✓ Neuropsychological outcome of 100 patients with severe head injuries is correlated with their clinical condition on admission. The aim of this paper is to estimate the reliability of several early indices of brain damage severity in formulating a prognosis. Both the Glasgow Coma Scale and the neurological syndrome involved appeared to be highly reliable in this respect. The duration of coma and of posttraumatic amnesia was not as significant. Since these two parameters were assessed when reviewing the cases, they have to be considered only as retrospective judgments. The findings emphasized the importance of reflex ocular motility and the value of recording eletroencephalographic (EEG) activity, particularly EEG sleep patterns. The relationship between rapid eye movement sleep impairment and cognitive defects was highly significant. Analysis of surgical observations demonstrated that purely compressive expanding lesions were not as harmful as parenchymal damage. Of paramount importance was the time lapse between injury and surgery, since secondary lesions may develop and affect cerebral areas that are involved both in sleep organization and in memory functions.
Alberto Alexandre, Federico Colombo, Paola Nertempi and Antonio Benedetti
Leopoldo Casentini, Umberto Fornezza, Zeno Perini, Egle Perissinotto and Federico Colombo
Microsurgery is not the only option for larger vestibular schwannomas (VSs); recent reviews have confirmed the feasibility and efficacy of radiosurgery for larger VSs. This study illustrates the outcomes of a series of large VSs after multisession stereotactic radiosurgery (SRS).
A series of 33 VSs larger than 8 cm3 (range 8–24 cm3, mean 11 cm3, median 9.4 cm3) were treated using the CyberKnife from 2003 to 2011 with the multisession SRS technique in 2–5 fractions (14–19.5 Gy). Five patients had undergone surgical removal and 5 had ventriculoperitoneal shunts. Nine patients were eligible for but refused surgery. Twelve patients were older than 70 years and 5 were younger than 40 years. Two female patients had neurofibromatosis.
The follow-up period ranged from 12 to 111 months (median 48 months); radiological growth control was achieved in 94% of cases: 19 tumors (58%) displayed no size variation or reduction in tumor diameter; 12 (36%), after a transient enlargement, presented with arrested growth or shrinkage. Seven patients had a volume reduction of more than 50%. Two patients (6%) needed debulking and 2 were treated with ventriculoperitoneal shunts. Actuarial progressionfree survival rates at 1 year and 5 years were 97% and 83%, respectively. Hearing was retained in 7 of the 8 patients with serviceable baseline hearing. Adverse events were limited to 1 case each of vertigo, tongue paresthesia, and trigeminal neuralgia.
The good control rate obtained with multisession SRS deepens the controversy of the radiobiology of VSs and may extend the indication of radiation therapy (fractionated or SRS) for large VSs to include patients without symptoms of mass effect. The limited number of cases and short follow-up period do not provide sufficient support for widespread application of multisession SRS in young patients. Further studies with multisession SRS are warranted.
Federico Biglioli, Valeria Colombo, Dimitri Rabbiosi, Filippo Tarabbia, Federica Giovanditto, Alessandro Lozza, Silvia Cupello and Pietro Mortini
Facial palsy is a well-known functional and esthetic problem that bothers most patients and affects their social relationships. When the time between the onset of paralysis and patient presentation is less than 18 months and the proximal stump of the injured facial nerve is not available, another nerve must be anastomosed to the facial nerve to reactivate its function. The masseteric nerve has recently gained popularity over the classic hypoglossus nerve as a new motor source because of its lower associated morbidity rate and the relative ease with which the patient can activate it. The aim of this work was to evaluate the effectiveness of masseteric–facial nerve neurorrhaphy for early facial reanimation.
Thirty-four consecutive patients (21 females, 13 males) with early unilateral facial paralysis underwent masseteric–facial nerve neurorrhaphy in which an interpositional nerve graft of the great auricular or sural nerve was placed. The time between the onset of paralysis and surgery ranged from 2 to 18 months (mean 13.3 months). Electromyography revealed mimetic muscle fibrillations in all the patients. Before surgery, all patients had House-Brackmann Grade VI facial nerve dysfunction. Twelve months after the onset of postoperative facial nerve reactivation, each patient underwent a clinical examination using the modified House-Brackmann grading scale as a guide.
