Assessment of Radiation Dosage to the Hippocampi during Treatment of Multiple Brain Metastases Using Gamma Knife Therapy.

Background and Objectives: Brain metastases (BMs) pose significant clinical challenges in systemic cancer patients. They often cause symptoms related to brain compression and are typically managed with multimodal therapies, such as surgery, chemotherapy, whole brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS). With modern oncology treatments prolonging survival, concerns about the neurocognitive side effects of BM treatments are growing. WBRT, though widely used for multiple BMs, has recognized neurocognitive toxicity. SRS, particularly Gamma Knife (GK) therapy, offers a minimally invasive alternative with fewer side effects, suitable for patients with a quantifiable number of metastases and better prognoses. Materials and Methods: A retrospective analysis was conducted on 94 patients with multiple BMs treated exclusively with GK at an academic medical center. Patients with prior WBRT were excluded. This study focused on the mean radiation dose received by the hippocampal area, estimated according to the 'Hippocampal Contouring: A Contouring Atlas for RTOG 0933' guidelines. Results: The precision of GK equipment results in mean doses of radiation that are lower than those suggested by RTOG 0933 and observed in other studies. This precision may help mitigate cognitive dysfunction and other side effects of hippocampal irradiation. Conclusions: GK therapy facilitates the administration of smaller, safer radiation doses to the hippocampi, which is advantageous even for lesions in the temporal lobe. It is feasible to treat multiple metastases, including cases with more than 10, but it is typically reserved for patients with fewer metastases, with an average of 3 in this study. This underlines GK's potential for reducing adverse effects while managing BMs effectively.

Analysis of Serum Markers of Perioperative Brain Injury and Inflammation Associated with Endovascular Treatment of Intracranial Aneurysms: A Preliminary Study.

Embolization is the preferred method for treating intracranial aneurysms due to its less invasive nature. However, recent findings suggest that even uncomplicated embolization may cause structural damage to the brain through ischemic or inflammatory mechanisms. This study aimed to find possible biomarkers of brain injury and inflammation in patients suffering from intracranial aneurysms who underwent endovascular treatment by measuring serological markers indicating brain damage. The study involved 26 patients who underwent uncomplicated intravascular stenting for unruptured intracranial aneurysms between January 2020 and December 2021. Blood samples were collected before the procedure, at 6-12 h, and at 24 h after the procedure. The following protein biomarkers levels were tested with ELISA: S100B, hNSE, TNF, hsCRP, FABP7, NFL, and GP39. Statistical analysis of the results revealed significant increases in serum levels for the four biomarkers: FABP7-before 0.25 (ng/mL) vs. 6-12 h 0.26 (p = 0.012) and vs. 24 h 0.27 (p < 0.001); GP39-before 0.03 (pg/mL) vs. 6-12 h 0.64 (p = 0.011) and vs. 24 h 0.57 (p = 0.001); hsCRP-before 1.65 (µg/mL) vs. 24 h 4.17 (p = 0.037); NFL-before 0.01 (pg/mL) vs. 6-12 h 3.99 (p = 0.004) and vs. 24 h 1.86 (p = 0.033). These biomarkers are recognized as potential indicators of neurovascular damage and should be monitored in clinical settings. Consequently, serum levels of NFL, GP39, hsCRP, and FABP7 measured before and 24 h after endovascular procedures can serve as important markers for assessing brain damage and indicate avenues for further research on biomarkers of neurovascular injury.

External validation of the Chicago Chiari Outcome Scale in adults with Chiari malformation type I.

