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Categoria: Medicina

Atualizado: 13/06/2012
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Scientists Stop Abnormal Brain Cell Growth In Mice With Neurofibromatosis Using Experimental Tumor D

A drug originally developed to stop cancerous tumors may hold the potential to prevent abnormal brain cell growth and learning disabilities in some children, if they can be diagnosed early enough, a new animal study suggests...





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Surgery for vestibular schwannomas: a systematic review of complications by approach

Neurosurgical Focus, Volume 33, Issue 3, Page E14, September 2012.
Object Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications. Methods MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery. Results The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5–3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5–3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches. Conclusions The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.





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Surgical approaches for resection of vestibular schwannomas: translabyrinthine, retrosigmoid, and mi

Neurosurgical Focus, Volume 33, Issue 3, Page E9, September 2012.
Surgical removal remains one of the key treatment modalities for vestibular schwannomas. A team approach between a neurotologist and a neurosurgeon offers the patient the expertise of both specialties and maximizes the chances for an optimal outcome. Vestibular schwannomas can typically be resected through 1 of 3 main surgical approaches: the translabyrinthine, the retrosigmoid, or the middle fossa approaches. In this report and videos, the authors describe and illustrate the indications and surgical techniques for the removal of these tumors.





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Pitfalls in intraoperative nerve monitoring during vestibular schwannoma surgery

Neurosurgical Focus, Volume 33, Issue 3, Page E5, September 2012.
Despite the widespread acceptance of intraoperative neurophysiological monitoring in skull base surgery over the last 2 decades, surgeon training in the technical and interpretive aspects of nerve monitoring has been conspicuously lacking. Inadequate fundamental knowledge of neurophysiological monitoring may lead to misinterpretations and an inability to troubleshoot system errors. Some surgeons perform both the technical and interpretive aspects of monitoring themselves while others enjoin coworkers (surgical residents, nurses, anesthetists, or a separate monitoring service) to perform the technical portion. Regardless, the surgeon must have a thorough understanding to avoid potential medical and legal pitfalls because poor monitoring is worse than no monitoring. A structured curriculum and protocol in both the technical and interpretive aspects of monitoring is recommended for all personnel involved in the monitoring process. This paper details the technical, interpretive, and surgical correlates necessary for optimal intraoperative nerve monitoring during vestibular schwannoma surgery with an emphasis on electromyographic monitoring for facial and recurrent laryngeal nerves. Just as the American Society of Anesthesiologists' 1986 "Standards for Basic Anesthetic Monitoring" became a useful tool for both patients and anesthesiologists, impending guidelines in intraoperative neurophysiological monitoring should likewise become an important instrument for optimizing intraoperative neurophysiological monitoring.





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The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation?

Neurosurgical Focus, Volume 33, Issue 3, Page E8, September 2012.
Object Management recommendations for patients with smaller-volume or newly diagnosed vestibular schwannomas (< 4 cm3) need to be based on an understanding of the anticipated natural history of the tumor and the side effects it produces. The natural history can then be compared with the risks and benefits of therapeutic intervention using a minimally invasive strategy such as stereotactic radiosurgery (SRS). Methods The authors reviewed the emerging literature stemming from recent recommendations to "wait and scan" (observation) and compared this strategy with published outcomes after early intervention using SRS or results from matched cohort studies of resection and SRS. Results Various retrospective studies indicate that vestibular schwannomas grow at a rate of 0–3.9 mm per year and double in volume between 1.65 and 4.4 years. Stereotactic radiosurgery arrests growth in up to 98% of patients when studied at intervals of 10–15 years. Most patients who select "wait and scan" note gradually decreasing hearing function leading to the loss of useful hearing by 5 years. In contrast, current studies indicate that 3–5 years after Gamma Knife surgery, 61%–80% of patients maintain useful hearing (speech discrimination score > 50%, pure tone average < 50). Conclusions Based on published data on both volume and hearing preservation for both strategies, the authors devised a management recommendation for patients with small vestibular schwannomas. When resection is not chosen by the patient, the authors believe that early SRS intervention, in contrast to observation, results in long-term tumor control and improved rates of hearing preservation.





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The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation?

