1
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Liu SJ, Casey-Clyde T, Cho NW, Swinderman J, Pekmezci M, Dougherty MC, Foster K, Chen WC, Villanueva-Meyer JE, Swaney DL, Vasudevan HN, Choudhury A, Pak J, Breshears JD, Lang UE, Eaton CD, Hiam-Galvez KJ, Stevenson E, Chen KH, Lien BV, Wu D, Braunstein SE, Sneed PK, Magill ST, Lim D, McDermott MW, Berger MS, Perry A, Krogan NJ, Hansen MR, Spitzer MH, Gilbert L, Theodosopoulos PV, Raleigh DR. Epigenetic reprogramming shapes the cellular landscape of schwannoma. Nat Commun 2024; 15:476. [PMID: 38216587 PMCID: PMC10786948 DOI: 10.1038/s41467-023-40408-5] [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: 02/06/2023] [Accepted: 05/25/2023] [Indexed: 01/14/2024] Open
Abstract
Mechanisms specifying cancer cell states and response to therapy are incompletely understood. Here we show epigenetic reprogramming shapes the cellular landscape of schwannomas, the most common tumors of the peripheral nervous system. We find schwannomas are comprised of 2 molecular groups that are distinguished by activation of neural crest or nerve injury pathways that specify tumor cell states and the architecture of the tumor immune microenvironment. Moreover, we find radiotherapy is sufficient for interconversion of neural crest schwannomas to immune-enriched schwannomas through epigenetic and metabolic reprogramming. To define mechanisms underlying schwannoma groups, we develop a technique for simultaneous interrogation of chromatin accessibility and gene expression coupled with genetic and therapeutic perturbations in single-nuclei. Our results elucidate a framework for understanding epigenetic drivers of tumor evolution and establish a paradigm of epigenetic and metabolic reprograming of cancer cells that shapes the immune microenvironment in response to radiotherapy.
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Affiliation(s)
- S John Liu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
- Arc Institute, Palo Alto, CA, 94304, USA
| | - Tim Casey-Clyde
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Nam Woo Cho
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Parker Institute for Cancer Immunotherapy, Chan Zuckerberg Biohub, and Departments of Otolaryngology, and Microbiology and Immunology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Jason Swinderman
- Arc Institute, Palo Alto, CA, 94304, USA
- Department of Urology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Melike Pekmezci
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Mark C Dougherty
- Departments of Otolaryngology and Neurosurgery, University of Iowa, Iowa City, IA, 52242, USA
| | - Kyla Foster
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - William C Chen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Danielle L Swaney
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Abrar Choudhury
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Joanna Pak
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
- Arc Institute, Palo Alto, CA, 94304, USA
| | - Jonathan D Breshears
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Ursula E Lang
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Dermatology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Charlotte D Eaton
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Kamir J Hiam-Galvez
- Parker Institute for Cancer Immunotherapy, Chan Zuckerberg Biohub, and Departments of Otolaryngology, and Microbiology and Immunology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Erica Stevenson
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Kuei-Ho Chen
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - David Wu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago, IL, 60611, USA
| | - Daniel Lim
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | | | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Arie Perry
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Nevan J Krogan
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Marlan R Hansen
- Departments of Otolaryngology and Neurosurgery, University of Iowa, Iowa City, IA, 52242, USA
| | - Matthew H Spitzer
- Parker Institute for Cancer Immunotherapy, Chan Zuckerberg Biohub, and Departments of Otolaryngology, and Microbiology and Immunology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Luke Gilbert
- Arc Institute, Palo Alto, CA, 94304, USA
- Department of Urology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA.
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA.
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA.
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Ammanuel SG, Kondapavulur S, Lu AY, Breshears JD, Clark JP, Silva AB, Chang EF. Intraoperative cortical stimulation mapping with laryngeal electromyography for the localization of human laryngeal motor cortex. J Neurosurg 2024:1-10. [PMID: 38181494 DOI: 10.3171/2023.10.jns231023] [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: 05/04/2023] [Accepted: 10/11/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE The objectives of this study were to describe the authors' clinical methodology and outcomes for mapping the laryngeal motor cortex (LMC) and define localization of the LMC in a cohort of neurosurgical patients undergoing intraoperative brain mapping. Because of mapping variability across patients, the authors aimed to define the probabilistic distribution of cortical sites that evoke laryngeal movement, as well as adjacent cortical somatotopic representations for the face (mouth), tongue, and hand. METHODS Thirty-six patients underwent left (n = 18) or right (n = 18) craniotomy with asleep motor mapping. For each patient, electromyography (EMG) electrodes were placed in the face, tongue, and hand; a nerve integrity monitor (NIM) endotracheal tube with surface electrodes detected EMG activity from the bilateral vocal folds. After dense cortical stimulation was delivered throughout the sensorimotor cortex, motor responses were then mapped onto a three-dimensional reconstruction of the patient's cortical surfaces for location characterization of the evoked responses. Finally, stimulation sites were transformed into a two-dimensional coordinate system for probabilistic mapping of the stimulation site relative to the central sulcus and sylvian fissure. RESULTS The authors found that the LMC was predominantly localized to a mid precentral gyrus region, dorsal to face representation and surrounding a transverse sulcus ventral to the hand knob. In 14 of 36 patients, the authors identified additional laryngeal responses located ventral to all orofacial representations, providing evidence for dual LMC representations. CONCLUSIONS The authors determined the probabilistic distribution of the LMC. Cortical stimulation mapping with an NIM endotracheal tube is an easy and effective method for mapping the LMC and is simply integrated into the current neuromonitoring methods for brain mapping.
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Affiliation(s)
- Simon G Ammanuel
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - Alex Y Lu
- Departments of2Neurological Surgery and
| | - Jonathan D Breshears
- 3Marion Bloch Neuroscience Institute, Saint Luke's Hospital, Kansas City, Missouri; and
| | - John P Clark
- 5Surgical Neurophysiology, University of California, San Francisco, California
| | | | - Edward F Chang
- Departments of2Neurological Surgery and
- 4Center for Integrative Neuroscience, University of California, San Francisco, California
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Habib A, Hanasono MM, DeMonte F, Haider A, Breshears JD, Nader ME, Gidley PW, Su SY, Hanna EY, Raza SM. Surgical Management of Skull Base Osteoradionecrosis in the Cancer Population – Treatment Outcomes and Predictors of Recurrence: A Case Series. Neurosurgery 2021. [DOI: 10.1093/neuros/opaa082_s149] [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: 11/13/2022] Open
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Habib A, Hanasono MM, DeMonte F, Haider A, Breshears JD, Nader ME, Gidley PW, Su SY, Hanna EY, Raza SM. Surgical Management of Skull Base Osteoradionecrosis in the Cancer Population - Treatment Outcomes and Predictors of Recurrence: A Case Series. Oper Neurosurg (Hagerstown) 2021; 19:364-374. [PMID: 32324878 DOI: 10.1093/ons/opaa082] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 06/11/2019] [Accepted: 02/10/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Skull base osteoradionecrosis (ORN) is a challenging treatment-related complication sometimes seen in patients with cancer. Although ORN management strategies for other anatomic sites have been reported, there is a paucity of data guiding the management of skull base ORN. OBJECTIVE To report a single-center tertiary care series of skull base ORN and to better understand the factors affecting ORN recurrence after surgical management. METHODS We conducted a retrospective cohort study of patients with skull base ORN treated at our center between 2003 and 2017. Univariate and multivariate binary logistic regressions were performed to identify predictors of recurrence. RESULTS A total of 31 patients were included in this study. The median age at ORN diagnosis was 61.1 yr (range, 32.8-84.9 yr). Of these 31 patients, 15 (48.4%) patients were initially treated medically. All 31 patients underwent surgery. Three (14.3%) of 21 patients treated with a free flap and 4 (50.0%) of 8 patients who underwent primary closure experienced recurrence. Cox regression analysis revealed that reconstruction with local tissue closure (P = .044) and ongoing treatment for active primary cancer (P = .022) were significant predictors of recurrence. The median overall survival from index surgery for ORN treatment was 83.9 mo. At 12-mo follow-up, 78.5% of patients were alive. CONCLUSION In this study, we assess the outcomes of our treatment approach, surgical debridement with vascularized reconstruction, on recurrence-free survival in patients with skull base ORN. Further studies with larger cohorts are needed to assess current treatment paradigms.
