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Subject: Cases of glioblastoma multiforme metastasizing to spinal cord Karaca M, Andrieu MN, Hicsonmez A, Guney Y, Kurtman C Neurol India
Date: Thu, 1 Jul 2010 20:22:53 +0200
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------=_NextPart_000_0000_01CB195B.2F744B20
Content-Type: text/css;
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Content-Transfer-Encoding: quoted-printable
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A:visited {
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------=_NextPart_000_0000_01CB195B.2F744B20
Content-Type: text/css;
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------=_NextPart_000_0000_01CB195B.2F744B20
Content-Type: text/css;
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Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.neurologyindia.com/templates/current_l.css

A {
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A:visited {
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}
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FONT-SIZE: 11px; BORDER-LEFT: #a6adc4 1px solid; COLOR: #464646; =
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}
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<META=20
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one of which also had leptomeningeal dissemination. Three patients with =
GBM were admitted to our clinic for postoperative radiotherapy after =
surgery. Leptomeningeal metastasis and dissemination were diagnosed with =
magnetic resonance imaging. Radiotherapy provided only temporary relief =
from pain with small improvement in neurological deficit but no survival =
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          <TD width=3D"100%" colSpan=3D3><FONT class=3DtocAT><B>CASE=20
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          <TD class=3Dother width=3D"100%" colSpan=3D3><B>Year </B>: =
2006&nbsp;=20
            |&nbsp; <B>Volume</B> : 54&nbsp; |&nbsp; <B>Issue</B> : =
4&nbsp;=20
            |&nbsp; <B>Page</B> : 428-430</TD></TR></TBODY></TABLE>
      <P><FONT class=3DsTitle>Cases of glioblastoma multiforme =
metastasizing to=20
      spinal cord</FONT><BR><BR><FONT class=3DarticleAuthor>Metehan =
Karaca, Meltem=20
      Nalca Andrieu, Ayse Hicsonmez, Yildiz Guney, Cengiz=20
      Kurtman</FONT><BR><FONT class=3DAuthorAff>&nbsp;Department of =
Radiation=20
      Oncology, Ankara University Faculty of Medicine, Cebeci Hospital, =
Dikimevi=20
      Ankara, Turkey<BR></FONT><BR></P>
      <P><FONT class=3DCorrsAdd><B>Correspondence Address</B>:<BR>Yildiz =

      Guney<BR>Department of Radiation Oncology, Cebeci Hospital, =
Dikimevi=20
      Ankara <BR>Turkey<BR><A=20
      =
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      <P><B>Source of Support:</B> None, <B>Conflict of Interest:</B>=20
      None</P><B>DOI:</B>&nbsp;10.4103/0028-3886.28122<BR><BR><A=20
      =
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          <TD class=3DpageSub width=3D"85%" height=3D15>&nbsp;=BB<A=20
            name=3DAbstract></A>&nbsp;Abstract</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD width=3D"15%" height=3D15></TD></TR></TBODY></TABLE>
      <P>Cases of glioblastoma multiforme (GBM) metastasizing to the =
leptomeninx=20
      or the intramedullary spine are quite rare and prognoses are =
relatively=20
      poor. We present three cases of GBM with spinal metastasis, one of =
which=20
      also had leptomeningeal dissemination. Three patients with GBM =
were=20
      admitted to our clinic for postoperative radiotherapy after =
surgery.=20
      Leptomeningeal metastasis and dissemination were diagnosed with =
magnetic=20
      resonance imaging. Radiotherapy provided only temporary relief =
from pain=20
      with small improvement in neurological deficit but no survival=20
      advantage.</P><BR>
      <P class=3Dkyds><B>Keywords:</B>&nbsp;Glioblastoma multiforme,=20
      intramedullary metastasis, leptomeningeal dissemination,=20
      radiotherapy</P><BR>
      <TABLE class=3Dsitethis width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3Dother><B>How to cite this article:</B><BR>Karaca =
M,=20
            Andrieu MN, Hicsonmez A, Guney Y, Kurtman C. Cases of =
glioblastoma=20
            multiforme metastasizing to spinal cord. Neurol India=20
          2006;54:428-30</TD></TR></TBODY></TABLE><BR>
      <TABLE class=3Dsitethis width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3Dother><B>How to cite this URL:</B><BR>Karaca M, =
Andrieu=20
            MN, Hicsonmez A, Guney Y, Kurtman C. Cases of glioblastoma=20
            multiforme metastasizing to spinal cord. Neurol India =
[serial=20
            online] 2006 [cited&nbsp;2010 Jul 1];54:428-30. Available=20
            from:&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/text.asp?2006/54/4/428/28122">http:=
//www.neurologyindia.com/text.asp?2006/54/4/428/28122</A></TD></TR></TBOD=
Y></TABLE><BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A=20
          name=3DIntroduction></A>&nbsp;=BB&nbsp;Introduction</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#top"><=
IMG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            =
border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Glioblastoma multiforme =

