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Mui OOT, Murray DB, Walsh B, Crimmins DW, Caird JD. Spontaneous intracerebral haemorrhage secondary to 5-ALA-induced thrombocytopaenia in a paediatric patient: case report and literature review. Childs Nerv Syst 2023; 39:1051-1058. [PMID: 36662275 PMCID: PMC10160215 DOI: 10.1007/s00381-023-05846-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The primary objective of neurosurgical management of malignant gliomas is maximal safe resection of the tumour. One of the main obstacles in achieving this is the ability to accurately discriminate between tumour edges and the surrounding healthy brain tissue. The use of fluorescence-guided surgery utilising 5-aminolevulinic acid (5-ALA), first introduced more than 20 years ago, has become an invaluable adjunct in high-grade glioma surgery in adults. However, as 5-ALA is not licensed for use in paediatric patients, the safety profile for such use remains undetermined. CASE REPORT We describe the case of a 4-year-old boy who underwent 5-ALA-guided resection of a fourth ventricle anaplastic ependymoma. Although complete resection was achieved and the patient awoke from surgery well with no neurological deficits, the patient developed acute transaminitis, anaemia, thrombocytopaenia and coagulopathy postoperatively. The patient had a sudden neurological deterioration on postoperative day 2; imaging revealed that he had suffered a spontaneous right frontal intracerebral haemorrhage. The patient returned to theatre for surgical decompression and evacuation of the haematoma, and ultimately went on to make a full recovery. CONCLUSION The use of 5-ALA in paediatric patients can be helpful in maximising surgical resection, but the associated safety profile remains undefined. Further research is urgently warranted in order to characterise the efficacy and risk of the use of 5-ALA in the paediatric population.
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Affiliation(s)
- Olivia O T Mui
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland. .,Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Daniel B Murray
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
| | - Bill Walsh
- Temple Street Children's University Hospital, Dublin, Ireland
| | - Darach W Crimmins
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
| | - John D Caird
- Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
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2
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Milos P, Haj-Hosseini N, Hillman J, Wårdell K. 5-ALA fluorescence in randomly selected pediatric brain tumors assessed by spectroscopy and surgical microscope. Acta Neurochir (Wien) 2023; 165:71-81. [PMID: 36242636 PMCID: PMC9840574 DOI: 10.1007/s00701-022-05360-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/25/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE Fluorescence-guided surgery applying 5-aminolevulinic acid (5-ALA) in high-grade gliomas is an established method in adults. In children, results have so far been ambiguous. The aim of this study was to investigate 5-ALA-induced fluorescence in pediatric brain tumors by using the surgical microscope and a spectroscopic hand-held probe. METHODS Fourteen randomly selected children (age 4-17) with newly MRI-verified brain tumors were included. No selection was based on the suspected diagnosis prior to surgery. All patients received 5-ALA (20 mg /kg) either orally or via a gastric tube prior to surgery. Intratumoral fluorescence was detected with the microscope and the probe. Moreover, fluorescence in the skin of the forearm was measured. Histopathology samples revealed seven low-grade gliomas, four medulloblastomas, one diffuse intrinsic pontine glioma, one glioblastoma and one atypical meningioma. Blood samples were analyzed, and potential clinical side effects were monitored. RESULTS Microscopically, vague fluorescence was visible in two patients. Intratumoral fluorescence could be detected in five patients with the probe, including the two patients with vague microscopic fluorescence. Three of the oldest children had PpIX fluorescence in the skin. Nine children did not show any fluorescence in the tumor or in the skin. No clinical side effects or laboratory adverse events were observed. CONCLUSION Fluorescence could not be used to guide surgery in this study, neither with the surgical microscope nor with the hand-held probe. In nine children, no fluorescence was discerned and children with noticeable fluorescence were all older than nine years. 5-ALA was considered safe to apply in children.
