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Jonathan M. Bledsoe, Michael J. Link, Scott L. Stafford, Paul J. Park and Bruce E. Pollock

preferred treatment when this can be accomplished safely, 18 but subtotal resection followed by fractionated radiotherapy or SRS is often performed when the risk of total removal is prohibitive. 6 , 10 , 12 , 16 , 19 The dose/volume relationship and how it relates to postradiosurgical complications has been well documented. 5 Nonetheless, the progressive trend to treat benign tumors with lower radiation doses theoretically permits patients with larger lesions to be considered for SRS. 7 In this study, we review the radiosurgical experience at our center for patients

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Brian D. Milligan, Bruce E. Pollock, Robert L. Foote and Michael J. Link

studies have documented increased morbidity following GKS for larger tumors, but the majority of these tumors were treated with higher tumor margin doses (16 Gy) than is generally used today. 4 , 10 , 14 , 20 , 30 One study of VSs treated with contemporary radiosurgical doses (tumor margin doses of 12–13 Gy) reported only a 57% 5-year PFS for patients with tumors larger than 15 cm 3 (24 tumors). 14 A more recent GKS study of larger VSs (5–22 cm 3 , median volume 9 cm 3 ) treated with a median margin dose of 12 Gy demonstrated an 87% tumor control rate at the last

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Kajetan L. von Eckardstein, Charles W. Beatty, Colin L. W. Driscoll and Michael J. Link

Mayo Clinic electronic imaging software. 10 The area of all planes was multiplied by the slice thickness of 3 mm to yield a tumor volume in cubic millimeters. After an initial increase in size of the untreated right VS, the tumor has subsequently spontaneously regressed steadily in size. The tumor has not undergone any cystic change. The volume had decreased 77%—from a maximum of 7900 mm 3 to 1900 mm 3 —at most recent follow-up ( Fig. 1 ). The greatest posterior fossa diameter decreased from 30.1 mm to 18.6 mm during this imaging interval ( Fig. 2 ). F ig . 1

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Bruce E. Pollock, Michael J. Link and Robert L. Foote

. Twenty-eight patients (9%) were excluded from our analysis because they had an imaging follow-up of < 24 months. A comparison of these excluded patients with the study population showed no difference in the mean patient age, tumor volume, tumor margin radiation dose, or maximum radiation dose. Three other patients (1%) refused research authorization. The remaining 293 patients, 146 men and 147 women, composed the study population. The mean patient age was 58.1 ± 15.1 years. Twenty-two patients (8%) had NF2, and 44 patients (15%) had recurrent tumors following a prior

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Jean Régis, Christine Delsanti and Pierre-Hugues Roche

transient tumor growth (see Fig. 1 ) without any predictive value for the long-term outcome in terms of tumor control. 12 However, in the subgroup of patients who presented with a marked increase in tumor volume between time of diagnosis and intervention (35%), the postoperative growth was more marked. But in the subgroup of patients in whom an increase in volume of > 30% of the extracanalicular portion was seen between diagnosis and treatment, we found an average tumor decrease of 40% at 4 years. FIG. 1. Chart showing comparative evolution of the average total tumor

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Theresa M. Cheng, Michael J. Link and Burton M. Onofrio

, or discography is the best diagnostic method since the diagnosis of disc herniation depends on the differential densities of the disc material, nerve roots, epidural fat, and the thecal sac. 3, 5, 6, 8, 11, 12, 14–17, 22, 23, 26, 28, 31, 32, 34, 35 Differential diagnosis of disc herniation includes metastatic neoplasm, primary neoplasm, conjoined root sheath anomaly, arachnoid diverticuli, perineural cysts, neurofibroma, vertebral osteophytes, prominent epidural or paraspinal venous plexuses, pseudodisc protrusion of scoliosis, and volume-averaging artifacts. 2, 6

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Mark P. Piedra, Paul D. Brown, Paul C. Carpenter and Michael J. Link

. Treatment Options The options of continued observation, WBRT, craniotomy for resection, and radiosurgery were discussed with the patient and her family. Given the tumor's small size, its location and solitary nature, and the status of the patient's systemic disease, radiosurgery was believed to be the best option for this patient. Gamma Knife Surgery On October 5, 2000, the patient underwent GKS, which was performed using the Leksell Gamma Knife model C (Elekta, Atlanta, GA). The dose plan consisted of two 4-mm isocenters of radiation to cover a tumor volume of

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Michael J. Link, Thomas C. Schermerhorn, Jimmy R. Fulgham and Douglas A. Nichols

AVM may have initiated the thrombosis, which then became exacerbated by the Leiden factor V mutation. Local damage to the venous endothelium caused by turbulent flow and the mechanical action of shearing stress on the endothelial surfaces has been proposed as the initiating event in the narrowing of the lumen and thrombosis of the AVM draining vein. 11, 34 Others have suggested that some instances of narrowing of the AVM draining vein may represent a vasoconstrictive response to increased shunt volume or elevated venous pressure. 28 Due to the large size of the

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Michael J. Link, Robert J. Coffey, Douglas A. Nichols and Deborah A. Gorman

chemosis and/or ophthalmoplegia 12 seizures 2 altered mental status 3 neurological deficit * 1 hemorrhage † 5 * Hemisensory loss and ataxia. † Based on strong clinical history in one patient without confirmatory imaging. Characteristics of Dural AVFs All dural AVFs were defined using conventional angiography. The location and venous drainage pattern of the fistulas are summarized in Table 2 . The mean nidus volume was 3.3 cm 3 (range 0.35–12.4 cm 3 ). Fourteen fistulas had retrograde cortical or

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Cormac O. Maher, Robert E. Anderson, Robyn L. McClelland and Michael J. Link

of the grafts in our patients. Similarly, we chose not to exceed 100 mm Hg of intracranial pressure in the experimental protocol because our goal was to recreate clinical conditions as accurately as possible. Other described methods for measuring leakage pressures from dural repair sites have included connecting the dura to a specially designed pressure chamber attached to a transducer, 10 as well as increasing intracranial pressure in animal models by compressing the thorax while maintaining pulmonary inflation. 4 We favored the volume-infusion technique