Philadelphia, Pa. (April 8, 2013) – A new functional magnetic resonance imaging (fMRI) technique may provide neurosurgeons with a non-invasive tool to help in mapping critical areas of the brain before surgery, reports a study in the April issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Evaluating brain fMRI responses to a “single, short auditory language task” can reliably localize critical language areas of the brain—in healthy people as well as patients requiring brain surgery for epilepsy or tumors, according to the new research by Melanie Genetti, PhD, and colleagues of Geneva University Hospitals, Switzerland.

Brief fMRI Task for Functional Brain Mapping

The researchers designed and evaluated a quick and simple fMRI task for use in functional brain mapping. Functional MRI can show brain activity in response to stimuli (in contrast to conventional brain MRI, which shows anatomy only). Before neurosurgery for severe epilepsy or brain tumors, functional brain mapping provides essential information on the location of critical brain areas governing speech and other functions.

The standard approach to brain mapping is direct electrocortical stimulation (ECS)—recording brain activity from electrodes placed on the brain surface. However, this requires several hours of testing and may not be applicable in all patients. Previous studies have compared fMRI techniques with ECS, but mainly for determining the side of language function (lateralization) rather than the precise location (localization).

The new fMRI task was developed and evaluated in 28 healthy volunteers and in 35 patients undergoing surgery for brain tumors or epilepsy. The test used a brief (eight minutes) auditory language stimulus in which the patients heard a series of sense and nonsense sentences.

Functional MRI scans were obtained to localize the brain areas activated by the language task—activated areas would “light up,” reflecting increased oxygenation. A subgroup of patients also underwent ECS, the results of which were compared to fMRI.

Non-invasive Test Accurately Localizes Critical Brain Areas

Based on responses to the language stimulus, fMRI showed activation of the anterior and posterior (front and rear) language areas of the brain in about 90 percent of subjects—neurosurgery patients as well as healthy volunteers. Functional MRI activation was weaker and the language centers more spread-out in the patient group. These differences may have reflected brain adaptations to slow-growing tumors or longstanding epilepsy.

Five of the epilepsy patients also underwent ECS using brain electrodes, the results of which agreed well with the fMRI findings. Two patients had temporary problems with language function after surgery. In both cases, the deficits were related to surgery or complications (bleeding) in the language area identified by fMRI.

Functional brain mapping is important for planning for complex neurosurgery procedures. It provides a guide for the neurosurgeon to navigate safely to the tumor or other diseased area, while avoiding damage to critical areas of the brain. An accurate, non-invasive approach to brain mapping would provide a valuable alternative to the time-consuming ECS procedure.

“The proposed fast fMRI language protocol reliably localized the most relevant language areas in individual subjects,” Dr. Genetti and colleagues conclude. In its current state, the new test probably isn’t suitable as the only approach to planning surgery—too many areas “light up” with fMRI, which may limit the surgeon’s ability to perform more extensive surgery with necessary confidence. The researchers add, “Rather than a substitute, our current fMRI protocol can be considered as a valuable complementary tool that can reliably guide ECS in the surgical planning of epileptogenic foci and of brain tumors.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2012 annual revenues of €3.6 billion ($4.6 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (April 8, 2013) – The recent discovery of circulating “nano-sized extracellular vesicles” (EVs) carrying proteins and nucleic acids derived from brain tumors may lead to exciting new avenues for brain cancer diagnosis, monitoring, and treatment, according to a special article in the April issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The review article by Dr. David Gonda from the laboratory of the corresponding author Dr. Clark C. Chen, with contributions from the senior author, Dr. Bob S. Carter of University of California, San Diego, Dr. Fred Hochberg at Massachusetts General Hospital and Dr. Steve Kalkanis of the Henry Ford Hospital brain tumor programs discusses “the biological processes mediated by these EVs and their applications as biomarkers for brain tumor diagnosis, monitoring, and therapeutic development.” The researchers add, “Opportunity exists to use EVs as delivery vehicles or immune modulatory tools” for brain cancer treatment.

