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OBJECTIVE: The literature on non-small cell lung cancer (NSCLC) brain metastases (BMs) managed using stereotactic radiosurgery (SRS) relies mainly on single-institution studies or randomized controlled trials (RCTs). There is a literature gap on clinical and radiological outcomes of SRS for NSCLC metastases in real-world practice. The objective of this study was to benchmark mortality and progression outcomes in patients undergoing SRS for NSCLC BMs and identify risk factors for these outcomes using a national quality registry. METHODS: The SRS Registry of the NeuroPoint Alliance was used for this study. This registry included patients from 16 enrolling sites who underwent SRS from 2017 to 2022. Data are prospectively collected without a prespecified research purpose. The main outcomes of this analysis were overall survival (OS), out-of-field recurrence, local progression, and intracranial progression. All time-to-event investigations included Kaplan-Meier analyses and multivariable Cox regressions. RESULTS: Two hundred sixty-four patients were identified, with a mean age of 66.7 years and a female proportion of 48.5%. Most patients (84.5%) had a Karnofsky Performance Status (KPS) score of 80-100, and the mean baseline EQ-5D score was 0.539 quality-adjusted life years. A single lesion was present in 53.4% of the patients, and 29.1% of patients had 3 or more lesions. The median OS was 28.1 months, and independent predictors of mortality included no control of primary tumor (hazard ratio [HR] 2.1), KPS of 80 (HR 2.4) or lower (HR 2.4), coronary artery disease (HR 2.8), and 5 or more lesions present at the time of SRS treatment (HR 2.3). The median out-of-field progression-free survival (PFS) was 24.8 months, and the median local PFS was unreached. Intralesional hemorrhage was an independent risk factor of local progression, with an HR of 6.0. The median intracranial PFS was 14.0 months and was predicted by the number of lesions at the time of SRS (3-4 lesions, HR 2.2; 5-14 lesions, HR 2.5). CONCLUSIONS: In this real-world prospective study, the authors used a national quality registry and found favorable OS in patients with NSCLC BMs undergoing SRS compared with results from previously published RCTs. The intracranial PFS was mainly driven by the emergence of new lesions rather than local progression. A greater number of lesions at baseline was associated with out-of-field progression, while intralesional hemorrhage at baseline was associated with local progression.
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Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population. In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma. The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.
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Edema Encefálico/cirurgia , Lesões Encefálicas/cirurgia , Craniectomia Descompressiva/estatística & dados numéricos , Medicina Baseada em Evidências/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Adulto , Fatores Etários , Encéfalo/crescimento & desenvolvimento , Encéfalo/fisiopatologia , Encéfalo/cirurgia , Edema Encefálico/fisiopatologia , Edema Encefálico/prevenção & controle , Lesões Encefálicas/fisiopatologia , Criança , Humanos , Lactente , Crânio/anatomia & histologia , Crânio/fisiopatologia , Crânio/cirurgiaRESUMO
INTRODUCTION: Giant pituitary adenomas of excessive size, fibrous consistency or unfavorable geometric configuration may be unresectable through conventional operative approaches. We present our select case series for operative resection and long-term follow-up for these unusual tumors, employing both a staged procedure and a combined transsphenoidal-transcranial above and below approach. METHOD: A retrospective chart review was performed on patients operated via the staged, and combined approaches by the senior author (J.N.B.). Preoperative characteristics and postoperative outcomes were reviewed. A detailed description of the operative technique and perioperative management is provided. RESULTS: Between 1993 and 1996, two patients harboring giant pituitary adenomas underwent an intentionally staged resection, and between 1997 and 2006, nine patients harboring giant pituitary adenomas underwent surgery via a single-stage above and below approach. Nine patients (82%) presented with non-secreting adenomas and two patients (18%) presented with prolactinomas refractory to medical management. Gross total resection was achieved in six patients (55%), near total resection in 1 (9%), and subtotal removal in 4 (36%). Seven patients (64%) experienced visual improvement postoperatively and no major complications occurred. Long-term follow-up averaged 51.6 months. Panhypopituitarism was observed in four patients, partial hypopituitarism in four, persistent DI in two, and persistent SIADH in one. CONCLUSIONS: The addition of a transcranial component to the transsphenoidal approach offers additional visualization of critical neurovascular structures during giant pituitary adenoma resection. Complications rates are similar to other series in which complex pituitary adenomas are resected by other means. The above and below approach is both safe and effective and the immediate and long-term advantages of a single-stage approach justify its utility in this select group of patients.
