Brain shift and tissue deformation during surgery for intracranial lesions are the main actual limitations of neuro-navigation (NN), which currently relies mainly on preoperative imaging. Ultrasound ...(US), being a real-time imaging modality, is becoming progressively more widespread during neurosurgical procedures, but most neurosurgeons, trained on axial computed tomography (CT) and magnetic resonance imaging (MRI) slices, lack specific US training and have difficulties recognizing anatomic structures with the same confidence as in preoperative imaging. Therefore real-time intraoperative fusion imaging (FI) between preoperative imaging and intraoperative ultrasound (ioUS) for virtual navigation (VN) is highly desirable. We describe our procedure for real-time navigation during surgery for different cerebral lesions.
We performed fusion imaging with virtual navigation for patients undergoing surgery for brain lesion removal using an ultrasound-based real-time neuro-navigation system that fuses intraoperative cerebral ultrasound with preoperative MRI and simultaneously displays an MRI slice coplanar to an ioUS image.
58 patients underwent surgery at our institution for intracranial lesion removal with image guidance using a US system equipped with fusion imaging for neuro-navigation. In all cases the initial (external) registration error obtained by the corresponding anatomical landmark procedure was below 2 mm and the craniotomy was correctly placed. The transdural window gave satisfactory US image quality and the lesion was always detectable and measurable on both axes. Brain shift/deformation correction has been successfully employed in 42 cases to restore the co-registration during surgery. The accuracy of ioUS/MRI fusion/overlapping was confirmed intraoperatively under direct visualization of anatomic landmarks and the error was < 3 mm in all cases (100 %).
Neuro-navigation using intraoperative US integrated with preoperative MRI is reliable, accurate and user-friendly. Moreover, the adjustments are very helpful in correcting brain shift and tissue distortion. This integrated system allows true real-time feedback during surgery and is less expensive and time-consuming than other intraoperative imaging techniques, offering high precision and orientation.
Chiari type 1 Malformation (CM 1) is a structural defect consisting of a displacement of the cerebellar tonsils through the foramen magnum causing obstruction of cerebrospinal fluid (CSF) outflow. CM ...1 has a variety of presentation with headache being the most common symptom. The evaluation and treatment of headache related to CM 1 are often difficult, because the pain in the occipital-suboccipital region or headache that is of cough-type suggests symptomatic CM 1, but patients suffering from CM 1 can also report migraine or tension-type headache. In 2015 we started a collaborative project in which our group of neurologists, neurosurgeons and neuroradiologists contribute to create a Chiari Special Outpatient Service; this was set up to provide a multidisciplinary evaluation, treatment and follow-up of patient suffering from CM 1. 201 patients (58 males, 143 females) suffering from CM 1 were multidisciplinary evaluated. Headache characteristics, clinical features, and treatment of patients are discussed. Further progress in multidisciplinary care of headache and CM 1 should be performed to define guidelines.
•Investigations on the biology of meningiomas did not have wide application due to the lack of appropriate in vivo and in vitro model systems.•Different dose rates might affect the tumoricidal ...action.•The rate of apoptotic cells is higher than that of necrotic cells, for any dose and at any time-point of analysis.•The induction of apoptosis was independent of malignancy grade.•The carried out in vitro model can be considered suitable for meningioma cell culture..
Meningioma are the second most common brain tumors in adults and can cause significant morbidity and mortality. The scarcity of in vitro and in vivo models represents the major obstacle to understand the molecular basis of meningioma tumorigenesis. The main aim of this study was to assess a method for radiobiology of meningioma cells colture by means of well-known meningioma lines.
We carried out a protocol of cells culture for irradiation of meningioma cells. We used the immortalized cell lines IOMM-Lee and CH-157 to study their radiation-reponse by means of clonogenic assays and to evaluate their proliferation and apoptosis. We irradiated the cells with different total doses using two different linear accelerators.
We observed a more radiation resistance of the IOMM-Lee than the CH-157. Indeed, the cellular death of CH-157 was obtained at a very low dose irradiation. Moreover, we showed a dose-response effect due to the early and late apoptosis, in fact the rate of apoptotic cells is greater than that of the necrotic cells at any dose of irradiation and at any time of analysis.
There is not a standardized method for radiobiology of meningioma experiments.
Our method of cells culture appears suitable for radiosensitivity studies on meningioma. We can confirm that the response to radiotherapy depends not only on irradiation features, but also on tumor radiosensitivity.
