Samuel F. Ciricillo

Interventional neuroradiological management of vein of Galen malformations in the neonate.

Since 1978, the authors have seen 14 neonates with vein of Galen malformations who were born with severe congestive heart failure. The 5 infants treated before 1983 underwent craniotomy and clipping of feeding vessels; all died in the perioperative period. Since 1983, 8 neonates have been treated with combined arterial and venous interventional neuroradiological techniques; 6 infants survived. Two-dimensional echocardiography, color Doppler flow imaging, and pulsed Doppler ultrasound were used to assess blood flow within the malformation before and after staged transluminal embolic procedures were performed. The results of the diagnostic studies and the clinical status of the infants were used to evaluate the success of embolic therapy and the need for further neuroradiological intervention.

Intracerebral arteriovenous fistulas associated with intraparenchymal varix in childhood: case reports.

This report describes three children, each of whom developed an unusual malformation consisting of one or more intracerebral arteriovenous fistulas and a large intraparenchymal venous varix. Their clinical symptoms were similar to those produced by aneurysms of the vein of Galen: increasing head circumference, seizures, hemorrhage, and developmental delay. We treated each child with endovascular embolization and/or surgery and obtained complete closure of all fistulas without mortality.

Gamma knife radiosurgery in children

52 pediatric patients were treated with radiosurgery at the University of California, San Francisco. Arteriovenous malformations were treated in 27 patients. Complete obliteration was noted in 4 of 12 patients imaged more than 2 years after radiosurgery. Arteriovenous malformation rebleed was noted in 1 patient. Symptomatic T2 changes were noted in 2 patients. Among 29 neoplasms treated in 25 patients, local control was noted in 5 of 7 low-grade gliomas, 5 of 14 high-grade gliomas, 4 of 5 craniopharyngiomas and 3 of 3 sarcomas. Three patients treated for neoplasms developed necrosis after radiosurgery.

Endoscopic Third Ventriculocisternostomy: MR Assessment of Patency with 2-D Cine Phase-Contrast versus T2-Weighted Fast Spin Echo Technique

Purpose: To determine if fast spin-echo T2 (FSE) is of equal value to flow-sensitive 2D cine phase-contrast (CPC) to assess patency of endoscopic third ventriculocisternostomies (VC). Patients and Methods: We reviewed clinical charts and MR scans of 27 patients who underwent third VC for treatment of obstructive hydrocephalus. Thirty-nine postoperative scans included both sequences and were assessed for the presence or absence of flow-related signal changes. Results: In 28 cases, FSE, CPC, and clinical findings suggested patency. In 1 case, CPC and FSE suggested occlusion, which was confirmed clinically and operatively. In the remaining cases, FSE showed better clinical correlation than did CPC. Conclusion: The assessment of third VC patency with FSE, a sequence available on most clinical scanners without a requirement for special hardware and software, is at least as sensitive in the qualitative assessment of VC function as CPC.

Serial Ultrasonographic Evaluation of Neonatal Vein of Galen Malformations to Assess the Efficacy of Interventional Neuroradiological Procedures

Two-dimensional echocardiography complemented with color-flow imaging and pulsed Doppler ultrasound was used to evaluate one fetus and five neonates with a vein of Galen malformation who had severe high-output congestive heart failure and cranial bruits at birth. Intracranial blood flow through the vein of Galen malformations, cardiac status, and direction of aortic blood flow were assessed before and after staged interventional neuroradiological treatment with transarterial and transvenous embolization procedures. Color-flow imaging in each infant displayed the major vascular anatomy including feeding vessels and the patterns of filling of the vein of Galen malformations. Pulsed Doppler ultrasound performed on the descending aorta above the diaphragm showed the degree of diastolic flow reversal indicative of runoff into the vein of Galen malformations. A reduction in blood flow through the vein of Galen malformation was seen on color-flow imaging in four patients treated successfully by embolic procedures. The ratio of diastolic retrograde flow velocity in the descending aorta to systolic antegrade velocity decreased from 0.51 +/- 0.15 (mean +/- standard deviation) to 0.15 +/- 0.20 (P less than 0.05). Color-flow imaging and pulsed Doppler ultrasonography provided anatomical and pathophysiological information regarding cardiac hemodynamics and intracranial blood flow; with the patients clinical status, these methods provided a reliable, noninvasive means to evaluate the effectiveness of therapy and the need for further treatment in neonates with vein of Galen malformations.

