Clinical Neuroscience

[125I brachytherapy of pineal parenchymal tumours]

JULOW Jenő1, VIOLA Árpád1,2, MAJOR Tibor3, VALÁLIK István1, SÁGI Sarolta4, MANGEL László3, KOVÁCS Rita Beáta5, HÁVEL János1, KISS Tibor1

JULY 10, 2005

Clinical Neuroscience - 2005;58(07-08)

[Introduction - Pineal parenchymal tumours make up 0,3% of all brain tumours. Stereotactic biopsy has by now become an indispensable method to detect these tumours and it can be safely performed. Patients and method - Two patients with pineoblastoma were treated with 125I brachytherapy. The MRI and CT images taken 15 and 18 months after irradiation showed significant tumour shrinkage. Results - Tumour volume was 0.76 cm3 in the control CT image in Case 1, a shrinkage by 73% compared to 2.87 cm3 measured at the time of planning the interstitial irradiation. In Case 2, tumour volume measured on the control MRI examination was 0.29 cm3 as opposed to 1.27 cm3 of original tumour volume, which represents a 77% shrinkage. Conclusion - The insertion of isotope seeds was performed at the same time as the biopsy, because thus the knowledge of the histological diagnosis could spare the patients from a second stereotactic intervention. The CT- and image fusion guided 125I stereotactical brachytherapy is a procedure that can be dosimetrically precisely planned and surgically accurately and safely performed.]

AFFILIATIONS

  1. Fõvárosi Önkormányzat, Szent János Kórház és Rendelõintézet, Idegsebészeti Osztály, Budapest
  2. Semmelweis Orvostudományi Egyetem, Doktori Iskola, Budapest
  3. Országos Onkológiai Intézet, Sugárterápiás Osztály, Budapest
  4. Fõvárosi Önkormányzat, Szent János Kórház és Rendelõintézet, Radiológiai Osztály, Budapest
  5. Fõvárosi Önkormányzat, Szent János Kórház és Rendelõintézet, Patológiai Osztály, Budapest

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Clinical Neuroscience

[Frontotemporal dementia - Part II Differential diagnosis, genetics, molecular pathomechanism and pathology]

GALARIOTIS Vasilis, BÓDI Nikoletta, JANKA Zoltán, KÁLMÁN János

[This is a comprehensive paper in three parts covering history, prevalence, clinical forms, differential diagnosis, genetics, molecular pathomechanism, pathology, clinical diagnosis and treatment of frontotemporal dementia (FTD). The second part focuses on the differential diagnosis, genetics, molecular pathomechanism and pathology. The clinical diagnosis of frontotemporal dementia is based on the presence of a prominent disturbance of the executive function and of frontal lobe syndrome or a progressive aphasic syndrome without severe global cognitive impairment. Of other dementias, it is primarily Alzheimer’s disease that it should be differentiated from, but other psychiatric disorders must also be ruled out. The disease has familial and sporadic forms. Recent identification of mutations in the gene encoding the microtubule-associated tau protein in the inherited frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17) has demonstrated that various tau dysfunctions can lead to neurodegeneration. Tau gene mutations have varied effects on the biology and function of the protein. This heterogeneous pathomechanism explains the wide range of clinical and neuropathological features observed in the FTDP-17. Tau and ubiquitin antibodies can be detected by sensitive immunohistochemical methods. The diagnosis of FTD should be based on neuropathological examination, and this is also the only method by which it can be definitely differentiated from other types of dementias.]

Clinical Neuroscience

[ELECTROPHYSIOLOGICAL SIGNS OF STRUCTURAL CHANGES IN MOTOR UNITS AFTER ISCHAEMIC STROKE]

LUKÁCS Miklós

[Introduction - While it is several decades ago that electrophysiological studies in the early stages after an ischaemic stroke revealed spontaneous activity in the affected muscles, today few data are available on the peripheral changes in later stages after a cerebrovascular event. The aim of this study was to detect electrophysiological signs that could indicate changes at the motor unit level occurring within a longer post-stroke period. Patients and methods - Forty-four patients who had developed hemiparesis after an ischaemic stroke in the area of the middle cerebral artery were involved in the study. Motor and sensory nerve conduction studies and electromyography were carried out on each side on six nerves and in five muscles respectively. Values between the affected and unaffected side were compared by statistical methods. Results - In patients with hemiparesis present for less then nine months, low M wave amplitudes, fibrillation potentials and an increased number of complex motor unit potentials were found on the affected side; in patients with symptoms present for more then nine months the mean duration and size index of the motor unit potentials in the paretic abductor digiti minimi muscle were increased. These data suggest a process of neurogenic type. The signs of distal axonal damage observed in the early period after stroke have been replaced later by chronic neurogenic changes. These changes could be the consequence of spinal motor neuron damage and axonal transport disturbance due to the loss of supraspinal trophic inputs. Conclusion - The correlation between the extent of electrophysiological changes and of the central motor deficit of the patient indicates the importance of delaying this process by appropriate rehabilitation procedures.]

