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Johnson TS, MacDonald TJ, Pacholczyk R, Aguilera D, Al-Basheer A, Bajaj M, Bandopadhayay P, Berrong Z, Bouffet E, Castellino RC, Dorris K, Eaton BR, Esiashvili N, Fangusaro JR, Foreman N, Fridlyand D, Giller C, Heger IM, Huang C, Kadom N, Kennedy EP, Manoharan N, Martin W, McDonough C, Parker RS, Ramaswamy V, Ring E, Rojiani A, Sadek RF, Satpathy S, Schniederjan M, Smith A, Smith C, Thomas BE, Vaizer R, Yeo KK, Bhasin MK, Munn DH. Indoximod-based chemo-immunotherapy for pediatric brain tumors: A first-in-children phase I trial. Neuro Oncol 2024; 26:348-361. [PMID: 37715730 PMCID: PMC10836763 DOI: 10.1093/neuonc/noad174] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/23/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Recurrent brain tumors are the leading cause of cancer death in children. Indoleamine 2,3-dioxygenase (IDO) is a targetable metabolic checkpoint that, in preclinical models, inhibits anti-tumor immunity following chemotherapy. METHODS We conducted a phase I trial (NCT02502708) of the oral IDO-pathway inhibitor indoximod in children with recurrent brain tumors or newly diagnosed diffuse intrinsic pontine glioma (DIPG). Separate dose-finding arms were performed for indoximod in combination with oral temozolomide (200 mg/m2/day x 5 days in 28-day cycles), or with palliative conformal radiation. Blood samples were collected at baseline and monthly for single-cell RNA-sequencing with paired single-cell T cell receptor sequencing. RESULTS Eighty-one patients were treated with indoximod-based combination therapy. Median follow-up was 52 months (range 39-77 months). Maximum tolerated dose was not reached, and the pediatric dose of indoximod was determined as 19.2 mg/kg/dose, twice daily. Median overall survival was 13.3 months (n = 68, range 0.2-62.7) for all patients with recurrent disease and 14.4 months (n = 13, range 4.7-29.7) for DIPG. The subset of n = 26 patients who showed evidence of objective response (even a partial or mixed response) had over 3-fold longer median OS (25.2 months, range 5.4-61.9, p = 0.006) compared to n = 37 nonresponders (7.3 months, range 0.2-62.7). Four patients remain free of active disease longer than 36 months. Single-cell sequencing confirmed emergence of new circulating CD8 T cell clonotypes with late effector phenotype. CONCLUSIONS Indoximod was well tolerated and could be safely combined with chemotherapy and radiation. Encouraging preliminary evidence of efficacy supports advancing to Phase II/III trials for pediatric brain tumors.
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Affiliation(s)
- Theodore S Johnson
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rafal Pacholczyk
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Ahmad Al-Basheer
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Radiation Oncology, Augusta University, Augusta, Georgia, USA
| | - Manish Bajaj
- Department of Radiology, Augusta University, Augusta, Georgia, USA
| | | | - Zuzana Berrong
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Eric Bouffet
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Robert C Castellino
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kathleen Dorris
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Jason R Fangusaro
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Diana Fridlyand
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Cole Giller
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Ian M Heger
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Chenbin Huang
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Nadja Kadom
- Department of Radiology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Eugene P Kennedy
- Lumos Pharma, Inc. (formerly NewLink Genetics Corporation), Austin, Texas, USA
| | - Neevika Manoharan
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, Georgia, USA
| | - Colleen McDonough
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Rebecca S Parker
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Vijay Ramaswamy
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Amyn Rojiani
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pathology, Augusta University, Augusta, Georgia, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Population Health Sciences, Augusta University, Augusta, Georgia, USA
| | - Sarthak Satpathy
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Matthew Schniederjan
- Children’s Healthcare of Atlanta and Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Christopher Smith
- Lumos Pharma, Inc. (formerly NewLink Genetics Corporation), Austin, Texas, USA
| | - Beena E Thomas
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rachel Vaizer
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Kee Kiat Yeo
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Manoj K Bhasin
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
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Johnson T, Pacholczyk R, Aguilera D, Al-Basheer A, Bajaj M, Bandopadhayay P, Berrong Z, Bouffet E, Castellino R, Dorris K, Eaton B, Esiashvili N, Foreman N, Fridlyand D, Giller C, Heger I, Kadom N, Kennedy E, Manoharan N, Martin W, McDonough C, Parker R, Ramaswamy V, Ring E, Rojiani A, Sadek R, Smith A, Smith C, Vaizer R, Yeo KK, MacDonald T, Munn D. CTIM-32. FIRST-IN-CHILDREN PHASE 1 TRIAL OF INDOXIMOD-BASED CHEMO-IMMUNOTHERAPY FOR PATIENTS WITH PEDIATRIC BRAIN TUMORS: ANALYSIS OF SAFETY, TOLERABILITY, AND 5-YEAR OUTCOME. Neuro Oncol 2022. [PMCID: PMC9660775 DOI: 10.1093/neuonc/noac209.264] [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: 11/16/2022] Open