Nano-Sized EVs Play Role in Cancer Growth and Survival

The authors use the term EVs to refer to various types of “membrane-encapsulated cellular components” released from cells. Microscopic EVs—tiny even in relation to the cells that produce them—have been isolated from all bodily fluids, including the blood and cerebrospinal fluid of patients with brain tumors. Extracellular vesicles are like nano-sized “bubbles” of material sent out by cells, containing proteins and other cellular materials—including nucleic acids that carry genetic information.

So far, researchers have identified three general biological functions of EVs: remodeling and removal of cellular components; elimination of “toxic metabolites or unneeded membrane components” from cells; and intercellular communication, providing a means for transferring proteins or genetic information from one cell to another.

In patients with brain cancer, EVs may also provide a way for tumor cells to alter the microenvironment in which they grow. Different types of EVs may perform functions enabling cancers to grow and spread while evading the immune responses that would target tumor cells for destruction.

Could EVs Be Used for Cancer Detection and Treatment?

Scientific efforts to understand EVs and their functions—in normal physiology as well as in cancers and other disease states—are just getting started. But researchers envision new opportunities for the development of biomarkers for diagnosis and monitoring of brain cancers, as well as possible new treatment strategies based on EVs.

Approaches based on identifying specific proteins and genetic material carried by EVs could be useful in identifying brain cancers, and monitoring their status over time. For example, EVs might be used in identifying specific mutations of the IDH1 gene, recently linked to a type of brain cancer called glioblastoma multiforme.  Corresponding author Dr. Chen noted in correspondence that “A large consortium effort among neurosurgeons and neuro-oncologists is emerging to assess the clinical utility of the basic science findings highlighted in our review.  We anticipate that the next several years will yield important information as teams of scientists and clinicians work to study these questions.”

Further studies of the function of EVs may open at least three directions for brain cancer treatment. Treatments could be devised to inhibit the secretion and uptake of tumor-related EVs, which might interfere with their ability to grow or spread. New approaches to immunotherapy might be developed, using EVs to stimulate immune responses against tumor cells. It might also be possible to engineer EVs to serve as “delivery vehicles” to target drugs directly to cancer cells.

“Enhanced secretion of EVs by tumors offers an opportunity to detect tumor-specific genetic material as biomarkers for diagnostic or therapeutic monitoring,” the authors conclude. While extensive research is still needed to understand how EVs work and how they can be exploited for specific uses, they write, “Awareness of these developments should augment the armamentarium available to oncology-dedicated neurosurgeons.”   

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2012 annual revenues of €3.6 billion ($4.6 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (March 11, 2013) – Patients with neck injuries incur increased health and social costs—which also affect their spouses and may begin years before the initial injury, reports a study in the March 1 issue of Spine.  The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Some individuals and families seem more susceptible to experiencing socioeconomic consequences of neck injury, according to the new research by Dr Poul Jennum of University of Copenhagen and colleagues.  Particularly for patients who develop chronic neck pain, the health and social costs may start to increase a decade or more before neck injury occurs

Higher Health and Social Costs for Patients with Neck Injuries

To analyze the “socioeconomic burdens” of neck injuries, the researchers used Danish national databases to identify approximately 94,000 patients who sustained neck injuries (other than fractures) from 1998 to 2009.  The patients with neck injuries were matched to controls without neck injuries.

In addition to direct health care costs and prescription drugs, the study addressed indirect costs such as work disability and social security payments.  The researchers also assessed health and social costs for the spouses of patients with neck injury; as well as changes in costs over time, including the years before the injury.

Nearly all cost categories were increased for patients with neck injuries.  “Neck injury patients had significantly higher rates of health-related contacts, medication use and higher socioeconomic costs than controls,” Dr Jennum and coauthors write.  The spouses of patients with neck injuries also had increased costs for doctor visits, hospital services, and medications.

Social costs—including sick pay, social welfare, and other “transfer payments”—were also significantly higher for patients with neck injuries and their spouses.  Despite receiving more welfare payments, patients with neck injuries had only slightly lower employment rates.

