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Marzese DM, Scolyer RA, Roqué M, Vargas-Roig LM, Huynh JL, Wilmott JS, Murali R, Buckland ME, Barkhoudarian G, Thompson JF, Morton DL, Kelly DF, Hoon DSB. DNA methylation and gene deletion analysis of brain metastases in melanoma patients identifies mutually exclusive molecular alterations. Neuro Oncol 2014; 16:1499-509. [PMID: 24968695 DOI: 10.1093/neuonc/nou107] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The brain is a common target of metastases for melanoma patients. Little is known about the genetic and epigenetic alterations in melanoma brain metastases (MBMs). Unraveling these molecular alterations is a key step in understanding their aggressive nature and identifying novel therapeutic targets. METHODS Genome-wide DNA methylation analyses of MBMs (n = 15) and normal brain tissues (n = 91) and simultaneous multigene DNA methylation and gene deletion analyses of metastatic melanoma tissues (99 MBMs and 43 extracranial metastases) were performed. BRAF and NRAS mutations were evaluated in MBMs by targeted sequencing. RESULTS MBMs showed significant epigenetic heterogeneity. RARB, RASSF1, ESR1, APC, PTEN, and CDH13 genes were frequently hypermethylated. Deletions were frequently detected in the CDKN2A/B locus. Of MBMs, 46.1% and 28.8% had BRAF and NRAS missense mutations, respectively. Compared with lung and liver metastases, MBMs exhibited higher frequency of CDH13 hypermethylation and CDKN2A/B locus deletion. Mutual exclusivity between hypermethylated genes and CDKN2A/B locus deletion identified 2 clinically relevant molecular subtypes of MBMs. CDKN2A/B deletions were associated with multiple MBMs and frequently hypermethylated genes with shorter time to brain metastasis. CONCLUSIONS Melanoma cells that colonize the brain harbor numerous genetically and epigenetically altered genes. This study presents an integrated genomic and epigenomic analysis that reveals MBM-specific molecular alterations and mutually exclusive molecular subtypes.
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Bresson D, McLaughlin N, Ditzel Filho LFS, Griffiths CF, Carrau RL, Kelly DF, Kassam AB. Endoscopic endonasal approach for the treatment of schwannomas of the pterygopalatine fossa: case report and review of the literature. Neurochirurgie 2014; 60:174-9. [PMID: 24952768 DOI: 10.1016/j.neuchi.2014.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 02/28/2014] [Accepted: 03/02/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Pterygopalatine fossa (PPF) schwannomas are rare lesions most often arising from branches of the trigeminal nerve. Symptomatic lesions have been traditionally treated by conventional external approaches. However, the development of an expanded endonasal approach (EEA) enables skull base surgeons to reach these deeply seated lesions via a different route with its own advantages and drawbacks. METHODS Case report and review of the literature. CASE DESCRIPTION A 41-year-old woman presented with a 6-year history of right facial pain and numbness. Her symptoms had increased progressively over a year, and she recently had developed right-sided otalgia. MRI revealed a right PPF mass, hypointense on T1 and T2 sequences with homogeneous enhancement following the use of gadolinium. A biopsy, attempted at another institution, was considered non-diagnostic. We totally removed the lesion through an endoscopic endonasal transmaxillary approach. Final pathology confirmed the diagnosis of schwannoma. Post-operatively, the patient noted a significant improvement of her facial pain (V2 territory). CONCLUSION The endonasal endoscopic transmaxillary approach provides adequate access to the PPF, thus enabling safe tumor removal with less morbidity than conventional routes.
