Minimally invasive surgery. Neurosurgery.

The introduction of minimally invasive techniques has greatly improved results for intracranial neurosurgery. Stereotaxy and improved imaging techniques have reduced surgical trauma by allowing surgeons to plan the least damaging route to operative sites and by increasing surgical precision. Stereotaxy has also allowed brain biopsies to be taken from sites such as the brain stem, which were rarely sampled before because free hand biopsy was so dangerous. Brain tumours can now be treated by interstitial radiotherapy--stereotactic insertion of catheters into the lesion for loading of radioactive iodine--or radiosurgery--focusing of intense beams of radiation on lesions without needing surgical incisions. Endoscopic neurosurgery can be used to reach cavities such as the ventricular system or cystic tumours. With interventional neuroradiology fine catheters can be introduced into most vessels in the cranium for embolisation or dilatation. The development of augmentative functional neurosurgery means that movement disorders, epilepsy, and intractable pain can be treated with implanted neurostimulating electrodes. Future developments will probably include frameless stereotaxy, when the rigid attachment of stereotactic apparatus to the patient''s head can be dispensed with, and at least partial automation of procedures such brain biopsy.     

Organic bioelectrodes in clinical neurosurgery

Background

Clinical neurosurgery deals with surgical procedures and intensive care of illnesses in the human central and peripheral nervous system. Neurosurgery should be looked upon as a high-tech specialty and very much dependent on new technological innovations aiming at improvements of patient's treatment and outcome. During the last decades neurosurgery has improved substantially thanks to the introduction of applied imaging technologies such as computerized tomography and magnetic resonance tomography, and new surgical modalities such as the microscope, brain navigation and neuroanesthesiology.Neurosurgical disorders, which should have the potential to benefit from conductive organic bioelectrodes, include traumatic brain and spinal cord injury and peripheral nerve injuries due to external violence in the restoration of healthy communication. This holds true also for cerebral nerves altered in their functions due to benign and malignant brain and spinal cord tumors. Further, new innovative devices in the field of functional nervous tissue disorders make the use of organic conductive electrodes attractive by considering the electrical neurochemical properties of neural interfaces.

Conclusions

Although in its infancy, conducting organic polymers as bioelectrodes have several potential applications in clinical neurosurgery. The time it takes for new innovations and basic research to be transferred into clinical neurosurgery should not take too long. However, a prerequisite for successful implementation is the close interdisciplinary collaboration between engineers and clinicians. This article is part of a Special Issue entitled Organic Bioelectronics—Novel Applications in Biomedicine.     

脑深部电刺激的临床应用

脑深部电刺激(deep brain stimulation,DBS)是近20年来神经外科领域发展最迅猛的技术。DBS是通过刺激发生器发出的高频电脉冲信号刺激脑神经核团或神经传导束来调节异常的神经环路。DBS已经成为治疗特发性震颤、帕金森病、肌张力障碍等运动障碍病的常规手术方法。自1997年深部脑刺激通过美国FDA认证用于治疗特发性震颤以来,已有超过数万名运动障碍患者接受该疗法,而国内脑深部电刺激最早在1999年应用于帕金森病临床治疗,迄今也有数千例患者接受了植入手术。近年,脑起搏器的临床适应症不断扩大,从最初的运动障碍病逐渐发展到治疗其他神经和精神疾病,如抽动秽语综合征、强迫症、抑郁症、神经性厌食症、难治性疼痛、癫痫、植物状态和阿尔茨海默病等,虽然DBS的治疗机理还不很清楚,但可以预见未来DBS将成为众多神经和精神疾病的重要治疗方法。     

Treatment of pediatric brain tumors

Over the past decades considerable advances have been made in neurosurgery, radiotherapy and chemotherapy resulting in improved survival and cure rates for children with brain tumors. Here we review four of the most common subtypes of pediatric brain tumors, low-grade and high-grade astrocytomas, medulloblastomas and ependymomas, highlighting their molecular features regarding their tumor biology, and promising potential therapeutic targets that may hold promise for finding new "molecular targeted" drugs. Importantly, appropriate clinical trial design will play a critical role in the evaluation of new and novel treatment approaches for pediatric brain tumors.     