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Neoplasias Hipofisárias/cirurgia , Adulto , Feminino , Humanos , Hipopituitarismo/etiologia , Hipopituitarismo/patologia , Síndrome de Secreção Inadequada de HAD/etiologia , Síndrome de Secreção Inadequada de HAD/patologia , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/patologia , Prolactinoma/etiologia , Prolactinoma/patologia , Estudos RetrospectivosRESUMO
OBJECTIVE: Up to 25% of patients experience subtle declines in post-operative neurocognitive function following, otherwise uncomplicated, carotid endarterectomy (CEA). We sought to determine if post-CEA neurocognitive deficits are associated with cerebral blood flow (CBF) abnormalities on post-operative MR perfusion brain scans. METHODS: We enrolled 22 CEA patients to undergo a battery of neuropsychometric tests pre-operatively and on post-operative day 1 (POD 1). Neurocognitive dysfunction was defined as a two standard deviation decline in performance in comparison to a similarly aged control group of lumbar laminectomy patients. All patients received MR perfusion brain scans on POD 1 that were analysed for asymmetries in CBF distribution. One patient experienced a transient ischemic attack within 24 hours before the procedure and was excluded from our analysis. RESULTS: Twenty-nine percent of CEA patients demonstrated neurocognitive dysfunction on POD 1. One hundred percent of those patients with cognitive deficits demonstrated CBF asymmetry, in contrast to only 27% of those patients without cognitive impairment. Post-CEA cognitive dysfunction was significantly associated with CBF abnormalities (RR=3.75, 95% CI: 1.62-8.67, p=0.004). CONCLUSION: Post-CEA neurocognitive dysfunction is significantly associated with post-operative CBF asymmetry. These results support the hypothesis that post-CEA cognitive impairment is caused by cerebral hemodynamic changes. Further work exploring the relationship between CBF and post-CEA cognitive dysfunction is needed.
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Circulação Cerebrovascular/fisiologia , Transtornos Cognitivos/etiologia , Imagem de Difusão por Ressonância Magnética , Endarterectomia das Carótidas/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/metabolismo , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Fatores de RiscoRESUMO
RATIONALE AND OBJECTIVES: An automated method for identification and segmentation of acute/subacute ischemic stroke, using the inherent bi-fold symmetry in brain images, is presented. An accurate and automated method for localization of acute ischemic stroke could provide physicians with a mechanism for early detection and potentially faster delivery of effective stroke therapy. MATERIALS AND METHODS: Segmentation of ischemic stroke was performed on magnetic resonance (MR) images of subacute rodent cerebral ischemia. Eight adult male Wistar rats weighing 225-300 g were anesthetized with halothane in a mix of 70% nitrous oxide/30% oxygen. Animal core temperature was maintained at 37 degrees C during the entire surgical procedure, including occlusion of the middle cerebral artery (MCA) and the 90-minute post-reperfusion period. To confirm cerebral ischemia, transcranial measurements of cerebral blood flow were performed with laser-Doppler flowmetry, using 15-mm flexible fiberoptic Doppler probes attached to the skull over the MCA territory. Animal MR scans were performed at 1.5 T using a knee coil. Three experts performed manual tracing of the stroke regions for each rat, using the histologic-stained slices to guide delineation of stroke regions. A strict tracing protocol was followed that included multiple (three) tracings of each stroke region. The volumetric MR image data were processed for each rat by computing the axis of symmetry and extracting statistical dissimilarities. A nonparametric Wilcoxon rank sum test operating on paired windows in opposing hemispheres identified seeds in the pixels exhibiting statistically significant bi-fold mirror asymmetry. Two brain reference maps were used for analysis: an absolute difference map (ADM) and a statistical difference map (SDM). Although an ADM simply displays the absolute difference by subtracting one brain hemisphere from its reflection, SDM highlights regions by labeling pixels exhibiting statistically significant asymmetry. RESULTS: To assess the accuracy of the proposed segmentation method, the surrogate ground truth (the stroke tracing data) was compared to the results of our proposed automated segmentation algorithm. Three accuracy segmentation metrics were utilized: true-positive volume fraction (TPVF), false-positive volume fraction (FPVF), and false-negative volume fraction (FNVF). The mean value of the TPVF for our segmentation method was 0.8877; 95% CI 0.7254 to 1.0500; the mean FPVF was 0.3370, 95% CI -0.0893 to 0.7633; the mean FNVF was 0.1122, 95% CI -0.0502 to 0.2747. CONCLUSIONS: Unlike most segmentation methods that require some degree of manual intervention, our segmentation algorithm is fully automated and highly accurate in identifying regions of brain asymmetry. This approach is attractive for numerous neurologic applications where the operator's intervention should be minimal or null.
