The effectiveness of Gamma Knife (GK) treatment for multiple metastatic brain tumors was retrospectively reviewed. Among 170 cases with brain metastases of non-small cell (NSC) lung cancer treated in Chiba Cardiovascular Center and Chiba Cancer Center between April 1990 and August 1999, 95 consecutive patients were analyzed for this study, each meeting the following 4 criteria ; 1) up to 10 multiple brain lesions at initial diagnosis, 2) no surgically inaccessible tumors of &gnE;3cm in diameter, 3) no meningitis carcinomatosa, and 4) more than 2months of life expectancy. Patients were divided into two groups : GK group (51cases) and non-GK group (44cases). In the GK group we resected large tumors (&gnE;3cm) and treated small lesions (<30cm) by GK radiosurgery. New lesions were treated by repeated GK therapy without prophylactic whole brain radiation therapy (WBRT). Patients in the non-GK group were treated by the traditional combined therapy of surgery, external fractionated brain radiation therapy, and chemotherapy. Intervals from the date of diagnosis to date of death, neurological death and impaired quality of life were longer in the GK group than in the non-GK group. The significant prognostic factors in the mono-variate analyses were control of systemic disease (high risk group : uncontrolled, p<0.0001), initial Karnofsky peformance scale score (<70, p=0.0269), treatment group (non-GK group, p=0.0032), chemotherapy (no, p=0.0303), and gender (male, p=0.0444), In multivariate analyses, significant prognostic factors were the control of systemic desease (high risk group : uncontrolled, p<0.0001), treatment group (non-GK group, p<0.0001), and the initial Karnofsky performance scale (<70, p=0.0050). GK radiosurgery combined with surgery following the repeated GK therapy without prophylactic WBRT could be one possible treatment for patients with up to 10 multiple metastatic brain tumors resulting from NSC lung cancer.

View full abstract

The application of navigation-assisted surgery for spinal instrumentation is reported. Fifteen procedures, including C1-2 transarticular screw fixation, posterior fusion with podicle screw fixation, and posterior lumbar interbody cage fixation, were performed in the preceding 15 months. In each case, a navigation system was used to select the proper screw size and to determine the appropriate orientation for the instrumentation. There were no intraoperative complications noted. The system increased the accuracy of spinal instrumentation and decreased the risk of neurovascular injury. In cases of spondylolytic spondylolisthesis, the probe error after registration was relatively large due to instability. The development of navigation guidance has improved the accuraccy of spinal instrumentation, because a multidimensional view of the anatomic relationships of the actual surgery is provided.

View full abstract

A 52-year-old male who complained of a headache was admitted to our hospital. A left basilar artery-superior cerebral artery (BA-SCA) saccular aneurysm and a left distal SCA fusiform aneurysm were detected. As the high position BA-SCA aneurysm was difficult to treat with direct surgery, coil embolization was selected. By inserting a microcatheter into the left SCA, we were able to examine the collateral flows of the distal SCA (occlusion test). After the occlusion test, the BA-SCA aneurysm was totally embolized with detachable coils including the orifice of the left SCA. Using these strategies, we were able to safely treat both aneurysms after the collateral flow of the distal SCA was evaluated by endovascular surgery.

View full abstract

We report a case of cerebellar hemangioblastoma with a marked peri-tumoral edema. A 70-year-old male was admitted to our hospital with a one-month history of truncal ataxia and right cerebellar signs. His CT scan demonstrated an intra-axial solid mass with an extensive peri-focal edema in the right cerebellar hemisphere. Vertebral angiograms showed a tumor stain lasting through the late venous phase as well as dilated feeding arteries and draining veins. The tumor was totally resected and histological evaluation confirmed it to be hemangioblastoma. The patient was discharged without neurological deficit. This rare case suggests that a solid cerebellar hemangioblastoma with a peri-focal edema may mimic a malignant cerebellar tumor. Possible mechanisms behind the development of the extensive edema are also discussed.