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Affiliation(s)
- Ahmed Habib
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ali Haider
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan D Breshears
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marc-Elie Nader
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul W Gidley
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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5
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Breshears JD, Morshed RA, Molinaro AM, McDermott MW, Cheung SW, Theodosopoulos PV. Residual Tumor Volume and Location Predict Progression After Primary Subtotal Resection of Sporadic Vestibular Schwannomas: A Retrospective Volumetric Study. Neurosurgery 2020; 86:410-416. [PMID: 31232426 DOI: 10.1093/neuros/nyz200] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 10/24/2018] [Accepted: 02/24/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Preservation of functional integrity during vestibular schwannoma surgery has become critical in the era of patient-centric medical decision-making. Subtotal tumor removal is often necessary when dense adhesions between the tumor and critical structures are present. However, it is unclear what the rate of tumor control is after subtotal resection (STR) and what factors are associated with recurrence. OBJECTIVE To determine the rate of residual tumor growth after STR and identify clinical and radiographic predictors of tumor progression. METHODS A single-institution retrospective study was performed on all sporadic vestibular schwannomas that underwent surgical resection between January 1, 2002 and December 31, 2015. Clinical charts, pathology, radiology, and operative reports were reviewed. Volumetric analysis was performed on all pre- and postoperative MR imaging. Univariate and multivariate logistic regression was performed to identify predictors of the primary endpoint of tumor progression. Kaplan-Meier analysis was performed to compare progression free survival between 2 groups of residual tumor volumes and location. RESULTS In this cohort of 66 patients who underwent primary STR, 30% had documented progression within a median follow up period of 3.1 yr. Greater residual tumor volume (OR 2.0 [1.1-4.0]) and residual disease within the internal auditory canal (OR 3.7 [1.0-13.4]) predicted progression on multivariate analysis. CONCLUSION These longitudinal data provide insight into the behavior of residual tumor, helping clinicians to determine if and when STR is an acceptable surgical strategy and to anchor expectations during shared medical decision-making consultation with patients.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Steven W Cheung
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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6
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Breshears JD, DeMonte F, Habib A, Gidley PW, Raza SM. Management of Recurrent or Progressing Skull Base Chondrosarcomas: Predictors of Long-Term Outcomes. J Neurol Surg B Skull Base 2020; 82:e155-e165. [PMID: 34306931 DOI: 10.1055/s-0040-1701523] [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: 08/20/2019] [Accepted: 12/02/2019] [Indexed: 10/24/2022] Open
Abstract
Background Skull base chondrosarcomas (CSA) are difficult tumors to cure and there is little data regarding salvage therapy. Objective This study aims to identify presentation and treatment-related factors which impact the progression free survival (PFS) and disease specific survival (DSS) for recurrent CSA, and to identify salvage treatment factors associated with successful restoration to the natural history following primary treatment. Methods This single-institution retrospective review included patients with recurrent/progressive CSA over a 25-year period. Survival analysis for factors impacting PFS and DSS was performed. Salvage treatment factors associated with achieving PFS ≥newly diagnosed median PFS were identified using univariate statistics. Analysis was performed on first recurrences and all recurrences combined. Results A total of 47 recurrence/progression events were analyzed from 17 patients (median two events/patient, range = 1-8). The overall PFS and DSS for the initial recurrence was 32 (range = 3-267) and 79 (range = 3-285) months, respectively. Conventional grade III or mesenchymal histology significantly predicted shorter PFS and DSS ( p < 0.0001). After stratification by histology, previous radiation predicted shorter PFS for low-grade tumors ( p = 0.009). Gross total resection (GTR) after a first time recurrence was significantly associated with successful salvage treatment ( p < 0.05); however, this was rare. Conclusion In this series, high grade histology and prior radiation treatment negatively impacted salvage treatment outcomes, while GTR was associated with restoration to natural history following primary treatment. Careful consideration of histology, systemic disease status, previous treatments, and the anatomic extent of the skull base disease can optimize the outcomes of salvage intervention.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Franco DeMonte
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ahmed Habib
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Paul W Gidley
- Department of Head & Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Shaan M Raza
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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7
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Breshears JD, Morshed RA, Theodosopoulos PV. In Reply: Residual Tumor Volume and Location Predict Progression After Primary Subtotal Resection of Sporadic Vestibular Schwannomas: A Retrospective Volumetric Study. Neurosurgery 2020; 86:E238. [PMID: 31690926 DOI: 10.1093/neuros/nyz493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jonathan D Breshears
- Division of Neurosurgery Department of Surgery Saint Luke's Marion Bloch Neuroscience Institute University of Missouri-Kansas City Kansas City, Missouri
| | - Ramin A Morshed
- Department of Neurological Surgery University of California San Francisco, California
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8
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Breshears JD, Chang J, Molinaro AM, Sneed PK, McDermott MW, Tward A, Theodosopoulos PV. Temporal Dynamics of Pseudoprogression After Gamma Knife Radiosurgery for Vestibular Schwannomas-A Retrospective Volumetric Study. Neurosurgery 2020. [PMID: 29518221 DOI: 10.1093/neuros/nyy019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The optimal observation interval after the radiosurgical treatment of a sporadic vestibular schwannoma, prior to salvage intervention, is unknown. OBJECTIVE To determine an optimal postradiosurgical treatment interval for differentiating between pseudoprogression and true tumor growth by analyzing serial volumetric data. METHODS This single-institution retrospective study included all sporadic vestibular schwannomas treated with Gamma Knife radiosurgery (Eketa AB, Stockholm, Sweden; 12-13 Gy) from 2002 to 2014. Volumetric analysis was performed on all available pre- and posttreatment magnetic resonance imaging scans. Tumors were classified as "stable/decreasing," "transient enlargement", or "persistent growth" after treatment, based on incrementally increasing follow-up durations. RESULTS A total of 118 patients included in the study had a median treatment tumor volume of 0.74 cm3 (interquartile range [IQR] = 0.34-1.77 cm3) and a median follow-up of 4.1 yr (IQR = 2.6-6.0 yr). Transient tumor enlargement was observed in 44% of patients, beginning at a median of 1 yr (IQR = 0.6-1.4 yr) posttreatment, with 90% reaching peak volume within 3.5 yr, posttreatment. Volumetric enlargement resolved at a median of 2.4 yr (IQR 1.9-3.6 yr), with 90% of cases resolved at 6.9 yr. Increasing follow-up revealed that many of the tumors initially enlarging 1 to 3 yr after stereotactic radiosurgery ultimately begin to shrink on longer follow-up (45% by 4 yr, 77% by 6 yr). CONCLUSION Tumor enlargement within ∼3.5 yr of treatment should not be used as a sole criterion for salvage treatment. Patient symptoms and tumor size must be considered, and giving tumors a chance to regress before opting for salvage treatment may be worthwhile.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Joseph Chang
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, Uni-versity of California, San Francisco, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron Tward
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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9
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Breshears JD, Liu JS, Vasudevan H, Pekmezci M, Castro MRH, Lang U, Chen W, Choudhury A, Magill ST, Braunstein S, Gopinath C, Nakamura JL, Sneed P, Perry A, McDermott MW, Villanueva-Meyer JE, Raleigh DR, Theodosopoulos PV. Multiplatform Molecular Profiling of Vestibular Schwannoma Reveals 2 Subgroups of Tumors With Distinct Radiographic Features and a Methylation-Based Predictor of Local Recurrence. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_317] [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: 11/14/2022] Open
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10
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Southwell DG, Breshears JD, Lyon WR, McDermott MW. A Method for Cranial Nerve XI Silencing During Surgery of the Foramen Magnum Region: Technical Case Report. Oper Neurosurg (Hagerstown) 2019; 16:E130-E133. [PMID: 29788281 DOI: 10.1093/ons/opy134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 01/16/2018] [Accepted: 04/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Skull base surgery involves the microdissection and intraoperative monitoring of cranial nerves, including cranial nerve XI (CN XI). Manipulation of CN XI can evoke brisk trapezius contraction, which in turn may disturb the surgical procedure and risk patient safety. Here we describe a method for temporarily silencing CN XI via direct intraoperative application of 1% lidocaine. CLINICAL PRESENTATION A 41-yr-old woman presented with symptoms of elevated intracranial pressure and obstructive hydrocephalus secondary to a hemangioblastoma of the right cerebellar tonsil. A far-lateral suboccipital craniotomy was performed for resection of the lesion. During the initial stages of microdissection, vigorous trapezius contraction compromised the course of the operation. Following exposure of the cranial and cervical portions of CN XI, lidocaine was applied to the course of the exposed nerve. Within 3 min, trapezius electromyography demonstrated neuromuscular silencing, and further manipulation of CN XI did not cause shoulder movements. Approximately 30 min after lidocaine application, trapezius contractions returned, and lidocaine was again applied to re-silence CN XI. Gross total resection of the hemangioblastoma was performed during periods of CN XI inactivation, when trapezius contractions were absent. CONCLUSION Direct application of lidocaine to CN XI temporarily silenced neuromuscular activity and prevented unwanted trapezius contraction during skull base microsurgery. This method improved operative safety and efficiency by significantly reducing patient movement due to the unavoidable manipulation of CN XI.
