Radiopaedia Vol 1: Brain Radiology Teaching File de Radiopaedia.org
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Monday, December 30, 2013
Sunday, December 29, 2013
The Volumetric Response of Brain Metastases After Stereotactic Radiosurgery and Its Post-treatment Implications
The Volumetric Response of Brain Metastases After Stereotactic Radiosurgery and Its Post-treatment Implications
Neurosurgery - Most Popular Articles
BACKGROUND: Changes in tumor volume are seen on magnetic resonance imaging within weeks after stereotactic radiosurgery (SRS), but it remains unclear what clinical outcomes early radiological changes portend. OBJECTIVE: We hypothesized that rapid, early reduction in tumor volume post-SRS is associated with prolonged local control and favorable clinical outcome. METHODS: A retrospective review of patients treated with CyberKnife SRS for brain metastases at the University of North Carolina from 2007 to 2009 was performed. Patients with at least 1 radiological follow-up, minimal initial tumor volume of 0.1 cm3, no previous focal radiation, and no recent whole-brain radiation therapy were eligible for inclusion. RESULTS: Fifty-two patients with 100 metastatic brain lesions were analyzed and had a median follow-up of 15.6 months (range, 2-33 months) and a median of 2 (range, 1-8) metastatic lesions. In treated metastases in which there was a significant tumor volume reduction by 6 or 12 weeks post-SRS, there was no local progression for the duration of the study. Furthermore, patients with metastases that did not reduce in volume by 6 or 12 weeks post-SRS were more likely to require corticosteroids (P = .01) and to experience progression of neurological symptoms (P = .003). CONCLUSION: Significant volume reductions of brain metastases measured at either 6 or 12 weeks post-SRS were strongly associated with prolonged local control. Furthermore, early volume reduction was associated with less corticosteroid use and stable neurological symptoms. ABBREVIATIONS: CI, confidence interval OS, overall survival RCC, renal cell carcinoma SBS, Schwarz bayesian criterion SRS, stereotactic radiosurgery WBRT, whole-brain radiotherapyOriginal Article: http://journals.lww.com/neurosurgery/Fulltext/2014/01000/The_Volumetric_Response_of_Brain_Metastases_After.2.aspx
Saturday, December 28, 2013
The 20 best free iPhone medical apps for healthcare professionals, edition 3
The 20 best free iPhone medical apps for healthcare professionals, edition 3
Julio Pereira, MDLinkedin:http://www.linkedin.com/in/juliommais Site: www.neurocirurgiabr.com
Friday, December 27, 2013
Neurosurgery Blog partilhou contigo uma foto do Instagram
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Wednesday, December 25, 2013
Helsinki Microneurosurgery Basics and Tricks
Helsinki Microneurosurgery Basics and Tricks by B. Braun Melsungen AG
https://itunes.apple.com/br/app/helsinki-microneurosurgery/id506365864?l=en&mt=8
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Tuesday, December 24, 2013
BRCA Testing Update: 'Do This, Don't Do That'
BRCA Testing Update: 'Do This, Don't Do That'
Medscape Today- Medscape
The US Preventive Services Task Force has reaffirmed its 2005 guidance on risk assessment and genetic counseling and testing for BRCA-related cancer in women.
Medscape Medical News
Original Article: http://www.medscape.com/viewarticle/818267?src=rss
The rationale for targeted therapies in medulloblastoma
The rationale for targeted therapies in medulloblastoma
Neuro-Oncology - current issue
Medulloblastoma (MB) is the most frequent malignant brain tumor in children. Patients with MB who are classified as having high-risk disease or those with recurrent disease respond poorly to current therapies and have an increased risk of MB-related mortality. Preclinical studies and molecular profiling of MB tumors have revealed upregulation or activation of several key signaling pathways such as the sonic hedgehog and WNT pathways. Although the exact mechanisms underlying MB tumorigenesis remain poorly understood, inhibiting these key pathways with molecularly targeted therapies represents an important approach to improving MB outcomes. Several molecularly targeted therapies are already under clinical investigation in MB patients. We discuss current preclinical and clinical data, as well as data from clinical trials of targeted therapies that are either ongoing or in development for MB.
Original Article: http://neuro-oncology.oxfordjournals.org/cgi/content/short/16/1/9?rss=1
Monday, December 23, 2013
Potential new therapeutic approach to promote tissue regeneration & repair of broken cell connections
Potential new therapeutic approach to promote tissue regeneration & repair of broken cell connections
Neurology News & Neuroscience News from Medical News Today
Suppressing the enzyme fidgetin promotes the re-growth of experimentally injured nerve cells and their connections, according to research with laboratory rats that was presented at the American Society for Cell Biology (ASCB) annual meeting in New Orleans.
