1
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Hanaei S, Maroufi SF, Sadeghmousavi S, Nejati A, Paeinmahalli A, Ohadi MAD, Teo C. Telovelar vs. Transvermian approach for the fourth ventricle tumors: A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 240:108259. [PMID: 38579552 DOI: 10.1016/j.clineuro.2024.108259] [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: 01/28/2024] [Revised: 03/01/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Tumors in the fourth ventricle can be critical due to the small size of the fourth ventricle, which causes symptoms to be detected even in the presence of lesser mass effects. A proper surgical approach to the fourth ventricle poses challenges due to its deep location and proximity to vital compartments within the brainstem. The two commonly used approaches to these tumors are the transvermian and telovelar approaches. METHODS A comprehensive systematic study was conducted based on a literature search of the databases. All case controls, cohorts, and case series including patients with fourth ventricle tumors, who were operated on with either telovelar or transvermian approaches were considered eligible. The evaluated outcomes were comparative postoperative complications of the telovelar vs. transvermian approach. After screening and data extraction, a meta-analysis was performed whenever adequate quantitative data were available. RESULTS Seven studies with a total number of 848 patients, discussed both telovelar and transvermian approaches, with comparative reporting of outcomes in each group. Postoperative outcomes including cranial nerve deficit, mutism, diplopia, CSF leak, need for CSF diversion, and postoperative gait disturbance were not significantly different between telovelar and transvermian approaches. CONCLUSION Postoperative complications were not significantly different between telovelar and transvermian approaches. Moreover, it could be proposed that such complications would be more likely to be a multifactorial matter concerning the patient's clinical condition, tumor characteristics, and surgeon's experience, rather than the surgical approach alone.
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Affiliation(s)
- Sara Hanaei
- Department of Neurosurgery, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences (TUMS), Tehran, Iran; Borderless Research, Advancement, and Innovation in Neuroscience Network (BRIANet), Tehran, Iran.
| | - Seyed Farzad Maroufi
- Department of Neurosurgery, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences (TUMS), Tehran, Iran; Neurosurgical Research Network, Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Shaghayegh Sadeghmousavi
- Borderless Research, Advancement, and Innovation in Neuroscience Network (BRIANet), Tehran, Iran; Neurosurgical Research Network, Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Arshia Nejati
- Department of Neurosurgery, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences (TUMS), Tehran, Iran.
| | - Abolfazl Paeinmahalli
- Department of Neurosurgery, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences (TUMS), Tehran, Iran; Borderless Research, Advancement, and Innovation in Neuroscience Network (BRIANet), Tehran, Iran.
| | - Mohammad Amin Dabbagh Ohadi
- Department of Neurosurgery, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences (TUMS), Tehran, Iran.
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Sydney, Australia; Department of Neurosurgery, NUH, Singapore, Singapore; Department of Neurosurgery, FJD University Hospital, Madrid, Spain; Department of Neurosurgery, Hanoi Medical University, Viet Nam.
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2
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Tang SJ, Holle J, Dadario NB, Lesslar O, Teo C, Ryan M, Sughrue M, Yeung JT. Personalized, parcel-guided rTMS for the treatment of major depressive disorder: Safety and proof of concept. Brain Behav 2023; 13:e3268. [PMID: 37798655 PMCID: PMC10636393 DOI: 10.1002/brb3.3268] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Not all patients with major depressive disorder (MDD) benefit from the US Food and Drug Administration-approved use of repetitive transcranial magnetic stimulation (rTMS) at the dorsolateral prefrontal cortex. We may be undertreating depression with this one-size-fits-all rTMS strategy. METHODS We present a retrospective review of targeted and connectome-guided rTMS in 26 patients from Cingulum Health from 2020 to 2023 with MDD or MDD with associated symptoms. rTMS was conducted by identifying multiple cortical targets based on anomalies in individual functional connectivity networks as determined by machine learning connectomic software. Quality of life assessed by the EuroQol (EQ-5D) score and depression symptoms assessed by the Beck Depression Inventory (BDI) were administered prior to treatment, directly after, and at a follow-up consultation. RESULTS Of the 26 patients treated with rTMS, 16 (62%) attained remission after treatment. Of the 19 patients who completed follow-up assessments after an average interval of 2.6 months, 11 (58%) responded to treatment and 13 (68%) showed significant remission. Between patients classified with or without treatment-resistant depression, there was no difference in BDI improvement. Additionally, there was significant improvement in quality of life after treatment and during follow-up compared to baseline. LIMITATIONS This review is retrospective in nature, so there is no control group to assess the placebo effect on patient outcomes. CONCLUSION The personalized, connectome-guided approach of rTMS is safe and may be effective for depression. This personalized rTMS treatment allows for co-treatment of multiple disorders, such as the comorbidity of depression and anxiety.
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Affiliation(s)
- Si Jie Tang
- School of MedicineUniversity of California Davis Medical CenterSacramentoCaliforniaUSA
| | | | - Nicholas B. Dadario
- Robert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | | | | | | | | | - Jacky T. Yeung
- Cingulum HealthSydneyAustralia
- Department of NeurosurgeryYale University School of MedicineNew HavenConnecticutUSA
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3
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Young IM, Taylor HM, Nicholas PJ, Mackenzie A, Tanglay O, Dadario NB, Osipowicz K, Davis E, Doyen S, Teo C, Sughrue ME. An agile, data-driven approach for target selection in rTMS therapy for anxiety symptoms: Proof of concept and preliminary data for two novel targets. Brain Behav 2023; 13:e2914. [PMID: 36949668 PMCID: PMC10175990 DOI: 10.1002/brb3.2914] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/04/2022] [Accepted: 01/22/2023] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Data-driven approaches to transcranial magnetic stimulation (TMS) might yield more consistent and symptom-specific results based on individualized functional connectivity analyses compared to previous traditional approaches due to more precise targeting. We provide a proof of concept for an agile target selection paradigm based on using connectomic methods that can be used to detect patient-specific abnormal functional connectivity, guide treatment aimed at the most abnormal regions, and optimize the rapid development of new hypotheses for future study. METHODS We used the resting-state functional MRI data of 28 patients with medically refractory generalized anxiety disorder to perform agile target selection based on abnormal functional connectivity patterns between the Default Mode Network (DMN) and Central Executive Network (CEN). The most abnormal areas of connectivity within these regions were selected for subsequent targeted TMS treatment by a machine learning based on an anomalous functional connectivity detection matrix. Areas with mostly hyperconnectivity were stimulated with continuous theta burst stimulation and the converse with intermittent theta burst stimulation. An image-guided accelerated theta burst stimulation paradigm was used for treatment. RESULTS Areas 8Av and PGs demonstrated consistent abnormalities, particularly in the left hemisphere. Significant improvements were demonstrated in anxiety symptoms, and few, minor complications were reported (fatigue (n = 2) and headache (n = 1)). CONCLUSIONS Our study suggests that a left-lateralized DMN is likely the primary functional network disturbed in anxiety-related disorders, which can be improved by identifying and targeting abnormal regions with a rapid, data-driven, agile aTBS treatment on an individualized basis.
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Grants
- Omniscient Neurotechnology provided support in the form of salaries for authors IY, HT, PN, AM, OT, KO, SD, MS, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This research did not receive any other specific grant from funding agencies in the public, commercial, or not-for-profit sectors
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Affiliation(s)
- Isabella M Young
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
- Cingulum Health, Sydney, New South Wales, Australia
| | - Hugh M Taylor
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
| | | | - Alana Mackenzie
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
| | - Onur Tanglay
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
| | - Nicholas B Dadario
- Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey
| | - Karol Osipowicz
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
| | - Ethan Davis
- Cingulum Health, Sydney, New South Wales, Australia
| | - Stephane Doyen
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
| | - Charles Teo
- Cingulum Health, Sydney, New South Wales, Australia
| | - Michael E Sughrue
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
- Cingulum Health, Sydney, New South Wales, Australia
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4
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Dadario NB, Tanglay O, Stafford JF, Davis EJ, Young IM, Fonseka RD, Briggs RG, Yeung JT, Teo C, Sughrue ME. Topology of the lateral visual system: The fundus of the superior temporal sulcus and parietal area H connect nonvisual cerebrum to the lateral occipital lobe. Brain Behav 2023; 13:e2945. [PMID: 36912573 PMCID: PMC10097165 DOI: 10.1002/brb3.2945] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Mapping the topology of the visual system is critical for understanding how complex cognitive processes like reading can occur. We aim to describe the connectivity of the visual system to understand how the cerebrum accesses visual information in the lateral occipital lobe. METHODS Using meta-analytic software focused on task-based functional MRI studies, an activation likelihood estimation (ALE) of the visual network was created. Regions of interest corresponding to the cortical parcellation scheme previously published under the Human Connectome Project were co-registered onto the ALE to identify the hub-like regions of the visual network. Diffusion Spectrum Imaging-based fiber tractography was performed to determine the structural connectivity of these regions with extraoccipital cortices. RESULTS The fundus of the superior temporal sulcus (FST) and parietal area H (PH) were identified as hub-like regions for the visual network. FST and PH demonstrated several areas of coactivation beyond the occipital lobe and visual network. Furthermore, these parcellations were highly interconnected with other cortical regions throughout extraoccipital cortices related to their nonvisual functional roles. A cortical model demonstrating connections to these hub-like areas was created. CONCLUSIONS FST and PH are two hub-like areas that demonstrate extensive functional coactivation and structural connections to nonvisual cerebrum. Their structural interconnectedness with language cortices along with the abnormal activation of areas commonly located in the temporo-occipital region in dyslexic individuals suggests possible important roles of FST and PH in the integration of information related to language and reading. Future studies should refine our model by examining the functional roles of these hub areas and their clinical significance.
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Affiliation(s)
- Nicholas B Dadario
- Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Onur Tanglay
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
| | - Jordan F Stafford
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | | | - R Dineth Fonseka
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Charles Teo
- Cingulum Health, Sydney, New South Wales, Australia
| | - Michael E Sughrue
- Omniscient Neurotechnology, Sydney, New South Wales, Australia.,Cingulum Health, Sydney, New South Wales, Australia.,Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
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5
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Muacevic A, Adler JR, Young IM, Yeung JT, Teo C, Sughrue ME. Delayed, Progressive Multivessel Occlusion After Resection of a Recurrent Glioma. Cureus 2022; 14:e33019. [PMID: 36721529 PMCID: PMC9879796 DOI: 10.7759/cureus.33019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 12/29/2022] Open
Abstract
Glioblastoma multiforme (GBM) is one of the most common primary brain tumors with an aggressive natural history consistent with a median survival of less than two years. Most clinical research has primarily focused on improving overall survival through aggressive cytoreductive surgery and adjuvant radiochemotherapy. However, far less clinical guidance has been given for unexpected instances of neurologic decline following safe glioma resection in the setting of vascular etiology. Here, we report a 50-year-old man who presented to our clinic with a seizure. His preoperative magnetic resonance imaging (MRI) demonstrated a left hippocampal glioblastoma. Ten months following total resection, the patient presented again with rapid loss of vision and hemorrhagic papilledema. An MRI demonstrated a recurrence of his glioma, which was partially resected with no complications. Eight days after surgery, the patient suddenly became unresponsive and imaging revealed moderate blood in the resection cavity, which was evacuated in the operating room. Follow-up scans showed a posterior cerebral artery infarction, and two days later, a middle cerebral artery infarction, upon which care was withdrawn. We do not propose a mechanism by which this delayed ischemia occurred, especially as the middle cerebral artery was not damaged during surgery, however, we note that delayed ischemia may be one mechanism of damage following glioma resection, which should be studied further to improve patient outcomes.
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6
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Yeung J, Tang J, Holle J, Teo C, Sughrue M. NCOG-46. PERSONALIZED, PARCEL-GUIDED RTMS FOR NEURO-REHABILITATION AFTER TUMOR NEUROSURGERY: SAFETY AND PROOF OF CONCEPT. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac209.797] [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
Deficits in neurological and psychocognitive function are common for patients who have undergone surgical removal of primary tumors. Repetitive Transcranial Magnetic Stimulation (rTMS) is an emerging non-invasive tool used for the treatment of neuropsychiatric disorders. We present a retrospective review of individualized, targeted rTMS in thirteen patients who presented with post-operative neurological deficits following craniotomy for tumor resection. Multiple cortical targets were selected based on the patient’s neurological disorder, the networks associated with the deficit, and anomalies in the functional connectivity of the patient’s brain as determined by machine-learning. TMS treatment was performed for 5 consecutive days. EuroQol quality of life (EQ-5D), functional extremity scales, and neuropsychiatric questionnaires related to the patient’s deficit were assessed prior to rTMS treatment, after treatment, and during follow-up. Five patients (38.5%) had glioblastomas; four patients (30.8%) had oligodendrogliomas; two patients (15.4%) had astrocytoma; one patient (7.7%) had ganglioglioma; and one patient (7.7%) had a pineal cyst. All thirteen patients reported significantly improved quality of life after rTMS treatment (p = 0.0065) and during follow-up (p = 0.0038) as compared to baseline. For patients with functional deficits, lower extremity functional scale (LEFS) was significantly improved one week after rTMS treatment (p = 0.0205). Upper extremity function scale (UEFS) showed non-significant trend in improvement after rTMS treatment (p = 0.0777). In the two patients who developed post-craniotomy depression, they showed a 26% and 88% reduction in depressive symptoms based on the Beck’s Depression Inventory (BDI) at two-month follow-up. These results suggest that the personalized, functional connectivity approach to rTMS target and treatment may be effective for patients with post-craniotomy functional impairments and neuropsychiatric disorders. This method of post-operative interventional neuro-rehabilitation is safe, noninvasive, and allows for the simultaneous treatment of multiple symptoms.
