Endonasal endoscopic repair of cerebrospinal fluid leaks versus craniotomy: comparison of the outcomes

BACKGROUND

Cerebrospinal fluid (CSF) leaks have been traditionally managed via craniotomy with an intradural repair. The endonasal endoscopic approach represents a minimally invasive alternative. This study aimed to compare the outcomes of the two methods.

CASE SERIES

This is a prospective case series of 18 consecutive patients who underwent endonasal repair of a CSF leak. Thirteen variables were evaluated during the study, including age, gender, body mass index, site of the defect, CSF leak etiology, days of hospitalization, use of lumbar drainage, the success of repair, complications, recurrence, duration, and cost of surgery as well as patient satisfaction. The outcomes were compared with a historical cohort of 25 patients treated for CSF leaks with a craniotomy. Though we found no significant difference in the success of the repair, the endoscopic group had a significantly shorter duration of the procedure and hospitalization, a lower rate of complications, lower cost, and higher patient satisfaction.

CONCLUSION

The presented data further solidify the endoscopic approach as the preferred method to address CSF leaks located in the anterior and middle skull base in cases not associated with complex intracranial pathology. Hippokratia 2016, 20(4): 299-302.

Long-term outcome after implantation of prosthetic disc nucleus device (PDN) in lumbar disc disease

BACKGROUND

The prosthetic disc nucleus (PDN) device offers an adjunct treatment for patients with degenerative disc disease and herniation, who necessitate surgical intervention, avoiding total-disc replacement or fusion. This prospective, clinical study aimed to gauge the long-term effectiveness of microdiscectomy followed by PDN implantation in relieving pain and improving functional status in patients with symptomatic degenerative lumbar disc disease and herniation.

METHODS

Ten patients with a) at least 6 months low back pain and/or sciatica resistant to conservative treatment and b) radiologically documented degenerative lumbar disc disease and herniation have been selected. Follow-up at 6 weeks, 3, 12, 48, and 96 months postoperatively included physical examination, radiological investigation (plain and dynamic radiographs and magnetic resonance imaging), and self-completion of outcome scales (visual analogue, Oswestry, and Prolo functional status). Short Form-36 version 2 Health Survey patient profile at 96 months completed the image of health related quality of life.

RESULTS

Patients' mean follow-up was 100.6 months. Significant improvements in Oswestry, Prolo, and VAS scores were documented (p: 0.004 in all scales at 48 months). Generic health status was rated within the average lumbar disease population (46.36.8 for physical component summary and 45.29.6 for mental component summary). Lumbar spine range of motion (20.211.8 at 96 months) was restricted in relation to normal, but maintained considerable mobility. Treated disc height increased postoperatively (p:0.002) and its maintenance could also be documented in all cases. Disc height at the level above did not show any significant modification. All postoperative MRI showed a non-clinically significant high signal of end-plate on T2 sequences. Clinically relevant complications included one case of pulmonary thrombosis and one case of device extrusion, which was subsequently explanted.

CONCLUSIONS

After implantation, most patients continue to enjoy significant pain relief, a considerable amount of mobility is conserved and the disease specific functional outcome is excellent and remains for long, although it could not be supported that the generic health related quality of life is that of the general population.

