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Li YD, Coxon AT, Huang J, Abraham CD, Dowling JL, Leuthardt EC, Dunn GP, Kim AH, Dacey RG, Zipfel GJ, Evans J, Filiput EA, Chicoine MR. Neoadjuvant stereotactic radiosurgery for brain metastases: a new paradigm. Neurosurg Focus 2022; 53:E8. [PMID: 36321291 PMCID: PMC10602665 DOI: 10.3171/2022.8.focus22367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/19/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE For patients with surgically accessible solitary metastases or oligometastatic disease, treatment often involves resection followed by postoperative stereotactic radiosurgery (SRS). This strategy has several potential drawbacks, including irregular target delineation for SRS and potential tumor "seeding" away from the resection cavity during surgery. A neoadjuvant (preoperative) approach to radiation therapy avoids these limitations and offers improved patient convenience. This study assessed the efficacy of neoadjuvant SRS as a new treatment paradigm for patients with brain metastases. METHODS A retrospective review was performed at a single institution to identify patients who had undergone neoadjuvant SRS (specifically, Gamma Knife radiosurgery) followed by resection of a brain metastasis. Kaplan-Meier survival and log-rank analyses were used to evaluate risks of progression and death. Assessments were made of local recurrence and leptomeningeal spread. Additionally, an analysis of the contemporary literature of postoperative and neoadjuvant SRS for metastatic disease was performed. RESULTS Twenty-four patients who had undergone neoadjuvant SRS followed by resection of a brain metastasis were identified in the single-institution cohort. The median age was 64 years (range 32-84 years), and the median follow-up time was 16.5 months (range 1 month to 5.7 years). The median radiation dose was 17 Gy prescribed to the 50% isodose. Rates of local disease control were 100% at 6 months, 87.6% at 12 months, and 73.5% at 24 months. In 4 patients who had local treatment failure, salvage therapy included repeat resection, laser interstitial thermal therapy, or repeat SRS. One hundred thirty patients (including the current cohort) were identified in the literature who had been treated with neoadjuvant SRS prior to resection. Overall rates of local control at 1 year after neoadjuvant SRS treatment ranged from 49% to 91%, and rates of leptomeningeal dissemination from 0% to 16%. In comparison, rates of local control 1 year after postoperative SRS ranged from 27% to 91%, with 7% to 28% developing leptomeningeal disease. CONCLUSIONS Neoadjuvant SRS for the treatment of brain metastases is a novel approach that mitigates the shortcomings of postoperative SRS. While additional prospective studies are needed, the current study of 130 patients including the summary of 106 previously published cases supports the safety and potential efficacy of preoperative SRS with potential for improved outcomes compared with postoperative SRS.
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Affiliation(s)
- Yuping Derek Li
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Andrew T. Coxon
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Christopher D. Abraham
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Joshua L. Dowling
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Eric C. Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Gavin P. Dunn
- Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Albert H. Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Ralph G. Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Gregory J. Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Eric A. Filiput
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R. Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
- Department of Neurosurgery, University of Missouri, Columbia, Missouri
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Yahanda AT, Rich KM, Dacey RG, Zipfel GJ, Dunn GP, Dowling JL, Smyth MD, Leuthardt EC, Limbrick DD, Honeycutt J, Sutherland GR, Jensen RL, Evans J, Chicoine MR. Survival After Resection of Newly-Diagnosed Intracranial Grade II Ependymomas: An Initial Multicenter Analysis and the Logistics of Intraoperative Magnetic Resonance Imaging. World Neurosurg 2022; 167:e757-e769. [PMID: 36028106 DOI: 10.1016/j.wneu.2022.08.077] [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: 08/07/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify factors, including the use of intraoperative magnetic resonance imaging (iMRI), impacting overall survival (OS) and progression-free survival (PFS) after resections of newly diagnosed intracranial grade II ependymomas performed across 4 different institutions. METHODS Analyses of a multicenter mixed retrospective/prospective database assessed the impact of patient, treatment, and tumor characteristics on OS and PFS. iMRI workflow and logistics were also outlined. RESULTS Forty-three patients were identified (mean age 25.4 years, mean follow-up 52.8 months). The mean OS was 52.8 ± 44.7 months. Univariate analyses failed to identify prognostic factors associated with OS, likely due to relatively shorter follow-up time for this less aggressive glioma subtype. The mean PFS was 43.7 ± 39.8 months. Multivariate analyses demonstrated that gross-total resection was associated with prolonged PFS compared to both subtotal resection (STR) (P = 0.005) and near-total resection (P = 0.01). Infratentorial location was associated with improved PFS compared to supratentorial location (P = 0.04). Log-rank analyses of Kaplan-Meier survival curves showed that increasing extent of resection (EOR) led to improved OS specifically for supratentorial tumors (P = 0.02) and improved PFS for all tumors (P < 0.001). Thirty cases (69.8%) utilized iMRI, of which 12 (27.9%) involved additional resection after iMRI. Of these, 8/12 (66.7%) resulted in gross-total resection, while 2/12 (16.7%) were near-total resection and 2/12 (16.7%) were subtotal resection. iMRI was not an independent prognosticator of PFS (P = 0.72). CONCLUSIONS Greater EOR and infratentorial location were associated with increased PFS for grade II ependymomas. Greater EOR was associated with longer OS only for supratentorial tumors. A longer follow-up is needed to establish prognostic factors for this cohort, including use of iMRI.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Garnette R Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Alberta, Canada