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Affiliation(s)
| | | | | | | | - Michael Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, New South Wales, Australia
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7
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Briggs RG, Young IM, Dadario NB, Fonseka RD, Hormovas J, Allan P, Larsen ML, Lin YH, Tanglay O, Maxwell BD, Conner AK, Stafford JF, Glenn CA, Teo C, Sughrue ME. Parcellation-based tractographic modeling of the salience network through meta-analysis. Brain Behav 2022; 12:e2646. [PMID: 35733239 PMCID: PMC9304834 DOI: 10.1002/brb3.2646] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/09/2022] [Accepted: 04/07/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The salience network (SN) is a transitory mediator between active and passive states of mind. Multiple cortical areas, including the opercular, insular, and cingulate cortices have been linked in this processing, though knowledge of network connectivity has been devoid of structural specificity. OBJECTIVE The current study sought to create an anatomically specific connectivity model of the neural substrates involved in the salience network. METHODS A literature search of PubMed and BrainMap Sleuth was conducted for resting-state and task-based fMRI studies relevant to the salience network according to PRISMA guidelines. Publicly available meta-analytic software was utilized to extract relevant fMRI data for the creation of an activation likelihood estimation (ALE) map and relevant parcellations from the human connectome project overlapping with the ALE data were identified for inclusion in our SN model. DSI-based fiber tractography was then performed on publicaly available data from healthy subjects to determine the structural connections between cortical parcellations comprising the network. RESULTS Nine cortical regions were found to comprise the salience network: areas AVI (anterior ventral insula), MI (middle insula), FOP4 (frontal operculum 4), FOP5 (frontal operculum 5), a24pr (anterior 24 prime), a32pr (anterior 32 prime), p32pr (posterior 32 prime), and SCEF (supplementary and cingulate eye field), and 46. The frontal aslant tract was found to connect the opercular-insular cluster to the middle cingulate clusters of the network, while mostly short U-fibers connected adjacent nodes of the network. CONCLUSION Here we provide an anatomically specific connectivity model of the neural substrates involved in the salience network. These results may serve as an empiric basis for clinical translation in this region and for future study which seeks to expand our understanding of how specific neural substrates are involved in salience processing and guide subsequent human behavior.
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Affiliation(s)
- Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Nicholas B Dadario
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - R Dineth Fonseka
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Jorge Hormovas
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Parker Allan
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Micah L Larsen
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Yueh-Hsin Lin
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Onur Tanglay
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - B David Maxwell
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jordan F Stafford
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Chad A Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia.,Omniscient Neurotechnology, Sydney, New South Wales, Australia
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8
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Shahab QS, Young IM, Dadario NB, Tanglay O, Nicholas PJ, Lin YH, Fonseka RD, Yeung JT, Bai MY, Teo C, Doyen S, Sughrue ME. A connectivity model of the anatomic substrates underlying Gerstmann syndrome. Brain Commun 2022; 4:fcac140. [PMID: 35706977 PMCID: PMC9189613 DOI: 10.1093/braincomms/fcac140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Received: 09/23/2021] [Revised: 04/05/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022] Open
Abstract
The Gerstmann syndrome is a constellation of neurological deficits that include agraphia, acalculia, left–right discrimination and finger agnosia. Despite a growing interest in this clinical phenomenon, there remains controversy regarding the specific neuroanatomic substrates involved. Advancements in data-driven, computational modelling provides an opportunity to create a unified cortical model with greater anatomic precision based on underlying structural and functional connectivity across complex cognitive domains. A literature search was conducted for healthy task-based functional MRI and PET studies for the four cognitive domains underlying Gerstmann’s tetrad using the electronic databases PubMed, Medline, and BrainMap Sleuth (2.4). Coordinate-based, meta-analytic software was utilized to gather relevant regions of interest from included studies to create an activation likelihood estimation (ALE) map for each cognitive domain. Machine-learning was used to match activated regions of the ALE to the corresponding parcel from the cortical parcellation scheme previously published under the Human Connectome Project (HCP). Diffusion spectrum imaging-based tractography was performed to determine the structural connectivity between relevant parcels in each domain on 51 healthy subjects from the HCP database. Ultimately 102 functional MRI studies met our inclusion criteria. A frontoparietal network was found to be involved in the four cognitive domains: calculation, writing, finger gnosis, and left–right orientation. There were three parcels in the left hemisphere, where the ALE of at least three cognitive domains were found to be overlapping, specifically the anterior intraparietal area, area 7 postcentral (7PC) and the medial intraparietal sulcus. These parcels surround the anteromedial portion of the intraparietal sulcus. Area 7PC was found to be involved in all four domains. These regions were extensively connected in the intraparietal sulcus, as well as with a number of surrounding large-scale brain networks involved in higher-order functions. We present a tractographic model of the four neural networks involved in the functions which are impaired in Gerstmann syndrome. We identified a ‘Gerstmann Core’ of extensively connected functional regions where at least three of the four networks overlap. These results provide clinically actionable and precise anatomic information which may help guide clinical translation in this region, such as during resective brain surgery in or near the intraparietal sulcus, and provides an empiric basis for future study.
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Affiliation(s)
- Qazi S. Shahab
- University of New South Wales School of Medicine, , 2052, Sydney, Australia
| | | | - Nicholas B. Dadario
- Rutgers Robert Wood Johnson Medical School , New Brunswick, New Jersey 08901, United States of America
| | - Onur Tanglay
- Omniscient Neurotechnology , Sydney, 2000, Australia
| | | | - Yueh-Hsin Lin
- Prince of Wales Private Hospital Centre for Minimally Invasive Neurosurgery, , Randwick, 2031, Australia
| | - R. Dineth Fonseka
- Prince of Wales Private Hospital Centre for Minimally Invasive Neurosurgery, , Randwick, 2031, Australia
| | - Jacky T. Yeung
- Prince of Wales Private Hospital Centre for Minimally Invasive Neurosurgery, , Randwick, 2031, Australia
| | - Michael Y. Bai
- Prince of Wales Private Hospital Centre for Minimally Invasive Neurosurgery, , Randwick, 2031, Australia
| | - Charles Teo
- Prince of Wales Private Hospital Centre for Minimally Invasive Neurosurgery, , Randwick, 2031, Australia
| | | | - Michael E. Sughrue
- Omniscient Neurotechnology , Sydney, 2000, Australia
- Prince of Wales Private Hospital Centre for Minimally Invasive Neurosurgery, , Randwick, 2031, Australia
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9
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Poologaindran A, Profyris C, Young IM, Dadario NB, Ahsan SA, Chendeb K, Briggs RG, Teo C, Romero-Garcia R, Suckling J, Sughrue ME. Interventional neurorehabilitation for promoting functional recovery post-craniotomy: a proof-of-concept. Sci Rep 2022; 12:3039. [PMID: 35197490 PMCID: PMC8866464 DOI: 10.1038/s41598-022-06766-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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] [Received: 03/17/2021] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
The human brain is a highly plastic ‘complex’ network—it is highly resilient to damage and capable of self-reorganisation after a large perturbation. Clinically, neurological deficits secondary to iatrogenic injury have very few active treatments. New imaging and stimulation technologies, though, offer promising therapeutic avenues to accelerate post-operative recovery trajectories. In this study, we sought to establish the safety profile for ‘interventional neurorehabilitation’: connectome-based therapeutic brain stimulation to drive cortical reorganisation and promote functional recovery post-craniotomy. In n = 34 glioma patients who experienced post-operative motor or language deficits, we used connectomics to construct single-subject cortical networks. Based on their clinical and connectivity deficit, patients underwent network-specific transcranial magnetic stimulation (TMS) sessions daily over five consecutive days. Patients were then assessed for TMS-related side effects and improvements. 31/34 (91%) patients were successfully recruited and enrolled for TMS treatment within two weeks of glioma surgery. No seizures or serious complications occurred during TMS rehabilitation and 1-week post-stimulation. Transient headaches were reported in 4/31 patients but improved after a single session. No neurological worsening was observed while a clinically and statistically significant benefit was noted in 28/31 patients post-TMS. We present two clinical vignettes and a video demonstration of interventional neurorehabilitation. For the first time, we demonstrate the safety profile and ability to recruit, enroll, and complete TMS acutely post-craniotomy in a high seizure risk population. Given the lack of randomisation and controls in this study, prospective randomised sham-controlled stimulation trials are now warranted to establish the efficacy of interventional neurorehabilitation following craniotomy.
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Affiliation(s)
- Anujan Poologaindran
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK.,The Alan Turing Institute, British Library, London, UK
| | - Christos Profyris
- Netcare Linksfield Hospital, Johannesburg, South Africa.,Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Isabella M Young
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Nicholas B Dadario
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Syed A Ahsan
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Kassem Chendeb
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Charles Teo
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Rafael Romero-Garcia
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - John Suckling
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK.,The Alan Turing Institute, British Library, London, UK
| | - Michael E Sughrue
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK. .,Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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10
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Dadario NB, Zaman A, Pandya M, Dlouhy BJ, Gunawardena MP, Sughrue ME, Teo C. Endoscopic-assisted surgical approach for butterfly glioma surgery. J Neurooncol 2022; 156:635-644. [PMID: 35032284 DOI: 10.1007/s11060-022-03945-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 10/04/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Gliomas that spread along the white matter tracts of the corpus callosum to both hemispheres have traditionally been considered surgically challenging largely due to the relative complexity of safely achieving complete resections. We present a series of endoscopic-assisted resections of butterfly gliomas with post-operative radiological assessment of EOR and clinical outcome data. METHODS Retrospective review of patients who underwent surgical resection of a butterfly glioma from 2007 to 2020. Butterfly gliomas were defined as gliomas, which appeared to arise from the corpus callosum with significant bilateral extension. All records were retrospectively reviewed with operative/clinical outcomes and complications recorded. RESULTS 70 patients who underwent an endoscopic-assisted transcortical or interhemispheric approach for butterfly glioma resection met inclusion criteria. A unilateral transcortical approach was used in 86% of cases and an interhemispheric approach in 14%. The endoscope enhanced the visualization of the contralateral hemisphere and allowed for resection of tumor, not reached by standard microscopic visualization, in 100% of cases. 90% of resections resulted in greater than a 95% resection rate. Neurological deficits mostly consisted of motor (10%) and memory (6%) deficits and were most common with posterior tumors of the splenium. CONCLUSION The endoscopic-assisted transcortical or interhemispheric approach for butterfly glioma resection is effective in achieving a greater than 95% resection with minimal complications. An angled approach allows careful maneuvering around complex anatomic structures and difficult corners, and should be examined further for its clinical benefits in a prospective manner.
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Affiliation(s)
- Nicholas B Dadario
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Ashraf Zaman
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Suite 19, Level 7 Prince of Wales Private Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia.,Garvan Institute of Medical Research, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Brian J Dlouhy
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Suite 19, Level 7 Prince of Wales Private Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa, 52242, USA
| | - Manuri P Gunawardena
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Suite 19, Level 7 Prince of Wales Private Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Suite 19, Level 7 Prince of Wales Private Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Suite 19, Level 7 Prince of Wales Private Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia.
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11
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Dadario NB, Teo C, Sughrue ME. Insular gliomas and tractographic visualization of the connectome. Neurosurg Focus Video 2022; 6:V4. [PMID: 36284592 PMCID: PMC9555346 DOI: 10.3171/2021.10.focvid21194] [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: 09/01/2021] [Accepted: 10/28/2021] [Indexed: 06/16/2023]
Abstract
In this video, the authors present a connectome-guided surgical resection of an insular glioma in a 39-year-old woman. Preoperative study with constrained spherical deconvolution (CSD)-based tractography revealed the surrounding brain connectome architecture around the tumor relevant for safe surgical resection. Connectomic information provided detailed maps of the surrounding language and salience networks, including eloquent white matter fibers and cortical regions, which were visualized intraoperatively with image guidance and artificial intelligence (AI)-based brain mapping software. Microsurgical dissection is presented with detailed discussion of the safe boundaries and angles of resection when entering the insular operculum defined by connectomic information. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21194.
