207 results on '"Keyoumars Ashkan"'
Search Results
2. H3 G34-mutant high-grade gliomas: integrated clinical, imaging and pathological characterisation of a single-centre case series
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José Pedro Lavrador, Zita Reisz, Naomi Sibtain, Kapil Rajwani, Asfand Baig Mirza, Francesco Vergani, Richard Gullan, Ranjeev Bhangoo, Keyoumars Ashkan, Cristina Bleil, Bassel Zebian, Barnaby Clark, Ross Laxton, Andrew King, Istvan Bodi, and Safa Al-Saraj
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Surgery ,Neurology (clinical) - Published
- 2023
3. Suicidal Ideation and Attempts in Brain Tumor Patients and Survivors: A Systematic Review
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Mohammad Mofatteh, Mohammad Sadegh Mashayekhi, Saman Arfaie, Yimin Chen, Armaan K Malhotra, Mohammed Ali Alvi, Nicholas Sader, Violet Antonick, Mostafa Fatehi Hassanabad, Alireza Mansouri, Sunit Das, Xuxing Liao, Roger S McIntyre, Rolando Del Maestro, Gustavo Turecki, Aaron A Cohen-Gadol, Gelareh Zadeh, and Keyoumars Ashkan
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Oncology ,Surgery ,Neurology (clinical) - Abstract
Background Subsequent to a diagnosis of a brain tumor, psychological distress has been associated with negative effects on mental health as well as suicidality. The magnitude of such impact has been understudied in the literature. We conducted a systematic review to examine the impact of a brain tumor on suicidality (both ideation and attempts). Methods In accordance with the PRISMA guidelines, we searched for relevant peer-reviewed journal articles on PubMed, Scopus, and Web of Science databases from inception to October 20th, 2022. Studies investigating suicide ideation and/or attempt among patients with brain tumors were included. Results Our search yielded 1,998 articles which were screened for eligibility. Seven studies consisting of 204,260 patients were included in the final review. Four studies comprising 203,906 patients (99.8%) reported elevated suicidal ideation and suicide attempt incidence compared with the general population. Prevalence of ideation and attempts ranged from 6.0% to 21.5% and 0.03% to 3.33%, respectively. Anxiety, depression, pain severity, physical impairment, glioblastoma diagnosis, male sex, and older age emerged as the primary risk factors associated with increased risk of suicidal ideation and attempts. Conclusion Suicidal ideation and attempts are increased in patients and survivors of brain tumors compared to the general population. Early identification of patients exhibiting these behaviors is crucial for providing timely psychiatric support in neuro-oncological settings to mitigate potential harm. Future research is required to understand pharmacological, neurobiological, and psychiatric mechanisms that predispose brain tumor patients to suicidality.
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- 2023
4. Non-motor effects of deep brain stimulation in Parkinson's disease motor subtypes
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Stefanie T. Jost, Agni Konitsioti, Philipp A. Loehrer, Keyoumars Ashkan, Alexandra Rizos, Anna Sauerbier, Maria Gabriela dos Santos Ghilardi, Franz Rosenkranz, Lena Strobel, Alexandra Gronostay, Michael T. Barbe, Julian Evans, Veerle Visser-Vandewalle, Christopher Nimsky, Gereon R. Fink, Monty Silverdale, Rubens G. Cury, Erich T. Fonoff, Angelo Antonini, K. Ray Chaudhuri, Lars Timmermann, Pablo Martinez-Martin, and Haidar S. Dafsari
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Neurology ,Neurology (clinical) ,ddc:610 ,Geriatrics and Gerontology - Abstract
Introduction: Deep brain stimulation (DBS) is a well-established treatment for patients with Parkinson's disease (PD) improving quality of life, motor, and non-motor symptoms. However, non-motor effects in PD subtypes are understudied. We hypothesized that patients with 'postural instability and gait difficulty' (PIGD) experience more beneficial non-motor effects than 'tremor-dominant' patients undergoing DBS for PD.Methods: In this prospective, observational, international multicentre study with a 6-month follow-up, we assessed the Non-Motor Symptom Scale (NMSS) as primary and the following secondary outcomes: Unified PD Rating Scale-motor examination (UPDRS-III), Scales for Outcomes in PD (SCOPA)-activities of daily living (ADL) and -motor complications, PDQuestionnaire-8 (PDQ-8), and levodopa-equivalent daily dose (LEDD). We analysed within-group longitudinal changes with Wilcoxon signed-rank test and Benjamini-Hochberg correction for multiple comparisons. Additionally, we explored outcome between-group differences of motor subtypes with Mann-Whitney U-tests.Results: In 82 PIGD and 33 tremor-dominant patients included in this study, baseline NMSS total scores were worse in PIGD patients, both groups experienced postoperative improvements of the NMSS sleep/fatigue domain, and between-group differences in postoperative outcomes were favourable in the PIGD group for the NMSS total and miscellaneous domain scores.Conclusions: This study provides evidence of a favourable outcome of total non-motor burden in PIGD compared to tremor-dominant patients undergoing DBS for PD. These differences of clinical efficacy on non-motor aspects should be considered when advising and monitoring patients with PD undergoing DBS.Keywords: Deep brain stimulation; Nonmotor symptoms; Postural instability and gait difficulty; Quality of life; Tremor-dominant.