Abstract
Abstract
BACKGROUND
Recurrent brain tumors are the leading cause of cancer death in children. We conducted a first-in-children, two-institution, Phase 1 open-label dose-confirmation study using a 3 + 3 design, with expansion cohorts, to determine the recommended pediatric dose of the IDO pathway-inhibitor indoximod (NCT02502708). DESIGN/
METHODS
Eligible patients were 3-22 years old with either recurrent malignant brain tumor or newly-diagnosed diffuse intrinsic pontine glioma (DIPG). Palliative radiation, surgery or dexamethasone were allowed as needed for patient management. Separate dose-finding arms were performed for indoximod plus temozolomide (200 mg/m2/day orally for 5 days of each 28-day cycle) and for indoximod plus conformal radiation (in patients for whom re-irradiation was planned as standard-of-care). At progression, patients who were otherwise clinically stable were offered crossover to indoximod plus a second-line chemotherapy regimen (cyclophosphamide 2.5 mg/kg/day orally and etoposide 50 mg/m2/day orally for 21 days of each 28-day cycle).
RESULTS
Between December 2015 and January 2019, the study enrolled 81 brain tumor patients, including newly-diagnosed DIPG (n = 13) or recurrent ependymoma (n = 27), glioblastoma/high-grade glioma (n = 19), medulloblastoma (n = 13), or other CNS tumors ( n= 9). Median follow-up was 52 months (range 39-77 months). No dose-limiting toxicities were observed, and the pediatric indoximod dose was determined (19.2 mg/kg/dose, given twice daily). Indoximod was well tolerated and did not affect the ability to deliver chemotherapy or radiation as planned. Median overall survival was 13.6 months (n = 81). Median overall survival was 34.7 months for the subset of patients who continued indoximod with second-line chemotherapy after progression on indoximod plus temozolomide (n = 18).
CONCLUSIONS
Indoximod was well tolerated and could be combined with a variety of standard treatments for pediatric brain tumors. Preliminary anti-tumor activity and overall survival suggest that indoximod with standard therapy should be further evaluated in pediatric brain tumors, and potentially other pediatric solid tumors.
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Affiliation(s)
- Theodore Johnson
- Georgia Cancer Center and Department of Pediatrics, Augusta University, Augusta, GA , Augusta, GA , USA
| | - Rafal Pacholczyk
- Georgia Cancer Center, Augusta University, Augusta, GA , Augusta , USA
| | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA , Atlanta , USA
| | - Ahmad Al-Basheer
- Georgia Cancer Center and Department of Radiation Oncology, Augusta University, Augusta, GA , Augusta , USA
| | - Manish Bajaj
- Department of Radiology, Augusta University, Augusta, GA (current address: Children’s Healthcare of Atlanta and Department of Radiology, Emory University, Atlanta, GA) , Augusta , USA
| | - Pratiti Bandopadhayay
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston MA , Boston, MA , USA
| | - Zuzana Berrong
- Georgia Cancer Center, Augusta University, Augusta, GA , Augusta , USA
| | - Eric Bouffet
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada , Toronto , Canada
| | - Robert Castellino
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA , Atlanta , USA
| | - Kathleen Dorris
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO , Aurora , USA
| | - Bree Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA , Atlanta, GA , USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA , Atlanta , USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO , Aurora , USA
| | - Diana Fridlyand
- Department of Pediatrics, Augusta University, Augusta, GA (current address: Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA) , Atlanta , USA
| | - Cole Giller
- Department of Neurosurgery, Augusta University, Augusta, GA , Augusta , USA
| | - Ian Heger
- Department of Neurosurgery, Augusta University, Augusta, GA (current address: Pediatric Neurosurgery Program, Medical City Children’s Hospital, Dallas, TX) , Augusta , USA
| | - Nadja Kadom
- Department of Radiology and Winship Cancer Institute of Emory University, Atlanta, GA , Atlanta , USA
| | - Eugene Kennedy
- Lumos Pharma (formerly NewLink Genetics Corporation), Ames, IA , Ames , USA
| | - Neevika Manoharan
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston MA (current address: Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia) , Boston , USA
| | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, GA , Augusta , USA
| | - Colleen McDonough
- Georgia Cancer Center and Department of Pediatrics, Augusta University, Augusta, GA , Augusta , USA
| | - Rebecca Parker
- Department of Pediatrics, Augusta University, Augusta, GA (current address: Cancer and Blood Diseases Institute, Children's Hospital Los Angeles, Los Angeles, CA) , Augusta , USA
| | - Vijay Ramaswamy
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada , Toronto , Canada
| | - Eric Ring
- Georgia Cancer Center and Department of Pediatrics, Augusta University, Augusta, GA , Augusta , USA
| | - Amyn Rojiani
