Can this 45 year old with grade 4/5 hemiparesis be offered gammaknife treatment? [I dont think so, considering proximity to brainstem, but just to be sure...]
Lesion measures 3.0X2.9X2.2 cms.
Question resolved:
As many of you suggested, the lesion is not suitable for gammaknife radiosurgery primarily because of mass effect on the brainstem which may even be aggravated by tumor swelling after radiosurgery. In fact, microsurgical excision is the primary option.
Outcome:
I could excise the lesion completely without new deficits [Subtemporal approach]. Hemiparesis is improving. Interestingly the fourth nerve comes from underneath the tent rather than between its leaves as they commonly describe.
1 comment:
Discussion on this topic [taken from yahoo group]
a#368 From: "brmrao1963"
Date: Thu May 24, 2007 4:28 pm
Subject: Re: Can this be gammknifed? brmrao1963
I do not think that the lesion should be gammaknifed. Personally I
would offer microsurgical excision to this patient as I have a series
of such patients who have undergone surgery with minimal morbidity.
However before making a final decision, the patient's fitness for
surgery, patient preference and the surgeon's comfort with surgical
option has to be taken into account.
Ravi Mohan Rao--- In
neurosurgery_nimhans@yahoogroups.com,
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#371 From: Dr Pramod Pillai
Date: Mon May 28, 2007 6:32 am
Subject: Re: Re: Can this be gammknifed? pramodpillai99
Congrats Prof Sampath and Prof BID
Regarding the case ,I would agree with Dr Ravi Mohan Rao,
With the shown images patient with significant hemiparesis, is a poor candidate for radiosurgery
The option of surgery should have been offered at the first instance, with a goal of gross total excision,( large tumor with significant brain stem compression, even there could be associated CSF pathway obstruction ~look at the prominant temporal horns and grossly compressed upper brain stem , All these findings contraindicate radiating this young patient)
If any part of the tumor is left behind at surgery , then we could consider radiosurgery depending on the residue.
proximity to brainstem is not an absolute contraindication for radiosurgery, its tolerance is upto 15Gy. Marginal dose to meningioma usually wont go beyond 15Gy.
Pramod
From: "neurosurgery_resident"
Date: Mon May 28, 2007 7:17 am
Subject: Re: Can this be gammknifed? neurosurgery...
I had discussed this case with my professor. Did a bit of googling as
well.
Literature and my Professor view are against "Marginal dose to
meningioma usually wont go beyond 15Gy. Probably Dr Pillai you need to
update your dose calculations. It can go upto 20 gy (marginal dose).
Brainstem my professor treats with arround 13 gy ( in and arround
midbrain).
>
> Congrats Prof Sampath and Prof BID
From: "neurosurgery_resident"
Date: Mon May 28, 2007 7:03 am
Subject: Re: Can this be gammknifed? neurosurgery...
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I agree with Dr Rao and Dr Gopal MS. This lesion looks like meningioma
arising from the meninges of the middle inscisural space.
1. Looks like the lesion is more than 3cm.
2. There is compression of the midbrain.
If the lesion was less than or equal to 3cm it can be treated with
Radiosurgery.
With good surgical technique it can be removed without any morbidity.
If there is problems with complete excision due to adherence to
brainstem then we can also treat with radiosurgery.
I would offer microsurgery.
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