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Waqar M, Yaseen O, Chadwick A, Lee JX, Khan G, Evans DG, Horner D, Jaiswal A, Freeman S, Bhalla R, Lloyd S, Hammerbeck-Ward C, Rutherford SA, King AT, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after skull base surgery. Acta Neurochir (Wien) 2024; 166:165. [PMID: 38565732 PMCID: PMC10987339 DOI: 10.1007/s00701-024-06035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis. METHODS Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons. RESULTS One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM. CONCLUSION Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Omar Yaseen
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jing Xian Lee
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ghazn Khan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - D Gareth Evans
- Department of Neurogenetics, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Archana Jaiswal
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Simon Freeman
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Rajiv Bhalla
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Simon Lloyd
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK.
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
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Hutchinson PJ, Edlmann E, Hanrahan JG, Bulters D, Zolnourian A, Holton P, Suttner N, Agyemang K, Thomson S, Anderson IA, Al-Tamimi Y, Henderson D, Whitfield P, Gherle M, Brennan PM, Allison A, Thelin EP, Tarantino S, Pantaleo B, Caldwell K, Davis-Wilkie C, Mee H, Warburton EA, Barton G, Chari A, Marcus HJ, Pyne S, King AT, Belli A, Myint PK, Wilkinson I, Santarius T, Turner C, Bond S, Kolias AG. A randomised, double blind, placebo-controlled trial of a two-week course of dexamethasone for adult patients with a symptomatic Chronic Subdural Haematoma (Dex-CSDH trial). Health Technol Assess 2024; 28:1-122. [PMID: 38512045 PMCID: PMC11017629 DOI: 10.3310/xwzn4832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/22/2024] Open
Abstract
Background Chronic subdural haematoma is a collection of 'old blood' and its breakdown products in the subdural space and predominantly affects older people. Surgical evacuation remains the mainstay in the management of symptomatic cases. Objective The Dex-CSDH (DEXamethasone in Chronic SubDural Haematoma) randomised trial investigated the clinical effectiveness and cost-effectiveness of dexamethasone in patients with a symptomatic chronic subdural haematoma. Design This was a parallel, superiority, multicentre, pragmatic, randomised controlled trial. Assigned treatment was administered in a double-blind fashion. Outcome assessors were also blinded to treatment allocation. Setting Neurosurgical units in the UK. Participants Eligible participants included adults (aged ≥ 18 years) admitted to a neurosurgical unit with a symptomatic chronic subdural haematoma confirmed on cranial imaging. Interventions Participants were randomly assigned in a 1 : 1 allocation to a 2-week tapering course of dexamethasone or placebo alongside standard care. Main outcome measures The primary outcome was the Modified Rankin Scale score at 6 months dichotomised to a favourable (score of 0-3) or an unfavourable (score of 4-6) outcome. Secondary outcomes included the Modified Rankin Scale score at discharge and 3 months; number of chronic subdural haematoma-related surgical interventions undertaken during the index and subsequent admissions; Barthel Index and EuroQol 5-Dimension 5-Level utility index score reported at discharge, 3 months and 6 months; Glasgow Coma Scale score reported at discharge and 6 months; mortality at 30 days and 6 months; length of stay; discharge destination; and adverse events. An economic evaluation was also undertaken, during which the net monetary benefit was estimated at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year. Results A total of 748 patients were included after randomisation: 375 were assigned to dexamethasone and 373 were assigned to placebo. The mean age of the patients was 74 years and 94% underwent evacuation of their chronic subdural haematoma during the trial period. A total of 680 patients (91%) had 6-month primary outcome data available for analysis: 339 in the placebo arm and 341 in the dexamethasone arm. On a modified intention-to-treat analysis of the full study population, there was an absolute reduction in the proportion of favourable outcomes of 6.4% (95% confidence interval 11.4% to 1.4%; p = 0.01) in the dexamethasone arm compared with the control arm at 6 months. At 3 months, the between-group difference was also in favour of placebo (-8.2%, 95% confidence interval -13.3% to -3.1%). Serious adverse events occurred in 60 out of 375 (16.0%) in the dexamethasone arm and 24 out of 373 (6.4%) in the placebo arm. The net monetary benefit of dexamethasone compared with placebo was estimated to be -£97.19. Conclusions This trial reports a higher rate of unfavourable outcomes at 6 months, and a higher rate of serious adverse events, in the dexamethasone arm than in the placebo arm. Dexamethasone was also not estimated to be cost-effective. Therefore, dexamethasone cannot be recommended for the treatment of chronic subdural haematoma in this population group. Future work and limitations A total of 94% of individuals underwent surgery, meaning that this trial does not fully define the role of dexamethasone in conservatively managed haematomas, which is a potential area for future study. Trial registration This trial is registered as ISRCTN80782810. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/15/02) and is published in full in Health Technology Assessment; Vol. 28, No. 12. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- Faculty of Health, Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
- South West Neurosurgical Centre, Derriford Hospital, Plymouth, UK
| | - John G Hanrahan
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Diederik Bulters
- Wessex Neurological Unit, University Hospital Southampton, Southampton, UK
| | - Ardalan Zolnourian
- Wessex Neurological Unit, University Hospital Southampton, Southampton, UK
| | - Patrick Holton
- Wessex Neurological Unit, University Hospital Southampton, Southampton, UK
| | - Nigel Suttner
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kevin Agyemang
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Simon Thomson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Ian A Anderson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | - Duncan Henderson
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | - Peter Whitfield
- South West Neurosurgical Centre, Derriford Hospital, Plymouth, UK
| | - Monica Gherle
- South West Neurosurgical Centre, Derriford Hospital, Plymouth, UK
| | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Annabel Allison
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Eric P Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Silvia Tarantino
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Beatrice Pantaleo
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Karen Caldwell
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Carol Davis-Wilkie
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Harry Mee
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Elizabeth A Warburton
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Garry Barton
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norfolk, UK
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital & Institute of Child Health, University College London, London, UK
| | - Hani J Marcus
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Sarah Pyne
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norfolk, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Phyo K Myint
- Ageing Clinical & Experimental Research Group, Institute of Applied Health Science, University of Aberdeen, Aberdeen, UK
| | - Ian Wilkinson
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Experimental Medicine and Immunotherapeutics, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Thomas Santarius
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Carole Turner
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
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Lewis D, Li KL, Waqar M, Coope DJ, Pathmanaban ON, King AT, Djoukhadar I, Zhao S, Cootes TF, Jackson A, Zhu X. Low-dose GBCA administration for brain tumour dynamic contrast enhanced MRI: a feasibility study. Sci Rep 2024; 14:4905. [PMID: 38418818 PMCID: PMC10902320 DOI: 10.1038/s41598-024-53871-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
A key limitation of current dynamic contrast enhanced (DCE) MRI techniques is the requirement for full-dose gadolinium-based contrast agent (GBCA) administration. The purpose of this feasibility study was to develop and assess a new low GBCA dose protocol for deriving high-spatial resolution kinetic parameters from brain DCE-MRI. Nineteen patients with intracranial skull base tumours were prospectively imaged at 1.5 T using a single-injection, fixed-volume low GBCA dose, dual temporal resolution interleaved DCE-MRI acquisition. The accuracy of kinetic parameters (ve, Ktrans, vp) derived using this new low GBCA dose technique was evaluated through both Monte-Carlo simulations (mean percent deviation, PD, of measured from true values) and an in vivo study incorporating comparison with a conventional full-dose GBCA protocol and correlation with histopathological data. The mean PD of data from the interleaved high-temporal-high-spatial resolution approach outperformed use of high-spatial, low temporal resolution datasets alone (p < 0.0001, t-test). Kinetic parameters derived using the low-dose interleaved protocol correlated significantly with parameters derived from a full-dose acquisition (p < 0.001) and demonstrated a significant association with tissue markers of microvessel density (p < 0.05). Our results suggest accurate high-spatial resolution kinetic parameter mapping is feasible with significantly reduced GBCA dose.
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Affiliation(s)
- Daniel Lewis
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK.
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Greater Manchester, M6 8HD, UK.
| | - Ka-Loh Li
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - David J Coope
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Ibrahim Djoukhadar
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sha Zhao
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Timothy F Cootes
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Xiaoping Zhu
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Trudel M, Stapleton EJ, Wadeson AM, Spiller W, North HJ, Heal C, Sebastian J, Freeman SR, Rutherford SA, Entwistle H, Hammerbeck-Ward CL, Pathmanaban O, King AT, Lloyd SKW. Improved Recovery after Vestibular Schwannoma Excision with Intratympanic Gentamicin Prehabilitation. Laryngoscope 2024. [PMID: 38332515 DOI: 10.1002/lary.31298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/04/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Translabyrinthine excision of a vestibular schwannoma is associated with acute vestibular failure. Preoperative intratympanic gentamicin (ITG) injections can improve objective balance function after surgery but its clinical benefits remain to be established. METHODS Adult patients undergoing translabyrinthine removal of a vestibular schwannoma between January 2014 and February 2018 underwent preoperative vestibular function testing. Patients were divided in to 3 groups, those with vestibular function (VF) who received ITG injections, those with VF but did not receive ITG and those with no VF. Groups were compared according to degree of vertigo, length of stay, time to unassisted mobilization, and postoperative anti-emetic consumption. RESULTS Forty six patients had ITG injections (Group 1), 7 had residual VF but refused treatment (Group 2), 21 had no VF (Group 3). Group 1 had a significant improvement in vertigo over time whereas groups 2 and 3 did not. There was a statistically significant 70% decrease in time to independent mobilization between Group 1 and other groups and a 19% decrease in length of stay in Group 1 compared to other groups although this did not reach statistical significance. Two patients had injection-related complications. Group 1 used less anti-emetics than other groups but this was not statistically significant. CONCLUSION Preoperative intratympanic gentamicin injection with vestibular rehabilitation exercises is associated with less postoperative vertigo and earlier postoperative mobilization. There was reduced duration of hospitalization and decreased consumption of anti-emetic but not significantly so possibly because of low numbers of patients in the no treatment group. LEVEL OF EVIDENCE 2 Laryngoscope, 2024.
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Affiliation(s)
- Mathieu Trudel
- Department of Otolaryngology Head and Neck Surgery, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester, UK
- Department of Otolaryngology-Head and Neck Surgery, CHU de Québec-Université Laval, Hôpital de l'Enfant-Jésus, Quebec City, Quebec, Canada
| | - Emma J Stapleton
- Department of Otolaryngology Head and Neck Surgery, Manchester Royal Infirmary, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andrea M Wadeson
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - William Spiller
- Department of Otolaryngology Head and Neck Surgery, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester, UK
| | - Hannah J North
- Department of Otolaryngology Head and Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Calvin Heal
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Joseph Sebastian
- Department of Anaesthesia, Salford Royal Hospital, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Simon R Freeman
- Department of Otolaryngology Head and Neck Surgery, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester, UK
- Department of Otolaryngology Head and Neck Surgery, Manchester Royal Infirmary, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Helen Entwistle
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Charlotte L Hammerbeck-Ward
- Department of Neurosurgery, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Omar Pathmanaban
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Division of Neuroscience, Faculty of Biology, Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Andrew T King
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Simon K W Lloyd
- Department of Otolaryngology Head and Neck Surgery, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester, UK
- Department of Otolaryngology Head and Neck Surgery, Manchester Royal Infirmary, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
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Schembari E, Richardson C, King AT, Layfield DM. Mesh mediated fascial traction in the management of the open abdomen: A video vignette. Colorectal Dis 2024; 26:207-210. [PMID: 38030879 DOI: 10.1111/codi.16816] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Elena Schembari
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Carl Richardson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew T King
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - David M Layfield
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Macarthur JI, O'Brien F, Hannan CJ, Hammerbeck-Ward C, Pathmanaban ON, Rutherford SA, Siripurapu R, King AT, Ng W. Does tumoral cavernous carotid stenosis predict an increased risk of future stroke in skull base meningiomas? J Neurosurg 2023; 139:1613-1618. [PMID: 37178029 DOI: 10.3171/2023.4.jns23378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Skull base meningiomas (SBMs) involving the cavernous sinus encase the internal carotid artery (ICA) and may lead to stenosis of the vessel. Although ischemic stroke has been reported in the literature, there are to the authors' knowledge no reported studies quantifying the risk of stroke in these patients. The authors aimed to determine the frequency of arterial stenosis in patients with SBMs that encase the cavernous ICA and to estimate the risk of ischemic stroke in these patients. METHODS Records of all patients with SBM encasing the ICA whose cases were managed by the skull base multidisciplinary team at Salford Royal Hospital between 2011 and 2017 were reviewed using a two-stage approach: 1) clinical and radiological strokes were identified from electronic patient records, and 2) cases were reviewed to examine the correlation between ICA stenosis associated with SBM encasement and anatomically related stroke. Strokes that were caused by another pathology or did not occur in the perfusion territory were excluded. RESULTS In the review of patient records the authors identified 118 patients with SBMs encasing the ICA. Of these, 62 SBMs caused stenosis. The median age at diagnosis was 70 (IQR 24) years, and 70% of the patients were female. The median follow-up was 97 (IQR 101) months. A total of 13 strokes were identified in these patients; however, only 1 case of stroke was associated with SBM encasement, which occurred in the perfusion territory of a patient without stenosis. Risk of acute stroke during the follow-up period for the entire cohort was 0.85%. CONCLUSIONS Acute stroke in patients with ICA encasement by SBMs is rare despite the propensity of these tumors to stenose the ICA. Patients with ICA stenosis secondary to their SBM did not have a higher incidence of stroke than those with ICA encasement without stenosis. The results of this study demonstrate that prophylactic intervention to prevent stroke is not necessary in ICA stenosis secondary to SBM.
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Affiliation(s)
- Joshua I Macarthur
- 1Faculty of Biology, Medicine and Health, University of Manchester
- 3Geoffrey Jefferson Brain Research Centre, Manchester
| | - Frazer O'Brien
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
| | - Cathal John Hannan
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
- 3Geoffrey Jefferson Brain Research Centre, Manchester
- 6Division of Cardiovascular Sciences, University of Manchester, United Kingdom
| | - Charlotte Hammerbeck-Ward
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
- 3Geoffrey Jefferson Brain Research Centre, Manchester
| | - Omar N Pathmanaban
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
- 3Geoffrey Jefferson Brain Research Centre, Manchester
- 4Division of Neuroscience & Experimental Psychology, University of Manchester
| | - Scott A Rutherford
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
- 3Geoffrey Jefferson Brain Research Centre, Manchester
| | - Rekha Siripurapu
- 5Department of Neuroradiology, Salford Royal Hospitals NHS Trust, Salford
| | - Andrew T King
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
- 3Geoffrey Jefferson Brain Research Centre, Manchester
- 6Division of Cardiovascular Sciences, University of Manchester, United Kingdom
| | - Wayne Ng
- 2Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester
- 7School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Queensland; and
- 8Department of Neurosurgery, Gold Coast University Hospital, Gold Coast, Australia
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Carlson ML, Lohse CM, Agazzi S, Babu SC, Barker FG, Barnett S, Bi WL, Biggs N, Boahene KD, Breen JT, Brown KD, Cayé-Thomasen P, Cosetti MK, Deep NL, Dey JK, Dornhoffer JR, Forner D, Gurgel RK, Hansen MR, Hunter JB, Kalamarides M, Kim IA, King AT, Kircher ML, Lassaletta L, Link MJ, Lloyd SKW, Lund-Johansen M, Marinelli JP, Matthies C, Mehta V, Moore EJ, Nassiri AM, Neff BA, Nelson RF, Olson JJ, Patel NS, Celda MP, Plitt AR, Price DL, Thomas Roland J, Sweeney AD, Tasche KK, Tatagiba M, Tveiten Ø, Van Gompel JJ, Vrabec JT, Wanna GB, Weisskopf PA. Rationale for the Development of a Novel Clinical Grading Scale for Postoperative Facial Nerve Function: Results of a Multidisciplinary International Working Group. Otol Neurotol 2023; 44:e747-e754. [PMID: 37875014 DOI: 10.1097/mao.0000000000004039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/26/2023]
Abstract
OBJECTIVE The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. STUDY DESIGN Survey. SETTING A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. RESULTS House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. CONCLUSIONS Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.
