Proposal of a Novel Anatomic Guide to the Sphenoid Sinus.

BACKGROUND: Landmarks for transsphenoidal surgery have been described to facilitate resection for pituitary lesions. However, carrying out sphenoidotomy for access to the sellar floor could still be challenging, especially for young surgeons during the steep learning curve. OBJECTIVE: We describe the LUTH (Lagos University Teaching Hospital) line as a simple anatomic guide to avoid missing the trajectory to the sella during anterior sphenoidotomy in microscopic transsphenoidal pituitary surgery. METHODS: We identified this line as an impression on the floor of the sphenoid sinus across the point at which the floor of the anterior cranial fossa and the bony projection from the clivus meet. We carried out a literature review of articles describing landmarks for anterior sphenoidotomy using data obtained from PubMed and Ovid MEDLINE databases according to PRISMA guidelines. RESULTS: A total of 80 patients were operated using the LUTH line as a guide for anterior sphenoidotomy during microscopic transsphenoidal pituitary. We did not find any previous description of this anatomic landmark over the anterior sphenoid sinus in the literature. The LUTH line was clearly identified in all 80 cases. The line was used as a bony landmark to the sphenoid sinus in all cases and was found to be consistently accurate. CONCLUSIONS: The LUTH line is a consistent and easy-to-identify landmark that could be useful in preventing potential complications of access to the pituitary sella through the sphenoid sinus. We believe it to be useful in the absence of intraoperative guidance, especially for young surgeons who are just starting off their career in pituitary surgery.

Early outcome of combined endoscopic third ventriculostomy and choroid plexus cauterization in childhood hydrocephalus.

OBJECT: Although shunts have been the mainstay in treating hydrocephalus over the past 5 decades, the use of endoscopic techniques in addressing this disorder in children offers both the neurosurgeon and the patient a unique opportunity to avoid shunting and its attendant complications. The combination of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) remains uncommon in most centers despite its potential promise. The authors sought to investigate the efficacy of combining ETV and CPC (ETV+CPC) in treating childhood hydrocephalus in Nigeria. Infection and spina bifida contribute a high percentage of the cases of hydrocephalus in Nigeria. METHODS: Over a 2-year period, all children 0-18 years of age who had endoscopic treatment for hydrocephalus were prospectively evaluated to determine the need for subsequent treatment. Children who had the combination of ETV+CPC were identified as a subcategory and form the basis of this retrospective study. RESULTS: Twenty-two of 38 endoscopically treated children had undergone the combination of ETV+CPC for hydrocephalus of varied etiology. There was a male preponderance (2.5:1), and 90% of the patients were infants. The overall success rate was 75%, with the best outcome in children with spina bifida. One child required a repeat ETV. CONCLUSIONS: The combination of ETV+CPC is useful in treating children with hydrocephalus of varied etiology. The complication profile is acceptable, and the overall success rate is comparable to that associated with shunt insertion.

Frameless stereotactic procedures in pediatric patients: safety and diagnostic efficacy.

PURPOSE: The aim of our retrospective study was to evaluate the feasibility, safety, and diagnostic yield of a frameless method for stereotactic neurosurgical procedures in pediatric patients. METHODS: Twenty-two frameless stereotactic neurosurgical procedures (18 biopsies, 4 catheter placements), using a modified frameless stereotactic navigational system, were performed in 21 pediatric patients in our institution from 2004 to 2009. All procedures were performed by the senior authors (AAK, SC). RESULTS: We completed 18 biopsy procedures in 18 patients, yielding usable diagnostic specimens in 100% of the procedures. Of this biopsy group, two patients experienced an asymptomatic hemorrhage per CT, and one patient experienced a transient hemiparesis, recovering to baseline within 1 week after surgery. Four catheter placement procedures were completed in three patients, including one patient who had to have the procedure repeated. We had no peri-operative mortality or technical difficulties related to the catheter placements. CONCLUSIONS: Frameless stereotactic neurosurgical procedures in the pediatric population are feasible and can be completed safely for histological tumor diagnosis as well as for accurate placement of intracranial catheters. This method has low rates of morbidity comparable to frame-based procedures, with the advantage of greater operative convenience.