Original Article: http://www.medicalnewstoday.com/releases/270354.php
Sunday, December 22, 2013
Rethinking the war on cancer.
Rethinking the war on cancer.
Unbound MEDLINE | Lancet journal articles
- Hanahan D
- Rethinking the war on cancer. [JOURNAL ARTICLE]
- Lancet 2013 Dec 13.
- AbstractPublisher Full Text
Some 40 years ago a metaphor was posed that cancer was such an insidious adversary that a declaration of war on the disease was justified. Although this statement was a useful inspiration for enlistment of resources, despite extraordinary progress in our understanding of disease pathogenesis, in most cases and for most forms of cancer this war has not been won. A second metaphor was about magic bullets-targeted therapies based on knowledge of mechanisms that were envisaged to strike with devastating consequences for the disease. The reality, however, is that targeted therapies are generally not curative or even enduringly effective, because of the adaptive and evasive resistance strategies developed by cancers under attack. In this Series paper, I suggest that, much like in modern warfare, the war on cancer needs to have a battlespace vision.
Original Article: http://www.unboundmedicine.com/medline/citation/24351321/Rethinking_the_war_on_cancer_
Saturday, December 21, 2013
Cancer survival: global surveillance will stimulate health policy and improve equity.
Cancer survival: global surveillance will stimulate health policy and improve equity.
Unbound MEDLINE | Lancet journal articles
- Coleman MP
- Cancer survival: global surveillance will stimulate health policy and improve equity. [JOURNAL ARTICLE]
- Lancet 2013 Dec 13.
- AbstractPublisher Full Text
Millions of people will continue to be diagnosed with cancer every year for the foreseeable future. These patients all need access to optimum health care. Population-based cancer survival is a key measure of the overall effectiveness of health systems in management of cancer. Survival varies very widely around the world. Global surveillance of cancer survival is needed, because unless these avoidable inequalities are measured, and reported on regularly, nothing will be done explicitly to reduce them.
Original Article: http://www.unboundmedicine.com/medline/citation/24351320/Cancer_survival:_global_surveillance_will_stimulate_health_policy_and_improve_equity_
Thursday, December 19, 2013
Blocking tumor-associated macrophages decreased glioblastoma's growth & extended survival in mice
Blocking tumor-associated macrophages decreased glioblastoma's growth & extended survival in mice
Neurology News & Neuroscience News from Medical News Today
An experimental drug that targets macrophages, a type of immune cell, in the microenvironment surrounding the lethal brain tumor glioblastoma multiforme decreased the cancer's growth and extended survival of laboratory mice with the cancer, scientists reported at the American Society for Cell Biology (ASCB) annual meeting in New Orleans.
Original Article: http://www.medicalnewstoday.com/releases/270241.php
80 Percent of Cancer Docs Have Faced Drug Shortages
80 Percent of Cancer Docs Have Faced Drug Shortages
Cancer: MedlinePlus
Many report using substitute chemo meds or delaying treatment
Source: HealthDay
Original Article: http://www.nlm.nih.gov/medlineplus/news/fullstory_143555.html
Wednesday, December 18, 2013
Craniotomy
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“Adult Survivors of Childhood Cancer at Risk of Becoming Frail at an Early Age”, St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center
"Adult Survivors of Childhood Cancer at Risk of Becoming Frail at an Early Age", St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
National Comprehensive Cancer Network
Young adults who survived childhood cancer are more likely than their peers to be frail, according to a St. Jude Children's Research Hospital study, which reported the condition is more common among female survivors than women decades older. The research appears in the current edition of the Journal of Clinical Oncology. St. Jude Children's Research Hospital/The University of Tennessee Health Science Center is one of the 23 NCCN Member Institutions....
Original Article: http://www.stjude.org/stjude/v/index.jsp?vgnextoid=55134cae77c52410VgnVCM100000290115acRCRD&vgnextchannel=fa1113c016118010VgnVCM1000000e2015acRCRD
Epilepsia App
Epilepsia App by Soda Virtual
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Monday, December 16, 2013
One step closer to understanding a deadly childhood brain cancer
One step closer to understanding a deadly childhood brain cancer
Neurology News & Neuroscience News from Medical News Today
A new study by Canadian researchers may pave the way for more effective treatment of an aggressive and deadly type of brain tumour, known as ETMR/ETANTR. The tumour, which is seen only in children under four, is almost always fatal, despite aggressive treatment. The study proposes a new model for how this brain tumour develops and suggests possible targets to investigate for novel therapies.
