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Gurses ME, Gökalp E, Gecici NN, Lu VM, Shah KH, Singh E, Luo A, Shah AH, Ivan ME, Komotar RJ. Minimally invasive resection of intracranial lesions using tubular retractors: A single surgeon series. Clin Neurol Neurosurg 2024; 241:108304. [PMID: 38718706 DOI: 10.1016/j.clineuro.2024.108304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Tubular retractors are increasingly used due to their low complication rates, providing easier access to lesions while minimizing trauma from brain retraction. Our study presents the most extensive series of cases performed by a single surgeon aiming to assess the effectiveness and safety of a transcortical-transtubular approach for removing intracranial lesions. METHODS We performed a retrospective review of patients who underwent resection of an intracranial lesion with the use of tubular retractors. Electronic medical records were reviewed for patient demographics, preoperative clinical deficits, diagnosis, preoperative and postoperative magnetic resonance imaging (MRI) scans, lesion characteristics including location, volume, extent of resection (EOR), postoperative complications, and postoperative deficits. RESULTS 112 transtubular resections for intracranial lesions were performed. Patients presented with a diverse number of pathologies including metastasis (31.3 %), GBM (21.4 %), and colloid cysts (19.6 %) The mean pre-op lesion volume was 14.45 cm3. A gross total resection was achieved in 81 (71.7 %) cases. Seventeen (15.2 %) patients experienced early complications which included confusion, short-term memory difficulties, seizures, meningitis and motor and visual deficits. Four (3.6 %) patients had permanent complications, including one with aphasia and difficulty finding words, another with memory loss, a third with left-sided weakness, and one patient who developed new-onset long-term seizures. Mean post-operative hospitalization length was 3.8 days. CONCLUSION Tubular retractors provide a minimally invasive approach for the extraction of intracranial lesions. They serve as an efficient tool in neurosurgery, facilitating the safe resection of deep-seated lesions with minimal complications.
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Affiliation(s)
- Muhammet Enes Gurses
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA.
| | - Elif Gökalp
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | | | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
| | - Khushi Hemendra Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
| | - Eric Singh
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
| | - Angela Luo
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
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Gurses ME, Lu VM, Gecici NN, Shah KH, Gökalp E, Bashti M, Haider S, Komotar RJ. Utilizing tubular retractors in colloid cyst resection: A single surgeon experience. Surg Neurol Int 2024; 15:179. [PMID: 38840593 PMCID: PMC11152534 DOI: 10.25259/sni_231_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/04/2024] [Indexed: 06/07/2024] Open
Abstract
Background Colloid cysts are intracranial lesions originating from abnormalities in the primitive neuroepithelium folding of the third ventricle. Various surgical approaches have been explored for the management of colloid cysts, each carrying its own set of advantages and limitations. Tubular retractors developed recently alleviate retraction pressure through radial distribution, potentially offering benefits for colloid cyst resection. This study aims to introduce and assess a modified microsurgical method utilizing the tubular retractor for addressing colloid cysts. Methods The study included a retrospective assessment of patients who had colloid cysts and who were treated between 2015 and 2023 by one experienced surgeon. The demographic, clinical, radiological, histological, and surgical data regarding these patients were evaluated. The patients were assessed using the colloid cyst risk score, indicating a risk for obstructive hydrocephalus. Results The minimally invasive microsurgical approach was successfully applied to all 22 identified patients. No postoperative surgical complications were reported. Gross total resection was achieved in 21 (95.5%) patients. The early complication rate was 22.7% (n = 5). There were no postoperative seizures, permanent neurological deficits, or venous injuries. The average hospital stay was 3 days. There was no evidence of recurrence at an average follow-up length of 25.9 months. Conclusion The transtubular approach is an effective, safe method for treating colloid cysts. It achieves complete cyst removal with minimal complications, offering the benefits of less invasiveness, improved visualization, and reduced tissue disruption, strengthening its role in colloid cyst surgery.
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Affiliation(s)
| | - Victor M. Lu
- Department of Neurosurgery, Miami University, Miami, United States
| | | | | | - Elif Gökalp
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Malek Bashti
- Department of Neurosurgery, Miami University, Miami, United States
| | - Sameah Haider
- Department of Neurosurgery, Miami University, Miami, United States
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García Pérez F, Vargas López AJ, Gomar Alba M, Velasco Albendea FJ, Guil Ibáñez JJ, Urreta Juárez G, Castelló Ruiz MJ, Narro Donate JM, Masegosa González J. Transcortical transcatheter ultrasound-assisted technique for deep-seated brain tumors. Technical note. J Ultrasound 2024; 27:191-197. [PMID: 38308121 PMCID: PMC10908735 DOI: 10.1007/s40477-023-00845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/09/2023] [Indexed: 02/04/2024] Open
Abstract
PURPOSE Surgery of deep-seated brain tumors can be challenging. Several methods have been described to facilitate transcortical approaches, including ultrasound-assisted resection. Ultrasound-guided placement of a standard ventricular catheter is a widely reported technique and has been used to approach these lesions via the transcortical route. We describe how we usually perform this useful technique to assist and enhance the transcortical resection of some deep-seated brain tumors. METHODS Standard electromagnetic frameless navigation (S8 Neuronavigation System, Medtronic, Minneapolis, USA) was employed to focus the craniotomy and to plan the trajectory of the ventricular catheter. After dural opening, an ultrasound device (Arietta 850, Hitachi-Aloka Medical, Tokyo, Japan) was used for intraoperative ultrasound (IOUS) assessment. A ventricular catheter was placed from the cortex to the lateral wall of the tumor under direct real-time IOUS visualization to guide the further transcortical dissection. RESULTS Transcortical transcatheter ultrasound-assisted technique involved minimal time and infrastructure requirements. There were no major technical difficulties during its use, providing confidence and improving subcortical white matter dissection by guiding the route to the tumor. CONCLUSIONS Recent improvement of IOUS image-quality devices offers several attractive options for real-time navigation. The combination of conventional neuronavigation systems with real-time IOUS assessment during the intradural step provides a higher degree of control by improving the execution of the surgery. We hope this description may be a useful tool for some selected cases and contribute to the further enhancement and improvement of this widely used technique.
