Intrinsic Tumors Research Articles

In Vivo Biodistribution of Engineered Lipid Microbubbles in Rodents.

Maximal resection of intrinsic brain tumors is a major prognostic factor for survival. Real-time intraoperative imaging tools, including ultrasound (US), are crucial for maximal resection of such tumors. Microbubbles (MBs) are clinically used in daily practice as a contrast agent for ultrasound and can be further developed to serve combined therapeutic and diagnostic purposes. To achieve this goal, we have developed novel MBs conjugated to specific ligands to receptors which are overexpressed in brain tumors. These MBs are designed to target a tumor tissue, visualize it, and deliver therapeutic molecules into it. The objective of this study was to assess the biodistribution of the test items: We used MBs labeled with indocyanine green (MB-ICG) for visualization and MBs conjugated to a cyclic molecule containing the tripeptide Arg-Gly-Asp (RGD) labeled with ICG (MB-RGD-ICG) to target brain tumor integrins as the therapeutic tools. Male Sprague Dawley rats received a single dose of each MB preparation. The identification of the MB in various organs was monitored by fluorescence microscopy in anesthetized animals as well as real-time US for brain imaging. Equally sized control groups under identical conditions were used in this study. One control group was used to establish fluorescence background conditions (ICG), and two control groups were used to test autofluorescence from the test items (MBs and MB-RGD). ICG with or without MBs (naked or RGD-modified) was detected in the brain vasculature and also in other organs. The pattern, duration, and intensity of the fluorescence signal could not be differentiated between animals treated with ICG alone and animals treated with microbubbles MBs-ICG or MBs-RGD-ICG. Following MB injection, either naked or combined with RGD, there was a sharp rise in the Doppler signal within seconds of injection in the brain. The signal was mainly located at the choroid plexus, septum pellucidum, and the meninges of the brain. The signal subsided within a few minutes. Injection of saline or ICG alone to respective animals did not result in a similar raised signal. Following a single intravenous administration of MB-ICG and MB-RGD-ICG to rats, the MBs were found to be effectively present in the brain.

Clinical significance of the histological and molecular characteristics of ependymal tumors: a single institution case series from China

BackgroundEpendymal tumors are pathologically defined intrinsic neoplasms originating in the intracranial compartments or the spinal cord that affect both children and adults. The recently integrated classification of ependymomas based on both histological and molecular characteristics is capable of subgrouping patients with various prognoses. However, the application of histological and molecular markers in Chinese patients with ependymomas has rarely been reported. We aimed to demonstrate the significance of histological characteristics, the v-relavian reticuloendotheliosis viral oncogene homolog A (RELA) fusions and other molecular features in ependymal tumors.MethodsWe reviewed the histological characteristics of ependymal tumors using conventional pathological slides and investigate the RELA fusions and Cylclin D1 (CCND1) amplification by Fluorescence in situ hybridization (FISH) and trimethylation of histone 3 lysine 27 (H3K27me3) expression by immunohistochemistry (IHC) methods. SPSS software was used to analyze the data.ResultsWe demonstrated that hypercellularity, atypia, microvascular proliferation, necrosis, mitosis, and an elevated Ki-67 index, were tightly associated with an advanced tumor grade. Tumor location, necrosis, mitosis and the Ki-67 index were related to the survival of the ependymomas, but Ki67 was the only independent prognostic factor. Additionally, RELA fusions, mostly presented in pediatric grade III intracranial ependymomas, indicated decreased survival times of patients, and closely related to the patients’ age, tumor grade, cellularity, cellular atypia, necrosis and Ki67 index in the intracranial ependymal tumors, whereas reduction of H3K27me3 predicted the worse prognosis in ependymal tumors.ConclusionsHistological and molecular features facilitate tumor grading and prognostic predictions for ependymal tumors in Chinese patients.

In Reply to the Letter to the Editor Regarding “Hypnosis-Aided Awake Surgery for the Management of Intrinsic Brain Tumors versus Standard Awake-Asleep-Awake Protocol: A Preliminary, Promising Experience”

In Reply to the Letter to the Editor Regarding “Hypnosis-Aided Awake Surgery for the Management of Intrinsic Brain Tumors versus Standard Awake-Asleep-Awake Protocol: A Preliminary, Promising Experience”

Integrated phenotype-genotype approach in diagnosis and classification of common central nervous system tumours.

