Tuesday, October 30, 2012

Check out Traumatic Brain Injury App

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Traumatic brain injury (TBI) is the main cause of mortality and morbidity in the young population worldwide. Knowing this reality, it is vital.
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Check out Neurointensive Care Guide App

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Saturday, October 27, 2012

Confira Traumatismo Crânio-Encefálico (TCE) english and portuguese

Traumatismo Crânio-Encefálico (TCE)

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Traumatismo Crânio-Encefálico (TCE)

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Categoria: Medicina

Atualizado: 19/06/2012
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Rural-urban disparities in health status among US cancer survivors

Abstract

BACKGROUND:

Although rural residents are more likely to be diagnosed with more advanced cancers and to die of cancer, little is known about rural-urban disparities in self-reported health among survivors.

METHODS:

The authors identified adults who had a self-reported history of cancer from the National Health Interview Survey (2006-2010). Rural-urban residence was defined using US Census definitions. Logistic regression with weighting to account for complex sampling was used to assess rural-urban differences in health status after accounting for differences in demographic characteristics.

RESULTS:

Of the 7804 identified cancer survivors, 20.8% were rural residents. This translated to a population of 2.8 million rural cancer survivors in the United States. Rural survivors were more likely than urban survivors to be non-Hispanic white (P < .001), to have less education (P < .001), and to lack health insurance (P < .001). Rural survivors reported worse health in all domains. After adjustment for sex, race/ethnicity, age, marital status, education, insurance, time since diagnosis, and number of cancers, rural survivors were more likely to report fair/poor health (odds ratio, 1.39; 95% confidence interval, 1.20-1.62), psychological distress (odds ratio, 1.23; 95% confidence interval, 1.00-1.50), ≥2 noncancer comorbidities (odds ratio, 1.15; 95% confidence interval, 1.01-1.32), and health-related unemployment (odds ratio, 1.66; 95% confidence interval, 1.35-2.03).

CONCLUSIONS:

The current results provide the first estimates of the proportion and number of US adult cancer survivors who reside in rural areas. Rural cancer survivors are at greater risk for a variety of poor health outcomes, even many years after their cancer diagnosis, and should be a target for interventions to improve their health and well being. Cancer 2012. © 2012 American Cancer Society.






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Central nervous system lymphoma in immunocompetent patients: The North Shore-Long Island Jewish Heal

Publication year: 2012
Source:Journal of Clinical Neuroscience
Xinmin Zhang, Qiang Hua Chen, Peter Farmer, Mansoor Nasim, Alexis Demopoulos, Craig Devoe, Tulika Ranjan, Mark B. Eisenberg, Michael Schulder, Chengpeng Bi, Jian Yi Li
Of the 74 immunocompetent patients diagnosed between July 2004 and June 2011 at the North Shore University Hospital and Long Island Jewish Medical Center with primary central nervous system lymphoma, 71 (95.9%) had diffuse large B-cell lymphomas (DLBCL). The median patient age was 68years (range: 19–87years) with a slight male preponderance (1.1:1). The overall median survival time was 21months. For patients older than 70years, the median survival time was 8months while for those 70years or younger, the median survival time was 27months (p <0.01). Female patients had a worse prognosis than male patients (p <0.05, median survival time, 17months compared to 23months). We had enough data from 52 of these 71 patients to define the lymphomas as either germinal center B-cell-like (GCB) or activated B-cell-like (ABC) DLBCL. Of these 52 patients, 42 (80.8%) had ABC DLBCL while only 10 (19.2%) had GCB DLBCL. The patients in the GCB subgroup seemed to survive longer than the patients in the ABC subgroup, although the difference did not reach statistical significance. No statistically significant difference in overall survival was seen between patients with BCL-6 positive or negative DLBCL; or between patients with BCL-2 positive or negative DLBCL.






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Glioblastoma resistance to anti-VEGF therapy is associated with myeloid cell infiltration, stem cell

Vascular endothelial growth factor (VEGF) is a critical regulator of angiogenesis. Inhibiting the VEGF–VEGF receptor (R) signal transduction pathway in glioblastoma has recently been shown to delay progression, but the relative benefit and mechanisms of response and failure of anti-VEGF therapy and VEGFR inhibitors are not well understood. The purpose of our study was to evaluate the relative effectiveness of VEGF sequestration and/or VEGFR inhibition on orthotopic tumor growth and the mechanism(s) of treatment resistance. We evaluated, not only, the effects of anti-VEGF therapy (bevacizumab), anti-VEGFR therapy (sunitinib), and the combination on the survival of mice bearing orthotopic gliomas, but also the differential effects of the treatments on tumor vascularity, cellular proliferation, mesenchymal and stem cell markers, and myeloid cell infiltration using flow cytometry and immunohistochemistry. Bevacizumab significantly prolonged survival compared with the control or sunitinib alone. Both antiangiogenic agents initially reduced infiltration of macrophages and tumor vascularity. However, multitargeted VEGFR inhibition, but not VEGF sequestration, rapidly created a vascular gradient and more rapidly induced tumor hypoxia. Re-infiltration of macrophages was associated with the induction of hypoxia. Combination treatment with bevacizumab and sunitinib improved animal survival compared with bevacizumab therapy alone. However, at the time of tumor progression, a significant increase in CD11b+/Gr1+ granulocyte infiltration was observed, and tumors developed aggressive mesenchymal features and increased stem cell marker expression. Collectively, our results demonstrate a more prolonged decrease in tumor vascularity with bevacizumab than with sunitinib, associated with a delay in the development of hypoxia and sustained reduction of infiltrated myeloid cells.






