Survival analysis in patients with newly diagnosed glioblastoma using pre- and postradiotherapy MR s

Background

The objective of this study was to examine the predictive value of parameters of 3D ¹H magnetic resonance spectroscopic imaging (MRSI) prior to treatment with radiation/chemotherapy (baseline) and at a postradiation 2-month follow-up (F2mo) in relationship to 6-month progression-free survival (PFS6) and overall survival (OS).

Methods

Sixty-four patients with newly diagnosed glioblastoma multiforme (GBM) being treated with radiation and concurrent chemotherapy were involved in this study. Evaluated were metabolite indices and metabolite ratios. Logistic linear regression and Cox proportional hazards models were utilized to evaluate PFS6 and OS, respectively. These analyses were adjusted by age and MR scanner field strength (1.5 T or 3 T). Stepwise regression was performed to determine a subset of the most relevant variables.

Results

Associated with shorter PFS6 were a decrease in the ratio of N-acetyl aspartate to choline-containing compounds (NAA/Cho) in the region with a Cho-to-NAA index (CNI) >3 at baseline and an increase of the CNI within elevated CNI regions (>2) at F2mo. Patients with higher normalized lipid and lactate at either time point had significantly worse OS. Patients who had larger volumes with abnormal CNI at F2mo had worse PFS6 and OS.

Conclusions

Our study found more 3D MRSI parameters that predicted PFS6 and OS for patients with GBM than did anatomic, diffusion, or perfusion imaging, which were previously evaluated in the same population of patients.

http://neuro-oncology.oxfordjournals.org/cgi/content/short/15/5/607?rss=1

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Julio Pereira, MD

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The relative patient benefit of gross total resection in adult choroid plexus papillomas

Publication date: Available online 25 April 2013
Source:Journal of Clinical Neuroscience
Author(s): Michael Safaee , Michael C. Oh , Michael E. Sughrue , Arthur R. DeLance , Orin Bloch , Matthew Sun , Gurvinder Kaur , Annette M. Molinaro , Andrew T. Parsa
Choroid plexus papillomas are rare neuroepithelial tumors found mainly in children. Although well studied in the pediatric population, there is a paucity of literature focusing specifically on adults. We sought to assess the relative advantage of gross total resection (GTR) and further characterize the natural history of this disease in adults. A comprehensive PubMed search was performed to identify adults who underwent surgical resection for choroid plexus papillomas with clearly reported age, tumor location, and extent of resection. Kaplan–Meier analysis was used to assess progression-free survival (PFS) and overall survival (OS). Multivariate analysis was performed using Cox proportional hazards models. A total of 193 patients were identified with a mean age of 39.9±1.1years. GTR was achieved in 72% of patients with subtotal resection (STR) in 28%. GTR was associated with a significant increase in both PFS (p=0.015) and OS (p=0.004) compared to STR. In a multivariate Cox proportional hazards model we found that only GTR was associated with recurrence (hazard ratio [HR]=0.47, 95% confidence interval [CI] 0.25–0.90), while both age (HR=1.03, 95% CI 1.00–1.05) and GTR (HR=0.36, 95% CI 0.17–0.78) were associated with OS. Interestingly, our observed recurrence and death rates were higher than those in previously published studies. These findings demonstrate the benefit of GTR for the treatment of choroid plexus papillomas in adults. Our analysis suggests that these lesions are not as indolent as previously thought and while GTR is preferred, it is not always curative.

http://rss.sciencedirect.com/action/redirectFile?&zone=main¤tActivity=feed&usageType=outward&url=http%3A%2F%2Fwww.sciencedirect.com%2Fscience%3F_ob%3DGatewayURL%26_origin%3DIRSSSEARCH%26_method%3DcitationSearch%26_piikey%3DS0967586812005334%26_version%3D1%26md5%3Dbe6113c0fc5e183bcba512572511228e

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Julio Pereira, MD

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Treatment Switch For Neuroblastoma Stem Cell Transplants

The stem cell transplant regimen that was commonly used in the United States to treat advanced neuroblastoma in children appears to be more toxic than the equally effective regimen employed in Europe and Egypt, according to a new study being presented at the 26th annual meeting of the American Society of Pediatric Hematology Oncology in Miami April 24-27. The U.S...

http://www.medicalnewstoday.com/releases/259617.php

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Julio Pereira, MD

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Long-term outcome of centrally located low-grade glioma in children

BACKGROUND

Optimal management of children with centrally located low-grade glioma (LGG) is unclear. Initial interventions in most children are chemotherapy in younger and radiation therapy (RT) in older children. A better understanding of the inherent risk factors along with the effects of interventions on long-term outcome can lead to reassessment of the current approaches to minimize long-term morbidity.

METHODS

To reassess the current treatment strategies of centrally located LGG, we compared the long-term survival and morbidity of different treatment regimens. Medical records of patients primarily treated at Texas Children's Cancer and Hematology Centers between 1987 and 2008 were reviewed.

