Tumores de tronco encefálico: reflexión moral sobre la conducta quirúrgica / Brainstem tumors: moral reflection on surgery management / Tumores do tronco encefálico: reflexão moral sobre conduta cirúrgica

Resumen Los tumores de tronco encefálico representan alrededor del 10% al 20% de los tumores del sistema nervioso central en niños. El glioma intrínseco difuso es el más frecuente (80% de los casos) de este grupo de tumores, que se caracterizan por la mala evolución y una sobrevida corta. El diagnóstico se puede hacer por resonancia magnética (con espectroscopía) o por biopsia estereotáxica, un método controvertido, que permite el estudio inmunohistoquímico y molecular del tumor. La reflexión moral se focaliza en la indicación de biopsia para pacientes vulnerables y con mal pronóstico. Se analiza la cirugía desde el punto de vista ético, con base en el mejor interés del niño y en la actitud altruista del paciente y su familia.

Abstract Brainstem tumors represent about 10% to 20% of central nervous system tumors in children. Diffuse intrinsic glioma is the most frequent (80% of cases) in this group of tumors, characterized by poor prognosis and short survival. Diagnosis can be made by magnetic resonance (with spectroscopy) or by stereotactic biopsy, a controversial method that allows immunohistochemical and molecular study of the tumor. Moral reflection focuses on the indication of biopsy for vulnerable patients with a poor prognosis. Surgery is analyzed from an ethical point of view based on the best interests of the child and altruistic attitude of patient and family.

Resumo Os tumores de tronco encefálico representam cerca de 10% a 20% dos tumores do sistema nervoso central em crianças. O glioma intrínseco difuso é o mais frequente (80% dos casos) desse grupo de tumores, caracterizados pela má evolução e por uma curta sobrevida. O diagnóstico pode ser feito por ressonância magnética (com espectroscopia) ou por biópsia estereotáxica, um método controverso, que permite o estudo imunohistoquímico e molecular do tumor. A reflexão moral se concentra na indicação de biópsia para pacientes vulneráveis e com mau prognóstico. A cirurgia é analisada do ponto de vista ético com base no melhor interesse da criança e na atitude altruísta do paciente e da família.

Biopsia Estereotáxica de tumores de tronco en pediatría. Indicaciones actuales y perspectivas futuras / Stereotaxic biopsy of trunk tumors in pediatrics. Current indications and future prospects

Introducción: Los tumores de tronco constituyen neoplasias frecuentes en pediatría. Durante las últimas décadas y con el avance de los métodos de estudios por imágenes fueron desarrolladas clasificaciones con implicancias diagnósticas y terapéuticas. Hoy en día la biopsia estereotáxica es un tema controversial especialmente en las lesiones difusas.El objetivo del presente artículo es realizar una actualización de las indicaciones de este tipo de procedimiento en pediatría analizando también perspectivas futuras. Desarrollo: En la actualidad las biopsias estereotáxicas en tumores de tronco tienen indicaciones precisas ante tumores sin indicación quirúrgica o en casos no quirúrgicos. En pacientes con lesiones atípicas definida por imagen, presentación clínica o edad fuera del rango habitual se torna necesario el diagnóstico por anatomía patológica. El avance del estudio oncológico por biología molecular despertó interés en los gliomas difusos de la protuberancia. Hoy en día es aceptada la realización de esta cirugía en caso de protocolos de investigación, aunque la misma no tenga relevancia en la evolución del paciente. La toma de tejido para determinar la aplicación de tratamientos blanco junto a técnicas que posibilitan la aplicación de fármacos por microcatéteres colocados directamente en la lesión son posibles futuras aplicaciones de la estereotaxia para este tipo de tumores. Conclusiones: Los tumores de tronco en pediatría, por ser una patología frecuente, requieren un capítulo especial. Los avances en la clasificación de estos junto con los nuevos métodos de estudio de biología molecular tornan necesario definir las indicaciones de biopsia estereotáxica en este tipo de lesiones pudiendo cambiar el paradigma en un futuro cercano.

