LINAC-based radiosurgery for functional and psychiatric disorders: Problems and their solutions.

This study examined the clinical efficacy of Gamma knife stereotactic radiosurgery as a treatment option in the management of pediatric primitive neuroectodermal tumours (PNETs).

The Dizziness Handicap Inventory (DHI) is a 25-item self-report quantifying dizziness-related physical and emotional symptoms and restrictions in daily activities. DHI scores do not correlate with severity of structural vestibular deficits; thus, high DHI scores may reflect other causes of morbidity. This study investigated the relationship between total DHI scores and the presence of structural, functional, and psychiatric disorders in tertiary neurotology patients. Retrospective. Tertiary center. Eighty-five patients who underwent multidisciplinary neurotologic evaluations. Diagnostic. Active illnesses identified by a multidisciplinary neurotology team were abstracted from medical records, cataloged as structural, functional, or psychiatric disorders, and used to group patients into diagnostic categories: structural (structural disorders only), functional (functional disorders with/without structural disorders), and psychiatric (psychiatric disorders with/without other conditions). DHI scores were compared across diagnostic categories. Sensitivities and specificities of DHI scores for identifying structural versus functional or psychiatric disorders were calculated. Mean DHI scores differed significantly by diagnostic category (structural 35 ± 18, functional 64 ± 15, and psychiatric 65 ± 19), before and after adjusting for age and sex (p < 0.001, Hedges' g>1.62 for structural versus functional and psychiatric categories). DHI≤30 (mild handicap) had specificity = 0.98 for structural disorders alone, whereas DHI>60 (severe handicap) had specificity = 0.88 for functional or psychiatric disorders. In this tertiary cohort, categories of illnesses had large effects on total DHI scores. Patients with scores ≤30 were likely to have structural disorders alone, whereas those with scores >60 were likely to have functional or psychiatric disorders, with or without coexisting structural conditions.

Psychiatric management of Patients in intensive care units.

BackgroundType 2 diabetes mellitus (T2DM) is linked with several neurodegenerative and psychiatric disorders, either as a comorbid condition or as a risk factor. We aimed to expand the evidence by examining associations with a broad range of brain disorders (psychiatric and neurological disorders, excluding late-onset neurodegenerative disorders), while also accounting for the temporal order of T2DM and these brain disorders.MethodsIn a population-based cohort-study of 1,883,198 Danish citizens, born 1955–1984 and followed until end of 2016, we estimated associations between T2DM and 16 brain disorders first diagnosed between childhood and mid-adulthood. We calculated odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals (CI) in temporally ordered analyses (brain disorder diagnosis after T2DM and vice versa), adjusted for sex, age, follow-up, birth year, and parental factors.ResultsA total of 67,660 (3.6%) of the study population were identified as T2DM cases after age 30 and by a mean age of 45 years (SD of 8 years). T2DM was associated with most psychiatric disorders. Strongest associations were seen with other (i.e. non-anorectic) eating disorders (OR [95% CI]: 2.64 [2.36–2.94]) and schizophrenia spectrum disorder (2.73 [2.63–2.84]). Among neurological disorders especially inflammatory brain diseases (1.73 [1.57–1.91]) and epilepsy (1.67 [1.60–1.75]) were associated with T2DM. Most associations remained in both directions in the temporally ordered analyses. For most psychiatric disorders, associations were strongest in females.ConclusionsT2DM was associated with several psychiatric and neurological disorders, and most associations were consistently found for both temporal order of disorders. This suggests a shared etiology of T2DM and those brain disorders. This study can form the starting point for studies directed at further elucidating potential causal links between disorders and shared biological mechanisms.

