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Rechberger JS, Zhang L, Ge J, Nesvick CL, Miller KJ, Daniels DJ. Feasibility of probe washing after stereotactic needle biopsy as a novel technique for developing cell lines and xenografts of H3 K27-altered diffuse midline gliomas. J Neurosurg Pediatr 2023; 32:413-420. [PMID: 37486856 DOI: 10.3171/2023.5.peds22557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/26/2023] [Indexed: 07/26/2023]
Abstract
H3 K27-altered diffuse midline gliomas (DMGs) are frequently biopsied to obtain tissue diagnosis, inform clinical decision-making, and determine clinical trial eligibility. Tissue yield from biopsies is typically low, leaving little material available for research. To advance understanding of disease biology and promote preclinical testing of novel therapeutics, collecting viable cellular material from treatment-naive tumors is of paramount importance. Here, the authors report the feasibility of a practicable technique for creating DMG cell lines and patient-derived xenografts (PDXs) without the need for additional biopsy specimens. Tumor cells are obtained by probe washing immediately after completion of biopsy. Wash fluid is collected, and viable cells are expanded in vitro. Cultured cells are used to establish PDX rodent models. A total of 5 patient samples were collected by this technique. Viable tumor cells were obtained from 3 of the 5 samples, and cell lines suitable for experiments were obtained within 6-8 months. Orthotopic implantation and flank engraftment was successful in 1 of the 3 established cell lines. Animals harboring intracranial tumors were euthanized due to disease burden 6-7 months after stereotactic injection. Flank tumors formed within 4-5 months and were serially passaged. Molecular and tissue analyses confirmed retention of H3 K27M expression and loss of H3 K27me3 in all cell lines and PDXs.
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Affiliation(s)
- Julian S Rechberger
- Departments of1Neurologic Surgery and
- 2Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | | | - Jizhi Ge
- Departments of1Neurologic Surgery and
| | | | | | - David J Daniels
- Departments of1Neurologic Surgery and
- 2Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
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2
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Rotter J, Kumar R, Nesvick CL, Krauss WE, Giannini C, Tobin WO. Teaching NeuroImage: Olfactory Stem Cell Injection Inducing Actively Secreting Respiratory Epithelium in a Cervical Syrinx. Neurology 2023; 101:497-498. [PMID: 37400242 PMCID: PMC10513884 DOI: 10.1212/wnl.0000000000207463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/13/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- Juliana Rotter
- From the Department of Neurologic Surgery (J.R., R.K., C.L.N., W.E.K.), Department of Pathology (C.G.), and Department of Neurology (W.O.T.), Mayo Clinic, Rochester, MN
| | - Rahul Kumar
- From the Department of Neurologic Surgery (J.R., R.K., C.L.N., W.E.K.), Department of Pathology (C.G.), and Department of Neurology (W.O.T.), Mayo Clinic, Rochester, MN
| | - Cody L Nesvick
- From the Department of Neurologic Surgery (J.R., R.K., C.L.N., W.E.K.), Department of Pathology (C.G.), and Department of Neurology (W.O.T.), Mayo Clinic, Rochester, MN
| | - William E Krauss
- From the Department of Neurologic Surgery (J.R., R.K., C.L.N., W.E.K.), Department of Pathology (C.G.), and Department of Neurology (W.O.T.), Mayo Clinic, Rochester, MN
| | - Caterina Giannini
- From the Department of Neurologic Surgery (J.R., R.K., C.L.N., W.E.K.), Department of Pathology (C.G.), and Department of Neurology (W.O.T.), Mayo Clinic, Rochester, MN
| | - William O Tobin
- From the Department of Neurologic Surgery (J.R., R.K., C.L.N., W.E.K.), Department of Pathology (C.G.), and Department of Neurology (W.O.T.), Mayo Clinic, Rochester, MN.
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Dang DD, Rechberger JS, Leonel LCPC, Rindler RS, Nesvick CL, Graepel S, Link MJ, Daniels DJ, Peris Celda M. Anatomical step-by-step dissection of common approaches to the third ventricle for trainees: surgical anatomy of the anterior transcortical and interhemispheric transcallosal approaches, surgical principles, and illustrative pediatric cases. Acta Neurochir (Wien) 2023; 165:2421-2434. [PMID: 37418043 DOI: 10.1007/s00701-023-05697-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE To create a high-quality, cadaver-based, operatively oriented resource documenting the anterior transcortical and interhemispheric transcallosal approaches as corridors to the third ventricle targeted towards neurosurgical trainees at all levels. METHODS Two formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic-assisted visualization. Dissections of the transcortical and transcallosal craniotomies with transforaminal, transchoroidal, and interforniceal transventricular approaches were performed. The dissections were documented in a stepwise fashion using three-dimensional photographic image acquisition techniques and supplemented with representative cases to highlight pertinent surgical principles. RESULTS The anterior transcortical and interhemispheric corridors afford excellent access to the anterior two-thirds of the third ventricle with varying risks associated with frontal lobe versus corpus callosum disruption, respectively. The transcortical approach offers a more direct, oblique view of the ipsilateral lateral ventricle, whereas the transcallosal approach readily establishes biventricular access through a paramedian corridor. Once inside the lateral ventricle, intraventricular angled endoscopy further enhances access to the extreme poles of the third ventricle from either open transcranial approach. Subsequent selection of either the transforaminal, transchoroidal, or interforniceal routes can be performed through either craniotomy and is ultimately dependent on individual deep venous anatomy, the epicenter of ventricular pathology, and the concomitant presence of hydrocephalus or embryologic cava. Key steps described include positioning and skin incision; scalp dissection; craniotomy flap elevation; durotomy; transcortical versus interhemispheric dissection with callosotomy; the aforementioned transventricular routes; and their relevant intraventricular landmarks. CONCLUSIONS Approaches to the ventricular system for maximal safe resection of pediatric brain tumors are challenging to master yet represent foundational cranial surgical techniques. We present a comprehensive operatively oriented guide for neurosurgery residents that combines stepwise open and endoscopic cadaveric dissections with representative case studies to optimize familiarity with third ventricle approaches, mastery of relevant microsurgical anatomy, and preparation for operating room participation.
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Affiliation(s)
- Danielle D Dang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA
| | - Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA
| | - Luciano C P C Leonel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA
| | - Rima S Rindler
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Stephen Graepel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Maria Peris Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA.
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
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Rechberger JS, Bouchal SM, Power EA, Nonnenbroich LF, Nesvick CL, Daniels DJ. Bench-to-bedside investigations of H3 K27-altered diffuse midline glioma: drug targets and potential pharmacotherapies. Expert Opin Ther Targets 2023; 27:1071-1086. [PMID: 37897190 DOI: 10.1080/14728222.2023.2277232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/26/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION H3 K27-altered diffuse midline glioma (DMG) is the most common malignant brainstem tumor in the pediatric population. Despite enormous preclinical and clinical efforts, the prognosis remains dismal, with fewer than 10% of patients surviving for two years after diagnosis. Fractionated radiation remains the only standard treatment options for DMG. Developing novel treatments and therapeutic delivery methods is critical to improving outcomes in this devastating disease. AREAS COVERED This review addresses recent advances in molecularly targeted pharmacotherapy and immunotherapy in DMG. The clinical presentation, diagnostic workup, unique pathological challenges, and current clinical trials are highlighted throughout. EXPERT OPINION Promising pharmacotherapies targeting various components of DMG pathology and the application of immunotherapies have the potential to improve patient outcomes. However, novel approaches are needed to truly revolutionize treatment for this tumor. First, combinational therapy should be employed, as DMG can develop resistance to single-agent approaches and many therapies are susceptible to rapid clearance from the brain. Second, drug-tumor residence time, i.e. the time for which a therapeutic is present at efficacious concentrations within the tumor, must be maximized to facilitate a durable treatment response. Engineering extended drug delivery methods with minimal off-tumor toxicity should be a focus of future studies.
