“Good stereotactic surgery for movement disorders can be performed with or without the microelectrode, and poor surgical results can occur both with and without the microelectrode.” – Dr. Roy Bakay1 A BRIEF HISTORY OF DBS AND NEUROIMAGING Stereotactic neurosurgery is founded on the ability to accurately localize and safely access targets within the brain in a minimally-invasive manner. The stereotactic method was first described in 1908 by Sir Victor Horsley and Robert Clarke at University College London, where they developed an apparatus for animal experimentation that allowed them to establish a threedimensional Cartesian coordinate system for targeting. At that time, however, x-rays were the only available form of imaging the human body and as such, localizing intracranial targets relied on a combination of knowledge from anatomical atlases and the visualization of a few intracranial landmarks such as the pineal gland or the foramen of Monroe. These landmarks could be visualized by filling the ventricles with air (pneumoencephalogram) or a contrast medium (ventriculogram) [Figure 1]. In 1947, Ernst Spiegel and Henry Wycis created the first human stereotactic frame that allowed for lesioning of deep brain nuclei for the treatment of psychiatric disease.2
“使用微电极或不使用微电极都可以进行良好的立体定向运动障碍手术，而使用和不使用微电极都可能出现手术效果不佳的情况。立体定向神经外科是建立在以最小的侵入方式准确定位和安全进入大脑目标的能力之上的。1908年，伦敦大学学院的维克多·霍斯利爵士(Sir Victor Horsley)和罗伯特·克拉克(Robert Clarke)首先描述了立体定向方法，他们在那里开发了一种用于动物实验的仪器，使他们能够建立一个用于定位的三维笛卡尔坐标系统。然而，在那个时候，x射线是唯一可用的人体成像形式，因此，颅内目标的定位依赖于解剖学地图集的知识和一些颅内标志(如松果体或门罗孔)的可视化的结合。这些标志可以通过向脑室填充空气(气脑图)或造影剂(脑室图)来显示[图1]。1947年，恩斯特·斯皮格尔(Ernst Spiegel)和亨利·威吉斯(Henry Wycis)创造了第一个人体立体定向框架，允许对脑深部核进行损伤，以治疗精神疾病
{"title":"Deep Brain Stimulation: Awake and Asleep Options","authors":"Chengyuan Wu, A. Sharan","doi":"10.29046/JHNJ.011.2.001","DOIUrl":"https://doi.org/10.29046/JHNJ.011.2.001","url":null,"abstract":"“Good stereotactic surgery for movement disorders can be performed with or without the microelectrode, and poor surgical results can occur both with and without the microelectrode.” – Dr. Roy Bakay1 A BRIEF HISTORY OF DBS AND NEUROIMAGING Stereotactic neurosurgery is founded on the ability to accurately localize and safely access targets within the brain in a minimally-invasive manner. The stereotactic method was first described in 1908 by Sir Victor Horsley and Robert Clarke at University College London, where they developed an apparatus for animal experimentation that allowed them to establish a threedimensional Cartesian coordinate system for targeting. At that time, however, x-rays were the only available form of imaging the human body and as such, localizing intracranial targets relied on a combination of knowledge from anatomical atlases and the visualization of a few intracranial landmarks such as the pineal gland or the foramen of Monroe. These landmarks could be visualized by filling the ventricles with air (pneumoencephalogram) or a contrast medium (ventriculogram) [Figure 1]. In 1947, Ernst Spiegel and Henry Wycis created the first human stereotactic frame that allowed for lesioning of deep brain nuclei for the treatment of psychiatric disease.2","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"63 4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2016-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123126832","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
50 Headache and facial pain are a commonly encountered wide spectrum of complex medical conditions. Unfortunately, aside from treating trigeminal neuralgias, interest in surgical management of facial pain and headache from the neurosurgical community has been historically low. The reasons for this are multifactorial and include waning reimbursement, lack of evidence to support a number of pain procedures, and the absence of pain education in neurosurgical residency programs. In this article, we present surgical therapies currently available for headache and facial pain and review the published evidence for commonly performed neurosurgical treatments for craniofacial pains.