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Affiliation(s)
- Nicholas B. Dadario
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales; and
| | - Michael E. Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales; and
- Omniscient Neurotechnology, Sydney, New South Wales, Australia
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12
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Yeung JT, Young IM, Doyen S, Teo C, Sughrue ME. Changes in the Brain Connectome Following Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation. Cureus 2021; 13:e19105. [PMID: 34858752 PMCID: PMC8614179 DOI: 10.7759/cureus.19105] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/09/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is a promising approach for post-stroke rehabilitation but there lacks a rationale strategy to plan, execute, and monitor treatment. We present a case of targeted rTMS using the Omniscient Infinitome software to devise targets for treatment in a post-stroke patient and describe the functional connectomic changes after treatment. A 19-year-old female with no medical history presented 19 months after suffering a left middle cerebral artery (MCA) superior division ischemic stroke, resulting in language impairment and diminished right upper extremity motor function. She underwent a resting-state MRI (rsMRI) with tractography and images were processed using the Omniscient Infinitome software. Analysis using the anomaly detection within the software enabled us to identify three targets for rTMS (left area 1, left area 45, and right area SFL). These areas were treated with 25 sessions of intermittent Theta Burst Stimulation (iTBS) over five days at 80% of motor threshold concomitantly with targeted physical therapy and speech therapy. At five months follow-up, her language and right upper extremity functions significantly improved. Her connectomic analysis revealed substantial neural changes, including normalization of the sensorimotor network, substantially thicker callosal fiber bundle connecting the two hemispheres, and increased cortical recruitment in her language network. We present the first description of robust connectomic alterations in a post-stroke patient following targeted rTMS treatment. Further studies on the use of rTMS with an emphasis on functional connectomics are warranted.
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Affiliation(s)
- Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, AUS
| | | | | | - Charles Teo
- Neurological Surgery, Prince of Wales Private Hospital, University of New South Wales, Sydney, AUS.,Research, Omniscient Neurotechnology, Sydney, AUS
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, AUS.,Research, Omniscient Neurotechnology, Sydney, AUS
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13
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Noor H, Zaman A, Teo C, Sughrue ME. PODNL1 Methylation Serves as a Prognostic Biomarker and Associates with Immune Cell Infiltration and Immune Checkpoint Blockade Response in Lower-Grade Glioma. Int J Mol Sci 2021; 22:ijms222212572. [PMID: 34830454 PMCID: PMC8625785 DOI: 10.3390/ijms222212572] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 10/15/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 12/27/2022] Open
Abstract
Lower-grade glioma (LGG) is a diffuse infiltrative tumor of the central nervous system, which lacks targeted therapy. We investigated the role of Podocan-like 1 (PODNL1) methylation in LGG clinical outcomes using the TCGA-LGG transcriptomics dataset. We identified four PODNL1 CpG sites, cg07425555, cg26969888, cg18547299, and cg24354933, which were associated with unfavorable overall survival (OS) and disease-free survival (DFS) in univariate and multivariate analysis after adjusting for age, gender, tumor-grade, and IDH1-mutation. In multivariate analysis, the OS and DFS hazard ratios ranged from 0.44 to 0.58 (p < 0.001) and 0.62 to 0.72 (p < 0.001), respectively, for the four PODNL1 CpGs. Enrichment analysis of differential gene and protein expression and analysis of 24 infiltrating immune cell types showed significantly increased infiltration in LGGs and its histological subtypes with low-methylation levels of the PODNL1 CpGs. High PODNL1 expression and low-methylation subgroups of the PODNL1 CpG sites were associated with significantly increased PD-L1, PD-1, and CTLA4 expressions. PODNL1 methylation may thus be a potential indicator of immune checkpoint blockade response, and serve as a biomarker for determining prognosis and immune subtypes in LGG.
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Affiliation(s)
- Humaira Noor
- Cure Brain Cancer Biomarkers and Translational Research Group, Prince of Wales Clinical School, University of New South Wales, Sydney, NSW 2031, Australia
- Adult Cancer Program, Lowy Cancer Research Centre, UNSW Sydney, Randwick, NSW 2031, Australia
- Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia;
- Correspondence:
| | - Ashraf Zaman
- Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia;
- Garvan-Weizmann Centre for Cellular Genomics, Garvan Institute of Medical Research, Darlinghurst, Sydney, NSW 2010, Australia
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW 2031, Australia; (C.T.); (M.E.S.)
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW 2031, Australia; (C.T.); (M.E.S.)
| | - Michael E. Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW 2031, Australia; (C.T.); (M.E.S.)
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14
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Poologaindran A, Romero-Garcia R, Hart M, Young I, Santarius T, Price S, Sinha R, Profyris C, Profyris C, Erez Y, Teo C, Sughrue M, Suckling J. OS14.4.A The Neuroplastic Potential of the Human Brain before and After Glioma Surgery: Towards “Interventional Neurorehabilitation. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab180.052] [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: 11/15/2022] Open
Abstract
Abstract
INTRODUCTION
The human brain is a highly neuroplastic ‘complex’ network: it self-organises without a hard blueprint, adapts to evolving circumstances, and can withstand insults. However, similar to other naturally occurring networks, brain networks can only endure a finite amount of damage before cognitive processes are affected. In this study, we first sought to establish the brain networks governing domain-general cognition (DGC) in healthy individuals across the lifespan. We then sought to map, track, and potentially rehabilitate networks governing DGC through connectomics and non-invasive brain stimulation (NIBS) when damaged by low-grade gliomas (LGG) and surgical oncology.
METHODS
Using MRI and cognitive data from n=629 individuals (aged 18–88, Female= 51%), we assessed the structural, functional, and topological relevance of the spatially-distributed multiple-demand (MD) system for DGC. Next, in n=17 patients undergoing glioma surgery, we longitudinally acquired connectomic and cognitive data at multiple time points: pre-surgery and post-surgery Day 1, Month 3, Month 12. In an independent cohort of n=34 patients, we sought to establish the safety profile for “interventional neurorehabilitation”: connectome-driven NIBS in the acute post-operative period to accelerate cognitive recovery.
RESULTS
In healthy individuals, the MD system across multiple scales of biological organisation was positively associated with higher-order cognition (Catell’s fluid intelligence). In our patients, pre-operative LGG infiltration into the structural MD system was negatively associated with the number of long-term cognitive deficits, suggesting a functional reorganisation. Mixed-effects modelling demonstrated the resilience of the functional MD system to infiltration and resection, while the early post-operative period was critical for effective neurorehabilitation. Graph analyses revealed increased perioperative modularity can distinguish patients with long-term cognitive improvements at one-year follow-up. Finally, NIBS within two weeks post-craniotomy had a 90% (n=31/34) recruitment rate into the trial. There were no seizures or serious complications due to NIBS in this patient population. Transient headaches and tingling were reported in a minority of patients.
CONCLUSION
For the first time, we elucidate long-term cognitive and network trajectories following LGG surgery while establishing a positive safety-profile for NIBS in the acute post-operative period. We argue that “mesoscale” brain mapping serves as a robust biomarker for intervention-related plasticity for future clinical trials. While we performed these experiments in the context of neurosurgery, connectomics and NIBS could be adopted across diverse neuro-oncological care pathways (i.e. chemotherapy/radiation).
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Affiliation(s)
| | | | - M Hart
- University of Cambridge, Cambridge, United Kingdom
| | - I Young
- Cingulum Health, Sydney, Australia
| | - T Santarius
- University of Cambridge, Cambridge, United Kingdom
| | - S Price
- University of Cambridge, Cambridge, United Kingdom
| | - R Sinha
- University of Cambridge, Cambridge, United Kingdom
| | - C Profyris
- Prince of Wales Private Hospital, Sydney, Australia
| | - C Profyris
- Prince of Wales Private Hospital, Sydney, Australia
| | - Y Erez
- University of Cambridge, Cambridge, United Kingdom
| | - C Teo
- Prince of Wales Private Hospital, Sydney, Australia
| | - M Sughrue
- University of Cambridge, Cambridge, United Kingdom
| | - J Suckling
- University of Cambridge, Cambridge, United Kingdom
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15
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Yeung JT, Taylor HM, Nicholas PJ, Young IM, Jiang I, Doyen S, Sughrue ME, Teo C. Using Quicktome for Intracerebral Surgery: Early Retrospective Study and Proof of Concept. World Neurosurg 2021; 154:e734-e742. [PMID: 34358688 DOI: 10.1016/j.wneu.2021.07.127] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Neurosurgeons have limited tools in their armamentarium to visualize critical brain networks during surgical planning. Quicktome was designed using machine-learning to generate robust visualization of important brain networks that can be used with standard neuronavigation to minimize those deficits. We sought to see whether Quicktome could help localize important cerebral networks and tracts during intracerebral surgery. METHODS We report on all patients who underwent keyhole intracranial surgery with available Quicktome-enabled neuronavigation. We retrospectively analyzed the locations of the lesions and determined functional networks at risks, including chief executive network, default mode network, salience, corticospinal/sensorimotor, language, neglect, and visual networks. We report on the postoperative neurologic outcomes of the patients and retrospectively determined whether the outcomes could be explained by Quicktome's functional localizations. RESULTS Fifteen high-risk patients underwent craniotomies for intra-axial tumors, with the exception of one meningioma and one case of leukoencephalopathy. Eight patients were male. The median age was 49.6 years. Quicktome was readily integrated in our existing navigation system in every case. New postoperative neurologic deficits occurred in 8 patients. All new deficits, except for one resulting from a postoperative stroke, were expected and could be explained by preoperative findings by Quicktome. In addition, in those who did not have new neurologic deficits, Quicktome offered explanations for their outcomes. CONCLUSIONS Quicktome helps to visualize complex functional connectomic networks and tracts by seamlessly integrating into existing neuronavigation platforms. The added information may assist in reducing neurological deficits and offer explanations for postsurgical outcomes.
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Affiliation(s)
- Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Randwick, NSW, Australia
| | | | | | | | - Ivy Jiang
- Omniscient Neurotechnology, Sydney, Australia
| | | | | | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Randwick, NSW, Australia; Omniscient Neurotechnology, Sydney, Australia
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16
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Stephens TM, Young IM, O'Neal CM, Dadario NB, Briggs RG, Teo C, Sughrue ME. Akinetic mutism reversed by inferior parietal lobule repetitive theta burst stimulation: Can we restore default mode network function for therapeutic benefit? Brain Behav 2021; 11:e02180. [PMID: 34145791 PMCID: PMC8413751 DOI: 10.1002/brb3.2180] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/24/2021] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transcranial magnetic stimulation is a noninvasive treatment used to modulate cortical excitability. Its use over the last two decades has expanded, ranging from psychiatric disorders to traumatic brain injury and poststroke rehabilitation. OBJECTIVES We present the case of a 59-year-old male patient who presented in a decreased state of consciousness due to a right frontal glioblastoma, wherein his state was not improved by a successful surgery and could not be explained by any other condition. Due to his poor prognosis, we examine the benefits of receiving transcranial magnetic stimulation treatment to improve his akinetic mutism. METHODS We utilized independent component analysis with resting-state functional magnetic resonance imaging (rsfMRI) to better understand his cortical functionality. The imaging suggested absence of the default mode network (DMN). The patient underwent five sessions of navigated intermittent theta burst stimulation to the ipsilesional inferior parietal lobule and inferior frontal gyrus, with the aim of improving his default mode network functionality. RESULTS No other treatments resulted in an improvement of this patient's condition; however, 3 weeks following transcranial magnetic stimulation treatment, the patient was more alert and interactive, and his follow-up rsfMRI scan demonstrated a partially intact default mode network. CONCLUSION This case raises important questions regarding the clinical utility of transcranial magnetic stimulation to improve the connectivity of important cerebral networks and subsequent related functional recovery.