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Kelly DF, Chaloner C, Evans D, Mathews A, Cohan P, Wang C, Swerdloff R, Sim MS, Lee J, Wright MJ, Kernan C, Barkhoudarian G, Yuen KCJ, Guskiewicz K. Prevalence of pituitary hormone dysfunction, metabolic syndrome, and impaired quality of life in retired professional football players: a prospective study. J Neurotrauma 2014; 31:1161-71. [PMID: 24552537 DOI: 10.1089/neu.2013.3212] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hypopituitarism is common after moderate and severe traumatic brain injury (TBI). Herein, we address the association between mild TBI (mTBI) and pituitary and metabolic function in retired football players. Retirees 30-65 years of age, with one or more years of National Football League (NFL) play and poor quality of life (QoL) based on Short Form 36 (SF-36) Mental Component Score (MCS) were prospectively enrolled. Pituitary hormonal and metabolic syndrome (MetS) testing was performed. Using a glucagon stimulation test, growth hormone deficiency (GHD) was defined with a standard cut point of 3 ng/mL and with a more stringent body mass index (BMI)-adjusted cut point. Subjects with and without hormonal deficiency (HD) were compared in terms of QoL, International Index of Erectile Function (IIEF) scores, metabolic parameters, and football career data. Of 74 subjects, 6 were excluded because of significant non-football-related TBIs. Of the remaining 68 subjects (mean age, 47.3±10.2 years; median NFL years, 5; median NFL concussions, 3; mean BMI, 33.8±6.0), 28 (41.2%) were GHD using a peak GH cutoff of <3 ng/mL. However, with a BMI-adjusted definition of GHD, 13 of 68 (19.1%) were GHD. Using this BMI-adjusted definition, overall HD was found in 16 (23.5%) subjects: 10 (14.7%) with isolated GHD; 3 (4.4%) with isolated hypogonadism; and 3 (4.4%) with both GHD and hypogonadism. Subjects with HD had lower mean scores on the IIEF survey (p=0.016) and trended toward lower scores on the SF-36 MCS (p=0.113). MetS was present in 50% of subjects, including 5 of 6 (83%) with hypogonadism, and 29 of 62 (46.8%) without hypogonadism (p=0.087). Age, BMI, median years in NFL, games played, number of concussions, and acknowledged use of performance-enhancing steroids were similar between HD and non-HD groups. In summary, in this cohort of retired NFL players with poor QoL, 23.5% had HD, including 19% with GHD (using a BMI-adjusted definition), 9% with hypogonadism, and 50% had MetS. Although the cause of HD is unclear, these results suggest that GHD and hypogonadism may contribute to poor QoL, erectile dysfunction, and MetS in this population. Further study of pituitary function is warranted in athletes sustaining repetitive mTBI.
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McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. In Reply. Neurosurgery 2014; 74:E143-4. [DOI: 10.1227/neu.0000000000000160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Marzese DM, Scolyer RA, Huynh JL, Huang SK, Hirose H, Chong KK, Kiyohara E, Wang J, Kawas NP, Donovan NC, Hata K, Wilmott JS, Murali R, Buckland ME, Shivalingam B, Thompson JF, Morton DL, Kelly DF, Hoon DS. Epigenome-wide DNA methylation landscape of melanoma progression to brain metastasis reveals aberrations on homeobox D cluster associated with prognosis. Hum Mol Genet 2014; 23:226-38. [PMID: 24014427 PMCID: PMC3857956 DOI: 10.1093/hmg/ddt420] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 07/29/2013] [Accepted: 08/26/2013] [Indexed: 12/19/2022] Open
Abstract
Melanoma brain metastasis (MBM) represents a frequent complication of cutaneous melanoma. Despite aggressive multi-modality therapy, patients with MBM often have a survival rate of <1 year. Alteration in DNA methylation is a major hallmark of tumor progression and metastasis; however, it remains largely unexplored in MBM. In this study, we generated a comprehensive DNA methylation landscape through the use of genome-wide copy number, DNA methylation and gene expression data integrative analysis of melanoma progression to MBM. A progressive genome-wide demethylation in low CpG density and an increase in methylation level of CpG islands according to melanoma progression were observed. MBM-specific partially methylated domains (PMDs) affecting key brain developmental processes were identified. Differentially methylated CpG sites between MBM and lymph node metastasis (LNM) from patients with good prognosis were identified. Among the most significantly affected genes were the HOX family members. DNA methylation of HOXD9 gene promoter affected transcript and protein expression and was significantly higher in MBM than that in early stages. A MBM-specific PMD was identified in this region. Low methylation level of this region was associated with active HOXD9 expression, open chromatin and histone modifications associated with active transcription. Demethylating agent induced HOXD9 expression in melanoma cell lines. The clinical relevance of this finding was verified in an independent large cohort of melanomas (n = 145). Patients with HOXD9 hypermethylation in LNM had poorer disease-free and overall survival. This epigenome-wide study identified novel methylated genes with functional and clinical implications for MBM patients.
