CYBERKNIFE RADIOSURGERY FOR BENIGN MENINGIOMAS

Neurosurgery ◽  
2009 ◽  
Vol 64 (suppl_2) ◽  
pp. A7-A13 ◽  
Author(s):  
Federico Colombo ◽  
Leopoldo Casentini ◽  
Carlo Cavedon ◽  
Paolo Scalchi ◽  
Stefania Cora ◽  
...  
Keyword(s):  
Selection Criteria ◽  
Tumor Volume ◽  
Clinical Symptoms ◽  
Petrous Bone ◽  
Surgical Removal ◽  
Single Session ◽  
Short Term ◽  
Cyberknife Radiosurgery ◽  
Optic Pathways

Abstract OBJECTIVE To present initial, short-term results obtained with an image-guided radiosurgery apparatus (CyberKnife; Accuray, Inc., Sunnyvale, CA) in a series of 199 benign intracranial meningiomas. METHODS Selection criteria included lesions unsuitable for surgery and/or remnants after partial surgical removal. All patients were either symptomatic and/or harboring growing tumors. Ninety-nine tumors involved the cavernous sinus; 28 were in the posterior fossa, petrous bone, or clivus; and 29 were in contact with anterior optic pathways. Twenty-two tumors involved the convexity, and 21 involved the falx or tentorium. One hundred fourteen patients had undergone some kind of surgical removal before radiosurgery. Tumor volumes varied from 0.1 to 64 mL (mean, 7.5 mL) and radiation doses ranged from 12 to 25 Gy (mean, 18.5 Gy). Treatment isodoses varied from 70 to 90%. In 150 patients with lesions larger than 8 mL and/or with tumors situated close to critical structures, the dose was delivered in 2 to 5 daily fractions. RESULTS The follow-up periods ranged from 1 to 59 months (mean, 30 months; median, 30 months). The tumor volume decreased in 36 patients, was unchanged in 148 patients, and increased in 7 patients. Three patients underwent repeated radiosurgery, and 4 underwent operations. One hundred fifty-four patients were clinically stable. In 30 patients, a significant improvement of clinical symptoms was obtained. In 7 patients, neurological deterioration was observed (new cranial deficits in 2, worsened diplopia in 2, visual field reduction in 2, and worsened headache in 2). CONCLUSION The introduction of the CyberKnife extended the indication to 63 patients (>30%) who could not have been treated by single-session radiosurgical techniques. The procedure proved to be safe. Clinical improvement seems to be more frequently observed with the CyberKnife than in our previous linear accelerator experience.

MULTISESSION CYBERKNIFE STEREOTACTIC RADIOSURGERY OF LARGE, BENIGN CRANIAL BASE TUMORS

Neurosurgery ◽  
2009 ◽  
Vol 65 (5) ◽  
pp. 898-907 ◽  
Author(s):  
Francesco Tuniz ◽  
Scott G. Soltys ◽  
Clara Y. Choi ◽  
Steven D. Chang ◽  
Iris C. Gibbs ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Stereotactic Radiosurgery ◽  
Radiation Injury ◽  
Tumor Volume ◽  
Neurological Status ◽  
Cranial Base ◽  
Single Session ◽  
Effective Option ◽  
Cyberknife Radiosurgery

Abstract OBJECTIVE Although radiosurgery plays an important role in managing benign cranial base lesions, the potential for increased toxicity with single-session treatment of large tumors is a concern. In this retrospective study, we report the intermediate-term rate of local control, morbidity, and clinical outcomes of patients with large cranial base tumors treated with multisession stereotactic radiosurgery with the CyberKnife (Accuray, Inc., Sunnyvale, CA). METHODS Between 1999 and 2008, 34 consecutive patients with large (>15 cm3), benign cranial base tumors (21 meningiomas, 9 schwannomas, 4 glomus jugulare tumors) underwent primary or postoperative radiosurgical treatment using a multisession approach at Stanford University and were considered in this retrospective study. Forty-four percent of these patients had undergone previous subtotal surgical resection or radiotherapy. CyberKnife radiosurgery was delivered in 2 to 5 sessions (median, 3 sessions) to a median tumor volume of 19.3 cm3 (range, 15.8–69.3 cm3). The median marginal dose was 24 Gy (range, 18–25 Gy) prescribed to a median 78% isodose line. RESULTS After a median clinical follow-up of 31 months (range, 12–77 months), 21% of patients experienced clinical improvement of neurological symptoms, whereas neurological status remained unchanged among the rest. Four patients experienced prolonged use of glucocorticoids owing to transient neurological worsening and radiographic signs of radiation injury. No permanent neurotoxicity was seen. To date, all tumors remain locally controlled. CONCLUSION Over our modest length of follow-up, multisession radiosurgery appears to be a safe and effective option for selected large, benign brain and cranial base lesions.