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Affiliation(s)
- Fernando García Pérez
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain.
| | - Antonio José Vargas López
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
| | - Mario Gomar Alba
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
| | | | - José Javier Guil Ibáñez
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
| | - Gaizka Urreta Juárez
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
| | - María José Castelló Ruiz
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
| | - José María Narro Donate
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
| | - José Masegosa González
- Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre S/N, 04009, Almería, Spain
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Sankhla SK, Warade A, Khan GM. Endoport-Guided Endoscopic Excision of Intraaxial Brain Tumors. Adv Tech Stand Neurosurg 2024; 52:63-72. [PMID: 39017786 DOI: 10.1007/978-3-031-61925-0_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
OBJECTIVE Transcortical approaches using a spatula-based retraction system have traditionally been used for the microsurgical resection of deep-seated intraventricular and parenchymal brain tumors. Recently, transparent cylindrical or tubular retractors have been developed to provide a stable corridor to access deeper brain lesions and perform bimanual microsurgical resection. The flexible endoports minimize brain retraction injury during surgery and, along with the superior vision of endoscopes, offer several advantages over standard microsurgery. In this chapter, we describe the surgical technique of the endoport-guided endoscopic excision of deep-seated intraaxial brain tumors. METHODS The endoscopic endoport technique that we use at our institution for the surgical management of intraventricular and intraparenchymal brain tumors has been described in detail with illustrative cases. RESULTS Results from the literature review of intraventricular and intraparenchymal port surgery were analyzed, and the feasibility and safety of this technique were discussed. Surgical complication avoidance and management were highlighted. The port technique offers numerous potential advantages, including (1) reducing focal brain injury by distributing retraction forces homogenously, (2) minimizing white matter disruption and the risk of fascicle injury during cannulation, (3) ensuring the stability of the surgical corridor during the procedure, (4) preventing inadvertent expansion of the corticectomy and white fiber tract dissection throughout surgery, and (5) protecting the surrounding tissues against iatrogenic injuries caused by instrument entry and reentry. CONCLUSION The endoport-assisted endoscopic technique is safe and offers an effective alternative option for the resection of intraventricular and intraparenchymal lesions.
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Affiliation(s)
- Suresh K Sankhla
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
| | - Anshu Warade
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
| | - G M Khan
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
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Sankhla SK, Warade A, Khan GM. Endoneurosurgical Resection of Parenchymal and Intraventricular Lesions Using Tubular Retraction System. Adv Tech Stand Neurosurg 2024; 53:79-92. [PMID: 39287804 DOI: 10.1007/978-3-031-67077-0_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
OBJECTIVE Endoscopic surgery has emerged in the recent years as an alternative to the conventional microsurgical approaches for removal of the deep-seated brain and intraventricular tumors. Endoport has enhanced the tumor access and visualization without any significant brain retraction. In this chapter, we describe the surgical technique of the endoscopic excision of the deep-seated intra-axial brain tumors using tubular retraction system with review of the literature. METHODS The endoscopic endoport technique that we use at our institution for the surgical management of intraventricular and intraparenchymal brain tumors has been described in details with illustrations. RESULTS Results from the literature review of brain parenchymal and intraventricular port surgery were analyzed, and the feasibility and safety of this technique were discussed. Surgical complication avoidance and management were highlighted. The port technique offers numerous potential advantages, including: (1) reducing focal brain injury by distributing retraction forces homogenously; (2) minimizing white matter disruption and the risk of fascicles injury during cannulation; (3) ensuring stability of the surgical corridor during the procedure; (4) preventing inadvertent expansion of the corticectomy and white fiber tract dissection throughout surgery; (5) protecting the surrounding tissues against iatrogenic injuries caused by instrument entry and reentry. CONCLUSION The endoport-assisted endoscopic technique is a safe and minimally invasive method that offers an effective alternative option for resection of intraventricular and parenchymal brain lesions. Excellent outcome comparable to other surgical approaches can be achieved with acceptable complications.
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Affiliation(s)
| | | | - G M Khan
- Global Gleneagle Hospital, Mumbai, India
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Sinha S, Kalyal N, Gallagher MJ, Richardson D, Kalaitzoglou D, Abougamil A, Silva M, Oviedova A, Patel S, Mirallave-Pescador A, Bleil C, Zebian B, Gullan R, Ashkan K, Vergani F, Bhangoo R, Pedro Lavrador J. Impact of Preoperative Mapping and Intraoperative Neuromonitoring in Minimally Invasive Parafascicular Surgery for Deep-Seated Lesions. World Neurosurg 2024; 181:e1019-e1037. [PMID: 37967744 DOI: 10.1016/j.wneu.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Transsulcal tubular retractor-assisted minimally invasive parafascicular surgery changes the surgical strategy for deep-seated lesions by promoting a deficit-sparing approach. When integrated with preoperative brain mapping and intraoperative neuromonitoring (IONM), this approach may potentially improve patient outcomes. In this study, we assessed the impact of preoperative brain mapping and IONM in tubular retractor-assisted neuro-oncological surgery. METHODS This retrospective single-center cohort study included patients who underwent transsulcal tubular retractor-assisted minimally invasive parafascicular surgery for resection of deep-seated brain tumors from 2016 to 2022. The cohort was divided into 3 groups: group 1, no preoperative mapping or IONM (17 patients); group 2, IONM only (25 patients); group 3, both preoperative mapping and IONM (38 patients). RESULTS We analyzed 80 patients (33 males and 47 females) with a median age of 46.5 years (range: 1-81 years). There was no significant difference in mean tumor volume (26.2 cm3 [range 1.07-97.4 cm3]; P = 0.740) and mean preoperative depth of the tumor (31 mm [range 3-65 mm], P = 0.449) between the groups. A higher proportion of high-grade gliomas and metastases was present within group 3 (P = 0.003). IONM was related to fewer motor (P = 0.041) and language (P = 0.032) deficits at hospital discharge. Preoperative mapping and IONM were also related to shorter length of stay (P = 0.008). CONCLUSIONS Preoperative and intraoperative brain mapping and monitoring enhance transsulcal tubular retractor-assisted minimally invasive parafascicular surgery in neuro-oncology. Patients had a reduced length of stay and prolonged overall survival. IONM alone reduces postoperative neurological deficit.
