Robert Corns

Long-term results of carmustine wafer implantation for newly diagnosed glioblastomas: a controlled propensity-matched analysis of a French multicenter cohort

BACKGROUNDnThe standard of care for newly diagnosed glioblastoma is maximal safe surgical resection, followed by chemoradiation therapy. We assessed carmustine wafer implantation efficacy and safety when used in combination with standard care.nnnMETHODSnIncluded were adult patients with (n = 354, implantation group) and without (n = 433, standard group) carmustine wafer implantation during first surgical resection followed by chemoradiation standard protocol. Multivariate and case-matched analyses (controlled propensity-matched cohort, 262 pairs of patients) were conducted.nnnRESULTSnThe median progression-free survival was 12.0 months (95% CI: 10.7-12.6) in the implantation group and 10.0 months (9.0-10.0) in the standard group and the median overall survival was 20.4 months (19.0-22.7) and 18.0 months (17.0-19.0), respectively. Carmustine wafer implantation was independently associated with longer progression-free survival in patients with subtotal/total surgical resection in the whole series (adjusted hazard ratio [HR], 0.76 [95% CI: 0.63-0.92], P = .005) and after propensity matching (HR, 0.74 [95% CI: 0.60-0.92], P = .008), whereas no significant difference was found for overall survival (HR, 0.95 [0.80-1.13], P = .574; HR, 1.06 [0.87-1.29], P = .561, respectively). Surgical resection at progression whether alone or combined with carmustine wafer implantation was independently associated with longer overall survival in the whole series (HR, 0.58 [0.44-0.76], P < .0001; HR, 0.54 [0.41-0.70], P < .0001, respectively) and after propensity matching (HR, 0.56 [95% CI: 0.40-0.78], P < .0001; HR, 0.46 [95% CI: 0.33-0.64], P < .0001, respectively). The higher postoperative infection rate in the implantation group did not affect survival.nnnCONCLUSIONSnCarmustine wafer implantation during surgical resection followed by the standard chemoradiation protocol for newly diagnosed glioblastoma in adults resulted in a significant progression-free survival benefit.

Vascular neurosurgery following the International Subarachnoid Aneurysm Trial: modern practice reflected by subspecialization

OBJECTnIn this paper the authors goal was to report on and examine (in the context of a large hospital with good endovascular intervention provisions) the activities of a neurosurgeon with a dedicated vascular interest in the era after the International Subarachnoid Aneurysm Trial in the United Kingdom. They also aimed to establish therapeutic trends and outcomes.nnnMETHODSnThe authors reviewed the multidisciplinary team activity of 1 neurosurgeon and 2 interventional radiologists during a period of 22 months (2005-2007). They reviewed 281 aneurysm interventions; the majority was used to treat subarachnoid hemorrhage. Data analysis showed a strong preference for endovascular treatment for acute rupture (86.6 vs 13.4%), with a progressively greater role for open microsurgery in the more elective context (57% endovascular vs 43% surgical). They also reviewed 66 interventions for arteriovenous malformations, of which only 6 were surgical. These data are compared against a sample year from 2001 to 2002 (pre-International Subarachnoid Aneurysm Trial), showing comparable rates of surgically treated aneurysms versus endovascularly treated aneurysms, but an increase overall in the number of patients requiring open surgery.nnnRESULTSnThe authors found that excellent outcomes for microsurgical clipping compared with endovascular therapy can be achieved within the current climate. These and previously published data strongly support a continuing role for vascular neurosurgery as a subspecialist interest in combination with a dedicated endovascular service and a multidisciplinary team.nnnCONCLUSIONSnDespite a trend to prefer coiling for ruptured aneurysms, the authors have shown that there is still a vital role for open surgery in the management of the ruptured and unruptured aneurysm. They consider the remaining role for surgery for arteriovenous malformations within the modern era of endovascular therapy.

Decreased calbindin-D28k immunoreactivity in aged rat sympathetic pelvic ganglionic neurons.

