Shamik Chakraborty

Erratum to: Superselective intraarterial cerebral infusion of cetuximab after osmotic blood/brain barrier disruption for recurrent malignant glioma: phase I study

Objective To establish a maximum tolerated dose of superselective intraarterial cerebral infusion (SIACI) of Cetuximab after osmotic disruption of the blood–brain barrier (BBB) with mannitol, and examine safety of the procedure in patients with recurrent malignant glioma.

Neuroprotection Trials in Traumatic Brain Injury

Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide. Current treatment of acute TBI includes surgical intervention when needed, followed by supportive critical care such as optimizing cerebral perfusion, preventing pyrexia, and treating raised intracranial pressure. While effective in managing the primary injury to the brain and skull, these treatment modalities do not address the complex secondary cascades that occur at a cellular level following initial injury and greatly affect the ultimate neurologic outcome. These secondary processes involve changes in ionic flux, disruption of cellular function, derangement of blood flow and the blood-brain barrier, and elevated levels of free radicals. Over the past few decades, numerous pharmacologic agents and modalities have been investigated in an attempt to interrupt these secondary processes. No neuroprotective agents currently exist that have been proven to improve neurologic outcome following TBI. However, these trials have contributed significantly to the understanding of the clinical sequelae of TBI and to improvements in the quality of care for TBI. With the experience and insights that have been accrued with the trials to date, we will be able to optimize future trial designs and refine established neurologic endpoints to better identify new therapeutic agents and further improve neurologic outcomes from this often devastating condition.

Supratentorial Neurenteric Cysts: Case Series and Review of Pathology, Imaging, and Clinical Management

BACKGROUND Neurenteric cysts are rare congenital lesions along the neuroaxis, typically found in the spine, and rarely intracranially. Here, we present 3 patients who presented to our institution during a 6-year period with supratentorial intracranial neurenteric cysts and conduct a comprehensive review of the literature to describe the salient pathology, radiologic features, and clinical issues regarding these lesions. CASE REPORTS Three patients were treated surgically for supratentorial neurenteric cysts. One patient presented in extremis, whereas the others were treated electively. Each patient presented with significantly different signs and symptoms and unique radiologic findings. All patients were neurologically intact after surgery. CONCLUSIONS Neurenteric cysts present with a variety of signs and symptoms. Given the increased use of neuroimaging, supratentorial neurenteric cysts may be encountered more frequently and are important to include on the differential diagnosis and managed accordingly. Postoperative seizures occur in more than 20%, even in patients who had no preoperative seizures. Surgery can be performed safely with good neurologic outcomes.

Neuro-oncology biotech industry progress report.

The Brain Tumor Biotech Center at the Feinstein Institute for Medical Research, in collaboration with Voices Against Brain Cancer hosted The Brain Tumor Biotech Summit at in New York City in June 2015. The focus was once again on fostering collaboration between neuro-oncologist, neurosurgeons, scientists, leaders from biotechnology and pharmaceutical industries, and members of the financial community. The summit highlighted the recent advances in the treatment of brain tumor, and specifically focused on targeting of stem cells and EGFR, use of prophage and immunostimulatory vaccines, retroviral vectors for drug delivery, biologic prodrug, Cesium brachytherapy, and use of electric field to disrupt tumor cell proliferation. This article summarizes the current progress in brain tumor research as presented at 2015 The Brain Tumor Biotech Summit.

Frameless Stereotactic Insertion of Viewsite Brain Access System with Microscope-Mounted Tracking Device for Resection of Deep Brain Lesions: Technical Report

The surgical management of deep brain tumors is often challenging due to the limitations of stereotactic needle biopsies and the morbidity associated with transcortical approaches. We present a novel microscopic navigational technique utilizing the Viewsite Brain Access System (VBAS) (Vycor Medical, Boca Raton, FL, USA) for resection of a deep parietal periventricular high-grade glioma as well as another glioma and a cavernoma with no related morbidity. The approach utilized a navigational tracker mounted on a microscope, which was set to the desired trajectory and depth. It allowed gentle continuous insertion of the VBAS directly to a deep lesion under continuous microscopic visualization, increasing safety by obviating the need to look up from the microscope and thus avoiding loss of trajectory. This technique has broad value for the resection of a variety of deep brain lesions.