Introduction: Brainstem tumors are frequent neoplasms in pediatrics. During the last decades and with the advancement of imaging methods, classifications with diagnostic and therapeutic implications were developed. Today the stereotaxic biopsy is a controversial topic especially in diffuse lesions. Objectives: To update the indications for this type of procedure in pediatrics, also analyzing future perspectives. Discussion: At the present, stereotaxic biopsies in brainstem tumors have precise indications for tumors without surgical indication or in non-surgical cases. In patients with atypical lesions defined by MRI, clinical presentation or age outside the usual range, diagnosis by pathological anatomy becomes necessary.Advances in molecular biology in oncology have sparked interest in diffuse gliomas of the pons. Nowadays, the performance of this surgery is accepted in the case of research protocols, although it has no relevance in the patient`s outcome.Taking tissue to determine the application of target treatments together with techniques that allow the application of drugs by microcatheters placed directly in the lesion are possible future applications of stereotaxy for this type of tumors. Conclusions: Brainstem tumors in pediatrics, as they are a frequent pathology, require a special chapter. Advances in the classification of these, together with new molecular biology study methods make it necessary to define the indications for stereotaxic biopsy for this type of lesion, which may change the paradigm in the future.

Diffuse Intrinsic Pontine Gliomas Exhibit Cell Biological and Molecular Signatures of Fetal Hindbrain-Derived Neural Progenitor Cells / 神经科学通报·英文版

Diffuse intrinsic pontine glioma (DIPG) is the main cause of brain tumor-related death among children. Until now, there is still a lack of effective therapy with prolonged overall survival for this disease. A typical strategy for preclinical cancer research is to find out the molecular differences between tumor tissue and para-tumor normal tissue, in order to identify potential therapeutic targets. Unfortunately, it is impossible to obtain normal tissue for DIPG because of the vital functions of the pons. Here we report the human fetal hindbrain-derived neural progenitor cells (pontine progenitor cells, PPCs) as normal control cells for DIPG. The PPCs not only harbored similar cell biological and molecular signatures as DIPG glioma stem cells, but also had the potential to be immortalized by the DIPG-specific mutation H3K27M in vitro. These findings provide researchers with a candidate normal control and a potential medicine carrier for preclinical research on DIPG.

Importancia del diagnóstico histopatológico en el tratamiento de las lesiones del tronco cerebral en adultos / Relevance of histopathological diagnosis in the treatment of brainstem lesions in adults

Los tumores del tronco cerebral son infrecuentes en la población adulta. Las controversias surgen cuando se considera la necesidad de confirmar el diagnóstico histopatológico en esta área elocuente del cerebro, balanceando los beneficios de obtener un diagnóstico certero y las desventajas de los procedimientos invasivos. Existen escasas publicaciones acerca de su tratamiento quirúrgico en adultos, todas series pequeñas analizadas retrospectivamente. Presentamos nuestra experiencia con el propósito de contribuir al proceso de toma de decisiones. Diez de 13 pacientes fueron intervenidos. Las lesiones se clasificaron en focales (n:7), infiltrativa difusa (n:1), tectal (1) y exofítica (1). El estado neurológico según la escala Karnofsky Performance Status fue ≥ 70 en 6 casos y < 70 en 7. Las muestras fueron obtenidas mediante abordaje microquirúrgico directo o por biopsia estereotáctica. Los hallazgos histopatológicos fueron confirmados en todos los casos: astrocitoma pilocítico (n:1), glioma de bajo grado (n:1), glioblastoma (n:1), hemangioblastoma celular (n:1), subependimoma (n:1), disgerminoma (n:1), y lesiones pseudotumorales (n:4, 3 cavernomas, 1 pseudotumor inflamatorio). La amplia variedad de hallazgos patológicos en esta localización en adultos exige una precisa definición histopatológica, que no solo determina la terapéutica adecuada sino que también previene las consecuencias potencialmente catastróficoas de los tratamientos empíricos.