      (GBM) is the most common primary malignancy of the central nervous =
system=20
      (CNS). Cerebrospinal fluid (CSF) seeding is observed in =
approximately=20
      15-25% of cases of supratentorial GBM,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref1" =

      name=3Dft1>[1]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref2" =

      name=3Dft2>[2]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref3" =

      name=3Dft3>[3]</A> while a higher incidence is seen in patients =
with=20
      infratentorial GBM.<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref3" =

      name=3Dft3>[3]</A> However, the exact incidence of CSF seeding is =
still=20
      uncertain because autopsy is not performed routinely. In addition, =
CSF=20
      cytology is not useful due to the high number of false negative =
results.<A=20
      class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref4" =

      name=3Dft4>[4]</A><BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A name=3D"Case =
Reports"></A>&nbsp;=BB&nbsp;Case=20
            Reports</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#top"><=
IMG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR><BR><I>Case =
1<BR><BR></I>In=20
      February 2004, a 67-year-old man presented with a history of =
headache and=20
      disarthria of two months duration. Brain MRI demonstrated a=20
      contrast-enhancing lesion with edema measuring 7.5 x 5.5 x 5 cm in =
the=20
      left temporal lobe. Gross total resection was performed. =
Histopathological=20
      findings showed GBM (WHO Grade 4). After surgery, cranial =
radiotherapy=20
      (RT) was delivered with a total dose of 60Gy in 2-Gy fractions. =
The=20
      patient complained of left leg weakness and back pain in the =
second week=20
      of RT. After a complete neurological examination and radiological=20
      evaluation, tumor recurrence in the operation field and a new =
lesion in=20
      the prepontine interpedincular system were found <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2006_54_4_428_28122_1.jpg=
')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#">[Fig=
ure=20
      - 1]</A>. Also, thoraco-lumbar spinal MRI revealed an expansive=20
      intramedullar lesion at the T11-L1 junction measuring 3.5 x 2 x 1 =
cm in=20
      diameter <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2006_54_4_428_28122_2.jpg=
')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#">[Fig=
ure=20
      - 2]</A>. After palliative external radiotherapy to T10-L2 with a =
total=20
      dose of 21 Gy in 3-Gy fractions, neurological findings were =
diminished.=20
      Additionally, two cycles of CCNU adjuvant chemotherapy were given. =
One=20
      month after the end of RT, control MRI demonstrated no progression =
of the=20
      lesion. <BR><BR>Although good local control and palliation of =
symptoms=20
      were achieved with RT, the patient survived only about four months =
after=20
      diagnosis of metastases.<BR><BR><I>Case 2<BR><BR></I>In November =
2003, a=20
      20-year-old woman was admitted to the emergency unit with a =
history of=20
      headache and diplopia. After radiological evaluation, a lesion =
measuring=20
      3.5 x 3.5 x 2.2 cm from the left lateral ventricule to the frontal =
lobe=20
      was found. Gross total resection was performed. Histopathological =
findings=20
      showed GBM. Postoperative cranial RT was delivered with a total =
dose of=20
      60Gy in 2-Gy fractions. There was no complain for one year after =
RT.=20
      However, at the last visit, the patient complained of left foot =
pain.=20
      After a through neurological examination and radiological =
evaluation,=20
      tumor recurrence in the operation field was found in December =
2004. Also,=20
      lumbar MRI showed multiple lesions at the lowest thoracic and =
upper lumbar=20
      vertebral region and between fibers of cauda equinea, but =
concurrent CSF=20
      study was negative <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2006_54_4_428_28122_3.jpg=
')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#">[Fig=
ure=20
      - 3]</A>. Palliative RT to T12-L2 with a total dose of 39Gy in =
3-Gy=20
      fractions was delivered in January 2005. Good palliation was =
achieved with=20
      RT, but the patient died in June 2005.<BR><BR><I>Case =
3<BR><BR></I>In=20
      January 2003, a 28-year-old woman was admitted to the emergency =
unit with=20
      a history of headache and sudden weakness of the right side. After =