Original Article: http://www.medicalnewstoday.com/releases/270029.php
A Phase 2 Trial of Stereotactic Radiosurgery Boost After Surgical Resection for Brain Metastases
A Phase 2 Trial of Stereotactic Radiosurgery Boost After Surgical Resection for Brain Metastases
International Journal of Radiation Oncology * Biology * Physics
Purpose: To evaluate local control after surgical resection and postoperative stereotactic radiosurgery (SRS) for brain metastases.Methods and Materials: A total of 49 patients (50 lesions) were enrolled and available for analysis. Eligibility criteria included histologically confirmed malignancy with 1 or 2 intraparenchymal brain metastases, age ≥18 years, and Karnofsky performance status (KPS) ≥70. A Cox proportional hazard regression model was used to test for significant associations between clinical factors and overall survival (OS). Competing risks regression models, as well as cumulative incidence functions, were fit using the method of Fine and Gray to assess the association between clinical factors and both local failure (LF; recurrence within surgical cavity or SRS target), and regional failure (RF; intracranial metastasis outside of treated volume).Results: The median follow-up was 12.0 months (range, 1.0-94.1 months). After surgical resection, 39 patients with 40 lesions were treated a median of 31 days (range, 7-56 days) later with SRS to the surgical bed to a median dose of 1800 cGy (range, 1500-2200 cGy). Of the 50 lesions, 15 (30%) demonstrated LF after surgery. The cumulative LF and RF rates were 22% and 44% at 12 months. Patients who went on to receive SRS had a significantly lower incidence of LF (P=.008). Other factors associated with improved local control include non-small cell lung cancer histology (P=.048), tumor diameter <3cm (P=.010), and deep parenchymal tumors (P=.036). Large tumors (≥3 cm) with superficial dural/pial involvement showed the highest risk for LF (53.3% at 12 months). Large superficial lesions treated with SRS had a 54.5% LF. Infratentorial lesions were associated with a higher risk of developing RF compared to supratentorial lesions (P<.001).Conclusions: Postoperative SRS is associated with high rates of local control, especially for deep brain metastases <3cm. Tumors ≥3 cm with superficial dural/pial involvement demonstrate the highest risk of LF.
Original Article: http://www.redjournal.org/article/S0360-3016(13)03191-X/abstract?rss=yes
Salvage Radiosurgery for Brain Metastases: Prognostic Factors to Consider in Patient Selection
Salvage Radiosurgery for Brain Metastases: Prognostic Factors to Consider in Patient Selection
International Journal of Radiation Oncology * Biology * Physics
Purpose: Stereotactic radiosurgery (SRS) is offered to patients for recurrent brain metastases after prior brain radiation therapy (RT), but few studies have evaluated the efficacy of salvage SRS or factors to consider in selecting patients for this treatment. This study reports overall survival (OS), intracranial progression-free survival (PFS), and local control (LC) after salvage SRS, and factors associated with outcomes.Methods and Materials: This is a retrospective review of patients treated from 2009 to 2011 with salvage SRS after prior brain RT for brain metastases. Survival from salvage SRS and from initial brain metastases diagnosis (IBMD) was calculated. Univariate and multivariable (MVA) analyses included age, performance status, recursive partitioning analysis (RPA) class, extracranial disease control, and time from initial RT to salvage SRS.Results: There were 106 patients included in the analysis with a median age of 56.9 years (range 32.5-82 years). A median of 2 metastases were treated per patient (range, 1-12) with a median dose of 21 Gy (range, 12-24) prescribed to the 50% isodose. With a median follow-up of 10.5 months (range, 0.1-68.2), LC was 82.8%, 60.1%, and 46.8% at 6 months, 1 year, and 3 years, respectively. Median PFS was 6.2 months (95% confidence interval [CI] = 4.9-7.6). Median OS was 11.7 months (95% CI = 8.1-13) from salvage SRS, and 22.1 months from IBMD (95% CI = 18.4-26.8). On MVA, age (P=.01; hazard ratio [HR] = 1.04; 95% CI = 1.01-1.07), extracranial disease control (P=.004; HR = 0.46; 95% CI = 0.27-0.78), and interval from initial RT to salvage SRS of at least 265 days (P=.001; HR = 2.46; 95% CI = 1.47-4.09) were predictive of OS.Conclusions: This study demonstrates that patients can have durable local control and survival after salvage SRS for recurrent brain metastases. In particular, younger patients with controlled extracranial disease and a durable response to initial brain RT are likely to benefit from salvage SRS.
Original Article: http://www.redjournal.org/article/S0360-3016(13)03195-7/abstract?rss=yes
Thoughts on the Future of Research, Teaching, and Testing in the Biological Sciences of Radiation Oncology
Thoughts on the Future of Research, Teaching, and Testing in the Biological Sciences of Radiation Oncology
International Journal of Radiation Oncology * Biology * Physics
The American Society for Radiation Oncology Cancer Biology/Radiation Biology Task Force consisted of 21 physician scientists and radiation biologists from North America, who discussed the present areas of research specialization in radiation biology and future opportunities to advance the field of radiation oncology. Their report is summarized in this issue of the International Journal of Radiation Oncology, Biology, Physics .