Brainstem tumors are uncommon beyond childhood. Controversies arise regarding the need of histological diagnosis in this eloquent area of the brain, weighting the benefits of a reliable diagnosis against the disadvantages of invasive procedures. There are scant publications about the surgical management of brainstem tumors in adults, all of them involving small retrospective cohorts. We are reporting our experience with the aim of contributing to the decision making process. Out of a series of 13 patients, 10 were approached surgically. According to Guillamo´s classification the lesions were: focal (n:7), diffuse infiltrative (n:1), tectal (n:1), and exophytic (n:1). According to the Karnofsky Performance Status scale, the neurological status was ≥ 70 in 6 cases and < 70 in 7. Histopathology was confirmed in all 10 treated cases and the samples were obtained by a direct microsurgical approach or by stereotactic biopsy. Histopathological findings were: pilocytic astrocytoma (n:1), low grade glioma (n:1), glioblastoma (n:1), cellular haemangioblastoma (n:1), subependimoma (n:1), pseudotumoral lesions (n:4; 3 cavernomas, 1 inflammatory pseudotumor), and disgerminoma (n:1). As a broad variety of pathologies could be found in this brain localization, an accurate histopathological definition can not only determine the adequate therapy, but also avoid the disastrous consequences of empiric treatments.

Diffuse Intrinsic Pontine Glioma : Clinical Features, Molecular Genetics, and Novel Targeted Therapeutics

Diffuse intrinsic pontine glioma (DIPG) is a deadly paediatric brain cancer. Transient response to radiation, ineffective chemotherapeutic agents and aggressive biology result in rapid progression of symptoms and a dismal prognosis. Increased availability of tumour tissue has enabled the identification of histone gene aberrations, genetic driver mutations and methylation changes, which have resulted in molecular and phenotypic subgrouping. However, many of the underlying mechanisms of DIPG oncogenesis remain unexplained. It is hoped that more representative in vitro and preclinical models–using both xenografted material and genetically engineered mice–will enable the development of novel chemotherapeutic agents and strategies for targeted drug delivery. This review provides a clinical overview of DIPG, the barriers to progress in developing effective treatment, updates on drug development and preclinical models, and an introduction to new technologies aimed at enhancing drug delivery.

Diffuse Intrinsic Pontine Glioma : Clinical Features, Molecular Genetics, and Novel Targeted Therapeutics

Diffuse intrinsic pontine glioma (DIPG) is a deadly paediatric brain cancer. Transient response to radiation, ineffective chemotherapeutic agents and aggressive biology result in rapid progression of symptoms and a dismal prognosis. Increased availability of tumour tissue has enabled the identification of histone gene aberrations, genetic driver mutations and methylation changes, which have resulted in molecular and phenotypic subgrouping. However, many of the underlying mechanisms of DIPG oncogenesis remain unexplained. It is hoped that more representative in vitro and preclinical models–using both xenografted material and genetically engineered mice–will enable the development of novel chemotherapeutic agents and strategies for targeted drug delivery. This review provides a clinical overview of DIPG, the barriers to progress in developing effective treatment, updates on drug development and preclinical models, and an introduction to new technologies aimed at enhancing drug delivery.

Bioinformatics analysis of microarray data to reveal the pathogenesis of diffuse intrinsic pontine glioma

BACKGROUND: Diffuse intrinsic pontine glioma (DIPG) is the main cause of pediatric brain tumor death. This study was designed to identify key genes associated with DIPG. METHODS: The gene expression profile GSE50021, which consisted of 35 pediatric DIPG samples and 10 normal brain samples, was downloaded from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) were identified by limma package. Functional and pathway enrichment analyses were performed by the DAVID tool. Protein-protein interaction (PPI) network, and transcription factor (TF)-microRNA (miRNA)-target gene network were constructed using Cytoscape. Moreover, the expression levels of several genes were validated in human glioma cell line U251 and normal glia HEB cells through real-time polymerase chain reaction (PCR). RESULTS: A total of 378 DEGs were screened (74 up-regulated and 304 down-regulated genes). In the PPI network, GRM1, HTR2A, GRM7 and GRM2 had higher degrees. Besides, GRM1 and HTR2A were significantly enriched in the neuroactive ligand-receptor interaction pathway, and calcium signaling pathway. In addition, TFAP2C was a significant down-regulated functional gene and hsa-miR-26b-5p had a higher degree in the TF-miRNA-target gene network. PCR analysis revealed that GRM7 and HTR2A were significantly downregulated while TFAP2C was upregulated in U251 cells compared with that in HEB cells (p < 0.001). GRM2 was not detected in cells. CONCLUSIONS: GRM1 and HTR2A might function in DIPG through the neuroactive ligand-receptor interaction pathway and the calcium signaling pathway. Furthermore, the TFAP2C and hsa-miR-26b-5p might play important roles in the development and progression mechanisms of DIPG.