After nearly a century of histological classification of central nervous system tumours, the 2016 revised WHO classification has incorporated molecular features with clinical and prognostic relevance into brain tumour classification. In this review, we discuss the latest integrated phenotype-genotype approach to the most common intrinsic brain tumours in adults and children. The key genetic mutations and abnormalities, essential to the definition of these tumours, in line with the current WHO classification are described. Practical dilemmas, including 'difficult' tumours, the utility of DNA methylation classifiers and relevant recent advances post-WHO 2016 consensus are also discussed.

WP1-21 Maximum safe resection of large medial temporal intrinsic tumours: does the outcome justify the risk?

ObjectivesTo analyse on the long-term outcomes in patients undergoing maximum safe resection (MSR) for large intrinsic temporal tumours.DesignCase seriesSubjectsAll patients undergoing MSR of large medial temporal intrinsic tumours between May 2006 and February 2012 at a tertiary neurosurgical centre with a minimum follow up of 6 years.MethodsRetrospective review of hospital records.ResultsFifty-one patients underwent MSR (28 male, 23 female); age range 20–80 years (mean age 55.3). There was no difference in laterality, although dysphasia was a feature in 32% of left-sided lesions. Presenting features in general included seizures (46%), headaches (27%), hemiparesis (12%) and visual field defects (6%). Surgery was generally well tolerated (median post-operative Karnofsky score 92.5). No patients developed new dysphasia or weakness, but there was transient worsening of existing hemiparesis (n=4) and dysphasia (n=2). Other complications included CSF leak/pseudomeningocoele (n=2), oculomotor palsy (n=1) and wound infection (n=1). Histopathological casemix was GBM (50%), WHO 3 gliomas (14%), WHO 2 gliomas (10%) and metastases (4%). In total, 57% of patients received radiotherapy and 35% received chemotherapy. Survival correlated with pathology; in glioblastoma patients it ranged from 2–19 months (mean 10.4 months). Survival in grade 3 tumours ranged from 10–38 months (mean 24.4 months). 60% of patients with Grade 2 tumours are surviving symptom free with no histological upscale at 8–10 years follow-up. No patient required a second debulking procedure.ConclusionsMSR did not result in survival benefit in glioblastoma. MSR is justified in lesions with pre-operative radiological features of Grade 2 glioma.

Letter to the Editor Regarding “Hypnosis-Aided Awake Surgery for the Management of Intrinsic Brain Tumors versus Standard Awake-Asleep-Awake Protocol: A Preliminary, Promising Experience”

Hypnosis could extend the time of Intraoperative Neuropsychological Testing and Brain Mapping in Awake Surgery. A clinical validation for the Hypnosis aided AS (HAs) is still ongoing and further evidences are required. The objective of the present study is to compare two homogeneous cohorts of patients undergoing AS, the first with the aid of the hypnosis and the second according to a standard AS (SAs) protocols. The clinical, radiological and surgical data of two comparable procedures cohorts were retrospectively examined for the present study. All surgeries in Group A were performed with a HAs protocol. Procedures belonging to Group B were performed with a SAs protocol. Endpoints: to compare 1. Incidence of complications in the immediate postoperative period, 2. Clinical and neurological status in the immediate postoperative period and 30 days after surgery, 3. Duration of surgical interventions, 4. Extent of Resection (EOR). The final cohort is composed of 15 procedures; 6 belonging to Group A and 9 to Group B. The different methods outline statistically comparable results from the clinical (Neurological outcomes) both in the postoperative period and one month after surgery and from the surgical point of view (comparable EOR). The incidence of complications is comparable either. The duration of the procedures was significantly longer in HAs group. Hypnosis is a promising approach to increasing the duration of intraoperative “testability” of patients at the price of a longer operative time. A specific professional is needed to induce hypnosis in the difficult intraoperative setting.

Somatotopic organization of corticospinal/corticobulbar motor tracts in controls and patients with tumours: A combined fMRI-DTI study.

