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Black PM, Alexander E, Martin C, Moriarty T, Nabavi A, Wong TZ, Schwartz RB, Jolesz F. Craniotomy for tumor treatment in an intraoperative magnetic resonance imaging unit. Neurosurgery 1999; 45:423-31; discussion 431-3. [PMID: 10493363 DOI: 10.1097/00006123-199909000-00001] [Citation(s) in RCA: 251] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE The complex three-dimensional anatomic features of the brain and its vulnerability to surgical intervention make the surgical treatment of intracranial tumors challenging. We evaluated the surgical treatment of supratentorial tumors using intraoperative magnetic resonance imaging (MRI), which provides real-time guidance, allows localization of intracranial tumors and their margins, and facilitates continuous assessment of surgical progress. METHODS Sixty patients underwent craniotomies for tumor treatment in the General Electric intraoperative MRI unit at the Brigham and Women's Hospital (Boston, MA) during a 1-year period. The patients selected were those with intracranial tumors that were considered difficult to resect because of their locations or previous incomplete operations. Twenty-nine low-grade and 19 high-grade gliomas, 8 metastatic lesions, 2 meningiomas, 1 pineoblastoma, and 1 astroblastoma were resected. RESULTS Tumors were accurately localized and targeted, and the extent of resection, as well as any intraoperative complications, could be immediately assessed during surgery. Marked brain shifting occurred during the procedures, and repeated intraoperative imaging allowed surgical accommodation for this shifting. In more than one-third of the cases, intraoperative imaging showed residual tumor when resection appeared complete on the basis of surgical observation alone. CONCLUSION Intraoperative MRI is a revolutionary tool for the surgical treatment of brain tumors, providing observation of the procedure as it is being performed. With intraoperative MRI, tumor resection is safer, the extent of resection can be directly evaluated, and intraoperative complications can be noted if they occur. Outcomes after resection depend on minimizing injury to normal brain tissue and achieving maximal tumor resection. The use of intraoperative MRI directly affects these factors.
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Alexander E, Pham D, Steck TR. The viable-but-nonculturable condition is induced by copper in Agrobacterium tumefaciens and Rhizobium leguminosarum. Appl Environ Microbiol 1999; 65:3754-6. [PMID: 10427081 PMCID: PMC91566 DOI: 10.1128/aem.65.8.3754-3756.1999] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Many bacteria respond to changes in environmental conditions by entering the viable-but-nonculturable state. We have determined that copper can induce nutrient-starved Agrobacterium tumefaciens and Rhizobium leguminosarum cells to become viable but nonculturable. This is the first report of a chemical inducer of this condition.
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Alexander E. Eric Oldberg. SURGICAL NEUROLOGY 1999; 52:100-2. [PMID: 10390183 DOI: 10.1016/s0090-3019(98)00034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Alexander E. Neurosurgical heritage. Fathers/sons/daughters in neurosurgery in the U.S. and Canada. SURGICAL NEUROLOGY 1999; 51:680-6. [PMID: 10369240 DOI: 10.1016/s0090-3019(99)00028-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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80
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Alexander E. Domestic violence: fueled by alcohol? N C Med J 1999; 60:122. [PMID: 10355272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
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81
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Pennacchio M, Syah YM, Alexander E, Ghisalberti EL. Mechanism of action of verbascoside on the isolated rat heart: increases in level of prostacyclin. Phytother Res 1999; 13:254-5. [PMID: 10353173 DOI: 10.1002/(sici)1099-1573(199905)13:3<254::aid-ptr430>3.0.co;2-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The mechanism of the positive cardioactive effects induced by verbascoside in the Lagendorff rat heart has been investigated. Isolated rat hearts treated with alpha- or beta-adrenergic agents did not show significant reduction of the positive chronotropism, inotropism and increased coronary perfusion rate mediated by verbascoside. A significant increase in prostacyclin levels (142%) observed following the administration of verbascoside suggests that prostacyclin stimulates formation of cAMP which induces the cardioactivity associated with verbascoside.