OBJECTIVE: The Chicago Chiari Outcome Scale (CCOS) serves as a standardized clinical outcome evaluation tool among patients with Chiari malformation type I (CM-I). While the reliability of this scale has been proven for pediatric patients, the literature lacks CCOS validation when used solely in adults. Therefore, this study aimed to determine the validity of the CCOS in an external cohort of adult patients. METHODS: The authors retrospectively analyzed the medical records of symptomatic patients with CM-I who underwent posterior fossa decompression between 2010 and 2018 in six neurosurgical departments. Each patient was clinically assessed at the latest available follow-up. Gestalt outcome was determined as improved, unchanged, or worsened compared with the preoperative clinical state. Additionally, the CCOS score was calculated for each patient based on the detailed clinical data. To verify the ability of the CCOS to determine clinical improvement, the area under the receiver operating characteristic (AUROC) curve was evaluated. A logistic regression analysis using all four components of the CCOS (pain symptoms, nonpain symptoms, functionality, and complications) was performed to establish predictors of the improved outcome. RESULTS: Seventy-five individuals with a mean age of 42 ± 15.32 years were included in the study. The mean follow-up duration was 52 ± 33.83 months. Considering gestalt outcome evaluation, 41 patients (54.7%) were classified as improved, 24 (32%) as unchanged, and 10 (13.3%) as worsened. All patients with a CCOS score of 14 or higher improved, while all those with a CCOS score of 8 or lower worsened. The AUROC was 0.986, suggesting almost perfect accuracy of the CCOS in delineating clinical improvement. A CCOS score of 13 showed high sensitivity (0.93) and specificity (0.97) for identifying patients with clinical improvement. Additionally, a meaningful correlation was found between higher CCOS scores in each component and better outcomes. Patient stratification by total CCOS score showed that those categorized as improved, unchanged, and worsened scored prevalently between 13 and 16 points, 10 and 12 points, and 4 and 9 points, respectively. CONCLUSIONS: In this adult cohort, the CCOS was found to be almost perfectly accurate in reflecting postoperative clinical improvement. Moreover, all four CCOS components (pain symptoms, nonpain symptoms, functionality, and complications) significantly correlated with patient clinical outcomes.

External validation of the Ruptured Arteriovenous Malformation Grading Scale (RAGS) in a multicenter adult cohort.

PURPOSE: While Ruptured Arteriovenous Malformation Grading Scale (RAGS) has recently been validated in children, the literature lacks validation on adults exclusively. Therefore, we aimed to determine the validity of RAGS on the external multicenter adult cohort and compare its accuracy with other scales. METHODS: A retrospective analysis was performed in five neurosurgical departments to extract patients who presented with the first episode of acute brain arteriovenous malformation (bAVM) rupture between 2012 and 2019. Standard logistic regression and area under the receiver operating curve (AUROC) calculations were performed to determine the value of the following scales: intracerebral hemorrhage (ICH), AVM-associated ICH (AVICH), Spetzler-Martin (SM), Supplemented SM (Supp-SM), Hunt and Hess (HH), Glasgow Coma Scale (GCS), World Federation of Neurological Surgeons (WFNS), and RAGS to predict change in categorical and dichotomized modified Rankin Scale (mRS) across three follow-up periods: within the 6 months, 6 months to 1 year, and above 1 year. RESULTS: Sixty-one individuals with a mean age of 43.6 years were included. The RAGS outperformed other grading scales during all follow-up time frames. It showed AUROC of 0.78, 0.74, and 0.71 at the first 6 months, between 6 and 12 months, and after 12 months of follow-up, respectively, when categorized mRS was applied, while corresponding values were 0.79, 0.76, and 0.73 for dichotomized mRS, respectively. CONCLUSION: The RAGS constitutes a reliable scale predicting clinical outcomes following bAVM rupture among adults. Furthermore, the RAGS proved its generalizability across medical centers with varying treatment preferences.

Role of transcranial Doppler ultrasonography in assessing stenosis after flow diversion.

INTRODUCTION: Patients after implantation of flow diverters (FD) due to intracranial aneurysms require radiological and clinical follow-up in view of in-stent stenosis. The aim of the study was to evaluate transcranial Doppler ultrasonography (TCD) as an alternative to more invasive digital subtraction angiography in monitoring patients with FD. PATIENTS AND METHODS: Twenty-five patients after FD deployment due to internal carotid artery (ICA) aneurysms were reviewed. The degree stenosis found on TCD was compared with the results of catheter angiography. The TCD examinations were recorded from two sides at the extracranial ICA and the most proximal and distal segment of intracranial ICA. Analyzed TCD factors included: peak systolic blood flow velocity, end diastolic velocity, mean velocity, pulsatility index, and resistivity index. The side-to-side differences and ratios between particular TCD indices were calculated. RESULTS: The cumulative frequency of angiographic in-stent stenosis was 5 of 25 (20 %). The analysis showed that pulsatility index measured on the most proximal intracranial segment of ICA is a predictor for angiographic instent stenosis (AUC = 0.854; p = 0.04; 95 % CI 0.59-1.00). The threshold of pulsatility index separating stenosis and non-stenosis groups was 1.05 with a sensitivity of 50 % and a specificity of 100 %. As the cut-off threshold of PI was set 0.75 the sensitivity and specificity was 100 % and 16.7 %, respectively. CONCLUSIONS: The increased TCD-derived pulsatility index measured on the most proximal intracranial segment of ICA is associated with in-stent stenosis demonstrated on angiograms.

