Hung-Chuan Pan, Ming-Hsih Sun, Clayton Chi-Chang Chen, Chun-Jung Chen, Chen-Hui Lee and Jason Sheehan
Gamma Knife surgery (GKS) has been shown to be effective for treating many patients with brain metastasis. Some brain metastases demonstrate significant peritumoral edema; radiation may induce cerebral edema or worsening preexisting edema. This study was conducted to evaluate the imaging and neurobehavioral outcomes in patients with preexisting peritumoral edema who then undergo GKS.
Between August 2003 and January 2008, 63 cases of brain metastasis with significant peritumoral edema (> 20 cm3) were prospectively studied. The study inclusion criteria were as follows: 1) a single metastatic lesion with significant edema (perilesional edema signal volume on FLAIR > 20 cm3); and 2) inclusion of only 1 lesion > 20 cm3 in the study (in cases of multiple lesions noted on FLAIR images). All patients received MR imaging with pulse sequences including T1-weighted imaging and FLAIR with or without contrast and T2-weighted imaging at an interval of 3 months. A neurological assessment and Brain Cancer Module (BCM-20) questionnaire were obtained every 2–3 months. Kaplan–Meier, Cox regression, and logistic regression were used for analysis of survival and associated factors.
At the time of GKS, the median Karnofsky Performance Scale (KPS) score was 70 (range 50–90), and the mean BCM-20 score was 45.5 ± 6.1. The mean tumor volume (± standard deviation) was 5.2 ± 4.6 cm3 with corresponding T2-weighted imaging and FLAIR volumes of 59.25 ± 37.3 and 62.1 ± 38.8 cm3, respectively (R2 = 0.977, p < 0.001). The mean edema index (volume of peritumoral edema/tumor volume) was 17.5 ± 14.5. The mean peripheral and maximum GKS doses were 17.4 ± 2.3 and 35 ± 4.7 Gy, respectively. The median survival was 11 months. The longer survival was related to KPS scores ≥ 70 (p = 0.008), age < 65 years (p = 0.022), and a reduction of > 6 in BCM-20 score (p = 0.007), but survival was not related to preexisting edema or tumor volume. A reduction in BCM-20 score of > 6 was related to decreased volume in T1-weighted and FLAIR imaging (p < 0.001). Thirty-eight (79.2%) of 48 patients demonstrated decreased tumor volume and accompanied by decreased T2-weighted imaging and FLAIR volume. Eight (16.7%) of the 48 patients exhibited increased or stable tumor volume. A margin dose > 18 Gy was more likely to afford tumor reduction and resolution of peritumoral edema (p = 0.005 and p = 0.006, respectively). However, prior external-beam radiation therapy correlated with worsened preexisting peritumoral edema (p = 0.013) and longer maintenance of corticosteroids (p < 0.001).
Patients demonstrating a reduction in the BCM-20 score > 6, age < 65 years, and KPS score ≥ 70 exhibited longer survival. Significant preexisting edema did not influence the tumor response or clinical outcome. The resolution of edema was related to better quality of life but not to longer survival.
Hui Pan, Thomas Zimmerman, Julia Zakhaleva, John M. Abrahams, Hongliang Jiang and Weiliam Chen
Treatment of cerebral aneurysms by endovascular deployment of liquid embolic agents has been proposed as an alternative strategy to conventional coiling, and new materials are being developed for embolization. In this study, the authors used a single-injection, biocompatible, biodegradable and pH-responsive acrylated chitosan (aCHN) with conjugated vascular endothelial growth factor (rhVEGF) in a rat aneurysm model.
The efficacy of the aCHN formulation with rhVEGF was tested using a common carotid artery occlusion model in rats, and the extent of embolization was evaluated using quantitative, qualitative, and histopathological techniques after 14 days of implantation.
The mean occlusion was significantly greater for the rhVEGF/aCHN-treated group (96.8 ± 3.0%) than for the group receiving aCHN (74.7 ± 5.6%) (p < 0.01). Through qualitative evaluation, intimal and medial proliferation were significantly greater with rhVEGF/aCHN than with aCHN and controls (p < 0.001). Degradation of the aCHN filler was monitored in concert with the production of extracellular matrix components. Macrophages migrated in and proliferated inside the occluded carotid artery lumens were identified by histological and immunostainings. Results showed resorption of chitosan with concurrent development of collagen and elastin into the vessel lumen, suggesting clot maturation into fibrosis.
Chitosan with a bioactive agent such as rhVEGF showed excellent results in occluding aneurysms in a rat model.
Jingyu Chen, Zhi Chen, Fei Li, Jiangkai Lin, Hui Meng and Hua Feng
The purpose of this study was to review 14 rare cases of cerebral paragonimiasis that first manifested as intracranial hemorrhage (ICH), and to investigate the characteristics of clinical manifestation, diagnosis, and treatment of the disease.
The authors have encountered 14 cases of cerebral paragonimiasis in patients between the ages of 6 and 16 years (mean age 11.5 years) who presented with sudden headache, nausea, and vomiting. Three of them were affected with varying degrees of limb hemiplegia, and in 1 this was combined with high fever; the blood eosinophil count and enzyme-linked immunosorbent assay showed positive results too. The ICHs were observed with cranial CT and MR imaging, and lung lesions were also detected in 5 cases on chest CT scans. Ten of the diagnosed cases were treated with oral praziquantel. Three of these patients were given carbamazepine from the beginning of parasiticidal treatment to prevent seizures; 4 of the remaining 7 patients experienced epileptic seizures during the treatment process. Four patients needed surgery to remove the lesions, and these individuals received praziquantel treatment right after the surgery.