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Affiliation(s)
- Tressie M Stephens
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Japan
| | | | - Christen M O'Neal
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Japan
| | | | - Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Japan
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, NSW, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, NSW, Australia
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17
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Briggs RG, Lin YH, Dadario NB, Young IM, Conner AK, Xu W, Tanglay O, Kim SJ, Fonseka RD, Bonney PA, Chakraborty AR, Nix CE, Flecher LR, Yeung JT, Teo C, Sughrue ME. Optimal timing of post-operative enoxaparin after neurosurgery: A single institution experience. Clin Neurol Neurosurg 2021; 207:106792. [PMID: 34233235 DOI: 10.1016/j.clineuro.2021.106792] [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] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Venous thromboembolism (VTE) is a well-known problem in patients with intracranial tumors, especially high-grade gliomas. Optimal management of VTE complications is critical given that the development of deep vein thrombosis (DVT) and/or pulmonary embolism can exacerbate medical comorbidities and increase mortality. However, little is known about the optimum time to initiate post-operative anticoagulant prophylaxis. Therefore, there is a keen interest amongst neurosurgeons to develop evidence-based protocols to prevent VTE in post-operative brain tumor patients. METHODS We retrospectively identified adult patients who underwent elective craniotomy for intracranial tumor resection between 2012 and 2017. Patients were categorized according to the time at which they began receiving prophylactic enoxaparin in the immediate post-operative period, within one day (POD 1), two days (POD 2), three days (POD 3), five days (POD 5), or seven days (POD 7). RESULTS A total of 1087 patients had a craniotomy for intracranial tumor resection between 2012 and 2017. Multivariate binomial logistic regression analysis demonstrated that initiation of prophylactic enoxaparin within 72 h of surgery was protective against the likelihood of developing a lower extremity DVT (OR: 0.32; CI: 0.10-0.95; p = 0.049) while controlling for possible risk factors for DVTs identified on univariate analysis. Furthermore, complication rates between the anticoagulation and non-anticoagulation groups were not statistically significant. CONCLUSION Initiating anticoagulant prophylaxis with subcutaneous enoxaparin sodium 40 mg once per day within 72 h of surgery can be done safely while reducing the risk of developing lower extremity DVT.
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Affiliation(s)
- Robert G Briggs
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Yueh-Hsin Lin
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Nicholas B Dadario
- Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey
| | | | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Wenjai Xu
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Onur Tanglay
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Sihyong J Kim
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - R Dineth Fonseka
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Phillip A Bonney
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Arpan R Chakraborty
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Cameron E Nix
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Lyke R Flecher
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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18
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O'Neal CM, Ahsan SA, Dadario NB, Fonseka RD, Young IM, Parker A, Maxwell BD, Yeung JT, Briggs RG, Teo C, Sughrue ME. A connectivity model of the anatomic substrates underlying ideomotor apraxia: A meta-analysis of functional neuroimaging studies. Clin Neurol Neurosurg 2021; 207:106765. [PMID: 34237682 DOI: 10.1016/j.clineuro.2021.106765] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with ideomotor apraxia (IMA) present with selective impairments in higher-order motor cognition and execution without damage to any motor or sensory pathways. Although extensive research has been conducted to determine the regions of interest (ROIs) underlying these unique impairments, previous models are heterogeneous and may be further clarified based on their structural connectivity, which has been far less described. OBJECTIVE The goal of this research is to propose an anatomically concise network model for the neurophysiologic basis of IMA, specific to the voluntary pantomime, imitation and tool execution, based on intrinsic white matter connectivity. METHODS We utilized meta-analytic software to identify relevant ROIs in ideomotor apraxia as reported in the literature based on functional neuroimaging data with healthy participants. After generating an activation likelihood estimation (ALE) of relevant ROIs, cortical parcellations overlapping the ALE were used to construct an anatomically precise model of anatomic substrates using the parcellation scheme outlined by the Human Connectome Project (HCP). Deterministic tractography was then performed on 25 randomly selected, healthy HCP subjects to determine the structural connectivity underlying the identified ROIs. RESULTS 10 task-based fMRI studies met our inclusion criteria and the ALE analysis demonstrated 6 ROIs to constitute the IMA network: SCEF, FOP4, MIP, AIP, 7AL, and 7PC. These parcellations represent a fronto-parietal network consisting mainly of intra-parietal, U-shaped association fibers (40%) and long-range inferior fronto-occipital fascicle (IFOF) fibers (50%). These findings support previous functional models based on dual-stream motor processing. CONCLUSION We constructed a preliminary model demonstrating the underlying structural interconnectedness of anatomic substrates involved in higher-order motor functioning which is seen impaired in IMA. Our model provides support for previous dual-stream processing frameworks discussed in the literature, but further clarification is necessary with voxel-based lesion studies of IMA to further refine these findings.
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Affiliation(s)
- Christen M O'Neal
- Department of Neurosurgery, University of Oklahoma Health Sciences Centre, Oklahoma City, OK, USA
| | - Syed A Ahsan
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | | | - R Dineth Fonseka
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | | | - Allan Parker
- Department of Neurosurgery, University of Oklahoma Health Sciences Centre, Oklahoma City, OK, USA
| | - B David Maxwell
- Department of Neurosurgery, University of Oklahoma Health Sciences Centre, Oklahoma City, OK, USA
| | - Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Centre, Oklahoma City, OK, USA
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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19
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Schloss J, Lacey J, Sinclair J, Steel A, Sughrue M, Sibbritt D, Teo C. A Phase 2 Randomised Clinical Trial Assessing the Tolerability of Two Different Ratios of Medicinal Cannabis in Patients With High Grade Gliomas. Front Oncol 2021; 11:649555. [PMID: 34094937 PMCID: PMC8176855 DOI: 10.3389/fonc.2021.649555] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background Cannabis for cancer is very topical and, given the use of illicit cannabis preparations used in this vulnerable population, research investigating standardised, quality-assured medicinal cannabis is critical to inform clinicians and assist patient safety. Methods A randomized trial involving adult patients diagnosed with a high-grade glioma, no history of substance abuse, liver or kidney damage or myocardial infarction were eligible for inclusion in a tolerability study on two different ratios of medicinal cannabis. Baseline screening of brain morphology, blood pathology, functional status, and cognition was conducted. A retrospective control group was used for comparison for secondary outcomes. Results Participants (n=88) were on average 53.3 years old. A paired t-test assessed the Functional Assessment of Cancer Therapy for Brain Cancer (FACT-Br) between groups from baseline to week 12 found that the 1:1 ratio favoured both physical (p=0.025) and functional (p=0.014) capacity and improved sleep (p=0.009). Analysis of changes from baseline to week 12 also found 11% of 61 participants had a reduction in disease, 34% were stable, 16% had slight enhancement, and 10% had progressive disease. No serious adverse events occurred. Side effects included dry mouth, tiredness at night, dizziness, drowsiness. Conclusion This study demonstrated that a single nightly dose of THC-containing medicinal cannabis was safe, had no serious adverse effects and was well tolerated in patients. Medicinal cannabis significantly improved sleep, functional wellbeing, and quality of life. Clinical Trial Registration Australian New Zealand Clinical Trials Registry (ANZCTR) http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373556&isReview=true, identifier ACTRN12617001287325.
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Affiliation(s)
- Janet Schloss
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, NSW, Australia.,Office of Research, Endeavour College of Natural Health, Brisbane, QLD, Australia.,Australian Research Centre in Complementary and Integrative Medicine, University of Technology, Sydney, NSW, Australia
| | - Judith Lacey
- National Institute of Complementary Medicine (NICM) Health Research Institute, Western Sydney University, Sydney, NSW, Australia.,Supportive Care, Chris O'Brien Lifehouse Cancer Hospital, Sydney, NSW, Australia.,Clinical School of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Justin Sinclair
- National Institute of Complementary Medicine (NICM) Health Research Institute, Western Sydney University, Sydney, NSW, Australia
| | - Amie Steel
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology, Sydney, NSW, Australia
| | - Michael Sughrue
- Prince of Wales Private Hospital, Centre for Minimally Invasive Neurosurgery, Sydney, NSW, Australia
| | - David Sibbritt
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology, Sydney, NSW, Australia
| | - Charles Teo
- Prince of Wales Private Hospital, Centre for Minimally Invasive Neurosurgery, Sydney, NSW, Australia
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Milton CK, Dhanaraj V, Young IM, Taylor HM, Nicholas PJ, Briggs RG, Bai MY, Fonseka RD, Hormovas J, Lin Y, Tanglay O, Conner AK, Glenn CA, Teo C, Doyen S, Sughrue ME. Parcellation-based anatomic model of the semantic network. Brain Behav 2021; 11:e02065. [PMID: 33599397 PMCID: PMC8035438 DOI: 10.1002/brb3.2065] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/16/2020] [Accepted: 01/17/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The semantic network is an important mediator of language, enabling both speech production and the comprehension of multimodal stimuli. A major challenge in the field of neurosurgery is preventing semantic deficits. Multiple cortical areas have been linked to semantic processing, though knowledge of network connectivity has lacked anatomic specificity. Using attentional task-based fMRI studies, we built a neuroanatomical model of this network. METHODS One hundred and fifty-five task-based fMRI studies related to categorization of visual words and objects, and auditory words and stories were used to generate an activation likelihood estimation (ALE). Cortical parcellations overlapping the ALE were used to construct a preliminary model of the semantic network based on the cortical parcellation scheme previously published under the Human Connectome Project. Deterministic fiber tractography was performed on 25 randomly chosen subjects from the Human Connectome Project, to determine the connectivity of the cortical parcellations comprising the network. RESULTS The ALE analysis demonstrated fourteen left hemisphere cortical regions to be a part of the semantic network: 44, 45, 55b, IFJa, 8C, p32pr, SFL, SCEF, 8BM, STSdp, STSvp, TE1p, PHT, and PBelt. These regions showed consistent interconnections between parcellations. Notably, the anterior temporal pole, a region often implicated in semantic function, was absent from our model. CONCLUSIONS We describe a preliminary cortical model for the underlying structural connectivity of the semantic network. Future studies will further characterize the neurotractographic details of the semantic network in the context of medical application.
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Affiliation(s)
- Camille K. Milton
- Department of NeurosurgeryUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Vukshitha Dhanaraj
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | | | | | | | - Robert G. Briggs
- Department of NeurosurgeryUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Michael Y. Bai
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | - Rannulu D. Fonseka
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | - Jorge Hormovas
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | - Yueh‐Hsin Lin
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | - Onur Tanglay
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | - Andrew K. Conner
- Department of NeurosurgeryUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Chad A. Glenn
- Department of NeurosurgeryUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Charles Teo
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
| | | | - Michael E. Sughrue
- Department of NeurosurgeryPrince of Wales Private HospitalSydneyNSWAustralia
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21
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Yeung JT, Young IM, Profyris C, Katsos K, Sughrue ME, Teo C. Resection of Symptomatic Pineal Cysts Provides Durable Clinical Improvement: A Breakdown of Presenting Symptoms and Lessons Learned. World Neurosurg 2021; 150:e668-e674. [PMID: 33771749 DOI: 10.1016/j.wneu.2021.03.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgical resection of symptomatic pineal cysts without hydrocephalus remains controversial because patients can present with variable symptoms. Hesitancies in surgical decision-making include determining surgical candidacy and whether results would be durable. METHODS We performed a retrospective analysis on patients who underwent resection of their pineal cysts in our practice. We examined the presenting symptomology and investigated the radiographic changes to the morphology of the cerebral aqueduct found on follow-up imaging. We examined the clinical outcomes and complications following surgical resection of symptomatic pineal cysts. RESULTS A total of 97 patients underwent resection of pineal cysts, with 84 patients who had adequate follow-up (mean: 30.5 months). The patient population were predominantly female (76%) presenting at a mean of 24 years of age. Almost half of the patients had headaches that were positional, with 82% being bilateral; 39% and 19% of patients presented with photophobia and sonophobia, respectively, concurrent with their headaches. Many patients presented with visual disturbance (73%) along with other non-headache symptoms. Surgery resulted in 89% of patients with clinical improvements of their headaches. CONCLUSIONS Pineal cysts can present with variable headache symptomatology. Surgical resection of pineal cysts in carefully selected symptomatic patients after exhaustive conservative management can be performed safely and result in durable symptomatic relief.
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Affiliation(s)
- Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
| | | | - Christos Profyris
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia; Department of Neurosurgery, Helen Joseph Hospital, University of the Witwatersrand, Auckland Park, Johannesburg, South Africa
| | - Konstantinos Katsos
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
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22
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Young IM, Yeung J, Glenn C, Teo C, Sughrue ME. Aggressive Progression of a WHO Grade I Meningioma of the Posterior Clinoid Process: An Illustration of the Risks Associated With Observation of Skull Base Meningiomas. Cureus 2021; 13:e14005. [PMID: 33884246 PMCID: PMC8054942 DOI: 10.7759/cureus.14005] [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] [Indexed: 11/30/2022] Open
Abstract
Benign, small, and asymptomatic World Health Organization grade I meningiomas are usually managed expectantly with surveillance imaging with the assumption that they are predictably slowing growing. In this paper, we report the case of an incidentally discovered small, right-sided posterior clinoid meningioma in a 53-year-old female. The tumor was managed conservatively but an annual surveillance magnetic resonance imaging demonstrated that the meningioma had an unexpected significant growth impinging on the brainstem, requiring surgical resection and radiosurgery for residual tumor. Despite histopathological confirmation of a grade I meningioma, the tumor recurred significantly and incurred substantial neurological deficits, requiring further surgery and radiotherapy. This report illustrates the potential pitfall for expectant management of small meningiomas in anatomically precarious locations and draws attention to the need for detailed informed discussions with patients regarding the management of these tumors.
