Bedjan Behmanesh

Management of Patients with Primary Intramedullary Spinal Cord Glioblastoma.

BACKGROUND Primary intramedullary spinal cord glioblastomas are very rare tumors of the spinal cord. They imply a very poor prognosis because complete surgical resection is not possible as the result of the infiltrative growth of these tumors. The aim of this study is to present our data achieved with an aggressive multimodality treatment. METHODS We retrospectively reviewed our clinical database. All patients with histologically proven intramedullary spinal cord glioblastoma treated in our department were included in this study. RESULTS Four patients with intramedullary spinal cord glioblastoma were identified between 2006 and 2015, all of whom were female. Mean age at the time of surgery was 33.5 years (range 14-50 years). Tumors were located in the cervical region in 2 patients and in the thoracic region in 2 patients. All 4 patients underwent microsurgical biopsy of the tumor. After surgery, all patients received radiation and temozolomide treatment. One patient underwent additional therapy with Bevacizumab, another patient received Rapamycin and Sunitinib, and the third patient received Chlorethyl-cyclohexyl-nitroso-urea and Etoposide as additional therapy after tumor regrowth. Tumor progression occurred in a mean time of 18.2 months (6-32 months). In this series, all patients died as the result of progression of the malignancy; median survival after diagnosis was 32.5 months. CONCLUSIONS The surgical outcome of intramedullary spinal cord glioblastoma still remains poor. Severe disability and amelioration of the neurologic status lead to reduced quality of life; however, an aggressive multimodal and interdisciplinary treatment for the disease may be associated with longer survival.

Noninvasive epicutaneous transfontanelle intracranial pressure monitoring in children under the age of 1 year: a novel technique

Monitoring of intracranial pressure (ICP) may be indicated in children with traumatic brain injury, premature intraventricular hemorrhage, or hydrocephalus. The standard technique is either a direct measurement with invasive intracranial insertion of ICP probes or indirect noninvasive assessment using transfontanelle ultrasonography to measure blood flow. The authors have developed a new technique that allows noninvasive epicutaneous transfontanelle ICP measurement with standard ICP probes. They compared the ICP measurements obtained using the same type of standard probe used in 2 different ways in 5 infants (age < 1 year) undergoing surgery for craniosynostosis. The first ICP probe was implanted epidurally (providing control measurements) and the second probe was fixed epicutaneously on the skin over the reopened frontal fontanelle. ICP values were measured hourly for the first 24 hours after surgery and the values obtained with the 2 methods were compared using Bland-Altman 2-methods analysis. A total of 110 pairs of measurements were assessed. There was no significant difference between the ICPs measured using the epicutaneous transfontanelle method (mean 13.10 mm Hg, SEM 6.68 mm Hg) and the epidural measurements (mean 12.46 mm Hg, SEM 6.45 mm Hg; p = 0.4643). The results of this analysis indicate that epicutaneous transfontanelle measurement of ICP is a reliable method that allows noninvasive ICP monitoring in children under the age of 1 year. Such noninvasive ICP monitoring could be implemented in the therapy of children with traumatic brain injury or intraventricular hemorrhage or for screening children with elevated ICP without invasive intracranial implantation of ICP probes.

Oblique Positioning of the Stereotactic Frame for Biopsies of Cerebellar and Brainstem Lesions.

BACKGROUND Frame-based stereotactic biopsy has proven to be a safe procedure with a high diagnostic yield for patients. Different supratentorial localizations can easily be accessed by standardized stereotactic approaches. Cerebellar and brainstem lesions, however, are not easy to reach because the positioning of the frame pins often makes it impossible to address the entry point properly. METHODS By oblique positioning of the frame, cerebellar and brainstem lesions also can easily be accessed to take tissue samples. CONCLUSION Modification of the standardized positioning of the frame allows for safe and straightforward stereotactic access even to cerebellar and brainstem lesions.