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John Evans
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Cler SJ, Dunn GP, Zipfel GJ, Dacey RG, Chicoine M. A Low Subfrontal Dural Opening for Operative Management of Anterior Skull Base Lesions. J Neurol Surg B Skull Base 2022; 84:201-209. [PMID: 37180868 PMCID: PMC10171938 DOI: 10.1055/a-1774-6281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022] Open
Abstract
Introduction
A low subfrontal dural opening technique that limits brain manipulation was assessed in patients that underwent frontotemporal approaches for anterior fossa lesions.
Methods
A retrospective review was performed for cases using a low subfrontal dural opening including characterization of demographics, lesion size and location, neurological and ophthalmological assessments, clinical course, and imaging findings.
Results
A low subfrontal dural opening was performed in 23 patients (17F, 6M), median age of 53 years (range 23-81) with median follow-up duration of 21.9 months (range 6.2-67.1). Lesions included 22 meningiomas (9 anterior clinoid, 12 tuberculum sellae, and 1 sphenoid wing), 1 unruptured internal carotid artery aneurysm clipped during a meningioma resection, and 1 optic nerve cavernous malformation. Maximal possible resection was achieved in all cases including gross total resection in 16/22 (72.7%), near total in 1/22 (4.5%), and subtotal in 5/22 (22.7%) in which tumor involvement of critical structures limited complete resection. Eighteen patients presented with vision loss; 11 (61%) improved postoperatively, 3 (17%) were stable, and 4 (22%) worsened. The mean ICU stay and time to discharge was 1.3 days (range 0-3) and 3.8 days (range 2-8).
Conclusions
A low subfrontal dural opening for approaches to the anterior fossa can be performed with minimal brain exposure, early visualization of the optico-carotid cistern for cerebrospinal fluid release, minimizing need for fixed brain retraction and Sylvian fissure dissection. This technique can potentially reduce surgical risk and provide excellent exposure for anterior skull base lesions with favorable extent of resection, visual recovery, and complication rates.
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Affiliation(s)
- Samuel J Cler
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Gavin P Dunn
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Gregory J Zipfel
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Ralph G Dacey
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Michael Chicoine
- Neurosurgery, Washington University in Saint Louis, Saint Louis, United States
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Fujii Y, Ogiwara T, Watanabe G, Hanaoka Y, Goto T, Hongo K, Horiuchi T. Intraoperative low-field magnetic resonance imaging-guided tumor resection in glioma surgery: Pros and cons. J NIPPON MED SCH 2021; 89:269-276. [PMID: 34526467 DOI: 10.1272/jnms.jnms.2022_89-301] [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] [Indexed: 11/19/2022]
Abstract
BACKGROUNDIntraoperative magnetic resonance imaging (MRI) is useful for identifying residual tumors during surgery. It can improve the resection rate; however, complications related to prolonged operating time may be increased. We assessed the advantages and disadvantages of using low-field intraoperative MRI and compared them with non-use of iMRI during glioma surgery.METHODSThe study included 22 consecutive patients who underwent total tumor resection at Shinshu University Hospital between September 2017 and October 2020. Patients were divided into two groups (before and after introducing 0.4-T low-field open intraoperative MRI at the hospital). Patient demographics, gross total resection (GTR) rate, postoperative neurological deficits, need for reoperation, and operating time were compared between the groups.RESULTSNo significant differences were observed in patient demographics. While GTR of the tumor was achieved in 8/11 cases (73%) with intraoperative MRI, 2/11 cases (18%) of the control group achieved GTR (p=0.033). Seven patients had transient neurological deficits: 3 in the intraoperative MRI group and 4 in the control group, without significant differences between groups. There was no unintended reoperation in the intraoperative MRI group, except for one case in the control group. Mean operating time (465.8 vs. 483.6 minutes for the intraoperative MRI and control groups, respectively) did not differ.CONCLUSIONSLow-field intraoperative MRI improves the GTR rate and reduces unintentional reoperation incidence compared to the conventional technique. Our findings showed no operating time prolongation in the MRI group despite intraoperative imaging, which considered that intraoperative MRI helped reduce decision-making time and procedural hesitation during surgery.