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Schwartz RB, Hsu L, Wong TZ, Kacher DF, Zamani AA, Black PM, Alexander E, Stieg PE, Moriarty TM, Martin CA, Kikinis R, Jolesz FA. Intraoperative MR imaging guidance for intracranial neurosurgery: experience with the first 200 cases. Radiology 1999; 211:477-88. [PMID: 10228532 DOI: 10.1148/radiology.211.2.r99ma26477] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To review preliminary experience with an open-bore magnetic resonance (MR) imaging system for guidance in intracranial surgical procedures. MATERIALS AND METHODS A vertically oriented, open-configuration 0.5-T MR imager was housed in a sterile procedure room. Receive and transmit surface coils were wrapped around the patient's head, and images were displayed on monitors mounted in the gap of the magnet and visible to surgeons. During 2 years, 200 intracranial procedures were performed. RESULTS There were 111 craniotomies, 68 biopsies, 12 intracranial cyst evaluations, four subdural drainages, and five transsphenoidal pituitary resections performed with the intraoperative MR unit. In each case, the intraoperative MR system yielded satisfactory results by allowing the radiologist to guide surgeons toward lesions and to assist in treatment. In two patients, hyperacute hemorrhage was noted and removed. The duration of the procedure and the complication rate were similar to those of conventional surgery. CONCLUSION Intraoperative MR imaging was successfully implemented for a variety of intracranial procedures and provided continuous visual feedback, which can be helpful in all stages of neurosurgical intervention without affecting the duration of the procedure or the incidence of complications. This system has potential advantages over conventional frame-based and frameless stereotactic procedures with respect to the safety and effectiveness of neurosurgical interventions.
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Alexander E, Loeffler JS. The role of radiosurgery for glial neoplasms. Neurosurg Clin N Am 1999; 10:351-8. [PMID: 10099099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Malignant gliomas are one of the most serious challenges in clinical neurosurgery. Despite advances in surgical and radiation techniques, chemotherapy, and other systemic antineoplastic regimens, such as gene therapy and immunotherapy, patients who suffer from malignant gliomas often succumb to their disease. Although some success has been made with forms of enhanced surgical guidance and localized radiotherapy, current techniques are unable to eradicate the infiltrative glioma cells.
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Alexander E, Brody H. Ethics by the numbers: monitoring physicians' integrity in managed care. THE JOURNAL OF CLINICAL ETHICS 1999; 9:297-305. [PMID: 10029830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Kamp J, Troy DE, Alexander E. FDA marketing v. First Amendment: Washington Legal Foundation legal challenges to off-label policies may force unprecedented changes at FDA. FOOD AND DRUG LAW JOURNAL 1999; 54:555-565. [PMID: 11824453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Hodgson D, Goumnerova L, Loeffler J, Dutton S, Black P, Alexander E, Xu R, Tarbell N. 2242 Stereotactic radiosurgery (SRS) in the management of pediatric brain tumors. Int J Radiat Oncol Biol Phys 1999. [DOI: 10.1016/s0360-3016(99)90511-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Shrieve DC, Alexander E, Black PM, Wen PY, Fine HA, Kooy HM, Loeffler JS. Treatment of patients with primary glioblastoma multiforme with standard postoperative radiotherapy and radiosurgical boost: prognostic factors and long-term outcome. J Neurosurg 1999; 90:72-7. [PMID: 10413158 DOI: 10.3171/jns.1999.90.1.0072] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT To assess the value of stereotactic radiosurgery (SRS) as adjunct therapy in patients suffering from glioblastoma multiforme (GBM), the authors analyzed their experience with 78 patients. METHODS Between June 1988 and January 1995, 78 patients underwent SRS as part of their initial treatment for GBM. All patients had undergone initial surgery or biopsy confirming the diagnosis of GBM and received conventional external beam radiotherapy. Stereotactic radiosurgery was performed using a dedicated 6-MV stereotactic linear accelerator. Thirteen patients were alive at the time of analysis with a median follow-up period of 40.8 months. The median length of actuarial survival for all patients was 19.9 months. Twelve- and 24-month survival rates were 88.5% and 35.9%, respectively. Patient age and Radiation Therapy Oncology Group (RTOG) class were significant prognostic indicators according to univariate analysis (p < 0.05). Twenty-three patients aged younger than 40 years had a median survival time of 48.6 months compared with 55 older patients who had 18.2 months (p < 0.001). Patients in this series fell into RTOG Classes III (27 patients), IV (29 patients), or V (22 patients). Class III patients had a median survival time of 29.5 months following diagnosis; this was significantly longer than median survival times for Classes IV and V, which were 19.2 and 18.2 months, respectively (p = 0.001). Only patient age (< 40 years) was a significant prognostic factor according to multivariate analysis. Acute complications were unusual and limited to exacerbation of existing symptoms. There were no new neuropathies secondary to SRS. Thirty-nine patients (50%) underwent reoperation for symptomatic necrosis or recurrent tumor. The rate of reoperation at 24 months following SRS was 54.8%. CONCLUSIONS The addition of a radiosurgery boost appears to confer a survival advantage to selected patients.
