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Kotaro Nakaya, Motohiro Hayashi, Masahiro Izawa, Taku Ochiai, Tomokatsu Hori and Kintomo Takakura

Object

Stereotactic radiosurgery for brain metastasis has become one of the standard treatment options in recent years. Some patients must undergo repeated stereotactic radiosurgery for new lesions. The authors retrospectively reviewed their data to estimate how soon the patients undergo repeated radiosurgery for new lesions.

Methods

Between October 1999 and March 2006, 1081 patients with brain metastases underwent Gamma Knife surgery (GKS) at Tokyo Women's Medical University. One hundred and forty-nine patients in whom GKS had been performed two or more times were evaluated. There were 68 men and 81 women with a median age of 61 years (range 29–90 years). The authors analyzed data on patient age, number of treated lesions, and period between GKSs. Follow-up imaging was performed in almost all patients every 2 to 3 months after GKS.

The number of lesions treated in a single session varied from one to 35. The median interval between GKSs was 26 weeks (range 3–175 weeks) for patients with breast cancer and 23 weeks (range 4–179 weeks) for patients with non–small cell lung carcinoma.

Conclusions

It would appear that follow-up imaging studies should be obtained every 2 to 3 months after GKS to monitor patients for tumor recurrence.

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Jean Régis, Philippe Metellus, Motohiro Hayashi, Philippe Roussel, Anne Donnet and Françoise Bille-Turc

Object

Stereotactic radiosurgery is an alternative to conventional surgery for the treatment of trigeminal neuralgia. The authors conducted a prospective evaluation of the safety and efficacy of this method in a large series of patients.

Methods

A total of 100 patients presenting with trigeminal neuralgia were treated and followed up for a minimum of 12 months. The mean age was 68.2 years; 54 patients were male, and 46 were female. Seven had a history of multiple sclerosis, and 42 had already received conventional surgical treatment for trigeminal neuralgia. The intervention consisted of gamma knife surgery to the retrogasserian cisternal portion of the fifth cranial nerve. The median dose used at the maximum was 85 Gy (range 70–90 Gy). The number and intensity of pain attacks were recorded by the patient from 3 months before radiosurgery to a minimum of 12 months after treatment. Before and a minimum of 12 months after treatment, the patient completed a quality-of-life questionnaire. Neurological examination and quantitative sensory testing to evaluate sensory perception were performed by an independent neurologist over this same time period.

At the last visit 83 of 100 patients were reported to be pain free. Fifty-eight of these 83 patients had stopped taking medication during the study. All quality-of-life parameters were improved (p < 0.001). Six patients reported facial paresthesia, and four patients reported hypesthesia. These symptoms were classified as mild. None of the complications reported for other techniques were observed.

Conclusions

Radiosurgery is a safe and effective alternative treatment for trigeminal neuralgia and is associated with a particularly low rate of hypesthesia.

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Jean Régis, Motohiro Hayashi, Denis Porcheron, Christine Delsanti, Xavier Muracciole and Jean Claude Peragut

Object. The technical advances associated with the model C gamma knife include a robotized system enabling automatic positioning of the stereotactic coordinates. The purpose of this study was to analyze the clinical impact of this technical modification.

Methods. The authors studied a sample of patients with vestibular schwannoma (VS). This sample included three groups treated using gamma knife radiosurgery. Group I comprised 21 patients with VS treated just before the installation of the Automatic Positioning System (APS). Group II included patients in Group I with new dose plans created using the APS (in other words, simulated dose plans). Group III consisted of a control group of 20 patients matched for tumor grade with the previous group and treated recently with the APS. Treatment times were calculated after correcting the time for each shot according to the age of the sources after reloading. The treatment times, including total time, irradiation time, and duration of the neurosurgical procedure, were analyzed. In addition, dose planning including number of isocenters, number of different collimators, malfunctions, and the conformity and selectivity indices were recorded.

The trend was to reduce the mean number of collimator runs from 7.9 to 1.2 and to increase the mean number of shots from 7.9 to 15.6, mostly by using the 4-mm collimator exclusively. The APS-related conformity and selectivity were improved from 95 to 97% and from 78 to 84%, respectively. The total treatment time was reduced by 53%, and time required to interact with the patient in the room was considerably reduced (75%), giving the neurosurgeon greater freedom to perform other tasks during the treatment period. The reduction of the time spent by the neurosurgeon at work in the room was 84%. The total radiation time was increased by 54%.

