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Thus, we present data of patients with spontaneous acoustic neuroma and long-term follow-up data on patients with a minimum follow-up of two years. Koos grades at time of diagnosis and at time of GKRS were evaluated. Patients were assessed according to the Gardner-Robertson hearing scale and House-Brackmann facial weakness scale prior to GKRS, and at times of follow-up. Data were evaluated retrospectively.
Whereas the combined treatment was favored especially prior tothe percentage of only radiosurgically treated cases has significantly increased since then. The overall complication rate after GKRS was low. The complication rate after GKRS further declined in the last decade. One case of malignant transformation after GKRS was diagnosed 0. Radiological outcome after GKRS revealed stable or decreased neuromas in the vast majority of cases including all Koos grades.
The rate of non-functional hearing was already rather high prior to GKRS. GKRS is a safe and effective treatment in patients of all Koos grades. Advancements in the radiosurgical treatment especially over the last decade have led to a low complication rate and excellent outcome.
Vestibular schwannoma VS is a benign tumor with associated morbidities and reduced quality of life. Except for mutations in NF2, the genetic landscape of VS remains to be elucidated.
The aim of this study was to characterize mutations occurring in this tumor to identify new genes and signaling pathways important for the development of VS.
In addition, the authors sought to evaluate whether GKRS resulted in an increase in the number of mutations. Forty-six sporadic VSs, including 8 GKRS-treated tumors and corresponding blood samples, were subjected to whole-exome sequencing and called tumor-specific DNA variants.
Pathway analysis was performed using the Ingenuity Pathway Analysis software. In addition, multiplex ligation-dependent probe amplification was performed to characterize copy number variations in the NF2 gene and microsatellite instability testing was done to investigate for DNA replication error. With the exception of a single sample with an aggressive phenotype that harbored a large number of mutations, most samples showed a relatively low number of mutations.NSCG Newcastle College - Academy of Sport Spotlight: Greg Butler
A median of 14 tumor-specific mutations in each sample were identified. The GKRS-treated tumors harbored no more mutations than the rest of the group. A clustering of mutations in the cancer-related axonal guidance pathway was identified 25 patientsas well as mutations in the CDC27 5 patients and USP8 3 patients genes.
Thirty-five tumors harbored mutations in NF2 and 16 tumors had 2 mutational hits. The samples without detectable NF2 mutations harbored mutations in genes that could be linked to NF2 or to NF2-related functions. None of the tumors showed microsatellite instability. The genetic landscape of VS seems to be quite heterogeneous; however, most samples had mutations in NF2 or in genes that could be linked to NF2.
Salvage treatment of vestibular schwannoma: University of Bergen, Dept. Although several small individual series on repeat Gamma Knife radiosurgery GKS for recurrent vestibular schwannoma VS following prior GKS have been published, we aim to systematically aggregate data from the literature as well as from our own institutions to better understand the safety and efficacy of repeat GKS for VS.
All patients that underwent repeat GKS of sporadic VS at two tertiary academic referral centers between and were eligible for study. An aggregated dataset of previously published cases plus our own data were analyzed. A cohort of patients treated with salvage microsurgery MS following failed GKS were used as comparison.
Sixteen patients from our own institutions were included for analysis. Five patients were previously treated with MS. Mean age at first treatment was Mean tumor volume at the first treatment was 0. Mean follow-up after the second GKS treatment was 34 months.
Of 10 patients with a complete dataset, one had worsened facial nerve function after the second GKS treatment. There were no new reported cases of trigeminal neuralgia. Overall, in 12 patients with complete follow-up: The combined dataset with patients previously reported in the literature included 88 patients: Salvage treatment of vestibular schwannoma is challenging.
Repeat GKS treatment provide poorer tumor control than what can be expected from initial GKS treatment and poorer tumor control than salvage microsurgery, few patients maintain good hearing.
The risk of facial and trigeminal nerve dysfunction however, is low and lower than what can be expected from salvage microsurgery. There has been a growing effort for automated targeting in the image-processing community based on diffusion-MRI. This technique enables the depiction of the different structural-connectivity properties and therefore, the specific fiber orientation inside each thalamic nucleus.
Our group proposed an automated and robust method across healthy subjects and tremor patients for parceling the thalamus in seven main groups of nuclei while exploring the local diffusion information from the spherical harmonics representation of the orientation distribution functions ODFs in k-means clustering framework.
We aim at further automatic subdivision of the VLV cluster. To this end, within the VLV, we first built a k-nn graph with edges corresponding to the respective ODFs distances and then, we performed a partition in 3 sub-clusters using the NCut algorithm. The proposed subdivision was compared to the radiological response in the follow-up images of 17 patients treated for tremor with GKS unilaterally. In general, the sub-partition followed a spatial-distribution pattern and for 12 out of 17 cases we observed that one specific sub-cluster encloses entirely or the major part of the contrast enhancement corresponding to the GKS target appearing on the follow-up images.
