Objective: The current treatment of craniopharyngiomas is evolving into a multimodal approach in which the aim is disease control and improved preservation of quality of life (QOL). In this the paper, the transcranial removal of craniopharyngiomas is discussed. Method: Fifty-two patients who were surgically treated for craniopharyngiomas extending outside the sellar-suprasellar region were evaluated. All the patients were operated on mainly by the fronto-basal interhemispheric approach. Results: Multiple surgeries were performed in 15 cases. A total of 10 patients were treated with GKS after surgical removal. In the immediate postoperative period, major complications, including impairment of the perforating arteries were observed in three cases. They exhibited hyperphagia and obesity due to infarction of the hypothalamic nuclei. Conclusion: In our experience, the cost of aggressive resection is hypothalamic dysfunction and a poor QOL. A good QOL may be achieved by careful total or near total resection followed by reoperation or GKS. The fronto-basal interhemispheric approach is a valid choice for the removal of craniopharyngiomas extending outside the sellar-suprasellar region. Using this approach, tumors can be removed without significant sequelae related to surgical technique due to easy preservation of the pituitary stalk, hypothalamic structures, and perforators. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.

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Long-term follow-up results of craniopharyngiomas after radiosurgery are reported. Among 125 cases of craniopharyngioma, long-term follow-up more than 6 months is obtained in 108 cases. Majority of the cases have had surgical excision before radiosurgery. The tumors, 19 mm in mean diameter were treated with the mean maximum dose of 22.1 Gy and with the marginal dose of 11.6 Gy. The final radiological outcomes during 63 months of mean follow-up showed 9 CRs, 61 PRs, 1 MR, 19 NCs and 18 PGs, indicating the response rate of 65% and the control rate of 83% respectively. Neurological and endocrinological signs were improved in 18%, unchanged in 53% and worsened in 15% of cases, meanwhile 8% of the patients were dead. Small and solid tumors were the best indication for radiosurgery due to excellent tumor control as well as no adverse effects. They may have a good chance for complete remission. In conclusion a sufficient tumor resection with microsurgery is required and subsequent radiosurgerv is most adequate for treating craniopharyngiomas.

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Although the ideal treatment of skull base meningiomas is complete surgical resection, in some cases total removal is impossible because of the tumor invasion to the cranial nerves, major blood vessels, or other important neural structures. The recent advances in skull base surgery have contributed to increase the radicality. On the other hand, stereotaxic radiotherapy has been established to treat small meningiomas located in areas, where surgical access is not easy. The goal of surgical removal should be estimated in each case to avoid serious surgical complications, and some kind of stereotaxic radiotherapy may be indicated according to the biological behavior of the tumor.

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Gamma Knife radiosurgery has been widely utilized for the treatment of skull base meningiomas but with the criticism that the follow-up period is not long enough considering that these are slow growing benign tumors. Recently, the number of patients who have been followed for more than 10 years is increasing worldwide and still a good local control rate around 90% accompanied by a very low complication rate has reported. Reports of malignant transformation and tumor induction after radiosurgery are still very few compared to the large number of patients include in the longer follow-up. We are able to say that we have enough evidence now showing the efficacy and safety of Gamma Knife radiosurgery for skull base meningiomas for a period of 10 years after treatment. To avoid radiation optic neuropathy, it used to be said that at least a few millimeters was needed between the optic apparatus and the tumor. Nevertheless, recent knowledge tells us that peripheral dose as low as 10 to 12 Gy can control tumors for a long time and higher doses can be tolerated by the optic apparatus. This, together with the development of less distorted fine MR images and refinement of dose planning computers and software systems enabled us to treat tumors that touch optic apparatus in short segment. Surgical removal is still the golden standard when surgical complete removal with acceptable morbidity is feasible because it is the only modality that has the possibility of completely curing the disease, but we now have a powerful tool to control skull base meningioma when surgical complete removal is difficult.

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Regenerative therapy against stroke is a novel concept. According to recent progress in stem cell biology, adult neurogenesis was rediscovered and a neural stem cell was able to be cultured in vitro. There are still a lot of problems to be clarified to regulate neurogenesis and transplantation. We can now start to use these materials to improve neurological findings after stroke.