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Affiliation(s)
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Siviero Agazzi
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | | | - Frederick G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel Barnett
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nigel Biggs
- Department of Otolaryngology, Head, Neck and Skull Base Surgery, St Vincent's Hospital, Sydney, Australia
| | - Kofi D Boahene
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joseph T Breen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kevin D Brown
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Per Cayé-Thomasen
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Maura K Cosetti
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine of Mount Sinai, New York, New York
| | - Nicholas L Deep
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
| | - Jacob K Dey
- Department of Otolaryngology-Head and Neck Surgery
| | | | - David Forner
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Richard K Gurgel
- Department of Otolaryngology, University of Utah Health, Salt Lake City, Utah
| | - Marlan R Hansen
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jacob B Hunter
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michel Kalamarides
- Department of Neurosurgery, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Irene A Kim
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester, UK
| | - Matthew L Kircher
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Chicago, Illinois
| | - Luis Lassaletta
- Department of Otolaryngology, IdiPAZ Institute for Health Research, La Paz University Hospital; Biomedical Research Networking Centre on Rare Diseases (CIBERER-U761), Institute of Health Carlos III, Madrid, Spain
| | | | - Simon K W Lloyd
- Department of Otolaryngology Head and Neck Surgery, Manchester Royal Infirmary, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | | | - Cordula Matthies
- Department of Neurosurgery, University of Würzburg, Würzburg, Germany
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery
| | - Ashley M Nassiri
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian A Neff
- Department of Otolaryngology-Head and Neck Surgery
| | - Rick F Nelson
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Neil S Patel
- Department of Otolaryngology, University of Utah Health, Salt Lake City, Utah
| | | | | | | | - J Thomas Roland
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York
| | - Alex D Sweeney
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Øystein Tveiten
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | | | | | - George B Wanna
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine of Mount Sinai, New York, New York
| | - Peter A Weisskopf
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona
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Campbell T, Goh SJ, Wadeson AM, Freeman SR, Rutherford SA, King AT, Hammerbeck-Ward CL, Pathmanaban O, Entwistle H, Bird J, Axon PR, Moffat DA, Lloyd SK. Changes in audiovestibular handicap following treatment of vestibular schwannomas. J Laryngol Otol 2023:1-7. [PMID: 38017610 DOI: 10.1017/s002221512300213x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVE This study aimed to assess degree of audiovestibular handicap in patients with vestibular schwannoma. METHODS Audiovestibular handicap was assessed using the Hearing Handicap Inventory, Tinnitus Handicap Inventory and Dizziness Handicap Inventory. Patients completed questionnaires at presentation and at least one year following treatment with microsurgery, stereotactic radiosurgery or observation. Changes in audiovestibular handicap and factors affecting audiovestibular handicap were assessed. RESULTS All handicap scores increased at follow up, but not significantly. The Tinnitus Handicap Inventory and Dizziness Handicap Inventory scores predicted tinnitus and dizziness respectively. The Hearing Handicap Inventory was not predictive of hearing loss. Age predicted Tinnitus Handicap Inventory score and microsurgery was associated with a deterioration in Dizziness Handicap Inventory score. CONCLUSION Audiovestibular handicap is common in patients with vestibular schwannoma, with 75 per cent having some degree of handicap in at least one inventory. The overall burden of handicap was, however, low. The increased audiovestibular handicap over time was not statistically significant, irrespective of treatment modality.
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Affiliation(s)
- Tim Campbell
- Brighton and Sussex Medical School, Brighton, UK
| | | | - Andrea M Wadeson
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Simon R Freeman
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Manchester, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Brain and Mental Health, University of Manchester, Manchester, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Brain and Mental Health, University of Manchester, Manchester, UK
| | - Charlotte L Hammerbeck-Ward
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Omar Pathmanaban
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Manchester, UK
| | - Helen Entwistle
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Judith Bird
- Department of Otolaryngology, Addenbrooke's Hospital, Cambridge, UK
| | - Patrick R Axon
- Department of Otolaryngology, Addenbrooke's Hospital, Cambridge, UK
| | - David A Moffat
- Department of Otolaryngology, Addenbrooke's Hospital, Cambridge, UK
| | - Simon K Lloyd
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
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Hannan CJ, McBain C, Whitfield G, Pathmanaban ON, Rutherford SA, Freeman SR, Lloyd SK, King AT, Evans DG. Letter: Stereotactic Radiosurgery for Vestibular Schwannoma in Neurofibromatosis Type 2: An International Multicenter Case Series of Response and Malignant Transformation Risk. Neurosurgery 2023; 93:e98-e99. [PMID: 37489892 DOI: 10.1227/neu.0000000000002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 07/26/2023] Open
Affiliation(s)
- Cathal John Hannan
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool , UK
| | | | | | - Omar N Pathmanaban
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester , UK
- Division of Neuroscience, University of Manchester, Manchester , UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester , UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester , UK
| | - Simon R Freeman
- Department of Otolaryngology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester , UK
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester , UK
| | - Simon K Lloyd
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester , UK
- Department of Otolaryngology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester , UK
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester , UK
- Division of Cancer Sciences, University of Manchester, Manchester , UK
| | - Andrew T King
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester , UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester , UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester , UK
| | - D Gareth Evans
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester , UK
- Division of Evolution and Genomic Medicine, Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, University of Manchester, St Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester , UK
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10
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Lewis D, Hannan CJ, Plitt AR, Snyder LR, Richardson G, King AT, Hammerbeck-Ward C, Pathmanaban ON, Neff BA, Driscoll CL, Van Gompel JJ, Carlson ML, Lane JI, Lloyd SK, Freeman SR, Laitt RD, Abdulla S, Siripurapu R, Potter GM, Link MJ, Rutherford SA. Intraoperative diagnosis of facial schwannomas: a multicenter summation of clinical experience, preoperative avoidance, and intraoperative management protocol. J Neurosurg 2023; 139:972-983. [PMID: 36933255 DOI: 10.3171/2023.2.jns222368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/02/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE Preoperative differentiation of facial nerve schwannoma (FNS) from vestibular schwannoma (VS) can be challenging, and failure to differentiate between these two pathologies can result in potentially avoidable facial nerve injury. This study presents the combined experience of two high-volume centers in the management of intraoperatively diagnosed FNSs. The authors highlight clinical and imaging features that can distinguish FNS from VS and provide an algorithm to help manage intraoperatively diagnosed FNS. METHODS Operative records of 1484 presumed sporadic VS resections between January 2012 and December 2021 were reviewed, and patients with intraoperatively diagnosed FNSs were identified. Clinical data and preoperative imaging were retrospectively reviewed for features suggestive of FNS, and factors associated with good postoperative facial nerve function (House-Brackmann [HB] grade ≤ 2) were identified. A preoperative imaging protocol for suspected VS and recommendations for surgical decision-making following an intraoperative FNS diagnosis were created. RESULTS Nineteen patients (1.3%) with FNSs were identified. All patients had normal facial motor function preoperatively. In 12 patients (63%), preoperative imaging demonstrated no features suggestive of FNS, with the remainder showing subtle enhancement of the geniculate/labyrinthine facial segment, widening/erosion of the fallopian canal, or multiple tumor nodules in retrospect. Eleven (57.9%) of the 19 patients underwent a retrosigmoid craniotomy, and in the remaining patients, a translabyrinthine (n = 6) or transotic (n = 2) approach was used. Following FNS diagnosis, 6 (32%) of the tumors underwent gross-total resection (GTR) and cable nerve grafting, 6 (32%) underwent subtotal resection (STR) and bony decompression of the meatal facial nerve segment, and 7 (36%) underwent bony decompression only. All patients undergoing subtotal debulking or bony decompression exhibited normal postoperative facial function (HB grade I). At the last clinical follow-up, patients who underwent GTR with a facial nerve graft had HB grade III (3 of 6 patients) or IV facial function. Tumor recurrence/regrowth occurred in 3 patients (16%), all of whom had been treated with either bony decompression or STR. CONCLUSIONS Intraoperative diagnosis of an FNS during a presumed VS resection is rare, but its incidence can be reduced further by maintaining a high index of suspicion and undertaking further imaging in patients with atypical clinical or imaging features. If an intraoperative diagnosis does occur, conservative surgical management with bony decompression of the facial nerve only is recommended, unless there is significant mass effect on surrounding structures.
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Affiliation(s)
- Daniel Lewis
- 1Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Manchester
- 2Geoffrey Jefferson Brain Research Centre, Manchester
- 3Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester
| | - Cathal John Hannan
- 1Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Manchester
- 2Geoffrey Jefferson Brain Research Centre, Manchester
- 4Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Aaron R Plitt
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Andrew T King
- 1Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Manchester
- 2Geoffrey Jefferson Brain Research Centre, Manchester
- 4Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | | | - Omar N Pathmanaban
- 1Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Manchester
- 2Geoffrey Jefferson Brain Research Centre, Manchester
- 3Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester
| | - Brian A Neff
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L Driscoll
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jamie J Van Gompel
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - John I Lane
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Simon K Lloyd
- 9Department of Otolaryngology, Salford Royal Hospital, Manchester
- 10Department of Otolaryngology, Manchester Royal Infirmary, Manchester
- 11Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester; and
| | - Simon R Freeman
- 9Department of Otolaryngology, Salford Royal Hospital, Manchester
- 10Department of Otolaryngology, Manchester Royal Infirmary, Manchester
| | - Roger D Laitt
- 12Department of Neuroradiology, Manchester Centre for Clinical Neuroscience, Manchester, United Kingdom
| | - Sarah Abdulla
- 12Department of Neuroradiology, Manchester Centre for Clinical Neuroscience, Manchester, United Kingdom
| | - Rekha Siripurapu
- 12Department of Neuroradiology, Manchester Centre for Clinical Neuroscience, Manchester, United Kingdom
| | - Gillian M Potter
- 12Department of Neuroradiology, Manchester Centre for Clinical Neuroscience, Manchester, United Kingdom
| | - Michael J Link
- Departments of5Neurologic Surgery and
- 6Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Scott A Rutherford
- 1Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Manchester
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Harris L, Bal JS, Drosos E, Matloob S, Roberts NY, Hammerbeck-Ward C, Pathmanaban O, Evans G, King AT, Rutherford SA, Pollock J, Shoakazemi A. The management of symptomatic hyperostotic bilateral spheno-orbital meningiomas: patient series. J Neurosurg Case Lessons 2023; 6:CASE23179. [PMID: 37773763 PMCID: PMC10555579 DOI: 10.3171/case23179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/16/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The occurrence of hyperostotic bilateral spheno-orbital meningiomas (BSOMs) is very rare. Patients present with bilateral symptoms and require bilateral treatment. This series describes 6 patients presenting to 2 UK neurosurgical units and includes a literature review. To the best of the authors' knowledge, this is the largest series documented. OBSERVATIONS This is a retrospective review of patients with BSOMs presenting between 2006 and 2023. Six females, whose mean age was 43 (range: 36-64) years, presented with features of visual disturbance. Bilateral sphen-oorbital meningiomas were identified. All patients underwent bilateral staged resections. The patients had an initial improvement in their symptoms. Extensive genetic testing was performed in 4 patients, with no variants in the NF2, LZTR1, SMARCB1, SMARCE1, and SMARCA4 genes or other variants detected. The mean follow-up was 100.3 (range: 64-186) months. Sixty-seven percent of patients had good long-term visual acuity. The progression rate was 75% and was particularly aggressive in 1 patient. Four patients required radiation therapy, and 2 needed further surgery. LESSONS Hyperostotic BSOMs are extensive, challenging tumors causing significant disability. They can recur, with significant patient impact. Multidisciplinary management and indefinite long-term follow-up are essential. The biology of these tumors remains unclear. As molecular testing expands, the understanding of BSOM oncogenesis and potential therapeutic targets is likely to improve.
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Affiliation(s)
- Lauren Harris
- Department of Neurosurgery, Essex Neuroscience Centre, Queens Hospital, Romford, United Kingdom
| | - Jarnail S Bal
- Department of Neurosurgery, Essex Neuroscience Centre, Queens Hospital, Romford, United Kingdom
| | - Evangelos Drosos
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance Foundation Trust, Manchester, United Kingdom
| | - Samir Matloob
- Department of Neurosurgery, Essex Neuroscience Centre, Queens Hospital, Romford, United Kingdom
| | - Nicola Y Roberts
- North West Genomic Laboratory Hub (Manchester), Genomic Diagnostics Laboratory, Manchester Centre for Genomic Medicine, Manchester, United Kingdom
| | - Charlotte Hammerbeck-Ward
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance Foundation Trust, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom; and
| | - Omar Pathmanaban
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance Foundation Trust, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom; and
| | - Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution Infection and Genomic Medicine, University of Manchester, St Mary’s Hospital, Manchester Universities NHS Foundation Trust, Manchester, United Kingdom
| | - Andrew T King
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance Foundation Trust, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom; and
| | - Scott A Rutherford
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance Foundation Trust, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom; and
| | - Jonathan Pollock
- Department of Neurosurgery, Essex Neuroscience Centre, Queens Hospital, Romford, United Kingdom
| | - Alireza Shoakazemi
- Department of Neurosurgery, Essex Neuroscience Centre, Queens Hospital, Romford, United Kingdom
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12
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Li KL, Lewis D, Zhu X, Coope DJ, Djoukhadar I, King AT, Cootes T, Jackson A. A Novel Multi-Model High Spatial Resolution Method for Analysis of DCE MRI Data: Insights from Vestibular Schwannoma Responses to Antiangiogenic Therapy in Type II Neurofibromatosis. Pharmaceuticals (Basel) 2023; 16:1282. [PMID: 37765090 PMCID: PMC10534691 DOI: 10.3390/ph16091282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
This study aimed to develop and evaluate a new DCE-MRI processing technique that combines LEGATOS, a dual-temporal resolution DCE-MRI technique, with multi-kinetic models. This technique enables high spatial resolution interrogation of flow and permeability effects, which is currently challenging to achieve. Twelve patients with neurofibromatosis type II-related vestibular schwannoma (20 tumours) undergoing bevacizumab therapy were imaged at 1.5 T both before and at 90 days following treatment. Using the new technique, whole-brain, high spatial resolution images of the contrast transfer coefficient (Ktrans), vascular fraction (vp), extravascular extracellular fraction (ve), capillary plasma flow (Fp), and the capillary permeability-surface area product (PS) could be obtained, and their predictive value was examined. Of the five microvascular parameters derived using the new method, baseline PS exhibited the strongest correlation with the baseline tumour volume (p = 0.03). Baseline ve showed the strongest correlation with the change in tumour volume, particularly the percentage tumour volume change at 90 days after treatment (p < 0.001), and PS demonstrated a larger reduction at 90 days after treatment (p = 0.0001) when compared to Ktrans or Fp alone. Both the capillary permeability-surface area product (PS) and the extravascular extracellular fraction (ve) significantly differentiated the 'responder' and 'non-responder' tumour groups at 90 days (p < 0.05 and p < 0.001, respectively). These results highlight that this novel DCE-MRI analysis approach can be used to evaluate tumour microvascular changes during treatment and the need for future larger clinical studies investigating its role in predicting antiangiogenic therapy response.
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Affiliation(s)
- Ka-Loh Li
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (K.-L.L.); (T.C.); (A.J.)
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester M13 9PL, UK; (D.L.); (D.J.C.); (A.T.K.)
| | - Daniel Lewis
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester M13 9PL, UK; (D.L.); (D.J.C.); (A.T.K.)
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9NT, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Xiaoping Zhu
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (K.-L.L.); (T.C.); (A.J.)
- Wolfson Molecular Imaging Centre, University of Manchester, 27 Palatine Road, Manchester M20 3LJ, UK
| | - David J. Coope
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester M13 9PL, UK; (D.L.); (D.J.C.); (A.T.K.)
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9NT, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Ibrahim Djoukhadar
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9NT, UK;
| | - Andrew T. King
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester M13 9PL, UK; (D.L.); (D.J.C.); (A.T.K.)
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9NT, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Timothy Cootes
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (K.-L.L.); (T.C.); (A.J.)
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (K.-L.L.); (T.C.); (A.J.)
