Timone University Hospital Research Articles

Fully endoscopic endonasal approach for the treatment of intrasellar arachnoid cysts.

To report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC). From 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported. Visual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39months. Patients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.

Balloon dilation versus surgery for severe neonatal aortic valve stenosis: A matched comparison

Two therapeutic approaches exist for first-line treatment of neonatal severe/critical aortic valve stenosis: percutaneous balloon dilatation and surgical valvuloplasty. For both interventions, the early and long-term results are satisfactory. Previous reports have failed to show clear superiority of one versus the other procedure. In la Timone university hospital (Marseille), balloon dilation is the usual therapeutic approach for neonatal critical/severe aortic valve stenosis. In Necker university hospital (Paris), surgical valvuloplasty remains the preferred option. The aim of our current study is to compare the 2 populations using propensity scores matching. Patients aged < 1 month who underwent percutaneous aortic valve balloon dilation for aortic valve stenosis in Marseille between 2003 and 2020, are included. Patients with borderline left ventricle or hypoplastic left heart syndrome are excluded. Balloon patients will be matched based on age, weight, duct-dependency, left ventricular function, aortic valve morphology and mitral function, with patients who underwent surgical aortic valvuloplasty in Necker (Paris). Early complications, survival, freedom from reintervention, residual stenosis and regurgitation will be retrospectively collected from hospital charts. Initial diagnosis and residual lesions will be confirmed by reviewing echocardiography studies. The primary outcome will be the all-cause mortality. The secondary outcomes will be reintervention, aortic valve replacement, presence of significant valve stenosis or insufficiency at latest follow-up. The results will be available in June 2021. Balloon dilation and surgical valvuloplasty are both efficient procedures for early relief of neonatal aortic stenosis. In case of superiority of one of the techniques, our current practice may need to be questioned and adapted. The complementary aspect of the 2 treatment strategies may also be highlighted.

Postoperative complications in cranial and spine neurosurgery: a prospective observational study.

Postoperative complications do occur in all neurosurgical departments, but the way they are defined, and their true incidence vary a lot. The aim of the present study was to objectively assess the morbidity and mortality related to all neurosurgical procedures performed in our department and provide insight on their main causes and identify key factors to reduce their incidence. Data were retrieved from a prospectively maintained database regarding all patients undergoing a cranial or spinal neurosurgical procedure between November 2016 and April 2016 in the neurosurgical department in Timone University Hospital (APHM- Marseille). Patients undergoing a functional, pediatric, or interventional neuroradiological procedures were not included. The medical records of a total number of 963 patients were analyzed. A postoperative complication occurred in 208 patients (21.6%) including 115 (26.6%) in the cranial surgery group and 93 (17.5%) in the spinal surgery group. A complication occurred 1.5 more frequently in the cranial than in the spinal surgery group. Cranial surgery is 1.5 times more at risk of complications than spinal surgery (P=0.007). Preoperative comorbidities (ASA Score >3 to 4) were significantly associated with the occurrence of complications (P<0.001). In the cranial group, procedures performed in an emergency setting were 1.8 times more at risk of complications than scheduled surgeries (P<0.001). Conversely, in the spine group, scheduled surgeries were 1.4 times less at risk than emergency procedures (P=0.04). The main complication in both groups was found to be postoperative infection, with an incidence of 9.3% and 11.1% for cranial and spinal surgery respectively. Postoperative mortality reached 4.9% and 1.7% and the average length of stay was 12 and 11 days respectively. The incidence of complication in our series was found to be relatively high with predominantly infection as the main cause of postoperative complications. Reinforcing good practice measures at every step should help to significantly decrease our complication rate.