scholarly journals Endoscopically controlled surgery with open hemilaminectomy for the treatment of intradural extramedullary tumors: an operative technique and short-term outcomes of 20 consecutive cases

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Xiaorong Yan ◽  
Huiqing Wang ◽  
Cai Li ◽  
Yuanxiang Lin ◽  
Lin Lin ◽  
...  
Keyword(s):  
Surgical Technique ◽  
Spinal Deformity ◽  
Tumor Recurrence ◽  
Clinical Symptoms ◽  
Short Term ◽  
Before And After ◽  
Intradural Extramedullary ◽  
Controlled Surgery

Abstract Background To present a surgical technique for the treatment of intradural extramedullary (IDEM) tumors by using endoscopically controlled surgery with open hemilaminectomy technique. Methods In this study, 20 patients with 22 IDEM tumors were enrolled. An endoscopically controlled surgery with open hemilaminectomy was employed to remove the tumors. Data related to clinical symptoms and medical images before and after surgery were collected for perioperative evaluation and follow-up analysis. Results All the tumors in 20 patients were well removed. The clinical symptoms were significantly reduced in all the patients as well. The short-term follow-up data showed that there was no tumor recurrence or spinal deformity. Conclusion The endoscopically controlled surgery with open hemilaminectomy technique provided favorable exposure and satisfactory resection to the IDEM tumors. It may be an effective surgical method for treating IDEM tumors. Larger samples and longer follow-up data are needed to verify its long-term effectiveness.

scholarly journals Endoscopically-controlled surgery with open hemi-laminectomy for the treatment of intradural extramedullary tumors: An operative technique and short-term outcomes of 20 consecutive cases

2020 ◽  
Author(s):  
Xiaorong Yan ◽  
Huiqing Wang ◽  
Cai Li ◽  
Yuanxiang Lin ◽  
Lin Lin ◽  
...  
Keyword(s):  
Surgical Technique ◽  
Spinal Deformity ◽  
Tumor Recurrence ◽  
Clinical Symptoms ◽  
Short Term ◽  
Before And After ◽  
Intradural Extramedullary ◽  
Controlled Surgery

Abstract Background To present a surgical technique for the treatment of intradural extramedullary (IDEM) tumors by using endoscopically-controlled surgery with open hemi-laminectomy technique. Methods In this study, 20 patients with 22 IDEM tumors were enrolled. An endoscopically-controlled surgery with open hemi-laminectomy was employed to remove the tumors. Data related to clinical symptoms and medical images before and after surgery were collected for perioperative evaluation and follow-up analysis. Results All the tumors in 20 patients were well removed. The clinical symptoms were significantly reduced in all the patients as well. The short term follow-up data showed that there was no tumor recurrence or spinal deformity. Conclusion The endoscopically-controlled surgery with open hemi-laminectomy technique provided favorable exposure and satisfactory resection to the IDEM tumors. It may be an effective surgical method for treating IDEM tumors. Larger samples and longer follow-up data are needed to verify its long-term effectiveness.