Original Article: http://www.redjournal.org/article/S0360-3016(13)03188-X/abstract?rss=yes
Thursday, December 5, 2013
Researcher studies pediatric brain stem tumors
Researcher studies pediatric brain stem tumors
Neurology News & Neuroscience News from Medical News Today
Children's National researcher, Javad Nazarian, PhD, authored a new study entitled, "Comparative Multidimensional Molecular Analyses of Pediatric Diffuse Intrinsic Pontine Glioma Reveals Distinct Molecular Subtypes." The study found, for the first time, two distinct subtypes in pediatric diffuse intrinsic pontine gliomas (DIPG).
Original Article: http://www.medicalnewstoday.com/releases/269695.php
Tuesday, December 3, 2013
Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma
Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma
Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents
Journal of Neurosurgery, Volume 119, Issue 6, Page 1447-1452, December 2013.
Object Volume reduction of nonfunctioning pituitary adenomas has been described, for example, after radiotherapy and pituitary tumor apoplexy. Even when considerable remnants remain after surgery, spontaneous shrinkage and relief of mass lesion symptoms can sometimes occur. The aim of this study was to assess shrinkage of tumor residues after transsphenoidal surgery and to identify predictors of tumor shrinkage. Methods A total of 140 patients with postoperative remnants of nonfunctioning pituitary adenomas treated at the Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany, were included in this study. All patients underwent transsphenoidal procedures with guidance by 1.5-T intraoperative MRI. The intraoperative images of remnants were compared with images taken at 3 months and at 1 year after surgery. The possible predictors analyzed were age; sex; preoperative and intraoperative tumor dimensions; tumor growth pattern; endocrinological, ophthalmological, and histological characteristics; and history of previous pituitary surgery. For statistical analyses, the Fisher's exact test, Mann-Whitney U-test, and multivariate regression table analysis were used. Results Follow-up imaging 3 months after surgery showed tumor remnant shrinkage of 0.5 ± 0.6 cm3 for 70 (50%) patients. This reduction was 89% ± 20% of the residual volume depicted by intraoperative MRI. In 45 (64%) patients, the remnants disappeared completely. Age, sex, and preoperative tumor volume did not significantly differ between the shrinkage and no-shrinkage groups. Positive predictors for postoperative shrinkage were cystic tumor growth (p = 0.02), additional resection of tumor remnants guided by intraoperative MRI (p = 0.04), smaller tumor volume (p = 0.04), and smaller craniocaudal tumor diameter of remnants (p = 0.0014). Negative predictors were growth into the cavernous sinus (p = 0.009), history of previous pituitary surgery (p = 0.0006) and tumor recurrence (p = 0.04), and preoperative panhypopituitarism (p = 0.04). Multivariate regression analysis indicated a positive correlation between tumor shrinkage and smaller tumor remnants (p < 0.0001) and no history of previous pituitary surgery (p = 0.003). No spontaneous change in tumor remnant volume was detected between 3 months and 1 year postoperatively. During a mean follow-up time of 2.7 years, 1 (2%) patient with postoperative tumor shrinkage had to undergo another operation because of tumor progression. Conclusions Spontaneous volume reduction of nonfunctioning pituitary adenoma remnants can occur within 3 months after surgery. Predictors of shrinkage are smaller tumor remnant volume and no history of previous pituitary surgery.
Original Article: http://thejns.org/doi/abs/10.3171/2013.8.JNS13790?ai=ru&mi=0&af=R
Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria
Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria
Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents
Journal of Neurosurgery, Volume 119, Issue 6, Page 1467-1477, December 2013.
Object Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature. Methods The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure. Results In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria. Conclusions In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.
Original Article: http://thejns.org/doi/abs/10.3171/2013.8.JNS13224?ai=ru&mi=0&af=R
Monday, December 2, 2013
The role of radiosurgery in the management of WHO Grade II and III intracranial meningiomas
The role of radiosurgery in the management of WHO Grade II and III intracranial meningiomas
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E16, December 2013.