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Affiliation(s)
- Yu Fujii
- Department of Neurosurgery, Shinshu University School of Medicine
| | | | - Gen Watanabe
- Department of Neurosurgery, Shinshu University School of Medicine
| | - Yoshiki Hanaoka
- Department of Neurosurgery, Shinshu University School of Medicine
| | - Tetsuya Goto
- Department of Neurosurgery, Saint Marianna University School of Medicine
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine.,Department of Neurosurgery, Ina Central Hospital
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Yahanda AT, Chicoine MR. Intraoperative MRI for Glioma Surgery: Present Overview and Future Directions. World Neurosurg 2021; 149:267-268. [PMID: 33940675 DOI: 10.1016/j.wneu.2021.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Cecchini AL, Cianci R, Lozupone E, Contegiacomo A, Gambassi G. A case of vertebral artery dissection: a cerebellar chameleon in a young man. Intern Emerg Med 2021; 16:1089-1091. [PMID: 33200344 DOI: 10.1007/s11739-020-02555-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Andrea Leonardo Cecchini
- UOC di Medicina Generale, Dipartimento di Scienze dell'invecchiamento, neurologiche, ortopediche e della testa-collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Rossella Cianci
- UOC di Medicina Generale, Dipartimento di Scienze dell'invecchiamento, neurologiche, ortopediche e della testa-collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Emilio Lozupone
- UOC di Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Andrea Contegiacomo
- UOC di Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Giovanni Gambassi
- UOC di Medicina Generale, Dipartimento di Scienze dell'invecchiamento, neurologiche, ortopediche e della testa-collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
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Muhsen BA, Ghzawi A, Hashem H, Elayyan M, Maraqa B, Al Masri M. Adult Pilocytic Astrocytoma in the insula: Case report and review of the literature. Ann Med Surg (Lond) 2021; 65:102300. [PMID: 33948171 PMCID: PMC8080460 DOI: 10.1016/j.amsu.2021.102300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION and Importance: Adult Pilocytic Astrocytomas (APA) are infrequent low grade tumors. While supratentorial APA is considered rare, insular APA is extremely rare. CASE PRESENTATION We present a case of pure insular APA along with surgical outcomes. Tractography and functional MRI were obtained pre-operatively. The patient underwent neuro-navigation guided microsurgical resection with sub-cortical white matter mapping, utilizing Intra-operative MRI guidance. The Sylvain fissure was opened to secure the M3 branches, and near total resection was achieved. CLINICAL DISCUSSION APA in the insula is a very rare presentation and is considered challenging. Its proximity to the middle cerebral and lenticulostriate arteries, motor areas, and language areas makes accessing and resecting the tumor challenging. A multidisciplinary approach by an experienced team is needed to plan the management of young adult patients and reach the best outcomes. CONCLUSION Implementing microsurgical techniques, modern imaging modalities and intraoperative mapping helps to achieve maximal safe resection without risking functions.
