Endoscopy in Temporal Lobe Glioma and Metastasis Resection: Is There a Role?

BACKGROUND: Surgical access to the temporal lobe is complex with many eloquent white fiber tracts, requiring careful preoperative surgical planning. Many microsurgical approaches to the temporal lobes are described, each with their own disadvantages. The adoption of the endoscope in neurosurgery has increased the options available when treating these difficult access tumors. We present our experience of a novel, minimally invasive, endoscopic approach to resect temporal lobe tumors. METHODS: All patients undergoing endoscopic temporal lobe tumor resection between December 1, 2011 and December 1, 2017, with a single surgeon, were included. Tumors were resected through a minicraniotomy using a high-definition rigid endoscope with a 0- and 30-degree viewing angle. Bimanual resection was performed using standard microsurgical technique. RESULTS: There were 45 patients (22 men and 23 women) with a mean age of 53 years. There were 23 (51%) glioblastoma multiforme, 11 (24%) metastases, 7 (16%) astrocytoma, 3 (7%) anaplastic astrocytoma, and 1 (2%) World Health Organization grade I glioneuronal tumor. In 82.2% of cases (37/45), >95% resection was achieved and 42.2% (19/45) of patients achieving gross total resection. CONCLUSIONS: The endoscope has a role in temporal lobe intraparenchymal tumor surgery, especially in 3 illustrative scenarios: 1) medial temporal, parahippocampal-gyrus low-grade nonenhancing gliomas, 2) subcortical high-grade glioma and metastases medial to the sagittal stratum, and 3) recurrent gliomas with cystic resection cavity. The endoscope offers a safe and useful adjunct to the surgeons' armamentarium in brain tumor surgery. A minimally invasive approach also reduces surgical morbidity and length of stay.

Epilepsy and Neuromodulation-Randomized Controlled Trials.

Neuromodulation is a treatment strategy that is increasingly being utilized in those suffering from drug-resistant epilepsy who are not appropriate for resective surgery. The number of double-blinded RCTs demonstrating the efficacy of neurostimulation in persons with epilepsy is increasing. Although reductions in seizure frequency is common in these trials, obtaining seizure freedom is rare. Invasive neuromodulation procedures (DBS, VNS, and RNS) have been approved as therapeutic measures. However, further investigations are necessary to delineate effective targeting, minimize side effects that are related to chronic implantation and to improve the cost effectiveness of these devices. The RCTs of non-invasive modes of neuromodulation whilst showing much promise (tDCS, eTNS, rTMS), require larger powered studies as well as studies that focus at better targeting techniques. We provide a review of double-blinded randomized clinical trials that have been conducted for neuromodulation in epilepsy.

Predicting Prognosis of Patients with Chronic Subdural Hematoma: A New Scoring System.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires operative intervention. With an increasing ageing demographic, more elderly and comorbid patients will present with symptomatic CSDH. This study evaluated clinical and radiologic factors to create a scoring system to aid prognostication. METHODS: A cohort of patients undergoing evacuation of CSDH at a single institution was established from 2010 to 2015. Primary endpoint was a dichotomized score on a modified Rankin Scale score at 1-year follow-up (favorable outcome score 0-1; unfavorable outcome score 2-6). Logistic regression analyses were performed to model determinants related to outcome. A prediction rule for diagnosing poor postoperative prognosis with unfavorable modified Rankin Scale score was developed with the obtained results. RESULTS: Logistic regression analyses showed that age >75 years, midline shift >10 mm, and hematoma thickness >30 mm were significantly associated with unfavorable outcome (age >75 years: odds ratio [OR] 0.01, 95% confidence interval [CI] 0.001-0.01; midline shift 11-20 mm: OR 0.18, 95% CI 0.04-0.88; midline shift >20 mm: OR 0.03, 95% CI 0.002-0.41; hematoma thickness >30 mm: OR 0.07, 95% CI 0.01-0.46). A scoring system was designed using the final fitted multivariate model. A minimum score of 3 is feasible, indicating worst prognosis, and maximum score of 13 is feasible, indicating best prognosis. A score of ≥9 showed favorable outcome. Receiver operating characteristic curves were constructed to predict favorable versus unfavorable outcomes with the sensitivity analysis yielding an excellent model discrimination with an area under curve of 0.95, 95% CI 0.92-0.98. CONCLUSIONS: A scoring system has been devised to predict outcome, which can aid in the necessity of surgery in certain patient demographics.