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13
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Gregory GE, Jones AP, Haley MJ, Hoyle C, Zeef LAH, Lin IH, Coope DJ, King AT, Evans DG, Paszek P, Couper KN, Brough D, Pathmanaban ON. The comparable tumour microenvironment in sporadic and NF2-related schwannomatosis vestibular schwannoma. Brain Commun 2023; 5:fcad197. [PMID: 37680691 PMCID: PMC10481781 DOI: 10.1093/braincomms/fcad197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 09/09/2023] Open
Abstract
Bilateral vestibular schwannoma is the hallmark of NF2-related schwannomatosis, a rare tumour predisposition syndrome associated with a lifetime of surgical interventions, radiotherapy and off-label use of the anti-angiogenic drug bevacizumab. Unilateral vestibular schwannoma develops sporadically in non-NF2-related schwannomatosis patients for which there are no drug treatment options available. Tumour-infiltrating immune cells such as macrophages and T-cells correlate with increased vestibular schwannoma growth, which is suggested to be similar in sporadic and NF2-related schwannomatosis tumours. However, differences between NF2-related schwannomatosis and the more common sporadic disease include NF2-related schwannomatosis patients presenting an increased number of tumours, multiple tumour types and younger age at diagnosis. A comparison of the tumour microenvironment in sporadic and NF2-related schwannomatosis tumours is therefore required to underpin the development of immunotherapeutic targets, identify the possibility of extrapolating ex vivo data from sporadic vestibular schwannoma to NF2-related schwannomatosis and help inform clinical trial design with the feasibility of co-recruiting sporadic and NF2-related schwannomatosis patients. This study drew together bulk transcriptomic data from three published Affymetrix microarray datasets to compare the gene expression profiles of sporadic and NF2-related schwannomatosis vestibular schwannoma and subsequently deconvolved to predict the abundances of distinct tumour immune microenvironment populations. Data were validated using quantitative PCR and Hyperion imaging mass cytometry. Comparative bioinformatic analyses revealed close similarities in NF2-related schwannomatosis and sporadic vestibular schwannoma tumours across the three datasets. Significant inflammatory markers and signalling pathways were closely matched in NF2-related schwannomatosis and sporadic vestibular schwannoma, relating to the proliferation of macrophages, angiogenesis and inflammation. Bulk transcriptomic and imaging mass cytometry data identified macrophages as the most abundant immune population in vestibular schwannoma, comprising one-third of the cell mass in both NF2-related schwannomatosis and sporadic tumours. Importantly, there were no robust significant differences in signalling pathways, gene expression, cell type abundance or imaging mass cytometry staining between NF2-related schwannomatosis and sporadic vestibular schwannoma. These data indicate strong similarities in the tumour immune microenvironment of NF2-related schwannomatosis and sporadic vestibular schwannoma.
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Affiliation(s)
- Grace E Gregory
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Adam Paul Jones
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Michael J Haley
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Christopher Hoyle
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Leo A H Zeef
- Bioinformatics Core Facility, University of Manchester, Manchester, UK
| | - I-Hsuan Lin
- Bioinformatics Core Facility, University of Manchester, Manchester, UK
| | - David J Coope
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Andrew T King
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - D Gareth Evans
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Pawel Paszek
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Kevin N Couper
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David Brough
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
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14
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Hutchinson PJ, Adams H, Mohan M, Devi BI, Uff C, Hasan S, Mee H, Wilson MH, Gupta DK, Bulters D, Zolnourian A, McMahon CJ, Stovell MG, Al-Tamimi YZ, Tewari MK, Tripathi M, Thomson S, Viaroli E, Belli A, King AT, Helmy AE, Timofeev IS, Pyne S, Shukla DP, Bhat DI, Maas AR, Servadei F, Manley GT, Barton G, Turner C, Menon DK, Gregson B, Kolias AG. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. N Engl J Med 2023; 388:2219-2229. [PMID: 37092792 DOI: 10.1056/nejmoa2214172] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [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: 04/25/2023]
Abstract
BACKGROUND Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear. METHODS We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group. CONCLUSIONS Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).
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Affiliation(s)
- Peter J Hutchinson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Hadie Adams
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Midhun Mohan
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Bhagavatula I Devi
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Christopher Uff
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Shumaila Hasan
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Harry Mee
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Mark H Wilson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Deepak K Gupta
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Diederik Bulters
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Ardalan Zolnourian
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Catherine J McMahon
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Matthew G Stovell
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Yahia Z Al-Tamimi
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Manoj K Tewari
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Manjul Tripathi
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Simon Thomson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Edoardo Viaroli
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Antonio Belli
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Andrew T King
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Adel E Helmy
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Ivan S Timofeev
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Sarah Pyne
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Dhaval P Shukla
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Dhananjaya I Bhat
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Andrew R Maas
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Franco Servadei
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Geoffrey T Manley
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Garry Barton
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Carole Turner
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - David K Menon
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Barbara Gregson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Angelos G Kolias
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
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15
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Gregory GE, Islim AI, Hannan CJ, Jones AP, Hammerbeck-Ward C, Rutherford SA, Freeman SR, Lloyd S, Kalamarides M, Smith MJ, Couper K, McBain CA, Jenkinson MD, Brough D, King AT, Evans DG, Pathmanaban ON. The clinical, genetic, and immune landscape of meningioma in patients with NF2-schwannomatosis. Neurooncol Adv 2023; 5:i94-i104. [PMID: 37287576 PMCID: PMC10243851 DOI: 10.1093/noajnl/vdac127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
NF2-schwannomatosis is the most common genetic predisposition syndrome associated with meningioma. Meningioma in NF2-schwannomatosis is a major source of morbidity and mortality. This is due to accumulative tumor burden in patients with synchronous schwannomas and ependymomas, sometimes including complex collision tumors. Balancing the impact of multiple interventions against the natural history of various index tumors, and the ongoing risk of de novo tumors over an individual's lifetime makes decision-making complex. The management of any given individual meningioma is often different from a comparable sporadic tumor. There is typically a greater emphasis on conservative management and tolerating growth until a risk boundary is reached, whereby symptomatic deterioration or higher risk from anticipated future treatment is threatened. Management by high-volume multidisciplinary teams improves quality of life and life expectancy. Surgery remains the mainstay treatment for symptomatic and rapidly enlarging meningioma. Radiotherapy has an important role but carries a higher risk compared to its use in sporadic disease. Whilst bevacizumab is effective in NF2-associated schwannoma and cystic ependymoma, it has no value in the management of meningioma. In this review, we describe the natural history of the disease, underlying genetic, molecular, and immune microenvironment changes, current management paradigms, and potential therapeutic targets.
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Affiliation(s)
| | - Abdurrahman I Islim
- Corresponding Authors: Abdurrahman I. Islim, MPhil (); Omar N. Pathmanaban, PhD, FRCS (SN) (), Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, M6 8FT, UK; Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9NQ, UK
| | - Cathal John Hannan
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Adam P Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Simon R Freeman
- Department of Ears, Nose and Throat, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Simon Lloyd
- Department of Ears, Nose and Throat, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Michel Kalamarides
- Department of Neurosurgery, Sorbonne Université Pitié-Salpêtrière, Paris, France
| | - Miriam J Smith
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kevin Couper
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Catherine A McBain
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Michael D Jenkinson
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - David Brough
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Andrew T King
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - D Gareth Evans
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Omar N Pathmanaban
- Corresponding Authors: Abdurrahman I. Islim, MPhil (); Omar N. Pathmanaban, PhD, FRCS (SN) (), Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, M6 8FT, UK; Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9NQ, UK
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16
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Evans DG, Halliday D, Obholzer R, Afridi S, Forde C, Rutherford SA, Hammerbeck-Ward C, Lloyd SK, Freeman SM, Pathmanaban ON, Thomas OM, Laitt RD, Stivaros S, Kilday JP, Vassallo G, McBain C, Lavin T, Paterson C, Whitfield G, McCabe MG, Axon PR, Halliday J, Mackeith S, Parry A, Harkness EF, Buttimore J, King AT. Radiation treatment of benign tumours in NF2-related-schwannomatosis: a national study of 266 irradiated patients showing a significant increase in malignancy/malignant progression. Neurooncol Adv 2023; 5:vdad025. [PMID: 37051330 PMCID: PMC10084499 DOI: 10.1093/noajnl/vdad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023] Open
Abstract
Abstract
Background
Radiation treatment of benign tumours in tumour-predisposition syndromes is controversial, but short-term studies from treatment centres suggests safety despite apparent radiation associated malignancy being reported. We determined whether radiation treatment in NF2-related-schwannomatosis patients is associated with increased rates of subsequent malignancy-(M)/malignant progression-(MP).
Methods
All UK patients with NF2 were eligible if they had a clinical/molecular diagnosis. Cases were NF2 patients treated with radiation for benign tumours. Controls were matched for treatment location with surgical/medical treatments based on age and year of treatment. Prospective data collection began in 1990 with addition of retrospective cases to 1969. Kaplan-Meier analysis was performed for malignancy incidence and survival. Outcomes were CNS M/MP (2cm annualised diameter growth) and survival from index tumour treatment.
Results
1345 NF2 patients, 266 (133-Male) underwent radiation treatments between 1969-2021 with median first radiotherapy aged 32.9-(IQR=22.4-46.0). Nine subsequent CNS malignancies/malignant progressions were identified in cases with only four in 1079 untreated-(p<0.001). Lifetime and 20-year CNS M/MP was ~6% in all irradiated patients-(4.9% for VS radiotherapy) versus <1% in the non-irradiated population-(p<0.001/0.01). Controls were well-matched for age at NF2 diagnosis and treatment-(Males=133-50%) and had no M/MP in the CNS post index-tumour treatment-(p=0.0016). Thirty-year survival from index tumour treatment was 45.62%-(95%CI=34.0–56.5) for cases and 66.4%-(57.3–74.0) for controls-(p=0.02), but was non-significantly worse for VS radiotherapy.
Conclusion
-NF2 patients should not be offered radiotherapy as first line treatment of benign tumours and should be given a frank discussion of the potential 5% excess absolute risk of M/MP.
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Affiliation(s)
- D Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine , University of Manchester, St Mary’s Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust , University of Manchester, UK
| | - Dorothy Halliday
- Department of Genomic Medicine, Neurology, Neurosurgery , ENT, Oxford University Hospitals NHS Foundation Trust
| | - Rupert Obholzer
- Department of ENT, and Neurology, 18 Guy’s and St Thomas’ NHS Trust , London, UK
| | | | - Claire Forde
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine , University of Manchester, St Mary’s Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Simon K Lloyd
- Department of Otolaryngology, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Simon M Freeman
- Department of Otolaryngology, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health , University of Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust , University of Manchester, UK
| | - Owen M Thomas
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Roger D Laitt
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Stavros Stivaros
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences , Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, United Kingdom
- Academic Unit of Paediatric Radiology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust , University of Manchester, UK
| | - John-Paul Kilday
- Children’s Brain Tumour Research Network (CBTRN), Royal Manchester Children’s Hospital, Oxford Road , Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health , University of Manchester, UK
| | - Grace Vassallo
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine , University of Manchester, St Mary’s Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | - Catherine McBain
- The Christie NHS Foundation Trust , Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust , University of Manchester, UK
| | - Timothy Lavin
- Department of Neurology, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
| | - Chay Paterson
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine , University of Manchester, St Mary’s Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | - Gillian Whitfield
- Children’s Brain Tumour Research Network (CBTRN), Royal Manchester Children’s Hospital, Oxford Road , Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health , University of Manchester, UK
- The Christie NHS Foundation Trust , Manchester, UK
| | - Martin G McCabe
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health , University of Manchester, UK
- The Christie NHS Foundation Trust , Manchester, UK
| | - Patrick R Axon
- Dept of Otolaryngology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, UK
| | - Jane Halliday
- Department of Genomic Medicine, Neurology, Neurosurgery , ENT, Oxford University Hospitals NHS Foundation Trust
| | - Samuel Mackeith
- Department of Genomic Medicine, Neurology, Neurosurgery , ENT, Oxford University Hospitals NHS Foundation Trust
| | - Allyson Parry
- Department of Genomic Medicine, Neurology, Neurosurgery , ENT, Oxford University Hospitals NHS Foundation Trust
| | - Elaine F Harkness
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences , Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, United Kingdom
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester Universities NHS Foundation Trust , Wythenshawe, Manchester, UK
| | - Juliette Buttimore
- Dept of Otolaryngology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust , Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust , University of Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health , University of Manchester, UK
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17
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Hannan CJ, Lewis D, O'Leary C, Waqar M, Brough D, Couper KN, Dyer DP, Vail A, Heal C, Macarthur J, Cooper C, Hammerbeck-Ward C, Evans DG, Rutherford SA, Lloyd SK, Mackenzie Freeman SR, Coope DJ, King AT, Pathmanaban ON. Increased Circulating Chemokines and Macrophage Recruitment in Growing Vestibular Schwannomas. Neurosurgery 2023; 92:581-589. [PMID: 36729787 DOI: 10.1227/neu.0000000000002252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/20/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND There is evidence that macrophage infiltration in the tumor microenvironment promotes vestibular schwannoma (VS) growth. Efficacy of bevacizumab in NF2-associated VS demonstrates the value of therapies targeting the microvascular tumor microenvironment, and tumor-associated macrophages (TAMs) may represent another druggable target. OBJECTIVE To characterize the relationship between growth, TAM infiltration, and circulating monocyte chemokines in a large cohort of patients with VS. METHODS Immunostaining for Iba1 (macrophages), CD31 (endothelium), and fibrinogen (permeability) was performed on 101 growing and 19 static sporadic VS. The concentrations of monocyte-specific chemokines were measured in the plasma of 50 patients with growing VS and 25 patients with static VS. RESULTS The Iba1 + cell count was significantly higher in growing as compared with static VS (592 vs 226/×20 HPF, P =<0.001). Similarly, the CD31 + % surface area was higher in growing VS (2.19% vs 1.32%, P = .01). There was a positive correlation between TAM infiltration and VS growth rate, which persisted after controlling for the effect of tumor volume (aR2 = 0.263, P =<0.001). The plasma concentrations of several monocytic chemokines were higher in patients with growing rather than static VS. CONCLUSION There is a strong positive correlation between TAM infiltration and volumetric growth of VS, and this relationship is independent of tumor size. There is a colinear relationship between TAM infiltration and tumor vascularity, implying that inflammation and angiogenesis are interlinked in VS. Chemokines known to induce monocyte chemotaxis are found in higher concentrations in patients with growing VS, suggestive of a potential pathophysiological mechanism.
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Affiliation(s)
- Cathal John Hannan
- Manchester Centre for Clinical Neurosciences, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, UK
| | - Daniel Lewis
- Manchester Centre for Clinical Neurosciences, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
| | - Claire O'Leary
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
| | - Mueez Waqar
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
| | - David Brough
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
- Lydia Becker Institute of Inflammation and Immunology, University of Manchester, UK
| | - Kevin N Couper
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Lydia Becker Institute of Inflammation and Immunology, University of Manchester, UK
| | - Douglas P Dyer
- Wellcome Centre for Cell-Matrix Research, University of Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, University of Manchester, UK
| | - Calvin Heal
- Centre for Biostatistics, University of Manchester, UK
| | | | | | | | - D Gareth Evans
- St. Mary's Centre for Genomic Medicine
- Division of Evolution and Genomic Sciences, University of Manchester, UK
| | | | - Simon K Lloyd
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester, UK
- Department of Otolaryngology, Salford Royal Hospital, Manchester, UK
| | - Simon Richard Mackenzie Freeman
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
- Department of Otolaryngology, Salford Royal Hospital, Manchester, UK
| | - David John Coope
- Manchester Centre for Clinical Neurosciences, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
| | - Andrew T King
- Manchester Centre for Clinical Neurosciences, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, UK
| | - Omar Nathan Pathmanaban
- Manchester Centre for Clinical Neurosciences, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, University of Manchester, UK
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18
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King AT, Matesic L, Keaveney ST, Jamie JF. An Investigation into the In Vitro Metabolic Stability of Aryl Sulfonyl Fluorides for their Application in Medicinal Chemistry and Radiochemistry. Mol Pharm 2023; 20:1061-1071. [PMID: 36638322 DOI: 10.1021/acs.molpharmaceut.2c00806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Molecules that feature a sulfonyl fluoride (SO2F) moiety have been gaining increasing interest due to their unique reactivity and potential applications in synthetic chemistry, medicinal chemistry, and other biological uses. A particular interest is towards 18F-radiochemistry where sulfonyl fluorides can be used as a method to radiolabel biomolecules or can be used as radiofluoride relay reagents that facilitate radiolabeling of other molecules. The low metabolic stability of sulfonyl fluoride S-F bonds, however, presents an issue and limits the applicability of sulfonyl fluorides. The aim of this work was to increase understanding of what features contribute to the metabolic instability of the S-F bond in model aryl sulfonyl fluorides and identify approaches to increasing sulfonyl fluoride stability for 18F-radiochemistry and other medicinal, synthetic chemistry and biological applications. To undertake this, 14 model aryl sulfonyl fluorides compounds with varying functional groups and substitution patterns were investigated, and their stabilities were examined in various media, including phosphate-buffered saline and rat serum as a model for biological conditions. The results indicate that both electronic and steric factors affect the stability of the S-F bond, with the 2,4,6-trisubstituted model aryl sulfonyl fluorides examined displaying the highest in vitro metabolic stability.
