Gliomas display a microRNA expression profile reminiscent of neural precursor cells.

Gliomas express many genes that play a role in neural precursor cells (NPCs), but no direct comparison between glioma and stem cell (SC) gene expression profiles has been performed. To investigate the similarities and differences between gliomas and SCs, we compared the microRNA (miRNA) expression signatures of glial tumors, embryonic SCs (ESCs), NPCs, and normal adult brains from both human and mouse tissues. We demonstrated that both human gliomas (regardless of their grade) and methylcholanthrene-induced mouse glioma shared an miRNA expression profile that is reminiscent of NPCs. About half of the miRNAs expressed in the shared profile clustered in seven genomic regions susceptible to genetic/epigenetic alterations in various cancers. These clusters comprised the miR17 family, mir183-182, and the SC-specific clusters mir367-302 and mir371-373, which are upregulated in gliomas, ESCs, and NPCs. The bipartite cluster of 7 + 46 miRNAs on chromosome 14q32.31, which might represent the largest tumor suppressor miRNA cluster, was downregulated in the shared expression profile. This study provides the first evidence for association between these clusters and gliomas. Despite the broad similarity in the miRNA expression profiles, 15 miRNAs showed disparate expression between SC and gliomas. Ten miRNAs belong to the 2 SC-specific clusters and the remaining (mir135b, mir141, mir205, mir200C, and mir301a) have been previously shown to associate with malignancies. Our finding showed that all gliomas displayed NPC-like miRNA signatures, which may have implications for studies of glioma origins. Furthermore, careful study of the 15 miRNAs that differ in expression between SCs and gliomas, particularly those 5 that are not SC-specific, may enhance our understanding of gliomagenesis.

Dural arteriovenous fistula of the greater sphenoid wing region in neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) has been infrequently associated with different cerebrovascular conditions that may lead to either ischemic or hemorrhagic stroke. Intracranial dural arteriovenous fistulas have not been described in NF1 patients. In this paper we present a unique case of an 8-year-old child with florid NF1 that presented a greater sphenoid wing dural arteriovenous fistula draining directly through the superior ophthalmic vein and causing exophthalmos. The fistula was cured by direct trans-superior ophthalmic vein approach, by means of detachable coils. Only a few cases of dural fistulas in the lesser sphenoidal wing region have been described in the literature but a fistula of the greater sphenoid wing has not been previously described.

Exsanguinating tracheoinnominate artery fistula repaired with endovascular stent-graft.

BACKGROUND: Tracheoinnominate artery fistula is a relatively rare but life-threatening complication of tracheostomy. Peristomal bleed or hemoptysis may be massive and usually fatal if treatment is not instituted immediately. CASE DESCRIPTION: We report the case of a 40-year-old woman who sustained surgical evacuation of a brainstem cavernoma and developed a massive hemoptysis 13 days after a percutaneous tracheostomy. Because of the patient's poor clinical condition, endovascular repair of the arterial injury was decided. The innominate artery was successfully repaired by means of urgent stent-graft placement. CONCLUSIONS: We believe that, if technically feasible, stent-graft placement can be a valuable therapeutic alternative for this dramatic condition. Physicians in charge of tracheostomized patients and neurointerventionalists should be familiar with this management strategy.

Spontaneous thrombosis of cerebral aneurysms presenting with ischemic stroke.

Complete spontaneous thrombosis of an unruptured cerebral aneurysm is a rare event that can be discovered incidentally on advanced neuroradiologic studies. Occasionally, this phenomenon may be symptomatic and can present as an ischemic stroke. The presumed mechanism is probably due to extension of the thrombi to the parent vessel, embolization of intra-aneurysmatic thrombi to distal arteries or arterial compression due to increased aneurysm mass effect. We present documented cases of this unusual entity and review the literature.

Patient, caregiver, and surgeon perceptions of quality of life following anterior skull base surgery.