      radiological evaluation, brain MRI demonstrated a =
contrast-enhancing=20
      lesion measuring 7 x 3.5 x 4.5 cm in the left frontal and parietal =
lobe.=20
      Gross total resection was performed. Histopathological studies =
showed GBM=20
      (WHO Grade 4). Postoperative cranial RT was delivered with a total =
dose of=20
      60Gy in 2-Gy fractions. She received temazolamid as concurrent=20
      chemotherapy. After surgery and RT, there was no symptom or =
complain for=20
      17 months. Although a small residual lesion was found in all =
control MRIs,=20
      it was stable. At the last control in June 2005, the patient =
complained of=20
      lower limb weakness and intradural-extramedullar lesions at T6 =
(5-6 mm),=20
      T8 (10-12 mm), T9 (7 mm) and T12-L1 (3 x 1.5 x 1 cm) were found by =
MRI. In=20
      consideration of the high performance status of the patient and no =
change=20
      in the diameter of the primary lesion during the 17-months period =
of=20
      postoperative cranial RT, spinal RT was to be delivered to the =
limit dose=20
      of the cord. Palliation of symptoms was achieved with RT, but the =
patient=20
      died in September 2005.<BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A =
name=3DDiscussion></A>&nbsp;=BB&nbsp;Discussion</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#top"><=
IMG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>The most =
common clinical=20
      features of leptomeningeal metastases are radicular pain in the =
upper and=20
      lower limbs, lower back, interscapular area and neck. This is =
frequently=20
      followed by paraparesis or, infrequently, quadraparesis.<A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref5" =

      name=3Dft5>[5]</A> Accordingly, our patients presented with pain =
during=20
      leptomeningeal dissemination. <BR><BR>The most common sites for =
spinal GBM=20
      metastases are the lower thoracic, upper lumbar and lumbosacral =
regions.<A=20
      class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref6" =

      name=3Dft6>[6]</A> Reports of intramedullary metastases are quite =
rare in=20
      the literature.<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref5" =

      name=3Dft5>[5]</A> Since patients with GBM usually do not live =
long enough=20
      for small tumor implants to grow to the symptomatic size, it is =
difficult=20
      to clinically evaluate symptomatic metastasis. The rate of spinal=20
      leptomeningeal seeding after diagnosis of GBM has been variably =
reported.=20
      A review of the literature by Erlich and Davis in 1978 revealed =
only 14=20
      well-documented cases of spinal subarachnoid seeding from primary=20
      intracranial GBM since 1931.<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref7" =

      name=3Dft7>[7]</A> In a study of 600 patients with GBM, only 2% =
had=20
      symptomatic CSF seeding.<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref5" =

      name=3Dft5>[5]</A> This result suggests that the symptomatic =
involvement=20
      occurs relatively late in the course of GBM. In our cases, =
metastases were=20
      diagnosed in the 2nd, 12th and 17th months after RT, respectively. =
Stark=20
      <I>et al</I><A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref8" =

      name=3Dft8>[8]</A> reported three patients (1.1%) of 267 adult =
cases of GBM=20
      who developed spinal drop metastases 5, 8 or 11 months after =
craniotomy.=20
      The incidence of symptomatic metastasis is certainly lower than =
the=20
      incidence observed postmortem. Most of the large series describe =
patients=20
      with meningeal and spinal spread discovered at autopsy. =
Metastases, which=20
      were associated with pain and/or neurological deficit, were =
usually=20
      verified by radiological studies. We suspected CSF spreading =
because of=20
      back pain and neurological deficit during RT. Magnetic resonance =
imaging=20
      findings demonstrated the dissemination of disease in Case =
1.<BR><BR>Until=20
      recently, myelography with CT follow-up was the most accurate =
diagnostic=20
      test for leptomeningeal metastasis,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref6" =