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Epilepsy in the end-of-life phase in patients with high-grade gliomas

Abstract  
Epilepsy is common in patients with brain tumors. Patients presenting seizures as the first sign of a malignant glioma are at increased risk of recurrent seizures despite treatment with antiepileptic drugs. However, little is known about the incidence of epilepsy in the last stage of disease and in the end–of-life phase of brain tumor patients. We retrospectively analyzed the incidence of seizures in the last months of life in a series of patients affected by high-grade gliomas who were assisted at home during the whole course of the disease until death. A total of 157 patients were available for analysis. Of these patients, 58 (36.9 %) presented seizures in the last month before death. The risk of seizures in the end-of-life phase is higher in patients presenting previous history of epilepsy, particularly in patients with late-onset epilepsy. Out of the 58 patients presenting seizures in the last month of life, 86.2 % had previously had seizures and 13.8 % were seizure free. Most patients may encounter swallowing difficulties in taking anticonvulsants orally due to dysphagia and disturbances of consciousness, thus anticonvulsant treatment needs to be modified in advance. Loss of seizure control in the end-of-life phase may influence the quality of life of patients and their caregivers.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-4
  • DOI 10.1007/s11060-012-0993-2
  • Authors
    • Andrea Pace, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
    • Veronica Villani, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
    • Cherubino Di Lorenzo, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
    • Lara Guariglia, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
    • Marta Maschio, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
    • Alfredo Pompili, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
    • Carmine Maria Carapella, Palliative Home Care Unit for Brain Tumor Patients, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy





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Tuesday, October 23, 2012

Trends in Neurosurgical Complication Rates at Teaching vs Nonteaching Hospitals Following Duty-Hour

imageBACKGROUND: In 2003 the Accreditation Council for Graduate Medical Education implemented duty-hour restrictions for residents, with an unclear impact on patient care. OBJECTIVE: The authors hypothesize that implementation of duty-hour restrictions is not associated with decreased morbidity for neurosurgical patients. This hypothesis was tested with the Nationwide Inpatient Sample to examine inpatient complications associated with a common elective procedure, craniotomy for meningioma. METHODS: The Nationwide Inpatient Sample was queried for all patients admitted for elective craniotomy for meningioma from 1998 to 2008, excluding the year 2003. Each case was queried for common in-hospital postoperative complications. The complication rate was compared for 5-year epochs at teaching and nonteaching hospitals before (1998-2002) and after (2004-2008) the adoption of the Accreditation Council for Graduate Medical Education work-hour restriction. Multivariate analysis was performed to control for the effects of age and medical comorbidities. RESULTS: We identified 21 177 patients who met inclusion criteria. We identified an effect of age, preexisting medical comorbidity, and timing of surgery on postoperative complication rates. At teaching hospitals, the complication rate increased from 14% to 16% (P < .001). In contrast, this increase was not mirrored at nonteaching hospitals, which saw a nearly constant postoperative complication rate of 15% from 1998 to 2002 and 15% for the years 2004 to 2008 (P = .979). This effect remained significant in a multivariate analysis including age and existing comorbidities as covariates (P = .016). CONCLUSION: In patients undergoing craniotomy for meningioma, postoperative complication rates increased at teaching hospitals, but not at nonteaching hospitals over the 5-year epochs before and after 2003. ABBREVIATIONS: ACGME, Accreditation Council for Graduate Medical Education ICD-9-CM, International Classification of Diseases, 9th Revision NIS, Nationwide Inpatient Sample





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Meningiomas in Pregnancy: A Clinicopathologic Study of 17 Cases

imageBACKGROUND: Dramatic growth of meningiomas is occasionally encountered during pregnancy. While cell proliferation is often assumed, hemodynamic changes have also been touted as a cause. OBJECTIVE: We identified 17 meningiomas resected during pregnancy or within 3 weeks post-partum and characterized them to determine the cause of occasional rapid growth in pregnancy. METHODS: Seventeen tumors were identified from searches at 4 university centers. All available clinical records, radiology images, and tissue specimens were reviewed, with immunohistochemical studies performed as needed. RESULTS: Sixteen patients underwent tumor resection and 1 died of complications prior to surgery. Average patient age was 32 years. Nine experienced onset of symptoms in the third trimester or within 8 days post-partum. Principle physical findings included visual complaints (59%) and cranial nerve palsies (29%). Ten tumors (59%) were located in the skull base region. The Ki-67 labeling index was low (0.5-3.6%) in 11 of 13 benign (grade I) tumors and elevated (11-23.2%) in 3 of 4 atypical (grade II) meningiomas. Eight (50%) tumors featured hypervascularity with at least focal CD34-positive hemangioma-like microvasculature. Fourteen (82%) showed evidence of intra- and/or extracellular edema, 1 so extensive that its meningothelial nature was not apparent. Five tumors (29%) exhibited intratumoral hemorrhage and/or necrosis. CONCLUSION: Our series suggests that pregnancy-associated meningiomas located in the skull base are likely to require surgical intervention for visual complaints and cranial nerve palsies. The rapid tumor growth is more often due to potentially reversible hemodynamic changes rather than hormone-induced cellular proliferation. ABBREVIATION: CI, confidence interval