RESULTS

Forty-seven patients with a median follow-up of 79 months were included in the analysis. The 5-year overall survival and progression-free survival (PFS) for all patients were 96% and 53%, respectively. The 5-year PFS for those treated initially with RT (12 patients; median age, 11 years [range, 3-15 years]) and with chemotherapy (28 patients; median age, 2 years [range 0-8 years]) were 76% and 37%, respectively (log-rank test P = .02). Among children who progressed after chemotherapy, the 5-year PFS after salvage RT was 55%. Patients diagnosed at a younger age (<5 years) were more likely to experience endocrine abnormalities (Fisher exact test; P<.00001).

CONCLUSIONS

Effective and durable tumor control was obtained with RT as initial treatment. In younger patients, chemotherapy can delay the use of RT; however, frequent progression and long-term morbidity are common. More effective and less toxic therapies are required in these patients, the majority of whom are long-term survivors. Cancer 2013;. © 2013 American Cancer Society.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002%2Fcncr.28110

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Julio Pereira, MD

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Plan Your Digital Death

Have you given any thought to your afterlife --I mean the digital one. Google has. The company says that after you're gone, it will act as electronic executor for the gigabytes of data left in Gmail and their other digital offerings, based on your instructions.

[More]

http://rss.sciam.com/click.phdo?i=52306554c98960df8d3146ccf0771857

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Julio Pereira, MD

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Advances In Understanding Of Genetic Defects Underlying Childhood Low-Grade Gliomas

The St. Jude Children's Research Hospital - Washington University Pediatric Cancer Genome Project has identified mutations responsible for more than half of a subtype of childhood brain tumor that takes a high toll on patients. Researchers also found evidence the tumors are susceptible to drugs already in development...

http://www.medicalnewstoday.com/releases/259105.php

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Julio Pereira, MD

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Headache as a risk factor for neurovascular events in pediatric brain tumor patients

Objective:

To determine whether severe recurrent headache is a risk factor for neurovascular events in children who received radiation for brain tumors.

Methods:

This is a retrospective cohort study of children with brain tumors who received cranial irradiation at a large tertiary care center, aged 0–21 years at diagnosis, with initial treatment between January 1, 1993 and December 31, 2002, and 2 or more follow-up visits. Patients were considered to have severe recurrent headache if this appeared as a complaint on 2 or more visits. Headaches attributed to tumor progression, shunt malfunction, or infection, or appearing at the end of life, were excluded. Medical records were reviewed for events of stroke or TIA.

Results:

Of 265 subjects followed for a median of 6.0 years (interquartile range 1.7–9.2 years), stroke or TIA occurred in 7/37 (19%) with severe headaches compared to 6/228 (3%) without these symptoms (hazard ratio 5.3, 95% confidence interval 1.8–15.9, p = 0.003). Adjusting for multiple variables did not remove the significance of this risk. Median time to first neurovascular event for the entire cohort was 4.9 years (interquartile range 1.7–5.5 years).

Conclusions:

Severe recurrent headache appears to be a risk factor or predictor for subsequent cerebral ischemia in pediatric brain tumor survivors treated with radiation. This finding has clinical implications for both monitoring survivors and targeting a specific population for primary stroke prevention.

http://www.neurology.org/cgi/content/short/80/16/1452?rss=1

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Julio Pereira, MD

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Initial and cumulative recurrence patterns of glioblastoma after temozolomide-based chemoradiotherap

Purpose: To analyze initial recurrence patterns in patients with newly diagnosed glioblastoma after radiotherapy plus concurrent and adjuvant temozolomide, and to investigate cumulative recurrence patterns after salvage treatment, including surgery, stereotactic radiotherapy, and chemotherapy. Methods: Twenty-one patients with glioblastoma that recurred after concurrent temozolomide and localized radiotherapy were retrospectively analyzed (11 male, 10 female; median age, 57 years; range, 27--74). Disease progression was assessed by new response criteria proposed by the Response Assessment in Neuro-Oncology Working Group of the American Society of Clinical Oncology. The pattern of recurrence was determined by relationships between locations of recurrent tumors and irradiated doses. Central, in-field, marginal, and out-field recurrences were defined relative to the prescribed isodose line. Distant recurrence was operationally defined as subependymal or disseminated disease. Initial and cumulative patterns of recurrence were evaluated in each patient. Results: The median follow-up of the recurrent patients was 501 (range, 217--1815) days after initial surgery. Initial recurrences were central in 14 patients (66.7), in-field in four patients (19.0%), marginal in no patient (0%), out-field in two patients (9.5%), and distant in four patients (19.0%). One patient had both central and in-field recurrences simultaneously, and two had both central and distant recurrences. In the analysis of cumulative recurrence patterns, five patients, who had no scans after initial recurrences, were excluded and the remaining 16 were included. Cumulative recurrences were central in 11 patients (68.8%), in-field in five patients (31.3%), marginal in three patients (18.8%), out-field in five patients (31.3%), and distant in 14 patients (87.5%). Regarding salvage treatments, 11 (52.4%), 11 (52.4%) and 17 (81.0%) patients underwent surgery, stereotactic radiotherapy and chemotherapy, respectively. Eighteen (85.7%) patients had died at the time of analysis, and 16 of them (88.9%) had suffered distant recurrences, which could have been the immediate causes of death. Conclusions: Recurrence patterns of glioblastoma after radiotherapy plus concomitant and adjuvant temozolomide were mainly central at first, and distant recurrences were often detected during the clinical course. Much better local control and prevention of distant recurrence, including effective salvage treatment, seem to be important.