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Prentice AG, Kelly DF, Scudamore CL. Future of disease surveillance. Vet Rec 2013; 173:585-6. [PMID: 24337092 DOI: 10.1136/vr.f7407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McLaughlin N, Cohan P, Barnett P, Eisenberg A, Chaloner C, Kelly DF. Early Morning Cortisol Levels as Predictors of Short-Term and Long-Term Adrenal Function After Endonasal Transsphenoidal Surgery for Pituitary Adenomas and Rathke’s Cleft Cysts. World Neurosurg 2013; 80:569-75. [DOI: 10.1016/j.wneu.2012.07.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 01/10/2012] [Accepted: 07/12/2012] [Indexed: 10/28/2022]
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McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. In reply. Neurosurgery 2013; 73:E557-8. [PMID: 23756738 DOI: 10.1227/neu.0000000000000020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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McLaughlin N, Kelly DF, Prevedello DM, Shahlaie K, Carrau RL, Kassam AB. Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma. J Neurol Surg B Skull Base 2013; 73:190-6. [PMID: 23730548 DOI: 10.1055/s-0032-1312706] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 11/15/2010] [Indexed: 10/28/2022] Open
Abstract
Introduction Petrous apex cholesterol granulomas (PACGs) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. Results A 19-year-old woman presented with a recurrent abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid sinus, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom-free and recurrence-free. Conclusion Endoscopic endonasal surgery must be adapted to manage a recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and the use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences.
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Marzese DM, Huynh JL, Huang S, Hirose H, Kiyohara E, Morton DL, Kelly DF, Hoon DSB. Identification of functional DNA methylation aberrations associated with outcome in melanoma patients with brain metastasis. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.9095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9095 Background: Brain metastasis (MBM) represents one of the most significant causes of death in melanoma patients. Identification of clinically relevant markers is necessary to recognize patients with high risk of MBM development. Alterations in DNA methylation patterns have been recognized as a major epigenetic hallmark of metastasis initiation and progression. Methods: To generate a comprehensive genomic DNA methylation landscape of MBM, we performed genome-wide data integrative analyses examining the DNA methylation (Illumina HumanMethylation 450K), gene expression (Affymetrix HumanExon 1.0), and genotype (Affymetrix SNP 6.0) of specimens related to melanoma progression from normal to MBM (n=65). Results: We observed significant genome-wide hypomethylation and CpG island hypermethylation according to melanoma progression to the brain. To identify significant differentially methylated CpG sites between lymph node metastasis and MBM, we applied a strict statistical threshold (β-value difference >0.3 and FDR-corrected p <0.005). We identified the homeobox D (HOXD) gene family members amongst the most significantly affected genes. The influence on gene expression and the frequency of HOXD hypermethylation were verified using integrative analysis of publicly available data generated from 168 melanoma specimens. In a cohort of clinically annotated melanoma patients (n = 159), we demonstrated that hypermethylation of a genomic region in the HOXD gene cluster was significantly associated with shorter disease-free survival (p = 0.004) and overall survival (p = 0.002).Multivariate analysis confirmed the association with poorer survival (p = 0.01 and HR = 2.8; CI95%: 1.3-6.1). Conclusions: The use of genome-wide DNA methylation, gene expression, and genotyping integrative analyses allowed the identification of novel markers with functional and clinical implications for melanoma patients with brain metastasis.