ObjectivesTo investigate the relative somatotopic organization of the motor corticospinal/corticobulbar foot, hand, lip and tongue fascicles by combining fMRI with DTI and to examine the influence of subjacent intrinsic tumours on these fascicles.MethodsThe study was approved by the local ethics committee. Seven male and three female volunteers (median age: 35 years) and one female and eight male patients with brain tumours (median age: 37 years) were scanned on a 1.5-T MRI scanner. fMRI data, analysed using SPM5, identified the motor task-driven fMRI grey matter activations of the hand, foot, lips and tongue as seed regions for probabilistic tractography. The relationship between the components of the CST was assessed and the distances between them were measured. A statistical comparison was performed comparing these distances in the group of healthy hemispheres with those of the group of non-affected hemispheres and healthy hemispheres.ResultsHand fascicles were identified in all subjects (38/38, 100%), followed by foot (32/38, 84%), lip (31/38, 81%) and tongue fascicles (28/38, 74%). At superior levels, the hand fascicles were anterolateral to the foot fascicles in 77–93% of healthy hemispheres (HH), in 50–71% of non-affected patients' hemispheres (pH) and in 67–89% of affected PH. At inferior levels, the hand fascicles were either anteromedial in 46–45% of HH or anterior in 75% of non-affected PH and in 67–83% of affected PH. Tongue and lip fascicles overlapped in 25–45% of HH, in 10–20% of non-affected PH and in 15–25% of affected PH. No significant difference was found between the group of affected hemispheres and that of healthy and non-affected hemispheres.ConclusionThe somatotopy of the hand fascicles in relation to the foot fascicles was anterolateral in patients and volunteers at superior levels but anteromedial in volunteers and mostly anterior in patients at inferior levels. The lip and tongue fascicles generally overlapped. Intracranial tumours displaced the motor fascicles without affecting their relative somatotopy.

Personality Traits in Patients with Neuroepithelial Tumors \u2013 A Prospective Study

Aim of this study was to analyze personality traits in patients with neuroepithelial brain tumors. Personality alteration is a common feature in brain tumor patients, but not much is known about associations between specific personality changes and brain tumors. We assessed potential factors influencing personality such as tumor location, tumor grade and tumor volume. Mini-mental state examination (MMSE), Beck’s Depression Inventory II (BDI-II), and the NEO Five-Factor Inventory (NEO-FFI) for the five factors of personality were acquired. Patients had lower scores regarding the factor openness and higher scores regarding the BDI-II compared to the norm population. No significant influencing factors (tumor entity, location) were found regarding personality traits. Neuroticism was associated with depression, whereas extraversion showed an opposed association. Patients with intrinsic brain tumors have differences in personality traits compared to the control population, with an emphasis on the factor openness. No significant confounding factors like tumor grade, entity, or location were found for personality traits.

Transcortical approach to lateral ventricular central neurocytomas: a case series and review of the literature

BackgroundCentral neurocytomas (CN) are relatively rare intrinsic brain tumors of an ectodermal origin that usually arise in the lateral ventricles close to the foramen of Monro and septum pellucidum. Surgical gross total resection is now considered the gold standard treatment for CNs. The choice of the most convenient approach (transcortical or transcallosal) remains controversial. This study was designed to assess the efficiency and safety of gross total resection using the transcortical approach in the treatment of patients with lateral ventricular central neurocytomas.Patients and methodsThis is a retrospective observational study conducted on eight patients who underwent surgical treatment for a lateral ventricular tumor that had a postoperative histopathological diagnosis of central neurocytoma via the transcortical approach. The included patients were operated upon at Ain Shams University Hospitals between October 2012 and August 2017. The postoperative clinical data were analyzed for the assessment of changes in the initial data and for any procedure-related complications.ResultsThe current study included two males and six females (a total of eight patients) with a mean age of 24.Seventy-five years ranging from 12 to 34 years. The main presenting symptom was a persistent headache. The mean duration of symptoms prior to diagnosis was 2.625 months ranging from 1 to 6 months. Preoperatively, five patients had hydrocephalic changes due to obstruction of the cerebrospinal fluid pathways; however, none of them had a cerebrospinal fluid diversion prior to direct tumor attack. Gross total resection (radiologically proven) was achieved in six (75%) patients. One patient had an approach-related visual field defect and one patient had postoperative epilepsy that required long-term use of antiepileptic therapy. The mean postoperative follow-up duration was 26 months ranging from 6 to 60 months. Regarding functional outcome, by the end of the third postoperative month, seven patients could achieve a score of 5 according to the Glasgow Outcome Scale.ConclusionThe transcortical approach provides a safe and effective corridor for the achievement of gross total resection of lateral ventricular central neurocytomas with the main limitation of being less effective regarding the degree of resection in cases of bilateral tumors.