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- 2023
5. The New Satisfaction with Life and Treatment Scale (SLTS-7) in Patients with Parkinson’s Disease
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Lars Timmermann, Michael T. Barbe, Keyoumars Ashkan, Leire Ambrosio, Pia Bachon, Pablo Martinez-Martin, Christopher Nimsky, Anna Sauerbier, Alexandra Rizos, Haidar S. Dafsari, K. Ray Chaudhuri, Gereon R. Fink, Europar, Philipp Alexander Loehrer, Stefanie T Jost, Veerle Visser-Vandewalle, Alexandra Gronostay, and Agni Konitsioti
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Psychometrics ,business.industry ,Visual analogue scale ,Reproducibility of Results ,Life satisfaction ,Parkinson Disease ,Personal Satisfaction ,Disease ,Exploratory factor analysis ,Cellular and Molecular Neuroscience ,Cross-Sectional Studies ,Convergent validity ,Quality of life ,Cronbach's alpha ,Patient Satisfaction ,Surveys and Questionnaires ,Scale (social sciences) ,Quality of Life ,Humans ,Medicine ,Neurology (clinical) ,business ,Clinical psychology - Abstract
Background: The satisfaction with life and, in particular, with treatment in Parkinson’s disease (PD) is understudied. Objective: To explore a new 7-item rating tool assessing satisfaction with life and treatment (SLTS-7) in PD. Methods: In this cross-sectional, multi-center study, including patients screened for advanced therapies, psychometric characteristics of the SLTS-7 were analyzed. An exploratory factor analysis identified the underlying factorial structure of the SLTS-7. Results: 117 patients were included, and the data quality of the SLTS-7 was excellent (computable data 100%), and acceptability measures satisfied standard criteria. Besides the global assessment (item 1), the exploratory factor analysis produced item 2 (physical satisfaction) as an independent item and two factors among the remaining items: items 3–5 (psycho-social satisfaction), and items 6 and 7 (treatment satisfaction). Cronbach’s alpha was 0.89, indicative of high internal consistency. The SLTS-7 total score correlated moderately with motor symptoms and weakly with non-motor symptoms total scores. SLTS-7 showed the highest correlations with the European Quality of Life with 5 items (EQ-5D) visual analog scale (0.43–0.58, p
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- 2022
6. Therapeutic Strategies and Challenges in the Management of Craniospinal Tumors in Pregnancy: A Ten-Year Retrospective Tertiary-Center Study, Systematic Review, and Proposal of Treatment Algorithms
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Prajwal Ghimire, Graeme Pang, Jerry Philip, Sally Hazem, Kapil Rajwani, Jose Pedro Lavrador, Gordan Grahovac, Cristina Bleil, Nicholas Thomas, Richard Gullan, Francesco Vergani, Ranjeev Bhangoo, and Keyoumars Ashkan
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Surgery ,Neurology (clinical) - Abstract
This study aims to review therapeutic strategies in the management of craniospinal tumors in pregnant patients and the factors that may influence the management along with their influence on maternal and fetal outcomes.A retrospective single-center cohort study was performed at a tertiary neurosurgical referral center. Pregnant patients referred to the neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumor were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed of the available literature as per PRISMA guidelines.Twenty-five patients were identified, with a mean age of 31 years. Of these patients, 88% (n = 22) had cranial lesions and 12% (n = 3) had spinal lesions. Most of the patients had World Health Organization grade I/II tumors. Of the patients, 44% underwent surgery when pregnant, whereas in 40%, this was deferred until after the due date. Of patients, 16% did not require surgical intervention and were followed up with serial imaging in the MDM. The left lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review and retrospective data led to proposal of treatment algorithms addressing the therapeutic strategy for management of craniospinal tumors during pregnancy. Factors that may influence maternal and fetal outcomes during management of these tumors were identified, including aggressiveness of the tumor and stage of pregnancy.Craniospinal tumors presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Factors influencing maternal and fetal outcomes are to be considered during management and patient counseling.