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Mitsumori M, Shrieve DC, Alexander E, Kaiser UB, Richardson GE, Black PM, Loeffler JS. Initial clinical results of LINAC-based stereotactic radiosurgery and stereotactic radiotherapy for pituitary adenomas. Int J Radiat Oncol Biol Phys 1998; 42:573-80. [PMID: 9806517 DOI: 10.1016/s0360-3016(98)00256-9] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To retrospectively evaluate the initial clinical results of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) for pituitary adenomas with regard to tumor and hormonal control and adverse effects of the treatment. SUBJECTS AND METHODS Forty-eight patients with pituitary adenoma who underwent SRS or SRT between September 1989 and September 1995 were analyzed. Of these, 18 received SRS and 30 received SRT. The median tumor volumes were 1.9 cm3 for SRS and 5.7 cm3 for SRT. Eleven of the SRS and 18 of the SRT patients were hormonally active at the time of the initial diagnosis. Four of the SRS and none of the SRT patients had a history of prior radiation therapy. Both SRS and SRT were performed using a dedicated stereotactic 6-MV linear accelerator (LINAC). The dose and normalization used for the SRS varied from 1000 cGy at 85% of the isodose line to 1500 cGy at 65% of the isodose line. For SRT patients, a total dose of 4500 cGy at 90% or 95% of the isodose line was delivered in 25 fractions of 180 cGy daily doses. RESULTS Disease control-The three year tumor control rate was 91.1% (100% for SRS and 85.3% for SRT). Normalization of the hormonal abnormality was achieved in 47% of the 48 patients (33% for SRS and 54% for SRT). The average time required for normalization was 8.5 months for SRS and 18 months for SRT. Adverse effects-The 3-year rate of freedom from central nervous system adverse effects was 89.7% (72.2% for SRS and 100% for SRT). Three patients who received SRS for a tumor in the cavernous sinus developed a ring enhancement in the temporal lobe as shown by follow-up magnetic resonance imaging. Two of these cases were irreversible and were considered to be radiation necrosis. None of the 48 patients developed new neurocognitive or visual disorders attributable to the irradiation. The incidence of endocrinological adverse effects were similar in the two groups, resulting in 3-year rates of freedom from newly initiated hormonal replacement of 78.4% (77.1% for SRS and 79.9% for SRT). CONCLUSION Considering the relatively high incidence of morbidity observed in the SRS group, we recommend SRT as the primary method of radiation therapy for pituitary tumors. When treating a lesion in the cavernous sinus with SRS, special attention should be paid to dose distribution in the adjacent brain parenchyma. Longer follow-up is necessary before drawing any conclusions about the advantages of these techniques over conventional external beam radiation therapy.
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Schwartz RB, Hsu L, Kacher DF, Wong TZ, Alexander E, Okon S, Guttmann CR, Black PM, Kelley RA, Moriarty T, Martin C, Isbister HG, Cahill CD, Spaulding SA, Jolesz FA. Intraoperative dynamic MRI: localization of sites of brain tumor recurrence after high-dose radiotherapy. J Magn Reson Imaging 1998; 8:1085-9. [PMID: 9786146 DOI: 10.1002/jmri.1880080513] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
In patients with malignant astrocytomas or metastatic brain disease treated with high-dose radiotherapy, conventional imaging methods may not adequately distinguish recurrent tumor from radiation change. We used a fast spoiled gradient refocusing technique in the open-configuration intraoperative MR system to assess the rate of regional enhancement of the treated tumor bed and to localize specific sites for pathologic sampling to determine whether gadolinium uptake correlated with histologic data. Twenty-four patients were studied. Fourteen of 15 patients with areas of early enhancement had recurrent tumor present in histologic samples, and 8 of the remaining 9 patients had only reactive changes. Dynamic MRI was predictive of recurrent tumor (P < .0005, Fisher exact test and P < .002, Student t test). We conclude that dynamic MRI in the open-bore magnet is a promising method for localizing potential sites of active tumor growth in patients treated for malignant astrocytomas and metastatic brain lesions.