http://www.ro-journal.com/content/8/1/97

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Julio Pereira, MD

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The Silent Loss of Neuronavigation Accuracy: A Systematic Retrospective Analysis of Factors Influen

BACKGROUND: Neuronavigation has become an intrinsic part of preoperative surgical planning and surgical procedures. However, many surgeons have the impression that accuracy decreases during surgery. OBJECTIVE: To quantify the decrease of neuronavigation accuracy and identify possible origins, we performed a retrospective quality-control study. METHODS: Between April and July 2011, a neuronavigation system was used in conjunction with a specially prepared head holder in 55 consecutive patients. Two different neuronavigation systems were investigated separately. Coregistration was performed with laser-surface matching, paired-point matching using skin fiducials, anatomic landmarks, or bone screws. The initial target registration error (TRE1) was measured using the nasion as the anatomic landmark. Then, after draping and during surgery, the accuracy was checked at predefined procedural landmark steps (Mayfield measurement point and bone measurement point), and deviations were recorded. RESULTS: After initial coregistration, the mean (SD) TRE1 was 2.9 (3.3) mm. The TRE1 was significantly dependent on patient positioning, lesion localization, type of neuroimaging, and coregistration method. The following procedures decreased neuronavigation accuracy: attachment of surgical drapes (DTRE2 = 2.7 [1.7] mm), skin retractor attachment (DTRE3 = 1.2 [1.0] mm), craniotomy (DTRE3 = 1.0 [1.4] mm), and Halo ring installation (DTRE3 = 0.5 [0.5] mm). Surgery duration was a significant factor also; the overall DTRE was 1.3 [1.5] mm after 30 minutes and increased to 4.4 [1.8] mm after 5.5 hours of surgery. CONCLUSION: After registration, there is an ongoing loss of neuronavigation accuracy. The major factors were draping, attachment of skin retractors, and duration of surgery. Surgeons should be aware of this silent loss of accuracy when using neuronavigation. ABBREVIATIONS: BMP, bone measurement point DTRE2, DTRE3 MMP, Mayfield measuring point TRE, target registration error TRE1, initial target registration error TRE2, target registration error at the Mayfield measurement point TRE3, target registration error at bone measurement point

http://journals.lww.com/neurosurgery/Fulltext/2013/05000/The_Silent_Loss_of_Neuronavigation_Accuracy___A.12.aspx

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Julio Pereira, MD

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Treatment-related brain tumor imaging changes: So-called "Pseudoprogression" vs. tumor progression:

Diem Kieu Thi Tran, Randy L Jensen

Surgical Neurology International 2013 4(4):129-135

Background: Glioblastoma multiforme (GBM) has a dismal prognosis despite aggressive therapy. Initial diagnosis and measurement of response to treatment is usually determined by measurement of gadolinium-enhanced tumor volume with magnetic resonance imaging (MRI). Unfortunately, many GBM treatment modalities can cause changes in tumor gadolinium enhancement patterns that mimic tumor progression. The lack of a definitive imaging modality to distinguish posttreatment radiographic imaging changes (PTRIC), including pseudoprogression and radiation necrosis, from true tumor progression presents a major unmet clinical need in the management of GBM patients. Methods: The authors discuss current modalities available for differentiating PTRIC and tumor progression, describe development of an animal model of PTRIC, and consider potential molecular and cellular pathways involved in the development of PTRIC. Results: An animal model using glioma cells transfected with a luciferase reporter has been developed, and after conventional GBM therapy, this animal model can be evaluated with posttreatment bioluminescence imaging and various MR tumor imaging modalities. Conclusions: Posttreatment radiographic changes that mimic tumor progression can influence clinicians to make treatment decisions that are inappropriate for the patient's actual clinical condition. Several imaging modalities have been used to try to distinguish PTRIC and true progression, including conventional MRI, perfusion MRI, MR spectroscopy, and positron emission tomography (PET); however, none of these modalities has consistently and reliably distinguished PTRIC from tumor growth. An animal model using glioma cells transfected with a luciferase reporter may enable mechanistic studies to determine causes and potential treatments for PTRIC.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2013;volume=4;issue=4;spage=129;epage=135;aulast=Tran

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Julio Pereira, MD

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The impact of stereotactic radiosurgery in the management of neurofibromatosis type 2-related vestib

Leonardo Lustgarten

Surgical Neurology International 2013 4(4):151-155

Although there is an ongoing debate about the ideal management of vestibular schwannomas, radiosurgical treatment has become popular in the past decade with good to excellent results reported. Given the young age at presentation, the bilateral nature of vestibular schwanomas, the presence of other associated central nervous system tumors, patients with neurofibromatosis Type 2 (NF2) are very complex and present significant management challenges. Although results do not seem to be as good as for patients with sporadic unilateral tumors, stereotactic radiosurgery has proven a safe, attractive, and effective management modality for NF2 vestibular schwannomas. An overview of the impact stereotactic radiosurgery has had in the management of these tumors is discussed.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2013;volume=4;issue=4;spage=151;epage=155;aulast=Lustgarten

