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  • Author or Editor: L. Fernando Gonzalez x
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De novo presentation of an arteriovenous malformation

Case report and review of the literature

L. Fernando Gonzalez, Ruth E. Bristol, Randall W. Porter and Robert F. Spetzler

✓ The authors report the case of a patient with a de novo arteriovenous malformation (AVM), indicating that the origin of these lesions may not always be congenital.

A 3-year-old girl who was struck by a car suffered a mild head injury and experienced posttraumatic epilepsy. The initial magnetic resonance (MR) image obtained in this child revealed only a small contusion in the left frontal lobe. Intractable epilepsy subsequently developed. A second MR image obtained almost 4 years after the injury demonstrated an AVM in the right posterior temporal lobe that was verified using angiography. The lesion was classified as a Spetzler—Martin Grade III AVM. The patient underwent embolization of the feeding vessels followed by gamma knife surgery. Fourteen months after treatment she was asymptomatic. Follow-up MR images demonstrate no evidence of an AVM and no changes in the white matter.

This case presents a de novo AVM that developed within approximately 4 years. The findings indicate that AVMs may not always be congenital and reinforce the concept that the natural history of AVMs is dynamic. Lesions may appear de novo, grow, and thrombose spontaneously.

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L. Fernando Gonzalez, Gregory P. Lekovic, Jennifer Eschbacher, Stephen Coons, Randall W. Porter and Robert F. Spetzler

✓Cavernous hemangiomas that occur within the cavernous sinus (CS) are different from cerebral cavernous malformations (CMs) clinically, on imaging studies, and in their response to treatment. Moreover, CMs are true vascular malformations, whereas hemangiomas are benign vascular tumors. Because of these differences, the authors suggest that these two entities be analyzed and grouped separately. Unfortunately, despite these differences, much confusion exists in the literature as to the nature, behavior, and classification of these two distinct lesions. This confusion is exacerbated by subtle histological differences and the inconsistent use of nomenclature. The authors use the term “cavernous malformation” to refer to intraaxial lesions only; they prefer to use the term “cavernous sinus hemangioma” to refer to extraaxial, intradural hemangiomas of the CS.

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Iman Feiz-Erfan, Patrick P. Han, Robert F. Spetzler, Giuseppe Lanzino, Mauro A. T. Ferreira, L. Fernando Gonzalez and Randall W. Porter

Object

Squamous cell carcinoma (SCC) of the head and neck may involve the carotid artery (CA) in the neck or skull base. Whether tumor resection should be associated with sacrifice of the CA is debatable.

Methods

Records obtained in five consecutive patients (three men, and two women; mean age 58 years, range 47–69 years) treated for recurrent or progressive SCC involving the internal carotid artery (ICA) at the skull base were reviewed retrospectively. The ICA was sacrificed, an extracranial–intracranial (EC–IC) bypass was performed using a saphenous vein graft, and the tumor and involved ICA segment were resected.

Gross-total resection of the SCC was achieved in four cases. One patient died of an acute postoperative stroke due to bypass occlusion and did not undergo tumor resection. No other permanent ischemic or neurological deficits were noted. The other four patients died of tumor progression (survival range 2–40 months, mean 14 months). One patient survived for more than 2 years (2-year overall survival rate 20%). Histological tumor invasion of the CA wall was verified in one of the three evaluated specimens.

Conclusions

A high rate of morbidity and mortality is associated with cases in which skull base CA sacrifice and an EC–IC bypass are performed. Not all resected arteries are shown to have malignant infiltration on histological examination. Better preoperative imaging criteria are needed to define malignant infiltration of the ICA at the skull base. Chemotherapy and radiotherapy without aggressive tumor resection may be an option for these patients.

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Nicholas C. Bambakidis, L. Fernando Gonzalez, Sepideh Amin-Hanjani, Vivek R. Deshmukh, Randall W. Porter, Philip C. Daspit and Robert F. Spetzler

Combined approaches to the skull base provide maximal exposure of the complex and eloquent anatomical structures contained within the posterior fossa. Common to these combined exposures are variable degrees of petrous bone removal. Understanding the advantages of each approach is critical when attempting to balance increases in operative exposure against the risk of potential complications. Despite their risks, aggressive combined exposures to the posterior fossa enable the greatest degree of visualization of the anatomy. Consequently, surgeons can approach lesions with maximal margins of safety, which cannot otherwise be realized. To minimize morbidity in all cases, the approach chosen must be applied individually, depending on the lesion and the patient's characteristics.

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Gregory P. Lekovic, L. Fernando Gonzalez, Andrew G. Shetter, Randall W. Porter, Kris A. Smith, David Brachman and Robert F. Spetzler

Object

Increasingly, radiosurgery is used to treat pineal region tumors, either as a primary treatment or as an adjunct to conventional radiation therapy. The authors report their experience with Gamma Knife surgery (GKS) for the treatment of pineal region tumors.

Methods

The authors retrospectively reviewed the charts of all patients undergoing GKS at their institution between 1997 and 2005. Seventeen patients underwent GKS for nonmetastatic tumors of the pineal region. All patients were treated using Leksell Gamma Plan treatment planning software (versions 4.12::5.34). The mean treatment volume was 7.42 cm3 (range 1.2–32.5 cm3). Prescribed doses ranged from 12 to 18 Gy. All doses were prescribed to the 50% isodose line. Independent neuroradiologists reviewed all follow-up imaging studies for evidence of progression of disease.

Results

One patient (Case 10) died 6 days after GKS. Mean clinical and imaging follow-up in the remaining 16 cases was 31 months. Local control was established during a mean neuroimaging follow-up period of 31 months (range 1–95) in 16 patients (100%). In 2 of these 16 patients (one with an anaplastic astrocytoma, the other with a primitive neuroectodermal tumor), leptomeningeal and spinal spread of tumor developed despite control of the pineal lesions. There were no new neurological deficits attributable to GKS. Three patients died (including the one who died 6 days after GKS) during the follow-up period.

Conclusions

Excellent control of pineal region brain tumors can be obtained with GKS when it is used in conjunction with surgery, conventional radiation therapy, or both. Patient survival and quality of life can be optimized through the use of multimodal treatment, including surgery, conventional radiation therapy and/or radiosurgery, and chemotherapy, when applicable.