Benign fibrous histiocytoma of the skull with increased intracranial pressure caused by cerebral venous sinus occlusion

The authors present a very rare case of benign fibrous histiocytoma of the skull with increased intracranial pressure caused by sinus occlusion. A 33-year-old woman was referred for investigation of a right occipital protrusion with tenderness and double vision. She had only mild divergence insufficiency and bilateral papilledema neurologically. Imaging findings showed that the skull tumor was located at the right occipital bone with bone disruption and a compressed right sigmoid sinus. When planning the resection, caution was required to spare the collateral flow so as to manage the intracranial pressure. Immunohistochemical analysis showed that the tumor was positive for CD68, α1-antichymotrypsin, and α1-antitrypsin. From these findings, the tumor was diagnosed as a primary benign fibrous histiocytoma of the skull.

Successful stereotactic radiosurgery with the CyberKnife of a giant arteriovenous malformation of the tongue: a case report

We report a successful outcome for a large arteriovenous malformation (AVM) of the tongue treated with CyberKnife (CK) image-based stereotactic radiosurgery (SRS). A 56-year-old man presenting with a tongue AVM underwent ligation of the lingual artery and partial resection of the nidus. Sixteen years later, his pulsating submandibular mass had enlarged. An image study revealed a remarkable re-expansion of the nidus involving the tongue and the oral floor, with a volume of 130 ml. CK SRS was performed with 2 fractions. The prescribed marginal dose was 22 Gy. Thirty-four months after SRS, angiography demonstrated complete obliteration of the nidus without major adverse effects. We conclude that CK SRS may be suitable for the treatment of AVMs in the head and neck region.

The influence of focal brain cooling on neurophysiopathology: validation for clinical application

Object

Focal brain cooling has been recognized to have a suppressive effect on epileptiform discharges or a protective effect on brain tissue. However, the precise influence of brain cooling on normal brain function and histology has not yet been thoroughly investigated. The aim of this study was to investigate the neurophysiopathological consequences of focal cooling and to detect the threshold temperature that causes irreversible histological change and motor dysfunction.

Methods

The experiments were performed in adult male Sprague-Dawley rats (weighing 250–350 g) after induction of halothane anesthesia. A thermoelectric chip (6 × 6 × 2 mm) was used as a cooling device and was placed on the surface of the sensorimotor cortex after a 10 × 8–mm craniotomy. A thermocouple was placed between the chip and the brain surface. Focal cooling of the cortex was performed at the temperatures of 20, 15, 10, 5, 0, and −5°C for 1 hour (5 rats in each group). Thereafter, the cranial window was repaired. Motor function was evaluated using the beam-walking scale (BWS) every day for 7 days. The rats were killed 7 days after the operation for histological examination with H & E, Klüver-Barrera, glial fibrillary acidic protein, and terminal deoxynucleotidyl transferasemediated deoxyuridine triphosphate nick-end labeling stainings. The authors also euthanized some rats 24 hours after cooling and obtained brain sections by the same methods.

Results

The BWS score was decreased on the day after cooling only in the −5°C group (p < 0.05), whereas the score did not change in the other temperature groups. Histologically, the appearance of cryoinjury such as necrosis, apoptosis, loss of neurons, and marked proliferation of astrocytes at the periphery of the lesion was observed only in the −5°C group, while no apparent changes were observed in the other temperature groups.

Conclusions

The present study confirmed that the focal cooling of the cortex for 1 hour above the temperature of 0°C did not induce any irreversible histological change or motor dysfunction. These results suggest that focal brain cooling above 0°C has the potential to be a minimally invasive and valuable modality for the treatment of severe brain injury or to assist in the examination of brain function.

INTRODUCING SITETRACK

OBJECTIVE

Immobilization of the head during stereotactic radiotherapy (STR) has, until recently, been fundamental for ensuring accuracy. We developed a continuous motion monitoring system (SiteTrack) to detect and quantify head movement during CyberKnife (Accuray, Inc., Sunnyvale, CA) STR and Leksell (Elekta AB, Stockholm, Sweden) frame fixation. In this study, we present findings obtained during tests of SiteTrack.

