Surgical resection of mesiotemporal lesions, particularly those in the dominant hemisphere, is often challenging. Standard approaches require excessive brain retraction, removal of normal cortex, or manipulation of the middle cerebral artery branches. This report describes a transsulcal temporal approach to mesiotemporal lesions and its application in three patients. Gross-total resection of the lesion was accomplished in all cases. An anatomical cadaveric study was also performed to delineate the microsurgical anatomy of this approach. Precise knowledge of temporal intraventricular landmarks allows navigation to the lesion without the need for a navigational system. This approach is helpful for neurologically intact patients with mesiotemporal lesions.
Anatomy, technique, and report of three cases
Isabelle M. Germano
Isabelle M. Germano
Ronald Benveniste and Isabelle M. Germano
Frameless image-guided stereotaxy is often used in the resection of high-grade gliomas. The authors of several studies, however, have suggested that brain shift may occur intraoperatively and result in inaccurate resection. To determine the usefulness of frameless stereotactic image-guided surgery of high-grade gliomas, the authors correlated factors predictive of brain shift, such as tumor size, periventricular location, and patient age (as an indicator of brain atrophy) with the extent of resection.
Inclusion criteria included the following: 1) stereotactic volumetric craniotomy for resection of tumor; 2) histologically proven high-grade glioma; 3) preoperative magnetic resonance (MR) imaging demonstration of an enhancing portion of tumor; 4) postoperative MR imaging within 48 hours to assess the extent of resection; and 5) preoperative intention to perform gross-total resection of the enhancing tumor. Fifty-four patients met these criteria between September 1997 and November 2002. Accurate resection was considered to be indicated by a lack of nodular enhancement on postoperative Gd-enhanced MR images obtained within 48 hours of surgery.
Frameless stereotactic image-guided surgery resulted in the successful resection of 46 (85%) of 54 high-grade gliomas. Accurate resection was significantly more likely with tumors less than 30 ml in volume than with those greater than 30 ml (93 and 58%, respectively [p < 0.05]). In addition, small periventricular tumors were associated with significant less successful resection compared with nonperiventricular tumor (77 and 96%, respectively [p = 0.5]). Patient age did not affect the likelihood of successful resection.
Frameless image-guided stereotactic techniques can be reliably used for accurate resection of high-grade gliomas when the tumor is less than 30 ml in volume and not adjacent to the ventricular system. In cases involving tumors larger in volume or located near the ventricles, intraoperative ultrasonography or MR imaging updates should be considered.
Isabelle M. Germano, Lawrence H. Pitts, Isabelle Berry, and Michael Moseley
✓ Recent advances in magnetic resonance (MR) imaging and MR spectroscopy (MRS) allow the noninvasive in vivo study of a variety of anatomical, physiological, and biochemical alterations that may occur in different cerebral pathologies. The authors have investigated the use of MR imaging and MRS to monitor the evolution of experimental focal cerebral ischemia in rats. Permanent focal cerebral ischemia was induced in 36 rats, and 12 normal rats were used as a control group. Changes in high-energy phosphate metabolites were followed in vivo using MRS during the 1st hour and at 3 and 6 hours after ischemic insult. Changes in in vivo MR images were evaluated at 1, 3, 6, 12, and 24 hours after ischemic insult. Significant decreases (p < 0.05) in phosphocreatine/inorganic phosphate ratios and intracellular pH values occurred immediately after the induction of ischemia. The presence of an infarcted area seen on MR images was a constant finding at 3 hours after ischemic insult, and was well defined and localized at 12 and 24 hours. The location of areas of infarction seen on MR images correlated well with areas identified histopathologically. The T1 and T2 MR relaxation times were significantly increased 3 hours after ischemic insult and remained prolonged for at least 24 hours. The results show that MR imaging is a sensitive method to measure cerebral infarction, and that MRS is a sensitive measure of changes that occur in the early phases of ischemia, perhaps when cellular changes may still be reversible. At 3 and 6 hours after the ischemic insult, however, 31P-MRS spectra may appear to be “normal” despite the presence of well-documented areas of infarction.
Mahmud Uzzaman, Gordon Keller, and Isabelle M. Germano
Death receptor targeting is an attractive approach in experimental treatment for tumors such as malignant gliomas, which are resistant to radiation and chemotherapy. Among the family of cytokines referred to as death li gands, tumor necrosis factor–related apoptosis-inducing ligand (TRAIL) has attracted clinical interest. The aim of this study was to assess whether TRAIL can be used as an adjuvant to temozolomide (TMZ) for apoptosis induction in malignant glioma cell lines.