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Affiliation(s)
- Andrew T King
- School of Natural Sciences, Wallumattagal Campus, Macquarie University, North Ryde, New South Wales 2109, Australia
| | - Lidia Matesic
- Australian Nuclear Science and Technology Organisation, New Illawarra Rd, Lucas Heights, New South Wales 2234, Australia
| | - Sinead T Keaveney
- School of Natural Sciences, Wallumattagal Campus, Macquarie University, North Ryde, New South Wales 2109, Australia.,School of Chemistry and Molecular Bioscience, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - Joanne F Jamie
- School of Natural Sciences, Wallumattagal Campus, Macquarie University, North Ryde, New South Wales 2109, Australia
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19
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Sadler KV, Bowes J, Rowlands CF, Perez-Becerril C, van der Meer CM, King AT, Rutherford SA, Pathmanaban ON, Hammerbeck-Ward C, Lloyd SKW, Freeman SR, Williams R, Hannan CJ, Lewis D, Eyre S, Evans DG, Smith MJ. Genome-wide association analysis identifies a susceptibility locus for sporadic vestibular schwannoma at 9p21. Brain 2022:6955845. [PMID: 36546557 DOI: 10.1093/brain/awac478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/26/2022] [Indexed: 12/24/2022] Open
Abstract
Vestibular schwannomas are benign nerve sheath tumours that arise on the vestibulocochlear nerves. Vestibular schwannomas are known to occur in the context of tumour predisposition syndromes NF2-related and LZTR1-related schwannomatosis. However, the majority of vestibular schwannomas present sporadically without identification of germline pathogenic variants. To identify novel genetic associations with risk of vestibular schwannoma development, we conducted a genome-wide association study in a cohort of 911 sporadic vestibular schwannoma cases collated from the neurofibromatosis type 2 genetic testing service in the North West of England, UK and 5,500 control samples from the UK Biobank resource. One risk locus reached genome-wide significance in our association analysis (9p21.3, rs1556516, P = 1.47e-13, odds ratio = 0.67, allele frequency = 0.52). 9p21.3 is a genome-wide association study association hotspot, and a number of genes are localised to this region, notably CDKN2B-AS1 and CDKN2A/B, also referred to as the INK4 locus. Dysregulation of gene products within the INK4 locus have been associated with multiple pathologies and the genes in this region have been observed to directly impact the expression of one another. Recurrent associations of the INK4 locus with components of well described oncogenic pathways provides compelling evidence that the 9p21.3 region is truly associated with risk of vestibular schwannoma tumourigenesis.
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Affiliation(s)
- Katherine V Sadler
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M13 9WL, UK
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - John Bowes
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Oxford Road, Manchester, UK
| | - Charlie F Rowlands
- Division of Genetics and Epidemiology, Institute of Cancer Research, Sutton, London, SM2 5NG, UK
| | - Cristina Perez-Becerril
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M13 9WL, UK
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - C Mwee van der Meer
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Andrew T King
- Department of Neurosurgery, and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M6 8HD, UK
| | - Scott A Rutherford
- Department of Neurosurgery, and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M6 8HD, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M6 8HD, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M6 8HD, UK
| | - Simon K W Lloyd
- Department of Otolaryngology, Manchester Royal Infirmary, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, M13 9WL, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, M13 9PL
| | - Simon R Freeman
- Department of Otolaryngology, Manchester Royal Infirmary, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, M13 9WL, UK
| | - Ricky Williams
- Brain Tumour Biobank, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre (MAHSC), Manchester, M6 8HD, UK
| | - Cathal John Hannan
- Department of Neurosurgery, and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M6 8HD, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Daniel Lewis
- Department of Neurosurgery, and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M6 8HD, UK
| | - Steve Eyre
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M13 9WL, UK
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Miriam J Smith
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Manchester, M13 9WL, UK
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
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20
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Pilkington SA, Bhome R, Gilbert S, Harris S, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study. Colorectal Dis 2021; 23:2436-2446. [PMID: 34032359 DOI: 10.1111/codi.15754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. METHOD Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . RESULTS Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. CONCLUSIONS Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.
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Affiliation(s)
- Sophie A Pilkington
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Rahul Bhome
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Sally Gilbert
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Scott Harris
- Primary Care and Population Studies, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Carl Richardson
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Thomas C Dudding
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - John S Knight
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Andrew T King
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Alex H Mirnezami
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Nicholas E Beck
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Paul H Nichols
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Karen P Nugent
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK
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21
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Forde C, King AT, Rutherford SA, Hammerbeck-Ward C, Lloyd SK, Freeman SR, Pathmanaban ON, Stapleton E, Thomas OM, Laitt RD, Stivaros S, Kilday JP, Vassallo G, McBain C, Kerrigan S, Smith MJ, McCabe MG, Harkness EF, Evans DG. Disease course of neurofibromatosis type 2: a 30-year follow-up study of 353 patients seen at a single institution. Neuro Oncol 2021; 23:1113-1124. [PMID: 33336705 DOI: 10.1093/neuonc/noaa284] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Limited data exist on the disease course of neurofibromatosis type 2 (NF2) to guide clinical trial design. METHODS A prospective database of patients meeting NF2 diagnostic criteria, reviewed between 1990 and 2020, was evaluated. Follow-up to first vestibular schwannoma (VS) intervention and death was assessed by univariate analysis and stratified by age at onset, era referred, and inheritance type. Interventions for NF2-related tumors were assessed. Cox regression was performed to determine the relationship between individual factors from time of diagnosis to NF2-related death. RESULTS Three hundred and fifty-three patients were evaluated. During 4643.1 follow-up years from diagnosis to censoring, 60 patients (17.0%) died. The annual mean number of patients undergoing VS surgery or radiotherapy declined, from 4.66 and 1.65, respectively, per 100 NF2 patients in 1990-1999 to 2.11 and 1.01 in 2010-2020, as the number receiving bevacizumab increased (2.51 per 100 NF2 patients in 2010-2020). Five patients stopped bevacizumab to remove growing meningioma or spinal schwannoma. 153/353 (43.3%) had at least one neurosurgical intervention/radiation treatment within 5 years of diagnosis. Patients asymptomatic at diagnosis had longer time to intervention and better survival compared to those presenting with symptoms. Those symptomatically presenting <16 and >40 years had poorer overall survival than those presenting at 26-39 years (P = .03 and P = .02, respectively) but those presenting between 16 and 39 had shorter time to VS intervention. Individuals with de novo constitutional variants had worse survival than those with de novo mosaic or inherited disease (P = .004). CONCLUSION Understanding disease course improves prognostication, allowing for better-informed decisions about care.
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Affiliation(s)
- Claire Forde
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | | | | | | | | | | | | | | | | | | | - Stavros Stivaros
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Academic Unit of Paediatric Radiology, Royal Manchester Children's Hospital, Manchester Universities NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - John-Paul Kilday
- Children's Brain Tumour Research Network (CBTRN), Royal Manchester Children's Hospital, Manchester, UK.,The Centre for Paediatric, Teenage and Young Adult Cancer, Institute of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Grace Vassallo
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | - Catherine McBain
- Departments of Paediatric and Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Simon Kerrigan
- Neurology.,Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Miriam J Smith
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | - Martin G McCabe
- Departments of Paediatric and Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Elaine F Harkness
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester, UK
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22
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Lewis D, McHugh DJ, Li KL, Zhu X, Mcbain C, Lloyd SK, Jackson A, Pathmanaban ON, King AT, Coope DJ. Detection of early changes in the post-radiosurgery vestibular schwannoma microenvironment using multinuclear MRI. Sci Rep 2021; 11:15712. [PMID: 34344960 PMCID: PMC8333359 DOI: 10.1038/s41598-021-95022-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/05/2021] [Indexed: 01/01/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is an established, effective therapy against vestibular schwannoma (VS). The mechanisms of tumour response are, however, unknown and in this study we sought to evaluate changes in the irradiated VS tumour microenvironment through a multinuclear MRI approach. Five patients with growing sporadic VS underwent a multi-timepoint comprehensive MRI protocol, which included diffusion tensor imaging (DTI), dynamic contrast-enhanced (DCE) MRI and a spiral 23Na-MRI acquisition for total sodium concentration (TSC) quantification. Post-treatment voxelwise changes in TSC, DTI metrics and DCE-MRI derived microvascular biomarkers (Ktrans, ve and vp) were evaluated and compared against pre-treatment values. Changes in tumour TSC and microvascular parameters were observable as early as 2 weeks post-treatment, preceding changes in structural imaging. At 6 months post-treatment there were significant voxelwise increases in tumour TSC (p < 0.001) and mean diffusivity (p < 0.001, repeated-measures ANOVA) with marked decreases in tumour microvascular parameters (p < 0.001, repeated-measures ANOVA). This study presents the first in vivo evaluation of alterations in the VS tumour microenvironment following SRS, demonstrating that changes in tumour sodium homeostasis and microvascular parameters can be imaged as early as 2 weeks following treatment. Future studies should seek to investigate these clinically relevant MRI metrics as early biomarkers of SRS response.
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Affiliation(s)
- Daniel Lewis
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK.
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK.
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK.
| | - Damien J McHugh
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Ka-Loh Li
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK
| | - Xiaoping Zhu
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK
| | - Catherine Mcbain
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Simon K Lloyd
- Department of Otolaryngology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Andrew T King
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - David J Coope
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
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23
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Li KL, Lewis D, Coope DJ, Roncaroli F, Agushi E, Pathmanaban ON, King AT, Zhao S, Jackson A, Cootes T, Zhu X. The LEGATOS technique: A new tissue-validated dynamic contrast-enhanced MRI method for whole-brain, high-spatial resolution parametric mapping. Magn Reson Med 2021; 86:2122-2136. [PMID: 33991126 DOI: 10.1002/mrm.28842] [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] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE A DCE-MRI technique that can provide both high spatiotemporal resolution and whole-brain coverage for quantitative microvascular analysis is highly desirable but currently challenging to achieve. In this study, we sought to develop and validate a novel dual-temporal resolution (DTR) DCE-MRI-based methodology for deriving accurate, whole-brain high-spatial resolution microvascular parameters. METHODS Dual injection DTR DCE-MRI was performed and composite high-temporal and high-spatial resolution tissue gadolinium-based-contrast agent (GBCA) concentration curves were constructed. The high-temporal but low-spatial resolution first-pass GBCA concentration curves were then reconstructed pixel-by-pixel to higher spatial resolution using a process we call LEGATOS. The accuracy of kinetic parameters (Ktrans , vp , and ve ) derived using LEGATOS was evaluated through simulations and in vivo studies in 17 patients with vestibular schwannoma (VS) and 13 patients with glioblastoma (GBM). Tissue from 15 tumors (VS) was examined with markers for microvessels (CD31) and cell density (hematoxylin and eosin [H&E]). RESULTS LEGATOS derived parameter maps offered superior spatial resolution and improved parameter accuracy compared to the use of high-temporal resolution data alone, provided superior discrimination of plasma volume and vascular leakage effects compared to other high-spatial resolution approaches, and correlated with tissue markers of vascularity (P ≤ 0.003) and cell density (P ≤ 0.006). CONCLUSION The LEGATOS method can be used to generate accurate, high-spatial resolution microvascular parameter estimates from DCE-MRI.
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Affiliation(s)
- Ka-Loh Li
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Daniel Lewis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom.,Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom
| | - David J Coope
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Federico Roncaroli
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Erjon Agushi
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom.,Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Sha Zhao
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Timothy Cootes
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Xiaoping Zhu
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
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24
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Smith MJ, Pathmanaban ON, Coope DJ, King AT, Evans DG. Comment on: SMARCB1 Gene Mutation Predisposes to Earlier Development of Glioblastoma: A Case Report of Familial GBM. J Neuropathol Exp Neurol 2021; 80:289-290. [PMID: 33617649 DOI: 10.1093/jnen/nlaa105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Miriam J Smith
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester, United Kingdom
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - David J Coope
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Division of Evolution and Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester Universities NHS Foundation Trust, Manchester, United Kingdom
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25
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Fountain DM, Smith MJ, O'Leary C, Pathmanaban ON, Roncaroli F, Bobola N, King AT, Evans DG. The spatial phenotype of genotypically distinct meningiomas demonstrate potential implications of the embryology of the meninges. Oncogene 2021; 40:875-884. [PMID: 33262459 PMCID: PMC8440207 DOI: 10.1038/s41388-020-01568-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/05/2020] [Accepted: 11/11/2020] [Indexed: 12/29/2022]
Abstract
Meningiomas are the most common primary brain tumor and their incidence and prevalence is increasing. This review summarizes current evidence regarding the embryogenesis of the human meninges in the context of meningioma pathogenesis and anatomical distribution. Though not mutually exclusive, chromosomal instability and pathogenic variants affecting the long arm of chromosome 22 (22q) result in meningiomas in neural-crest cell-derived meninges, while variants affecting Hedgehog signaling, PI3K signaling, TRAF7, KLF4, and POLR2A result in meningiomas in the mesodermal-derived meninges of the midline and paramedian anterior, central, and ventral posterior skull base. Current evidence regarding the common pathways for genetic pathogenesis and the anatomical distribution of meningiomas is presented alongside existing understanding of the embryological origins for the meninges prior to proposing next steps for this work.
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Affiliation(s)
- Daniel M Fountain
- Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust and the University of Manchester, Manchester, UK.
| | - Miriam J Smith
- Manchester Centre for Genomic Medicine, Manchester Academic Health Sciences Centre (MAHSC), St Mary's Hospital, School of Biological Sciences, Division of Evolution and Genomic Sciences, University of Manchester, Manchester, UK
| | - Claire O'Leary
- Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust and the University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust and the University of Manchester, Manchester, UK
| | - Federico Roncaroli
- Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust and the University of Manchester, Manchester, UK
| | - Nicoletta Bobola
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Andrew T King
- Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust and the University of Manchester, Manchester, UK
| | - Dafydd Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Sciences Centre (MAHSC), St Mary's Hospital, School of Biological Sciences, Division of Evolution and Genomic Sciences, University of Manchester, Manchester, UK
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26
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Hutchinson PJ, Edlmann E, Bulters D, Zolnourian A, Holton P, Suttner N, Agyemang K, Thomson S, Anderson IA, Al-Tamimi YZ, Henderson D, Whitfield PC, Gherle M, Brennan PM, Allison A, Thelin EP, Tarantino S, Pantaleo B, Caldwell K, Davis-Wilkie C, Mee H, Warburton EA, Barton G, Chari A, Marcus HJ, King AT, Belli A, Myint PK, Wilkinson I, Santarius T, Turner C, Bond S, Kolias AG. Trial of Dexamethasone for Chronic Subdural Hematoma. N Engl J Med 2020; 383:2616-2627. [PMID: 33326713 DOI: 10.1056/nejmoa2020473] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [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: 11/19/2022]
Abstract
BACKGROUND Chronic subdural hematoma is a common neurologic disorder that is especially prevalent among older people. The effect of dexamethasone on outcomes in patients with chronic subdural hematoma has not been well studied. METHODS We conducted a multicenter, randomized trial in the United Kingdom that enrolled adult patients with symptomatic chronic subdural hematoma. The patients were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The decision to surgically evacuate the hematoma was made by the treating clinician. The primary outcome was a score of 0 to 3, representing a favorable outcome, on the modified Rankin scale at 6 months after randomization; scores range from 0 (no symptoms) to 6 (death). RESULTS From August 2015 through November 2019, a total of 748 patients were included in the trial after randomization - 375 were assigned to the dexamethasone group and 373 to the placebo group. The mean age of the patients was 74 years, and 94% underwent surgery to evacuate their hematomas during the index admission; 60% in both groups had a score of 1 to 3 on the modified Rankin scale at admission. In a modified intention-to-treat analysis that excluded the patients who withdrew consent for participation in the trial or who were lost to follow-up, leaving a total of 680 patients, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (difference, -6.4 percentage points [95% confidence interval, -11.4 to -1.4] in favor of the placebo group; P = 0.01). Among the patients with available data, repeat surgery for recurrence of the hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group. More adverse events occurred in the dexamethasone group than in the placebo group. CONCLUSIONS Among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.).