Copyright: © 2014 Vacsulka J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Stereotactic radiosurgery using the Leksell Gamma Knife® (AB Elekta, Stockholm, Sweden), refers tonon-invasive brain surgery that is performed in a single outpatient procedure.This technology allows extremely precise focal radiation of intracranial targets and spares tissues adjacent to the target, using 192-201 photon beams generated from the decay of Cobalt 60 sources. Gamma Knife surgery represents a major advancement in brain surgery that now has a long track record of success. The first patient procedure was performed in Stockholm in 1967. Since then almost 1 million patients worldwide have undergone this procedure at more than 300 worldwide sites. Its development has enhanced neurosurgical options for patients with brain tumors, vascular malformations, and functional disorders such as pain, movement disorders, and epilepsy. More than 2000 publications now testify to the ability of Gamma knife surgery to provide a safe, accurate, and reliable treatment option. The Gamma Knife enables patients to undergo a non-invasive form of brain surgery without traditional surgical risks such as bleeding or infections, does not require a hospital stay, or subsequent rehabilitation.

Object Little is known about long-term outcomes, including tumor control and adverse radiation effects, in patients harboring vestibular schwannomas (VSs) treated with stereotactic radiosurgery > 10 years previously. The aim of this study was to confirm whether Gamma Knife surgery (GKS) for VSs continues to be safe and effective > 10 years after treatment. Methods A total of 440 patients with VS (including neurofibromatosis Type 2) treated with GKS between May 1991 and December 2000 were evaluable. Of these, 347 patients (79%) underwent GKS as an initial treatment and 93 (21%) had undergone prior resection. Three hundred fifty-eight patients (81%) had a solid tumor and 82 (19%) had a cystic tumor. The median tumor volume was 2.8 cm(3) and the median marginal dose was 12.8 Gy. Results The median follow-up period was 12.5 years. The actuarial 5- and ≥ 10-year progression-free survival was 93% and 92%, respectively. No patient developed treatment failure > 10 years after treatment. According to multivariate analysis, significant factors related to worse progression-free survival included brainstem compression with a deviation of the fourth ventricle (p < 0.0001), marginal dose ≤ 13 Gy (p = 0.01), prior treatment (p = 0.02), and female sex (p = 0.02). Of 287 patients treated at a recent optimum dose of ≤ 13 Gy, 3 (1%) developed facial palsy, including 2 with transient palsy and 1 with persistent palsy after a second GKS, and 3 (1%) developed facial numbness, including 2 with transient and 1 with persistent facial numbness. The actuarial 10-year facial nerve preservation rate was 97% in the high marginal dose group (> 13 Gy) and 100% in the low marginal dose group (≤ 13 Gy). Ten patients (2.3%) developed delayed cyst formation. One patient alone developed malignant transformation, indicating an incidence of 0.3%. Conclusions In this study GKS was a safe and effective treatment for the majority of patients followed > 10 years after treatment. Special attention should be paid to cyst formation and malignant transformation as late adverse radiation effects, although they appeared to be rare. However, it is necessary to collect further long-term follow-up data before making conclusions about the long-term safety and efficacy of GKS, especially for young patients with VSs.

The presentation of irritable bowel syndrome in the context of somatization disorder

A 40-year-old Chinese woman presented with a cystic mass (size of 23×23×27 mm, volume 7.9 cm3) with tumor nodule in the pons. The patient received initial gamma knife surgery (GKS) treatment of dose 18.0 Gy, and the mass increased in volume to 12.8 cm3 after 7 weeks. Stereotactic aspiration surgery of the intratumoral cyst was performed, yielding 10.5 mL of yellowish-white fluid; biopsy confirmed the diagnosis of glioma. A second GKS of dose 10.5 Gy was performed 1 week later. Follow-up magnetic resonance imaging revealed a cyst volume of 1.0 cm3, with an obvious decrease in size of the tumor nodule at 18 months after the second GKS. The patient is alive and well 36 months after the combined therapy. To the best of our knowledge, cystic brainstem glioma treated by repeat gamma knife treatment combined with stereotactic aspiration surgery in a single patient has not been reported previously in the English-language literature. The findings of this case suggest that cyst drainage by stereotactic aspiration surgery can improve the effect of GKS for small brainstem glioma, even if the diameter of tumor is less than 30 mm.