      name=3Dft6>[6]</A> but CT myelography has now been replaced with =
MRI. Spinal=20
      MRI with gadolinium enhancement is the current investigation of =
choice for=20
      leptomeningeal metastasis.<BR><BR>Although there is still no =
satisfactory=20
      treatment for leptomeningeal metastasis, RT is the most commonly =
used=20
      treatment modality, with a total dose of 25 to 40Gy. Because of =
the=20
      diffuse nature of the disease, leptomeningeal metastasis is often=20
      unsuitable for surgical decompression. The advantage of =
intravenous or=20
      intrathecal chemotherapy has not been proven for intramedullary=20
      metastasis. Because curative treatment is not applicable, the =
treatment=20
      modality for these patients is solely palliative. Our patients =
were=20
      treated with a total dose of 21Gy, 39Gy or 46Gy and good =
palliation of=20
      symptoms was achieved.<BR><BR>Leptomeningeal metastasis with CSF =
tumor=20
      dissemination almost always results in a fatal outcome. The median =
time=20
      from diagnosis of the primary intracranial GBM to diagnosis of CSF =
tumor=20
      dissemination ranges from 8 to 14 months, median survival ranges =
from 11=20
      to 17 months and the average time interval between diagnosis of=20
      leptomeningeal metastasis and death is two to three months.<A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref9" =

      name=3Dft9>[9]</A> As mentioned by Fakhrai <I>et al</I> ,<A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ref10"=
=20
      name=3Dft10>[10]</A> survival periods are shorter in patients who =
have GBM=20
      with spinal seeding and these patients should be given adequate =
palliative=20
      care. One of our patients survived about four months after the =
diagnosis=20
      of metastasis, but the time between the initial diagnosis of GBM =
and=20
      leptomeningeal dissemination was only about two months. To our =
knowledge,=20
      Case 1 is only the second case reported in the literature with=20
      simultaneous leptomeningeal and intramedullary metastases. =
<BR><BR>In=20
      conclusion, cases of GBM with recent extremity and back pain =
and/or=20
      associated spinal root nerve signs should cause clinicians to =
consider=20
      leptomeningeal and/or spinal dissemination of GBM.<BR><BR>&nbsp;
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub height=3D15><A=20
            name=3DReference></A>&nbsp;=BB&nbsp;References</TD>
          <TD class=3Dinthis align=3Dright height=3D15>&nbsp;</TD>
          <TD align=3Dright width=3D"15%" height=3D15><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#top"><=
IMG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR>
      <TABLE class=3Dbody cellSpacing=3D0 cellPadding=3D0 width=3D"100%" =
border=3D0>
        <TBODY>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft1"=20
            name=3Dref1>1.</A></TD>
          <TD>Cairns H, Russell DS. Intracranial and spinal metastases =
in=20
            gliomas of the brain. Brain 1931;54:377-420.<B> =
</B>&nbsp;&nbsp;<A=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft1"><=
IMG=20
            alt=3D"Back to cited text no. 1"=20
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            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft2"=20
            name=3Dref2>2.</A></TD>
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dissemination of=20
            malignant gliomas: Incidence, diagnosis and outcome. Acta =
Neurochir=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft2"><=
IMG=20
            alt=3D"Back to cited text no. 2"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;[<A=20
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href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&amp;=
db=3DPubMed&amp;list_uids=3D8042560&amp;dopt=3DAbstract"=20
            target=3D_blank><FONT =
class=3Dref>PUBMED</FONT></A>]&nbsp;&nbsp;</TD></TR>
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          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft3"=20
            name=3Dref3>3.</A></TD>
          <TD>Salazar OM, Rubin P. The spread of glioblastoma multiforme =
as a=20
            determining factor in the radiation treadted volume. Int J =
Radiat=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft3"><=
IMG=20
            alt=3D"Back to cited text no. 3"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;[<A=20
            =
href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&amp;=
db=3DPubMed&amp;list_uids=3D185169&amp;dopt=3DAbstract"=20
            target=3D_blank><FONT =
class=3Dref>PUBMED</FONT></A>]&nbsp;&nbsp;</TD></TR>
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          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft4"=20
            name=3Dref4>4.</A></TD>
          <TD>Balhuizen JC, Bots GT, Schaberg A, Bosman FT. Value of=20
            cerebrospinal fluid cytology for the diagnosis of =
malingnancies in=20
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            &nbsp;&nbsp;<A=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft4"><=
IMG=20
            alt=3D"Back to cited text no. 4"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;[<A=20
            =
href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&amp;=
db=3DPubMed&amp;list_uids=3D641554&amp;dopt=3DAbstract"=20
            target=3D_blank><FONT =
class=3Dref>PUBMED</FONT></A>]&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft5"=20
            name=3Dref5>5.</A></TD>
          <TD>Stanley P, Senac MO Jr, Segall HD. Intraspinal seeding =
from=20
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            1985;144:157-61.&nbsp;&nbsp;<A=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft5"><=
IMG=20
            alt=3D"Back to cited text no. 5"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;[<A=20
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href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&amp;=
db=3DPubMed&amp;list_uids=3D3871135&amp;dopt=3DAbstract"=20
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class=3Dref>PUBMED</FONT></A>]&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft6"=20
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Apperance on=20
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2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft6"><=
IMG=20
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            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft7"=20
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2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft7"><=
IMG=20
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            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;[<A=20
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href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&amp;=
db=3DPubMed&amp;list_uids=3D215298&amp;dopt=3DAbstract"=20
            target=3D_blank><FONT =
class=3Dref>PUBMED</FONT></A>]&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft8"=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft8"><=
IMG=20
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            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft9"=20
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2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft9"><=
IMG=20
            alt=3D"Back to cited text no. 9"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;[<A=20
            =
href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&amp;=
db=3DPubMed&amp;list_uids=3D1738457&amp;dopt=3DAbstract"=20
            target=3D_blank><FONT =
class=3Dref>PUBMED</FONT></A>]&nbsp;&nbsp;[<A=20
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href=3D"http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/m=
edia/landingpage.htm?issn=3D0148-396X&amp;amp;volume=3D30&amp;amp;issue=3D=
1&amp;amp;spage=3D64"=20
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class=3Dref>FULLTEXT</FONT></A>]</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft10" =

