Wednesday, April 23, 2014
Significance of Cochlear Dose in the Radiosurgical Treatment of Vestibular Schwannoma: Controversies and Unanswered Questions
BACKGROUND: Cochlear dose has been identified as a potentially modifiable contributor to hearing loss after stereotactic radiosurgery (SRS) for vestibular schwannoma (VS). OBJECTIVE: To evaluate the association between computed tomography-based volumetric cochlear dose and loss of serviceable hearing after SRS, to assess intraobserver and interobserver reliability when determining modiolar point dose with the use of magnetic resonance imaging and computed tomography, and to discuss the clinical significance of the cochlear dose with regard to radiosurgical planning strategy. METHODS: Patients with serviceable pretreatment hearing who underwent SRS for sporadic VS between the use of Gamma Knife Perfexion were studied. Univariate and multivariate associations with the primary outcome of time to nonserviceable hearing were evaluated. RESULTS: A total of 105 patients underwent SRS for VS during the study period, and 59 (56%) met study criteria and were analyzed. Twenty-one subjects (36%) developed nonserviceable hearing at a mean of 2.2 years after SRS (SD, 1.0 years; median, 2.1 years; range 0.6-3.8 years). On univariate analysis, pretreatment pure tone average, speech discrimination score, American Academy of Otolaryngology-Head and Neck Surgery hearing class, marginal dose, and mean dose to the cochlear volume were statistically significantly associated with time to nonserviceable hearing. However, after adjustment for baseline differences, only pretreatment pure tone average was statistically significantly associated with time to nonserviceable hearing in a multivariable model. CONCLUSION: Cochlear dose is one of many variables associated with hearing preservation after SRS for VS. Until further studies demonstrate durable tumor arrest with reduced dose protocols, routine tumor dose planning should not be modified to limit cochlear dose at the expense of tumor control. ABBREVIATIONS: AAO-HNS, American Academy of Otolaryngology-Head and Neck Surgery CI, confidence interval PTA, pure tone average SDS, speech discrimination score SRS, stereotactic radiosurgery VS, vestibular schwannoma
Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/05000/Significance_of_Cochlear_Dose_in_the_Radiosurgical.2.aspx
Surgically Relevant Localization of the Central Sulcus With High-Density Somatosensory-Evoked Potentials Compared With Functional Magnetic Resonance Imaging
BACKGROUND: Resection of abnormal brain tissue lying near the sensorimotor cortex entails precise localization of the central sulcus. Mapping of this area is achieved by applying invasive direct cortical electrical stimulation. However, noninvasive methods, particularly functional magnetic resonance imaging (fMRI), are also used. As a supplement to fMRI, localization of somatosensory-evoked potentials (SEPs) recorded with an electroencephalogram (EEG) has been proposed, but has not found its place in clinical practice. OBJECTIVE: To assess localization accuracy of the hand somatosensory cortex with SEP source imaging. METHODS: We applied electrical source imaging in 49 subjects, recorded with high-density EEG (256 channels). We compared it with fMRI in 18 participants and with direct cortical electrical stimulation in 6 epileptic patients. RESULTS: Comparison of SEP source imaging with fMRI indicated differences of 3 to 8 mm, with the exception of the mesial-distal orientation, where variances of up to 20 mm were found. This discrepancy is explained by the fact that the source maximum of the first SEP peak is localized deep in the central sulcus (area 3b), where information initially arrives. Conversely, fMRI showed maximal signal change on the lateral surface of the postcentral gyrus (area 1), where sensory information is integrated later in time. Electrical source imaging and fMRI showed mean Euclidean distances of 13 and 14 mm, respectively, from the contacts where electrocorticography elicited sensory phenomena of the contralateral upper limb. CONCLUSION: SEP source imaging, based on high-density EEG, reliably identifies the depth of the central sulcus. Moreover, it is a simple, flexible, and relatively inexpensive alternative to fMRI. ABBREVIATIONS: DCES, direct cortical electrical stimulation EEG, electroencephalography ESI, electric source imaging fMRI, functional magnetic resonance imaging GFP, global field power HD, high density MEG, magnetoencephalogram MNI, Montreal Neurological Institute SEP, somatosensory evoked potential SI, primary somatosensory cortex
Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/05000/Surgically_Relevant_Localization_of_the_Central.6.aspx
BACKGROUND: Contrast-enhanced ultrasound (CEUS) is a dynamic and continuous modality that offers a real-time, direct view of vascularization patterns and tissue resistance for many organs. Thanks to newer ultrasound contrast agents, CEUS has become a well-established, live-imaging technique in many contexts, but it has never been used extensively for brain imaging. The use of intraoperative CEUS (iCEUS) imaging in neurosurgery is limited. OBJECTIVE: To provide the first dynamic and continuous iCEUS evaluation of a variety of brain lesions. METHODS: We evaluated 71 patients undergoing iCEUS imaging in an off-label setting while being operated on for different brain lesions; iCEUS imaging was obtained before resecting each lesion, after intravenous injection of ultrasound contrast agent. A semiquantitative, offline interobserver analysis was performed to visualize each brain lesion and to characterize its perfusion features, correlated with histopathology. RESULTS: In all cases, the brain lesion was visualized intraoperatively with iCEUS. The afferent and efferent blood vessels were identified, allowing evaluation of the time and features of the arterial and venous phases and facilitating the surgical strategy. iCEUS also proved to be useful in highlighting the lesion compared with standard B-mode imaging and showing its perfusion patterns. No adverse effects were observed. CONCLUSION: Our study is the first large-scale implementation of iCEUS in neurosurgery as a dynamic and continuous real-time imaging tool for brain surgery and provides the first iCEUS characterization of different brain neoplasms. The ability of CEUS to highlight and characterize brain tumor will possibly provide the neurosurgeon with important information anytime during a surgical procedure. ABBREVIATIONS: CE, contrast enhancement CEUS, contrast-enhanced ultrasound EFSUMB, European Federation of Societies for Ultrasound in Medicine and Biology 5-ALA, 5-aminolevulinic acid iCEUS, intraoperative contrast-enhanced ultrasound UCA, ultrasound contrast agent; US, ultrasound
Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/05000/Intraoperative_Contrast_Enhanced_Ultrasound_for.9.aspx
A comparison of long-term survivors and short-term survivors with glioblastoma, subventricular zone involvement: a predictive factor for survival?
