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Anichini G, Shah I, Mahoney DE, Patel N, Pakzad-Shahabi L, Da Costa OF, Syed N, Perryman R, Waldman A, O’Neill K. 3D ultrasound-augmented image guidance for surgery of high-grade gliomas - A quantitative analysis focused on the extent of resection. Surg Neurol Int 2024; 15:324. [PMID: 39373000 PMCID: PMC11450865 DOI: 10.25259/sni_369_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: 05/14/2024] [Accepted: 08/03/2024] [Indexed: 10/08/2024] Open
Abstract
Background We have retrospectively reviewed our series of brain tumor patients operated on using 3D IntraOperative UltraSound (IOUS) to report technical advantages and areas of improvement. Methods Clinical and radiological data of patients with a diagnosis of high-grade glioma IV operated with and without IOUS were retrieved and analyzed. Results We have found 391 patients operated using IOUS coupled with neuronavigation and 257 using neuronavigation standalone. We have selected a pool of 60 patients with a diagnosis of GlioBlastoma (GB), comparing two equally sized groups operated with and without IOUS, respectively. The average extent of resection (EOR) in the IOUS group was 93%, while in the control group, it was 80%. IOUS was significantly associated with improved EOR (P < 0.0004), even when accounting for other factors affecting EOR. The average overall survival (OS) was 13.4 months, and the average progression-free survival (PFS) was 7.4 months. The Cox proportional hazard model showed an advantage in OS on patients operated using the IOUS. No statistically significant effect was observed on PFS. Conclusion Intraoperative ultrasound coupled with image guidance is associated with an improved EOR and possibly an improved OS. While we are aware of several limitations related to the present analysis, these data support the routine use of IOUS as a safe and reliable technology. Larger, prospective series with updated IOUS technology are desirable to verify the accuracy of these results.
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Affiliation(s)
- Giulio Anichini
- Department of Brain Sciences, Imperial College London, England, United Kingdom
| | - Islam Shah
- Department of Surgery and Cancer, Neuroradiology, Imperial College London, England, United Kingdom
| | - Dominic Edward Mahoney
- Department of Neurosurgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, England, United Kingdom
| | - Neekhil Patel
- Department of Brain Sciences, Imperial College London, England, United Kingdom
| | - Lillie Pakzad-Shahabi
- Department of Neuro-oncology, Imperial College of London, London, England, United Kingdom
| | | | - Nelofer Syed
- Department of Brain Sciences, Imperial College London, England, United Kingdom
| | - Richard Perryman
- Department of Brain Sciences, Imperial College London, England, United Kingdom
| | - Adam Waldman
- Centre for Clinical Brain Science, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Kevin O’Neill
- Department of Brain Sciences, Imperial College London, England, United Kingdom
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Massaad E, Smith WJ, Bradley J, Esposito E, Gupta M, Burns E, Burns R, Velarde JK, Berglar IK, Gupta R, Martinez-Lage M, Dietrich J, Lennerz JK, Dunn GP, Jones PS, Choi BD, Kim AE, Frosch M, Barker FG, Curry WT, Carter BS, Nahed BV, Cahill DP, Shankar GM. Radical surgical resection with molecular margins is associated with improved survival in IDH wild-type glioblastoma. Neuro Oncol 2024; 26:1660-1669. [PMID: 38581292 PMCID: PMC11376447 DOI: 10.1093/neuonc/noae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Survival is variable in patients with glioblastoma IDH wild-type (GBM), even after comparable surgical resection of radiographically detectable disease, highlighting the limitations of radiographic assessment of infiltrative tumor anatomy. The majority of postsurgical progressive events are failures within 2 cm of the resection margin, motivating supramaximal resection strategies to improve local control. However, which patients benefit from such radical resections remains unknown. METHODS We developed a predictive model to identify which IDH wild-type GBMs are amenable to radiographic gross-total resection (GTR). We then investigated whether GBM survival heterogeneity following GTR is correlated with microscopic tumor burden by analyzing tumor cell content at the surgical margin with a rapid qPCR-based method for detection of TERT promoter mutation. RESULTS Our predictive model for achievable GTR, developed on retrospective radiographic and molecular data of GBM patients undergoing resection, had an area under the curve of 0.83, sensitivity of 62%, and specificity of 90%. Prospective analysis of this model in 44 patients found that 89% of patients were correctly predicted to achieve a residual volume (RV) < 4.9cc. Of the 44 prospective patients undergoing rapid qPCR TERT promoter mutation analysis at the surgical margin, 7 had undetectable TERT mutation, of which 5 also had a GTR (RV < 1cc). In these 5 patients at 30 months follow-up, 75% showed no progression, compared to 0% in the group with TERT mutations detected at the surgical margin (P = .02). CONCLUSIONS These findings identify a subset of patients with GBM that may derive local control benefits from radical resection to undetectable molecular margins.