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Affiliation(s)
- Baha'eddin A. Muhsen
- Division of Neurosurgery, Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Ansam Ghzawi
- Faculty of Medicine- Yarmouk University, Irbid, Jordan
| | - Hasan Hashem
- Division of Pediatric Hematology Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Maher Elayyan
- Division of Neurosurgery, Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Bayan Maraqa
- Department of Pathology, King Hussein Cancer Center, Amman, Jordan
| | - Mahmoud Al Masri
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
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Cler SJ, Sharifai N, Baker B, Dowling JL, Pipkorn P, Yaeger L, Clifford DB, Dahiya S, Chicoine MR. IgG4-Related Disease of the Skull and Skull Base-A Systematic Review and Report of Two Cases. World Neurosurg 2021; 150:179-196.e1. [PMID: 33746107 DOI: 10.1016/j.wneu.2021.03.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) is an inflammatory process that uncommonly can present in the skull base and calvarium and mimic a tumor but the nature of this condition is not well summarized in the neurosurgical literature. METHODS A review was performed of 2 cases of IgG4-RD in the skull base highlighting the diagnostic challenges with assessment of these skull base lesions, and a systematic review of relevant literature was carried out. RESULTS A systematic review of the literature conducted in accordance with PRISMA guidelines identified 113 articles, with 184 cases of IgG4-RD in the skull base or calvarium. The most commonly affected locations include the meninges, cavernous sinus, base of the posterior fossa, clivus, and mastoid bone. Headache, visual and auditory disturbances, cranial nerve dysfunction, and seizures were the most common presenting symptoms. Medical treatment was highly successful and most commonly consisted of corticosteroids coadministered with immunosuppressive agents such as rituximab. Prevalence seemed to be equal between sexes, and serum IgG4 levels were increased in 61% of patients. Delayed diagnosis and a need for multiple biopsies were reported in numerous cases. Two cases of skull base IgG4-RD from the authors' institution show the variable presentations of this disease. More invasive surgical biopsies were required in both cases, and corticosteroid treatment led to significant clinical improvement. CONCLUSIONS IgG4-RD is an uncommon condition with an increasing body of reported cases that can affect the skull base and calvarium and should be in the differential diagnosis, because delay in diagnosis and treatment may be common.
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Affiliation(s)
- Samuel J Cler
- Department of Neurosurgery, Washington University School of Medicine, Washington, D.C., USA.
| | - Nima Sharifai
- Department of Pathology and Immunology, Washington University School of Medicine, Washington, D.C., USA
| | - Brandi Baker
- Department of Neurology, Washington University School of Medicine, Washington, D.C., USA
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine, Washington, D.C., USA
| | - Patrik Pipkorn
- Department of Otolaryngology, Washington University School of Medicine, Washington, D.C., USA
| | - Lauren Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, Washington, D.C., USA
| | - David B Clifford
- Department of Neurology, Washington University School of Medicine, Washington, D.C., USA; Department of Infectious Disease, Washington University School of Medicine, Washington, D.C., USA
| | - Sonika Dahiya
- Department of Pathology and Immunology, Washington University School of Medicine, Washington, D.C., USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, Washington, D.C., USA
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Rogers CM, Jones PS, Weinberg JS. Intraoperative MRI for Brain Tumors. J Neurooncol 2021; 151:479-490. [PMID: 33611714 DOI: 10.1007/s11060-020-03667-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of intraoperative imaging has been a critical tool in the neurosurgeon's armamentarium and is of particular benefit during tumor surgery. This article summarizes the history of its development, implementation, clinical experience and future directions. METHODS We reviewed the literature focusing on the development and clinical experience with intraoperative MRI. Utilizing the authors' personal experience as well as evidence from the literature, we present an overview of the utility of MRI during neurosurgery. RESULTS In the 1990s, the first description of using a low field MRI in the operating room was published describing the additional benefit provided by improved resolution of MRI as compared to ultrasound. Since then, implementation has varied in magnetic field strength and in configuration from floor mounted to ceiling mounted units as well as those that are accessible to the operating room for use during surgery and via an outpatient entrance to use for diagnostic imaging. The experience shows utility of this technique for increasing extent of resection for low and high grade tumors as well as preventing injury to important structures while incorporating techniques such as intraoperative monitoring. CONCLUSION This article reviews the history of intraoperative MRI and presents a review of the literature revealing the successful implementation of this technology and benefits noted for the patient and the surgeon.