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McLaughlin N, Carrau RL, Kelly DF, Prevedello DM, Kassam AB. Teamwork in skull base surgery: An avenue for improvement in patient care. Surg Neurol Int 2013; 4:36. [PMID: 23607058 PMCID: PMC3622378 DOI: 10.4103/2152-7806.109527] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 01/28/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND During the past several decades, numerous centers have acquired significant expertise in the treatment of skull base pathologies. Favorable outcomes are not only due to meticulous surgical planning and execution, but they are also related to the collaborative efforts of multiple disciplines. We review the impact of teamwork on patient care, elaborate on the key processes for successful teamwork, and discuss its challenges. METHODS Pubmed and Medline databases were searched for publications from 1970 to 2012 using the following keywords: "teamwork", "multidisciplinary", "interdisciplinary", "surgery", "skull base", "neurosurgery", "tumor", and "outcome". RESULTS Current literature testifies to the complexity of establishing and maintaining teamwork. To date, few reports on the impact of teamwork in the management of skull base pathologies have been published. This lack of literature is somewhat surprising given that most patients with skull base pathology receive care from multiple specialists. Common factors for success include a cohesive and well-integrated team structure with well-defined procedural organization. Although a multidisciplinary work force has clear advantages for improving today's quality of care and propelling research efforts for tomorrow's cure, teamwork is not intuitive and requires training, guidance, and executive support. CONCLUSIONS Teamwork is recommended to improve quality over the full cycle of care and consequently patient outcomes. Increased recognition of the value of an integrated team approach for skull base pathologies will hopefully encourage centers, physicians, allied health caregivers, and scientists devoted to treating these patients and advancing the field of knowledge to invest the time, effort, and resources to optimize and organize their collective expertise.
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McLaughlin N, Ditzel Filho LFS, Prevedello DM, Kelly DF, Carrau RL, Kassam AB. Side-cutting aspiration device for endoscopic and microscopic tumor removal. J Neurol Surg B Skull Base 2013; 73:11-20. [PMID: 23372990 DOI: 10.1055/s-0032-1304834] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Accepted: 07/12/2011] [Indexed: 10/28/2022] Open
Abstract
The authors present a unique side-cutting instrument (NICO Myriad, Indianapolis, IN) with variable aspiration designed specifically for tumor resection. The study included retrospective review of data collected from 10/2009 to 01/2011. We detail the use of the Myriad in 31 patients with the following pathologies: meningioma (n=16), chordoma (n = 3), schwannoma (n = 3), pituitary adenoma (n = 2), metastasis (n = 3), hemangioblastoma (n = 1), craniopharyngioma (n = 1), and nasopharyngeal tumors (n = 2). Surgical approaches included expanded endonasal approach (n = 19), endoscopic brain port (n = 3), supraorbital "eyebrow" craniotomy (n = 3), retrosigmoid suboccipital craniotomy (n = 3), pterional craniotomy (n = 1), extreme far lateral (n = 1), and laminectomy (n = 1). Successful tumor resection was achieved in 30 cases. Instrument failure was noted in only one extremely fibrous meningioma. The design of this instrument facilitated maneuvering through narrow corridors while providing direct visualization of the suction aperture during tumor resection. These features allowed for tumor removal without injury to adjacent neurovascular structures. The side-cutting aspiration device allows safe and effective tumor removal. Its low profile, variable aspiration, and lack of thermal heat energy are particularly useful in tumor resection through narrow corridors, such as endonasal, port, and keyhole approaches. The multifunctional nature of the instrument (suction, scissors, and dissectors) minimizes multiple exchanges, facilitating tumor resection through these minimal access corridors.