Thromboembolism during coiling of intracranial aneurysms: predictors and clinical outcome.

INTRODUCTION: Thromboembolism is one of the most serious complications associated with coil embolization therapy. AIM: To identify predisposing factors for thromboembolic complications, as well as to determine whether thromboembolism has an impact on clinical outcome. MATERIAL AND METHODS: From February 2008 to March 2015, 273 consecutive patients were treated at our institution via endovascular coil embolization. Patient medical records were reviewed with an emphasis on procedure description, potential risk factors and clinical outcomes related to thromboembolism. Thromboembolic incidents occurred in 19 (6.9%) cases. Multivariate logistic regression models were used to determine independent predictors of thromboembolism. Clinical outcome was analyzed using the Glasgow Outcome Scale (GOS). RESULTS: Multivariate analysis showed that subarachnoid hemorrhage was an independent risk factor for thromboembolic complications (p = 0.003; OR = 4.4; 95% CI: 1.67-12.02). The difference in frequency of perioperative mortality (GOS 1) in patients with thromboembolism and without thromboembolism was not statistically significant (p = 0.22). The differences in frequencies of severe disability (GOS 2-3) and moderate to low disability (GOS 4-5) between patients with thromboembolism and without thromboembolism were statistically significant in the general study population (p < 0.05). CONCLUSIONS: Subarachnoid hemorrhage is an independent predictor of thromboembolic complications associated with endovascular coiling of cerebral aneurysms. Thromboembolism is associated with significantly increased risk of morbidity, and it affects to a certain extent the periprocedural mortality.

Endovascular treatment of small (< 5 mm) unruptured middle cerebral artery aneurysms.

PURPOSE: We report our experience with endovascular treatment of these lesions, with special consideration of angiographic and clinical outcomes and periprocedural complications. MATERIAL AND METHODS: The analysis included treatment results of 19 patients with 20 aneurysms. The aneurysm size ranged from 1.9 to 4.7 mm (mean 3.8, SD 0.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially postembolisation and at a minimum follow-up of six months. RESULTS: Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 19 (95%) cases and incomplete occlusion in one (5%) case. Imaging follow-up, performed in 17 (89.4%) patients, showed no change in the degree of occlusion in 16 (94.1%) patients and coil compaction in one (5.9%). There were no retreatment procedures. The procedure-related mortality rate was 5% (1/20) and was associated with intraprocedural aneurysm rupture. There was a case of a clinically silent coil prolapse into the parent artery. The clinical follow-up evaluation achieved in 17 (89.4%) patients showed no change in clinical status in all followed patients. CONCLUSIONS: Endovascular treatment of small unruptured middle cerebral artery aneurysms is feasible and effective. The procedure-related complications are not negligible, especially in terms of the benign natural course of these lesions.

Alternative Definitions of Cerebral Aneurysm Morphologic Parameters Have an Impact on Rupture Risk Determination.

