Adjuvant Treatment in the Management of Low-Grade Gliomas

The use of chemotherapy in low-grade gliomas has been very thoroughly studied in the setting of oligodendrogliomas and oligoastrocytomas. According to the Radiation Oncology staff here at Thomas Jefferson University Hospital, the current practices in our institution are as follows: Three-dimensional conformal radiation is provided in patients with low-grade gliomas 2-4 weeks post-operatively. The total dose ranges between 50 and 54 Gy and is delivered in 1.8 fractions at five fractions per week. In the presence of recurrence, a stereotactic boost with or without re-operation is provided. For the most part, these practices are similar to the aforementioned recommendations. However, factors such as the age of the patient, and optimal timing of the radiation are not considered in our institution at this given time. Chemotherapy is restricted to patients with known pathology of oligodendroglioma. PCV is the chemotherapeutic agent of choice in both research recommendations and our clinical practice. Specifically, the use of PCV in an established oligodendroglioma case has shown to increase the time to progression and provide a statistically significant survival benefit. Furthermore, this response is augmented in patients with chromosomal analysis positive for the 1p and 19q allele mutation. For these patients, further chromosomal analysis is performed in order to predict the chemotherapy response rate. Recurrent disease is managed on a patient specific basis

Cerebrospinal Fluid Leakage and Cerebral Venous Sinus Thrombosis: A Case Report

Cerebrovascular venous thrombosis is an uncommon entity that may occur in the sinuses of the dura, the cortical veins, or the deep venous system. Common etiologies include states of hypercoagulability, such as oral contraceptives intake, malignancy, and trauma. Additional causes include inherent thrombophilic states, such as those caused by systemic lupus erythematosus, protein C or S deficiency, and antithrombin III deficiency. The pathogenesis of cerebral venous sinus thrombosis stems from the obstruction of venous outflow. Consequently, venous engorgement occurs, leading to decreased effective blood flow and white matter edema. Infarction or hemorrhage are not uncommon in the setting of venous thrombosis. Intracranial pressure also rises. The most common presenting symptom is headache.2,3 The impact of intracranial hypotension due to cerebrospinal fluid (CSF) leak on venous flow and thrombosis is not clear.1, 4-8, 10, 11 We present the case and treatment course of a patient who initially presented with an acute venous sinus thrombosis and in was later found to have a CSF leak and intracranial hypotension

Flow-diversion panacea or poison?

Endovascular therapy is now the treatment of choice for intracranial aneurysms (IAs) for its efficacy and safety profile. The use of flow diversion (FD) has recently expanded to cover many types of IAs in various locations. Some institutions even attempt FD as first line treatment for unruptured IAs. The most widely used devices are the pipeline embolization device (PED), the SILK flow diverter (SFD), the flow redirection endoluminal device (FRED), and Surpass. Many questions were raised regarding the long-term complications, the optimal regimen of dual antiplatelet therapy, and the durability of treatment effect. We reviewed the literature to address these questions as well as other concerns on FD when treating IAs

Dural Arteriovenous Malformations: A Review of the Literature and a Presentation of the JHN Series

Dural arteriovenous malformations (DAVMs), also known as dural arteriovenous fistulas, are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus.1 The etiology of these lesions is not fully understood. DAVMs in the pediatric population are associated with structural venous abnormalities ,2 but the majority of DAVMs are thought to be acquired. Different etiologies have been implicated in this phenomenon, namely: sinus thrombosis, trauma or surgery.2–

Stereotactic Radiosurgery for Management of Cavernous Malformations

Cavernous malformations (CMs) are abnormal vascular formations of the brain with an estimated incidence of 0.4%-0.8% in the general population.1 CMs have the potential to cause significant morbidity, and have been associated with epileptic seizures, intracranial hemorrhage, and focal neurological deficits.2 Management options include non-treatment, surgical resection, and radiosurgery. We review here the efficacy of different management strategies for cavernous malformations and highlight the specific role of radiosurgery. One of the major complications of cerebral cavernous malformations is intracranial hemorrhage. To optimize patient treatment, it is beneficial to be able to identify patients that are at an increased risk of developing a hemorrhage and would most benefit from intervention. The overall rate of hemorrhage in patients with CMs has been estimated to be 2.25%.3 The rate of hemorrhage, however, is significantly affected by the initial symptom presentation. Patients presenting with a hemorrhage have significantly higher rates of rehemorrhage compared to patients presenting due to incidental findings.3,4 Flemming et al. found that patients presenting with hemorrhage had an overall annual rate of hemorrhage of 6.19% compared to patients presenting without hemorrhage of 0.33%. With increasing use of MR imaging, the percentage of cavernous malformations found incidentally approaches 40%.1 Because the risk of hemorrhage is low in patients with CMs found incidentally, surgical or radiosurgery management may not be indicated. In contrast, patients presenting with symptoms of hemorrhage should be considered for therapeutic intervention due to a high risk for subsequent hemorrhage. One option for the management of cavernous malformations is surgical intervention by CM resection. There is conflicting evidence in the literature regarding the effectiveness of CM resection, likely due to different methodologies used for determining efficacy. When post-operative outcomes are compared to pre-operative values, significant improvement is observed as demonstrated by improvements in the modified Rankin scale and decreased annual hemorrhage rate.5,6 However, the results are limited by the fact that studies did not include a control group of patients that did not receive surgery. A recent retrospective study by Moultrie and colleagues compared the outcome of patients treated with surgical to conservative management. Patients who underwent CM resection had worsened short-term disability scores, increased risk of developing intracranial hemorrhage, and new focal neurologic deficits.

Staged Endovascular and Open Surgical Approach for Treatment of a Giant Left Upper Back Arteriovenous Malformation

We present a case of a symptomatic, giant, left upper back arteriovenous malformation that was treated through a staged endovascular and open approach. Through a series of embolizations, followed by resection, we were able to preserve the limb and upper back neurovascular supply, demonstrating an approach to preserve sensation and function and improving quality of life

Endovascular Treatment of Cerebral Mycotic Aneurysm: A Review of the Literature and Single Center Experience

The management of mycotic aneurysm has always been subject to controversy. The aim of this paper is to review the literature on the intracranial infected aneurysm from pathogenesis till management while focusing mainly on the endovascular interventions. This novel solution seems to provide additional benefits and long-term favorable outcomes

Management of head and neck pseudoaneurysms: a review of 33 consecutive cases.

Background. Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are all endovascular treatment options for pseudoaneurysms (PAs) of the head and neck. We explore different clinical situations in which these were selected for PA management at a single institution. Methods. Over a period of ten years, 33 patients presented to our hospital with PAs of the head and neck. Their outcomes and procedural complications are discussed. Results. We observed a complication rate of 18.2% (6 of 33), consisting predominantly of infarcts following vessel occlusion. As measured by the modified Rankin Scale, 25 (75.8%) patients had achieved favorable outcomes on discharge. A single patient who was treated with stent-assisted coiling expired following procedural complications. Conclusions. In our series, most patients with traumatic/iatrogenic PAs were successfully treated with parent vessel sacrifice. When parent vessel occlusion is not an option, stenting with or without coiling, or flow diversion, may also be safe and effective alternatives