{"title":"Evidence for Surgical Management of Facial Pain and Headache","authors":"Shannon W. Clark, Chengyuan Wu","doi":"10.29046/jhnj.011.2.010","DOIUrl":"https://doi.org/10.29046/jhnj.011.2.010","url":null,"abstract":"50 Headache and facial pain are a commonly encountered wide spectrum of complex medical conditions. Unfortunately, aside from treating trigeminal neuralgias, interest in surgical management of facial pain and headache from the neurosurgical community has been historically low. The reasons for this are multifactorial and include waning reimbursement, lack of evidence to support a number of pain procedures, and the absence of pain education in neurosurgical residency programs. In this article, we present surgical therapies currently available for headache and facial pain and review the published evidence for commonly performed neurosurgical treatments for craniofacial pains.","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2016-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128839226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael J. Lang, Ameet Md Chitale, A. Sharan, Chengyuan Wu
32 has found distinct advantages with SEEG in terms of safety and patient comfort for large bihemispheric implantations and in patients with prior history of craniotomy. Finally, SEEG allows for the generation of a four dimensional picture of epileptogenic zone and spread patterns, which is not reliably achieved with cortical surface recording techniques. As such, our center is actively pursuing SEEG-based white-matter recording guided by functional imaging to further define cerebral networks and spread patterns in epilepsy.
{"title":"Advancements in Stereotactic Epilepsy Surgery: Stereo-EEG, Laser Interstitial Thermotherapy, and Responsive Neurostimulation","authors":"Michael J. Lang, Ameet Md Chitale, A. Sharan, Chengyuan Wu","doi":"10.29046/JHNJ.011.2.005","DOIUrl":"https://doi.org/10.29046/JHNJ.011.2.005","url":null,"abstract":"32 has found distinct advantages with SEEG in terms of safety and patient comfort for large bihemispheric implantations and in patients with prior history of craniotomy. Finally, SEEG allows for the generation of a four dimensional picture of epileptogenic zone and spread patterns, which is not reliably achieved with cortical surface recording techniques. As such, our center is actively pursuing SEEG-based white-matter recording guided by functional imaging to further define cerebral networks and spread patterns in epilepsy.","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"34 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2016-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123994464","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Feroze Mohamed, Chris Conklin, S. Saksena, M. Alizadeh, D. Middleton
Several imaging modalities are currently being used to obtain diagnostic information in patient with spinal cord injuries. Among them, magnetic resonance imaging, computed tomography myelography, and plain radiography are the most widely used. Magnetic resonance imaging or MRI is a non-invasive imaging method that uses magnetic fields and radio frequency (RF) waves and provides soft tissue contrast of the spinal cord and surrounding tissues within the spinal canal. On the other hand, computed tomography or CT is based on x-rays, to provide excellent bone contrast, and is the first line of diagnostic imaging performed following a traumatic injury in both adults and kids to evaluate for fractures and spinal subluxation. Subsequently, MRI is performed to evaluate for the presence of spinal cord compression, spinal cord edema and/or hemorrhage, epidural/subdural hemorrhage, prevertebral edema, and ligamentous injury. Although still not widely available, in addition to providing good structural information, MRI has evolved in the recent years to provide functional characteristics of the spinal cord. These include information such as diffusion of the water molecules within the spinal cord providing functional information of white matter based on diffusion tensor imaging (DTI), and neuronal activation sites within the gray matter of the spinal cord based on Blood oxygenation level dependant (BOLD) imaging. In our center at Jefferson we are utilizing these functional neuroimaging biomarkers to potentially help us to understand the mechanisms of spinal cord injury (SCI) as well as guide and track changes of new therapeutic procedures. In the following sections we will discuss the methodologies underlying these techniques.