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Affiliation(s)
- Peter J Hutchinson
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Ellie Edlmann
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Diederik Bulters
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Ardalan Zolnourian
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Patrick Holton
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Nigel Suttner
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Kevin Agyemang
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Simon Thomson
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Ian A Anderson
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Yahia Z Al-Tamimi
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Duncan Henderson
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Peter C Whitfield
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Monica Gherle
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Paul M Brennan
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Annabel Allison
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Eric P Thelin
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Silvia Tarantino
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Beatrice Pantaleo
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Karen Caldwell
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Carol Davis-Wilkie
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Harry Mee
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Elizabeth A Warburton
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Garry Barton
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Aswin Chari
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Hani J Marcus
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Andrew T King
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Antonio Belli
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Phyo K Myint
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Ian Wilkinson
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Thomas Santarius
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Carole Turner
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Simon Bond
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
| | - Angelos G Kolias
- From the Divisions of Neurosurgery (P.J.H., E.E., E.P.T., S. Tarantino, K.C., H.M., T.S., C.T., A.G.K.) and Neurology (E.A.W.), Department of Clinical Neurosciences, and the Division of Experimental Medicine and Immunotherapeutics (I.W.), Addenbrooke's Hospital, University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (A.A., B.P., C.D.-W., I.W., S.B.), Cambridge, the Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth (E.E.), and the South West Neurosurgical Centre, Derriford Hospital (E.E., P.C.W., M.G.), Plymouth, Wessex Neurological Unit, University Hospital Southampton, Southampton (D.B., A.Z., P.H.), the Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow (N.S., K.A.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S. Thomson, I.A.A.), the Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield (Y.Z.A.-T., D.H.), Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh (P.M.B.), Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich (G.B.), the Department of Neurosurgery, Great Ormond Street Hospital and Institute of Child Health, University College London (A.C.), and the National Hospital for Neurology and Neurosurgery (H.J.M.), London, the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester Academic Health Science Centre, Manchester (A.T.K.), the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre and Institute of Inflammation and Ageing, University of Birmingham, Birmingham (A.B.), and the Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen (P.K.M.) - all in the United Kingdom; and the Department of Neurology, Karolinska University Hospital, Stockholm (E.P.T.)
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Hannan CJ, Lewis D, O'Leary C, Donofrio CA, Evans DG, Stapleton E, Freeman SR, Lloyd SK, Rutherford SA, Hammerbeck-Ward C, Brough D, Allan SM, Coope D, King AT, Pathmanaban ON. Beyond Antoni: A Surgeon's Guide to the Vestibular Schwannoma Microenvironment. Skull Base Surg 2020; 83:1-10. [DOI: 10.1055/s-0040-1716688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
Abstract
Introduction Vestibular schwannomas (VS) are histologically benign tumors arising from cranial nerve VIII. Far from a homogenous proliferation of Schwann cells, mounting evidence has highlighted the complex nature of the inflammatory microenvironment in these tumors.
Methods A review of the literature pertaining to inflammation, inflammatory molecular pathways, and immune-related therapeutic targets in VS was performed. Relevant studies published up to June 2020 were identified based on a literature search in the PubMed and MEDLINE databases and the findings were synthesized into a concise narrative review of the topic.
Results The VS microenvironment is characterized by a dense infiltrate of inflammatory cells, particularly macrophages. Significantly higher levels of immune cell infiltration are observed in growing versus static tumors, and there is a demonstrable interplay between inflammation and angiogenesis in growing VS. While further mechanistic studies are required to ascertain the exact role of inflammation in angiogenesis, tumor growth, and Schwann cell control, we are beginning to understand the key molecular pathways driving this inflammatory microenvironment, and how these processes can be monitored and targeted in vivo.
Conclusion Observational research has revealed a complex and heterogeneous tumor microenvironment in VS. The functional landscape and roles of macrophages and other immune cells in the VS inflammatory infiltrate are, however, yet to be established. The antiangiogenic drug bevacizumab has shown the efficacy of targeted molecular therapies in VS and there is hope that agents targeting another major component of the VS microenvironment, inflammation, will also find a place in their future management.
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Affiliation(s)
- Cathal J. Hannan
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Daniel Lewis
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
| | - Claire O'Leary
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Carmine A. Donofrio
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
| | - Dafydd G. Evans
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, Manchester University Hospitals National Health Service Foundation Trust, Manchester, United Kingdom
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Emma Stapleton
- Department of Otolaryngology, Salford Royal Foundation Trust, Manchester, United Kingdom
- Department of Otolaryngology, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Simon R. Freeman
- Department of Otolaryngology, Salford Royal Foundation Trust, Manchester, United Kingdom
- Department of Otolaryngology, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Simon K. Lloyd
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Otolaryngology, Salford Royal Foundation Trust, Manchester, United Kingdom
- Department of Otolaryngology, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Scott A. Rutherford
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
| | - Charlotte Hammerbeck-Ward
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
| | - David Brough
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Stuart M. Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - David Coope
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Andrew T. King
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Omar N. Pathmanaban
- Surgical Neuro-Oncology Manchester (SNO-MAN) Laboratory, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, United Kingdom
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
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Lewis D, Donofrio CA, O'Leary C, Li KL, Zhu X, Williams R, Djoukhadar I, Agushi E, Hannan CJ, Stapleton E, Lloyd SK, Freeman SR, Wadeson A, Rutherford SA, Hammerbeck-Ward C, Evans DG, Jackson A, Pathmanaban ON, Roncaroli F, King AT, Coope DJ. The microenvironment in sporadic and neurofibromatosis type II-related vestibular schwannoma: the same tumor or different? A comparative imaging and neuropathology study. J Neurosurg 2020; 134:1419-1429. [PMID: 32470937 DOI: 10.3171/2020.3.jns193230] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Inflammation and angiogenesis may play a role in the growth of sporadic and neurofibromatosis type 2 (NF2)-related vestibular schwannoma (VS). The similarities in microvascular and inflammatory microenvironment have not been investigated. The authors sought to compare the tumor microenvironment (TME) in sporadic and NF2-related VSs using a combined imaging and tissue analysis approach. METHODS Diffusion MRI and high-temporal-resolution dynamic contrast-enhanced (DCE) MRI data sets were prospectively acquired in 20 NF2-related and 24 size-matched sporadic VSs. Diffusion metrics (mean diffusivity, fractional anisotropy) and DCE-MRI-derived microvascular biomarkers (transfer constant [Ktrans], fractional plasma volume, tissue extravascular-extracellular space [ve], longitudinal relaxation rate, tumoral blood flow) were compared across both VS groups, and regression analysis was used to evaluate the effect of tumor size, pretreatment tumor growth rate, and tumor NF2 status (sporadic vs NF2-related) on each imaging parameter. Tissues from 17 imaged sporadic VSs and a separate cohort of 12 NF2-related VSs were examined with immunohistochemistry markers for vessels (CD31), vessel permeability (fibrinogen), and macrophage density (Iba1). The expression of vascular endothelial growth factor (VEGF) and VEGF receptor 1 was evaluated using immunohistochemistry, Western blotting, and double immunofluorescence. RESULTS Imaging data demonstrated that DCE-MRI-derived microvascular characteristics were similar in sporadic and NF2-related VSs. Ktrans (p < 0.001), ve (p ≤ 0.004), and tumoral free water content (p ≤ 0.003) increased with increasing tumor size and pretreatment tumor growth rate. Regression analysis demonstrated that with the exception of mean diffusivity (p < 0.001), NF2 status had no statistically significant effect on any of the imaging parameters or the observed relationship between the imaging parameters and tumor size (p > 0.05). Tissue analysis confirmed the imaging metrics among resected sporadic VSs and demonstrated that across all VSs studied, there was a close association between vascularity and Iba1+ macrophage density (r = 0.55, p = 0.002). VEGF was expressed by Iba1+ macrophages. CONCLUSIONS The authors present the first in vivo comparative study of microvascular and inflammatory characteristics in sporadic and NF2-related VSs. The imaging and tissue analysis results indicate that inflammation is a key contributor to TME and should be viewed as a therapeutic target in both VS groups.
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Affiliation(s)
- Daniel Lewis
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,2Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester
| | - Carmine A Donofrio
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Claire O'Leary
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,3Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester
| | - Ka-Loh Li
- 2Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester
| | - Xiaoping Zhu
- 2Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester
| | - Ricky Williams
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Ibrahim Djoukhadar
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Erjon Agushi
- 2Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester
| | - Cathal J Hannan
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Emma Stapleton
- 4Department of Otolaryngology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Simon K Lloyd
- 4Department of Otolaryngology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Simon R Freeman
- 4Department of Otolaryngology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Andrea Wadeson
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Scott A Rutherford
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Charlotte Hammerbeck-Ward
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - D Gareth Evans
- 5Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester
| | - Alan Jackson
- 2Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester
| | - Omar N Pathmanaban
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,6Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester; and
| | - Federico Roncaroli
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,3Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester
| | - Andrew T King
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,7Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - David J Coope
- 1Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre.,3Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester
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Evans BJ, King AT, Katsifis A, Matesic L, Jamie JF. Methods to Enhance the Metabolic Stability of Peptide-Based PET Radiopharmaceuticals. Molecules 2020; 25:molecules25102314. [PMID: 32423178 PMCID: PMC7287708 DOI: 10.3390/molecules25102314] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 12/28/2022] Open
Abstract
The high affinity and specificity of peptides towards biological targets, in addition to their favorable pharmacological properties, has encouraged the development of many peptide-based pharmaceuticals, including peptide-based positron emission tomography (PET) radiopharmaceuticals. However, the poor in vivo stability of unmodified peptides against proteolysis is a major challenge that must be overcome, as it can result in an impractically short in vivo biological half-life and a subsequently poor bioavailability when used in imaging and therapeutic applications. Consequently, many biologically and pharmacologically interesting peptide-based drugs may never see application. A potential way to overcome this is using peptide analogues designed to mimic the pharmacophore of a native peptide while also containing unnatural modifications that act to maintain or improve the pharmacological properties. This review explores strategies that have been developed to increase the metabolic stability of peptide-based pharmaceuticals. It includes modifications of the C- and/or N-termini, introduction of d- or other unnatural amino acids, backbone modification, PEGylation and alkyl chain incorporation, cyclization and peptide bond substitution, and where those strategies have been, or could be, applied to PET peptide-based radiopharmaceuticals.
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Affiliation(s)
- Brendan J. Evans
- Department of Molecular Sciences, Macquarie University, Sydney, NSW 2109, Australia; (B.J.E.); (A.T.K.)
| | - Andrew T. King
- Department of Molecular Sciences, Macquarie University, Sydney, NSW 2109, Australia; (B.J.E.); (A.T.K.)
| | - Andrew Katsifis
- Department of Molecular Imaging, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
| | - Lidia Matesic
- Australian Nuclear Science and Technology Organisation (ANSTO), Lucas Heights, NSW 2234, Australia;
| | - Joanne F. Jamie
- Department of Molecular Sciences, Macquarie University, Sydney, NSW 2109, Australia; (B.J.E.); (A.T.K.)
- Correspondence: ; Tel.: +61-2-9850-8283
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Anton-Rodriguez JM, Lewis D, Djoukhadar I, Russell D, Julyan P, Coope D, King AT, Lloyd SKL, Evans DG, Jackson A, Matthews JC. [18F]fluorothymidine and [18F]fluorodeoxyglucose PET Imaging Demonstrates Uptake and Differentiates Growth in Neurofibromatosis 2 Related Vestibular Schwannoma. Otol Neurotol 2020; 40:826-835. [PMID: 31033921 PMCID: PMC6594723 DOI: 10.1097/mao.0000000000002272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text Objective: To investigate whether [18F]fluorothymidine (FLT) and/or [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) can differentiate growth in neurofibromatosis 2 (NF2) related vestibular schwannomas (VS) and to evaluate the importance of PET scanner spatial resolution on measured tumor uptake. Methods: Six NF2 patients with 11 VS (4 rapidly growing, 7 indolent), were scanned with FLT and FDG using a high-resolution research tomograph (HRRT, Siemens) and a Siemens Biograph TrueV PET-CT, with and without resolution modeling image reconstruction. Mean, maximum, and peak standardised uptake values (SUV) for each tumor were derived and the intertumor correlation between FDG and FLT uptake was compared. The ability of FDG and FLT SUV values to discriminate between rapidly growing and slow growing (indolent) tumors was assessed using receiver operator characteristic (ROC) analysis. Results: Tumor uptake was seen with both tracers, using both scanners, with and without resolution modeling. FDG and FLT uptake was correlated (R2 = 0.67–0.86, p < 0.01) and rapidly growing tumors displayed significantly higher uptake (SUVmean and SUVpeak) of both tracers (p < 0.05, one tailed t test). All of the PET analyses performed demonstrated better discriminatory power (AUCROC range = 0.71–0.86) than tumor size alone (AUCROC = 0.61). The use of standard resolution scanner with standard reconstruction did not result in a notable deterioration of discrimination accuracy. Conclusion: NF2 related VS demonstrate uptake of both FLT and FDG, which is significantly increased in rapidly growing tumors. A short static FDG PET scan with standard clinical resolution and reconstruction can provide relevant information on tumor growth to aid clinical decision making.
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Affiliation(s)
- Jose M Anton-Rodriguez
- Division of Informatics, Imaging and Data Sciences, MAHSC, University of Manchester.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester
| | - Daniel Lewis
- Division of Informatics, Imaging and Data Sciences, MAHSC, University of Manchester.,Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust
| | - Ibrahim Djoukhadar
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - David Russell
- Department of Radiology, Manchester University NHS Foundation Trust
| | - Peter Julyan
- Division of Informatics, Imaging and Data Sciences, MAHSC, University of Manchester.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester
| | - David Coope
- Division of Informatics, Imaging and Data Sciences, MAHSC, University of Manchester.,Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust
| | - Andrew T King
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust
| | - Simon K L Lloyd
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University Hospitals National Health Service Foundation Trust and Manchester Academic Health Science Centre, Manchester, UK
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, MAHSC, University of Manchester.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester
| | - Julian C Matthews
- Division of Informatics, Imaging and Data Sciences, MAHSC, University of Manchester.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester
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Mazza M, Ahmad H, Hadjidemetriou M, Agliardi G, Pathmanaban ON, King AT, Bigger BW, Vranic S, Kostarelos K. Hampering brain tumor proliferation and migration using peptide nanofiber:si PLK1/ MMP2 complexes. Nanomedicine (Lond) 2019; 14:3127-3142. [PMID: 31855120 DOI: 10.2217/nnm-2019-0298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To develop a nonviral tool for the delivery of siRNA to brain tumor cells using peptide nanofibers (PNFs). Materials & methods: Uptake of PNFs was evaluated by confocal microscopy and flow cytometry. Gene silencing was determined by RT-qPCR and cell invasion assay. Results: PNFs enter phagocytic (BV-2) and nonphagocytic (U-87 MG) cells via endocytosis and passive translocation. siPLK1 delivered using PNFs reduced the expression of polo-like kinase 1 mRNA and induced cell death in a panel of immortalized and glioblastoma-derived stem cells. Moreover, targeting MMP2 using PNF:siMMP2 reduced the invasion capacity of U-87 MG cells. We show that stereotactic intra-tumoral administration of PNF:siPLK1 significantly extends the survival of tumor bearing mice comparing with the untreated tumor bearing animals. Conclusion: Our results suggest that this nanomedicine-based RNA interference approach deserves further investigation as a potential brain tumor therapeutic tool.
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Affiliation(s)
- Mariarosa Mazza
- Nanomedicine Lab, Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester, M13 9PT, UK
| | - Hassan Ahmad
- Nanomedicine Lab, Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester, M13 9PT, UK
| | - Marilena Hadjidemetriou
- Nanomedicine Lab, Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester, M13 9PT, UK
| | - Giulia Agliardi
- Nanomedicine Lab, Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester, M13 9PT, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, M6 8HD, UK
| | - Andrew T King
- Department of Neurosurgery, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, M6 8HD, UK
| | - Brian W Bigger
- Stem Cell & Neurotherapies Group, School of Biological Sciences, Faculty of Biology Medicine & Health, Division of Cell Matrix Biology & Regenerative Medicine, University of Manchester, Manchester, M13 9PT, UK
| | - Sandra Vranic
- Nanomedicine Lab, Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester, M13 9PT, UK
- National Graphene Institute, The University of Manchester, Booth Street East, Manchester, M13 9PL, UK
| | - Kostas Kostarelos
- Nanomedicine Lab, Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester, M13 9PT, UK
- National Graphene Institute, The University of Manchester, Booth Street East, Manchester, M13 9PL, UK
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King AT, Rutherford SA, Hammerbeck-Ward C, Lloyd SK, Freeman SM, Pathmanaban ON, Rodriguez-Valero M, Thomas OM, Laitt RD, Stivaros S, Kellett M, Evans DG. High-Grade Glioma is not a Feature of Neurofibromatosis Type 2 in the Unirradiated Patient. Neurosurgery 2019; 83:193-196. [PMID: 28973691 DOI: 10.1093/neuros/nyx374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/25/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Manchester criteria for neurofibromatosis type 2 (NF2) include a range of tumors, and gliomas were incorporated in the original description. The gliomas are now widely accepted to be predominantly spinal cord ependymomas. OBJECTIVE To determine whether these gliomas include any cases of malignant glioma (WHO grade III and IV) through a database review. METHODS The prospective database consists of 1253 patients with NF2. 1009 are known to be alive at last follow-up. RESULTS There was a single case of glioblastoma multiforme (GBM; World Health Organization grade IV) in the series and no WHO grade III gliomas. The GBM was in a patient who had previously undergone stereotactic radiosurgery for a vestibular schwannoma. CONCLUSION High-grade gliomas are not a feature of NF2 in the unirradiated patient and should be excluded from the diagnostic criteria.