Six human malignant glioma cell lines (A172, U87, U251, T98, U343, and U373) were exposed to human (h)TRAIL, TMZ, or an hTRAIL/TMZ combined treatment. Cell viability was assayed using 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide and phase-contrast microscopy. Cell apoptosis was detected using the terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick-end labeling technique and quantified using flow cytometric analysis. The apoptosis signaling cascade was studied with Western blotting.
The additive effects of hTRAIL and TMZ resulted in a significant decrease in cell viability and an increased apoptotic rate. Expression of the death receptors DR5 and DR4 in two cell lines (A172 and U251) upregulated significantly when they were used in combination hTRAIL/TMZ treatment (p < 0.05 compared with baseline control), leading to activation of caspase-8 and caspase-3 (p < 0.05 compared with baseline control) and confirming an extrinsic apoptotic pathway. A cell intrinsic pathway through mitochondrial cytochrome c was not activated.
Based on this work, one may infer that hTRAIL should be considered as an adjuvant treatment for TMZ-resistant human malignant gliomas.
Ronald J. Benveniste, Gordon Keller, and Isabelle Germano
Embryonic stem cell (ESC)—derived astrocytes have many theoretical and practical advantages as vectors for delivery of gene therapy to the central nervous system (CNS). The aim of this study was to generate highly pure populations of ESC-derived astrocytes expressing drug-inducible transgenes, while minimizing contamination by undifferentiated ESCs
Embryonic stem cells carrying a doxycycline-inducible green fluorescent protein (GFP) transgene were induced to differentiate into astrocytes by using feeder cell—free conditions that are completely defined. More than 95% of these cells expressed the astrocyte markers glial fibrillary acidic protein and GLT-1 glutamate transporter, and the morphological characteristics of these cells were typical of astrocytes. The expression of additional astrocyte markers was detected using reverse transcription—polymerase chain reaction. Undifferentiated ESCs comprised fewer than 0.1% of the cells after 10 days in this culture. Positive and negative selection techniques based on fluorescence-activated cell sorting were successfully used to decrease further the numbers of undifferentiated ESCs. Fully differentiated astrocytes expressed a GFP transgene under the tight control of a doxycycline-responsive promoter, and maintained their astrocytic phenotype 24 hours after transplantation into the mouse brain.
This study shows that transgenic ESCs can be induced to differentiate into highly pure populations of astrocytes. The astrocytes continue to express the transgene under the tight control of a drug-inducible promoter and are suitable for transplantation into the mouse brain. The number of potentially hazardous ESCs can be minimized using cell-sorting techniques. This strategy may be used to generate cellular vectors for delivering gene therapy to the CNS.
Isabelle M. Germano, Michael S. B. Edwards, Richard L. Davis, and Davide Schiffer
✓ Meningiomas arising in the first two decades of life are uncommon and their characteristics are controversial. Some authors believe meningiomas in younger patients occur in different locations, have more malignant histological features, and have a worse prognosis than those in adults. To address this controversy, the authors retrospectively reviewed 23 cases of meningiomas in patients under 21 years of age at diagnosis who were operated on at the University of Turin (1948 to 1990) or at the University of California, San Francisco (1970 to 1989). These tumors represented 2.9% of all tumors in this age group and 1.8% of all meningiomas during the study period at the two institutions. There were 14 males and nine females. The mean age at surgery was 13.3 ± 5.6 years; nine cases occurred in the first decade and 14 in the second. The most common neurological symptoms were a focal neurological deficit (33%) and seizures (25%). Seventy percent of the tumors were supratentorial. A gross total resection was performed in 60% of the cases. Histologically, the majority (74%) of the tumors were meningothelial or mixed. An increased number of mitoses was observed in 33% of the tumors, focal necrosis in 29%, and invasion of adjacent brain in 14%; however, none of the tumors was classified as a Grade III (anaplastic) meningioma. All patients are alive without evidence of recurrent disease 3 to 22 years (mean ± standard deviation: 10 ± 7.3 years) after surgery. This study confirms the rarity of meningiomas of the first two decades of life and the absence of the female predominance associated with meningiomas in adults. The location and histological features of these tumors are similar to those in adults; they have a low recurrence rate, and the outcome and survival rate are excellent.
