Matthew Crocker

Serum angiogenic profile of patients with glioblastoma identifies distinct tumor subtypes and shows that TIMP-1 is a prognostic factor

Angiogenesis plays a key role in glioblastoma biology and antiangiogenic agents are under clinical investigation with promising results. However, the angiogenic profiles of patients with glioblastoma and their clinical significance are not well understood. Here we characterize the serum angiogenic profile of patients with glioblastoma, and examine the prognostic significance of individual angiogenic factors. Serum samples from 36 patients with glioblastoma were collected on admission and simultaneously assayed for 48 angiogenic factors using protein microarrays. The data were analyzed using hierarchical cluster analysis. Vessel morphology was assessed histologically after immunostaining for the pan-endothelial marker CD31. Tumor samples were also immunostained for tissue inhibitor of metalloproteinase-1 (TIMP-1). Cluster analysis of the serum angiogenic profiles revealed 2 distinct subtypes of glioblastoma. The 2 subtypes had markedly different tumor microvessel densities. A low serum level of TIMP-1 was associated with significantly longer survival independent of patient age, performance status, or treatment. The serum angiogenic profile in patients with glioblastoma mirrors tumor biology and has prognostic value. Our data suggest the serum TIMP-1 level as an independent predictor of survival.

Symptomatic venous sinus thrombosis following bone wax application to emissary veins.

A retrosigmoid craniectomy was performed for acoustic neuroma during which bone wax was used to control emissary vein bleeding. Postoperatively the patient developed an extensive venous thrombosis due to wax in the sigmoid sinus from which she recovered. We discuss this rare complication of posterior fossa surgery.

Modified acrylic cranioplasty for large cranial defects

OBJECTIVE To describe a novel technique for constructing polymethylmethacrylate (acrylic) cranioplasty to repair large cranial defects. METHODS A rim of bone is cut from the edge of the skull defect using a craniotome. This bony rim provides a scaffold to fashion the acrylic cement away from the patient thus avoiding thermal injury to the brain. The inner edge of the bony rim is drilled circumferencially to form a groove. Acrylic is then used to fill the defect in the bony rim with continuous manipulation of the paste from both sides to form a dome in the shape of the skull. The groove allows the edge of the acrylic dome to fit snugly with the bony rim thus avoiding sinking. The final cranioplasty, comprised of the hardened acrylic dome with the surrounding bone rim, is firmly attached to the skull with bioplates. RESULTS We used the modified acrylic cranioplasty technique in three patients. Modified acrylic cranioplasty is cheaper and immediately available, compared with ten cases of titanium cranioplasty, with similar cosmetic outcome, intraoperative blood loss and operating theatre time. CONCLUSION Our technique is quick and easy to perform, avoids thermal injury to the brain and produces a strong implant with excellent cosmesis even with large bony defects.

Delays in treating patients with good grade subarachnoid haemorrhage in London.

Background and purpose. Spontaneous aneurysmal subarachnoid haemorrhage (SAH) is managed as a neurosurgical priority with guidelines and published literature emphasising the identification and the treatment of the ruptured aneurysm within 48 h of ictus. We audited the timing of management of good grade (WFNS 1 & 2) SAH in a neurosurgical unit in Greater London. We also reviewed the available services for treating SAH within Greater London. Materials and methods. Retrospective audit of patients admitted with SAH to St. Georges Hospital between 31 May 2007 and 31 May 2009 was performed. Prospective telephone and public record review of the catchment area and neurovascular provisions of the seven London neurosurgical units were assessed. Results. There were 141 WFNS grade 1 and 2 SAH patients admitted. Only a quarter were treated within 48 h of ictus. Patients destined for endovascular treatment waited significantly longer periods until treatment when compared with that of clipping group patients. The day of the week on which diagnostic angiography occurred was critical in determining treatment delays, probably due to the lack of routine provision of clipping at weekends and next day coiling services. We estimated that 440 good grade SAH are admitted per annum in Greater London. There are 20 neurovascular surgeons and 16 interventional neuroradiologists across seven neurosurgical units that routinely treat SAH. Conclusions. We have identified significant delays in treating three quarters of good grade SAH patients in London. This appears to be due to a lack of next day treatment availability. A collaborative strategy between the seven London neurosurgical units could reduce treatment delays.

Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better?