{"title":"Advances in Functional Spine Neuroimaging","authors":"Feroze Mohamed, Chris Conklin, S. Saksena, M. Alizadeh, D. Middleton","doi":"10.29046/JHNJ.011.2.008","DOIUrl":"https://doi.org/10.29046/JHNJ.011.2.008","url":null,"abstract":"Several imaging modalities are currently being used to obtain diagnostic information in patient with spinal cord injuries. Among them, magnetic resonance imaging, computed tomography myelography, and plain radiography are the most widely used. Magnetic resonance imaging or MRI is a non-invasive imaging method that uses magnetic fields and radio frequency (RF) waves and provides soft tissue contrast of the spinal cord and surrounding tissues within the spinal canal. On the other hand, computed tomography or CT is based on x-rays, to provide excellent bone contrast, and is the first line of diagnostic imaging performed following a traumatic injury in both adults and kids to evaluate for fractures and spinal subluxation. Subsequently, MRI is performed to evaluate for the presence of spinal cord compression, spinal cord edema and/or hemorrhage, epidural/subdural hemorrhage, prevertebral edema, and ligamentous injury. Although still not widely available, in addition to providing good structural information, MRI has evolved in the recent years to provide functional characteristics of the spinal cord. These include information such as diffusion of the water molecules within the spinal cord providing functional information of white matter based on diffusion tensor imaging (DTI), and neuronal activation sites within the gray matter of the spinal cord based on Blood oxygenation level dependant (BOLD) imaging. In our center at Jefferson we are utilizing these functional neuroimaging biomarkers to potentially help us to understand the mechanisms of spinal cord injury (SCI) as well as guide and track changes of new therapeutic procedures. In the following sections we will discuss the methodologies underlying these techniques.","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"14 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2016-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126587401","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
James J. Evans, P. Amenta, A. Mansouri, C. Farrell, M. Rosen, G. Nyquist
Recommended Citation Evans, MD, James J.; Amenta, MD, Peter S; Mansouri, MD, Alireza; Farrell, MD, Christopher J; Rosen, MD, Marc R.; and Nyquist, MD, Gurston G. (2015) "Prevention and Management of Bleeding During Endoscopic Approaches to Skull Base Pathologies," JHN Journal: Vol. 10 : Iss. 2 , Article 6. DOI: https://doi.org/10.29046/JHNJ.010.2.003 Available at: https://jdc.jefferson.edu/jhnj/vol10/iss2/6
Evans, MD, James J.;Amenta, MD, Peter S;曼苏里，马里兰州，阿里雷扎;法雷尔，医学博士，克里斯托弗·J;Rosen, MD, Marc R.;奈奎斯特，医学博士，古尔斯顿G. (2015)“内窥镜治疗颅底病变时出血的预防和处理”，《中华外科杂志》第10卷第2期，第6篇。DOI: https://doi.org/10.29046/JHNJ.010.2.003可在:https://jdc.jefferson.edu/jhnj/vol10/iss2/6