This study assesses the incidence of malignant transformation (MT) in vestibular schwannomas (VSs) treated with stereotactic radiosurgery (SRS) over a 30-year period, with a median follow-up of 12 years. A retrospective analysis was performed on 1,051 individuals who underwent gamma knife surgery (GKS) for VS between May 1991 and March 2023. The cohort comprised 1,013 individuals with sporadic VSs and 38 with neurofibromatosis type 2-related schwannomatosis (NF2-SWN), totaling 1,061 treated VSs. The annual MT risk was calculated based on lesion-years at risk. Among the 1,061 VSs treated with GKS, MT occurred in 2 cases (0.19%), both in individuals with sporadic VSs. Over 12,940 lesion-years from GKS to the latest follow-up, the annual MT risk was 0.016% for all VSs, with no cases observed within the first 5 years post-GKS. However, the risk increased to 0.025% beyond 5 years. No instances of MT were identified in individuals with NF2-SWN. This study represents the most extensive investigation specifically examining the incidence of MT in VSs treated with SRS, leveraging the largest case series and longest observation period to date. The findings indicate that MT following SRS for VSs is exceedingly rare. Although the overall risk remains minimal, it may increase slightly with extended follow-up. These results support the continued use of SRS as a safe and effective treatment for VS while emphasizing the need for long-term monitoring.

Pituitary adenomas have been treated using a variety of modalities including resection, medication, fractionated radiotherapy, and stereotactic radiosurgery. The policy has been that all adenomas should first be treated with resection to reduce the volume of the tumor. The authors' study was conducted to determine the efficacy of using Gamma Knife surgery (GKS) for pituitary adenomas invading the cavernous sinus. Of 397 patients with pituitary tumors who underwent GKS between October 1994 and October 2005, 68 patients had pituitary macroadenomas invading the cavernous sinus. Sixty-seven cases were available for follow up. The mean age of the patients in these cases was 42.8 years (range 14-73 years). The male/female ratio was 0.8:1. The mean adenoma volume was 9.3 cm3. A total of 24 patients had undergone craniotomies and resection, and 11 patients had undergone transsphenoidal surgery prior to GKS. The mean follow-up period was 32.8 months. Tumor control was defined as a decrease or no change in tumor volume after GKS. Endocrinological improvement was defined as a decline in hormone levels to below 50% of the pre-GKS level. Tumor control was achieved in 95.5% of the cases. Endocrinological improvement was achieved in 68% of 25 patients. One patient suffered hypopituitarism after GKS. Gamma Knife surgery is a safe and effective treatment for invasive pituitary macroadenoma with few complications.

The aim of this study was to evaluate the outcomes of Gamma Knife surgery (GKS) when used for patients with intractable cluster headache (CH). Four participating centers of the North American Gamma Knife Consortium identified 17 patients who underwent GKS for intractable CH between 1996 and 2008. The median patient age was 47 years (range 26-83 years). The median duration of pain before GKS was 10 years (range 1.3-40 years). Seven patients underwent unsuccessful prior surgical procedures, including microvascular decompression (2 patients), microvascular decompression with glycerol rhizotomy (2 patients), deep brain stimulation (1 patient), trigeminal ganglion stimulation (1 patient), and prior GKS (1 patient). Fourteen patients had associated autonomic symptoms. The radiosurgical target was the trigeminal nerve (TN) root and the sphenopalatine ganglion (SPG) in 8 patients, only the TN in 8 patients, and only the SPG in 1 patient. The median maximum TN and SPG dose was 80 Gy. Favorable pain relief (Barrow Neurological Institute Grades I-IIIb) was achieved and maintained in 10 (59%) of 17 patients at a median follow-up of 34 months. Three patients required additional procedures (repeat GKS in 2 patients, hypothalamic deep brain stimulation in 1 patient). Eight (50%) of 16 patients who had their TN irradiated developed facial sensory dysfunction after GKS. Gamma Knife surgery for intractable, medically refractory CH provided lasting pain reduction in approximately 60% of patients, but was associated with a significantly greater chance of facial sensory disturbances than GKS used for trigeminal neuralgia.