BACKGROUND: Differentiating radionecrosis from local tumor recurrence is a major concern in the management of patients harbouring a cerebral tumor and treated with radiotherapy. In these cases, ...contrast-enhanced MRI usually shows ambiguous enhancement, while advanced imaging techniques (MRI spectroscopy, DWI, DTI, perfusion and PET) are still far from being validated as a reliable alternative to biopsy and histological assessment. CASE REPORT: We report the case of a patient who underwent cyberknife radiosurgery (21Gy) for a left rolandic brain metastasis from a lung carcinoma. Four months after radiotherapy, she started experiencing a progressive worsening of her upper right limb's strenght, with a neuroradiological evidence at serial MRIs of a progressive enhancing rolandic lesion. The patient underwent surgical removal of the lesion at our Neurosurgical Division: neurophysiological monitoring, standard B-mode UltraSonography and Contrast-Enhanced UltraSonography (CEUS) were performed intraoperatively to assist in tumor resection. Very interestingly, CEUS did not show any enhancement of the pathologic tissue, differently from what is expected for brain metastases, as reported in previous studies. Histopathological examination showed nervous tissue with post-treatment radiation effects (radionecrosis) with a few metastatic cells. DISCUSSION: Contrast-Enhanced UltraSound is progressively becoming a widespread tool in neurosurgery. Previous studies have described the contrastographic pattern of different cerebral lesions, including metastases. Surprisingly, despite a strong uptake of contrast agent at MRI, we observed that radionecrotic tissue did not show any enhancement at CEUS. For the first time we report the appearance of radionecrosis at CEUS; the lack of contrast enhancement could represent an important hallmark in differential diagnosis with neoplastic tissue. Moreover, in this report, the use of CEUS was confined to the intraoperative stage; however, new approaches to transcranial ultrasonography could extend the value of this technique to the bedside decision-making process. CONCLUSION: Of course, further investigation is required beyond this case report; nonetheless the findings here reported suggest that CEUS could become a promising tool in helping differentiating radionecrosis from tumor recurrence.
Aim Recent meta‐analyses and randomized clinical trials have concluded that mechanical bowel preparation (MBP) before elective colorectal surgery is not associated with a reduction of surgical site ...infection (SSI). The aim of this randomized clinical trial was to evaluate the impact of preoperative MBP for colon and rectal cancer surgery in comparison with a single glycerine enema.
Method Patients scheduled for radical colorectal resection for malignancy with primary anastomosis were randomized to preoperative MBP (4 l of polyethylene glycol) (group 1, 114 patients) plus a glycerine 5% enema (2 l) or a single glycerine 5% enema (2 l) (group 2, 115 patients). The postoperative incidence of SSI was recorded prospectively. Patients undergoing minimally invasive surgery (laparoscopy or robotic) accounted for 55 and 51 in groups 1 and 2 respectively.
Results In all, 229 patients were included in the study, 114 in group 1 and 115 in group 2. At least one SSI was reported in 16 (14.0%) group 1 and in 20 (17.8%) group 2 patients (P = 0.475). Perioperative mortality was nil. The incidence of SSI was comparable also in the 73 patients who had a low anterior resection (seven of 33 vs eight of 40, P = 1.000), and for the 106 patients who underwent a minimally invasive procedure (nine of 55 vs four of 51, P = 0.241).
Conclusion A single large‐volume glycerine enema is effective bowel preparation before colorectal resection whether performed by an open or minimally invasive technique.
BACKGROUND AND AIMS: Treatment of high grade gliomas is maximal safe resection followed by radiation and chemotherapy. When tumor is located in eloquent areas, the best practice would imply ...neurophysiological monitoring. To guarantee best mapping, some authors propose to perform routinely wide craniotomies to expose both the tumor and motor and language areas, whereas others prefer a smaller approach tailored on the lesion. In this study we present our data on motor performances in those patients harbouring a high grade glioma in motor areas operated on with a tailored craniotomy. METHODS: Data were collected for a series of 50 patients. An image-guided approach was performed including linear skin incision and craniotomy centred on the tumor. A 4-contacts-strip-electrode was positioned under the dura towards the motor strip to record electrocorticography, SSEP and motor evoked potentials. Brain mapping was performed stimulating the tumor and the surrounding cortex looking for negative and positive responses. Motor performances were evaluated with the BMRC 1-5 score. RESULTS: Adequate neurophysiological monitoring was achieved in all patients. Brain stimulation evoked muscular activity in 46% of patients: most cases had muscle response in hand or leg and fewer on the face muscles. Stimulation intensity ranged between 2 and 9mA. 21% of patients experienced worsening of their pre-existing deficits in the first week after surgery. At 3 month follow-up 50% of those patients had BMRC scores equal or better than before surgery. CONCLUSIONS: Our data suggest that fashioning a tailored craniotomy with IOM is safe and effective in preventing new motor deficits.