- Georgia Cancer Center and Department of Pathology, Augusta University, Augusta, GA (current address: Department of Pathology, Penn State Health/College of Medicine, Hershey, PA) , Hershey , USA
| | - Ramses Sadek
- Georgia Cancer Center and Department of Population Health Sciences, Augusta University, Augusta, GA , Augusta , USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, FL , Orlando , USA
| | - Chris Smith
- Lumos Pharma (formerly NewLink Genetics Corporation), Ames, IA , Ames , USA
| | - Rachel Vaizer
- Department of Pediatrics, Augusta University, Augusta, GA (current address: Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA) , Augusta , USA
| | - Kee Kiat Yeo
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston MA , Boston , USA
| | - Tobey MacDonald
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA , Atlanta , USA
| | - David Munn
- Georgia Cancer Center and Department of Pediatrics, Augusta University, Augusta, GA , Augusta , USA
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Gupta VR, Giller C, Kolhe R, Forseen SE, Sharma S. Polymorphous Low-Grade Neuroepithelial Tumor of the Young: A Case Report with Genomic Findings. World Neurosurg 2019; 132:347-355. [PMID: 31520766 DOI: 10.1016/j.wneu.2019.08.221] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a recently recognized epileptogenic neuroepithelial tumor. Despite its distinctiveness, its polymorphous histology and the nature of its oligodendrocyte-like cells remain unclear. CASE DESCRIPTION A 30-year-old, right-handed man was diagnosed with intractable epilepsy since 22 years of age. Magnetic resonance imaging revealed T2 signal hyperintensity and corresponding T1 signal hypointensity within the subcortical white matter of the right middle temporal gyrus. Positron emission tomography scan demonstrated hypometabolism in the right anterior temporal region. Electroencephalography and stereo-electroencephalography monitoring localized seizures to the right temporal lobe, allowing the patient to undergo right temporal lobectomy. Histologic sections demonstrated cortical dysplasia, white matter heterotopia, and hippocampal reactive gliosis without neuronal loss. Interestingly, an approximately 6-mm subcortical neoplasm was identified in the temporal lobectomy. It was composed of well-differentiated oligodendroglial-like cells but exhibited mild-to-moderate nuclear variability and pleomorphism, and mild infiltration into the overlying cortex without perineuronal satellitosis. No mitotic activity, microvascular proliferation, or necrosis was identified, and Ki-67 labeling index was less than 1%. The tumor was diffusely CD34 positive with moderate glial fibrillary acidic protein and retained ATRX staining, and demonstrated the presence of the BRAF V600E mutation. The tumor was negative for reticulin condensation, synaptophysin, SMI31, neuronal nuclei immunostains, and both the IDH1 mutation and 1p19q codeletion. Overall histologic findings were most consistent with PLNTY. CONCLUSIONS The correct diagnosis of PLNTY and its distinction from closely resembling low-grade neuroepithelial tumors is important. We hope our proposed diagnostic features will aid in its proper diagnosis and management.
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Affiliation(s)
- V Rohan Gupta
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Cole Giller
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Ravindra Kolhe
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Scott E Forseen
- Department of Radiology and Imaging, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Suash Sharma
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
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Yowtak J, Jenkins P, Giller C. Transection of Omohyoid Muscle as an Aid During Vagus Nerve Stimulator Implantation. World Neurosurg 2016; 99:118-121. [PMID: 27931947 DOI: 10.1016/j.wneu.2016.11.146] [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: 10/01/2016] [Revised: 11/26/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Exposure of the carotid sheath during vagus nerve stimulator (VNS) implantation is usually straightforward but can be difficult for patients with a large body habitus. In addition, the exposure must be done with care if the surgeon wants to keep the vagus nerve in situ without using retractors that might impair access. OBJECTIVE We describe the use of the omohyoid muscle as a landmark for the jugular vein and report how transection of the omohyoid can facilitate rapid and wide exposure of the carotid sheath. METHODS We review the records of 59 consecutive patients undergoing VNS implantation from 2009-2015 and describe our technique incorporating omohyoid transection. We also summarize complications such as postoperative hoarseness, cough, dysphagia, or wound issues. RESULTS Forty-two of the 59 patients (29 adults and 13 children) underwent omohyoid transection during implantation. In all cases, the carotid sheath and jugular vein were immediately visible after transection. One patient developed permanent hoarseness and coughing due to left vocal cord paresis, requiring further surgery. This result was most likely due to manipulation of the vagus nerve rather than division of the omohyoid muscle. CONCLUSION Omohyoid transection provides excellent exposure of the carotid sheath during VNS implantation.
