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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O’Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa460_s089] [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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Sadler B, Skidmore A, Gewirtz J, Anderson RCE, Haller G, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Averill C, Baird LC, Bauer DF, Bethel-Anderson T, Bierbrauer KS, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Khan N, Krieger MD, Leonard JR, Maher CO, Mangano FT, Mapstone TB, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Ragheb J, Selden NR, Shah MN, Shannon CN, Smith J, Smyth MD, Stone SSD, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Strahle JM. Extradural decompression versus duraplasty in Chiari malformation type I with syrinx: outcomes on scoliosis from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2021:1-9. [PMID: 34144521 DOI: 10.3171/2020.12.peds20552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is common in patients with Chiari malformation type I (CM-I)-associated syringomyelia. While it is known that treatment with posterior fossa decompression (PFD) may reduce the progression of scoliosis, it is unknown if decompression with duraplasty is superior to extradural decompression. METHODS A large multicenter retrospective and prospective registry of 1257 pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for patients with scoliosis who underwent PFD with or without duraplasty. RESULTS In total, 422 patients who underwent PFD had a clinical diagnosis of scoliosis. Of these patients, 346 underwent duraplasty, 51 received extradural decompression alone, and 25 were excluded because no data were available on the type of PFD. The mean clinical follow-up was 2.6 years. Overall, there was no difference in subsequent occurrence of fusion or proportion of patients with curve progression between those with and those without a duraplasty. However, after controlling for age, sex, preoperative curve magnitude, syrinx length, syrinx width, and holocord syrinx, extradural decompression was associated with curve progression > 10°, but not increased occurrence of fusion. Older age at PFD and larger preoperative curve magnitude were independently associated with subsequent occurrence of fusion. Greater syrinx reduction after PFD of either type was associated with decreased occurrence of fusion. CONCLUSIONS In patients with CM-I, syrinx, and scoliosis undergoing PFD, there was no difference in subsequent occurrence of surgical correction of scoliosis between those receiving a duraplasty and those with an extradural decompression. However, after controlling for preoperative factors including age, syrinx characteristics, and curve magnitude, patients treated with duraplasty were less likely to have curve progression than patients treated with extradural decompression. Further study is needed to evaluate the role of duraplasty in curve stabilization after PFD.
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Affiliation(s)
- Brooke Sadler
- 1Department of Pediatrics, Washington University in St. Louis, MO
| | - Alex Skidmore
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jordan Gewirtz
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Gabe Haller
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 5Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Gregory W Albert
- 7Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 8Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 9Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Christine Averill
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Lissa C Baird
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - David F Bauer
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin S Bierbrauer
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Christopher M Bonfield
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Douglas L Brockmeyer
- 13Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 14Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 15Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 18Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 20Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | | | - Timothy M George
- 22Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 23Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital and Stanford University School of Medicine, Palo Alto, CA
| | - Patrick C Graupman
- 24Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 26Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 27Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 28Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 30Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 31Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 32Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew H Jea
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - James M Johnston
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 34Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus Khan
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Mark D Krieger
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Jeffrey R Leonard
- 38Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 3Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Francesco T Mangano
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | | | - J Gordon McComb
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael Muhlbauer
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - W Jerry Oakes
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Greg Olavarria
- 40Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - Brent R O'Neill
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - John Ragheb
- 41Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 42Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Jodi Smith
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Matthew D Smyth
