Posterolateral route for a midbrain cavernous malformation reaching the anterior surface of the brainstem

Cavernous malformations in the midbrain can be accessed via several safe entry zones. The accepted rule of thumb is to enter at the point where the lesion is visible at the surface of the brainstem to pass through as little normal brain tissue as possible. However, in some cases, in order to avoid critical neural structures, this rule may not apply. A different safe entry zone can be chosen. Our video presents a case of a ruptured cavernous malformation in the midbrain reaching its anterior surface which was successfully resected via a posterolateral route using the supracerebellar infratentorial approach.The video can be found here: https://youtu.be/j7VTqRO7qd4.

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Using the Lateral Pontine Safe Entry Zone for Resection of Deep-Seated Cavernous Malformations in the Lateral Pons: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa142 ◽

2020 ◽

Vol 19 (5) ◽

pp. E518-E519

Author(s):

Daniel D Cavalcanti ◽

Joshua S Catapano ◽

Paulo Niemeyer Filho

Keyword(s):

Trigeminal Nerve ◽

Cranial Nerve ◽

Cavernous Malformation ◽

Vascular Malformations ◽

Cranial Nerves ◽

Cavernous Malformations ◽

Entry Zone ◽

History Of ◽

Tumor Biopsies ◽

Safe Entry Zone

Abstract The retrosigmoid approach is one of the main approaches used in the surgical management of pontine cavernous malformations. It definitely provides a lateral route to large central lesions but also makes possible resection of some ventral lesions as an alternative to the petrosal approaches. However, when these vascular malformations do not emerge on surface, one of the safe corridors delimited by the origin of the trigeminal nerve and the seventh-eight cranial nerve complex can be used.1-5 Baghai et al2 described the lateral pontine safe entry zone in 1982, as an alternative to approaches through the floor of the fourth ventricle when performing tumor biopsies. They advocated a small neurotomy performed right between the emergence of the trigeminal nerve and the facial-vestibulocochlear cranial nerves complex. Accurate image guidance, intraoperative cranial nerve monitoring, and comprehensive anatomical knowledge are critical for this approach.4,5 Knowing the natural history of a brainstem cavernous malformation after bleeding,6 we sought to demonstrate in this video: (1) the use of the retrosigmoid craniotomy in lateral decubitus for resection of deep-seated pontine cavernous malformations; (2) the wide opening of arachnoid membranes and dissection of the superior petrosal vein complex to improve surgical freedom and prevent use of fixed cerebellar retraction; and (3) the opening of the petrosal fissure and exposure of the lateral pontine zone for gross total resection of a cavernous malformation in a 19-yr-old female with a classical crossed brainstem syndrome. She had full neurological recovery after 3 mo of follow-up. The patient consented in full to the surgical procedure and publication of the video and manuscript.

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Posterior petrosectomy for resection of pontine cavernous malformation

Neurosurgical Focus: Video ◽

10.3171/2019.10.focusvid.19389 ◽

2019 ◽

Vol 1 (2) ◽

pp. V18

Author(s):

Avital Perry ◽

Thomas J. Sorenson ◽

Christopher S. Graffeo ◽

Colin L. Driscoll ◽

Michael J. Link

Keyword(s):

Real Time ◽

Surgical Resection ◽

Cavernous Malformation ◽

Low Pressure ◽

Vascular Lesions ◽

Cavernous Malformations ◽

Entry Zone ◽

Microsurgical Techniques ◽

Safe Entry Zone ◽

Ultrasound Probes

Cavernous malformations (CMs) are low-pressure, focal, vascular lesions that may occur within the brainstem and require treatment, which can be a substantial challenge. Herein, we demonstrate the surgical resection of a hemorrhaged brainstem CM through a posterior petrosectomy approach. After dissection of the overlying vascular and meningeal structures, a safe entry zone into the brainstem is identified based on local anatomy and intraoperative neuronavigation. Small ultrasound probes can also be useful for obtaining real-time intraoperative feedback. The CM is internally debulked and resected in a piecemeal fashion through an opening smaller than the CM itself. As brainstem CMs are challenging lesions, knowledge of several surgical nuances and adoption of careful microsurgical techniques are requisite for success.The video can be found here: https://youtu.be/szB6YpzkuCo.