Basal cell carcinoma of the scalp with destruction and invasion into the calvarium and dura mater: Report of 7 cases and review of literature.

Basal cell carcinoma (BCC) is the most common skin malignancy in humans. Giant BCC is a rarer entity that is characterised by aggressive biological behaviour. Intracranial invasion by a BCC on the scalp is extremely rare. The gold standard treatment of BCCs is represented by surgical excision with a wide variety of reconstructive techniques. In this paper, we describe the largest series to date of recurrent BCCs with intracranial extension involving the dura mater. We report recurrent giant BCC of the scalp with dura mater invasion in 7 patients. All patients in this series previously had more than 2 operations. Gadolinium-enhanced MRI revealed neoplastic invasion of the meninges and brain tissues. All patients had a multi-disciplinary team approach with the surgical margins ranging between 1 and 2 cm depending on the location and the size of the tumour. 5 of the patients underwent reconstruction of the skin defect by antero-lateral thigh flap, 1 patient underwent reconstruction with pedicled myocutaneous (trapezius) flap, and 1 with a pedicled myocutaneous latissimus dorsi flap. There was a mean follow-up of 5.3 years. 2 patients died due to cardio-pulmonary complications in the neuro-intensive care unit. A multi-disciplinary team approach and early aggressive tumour resection followed by sophisticated reconstructive and aesthetic procedures appears to be a reliable and realistic treatment modality for invasive BCC.

Fatal Liver and Lung Alveolar Echinococcosis with Newly Developed Neurologic Symptoms due to the Brain Involvement.

The fox tapeworm Echinococcus multilocularis causes human alveolar echinococcosis, commonly affecting the liver. However, in ∼1% of cases, systematic spread of the disease involves the brain as well. A patient had a 6-year history of liver and lung alveolar echinococcosis that was considered not suitable for surgery, and treatment with albendazole was introduced. After the appearance of neurologic disturbances, an intracranial mass lesion was demonstrated by radiologic imaging. The lesion was surgically removed, and histologic analysis revealed metacestode tissue of E. multilocularis . Despite the surgical resection of the lesion, the patient died of progression of systemic alveolar echinococcosis. The authors highly recommend implementing neurologic monitoring to the follow-up algorithm for patients with systemically disseminated alveolar echinococcosis. When neurologic symptoms occur, radiologic imaging of the brain should be obtained immediately. Surgery should be considered for all intracranial echinococcal lesions, unless the lesion is located in the eloquent brain area.

Case report: isolated cardiac amyloidosis: an enigma unravelled.

Amyloidosis is a rare, multisystem disease characterized by deposition of fibrils in extracellular tissue involving kidney, liver, heart, autonomic nervous system, and several other organs. This report discusses a 75-year-old male who presented with worsening dyspnea on exertion, orthopnea, and lower-extremity edema. On physical exam, he had elevated jugular venous pressure and lower-extremity edema. Electrocardiogram depicted low voltage in limb leads and a prolonged PR interval. Echocardiogram revealed left ventricular hypertrophy, severe biatrial dilatation, and restrictive filling physiology. Coronary angiography showed absence of significant epicardial coronary artery disease. On right heart catheterization, a "dip-and-plateau sign" was noted on right ventricular pressure tracings. A diagnosis of cardiac amyloidosis was considered, but a complete hematology work-up for systemic amyloidosis was negative. Cardiac magnetic resonance imaging was pursued, showing delayed gadolinium enhancement, and this ultimately led to the myocardial biopsy confirming the diagnosis of isolated cardiac amyloidosis. Further genetic analyses confirmed isolated cardiac amyloid caused by mutant transthyretin protein (Val-122-Ile). Isolated cardiac amyloidosis is an extremely rare entity, and diagnosis may be difficult despite the use of multimodality imaging. If the index of suspicion is high, then myocardial biopsy should be considered.