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Affiliation(s)
- Isabella M Young
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, AUS
| | - Jacky Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, AUS
| | - Chad Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, AUS
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Briggs RG, Allan PG, Poologaindran A, Dadario NB, Young IM, Ahsan SA, Teo C, Sughrue ME. The Frontal Aslant Tract and Supplementary Motor Area Syndrome: Moving towards a Connectomic Initiation Axis. Cancers (Basel) 2021; 13:cancers13051116. [PMID: 33807749 PMCID: PMC7961364 DOI: 10.3390/cancers13051116] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 02/07/2021] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Connectomics enables us to map whole brain networks that can be applied to operative neurosurgery to improve neuro-oncological outcomes. Damage to the superior frontal gyrus during frontal lobe surgery is thought to induce supplementary motor area (SMA) syndrome in patients. However, network-based modeling may provide a more accurate cortical model of SMA syndrome, including the Frontal Aslant Tract (FAT). The aim of our study was to retrospectively assess if surgical tractography with diffusion tensor imaging (DTI) decreases the likelihood of SMA syndrome. Compared to patients who underwent surgery preserving the SFG (n = 23), patients who had their FAT and SMA networks mapped through DTI and subsequently preserved were less likely to experience transient SMA syndrome. Preserving the FAT and SMA improves functional outcomes in patients following medial frontal glioma surgery and demonstrates how network-based approaches can improve surgical outcomes. Abstract Connectomics is the use of big data to map the brain’s neural infrastructure; employing such technology to improve surgical planning may improve neuro-oncological outcomes. Supplementary motor area (SMA) syndrome is a well-known complication of medial frontal lobe surgery. The ‘localizationist’ view posits that damage to the posteromedial bank of the superior frontal gyrus (SFG) is the basis of SMA syndrome. However, surgical experience within the frontal lobe suggests that this is not entirely true. In a study on n = 45 patients undergoing frontal lobe glioma surgery, we sought to determine if a ‘connectomic’ or network-based approach can decrease the likelihood of SMA syndrome. The control group (n = 23) underwent surgery avoiding the posterior bank of the SFG while the treatment group (n = 22) underwent mapping of the SMA network and Frontal Aslant Tract (FAT) using network analysis and DTI tractography. Patient outcomes were assessed post operatively and in subsequent follow-ups. Fewer patients (8.3%) in the treatment group experienced transient SMA syndrome compared to the control group (47%) (p = 0.003). There was no statistically significant difference found between the occurrence of permanent SMA syndrome between control and treatment groups. We demonstrate how utilizing tractography and a network-based approach decreases the likelihood of transient SMA syndrome during medial frontal glioma surgery. We found that not transecting the FAT and the SMA system improved outcomes which may be important for functional outcomes and patient quality of life.
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Affiliation(s)
- Robert G. Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (R.G.B.); (P.G.A.)
| | - Parker G. Allan
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (R.G.B.); (P.G.A.)
| | - Anujan Poologaindran
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge CB2 1TN, UK;
- Doctoral Program, The Alan Turing Institute, British Library, London NW1 2DB, UK
| | - Nicholas B. Dadario
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney 2031, Australia; (N.B.D.); (I.M.Y.); (S.A.A.); (C.T.)
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Isabella M. Young
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney 2031, Australia; (N.B.D.); (I.M.Y.); (S.A.A.); (C.T.)
| | - Syed A. Ahsan
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney 2031, Australia; (N.B.D.); (I.M.Y.); (S.A.A.); (C.T.)
| | - Charles Teo
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney 2031, Australia; (N.B.D.); (I.M.Y.); (S.A.A.); (C.T.)
| | - Michael E. Sughrue
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney 2031, Australia; (N.B.D.); (I.M.Y.); (S.A.A.); (C.T.)
- Correspondence:
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24
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Yeung JT, Caminer DM, Young IM, Sughrue ME, Teo C. Radical Exenteration of the Skull Base for End-Stage, Locally Advanced Sinonasal Malignancies: Challenging the Dictum of Unresectability. World Neurosurg 2021; 150:e102-e107. [PMID: 33647490 DOI: 10.1016/j.wneu.2021.02.092] [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: 12/09/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The role of surgery is not well defined in locally advanced sinonasal cancers with intracranial involvement after all medical options have been exhausted. We hypothesize that patients whose tumors are deemed unresectable and referred to palliative care may benefit from radical salvage surgery. METHODS We performed a single-center retrospective review of patients with malignant, locally advanced (stage T4b) sinonasal cancers with intracranial involvement from 2000 to 2020, inclusive. Data were collected on the patient demographics, details of chemotherapy, radiation, histology, perioperative complications, surgical approaches, and survival. We compared the survival outcomes of patients with different duration of disease before presentation. RESULTS We identified 17 patients who had undergone salvage surgical resection of treatment-recalcitrant, locally advanced sinonasal tumors. Almost all patients had undergone prior surgery, radiotherapy, and chemotherapy. Perioperative complications occurred in 6 of 17 patients with 1 death. Patients with clinically less aggressive disease had significantly longer progression-free and overall survival compared with the more aggressive group. CONCLUSIONS Salvage surgery for locally advanced sinonasal cancers with intracranial invasion that is recalcitrant to all other therapies should be considered for patients who otherwise have no other treatment options.
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Affiliation(s)
- Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - David M Caminer
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia; Department of Plastic Surgery, St. Vincent's Hospital, Sydney, Australia
| | | | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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25
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Lin YH, Dhanaraj V, Mackenzie AE, Young IM, Tanglay O, Briggs RG, Chakraborty AR, Hormovas J, Fonseka RD, Kim SJ, Yeung JT, Teo C, Sughrue ME. Anatomy and White Matter Connections of the Parahippocampal Gyrus. World Neurosurg 2021; 148:e218-e226. [PMID: 33412321 DOI: 10.1016/j.wneu.2020.12.136] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/20/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The parahippocampal gyrus is understood to have a role in high cognitive functions including memory encoding and retrieval and visuospatial processing. A detailed understanding of the exact location and nature of associated white tracts could significantly improve postoperative morbidity related to declining capacity. Through diffusion tensor imaging-based fiber tracking validated by gross anatomic dissection as ground truth, we have characterized these connections based on relationships to other well-known structures. METHODS Diffusion imaging from the Human Connectome Project for 10 healthy adult controls was used for tractography analysis. We evaluated the parahippocampal gyrus as a whole based on connectivity with other regions. All parahippocampal gyrus tracts were mapped in both hemispheres, and a lateralization index was calculated with resultant tract volumes. RESULTS We identified 2 connections of the parahippocampal gyrus: inferior longitudinal fasciculus and cingulum. Lateralization of the cingulum was detected (P < 0.05). CONCLUSIONS The parahippocampal gyrus is an important center for memory processing. Subtle differences in executive functioning following surgery for limbic tumors may be better understood in the context of the fiber-bundle anatomy highlighted by this study.
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Affiliation(s)
- Yueh-Hsin Lin
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Vukshitha Dhanaraj
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Alana E Mackenzie
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | | | - Onur Tanglay
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Arpan R Chakraborty
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jorge Hormovas
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - R Dineth Fonseka
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Sihyong J Kim
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery Prince of Wales Private Hospital, Sydney, Australia.
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26
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Faulkner H, Arnaout O, Hoshide R, Young IM, Yeung JT, Sughrue ME, Teo C. The Surgical Resection of Brainstem Glioma: Outcomes and Prognostic Factors. World Neurosurg 2020; 146:e639-e650. [PMID: 33152495 DOI: 10.1016/j.wneu.2020.10.147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/05/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of brainstem glioma remains controversial, with increasing evidence supporting surgical resection as the primary treatment for a select subgroup of tumors. However, there remains no consensus on the specific benefits and risks, the selection of surgical candidates, and prognostic factors that may further refine surgical indications. METHODS A retrospective single-surgeon chart review was performed for all patients who underwent surgical treatment for radiographically suspected brainstem glioma between 2000 and 2017. Preoperative and postoperative radiographic evaluations on magnetic resonance imaging were conducted. Survival outcomes were collected, and machine-learning techniques were used for multivariate analysis. RESULTS Seventy-seven patients with surgical treatment of brainstem glioma were identified, with a median age of 9 years (range, 0-58 years). The cohort included 64% low-grade (I and II) and 36% high-grade (III and IV) tumors. For all patients, the 1-year and 5-year overall survival were 76.4% and 62.3%, respectively. Transient neurologic deficit was present in 34% of cases, and permanent deficit in a further 29%. CONCLUSIONS The radical surgical resection of brainstem gliomas can be performed with acceptable risk in well-selected cases and likely confers survival advantage for what is otherwise a rapidly and universally fatal disease. Various radiographic features are useful during patient selection and may guide treatment selection.
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Affiliation(s)
- Harrison Faulkner
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia; Faculty of Medicine, The University of New South Wales Sydney, New South Wales, Australia
| | - Omar Arnaout
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School Boston, Massachusetts, USA
| | - Reid Hoshide
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia; Department of Neurosurgery, University of California - San Diego, San Diego, California, USA
| | - Isabella M Young
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia
| | - Jacky T Yeung
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia
| | - Michael E Sughrue
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia.
| | - Charles Teo
- The Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia
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Profyris C, Chen E, Young IM, Chendeb K, Ahsan SA, Briggs RG, Sughrue ME, Teo C. Anaplastic Oligodendroglioma - Is Adjuvant Radiotherapy Mandatory following Maximal Surgical Resection?: Grade 3 Oligo Radiotherapy. Clin Neurol Neurosurg 2020; 200:106303. [PMID: 33109468 DOI: 10.1016/j.clineuro.2020.106303] [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: 07/21/2020] [Revised: 09/25/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current anaplastic oligodendroglioma (AO) management strategies involve surgical resection followed by adjuvant radiotherapy and/or chemotherapy. We investigated a subset of patients at our institution with AO, who, based on their treatment preferences, received surgery without any form of adjuvant therapy. This subset of patients was compared to a cohort with AO who received adjuvant therapy in order to investigate any differences in clinical and survival outcomes. METHODS A retrospective review of all AO patients treated by the senior author was undertaken between 1994 and 2018. A total of thirty-three cases were identified. Eleven had surgery alone, and twenty-two had surgery with adjuvant therapy. Progression free (PFS) and overall survival (OS) were compared between cohorts and potential confounders were addressed. RESULTS Gross total resection was achieved in 29 patients, and near total resection in 4 patients. PFS was not statistically different between patients treated with surgery alone versus patients receiving surgery plus adjuvant therapy (surgery alone: 84 ± 16 months; surgery with radiotherapy: 60 ± 9 months; p = 0.08). In addition, OS was also not statistically different between these groups (surgery alone: 215 ± 17 months; surgery with therapy: 241 ± 22 months; p = 0.44). CONCLUSIONS It is reasonable to consider a "watch and monitor" surveillance strategy in patients who decline adjuvant radiotherapy following surgical resection of their AO. Patients should be made aware that this treatment plan is not standard within current models of care for AO.
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Affiliation(s)
- Christos Profyris
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW, Australia; Department of Neurosurgery, Helen Joseph Hospital, University of the Witwatersrand, Auckland Park, Johannesburg, South Africa
| | - Emily Chen
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW, Australia
| | | | - Kassem Chendeb
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW, Australia
| | - Syed A Ahsan
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Michael E Sughrue
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW, Australia.
| | - Charles Teo
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, NSW, Australia
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Chaurasia B, Deora H, El-Ghandour NMF, Oyesiku NM, Chaurasia RK, Schulder M, Soriano Sanchez JA, Teo M, Hernesniemi J, Linzey JR, Schwartz TH, Cohen-Gadol AA, Lawton M, Umana G, Mura J, Grotenhuis A, Sinha AK, Schroeder HWS, Natarajan S, Sughrue ME, Spetzler RF, Drummond K, Tanikawa R, Seixo Kadri PAD, Kato Y, Teo C, Suri A, Tomasi SO, Winkler PA, Scalia G, Sampron N, Rasulic L, Cappabianca P, Fontanella MM, Laws ER. In Memoriam: A Memoir for Our Fallen "Heroes". Neurosurgery 2020; 87:854-856. [PMID: 32657330 PMCID: PMC7454769 DOI: 10.1093/neuros/nyaa314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: "When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session-all these require surgical judgment which is a matter of long experience." It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us.