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Affiliation(s)
- Peter Milos
- Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping University Hospital, 581 85, Linköping, Sweden.
| | - Neda Haj-Hosseini
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Jan Hillman
- Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping University Hospital, 581 85, Linköping, Sweden
| | - Karin Wårdell
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
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de Laurentis C, Bteich F, Beuriat PA, Mottolese C, Giussani C, Szathmari A, Vinchon M, Di Rocco F. Sodium fluorescein in pediatric neurosurgery: a systematic review with technical considerations and future perspectives. Childs Nerv Syst 2022; 39:1451-1462. [PMID: 36459209 DOI: 10.1007/s00381-022-05772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Sodium fluorescein (SF) is routinely used in several centers as a valid intraoperative adjunct in adult oncological neurosurgery. Its use in pediatric neurosurgery is increasing, although its role is not yet well-defined in children. We reviewed the current literature in order to evaluate the use of SF in children with CNS and PNS lesions. METHODS For this systematic review, we searched PubMed, Scopus, and Embase databases, and forward and backward citations for studies published between database inception and July 31st, 2022. We included any article type or congress abstract adding at least a new case, without restrictions of language or publication status, concerning the use of SF in neurosurgical procedures in patients under 18 years of age. We excluded studies concerning purely vascular cases and cerebrospinal fluid leaks. RESULTS Of 4094 records identified, 19 articles were eligible and included for further analysis. As per July 31st, 2022, at least 119 patients aged from 11 months to 17.9 years underwent surgery with SF. No serious adverse events were reported. A large variety of tumor types was operated, in most cases resected under the specific YELLOW 560 nm filter after a low-dose SF injection (2-5 mg/kg) at the end of anesthesia induction. SF was reported particularly useful in gangliogliomas and pilocytic astrocytomas. DISCUSSION/CONCLUSION Given its easy-to-use profile, low cost, and safety, SF seems to be a feasible and valid adjunct in the pediatric population when aiming at individuating a biopsy target or maximizing extent of resection, particularly in some tumor types. Further studies are required to strengthen the evidence on its impact on outcomes.
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Affiliation(s)
- Camilla de Laurentis
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France. .,Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy.
| | - Fred Bteich
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | | | - Carmine Mottolese
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | - Carlo Giussani
- Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy.,Neurosurgery Unit, San Gerardo Hospital, Monza, Italy
| | | | - Matthieu Vinchon
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | - Federico Di Rocco
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France.,Department of Medicine and Surgery, Université Claude Bernard Lyon I, Lyon, France
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Chiba K, Aihara Y, Oda Y, Fukui A, Tsuduki S, Saito T, Nitta M, Muragaki Y, Kawamata T. Photodynamic therapy for malignant brain tumors in children and young adolescents. Front Oncol 2022; 12:957267. [PMID: 36505805 PMCID: PMC9731766 DOI: 10.3389/fonc.2022.957267] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/06/2022] [Indexed: 11/25/2022] Open
Abstract
Photodynamic therapy (PDT) targets tumor cell remnants after resection. Here, we evaluated the feasibility of PDT for malignant brain tumors in children and young adolescents. This was a single-center, non-randomized, phase I/II clinical study. The primary endpoints were the safety of treatment with talaporfin sodium (TS) (phase I) and overall survival (OS) after PDT (phase II). The secondary endpoint was progression-free survival (PFS) after PDT. The TS dose was determined by dose escalation from 10 to 20 to 40 mg/m2 for every three cases starting from the initial enrolled case. Eight patients with a mean age of 170.2 months (129-214 months) at the time of PDT received nine procedures with a mean follow-up duration of 16.8 months (1-42 months) after PDT. Histopathological diagnoses included supratentorial anaplastic ependymoma (n = 2), anaplastic astrocytoma (n = 1), diffuse midline glioma with H3K27M mutation (n = 1), glioblastoma (n = 3), and pediatric high-grade glioma (n = 1). The outcome was survival in five patients and death in three patients. Recurrence occurred in six of the eight patients; the remaining two were recurrence-free after PDT. Therefore, OS and PFS were calculated as 21 and 6 months, respectively. Seizures and fevers, which were likely surgery-related symptoms, were commonly observed. Photosensitive skin rashes or liver dysfunction, which are common adverse effects in adults, were not observed. Our results showed that TS can be used safely in children at doses comparable to those used in adults, as there was no major complication associated with TS administration. However, we cannot make a definitive conclusion about the efficacy of PDT because of the small number of participants. Accumulating cases was difficult because of the rarity of pediatric brain tumors and the difficulty in making a preoperative differential diagnosis, considering the wide range of histopathological findings. Moreover, the psychological stress associated with light-shielding management in pediatric patients was more severe than initially expected. In conclusion, TS at doses comparable to those used in adults may be safe for use in children and young adolescents between the ages of 6 and 20 years. However, further studies are needed to clarify its efficacy.