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Median suboccipital craniotomy and telovelar approach for posterior pontine cavernous malformations

Neurosurgical Focus: Video ◽

10.3171/2019.7.focusvid.19134 ◽

2019 ◽

Vol 1 (1) ◽

pp. V8

Author(s):

Daniel D. Cavalcanti ◽

Paulo Niemeyer Filho

Keyword(s):

Cavernous Malformation ◽

Resonance Imaging ◽

Cavernous Malformations ◽

Entry Zone ◽

Suboccipital Craniotomy ◽

Telovelar Approach ◽

Lateral Decubitus ◽

Neurologically Intact ◽

Safe Entry Zone

The pons is the preferred location for cavernous malformations in the brainstem. When these lesions do not surface, it is critical to select the optimal safe entry zone to reduce morbidity.1–3 In this video, we demonstrate in a stepwise manner the medial suboccipital craniotomy and the telovelar approach performed in a lateral decubitus position. They were used to successfully resect a pontine cavernous malformation in a centroposterior location in a 19-year-old patient with diplopia, right-sided numbness, and imbalance. The paramedian supracollicular safe entry zone was used once the lesion did not reach the ependymal surface.2,3 Late magnetic resonance imaging demonstrated total resection and the patient was neurologically intact after 3 months of follow-up. The approach is also demonstrated in a cadaveric dissection to better illustrate all steps.The video can be found here: https://youtu.be/ChArkxA8kig.

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Neuroinflammatory changes of the normal brain tissue in cured mice following combined radiation and anti-PD-1 blockade therapy for glioma

Scientific Reports ◽

10.1038/s41598-021-84600-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Mariano Guardia Clausi ◽

Alexander M. Stessin ◽

Zirun Zhao ◽

Stella E. Tsirka ◽

Samuel Ryu

Keyword(s):

Brain Tissue ◽

Cranial Irradiation ◽

Subcortical White Matter ◽

Glioma Cell Line ◽

Hippocampal Neurogenesis ◽

Normal Brain ◽

Long Term Effects ◽

Normal Brain Tissue ◽

Molecule Inhibitor

AbstractThe efficacy of combining radiation therapy with immune checkpoint inhibitor blockade to treat brain tumors is currently the subject of multiple investigations and holds significant therapeutic promise. However, the long-term effects of this combination therapy on the normal brain tissue are unknown. Here, we examined mice that were intracranially implanted with murine glioma cell line and became long-term survivors after treatment with a combination of 10 Gy cranial irradiation (RT) and anti-PD-1 checkpoint blockade (aPD-1). Post-mortem analysis of the cerebral hemisphere contralateral to tumor implantation showed complete abolishment of hippocampal neurogenesis, but neural stem cells were well preserved in subventricular zone. In addition, we observed a drastic reduction in the number of mature oligodendrocytes in the subcortical white matter. Importantly, this observation was evident specifically in the combined (RT + aPD-1) treatment group but not in the single treatment arm of either RT alone or aPD-1 alone. Elimination of microglia with a small molecule inhibitor of colony stimulated factor-1 receptor (PLX5622) prevented the loss of mature oligodendrocytes. These results identify for the first time a unique pattern of normal tissue changes in the brain secondary to combination treatment with radiotherapy and immunotherapy. The results also suggest a role for microglia as key mediators of the adverse treatment effect.

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Quantitative Measurements of Regional Glucose Utilization and Rate of Valine Incorporation into Proteins by Double-Tracer Autoradiography in the Rat Brain Tumor Model

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.1989.12 ◽

1989 ◽

Vol 9 (1) ◽

pp. 87-95 ◽

Cited By ~ 22

Author(s):

Michihiro Kirikae ◽

Mirko Diksic ◽

Y. Lucas Yamamoto

Keyword(s):