Abstract 791: Low DARPP32 and related profiles in glioblastomas

DARPP32 (PPP1R1B, an inhibitor of protein phosphatase-1) plays a central role in dopamine signalling in the brain and has been associated with a number of diverse conditions, ranging from nicotine dependence to cancer drug resistance, while its overexpression has been reported as pro-oncogenic in various epithelial cancers. Since data on this molecule in astrocytic carcinogenesis are missing, this study focused on DARPP32 expression and related profiles in astrocytic gliomas. In a panel of 157 routinely diagnosed astrocytic glioma tissues we assessed (i) relative expression of DARPP32 along with 21 additional transcript targets from key regulators in signalling pathways commonly disturbed in glioblastomas (GBM), (ii) genomic status of selected genes and (iii) activation status of the Akt and Stat pathways. Normal brain tissues expressed DARPP32 at considerable levels. In comparison, the expression of this molecule was strongly decreased (low = decrease of >1 order of magnitude) according to histological grade, more frequently in grade IV (GBM, 89/116 [77%]) than in grade III (11/22 [50%]) and grade II (4/19 [21%]) tumors (p<0.0001). Low DARPP32 was associated with EGFR gene amplification (p=0.0006) and mRNA/protein overexpression; high pro-angiogenic VEGF isoform (p=0.0002) and hTERT expression (p=0.0008); low SRC/STAT expression (STAT3, 5A and 5B p's<0.0001) but common Stat3 (p=0.0003) and Akt/PKB phosphorylation (p=0.0036). Two specific Akt deactivating phosphatases, PHLPP2 and PHLPP1 were also identified to be downregulated/absent in GBM (63% and 23%, respectively), in line with their proposed tumor suppressor role. Strikingly, low expression of these two genes almost coincided with low DARPP32, with strongly decreased DARPP32/PHLPP2 and DARPP32/PHLPP2/PHLPP1 in 54% and 17.2% of GBMs, respectively. In 66 out of the 116 GBM patients with known follow-up, this latter profile was associated with a slightly better survival (log rank, p=0.0496); all corresponding tumors had activated Akt-Thr308 but lacked EGFR/EGFRvIII, MET, SRC, STATs, TERT (12/12), and VEGF isoform (8/12) overexpression, and 12q gene amplification (10/12). In conclusion, DARPP32 expression is strongly decreased in high grade astrocytic tumors where, in contrast to what has been described for common epithelial cancers, low DARPP32 seems to be related to pro-oncogenic and adverse prognostic parameters. This study also demonstrates that, except for PTEN, additional phosphatases regulating Akt signalling are commonly missing in GBM, mostly in parallel with low DARPP32. Further dissecting the molecular environment accompanying the decreased expression of these genes seems important for understanding the behaviour of this highly heterogeneous group of tumors.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 791.

Primary extracerebral meningeal glioblastoma: clinical and pathological analysis

Primary meningeal gliomas are uncommon tumors in the subarachnoid space, their primary characteristic being the absence of any obvious connection to the brain parenchyma. Rarely, they are quite malignant and assume a bulky, well circumscribed appearance rendering the differential diagnosis from other CNS neoplasms difficult. A 53-year-old man presented with a history of persistent headaches and left sided weakness. Magnetic resonance imaging revealed a temporoparietal mass attached to the dura that strongly resembled a meningioma. At surgery, the outer layer of the dura mater was intact and there was a clear brain-tumor interface without obvious pial disruption. Histological examination showed a biphasic pattern consisting of benign connective tissue intermingled with bundles of what seemed to be a glioblastoma. The mass demonstrated strong positivity for GFAP and the MIB labeling index focally exceeded 20%. The tumor was identified as a primary meningeal glioblastoma. The patient was disease-free for 42 months, after which he developed a recurrence for which he was re-operated. This time, the pathological findings of the tumor were those of a typical glioblastoma multiforme. We discuss the origin of the initial neoplasm and also the differential diagnosis that needs to include meningioma, aggressive glioblastoma infiltrating the dura and a recently recognized bimorphic CNS tumor: the desmoplastic glioblastoma.

Phase II study of neoadjuvant imatinib in glioblastoma: evaluation of clinical and molecular effects of the treatment

PURPOSE

Phase I-II studies indicate that imatinib is active in glioblastoma multiforme. To better understand the molecular and clinical effects of imatinib in glioblastoma multiforme, we conducted a neoadjuvant study of imatinib with pretreatment and posttreatment biopsies.