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Meningiomas in Pregnancy: A Clinicopathologic Study of 17 Cases

imageBACKGROUND: Dramatic growth of meningiomas is occasionally encountered during pregnancy. While cell proliferation is often assumed, hemodynamic changes have also been touted as a cause. OBJECTIVE: We identified 17 meningiomas resected during pregnancy or within 3 weeks post-partum and characterized them to determine the cause of occasional rapid growth in pregnancy. METHODS: Seventeen tumors were identified from searches at 4 university centers. All available clinical records, radiology images, and tissue specimens were reviewed, with immunohistochemical studies performed as needed. RESULTS: Sixteen patients underwent tumor resection and 1 died of complications prior to surgery. Average patient age was 32 years. Nine experienced onset of symptoms in the third trimester or within 8 days post-partum. Principle physical findings included visual complaints (59%) and cranial nerve palsies (29%). Ten tumors (59%) were located in the skull base region. The Ki-67 labeling index was low (0.5-3.6%) in 11 of 13 benign (grade I) tumors and elevated (11-23.2%) in 3 of 4 atypical (grade II) meningiomas. Eight (50%) tumors featured hypervascularity with at least focal CD34-positive hemangioma-like microvasculature. Fourteen (82%) showed evidence of intra- and/or extracellular edema, 1 so extensive that its meningothelial nature was not apparent. Five tumors (29%) exhibited intratumoral hemorrhage and/or necrosis. CONCLUSION: Our series suggests that pregnancy-associated meningiomas located in the skull base are likely to require surgical intervention for visual complaints and cranial nerve palsies. The rapid tumor growth is more often due to potentially reversible hemodynamic changes rather than hormone-induced cellular proliferation. ABBREVIATION: CI, confidence interval





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Radiosurgery to the Surgical Cavity as Adjuvant Therapy for Resected Brain Metastasis

imageBACKGROUND: The standard treatment of resected brain metastasis is whole-brain radiotherapy (WBRT). To avoid the potential toxicity of WBRT and to improve local control, we have used radiosurgery alone to the surgical cavity. OBJECTIVE: To demonstrate the rates of local control, new intracranial metastasis, and overall survival using this treatment scheme without WBRT. METHODS: Eighty-five consecutive patients with brain metastasis were treated with surgical resection of at least 1 lesion followed by radiosurgery alone to the surgical cavity and any unresected lesions from August 2000 to March 2011. Sixty-eight percent had gross total resections. After surgery, radiosurgery was delivered to the surgical cavity with a 2- to 3-mm margin. The median marginal radiosurgery dose was 16 Gy, and median target volume was 13.96 cm3. Follow-up imaging and clinical examination were obtained every 2 to 3 months. RESULTS: Median follow-up time was 11.2 months. Overall local control was 81.2%. The 6-month, 1-year, and 2-year rates of local control were 88.7%, 81.4%, and 75.7%, respectively. Forty-seven patients (55%) developed new intracranial metastases at a median time of 5.6 months. For the entire population, the rate of new metastases was 32.1%, 58.1%, and 62.9% at 6 months, 1 year, and 2 years, respectively. Median overall survival time was 12.1 months. From initial treatment until death or last follow-up, only 30 patients (35%) received WBRT as salvage treatment. CONCLUSION: Radiosurgery to the surgical cavity without WBRT achieved excellent local control of resected brain metastasis. Close imaging follow-up allows early intervention for any new metastasis. ABBREVIATIONS: GTR, gross total resection SRS, stereotactic radiosurgery WBRT, whole-brain radiation therapy





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Sunday, October 21, 2012

Brain metastasis



Lucas Alverne F. Albuquerque
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Glioblastoma multiforne



Lucas Alverne F. Albuquerque
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Friday, October 19, 2012

TEDMED Grandes palestras em medicina

"TEDMED is a community of people who are passionate about imagining the future of health and medicine.