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 44Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Gerald F Tuite
- 45Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jennifer M Strahle
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
- 35Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021; 88:332-341. [PMID: 33313928 DOI: 10.1093/neuros/nyaa460] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology. OBJECTIVE To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD. METHODS The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD + OCF or PFD + OCF/VD. RESULTS All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD + OCF), whereas 4 had OCF and VD (PFD + OCF/VD). Of those with complete data, a history of platybasia (3/10, P = .011), Klippel-Feil (2/10, P = .015), and basilar invagination (3/12, P < .001) were increased within the OCF group, whereas only basilar invagination (1/4, P < .001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8 ± 15.3°, P = .008) and OCF/VD (115.0 ± 11.6°, P = .025) groups when compared to PFD-only group (145.3 ± 12.7°). pB-C2 did not differ among groups. CONCLUSION Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Gabrielle W Johnson
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Raheel Ahmed
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Phillipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - Lissa Baird
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - David F Bauer
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karin S Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Daniel E Couture
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Robert C Dauser
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Susan R Durham
- Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Timothy M George
- Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Patrick C Graupman
- Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Naina L Gross
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gabe Haller
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Gregory G Heuer
- Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew H Jea
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - James M Johnston
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nickalus Khan
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Mark D Krieger
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Jeffrey R Leonard
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Timothy B Mapstone
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - J Gordon McComb
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael Muhlbauer
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - W Jerry Oakes
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Greg Olavarria
- Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Tae Sung Park
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - John Ragheb
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis Shannon
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Joshua S Shimony
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jodi Smith
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mandeep S Tamber
- Department of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - James C Torner
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Scott D Wait
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Schroeppel TJ, Sharpe JP, Shahan CP, Clement LP, Magnotti LJ, Lee M, Muhlbauer M, Weinberg JA, Tolley EA, Croce MA, Fabian TC. Beta-adrenergic blockade for attenuation of catecholamine surge after traumatic brain injury: a randomized pilot trial. Trauma Surg Acute Care Open 2019; 4:e000307. [PMID: 31467982 PMCID: PMC6699724 DOI: 10.1136/tsaco-2019-000307] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/24/2019] [Accepted: 07/05/2019] [Indexed: 12/02/2022] Open
Abstract
Background Beta-blockers have been proven in multiple studies to be beneficial in patients with traumatic brain injury. Few prospective studies have verified this and no randomized controlled trials. Additionally, most studies do not titrate the dose of beta-blockers to therapeutic effect. We hypothesize that propranolol titrated to effect will confer a survival benefit in patients with traumatic brain injury. Methods A randomized controlled pilot trial was performed during a 24-month period. Patients with traumatic brain injury were randomized to propranolol or control group for a 14-day study period. Variables collected included demographics, injury severity, physiologic parameters, urinary catecholamines, and outcomes. Patients receiving propranolol were compared with the control group. Results Over the study period, 525 patients were screened, 26 were randomized, and 25 were analyzed. Overall, the mean age was 51.3 years and the majority were male with blunt mechanism. The mean Injury Severity Score was 21.8 and median head Abbreviated Injury Scale score was 4. Overall mortality was 20.0%. Mean arterial pressure was higher in the treatment arm as compared with control (p=0.021), but no other differences were found between the groups in demographics, severity of injury, severity of illness, physiologic parameters, or mortality (7.7% vs. 33%; p=0.109). No difference was detected over time in any variables with respect to treatment, urinary catecholamines, or physiologic parameters. Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation scores all improved over time. GCS at study end was significantly higher in the treatment arm (11.7 vs. 8.9; p=0.044). Finally, no difference was detected with survival analysis over time between groups. Conclusions Despite not being powered to show statistical differences between groups, GCS at study end was significantly improved in the treatment arm and mortality was improved although not at a traditional level of significance. The study protocol was safe and feasible to apply to an appropriately powered larger multicenter study. Level of evidence Level 2—therapeutic.