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Affiliation(s)
- Cara Marie Rogers
- Department of Neurosurgery, Virginia Tech Carilion, Roanoke, VA, USA
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
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Laochamroonvorapongse D, Theard MA, Yahanda AT, Chicoine MR. Intraoperative MRI for Adult and Pediatric Neurosurgery. Anesthesiol Clin 2021; 39:211-225. [PMID: 33563383 DOI: 10.1016/j.anclin.2020.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Intraoperative MRI (iMRI) technology and its use in both adult and pediatric neurosurgery have advanced significantly over the past 2 decades, allowing neurosurgeons to account for brain shift and optimize resection of brain lesions. Combining the risks of the MR environment with those of the operating room creates a challenging, zero-tolerance environment for the anesthesiologist. This article provides an overview of the currently available iMRI systems, the neurosurgical evidence supporting iMRI use, and the anesthetic and safety considerations for iMRI procedures.
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Affiliation(s)
- Dean Laochamroonvorapongse
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code-UH2, Portland, OR 97239, USA.
| | - Marie A Theard
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code-UH2, Portland, OR 97239, USA
| | - Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
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Yahanda AT, Patel B, Shah AS, Cahill DP, Sutherland G, Honeycutt J, Jensen RL, Rich KM, Dowling JL, Limbrick DD, Dacey RG, Kim AH, Leuthardt EC, Dunn GP, Zipfel GJ, Leonard JR, Smyth MD, Shah MV, Abram SR, Evans J, Chicoine MR. Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study. Neurosurgery 2020; 88:63-73. [DOI: 10.1093/neuros/nyaa320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.
OBJECTIVE
To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.
METHODS
Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.
RESULTS
A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P = .03) and 1p/19q gene deletions (P = .02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P = .002, odds ratio [OR]: 1.04) and EOR (P = .003, OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.
CONCLUSION
EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Garnette Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Canada
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Mitesh V Shah
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Steven R Abram
- Department of Neurological Surgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Kim BJ, Kim Y, Youn DH, Park JJ, Rhim JK, Kim HC, Kang K, Jeon JP. Genome-wide blood DNA methylation analysis in patients with delayed cerebral ischemia after subarachnoid hemorrhage. Sci Rep 2020; 10:11419. [PMID: 32651463 PMCID: PMC7351711 DOI: 10.1038/s41598-020-68325-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
Little is known about the epigenetic changes associated with delayed cerebral ischemia (DCI) pathogenesis after subarachnoid hemorrhage (SAH). Here, we investigated genome-wide DNA methylation profiles specifically associated with DCI, which is a major contributor to poor clinical outcomes. An epigenome-wide association study (EWAS) and quantitative real-time PCR (qRT-PCR) were conducted in 40 SAH patients (DCI, n = 13; non-DCI, n = 27). A replication study using bisulfite modification and methylation-specific PCR was further performed in 36 patients (DCI, n = 12; non-DCI, n = 24). The relative degree of methylation was described as the median and 25th–75th percentile. No significant differences in clinical characteristics between DCI and non-DCI groups were observed. Among the top 10 differentially methylated genes analyzed via EWAS, two aberrantly methylated CpG sites of cg00441765 (INSR gene) and cg11464053 (CDHR5 gene) were associated with decreased mRNA expression (2−ΔCt). They include INSR [0.00020 (0.00012–0.00030) in DCI vs. 0.00050 (0.00030–0.00068) in non-DCI] and CDHR5 [0.114 (0.053–0.143) in DCI vs. 0.170 (0.110–0.212) in non-DCI]. Compared with non-DCI cases, patients with DCI exhibited an increased degree of methylation in the replication study: INSR, 0.855 (0.779–0.913) in DCI vs. 0.582 (0.565–0.689) in non-DCI; CDHR5, 0.786 (0.708–0.904) in DCI vs. 0.632 (0.610–0.679) in non-DCI. Hypermethylation of two novel genes, INSR and CDHR5 may serve as a biomarker for early detection of DCI following SAH.
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Affiliation(s)
- Bong Jun Kim
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Youngmi Kim
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong Hyuk Youn
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul, Korea
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Korea
| | - Heung Cheol Kim
- Department of Radioilogy, Hallym University College of Medicine, Chuncheon, Korea
| | - Keunsoo Kang
- Department of Microbiology, College of Science & Technology, Dankook University, Cheonan, 31116, Korea.
| | - Jin Pyeong Jeon
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea. .,Department of Neurosurgery, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon, 24253, Korea. .,Genetic and Research Inc., Chuncheon, Korea.
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