Long-term seizure outcome following surgery for dysembryoplastic neuroepithelial tumor

2006 ◽  
Vol 104 (1) ◽  
pp. 62-69 ◽  
Author(s):  
Chow Huat Chan ◽  
Richard G. Bittar ◽  
Gavin A. Davis ◽  
Renate M. Kalnins ◽  
Gavin C. A. Fabinyi
Keyword(s):  
Outcome Data ◽  
Temporal Lobectomy ◽  
Class I ◽  
Surgical Removal ◽  
Dysembryoplastic Neuroepithelial Tumor ◽  
Seizure Outcome ◽  
Short Term ◽  
Long Term Follow Up

Object Resection of dysembryoplastic neuroepithelial tumor (DNET) is thought to result in favorable seizure outcome, but long-term follow-up data are scarce. The authors present a review of 18 patients who underwent surgical removal of a DNET: 12 via temporal lobectomy and six via lesionectomy. Methods The mean long-term follow up was 10.8 years (median 10.4 years, range 7.8 to 14.8 years), and results obtained during this time period were compared with previously reported short-term (mean 2.7 years) seizure outcome data. In the current study, 66.7% patients had an Engel Class I outcome and 55.6% had an Engel Class IA outcome compared with 77.8% and 55.6%, respectively. Temporal lobectomy (Engel Class I, 83.3%; Engel Class IA, 66.7%) led to a better seizure outcome than lesionectomy (Engel Classes I and IA, 33.3%). Two patients (11.1%) required repeated operation and both had an incomplete lesionectomy initially. Conclusions Results indicated that complete resection of a DNET leads to a favorable seizure outcome, with epilepsy cure in those who had experienced early postoperative seizure relief. Long-term seizure outcome after surgery is predictable based on the result of short-term follow up.

scholarly journals Outcome of Stereotactic Radiotherapy for Patients with Uncontrolled Acromegaly

2009 ◽  
Vol 36 (4) ◽  
pp. 468-474 ◽  
Author(s):  
Syed Ali Imran ◽  
Ian G. Fleetwood ◽  
Colleen M. O'Connell ◽  
Thomas P. Ransom ◽  
Liam A. Mulroy ◽  
...  
Keyword(s):  
Tumor Volume ◽  
Pharmacologic Therapy ◽  
Pituitary Hormone ◽  
Short Term ◽  
Visual Field Examination ◽  
Term Outcome ◽  
Stereotactic Radiation ◽  
Short Term Outcome ◽  
The Mean

Objective:Linear accelerator based stereotactic radiation therapy (SRT) has been used for the treatment of pituitary tumours; however, little is known concerning the use of this modality for the treatment of patients with acromegaly. We have prospectively studied the short-term outcome of SRT in 12 acromegaly patients who failed to achieve biochemical remission despite surgery and/or pharmacologic therapy.Methods:We identified all patients who had biochemically uncontrolled acromegaly and were treated with SRT between April 2003 and December 2006. All patients were followed prospectively based on a pre-defined protocol that included Goldman visual field examination, MRI of the sella, and pituitary hormone testing at 3, 6, 12 months, and then yearly.Results:A total of 12 patients with acromegaly were treated with SRT. There were 9 females and the median age of the group was 50 years. The median follow-up was 28.5 months during which time the mean tumor volume decreased by 40%, the median GH fell from 4.1 μg/L to 1.3 μg/L (p=0.003) and the median IGF-1 dropped more than half from 545.5 μg/L to 260.5 μg/L (p=0.002). Four patients achieved normal, while an additional 2 achieved near-normal, IGF-1 levels. One patient was able to discontinue and two were able to reduce their acromegaly medications while maintaining a normal IGF-1. A new pituitary hormonal deficit was found at 24 months in one patient who developed hypoadrenalism requiring corticosteroid replacement.Conclusion:Based on our early experience, we believe that SRT should be considered in treating patients with uncontrolled acromegaly.

scholarly journals Short Term Effectiveness of Gamma Knife Radiosurgery in the Management of Brain Arteriovenous Malformation

2019 ◽  
Vol 7 (19) ◽  
pp. 3221-3224
Author(s):  
Bassam Mahmood Flamerz Arkawazi ◽  
Moneer K. Faraj ◽  
Zaid Al-Attar ◽  
Hayder Ali A. Hussien
Keyword(s):  
Arteriovenous Malformation ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Clinical Symptoms ◽  
Gamma Knife Radiosurgery ◽  
Signs And Symptoms ◽  
Brain Arteriovenous Malformation ◽  
Short Term ◽  
Brain Malformations