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Affiliation(s)
- Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Samantha M Bouchal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Erica A Power
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Leo F Nonnenbroich
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
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Naylor RM, Graffeo CS, Nesvick CL, Link MJ, Brown PD, Stafford S, Laack N, Pollock BE. 391 Stereotactic Radiosurgery for Intermediate and High-Grade Arteriovenous Malformations: Outcomes Stratified by the Supplemented Spetzler-Martin Grading System. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Naylor RM, Graffeo CS, Nesvick CL, Link MJ, Brown PD, Stafford SL, Laack NN, Pollock BE. Stereotactic radiosurgery for intermediate- and high-grade arteriovenous malformations: outcomes stratified by the supplemented Spetzler-Martin grading system. J Neurosurg 2023; 138:804-809. [PMID: 35901695 DOI: 10.3171/2022.5.jns22761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The supplemented Spetzler-Martin (Supp-SM) grading system was developed to improve the predictive accuracy of surgical risk for patients with brain arteriovenous malformations (AVMs). The aim of this study was to apply the Supp-SM grading system to patients having stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) intermediate- (grade III) or high-grade (grade IV-V) AVMs to enable comparison with published microsurgical series. METHODS In 219 patients who underwent SRS during the period from 1990 to 2016, the Supp-SM grade was calculated for SM grade III (n = 154) or SM grade IV-V (n = 65) AVMs. The Supp-SM grades in these patients were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). Sixty patients (27%) had deep AVMs (basal ganglia, thalamus, or brainstem). Thirty-nine patients (18%) had volume-staged SRS; 41 patients (19%) underwent repeat SRS. The median follow-up period was 69 months for SM grade III AVMs and 113 months for SM grade IV-V AVMs. RESULTS AVM obliteration was confirmed in 163 patients (74%) at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. Thirty-one patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). Six patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurological decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of nonobliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurological decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading score did not correlate with either obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurological decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38). CONCLUSIONS The Supp-SM grading system was not predictive of outcomes after SRS of intermediate- or high-grade AVM. In a cohort that included a high percentage (47%) of "inoperable" AVMs according to Supp-SM grade (≥ 7), most patients had obliteration after SRS, although there was a high risk of neurological decline.
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Affiliation(s)
- Ryan M Naylor
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Christopher S Graffeo
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Cody L Nesvick
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Scott L Stafford
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia N Laack
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Rechberger JS, Power BT, Power EA, Nesvick CL, Daniels DJ. H3K27-altered diffuse midline glioma: a paradigm shifting opportunity in direct delivery of targeted therapeutics. Expert Opin Ther Targets 2023; 27:9-17. [PMID: 36744399 PMCID: PMC10165636 DOI: 10.1080/14728222.2023.2177531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite much progress, the prognosis for H3K27-altered diffuse midline glioma (DMG), previously known as diffuse intrinsic pontine glioma when located in the brainstem, remains dark and dismal. AREAS COVERED A wealth of research over the past decade has revolutionized our understanding of the molecular basis of DMG, revealing potential targetable vulnerabilities for treatment of this lethal childhood cancer. However, obstacles to successful clinical implementation of novel therapies remain, including effective delivery across the blood-brain barrier (BBB) to the tumor site. Here, we review relevant literature and clinical trials and discuss direct drug delivery via convection-enhanced delivery (CED) as a promising treatment modality for DMG. We outline a comprehensive molecular, pharmacological, and procedural approach that may offer hope for afflicted patients and their families. EXPERT OPINION Challenges remain in successful drug delivery to DMG. While CED and other techniques offer a chance to bypass the BBB, the variables influencing successful intratumoral targeting are numerous and complex. We discuss these variables and potential solutions that could lead to the successful clinical implementation of preclinically promising therapeutic agents.
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Affiliation(s)
- Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Blake T Power
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Erica A Power
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
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Power EA, Rechberger JS, Zhang L, Oh JH, Anderson JB, Nesvick CL, Ge J, Hinchcliffe EH, Elmquist WF, Daniels DJ. Overcoming translational barriers in H3K27-altered diffuse midline glioma: Increasing the drug-tumor residence time. Neurooncol Adv 2023; 5:vdad033. [PMID: 37128506 PMCID: PMC10148679 DOI: 10.1093/noajnl/vdad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background H3K27-altered diffuse midline glioma (DMG) is the deadliest pediatric brain tumor; despite intensive research efforts, every clinical trial to date has failed. Is this because we are choosing the wrong drugs? Or are drug delivery and other pharmacokinetic variables at play? We hypothesize that the answer is likely a combination, where optimization may result in a much needed novel therapeutic approach. Methods We used in vitro drug screening, patient samples, and shRNA knockdown models to identify an upregulated target in DMG. A single small molecule protein kinase inhibitor with translational potential was selected for systemic and direct, loco-regional delivery to patient-derived xenografts (PDX) and genetically engineered mouse models (GEMM). Pharmacokinetic studies were conducted in non-tumor bearing rats. Results Aurora kinase (AK) inhibitors demonstrated strong antitumor effects in DMG drug screens. Additional in vitro studies corroborated the importance of AK to DMG survival. Systemic delivery of alisertib showed promise in subcutaneous PDX but not intracranial GEMM and PDX models. Repeated loco-regional drug administration into the tumor through convection-enhanced delivery (CED) was equally inefficacious, and pharmacokinetic studies revealed rapid clearance of alisertib from the brain. In an effort to increase the drug to tumor residence time, continuous CED over 7 days improved drug retention in the rodent brainstem and significantly extended survival in both orthotopic PDXs and GEMMs. Conclusions These studies provide evidence for increasing drug-tumor residence time of promising targeted therapies via extended CED as a valuable treatment strategy for DMG.
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Affiliation(s)
- Erica A Power
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Julian S Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Liang Zhang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ju-Hee Oh
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jacob B Anderson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jizhi Ge
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - William F Elmquist
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
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Mikula AL, Ransom RC, Nesvick CL, Douse DM, Smith AJ, Maldonado G, Clements CM, Kim BD, Driscoll CL, Elder BD. Toothbrush Oropharyngeal Impalement With Spinal Canal Compromise: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e377-e378. [DOI: 10.1227/ons.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/18/2022] [Indexed: 11/16/2022] Open
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10
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Rotter J, Carlstrom LP, Graffeo CS, Nesvick CL, Gunnels M, Hellickson JD, Marcellino C, Atkinson JLD. Streamlining the External Ventricular Drain and Intracranial Pressure Monitor Procedural Setup: A Quality Improvement Initiative. World Neurosurg 2022; 166:e475-e483. [PMID: 35843582 DOI: 10.1016/j.wneu.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE External ventricular drain (EVD) and intracranial pressure (ICP) monitor placements are among the most common critical care procedures for severe brain injury. Quality improvement initiatives have streamlined similar processes. The aim of the project was to decrease the time to collect supplies for EVD or ICP monitor placement by 25% by April 1, 2021. METHODS The project followed the define-measure-analyze-improve-control 6 sigma framework. Several quality gaps were identified: equipment stored separately, delays in replacing faulty items, and wasted resources. The team defined the process using the suppliers-inputs-processes-outputs-customers + requirements method, measured time to collect supplies, and analyzed data with an Ishikawa/fishbone diagram. The improve phase included a kaizen burst to generate solutions and an impact/effort grid to evaluate options. The team concluded that the optimal plan was to stock a mobile EVD cart and an ICP monitor pole with disposable go-bags. RESULTS The average time for nurses to collect EVD placement supplies decreased from 411 to 63 seconds (7-1 minute), and the average time for nurses to collect ICP monitor placement supplies decreased from 418 to 53 seconds (7-<1 minute). Residents decreased the time to obtain EVD placement supplies from 330 to 56 seconds (6-<1 minute) and ICP monitor supplies from 489 to 77 seconds (8-1 minute). Feedback was overwhelmingly positive and focused on improved process efficiency and reduced waste. CONCLUSIONS The time reduction and enthusiasm are likely associated with the simplicity and comprehensiveness of the intervention design. Including key stakeholders in decision-making and succinct communications reduced resistance to change.