Pediatric emergency room visits for neurological conditions: Description and use of pediatric neurologist advice

Introduction and objectiveInformation on the spectrum and frequencies of pediatric neurological presentations to emergency departments is vital to optimize quality of care. The objective of this study was to determine the incidence of pediatric neurological emergencies and to analyze the impact of specialist neurological advice in emergency care. Patients and methodsWe performed a retrospective descriptive study of pediatric emergency room visits for neurological reasons at the Timone University Hospital in Marseille over a 6-month period (from October 2017 to March 2018). ResultsOf the 14,572 emergencies analyzed, 370 (2.5%) were for neurological conditions. These were most commonly seizures (56.7% of cases), headache (19.7%), and motor or sensory deficits (5.1%). The most frequent diagnosis was epileptic seizure (30%), followed by febrile seizure (26.1%) and migraine (15%). Around two in every five patients (37.6%) required hospitalization. Neurological emergencies requiring critical care occurred at a frequency of about one per month (1.6% of cases). A pediatric neurologist was consulted in 37.3% of cases, resulting in a modification of the diagnosis or treatment in 66% of these referrals. ConclusionThe results of this study suggest that a formal referral system between the emergency department and pediatric neurologists would be useful.

Point de vue : une leçon tirée du confinement, l’histopathologie en visioconférence

Le confinement et la distanciation sociale ont généralisé l’usage de la visioconférence, tant dans la sphère privée que professionnelle. Ainsi, l’utilisation de la visioconférence a considérablement augmenté durant la période du confinement et cette technologie a été utilisée dans le service d’anatomie pathologique du centre hospitalo-universitaire Timone, à Marseille, à visée universitaire, hospitalière et de recours. Nous apportons notre point de vue concernant l’utilisation de cet outil informatique. La discussion de lames par visioconférence est un exercice nouveau et particulier ; plusieurs recommandations sont émises pour un bon déroulement de ces réunions d’histopathologie à distance.

Cinq ans d’expérience d’un atelier de maquillage médical correcteur des dermatoses affichantes : évaluation par la satisfaction des patients

Living with disfiguring disorders can impair the emotional well-being and relationships of patients as well as their social and professional life. Since 2010, courses in medical cosmetic correction for disfiguring diseases have been conducted at the dermatology department of the Timone University Hospital in Marseille and they form part of an educational program. The aim of this study was to assess the satisfaction of patients taking part in this program. This is a retrospective study of 55patients taking part in make-up sessions from January 2010to December 2014and subsequently completing a questionnaire. The median patient age was 46years with most being women (n=49, 89%). They presented pigmentary disorders (54.5%), inflammatory diseases (27.3%) and scars (18.2%). 75% of patients stated that they had improved their knowledge and 82% remarked that the technique was personalized to their needs. The technique was considered as easy by 62% and reproducible by 87% of patients. 55% of patients considered that cosmetic camouflage improved their quality of life and 56% stated that it helped them accept the gaze of others. In our study skin camouflage appears easy to use and meets patient expectations.

Safety and efficacy of Gamma Knife radiosurgery in hypothalamic hamartomas with severe epilepsies: A prospective trial in 48 patients and review of the literature.

Epilepsies associated with hypothalamic hamartomas (HHs) are frequently drug resistant with severe psychiatric and cognitive comorbidities. We performed a prospective trial to evaluate the safety and efficacy of Gamma Knife radiosurgery (GKS). Between October 1999 and October 2007, a total of 57 patients were investigated, included and treated by GKS in Timone University Hospital. Preoperative workup and 3-year postoperative evaluation consisted of seizure diary, neuropsychological, psychiatric, endocrinologic, visual field, and visual acuity examinations. Follow-up of >3years was available for 48 patients. Topologic type was type I in 11 patients, type II in 15, type III in 17, type IV in one, type V in one, type VI in one, and mixed type in 2. The median marginal dose was 17Gy (min 14 and max 25Gy). The median target volume was 398mm3 (28-1,600 mm3 ). Due to partial results, 28 patients (58.3%) required a second treatment. The median follow-up was 71months (36-153 months). At last follow-up, the rate of Engel class I outcome was 39.6%, Engel class II was 29.2% (I+II 68.8%), and Engel class III was 20%. Global psychiatric comorbidity was considered cured in 28%, improved in 56%, stable in 8%, and continued to worsen in 8%. No permanent neurologic side effect was reported (in particular, no memory deficit). Nondisabling transient poikilothermia was observed in three patients (6.2%). A transient increase of seizure frequency was reported in 8 patients (16.6%) with a median duration of 30days (9-90days). Microsurgery was proposed because of insufficient efficacy of GKS in seven patients (14.5%) with a postoperative Engel class I-IIin 28.6%. This prospective trial demonstrates very good long-term safety and efficacy of GKS for 2 patients. Beyond seizure reduction, the improvement of psychiatric and cognitive comorbidities along with better school performance and social functioning, being better socially integrated, having friends having a social life, working, participating to group activities turn out to be major benefits of GKS in this group of patients with frequently catastrophic epilepsy.

