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Glioblastoma (GBM) is the most common malignant central nervous system tumor. The emerging field of epigenetics stands out as particularly promising. Notably, the discovery of micro RNAs (miRNAs) has paved the way for advancements in diagnosing, treating, and prognosticating patients with brain tumors. We aim to provide an overview of the emergence of miRNAs in GBM and their potential role in the multifaceted management of this disease. We discuss the current state of the art regarding miRNAs and GBM. We performed a narrative review using the MEDLINE/PUBMED database to retrieve peer-reviewed articles related to the use of miRNA approaches for the treatment of GBMs. MiRNAs are intrinsic non-coding RNA molecules that regulate gene expression mainly through post-transcriptional mechanisms. The deregulation of some of these molecules is related to the pathogenesis of GBM. The inclusion of molecular characterization for the diagnosis of brain tumors and the advent of less-invasive diagnostic methods such as liquid biopsies, highlights the potential of these molecules as biomarkers for guiding the management of brain tumors such as GBM. Importantly, there is a need for more studies to better examine the application of these novel molecules. The constantly changing characterization and approach to the diagnosis and management of brain tumors broaden the possibilities for the molecular inclusion of novel epigenetic molecules, such as miRNAs, for a better understanding of this disease.
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Spinal metastasis of Glioblastoma is a rare occurrence, especially in pediatric patients, and extremely rare to become symptomatic. The pathology is poorly understood and remains with unclear dissemination mechanisms. The treatment approaches are varied and multimodal therapy (surgery, chemotherapy, and radiotherapy) can be employed to manage this type of metastasis. We report a case of a 17-year-old female who underwent a gross-total resection of a right frontal glioblastoma and had adjuvant therapy with chemo- and radiotherapy. In the sixth month of follow-up, the patient presented a paraparesis, and a distant recurrence at T7-T8 was detected. The patient was treated with gross-total resection of the tumor through a laminectomy. The histopathological results were consistent with an isocitrate dehydrogenase (IDH) wildtype GBM metastasis. The patient was treated with multimodal therapy, including surgery, radiotherapy, and chemotherapy. A complementary comprehensive review of current available literature on this topic is also presented.
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BACKGROUND: Trigeminal schwannoma is a rare type of tumor that arises from the Schwann cells of the trigeminal nerve. METHOD: We present a case of a patient with a giant V2 trigeminal schwannoma with painful swelling in the left maxilla. A complete resection using a combined open maxillectomy and endoscopic endonasal approach was performed. CONCLUSION: This case highlights the importance of a multidisciplinary approach to perform a combined open and endoscopic approach for safe resection while preserving adequate speech and swallowing.
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Neoplasias de los Nervios Craneales , Neurilemoma , Humanos , Neoplasias de los Nervios Craneales/cirugía , Neoplasias de los Nervios Craneales/patología , Neoplasias de los Nervios Craneales/diagnóstico por imagen , Endoscopía/métodos , Maxilar/cirugía , Maxilar/diagnóstico por imagen , Cirugía Endoscópica por Orificios Naturales/métodos , Neurilemoma/cirugía , Neurilemoma/diagnóstico por imagen , Neurilemoma/patología , Resultado del Tratamiento , Nervio Trigémino/cirugía , Nervio Trigémino/patología , Enfermedades del Nervio Trigémino/cirugía , Enfermedades del Nervio Trigémino/patologíaRESUMEN
OBJECTIVE: This study aimed to investigate the limitations, barriers, and complications in the early transition from the microscopic transsphenoidal approach (MTA) to the endonasal endoscopic approach (EEA) to the skull base in our institution. METHODS: Technical challenges, as well as clinical features and complications, were compared between MTA, EEA, and mixed cases during the early surgical curve. RESULTS: The period from the early learning curve was 1 year until the EEA protocol was used routinely. A total of 34 patients registered a resection using a transsphenoidal approach. Eighteen patients underwent EEA, 11 underwent MTA, and five underwent a mixed endonasal and microscopic approach. Non-significant differences were found in endocrine outcomes between the three groups. Patients with unchanged or improved visual function were higher in the EEA group (p = 0.147). Non-significant differences were found in terms of the extent of resection (EOR) between groups (p = 0.369). Only 1 (2.9%) patient in the whole series developed a post-operative CSF leaking that resolved with medical management, belonging to the EEA group (5.5%). CONCLUSIONS: The early phase of the learning curve did not affect our series significantly in terms of the EOR, endocrine status, and visual outcomes.