‘Pre-existing Increased Vulnerability’ to Higher Costs

Overall direct and indirect costs were about €2,500 higher for patients with neck injuries and €1,600 higher for spouses.  “The consequences for the spouse were not negligible, accounting for approximately one-third of the total familial health-related costs,” the researchers write.

The increases in both direct and indirect costs began to occur well before neck injury—up to eleven years earlier.  Dr Jennum and colleagues write, “Particularly among those subjects whose injury had a long-term socioeconomic impact—ie, those who developed persistent symptoms after neck injuries—there was evidence of a negative social- and health-related status several years before the accident.”  This pattern suggests a “pre-existing increased vulnerability” to the economic and social costs of neck injury, for both patient and spouse.

How could costs increase even before the neck injury?  It may reflect the well-recognized psychosocial factors affecting people’s ability to cope with back and neck pain, Dr Jennum and coauthors suggest.  The increased costs for spouses may reflect a trend for people with “low-threshold sickness behavior” to choose spouses with similar tendencies.

Neck injury is a common and costly problem, with approximately ten percent of injured patients developing chronic neck pain and other symptoms.  Whiplash-associated disorders occurring after traffic accidents are an example of a potentially chronic neck injury leading to high medical and social costs.

“Neck injuries are associated with major socioeconomic consequences for patients, their spouses and society,” Dr the researchers conclude.  The new findings suggest that some individuals and families may be predisposed to chronic neck pain and its adverse health and social impact.  Dr Jennum and coauthors call for further research to “identify high-risk groups for chronic disease development and disease management, so that the costs and consequences for patients and society can be reduced.”

Read the full article at spinejournal.com.

About Spine

Recognized internationally as the leading journal in its field, Spine (www.spinejournal.com) is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine.  According to the latest ISI Science Citation Impact Factor, Spine is the most frequently cited spinal deformity journal among general orthopaedic journals and subspecialty titles.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (March 4, 2013) – Patients undergoing cerebral angiography and neurointerventional procedures on the brain are at very low risk of infection—even without preventive antibiotics, reports a study in the March issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

“These data suggest that the overall risk of infection associated with most neuroangiographic procedures is very low,” according to the study by Dr. Prashant S. Kelkar and colleagues of University of Alabama, Birmingham. Based on their results, the researchers believe routine preventive antibiotics may not be needed for patients undergoing brain angiography and interventions.

Out of 2,900 Procedures, Just Three Infections

The authors reviewed their experience with more than 2,900 cerebral angiograms and neurointerventional procedures performed between 2004 and 2011. An angiogram is an x-ray procedure using a special dye injected into the brain blood vessels. Neurointerventional procedures are various types of minimally invasive (nonsurgical) procedures performed to treat brain lesions such as aneurysms.

Both types of procedures are performed by threading a catheter through the patient’s blood vessels—usually accessing the femoral artery through a tiny incision in the upper thigh. Unlike at some other centers, the authors did not routinely give antibiotics to prevent infections in patients undergoing these procedures.

The experience included approximately 2,000 angiographic and 900 neurointerventional procedures. Just three patients had infections directly attributable to the procedure—a rate of one-tenth of one percent (0.1%). All were localized infections involving the femoral artery access site in the thigh. There were no infections of the brain or central nervous system.

All infections were successfully treated with antibiotics; two of the patients underwent minor surgery as well. In one patient, the infection was likely related to suppressed immune function because of cancer treatment. None of the patients died as a result of their infection.

Routine Antibiotics May Be Unnecessary

Cerebral angiography is a common diagnostic test for patients with stroke and other disorders. Neurointerventional procedures provide a less-invasive alternative to surgery for selected patients with aneurysms or other lesions of the brain blood vessels.

At many hospitals, patients undergoing these procedures are routinely given antibiotics to prevent infections. However, few studies have evaluated the risk of infection in patients undergoing cerebral angiography and neurointerventional procedures.

