We recommend conservative parameter selection at the initial procedure.

Ectopic Prolactinoma Presenting as Bacterial Meningitis: A Diagnostic Conundrum.

BACKGROUND: Prolactinomas may rarely present with meningitis and cerebrospinal fluid (CSF) rhinorrhea secondary to erosion of the wall of the sella turcica. It is even more uncommon for this abnormal communication to be caused by an ectopic prolactinoma arising from the sphenoid sinus and eroding into the sella. This atypical growth pattern makes diagnosis very difficult because there may be no displacement of the normal pituitary gland. The first reported case of a patient with an ectopic prolactinoma originating within the sphenoid sinus presenting primarily with meningitis is presented, and the management strategy and surgical and nonsurgical treatment options are discussed. CASE DESCRIPTION: A 48-year-old woman presented with confusion, low-pressure headache, and fever. A lumbar puncture revealed Streptococcus pneumoniae meningitis, and she was placed on intravenous penicillin G. After initiation of antibiotics, she noticed salty tasting postnasal fluid leakage. Imaging was remarkable for bony erosion of the sphenoid sinus wall by a soft tissue mass growing from within the sinus, with no disruption of the normal pituitary gland. A biopsy was then performed with an endoscopic transnasal transsphenoidal approach, and the CSF leak was repaired with a pedicled nasoseptal flap. The final pathology was prolactinoma, and she was placed on cabergoline. CONCLUSIONS: Ectopic prolactinomas may rarely present as meningitis secondary to retrograde transmission of bacteria through a bony defect in the sphenoid sinus, and must be included in the differential diagnosis of any sphenoid sinus mass. Management should first address the infection, followed by surgical repair of the bony defect.

Infection or Glioma? The False Dilemma of Primary Central Nervous System Histiocytic Sarcoma.

BACKGROUND: Primary central nervous system (CNS) histiocytic sarcoma is an extremely rare lymphoproliferative disorder that affects the CNS and behaves aggressively. Only 27 cases of primary CNS histiocytic sarcoma have been reported. The paucity of literature on this entity has made diagnosis and treatment difficult both for the surgeon and the pathologist. CASE DESCRIPTION: In this case of primary CNS histiocytic sarcoma, a middle-aged woman presented from an outside institution with a supposed cerebellar abscess. Intraoperative frozen pathology was initially interpreted as high-grade glioma; however, final pathology demonstrated histiocytic sarcoma. CONCLUSIONS: This report makes a significant contribution to the literature on this rare malignant disease by outlining a similar presentation among several cases and providing a thorough overview of existing criteria for diagnosis and management.

Stem cell therapy and its potential role in pituitary disorders.

PURPOSE OF REVIEW: The pituitary gland is one of the key components of the endocrine system. Congenital or acquired alterations can mediate destruction of cells in the gland leading to hormonal dysfunction. Even though pharmacological treatment for pituitary disorders is available, exogenous hormone replacement is neither curative nor sustainable. Thus, alternative therapies to optimize management and improve quality of life are desired. RECENT FINDINGS: An alternative modality to re-establish pituitary function is to promote endocrine cell regeneration through stem cells that can be obtained from the pituitary parenchyma or pluripotent cells. Stem cell therapy has been successfully applied to a plethora of other disorders, and is a promising alternative to hormonal supplementation for resumption of normal hormone homeostasis. SUMMARY: In this review, we describe the common causes for pituitary deficiencies and the advances in cellular therapy to restore the physiological pituitary function.

Technical feasibility and safety of image-guided parieto-occipital ventricular catheter placement with the assistance of a wearable head-up display.

BACKGROUND: Wearable technology is growing in popularity as a result of its ability to interface with normal human movement and function. METHODS: Using proprietary hardware and software, neuronavigation images were captured and transferred wirelessly via a password-encrypted network to the head-up display. The operating surgeon wore a loupe-mounted wearable head-up display during image-guided parieto-occipital ventriculoperitoneal shunt placement in two patients. RESULTS: The shunt placement was completed successfully without complications. The tip of the catheter ended well within the ventricles away from the ventricular wall. The wearable device allowed for continuous monitoring of neuronavigation images in the right upper corner of the surgeon's visual field without the need for the surgeon to turn his head to view the monitors. CONCLUSIONS: The adaptable nature of this proposed system permits the display of video data to the operating surgeon without diverting attention away from the operative task. This technology has the potential to enhance image-guided procedures.

Spinocerebellar ataxia 15: A phenotypic review and expansion.

