Waterjet dissection in neurosurgical procedures: clinical results in 35 patients

2002 ◽  
Vol 96 (4) ◽  
pp. 690-696 ◽  
Author(s):  
Juergen Piek ◽  
Joachim Oertel ◽  
Michael Robert Gaab
Keyword(s):  
Blood Loss ◽  
Blood Vessels ◽  
Epilepsy Surgery ◽  
Tumor Resection ◽  
Neurosurgical Procedures ◽  
Normal Brain ◽  
Content Type ◽  
Waterjet Dissection ◽  
Ica Stenosis ◽  
Fine Print

Object. Waterjet dissection represents a new minimally traumatic surgical method for dissection that can be used in various parenchymal organs, in which it allows highly precise parenchymal dissection while preserving blood vessels, resulting in reduced intraoperative blood loss. This study was performed to investigate the clinical application of this new technique in neurosurgical procedures, such as brain tumor resection and epilepsy surgery. Methods. Thirty-four patients with gliomas (Grades II–IV), cerebral metastases, temporal lobe epilepsy, or cerebellar hemangioblastomas, and one patient with internal carotid artery (ICA) stenosis were treated surgically with the aid of the waterjet. Resection was performed using waterjet dissection in combination with conventional neurosurgical procedures. Intraoperatively, the waterjet was easy to handle, and no complications due to the device were observed. Dissection of tissue was possible for all pathological conditions, and pressures between 3 and 45 bars were used. In gliomas, metastases, epilepsy surgery, and hemangioblastoma, the tissue was dissected at pressures between 3 and 17 bars, which preserved blood vessels. Dissection of meningiomas and the ICA stenosis required higher pressures (between 20 and 45 bars); with these pressures, blood vessels were also dissected. Conclusions. These results indicate that the waterjet dissection procedure can be used intraoperatively without complications. This device appears to be particularly suitable for the dissection of highly vascularized gliomas or normal brain tissue, in which tissue dissection with sparing of blood vessels can be achieved. To prove that this is a useful addition to the neurosurgical armamentarium, reduction of blood loss or postoperative brain edema compared with conventional methods should be demonstrated in future studies.

Intracranial navigation by using low-field intraoperative magnetic resonance imaging: preliminary experience

2002 ◽  
Vol 97 (5) ◽  
pp. 1115-1124 ◽  
Author(s):  
Andrew A. Kanner ◽  
Michael A. Vogelbaum ◽  
Marc R. Mayberg ◽  
Joseph P. Weisenberger ◽  
Gene H. Barnett
Keyword(s):  
Magnetic Resonance ◽  
Imaging System ◽  
Intraoperative Imaging ◽  
Tumor Resection ◽  
Cortical Mapping ◽  
Subtotal Resection ◽  
Neurosurgical Procedures ◽  
Content Type ◽  
Low Field ◽  
Fine Print

Object. Intracranial navigation by using intraoperative magnetic resonance (iMR) imaging allows the surgeon to reassess anatomical relationships in near—real time during brain tumor surgery. The authors report their initial experience with a novel neuronavigation system coupled to a low-field iMR imaging system. Methods. Between October 2000 and December 2001, 70 neurosurgical procedures were performed using the mobile 0.12-tesla PoleStar N-10 iMR imaging system. The cases included 38 craniotomies, 15 brain biopsies, nine transsphenoidal approaches, and one drainage of a subdural hematoma. Tumor resection was performed using the awake method in seven of 38 cases. Of the craniotomies, image-confirmed complete or radical tumor resection was achieved in 28 cases, subtotal resection in eight cases, and open biopsies in two cases. Tumor resection was controlled with the use of image guidance until the final intraoperative images demonstrated that there was no residual tumor or that no critical brain tissue was at risk of compromise. In each stereotactic biopsy the location of the biopsy needle could be verified by intraoperative imaging and diagnostic tissue was obtained. Complications included a case of aseptic meningitis after a biopsy and one case of temporary intraoperative failure of the anesthesia machine. Awake craniotomies were performed successfully with no permanent neurological complications. Conclusions. Intraoperative MR image—based neuronavigation is feasible when using the Odin PoleStar N-10 system for tumor resections that require multiple other surgical adjuncts including awake procedures, cortical mapping, monitoring of somatosensory evoked potentials, or electrocorticography. Use of the system for brain biopsies offers the opportunity of immediate verification of the needle tip location. Standard neurosurgical drills, microscopes, and other equipment can be used safely in conjunction with this iMR imaging system.