Regional Spinal Cord Atrophy Is Associated with Poor Outcome After Surgery on Intramedullary Spinal Cord Ependymoma: A New Aspect of Delayed Neurological Deterioration

BACKGROUND A considerable number of patients suffer delayed neurologic deficits, even after a successful removal of intramedullary spinal cord ependymoma. The underlying pathology remains unknown. Radiologic findings could provide an explanation for poor outcome after surgery. METHODS We conducted a retrospective study of all cases treated from 1980 to 2016 in our department. The cohort included all patients with intramedullary spinal cord ependymoma treated with microsurgical excision. The cross-sectional area of the spinal cord at the level of the former performed surgery was compared using magnetic resonance imaging (MRI), follow-up MRI, adjacent unaffected levels, and the control group. RESULTS Fifty-four patients with an intramedullary spinal cord lesion were treated in this period. Ependymoma was the predominant tumor (n = 28) followed by intramedullary gliomas and vascular lesions. Mean age (±SD) was 48.2 ± 10.5 years with a female predominance (16 women, 12 men). An unfavorable outcome was observed in 53% of the patients after an initially uneventful postoperative course. The follow-up cross-sectional area of the spinal cord was significantly reduced in these patients compared to adjacent unoperated levels and the control group. Sagittal and axial spinal MRI showed spinal cord narrowing owing to atrophic changes in the area of the performed surgery in 53% of patients with resected ependymoma after a mean follow-up time of 9 years. Functional outcome in ependymoma was significantly associated with spinal cord atrophy (P < 0.05). CONCLUSIONS Spinal cord atrophy seems to be a predicting factor in long-term outcome after surgical removal of intramedullary spinal cord ependymoma.

Biopsies of pediatric brainstem lesions display low morbidity but strong impact on further treatment decisions.

OBJECTIVE The course of malignant brain stem gliomas in childhood is rarely positive. Because of limited therapeutic options and potentially hazardous biopsies oncologist often relay on MRI diagnoses only for further therapy decisions. In this study we show that brain stem biopsies display a low morbidity rate and neuropathological assessment has a considerable impact on further treatment decision. METHODS Within 18-months five children with brainstem symptoms and the radiological diagnosis of a malignant brainstem glioma, were identified. From this time point it was possible to analyze all samples with the 450K methylome analysis. Other neuropathological techniques included classical histology with immunohistochemistry. Surgery was performed as biopsy, either microsurgical, frame-guided (Leksell), robot-assisted (ROSA) or navigated (BrainLab, two children). RESULTS Mean age of the children was 7.5years (range: newborn to 12years). There was no biopsy-related morbidity or mortality. The mean number of taken samples was 12 (range: 1-25). Histologic diagnosis could be established in all children, however, 450K methylome diagnosis was positive in only two out of five patients. CONCLUSION Despite the technically difficult biopsies, all specimens were sufficient for immunohistochemical diagnosis, however, 450K methylome analysis could only be better established where multiple small samples were taken, instead of few larger ones. Based on the preoperative radiological diagnosis suggesting malignant brainstem glioma, all children would have been treated with combined radiation and temozolomid chemotherapy. Nevertheless, due to the availability of histology and molecular diagnostics, individualized therapy could be performed, preventing in two out of five children from unnecessary radiation and chemotherapy.

Immature teratoma of the tectum mesencephali with histopathological detection of rudimentary eye anlage in a 3-year-old boy: Report of a rare case

Intracranial teratoma is a rare neoplasm derived from omnipotent germinal cells that can contain mesoderm, endoderm and/or ectoderm layer tissue. Histologically teratomas are characterized by abnormal structures like teeth or bone that can be further subdivided into mature and immature according to the presence of incompletely differentiated tissue. Characteristic intracranial teratomas are space‐occupying lesions in the pineal region and often present with hydrocephalic symptoms due to aqueduct stenosis. A 3‐year‐old boy presented with a peracute hemiparesis, fatigue and speech deficit. MRI diagnostics showed a cystic, partially solid, inhomogeneous contrast‐enhancing formation at the top of the tectum mesencephali with consecutive aqueduct compression. The patient underwent a sub‐occipital craniotomy via a supracerebellar approach and complete resection was achieved. The histopathological examination mainly showed mature tissue of ectodermal, mesodermal and endodermal origin. However, small areas of undifferentiated neuroectodermal tissue within an optic vesicle formation were detected, leading to the diagnosis of an immature teratoma. In due course, the patient was discharged in good health without neurological deficits. To our knowledge, optic vesicle‐containing intracranial germ cell tumors are extremely rare. Here we report a unique case with immature neuroectodermal tissue within an optic vesicle formation in an otherwise mature teratoma.