The new study finds that the risk of infection is very low, even without routine use of antibiotics. The authors suggest the low risk of infection may reflect the minimally invasive nature of these procedures; their short duration, compared to brain surgery; and the “blood-brain barrier” preventing bacteria from crossing from the bloodstream into the brain.

Dr. Kelkar and colleagues believe their results question the need for routine antibiotics for patients undergoing these procedures. “Prophylatic antibiotic use may be a reasonable option for selected patients,” they write, “but is probably unnecessary for standard use in the context of meticulous care during procedures.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2012 annual revenues of €3.6 billion ($4.6 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (February  19, 2013) – For patients with spinal stenosis, epidural steroid injections (ESI) may actually lead to worse outcomes—whether or not the patient later undergoes surgery, according to a study in the February 15 issue of Spine.  The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The study raises questions about the benefits of steroid injection—a widely used treatment for the common problem of spinal stenosis in the lower (lumbar) spine.  “There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically,” according to the study by Dr Kris E. Radcliff of Thomas Jefferson University, Philadelphia, and colleagues.

Do Steroid Injections Help in Spinal Stenosis?

The researchers analyzed data from the Spine Outcomes Research Trial (SPORT)—one of the largest clinical trials of surgery for spinal disorders.  In SPORT, patients meeting strict criteria for spinal stenosis (or other common spinal problems) were randomly assigned to surgery or nonsurgical treatment (such as physical therapy and medications).  Patients with spinal stenosis have narrowing of the spinal canal, causing back pain, leg pain, and other symptoms.

The current analysis focused on the effects of ESI as part of treatment for spinal stenosis.  Steroid injection is commonly recommended for patients whose symptoms don’t improve with initial treatment.

Dr Radcliff and colleagues compared outcomes for 69 patients who underwent steroid injection during their first three months of enrollment in SPORT versus 207 patients who did not receive ESI.  The two groups were similar in terms of most initial characteristics, although patients receiving steroid injections were more likely to prefer nonsurgical treatment:  62 versus 33 percent.

‘Significantly Less Improvement’ in Patients with ESI

“Despite equivalent baseline status, ESI were associated with significantly less improvement at four years among all patients with spinal stenosis in SPORT,” the researchers write.  Among patients who eventually had surgery, those who had ESI showed less improvement in physical functioning through four years’ follow-up.  For those treated nonsurgically, steroid injections were associated with less improvement in pain as well as functioning.

There was also evidence that surgery was more complicated in patients who had previously been treated with epidural steroids.  On average, surgery took about one-half hour longer in patients who had received ESI, who also spent about one day longer in the hospital.  Patients who received ESI were also more likely to “crossover” from their initially assigned treatment to the other treatment group.  There was no evidence that receiving steroid injections helped patients to avoid surgery.

Lumbar spinal stenosis is a common problem in older adults.  Epidural steroid injection is a common treatment for spinal stenosis, despite a lack of evidence showing its long-term benefits.  The SPORT data provides an opportunity to examine how steroid injections affect long-term outcomes of spinal stenosis.

The new study has some important limitations, especially in that patients weren’t randomly assigned to epidural steroid treatment.  However, the results suggest that patients with spinal stenosis who receive ESI have less improvement at four years’ follow-up, whether or not they subsequently undergo surgery.

Dr Radcliff and colleagues conclude, “Despite the common treatment practice of incorporating one or more ESI in the initial nonoperative management of patients with spinal stenosis, these results suggest that ESI is associated with worse outcome in the treatment of spinal stenosis,” write.  They believe the “most likely” reason for the worse outcomes after ESI is that the injection causes worsening of the spinal narrowing or result spinal nerve impingement, although other explanations are possible.  The authors call for further research to clarify the “indications and results of this common procedure.”