Waterjet dissection of the brain: experimental and first clinical results

1998 ◽  
Vol 89 (5) ◽  
pp. 861-864 ◽  
Author(s):  
Jürgen Piek ◽  
Christian Wille ◽  
Rolf Warzok ◽  
Michael-Robert Gaab
Keyword(s):  
Clinical Results ◽  
New Method ◽  
Surrounding Tissue ◽  
Histological Evaluation ◽  
Neurosurgical Procedures ◽  
Content Type ◽  
New Device ◽  
Waterjet Dissection ◽  
The Brain ◽  
Fine Print

✓ Control of bleeding during dissection is a problem that is still not completely resolved in neurosurgical procedures. To overcome this problem in some settings, the authors, in close collaboration with their institution, developed a new device for blunt dissection of brain tumors that is based on a waterjet technique. This report describes their first experimental and clinical experience with this new method. Numerous cutting experiments were performed in porcine cadaver brains. The best results were obtained using pressures from 4 to 6 bars with a 100-jxm tip, which produced very small, precise cuts. Histological evaluation showed no disruption or vacuolization of the surrounding tissue. The authors have used the new device in nine patients (seven with gliomas and two undergoing temporal lobe resections for epilepsy), and no complications have been observed. The waterjet device allowed dissection of the brain tissue while even small exposed vessels were spared injury. The instrument was found to be easy to use. Future investigations will concentrate on adapting this new method to endoscopic surgery and evaluating fluids with low surface tension to avoid foaming and bubbling during open surgery.

The deposition of Hg203-chlormerodrin in experimental brain tumors

1971 ◽  
Vol 35 (3) ◽  
pp. 303-308 ◽  
Author(s):  
Tatsuya Kobayashi ◽  
Louis Bakay ◽  
Joseph C. Lee
Keyword(s):  
Brain Tumors ◽  
Tumor Cells ◽  
Normal Brain ◽  
Intracranial Tumors ◽  
Electron Microscopic ◽  
Electron Microscopic Autoradiography ◽  
Content Type ◽  
Meningeal Tumors ◽  
Vacuolar System ◽  
Fine Print

✓ The deposition of Hg203-chlormerodrin was studied in intracranial tumors in mice induced by implantation of 20-methyl cholanthrene by tissue assay, as well as light microscopic and electron microscopic autoradiography. The investigations were carried out in astrocytomas, glioblastomas, and meningeal tumors. The chlormerodrin content of the tumors exceeded that of normal brain with a significant tumor/brain ratio ranging from 5.8 to 22.5. It was found that the chlormerodrin molecule becomes rapidly incorporated in the tumor cells, with a preference for that portion of the cytoplasm associated with the vacuolar system.

Cerebral hemorrhage and edema following brain biopsy in rats: significance of mean arterial blood pressure

2000 ◽  
Vol 92 (1) ◽  
pp. 100-107 ◽  
Author(s):  
Helene Benveniste ◽  
Katie R. Kim ◽  
Laurence W. Hedlund ◽  
John W. Kim ◽  
Allan H. Friedman
Keyword(s):  
Blood Pressure ◽  
Arterial Blood Pressure ◽  
Mean Arterial Blood Pressure ◽  
Neurosurgical Procedures ◽  
Shr Rats ◽  
Mr Microscopy ◽  
Content Type ◽  
Wky Rats ◽  
Arterial Blood ◽  
Fine Print