Spinocerebellar ataxia 15 (SCA15) is a clinically heterogeneous movement disorder characterized by the adult onset of slowly progressive cerebellar ataxia. ITPR1 is the SCA15 causative gene. However, despite numerous reports of genetically-confirmed SCA15, phenotypic uncertainty persists. We reviewed the phenotypes of 60 patients for whom SCA15 was confirmed by the presence of a genetic deletion involving ITPR1. The most prevalent symptoms were gait ataxia (88.3%), dysarthria (75.0%), nystagmus (73.3%), and limb ataxia (71.7%). We also present a novel SCA15 phenotype in a woman with an ITPR1 variant found to have hydrocephalus that improved with ventriculoperitoneal shunting. This is the first reported case of hydrocephalus associated with SCA15. In this review, we analyzed previously reported SCA15 phenotypes and present a novel SCA15 phenotype. We also address important considerations for evaluating patients with complex hereditary movement disorders.

Laryngeal Mask Airway and Valsalva Maneuver During Ophthalmic Surgery: A Case Report.

The use of a supraglottic airway, also called laryngeal mask airway (LMA), is gaining in popularity for delivery of general anesthesia in certain situations and is shown to be safe. Use of infraglottic airways (tracheal tubes) allows for positive pressure ventilation and maneuvers, such as holding continuous positive pressure in the airway to check for pleural and dural leaks. We describe the successful use of the LMA (Teleflex Inc) for general anesthesia, in which continuous positive airway pressure of 15 cm H2O held for 20 seconds allowed the neurosurgeon to identify the site of a cerebrospinal fluid (CSF) leak and successfully repair the leak. A well-seated LMA can be successfully used to produce continuous positive pressure in the airway not exceeding 20 cm H2O for 20 seconds to facilitate surgical identification of CSF leaks.

Migration to the ICD-10 coding system: A primer for spine surgeons (Part 1).

BACKGROUND: On 1 October 2015, a new federally mandated system goes into effect requiring the replacement of the International Classification of Disease-version 9-Clinical Modification (ICD-9-CM) with ICD-10-CM. These codes are required to be used for reimbursement and to substantiate medical necessity. ICD-10 is composite with as many as 141,000 codes, an increase of 712% when compared to ICD-9. METHODS: Execution of the ICD-10 system will require significant changes in the clinical administrative and hospital-based practices. Through the transition, diminished productivity and practice revenue can be anticipated, the impacts of which the spine surgeon can minimizeby appropriate education and planning. RESULTS: The advantages of the new system include increased clarity and more accurate definitions reflecting patient condition, information relevant to ambulatory and managed care encounters, expanded injury codes, laterality, specificity, precise data for safety and compliance reporting, data mining for research, and finally, enabling pay-for-performance programs. The disadvantages include the cost per physician, training administrative staff, revenue loss during the learning curve, confusion, the need to upgrade hardware along with software, and overall expense to the healthcare system. CONCLUSIONS: With the deadline rapidly approaching, gaps in implementation result in delayed billing, delayed or diminished reimbursements, and absence of quality and outcomes data. It is thereby essential for spine surgeons to understand their role in transitioning to this new environment. Part I of this article discusses the background, coding changes, and costs as well as reviews the salient features of ICD-10 in spine surgery.

Implementation and impact of ICD-10 (Part II).

BACKGROUND: The transition from the International Classification of Disease-9(th) clinical modification to the new ICD-10 was all set to occur on 1 October 2015. The American Medical Association has previously been successful in delaying the transition by over 10 years and has been able to further postpone its introduction to 2015. The new system will overcome many of the limitations present in the older version, thus paving the way to more accurate capture of clinical information. METHODS: The benefits of the new ICD-10 system include improved quality of care, potential cost savings, reduction of unpaid claims, and improved tracking of healthcare data. The areas where challenges will be evident include planning and implementation, the cost to transition, a shortage of qualified coders, training and education of the healthcare workforce, and a loss of productivity when this occurs. The impacts include substantial costs to the healthcare system, but the projected long-term savings and benefits will be significant. Improved fraud detection, accurate data entry, ability to analyze cost benefits with procedures, and enhanced quality outcome measures are the most significant beneficial factors with this change. RESULTS: The present Current Procedural Terminology and Healthcare Common Procedure Coding System code sets will be used for reporting ambulatory procedures in the same manner as they have been. ICD-10-PCS will replace ICD-9 procedure codes for inpatient hospital services. The ICD-10-CM will replace the clinical code sets. Our article will focus on the challenges to execution of an ICD change and strategies to minimize risk while transitioning to the new system. CONCLUSION: With the implementation deadline gradually approaching, spine surgery practices that include multidisciplinary health specialists have to anticipate and prepare for the ICD change in order to mitigate risk. Education and communication is the key to this process in spine practices.