About Spine

Recognized internationally as the leading journal in its field, Spine (www.spinejournal.com) is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine.  According to the latest ISI Science Citation Impact Factor, Spine is the most frequently cited spinal deformity journal among general orthopaedic journals and subspecialty titles.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (February 7, 2013) – Injury to the subcortical structures of the inner brain is a major contributor to worsening neurological abnormalities after “awake craniotomy” for brain tumors, reports a study in the February issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

During a procedure intended to protect critical functional areas in the outer brain (cortex), damage to subcortical areas—which may be detectable on MRI scans—is a major risk factor for persistent neurological deficits. “Our ability to identify and preserve cortical areas of function can still result in significant neurological decline postoperatively as a result of subcortical injury,” write Dr. Victoria T. Trinh and colleagues of The University of Texas MD Anderson Cancer Center, Houston.

Risk Factors for Neurological Deficits after Awake Craniotomy

The researchers analyzed factors associated with worsening neurological function after awake craniotomy for brain tumor surgery. In awake craniotomy, the patient is sedated but conscious so as to be able to communicate with the surgeon during the operation.

The patient is asked to perform visual and verbal tasks while specific areas of the cortex are stimulated, generating a functional map of the brain surface. This helps the surgeon navigate safely to the tumor without damaging the “eloquent cortex”—critical areas of the brain involved in language or movement.

The study included 241 patients who underwent awake craniotomy with functional brain mapping from 2005 through 2010. Of these, 40 patients developed new neurological abnormalities. Dr. Trinh and colleagues examined potential predictive factors—including changes on a type of MRI scan called diffusion-weighted imaging (DWI).

Of the 40 cases with new neurological deficits, 36 developed while the surgeon was operating in the subcortical areas of the brain. These are the inner structures of the brain, located beneath the outer, folded brain cortex. Just one abnormality developed while the surgeon was operating in the cortex only.

MRI Changes May Reflect Subcortical Damage

Neurological abnormalities developing while the surgeon was operating in the subcortex were likely to remain after surgery, and to persist at three months’ follow-up evaluation. Dr. Trinh and coauthors write, “Patients with intraoperative deficits during subcortical dissection were over six times more likely to have persistently worsened neurological function at three-month follow-up.”

In these patients, MRI scans showing more severe changes in the DWI pattern in the subcortex also predicted lasting neurological abnormalities. Of patients who had neurological deficits immediately after surgery and significant DWI changes, 69 percent had persistent deficits three months after surgery.

Patients who had “positive” cortical mapping—that is, in whom eloquent cortex was located during functional mapping—were somewhat more likely to have neurological abnormalities immediately after surgery. However, the risk of lasting abnormalities was not significantly higher compared to patients with negative cortical mapping.

Awake craniotomy with brain stimulation produces a “real-time functional map” of the brain surface that is invaluable to the neurosurgeon in deciding how best to approach the tumor. The new results suggest that, even when the eloquent cortex is not located on cortical mapping, subcortical areas near the tumor can still be injured during surgery. “Subcortical injury is the primary cause of neurological deficits following awake craniotomy procedures,” Dr. Trinh and colleagues write.

The researchers add, “Preserving subcortical areas during tumor resections may reduce the severity of both immediate and late neurological sequelae.” Based on their findings, they believe subcortical mapping techniques may play an important role in avoiding complications after awake craniotomy.

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (February 7, 2013) – For women with aneurysms involving the brain blood vessels, pregnancy and delivery don’t appear to increase the risk of aneurysm rupture, reports a paper in the February issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The study also finds that women with known, unruptured aneurysms have a very high rate of cesarean delivery—which isn’t supported by evidence and “may not be necessary,” according to Dr. Brian L. Hoh of University of Florida, Gainesville, and colleagues.

Pregnancy Doesn’t Increase Risk of Aneurysm Rupture

The researchers used a national hospital database (the Nationwide Inpatient Sample) to estimate the risk of brain aneurysm rupture during pregnancy and delivery. An aneurysm is a weakened spot in a blood vessel wall. If the aneurysm enlarges or ruptures (breaks), it can cause life-threatening bleeding in the brain.

The database identified 714 women hospitalized for ruptured aneurysm during pregnancy and 172 during delivery between 1988 and 2009. Based on an estimated rate of 1.8 percent among women of childbearing age, Dr. Hoh and colleagues calculated that, across the United States, approximately 49,000 women with unruptured aneurysms were hospitalized during pregnancy and 312,000 during delivery.