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Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William J Smith
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph Bradley
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric Esposito
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mihir Gupta
- Department of Neurosurgery, Yale New Heaven Health, New Haven, Connecticut, USA
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Evan Burns
- Jacobs School of Medicine, University of Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan Burns
- Department of Biology, Boston College, Newton, Massachusetts, USA
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - José K Velarde
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Inka K Berglar
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rajiv Gupta
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria Martinez-Lage
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jochen K Lennerz
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gavin P Dunn
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Albert E Kim
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew Frosch
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William T Curry
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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3
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Karschnia P, Gerritsen JKW, Teske N, Cahill DP, Jakola AS, van den Bent M, Weller M, Schnell O, Vik-Mo EO, Thon N, Vincent AJPE, Kim MM, Reifenberger G, Chang SM, Hervey-Jumper SL, Berger MS, Tonn JC. The oncological role of resection in newly diagnosed diffuse adult-type glioma defined by the WHO 2021 classification: a Review by the RANO resect group. Lancet Oncol 2024; 25:e404-e419. [PMID: 39214112 DOI: 10.1016/s1470-2045(24)00130-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 09/04/2024]
Abstract
Glioma resection is associated with prolonged survival, but neuro-oncological trials have frequently refrained from quantifying the extent of resection. The Response Assessment in Neuro-Oncology (RANO) resect group is an international, multidisciplinary group that aims to standardise research practice by delineating the oncological role of surgery in diffuse adult-type gliomas as defined per WHO 2021 classification. Favourable survival effects of more extensive resection unfold over months to decades depending on the molecular tumour profile. In tumours with a more aggressive natural history, supramaximal resection might correlate with additional survival benefit. Weighing the expected survival benefits of resection as dictated by molecular tumour profiles against clinical factors, including the introduction of neurological deficits, we propose an algorithm to estimate the oncological effects of surgery for newly diagnosed gliomas. The algorithm serves to select patients who might benefit most from extensive resection and to emphasise the relevance of quantifying the extent of resection in clinical trials.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, Ludwig-Maximilians-University, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Jasper K W Gerritsen
- Department of Neurosurgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands; Department of Neurosurgery and Division of Neuro-Oncology, University of San Francisco, San Francisco, CA, USA
| | - Nico Teske
- Department of Neurosurgery, Ludwig-Maximilians-University, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Asgeir S Jakola
- Department of Neurosurgery, University of Gothenburg, Gothenburg, Sweden; Section of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Martin van den Bent
- Department of Neurology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Oliver Schnell
- Department of Neurosurgery, Universitaetsklinikum Erlangen, Friedrich-Alexander-Universitaet, Erlangen-Nuernberg, Germany
| | - Einar O Vik-Mo
- Department of Neurosurgery, Oslo University Hospital and Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Niklas Thon
- Department of Neurosurgery, Ludwig-Maximilians-University, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Guido Reifenberger
- Institute of Neuropathology, Heinrich Heine University Medical Faculty and University Hospital Düsseldorf, Düsseldorf, Germany; German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Germany
| | - Susan M Chang
- Department of Neurosurgery and Division of Neuro-Oncology, University of San Francisco, San Francisco, CA, USA
| | - Shawn L Hervey-Jumper
- Department of Neurosurgery and Division of Neuro-Oncology, University of San Francisco, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurosurgery and Division of Neuro-Oncology, University of San Francisco, San Francisco, CA, USA
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany.