EXPERIMENTAL DESIGN

Patients underwent a computerized tomography-guided biopsy of their brain tumors. If diagnosed with glioblastoma multiforme, they were immediately treated with 7 days of imatinib 400 mg orally twice daily followed by either definitive surgery or re-biopsy. Pretreatment and posttreatment tissue specimens were tested by immunohistochemistry for Ki67 and microvessel destiny, and posttreatment specimens were analyzed for the presence of intact imatinib in tissue. Furthermore, pretreatment and posttreatment pairs were analyzed by Western blotting for activation of platelet-derived growth factor receptor, epidermal growth factor receptor (EGFR), phosphoinositide 3-kinase/AKT, and mitogen-activated protein kinase signaling pathways. Pharmacokinetic studies were also done.

RESULTS

Twenty patients were enrolled. Median survival was 6.2 months. Intact imatinib was detected in the posttreatment tissue specimens using mass spectrometry. There was no evidence of a drug effect on proliferation, as evidenced by a change in Ki67 expression. Biochemical evidence of response, as shown by decreased activation of AKT and mitogen-activated protein kinase or increased p27 level, was detected in 4 of 11 patients with evaluable, matched pre- and post-imatinib biopsies. Two patients showed high-level EGFR activation and homozygous EGFR mutations, whereas one patient had high-level platelet-derived growth factor receptor-B activation.

CONCLUSIONS

Intact imatinib was detected in glioblastoma multiforme tissue. However, the histologic and immunoblotting evaluations suggest that glioblastoma multiforme proliferation and survival mechanisms are not substantially reduced by imatinib therapy in most patients.

Biochemical evidence of tumor response and measurable levels of the drug in glioblastoma tissue from patients treated with imatinib

2023

Background: Glioblastoma multiforme (GBM) carries a grave prognosis. There are phase I-II studies indicating that imatinib is active in GBM in pre-treated patients. To better understand the molecular basis of imatinib’s activity in this disease we performed a pharmacodynamic neoadjuvant study with imatinib in GBM. Methods: Patients underwent CT guided biopsy of their brain tumors. If diagnosed with GBM they were immediately treated with 7 days of imatinib 400mg po BID followed by either definitive surgery or, if that was not feasible, followed by re-biopsy. Corticosteroid dose was stable during this period and valproic acid was the only anti-epileptic drug allowed in order to avoid pharmacokinetic interaction with imatinib. Treatment after recovery was as per usual institutional policy. Pre and post treatment tissue specimens were analyzed by immunohistochemistry, proteomic technology and molecular biological methods. Pharmacokinetic studies were also performed. Results: Twenty patients were enrolled in 2 institutions with a median age of 64, of which 14 were male and 6 female. PS was 0 in 2, 1 in 9 and 2 in 9. Seventeen patients had pure GBM, 2 had mixed GBM with astrocytoma and one had anaplastic astrocytoma. Eighteen patients had stable disease on pre and post treatment MRI, one had progressed and one was not evaluable. Median survival was 6.2 months (1.1–18mo). Intact imatinib was quantified in the post treatment tissue specimens and correlations were made with serum imatinib levels per patient. No correlation was seen. Tissue specimens were analyzed by in situ MALDI mass spectroscopy and differential protein expression profiles were detected, when pre and post treatment specimens were compared. The identification of candidate proteins is ongoing. In 11 patients with evaluable, high-quality, matched pre and post imatinib biopsies, 4 had biochemical evidence of tumor response (decreased AKT or MAPK, or increased p27). In addition, 2 patients showed high-level EGFR activation, and one patient had high-level PDGFR activation. Conclusions: Treatment of GBM patients with imatinib results in measurable levels of the drug in the tumor. Potential indicators of biochemical response in a subset of patients were identified.

No significant financial relationships to disclose.