The Value of Computed Tomography Imaging of the Head After Ventriculoperitoneal Shunt Surgery in Adults

BACKGROUND Patients with a ventriculoperitoneal shunt for hydrocephalus often undergo multiple follow-up computed tomography (CT) scans of the head, increasing the risk for long-term effects of ionizing radiation. The purpose of our study was to evaluate the necessity as a routine diagnostic procedure and cost analysis of routine postoperative CT scan of the head after ventriculoperitoneal shunt surgery. METHODS In this study, we comprised adults with ventriculoperitoneal shunt operations who underwent early CT scans within 48 hours postoperatively. We reviewed the correlation between revision surgery rate and the experience of surgeons who performed surgery and provided a cost analysis. RESULTS In total, 479 surgeries were performed in 439 patients. Early revision surgery was performed in 11 (2.3%) patients. Reason for revision surgery was malposition in 9 cases and intracerebral hemorrhage in 2 patients. There was no significant correlation between the surgeons experience and the rate of revision surgery. Placement of the ventricular catheter via an approach other than a standard right or left frontal burr hole resulted in risk of need for surgical shunt revision (P ≥ 0.002, odds ratio 54, confidence interval 13.5-223). A total of 468 CT scans of the head revealed a normal finding; thus, ∼

The clinical relevance of ABO blood type in 100 patients with acute subdural hematoma

562,000 could be saved by omitting postoperative head CT scans. CONCLUSIONS Routine postoperative head CT scans after fentriculoperitoneal shunting are not necessary in all cases. The reduction of exposure to ionization radiation and the beneficial economic factor are main advantages.

Dexamethasone-induced leukocytosis is associated with poor survival in newly diagnosed glioblastoma

Objective The correlation of depleted blood through midline shift in acute subdural hematoma remains the most reliable clinical predictor to date. On the other hand, patient’s ABO blood type has a profound impact on coagulation and hemostasis. We conducted this study to evaluate the role of patient’s blood type in terms of incidence, clinical course and outcome after acute subdural hematoma bleeding. Methods 100 patients with acute subdural hematoma treated between 2010 and 2015 at the author’s institution were included. Baseline characteristics and clinical findings including Glasgow coma scale, Glasgow outcome scale, hematoma volume, rebleeding, midline shift, postoperative seizures and the presence of anticoagulation were analyzed for their association with ABO blood type. Results Patient’s with blood type O were found to have a lower midline shift (p<0.01) and significantly less seizures (OR: 0.43; p<0.05) compared to non-O patients. Furthermore, patients with blood type A had the a significantly higher midline shift (p<0.05) and a significantly increased risk for postoperative seizures (OR: 4.01; p<0.001). There was no difference in ABO blood type distribution between acute subdural hematoma patients and the average population. Conclusion The ABO blood type has significant influence on acute subdural hematoma sequelae. Patient’s with blood type O benefit in their clinical course after acute subdural hematoma whereas blood type A patients are at highest risk for increased midline shift and postoperative seizures. Further studies elucidating the biological mechanisms of blood type depended hemostaseology and its role in acute subdural hematoma are required for the development of an appropriate intervention.

Influence of ABO blood type on the outcome after non-aneurysmal subarachnoid hemorrhage

Despite its well-characterized side effects, dexamethasone is widely used in the pre-, peri- and postoperative neurosurgical setting due to its effective relief of tumor-induced symptoms through the reduction of tumor-associated edema. However, some patients show laboratory-defined dexamethasone induced elevation of white blood cell count, and its impact on glioblastoma progression is unknown. We retrospectively analyzed 113 patients with newly diagnosed glioblastoma to describe the incidence, risk factors and clinical features of dexamethasone-induced leukocytosis in primary glioblastoma patients. We further conducted an immunohistochemical analysis of the granulocyte and lymphocyte tumor-infiltration in the available corresponding histological sections. Patient age was identified to be a risk factor for the development of dexamethasone-induced leukocytosis (p < 0.05). The presence of dexamethasone-induced leukocytosis decreased overall survival (HR 2.25 95% CI [1.15–4.38]; p < 0.001) and progression-free survival (HR 2.23 95% CI [1.09–4.59]; p < 0.01). Furthermore, patients with dexamethasone-induced leukocytosis had significantly reduced CD15 + granulocytic- (p < 0.05) and CD3 + lymphocytic tumour infiltration (p < 0.05). We identified a subgroup of glioblastoma patients that are at particularly high risk for poor outcome upon dexamethasone treatment. Therefore, restrictive dosage or other edema reducing substances should be considered in patients with dexamethasone-induced leukocytosis.