Clinical Neuroscience

[Increasing cerebral perfusion pressure in serious cranial injury - contradictory effects of dopamine]

BARZÓ Pál, CZIGNER Andrea, ANTHONY Marmarou, ANDREW Beaumont, DEÁK Gábor, PANOS Fatouros, FRANK Corwin

[Background - Management of cerebral perfusion pressure is an important element of the treatment of traumatic brain injury. Vasopressors are accepted as a method of choice to increase mean arterial blood pressure and thus cerebral perfusion pressure in the face of rising intracranial pressure. There are, however, some unresolved issues and potential risks to this therapy. Matherial and methods - This study therefore examines the effects of dopamine on physiological changes as well as on brain edema and water content that can be readily assessed by MRI/MRS in 1. a rodent model of rapidly rising intracranial pressure, caused by diffuse injury with secondary insult and 2. a model of cortical contusion. Results - Dopamine was capable of restoring cerebral perfusion pressure in the model of rapidly rising intracranial pressure. However, this was associated with only a partial restoration of cerebral blood flow. In the brain tissue two profiles of change in the apparent diffusion coefficient of water (ADCw) were seen; one in which ADCw recovered to baseline, and one in which ADCw remained persistently low. Despite that dopamine did not alter these profiles, MRI-assessed tissue water content was increased four hours after injury and dopamine increased cerebral water content in both subgroups of injury, especially in the subgroup with a persistently low ADCw (p<0,01). In the contusion group dopamine significantly worsened the edema both in the injured and in the contralateral area of hippocampus and temporal cortex even though the ADCw values did not change, except for the contralateral hippocampus, where both water content and ADCw values rose with treatment, suggesting extracellular accumulation of water. Conclusion - The results suggest that dopamine has a double effect - while it temporarily and partially restores cerebral blood perfusion, at the same time it induces an increase in brain swelling and thus an increase in intracranial pressure in some cases. It is possible that in a subgroup of patients vasopressor treatment leads to an opposite effect several hours later. Vasopressor therapy in the clinical setting therefore should be cautiously applied.]

Clinical Neuroscience

[Investigation of cerebral autoregulation in Parkinson’s disease]

DEBRECZENI Róbert, AMREIN Ilona, KOLLAI Márk, LÉNÁRD Zsuzsanna, PÁLVÖLGYI László, TAKÁTS Annamária, GERTRÚD Tamás, SZIRMAI Imre

[Background and purpose - The frequent orthostatic intolerance in Parkinson’s disease could be the consequence of cardiovascular autonomic failure and/or a damaged cerebral autoregulation (AR). To clarify this question the regulation of cerebral circulation was investigated by polygraphic method. Methods - On a tilt table simultaneous and continuous registrations were made of MCA velocity (VMCA) by transcranial Doppler, arterial blood pressure by non-invasive method, and end-tidal CO2, in supine and in tilted positions of 10°, 30°, 70° grades. The cerebral autoregulation was characterized by the slope of the curve of the arterial blood pressure at the level of the Willis-circle (BPW, as MCA perfusion pressure) plotted against the MCA velocity, achieved by linear regression (y=ax+b function, a=AR, or index of autoregulation). Patients - The data of 17 parkinsonian patients (PP) and eight age-matched controls (C) were analyzed. Results - The decrease of blood pressure in parkinsonian patients was significantly lower than in the controls when supine position was restored from 70° (ΔABP 70°-0°PP= -3.1±7.5 Hgmm; ΔABP 70°-0C°=-11.1±7.3 Hgmm; p<0.05), which suggests a damage to the sympathetic cardiovascular system. A disturbance of the cerebral autoregulation in patients was suggested by a progressively decreasing MCA average velocity (VMCA) during graded tilt, which was significiant at 70° (ΔVACM=9.8±8.82% cms-1; pCPP <0,05), and by a higher slope of pressure-velocity curve (ARC=0.143±0.125% cms-1/Hgmm; ARPP=0.38±0.25% cms-1/Hgmm; pC-PP<0.05). Conclusions - The results show that the cerebral blood flow of patients is more dependent on perfusion pressure compared to healthy controls. The disturbance of the sympathetic cardiovascular system and of cerebral autoregulation could be the consequence of a damage to the postganglionic structures in Parkinson’s disease. These results could explain the frequent orthostatic intolerance of patients even with normal blood pressure.]

