Treatment of severe, disabling spasticity with continuous intrathecal baclofen therapy following acquired brain injury: the experience of a tertiary institution in Singapore

<p><b>INTRODUCTION</b>Intrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months.</p><p><b>METHODS</b>A retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications.</p><p><b>RESULTS</b>From 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day.</p><p><b>CONCLUSION</b>Our preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.</p>

An unusual presentation of primary malignant B-cell-type dural lymphoma

Primary malignant B-cell-type dural lymphoma is a rare subtype of primary central nervous system lymphoma (PCNSL). We herein report an unusual case of diffuse B-cell lymphoma that presents as a chronic subdural haematoma without extracranial involvement. The notable aspects of this case include the patient's immunocompetence, a short clinical history of symptom onset, rapid neurological deterioration and a fi nal diagnosis of high-grade PCNSL. This case highlights the challenges neurosurgeons face, especially in the emergency setting, when the disease manifests in varied presentations.

Tension pneumocephalus

Tension pneumocephalus is a rare but treatable neurosurgical emergency. Prompt and accurate diagnosis of tension pneumocephalus requires a high index of clinical suspicion corroborated by imaging. Herein, we describe a case of extensive tension pneumocephalus in a patient who had undergone transsphenoidal surgery and repair of the sellar floor, with subsequent successful decompression. This case report discusses the pertinent imaging features of tension pneumocephalus and its management.

Multivoxel MR spectroscopic imaging--distinguishing intracranial tumours from non-neoplastic disease

<p><b>INTRODUCTION</b>Multi-voxel MR spectroscopic imaging (MRSI) provides chemical metabolite information that can supplement conventional MR imaging in the study of intracranial neoplasia. Our purpose was to use a robust semi-automated spectroscopic analysis to distinguish intracranial tumours from non-neoplastic disease.</p><p><b>MATERIALS AND METHODS</b>Twenty intracranial tumours and 15 patients with non-neoplastic disease confirmed on histological examination or serial neuroimaging were studied with 2-dimensional MRSI using point-resolved spectroscopic (PRESS) imaging localisation. Using semi-automated post-processing software, spectra were analysed for peak heights of choline (Cho), creatine (Cr), N-acetyl aspartate (NAA), lactate (Lac) and lipid (Lip). Normalised Cho (nCho) ratios, computed by dividing maximum Cho in the lesion by the normal-appearing brain, were compared between intracranial tumours and non-neoplastic disease.</p><p><b>RESULTS</b>Meningiomas displayed homogeneously elevated Cho. Malignant tumours, especially large glioblastoma multiforme, displayed inhomogeneity of metabolites within the tumour. All tumours had elevation of nCho >1 (mean 1.91 +/- 0.65), and non-neoplastic diseases had tumour nCho <1 (mean 0.91 +/- 0.46), which was significantly lower (P <0.05). Two patients with non-neoplastic lesions, one with subacute cerebral infarction and the other with cryptococcoma, had elevated Cho compared to normal tissue (false positive rate 13%).</p><p><b>CONCLUSION</b>Using semi-automated MRSI method, a simplified normalised Cho algorithm provides a method to distinguish intracranial tumours from non-neoplastic disease.</p>

Awake craniotomy under local anaesthesia and monitored conscious sedation for resection of brain tumours in eloquent cortex--outcomes in 20 patients

<p><b>INTRODUCTION</b>Resection or even biopsy of an intra-axial mass lesion in close relationship to eloquent cortex carries a major risk of neurological deficit. We review the safety and effectiveness of craniotomy under local anaesthesia and monitored conscious sedation for resection of mass lesions involving eloquent cortex.</p><p><b>MATERIALS AND METHODS</b>We performed a 3-year retrospective review of patients who underwent awake craniotomy under local anaesthesia at the National Neuroscience Institute, Singapore. All patients had tumours in close proximity to eloquent cortex, including speech areas in the dominant hemisphere as well as primary sensory and motor cortex in either hemisphere. Brain mapping was performed by direct cortical stimulation using the Ojemann stimulator to identify a safe corridor for surgical approach to the tumour. Intraoperative physiological monitoring was carried out by assessment of speech, motor and sensory functions during the process of surgical resection. All resections were evaluated and verified by postoperative imaging and reviewed by an independent assessor. Postoperative complications and neurological deficits, as well as extent of tumour resection, were evaluated.</p><p><b>RESULTS</b>A total of 20 patients underwent stereotactic resection over a period of 3 years from July 2003 to August 2006. There were 7 male patients and 13 female patients, with a mean age of 39.8 years. The average length of stay was 5.5 days. There were no major anaesthetic complications and no perioperative deaths. Postoperative neurological deficits were seen in 6 patients (30%) and this was permanent in only 1 patient (5%). The degree of cytoreduction achieved was greater than 90% in 58% of patients and a further 21% had greater than 80% cytoreduction.</p><p><b>CONCLUSION</b>Tumour surgery with conscious sedation in combination with frameless computer stereotactic guidance is a safe technique that allows maximal resection of lesions in close relationship to eloquent cortex and has a low risk of neurological deficit.</p>