BACKGROUND: A discrepancy between definitions of morphologic parameters describing cerebral aneurysms across studies leads to conflicting results concerning performances of these factors and threshold values for rupture status prediction. The aim of the study was to evaluate how various definitions of morphologic parameters may influence the prediction of the risk for aneurysm rupture. METHODS: A total of 425 intracranial aneurysms were reviewed. Analyzed factors included demographic and clinical parameters, aneurysm maximal height (Hmax), dome length (Dlength), dome width (Dwidth), dome maximal diameter (Dmax) and dome minimal diameter (Dmin), neck length (Nlength), neck width (Nwidth), and neck maximal diameter (Nmax) and neck minimal diameter (Nmin). Alternative definitions of aspect ratio (AR), bottleneck factor (BNF), and height-to-width ratio (HW) were used. Univariate and multivariate analysis were performed to identify predictors for aneurysm rupture. RESULTS: Hmax, AR defined as Hmax/Nwidth and Hmax/Nmin, BNF definitions using Nwidth and Nmin, and selected definitions of HW (Hmax/Dlength and Hmax/Dmin) were indicated as potential predictors for rupture. Aneurysm location was found to be a confounding factor with statistical significance. AR defined as Hmax/Nwidth and Hmax/Nmin were the best performers (P < 0.001; area under the curve, 0.64). In multivariate analysis, AR defined as Hmax/Nwidth and aneurysm location with significantly higher risk for rupture of anterior communicating artery aneurysms were independent predictors for subarachnoid hemorrhage. CONCLUSIONS: Different definitions of aneurysm parameters affect various rupture risk determination. AR defined as Hmax/Nwidth and aneurysm location with significantly higher rupture risk of anterior communicating artery aneurysms are independent predictors for aneurysm rupture.

Molecular classification of pituitary adenomas: in search for criteria useful for high-throughput studies.

INTRODUCTION: The mechanism of pathogenesis of pituitary adenomas is still unknown, and it shows differences in pituitary cells of different origin. The aim of our study was to analyse the gene expression profile of pituitary hormones and their precursor genes: PRL, GH, POMC, TSHb, LHb, FSHb, and CGA by QPCR in particular types of pituitary adenomas, and to evaluate the results in the context of sample selection for microarray studies. MATERIAL AND METHODS: Analysis of the gene expression profile was performed in 84 samples of pituitary adenomas, by real-time quantitative PCR (QPCR). RESULTS: As expected, expression of GH gene was significantly higher in somatotropinomas than in prolactinomas (p < 0.05). For POMC gene we noticed lower expression in all pituitary adenomas, except adrenocorticotropinomas (p < 0.05). In the case of PRL gene, the highest expression was observed; PRL+ adenomas were in third place. LHb and FSHb genes showed the highest expression, respectively, in LH-producing and FSH-producing pituitary adenomas; however, our analysis did not show statistically significant differences between LH-producing and FSH-producing adenomas. CONCLUSIONS: Our study showed that GH is a characteristic gene for somatotropinomas. We drew a similar conclusion for POMC gene and adrenocorticotropinomas. However, the results that we obtained for PRL, TSHb, LHb, FSHb, and CGA genes indicate that evaluation of gene expression is not sufficient for classification of particular subtypes of pituitary adenomas.

Hypofractionated stereotactic radiotherapy for large or involving critical organs cerebral arteriovenous malformations.

BACKGROUND: The treatment of large arteriovenous malformations (AVMs) or AVMs involving eloquent regions of the brain remains a challenge. For inoperable lesions, observation, volume-staged radiosurgery or hypofractionated stereotactic radiotherapy (HFSRT) are proposed. The aim of our study was to assess the safety and efficiency of HFSRT for large AVMs located in eloquent areas of the brain. MATERIALS AND METHODS: An analysis of records of 49 patients irradiated for cerebral AVMs with a mean dose of 19.9 Gy (12-28 Gy) delivered in 2-4 fractions with planned gap (at least one week) between fractions. Actuarial obliteration rates and annual bleeding hazard were calculated using Kaplan-Meier survival analysis and life tables. RESULTS: Annual bleeding hazard rates were 4.5% and 1.6% after one and two years of the follow-up, respectively. Actuarial total obliteration rates were 7%, 11%, and 21% and total response rate (total and partial obliterations) 22%, 41%, and 55% after one, two and three years of the follow-up, respectively. There was a trend towards larger total obliteration rate in patients irradiated with fraction dose ≥ 8 Gy and total dose > 21 Gy for lesions of volume ≤ 8.18 cm(3) which was not observed in case of partial obliterations. CONCLUSIONS: HFSRT results with relatively low obliteration rate but is not associated with a significant risk of permanent neurological deficits if both total and fraction doses are adjusted to size and location of the lesion. Predictive factors for total and partial obliterations can be different; this observation, however, is not firmly supported and requires further studies.

Expression of genes FOLR1, BAG1 and LAPTM4B in functioning and non-functioning pituitary adenomas.