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Affiliation(s)
- Juliana Rotter
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA.
| | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | | | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Marshall Gunnels
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Jodi D Hellickson
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | | | - John L D Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
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11
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Himes BT, Fain CE, Tritz ZP, Nesvick CL, Jin-Lee HJ, Geiger PA, Peterson TE, Jung MY, Parney IF. Use of heparin to rescue immunosuppressive monocyte reprogramming by glioblastoma-derived extracellular vesicles. J Neurosurg 2022; 138:1291-1301. [PMID: 36115048 DOI: 10.3171/2022.6.jns2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The profound immunosuppression found in glioblastoma (GBM) patients is a critical barrier to effective immunotherapy. Multiple mechanisms of tumor-mediated immune suppression exist, and the induction of immunosuppressive monocytes such as myeloid-derived suppressor cells (MDSCs) is increasingly appreciated as a key part of this pathology. GBM-derived extracellular vesicles (EVs) can induce the formation of MDSCs. The authors sought to identify the molecular consequences of these interactions in myeloid cells in order to identify potential targets that could pharmacologically disrupt GBM EV-monocyte interaction as a means to ameliorate tumor-mediated immune suppression. Heparin-sulfate proteoglycans (HSPGs) are a general mechanism by which EVs come into association with their target cells, and soluble heparin has been shown to interfere with EV-HSPG interactions. The authors sought to assess the efficacy of heparin treatment for mitigating the effects of GBM EVs on the formation of MDSCs. METHODS GBM EVs were collected from patient-derived cell line cultures via staged ultracentrifugation and cocultured with monocytes collected from apheresis cones from healthy blood donors. RNA was isolated from EV-conditioned and unconditioned monocytes after 72 hours of coculture, and RNA-sequencing analysis performed. For the heparin treatment studies, soluble heparin was added at the time of EV-monocyte coculture and flow cytometry analysis was performed 72 hours later. After the initial EV-monocyte coculture period, donor-matched T-cell coculture studies were performed by adding fluorescently labeled and stimulated T cells for 5 days of coculture. RESULTS Transcriptomic analysis of GBM EV-treated monocytes demonstrated downregulation of several important immunological and metabolic pathways, with upregulation of the pathways associated with synthesis of cholesterol and HSPG. Heparin treatment inhibited association between GBM EVs and monocytes in a dose-dependent fashion, which resulted in a concomitant reduction in MDSC formation (p < 0.01). The authors further demonstrated that reduced MDSC formation resulted in a partial rescue of immune suppression, as measured by effects on activated donor-matched T cells (p < 0.05). CONCLUSIONS The authors demonstrated that GBM EVs induce broad but reproducible reprogramming in monocytes, with enrichment of pathways that may portend an immunosuppressive phenotype. The authors further demonstrated that GBM EV-monocyte interactions are potentially druggable targets for overcoming tumor-mediated immune suppression, with heparin inhibition of EV-monocyte interactions demonstrating proof of principle.
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Affiliation(s)
| | - Cori E Fain
- 2Department of Immunology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | - Ian F Parney
- 1Department of Neurologic Surgery and.,2Department of Immunology, Mayo Clinic, Rochester, Minnesota
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12
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Alexiades NG, Shao B, Ahn ES, Blount JP, Brockmeyer DL, Hankinson TC, Nesvick CL, Sandberg DI, Heuer GG, Saiman L, Feldstein NA, Anderson RCE. High prevalence of gram-negative and multiorganism surgical site infections after pediatric complex tethered spinal cord surgery: a multicenter study. J Neurosurg Pediatr 2022; 30:1-7. [PMID: 35901675 DOI: 10.3171/2022.6.peds2238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complex tethered spinal cord (cTSC) release in children is often complicated by surgical site infection (SSI). Children undergoing this surgery share many similarities with patients undergoing correction for neuromuscular scoliosis, where high rates of gram-negative and polymicrobial infections have been reported. Similar organisms isolated from SSIs after cTSC release were recently demonstrated in a single-center pilot study. The purpose of this investigation was to determine if these findings are reproducible across a larger, multicenter study. METHODS A multicenter, retrospective chart review including 7 centers was conducted to identify all cases of SSI following cTSC release during a 10-year study period from 2007 to 2017. Demographic information along with specific microbial culture data and antibiotic sensitivities for each cultured organism were collected. RESULTS A total of 44 SSIs were identified from a total of 655 cases, with 78 individual organisms isolated. There was an overall SSI rate of 6.7%, with 43% polymicrobial and 66% containing at least one gram-negative organism. Half of SSIs included an organism that was resistant to cefazolin, whereas only 32% of SSIs were completely susceptible to cefazolin. CONCLUSIONS In this study, gram-negative and polymicrobial infections were responsible for the majority of SSIs following cTSC surgery, with approximately half resistant to cefazolin. Broader gram-negative antibiotic prophylaxis should be considered for this patient population.
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Affiliation(s)
| | - Belinda Shao
- 2Department of Neurosurgery, Brown University, Providence, Rhode Island
| | - Edward S Ahn
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Blount
- 4Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Todd C Hankinson
- 6Department of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Cody L Nesvick
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - David I Sandberg
- 7Division of Pediatric Neurosurgery, McGovern Medical School/UT Health/Children's Memorial Hermann Hospital, Houston, Texas
| | - Gregory G Heuer
- 8Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Lisa Saiman
- 9Department of Pediatric Infectious Disease, Columbia University Medical Center, New York, New York
| | - Neil A Feldstein
- 10Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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13
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Oushy S, Gilder HE, Nesvick CL, Lanzino G, Pollock BE, Daniels DJ, Ahn ES. Delayed recurrence of pediatric arteriovenous malformations after radiologically confirmed obliteration. J Neurosurg Pediatr 2022; 30:1-8. [PMID: 35623369 DOI: 10.3171/2022.4.peds21471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) are a major cause of intracerebral hemorrhage in children, resulting in significant morbidity and mortality. Moreover, the rate of AVM recurrence in children is significantly higher than in adults. The aim of this study was to define the risk of delayed pediatric AVM (pAVM) recurrence following confirmed radiological obliteration. Further understanding of this risk could inform the role of long-term radiological surveillance. METHODS The authors conducted a retrospective review of ruptured and unruptured pAVM cases treated at a single tertiary care referral center between 1994 and 2019. Demographics, clinical characteristics, treatment modalities, and AVM recurrence were analyzed. RESULTS A total of 102 pediatric patients with intracranial AVMs, including 52 (51%) ruptured cases, were identified. The mean patient age at presentation was 11.2 ± 4.4 years, and 51 (50%) patients were female. The mean nidus size was 2.66 ± 1.44 cm. The most common Spetzler-Martin grades were III (32%) and II (31%). Stereotactic radiosurgery was performed in 69.6% of patients. AVM obliteration was radiologically confirmed in 68 (72.3%) of 94 patients with follow-up imaging, on angiography in 50 (73.5%) patients and on magnetic resonance imaging in 18 (26.5%). AVM recurrence was identified in 1 (2.3%) of 43 patients with long-term surveillance imaging over a mean follow-up of 54.7 ± 38.9 months (range 2-153 months). This recurrence was identified in a boy who had presented with a ruptured AVM and had been surgically treated at 5 years of age. The AVM recurred 54 months after confirmed obliteration on surveillance digital subtraction angiography. Two other cases of presumed AVM recurrence following resection in young children were excluded from recurrence analysis because of incomplete sets of imaging available for review. CONCLUSIONS AVM recurrence following confirmed obliteration on imaging is a rare phenomenon, though it occurs more frequently in the pediatric population. Regular long-term follow-up with dedicated surveillance angiography is recommended even after obliteration following resection.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Departments of1Neurologic Surgery
- 3Radiology, Mayo Clinic, Rochester, Minnesota
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14
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Rechberger JS, Porath KA, Zhang L, Nesvick CL, Schrecengost RS, Sarkaria JN, Daniels DJ. IL-13Rα2 Status Predicts GB-13 (IL13.E13K-PE4E) Efficacy in High-Grade Glioma. Pharmaceutics 2022; 14:922. [PMID: 35631512 PMCID: PMC9143740 DOI: 10.3390/pharmaceutics14050922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 02/05/2023] Open
Abstract
High-grade gliomas (HGG) are devastating diseases in children and adults. In the pediatric population, diffuse midline gliomas (DMG) harboring H3K27 alterations are the most aggressive primary malignant brain tumors. With no effective therapies available, children typically succumb to disease within one year of diagnosis. In adults, glioblastoma (GBM) remains largely intractable, with a median survival of approximately 14 months despite standard clinical care of radiation and temozolomide. Therefore, effective therapies for these tumors remain one of the most urgent and unmet needs in modern medicine. Interleukin 13 receptor subunit alpha 2 (IL-13Rα2) is a cell-surface transmembrane protein upregulated in many HGGs, including DMG and adult GBM, posing a potentially promising therapeutic target for these tumors. In this study, we investigated the pharmacological effects of GB-13 (also known as IL13.E13K-PE4E), a novel peptide-toxin conjugate that contains a targeting moiety designed to bind IL-13Rα2 with high specificity and a point-mutant cytotoxic domain derived from Pseudomonas exotoxin A. Glioma cell lines demonstrated a spectrum of IL-13Rα2 expression at both the transcript and protein level. Anti-tumor effects of GB-13 strongly correlated with IL-13Rα2 expression and were reflected in apoptosis induction and decreased cell proliferation in vitro. Direct intratumoral administration of GB-13 via convection-enhanced delivery (CED) significantly decreased tumor burden and resulted in prolonged survival in IL-13Rα2-upregulated orthotopic xenograft models of HGG. In summary, administration of GB-13 demonstrated a promising pharmacological response in HGG models both in vitro and in vivo in a manner strongly associated with IL-13Rα2 expression, underscoring the potential of this IL-13Rα2-targeted therapy in a subset of HGG with increased IL-13Rα2 levels.