Real Time Intraoperative Functional Brain Mapping Based on RGB Imaging

Intraoperative optical imaging is a localization technique for the functional areas of the human brain cortex during neurosurgical procedures. However, it still lacks robustness to be used as a clinical standard. In particular new biomarkers of brain functionality with improved sensitivity and specificity are needed. We present a method for the real time identification of the activated cortical areas based on the analysis of the cortical hemodynamic using a RGB camera and a white light source. We measure the quantitative oxy and deoxy-hemoglobin concentration changes in the human brain cortex with the modified Beer-Lambert law and Monte Carlo simulations. A functional model has been implemented to define in real time a binary biomarker of the cortical activation following neuronal activation by physiological stimuli. The results show a good correlation between the computed activation maps and the brain areas localized by electrical brain stimulation. We demonstrate that a RGB camera combined with a quantitative modeling of brain hemodynamics biomarkers can evaluate in real time the functional areas during neurosurgery and serve as a tool of choice to complement electrical brain stimulation.     

Therapy of brain metastasis based on the RPA classification

RPA classification of patients suffering from brain metastases is not widely used in Hungary. The authors reviewed the RPA disposition-based therapeutic recommendations in the literature. Retrospective analysis of their 123 brain metastatic cases showed 3.8 months median, 34.1% 1-year and 7.9% 2-year overall survival. Patient number and median survival in subgroups: RPA 1: 42/14 months, RPA 2: 38/6,2 months, RPA 3a: 6/3.1 months, 3b: 13/2 months, 3c: 10/0.7 months. Median survival of patients with brain metastases from cancer of unknown primary (CUP) was 3 months. In RPA class 1 and 2, 10% undertreatment has been found for solid brain metastases, and all of the 3c patients were over-treated according to literature recommendations. The authors strongly recommend the use of RPA classification in the management of brain metastases and in contemplation of the capacity of radiotherapy/neurosurgery and oncology.     

Neurosurgical brain tumor detection based on intraoperative optical intrinsic signal imaging technique: A case report of glioblastoma

The delineation of brain tumor margins has been a challenging objective in neurosurgery for decades. Despite the development of various preoperative imaging techniques, the current methodology is still insufficient for clinical practice. We present an intraoperative optical intrinsic signal imaging system for brain tumor surgery and establish a data processing procedure model to localize tumors. From the experimental result of a glioblastoma patient, we observe a relative small oscillation of ΔHbD in tumor region and speculate that vessels in tumor region have poor ability to provide oxygen. We applied the same data processing procedure on the second time data and proclaimed a successful surgery. Figure: Merged ΔHbD image captured prior and posterior to tumor removal.      

New approaches in developmental genetics and gene therapy: xenotransplantation of Drosophila embryonic nerve cells into the brain of vertebrate animals

The author's studies dealing with xenotransplantations of the embryonic nervous tissue into the brain of amphibian and mammals are reviewed. Drosophila nerve cells have been shown to survive inside the brain, differentiate, form ganglion-resembling structure, and come into synaptic contact with the host tissue. The embryonic nerve cells of transgenic Delta mutants of Drosophila melanogaster carrying a gene of bacterial galactosidase (lacZ) were also transplanted into the brain of adult rats and then identified histologically by X-gal staining of brain sections for the lacZ-gene product. The xenografts were shown to survive in the host brain for at least 2-3 weeks, after which they were attacked by macrophages. No glial scar tissue formed around the site of the xenograft. Cotransplantation of Drosophila embryonic nerve cells and the homologous embryonic nerve tissue was favorable for homograft survival and development, because formation of the glial scar was blocked, whereas homograft vascularization and differentiation of its nerve cells were stimulated. The results obtained are of interest with regard to neurosurgery, because they may be used to prevent formation of glial scar, an important factor in successful neurotransplantation.     