Radiographic fusion rate after implantation of facet bone dowels.

BACKGROUND CONTEXT: Achieving a posterolateral fusion in conjunction with performing decompressive laminectomies can prevent recurrence of stenosis or worsening of spondylolisthesis. Facet bone dowels have been introduced and marketed as a less invasive alternative to pedicle screws. Surgeons have been placing them during lumbar laminectomy surgery and coding for intervertebral biomechanical device and posterolateral fusion. These bone dowels have also been placed percutaneously in outpatient surgery centers and pain clinics for facet-mediated back pain. PURPOSE: To describe fusion outcomes in patients who underwent facet bone dowel placement. STUDY DESIGN/SETTING: Retrospective analysis of a single center's experience. PATIENT SAMPLE: Ninety-six patients comprise the entire cohort of patients who underwent facet bone dowel implantation at our institution with adequate postoperative imaging to determine fusion status. OUTCOME MEASURES: Fusion rates as determined on postoperative computed tomography (CT) scans and dynamic lumbar X-rays if CT is not available. METHODS: Threaded facet bone dowels in this study were placed according to the manufacturer's recommended methods. The bone dowels were placed after open exploration of the facet complex or percutaneously through a tubular retractor on the contralateral side from a microdiscectomy or synovial cyst resection. The most recent available postoperative imaging was reviewed to determine fusion status. RESULTS: Of 96 patients in our series, 6 (6.3%) had a fusion seen on CT and 4 did not exhibit any movement on dynamic lumbar X-rays for a total fusion rate of 10.4% (10/96). Eighty-six (89.6%) patients were shown on imaging to not have a solid fusion either by visualizing a patent facet joint on CT or measurable movement between the flexion and the extension lumbar X-rays. CONCLUSIONS: This article is mainly intended to question whether the implantation of facet bone dowels can produce a solid fusion radiographically. In our experience, the placement of facet bone dowels does not equal the time, skill, or attention to detail that is necessary for a posterolateral lumbar arthrodesis, and our follow-up radiographic studies clearly demonstrate an inadequate fusion rate.

Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure.

OBJECT: Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable-shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP). METHODS: The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory. RESULTS: Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs. 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs. 27.0, respectively; p = 0.005). CONCLUSIONS: Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.

Primary central nervous system B cell lymphoma with features intermediate between diffuse large B cell lymphoma and Burkitt lymphoma.

B cell lymphoma with features intermediate between diffuse large B cell lymphoma and Burkitt lymphoma (DLBCL/BL) is a new lymphoma entity which is recognized in the current World Health Organization (WHO) classification (2008). We report a case of a primary central nervous system lymphoma (PCNSL) with findings consistent with DLBCL/BL. It is characterized by a very aggressive clinical course, and a widespread multifocal involvement of the CNS. Our case shows that a DLBCL/BL can manifest in the CNS alone without any systemic involvement.

Correlation of clinical findings and results of percutaneous balloon compression for patients with trigeminal neuralgia.

OBJECTIVE: To investigate pain relief and recurrence after percutaneous balloon compression (PBC) and its association with type of pain, prior surgery, or other clinical factors. METHODS: Fifty-nine patients with medically refractory trigeminal pain were enrolled into this study. Patients were divided into those with typical trigeminal neuralgia (TN), and those with other types of trigeminal pain or "atypical pain." The post-surgical rate of recurrence was estimated by the Kaplan-Meier method. Cox-proportional hazards models were used to investigate associations between patient characteristics and recurrence of pain. RESULTS: Forty-two patients had TN, 17 patients had atypical pain. At last follow-up, 40 patients had excellent, 9 good, 7 fair and 3 poor pain relief. Recurrence was observed in 35 patients, and was associated with pain type (relative risk (RR)=2.38, 95% confidence interval (CI): 1.22-4.63, P=0.011) and pain duration before PBC (RR=1.33, 95% CI: 1.02-1.72, P=0.033). Other clinical factors were not significant. Two patients had transient paresis of the sixth cranial nerve, however, there were no permanent post-surgical complications. CONCLUSIONS: Our study demonstrates the safety and efficacy of PBC with 83% of patients being pain free at last follow-up. Patients with atypical pain and longer pre-surgical symptom duration appear to have a higher risk of recurrence. Repeat surgery is just as effective as initial surgery, justification for being conservative in parameter selection at the initial procedure to minimize complications.