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4
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Karschnia P, Tonn JC. Shaping the future of molecular neurosurgery: Toward epigenetic precision in surgical neuro-oncology? Neuro Oncol 2024; 26:1355-1356. [PMID: 38832720 PMCID: PMC11299998 DOI: 10.1093/neuonc/noae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Indexed: 06/05/2024] Open
Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, LMU University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, LMU University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
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5
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Ruella ME, Caffaratti G, Chaves H, Yañez P, Cervio A. Transoperative Magnetic Resonance Imaging in Awake Glioma Surgery: Experience in a Latin American Tertiary-Level Center. World Neurosurg 2024; 186:e65-e74. [PMID: 38417621 DOI: 10.1016/j.wneu.2024.02.104] [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: 12/29/2023] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Analyze the usefulness, efficacy, and safety of transoperative magnetic resonance imaging (tMRI) in glioma surgery in awake patients. METHODS Retrospective, single-center, analytical study of a cohort of patients who underwent awake surgery for gliomas by the same surgeon in a third-level Argentine center, in the period between 2012 and 2022. Only patients with pathology-confirmed gliomas, with 6-month follow-up, who had preoperative and postoperative volumetric magnetic resonance imaging, were included in this sample. Subsequently, we analyzed which patients received surgery with the tMRI protocol and the results using multivariate regression analysis. RESULTS A total of 71 patients were included. A tMRI study was performed on 22 (31%) of these patients. The use of tMRI increased the percentage of resection by 20% (P = 0.03), thereby increasing the possibility of gross total resection. However, using tMRI significantly extended surgical time by 84 minutes (P < 0.001). In 55% of the patients in whom tMRI was performed, the resection was continued after it. The use of tMRI did not increase the rate of infections or the development of surgically associated neurological deficits in the long term, despite the fact that 47% of the patients showed the development of a new deficit or worsening of a previous one during the intraoperative period. CONCLUSIONS The use of tMRI in awake glioma surgery proved to be a safe tool that contributes to increasing the degree of tumor resection, compared to the use of neurophysiological mapping and neuronavigation, at the expense of increased surgical times and costs. We consider tMRI in awake glioma surgery should be used in properly selected cases.
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Affiliation(s)
- Mauro E Ruella
- Department of Neurosurgery, Fleni, Buenos Aires, Argentina.
| | | | - Hernan Chaves
- Department of Neuro-Radiology, Fleni, Buenos Aires, Argentina
| | - Paulina Yañez
- Department of Neuro-Radiology, Fleni, Buenos Aires, Argentina
| | - Andrés Cervio
- Department of Neurosurgery, Fleni, Buenos Aires, Argentina
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6
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Stummer W, Müther M, Spille D. Beyond fluorescence-guided resection: 5-ALA-based glioblastoma therapies. Acta Neurochir (Wien) 2024; 166:163. [PMID: 38563988 PMCID: PMC10987337 DOI: 10.1007/s00701-024-06049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
Glioblastoma is the most common primary malignant brain tumor. Despite advances in multimodal concepts over the last decades, prognosis remains poor. Treatment of patients with glioblastoma remains a considerable challenge due to the infiltrative nature of the tumor, rapid growth rates, and tumor heterogeneity. Standard therapy consists of maximally safe microsurgical resection followed by adjuvant radio- and chemotherapy with temozolomide. In recent years, local therapies have been extensively investigated in experimental as well as translational levels. External stimuli-responsive therapies such as Photodynamic Therapy (PDT), Sonodynamic Therapy (SDT) and Radiodynamic Therapy (RDT) can induce cell death mechanisms via generation of reactive oxygen species (ROS) after administration of five-aminolevulinic acid (5-ALA), which induces the formation of sensitizing porphyrins within tumor tissue. Preliminary data from clinical trials are available. The aim of this review is to summarize the status of such therapeutic approaches as an adjunct to current standard therapy in glioblastoma.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Michael Müther
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Dorothee Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
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7