Análise de sobrevida de pacientes portadores de tumores do sistema nervoso central / Survival analysis of patients with central nervous tumor

Objetivos: analisar a sobrevida de pacientes com diagnóstico de tumores do sistema nervoso central (SNC) em um serviço de referência em Oncologia Pediátrica, sua apresentação clínica, evolução e influência de fatores prognósticos. Métodos: estudo de coorte histórica. Foram estudados pacientes menores de 19 anos, no período de março de 2003 a dezembro de 2009. O método de Kaplan-Meier foi utilizado para estimar a probabilidade de sobrevida global (SGLO). O teste de log rank e o modelo de regressão de Cox foram usados nas análises univariada e multivariada. Resultados: foram incluídos 159 pacientes, com mediana de tempo de seguimento de 13 meses. O intervalo entre o início dos sintomas e o diagnóstico teve mediana de 1,9 mês; 52% eram do gênero masculino. A mediana de idade ao diagnóstico foi de 7,2 anos. Os diagnósticos histológicos mais frequentes foram glioma de baixo grau (27%), meduloblastoma (19,5%) e tumor de tronco encefálico (17,6%). Cefaleia foi o sintoma mais frequente ao diagnóstico. A localização primária mais comum dos tumores foi a infratentorial (55,3%). A SGLO aos cinco anos foi de 42% (IC 95, 33 a 53%). Na análise univariada, foi observada associação significativa entre tempo de surgimento dos sintomas e o diagnóstico (p=0,046) e diagnóstico histológico (p<0,001). Na análise multivariada, esses fatores mantiveram-se e foram acrescidos da localização primária do tumor. Discussão: a SGLO observada neste estudo foi claramente inferior às descritas na literatura internacional, porém semelhante à de dois outros centros de referência nacionais. Estudos multicêntricos em nível nacional são necessários para confirmação desses resultados.

Objetives: To evaluate outcome of patients with the diagnosis of Central Nervous System tumors at a local reference pediatric oncology service, their clinical presentation, evolution and influence of prognostic factors. Methods: Patients enrolled in this retrospective study between March,2003 and December,2009, were less than nineteen years old at the time of the diagnosis. Kaplan-Meier method was used to estimate the overall survival (OS). Log rank test and Cox?s method were used in the statistical analysis. Results: Study population consisted of 159 patients with median follow up period of 13 months. Median of the time between onset of symptoms and diagnosis was 1,9 months. Boys comprised 52% of the studied population. Median age at diagnosis was 7,2 years. Most common diagnostic subtypes were low grade glioma (27%), medulloblastoma (19,5%) and brain stem tumors (17,6%). Headache was the most frequent symptom (57%) and infratentorial tumors correspond to 55,3% of the cases. An estimated OS of 42% (CI 95%, 33% to 53%) was observed for the role group. An association between outcome and the following variables was observed: interval between the time of onset of symptoms and diagnosis (p=0,046)and histological classification of the tumors (p<0,001). In the multivariate analysis, these variables were sustained, added of the primary location of the tumor in the Central Nervous System. Discussion: Overall survival detected in this study was clearly worse when compared with international centers rates, although were similar to other Brazilian studies. It?s important to develop multicentric studies to confirm data showed in this study

Tumores de tronco cerebral en niños tratados con radioterapia / Radiation therapy in the treatment of brain-stem tumors in children