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Affiliation(s)
- Thomas J Schroeppel
- Department of Acute Care Surgery, UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
| | - John P Sharpe
- Department of Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
| | - Charles Patrick Shahan
- Department of Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
| | - Lesley P Clement
- Department of Pharmacy, UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
| | - Marilyn Lee
- Department of Pharmacy, Regional One Health, Memphis, Tennessee, USA
| | - Michael Muhlbauer
- Department of Neurosurgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
| | - Jordan A Weinberg
- Department of Surgery, Dignity Health Medical Group Arizona, Phoenix, Arizona, USA
| | - Elizabeth A Tolley
- Department of Preventative Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
| | - Timothy C Fabian
- Department of Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
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Meiler C, Muhlbauer M, Johann M, Hartmann A, Schnabl B, Wodarz N, Schmitz G, Scholmerich J, Hellerbrand C. Different effects of a CD14 gene polymorphism on disease outcome in patients with alcoholic liver disease and chronic hepatitis C infection. World J Gastroenterol 2005; 11:6031-7. [PMID: 16273620 PMCID: PMC4436730 DOI: 10.3748/wjg.v11.i38.6031] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Clinical and experimental data suggest that gut-derived endotoxins are an important pathogenic factors for progression of chronic liver disease. Recently, a C-T (-159) polymorphism in the promoter region of the CD14 gene was detected and found to confer increased CD14 expression and to be associated with advanced alcoholic liver damage. Here, we investigated this polymorphism in patients with less advanced alcoholic liver disease (ALD) and chronic hepatitis C virus (HCV) infection.
METHODS: CD14 genotyping was performed by PCR-RFLP analysis in (a) 121 HCV patients, (b) 62 patients with alcohol-associated cirrhosis (Alc-Ci), (c) 118 individuals with heavy alcohol abuse without evidence of advanced liver damage (Alc-w/o Ci), and (d) 247 healthy controls. Furthermore, serum levels of soluble CD14 (sCD14) and transaminases were determined.
RESULTS: The TT genotype was significantly more frequent in Alc-Ci compared to Alc-w/o Ci or controls (40.3% vs 23.7% or 24.0%, respectively). In Alc-w/o Ci, serum levels of transaminases did not differ significantly between patients with different CD14 genotypes. In HCV patients, TT-homozygotes had significantly higher sCD14 levels and sCD14 serum levels were significantly higher in patients with advanced fibrosis or cirrhosis. However, no association was found between CD14 genotypes and histological staging or grading.
CONCLUSION: Considering serum transaminases as surrogate markers for alcoholic liver damage, the CD14 polymorphism seems to exhibit different effects during the course of ALD. Differences in genotype distribution between cirrhotic HCV patients and alcoholics and the known functional impact of this polymorphism on CD14 expression levels further indicate differences in the pathophysiological role of CD14 and CD14-mediated lipopolysaccharides signal transduction with regard to the stage as well as the type of the underlying liver disease.
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Affiliation(s)
- C Meiler
- Department of Internal Medicine I, University of Regensburg, Regensburg D-93042, Germany
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Junge RE, Muhlbauer M, Haines V, West G. Clinical challenge. Transitional vertebra at the lumbosacral junction. J Zoo Wildl Med 2002; 33:87-8. [PMID: 12216802 DOI: 10.1638/1042-7260(2001)033[0087:tviarl]2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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7
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Muhlbauer M, Pfisterer W, Eyb R, Knosp E. Minimally invasive retroperitoneal approach for lumbar corpectomy and reconstruction. Technical note. Neurosurg Focus 1999; 7:e4. [PMID: 16918209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Anterior decompressive surgery with spinal fusion is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgical approach-related trauma. The purpose of this study was to show that lumbar corpectomy and spinal reconstruction can be performed via a minimally invasive retroperitoneal (MIR) approach and therefore, the surgical approach-related trauma can be reduced. The hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59-76 years) who underwent lumbar corpectomy and spinal fusion via an MIR approach were studied retrospectively. Four patients presented with osteoporotic compression fractures at L-2 and L-3 and one patient with metastatic disease at L-4 from prostate cancer. In all patients neurological deficits due to cauda equina compression were demonstrated. The MIR approach provided excellent exposure to facilitate complete spinal decompression and reconstruction in all patients, as verified on follow-up x-ray studies. All patients improved clinically. A 1-year follow-up record, available for four patients, showed evidence of continuing clinical improvement and, radiographically, a solid fusion or a stable compound union and anatomically correct reconstruction. The MIR approach allows anterior lumbar spine surgery to be performed less invasively. The efficacy and safety of this technique compared with the conventional retroperitoneal approach to lumbar spine surgery should be further investigated in a larger series.