METHODS

SiteTrack is composed of a potentiometer with 4 encoders connected through 4 threads tied to the plastic buttons attached to the thermoplastic mask, in the case of CyberKnife, or by 3 threads directly connected to the Leksell frame. The accuracy of SiteTrack was studied with a phantom using the target localization system of the CyberKnife. During CyberKnife treatment, SiteTrack software sends an emergency stop signal (E-stop) if the patient moves beyond a limit. Seventy-three cases of CyberKnife STR and 7 cases of Leksell frame fixation were monitored.

RESULTS

In the phantom study, regression analysis showed a significant correlation between SiteTrack and target localization system parameters. The expected root mean square position error at the moment of E-stop was 0.62 ± 0.44 mm when the E-stop limit was set at ±0.5 mm. Twenty-two (30%) of 73 patients kept still during CyberKnife treatment (&lt;0.5 mm); 51 (70%) of 73 patients moved more than 0.5 mm and, thus, caused E-stops. SiteTrack monitoring during frame fixation showed motion beyond ±1 mm in 4 cases and ±0.5 mm in 3 other cases.

CONCLUSION

Significant head movement can occur during CyberKnife treatment or fixation with a Leksell frame. SiteTrack may improve the accuracy of the CyberKnife as well as frame-based STR.

Proposal and experimental verification of Bragg wavelength distribution measurement within a long-length FBG by synthesis of optical coherence function

In this paper, a sensor system for measuring continuous Bragg wavelength distribution in a long-length fiber Bragg grating is newly proposed, using synthesis of optical coherence function (SOCF), which is one of the spatial resolving techniques used for reflectometry. Experimental results are also reported. In the process of synthesizing optical coherence function, it is found that an apodization scheme is necessary to obtain the reflection spectrum of local section in a long-length FBG around the coherence peak. As a verification of this method, the detection of local Bragg wavelength shift due to temperature change within a short section in a long-length FBG is demonstrated experimentally.

Function of surfactants in hair dyeing by oxidation dyes 2. Effect on formation of oxidation dyes by p-aminophenol and 5-amino-o-cresol in dye bath(1)

The effect of surfactants on an oxidation-hair-dye-formation reaction in a dye bath was studied in order to learn the mechanism of the effect of surfactants on the dyeability of hair by the oxidation dye. The dye-formation behaviours for the p-aminophenol and 5-amino-o-cresol system with the surfactants, of which the hydrophilic parts have different charges, were compared changing the concentration of surfactants. It was found that the same dyes are produced, regardless of the charge of surfactants added, and the rate of dye produced in the dyebath is increased in the presence of surfactants. The order of the production rate is, with an anionic surfactant > with non-ionic surfactant > with cationic surfactant > without surfactant. The relation between the dyeability of hair and the rate of dye produced in the dyebath in the presence of surfactants is not found. The major factor governing the dyeability of hair is different from the mechanism of the increased dye in the solution. It was also found that the dye-formation rate is increased by immersing hair into the reaction solution, and hair works as an accelerator for the dye-formation reaction.

Transvenous embolization for dural arteriovenous shunt of the cavernous sinus. Comparison of multi-staged transvenous embolization and transvenous embolization with sinus packing

SUMMARY

We describe the treatment and follow-up clinical symptoms and angiographic results in patients with dural arteriovenous fistula of the cavernous sinus treated by transvenous embolization (TVE). We have treated eight cases of dural arteriovenous fistula of the cavernous sinus by multi-staged TVE in two cases and TVE with sinus packing in six and three of six cases were treated with a combination of transarterial embolization. Multi-staged TVE was performed by occlusion from dangerous drainage veins to the cavernous sinus on several occasions. Angiographical results showed disappearance or reduction of the arteriovenous shunt in all cases. Six patients presented with ophthalmic symptoms and two had tinnitus. Six cases had complete disappearance of clinical symptoms after treatment. There was a deterioration of ocular movement in one patient treated by TVE with sinus packing. Multi-staged TVE was performed to reduce the coil volume for the packing of the cavernous sinus in two cases without cranial nerve palsy. Embolization, especially multi-staged TVE, was considered a good treatment to occlude arteriovenous shunts at the cavernous sinus without cranial nerve complications.

