Purpose: Navigated transcranial magnetic stimulation (nTMS) provides noninvasive visualization of eloquent brain areas. The nTMS is usually applied in presurgical planning to minimize the risk of surgery-related neurological deterioration. The aim of this study was to evaluate the usefulness of nTMS data for GammaKnife treatment planning for patients suffering from brain metastases. Methods: Motor cortex mapping with nTMS was performed in eight patients with brain metastases within or adjacent to the precentral gyrus. The nTMS data set was imported into the planning software and fused with anatomical MRI. Then contouring of the target and critical structures was performed. Treatment plans with and without visualization of the functional structures by nTMS were analyzed and compared by neurosurgeon and medical physicist. Results: The primary motor cortex was successfully delineated even in all cases despite significant peritumoral edema. Beam shaping and combined isocenters were used for conformal dose distribution and steeper dose fall-off near the identified eloquent zone. Compared with plans without nTMS data, treatment plans with integration of cortical nTMS mapping data showed a 2% to 78% (mean, 35.2% ± 22.7%) lower 12-Gy volume within the motor cortex without reduction of the dose applied to the tumor. Conclusions: The presented approach allows the easy and reliable integration of neurophysiological mapping data into GammaKnife treatment plans by the standard GammaPlan software. Diminishing the dose to critical structures might help to minimize side effects and therefore improve quality of life for brain metastasis patients.

BACKGROUND Structural damage to the brain substance in adults is one of the most common causes of epilepsy. Currently, such patients are prescribed drug therapy and/or surgery. With this approach, epileptic symptoms can persist in a significant proportion of patients (up to 30%, depending on the disease).AIM OF STUDY To clarify the efficacy of stereotactic radiosurgery (STS) as part of the complex treatment of patients suffering from pharmacoresistant symptomatic epilepsy with hippocampal sclerosis, vascular malformations, and some benign tumors of the brain and its membranes.MATERIAl AND METHODS Examination and radiosurgical treatment were carried out in 45 patients with various brain diseases accompanied by symptomatic epilepsy, provided that the previous conservative or surgical treatment was insufficiently effective. During the observation period, the frequency of seizures was assessed and the presence and nature of postoperative complications were recorded.RESUlTS With a median follow-up of 30 months, good outcomes (class I–II according to J. Engel’s scale) were observed in 5 out of 8 patients with hippocampal sclerosis who underwent STS after  amygdaloghippocamplobectomy; seizure frequency decreased in all patients. Complications of STS were noted in 2 patients and had a transient nature. In the group of patients with meningiomas, in 4 out of 8 patients, seizures completely stopped, in 3 patients the frequency of seizures decreased by more than 90%, in another 1 the frequency of seizures decreased by 60%. There were no complications of STS during the observation period. Inintracerebral tumors (diffuse astrocytoma), Engel Ia outcome was observed in both patients. In the group of patients with cavernous angiomas, there were good outcomes (class I–II according to J. Engel’s scale) in 17 patients (85%). Deterioration (Engel IVc outcome) was observed in 1 patient (5%), 2 patients (10%) had complications of STS. In the group of patients with arteriovenous malformations, good outcomes (classes I–II according to J. Engel’s scale) were found in all 7 patients. The complication after STS was revealed in 1 patient.CONClUSION The presented results confirm the high efficiency and low risk of side effects when using stereotactic radiosurgery in the complex treatment of patients with epilepsy associated with common structural brain lesions.

In contrast to conventional microsurgery, stereotactic radiosurgery has an advantage in the treatment of intracranial masses, avoiding severe complications associated with open surgery. In rare cases, the use of the method is associated with the development of radiation-induced injuries, one of which is radiation necrosis (RN). This is a late complication of radiosurgery, developing mainly 6 months after radiation exposure. The neurological manifestations of this complication depend on location, and the clinical picture is very diverse. The method of magnetic resonance imaging (MRI) with intravenous contrast enhancement is quite often the first link in neuroimaging, which helps to suggest the presence of this complication based on the X-ray picture and to clarify the location of changes.We presented the experience of radiation necrosis treatment in a 47-year-old patient who was referred to our department with a diagnosis of frontal meningioma. The patient underwent stereotactic radiosurgical treatment using the Elekta Leksell Gamma Knife Perfextion device, and 6 months later the gradual deterioration began, the patient complained of headache, nausea; central prosoparesis developed. Considering the clinical picture and control MRI data, the changes were interpreted as radionecrosis. In order to control the complication, the patient underwent standard glucocroticosteroid therapy, supplemented by hyperbaric oxygenation (HBO), which made it possible to achieve regression of the adverse clinical and radiological manifestations of the complication. Thus, on a clinical example, it was demonstrated that the combined use of glucocorticosteroids and HBOs is highly effective in the treatment of RN.

Treatment strategies for dural arterio-venous fistulas (DAFs) include single or multimodal schemes, including microsurgery, endovascular transarterial or transvenous embolization, or stereotactic radiosurgery (SRS).In the scientific medical resources, only 9 cases of bilateral DAFs of the brain are described, which required surgical intervention, and 4 were treated with endovascular or microsurgical approach; SRS was used in 5 cases, of which in 4 cases with previous or subsequent endovascular embolization.We have presented a case of successful SRS with Gamma Knife of bilateral DAF from the branches of meningo-hypophyseal trunks from inner carotid arteries without preliminary embolization or surgical resection.The use of SRS with Gamma Knife is possible with low-flow DAFs, as well as a part of a multimodal strategy with high-flow DAFs, which requires further study.

Научно-исследовательский институт скорой помощи им. Н. В. Склифосовского, Москва, Россия Введение. Радиохирургическое лечение является методом выбора при метастатическом поражении головного мозга. В клинической практике встречаются опухоли с относительно небольшой частотой вторичного поражения головного мозга, для которых применение стереотаксической радиохирургии изучено недостаточно. Одним из примеров таких заболеваний являются злокачественные опухоли женской репродуктивной системы. Материалы и методы. Нами описано применение стереотаксической радиохирургии метастазов рака яичника в головной мозг с использованием режима трехкратного гипофракционирования дозы. Мы прибегли к этому методу с целью снижения негативного воздействия на функциональную зону головного мозга и сохранения эффективности облучения при лечении метастатического очага, расположенного в области подкорковых ядер. С целью оценки результатов проводили магнитнорезонансную томографию с последующей волюметрией патологических очагов в программе для планирования стереотаксической радиохирургии Leksell Gamma plan® 10.1. Результаты и их обсуждение. При динамическом наблюдении отмечен продолжительный локальный контроль со стороны всех облученных опухолей с идентичными результатами применения однократного облучения и режима гипофракционирования. При наличии ограничения к проведению однократного стереотаксического радиохирургического лечения, связанного с локализацией патологического очага в элоквентной зоне головного мозга, существует возможность его облучения в режиме гипофракционирования. Метод позволяет достичь локального контроля роста опухоли без высокого риска развития лучевой токсичности. Ключевые слова: стереотаксическая радиохирургия, гипофракционирование, метастазы рака яичников в головной мозг Контакт: Токарев Алексей Сергеевич,