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Affiliation(s)
- M Muhlbauer
- Departments of Neurosurgery and Orthopaedic Surgery, Donauspital SMZ-Ost, Vienna, Austria
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8
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Abstract
BACKGROUND Radiation-induced necrosis (RIN) of the brain is a complication associated with the use of aggressive focal treatments such as radioactive implants and stereotactic radiosurgery. In an attempt to treat patients with central nervous system (CNS) RIN, ten patients received hyperbaric oxygen treatment (HBOT). METHODS Patients presented with new or increasing neurologic deficits associated with imaging changes after radiotherapy. Necrosis was proven by biopsy in eight cases. HBOT was comprised of 20-30 sessions at 2.0 to 2.4 atmospheres, for 90 minutes-2 hours. Sites of RIN included the brain stem (n = 2), posterior fossa (n = 1), and supratentorial fossa (n 7). Histologic types included brain stem glioma (n = 2), ependymoma (n = 2), germinoma (n = 2), low grade astrocytoma (n = 1), oligodendroglioma (n = 1), glioblastoma multiforme (n = 1), and arteriovenous malformation (n = 1). RESULTS Initial improvement or stabilization of symptoms and/or imaging findings were documented in all ten patients studied and no severe HBOT toxicity was observed. Four patients died, with the cause of death attributed to tumor progression. Five of six surviving patients were improved by clinical and imaging criteria; one patient was alive with tumor present at last follow-up. CONCLUSIONS HBOT may prove to be an important adjunct to surgery and steroid therapy for CNS RIN.
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Affiliation(s)
- P J Chuba
- Department of Radiation Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan 48236, USA
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9
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Gajjar A, Sanford RA, Heideman R, Jenkins JJ, Walter A, Li Y, Langston JW, Muhlbauer M, Boyett JM, Kun LE. Low-grade astrocytoma: a decade of experience at St. Jude Children's Research Hospital. J Clin Oncol 1997; 15:2792-9. [PMID: 9256121 DOI: 10.1200/jco.1997.15.8.2792] [Citation(s) in RCA: 143] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To evaluate the impact of primary tumor site, age at diagnosis, extent of resection, and histology on progression-free survival (PFS) in pediatric low-grade astrocytoma. PATIENTS AND METHODS Medical, pathologic, and imaging information were reviewed for 142 children (ages 2 months to 19 years) with low-grade astrocytoma treated between January 1984 and July 1994. Gross total resection (GTR) was attempted for cerebellar and cerebral hemisphere tumors, with biopsy or less aggressive resection used predominantly for tumors in other sites. Surgery was followed by observation in 107 cases, radiation therapy in 31, and chemotherapy in four. RESULTS The overall survival rate was 90% +/- 3% (SE) at 4 years. PFS was significantly better for patients with cerebellar and cerebral hemisphere tumors (n = 75) than those with tumors in all other sites (P = .0006). Within the former group, there was no significant difference in PFS for patients in whom GTR was achieved versus those with incomplete resections (4-year estimates, 89% and 77%, respectively). Histology (juvenile pilocytic v astrocytoma not otherwise specified [NOS]) was not related to PFS in an analysis that controlled for tumor site and patient age. Patients younger than 5 years at diagnosis had a significantly poorer PFS than older children, regardless of histology (P < .03) or tumor site (P < .002). Treatment for progressive/recurrent disease was effective in a majority of patients, but appeared more successful in patients with hemispheric than thalamic or hypothalamic tumors. CONCLUSION The overall survival in this series of pediatric low-grade astrocytomas is excellent. Age at diagnosis and tumor location, but not histology, had a significant impact on PFS. Efforts to improve treatment outcome should focus on young patients (< 5 years) and on those with central midline tumors. The majority of patients with completely resected hemispheric tumors were monitored without further therapy, which supports attempted GTR of cerebral and cerebellar hemisphere low-grade astrocytoma.
