Eleftherios Archavlis

Salvage therapy for recurrent glioblastoma multiforme: a multimodal approach combining fluorescence-guided resurgery, interstitial irradiation, and chemotherapy.

Abstract Objectives: Several studies have revealed that different salvage treatments in glioblastoma multiforme patients presenting a recurrence have limited palliative treatment options. The aim of this study was to evaluate the utility and limitations of multimodal salvage treatments in recurrent glioblastoma multiforme patients combining 5-aminolevulinic acid (5-ALA) fluorescence-guided resurgery, interstitial irradiation, and dense dose temozolomide chemotherapy (ddTMZ). Methods: Seventeen consecutive patients with recurrent globlastoma multiforme underwent a combined scheme of salvage treatments including fluorescence-guided reoperation, high dose rate (HDR) brachytherapy, and ddTMZ chemotherapy and were included in this prospective study. This multimodal treatment group was compared with a 1∶1 matched historical control group of 17 patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. All patients were previously treated with surgery of the primary pathology, concomitant, and adjuvant radiochemotherapy with temozolomide. Results: Median follow-up was 32 months (range: 28–36 months). Median survival was 9 months for the entire cohort after salvage treatment and can be translated into a 3-month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P  =  0·043). Complications rates of multimodal salvage treatment were comparable with the temozolomide control group. Discussion: Our experience suggests that a combined salvage treatment plan have the advantages of all three methods and, thus, provide additional survival benefit and can be considered in selected patients affected by recurrent high grade gliomas. Nonetheless, more cases and additional studies are necessary to further prove the advantages of this multimodal treatment.

Cerebral vasospasm: a review of current developments in drug therapy and research

Abstract In this manuscript a comprehensive coverage of recent developments in the drug therapy of vasospasm while providing the background information that neuroscientists need to understand its rationale. The range of new agents

A Modified Microsurgical Endoscopic-Assisted Transpedicular Corpectomy of the Thoracic Spine Based on Virtual 3-Dimensional Planning

BACKGROUND AND OBJECTIVE The main difficulties of transpedicular corpectomies are lack of space for vertebral body replacement in the neighborhood of critical structures, the necessity for sacrifice of nerve roots in the thoracic spine. and the extent of hemorrhage due to venous epidural bleeding. We present a modified technique of transpedicular corpectomy by using an endoscopic-assisted microsurgical technique performed through a single posterior approach. A 3-dimensional (3D) preoperative reconstruction could be helpful in the planning for this complex anatomic region. METHODS Surface and volume 3D reconstruction were performed by Amira or the Dextroscope. The clinical experience of this study includes 7 cases, 2 with an unstable burst fracture and 5 with metastatic destructive vertebral body disease, all with significant retropulsion and obstruction of the spinal canal. We performed a comparison with a conventional cohort of transpedicular thoracic corpectomies. RESULTS Qualitative parameters of the 3D virtual reality planning included degree of bone removal and distance from critical structures such as myelon and implant diameter. Parameters were met in each case, with demonstration of optimal positioning of the implant without neurological complications. In all patients, the endoscope was a significant help in identifying the origins of active bleeding, residual tumor, extent of bone removal, facilitating cage insertion in a minimally invasive way, and helping to avoid root sacrifice on both sides. CONCLUSIONS Microsurgical endoscopic-assisted transpedicular corpectomy may prove valuable in enhancing the safety of corpectomy in destructive vertebral body disease. The 3D virtual anatomic model greatly facilitated the preoperative planning.

Combined suture and clipping for the reconstruction of a ruptured blister-like aneurysm

Blister-like aneurysms of the internal carotid artery (ICA) present a severe therapeutical challenge. While several reconstructive techniques are in use in case of acute rupture sacrifice of the parent vessel may be required. We present a combined technique of micro-sutures and clip application to repair the parent vessel in an intraoperatively ruptured blister-like aneurysm. Following temporary trapping of an intraoperatively ruptured 7-mm blister-like aneurysm four 8-0 nylon sutures were applied to adapt the vessel walls and support the branches of subsequently applied mini-clips. The combination of micro-sutures and mini-clips might be a valuable alternative to direct clipping or suturing in some cases with intraoperative rupture of blister-like aneurysms.

Corpectomy in destructive thoracolumbar spine disease: Cost-effectiveness of 3 different techniques and implications for cost reduction of delivered care.

