立体定向放射外科治疗脑转移瘤的进展

脑转移瘤(brain metastases，BM)在恶性肿瘤病人尸检中发现率为10％～50％，单发性BM占40%。近年来对癌症病人的原发灶和颅外转移灶治疗技术和方法改进，医疗条件提高，生存期延长，BM的发病率也在上升。BM已成为癌症病人残废和死亡的重要原因，因此，BM治疗是对神经外科医师的一个挑战。     

立体定向放射外科治疗脑转移瘤

目的：探讨脑转移瘤的立体定向放射治疗的方法,临床结果。方法：采用单纯ＳＲＳ治疗颅内转移瘤３３例,ＳＲＳ＋ＷＢＲＴ治疗４２例,３１例行单纯全脑放疗。单纯ＳＲＳ治疗的剂量为１４～２２Ｇｙ／单次,ＳＲＳ＋ＷＢＲＴ则在单次ＳＲＳ后在行全脑放疗３０～４０（ｙ）３～４周,单纯ＷＢＲＴ治疗剂量４０～５０Ｇｙ／４～５周。结果：经２～３年随访,ＳＲＳ组３３例ＰＲ＋ＣＲ局部控制率８７．８％,一年生存率７５．８％,两年生存率４５．５％;ＳＲＳ＋ＷＢＲＴ组４１例,ＣＲ＋ＰＲ９２．９％,一年生存率８８．１％,两年生存率４７．６％;两组对照无显著差异（Ｐ〉０．１０）,但无对照有显著差异（Ｐ〈０．０５）,ＷＢＲＴ组３１例,ＣＲ＋ＰＲ８７．１％,两年生存率２５．８％,与ＳＲＳ＋ＷＢＲＴ组对照无显著差异（Ｐ〉０．１０）,瘤生存率分别为４８．４％     

应用旋转式伽玛刀治疗脑转移瘤

全身肿瘤病人中大约有 5 0 %以上会发生脑转移。我院从 1997年 9月至 2 0 0 1年 6月 ,应用ＯＵＲ旋转式伽玛刀治疗颅内转移瘤病人 2 0 7例。治疗方法及其随访结果报道如下。临床资料一般资料男性 10 9例 ,女性 98例。年龄 30～ 78岁。单发转移 91例 (44 % ) ,多发转移 116例 (5     

脑转移瘤的立体定向放射手术：附272例临床报告

目的探讨立体定向放射手术（伽玛刀）治疗脑转移瘤的临床疗效。方法对２７２例脑转移瘤病人,用１．５Ｔｅｓｌａ磁共振仪和Ｇａｍｍａ－Ｐｌａｎ计算机联网定位,Ｌｅｋｓｅｌｌ伽玛刀实施放射手术,其中单发１５６例,多发１１６例;男１８１例,女９１例,年龄１８－８６岁,平均５８岁。肿瘤直径３．５－５０．１ｍｍ;周边剂量１０－３５Ｇｙ,平均１８．８Ｇｙ,中心剂量２７－７０Ｇｙ,平均４６Ｇｙ;靶点数１－１１个,平均     

脑转移瘤治疗的研究进展

脑转移瘤是全身恶性肿瘤远距离转移的结果,全身恶性肿瘤死亡尸检中脑转移瘤检出率为10%～50%[1,2],如不治疗,平均生存时间1个月,激素治疗可使生存时间延长至2个月[1～3].     

脑转移瘤的立体定向放射外科治疗

立体定向放射外科(SRS)是一种微侵袭性外科。SRS方法有γ—刀,x—刀及荷电重粒子射线。本文介绍了这三种方法及其优缺点,综述了SRS治疗脑转移瘤的生物学反应,适应症,放射剂量,疗效,术后反应和并发症,并与手术切除进行临床比较。     

脑转移瘤的治疗

脑转移瘤(brainmetastases,BM)在全身恶性肿瘤死亡尸检中检出率为10%￣50%[1,2]如不治疗平均,生存时间1个月,激素治疗可使生存时间延长至2,个月[1～3],近年来随着新技术新方法的不断引进人,们对BM的认识也不断提高,治疗的方法也日新月异,本文对化疗全脑放射治疗,立体定向放射外科开颅术治疗BM进行总结。以探讨其治疗最佳。方法1化疗化疗可分为全身化疗和导向化疗,一般认为颅内多发肿瘤瘤体位于重要,功能区不适合做手术,或立体定向放射外科(Stereotaticradiosurgery,SRS)治疗且患者一般状况良好可行化疗,化疗也可作为开颅术后的辅助治疗…     