{"title":"Prevention and Management of Bleeding During Endoscopic Approaches to Skull Base Pathologies","authors":"James J. Evans, P. Amenta, A. Mansouri, C. Farrell, M. Rosen, G. Nyquist","doi":"10.29046/JHNJ.010.2.003","DOIUrl":"https://doi.org/10.29046/JHNJ.010.2.003","url":null,"abstract":"Recommended Citation Evans, MD, James J.; Amenta, MD, Peter S; Mansouri, MD, Alireza; Farrell, MD, Christopher J; Rosen, MD, Marc R.; and Nyquist, MD, Gurston G. (2015) \"Prevention and Management of Bleeding During Endoscopic Approaches to Skull Base Pathologies,\" JHN Journal: Vol. 10 : Iss. 2 , Article 6. DOI: https://doi.org/10.29046/JHNJ.010.2.003 Available at: https://jdc.jefferson.edu/jhnj/vol10/iss2/6","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"60 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126494725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
H. Do, A. Farag, V. Kshettry, G. Nyquist, M. Rosen, James J. Evans, C. Farrell
{"title":"Endonasal Vascularized Flaps For Cranial Base Reconstruction","authors":"H. Do, A. Farag, V. Kshettry, G. Nyquist, M. Rosen, James J. Evans, C. Farrell","doi":"10.29046/JHNJ.010.2.004","DOIUrl":"https://doi.org/10.29046/JHNJ.010.2.004","url":null,"abstract":"","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128417464","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
G. Barros, K. Krupa, Kristin Krupa, Ravi Madineni, L. Kenyon, C. Farrell
{"title":"A Rare Case of a Systemic Non-Langerhans Histiocytosis Presenting with Diabetes Insipidus and a Tentorial Mass","authors":"G. Barros, K. Krupa, Kristin Krupa, Ravi Madineni, L. Kenyon, C. Farrell","doi":"10.29046/JHNJ.010.1.004","DOIUrl":"https://doi.org/10.29046/JHNJ.010.1.004","url":null,"abstract":"","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2015-07-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115078855","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Review of Concussion and Return-to-Play Guidelines in Sport","authors":"Michael J. Lang, A. Chitale, K. Judy","doi":"10.29046/JHNJ.008.1.001","DOIUrl":"https://doi.org/10.29046/JHNJ.008.1.001","url":null,"abstract":"","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"29 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129365583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The use of radiation treatment (RT) is usually reserved for residual or recurrent craniopharyngiomas, and the role of RT alone and not as an adjunctive therapy to surgery has not been clearly defined. The authors describe a case of a 50-year-old man presenting with a large suprasellar craniopharyngioma with extension into the third ventricle, producing acute hydrocephalus. A ventriculoperitoneal shunt was performed concurrently with an endoscopic biopsy. Treatment with fractionated stereotactic radiosurgery (FSR) resulted in near resolution of the lesion with no evidence of recurrence over six years. A review of RT for the treatment of craniopharyngiomas without surgical resection is performed. Introduction Craniopharyngiomas are histologically benign extraaxial epithelial tumors that arise form embryologic remnants of Rathke’s pouch.12 These rare lesions have an estimated incidence of 1.5 per million people per year, but comprise 10-15% of all pediatric brain tumors.7,21 Despite their benign histology, craniopharyngiomas cause significant morbidity from damage to the hypothalamus, optic apparatus, and endocrine system. Aggressive treatment is advocated, but the optimal treatment is often debated. Radical resection is often utilized as a first line treatment due to the frequently large size of these lesions at presentation and associated mass effect.6,24 Such surgery, however, can carry a high risk of morbidity with hypothalamic