[Surgical treatment for intractable epilepsy caused by tuberous sclerosis complex with multiple tubers: case report]

We report a case of intractable epilepsy caused by tuberous sclerosis with multiple tubers that was treated successfully by single resection of a tuber A 2-year-old boy developed tonic spasm-like seizures at the age of 4 months and the frequency of the seizures increased despite therapy with various anticonvulsants. He had no neurological deficits, and his intelligence was normal. MRI showed lesions in the left frontal and the right parietal lobe, and EEG (electroencephalogram) demonstrated sharp waves and spike-and-wave complex bursts over the right parietal region. Subdural electrodes were implanted over these lesions, and ictal low-voltage fast waves were demonstrated on the right parietal lesion. Therefore the right cortical lesion and the epileptogenic cortex were resected. Multiple subpial transaction was also added in the irritative cortex. Histological examination proved that the lesion was a tuberous sclerosis complex (TSC) tuber. Since surgery, the patient has remained seizure-free for 2 years. In patients with multiple TSC tubers in the cortex, we suggest that seizures can be suppressed by single resection of a tuber if the tuber can be identified as epileptogenic before surgery.

De novo aneurysm formation on middle cerebral artery branches adjacent to the anastomotic site of superficial temporal artery-middle cerebral artery bypass surgery in two patients: technical case report

OBJECTIVE

Aneurysm formation is a complication of superficial temporal artery-middle cerebral artery bypass surgery occurring as pseudoaneurysms caused by technical failure, but also as true aneurysms discovered after long-term follow-up.

CLINICAL PRESENTATION

A 53-year-old woman presented with a left internal carotid artery cavernous aneurysm manifesting as double vision. Superficial temporal artery-middle cerebral artery bypass, internal trapping of the internal carotid artery, and embolization were performed. Three years later, angiography disclosed a distal middle cerebral artery aneurysm. A 70-year-old man who had undergone right superficial temporal artery-middle cerebral artery bypass after internal carotid artery occlusion died of subarachnoid hemorrhage from a ruptured anterior spinal artery aneurysm 21 years later. Angiography and postmortem examination revealed de novo aneurysm formation on a middle cerebral artery branch adjoining the anastomotic site. Both patients had hypertension and multiplicity of aneurysms.

INTERPRETATION

Both cases were de novo true aneurysms caused by hemodynamic stress because of saccular to fusiform shape, location extending to the middle cerebral artery, high perfusion pressure, projection along the hemodynamic stress, and presence of common risk factors.

CONCLUSION

Bypass surgery is increasingly performed in patients with complicated aneurysms if sacrifice or temporary occlusion of any major vessel is required. Therefore, de novo aneurysm formation may not be rare in patients with risk factors such as hypertension or multiple aneurysms. Extended follow-up examination is required in such patients.

Neurotoxic effects of exogenous recombinant tissue-type plasminogen activator on the normal rat brain

Thrombolytic therapy with intravenous and intra-arterial recombinant tissue-type plasminogen activator (rtPA) has been established for the treatment of acute ischemic stroke. However, tPA has also been suggested to have neurotoxic effects. The purpose of this study was to examine direct neurotoxicity of rtPA in vivo. The animals (Wistar rats) were divided to the following three groups: low-dose (15 micromol/L) rtPA group (n = 6); high-dose (30 micromol/L) rtPA group (n = 6); and control (physiological saline) group (n = 6). The rtPA solution was perfused into the cortex via a microdialysis probe. The volume of the lesion was quantified histologically by image analysis of the lesions. Blood-brain barrier (BBB) disruption was evaluated by intravenous injection of Evans blue, and injury to the basal lamina was evaluated by immunohistochemistry using an anti-laminin antibody. In the rtPA-perfused animals, a pale lesion was produced around the probe, and microscopically, neurons showed necrotic changes. The volume of the lesions increased significantly as the concentration of perfused rtPA was increased. Marked extravasation of Evans blue was observed, and laminin immunoreactivity of blood vessels in the rtPA-induced lesions was lost. These results suggest that rtPA promotes acute direct neurotoxicity and participates in disruption of the microvascular basal lamina to cause BBB disruption, thereby increasing edema formation.

Antitumor effects of vaccination with dendritic cells transfected with modified receptor for hyaluronan-mediated motility mRNA in a mouse glioma model

OBJECT

The receptor for hyaluronan-mediated motility (RHAMM) is frequently overexpressed in brain tumors and was recently identified as an immunogenic antigen by using serological screening of cDNA expression libraries. In this study, which was conducted using a mouse glioma model, the authors tested the hypothesis that vaccination with dendritic cells transfected with RHAMM mRNA induces strong immunological antitumor effects.