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Isquemia Encefálica/diagnóstico , Imageamento por Ressonância Magnética , Algoritmos , Animais , Modelos Animais de Doenças , Fluxometria por Laser-Doppler , Masculino , Ratos , Ratos WistarRESUMO
OBJECT: The aim of this study was to test the validity of the hypothesis that patients in whom brain metastasis is the first indication of an undiagnosed primary tumor have a better chance of survival than similar patients with a known primary lesion. METHODS: Between January 1983 and December 1998, 342 patients with computed tomography-diagnosed brain metastases were treated at a single institution. Information on potential prognostic factors, including primary diagnosis status, was collected retrospectively. Univariate and multivariate analyses were performed to identify prognostic factors related to survival. Survival was not statistically different between patients with an undiagnosed primary (UDP) lesion and those with a diagnosed primary (DP) tumor (6 and 4.5 months, respectively; p = 0.097). In the UDP group (122 patients [36%]), survival was not affected by the eventual identification of the primary disease (p = 0.905). The median survival for the entire population was 5.2 months, with 1-, 2-, and 3-year survival rates of 25, 11, and 4%, respectively. Prognostic factors for the overall population included treatment (p < 0.0001), an age less than 65 years (p = 0.004), discharge status (p < 0.001), absence of systemic metastasis (p = 0.036), and asymptomatic cerebral metastasis (p = 0.05). CONCLUSIONS: Treatment modality was the most significant independent variable affecting survival in patients with brain metastases. Eventual identification of a primary tumor does not affect overall survival; therefore, delaying therapeutic intervention in pursuit of a primary diagnosis may not be appropriate. Data in this study failed to demonstrate a statistically significant difference in survival between patients with UDP and those with DP lesions, on first presenting with brain metastases.
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Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/secundário , Neoplasias Primárias Desconhecidas/diagnóstico , Idoso , Neoplasias Encefálicas/terapia , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Primárias Desconhecidas/terapia , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Prognóstico , Qualidade da Assistência à Saúde/estatística & dados numéricos , Radiocirurgia/estatística & dados numéricos , Radioterapia/estatística & dados numéricos , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Purpose: Standard therapy for newly diagnosed glioblastoma (GBM) is surgical resection, followed by concurrent radiotherapy and temozolomide chemotherapy. In this phase II clinical trial, the addition of an autologous heat-shock protein vaccine to standard therapy was evaluated. Tumor-induced immunosuppression, mediated by expression of PD-L1 on tumor and circulating immune cells, may impact the efficacy of vaccination. Expression of PD-L1 on peripheral myeloid cells was evaluated for the first time as a predictor of survival.Experimental Design: In this single arm, phase II study, adult patients with GBM underwent surgical resection followed by standard radiation and chemotherapy. Autologous vaccine (Prophage) was generated from resected tumors and delivered in weekly vaccinations after completion of radiotherapy. The primary endpoint was overall survival.Results: Forty-six patients received the vaccine with a median overall survival of 23.8 months [95% confidence interval (CI), 19.8-30.2]. Median overall survival for patients with high PD-L1 expression on myeloid cells was 18.0 months (95% CI, 10.0-23.3) as compared with 44.7 months (95% CI, incalculable) for patients with low PD-L1 expression (hazard ratio 3.3; 95% CI, 1.4-8.6; P = 0.007). A multivariate proportional hazards model revealed MGMT methylation, Karnofsky performance status, and PD-L1 expression as the primary independent predictors of survival.Conclusions: Vaccination with autologous tumor-derived heat shock proteins may improve survival for GBM patients when combined with standard therapy and warrants further study. Systemic immunosuppression mediated by peripheral myeloid expression of PD-L1 is a recently identified factor that may significantly impact vaccine efficacy. Clin Cancer Res; 23(14); 3575-84. ©2017 AACR.
