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 12, 2013) – For patients with “drug-resistant” epilepsy requiring surgery, an updated stereoelectroencephalography (SEEG) technique provides a more efficient process for obtaining critical data for surgical planning, according to 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.

“SEEG is a safe and accurate procedure for invasive assessment of the epileptogenic zone,” according to the new report by Dr. Francesco Cardinale of Niguarda Ca’ Granda Hospital, Milan, and colleagues. Their “updated workflow” combines sophisticated imaging data reconstructions and robot-assisted surgery, “providing essential information in the most complex cases of drug-resistant epilepsy.”

Stereo EEG Technique Updated and Simplified

The researchers describe the development of and initial experience with an updated SEEG technique for planning epilepsy surgery. The concept of SEEG is not new. Originally developed by French researchers named Talairach and Bancaud, SEEG uses electrodes implanted in the brain to localize the epileptogenic zone—the area in which seizures originate. The traditional SEEG technique includes two surgical steps: 3-D imaging of the brain blood vessels (stereotactic angiography) followed by electrode implantation.

Over the last few years, Dr. Cardinale and colleagues have been working to develop an updated SEEG workflow allowing a one-step surgical technique. Before surgery, the patient undergoes 3-D magnetic resonance imaging and 3-D digital subtraction angiography. The digital imaging data then undergo processing for reconstruction, resulting in the creation of a detailed computerized model of the brain and of the vascular tree. A key part of the development process was creating a “homemade” computer script to automate the necessary series of data processing steps.

Using the software program from an image-guided neurosurgical robot, the reconstructed data are used to plan the surgical approach, or “trajectory.” Robot-assisted surgery was then performed to implant the electrodes. Whether performed by the traditional or updated workflow, the goal of SEEG is to provide the surgeon with highly precise information on the location of the epileptogenic zone, used for planning epilepsy surgery. (In a brief online video, Dr. Cardinale outlines the steps involved in the updated workflow: http://links.lww.com/NEU/A513)

The researchers report on the outcomes of 500 SEEG procedures performed between 1996 and 2011 in patients with drug-resistant epilepsy. Both techniques were highly successful in guiding electrode placement to localize the epileptogenic zone. Complications occurred in 12 cases, for a rate of 2.4 percent.

The first 419 procedures were done with the traditional two-step process; the next 81 procedures were done using the new workflow. The updated technique provided good data reconstructions with no loss of information and a “dramatic reduction in procedural error risks.” Use of the 3-D data with the neurosurgical robot allowed neurosurgeons to target any area of the brain, from a wide range of angles. They were also able to create 3-D representations of the brain anatomy and electrode placement, which facilitated communication among the surgical team members and patients.

Detailed analysis in a subset of cases found improved accuracy with the new technique. Median error in localizing the implanted electrodes decreased by about 1 millimeter both at the entry point (the most risky zone) and at the deepest point. The authors believe their technique allows them to estimate a “safe entry region” for electrode placement with 99 percent accuracy.

The new experience adds to the evidence that SEEG is a safe and effective procedure for electrode placement and surgical planning in patients with drug-resistant epilepsy.  Dr. Cardinale and colleagues conclude, “The traditional Talairach methodology, recently updated by the use of the most advanced multimodal planning tools and robot-assisted surgery, allows one to directly record electric activity from every brain structure, providing valuable information in the most complex cases of refractory epilepsy.” They are currently working on developing a “SEEG automatic planner.”

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 Wolters Kluwer Health

Wolters Kluwer Health (Philadelphia, PA) is a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Serving more than 150 countries and territories worldwide, Wolters Kluwer Health’s customers include professionals, institutions and students in medicine, nursing, allied health and pharmacy. Major brands include Lippincott Williams & Wilkins, Ovid^®, Medknow, UpToDate^®, Medi-Span^®, Facts & Comparisons^®, Pharmacy OneSource^®, Lexicomp^® and ProVation^® Medical.

Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company. Wolters Kluwer had 2012 annual revenues of €3.6 billion ($4.6 billion), employs approximately 19,000 people worldwide, and maintains operations in over 40 countries across Europe, North America, Asia Pacific, and Latin America.

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).

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 12, 2013) – Ten years after stroke caused by a ruptured aneurysm of the brain, surviving patients have persistent difficulties in several areas affecting quality of life, 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.

The long-term impact of ruptured aneurysms causing subarachnoid hemorrhage (SAH) highlights the need for “survivorship care plans” comparable to those made for long-term cancer survivors, according to the report by Ann-Christin von Vogelsang, MSN, PhD, and colleagues of Karolinska University Hospital, Stockholm, Sweden.

Quality of Life Ten Years after Ruptured Aneurysm

The researchers performed a long-term follow-up study in 217 patients who had survived SAH caused by a ruptured aneurysm. Subarachnoid hemorrhage is a life-threatening type of stroke in which there is bleeding into the brain. It most commonly occurs when an aneurysm—a weak spot in one of the blood vessels supplying the brain—ruptures or breaks.

Approximately ten years after treatment for ruptured aneurysm and SAH, the patients completed a questionnaire evaluating key areas of health-related quality of life. Responses were compared with a general population sample of similar age and sex.

The aneurysm survivors were 154 women and 63 men, average age 61 years. Most underwent surgery for treatment for their ruptured aneurysm. At ten years’ follow-up, 30 percent rated themselves as “fully recovered.”

But compared to the general population, the SAH survivors had increased problems in four out of five dimensions of quality of life: mobility, self-care, usual activities, and anxiety/depression. (The only area that wasn’t significantly worse was pain/discomfort.) On a 100-point scale, overall quality of life score averaged 71 for the aneurysm survivors, compared to 78 for the general population group.