Clinical Neuroscience

[Stiff-person syndrome - two Hungarian cases and review of the literature]

LENGYEL András, LAKOS Gabriella, SIPKA Sándor, HEGEDÛS Katalin

[The stiff-man syndrome is a rare neurological disorder characterized by progressive stiffness of the axial muscles and co-contraction of agonist and antagonist muscles sometimes accompanied by involuntary sudden muscle spasms. The disease is thought to be caused by immunological changes leading to a GABA transmission disturbance, but the precise pathogenesis is not clear. Two Hungarian cases are presented in this article accompanied by a review of the literature. The aim of the paper is to call the attention on this presumably underdiagnosed disease. The diagnostic laboratory tests of the disease are available in Hungary.]

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Clinical Neuroscience

[Brachytherapy of brain stem tumours]

JULOW Jenő, VIOLA Árpád, MAJOR Tibor, VALÁLIK István, SÁGI Sarolta, MANGEL László, KOVÁCS Rita Beáta, REPA Imre, BAJZIK Gábor, NÉMETH György

[Introductions - The optimal therapy of brain stem tumours of different histopathology determines the expected length of survival. Authors report 125Iodine interstitial irradiation of brain stem tumours with stereotactic brachytherapy. Case reports - Two patients having brain stem tumours were suffering from glioma or from metastases of a carcinoma. In Case 1 the tumour volume was 1.98 cm3 at the time of planning interstitial irradiation. The control MRI examination performed at 42 months post-op showed a postirradiation cyst size of 5.73 cm3 indicating 65.5% shrinkage. In Case 2 the shrinkage was more apparent as the tumour vo-lume measured on the control MRI at 8 moths post-op was only 0.16 cm3 indicating 97.4% shrinkage of the 6.05 cm3 target volume at the time of brachytherapy with the metastasis practically disappearing. Quick access to histopathological results of the stereotactic intraoperative biopsy made it possible to carry out the 125Iodine stereotactic brachytherapy immediately after the biopsy, resulting in less inconvience for patients of a second possible intervention. The control MRI scans show significant shrinkage of tumours in both patients. Conclusion - The procedure can be performed as a biopsy. The CT and image fusion guided 125Iodine stereotactic brachytherapy can be well planned dosimetrically and is surgically precise.]

Clinical Neuroscience

[Image fusion guided brachytherapy of brain tumors]

JULOW Jenő

[The paper is the summary of mostly published works of the clinical results of intracavitary Yttrium-90 colloid irradiation of recurrent cystic craniopharyngiomas, and Iodine-125 interstitial irradiation of gliomas, pinealomas, brainstem tumors, recurrent meningeomas, solid craniopharyngiomas and metastases. It concisely demonstrates the usefulness of image fusion in the verification of isotope seeds and catheters, the comparison of 125 Iodine stereotactic brachytherapy and LINAC radiosurgery modalities on physical dose distribution and radiobiological efficacy, and the analysis of volumetric changes after interstitial irradiation of gliomas. Results of the immunohistochemical study deal with the role of microglia/macrophage system in the tissue response to I- 125 interstitial brachytherapy of cerebral gliomas. Due to financial reasons, gamma knife and Linac are not available to many countries and neurosurgical institutes. In the absence of the above mentioned radiosurgical methods, we have shown brachytherapy as an alternative solution in the treatment of different types of inoperable or recurrent brain tumors. The observed results may be noticable at LINAC and gamma knife irradiation too.]