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Affiliation(s)
- Siddharth Sinha
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom.
| | - Nida Kalyal
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Mathew J Gallagher
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Daniel Richardson
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Dimitrios Kalaitzoglou
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ahmed Abougamil
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Melissa Silva
- Department of Neurosurgery, Intraoperative Neurophysiology, King's College Hospital Foundation Trust, London, United Kingdom
| | - Anna Oviedova
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Sabina Patel
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ana Mirallave-Pescador
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom; Departamento de Neurocirurgia, Hospital Garcia de Orta, Almada, Portugal
| | - Cristina Bleil
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Bassel Zebian
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - José Pedro Lavrador
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
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Rakovec M, Camp S, Day D, Chakravarti S, Parker M, Porras JL, Jackson CM, Huang J, Bettegowda C, Lim M, Mukherjee D. Use of tubular retractors to access deep brain lesions: A case series. J Clin Neurosci 2023; 114:64-69. [PMID: 37321019 DOI: 10.1016/j.jocn.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Deep-seated intracranial lesions can be accessed using blade retractors that may disrupt white matter tracts, exert pressure on adjacent tissue, and lead to post-operative venous injury. Tubular retractors may minimize disruption to white matter tracts by radially dispersing pressure onto surrounding tissue. This study characterizes perioperative outcomes in patients undergoing biopsy or resection of intracranial pathologies using tubular retractors. METHODS Adult patients (≥18 years) undergoing neurosurgical intervention using tubular retractors at a single health system (January 2016-February 2022) were identified through chart review. Demographics, disease characteristics, management data, and clinical outcomes were collected. RESULTS A total of 49 patients were included; 23 (47%) had primary brain tumors, 8 (16%) metastases, 6 (12%) intracranial hemorrhage (ICH), 5 (10%) cavernomas, and 7 (14%) other pathologies. Lesions were located subcortically (n = 19, 39%), intraventricularly (n = 15, 31%), and in deep gray matter (n = 11, 22%). Gross total resection (GTR) or near GTR was achieved in 21 of 26 (80.8%) patients with intracranial lesions where GTR was the goal of surgery; 10 of 11 (90.9%) biopsies in patients with masses were diagnostic. Five of six (83.3%) ICHs were totally or near totally evacuated. Seventeen patients (35%) had major complications post-operatively. The most common complications were DVT/PE (n = 7, 14%) and seizures (n = 6, 12%). For patients who experienced post-operative seizures, 3 had seizures preoperatively and 1 had seizures in the context of electrolyte derangements. No patients died of post-operative complications. CONCLUSION This operative approach may facilitate safe and efficacious biopsy or resection of deep-seated intracranial pathologies.
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Affiliation(s)
- Maureen Rakovec
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Samantha Camp
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - David Day
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Megan Parker
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Jose L Porras
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States.
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Sankhla SK, Warade A, Khan GM. Endoport-Assisted Endoscopic Surgery for Removal of Lateral Ventricular Tumors: Our Experience and Review of the Literature. Neurol India 2023; 71:99-106. [PMID: 36861581 DOI: 10.4103/0028-3886.370438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Background Endoscopic surgery has emerged in recent years as an alternative to conventional microsurgical approaches for removal of intraventricular tumors. Endoports have enhanced tumor access and visualization with a significant reduction in brain retraction. Objective To evaluate the safety and efficacy of endoport-assisted endoscopic technique for the removal of tumors from the lateral ventricle. Methods The surgical technique, complications, and postoperative clinical outcomes were analyzed with a review of the literature. Results Tumors were primarily located in one lateral ventricular cavity in all 26 patients, and extension to the foramen Monro and the anterior third ventricle was observed in seven and five patients, respectively. Except for three patients with small colloid cysts, all other tumors were larger than 2.5 cm. A gross total resection was performed in 18 (69%), subtotal in five (19%), and partial removal in three (11.5%) patients. Transient postoperative complications were observed in eight patients. Two patients required postoperative CSF shunting for symptomatic hydrocephalus. All patients improved on KPS scoring at a mean follow-up of 4.6 months. Conclusions Endoport-assisted endoscopic technique is a safe, simple, and minimally invasive method to remove intraventricular tumors. Excellent outcomes comparable to other surgical approaches can be achieved with acceptable complications.
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Affiliation(s)
- Suresh K Sankhla
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
| | - Anshu Warade
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
| | - Ghulam M Khan
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
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Gallagher MJ, Lavrador JP, Coelho P, Mirallave-Pescador A, Bleil C, Gullan R, Ashkan K, Vergani F, Bhangoo R. Continuous Microdebrider-Based Dynamic Subcortical Motor Mapping: A Technical Advance in Tubular Retractor-Assisted Surgery. Oper Neurosurg (Hagerstown) 2022; 23:217-224. [PMID: 35972085 DOI: 10.1227/ons.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Transsulcal minimally invasive parafasicular (TsMIP) approaches to brain tumor resection use tubular retractors to minimize iatrogenic brain injury. Dynamic cortical and subcortical continuous neurophysiological mapping facilitates safer resection of motor-eloquent tumors. OBJECTIVE To describe a new technique to address the challenge of combining TsMIP with tubular retractors and dynamic subcortical mapping using a single electrified stimulating microdebrider instrument. METHODS We adapted the NICO Myriad microdebrider with continuous monopolar stimulation electrification using high-frequency stimulation with the train-of-5 technique. We performed continuous subcortical mapping using this device and compared it with standard dynamic monopolar subcortical mapping using a suction stimulation device. We found no significant difference in recorded stimulation response. RESULTS Using a single operating instrument that provides synchronous tumor resection and monopolar subcortical mapping with the NICO Brainpath tubular retractor, we observed increased degrees of movement, faster surgical resection times with an enlarged working channel down the retractor, and improved safety because the stimulating probe sits 2 mm deep to the resection window. CONCLUSION We show that the adapted device is reliable and provides similar stimulation response as conventional subcortical mapping. We advocate the use of our adapted microdebrider in TsMIP tubular retractor approaches.