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Affiliation(s)
- Kentaro Chiba
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Yasuo Aihara
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan,*Correspondence: Yasuo Aihara,
| | - Yuichi Oda
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Atsushi Fukui
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Shunsuke Tsuduki
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Taiichi Saito
- Department of Neurosurgery, Faculty of Advanced Techno-Surgery (FATS), Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Masayuki Nitta
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Yoshihiro Muragaki
- Department of Neurosurgery, Faculty of Advanced Techno-Surgery (FATS), Tokyo Women’s Medical University (TWMU), Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women’s Medical University (TWMU), Tokyo, Japan
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Labuschagne JJ. 5-Aminolevulinic Acid-Guided Surgery for Recurrent Supratentorial Pediatric Neoplasms. World Neurosurg 2020; 141:e763-e769. [PMID: 32526366 DOI: 10.1016/j.wneu.2020.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of 5-aminolevulinic acid (5-ALA) in pediatric neuro-oncology is considered off-label, and little data are available on its use in tumor recurrence surgery. Here we present our experience with 5-ALA fluorescence-guided surgery for recurrent supratentorial tumors in the pediatric population. METHODS Eleven pediatric patients presenting with recurrence of a supratentorial high-grade malignancy (5 glioblastoma [GBM], 6 non-GBM) underwent 5-ALA-assisted surgery. Biopsy specimens were obtained from pathological and normal-appearing areas of the tumor margin. RESULTS From the margin of the tumor displaying solid fluorescence, a total of 36 samples were obtained. All of these histological samples were found to harbor tumor cells. From areas of vague enhancement, a total of 49 histological samples were taken, of which 38 samples (77%) harbored tumor cells. There was no significant difference in the percentage of biopsy-positive vague fluorescent areas between the GBM cases (80%) and non-GBM cases (75%). A total of 59 biopsy specimens were taken from the tumor margin that appeared completely negative for fluorescence. On analysis, 24 (40.7%) of these specimens demonstrated tumor cells. There was no significant difference in the number of false-negative biopsies between the GBM group (40%) and the non-GBM group (41%). CONCLUSIONS The positive predictive value of solid fluorescence is high in recurrent disease but is substantially lower in areas of vague fluorescence. The rate of false-negative fluorescence is high. 5-ALA should be considered as an adjuvant in revision surgery with the aforementioned caveats in mind.
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Affiliation(s)
- Jason John Labuschagne
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg and Department of Paediatric Neurosurgery, Nelson Mandela Children's Hospital, Johannesburg, South Africa.
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Spectroscopic measurement of 5-ALA-induced intracellular protoporphyrin IX in pediatric brain tumors. Acta Neurochir (Wien) 2019; 161:2099-2105. [PMID: 31435824 DOI: 10.1007/s00701-019-04039-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better delineation between tumor and normal brain, allowing improved resection and improved patients' outcome. Recently, several reports were published regarding 5-ALA for resection of pediatric brain tumors. The aim of the study was to determine the intracellular fluorescence of protoporphyrin IX (PPIX) in pediatric brain tumors by hyperspectral imaging and to compare it with visually observed intraoperative fluorescence. METHODS 5-ALA was administered orally 4 h prior to surgery. During tumor resection, the surgeon assessed the fluorescence signal to be strong, weak, or absent. Subsequently, fluorescence intensity of tumor samples was measured via spectroscopy. In addition, clinical data, imaging, and laboratory data were analyzed. RESULTS Eleven children (1-16 years) were operated. Tumor entities included three (n = 3) medulloblastomas, two (n = 2) pilocytic astrocytomas (PA), two (n = 2) anaplastic ependymomas and one (n = 1) diffuse astrocytoma, anaplastic astrocytoma (n = 1), pilomyxoid astrocytoma (n = 1) and anaplastic pleomorphic xanthoastrocytoma (n = 1). Strong fluorescence was visible in all anaplastic tumors and one PA; one PA demonstrated weak fluorescence. Visible fluorescence was strongly associated with intracellular fluorescence intensity and PPIX concentration (P < 0.05). Within all tumors with visible fluorescence, the intracellular PPIX concentration was greater than 4 μg/ml. Except for moderate and transient elevation of liver enzymes, no 5-ALA related adverse events were reported. CONCLUSION We demonstrate a strong association between intraoperative observations and spectrometric measurements of PPIX fluorescence in tumor tissue. As in former studies, fluorescence signal was more commonly observed in malignant glial tumors. Further prospective controlled trials should be conducted to investigate the feasibility of 5-ALA-guided resection of pediatric brain tumors.