Object WHO Grade II and III intracranial meningiomas are uncommon, but they portend a significantly worse prognosis than their benign Grade I counterparts. The mainstay of current management is resection to obtain cytoreduction and histological tissue diagnosis. The timing and benefit of postoperative fractionated external beam radiation therapy and stereotactic radiosurgery remain controversial. The authors review the stereotactic radiosurgery outcomes for Grade II and III meningiomas. Methods A comprehensive literature search was performed using PubMed to identify all radiosurgery series reporting the treatment outcomes for Grade II and III meningiomas. Case reports and case series involving fewer than 10 patients were excluded. Results From 1998 to 2013, 19 radiosurgery series were published in which 647 Grade II and III meningiomas were treated. Median tumor volumes were 2.2–14.6 cm3. The median margin doses were 14–21 Gy, although generally the margin doses for Grade II meningiomas were 16–20 Gy and the margin doses for Grade III meningiomas were 18–22 Gy. The median 5-year PFS was 59% for Grade II tumors and 13% for Grade III tumors, which may have been affected by patient age, prior radiation therapy, tumor volume, and radiosurgical dose and timing. The median complication rate following radiosurgery was 8%. Conclusions The current data for radiosurgery suggest that it has a role in the management of residual or recurrent Grade II and III meningiomas. However, better studies are needed to fully define this role. Due to the relatively low prevalence of these tumors, it is unlikely that prospective studies will be feasible. As such, well-designed retrospective analyses may improve our understanding of the effect of radiosurgery on tumor recurrence and patient survival and the incidence and impact of treatment-induced complications.
Original Article: http://thejns.org/doi/abs/10.3171/2013.9.FOCUS13364?ai=rw&mi=3ba5z2&af=R
Petroclival meningiomas: an update on surgical approaches, decision making, and treatment results
Petroclival meningiomas: an update on surgical approaches, decision making, and treatment results
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E11, December 2013.
Object Petroclival meningiomas remain a formidable challenge for neurosurgeons because of their location deep within the skull base and proximity to eloquent neurovascular structures. Various skull base approaches have been used in their treatment, and deciding which is the optimal one remains controversial. Attempts at achieving gross- or near-total resections are associated with an increased rate of morbidity and mortality. As adjunctive treatment options such as stereotactic radiosurgery have been developed and become widely available, there has been a trend toward accepting subtotal resections in an effort to minimize neurological morbidity. This paper reviews a recent series of patients with petroclival meningiomas and highlights current management trends and important considerations useful in surgical decision making. Methods The records of patients with large (> 3 cm) petroclival meningiomas surgically treated by the senior author over the past 5 years were reviewed. The clinical results are presented as examples of the surgical approaches available for approaching these tumors, and treatment options are reviewed. Results Of 196 meningiomas surgically treated during the study period, 8 lesions in 8 patients met the study criteria. Overall clinical results were excellent, with no death or major morbidity. Intracranial gross- or near-total resection (Simpson Grade 1, 2, or 3) was achieved in 5 patients (67%). New cranial nerve deficits occurred in 3 patients (37%) and were more common in patients in whom a subtotal resection was performed (2 of 3 cases). A variety of surgical approaches were used. Important considerations determining the best approach include the location of the tumor relative to the internal auditory canal, the presence of preoperative hearing loss, and the location of the tumor relative to the tentorium. Conclusions Achieving gross- or near-total resections of large petroclival meningiomas remains achievable and should be the primary goal of surgical treatment. A retrosigmoid craniotomy remains a workhorse surgical approach for most petroclival tumors of any size. Tumors that are medial to the internal auditory canal and span both middle and posterior cranial fossae are often best treated with a combined transpetrosal approach, which is especially true if there is a preoperative hearing deficit.
Original Article: http://thejns.org/doi/abs/10.3171/2013.9.FOCUS13319?ai=rw&mi=3ba5z2&af=R
Technical nuances in the management of tuberculum sellae and diaphragma sellae meningiomas
Technical nuances in the management of tuberculum sellae and diaphragma sellae meningiomas
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E7, December 2013.
Object Tuberculum sellae meningiomas (TSMs) and diaphragma sellae meningiomas (DSMs) are challenging lesions to treat due to their proximity to neurovascular structures. Methods The authors reviewed the medical records of patients who underwent surgical excision of TSMs and DSMs from 1990 to 2013. They also describe the technical strategies used to minimize injury to the optic apparatus, vascular structures, and pituitary stalk. Results Twenty-four patients with TSM and 6 patients with DSM were included in the study. Seventy percent of the tumors were large (≥ 5 cm). The pterional approach was employed in most cases. Optic canal involvement was observed in 4 patients. Twenty-one patients (70%) had visual dysfunction before surgery. At follow-up (median 18 months), visual improvement was noted in 10 (47.6%) of 21 patients. Gross-total excision was achieved in 22 patients (91.6%) with TSM and 5 (83.3%) with DSM. At last follow-up, 28 patients (93.3%) had a Glasgow Outcome Scale score of 5. There were no deaths in this series. Conclusions Tuberculum and diaphragma sellae meningiomas present a unique subset of tumors due to their location. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. Attention to technical details during surgery leads to greater respectability and superior visual outcome.