The evaluation of the sub-partition outcome was further extended in one additional tremor patient treated with DBS, bilaterally. We observed that in each hemisphere both initial targeting point and the final electrode position are inside the anticipated sub-cluster. Our preliminary results will be further investigated in a larger patients dataset, treated by either GKS or DBS, and on diffusion images with higher spatial resolution.
Dade Lunsford 1 1. Gamma knife thalamotomy GKT is a well-established treatment for medically refractory tremor patients who are at risk for invasive procedures. The purpose of this study was to evaluate whether staged bilateral GKT provides benefit and acceptable risk to patients suffering from disabling bilateral tremor.
At a median interval of 22 months, 11, patients underwent staged bilateral GKT during a 17 year period For the 1st GKT, a median maximum dose of Gy was delivered to the posterior-inferior region of the nucleus ventralis intermedius VIM through a single isocenter with 4-mm collimators. All patients had improvement in tremor after 1st GKT. The median time to last follow-up after the 1st GKT was 35 months range, months.
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No patients had tremor recurrence or diminished tremor relief. One patient experienced new temporary neurological deficit contralateral lower extremity hemiparesis from the 1st GKT which improved on corticosteroids.
The median time to last follow-up after the 2nd GKT was 12 months range, months. Two patients had tremor arrest and complete resolution of function. No patient experienced tremor recurrence or diminished tremor relief after the 2nd GKT. No patient experienced new neurological or radiological adverse effect from the 2nd GKT.
Staged bilateral GKT provides effective relief for medically refractory, disabling, bilateral tremor without increased risk of neurological complications. It is an appropriate strategy for carefully selected medically refractory bilateral tremor patients ineligible for deep brain stimulation. Unilateral GKT is an established treatment for severe tremors.
However, essential tremor is usually bilateral. The persistence of contralateral tremor may induce an impairment in activities of daily living ADL.
Bilateral procedures with thermocoagulation were contraindicated because of the risk of balance, cognitive or speech problems. As the lesion induced by radiosurgery within the VIM is progressive and limited, we proposed a study on bilateral GKT. Here are the preliminary results. Patients were included if there was no impairment in their balance or speech and if the neuropsychological assessment was stable. VIM lesioning was performed with Leksell Gamma unit with a single exposure through a 4mm collimator.
Radiosurgical dose was Grays. Cognitive score and gait assessment were stable. No patient had hypophonia or dysarthria. Two patients were not significantly improved. One patient had a side effect related to GKT2. She developed hemiataxia and dysarthria induced by a hyperresponse pattern 11months after GKT. These preliminary results on bilateral GKT for severe ET in a selected cohort of patients shows that the procedure is feasible without a major risk of cognitive or balance problems.
Consequently, the targeting strategies are indirect, such as atlas-based registration and stereotactic coordinates. Recent findings have shown the potential of the susceptibility-weighted imaging SWI acquired at 7T for imaging the thalamic nuclei with Vim being one of them.
The aim of this study is to compare the localization of the target points defined by the quadrilateral of Guiot, as used in daily clinical practice, with the visual Vim-area on SWI at ultra-high field. Guiot targeting was performed bilaterally, six times for each subject using the 3T images. The left and the right Vim-area were manually delineated based upon the intensity variation observed from the SWI as well as the Schaltenbrand and Wahren stereotactic atlas.
The Vim was outlined for nine out of ten thalami, while the last one was difficult to discriminate due to a presence of a blood vessel. The volumes of the delimitated Vim-area are in the interval [ The quadrilateral of Guiot showed to be highly reproducible with a maximum intra-subject variability of 1.
Additionally, these points were always inside the manually delineated Vim and predominantly in the ventral part of the outlined volume showing a tendency of their localization. This study reports for the first time, to the best of our knowledge, a validation of the clinical targeting against subject-related imaging reference. Moreover, we observed that the clinically used Guiot targeting points are confined in the ventral part of the visually distinguishable Vim as provided by SWI acquired at ultra-high field.
Further studies with larger datasets, such as tremor patients and their electrophysiological confirmation, should validate these findings. To assess for the first time structural brain changes, by voxel-based morphometry VBMbefore and after unilateral Gamma Knife thalamotomy GKT for drug-resistant tremor. To identify differences between clinical responders and non-responders to GKT.
Thirty-eight patients mean age Targeting of ventro-intermediate nucleus Vim was performed with Leksell Gamma Knife using a single 4-mm collimator and Gy. Neurological, neuropsychological and neuroimaging 3 Tesla, including 3D T1 weighted assessment had been done at baseline and 1 year after GKT. With regard to GM changes after GKT, independently of clinical answer, atrophy was present in extensive areas right globus pallidus, left putamen, left thalamus, right anterior and medio-dorsal thalamus, cerebellar, right premotor and supplementary motor area, left and right visual association cortex, right ventral temporal, left parahippocampal and posterior cingulate gyrus.