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Affiliation(s)
- Julian S. Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
| | - Kendra A. Porath
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (K.A.P.); (J.N.S.)
| | - Liang Zhang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
| | - Cody L. Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
| | | | - Jann N. Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (K.A.P.); (J.N.S.)
| | - David J. Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (J.S.R.); (L.Z.); (C.L.N.)
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
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15
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Zhang L, Nesvick CL, Day CA, Choi J, Lu VM, Peterson T, Power EA, Anderson JB, Hamdan FH, Decker PA, Simons R, Welby JP, Siada R, Ge J, Kaptzan T, Johnsen SA, Hinchcliffe EH, Daniels DJ. STAT3 is a biologically relevant therapeutic target in H3K27M-mutant diffuse midline glioma. Neuro Oncol 2022; 24:1700-1711. [PMID: 35397475 PMCID: PMC9527528 DOI: 10.1093/neuonc/noac093] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background H3K27M-mutant diffuse midline glioma (DMG) is a lethal brain tumor that usually occurs in children. Despite advances in our understanding of its underlying biology, efficacious therapies are severely lacking. Methods We screened a library of drugs either FDA-approved or in clinical trial using a library of patient-derived H3K27M-mutant DMG cell lines with cell viability as the outcome. Results were validated for clinical relevance and mechanistic importance using patient specimens from biopsy and autopsy, patient-derived cell lines, inhibition by gene knockdown and small molecule inhibitors, and patient-derived xenografts. Results Kinase inhibitors were highly toxic to H3K27M-mutant DMG cells. Within this class, STAT3 inhibitors demonstrated robust cytotoxic activity in vitro. Mechanistic analyses revealed one form of activated STAT3, phospho-tyrosine- 705 STAT3 (pSTAT3), was selectively upregulated in H3K27M-mutant cell lines and clinical specimens. STAT3 inhibition by CRISPR/Cas9 knockout, shRNA or small molecule inhibition reduced cell viability in vitro, and partially restored expression of the polycomb repressive mark H3K27me3, which is classically lost in H3K27M-mutant DMG. Putative STAT3-regulated genes were enriched in an H3K27M-knockout DMG cell line, indicating relative gain of STAT3 signaling in K27M-mutant cells. Treatment of patient-derived intracranial xenografts with WP1066, a STAT3 pathway inhibitor currently in clinical use for pediatric brain tumors, resulted in stasis of tumor growth, and increased overall survival. Finally, pSTAT3(Y705) was detected in circulating plasma extracellular vesicles of patients with H3K27M-mutant DMG. Conclusions STAT3 is a biologically relevant therapeutic target in H3K27M-mutant DMG. STAT3 inhibition should be considered in future clinical trials.
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Affiliation(s)
- Liang Zhang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Charlie A Day
- The Hormel Institute, University of Minnesota, Austin, Minnesota, USA
| | - Jonghoon Choi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Timothy Peterson
- Department of Cardiac Regeneration Program, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jacob B Anderson
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Feda H Hamdan
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A Decker
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Renae Simons
- Campbell University Jerry M. Wallace School of Osteopathic Medicine
| | - John P Welby
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ruby Siada
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jizhi Ge
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tatiana Kaptzan
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Steven A Johnsen
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA.,Robert Bosch Center for Tumor Diseases, Stuttgart, Germany
| | | | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Molecular Pharmacology and Experimental Therapeutics Program
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16
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Affiliation(s)
- Julian S Rechberger
- Mayo Clinic Graduate School of Biomedical Sciences, Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN, United States.,Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
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17
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Goyal A, Nesvick CL, Raghunathan A, Schwartz JD, Daniels DJ. Precision Medicine in Pediatric Bithalamic Glioma: Significance of the EGFR exon 20 Insertion Mutation. World Neurosurg 2021; 149:271-273. [PMID: 33940677 DOI: 10.1016/j.wneu.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Anshit Goyal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan D Schwartz
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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18
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Goyal A, Nesvick CL, Spear JA, Daniels DJ. Asymptomatic superficial siderosis after posterior fossa tumor resection: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 1:CASE2174. [PMID: 35855469 PMCID: PMC9245759 DOI: 10.3171/case2174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Superficial siderosis of the central nervous system is a rare syndrome notable for the presence of hemosiderin deposition due to chronic, repetitive hemorrhages into the subarachnoid space. OBSERVATIONS The authors presented a case of superficial siderosis in a 14-year-old girl. It arose as a late postoperative complication after resection of a medulloblastoma. Despite the patient being asymptomatic, surveillance imaging demonstrated diffuse hemosiderin deposition within the cerebellar folia and cisternal segments of cranial nerves VII and VIII on gradient echo (GRE) sequences. Formal audiometric testing demonstrated bilateral loss of high-frequency tone recognition consistent with early sensorineural hearing loss. A pseudomeningocele due to multiple dural defects was identified as the likely cause, and definitive surgical repair was performed. Intraoperatively, the presence of blood-tinged cerebrospinal fluid confirmed a diagnosis of superficial siderosis. LESSONS This case highlighted the potential need to routinely include GRE or susceptibility-weighted sequences in postoperative surveillance imaging after resection of pediatric posterior fossa tumors.
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19
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Nesvick CL, Graffeo CS, Brown PD, Link MJ, Stafford SL, Foote RL, Laack NN, Pollock BE. The Role of Biological Effective Dose in Predicting Obliteration After Stereotactic Radiosurgery of Cerebral Arteriovenous Malformations. Mayo Clin Proc 2021; 96:1157-1164. [PMID: 33958052 DOI: 10.1016/j.mayocp.2020.09.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether biological effective dose (BED) was predictive of obliteration after stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs). PATIENTS AND METHODS We studied patients undergoing single-session AVM SRS between January 1, 1990, and December 31, 2014, with at least 2 years of imaging follow-up. Excluded were patients with syndromic AVM, previous SRS or embolization, and patients treated with volume-staged SRS. Biological effective dose was calculated using a mono-exponential model described by Jones and Hopewell. The primary outcome was likelihood of total obliteration defined by digital subtraction angiography or magnetic resonance imaging (MRI). Variables were analyzed as continuous and dichotomous variables based on the maximum value of (sensitivity-[1-specificity]). RESULTS This study included 352 patients (360 AVM, median follow-up, 5.9 years). The median margin dose prescribed was 18.75 Gy (interquartile range [IQR]: 18 to 20 Gy). Two hundred fifty-nine patients (71.9%) had obliteration shown by angiography (n=176) or MRI (n=83) at a median of 36 months after SRS (IQR: 26 to 44 months). Higher BED was associated with increased likelihood of obliteration in univariate Cox regression analyses, when treated as either a dichotomous (≥133 Gy; hazard ratio [HR],1.52; 95% confidence interval [CI], 1.19 to 1.95; P<.001) or continuous variable (HR, 1.00, 95% CI, 1.0002 to 1.005; P=.04). In multivariable analyses including dichotomized BED and location, BED remained associated with obliteration (P=.001). CONCLUSION Biological effective dose ≥133 Gy was predictive of AVM obliteration after single-session SRS within the prescribed margin dose range 15 to 25 Gy. Further study is warranted to determine whether BED optimization should be considered as well as treatment dose for AVM SRS planning.