立体定向放射外科治疗脑转移瘤的进展

脑转移瘤(brain metastases,BM)在恶性肿瘤病人尸检中发现率为10%～50%,单发性BM占40%.近年来对癌症病人的原发灶和颅外转移灶治疗技术和方法改进,医疗条件提高,生存期延长,BM的发病率也在上升.BM已成为癌症病人残废和死亡的重要原因,因此SM治疗是对神经外科医师的一个挑战.BM病人如不给予治疗,平均生存期为1～2个月,给予全脑放射治疗(whole brain radiotherapy,WBR),平均生存期为3～6个月,其中部分病人直接死亡原因为颅外病灶所致,WBR已作为常规治疗.近来发现外科手术切除加WBR能改善预后.即比单纯WBR效果好.尤其是一部分病人只发现脑内孤立性单发性转移灶而找不到原发灶,或原发灶已被手术切除,未发现其它转移灶,手术治     

脑转移瘤治疗方法的选择及疗效分析

目的探讨脑转移瘤的治疗方法并分析疗效。方法对103例脑转移瘤的肿瘤来源、大小、数目及不同治疗方法进行比较分析。结果46例（44．7％）存活1年以上。单发肿瘤行手术切除或立体定向放射外科治疗,2cm以下的多发肿瘤行放疗加化疗或行立体定向放射外科治疗其生存期较长。结论对于4cm以上大型转移瘤可行手术切除,小于4cm的单发或3cm以下的多发肿瘤应首选立体定向放射外科治疗。     

立体定向放射外科治疗的临床研究(附923例报告)

目的探讨颅内病变立体定向放射外科治疗的疗效及科学性.方法应用我院早期设计的直线加速器放射外科治疗系统和Libinger-Fischer治疗系统治疗颅内病变923例,包括颅内肿瘤、血管瘤和三叉神经痛,并进行随访和分析.结果73.4%病例获得随访,治疗的结果与Leksellγ-刀的有关报道相近,并发症少.结论立体定向放射外科治疗疗效确切,剂量规划是其核心技术环节.严格掌握适应证,制定个体化的治疗计划和对整个治疗过程实施严格的质量控制,是确保疗效及降低并发症的重要措施.     

混合性脑瘫的外科治疗

目的探讨立体定向核团毁损加选择性脊神经后根切断术治疗混合性脑瘫的手术疗效。方法对6例混合性脑瘫病人行立体定向苍白球腹后内侧部（Gpi，3例）或丘脑底核（STN，3例）毁损，加选择性脊神经后根切断术（L2-S1 5例，C5～C8 1例），手术同期进行2例，间隔约2周后分期进行4例。随访24个月，观察手术肢体痉挛、肌张力障碍及运动功能改善情况。结果6例病人Ashworth痉挛评分及Fahn肌张力障碍评分降低，运动功能明显改善。结论应用立体定向核团毁损加选择性脊神经后根切断术治疗混合性脑瘫疗效可靠。     

立体定向活检联合陀螺刀治疗囊性脑转移瘤

目的探讨囊性肺癌脑转移瘤采用立体定向活检与陀螺刀相结合治疗的疗效。方法对58例囊性肺癌脑转移瘤在CT导向下立体定向穿刺活检,并穿刺引流囊液使囊腔缩小,再行陀螺刀治疗。结果 58例患者57例明确了病理类型,肿瘤体积缩小,患者临床症状改善,陀螺刀治疗效果提高。结论立体定向手术联合陀螺刀治疗囊性肺癌脑转移瘤具有微创、安全、并发症少、有明显的近期效果和有效的肿瘤控制率等优点。     

11例非Galen静脉脑动静脉瘘的血管内栓塞治疗

作者报告了1979年至1995年治疗的11例非Galen静脉的脑动静脉瘘(AVF),对其诊断标准及治疗原则进行探讨.1例以球囊栓塞失败后行手术夹闭供血动脉;8例以IBCA/NBCA栓塞治疗,其中1例经3次栓塞缩小静脉球后手术切除残留的动静脉畸形(AVM);2例以弹簧圈栓塞瘘口.结果:动静脉瘘100%闭塞8例,恢复良好.8例中的6例脑血管造影复查,未见复发;植物生存1例;死亡2例.对治疗原则,血管内栓塞进行了讨论,认为栓塞材料首选弹簧圈.     

Surgical treatment of brain metastasis: a review

Brain metastasis is the most common intracranial tumor in adults. Currently, treatment of brain metastasis requires multidisciplinary approach tailored for each individual patient. Surgery has an indispensible role in relieving intracranial mass effect, improving neurological status and survival while providing or confirming neuropathological diagnosis with low mortality and morbidity rates. Besides the resection of a single brain metastasis in patients with accessible lesions, good functional status, and absent/controlled extracranial disease; surgery is proven to play a role in management of multiple metastases. Surgical technique has an impact on the outcome since piecemeal resection rather than en bloc resection and leaving infiltrative zone behind around resection cavity may have a negative influence on local control. Best local control of brain metastasis can be accomplished with optimal surgical resection involving current armamentarium of preoperative structural and functional imaging, intraoperative neuromonitoring, and advanced microneurosurgical techniques; followed by adjunct therapies like stereotactic radiosurgery, whole brain radiotherapy, or intracavitary therapies. Here, treatment options for brain metastasis are discussed with controversies about surgery.     

Comparing the cost-effectiveness of two brain metastasis treatment modalities from a payer's perspective: Stereotactic radiosurgery versus surgical resection

Objectives

This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System.