AIM: To evaluate the short-term effectiveness of Gamma knife radiosurgery as a modality of treatment of brain arteriovenous malformation. METHODS: Sixty-three patients with arteriovenous brain malformations underwent Gamma knife radiosurgery included in this prospective study between April 2017 and September 2018 with clinical and radiological with MRI follow up was done at three months and six months post-Gamma knife radiosurgery. By the end of the 12th-month post-Gamma knife radiosurgery, the patients were re-evaluated using digital subtraction angiography co-registered with M.R.I. During the 12 months follow up, CT scan or MRI was done at any time if any one of the patients᾽ condition deteriorated or developed signs and symptoms of complications. The mean volume of the arteriovenous malformations treated was 26.0 ± 5 cm3 (range 12.5–39.5 cm3) in The Neurosciences Hospital, Baghdad/Iraq. RESULTS: By the end of the 12th month of follow up, the overall obliteration of the arteriovenous malformations was seen in six patients only (9.5%), while shrinkage was noticed in 57 patients (90.5%). Improvement or clinical stability was found in 24 out of 39 patients (61.5%) presented with epilepsy as a chief complaint before Gamma knife radiosurgery and 21 out of 24 patients (87.0%) complained of a headache before Gamma knife radiosurgery. Post-Gamma knife radiosurgery bleeding was found in only three patients (5.0%). CONCLUSION: Even with the short term follow up, Gamma knife radiosurgery has an excellent clinical outcome in most patients with arteriovenous brain malformations. The clinical symptoms like headache and seizure were either diminished or controlled with the same medical treatment dose before Gamma knife radiosurgery. Long term clinical and radiological follow up is recommended.

Hydroxyurea and Neurologic Follow-Up Including Transcranial Doppler Flow Velocities in Children with Sickle Cell Anemia.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 3796-3796
Author(s):  
Gabriele Martin ◽  
Hulya Ozsahin ◽  
Roman Sztajzel ◽  
Yse Coulondre ◽  
JeanFrancois Babel
Keyword(s):  
Sickle Cell ◽  
Transcranial Doppler ◽  
Clinical Symptoms ◽  
Red Blood Cell Transfusion ◽  
Single Center ◽  
Short Term ◽  
Neurologic Symptom ◽  
Doppler Flow ◽  
Flow Velocities

Abstract Introduction: Progress in the management of sickle cell disease (SCD) has improved life expectancy. However, stroke remains one of the most serious complications of SCD. The purpose of this single-center longitudinal descriptive study is to demonstrate that hydroxyurea (HU), apart from lowering transcranial doppler flow (TCD) velocities, improves the clinical symptoms in SCD. Furthermore, starting the children at risk for stroke concomitantly on HU and short-term transfusion ameliorates rapidly the TCD velocities and clinical symptoms. Patients and Methods: Twenty-eight consecutive patients with a median age of 10.8 years (range 6.0–21.0 years) had biologic and clinical follow-up for a median of 9 years (range 2.5–18 y). A total of 27 patients were followed by TCD screening of the middle cerebral artery (MCA), anterior (ACA) and posterior cerebral arteries (PCA), carotid siphons (ICA) and basilar artery (BA). Twenty-one patients received hydroxyurea for a median of 5.9 years (range 4 months-9.5 years). HU was started for the following: 3 or more severe vaso-occlusive crises requiring hospitalization, abnormal MRI, TCD velocities of 200 cm/sec, and parental refusal to transfusion. Three patients had monthly red blood cell transfusion for 6 months concomitantly to HU. Myelotoxicity was controlled at two-week intervals for the first 3 months. Twenty-one patients under HU were retained for analysis. TCD velocities of a given patient were compared using the nonparametric Wilcoxon sum test. Results: All patients improved clinically under HU treatment with decrease in the number of crises. Concerning the neurologic findings of the patients, 13 with increased TCD velocities in the MCA (median190 cm/sec) showed decreases under HU (table). MCA flow velocities for 13 children with SCD, before and 3, 6, 12 and 24 months after starting therapy MCA flow velocity (cm/s) before 3 months 6 months 12 months 24 months NS indicates not significant; P values indicate comparison between each month under HU and before treatment. median (range) 190(156–246) 172(128–232) 172(149–244) 158(121–222) 164(150–228) P 0.03 NS 0.03 0.03 Two patients with headaches accompanying increases in TCD velocities had disappearance of the headaches 1–2 months after starting treatment. One of these had concomitant monthly transfusions for 6 months. After the end of transfusions, she remained asymptomatic under HU. One patient with stroke, severe headaches and pathologic MRI before HU had very rapid and stable recovery of symptoms under HU and short-term transfusions. She is at present 15 months after the last transfusion asymptomatic under HU therapy. None of the other 28 patients manifested any neurologic symptom during the follow-up. DISCUSSION Our single-center longitudinal study, although limited in number, shows the benefits of HU on the neurologic outcome in pediatric SCD patients, and brings the observation that concomitant use of short-term transfusion prophylaxis and HU might produce a faster response in clinical and biologic parameters which will be stable over the years. Long-term follow-up will show if short-term transfusion prophylaxis is periodically necessary in these patients under HU.