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Affiliation(s)
- Mathew J Gallagher
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Jose P Lavrador
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Pedro Coelho
- Neurophysiology Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Ana Mirallave-Pescador
- Neurophysiology Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Cristina Bleil
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Richard Gullan
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Keyoumars Ashkan
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Francesco Vergani
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Ranjeev Bhangoo
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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Gradišnik L, Bošnjak R, Bunc G, Ravnik J, Maver T, Velnar T. Neurosurgical Approaches to Brain Tissue Harvesting for the Establishment of Cell Cultures in Neural Experimental Cell Models. MATERIALS (BASEL, SWITZERLAND) 2021; 14:6857. [PMID: 34832259 PMCID: PMC8624371 DOI: 10.3390/ma14226857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 12/30/2022]
Abstract
In recent decades, cell biology has made rapid progress. Cell isolation and cultivation techniques, supported by modern laboratory procedures and experimental capabilities, provide a wide range of opportunities for in vitro research to study physiological and pathophysiological processes in health and disease. They can also be used very efficiently for the analysis of biomaterials. Before a new biomaterial is ready for implantation into tissues and widespread use in clinical practice, it must be extensively tested. Experimental cell models, which are a suitable testing ground and the first line of empirical exploration of new biomaterials, must contain suitable cells that form the basis of biomaterial testing. To isolate a stable and suitable cell culture, many steps are required. The first and one of the most important steps is the collection of donor tissue, usually during a surgical procedure. Thus, the collection is the foundation for the success of cell isolation. This article explains the sources and neurosurgical procedures for obtaining brain tissue samples for cell isolation techniques, which are essential for biomaterial testing procedures.
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Affiliation(s)
- Lidija Gradišnik
- Faculty of Medicine, Institute of Biomedical Sciences, University of Maribor, Taborska 8, 2000 Maribor, Slovenia;
- Alma Mater Europaea ECM, Slovenska 17, 2000 Maribor, Slovenia
| | - Roman Bošnjak
- Department of Neurosurgery, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia;
| | - Gorazd Bunc
- Department of Neurosurgery, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia; (G.B.); (J.R.)
| | - Janez Ravnik
- Department of Neurosurgery, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia; (G.B.); (J.R.)
| | - Tina Maver
- Faculty of Medicine, Institute of Biomedical Sciences, University of Maribor, Taborska 8, 2000 Maribor, Slovenia;
- Department of Pharmacology, Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
| | - Tomaž Velnar
- Alma Mater Europaea ECM, Slovenska 17, 2000 Maribor, Slovenia
- Department of Neurosurgery, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia;
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Polunina NA, Semenov DE, Orlov EA, Veselkov AA, Galitskiy EV, Grigorievskiy ED, Kudashev AY. [Brain retraction injury]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:103-110. [PMID: 34463457 DOI: 10.17116/neiro202185041103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review is devoted to various techniques for reduction of brain damage during retraction. Searching for reports was carried out in Russian and English languages using the PubMed database (n=721) without restrictions on language, date and study design according to the following keywords: «brain retraction injury», «spatula brain retractors», «tubular brain retractors», «retractorless neurosurgery». Primary screening and exclusion of duplicate manuscripts allowed us to single out the main group of articles (n=121). Some reports were excluded due to non-compliance with inclusion criteria (no description of methods, few references and insufficient data). The final list included 32 studies which were represented by cohort studies, retrospective analyses of surgical interventions, as well as experimental and laboratory studies. Small number of publications did not allow us to obtain unambiguous conclusions. Further research is required to reduce brain retraction trauma.
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Affiliation(s)
- N A Polunina
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - D E Semenov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - E A Orlov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Veselkov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - E V Galitskiy
- Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - A Yu Kudashev
- Sechenov First Moscow State Medical University, Moscow, Russia
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Kutlay M, Durmaz MO, Kırık A, Yasar S, Ezgu MC, Kural C, Temiz C, Tehli O, Daneyemez M, Izci Y. Resection of intra- and paraventricular malignant brain tumors using fluorescein sodium-guided neuroendoscopic transtubular approach. Clin Neurol Neurosurg 2021; 207:106812. [PMID: 34280673 DOI: 10.1016/j.clineuro.2021.106812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The requirement of brain retraction and difficulty in distinguishing the tumor demarcation are challenging in conventional approaches to intra- and paraventricular malignant tumors (IV-PVMTs). Tubular retractors can minimize the retraction injury, and fluorescein-guided (FG) surgery may promote the resection of tumors. Our aim is to evaluate the feasibility, safety, and effectiveness of fluorescein-guided endoscopic transtubular surgery for the resection of IV-PVMTs. METHODS Twenty patients with IV-PVMTs underwent FG endoscopic transtubular tumor resection. Fluorescein sodium was administered before the dural opening. The intraoperative fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was assessed using postoperative magnetic resonance imaging. Karnofsky Performance Status (KPS) score was used to evaluate the general physical condition of patients. RESULTS There were 9 glioblastomas, 4 anaplastic astrocytomas and 7 metastatic tumors. "Helpful" fluorescence staining was observed in 16(80%) of 20 patients. Gross total resection was achieved in 16(80%) cases, near-total in 3(15%) cases, and subtotal in 1 (5%) case. No intra- or postoperative complications related to the fluorescein sodium occurred. The median preoperative KPS score was 83, and the median KPS score 3-month after surgery was 88. CONCLUSION FG endoscopic transtubular surgery is a feasible technique for the resection of IV-PVMTs. It may be a safe and effective option for patients with these tumors. Future prospective randomized studies with larger samples are needed to confirm these preliminary data.
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Affiliation(s)
- Murat Kutlay
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Ozan Durmaz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Alparslan Kırık
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Soner Yasar
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Can Ezgu
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Cahit Kural
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Caglar Temiz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ozkan Tehli
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Daneyemez
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Yusuf Izci
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey.
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13
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Eichberg DG, Di L, Shah AH, Luther EM, Jackson C, Marenco-Hillembrand L, Chaichana KL, Ivan ME, Starke RM, Komotar RJ. Minimally invasive resection of intracranial lesions using tubular retractors: a large, multi-surgeon, multi-institutional series. J Neurooncol 2020; 149:35-44. [PMID: 32556805 DOI: 10.1007/s11060-020-03500-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/13/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Lesions located in subcortical areas are difficult to safely access. Tubular retractors have been increasingly used successfully with low complication profile to access lesions by minimizing brain retraction trauma and distributing pressure radially. Both binocular operative microscope and monocular exoscope are utilized for lesion visualization through tubular retractors. We present the largest multi-surgeon, multi-institutional series to determine the efficacy and safety profile of a transcortical-transtubular approach for intracranial lesion resections with both microscopic and exoscopic visualization. METHODS We reviewed a multi-surgeon, multi-institutional case series including transcortical-transtubular resection of intracranial lesions using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (VBAS, Vycor Medical, Boca Raton, Florida) tubular retractors (n = 113). RESULTS One hundred thirteen transtubular resections for intracranial lesions were performed. Patients presented with a diverse number of pathologies including 25 cavernous hemangiomas (21.2%), 15 colloid cysts (13.3%), 26 GBM (23.0%), two meningiomas (1.8%), 27 metastases (23.9%), 9 gliomas (7.9%) and 9 other lesions (7.9%). Mean lesion depth below the cortical surface was 4.4 cm, and mean lesion size was 2.7 cm. A gross total resection was achieved in 81 (71.7%) cases. Permanent complication rate was 4.4%. One patient (0.8%) experienced one early postoperative seizure (< 1 week postop). No patients experienced late seizures (> 1 week follow-up). Mean post-operative hospitalization length was 4.1 days. CONCLUSION Tubular retractors provide a minimally invasive operative corridor for resection of intracranial lesions. They provide an effective tool in the neurosurgical armamentarium to resect subcortical lesions with a low complication profile.
