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Nikolay L. Martirosyan, Jennifer M. Eschbacher, M. Yashar S. Kalani, Jay D. Turner, Evgenii Belykh, Robert F. Spetzler, Peter Nakaji, and Mark C. Preul

patients who were imaged had no intracranial tumor ( Fig. 2E ). Tumor tissue was not detected with either CLE or with conventional histological methods, including in 1 case of glioblastoma-associated postradiation treatment effect. One patient had cortical dysplasia, 6 had reactive gliosis, and 1 patient had sarcoidosis. Sixty-six patients had brain neoplasms requiring surgical treatment. Of the 66 tumors, 30 were meningiomas (World Health Organization [WHO] Grade I [n = 25], II [n = 4], and III [n = 1]). Gliomas were diagnosed in 21 cases (WHO Grade II [n = 8], Grade

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Patrick J. Kelly, Bruce A. Kall, Stephan Goerss, and Franklin Earnest IV

✓ Computer interpolation of stereotaxic computerized tomography (CT) scanning data allows the transposition of a tumor volume in stereotaxic space. A stereotaxically directed and computer-monitored CO2 laser is then utilized to vaporize that volume as the surgeon monitors the position of a cursor representing the laser beam against planar contours of the tumor displayed on an operating room computer monitor. Computer-assisted stereotaxic laser microsurgery provides precise three-dimensional control for aggressive resection of deep-seated tumors from neurologically important areas with acceptable postoperative results. Thus, a significant cytoreduction can be achieved in addition to providing a tissue diagnosis and internal decompression.

The authors report 83 computer-assisted stereotaxic laser procedures for tumor excision in 78 patients. The tumors were located in the thalamus/basal ganglia in 15 patients, ventricular system in five, corpus callosum in four, brain stem in three, and deep and centrally in the hemispheres in 51. Histologically, there were 26 glioblastomas, seven grade III astrocytomas, 14 grade II astrocytomas, 14 metastatic tumors, nine vascular lesions, and eight miscellaneous lesions. Resection of these subcortical lesions was confirmed by postoperative contrast-enhanced CT scanning. Neurological examinations performed 1 week after the 83 procedures revealed that 48 patients had improved from their preoperative level and 23 were unchanged (12 were neurologically normal preoperatively). Twelve patients had an increase in a preoperative neurological deficit, three of whom died in the postoperative period: one from infection, one from pulmonary emboli, and one from brain-stem edema.

The average survival period (37.6 weeks) of patients having glioblastomas treated by this technique and irradiation was no different from that of patients having glioblastomas in more favorable locations treated by conventional surgery and irradiation. Patients with circumscribed lower-grade astrocytomas did better in terms of morbidity and completeness of resection than those with infiltrative neoplasms. Other circumscribed lesions, such as metastatic tumors, vascular lesions, and intraventricular tumors, were easily resected by the technique described.

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Ernst M. H. van den Doel, Gert Rijksen, Paul J. M. Roholl, Cees W. M. van Veelen, and Gerard E. J. Staal

electrophoresis (which gives quantitative results and discriminates between γγ-and αγ-enolases) and immunohistochemistry (to avoid the pitfall of varying specificity and sensitivity of the antibodies used). The results prompted us to evaluate the significance of the γ-enolase level in plasma as a marker for brain neoplasms, because elevated serum levels have been reported in patients severely ill with neuroblastomas and several other tumors of the APUD system. 1, 2, 7, 8, 16, 22, 24, 43 The γ-enolase content of gliomas being known, this investigation would give further insight

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Damien Galanaud, Olivier Chinot, François Nicoli, Sylviane Confort-Gouny, Yann Le Fur, Maryline Barrié-Attarian, Jean-Philippe Ranjeva, Stéphane Fuentès, Patrick Viout, Dominique Figarella-Branger, and Patrick J. Cozzone

suggests that GC has an original metabolic signature, independent of the corresponding histological findings, and demonstrates that our initial definition of GC 22 is consistent from a metabolic point of view. Conclusions Magnetic resonance spectroscopy clearly differentiates GC from an LGG. An uncommon brain neoplasm, remarkable for its lack of response to treatment and the short survival of patients with the disease, GC displays a characteristic pattern on MR spectroscopy. Its prominent metabolic features are elevated levels of Cr and NAA and a lower level

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Michael A. Mooney, Aqib H. Zehri, Joseph F. Georges, and Peter Nakaji

brain neoplasms at the cellular level can be gathered in the operating room. In this review, we provide a background on intraoperative confocal devices and fluorophore technology, describe the application of this technology in both animal models and human studies, and discuss the future directions and potential applications of confocal endomicroscopy in neurosurgery. Technical Considerations: Confocal Endoscopes and Fluorophores Laser scanning confocal microscopy (LSCM) is an optical fluorescence imaging modality used for imaging thick in vivo and ex vivo

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Ivar Amund Grimstad, Henry Hirschberg, and Kjell Rootwelt