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Schwartz RB, Hsu L, Black PM, Alexander E, Wong TZ, Klufas RA, Moriarty T, Martin C, Isbister HG, Cahill CD, Spaulding SA, Kanan AR, Jolesz FA. Evaluation of intracranial cysts by intraoperative MR. J Magn Reson Imaging 1998; 8:807-13. [PMID: 9702881 DOI: 10.1002/jmri.1880080409] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Eleven patients with intracranial cystic collections were evaluated in the open-bore intraoperative MR system. In each case, the cystic collection or the surrounding cerebrospinal fluid (CSF) space was injected with .02 to .5 cc of .5 mol/l gadopentetate dimeglumine. Serial imaging was performed using T1-weighted imaging. In seven patients, free communication was demonstrated between the cystic collection and the surrounding CSF spaces. In four cases, the cyst did not communicate with the CSF; two of these were drained in the intraoperative MR system with reduction in symptoms. One patient developed an aseptic meningitis 10 days after the study, which was successfully treated with steroids; no other complications were noted. We conclude that the communication of intracranial cystic collections with the cisterns and ventricles can be safely and effectively elucidated with gadolinium injection in the intraoperative MR system.
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Schwartz RB, Holman BL, Polak JF, Garada BM, Schwartz MS, Folkerth R, Carvalho PA, Loeffler JS, Shrieve DC, Black PM, Alexander E. Dual-isotope single-photon emission computerized tomography scanning in patients with glioblastoma multiforme: association with patient survival and histopathological characteristics of tumor after high-dose radiotherapy. J Neurosurg 1998; 89:60-8. [PMID: 9647173 DOI: 10.3171/jns.1998.89.1.0060] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The study was conducted to determine the association between dual-isotope single-photon emission computerized tomography (SPECT) scanning and histopathological findings of tumor recurrence and survival in patients treated with high-dose radiotherapy for glioblastoma multiforme. METHODS Studies in which SPECT with 201Tl and 99mTc-hexamethypropyleneamine oxime (HMPAO) were used were performed 1 day before reoperation in 47 patients with glioblastoma multiforme who had previously been treated by surgery and high-dose radiotherapy. Maximum uptake of 201Tl in the lesion was expressed as a ratio to that in the contralateral scalp, and uptake of 99mTc-HMPAO was expressed as a ratio to that in the cerebellar cortex. Patients were stratified into groups based on the maximum radioisotope uptake values in their tumor beds. The significance of differences in patient gender, histological characteristics of tissue at reoperation, and SPECT uptake group with respect to 1-year survival was elucidated by using the chi-square statistic. Comparisons of patient ages and time to tumor recurrence as functions of 1-year survival were made using the t-test. Survival data at 1 year were presented according to the Kaplan-Meier method, and the significance of potential differences was evaluated using the log-rank method. The effects of different variables (tumor type, time to recurrence, and SPECT grouping) on long-term survival were evaluated using Cox proportional models that controlled for age and gender. All patients in Group I (201Tl ratio < 2 and 99mTc-HMPAO ratio < 0.5) showed radiation changes in their biopsy specimens: they had an 83.3% 1-year survival rate. Group II patients (201Tl ratio < 2 and 99mTc-HMPAO ratio of > or = 0.5 or 201Tl ratio between 2 and 3.5 regardless of 99mTc-HMPAO ratio) had predominantly infiltrating tumor (66.6%); they had a 29.2% 1-year survival rate. Almost all of the patients in Group III (201Tl ratio > 3.5 and 99mTc-HMPAO ratio > or = 0.5) had solid tumor (88.2%) and they had a 6.7% 1-year survival rate. Histological data were associated with 1-year survival (p < 0.01): however, SPECT grouping was more closely associated with 1-year survival (p < 0.001) and was the only variable significantly associated with long-term survival (p < 0.005). CONCLUSIONS Dual-isotope SPECT data correlate with histopathological findings made at reoperation and with survival in patients with malignant gliomas after surgical and high-dose radiation therapy.