Overall, 91.2% of the patients experienced facial nerve function reactivation. Facial recovery began within 2–12 months (mean 6.3 months) with the restoration of facial symmetry at rest. According to the modified House-Brackmann grading scale, 5.9% of the patients had Grade I function, 61.8% Grade II, 20.6% Grade III, 2.9% Grade V, and 8.8% Grade VI. The morbidity rate was low; none of the patients could feel the loss of masseteric nerve function. There were only a few complications, including 1 case of postoperative bleeding (2.9%) and 2 local infections (5.9%), and a few patients complained about partial loss of sensitivity of the earlobe or a small area of the ankle and foot, depending on whether great auricular or sural nerves were harvested.
The surgical technique described here seems to be efficient for the early treatment of facial paralysis and results in very little morbidity.
Federico Colombo, Carlo Cavedon, Paolo Francescon, Leopoldo Casentini, Umberto Fornezza, Lucio Castellan, Francesco Causin and Stefano Perini
Object. Radiosurgical treatment of a cerebral arteriovenous malformation (AVM) requires the precise definition of the nidus of the lesion in stereotactic space. This cannot be accomplished using simple stereotactic angiography, but requires a combination of stereotactic biplanar angiographic images and stereotactic contrast-enhanced computerized tomography (CT) scans. In the present study the authors describe a method in which three-dimensional (3D) rotational angiography is integrated into stereotactic space to aid treatment planning for radiosurgery.
Methods. Twenty patients harboring AVMs underwent treatment planning prior to linear accelerator radiosurgery. Planning involved the acquisition of two different data sets, one of which was obtained using the standard method (a combination of biplanar stereotactic angiography with stereotactic CT scanning), and the other, which was procured using a new technique (nonstereotactic 3D rotational angiography combined with stereotactic CT scanning by a procedure of image fusion).
The treatment plan that was developed using the new method was compared with that developed using the standard one. For each patient the number of isocenters and the dimension of selected collimators were the same, based on the information supplied in both methods. Target coordinates were modified in only five cases and by a limited amount (mean 0.7 mm, range 0.3–1 mm).
Conclusions. The new imaging modality offers an easier and more immediate interpretation of 3D data, while maintaining the same accuracy in target definition as that provided by the standard technique. Moreover, the new method has the advantage of using nonstereotactic 3D angiography, which can be performed at a different site and a different time with respect to the irradiation procedure.
Federico Colombo, Carlo Cavedon, Leopoldo Casentini, Paolo Francescon, Francesco Causin and Vittore Pinna
The authors describe a method that utilizes an image-guided robotic radiosurgical apparatus (the CyberKnife) for treatment of cerebral arteriovenous malformations (AVMs). This procedure required the development of an original technique that allows a high degree of automation.
Angiographic images were imported into the treatment planning software by coregistering CT and 3D rotational angiography. The nidus contour was delineated using the contouring tools of the treatment planning system. Functional MR imaging was employed for contouring critical cortical regions, such as the motor cortex and language areas. Once the radiation dose to be delivered to the target volume and dose constraints to critical structures were prescribed, the inverse treatment planning function determined the optimal treatment plan.
A series of 279 patients with cerebral AVMs underwent CyberKnife radiosurgery. One transitory adverse effect of the radiation procedure was observed. Eight bleeding occurrences were noted before complete AVM obliteration. Of the 102 patients with follow-up > 36 months, 80 underwent angiographic evaluation. In this group, 65 patients (81.2%) showed complete angiographic obliteration of their AVM. In 8 more patients, complete angiographic obliteration was demonstrated by MR angiography only.
This is the first report describing a technique developed for CyberKnife radiosurgery of cerebral AVMs. The use of different imaging modalities for automatic delineation of the target and critical structures combined with the employment of the inverse treatment planning capability is the crucial point of the procedure. The procedure proved to be safe and efficient.