and endocrine dysfunction.26 For this reason, many favor subtotal resection with preservation of adjacent anatomical structures and adjuvant therapies for residual tumor.11,18 The use of radiotherapy in isolation for the treatment of craniopharyngiomas is infrequent. Case Report A 50-year-old man suffering from two months of headache and neck pain presented to the emergency department with a dramatic deterioration of his vision, limb paresis, and seizures. Cranial imaging demonstrated a 3.7 x 2.5 X 3.2 cm, solid suprasellar mass with extension into the third ventricle, producing acute hydrocephalus (Figures 1 and 2). Through a right frontal burrhole, placement of a ventriculoperitoneal shunt was performed concurrently with an endoscopic biopsy of the third ventricular mass tumor (Figure 3). Intraoperatively, a yellow-colored frond-like mass with a consistency similar to choroid plexus was seen filling the right foramen of Monro. Pathology was consistent with a papillary craniopharyngioma. The patient was subsequently treated with fractionated stereotactic radiosurgery (FSR) for a total of 54 Gy to the 88% isodose line in thirty 1.8 Gy fractions. Within a month of FSR completion, the tumor volume was reduced by nearly half and continued to diminish on each following imaging study. With six years of follow-up, the lesion continues to demonstrate near resolution with no recurrence and further treatment has not been necessary (Figure 4). Discussion The treatment of craniopharyngiomas is highly controversial. This controversy
放射治疗(RT)通常用于残余或复发的颅咽管瘤，并且单独放疗而不是作为手术辅助治疗的作用尚未明确定义。作者描述了一个病例50岁的男子表现为一个大鞍上颅咽管瘤延伸到第三脑室，产生急性脑积水。脑室腹腔分流术与内窥镜活检同时进行。分块立体定向放射外科(FSR)治疗导致病灶接近消退，6年内无复发迹象。回顾RT治疗颅咽管瘤不手术切除进行。颅咽管瘤是组织学上良性的轴外上皮肿瘤，起源于Rathke氏囊的胚胎残余这些罕见病变的发生率估计为每年每百万人1.5例，但占所有儿科脑肿瘤的10-15%。7,21尽管颅咽管瘤在组织学上是良性的，但由于对下丘脑、视器官和内分泌系统的损害，其发病率很高。积极的治疗被提倡，但是最佳的治疗方法经常被争论。根治性切除通常被用作一线治疗，因为这些病变在出现时通常较大，并伴有肿块效应。然而，这种手术有很高的下丘脑和内分泌功能障碍的发病率因此，许多人倾向于次全切除，保留邻近解剖结构，并对残余肿瘤进行辅助治疗。11,18孤立放疗治疗颅咽管瘤的情况并不多见。病例报告一名50岁男性，因两个月的头痛和颈部疼痛而就诊于急诊科，伴有视力急剧恶化、肢体麻痹和癫痫发作。颅成像显示一个3.7 x 2.5 x 3.2 cm的实心鞍上肿块，延伸至第三脑室，导致急性脑积水(图1和2)。通过右侧额部钻孔，放置脑室-腹膜分流器，同时对第三脑室肿块肿瘤进行内镜活检(图3)。术中可见一个黄色的叶状肿块，其一致性与脉络膜丛相似，填充Monro右侧孔。病理表现为乳头状颅咽管瘤。患者随后接受了分次立体定向放射手术(FSR)治疗，共54 Gy至88%等剂量线，分为30个1.8 Gy的分数。在FSR完成的一个月内，肿瘤体积缩小了近一半，并且在随后的每次影像学研究中继续缩小。经过六年的随访，病变继续显示接近消退，无复发，无需进一步治疗(图4)。颅咽管瘤的治疗存在很大争议。这一争议进一步加剧了无数可用的治疗方式:囊性引流、腔内化疗、有限切除或总切除(GTR)和放射治疗。在赞成根治性手术切除和认为次全切除术后辅助治疗最好避免与积极手术相关的潜在发病率之间存在最大的争论。虽然对手术治疗的批评主要基于开放入路的结果，但内镜鼻内切除术在限制发病率方面的作用尚不清楚(图5)。无论是在次全切除后残留肿瘤的情况下，还是在肿瘤复发时，放疗最常被用作颅咽管瘤的辅助治疗。已发表的系列报告显示，这些患者的局部控制率为79-95%。2,13,14,18,19,22,23在对长期随访的颅咽管瘤患者的回顾中，Karavitaki等人将121例患者分为四组:1)GTR, 2) GTR + RT, 3)次全切除术(STR)和4)STR + RT。在该队列中，10年无复发生存率分别为100%，100%，38%和77%这些结果已经在研究新的分步放射治疗技术的文献中得到了重复。通常，在1.8-2.0 Gy的范围内使用45-55 Gy，术后FSR手术的10年局部控制率为57-89%，而单纯手术的控制率为31-42%放射治疗颅咽管瘤的效果似乎受到病变一致性的影响，实体瘤较多，平均控制率最高，为90%。囊性或混合性肿瘤的发生率分别为88%和60%组织学对辐射效应的影响还不太清楚。虽然一些小组没有发现硬瘤和乳头状颅咽管瘤之间的显著差异，但Inoue等人确实发现后者的反应更好。 4,10,15大多数关于放疗的报道讨论颅咽管瘤的稳定性和局部肿瘤控制。很少有研究描述它对肿瘤大小的影响。经分次外照射和立体定向放射治疗后，病变明显缩小在我们报告的患者中，我们观察到肿瘤在一个月内显著缩小，这种效果目前已经持续了六年，这表明FSR在某些病例中可能是初始治疗的替代方案。尽管有这样的结果，我们继续使用并推荐手术作为颅咽管瘤的一线治疗。我们为有明显肿瘤残留或复发的患者保留FSR。尽管其作为初次表现的颅脑CT具有吸引力，但显示第三脑室等密度肿块伴侧脑室扩张a