View full abstract

We report a case of a large recurrent craniopharyngioma successfully treated with gamma-knife radiosurgery followed by intratumoral injections of bleomycin. This 27-year-old woman was first treated with subtotal removal of the tumor via the rigth pterional approach and postoperative external radiotherapy at the age of 12 years. Ten years later, magnetic resonance imaging (MRI) revealed regrowth of the tumor. Since then, she has undergone tumor removal surgery 4 times over a 5 years period through either a pterional or transsphenoidal approach, but each attempt proved unsuccessful. In 1997, She was treated with gamma-knife radiosurgery (central dose 30 Gy, marginal dose 15Gy ; 5 fractionated). After 1 week, because of expansion of the cystic part, she received a craniotomy and an Ommaya tube was inserted into the cyst. Two months later, intratumoral injections of bleomycin were started as an adjuvant therapy. Twelve months after the treatment, an MRI revealed significant reduction of the tumor without any side effects.

View full abstract

We report a case of choroid plexus metastasis from renal cell carcinoma causing intracerebral hemorrhage. A 70-year-old woman was admitted to our hospital because of intracerebral hemorrhage. She presented with severe headache and disturbed consciousness. She had left nephrectomy for renal cell carcinoma 15 years prior to admission. MRI revealed a well enhanced tumor with a peri-tumoral hemorrhage located in the trigone of the left lateral ventricle. The tumor and hematoma were totally removed via the left transcortical approach. The tumor was histologically diagnosed as clear cell carcinoma. She returned to her daily life with right homonymous hemianopsia and dyscalculia. A literature review suggested that a slowly progressive type of renal cell carcinoma is likely to metastasize to the choroid plexus of the lateral ventricle.

View full abstract

We report successful hyperbaric oxygen therapy (HBT) in a patient with central pontine myelinolysis (CPM). The patient was a 51-year-old woman with a history of alcoholism. She had dysarthria, dysphasia, hyperactive deep tendon reflexes and poor tandem gait. A T2-weighted magnetic resonance image (MRI) revealed an oval hyperintense lesion in the pons. Ten days of HBT completely dissolved her symptoms. One year after the HBT, the lesion markedly decreased in size on MRI. Resolution of the brain edema by HBT may explain the improvement of the symptoms and decreased size of the lesion on MRI.

View full abstract

We report a case of a posttraumatic carotid cavernous fistula (CCF) with contralateral ocular symptoms. Angiography revealed a fistula to the contralateral cavernous sinus via the intercavernous sinus. We successfully treated the CCF with a Guglielmi detachable coil. However 2 months later the patient suffered from subarachnoid hemorrhaging due to a newly formed aneurysm of the left middle cerebral artery. It was suggested that this new de novo aneurysm was formed by the hemodynamic stress following the coil occlusion of the cavernous fistula.

View full abstract

We report a case of intracranial embryonal carcinoma mimicking a HCG-producing germinoma. This 23-year-old male developed double vision, nausea, vomiting, and headache over the course of several days and was transferred to our department. CT and MRI revealed a partially calcified, well-circumscribed, markedly enhanced, homogeneous mass in the pineal region with obstructive hydrocephalus. Clinical diagnosis was HCG-producing germinoma, since his serum titer of human chorionic gonadotropin HCG was slightly elevated (9.9mIU/ml) and that of α-fetoprotein (AFP) remained within the normal range. He underwent partial removal of the tumor, which was histologically verified as embryonal carcinoma. Although residual tumor disappeared completely after 4 courses of chemotherapy consisting of ifosphamide, CDDP, and etoposide in combination with radiotherapy to the whole neural axis, he died of a recurrent tumor 6 months after the initial diagnosis. It is necessary to establish the comprehensive management for embryonal carcinoma, including diagnostic surgery, because patients with embryonal carcinoma infrequently have the characters of markedly elevated serum titers of HCG and/or AFP ; symptoms of which are also observed in those with yolk sac tumor or choriocarcinoma.

View full abstract

The fibrin glue has been applied as an adjunct to dural closure. Particularly, it may be a useful material as a prophylactic measure in some patients in whom the dural closure is potentially inadequate and for patients with established the cerebrospinal fluid (CSF) fistulae. But, the CSF leakage and collection in the subdural, epidural and subcutaneous space are postoperative complication in some cases. Opening the arachnoid membrane causes of the CSF leakage. The authors describe an arachnoid closure method of preventing CSF leakage making effective use of a fibrin membrane. The fibrin membrane is made by the spray method of fibrin glue and tolerated waterpressure over 80 cmH_2O. The arachnoid defects are covered with the fibrin membrane. Then the fibrin membrane adhere to the arachnoid membrane with fibrin glue. The use of this technique might be reduced the incidence of postoperative CSF complication.

View full abstract