            name=3Dref10>10.</A></TD>
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            Glioblastoma with spinal seeding. Strahlenther Onkol=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#ft10">=
<IMG=20
            alt=3D"Back to cited text no. 10"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            =
border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR></TBODY></TABLE><BR><BR>=

      <P class=3DpageSub>&nbsp;&nbsp;&nbsp;&nbsp;<A=20
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      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2006_54_4_428_28122_1.jpg=
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#">[Fig=
ure=20
      - 1]</A>, <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2006_54_4_428_28122_2.jpg=
')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#">[Fig=
ure=20
      - 2]</A>, <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2006_54_4_428_28122_3.jpg=
')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2006;volume=3D54;issue=3D4;spage=3D428;epage=3D430;aulast=3DKaraca#">[Fig=
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      - 3]</A>=20
      <TABLE cellSpacing=3D0 cellPadding=3D0 width=3D"100%" border=3D0>
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          <TD width=3D"100%"><BR>
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#cccccc 1px solid; BORDER-LEFT: #cccccc 1px solid; BORDER-BOTTOM: =
#cccccc 1px solid">
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	default_menu_item=3Ditem;=09
	resetTDs(item);
	writeSubmenu("submenu",item);
	showHideLayer("submenu","visible");
}


function navMouseBotOut(src)
{
	src.className=3D"footer";
}


function navMouseBotOver(src)
{
	src.className=3D"pageSub";
}


function menu(src,item)
{=20

=09
	default_menu_item =3D item;
	writeSubmenu("submenu",item);
	showHideLayer("submenu","visible");=09
	resetTDs(item);