Once a year, TEDMED holds a "grand gathering" where leaders from all sectors of society come together for three and a half days. They explore the promise of technology and the potential of human achievement. This unique event combines dazzling celebration, high-powered learning and





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Racial disparities in medicaid patients after brain tumor surgery

Publication year: 2012
Source:Journal of Clinical Neuroscience
Debraj Mukherjee, Chirag G. Patil, Nathan Todnem, Beatrice Ugiliweneza, Miriam Nuño, Michael Kinsman, Shivanand P. Lad, Maxwell Boakye
The presence of healthcare-related disparities is an ongoing, widespread, and well-documented societal and health policy issue. We investigated the presence of racial disparities among post-operative patients either with meningioma or malignant, benign, or metastatic brain tumors. We used the Medicaid component of the Thomson Reuter's MarketScan database from 2000 to 2009. Univariate and multivariate analysis assessed death, 30-day post-operative risk of complications, length of stay, and total charges. We identified 2321 patients, 73.7% were Caucasian, 57.8% were women; with Charlson comorbidity scores of <3 (56.2%) and treated at low-volume centers (73.4%). Among all, 26.3% of patients were of African-American ethnicity and 22.1% had meningiomas. Mortality was 2.0%, mean length of stay (LOS) was 9days, mean total charges were US$42,422, an adverse discharge occurred in 22.5% of patients, and overall 30-day complication rate was 23.4%. In a multivariate analysis, African-American patients with meningiomas had higher odds of developing a 30-day complication (p =0.05) and were significantly more likely to have longer LOS (p <0.001) and greater total charges (p <0.001) relative to Caucasian counterparts. The presence of one post-operative complication doubled LOS and nearly doubled total charges, while the presence of two post-operative complications tripled these outcomes. Patients of African-American ethnicity had significantly higher post-operative complications than those of Caucasian ethnicity. This higher rate of complications seems to have driven greater healthcare utilization, including greater LOS and total charges, among African-American patients. Interventions aimed at reducing complications among African-American patients with brain tumor may help reduce post-operative disparities.






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A retrospective study of primary cerebellar glioblastoma multiforme in adults

Publication year: 2012
Source:Journal of Clinical Neuroscience
C.V. Gopalakrishnan, Amit Dhakoji, Suresh Nair, Girish Menon, R. Neelima
Primary cerebellar glioblastoma multiforme (GBM) is a rare tumour in adults that accounts for less than 1% of all patients with GBM. In view of their rarity, the pathogenesis and prognosis of cerebellar GBM are not yet completely understood. The aim of this study was to retrospectively analyse patients with primary cerebellar GBM treated in our institute over a period of 10years. Data from the case records of five adult patients with cerebellar GBM was evaluated and their outcome was assessed. We observed local failure in patients who reported back with recurrence. The presence of brainstem infiltration was a significant factor influencing progression-free survival. The overall prognosis was worse than for patients with supratentorial GBM. In view of their rarity, a meta-analysis is required to assess the pathogenesis and prognostic factors affecting overall survival in patients with cerebellar GBM.






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Tumor Bed Dynamics After Surgical Resection of Brain Metastases: Implications for Postoperative Radi

Purpose: To analyze 2 factors that influence timing of radiosurgery after surgical resection of brain metastases: target volume dynamics and intracranial tumor progression in the interval between surgery and cavity stereotactic radiosurgery (SRS).Methods and Materials: Three diagnostic magnetic resonance imaging (MRI) scans were retrospectively analyzed for 41 patients with a total of 43 resected brain metastases: preoperative MRI scan (MRI-1), MRI scan within 24 hours after surgery (MRI-2), and MRI scan for radiosurgery planning, which is generally performed ≤1 week before SRS (MRI-3). Tumors were contoured on MRI-1 scans, and resection cavities were contoured on MRI-2 and MRI-3 scans.Results: The mean tumor volume before surgery was 14.23 cm3, and the mean cavity volume was 8.53 cm3 immediately after surgery and 8.77 cm3 before SRS. In the interval between surgery and SRS, 20 cavities (46.5%) were stable in size, defined as a change of ≤2 cm3; 10 cavities (23.3%) collapsed by >2 cm3; and 13 cavities (30.2%) increased by >2 cm3. The unexpected increase in cavity size was a result of local progression (2 cavities), accumulation of cyst-like fluid or blood (9 cavities), and nonspecific postsurgical changes (2 cavities). Finally, in the interval between surgery and SRS, 5 cavities showed definite local tumor progression, 4 patients had progression elsewhere in the brain, 1 patient had both local progression and progression elsewhere, and 33 patients had stable intracranial disease.Conclusions: In the interval between surgical resection and delivery of SRS, surgical cavities are dynamic in size; however, most cavities do not collapse, and nearly one-third are larger at the time of SRS. These observations support obtaining imaging for radiosurgery planning as close to SRS delivery as possible and suggest that delaying SRS after surgery does not offer the benefit of cavity collapse in most patients. A prospective, multi-institutional trial will provide more guidance to the optimal timing of cavity SRS.