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- 2022
7. Evaluation of the effect of bilateral subthalamic nucleus deep brain stimulation on fatigue in Parkinson’s Disease as measured by the non-motor symptoms scale
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Keyoumars Ashkan, Alexandra Rizos, K. Ray Chaudhuri, Julia Koch, Anna Sauerbier, Daniel J. van Wamelen, Aleksandra Podlewska, Valentina Leta, Lars Timmermann, Claudia Lazcano-Ocampo, Monty Silverdale, Michael Samuel, and Haidar S. Dafsari
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Deep brain stimulation ,Parkinson's disease ,Scale (ratio) ,business.industry ,medicine.medical_treatment ,Subthalamic nucleus deep brain stimulation ,General Medicine ,medicine.disease ,nervous system diseases ,Subthalamic nucleus ,surgical procedures, operative ,nervous system ,medicine ,Non motor ,Surgery ,Neurology (clinical) ,business ,therapeutics ,Neuroscience - Abstract
Fatigue is a common and disabling non-motor symptom (NMS) in Parkinson's disease (PD) patients. However, the effect of subthalamic nucleus (STN) deep brain stimulation (DBS) on fatigue has not been widely studied.To determine the effect of STN DBS on fatigue in PD patients, measured by the Non-motor symptoms scale (NMSS).Cross-sectional analysis of 50 patients with PD who underwent STN DBS at King's College Hospital and Salford Royal Hospital with fatigue scores (measured by question number 4 from domain 2 (sleep/fatigue) of the NMSS as the primary outcome measure. Secondary outcome measures included the PD Sleep Scale (PDSS), Scales for Outcome in PD (SCOPA)-motor examination, activities of daily living, motor complications, Hoehn and Yahr (HY) stage and changes in Levodopa Equivalent Daily Dose (LEDD).50 patients with a mean follow-up period of 1.98 ± 1.36 years were studied. Significant improvement in median fatigue scores (4.00 (0.75-9.00) to 1.00 (0.00-4.50);Even though open label and not using a validated fatigue scale, this observational analysis suggest that fatigue improves significantly after STN DBS with persisting benefits at two years follow-up.