OBJETIVO: Investigar las limitaciones, las barreras y las complicaciones en la transición del abordaje transesfenoidal microscópico (ATM) al abordaje endonasal endoscópico (AEE) para la base del cráneo en nuestra institución. MÉTODO: Se compararon las características clínicas y las complicaciones entre ATM, AEE y casos mixtos durante la curva quirúrgica temprana. RESULTADOS: El periodo desde la curva de aprendizaje inicial fue de 1 año hasta que se utilizó el protocolo AEE de forma sistemática. Un total de 34 pacientes tuvieron una resección por vía transesfenoidal. A 18 pacientes se les realizó AEE, a 11 ATM y a 5 abordaje mixto endonasal y microscópico. Se encontraron diferencias no significativas en los resultados endocrinos entre los tres grupos. Los pacientes con función visual sin cambios o mejorada fueron más en el grupo AEE (p = 0.147). No se encontraron diferencias significativas respecto a la extensión de la resección (p = 0.369). Solo 1 (2.9%) paciente desarrolló una fístula de líquido cefalorraquídeo que se resolvió con manejo médico, perteneciente al grupo AEE (5.5%). CONCLUSIONES: La fase inicial de la curva de aprendizaje no afectó significativamente a nuestra serie en términos de extensión de la resección, estado endocrino y resultados visuales.
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Curva de Aprendizaje , Humanos , Femenino , Masculino , Persona de Mediana Edad , Adulto , Neoplasias Hipofisarias/cirugía , Anciano , Estudios Retrospectivos , Microcirugia/métodos , Silla Turca/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Cavidad Nasal/cirugía , Cirugía Endoscópica por Orificios Naturales/métodos , Neuroendoscopía/métodos , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/epidemiología , Endoscopía/métodosRESUMEN
OBJECTIVES: This study aims to describe resting state networks (RSN) in patients with disorders of consciousness (DOC)s after acute severe traumatic brain injury (TBI). METHODS: Adult patients with TBI with a GCS score <8 who remained in a coma, minimally conscious state (MCS), or unresponsive wakefulness syndrome (UWS), between 2017 and 2020 were included. Blood-oxygen-level dependent imaging was performed to compare their RSN with 10 healthy volunteers. RESULTS: Of a total of 293 patients evaluated, only 13 patients were included according to inclusion criteria: 7 in coma (54%), 2 in MCS (15%), and 4 (31%) had an UWS. RSN analysis showed that the default mode network (DMN) was present and symmetric in 6 patients (46%), absent in 1 (8%), and asymmetric in 6 (46%). The executive control network (ECN) was present in all patients but was asymmetric in 3 (23%). The right ECN was absent in 2 patients (15%) and the left ECN in 1 (7%). The medial visual network was present in 11 (85%) patients. Finally, the cerebellar network was symmetric in 8 patients (62%), asymmetric in 1 (8%), and absent in 4 (30%). CONCLUSIONS: A substantial impairment in activation of RSN is demonstrated in patients with DOC after severe TBI in comparison with healthy subjects. Three patterns of activation were found: normal/complete activation, 2) asymmetric activation or partially absent, and 3) absent activation.
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Lesiones Traumáticas del Encéfalo , Trastornos de la Conciencia , Humanos , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/fisiopatología , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Masculino , Femenino , Adulto , Persona de Mediana Edad , Trastornos de la Conciencia/fisiopatología , Trastornos de la Conciencia/etiología , Trastornos de la Conciencia/diagnóstico por imagen , Red Nerviosa/diagnóstico por imagen , Red Nerviosa/fisiopatología , Imagen por Resonancia Magnética , Anciano , Adulto Joven , Descanso/fisiología , Estado Vegetativo Persistente/fisiopatología , Estado Vegetativo Persistente/diagnóstico por imagen , Estado Vegetativo Persistente/etiologíaRESUMEN
OBJECTIVE: Establish the evolution of the connectome before and after resection of motor area glioma using a comparison of connectome maps and high-definition differential tractography (DifT). METHODS: DifT was done using normalized quantitative anisotropy (NQA) with DSI Studio. The quantitative analysis involved obtaining mean NQA and fractional anisotropy (FA) values for the disrupted pathways tracing the corticospinal tract (CST), and white fiber network changes over time. RESULTS: We described the baseline tractography, DifT, and white matter network changes from two patients who underwent resection of an oligodendroglioma (Case 1) and an IDH mutant astrocytoma, grade 4 (Case 2). CASE 1: There was a slight decrease in the diffusion signal of the compromised CST in the immediate postop. The NQA and FA values increased at the 1-year follow-up (0.18 vs. 0.32 and 0.35 vs. 0.44, respectively). CASE 2: There was an important decrease in the immediate postop, followed by an increase in the follow-up. In the 1-year follow-up, the patient presented with radiation necrosis and tumor recurrence, increasing NQA from 0.18 in the preop to 0.29. Fiber network analysis: whole-brain connectome comparison demonstrated no significant changes in the immediate postop. However, in the 1-year follow up there was a notorious reorganization of the fibers in both cases, showing the decreased density of connections. CONCLUSIONS: Connectome studies and DifT constitute new potential tools to predict early reorganization changes in a patient's networks, showing the brain plasticity capacity, and helping to establish timelines for the progression of the tumor and treatment-induced changes.