Genome-wide expression profiling of glioblastoma using a large combined cohort

Glioblastomas (GBMs), are the most common intrinsic brain tumors in adults and are almost universally fatal. Despite the progresses made in surgery, chemotherapy, and radiation over the past decades, the prognosis of patients with GBM remained poor and the average survival time of patients suffering from GBM was still short. Discovering robust gene signatures toward better understanding of the complex molecular mechanisms leading to GBM is an important prerequisite to the identification of novel and more effective therapeutic strategies. Herein, a comprehensive study of genome-scale mRNA expression data by combining GBM and normal tissue samples from 48 studies was performed. The 147 robust gene signatures were identified to be significantly differential expression between GBM and normal samples, among which 100 (68%) genes were reported to be closely associated with GBM in previous publications. Moreover, function annotation analysis based on these 147 robust DEGs showed certain deregulated gene expression programs (e.g., cell cycle, immune response and p53 signaling pathway) were associated with GBM development, and PPI network analysis revealed three novel hub genes (RFC4, ZWINT and TYMS) play important role in GBM development. Furthermore, survival analysis based on the TCGA GBM data demonstrated 38 robust DEGs significantly affect the prognosis of GBM in OS (p < 0.05). These findings provided new insights into molecular mechanisms underlying GBM and suggested the 38 robust DEGs could be potential targets for the diagnosis and treatment.

THREE-DIMENSIONAL MULTICOLOUR LINEAGE TRACING OF INTRINSIC BRAIN TUMOUR MODELS

Multicolour lineage tracing has provided striking demonstrations of stem cell tissue maintenance and development. Our objective is to gain insight into histogenesis, clonal expansion and migration of intrinsic brain tumours. We aim to investigate intratumoral heterogeneity through the identification of differently labelled clones but also the impact of different genetic lesions on tumour propagation. Combining multicolour tracing with advanced tissue clearing and image analysis we will interrogate these parameters in three-dimensions (3D). Rosa26-Confetti and Brainbow mice were crossed into lines containing different combinations of floxed tumour suppressor alleles. In this model, recombination is targeted to neural stem cells by intraventricular injection of a retrovirus expressing Cre recombinase and PDGFβ. Using this method multicolour tumours with histological hallmarks of human gliomas can be induced within 4 – 6 weeks. This rapid induction model will be used for the development of the methodology, including 3D image acquisition and image processing. Traditional sectioning and passive clarity (PACT) are used to prepare tissue for 2D and 3D imaging. This model of primary murine brain tumours will be complemented by a xenogafting approach, using genetically characterised multiple human glioma initiating cell lines, genetically labelled with lineage tracing vectors. Tumour formation will be assessed with methods established using the retroviral model. Retroviral injections induce tumour formation currently at an efficiency of ~50%. On frozen sections multiple colours are visible within all tumours representing the identification of different genetic clones. Tissue clearing has been successfully employed to image 3D volumes. The presence of differentially labelled cells in our tumour model opens the potential for assessing clonal expansion and tumour heterogeneity.

Surgical Management of Intrinsic Tumors of the Facial Nerve

Intrinsic tumors of the facial nerve are a rare entity. Dealing with this subset of tumors is challenging both in terms of decision making and surgical intervention. To review the outcomes of surgical management of facial nerve tumors and cable nerve graft interpositioning. A retrospective analysis was performed at a referral center for skull base pathology. One hundred fifteen patients who were surgically treated for facial nerve tumors were included. In case of nerve interruption during surgery, the cable nerve interpositioning technique was employed wherein the facial nerve palsy lasted for less than 1-yr duration. In cases of facial nerve palsy lasting for greater than 1 yr, the nerve was restituted by a hypoglossal facial coaptation. Various degrees of progressive paralysis were seen in 84 (73%) cases. Sixty nine (60%) of the tumors involved multiple segments of the facial nerve. Sixty-two (53.9%) tumors involved the geniculate ganglion. Seventy four (64.3%) of the cases were schwannomas. Hearing preservation surgeries were performed in 60 (52.1%). Ninety one (79.1%) of the nerves that were sectioned in association with tumor removal were restituted primarily by interposition cable grafting. The mean preoperative House-Brackmann grading of the facial nerve was 3.6. The mean immediate postoperative grading was 5.4, which recovered to a mean of 3.4 at the end of 1 yr. In patients with good facial nerve function (House-Brackmann grade I-II), a wait-and-scan approach is recommended. In cases where the facial nerve has been interrupted during surgery, the cable nerve interpositioning technique is a convenient and well-accepted procedure for immediate restitution of the nerve.