Étude épidémiologique des pathologies de la muqueuse buccale dans une consultation spécialisée de centre hospitalo-universitaire (CHU)

Oral diseases (OD) are common and affect, according to studies, 2.5to 61.6% of general population. The main objective of our study was to determine the most common diagnoses of OD in a dedicated consultation in a University Hospital. We conducted a descriptive observational study over 12months from weekly OD consultations provided within the oral and maxillofacial surgery department at the Timone university hospital, Marseille, France. We divided our patient population into 4subgroups: subgroup A, in which each patient was considered as a new one for each consultation; subgroup B, in which each patient was only considered once; subgroup C, including patients seen three times at least and subgroup D, including the children. At each consultation, were identified: age, sex, alcohol and tobacco consumption, corresponding physician specialty, time between onset of symptoms and consultation, reason for consultation and final diagnosis. Subgroups A, B, C and D respectively included 393, 208, 23and 11cases. Age and sex were similar in the subgroups A, B and C (mean age: 53.6, 54.3and 51.4years, respectively; female predominance: 62.9%, 66.8% and 65.2%, respectively). The most commonly encountered diagnoses were similar in the subgroups A and B: oral lichen planus (19.6% and 19.2%), aphthous stomatitis (11.5and 7.2%), burning mouth syndrome (11.5and 14.9%). In subgroup C, were found: oral lichen planus (34.8%), aphthous stomatitis (21.7%), cicatricial pemphigoid (13%) and pemphigus (13%). In the subgroup D, the most common diagnoses were aphthous stomatitis (45.5%) and traumatic injury (18.2%). The mean time before diagnosis was about 2years. The most common diagnoses in a specialized OD consultation are: lichen planus, aphthous stomatitis and burning mouth syndrome. The time before diagnosis could be improved by means of more information for practitioners and patients.

Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study.

Gamma Knife surgery (GKS) is one of the surgical alternatives for the treatment of drug-resistant trigeminal neuralgia (TN). This study aims to evaluate the safety and efficacy of GKS in a large population of patients with TN with very long-term clinical follow-up. Between July 1992 and November 2010, 737 patients presenting with TN were treated using GKS. Data were collected prospectively and were further retrospectively evaluated at Timone University Hospital. The frequency and severity of pain, as well as trigeminal nerve function, were evaluated before GKS and regularly thereafter. Radiosurgery using the Gamma Knife (model B, C, 4C, or Perfexion) was performed with the help of both MR and CT targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 85 Gy (range 70-90 Gy) was prescribed. The safety and efficacy are reported for 497 patients with medically refractory classical TN who were never previously treated by GKS and had a follow-up of at least 1 year. The median age in this series was 68.3 years (range 28.1-93.2 years). The median follow-up period was 43.8 months (range 12-174.4 months). Overall, 456 patients (91.75%) were initially pain free in a median time of 10 days (range 1-180 days). Their actuarial probabilities of remaining pain free without medication at 3, 5, 7, and 10 years were 71.8%, 64.9%, 59.7%, and 45.3%, respectively. One hundred fifty-seven patients (34.4%) who were initially pain free experienced at least 1 recurrence, with a median delay of onset of 24 months (range 0.6-150.1 months). However, the actuarial rate of maintaining pain relief without further surgery was 67.8% at 10 years. The hypesthesia actuarial rate at 5 years was 20.4% and at 7 years reached 21.1%, but remained stable until 14 years with a median delay of onset of 12 months (range 1-65 months). Very bothersome facial hypesthesia was reported in only 3 patients (0.6%). Retrogasserian GKS proved to be safe and effective in the long term and in a very large number of patients. Even if the probability of long-lasting effects may be modest compared with microvascular decompression, the rarity of complications prompts discussion of using GKS as the pragmatic surgical first- or second-intention alternative for classical TN. However, a randomized trial, or at least a case-matched control study, would be required to compare with microvascular decompression.