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A Phase I Study of Short-Course Accelerated Whole Brain Radiation Therapy for Multiple Brain Metasta

Purpose: To define the maximum tolerated dose (MTD) of a SHort-course Accelerated whole brain RadiatiON therapy (SHARON) in the treatment of patients with multiple brain metastases.Methods and Materials: A phase 1 trial in 4 dose-escalation steps was designed: 12 Gy (3 Gy per fraction), 14 Gy (3.5 Gy per fraction), 16 Gy (4 Gy per fraction), and 18 Gy (4.5 Gy per fraction). Eligibility criteria included patients with unfavorable recursive partitioning analysis (RPA) class > or =2 with at least 3 brain metastases or metastatic disease in more than 3 organ systems, and Eastern Cooperative Oncology Group (ECOG) performance status ≤3. Treatment was delivered in 2 days with twice-daily fractionation. Patients were treated in cohorts of 6-12 to define the MTD. The dose-limiting toxicity (DLT) was defined as any acute toxicity ≥grade 3, according to the Radiation Therapy Oncology Group scale. Information on the status of the main neurologic symptoms and quality of life were recorded.Results: Characteristics of the 49 enrolled patients were as follows: male/female, 30/19; median age, 66 years (range, 23-83 years). ECOG performance status was <3 in 46 patients (94%). Fourteen patients (29%) were considered to be in recursive partitioning analysis (RPA) class 3. Grade 1-2 acute neurologic (26.4%) and skin (18.3%) toxicities were recorded. Only 1 patient experienced DLT (neurologic grade 3 acute toxicity). With a median follow-up time of 5 months (range, 1-23 months), no late toxicities have been observed. Three weeks after treatment, 16 of 21 symptomatic patients showed an improvement or resolution of presenting symptoms (overall symptom response rate, 76.2%; confidence interval 0.95: 60.3-95.9%).Conclusions: Short-course accelerated radiation therapy in twice-daily fractions for 2 consecutive days is tolerated up to a total dose of 18 Gy. A phase 2 study has been planned to evaluate the efficacy on overall survival, symptom control, and quality of life indices.





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Sunday, October 14, 2012

Combined Cranionasal Surgery for Spheno-orbital Meningiomas Invading the Paranasal Sinuses, Pterygop

Publication year: 2012
Source:World Neurosurgery
Moshe Attia, Kunal S. Patel, Jothy Kandasamy, Philip E. Stieg, Henry M. Spinelli, Howard A. Riina, Vijay K. Anand, Theodore H. Schwartz
Objectives To evaluate the efficacy of combining an endonasal endoscopic skull base approach and repair with a transcranial orbitozygomatic approach for Spheno-orbital meningiomas (SOMs). Methods Three patients with recurrent SOMs were underwent combined orbitozygomatic and endonasal endoscopic surgery. In two patients both procedures were done in one operation and in one patient the endonasal surgery was done 2.5 months after the craniotomy. Extent of resection, complications, morbidity and mortality were evaluated. Results GTR was achieved in one patient and near total resection in the other two with tumor left in the cavernous sinus and parapharyngeal space. Two patients suffered cranial neuropathy from the transcranial surgery and the other developed a pseudomeningocele. There were no complications from the endonasal surgery. Patients having combined single setting cranionasal surgery were discharged on day 6 and 8 whereas the patient having only the endonasal component on a later date was discharged on day 2. Conclusion A combined cranionasal approach involving transcranial orbitozygomatic and endonasal endoscopic approaches is an effective two-stage surgery for resecting SOMs invading into the sinuses and paranasal compartments. The ability to perform a multilayer closure involving a vascularized nasoseptal flap additionally decreases the risk of post-operative CSF leak.






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Saturday, October 13, 2012

Treatment outcomes after surgical resection of midline anterior skull base meningiomas at a single c

Publication year: 2012
Source:Journal of Clinical Neuroscience
Ho-Young Park, Ho Jun Seol, Do-Hyun Nam, Jung-Il Lee, Doo-Sik Kong, Jong Hyun Kim, Kwan Park
Meningiomas of the midline anterior skull base (ASB) typically grow around the optic chiasm. These tumors can displace or adhere to the optic apparatus, resulting in visual abnormalities. For this reason, in most studies of surgically resected meningiomas, only surgical and visual outcomes have been evaluated. However, in this study, we assessed overall clinical outcomes and the effects of different surgical approaches on outcomes. Clinical data for 126 patients who were treated surgically for midline ASB meningiomas between 1994 and 2009 were collected and reviewed retrospectively. The mean follow-up duration was 39months (range: 0.5–146months). Most procedures were performed via a pterional approach and did not require an aggressive skull base approach. Clinical outcomes were evaluated using our own criteria, and potential predictive factors for visual and clinical outcomes were tested statistically. The tumor control rate was 83% (105/126). Immediate postoperative visual status and optic canal involvement were correlated with visual outcome. Of the patients who ultimately had improved visual status, only six were originally categorized as having severe visual impairment (all were only able to count fingers). In terms of clinical outcome, 41 patients were classified as "excellent", 32 as "good", 29 as "fair", and 20 as "poor". A symptom duration of less than six months, less severe preoperative visual symptoms of the affected eye, and the extent of resection were all correlated with improved clinical outcome. Involvement of the optic canal, adherence of the tumor to the optic nerve, and major arterial encasement by the tumor were associated with poor clinical outcome. We recommend that in patients with unilateral severe visual impairment, the focus should be on improving visual function in the contralateral eye. Preoperative and postoperative evaluation of several variables allows for the prediction of clinical and visual outcomes.






