Sevgi Sarikaya-Seiwert

The Usefulness of Dynamic O-(2-18F-Fluoroethyl)-l-Tyrosine PET in the Clinical Evaluation of Brain Tumors in Children and Adolescents

Experience regarding O-(2-18F-fluoroethyl)-l-tyrosine (18F-FET) PET in children and adolescents with brain tumors is limited. Methods: Sixty-nine 18F-FET PET scans of 48 children and adolescents (median age, 13 y; range, 1–18 y) were analyzed retrospectively. Twenty-six scans to assess newly diagnosed cerebral lesions, 24 scans for diagnosing tumor progression or recurrence, 8 scans for monitoring of chemotherapy effects, and 11 scans for the detection of residual tumor after resection were obtained. Maximum and mean tumor-to-brain ratios (TBRs) were determined at 20–40 min after injection, and time–activity curves of 18F-FET uptake were assigned to 3 different patterns: constant increase; peak at greater than 20–40 min after injection, followed by a plateau; and early peak (≤20 min), followed by a constant descent. The diagnostic accuracy of 18F-FET PET was assessed by receiver-operating-characteristic curve analyses using histology or clinical course as a reference. Results: In patients with newly diagnosed cerebral lesions, the highest accuracy (77%) to detect neoplastic tissue (19/26 patients) was obtained when the maximum TBR was 1.7 or greater (area under the curve, 0.80 ± 0.09; sensitivity, 79%; specificity, 71%; positive predictive value, 88%; P = 0.02). For diagnosing tumor progression or recurrence, the highest accuracy (82%) was obtained when curve patterns 2 or 3 were present (area under the curve, 0.80 ± 0.11; sensitivity, 75%; specificity, 90%; positive predictive value, 90%; P = 0.02). During chemotherapy, a decrease of TBRs was associated with a stable clinical course, and in 2 patients PET detected residual tumor after presumably complete tumor resection. Conclusion: Our findings suggest that 18F-FET PET can add valuable information for clinical decision making in pediatric brain tumor patients.

Traumatic brain injuries in illustrated literature: experience from a series of over 700 head injuries in the Asterix comic books

BackgroundThe goal of the present study was to analyze the epidemiology and specific risk factors of traumatic brain injury (TBI) in the Asterix illustrated comic books. Among the illustrated literature, TBI is a predominating injury pattern.MethodsA retrospective analysis of TBI in all 34 Asterix comic books was performed by examining the initial neurological status and signs of TBI. Clinical data were correlated to information regarding the trauma mechanism, the sociocultural background of victims and offenders, and the circumstances of the traumata, to identify specific risk factors.ResultsSeven hundred and four TBIs were identified. The majority of persons involved were adult and male. The major cause of trauma was assault (98.8%). Traumata were classified to be severe in over 50% (GCS 3–8). Different neurological deficits and signs of basal skull fractures were identified. Although over half of head-injury victims had a severe initial impairment of consciousness, no case of death or permanent neurological deficit was found. The largest group of head-injured characters was constituted by Romans (63.9%), while Gauls caused nearly 90% of the TBIs. A helmet had been worn by 70.5% of victims but had been lost in the vast majority of cases (87.7%). In 83% of cases, TBIs were caused under the influence of a doping agent called “the magic potion”.ConclusionsAlthough over half of patients had an initially severe impairment of consciousness after TBI, no permanent deficit could be found. Roman nationality, hypoglossal paresis, lost helmet, and ingestion of the magic potion were significantly correlated with severe initial impairment of consciousness (p ≤ 0.05).

Intraoperative Indocyanine Green–Based Cortical Perfusion Assessment in Patients Suffering from Severe Traumatic Brain Injury

OBJECTIVES The pathophysiology of traumatic brain injury (TBI) largely involves the brains vascular structural integrity. We analyzed the value of an intraoperative cortical indocyanine green (ICG) angiography in patients with severe TBI and acute subdural hematoma who underwent decompressive craniectomy. METHODS ICG-derived fluorescence curves of cortex and cerebral vessels were recorded by the use of software integrated into a surgical microscope in 10 patients. The maximum intensity, rise time (RT), time to peak, and residual fluorescence intensity (FI) were estimated from cortical arteries, the parenchyma, and veins. RESULTS ICG-derived fluorescence parameters were correlated with the short-term outcome 3 months after discharge. Five patients had a favorable and 5 an unfavorable outcome. Patients with a favorable outcome showed a significant longer RT in the arteries and a trend towards a significant longer RT in the veins. Overall mean residual FI was 47.5 ± 6.8% for the arteries, 45.0 ± 7% for the parenchyma and 57.6 ± 6% for the veins. The residual FI of the parenchyma and the veins was significantly greater in patients with an unfavorable clinical outcome. CONCLUSIONS Patients with an unfavorable clinical outcome showed an altered shape of the ICG-derived fluorescence curve, a shorter increase of the ICG-derived fluorescence intensity in the cortical arteries, and significantly greater residual fluorescence intensity. These observations are likely a correlate of an increased intracranial pressure, a capillary leak, and venous congestion. Intraoperative quantification of the ICG-derived fluorescence might help to appreciate the clinical outcome in patients with severe TBI.