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Affiliation(s)
- A Gajjar
- St Jude Children's Research Hospital/Le Bonheur Children's Medical Center Brain Tumor Team, Memphis, TN 38105-2794, USA.
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10
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Aggarwal R, Yeung D, Kumar P, Muhlbauer M, Kun LE. Efficacy and feasibility of stereotactic radiosurgery in the primary management of unfavorable pediatric ependymoma. Radiother Oncol 1997; 43:269-73. [PMID: 9215786 DOI: 10.1016/s0167-8140(97)01926-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Stereotactic radiosurgery was given as a boost in the initial radiation management of five children with localized intracranial ependymoma. Preliminary results in young children with high-risk tumors indicate good local control without excessive neurotoxicity.
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Affiliation(s)
- R Aggarwal
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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11
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Gajjar A, Sanford RA, Bhargava R, Heideman R, Walter A, Li Y, Langston JW, Jenkins JJ, Muhlbauer M, Boyett J, Kun LE. Medulloblastoma with brain stem involvement: the impact of gross total resection on outcome. Pediatr Neurosurg 1996; 25:182-7. [PMID: 9293545 DOI: 10.1159/000121121] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We studied the impact of gross total resection on progression-free survival (PFS) and postoperative morbidity in 40 children with locally advanced medulloblastoma characterized by tumor invading the brain stem. These patients represented 40% of children treated for newly diagnosed medulloblastoma at a pediatric oncology center over a 10-year period. All patients underwent aggressive initial surgical resection. Review of surgical and neuroimaging findings documented gross total resection in 13 cases, near-total resection (< 1.5 cm2 residual tumor on imaging) in 14 cases, and subtotal resection (> than 50% resection with > or = 1.5 cm2 residual) in 13 cases. Overall, 85% of patients had a > 90% resection. Subsequent therapy comprised craniospinal irradiation in all cases and chemotherapy on institutional or cooperative group protocols in 35 cases. At a median follow-up of 4 years, postirradiation PFS is 61% (SE = 10%). There was no difference in PFS for patients who underwent gross total resection compared to those with any detectable residual tumor (p > 0.70). The posterior fossa syndrome occurred in 25% of cases, and had no apparent relationship to the extent of resection (p > 0.5, exact test). In this series, true gross total resection was not associated with a PFS advantage when compared to strictly defined near-total and subtotal resection. Although there was no operative mortality, the frequency of the posterior fossa syndrome is of concern and emphasizes the need for careful consideration of the risk/benefit ratio in the surgical approach to this subgroup of patients.
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Affiliation(s)
- A Gajjar
- Le Bonheur Children's Medical Center, Brain Tumor Team, Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, TN 38101-0318, USA.
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Kun LE, Gajjar A, Muhlbauer M, Heideman RL, Sanford R, Brenner M, Walter A, Langston J, Jenkins J, Facchini S. Stereotactic injection of herpes simplex thymidine kinase vector producer cells (PA317-G1Tk1SvNa.7) and intravenous ganciclovir for the treatment of progressive or recurrent primary supratentorial pediatric malignant brain tumors. Hum Gene Ther 1995; 6:1231-55. [PMID: 8527482 DOI: 10.1089/hum.1995.6.9-1231] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
This study will evaluate the safety and efficacy of in vivo gene transfer of the herpes simplex thymidine kinase (HSV-Tk1) gene using PA317/G1Tk1SvNa.7 vector producer cells (VPC) in pediatric patients with progressive or recurrent primary supratentorial malignant brain tumors. Insertion of the HSV-Tk1 gene confers a sensitivity to the anti-herpes drug ganciclovir. It has been demonstrated that the direct injection of HSV-Tk vector producer cells into growing tumors in animals can result in their complete destruction with ganciclovir therapy. This selective destruction of growing tumors in situ is thought to result from the transfer of the HSV-Tk gene into the tumor cells and the production of toxic ganciclovir metabolites which result from the interaction of HSV-Tk and ganciclovir. This procedure can result in the cure of some experimental animals with limited systemic toxicity due to selective gene transfer into tumors. This clinical trial will focus on maximizing the relative number of vector producer cells to the tumor mass by stereotactically injecting VPCs into the tumor mass. Children with progressive or recurrent primary supratentorial malignant brain tumor which is accessible to stereotactic injection will be evaluated for the extent and location(s) of their disease before being entered into the study. Fifteen days after stereotactic injection of the tumor mass, ganciclovir will be administered at 5 mg/kg IV b.i.d. for 14 days. Upon completion of the treatment with HSV-Tk1 vector producer cells and ganciclovir, the patient will be followed monthly for the first three months, then every two months for the next twenty-one months, and annually for life thereafter.