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Julio Pereira, MD

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Diagnostic yield of stereotactic needle-biopsies of sub-cubic centimeter intracranial lesions

J Dawn Waters, David D Gonda, Hasini Reddy, Ekkehard M Kasper, Peter C Warnke, Clark C Chen

Surgical Neurology International 2013 4(4):176-181

Background: Stereotactic brain biopsies are widely used for establishing the diagnosis of intracranial lesions. Here we examine whether stereotactic biopsy of smaller brain lesions, defined for this study as being less than 1 cubic centimeter (1 cc) in volume, are associated with lowered diagnostic yield. Methods: We conducted a retrospective analysis of 267 consecutive patients who underwent stereotactic brain biopsy between 2007 and 2011. Lesion volumes were calculated and were stratified by <1 or >1 cc. Results: A total of 13 of 246 (5.2%) biopsies for lesions >1 cc resulted in nondiagnostic tissue or an incorrect diagnosis. In contrast, 5 of 21 (23.8%) biopsies for <1 cc lesions yielded nondiagnostic or incorrect diagnosis. Posthoc review of tissue from the <1 cc lesions suggests the neuropathologist's expertise in the handling and analysis of limited specimen as a critical parameter of successful diagnosis. The operative morbidities were low for both the <1 and >1 cc biopsies (0% and 1%, respectively). Conclusion: This study demonstrates that stereotactic cerebral biopsy of lesions less than a cubic centimeter in volume results in a lower diagnostic yield versus larger lesions (76.2% versus 94.8%). While auxiliary measures may be taken to improve diagnostic yield, these patients may be best managed in a specialized center with experienced stereotactic neurosurgeons and neuropathologists.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2013;volume=4;issue=4;spage=176;epage=181;aulast=Waters

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Julio Pereira, MD

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Stereotactic surgery for eating disorders

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2013;volume=4;issue=4;spage=164;epage=169;aulast=Sun

Neurosurgery Blog Apps (iPad, iPhone and Android) #neurology #neurologia #infectology #medicine #medlife #medicina

Neurosurgery Blog Apps (iPad, iPhone and Android)

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!
Now we have more than 14,000 downloads in more than 120 countries !


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Neurosurgery Blog iOS (click here)
Neurosurgery Blog app  Android (Click Here)



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



Neuroexame (click here) Portuguese Only iPad and iPhone


Neuro Exam App iOS ( Only English and Spanish)

Neurointensive Care (APPSTORE CLICK HERE English/Portuguese)

Neurointensive Care (English and Portuguese ANDROID) CLICK HERE


 Epilepsia App (portuguese and English) CLICK HERE iOS


   

Neuroinfect App ( Portuguese and English) Click here Android
Neuroinfect App ( Portuguese and English) Click here iOS


Craniotomy (Portuguese and English) CLICK HERE Android
Craniotomy (Portuguese and English) CLICK HERE  iOS ( COME SOON)



Anamnesis (English) Click Here iPad and iPhone
Anamnese (Portuguese) Click Here iPad and iPhone


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

Neuroinfect App FREE Trial – iOS and Android (English and Portuguese) #neurology #neurologia #infectology #medicine #medlife #medicina

CLICK HERE ( iOS)
CLICK HERE (andoid)

Description

Infectious diseases of the central nervous system are very due it`s morbidity and mortality when not diagnosed precisely. Know of this reality it`s imperative that all health professionals, specially the medicine students, generalist doctors, neurologists and intensivists master the subject.
The app Neuroinfect, aims to help in the learning of this complex subject on medicine. The content was developed by a team of neurosurgeons that work at Santa Casa de Belo Horizonte – MG – Brazil and members of Neurosurgery Blog. Composed by the medics: Dr. Mauro Cruz Machado Borgo, Dr. Lucas Alverne Freitas de Albuquerque, Dr. Júlio Leonardo Barbosa Pereira, Dr. José Lopes Filho, Prof. Dr. Gervásio Teles Cardoso de Carvalho, Dr. Paulo Pereira Christo.
The app Neuroinfect has illustrations, MRI and cranial CT to facilitate the learning process.
Covered subjects on the app:
1. Meningitis
2. Bacterial brain abscess
3. Cranial subdural empyema
4. Viral encephalitis
5. SNC infections in AIDS
6. Neurocysticercosis
7. Neuroschistosomiasis
8. Spinal epidural abscess
9. Spondylodiscitis
10. Spinal tuberculosis (Pott`s disease)
11. Operative wound infection
12. Infection of the ventricular shunt system

Neuroinfect Support

iPhone Screenshots

How technology can empower patients, including 4 diagnostic tools for your iPhone

How technology can empower patients, including 4 diagnostic tools for your iPhone
TED BLOG | APRIL 11, 2013
http://pulse.me/s/kx1mD


Eric Dishman is used to thinking about how technology can transform the world of health care. As an Intel Fellow and general ... Read more

Júlio Leonardo B. Pereira

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Brain Scans Offer Precise Measurement Of Human Pain

