Lipid Fraction Derived From MRI In- and Opposed-Phase Sequence as a Novel Biomarker for Predicting Survival Outcome of Glioma.

RATIONALE AND PURPOSE: Our study evaluated the capability of magnetic resonance imaging in- and opposed-phase (IOP) derived lipid fraction as a novel prognostic biomarker of survival outcome in glioma. MATERIALS AND METHODS: We analyzed 46 histologically proven glioma (WHO grades II-IV) patients using standard 3T magnetic resonance imaging brain tumor protocol and IOP sequence. Lipid fraction was derived from the IOP sequence signal-loss ratio. The lipid fraction of solid nonenhancing region of glioma was analyzed, using a three-group analysis approach based on volume under surface of receiver-operating characteristics to stratify the prognostic factors into three groups of low, medium, and high lipid fraction. The survival outcome was evaluated, using Kaplan-Meier survival analysis and Cox regression model. RESULTS: Significant differences were seen between the three groups (low, medium, and high lipid fraction groups) stratified by the optimal cut-off point for overall survival (OS) (p ≤ 0.01) and time to progression (p ≤ 0.01) for solid nonenhancing region. The group with high lipid fraction had five times higher risk of poor survival and earlier time to progression compared to the low lipid fraction group. The OS plot stratified by lipid fraction also had a strong correlation with OS plot stratified by WHO grade (R = 0.61, p < 0.01), implying association to underlying histopathological changes. CONCLUSION: The lipid fraction of solid nonenhancing region showed potential for prognostication of glioma. This method will be a useful adjunct in imaging protocol for treatment stratification and as a prognostic tool in glioma patients.

Electroacupuncture-Assisted Craniotomy on an Awake Patient.

Although acupuncture has existed for over 2000 years, its application as an anesthetic aid began in the 1950s in China. The first surgical procedure performed under acupuncture anesthesia was a tonsillectomy. Soon thereafter, major and minor surgical procedures took place with electroacupuncture alone providing the anesthesia. The procedures performed were diverse, ranging from cardiothoracic surgery to dental extractions. Usage of acupuncture anesthesia, specifically in neurosurgery, has been well documented in hospitals across China, especially in Beijing, dating back to the 1970s. We present a case of a 65-year-old man who presented with right-sided body weakness. He had a past medical history of uncontrolled diabetes mellitus, hypertension, and obstructive sleep apnea requiring use of a nasal continuous positive airway pressure device during sleep. We performed a computed tomography brain scan, which revealed a left-sided acute on chronic subdural hemorrhage. Due to his multiple comorbidities, we decided to perform the surgical procedure under electroacupuncture anesthesia. The aim of this case report is to describe a craniotomy performed under electroacupuncture on an elderly patient with multiple comorbidities who was awake during the procedure and in whom this procedure, if it had been performed under general anesthesia, would have carried high risk.

Combined endoscopic transnasal and transoral approach for extensive upper cervical osteoradionecrosis.

PURPOSE: Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN. METHODS: A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed. RESULTS: Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence. CONCLUSION: Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN.

Development of a bone substitute material based on alpha-tricalcium phosphate scaffold coated with carbonate apatite/poly-epsilon-caprolactone.

Interconnected porous tricalcium phosphate ceramics are considered to be potential bone substitutes. However, insufficient mechanical properties when using tricalcium phosphate powders remain a challenge. To mitigate these issues, we have developed a new approach to produce an interconnected alpha-tricalcium phosphate (α-TCP) scaffold and to perform surface modification on the scaffold with a composite layer, which consists of hybrid carbonate apatite / poly-epsilon-caprolactone (CO3Ap/PCL) with enhanced mechanical properties and biological performance. Different CO3Ap combinations were tested to evaluate the optimal mechanical strength and in vitro cell response of the scaffold. The α-TCP scaffold coated with CO3Ap/PCL maintained a fully interconnected structure with a porosity of 80% to 86% and achieved an improved compressive strength mimicking that of cancellous bone. The addition of CO3Ap coupled with the fully interconnected microstructure of the α-TCP scaffolds coated with CO3Ap/PCL increased cell attachment, accelerated proliferation and resulted in greater alkaline phosphatase (ALP) activity. Hence, our bone substitute exhibited promising potential for applications in cancellous bone-type replacement.

Prognostic factors in patients with non-small cell lung carcinoma and brain metastases: a Malaysian perspective.