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Affiliation(s)
- Derek G Southwell
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, California
| | - William R Lyon
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, California
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11
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Breshears JD, Haddad AF, Viner J, Rau J, Sankaran S, McDermott MW. A Reduced Exogenous Steroid Taper for Postoperative Brain Tumor Patients-A Case-Control Study. World Neurosurg 2019; 125:e44-e47. [PMID: 30639502 DOI: 10.1016/j.wneu.2018.12.173] [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: 09/13/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Dexamethasone is a standard treatment for cerebral edema after brain tumor surgery. However, its side effects can negatively impact the quality and safety of care provided to patients. Sparse evidence exists in the literature regarding postoperative steroid dosing to guide clinicians. The objective of this study was to determine if a new reduced exogenous steroid taper (REST) protocol would effectively treat postoperative cerebral edema while reducing the incidence of steroid-related side effects including diabetes, hypertension, and insomnia. METHODS A REST protocol (dexamethasone 38.5 mg tapered over 10 days) was instituted for patients with postoperative brain tumor of a single surgeon. Historical controls treated with a high-dose taper (dexamethasone 117 mg taper over 17 days) were selected to match for baseline characteristics. Outcomes of new or worsened diabetes, hypertension, and insomnia, as well as length of stay (LOS) and 30-day readmission rates, were compared. RESULTS Twenty-five patients were included in each group. There were no significant differences in baseline characteristics. The REST group received a median of 34.5 mg (interquartile range, 32-41 mg) of dexamethasone, whereas controls received 43 mg (interquartile range, 16-91 mg) (P = 0.04). There was a significant reduction in the incidence of new or worsened hypertension in the REST group (0%) compared with controls (20%, P = 0.02). No difference was seen in the rates of diabetes mellitus, insomnia, LOS, or 30-day readmission rates. CONCLUSIONS A reduced steroid taper after brain tumor surgery significantly reduced the incidence of hypertension without increasing LOS or 30-day readmissions compared with controls treated with a high-dose taper.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander F Haddad
- School of Medicine, University of California San Francisco, San Francisco, California, USA.
| | - Jennifer Viner
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Johnny Rau
- Department of Pharmaceutical Services, University of California San Francisco, San Francisco, California, USA
| | - Sujatha Sankaran
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Southwell DG, Breshears JD, Lyon WR, McDermott MW. In Reply: A Method for Cranial Nerve XI Silencing During Surgery of the Foramen Magnum Region: Technical Case Report. Oper Neurosurg (Hagerstown) 2019; 16:E36. [PMID: 30476285 DOI: 10.1093/ons/opy316] [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: 11/14/2022] Open
Affiliation(s)
- Derek G Southwell
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| | - Jonathan D Breshears
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| | - William R Lyon
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
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13
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Breshears JD, Southwell DG, Chang EF. Inhibition of Manual Movements at Speech Arrest Sites in the Posterior Inferior Frontal Lobe. Neurosurgery 2018; 85:E496-E501. [DOI: 10.1093/neuros/nyy592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 11/11/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Intraoperative stimulation of the posterior inferior frontal lobe (IFL) induces speech arrest, which is often interpreted as demonstration of essential language function. However, prior reports have described “negative motor areas” in the IFL, sites where stimulation halts ongoing limb motor activity.
OBJECTIVE
To investigate the spatial and functional relationship between IFL speech arrest areas and negative motor areas (NMAs).
METHODS
In this retrospective cohort study, intraoperative stimulation mapping was performed to localize speech and motor function, as well as arrest of hand movement, hand posture, and guitar playing in a set of patients undergoing awake craniotomy for dominant hemisphere pathologies. The incidence and localization of speech arrest and motor inhibition was analyzed.
RESULTS
Eleven patients underwent intraoperative localization of speech arrest sites and inhibitory motor areas. A total of 17 speech arrest sites were identified in the dominant frontal lobe, and, of these, 5 sites (29.4%) were also identified as NMAs. Speech arrest and arrest of guitar playing was also evoked by a single IFL site in 1 subject.
CONCLUSION
Inferior frontal gyrus speech arrest sites do not function solely in speech production. These findings provide further evidence for the complexity of language organization, and suggest the need for refined mapping strategies that discern between language-specific sites and inhibitory motor areas.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Derek G Southwell
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Edward F Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
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Chang J, Breshears JD, Molinaro AM, Sneed PK, McDermott MW, Theodosopoulos PV, Tward AD. Impact of pretreatment growth on Tumor control for vestibular schwannomas following gamma knife. Laryngoscope 2018; 129:743-747. [PMID: 30408172 DOI: 10.1002/lary.27427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 01/24/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine if volumetric growth prior to gamma knife (GK) radiosurgery predicts long-term tumor control. STUDY DESIGN Retrospective cohort study. METHODS Sporadic vestibular schwannomas (VS) treated with GK between 2002 and 2014 at a single tertiary care center were identified. Patients were included if they had over 6 months of pretreatment observation and over 1.5 years of posttreatment follow-up. Volumetric tumor analysis was performed on T1 postcontrast imaging. Pretreatment and posttreatment volume change was calculated. Tumors with over 20% volume increase were classified as growing. RESULTS There were 62 patients included in this study; 48 had pretreatment growth and 14 had no pretreatment growth. Median tumor volume was 0.58 ± 1.8 cm3 and median follow-up was 3.3 ± 2.0 years. For tumors with and without pretreatment growth, salvage treatment rates were 2% and 7% (P = .35), and posttreatment radiologic stability rates were 73% and 86%, respectively (P = .33). Median pretreatment growth was 27 ± 33% per year for tumors with posttreatment radiographic growth and 18 ± 26% per year for tumors without posttreatment radiographic growth (P = .99). CONCLUSIONS Pretreatment growth was not associated with increased salvage treatment or posttreatment radiographic progression rates in VS following GK. LEVEL OF EVIDENCE 4 Laryngoscope, 129:743-747, 2019.