Our results show brain plasticity after unilateral left GKT. Kate passed away in hospital after a period of illness.
Stafford Apex Autumn Open Meet
Our thoughts are with Len, family and friends at this sad time. Please note the voting rules below You can give one vote for your candidate once every 24 hours so please log on and cast a vote for tug of war each day. Once you have received an email, click the link to cast and confirm your vote.
Use the link in your confirmation email to cast your vote every day to allow your two votes to count if you use different devices to go online! Votes close on 31 January Please vote every day and help put tug of war on the map! To begin the voting process, please click the following link: Unfortunately there was a reduced number of teams participating this year, but that did not detract from the pulling that took place and we were treated to some good finals.
The teams that took part were Kilroe, Raunds, Uppertown and Sheen. The day started with a moments silence in memory of Sheen Anchor Andy Hall who sadly passed away recently, and no doubt he would have been competing on the day had he not been taken from us so early. Five weight classes took place on the day from kg up to the catchweight division. The day started with the catchweight competition with Sheen and Kilroe contesting a good final, with Sheen taking the gold medal for the twelfth year in a row.
The remainder of the weight classes saw Raunds claim 4 gold medals, winning the kg, kg, kg and kg titles. Kilroe finished as silver medallists in the kg competition, with Sheen finishing in third place. A close kg competition saw quite a few pulls take place, with Raunds and Uppertown contesting the final.
Kilroe took the bronze with a 2 end to 0 win against Sheen. The kg competition was another good competition, with Sheen and Kilroe providing an exciting bronze medal match, which Sheen won by 2 ends to 0, with Raunds and Uppertown contesting the final, which Raunds took by 2 ends to 0.
Raunds won the kg competition by defeating Sheen in the final. Uppertown As a final note, we would like to thank all of the officials who helped to run the competition on the day - Judges: Raunds We would love to see more teams giving indoor tug of war a go next year, with the season starting in October.
If any clubs wish to give indoor tug of war a go and would like to know how to get started and how to get involved, then please contact us. We would like to thank everyone who has supported the Tug of War Association this year, in what has been both a challenging year and a rewarding year on and off the field. We wish everyone well over the festive period and we look forward to seeing teams, officials and tug of war supporters in - the 60th Anniversary of the Tug of War Association.
Everyone is welcome to attend. Brian started the sport of tug of war first and briefly with Cheddleton Saxons Staffordshire. Later he joined Sheen Farmers. Brian had immense strength and with his team he was to win national and international championships in many parts of the world, visiting the USA twice for the World Games and a World Championships as well as competing in South Africa and many European countries including the Channel Islands.
New Developments in Management of Meningioma
Brian's son John is still an active member of the Sheen Farmers Team today. The link to the web site is below: Hosting a tug of war competition is a great way of promoting the sport and your club in your local area. Meningiomas most common arise from the arachnoid cap cells imbedded in the arachnoid vill [ 3 ], optic nerve sheath, choroids plexus and rare from unknown and progenitor cells origin [ 1213 ]. According to Word Health Organization WHOthey classified on the basis of the tissues involvement, dural site origin and histological type [ 14 ].
While asymptomatic meningiomas are traditionally managed conservatively until symptoms develop or lesion growth occurs, it is likely thatpatients at high risk for symptom development — most common young people because of the higher growth potential, may benefit from earlier clinical and radiological follow-up in order to decrease this possibility [ 46 ]. Furthermore, in surgical treatment of asymptomatic meningiomas, themorbidityrate was 4. Some studies proposed a stereotactic radiotherapy as an alternative method, with low toxicity and the lack of treatment-associated mortality [ 26 ].
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In order to reduce the surgical complications in more aged patients with symptomatic meningiomas, Sacko et al. On the other hand, for subtotal resected and recurrent meningiomas, radiotherapy conventional or stereotactic may be proposed.
When all treatments surgery and radiotherapy have failed; hormonal therapy or chemotherapy can be applied [ 28 ]. In the current study we reviewed the available treatment modalities for meningioma treatment. Results After investigation of articles, only article were eligible.
When meningiomas are symptomatic, surgery with radical excision, constitutes the first choice of treatment. Parasagittal meningiomas constitute a challenge for the surgeon; mainly when they arise from the middle. If meningiomas involve the optic canal, the decompression and removal of the tumor inside optimize visual recovery and prevent tumor recurrence. For parasellar and posterior fossa meningiomas, usual excision of the tumor followed by irradiation is advocated in order to reduce postoperative neurological injuries.