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Potts GF, Gugino LD, Leventon ME, Grimson WE, Kikinis R, Cote W, Alexander E, Anderson JE, Ettinger GJ, Aglio LS, Shenton ME. Visual hemifield mapping using transcranial magnetic stimulation coregistered with cortical surfaces derived from magnetic resonance images. J Clin Neurophysiol 1998; 15:344-50. [PMID: 9736468 DOI: 10.1097/00004691-199807000-00006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The perception of a visual stimulus can be inhibited by occipital transcranial magnetic stimulation. This visual suppression effect has been attributed to disruption in the cortical gray matter of primary visual cortex or in the fiber tracts leading to V1 from the thalamus. However, others have suggested that the visual suppression effect is caused by disruption in secondary visual cortex. Here the authors used a figure-eight coil, which produces a focal magnetic field, and a Quadropulse stimulator to produce visual suppression contralateral to the stimulated hemisphere in five normal volunteer subjects. The authors coregistered the stimulation sites with magnetic resonance images in these same subjects using optical digitization. The stimulation sites were mapped onto the surface of the occipital lobes in three-dimensional reconstructions of the cortical surface to show the distribution of the visual suppression effect. The results were consistent with disruption of secondary visual cortical areas.
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Ettinger GJ, Leventon ME, Grimson WE, Kikinis R, Gugino L, Cote W, Sprung L, Aglio L, Shenton ME, Potts G, Hernandez VL, Alexander E. Experimentation with a transcranial magnetic stimulation system for functional brain mapping. Med Image Anal 1998; 2:133-42. [PMID: 10646759 DOI: 10.1016/s1361-8415(98)80008-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We describe functional brain mapping experiments using a transcranial magnetic stimulation (TMS) device. This device, when placed on a subject's scalp, stimulates the underlying neurons by generating focused magnetic field pulses. A brain mapping is then generated by measuring responses of different motor and sensory functions to this stimulation. The key process in generating this mapping is the association of the 3-D positions and orientations of the TMS probe on the scalp to a 3-D brain reconstruction such as is feasible with a magnetic resonance image (MRI). We have developed a registration system which not only generates functional brain maps using such a device, but also provides real-time feedback to guide the technician in placing the probe at appropriate points on the head to achieve the desired map resolution. Functional areas we have mapped are the motor and visual cortex. Validation experiments focus on repeatability tests for mapping the same subjects several times. Applications of the technique include neuroanatomy research, surgical planning and guidance, treatment and disease monitoring, and therapeutic procedures.
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Martin C, Alexander E, Wong T, Schwartz R, Jolesz F, Black PM. Surgical treatment of low-grade gliomas in the intraoperative magnetic resonance imager. Neurosurg Focus 1998; 4:e8. [PMID: 17168508 DOI: 10.3171/foc.1998.4.4.11] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Radical resection of low-grade gliomas can decrease the incidence of recurrence, the time to tumor progression, and the incidence of malignant transformation. The authors present a series of 25 patients who underwent craniotomy and resection of low-grade tumor in an intraoperative magnetic resonance (MR) imager. This is an open configuration 0.5-tesla imager developed by The Brigham and Women's Hospital and General Electric, in which a patient can be placed to undergo surgery. Gross-total removal was accomplished under real-time image guidance. These intraoperative images allow definitive localization and targeting of the lesions and accommodate anatomical changes that may occur during surgery. The authors consistently found that the extent of abnormality seen on the intraoperatively obtained films of resection was larger than that apparent in the surgical field of view alone. Intraoperative imaging made accurate surgical identification of these abnormal areas and subsequent resection possible. Patients with tumors adjacent to or within motor or language cortex underwent resection while awake, with monitoring of neurological function. In these cases, an aggressive resection without increased neurological morbidity was accomplished using the image guidance in conjunction with serial testing. A 1-month postoperative MR image was obtained in all patients. These correlated with the final intraoperative images obtained after the resection was completed. Only one patient had a mild postoperative deficit that remained at the 1-month follow-up examination. As the long-term outcome in patients with low-grade gliomas has been shown to correspond to the degree of resection, surgical resection in which intraoperative MR imaging guidance is used can be an invaluable modality in the treatment of these tumors.