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Affiliation(s)
- Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neuroscience, Bangalore, Karnataka, India
| | | | - Nelson M Oyesiku
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Michael Schulder
- Department of Neurosurgery, Brain Tumor Center Zucker School of Medicine, Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
| | | | - Mario Teo
- Bristol Institute of Clinical Neuroscience, Bristol University Hospital, Bristol, United Kingdom
| | | | | | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | | | - Michael Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Giuseppe Umana
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Centre, Gamma Knife Centre, Catania, Italy
| | - Jorge Mura
- Cerebrovascular and Skull Base department, Institute of Neurosurgery Asenjo, Providencia, Santiago, Chile
| | - Andre Grotenhuis
- Emeritus Professor of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ajit K Sinha
- Department of Neurosurgery, Sir Ganga Ram Institute of Postgraduate Medical Education and Research, New Delhi, India
| | | | - Sabareesh Natarajan
- Department of Neurosurgery, University of Massachusetts Medical School, Massachusetts
| | | | | | - Katharine Drummond
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Paulo Abdo do Seixo Kadri
- Adjunct Professor of Neurosurgery, Federal University of Mato Grosso do Sul Campo Grande, Mato Grosso do Sul, Brazil
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Aichi, Toyoake, Japan
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Sydney, Australia
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Peter A Winkler
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialised Hospital of National Importance "Garibaldi", Catania, Italy
| | - Nicolas Sampron
- Servicio de Neurocirugia, Hospital Universitario Donostia, San Sebastian, Spain
| | - Lukas Rasulic
- Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | | | - Edward R Laws
- Pituitary/Neuroendocrine Centre, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Takeuchi H, Borlido C, Sanches M, Teo C, Harber L, Agid O, Remington G. Adherence to clozapine vs. other antipsychotics in schizophrenia. Acta Psychiatr Scand 2020; 142:87-95. [PMID: 32627168 DOI: 10.1111/acps.13208] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 04/25/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND To date, there have been no studies evaluating adherence to clozapine with electronic adherence monitoring (EAM) such as the Medication Event Monitoring System (MEMS® ). METHODS In outpatients with schizophrenia, we conducted a 3-month prospective study investigating antipsychotic adherence with EAM (eCAP® ). Participants were treated with different oral antipsychotics, including clozapine, and blind to EAM monitoring; all were on antipsychotic monotherapy administered once daily. Outcome measures included adherence rate, missed dose, and medication gap. Adherence trajectory patterns were also analyzed for clozapine vs. other antipsychotics collectively. RESULTS A total of 111 patients were included in the study; 33 and 78 patients received clozapine or other antipsychotics, respectively. Adherence rates, defined as proportion of days that the subject took the medication at the prescribed time ± 3 h and proportion of subjects with ≥80% adherence, were numerically higher in patients receiving clozapine vs. other antipsychotics (72.0% vs. 65.1%, P = 0.10; 49.5% vs. 35.7%, P = 0.11, respectively). Along similar lines, some of the missed dose and medication gap outcomes were significantly better in patients receiving clozapine vs. other antipsychotics. Three adherence trajectory patterns were identified for both clozapine and other antipsychotics, with two shared by both groups (i.e., low adherence with a slight decrease over time; high and stable adherence). CONCLUSION Findings suggest that in patients with schizophrenia clozapine adherence is at least comparable, if not slightly better, compared with other antipsychotics.
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Affiliation(s)
- H Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - C Borlido
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - M Sanches
- Biostatistical Consulting Service, Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - C Teo
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - L Harber
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - O Agid
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - G Remington
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [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: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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31
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Lacey J, Schloss JM, Sinclair J, Steel A, Sughrue M, Teo C, Sibbritt D. A phase II double-blind, randomized clinical trial assessing the tolerability of two different ratios of cannabis in patients with glioblastoma multiforme (GBM). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2530 Background: Cannabis has been used for cancer-related symptoms but few trials have assessed quality of life or tolerability, and trials assessing tumour response or survival remain scarce. Treatment for recurrent glioblastoma (rGBM) remains palliative with poor prognosis. The tolerability of THC-containing cannabis products, and their effect on symptoms and quality of life in people with rGBM patients is poorly defined but is essential before efficacy trials can be conducted. Methods: We conducted a randomised double-blinded trial assessing the tolerability of two preparations of cannabis in 88 people with rGBM. The two preparations used different cannabidiol (CBD) to tetrahydrocannibidiol (THC) ratios; 1:1 (5.8mg/ml:5.6mg/ml) and 1:4 (3.8mg/ml:15mg/ml). Daily evening doses were individually monitored and titrated. Outcomes included disease response by FACT-Br, MRI imaging 12 weekly, blood pathology, NCI-CTC and clinical monitoring. Symptom assessments were performed 4 weekly for 12 weeks. Results: 921 people volunteered for screening across Australia, with 642 excluded, 92 recruited with 88 enrolled. 61 participants completed 12-week follow-up (attrition 30%). Both cannabis oils were well tolerated. Total FACT-Br was similar for both preparations, however, statistical significance was found for the physical section (p = 0.025) and functional (p = 0.014) identifying the 1:1 ratio as the more appropriate combination. Comparing groups to baseline, participants reported improvement of sleep (p = 0.009), improved energy (p = 0.015), and contentment with QoL (p = 0.006). Total cohort compared to baseline, participants reported improvement of sleep (p = 0.0001), pain (p = 0.046), nausea (p = 0.017), anxiety (p = 0.005) and seizure activity (p = 0.022). There were no major adverse events attributable to the cannabis with main side effects noted as dizziness, drowsiness, tiredness, and dry mouth. No abnormal blood pathology nor variance in NCI-CTCAE scores were observed. Conclusions: A single nightly dose of THC-containing cannabis was well tolerated in patients in both groups with rGBM and significantly improved sleep and functional wellbeing and QOL in a sample of patients compared to baseline. From this trial, the 1:1 ratio has been identified as the better tolerated product with suprerior symptom and QoL outcomes compared to the 1:4 product. Clinical trial information: ACTRN12617001287325 .
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Affiliation(s)
- Judith Lacey
- Supportive Care, Chris O’Brien Lifehouse Cancer Hospital, Camperdown, NSW, Australia
| | - Janet Margaret Schloss
- Endeavour College of Natural Health, Unversity of Technology Sydney, Fortitude Valley, QLD, Australia
| | - Justin Sinclair
- NICM Health Research Institute, Western University of Sydney, Westmead, NSW, Australia
| | - Amie Steel
- ARCCIM, The University of Technology Sydney, Ultimo,, NSW, Australia
| | - Mike Sughrue
- Research Director, Centre for Minimally Invasive Neurosurgery, Randwick, NSW, Australia
| | - Charles Teo
- Director, Centre for Minimally Invasive Neurosurgery, Randwick, NSW, Australia
| | - David Sibbritt
- ARCCIM, The University of Technology Sydney, Ultimo, NSW, Australia
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Briggs RG, Conner AK, Chakraborty AR, Allan PG, Young IM, Teo C, Sughrue ME. An Eyebrow, Supracarotid Triangle Approach for Lesions at the Ventral Thalamopeduncular Junction: A Technical Report. World Neurosurg 2020; 140:e41-e45. [PMID: 32311564 DOI: 10.1016/j.wneu.2020.04.048] [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: 09/26/2019] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Lesions arising at the ventral thalamopeduncular junction are difficult to resect. In addition to being relatively inaccessible, these lesions are located in one of the most sensitive areas of the brain. A critical question is whether new approaches could be developed to allow surgeons to adequately resect these lesions with reasonable outcomes. In the present report, we describe our approach to resect lesions in this region of the brain using an eyebrow craniotomy approach with a trajectory through the supracarotid triangle. METHODS Through retrospective data collection, we present a small series of patients who had undergone an eyebrow, supracarotid triangle approach to resect lesions located at the thalamopeduncular junction. We describe our surgical technique and report patient outcomes using this approach. RESULTS Three patients had undergone an eyebrow, supracarotid approach for resection of a lesion arising at the ventral thalamopeduncular junction. Two patients had presented with a cavernoma and one with a pilocytic astrocytoma. Complete resection of all 3 lesions was achieved during surgery without any intraoperative complications. No patient developed permanent contralateral weakness despite entering the peduncle during surgery. One patient developed permanent paresthesia in his left hand. CONCLUSIONS Lesions arising at the ventral thalamopeduncular junction can be adequately resected with reasonable outcomes using an eyebrow, supracarotid triangle approach. This operative technique establishes another potential operative corridor by which neurosurgeons can resect lesions arising within this relatively inaccessible part of the brain.
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Affiliation(s)
- Robert G Briggs
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Arpan R Chakraborty
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Parker G Allan
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Isabella M Young
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Charles Teo
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Michael E Sughrue
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia.
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Jones RG, Briggs RG, Conner AK, Bonney PA, Fletcher LR, Ahsan SA, Chakraborty AR, Nix CE, Jacobs CC, Lack AM, Griffin DT, Teo C, Sughrue ME. Measuring graphical strength within the connectome: A neuroanatomic, parcellation-based study. J Neurol Sci 2020; 408:116529. [DOI: 10.1016/j.jns.2019.116529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 01/15/2023]
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Ahsan SA, Chendeb K, Briggs RG, Fletcher LR, Jones RG, Chakraborty AR, Nix CE, Jacobs CC, Lack AM, Griffin DT, Teo C, Sughrue ME. Beyond eloquence and onto centrality: a new paradigm in planning supratentorial neurosurgery. J Neurooncol 2020; 146:229-238. [PMID: 31894519 DOI: 10.1007/s11060-019-03327-4] [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: 07/21/2019] [Accepted: 10/31/2019] [Indexed: 01/20/2023]
Abstract
PURPOSE Minimizing post-operational neurological deficits as a result of brain surgery has been one of the most pertinent endeavours of neurosurgical research. Studies have utilised fMRIs, EEGs and MEGs in order to delineate and establish eloquent areas, however, these methods have not been utilized by the wider neurosurgical community due to a lack of clinical endpoints. We sought to ascertain if there is a correlation between graph theory metrics and the neurosurgical notion of eloquent brain regions. We also wanted to establish which graph theory based nodal centrality measure performs the best in predicting eloquent areas. METHODS We obtained diffusion neuroimaging data from the Human Connectome Project (HCP) and applied a parcellation scheme to it. This enabled us to construct a weighted adjacency matrix which we then analysed. Our analysis looked at the correlation between PageRank centrality and eloquent areas. We then compared PageRank centrality to eigenvector centrality and degree centrality to see what the best measure of empirical neurosurgical eloquence was. RESULTS Areas that are considered neurosurgically eloquent tended to be predicted by high PageRank centrality. By using summary scores for the three nodal centrality measures we found that PageRank centrality best correlated to empirical neurosurgical eloquence. CONCLUSION The notion of eloquent areas is important to neurosurgery and graph theory provides a mathematical framework to predict these areas. PageRank centrality is able to consistently find areas that we consider eloquent. It is able to do so better than eigenvector and degree central measures.
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Affiliation(s)
- Syed Ali Ahsan
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Suite 3, Level 7, Barker Street, Randwick, Sydney, NSW, 2031, Australia
| | - Kassem Chendeb
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Suite 3, Level 7, Barker Street, Randwick, Sydney, NSW, 2031, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Luke R Fletcher
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Ryan G Jones
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Arpan R Chakraborty
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Cameron E Nix
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Christina C Jacobs
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Alison M Lack
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Daniel T Griffin
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Charles Teo
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Suite 3, Level 7, Barker Street, Randwick, Sydney, NSW, 2031, Australia
| | - Michael Edward Sughrue
- Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Suite 3, Level 7, Barker Street, Randwick, Sydney, NSW, 2031, Australia.