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Affiliation(s)
- Joseph Chang
- Department of Otolaryngology-Head and Neck Surgery, San Francisco, San Francisco, California, U.S.A
| | - Jonathan D Breshears
- Department of Neurological Surgery, San Francisco, San Francisco, California, U.S.A
| | - Annette M Molinaro
- Department of Neurological Surgery, San Francisco, San Francisco, California, U.S.A
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, U.S.A
| | - Michael W McDermott
- Department of Neurological Surgery, San Francisco, San Francisco, California, U.S.A
| | | | - Aaron D Tward
- Department of Otolaryngology-Head and Neck Surgery, San Francisco, San Francisco, California, U.S.A
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15
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Breshears JD, Hamilton LS, Chang EF. Spontaneous Neural Activity in the Superior Temporal Gyrus Recapitulates Tuning for Speech Features. Front Hum Neurosci 2018; 12:360. [PMID: 30279650 PMCID: PMC6153351 DOI: 10.3389/fnhum.2018.00360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/21/2018] [Indexed: 11/26/2022] Open
Abstract
Background: Numerous studies have demonstrated that individuals exhibit structured neural activity in many brain regions during rest that is also observed during different tasks, however it is still not clear whether and how resting state activity patterns may relate to underlying tuning for specific stimuli. In the posterior superior temporal gyrus (STG), distinct neural activity patterns are observed during the perception of specific linguistic speech features. We hypothesized that spontaneous resting-state neural dynamics of the STG would be structured to reflect its role in speech perception, exhibiting an organization along speech features as seen during speech perception. Methods: Human cortical local field potentials were recorded from the superior temporal gyrus (STG) in 8 patients undergoing surgical treatment of epilepsy. Signals were recorded during speech perception and rest. Patterns of neural activity (high gamma power: 70–150 Hz) during rest, extracted with spatiotemporal principal component analysis, were compared to spatiotemporal neural responses to speech features during perception. Hierarchical clustering was applied to look for patterns in rest that corresponded to speech feature tuning. Results: Significant correlations were found between neural responses to speech features (sentence onsets, consonants, and vowels) and the spontaneous neural activity in the STG. Across subjects, these correlations clustered into five groups, demonstrating tuning for speech features—most robustly for acoustic onsets. These correlations were not seen in other brain areas, or during motor and spectrally-rotated speech control tasks. Conclusions: In this study, we present evidence that the RS structure of STG activity robustly recapitulates its stimulus-evoked response to acoustic onsets. Further, secondary patterns in RS activity appear to correlate with stimulus-evoked responses to speech features. The role of these spontaneous spatiotemporal activity patterns remains to be elucidated.
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Affiliation(s)
- Jonathan D. Breshears
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
| | - Liberty S. Hamilton
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Communication Sciences and Disorders, University of Texas at Austin, Austin, TX, United States
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Edward F. Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Edward F. Chang
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Dichter BK, Breshears JD, Leonard MK, Chang EF. The Control of Vocal Pitch in Human Laryngeal Motor Cortex. Cell 2018; 174:21-31.e9. [PMID: 29958109 PMCID: PMC6084806 DOI: 10.1016/j.cell.2018.05.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [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: 01/07/2018] [Revised: 03/23/2018] [Accepted: 05/08/2018] [Indexed: 11/24/2022]
Abstract
In speech, the highly flexible modulation of vocal pitch creates intonation patterns that speakers use to convey linguistic meaning. This human ability is unique among primates. Here, we used high-density cortical recordings directly from the human brain to determine the encoding of vocal pitch during natural speech. We found neural populations in bilateral dorsal laryngeal motor cortex (dLMC) that selectively encoded produced pitch but not non-laryngeal articulatory movements. This neural population controlled short pitch accents to express prosodic emphasis on a word in a sentence. Other larynx cortical representations controlling voicing and longer pitch phrase contours were found at separate sites. dLMC sites also encoded vocal pitch during a non-speech singing task. Finally, direct focal stimulation of dLMC evoked laryngeal movements and involuntary vocalization, confirming its causal role in feedforward control. Together, these results reveal the neural basis for the voluntary control of vocal pitch in human speech. VIDEO ABSTRACT.
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Affiliation(s)
- Benjamin K Dichter
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94158, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA; UC Berkeley and UCSF Joint Program in Bioengineering, Berkeley, CA 94720, USA
| | - Jonathan D Breshears
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94158, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Matthew K Leonard
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94158, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Edward F Chang
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94158, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143, USA; UC Berkeley and UCSF Joint Program in Bioengineering, Berkeley, CA 94720, USA.
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17
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Breshears JD, Partow C, Tihan T, McDermott MW, Sneed P, Cheung SW, Theodosopoulos PV. 322 Rate of Residual Tumor Growth After Primary Subtotal Resection (STR) and the Role of Upfront Versus Salvage Stereotactic Radiosurgery (SRS) for Sporadic Vestibular Schwannomas. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.322] [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: 11/14/2022] Open
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18
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Walcott BP, Breshears JD, Choudhri O, Lawton MT. Transcallosal-transchoroidal Fissure Approach for Resection of Third Ventricle Cavernous Malformation: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2017; 13:398. [DOI: 10.1093/ons/opw028] [Citation(s) in RCA: 3] [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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19
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Breshears JD, Osorio JA, Cheung SW, Barani IJ, Theodosopoulos PV. Surgery After Primary Radiation Treatment for Sporadic Vestibular Schwannomas: Case Series. Oper Neurosurg (Hagerstown) 2017; 13:441-447. [DOI: 10.1093/ons/opx023] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 01/26/2017] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND: As radiation has become an increasingly popular primary treatment option for sporadic vestibular schwannomas, there is a minority of tumors that do not respond favorably to radiation. Data on repeat radiosurgery are emerging, and salvage surgery has been associated with increased technical difficulty and poor facial nerve outcomes.
OBJECTIVE: To review the current literature and report our results with surgical resection of sporadic vestibular schwannomas that have failed primary radiation treatment.
METHODS: This is a retrospective, single-surgeon case series of patients with sporadic vestibular schwannomas who failed primary radiation treatment and underwent subsequent surgical resection. We analyze demographics, clinical information, and intraoperative findings, focusing on facial nerve functional outcomes and extent of resection.
RESULTS: Between 2006 and 2015, 10 patients with sporadic vestibular schwannomas whose only prior treatment was radiation underwent microsurgical resection. Eight of 10 patients had a postoperative House-Brackmann score of 1 at a median follow-up of 14 months, while 2 patients had House-Brackmann score of 4. Gross total resection was achieved in 7 of 10 cases. Near total resection was achieved in 2 cases, and only subtotal resection was achieved in 1 case.
CONCLUSION: Salvage surgery is a safe and effective option after failure of primary radiation and may offer benefits over repeat radiosurgery.