Brain Scans Offer Precise Measurement Of Human Pain
BEST OF SCIENCE | APRIL 10, 2013
http://pulse.me/s/kqZjH


Pain In The Brain Regions in the brain researchers found are activated when someone is experiencing pain from heat. The yellow regions are active when... Read more

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Júlio Leonardo B. Pereira

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Clinical Practice Guidelines on Managing Pain in Older People

How do the latest clinical practice guidelines suggest treating and managing pain in older adults? Are there any new therapeutic strategies?
Age and Ageing

http://www.medscape.com/viewarticle/779782?src=rss

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Julio Pereira, MD

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Neurosurgery and prognosis in patients with radiation-induced brain injury after nasopharyngeal carc

Background: Radiotherapy is the standard radical treatment for nasopharyngeal carcinoma (NPC) and may cause radiation-induced brain injury (RI). Treatment for RI remains a challenge. We conducted this study to investigate the indications of neurosurgery, operation time and prognosis of patients with RI after NPC radiotherapy who underwent neurosurgical management. Methods: This was a follow-up study between January 2005 and July 2011. Fifteen NPC cases of RI who underwent neurosurgery were collected. Brain Magnetic resonance imaging (MRI), surgery and histology were studied. The outcome was assessed by LENT/SOMA scales and modified Rankin scale. Results: Brain lesion resection (86.7%) was more common than decompressive craniotomy (13.3%). According to LENT/SOMA scale before and six months after surgery, 13 of 15, 12 of 15, 14 of 15, and 14 of 15 cases showed improvement at subjective, objective, management and analytic domains, respectively. 12 of 15 patients showed improvement of modified Rankin scale after surgery. Three patients who underwent emergency surgery showed significant improvement (average score increment of 2, 2.7, 2.7, 3 and 2 at LENT/SOMA scale subjective, objective, management, analytic, and modified Rankin scale, respectively), as compared with 12 cases underwent elective surgery (average score increment of 1, 1, 1.4, 1.8 and 1 at LENT SOMA scale subjective, objective, management, analytic, and modified Rankin scale, respectively). Conclusions: Neurosurgery, including brain necrotic tissue resection and decompressive craniotomy, improves the prognosis for RI patients, especially for those with indications of emergency surgery.

http://www.ro-journal.com/content/8/1/88

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Julio Pereira, MD

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The effect of weight in the outcomes of meningioma patients

Holly Dickinson, Christine Carico, Miriam Nuño, Kristin Nosova, Adam Elramsisy, Chirag G Patil

Surgical Neurology International 2013 4(1):45-45

Background: Meningiomas are more prevalent in women and mostly benign in nature. Our aim was to evaluate the association of weight and outcomes of meningioma patients undergoing craniotomy. Methods: A retrospective analysis of meningioma patients discharged postcraniotomy between 1998 and 2007 was conducted. Univariate and multivariate analysis evaluated in-hospital mortality, complications, length of stay (LOS), and cost. Results: According to the nationwide inpatient sample (NIS) database, an estimated 72,257 adult meningioma patients underwent a craniotomy in US hospitals during the study period. Female and male weight loss rates were 0.7% and 1.2%, respectively; obesity rates were 5.2% and 3.7%. Males had higher rates of malignant tumors than females (6.2% vs. 3.5%, P < 0.0001), and malignant tumors were more common in patients with weight loss (6.4% vs. 4.3%, P = 0.03). Weight loss was associated with higher mortality in men (OR 6.66, P < 0.0001) and women (OR 3.92, P = 0.04) as well as higher rates of postoperative complications in both men (OR 6.13, P < 0.0001) and women (OR 8.37, P < 0.0001). Furthermore, patients suffering weight loss had longer LOS and higher overall hospital cost when compared with all patients. In contrast, obesity seemed to reduce mortality (OR 0.47, P = 0.0006) and complications (OR 0.8, P = 0.0007) among women. Conclusions: In summary, weight loss seems to be the single most critical factor present in patients experiencing higher mortality, complications, hospital charges, and longer LOS. However, further studies aimed to assess the inter-relation of potential preexisting comorbidities and weight loss are needed to establish causation.

http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2013;volume=4;issue=1;spage=45;epage=45;aulast=Dickinson

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Julio Pereira, MD

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Synchronized Sounds Improve Memory During Sleep

Listening to certain types of sounds could improve your memory while you sleep, a new study suggests. The study, published in the journal Neuron, revealed that specifically timed sounds that rise and fall at the same rate as brain waves during sleep can improve memory...

http://www.medicalnewstoday.com/articles/259070.php

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Julio Pereira, MD

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Brain carcinoid metastases: outcomes and prognostic factors