ObjectiveLong-term survival is rare in patients with glioblastoma (GBM). We set out to determine prognostic factors for patients with favorable and poor prognosis in regard of tumor localization to the subventricular zone (SZV). Methods: We reviewed the clinical records, pre-operative and post-operative MRI imaging of 50 LTS long-term survivors (LTS) (>3 years) and 50 short-term survivors (STS) (<1 year) with glioblastoma. These groups were matched for clinical characteristics being consistently associated with prolonged or shortened survival. All patients had undergone initial surgery or biopsy to confirm GBM diagnosis followed by radio- or chemoradiotherapy. Results: LTS had a median progression-free survival PFS of 25,4 months (2,3 - 97,8 months) and overall-survival (OS) of 55,9 months (38,2 - 98,6 months) compared to STS who had a significantly lower PFS of 4,2 months (1,4 - 10,2 months) and OS of 6,6 months (2,2 - 11,6 months) (each p < 0,001).Survival analysis showed that age under 60 years (p < 0,001), total resection status (p < 0,001) and tumor localization without SVZ contact (p = 0,05) were significant factors for prolonged survival. Conclusion: Our findings underline that survival in GBM patients is heterogeneous and influenced by multiple factors. This study confirms that tumor location with regard to the SVZ is significantly associated with survival.
Original Article: http://www.ro-journal.com/content/9/1/95
In patients with idiopathic intracranial hypertension and mild vision loss, the use of the drug acetazolamide, along with a low-sodium weight-reduction diet, resulted in modest improvement in...
Original Article: http://www.medicalnewstoday.com/releases/275780.php
Monday, April 21, 2014
O coração acelerou. Ela ainda não sabia agir como médica. Balbuciou um pedido de ajuda: eu quero meu assistente! Entrou no isolamento respiratório sem máscara e percebeu a paciente azul, encolhida, parada cardiorrespiratória?
O caminho parecia infinito, talvez uns doze metros.
Antes de chegar à sala de emergência, antes que chegasse qualquer ajuda, a criança ficou quentinha no colo dela, se mexeu, gemeu, fez barulhinhos estranhos com a boquinha e deu um sorriso social.
Como é lindo esse desenvolvimento neuropsicomotor!
Dr. Gerson Salvador
Médico infectologista Universidade de São Paulo
Disciplina de propedeutica médica Faculdade de Medicina da USP
Médico da divisão de Clínica Médica Hospital Universitário da USP
Outros Contos de Gerson Salvador:
The post Tratamento: abraço quentinho ( Contos de Gerson Salvador) appeared first on NEUROSURGERY BLOG.
