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Evaluation of the Effect Oftreatment on Movement Disorders In Journal ofNeurology, Neurosurgery, and Psychiatry 1993;56: 1113-1118 1113 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.10.1113 on 1 October 1993. Downloaded from Evaluation of the effect of treatment on movement disorders in astrocytomas of the basal ganglia and the thalamus Joachim K Krauss, Dieter F Braus, Mohsen Mohadjer, Fritz Nobbe, Fritz Mundinger Abstract Methods Twenty patients with movement disor- A total of 225 patients had astrocytomas ders associated with astrocytomas (grade grades I-IV of the basal ganglia or the thala- I-IV according to the WHO tumour clas- mus confirmed histologically by stereotactic sification) of the basal ganglia and the biopsy between 1965-86 in the department of thalamus were evaluated for the effects stereotaxy. Twenty were identified as having of treatment. Five patients had more an MD at the time of biopsy.5 The patients than one movement disorder when the were followed up and examined at various histological diagnosis was verified by times with recent follow ups in 1989, 90 or stereotactic biopsy. Twelve had tremors, 91. No follow up data concerning the tremor eight hemidystonia, three hemichorea, in patient 16 could be obtained. Some and one hemichorea/ballismus, and patients had serial film recordings over the myoclonus respectively. Ten patients years. Most of the long term surviving died during the follow up period, and for patients returned at regular intervals for con- the surviving patients foilow up periods trol CT scans. In addition, the relatives, ranged from 6-21 years. The movement attending physicians and neurologists were disorders changed over long periods of interviewed to compile the data. time related to therapeutic interventions. Stereotactic biopsy was performed under CSF shunt operations and percutaneous local anaesthesia, except in the younger radiotherapy had no definite effect on the children. Tumour site, volume and the irradi- movement disorders. There was a mod- ation dosimetry were determined from CT erate response to medical treatment in a data available since 1975. The Riechert- few patients. Stereotactic aspiration of Mundinger stereotactic device in the com- tumour cysts had a marked influence on puter-compatible version was used for the movement disorder in two patients, stereotactic biopsy, interstitial implantation of and functional stereotactic surgery abol- radioactive isotopes, cyst aspiration and func- ished tumour induced tremor in one. tional stereotactic surgery. The principles and Interstitial radiotherapy was performed methods are described in detail elsewhere.21-26 in fifteen patients for treatment of the The decision whether or not to perform inter- underlying neoplasm and resulted in dif- stitial radiotherapy was made according to the ferent and variable alterations of the clinical state of the patient, the tumour size http://jnnp.bmj.com/ movement disorders. These differences and the results of the intraoperative smear may be explained by complex interac- preparation. The presence of an MD was not tions involving structures affected pri- relevant. Interstitial radiotherapy was per- marily by the tumour, as weli as by formed in the same session via the puncture Department of secondary functional lesions of adjacent track for biopsy. To produce radionecroses of Neurosurgery, Albert- structures. the tumours the radioactive isotopes 125I Ludwigs-Universitat, Freiburg (half-life 60-2 days, photon energy spectrum J K Krauss ( Neurol Neurosurg Psychiatry 1993;56: 1113-1118) ranging between 27 and 35 keV) and 192Ir on September 29, 2021 by guest. Protected copyright. F Nobbe (half-life 74-2 days, energy spectrum ranging Department of from 300 to 610 keV) were used. The periph- Stereotaxy and Neuronuclear eral tumour accumulation dose (that is, at the Medicine surface of the tumour) ranged from 90 to 120 M Mohadjer Movement disorders (MDs) in tumours of Gy. It was exceptionally high in patient 10 Zentralinstitut fulr the basal ganglia and the thalamus have been (150 Gy), and low (50 Gy) in patient 3. It Seelische Gesundheit described within a range from 1-9% in recent was generally lower in more recent years. Mannheim D F Braus studies and from 4-33% in earlier ones.1-5 Shunts placed were either ventriculoatrial St. Josefs- The further course following treatment has or ventriculoperitoneal, and if necessary, Krankenhaus, been documented only rarely in patients with bilateral. Freiburg, Germany MDs due to basal ganglia and thalamic F Mundinger astrocytomas.620 This study deals with the Correspondence to: Dr