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Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. .,University of Miami Hospital, 1321 N.W. 14th Street, West Building, Suite 306, Miami, FL, 33125, USA.
| | - Long Di
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Evan M Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christina Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.,Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.,Sylvester Comprehensive Cancer Center, Miami, FL, USA
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14
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Zhu J, Wen G, Tang C, Zhong C, Yang J, Ma C. A Practical 3D-Printed Model for Training of Endoscopic and Exoscopic Intracerebral Hematoma Surgery with a Tubular Retractor. J Neurol Surg A Cent Eur Neurosurg 2020; 81:404-411. [PMID: 32294793 DOI: 10.1055/s-0039-1697023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To present a three-dimensional (3D)-printed model that simulates endoscopic and exoscopic intracerebral hematoma (ICH) surgery with a tubular retractor. METHODS We used 3D printing technology to develop the model that consisted of the skull frame and a replaceable inserted module. Edible gelatin and animal blood were placed into the module to mimic brain tissue and the hematoma. Twenty neurosurgeons were recruited to participate in our training program that required the use of an endoscope and an exoscope to aspirate the hematoma with a tubular retractor. Five postgraduates were asked to complete the entire training with the endoscope five times. Questionnaires were distributed for feedback after the training program. RESULTS The more experienced surgeons obviously performed better than the rather inexperienced surgeons, verifying that our model could reflect the ability of the trainees. As the training progressed, the scores of the postgraduates increased, and the average score of the fifth training was obviously higher than the first score. No significant differences were observed in the trainees' performance with the endoscope and the exoscope. The feedback questionnaires showed the average score for value of the simulator as a training tool was a 3.65 (on a 4-point scale). Our model received better comments regarding the bone texture (mean: 3.20), the brain tissue texture (mean: 3.20), and the experience in aspirating the hematoma (mean: 3.10). The surgical position (mean: 2.95), surgical approach (mean: 2.90), and simulated brain tissue (mean: 2.85) should be improved. CONCLUSION Our model was practical for endoscopic and exoscopic ICH surgery training. The results of our program showed that prior surgical experience benefited the mastery of both the endoscopic and the exoscopic ICH surgery in the 3D-printed model. Our model could make mastering basic skills more efficient.
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Affiliation(s)
- Junhao Zhu
- Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Guodao Wen
- Department of Neurosurgery, Dongguan Tungwah Hospital, School of Medicine, Sun Yat-sen University, Dongguan, China
| | - Chao Tang
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Chunyu Zhong
- Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
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15
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Shapiro SZ, Sabacinski KA, Mansour SA, Echeverry NB, Shah SS, Stein AA, Snelling BM. Use of Vycor Tubular Retractors in the Management of Deep Brain Lesions: A Review of Current Studies. World Neurosurg 2020; 133:283-290. [DOI: 10.1016/j.wneu.2019.08.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 02/08/2023]
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16
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Eichberg DG, Di L, Shah AH, Ivan ME, Komotar RJ, Starke RM. Use of Tubular Retractors for Minimally Invasive Resection of Deep-Seated Cavernomas. Oper Neurosurg (Hagerstown) 2019; 18:629-639. [DOI: 10.1093/ons/opz184] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/11/2019] [Indexed: 12/18/2022] Open
Abstract
Abstract
BACKGROUND
Cavernomas located in subcortical or eloquent locations are difficult lesions to access safely. Tubular retractors, which distribute retraction pressure radially, have been increasingly employed successfully. These retractors may be beneficial in subcortical cavernoma resection.
OBJECTIVE
To review a single institution's case series to determine the safety profile and efficacy of transcortical-transtubular cavernoma resections and to describe our transtubular operative technique.
METHODS
We reviewed a single institution's transcortical-transtubular cavernoma resections using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) tubular retractors performed from 2013 to 2018 (n = 20).
RESULTS
Gross total resection was achieved in all patients. When a developmental venous anomaly (DVA) was present, avoidance of DVA resection was achieved in all cases (n = 4). All patients had a supratentorial cavernoma with mean depth below cortical surface of 44.1 mm. Average postoperative clinical follow-up was 20.4 wk. Early neurologic deficit rate was 10% (n = 2); permanent neurologic deficit rate was 0%. One patient (5%) experienced early postoperative seizures (< 1 wk postop). No patients experienced late seizures (> 1 wk follow-up). Engel class 1 seizure control at final clinical follow-up was achieved in 87.5% of patients presenting with preoperative epilepsy.
CONCLUSION
Tubular retractors provide a low-profile, minimally invasive operative corridor for resection of subcortical cavernomas. There were no permanent neurologic complications in our series of 20 cases, and long-term seizure control was achieved in all patients. Thus, tubular retractors appear to be a safe and efficacious tool for resection of subcortical cavernomas.