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Affiliation(s)
- Cody L Nesvick
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN; Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
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20
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Lu VM, O'Connor KP, Himes BT, Brown DA, Nesvick CL, Siada RG, Niazi TN, Schwartz J, Daniels DJ. Effect of surgery and chemotherapy on long-term survival in infants with congenital glioblastoma: an integrated survival analysis. J Neurosurg Pediatr 2020; 26:563-571. [PMID: 32796143 DOI: 10.3171/2020.5.peds20226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Glioblastoma (GBM) during infancy is rare, and the clinical outcomes of congenital GBM are not well understood. Correspondingly, the aim of this study was to present a long-term survivor case from the authors' institution, and establish an integrated cohort of cases across the published literature to better understand the clinical course of this disease in this setting. METHODS The authors report the outcomes of an institutional case of congenital GBM diagnosed within the first 3 months of life, and performed a comprehensive literature search for published cases from 2000 onward for an integrated survival analysis. All cases were integrated into 1 cohort, and Kaplan-Meier estimations, Fisher's exact test, and logistic regression were used to interrogate the data. RESULTS The integrated cohort of 40 congenital GBM cases consisted of 23 (58%) females and 17 (42%) males born at a median gestational age of 38 weeks (range 22-40 weeks). Estimates of overall survival (OS) at 1 month was 67%, at 1 year it was 59%, and at 10 years it was 45%, with statistically superior outcomes for subgroups in which patients survived to be treated by resection and chemotherapy. In the overall cohort, multivariable analysis confirmed resection (p < 0.01) and chemotherapy (p < 0.01) as independent predictors of superior OS. Gestational age > 38 weeks (p < 0.01), Apgar scores ≥ 7 at 5 minutes (p < 0.01), absence of prenatal hydrocephalus (p < 0.01), and vaginal delivery (p < 0.01) were associated with greater odds of surgical diagnosis versus autopsy diagnosis. CONCLUSIONS Congenital GBM can deviate from the expected poor prognosis of adult GBM in terms of OS. Both resection and chemotherapy confer statistically superior prognostic advantages in those patients who survive within the immediate postnatal period, and should be first-line considerations in the initial management of this rare disease.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,2Department of Neurological Surgery, University of Miami Miller School of Medicine, Nicklaus Children's Hospital, Miami, Florida
| | - Kyle P O'Connor
- 3Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Benjamin T Himes
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Desmond A Brown
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cody L Nesvick
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ruby G Siada
- 4Department of Pediatric Oncology, Mayo Clinic Children's Center, Rochester, Minnesota
| | - Toba N Niazi
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Nicklaus Children's Hospital, Miami, Florida
| | - Jonathan Schwartz
- 4Department of Pediatric Oncology, Mayo Clinic Children's Center, Rochester, Minnesota
| | - David J Daniels
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Pediatric Oncology, Mayo Clinic Children's Center, Rochester, Minnesota
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21
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Scheitler KM, Nesvick CL, Wijdicks EF. Pretruncal Subarachnoid Hemorrhage in a Patient with Cerebrospinal Fluid Leak. Neurocrit Care 2020; 34:350-353. [PMID: 32588332 DOI: 10.1007/s12028-020-01030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Kristen M Scheitler
- Department of Neurological Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Cody L Nesvick
- Department of Neurological Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Eelco F Wijdicks
- Department of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA.
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22
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Nesvick CL, Oushy S, Daniels DJ, Ahn ES. Safety of immediate use of nonsteroidal antiinflammatory drugs after pediatric craniotomy for tumor. J Neurosurg Pediatr 2020; 26:327-333. [PMID: 32502999 DOI: 10.3171/2020.4.peds2055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative pain can limit the recovery of children undergoing craniotomy for tumor resection, and pain management is highly variable between institutions and practitioners. Nonsteroidal antiinflammatory drugs (NSAIDs) are effective in treating postoperative pain following craniotomy, but their use has been limited by concerns about postoperative hemorrhage. The risk of postoperative hemorrhage is not insignificant in patients undergoing craniotomy for tumor resection. No study has specifically addressed the safety of NSAIDs in the immediate postoperative setting following craniotomy for tumor resection in pediatric patients. METHODS The authors performed a retrospective cohort study in patients younger than 18 years of age who underwent craniotomy for tumor resection at a single tertiary referral center between 2009 and 2019. The study outcomes were 1) postoperative hemorrhage requiring return to the operating room for decompression, evacuation, or CSF diversion for hemorrhage-associated hydrocephalus; and 2) more-than-minimal hemorrhage on routine postoperative imaging. Patients receiving any NSAID in the hospital formulary on the same day as surgery (postoperative day zero [POD0]) were designated as such. RESULTS Two hundred seventy-six children underwent 308 craniotomies for tumor resection over the study period. One hundred fifty-four patients (50.0%) received at least one dose of an NSAID on POD0. Six patients (1.9%) required a return to the operating room for a hemorrhagic complication, including 3 who received an NSAID on POD0 (OR 1.00, 95% CI 0.20-5.03). Seventeen patients (6.3% of patients imaged) had more-than-minimal hemorrhage on routine postoperative imaging, 9 of whom received an NSAID on POD0 (OR 1.08, 95% CI 0.40-2.89). CONCLUSIONS Use of NSAIDs on POD0 was not associated with either an increased risk of hemorrhage requiring a return to the operating room or asymptomatic hemorrhage on routine postoperative imaging. The overall incidence of clinically significant postoperative intracranial hemorrhage is low. These data support the use of NSAIDs as a safe measure for pain control in the postoperative setting for children undergoing craniotomy for tumor resection.
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23
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Yu J, Shi X, Yang C, Bullova P, Hong CS, Nesvick CL, Dmitriev P, Pacak K, Zhuang Z, Cao H, Li L. A novel germline gain-of-function HIF2A mutation in hepatocellular carcinoma with polycythemia. Aging (Albany NY) 2020; 12:5781-5791. [PMID: 32235007 PMCID: PMC7185130 DOI: 10.18632/aging.102967] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 01/27/2020] [Indexed: 01/04/2023]
Abstract
Hypoxia-inducible factors (HIFs) regulate oxygen sensing and expression of genes involved in angiogenesis and erythropoiesis. Polycythemia has been observed in patients with hepatocellular carcinoma (HCC), but the underlying molecular basis remains unknown. Liver tissues from 302 HCC patients, including 104 with polycythemia, were sequenced for HIF2A mutations. A germline HIF2A mutation was detected in one HCC patient with concurrent polycythemia. Three additional family members carried this mutation, but none exhibited polycythemia or were diagnosed with HCC. The gain-of-function mutation resulted in a HIF-2α protein that was transcribed normally but resistant to degradation. HIF-2α target genes EDN1, EPO, GNA14, and VEGF were significantly upregulated in the tumor bed but not in the surrounding liver tissue. Polycythemia resolved upon total resection of the tumor tissue. This newly described HIF2A mutation may promote HCC oncogenesis.