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Hakim R, Alexander E, Loeffler JS, Shrieve DC, Wen P, Fallon MP, Stieg PE, Black PM. Results of linear accelerator-based radiosurgery for intracranial meningiomas. Neurosurgery 1998; 42:446-53; discussion 453-4. [PMID: 9526976 DOI: 10.1097/00006123-199803000-00002] [Citation(s) in RCA: 189] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We report the outcomes of patients treated with linear accelerator-based radiosurgery for intracranial meningiomas at our institution. METHODS We reviewed 127 patients with 155 meningiomas treated with stereotactic radiosurgery (SRS) at the study institutions between October 1988 and December 1995. RESULTS There were 86 female and 41 male patients (median age, 61.5 yr; range, 19.9-87.9 yr). The median follow-up period was 31 months (range, 1.2-79.8 mo). The median tumor volume was 4.1 cc (range, 0.16-51.2 cc), and the median marginal dose was 15 Gy (range, 9-20 Gy). The tumor locations were as follows: convexity, 31 tumors; parasagittal/falcine, 39 tumors; cranial base, 82 tumors; and ventricular/pineal, 3 tumors. There were 106 benign, 26 atypical, and 18 malignant meningiomas and 5 cases of meningiomatosis. SRS was performed on 48 lesions as the initial treatment and on 107 lesions as adjunct therapy. Freedom from progression was observed in 107 patients (84.3%) at a median time of 22.9 months (range, 1.2-79.8 mo). Twenty patients (15.7%) had disease progression (16 marginal [12.6%] and 4 local [3.1%]) at a median time of 19.6 months (range, 4.1-69.3 mo); the median time for freedom from progression for the benign, atypical, and malignant meningiomas was 20.9, 24.4, and 13.9 months, respectively. Actuarial tumor control for the patients with benign meningiomas was 100, 92.9, 89.3, 89.3, and 89.3% at 1, 2, 3, 4, and 5 years, respectively. Six patients (4.7%) had permanent complications attributable to SRS (median time, 10.3 mo; range, 4.3-18.0 mo); 13 patients died as a result of causes related to the meningiomas (median, 17.5 mo; range, 4.3-37.3 mo). The 1-, 2-, 3-, 4-, and 5-year survival probability for the entire group of patients was 90.3, 82.6, 73.6, 70.5, and 68.2%, respectively; for patients with benign meningiomas, excluding death resulting from intercurrent disease, the survival probability was 97.6, 94.8, 91.0, 91.0, and 91.0%, respectively. The 1-, 2-, 3-, and 4-year survival probability for the patients with atypical and malignant meningiomas was 91.7, 83.3, 83.3, and 83.3% and 92.3, 64.6, 43.1, and 21.5%, respectively. CONCLUSION Even though complications from SRS are expected more frequently with large tumors near critical structures, SRS is a safe and effective means of treating selected meningiomas.
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Abstract
Despite the ability of surgery, radiotherapy, and chemotherapy to prolong survival in patients with glioblastoma multiforme (GBM), most patients succumb to their disease, usually as a result of local tumor persistence or recurrence. Stereotactic radiosurgery (SRS) allows a substantial increase in total dose at sites of greatest tumor cell density while sparing most of the normal brain, resulting in significantly improved survival. SRS was designed as a technique to deliver a large single dose of radiation to a small and focal target: two of its hallmarks are the focal distribution of dose and the inverse relationship between dose and volume. Acute complications of SRS are related to edema and are manifested as a worsening of pre-existing symptoms: seizure, aphasia, and motor deficits--these are treatable with steroids and are transient in the majority of cases. The actuarial risk of undergoing reoperation was 33% at 12 months and 48% at 24 months, following SRS. Patterns of failure were similar following brachytherapy or SRS as treatment for recurrent GBM with most patients experiencing marginal failure outside the original treatment volume. Patients with small (< 30 mm diameter), radiographically distinct and focally recurrent GBM should be considered for SRS. Larger lesions (> 30 mm diameter), especially those adjacent to eloquent cortex or critical white matter pathways, must be evaluated with caution. The potential for acute toxicity associated with SRS increases substantially for larger lesions. There is a significant survival advantage using SRS in many patients with gliomas, especially if appropriately used with surgery and other adjuvant therapy.
