Progress in neurological surgery最新文献

Psychiatric illnesses create great suffering for patients and the medical solution is sometimes limited. The experience observed after treating patients with obsessive-compulsive disorder (OCD), depression, and anorexia nervosa by Gamma Knife radiosurgery (GKRS) is presented. Ten patients with medically refractory OCD, 3 patients with depression resistant to medical treatment and electroconvulsive therapy, and 5 patients with refractory anorexia nervosa have been treated. Bilateral anterior capsulotomy has been performed to treat OCD and bilateral cingulotomy has been applied to treat severe depression and anorexia nervosa. The accumulated experience about treatment of OCD by GKRS is reviewed. In our experience, 70% of OCD patients achieved a full response. We observed a significant improvement in patients with depression and anorexia nervosa evidenced by the scales of assessment (mean reduction of 40% in the Beck Depression Inventory at 1-year follow-up and 40% average increase of body mass index at 6-month follow-up). No side effects have been observed. These procedures are effective in reducing obsession, compulsion, depression, and anxiety, improving the quality of life of the patients without side effects.

Leksell stereotactic radiosurgery has proven to be effective for less common tumors encountered in the brain, including hemangiomas of the orbit or cavernous sinus, recurrent hemangiopericytomas, and both sporadic hemangioblastomas as well as those encountered in the context of von Hippel-Lindau (VHL) disease. While all three tumors are responsive to single-session radiosurgery, hemangiomas and hemangiopericytomas are the most likely to demonstrate tumor regression. Hemangiopericytomas that recur after initial resection can be lower grade or anaplastic and have both higher local as well as distant recurrence risks. Sporadic hemangioblastomas undergo Leksell radiosurgery at the time of recurrence after initial surgery. In the context of VHL, growing or recurrent tumors are treated with tumor control rates exceeding 90%. Tumor control improves with higher dose delivery, typically >15 Gy at the margin. Dose-limiting structures may include the optic apparatus for hemangiomas and brain stem locations for hemangioblastomas.

Tremor is the most prevalent movement disorder in adults. Patients who are refractory to medical management can explore surgical intervention. Deep-brain stimulation (DBS) and radiofrequency thalamotomy (RFT) are surgical procedures for intractable tremor that target the ventralis intermedius (VIM) nucleus to relieve contralateral tremor. For patients who are not candidates for surgical procedures, stereotactic radiosurgery (SRS) is a minimally invasive management option for tremor relief. SRS has been used for the elderly, those considered high surgical risk for other surgical procedures, those who are unresponsive to either DBS or RFT, and those who prefer a less invasive option. Radiosurgical thalamotomy is performed using a central dose of 130-140 Gy delivered to the VIM nucleus of the thalamus. The critical aspect of the dose planning procedure is the selection of the target, which requires a neurosurgeon experienced with movement disorder surgery. More than 90% of patients experience improvements in their tremor and quality of life after radiosurgical thalamotomy. Adverse radiation effects rates are low (4%). In selected cases, staged bilateral procedure can also be performed to relieve bilateral refractory tremor. In patients with tremor-predominant Parkinson's disease, VIM thalamotomy is also effective.

Stereotactic radiosurgery using the Leksell Gamma Knife has proven to be a valuable alternative to orbital enucleation or fractionated radiation therapy for primary tumors of the orbit, metastatic tumors to the choroid, and primary uveal melanomas. With this approach in a single outpatient setting, the eye is immobilized by a local block after which high-definition MRI or CT is performed to define the target. After rapid dose planning, radiation delivery is completed before the local block dissipates. The tumor response is often dramatic. The risk of acute narrow-angle glaucoma, radiation-related retinopathy, or cataract formation has been relatively low. Other worldwide centers have confirmed that this approach is superior to either enucleation or fractionated radiation therapy for these relatively rare problems.

Pituitary adenomas represent a common intracranial pathology, usually resulting in the systemic secretion of hormones and compression of local endocrine and optic structures, causing a wide variety of clinical sequelae. While they are typically treated with upfront endocrine and/or surgical decompressive therapy, in patients with residual, recurrent, or refractory disease, decades of data support management with stereotactic radiosurgery. This modality offers favorable local tumor control, endocrine remission rates, and infrequent toxicity. In the future, this alternative to resection will continue to gain popularity among patients and health care providers.

Management of craniopharyngiomas remains challenging due to the tumor's often intimate relationship with the optic apparatus, the hypothalamus, and the pituitary gland. Often multimodal management is needed to achieve the best treatment outcome: tumor control coupled with endocrine, visual, and neurocognitive preservation. Many surgeons favor initial subtotal resection followed by adjunctive therapy to improve quality of life in a tumor with potentially long-term survival even if coupled with a need for periodic new interventions. During the patient's subsequent follow-up, solid or cystic tumor recurrence or progression often require additional management options. Leksell stereotactic radiosurgery (SRS) is a valuable adjuvant strategy that enhances long-term outcomes in patients with residual or recurrent craniopharyngiomas. Tumor control rates of 70-90% have been reported using 11- to 13-Gy tumor margin doses delivered using the Gamma Knife. Smaller tumors are associated with better radiosurgery outcomes. SRS is an effective management for residual or recurrent solid craniopharyngiomas with a favorable benefit-to-risk profile.

Chordomas and chondrosarcomas are rare locally aggressive skull base tumors with high progression or recurrence rates. Ultimately, they have high mortality rates unless they respond to multimodality management options that include one or more surgical resections, fractionated radiation therapy, and stereotactic radiosurgery (SRS). SRS has become a standard management option for recurrent or residual chordomas and chondrosarcomas after failed surgical resection and fractionated radiation therapy. This report examines the role of SRS in these skull base tumors.

Here we discuss the low risk of radiation-related complications after Leksell radiosurgery, as well as its diagnosis and management. Using multimodality imaging in the context of clinical suspicion of radiation injury clinicians can now start management with agents designed to reduce the progression of radiation vasculopathy. In more severe cases both medical and surgical management options can be offered.