Study Design. Retrospective cohort study. Objective. To give some insight in balancing cost and effectiveness of 3 different techniques of corpectomy in destructive thoracolumbar spine disease. Summary of Background Data. Although there are several accepted methods of surgical treatment of single-level corpectomy in destructive metastatic thoracolumbar spine disease, the choice depends on the surgeons preference. The techniques may vary in perioperative morbidity and short- and long-term outcome, but no study so far has analyzed their cost-effectiveness. Methods. Seventy-five consecutive patients, mean age of 57 years (range: 39–72 yr) with single-level destructive thoracolumbar lesion underwent surgical treatment with 3 different techniques in 2 centers from 2009 to 2013. The 3 groups were (1) mini open transpedicular corpectomy, (2) conventional open transpedicular corpectomy, and (3) the combined posterior-anterior approach. The data were collected prospectively according to our protocol and subsequently analyzed. The clinical outcome was assessed comparing visual analogue scale score of back pain and the short form 12 (SF-12) questionnaire both pre- and postoperatively. The cost analysis was done calculating the operative time, hospital stay, and the implant cost. Results. The mean follow-up period was 25 months (range: 24–30 mo). The clinical outcome in terms of visual analogue scale score of thoracolumbar pain and SF-12 physical and mental score improvement (P < 0.005) were comparable with all 3 techniques. The radiological outcome was comparable with current available data. As the intensive care unit stay (average: 7 d) and the hospital stay were longer (average: 15 d) with combined posterior-anterior approach, the total cost was maximum (average: &OV0556;20,952) with this group. Conclusion. Using the posterior approach only was the most cost-effective technique, but the mini open was comparable with the conventional open transpedicular approach. Level of Evidence: 3

Preliminary Results of Minimally Invasive Decompression, TLIF and Percutaneous Pedicle Screw Insertion in Stenotic Spondylolisthesis with Severe Facet Joint Osteoarthritis

Object: Minimally invasive spine (MIS) procedures are increasingly being recognized as equivalent to open procedures with regard to clinical and radiographic outcomes. These techniques are also believed to result in less pain and disability in the immediate postoperative period. There are, however, little data to assess whether these procedures in combination with minimally invasive transforaminal interbody fusion (MI-TLIF) and percutaneous pedicle screw insertion are effective in complex cases of stenotic degenerative spondylolisthesis with severe facet joint osteoarthritis (FJO). Methods: This study retrospectively reviewed all patients who underwent lumbar instrumentation, fusion and decompression for degenerative spondylolisthesis with severe stenosis and facet joint osteoarthritis (FJO) between June 2010 and June 2011. Blood loss, operative time and intraoperative complications were assessed in all surgically treated patients who were treated with MIS decompression, MI-TLIF and percutaneous transpedicular instrumentation. Clinical outcome was measured using the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for back pain, leg pain, and activity level. Satisfaction was assessed with VAS for satisfaction. Radiological follow-up includes x-ray films, computed tomography and in some cases magnetic tomography scan. Results: Twenty four cases with severe stenotic changes accompanied by severe FJO were treated with minimally invasive procedure. The minimum follow-up was 6 months with a mean of 8 months. The mean preoperative ODI score was 46.8, decreasing to a mean of 23 postoperatively. The mean VAS leg and back pain scores were 67.5 improving to means of 25.8. Twenty one out of 24 cases experienced a clinical benefit according to VAS for satisfaction and ODI. Complications included wound healing disturbance (4%), CSF fistula (4%) and contralateral radiculopathy due to articular bone spurs (8%). The accuracy of pedicle screws was high and only one revision surgery was performed. Conclusion: MIS for severe stenotic spondylolisthesis leads to adequate and safe decompression of lumbar stenosis and results in a highly significant reduction of symptoms and disability. MIS-TLIF and percutaneous pedicle screw insertion constitute a promising treatment alternative for patients with severe stenosis and facet joint osteoarthritis.

A novel minimally invasive, dorsolateral, tubular partial odontoidectomy and autologous bone augmentation to treat dens pseudarthrosis: cadaveric, 3D virtual simulation study and technical report

OBJECTIVE The goal of this study was to demonstrate the clinical and technical nuances of a minimally invasive, dorsolateral, tubular approach for partial odontoidectomy, autologous bone augmentation, and temporary C1-2 fixation to treat dens pseudarthrosis. METHODS A cadaveric feasibility study, a 3D virtual reality reconstruction study, and the subsequent application of this approach in 2 clinical cases are reported. Eight procedures were completed in 4 human cadavers. A minimally invasive, dorsolateral, tubular approach for odontoidectomy was performed with the aid of a tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT, using 3D volumetric averaging software, were used to evaluate the degree of bone removal of C1-2 lateral masses and the C-2 pars interarticularis. Two clinical cases were treated using the approach: a 23-year-old patient with an odontoid fracture and pseudarthrosis, and a 35-year-old patient with a history of failed conservative treatment for odontoid fracture. RESULTS At 8 cadaveric levels, the mean volumetric bone removal of the C1-2 lateral masses on 1 side was 3% ± 1%, and the mean resection of the pars interarticularis on 1 side was 2% ± 1%. The median angulation of the trajectory was 50°, and the median distance from the midline of the incision entry point on the skin surface was 67 mm. The authors measured the diameter of the working channel in relation to head positioning and assessed a greater working corridor of 12 ± 4 mm in 20° inclination, 15° contralateral rotation, and 5° lateral flexion to the contralateral side. There were no violations of the dura. The reliability of C-2 pedicle screws and C-1 lateral mass screws was 94% (15 of 16 screws) with a single lateral breach. The patients treated experienced excellent clinical outcomes. CONCLUSIONS A minimally invasive, dorsolateral, tubular odontoidectomy and autologous bone augmentation combined with C1-2 instrumentation has the ability to provide excellent 1-stage management of an odontoid pseudarthrosis. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to provide not only a less invasive approach but also a function-preserving option to treat complex C1-2 anterior disease.