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Affiliation(s)
- L E Kun
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee 38101-0318, USA
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Muhlbauer M, Saringer W, Aichholzer M, Sunder-Plassmann M. Microsurgical anterior decompression and internal fixation with iliac bone graft and titanium plates for treatment of cervical intervertebral disc herniation. Acta Neurochir (Wien) 1995; 134:207-13. [PMID: 8748783 DOI: 10.1007/bf01417691] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
42 cervical interbody fusions with iliac bone graft and titanium plate fixation were performed between October 1991 and March 1994. The mean follow up period in this study was 10.7 months. In 32 cases fusion was done for 1 and in 10 cases for 2 segments. 2 different types of plates were used. In 25 cases micro-osteosynthesis plates and screws with 2.7 mm diameter were used, and in 17 cases cervical H-plates and screws with 3.5 mm diameter. A favourable outcome was achieved in 31 of 42 cases (74%). Satisfactory pain relief was achieved in 90%. For radicular motor deficit good results were obtained in 84% and for cervical myelopathy in 54%. The 2 different types of plates showed a remarkable difference in the clinical outcome. The results were regarded favourable in 15 of 25 microplate fusions (60%) and in 16 of 17 H-plate fusions (94%). Compression of the bone graft was seen in 5 patients of the micro plate group, however, radiological signs for fusion were present in all 42 cases at follow up. Major surgical complications, damage to neural structures or neurological deterioration did not occur in this study. Plate fixation in cervical interbody fusions seems to be a safe procedure and may reduce graft related complications at the fusion site if the plates and screws are sufficiently well proportioned. A favourable impact upon the results for cervical interbody fusion might be expected and should be further investigated in a long term follow up study.
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Affiliation(s)
- M Muhlbauer
- Department of Neurosurgery, University of Vienna Medical School, Austria
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Gajjar A, Bhargava R, Jenkins JJ, Heideman R, Sanford RA, Langston JW, Walter AW, Kuttesch JF, Muhlbauer M, Kun LE. Low-grade astrocytoma with neuraxis dissemination at diagnosis. J Neurosurg 1995; 83:67-71. [PMID: 7782852 DOI: 10.3171/jns.1995.83.1.0067] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Little is known about low-grade astrocytoma with neuraxis dissemination at diagnosis. A review of medical records identified this phenomenon in eight of 150 pediatric patients evaluated between 1985 and 1994 for histologically confirmed low-grade astrocytoma. These patients (five male and three female) ranged in age from 5 months to 20 years (median 8 years). Symptoms of neuraxis disease were minimal or absent. Primary tumor sites were the hypothalamus in four cases, brainstem/spinal cord in three, and temporal lobe in one. Patterns of dissemination (evaluated by computerized tomography and/or magnetic resonance imaging techniques) appeared to be related to the primary site: hypothalamic tumors metastasized along the ventricular cerebrospinal fluid pathways, and tumors in other locations disseminated along subarachnoid pathways. Following initial treatment with chemotherapy (in three), partial resection (in one), radiation therapy (in three), and chemotherapy plus irradiation (in one), four patients required salvage therapy for progressive or recurrent disease. Seven of the eight patients are alive with stable or progressive disease 6 to 105 months postdiagnosis (median 15 months). Low-grade astrocytoma with initial neuraxis dissemination is responsive to chemotherapy and radiation, a proportion showing periods of stable disease. The optimum therapy or combination of therapies remains unclear.