Derivation of Injury-Responsive Dendritic Cells for Acute Brain Targeting and Therapeutic Protein Delivery in the Stroke-Injured Rat

Research with experimental stroke models has identified a wide range of therapeutic proteins that can prevent the brain damage caused by this form of acute neurological injury. Despite this, we do not yet have safe and effective ways to deliver therapeutic proteins to the injured brain, and this remains a major obstacle for clinical translation. Current targeted strategies typically involve invasive neurosurgery, whereas systemic approaches produce the undesirable outcome of non-specific protein delivery to the entire brain, rather than solely to the injury site. As a potential way to address this, we developed a protein delivery system modeled after the endogenous immune cell response to brain injury. Using ex-vivo-engineered dendritic cells (DCs), we find that these cells can transiently home to brain injury in a rat model of stroke with both temporal and spatial selectivity. We present a standardized method to derive injury-responsive DCs from bone marrow and show that injury targeting is dependent on culture conditions that maintain an immature DC phenotype. Further, we find evidence that when loaded with therapeutic cargo, cultured DCs can suppress initial neuron death caused by an ischemic injury. These results demonstrate a non-invasive method to target ischemic brain injury and may ultimately provide a way to selectively deliver therapeutic compounds to the injured brain.     

miR-145 is a potential biomarker for predicting clinical outcome in glioblastomas

miR-145 has been found to be significantly downregulated in gliomas, and overexpression of miR-145 increases glioma cell apoptosis and enhances chemosensitivity or herpes simplex virus thymidine kinase gene therapy. However, the correlation between miR-145 and the clinical prognosis of glioblastomas has never been explored. In this study, a retrospective study was conducted in 86 cases of patients with glioblastoma after neurosurgery combined with chemoradiotherapy, and 36 cases with traumatic brain injury. Our results showed that miR-145 was significantly lower in glioblastoma tissues than that in normal brain tissue (P < 0.05). Furthermore, miR-145 was lower in patients with lower Karnofsky Performance Scale (KPS) scores than in patients with higher KPS scores ( P < 0.05). Cox Regression analysis showed that low miR-145 expression was associated with poor patient survival ( P < 0.05). These data suggested that patients with glioblastoma with lower miR-145 expression are prone to shorter overall survival.     

Correlation of ultrastructural changes of endothelial cells and astrocytes occurring during blood brain barrier damage after traumatic brain injury with biochemical markers of BBB leakage and inflammatory response

Focal cerebral contusion can be dynamic and expansive. It has been proved that subsequent expansive contusion is caused by brain parenchyma damage, especially BBB damage. We investigated a group of patients with traumatic brain injury. The patients (n=18) were divided into group I (n=7) of patients submitted to neurosurgery due to expansive contusion, and group II (n=11) of patients without surgery. Serum concentrations of NSE and S-100B protein were measured by electrochemiluminescence immunoassay, interleukin-6 (IL-6) was measured by chemiluminescent sequential immunometric assay and matrix metalloproteinases (MMP-9, MMP-2) were measured by immunoassays. Cortical biopsy specimens of brain were investigated by electron microscopy in patients with trauma brain injury submitted to neurosurgery. Biochemical investigation from first day up to third day after traumatic brain injury proved increased values of IL-6 (302.2+/-119.9 vs. 59.6+/-11.9 ng/l, p<0.02) and S-100B protein (3.064+/-1.064 vs. 0.649+/-0.182 microg/l, p<0.05) in patients with expansive lesion compared to patients without expansive contusion. Significantly higher levels of MMP-9 (150.4+/-28.46 vs. 74.11+/-13.16 ng/l, p<0.05) and of MMP-2 (814.5+/-126.3 vs. 523.1+/-25.28 ng/l, p<0.05) were found during first 3 days after admission in group I compared to group II. MMP-9 has also elevated in group II from lower values after admission (74.11+/-13.16 ng/l) up to high levels on the 10th day of hospitalization (225.1+/-49.35 ng/l). Ultrastructural investigation of endothelial cells and surrounded tissue revealed perivascular hemorrhage, increased pinocytic activity of endothelial cells, and cytotoxic edema of astroglial cells. Multivesical bodies were disclosed inside the endothelial cells. Higher levels of serum protein S-100B and IL-6 correlated with ultrastructural changes of endothelial cells, and with inflammatory response following TBI, respectively.     