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7
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Goryaynov SA, Okhlopkov VA, Golbin DA, Chernyshov KA, Svistov DV, Martynov BV, Kim AV, Byvaltsev VA, Pavlova GV, Batalov A, Konovalov NA, Zelenkov PV, Loschenov VB, Potapov AA. Fluorescence Diagnosis in Neurooncology: Retrospective Analysis of 653 Cases. Front Oncol 2019; 9:830. [PMID: 31552168 PMCID: PMC6747044 DOI: 10.3389/fonc.2019.00830] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/13/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: This study is to analyze fluorescence sensitivity in the diagnosis of brain and spinal cord tumors. Material and methods: The authors conducted a multicenter retrospective analysis of data on 653 cases in 641 patients: 553 of them had brain tumors and 88 spinal cord tumors. Brain tumor resection was performed in 523 patients, of whom 484 were adults and 39 children. The analyzed series was presented by 320 gliomas, 101 meningiomas, and 72 metastases. A stereotactic biopsy was performed in 20 patients and endoscopic surgery in 10 patients. In all cases, 20 mg/kg of 5-Aminolaevulinic acid was administered orally 2-h before surgery. All surgical interventions were performed with a microscope BLUE 400 to visualize fluorescence, while endoscopic surgery-with an endoscope equipped with a fluorescent module. Fluorescence spectroscopy was conducted in 20 cases of stereotactic biopsies and in 88 cases of spinal cord tumors. Results: Among adult brain tumors operated by microsurgical techniques, meningiomas showed the highest 5-ALA fluorescence sensitivity 94% (n = 95/101), brain metastases 84.7% (n = 61/72), low-grade gliomas 46.4% (n = 26/56), and high-grade gliomas 90.2% (n = 238/264). In children the highest 5-ALA visible fluorescence was observed in anaplastic astrocytomas 100% (n = 4/4) and in anaplastic ependymomas 100% (n = 4/4); in low-grade gliomas it made up 31.8% (n = 7/22). As for the spinal cord tumors in adults, the highest sensitivity was demonstrated by glioblastomas 100% (n = 4/4) and by meningiomas 100% (n = 4/4); Fluorescence was not found in gemangioblastomas (n = 0/6) and neurinomas (n = 0/4). Fluorescence intensity reached 60% (n = 6/10) in endoscopic surgery and 90% (n = 18/20) in stereotactic biopsy. Conclusion: 5-ALA fluorescence diagnosis proved to be most sensitive in surgery of HGG and meningioma (90.2 and 94.1%, respectively). Sensitivity in surgery of intracranial metastases and spinal cord tumors was slightly lower (84.7 and 63.6%, correspondingly). The lowest fluorescence sensitivity was marked in pediatric tumors and LGG (50 and 46.4%, correspondingly). Fluorescence diagnosis can also be used in transnasal endoscopic surgery of skull base tumors and in stereotactic biopsy.