BACKGROUND: Contrast Enhanced Ultrasound (CEUS) is a dynamic and continuous modality that offers a real-time direct view of vascularization and flow distribution patterns of different organs and type ...of tumors. Nevertheless its intraoperative use for brain tumors visualization has been performed few times, and there are no guidelines on this regard. Furthermore a thorugh characterization of cerebral glioma had never been performed. OBJECTIVE: To describe the different patterns of enhancement of cerebral gliomas using the CEUS technique. METHODS: We performed intra-operative CEUS in an off-label setting in 69 patients undergoing surgery for cerebral glioma. An on-site and a post-procedural semi-quantitative analysis was performed for each case, evaluating CEUS parameters: timing, degree of CE and contrast distribution. RESULTS: Both low grade glioma (LGG) and high grade glioma (HGG) appear hyper-echoic relative to the adjacent brain parenchyma on B-mode US. Different contrast enhancement patterns were observed according to lesion characteristics: LGG showed a dotted or diffuse appearance with a slower and delayed arterial and venous phase compared with HGG, whereas HGG have a more nodular, non-homogeneous appearance, with faster and major contrast enhancement. CONCLUSION: Our study characterizes for the first time, human brain glioma with CEUS, giving us further insight regarding the biology of these tumors: being a dynamic and continuous modality it offers a real-time direct view of the tumor perfusion and of the afferent and efferent vessels. CEUS is a fast, safe, dynamic, real-time, economic tool that might be helpful during surgery in differentiating malignant and benign gliomas and refining the surgical strategy.
Abstract
BACKGROUND
NF2 related Schwannomatosis (NF2 -SCHW MIM # 101000) is a rare autosomal dominant familial cancer syndromes caused by mutations in the NF2 gene, mainly due to NF2 point mutations ...or intragenic deletions. NF2 patients. In 95% of patients, bilateral vestibular schwannomas are present, but NF2 -SCHW patients can develop other tumors and show ophthalmic and dermatological signs. Several studies established a genotype-phenotype correlations; the UK NF2 Reference Group proposed a Genetic Severity Score (GSS) based on the type and location of NF2 germline variant observed. Catasus et al. after validation of the score in a Spanish cohort suggested a new score based also on a functional assay of Merlin and its downstream pathways (FGSS). Recently Teranish et al. used targeted deep sequencing to predict functional prognosis in those patients.
MATERIAL AND
methods 70 patients (median age 40) were identified by scanning the electronic NF2-SCHW patient database at Fondazione IRCCS C. Besta, where the patients had undergone full neurological, ophthalmic, and audiological assessment. The median follow-up was 14 yrs. Clinical diagnosis was established following the Updated diagnostic criteria and nomenclature for neurofibromatosis type 2 and schwannomatosis”. All patients underwent NF2, SMARCB1 and LZTR1 mutational screening by NGS and MPLA analysis using blood DNA or the tissue of two different tumors when available.NF2 gene germline pathogenic were found in 45 subjects (64%), in most cases NF2 point mutations, but in 4 cases and whole gene deletions was observed and in 2 a ring NF2 chromosome was identified, in four cases a mosaic NF2-SCH was identified and in 21 (30%) patients no pathogenic variant was found. We assessed NF2-SCHW clinical phenotype in relation to the UK GSS and FGSS to validate their use as clinical and research tools, despite the significant phenotypic variability observed.
RESULTS
The disease outcome differed significantly depending both on clinicaland genetic factors. Among these factors,” Age of symptom onset” “Truncating”, “Mosaic”, and “whole gene deletion” had the most significant effects on functional disability. Conclusion GSS and FGSS showed significant correlation with several measures, allowing stratification of patients with severe and mild disease but not with moderate phenotype. Furthermore, we provided evidence on correlation between whole NF2 deletion extent and phenotype severity. Large cohorts of NF2-SCHW patients are needed to identify more accurate scores, becoming useful tools for patient management.
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