Original Article: http://neurocirurgiabr.com/tratamento-abraco-quentinho-contos-de-gerson-salvador/?utm_source=rss&utm_medium=rss&utm_campaign=tratamento-abraco-quentinho-contos-de-gerson-salvador
OBJECTIVE: To review the literature on brain metastasis (BM) from ovarian cancer, and assess the frequency, anatomical, clinical and paraclinical information and factors associated with prognosis.BACKGROUND: Ovarian cancer is a rare cause of brain metastasis. Progressive neurologic disability often results and the prognosis is generally poor. A comprehensive review on this subject has not been published previously.DESIGN/METHODS:This systematic literature search used the Pubmed and Yale library search engine and included all relevant articles in English literature. A total of 66 publications were found, 57 of which were used representing 591 patients with BM from ovarian cancer.RESULTS: The median age of the patients was 54.3 years (range 20-81). A majority of patients (57.3%) had multiple brain lesions. The location of the lesion was cerebellar( 30%), frontal (20%), parietal (18%) and occipital (11% ) . Extracranial metastasis was present in 49.8% of cases involving liver (20.7%), lung(20.4%), lymph nodes (12.6%), bones (6.6%) and pelvic organs (4.3%). The most common symptoms were weakness (16%), seizures (11%), altered mentality (11%) visual disturbances (9%) and dizziness (8%). The interval from diagnosis of breast cancer to BM ranged from 0-133 months (median 24 ) and median survival was 8.2 months. Treatment included local radiation, surgical resection, stereotactic radiosurgery and medical therapy. Factors that significantly increased the survival were younger age at the time of ovarian cancer diagnosis and at the time of brain metastasis diagnosis, higher KPS score and multimodality treatment for the brain metastases.CONCLUSIONS:Ovarian cancer is a rare cause of brain metastasis. Development of brain metastasis among older patients and lower KPS score correlate with less favorable prognosis. The more prolonged survival after using multimodality treatment for brain metastasis is important information that can potentially impact the management of such brain metastasis in future.Study Supported by: no support
Disclosure: Dr. Pakneshan has nothing to disclose. Dr. Safarpour has nothing to disclose. Dr. Tavassoli has nothing to disclose. Dr. Jabbari has received research support from Allergan Inc., Merz Pharma, and Ipsen.
Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/P7.254?rss=1
Early retirement in cancer patients with or without comorbid mental health conditions: A prospective cohort study
The authors investigated whether cancer patients who have comorbid mental health disorders (MD) are at greater risk of early retirement compared with those who do not have MD.
Individuals ages 18 to 55 years from a consecutive sample of patients who were admitted for inpatient oncologic treatment were interviewed using structured clinical interviews to ascertain MD. The patients were followed for 15 months, and the date of early retirement was documented. Rates of early retirement per 100 person-years (py) in patients with and without MD were compared using multivariate Poisson regression models.
At baseline, 491 patients were interviewed, and 150 of those patients (30.6%) were diagnosed with MD. Forty-one patients began full early retirement during follow-up. In patients with MD, the incidence of early retirement was 9.3 per 100 py compared with 6.1 per 100 py in mentally healthy patients. The crude rate ratio (RR) was 1.5 (95% confidence interval [CI], 0.8-2.8). The effect of MD on early retirement was modified in part by income: in patients with low income, the adjusted RR was 11.7, whereas no effect was observed in higher income groups. Patients with depression were at greater risk of retirement when they had higher income (RR, 3.4; P = .05). The effects of anxiety (RR, 2.4; P = .05), adjustment disorders (RR, 1.7; P = .21), and alcohol dependence (RR, 1.8; P = .40) on early retirement were equal across income groups.
Mental health conditions are risk factors for early retirement in cancer patients, although this effect differs according to the type of disorder and the patient's income level. Cancer 2014. © 2014 American Cancer Society.
Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28716
Thursday, April 17, 2014
Survival and Neurocognitive Outcomes After Cranial or Craniospinal Irradiation Plus Total-Body Irradiation Before Stem Cell Transplantation in Pediatric Leukemia Patients With Central Nervous System Involvement
Purpose: To evaluate survival and neurocognitive outcomes in pediatric acute lymphoblastic leukemia (ALL) patients with central nervous system (CNS) involvement treated according to an institutional protocol with stem cell transplantation (SCT) and a component of craniospinal irradiation (CSI) in addition to total-body irradiation (TBI) as preparative regimen.Methods and Materials: Forty-one pediatric ALL patients underwent SCT with TBI and received additional cranial irradiation or CSI because of CNS leukemic involvement. Prospective neurocognitive testing was performed before and after SCT in a subset of patients. Cox regression models were used to determine associations of patient and disease characteristics and treatment methods with outcomes.Results: All patients received a cranial radiation boost; median total cranial dose was 24 Gy. Eighteen patients (44%) received a spinal boost; median total spinal dose for these patients was 18 Gy. Five-year disease-free survival (DFS) for all patients was 67%. Those receiving CSI had a trend toward superior DFS compared with those receiving a cranial boost alone (hazard ratio 3.23, P=.14). Patients with isolated CNS disease before SCT had a trend toward superior DFS (hazard ratio 3.64, P=.11, 5-year DFS 74%) compared with those with combined CNS and bone marrow disease (5-year DFS 59%). Neurocognitive testing revealed a mean post-SCT overall intelligence quotient of 103.7 at 4.4 years. Relative deficiencies in processing speed and/or working memory were noted in 6 of 16 tested patients (38%). Pre- and post-SCT neurocognitive testing revealed no significant change in intelligence quotient (mean increase +4.7 points). At a mean of 12.5 years after transplant, 11 of 13 long-term survivors (85%) had completed at least some coursework at a 2- or 4-year college.Conclusion: The addition of CSI to TBI before SCT in pediatric ALL with CNS involvement is effective and well-tolerated. Craniospinal irradiation plus TBI is worthy of further protocol investigation in children with CNS leukemia.
Original Article: http://www.redjournal.org/article/S0360-3016(14)00184-9/abstract?rss=yes