Object. It is taken for granted that patients with hypertension are at greater risk for intracerebral hemorrhage during neurosurgical procedures than patients with normal blood pressure. The anesthesiologist, therefore, maintains mean arterial blood pressure (MABP) near the lower end of the autoregulation curve, which in patients with preexisting hypertension can be as high as 110 to 130 mm Hg. Whether patients with long-standing hypertension experience more hemorrhage than normotensive patients after brain surgery if their blood pressure is maintained at the presurgical hypertensive level is currently unknown. The authors tested this hypothesis experimentally in a rodent model.Methods. Hemorrhage and edema in the brain after needle biopsy was measured in vivo by using three-dimensional magnetic resonance (MR) microscopy in the following groups: WKY rats, acutely hypertensive WKY rats, spontaneously hypertensive rats (SHR strain), and SHR rats treated with either sodium nitroprusside or nicardipine. Group differences were compared using Tukey's studentized range test followed by individual pairwise comparisons of groups and adjusted for multiple comparisons.There were no differences in PaCO2, pH, and body temperature among the groups. The findings in this study indicated that only acutely hypertensive WKY rats had larger volumes of hemorrhage. Chronically hypertensive SHR rats with MABPs of 130 mm Hg did not have larger hemorrhages than normotensive rats. There were no differences in edema volumes among groups.Conclusions. The brains of SHR rats with elevated systemic MABPs are probably protected against excessive hemorrhage during surgery because of greater resistance in the larger cerebral arteries and, thus, reduced cerebral intravascular pressures.

Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome

2000 ◽  
Vol 92 (2) ◽  
pp. 235-241 ◽  
Author(s):  
Madjid Samii ◽  
Marcos Tatagiba ◽  
Gustavo A. Carvalho
Keyword(s):  
Tumor Resection ◽  
Neurological Deficits ◽  
Subtotal Resection ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Content Type ◽  
Simpson Grade ◽  
Petroclival Meningiomas ◽  
Meckel's Cave ◽  
Fine Print

Object. The goal of this study was to determine whether some petroclival tumors can be safely and efficiently treated using a modified retrosigmoid petrosal approach that is called the retrosigmoid intradural suprameatal approach (RISA).Methods. The RISA was introduced in 1983, and since that time 12 patients harboring petroclival meningiomas have been treated using this technique. The RISA includes a retrosigmoid craniotomy and drilling of the suprameatus petrous bone, which is located above and anterior to the internal auditory meatus, thus providing access to Meckel's cave and the middle fossa.Radical tumor resection (Simpson Grade I or II) was achieved in nine (75%) of the 12 patients. Two patients underwent subtotal resection (Simpson Grade III), and one patient underwent complete resection of tumor at the posterior fossa with subtotal resection at the middle fossa. There were no deaths or severe complications in this series; all patients did well postoperatively, being independent at the time of their last follow-up examinations (mean 5.6 years). Neurological deficits included facial paresis in one patient and worsening of hearing in two patients.Conclusions. Theapproach described here is a useful modification of the retrosigmoid approach, which allows resection of large petroclival tumors without the need for supratentorial craniotomies. Although technically meticulous, this approach is not time-consuming; it is safe and can produce good results. This is the first report on the use of this approach for petroclival meningiomas.

Quantification and pharmacokinetics of blood-brain barrier disruption in humans

1996 ◽  
Vol 85 (6) ◽  
pp. 1056-1065 ◽  
Author(s):  
Bernhard Zünkeler ◽  
Richard E. Carson ◽  
Jeff Olson ◽  
Ronald G. Blasberg ◽  
Hetty Devroom ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Blood Brain Barrier ◽  
Brain Barrier ◽  
Normal Brain ◽  
Content Type ◽  
Barrier Disruption ◽  
Blood Brain Barrier Disruption ◽  
Blood Brain ◽  
Brain Barrier Disruption ◽  
Fine Print