Laparoscopic Placement of Ventriculoperitoneal Shunts: An Innovative Simplification of the Existing Techniques

Ventriculoperitoneal shunting (VPS) remains one of the alternative choices for the surgical treatment of hydrocephalus. During the last two decades laparoscopy has been utilized to facilitate the placement of the abdominal portion of the shunt. We describe a minimally invasive laparoscopic technique, which facilitates the rapid, safe and direct placement of the peritoneal component of the VPS. A side frontal ventricular catheter is placed through a small burr hole and connected to the valve at the postauricular region. An infra-umbilical trocar is placed, using the Hasson technique, and after the pneumoperitoneum is established, a 10-mm laparoscope is introduced for identification of a VPS entry side free of adhesions. A 5-mm skin incision is made at the decided point of catheter insertion, usually at the right upper quadrant. Using a tunneler, the VPS catheter is placed subcutaneously from abdomen insertion point, to the postauricular region, where it is connected to the valve. A split type, 10-12 Fr and 12-15 cm long metallic puncture cannula, like those used for suprapelvic percutaneous bladder drainage, is introduced into the abdomen. Under direct laparoscopic vision the peritoneal portion of the VPS is passed into the abdomen through the cannula. The catheter is leaded to a desirable location by pointing the needle accordingly. Alteration of the position of the catheter can also be attained by entraining the catheter with the laparoscope and without using auxiliary graspers. The function of the VPS is confirmed under direct visualization. Suturing the abdominal and cranial incisions completes the procedure. We used this technique in a series of 12 patients with excellent outcome. There were no intra- or postoperative complications and no mortalities. Our technique is less invasive than a minilaparotomy, embraces all laparoscopic benefits and does not require auxiliary forceps or guidewires. It uses easy available materials with low cost, and attains an easy, rapid, and safe placement of the abdominal portion of the VPS.

Intracranial aneurysms: evaluation using CTA and MRA. Correlation with DSA and intraoperative findings

Computed tomographic angiography (CTA) and magnetic resonance angiography (MSA) have been used recently for evaluation of intracranial aneurysms. If they are to replace conventional digital subtraction angiography (DSA), their sensitivity and specificity should be equal to the latter. In order to determine whether computed tomographic angiography and magnetic resonance angiography can provide the necessary information for presurgical evaluation we compared blindly the results of helical CT angiography and MR angiography with the results of digital subtraction angiography and the intraoperative findings. We evaluated 35 patients with the possible clinical diagnosis of intracranial aneurysm. Our data suggest that both CTA and MRA can provide valuable preoperative information concerning the location, the characteristics and the relationships of most intracranial aneurysms. Both original and reconstructed images should be evaluated together for higher accuracy. In addition helical CT, being a fast, inexpensive and noninvasive method, can be used as a reliable alternative to DSA in emergency situations demanding immediate operation.

Fusiform aneurysm of the posterior cerebral artery: report of two cases

Two cases with fusiform aneurysm in the posterior cerebral artery are presented: The first one is a large fusiform aneurysm of the P(2) segment of posterior cerebral artery (PCA) in a 58 years old patient and the second a fusiform aneurysm of the P(3) segment of PCA in a 43 years old patient. The aneurysms were successfully treated the first by proximal ligation and the second by trapping of the aneurysm. The patients had no additional neurological deficits postoperatively and they are in an good condition, in four years and one year follow up respectively. The operative approaches and the radiological investigation in relation to the micro-anatomy of the posterior cerebral artery, as well as the outcome in these cases are discussed.

Radiation and concomitant weekly administration of paclitaxel in patients with glioblastoma multiforme. A phase II study

The present study was conducted to evaluate the activity and toxicity profile of radiation (RT) and concomitant chemotherapy in patients with glioblastoma multiforme (GBM). Thirty-nine patients were treated postoperatively with RT and concomitant administration of paclitaxel. Cranial irradiation was initiated 2-3 weeks postoperatively and was administered in 2.0 fractions, one fraction per day, for 5 consecutive days per week, to a total of 60 Gy. Paclitaxel was delivered at a dose of 100 mg/m2 over 3-h once weekly for 6 weeks. Thirty-three patients received all 6 cycles of paclitaxel according to the protocol. Totally, 217 cycles were delivered all of them at full dose. The median relative dose intensity of paclitaxel was 1 (range 0.88-1.1). Three (7.5%) patients achieved complete and 9 (23%) partial response, while 12 (30.5%) patients demonstrated stabilization of the disease. Side effects from combined chemoradiotherapy were mainly mild. Grade III toxicity included infection (7.5%) and alopecia (5%). Median time to progression was 6 (range 0.9-27) months and median survival 10.7 (range 0.9-39.5+) months. The present study has clearly shown that 100 mg/m2 of paclitaxel in 1-h infusion weekly can be safely given concomitantly with RT in patients with GBM with manageable toxicity. However, the efficacy of this combined modality treatment does not appear to be superior to that of RT alone.