The rat major pelvic ganglion contains the majority of sympathetic and parasympathetic postganglionic neurons that innervate the pelvic viscera. Previous studies have indicated that it is only the sympathetic population of this ganglion that is susceptible to age-associated changes. We have examined the distribution of the neuronal calcium binding proteins calbindin-D28k, calretinin and parvalbumin by immunohistochemistry in young adult and aged rats and have discovered that calbindin-D28k is only present in the sympathetic neurons (identified by tyrosine hydroxylase immunostaining) and not in parasympathetic neurons (identified by VIP immunostaining). In the aged rats the number of calbindin-immunoreactive sympathetic neurons of the major pelvic ganglion was dramatically reduced. Calretinin and parvalbumin-immunoreactivity was present at a lower level of fluorescence than that of calbindin immunoreactivity in all the neurons of the major pelvic ganglion and this level was unchanged in aged rats. Thus we suggest that the decline of intracellular calbindin D28k levels may lead to impaired calcium buffering capacity which might be a contributory factor in the age-associated attrition of pelvic sympathetic neurons.

Anterior cervical discectomy and fusion versus posterior cervical foraminotomy in the treatment of brachialgia: the Leeds spinal unit experience (2008–2013)

BackgroundThe surgical management of cervical brachialgia utilising anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF) is a controversial area in spinal surgery. Previous studies are limited by utilisation of non-validated outcome measures and, importantly, absence of pre-operative analysis to ensure both groups are matched. The authors aimed to compare the effectiveness of ACDF and PCF using validated outcome measures. To our knowledge, it is the first study in the literature to do this.MethodsThe authors conducted a 5-year retrospective review (2008–2013) of outcomes following both the above procedures and also compared the effectiveness of both techniques. Patients with myelopathy and large central discs were excluded. The main outcome variables measured were the neck disability index (NDI) and visual analogue scores (VAS) for neck and arm pain pre-operatively and again at 2-year follow-up. The Wilcoxon signed-rank test and Student t-tests were used to test differences.ResultsA total of 150 ACDFs and 51 PCFs were performed for brachialgia. There was no differences in the pre-operative NDI, VAS neck and arm scores between both groups (pu2009>u20090.05). As expected, both ACDF and PCF delivered statistically significant improvement in NDI, VAS-neck and VAS-arm scores. The degree of improvement of NDI, VAS-neck and VAS-arm were the same between both groups of patients (pu2009>u20090.05) with a trend favouring the PCF group. In the ACDF group, two (1.3xa0%) patients needed repeat ACDF due to adjacent segment disease. One patient (0.7xa0%) needed further decompression via a foraminotomy. In the PCF group one (2.0xa0%) patient needed ACDF due to persistent brachialgia.ConclusionsWe found both interventions delivered similar improvements in the VAS and NDI scores in patients. Both techniques may be appropriately utilised when treating a patient with cervical brachialgia.

Prevalence of recurrence and retreatment of ruptured intracranial aneurysms treated with endovascular coil occlusion

Abstract Object. Endovascular coiling is a common treatment for ruptured intracranial aneurysms. However, concerns have been raised over the durability of this treatment. The aim of this study was to establish the rate of recurrence and retreatment of coiled aneurysms treated in our unit. Methods. We performed a retrospective analysis of 264 surviving patients with ruptured aneurysms treated by endovascular coiling between November 2003 and April 2007. Data was collected on patient age, location of aneurysm, angiogram results and any subsequent retreatment. Results. Follow-up angiography performed at 6 months was available in 239 cases (91%) and revealed 158 (66%) aneurysms completely occluded, 51 (21%) had neck recurrence and 31 (13%) had significant recurrence. Thirty (12.6%) aneurysms required retreatment over a mean follow-up period of 46 (range 24–66) months. Younger age predisposed to a higher risk of recurrence and retreatment. Aneurysms of the anterior communicating and anterior cerebral arteries were less likely to recur or require retreatment (relative risk 0.42 and 0.29, respectively); aneurysms of the posterior communicating arteries were more likely to recur (relative risk 2.22). Aneurysms of the basilar and carotid arteries were more likely to undergo retreatment (relative risk 2.84 and 2.46, respectively). Conclusion. Long-term follow-up is required for ruptured aneurysms treated by coiling. Certain subgroups may require closer follow-up due to the increased risk of recurrence or retreatment, such as younger patients and those with aneurysms of the posterior communicating, basilar or carotid arteries.