Original Article: http://thejns.org/doi/abs/10.3171/2013.10.FOCUS13350?ai=rw&mi=3ba5z2&af=R
A proposed grading system for standardizing tumor consistency of intracranial meningiomas
A proposed grading system for standardizing tumor consistency of intracranial meningiomas
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E1, December 2013.
Object Tumor consistency plays an important and underrecognized role in the surgeon's ability to resect meningiomas, especially with evolving trends toward minimally invasive and keyhole surgical approaches. Aside from descriptors such as "hard" or "soft," no objective criteria exist for grading, studying, and conveying the consistency of meningiomas. Methods The authors designed a practical 5-point scale for intraoperative grading of meningiomas based on the surgeon's ability to internally debulk the tumor and on the subsequent resistance to folding of the tumor capsule. Tumor consistency grades and features are as follows: 1) extremely soft tumor, internal debulking with suction only; 2) soft tumor, internal debulking mostly with suction, and remaining fibrous strands resected with easily folded capsule; 3) average consistency, tumor cannot be freely suctioned and requires mechanical debulking, and the capsule then folds with relative ease; 4) firm tumor, high degree of mechanical debulking required, and capsule remains difficult to fold; and 5) extremely firm, calcified tumor, approaches density of bone, and capsule does not fold. Additional grading categories included tumor heterogeneity (with minimum and maximum consistency scores) and a 3-point vascularity score. This grading system was prospectively assessed in 50 consecutive patients undergoing craniotomy for meningioma resection by 2 surgeons in an independent fashion. Grading scores were subjected to a linear weighted kappa analysis for interuser reliability. Results Fifty patients (100 scores) were included in the analysis. The mean maximal tumor diameter was 4.3 cm. The distribution of overall tumor consistency scores was as follows: Grade 1, 4%; Grade 2, 9%; Grade 3, 43%; Grade 4, 44%; and Grade 5, 0%. Regions of Grade 5 consistency were reported only focally in 14% of heterogeneous tumors. Tumors were designated as homogeneous in 68% and heterogeneous in 32% of grades. The kappa analysis score for overall tumor consistency grade was 0.87 (SE 0.06, 95% CI 0.76–0.99), with 90% user agreement. Kappa analysis scores for minimum and maximum grades of tumor regions were 0.69 (agreement 72%) and 0.75 (agreement 78%), respectively. The kappa analysis score for tumor vascularity grading was 0.56 (agreement 76%). Overall consistency did not correlate with patient age, tumor location, or tumor size. A higher tumor vascularity grade was associated with a larger tumor diameter (p = 0.045) and with skull base location (p = 0.02). Conclusions The proposed grading system provides a reliable, practical, and objective assessment of meningioma consistency and facilitates communication among providers. This system also accounts for heterogeneity in tumor consistency. With the proposed scale, meningioma consistency can be standardized as groundwork for future studies relating to surgical outcomes, predictability of consistency and vascularity using neuroimaging techniques, and effectiveness of various surgical instruments.
Original Article: http://thejns.org/doi/abs/10.3171/2013.8.FOCUS13274?ai=rw&mi=3ba5z2&af=R
Patterns of recurrence after stereotactic radiosurgery for treatment of meningiomas
Patterns of recurrence after stereotactic radiosurgery for treatment of meningiomas
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E14, December 2013.
Object The purpose of this study was to evaluate patterns of failure after stereotactic radiosurgery (SRS) for meningiomas and factors that may influence these outcomes. Methods Based on a retrospective chart review, 279 patients were treated with SRS for meningiomas between January 1999 and March 2011 at Wake Forest Baptist Health. Disease progression was determined using serial imaging, with a minimum follow-up of 6 months (median 34.2 months). Results The median margin dose was 12.0 Gy (range 8.8–20 Gy). Local control rates for WHO Grade I tumors were 96.6%, 84.4%, and 75.7% at 1, 3, and 5 years, respectively. WHO Grade II and III tumors had local control rates of 72.3%, 57.7%, and 52.9% at 1, 3, and 5 years, respectively. Tumors without pathological grading had local control rates of 98.7%, 97.6%, and 94.2% at 1, 3, and 5 years, respectively. Of the local recurrences, 63.1% were classified as marginal (within 2 cm of treatment field). The 1-, 3-, and 5-year rates of distant failure were 6.5%, 10.3%, and 16.6%, respectively, for Grade I tumors and 11.4%, 17.2%, and 22.4%, respectively, for Grade II/III tumors. Tumors without pathological grading had distant failure rates of 0.7%, 3.2%, and 6.5% at 1, 3, and 5 years, respectively. Wilcoxon analysis revealed that multifocal disease (p < 0.001) and high-grade histology (WHO Grade II or III; p < 0.001) were significant predictors of local recurrence. Additionally, male sex was a significant predictor of distant recurrence (p = 0.04). Multivariate analysis also showed that doses greater than or equal to 12 Gy were associated with improved local control (p = 0.015). Conclusions In this patient series, 12 Gy was the minimum sufficient margin dose for the treatment of meningiomas. Male sex is a risk factor for distant failure, whereas high-grade histology and multifocal disease are risk factors for local failure.