Improved median survival for glioblastoma multiforme following introduction of adjuvant temozolomide chemotherapy

<p><b>INTRODUCTION</b>The use of adjuvant temozolomide (TMZ) in patients managed with surgery and adjuvant radiation therapy (RT) for glioblastoma multiforme (GBM) has been demonstrated to improve median and 2-year survival in a recent large international multicentre study. To confirm this result in routine clinical practice, an audit of the management and outcome of patients with GBM at The Cancer Institute Radiation Oncology was performed.</p><p><b>MATERIALS AND METHODS</b>All patients with GBM managed radically at The Cancer Institute Radiation Oncology from May 2002 to 2006 were entered into a prospective database. Patient, tumour and treatment factors were analysed for association with the outcome of median survival (MS). Survival was calculated using the Kaplan-Meier technique and correlation was assessed using Cox proportional hazards regression.</p><p><b>RESULTS</b>Forty-one patients with GBM were managed with radical intent over the 4- year period. The median age was 54 years and 66% were Eastern Cooperative Oncology Group (ECOG) 0-1 performance status. Macroscopic, subtotal and biopsy alone procedures were performed in 61%, 29% and 10% of patients, respectively. The median time from surgery to RT was 26 days. Adjuvant TMZ was used in 44% of patients (n = 18). The MS of the total group was 13.6 months, with a 24% 2-year overall survival. The use of TMZ was associated with improved MS (19.6 versus 12.8 months; P = 0.035) and improved 2-year survival (43% versus 0%). A requirement of dexamethasone dose greater than 4 mg at the end of RT (P = 0.012) was associated with worse survival, but there was no association of MS with age, ECOG, tumour size or extent of surgery.</p><p><b>CONCLUSION</b>The median and 2-year survival outcomes are comparable to the results of the European Multicentre Study and justify the continued use of TMZ in routine clinical practice.</p>

Improvements in quality of care resulting from a formal multidisciplinary tumour clinic in the management of high-grade glioma

<p><b>INTRODUCTION</b>There is increasing belief that a formal protocol-based multidisciplinary care model should be adopted as an optimal care model in oncology. However, there is minimal outcome evidence to demonstrate an improvement in patient care. The aim of this study was to compare clinical quality outcomes between patients with high-grade glioma managed at one hospital using a formal neuro-oncology multidisciplinary tumour clinic (MTC) and a second hospital with a traditional on-call referral pattern (non-MTC).</p><p><b>MATERIALS AND METHODS</b>Patients with high-grade glioma managed radically with radiation therapy at 2 Singapore hospitals from May 2002 to May 2006 were entered into a prospective database. Patients were grouped into management via MTC or non-MTC. Four clinical quality indicators were chosen retrospectively to assess the variation in practice: a) Use of computed tomography (CT) or magnetic resonance (MR) imaging post-resection (POI) for assessment of residual disease; b) Commencement of radiation therapy (RT) within 28 days of surgery; c) Adjuvant chemotherapy use for glioblastoma multiforme (CTGBM) and d) Median survival.</p><p><b>RESULTS</b>Sixty-seven patients were managed radically, with 47 by MTC and by 20 by non-MTC. MTC patients were more likely to have POI (P = 0.042), and CTGBM (P = 0.025). Although the RT start time was similar for the whole cohort (60% versus 45%: P = 0.296); for GBM patients, the RT start was earlier (63% vs 33% P = 0.024). The median survival for the MTC group was 18.7 months versus 11.9 months for the non-MTC group (P = 0.11).</p><p><b>CONCLUSION</b>Clinical quality outcomes were significantly improved in patients with high-grade glioma managed in this neuro-oncology MTC.</p>

The role of surgery in high-grade glioma--is surgical resection justified? A review of the current knowledge

<p><b>INTRODUCTION</b>The aims of this article were to review the role of surgical resection in the management of high-grade gliomas and to determine whether there is any survival benefit from surgical resection.</p><p><b>METHODS</b>A literature review of the influence of surgical resection on outcome was carried out. Relevant original and review papers were obtained through a PubMed search using the following keywords: glioma, resection, prognosis and outcome.</p><p><b>RESULTS</b>Presently, there is a lack of evidence to support a survival benefit with aggressive glioma resection, but this should not detract patients from undergoing surgery as there are many other clinical benefits of glioma excision. In addition, limiting surgical morbidity through the use of adjuvant techniques such as intraoperative magnetic resonance imaging (MRI), functional MRI and awake craniotomy is becoming increasingly important.</p><p><b>CONCLUSIONS</b>Ideally, a randomised controlled trial would be the best way to resolve the issue of whether (and to what extent) surgical resection leads to improvements in patient outcome and survival, but this would not be ethical. The second best option would be well-controlled retrospective studies with a multivariate analysis of all potential confounding factors.</p>