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Affiliation(s)
- Andrew T King
- Department of Neurosurgery, Manche-ster Academic Health Science Centre, Sal-ford Royal NHS Foundation Trust, Man-chester, United Kingdom
| | - Scott A Rutherford
- Department of Neurosurgery, Manche-ster Academic Health Science Centre, Sal-ford Royal NHS Foundation Trust, Man-chester, United Kingdom
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manche-ster Academic Health Science Centre, Sal-ford Royal NHS Foundation Trust, Man-chester, United Kingdom
| | - Simon K Lloyd
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Simon M Freeman
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manche-ster Academic Health Science Centre, Sal-ford Royal NHS Foundation Trust, Man-chester, United Kingdom
| | - Monica Rodriguez-Valero
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Owen M Thomas
- Department of Neuroradiology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Roger D Laitt
- Department of Neuroradiology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Stavros Stivaros
- Department of Neuroradiology, Manchester Academic Health Science Centre, Central Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Mark Kellett
- Department of Neurology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - D Gareth Evans
- Department of Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Central Manchester NHS Foundation Trust, Manchester, United Kingdom
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King AT, Rutherford SA, Hammerbeck-Ward C, Lloyd SK, Freeman SR, Pathmanaban ON, Kellett M, Obholzer R, Afridi S, Axon P, Halliday D, Parry A, Thomas OM, Laitt RD, McCabe MG, Stivaros S, Erridge S, Evans DG. Malignant Peripheral Nerve Sheath Tumors are not a Feature of Neurofibromatosis Type 2 in the Unirradiated Patient. Neurosurgery 2019; 83:38-42. [PMID: 28973692 DOI: 10.1093/neuros/nyx368] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 06/25/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The published literature suggests that malignant peripheral nerve sheath tumors (MPNST) occur at increased frequency in neurofibromatosis type 2 (NF2). A recent review based on incidence data in North America showed that 1 per 1000 cerebellopontine angle nerve sheath tumors were malignant. OBJECTIVE To determine whether MPNST occurred spontaneously in NF2 by reviewing our NF2 database. METHODS The prospective database consists of 1253 patients with NF2. One thousand and nine are known to be alive at last follow-up. The presence and laterality/pathology of vestibular schwannoma at diagnosis and last follow-up was sought. RESULTS There were no cases of spontaneous MPNST with 2114 proven (n = 1150) and presumed benign (n = 964) vestibular schwannomas found. Two patients had developed MPNST (1 presumed) after having previously undergone stereotactic radiosurgery for a vestibular schwannoma. CONCLUSION In this series, and from the literature, malignant transformation of a vestibular schwannoma was not a feature of NF2 in the unirradiated patient. NF2 patients should not be told that they have an increased risk of malignant change in a vestibular schwannoma unless they undergo radiation treatment. However, very much larger datasets are required before it can be determined whether there is any association between NF2 and MPNST in the unirradiated patient.
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Affiliation(s)
- Andrew T King
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Simon K Lloyd
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Simon R Freeman
- Department of Otolaryngology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Mark Kellett
- Department of Neurology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Rupert Obholzer
- Department of Otolaryngology, Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Shazia Afridi
- Department of Neurology, Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Patrick Axon
- Department of Otolaryngology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Dorothy Halliday
- Department of Clinical Genetics, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Allyson Parry
- Department of Neurology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Owen M Thomas
- Department of Neuroradiology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Roger D Laitt
- Department of Neuroradiology, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Martin G McCabe
- Centre for Paediatric, Teenage and Young Adult Cancer, Institute of Cancer Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Stavros Stivaros
- Department of Neuroradiology, Manchester Academic Health Science Centre, Central Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Sara Erridge
- Institute of Cancer Sciences, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, United Kingdom
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Science Centre, Central Manchester NHS Foundation Trust, Manchester, United Kingdom
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Waqar M, Davies BM, Zakaria R, Barone DG, Kolias AG, Yu KK, Ellenbogen JR, Brennan PM, Kotter MR, Gray WP, King AT, Turner C, Kitchen N, May P, Jenkinson MD, Hutchinson PJ. Academic neurosurgery in the UK: present and future directions. Postgrad Med J 2019; 95:524-530. [PMID: 31431519 DOI: 10.1136/postgradmedj-2019-136805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/28/2019] [Indexed: 11/04/2022]
Abstract
Academic neurosurgery encompasses basic science and clinical research efforts to better understand and treat diseases of relevance to neurosurgical practice, with the overall aim of improving treatment and outcome for patients. In this article, we provide an overview of the current and future directions of British academic neurosurgery. Training pathways are considered together with personal accounts of experiences of structured integrated clinical academic training and unstructured academic training. Life as an academic consultant is also described. Funding is explored, for the specialty as a whole and at the individual level. UK academic neurosurgical organisations are highlighted. Finally, the UK's international standing is considered.
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Affiliation(s)
- Mueez Waqar
- Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Benjamin M Davies
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Rasheed Zakaria
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Damiano G Barone
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Kenny K Yu
- Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh and Western General Hospital, Edinburgh, UK
| | - Mark Rn Kotter
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - William P Gray
- Neurosurgery, University Hospital Wales, Heath Park, Cardiff, UK
| | - Andrew T King
- Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Carole Turner
- Surgery Theme, Cambridge Clinical Trials Unit, Cambridge, UK
| | - Neil Kitchen
- Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Paul May
- Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Peter J Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
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Evans DG, Hartley CL, Smith PT, King AT, Bowers NL, Tobi S, Wallace AJ, Perry M, Anup R, Lloyd SKW, Rutherford SA, Hammerbeck-Ward C, Pathmanaban ON, Stapleton E, Freeman SR, Kellett M, Halliday D, Parry A, Gair JJ, Axon P, Laitt R, Thomas O, Afridi SK, Obholzer R, Duff C, Stivaros SM, Vassallo G, Harkness EF, Smith MJ. Incidence of mosaicism in 1055 de novo NF2 cases: much higher than previous estimates with high utility of next-generation sequencing. Genet Med 2019; 22:53-59. [PMID: 31273341 DOI: 10.1038/s41436-019-0598-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [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: 03/22/2019] [Accepted: 06/19/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the incidence of mosaicism in de novo neurofibromatosis 2 (NF2). METHODS Patients fulfilling NF2 criteria, but with no known affected family member from a previous generation (n = 1055), were tested for NF2 variants in lymphocyte DNA and where available tumor DNA. The proportion of individuals with a proven or presumed mosaic NF2 variant was assessed and allele frequencies of identified variants evaluated using next-generation sequencing. RESULTS The rate of proven/presumed mosaicism was 232/1055 (22.0%). However, nonmosaic heterozygous pathogenic variants were only identified in 387/1055 (36.7%). When variant detection rates in second generation nonmosaics were applied to de novo cases, we assessed the overall probable mosaicism rate to be 59.7%. This rate differed by age from 21.7% in those presenting with bilateral vestibular schwannoma <20 years to 80.7% in those aged ≥60 years. A mosaic variant was detected in all parents of affected children with a single-nucleotide pathogenic NF2 variant. CONCLUSION This study has identified a very high probable mosaicism rate in de novo NF2, probably making NF2 the condition with the highest expressed rate of mosaicism in de novo dominant disease that is nonlethal in heterozygote form. Risks to offspring are small and probably correlate with variant allele frequency detected in blood.
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Affiliation(s)
- D Gareth Evans
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK.
| | - Claire L Hartley
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Philip T Smith
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Naomi L Bowers
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Simon Tobi
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Andrew J Wallace
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Mary Perry
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Raji Anup
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Simon K W Lloyd
- Department of Otolaryngology, Manchester Royal Infirmary, University of Manchester, Manchester, UK.,Salford Royal Foundation Trust, Manchester, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Emma Stapleton
- Department of Otolaryngology, Manchester Royal Infirmary, University of Manchester, Manchester, UK.,Salford Royal Foundation Trust, Manchester, UK
| | - Simon R Freeman
- Department of Otolaryngology, Manchester Royal Infirmary, University of Manchester, Manchester, UK.,Salford Royal Foundation Trust, Manchester, UK
| | - Mark Kellett
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Dorothy Halliday
- Oxford Centre for Genomic Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Allyson Parry
- Neurosciences, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Juliette J Gair
- Department of Otolaryngology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick Axon
- Department of Otolaryngology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Roger Laitt
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Owen Thomas
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal Foundation Trust, Manchester, UK
| | - Shazia K Afridi
- Department of Neurology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rupert Obholzer
- Department of Neurology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Chris Duff
- Department of Plastic Surgery, Manchester Universities Foundation Trust, Manchester, UK
| | - Stavros M Stivaros
- Department of Paediatric Neurology, Manchester Universities Foundation Trust, Manchester, UK
| | - Grace Vassallo
- Department of Paediatric Neurology, Manchester Universities Foundation Trust, Manchester, UK
| | - Elaine F Harkness
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Miriam J Smith
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, St Mary's Hospital, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
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King AT, Hiscocks HG, Matesic L, Bhadbhade M, Bishop R, Ung AT. Formation of an unexpected 3,3-diphenyl-3 H-indazole through a facile intramolecular [2 + 3] cycloaddition of the diazo intermediate. Beilstein J Org Chem 2019; 15:1347-1354. [PMID: 31293684 PMCID: PMC6604747 DOI: 10.3762/bjoc.15.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/07/2019] [Indexed: 11/23/2022] Open
Abstract
The one-pot reaction of 2,6-bis(diphenylmethyl)-4-methoxyaniline with tert-butylnitrite, BTEAC and DABSO in the presence of CuCl2 provided an unexpected 3H-indazole product 8. The structure of the compound was determined by HRMS, IR, NMR and further confirmed by single crystal X-ray crystallography. The compound crystallises in the triclinic P-1 space group, with unit cell parameters a = 9.2107 (4), b = 10.0413 (5), c = 14.4363 (6) Å, α = 78.183 (2), β = 87.625 (2), γ = 71.975 (2)°. The formation of 8 proceeded through a facile intramolecular [2 + 3] cycloaddition of the diazo intermediate 9. The molecules of 8 are organised by edge-face Ar-H···π, face-face π···π, and bifurcated OCH2-H···N interactions. In addition to these, there are Ar-H···H-Ar close contacts, (edge-edge and surrounding inversion centres) arranged as infinite tapes along the a direction.
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Affiliation(s)
- Andrew T King
- School of Mathematical and Physical Sciences, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
| | - Hugh G Hiscocks
- School of Mathematical and Physical Sciences, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
| | - Lidia Matesic
- School of Mathematical and Physical Sciences, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
- Australian Nuclear Science and Technology Organisation, Locked Bag 2001, Kirrawee DC, NSW, 2232, Australia
| | - Mohan Bhadbhade
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Roger Bishop
- School of Chemistry, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Alison Thavary Ung
- School of Mathematical and Physical Sciences, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia
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Lewis D, Roncaroli F, Agushi E, Mosses D, Williams R, Li KL, Zhu X, Hinz R, Atkinson R, Wadeson A, Hulme S, Mayers H, Stapleton E, Lloyd SKL, Freeman SR, Rutherford SA, Hammerbeck-Ward C, Evans DG, Pathmanaban O, Jackson A, King AT, Coope DJ. Inflammation and vascular permeability correlate with growth in sporadic vestibular schwannoma. Neuro Oncol 2019; 21:314-325. [PMID: 30388263 PMCID: PMC6380424 DOI: 10.1093/neuonc/noy177] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inflammation is hypothesized to be a key event in the growth of sporadic vestibular schwannoma (VS). In this study we sought to investigate the relationship between inflammation and tumor growth in vivo using the PET tracer 11C-(R)-PK11195 and dynamic contrast enhanced (DCE) MRI derived vascular biomarkers. METHODS Nineteen patients with sporadic VS (8 static, 7 growing, and 4 shrinking tumors) underwent prospective imaging with dynamic 11C-(R)-PK11195 PET and a comprehensive MR protocol, including high temporal resolution DCE-MRI in 15 patients. An intertumor comparison of 11C-(R)-PK11195 binding potential (BPND) and DCE-MRI derived vascular biomarkers (Ktrans, vp, ve) across the 3 different tumor growth cohorts was undertaken. Tissue of 8 tumors was examined with immunohistochemistry markers for inflammation (Iba1), neoplastic cells (S-100 protein), vessels (CD31), the PK11195 target translocator protein (TSPO), fibrinogen for vascular permeability, and proliferation (Ki-67). Results were correlated with PET and DCE-MRI data. RESULTS Compared with static tumors, growing VS displayed significantly higher mean 11C-(R)-PK11195 BPND (-0.07 vs 0.47, P = 0.020), and higher mean tumor Ktrans (0.06 vs 0.14, P = 0.004). Immunohistochemistry confirmed the imaging findings and demonstrated that TSPO is predominantly expressed in macrophages. Within growing VS, macrophages rather than tumor cells accounted for the majority of proliferating cells. CONCLUSION We present the first in vivo imaging evidence of increased inflammation within growing sporadic VS. Our results demonstrate that 11C-(R)-PK11195 specific binding and DCE-MRI derived parameters can be used as imaging biomarkers of inflammation and vascular permeability in this tumor group.
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Affiliation(s)
- Daniel Lewis
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Wolfson Molecular Imaging Centre, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Federico Roncaroli
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Erjon Agushi
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Wolfson Molecular Imaging Centre, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Dominic Mosses
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Ricky Williams
- Brain Tumour Biobank, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ka-loh Li
- Wolfson Molecular Imaging Centre, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Xiaoping Zhu
- Wolfson Molecular Imaging Centre, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Rainer Hinz
- Wolfson Molecular Imaging Centre, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Ross Atkinson
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrea Wadeson
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sharon Hulme
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Helen Mayers
- Department of Cellular Pathology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Emma Stapleton
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon K L Lloyd
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon R Freeman
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Scott A Rutherford
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Charlotte Hammerbeck-Ward
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University Hospitals National Health Service Foundation Trust and Manchester Academic Health Science Centre, Manchester, UK
| | - Omar Pathmanaban
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alan Jackson
- Wolfson Molecular Imaging Centre, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Andrew T King
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Manchester Skull Base Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David J Coope
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Evans DG, Bowers NL, Tobi S, Hartley C, Wallace AJ, King AT, Lloyd SKW, Rutherford SA, Hammerbeck-Ward C, Pathmanaban ON, Freeman SR, Ealing J, Kellett M, Laitt R, Thomas O, Halliday D, Ferner R, Taylor A, Duff C, Harkness EF, Smith MJ. Schwannomatosis: a genetic and epidemiological study. J Neurol Neurosurg Psychiatry 2018; 89:1215-1219. [PMID: 29909380 DOI: 10.1136/jnnp-2018-318538] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Schwannomatosis is a dominantly inherited condition predisposing to schwannomas of mainly spinal and peripheral nerves with some diagnostic overlap with neurofibromatosis-2 (NF2), but the underlying epidemiology is poorly understood. We present the birth incidence and prevalence allowing for overlap with NF2. METHODS Schwannomatosis and NF2 cases were ascertained from the Manchester region of England (population=4.8 million) and from across the UK. Point prevalence and birth incidence were calculated from regional birth statistics. Genetic analysis was also performed on NF2, LZTR1 and SMARCB1 on blood and tumour DNA samples when available. RESULTS Regional prevalence for schwannomatosis and NF2 were 1 in 126 315 and 50 500, respectively, with calculated birth incidences of 1 in 68 956 and 1 in 27 956. Mosaic NF2 causes a substantial overlap with schwannomatosis resulting in the misdiagnosis of at least 9% of schwannomatosis cases. LZTR1-associated schwannomatosis also causes a small number of cases that are misdiagnosed with NF2 (1%-2%), due to the occurrence of a unilateral vestibular schwannoma. Patients with schwannomatosis had lower numbers of non-vestibular cranial schwannomas, but more peripheral and spinal nerve schwannomas with pain as a predominant presenting symptom. Life expectancy was significantly better in schwannomatosis (mean age at death 76.9) compared with NF2 (mean age at death 66.2; p=0.004). CONCLUSIONS Within the highly ascertained North-West England population, schwannomatosis has less than half the birth incidence and prevalence of NF2.