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Antígeno B7-H1/imunologia , Glioblastoma/tratamento farmacológico , Receptor de Morte Celular Programada 1/imunologia , Vacinas de Subunidades Antigênicas/administração & dosagem , Adulto , Idoso , Metilação de DNA/imunologia , Intervalo Livre de Doença , Feminino , Regulação Neoplásica da Expressão Gênica , Glioblastoma/genética , Glioblastoma/imunologia , Glioblastoma/patologia , Proteínas de Choque Térmico/imunologia , Proteínas de Choque Térmico/uso terapêutico , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Peptídeos/imunologia , Peptídeos/uso terapêutico , Prognóstico , Vacinas de Subunidades Antigênicas/imunologiaRESUMO
The Adhesive Removal (sticky-tape) test is a commonly used test of somatosensory dysfunction following cerebral ischemia in rats. This test requires several days of pre-training prior to surgery, which can be time consuming. We present our results with an improved version of the sticky-tape test. Male Wistar rats were subjected to either sham surgery (n = 4) or right middle cerebral artery occlusion (rMCAo) using an intraluminal filament (n = 9), followed by a 10-day survival period. On post-operative days (POD) 1, 3, 7, and 10 animals underwent both the conventional sticky-tape test (CST) with measurement of the time to remove the stimulus (trs), as well as a modified sticky-tape test (MST), in which a non-removable tape sleeve was placed around the animal's paw. Time spent attending to this stimulus (tas) was recorded. Despite 3 days of pre-training, animals undergoing baseline CST still exhibited marked variability in pre-operative baseline test performance (trs range 1-60s). In contrast, animals undergoing MST for the first time demonstrated nearly uniformly excellent performance (% tas range 91.5-98.5% of the 30s testing period). Although, affected (left) limb performance on both CST (6.8-fold increase in trs on POD 1 compared to baseline) and MST (100% decrease in tas on POD 1 compared to baseline) was markedly altered by rMCAo, CST performance declined bilaterally, and no significant differences in the ratio of affected (left) and unaffected (right) limb performance between sham-operated and rMCAo animals were observed at any time point. In contrast, the ratio of left to right performance on the MST was significantly different at all time points (P<0.01). In conclusion, we present a simple modification of the widely used Adhesive Removal test and provide evidence that this test can accurately assess neurological dysfunction in rodents, not only with minimal pre-training, but also with improved localization of the side of injury.
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Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Técnicas de Diagnóstico Neurológico , Estimulação Física/métodos , Distúrbios Somatossensoriais/diagnóstico , Distúrbios Somatossensoriais/fisiopatologia , Animais , Bandagens , Isquemia Encefálica/complicações , Masculino , Ratos , Ratos Wistar , Índice de Gravidade de Doença , Distúrbios Somatossensoriais/etiologiaRESUMO
RATIONALE AND OBJECTIVES: Perfusion-weighted computed tomography (CTP) is a relatively recent innovation that estimates a value for cerebral blood flow (CBF) using a series of axial head CT images tracking the time course of a signal from an intravenous contrast bolus. MATERIALS AND METHODS: CTP images were obtained using a standard imaging protocol and were analyzed using commercially available software. A novel computer-based method was used for objective quantification of side-to-side asymmetries of CBF values calculated from CTP images. RESULTS: Our method corrects for the inherent variability of the CTP methodology seen in the subarachnoid hemorrhage (SAH) patient population to potentially aid in the diagnosis of cerebral vasospasm (CVS). This method analyzes and quantifies side-to-side asymmetry of CBF and presents relative differences in a construct termed a Relative Difference Map (RDM). To further automate this process, we have developed a unique methodology that enables a computer to delineate vascular territories within a brain image, regardless of the size and shape of the brain. CONCLUSIONS: While both the quantification of image symmetry using RDMs and the automated assignment of vascular territories were initially designed for the analysis of CTP images, it is likely that they will be useful in a variety of applications.
