Treatment for posterior fossa dissemination of primary supratentorial glioma

OBJECT: This study was designed to assess the presentation, management, and outcome of cases involving patients who had a supratentorial glioma that subsequently progressed in the posterior fossa (PF). METHODS: The authors performed a retrospective chart review of adult patients treated between 1997 and 2005 for supratentorial gliomas that progressed in the PF. The 29 patients with PF progression in this study were relatively young (median age of 34 years at original presentation). Twenty of these patients presented with symptoms. The symptoms were typically nonspecific to this population, at times leading to delays in diagnosis. Overall, these symptoms resolved in eight patients (40%) and progressed or remained unchanged in 12 (60%). Patients treated with more than 5000 cGy of radiation administered to the PF were more likely to have symptom resolution than those who received any other form of treatment, including reduced doses of radiation (p = 0.004). The patients treated with higher doses also survived significantly longer after PF progression (univariate analysis, p = 0.01, and after adjusting for tumor grade, p = 0.04). CONCLUSIONS: Patients with PF progression of supratentorial infiltrative gliomas may benefit from treatment, and the authors recommend more than 5000 cGy of radiation to the PF if prior radiotherapy ports and doses allow.     

Dramatic MRI improvement with refractory neurosarcoidosis treated with infliximab

BACKGROUND: Neurosarcoidosis is often a devastating, refractory condition without definite pharmacotherapies beyond corticosteroids. AIM: To describe a case of steroid-refractory neurosarcoidosis with a marked clinical and radiological response to infliximab. METHODS: We describe the case of a young female patient with biopsy-proven neurosarcoidosis leading to gait failure. She described significant corticosteroid-related side effects without clinical response to the therapy. Infliximab therapy was considered as a possible rescue medication. RESULTS: Within months of starting intravenous infliximab therapy, she regained her ability to walk and magnetic resonance imaging identified significant improvements over a sustained course of infliximab therapy, including loss of enhancing nodules and loss of meningeal enhancement. CONCLUSION: Mounting evidence suggests that infliximab is a valuable pharmacological agent in the management of patients with refractory and disabling neurosarcoidosis. Controlled studies of infliximab in this condition are needed.     

Radiosurgery to the Postoperative Surgical Cavity: Who Needs Evidence?

There is a growing interest in adjuvant radiosurgery after resection of hematogenous brain metastases. This is exemplified by the approximately 1000 cases reported in mainly retrospective series. These cases fall into four paradigms: adjuvant radiosurgery as an alternative to whole-brain radiotherapy (WBRT), radiosurgery neoadjuvant to the surgical resection, radiosurgery as an intensification of adjuvant WBRT, and adjuvant radiosurgery for patients having failed prior WBRT. These procedures seem well tolerated, with an approximate 5% risk of radiation necrosis. Although crude local control rates for each strategy seem improved over surgery alone, multiple biases make comparisons with standard WBRT difficult without prospective data. Because evidence lags behind clinical practice, an upcoming intergroup trial will aim to clarify the value of the most common tumor bed radiosurgery strategy by randomizing oligometastatic patients between adjuvant WBRT and adjuvant radiosurgery.     

Leptomeningeal disease from oligodendroglioma: clinical and molecular analysis

BACKGROUND: Leptomeningeal disease (LMD) is a late complication of malignant glioma, mostly of glioblastoma, that usually responds poorly to treatment and is rapidly fatal. A long surviving case led us to review our experience with LMD in patients with oligodendrogliomas. METHODS: A 15-year retrospective chart review was performed. Patients with both oligodendroglial tumors and LMD were identified. A single neuro-pathologist reviewed all histological sections, a single neuro-radiologist reviewed all available images and 1p/19q status was assessed. RESULTS: Seven out of 145 patients with oligodendroglioma were diagnosed with LMD. Six were male. Median age at tumor diagnosis was 41 years (range, 28-50). None had radiographic or pathological evidence of leptomeningeal or subependymal tumor at initial diagnosis. Most patients had pure anaplastic oligodendrogliomas (4/7); 6/7 had 1p/19q co-deletion. The median time to first relapse was 41 months (range, 19-127). The median time to LMD was 76 months (range, 19-151) from initial diagnosis and 28 months (range, 0-36) from first relapse, respectively. Leptomeningeal disease treatments included spinal radiation and intrathecal and systemic chemotherapy. After progression, some patients with LMD remained stable clinically. The median survival from initial diagnosis was 104 months (range, 19-183) and from LMD diagnosis was 32 months (range, 2-43). CONCLUSIONS: Leptomeningeal disease is a complication of oligodendroglioma that may occur preferentially in long surviving patients with 1p/19q co-deletion. Leptomeningeal disease in patients with oligodendrogliomas appears to be relatively indolent which may have implications for their treatment and be related to 1p/19q status.     

The role of corticosteroids in severe community-acquired pneumonia: a systematic review

Introduction  

The purpose of this review was to evaluate the impact of corticosteroids on the outcomes of patients with severe community-acquired pneumonia (CAP).     

The clinical picture of ectasia of the intracerebral arteries

Thirty-one patients with ectasia of intracranial arteries were studied. The carotid system was more frequently involved than the vertebrobasilar. The condition is relatively rare and usually occurs with other vascular disease. Ectasia presents with a variety of neurological symptoms, amongst which visual disorders are common. The overall mortality was 52%, but the prognosis was appreciably worse for the vertebrobasilar group, probably because of a higher incidence of compression of surrounding neural structures. Defects in the internal elastic lamina, with or without associated atheroma, are often found in the affected arteries.