Localization techniques in resection of deep seated cavernous angiomas – review and reevaluation of frame based stereotactic approaches

Abstract Background. Providing high accuracy is crucial in neurosurgery especially for resection of deep seated small cerebral pathologies such as cavernous angiomas. The goal of the present series was to reevaluate the feasibility, accuracy, efficacy and safety of frame-based, stereotactically guided resection for patients suffering from small deep-seated cavernous angiomas. Additionally a review of the literature on navigational tools in cavernoma surgery is provided comparing different navigation strategies. Methods. Ten patients with deep-seated, small intracranial, cavernous angiomas being subject to frame-based, stereotactically aided resection are included in this survey. Based on the stereotactic-fused image, set entry and target point aimed at the rim of the cavernoma were calculated. A minicraniotomy (< 3 cm in diameter) was performed followed by positioning of the stereotactic needle. Following the needle in situ the cavernous angioma was localized and resected. Assets and drawbacks of the stereotactic-aided approach were evaluated, patients were analyzed for surgery-related neurological deficits and completeness of resection. Results. Complete resection was achieved in all ten patients verified by post-surgery MRI imaging. The surgical procedure itself was only slightly aggravated by the stereotactic equipment. No adverse events such as bleedings or infections were observed in our series. Conclusions. Stereotactically guided, minimally invasive resection of deep seated and small cavernous angiomas is accurate and effective. The frame-based stereotactic guidance requires some additional time and effort which seems justified only for deep seated and small cavernous angiomas. Frameless neuronavigation is a common tool in cavernoma surgery and its spatial resolution is sufficient for the majority of cases.

Headache and Shunt-Related Impact on Activities of Daily Life in Patients Growing Up with a Ventriculoperitoneal Shunt

Background/Aims Ventriculoperitoneal shunts (VPS) are a mainstay of treatment for hydrocephalus. Morbidity related to infection and dysfunction is well known, whereas data on psychosocial outcome and quality of life are scarce. Our aim was to assess headache burden and shunt‐related impact on daily life in children growing up with a VPS. Methods Patients between 3 and 21 years of age were identified and their families were contacted. A set of standardized questionnaires was used to assess headache and quality of life. Results Fifteen patients with a mean age of 12 years agreed to participate in this study. Satisfaction with the VPS and improvement of the patients condition was reported by 87%. A total of 67% denied negative impact on everyday life, reported a headache less than once a month, and never or rarely miss school. However, 53% take precautions before special activities. Conclusions The results demonstrate that modern VPS systems are tolerated very well and do not per se reduce quality of life. However, patients adapt to the presence of a VPS by avoiding risks and taking precautions. Chronic headache is not a major problem and not necessarily attributed to the VPS. Nevertheless, most patients asked for technical improvements, which might guide future research and the technical development of VPS.

Giant Dumbbell-Shaped Intra- and Extracranial Nerve Schwannoma in a Child Presenting with Glossopharyngeal Neuralgia Syncope Syndrome: A Case Report and Review of the Literature

Lower cranial nerve schwannomas are benign tumors of the neurolemmocytes of the cranial nerves. Among children, cranial nerve schwannomas are extremely rare and are predominantly associated with neurofibromatosis (NF) type 2. The purpose of the current case report is to describe a unique giant extra- and intracranial foramen jugular schwannoma in a young boy with lower cranial nerve deficits and glossopharyngeal neuralgia syncope syndrome and to review the pertinent literature. In the current case report, we illustrate the course of disease in a 14-year-old boy with a 4-month history of recurrent syncope and a big bulge on the left side of his neck. Audiometry showed deafness of the left ear. Magnetic resonance imaging (MRI) demonstrated a giant unilateral dumbbell-shaped intra- and extracranial foramen jugular schwannoma with a volume of 156 cm3 causing severe brain stem compression and obstructive hydrocephalus. The tumor was removed completely in a two-step surgery. The tumor was confirmed during surgery to originate from the glossopharyngeal nerve. The histological examination revealed the characteristic features of a schwannoma. The MRI 3 months after the second surgery confirmed complete tumor removal. The genetic examination for NF was negative. Review of literature showed that dumbbell-shaped lower cranial nerve schwannomas in the childhood population are rare.

Reply to the comment re: "Traumatic brain injuries in illustrated literature: experience from a series of over 700 head injuries in the Asterix comic books" by Nikolas Lloyd

Dear Editor,Thank you very much for giving us the opportunity to replyto the comment on our article by Nikolas Lloyd.We really appreciate such comments—especially thosewhich make an effort to improve the standard of science.Thus, the study design and the follow-up were criticized byNikolas Lloyd, and it was suggested to make controlexaminations at 1 and 3 months as well as 2 years. Further, adouble-blinded test was recommended to test effects of themagicpotion(magicpotionvsplacebo).Indeed,thelimitationsofthestudyabouttraumaticbraininjuries(TBIs)intheAsterixcomic books arise from its retrospective study design and theinsufficient follow-up, as emphasized in the “Discussion” ofthe article [1]. Undoubtfully, prospective double-blindedstudies are commonly believed to have greater scientificimpact than retrospective studies with an inconsistent follow-up. Therefore, even medical “Christmas articles” weredesigned as meta-analyses [ 2]. However, characters analysedin the present paper took drugs (the magic potion) in the year50 B.C. and suffered from TBIs in the same year. For us, itwas very difficult to design a study analysing those patientswith follow-up examinations (at 1 and 3 months as well as2 years) in the year 2011 A.D.However,ourarticleaboutTBIsintheAsterixcomicbookswas meant as a Christmas article, even though it was actuallypublished by Acta Neurochirurgica at Easter. Christmasarticles have a tradition in medicine and are frequentlypublished, e.g. by the British Medical Journal [2]. Therefore,our study about TBIs in Asterix comic books was meantneither seriously nor purely as a joke. Besides, our studymight help to focus public attention on TBIs as an importantfield of our daily activities and a leading cause of morbidityand mortality. Further studies on TBI might not only lead to abetter understanding of TBI in Asterix comics but —moreimportantly—might lead to new insights and perhapssubsequently to new therapeutic opportunities for patientssuffering from TBIs.