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Circulação Cerebrovascular , Processamento de Imagem Assistida por Computador/métodos , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Vasoespasmo Intracraniano/diagnóstico por imagem , Adulto , Idoso , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Hemorragia Subaracnóidea/patologia , Vasoespasmo Intracraniano/patologiaRESUMO
OBJECTIVE: Proximal posteroinferior cerebellar artery (PICA) aneurysms are challenging to treat surgically, with high reported perioperative complication rates. We describe the perioperative course and long-term clinical outcomes obtained via a far lateral suboccipital approach in 20 consecutive proximal PICA aneurysms. METHODS: Data were collected prospectively on the first 20 proximal PICA aneurysms treated surgically by a single surgeon (ESC) between December 1997 and April 2003. All aneurysms were clipped via a far lateral approach. Patients with unruptured aneurysms were assessed at 3 and 12 months after surgery. For all subarachnoid hemorrhage patients, a battery of outcome tests was performed at 3- and 12-month intervals. Outcomes were then compared with those of a contemporaneously managed population of ruptured right-sided posterior communicating artery aneurysms. RESULTS: The far lateral suboccipital approach achieved adequate exposure in all cases. There were no intraoperative complications or intraoperative aneurysm ruptures. All patients with unruptured aneurysms were fully functional at long-term follow-up. At 3 months of follow-up, 93% of the subarachnoid hemorrhage patients achieved a Glasgow Outcome Scale score of 1 to 2. At 12 months of follow-up, 92% achieved a Glasgow Outcome Scale score of 1 to 2. Compared with the patients with a ruptured right-sided posterior communicating artery aneurysm, no difference could be found in quality of life or activities of daily living at either time point. CONCLUSION: The favorable outcomes and low postoperative morbidity in this subset of patients argues that clipping via this approach be considered a first-line therapeutic option. When performed in this manner, PICA aneurysm surgery seems to have no greater morbidity than right-sided posterior communicating artery aneurysm surgery.
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Cerebelo/irrigação sanguínea , Cerebelo/cirurgia , Craniotomia/métodos , Aneurisma Intracraniano/cirurgia , Osso Occipital/cirurgia , Complicações Pós-Operatórias , Adulto , Idoso , Artérias/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do TratamentoRESUMO
There is renewed interest in primate models of acute stroke for the evaluation of potential therapeutic agents prior to clinical trials. The development of more precise functional outcome measures would improve the pre-clinical assessment of neuroprotective strategies. We have constructed a grading scale that utilizes an increased number of goal-oriented tasks to assess both behavior and motor function. The new scoring system is designed to enhance precision and accuracy when compared to existing scales. Twenty-seven male baboons were subjected to 1 h of middle cerebral artery territory occlusion followed by reperfusion. Outcome was evaluated using both a standard neurological function scale and a new task-oriented scale. Each scoring system was assessed for reproducibility (inter-observer reliability) and for association with radiographic infarct volume. The task-oriented grading system was significantly less variable than the standard outcome measure (p < 0.0001). The task-oriented neurological scale demonstrated stronger correlation with radiographic infarct volume (p < 0.0001) than the standard scale (p < 0.01) and more accurately reflected infarct size in animals with small strokes. Compared to the accepted system for grading neurological function, the task-oriented scale demonstrates improved inter-observer variability and a better association with radiographic outcome measures. Incorporating this refined neurological evaluation into a baboon model of stroke may serve to increase the functional predictive value of pre-clinical studies.
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Isquemia Encefálica/fisiopatologia , Modelos Animais , Animais , Comportamento Animal , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Isquemia Encefálica/patologia , Infarto da Artéria Cerebral Média/complicações , Imageamento por Ressonância Magnética , Masculino , Atividade Motora , Exame Neurológico/métodos , Papio , Radiografia , Traumatismo por Reperfusão/diagnóstico por imagem , Traumatismo por Reperfusão/patologia , Traumatismo por Reperfusão/fisiopatologia , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Although the development of significant interhemispheric intracranial pressure (ICP) gradients in the setting of unilateral stroke remains controversial, no study to date has investigated the existence of these gradients in a controlled, reproducible, clinically relevant model. Therefore, we used a primate model of reperfused hemispheric stroke to better characterize the development of these gradients. METHODS: Bilateral intraparenchymal ICP was continuously monitored in 7 adult male baboons subjected to left hemisphere reperfused stroke. Interhemispheric ICP gradients were calculated for each baboon and plotted over time. Infarct volume was determined using T2-weighted magnetic resonance imaging (MRI) at sacrifice. RESULTS: A bimodal distribution of interhemispheric ICP gradients was observed in animals with >20% infarct volume (22.1% +/- 0.9; range 21-23%) versus < or = 15% infarct volume (6.6% +/- 2.7; range 1-15%). In animals with >20% infarct volume, interhemispheric gradients developed early and persisted throughout the monitoring period. At 12 hours postreperfusion, animals with large infarcts demonstrated a mean pressure gradient of 13.8 +/- 4.3 mm Hg, compared to a mean gradient of -2.6 +/- 1.1 mm Hg for animals with < or =15% infarct volume. The difference in pressure gradients was statistically significant at all time points from 4 to 12 hours postreperfusion (p < 0.01). CONCLUSIONS: These data suggest that, in nonhuman primates, infarcts of a size approaching 20% of the hemisphere may be associated with significant ICP gradients. With these larger infarcts, ipsilateral monitoring is required if regional cerebral perfusion pressure is to be accurately assessed.