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Affiliation(s)
- Jonathan D. Breshears
- Department of Neurosurgery, University of California San Francisco, San Franci-sco, California
| | - Joseph A. Osorio
- Department of Neurosurgery, University of California San Francisco, San Franci-sco, California
| | - Steven W. Cheung
- Department of Oto-laryngology, University of California San Francisco, San Francisco, California
| | - Igor J. Barani
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
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20
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Bandt SK, Roland JL, Pahwa M, Hacker CD, Bundy DT, Breshears JD, Sharma M, Shimony JS, Leuthardt EC. The impact of high grade glial neoplasms on human cortical electrophysiology. PLoS One 2017; 12:e0173448. [PMID: 28319187 PMCID: PMC5358752 DOI: 10.1371/journal.pone.0173448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 02/21/2017] [Indexed: 11/18/2022] Open
Abstract
Objective The brain’s functional architecture of interconnected network-related oscillatory patterns in discrete cortical regions has been well established with functional magnetic resonance imaging (fMRI) studies or direct cortical electrophysiology from electrodes placed on the surface of the brain, or electrocorticography (ECoG). These resting state networks exhibit a robust functional architecture that persists through all stages of sleep and under anesthesia. While the stability of these networks provides a fundamental understanding of the organization of the brain, understanding how these regions can be perturbed is also critical in defining the brain’s ability to adapt while learning and recovering from injury. Methods Patients undergoing an awake craniotomy for resection of a tumor were studied as a unique model of an evolving injury to help define how the cortical physiology and the associated networks were altered by the presence of an invasive brain tumor. Results This study demonstrates that there is a distinct pattern of alteration of cortical physiology in the setting of a malignant glioma. These changes lead to a physiologic sequestration and progressive synaptic homogeneity suggesting that a de-learning phenomenon occurs within the tumoral tissue compared to its surroundings. Significance These findings provide insight into how the brain accommodates a region of “defunctionalized” cortex. Additionally, these findings may have important implications for emerging techniques in brain mapping using endogenous cortical physiology.
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Affiliation(s)
- S. Kathleen Bandt
- Department of Neurological Surgery, Yale University School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
| | - Jarod L. Roland
- Department of Neurological Surgery, Washington University, St. Louis, Missouri, United States of America
| | - Mrinal Pahwa
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri, United States of America
| | - Carl D. Hacker
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri, United States of America
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - David T. Bundy
- Department of Rehabilitation Medicine, University of Kansas, Kansas City, Kansas, United States of America
| | - Jonathan D. Breshears
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Mohit Sharma
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri, United States of America
| | - Joshua S. Shimony
- Washington University School of Medicine, St. Louis, Missouri, United States of America
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Eric C. Leuthardt
- Department of Neurological Surgery, Washington University, St. Louis, Missouri, United States of America
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri, United States of America
- Washington University School of Medicine, St. Louis, Missouri, United States of America
- Center for Innovation in Neuroscience and Technology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Brain Laser Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
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21
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Chang EF, Breshears JD, Raygor KP, Lau D, Molinaro AM, Berger MS. Stereotactic probability and variability of speech arrest and anomia sites during stimulation mapping of the language dominant hemisphere. J Neurosurg 2017; 126:114-121. [DOI: 10.3171/2015.10.jns151087] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Functional mapping using direct cortical stimulation is the gold standard for the prevention of postoperative morbidity during resective surgery in dominant-hemisphere perisylvian regions. Its role is necessitated by the significant interindividual variability that has been observed for essential language sites. The aim in this study was to determine the statistical probability distribution of eliciting aphasic errors for any given stereotactically based cortical position in a patient cohort and to quantify the variability at each cortical site.
METHODS
Patients undergoing awake craniotomy for dominant-hemisphere primary brain tumor resection between 1999 and 2014 at the authors' institution were included in this study, which included counting and picture-naming tasks during dense speech mapping via cortical stimulation. Positive and negative stimulation sites were collected using an intraoperative frameless stereotactic neuronavigation system and were converted to Montreal Neurological Institute coordinates. Data were iteratively resampled to create mean and standard deviation probability maps for speech arrest and anomia. Patients were divided into groups with a “classic” or an “atypical” location of speech function, based on the resultant probability maps. Patient and clinical factors were then assessed for their association with an atypical location of speech sites by univariate and multivariate analysis.
RESULTS
Across 102 patients undergoing speech mapping, the overall probabilities of speech arrest and anomia were 0.51 and 0.33, respectively. Speech arrest was most likely to occur with stimulation of the posterior inferior frontal gyrus (maximum probability from individual bin = 0.025), and variance was highest in the dorsal premotor cortex and the posterior superior temporal gyrus. In contrast, stimulation within the posterior perisylvian cortex resulted in the maximum mean probability of anomia (maximum probability = 0.012), with large variance in the regions surrounding the posterior superior temporal gyrus, including the posterior middle temporal, angular, and supramarginal gyri. Patients with atypical speech localization were far more likely to have tumors in canonical Broca's or Wernicke's areas (OR 7.21, 95% CI 1.67–31.09, p < 0.01) or to have multilobar tumors (OR 12.58, 95% CI 2.22–71.42, p < 0.01), than were patients with classic speech localization.
CONCLUSIONS
This study provides statistical probability distribution maps for aphasic errors during cortical stimulation mapping in a patient cohort. Thus, the authors provide an expected probability of inducing speech arrest and anomia from specific 10-mm2 cortical bins in an individual patient. In addition, they highlight key regions of interindividual mapping variability that should be considered preoperatively. They believe these results will aid surgeons in their preoperative planning of eloquent cortex resection.
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Affiliation(s)
- Edward F. Chang
- Departments of 1Neurological Surgery,
- 2Physiology, and
- 3Center for Integrative Neuroscience, University of California, San Francisco; and
- 4Center for Neural Engineering and Prostheses, University of California, Berkeley, and University of California, San Francisco, California
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22
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Osorio JA, Breshears JD, Arnaout O, Simon NG, Hastings-Robinson AM, Aleshi P, Kliot M. Ultrasound-guided percutaneous injection of methylene blue to identify nerve pathology and guide surgery. Neurosurg Focus 2016; 39:E2. [PMID: 26323820 DOI: 10.3171/2015.6.focus15220] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT The objective of this study was to provide a technique that could be used in the preoperative period to facilitate the surgical exploration of peripheral nerve pathology. METHODS The authors describe a technique in which 1) ultrasonography is used in the immediate preoperative period to identify target peripheral nerves, 2) an ultrasound-guided needle electrode is used to stimulate peripheral nerves to confirm their position, and then 3) a methylene blue (MB) injection is performed to mark the peripheral nerve pathology to facilitate surgical exploration. RESULTS A cohort of 13 patients with varying indications for peripheral nerve surgery is presented in which ultrasound guidance, stimulation, and MB were used to localize and create a road map for surgeries. CONCLUSIONS Preoperative ultrasound-guided MB administration is a promising technique that peripheral nerve surgeons could use to plan and execute surgery.