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Affiliation(s)
- Jiong Yu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, China
| | - Xiaowei Shi
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, China
| | - Chunzhang Yang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Health (NIH), Bethesda, MD 20892, USA
| | - Petra Bullova
- Department of Molecular Medicine, Institute of Virology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Christopher S. Hong
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Health (NIH), Bethesda, MD 20892, USA
| | - Cody L. Nesvick
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Health (NIH), Bethesda, MD 20892, USA
| | - Pauline Dmitriev
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Health (NIH), Bethesda, MD 20892, USA
| | - Karel Pacak
- Department of Molecular Medicine, Institute of Virology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Zhengping Zhuang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Health (NIH), Bethesda, MD 20892, USA
| | - Hongcui Cao
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, China
| | - Lanjuan Li
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, China
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Lu VM, Welby JP, Nesvick CL, Daniels DJ. Efficacy and safety of bevacizumab in progressive pediatric low-grade glioma: a systematic review and meta-analysis of outcome rates. Neurooncol Pract 2020; 7:359-368. [PMID: 33282324 DOI: 10.1093/nop/npz076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Successful management of pediatric low-grade glioma (pLGG) can be complicated by eloquent anatomical location, as well as specific pathologic and molecular features. Some authors have proposed using the VEGF inhibitor bevacizumab to improve disease control, but its safety and efficacy are poorly defined. Correspondingly, our aim was to pool systematically identified clinical data in the literature to assess the clinical utility of bevacizumab for pLGG at progression. Methods A systematic search of 7 electronic databases from inception to June 2019 was conducted following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Articles were screened against prespecified criteria. Outcomes were then pooled by random-effects meta-analyses of proportions. Results Seven pertinent studies described the outcomes of 110 progressive pLGG patients managed with bevacizumab in largely multiagent regimens. While on treatment, the rate of clinical response was 58% (95% CI, 43%-72%), and the rate of response on imaging was 80% (95% CI, 58%-96%). The rate of grade 3 or higher toxicity was 8% (95% CI, 2%-17%), with proteinuria the most commonly described. In the off-treatment period up to median 1 year, the rate of progression was estimated to be 51% (95% CI, 28%-74%). Conclusions Bevacizumab has the potential to control clinical and radiographic disease with relatively low grade 3 or higher toxicity risk in progressive pLGG patients. However, the long-term off-treatment benefits of this therapy are not yet well defined. Heterogeneity in the literature precludes any formal recommendations regarding its use until larger, more standardized investigations can be performed.
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Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - John P Welby
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
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25
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Rinaldo L, Nesvick CL, Rabinstein AA, Lanzino G. Differences in Size Between Unruptured and Ruptured Saccular Intracranial Aneurysms by Location. World Neurosurg 2020; 133:e828-e834. [DOI: 10.1016/j.wneu.2019.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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26
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Nesvick CL, Graffeo CS, Link MJ, Pollock BE. Is Biological Effective Dose (BED) Predictive of Outcomes After Radiosurgery for Cerebral Arteriovenous Malformations? Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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27
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Rinaldo L, Bhargav AG, Nesvick CL, Lanzino G, Elder BD. Effect of fixed-setting versus programmable valve on incidence of shunt revision after ventricular shunting for idiopathic normal pressure hydrocephalus. J Neurosurg 2019; 133:1-9. [PMID: 31174190 DOI: 10.3171/2019.3.jns183077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although ventricular shunting is an effective therapy for idiopathic normal pressure hydrocephalus (iNPH), the effect of shunt valve type on the incidence of revision surgery is not well defined. To address this issue, shunt revision rates between patients with iNPH receiving a fixed-setting valve (FSV) versus a programmable valve (PV) were compared. METHODS Patients with iNPH treated with ventricular shunting between 2001 and 2017 were included for analysis. The incidence of shunt revision was noted and risk factors for revision were identified using a Cox proportional hazards model. Costs associated with admission for ventricular shunt procedures were obtained from the Vizient national database. RESULTS There were 348 patients included for analysis, with 98 patients (28.1%) receiving a PV. Shunt revision occurred in 73 patients (21.0%), with 12 patients (3.4%) undergoing multiple revisions. Overall revision rates were lower in patients receiving a PV (13.3% vs 24.0%; p = 0.027), as was the incidence of multiple revisions (0.0% vs 4.8%; p = 0.023). Patients with initial placement of an FSV were also more likely to undergo valve exchange during follow-up (12.4% vs 2.0%; p = 0.003). Patients with a PV were less likely to undergo revision due to persistent symptoms without obstruction (2.0% vs 8.8%; p = 0.031) and distal obstruction (1.0% vs 6.8%; p = 0.030). In a multivariate Cox proportional hazards model, initial placement of a PV was associated with reduced risk of revision due to persistent symptoms without obstruction (OR 0.27, 95% CI 0.04-0.93; p = 0.036). PVs were associated with more frequent shunt series (1.3 vs 0.6; p < 0.001) and head CT scans (3.6 vs 2.7; p = 0.038) during follow-up. There was no significant difference in mean total costs between patients receiving an FSV and a PV ($24,282.50 vs $24,396.90; p = 0.937). CONCLUSIONS The authors' results suggest that PVs lead to reduced rates of shunt revision in patients with iNPH, and decreased risk of revision due to persistent symptoms of iNPH, thereby justifying the higher upfront cost of PVs despite similar overall treatment costs between these devices.
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Affiliation(s)
| | - Adip G Bhargav
- 2Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota
| | | | | | - Benjamin D Elder
- Departments of1Neurosurgery
- 4Bioengineering, and
- 5Orthopedics, Mayo Clinic; and
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Nesvick CL, Oushy S, Rinaldo L, Wijdicks EF, Lanzino G, Rabinstein AA. Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage. Neurology 2019; 92:e2385-e2394. [PMID: 30996058 DOI: 10.1212/wnl.0000000000007501] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/19/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To define the in-hospital course, complications, short- and long-term functional outcomes of patients with angiographically negative subarachnoid hemorrhage (anSAH), particularly those with aneurysmal-pattern anSAH (aanSAH). METHODS Retrospective cohort study of patients with aneurysmal subarachnoid hemorrhage (aSAH), aanSAH, and perimesencephalic-pattern anSAH (panSAH) treated at a single tertiary referral center between January 2006 and April 2018. Ninety-nine patients with anSAH (33 aanSAH and 66 panSAH) and 464 patients with aSAH were included in this study. Outcomes included symptomatic hydrocephalus requiring CSF drainage, need for ventriculoperitoneal shunt, radiographic vasospasm, delayed cerebral ischemia (DCI), radiographic infarction, disability level within 1 year of ictus, and at last clinical follow-up as defined by the modified Rankin Scale. RESULTS Patients with aanSAH and panSAH had similar rates of DCI and radiologic infarction, and patients with aanSAH had significantly lower rates compared to aSAH (p ≤ 0.018). Patients with aanSAH were more likely than those with panSAH to require temporary CSF diversion and ventriculoperitoneal shunt (p ≤ 0.03), with similar rates to those seen in aSAH. Only one patient with anSAH died in the hospital. Compared to those with aSAH, patients with aanSAH were significantly less likely to have a poor functional outcome within 1 year of ictus (odds ratio 0.26, 95% confidence interval 0.090-0.75) and at last follow-up (hazard ratio 0.30, 95% confidence interval 0.19-0.49, p = 0.002). CONCLUSIONS DCI is very uncommon in anSAH, but patients with aanSAH have a similar need for short- and long-term CSF diversion to patients with aSAH. Nevertheless, patients with aanSAH have significantly better short- and long-term outcomes.
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Affiliation(s)
- Cody L Nesvick
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Soliman Oushy
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Lorenzo Rinaldo
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Eelco F Wijdicks
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN.
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Abstract
Motocross is a competitive outdoor extreme sport in which motorcyclists race across vast courses of jumps, berms and long straightaways of unpredictable terrain. While the sport has gained notoriety in adult popular culture through contests like the X Games, motocross is also increasingly popular among youth in the Unites States and beyond. In the setting of contemporary discussions on traumatic brain injury, this poses an obvious challenge to those advising children and parents on the risks of motocross to the developing brain and spine. The available literature demonstrates that even when practiced with appropriate protective equipment, motocross poses an increased risk for acquiring major trauma to the brain, spine and limbs for which the long-term consequences have been poorly studied. Riders and parents should be counseled about the risks of these injuries prior to participation and in accordance with state laws. Furthermore, formal return-to-play guidelines following concussions should be developed.