Original Article: http://thejns.org/doi/abs/10.3171/2013.8.FOCUS13283?ai=rw&mi=3ba5z2&af=R
Controversies in the role of preoperative embolization in meningioma management
Controversies in the role of preoperative embolization in meningioma management
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E17, December 2013.
The role of preoperative embolization in meningioma management remains controversial, even though 4 decades have passed since it was first described. It has been shown to offer benefits such as decreased blood loss and "softening of the tumor" during subsequent resection. However, the actual benefits remain unclear, and the potential harm of an additional procedure along with the cost of embolization have limited its use to a small proportion of the meningiomas treated. In this article the authors retrospectively reviewed their experience with preoperative embolization of meningiomas over the previous 6 years (March 2007–March 2013). In addition, they performed a MEDLINE search using a combination of the terms "meningioma," "preoperative," and "embolization" to analyze the indications, embolizing agents, timing, and complications reported during preoperative embolization of meningiomas. In this retrospective review, 18 cases (female/male ratio 12:6) were identified in which endovascular embolization was used prior to resection of an intracranial meningioma. Craniotomy for tumor resection was performed within 4 days after endovascular embolization in all cases, with an average time to surgery of 1.9 days. The average duration of surgery was 4 hours and 18 minutes, and the average blood loss was 574 ml, with a range of 300–1000 ml. Complications following endovascular therapy were identified in 3 (16.7%) of 18 cases, including one each of transient hemiparesis, permanent hemiparesis, and tumor swelling. The literature review returned 15 articles consisting of a study population greater than 25 patients. No randomized controlled study was found. The use of small polyvinyl alcohol particles (45–150 μm) is more effective in preoperative devascularization than larger particles (150–250 μm), but is criticized due to the higher risk of complications such as cranial nerve palsies and postprocedural hemorrhage. Time to surgery after embolization is inconsistently reported across the articles, and conclusions on the appropriate timing of surgery could not be drawn. The overall complication rate reported after treatment with preoperative meningioma embolization ranges from as high as 21% in some of the older literature to approximately 6% in recent literature describing treatment with newer embolization techniques. The evidence in the literature supporting the use of preoperative meningioma embolization is mainly from case series, and represents Level III evidence. Due to the lack of randomized controlled clinical trials, it is difficult to draw any significant conclusions on the overall usefulness of preoperative embolization during the management of meningiomas to consider it a standard practice.
Original Article: http://thejns.org/doi/abs/10.3171/2013.9.FOCUS13351?ai=rw&mi=3ba5z2&af=R
Atypical meningiomas: is postoperative radiotherapy indicated?
Atypical meningiomas: is postoperative radiotherapy indicated?
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E15, December 2013.
Object The role of postoperative radiation therapy after surgery for atypical meningiomas remains controversial. In this retrospective cohort study, the authors examine the recurrence rates for atypical meningiomas after resection (with or without adjuvant radiotherapy) and identify which factors were associated with recurrence. Methods Of 90 patients with atypical meningiomas who underwent surgery between 1999 and 2009, 71 (79%) underwent gross-total resection (GTR) and 19 (21%) underwent subtotal resection (STR); 31 patients received adjuvant radiotherapy. All tumors were pathology-confirmed WHO Grade II atypical meningiomas. Univariate and multivariate analyses were performed to identify factors associated with recurrence-free survival. Results Among 90 patients, 17 developed tumor recurrence (81% recurrence-free survival at 5 years). In the overall group, adjuvant radiotherapy reduced the recurrence rate to 9% from 19% at 5 years (p = 0.048). After STR, adjuvant radiotherapy significantly reduced recurrence from 91% to 20% (p = 0.0016). However, after GTR, adjuvant radiotherapy did not significantly reduce the recurrence rate (16.7% without radiation therapy vs 11.8% with radiation therapy) (p = 1.00). Five factors independently predictive of tumor recurrence included mitotic index, sheeting, necrosis, nonuse of radiation therapy, and STR. Further recursive partitioning analysis showed significant increases in risk for patients older than 55 years with mitoses and sheeting. Conclusions Adjuvant radiotherapy was effective at lowering recurrence rates in patients after STR but delivered no significant improvement in patients after GTR. Given that rates after GTR were similar with or without adjuvant radiotherapy, close observation without postoperative radiation therapy may be a viable option for these patients. Patients older than 55 years and those with mitoses noted during pathological examination had a significant risk of recurrence after GTR; for these patients, postoperative radiotherapy is recommended.