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Affiliation(s)
- Sergey A. Goryaynov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Vladimir A. Okhlopkov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Denis A. Golbin
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Konstantin A. Chernyshov
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Dmitrij V. Svistov
- S. M. Kirov Military Medical Academy of the Ministry of Defense of the Russian Federation, St-Petersburg, Russia
| | - Boris V. Martynov
- S. M. Kirov Military Medical Academy of the Ministry of Defense of the Russian Federation, St-Petersburg, Russia
| | - Alexandr V. Kim
- V. A. Almazov Federal North-West Medical Research Centre of the Ministry of Health of the Russian Federation, St-Petersburg, Russia
| | - Vadim A. Byvaltsev
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Galina V. Pavlova
- Institute of Gene Biology, Russian Academy of Science, Moscow, Russia
| | - Artem Batalov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Nikolay A. Konovalov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Petr V. Zelenkov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Victor B. Loschenov
- Prokhorov General Physics Institute of the Russian Academy of Science, Moscow, Russia
- National Research Nuclear University MEPhI, Moscow, Russia
| | - Alexandr A. Potapov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
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8
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Schwake M, Schipmann S, Müther M, Köchling M, Brentrup A, Stummer W. 5-ALA fluorescence-guided surgery in pediatric brain tumors-a systematic review. Acta Neurochir (Wien) 2019; 161:1099-1108. [PMID: 30989383 DOI: 10.1007/s00701-019-03898-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better differentiation between tumor and normal brain tissue, allowing a higher degree of resection, and improves patient outcomes. In recent years, several reports have emerged regarding the use of 5-ALA in other brain tumor entities, including pediatric brains tumors. Since gross total resection (GTR) of many brain tumors in children is crucial and the role of 5-ALA-guided resection of these tumors is not clear, we sought to perform a comprehensive literature review on this topic. METHODS A systematic literature review of EMBASE and MEDLINE/PubMed databases revealed 19 eligible publications encompassing 175 5-ALA-guided operations on pediatric brain tumors. To prevent bias, publications were revised independently by two authors. RESULTS We found that 5-ALA-guided resection enabled the surgeons to identify the tumor more easily and was considered helpful mainly in cases of glioblastoma (GBM, 21/27, 78%), anaplastic ependymoma WHO grade III (10/14, 71%), and anaplastic astrocytoma (4/6, 67%). In contrast, cases of pilocytic astrocytomas (PAs) and medulloblastomas 5-ALA-guided surgery did not show consistent fluorescent signals and 5-ALA was considered helpful only in 12% and 22% of cases, respectively. Accumulation of fluorescent porphyrins seems to depend on WHO tumor grading. One important finding is that when 5-ALA-guided resections were considered helpful, the degree of resection was higher than is cases where it was not helpful. The rate of adverse events related to 5-ALA was negligible, especially new postoperative sequelae. CONCLUSION 5-ALA could play a role in resection of pediatric brain tumors. However, further prospective clinical trials are needed.
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Patel P, Wallace D, Boop FA, Vaughn B, Robinson GW, Gajjar A, Klimo P. Reoperation for Medulloblastoma Prior to Adjuvant Therapy. Neurosurgery 2019; 84:1050-1058. [PMID: 29660028 DOI: 10.1093/neuros/nyy095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 04/04/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgery remains an integral part of the treatment of medulloblastoma. We present our experience with repeat surgery for this tumor before initiation of adjuvant therapy. OBJECTIVE To report what was found intraoperatively and where at time of second-look surgery and detail any postoperative events or readmissions within 90 days of surgery. METHODS Two separate institutional databases were queried to identify patients who underwent repeat resection of suspected residual medulloblastoma from January 2003 to January 2017. RESULTS We identified 51 patients (36 male, 15 female) who underwent repeat surgery. Average age at diagnosis was 8.31 years (range, 1.3-21.2). Imaging prior to repeat surgery demonstrated unequivocal residual tumor in 37 patients, but indeterminate in 14 patients. All but 1 patient had histopathologically confirmed residual tumor (50/51, 98%). The fourth ventricle was the primary site in 39 (76%) cases, compared with hemispheric in 12 cases (24%). Thirty (59%) tumors were non-WNT/non-SHH. All indeterminate cases (except for 1 patient) had residual tumor. Hemostatic agents were found within the resection cavity in 80% of indeterminate cases. The most common sites of residual tumor were lateral (26/39, 67%, lateral recess and/or foramen of Luschka) and roof (25/39, 64%); the superior medullary velum was the most common region of the roof (19/25, 76%). Eight (16%) patients developed new neurological deficits: cranial nerve palsies in 5 patients and posterior fossa syndrome in 3 patients. CONCLUSION Meticulous inspection of the resection cavity is necessary, paying particular attention to the roof and lateral recess. Hemostatic agents can conceal residual tumor.