{"title":"Fractionated Stereotactic Radiosurgery Alone for the Treatment of a Papillary Craniopharygioma","authors":"Tyler J. Kenning, James J. Evans","doi":"10.29046/JHNJ.007.1.005","DOIUrl":"https://doi.org/10.29046/JHNJ.007.1.005","url":null,"abstract":"The use of radiation treatment (RT) is usually reserved for residual or recurrent craniopharyngiomas, and the role of RT alone and not as an adjunctive therapy to surgery has not been clearly defined. The authors describe a case of a 50-year-old man presenting with a large suprasellar craniopharyngioma with extension into the third ventricle, producing acute hydrocephalus. A ventriculoperitoneal shunt was performed concurrently with an endoscopic biopsy. Treatment with fractionated stereotactic radiosurgery (FSR) resulted in near resolution of the lesion with no evidence of recurrence over six years. A review of RT for the treatment of craniopharyngiomas without surgical resection is performed. Introduction Craniopharyngiomas are histologically benign extraaxial epithelial tumors that arise form embryologic remnants of Rathke’s pouch.12 These rare lesions have an estimated incidence of 1.5 per million people per year, but comprise 10-15% of all pediatric brain tumors.7,21 Despite their benign histology, craniopharyngiomas cause significant morbidity from damage to the hypothalamus, optic apparatus, and endocrine system. Aggressive treatment is advocated, but the optimal treatment is often debated. Radical resection is often utilized as a first line treatment due to the frequently large size of these lesions at presentation and associated mass effect.6,24 Such surgery, however, can carry a high risk of morbidity with hypothalamic and endocrine dysfunction.26 For this reason, many favor subtotal resection with preservation of adjacent anatomical structures and adjuvant therapies for residual tumor.11,18 The use of radiotherapy in isolation for the treatment of craniopharyngiomas is infrequent. Case Report A 50-year-old man suffering from two months of headache and neck pain presented to the emergency department with a dramatic deterioration of his vision, limb paresis, and seizures. Cranial imaging demonstrated a 3.7 x 2.5 X 3.2 cm, solid suprasellar mass with extension into the third ventricle, producing acute hydrocephalus (Figures 1 and 2). Through a right frontal burrhole, placement of a ventriculoperitoneal shunt was performed concurrently with an endoscopic biopsy of the third ventricular mass tumor (Figure 3). Intraoperatively, a yellow-colored frond-like mass with a consistency similar to choroid plexus was seen filling the right foramen of Monro. Pathology was consistent with a papillary craniopharyngioma. The patient was subsequently treated with fractionated stereotactic radiosurgery (FSR) for a total of 54 Gy to the 88% isodose line in thirty 1.8 Gy fractions. Within a month of FSR completion, the tumor volume was reduced by nearly half and continued to diminish on each following imaging study. With six years of follow-up, the lesion continues to demonstrate near resolution with no recurrence and further treatment has not been necessary (Figure 4). Discussion The treatment of craniopharyngiomas is highly controversial. This controversy ","PeriodicalId":355574,"journal":{"name":"JHN Journal","volume":"5 11-12","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2012-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114038608","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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