Chondromyxoid fibroma of the skull base invading the occipitocervical junction: report of a unique case and discussion.

Chondromyxoid fibroma (CMF) is a rare bone tumor representing less than 1% of total bone neoplasms. It is a slow-growing, locally destructive tumor that usually affects the metaphyseal region of long bones. The occurrence of this tumor in the skull base or cervical spine is exceptionally rare. We present the first case of CMF originating in the clivus and extending into the atlas and discuss the surgical management of this case.

Resection of olfactory groove meningioma - a review of complications and prognostic factors

Introduction. High complication rates have been cited following olfactory groove meningioma (OGM) resection but data are lacking on attendant risk factors. We aimed to review the complications following OGM resection and identify prognostic factors. Methods. A retrospective review was performed on 34 consecutive patients who underwent primary OGM resection at a single London institution between March 2008 and February 2013. Collected data included patient comorbidities, pre-operative corticosteroid use, tumour characteristics, imaging features, operative details, extent of resection, histology, use of elective post-operative ventilation, complications, recurrence and mortality. Results. Complication rate was 39%. 58% of complications required intensive care or re-operation. Higher complication rates occurred with OGM > 40 mm diameter versus ≤ 40 mm (53 vs. 28%; p = 0.16); OGM with versus without severe perilesional oedema (59 vs. 19%; p = 0.26), more evident when corrected for tumour size; and patients receiving 1–2 days versus 3–5 days of pre-operative dexamethasone (75 vs. 19%; p = 0.016). Patients who were electively ventilated post-operatively versus those who were not had higher risk tumours but a lower complication rate (17 vs. 44%; p = 0.36) and a higher proportion making a good recovery (83 vs. 55%; p = 0.20). Complete versus incomplete resection had a higher complication rate (50 vs. 23%; p = 0.16) but no recurrence (0 vs. 25%; p = 0.07). Conclusion. Risk of morbidity with OGM resection is high. Higher complication risk is associated with larger tumours and greater perilesional oedema. Pre-operative dexamethasone for 3–5 days versus shorter periods may reduce the risk of complications. We describe a characteristic pattern of perilesional oedema termed ‘sabre-tooth’ sign, whose presence is associated with a higher complication rate and may represent an important radiological prognostic sign. Elective post-operative ventilation for patients with high-risk tumours may reduce the risk of complications.

Report of a successful human trepanation from the Dark Ages of neurosurgery in Europe

Dear Editor, Cranial trepanation is among the oldest surgical procedures performed. Remains of human skulls with evidence of successful trepanation have been found in many countries such as Peru [1], Syria [2] and China [3], dating from the Neolithic Age to modern times [4]. In 1876 [5], Paul Broca described three putative goals for such trepanations: (1) an intra-vitam trepanation as a surgical procedure to cure a specific disease; (2) a post-mortem trepanation as a ritual or magical ceremony and (3) a symbolic trepanation, performed on a healthy person, to form a shallow depression on the head [4]. During the Middle Ages in Europe, there was a general diminution in the frequency of surgical procedures performed. An anthropologic collection of 1,583 sets of human remains, originating from the ossuary in the basement of the High Court of Péronne, Somme, France, was examined. One skull, referenced as C8 (for Crâne 8), showed evidence of a trepanation (Fig. 1). Radiocarbon dating analysis demonstrated that the skull dated from between 990 and 1120 AD. The anthromorphic analysis suggested an adult but gave no clues as to the gender, given the limited material available. The dimensions of the skull were 13.3 cm in the anterioposterior axis, 14.8 cm in the transverse axis and 8.7 cm in the craniocaudal axis. Forensic analysis identified a bone perforation at the bregma (namely the anatomical point on the skull at which the coronal suture is intersected perpendicularly by the sagittal suture). The hole extended into the two parietal bones and presumably also on the frontal bone. The hole appeared to be circular or semicircular. The edge of the hole was regular in the outer table, while the edge of the hole was more irregular in the inner table. The hole shows a filling of the diploic alveolus, uncovered by the perforation. The measurements demonstrated a slight internal angle 10° from the strict perpendicular, with an external diameter of 24.0 mm at the outer table and with an internal diameter of 22.0 mm at the inner table. There was no notch or abrasion near the hole or anywhere else on the skull fragment. The skull showed no evidence of trauma, tumor or infection. This case is intriguing in a number of ways: (1) it was performed during the Dark Ages of surgery in Europe at a transitional period between the early and central medieval times; (2) it was performed on the bregma for a questionable indication. In Europe, trepanations are extremely rarely reported after the Neolithic era, partly because the dead were generally cremated during the later Bronze Age and partly because the frequency with which they were performed never reached the numbers observed during the Neolithic Age [6]. French cases date mostly from the Neolithic Era [7, 8]. If we consider the entire period of the Middle Ages, very few medieval surgical trepanations are reported from Europe [9]. The frequency of trepanations encompassing one or more skull sutures was quite high: (1) the first detailed analysis made by Stewart on an historical cohort of 112 trepanations from Peru, performed during the period of the Inca civilization, found a location involving the midline in 22 % and Johan Pallud and Philippe Charlier contributed equally. M. Zanello : J. Pallud Department of Neurosurgery, Sainte-Anne Hospital, Paris, France