Frameless and Maskless Stereotactic Navigation with a Skull-Mounted Tracker

OBJECTIVE In this series, we present 3 cases that show the use of a skull-mounted tracker for image-guided navigation for anterior skull base surgery and ventricular catheter placement procedures. This system obviates fiducials or face masks during the surgical procedure itself and allows for the performance of facial incisions using the Weber-Ferguson approach. METHODS Our series presents the use of a novel intraoperative navigational system that uses a skull-mounted tracker to navigated anterior skull base surgery. RESULTS We present 3 cases using this new system: 1 anterior skull base tumor removal that was operated on without a facemask for navigation and 2 ventricular catheter placement procedures. CONCLUSIONS Intraoperative image-guided navigation has revolutionized neurosurgery. It undoubtedly increases the surgeons confidence and the perception of safety. Although fiducials and facial masks are the most widely used tools for intraoperative navigation, their use is associated with certain complications. This technique permits free movement of the head during surgery, which in turn facilitates the exposure of head and neck lesions and expedites the approach to ventricular catheter placement. Our case series shows the precision and ease of our technique, which is less time consuming and less cumbersome than the traditional frame-based stereotaxy. In addition, the skull-mounted tracker system allows improved anatomic localization and shorter operating time and avoids the complications associated with the use of rigid fixating head frames.

Novel Focal Treatment Modalities in Glioma Management

Malignant gliomas, including glioblastomas (GBMs) and anaplastic astrocytomas (AAs), remain difficult to treat. Overall prognosis for patients harboring these tumors is poor despite maximal surgical resection with appropriate chemotherapy and radiation. Here we outline several novel treatment modalities for focal control of malignant gliomas. The first set of therapies described rely on bypassing the blood brain barrier (BBB) to better deliver chemotherapeutics directly to the tumor and tumor cells infiltrating into the brain parenchyma. These include convection-enhanced drug delivery, intra-arterial (IA) chemotherapy, focused ultrasound, and laser interstitial thermal therapy. Another modality that has shown promising tumor control is tumor treatment fields therapy, which disrupts tumor mitosis and has increased survival in some studies. We also discuss the challenges associated with these treatments and examine the future of these and other glioma management strategies.

Commentary: Surgical Outcomes Following Repeat Transsphenoidal Surgery for Nonfunctional Pituitary Adenomas: A Retrospective Comparative Study

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Neuroradiological and Neuropathological Changes After 177Lu-Octreotate Peptide Receptor Radionuclide Therapy of Refractory Esthesioneuroblastoma

BACKGROUND AND IMPORTANCE Olfactory neuroblastoma, also known as esthesioneuroblastoma (ENB), is a malignant neoplasm with an unpredictable behavior. Currently, the widely accepted treatment is inductive chemotherapy, with or without surgery, followed by radiotherapy. Since data on genetics and molecular alterations of ENB are lacking, there is no standard molecularly targeted therapy. However, ENB commonly expresses the somatostatin receptor (SSTR) that is also expressed by neuroendocrine tumors. Peptide receptor radionuclide therapy (PRRT) using radiolabeled somatostatin analogues, such as 177Lu-octreotate, is an effective treatment for the latter. We present the complex neuroradiological and neuropathological changes associated with 177Lu-octreotate treatment of a patient with a highly treatment-resistant ENB. CLINICAL PRESENTATION A 60-yr-old male presented with an ENB that recurred after chemotherapy, surgery, stereotactic radiosurgery, and immunotherapy. Pathology revealed a Hyams grade 3 ENB and the tumor had metastasized to lymph nodes. Tumor SSTR expression was seen on 68Ga-octreotate positron emission tomography (PET)/computed tomography (CT), suggesting that PRRT may be an option. He received 4 cycles of 177Lu-octreotate over 6 mo, with a partial response of all lesions and symptomatic improvement. Four months after the last PRRT cycle, 2 of the lesions rapidly relapsed and were successfully resected. Three months later, 68Ga-octreotate PET/CT and magnetic resonance imaging indicate no progression of the disease. CONCLUSION We describe imaging changes associated with 177Lu-octreotate PRRT of relapsing ENB. To our knowledge, this is the first report describing neuropathological changes associated with this treatment. PRRT is a promising therapeutic option to improve the disease control, and potentially, the survival of patients with refractory ENB.

Chapter 5 – Traumatic Brain Injury

Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide. Current treatment of acute TBI includes surgical intervention when needed, followed by supportive critical care such as optimizing cerebral perfusion, preventing pyrexia, and treating raised intracranial pressure. While effective in managing the primary injury to the brain and skull, these treatment modalities do not address the complex secondary cascades that occur at a cellular level following initial injury and greatly affect the ultimate neurologic outcome. These secondary processes involve changes in ionic flux, disruption of cellular function, derangement of blood flow and the blood–brain barrier, and elevated levels of free radicals. Over the past few decades, numerous pharmacologic agents and modalities have been investigated in an attempt to interrupt these secondary processes. No neuroprotective agents currently exist that have been proven to improve neurologic outcome following TBI. However, these trials have contributed significantly to the understanding of the clinical sequelae of TBI and to improvements in the quality of care for TBI. Herein, we discuss the history behind TBI trials and the issues related to the difficulty in finding effective treatments for TBI.