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Survival in patients with metastatic recurrent breast cancer after adjuvant chemotherapy

Abstract

BACKGROUND:

Population-based studies have shown improved survival for patients diagnosed with metastatic breast cancer over time, presumably because of the availability of new and more effective therapies. The objective of the current study was to determine whether survival improved for patients who developed distant recurrence of breast cancer after receiving adjuvant therapy.

METHODS:

Adjuvant chemotherapy trials coordinated by the Eastern Cooperative Oncology Group that accrued patients between 1978 and 2002 were reviewed. Survival after distant disease recurrence was estimated for progressive time periods, and adjusted for baseline covariates in a Cox proportional hazards model.

RESULTS:

Of the 13,785 patients who received adjuvant chemotherapy in 11 trials, 3447 (25%) developed distant disease recurrence; the median survival after recurrence was 20 months (95% confidence interval, 19 months-21 months). Factors associated with inferior survival included a shorter distant recurrence-free interval (DRFI), estrogen receptor-negative and progesterone receptor-negative disease, the number of positive axillary lymph nodes present at the time of diagnosis, and black race (P < .0001 for all). When the time period of recurrence was added to the model, it was not found to be significantly associated with survival for the general population with disease recurrence. Survival improved over time only in those patients with hormone receptor-negative disease with a DRFI ≤ 3 years, both among the 5 most recent and the entire trial data sets (P = .01 and P = .05, respectively).

CONCLUSIONS:

In contrast to reports from population-based studies, no general improvement in survival was observed over the last 30 years for patients who developed distant disease recurrence after adjuvant chemotherapy after adjusting for DRFI. Improved survival for patients with hormone receptor-negative disease with a short DRFI suggests a benefit from trastuzumab. Cancer 2012. © 2012 American Cancer Society.






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Short-term outcomes of craniotomy for malignant brain tumors in the elderly

Abstract

BACKGROUND.

Disparity in resection rates for malignant brain tumors in elderly patients is partially attributed to a belief that advanced age is associated with an increased risk of postoperative morbidity and mortality. The objective of this study was to investigate the effect of advanced age (≥75 years) on 30-day outcomes in patients with primary and metastatic brain tumors who underwent craniotomy for definitive resection of a malignant brain tumor.

METHODS.

The authors conducted prospective analyses of the American College of Surgeons' National Surgical Quality-Improvement Project (NSQIP) database from 2006 to 2010 of 970 patients aged ≥40 years who underwent craniotomy for definitive resection of neoplasm. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by age. By using propensity scores, 134 patients (aged ≥75 years) were matched to 134 patients ages 40 to 74 years. Logistic regression was used to predict adverse postoperative outcomes.

RESULTS.

The median length of hospital stay was 5 days; the rate of minor and major complications were 5.9% and 13.1%, respectively; 5.7% of patients returned to the operating room; and 4.3% of patients died within 30 days. Advanced age did not increase the odds for poorer short-term outcomes.

CONCLUSIONS.

Advanced age did not increase the risk of poor outcomes after surgical resection of primary or metastatic intracranial tumors when analyses were controlled for other risk factors. These results suggest that age should not be used, in isolation, as an a priori factor to discourage pursuing craniotomy. Cancer 2012. © 2012 American Cancer Society.






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A score to identify patients with metastatic spinal cord compression who may be candidates for best

Abstract

BACKGROUND:

The objective of the current study was to develop a scoring system that identifies those patients with metastatic spinal cord compression who may be candidates for best supportive care or single-fraction radiotherapy.

METHODS:

Ten potential prognostic factors were retrospectively analyzed in 2029 patients, including age, gender, Eastern Cooperative Oncology Group performance status, tumor type, number of involved vertebrae, further bone metastases, visceral metastases, interval from time of cancer diagnosis to the development of MSCC, time to the development of motor deficits, and ambulatory status.

RESULTS:

On multivariate analysis, Eastern Cooperative Oncology Group performance status, tumor type, bone metastases, visceral metastases, interval from cancer diagnosis to the development of metastatic spinal cord compression, time to the development of motor deficits, and ambulatory status were found to be significantly associated with survival. The risk score represented the sum of the scores for each of these factors, obtained from the probability of the patient dying within 2 months (shown as the percentage) divided by 10. Risk scores ranged between 6 and 25 points. At a cutoff value of ≥ 24 points, the specificity was 99.8% and the positive predictive value was 96.0%, which indicates that approximately 4% of the patients predicted to die within 2 months survived > 2 months.

CONCLUSIONS:

This score identifies patients who have a very poor survival with a high specificity and a high positive predictive value. Patients with a score of ≥ 24 points have a very high probability of dying within 2 months. Thus, overtreatment with intensive therapies can be avoided in these patients, who are very unlikely to benefit.Cancer 2012. © 2012 American Cancer Society.