BACKGROUND: Brain metastases occur in about 20-40% of patients with non-small-cell lung carcinoma (NSCLC), and are usually associated with a poor outcome. Whole brain radiotherapy (WBRT) is widely used but increasingly, more aggressive local treatments such as surgery or stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) are being employed. In our study we aimed to describe the various factors affecting outcomes in NSCLC patients receiving local therapy for brain metastases. MATERIALS AND METHODS: The case records of 125 patients with NSCLC and brain metastases consecutively treated with radiotherapy at two tertiary centres from January 2006 to June 2012 were analysed for patient, tumour and treatment-related prognostic factors. Patients receiving SRS/SRT were treated using Cyberknife. Variables were examined in univariate and multivariate testing. RESULTS: Overall median survival was 3.4 months (95%CI: 1.7-5.1). Median survival for patients with multiple metastases receiving WBRT was 1.5 months, 1-3 metastases receiving WBRT was 3.6 months and 1-3 metastases receiving surgery or SRS/SRT was 8.9 months. ECOG score (≤2 vs >2, p=0.001), presence of seizure (yes versus no, p=0.031), treatment modality according to number of brain metastases (1-3 metastases+surgery or SRS/SRT±WBRT vs 1-3 metastases+WBRT only vs multiple metastases+WBRT only, p=0.007) and the use of post-therapy systemic treatment (yes versus no, p=0.001) emerged as significant on univariate analysis. All four factors remained statistically significant on multivariate analysis. CONCLUSIONS: ECOG ≤2, presence of seizures, oligometastatic disease treated with aggressive local therapy (surgery or SRS/SRT) and the use of post-therapy systemic treatment are favourable prognostic factors in NSCLC patients with brain metastases.

Injecting realism in surgical training-initial simulation experience with custom 3D models.

UNLABELLED: The traditionally accepted form of training is direct supervision by an expert; however, modern trends in medicine have made this progressively more difficult to achieve. A 3-dimensional printer makes it possible to convert patients imaging data into accurate models, thus allowing the possibility to reproduce models with pathology. This enables a large number of trainees to be trained simultaneously using realistic models simulating actual neurosurgical procedures. The aim of this study was to assess the usefulness of these models in training surgeons to perform standard procedures that require complex techniques and equipment. METHODS: Multiple models of the head of a patient with a deep-seated small thalamic lesion were created based on his computed tomography and magnetic resonance imaging data. A workshop was conducted using these models of the head as a teaching tool. The surgical trainees were assessed for successful performance of the procedure as well as the duration of time and number of attempts taken to learn them. FINDINGS: All surgical candidates were able to learn the basics of the surgical procedure taught in the workshop. The number of attempts and time taken reflected the seniority and previous experience of each candidate. DISCUSSION: Surgical trainees need multiple attempts to learn essential procedures. The use of these models for surgical-training simulation allows trainees to practice these procedures repetitively in a safe environment until they can master it. This would theoretically shorten the learning curve while standardizing teaching and assessment techniques of these trainees.

Anterior cervical discectomy plus intervertebral polyetheretherketone cage fusion over three and four levels without plating is safe and effective long-term.

Anterior cervical discectomy and fusion (ACDF) is an established treatment for single-level cervical spondylotic myelopathy and radiculopathy, yet its stand-alone use for multi-level disease of the subaxial cervical spine remains controversial. We report a prospectively studied case series of 30 patients receiving polyetheretherketone (PEEK) cage fusion over three and four cervical levels without anterior plating. Seven (23.3%) four-level procedures (all C3 to C7) were performed, the other 23 (76.7%) being three-level, with 19 (64.4%) at C4 to C7 and four (12.3%) at C3 to C6. Long-term follow-up of more than 2 years was available in 67% of patients. This cohort showed statistically significant improvements in visual analogue score for neck pain (p=0.0006), arm pain (p=0.0003) and Japanese Orthopaedic Association myelopathy score (p=0.002). Fused segment heights increased by 0.6-1.1%. Adjacent segment disease requiring ACDF at C3-4 was seen in 6.7% of patients (one after trauma) at a mean follow-up of 62 months. Same segment recurrence requiring posterior decompression with instrumented fusion was found in 10% of patients at a mean follow-up of 49 months, only one of whom had radiological evidence of cage subsidence. The results suggest the procedure is safe and effective with potentially less morbidity than anterior plating, shorter inpatient stays than posterior approaches, acceptable same segment recurrence and lower than predicted adjacent segment disease rates.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications.

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Infratentorial benign cystic meningioma mimicking a hemangioblastoma radiologically and a pilocytic astrocytoma intraoperatively: a case report.

INTRODUCTION: Cystic meningiomas are rare variants of meningiomas; they can pose a radiological diagnostic dilemma. CASE PRESENTATION: We present a rare case of a 30-year-old Chinese woman with a histopathological diagnosis of infratentorial cystic meningioma (World Health Organization Grade 1) in which the features in imaging modalities were suggestive of a hemangioblastoma. Intraoperatively, however, the gross macroscopic features were more in keeping with a pilocytic astrocytoma. CONCLUSION: In benign cystic meningiomas, particularly the infratentorial variety, radiological findings utilizing the various imaging modalities and intraoperative impressions may not be reflective of or in keeping with the final histopathological diagnosis.

Calcified pseudomeningocele of the lumbar spine: a review.

