11 research outputs found

    Regression of multiple meningiomata after cessation of cyproterone acetate treatment

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    Objectives: We report a case of regression of multiple meningiomata after cessation of cyproterone acetate treatment. Design: Case report and PubMed review of the literature. Subjects: A 59-year-old man had been on prolonged cyproterone for hypersexuality. He presented with 6 months increasing right-sided headaches and right-eye proptosis. He also had early signs of right optic nerve edema. MRI showed multiple meningiomata with the largest being over the right sphenoid wing. Cyproterone was discontinued. Methods: Patient review in outpatients with serial MRI scans and PubMed search using the terms “meningioma” and “cyproterone acetate” or “hormone” and “regression.” Results: Within 3 months of discontinuing cyproterone, the patient had marked clinical and radiological regression of his meningiomas. He has been reviewed with three monthly MRI scans for 1 year, and his symptoms have clinically resolved. So far, he has not required surgery and his hypersexuality is being effectively managed with Zoladex. Our literature review indicates a clinical association of meningioma formation with long-term cyproterone use. There are only two similar cases of tumor regression on cessation of cyproterone treatment. Conclusions: This case illustrates how cyproterone may result in hormone-receptive meningiomata growth. It also shows how discontinuing the cyproterone has so far resulted in clinical resolution of symptoms and radiological tumor regression in this case

    OP23. T cell expression in CNS lymphomas: A single centre experience of Primary CNS T-Cell Lymphomas

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    INTRODUCTION: Primary CNS lymphomas (PCNSLs) are a rare entity and comprise only 5% of brain tumours. Histopathologically they are primarily of B-cell phenotype. Primary CNS T-Cell Lymphomas (PCNSTLs) constitute \u3c5% of all PCNSLs. Such rarity in clinical practice means there is a paucity of robust data on the long term outcomes for patients with PCNSTLs. We report our PCNSTL (or T-Cell rich PCNSLs) experience over 7 years. METHODS: We reviewed our pathology database for all PCNSLs diagnosed between 2009 and 2016. Specifically T-cell expression, Ki67 Proliferative Index (KPI) and CD expression were looked reviewed from histopathological reports. Treatment options, survival and complications were also reviewed. RESULTS: We identified a total of 58 PCNSLs of which 2 were pure T-cell lymphomas and 3 were B cell lymphomas with T cell expression (2 were ‘T-cell rich’; 1 was anaplastic). Mean age was 58.4 (44–66 years). These 5 patients comprised of 4 males and 1 female. One patient was HIV positive; and another had a previous history of lung cancer. On FLAIR MR Imaging, three patients had supratentorial bihemispheric lesions; and one patient (who is still alive) had a left cerebellar lesion. In our small sample, those with bihemispheric lesions had shorter survival times which would correlate with extent of disease dissemination within the white matter tracts. The 2 ‘T-cell rich’ samples had a KPI of 70–80%. (In the PCNSLs with T cell expression, the KPI ranged from 20% - 90% and in our group this correlated with survival).One patient whose cells demonstrated a KPI of 90% survived for only 56 days from diagnostic biopsy. Immunohistochemistry showed variable CD expression (as in previous published literature). All 5 patients had their histology dually reported by a neuropathologist and haemotopathologist. One patient was not fit enough for oncology treatment. The other 4 had chemotherapy and all had relapses or progression on treatment. Mean survival time was 275.2 days (7.56months with a range of 56–571 days). At the time of writing, 1 patient was still alive with ongoing haematology clinic review; 1 was discharged to a palliative care facility and 3 patients had died. SUMMARY: With PCNSTls or PCNSLs with T-cell expression, there seems to be an association between survival and the Ki67 proliferative index in addition to presence of bilateral supratentorial disease on MR imaging. As they are extremely rare presentations, further studies would perhaps benefit from multi-centre involvement. Their histological diagnosis (especially immunohistochemistry) remains challenging due to the heterogeneity of the cells and CD expression, and in our experience has often required multiple histology reviews

    Optic Nerve Decompression with Release of the Meningo-Orbital Band in Medial Sphenoid Wing Meningiomas Improves and Preserves Visual Acuity