Journal of Neurosurgery, Volume 118, Issue 4, Page 889-895, April 2013.
Object Carcinoid tumors are rare and have generally been regarded as indolent neoplasms. Systemic disease is often incurable; however, patients may live years with this disease. Furthermore, metastatic brain lesions are extremely uncommon. As such, few series have examined outcomes and prognostic factors in those with brain involvement. Methods The authors performed a retrospective review of patients who underwent primary treatment at Mayo Clinic in Rochester, Minnesota, for metastatic carcinoid tumors to the brain between 1986 and 2011. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier statistics. Cox proportional hazards were used to determine predictors of survival. Results Fifteen patients underwent primary treatment for metastatic carcinoid tumors to the brain between 1986 and 2011. Their mean age was 58 ± 12 years. Eighty percent (n = 12) of patients underwent surgery, whereas 2 received stereotactic radiosurgery and 1 had whole-brain radiation therapy (WBRT) as the primary treatment. The median follow-up duration was 19 months (maximum 124 months). Systemic disease progression occurred in 73% and was the leading cause of death in known cases, while intracranial disease recurred in 40%. The median PFS and OS were 21 and 19 months, respectively. The use of adjuvant WBRT correlated with improved PFS (HR 0.15, CI 0.0074–0.95, p = 0.044). Those who underwent surgery as primary modalities trended toward longer progression-free intervals (p = 0.095), although this did not reach significance. Conclusions Metastatic carcinoid disease to the brain appears to have a worse prognosis than that of other extracranial metastases. Although there was a trend toward a survival advantage in patients who underwent surgery and WBRT, further study is needed to establish definitive treatment recommendations.

http://thejns.org/doi/abs/10.3171/2013.1.JNS121556?ai=ru&mi=0&af=R

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Julio Pereira, MD

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Brainstem gangliogliomas: a retrospective series

Journal of Neurosurgery, Volume 118, Issue 4, Page 884-888, April 2013.
Object The authors retrospectively analyzed data on brainstem gangliogliomas treated in their department and reviewed the pertinent literature to foster understanding of the preoperative characteristics, management, and clinical outcomes of this disease. Methods In 2006, the authors established a database of treated lesions of the posterior fossa. The epidemiology findings, clinical presentations, radiological investigations, pathological diagnoses, management, and prognosis for brainstem gangliogliomas were retrospectively analyzed. Results Between 2006 and 2012, 7 patients suffering from brainstem ganglioglioma were treated at the West China Hospital of Sichuan University. The mean age of the patients, mean duration of symptoms prior to diagnosis, and mean duration of follow-up were 28.6 years, 19.4 months, and 38.1 months, respectively. The main presentations were progressive cranial nerve deficits and cerebellar signs. Subtotal resection was achieved in 2 patients, and partial resection in 5. All tumors were pathologically diagnosed as WHO Grade I or II ganglioglioma. Radiotherapy and adjuvant chemotherapy were not administered. After 21–69 months of follow-up, patient symptoms were resolved or stable without aggravation, and MRI showed that the size of residual lesions was unchanged without progression or recurrence. Conclusions The diagnosis of brainstem ganglioglioma is of great importance given its favorable prognosis. The authors recommend the maximal safe resection followed by close observation without adjuvant therapy as the optimal treatment for this disease.

http://thejns.org/doi/abs/10.3171/2013.1.JNS121323?ai=ru&mi=0&af=R

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Julio Pereira, MD

Phone: (+1) 424-2301706

Linkedin:http://www.linkedin.com/in/juliommais 

Site: www.neurocirurgiabr.com

Multiple resections for patients with glioblastoma: prolonging survival

Journal of Neurosurgery, Volume 118, Issue 4, Page 812-820, April 2013.
Object Glioblastoma is the most common and aggressive type of primary brain tumor in adults. These tumors recur regardless of intervention. This propensity to recur despite aggressive therapies has made many perceive that repeated resections have little utility. The goal of this study was to evaluate if patients who underwent repeat resections experienced improved survival as compared with patients with fewer numbers of resections, and whether the number of resections was an independent predictor of prolonged survival. Methods The records of adult patients who underwent surgery for an intracranial primary glioblastoma at an academic tertiary-care institution between 1997 and 2007 were retrospectively reviewed. Multivariate proportionalhazards regression analysis was used to identify an association between glioblastoma resection number and survival after controlling for factors known to be associated with survival, such as age, functional status, periventricular location, extent of resection, and adjuvant therapy. Survival as a function of time was plotted using the Kaplan-Meier method, and survival rates were compared using log-rank analysis. Results Five hundred seventy-eight patients with primary glioblastoma met the inclusion/exclusion criteria. At last follow-up, 354, 168, 41, and 15 patients underwent 1, 2, 3, or 4 resections, respectively. The median survival for patients who underwent 1, 2, 3, and 4 resections was 6.8, 15.5, 22.4, and 26.6 months (p < 0.05), respectively. In multivariate analysis, patients who underwent only 1 resection experienced shortened survival (relative risk [RR] 3.400, 95% CI 2.423–4.774; p < 0.0001) as compared with patients who underwent 2 (RR 0.688, 95% CI 0.525–0.898; p = 0.0006), 3 (RR 0.614, 95% CI 0.388–0.929; p = 0.02), or 4 (RR 0.600, 95% CI 0.238–0.853; p = 0.01) resections. These results were verified in a case-control evaluation, controlling for age, neurological function, periventricular tumor location, extent of resection, and adjuvant therapy. Patients who underwent 1, 2, or 3 resections had a median survival of 4.5, 16.2, and 24.4 months, respectively (p < 0.05). Additionally, the risk of infections or iatrogenic deficits did not increase with repeated resections in this patient population (p > 0.05). Conclusions Patients with glioblastoma will inevitably experience tumor recurrence. The present study shows that patients with recurrent glioblastoma can have improved survival with repeated resections. The findings of this study, however, may be limited by an intrinsic bias associated with patient selection. The authors attempted to minimize these biases by using strict inclusion criteria, multivariate analyses, and case-control evaluation.