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Affiliation(s)
- June Yowtak
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA.
| | - Patrick Jenkins
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Cole Giller
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
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Amoush A, Aletan M, Ferjani S, Rabatic B, Madden N, Al-Basheer A, Marascio J, Zaenger D, Huang K, Green A, Shaaban S, Pishgou M, Marchan E, Giller C, Forseen S, Choudhri H, Ferguson C, Vender J, Alleyne C, Mourad W. Dosimetric Study of the Effect of the 6-Dimensional Calypso-Compatible Couch Top and Rails for Spine Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.2233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Maugeri R, Giugno A, Graziano F, Visocchi M, Giller C, Iacopino DG. Delayed chronic intracranial subdural hematoma complicating resection of a tanycytic thoracic ependymoma. Surg Neurol Int 2016; 7:S20-2. [PMID: 26862454 PMCID: PMC4722516 DOI: 10.4103/2152-7806.173563] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 08/21/2015] [Accepted: 10/17/2015] [Indexed: 12/02/2022] Open
Abstract
Background: To demonstrate that the diagnosis of an intracranial subdural hematoma should be considered for patients presenting with acute or delayed symptoms of intracranial pathology following resection of a spinal tumor. Case Description: We present a case of a 57-year-old woman found to have a chronic subdural hematoma 1 month following resection of a thoracic extramedullary ependymoma. Evacuation of the hematoma through a burr hole relieved the presenting symptoms and signs. Resolution of the hematoma was confirmed with a computed tomography (CT) scan. Conclusion: Headache and other symptoms not referable to spinal pathology should be regarded as a warning sign of an intracranial subdural hematoma, and a CT scan of the head should be obtained. The mechanism of the development of the hematoma may be related to the leakage of cerebrospinal fluid with subsequent intracranial hypotension leading to an expanding subdural space and hemorrhage.
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Affiliation(s)
- Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neuroscience, Neurosurgical Unit, Paolo Giaccone University Hospital, Palermo, Italy
| | - Antonella Giugno
- Department of Experimental Biomedicine and Clinical Neuroscience, Neurosurgical Unit, Paolo Giaccone University Hospital, Palermo, Italy
| | - Francesca Graziano
- Department of Experimental Biomedicine and Clinical Neuroscience, Neurosurgical Unit, Paolo Giaccone University Hospital, Palermo, Italy
| | | | - Cole Giller
- Neurosurgical Unit, Medical College of Georgia Hospital, Augusta, GA, USA
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neuroscience, Neurosurgical Unit, Paolo Giaccone University Hospital, Palermo, Italy
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Abstract
OBJECTIVE The feasibility of high resolution CT imaging for evaluating experimentally-induced brain tumors in rats was assessed. METHODS The gliosarcoma cell line (9 L/lacZ) was inoculated in 34 male Fischer 344 rats and CT studies were performed prior to and at 4, 7, 9, 12 and 14 days post-tumor cell implantation. Brain imaging pre- and post-contrast was performed and correlated with autopsy findings. RESULTS Tumors were identified by CT in 19 of the 34 animals after contrast administration and their presence was confirmed at autopsy. Tumors were present at autopsy and not identified by CT scanning in eight additional animals and in the remaining seven animals, the CT scan was normal and no tumors were present at autopsy. The sensitivity and specificity of CT scanning with contrast in detecting tumors in this rat model of gliosarcoma was 70 and 100%, respectively. CONCLUSION The improved CT technology currently available can be used to identify and follow tumor burden in a rat model of gliosarcoma, and be a good tool to utilize in determining treatment outcomes experimentally, especially when MR imaging is not available.