METHODS

The authors constructed a plasmid for transduction of the mRNAs transcribed in vitro into dendritic cells, which were then used to transport the intracellular protein RHAMM efficiently into major histocompatibility complex class II compartments by adding a late endosomal-lysosomal sorting signal to the RHAMM gene. The dendritic cells transfected with this RHAMM mRNA were injected intraperitoneally into the mouse glioma model 3 and 10 days after tumor cell implantation. The antitumor effects of the vaccine were estimated by the survival rate, histological analysis, and immunohistochemical findings for immune cells. Mice in the group treated by vaccination therapy with dendritic cells transfected with RHAMM mRNA survived significantly longer than those in the control groups. Immunohistochemical analysis revealed that greater numbers of T lymphocytes containing T cells activated by CD4+, CD8+, and CD25+ were found in the group vaccinated with dendritic cells transfected with RHAMM mRNA.

CONCLUSIONS

These results demonstrate the therapeutic potential of vaccination with dendritic cells transfected with RHAMM mRNA for the treatment of malignant glioma.

[MALT-type lymphoma of lacrimal gland: case report]

A 72-year-old female presented with a lump in the left superior-lateral eyelid. The magnetic resonance imaging showed a well-delineated mass in the left lacrimal gland. The tumor was isointense on both the T1 and T2 weighted images, and it was homogenously enhanced with Gd-DTPA. Surgery via the trans-cranial approach revealed a pinkish and elastic-hard tumor. Total resection was successfully performed. The hematoxilyn-eosin staining of the surgical specimen showed a dense infiltrate of lymphocytes, which were composed predominantly of small lymphocytes, centrocyte-like cells, monocytoid cells, and occasionally transformed lymphocytes. The immunohistochemical findings for CD20, CD3, UCHL-1, CD23, CD5, cyclinD1, and bcl-2 were compatible with Mucosa Associated Lymphoid Tissue (MALT)-type lymphoma. The patient received local radiation therapy (30 Gy/15 fractions). She remained in complete clinical remission of the disease about one and a half years after treatment.

Various magnetic resonance imaging patterns of chronic subdural hematomas: indicators of the pathogenesis?

Magnetic resonance (MR) imaging can detect various patterns in chronic subdural hematomas. These patterns were compared to the computed tomography (CT) appearances and chemical analysis of the content in 60 hematomas from 44 patients. The hematomas could be classified into five types on both T(1)- and T(2)-weighted images: low, high, and mixed intensity, isointensity, and layered. Combining the T(1)- and T(2)-weighted images of all 60 hematomas revealed a total of 14 different imaging patterns. Combining the CT and MR imaging findings of 55 hematomas identified 25 different patterns. Analysis of the hematoma contents showed that hemolysis-related parameters, such as potassium, glutamate oxaloacetate transaminase, bilirubin, lactate dehydrogenase, and protein concentration, were markedly higher than in the peripheral blood, and there were significant correlations between these parameters. Mixed intensity hematomas were significantly thicker than the other types, and showed markedly higher values of hemolysis-related parameters. Factors affecting the CT and MR imaging findings, such as fresh bleeding, hemolysis, and hemoglobin changes, coexist in a hematoma to varying degrees, and these factors may interact with the age of the hematoma to produce the different patterns that are observed.

The Role of Cyberknife Radiosurgery/Radiotherapy for Brain Metastases of Multiple or Large-Size Tumors

OBJECTIVE

Focused, highly targeted radiosurgery and fractionated radiotherapy using the Cyberknife are useful treatments for multiple or large metastases. Here we present our results of Cyberknife radiosurgery for 71 patients with 148 metastatic brain lesions.

METHODS

There were 32 women and 39 men with a median age of 63 (range: 30-88) years. Radiographic follow-up was available for 60 patients with 104 lesions. The mean and median initial volumes of the tumor per lesion were 6.6 and 2.9 cm(3) (range: 0.1-53.2 cm(3)), respectively, at the time of the initial Cyberknife treatment. Forty patients (56%) had a single lesion, and 31 (44%) had multiple lesions (range: 2-7) at initial treatment. The number of fractions ranged from 1 to 3, and forty (27%) of 148 lesions were treated by a fractionated course of Cyberknife therapy. The mean marginal dose was 20.2 Gy (range 7.8-30.1 Gy, median: 20.7 Gy).

