0000000000064492
AUTHOR
Sven R. Kantelhardt
Strategies in Glioma-Surgery
1.1 Epidemiology and classification of gliomas Malignant glioma is one of the most feared diseases in the industrialized nations. About 77% of all malignant tumors within the central nervous system are gliomas. There are about 18.000 newly diagnosed cases annually within the USA (9/100.000 inhabitants per year) and the disease causes about 13.000 deaths each year. Statistically this is a higher loss of life-time than all other tumor-entities together (Schwartzbaum et al., 2006). About 45-50% of these gliomas are histologically classified as gliobalstoma multiforme (GBM) the most aggressive type of glioma which is classified as WHO grade IV (following the classification of Kleihues et al., 2…
Evaluation of the Department of Neurosurgery of the Seoul National University Hospital
The Department of Neurosurgery (DNS) of the Seoul National University Hospital (SNUH), belongs to the largest and oldest such institutions in Korea. Because of its growing reputation it is hardly surprising that the DNS draws visitor and scholars for clinical education and academic exchange from far beyond Korea. I myself visited the SNUH in February and March 2013. During this time I composed this evaluation in which I compare the DNS to my home Department at the Johannes Gutenberg-University in Mainz/Germany, as well as the situation of Neurosurgery in Korea and Germany in general. In the first part this evaluation summarizes data concerning equipment, staff and organizational structure, …
Comprehensive Anatomic Assessment of Ipsilateral Pterional Versus Contralateral Subfrontal Approaches to the Internal Carotid Ophthalmic Segment: A Cadaveric Study and Three-Dimensional Simulation
Objective Medially pointing aneurysms of the ophthalmic segment of the internal carotid artery (oICA) represent a neurosurgical challenge. Conventional ipsilateral approaches require internal carotid artery and optic nerve (ON) mobilization as well as anterior clinoidectomy (AC), all associated with increased surgical risk. Contralateral approaches could provide a better exposure of the superomedial aspect of the oICA, ophthalmic artery, and superior hypophyseal artery, sparing AC and internal carotid artery or ON mobilization. However, the microsurgical anatomy of this approach has not been systematically studied. In the present work, we exhaustibly analyzed the anatomic and morphometric c…
A Volumetric Method for Quantification of Cerebral Vasospasm in a Murine Model of Subarachnoid Hemorrhage
Subarachnoid hemorrhage (SAH) is a subtype of hemorrhagic stroke. Cerebral vasospasm that occurs in the aftermath of the bleeding is an important factor determining patient outcome and is therefore frequently taken as a study endpoint. However, in small animal studies on SAH, quantification of cerebral vasospasm is a major challenge. Here, an ex vivo method is presented that allows quantification of volumes of entire vessel segments, which can be used as an objective measure to quantify cerebral vasospasm. In a first step, endovascular casting of the cerebral vasculature is performed using a radiopaque casting agent. Then, cross-sectional imaging data are acquired by micro computed tomograp…
Microsurgical fenestration of perineural cysts to the thecal sac at the level of the distal dural sleeve
Background Surgery for symptomatic sacral perineural cysts remains an issue of discussion. Assuming micro-communications between the cyst and thecal sac resulting in a valve mechanism and trapping of CSF as a pathomechanism, microsurgical fenestration from the cyst to the thecal sac was performed to achieve free CSF communication. Methods In 13 consecutive patients (10 female, 3 male), MRI revealed sacral perineural cysts and excluded other pathologies. Micro-communication between the thecal sac and the cysts was shown by delayed contrast filling of the cysts on postmyelographic CT. Surgical fenestration achieved free CSF communication between the thecal sac and cysts in all patients. The p…
Automatic scanning of large tissue areas in neurosurgery using optical coherence tomography
Background With its high spatial and temporal resolution, optical coherence tomography (OCT) is an ideal modality for intra-operative imaging. One possible application is to detect tumour invaded tissue in neurosurgery, e.g. during complete resection of glioblastoma. Ideally, the whole resection cavity is scanned. However, OCT is limited to a small field of view (FOV) and scanning perpendicular to the tissue surface. Methods We present a new method to use OCT for scanning of the resection cavity during neurosurgical resection of brain tumours. The main challenges are creating a map of the cavity, scanning perpendicular to the surface and merging the three-dimensional (3D) data for intra-ope…
First multiphoton tomography of brain in man
We report on the first two-photon in vivo brain tissue imaging study in man. High resolution in vivo histology by multiphoton tomography (MPT) including two-photon FLIM was performed in the operation theatre during neurosurgery to evaluate the feasibility to detect label-free tumor borders with subcellular resolution. This feasibility study demonstrates, that MPT has the potential to identify tumor borders on a cellular level in nearly real-time.
