Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: A systematic review

Background

Stereotactic radiosurgery (SRS) has recently gained space as an accepted non-invasive alternative treatment option for drug resistant Glossopharyngeal neuralgia (GPN). The purpose of this systematic review was to provide an overview of the outcomes of SRS treatment in patients with GPN.

Methods

A literature review until March 2023 was performed. Data about patient's demographics, complications and recurrence rates, additional treatment post procedure as well as pain outcomes in the short and long term were collected. Studies without reported pain outcomes were excluded.

Results

Sixteen studies with a total of 97 patients diagnosed with GPN who had undergone SRS were identified. The mean reported maximal radiation dose ranged from 70 to 88.7 Gy with the glossopharyngeal meatus (GPM) being the most common target in 12/16 studies. The median time from SRS till pain response was between 2 and 120 days. The mean proportion of patients requiring further treatment after SRS ranged from 11.1 to 57.14% in a time frame between 2 and 36 months post procedure. Favourable pain response rates after SRS (BNI-IIIb) ranged from 60% to 100% and 57.1%-100% in short and long term respectively.

Conclusion

SRS for GPN remains a safe alternative to surgery with low complication rates and favourable pain outcomes in both short and long term.

Novel concepts in the pathogenesis of hydrocephalus

PURPOSE

Hydrocephalus is a multifactorial neurological disorder and one of the most common neurosurgical conditions characterized by excessive cerebrospinal fluid (CSF) accumulation within the brain's ventricles. It can result in dilatation of the ventricular system caused by the inadequate passage of CSF from its point of production within the ventricles to its point of absorption into the systemic circulation. Recent findings on the genetics and molecular studies of hydrocephalus have the potential to improve treatment and quality of life.

METHODS

Review of literature on the novel studies of the pathogenesis of hydrocephalus.

CONCLUSION

Molecular studies on the pathogenesis of hydrocephalus have provided a means to improve the treatment and follow-up of patients with hydrocephalus.

Advances in Intraoperative Flow Cytometry

Flow cytometry is the gold-standard laser-based technique to measure and analyze fluorescence levels of immunostaining and DNA content in individual cells. It provides a valuable tool to assess cells in the G0/G1, S, and G2/M phases, and those with polyploidy, which holds prognostic significance. Frozen section analysis is the standard intraoperative assessment for tumor margin evaluation and tumor resection. Here, we present flow cytometry as a promising technique for intraoperative tumor analysis in different pathologies, including brain tumors, leptomeningeal dissemination, breast cancer, head and neck cancer, pancreatic tumor, and hepatic cancer. Flow cytometry is a valuable tool that can provide substantial information on tumor analysis and, consequently, maximize cancer treatment and expedite patients’ survival.

Near-Complete Remission of Glioblastoma in a Patient Treated with an Allogenic Dendritic Cell-Based Vaccine: The Role of Tumor-Specific CD4+T-Cell Cytokine Secretion Pattern in Predicting Response and Recurrence

Immunotherapy has brought hope to the fight against glioblastoma, but its efficacy remains unclear. We present the case of CST, a 25-year-old female patient with a large right-hemisphere glioblastoma treated with a dendritic-tumor cell fusion vaccine. CST showed a near-complete tumor response, with a marked improvement in her functional status and simultaneous increases in tumor-specific CD8+ and CD4+ T cells. Two months before recurrence, the frequency of tumor-specific T cells decreased, while that of IL-17 and CD4+ T cells increased. CST passed away 15 months after enrollment. In this illustrative case, the tumor-specific CD4+ T-cell numbers and phenotype behaved as treatment efficacy biomarkers, highlighting the key role of the latter in glioblastoma immunotherapy.