✓ Hyperosmolar blood-brain barrier disruption (HBBBD), produced by infusion of mannitol into the cerebral arteries, has been used in the treatment of brain tumors to increase drug delivery to tumor and adjacent brain. However, the efficacy of HBBBD in brain tumor therapy has been controversial. The goal of this study was to measure changes in vascular permeability after HBBBD in patients with malignant brain tumors. The permeability (K1) of tumor and normal brain blood vessels was measured using rubidium-82 and positron emission tomography before and repeatedly at 8- to 15-minute intervals after HBBBD. Eighteen studies were performed in 13 patients, eight with glioblastoma multiforme and five with anaplastic astrocytoma. The HBBBD increased K1 in all patients. Baseline K1 values were 2.1 ± 1.4 and 34.1 ± 22.1 µl/minute/ml (± standard deviation) for brain and tumor, respectively. The peak absolute increases in K1 following HBBBD were 20.8 ± 11.7 and 19.7 ± 10.7 µl/minute/ml for brain and tumor, corresponding to percentage increases of approximately 1000% in brain and approximately 60% in tumor. The halftimes for return of K1 to near baseline for brain and tumor were 8.1 ± 3.8 and 4.2 ± 1.2 minutes, respectively. Simulations of the effects of HBBBD made using a very simple model with intraarterial methotrexate, which is exemplary of drugs with low permeability, indicate that 1) total exposure of the brain and tumor to methotrexate, as measured by the methotrexate concentration-time integral (or area under the curve), would increase with decreasing infusion duration and would be enhanced by 130% to 200% and by 7% to 16%, respectively, compared to intraarterial infusion of methotrexate alone; and 2) exposure time at concentrations above 1 µM, the minimal concentration required for the effects of methotrexate, would not be enhanced in tumor and would be enhanced by only 10% in brain. Hyperosmolar blood-brain barrier disruption transiently increases delivery of water-soluble compounds to normal brain and brain tumors. Most of the enhancement of exposure results from trapping the drug within the blood-brain barrier, an effect of the very transient alteration of the blood-brain barrier by HBBBD. Delivery is most effective when a drug is administered within 5 to 10 minutes after disruption. However, the increased exposure and exposure time that occur with methotrexate, the permeability of which is among the lowest of the agents currently used clinically, are limited and the disproportionate increase in brain exposure, compared to tumor exposure, may alter the therapeutic index of many drugs.

Effect of the expression of transforming growth factor-β2 in primary human glioblastomas on immunosuppression and loss of immune surveillance

1992 ◽  
Vol 76 (5) ◽  
pp. 799-804 ◽  
Author(s):  
Marius Maxwell ◽  
Theofanis Galanopoulos ◽  
Janine Neville-Golden ◽  
Harry N. Antoniades
Keyword(s):  
Growth Factor ◽  
Transforming Growth Factor ◽  
Immune Surveillance ◽  
Protein Product ◽  
Normal Brain ◽  
Normal Brain Tissue ◽  
Content Type ◽  
Messenger Ribonucleic Acid ◽  
Transforming Growth Factor Β2 ◽  
Fine Print

✓ Glioblastomas are malignant brain tumors that are attended by an immunosuppressed state. The authors have studied the expression of transforming growth factor-β2, which is known to have potent immunosuppressive and angiogenic properties. Transforming growth factor-β2 messenger ribonucleic acid and its protein product are both found to be greatly overexpressed in these tumors and are absent from normal brain tissue. The overexpression of this growth factor may contribute to the escape of neoplastic astrocytes from immune surveillance and, furthermore, to the immunosuppressed state that is characteristic of many of these patients.

Recovery from complete hemiplegia following resection of a retrocentral metastasis: the prognostic value of intraoperative cortical stimulation

2001 ◽  
Vol 95 (6) ◽  
pp. 1050-1052 ◽  
Author(s):  
Hugues Duffau
Keyword(s):  
Tumor Resection ◽  
Prognostic Indicator ◽  
Acute Onset ◽  
Motor Area ◽  
Primary Motor Area ◽  
Content Type ◽  
Motor Responses ◽  
Motor Mapping ◽  
Intraoperative Electrical Stimulation ◽  
Fine Print