Introduction: Due to their location, tumors of the trunk (TT) present a high surgical risk and the diagnosis is usually made by imaging. In Chile, these cases are treated according to the PINDA Program (national treatment guide for pediatric tumors). All patients receive radiotherapy (RT) after diagnosis. The aim of this study is to evaluate the treatment results for TT at the National Cancer Institute (NCI) between 1993 and 2011. Patients and Method: A retrospective review of patients diagnosed with TT at NCI was conducted. Patient population, symptoms, treatment received and overall survival are described. Prognostic factors were analyzed. Results: From November 1993 to December 2011, 70 children were referred for possible RT, 68 of them actually received it. The median age at diagnosis was 7 years old. In June 2012, out of 70 patients, 60 were deceased, all due to disease progression. The median survival of patients who received RT (68 patients) was 8.5 months from the end of treatment; the survival rates at 1, 2 and 3 years was 31.5 percent 14.3 percent and 12.8 percent respectively. Univariate analysis showed that survival was affected by the MRN high resolution imaging (p = 0.07) and by the diffuse tumor pattern (p = 0.025). Multivariate analysis showed survival is affected by the MRN high resolution imaging (p = 0.011) and a higher dose of RT protector (p = 0.015). Conclusions: The poor results obtained in the treatment of TT with RT at the INC are similar to those reported by other centers. Further explorations regarding other treatment options based on combined therapy using RT are needed.

Introducción: Los tumores de tronco (TT), por su ubicación, conllevan un alto riesgo quirúrgico, por lo que generalmente el diagnóstico se realiza por imágenes. En Chile se tratan según el programa PINDA (guía para tratamiento de tumores pediátricos nacional). Todos reciben radioterapia (RT) luego del diagnóstico. El objetivo de esta publicación es evaluar los resultados de tratamiento de los TT en el Instituto Nacional del Cáncer (INC) en el período 1993-2011. Pacientes y Método: Revisión retrospectiva de los pacientes tratados con el diagnóstico de TT en el INC. Se describe la población de pacientes, síntomas de presentación, tratamientos recibidos y sobrevida global. Se exploraron factores pronósticos. Resultados: Desde noviembre de 1993 hasta diciembre de 2011 fueron derivados para consideración de RT 70 niños, de ellos 68 la recibieron. La mediana de edad al diagnóstico fue de 7 años. A junio de 2012, del total de 70 pacientes, 60 se encontraban fallecidos, todos por progresión de enfermedad. La mediana de sobrevida, de los pacientes que recibieron RT (68 pacientes), fue de 8,5 meses desde el fin de esta; la sobrevida a 1, 2 y 3 años fue de 31,5 por ciento, 14,3 por ciento, 12,8 por ciento respectivamente. Al análisis univariado, fue peor para la sobrevida, el alto grado a la imagen de RNM (p = 0,07) y el patrón tumoral difuso (p = 0,025). Al análisis multivariado, es peor para la sobrevida el alto grado a la imagen de RNM (p = 0,011) y protector una mayor dosis de RT (p = 0,015). Conclusiones: Los pobres resultados obtenidos en el tratamiento con RT de TT en el INC son similares a los reportados por los otros centros. Sería sin duda interesante explorar otras alternativas de tratamiento en base a tratamientos combinados con RT.

Treatment and Outcomes for Gangliogliomas: A Single-Center Review of 16 Patients

BACKGROUND: Ganglioglioma is a rare and slowly growing benign tumor. We investigated the outcomes of patients who underwent different combination treatments. METHODS: Between 1998 and 2012, 16 patients, including 11 men and 5 women, with a median age of 12.5 years (range, 2.5-65 years) were treated for intracranial gangliogliomas at our institution. The median follow-up period was 5.7 years (range, 48 days-15.6 years). Fifteen cases were included in the outcome assessment because one patient was lost to follow-up. Complete resection was achieved in 8 (53%) patients. Six (40%) patients underwent incomplete resection with or without adjuvant radiotherapy, and one patient with a brainstem tumor underwent only stereotactic biopsy. RESULTS: Gangliogliomas predominantly affected young (87.5%), male patients and most frequently presented with seizures (64%). Of eight patients who underwent complete resection, seven did not show recurrence, whereas only three of six with incomplete resection showed no recurrence. Four patients with recurrence received salvage treatments (two repeat surgeries and two radiosurgeries). A tumor control rate of 93% (14/15) was achieved at the last follow-up. No recurrence or malignant changes were observed after a median follow-up of 12 and 4.5 years in four patients who received gamma knife (GK) radiosurgery as adjuvant and salvage treatment. CONCLUSION: Complete resection produced the best outcomes and incomplete resection followed by adjuvant or salvage treatments showed favorable outcomes. In patients who are not eligible for complete resection because of tumor location or potential neurologic deficits following surgery, GK radiosurgery should be considered for the treatment of residual or recurrent tumors.