✓ The demonstration and accurate localization of intracerebral mass lesions are commonly performed with computerized tomography (CT), which often cannot determine the nature of the lesion. As an aid in the differential diagnosis between brain abscess and neoplasm, the authors have evaluated both 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) leukocyte scintigraphy and the serum C-reactive protein level. Of 23 patients with intracranial mass lesions, 22 individuals showed ring-like contrast enhancement on CT scans; the one exception was a patient treated for a meningioma who had a negative CT scan despite clinical suspicion of intra- or extracranial abscess. The final diagnosis was invariably established by microscopic examination of tissue specimens. In 10 patients the final diagnosis was brain abscess; the other 13 patients harbored a brain neoplasm (glioma in nine, astrocytoma in one, and metastasis in three). The 99mTc-HMPAO leukocyte scintigraphy detected all cases of abscess. There were no false-positive results. An elevated C-reactive protein level (> 13 mg/liter) was found in all but one patient with abscess and in three patients with neoplasm; two of these three patients had dental root infections which could account for the elevation of C-reactive protein.

It is concluded that 99mTc-HMPAO leukocyte scintigraphy should be performed when there is a possibility that a brain abscess may exist. Any steroid treatment should be discontinued for 48 hours prior to leukocyte scintigraphy. Also, C-reactive protein determination should be performed and is useful even when steroids are given.

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Patrick J. Kelly, Stephan J. Goerss, and Bruce A. Kall

: Computer-assisted resection of posterior fossa lesions. Surg Neurol 25: 530–534, 1986 7. Kelly PJ , Kall BA , Goerss S , et al : Computer-assisted stereotaxic resection of intra-axial brain neoplasms. J Neurosurg 64 : 427 – 439 , 1986 Kelly PJ, Kall BA, Goerss S, et al: Computer-assisted stereotaxic resection of intra-axial brain neoplasms. J Neurosurg 64: 427–439, 1986 8. Kelly PJ , Sharbrough FW , Kall BA , et al : Magnetic resonance imaging-based computer-assisted stereotactic

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Jesús Vaquero, Mercedes Zurita, Santiago de Oya, Santiago Coca, Carmen Morales, and Clara Salas

T he presence of tumor-associated cysts in brain neoplasms constitutes an important challenge because these cysts may contribute to the development of an intracranial hypertension syndrome, regardless of the tumor size. The formation of cysts in gliomas has recently been related to the expression of vascular endothelial growth/permeability factor (VEG/PF) by tumor cells, indicating the pivotal role of this protein in the pathophysiological development of tumor-associated cysts. 13 Because craniopharyngioma is an intracranial tumor that characteristically may

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Leslie N. Sutton, Robert E. Lenkinski, Bruce H. Cohen, Roger J. Packer, and Robert A. Zimmerman

, McGauley JL : Comparison of glucose metabolism in normal brain and edematous brain surrounding an experimental brain neoplasm. Acta Neurol Scand 64 (Suppl) : 508 – 509 , 1977 Altenau LL, Kindt GW, McGauley JL: Comparison of glucose metabolism in normal brain and edematous brain surrounding an experimental brain neoplasm. Acta Neurol Scand 64 (Suppl): 508–509, 1977 3. Behar KL , Den Hollander JA , Stromski ME , et al : High-resolution 1 H nuclear magnetic resonance study of cerebral hypoxia in vivo

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Dov Front, Einat Even-Sapir, Galina Iosilevsky, Ora Israel, Alex Frenkel, Gerald M. Kolodny, and Moshe Feinsud

✓ The concentration of cobalt-57 (57Co)-labeled bleomycin delivered to three brain metastases and to their tumors of origin in the lungs was measured using a single-photon emission computerized tomography technique. In two brain metastases the 57Co-bleomycin concentration measured at different times after the intravenous injection was significantly lower than that in the originating lung tumors (p < 0.01 and p < 0.001). In these two patients, the tumor cumulative concentration (TCC) of drug in the brain neoplasm compared to the lung carcinoma was 12.92 versus 15.12 and 10.30 versus 19.74 µg/cc/min. In the third patient there was no significant difference in drug concentration between the tumor in the brain and in the lung (TCC 16.02 vs. 15.09 µg/cc/min). There was a significant difference in the drug TCC between the three brain metastases: the difference between the lowest and highest concentrations was more than 50% (10.3 vs. 16.02 µg/cc/min). When the concentration in the tumor over time (CT(t)) of the 57Co-bleomycin was compared in the brain and lung tumors, a good correlation was found in each of the three cases (r = 0.93, 0.99, and 0.97). This suggests that the difference in drug uptake between brain metastases and their originating lung tumor is a quantitative rather than a qualitative phenomenon. The results show that the amount of drug to which brain metastases are exposed varies and may be very low in some tumors; therefore, effectiveness of drug delivery may play a role in the nonresponsiveness of brain metastases to treatment.