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PURPOSE: Carotid endarterectomy (CEA) is effective in treating carotid artery stenosis to prevent stroke. Historically, this operation has been performed utilizing loupe magnification with or without the operating microscope (OM). However, there remains a need for continued improvement in operative visualization and surgical ergonomics. Recently, newly developed digital 'exoscope' has provided the surgeon with unique lighting and magnification as well as improvements in surgical ergonomics and working angle. We sought to review our cumulative experience using a novel 4K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for CEA surgery. METHODS: All CEA surgery cases at our institution between 2013 and 2019 using the 4K-HD 3D EX were reviewed. Operative parameters, patient outcome and operator's assessment of the EX compared to OM-assisted cases was conducted. RESULTS: 28 patients were treated, 10 of which were operated using the EX. All procedures were performed without perioperative complications, or significant differences in operative parameters (blood loss <20 cm3 and 164 ± 49.5 minutes) compared to OM-assisted cases. Operators reported improved level of comfort performing 'high' bifurcation surgery and improved visualization and posture during inspection of the distal ICA lumen as primary advantages of EX-assisted CEA over OM-assisted CEA. CONCLUSIONS: The ORBEYE EX, albeit a learning curve necessitating a short period of the OR team, provided safety and outcome comparable to OM-assisted surgery. Potential advantages noted were improved visualization and ergonomics specifically for when extreme working angles were required. Our experience suggests that the exoscope may become a valuable alternative to standard magnification tools in CEA surgery.
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BACKGROUND: High-dose bevacizumab delivered via super selective intra-arterial cerebral infusion (SIACI) is one promising clinical trial combination for patients with glioblastoma (GBM). Although both continuous intravenous and intra-arterial administration of bevacizumab, and rechallenge with intravenous bevacizumab, have demonstrated improved survival, this is the first description of rechallenging GBM with SIACI of bevacizumab. CASE DESCRIPTION: We report a case of a 43-year-old woman with recurrent GBM who had received treatment from 3 clinical trials, including a rechallenge with SIACI of bevacizumab. First, she enrolled into a phase I/II trial for patients newly diagnosed with GBM (NCT01811498) and received 3 doses of SIACI bevacizumab over 180 days in addition to standard of care chemotherapy and radiation. Following progression, as indicated on her magnetic resonance imaging scan, she consented for a separate clinical trial for her disease and received 2 cycles of temozolomide with an investigational agent. The patient was removed from the study on tumor progression. Subsequently, she was rechallenged with SIACI of bevacizumab via a third clinical trial (NCT01269853) and then completed 3 intravenous infusions. After completing the third trial, her magnetic resonance imaging scan demonstrated improvement based on Response Assessment In Neuro-Oncology criteria. CONCLUSIONS: This is the first report to highlight the effect of rechallenging a patient with SIACI of bevacizumab following disease progression after initial bevacizumab treatment and subsequent alternate clinical trial failure. There is a need to conduct further clinical trials to evaluate the benefits of rechallenge with SIACI versus intravenous bevacizumab for GBM and further explore theories of bevacizumab resistance.
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Antineoplásicos Imunológicos/administração & dosagem , Bevacizumab/administração & dosagem , Neoplasias Encefálicas/tratamento farmacológico , Glioblastoma/tratamento farmacológico , Recidiva Local de Neoplasia/tratamento farmacológico , Adulto , Barreira Hematoencefálica/efeitos dos fármacos , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirurgia , Ensaios Clínicos como Assunto , Terapia Combinada , Progressão da Doença , Resistencia a Medicamentos Antineoplásicos , Drogas em Investigação/administração & dosagem , Evolução Fatal , Feminino , Glioblastoma/radioterapia , Glioblastoma/cirurgia , Humanos , Infusões Intra-Arteriais , Infusões Intravenosas , Imageamento por Ressonância Magnética , Retratamento/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Cerebral bypass operation is a technically challenging operation that requires excellent surgical visibility and efficient ergonomics to minimize complications and maximize successful revascularization. Despite the operative microscope's utilization for the past two generations, there remains a need for continued improvement in operative visualization and surgical ergonomics. OBJECTIVE: To report the positives and negatives of our initial experience using a novel 4 K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for cranial bypass surgery. METHODS: A retrospective review over 6 mo was performed of all patients who have undergone cerebral bypass surgery at a single institution using the 4K-HD 3D EX. Advantages and disadvantages of the EX and clinical outcome of the patients were assessed. RESULTS: A total of 5 patients underwent cerebral EC-IC bypass surgery with no EX-related complications and successful revascularization. The lightweight design of the EX allowed for easy instrument maneuverability as well as uncomplicated surgical set up in the operating room. The assistance of the cosurgeon was significantly more efficient compared to that of the operating microscope. The large monitor allowed for an immersive, collaborative, and valuable educational surgical experience. CONCLUSION: Using the EX for cerebral bypass surgery, with 3D ultra-high-definition optics, enhancements of ergonomics, and improved training, we believe that the 3D 4K-HD EX may represent the next generation of operative scopes in microneurosurgery.