Decreased neurocalcin immunoreactivity in sympathetic and parasympathetic neurons of the major pelvic ganglion in aged rats

In the rat the majority of sympathetic and parasympathetic postganglionic neurons that innervate the pelvic viscera are located together in the major pelvic ganglia. We have ascertained that it is only the sympathetic population of this ganglion that exhibits age-associated attrition. Recent immunohistochemical investigations of the distribution of calcium binding proteins in this ganglion in young adult and aged rats have demonstrated that calbindin-D28k is only present in the sympathetic neurons and that the number of calbindin-immunoreactive sympathetic neurons of the aged ganglion was dramatically reduced. In the present study we have investigated the distribution of neurocalcin (NC) alpha isoform in the major pelvic ganglion. In young adults 98.7% of sympathetic neurons (identified by anti-tyrosine hydroxylase immunostaining) and 98% of parasympathetic neurons (identified by anti-nitric oxide synthase immunostaining) contained NC immunoreactivity and these figures are reduced to 68 and 45.5% in the aged group. Thus, unlike calbindin-D28k, NC is not confined to the sympathetic neuron population in the major pelvic ganglion and decreases significantly in old age in both neuronal populations. The likely effects are to impair intracellular calcium-dependent signalling in neurons of the major pelvic ganglion, possibly compounding the effects of the previously reported decrease in calbindin-D28k in the sympathetic population.

Direct electrical bipolar electrostimulation for functional cortical and subcortical cerebral mapping in awake craniotomy. Practical considerations

INTRODUCTIONnThe aim of brain glioma surgery is to maximize the quality of resection, while minimizing the risk of sequelae. Due to the frequent location of gliomas near or within eloquent areas, owing to their infiltrative feature, and because of major interindividual variability, the anatomofunctional organization and connectivity must be studied individually. Therefore, to optimize the benefit-to-risk ratio of surgery, intraoperative functional mapping is extensively used.nnnMATERIAL AND METHODSnThis article aims at describing the rationale, indications and practical aspects of intraoperative direct electrical bipolar electrostimulation for cortical and subcortical mapping under awake conditions using the asleep-awake asleep anaesthetic protocol in the setting of cerebral gliomas. We will address the operative approach, including patient positioning, functional mapping resection strategy, anaesthetic conditions, as well as tips and pitfalls.nnnRESULTSnThe intraoperative direct electrical bipolar electrostimulation enables: (i) to study the real-time individual cortical functional organization; (ii) to study the anatomofunctional subcortical connectivity along the resection; (iii) to tailor the resection according to individual corticosubcortical functional boundaries. This is an easy, accurate, reliable, well-tolerated and safe detection technique of both cortical and subcortical functionally essential structures during resection. It should be performed in the context of a standardized protocol involving members of both anaesthesiology and neurosurgery teams at neurosurgical centers specialized in surgical neuro-oncology.nnnCONCLUSIONnIntraoperative direct electrical bipolar electrostimulation for cortical and subcortical mapping under awake conditions is currently considered the gold standard clinical tool for brain mapping during cerebral resection in neuro-oncology.