INTRODUCTION: The mechanism of pathogenesis of adenomas pituitary is still unknown; differences between pituitary cells of different origin are observed. Identification of genes specific to pituitary adenomas should give better understanding of differences in their response to therapy, especially to radiotherapy. The aim of our study was to independently validate differences in the expression of FOLR1, BAG1, LAPTM4B between functioning (FA) and non-functioning (NFA) pituitary adenomas reported by microarray-based studies. MATERIAL AND METHODS: Analysis of gene expression was performed by real-time quantitative PCR (QPCR) in 76 pituitary adenomas, 25 functioning and 51 non-functioning ones. The expression of the examined genes was normalized to the reference index, obtained by calculation of the geometric mean of reference genes expression: GUS-B, B2M, ACTB, EIF3S10, UBE2D2 and ATP6V1E. RESULTS: Two genes showed significant differences in expression between non-functioning adenomas and functioning ones (FA) (FOLR1 32.4 x greater p = 0.022, BAG1 2.2 x lower p = 0.0002). The expression of LAPTM4B (1.1 x lower) was only insignificantly changed. The expression of FOLR1 in all tumours (functioning and non-functioning) was higher in older patients (over 50 years of age) (p = 0.018). Expression of BAG1 was significantly lower in older patients (p = 0.015). In a subgroup of pure non-functioning adenomas there was a higher expression of FOLR1 in older patients (p = 0.006). Analysis of expression profiles and invasiveness of tumours did not reveal any significant differences both in non-functioning and functioning tumours. CONCLUSIONS: Among pituitary adenomas, the highest level of expression FOLR1 is seen in NFA which are negative by immunohistochemistry to all pituitary hormones while GH-producing adenomas are the only class of pituitary tumours where FOLR1 expression is virtually absent. For BAG1 we confirm a significantly higher expression in functioning (both PRL and GH producing) adenomas than non-functioning ones, while LAPTM4B does not exhibit any expression changes between different classes of pituitary tumours.

Clinical aspects of molecular biology of pituitary adenomas.

Pituitary adenomas are primary, benign CNS tumors. Sporadically, they metastasize or become malignant. However, they can infiltrate adjacent structures even if they are benign and without hormonal activity. Moreover, by compressing adjacent tissues they cause their gradual degradation and, as a result, irreversible CNS damage. Pure endoscopic transnasal transsphenoidal approach enables minimally invasive resection of the aforementioned tumors. In most cases, standard total resection is sufficient but in some cases tumors could be recurrent. There are still unknown risk factors leading to recurrence and subsequent progression of these tumors. This is the reason why pituitary adenomas are a serious clinical and social problem in spite of their benign histology. Continuous development of immunohistochemical and proteomic examinations and application of advanced methods of functional genomics allow for better understanding of biology and pathogenesis of these tumors. In the paper authors discuss molecular etiopathogenesis of pituitary adenomas.

Epidermal growth factor receptor gene expression in high grade gliomas.

BACKGROUND: Epidermal growth factor receptor (EGFR) gene amplification and protein expression in malignant gliomas (anaplastic astrocytoma, AA and glioblastoma, GBL) were suggested to be correlated with the degree of malignancy. Large deletions within the EGFR gene occur frequently in glioma patients. The aim of our study was to analyse EGFR gene expression by real-time PCR by three different amplicons located across the gene and relate it to the age of patients and EGFR mutation status. MATERIAL AND METHODS: We analysed EGFR gene expression in 75 patients, median age 58 years (range 28-75), 52% of glioblastomas, 39% of anaplastic astrocytomas and 9% of low grade gliomas. EGFR expression was measured by real-time PCR, three amplicons located at exons 2-3, 13-14, and 17-18 junctions were analysed, gene expression was normalized by 18S RNA expression. EGFRvIII deletion was detected by RT-PCR. RESULTS: EGFR was found to be expressed in 61.8% of brain gliomas, with strongly positive expression in 12.2% of them. We simultaneously analysed by RT-PCR the EGFRvIII status and found the deletion in 21.3% of tumours. In our group EGFRvIII mutation was significantly more frequent in patients older than 50 years of age (48.6%) than in younger patients (23.5%, p < 0.05). When only GBL patients were assessed, none of the patients younger than 50 years of age had EGFRvIII mutation, whereas in the older subgroup they constituted 36.67% of subjects. We observed that younger patients (below 50 yrs) had slightly lower EGFR expression in comparison to older patients, but this difference was not statistically significant. CONCLUSIONS: As nearly 1/3 of high grade gliomas do not demonstrate abnormal gene expression levels, EGFR status should be taken into account in any targeted therapy attempt. The significance of EGFR axis-related differences between young and old glioma patients and their impact on the prognosis warrant further study.