Introduction. District general hospital scanners have historically been linked to regional neuroscience units for specialist opinions on scans and to make decisions on transfer of patients requiring neurosurgical management. The implementation of digital picture archiving and communication systems (PACS) in all hospitals in the UK has disrupted these dedicated links and technical and information governance issues have delayed reprovision of electronic transfer of images for rapid expert decision making in this group of patients. We studied improvement in image transfer to acute neurosurgery units over a 4-year period. Methods. Four-year sequential review of national provision of image transfer facilities into neurosurgery units; observational study of delays associated with image transfer modalities in one representative tertiary referral centre. Results. During the 4 years of study, all hospitals nationally have implemeted digital PACS systems for image viewing. Remote image viewing facilities have gradually changed with dedicated image links being replaced by remote PACS access. However, a minority of referrals (12%) still require images to be physically transferred between hospitals using couriers for CD-ROMs. The detailed study within our own unit shows that this adds a mean delay of 5.8 h to decision making. Conclusions. Image transfer in neuroscience has been neglected following the shift to PACS servers. The recommendations of the 2004 Neuroscience Critical Care Report are unmet and patient safety is being threatened by a continued failure to implement a coordinated solution to this problem.

Three-dimensional semi-automatic segmentation of intracranial aneurysms in CTA

This paper proposes a method for the semi-automatic segmentation of cerebral aneurysms from CTA datasets. The method consists of two phases: a region growing-based approach followed by a level set method, firstly to extract the cerebral artery and then to segment the aneurysm. The first phase automatically locates a seed point for initialization of the region growing in a seed slice, detection of which is based on a measure of maximum entropy, combined with prior anatomical knowledge. Two masks are defined to confine the region growing. A halting criterion is defined as the intensity difference between each voxel and its neighbour.

Sir Victor Horsley (1857-1916): lessons for the modern clinician

Sir Victor Horsley is well known for his pioneering work as a neurological surgeon but his vital contributions to the regulation and advancement of the medical profession are less well understood. This archived literature review of The Horsley collection of papers (UCL Special Collections Library) documents Sir Victors campaign for the autonomy of the stagnating medical profession of over a century ago. These lessons should empower modern clinicians to retain the professionalism they worry about losing.

Glioblastoma blood flow measured with stable xenon CT indicates tumor necrosis, vascularity, and brain invasion

Tumor vasculature is a promising therapeutic target in glioblastoma. Imaging tumor blood flow may help assess the efficacy of anti-angiogenic treatments. We determined the clinical usefulness of stable xenon CT performed preoperatively in patients with glioblastoma. This is a prospective cohort study. We determined absolute tumor blood flow before surgery in 38 patients with glioblastoma using stable xenon CT. We also histologically examined tumor specimens obtained from surgery and quantified their vascularity (by CD31 and CD105 immunostain), necrosis (by hematoxylin and eosin stain), and the presence of neuronal processes (by neurofilament immunostain). According to the xenon CT blood flow map, there are 3 types of glioblastoma. Type I glioblastomas have unimodal high blood flow histograms; histologically there is little necrosis and vascular proliferation. Type II glioblastomas have unimodal low blood flow histograms; histologically there is prominent necrosis and vascular proliferation. We propose that in type II glioblastoma, the abnormal vessels induced by hypoxia are inefficient at promoting blood flow. Type III glioblastomas have multimodal blood flow histograms. Histologically there is significant neuronal tissue within the tumor. Patients with type III glioblastomas were more likely to develop a post-surgical deficit, consistent with the inclusion of normal tissue within the tumor. Preoperative measurement of absolute blood flow with stable xenon CT in patients with glioblastoma predicts key biological features of the tumor and may aid surgical planning.

Oxford case histories in neurosurgery

Oxford case histories in neurosurgery / , Oxford case histories in neurosurgery / , کتابخانه دیجیتال جندی شاپور اهواز

Surgery for Spinal Tumours

This chapter considers surgical management of spinal tumours. Surgical considerations for spinal tumours relate to various clinical aspects: the nature of the patient’s symptoms and the prospect of surgery improving them or at least preventing decline, either due to continued growth of the tumour or bony destruction and instability. There is in addition the prospect of surgery being curative for benign tumours or rarely for isolated malignant tumours. Surgical considerations include the presence of disease elsewhere, the ease of complete or substantial resection of a tumour, or more simple surgery to relieve mass effect on neural structures. Spinal tumour surgery is complicated by the issue of stability and the need to stabilize the diseased spine in the presence of overt or impending mechanical failure causing neurological compression or intolerable pain. This is facilitated by many modern medical devices. Tumours of the spine are categorized according to their anatomical relations to the dura and the structures they arise from. Careful preoperative assessment, judicious use of modern equipment and techniques and good working relations with colleagues in other specialties will continue to underpin best management.