Clinical Neuroscience

[DYNAMICS OF THE TRIPLE RING, VOLUMETRICAL ANALYSIS, PREDICTIONS FOR TREATMENT PLANNING]

KOLUMBÁN Zsuzsa, VIOLA Árpád, MAJOR Tibor, BAJZIK Gábor, JULOW Jenő

[Objective - The aim of this study is to reveal the volumetrical changes in tumor necrosis, reactive zone and edema following low-dose rate I-125 interstitial irradiation of 20 inoperable (partially irresecable, partially inoperable) lowgrade gliomas. Methods - The volumes of the three regions on imagefused control CT/MRI images were measured for a 24- month period with 36 occasions. The delivered dose on the tumor surface (GTV) was 50-60 Gy. Dose planning and image fusion were performed with the BrainLab Target 1.19 software, mathematical and statistical computations were carried out with the Matlab Numeric Computation and Visualization software. The control images with the „triple ring” were fused with the planning images, and the isodose curves were adjusted to them. Results - Relative volumes normalized to volume of the reference dose were calculated and plotted in the time domain. The mean values of volumes were determined from the patients' measured data then a polynom was fitted to the mean values using the polynomial curve fitting method. The accuracy of our results were verified by statistical tools. Conclusions - The new polynomial prediction approach using image fusion analysis of the volume of tumor necrosis, reactive ring and edema caused by interstitial irradiation as a function of time provides valuable information for 1. selecting the best patient’s treatment option, 2. following up patient’s condition and 3. planning reirradiation or reoperation if necessary.]

Clinical Neuroscience

[Volumetric changes following 125 I interstitial irradiation of low grade gliomas]

JULOW Jenő, VIOLA Árpád, MAJOR Tibor, MANGEL László, BAJZIK Gábor, REPA Imre, SÁGI Sarolta, VALÁLIK István, EMRI Miklós, TRÓN Lajos, NÉMETH György

[Background - Image fusion permits quantitative analysis of the consequences of 125 Iodine interstitial irradiation of brain tumors. The volume of tumor necrosis, reactive zone and edema can be compared to the dosimetric data. Patients and method - Nineteen patients with low grade glioma were analyzed on the average 14.5 months following 125 Iodine interstitial irradiation. Dose planning and image fusion were performed with the Target 1.19 (BrainLab) software. The CT/MR images showing the so called “triple ring” (necrosis, reactive ring and edema) developing after the interstitial irradiation of brain tumors were fused with the planning images and the isodose curves. The volume of the three regions was measured. Values at the intersections of isodose curves and necrosis borders were averaged and used for calculation of tumor necrosis. The volume of normal brain tissue irradiated by given dose values, as well as homogeneity and conformality indices were also determined. Results - The relative volumes of the different parts of the “triple-ring” compared to the reference dose volume were the following: necrosis 54.9%, reactive zone 59.7%, and edema 445.3% . Tumor necrosis developed at 71.9 Gy dose. At the irradiation of an average size glioma with a volume of 12.7 cm3, 5 to 7 cm3 normal brain tissue around the tumor received 60-70 Gy dose. The average homogeneity and conformality indices were 0.24 and 0.57, respectively. Conclusion - The analysis of changes in the volume of edema, reactive ring and necrosis caused by interstitial irradiation, and their correlation with the dozimetric data using the image fusion method provide useful information for patient follow-up, clinical management and further therapeutic decisions.]

Clinical Neuroscience

[CT- and image fusion guided 125I stereotactic brachytherapy of acoustic neurinoma: three cases]

VIOLA Árpád, MAJOR Tibor, VALÁLIK István, SÁGI Sarolta, MANGEL László, SPELLENBERG Sándor, HÁVEL János, JULOW Jenő

[Gamma knife and multi leaf collimator Linac have recently gained significant space in the treatment of acustic neurinomas. As our neurosurgical department does not own gamma knife or Linac, we have successfully pursued the 125Iodine interstitial irradiation of three acustic neurinomas. Our patients were elderly people with poor general condition, therefore we decided to undertake interstitial irradiation because of the low tolerance for surgery. The follow-up period until March 2002, lasted five, 23 and 40 months in the three cases. At the end of the follow-up period the audiometrical examination stated slight enhancement of hearing in case one and case two. In case one, the tumor volume, as measured on the control MRI was 5.32 cm3, which meant a 21% shrinkage in contrast to the 6.74 cm3 target volume at the brachytherapy. In case two, the shrinkage was even more apparent. The tumor volume measured on the control MRI examination was 6.64 cm3, which was a 42% shrinkage of the 11.45 cm3 target volume at the moment of brachytherapy. Due to financial reasons, gamma knife and Linac are not available for many countries and neurosurgical institutes. In the absence of the above mentioned radiosurgical methods, we have shown brachytherapy as a new alternative and solution in the treatment of acoustic neurinoma in three patients.]