The incidence of imaging abnormalities after stereotactic radiosurgery for cerebral arteriovenous and cavernous malformations.

OBJECTIVE: The aim of the study was to evaluate the incidence of postirradiation imaging changes after stereotactic radiosurgery for arteriovenous malformations (AVM) and cerebral cavernous malformations (CCM). MATERIAL AND METHODS: A group of 85 patients treated for arteriovenous malformations (62 patients, 73%) and cavernomas (23 patients, 27%) between October 2001 and December 2005 was analyzed. All patients were treated with stereotactic radiosurgery with doses ranging from 8-28 Gy. After the irradiation, magnetic resonance imaging (MRI) or computed tomography (CT) was performed at 6 to 12-month intervals to assess the effects of the treatment. The mean follow-up time for the whole group was 27.3 months; AVM group -- 26 months; CCM group -- 30.9 months. All the imaging data were carefully reviewed to identify the radiological symptoms of postradiosurgical damage. T2 or FLAIR hyperintensity, T1-hypointensity and contrast enhancement on MRI and the presence of hypodense areas and contrast enhancement on CT examinations were assessed. RESULTS: Imaging abnormalities were found in 28 (33%) patients. The symptoms of postradiosurgical damage were observed in 21 (33.9%) patients in the AVM group and 7 (30.4%) patients in the CCM group. Radiological symptoms of radiation necrosis associated with neurological deterioration were identified in two patients with cavernomas, while no radiation necrosis was found in the AVM group. Patients in whom radiological signs of focal brain edema or gliosis existed were asymptomatic. CONCLUSIONS: Radiological symptoms of postradiosurgical damage affected about one third of the irradiated patients, typically without any clinical manifestations. Patients irradiated for CCMs seem to be more prone to develop symptomatic postradiosurgical necrosis; this observation, however, requires further investigation.

Is there any relation between hyperinsulinemia, insulin resistance and colorectal lesions in patients with acromegaly?

INTRODUCTION: Pathogenesis of colonic lesions in patients with acromegaly remains still unclear. There are suggestions that apart from somatotropin axis hormones (GH and IGF-1), other agents also take part in this process. Molecular and animal studies indicate a vital role of hyperinsulinemia in development of colorectal neoplasms. AIM OF THE STUDY: To evaluate a relation between insulin level, insulin resistance and its anthropometric markers and colorectal lesions in patients with acromegaly. MATERIAL AND METHODS: The study consisted of 40 patients with active, newly diagnosed acromegaly; 24 women and 16 men aged from 24 to 77 years (mean age 50.1, SD+/-12.1). The analysis included the results of somatotropin axis function (GH and IGF-1 level), carbohydrate metabolism assessment (fasting serum glucose and insulin levels, oral glucose tolerance test, HOMA-IR for insulin resistance), the results of anthropometric measurement (BMI, WHR) and colonoscopy. RESULTS: Colon pathologies (60 polyps and 2 flat lesions) were discovered in 19 (47.5%) patients with acromegaly, 8 of them had multiple polyps. Hyperplastic polyps were revealed in 11 (27.5%), while adenomas in 8 (20%) acromegalics. Patients with colorectal lesions were found to have higher WHR then subjects with normal colon (p=0.033). Positive correlation between the number of hyperplastic polyps in the patients with multiple changes in the colon and IGF-1 (p=0.025), insulin level (p=0.005) and HOMA-IR (p=0.001) was found. Multiple adenomas correlated positively with insulin level (p=0.007), HOMA-IR (p=0.006) and BMI (p=0.015). CONCLUSIONS: The study results show a relation between hyperinsulinemia, insulin resistance and colon pathologies in acromegaly. Fasting insulin level and HOMA-IR correlate positively with the number of hyperplastic polyps and adenomas in acromegalic patients with multiply colorectal lesions.

Primary pituitary lymphoma.