Intraoperative Spinal Navigation for the Removal of Intradural Tumors: Technical Notes.

In recent years, spinal surgery has incorporated the many advantages of navigation techniques to facilitate the placement of pedicle screws during osteosynthesis, mainly for degenerative diseases. However, spinal intradural tumors are not clearly visible by intraoperative fluoroscopy or computed tomography scans, thereby making navigation necessary. To evaluate the use of spinal navigation for the removal of intradural and spinal cord tumors using spinal magnetic resonance imaging (MRI) merged with intraoperative 3-dimensional (3-D) fluoro images. After fixing the patient reference frame on the spinous process, the 3-D fluoro images were obtained in the surgical room. Using this image as the reference, the preoperative volumetric MRI images and intraoperative 3-D fluoro images were merged using automated software or manually. From January to July 2016, we performed 10 navigated procedures for intradural spinal tumors by merging MRI and 3-D fluoro images. Nine patients had an intradural extramedullary tumor, 6 had neurinomas, and 3 had meningiomas; 1 patient had an intramedullary spinal cord metastasis. The surgically demonstrated benefits of spinal navigation for the removal of intradural tumors include the decreased risk of surgery at the wrong spinal level, a minimal length of skin incision and muscle strip, and a reduction in bone removal extension. Furthermore, this technique offers the advantage of opening the dura as much as is necessary and, in the case of intrinsic spinal cord tumors, it allows the tumor to be centered. Otherwise, this would not be visible, thus enabling the precise level and the posterior midline sulcus to be determined when performing a mielotomy.

The Treatment of Gliomas in Adulthood.

Gliomas are the most common intrinsic tumors of the brain, with an incidence of 6 per 100 000 persons per year. Recent years have seen marked changes in the diagnosis and treatment of gliomas, with molecular parameters now being an integral part of the diagnostic evaluation. This review is based on pertinent articles retrieved by a selective search in PubMed, with special attention to the new WHO glioma classification. The classification of gliomas on the basis of additional molecular parameters enables more accurate prognostication and serves as a basis for therapeutic decision-making and treatment according to precisely specified algorithms. PET scanning with 18F-fluoroethyl tyrosine and 11C-methionine for the measurement of metabolic activity in gliomas has further refined the diagnostic evaluation. The median overall survival of patients with glioblastoma who have undergone resection of all tumor tissue with a disrupted blood-brain barrier (i.e., all contrast-enhancing tumor tissue) has been prolonged to up to 20 months. The 5-year survival of patients with WHO grade II gliomas is now as high as 97% after near-total resection. The surgical resection of all contrast-enhancing tumor tissue and subsequent radiotherapy and chemotherapy remain the key elements of treatment. New surgical strategies and new methods of planning radiotherapy have made these techniques safer and more effective. The percutaneous application of tumor-treating fields is a new therapeutic option that has gained a degree of acceptance. Accompanying measures such as psycho-oncology and palliative care are very important for patients and should be considered mandatory. The consistent application of the existing multimodal treatment options for glioma has led in recent years to improved survival. Areas of important current and future scientific activity include immunotherapy and targeted and combined chemotherapy, as well as altered neurocognition, modern approaches to palliative care, and complementary therapies.

WHO 2016 Classification of gliomas.

Gliomas are the most frequent intrinsic tumours of the central nervous system and encompass two principle subgroups: diffuse gliomas and gliomas showing a more circumscribed growth pattern ('nondiffuse gliomas'). In the revised fourth edition of the WHO Classification of CNS tumours published in 2016, classification of especially diffuse gliomas has fundamentally changed: for the first time, a large subset of these tumours is now defined based on presence/absence of IDH mutation and 1p/19q codeletion. Following this approach, the diagnosis of (anaplastic) oligoastrocytoma can be expected to largely disappear. Furthermore, in the WHO 2016 Classification gliomatosis cerebri is not an entity anymore but is now considered as a growth pattern. The most important changes in the very diverse group of 'nondiffuse' gliomas and neuronal-glial tumours are the introduction of anaplastic pleomorphic xanthoastrocytoma, of diffuse leptomeningeal glioneuronal tumour and of RELA fusion-positive ependymoma as entities. In the last part of this review, after very briefly touching upon classification of neuronal, choroid plexus and pineal region tumours, some practical implications and challenges associated with the WHO 2016 Classification of gliomas are discussed.