By the development of 3D Conformal Radiotherapy CFRTwhere the high-dose suits the target and avoids normal tissues, the effectiveness of radiotherapy has been improved. Traditional chemotherapeutic agents are not very effective against meningiomas. Hormonal manipulation is also under review in cases with untreatable tumors or those who are inappropriate for surgery.
Angiography and more recently, selective intra-arterial injection of dilute MR contrast media, can be offer a better understanding and more clear view to the vascular blood supply of the meningiomas. Discussion Surgery Surgery constitutes the first choice of treatment, when meningiomas are symptomatic, with more radical excision, because of latest approaches.
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Thus, the use of dorsolateral approach for foramen magnum meningioma [ 29 ], retrosigmoidal for petroclival [ 30 ] or skull base approach for giant anterior clinoidal meningiomas [ 31 - 33 ], usually offer very good results.
Furthermore, microsurgical operation has given grate results and an effective resection [ 34 - 36 ]. The new imaging techniques also, allows a better preoperative planning.
Meningiomas are well MR perfused tumors [ 37 ] and 3D-CTA helps to avoid vascular events, during surgical removal of the tumor [ 38 ]. Many meningiomas cannot be totally resected because of their involving with vital neural, vascular central veins structures or are en plaque. If the sinus is partially or completely occluded, may be opened and a total tumor resection could be proposed, followed by venous reconstruction [ 32 ]. Also, an alternative plan is the outside of sinus tumor excision and coagulation of remnants or the use of radiation treatment [ 44 ].
The restore of flow, by venous reconstruction and maintenance of cortical veins, offer a very useful collateral drainage [ 45 ]. If meningioma involves the optic canal, the decompression and removal of the tumor, optimize visual recovery and prevent tumor recurrence [ 4647 ]. The management of spheno-orbital meningiomas with diffuse orbital tumors and invasion of the optic canal, is a supraorbital-pterional approach and wide opening of the optic canal [ 48 ].
For lateral intraorbital tumors with invasion of the lateral aspect of the optic canal, a complete tumor resection offers good decompression of the optic nerve via a less invasive lateral orbitocranial approach without craniotomy [ 48 ].
For the cases of bilateral hyperostotic sphenoorbital meningiomas, which are quite rare, the proposed management includes pterional approach for surgical resection, in two stages first treating the most impaired sideincluding the decompression of the optic nerve [ 50 ]. When cavernous sinus infiltration coexists, radiation therapy can be added [ 50 ]. For lateral sphenoid wing and olfactory groove meningioma, the complete resection is the goal [ 51 ].
Direct intratumoral hydrogen peroxide injection may reduce blood lossthe need of preoperative embolization and shorted resection times [ 52 ]. At sphenoid wing meningiomas, the tumors without cavernous sinus involvement had a more favorable visual outcome and overall prognosis, compared with tumors presenting cavernous sinus involvement [ 53 ].
For the olfactory groove meningiomas many approaches have been used depend on tumor size, location, origin and extension, with less morbidity rate and better access in bifrontal and frontolateral approaches [ 5455 ]. For parasellar and posterior fossa meningiomas, usual excision of the tumor followed by irradiation is advocated in order to reduce postoperative neurological injuries [ 56 ].
In tuberculum and diaphragma sella meningioma, an early surgery using the subfrontal approach with better preoperative visual function and smaller tumor size is associated with better outcome [ 57 ].
Moreover, the management of tuberculum sellae meningiomas can include pterional [ 58 ] or frontolateral approach with microsurgical dissection of the Sylvian fissure, giving a quick access, safe and totally resection of the meningioma, with improvement of the vision and reduction of the morbidity [ 59 ].
The retrosigmoid approach for the management of the cerebellopontine angle CPA meningiomas, is a common and safe surgical procedure [ 60 ]. Large meningiomas of CPA, can compress the brainstem and may have a vascular and neuronal attachment.
A combined retrosigmoid—transpetrosal—transcochlear approach can provide wide exposure to the CPA and easier surgical resection of large meningiomas [ 61 ]. In a case of a small residual tumor, it can be managed with radiosurgery for a long period free of tumor recurrence.
On the other hand, the retrolabyrinthine approach described in by Hitselberger and Pulec, allows an easier exposure in anatomical entities at this region with a better tumor resection and lateral sinus control [ 62 ]. Anterior clinoidal meningiomas constitute a more challenging tumor for surgery and many base approaches can be used with good results [ 63 ]. There are reports, showed that the pterional craniotomy is a satisfactory approach regardless of tumor size [ 64 ]. Other challenged managing tumors are the foramen magnum meningiomas, mainly when they have anterolateral localization [ 65 ].
In difficult cases, a subtotal resection can be proposed; when they are asymptomatic. In elderly population with mild symptoms, the treatment is conservative.
For giant meningiomas of the anterior cranial fossathe extended anterior skull base approaches, using orbital osteotomies, have improved the possibility of gross-total tumor removal with minimal neurological morbidity [ 66 ].