Estudo epidemiológico das fraturas de coluna em centro de referência para patologia espinhal no Paraná

Objetivo: Realizar um estudo epidemiológico das fraturas de coluna ocorridas no período de março de 2007 até dezembro de 2011 em um centro de referência para patologia espinhal. Métodos: Análise retrospectiva dos prontuários de pacientes submetidos a tratamento neurocirúrgico para artrodese da coluna vertebral por causa de patologia traumática, realizada de março de 2007 até dezembro de 2011. Os dados foram compilados a partir do setor de arquivo médico do Hospital Universitário Evangélico de Curitiba (HUEC). Os elementos encontrados foram analisados observando-se as variáveis idades, sexo, o nível e a vértebra mais acometida. Resultados: Dos 104 pacientes submetidos a tratamento neurocirúrgico visando à artrodese por causa de fratura de coluna, houve uma predominância considerável do sexo masculino, com 73,07% (76). A média de idade na data do procedimento cirúrgico foi de 38,08 anos. A idade mínima registrada foi de12 anos e a máxima, de 73 anos. Houve predomínio das fraturas em coluna lombar de 59,61% (62) dos casos. O corpo de L1 foi mais acometido (30,76%). Conclusão: Há escassez de trabalhos epidemiológicos no que se refere à patologia traumática da coluna vertebral. A falta de dados em nosso país dificulta a elaboração de medidas preventivas que respeitem as características regionais, vislumbrando um melhor manejo dessa patologia que atinge, em sua maior parte, a população economicamente ativa, gerando prejuízos crescentes ao sistema de saúde.

Upregulated Heat Shock Proteins After Hyperthermic Chemotherapy Point to Induced Cell Survival Mechanisms in Affected Tumor Cells From Peritoneal Carcinomatosis

In patients with peritoneal carcinomatosis cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) represents a promising treatment strategy. Here, we studied the role of hyperthermic chemotherapy on heat shock protein (HSP) expression and induction of tumor cell death and survival. HSP27, HSP70, and HSP90 combined with effects on tumor cell proliferation and chemosensitivity were analyzed in human colon cancer. Hyperthermic chemotherapy resulted in significant HSP27/HSP70 and HSP90 gene/protein overexpression in analyzed HT-29/SW480/SW620 colon cancer cells and peritoneal metastases from patients displaying amplified expression of proliferation markers, proliferating cell nuclear antigen and antiapoptotic protein Bcl-xL. Moreover, functionally increased chemoresistance against 5-fluorouracil/mitomycin C and oxaliplatin after hyperthermic chemotherapy points to induced survival mechanisms in cancer cells. In conclusion, the results indicate that intracellular HSP-associated antiapoptotic and proliferative effects after hyperthermic chemotherapy negatively influence beneficial effects of hyperthermic chemotherapy-induced cell death. Therefore, blocking HSPs could be a promising strategy to further improve the rate of tumor cell death and outcome of patients undergoing HIPEC therapy.

Creation of a novel simulator for minimally invasive neurosurgery: fusion of 3D printing and special effects