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Neoplasias Encefálicas , Conectoma , Imagen de Difusión Tensora , Estudios de Factibilidad , Glioma , Humanos , Imagen de Difusión Tensora/métodos , Conectoma/métodos , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/patología , Glioma/cirugía , Glioma/diagnóstico por imagen , Glioma/patología , Masculino , Persona de Mediana Edad , Adulto , Corteza Motora/diagnóstico por imagen , Corteza Motora/cirugía , Corteza Motora/fisiopatología , Tractos Piramidales/diagnóstico por imagen , Femenino , Oligodendroglioma/cirugía , Oligodendroglioma/diagnóstico por imagen , Oligodendroglioma/patología , Astrocitoma/cirugía , Astrocitoma/diagnóstico por imagen , Astrocitoma/patologíaAsunto(s)
Antineoplásicos Alquilantes , Neoplasias Encefálicas , Carmustina , Glioblastoma , Isocitrato Deshidrogenasa , Humanos , Glioblastoma/tratamiento farmacológico , Glioblastoma/cirugía , Neoplasias Encefálicas/cirugía , Isocitrato Deshidrogenasa/genética , Carmustina/administración & dosificación , Carmustina/efectos adversos , Antineoplásicos Alquilantes/efectos adversos , Antineoplásicos Alquilantes/administración & dosificación , Adulto , Resultado del TratamientoRESUMEN
OBJECTIVE: Pyogenic cerebral ventriculitis (PCV) is a rare infectious entity characterized by a potent inflammatory reaction of the ventricular ependyma, which in most cases leads to death. We aim to present the technical note and protocol, based on our center's 10-year experience of the use of endoscopic ventricular lavage (EVL) in pediatric patients with PCV and ventricular peritoneal shunt. METHODS: For this study, all pediatric patients (<16 years) with VP shunts and PCV who were treated with EVL between January 2012 and January 2022 were included. RESULTS: Thirty-four pediatric patients with ventriculitis were analyzed. The median age was 6 years, with 61.7% being male. Most consultations occurred on Day 2 of symptoms. Fever (38.2%) and altered consciousness (26.5%) were the most common initial symptoms. Early ventriculitis was observed in 67.7% of patients. Pathogen identification in the initial cerebrospinal fluid sample was 70.6%, while samples from ventricular peritoneal shunt yielded 23.53% and catheter culture 79.4%. Gram-positive bacteria, mainly S.epidermidis (44.1%), was the most commonly isolated agent. EVL was performed in 73.5% on the second or third day. Reinfection occurred in 23.5%, and 26.5% of patients died. Concordance analysis showed 85.3% agreement between LP and catheter tip samples. Functionality improved, with 55.88% achieving a Lansky score of 90. Early ventriculitis was associated with better Lansky scores. CONCLUSION: EVL can be a useful tool in the management of PCV in cases with VP shunts. Our study suggests a higher chance of isolating an infection-causing germ in the catheter tip culture specimen compared to the cerebrospinal fluid culture. However, future studies with a larger number of patients, or multicentric studies are required for further analysis.