Protein Synthesis ◽

Brain Tumor ◽

Rat Brain ◽

Brain Tissue ◽

Glucose Utilization ◽

Tumor Model ◽

Normal Brain ◽

Normal Brain Tissue ◽

Rat Brain Tumor ◽

Brain Tumor Model

We examined the rate of glucose utilization and the rate of valine incorporation into proteins using 2-[18F]fluoro-2-deoxyglucose and L-[1-14C]-valine in a rat brain tumor model by quantitative double-tracer autoradiography. We found that in the implanted tumor the rate of valine incorporation into proteins was about 22 times and the rate of glucose utilization was about 1.5 times that in the contralateral cortex. (In the ipsilateral cortex, the tumor had a profound effect on glucose utilization but no effect on the rate of valine incorporation into proteins.) Our findings suggest that it is more useful to measure protein synthesis than glucose utilization to assess the effectiveness of antitumor agents and their toxicity to normal brain tissue. We compared two methods to estimate the rate of valine incorporation: “kinetic” (quantitation done using an operational equation and the average brain rate coefficients) and “washed slices” (unbound labeled valine removed by washing brain slices in 10% thrichloroacetic acid). The results were the same using either method. It would seem that the kinetic method can thus be used for quantitative measurement of protein synthesis in brain tumors and normal brain tissue using [11C]-valine with positron emission tomography.

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PET Study of Methionine Accumulation in Glioma and Normal Brain Tissue

Journal of Computer Assisted Tomography ◽

10.1097/00004728-198703000-00002 ◽

1987 ◽

Vol 11 (2) ◽

pp. 208-213 ◽

Cited By ~ 71

Author(s):

Mats Bergström ◽

Kaj Ericson ◽

Lars Hagenfeldt ◽

Mikael Mosskin ◽

Hans von Holst ◽

...

Keyword(s):

Brain Tissue ◽

Normal Brain ◽

Normal Brain Tissue

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Quantitative Analysis of Mobile Proteins in Normal Brain Tissue by Amide Proton Transfer Imaging

Journal of Computer Assisted Tomography ◽

10.1097/rct.0000000000001141 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Kazuaki Sugawara ◽

Tosiaki Miyati ◽

Ryo Ueda ◽

Daisuke Yoshimaru ◽

Masanobu Nakamura ◽

...

Keyword(s):

Quantitative Analysis ◽

Proton Transfer ◽

Brain Tissue ◽

Amide Proton ◽

Normal Brain ◽

Normal Brain Tissue ◽

Amide Proton Transfer ◽

Amide Proton Transfer Imaging

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Glutathione S-Transferases and Cytochrome P450 Enzyme Expression in Patients with Intracranial Tumors: Preliminary Report of 55 Patients

Medical Principles and Practice ◽

10.1159/000494496 ◽

2018 ◽

Vol 28 (1) ◽

pp. 56-62

Author(s):

Cahit Kural ◽

Arzu Kaya Kocdogan ◽

Gulcin Güler Şimşek ◽

Serpil Oğuztüzün ◽

Pınar Kaygın ◽

...

Keyword(s):

Cytochrome P450 ◽

Brain Tissue ◽

Pituitary Adenomas ◽

Normal Brain ◽

Cytochrome P450 Enzyme ◽

Intracranial Tumors ◽

Glutathione S Transferase ◽

Normal Brain Tissue ◽

Tissue Samples ◽

P450 Enzyme

Objective: Intracranial tumors are one of the most frightening and difficult-to-treat tumor types. In addition to surgery, protocols such as chemotherapy and radiotherapy also take place in the treatment. Glutathione S-transferase (GST) and cytochrome P450 (CYP) enzymes are prominent drug-metabolizing enzymes in the human body. The aim of this study is to show the expression of GSTP1, GSTM1, CYP1A1, and CYP1B1 in different types of brain tumors and compare our results with those in the literature. Subjects and Methods: The expression of GSTP1, GSTM1, CYP1A1, and CYP1B1 was analyzed using immunostaining in 55 patients with intracranial tumors in 2016–2017. For GST and CYP expression in normal brain tissue, samples of a portion of surrounding normal brain tissue as well as a matched far neighbor of tumor tissue were used. The demographic features of the patients were documented and the expression results compared. Results: The mean age of the patients was 46.72 years; 29 patients were female and 26 were male. Fifty-seven specimens were obtained from 55 patients. Among them, meningioma was diagnosed in 12, metastases in 12, glioblastoma in 9, and pituitary adenoma in 5. The highest GSTP1, GSTM1, and CYP1A1 expressions were observed in pituitary adenomas. The lowest GSTP1 expression was detected in glioblastomas and the lowest CYP1B1 expression in pituitary adenomas. Conclusion: GSTP1 and CYP expression is increased in intracranial tumors. These results should be confirmed with a larger series and different enzyme subtypes.

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