}=20

function resetTDs(item)
{
	var ob;
	for(x=3D0;x<8;x++)
	{
	obj=3D"m" + x;
 	ob=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	ob.className=3D"topBand1";
	if (x =3D=3D item)
		{
		ob.className=3D"topBand1Sel";
		}=09
	}
}


function writehDetail(obj,nm,cate,sing,dble,chkout,webadd)
	{			=09

   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false;
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09

	var det;
	if (sing=3D=3D0){
		sing=3D"N.A";}
	else{
		sing=3D sing + " INR";}

	if (dble=3D=3D"0")
		dble =3D"N.A"
	else
		dble=3D dble+ " INR";

	if (webadd !=3D '')
	{
		=
det=3D'Hotel&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;:=
 <b>'+nm + '</b><br>Category&nbsp;&nbsp;&nbsp;&nbsp;:<b> '+ cate =
+'</b><br>Singlebed&nbsp;&nbsp;&nbsp;:<b> '+ sing =
+'</b><br>Doublebed&nbsp;&nbsp;:<b> '+ dble + =
'</b><br>Checkout&nbsp;&nbsp;&nbsp;&nbsp;: <b>' + chkout + =
'</b>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a target=3D"_blank" =
href=3D"'+webadd+'">More Details >></a>';
	}
	else
	{
		=
det=3D'Hotel&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;:=
 <b>'+nm + '</b><br>Category&nbsp;&nbsp;&nbsp;&nbsp;:<b> '+ cate =
+'</b><br>Singlebed&nbsp;&nbsp;&nbsp;:<b> '+ sing =
+'</b><br>Doublebed&nbsp;&nbsp;:<b> '+ dble + =
'</b><br>Checkout&nbsp;&nbsp;&nbsp;&nbsp;: <b>' + chkout + '</b>';
	}=09

	this.wref.innerHTML=3Ddet;
}


function writetoObj(obj,curr, valu)
	{=09


   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false;
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09
	this.wref.innerHTML=3D"<b>"+ curr+ valu + "</b>";
}
function openLogo(ClientID)
{
var attributes =3D 'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D550,height=3D600,left=3D=
0,top=3D0';
sealWin=3Dwindow.open('http://www.ccavenue.com/verifySeal.jsp?ClientID=3D=
'+ClientID ,'win',attributes);=20
self.name =3D 'mainWin';=20
}
function openWin(pg)
{

	if (pg.indexOf('special') >=3D 0 )
		{
		var attributes =3D =
'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D800,height=3D600,left=3D=
0,top=3D0';
		}
	else
		{
		var attributes =3D =
'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D600,height=3D400,left=3D=
0,top=3D0';
		}

	sealWin=3Dwindow.open(pg ,'',attributes);=20
	self.name =3D pg;=20
}

function chkgcform(frm)
{
	if (document.gc_form.gc_login.value=3D=3D'')
	{
		alert("Please enter your Gold Con username");
		return false;
	}
	if (document.gc_form.gc_pswd.value=3D=3D'')
	{
		alert("Please enter your Gold Con password");
		return false;
	}
	return true;
}
function writetCV(obj,cv,photo)
	{=09


   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false;
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09
	this.wref.innerHTML=3D"<img src=3D'gc_images/" + photo + "'><br><br>" + =
cv;
}

function valfld(field)
{

	var valid =3D "0123456789"; // these are allowed values
	var ok =3D "yes";
	var temp;
	if (field.value.length =3D=3D 0 )
	{
		//alert("Invalid entry! please enter number");
		field.value =3D ""
		field.focus();
		field.select();
		return false;=09
	}
	for (var i=3D0; i<field.value.length; i++)
	{
		temp =3D "" + field.value.substring(i, i+1);
		if (valid.indexOf(temp) =3D=3D "-1")=20
		ok =3D "no";
	}
	if (ok =3D=3D "no")=20
	{
		alert("Invalid entry! Only numbers are allowed!");
		field.value =3D ""
		field.focus();
		field.select();

		return false;
	}
	else
		return true;
	}


function chkvldemail(email_address)
   {
         //Assumes that valid email addresses consist of =
user_name@domain.tld
         at =3D email_address.indexOf('@');
         dot =3D email_address.indexOf('.');
        =20
         if(at =3D=3D -1 ||=20
            dot =3D=3D -1 ||        =20
            dot =3D=3D 0 ||=20
            dot =3D=3D email_address.length - 1)
		{alert("Please enter valid email address.");
            return(false);
		}
           =20
         user_name =3D email_address.substr(0, at);
         domain_name =3D email_address.substr(at + 1, =
email_address.length);                 =20