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Affiliation(s)
- T G Psarros
- Department of Neurosurgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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Giller C, Mehta S, Yanasak N, Jenkins P. Avoidance of electrode related MRI artifact during staged deep brain stimulator implantation. J Neurol Surg A Cent Eur Neurosurg 2012; 73:320-3. [PMID: 22847067 DOI: 10.1055/s-0032-1322590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Centers implanting deep brain stimulator (DBS) electrodes on different days often protect the first electrode tip with a protective cap, tunnel it under the scalp, and connect it to the generator at a later procedure. If magnetic resonance imaging (MRI) is used for planning during the second implantation, MRI artifacts from the protective cap could potentially corrupt the stereotactic coordinates. The importance of this problem may increase if emerging MRI safety data lead to more frequent use of MRI for these purposes. OBJECTIVE To describe an MRI artifact arising from the use of the standard protective DBS cap that corrupts stereotactic planning and to describe a way to avoid the artifact. METHODS After noting the artifact during a staged DBS procedure, a nonmetallic silastic sleeve contained in the existing DBS implantation kit was used in nine subsequent patients. Two caps with standard metallic screws were also tested with MRI phantoms. RESULTS The silastic sleeve protected the DBS electrode but did not produce MRI artifact. The phantom studies demonstrated significant artifact from caps containing screws. CONCLUSION A silastic sleeve provides adequate protection of the DBS electrode during staged implantation and avoids the MRI artifact associated with protective caps with screws.
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Affiliation(s)
- Cole Giller
- Department of Neurosurgery, Georgia Health Sciences University, Augusta, GA 30912, USA.
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Psarros TG, Mickey B, Gilio J, Drees J, Gall K, Carlson D, Giller C, Willis MS. Gliosarcoma cell death after radiosurgery in a rat model. ACTA ACUST UNITED AC 2005; 48:142-8. [PMID: 16015490 DOI: 10.1055/s-2004-830266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Therapeutic radiation and subsequent detection of tumor cell death has been performed mainly in vitro systems, making it difficult to accurately characterize the mechanisms of tumor cell death after radiosurgery. To better characterize what occurs to glioma cells after radiation therapy, we developed a rat model using the 9L gliosarcoma cell line implanted reproducibly to the caudate nucleus in rats. After 1 Gy radiation, 9L tumors in vivo induced mainly necrosis (determined by trypan blue exclusion) of 10 - 74 % at 6 - 72 hours post-radiation. This is in contrast to a previous in vitro study which demonstrated that 18 Gy of radiation induces considerably less cell death as determined by trypan blue exclusion (approximately 20 - 25 % at 6 - 72 hours post-radiation). However, significant amounts of apoptosis were detected as early as 6 hours after radiation. Apoptosis determination was by annexin V (marker of early apoptosis) and propidium iodide (marker of membrane stability) staining followed by flow cytometry detection. When caspase 3 and caspase 8 enzymatic activities (mediators of apoptosis) were measured from freshly explanted tumor cells, peak activity was found 6 hours after 1 Gy radiation (p < 0.01). Taken together, these data indicate the presence of apoptosis early after radiation therapy (1 Gy) which progressed to necrosis in a unique in vivo model of gliosarcoma that may prove useful in determining new therapeutic approaches to radiation therapy and tumor cell biology.
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Affiliation(s)
- T G Psarros
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas 75390, USA.
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Johns M, Giller C, German D, Liu H. Determination of reduced scattering coefficient of biological tissue from a needle-like probe. Opt Express 2005; 13:4828-42. [PMID: 19498468 DOI: 10.1364/opex.13.004828] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Detection of interactions between light and tissue can be used to characterize the optical properties of the tissue. The purpose of this paper is to develop an algorithm that determines the reduced scattering coefficient (mus') of tissues from a single optical reflectance spectrum measured with a small source-detector separation. A qualitative relationship between mus' and optical reflectance was developed using both Monte Carlo simulations and empirical tissue calibrations for each of two fiber optic probes with 400-mum and 100-mum fibers. Optical reflectance measurements, using a standard frequency-domain oximeter, were performed to validate the calculated mus' values. The algorithm was useful for determining mus' values of in vivo human fingers and rat brain tissues.
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Taylor CL, Dutton K, Rappard G, Pride GL, Replogle R, Purdy PD, White J, Giller C, Kopitnik TA, Samson DS. Complications of preoperative embolization of cerebral arteriovenous malformations. J Neurosurg 2004; 100:810-2. [PMID: 15137598 DOI: 10.3171/jns.2004.100.5.0810] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.7] [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: 11/06/2022]
Abstract
Object. Preoperative embolization is viewed by the authors as a useful adjunct in the surgical management of cerebral arteriovenous malformations (AVMs). This study was performed to determine the rate of significant complication in patients undergoing this procedure.