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Li Z, Song Y, Farrukh Hameed NU, Yuan S, Wu S, Gong X, Zhuang D, Lu J, Zhu F, Qiu T, Zhang J, Aibaidula A, Geng X, Yang Z, Tang W, Chen H, Zhou L, Mao Y, Wu J. Effect of high-field iMRI guided resection in cerebral glioma surgery: A randomized clinical trial. Eur J Cancer 2024; 199:113528. [PMID: 38218157 DOI: 10.1016/j.ejca.2024.113528] [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: 10/11/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Extent of resection (EOR) in glioma contributes to longer survival. The purpose of NCT01479686 was to prove whether intraoperative magnetic resonance imaging (iMRI) increases EOR in glioma surgery and benefit survival. METHODS Patients were randomized (1:1) to receive the iMRI (n = 161) or the conventional neuronavigation (n = 160). The primary endpoint was gross total resection (GTR); secondary outcomes reported were progression-free survival (PFS), overall survival (OS), and safety. RESULTS 188 high-grade gliomas (HGGs) and 133 low-grade gliomas (LGGs) were enrolled. GTR was 83.85% in the iMRI group vs. 50.00% in the control group (P < 0.0001). In 321 patients, the median PFS (mPFS) was 65.12 months in the iMRI group and 61.01 months in the control group (P = 0.0202). For HGGs, mPFS was improved in the iMRI group (19.32 vs. 13.34 months, P = 0.0015), and a trend of superior OS compared with control was observed (29.73 vs. 25.33 months, P = 0.1233). In the predefined eloquent area HGG subgroup, mPFS, and mOS were 20.47 months and 33.58 months in the iMRI vs. 12.21 months and 21.16 months in the control group (P = 0.0098; P = 0.0375, respectively). From the exploratory analyses of HGGs, residual tumor volume (TV) < 1.0 cm3 decreased the risk of survival (mPFS: 18.99 vs. 9.43 months, P = 0.0055; mOS: 29.77 vs. 18.10 months, P = 0.0042). LGGs with preoperative (pre-OP) TV > 43.1 cm3 and postoperative (post-OP) TV > 4.6 cm3 showed worse OS (P= 0.0117) CONCLUSIONS: It showed that iMRI significantly increased EOR and indicated survival benefits for HGGs, particularly eloquent HGGs. Residual TV in either HGGs or LGGs is a prognostic factor for survival.
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Affiliation(s)
- Zeyang Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China
| | - Yanyan Song
- Department of Biostatistics, Clinical research institute, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - N U Farrukh Hameed
- University of Pittsburgh Medical Center and Hillman Cancer Center, Department of Neurosurgery, Pittsburgh, USA
| | - Shiwen Yuan
- Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, 146 West River Street, Providence, RI 02904, USA
| | - Shuai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China
| | - Xiu Gong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Dongxiao Zhuang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; National Neurological Diseases Center, China
| | - Junfeng Lu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Fengping Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Tianming Qiu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Jie Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Abudumijiti Aibaidula
- Department of Neurosurgery, University of Missouri in Columbia, One Hospital Drive, MO, 65212, Columbia
| | - Xu Geng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Zhong Yang
- Department of Radiotherapy, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Weijun Tang
- Department of Radiotherapy, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Hong Chen
- Department of Pathology, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China; Institute of Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jinsong Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China; Institute of Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China.
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8
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Gautheron A, Bernstock JD, Picart T, Guyotat J, Valdés PA, Montcel B. 5-ALA induced PpIX fluorescence spectroscopy in neurosurgery: a review. Front Neurosci 2024; 18:1310282. [PMID: 38348134 PMCID: PMC10859467 DOI: 10.3389/fnins.2024.1310282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024] Open
Abstract
The review begins with an overview of the fundamental principles/physics underlying light, fluorescence, and other light-matter interactions in biological tissues. It then focuses on 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence spectroscopy methods used in neurosurgery (e.g., intensity, time-resolved) and in so doing, describe their specific features (e.g., hardware requirements, main processing methods) as well as their strengths and limitations. Finally, we review current clinical applications and future directions of 5-ALA-induced protoporphyrin IX (PpIX) fluorescence spectroscopy in neurosurgery.