Primary intracerebral osteosarcoma: A case report

Primary intracerebral sarcomas are rare tumors. Malignantfibrous histiocytoma and fibrosarcoma are the predominant histologies. A 3 year old girl with a primary, intraparenchymalcerebral osteosarcoma, the second case reported in the literature,is described. Partial surgical resection, systemic chemotherapy and radiosurgery has provided tumor control at 18 months. Treatment issues are discussed.

Stereotactic radiosurgery in children.

The role of stereotactic radiosurgery in the treatment of pediatric patients is still being explored. We report the Gamma Knife treatment of 33 patients under the age of 21, at the University of California, San Francisco, between the years 1991 and 1993. Treatment-related toxicity has been low. 10/14 patients treated for arteriovenous malformation (AVM) with follow-up > 1 month have shown partial or complete AVM obliteration. No patient has had a new hemorrhage after AVM treatment. In children with malignant tumors, treatment was well tolerated, although most patients, ultimately, had progressive disease. Stereotactic radiosurgery is logistically possible in the pediatric population. Its use in selected patients with AVMs seems appropriate, although its role in the treatment of malignant brain tumors remains to be defined.

Stereotactic insertion of an ommaya reservoir: technical note.

BACKGROUND Stereotactic insertion of catheters into deep-seated tumors or developmental cysts is easily accomplished, but connecting the catheter to an Ommaya reservoir while maintaining catheter position can be difficult. We describe a technique for easy placement of a catheter-Ommaya reservoir construct with one pass. METHODS Standard stereotactic imaging is performed. The distance from the outer table of the skull to the target point is measured. A catheter-Ommaya reservoir construct is assembled to this length and directed to the target position with a standard Cosman-Robert-Wells (CRW) stereotactic frame. RESULTS Use of this technique placed catheters into tumor or developmental cysts accurately and with no surgical complications in 12 patients. CONCLUSIONS This technique is simple, safe, reliable, and requires no special equipment. It avoids the risk of dislodging the catheter when it is being connected to the Ommaya reservoir, reducing the chances of cyst leakage and collapse.

Anesthesia for pediatric stereotactic radiosurgery

STEREOTACTIC radiosurgery has become an important technique to treat various intracranial lesions in children. 1 Providing anesthesia for this therapy differs in several important ways frm other out of the operating room procedures. First, the entire procedure can take 6-10 h and involves the placement of a bulky stereotactic frame around the head, imaging in the magnetic resonance imaging (MRI) suite (and sometimes inthe neuroangiography suite), and transport to at least three different sites in the hospital. Finally, after the stereotactic frame is placed and the magnetic resonance image is obtained, the radiation oncologists require from 1 to 4 h to programl the specific radiation therapy for a particular patient. Because the stereotactic frame must remain in place until the radiation is delivered, young infants and children must remain quiet to avoid displacing this frame. Thus, the patient remains sedated or anesthetized for a prolonged (often umnpredictable) period before the radiation can be delivered. Finally, the anesthesiologist must be able to monitor the patient from outside of the room while the radiation is delivered. For the most part, infants and young children are unable to cooperate for such a complicated and lengthy therapy and, therefore, require general anesthesia or deep sedation to provide conditions that allow accurate imaging and precise delivery of radiation.

Long experimental durations are required for double label [14C]- and [3H]2-deoxyglucose autoradiographic methods

Double-label 2-deoxyglucose (2-DG) studies using sequential [14C]- and [3H]2-DG injections demonstrate increased [14C]2-DG uptake during the first and second stimulation periods. To understand why this occurs, the rat mystacial vibrissae were stimulated at various times following [14C]2-DG injection. Local cerebral glucose utilization (LCGU) increased when whisker stimulation was performed at 0-90 min following [14C]2-DG injection. LCGU did not increase when whisker stimulation was performed at 90-150 min following [14C]2-DG injection. To minimize contamination of the two tracers in double label 2-DG mapping studies, the time between [14C]- and [3H]2-DG administration should be increased to 90 min.