Abdulrazag Ajlan

DRR drives brain cancer invasion by regulating cytoskeletal-focal adhesion dynamics

Malignant glioma invasion is a primary cause of brain cancer treatment failure, yet the molecular mechanisms underlying its regulation remain elusive. We developed a novel functional-screening strategy and identified downregulated in renal cell carcinoma (DRR) as a regulator of invasion. We show that DRR drives invasion in vitro and in vivo. We found that while DRR is not expressed in normal glial cells, it is highly expressed in the invasive component of gliomas. Exploring underlying mechanisms, we show that DRR associates with and organizes the actin and microtubular cytoskeletons and that these associations are essential for focal adhesion (FA) disassembly and cell invasion. These findings identify DRR as a new cytoskeletal crosslinker that regulates FA dynamics and cell movement.

Endoscopic Resection of a Giant Intradural Retroclival Ecchordosis Physaliphora: Surgical Technique and Literature Review

OBJECTIVE To report the first complete resection of a giant ecchordosis physaliphora using an endoscopic transclival approach and to provide a current review of the literature. METHODS This rare benign lesion, originating from embryonic notochordal remnants, was located in the prepontine cistern of a 63-year-old man presenting with progressive tremor and imbalance. Preoperative imaging demonstrated a 2.1-cm intradural lesion abutting the pons and basilar artery and extending through the dura mater. RESULTS A gross total resection was successfully achieved endoscopically without neurovascular compromise or additional complications. Postoperative histopathologic examination was consistent with a diagnosis of giant ecchordosis physaliphora. CONCLUSIONS An endoscopic endonasal transclival approach provided a direct, minimally invasive route for safe and complete resection of this rare prepontine tumor, as it has for similarly located skull base chordomas. Our experience highlights the utility of endoscopy in visualization of both pathologic entities and nearby critical neurovascular structures in the management of ecchordosis physaliphora and other cranial base neoplasms.

Fahr's Disease Presenting with Aneurysmal Subarachnoid Hemorrhage

Fahrs disease is a rare disorder of slowly progressive cognitive, psychiatric, and motor decline associated with idiopathic basal ganglia calcification (IBGC) and widespread calcification in the brain and cerebellum. Acute presentation of IBGC is most often as a seizure disorder; however, we present a case of an acute IBCG presentation in which the cause of the deterioration was an aneurysmal subarachnoid hemorrhage.

Awake craniotomy. A patient`s perspective.

Objective: To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection. Methods: We carried out a qualitative descriptive survey of patients’ experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital. Results: Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated. Conclusion: Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations.

Meningiomas of the tuberculum and diaphragma sellae.

Introduction Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification. Methods We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height. Results Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI. Conclusion Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.

Perioperative Cerebrospinal Fluid Diversion Utilizing Lumbar Drains in Transsphenoidal Surgery

Lumbar drains (LD) for cerebrospinal fluid (CSF) diversion are commonly used in pituitary surgery. CSF perioperative diversion can be utilized as a prophylactic measure and/or as a first line treatment for CSF rhinorrhea following transsphenoidal pituitary surgery. In theory, lumbar drainage can prevent and/or treat CSF leaks and may preclude reexploration surgery. We performed a literature review to study the value of LDs in decreasing the postoperative CSF leak rates in transsphenoidal surgery and the reported perioperative complications in relation to perioperative LD insertion. We included studies with more than 100 patients, in the period from 2000 to 2012. The overall incidence of postoperative CSF rhinorrhea was 1.7%. Out of 6,401 patients, 385 patients (6%) received LD to prevent postoperative CSF leak or as a therapeutic intervention. Complications with the use of LDs are not common; however, LDs can increase the length of hospitalization. The most common reported complications are headaches and patient discomfort. Major potential morbidities include additional surgery, meningitis, and tension pneumocephalus. Postoperative meningitis rate increases from 0.3% to 3% in cases with LD perioperative usage. The current literature does not provide conclusive evidence that lumbar drainage during pituitary surgery decreases postoperative CSF leaks; however, its use during pituitary surgery is safe and can beneficial in selected cases.

Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection

Background Parasellar invasion of pituitary adenomas (PAs) into the cavernous sinus (CS) is common. The management of the CS component of PA remains controversial. Objective The objective of this study was to analyze CS involvement in PA treated with endoscopic endonasal approaches, including incidence, surgical risks, surgical strategies, long‐term outcomes, and our treatment algorithm. Methods We reviewed a series of 176 surgically treated PA with particular attention to CS involvement and whether the CS tumor was approached medial or lateral to the internal carotid artery. Results The median duration of follow‐up was 36 months. Macroadenomas and nonfunctional adenomas represented 77 and 60% of cases, respectively. CS invasion was documented in 23% of cases. CS involvement was associated with a significantly diminished odds of gross total resection (47 vs. 86%, odds ratio [OR]: 5.2) and increased the need for subsequent intervention (4 vs. 40%, OR: 14.4). Hormonal remission was achieved in 15% of hormonally active tumors. Rates of surgical complication were similar regardless of CS involvement. Conclusion Our tailored strategy beginning with a medial approach and adding lateral exposure as needed resulted in good outcomes with low morbidity in nonfunctional adenomas. Functional adenomas involving the CS were associated with low rates of hormonal remission necessitating higher rates of additional treatment.

The Human Factor and Safety Attitudes in Neurosurgical Operating Rooms

n October 2012, the world watched Austrian skydiver Felix Baumgartner’s free fall jump from a vertical distance of I 36,402.6 m. This jump, heralded as a jump from the “edge of space” broke multiple Fédération Aéronautique Internationale, records. It was clear to all that the success of such a complicated task depended on organization and teamwork. During the event, Baumgartner and his team repeatedly reviewed checklists guiding each step. Each checklist item was sequentially noted and faithfully completed in an effort to eliminate all preventable error. Recently, Atul Gawande in his book, The Checklist Manifesto (8), emphasized the utility of checklists in ensuring safe medical practice.

Spontaneous Sphenoid Wing Meningoencephaloceles with Lateral Sphenoid Sinus Extension: The Endoscopic Transpterygoid Approach

Spontaneous meningoencephalocele (SME) of the sphenoid wing is a rare cause of cerebrospinal fluid (CSF) leakage. Surgical closure of the fistula is usually required. The approach taken depends on the location of the defect and the extension of the meningoencephalocele. The endoscopic transpterygoid approach may be useful. We prospectively analyzed the three cases of SME of the sphenoid wing with lateral sphenoid sinus extension treated endoscopically at Stanford over the last 3 years with regard to imaging findings, operative technique, and operative morbidity. In our three cases, the extent of pterygopalatine fossa (PPF) exposure undertaken, complete in one and partial in two, depended on the defect site. Follow-up ranged from 17 to 25 months. The fistula was completely closed in all three cases. Extant literature reports a 97% rate of successful closure (N = 65 of 67, with a mean follow-up of 25 months) and no major complications. Endoscopic transpterygoid repair is a useful, safe alternative to traditional approaches for repair of SME of the sphenoid wing. Its feasibility depends on the site of the defect, which can be identified by preoperative imaging. Larger PPF exposure and postoperative lumbar drainage of CSF can be useful and have a low risk of morbidity.

Comparison Between Manual and Semiautomated Volumetric Measurements of Pituitary Adenomas

Linear measurements have many limitations. The aim of this study is to compare manual and semiautomated volumetric measurements of pituitary adenomas. Magnetic resonance imaging (MRI) scans of 38 patients with pituitary adenomas were analyzed. Preoperative MRI was acquired on a 1.5 T. MRI volumes of the pituitary adenomas were obtained by two methods: manual (MA) and semiautomated (SA). The concurrent validity for SA and MA methods on 38 patients in the form of correlation coefficient was 0.97 (p < 0.0001). The intraobserver and the interobserver correlation coefficients for SA volumes were both 0.98, as for the intraobserver MA volumes were 0.98. Although the results of both methods are comparable, analysis of volumetric measurements by SA method is more time-efficient than MA segmentation. Precision in volumetric measurement techniques is likely to increase reliability of posttherapeutic monitoring of pituitary adenomas.