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Affiliation(s)
- A. Gautheron
- Université Jean Monnet Saint-Etienne, CNRS, Institut d Optique Graduate School, Laboratoire Hubert Curien UMR 5516, Saint-Étienne, France
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
| | - J. D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - T. Picart
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, INSERM 1052, CNRS 5286, Lyon, France
| | - J. Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - P. A. Valdés
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, United States
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, United States
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, United States
| | - B. Montcel
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
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9
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Feucht D, Haas P, Skardelly M, Behling F, Rieger D, Bombach P, Paulsen F, Hoffmann E, Hauser TK, Bender B, Renovanz M, Niyazi M, Tabatabai G, Tatagiba M, Roder C. Preoperative growth dynamics of untreated glioblastoma: Description of an exponential growth type, correlating factors, and association with postoperative survival. Neurooncol Adv 2024; 6:vdae053. [PMID: 38680987 PMCID: PMC11046984 DOI: 10.1093/noajnl/vdae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Background Little is known about the growth dynamics of untreated glioblastoma and its possible influence on postoperative survival. Our aim was to analyze a possible association of preoperative growth dynamics with postoperative survival. Methods We performed a retrospective analysis of all adult patients surgically treated for newly diagnosed glioblastoma at our center between 2010 and 2020. By volumetric analysis of data of patients with availability of ≥3 preoperative sequential MRI, a growth pattern was aimed to be identified. Main inclusion criterion for further analysis was the availability of two preoperative MRI scans with a slice thickness of 1 mm, at least 7 days apart. Individual growth rates were calculated. Association with overall survival (OS) was examined by multivariable. Results Out of 749 patients screened, 13 had ≥3 preoperative MRI, 70 had 2 MRI and met the inclusion criteria. A curve estimation regression model showed the best fit for exponential tumor growth. Median tumor volume doubling time (VDT) was 31 days, median specific growth rate (SGR) was 2.2% growth per day. SGR showed negative correlation with tumor size (rho = -0.59, P < .001). Growth rates were dichotomized according to the median SGR.OS was significantly longer in the group with slow growth (log-rank: P = .010). Slower preoperative growth was independently associated with longer overall survival in a multivariable Cox regression model for patients after tumor resection. Conclusions Especially small lesions suggestive of glioblastoma showed exponential tumor growth with variable growth rates and a median VDT of 31 days. SGR was significantly associated with OS in patients with tumor resection in our sample.
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Affiliation(s)
- Daniel Feucht
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Haas
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Marco Skardelly
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, Klinikum am Steinenberg, Reutlingen, Germany
| | - Felix Behling
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - David Rieger
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paula Bombach
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
| | - Elgin Hoffmann
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Till-Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Benjamin Bender
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Tübingen, Germany
| | - Mirjam Renovanz
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Maximilian Niyazi
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Ghazaleh Tabatabai
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Constantin Roder
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Tübingen, Germany
- Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
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10
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Padayachy L, Prada F. Multimodality Structural and Functional Monitoring in Brain Tumor Surgery: The Role of IONM and IOUS. Adv Tech Stand Neurosurg 2024; 53:1-12. [PMID: 39287799 DOI: 10.1007/978-3-031-67077-0_1] [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
Brain tumor surgery represents the pinnacle of technical and technological advances in the neurosurgery. The goal remains optimized extent of resection with preservation of neurological function. The benefit of a multimodal structural and functional intra-operative monitoring approach is to improve the ability of the surgeon to achieve the goal of optimized surgical resection. Despite significant technological advances, challenges in defining tumor and functional neural tissue interface remain a significant barrier. The opportunity to address this challenge, however, presents us with an exciting path ahead.
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Affiliation(s)
- Llewellyn Padayachy
- Brain Tumor and Translational Neuroscience Centre, Department of Neurosurgery, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Francesco Prada
- Acoustic Neuro-Imaging and Therapy Lab (ANTY-Lab), Department of Neurosurgery, Fondazione IRCCS Istituto C. Besta, Milan, Italy.