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35
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Loh K, Poh L, Yao Y, Wong P, Chan Z, Teo C, Ng Y, Pang A. MEDICATION THERAPY MANAGEMENT (MTM) IN ELDERLY CANCER PATIENTS: A PILOT STUDY. J Geriatr Oncol 2019. [DOI: 10.1016/s1879-4068(19)31319-0] [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: 10/25/2022]
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Abstract
OBJECTIVE There are numerous treatment strategies in the management for large vestibular schwannomas, including resection only, staged resections, resections followed by radiosurgery, and radiosurgery only. Recent evidence has pointed toward maximal resection as being the optimum strategy to prevent tumor recurrence; however, durable tumor control through aggressive resection has been shown to occur at the expense of facial nerve function and to risk other approach-related complications. Through a retrospective analysis of their single-institution series of keyhole neurosurgical approaches for large vestibular schwannomas, the authors aim to report and justify key techniques to maximize tumor resection and reduce surgical morbidity. METHODS A retrospective chart review was performed at the Centre for Minimally Invasive Neurosurgery. All patients who had undergone a keyhole retrosigmoid approach for the resection of large vestibular schwannomas, defined as having a tumor diameter of ≥ 3.0 cm, were included in this review. Patient demographics, preoperative cranial nerve status, perioperative data, and postoperative follow-up were obtained. A review of the literature for resections of large vestibular schwannomas was also performed. The authors' institutional data were compared with the historical data from the literature. RESULTS Between 2004 and 2017, 45 patients met the inclusion criteria for this retrospective chart review. When compared with findings in a historical cohort in the literature, the authors' minimally invasive, keyhole retrosigmoid technique for the resection of large vestibular schwannomas achieved higher rates of gross-total or near-total resection (100% vs 83%). Moreover, these results compare favorably with the literature in facial nerve preservation (House-Brackmann I-II) at follow-up after gross-total resections (81% vs 47%, p < 0.001) and near-total resections (88% vs 75%, p = 0.028). There were no approach-related complications in this series. CONCLUSIONS It is the experience of the senior author that complete or near-complete resection of large vestibular schwannomas can be successfully achieved via a keyhole approach. In this series of 45 large vestibular schwannomas, a greater extent of resection was achieved while demonstrating high rates of facial nerve preservation and low approach-related and postoperative complications compared with the literature.
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Affiliation(s)
- Reid Hoshide
- 1Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital.,2Department of Neurosurgery, University of California, San Diego, California; and
| | - Harrison Faulkner
- 1Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital.,3Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mario Teo
- 1Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital.,4Department of Neurosurgery, North Bristol University Hospital, Bristol, United Kingdom
| | - Charles Teo
- 1Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital
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37
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Briggs RG, Nix CE, Conner AK, Palejwala AH, Smitherman AD, Teo C, Sughrue ME. An Awake Contralateral, Transcallosal Approach for Deep-Seated Gliomas of the Basal Ganglia. World Neurosurg 2019; 130:e880-e887. [DOI: 10.1016/j.wneu.2019.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/29/2022]
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Abstract
Introduction: Atypical meningiomas are aggressive tumors associated with high rates of recurrence and mortality. Current therapy is surgical resection followed by radiotherapy which has reasonable success rates. However, there are cases where surgical resection is not possible, and radiotherapy is not advisable. Areas covered: In this short review, the authors have searched the current literature for explorations of adjuvant treatments such as chemotherapy and pharmaceutical agents. Most current chemotherapeutic agents have been unsuccessful in producing radiographic reduction or disease stabilization, although drugs like somatostatin analogs and plant-derived chemotherapeutics have shown some promise. The authors note that most of the studies in this field have been case series with a few randomized trials present. This makes it hard to ascertain the effectiveness of the drugs and so further research is required in the field. Expert opinion: Finding pharmacotherapies to combat atypical meningiomas needs Big data genomic analysis. This will assist in generating drug candidates and a multidrug approach to therapy that will exploit several of the pathological pathways of atypical meningiomas. Using multidrug therapy that affects several pathways also addresses the issue of meningioma heterogeneity and adaptability.
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Affiliation(s)
- Syed Ali Ahsan
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital , Sydney , Australia
| | - Kassem Chendeb
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital , Sydney , Australia
| | - Christos Profyris
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital , Sydney , Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital , Sydney , Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital , Sydney , Australia
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Giewekemeyer K, Aquila A, Loh NTD, Chushkin Y, Shanks KS, Weiss J, Tate MW, Philipp HT, Stern S, Vagovic P, Mehrjoo M, Teo C, Barthelmess M, Zontone F, Chang C, Tiberio RC, Sakdinawat A, Williams GJ, Gruner SM, Mancuso AP. Experimental 3D coherent diffractive imaging from photon-sparse random projections. IUCrJ 2019; 6:357-365. [PMID: 31098017 PMCID: PMC6503918 DOI: 10.1107/s2052252519002781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/24/2019] [Indexed: 05/19/2023]
Abstract
The routine atomic resolution structure determination of single particles is expected to have profound implications for probing structure-function relationships in systems ranging from energy-storage materials to biological molecules. Extremely bright ultrashort-pulse X-ray sources - X-ray free-electron lasers (XFELs) - provide X-rays that can be used to probe ensembles of nearly identical nanoscale particles. When combined with coherent diffractive imaging, these objects can be imaged; however, as the resolution of the images approaches the atomic scale, the measured data are increasingly difficult to obtain and, during an X-ray pulse, the number of photons incident on the 2D detector is much smaller than the number of pixels. This latter concern, the signal 'sparsity', materially impedes the application of the method. An experimental analog using a conventional X-ray source is demonstrated and yields signal levels comparable with those expected from single biomolecules illuminated by focused XFEL pulses. The analog experiment provides an invaluable cross check on the fidelity of the reconstructed data that is not available during XFEL experiments. Using these experimental data, it is established that a sparsity of order 1.3 × 10-3 photons per pixel per frame can be overcome, lending vital insight to the solution of the atomic resolution XFEL single-particle imaging problem by experimentally demonstrating 3D coherent diffractive imaging from photon-sparse random projections.
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Affiliation(s)
| | - A. Aquila
- European XFEL GmbH, Holzkoppel 4, 22869 Schenefeld, Germany
| | - N.-T. D. Loh
- Centre for Bio-imaging Sciences, National University of Singapore, 14 Science Drive 4, 117557 Singapore
- Department of Physics, National University of Singapore, 2 Science Drive 3, 117551 Singapore
- Department of Biological Sciences, National University of Singapore, 14 Science Drive 4, 117557 Singapore
| | - Y. Chushkin
- ESRF – The European Synchrotron, 71 avenue des Martyrs, 38000 Grenoble, France
| | - K. S. Shanks
- Laboratory for Atomic and Solid State Physics, Cornell University, Ithaca, NY 14853, USA
| | - J.T. Weiss
- Laboratory for Atomic and Solid State Physics, Cornell University, Ithaca, NY 14853, USA
| | - M. W. Tate
- Laboratory for Atomic and Solid State Physics, Cornell University, Ithaca, NY 14853, USA
| | - H. T. Philipp
- Laboratory for Atomic and Solid State Physics, Cornell University, Ithaca, NY 14853, USA
| | - S. Stern
- European XFEL GmbH, Holzkoppel 4, 22869 Schenefeld, Germany
- Center for Free-Electron Laser Science, Deutsches Elektronen-Synchrotron, 22607 Hamburg, Germany
| | - P. Vagovic
- European XFEL GmbH, Holzkoppel 4, 22869 Schenefeld, Germany
- Center for Free-Electron Laser Science, Deutsches Elektronen-Synchrotron, 22607 Hamburg, Germany
| | - M. Mehrjoo
- European XFEL GmbH, Holzkoppel 4, 22869 Schenefeld, Germany
| | - C. Teo
- Centre for Bio-imaging Sciences, National University of Singapore, 14 Science Drive 4, 117557 Singapore
- Department of Biological Sciences, National University of Singapore, 14 Science Drive 4, 117557 Singapore
| | - M. Barthelmess
- Center for Free-Electron Laser Science, Deutsches Elektronen-Synchrotron, 22607 Hamburg, Germany
| | - F. Zontone
- ESRF – The European Synchrotron, 71 avenue des Martyrs, 38000 Grenoble, France
| | - C. Chang
- SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, CA 94025, USA
| | - R. C. Tiberio
- Stanford Nano Shared Facilities, Stanford University, 348 Via Pueblo, Stanford, CA 94305, USA
| | - A. Sakdinawat
- SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, CA 94025, USA
| | - G. J. Williams
- SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, CA 94025, USA
| | - S. M. Gruner
- Laboratory for Atomic and Solid State Physics, Cornell University, Ithaca, NY 14853, USA
- Cornell High Energy Synchrotron Source (CHESS), Cornell University, Ithaca, NY 14853, USA
- Kavli Institute at Cornell for Nanoscale Science, Cornell University, Ithaca, NY 14853, USA
| | - A. P. Mancuso
- European XFEL GmbH, Holzkoppel 4, 22869 Schenefeld, Germany
- Department of Chemistry and Physics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, Victoria 3086, Australia
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Oakley GM, Ebenezer J, Hamizan A, Sacks PL, Rom D, Sacks R, Winder M, Davidson A, Teo C, Solares CA, Harvey RJ. Finding the Petroclival Carotid Artery: The Vidian-Eustachian Junction as a Reliable Landmark. J Neurol Surg B Skull Base 2017; 79:361-366. [PMID: 30009117 DOI: 10.1055/s-0037-1608650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 06/15/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022] Open
Abstract
Introduction Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa pathology is essential for the skull base surgeon. The vidian nerve and eustachian tube (ET) cartilage come together at the foramen lacerum, the vidian-eustachian junction (VEJ). The ICA position, relative to the VEJ is described. Methods Endoscopic dissection of adult fresh-frozen cadaver ICAs and a case series of patients with petroclival pathology were performed. The relationship of the VEJ to the ICA horizontal segment, vertical segment, and second genu was assessed. The distance of the ICA second genu to VEJ was determined in coronal, axial, and sagittal planes. The length of the vidian nerve and ET was measured from the pterygopalatine fossa (PPF) and nasopharyngeal orifice to the VEJ. Results In this study, 10 cadaver dissections (82.3 ± 6.7 years, 40% female) were performed. The horizontal petrous ICA was at or behind VEJ in 100%, above VEJ in 100%, and lateral to VEJ in 80%. The vertical paraclival segment was at or behind VEJ in 100%, above in 100%, and medial in 100%. The second genu was at or behind VEJ in 100% (3.3 ± 2.4 mm), at or above in 100% (2.5 ± 1.6 mm), and medial in 100% (3.4 ± 2.0 mm). The VEJ was successfully used to locate the ICA in nine consecutive patients (53.3 ± 13.6 years, 55.6% female) where pathology was also present. The VEJ was 15.0 ± 6.0 mm from the ET and 17.4 ± 4.1 mm from the PPF. Conclusion The VEJ is an excellent landmark as it defines both superior and posterior limits when isolating the ICA in skull base surgery.
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Affiliation(s)
- Gretchen M Oakley
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, United States.,Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Jareen Ebenezer
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Aneeza Hamizan
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Peta-Lee Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Darren Rom
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Mark Winder
- Department of Neurosurgery, St Vincent's Hospital, Sydney, Australia
| | - Andrew Davidson
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, Australia
| | - C Arturo Solares
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, United States
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Jayamanne D, Wheeler H, Cook R, Teo C, Brazier D, Schembri G, Kastelan M, Guo L, Back MF. Survival improvements with adjuvant therapy in patients with glioblastoma. ANZ J Surg 2017; 88:196-201. [DOI: 10.1111/ans.14153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/13/2017] [Accepted: 06/22/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Dasantha Jayamanne
- Northern Sydney Cancer Centre; Royal North Shore Hospital; Sydney New South Wales Australia
- Central Coast Cancer Centre; Gosford Hospital; Sydney New South Wales Australia
| | - Helen Wheeler
- Northern Sydney Cancer Centre; Royal North Shore Hospital; Sydney New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Sydney NeuroOncology Group; Sydney New South Wales Australia
| | - Raymond Cook
- Sydney NeuroOncology Group; Sydney New South Wales Australia
- Department of Neurosurgery; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Charles Teo
- Department of Neurosurgery; Prince of Wales Private Hospital; Sydney New South Wales Australia
| | - David Brazier
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Radiology; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Geoff Schembri
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Nuclear Medicine; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Marina Kastelan
- Northern Sydney Cancer Centre; Royal North Shore Hospital; Sydney New South Wales Australia
- Sydney NeuroOncology Group; Sydney New South Wales Australia
| | - Linxin Guo
- Northern Sydney Cancer Centre; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Michael F. Back
- Northern Sydney Cancer Centre; Royal North Shore Hospital; Sydney New South Wales Australia
- Central Coast Cancer Centre; Gosford Hospital; Sydney New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Sydney NeuroOncology Group; Sydney New South Wales Australia
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Hoshide R, Teo C. Neuroendoscopy to Achieve Superior Glioma Resection Outcomes. Neurosurgery 2017; 64:139-143. [PMID: 28899051 DOI: 10.1093/neuros/nyx274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 07/28/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Reid Hoshide
- Centre for Minimally Invasive Neuro-surgery, Randwick, New South Wales 2031, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neuro-surgery, Randwick, New South Wales 2031, Australia
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Abstract
Objective Hyperaggressive resection refers to a philosophy that maximal resection should be pursued in gliomas, wherever possible. In this study, we provide a detailed report of the outcomes with hyperaggressive surgery for multilobar insular-involving gliomas (MIGs). Methods We report outcomes in patients with MIGs undergoing surgery aiming at gross total resection in all cases. Risk factors for neurologic deficits and survival were modeled using logistic and Cox regression. Results There were 72 consecutive patients, of whom 53 (74%) had undergone previous surgery. A greater than 90% resection was obtained in 67 patients (93%). Nineteen of 23 patients (83%) with Grade 2 tumors survived to the end of the follow-up period. Patients with Grade 3 tumors experienced 75% two-year survival rates and 48% four-year survival rates. Patients with Grade 4 tumors experienced 55% one-year survival rates and 33% two-year survival rates; eight of 33 patients (24%) lived longer than three years and three of 33 patients were alive at five years. Fifty-eight of 68 patients (85%) surviving to the three-month follow-up had a Karnofsky performance status (KPS) of 70 or greater, and 31 of 72 patients (43%) experienced improvement in KPS postoperatively. Permanent weakness occurred in 12 patients (17%), and permanent speech problems in three patients (13% of left-sided tumors). Conclusion Hyperaggressive surgical resection of MIGs yields rates of neurologic deficits within acceptable ranges and are lower than expected. In many cases, patients exceed the long-term survival expectations of conventional treatment.