OBJECTIVE Recent advances in optics and miniaturization have enabled the development of a growing number of minimally invasive procedures, yet innovative training methods for the use of these techniques remain lacking. Conventional teaching models, including cadavers and physical trainers as well as virtual reality platforms, are often expensive and ineffective. Newly developed 3D printing technologies can recreate patient-specific anatomy, but the stiffness of the materials limits fidelity to real-life surgical situations. Hollywood special effects techniques can create ultrarealistic features, including lifelike tactile properties, to enhance accuracy and effectiveness of the surgical models. The authors created a highly realistic model of a pediatric patient with hydrocephalus via a unique combination of 3D printing and special effects techniques and validated the use of this model in training neurosurgery fellows and residents to perform endoscopic third ventriculostomy (ETV), an effective minimally invasive method increasingly used in treating hydrocephalus. METHODS A full-scale reproduction of the head of a 14-year-old adolescent patient with hydrocephalus, including external physical details and internal neuroanatomy, was developed via a unique collaboration of neurosurgeons, simulation engineers, and a group of special effects experts. The model contains "plug-and-play" replaceable components for repetitive practice. The appearance of the training model (face validity) and the reproducibility of the ETV training procedure (content validity) were assessed by neurosurgery fellows and residents of different experience levels based on a 14-item Likert-like questionnaire. The usefulness of the training model for evaluating the performance of the trainees at different levels of experience (construct validity) was measured by blinded observers using the Objective Structured Assessment of Technical Skills (OSATS) scale for the performance of ETV. RESULTS A combination of 3D printing technology and casting processes led to the creation of realistic surgical models that include high-fidelity reproductions of the anatomical features of hydrocephalus and allow for the performance of ETV for training purposes. The models reproduced the pulsations of the basilar artery, ventricles, and cerebrospinal fluid (CSF), thus simulating the experience of performing ETV on an actual patient. The results of the 14-item questionnaire showed limited variability among participants' scores, and the neurosurgery fellows and residents gave the models consistently high ratings for face and content validity. The mean score for the content validity questions (4.88) was higher than the mean score for face validity (4.69) (p = 0.03). On construct validity scores, the blinded observers rated performance of fellows significantly higher than that of residents, indicating that the model provided a means to distinguish between novice and expert surgical skills. CONCLUSIONS A plug-and-play lifelike ETV training model was developed through a combination of 3D printing and special effects techniques, providing both anatomical and haptic accuracy. Such simulators offer opportunities to accelerate the development of expertise with respect to new and novel procedures as well as iterate new surgical approaches and innovations, thus allowing novice neurosurgeons to gain valuable experience in surgical techniques without exposing patients to risk of harm.

Clinical Significance of Disseminated Pluripotent Tumor Cell Signature Expression in the Bone Marrow from Patients with Colorectal Cancer

Purpose:

Disseminated tumor cells (DTCs) are critically involved in tumor relapse and survival in several invasive tumors. We previously showed that the ATP-binding cassette (ABC) transporter, ABCB5, is a chemoresistance mediator expressed on specific cell subsets in colorectal cancer (CRC) and other malignancies. This study evaluated the molecular signature expression and its clinical relevance of DTCs in bone marrow from patients with colon cancer.

Methods:

This study included 49 consecutive patients (UICC stage I-IV) that underwent curatively intended or palliative surgery for CRC. We analyzed cells from bone marrow aspirates obtained before surgery and derived from patients that had completed minimally a 5-year follow-up. The gene expression of ABCB5 in comparison to CD133 (molecule for identifying cancer initiating cells), Lgr5 (an intestinal stem cell marker) as well as Cytokeratin (CK) 20 (terminally differentiated tumor cells of epithelial origin) in these cells was evaluated.

Results:

Bone marrow analysis showed differential expression between the analyzed genes. ABCB5 and Lgr5 and to lesser extent CD133 and CK20 genes were significantly expressed in the analyzed cells from bone marrow aspirates while only ABCB5 and Lgr5 were significantly negative associated with tumor progress and overall survival.

Conclusion:

Overexpression of ABCB5 and Lgr5 in bone marrow negatively influenced patient survival pointing to a specific chemo resistant and pluripotent cell subgroup of DTCs in the bone marrow. ABCB5 like Lgr5 positive cells seem to be involved in limited tumor related patient survival, suggesting that ABCB5- and Lgr5-positive cells may be relevant for specific clinical intervention strategies

Toll Like Receptor 2, 4, and 9 Signaling Promotes Autoregulative Tumor Cell Growth and VEGF/PDGF Expression in Human Pancreatic Cancer