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Affiliation(s)
- D Gareth Evans
- Department of Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Naomi L Bowers
- Department of Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Simon Tobi
- Department of Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Claire Hartley
- Department of Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Andrew J Wallace
- Department of Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
| | - Andrew T King
- Department of Neurosurgery and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Simon K W Lloyd
- Department of Otolaryngology, Manchester Royal Infirmary, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Scott A Rutherford
- Department of Neurosurgery and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Simon R Freeman
- Department of Otolaryngology, Manchester Royal Infirmary, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - John Ealing
- Department of Neurology, Salford Royal Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Mark Kellett
- Department of Neurology, Salford Royal Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Roger Laitt
- Department of Neurosurgery and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Owen Thomas
- Department of Neurosurgery and Neuroradiology Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Dorothy Halliday
- Oxford Centre for Genomic Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rosalie Ferner
- Department of Neurology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amy Taylor
- Department of Medical Genetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Chris Duff
- Department of Plastic Surgery, Wythenshawe Hospital, Manchester Universities Foundation Trust, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Elaine F Harkness
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Miriam J Smith
- Department of Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
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Evans DG, Wallace AJ, Hartley C, Freeman SR, Lloyd SK, Thomas O, Axon P, Hammerbeck-Ward CL, Pathmanaban O, Rutherford SA, Kellett M, Laitt R, King AT, Bischetsrieder J, Blakeley J, Smith MJ. Familial unilateral vestibular schwannoma is rarely caused by inherited variants in the NF2 gene. Laryngoscope 2018; 129:967-973. [PMID: 30325044 PMCID: PMC6563429 DOI: 10.1002/lary.27554] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/20/2018] [Accepted: 08/15/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES/HYPOTHESIS Unilateral vestibular schwannoma (VS) occurs with a lifetime risk of around 1 in 1,000 and is due to inactivation of the NF2 gene, either somatically or from a constitutional mutation. It has been postulated that familial occurrence of unilateral VS occurs more frequently than by chance, but no causal mechanism has been confirmed. STUDY DESIGN Retrospective database analysis. METHODS The likelihood of chance occurrence of unilateral VS, or occurring in the context of neurofibromatosis type 2 (NF2), was assessed using national UK audit data and data from the national NF2 database. Families with familial unilateral VS (occurrence in first- and second-degree relatives) were assessed for constitutional NF2 and LZTR1 genetic variants, and where possible the tumor was also analyzed. RESULTS Approximately 1,000 cases of unilateral VS occurred annually in the United Kingdom between 2013 and 2016. Of these, 2.5 may be expected to have a first-degree relative who had previously developed a unilateral VS. The likelihood of this occurring in NF2 was considered to be as low as 0.05 annually. None of 28 families with familial unilateral VS had a constitutional NF2 intragenic variant, and in nine cases where the VS was analyzed, both mutational events in NF2 were identified and excluded from the germline. Only three variants of uncertain significance were found in LZTR1. CONCLUSIONS Familial occurrence of unilateral VS is very unlikely to be due to a constitutional NF2 or definitely pathogenic LZTR1 variant. The occurrence of unilateral VS in two or more first-degree relatives is likely due to chance. This phenomenon may well increase in clinical practice with increasing use of cranial magnetic resonance imaging in older patients. LEVEL OF EVIDENCE 2b Laryngoscope, 129:967-973, 2019.
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Affiliation(s)
- D Gareth Evans
- Department of Genomic Medicine, Manchester, United Kingdom
| | | | - Claire Hartley
- Department of Genomic Medicine, Manchester, United Kingdom
| | - Simon R Freeman
- Department of Otolaryngology, University of Manchester, Manchester Academic Health Science Centre, Division of Evolution and Genomic Sciences, Manchester Universities NHS Foundation Trust, Manchester, United Kingdom
| | - Simon K Lloyd
- Department of Otolaryngology, University of Manchester, Manchester Academic Health Science Centre, Division of Evolution and Genomic Sciences, Manchester Universities NHS Foundation Trust, Manchester, United Kingdom
| | - Owen Thomas
- Department of NeuroRadiology, Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom
| | - Patrick Axon
- Department of Otolaryngology, Addenbrooke's Hospital Cambridge, United Kingdom
| | | | - Omar Pathmanaban
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom
| | - Scott A Rutherford
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom
| | - Mark Kellett
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom
| | - Roger Laitt
- Department of NeuroRadiology, Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom
| | - Andrew T King
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, Manchester, United Kingdom
| | | | | | - Miriam J Smith
- Department of Genomic Medicine, Manchester, United Kingdom
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Pilkington SA, Bhome R, Welch RE, Ku F, Warden C, Harris S, Hicks J, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Bilateral versus unilateral botulinum toxin injections for chronic anal fissure: a randomised trial. Tech Coloproctol 2018; 22:545-551. [PMID: 30022331 PMCID: PMC6097731 DOI: 10.1007/s10151-018-1821-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Botulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection. METHODS Participants were randomised to receive bilateral (50 + 50 units) or unilateral (100 units) Dysport® injections into the internal anal sphincter in an outpatient setting. Injection-related pain assessed by visual analogue scale was the primary outcome measure. Secondary outcomes were healing rate, fissure pain, incontinence, and global health scores. RESULTS Between October 2008 and April 2012, 100 patients with chronic anal fissure were randomised to receive bilateral or unilateral injections. Injection-related pain was comparable in both groups. There was no difference in healing rate. Initially, there was greater improvement in fissure pain in the bilateral group but at 1 year the unilateral group showed greater improvement. Cleveland Clinic Incontinence score was lower in the unilateral group in the early post-treatment period and global health assessment (EuroQol EQ-VAS) was higher in the unilateral group at 1 year. CONCLUSIONS Injection-related pain was similar in bilateral and unilateral injection groups. Unilateral injection was as effective as bilateral injections in healing and improving fissure pain without any deterioration in continence.
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Affiliation(s)
- S A Pilkington
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - R Bhome
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - R E Welch
- School of Medicine, University of Southampton, Southampton, UK
| | - F Ku
- School of Medicine, University of Southampton, Southampton, UK
| | - C Warden
- Department of Colorectal Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - S Harris
- Primary Care and Population Studies Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - J Hicks
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - C Richardson
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - T C Dudding
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - J S Knight
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - A T King
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - A H Mirnezami
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - N E Beck
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - P H Nichols
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK
| | - K P Nugent
- Department of Colorectal Surgery, Southampton General Hospital, University Hospitals Southampton NHS Trust, Southampton, UK.
- Academic Surgical Unit, University of Southampton, Level C South Academic Block, Southampton General Hospital, Southampton, SO16 6YD, UK.
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Zador Z, King AT, Geifman N. New drug candidates for treatment of atypical meningiomas: An integrated approach using gene expression signatures for drug repurposing. PLoS One 2018; 13:e0194701. [PMID: 29558515 PMCID: PMC5860760 DOI: 10.1371/journal.pone.0194701] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/07/2018] [Indexed: 12/15/2022] Open
Abstract
Background Atypical meningiomas are common central nervous system neoplasms with high recurrence rate and poorer prognosis compared to their grade I counterparts. Surgical excision and radiotherapy remains the mainstay therapy but medical treatments are limited. We explore new drug candidates using computational drug repurposing based on the gene expression signature of atypical meningioma tissue with subsequent analysis of drug-generated expression profiles. We further explore possible mechanisms of action for the identified drug candidates using ingenuity pathway analysis (IPA). Methods We extracted gene expression profiles for atypical meningiomas (12 samples) and normal meningeal tissue (4 samples) from the Gene Expression Omnibus, which were then used to generate a gene signature comprising of 281 differentially expressed genes. Drug candidates were explored using both the Board Institute Connectivity Map (cmap) and Library of Integrated Network-Based Cellular Signatures (LINCS). Functional analysis of significant differential gene expression for drug candidates was performed with IPA. Results Using our integrated approach, we identified multiple, already licensed, drug candidates such as emetine, verteporfin, phenoxybenzamine and trazodone. Analysis with IPA revealed that these drugs target signal cascades potentially relevant in pathogenesis of meningiomas, particular examples are the effect on ERK by trazodone, MAP kinases by emetine, and YAP-1 protein by verteporfin. Conclusion Gene expression profiling and use of drug expression profiles have yielded several plausible drug candidates for treating atypical meningioma, some of which have already been suggested by preceding studies. Although our analyses suggested multiple anti-tumour mechanisms for these drugs, further in vivo studies are required for validation. Importance of the study To our knowledge this is the first study which combines relatively new, yet established computational techniques to identify additional treatments for a difficult to manage cerebral neoplasm. Beyond proposing already approved drug candidates in the management of atypical meningioma the study highlights the promise held by computational techniques in improving our management strategies.
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Affiliation(s)
- Zsolt Zador
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom
- Institute of Cardiovascular Sciences, Centre for Vascular and Stroke Research, University of Manchester, Manchester, United Kingdom
- Division of Neurosurgery, Department of Surgery, St. Michaels Hospital, University of Toronto, Toronto, ON, Canada
- * E-mail:
| | - Andrew T. King
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Nophar Geifman
- Centre for Health Informatics, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
- The Manchester Molecular Pathology Innovation Centre, University of Manchester, Manchester, United Kingdom
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Galea J, Ogungbenro K, Hulme S, Patel H, Scarth S, Hoadley M, Illingworth K, McMahon CJ, Tzerakis N, King AT, Vail A, Hopkins SJ, Rothwell N, Tyrrell P. Reduction of inflammation after administration of interleukin-1 receptor antagonist following aneurysmal subarachnoid hemorrhage: results of the Subcutaneous Interleukin-1Ra in SAH (SCIL-SAH) study. J Neurosurg 2018; 128:515-523. [PMID: 28298024 DOI: 10.3171/2016.9.jns16615] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular event with long-term morbidity and mortality. Patients who survive the initial bleeding are likely to suffer further early brain injury arising from a plethora of pathological processes. These may result in a worsening of outcome or death in approximately 25% of patients and may contribute to longer-term cognitive dysfunction in survivors. Inflammation, mediated by the cytokine interleukin-1 (IL-1), is an important contributor to cerebral ischemia after diverse forms of brain injury, including aSAH. Its effects are attenuated by its naturally occurring antagonist, IL-1 receptor antagonist (IL-1Ra [anakinra]). The authors hypothesized that administration of additional subcutaneous IL-1Ra would reduce inflammation and associated plasma markers associated with poor outcome following aSAH. METHODS This was a randomized, open-label, single-blinded study of 100 mg subcutaneous IL-1Ra, administered twice daily in patients with aSAH, starting within 3 days of ictus and continuing until 21 days postictus or discharge from the neurosurgical center, whichever was earlier. Blood samples were taken at admission (baseline) and at Days 3-8, 14, and 21 postictus for measurement of inflammatory markers. The primary outcome was difference in plasma IL-6 measured as area under the curve between Days 3 and 8, corrected for baseline value. Secondary outcome measures included similar area under the curve analyses for other inflammatory markers, plasma pharmacokinetics for IL-1Ra, and clinical outcome at 6 months. RESULTS Interleukin-1Ra significantly reduced levels of IL-6 and C-reactive protein (p < 0.001). Fibrinogen levels were also reduced in the active arm of the study (p < 0.002). Subcutaneous IL-1Ra was safe, well tolerated, and had a predictable plasma pharmacokinetic profile. Although the study was not powered to investigate clinical effect, scores of the Glasgow Outcome Scale-extended at 6 months were better in the active group; however, this outcome did not reach statistical significance. CONCLUSIONS Subcutaneous IL-1Ra is safe and well tolerated in aSAH. It is effective in reducing peripheral inflammation. These data support a Phase III study investigating the effect of IL-1Ra on outcome following aSAH. Clinical trial registration no.: EudraCT: 2011-001855-35 ( www.clinicaltrialsregister.eu ).
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Affiliation(s)
- James Galea
- 1Ninewells Hospital and Medical School, University of Dundee
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | - Kayode Ogungbenro
- 3Centre for Applied Pharmacokinetic Research, Manchester Pharmacy School
| | - Sharon Hulme
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | - Hiren Patel
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | - Sylvia Scarth
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | - Margaret Hoadley
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | - Karen Illingworth
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | | | - Nikolaos Tzerakis
- 5University Hospital of North Midlands, Royal Stoke University Hospital, Stoke-on-Trent,United Kingdom
| | - Andrew T King
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | - Andy Vail
- 6Centre for Biostatistics, Institution of Population Health, University of Manchester
| | - Stephen J Hopkins
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
| | | | - Pippa Tyrrell
- 2Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, Salford
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Abstract
National Health Service Hospitals are under pressure to reduce waiting lists within the constraints of a limited infrastructure. We implemented two systems to reduce waiting times for elective non-complex spinal surgery. The first of these was the introduction of managed generic waiting lists for both initial outpatient appointments and subsequent surgery. Thereafter, the MRI booking system was integrated with outpatient review appointments. Times from referral to first outpatient appointment and from scan to outpatient review and time on waiting list for surgery were analysed before and after implementation of these changes. Despite constant unit capacity there was a global decrease in waiting times. Before introduction of the generic waiting list, 37% of listed patients waited for more than 9 months; this figure fell to zero. Time from scan to outpatient review was 185 days before integration, 30 days after. Changes of this sort demand a quorum of consultants who will accept each others' recommendations. The generic waiting list will have impact only when there are large disparities in waiting times for different consultants. Targets are met at the expense of continuity of care.
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Affiliation(s)
- P Leach
- Department of Neurosurgery, Hope Hospital, Salford, Manchester M6 8HD, UK.
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North HJD, Mawman D, O'Driscoll M, Freeman SR, Rutherford SA, King AT, Hammerbeck-Ward C, Evans DG, Lloyd SKW. Outcomes of cochlear implantation in patients with neurofibromatosis type 2. Cochlear Implants Int 2017; 17:172-177. [PMID: 27691934 DOI: 10.1080/14670100.2016.1197587] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In neurofibromatosis type 2 (NF2) bilateral vestibular schwannomas (VS) or their treatment usually results in bilateral hearing loss. Cochlear implantation (CI) was traditionally not used in these patients due to concern that retrocochlear disease would render the implant ineffective. This paper describes the auditory outcomes of CI in 13 patients with NF2 and includes patients with untreated VS and patients undergoing VS removal with cochlear nerve preservation. The non-user rate was 7.7%. Of the active users, median CUNY score was 98%, median BKB score in quiet was 90% and median BKB score in noise was 68%. CI is a viable option in selected patients with NF2.
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Affiliation(s)
- Hannah J D North
- a Department of Otolaryngology , Salford Royal NHS Foundation Trust , Manchester M6 8HD , UK
| | - Deborah Mawman
- b The Richard Ramsden Centre for Auditory Implants, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester M13 9WL , UK
| | - Martin O'Driscoll
- b The Richard Ramsden Centre for Auditory Implants, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester M13 9WL , UK
| | - Simon R Freeman
- a Department of Otolaryngology , Salford Royal NHS Foundation Trust , Manchester M6 8HD , UK.,b The Richard Ramsden Centre for Auditory Implants, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester M13 9WL , UK
| | - Scott A Rutherford
- c Department of Neurosurgery , Salford Royal NHS Foundation Trust , Manchester M6 8HD , UK
| | - Andrew T King
- c Department of Neurosurgery , Salford Royal NHS Foundation Trust , Manchester M6 8HD , UK
| | | | - D Gareth Evans
- d Manchester Centre for Genomic Medicine, University of Manchester, Manchester Academic Health Science Centre , Manchester M13 9WL , UK.,e Institute of Cancer Sciences, University of Manchester , UK
| | - Simon K W Lloyd
- a Department of Otolaryngology , Salford Royal NHS Foundation Trust , Manchester M6 8HD , UK.,b The Richard Ramsden Centre for Auditory Implants, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester M13 9WL , UK.,e Institute of Cancer Sciences, University of Manchester , UK
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Pathmanaban ON, Sadler KV, Kamaly-Asl ID, King AT, Rutherford SA, Hammerbeck-Ward C, McCabe MG, Kilday JP, Beetz C, Poplawski NK, Evans DG, Smith MJ. Association of Genetic Predisposition With Solitary Schwannoma or Meningioma in Children and Young Adults. JAMA Neurol 2017; 74:1123-1129. [PMID: 28759666 DOI: 10.1001/jamaneurol.2017.1406] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Importance Meningiomas and schwannomas are usually sporadic, isolated tumors occurring in adults older than 60 years and are rare in children and young adults. Multiple schwannomas and/or meningiomas are more frequently associated with a tumor suppressor syndrome and, accordingly, trigger genetic testing, whereas solitary tumors do not. Nevertheless, apparently sporadic tumors in young patients may herald a genetic syndrome. Objective To determine the frequency of the known heritable meningioma- or schwannoma-predisposing mutations in children and young adults presenting with a solitary meningioma or schwannoma. Design, Setting, and Participants Using the database of the Manchester Centre for Genomic Medicine, this cohort study analyzed lymphocyte DNA from young individuals prospectively referred to the clinic for genetic testing between January 1, 1990, and December 31, 2016, on presentation with a single meningioma (n = 42) or schwannoma (n = 135) before age 25 years. Sequencing data were also examined from an additional 39 patients with neurofibromatosis type 2 who were retrospectively identified as having a solitary tumor before age 25 years. Patients with schwannoma were screened for NF2, SMARCB1, and LZTR1 gene mutations, while patients with meningioma were screened for NF2, SMARCB1, SMARCE1, and SUFU. Main Outcomes and Measures The type of underlying genetic mutation, or lack of a predisposing mutation, was associated with the presenting tumor type and subsequent development of additional tumors or other features of known schwannoma- and meningioma-predisposing syndromes. Results In 2 cohorts of patients who presented with an isolated meningioma (n = 42; median [range] age, 11 [1-24] years; 22 female) or schwannoma (n = 135; median [range] age, 18 [0.2-24] years; 60 female) before age 25 years, 16 of 42 patients (38%) had a predisposing mutation to meningioma and 27 of 135 patients (20%) to schwannoma, respectively. In the solitary meningioma cohort, 34 of 63 patients (54%) had a constitutional mutation in a known meningioma predisposition gene. Twenty-five of 63 patients (40%) had a constitutional NF2 mutation, and 9 (14%) had a constitutional SMARCE1 mutation. In the cohort of those who developed a solitary schwannoma before age 25 years, 44 of 153 patients (29%) had an identifiable genetic predisposition. Twenty-four patients (55%) with a spinal schwannoma had a constitutional mutation, while only 20 (18%) with a cranial schwannoma had a constitutional predisposition (P < .001). Of 109 cranial schwannomas, 106 (97.2%) were vestibular. Four of 106 people (3.8%) with a cranial schwannoma had an LZTR1 mutation (3 were vestibular schwannomas and 1 was a nonvestibular schwannoma), and 9 (8.5%) had an NF2 mutation. Conclusions and Relevance A significant proportion of young people with an apparently sporadic solitary meningioma or schwannoma had a causative predisposition mutation. This finding has important clinical implications because of the risk of additional tumors and the possibility of familial disease. Young patients presenting with a solitary meningioma or schwannoma should be referred for genetic testing.