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Affiliation(s)
- Daniel G Eichberg
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Long Di
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Ashish H Shah
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Michael E Ivan
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Robert M Starke
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, Florida
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17
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Mandel M, Petito CE, Tutihashi R, Paiva W, Abramovicz Mandel S, Gomes Pinto FC, Ferreira de Andrade A, Teixeira MJ, Figueiredo EG. Smartphone-assisted minimally invasive neurosurgery. J Neurosurg 2019; 130:90-98. [PMID: 29529913 DOI: 10.3171/2017.6.jns1712] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 06/05/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Advances in video and fiber optics since the 1990s have led to the development of several commercially available high-definition neuroendoscopes. This technological improvement, however, has been surpassed by the smartphone revolution. With the increasing integration of smartphone technology into medical care, the introduction of these high-quality computerized communication devices with built-in digital cameras offers new possibilities in neuroendoscopy. The aim of this study was to investigate the usefulness of smartphone-endoscope integration in performing different types of minimally invasive neurosurgery. METHODS The authors present a new surgical tool that integrates a smartphone with an endoscope by use of a specially designed adapter, thus eliminating the need for the video system customarily used for endoscopy. The authors used this novel combined system to perform minimally invasive surgery on patients with various neuropathological disorders, including cavernomas, cerebral aneurysms, hydrocephalus, subdural hematomas, contusional hematomas, and spontaneous intracerebral hematomas. RESULTS The new endoscopic system featuring smartphone-endoscope integration was used by the authors in the minimally invasive surgical treatment of 42 patients. All procedures were successfully performed, and no complications related to the use of the new method were observed. The quality of the images obtained with the smartphone was high enough to provide adequate information to the neurosurgeons, as smartphone cameras can record images in high definition or 4K resolution. Moreover, because the smartphone screen moves along with the endoscope, surgical mobility was enhanced with the use of this method, facilitating more intuitive use. In fact, this increased mobility was identified as the greatest benefit of the use of the smartphone-endoscope system compared with the use of the neuroendoscope with the standard video set. CONCLUSIONS Minimally invasive approaches are the new frontier in neurosurgery, and technological innovation and integration are crucial to ongoing progress in the application of these techniques. The use of smartphones with endoscopes is a safe and efficient new method of performing endoscope-assisted neurosurgery that may increase surgeon mobility and reduce equipment costs.
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Affiliation(s)
- Mauricio Mandel
- 1Division of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School; and
- 2Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Carlo Emanuel Petito
- 1Division of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School; and
- 2Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rafael Tutihashi
- 1Division of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School; and
- 2Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Wellingson Paiva
- 1Division of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School; and
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18
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Tubular brain tumor biopsy improves diagnostic yield for subcortical lesions. J Neurooncol 2018; 141:121-129. [PMID: 30446900 DOI: 10.1007/s11060-018-03014-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/08/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Molecular data has become an essential part of the updated World Health Organization (WHO) grading of central nervous system tumors. However, stereotactic needle biopsies provide only small volume specimens and limit the extent of histologic and molecular testing that can be performed. We assessed the use of a tubular retractor-based minimally invasive biopsy technique to provide improved tissue yield and diagnostic data compared to needle biopsy. METHODS Eighteen patients underwent an open transtubular biopsy compared to 146 stereotactic biopsies during the years of 2010-2018. RESULTS Tubular biopsies resulted in a higher volume of tissue provided to the pathologist than needle biopsies (1.26 cm3 vs. 0.3 cm3; p < 0.0001). There was a higher rate of non-diagnostic sample with stereotactic compared to transtubular biopsy (13% vs. 0%; p = 0.13). Six patients who underwent stereotactic biopsy required reoperation for diagnosis, while no transtubular biopsy patient required reoperation in order to obtain a diagnostic specimen. Postoperative hematoma was the most common post-operative complication in both groups. CONCLUSIONS Stereotactic transtubular biopsies are a viable alternative to stereotactic needle biopsies with excellent rates of diagnostic success and acceptable morbidity relative to the needle biopsy technique. As molecular data begins to increasingly drive treatment decisions, additional biopsy techniques that afford large tissue volumes may be necessary to adapt to the new needs of pathologists and treating oncologists.
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19
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Eichberg DG, Buttrick SS, Sharaf JM, Snelling BM, Shah AH, Ivan ME, Komotar RJ. Use of Tubular Retractor for Resection of Colloid Cysts: Single Surgeon Experience and Review of the Literature. Oper Neurosurg (Hagerstown) 2018; 16:571-579. [DOI: 10.1093/ons/opy249] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 08/01/2018] [Indexed: 12/15/2022] Open
Abstract
Abstract
BACKGROUND
Colloid cysts are challenging lesions to access. Various surgical approaches are utilized which all require brain retraction, creating focal pressure, local trauma, and potentially surgical morbidity. Recently, tubular retractors have been developed that reduce retraction pressure by distributing it radially. Such retractors may be beneficial in colloid cyst resection.
OBJECTIVE
To retrospectively review a single neurosurgeon's case series, as well as the literature, to determine the efficacy and safety profile of transtubular colloid cyst resections. We also aim to describe our operative technique for this approach.
METHODS
We conducted a retrospective review of colloid cyst resections using either ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) or BrainPath (NICO, Indianapolis, Indiana) tubular retractors performed by a single neurosurgeon from 2015 to 2017 (n = 10). A literature review was performed to find all published cases of transtubular colloid cyst resections.
RESULTS
Gross total resection was achieved in all patients. Early neurologic deficit rate was 10% (n = 1), and permanent neurologic deficit rate was 0%. There were no postoperative seizures or venous injuries. Average hospital stay was 2.0 d. There was no evidence of recurrence at average follow-up length of 13.6 mo. A literature review demonstrated nine studies (n = 77) with an overall complication rate of 7.8%.
CONCLUSION
Tubular retractors offer an attractive surgical corridor for colloid cyst resections, avoiding much of the morbidity of interhemispheric approaches, while minimizing damage to normal cortex. There were no permanent complications in our series of ten cases, and a literature review found a similarly benign safety profile.
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Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Simon S Buttrick
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jake M Sharaf
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Brian M Snelling
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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20
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Almubarak AO, Alobaid A, Qoqandi O, Bafaquh M. Minimally Invasive Brain Port Approach for Accessing Deep-Seated Lesions Using Simple Syringe. World Neurosurg 2018; 117:54-61. [DOI: 10.1016/j.wneu.2018.05.236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
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21
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Moosa S, Ding D, Mastorakos P, Sheehan JP, Liu KC, Starke RM. Endoport-assisted surgical evacuation of a deep-seated cerebral abscess. J Clin Neurosci 2018; 53:269-272. [DOI: 10.1016/j.jocn.2018.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/09/2018] [Indexed: 12/01/2022]
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22
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Eichberg DG, Buttrick S, Brusko GD, Ivan M, Starke RM, Komotar RJ. Use of Tubular Retractor for Resection of Deep-Seated Cerebral Tumors and Colloid Cysts: Single Surgeon Experience and Review of the Literature. World Neurosurg 2018; 112:e50-e60. [DOI: 10.1016/j.wneu.2017.12.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/01/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
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23
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Chen YN, Omay SB, Shetty SR, Liang B, Almeida JP, Ruiz-Treviño AS, Lavi E, Schwartz TH. Transtubular excisional biopsy as a rescue for a non-diagnostic stereotactic needle biopsy-case report and literature review. Acta Neurochir (Wien) 2017; 159:1589-1595. [PMID: 28688051 DOI: 10.1007/s00701-017-3260-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/26/2017] [Indexed: 02/03/2023]
Abstract
Stereotactic needle biopsy, a standard of care for acquiring deep-seated pathology, has limitations and risks in some situations. We present an uncommon case with basal ganglia dematiaceous mycetoma. Due to the firm consistency of the lesion, the initial stereotactic needle biopsy failed to provide a diagnosis. In a second operation, transtubular excisional biopsy was successfully performed to remove the entire mycetoma. We reviewed recent case series of transtubular approaches to deep-seated brain lesions and suggest this method could be a rescue for a non-diagnostic stereotactic needle biopsy and even may be the approach of choice in some cases.