Primary CNS lymphoma (PCNSL) is now thought to constitute 3% of all intracranial neoplasms. PCNSL occurrence in the sella turcica region is an extremely rare finding. We present a 37-year-old male with primary pituitary lymphoma treated in our department. The patient, who had had no previous illnesses, was admitted to the hospital because of bilateral blurred vision. Findings on physical examination were normal except for temporal parts of field of vision deficit. No abnormalities were found in his bilateral ocular movement, facial sensory function or motor function. His blood count and biochemical profile were normal. Basic hormonal studies revealed no symptoms of panhypopituitarism. MRI demonstrated a large intrasellar mass with supra- and parasellar extension. MRS revealed decrease in NAA/tCr proportion and increase in Cho/NAA and Cho/tCr proportions. Endoscopic surgery was performed using the transsphenoidal approach. Histopathological examination demonstrated a large B-cell lymphoma. The patient received 6 cycles of CHOP chemotherapy. He was also irradiated with 6 MV photons to the whole brain to a total dose of 40 Gy and then there was a boost to the tumour to a total dose of 50 Gy. Next he was reoperated on with the fronto-temporo-sphenoidal craniotomy approach and subtotal resection of the tumour was performed. After the treatment the visual disturbances significantly decreased. Control MRI revealed a stable remnant of the tumour. Nowadays the patient has 52 months' follow-up and he has only a stable, slight visual field deficit on the upper temporal side of the right eye.

Endoscopic transsphenoidal treatment of hormonally active pituitary adenomas.

AIM OF THE STUDY: The paper presents endoscopic surgical technique used in the treatment of hormonally active pituitary adenomas and assessment of the method in terms of its effectiveness and safety. MATERIAL AND METHODS: In 217 cases the surgery was performed due to pituitary adenomas applying the technique developed by Jho and Carrau, with our own modifications. 70 patients were treated for hormonally active adenomas. The group consisted of 36 somatotrophic adenomas, 21 prolactinomas and 13 corticotrophic adenomas. There were 51 females and 19 males with mean age of 42.6 years (range 11-77 years). The follow-up period was between 7 and 56 months (mean - 34 months). The effectiveness and occurrence of complications were confirmed on the basis of neurosurgical, laryngological, endocrinological, ophthalmological examinations and neuroimaging. RESULTS: Biochemical and neurosurgical criteria for complete resection were obtained in 21 (58.3%) of 36 patients with all somatotrophic adenomas. In the group of prolactinomas complete resection was achieved in 17 (80.9%) of 21 patients. Of the 13 patients with Cushing's disease 11 (84.6%) were cured. In the studied group there were no deaths. In the postoperative course only 2 (2.8%) patients suffered liquorrhoeas and new anterior lobe pituitary insufficiency was noted in 8 (11.4%) cases. Meningitis was noted in 1 (1.4%) case and another 1 (1.4%) patient had epistaxis which required repeated endoscopic surgery. CONCLUSIONS: Endoscopic technique is an effective method of treatment of hormonally active pituitary adenomas. It is characterised as being minimal invasive and has a low severe complication rate.

Idiopathic hypertrophic pachymeningitis - case report and literature review.

Idiopathic hypertrophic pachymeningitis (IHPM) is a rare pathological state, with still unclear aetiopathogenesis. We present a case of a 63-year-old woman with cranial variety of that disease. The manifestations of the disease included headaches, paresis of VI, IX, X nerves and cerebellar ataxia. The disease was diagnosed with magnetic resonance imaging (MRI) and histopathological assessment of the pachymeninx biopsy specimen. The MRI revealed significant thickening of the cranial base pachymeninx, compressing the pons and medulla oblongata. MRI examinations could be misinterpreted as extensive meningioma of the skull base. Dura mater biopsy revealed however inflammation with abundant lymphocytic infiltrations. Clinical improvement was obtained after the application of corticosteroids. We noted the subsidence of all symptoms of the disease, as well as radiological improvement, manifested through substantial regression of the described changes in the pachymeninx. The patient has been presented in the context of 65 cases of idiopathic hypertrophic pachymeningitis, described in the literature of English-speaking countries in the last five years. Recently, the importance of the autoimmunogenic background of IHPM has been underlined. In that respect IHPM has become an interdisciplinary problem. Its diagnosis and treatment requires not only radiologists, neurologists, pathomorphologists and neurosurgeons, but also specialists in internal medicine, including immunologists, allergologists and rheumatologists as well - in other words, physicians that rarely take part in the processes of diagnosing and treating intracranial pathologies.