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Edema Encefálico/etiologia , Pressão Intracraniana , Acidente Vascular Cerebral/fisiopatologia , Animais , Edema Encefálico/fisiopatologia , Circulação Cerebrovascular , Modelos Animais de Doenças , Masculino , Monitorização Fisiológica , Papio , Traumatismo por Reperfusão/fisiopatologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/etiologia , Fatores de TempoRESUMO
BACKGROUND: The progression of laser technology in neurosurgery has been limited by the poor maneuverability of traditional line-of-sight carbon dioxide (CO2) lasers and the propensity of other laser energies to cause collateral thermal injury to adjacent neural structures. The advent of a dielectric omnidirectional reflector and the subsequent development of phototonic bandgap fibers (PBF) have transformed the CO2 laser into a low-profile instrument with considerable dexterity and many potential new neurosurgical applications. CASE DESCRIPTION: A 48-year-old woman presented with a large mass in the left lateral ventricle that was first diagnosed>20 years ago. The patient was asymptomatic until 1 month before presentation, when she began to experience progressive memory loss and neurocognitive decline. RESULTS: The hand-held CO2 laser was used to debulk the tumor. The CO2 laser vaporized neoplastic cellular material and simultaneously cauterized microvascular structures. CONCLUSIONS: The CO2 laser was exceptionally useful in the resection of this long-standing and extremely calcified, yet vascular mass. A review of the evolution of laser technology applications in neurosurgery is presented, with a specific focus on the innovations that led to the development of the new PBF CO2 laser. This new technology may be advantageous in tumor surgery, particularly in the resection of long-standing calcified and vascular tumors that are not amendable to traditional surgical techniques.
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Calcinose/cirurgia , Neoplasias do Ventrículo Cerebral/cirurgia , Terapia a Laser/instrumentação , Lasers de Gás , Ventrículos Laterais/cirurgia , Neovascularização Patológica/cirurgia , Papiloma do Plexo Corióideo/cirurgia , Calcinose/diagnóstico , Calcinose/patologia , Neoplasias do Ventrículo Cerebral/irrigação sanguínea , Neoplasias do Ventrículo Cerebral/diagnóstico , Neoplasias do Ventrículo Cerebral/patologia , Desenho de Equipamento , Seguimentos , Humanos , Ventrículos Laterais/irrigação sanguínea , Ventrículos Laterais/patologia , Masculino , Pessoa de Meia-Idade , Neovascularização Patológica/diagnóstico , Neovascularização Patológica/patologia , Exame Neurológico , Papiloma do Plexo Corióideo/irrigação sanguínea , Papiloma do Plexo Corióideo/patologia , Complicações Pós-Operatórias/diagnóstico , Tomografia Computadorizada por Raios XRESUMO
Stereotactic radiosurgery (SRS) should be considered in the comprehensive treatment paradigm for all patients with brain metastases. This technique has proven benefits for local tumor control in individuals with as many as 4 lesions, and when combined with structured radiographic follow-up, will likely preserve a better quality of life for appropriately selected patients. Institutions and physicians treating patients with brain metastases should have the capability of safely performing SRS and individual cases should be prospectively reviewed by multidisciplinary teams to provide the best comprehensive care.