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Affiliation(s)
- Prayash Patel
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - David Wallace
- College of Medicine, University of Tennessee Health Sciences, Memphis, Tennessee
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey, Memphis, Tennessee
| | | | - Giles W Robinson
- Division of Neuro-oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Division of Neuro-oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey, Memphis, Tennessee
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de Laurentis C, Höhne J, Cavallo C, Restelli F, Falco J, Broggi M, Bosio L, Vetrano IG, Schiariti M, Zattra CM, Ferroli P, Schebesch KM, Acerbi F. The impact of fluorescein-guided technique in the surgical removal of CNS tumors in a pediatric population: results from a multicentric observational study. J Neurosurg Sci 2019; 63:679-687. [PMID: 31037934 DOI: 10.23736/s0390-5616.19.04601-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgery has a fundamental role in central nervous system (CNS) tumors in the pediatric population, as aggressive resection correlates with prognosis. Due to its accumulation in areas with damaged blood brain barrier, sodium fluorescein (SF) could be a valid tool to improve the extent of resection in tumors enhancing at preoperative MRI. This study is aimed to systematically assess the utility of SF in a pediatric population. METHODS Patient data were collected in two centers, one in Italy and the other in Germany. At the induction of anesthesia, SF was administered intravenously (5 mg/kg). Surgery was performed using a YELLOW560 filter. Fluorescence intensity was graduated as bright, moderate or absent based on surgeon's opinion; furthermore, SF use was judged as "helpful," "not helpful" or "not essential" in tumor removal. RESULTS Twenty-four patients for 27 surgical procedures were identified. In 21 of 27 (77.8%) procedures fluorescence was reported as bright or moderate, in two of 27 (7.4%) absent and in four of 27 (14.8%) data were unavailable. Intraoperative fluorescence was reported in 21 of 25 (84%) surgeries whose corresponding preoperative MRI had shown contrast enhancement. In 14 of 27 (51.8%) surgical procedures SF was considered "helpful"; in two of 27 (7.4%) not "helpful"; in seven of 27 (25.9%) "not essential." In four of 27 (14.8%) data were unavailable. No adverse effect to SF was registered. CONCLUSIONS SF could be considered a valid and safe tool to improve visualization of tumors enhancing at preoperative MRI also in pediatric patients. Future prospective studies are needed to confirm these preliminary data.
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Affiliation(s)
- Camilla de Laurentis
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Julius Höhne
- Department of Neuropathology and Neurosurgery, Regensburg University Hospital, Regensburg, Germany
| | - Claudio Cavallo
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy.,Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Francesco Restelli
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Lorenzo Bosio
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Ignazio G Vetrano
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Costanza M Zattra
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Karl-Michael Schebesch
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy -
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Zhang C, Boop FA, Ruge J. The use of 5-aminolevulinic acid in resection of pediatric brain tumors: a critical review. J Neurooncol 2018; 141:567-573. [PMID: 30443833 DOI: 10.1007/s11060-018-03004-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/23/2018] [Indexed: 01/10/2023]
Abstract
The compound, 5-aminolevulinic acid (5-ALA) is approved for fluorescence-guided resections of malignant gliomas in Europe and other countries for use in adults, but not for children. The application of 5-ALA in children remains an off-label use. Several case reports on fluorescence-guided surgery use in children have been published, yet no prospective study has been conducted. Here we systematically review the reported studies and discuss the usefulness, application, and safety of 5-ALA use in resection of pediatric brain tumors.