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The present study analyzed 11 patients who required urgent alternative bilateral craniotomies for intracranial hematomas from among 195 patients who underwent emergency craniotomy in our institution from January 1995 to January 2004. Mean age of the patients undergoing the urgent bilateral craniotomies was 30.8 years (range, 16〜56 years) with a male preponderance (male:female, 10:1). Overall frequency of bilateral craniotomies was 5.6% among emergency craniotomies. Cause of injury was traffic accident in 9 patients and falls in the other 2 patients. Preoperative Glasgow coma scale was 3〜8 in 7 patients, 9〜12 in 2 patients and 13〜15 in 2 patients. In terms of the hematoma combination, acute subdural hematoma (ASDH) following contralateral acute epidural (AEDH) was most frequent occurring in 6 patients, with AEDH following AEDH in 2 patients, AEDH following ASDH in 2 patients, and ASDH following ASDH in 1 patient. Skull fractures associated with AEDH were seen in all patients except the patient with ASDH following ASDH. All patients underwent urgent hematoma evacuation and good outcomes were obtained in 3 patients who were < 30-years-old with a GCS &ge; 10 on arrival to the emergency room. Early diagnosis and urgent craniotomy are indispensable in treating unilateral hematoma following contralateral hematoma, particularly in patients with ASDH associated with contralateral skull fracture.

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Objective: We evaluated the effectiveness of gamma knife surgery alone for oligo-brain metastastases without prophylactic whole brain radiation therapy (WBRT). Materials and Methods: Six hundred twenty consecutive cases with less than 5 brain metastases were analyzed in this study. Huge tumors (≧ 3.5 cm in maximum diameter) were totally removed, while smaller lesions (< 3.5 cm) were all irradiated with the gamma knife. No upfront WBRT was applied and new distant lesions were appropriately re-treated with the gamma knife. Tumor progression free, overall, neurological, functional preservation, new lesion-free and salvage treatment-free survival curves were calculated by the Kaplan-Meier method. Results: In total, 1,017 separate gamma knife procedures were required to treat 3,027 lesions. The tumor control rates at one year were 98.7% in tiny, 90.5% in small, 81.3% in medium sized, and 60.0% in large lesions. Median survival period was 0.86 years. Neurological, functional preservation, new lesion-free and salvage treatment-free survival rates at one year were 91.7%, 85.4%, 63.7%, 73.7%, respectively. Neurological and functional preservation survivals were significantly worse in subjects with carcinomatous meningitis than those without carcinomatous meningitis (p < 0.0001). New lesions and salvage treatments were more frequent in patients with multiple brain metastases than those with a single metastasis (p < 0.0001). The number of salvage gamma knife treatments for new distant lesions was zero in 430 (69.4%), one in 96 (15.5%), two in 54 (8.7%), and ≧ 3 in 40 cases (6.5%). Conclusion ・ In meeting the goal of preventing neurological death and maintaining activities of daily living for patients with less than 5 brain metastases, gamma knife alone provides excellent palliation without prophylactic WBRT. New distant lesions were quite well controlled with gamma knife salvage treatment alone.

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Fiber tracking using diffusion-weighted tensor imaging is a technique revealing the anisotropy and orientation of white matter tracts in the brain, and may become an important tool for the diagnosis and deciding treatment strategies for diseases of the central nervous system. However, several problems with this technique have been pointed out in the past studies, such as, how to define the regions of interest (ROI), how to track the fibers in edematous areas, and how to resolve crossing fibers. To analyze the utility of the fiber tracking method, we applied this technique to 178 patients with intracranial mass lesions. In the present study, we would like to mention two other issues in utilizing fiber tracking as follows: 1) fibers sometimes can be drawn along with the boundary of large tumors, which misleads the position of the primary fibers, 2) obviously different depictions of fibers can be obtained by simply exchanging seed ROI and target ROI with each other. Fiber tracking is a developing tool, so further investigation about the problems pointed in this study and a validation study of depicted fibers are required.

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