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11
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Hardigan AA, Jackson JD, Patel AP. Surgical Management and Advances in the Treatment of Glioma. Semin Neurol 2023; 43:810-824. [PMID: 37963582 PMCID: PMC11229982 DOI: 10.1055/s-0043-1776766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The care of patients with both high-grade glioma and low-grade glioma necessitates an interdisciplinary collaboration between neurosurgeons, neuro-oncologists, neurologists and other practitioners. In this review, we aim to detail the considerations, approaches and advances in the neurosurgical care of gliomas. We describe the impact of extent-of-resection in high-grade and low-grade glioma, with particular focus on primary and recurrent glioblastoma. We address advances in surgical methods and adjunct technologies such as intraoperative imaging and fluorescence guided surgery that maximize extent-of-resection while minimizing the potential for iatrogenic neurological deficits. Finally, we review surgically-mediated therapies other than resection and discuss the role of neurosurgery in emerging paradigm-shifts in inter-disciplinary glioma management such as serial tissue sampling and "window of opportunity trials".
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Affiliation(s)
- Andrew A Hardigan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Joshua D Jackson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Anoop P Patel
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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12
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Karschnia P, Smits M, Reifenberger G, Le Rhun E, Ellingson BM, Galldiks N, Kim MM, Huse JT, Schnell O, Harter PN, Mohme M, von Baumgarten L, Albert NL, Huang RY, Mehta MP, van den Bent M, Weller M, Vogelbaum MA, Chang SM, Berger MS, Tonn JC. A framework for standardised tissue sampling and processing during resection of diffuse intracranial glioma: joint recommendations from four RANO groups. Lancet Oncol 2023; 24:e438-e450. [PMID: 37922934 PMCID: PMC10849105 DOI: 10.1016/s1470-2045(23)00453-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/23/2023] [Accepted: 09/07/2023] [Indexed: 11/07/2023]
Abstract
Surgical resection represents the standard of care for people with newly diagnosed diffuse gliomas, and the neuropathological and molecular profile of the resected tissue guides clinical management and forms the basis for research. The Response Assessment in Neuro-Oncology (RANO) consortium is an international, multidisciplinary effort that aims to standardise research practice in neuro-oncology. These recommendations represent a multidisciplinary consensus from the four RANO groups: RANO resect, RANO recurrent glioblastoma, RANO radiotherapy, and RANO/PET for a standardised workflow to achieve a representative tumour evaluation in a disease characterised by intratumoural heterogeneity, including recommendations on which tumour regions should be surgically sampled, how to define those regions on the basis of preoperative imaging, and the optimal sample volume. Practical recommendations for tissue sampling are given for people with low-grade and high-grade gliomas, as well as for people with newly diagnosed and recurrent disease. Sampling of liquid biopsies is also addressed. A standardised workflow for subsequent handling of the resected tissue is proposed to avoid information loss due to decreasing tissue quality or insufficient clinical information. The recommendations offer a framework for prospective biobanking studies.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Marion Smits
- Department of Neuroradiology and Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Guido Reifenberger
- Institute of Neuropathology, Heinrich Heine University Medical Faculty and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Emilie Le Rhun
- Department of Neurosurgery, University Hospital of Zurich and University of Zurich, Zurich, Switzerland; Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Norbert Galldiks
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany; Research Center Juelich, Institute of Neuroscience and Medicine, Juelich, Germany
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Jason T Huse
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Oliver Schnell
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Patrick N Harter
- German Cancer Consortium, Partner Site Munich, Munich, Germany; Center for Neuropathology and Prion Research, Faculty of Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Raymond Y Huang
- Division of Neuroradiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Martin van den Bent
- Department of Neurology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Michael Weller
- Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | | | - Susan M Chang
- Department of Neurosurgery and Division of Neuro-Oncology, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurosurgery and Division of Neuro-Oncology, University of California, San Francisco, CA, USA
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany.
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13
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Bin-Alamer O, Abou-Al-Shaar H, Gersey ZC, Huq S, Kallos JA, McCarthy DJ, Head JR, Andrews E, Zhang X, Hadjipanayis CG. Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review. Cancers (Basel) 2023; 15:4890. [PMID: 37835584 PMCID: PMC10571802 DOI: 10.3390/cancers15194890] [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: 08/29/2023] [Revised: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.
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Affiliation(s)
- Othman Bin-Alamer
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Hussam Abou-Al-Shaar
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Zachary C. Gersey
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Sakibul Huq
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Justiss A. Kallos
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David J. McCarthy
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jeffery R. Head
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Edward Andrews
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Xiaoran Zhang
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Constantinos G. Hadjipanayis
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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