Isabelle M. Germano, Richard L. Davis, Charles B. Wilson, and Grant B. Hieshima
✓ Embolization with polyvinyl alcohol (PVA) is an accepted method of rendering complex arteriovenous malformations (AVM's) more amenable to surgery, but its effects on human vascular tissues have not been adequately documented. The authors reviewed the histopathology of 66 intracranial AVM's resected 1 to 76 days after embolization with PVA. The mean age of the patients was 36 years, and their AVM's were located in the cerebral hemispheres (92%), the cerebellum (6%), or the corpus callosum (2%). In 79% of cases, at least one vessel contained PVA particles; in most cases, the vessel was filled with sharp, angular PVA particles in a serpiginous pattern. Polyvinyl alcohol particles indented the endothelium in 69% of cases but were rarely found subendothelially. Clotted blood and fibroblasts were present among the particles, and abundant intraluminal mononuclear and polymorphonuclear inflammatory cells were found in all vessels containing PVA particles. Foreign-body giant cells appeared 2 to 14 days after embolization in the majority of cases. Patchy mural angionecrosis and necrotizing vasculitis were found in 39% of the cases. Recanalized lumina were seen in 18% of PVA-embolized vessels. Foreign materials resembling cotton fibers and other particulate substances, which were probably contaminants of the contrast solution or the embolic material, were found in 65% of the cases. These findings suggest a specific chain of events in the interaction between PVA and vessel wall components and may explain some important sequelae of embolization therapy.
Isabelle M. Germano, Nicole Poulin, and André Olivier
✓ The indications for and the risks and outcome of reoperation for medically refractory temporal lobe epilepsy have not been well documented. A retrospective review is presented of 40 patients who underwent reoperation on the temporal lobe for recurrent seizures. The mean patient age at the first operation was 22 ± 7 years (± standard deviation). Electrocorticography during the first operation showed interictal epileptic abnormalities from surface electrodes in 97% of the cases and from depth electrodes in the mesiotemporal structures in 38%. The seizures recurred with the same pattern within 6 months after the first operation in 60% of patients and within 2 years in 90%. Postoperative neuroimaging studies showed residual mesiotemporal structures in all cases. The mean time between the two operations was 5.5 ± 5 years and the mean patient age at the second operation was 28 ± 8 years. The second operation involved focal resection of the mesiotemporal structures in 30 cases. The mean postoperative follow-up period was 4.8 ± 2.7 years (range 2 to 11 years). After the second operation, 63% of the patients were seizure-free or had rare seizures (one or two per year). There were no permanent neurological complications. Patients who did not benefit from reoperation had electroencephalographic abnormalities in multiple brain areas.
Reoperation for temporal lobe epilepsy effectively controls seizures in the majority of patients, and the procedure is safe if rigorous technical rules are observed. More complete resection of mesiotemporal structures during the first operation, even in the absence of intraoperative electrographic abnormalities, could prevent the need for reoperation in defined cases.
Kurt A. Yaeger, Alexander J. Schupper, Jeffrey T. Gilligan, and Isabelle M. Germano
Neurosurgery is a highly competitive residency field with a match rate lower than that of other specialties. The aim of this study was to analyze trends associated with the residency match process from the applicants’ and program directors’ perspectives.
Between 2010 and 2020, the National Residency Matching Program (NRMP) Applicant and Program Director Surveys, the NRMP Charting Outcomes reports, and the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books were analyzed to identify the number of applicants interviewed and ranked in US programs, the applicants’ ranking preferences, the program directors’ preferential factors in offering interviews, and rank list order. Applicants were divided between US senior medical students and independent applicants. Each cohort was dichotomized for matched and unmatched applicants.
Over the study period, 2935 applicants applied to neurosurgery residency, including 2135 US senior medical students and 800 independent applicants, with an overall match rate of 65%. Overall, matched applicants had a significantly higher number of publications (p < 0.05). Among US senior medical student applicants, the application-to-interview ratio more than doubled over the study period, yet the number of interview invitations received, interviews accepted, and programs ranked remained unchanged. In the US senior medical student cohort, the number of submitted applications, interview invitations, accepted interviews, and programs ranked did not significantly differ between matched and unmatched applicants. In both cohorts, applicants shifted ranking factors from a more academic focus in early years to more well-being in later years. Letters of recommendation and board scores were key factors for program directors while screening applicants for interviews and ranking.
Neurosurgery residency continues to be a highly competitive field in medicine, with match rates of 65%. Recently, applicants have placed greater importance on ranking programs that value residents’ well-being, as opposed to strictly academic factors. A data-driven understanding of factors important to applicants and program directors during the match process has the potential to improve resident candidate recruitment and overall resident-program fit, thereby improving well-being during residency, reducing the attrition rate, and overall enhancing the diversity of the neurosurgery resident workforce.