Decreased Probability of Initial Pain Cessation in Classic Trigeminal Neuralgia Treated With Gamma Knife Surgery in Case of Previous Microvascular Decompression: A Prospective Series of 45 Patients With >1 Year of Follow-up.

Microvascular decompression (MVD) is the reference technique for pharmacoresistant trigeminal neuralgia (TN). To establish whether the safety and efficacy of Gamma Knife surgery for recurrent TN are influenced by prior MVD. Between July 1992 and November 2010, 54 of 737 patients (45 of 497 with >1 year of follow-up) had a history of MVD (approximately half also with previous ablative procedure) and were operated on with Gamma Knife surgery for TN in the Timone University Hospital. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range, 3.9-11.9 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range, 70-90 Gy) was delivered. The median follow-up time was 39.5 months (range, 14.1-144.6 months). Thirty-five patients (77.8%) were initially pain free in a median time of 14 days (range, 0-180 days), much lower compared with our global population of classic TN (P = .01). Their actuarial probabilities of remaining pain-free without medication at 3, 5, 7, and 10 years were 66.5%, 59.1%, 59.1%, and 44.3%. The hypoesthesia actuarial rate at 1 year was 9.1% and remained stable until 12 years (median, 8 months). Patients with previous MVD showed a significantly lower probability of initial pain cessation compared with our global population with classic TN (P = .01). The toxicity was low (only 9.1% hypoesthesia); furthermore, no patient reported bothersome hypoesthesia. However, the probability of maintaining pain relief without medication was 44.3% at 10 years, similar to our global series of classic TN (P = .85).

Editorial introductions

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Thierry MesanaThierry MesanaDr Mesana is the President and Chief Executive Officer of the University of Ottawa Heart Institute. He received his medical degree in 1985 at the Université de la Méditerranée, Marseille, France, where he trained in thoracic and cardiovascular surgery. In 1990, he received his PhD in biophysics and biomechanics from the Université de la Méditerranée after extensive experimental work and design development on artificial hearts and ventricular assist devices. In 1991, Dr Mesana was, at the time, the youngest cardiac surgeon in France to receive a full Professorship. He then became the Chair of Thoracic and Cardiovascular Surgery at La Timone University Hospital, France, the largest hospital in Marseilles, where he introduced a number of advanced techniques in valve surgery, thoracic aorta surgery and ventricular assist devices and greatly expanded their cardiac surgery program, doubling its size in a 10-year period. Dr Mesana was appointed Chief of Cardiac Surgery at the University of Ottawa Heart Institute in 2001. Under his leadership, the Institute's surgical program became a leading Canadian and International program and his valve repair program has become recognized as one of the best in the world. His emphasis on repairing failing heart valves helped to establish this approach as a gold standard for treatment. He is a strong advocate of basic science research in the field of myocardial regeneration. In the last few years, his group in Ottawa has published papers extensively on studies in basic research related to stem cells and angiogenesis, clinical research papers on long-term follow-up of patients with heart valve prosthesis, as well as studies on aortic prosthesis mismatch and predictors of long-term outcome such as stroke, heart failure and reoperation. In addition, he has encouraged the development of minimally invasive surgical procedures for coronary bypass grafting and complex cardiac arrhythmias, and utilization of miniaturized rotary blood pumps as bridge to transplantation. During his tenure at the Institute, he marked the milestone of its 500th heart transplant. Haissam HaddadHaissam HaddadDr Haddad received his BSc from Tichreen University in Syria in 1980 and graduated from Medical School at Tichreen University in 1983. Following a family medicine practice in Syria, Dr Haddad immigrated to Canada and trained in internal medicine at Dalhousie University, Canada, and successfully completed his Cardiology training at the University of Alberta, Canada. In July 1997, Dr Haddad joined the Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Dalhousie University in Halifax, Nova Scotia and was Medical Director of the Heart Transplant Program and Director of the Cardiac Rehabilitation Program. In September 2001, Dr Haddad joined the University of Ottawa Heart Institute, Canada; he is Professor of Medicine, Division of Cardiology, Director of the Heart Failure Program, and Medical Director of Heart Transplant Program (2001–2013). He is also the Vice President of Medical Staff, The Ottawa Hospital and member of The Board of Directors. Dr Haddad was a member of the Primary Panel of the Canadian Cardiovascular Society's consensus conferences on the management of heart failure (2001–2010), on heart transplantation in adults (2003) and on heart transplantation in pediatrics (2005). He also chaired the Society's consensus conference for heart transplant in 2008–2009. Dr Haddad was the chair of The Canadian Cardiac Transplant Group, 2006–2008. He is the vice president, Canadian Heart Failure Association. He is the founder of the annual educational meeting for The Canadian Cardiac Transplant programs (Ottawa 2008, Calgary 2009, Quebec City 2010). Dr Haddad has earned numerous prestigious awards, namely the Anemia Institute for Research and Education Award in 2005, and the 1st Award Prize in the International Competition of the American College of Physicians in 2000.

Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review.

The purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN). Using the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70-90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study. The median time to retreatment in the Marseille study was 72 months (range 12-125 months) and in the literature it was 17 months (range 3-146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12-96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1-180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%-100%) and for new hypesthesia of 33% (range 11%-80%). Results from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.

Editorial introductions

Editorial introductions

Assessing the quality of life among caregivers of patients with gliomas.

The aim of the study was to analyze the impact of gliomas in caregivers' quality of life (QoL) and to compare this specific population to other oncology caregivers and the normative population in order to find differences and understand which aspects of QoL are more impacted. The sample was composed of caregivers of patients with gliomas from the Neuro-Oncology Department of Timone University Hospital of Marseilles, France. Control caregivers were selected from different oncology departments and were matched with caregivers of patients with brain cancer on age, sex, and relationship with the patients. We used the specific CareGiver Oncology Quality of Life questionnaire (CarGOQoL) to assess the impact of cancer and its treatment on caregivers' QoL. Caregivers also completed the Short Form 36 (SF36) for comparison with the French normative sample. The study sample included 50 caregivers of patients with gliomas, aged 30-77 years, 28% of whom were men. When comparing specific CarGOQoL scores with those of the control caregivers, brain cancer caregivers had significantly lower scores for the burden and leisure time dimensions, with an effect size of 0.4. No significant differences between cases and controls were observed with SF36. Caregivers of patients with gliomas showed increased burden scores and lower scores for the leisure time dimension. This could be explained by their unique care situation, in which patients become more limited physically and cognitively.