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Affiliation(s)
- Joseph A Osorio
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Omar Arnaout
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Neil G Simon
- Prince of Wales Clinical School, University of New South Wales, Randwick, and Department of Neurology, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia; and
| | - Ashley M Hastings-Robinson
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pedram Aleshi
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, California
| | - Michel Kliot
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Abla AA, McDougall CM, Breshears JD, Lawton MT. Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients. J Neurosurg 2016; 124:1275-1286. [PMID: 26566199 DOI: 10.3171/2015.5.jns15368if:5.408q1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECT Intracranial-to-intracranial (IC-IC) bypasses are alternatives to traditional extracranial-to-intracranial (EC-IC) bypasses to reanastomose parent arteries, reimplant efferent branches, revascularize branches with in situ donor arteries, and reconstruct bifurcations with interposition grafts that are entirely intracranial. These bypasses represent an evolution in bypass surgery from using scalp arteries and remote donor sites toward a more local and reconstructive approach. IC-IC bypass can be utilized preferentially when revascularization is needed in the management of complex aneurysms. Experiences using IC-IC bypass, as applied to posterior inferior cerebellar artery (PICA) aneurysms in 35 patients, were reviewed. METHODS Patients with PICA aneurysms and vertebral artery (VA) aneurysms involving the PICA's origin were identified from a prospectively maintained database of the Vascular Neurosurgery Service, and patients who underwent bypass procedures for PICA revascularization were included. RESULTS During a 17-year period in which 129 PICA aneurysms in 125 patients were treated microsurgically, 35 IC-IC bypasses were performed as part of PICA aneurysm management, including in situ p3-p3 PICA-PICA bypass in 11 patients (31%), PICA reimplantation in 9 patients (26%), reanastomosis in 14 patients (40%), and 1 V3 VA-to-PICA bypass with an interposition graft (3%). All aneurysms were completely or nearly completely obliterated, 94% of bypasses were patent, 77% of patients were improved or unchanged after treatment, and good outcomes (modified Rankin Scale ≤ 2) were observed in 76% of patients. Two patients died expectantly. Ischemic complications were limited to 2 patients in whom the bypasses occluded, and permanent lower cranial nerve morbidity was limited to 3 patients and did not compromise independent function in any of the patients. CONCLUSIONS PICA aneurysms receive the application of IC-IC bypass better than any other aneurysm, with nearly one-quarter of all PICA aneurysms treated microsurgically at our center requiring bypass without a single EC-IC bypass. The selection of PICA bypass is almost algorithmic: trapped aneurysms at the PICA origin or p1 segment are revascularized with a PICA-PICA bypass, with PICA reimplantation as an alternative; trapped p2 segment aneurysms are reanastomosed, bypassed in situ, or reimplanted; distal p3 segment aneurysms are reanastomosed or revascularized with a PICA-PICA bypass; and aneurysms of the p4 segment that are too distal for PICA-PICA bypass are reanastomosed. Interposition grafts are reserved for when these 3 primary options are unsuitable. A constructive approach that preserves the PICA with direct clipping or replaces flow with a bypass when sacrificed should remain an alternative to deconstructive PICA occlusion and endovascular coiling when complete aneurysm occlusion is unlikely.
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Affiliation(s)
- Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Cameron M McDougall
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, California
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Abla AA, McDougall CM, Breshears JD, Lawton MT. Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients. J Neurosurg 2015; 124:1275-86. [PMID: 26566199 DOI: 10.3171/2015.5.jns15368] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [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: 11/06/2022]
Abstract
OBJECT Intracranial-to-intracranial (IC-IC) bypasses are alternatives to traditional extracranial-to-intracranial (EC-IC) bypasses to reanastomose parent arteries, reimplant efferent branches, revascularize branches with in situ donor arteries, and reconstruct bifurcations with interposition grafts that are entirely intracranial. These bypasses represent an evolution in bypass surgery from using scalp arteries and remote donor sites toward a more local and reconstructive approach. IC-IC bypass can be utilized preferentially when revascularization is needed in the management of complex aneurysms. Experiences using IC-IC bypass, as applied to posterior inferior cerebellar artery (PICA) aneurysms in 35 patients, were reviewed. METHODS Patients with PICA aneurysms and vertebral artery (VA) aneurysms involving the PICA's origin were identified from a prospectively maintained database of the Vascular Neurosurgery Service, and patients who underwent bypass procedures for PICA revascularization were included. RESULTS During a 17-year period in which 129 PICA aneurysms in 125 patients were treated microsurgically, 35 IC-IC bypasses were performed as part of PICA aneurysm management, including in situ p3-p3 PICA-PICA bypass in 11 patients (31%), PICA reimplantation in 9 patients (26%), reanastomosis in 14 patients (40%), and 1 V3 VA-to-PICA bypass with an interposition graft (3%). All aneurysms were completely or nearly completely obliterated, 94% of bypasses were patent, 77% of patients were improved or unchanged after treatment, and good outcomes (modified Rankin Scale ≤ 2) were observed in 76% of patients. Two patients died expectantly. Ischemic complications were limited to 2 patients in whom the bypasses occluded, and permanent lower cranial nerve morbidity was limited to 3 patients and did not compromise independent function in any of the patients. CONCLUSIONS PICA aneurysms receive the application of IC-IC bypass better than any other aneurysm, with nearly one-quarter of all PICA aneurysms treated microsurgically at our center requiring bypass without a single EC-IC bypass. The selection of PICA bypass is almost algorithmic: trapped aneurysms at the PICA origin or p1 segment are revascularized with a PICA-PICA bypass, with PICA reimplantation as an alternative; trapped p2 segment aneurysms are reanastomosed, bypassed in situ, or reimplanted; distal p3 segment aneurysms are reanastomosed or revascularized with a PICA-PICA bypass; and aneurysms of the p4 segment that are too distal for PICA-PICA bypass are reanastomosed. Interposition grafts are reserved for when these 3 primary options are unsuitable. A constructive approach that preserves the PICA with direct clipping or replaces flow with a bypass when sacrificed should remain an alternative to deconstructive PICA occlusion and endovascular coiling when complete aneurysm occlusion is unlikely.
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Affiliation(s)
- Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Cameron M McDougall
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, California
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Abstract
OBJECT
The human ventral sensorimotor cortex (vSMC) is involved in facial expression, mastication, and swallowing, as well as the dynamic and highly coordinated movements of human speech production. However, vSMC organization remains poorly understood, and previously published population-driven maps of its somatotopy do not accurately reflect the variability across individuals in a quantitative, probabilistic fashion. The goal of this study was to describe the responses to electrical stimulation of the vSMC, generate probabilistic maps of function in the vSMC, and quantify the variability across individuals.
METHODS
Photographic, video, and stereotactic MRI data of intraoperative electrical stimulation of the vSMC were collected for 33 patients undergoing awake craniotomy. Stimulation sites were converted to a 2D coordinate system based on anatomical landmarks. Motor, sensory, and speech stimulation responses were reviewed and classified. Probabilistic maps of stimulation responses were generated, and spatial variance was quantified.
RESULTS
In 33 patients, the authors identified 194 motor, 212 sensory, 61 speech-arrest, and 27 mixed responses. Responses were complex, stereotyped, and mostly nonphysiological movements, involving hand, orofacial, and laryngeal musculature. Within individuals, the presence of oral movement representations varied; however, the dorsal-ventral order was always preserved. The most robust motor responses were jaw (probability 0.85), tongue (0.64), lips (0.58), and throat (0.52). Vocalizations were seen in 6 patients (0.18), more dorsally near lip and dorsal throat areas. Sensory responses were spatially dispersed; however, patients' subjective reports were highly precise in localization within the mouth. The most robust responses included tongue (0.82) and lips (0.42). The probability of speech arrest was 0.85, highest 15–20 mm anterior to the central sulcus and just dorsal to the sylvian fissure, in the anterior precentral gyrus or pars opercularis.
CONCLUSIONS
The authors report probabilistic maps of function in the human vSMC based on intraoperative cortical electrical stimulation. These results define the expected range of mapping outcomes in the vSMC of a single individual and shed light on the functional organization of the vSMC supporting speech motor control and nonspeech functions.