Using these figures, the researchers estimated a 1.4 percent risk of aneurysm rupture during pregnancy and 0.05 percent during delivery. Based on previous studies, these rates were “comparable with the risk of aneurysm rupture in the general population,” Dr. Hoh and coauthors write.

Women with ruptured aneurysms were at high risk of poor outcomes—including maternal mortality rates of 9.5 percent for those with rupture during pregnancy and 18 percent with rupture during delivery. The risk of poor outcomes appeared lower for women who underwent treatment for ruptured aneurysms: either surgical clipping or less-invasive, endovascular “coiling.” However, because of the relatively small number of patients, these differences were not statistically significant.

High Rate of Cesarean Section May Be Unnecessary

The researchers also identified 218 deliveries in women with known unruptured aneurysms. Approximately 70 percent of these were cesarean deliveries—much higher than the 25 percent rate in women without aneurysms. However, there was no evidence that cesarean delivery improved outcomes for either the mother or baby, compared to “closely supervised vaginal delivery,” Dr. Hoh and colleagues note. “Therefore, the method of delivery in patients with intracranial unruptured aneurysm should be based on obstetric considerations.”

Aneurysms of the brain blood vessels are rarely detected in pregnant women. However, ruptured aneurysm during pregnancy and delivery is an unpredictable complication with a substantial risk of death for both the mother and infant. With MRI and other advanced brain imaging studies, more brain aneurysms are being detected before rupture or other problems occur.

In the absence of data on how pregnancy or delivery affects the risk of aneurysm rupture, the optimal management of unruptured aneurysms in pregnant women has been unclear. “We were not able to find an increased association between pregnancy or delivery and the risk of rupture of cerebral aneurysms,” Dr. Hoh and colleagues conclude. “Once ruptured, however, prompt aneurysmal obliteration (either surgical clipping or endovascular coiling) should be helpful in decreasing the rate of poor outcomes.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (January 22, 2013) – Researchers are making new strides in understanding the health consequences  and treatment and rehabilitation needs of combat veterans and other service members affected by traumatic brain injury (TBI).  The January-February issue of The Journal of Head Trauma Rehabilitation, official journal of the Brain Injury Association of America, is a special issue devoted to new research in military TBI.  The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

“For the second consecutive year, we’ve expedited publication of new papers related to diagnosis, management, and rehabilitation of the many thousands of military personnel affected by TBI,” comments John D. Corrigan, PhD, ABPP, Editor-in-Chief of JHTR.  Contributed by leading U.S. experts in brain injury and rehabilitation, the eight papers in the special issue address a wide range of aspects of military TBI—from combat to peacetime, and from active duty to many years after trauma.

Important Updates on Brain Injury in Military Personnel

There’s a pressing need for new research on military TBI—a problem with lasting consequences on the lives of thousands of Iraq and Afghanistan war veterans.  It has been estimated that 19 percent of military personnel will sustain a TBI during combat deployment.  Although most of these injuries are mild, some of those service members who incur a mild TBI will go on to develop a “post-concussive” syndrome, consisting of chronic cognitive, behavioral, and psychological problems.

Several papers in the special issue address associations of mild TBI with post-concussive symptoms and other co-occurring problems, including posttraumatic stress disorder (PTSD), depression, suicidal thoughts and behavior, and pain. Dr Corrigan comments, “The interplay of TBI, post-concussive symptoms, PTSD, depression, suicidality, pain, and substance abuse is the most challenging problem facing the Department of Defense and VA when treating service members with TBI.”