         if(Validate_String(user_name) =3D=3D=3D false || =
Validate_String(domain_name) =3D=3D=3D false)
		{=09
			alert("Please enter valid email address.");
	            return(false);=20
                }
         else
		 return(true);
}

function Validate_String(string, return_invalid_chars)
         {
         valid_chars =3D =
'1234567890-_.^~abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ';
         invalid_chars =3D '';
        =20
         if(string =3D=3D null || string =3D=3D '')
            return(true);
        =20
         //For every character on the string.  =20
         for(index =3D 0; index < string.length; index++)
            {
            charx =3D string.substr(index, 1);                       =20
           =20
            //Is it a valid character?
            if(valid_chars.indexOf(charx) =3D=3D -1)
              {
              //If not, is it already on the list of invalid characters?
              if(invalid_chars.indexOf(charx) =3D=3D -1)
                {
                //If it's not, add it.
                if(invalid_chars =3D=3D '')
                   invalid_chars +=3D charx;
                else
                   invalid_chars +=3D ', ' + charx;
                }
              }
            }                    =20
           =20
         //If the string does not contain invalid characters, the =
function will return true.
         //If it does, it will either return false or a list of the =
invalid characters used
         //in the string, depending on the value of the second =
parameter.
         if(return_invalid_chars =3D=3D true && invalid_chars !=3D '')
           {
           last_comma =3D invalid_chars.lastIndexOf(',');
          =20
           if(last_comma !=3D -1)
              invalid_chars =3D invalid_chars.substr(0, $last_comma) +=20
              ' and ' + invalid_chars.substr(last_comma + 1, =
invalid_chars.length);
                     =20
           return(invalid_chars);
           }
         else
           return(invalid_chars =3D=3D '');=20
         }

function trimstr(par)
{

while (par.charAt(0)=3D=3D" "){
par=3Dpar.replace(" ","")
}
i=3Dpar.length-1
while(par.charAt(i)=3D=3D" "){
par=3Dpar.slice(0,i)
i=3Di-1
}
return par
}

// var xyz =3D createBar(
// total_width,
// total_height,
// background_color,
// border_width,
// border_color,
// block_color,
// scroll_speed,
// block_count,
// scroll_count,
// action_to_perform_after_scrolled_n_times
// )

var w3c=3D(document.getElementById)?true:false;
var ie=3D(document.all)?true:false;
var N=3D-1;
var back_color=3D'white';
var bar_color=3D'green';
function =
createBar(w,h,bgc,brdW,brdC,blkC,speed,blocks,count,action,flag){
if(ie||w3c){

	bgc=3Dback_color;
	blkC=3Dbar_color;

if (flag!=3D''){
	h=3D13;
	}
h=3D10
var t=3D'<div id=3D"_xpbar'+(++N)+'" style=3D"visibility:visible; =
position:relative; overflow:hidden; width:'+w+'px; height:'+h+'px; =
background-color:'+bgc+'; border-color:'+brdC+'; =
border-width:'+brdW+'px; border-style:solid; font-size:1px;">';
t+=3D'<span id=3D"blocks'+N+'" style=3D"left:-'+(h*2+1)+'px; =
position:absolute; font-size:1px">';
for(i=3D0;i<blocks;i++){
t+=3D'<span style=3D"background-color:'+blkC+'; left:-'+((h*i)+i)+'px; =
font-size:1px; position:absolute; width:'+h+'px; height:'+h+'px; '
t+=3D(ie)?'filter:alpha(opacity=3D'+(100-i*(100/blocks))+')':'-Moz-opacit=
y:'+((100-i*(100/blocks))/100);
t+=3D'"></span>';
}
t+=3D'</span></div>';
document.write(t);
var =
bA=3D(ie)?document.all['blocks'+N]:document.getElementById('blocks'+N);
bA.bar=3D(ie)?document.all['_xpbar'+N]:document.getElementById('_xpbar'+N=
);
bA.blocks=3Dblocks;
bA.N=3DN;
bA.w=3Dw;
bA.h=3Dh;
bA.speed=3Dspeed;
bA.ctr=3D0;
bA.count=3Dcount;
bA.action=3Daction;
bA.togglePause=3DtogglePause;
bA.showBar=3Dfunction(){
this.bar.style.visibility=3D"visible";
}
bA.hideBar=3Dfunction(){
this.bar.style.visibility=3D"hidden";
}
bA.tid=3DsetInterval('startBar('+N+')',speed);
return bA;
}}