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    Objectives: Medial sphenoid wing meningiomas often present with reduced vision from compression of the optic nerve. We postulated that optic nerve decompression with bony decompression and release of the meningo-orbital band can result in stable or improved vision. Methods: Retrospective review of medial meningiomas with optic nerve compression operated in a single unit from 2006 to 2015. Visual acuity was compared pre and post-op. Results: We identified 18 patients. All had craniotomies.15/18 (83.3%) patients presented with reduced vision. 5 had only light perception in the affected eye. 12/18 (66.7%) of the patients had decompression of the optic nerve including release of the meningo-orbital band. One patient experienced worsening acuity due to hydrocephalus. A third of patients 6/18 (33%) had improvement of their vision with 5/18 (27.8%) having undergone optic nerve decompression. Excluding those who presented with only light perception, this increases to 5/13 (38.5%). 6/12 of those decompressed had stable vision (2 had normal vision preoperatively). Patients who presented with only light perception had no improvement in vision. Conclusion: In patients with optic nerve compression from medial meningiomas, optic nerve decompression with the release of the meningo-orbital band is useful in preservation of vision. In those decompressed 5/12(41.6%) had improvement and a further 6/12(50%) had stable vision. Optic nerve decompression should be considered before or at early stages of visual loss, as no improvement was demonstrated in those with minimal vision preoperatively

    Use of 18F-FDG-PET-CT in glioma surveillance: A single centre experience

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    INTRODUCTION Radiological surveillance in glioma surgery is primarily with MRI. Differentiating between disease progression and radionecrosis can be challenging. In our unit, in selected cases when there is suspicion of radiological recurrence, progression or to aid in differentiating progression from radionecrosis, we have augmented our surveillance with 18F-FDG-PET-CT which can highlight areas of metabolic activity which correlate with increased tumour activity. RESULTS We identified 19 cases of PET imaging for glioma surveillance of whom we could assess 17 notes and images. Mean age was 45.06 (30–67) with male: female ratio 9:8. 15 /17(88.2%) patients had surgery and 2 declined surgery(7 biopsy only, 8 debulk and 2 declined surgery). Initial histology was pilocytic astrocytoma (1), grade II (4, 26.7%), grade III (6, 40%), GBM (3) and non-specific tissue (1). 5 patients had evidence of increased uptake on PET and all showed clinical progression, with only 3 clinically fit for surgery (histology showed 2 recurrence, 1 transformation). 10 patients had no increased uptake on FDG with 4 on on-going surveillance for an average of 8.5 years (7–12), 2 clinically progressed at 2 and 8 years after initial presentation at the point of PET imaging and received palliative chemotherapy, 1 had concurrent inoperable lung cancer and was palliated, 1 patient had transformation from glioma grade II - III, 1 had grade 2 histology, and 1 had only gliotic tissue on re-operation CONCLUSIONS A positive FDG PET has a positive correlation with disease progression and may be considered as an adjunct test in glioma surveillance

    PP78. Primary CNS Lymphoma Outcomes in a Single Centre: A 7 Year Study

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    INTRODUCTION: Primary CNS Lymphoma (PCNSL) in the immunocompetent population is reported as comprising 3–5% of all primary CNS neoplasms. They are considered aggressive tumours and their management remains controversial. We report a single centre experience of PCNSL over 7 years. METHODS: This is a retrospective cohort study of all biopsy confirmed PCNSLs between 2009 and 2016 in a busy London neurosurgical unit. Data was sourced from the lymphoma database, pathology reports, patient notes and radiology. We then reviewed their oncology treatment and outcomes. Primary endpoints were mortality, relapse and treatment complication rates. RESULTS: We had 58 patients (35 males and 23 females). 13 (22.4%) had a previous history of cancer and 10(17.2%) were immunocompromised. The rate of mortality during the seven years was 58.6% (34/58). The mean survival was 1.9 years (11 days to 7.16 years) Biopsies for tissue diagnosis had a low complication rate in our cohort (1 patient with biopsy related intracranial haematoma; 1 patient with wound breakdown). We were able to review treatment plans of 30 patients of whom 19 underwent chemotherapy and 10 had palliative radiotherapy only. 3 patients were not fit for either chemotherapy or radiotherapy. Neutropenic sepsis occurred in 26.1% (6/30) of the treated group with a similar proportion having neurological problems such as short term memory loss, seizures and hydrocephalus. 21.7% (5/30) had relapse despite treatment. CONCLUSIONS: 40% of our cohort had a history of cancer or being immunocompromised which can be attributed to the presence of activated oncogenes and failure of cell cycle repair mechanisms. A significant proportion (21.7% in our cohort) had relapse despite treatment which supports previous studies of PCNSL as an aggressive disease. It remains a disease with a high mortality and significant complications during treatment