Original Article: http://thejns.org/doi/abs/10.3171/2013.9.FOCUS13325?ai=rw&mi=3ba5z2&af=R
Neurosurgery Blog – Facebook more than 40,000 likes
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Original Article: http://neurocirurgiabr.com/neurosurgery-blog-facebook-more-than-40000-likes/?utm_source=rss&utm_medium=rss&utm_campaign=neurosurgery-blog-facebook-more-than-40000-likes
Improvement of therapeutic index for brain tumors with daily image guidance
Improvement of therapeutic index for brain tumors with daily image guidance
Radiation Oncology
Background: Image-guidance maximizes the therapeutic index of brain irradiation by decreasing setup uncertainty. As dose-volume data emerge defining the tolerance of critical normal structures responsible for neuroendocrine function and neurocognition, minimizing clinical target volume (CTV) to planning target volume (PTV) expansion of targets near these structures potentially lessens long-term toxicity. Methods: We reviewed the treatment records of 29 patients with brain tumors, with a total of 517 fractions analyzed. The CTV was uniformly expanded by 3 mm to create the PTV for all cases. We determined the effect of patient specific factors (prescribed medications, weight gain, tumor location) and image-guidance technique on setup uncertainty and plotted the mean +/- standard deviation for each factor. ANOVA was used to determine significance between these factors on setup uncertainty. We determined the impact of applying the initial three fraction variation as custom PTV-expansion on dose to normal structures. Results: The initial 3 mm margin encompassed 88% of all measured shifts from daily imaging for all fractions. There was no difference (p = n.s.) in average setup uncertainty between CBCT or kV imaging for all patients. Vertical, lateral, longitudinal, and 3D shifts were similar (p = n.s.) between days 1, 2, and 3 imaging and later fractions. Patients prescribed sedatives experienced increased setup uncertainty (p < 0.05), while weight gain, corticosteroid administration, and anti-seizure medication did not associate with increased setup uncertainty. Patients with targets near OAR with individualized margins led to decreased OAR dose. No reductions to targets occurred with individualized PTVs. Conclusions: Daily imaging allows application of individualized CTV expansion to reduce dose to OAR responsible for neurocognition, learning, and neuroendocrine function below doses shown to correlate with long-term morbidity. The demonstrated reduction in dose to OAR in this study has implications for quality of life and provides the motivation to pursue custom PTV expansion.
Original Article: http://www.ro-journal.com/content/8/1/283
Management of meningiomas involving the transverse or sigmoid sinus
Management of meningiomas involving the transverse or sigmoid sinus
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E9, December 2013.
Meningiomas that invade the transverse or sigmoid sinuses are uncommon tumors that are challenging to treat surgically. Although the risk of recurrence is associated with the extent of resection, complete removal of meningiomas in these locations must be balanced with avoidance of venous outflow obstruction, which could cause venous infarction and significant neurological consequences. When a meningioma occludes a venous sinus completely, gross-total resection of the intravascular portion is commonly performed. When the tumor invades but does not completely obliterate a major venous sinus, however, opinions differ on whether to accept a subtotal resection or to open the sinus, perform a complete resection, and reconstruct the venous outflow tract. In this paper, the authors review the different strategies used to treat these lesions and provide illustrative case examples.
Original Article: http://thejns.org/doi/abs/10.3171/2013.8.FOCUS13340?ai=rw&mi=3ba5z2&af=R
Current standing and frontiers of gene therapy for meningiomas
Current standing and frontiers of gene therapy for meningiomas
Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents
Neurosurgical Focus, Volume 35, Issue 6, Page E4, December 2013.
Meningiomas are among the most common intracranial tumors. The treatment of choice for these lesions is complete resection, but in 50% of cases it is not achieved due to tumor location and/or surgical morbidities. Moreover, benign meningiomas have high recurrence rates of up to 32% in long-term follow-up. Molecular analyses have begun to uncover the genetics behind meningiomas, giving rise to potential genetics-based treatments, including gene therapy. The authors performed a literature review on the most relevant genes associated with meningiomas and both current and potential gene therapy strategies to treat these tumors. Wild-type NF2 gene insertion, oncolytic viruses, and transfer of silencing RNA have all shown promising results both in vitro and in mice. These strategies have decreased meningioma cell growth, proliferation, and angiogenesis. However, no clinical trial has been done to date. Future research and trials in gene insertion, selective inhibition of oncogenes, and the use of oncolytic viruses, among other potential treatment approaches, may shape the future of meningioma management.
Original Article: http://thejns.org/doi/abs/10.3171/2013.8.FOCUS13305?ai=rw&mi=3ba5z2&af=R
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