Highlighted topics include:

• Research by Dr Jeffrey J. Bazarian of the University of Rochester, linking PTSD to structural brain damage seen on diffusion tensor imaging—even in service members with no reported history of mild TBI.  Blast-related trauma may have subclinical effects—not experienced at the time of injury, or not recalled—that are associated with PTSD. “Some of the effects of blast exposure may be below the threshold of symptom experience, including a predisposition to PTSD,” Dr Corrigan comments. “If so, this would offer additional support for the policy of event-based screening for 24-hour removal from combat in Afghanistan, recently introduced by the Army and Marine Corps.”
• A study by Kelly J. Miller, MPH, and colleagues of the Defense and Veterans Brain Injury Center, reporting that service members with previous TBIs had more symptoms in the first three months after a subsequent injury, compared to those with their first TBI.  ”These findings underscore the growing appreciation that in addition to severity of TBI, prior experience of TBI is also an important determinant of consequences both short- and long-term,” says Dr Corrigan.
• A study by Andrew J. MacGregor, PhD, MPH, and colleagues of the Naval Health Research Center, San Diego, which found that service members with mild TBI were more likely to report health symptoms, such as headache, back pain, ringing in the ears, dizziness and memory problems.  Those with dizziness and memory problems were at particularly high risk of declining health after mild TBI.

Other topics in the special issue include important associations of loss of consciousness, altered consciousness, or amnesia with the outcomes of TBI; factors associated with use of health care services by veterans with TBI; and the high rate of TBI among veterans seeking mental health services.  The editors have also announced that a collection of the most popular articles on military TBI published in JHTR over the past three years has been made available free on the journal website.  Dr Corrigan adds, “We hope these papers will help to increase awareness of TBI and its consequences among returning veterans, and spur further research into the most effective approaches to treatment and rehabilitation.” 

About The Journal of Head Trauma Rehabilitation

The Journal of Head Trauma Rehabilitation (JHTR) is a bimonthly journal s a peer-reviewed journal that provides information on clinical management and rehabilitation of persons with head injuries for the practicing professional. It is the official journal of the Brain Injury Association of America.

About the Brain Injury Association of America

The Brain Injury Association of America (BIAA) is the country’s oldest and largest nationwide brain injury advocacy organization.   Its mission is advance brain injury prevention, research, treatment and education and to improve the quality of life for all individuals impacted by brain injury. Through advocacy, the BIAA brings help, hope and healing to millions of individuals living with brain injury, their families and the professionals who serve them.

About Lippincott Williams & Wilkins
Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (January 16, 2013) – With the rapidly expanding use of brain and spinal cord stimulation therapy (neuromodulation), new “remote presence” technologies may help to meet the demand for experts to perform stimulator programming, reports a study in the January issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The preliminary study by Dr. Ivar Mendez of Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, Canada, supports the feasibility and safety of using a remote presence robot—called the “RP-7″—to increase access to specialists qualified to program the brain and spine stimulators used in neuromodulation.

Robot Lets Experts Guide Nurses in Programming Stimulators

Dr. Mendez and his group developed the RP-7 as a way of allowing experts to “telementor” nonexpert nurses in programming stimulator devices. Already widely used for Parkinson’s disease and severe chronic pain, neuromodulation is being explored for use in other conditions, such as epilepsy, severe depression, and obsessive-compulsive disorder.

In this form of therapy, a small electrode is surgically placed in a precise location in the brain or spine. A mild electrical current is delivered to stimulate that area, with the goal of interrupting abnormal activity.  As more patients undergo brain and spine stimulation therapy, there’s a growing demand for experts to program the stimulators that generate the electrical current.

The RP-7 is a mobile, battery-powered robot that can be controlled using a laptop computer. It is equipped with digital cameras and microphones, allowing the expert, nurse, and patient to communicate. The robot’s “head” consists of a flat-screen monitor that displays the face of the expert operator.

The RP-7 also has an “arm” equipped with a touch-screen programmer, which the nurse can use to program the stimulator. The expert can “telestrate” to indicate to the nurse the correct buttons to push on the programming device.

Access to Specialists in the Next Room—or Miles Away

In the preliminary study, patients with neuromodulation devices were randomly assigned to conventional programming, with the expert in the room; or remote programming, with the expert using the RP-7 to guide a nurse in programming the stimulator. For the study, the expert operators were simply in another room of the same building. However, since the RP-7 operates over a conventional wireless connection, the expert can be anyplace that has Internet access.