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Affiliation(s)
- Michael Sughrue
- Department of Neurosurgery, University of Oklahoma Health Sciences Center
| | - Phillip A Bonney
- Department of Neurosurgery, University of Oklahoma Health Sciences Center
| | - Joshua D Burks
- Department of Neurosurgery, University of Oklahoma Health Sciences Center
| | - Jad Othman
- Prince of Wales Private Hospital, University of New South Wales
| | - Cordell Baker
- Department of Neurosurgery, University of Oklahoma Health Sciences Center
| | - Chad A Glenn
- Neurosurgery, University of Oklahoma Health Sciences Center
| | - Charles Teo
- Prince of Wales Private Hospital, University of New South Wales
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Abuhusain H, Gunawardena M, Auschwitz T, Teo C, Koechlin N. Symptomatic Outcome after Bone-only Suboccipital Decompression in Adult Patients with Chiari Type I Malformations in the Absence of Hydromyelia or Hydrocephalus. J Neurol Surg A Cent Eur Neurosurg 2017; 78:344-349. [DOI: 10.1055/s-0037-1599841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Type I Chiari malformation presents without an associated hydromyelia in 30 to 70% of cases, yet there is no agreement regarding the optimal surgical treatment for these patients. We review our experience for treating symptomatic adult type I Chiari malformation without hydromyelia using a suboccipital bone decompression of the hindbrain and no duraplasty in 12 adult patients. Outcome was measured according to the Chicago Chiari Outcome Scale (CCOS).
Results Nine of 12 patients were female; average age at surgery was 34.4 years (range: 17–67 years). Average duration of symptoms prior to surgery was 9.6 years (2 months–29 years). The most common symptom was head and/or neck pain (11/12 patients). All patients additionally presented with at least one non-pain symptom. Mean degree of tonsillar herniation on magnetic resonance imaging was 6.8 mm (range: 5–12 mm) below McRae's line. Operative time was on average 68 minutes (range: 47–120 minutes). No surgical complications were noted in any patient. Length of hospital stay was 2 days (1 overnight) for all patients. Mean follow-up was 167 weeks (range: 13–378 weeks). CCOS for all patients on average was 14.50 (range: 12–16). Pain symptoms underwent improvement (7/11 [63.6%]) or complete resolution (4/11 [36.4%]) in all affected patients. A shorter duration of preoperative symptoms significantly correlated with a better CCOS (p = 0.03). Degree of tonsillar herniation had no significant effect on CCOS (p = 0.67). Of non-pain symptoms, paresthesias/dysesthesias and visual symptoms improved or resolved completely in all affected patients. No patient experienced a worsening of either pain or non-pain symptoms.
Conclusion In the subset of adult patients with a type I Chiari malformation and no associated hydromyelia, a craniectomy without an additional opening of the dura may achieve good overall results according to the CCOS.
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Affiliation(s)
- Hazem Abuhusain
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Manuri Gunawardena
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Tyler Auschwitz
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
- Department of Neurosurgery, University of Tennessee Health Science Center, Tennessee, United States
| | - Charles Teo
- Department of Neurosurgery, Centre for Minimally Invasive Neurosurgery, Sydney, New South Wales, Australia
| | - Nicolas Koechlin
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
- Endoskopische und Minimal Invasive Neurochirurgie, Klinik Birshof, Munchenstein, Switzerland
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Hayhurst C, Sughrue ME, Gore PA, Bonney PA, Burks JD, Teo C. Results with Expanded Endonasal Resection of Skull Base Meningiomas Technical Nuances and Approach Selection Based on an Early Experience. Turk Neurosurg 2017; 26:662-70. [PMID: 27337239 DOI: 10.5137/1019-5149.jtn.16105-15.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM Reconstruction technique advances have created renewed enthusiasm for the expanded endonasal approach (EEA). However, as with any new technique, early experiences inevitably lead to more selective use of these techniques. We reviewed our experience of the expanded endonasal endoscopic approach for skull base meningiomas and place it in context of the literature. MATERIAL AND METHODS We performed retrospective review of all endonasal cases performed at our center for histologically proven meningioma. Tumor locations in 26 patients included the olfactory groove (n=9), tuberculum sellae (n=7), optic nerve sheath (n=1), planum sphenoidale (n=2), clival (n=1) petroclival (n=3), cavernous sinus (n=2) and extensive pan-basal meningioma (n=1). RESULTS The median follow-up was 38.6 months. Excluding 3 patients with tumors found incidentally, pre-operative symptoms improved in 14 of 23 (61%), were the same in 8 of 23 (35%) and worsened in one of 23 patients (4%) at time of last follow-up. Of all 26 patients, 16 (62%) had complete macroscopic resection of their tumor, 5 (19%) underwent at least 90% resection, and 5 (19%) underwent subtotal resection. There were two neurological complications and one cerebrospinal fluid leak. CONCLUSION This study presents outcomes of patients treated with endonasal endoscopic meningioma surgery. We believe that very low rates of morbidity can be achieved in carefully selected patients, thus avoiding brain manipulation.
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Affiliation(s)
- Caroline Hayhurst
- University Hospital of Wales, Department of Neurosurgery, Cardiff, United Kingdom
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Sughrue ME, Othman J, Mills SA, Bonney PA, Maurer AJ, Teo C. Keyhole Transsylvian Resection of Infiltrative Insular Gliomas: Technique and Anatomic Results. Turk Neurosurg 2016; 26:475-83. [PMID: 27400092 DOI: 10.5137/1019-5149.jtn.14534-15.0] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM Insular gliomas have traditionally been approached through variations of large frontotemporal craniotomies exposing much of the Sylvian fissure. Due to the importance of many structures exposed by such an approach, a less-invasive approach to these lesions is a viable alternative for resection. We present the technique and results of our keyhole transsylvian approach to remove infiltrating insular tumors. MATERIAL AND METHODS A small linear incision and keyhole craniotomy is planned under image guidance to open a transsylvian window. Using a combination of the microscope and endoscope, we remove the insula circumferentially outward. We present our results of 20 patients with gliomas confined to the insula evaluated with volumetric imaging analysis. RESULTS There were 12 right-sided and 8 left-sided tumors. The median skin-to-skin operative time was 215 minutes. 15/20 patients were discharged from the hospital on or before post-operative day 3, with 5 of those going home the day after surgery. Greater than 90% of the tumor was removed in 18 of 20 cases, with an additional case achieving 89.5% resection. In no case was the residual tumor volume greater than 3 cc. Permanent weakness occurred in 2 patients (10%). Despite a significant number of left-sided tumors, temporary dysphasia occurred in only 1 patient (12.5%), which resolved by first follow up. CONCLUSION Localized insular gliomas can be effectively removed through a minimally invasive approach without increasing the risk of neurological morbidity. This minimizes manipulation of uninvolved, potentially eloquent cortices, and minimizes damage to the overlying soft tissue.
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Affiliation(s)
- Michael E Sughrue
- University of Oklahoma Health Sciences Center, Department of Neurological Surgery, Oklahoma City, OK, USA
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Harvey RJ, Malek J, Winder M, Davidson A, Steel T, Mrad N, Barham H, Knisely A, Teo C. Sinonasal morbidity following tumour resection with and without nasoseptal flap reconstruction. Rhinology 2015; 53:122-8. [PMID: 26030034 DOI: 10.4193/rhino14.247] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Sinonasal function can be affected by multiple treatment modalities but surgical techniques, such as the nasoseptal flap or Draf 3 procedure, have been implicated in poor post-treatment function. Prior studies have rarely used comparable populations and this study aims to assess the impact of surgical technique, mainly the nasoseptal flap, on sinonasal function in a group of comparable patients. METHODS A prospective cohort of patients undergoing endoscopic surgery for sinonasal and skull base tumours was studied. Patients were analysed according to whether a nasoseptal flap was used. Other treatment factors included; use of the Draf 3, radiotherapy, removal of olfactory apparatus and dural resection. The Sinonasal Outcome Test 22 (SNOT22), a nasal symptom score (NSS), global function score and nasal obstruction scores were recorded pre and post treatment. RESULTS One hundred and eighteen patients were assessed. Forty-two patients had a nasoseptal flap. Perioperative radiotherapy was higher in the nasoseptal group, as was dural resection and the need to remove the olfactory apparatus. Despite this, there was no significant difference in SNOT22 scores and NSS. Radiotherapy was detrimental to sinonasal function with SNOT22 and NSS. CONCLUSION The use of a nasospetal flap in surgery does not affect patient quality of life and sinonasal function after endoscopic tumour resection. Pathology is a better predictor of morbidity, with loss of function from radiotherapy or resection of functional areas such as the olfactory apparatus having a greater impact.
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Teo C. Response. J Neurosurg 2015; 123:350-351. [PMID: 26447234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Kalani MYS, Wilson DA, Koechlin NO, Abuhusain HJ, Dlouhy BJ, Gunawardena MP, Nozue-Okada K, Teo C. Pineal cyst resection in the absence of ventriculomegaly or Parinaud's syndrome: clinical outcomes and implications for patient selection. J Neurosurg 2015; 123:352-6. [DOI: 10.3171/2014.9.jns141081] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Surgical indications for patients with pineal cysts are controversial. While the majority of patients harboring a pineal cyst require no treatment, surgery is a well-accepted option for a subset of those patients with secondary hydrocephalus or Parinaud's syndrome. The majority of pineal cysts are identified incidentally during workup for other potential conditions, which may or may not be related to the presence of the cyst. In the absence of clear obstruction of CSF pathways, the treatment of presumed symptomatic pineal cysts is debatable. To clarify the role of surgery in these borderline cases, the authors reviewed their experience with resection of pineal cysts in the absence of ventriculomegaly or Parinaud's syndrome.
METHODS
The authors retrospectively reviewed medical records and imaging of all patients surgically treated between 2001 and 2014 with a pineal cyst in the absence of ventriculomegaly and Parinaud's syndrome. The presenting symptoms, preoperative cyst size, preoperative radiographic aqueductal compression, extent of resection, and radiographic and clinical follow-up were documented.
RESULTS
Eighteen patients (14 female and 4 male; mean age 24 years, range 4–47 years) underwent cyst resection in the absence of ventriculomegaly or Parinaud's syndrome. Presenting symptoms included headache (17 patients), visual disturbances (10 patients), gait instability (5 patients), dizziness (5 patients), episodic loss of consciousness (2 patients), and hypersomnolence (1 patient). The mean preoperative cyst diameter was 1.5 cm (range 0.9–2.2 cm). All patients had a complete resection. At a mean clinical follow-up of 19.1 months (range postoperative to 71 months), 17 (94%) patients had resolution or improvement of their presenting symptoms.
CONCLUSIONS
The authors' results suggest that ventriculomegaly and Parinaud's syndrome are not absolute requisites for a pineal cyst to be symptomatic. Analogous to colloid cysts of the third ventricle, intermittent occlusion of cerebrospinal fluid pathways may cause small pineal cysts to become intermittently symptomatic. A select cohort of patients with pineal cysts may benefit from surgery despite a lack of hydrocephalus or other obvious compressive pathology.
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Affiliation(s)
- M. Yashar S. Kalani
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - David A. Wilson
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicolas Olmo Koechlin
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - Hazem J. Abuhusain
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - Brian J. Dlouhy
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
- 3Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Kyoko Nozue-Okada
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - Charles Teo
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
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Sughrue ME, Bonney PA, Choi L, Teo C. Early Discharge After Surgery for Intra-Axial Brain Tumors. World Neurosurg 2015; 84:505-10. [DOI: 10.1016/j.wneu.2015.04.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 11/28/2022]
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