✓ The goal in this study was to determine if intraoperative electrical stimulation mapping is useful during surgical resection of lesions located in the central region, even in cases of preoperative hemiplegia. This 45-year-old man with a retrocentral metastasis from an embryonal carcinoma of the testis suffered an acute complete hemiplegia after intratumoral bleeding. Emergency surgery was performed with the aid of intraoperative motor mapping despite the preoperative deficit. Cortical stimulations (CSs) elicited motor responses, allowing the detection and hence preservation of the primary motor area during tumor removal. Postoperatively, the patient recovered almost completely within 1 week; the tumor resection was total. It is possible that CSs give an early and valuable prognostic indicator of motor recovery in cases of complete hemiplegia, at least in patients with acute onset and short duration of the deficit. Consequently, if motor responses can be elicited by CSs, it becomes mandatory for the surgeon to respect the primary motor area despite the preoperative hemiplegia, with the aim of preserving the chances of an eventual recovery.

The fine anatomy of the human spinal meninges

1988 ◽  
Vol 69 (2) ◽  
pp. 276-282 ◽  
Author(s):  
David S. Nicholas ◽  
Roy O. Weller
Keyword(s):  
Spinal Cord ◽  
Blood Vessels ◽  
Transverse Section ◽  
Human Cerebral Cortex ◽  
Pia Mater ◽  
Content Type ◽  
Inner Aspect ◽  
Dentate Ligament ◽  
Arachnoid Mater ◽  
Fine Print

✓ The fine anatomy of the human spinal meninges was examined in five postmortem spinal cords taken within 12 hours after death from patients aged 15 months to 46 years. Specimens of spinal cord were viewed in transverse section and from the dorsal and ventral aspects by scanning electron microscopy. Transverse sections of spinal cord and meninges were also examined by light microscopy. The arachnoid mater was seen to be closely applied to the inner aspect of the dura. An intermediate fenestrated leptomeningeal layer was observed attached to the inner aspect of the arachnoid mater and was reflected ventrally to form a series of dorsal septa. As it arborized laterally over the surface of the cord to surround nerves and blood vessels, the intermediate layer became highly fenestrated but remained distinct from the pia and arachnoid mater. The pia mater appeared to form a continuous layer which was reflected off the surface of the cord to coat blood vessels within the subarachnoid space in a manner similar to that described in the leptomeninges over the human cerebral cortex. Each dentate ligament consisted of a collagenous core which was continuous with the subpial connective tissue and was attached at intervals to the dura; pia-arachnoid cells coated the surface of the dentate ligaments. The present study suggests that the fine anatomy of the human spinal meninges differs significantly from that described in other mammals.

Total calvarial reconstruction for sagittal synostosis in older infants and children

1993 ◽  
Vol 78 (2) ◽  
pp. 199-204 ◽  
Author(s):  
Roger J. Hudgins ◽  
Fernando D. Burstein ◽  
William R. Boydston
Keyword(s):  
Blood Loss ◽  
Craniofacial Surgery ◽  
Acute Blood Loss ◽  
Skull Defect ◽  
Sagittal Suture ◽  
Sagittal Synostosis ◽  
Content Type ◽  
Biparietal Diameter ◽  
Postoperative Hyponatremia ◽  
Fine Print

✓ Premature closure of the sagittal suture is the most common form of craniosynostosis, but this condition occasionally goes unrecognized until the child is too old to undergo procedures that depend upon continued calvarial growth for success. As the entire calvaria is affected and thus misshapen by sagittal synostosis, late correction involves total calvarial reconstruction. The extensive nature of this undertaking has precluded its utilization despite the presence of significant deformities. Adapting the techniques and experience gained from craniofacial surgery, the authors performed total calvarial reconstruction on nine children with sagittal synostosis and subsequent scaphocephaly diagnosed after the age of 1 year. In each case the goals of shortening the anteroposterior length, widening the biparietal diameter, and reducing frontal and occipital deformities were met. Morbidity consisted of acute blood loss, postoperative hyponatremia, and in one case a residual skull defect. The rationale for this procedure and the techniques utilized are discussed.

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