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Affiliation(s)
| | | | - Edward F. Chang
- Departments of 1Neurological Surgery,
- 3Physiology, and
- 4Center for Integrative Neuroscience, University of California, San Francisco; and
- 5Center for Neural Engineering and Prostheses, University of California, Berkeley and San Francisco, California
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Breshears JD, Rutkowski MJ, McDermott MW, Cha S, Tihan T, Theodosopoulos PV. Surgical Management of Intracranial Neuroenteric Cysts: The UCSF Experience. J Neurol Surg B Skull Base 2015; 76:475-9. [PMID: 26682127 DOI: 10.1055/s-0035-1554906] [Citation(s) in RCA: 7] [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: 02/09/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022] Open
Abstract
Objective Modern surgical experience with intracranial neuroenteric cysts is limited in the literature. We review our 15-year institutional experience with these rare lesions. Design Single-institution retrospective study. Setting Large North American tertiary care center. Participants Histologically confirmed cases of intracranial neuroenteric cyst from January 2000 to September 2014. Main Outcome Measures Pre- and postoperative modified Rankin Scale (mRS) scores, extent of resection, and postoperative complications are reported. Clinical presentation, imaging features, pathology, and operative approach are discussed. Results Five spinal and six intracranial neuroenteric cysts were surgically treated over a 15-year period. Median age at presentation for the intracranial cysts was 38.5 years. Mean cyst diameter was 3.8 cm. Five cysts were located in the pre-pontomedullary cistern, and one was located in the third ventricle. Gross total resection was achieved in four of the five posterior fossa cysts through a far lateral transcondylar approach. Postoperative complications included aseptic meningitis (one), transient abducens palsy (one), and pseudomeningocele requiring reoperation (three). Postoperative mRS scores improved to ≤1 by 6.5 months median follow-up. Conclusions Intracranial neuroenteric cysts are rare lesions with a variable imaging appearance. Complete surgical resection through a far lateral transcondylar approach is possible and usually results in symptom improvement or resolution.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Martin J Rutkowski
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Soonmee Cha
- Department of Radiology and Neurological Surgery, University of California, San Francisco, California, United States
| | - Tarik Tihan
- Department of Pathology, University of California, San Francisco, California, United States
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, California, United States
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27
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Abstract
INTRODUCTION Cushing's disease is a neuroendocrine disorder marked by hypercortisolemia secondary to overproduction of ACTH by a corticotropic pituitary adenoma. Due to the diverse and deleterious effects of hypercortisolemia including diabetes mellitus, hypertension, and cardiovascular disease, prompt and accurate diagnosis followed by surgical resection of the responsible corticotropic adenoma is critical. METHODS In the following review, we present a focused synopsis of recently published data and management strategies for the post-operative Cushing's disease patient with a particular focus on studies examining perioperative complications, establishment of biochemical remission, factors associated with disease remission, and predictors of recurrence. CONCLUSIONS Although no standard definition of remission exists, we suggest measurement of serum cortisol level on the morning of postoperative day 1 given the preponderance of evidence in the published literature suggesting its association with long-term remission and relatively low rates of recurrence. Nevertheless, all patients should be counseled that recurrence can occur in a delayed fashion and that annual endocrine testing should be utilized to track and confirm disease status.
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Affiliation(s)
- Martin J Rutkowski
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M-779, San Francisco, CA, 94143, USA,
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Breshears JD, Ivan ME, Cotter JA, Bollen AW, Theodosopoulos PV, Berger MS. Primary glioblastoma of the trigeminal nerve root entry zone: case report. J Neurosurg 2015; 122:78-81. [PMID: 25380115 DOI: 10.3171/2014.10.jns14449] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 11/06/2022]
Abstract
Gliomas of the cranial nerve root entry zone are rare clinical entities. There have been 11 reported cases in the literature, including only 2 glioblastomas. The authors report the case of a 67-year-old man who presented with isolated facial numbness and was found to have a glioblastoma involving the trigeminal nerve root entry zone. After biopsy the patient completed treatment with conformal radiation and concomitant temozolomide, and at 23 weeks after surgery he demonstrated symptom progression despite the treatment described. This is the first reported case of a glioblastoma of the trigeminal nerve root entry zone.
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Breshears JD, Osorio JA, Hoffman W, McDermott MW. Temporalis Muscle Suspension on Synthetic Cranioplasty: Technical Note. Cureus 2014. [DOI: 10.7759/cureus.237] [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: 11/05/2022] Open
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30
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Mitchell TJ, Hacker CD, Breshears JD, Szrama NP, Sharma M, Bundy DT, Pahwa M, Corbetta M, Snyder AZ, Shimony JS, Leuthardt EC. A novel data-driven approach to preoperative mapping of functional cortex using resting-state functional magnetic resonance imaging. Neurosurgery 2014; 73:969-82; discussion 982-3. [PMID: 24264234 PMCID: PMC3871406 DOI: 10.1227/neu.0000000000000141] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. BACKGROUND: Recent findings associated with resting-state cortical networks have provided insight into the brain's organizational structure. In addition to their neuroscientific implications, the networks identified by resting-state functional magnetic resonance imaging (rs-fMRI) may prove useful for clinical brain mapping. OBJECTIVE: To demonstrate that a data-driven approach to analyze resting-state networks (RSNs) is useful in identifying regions classically understood to be eloquent cortex as well as other functional networks. METHODS: This study included 6 patients undergoing surgical treatment for intractable epilepsy and 7 patients undergoing tumor resection. rs-fMRI data were obtained before surgery and 7 canonical RSNs were identified by an artificial neural network algorithm. Of these 7, the motor and language networks were then compared with electrocortical stimulation (ECS) as the gold standard in the epilepsy patients. The sensitivity and specificity for identifying these eloquent sites were calculated at varying thresholds, which yielded receiver-operating characteristic (ROC) curves and their associated area under the curve (AUC). RSNs were plotted in the tumor patients to observe RSN distortions in altered anatomy. RESULTS: The algorithm robustly identified all networks in all patients, including those with distorted anatomy. When all ECS-positive sites were considered for motor and language, rs-fMRI had AUCs of 0.80 and 0.64, respectively. When the ECS-positive sites were analyzed pairwise, rs-fMRI had AUCs of 0.89 and 0.76 for motor and language, respectively. CONCLUSION: A data-driven approach to rs-fMRI may be a new and efficient method for preoperative localization of numerous functional brain regions. ABBREVIATIONS: AUC, area under the curve BA, Brodmann area BOLD, blood oxygen level dependent ECS, electrocortical stimulation fMRI, functional magnetic resonance imaging ICA, independent component analysis MLP, multilayer perceptron MP-RAGE, magnetization-prepared rapid gradient echo ROC, receiver-operating characteristic rs-fMRI, resting-state functional magnetic resonance imaging RSN, resting-state network
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Affiliation(s)
- Timothy J Mitchell
- Departments of *Neurological Surgery, ‡Neurology, §Biomedical Engineering, and ¶Mechanical Engineering and Material Sciences, ‖Mallinckrodt Institute of Radiology, #Center for Innovation in Neuroscience and Technology, Washington University School of Medicine, St. Louis, Missouri
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31
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Englot DJ, Breshears JD, Sun PP, Chang EF, Auguste KI. Seizure outcomes after resective surgery for extra-temporal lobe epilepsy in pediatric patients. J Neurosurg Pediatr 2013; 12:126-33. [PMID: 23768201 DOI: 10.3171/2013.5.peds1336] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
While temporal lobe epilepsy (TLE) is the most common epilepsy syndrome in adults, seizures in children are more often extratemporal in origin. Extra-temporal lobe epilepsy (ETLE) in pediatric patients is often medically refractory, leading to significantly diminished quality of life. Seizure outcomes after resective surgery for pediatric ETLE vary tremendously in the literature, given diverse patient and epilepsy characteristics and small sample sizes. The authors performed a systematic review and meta-analysis of studies including 10 or more pediatric patients (age ≤ 19 years) published over the last 20 years examining seizure outcomes after resective surgery for ETLE, excluding hemispherectomy. Thirty-six studies were examined. These 36 studies included 1259 pediatric patients who underwent resective surgery for ETLE. Seizure freedom (Engel Class I outcome) was achieved in 704 (56%) of these 1259 patients postoperatively, and 555 patients (44%) continued to have seizures (Engel Class II-IV outcome). Shorter epilepsy duration (≤ 7 years, the median value in this study) was more predictive of seizure freedom than longer (> 7 years) seizure history (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.07-2.14), suggesting that earlier intervention may be beneficial. Also, lesional epilepsy was associated with better seizure outcomes than nonlesional epilepsy (OR 1.34, 95% CI 1.19-1.49). Other predictors of seizure freedom included an absence of generalized seizures (OR 1.61, 95% CI 1.18-2.35) and localizing ictal electroencephalographic findings (OR 1.55, 95% CI 1.24-1.93). In conclusion, seizure outcomes after resective surgery for pediatric ETLE are less favorable than those associated with temporal lobectomy, but seizure freedom may be more common with earlier intervention and lesional epilepsy etiology. Children with continued debilitating seizures despite failure of multiple medication trials should be referred to a comprehensive pediatric epilepsy center for further medical and surgical evaluation.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, CA 94143-0112, USA.