Radiation treatment of spinal tumors using Cyberknife radiosurgery

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 1545-1545
Author(s):  
J. J. Liao ◽  
N. M. Nasr ◽  
G. J. Gagnon ◽  
F. C. Henderson ◽  
B. T. Collins ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Spinal Cord ◽  
Stereotactic Radiosurgery ◽  
Tumor Volume ◽  
Spinal Tumors ◽  
High Dose ◽  
Cyberknife Radiosurgery ◽  
Fractionated Stereotactic Radiosurgery

1545 Background: Morbidity associated with spinal tumors can leave patients with functional limitations, pain, and poor quality of life. Since the integrity of the spinal column and the spinal cord must be preserved, treatments are limited especially in the setting of previous radiotherapy. We describe our experience using Cyberknife fractionated stereotactic radiosurgery in the initial treatment and retreatment of spinal tumors and its impact on patient quality of life. Methods: 152 patients with primary or metastatic spinal tumors were treated to 228 spinal sites at Georgetown University Hospital from 2002 to 2005. Neurologic examination, pain assessment by visual analog scale (0–100), and quality of life evaluations by SF-12 survey (mental and physical health scores) were performed initially and at 1, 3, 6, 9, 12, 18, and 24 months following treatment. The primary endpoints were pain and quality of life. 44 patients (109 sites) received Cyberknife radiosurgery as a component of their initial management. The median dose delivered was 2400 cGy (range 1400–8000) in 1–5 fractions (median 3). Median tumor volume was 56 mm3 (range 0.65–457.26). 108 patients (119 sites) with recurrent/persistent disease and a history of prior conventional radiation to the spine received Cyberknife radiosurgery as retreatment. Previous radiation doses ranged from 2000–5940 cGy. The median retreatment dose delivered was 2100 cGy (range 750–3500) in 1–5 fractions (median 3). Median tumor volume was 107.2 mm3 (range 0.94–838.9). Results: Optimized treatment plans were designed with the goal of limiting spinal cord doses. Median follow up is 13 months. No complications have been observed, including treatment related myelitis. Across all patients, the mean initial pain score was 73. Mean pain scores decreased significantly after the first month to 49 and remained significantly lower (40–44) for over one year. SF-12 PCS (initial mean 33) and MCS scores (initial mean 47) remained stable during the duration of the study. Conclusions: Fractionated stereotactic radiosurgery using the CyberKnife is a safe and effective treatment capable of delivering high-dose radiation to primary and recurrent spinal tumors. Follow-up data demonstrates durable pain relief and stable quality of life. No significant financial relationships to disclose.

A Double Blind Three Center Clinical Trial on the Short-Term Efficacy of 0-(β-Hydroxyethyl)-Rutosides in Patients with Post-Thrombotic Syndrome

1989 ◽  
Vol 62 (03) ◽  
pp. 826-829 ◽  
Author(s):  
A B de Jongste ◽  
J J C Jonker ◽  
M V Huisman ◽  
J W ten Cate ◽  
A J Azar
Keyword(s):  
Clinical Trial ◽  
Treatment Effect ◽  
Clinical Symptoms ◽  
Postthrombotic Syndrome ◽  
Efficacy And Safety ◽  
Short Term ◽  
Double Blind ◽  
Post Thrombotic Syndrome ◽  
The Mean