2 Cases of Peripheral Facial Nerve Palsy Caused by Leukemia and Brain Stem Tumor / 대한소아신경학회지

Idiopathic facial palsy of the peripheral type is the most common facial palsy. However, the rate of incident is much lower in children under 10 years. In children, many other conditions can cause peripheral facial nerve palsy. We present the cases of 2 children with whom the initial manifestation of their leukemia and brain stem tumor were shown through the peripheral type of facial nerve palsy. These cases should alert physicians to consider other serious causes in younger children with facial palsy.

Tumefactive demyelinating lesions: A Clinicopathological correlative study.

Tumefactive demyelinating (TDL) lesions are focal zones of demyelination in the central nervous system and they often mimic the neuroimaging features of an intraxial neoplasm. In this report we describe the clinical, neuroimaging and neuropathological features of six cases of TDL. Only in two patients the neuroimaging features in MRI (magnetic resonance imaging) scans were suggestive of TDL while in the other four cases a diagnosis of glioma was suggested. In order to establish a confirmatory diagnosis neuronavigation/stereotactic biopsy was undertaken and the diagnosis of TDL was established in all six cases at histopathology. Two out of six patients did not respond to the conventional corticosteroid therapy and they were treated with plasma exchange. It is being concluded that neuronavigation biopsy, though provide only a small amount of tissue, and is extremely useful in making the diagnosis of TDL.

Brainstem cavernomas: a surgical challenge / Cavernomas de tronco: desafio cirúrgico

Objective: The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. Methods: From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. Results: The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. Conclusions: Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.

Objetivo: Os autores mostram sua experiência com cavernomas de tronco cerebral, comparando seus dados com os de uma revisão da literatura. Métodos: De 1998 a 2009, 13 pacientes com cavernoma de tronco cerebral foram submetidos a ressecção cirúrgica. Todos os filmes, prontuários e imagens foram revisados para exposição dos dados mais importantes, como epidemiologia, detalhes clínicos, achados radiológicos e resultados cirúrgicos, bem como as principais complicações. Resultados: A média de idade foi de 42,4 anos (variação de 19 a 70). Não houve predominância de gênero na taxa masculino versus feminino, 6:7. Os casos pontinos foram os mais frequentes. Ressonância nuclear magnética foi o método de imagem para o diagnóstico de cavernomas em todos os casos. A média do acompanhamento foi de 71,3 meses (variação de 1 a 138 meses). A apresentação clínica mais frequente foi a paresia do VIII nervo craniano, tinitus e perda auditiva (69,2%). Todos os 13 pacientes com cavernomas de tronco sintomáticos foram submetidos à ressecção cirúrgica. A remoção total foi realizada em 11 pacientes. A morbidade e a mortalidade foram de 15,3 e 7,6%, respectivamente. Conclusão: Os cavernomas podem ser seguramente ressecados por meio de acessos cirúrgicos ideais (zonas de entrada seguras) e técnicas de microcirurgia, sendo que o objetivo é remover toda a lesão sem o comprometimento dos nervos cranianos.