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Affiliation(s)
- A Gajjar
- St. Jude Children's Research Hospital/LeBonheur Children's Medical Center Brain Tumor Team, Memphis, Tennessee, USA
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Fontanesi J, Heideman RL, Muhlbauer M, Mulhern R, Sanford RA, Douglass EC, Kovnar E, Ochs JJ, Kuttesch JF, Tai D. High-activity 125I interstitial irradiation in the treatment of pediatric central nervous system tumors: a pilot study. Pediatr Neurosurg 1995; 22:289-97; discussion 98. [PMID: 7577662 DOI: 10.1159/000120918] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Malignant pediatric tumors of the central nervous system (CNS) have a poor prognosis, with local failure rates as high as 50%. In an attempt to improve local tumor control, we used stereotactic interstitial therapy with 125I implants in patients with recurrent/secondary or newly diagnosed CNS malignancies. Catheters were placed using computed tomography (CT) guidance; computerized dosimetry was completed with the aid of orthogonal films. Implants delivered 1,000 cGy/day to the tumor periphery (0.5 cm beyond the boundary of enhancement on CT scans), to a total dose of 60 Gy. Hyperfractionated external beam irradiation (HEBI), started 2-4 weeks after removal of implants, delivered total doses of 66-70.4 Gy in 110-cGy fractions twice daily to a 3-cm margin around the implant volume. Eight of the 11 patients with newly diagnosed tumors also received 48.4 Gy HEBI to the craniospinal axis. Tumor regression was noted at 2 months after implantation in the 4 patients treated for recurrent/secondary tumors; local progression was subsequently documented in 2 cases at 6 and 20 months after implantation, while a third patient died 6 months after implantation with no evidence of local recurrence. The remaining recurrent/secondary tumor patient has no evidence of active recurrence 15 months after implantation. Local control was maintained in 9 of the 11 patients treated for primary tumors for a median of 27 months (range 15 to 48+ months). The two local failures occurred at 5 and 7 months after implantation. Six patients are alive without evidence of progressive disease (median = 23 months after implantation). There were no severe acute toxicities, but 7 patients later developed histologically confirmed tumor necrosis. Quality of life assessment (QLA) following initial primary therapy with implantation was evaluated utilizing an established criteria and found to be excellent with only one child showing marked QLA score decrease which was related to neurosurgical intervention for radiation-induced necrosis and dysfunctional family social situation. This small series suggests that stereotactic 125I implantation followed by HEBI merits further evaluation in selected children with supratentorial malignant lesions.
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Affiliation(s)
- J Fontanesi
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tenn., USA
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Abstract
Endogenous opioid receptoractive peptides in the cerebrospinal fluid (CSF) of human controls and in those patients diagnosed as having senile dementia of the Alzheimer's type (SDAT) are measured with a radioreceptorassay following HPLC separation. [3H]Etorphine is the ligand used to detect in the HPLC fractions the presence of those endogenous peptides that preferentially interact with several opioid receptors. The RRA uses a receptor-rich P2 fraction extracted from a canine limbic system. The total opioid peptide content found in the HPLC fractions 6-20 (to avoid salts in fractions 1-5) of SDAT CSF (383 +/- 187 pmol ME-equivalents per ml CSF) is significantly higher than the corresponding total from patients with no known neurological disorders (89.1 +/- 46.3 pmol ME-equivalents per ml).
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Affiliation(s)
- M Muhlbauer
- Department of Neurosurgery, University of Tennessee-Memphis 38163
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Ross ED, Muhlbauer M. Speed of movement, gravity, and the neural coordination of muscular actions. Electromyogr Clin Neurophysiol 1983; 23:385-92. [PMID: 6884268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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