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Ventriculitis Cerebral , Neuroendoscopía , Irrigación Terapéutica , Derivación Ventriculoperitoneal , Humanos , Ventriculitis Cerebral/etiología , Masculino , Femenino , Niño , Preescolar , Lactante , Neuroendoscopía/métodos , Irrigación Terapéutica/métodos , Adolescente , Resultado del Tratamiento , Estudios Retrospectivos , Ventrículos Cerebrales/cirugíaRESUMEN
Postoperative complications, exemplified by surgical site infections, are commonplace in the realm of daily surgical interventions. Conversely, certain infectious entities, such as cerebral myiasis (CM), are distinctly rare. This report elucidates the clinical presentation of a 74-year-old female afflicted with a CSF fistula, within the context of a preceding surgical microvascular decompression employing a suboccipital craniotomy approach. Notably, the course of evaluation and treatment unveiled an intraoperative manifestation of severe CM. This case report underscores the critical significance of prompt identification, precise diagnostic elucidation, and comprehensive multidisciplinary management to optimize patient outcomes in instances of CM. Furthermore, a systematic literature review on CM supplements this report, contributing to the understanding of this infrequent complication.
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Miasis , Humanos , Femenino , Anciano , Miasis/cirugía , Miasis/diagnóstico , Miasis/diagnóstico por imagen , Craneotomía/métodos , Cirugía para Descompresión Microvascular/métodosRESUMEN
Augmented reality (AR) integrates computer-generated content and real-world scenarios. Artificial intelligence's continuous development has allowed AR to be integrated into medicine. Neurosurgery has progressively introduced image-guided technologies. Integration of AR into the operating room has permitted a new perception of neurosurgical diseases, not only for neurosurgical planning, patient positioning, and incision design but also for intraoperative maneuvering and identification of critical neurovascular structures and tumor boundaries. Implementing AR, virtual reality, and mixed reality has introduced neurosurgeons into a new era of artificial interfaces. Meningiomas are the most frequent primary benign tumors commonly related to paramount neurovascular structures and bone landmarks. Integration of preoperative 3D reconstructions used for surgical planning into AR can now be inserted into the microsurgical field, injecting information into head-up displays and microscopes with integrated head-up displays, aiming to guide neurosurgeons intraoperatively to prevent potential injuries. This manuscript aims to provide a mini-review of the usage of AR for intracranial meningioma resection.
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Background: Diffusion tensor imaging (DTI) tractography facilitates maximal safe resection and optimizes planning to avoid injury during subcortical dissection along descending motor pathways (DMPs). We provide an affordable, safe, and timely algorithm for preoperative DTI motor reconstruction for gliomas adjacent to DMPs. Methods: Preoperative DTI reconstructions were extracted from a prospectively acquired registry of glioma resections adjacent to DMPs. The surgeries were performed over a 7-year period. Demographic, clinical, and radiographic data were extracted from patients' electronic medical records. Results: Nineteen patients (12 male) underwent preoperative tractography between January 1, 2013, and May 31, 2020. The average age was 44.5 years (range, 19-81 years). A complete radiological resection was achieved in nine patients, a subtotal resection in five, a partial resection in three, and a biopsy in two. Histopathological diagnoses included 10 patients with high-grade glioma and nine with low-grade glioma. A total of 16 perirolandic locations (10 frontal and six frontoparietal) were recorded, as well as two in the insula and one in the basal ganglia. In 9 patients (47.3%), the lesion was in the dominant hemisphere. The median preoperative and postoperative Karnofsky Performance Scores were 78 and 80, respectively. Motor function was unchanged or improved over time in 15 cases (78.9%). Conclusion: This protocol of DTI reconstruction for glioma removal near the DMP shows good results in low-term neurological functional outcomes.
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Gross-total resection of foramen magnum meningiomas remains the gold standard of treatment and should be performed whenever possible. The transcondylar approach (and its variations) represents the most used approach for meningiomas located in the lateral or anterior borders of the foramen magnum. Endoscopic transclivus approaches represent a useful option in selected cases of anterior midline foramen magnum meningiomas, to be performed in centers with advanced experience in endoscopic skull base surgery, with the caveats of increased risk of postoperative cerebrospinal fluid leak. Alternatively, radiosurgery remains an option for well-selected cases, especially for the management of asymptomatic patients with small enlarging tumors. Advances in molecular profiling, as well as genetic analysis, may guide adjuvant treatment.