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- 2021
8. Deep brain stimulation in the management of paediatric neuropsychiatric conditions: Current evidence and future directions
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Keyoumars Ashkan, Asfand Baig Mirza, Luciano Furlanetti, and Kantharuby Tambirajoo
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Obsessive-Compulsive Disorder ,medicine.medical_specialty ,Deep brain stimulation ,Adolescent ,Deep Brain Stimulation ,medicine.medical_treatment ,Tourette syndrome ,Neurosurgical Procedures ,03 medical and health sciences ,0302 clinical medicine ,Obsessive compulsive ,030225 pediatrics ,medicine ,Humans ,Child ,Intensive care medicine ,Paediatric patients ,business.industry ,General Medicine ,medicine.disease ,Eating disorders ,Pediatrics, Perinatology and Child Health ,Major depressive disorder ,Neurology (clinical) ,Neurosurgery ,business ,Treatment-resistant depression ,030217 neurology & neurosurgery ,Tourette Syndrome - Abstract
Introduction Neurosurgery has provided an alternative option for patients with refractory psychiatric indications. Lesion procedures were the initial techniques used, but deep brain stimulation (DBS) has the advantage of relative reversibility and adjustability. This review sets out to delineate the current evidence for DBS use in psychiatric conditions, with an emphasis on the paediatric population, highlighting pitfalls and opportunities. Methods A systematic review of the literature was conducted on studies reporting the use of DBS in the management of psychiatric disorders. The PRISMA guidelines were employed to structure the review of the literature. Data was discussed focusing on the indications for DBS management of psychiatric conditions in the paediatric age group. Results A total of seventy-three full-text papers reported the use of DBS surgery for the management of psychiatric conditions matching the inclusion criteria. The main indications were Tourette Syndrome (GTS) (15 studies), Obsessive Compulsive Disorder (OCD) (20), Treatment Resistant Depression (TRD) (27), Eating Disorders (ED) (7) and Aggressive Behaviour and self-harm (AB) (4). Out of these, only 11 studies included patients in the paediatric age group (≤18 years-old). Among the paediatric patients, the indications for surgery included GTS, AB and ED. Conclusions The application of deep brain stimulation for psychiatric indications has progressed at a steady pace in the adult population and at a much slower pace in the paediatric population. Future studies in children should be done in a trial setting with strict and robust criteria. A move towards personalising DBS therapy with new stimulation paradigms will provide new frontiers and possibilities in this growing field.
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- 2021
9. On Natural History and Management of Colloid Cysts: Time to Rethink?
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Maria Alexandra Velicu, Kristin Rossmann, Ali Vahedi, Jose Pedro Lavrador, Francesco Vergani, Ranjeev Bhangoo, Richard Gullan, Thomas Booth, and Keyoumars Ashkan
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Surgery ,Neurology (clinical) - Abstract
Background: Colloid cysts, although benign, may occasionally cause obstructive hydrocephalus and sudden death. Reliable prognostic factors for symptomatic progression have been sought, with heterogenous results. Methods: We conducted a retrospective review of all cases of colloid cysts of the third ventricle managed at our center between 2009 and 2019. Clinical and neuroimaging characteristics were analyzed using logistic regression in relation to symptomatic status and hydrocephalus. The cutoff values for outcome prediction were calculated using the receiver operating characteristic curve analysis. Results: There were 82 patients with colloid cysts, of whom 60 were asymptomatic and 22 symptomatic. None of the asymptomatic patients experienced acute neurologic decline or hydrocephalus during follow-up, whereas half (n = 11) of the symptomatic patients presented with hydrocephalus, 8 of whom had acute hydrocephalus. We found 3 putative candidate risk factors for symptomatic colloid cysts: T1-weighted magnetic resonance imaging hyperintense/mixed signal appearance (P = 0.004), location in risk zone I (P = 0.007), and a volume >236.49 mm 3 (P = 0.007). Cyst diameter and volume/foramen of Monro diameter ratios had a decreasing trend over time among asymptomatic patients, providing new insights into the natural history of the disease. Conclusions: Only a few asymptomatic colloid cysts showed progression requiring surgery, with no acute deterioration or fatal events, whereas the rest remained stable over time, thus supporting a more conservative approach for this group of patients. Higher risk for developing symptomatic colloid cyst was defined by a risk score that included T1-weighted magnetic resonance imaging appearance, risk zone, and colloid cyst volume, aiding the detection of patients at risk of clinical deterioration.