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Ditzel Filho LFS, McLaughlin N, Bresson D, Solari D, Kassam AB, Kelly DF. Supraorbital eyebrow craniotomy for removal of intraaxial frontal brain tumors: a technical note. World Neurosurg 2013; 81:348-56. [PMID: 23352966 DOI: 10.1016/j.wneu.2012.11.051] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 09/09/2012] [Accepted: 11/16/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present the utility and selection criteria for the supraorbital (SO) craniotomy, an approach commonly used to remove extraaxial tumors such as meningiomas and craniopharyngiomas, to resect intraaxial frontal brain lesions. METHODS All consecutive patients who underwent a SO craniotomy for an intraaxial lesion were retrospectively analyzed for lesion location, pathology, extent of resection, operative times, length of stay, and complications. RESULTS During 28 months, 10 patients (mean age, 67.6 years; 7 women) underwent 11 SO procedures to resect intraaxial brain lesions. Pathologies included metastatic carcinoma (n = 7), glioma (n = 2), and radiation necrosis (n = 1). The mean distance of the shortest trajectory to the lesion was 2.4 mm. Gross total or near-total removal was achieved in 80% of the cases. Median length of hospital stay was 3 days (range, 2-6 days); it was 2 days for patients admitted electively for SO craniotomy. There were no new neurologic deficits, postoperative hematomas, or cerebrospinal fluid leaks. CONCLUSIONS The SO "eyebrow" craniotomy is a safe and effective keyhole method to remove intraaxial frontal lobe lesions, particularly lesions of the frontal pole and orbitofrontal region, allowing for minimal disruption of normal brain parenchyma and promoting a rapid recovery and short hospital stay. Metastatic tumors and select gliomas in this area are most amenable to this approach. Deeper intraaxial tumors can also be effectively accessed via this route with excellent clinical outcomes.
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Cutler AR, Barkhoudarian G, Griffiths CF, Kelly DF. Transsphenoidal endoscopic skull base surgery: state of the art and future perspective. ACTA ACUST UNITED AC 2013. [DOI: 10.1515/ins-2012-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McLaughlin N, Eisenberg AA, Cohan P, Chaloner CB, Kelly DF. Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J Neurosurg 2012; 118:613-20. [PMID: 23240699 DOI: 10.3171/2012.11.jns112020] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECT Endoscopy as a visual aid (endoscope assisted) or as the sole visual method (fully endoscopic) is increasingly used in pituitary adenoma surgery. Authors of this study assessed the value of endoscopic visualization for finding and removing residual adenoma after initial microscopic removal. METHODS Consecutive patients who underwent endoscope-assisted microsurgical removal of pituitary adenoma were included in this study. The utility of the endoscope in finding and removing residual adenoma not visualized by the microscope was noted intraoperatively. After maximal tumor removal under microscopic visualization, surgeries were categorized as to whether additional tumor was removed via endoscopy. Tumor removal and remission rates were also noted. Patients undergoing fully endoscopic tumor removal during this same period were excluded from the study. RESULTS Over 3 years, 140 patients (41% women, mean age 50 years) underwent endoscope-assisted adenoma removal of 30 endocrine-active microadenomas and 110 macroadenomas (39 endocrine-active, 71 endocrine-inactive); 16% (23/140) of patients had prior surgery. After initial microscopic removal, endoscopy revealed residual tumor in 40% (56/140) of cases and the additional tumor was removed in 36% (50 cases) of these cases. Endoscopy facilitated additional tumor removal in 54% (36/67) of the adenomas measuring ≥ 2 cm in diameter and in 19% (14/73) of the adenomas smaller than 2 cm in diameter (p < 0.0001); additional tumor removal was achieved in 20% (6/30) of the microadenomas. Residual tumor was typically removed from the suprasellar extension and folds of the collapsed diaphragma sellae or along or within the medial cavernous sinus. Overall, 91% of endocrine-inactive tumors were gross-totally or near-totally removed, and 70% of endocrine-active adenomas had early remission. CONCLUSIONS After microscope-based tumor removal, endoscopic visualization led to additional adenoma removal in over one-third of patients. The panoramic visualization of the endoscope appears to facilitate more complete tumor removal than is possible with the microscope alone. These findings further emphasize the utility of endoscopic visualization in pituitary adenoma surgery. Longer follow-ups and additional case series are needed to determine if endoscopic adenomectomy translates into higher long-term remission rates.