Krauss, clinical course and the change and outcome Results Neurochirurgische of MDs in relation to treatment of either the The study consisted of eleven female and Universitatsklinik, Hugstetter Str 55, D-7800 tumour responsible for them or of the symp- nine male patients. The age at biopsy ranged Freiburg, Germany. tomatic MDs themselves in twenty patients from three to 70 years (table). Demographic, Received 2 September 1992 with basal ganglia and thalamic astrocytomas clinical and neuroradiological data have been and in final revised form 11 December 1992. grade I-IV presenting with MDs at the time reported recently.5 Ten patients were alive on Accepted 18 December 1992 of biopsy. recent follow up. Follow up periods ranged 1114 Krauss, Braus, Mohadjer, Nobbe, Mundinger J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.10.1113 on 1 October 1993. Downloaded from Demographic data, treatment andfollow-up of20 patients with movement disorders in basal ganglia and thalamic astrocytomas. Sexl Grade Age at Biopsy Movement ofastro- Follow KPS: Interstitial Shunt Movement disorder Case Age at Onset disorder cytoma Status up alb curietherapy operation Other treatment Course-Outcome 1 M/25/13 Tremor, 3-4 Hz I A 12y 60/80 - + (-12y) Perc. radiotherapy (- 12y) Dis of tremor after 1 arm: Stereotactic aspiration of cyst aspiration rest, post, int r thalamic tumour cyst (0) 2 M/3/3 Tremor, 3-5 Hz D 6m 80 I-125 + (4m) Perc, radiotherapy (- 4m) Inc of athetosis (4w), 1 arm > leg: post, int temporary imp with Athetosis, 1 hand: rest corticosteroids (2m) Head tilt 3 M/50/44 Tremor, 3-4 Hz A 8y 60/70 I-125 - Medication with biperiden Tremor unc after curie- 1 arm > leg: therapy, slight imp after rest, post, int biperiden 4 Ff49/43 Chorea II D 2-5y 60 a: Ir-192 - Perc, radiotherapy (-4y) a: Inc ofhemichorea (6m) face bilat, 1 > r II-III b: Ir-192 Medication with haloperidol b: 2 w after 2nd stereotactic 1 arm > leg (8m) (8m) (8m) operation imp of chorea with haloperidol, dis 2 w later 5 F/70/70 Parkinsonism IV D Im 40 + (-1w) - Parkinsonian symptoms unc 6 M/37/31 Tremor, 4-5 Hz II D 4y 60 - - - Fluctuation of intensity of I arm: tremor, presumably related rest, post, int to medication with cortico- steroids 7 F/11/10 Dystonia I A 9y 60/70 I-125 + (-3m) Stereotactic aspiration Inc ofhp and dystonia (0,5-ly) 1 arm: of tumour cyst (2y) imp of hp + dystonia (3y), rest, on action 2nd stereotactic aspiration inc of hp + dystonia (6-7y) of tumour cyst (8y) imp of hp + dystonia (8y) 8 M/12/9 Dystonia I A 13y 70/80 a: Ir-192 + (1w) - a: imp of tremor + hp (6m), 1 hand: on action b: Ir-192 + (2y) b: unc in further course Tremor, 4-5 Hz (9m) 1 arm: post, int 9 M/42/41 Tremor, 4 Hz II D 2-5y 70 - - Medication with biperiden, No response of tremor to r arm: later with metixen biperiden, imp after metixen rest, post, int (ly), later red of tremor with parallel app ofhp 10 M/25/25 Dystonia I A 20y 60/60 a: Ir-192 a: inc of hp and dystonia r arm: b: Ir-192 over years, no change in b: rest, on action (18y) further course 11 M/15/13 Tremor, 4-5 Hz I A I Oy 70/60 I-125 - Various medication Inc of tremor after r arm: thioridazine, no response to rest, post, int trihexyphenidyl, imp after biperiden, inc ofhp, dis of tremor (6 m), spastic hp (7y) 12 F/11/9 Chorea II A 21y 70/80 Ir-192 + (-2y) - Dis of chorea without inc r arm > leg of hp (05y), no MD in marked on action further course 13 F/10/9 Dystonia I D 5y 60 a: Ir-192 + (4y) a: Dis of chorea + ballismus, 1 arm > leg III(4y) b: Ir-192(ly) inc of dystonia + hp (05y) Chorea-Ballismus 1 arm > leg 14 F/12/3 Tremor, 3-5 Hz II A 6y 60/70 I-125 + (-3m) - post shunt imp ofhp, no effect I arm: on tremor (- 2m), inc oftremor rest, post, int (8m), imp of tremor + app of mild dystonia arm (2y) 15 M/16/15 Dystonia + Chorea D 3d 40 - + (2d) - Postop inc of obtundation, 1 arm> leg> face: coma (possibly related to rest, on action inc of edema), death 16 Ff62/59 Tremor, high- D 6m 60 I-125 unknown unknown frequency bilateral, 1 > r fingers + eyelids 17 F/13/11 Dystonia, r arm: I D 5y 70 a: Ir-192 + (4d) Imp of dystonia, dis of rest, on action b: Gamma myoclonus (2y) Myoclonus, r shoulder Med (4y) http://jnnp.bmj.com/ 18 Ff3/2 Tremor, 3-4 Hz I D 11i5y 70 a: Ir-192 + (2w) a: Dis of tremor (6m) r arm: int b: Ir-192 (3y) c: Ir-192 (lOy) 19 F/5/5 Dystonia, r arm: I A 16y 60/70 a: Ir-192 + (ly) a: imp of dystonia + hp (3m), rest, on action b: Ir-192 inc of dystonia + app of r (ly) chorea (ly), b: inc ofhp, imp of dystonia, disofchorea (3y) 20 F/12/10 Tremor, 3-4 Hz I A 20y 60/70 a: Ir-192 - Functional stereo- a: Imp of hp + tremor (ly), on September 29, 2021 by guest.
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