Methods. Demographic, anatomical, and procedure data were collected prospectively. The treating physician reported complications. In addition, a review of medical records including procedure reports, operative reports, and discharge summaries was performed. Univariate statistical analysis was performed to determine if any of the variables was predictive of a poor outcome of embolization (death or permanent neurological deficit).
Endovascular procedures for embolization were performed 339 times in 201 patients during an 11-year period. Female patients comprised 53.7% of the study group and 85.6% of the AVMs were supratentorial. Embolization was performed using polyvinyl alcohol particles, N-butyl cyanoacrylate, detachable coils, and/or the liquid polymer Onyx. Analyzed by procedure, a poor result of embolization occurred in 7.7%. Analyzed by patient, 11% died or had a permanent neurological deficit as a result of the embolization. None of the demographic, anatomical, or procedure variables identified were predictive of a poor outcome.
Conclusions. Preoperative embolization may gradually reduce flow to an AVM, reduce intraoperative blood loss, and reduce operative time. The risks of this procedure, however, are not insignificant and must be considered in planning treatment for patients with AVMs.
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Affiliation(s)
- Christopher L Taylor
- Department of Neurological Surgery, The University of Southwestern Texas Medical Center, Dallas, Texas 75390-8855, USA.
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Abstract
Complications arising from antibiotic use are of interest to neurosurgeons because many neurosurgical patients are treated for infection. In this report, the authors describe three patients with spine disorders who developed coagulopathies after treatment with levofloxacin, an antibiotic commonly used by neurosurgical services. Three patients with spine disorders developed urinary tract infections (UTIs) for which they received a 3-day course of oral levofloxacin. Subsequently, they demonstrated prolonged prothrombin times and increased international normalized ratios. One of those patients later developed acquired von Willebrand syndrome during surgery. Coagulopathies were successfully corrected preoperatively with parenteral vitamin K. The patient with acquired von Willebrand syndrome required multiple transfusions. There seems to be an association between levofloxacin and coagulation abnormalities in neurosurgical patients treated for UTIs. Neurosurgical services prescribing this common antibiotic should be aware of this problem.
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Affiliation(s)
- Thomas Psarros
- Department of Neurosurgery, The University of Texas Southwestern Medical Center at Dallas, Texas, USA.
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Abstract
A 38-year-old man developed parkinsonism that progressed to Hoehn and Yahr stage 5 within 4 years of onset. Response to ropinirole deteriorated, levodopa was not tolerated, and subthalamic nucleus stimulation has provided only partial relief of symptoms. He reported heavy use of Ecstasy through most of his twenties and thirties. His neurological problems may be unrelated to his drug use, but it is also possible they represent an idiosyncratic reaction.
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Affiliation(s)
- Padraig O'Suilleabhain
- Department of Neurology, University of Texas Southwestern Medical School, Dallas, Texas, USA
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15
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Qian Z, Victor S, Gu Y, Giller C, Liu H. Look-Ahead Distance of a fiber probe used to assist neurosurgery: Phantom and Monte Carlo study. Opt Express 2003; 11:1844-1855. [PMID: 19466067 DOI: 10.1364/oe.11.001844] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A short-separation, optical reflectance probe has been developed to assist the neurosurgeon in functional neurosurgery for accurate localization of the surgical target. Because of the scattering nature of tissue, the optical probe has a "Look Ahead Distance" (LAD), at which the measured optical reflectance starts to "see" or "sense" the underlying brain structure due to the difference in light scattering of tissue. To quantify the LAD, 2-layer laboratory phantoms have been developed to mimic gray and white matter of the brain, and Monte Carlo simulations have been also used to confirm the experimental findings. Based on both the laboratory and simulation results, a quantitative empirical equation is developed to express the LAD as a function of scattering coefficient of the measured tissue for a 400-micron-diameter fiber probe. The quantified LAD of the probe is highly desirable so as to improve the spatial resolution of the probe for better surgery guidance.