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- 2022
10. Stress, Anxiety, and Depression Associated With Awake Craniotomy: A Systematic Review
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Mohammad Mofatteh, Mohammad Sadegh Mashayekhi, Saman Arfaie, Yimin Chen, Kasra Hendi, Angela Tian Hui Kwan, Faraz Honarvar, Arad Solgi, Xuxing Liao, and Keyoumars Ashkan
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Surgery ,Neurology (clinical) - Abstract
Awake craniotomy (AC) enables real-time monitoring of cortical and subcortical functions when lesions are in eloquent brain areas. AC patients are exposed to various preoperative, intraoperative, and postoperative stressors, which might affect their mental health.To conduct a systematic review to better understand stress, anxiety, and depression in AC patients.PubMed, Scopus, and Web of Science databases were searched from January 1, 2000, to April 20, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.Four hundred forty-seven records were identified that fit our inclusion and exclusion criteria for screening. Overall, 24 articles consisting of 1450 patients from 13 countries were included. Sixteen studies (66.7%) were prospective, whereas 8 articles (33.3%) were retrospective. Studies evaluated stress, anxiety, and depression during different phases of AC. Twenty-two studies (91.7%) were conducted on adults, and 2 studies were on pediatrics (8.3 %). Glioma was the most common AC treatment with 615 patients (42.4%). Awake-awake-awake and asleep-awake-asleep were the most common protocols, each used in 4 studies, respectively (16.7%). Anxiety was the most common psychological outcome evaluated in 19 studies (79.2%). The visual analog scale and self-developed questionnaire by the authors (each n = 5, 20.8%) were the most frequently tools used. Twenty-three studies (95.8%) concluded that AC does not increase stress, anxiety, and/or depression in AC patients. One study (4.2%) identified younger age associated with panic attack.In experienced hands, AC does not cause an increase in stress, anxiety, and depression; however, the psychiatric impact of AC should not be underestimated.
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- 2022
11. Neuromate® robot-assisted ventricular catheter insertion
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Harischandra Lalgudi Srinvasan, Harutomo Hasegawa, Ahmed Raslan, Kantharuby Tambirajoo, Keyoumars Ashkan, and Richard Selway
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Foramen magnum ,medicine.medical_specialty ,Neuronavigation ,business.industry ,Decompression ,General Medicine ,medicine.disease ,Shunt (medical) ,03 medical and health sciences ,0302 clinical medicine ,medicine.anatomical_structure ,Ventricle ,030220 oncology & carcinogenesis ,medicine ,Surgery ,Epilepsy surgery ,Syrinx (medicine) ,Neurology (clinical) ,Radiology ,business ,Robotic arm ,030217 neurology & neurosurgery - Abstract
Background and importance Insertion of ventricular catheters into small ventricles may require image guidance. Several options exist, including ultrasound guidance, frameless, and frame-based stereotactic approaches. There is no literature on management options when conventional image guidance fails to cannulate the ventricle. The accuracy of the robotic arm is well established in functional and epilepsy surgery. We report the first case using the Neuromate® robot for the placement of a shunt ventricular catheter into the lateral ventricle after a failed attempt with a more commonly used frameless electromagnetic navigation system. Clinical presentation A 30-year-old man had twice previously undergone foramen magnum decompression for a Chiari 1 malformation. He subsequently developed a significant cervical syrinx with clinical deterioration and a decision was made to place a ventriculoperitoneal shunt. As the ventricles were small, frameless electromagnetic navigation was used but the ventricle could not be cannulated. The Neuromate® robot was subsequently used to place the ventricular catheter successfully. Conclusion Neuromate® robot-assisted ventricular catheter placement may be considered when difficulty is experienced with more commonly used image guidance techniques.