Use of monoclonal anti-EGFR antibody in the radioimmunotherapy of malignant gliomas in the context of EGFR expression in grade III and IV tumors.

We investigated the putative benefits of simultaneous teleradiotherapy and anti-epidermal growth factor receptor (EGFR) 125I monoclonal antibody (MAb) 425 radioimmunotherapy, when applied after neurosurgery in high-grade gliomas, over teleradiotherapy alone. In comparison to previous studies which have reported good results with this type of radioimmunotherapy, we advanced the adjuvant radioimmunotherapy step, that is, gave it during, not after, teleradiotherapy. The randomized prospective study examined two groups: simultaneous postoperative teleradiotherapy and radioimmunotherapy (TRT + RIT; eight patients) versus teleradiotherapy alone (TRT; 10 patients). Patients who after primary operation of grade III (6 cases) or IV glioma (12 cases), showed no or less than 2 mL of remnant tumor on post-operative magnetic resonance (MR) study and were not treated postoperatively by chemotherapy were enrolled and randomized. Anti-EGFR 125IMAb 425 RIT was started during week 4 of radiotherapy, not later than 8 weeks after neurosurgery, and was repeated three times at 1-week intervals. Total activity given was 5026 + 739 MBq/patient. The tolerance of TRT was good. No immediate side effects of concomitant anti-EGRF 125I RIT were observed. Observation showed a median total survival (as evaluated from the primary neurosurgical treatment) of 14 months (range 3.5-28 months). There was no improvement in disease-free or total survival in the group of patients treated by TRT + RIT after neurosurgery. In addition, an immunohistochemical analysis of EGFR expression in gliomas was performed in a group of 100 cases and was distinctly positive in 50% grade IV gliomas and 68% grade III gliomas. We conclude that simultaneous radiotherapy and radioimmunotherapy with anti-EGFR 125I-MAb 425 is not beneficial over radiotherapy alone in adjuvant treatment of high-grade gliomas after neurosurgery. We also recommend individual confirmation of EGFR expression in further anti-EGFR radioimmunotherapy trials.

[The evaluation of the brain arteriovenous malformations' operative treatment in the clinical material of Silesian Medical University's Departament of Neurosurgery]. / Ocena wyników operacyjnego leczenia naczyniaków tetniczo-zylnych mózgu w materiale Kliniki Neurochirurgii w Katowicach.

UNLABELLED: A risk of haemorrhage in arteriovenous malformations (AVM) of the brain is estimated as 2-4% per year. A mortality rate from this reason is estimated as 1% per year and morbidity 10-20%. The methods of treatment ofAVM are: microsurgical treatment, radiosurgery, endovascular treatment. The aim of this work is presentation of our results of surgical treatment of AVM and comparison with the results of radiosurgical and endovascular treatment presented by other authors in the literature. MATERIAL AND METHODS: Between 1990-2002 in the Department of Neurosurgery of Medical University of Silesia in Katowice 31 patients were operated with AVM's of the brain. Among them there were 10 female and 21 male at the age from 10 to 69 years. The average age was 36.1. The first sign was intracranial haemorrhage in 19 cases and epileptic seizures in 9 cases. In all cases the cerebral angiography was performed and all patients were assessed as I to III score according to the Spetzler-Martin scale. All patients were operated on using microneurosurgical techniques. The total removal of the tumour was assessed using the intraoperative Doppler examination. The state of the patients at the discharge was estimated according to Glasgow Outcome Scale (GOS). RESULTS: In all cases the malformations were removed totally. In 2 cases (6.4%) we noticed the deterioration of neurological condition after operation. The state of 28 patients (90.3%) was assessed as very good and good (I or II score) according to GOS at the discharge. We didn't notice any mortality in our group of patients. CONCLUSIONS: In the conclusion we want to emphasize the advantages of surgical treatment of AVM's of the brain especially these including in I to III score according to Spetzler-Martin scale comparing with the results ofradiosurgical and endovascular methods of treatment.