Stereotactic radiosurgery is being increasingly advocated as the primary modality for treatment of vestibular schwannomas (VS). This modality has been shown to arrest tumor growth, with few associated short-term morbidities, and with possibly better hearing and facial nerve preservation rates than microsurgery. Radiation-induced oncogenesis has long been recognized, although stereotactic radiosurgery de novo induction of a secondary tumor has never been clearly described. The authors report on a patient with a VS who did not have neurofibromatosis Type 2 and who underwent gamma knife surgery (GKS). This patient required microsurgical removal of the VS within 8 months because of development of a tumor cyst with associated brainstem compression and progressive hydrocephalus. The operation resulted in clinical stabilization and freedom from tumor recurrence. Seven and a half years after undergoing GKS, the patient presented with symptoms of raised intracranial pressure. Magnetic resonance imaging demonstrated a new ring-enhancing lesion in the inferior temporal lobe adjacent to the area of radiosurgery, which on craniotomy was confirmed to be a glioblastoma multiforme (GBM). Despite additional conventional external-beam radiation to the temporal lobe, the GBM has progressed. Whereas this first reported case of a GBM within the scatter field of GKS does not conclusively prove a direct causal link, it does fulfill all of Cahan's criteria for radiation-induced neoplasia, and demands increased vigilance for the potential long-term complications of stereotactic radiosurgery, and reporting of any similar cases.

A functional disorder is a constellation of bothersome physical symptoms that compromise regular function but for which there is no identifiable organic or psychiatric pathology. Functional disorders can present with various symptoms. Common forms of functional disorders include functional neurologic symptom disorder (also referred to as "conversion disorder"), functional gastrointestinal disorders, chronic pain syndromes, and chronic fatigue. One-third to one-half of outpatient consultations in many practices are due to functional disorders. Functional disorders must be distinguished from structural and psychiatric disorders but should not be considered diagnoses of exclusion. Recovery is facilitated by good relationships between patients and practitioners, with good explanations of the pathophysiology of functional disorders and effective encouragement and education of patients.