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Neoplasias Encefálicas/secundário , Neoplasias Encefálicas/cirurgia , Encéfalo/cirurgia , Metástase Neoplásica/radioterapia , Radiocirurgia/métodos , Radiocirurgia/tendências , Encéfalo/patologia , Humanos , Radiocirurgia/normasRESUMO
In the past 20 years, surgical resection has found an established role in the management of metastatic brain tumors. Several factors, however, make strong evidence-based medicine impossible to provide for all possible patient presentations. These important factors, such as patient variables (eg, age, medical comorbidities, preoperative performance), tumor variables (eg, number, size, location, histology), and primary disease status must be taken into account on a case-by-case basis to guide patient selection and treatment strategy. Although progress has been made to answer some of the major questions in the management of metastatic brain tumors, several important questions remain. Future studies comparing surgery with stereotactic radiosurgery, for example, are needed to delineate patient selection, complications, and outcome for both of these important modalities.
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Neoplasias Encefálicas/secundário , Neoplasias Encefálicas/cirurgia , Encéfalo/patologia , Encéfalo/cirurgia , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/tendências , Neoplasias Encefálicas/mortalidade , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Medicina Baseada em Evidências/tendências , Humanos , Procedimentos Neurocirúrgicos/normasRESUMO
Dehydroascorbic acid (DHA), a blood-brain barrier transportable form of ascorbic acid, confers robust neuroprotection following murine stroke. In an effort to translate this promising neuroprotective strategy into human clinical trial, we evaluated postischemic DHA administration in a large-animal stroke model. Thirty-six adult male baboons were initially randomized to undergo transorbital craniectomy to induce transient cerebral artery occlusion and to receive postischemic dosing of either 500 mg/kg of DHA or vehicle. Primary outcomes included infarct volume, determined by magnetic resonance imaging, as well as neurological function evaluated on the day of sacrifice. The midpoint interim analysis (n = 9 per cohort) revealed that DHA administration did not significantly improve either infarct volume or neurological function. The study was terminated after a determination of statistical futility. We were unable to confirm a neuroprotective effect for postischemic DHA administration in our large-animal model using a dosing scheme that was previously successful in rodents. Further analysis of the efficacy of DHA administration must thus be undertaken prior to clinical translation.
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BACKGROUND: Computer-based surgical simulators create a no-risk virtual environment where surgeons can develop and refine skills through harmless repetition. These applications may be of particular benefit to neurosurgeons, as the vulnerability of nervous tissue limits the margin for error. The rapid progression of computer-processing capabilities in recent years has led to the development of more sophisticated and realistic neurosurgery simulators. OBJECTIVE: To catalogue the most salient of these advances and characterize our current effort to create a spine surgery simulator. METHODS: An extensive search of the databases Ovid-MEDLINE, PubMed, and Google Scholar was conducted. Search terms included, but were not limited to: neurosurgery combined with simulation, virtual reality, haptics, and 3-dimensional imaging. RESULTS: A survey of the literature reveals that surgical simulators are evolving from platforms used for preoperative planning and anatomic education into programs that aim to simulate essential components of key neurosurgical procedures. This evolution is predicated upon the advancement of 3 main components of simulation: graphics/volume rendering, model behavior/tissue deformation, and haptic feedback. CONCLUSION: The computational burden created by the integration of these complex components often limits the fluidity of real-time interactive simulators. Although haptic interfaces have become increasingly sophisticated, the production of realistic tactile sensory feedback remains a formidable and costly challenge. The rate of future progress may be contingent upon international collaboration between research groups and the establishment of common simulation platforms. Given current limitations, the most potential for growth lies in the innovative design of models that expand the procedural applications of neurosurgery simulation environments.
Assuntos
Simulação por Computador , Neurocirurgia , Cirurgia Assistida por Computador/métodos , Interface Usuário-Computador , Simulação por Computador/tendências , Bases de Dados Factuais/estatística & dados numéricos , Humanos , Doenças do Sistema Nervoso/cirurgia , Cirurgia Assistida por Computador/tendênciasRESUMO
Foramen magnum (FM) lesions represent some of the most complex cases for the modern neurosurgeon because of their location near vital brainstem structures, the vertebral arteries, and lower cranial nerves. In particular, anterior or anterolaterally located FM tumors have traditionally been most difficult to resect with high morbidity and mortality resulting from approaches through the posterior midline or transorally. For many neurosurgeons, the far lateral, extreme lateral approach, and more recently, endoscopic endonasal approaches have become the preferred modern methods for the resection of anterior or anterolateral FM tumors. In this review, we examine both operative and non-operative approaches to FM tumors, including surgical anatomy, surgical technique, and indications for operative intervention in these complex cases. In addition, we compared outcomes from prior series.