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Affiliation(s)
- Chenran Zhang
- Department of Pediatric Neurosurgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1665 Kongjiang RD, Shanghai, 200092, China. .,Clinical Research Unit, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China. .,Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN, USA. .,St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Frederick A Boop
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN, USA.,St Jude Children's Research Hospital, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Semmes-Murphey Brain and Spine Institute, Memphis, TN, USA
| | - John Ruge
- Department of Pediatric Neurosurgery, Advocate Children's Hospital, Park Ridge, IL, USA
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12
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Briel-Pump A, Beez T, Ebbert L, Remke M, Weinhold S, Sabel MC, Sorg RV. Accumulation of protoporphyrin IX in medulloblastoma cell lines and sensitivity to subsequent photodynamic treatment. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2018; 189:298-305. [PMID: 30445362 DOI: 10.1016/j.jphotobiol.2018.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/04/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Medulloblastoma (MB) is the most common malignant primary brain tumor of childhood. High risk patients still have a poor outcome, and especially young patients suffer from standard therapy induced sequelae. Therefore, other therapeutic options need to be explored. In glioblastoma (GBM), application of 5-aminolaevulinic acid (5-ALA) results in selective accumulation of protoporphyrin IX (PPIX) in the tumor cells, which can be exploited during fluorescence-guided surgery to increase the extent of resection or for photodynamic therapy (PDT) induced phototoxicity. It is not entirely clear, whether MB cells accumulate PPIX and are sensitive to PDT. METHODS Human MYC-amplified (Med8A and D283) and non-amplified (UW228-2 and ONS76) MB cell lines were incubated for 2, 4 or 6 h with increasing doses (0-100 μg/ml) of 5-ALA, and PPIX accumulation was determined by flow cytometry. To assess sensitivity to 5-ALA/PDT, cells were incubated with 5-ALA and subsequently exposed to laser light of 635 nm wavelength (18.75 J/cm2). After an additional 24 h culture period, viability of cells was quantified using the WST-1 assay. Expression of ferrochelatase was detected by reverse transcription and quantitative polymerase chain reaction. Ferrochelatase activity was quantified by measuring the enzymatic conversion of PPIX to zinc-protoporphyrin. Expression of the ABCG2 transporter protein CD338 was detected by flow cytometry. RESULTS All MB cell lines showed a time- and dose-dependent accumulation of PPIX after exposure to exogenous 5-ALA and became sensitive to 5-ALA/PDT-induced phototoxicity. PPIX accumulation was reduced compared to U373 GBM cells at shorter incubation periods and limiting 5-ALA doses. Moreover, not all MB cells became PPIX positive and overall phototoxicity was lower in the MB cell lines. Notably, the MYC-amplified MB cells demonstrated a more pronounced photosensitivity compared to their non-amplified counterparts. There was no difference in expression of ferrochelatase, but enzymatic activity appeared to be reduced in the MB cells compared to U373 GBM cells, whereas CD338 was expressed on the MB cells only. CONCLUSION Medulloblastoma cell lines accumulate PPIX after application of 5-ALA and become sensitive to PDT, associated with low ferrochelatase expression and activity. Photosensitivity is more pronounced in MYC-amplified cell lines. In contrast to GBM cells, however, PPIX accumulation appears to be reduced, restricted to a subset of cells and associated with lower photosensitivity of the MB cell lines, possibly due to expression of the ABCG2 transporter protein CD338 on MB cells.
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Affiliation(s)
- Anna Briel-Pump
- Institute for Transplantation Diagnostics and Cell Therapeutics, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany; Department of Neurosurgery, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Thomas Beez
- Department of Neurosurgery, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Lara Ebbert
- Institute for Transplantation Diagnostics and Cell Therapeutics, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Marc Remke
- Department of Pediatric Oncology, Hematology and Immunology, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany; Department of Neuropathology, Medical Faculty, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany; Department of Pediatric Neuro-Oncogenomics, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany
| | - Sandra Weinhold
- Institute for Transplantation Diagnostics and Cell Therapeutics, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Michael C Sabel
- Department of Neurosurgery, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Rüdiger V Sorg
- Institute for Transplantation Diagnostics and Cell Therapeutics, Heinrich Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany.
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13
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Agawa Y, Wataya T. The use of 5-aminolevulinic acid to assist gross total resection of pediatric astroblastoma. Childs Nerv Syst 2018; 34:971-975. [PMID: 29305683 DOI: 10.1007/s00381-017-3714-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 12/25/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Astroblastoma is an uncommon pediatric neuroepithelial tumor. The prognosis and appropriate treatment of astroblastoma were not well understood. Previous reports suggested the best treatment for astroblastoma is surgical total resection. The authors report a case of pediatric astroblastoma that underwent gross total resection with the use of fluorescent guidance by 5-aminolevulinic acid (5-ALA). CASE REPORT A 13-year-old girl presented with the tumor that was well-circumscribed cystic and solid mass with marked gadolinium enhancement in the right occipital lobe. At surgery, fluorescence of the tumor was clearly distinctive from the normal cerebral tissue. All fluorescent tissue including residual cyst wall was removed. Postoperative MRI showed gross total resection of the tumor. No serious side effect or complications occurred. The histopathologic diagnosis was suggestive of astroblastoma. The patients had no evidence of recurrence of tumor without adjuvant radiotherapy during the last 1 year of follow-up time. CONCLUSION 5-ALA is useful to achieve gross total resection including cystic lesion of pediatric astroblastoma. A larger prospective study is warranted to establish the use of 5-ALA in pediatric brain tumor.