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Chhetri UD, Shrestha S, Pradhan R, Shrestha A, Adhikari N, Thorson S, Pollard AJ, Murdoch DR, Kelly DF. Clinical profile of invasive pneumococcal diseases in Patan Hospital, Nepal. Kathmandu Univ Med J (KUMJ) 2012; 9:45-9. [PMID: 22610809 DOI: 10.3126/kumj.v9i1.6262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pneumococcal infection is one of the leading causes of pneumonia, meningitis and septicemia in developing countries. It accounts for one million deaths each year in children. OBJECTIVES The objective of this study is to see the clinical profile of invasive pneumococcal disease, antibiotics sensitivity pattern and prevalent serotypes in children admitted at Patan Hospital. METHODS This is a retrospective analytical study conducted in the department of Paediatrics, Patan hospital. The lab data of those children who grew pneumococci in their blood, cerebrospinal fluid or body fluids over a period of 3 years (January 2007 to Dec 2009) were collected and the case files were then studied. RESULTS Out of 42 cases of invasive pneumococcal diseases studied admitted diagnoses included pneumonia, febrile seizure, bacteremia or septicemia, meningitis, acute gastroenteritis and glomerulonephritis. Twenty seven of them were children under five. The male to female ratio was 1.7:1. On investigation 64%, 52% and 5% of the patients had leucocytosis, anaemia, and leucopenia respectively. Twenty six of them had radiological changes suggestive of pneumonia. Streptococcus pneumoniae grew in 38 blood samples, 5 cerebrospinal fluid and 3 pleural fluids. Almost all of these isolates were sensitive to penicillin, cefotaxime, amoxycillin, choloramphenicol, erythromycin and ofloxacin and resistant to cotrimoxazole and gentamicin. Pneumococcal serotypes found in our study were 1, 14, 5, 23B, 6B, 8, 9A, 9V, 10A, 15 and 23F (11 serotypes). CONCLUSIONS Penicillin is still the most effective antibiotic for streptococcal infection in our study. Of the pneumococcal serotypes identified; 36% were covered by the 7-valent pneumococcal conjugate vaccine, 54% each by PCV-10 and PCV-13, and 72% by the e 23 valent vaccines.
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McLaughlin N, Kelly DF, Prevedello DM, Carrau RL, Kassam AB. Hemostasis management during completely endoscopic removal of a highly vascular intraparenchymal brain tumor: technique assessment. J Neurol Surg A Cent Eur Neurosurg 2012; 75:42-7. [PMID: 23065778 DOI: 10.1055/s-0032-1325631] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recently, stereotactic-guided removal of intraparenchymal lesions using endoscopic visualization through a brain port has been successfully reported. Although endoneurosurgical tumor resection uses the same principles as those used in microneurosurgery, the ability to control bleeding through the port requires an adapted technique. MATERIAL AND METHODS We present a patient that underwent a completely endoscopic resection of a vascular brain tumor through a brain port and describe the hemostatic technique. RESULTS A 68 year-old female presented with progressive gait difficulties. She had been previously treated for a breast cancer. Magnetic resonance imaging (MRI) showed a right subcortical solitary cerebellar lesion that homogeneously enhanced. The patient underwent an endoscopic brain port removal of a supposed brain metastasis. After port cannulation, the tumor partly delivered itself into the port. Following initial tumor biopsy, active bleeding occurred. Irrigation and application of Surgifoam allowed to control the bleeding. Coagulation with an adapted bipolar and removal of coagulated tissue with the side-cutting aspiration device were sequentially repeated. Once the tumor was resected, the suction served as counter-traction elongating the vessels whereas the bipolar cauterized them over a long segment. Hemostasis was performed circumferentially along the cavity's walls from deep to superficial, benefiting from the endoscope's dynamic properties and magnification. Pathology confirmed intraoperative suspicion of hemangioblastoma. CONCLUSION Removal of vascular tumors is feasible through the brain port, despite a relatively narrow corridor of 11.5 mm. However, specific hemostasis techniques are required and adapted instruments are needed to ensure hemostasis through these small corridors.