Factors predicting favourable outcome for recovery of peri-operative neurological deficits in cranio-spinal intrinsic tumours: A single centre experience

To review demographic, pathological and surgical factors that minimise long-term neurological deficits in cranio-spinal intrinsic tumours. DESIGN Retrospective analysis. SUBJECTS 33 patients with cranio-spinal intrinsic tumours located in eloquent areas treated at a single centre over a period of five years. From a cohort of 780 neuro-oncology patients, 33 (24 cranial and9 spinal) patients harbouring brain or spinal cord intrinsic tumours in eloquent areas were identified who had significant perioperative neurological deficits but near-complete recovery of the deficits within three months of surgical intervention. In addition to demographic data, technical factors related to surgery and tumour pathology were analysed to determine which factors may influence recovery of deficits. Surgical technical factors were studied for feasibility of gross macroscopic resection. All patients who recovered from their deficits were less than 63 years of age, all except three patients had pathology ranging Gr I-III. In three patients, it wasGr IV. All except three had radical resection of tumour as proven by contrastimaging in the immediate post-operative period and at three months. Age, tumourgrade &amp; extent of surgical resection appeared to be the factors influencingrecovery of neurological deficits. Younger age, lower grade of tumour and grosstotal excision of the tumour at surgery appeared to be favourable factors forrecovery of peri-operative deficits. In a retrospectiveanalysis, younger age, lower grade of tumour and radical surgical excisionappear to be factors predicting favourable outcome for recovery ofperioperative neurological deficits in patients with cranio-spinal intrinsictumours.

Minimising length of stay following brain tumour surgery: benefits to patients, providers and the NHS

Length of stay (LOS) following surgery is highly variable between providers. Techniques can be employed to minimise LOS to the benefit of patients, providers and the NHS. Data is now available to benchmark and to provide an opportunity for aspiring to best practice. We introduced measures to reduce LOS. We explored data from Hospital Episode Statistics published for providers by the National Neurosurgical Audit Program (NNAP) and Get It Right First Time (GIRFT) in 2016/7. In our unit the most frequent pathway for surgery for brain tumours was as elective admissions: 75% of patients with high-grade gliomas; 81% with metastases and 85% with benign tumours were admitted for surgery in an elective manner. Median LOS for intrinsic tumours was 1 day (versus national 6 days, NNAP). Mean LOS (vs national) was 2.5 (6.4) days for HGG; 2.9 (6.5) days for metastases; 4.7 (9.2) days for benign tumours; all the lowest in UK. Despite this, readmission rates were within the normal range at 20% (18%) for HGG; 21% (20%) for metastases;15% (14%) for benign tumours. Re-operation rates over 1 year were also in normal range: 11% (12%) HGG; 9% (11%) for metastases; 12% (11%) for benign tumours. Elective cranial mortality was 0.87 (0.94). Adopting several strategies to minimise LOS has proven very successful and resulted in excellent benchmarked data. This has proven popular with patients, has improved efficiency at our trust, reduced cost, cancellations and waiting times and has more widespread implications across the NHS. Short stay neurosurgery for brain tumours is safe and does not significantly increase readmission, re-operation or mortality rates.Techniques employed to deliver this will be discussed. All providers of neurosurgery should use national data to improve practice in the future, including engaging with peers and utilising strategies proven to be successful elsewhere.

Preoperative functional magnetic resonance imaging in patients undergoing surgery for tumors around left (dominant) inferior frontal gyrus region.

Background:Preoperative functional magnetic resonance imaging (fMRI) helps to preserve neurological function and ensure maximal tumor tissue excision. We studied the lateralization and localization of speech centers in select cases of tumors around the left (dominant) inferior frontal gyrus (IFG).Methods:Twenty-three right-handed patients, harboring tumors involving the left (dominant) IFG or causing mass effect or edema extending onto the left IFG, were recruited over 17 months. Preoperatively, all patients underwent language and speech assessment followed by MRI and fMRI with paradigm (picture naming). Normative data for language fMRI was taken from the institute's imaging data bank.Results:The study included 23 patients [mean age: 38.9 (±11.9) years; M: F = 16:7; 9 – normal speech, 14 – abnormal speech]. Group analysis of controls showed significant activation in the region of interest (ROI) – left Brodmann's areas (BAs) 44,45. Group analysis of patients with normal speech showed no activation in the left BAs 44,45; however, activation was noted in the immediate adjacent areas, left BAs 13,47 and contralateral prefrontal cortex. Group analysis of patients with impaired speech showed no activation in BAs 44,45 or in the immediate adjacent areas.Conclusions:Neuroplasticity in the brain may enable functional language areas to shift to adjoining or distant regions in the brain when the primary areas are involved by intrinsic tumors. This phenomenon is more likely in slow-growing compared to fast-growing tumors. Preoperative language fMRI may help us in identifying and protecting these areas during surgery.