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Abstract
BACKGROUND Thalamic deep brain stimulation ameliorates essential and parkinsonian tremors refractory to medications. Stimulus voltage, polarity configuration, frequency, and pulsewidth can each be adjusted in order to optimize tremor control and maximize battery life. The relative impacts of these programmable variables have not previously been quantified. METHODS The thalamus of 11 patients (bilaterally in 2) was studied 4 to 59 months postoperatively. The stimulator was inactivated and medications withheld for 12 hours, and optimal electrode contacts were selected. Stimulation followed at a range of voltages (0, 1, 2, 3, or 4 V), pulsewidths (60, 90, or 120 micros), and frequencies (130, 160, or 185 Hz) for both monopolar and bipolar configurations. Seventy-eight combinations of variables were programmed in random sequence. Postural and action tremors were measured with an electromagnetic tracker, tremor was subjectively graded, and side effects were noted. RESULTS Voltage was consistently predictive of tremor response. Mean postural tremor amplitude in PD fell from 6.4 cm at 0 V to 2.6, 1.0, 0.3, and 0 cm at 1 through 4 V (bipolar configuration). The voltage response curve for essential tremor was flatter. The monopolar configuration was 10 to 25% more effective than bipolar. The longest pulsewidth tested was up to 30% more effective than the shortest, but frequency changes had little effect on tremor amplitude. Side effects occurred only with monopolar stimulation, and the only setting that was intolerable for the majority was 4 V, 120 micros, and 185 Hz. CONCLUSION Bipolar deep brain stimulation at 90 micros, 130 Hz, adjusting the voltage up to 3 V, tends to be effective and well tolerated. Monopolar provides similar benefits for lower voltage, but side effects become common at 3 or 4 V.
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Metry G, Spittle M, Rahmati S, Giller C, Giller A, Kaufman A, Schneditz D, Manno E, Brener Z, Boniece I, Ronco F, Ronco C, Levin NW. Online monitoring of cerebral hemodynamics during hemodialysis. Am J Kidney Dis 2002; 40:996-1004. [PMID: 12407645 DOI: 10.1053/ajkd.2002.36333] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [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: 11/11/2022]
Abstract
BACKGROUND Several factors, including anemia, diabetes, and hypertension, potentially could disturb the cerebral autoregulation mechanism in hemodialysis (HD) patients. This study examined the effect of hemodynamic and rheological changes on mean cerebral blood flow (CBF) velocity (MV) during HD. METHODS Continuous online monitoring of MV and pulsatility index in the middle cerebral artery were performed in 18 HD patients by transcranial Doppler ultrasound during the entire HD period (range, 3 to 4 hours). In addition, blood pressure, hematocrit (Hct), and relative decrease in blood volume were continuously monitored. Blood samples were obtained at the beginning and end of HD to measure hemorheological variables. RESULTS After HD, Hct increased significantly from 33.6% +/- 5.9% to 41.4% +/- 5.7% (P < 0.001). Blood and plasma viscosity increased significantly from 3.33 +/- 0.77 to 4.36 +/- 1.3 mPa.s (P < 0.001) and from 1.35 +/- 0.29 to 1.54 +/- 0.38 mPa.s (P < 0.001), respectively. The change in MV (DeltaMV) was not significantly different from zero and correlated significantly with change in Hct. During HD, mean arterial pressure (MAP) in 15 patients changed within the normal range (group I), whereas 3 patients developed hypotension (group II) and their MAP decreased from 99 +/- 5 to 60 +/- 8 mm Hg (P < 0.05). In both groups, DeltaMV were not significant. CONCLUSION Results of this study suggest that CBF does not appear to be diminished significantly during HD.
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Affiliation(s)
- George Metry
- Division of Nephrology, Beth Israel Medical Center, New York, NY, USA.
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Abstract
Essential tremor (ET) is the most common type of movement disorder, although its etiology and neurophysiological substrates remain unclear. While thought to be a benign condition, it has yet to be studied from a neuropsychological perspective. We examined the neurocognitive functioning of 13 nondemented subjects with severe ET, including aspects of memory, cognitive flexibility, and attention. Results revealed that 12/13 subjects demonstrated impairment on 1 or more cognitive measures in comparison with published normative data. The pattern of findings was suggestive of relative dysfunction of frontal-mediated processes not unlike that seen in Parkinson's disease. These deficits were found in subjects irrespective of the presence of cognitive complaints, depression, or the existence of other potential neurocognitive risk factors. These findings suggest that mild cognitive deficits are not uncommon in association with severe ET and may be related to subcortical systems.
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Affiliation(s)
- Laura H Lacritz
- Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas, 75390-8898, USA.