http://thejns.org/doi/abs/10.3171/2012.9.JNS1277?ai=ru&mi=0&af=R

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Julio Pereira, MD

Phone: (+1) 424-2301706

Linkedin:http://www.linkedin.com/in/juliommais 

Site: www.neurocirurgiabr.com

Presentation, management, and outcome of newly diagnosed glioblastoma in elderly patients

Journal of Neurosurgery, Volume 118, Issue 4, Page 786-798, April 2013.
Object Optimum management for elderly patients with newly diagnosed glioblastoma (GBM) in the temozolomide (TMZ) era is not well defined. The object of this study was to clarify outcomes in this population. Methods The authors retrospectively reviewed 105 consecutive cases involving elderly patients (age ≥ 65 years) with newly diagnosed GBM who were treated at the Mayo Clinic between 2003 and 2008. Results The patients' median age was 74 years (range 66–87 years), and the median Karnofsky Performance Status (KPS) score was 80 (range 40–90). Half of the patients underwent biopsy and half underwent resection. Patients with deep-seated lesions (19 patients [18%]) or multifocal lesions (34 patients [32%]) were more likely to have biopsy than resection (p = 0.0001 and 0.0009, respectively). New persistent neurological deficits developed in 7 patients (6.7%). Postoperative hemorrhage occurred in 6 patients (5.7%), all of whom underwent biopsy. Complete follow-up data regarding adjuvant treatment was available in 84 patients. Forty-one (49%) were treated with chemotherapy (mostly TMZ) and radiation therapy (RT), and 23 (27%) with RT alone. Nineteen (23%) received only palliative care after surgery (more common with biopsy, p = 0.03). Chemotherapy complications occurred in 28.6% (Grade 3 or 4 hematological complications in 11.9%). The median values for progression-free survival (PFS) and overall survival (OS) were 3.5 and 5.5 months. In a multivariate analysis, younger age (p = 0.03, risk ratio [RR] 0.34, 95% CI 0.13–0.89), single lesion (p = 0.02, RR 0.51, 95% CI 0.30–0.89), resection (p = 0.04, RR 0.54, 95% CI 0.31–0.94), and adjuvant treatment (p = 0.0001, RR 0.24, 95% CI 0.11–0.49) were associated with better OS. Only adjuvant treatment was significantly associated with prolonged PFS (p = 0.0007, RR 0.27, 95% CI 0.13–0.57). With combined therapy with resection, RT, and chemotherapy, the median PFS and OS were 8 and 12.5 months, respectively. Conclusions The prognosis for GBM worsens with increasing age in elderly patients. With important risks, resection and adjuvant treatment are associated with prolonged survival. Although selection bias cannot be excluded in this retrospective study, advanced age alone should not necessarily preclude optimal resection followed by adjuvant radiochemotherapy.

http://thejns.org/doi/abs/10.3171/2012.10.JNS112268?ai=ru&mi=0&af=R

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Julio Pereira, MD

Phone: (+1) 424-2301706

Linkedin:http://www.linkedin.com/in/juliommais 

Site: www.neurocirurgiabr.com

Association of functional magnetic resonance imaging indices with postoperative language outcomes in

Neurosurgical Focus, Volume 34, Issue 4, Page E6, April 2013.
Object Functional MRI (fMRI) has the potential to be a useful presurgical planning tool to treat patients with primary brain tumor. In this study the authors retrospectively explored relationships between language-related postoperative outcomes in such patients and multiple factors, including measures estimated from task fMRI maps (proximity of lesion to functional activation area, or lesion-to-activation distance [LAD], and activation-based language lateralization, or lateralization index [LI]) used in the clinical setting for presurgical planning, as well as other factors such as patient age, patient sex, tumor grade, and tumor volume. Methods Patient information was drawn from a database of patients with brain tumors who had undergone preoperative fMRI-based language mapping of the Broca and Wernicke areas. Patients had performed a battery of tasks, including word-generation tasks and a text-versus-symbols reading task, as part of a clinical fMRI protocol. Individually thresholded task fMRI activation maps had been provided for use in the clinical setting. These clinical imaging maps were used to retrospectively estimate LAD and LI for the Broca and Wernicke areas. Results There was a relationship between postoperative language deficits and the proximity between tumor and Broca area activation (the LAD estimate), where shorter LADs were related to the presence of postoperative aphasia. Stratification by tumor location further showed that for posterior tumors within the temporal and parietal lobes, more bilaterally oriented Broca area activation (LI estimate close to 0) and a shorter Wernicke area LAD were associated with increased postoperative aphasia. Furthermore, decreasing LAD was related to decreasing LI for both Broca and Wernicke areas. Preoperative deficits were related to increasing patient age and a shorter Wernicke area LAD. Conclusions Overall, LAD and LI, as determined using fMRI in the context of these paradigms, may be useful indicators of postsurgical outcomes. Whereas tumor location may influence postoperative deficits, the results indicated that tumor proximity to an activation area might also interact with how the language network is affected as a whole by the lesion. Although the derivation of LI must be further validated in individual patients by using spatially specific statistical methods, the current results indicated that fMRI is a useful tool for predicting postoperative outcomes in patients with a single brain tumor.