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Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Doença de Moyamoya/diagnóstico por imagem , Doença de Moyamoya/cirurgia , Procedimentos Neurocirúrgicos/instrumentação , Procedimentos Neurocirúrgicos/métodos , Cirurgia Vídeoassistida/métodos , Anastomose Cirúrgica/instrumentação , Anastomose Cirúrgica/métodos , Ergonomia , Humanos , Imageamento Tridimensional/instrumentação , Imageamento Tridimensional/métodos , Microdissecção , Microscopia de Vídeo , Artéria Cerebral Média/patologia , Artéria Cerebral Média/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Amyloidosis encompasses a group of disorders sharing the common feature of intercellular deposition of amyloid protein by several different pathogenetic mechanisms. Primary solitary amyloidosis, or amyloidoma, is a rare subset of amyloidosis in which amyloid deposition is focal and not secondary to a systemic process or plasma cell dyscrasia. CASE DESCRIPTION: This 84-year-old female presented with history of multiple syncopal episodes, dysphagia, and ataxia. Motor strength was 3+/5 in the right upper extremity. Rheumatoid factor, cyclic citrullinated peptide (CCP), and anti-nuclear antibody (ANA) were normal. Serum and urine immune-electrophoresis detected no abnormal bands. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a non-enhancing soft-tissue mass extending from the retro-clivus to C2 posteriorly, eccentric to the right with severe mass effect on the upper cervical medullary junction. Endoscopic trans-nasal debulking of the retro-clival mass was performed with occiput to C5 posterior instrumentation for spinal stabilization. CONCLUSIONS: Primary solitary amyloidosis, unlike other forms of amyloidosis, has an excellent prognosis with local resection. Diagnosis requires special stains and a degree of suspicion for the disease. This is the first report to document an endoscopic trans-nasal approach for removal of a primary solitary amyloidosis of the retro-clivus. Management of vertebral amyloidoma involves aggressive local resection of the tumor when feasible and spine stabilization as the degree of tumor involvement mandates. Complete evaluation for the diagnosis of systemic amyloidosis is essential for the management and prognostication. Surgeons encountering such lesions must maintain high suspicion for this rare disease and advise pathologists accordingly to establish the correct diagnosis.
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OBJECTIVE: We describe the first case of a novel treatment for a newly diagnosed glioblastoma (GBM) using superselective intraarterial cerebral infusion (SIACI) of cetuximab after osmotic disruption of the blood-brain barrier (BBB) with mannitol. A 51year-old female underwent craniotomy for removal of a right frontal GBM. Pathology confirmed EGFR amplification, and she underwent three treatments of SIACI of cetuximab to the tumor site. The first treatment was given within a week of starting standard of care chemoradiation (Stupp protocol), which is a combination of radiation treatment (2 Gy per/ day x 30 days, total of 60 Gy) and oral temozolomide (75 mg/m2). The second and third SIACI of cetuximab were administered 3 and 6 months later, while the patient continued on maintenance temozolomide. Post-radiation changes on MRI were stable, and there were no signs of recurrence at 4 and 6 months post-resection. Herein, we detail the technical aspects of this novel treatment paradigm and suggest that SIACI of cetuximab after BBB disruption using mannitol, combined with the standard of care chemoradiation therapy, may be an effective treatment method for newly diagnosed EGFR amplified glioblastoma.