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Roland JL, Hacker CD, Breshears JD, Gaona CM, Hogan RE, Burton H, Corbetta M, Leuthardt EC. Brain mapping in a patient with congenital blindness - a case for multimodal approaches. Front Hum Neurosci 2013; 7:431. [PMID: 23914170 PMCID: PMC3728570 DOI: 10.3389/fnhum.2013.00431] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 04/05/2013] [Accepted: 07/15/2013] [Indexed: 11/21/2022] Open
Abstract
Recent advances in basic neuroscience research across a wide range of methodologies have contributed significantly to our understanding of human cortical electrophysiology and functional brain imaging. Translation of this research into clinical neurosurgery has opened doors for advanced mapping of functionality that previously was prohibitively difficult, if not impossible. Here we present the case of a unique individual with congenital blindness and medically refractory epilepsy who underwent neurosurgical treatment of her seizures. Pre-operative evaluation presented the challenge of accurately and robustly mapping the cerebral cortex for an individual with a high probability of significant cortical re-organization. Additionally, a blind individual has unique priorities in one’s ability to read Braille by touch and sense the environment primarily by sound than the non-vision impaired person. For these reasons we employed additional measures to map sensory, motor, speech, language, and auditory perception by employing a number of cortical electrophysiologic mapping and functional magnetic resonance imaging methods. Our data show promising results in the application of these adjunctive methods in the pre-operative mapping of otherwise difficult to localize, and highly variable, functional cortical areas.
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Affiliation(s)
- Jarod L Roland
- Department of Neurological Surgery, Washington University School of Medicine , St. Louis, MO , USA
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33
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Breshears JD, Gaona CM, Roland JL, Sharma M, Bundy DT, Shimony JS, Rashid S, Eisenman LN, Hogan RE, Snyder AZ, Leuthardt EC. Mapping sensorimotor cortex with slow cortical potential resting-state networks while awake and under anesthesia. Neurosurgery 2013; 71:305-16; discussion 316. [PMID: 22517255 DOI: 10.1227/neu.0b013e318258e5d1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The emerging insight into resting-state cortical networks has been important in our understanding of the fundamental architecture of brain organization. These networks, which were originally identified with functional magnetic resonance imaging, are also seen in the correlation topography of the infraslow rhythms of local field potentials. Because of the fundamental nature of these networks and their independence from task-related activations, we posit that, in addition to their neuroscientific relevance, these slow cortical potential networks could play an important role in clinical brain mapping. OBJECTIVE To assess whether these networks would be useful in identifying eloquent cortex such as sensorimotor cortex in patients both awake and under anesthesia. METHODS This study included 9 subjects undergoing surgical treatment for intractable epilepsy. Slow cortical potentials were recorded from the cortical surface in patients while awake and under propofol anesthesia. To test brain-mapping utility, slow cortical potential networks were identified with data-driven (seed-independent) and anatomy-driven (seed-based) approaches. With electrocortical stimulation used as the gold standard for comparison, the sensitivity and specificity of these networks for identifying sensorimotor cortex were calculated. RESULTS Networks identified with a data-driven approach in patients under anesthesia and awake were 90% and 93% sensitive and 58% and 55% specific for sensorimotor cortex, respectively. Networks identified with systematic seed selection in patients under anesthesia and awake were 78% and 83% sensitive and 67% and 60% specific, respectively. CONCLUSION Resting-state networks may be useful for tailoring stimulation mapping and could provide a means of identifying eloquent regions in patients while under anesthesia.
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Breshears JD, Gaona CM, Roland JL, Sharma M, Anderson NR, Bundy DT, Freudenburg ZV, Smyth MD, Zempel J, Limbrick DD, Smart WD, Leuthardt EC. Decoding motor signals from the pediatric cortex: implications for brain-computer interfaces in children. Pediatrics 2011; 128:e160-8. [PMID: 21690116 DOI: 10.1542/peds.2010-1519] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To demonstrate the decodable nature of pediatric brain signals for the purpose of neuroprosthetic control. We hypothesized that children would achieve levels of brain-derived computer control comparable to performance previously reported for adults. PATIENTS AND METHODS Six pediatric patients with intractable epilepsy who were invasively monitored underwent screening for electrocortical control signals associated with specific motor or phoneme articulation tasks. Subsequently, patients received visual feedback as they used these associated electrocortical signals to direct one dimensional cursor movement to a target on a screen. RESULTS All patients achieved accuracies between 70% and 99% within 9 minutes of training using the same screened motor and articulation tasks. Two subjects went on to achieve maximum accuracies of 73% and 100% using imagined actions alone. Average mean and maximum performance for the 6 pediatric patients was comparable to that of 5 adults. The mean accuracy of the pediatric group was 81% (95% confidence interval [CI]: 71.5-90.5) over a mean training time of 11.6 minutes, whereas the adult group had a mean accuracy of 72% (95% CI: 61.2-84.3) over a mean training time of 12.5 minutes. Maximum performance was also similar between the pediatric and adult groups (89.6% [95% CI: 83-96.3] and 88.5% [95% CI: 77.1-99.8], respectively). CONCLUSIONS Similarly to adult brain signals, pediatric brain signals can be decoded and used for BCI operation. Therefore, BCI systems developed for adults likely hold similar promise for children with motor disabilities.
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Affiliation(s)
- Jonathan D Breshears
- Washington University, School of Medicine, Campus Box 8057, 660 S Euclid Ave, St Louis, MO 63130, USA
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35
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Patschke R, Breshears JD, Brazis P, Kannewurf CR, Billinge SJ, Kanatzidis MG. Cu(x)UTe3: stabilization of UTe3 in the ZrSe3 structure type via copper insertion. The artifact of Te-Te chains and evidence for distortions due to long range modulations. J Am Chem Soc 2001; 123:4755-62. [PMID: 11457285 DOI: 10.1021/ja0042534] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The ternary phase, Cu(x)UTe3 (x = 0.25 and 0.33), was synthesized from a 3/1/4 mixture of Cu/U/Te that was heated to 800 degrees C for 6 days and cooled at a rate of -4 degrees C x h(-1). It adopts the monoclinic space group P2(1)/m with a = 6.0838(12) A, b = 4.2140(8) A, c = 10.361(2) A, beta = 98.83(3) degrees, and V = 262.47(9) A3 (for x approximately 0.25). The structure is built from UTe3 layers of ZrSe3-type that are connected in the [001] direction by Cu atoms. The Cu atoms stabilize alpha-UTe3 by inserting between the layers. Cu(x)UTe3 can be prepared rationally via a soft chemistry route by reaction of Cu with alpha-UTe3. The structural analysis suggests the presence of straight chains of Te atoms ( approximately 3.0 A apart) along the a-axis but this is an artifact as shown by electron diffraction studies of Cu(x)UTe3 that indicate the existence of a supercell along the a-axis. Pair distribution function analysis (PDF) was used to show that the Te-Te chains contain Te-Te dimers at 2.74 A. Charge transport measurements suggest a narrow gap semiconductor but they also indicate anomalous behavior as a function of temperature with a n-type to p-type transition at approximately 40 K.
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Affiliation(s)
- R Patschke
- Department of Chemistry, Michigan State University, East Lansing, Michigan 48824, USA
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