Neurosurgery
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Although stereotactic radiosurgery is an established procedure for treating trigeminal neuralgia (TN), the likelihood of a prompt and durable complete response is not assured. Moreover, the incidence of facial numbness remains a challenge. To address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongated segment of the retrogasserian cisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high incidence of facial numbness, a gradual dose and volume de-escalation was performed over several years. In this single-institution prospective study, we evaluated clinical outcomes in a group of TN patients who underwent lesioning with seemingly optimized nonisocentric radiosurgical parameters. ⋯ Optimized nonisocentric CyberKnife parameters for TN treatment resulted in high rates of pain relief and a more acceptable incidence of facial numbness than reported previously. Longer follow-up periods will be required to establish whether or not the durability of symptom relief after lesioning an elongated segment of the trigeminal root is superior to isocentric radiosurgical rhizotomy.
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Controlled Clinical Trial
Cranial dural arteriovenous fistulae: asymptomatic cortical venous drainage portends less aggressive clinical course.
Cranial dural arteriovenous fistulae (dAVF) with cortical venous drainage (CVD) (Borden Types 2 and 3) are reported to carry a 15% annual risk of intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND). The purpose of this study was to compare the clinical course of Type 2 and 3 dAVFs that present with ICH or NHND with those that do not. ⋯ Cranial dAVFs with aCVD may have a less aggressive clinical course than those with sCVD.
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Craniopharyngiomas are benign tumors that originate from squamous cell rests of the embryonal hypophyseal-pharyngeal duct located along the pituitary stalk. After their surgical resection, recurrence usually occurs in the region of the original tumor bed. Ectopic recurrence of craniopharyngiomas is extremely rare. It usually occurs either along the surgical route, because of direct surgical seeding, or at a distal location in the subarachnoid space, because of seeding along the cerebrospinal fluid pathways. We present 3 examples of ectopic recurrences of craniopharyngiomas. ⋯ Although ectopic recurrence of a craniopharyngioma is very rare, it should always be considered in the differential diagnosis of what appears to be a new tumor in a patient with a history of previously resected craniopharyngiomas. Long-term follow-up of patients with resected craniopharyngioma is very important.
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Controlled Clinical Trial
Radiosurgery facilitates resection of brain arteriovenous malformations and reduces surgical morbidity.
Stereotactic radiosurgery makes brain arteriovenous malformations (AVM) more manageable during their microsurgical resection. To better characterize these effects, we compared results of microsurgical resection of radiated (RS) and nonradiated (RS) AVMs to demonstrate that previous radiosurgery facilitates surgery and decreases operative morbidity. ⋯ Previous radiosurgery facilitates AVM microsurgery and decreases operative morbidity. Radiosurgery is recommended for unruptured AVMs that are not favorable for microsurgical resection. Microsurgical resection is recommended for radiated AVMs that are not completely obliterated after the 3-year latency period but are altered favorably for surgery, even in asymptomatic patients. Prompt resection of persistent AVMs should be considered to avoid the risk of postlatency hemorrhage and to optimize patient outcomes.
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To investigate the time-dependent obliteration of cerebral arteriovenous malformations (cAVM) after CyberKnife radiosurgery (CKRS) (Accuray, Inc., Sunnyvale, CA) by means of sequential 3-T, 3-dimensional (3D), time-of-flight (TOF) magnetic resonance angiography (MRA), and volumetry of the arteriovenous malformation (AVM) nidus. ⋯ The use of sequential 3D TOF MRA at 3 T and nidus volumetry enables a noninvasive quantitative assessment of the dynamic obliteration process induced by CKRS in cAVMs. This method may be helpful to identify factors related to AVM obliteration after RS when larger patient cohorts become available.