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Radiosurgical third ventriculostomy: Technical note

Guillermo Axayacalt Gutiérrez-Aceves, Sergio Moreno-Jiménez, Miguel Ángel Celis, Mariana Hernández-Bojórquez

Surgical Neurology International 2012 3(1):121-121

Background: We describe a minimally invasive technique to perform a radiosurgical third ventriculostomy in a patient with mild obstructive hydrocephalus secondary to malignant pathology. Methods: A 42 years old woman with diagnosis of clear cells renal carcinoma and with right nefrectomy performed last year. Cranial Magnetic Resonance Imaging showed two brain metastasis: one right temporal, and other in the pons with Sylvian aqueduct partial obliteration and mild ventricular enlargement. The patient received radiosurgical treatment for brain metastasis; after this procedure a new target was defined on the floor of the third ventricle, in the midpoint between the mamillary bodies and the infundibular recess where we delivered 100 Gy delivered by an isocentric multiple noncoplanar arcs technique, with a 6 MV Novalis&#174; dedicated LINAC. A series of 21 arcs was arranged with a radiation field generated by a 4 mm circular collimator. Results: One week pos-irradiation in the head CT we did not find significant changes in the metastatic lesions; however the VSI diminished 4%, despite of persistent aqueduct obliteration.At three months we perform 3.0 T MRI where we confirmed the presence of the third ventriculostomy (2.63 mm diameter). Conclusion: This report demonstrates, for the first time, the ability of a dedicated LINAC to perform a precise third ventriculostomy without associate morbility in short term.





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Tuesday, October 9, 2012

Initial experience of real time intraoperative C-arm CT-guided navigation surgery for pituitary tumo

Publication year: 2012
Source:World Neurosurgery
Ryosuke Mori, Tatsuhiro Joki, Yoshinori Matsuwaki, Kostadin Karagiozov, Yuichi Murayama, Toshiaki Abe
Objective We report our initial experience of real time intraoperativeC-arm computed tomography (C arm-CT: DynaCT)-guided navigation surgery for pituitary tumors. Methods Recent advancement of Flat panel technology enables to obtain CT like images by using rotation of C-arm of Digital Subtraction Angiography (DSA) system. Specially designed new suite, which has C-arm CT imaging capability DSA in combination with Navigation system (VectorVision Sky, Brain Lab, Germany) allows neurosurgeons to perform an endoscopic transsphenoidal procedures under real-time navigation support. Thirty one pituitary tumor patients were examined.During or after tumor removal, contrast enhanced DynaCT was conducted to rule out residual tumor in 12 cases. When enhanced tumor was confirmed, additional removal was continued without moving the patients. Results DynaCT and subsequent image transfer to navigation system was performed in all cases without difficulties, requiring only additional 15minutes of surgical time. Sellar fenestration in relation to tumors and absence of hidden hematomas was confirmed in all cases. The contrast enhanced DynaCT was found contributing to a better handling of the residual tumor. In 9 of these 12 cases (75%), residual tumor was detected on DynaCT, consequently further removal was considered. In 2 cases (16%), there was no enhanced lesion, indicating complete removal. Conclusion The proposed technique of intraoperative visualization in the hybrid operating room can be an easy to perform and may be useful adjunct to conventional transsphenoidal surgery for improved resection rate and less cavernous sinus and internal carotid artery injury.






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Apps | Neurosurgery Blog

Apps

The Neurosurgery Blog group is developing a series of apps dedicated to medicine and more specifically neuroscience.

This is a space created to divulge our apps. You can found more information about than by clicking in the apps logos.

Let us know about your opinion, critics, suggestions or ideas in the "Contact us" space. With your help we may improve the apps you adquired and create new ones!

We hope you enjoy!

More apps are coming soon!

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Anamnesis (English) Click Here iPad and iPhone

Anamnese (Portuguese) Click Here iPad and iPhone


Traumatic Brain Injury (Click here)iPad and iPhone

Traumatismo Cranio-encefalico (Click here)iPad and iPhone

Traumatic Brain Injury (Click here) Android

Traumatismo Cranio-encefalico (Click here) Android

 

 

Hedache apps (Click here) iPad and iPhone

Dor de cabeça ( Click here) iPad and iPhone

Hedache apps (Click here) Android 

Dor de cabeça ( Click here) Android

 

Sus para concursos (click here) Portuguese Only iPad and iPhone 

Sus para concursos (click here) Portuguese Only  Android

Neuroexame (click here) Portuguese Only iPad and iPhone

Neurosurgery Blog app Only Android (Click Here)

 

Neurointensive Care

(APPSTORE CLICK HERE ENGLISH) and(APPSTORE CLICK HERE PORTUGUESE)

ANDROID CLICK HERE

 

 

 

http://www.neurocirurgiabr.com





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Friday, October 5, 2012

Impact of ultra-low-field intraoperative MRI on extent of resection and frequency of tumor recurrenc