Concurrent radiation and intracarotid cisplatin infusion in malignant gliomas: a feasibility study

Twenty-two patients with supratentorial malignant gliomas were treated postoperatively with concurrent intracarotid chemotherapy and radiation therapy. There were seven women and 15 men with a median age of 56 years (range, 22-69) and median performance status (Karnofsky score) of 70 (range, 40-90). In all except two cases, histologic studies confirmed malignant glioma. All patients were irradiated with a cobalt 60 equipment. They should have received 45 Gy to the whole brain plus a 15-Gy coned-down boost to the tumor area. Chemotherapy consisted of cisplatin infusion at a dose of 60 mg/m2 on days 2, 22, and 42. Treatment was interrupted in two patients because of progressive disease and voluntary withdrawal in one patient each. In all, 63 courses of cisplatin infusion were administered, all at full dose. Two patients achieved a partial response, and nine had stable disease. Toxicities included nausea/vomiting in nine patients (41%) and transient hemiparesis, confusion, diarrhea, and thrombophlebitis in one patient each. Median time to progression was 26 weeks (range, 4-226+), and median survival was 58 weeks (range, 14-226+). In conclusion, the present study suggests that intracarotid cisplatin administered concurrently with radiation does not improve the therapeutic index in malignant gliomas.

Intraventricular administration of morphine for control of intractable cancer pain in 90 patients

OBJECTIVE

To quantitate the relief of intractable cancer pain by the use of intraventricular morphine administration.

METHODS

Intraventricular morphine administration was performed through an Ommaya reservoir. An initial dose of 0.25 mg of morphine sulfate per 24 hours was administered to all of the patients. This dose was progressively increased in 0.25-mg increments until optimal analgesia was attained.

RESULTS

Sixty men and 30 women with a median age of 58 years (range, 23-80 yr) entered the study. The median duration of pain was 6 months (range, 0.5-120 mo). A daily morphine dose of up to 1 mg was adequate to achieve an analgesic effect in 77% of the patients. Only nine patients (10%) achieved < 50% pain relief. Using a multiple regression analysis, only the morphine dosage was found to be an independent prognostic factor. The most frequent side effect (22%) was nausea/vomiting. Also, there were two patients with opioid intolerance and two with intracerebral hematomas. Three reservoirs failed.

CONCLUSION

Intraventricular morphine administration is a useful method for palliation of intractable cancer pain.

Primary angiosarcoma of the brain: case report

A 41-year-old patient with a primary angiosarcoma of the brain is reported. The tumor was located in the left parietal lobe and was radically removed. The diagnosis of angiosarcoma was established by immunohistochemistry. The patient was postoperatively treated with adjuvant chemotherapy and then radiation therapy. After 41 months, she was in excellent clinical and neurological condition without any sign of recurrence.

Aneurysm of the vermian branch of the superior cerebellar artery

We report a case of an aneurysm originated from a vermian branch of the superior cerebellar artery. The aneurysm located in the precerebellar space of the tegmentum was successfully clipped via a transoccipital transtentorial approach.

Symptomatic trigeminal neuralgia

In four cases with trigeminal neuralgia an intracranial neoplasm was detected. In the first two cases a meningioma of the cerebellopontine angle was producing symptomatic trigeminal neuralgia almost identical to the essential one. In the other two cases with a tumor in the gasserian ganglion area the facial pain was of a more atypical nature. In all four cases associated sensory trigeminal deficits were present. The causative factors which may produce symptomatic trigeminal neuralgia are especially discussed in this paper.