中枢神经系统念珠菌病的诊疗进展

中枢神经系统念珠菌病临床上相对少见,但病死率高。近年来,随着免疫低下人群和神经外科相关手术操作的增多,其发病率有明显上升的趋势。脑脊液培养和脑组织活检病理是诊断的金标准,但敏感性低。脑脊液抗原检测方法、分子诊断技术等非培养技术为其快速诊断提供了新的手段。目前抗真菌药物治疗策略初步成形,但最佳治疗方案和疗程尚无定论。本文对近年来中枢神经系统念珠菌病的相关诊断及治疗策略进行阐述。     

近红外光谱技术在神经外科患者脑氧和血流动力学监测中的应用研究进展

神经外科患者,尤其是脑血流自动调节功能受损的重症患者,脑氧饱和度是反应患者脑组织氧代谢情况的重要指标,实时、准确的脑氧饱和度监测方法对于指导选择有效的治疗措施和判断患者预后具有重要价值。基于血红蛋白不同氧合状态,即氧合血红蛋白(oxyhemoglobin,Hb O2),还原血红蛋白(deoxygenated hemoglobin,Hb)具有的差异性分子光谱,近红外光谱技术near infrared spectroscopy,NIRS)可监测人体局部组织氧饱和度。由于近红外射线能穿透颅骨直接获得脑组织内平均氧饱和度的特性,可协助临床实现无创持续监测脑氧饱和度的目的,近年来该技术在神经外科领域的应用研究获得了迅速发展,在颅脑创伤和其它神经外科疾病的应用研究中均取得了显著的进展,本文将对最新研究结果及其意义和未来发展方向进行综述。     

Widefield fluorescence lifetime imaging of protoporphyrin IX for fluorescence‐guided neurosurgery: An ex vivo feasibility study

Achieving a maximal safe extent of resection during brain tumor surgery is the goal for improved patient prognosis. Fluorescence‐guided neurosurgery using 5‐aminolevulinic acid (5‐ALA) induced protoporphyrin IX has thereby become a valuable tool enabling a high frequency of complete resections and a prolonged progression‐free survival in glioblastoma patients. We present a widefield fluorescence lifetime imaging device with 250 mm working distance, working under similar conditions such as surgical microscopes based on a time‐of‐flight dual tap CMOS camera. In contrast to intensity‐based fluorescence imaging, our method is invariant to light scattering and absorption while being sensitive to the molecular composition of the tissue. We evaluate the feasibility of lifetime imaging of protoporphyrin IX using our system to analyze brain tumor phantoms and fresh 5‐ALA‐labeled human tissue samples. The results demonstrate the potential of our lifetime sensing device to go beyond the limitation of current intensity‐based fluorescence‐guided neurosurgery.      

Changes of the GPR17 receptor, a new target for neurorepair, in neurons and glial cells in patients with traumatic brain injury

Unveiling the mechanisms participating in the damage and repair of traumatic brain injury (TBI) is fundamental to develop new therapies. The P2Y-like GPR17 receptor has recently emerged as a sensor of damage and a key actor in lesion remodeling/repair in the rodent brain, but its role in humans is totally unknown. Here, we characterized GPR17 expression in brain specimens from seven intensive care unit TBI patients undergoing neurosurgery for contusion removal and from 28 autoptic TBI cases (and 10 control subjects of matched age and gender) of two university hospitals. In both neurosurgery and autoptic samples, GPR17 expression was strong inside the contused core and progressively declined distally according to a spatio-temporal gradient. Inside and around the core, GPR17 labeled dying neurons, reactive astrocytes, and activated microglia/macrophages. In peri-contused parenchyma, GPR17 decorated oligodendrocyte precursor cells (OPCs) some of which had proliferated, indicating re-myelination attempts. In autoptic cases, GPR17 expression positively correlated with death for intracranial complications and negatively correlated with patients’ post-traumatic survival. Data indicate lesion-specific sequential involvement of GPR17 in the (a) death of irreversibly damaged neurons, (b) activation of microglia/macrophages remodeling the lesion, and (c) activation/proliferation of multipotent parenchymal progenitors (both reactive astrocytes and OPCs) starting repair processes. Data validate GPR17 as a target for neurorepair and are particularly relevant to setting up new therapies for TBI patients.     