Back to table of contents Previous article Next article Professional NewsFull AccessMINDS Opens Students To Mental Illness ConcernsEve BenderEve BenderPublished Online:15 Nov 2002https://doi.org/10.1176/pn.37.22.0016aA mental health awareness program in Michigan is liberating high school students from their preconceived notions about mental illness and empowering them with the knowledge that mental illnesses are treatable.The program, Mental Illness Needs Discussion Sessions (MINDS), has been gaining momentum since 1989, when it started with little more than $5,000 and the hope that the next generation of Americans would view mental illness with understanding and compassion rather than shame and stigma.Heather Irish leads a MINDS seminar at West Bloomfield High School in West Bloomfield, Mich.This hope belonged to family advocate Heather Irish, who is president and founder of MINDS. In 1989 she was a disenchanted law school student who realized that legal studies weren't the most direct route to her goal—the destigmatization of mental illness.She told Psychiatric News that she said to herself at the time, "If I want to be an advocate, I should be out there helping people with mental illness in some way."Irish sought to enlighten youth about mental illness by teaching them the facts in a place where mental health education has usually been absent—high school health class.She approached a community business leader in the Detroit area to get seed money to begin her program and to assemble a board of directors that included psychiatrists, school administrators, corporate leaders, and other mental health advocates.MINDS began in two ninth-grade health classes in Bloomfield Hills, Mich., and has since reached 15,000 students in the southeastern part of the state.During a 55-minute class period, Irish typically teaches students about the symptoms of depression, anxiety disorders, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), eating disorders, schizophrenia, and substance abuse.Students also learn about treatments available for people with these disorders and where to turn for help if they or a loved one show signs of any of the illnesses.In the classroom, Irish displays posters of famous people who had a mental illness, including Abraham Lincoln, Winston Churchill, Kurt Cobain, and Princess Diana. The students are surprised to learn that Mark Somers, whom many of them know as the host of the game show "Double Dare," has obsessive-compulsive disorder, Irish said."We want to show the students that mental illness is going on every day around them."Opening the FloodgatesThe MINDS seminar presents the first opportunity many students have had to discuss mental illness. "It's like the floodgates have opened," Irish said.Some begin speaking openly with stories of their own depression, for instance, and tell the students around them how they sought help and have since recovered. The story resonates with one or two other students in the class, and a conversation ensues.In addition, the students' misconceptions fall to the wayside when Irish takes her place at the front of the room. "Scary, stupid, crazy, retarded—these are the words that my students used to think of when they heard the term mental illness," Irish said.Many of the students didn't know that mental illnesses are brain disorders, according to Irish, and took a "bootstraps" view of a disorder such as depression. It is a character flaw, many believed.For some students who have been diagnosed with ADHD, the seminar comes as a welcome relief. Many visit the school nurse to get medications during the school day, but lack knowledge about their illness."No one really sat down and talked to these students about the fact that ADHD is a brain-based disorder," Irish said.The status quo on drug abuse education for many high school students amounts to little more than the "Just Say No" refrain that became popular in the 1980s. But the slogan doesn't explain anything to young people about what addiction really is, according to Irish."MINDS teaches them about what happens with the neurotransmitters and nerve cells" in substance abuse disorders and other mental illnesses, she noted.Students leave the classroom with two brochures—one describing the symptoms of different mental disorders, and the other listing local, state, and national help lines, referral agencies, and other organizations.Targeting the StigmaErasing the stigma associated with mental illness is especially rewarding for Irish, since she encountered it on a regular basis growing up. Doctors diagnosed her grandmother with paranoid schizophrenia in 1968, and Irish witnessed her grandmother's marginalization from society. "People didn't understand that she was sick," Irish recalled. "They thought she was bad."Irish said she saw stigma "over and over again in a multitude of places, which was just heartbreaking." Even in hospitals, Irish's grandmother couldn't escape the stigma that surrounded her. When she sought nonpsychiatric medical attention at the local hospital, Irish said, the hospital staff would make a circular motion around their ears and say, "There is nothing wrong with her—she's just crazy."For years, Irish studied everything she could find about mental illness and acquired an extensive knowledge of the subject. By the time she launched the MINDS program, she was prepared to explain mental illness in a way that others could understand.Upon the release of the 1999 Surgeon General's report, "A Call to Action to Prevent Suicide," Irish realized that MINDS fulfilled a number of the recommendations set forth in the report, such as education, destigmatization, and community outreach.At the urging of Col. David Litts, a physician who serves as special advisor on suicide prevention to the assistant secretary for health and the U.S. Surgeon General, Irish decided to measure the impact of MINDS on high school students.She contracted with the Detroit-based program evaluation firm SPEC Associates last year to survey 894 ninth graders about their attitudes toward mental illness before and after participating in a MINDS seminar. Irish ensured that a cross-section of students attending rural, suburban, and urban schools completed the survey.The evaluation showed that after attending the seminar, the students were much less likely to avoid someone with a mental illness and to believe that people with mental illnesses are dangerous. In addition, the percentage of students who believed that mental illnesses are treatable increased significantly.Irish plans to publish the results of her preliminary study and is working with Kerry Knox, Ph.D., of the University of Rochester, to conduct an additional study. This one will measure students' attitudes toward mental illness at three, six, and nine months after the MINDS seminar.The MINDS program is free to schools and is funded by donations and grants from the Thomas Group, the Metro Health Foundation, the Isaiah Thomas Foundation, and Novartis Pharmaceuticals.Currently, Irish is leading seminars in 25 Michigan high schools with the help of Senta Furman, a medical student at Wayne State University in Detroit, who plans to specialize in psychiatry.Perhaps the best testimony of the program's success comes from the students themselves. "My brother has ADD, and I used to think he just wasn't trying," wrote one 14-year-old student. "Now I know that it is not his fault, and I will help him remember to take his medicine."Information about the MINDS program is posted at www.mindsprogram.org. ▪ ISSUES New Archived

ABSTRACTThe diagnosis of functional neurological disorders is a major challenge in neurologist practice. Some clinical strategies can facilitate the recognition of functional disorders, but several pitfalls make their diagnosis difficult. Here we highlight the following points of attention during evaluation of patients with functional disorder: not all bizarre behavior is functional; not every event triggered by an emotional factor is a functional disorder; not every topographic incongruity is a functional disorder; patients may present functional and organic symptoms at the same time; psychiatric comorbid condition is not always evident in the history of a functional disorder; problematic communication at the time of diagnosis can compromise treatment and prognosis. In conclusion, we emphasize that special attention to these possible pitfalls facilitate the correct diagnosis and management of functional neurological disorders.