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McLaughlin N, Kelly DF. Corticospinal tractography as a prognosticator for motor improvement after brainstem cavernoma resection. Br J Neurosurg 2012; 27:108-10. [DOI: 10.3109/02688697.2012.714014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary Centers of Excellence. Neurosurgery 2012; 71:916-24; discussion 924-6. [DOI: 10.1227/neu.0b013e31826d5d06] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Pituitary tumors and associated neuroendocrine disorders pose significant challenges in diagnostic and therapeutic management. Optimal care of the “pituitary patient” is best provided in a multidisciplinary collaborative environment that includes not only experienced pituitary practitioners in neurosurgery and endocrinology, but also in otorhinolaryngological surgery, radiation oncology, medical oncology, neuro-ophthalmology, diagnostic and interventional neuroradiology, and neuropathology. We provide the background and rationale for recognizing pituitary centers of excellence and suggest a voluntary verification process, similar to that used by the American College of Surgeons for Trauma Center verification. We propose that pituitary centers of excellence should fulfill 3 key missions: (1) provide comprehensive care and support to patients with pituitary disorders; (2) provide residency training, fellowship training, and/or continuing medical education in the management of pituitary and neuroendocrine disease; and (3) contribute to research in pituitary disorders. As this is a preliminary proposal, we recognize several issues that warrant further consideration including center and surgeon practice volume as well as oversight of the verification process.
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McLaughlin N, Vandergrift A, Ditzel Filho LF, Shahlaie K, Eisenberg AA, Carrau RL, Cohan P, Kelly DF. Endonasal management of sellar arachnoid cysts: simple cyst obliteration technique. J Neurosurg 2012; 116:728-40. [DOI: 10.3171/2011.12.jns11399] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Symptomatic sellar arachnoid cysts (ACs) have typically been treated via the transsphenoidal route. After sellar cyst wall fenestration, some authors have advocated cyst wall resection and increasing communication between the AC and suprasellar subarachnoid space (SAS). This study is a report of the authors' experience using a simplified approach to reinforce a defective diaphragma sellae or unseen arachnoid diverticulum by deliberately not enlarging the AC-SAS communication and obliterating the cyst cavity with adipose tissue followed by skull base reconstruction.
Methods
A retrospective analysis was conducted of patients who underwent an endonasal transsphenoidal obliteration of symptomatic ACs with a fat graft and skull base repair.
Results
Between July 1998 and September 2010, 8 patients with a sellar AC were identified (6 women and 2 men, mean age 57 years). Clinical presentation included headache, pituitary dysfunction, and visual dysfunction (4 patients each group). Maximal cyst diameter averaged 22 mm (range 15–32 mm). In all cases the sellar communication to the SAS was deliberately not enlarged. The endoscope was used for visualization in 8 of 9 procedures. Postoperatively, headache improved in all 4 patients, vision in all 4 patients, and partial resolution of endocrine dysfunction (hyperprolactinemia and/or recurrent hyponatremia) occurred in 3 (75%) of 4 patients. No new endocrinopathy, CSF leak, meningitis, or neurological deficits occurred. Two patients experienced cyst reaccumulation: 1 symptomatic recurrence was treated with reoperation at 43 months postsurgery, and 1 asymptomatic partial recurrence continued to be monitored at 29 months postsurgery.
Conclusions
Sellar ACs can be effectively treated using endonasal fenestration and obliteration with fat with resultant reversal of presenting symptoms in the majority of patients. This simplified technique of AC cavity obliteration without enlarging communication to the SAS has a low risk of CSF leakage, and in most cases appears to effectively disrupt cyst progression, although longer follow-up is required to monitor for cyst recurrence.
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Abstract
The complex pathophysiology of traumatic brain injury (TBI) involves not only the primary mechanical event but also secondary insults such as hypotension, hypoxia, raised intracranial pressure and changes in cerebral blood flow and metabolism. It is increasingly evident that these initial insults as well as transient events and treatments during the early injury phase can impact hypothalamic-pituitary function both acutely and chronically after injury. In turn, untreated pituitary hormonal dysfunction itself can further hinder recovery from brain injury. Secondary adrenal insufficiency, although typically reversible, occurs in up to 50% of intubated TBI victims and is associated with lower systemic blood pressure. Chronic anterior hypopituitarism, although reversible in some patients, persists in 25-40% of moderate and severe TBI survivors and likely contributes to long-term neurobehavioral and quality of life impairment. While the rates and risk factors of acute and chronic pituitary dysfunction have been documented for moderate and severe TBI victims in numerous recent studies, the pathophysiology remains ill-defined. Herein we discuss the hypotheses and available data concerning hypothalamic-pituitary vulnerability in the setting of head injury. Four possible pathophysiological mechanisms are considered: (1) the primary brain injury event, (2) secondary brain insults, (3) the stress of critical illness and (4) medication effects. Although each of these factors appears to be important in determining which hormonal axes are affected, the severity of dysfunction, their time course and possible reversibility, this process remains incompletely understood.