On analysis of 20 patients (10 in each group), there was no significant difference in the accuracy or clinical outcomes of remote-presence versus conventional programming. No adverse events occurred with either type of session.

The remote-presence sessions took a little more time: 33 versus 26 minutes, on average. Patients, experts, and nonexpert nurses all gave high satisfaction scores for the programming experience.

“This study demonstrated that remote presence can be used for point-of-care programming of neuromodulation devices,” Dr. Mendez and coauthors write. The study provides “proof of principle” that the RP-7 or similar devices can help to meet the need for experts needed to serve the rapidly expanding number of patients with neuromodulation therapies.

The researchers have also started a pilot study using a new mobile device, called the RP-Xpress. About the size of a small suitcase, the RP-Xpress is being used to perform long-distance home visits for patients living hundreds of miles away, using existing local cell phone networks. Dr. Mendez and colleagues conclude, “We envision a time, in the near future, when patients with implanted neuromodulation devices will have real-time access to an expert clinician from the comfort of their own home.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (January 16, 2013) – Researchers using sophisticated genetic testing techniques have identified a promising new biomarker for diagnosis of glioma—the most common type of malignant brain tumor, reports the January issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The biomarker ELTD1 “may serve as an additional biomarker for gliomas in preclinical and clinical diagnosis of gliomas,” according to the study by Rheal A. Towner of Oklahoma Medical Research Foundation, Oklahoma City.

Biomarker Reflects Rapid Blood Vessel Development

Dr. Towner and colleagues used advanced “data mining and bioinformatic” techniques to evaluate genes and gene products potentially associated with gliomas. Glioma is a general term referring to tumors originating in the glial cells of the brain and spinal cord. Gliomas make up about 40 percent of all brain tumors and 80 percent of central nervous system cancers. Especially for advanced (high-grade) gliomas such as glioblastoma multiforme (GBM), expected survival is very poor.

Out of nearly 200 possible markers analyzed, ELTD1 was identified as the strongest candidate for a significant association with glioma. There’s special interest in ELTD1 because it is linked to development of new blood vessels, or angiogenesis—a characteristic of rapidly growing cancers. (ELTD1 stands for “epidermal growth factor, latrophilin and seven transmembrane domain-containing protein 1.”)

Studies in human patients suggested that ELTD1 was strongly associated with gliomas. ELTD1 was more highly expressed in specimens from 50 patients with high-grade gliomas, compared to 21 patients with lower-grade gliomas.

Higher levels of ELDT1 expression were associated with a higher grade of glioma, and with lower survival. ELTD1 compared well with other known markers of glioma, such as vascular endothelial growth factor. It also appeared to be associated with one specific subtype of GBM (mesenchymal GBM).

In further experiments, the researchers transplanted glioma cells into the brains of rats. As the tumors developed, they showed elevated levels of ELTD1, compared to normal brain tissue. The rat studies included evaluation of a “molecular MRI technique” for measuring ELDT1 levels in the living brain.

A Helpful Marker for Glioma Diagnosis?

Even with modern treatments, GBM and other malignant gliomas are devastating cancers. In recent years, advances in research have led to the identification of biomarkers associated with glioma. Dr. Towner and colleagues write, “Validation of more biomarkers for GBM could be beneficial in the diagnosis and therapeutic intervention of this disease.”

With further study, ELTD1 could become a useful new marker of glioma, including GBM. Gliomas show increased expression of ELTD1, and higher levels of ELTD1 expression are associated with higher tumor grade and a worse prognosis. “Any increase in ELTD1 will more than likely be associated with increased angiogenesis or neovascularization [new blood vessel development] in gliomas,” the researchers write.

Although the findings are only preliminary, Dr. Towner and coauthors suggest that ELTD1 could be useful in detecting the presence and grade of gliomas—particularly high-grade gliomas such as GBM. They conclude, “[T]his biomarker may play an important diagnostic role in addition to currently used markers for gliomas, particularly as a histological marker for identifying vascular proliferation.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com