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Pavlina Lenga, Christian Hohaus, Bujung Hong, Adisa Kursumovic, Nicolai Maldaner, Jan-Karl Burkhardt, Philippe Bijlenga, Daniel A. Rüfenacht, Nils O. Schmidt, Peter Vajkoczy and Julius Dengler

cranial nerves. 2 , 27 They usually cause clinical symptoms such as cranial nerve deficits (CNDs), motor deficits, hydrocephalus, and different degrees of disability. 2 , 13 , 16 , 18 They also frequently present with partial thrombosis (PT) and have various shapes. 6 , 9 Previously published series describing brainstem compression by posterior circulation aneurysms either predominantly examined nongiant posterior circulation aneurysms or did not analyze GPCirA as a separate size category. 15 , 27 So far, there has been no systematic analysis of factors associated

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Jay Jagannathan, Jason P. Sheehan, Nader Pouratian, Edward R. Laws, Ladislau Steiner and Mary Lee Vance

Object

In this study the authors address the efficacy and safety of Gamma Knife surgery (GKS) in patients with adrenocorticotropic hormone–secreting pituitary adenomas.

Methods

A review of data collected from a prospective GKS database between January 1990 and March 2005 was performed in patients with Cushing's disease. All but one patient underwent resection for a pituitary tumor, without achieving remission. Successful endocrine outcome after GKS was defined as a normal 24-hour urinary free cortisol (UFC) concentration posttreatment after a minimum of 1 year of follow up. Patient records were also evaluated for changes in tumor volume, development of new hormone deficiencies, visual acuity, cranial nerve neuropathies, and radiation-induced imaging changes. Ninety evaluable patients had undergone GKS, with a mean endocrine follow-up duration of 45 months (range 12–132 months). The mean dose to the tumor margin was 23 Gy (median 25 Gy).

Normal 24-hour UFC levels were achieved in 49 patients (54%), with an average time of 13 months after treatment (range 2–67 months). In the 49 patients in whom a tumor was visible on the planning magnetic resonance (MR) image, a decrease in tumor size occurred in 39 (80%), in seven patients there was no change in size, and tumor growth occurred in three patients. Ten patients (20%) experienced a relapse of Cushing's disease after initial remission; the mean time to recurrence was 27 months (range 6–60 months). Seven of these patients underwent repeated GKS, with three patients achieving a second remission. New hormone deficiencies developed in 20 patients (22%), with hypothyroidism being the most common endocrinopathy after GKS. Five patients experienced new visual deficits or third, fourth, or sixth cranial nerve deficits; two of these patients had undergone prior conventional fractionated radiation therapy, and four of them had received previous GKS. Radiation-induced changes were observed on MR images in three patients; one had symptoms attributable to these changes.

Conclusions

Gamma Knife surgery is an effective treatment for persistent Cushing's disease. Adenomas with cavernous sinus invasion that are not amenable to resection are treatable with the Gamma Knife. A second GKS treatment appears to increase the risk of cranial nerve damage. These results demonstrate the value of combining two neurosurgical treatment modalities—microsurgical resection and GKS—in the management of pituitary adenomas.

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John C. Liu, Joseph D. Ciacci and Timothy M. George

Complications due to shunting are common in children with DWS. There is a higher rate of CP shunt malfunction and infection, along with more severe complications such as posterior fossa subdural hematomas, than that experienced with the VP shunt. 2, 3 In this paper, we report an unusual complication of CP shunting in a DWS patient. A 5-year-old child with a cystoperitoneal shunt presented with headaches and cranial nerve deficits after treatment of an infected posterior fossa cyst. A sagittal magnetic resonance (MR) imaging study revealed tethering of the brainstem. A

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Sherise D. Ferguson, Nicholas B. Levine, Dima Suki, Andrew J. Tsung, Fredrick F. Lang, Raymond Sawaya, Jeffrey S. Weinberg and Ian E. McCutcheon

(16%) had cranial nerve deficits at initial presentation. Several patients presented with multiple symptoms. TABLE 1. Patient and tumor characteristics in 55 cases Characteristic No. of Pts (%) Sex   Female 24 (44)   Male 31 (56) Age   Adult 39 (71)   Child (<18 yrs) 16 (29) Presenting symptom *   Headache 25 (45)   Nausea & vomiting 21 (38)   Unsteady gait 18 (33)   Visual impairment 16 (29)   Dizziness 13 (24)   Cranial nerve deficit 9 (16)   Weakness 7 (13)   Memory impairment 6 (11)   Sensory changes 4 (7)   Seizure 2 (4)   Altered mental status 1 (2)   Speech

