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L. Dade Lunsford, Douglas Kondziolka, John C. Flickinger, David J. Bissonette, Charles A. Jungreis, Ann H. Maitz, Joseph A. Horton and Robert J. Coffey

complete obliteration has occurred, but a longer follow-up period is required. Although Kjellberg, et al. , 23 stated that stereotactic Braag-peak proton-beam irradiation of AVM's reduces the expected patient mortality rate based on life-table analysis, the actual rebleeding rate for AVM's treated but not obliterated is the same as if no treatment had been given. 4, 6, 27, 43, 45 Complications and Limitations of Radiosurgery Radiation-induced complications are related to the dose and volume of tissue irradiated. Surprisingly, within the dose range utilized in

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Mark E. Linskey, A. Julio Martinez, Douglas Kondziolka, John C. Flickinger, Ann H. Maitz, Theresa Whiteside and L. Dade Lunsford

microscopic analysis as well as unexpected mortality rates were compared between experimental arms by chi-squared analysis. Results Xenograft Survival Rate The overall “take rate” for tumor implants (no reduction in size plus 75% or greater surface vascularity) as assessed at initial surgical re-exploration was 78.3%. The mean overall “take rate” per donor tumor specimen was 80.9% ± 10.6% (± standard deviation) (range 60% to 100%). Adequacy of Matching Figure 3 is a scattergram depicting the distribution of tumor material from the 18 donor patients

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Salvador Somaza, Douglas Kondziolka, L. Dade Lunsford, John M. Kirkwood and John C. Flickinger

venous thrombosis, steroid psychosis, infection, and seizure (once each in four patients). The 30-day mortality rate was zero; five of seven patients who subsequently died did so as a result of recurrent brain metastases. A median survival period of 10 months was achieved. Wornom, et al. , 32 reported 22% morbidity and 11% mortality rates after resection in their series of 17 patients. Fell, et al. , 14 detailed an operative mortality rate of 5.4%. Major complications from surgery occurred in 17% of 31 patients in the series reported by Guazzo, et al. 17 Hafström

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L. Dade Lunsford, Salvador Somaza, Douglas Kondziolka and John C. Flickinger

total resection was approximately 20%. McCormack, et al. , 20 found that 5.6% of 53 patients who were neurologically intact before surgery developed mild postoperative deficits, two patients developed bone flap infections, and one developed cerebrospinal fluid leakage. Sixty years before McCormack, Cushing 5 reported an operative mortality of 11% for intracranial gliomas. In 1955, MacCarty 17 noted a mortality of 7.9%. Reports in 1987, 1990, and 1993 24–26 found a mortality rate of 3.3% to 6.5% after resection of low-grade astrocytomas. Morbidity and

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series reported by Ondra, et al., 10 85% of patients who bled after enrollment in their study suffered major morbidity or death. Brown, et al., 2 reported that rupture of AVMs had a mortality risk of 29% and a significant long-term morbidity rate of 23%. Furthermore, the risk surrounding brain AVMs is not limited to the risk of hemorrhage, and seizures and progressive deficit are especial dangers for large AVMs. Follow-up data gathered 20 years after enrollment showed that there was a mortality rate of 29% and a 27% rate of neurological handicap in the series by

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Vestibular schwannoma management

Part I. Failed microsurgery and the role of delayed stereotactic radiosurgery

Bruce E. Pollock, L. Dade Lunsford, John C. Flickinger, Brent L. Clyde and Douglas Kondziolka

, 29, 31, 37 The mortality rate after vestibular schwannoma resection is approximately 1% at centers of excellence in the modern era. 13, 31, 32 Gross-total resection of vestibular schwannomas is now accomplished in the vast majority of cases. The tumor recurrence rate after complete resection has been reported to be as low as 0 to 3%. 6, 7, 13, 28, 31–33 However, tumor recurrence rates of 7 to 11% have been documented during the magnetic resonance (MR) imaging era in cases having a follow-up period lasting 3 to 16 years (JP Epron, et al. unpublished data). 3, 22

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Brian R. Subach, Douglas Kondziolka, L. Dade Lunsford, David J. Bissonette, John C. Flickinger and Ann H. Maitz

radiosurgery are thought to occur as a result of ischemic neuropathy or demyelination arising from radiation exposure. 17 The cumulative tumor control rate and risk of delayed cranial nerve morbidity associated with radiosurgery are similar to those reported in operative series. However, the operative morbidity and mortality rates were significantly lower with radiosurgery. Given the current rate of hearing preservation (67% after 1992), we are still cautious about advocating radiosurgery for patients with functional hearing. For patients with large acoustic tumors (> 3 cm

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Nicolas Massager, Jean Régis, Douglas Kondziolka, Théodore Njee and Marc Levivier

 death due to hemorrhage <2 yrs 1 * oblit = obliteration. Discussion Rationale for the Treatment of Brainstem AVM by GKS The management of brainstem AVMs remains controversial. The significant cumulative risk of bleeding 2 and the high morbidity and mortality rates associated with a hemorrhage in this location force us to treat patients presenting with a brainstem AVM. When the nidus of the AVM is inside the brainstem parenchyma, microsurgical removal or embolization is very risky. 1 For small AVMs in this location, GKS, because

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Constantinos G. Hadjipanayis, Douglas Kondziolka, Paul Gardner, Ajay Niranjan, Shekhar Dagam, John C. Flickinger and L. Dade Lunsford

patients harboring pilocytic astrocytomas compared with those harboring other low-grade tumors. In their series of 88 children with low-grade astrocytomas, the researchers performed biopsies to confirm that 32 were pilocytic astrocytomas located in the optic chiasm/hypothalamus (25 patients), thalamus (four patients), and medulla (three patients). The rate of recurrence of pilocytic astrocytomas was 62.5%, with a mortality rate of 28.1%. Radiation Therapy For those patients in whom total or subtotal resection cannot be safely performed, alternative management

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John Y. K. Lee, Ajay Niranjan, James McInerney, Douglas Kondziolka, John C. Flickinger and L. Dade Lunsford

base (Simpson Grade I) is the preferred treatment for many patients. 4, 23, 24, 27 Complete resection of meningiomas of the cavernous sinus, however, is not feasible without causing serious disease or death. Overall, the estimated likelihood of obtaining a complete resection of a cavernous sinus tumor ranges from 22.9 to 100%. 3, 6, 10, 11, 18, 29, 30, 34, 37 The mortality rate in modern microsurgical series ranges from 0 to 7%. 10, 29, 35 Permanent cranial nerve deficits were noted in a significant percentage of patients (8–26%). 10, 16, 29 In patients in our