RESULTS

At 44 weeks of median follow-up, there were no permanent symptoms resulting from radiation necrosis. Overall 6-month and 1-year survival rates were 74% and 47%, respectively, and the median survival time was 56 weeks. The Karnofsky performance score and extracranial metastasis were significant prognostic factors at 6 months and 1 year, respectively, in both univariate and multivariate analyses. Age or multiple metastases did not influence prognosis at 6 months and 1 year. Local control was achieved in 83% (86 lesions). After additional radiosurgical or surgical salvage, no patient died as a result of intracranial disease. Twenty-five patients developed 92 new metastases (range 1-13) outside of the treated lesions with 22.4 weeks of median follow-up. Among them, 21 patients (84 lesions) were treated by salvage Cyberknife.

CONCLUSION

Despite the inclusion of an unfavorable group of patients with large tumors, our results for survival and tumor control rates are comparable to those of published series. The Cyberknife provides the advantage of allowing for fractionated treatment to multiple or large-size tumors.

Designing novel pH-sensitive non-phospholipid vesicle: characterization and cell interaction

In this work, we report the preparation, the characterization and interaction with cells of novel pH-sensitive non-phospholipid vesicle formulations, from a non-ionic surfactant mixed with cholesterol (CHOL) and his derivative cholesteryl hemisuccinate (CHEMS), as pH-sensitive molecule. This molecule, can destabilize the vesicle lipid bilayer when exposed to an acidic environment, with a subsequent release of vesicular content, enhancing the cytoplasmatic delivery of drugs to target cells. Vesicles were characterized by static and dynamic light scattering, in order to evaluate their dimensions, bilayer thickness and vesicle stability. Membrane permeability changes were determined by the release of entrapped hydroxypyrene-1,3,6-trisulfonic acid (HPTS). Also diphenylhesatriene (DPH) fluorescence anisotropy and zeta potential measurements were used to evidence the pH sensitivity. Furthermore vesicles were characterized by means of electronic microscopy after freeze-fracture. The interaction of non-lipid vesicles containing different fluorescent dyes with Raw 264.7, mouse monocite macrophage, were analyzed by flow cytometric analysis. The obtained results indicate that the pH-sensitive vesicular structures show good plasma stability and relevant pH-sensitivity. Moreover this formulation was able to interact with target membranes (i.e. plasma or endosomal membrane) and to release the encapsulated material into the cytoplasm.

CyberKnife Stereotactic Radiotherapy for Patients with Malignant Glioma

OBJECTIVE

The CyberKnife is a new frameless image-guided radiosurgical modality. The authors report on their experience using the CyberKnife in 25 patients with malignant gliomas.

METHODS

Twenty-five patients with histologically proven malignant gliomas (18 glioblastoma: GB, 7 anaplastic astrocytoma: AA) were treated with the CyberKnife at Konan St. Hill Hospital between June 1998 and November 2002. CyberKnife therapy was performed on 44 lesions (31 GB lesions, 13 AA lesions) in the 25 patients. The median target volume was 19.1 mL (range: 0.3 - 90.2). The median prescribed dose was 20.3 Gy (range: 13.9 - 26.4). Patient-, tumor-, and treatment-related variables were analyzed by univariate analysis, and survival curves were generated by the Kaplan-Meier product limit.

RESULTS

In the 18 GB patients, the median survival after diagnosis was 20.7 months (82.6 weeks) with a mean follow-up of 85.7 weeks. Of the 7 AA patients, 6 were alive at the time of analysis with follow-up periods ranging from 11.4 to 52.8 months. Patients younger than 70 years had a median survival after diagnosis of 37.1 months, compared to 12.4 months for older patients (p = 0.003). Similarly, patients with well-controlled lesions had a median survival after diagnosis of 39.8 months compared to 16.0 months for those with uncontrolled lesions (p = 0.031). Late delayed radiation necrosis was seen in 1 GB patient. No other patient suffered acute or delayed neurological morbidity after CyberKnife therapy.

CONCLUSION

This is the first report of CyberKnife stereotactic radiotherapy applied to the treatment of malignant gliomas. The frameless and painless CyberKnife stereotactic radiotherapy has the potential to be as useful for treatment of malignant glioma as other radiosurgical modalities.