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Severe traumatic brain injury (TBI) is often associated with diffuse axonal injury. Diffuse axonal injury affecting the corpus callosum may present with intraventricular hemorrhage on baseline computed tomography (CT) scan. Posttraumatic corpus callosum damage is a chronic condition that can be diagnosed over the long term using various magnetic resonance imaging (MRI) sequences. Here, we present two cases of severe survivors of TBI with isolated intraventricular hemorrhage detected on an initial CT scan. After acute trauma management, long-term follow-up was performed. Diffusion tensor imaging and subsequent tractography revealed a significant decrease in the fractional anisotropy values and the number of corpus callosum fibers compared with those in healthy control patients. This study presents a possible correlation between traumatic intraventricular hemorrhage on admission CT and long-term corpus callosum impairment detected on MRI in patients with severe head injury by presenting demonstrative cases and conducting a literature review.
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In recent years, the endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, we performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X2 and Fisher exact test, and a comparison between quantitative variables through a Kruskal-Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm3, -TCA 13.23 cm3). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). Our results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative CSF leak rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person's characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery.
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Background: Parkinson's disease is poorly studied in Colombia. It is pharmacologically managed, but for refractory cases, surgery is a therapeutic option, positively impacting on quality of life. Objective: To determine the impact of deep brain stimulation as management in the control of progression in patients with Parkinson's disease attended our institution between the years 2014 to 2020. Method: Descriptive retrospective study, with patients collected between 2014 and 2020 undergoing deep brain stimulation surgery. The MDS-UPDRS (Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale) was applied in the pre- and postoperative period, and the results were compared. Results: 21 patients were included and the UPDRS was applied, finding a decrease in scores in the postoperative period. One patient had an operative site infection. Conclusions: There was an improvement in the MDS-UPDRS score, with a low rate of complications. The procedure time was prolonged from the preoperative evaluation. Deep brain stimulation is the management of choice for refractory Parkinson's disease. The patients in this series showed improvement in their symptoms. Unfortunately, there are limitations to perform this procedure in Colombia, such as the delay in the authorization of the procedure.
Antecedentes: La enfermedad de Parkinson está poco estudiada en Colombia. Es de manejo farmacológico, pero para casos refractarios la cirugía es una opción terapéutica que impacta positivamente en la calidad de vida. Objetivo: Determinar el impacto de la estimulación cerebral profunda como manejo en el control de la progresión en pacientes con enfermedad de Parkinson atendidos nuestra institución entre los años 2014 a 2020. Método: Estudio descriptivo de corte retrospectivo con pacientes recolectados entre los años 2014 y 2020 sometidos a cirugía de estimulación cerebral profunda. Se aplicó la MDS-UPDRS (Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale) en el pre- y el posoperatorio, y se compararon los resultados. Resultados: Se incluyeron 21 pacientes y se les aplicó la MDS-UPDRS, encontrando una disminución en las puntuaciones en el posoperatorio. Un paciente presentó infección del sitio operatorio. Conclusiones: Hubo mejoría en la puntuación de la MDS-UPDRS, con baja tasa de complicaciones. El tiempo de realización del procedimiento fue prolongado desde la valoración preoperatoria. La estimulación cerebral profunda es el manejo de elección para la enfermedad de Parkinson refractaria. Los pacientes de esta serie mostraron mejoría en sus síntomas. Desafortunadamente, existen limitaciones para la realización de este procedimiento en Colombia, como el retraso en la autorización del procedimiento.
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AIM: To weight the benefits and limitations of intraoperative use of micromirrors in neurosurgery. MATERIAL AND METHODS: Surgical cases where micromirrors were employed were retrospectively selected from the surgical database of five different surgeons in different hospitals. Complications directly attributable to the micromirrors were assessed intraoperatively and confirmed with postoperative neuroimaging studies. RESULTS: Fourteen patients were selected. The site of the lesion was as follows: posterior fossa (43%), frontal lobe (22%), temporal lobe (14%), parietal lobe (7%), insula (7%), and basal ganglia (7%). Five tumors (35%) were gliomas, 3 (21%) epidermoid, and 3 (21 %) supratentorial metastases. Two patients underwent microvascular decompression for neurovascular conflict, and 1 harbored a brain arteriovenous malformation. A gross total resection was achieved in all the tumors and the AVM, while an effective decompression was successfully performed in both patients with conflict. No complications directly attributable to the use of the micromirror occurred. A relatively easy learning curve was noted. CONCLUSION: Micromirrors proved to be useful in enhancing the visualization of neurovascular structures and pathology residuals within deep-seated surgical fields without the need for fixed brain retraction. Their cost-effectiveness and easy learning curve constitute solid reasons for advocating a revitalization of this ?old but gold? tool in neurosurgery.