OBJECTIVE: To estimate the agreement between surgeons' and lay caregivers' quality-of-life (QOL) perceptions of patients undergoing major skull base surgery. DESIGN: Cohort survey of patients who had undergone anterior skull base tumor excision. SETTING: University-affiliated medical center. PARTICIPANTS: Thirty-five patients and their lay caregivers participated in the study. MAIN OUTCOME MEASURES: A triple survey was performed: each patient and his or her caregiver were asked to answer 35 questions related to 6 distinct QOL domains: role of performance, physical function, vitality, pain, specific symptoms, and effect on emotions. The composite health-related QOL of the patients was also rated on an ordinal scale by 3 surgeons who participated in the operation and follow-up. RESULTS: An overall significant agreement was found between patients' and caregivers' scores at the group level (mean scores of each domain) and individual level (patient-caregiver pairs) (r = 0.76, P<.001). There was a minor correlation in the effect on emotions domain and no correlation in the pain domain. We found no correlation between the surgeons' and patients' ratings. The operating surgeons tended to overate their patients' QOL. CONCLUSIONS: The study results show that the surgeon's perception of his or her patient's QOL is not sufficiently accurate to correctly estimate patients' QOL status. These judgments should come from the patient or from the caregiver, whose perception can be used in clinical trials as a proxy for estimation of a patient's QOL.

[Quality of life following anterior skull base surgery].

Surgery for craniofacial resections is continuously improving, enabling the extirpation of tumors once considered unresectable. Nevertheless, the physical and psychological sequelae of these procedures and their affect on patients' everyday lives have not been systematically evaluated. The purpose of this study was to estimate the impact of anterior skull base surgery on the long-term quality of life (QOL) and on the family relations of patients with anterior skull base tumors. Demographic, medical and outcome data on 69 patients undergoing subcranial surgery for extirpation of tumors were retrospectively analyzed. Within this group, 35 patients and their lay caregiver successfully completed a disease-specific questionnaire. We did not find significant differences in QOL estimation between patients and their caregivers. Malignancy had the most significant impact on QOL, leading to a significant decrease in the overall score. Radiotherapy significantly decreased the scores in the specific symptoms and influence upon emotions domains. Age and comorbidity reduced the scores in the role of performance and physical function domains. A better correlation was found between the scores of married couples than between patients and lay caregivers who weren't married. Eighty three percent of the married couple's replies noted that the disease and surgery did not influence their relations. We conclude that malignancy, radiotherapy, comorbidity and age over 60, significantly impair quality of life in patients undergoing anterior skull base surgery. We suggest that a rehabilitation program should be implemented in these patients in order to improve their overall QOL.

Quality of life following surgery for anterior skull base tumors.

OBJECTIVES: To evaluate patients' quality of life (QOL) after surgical extirpation of anterior skull base tumors, to elucidate different QOL domains, and to define possible predictors of functional outcome postoperatively. DESIGN: Retrospective survey. SETTING: University-affiliated medical center. PARTICIPANTS: Sixty-nine patients (76 consecutive cases) who underwent subcranial surgery between 1994 and 2002 for extirpation of anterior skull base tumors. MAIN OUTCOME MEASURE: A multidimensional, disease-specific questionnaire with 39 items was used. Six relevant domains of QOL were assessed: role of performance, physical functioning, vitality, pain, specific symptoms, and impact on emotions. RESULTS: The response rate for completing the questionnaire was 98% (40/41) after excluding patients who died (n = 13), were lost to follow-up (n = 10), and were operated on within 3 months of commencement of the study (n = 5). Thirty patients (74%) reported a significant improvement or no change in overall QOL within 6 months after surgery. The worst impact of surgery on the patients' QOL was on their financial status and emotional state. The most influential factor on QOL was malignancy leading to a significant decrease in the overall score. Radiotherapy, old age, comorbidity, and wide resection also significantly worsened QOL scores of specific domains. CONCLUSION: After subcranial extirpation of anterior skull base tumors, the overall outcome of the patients is good. Old age, malignancy, comorbidity, wide resection, and radiotherapy are negative prognostic factors for these patients' QOL.

[The subcranial approach for tumors involving the anterior skull base].