One burr-hole craniotomy: Enough lateral approach to foramen magnum in helsinki neurosurgery.

Background:In this video-abstract, we present a one burr-hole craniotomy for the enough lateral approach (ELA) to the foramen magnum developed in Helsinki Neurosurgery, a less invasive variant of the classical far lateral approach. ELA does not require the resection of the occipital condyle nor the exposure of the extracranial/intraosseal course of the lower cranial nerves. The vertebral artery is not transposed and the sigmoid sinus is not skeletonized. ELA allow us to access lesions that are close to the level of the foramen magnum (less than 10 mm). In this regard, low-lying vertebral aneurysms, foramen magnum meningiomas, or low brainstem cavernomas and intrinsic tumors are our common indications for this approach.Case Description:The patient with a foramen magnum meningioma is placed in park bench position with slight backward rotation and elevation of the upper body to maintain the head around 20 cm above the cardiac level. The correct positioning of the head requires slight forward flexion, contralateral rotation, and contralateral tilt to open the angle with the upper shoulder. Under microscopic vision, a straight incision is made behind the mastoid process running between the zygomatic line and 4–5 cm below to the level of the mastoid process. The suboccipital muscles are split with electrocoagulation while the vertebral artery is recognized by digital palpation. Blunt dissection with cotton balls is performed at the occipitocervical junction. Strong retraction maintains a clean space for the craniotomy. A single burr-hole is placed at the posterior border of the craniotomy, and a small 3 × 4 cm craniotomy is performed over the anterior border of the intradural origin of the vertebral artery. The anterior lateral border of the craniotomy is reached under visual control using a diamond drill. In this regard, one more burr hole opposite to the first one would be a tiring and difficult procedure deep inside the lateral margin of the craniotomy. The dura is opened based on the sigmoid sinus and cerebrospinal fluid is released. Finally, under high microscopic magnification, the lesion is properly removed.Conclusion:The described procedure may represent a more efficient lateral approach to the foramen magnum.Videolink:http://surgicalneurologyint.com/videogallery/enough-lateral-approach-for-the-foramen-magnum/

One burr-hole craniotomy: Supracerebellar infratentorial paramedian approach in Helsinki Neurosurgery.

Background:In this video abstract, we present a one burr-hole craniotomy for the standard supracerebellar infratentorial (SCIT) paramedian approach developed in Helsinki Neurosurgery for the microsurgical management of pineal region lesions, tentorial meningiomas, as well as arteriovenous malformations, aneurysms, and intrinsic tumors of the superior surface of the cerebellum. In this regard, the use of praying sitting position in Helsinki Neurosurgery, which is a more ergonomic variant of the classic sitting position, offers several advantages such as lower intracranial pressure, good venous outflow, gravitational retraction, and straight anatomical orientation.Case Description:The patient is placed in sitting praying position. A straight single-layer incision is made 2–3 cm lateral from the midline, starting about 1 inch cranial from the inion and extending caudally toward the foramen magnum. Curved retractors provide a wide clean space for craniotomy. A burr-hole is made above the transverse sinus, which may be identified by its anatomic relation with superior muscle insertion line on the occipital bone. After detachment of the dura with blunt dissectors, a craniotomy around the transverse sinus and continuing to the confluens sinuum is performed to expose about 3 cm of the dura below the level of the transverse sinus. In case of an adherent dura particularly present in elderly patients, a long blunt flexible dissector (Yasargil dissector) is used for the detachment of the bone from the dura. A few drill holes are made for tack-up sutures. Finally, a hemostatic agent covers the transverse sinus and a sinus-based dura opening is performed under the microscope.Conclusion:One burr-hole craniotomy for an SCIT paramedian approach may represent the more efficient procedure for approaching the pineal region, inferior surface of the tentorium, and the superior surface of the cerebellum as well.Videolink:http://surgicalneurologyint.com/videogallery/paramedian-subocciptal-approach