P17.20 * PATTERNS OF CARE AND OUTCOME FOR PATIENTS WITH RECURRENT GLIOBLASTOMA

BACKGROUND: Access to salvage treatment for patients with recurrent GB is poorly documented in daily practice. Our objective was to assess patterns of care and outcome in patients with recurrent GB. METHODS: A retrospective analysis of consecutive patients with histologically proven GB treated in 2008 and 2011 at Timone University Hospital was performed. Clinical, therapeutic and outcome data were collected. RESULTS: 207 patients were identified (2008: n = 99; 2011: n = 108). Patient's characteristics, pattern of care and outcome were similar between 2008 and 2011 and, therefore analyzed together. Overall survival from initial diagnosis (OSI) was 15.0 months (95% CI 12.9-17.1). Recurrence was diagnosed in 158 pts (76.3%). Overall survival from recurrence (OSR) was 6.6 months (95% CI 5.6-7.5). 117/158 pts (74%) of them received salvage treatment; 41 (26%) received no trt. 53, 48, and 16 pts received 1, 2 and > 2 lines at recurrence respectively. 2line treatment consist of chemotherapy (CT), n = 23 (19.7%), bevacizumab (BEV) +/- CT, n = 63 (53.8%), surgery +/- carmustine wafer (CW), n = 16 (10.1%), reirradiation (RRT) (1) and inclusion in clinical trials, n = 16 (9.5%). OSR in patient treated with CT + /-BEV was 8.0 months (95% CI 6.9-9.1) and OSI was 18.9 months (95% CI 16.3-21.5). OSR in patients with local treatment (surgery +/-CW, RRT) was 10.8 months (95% CI 7.7-13.8); OSI was 29.7 months (CI 95% 10.5-39). In pts who received no salvage trt, OSR and OSI were 1.8 (95% CI 1.4-2.1) and 7.5 (95% CI 6.4-8.6) months respectively. In patients aged over 70 years (n = 76), recurrence was determined in 50 of whom 30 (60%) received a salvage treatment. OSR was 5.2 months (95% CI 3.9-6.6) and OSI was 8.9 months (95% CI 7.5-10.4). In pts aged ≤70 years (n = 131), recurrence was determined in 108 of whom 87 (81%) received a treatment at progression. OSR was 7.1 months (95% CI 5.9-8.4) and OSI was 18.1 months (95% CI 15.2-21.0). CONCLUSION: In a center assuming mainly primary care of patients, 75% of the pts identified with recurrent GB received salvage treatment. Differences in outcome associated to systemic treatment, second surgery, and no treatment could be related to pts/tumor heterogeneity and treatment. Access to and results of salvage treatment in elderly are limited.

Multiple Sclerosis-Related Trigeminal Neuralgia: A Prospective Series of 43 Patients Treated with Gamma Knife Surgery with More than One Year of Follow-Up

Background: Trigeminal neuralgia (TN) related to multiple sclerosis (MS) is more difficult to manage pharmacologically and surgically. Objective: This article aims to evaluate the safety and efficacy of Gamma Knife surgery (GKS) in this special group of patients. Methods: Between July 1992 and November 2010, 43 cases with more than 1 year of follow-up were operated with GKS for TN related to MS and prospectively evaluated in the Timone University Hospital, Marseille, France. Radiosurgery using the Gamma Knife (model B or C or Perfexion) was performed. A single 4-mm isocenter was positioned at a median distance of 8 mm (range 5.7-14.7) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 75-90) was delivered. Results: The median follow-up period was 53.8 months (12-157.1). Thirty-nine patients (90.7%) were initially pain free. Their actuarial probability of remaining pain free without medication at 6 months, 1, 3, 5 and 10 years was 87.2, 71.8, 43.1, 38.3 and 20.5%, respectively, and remained stable till 12 years. The hypoesthesia actuarial rate at 6 months, 1 and 2 years was 11.5, 11.5 and 16%, and remained stable till 12 years. Conclusions: GKS proved safe and effective in this special group of patients.

Trigeminal Neuralgia Related to Megadolichobasilar Artery Compression: A Prospective Series of Twenty-Nine Patients Treated with Gamma Knife Surgery, with More Than One Year of Follow-Up

Background: Trigeminal neuralgia (TN) secondary to megadolichobasilar artery (MBA) compression is considerably difficult to manage surgically. Objective: This study aims to evaluate the safety/efficacy of Gamma Knife surgery (GKS) in this special group of patients. Methods: Between July 1992 and November 2010, 29 patients with >1 year of follow-up presenting with MBA compression were treated with GKS at Timone University Hospital. Radiosurgery was performed using a Gamma Knife (model B, C or Perfexion). A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 9.1 mm (range: 6-18.2 mm) from the emergence. Results: The median follow-up period was 46.1 months (range: 12.9-157.9 months). Initially, all patients (100%) were pain free; the average time to complete pain relief was 13.5 days (range: 0-240 days). Their actuarial probability of remaining pain free without medication at 0.5, 1 and 2 years was 93.1, 79.3 and 75.7%, respectively, and remained stable until 13 years after treatment. The actuarial probability of hypoesthesia onset at 6 months was 4.3%; at 1 year it reached 13% and remained stable until 13 years after treatment. Conclusions: GKS proved to be reasonably safe and effective on a long-term basis as a first- and/or second-line surgical treatment for TN due to MBA compression.