The technical approach for anterior skull base tumors has progressed considerably during the last decade. In the classical combined craniofacial resection (CFR) technique, anterior skull base lesions have been approached through bi-frontal craniotomy coupled with Weber-Ferguson and related modifications incisions. The purpose of this work is to present our experience with the subcranial approach for treatment of anterior skull base tumors. During the years 1994-2002, 64 patients underwent 72 procedures of anterior skull base tumor resection via the subcranial approach. The ages of the patients ranged from 2 to 81 years (mean 42 years). Twenty-nine cases involved malignant tumors (40%), and 43 cases involved benign tumors (60%). The most common benign pathology was meningioma (n = 12) and the most common malignant tumor was squamous cell carcinoma (n = 8). The principle skull base reconstruction procedure was performed using a multi-layered fascia: limited defects of the dura were reconstructed with the use of temporalis fascia, whereas reconstruction of large dural defects was performed using a multi-layered fascia lata sheath. Reconstruction of significant bony defects was achieved by utilizing a split calvarial bone graft, posterior sinus wall, or titanium mash covered with pericranial flap. Postoperative follow-up (26 months in average) revealed that 76% of the patients are without evidence of disease, 14% are alive with disease, 3% died of their diseases and 7% died of unrelated causes. Twenty-seven patients (44%) have suffered from anosmia following the operation. The rate of severe complications was 5.6%, and included meningitis (n = 2), cerebrospinal fluid rhinorrhea (n = 1) and tension pneumocephalus (n = 1). We conclude that the extirpation of anterior skull base tumors via the subcranial approach is simple, reproducible and reliable, and is associated with reasonable complication rates.

Anterior skull base surgery without prophylactic airway diversion procedures.

OBJECTIVE: Although anterior skull base surgery has become a relatively safe and effective procedure, postoperative complications remain a serious problem. One of the most devastating complications of anterior skull base procedures is tension pneumocephalus (TP). In order to prevent TP, authors have recommended the use of prophylactic airway diversion procedures, such as prolonged endotracheal intubation or prophylactic tracheostomy. However, these procedures may mask neurologic deterioration, delay treatment, and prolong rehabilitation. The purpose of this study was to determine the need for airway diversion procedures in anterior skull base surgery. STUDY DESIGN: Eighty-five patients underwent anterior skull base operations through the subcranial approach without prophylactic airway diversion. Sixty-four patients underwent resection of tumors, 12 patients underwent repair of cerebrospinal fluid leak, 6 patients underwent surgery due to anterior skull base fungal infections, and 3 patients underwent anterior skull base reconstruction procedures. RESULTS: The complication rate of TP was 1.2% (1/85). This complication rate is similar to that previously reported for operations performed with airway diversion procedures. CONCLUSION: Prophylactic airway diversion procedures are unnecessary in routine anterior skull base operations. Airway diversion should be indicated only when factors that might predispose the patient to risk of TP have been identified (ie, chronic cough or obstructive pulmonary diseases).

The role of hair shaving in skull base surgery.

OBJECTIVE: We sought to evaluate surgical wound infection rates in patients undergoing skull base surgery without hair removal. METHODS: We undertook a retrospective study of 175 skull base operations performed without hair removal. Anterior operations were conducted via the subcranial approach (n = 120) and lateral or posterior procedures via various approaches (n = 55). Wounds were examined daily during hospitalization and at routine outpatient follow-up (8 to 45 months) and classified according to the Center for Disease Control and Prevention guidelines. RESULTS: The overall surgical wound infection rate was 1.1% (2 of 175): 0.8% (1 of 120) for anterior and 1.8% (1 of 55) for lateral or posterior procedures. It was similar for clean operations (lateral and posterior) and clean-contaminated (anterior) procedures and was less than or similar to the rates reported for skull base procedures with hair removal. No wound infection occurred among the infected (trauma, fungal infections, and brain abscess) patients. CONCLUSIONS: Skull base surgery without hair removal is safe and not associated with increased risk of wound infection. The method may prevent additional psychologic stress, promote restoration of the patient's self-image, and accelerate his or her return to normal life.