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Affiliation(s)
- Yu-Ning Chen
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA
| | - Sacit Bulent Omay
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA
| | - Sathwik R Shetty
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA
| | - Buqing Liang
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA
| | - João Paulo Almeida
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA
| | - Armando S Ruiz-Treviño
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA
| | - Ehud Lavi
- Department of Pathology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Avenue, 9th Floor, Box #99, New York, NY, 10021, USA.
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
- Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
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Witek AM, Moore NZ, Sebai MA, Bain MD. BrainPath-Mediated Resection of a Ruptured Subcortical Arteriovenous Malformation. Oper Neurosurg (Hagerstown) 2017; 15:32-38. [DOI: 10.1093/ons/opx186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/19/2017] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDAlthough tubular retractor systems have gained popularity for other indications, there have been few reports of their use for arteriovenous malformation (AVM) surgery. A patient was diagnosed with a ruptured 1.2-cm subcortical AVM after presenting with intracerebral hemorrhage in the right frontal lobe and anterior basal ganglia. The characteristics of this AVM made it amenable to resection using a tubular retractor.OBJECTIVETo demonstrate the feasibility and safety of AVM resection using a tubular retractor system.METHODSResection of the ruptured 1.2-cm subcortical AVM was performed utilizing the BrainPathTM (NICO corp, Indianapolis, Indiana) tubular retractor system.RESULTSThe BrainPathTM approach provided sufficient visualization and surgical freedom to permit successful AVM resection and hematoma evacuation. Postoperative imaging demonstrated near total hematoma removal and angiographic obliteration of the AVM. There were no complications, and the patient made an excellent recovery.CONCLUSIONTubular retractors warrant consideration for accessing small, deep, ruptured AVMs. The nuances of such systems and their role in AVM surgery are discussed.
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Affiliation(s)
- Alex M Witek
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio
| | - Nina Z Moore
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio
| | - M Adeeb Sebai
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mark D Bain
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio
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Habboub G, Sharma M, Barnett GH, Mohammadi AM. A novel combination of two minimally invasive surgical techniques in the management of refractory radiation necrosis: Technical note. J Clin Neurosci 2017; 35:117-121. [DOI: 10.1016/j.jocn.2016.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/26/2016] [Indexed: 11/25/2022]
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Minimally Invasive Transsulcal Resection of Intraventricular and Periventricular Lesions Through a Tubular Retractor System: Multicentric Experience and Results. World Neurosurg 2016; 90:556-564. [DOI: 10.1016/j.wneu.2015.12.100] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/29/2015] [Accepted: 12/30/2015] [Indexed: 11/20/2022]
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Bander ED, Jones SH, Kovanlikaya I, Schwartz TH. Utility of tubular retractors to minimize surgical brain injury in the removal of deep intraparenchymal lesions: a quantitative analysis of FLAIR hyperintensity and apparent diffusion coefficient maps. J Neurosurg 2016; 124:1053-60. [DOI: 10.3171/2015.4.jns142576] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Brain retraction systems are frequently required to achieve surgical exposure of deep-seated brain lesions. Spatula-based systems can be associated with injury to the cortex and deep white matter, particularly adjacent to the sharp edges, which can result in uneven pressure on the parenchyma over the course of a long operation. The use of tubular retractor systems has been proposed as a method to overcome these limitations. There have been no studies assessing the degree of brain injury associated with the use of tubular retractors.
METHODS
Twenty patients were retrospectively identified at Weill Cornell Medical College who underwent resection of deep-seated brain lesions between 2005 and 2014 with the aid of a METRx tubular retractor system. Using the Brainlab software, pre- and postoperative images were analyzed to assess volume, depth, extent of resection, and change in postoperative MR FLAIR hyperintensity and restricted diffusion on diffusion-weighted imaging (DWI).
RESULTS
The mean preoperative tumor volume was 16.25 ± 17.6 cm3. Gross-total resection was achieved in 75%, near-total resection in 10%, and subtotal resection in 15% of patients. There was a small but not statistically significant increase in average FLAIR hyperintensity volume by 3.25 ± 10.51 cm3 (p = 0.16). The average postoperative volume of DWI high signal area with restricted diffusion on apparent diffusion coefficient maps was 8.35 ± 3.05 cm3. Assuming that the volume of restricted diffusion on DWI around tumor was 0 preoperatively, this represented a statistically significant increase on DWI (p < 0.001).
CONCLUSIONS
Although tubular retractors do not appear to significantly increase FLAIR signal in the brain, DWI intensity around the retractors can be identified. These data indicate that although tubular retractors may minimize damage to surrounding tissues, they still cause cytotoxic edema and cellular damage. Objective comparison against other retraction methods, as compared by 3D volumetric analysis or similar methods, will be important in determining the true advantage of tubular retractor systems.