Toll like receptor (TLR) signaling has been suggested to play an important role in the inflammatory microenvironment of solid tumors and through this inflammation-mediated tumor growth. Here, we studied the role of tumor cells in their process of self-maintaining TLR expression independent of inflammatory cells and cytokine milieu for autoregulative tumor growth signaling in pancreatic cancer. We analyzed the expression of TLR2, -4, and -9 in primary human cancers and their impact on tumor growth via induced activation in several established pancreatic cancers. TLR-stimulated pancreatic cancer cells were specifically investigated for activated signaling pathways of VEGF/PDGF and anti-apoptotic Bcl-xL expression as well as tumor cell growth. The primary pancreatic cancers and cell lines expressed TLR2, -4, and -9. TLR-specific stimulation resulted in activated MAP-kinase signaling, most likely via autoregulative stimulation of demonstrated TLR-induced VEGF and PDGF expression. Moreover, TLR activation prompted the expression of Bcl-xL and has been demonstrated for the first time to induce tumor cell proliferation in pancreatic cancer. These findings strongly suggest that pancreatic cancer cells use specific Toll like receptor signaling to promote tumor cell proliferation and emphasize the particular role of TLR2, -4, and -9 in this autoregulative process of tumor cell activation and proliferation in pancreatic cancer.

Variation of the slope of the tentorium during childhood

BACKGROUND AND PURPOSE

Neural structures in the posterior fossa grow at different rates during development. While there are computationally intensive approaches to analyze growth of the cerebellum and brainstem, there is a paucity of information about summary measures of normal posterior fossa development suitable for real-time clinical use. The present study investigates changes in the trajectory of the tentorium as measured by the occipital and tentorial angles at different stages of development.

METHODS

A retrospective study was conducted drawing from a Boston Children's Hospital database of over 1500 magnetic resonance imaging (MRI) studies. The imaging study population included fetuses older than 20 gestational weeks and children between the ages of 0 and 10 years. Two parameters were measured for all subjects: (1) the tentorial angle (the angle between the tentorium and a line from the internal occipital protuberance to the tuberculum sellae) and (2) the occipital angle (the angle between the tentorium and a line from the internal occipital protuberance to the opisthion). Descriptive statistics were used to analyze the study cohort.

RESULTS

We reviewed 1510 brain MRI studies, and 367 studies met the inclusion criteria (125 fetal and 242 postnatal studies). During fetal development, the inclination of the tentorium showed an ascending course, while it plateaus after birth.

CONCLUSIONS

During the second and third trimesters, the tentorial and occipital angles steadily increase reflecting the dynamic growth of the posterior fossa structures. Postnatally, the tentorial angle decreases and the tentorium slopes downward and plateaus, possibly due to stabilization of posterior fossa development and ongoing growth of the cerebrum. Together, these findings suggest that the tentorial angle can serve as an imaging biomarker of posterior fossa development during the second half of fetal life.

The role of simulation in neurosurgery

PURPOSE

In an era of residency duty-hour restrictions, there has been a recent effort to implement simulation-based training methods in neurosurgery teaching institutions. Several surgical simulators have been developed, ranging from physical models to sophisticated virtual reality systems. To date, there is a paucity of information describing the clinical benefits of existing simulators and the assessment strategies to help implement them into neurosurgical curricula. Here, we present a systematic review of the current models of simulation and discuss the state-of-the-art and future directions for simulation in neurosurgery.

METHODS

Retrospective literature review.

RESULTS

Multiple simulators have been developed for neurosurgical training, including those for minimally invasive procedures, vascular, skull base, pediatric, tumor resection, functional neurosurgery, and spine surgery. The pros and cons of existing systems are reviewed.

CONCLUSION

Advances in imaging and computer technology have led to the development of different simulation models to complement traditional surgical training. Sophisticated virtual reality (VR) simulators with haptic feedback and impressive imaging technology have provided novel options for training in neurosurgery. Breakthrough training simulation using 3D printing technology holds promise for future simulation practice, proving high-fidelity patient-specific models to complement residency surgical learning.