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Jason P. Sheehan, Shota Tanaka, Michael J. Link, Bruce E. Pollock, Douglas Kondziolka, David Mathieu, Christopher Duma, A. Byron Young, Anthony M. Kaufmann, Heyoung McBride, Peter A. Weisskopf, Zhiyuan Xu, Hideyuki Kano, Huai-che Yang and L. Dade Lunsford

.119 0.327 0.080–1.335 tumor vol (cm 3 ) NA max dose (Gy) NA no. of isocenters 0.005 0.767 0.637–0.925 new or worsened CN deficit vs stable or improved 0.002 7.618 2.096–27.684 * NA = not applicable. Clinical Response Prior to radiosurgery, the following cranial nerve deficits were noted: CN V in 15 patients (11%); CN VI in 6 (4.5%); CN VII in 33 (25%); CN VIII in 91 (68%); CN IX in 44 (33%); CN X in 62 (46%); CN XI in 27 (20%); and CN XII in 47 (35%). Many patients had more than one cranial nerve deficit. At last

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Raafat R. Yahya, Peter Dirks, Robin Humphreys, James T. Rutka, Michael Taylor and James M. Drake

. One patient was in a very poor neurological condition with fixed dilated pupils, three had cranial nerve deficit, and three had otorrhea, otorrhagia, or hemotympanum. TABLE 1 Characteristics of 18 patients with head injuries from falling television sets Case No. Age (mos), Sex Year of Injury 1 60, M 1992 2 12, F 1992 3 30, M 1994 4 48, F 1996 5 24, M 1996 6 24, M 1996 7 82, M 1998 8 22, M 1998 9 30, F 1999 10 16, F 1999 11 120

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Alan Siu, Michaela Lee, Robert Rice and John S. Myseros

/RT as it relates to cranial nerves, specifically the facial nerve, is unknown. As a distinct tumor entity that was once misdiagnosed as a primitive neuroectodermal tumor, 14 it is very likely that it carries a differential interaction with the tissue types in the CPA that is distinct from the classic medulloblastoma. This is in contrast to classic medulloblastoma in the CPA, which occurs in older patients, and often presents with multiple cranial nerve deficits over the course of months, with facial nerve weakness being uncommon and manifesting later. 9 Although the

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Gabriel Zada, Thomas C. Solomon and Steven L. Giannotta

. According to our review, most cases of spontaneous ICH–related ophthalmoplegia will reverse following standard treatment. In advanced cases, if significant downward brainstem injury or ischemic injury has occurred, irreversible central cranial nerve deficits can be observed that may not be reversible. Conclusions Intracranial hypotension can present with a wide variety of visual symptoms and findings. Deficits in visual acuity, visual fields, and ophthalmoplegia have been frequently described. By far, the most commonly encountered cranial nerve deficit is an

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Tim W. Malisch, Guido Guglielmi, Fernando Viñuela, Gary Duckwiler, Y. Pierre Gobin, Neil A. Martin, John G. Frazee and Joan S. Chmiel

E ndovascular treatment of intracranial aneurysms by using the Guglielmi detachable coil (GDC) is proving to be a safe method of preventing aneurysm rupture. 13–15, 24, 25, 39 Patients with unruptured intracranial aneurysms may present with symptoms related to the aneurysm's mass effect on either the brain parenchyma or cranial nerves. Previous reports have suggested that such symptoms can be affected by GDC embolization of the aneurysm. 11, 17, 18, 22, 24, 25, 38 This study was undertaken to evaluate the response of patients with cranial nerve deficits to

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Rami Almefty, Ian F. Dunn, Svetlana Pravdenkova, Mohammad Abolfotoh and Ossama Al-Mefty

–73 years), and the female/male ratio was 3:1 (48 women, 16 men). Fifty-eight patients presented with de novo tumors; 6 had recurrent meningioma after having had surgery elsewhere. Four of these 6 patients had sizeable residual tumor after resection, and 3 patients had been treated with radiation therapy in addition to resection. Ten patients had less than 2 months' follow-up. The mean duration of follow-up for the remaining 54 patients was 70.57 months (range 4–276 months). Fifty-seven (89%) of 64 patients had cranial nerve deficits on presentation, with CN V deficit