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Affiliation(s)
- Cody L Nesvick
- a Department of Neurologic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Joseph R Kapurch
- a Department of Neurologic Surgery , Mayo Clinic , Rochester , MN , USA
| | - David J Daniels
- a Department of Neurologic Surgery , Mayo Clinic , Rochester , MN , USA
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Abstract
Atypical teratoid/rhabdoid tumor (AT/RT) is a rare CNS cancer that typically occurs in children younger than 3 years of age. Histologically, AT/RTs are embryonal tumors that contain a rhabdoid component as well as areas with primitive neuroectodermal, mesenchymal, and epithelial features. Compared to other CNS tumors of childhood, AT/RTs are characterized by their rapid growth, short symptomatic prodrome, and large size upon presentation, often leading to brain compression and intracranial hypertension requiring urgent intervention. For decades, the mainstay of care has been a combination of maximal safe surgical resection followed by adjuvant chemotherapy and radiotherapy. Despite advances in each of these modalities, the relative paucity of data on these tumors, their inherently aggressive course, and a lack of molecular data have limited advances in treatment over the past 3 decades. Recent large-scale, multicenter interdisciplinary studies, however, have significantly advanced our understanding of the molecular pathogenesis of these tumors. Multiple clinical trials testing molecularly targeted therapies are underway, offering hope for patients with AT/RT and their families.
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Affiliation(s)
- Cody L Nesvick
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amulya A Nageswara Rao
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jaclyn A Biegel
- Department of Pathology and Laboratory Medicine, Children's Hospital of Los Angeles, Keck School of Medicine of University of Southern California, USA
| | - David J Daniels
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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31
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Nesvick CL, Perry A, Graffeo CS, Raghunathan A, Hammack JE, Van Gompel JJ. Trochlear Schwannoma Presenting with Isolated Trigeminal Neuralgia. World Neurosurg 2017; 103:951.e13-951.e20. [DOI: 10.1016/j.wneu.2017.04.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 11/16/2022]
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32
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Zhang C, Yang C, Feldman MJ, Wang H, Pang Y, Maggio DM, Zhu D, Nesvick CL, Dmitriev P, Bullova P, Chittiboina P, Brady RO, Pacak K, Zhuang Z. Vorinostat suppresses hypoxia signaling by modulating nuclear translocation of hypoxia inducible factor 1 alpha. Oncotarget 2017; 8:56110-56125. [PMID: 28915577 PMCID: PMC5593548 DOI: 10.18632/oncotarget.18125] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/10/2017] [Indexed: 01/29/2023] Open
Abstract
Histone deacetylase inhibitors (HDACis) are a potent class of tumor-suppressive agents traditionally believed to exert their effects through loosening tightly-wound chromatin resulting in de-inhibition of various tumor suppressive genes. Recent literature however has shown altered intratumoral hypoxia signaling with HDACi administration not attributable to changes in chromatin structure. We sought to determine the precise mechanism of HDACi-mediated hypoxia signaling attenuation using vorinostat (SAHA), an FDA-approved class I/IIb/IV HDACi. Through an in-vitro and in-vivo approach utilizing cell lines for hepatocellular carcinoma (HCC), osteosarcoma (OS), and glioblastoma (GBM), we demonstrate that SAHA potently inhibits HIF-a nuclear translocation via direct acetylation of its associated chaperone, heat shock protein 90 (Hsp90). In the presence of SAHA we found elevated levels of acetyl-Hsp90, decreased interaction between acetyl-Hsp90 and HIF-a, decreased nuclear/cytoplasmic HIF-α expression, absent HIF-α association with its nuclear karyopharyin Importin, and markedly decreased HIF-a transcriptional activity. These changes were associated with downregulation of downstream hypoxia molecules such as endothelin 1, erythropoietin, glucose transporter 1, and vascular endothelial growth factor. Findings were replicated in an in-vivo Hep3B HRE-Luc expressing xenograft, and were associated with significant decreases in xenograft tumor size. Altogether, this study highlights a novel mechanism of action of an important class of chemotherapeutic.
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Affiliation(s)
- Chao Zhang
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China.,Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Chunzhang Yang
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Michael J Feldman
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Herui Wang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Ying Pang
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Dominic M Maggio
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Dongwang Zhu
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Cody L Nesvick
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Pauline Dmitriev
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Petra Bullova
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA.,Department of Molecular Medicine, Institute of Virology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Roscoe O Brady
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Karel Pacak
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Zhengping Zhuang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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33
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Khan NR, Smalley Z, Nesvick CL, Lee SL, Michael LM. The use of lumbar drains in preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: an updated systematic review and meta-analysis. J Neurosurg Spine 2016; 25:383-93. [PMID: 27058497 DOI: 10.3171/2016.1.spine151199] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Paraplegia and paraparesis following aortic aneurysm repair occur at a substantially high rate and are often catastrophic to patients, their families, and the overall health care system. Spinal cord injury (SCI) following open thoracoabdominal aortic aneurysm (TAAA) repair is reported to be as high as 20% in historical controls. The goal of this study was to determine the impact of CSF drainage (CSFD) on SCI following TAAA repair. METHODS In August 2015 a systematic literature search was performed using clinicaltrials.gov , the Cochrane Library, PubMed/MEDLINE, and Scopus that identified 3478 articles. Of these articles, 10 met inclusion criteria. Random and fixed-effect meta-analyses were performed using both pooled and subset analyses based on study type. RESULTS The meta-analysis demonstrated that CSFD decreased SCI by nearly half (relative risk 0.42, 95% confidence interval 0.25-0.70; p = 0.0009) in the pooled analysis. This effect remained in the subgroup analysis of early SCI but did not remain significant in late SCI. CONCLUSIONS This meta-analysis showed that CSFD could be an effective strategy in preventing SCI following aortic aneurysm repair. Care should be taken to prevent complications related to overdrainage. No firm conclusions can be drawn about the newer endovascular procedures at the current time.
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Affiliation(s)
| | - Zachary Smalley
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Cody L Nesvick
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Siang Liao Lee
- Department of Surgery, Metropolitan Group Hospitals, University of Illinois at Chicago, Illinois; and
| | - L Madison Michael
- Department of Neurosurgery.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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34
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Xu H, Rahimpour S, Nesvick CL, Zhang X, Ma J, Zhang M, Zhang G, Wang L, Yang C, Hong CS, Germanwala AV, Elder JB, Ray-Chaudhury A, Yao Y, Gilbert MR, Lonser RR, Heiss JD, Brady RO, Mao Y, Qin J, Zhuang Z. Activation of hypoxia signaling induces phenotypic transformation of glioma cells: implications for bevacizumab antiangiogenic therapy. Oncotarget 2016; 6:11882-93. [PMID: 25957416 PMCID: PMC4494911 DOI: 10.18632/oncotarget.3592] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 02/19/2015] [Indexed: 11/25/2022] Open
Abstract
Glioblastoma (GBM) is the most common and deadly primary brain tumor in adults. Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), can attenuate tumor-associated edema and improve patient symptoms but based on magnetic resonance imaging, is associated with non-enhancing tumor progression and possibly gliosarcoma differentiation. To gain insight into these findings, we investigated the role of hypoxia and epithelial-mesenchymal transition (EMT)-associated proteins in GBM. Tumor markers of hypoxia and EMT were upregulated in bevacizumab-treated tumors from GBM patients compared to untreated counterparts. Exposure of glioma cells to 1% oxygen tension increased cell proliferation, expression of EMT-associated proteins and enhanced cell migration in vitro. These phenotypic changes were significantly attenuated by pharmacologic knockdown of hypoxia-inducible Factor 1α (HIF1α) or HIF2α, indicating that HIFs represent a therapeutic target for mesenchymal GBM cells. These findings provide insights into potential development of novel therapeutic targeting of angiogenesis-specific pathways in GBM.