function startBar(bn){
var =
t=3D(ie)?document.all['blocks'+bn]:document.getElementById('blocks'+bn);
if(parseInt(t.style.left)+t.h+1-(t.blocks*t.h+t.blocks)>t.w){
t.style.left=3D-(t.h*2+1)+'px';
t.ctr++;
if(t.ctr>=3Dt.count){
eval(t.action);
t.ctr=3D0;
}}else t.style.left=3D(parseInt(t.style.left)+t.h+1)+'px';
}

function togglePause(){
if(this.tid=3D=3D0){
this.tid=3DsetInterval('startBar('+this.N+')',this.speed);
}else{
clearInterval(this.tid);
this.tid=3D0;
}}

function togglePause(){
if(this.tid=3D=3D0){
this.tid=3DsetInterval('startBar('+this.N+')',this.speed);
}else{
clearInterval(this.tid);
this.tid=3D0;
}}
function showpp(el_id)

{

	if (document.getElementById(el_id).style.display=3D=3D"")
	{
	document.getElementById(el_id).style.display=3D"none";
	}
	else
	{
	document.getElementById(el_id).style.display=3D""
	var attributes =3D =
'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D1,height=3D1,left=3D0,to=
p=3D0';


	=
sealWin=3Dwindow.open('http://www.jpgmonline.com/vans.asp','',attributes)=
;=20
	}=09
}


var ns =3D (navigator.appName.indexOf("Netscape") !=3D -1);
var d =3D document;
var px =3D document.layers ? "" : "px";

function JSFX_FloatDiv(id, sx, sy)
{
	var =
el=3Ddocument.getElementById?document.getElementById(id):document.all?doc=
ument.all[id]:document.layers[id];
	window[id + "_obj"] =3D el;
	if(document.layers)el.style=3Del;
	el.cx =3D el.sx =3D sx;el.cy =3D el.sy =3D sy;
	el.sP=3Dfunction(x,y){this.style.left=3Dx+px;this.style.top=3Dy+px;};
	el.flt=3Dfunction()
	{
		var pX, pY;
		pX =3D (this.sx >=3D 0) ? 0 : ns ? innerWidth :=20
		document.documentElement && document.documentElement.clientWidth ?=20
		document.documentElement.clientWidth : document.body.clientWidth;
		pY =3D ns ? pageYOffset : document.documentElement && =
document.documentElement.scrollTop ?=20
		document.documentElement.scrollTop : document.body.scrollTop;
		if(this.sy<0)=20
		pY +=3D ns ? innerHeight : document.documentElement && =
document.documentElement.clientHeight ?=20
		document.documentElement.clientHeight : document.body.clientHeight;
		this.cx +=3D (pX + this.sx - this.cx)/8;this.cy +=3D (pY + this.sy - =
this.cy)/8;
		this.sP(this.cx, this.cy);
		setTimeout(this.id + "_obj.flt()", 40);
	}
	return el;
}

document.write('<script type=3D"text/javascript" =
src=3D"http://ajax.googleapis.com/ajax/libs/jquery/1.3.2/jquery.min.js"><=
\/script>')
document.write('<script type=3D"text/javascript" =
src=3D"http://www.medknow.com/if/iflogo.js"><\/script>')

document.write('<script type=3D"text/javascript" =
src=3D"http://www.medknow.com/js/_dirj.js"><\/script>')
document.write('<script type=3D"text/javascript" =
src=3D"http://www.medknow.com/js/commonjsinclude.js"><\/script>')
document.write('<script language=3D"javascript" type=3D"text/javascript" =
src=3D"http://www.medknow.com/js/countries.js"></script>')

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"1658799983")



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			return j_UA[i];
			break;
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}

function getAdSenseCode()
{
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	j_domn=escape(document.domain);
	j_domn = j_domn.toLowerCase();
	j_domn= j_domn.replace(/www./,'');

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		if(j_ur[i]==j_domn)
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			return j_Adsense[i];
			break;
		}
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