Publication year: 2012
Source:World Neurosurgery
Martin Hlavica, David Bellut, Doreen Lemm, Christoph Schmid, Rene Ludwig Bernays
Background Non-functioning pituitary adenomas (NFPAs) are among the most frequent intracranial neoplasms. Surgical therapy is the treatment of choice whereupon complete tumor resection should be aimed for to ensure long term tumor control. Objective The aim of this study was to analyze the impact of intraoperative ultra-low field magnetic resonance imaging on the extent of tumor resection. Methods A series of 104 consecutive cases receiving transsphenoidal iMRI-guided surgery for NFPA was retrospectively analyzed. General patient data, endocrinological parameters, neurological examinations, pre-/post-operative symptoms, pre-/post- and intraoperative imaging and the proliferation index were evaluated in an overall mean follow-up of 34 months. Results The use of iMRI lead to an increase of the overall remission rate by 52.2% from 44.2% to 67.3%. Tumor characteristics such as size and invasiveness showed an important impact on postoperative remission rate. In patients with macroadenoma and without previous pituitary surgery, a remission rate of 82.2% was achieved. Overall the sensitivity of the iMRI in the study was 32.4%. On the other hand, there was no false positive interpretation. Furthermore, we found a higher PI in the 15 patients with postoperative enlargement of residual adenomas or tumor recurrence compared to the other patients of our study group. Conclusions This study shows that the outcome of surgical treatment of NFPAs was improved by the use of iMRI due to more radical resection. The remission rate seems to be dependend on tumor characteristics. Recurrent disease might be lowered by the use of iMRI due to more complete surgical resection.






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Thursday, October 4, 2012

Pre- and postoperative magnetic resonance imaging appearance of the normal residual pituitary gland

Salvatore Di Maio, Arundhati Biswas, Jean Lorrain Vézina, Jules Hardy, Gérard Mohr

Surgical Neurology International 2012 3(1):67-67

Background: To assess the relationship between the preoperative magnetic resonance imaging (MRI) appearance of the normal residual pituitary gland (NRPG) and pituitary functional outcome following transsphenoidal resection of pituitary macroadenomas. Methods: We retrospectively reviewed the medical records of 100 consecutive patients with a pituitary macroadenoma, who underwent transsphenoidal resection. The preoperative configuration of the displaced NRPG was stratified as superior, superolateral or lateral. The extent of postoperative restitution of the NRPG was divided into four groups: Group 1 - normal residual gland or almost normal; Group 2 - more than 50% restitution; Group 3 - less than 50% of the normal residual gland; and Group 4 - barely visible or absent residual gland. The pre- and postoperative NRPG appearance was correlated with pituitary functional status. Results: Preoperatively, the NRPG was identifiable in 79 patients, with extrasellar displacement in 53%. The displacement pattern was superior in 8%, superolateral in 32%, and lateral in 58% of the patients. If the NRPG was displaced laterally, the ipsilateral cavernous sinus was not invaded by the pituitary macroadenoma. Partial or complete pituitary function was lost in 6 / 23 (26.1%) patients with superior or superolateral displacement of the NRPG, compared to only 1 / 36 (2.8%) patients without superior displacement of the NRPG (P = 0.025). Progressive postoperative reconstitution of the NRPG was related to the preservation of the pituitary hormonal axis (Pearson Chi-Square P < 0.001). Conclusions: Progressive displacement of the NRPG preoperatively, and lack of restitution of the NRPG on postoperative MRI appeared to correlate with the postoperative pituitary functional loss.





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Medical Versus Surgical Management of Prolactinomas

Prolactinomas are the most common hormone-secreting pituitary adenomas, comprising 40% of all pituitary tumors. Prolactinomas present a unique challenge for clinicians, as these tumors are amenable to either medical or surgical treatments based on patients' comorbidities, tolerance to medical treatment, and the response of tumors to medical treatment. Rare prolactinomas that are unresponsive to either medical or surgical treatment modalities may be responsive to radiation therapy. This article reviews the recent advancements in the management of prolactinomas.





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Management of Large Aggressive Nonfunctional Pituitary Tumors: Experimental Medical Options When Sur

Pituitary adenomas are generally considered benign tumors; however, a subset of these tumors displays aggressive behavior and are not easily cured. The protocol for nonsurgical treatment of aggressive pituitary lesions is less standardized than that of other central nervous system tumors. Aggressive surgical treatment, radiation, dopamine agonists, antiangiogenic drugs, and other chemotherapeutics all have roles in the treatment of aggressive pituitary tumors. More studies are needed to improve outcomes for patients with aggressive pituitary tumors.





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Endoscopic Surgery for Pituitary Tumors

The endoscopic transsphenoidal approach to the sella turcica has been developed and refined for the treatment of pituitary lesions. Studies comparing endoscopic transsphenoidal surgery with the traditional microscopic transsphenoidal technique have found equivalent or improved rates of tumor resection and hormonal remission, and equal or lower rates of complications. This procedure affords improved panoramic visualization, illumination, surgical freedom, and mobility. This approach facilitates two-handed microdissection and the ability to look around corners using angled lenses, promoting maximal tumor resection and preservation of the pituitary gland. Experience, technologic advancements, and improved instrumentation are likely to contribute to improved surgical outcomes.





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