Glioblastoma Multiforme Oncogenomics and Signaling Pathways.

In the adult population, glioblastoma multiforme is one of the most common primary brain tumors encountered. Unfortunately, this highly malignant tumor represents over 50% of all types of primary central nervous system gliomas. The vast majority of GBMs develops quite rapidly without clinical, radiological, or morphologic evidence of a less malignant precursor lesion (primary or de novo GBMs), as compared to secondary GBMs that develop slowly by progression from diffuse low-grade astrocytomas. These GBM subtypes must be kept in mind because they may constitute distinct disease entities. Even though they look histologically quite similar, they likely involve different genetic alterations and signaling pathways. Decades of surgical therapy, radiotherapy, and chemotherapy have failed to drastically change survival. Clearly, we do not fully understand this tumor; however, the exciting genetic revolution in glioma research over the past decade is providing a promising outlook for exploring this tumor at the genetic level. Science has begun to elucidate the numerous genetic alterations and critical signaling pathways, and it has opened new exciting areas of research such as glioma stem cell biology and neoangiogenesis. This work has already begun to improve our understanding of GBM cell proliferation, migration, and invasion. Indeed, exciting novel targeted therapies are making their way to clinical trials based on this increased knowledge. This review provides the current understanding of GBM oncogenomics, signaling pathways, and glioma stem cell biology and discusses the potential new therapeutic targets on the horizon.

Glioblastoma multiforme: a review of where we have been and where we are going.

Malignant gliomas such as glioblastoma multiforme (GBM) present some of the greatest challenges in the management of cancer patients worldwide, despite notable recent achievements in oncology. Even with aggressive surgical resections using state-of-the-art preoperative and intraoperative neuroimaging, along with recent advances in radiotherapy and chemotherapy, the prognosis for GBM patients remains dismal: median survival after diagnosis is about 14 months. Established good prognostic factors are limited, but include young age, high Karnofsky Performance Status (KPS), high mini-mental status examination score, O6-methylguanine methyltransferase promoter methylation, and resection of > 98% of the tumor. Standard treatment includes resection, followed by concurrent chemotherapy and radiotherapy. GBM research is being conducted worldwide at a remarkable pace, with some of the more recent promising studies focused on identification of aberrant genetic events and signaling pathways, tumor stem cell identification and characterization, modulation of tumor immunological responses, combination therapies, and understanding of the rare long-term survivors. Past treatment strategies have failed for various reasons; however, newer strategies in trials today and on the horizon encourage optimism. To help illustrate 'where we have been' with this fatal disease and 'where we are going' with contemporary studies, we include in this review a detailed history of Phase III clinical trials for GBM, with a final emphasis on exciting new treatment strategies that offer hope for future GBM therapy.

Glioblastoma multiforme: a review of therapeutic targets.

Glioblastoma is the commonest primary brain tumor, as well as the deadliest. Malignant gliomas such as glioblastoma multiforme (GBM) present some of the greatest challenges in the management of cancer patients worldwide, despite notable recent achievements in oncology. Even with aggressive surgical resections using state-of-the-art preoperative and intraoperative neuroimaging, along with recent advances in radiotherapy and chemotherapy, the prognosis for GBM patients remains dismal: survival after diagnosis is about 1 year. Established prognostic factors are limited, but include age, Karnofsky performance status, mini-mental status examination score, O6-methylguanine methyltransferase promoter methylation and extent of surgery. Standard treatment includes resection of > 95% of the tumor, followed by concurrent chemotherapy and radiotherapy. Nevertheless, GBM research is being conducted worldwide at a remarkable pace, in the laboratory and at the bedside, with some of the more recent promising studies focused on identification of aberrant genetic events and signaling pathways to develop molecular-based targeted therapies, tumor stem cell identification and characterization, modulation of tumor immunological responses and understanding of the rare long-term survivors. With this universally fatal disease, any small breakthrough will have a significant impact on survival and provide hope to the thousands of patients who receive this diagnosis annually. This review describes the epidemiology, clinical presentation, pathology and tumor immunology, with a focus on understanding the molecular biology that underlies the current targeted therapeutics being tested.