Unsung hero: Donald Darrow Matson's legacy in pediatric neurosurgery

Donald Darrow Matson made seminal contributions to the field of pediatric neurosurgery. Born in 1913 in Fort Hamilton, New York, Matson was the youngest of four sons of an army colonel. He graduated from Cornell University and, years later, from Harvard Medical School. Matson selected Peter Bent Brigham Hospital for his neurosurgical training, which was interrupted during World War II. As a neurosurgeon, he worked close to the front lines under Brigadier General Elliot Cutler in Europe, earning a Bronze Star. Matson returned to Boston to become Franc Ingraham's fellow and partner. He was a masterful surgeon and, with Ingraham, published Neurosurgery of Infancy and Childhood in 1954, the first pediatric neurosurgery textbook in the world. Upon Ingraham's retirement, Matson became chairman of the department of neurosurgery at Boston Children's Hospital and Peter Bent Brigham. In 1968, he became the inaugural Franc D. Ingraham Professor of Neurological Surgery at Harvard Medical School. Among his neurosurgical accomplishments, Matson served as President of the Harvey Cushing Society, later known as the American Association of Neurological Surgeons. He was unable to preside at the 1969 meeting that marked the 100th anniversary of Cushing's birth, having contracted Creutzfeldt-Jakob disease. Matson died at the age of 55, surviving his mentor Ingraham by only 4 years.

Eccentric neurosurgical virtuoso: the life and times of William Sharpe

William Sharpe was an intriguing figure in the history of American neurosurgery. He was an extraordinarily bright and gifted man who led a flamboyant, colorful, and unconventional life. He had an international impact on the field of neurosurgery during the first half of the 20th century, yet few practicing neurosurgeons know his name. In this report, the authors discuss Sharpe’s contributions to neurosurgery along with the remarkable quirkiness that came to define his professional and personal life.

Complications of the anterior approach to the cervical spine

OBJECTIVE: To evaluate the complications of anterior approach to the cervical spine in patients who underwent cervical arthrodesis with instrumentation. METHODS: Prospective and descriptive study was conducted from January 2009 to April 2010. All patients who underwent arthrodesis of the cervical spine by anterior approach were included, regardless the diagnosis. Access was made by the anterior approach on the right side. We evaluated the number of operated levels (1, 2 or 3 levels) and, the type of procedure performed: discectomy and placement of cage and plate (D+C+P), discectomy with placement of a cage (D+C) or corpectomy with placement of cage and plate (C+C+P). All complications related to surgical approach were reported. RESULTS: We studied 34 patients, 70% male. The average age was 50 years and mean follow-up was 8 months. Eighteen percent of patients had complications, distributed as follows: dysphasia (33%) and dysphonic (67%). Among patients who developed complications, most underwent to D+C+P (83%) and no complications were found in patients where no cervical plate was used. Regarding levels, both complications were identified in patients operated to one or two levels. However, in patients operated on three levels, only dysphonia was identified. CONCLUSION: The most frequent complication was dysphonia. Patients who presented more complications were those undergoing discectomy and fusion with cage and anterior cervical plate. All cases of dysphonia were in this group. The number of accessible levels does not seem to have affected the incidence of complications.

Traumatismo raquimedular por ferimento de projétil de arma de fogo: avaliação epidemiológica

OBJETIVO: Avaliar a incidência de trauma raquimedular causado por projétil de arma de fogo nos pacientes atendidos no pronto socorro de um hospital de Curitiba (PR). MÉTODOS: Estudo retrospectivo, realizado no período de fevereiro de 2005 a julho de 2008, incluindo todos os pacientes, vitimas de lesão na coluna vertebral causada por projétil de arma de fogo (n = 54). RESULTADOS: A grande maioria dos pacientes acometidos é do sexo masculino e em idade produtiva, com média de 27,18 anos. O segmento mais afetado foi a coluna torácica, com ferimentos transfixantes e lesão ASIA A (lesão completa). A maioria dos casos foi tratada de forma conservadora. O período da semana em que houve maior incidência foi o fim e semana, com predomínio do sábado e da sexta-feira. O motivo mais comum foi assalto. CONCLUSÃO: São lesões com alto impacto no custo de saúde pública e de previdência, uma vez que são lesões de alta taxa de morbidade e acometimento predominante de pessoas em faixa etária produtiva.