• H&P

    • 38 year-old M presented with syncope and underwent imaging of his brain that revealed an abnormality
    • PMH/SurgHx – neg
    • Meds – none
    • All – NKDA
    • SocHx – research assistant
    • PE – AF VSS
    • Neurologically intact
    • The patient was treated with SRS
    • He returned 4 months later with intermittent visual disturbance consistent with seizure activity. He was placed on anti-epileptic medications and underwent new imaging.

    Figure 1: Imaging – T1 with contrast MRI

    Figure 2: FLAIR sequence MRI

    Figure 3: MRI – FLAIR and T1 with contrast

    1. What dose of SRS would you use?

    2. What is the next step in evaluation/treatment?

    3. What is the risk of radiation necrosis or cerebral edema with SRS treatment?

    4. Which of the following best describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:
     
    • I would have respected the lesion up front in this young man
    • I would start Decadron 4 mg bid, Trental 400 mg tid, and vitamin E 400 IU bid. Taper Decadron when improved but continue Trental and vitamin E until maximal response.
    • ????? A 38 yo received SRS as primary RX instead of resection without tissue dx ?? I understand that resection might not be total due to residual tumor along sinus but SRS could have been given to any small residual tumor.
    • My opinion SRS shouldn't be done and surgical resection was the optimal treatment.
    • I believe that this patient should be from the beginning to surgery and the histopathology dpendiendo and define the extent of resection if required Radiosurgery
    • In a young person with an extra-axial mass, there is a there is a chance that this might not have been a meningioma (I.e.dural based metastasis). I believe craniotomy would have been safer initial treatment choice- as definitive treatment, as well as establishing diagnosis.
    • What I can see is a PRS hemorragic lesion with a tumor is the reason why I woul prefer a craneotomy and make extirpation of both tumor and the hemoragic lesion.
    • I had a similar case in the first month of practice. Never seen it since in 15 years
    • It would be nice to see the radiosurgical planning if this case. In my practice I would use 12 Gy to the 50% isodose if the tumor is up to 10 cc in volume. Assuming the fact that today we can see the tendency to use lower doses for meningiomas I would rise the question if there is a radiation reaction in this case or we are just dealing with venous compression and subsequent infarct. In my experience with over 800 meningiomas irradiated by means of GK Perfexion I would very rarely seen radionecrosis after 4 months. Maybe DWI and PET-CT studies would answer the question. The parasagittal meningioma are usually surrounded by bridging veins that may be compressed by oedematic tumor after stereotactic radiosurgery.
    • Extremely poor advice to recommend radiosurgery in the first place in this 38 year-old with relatively large, accessible (at least for subtotal resection, meningioma.
    • i practice in El Salvador CENTRAL AMERICA
    • This needs to be resected. Surgical extirpation can be performed fairly safely. Radiosurgery should be reserved in this situation for the patient that for some reason cannot tolerate craniotomy (ie: not this patient).
    • could we have considered primary resection instead of SRS?
    • I do not understand why every neurosurgeon jumps for rediation surgery. Are they disabled by SRT/SRS facility? Or their surgical result POOR? I think craniotomy does cytoreduction and definitive tissue diagnosis. If doubt remains abour clearing tumours do post OP MRI and consider SRT if necessary. In my opinion SURGERY IS SAFE AND BENIGN PROCEDURE TILL THIS DAY in the hands of Neurosurgeons if he gets his proper training.
    • Very unfortunate that no suggested answers by an expert, for questions 1-3, will be provided next month.
    • My first approach would be open surgery, it is a very suitable tumor for a craniotomy and its morbidity in this situation is low. I think is not the first choice treatment SRS.
    • More info would have been better, i.e., tumor dimensions. Additionally, incidence of edema following SRS is specific to this type of tumor as opposed to a met of similar size.

     

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