Abnormal rhythms in patients without known cardiac disease after a first dose of fingolimod.

BACKGROUND: Fingolimod is used to reduce the rates of relapse and slow the progression of disability in relapsing-remitting multiple sclerosis (RRMS). In-office monitoring of patients for 6h after the first dose of fingolimod is currently recommended due to rare cardiac rhythm disturbances. The objective of this paper is to describe our experience with continuous electrocardiographic monitoring of patients with RRMS starting on fingolimod. METHODS: Since changes to the FDA recommendations for first dose observation, a total of 59 patients with RRMS began treatment with fingolimod. After the first dose, all patients were observed for 6h with continuous electrocardiographic telemetry, vital signs were checked every hour, and 12 lead ECG performed before and after the 6-h period. RESULTS: Three out of 59 (5%) patients developed arrhythmia that led to discontinuation of fingolimod. The first patient had a sinus bradycardia with idioventricular escape rhythm that lasted 45s and two patients developed second-degree atrio-ventricular block Mobitz type I. None of the patients had a history of prior cardiacc disease or was taking other medications that may cause arrhythmia or bradycardia. CONCLUSION: Continuous on-line electrocardiographic telemetry may detect abnormal rhythms in a small number of patients started on fingolimod. The clinical significance of these is unclear and warrants further study.

Changes of red blood cell surface markers in a blood doping model of neocytolysis.

BACKGROUND: Neocytolysis, the selective hemolysis of young circulating red blood cells (RBCs), contributes to the physiologic control of red cell mass and to pathophysiologic phenomena such as anemia of renal disease, anemia after spaceflight, and blood doping by athletes. Progress in understanding the process is hampered by the lack of established markers to distinguish young from older RBC. METHODS: Twelve potentially informative RBC surface markers were assayed by flow cytometry in normal blood samples, and 4 were preferentially expressed in young RBC. To create a model of neocytolysis, 3 normal volunteers had recombinant human erythropoietin (rhEpo) administered until mild erythrocytosis occurred, then were studied upon rhEpo withdrawal. RESULTS: Neocytolysis ensued that most evident from a rapid rise in serum ferritin as the iron from young RBC was transferred back to stores. Five additional volunteers had surface markers monitored during and after rhEpo administration. Three subjects with marginal baseline iron stores had blunted response to rhEpo, no significant neocytolysis, and no change in RBC surface marker expression. Two subjects with adequate baseline iron stores developed erythrocytosis followed by neocytolysis. Decreased expression of CD44 (homing-associated cell adhesion molecule) and CD71 (transferrin receptor) seemed to correlate best with neocytolysis; CD35 (complement receptor) less so. Of note, further studies are needed to determine if these changes are causative of red cell destruction. CONCLUSION: This study begins to establish a human model of neocytolysis, to establish markers differentiating young and old RBC, and to establish a basis for better definition of the process. Although our study is preliminary, the results support the possibility that flow could be useful to detect blood doping because neocytolysis should predictably occur in athletes who surreptitiously blood dope.

Treatment of transformed mycosis fungoides with intermittent low-dose gemcitabine.

The malignant helper T cells of mycosis fungoides, a type of cutaneous T cell lymphoma, are capable of transforming into large cerebriform cells. Large cell transformation usually renders the disease more resistant to treatment and prone to relapse. Currently investigated treatment modalities for transformed mycosis fungoides are few and include phototherapy, chemotherapy, biologic response modification, targeted molecular therapy and combinations thereof. A tolerable and reliable modality has yet to be identified. Gemcitabine, a novel purine analogue, is gaining recognition as a potent agent for advanced nontransformed cutaneous T cell lymphoma. Here we present a brief review of the literature with 3 illustrative cases that additionally reveal gemcitabine monotherapy to be a practical, safe and efficacious option for mycosis fungoides that has undergone large cell transformation.