http://thejns.org/doi/abs/10.3171/2013.2.FOCUS12413?ai=rw&mi=3ba5z2&af=R

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Julio Pereira, MD

Phone: (+1) 424-2301706

Linkedin:http://www.linkedin.com/in/juliommais 

Site: www.neurocirurgiabr.com

Use of diffusion tensor imaging in glioma resection

Neurosurgical Focus, Volume 34, Issue 4, Page E1, April 2013.
Diffusion tensor imaging (DTI) is increasingly used in the resection of both high- and low-grade gliomas. Whereas conventional MRI techniques provide only anatomical information, DTI offers data on CNS connectivity by enabling visualization of important white matter tracts in the brain. Importantly, DTI allows neurosurgeons to better guide their surgical approach and resection. Here, the authors review basic scientific principles of DTI, include a primer on the technology and image acquisition, and outline the modality's evolution as a frequently used tool for glioma resection. Current literature supporting its use is summarized, highlighting important clinical studies on the application of DTI in preoperative planning for glioma resection, preoperative diagnosis, and postoperative outcomes. The authors conclude with a review of future directions for this technology.

http://thejns.org/doi/abs/10.3171/2013.1.FOCUS12412?ai=rw&mi=3ba5z2&af=R

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Julio Pereira, MD

Phone: (+1) 424-2301706

Linkedin:http://www.linkedin.com/in/juliommais 

Site: www.neurocirurgiabr.com

Factors affecting functional outcomes in long-term survivors of intracranial germinomas: a 20-year e

Journal of Neurosurgery: Pediatrics, Volume 11, Issue 4, Page 454-463, April 2013.
Object Radiation monotherapy—prophylactic craniospinal or whole-brain irradiation paired with a radiation boost to the primary tumor—is the standard treatment for intracranial germinomas at the authors' institution. The authors assessed long-term outcomes of patients with germinoma who underwent therapy and identified factors affecting them. Methods The authors retrospectively analyzed data obtained in 46 patients (35 males and 11 females, age 5–43 years at diagnosis) who had been treated for intracranial germinomas between 1990 and 2009 at the authors' institution. Thirty patients had germinomas in localized regions and 16 in multiple regions. Thirty-eight patients (83%) underwent radiotherapy alone (craniospinal irradiation in 32 and whole-brain irradiation in 6). Seven patients underwent radiochemotherapy and 1 underwent chemotherapy alone. The mean radiation doses for the whole brain, spine, and primary tumor site were 26.9, 26.6, and 49.8 Gy, respectively. The median follow-up period was 125 months. Results The 10-year overall and recurrence-free survival rates were 93.3% and 89.3%, respectively. None of the 38 patients who received radiation monotherapy developed a recurrent lesion, whereas 1 of 7 who underwent radiochemotherapy and the 1 patient who underwent chemotherapy had a recurrent lesion. Of the entire population, 26 patients required hormone replacement therapy, 2 had short stature, and 1 developed a radiation-induced meningioma. Seventeen of the 25 childhood- or adolescent-onset patients were 19 years or older at the latest follow-up visit, 15 of whom graduated from senior high school, and only 2 of whom graduated from college. Of 34 patients who were 19 years or older at the latest visit, 4 were students, 18 worked independently, 4 worked in sheltered workplaces, and 8 were unemployed. Of the 34 patients, 4 got married after the initial treatment, 3 of whom had children. There were 8 patients (17%) with low postoperative Karnofsky Performance Scale (KPS) scores that were significantly associated with impaired neurocognitive functions, severe surgical complications, and neurological impairments. In 10 of the 46 patients, KPS scores at the latest visit were lower than their postoperative KPS scores. These decreases in KPS scores were significantly correlated with a delayed decline in neurocognitive functions in childhood-onset patients and a postoperative impairment of neurocognitive functions in patients with adolescent- or adult-onset germinoma. Conclusions No tumor recurrence occurred in germinoma patients treated with the authors' radiation monotherapy, which appears to be effective enough to cure the tumor. Brain damage caused by tumors themselves and surgical complications were found to adversely affect functional outcomes in patients regardless of their age. Although radiotherapy rarely caused late adverse effects in patients with adolescent- or adult-onset, in some childhood-onset lesions, the radiation seems to carry the risk of neurocognitive dysfunctions, which are attributable to late adverse effects. Accordingly, treatments for germinoma patients should be selected according to a patient's age and the extent of the tumor and with particular care to avoid surgical complications.

http://thejns.org/doi/abs/10.3171/2012.12.PEDS12336?ai=3f6&mi=3ba5z2&af=R

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Julio Pereira, MD

Phone: (+1) 424-2301706

Linkedin:http://www.linkedin.com/in/juliommais 

Site: www.neurocirurgiabr.com