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Affiliation(s)
- Hui Xu
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Shervin Rahimpour
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Cody L Nesvick
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Xu Zhang
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Jingyun Ma
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Min Zhang
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Ge Zhang
- Department of Immunology, Dalian Medical University, Dalian, China
| | - Li Wang
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Chunzhang Yang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Christopher S Hong
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Anand V Germanwala
- Department of Neurological Surgery, Loyola University Medical Center, Chicago, Illinois, USA
| | - J Bradley Elder
- Department of Neurological Surgery, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Abhik Ray-Chaudhury
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Yu Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Mark R Gilbert
- Department of Neuro-Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Russell R Lonser
- Department of Neurological Surgery, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - John D Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Roscoe O Brady
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianhua Qin
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Zhengping Zhuang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
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Abstract
OBJECT Malignant tumors of the brainstem, excluding classic diffuse intrinsic pontine gliomas (DIPGs), are a very rare, heterogeneous group of neoplasms that have been infrequently described in the literature. In this paper, the authors present their experiences with treating these unique cancers. METHODS A retrospective chart review was conducted to identify eligible cases over a 15-year period. All tumors involving the pons were, by consensus, felt not to be DIPGs based on their neuroimaging features. Demographic information, pathological specimens, neuroimaging characteristics, surgical and nonsurgical management plans, and survival data were gathered for analysis. RESULTS Between January 2000 and December 2014, 29 patients were identified. The mean age at diagnosis was 8.4 years (range 2 months to 25 years), and 17 (59%) patients were male. The most common presenting signs and symptoms were cranial neuropathies (n = 24; 83%), hemiparesis (n = 12; 41%), and ataxia or gait disturbance (n = 10; 34%). There were 18 glial and 11 embryonal tumors. Of the glial tumors, 5 were radiation-induced and 1 was a malignant transformation of a previously known low-grade tumor. Surgical intervention consisted of biopsy alone in 12 patients and some degree of resection in another 15 patients. Two tumors were diagnosed postmortem. The median overall survival for all patients was 196 days (range 15 to 3999 days). There are currently 5 (17%) patients who are still alive: 1 with an anaplastic astrocytoma and the remaining with embryonal tumors. CONCLUSIONS In general, malignant non-DIPG tumors of the brainstem carry a poor prognosis. However, maximal cytoreductive surgery may be an option for select patients with focal tumors. Long-term survival is possible in patients with nonmetastatic embryonal tumors after multimodal treatment, most importantly maximal resection.
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Affiliation(s)
- Paul Klimo
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Departments of 2 Surgery.,Semmes-Murphey Neurologic & Spine Institute;,Departments of 4 Neurosurgery
| | - Cody L Nesvick
- University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Brent A Orr
- Pathology, St. Jude Children's Research Hospital
| | - Asim F Choudhri
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital;,Departments of 4 Neurosurgery.,Radiology, University of Tennessee Health Science Center; and
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Klimo P, Nesvick CL. Letter to the Editor: Stereotactic radiosurgery for AVMs with and without Onyx embolization. J Neurosurg 2015; 123:1610-1. [PMID: 26473776 DOI: 10.3171/2015.7.jns151577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paul Klimo
- University of Tennessee Health Science Center, Memphis, TN; ,Semmes Murphey Neurologic and Spine Institute, Memphis, TN; and ,College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Cody L Nesvick
- University of Tennessee Health Science Center, Memphis, TN; ,Semmes Murphey Neurologic and Spine Institute, Memphis, TN; and ,College of Medicine, University of Tennessee Health Science Center, Memphis, TN
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Abstract
Abstract
BACKGROUND:
Ventricular shunt placement for treating hydrocephalus is one of the most common neurosurgical procedures. The rate of shunt failure, however, has not appreciably changed with time.
OBJECTIVE:
To investigate whether intraoperative image guidance using ultrasound or stereotaxy contributes to accurate shunt catheter placement and survival.
METHODS:
We performed a systematic literature review using PubMed and MEDLINE databases for studies that use ultrasound and frameless stereotaxy for ventricular catheter placement for hydrocephalus. All articles assessed the accuracy of catheter tip placement and/or overall shunt survival, and the rate of accurate shunt catheter placement, the overall failure rate, and the average time to shunt failure were extracted for analysis.
RESULTS:
Although each modality (ultrasound/stereotaxy) did not increase catheter placement accuracy, a combined random-effects meta-analysis of 738 catheters (136 guided by ultrasound, 168 guided by frameless stereotaxy, and 434 freehand) demonstrated a weak benefit of image guidance (risk ratio: 1.19, 95% confidence interval: 1.02-1.39, P = .02), but this result was limited by considerable heterogeneity among studies (I2 = 86%, P < .001 by Cochrane's Q test). A meta-analysis could not be performed for shunt survival due to heterogeneity in data reporting.
CONCLUSION:
Although image guidance offers a promising solution to lower the risk of inaccurate catheter placement, which could lead to lower premature failure of ventricular shunts, our review demonstrated that there is not yet a clear benefit of these technologies. Current literature is limited to case series and cohort studies, and significant between-study heterogeneity in methodology and reporting currently limits a higher order analysis.
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Affiliation(s)
- Cody L. Nesvick
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Nickalus R. Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Gautam U. Mehta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Zhang C, Yang AI, Vasconcelos L, Moon S, Yang C, Nesvick CL, Saidkhodjaeva L, Abdullaev Z, Pack SD, Ghosh A, Chittiboina P, Heiss JD, Zhuang Z, Quezado MM, Zaghloul KA. Von hippel-lindau disease associated pulmonary carcinoid with cranial metastasis. J Clin Endocrinol Metab 2014; 99:2633-6. [PMID: 24878057 PMCID: PMC4121022 DOI: 10.1210/jc.2014-1732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Carcinoids have rarely been described in von Hippel-Lindau (VHL) disease. OBJECTIVE We describe the first reported case of a patient with VHL who developed a pulmonary carcinoid that subsequently metastasized to a pre-existent cranial hemangioblastoma. RESULTS Histological and immunohistochemical features of the metastatic lesion were similar to the primary carcinoid. Both lesions demonstrated heterozygous VHL gene deletions with fluorescence in situ hybridization analysis. CONCLUSIONS This case provides direct molecular genetic evidence of an association between VHL and carcinoids.
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Affiliation(s)
- Chao Zhang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke (C.Z., A.I.Y., C.Y., C.L.N., P.C., J.D.H., Z.Z., K.A.Z.), and Laboratory of Pathology, National Cancer Institute (L.V., S.M., L.S., Z.A., S.D.P., A.G., M.M.Q.), National Institutes of Health, Bethesda, Maryland 20892; and Department of Orthopedics (C.Z.), Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, China
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Abstract
OBJECT Observational studies, such as cohort and case-control studies, are valuable instruments in evidence-based medicine. Case-control studies, in particular, are becoming increasingly popular in the neurosurgical literature due to their low cost and relative ease of execution; however, no one has yet systematically assessed these types of studies for quality in methodology and reporting. METHODS The authors performed a literature search using PubMed/MEDLINE to identify all studies that explicitly identified themselves as "case-control" and were published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Each paper was evaluated for 22 descriptive variables and then categorized as having either met or missed the basic definition of a case-control study. All studies that evaluated risk factors for a well-defined outcome were considered true case-control studies. The authors sought to identify key features or phrases that were or were not predictive of a true case-control study. Those papers that satisfied the definition were further evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. RESULTS The search detected 67 papers that met the inclusion criteria, of which 32 (48%) represented true case-control studies. The frequency of true case-control studies has not changed with time. Use of odds ratios (ORs) and logistic regression (LR) analysis were strong positive predictors of true case-control studies (for odds ratios, OR 15.33 and 95% CI 4.52-51.97; for logistic regression analysis, OR 8.77 and 95% CI 2.69-28.56). Conversely, negative predictors included focus on a procedure/intervention (OR 0.35, 95% CI 0.13-0.998) and use of the word "outcome" in the Results section (OR 0.23, 95% CI 0.082-0.65). After exclusion of nested case-control studies, the negative correlation between focus on a procedure/intervention and true case-control studies was strengthened (OR 0.053, 95% CI 0.0064-0.44). There was a trend toward a negative association between the use of survival analysis or Kaplan-Meier curves and true case-control studies (OR 0.13, 95% CI 0.015-1.12). True case-control studies were no more likely than their counterparts to use a potential study design "expert" (OR 1.50, 95% CI 0.57-3.95). The overall average STROBE score was 72% (range 50-86%). Examples of reporting deficiencies were reporting of bias (28%), missing data (55%), and funding (44%). CONCLUSIONS The results of this analysis show that the majority of studies in the neurosurgical literature that identify themselves as "case-control" studies are, in fact, labeled incorrectly. Positive and negative predictors were identified. The authors provide several recommendations that may reverse the incorrect and inappropriate use of the term "case-control" and improve the quality of design and reporting of true case-control studies in neurosurgery.
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