SummaryA multi-centre, double blind randomized clinical triatr was designed to assess the efficacy and safety of orally administered 0-(β-hydroxyethyl)-rutosides (HR) capsules in the treatment of L0L patients with post-thrombotic syndrome. Seventeen patients were excluded from the analysis for violation of the study protocol, 4l received HR capsules (I,200 mg/day) and 43 placebo.Mean follow-up scores at the 4th and 8th week show that the HR patients displayed an improved state of tiredness as compared to the placebo's. The mean circumference of the calf for the HR group decreased from 390 (± 33) mm at visit one to 382 (± 33) mm at visit three, with a mean circumference reduction of 8.7 (± 8) mm, compared to a steady placebo circumference of 387 (± 31) mm at all 3 visits with a mean circumference reduction of only 2 mm (± 9). The estimated treatment effect at week 8 was −6.7 ffiffi, 95% confidence interval (−10.3, −3.0).The mean circumference of the ankle, decreased from 243 (± 20) mm to 238 (± 20) mm at the 4th week, contrasted with a constant placebo circumference of.24l (± 22) mm at both visits. The estimated treatment effect at week 4 was-5.4 ffiffi, 95% confidence intenral (−10.2, −0.6). However, at week 8, the estimated treatment effect was only −3.4 mm; 95% corrfidence interval (−8.6, + 1.8).In conclusion, HR capsules may show an improvement in the clinical symptoms and may show a mean circumference reduction of the calf and ankle at the 8th week, in patients with postthrombotic syndrome.

Hypofractionated stereotactic radiosurgery: a new treatment strategy for giant cavernous sinus hemangiomas

2018 ◽  
Vol 128 (1) ◽  
pp. 60-67 ◽  
Author(s):  
Xin Wang ◽  
Huaguang Zhu ◽  
Jonathan Knisely ◽  
Guanghai Mei ◽  
Xiaoxia Liu ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Tumor Volume ◽  
Clinical Status ◽  
Neurological Deficits ◽  
Vascular Tumors ◽  
Imaging Features ◽  
Patient Reported ◽  
Cyberknife Radiosurgery

OBJECTIVECavernous sinus hemangiomas (CSHs) are rare benign vascular tumors that arise from the dural venous sinuses lateral to the sella. Stereotactic radiosurgery (SRS) has emerged as a principal alternative to microresection for small- and medium-sized CSHs. Resection is a reasonable option for large (3–4 cm in diameter) and giant (> 4 cm in diameter) CSHs. However, management of giant CSHs remains a challenge for neurosurgeons because of the high rates of morbidity and even death that stem from uncontrollable and massive hemorrhage during surgery. The authors report here the results of their study on the use of hypofractionated SRS (H-SRS) to treat giant CSH.METHODSBetween January 2008 and April 2014, 31 patients with a giant CSH (tumor volume > 40 cm3, > 4 cm in diameter) treated using CyberKnife radiosurgery were enrolled in a cohort study. Clinical status and targeted reduction of tumor volume were evaluated by means of serial MRI. The diagnosis for 27 patients was determined on the basis of typical imaging features. In 4 patients, the diagnosis of CSH was confirmed histopathologically. The median CSH volume was 64.4 cm3 (range 40.9–145.3 cm3). Three or 4 sessions of CyberKnife radiosurgery were used with a prescription dose based on the intent to cover the entire tumor with a higher dose while ensuring dose limitation to the visual pathways and brainstem. The median marginal dose to the tumor was 21 Gy (range 19.5–21 Gy) in 3 fractions for 11 patients and 22 Gy (range 18–22 Gy) in 4 fractions for 20 patients.RESULTSThe median duration of follow-up was 30 months (range 6–78 months) for all patients. Follow-up MRI scans revealed a median tumor volume reduction of 88.1% (62.3%–99.4%) at last examination compared with the pretreatment volume. Ten patients developed new or aggravated temporary headache and 5 experienced vomiting during the treatment; these acute symptoms were relieved completely after steroid administration. Among the 30 patients with symptoms observed before treatment, 19 achieved complete symptomatic remission, and 11 had partial remission. One patient reported seizures, which were controlled after antiepileptic drug administration. No radiation-induced neurological deficits or delayed complications were reported during the follow-up period.CONCLUSIONSHypofractionated SRS was an effective and safe modality for treating giant CSH. Considering the risks involved with microsurgery, it is possible that H-SRS might be able to serve as a definitive primary treatment option for giant CSH.

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