Conclusions. The preliminary results of this study indicate that the robotization of the gamma knife is likely a major advance in radiosurgery.

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Masahiro Izawa, Motohiro Hayashi, Kohtarou Nakaya, Hiroyuki Satoh, Taku Ochiai, Tomokatsu Hori and Kintomo Takakura

Object. The purpose of this study was the analysis of a large series of patients treated with gamma knife radiosurgery for pituitary adenoma in a single institution.

Methods. One hundred eight patients with pituitary adenomas were treated over the last 7 years. Seventy-four patients have been followed for more than 6 months and form the basis of this report.

Conclusions. Twenty-three patients harbored nonfunctioning adenomas, and 56 harbored functioning adenomas. The mean margin dose was 22.5 Gy (nonfunctioning adenomas, 19.5 Gy; functioning adenomas, 23.8 Gy). Control of tumor growth was achieved in 91%. A significant decrease of excessive hormone production was seen in 80% of patients, and the endocrinological normalization rate was 30.3%. Postradiosurgical complications were seen in 2.5%.

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Jean Régis, Fabrice Bartolomei, M. Rey, Motohiro Hayashi, Patrick Chauvel and Jean-Claude Peragut

Object. Gamma knife radiosurgery (GKS) allows precise and complete destruction of chosen target structures containing healthy and/or pathological cells, without causing significant radiation damage to adjacent tissues. Almost all the well-documented cases of radiosurgery for epilepsy are for epilepsies associated with space-occupying lesions. These results prompted the authors to investigate the use of radiosurgery as a new way of treating epilepsy not associated with space-occupying lesions.

Methods. To evaluate this new method, 25 patients who presented with drug-resistant mesial temporal lobe epilepsy (MTLE) were selected. A follow up of more than 24 months is now available for 16 patients. The preoperative evaluation was performed as it usually is in patients selected for microsurgery for MTLE. In lieu of microsurgery, the treatment of amygdalohippocampal structures was performed using GKS.

Thirteen (81%) of these 16 patients are seizure free, and two are improved. The median latent interval from GKS to seizure cessation was 10.5 months (range 6–21 months). Two patients were immediately seizure free. The median latency in aura cessation was 15.5 months (range 9–22 months). Morphological changes on magnetic resonance imaging were visible at 11 months (median) after GKS (range 7–22 months). During the onset period of these radiological changes, three patients experienced headache associated, in two cases, with nausea and vomiting. In these three patients the signs resolved immediately after prescription of low doses of steroids. No cases of permanent neurological deficit (except three cases of nonsymptomatic visual field deficit), or morbidity, or mortality were observed.

Conclusions. This initial experience indicates that there is short- to middle-term efficiency and safety when using GKS to treat MTLE. Further long-term follow up is required. It seems that the introduction of GKS into epilepsy treatment can reduce the invasiveness and morbidity.

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Motohiro Hayashi, Taku Ochiai, Kotaro Nakaya, Mikhail Chernov, Noriko Tamura, Shoji Yomo, Masahiro Izawa, Tomokatsu Hori, Kintomo Takakura and Jean Regis

✓Gamma Knife surgery (GKS) is image-guided surgery for brain tumors. Precise tumor visualization is needed in dose planning to control tumor progression. The surrounding vital structures must also be clearly defined to allow the preservation of their function. A special magnetic resonance (MR) imaging sequence was chosen for use with GKS to treat skull base and suprasellar tumors.

Gadolinium-enhanced 0.5-mm constructive interference in steady-state (CISS) slices were obtained in skull base and suprasellar tumors. Each structure that was adjacent to the tumor could be visualized more clearly by using this imaging technique because the tumor became transparent even though there was no change in the appearance of the surrounding structures after injection of Gd. Use of this technique in acoustic tumors allowed the seventh and eighth cranial nerves to be visualized in the cisternal and intrameatal portions; both of which were distinguishable from the tumor. Suprasellar tumor could be distinguished from the adjacent optic pathway. The use of Gd-enhanced CISS imaging allowed for optimal dose planning with very high conformity in every tumor. Achieving this high conformity allowed the preservation of adjacent structures and their functions.

Establishing optimal dose planning in brain tumors is very important to overcome the problem of producing new neurological deficits in patients who may already be suffering disease-related deficits. The use of this special CISS MR imaging sequence may help accomplish this goal.