PURPOSE: In this article, we review the English literature of calcified pseudomeningoceles in the lumbar region. METHODS: A systematic review using the Medline Database using the varied nomenclature for pseudomeningoceles, as well as reviewing the reference lists of relevant article found. RESULTS: We discuss the different pathological theories on formation of a pseudomeningocele, the formation of a calcified wall and the optimal management for this entity. To date, 17 cases have been described, of which 13 are reviewed here. Calcification of pseudomeningocele is a rare entity and in the lumbar spine this occurs postsurgically. The only predisposing factor is prior surgery to the lumbar spine. Computer tomography, magnetic resonance imaging (MRI) and MRI myelography in combination are the preoperative investigations of choice. The radiological work-up can be preoperatively diagnostic and is important in the surgical planning. CONCLUSIONS: The treatment is surgicel removal and the decision to treat is based on patient symptoms and correlating these with imaging. There is an average reported follow-up of 1.7 years postoperatively for these patients and the reported outcome after surgery is good.

The creation and verification of cranial models using three-dimensional rapid prototyping technology in field of transnasal sphenoid endoscopy.

BACKGROUND: Surgical navigation systems have been used increasingly in guiding complex ear, nose, and throat surgery. Although these are helpful, they are only beneficial intraoperatively; thus, the novice surgeon will not have the preoperative training or exposure that can be vital in complex procedures. In addition, there is a lack of reliable models to give surgeons hands-on training in performing such procedures. METHODS: A technique using an industrial rapid prototyping process by three-dimensional (3D) printing was developed, from which accurate spatial models of the nasal cavity, paranasal sinuses (sphenoid sinus in particular), and intrasellar/pituitary pathology were produced, according to the parameters of an individual patient. Image-guided surgical (IGS) techniques on two different platforms were used during endoscopic transsphenoidal surgery to test and validate the anatomical accuracy of the sinus models by comparing the models with radiological images of the patient on IGS. RESULTS: It was possible to register, validate, and navigate accurately on these models using commonly available navigation stations, matching accurately the anatomy of the model to the IGS images. CONCLUSION: These 3D models can be reliably used for teaching/training and preoperative planning purposes.

The creation and verification of cranial models using three-dimensional rapid prototyping technology in field of transnasal sphenoid endoscopy.

BACKGROUND: Surgical navigation systems have been used increasingly in guiding complex ear, nose, and throat surgery. Although these are helpful, they are only beneficial intraoperatively; thus, the novice surgeon will not have the preoperative training or exposure that can be vital in complex procedures. In addition, there is a lack of reliable models to give surgeons hands-on training in performing such procedures. METHODS: A technique using an industrial rapid prototyping process by three-dimensional (3D) printing was developed, from which accurate spatial models of the nasal cavity, paranasal sinuses (sphenoid sinus in particular), and intrasellar/pituitary pathology were produced, according to the parameters of an individual patient. Image-guided surgical (IGS) techniques on two different platforms were used during endoscopic transsphenoidal surgery to test and validate the anatomical accuracy of the sinus models by comparing the models with radiological images of the patient on IGS. RESULTS: It was possible to register, validate, and navigate accurately on these models using commonly available navigation stations, matching accurately the anatomy of the model to the IGS images. CONCLUSION: These 3D models can be reliably used for teaching/training and preoperative planning purposes.

Disseminated intravascular coagulation after isolated mild head injury.

A rare case is described of acute disseminated intravascular coagulation (DIC) following isolated mild head injury with acute subdural haematoma, coagulopathy onset preceding craniotomy. Surgical treatment of the cause followed by swift diagnosis and treatment soon after surgery enabled a good outcome. Post-operative recollection of subdural and extadural blood was treated by further surgery. DIC following isolated mild head injury without axonal damage is rare, but fatal if missed. Thrombocytopaenia in head injured patients should be investigated expediently. Post-operative interim imaging (if not standard practice) should also be considered to exclude haemorrhagic recollection requiring further surgery.

A commentary on the use of depression rating scales in clinical trials conducted in India.

India representing over a sixth of the world's population is a popular venue for clinical trials, including those of psychotropic agents. In this commentary, we have focused on the rating scales employed to assess major depressive disorder, especially the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS) in the Indian clinical setting. The prominence given to somatic symptoms in the HAM-D scale may be appropriate for the less "westernized" Indian patients who do not speak English fluently, while the MADRS with more emphasis on cognitive symptoms may be better suited for the urban and westernized Indian subjects. Research into the prevalence of "persecutory ideation" or "fearful mood" or "decreased interest in religious activity" should be undertaken to determine if some of the individual items enquired in these scales require change and/or modification. Finally, even though these are observer rated scales, translations into various Indian languages will likely result in improved quality and validity of clinical trials of major depressive disorder conducted in India. This commentary may be relevant to other non-English speaking populations as well.