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Kelly DF. Cavitating pulmonary lesions in German shepherd dogs. J Small Anim Pract 2011; 52:665. [PMID: 22136451 DOI: 10.1111/j.1748-5827.2011.01159.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nabili V, Kelly DF, Fatemi N, St John M, Calcaterra TC, Abemayor E. Transnasal, transfacial, anterior skull base resection of olfactory neuroblastoma. Am J Otolaryngol 2011; 32:279-85. [PMID: 20728963 DOI: 10.1016/j.amjoto.2010.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 05/17/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE Using a transnasal, transfacial, anterior skull base approach, we have removed olfactory neuroblastomas (OFN) obviating the need for a frontal craniotomy. The objectives were to present our surgical approach in achieving clear margins, to assess patient survival, and to recommend eligibility criteria. MATERIALS AND METHODS A retrospective chart review was done to identify patients diagnosed with OFN who underwent this surgical approach. Thirteen patients were identified who underwent our pictorially described approach. Postoperative assessment of pathologic margins, patient survival, and limitations of surgical approach was determined. RESULTS Of the 13 patients, 12 (92%) had clear postsurgical margins. One patient had residual intracranial disease due to coagulopathy preventing further resection. Twelve patients remain alive with 10 patients remaining disease-free (follow-up ranging from 11 to 64 months). Three patients presented with recurrent disease initially, with 2 having had subsequent repeat local and regional recurrences, respectively; one of whom died recently of the re-recurrent disease. One patient had a postoperative cerebrospinal fluid leak repaired via the original surgical approach. CONCLUSIONS Although craniofacial resection remains an accepted approach for surgical treatment of OFN, we have adopted a transnasal, transfacial approach eliminating the need for a frontal craniotomy. This approach allows for adequate exposure of the cribriform plate, dura, and anterior skull base. Our technique minimizes dural defects and prevents many craniotomy-associated complications, including frontal lobe retraction. Long-term follow-up is needed to compare survival using this approach; however, our results to date are quite promising.
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McLaughlin N, Kelly DF, Prevedello DM, Shahlaie K, Carrau RL, Kassam AB. Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma. SKULL BASE REPORTS 2011; 1:27-32. [PMID: 23984199 PMCID: PMC3743582 DOI: 10.1055/s-0031-1275253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 11/15/2010] [Indexed: 11/19/2022]
Abstract
Petrous apex cholesterol granulomas (PACG) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. A 19-year-old woman presented with a recurrent right abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom- and recurrence-free. Endoscopic endonasal surgery must be adapted to manage recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences.
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McLaughlin N, Kassam AB, Prevedello DM, Kelly DF. Management of Cushing's disease after failed surgery--a review. Can J Neurol Sci 2011; 38:12-21. [PMID: 21156424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Selective transsphenoidal adenomectomy is generally recommended for initial treatment of Cushing's disease (CD) because it achieves a high (70-85%) rate of remission. However, if initial surgery is not successful, the approach to persistent or recurrent CD is more complex. Because residual or recurrent adenoma is typically found at the site of the original adenoma, repeat transsphenoidal surgery is recommended including selective adenomectomy, hemihypophysectomy or total hypophysectomy. If repeat pituitary surgery does not achieve remission, then possible adjuvant therapies include radiosurgery or stereotactic radiotherapy, bilateral adrenalectomy, and/or medical therapy. In all cases of persistent or recurrent CD, successful treatment requires close collaboration of endocrinologists, radiation oncologists and neurosurgeons.
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