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Noriko Tamura, Motohiro Hayashi, Mikhail Chernov, Manabu Tamura, Ayako Horiba, Yoshiyuki Konishi, Yoshihiro Muragaki, Hiroshi Iseki and Yoshikazu Okada

Object

The focus of the present study was the evaluation of outcomes after unstaged and staged-volume Gamma Knife surgery (GKS) in children harboring intracranial arteriovenous malformations (AVMs).

Methods

Twenty-two children (median age 9.5 years) underwent GKS for AVMs and were followed up for at least 2 years thereafter. The disease manifested with intracranial hemorrhage in 77% of cases. In 68% of patients the lesion affected eloquent brain structures. The volume of the nidus ranged from 0.1 to 6.7 cm3. Gamma Knife surgery was guided mainly by data from dynamic contrast-enhanced CT scans, with preferential targeting of the junction between the nidus and draining vein. The total prescribed isodose volume was kept below 4.0 cm3, and the median margin dose was 22 Gy (range 20–25 Gy). If the volume of the nidus was larger than 4.0 cm3, a second radiosurgical session was planned for 3–4 years after the first one. Nine patients in the present series underwent unstaged radiosurgery, whereas staged-volume treatment was scheduled in 13 patients.

Results

Complete obliteration of the AVM was noted in 17 (77%) of 22 patients within a median period of 47 months after the last radiosurgical session. Complete obliteration of the lesion occurred in 89% of patients after unstaged treatment and in 62.5% after staged GKS. Four (67%) of 6 high-grade AVMs were completely obliterated. Complications included 3 bleeding episodes, the appearance of a region of hyperintensity on T2-weighted MR images in 2 patients who had no symptoms, and reappearance of the nidus in the vicinity of the completely obliterated AVM in 1 patient.

Conclusions

Radiosurgery is a highly effective management option for intracranial AVMs in children. For larger lesions, staged GKS may be applied successfully. Initial targeting of the nidus adjacent to the draining vein and application of a sufficient radiation dose to a relatively small volume (≤ 4 cm3) provides a good balance between a high probability of obliteration and a low risk of treatment-related complications.

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Motohiro Hayashi, Mikhail Chernov, Masao Usukura, Kayoko Abe, Yuko Ono, Masahiro Izawa, Sadao Hori, Tomokatsu Hori and Kintomo Takakura

The authors conducted a study to determine a way of overcoming the poor-quality demonstration of choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD) on conventional magnetic resonance (MR) imaging studies.

The poor MR imaging demonstration of CNV in patients with AMD makes the use of gamma knife surgery more difficult. This difficulty, however, can be overcome by use of a modified time-of-flight MR imaging sequence with Gd enhancement and coronal reconstruction.

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Masahiro Izawa, Motohiro Hayashi, Mikhail Chernov, Koutarou Nakaya, Taku Ochiai, Noriko Murata, Yuichi Takasu, Osami Kubo, Tomokatsu Hori and Kintomo Takakura

Object. The authors analyzed of the long-term complications that occur 2 or more years after gamma knife surgery (GKS) for intracranial arteriovenous malformations (AVMs).

Methods. Patients with previously untreated intracranial AVMs that were managed by GKS and followed for at least 2 years after treatment were selected for analysis (237 cases). Complete AVM obliteration was attained in 130 cases (54.9%), and incomplete obliteration in 107 cases (45.1%). Long-term complications were observed in 22 patients (9.3%). These complications included hemorrhage (eight cases), delayed cyst formation (eight cases), increase of seizure frequency (four cases), and middle cerebral artery stenosis and increased white matter signal intensity on T2-weighted magnetic resonance imaging (one case of each). The long-term complications were associated with larger nidus volume (p < 0.001) and a lobar location of the AVM (p < 0.01). Delayed hemorrhage was associated only with incomplete obliteration of the nidus (p < 0.05). Partial obliteration conveyed no benefit. Delayed cyst formation was associated with a higher maximal GKS dose (p < 0.001), larger nidus volume (p < 0.001), complete nidus obliteration (p < 0.01), and a lobar location of the AVM (p < 0.05).

Conclusions. Incomplete obliteration of the nidus is the most important factor associated with delayed hemorrhagic complications. Partial obliteration does not seem to reduce the risk of hemorrhage. Complete obliteration can be complicated by delayed cyst formation, especially if high maximal treatment doses have been administered.