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Affiliation(s)
- Evan D. Bander
- 5Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Samuel H. Jones
- 5Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Ranger A, Diosy D. Seizures in children with dysembryoplastic neuroepithelial tumors of the brain--A review of surgical outcomes across several studies. Childs Nerv Syst 2015; 31:847-55. [PMID: 25795072 PMCID: PMC4445255 DOI: 10.1007/s00381-015-2675-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE In children and adolescents, dysembryoplastic neuroepithelial tumors (DNETs) of the brain present with seizures almost 100% of the time, potentially creating significant long-term morbidity and disability despite the generally indolent course of the lesion. These tumors also tend to be quite resistant to anti-epileptic drugs which, themselves, can be associated with long-term side effects and resultant disability. Many clinicians advocate early surgical resection of these lesions, but how effective this approach is, and how aggressive tumor removal should be, continues to be debated. METHODS We performed a systematic review of the relevant literature to identify all reports of DNET resections in pediatric patients published over the past 20 years. In all, over 3000 MEDLINE abstracts were reviewed, ultimately resulting in 13 studies with 185 pediatric DNET patients to review. RESULTS Surgical resection of the lesion was effective at improving seizures in over 98% of patients and at achieving long-term seizure freedom in 86%. Surgical resection of DNETs also appeared to be quite safe, with no reported perioperative deaths and an overall rate of postoperative complications of 12%; the vast majority of these complications were transient. CONCLUSIONS Total gross resection of the lesion was the only factor statistically correlated with long-term seizure freedom (r = 0.63, p = 0.03). However, data remain lacking regarding whether this translates into more extensive procedures-like brain mapping and partial lobectomies-being any more effective than simple lesionectomies alone. Further research is clearly needed to address this and other crucial questions.
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Affiliation(s)
- Adrianna Ranger
- Department of Clinical Neurological Sciences, Division of Neurosurgery (Pediatric Neurosurgery), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada,
| | - David Diosy
- Department of Clinical Neurological Sciences, Division of Neurology (Epilepsy), Schulich School of Medicine and Dentistry, Western University, London, Ontario Canada
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Noh JH, Cho KR, Yeon JY, Seol HJ, Shin HJ. Microsurgical treatment and outcome of pediatric supratentorial cerebral cavernous malformation. J Korean Neurosurg Soc 2014; 56:237-42. [PMID: 25368767 PMCID: PMC4217061 DOI: 10.3340/jkns.2014.56.3.237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/20/2014] [Accepted: 09/06/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the clinical features and outcomes of pediatric cavernous malformation (CM) in the central nervous system. METHODS Twenty-nine pediatric patients with supratentorial CM underwent microsurgical excision. In selected cases, transparent tubular retractor system (TTRS) was used to reduce retraction injury and intraoperative neuromonitoring (IONM) was held to preserve functioning cortex. Patients' demographics and symptoms were reviewed and surgical outcomes were discussed. RESULTS THE MAIN INITIAL CLINICAL MANIFESTATIONS INCLUDED THE FOLLOWING : seizures (n=13, 45%), headache (n=7, 24%), focal neurological deficits (n=3, 10%), and an incidental finding (n=6, 21%). Overt hemorrhage was detected in 7 patients (24%). There were 19 children (66%) with a single CM and 10 (34%) children with multiple CMs. In 7 cases with deep-seated CM, we used a TTRS to minimize retraction. In 9 cases which location of CM was at eloquent area, IONM was taken during surgery. There was no major morbidity or mortality after surgery. In the 29 operated children, the overall long-term results were satisfactory : 25 (86%) patients had no signs or symptoms associated with CMs, 3 had controllable seizures, and 1 had mild weakness. CONCLUSION With the assistance of neuronavigation systems, intraoperative neuromonitoring, and TTRS, CMs could be targeted more accurately and excised more safely. Based on the satisfactory seizure outcome achieved, complete microsurgical excision in children is recommended for CMs presenting with seizures but removal of hemosiderin-stained areas seems to be unnecessary.
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Affiliation(s)
- Jung-Hoon Noh
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Seizure outcomes of lesionectomy in pediatric lesional epilepsy with brain tumor -- single institute experience. Brain Dev 2013; 35:810-5. [PMID: 23688973 DOI: 10.1016/j.braindev.2013.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 04/21/2013] [Accepted: 04/24/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the clinical characteristics, surgical strategy, and outcome in pediatric lesional epilepsy patients younger than 5years of age undergoing surgery in a single institute. METHOD Retrospective data were collected and analyzed on patients younger than 5years of age who underwent lesionectomy for lesional epilepsy at single institute from January 2001 to August 2010. Fourteen pediatric lesional epilepsy patients were enrolled in this study. Engel classification was used to classify seizure outcome. RESULTS Median preoperative seizure period was 1month (range, 1-21). Median post-operative follow up period was 35months (range 13-84). Ten patients who underwent gross total resection of tumor showed Engel class Ia seizure outcome without any antiepileptic drug (AED). Subtotal resection was performed in four patients to avoid eloquent area injury. Two of these four patients with subtotal removal became seizure-free (Engel class Ia) without AED, while two were in Engel class Ib with AED medication. There was no significant surgical morbidity or mortality. CONCLUSION Lesionectomy in children younger than 5years of age is relatively safe and effective in controlling seizures. Short preoperative seizure periods and total removal of tumor might be associated with good outcome. Therefore, early and complete lesionectomy alone may help allow for seizure freedom and optimal brain development in pediatric patients.
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3D preoperative planning in the ER with OsiriX®: when there is no time for neuronavigation. SENSORS 2013; 13:6477-91. [PMID: 23681091 PMCID: PMC3690066 DOI: 10.3390/s130506477] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 05/01/2013] [Accepted: 05/08/2013] [Indexed: 11/23/2022]
Abstract
The evaluation of patients in the emergency room department (ER) through more accurate imaging methods such as computed tomography (CT) has revolutionized their assistance in the early 80s. However, despite technical improvements seen during the last decade, surgical planning in the ER has not followed the development of image acquisition methods. The authors present their experience with DICOM image processing as a navigation method in the ER. The authors present 18 patients treated in the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo. All patients were submitted to volumetric CT. We present patients with epidural hematomas, acute/subacute subdural hematomas and contusional hematomas. Using a specific program to analyze images in DICOM format (OsiriX®), the authors performed the appropriate surgical planning. The use of 3D surgical planning made it possible to perform procedures more accurately and less invasively, enabling better postoperative outcomes. All sorts of neurosurgical emergency pathologies can be treated appropriately with no waste of time. The three-dimensional processing of images in the preoperative evaluation is easy and possible even within the emergency care. It should be used as a tool to reduce the surgical trauma and it may dispense methods of navigation in many cases.
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Minimal access to deep intracranial lesions using a serial dilatation technique. Neurosurg Rev 2012; 36:321-9; discussion 329-30. [DOI: 10.1007/s10143-012-0442-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 07/22/2012] [Accepted: 10/06/2012] [Indexed: 10/27/2022]
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