Outcome of multimodal therapy in operated acromegalic patients, a study in 115 patients

Given the new therapeutic options in acromegaly, it seemed important to evaluate the outcome of operated acromegalic patients today. To analyse the characteristics and short- and long-term surgical outcome of patients who underwent transsphenoidal surgery for a growth hormone (GH)-secreting adenoma in our centre and to determine predictive factors of remission. This retrospective 10-year study included 115 newly diagnosed acromegalic patients operated on at Timone University Hospital, Marseille, France, between 1997 and 2007. Initial and long-term outcomes were evaluated using stringent and current remission criteria, associating GH nadir after oral glucose tolerance test <0·4μg/l and normal insulin-like growth factor-1 (IGF-1) at 3months, and a normal IGF-1 at the end of follow-up (52·4±36·8months, median 41months, range 6·7-135·4months, n=99). At the end of follow-up, 90·9% of patients had controlled disease. Overall, 49·5% of patients were in long-term remission after surgery alone, and only 2·0% of patients experienced recurrent disease. Multivariate predictors of 3-month remission included mean GH at diagnosis (P=0·033), tumour invasion (P=0·013) and surgeon report of incomplete or uncertain macroscopic resection (P=0·003 and P=0·047, respectively). Multivariate predictors at diagnosis of long-term remission included mean GH level (P=0·048), adenoma size (P=0·007) and absence of pituitary deficit (P=0·026). In long-term follow-up after surgery of acromegaly, half of the patients achieved remission after surgery alone and more than 90% had their disease controlled. With stringent 3-month remission criteria, recurrence was rare.

Patterns of pain-free response in 497 cases of classic trigeminal neuralgia treated with Gamma Knife surgery and followed up for least 1 year

OBJECT: The goal of this study was to establish whether clear patterns of initial pain freedom could be identified when treating patients with classic trigeminal neuralgia (TN) by using Gamma Knife surgery (GKS). The authors compared hypesthesia and pain recurrence rates to see if statistically significant differences could be found. METHODS: Between July 1992 and November 2010, 737 patients presenting with TN underwent GKS and prospective evaluation at Timone University Hospital in Marseille, France. In this study the authors analyzed the cases of 497 of these patients, who participated in follow-up longer than 1 year, did not have megadolichobasilar artery- or multiple sclerosis-related TN, and underwent GKS only once; in other words, the focus was on cases of classic TN with a single radiosurgical treatment. Radiosurgery was performed with a Leksell Gamma Knife (model B, C, or Perfexion) using both MR and CT imaging targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.8 mm (range 4.5-14 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 70-90 Gy) was delivered. Using empirical methods and assisted by a chart with clear cut-off periods of pain free distribution, the authors were able to divide patients who experienced freedom from pain into 3 separate groups: patients who became pain free within the first 48 hours post-GKS; those who became pain free between 48 hours and 30 days post-GKS; and those who became pain free more than 30 days after GKS. RESULTS: The median age in the 497 patients was 68.3 years (range 28.1-93.2 years). The median follow-up period was 43.75 months (range 12-174.41 months). Four hundred fifty-four patients (91.34%) were initially pain free within a median time of 10 days (range 1-459 days) after GKS. One hundred sixty-nine patients (37.2%) became pain free within the first 48 hours (Group PF(≤ 48 hours)), 194 patients (42.8%) between posttreatment Day 3 and Day 30 (Group PF((>48 hours, ≤ 30 days))), and 91 patients (20%) after 30 days post-GKS (Group PF(>30 days)). Differences in postoperative hypesthesia were found: in Group PF(≤ 48 hours) 18 patients (13.7%) developed postoperative hypesthesia, compared with 30 patients (19%) in Group PF((>48 hours, ≤ 30 days)) and 22 patients (30.6%) in Group PF(>30 days) (p = 0.014). One hundred fifty-seven patients (34.4%) who initially became free from pain experienced a recurrence of pain with a median delay of 24 months (range 0.62-150.06 months). There were no statistically significant differences between the patient groups with respect to pain recurrence: 66 patients (39%) in Group PF(≤ 48 hours) experienced pain recurrence, compared with 71 patients (36.6%) in Group PF((>48 hours, ≤ 30 days)) and 27 patients (29.7%) in Group PF(>30 days) (p = 0.515). CONCLUSIONS: A substantial number of patients (169 cases, 37.2%) became pain free within the first 48 hours. The rate of hypesthesia was higher in patients who became pain free more than 30 days after GKS, with a statistically significant difference between patient groups (p = 0.014).