Cesarean section in spinal anesthesia on a patient with mesencephalic tumor and ventriculoperitoneal drainage: A case report / 대한마취과학회지

A seventeen-year-old pregnant woman with a mesencephalic tumor and ventriculoperitoneal (VP) drainage was admitted to the hospital at full term pregnancy to give birth. Elective cesarean section was performed because of her prime disease (mesencephalic tumor), breech position of the baby, gestational diabetes and expected weight of the baby of more than 4 kg. The operation was performed under spinal anesthesia. Spinal block was performed smoothly, using a pencil point spinal needle 27 G, at the L3-L4 intervertebral space, with hyperbaric bupivacaine 8 mg plus fentanyl 15 microg. Sensory block Th 5 was reached within 5 minutes. The patient was hemodynamically stabile during the anesthesia and the procedure was uneventful. The woman developed no neurologic symptoms, and a healthy female child was born. This is the first case of a pregnant woman with a cerebral tumor and VP drainage on whom a successful delivery was performed with C-section under spinal anesthesia.

Preliminary study on aberrant expression of miRNAs related to the formation of the distinction between pediatric and adult types of brainstem gliomas / 中华外科杂志

<p><b>OBJECTIVES</b>To study the different expression of miRNA between pediatric and adult types of brainstem gliomas, and to provide the target miRNAs for explore the mechanism and miRNA interference of the malignant progression of pediatric BSG.</p><p><b>METHODS</b>miRNA expression profiles in orthotopic models which could simulate the BSG heterogeneity were examined by microarray and analyzed to obtain the aberrantly expressed miRNAs. The two types of human BSG tissue were utilized to verify the microarray data by qRT-PCR and in situ hybridization for the putative causative miRNAs.</p><p><b>RESULTS</b>There were 216 miRNAs detected in both the pediatric BSG group and the adult BSG group, 39 miRNAs to be differential expressed in the pediatric BSG group versus adult group, including 10 up-regulated and 29 down-regulated. qRT-PCR and in situ hybridization indicated good consistency with that of the microarray method.</p><p><b>CONCLUSIONS</b>Aberrantly expressed miRNA may serve as putative causative involvement of malignant progression of pediatric BSG, thereby might be potentially novel targets for therapy.</p>

Fulminant neurogenic pulmonary edema developed after spontaneous cerebellar hemorrhage: A case report

Neurogenic pulmonary edema (NPE) was first reported in the literature in 1874. NPE has been described following head injury, subarachnoid hemorrhage (SAH), intracerebral hemorrhage, seizures, brain stem tumor and cervical spinal cord injury. According to the reports in the literature since 1990, the most frequent underlying factor for NPE has been subarachnoid hemorrhage and aneurysm rupture is following. The incidence of NPE was reported to be 6% in a series of 457 patients with SAH. We present here a case of NPE arising from cerebellar hemorrhage, which is a very rare cause of NPE.

Expression and significance of sonic hedgehog signaling pathway-related components in brainstem and supratentorial astrocytomas / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Studies have shown that abnormal activation of the sonic hedgehog pathway is closely related to tumorigenesis in central nervous system. This study aimed to investigate the role of the sonic hedgehog signaling pathway in the occurrence of brainstem and supratentorial glioma.</p><p><b>METHODS</b>Real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) and immunohistochemistry were used to detect the expression of sonic hedgehog-related components in 5 specimens of normal brain tissue, 10 of grade II brainstem glioma, and 10 of grade II supratentorial glioma. The significance of differences between two groups was determined using the Mann-Whitney U test or the two-sample test according to the results of normality distribution tests.</p><p><b>RESULTS</b>The mRNA expression levels of sonic hedgehog-related genes were higher in brainstem astrocytomas than in supratentorial astrocytomas and normal brain tissue. The level of protein patched homolog 1 (PTCH1) was significantly higher in brainstem astrocytomas than in supratentorial astrocytomas and normal brain tissue (P < 0.01). Immunohistochemistry semi-quantitative analysis was consistent with the qRT-PCR result that PTCH1 expression was increased significantly in brainstem astrocytomas at the protein level (P < 0.05).</p><p><b>CONCLUSIONS</b>Enhanced PTCH1 expression and activation of the sonic hedgehog pathway are involved in brainstem glioma. This may be related to the difference in malignant biological behavior between brainstem and hemispheric glioma, and could be an ideal therapeutic target in brainstem glioma.</p>