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 acc…
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 postprocedur…
Maintenance of Integrity of Upper Facet Joints during Simulated Percutaneous Pedicle Screw Insertion Using 2D versus 3D Planning
Background No studies have directly and quantitatively compared two-dimensional (2D) and three-dimensional (3D) planning as applied during conventional percutaneous or navigated percutaneous pedicle screw placement. Study Aims This lumbar pedicle-based stabilization simulation study aimed to investigate the risk of upper facet joint violation (FJV) during posterior percutaneous pedicle screw placement with conventional 2D planning of screw implantation (as a model for fluoroscopically guided screws) compared with 3D planning (as used with navigation techniques). Methods The placement of monosegmental lumbar pedicle screws using the data sets of 250 consecutive patients was simulated. Conve…
Load Distribution in the Lumbar Spine During Modeled Compression Depends on Lordosis.
Excessive or incorrect loading of lumbar spinal structures is commonly assumed as one of the factors to accelerate degenerative processes, which may lead to lower back pain. Accordingly, the mechanics of the spine under medical conditions, such as scoliosis or spondylolisthesis, is well-investigated. Treatments via both conventional therapy and surgical methods alike aim at restoring a “healthy” (or at least pain-free) load distribution. Yet, surprisingly little is known about the inter-subject variability of load bearings within a “healthy” lumbar spine. Hence, we utilized computer tomography data from 28 trauma-room patients, whose lumbar spines showed no visible sign of degeneration, to …
Evaluation of robot-guided minimally invasive implantation of 2067 pedicle screws
ObjectiveRecent studies have investigated the role of spinal image guidance for pedicle screw placement. Many authors have observed an elevated placement accuracy and overall improvement of outcome measures. This study assessed a bi-institutional experience following introduction of the Renaissance miniature robot for spinal image guidance in Europe.MethodsThe medical records and radiographs of all patients who underwent robot-guided implantation of spinal instrumentation using the novel system (between October 2011 and March 2015 in Mainz and February 2014 and February 2016 in Regensburg) were reviewed to determine the efficacy and safety of the newly introduced robotic system. Screw posit…
Tentorial Incision vs. Retraction of the Tentorial Edge during the Subtemporal Approach: Anatomical Comparison in Cadaveric Dissections and Retrospective Clinical Case Series.
Abstract Objective The aim of this study was to compare tentorial incision (group A) versus retraction and tack up suture (group B) of the tentorial edge during the subtemporal approach for surgery in the high basilar region. Design 24 cadaveric dissections and 4 clinical cases of aneurysms of the high basilar region are presented. Assessment included visibility and operability afforded by either tentorial incision creating a dural flap (group A) or retraction of the tentorial edge and tethering with a suture (group B). Four patients, two with superior cerebellar artery aneurysms and two with proximal posterior cerebral artery aneurysms were treated with each approach. Results In the quanti…
Evaluation of a Completely Robotized Neurosurgical Operating Microscope
BACKGROUND Operating microscopes are essential for most neurosurgical procedures. Modern robot-assisted controls offer new possibilities, combining the advantages of conventional and automated systems. OBJECTIVE We evaluated the prototype of a completely robotized operating microscope with an integrated optical coherence tomography module. METHODS A standard operating microscope was fitted with motors and control instruments, with the manual control mode and balance preserved. In the robot mode, the microscope was steered by a remote control that could be fixed to a surgical instrument. External encoders and accelerometers tracked microscope movements. The microscope was additionally fitted…
Image-Guided Transcranial Doppler Ultrasound for Monitoring Posthemorrhagic Vasospasms of Infratentorial Arteries: A Feasibility Study
Background A considerable number of patients with subarachnoid hemorrhage (SAH) develop vasospasms of the infratentorial arteries. Transcranial Doppler sonography (TCD) is used to screen for vasospasm. In this study, we used a technical modification that combines TCD with an image guidance device that the operator can use to navigate to the ultrasonic window and to predefined intracranial vascular targets. Our aim was to analyze the feasibility, spatial precision, and spatial reproducibility of serial image-guided TCD of infratentorial and—for comparison—supratentorial arteries in the clinical setting of monitoring for vasospasm after SAH. Methods The study included 10 SAH patients, who eac…
Algorithmically deduced FREM2 molecular pathway is a potent grade and survival biomarker of human gliomas
Gliomas are the most common malignant brain tumors with high mortality rates. Recently we showed that the FREM2 gene has a role in glioblastoma progression. Here we reconstructed the FREM2 molecular pathway using the human interactome model. We assessed the biomarker capacity of FREM2 expression and its pathway as the overall survival (OS) and progression-free survival (PFS) biomarkers. To this end, we used three literature and one experimental RNA sequencing datasets collectively covering 566 glioblastomas (GBM) and 1097 low-grade gliomas (LGG). The activation level of deduced FREM2 pathway showed strong biomarker characteristics and significantly outperformed the FREM2 expression level it…
Interface transition checklists in spinal surgery
Issue Recently, quality tools have been promoted to improve patient safety and process efficiency in healthcare. While surgeons primarily focused on surgical issues, like infection rates or implant design, we introduced pre-admission and preoperative checklists in the early 2000s. Initial assessment To assess the efficiency of these tools in a neurosurgical department, we performed a survey of all spinal instrumentation patients operated in 2011 ( n = 147). The results revealed several problems. Choice of solution We consequently redesigned the checklists accompanied by flanking measures, such as written and online accessible standards. Furthermore, the staff was trained to use the update…
Anterior Cervical Subaxial Treatment (Fusion)
Cervical radiculopathy caused by a soft disc herniation or a foraminal stenosis is a common problem. While symptoms from soft disc herniations have high chances to recover after conservative therapy persisting radicular pain or a neurological deficit are accepted as an indication for surgical treatment. The surgical technique regarded as gold standard for cervical radiculopathy due to a disc herniation or foraminal stenosis is an anterior cervical discectomy followed by fusion. The chapter will outline the indications for anterior cervical discectomy, the clinical and radiographic results as well as the potential complications and secondary problems.