Unique case of trigeminal neuralgia due to Epstein-Barr-virus-associated B-cell lymphomatoid granulomatosis of the Meckel's cave and cavernous sinus: Important clinical and therapeutic implications

Background: Trigeminal neuralgia (TN) represents one of the most disabling pain syndromes. Several diseases have been described as etiological triggers of TN, vascular compression of the trigeminal nerve being the most frequent cause. Here, we describe for the first time a rare case of TN caused by an infiltration of an isolated Epstein–Barr virus (EBV) B-cell lymphomatoid granulomatosis (LYG) mass into the Meckels cave and cavernous sinus. Case Description: A 51-year-old woman undergoing immunosuppressant treatment for Crohns disease presented due to right-sided TN. Magnetic resonance imaging (MRI) scans revealed an isolated lesion affecting the right Meckels cave and lateral wall of the cavernous sinus. We accomplished tumor resection through a subtemporal extradural approach and the patient recovered successfully from surgery. Histological examination revealed an LYG, and a blood test confirmed low but positive EBV counts. The immunosuppressant therapy was discontinued and we assumed a watchful waiting management. During a 41-months’ follow-up there was neither evidence of LYG recurrence nor an increase of EBV counts. Conclusions: LYG, an angiodestructive disease associated with EBV reactivation in the context of immune dysfunction and often associated with an aggressive behavior or even malignant transformation, should be considered as a rare differential diagnosis of TN associated with skull base lesions. The management of this rare disease is still controversial and varies from limiting the treatment to correcting immune dysfunction up to chemotherapy. In this case of an isolated mass, surgical excision and discontinuation of immunosuppressants were effective to prevent the relapse of the disease in a long-term follow-up.

Rates of Upper Facet Joint Violation in Minimally Invasive Percutaneous and Open Instrumentation: A Comparative Cohort Study of Different Insertion Techniques

Background Minimally invasive pedicle screw placement may have a higher incidence of violation of the superior cephalad unfused facet joint. Study Aims We investigated the incidence and risk factors of upper facet joint violation in percutaneous robot‐assisted instrumentation versus percutaneous fluoroscopy‐guided and open transpedicular instrumentation. Methods A retrospective study including all consecutive patients who underwent lumbar instrumentation, fusion, and decompression for spondylolisthetic stenosis and degenerative disk disease was conducted between January 2012 and January 2016. All operations were performed by the same surgeon; the patients were divided into three groups according to the method of instrumentation. Group 1 involved the robot‐assisted instrumentation in 58 patients, group 2 consisted of 64 patients treated with a percutaneous transpedicular instrumentation using fluoroscopic guidance, and 72 patients in group 3 received an open midline approach for pedicle screw insertion. Results Superior segment facet joint violation occurred in 2 patients in the robot‐assisted group 1 (7%), in 22 of the percutaneous fluoroscopy‐guided group 2 (34%), and in 6 cases of the open group (8%). The incidence of facet joint violation was present in 5% (3) of the screws in group 1, 22% (28) of the screws in group 2, and 3% (4) of the screws in group 3. Conclusion Meticulous surgical planning of the appropriate entry site (Weinsteins method), trajectory planning, and proper robot‐assisted instrumentation of pedicle screws reduced the risk of superior segment facet joint violation.

Spinal Intradural Intramedullary Dissemination in the Absence of Intracranial Relapse of a Previously Radically Treated Temporal Lobe Glioblastoma Multiforme

Intracranial glioblastoma multiforme (GBM) constitutes the most frequent and unfortunately aggressive primary central nervous system malignancy. Despite the high tendency of these tumors to show local relapse within the brain after primary therapy, dissemination into the spinal axis is an infrequent event. If spinal metastases occur they are leptomeningeal in the vast majority of cases and always in the context of intracranial progressive disease. Spinal intramedullary metastases of intracranial GBM have rarely been described to date. We report the unique case of a young woman with subacute progressive paraparesis due to spinal intramedullary metastases of a temporal lobe GBM despite the remarkable absence of intracranial tumor relapse. The patient had undergone gross total resection of a left temporal GBM in contact with the ventricles and cisternal space followed by radio- and chemotherapy 13 months before. At the moment of diagnosis of spinal intramedullary metastases, there were no signs of intracranial tumor recurrence as revealed by MRI scans. Since a high level of suspicion may be needed to detect this rare evolution of intracranial GBM and other differential diagnoses must be ruled out at presentation, we discuss the important features of this case regarding clinical manifestation, diagnosis, surgery, and management. Furthermore, we mention possible factors that may have contributed to the development of these metastases in the context of intracranial remission.