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Sackeim HA, Rush AJ, George MS, Marangell LB, Husain MM, Nahas Z, Johnson CR, Seidman S, Giller C, Haines S, Simpson RK, Goodman RR. Vagus nerve stimulation (VNS) for treatment-resistant depression: efficacy, side effects, and predictors of outcome. Neuropsychopharmacology 2001; 25:713-28. [PMID: 11682255 DOI: 10.1016/s0893-133x(01)00271-8] [Citation(s) in RCA: 324] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This open pilot study of vagus nerve stimulation (VNS) in 60 patients with treatment-resistant major depressive episodes (MDEs) aimed to: 1) define the response rate; 2) determine the profile of side effects; and, most importantly; 3) establish predictors of clinical outcome. Participants were outpatients with nonatypical, nonpsychotic, major depressive or bipolar disorder who had not responded to at least two medication trials from different antidepressant classes in the current MDE. While on stable medication regimens, the patients completed a baseline period followed by device implantation. A 2-week, single blind, recovery period (no stimulation) was followed by 10 weeks of VNS. Of 59 completers (one patient improved during the recovery period), the response rate was 30.5% for the primary HRSD(28) measure, 34.0% for the Montgomery-Asberg Depression Rating Scale (MADRAS), and 37.3% for the Clinical Global Impression-Improvement Score (CGI-I of 1 or 2). The most common side effect was voice alteration or hoarseness, 55.0% (33/60), which was generally mild and related to output current intensity. History of treatment resistance was predictive of VNS outcome. Patients who had never received ECT (lifetime) were 3.9 times more likely to respond. Of the 13 patients who had not responded to more than seven adequate antidepressant trials in the current MDE, none responded, compared to 39.1% of the remaining 46 patients (p =.0057). Thus, VNS appears to be most effective in patients with low to moderate, but not extreme, antidepressant resistance. Evidence concerning VNS' long-term therapeutic benefits and tolerability will be critical in determining its role in treatment-resistant depression.
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Affiliation(s)
- H A Sackeim
- Department of Biological Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA
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Rush AJ, George MS, Sackeim HA, Marangell LB, Husain MM, Giller C, Nahas Z, Haines S, Simpson RK, Goodman R. Vagus nerve stimulation (VNS) for treatment-resistant depressions: a multicenter study. Biol Psychiatry 2000; 47:276-86. [PMID: 10686262 DOI: 10.1016/s0006-3223(99)00304-2] [Citation(s) in RCA: 371] [Impact Index Per Article: 15.5] [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: 11/30/2022]
Abstract
BACKGROUND Vagus Nerve Stimulation (VNS) delivered by the NeuroCybernetic Prosthesis (NCP) System was examined for its potential antidepressant effects. METHODS Adult outpatients (n = 30) with nonpsychotic, treatment-resistant major depressive (n = 21) or bipolar I (n = 4) or II (n = 5; depressed phase) disorders who had failed at least two robust medication trials in the current major depressive episode (MDE) while on stable medication regimens completed a baseline period followed by NCP System implantation. A 2-week, single-blind recovery period (no stimulation) was followed by 10 weeks of VNS. RESULTS In the current MDE (median length = 4.7 years), patients had not adequately responded to two (n = 9), three (n = 2), four (n = 6), or five or more (n = 13) robust antidepressant medication trials or electroconvulsive therapy (n = 17). Baseline 28-item Hamilton Depression Rating Scale (HDRS(28)) scores averaged 38.0. Response rates (> or =50% reduction in baseline scores) were 40% for both the HDRS(28) and the Clinical Global Impressions-Improvement index (score of 1 or 2) and 50% for the Montgomery-Asberg Depression Rating Scale. Symptomatic responses (accompanied by substantial functional improvement) have been largely sustained during long-term follow-up to date. CONCLUSIONS These open trial results suggest that VNS has antidepressant effects in treatment-resistant depressions.
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Affiliation(s)
- A J Rush
- Departments of Psychiatry and Neurosurgery, University of Texas Southwestern Medical Center, Dallas 75235-9086, USA
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Johns M, Giller C, Liu H. Computational and in vivo investigation of optical reflectance from human brain to assist neurosurgery. J Biomed Opt 1998; 3:437-445. [PMID: 23015144 DOI: 10.1117/1.429894] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Parkinson's disease (PD) is a chronic, progressive disease involving the globus pallidus (GP), which is a gray matter mass, surrounded by white matter deep within the brain. During a neurosurgery procedure, a thin probe is inserted into the GP to create a lesion that often relieves the cardinal symptoms of PD. The goal of this study is to develop an optical method to accurately locate the GP border. In theory, Monte Carlo simulations were performed to predict the optical reflectance from brain tissue. In experiment, a portable, real-time display spectrometer with a fiber optic reflectance probe was developed and used during human surgery. Optical reflectance values were recorded at 1 mm intervals to obtain a spatial profile of the tissue as the probe passed through regions of gray and white matter. The simulation and in vivo studies of the reflectance from the brain are in good agreement with one another. The clinical data show that the reflectance from gray matter is approximately 50% or less than that from white matter between 650 and 800 nm. A slope algorithm is developed to distinguish gray and white matter in vivo. This study provides previously unknown optical reflectance of the human brain. © 1998 Society of Photo-Optical Instrumentation Engineers.
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