Individual quantitative differences in the structure of the human hippocampus

The volume of the hippocampal grey substance (Corpus Ammoni--CA) and that of the denticulated plate (Fasciculus dentatus--FD) have been studied in mature persons of various sex and age (17 subjects, 22 cerebral hemispheres) under cytoarchitectonic control defining the borders of the cerebral formations mentioned. Certain quantitative and spatial differences of CA and FD have been revealed in some subjects. Especially great differences are noted between more seldom occurring extreme individual variants, their difference being as great as three times. The differences revealed are demonstrated to be independent on the brain mass of the human beings studied. The observation performed causes to revise the competency of the principle concerning a constant proportional dependence between the reference points on the cerebral surface and the internal cerebral structures. These data are used in neurosurgery when surgical interventions are performed on brains with different dimensions. A suggestion is made that the individual volumetric differences revealed in the hippocamp of various persons are defined by its functional specificity.     

Binding of Paroxetine to the Serotonin Transporter in Membranes from Different Cells,Subcellular Fractions and Species

The binding of [³H]-paroxetine to membrane serotonin transporter (SERT) has been studied in membranes from different sources and subcellular fractions. From rat were membranes from venous blood platelets, brain total cortex, brain microsomes, brain crude and purified synaptosomes. Membranes were obtained from venous blood platelets from human volunteers and from brain cortex tissue from neurosurgery (cerebral lobectomies following craniocerebral injuries). The main finding was that the K _D of paroxetine binding to the SERT was the same for platelet and nerve ending (synaptosomal) membranes. That parameter was significantly lower in membranes from brain microsomes and cortex total tissue. No species related difference was found, where comparison was possible, between human and rat tissue. The equality of K _D of paroxetine binding to blood platelet membranes and to membranes from nerve endings appears to encourage the use of such membranes as a model for brain SERT. Binding at two different temperatures for several of the fractions suggests that paroxetine–SERT interaction is entropy-driven.     

The Importance of a Proper Aetiological Diagnosis in the Management of Patients with Invasive Mycoses: A Case Report of a Brain Abscess by <Emphasis Type="Italic">Scedosporium apiospermum</Emphasis>

Scedosporium apiospermum is a saprobic fungus responsible for many different clinical manifestations. Although it affects mostly immunocompromised patients, pulmonary and disseminated scedosporiosis have also been reported in immunocompetent subjects. It often causes subcutaneous mycetoma, despite its preferential tropism to CNS. The authors describe a fatal case of a S. apiospermum brain abscess in a 58-year-old female. She was affected by chronic liver disease and idiopathic pulmonary fibrosis and had been treated with corticosteroid therapy for a long time. She recovered in a neurosurgery unit, wherein TC scan and cerebral MRI revealed an expansive left temporo-parietal process with vasogenic oedema. A stereotactic puncture of the lesion was carried out, and pus of brain abscess was evacuated. Empirical antifungal therapy was initiated with liposomal amphotericine B based on the clinical suspicion of Zygomycetes infection; after 3 days, posaconazole was added. The correct aetiological diagnosis arrived too late and the patient was treated with no specific therapy. This fatal case confirms the necessity of having a fast and correct aetiological diagnosis to improve the patient’s outcome.     

Etiology, risks factors, therapy of nosocomial cerebrovascular infections

Nosocomial cerebrovacsular infections are substantial cause of mortality and morbidity in patients after neurosurgery. Risk factors, etiology, treatment strategies and outcome of nosocomial meningitis and brain abscess are briefly reviewed.     

Epilepsy and Nonlinear Dynamics

This overview summarizes findings obtained from analyzing electroencephalographic (EEG) recordings from epilepsy patients with methods from the theory of nonlinear dynamical systems. The last two decades have shown that nonlinear time series analysis techniques allow an improved characterization of epileptic brain states and help to gain deeper insights into the spatial and temporal dynamics of the epileptic process. Nonlinear EEG analyses can help to improve the evaluation of patients prior to neurosurgery, and with an unequivocal identification of precursors of seizures, they can be of great value in the development of seizure warning and prevention techniques.