Patterns of pain-free response in 497 cases of classic trigeminal neuralgia treated with Gamma Knife surgery and followed up for least 1 year

Object The goal of this study was to establish whether clear patterns of initial pain freedom could be identified when treating patients with classic trigeminal neuralgia (TN) by using Gamma Knife surgery (GKS). The authors compared hypesthesia and pain recurrence rates to see if statistically significant differences could be found. Methods Between July 1992 and November 2010, 737 patients presenting with TN underwent GKS and prospective evaluation at Timone University Hospital in Marseille, France. In this study the authors analyzed the cases of 497 of these patients, who participated in follow-up longer than 1 year, did not have megadolichobasilar artery– or multiple sclerosis–related TN, and underwent GKS only once; in other words, the focus was on cases of classic TN with a single radiosurgical treatment. Radiosurgery was performed with a Leksell Gamma Knife (model B, C, or Perfexion) using both MR and CT imaging targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.8 mm (range 4.5–14 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 70–90 Gy) was delivered. Using empirical methods and assisted by a chart with clear cut-off periods of pain free distribution, the authors were able to divide patients who experienced freedom from pain into 3 separate groups: patients who became pain free within the first 48 hours post-GKS; those who became pain free between 48 hours and 30 days post-GKS; and those who became pain free more than 30 days after GKS. Results The median age in the 497 patients was 68.3 years (range 28.1–93.2 years). The median follow-up period was 43.75 months (range 12–174.41 months). Four hundred fifty-four patients (91.34%) were initially pain free within a median time of 10 days (range 1–459 days) after GKS. One hundred sixty-nine patients (37.2%) became pain free within the first 48 hours (Group PF≤ 48 hours), 194 patients (42.8%) between posttreatment Day 3 and Day 30 (Group PF(&gt;48 hours, ≤ 30 days)), and 91 patients (20%) after 30 days post-GKS (Group PF&gt;30 days). Differences in postoperative hypesthesia were found: in Group PF≤ 48 hours 18 patients (13.7%) developed postoperative hypesthesia, compared with 30 patients (19%) in Group PF(&gt;48 hours, ≤ 30 days) and 22 patients (30.6%) in Group PF&gt;30 days (p = 0.014). One hundred fifty-seven patients (34.4%) who initially became free from pain experienced a recurrence of pain with a median delay of 24 months (range 0.62–150.06 months). There were no statistically significant differences between the patient groups with respect to pain recurrence: 66 patients (39%) in Group PF≤ 48 hours experienced pain recurrence, compared with 71 patients (36.6%) in Group PF(&gt;48 hours, ≤ 30 days) and 27 patients (29.7%) in Group PF&gt;30 days (p = 0.515). Conclusions A substantial number of patients (169 cases, 37.2%) became pain free within the first 48 hours. The rate of hypesthesia was higher in patients who became pain free more than 30 days after GKS, with a statistically significant difference between patient groups (p = 0.014).