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Affiliation(s)
- Yuji Agawa
- Department of Neurosurgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Takafumi Wataya
- Department of Neurosurgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan.
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14
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Roth J, Constantini S. 5ALA in pediatric brain tumors is not routinely beneficial. Childs Nerv Syst 2017; 33:787-792. [PMID: 28293736 DOI: 10.1007/s00381-017-3371-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Over recent years, 5-aminoluvolinic acid (5ALA) has been increasingly used for resection guidance in adult high-grade gliomas. However, amongst pediatric patients, publication of intraoperative fluorescence has been limited, with inconsistent outcomes. We describe our experience and intraoperative finding amongst children with various brain tumors that were given 5ALA prior to tumor resection. METHODS Since October 2014, data regarding intraoperative findings amongst children that received 5ALA prior to tumor resection were prospectively collected. Inclusion criteria included any intracranial tumor amongst children 3-18 years of age. Data included intraoperative findings (regarding fluorescence of the tumor), as well as postoperative follow-up and documentation of complications. RESULTS Fourteen children were included, covering a wide pathological spectrum: pilocytic astrocytoma (PA) (6), medulloblastoma (2), and one each of DNET, hemangiopericytoma, hemangioblastoma, ganglioneuroblastoma, oligodendroglioma grade II (OD), and ganglioglioma grade I. Fluorescence was clearly visible in one case (PA), and in a heterogeneous and slighter degree in two (PA, OD). One patient had a rash, fever, and leukocytosis 6 days after surgery and died 1 month later from extensive tumor progression (large cell medulloblastoma with leptomeningeal spread). CONCLUSION 5ALA showed a low rate of fluorescence amongst this pediatric brain tumor cohort. These findings are consistent with the literature, where the role of 5ALA in guidance of pediatric brain tumor resection is limited mainly to glioblastoma multiforme. This stems not only from the low rate of significant fluorescence, but also from inherent structural properties of these lesions such as color, consistency, and invasion.
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Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel.
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel
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15
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Kim AV, Khachatryan VA. [Intraoperative fluorescence diagnosis using 5-aminolevulinic acid in surgical treatment of children with recurrent neuroepithelial tumors]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 81:51-57. [PMID: 28291213 DOI: 10.17116/neiro201780751-57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the efficacy and safety of 5-aminolevulinic acid for intraoperative fluorescence diagnosis (FD) during repeated surgery for recurrent neuroepithelial tumors (NETs) in children. MATERIAL AND METHODS We performed a retrospective analysis of the results of recurrent NET resection in 13 children aged from 3 to 17 years in the period between December 2013 and May 2015. The source of 5-ALA was a drug "Alasens" that was administered at a dose of 20 mg/kg of body weight 4 h before the beginning of tumor resection. A visual scale was used to evaluate the fluorescence intensity. The drug was used with the informed consent of the child's parents and approval of the Polenov Neurosurgical Institute ethics committee. All patients underwent complex clinical and introscopic examination in the pre- and postoperative periods and a repeated histological tumor examination. RESULTS There was no fluorescence in 4 cases (Gr I in 2 cases; Gr II in 2 cases). Grade 1 fluorescence (Gr II) was observed in one case, and grade 2-3 fluorescence was observed in the remaining 8 patients. Total and subtotal tumor resection was achieved in 11 (84.6%) of 13 patients. There were no clinically significant adverse effects. A transient increase in transaminases was observed in 2 patients. Two girls had an elevated photosensitivity to light for two days. CONCLUSION FD is a safe technique in childhood and can improve intraoperative detection of NET during its repeated growth as well as differentiate the tumor from pathological tissues of non-tumorous nature, which increases completeness of blastomatous tissue removal. However, the character and intensity of fluorescence may change in recurrent NETs. Further research is required to investigate the FD effectiveness in various age patients with tumors of a different histological structure and malignancy in the case of both primary and recurrent lesions.
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Affiliation(s)
- A V Kim
- Polenov Neurosurgical Institute, Branch of the Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russia
| | - V A Khachatryan
- Polenov Neurosurgical Institute, Branch of the Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russia
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