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Antineoplásicos Alquilantes/administração & dosagem , Antineoplásicos Imunológicos/administração & dosagem , Barreira Hematoencefálica/efeitos dos fármacos , Neoplasias Encefálicas/terapia , Cetuximab/administração & dosagem , Dacarbazina/análogos & derivados , Fracionamento da Dose de Radiação , Glioblastoma/terapia , Manitol/uso terapêutico , Angiografia Digital , Barreira Hematoencefálica/metabolismo , Barreira Hematoencefálica/patologia , Neoplasias Encefálicas/metabolismo , Neoplasias Encefálicas/patologia , Angiografia Cerebral/métodos , Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Craniotomia , Dacarbazina/administração & dosagem , Feminino , Glioblastoma/metabolismo , Glioblastoma/patologia , Humanos , Infusões Intra-Arteriais , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Temozolomida , Resultado do TratamentoRESUMO
BACKGROUND AND IMPORTANCE: Olfactory neuroblastoma, also known as esthesioneuroblastoma (ENB), is a malignant neoplasm with an unpredictable behavior. Currently, the widely accepted treatment is inductive chemotherapy, with or without surgery, followed by radiotherapy. Since data on genetics and molecular alterations of ENB are lacking, there is no standard molecularly targeted therapy. However, ENB commonly expresses the somatostatin receptor (SSTR) that is also expressed by neuroendocrine tumors. Peptide receptor radionuclide therapy (PRRT) using radiolabeled somatostatin analogues, such as 177Lu-octreotate, is an effective treatment for the latter. We present the complex neuroradiological and neuropathological changes associated with 177Lu-octreotate treatment of a patient with a highly treatment-resistant ENB. CLINICAL PRESENTATION: A 60-yr-old male presented with an ENB that recurred after chemotherapy, surgery, stereotactic radiosurgery, and immunotherapy. Pathology revealed a Hyams grade 3 ENB and the tumor had metastasized to lymph nodes. Tumor SSTR expression was seen on 68Ga-octreotate positron emission tomography (PET)/computed tomography (CT), suggesting that PRRT may be an option. He received 4 cycles of 177Lu-octreotate over 6 mo, with a partial response of all lesions and symptomatic improvement. Four months after the last PRRT cycle, 2 of the lesions rapidly relapsed and were successfully resected. Three months later, 68Ga-octreotate PET/CT and magnetic resonance imaging indicate no progression of the disease. CONCLUSION: We describe imaging changes associated with 177Lu-octreotate PRRT of relapsing ENB. To our knowledge, this is the first report describing neuropathological changes associated with this treatment. PRRT is a promising therapeutic option to improve the disease control, and potentially, the survival of patients with refractory ENB.
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Estesioneuroblastoma Olfatório/radioterapia , Cavidade Nasal/patologia , Neoplasias Nasais/radioterapia , Octreotida/análogos & derivados , Compostos Radiofarmacêuticos/uso terapêutico , Estesioneuroblastoma Olfatório/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Nasais/patologia , Octreotida/uso terapêutico , Radioimunoterapia , Receptores de Somatostatina , Resultado do TratamentoRESUMO
BACKGROUND: Ganglioglioma is a rare, benign, intraaxial glioneuronal tumor but a relatively common cause of pharmacoresistant temporal lobe epilepsy (TLE). Given its often nonspecific neuropsychiatric manifestations and frequently negative electroencephalographic workup, TLE can be easily misdiagnosed as a psychiatric disorder, particularly panic attacks. CASE DESCRIPTION: We present a case of a 17-year-old boy who was found to have lesional TLE secondary to a left temporal ganglioglioma, 5 years after having been misdiagnosed with panic disorder and having undergone ineffective and unnecessary psychotherapy. He was successfully cured by surgery. Although a few similar cases of TLE masquerading as a panic disorder have been previously reported in the literature, this is the youngest and only pediatric patient described to date. CONCLUSION: This report underscores the challenges in making an accurate clinical diagnosis of TLE and the importance of timely brain imaging whenever an atypical or medically refractory panic disorder is encountered.
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Neoplasias Encefálicas/complicações , Erros de Diagnóstico , Epilepsia do Lobo Temporal/etiologia , Ganglioglioma/complicações , Transtorno de Pânico/etiologia , Adolescente , Neoplasias Encefálicas/diagnóstico , Epilepsia do Lobo Temporal/diagnóstico , Ganglioglioma/diagnóstico , Humanos , Masculino , Transtorno de Pânico/diagnósticoRESUMO
BACKGROUND: While craniopharyngiomas (CPs) are the most common cystic suprasellar lesions in adults, cavernous malformations (CMs) only exceptionally occur in this location and are seldom considered in the differential diagnosis of such lesions. However, unlike CPs, suprasellar CMs are not typically approached via an endoscopic endonasal approach. CASE DESCRIPTION: We present a unique clinical case of suprasellar and third ventricular CM mimicking a CP, posing a major decision-making dilemma at the levels of both preoperative diagnosis and surgical planning. CONCLUSION: This case highlights the importance of carefully considering all the differential diagnoses of sellar pathology to select the most appropriate management strategy and surgical approach.
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Meningiomas are most often benign primary intracranial tumors that are frequently found incidentally on imaging. Larger sized meningiomas may present with symptoms such as seizures and headaches. Smaller meningiomas are commonly asymptomatic and usually observed with serial imaging. We present two female patients, both of whom were found to have very small left frontal meningiomas that marginated Broca's area. The first patient in this case series experienced episodes resembling seizures which consisted of weakness, vision loss, and slurred speech, as well as subtle language dysfunction in her day-to-day conversations. The second patient presented with headaches and an enlarging meningioma. Both meningiomas were surgically resected and the patients' symptoms resolved. Small meningiomas should not be overlooked as they may very well be the source of neurologic symptoms.