Video-Assisted Navigation for Adjustment of Image-Guidance Accuracy to Slight Brain Shift
Background Information supplied by an image-guidance system can be superimposed on the operating microscope oculars or on a screen, generating augmented reality. Recently, the outline of a patient's head and skull, injected in the oculars of a standard operating microscope, has been used to check the registration accuracy of image guidance. Objective To propose the use of the brain surface relief and superficial vessels for real-time intraoperative visualization and image-guidance accuracy and for intraoperative adjustment for brain shift. Methods A commercially available image-guidance system and a standard operating microscope were used. Segmentation of the brain surface and cortical bloo…
Multicolor 3D Printing of Complex Intracranial Tumors in Neurosurgery.
Three-dimensional (3D) printing technologies offer the possibility of visualizing patient-specific pathologies in a physical model of correct dimensions. The model can be used for planning and simulating critical steps of a surgical approach. Therefore, it is important that anatomical structures such as blood vessels inside a tumor can be printed to be colored not only on their surface, but throughout their whole volume. During simulation this allows for the removal of certain parts (e.g., with a high-speed drill) and revealing internally located structures of a different color. Thus, diagnostic information from various imaging modalities (e.g., CT, MRI) can be combined in a single compact …
Autostereoscopic Three-Dimensional Neuronavigation to the Sella: Technical Note.
Background A drawback of conventional neuronavigation is the necessity of focusing on two-dimensional images in 3 planes at the same time to determine one's position in the operating field. A solution would be to merge the images into a single three-dimensional (3D) image that mirrors the actual anatomy. The introduction of holographic glassless 3D monitors paved the way to 3D navigation. We present our experience with 3D neuronavigation as exemplified by navigation to and within the sella. Methods Operative planning was conducted with a navigation system using cranial computed tomography and magnetic resonance imaging. The image data sets were processed by the prototype Clariti 3D system t…
RNA-sequencing and bioinformatic analysis to pre-assess sensitivity to targeted therapeutics in recurrent glioblastoma.
e13533 Background: This study developed molecular guided tools for individualized selection of chemotherapeutics for recurrent glioblastoma (rGB). A consortium involving clinical neurooncologists, molecular biologists and bioinformaticians identified gene expression patterns in rGB and quantitatively analyzed pathways involved in response to FDA approved oncodrugs. Methods: From2016 to 2018 biopsies from GB were collected using a multisampling approach. Biopsy material was used to isolate glioma stem-like cells and examined by RNA-sequencing. RNA-seq results were subjected to differential expression (DE) analysis and Oncobox analysis – a bioinformatic tool for quantitative pathway activati…
Intratumoral Heterogeneity and Longitudinal Changes in Gene Expression Predict Differential Drug Sensitivity in Newly Diagnosed and Recurrent Glioblastoma.
Background: Inevitable recurrence after radiochemotherapy is the major problem in the treatment of glioblastoma, the most prevalent type of adult brain malignancy. Glioblastomas are notorious for a high degree of intratumor heterogeneity manifest through a diversity of cell types and molecular patterns. The current paradigm of understanding glioblastoma recurrence is that cytotoxic therapy fails to target effectively glioma stem cells. Recent advances indicate that therapy-driven molecular evolution is a fundamental trait associated with glioblastoma recurrence. There is a growing body of evidence indicating that intratumor heterogeneity, longitudinal changes in molecular biomarkers and spe…
Three-dimensional Cross-Platform Planning for Complex Spinal Procedures
STUDY DESIGN A feasibility study. OBJECTIVE To develop a method based on the DICOM standard which transfers complex 3-dimensional (3D) trajectories and objects from external planning software to any navigation system for planning and intraoperative guidance of complex spinal procedures. SUMMARY OF BACKGROUND DATA There have been many reports about navigation systems with embedded planning solutions but only few on how to transfer planning data generated in external software. MATERIALS AND METHODS Patients computerized tomography and/or magnetic resonance volume data sets of the affected spinal segments were imported to Amira software, reconstructed to 3D images and fused with magnetic reson…