Pathological examinations demonstrated eosinophilic granuloma in these patients. There was no disease recurrence or epilepsy in 11–40 months of follow-up; however, mild hemiplegia could still be observed in 2 cases after 12 months and 17 months of follow-up.
The possibility of cerebral paragonimiasis should be considered when ICH is detected in young patients who are either from an endemic area or have recently visited such an area; the relatively small amount of hemorrhage in cerebral paragonimiasis is often represented as small lesions surrounded by disproportionately larger edema on the imaging study. Preventive antiepileptic drugs should be used along with the administration of parasiticide.
JianMing Luo, Bin Liu, ZeYu Xie, Shan Ding, ZeRui Zhuang, Lan Lin, YanChun Guo, Hui Chen and Xiaojun Yu
The object of this study was to compare the effects and complications of manual and computer-aided shaping of titanium meshes for repairing large frontotemporoparietal skull defects following traumatic brain injury.
From March 2005 to June 2011, 161 patients with frontotemporoparietal skull defects were observed. Patients were divided into 2 groups according to the repair materials used for cranioplasty: 83 cases used computer-aided shaping for the titanium mesh, whereas the remaining 78 cases used a manually shaped titanium mesh. The advantages and disadvantages of the 2 methods were compared.
No case of titanium mesh loosening occurred in either group. Subcutaneous fluid collection, titanium mesh tilt, and temporal muscle pain were the most common complications. In the manually shaped group, there were 14 cases of effusion, 10 cases of titanium mesh tilt, and 15 cases of temporal muscle pain. In the computer-aided group, there were 6 cases of effusion, 3 cases of titanium mesh tilt, and 6 cases of temporal muscle pain. The differences were significant between the 2 groups (p < 0.05). Other common complications were scalp infection, exposure of titanium mesh, epidural hematoma, and seizures. In the computer-aided group, the operative time decreased (p < 0.01), the number of screws used was reduced (p < 0.01), and the satisfaction of patients was significantly increased (p < 0.05).
Computer-aided shaping of titanium mesh for repairing large frontotemporoparietal skull defects decreases postoperative complications and the operative duration, reduces the number of screws used, increases the satisfaction of patients, and restores the appearance of the patient's head, making it an ideal choice for cranioplasty.
Sheng-Tzung Tsai, Hsiang-Yi Hung, Chien-Hui Lee and Shin-Yuan Chen
Sheng-Tzung Tsai, Hsin-Chi Tsai, Chung-Chih Kuo, Hsiang-Yi Hung, Chien-Hui Lee and Shin-Yuan Chen
Miaomiao Suo, Yahui Lin, Hui Yu, Weihua Song, Kai Sun, Yan Song, Yinhui Zhang, Channa Zhang, Yufang Zhu, Qi Pang, Rutai Hui and Jingzhou Chen
Variants of Kallikreins have been shown to be risk factors for intracranial aneurysm (IA) in a Finnish population. In the present study, the authors investigated the correlation between polymorphisms in the Kallikrein gene cluster and IAs in the Chinese population.
The association of Kallikrein variants (rs1722561 and rs1701946) with sporadic IAs was tested in 308 cases and 443 controls. The differences in allelic frequencies between patients and the control group were evaluated with the chi-square test.
The C allele of rs1722561 showed a significant reduction in the risk of sporadic IA (OR 0.71, 95% CI 0.53–0.95; p = 0.023). However, no association of the variant rs1701946 with sporadic IA was found (OR 0.78, 95% CI 0.57–1.06; p = 0.115).
The variant rs1722561 of Kallikreins might reduce the risk of sporadic IAs among individuals of Chinese Han ethnicity. This study confirms the association between Kallikreins and IAs.
Peng-Fan Yang, Hui-Jian Zhang, Jia-Sheng Pei, Qiao Lin, Zhen Mei, Zi-Qian Chen, Yan-Zeng Jia, Zhong-Hui Zhong and Zhi-Yong Zheng
The objectives of this study were to describe a novel minimal-access subtemporal approach for selective resection of the amygdala and hippocampus in patients with medically refractory mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis, and to analyze the related outcomes.
The authors analyzed data from all cases involving patients with unilateral MTLE due to hippocampal sclerosis who were treated with selective amygdalohippocampectomy via the posterior subtemporal approach through a relatively small craniotomy, without a neuronavigation system, at their institution during the period from September 2010 to September 2012. Data were obtained on baseline characteristics, preoperative evaluations of unilateral mesial temporal sclerosis, surgical complications, and Engel class seizure outcomes. All patients underwent memory testing, IQ testing, and language testing.
The mean duration of follow-up was 33.6 months (range 24–48 months). There were no deaths and no cases of significant postoperative morbidity. One patient had a mild complication. At 2-year follow-up, 19 patients were seizure free (Engel Class I outcome). Verbal memory scores obtained at 3 months and at 2 years after surgery were significantly lower than preoperative scores for patients who underwent surgery on the left side of the brain (p < 0.05). Pictorial memory scores were higher following surgery compared with before surgery regardless of whether patients underwent left- or right-sided brain surgery. There was also improvement in performance IQ and total IQ following surgery in both groups. For patients who underwent right-sided brain surgery, verbal comprehension and semantic fluency testing scores were significantly higher at both 3 months and 2 years after surgery than before surgery. For patients who underwent left-sided brain surgery, scores on all language tests were significantly lower at 3 months after surgery than before surgery. Verbal comprehension testing scores returned to the preoperative level at 2 years after surgery.
The posterior subtemporal approach through a relatively small craniotomy allows adequate exposure and safe resection of mesial temporal structures and effectively reduces medically intractable MTLE. It preserves IQ but may have a detrimental effect on verbal memory and language ability.