Methods

Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n = 113) and SRS (n = 260). Propensity score matching was used to adjust for selection bias (n = 98 each); means of survival time and survival curves were defined by the Kaplan–Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty.

Results

Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P = 0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P = 0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R² = 0.249; P = 0.006). SRS had a lower average cost per patient (€9964 – SD: 1047; Skewness: 7273) than SR (€11647 – SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €−3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years.

Conclusion

SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised.     

凝血酶治疗脑立体定向活检术中出血初步探讨

脑立体定向手术非直视下操作，术中可能损伤深部脑血管而致颅内出血。特别是小动脉出血，处理困难。本文报告凝血酶脑内局部灌注治疗走向术中出血１０例，包括动脉出血２例。控制出血快速有效，无并发症。尽管凝血酶用量过多可造成脑血管痉挛和脑梗塞，但只要用量适当则可有效止血，挽救生命，故局部灌注适量凝血酶的方法是可取的。     

立体定向联合尿激酶治疗脑出血的疗效分析

目的对比立体定向联合尿激酶治疗与单纯药物治疗后脑出血后患者血肿周围水肿(Perihematomal edema,PHE)程度及近期疗效。方法回顾性分析2015年1月至2019年6月湖南师范大学附属张家界医院行立体定向联合尿激酶治疗或单纯药物治疗的96名患者的临床病例资料。采用倾向性评分匹配法以1∶1的比例对患者进行匹配,匹配变量包括年龄、性别、是否破入脑室、ICH评分、GCS评分、基线血肿体积、基线血糖、基线收缩压及基线舒张压。最终将完成立体定向微创引流术联合尿激酶治疗(立体定向组)与单纯药物治疗(药物治疗组)的各28例患者纳入本研究。结果两组均无治疗期间死亡病例。水肿延伸距离(Edema extension distance,EED)、血肿体积、血肿及水肿总体积随时间变化显著,差异有统计学意义(P 0. 05),血肿体积及总体积的组别与测量时间的交互作用显著,差异有统计学意义(P 0. 05),两组EED在入院时,治疗后第1天,治疗后第3天相似(P 0. 05),治疗后第3天立体定向组EED大于药物治疗组,但差异无统计学意义。立体定向组血肿体积在治疗后第1天,治疗后第3天及治疗后第7天显著少于药物治疗组(P 0. 01),且立体定向组总体积在第1天及第3天也小于药物治疗组(P 0. 01),差异有统计学意义。两组治疗后1月(Activities of daily living) ADL评分与1月m RS评分相似(P 0. 05),差异无统计学意义。结论立体定向微创引流术联合尿激酶治疗与单纯药物治疗相比虽能明显减轻占位效应,但可能不能改善PHE及近期功能预后。     

脑脂肪栓塞早期诊断及治疗

目的探讨脑脂肪栓塞的早期诊断及治疗。方法回顾性分析我院收治的颅脑外伤并发脑脂肪栓塞2例。结果患者MRI提示两侧大脑半球、基底节区、卵圆中心及脑干可见多发斑点斑块状等T1、长T2异常信号影,液体衰减反转成像（FLAIR）呈高信号,弥散加权成像（DWI）呈高信号。患者凝血机制也发生改变。结论通过早期的MRI结合凝血机制改变可以尽早诊断脑脂肪栓塞,使患者得到有效救治。     

Fractionated radiosurgical management of intramedullary spinal cord metastasis: A case report and review of the literature

Objective and importance

Intramedullary spinal cord metastasis (ISCM) comprises 8.5% of central nervous system metastases and confers significant morbidity. Radioresistant histologies such renal cell carcinoma and melanoma are not generally amenable to long-term palliation with conventional radiotherapy while surgery has often been found to be technically challenging and frequently morbid. In this report, we present a patient with a C5 ISCM from renal cell carcinoma treated with fractionated stereotactic radiosurgery.

Clinical presentation

A 50-year-old gentleman with metastatic renal cell carcinoma presented with profound bilateral shoulder pain and upper extremity paresthesias. Magnetic resonance imaging revealed an intramedullary lesion at the level of fifth cervical vertebra (C5). Medical management and chiropractic manipulation proved to be ineffective. The patient was then treated with external beam radiation therapy, but continued to experience severe pain, paresthesias, and progressive, profound neurologic symptoms.

Intervention

The patient was referred to radiation oncology and neurosurgery for evaluation. Consideration was given to cordotomy and resection but the location and procedure was deemed to be high-risk and therefore was deferred. The decision was made to treat with fractionated stereotactic radiosurgery. A dose of 15 Gy was successfully delivered in 3 fractions to the 80% isodose line without complication or adverse effects. Twenty-six months following treatment, the patient was still alive, fully functional, and reported no pain and rare of paresthesias.

Conclusion

Fractionated stereotactic radiosurgery is a feasible, safe, and effective modality for the treatment of ICSM and should be carefully considered in the management of this difficult to treat condition.