Neurosurgical Focus, Volume 33, Issue 3, Page E8, September 2012.
Object Management recommendations for patients with smaller-volume or newly diagnosed vestibular schwannomas (< 4 cm3) need to be based on an understanding of the anticipated natural history of the tumor and the side effects it produces. The natural history can then be compared with the risks and benefits of therapeutic intervention using a minimally invasive strategy such as stereotactic radiosurgery (SRS). Methods The authors reviewed the emerging literature stemming from recent recommendations to "wait and scan" (observation) and compared this strategy with published outcomes after early intervention using SRS or results from matched cohort studies of resection and SRS. Results Various retrospective studies indicate that vestibular schwannomas grow at a rate of 0–3.9 mm per year and double in volume between 1.65 and 4.4 years. Stereotactic radiosurgery arrests growth in up to 98% of patients when studied at intervals of 10–15 years. Most patients who select "wait and scan" note gradually decreasing hearing function leading to the loss of useful hearing by 5 years. In contrast, current studies indicate that 3–5 years after Gamma Knife surgery, 61%–80% of patients maintain useful hearing (speech discrimination score > 50%, pure tone average < 50). Conclusions Based on published data on both volume and hearing preservation for both strategies, the authors devised a management recommendation for patients with small vestibular schwannomas. When resection is not chosen by the patient, the authors believe that early SRS intervention, in contrast to observation, results in long-term tumor control and improved rates of hearing preservation.





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Incidental vestibular schwannomas: a review of prevalence, growth rate, and management challenges

Neurosurgical Focus, Volume 33, Issue 3, Page E4, September 2012.
With the relatively recent increase in the use of MRI techniques, there has been a concurrent rise in the number of vestibular schwannomas (VSs) detected as incidental findings. These incidental VSs may be prevalent in up to 0.02%–0.07% of individuals undergoing MRI and represent a significant portion of all diagnosed VSs. The management of these lesions poses a significant challenge for practitioners. Most incidental VSs tend to be small and associated with minimal symptoms, permitting them to be managed conservatively at the time of diagnosis. However, relatively few indicators consistently predict tumor growth and patient outcomes. Furthermore, growth rates have been shown to vary significantly over time with a large variety of long-term growth patterns. Thus, early MRI screening for continued tumor growth followed by repeated MRI studies and clinical assessments throughout the patient's life is an essential component in a conservative management strategy. Note that tumor growth is typically associated with a worsening of symptoms in patients who undergo conservative management, and many of these symptoms have been shown to significantly impact the patient's quality of life. Specific indications for the termination of conservative management vary across studies, but secondary intervention has been shown to be a relatively safe option in most patients with progressive disease. Patients with incidental VSs will probably qualify for a course of conservative management at diagnosis, and regular imaging combined with the expectation that the tumor and symptoms may change at any interval is crucial to ensuring positive long-term outcomes in these patients. In this report, the authors discuss the current literature pertaining to the prevalence of incidental VSs and various considerations in the management of these lesions. It is hoped that by incorporating an understanding of tumor growth, patient outcomes, and management strategies, practitioners will be able to effectively address this challenging disease entity.





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An update on unilateral sporadic small vestibular schwannoma

Neurosurgical Focus, Volume 33, Issue 3, Page E1, September 2012.
Advances in neuroimaging have increased the detection rate of small vestibular schwannomas (VSs, maximum diameter < 25 mm). Current management modalities include observation with serial imaging, stereotactic radiosurgery, and microsurgical resection. Selecting one approach over another invites speculation, and no standard management consensus has been established. Moreover, there is a distinct clinical heterogeneity among patients harboring small VSs, making standardization of management difficult. The aim of this article is to guide treating physicians toward the most plausible therapeutic option based on etiopathogenesis and the highest level of existing evidence specific to the different cohorts of hypothetical case scenarios. Hypothetical cases were created to represent 5 commonly encountered scenarios involving patients with sporadic unilateral small VSs, and the literature was reviewed with a focus on small VS. The authors extrapolated from the data to the hypothetical case scenarios, and based on the level of evidence, they discuss the most suitable patient-specific treatment strategies. They conclude that observation and imaging, stereotactic radiosurgery, and microsurgery are all important components of the management strategy. Each has unique advantages and disadvantages best suited to certain clinical scenarios. The treatment of small VS should always be tailored to the clinical, personal, and social requirements of an individual patient, and a rigid treatment protocol is not practical.





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The approach to the patient with incidentally diagnosed vestibular schwannoma

Neurosurgical Focus, Volume 33, Issue 3, Page E2, September 2012.
With the increasing prevalence and decreasing cost of MRI scans, incidental discovery of vestibular schwannoma (VS) has become more common. Scarce literature exists regarding management of the tumors in those patients with incidentally discovered VSs, and clear guidelines for management do not exist. In this review, the authors examine the available literature for insights into management of incidentally diagnosed VS and provide an algorithm for their management.





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