Patients who were more disabled after their SAH had lower quality of life scores at follow-up, as did those who rated themselves as less than fully recovered. Patients with other (comorbid) health problems also had more difficulties affecting quality of life.

Survivors of SAH Need Long-Term Follow-Up and Support

Ruptured aneurysm leading to SAH is a potentially life-threatening condition. Patients who survive this serious form of stroke are at risk of physical disability and depression. Previous studies have evaluated quality of life for survivors of ruptured aneurysm, but few have looked at outcomes more than five years after the event.

One recent study suggested that patients may show continued improvement even more than a decade after SAH. Quality of life is increasingly regarded as an important factor affecting patient outcomes.

The new findings show that survivors of ruptured aneurysm have decreased quality of life and an increased rate of health problems. “The implications for health care from our study are that aneurysmal SAH patients need to be followed up and that support needs to be provided long term after the onset,” Dr. von Vogelsang and colleagues write. Unrealistic expectations of recovery may be a key issue.

They believe that patients who have experienced a ruptured aneurysm might benefit from survivorship care plans, similar to those used for long-term cancer survivors. “A survivorship care plan aims to inform the patient of long-term effects, to identify psychosocial resources in their community, and to provide guidance on follow-up care, prevention, and health maintenance,” Dr. von Vogelsang and coauthors add. They call for further research on how best to provide follow-up and support for SAH survivors, including studies to explore patients’ expectations for recovery.

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 Wolters Kluwer Health

Wolters Kluwer Health (Philadelphia, PA) is a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Serving more than 150 countries and territories worldwide, Wolters Kluwer Health’s customers include professionals, institutions and students in medicine, nursing, allied health and pharmacy. Major brands include Lippincott Williams & Wilkins, Ovid^®, Medknow, UpToDate^®, Medi-Span^®, Facts & Comparisons^®, Pharmacy OneSource^®, Lexicomp^® and ProVation^® Medical.

Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company. Wolters Kluwer had 2012 annual revenues of €3.6 billion ($4.6 billion), employs approximately 19,000 people worldwide, and maintains operations in over 40 countries across Europe, North America, Asia Pacific, and Latin America.

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 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 13, 2013) – For many patients with difficult-to-treat neuropathic pain, deep brain stimulation (DBS) can lead to long-term improvement in pain scores and other outcomes, according to 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.

About two-thirds of eligible patients who undergo DBS achieve significant and lasting benefits in terms of pain, quality of life, and overall health, according to the report by Sandra G.J. Boccard, PhD, and colleagues of University of Oxford, led by Tipu Aziz FMedSci and Alex Green, MD. Some outcomes show continued improvement after the first year, according to the new report, which is one of the largest studies of DBS for neuropathic pain performed to date.

Most Patients Benefit from DBS for Neuropathic Pain

The authors reviewed their 12-year experience with DBS for neuropathic pain. Neuropathic pain is a common and difficult-to-treat type of pain caused by nerve damage, seen in patients with trauma, diabetes, and other conditions. Phantom limb pain after amputation is an example of neuropathic pain.

In DBS, a small electrode is surgically placed in a precise location in the brain. A mild electrical current is delivered to stimulate that area of the brain, with the goal of interrupting abnormal activity. Deep brain stimulation has become a standard and effective treatment for movement disorders such as Parkinson’s disease. Although DBS has also been used to treat various types of chronic pain, its role in patients with neuropathic pain remains unclear.

Between 1999 and 2011, that authors’ program evaluated 197 patients with chronic neuropathic pain for eligibility for DBS. Of these, 85 patients proceeded to DBS treatment. The remaining patients did not receive DBS—most commonly because they were unable to secure funding from the U.K. National Health Service or decided not to undergo electrode placement surgery.

The patients who underwent DBS were 60 men and 25 women, average age 52 years. Stroke was the most common cause of neuropathic pain, followed by head and face pain, spinal disease, amputation, and injury to nerves from the upper spinal cord (brachial plexus).

In 74 patients, a trial of DBS produced sufficient pain relief to proceed with implantation of an electrical pulse generator. Of 59 patients with sufficient follow-up data, 39 had significant improvement in their overall health status up to four years later. Thus, 66 percent of patients “gained benefit and efficacy” by undergoing DBS.

Benefits Vary by Cause; Some Outcomes Improve with Time

The benefits of DBS varied for patients with different causes of neuropathic pain. Treatment was beneficial for 89 percent for patients with amputation and 70 percent of those with stroke, compared to 50 percent of those with brachial plexus injury.

On average, scores on a 10-point pain scale (with 10 indicating the most severe pain) decreased from about 8 to 4 within the first three months, remaining about the same with longer follow-up. Continued follow-up in a small number of patients suggested further improvement in other outcomes, including quality-of-life scores.

Deep brain stimulation has long been regarded as potentially useful for patients with severe neuropathic pain that is not relieved by other treatments. However, because of the difficulties of performing studies of this highly specialized treatment, there has been relatively little research to confirm its benefits; only about 1,500 patients have been treated worldwide. The new study—accounting for about five percent of all reported patients—used up-to-date DBS technologies, imaging, and surgical techniques.

Dr. Boccard and coauthors acknowledge some important limitations of their study—especially the lack of complete patient follow-up. However, they believe their experience is sufficiently encouraging to warrant additional studies, especially with continued advances in stimulation approaches and technology. The researchers conclude, “Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.”

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) – 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 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