    The next frontier in neurocritical care in resource-constrained settings

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    Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS

    Encephaloduroateriosynangiosis (EDAS) in the management of Moyamoya syndrome in children with sickle cell disease

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    Background: Encephalo-duro-arterio-synangiosis (EDAS) in Moyamoya syndrome (MMS) treatment has been well described in the literature, however in MMS caused by sickle cell anaemia (SCA), EDAS use remains controversial with poor long-term follow-up. We present a case-series of SCA patients who have undergone EDAS for SCA-related MMS and describe their post-operative course as well as provide a literature review of the role of EDAS in the treatment of sickle cell anaemia. Methods: A retrospective review of all the paediatric EDAS procedures conducted in our institution for SCA from 2007 to 2015. Two patients underwent behavioural screening. Results: A total of eight patients with MMS secondary to SCA underwent EDAS. Unilateral EDAS was performed without complication in seven patients. One patient underwent bilateral EDAS but with a two-year gap in between procedures. Follow-up magnetic resonance angiography demonstrated no progression of Moyamoya collaterals or further ischaemic events with regression of collaterals clearly visible in one patient. All patients have demonstrated a return to normal school activities. Conclusions: EDAS is a well-tolerated revascularisation procedure for children with MMS. The prevention of further infarcts in our group with sickle cell disease has allowed these children to resume normal school activities

    Cerebellar infarction following division of Dandy\u27s vein in microvascular decompression for trigeminal neuralgia

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    Objectives: Does dividing Dandy\u27s (superior petrosal) or other tentorial veins increase the risk of cerebellar infarction following microvascular decompression (MVD) of the trigeminal nerve? Design: A retrospective review of all patients with trigeminal neuralgia who underwent MVD by the senior author between 1999 and 2012. Materials and Methods: Patients were identified from operative logbooks and discharge summaries. Data were collected from the medical notes. Results: Of 162 patients who underwent microvascular decompression of the trigeminal nerve, we had a 96% follow-up rate, which provided 156 of the operative cases for review. Over 75% report to be neuralgia free at first follow-up. Cerebellar infarction occurred in six patients, all of whom had division of the superior petrosal or tentorial veins. Fifty-one patients did not suffer cerebellar infarction following division of Dandy\u27s or other tentorial veins. In our series, this gives an overall risk of 3.85% of cerebellar infarction following microvascular decompression of the trigeminal nerve. In the group of patients that had division of the veins, 9.5% experienced cerebellar infarction. Conclusions: Since Walter Dandy\u27s original description of microvascular decompression of the trigeminal nerve through a retrosigmoid approach, it has been suggested that it is safe to divide the superior petrosal or any other bridging vein. In this series of 156 cases, 6 patients experienced a cerebellar infarction associated with the division of part of Dandy\u27s vein alone or in association with division of tentorial veins. We would suggest that with a rate of 9.5% of cerebellar venous infarction, division of any bridging veins should only be considered if absolutely necessary

    Referrers’ point of view on the referral process to neurosurgery and opinions on neurosurgeons: a large-scale regional survey in the UK

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    Objectives There is an increased reliance on online referral systems (ORS) within neurosurgical departments across the UK. Opinions of neurosurgeons on ORS are extensively reported but those of referrers have hardly been sought. Our study aims at ascertaining our referring colleagues’ views on our ORS and its impact on patient care, their opinions on neurosurgeons and how to improve our referral process. Setting 14 district general hospitals and one teaching hospital. Participants 641 healthcare professionals across a range of medical and surgical specialties including doctors of all grades, nurses and physiotherapists. Survey responses were obtained by medical students using a smartphone application. Results Although 92% of respondents were aware of the ORS, 74% would routinely phone the on-call registrar either before or after making referrals online. The majority (44%) believed their call to relate to a life-threatening emergency. 62% of referrers considered the ORS helpful in informing patients’ care and 48% had a positive opinion of their interaction with neurosurgical registrars. On ways to improve the ORS, 50% selected email/text confirmation of response sent to referrers and 16% to referring consultants. Conclusion Our results confirm that referrers feel that using our ORS positively impacts patient care but that it remains in need of improvement in order to better suit our colleagues’ needs when it comes to managing neurosurgical patients. We feel that the promotion of neurosurgical education and mitigation of the effects of adverse workplace human factors are likely to achieve the common goal of neurosurgeons and referrers alike: a high standard in patient care
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