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Affiliation(s)
- Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, England.,Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Centre for Paediatric, Teenage, and Young Adult Cancer, University of Manchester, Manchester, England
| | - Katherine V Sadler
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals National Health Service Foundation Trust and Manchester Academic Health Science Centre, Manchester, England
| | - Ian D Kamaly-Asl
- Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Centre for Paediatric, Teenage, and Young Adult Cancer, University of Manchester, Manchester, England.,Division of Molecular and Clinical Cancer Sciences, School of Medical Science, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, Manchester, England
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Martin G McCabe
- Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Centre for Paediatric, Teenage, and Young Adult Cancer, University of Manchester, Manchester, England.,Division of Molecular and Clinical Cancer Sciences, School of Medical Science, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, Manchester, England
| | - John-Paul Kilday
- Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Centre for Paediatric, Teenage, and Young Adult Cancer, University of Manchester, Manchester, England.,Division of Molecular and Clinical Cancer Sciences, School of Medical Science, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, Manchester, England
| | - Christian Beetz
- Institut für Klinische Chemie und Laboratoriumsdiagnostik, Universitätsklinikum Jena, Jena, Germany
| | - Nicola K Poplawski
- Adult Genetics Unit, South Australia Pathology at the Women's and Children's Hospital, and University Department of Paediatrics, University of Adelaide, Adelaide, Australia
| | - D Gareth Evans
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals National Health Service Foundation Trust and Manchester Academic Health Science Centre, Manchester, England
| | - Miriam J Smith
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals National Health Service Foundation Trust and Manchester Academic Health Science Centre, Manchester, England
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Pascali G, Matesic L, Zhang B, King AT, Robinson AJ, Ung AT, Fraser BH. Sulfur - fluorine bond in PET radiochemistry. EJNMMI Radiopharm Chem 2017; 2:9. [PMID: 29503850 PMCID: PMC5824700 DOI: 10.1186/s41181-017-0028-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/14/2017] [Indexed: 12/02/2022] Open
Abstract
The importance of the sulfur-fluorine bond is starting to increase in modern medicinal chemistry literature. This is due to a better understanding of the stability and reactivity of this moiety depending on the various oxidation states of sulfur. Furthermore, several commercial reagents used for mild and selective fluorination of organic molecules are based on the known reactivity of S-F groups. In this review, we will show how these examples are translating into the 18F field, both for use as stable tags in finished radiopharmaceuticals and as mildly reactive fluoride-relay intermediates. Finally, we also discuss current opportunities where examples of non-radioactive S-F applications/chemistry may be translated into future 18F radiochemistry applications.
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Affiliation(s)
- Giancarlo Pascali
- 1Australian Nuclear Science and Technology Organisation, New South Wales, Australia.,2Brain and Mind Centre, University of Sydney, New South Wales, Australia
| | - Lidia Matesic
- 1Australian Nuclear Science and Technology Organisation, New South Wales, Australia
| | - Bo Zhang
- 1Australian Nuclear Science and Technology Organisation, New South Wales, Australia.,3School of Chemistry, Monash University, Victoria, Australia
| | - Andrew T King
- 1Australian Nuclear Science and Technology Organisation, New South Wales, Australia.,4School of Mathematical and Physical Sciences, University of Technology Sydney, Sydney, NSW Australia
| | | | - Alison T Ung
- 4School of Mathematical and Physical Sciences, University of Technology Sydney, Sydney, NSW Australia
| | - Benjamin H Fraser
- 1Australian Nuclear Science and Technology Organisation, New South Wales, Australia
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Lloyd SKW, King AT, Rutherford SA, Hammerbeck-Ward CL, Freeman SRM, Mawman DJ, O'Driscoll M, Evans DG. Hearing optimisation in neurofibromatosis type 2: A systematic review. Clin Otolaryngol 2017; 42:1329-1337. [PMID: 28371358 DOI: 10.1111/coa.12882] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is common for patients with neurofibromatosis type 2 to develop bilateral profound hearing loss hearing loss, and this is one of the main determinants of quality of life in this patient group. OBJECTIVES The aim of this systematic review was to review the current literature regarding hearing outcomes of treatments for vestibular schwannomas in neurofibromatosis type 2 including conservative and medical management, radiotherapy, hearing preservation surgery and auditory implantation in order to determine the most effective way of preserving or rehabilitating hearing. SEARCH STRATEGY A MESH search in PubMed using search terms (('Neurofibromatosis 2' [Mesh]) AND 'Neuroma, Acoustic'[Mesh]) AND 'Hearing Loss' [Mesh] was performed. A search using keywords was also performed. Studies with adequate hearing outcome data were included. With the exception of the cochlear implant studies (cohort size was very small), case studies were excluded. EVALUATION METHOD The GRADE system was used to assess quality of publication. Formal statistical analysis of data was not performed because of very heterogenous data reporting. RESULTS Conservative management offers the best chance of hearing preservation in stable tumours. The use of bevacizumab probably improves the likelihood of hearing preservation in growing tumours in the short term and is probably more effective than hearing preservation surgery and radiotherapy in preserving hearing. Of the hearing preservation interventions, hearing preservation surgery probably offers better hearing preservation rates than radiotherapy for small tumours but recurrence rates for hearing preservation surgery were high. For patients with profound hearing loss, cochlear implantation provides significantly better auditory outcomes than auditory brainstem implantation. Patients with untreated stable tumours are likely to achieve the best outcomes from cochlear implantation. Those who have had their tumours treated with surgery or radiotherapy do not gain as much benefit from cochlear implantation than those with untreated tumours. CONCLUSIONS This review summarises the current literature related to hearing preservation/rehabilitation in patients with NF2. Whilst it provides indicative data, the quality of the data was low and should be interpreted with care. It is also important to consider that the management of vestibular schwannomas in NF2 is complex and decision-making is determined by many factors, not just the need to preserve hearing.
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Affiliation(s)
- S K W Lloyd
- Department of Otolaryngology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK.,Department of Otolaryngology, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,School of Medical Sciences, University of Manchester, Manchester, UK
| | - A T King
- Department of Neurosurgery, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - S A Rutherford
- Department of Neurosurgery, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - C L Hammerbeck-Ward
- Department of Neurosurgery, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - S R M Freeman
- Department of Otolaryngology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK.,Department of Otolaryngology, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - D J Mawman
- Richard Ramsden Auditory Implant Centre, Central Manchester NHS Foundation Trust, Manchester, UK
| | - M O'Driscoll
- Richard Ramsden Auditory Implant Centre, Central Manchester NHS Foundation Trust, Manchester, UK
| | - D G Evans
- Department of Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Pathmanaban ON, O'Brien F, Al-Tamimi YZ, Hammerbeck-Ward CL, Rutherford SA, King AT. Safety of Superior Petrosal Vein Sacrifice During Microvascular Decompression of the Trigeminal Nerve. World Neurosurg 2017; 103:84-87. [PMID: 28377255 DOI: 10.1016/j.wneu.2017.03.117] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/24/2017] [Accepted: 03/25/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Microvascular decompression (MVD) is a safe and effective treatment for trigeminal neuralgia. Cerebellar venous infarction is a complication associated with surgical sacrifice of the superior petrosal vein (SPV). The SPV intervenes between the trigeminal nerve and the surgeon. Optimal exposure of the cisternal trigeminal nerve, particularly at the brainstem, can be achieved by sacrificing the SPV. We analyzed a cohort of 224 patients to determine the frequency of cerebellar venous infarction. METHODS Retrospective analysis of records and neuroradiology for patients undergoing trigeminal MVD at the Manchester Skull Base Unit between August 1st 2008 and July 31st 2015. RESULTS A total of 184 of 224 (82%) patients had coagulation and division of the main stem of the SPV. There were no cases of venous infarction. There was one case of mild, transient, cerebellar symptoms and signs, with no radiologic evidence of venous infarction. This patient had SPV sacrifice at surgery but also had postoperative thrombosis of the transverse sinus. Venous sinus thrombosis affected 5 of 184 (2.7%) patients. A total of 208 of 224 (93%) patients had a good outcome with improvement or resolution of their trigeminal neuralgia at 3 months. CONCLUSIONS The overall rate of venous complications in this study was 2.7%; however, we had no cases of venous infarction in 184 patients who had sacrifice of the SPV. The incidence of venous infarction associated with SPV obliteration during MVD surgery is therefore <0.5%. SPV sacrifice may be used where necessary to optimize visualization of the root entry zone and maximize the chance of effective decompression of the trigeminal nerve.
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Affiliation(s)
- Omar N Pathmanaban
- Manchester Skull Base Unit, Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.
| | - Frazer O'Brien
- Manchester Skull Base Unit, Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Yahia Z Al-Tamimi
- Manchester Skull Base Unit, Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Charlotte L Hammerbeck-Ward
- Manchester Skull Base Unit, Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Scott A Rutherford
- Manchester Skull Base Unit, Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andrew T King
- Manchester Skull Base Unit, Department of Neurosurgery, Manchester Centre for Clinical Neuroscience, Salford Royal Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Smith MJ, Bowers NL, Bulman M, Gokhale C, Wallace AJ, King AT, Lloyd SKL, Rutherford SA, Hammerbeck-Ward CL, Freeman SR, Evans DG. Revisiting neurofibromatosis type 2 diagnostic criteria to exclude LZTR1-related schwannomatosis. Neurology 2016; 88:87-92. [PMID: 27856782 DOI: 10.1212/wnl.0000000000003418] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 09/21/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the specificity of the current clinical diagnostic criteria for neurofibromatosis type 2 (NF2) relative to the requirement for unilateral vestibular schwannoma (VS) and at least 2 other NF2-related tumors. METHODS We interrogated our Manchester NF2 database, which contained 205 individuals meeting NF2 criteria who initially presented with a unilateral VS. Of these, 83 (40.7%) went on to develop a contralateral VS. We concentrated our genetic analysis on a group of 70 who initially fulfilled NF2 criteria with a unilateral vestibular schwannoma and at least 2 additional nonintradermal schwannomas. RESULTS Overall, 5/70 (7%) individuals with unilateral VS and at least 2 other schwannomas had a pathogenic or likely pathogenic LZTR1 mutation. Twenty of the 70 subsequently developed bilateral disease. Of the remaining 50, 5 (10%) had a germline LZTR1 mutation, equivalent to the number (n = 5) with a germline NF2 mutation. CONCLUSIONS The most common etiology for unilateral VS and 2 additional NF2-associated tumors in this cohort was mosaic NF2. Germline LZTR1 and germline NF2 mutations were equally common in our cohort. This indicates that LZTR1 must be considered when making a diagnosis of NF2 in the presence of unilateral VS in individuals without a germline NF2 mutation.
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Affiliation(s)
- Miriam J Smith
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Naomi L Bowers
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Michael Bulman
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Carolyn Gokhale
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Andrew J Wallace
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Andrew T King
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Simon K L Lloyd
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Scott A Rutherford
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Charlotte L Hammerbeck-Ward
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Simon R Freeman
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - D Gareth Evans
- From the Centre for Genomic Medicine, Division of Evolution and Genomic Science, School of Biological Sciences, St Mary's Hospital (M.J.S., N.L.B., M.B., C.G., A.J.W., D.G.E.), Department of Otolaryngology, Manchester Royal Infirmary (S.K.L.L., S.R.F.), and the Department of Neurosurgery, Salford Royal Foundation Trust (A.T.K., S.A.R., C.L.H.-W.), Manchester Academic Health Sciences Centre, University of Manchester, UK.
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Zador Z, Sperrin M, King AT. Predictors of Outcome in Traumatic Brain Injury: New Insight Using Receiver Operating Curve Indices and Bayesian Network Analysis. PLoS One 2016; 11:e0158762. [PMID: 27388421 PMCID: PMC4936732 DOI: 10.1371/journal.pone.0158762] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/21/2016] [Indexed: 11/28/2022] Open
Abstract
Background Traumatic brain injury remains a global health problem. Understanding the relative importance of outcome predictors helps optimize our treatment strategies by informing assessment protocols, clinical decisions and trial designs. In this study we establish importance ranking for outcome predictors based on receiver operating indices to identify key predictors of outcome and create simple predictive models. We then explore the associations between key outcome predictors using Bayesian networks to gain further insight into predictor importance. Methods We analyzed the corticosteroid randomization after significant head injury (CRASH) trial database of 10008 patients and included patients for whom demographics, injury characteristics, computer tomography (CT) findings and Glasgow Outcome Scale (GCS) were recorded (total of 13 predictors, which would be available to clinicians within a few hours following the injury in 6945 patients). Predictions of clinical outcome (death or severe disability at 6 months) were performed using logistic regression models with 5-fold cross validation. Predictive performance was measured using standardized partial area (pAUC) under the receiver operating curve (ROC) and we used Delong test for comparisons. Variable importance ranking was based on pAUC targeted at specificity (pAUCSP) and sensitivity (pAUCSE) intervals of 90–100%. Probabilistic associations were depicted using Bayesian networks. Results Complete AUC analysis showed very good predictive power (AUC = 0.8237, 95% CI: 0.8138–0.8336) for the complete model. Specificity focused importance ranking highlighted age, pupillary, motor responses, obliteration of basal cisterns/3rd ventricle and midline shift. Interestingly when targeting model sensitivity, the highest-ranking variables were age, severe extracranial injury, verbal response, hematoma on CT and motor response. Simplified models, which included only these key predictors, had similar performance (pAUCSP = 0.6523, 95% CI: 0.6402–0.6641 and pAUCSE = 0.6332, 95% CI: 0.62–0.6477) compared to the complete models (pAUCSP = 0.6664, 95% CI: 0.6543–0.679, pAUCSE = 0.6436, 95% CI: 0.6289–0.6585, de Long p value 0.1165 and 0.3448 respectively). Bayesian networks showed the predictors that did not feature in the simplified models were associated with those that did. Conclusion We demonstrate that importance based variable selection allows simplified predictive models to be created while maintaining prediction accuracy. Variable selection targeting specificity confirmed key components of clinical assessment in TBI whereas sensitivity based ranking suggested extracranial injury as one of the important predictors. These results help refine our approach to head injury assessment, decision-making and outcome prediction targeted at model sensitivity and specificity. Bayesian networks proved to be a comprehensive tool for depicting probabilistic associations for key predictors giving insight into why the simplified model has maintained accuracy.
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Affiliation(s)
- Zsolt Zador
- Department of Neurosurgery, Salford Royal Foundation Trust, Salford, Greater Manchester, United Kingdom
- Institute of Cardiovascular Sciences, Centre for Vascular and Stroke Research, University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Matthew Sperrin
- Health eResearch Centre, Farr Institute, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andrew T. King
- Department of Neurosurgery, Salford Royal Foundation Trust, Salford, Greater Manchester, United Kingdom
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