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Chang EL, Loeffler JS, Riese NE, Wen PY, Alexander E, Black PM, Coleman CN. Survival results from a phase I study of etanidazole (SR2508) and radiotherapy in patients with malignant glioma. Int J Radiat Oncol Biol Phys 1998; 40:65-70. [PMID: 9422559 DOI: 10.1016/s0360-3016(97)00486-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To report the survival results from a previous Phase I study of etanidazole (ETA) and radiotherapy in patients with glioblastoma multiforme (GBM n = 50) or anaplastic astrocytoma (AA n = 19) and examine survival according to age, Karnofsky performance status (KPS), and implant status. PATIENTS AND METHODS In a previous Phase I study, 70 previously untreated patients (median age 49) with malignant gliomas were accrued. One patient was excluded from analysis because pathology was unverifiable. All had KPS > or = 70. Prior to initiation of treatment, patients were stratified according to whether they were candidates for interstitial implantation. The implant patients (IMP n = 14) received accelerated fractionation radiotherapy (XRT) 2 Gy BID (6 hours apart) to 40 Gy in 2 weeks with ETA 2 gm/m2 x 6 doses, a 2 week break, and then interstitial implant for an additional 50 Gy (4-7 days) with a continuous infusion of ETA over 90-96 hours. There were 55 patients treated on two sequentially conducted non-implant arms. These patients started with accelerated fractionation XRT 2 Gy BID (6 hours apart) to 40 Gy in 2 weeks with ETA 2 gm/m2 x 4-5 doses/week. Non-IMP1 arm (n = 41) received a 2-week break before standard fractionated boost XRT of 2 Gy/day for 2 weeks to a total dose of 60 Gy with ETA. Non-IMP2 arm (n = 14) did not have the 2-week break. All patients had plasma pharmacokinetic monitoring of ETA. Subsequent follow-up study provided information regarding long-term survival status of this group of patients. The Phase I toxicity evaluation was conducted according to the RTOG toxicity scale and was found well tolerated in both groups. Overall actuarial survival was plotted for all patients, by histologic group, and by implant status. Subset analyses of GBM patients by age (< or = 49 or > 49 years), KPS (< or = 80 or > 80) and implant versus non-implant were also performed. RESULTS Median survival of GBM patients was 1.1 years and that of anaplastic astrocytoma patients was 3.1 years (p = 0.0001). In GBM patients, KPS > 80, implanted patients, and age < or = 49 were factors found not to be associated with a statistically improved survival. CONCLUSION The results of survival in this Phase I etanidazole study of patients with anaplastic astrocytoma are comparable to the results from other studies using bromodeoxyuridine, iododeoxyuridine, or procarbazine, lomustine (CCNU), and vincristine. The use of etanidazole with accelerated radiotherapy does not appear to improve survival in patients with glioblastoma multiforme compared to those treated with conventional therapies.
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Black PM, Moriarty T, Alexander E, Stieg P, Woodard EJ, Gleason PL, Martin CH, Kikinis R, Schwartz RB, Jolesz FA. Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 1997; 41:831-42; discussion 842-5. [PMID: 9316044 DOI: 10.1097/00006123-199710000-00013] [Citation(s) in RCA: 508] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE We describe the development and implementation of a new open configuration magnetic resonance imaging (MRI) system, with which neurosurgical procedures can be performed using image guidance. Our initial neurosurgical experience consists of 140 cases, including 63 stereotactic biopsies, 16 cyst drainages, 55 craniotomies, 3 thermal ablations, and 3 laminectomies. The surgical advantages derived from this new modality are presented. METHODS The 0.5-T intraoperative MRI system (SIGNA SP, Boston, MA), developed by General Electric Medical Systems in collaboration with the Brigham and Women's Hospital, has a vertical gap within its magnet, providing the physical space for surgery. Images are viewed on monitors located within this gap and can also be acquired in conjunction with optical tracking of surgical instruments, establishing accurate intraoperative correlations between instrument position and anatomic structures. RESULTS A wide range of standard neurosurgical procedures can be performed using intraoperative MRI. The images obtained are clear and provide accurate and immediate information to use in the planning and assessment of the progress of the surgery. CONCLUSION Intraoperative MRI allows lesions to be precisely localized and targeted, and the progress of a procedure can be immediately evaluated. The constantly updated images help to eliminate errors that can arise during frame-based and frameless stereotactic surgery when anatomic structures alter their position because of shifting or displacement of brain parenchyma but are correlated with images obtained preoperatively. Intraoperative MRI is particularly helpful in determining tumor margins, optimizing surgical approaches, achieving complete resection of intracerebral lesions, and monitoring potential intraoperative complications.
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