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- 2021
12. Neurosurgery and coronavirus: impact and challenges—lessons learnt from the first wave of a global pandemic
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Alexandra Maria Velicu, Francesco Vergani, Harutomo Hasegawa, Mohammed Faruque, Gordan Grahovac, Nicholas Thomas, Irfan Malik, Eleni Maratos, Christopher Chandler, Christos M. Tolias, Ahilan Kailaya-Vasan, Sinan Barazi, Josephine Jung, David E. Bell, Pandurang Kulkarni, Richard Gullan, Keyoumars Ashkan, Ahmed Raslan, Cristina Bleil, Sanjeev Bassi, Bassel Zebian, Richard Selway, Ranjeev Bhangoo, and Daniel C. Walsh
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Male ,Emergency Medical Services ,medicine.medical_specialty ,Neurosurgery ,Clinical Neurology ,Comorbidity ,Global Health ,Emergency referrals ,Subspecialty ,Neurosurgical Procedures ,State Medicine ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Multidisciplinary approach ,Health care ,Pandemic ,medicine ,Humans ,Prospective Studies ,030212 general & internal medicine ,Pandemics ,Referral and Consultation ,Patient Care Team ,SARS-CoV-2 ,business.industry ,COVID-19 ,Original Article - Infection ,Perioperative ,Private sector ,United Kingdom ,Hospitalization ,Coronavirus ,Elective Surgical Procedures ,Emergency medicine ,Female ,Interdisciplinary Communication ,Surgery ,Patient Safety ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Cohort study - Abstract
Introduction and objectivesThe novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population.MethodsA prospective single-centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multidisciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020–15th May 2020) compared to pre-COVID-19 (18th of January 2020–17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed.ResultsOverall, there was a reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75.2% of total,n=155) when compared to pre-COVID-19 (n= 198, 43.7% of total,p< 0.00001). In contrast to other published series, the 30-day perioperative mortality remained low (2.0%) with the majority of post-operative COVID-19-infected patients (n= 13) having underlying medical co-morbidities and/or suffering from post-operative complications.ConclusionThe capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern technology to run clinics and MDTs, restructuring patient pathways/facilities, and initiating the delivery of NHS care within private sector hospitals. Through this multi-modal approach we were able to minimize service disruptions, the complications, and mortality.
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- 2020
13. Diffuse Traumatic Subarachnoid Hemorrhage Mimicking Aneurysmal Bleeding Secondary to Ophthalmic Artery Avulsion: Case Report and Review of the Literature
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Ahmed Raslan, Keyoumars Ashkan, Ahmed B. Abougamil, Mohamed Okasha, and Milena Angelova-Chee
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medicine.medical_specialty ,Subarachnoid hemorrhage ,Traumatic brain injury ,Aneurysm, Ruptured ,Diagnosis, Differential ,Avulsion ,Ophthalmic Artery ,03 medical and health sciences ,Subarachnoid Hemorrhage, Traumatic ,0302 clinical medicine ,medicine.artery ,Cerebrospinal fluid diversion ,Humans ,Medicine ,cardiovascular diseases ,business.industry ,Vasospasm ,Middle Aged ,medicine.disease ,nervous system diseases ,Surgery ,Hydrocephalus ,030220 oncology & carcinogenesis ,Ophthalmic artery ,Accidental Falls ,Female ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,External ventricular drain - Abstract
Background Traumatic subarachnoid hemorrhage (SAH) is a common finding following traumatic brain injury. In some cases, it can be associated with hydrocephalus. This type of hemorrhage is mostly caused by the rupture of small vessels in the brain and is usually managed conservatively. Case Description We present a case of a 60-year-old woman who presented with traumatic luxation of the eye following a fall. This resulted in diffuse SAH (Fisher grade IV) with associated hydrocephalus. We also report on 3 previous similar cases found in the literature. Avulsion of the ophthalmic artery was found to be the cause of the traumatic SAH. Apart from cerebrospinal fluid diversion using an external ventricular drain, the case was managed conservatively. There was no evidence of delayed clinical or radiologic vasospasm. Conclusions Traumatic avulsion of the ophthalmic artery may result in diffuse SAH, mimicking that of aneurysmal rupture. This case shows that management of early complications, such as hydrocephalus and seizures, should be the main aim. Surgical or endovascular treatment of the injured artery, however, would be unnecessary.
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- 2020
14. Primary Lumbar Paraganglioma: Clinical, Radiologic, Surgical, and Histopathologic Characteristics from a Case Series of 13 Patients
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Francesco Fiorini, Zita Reisz, Richard Gullan, José Pedro Lavrador, Francesco Vergani, Ranjeev Bhangoo, Keyoumars Ashkan, and Safa Al-Sarraj
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Adult ,Male ,Ependymoma ,medicine.medical_specialty ,Cauda Equina ,Cauda equina syndrome ,Cauda Equina Syndrome ,Cohort Studies ,Meningioma ,03 medical and health sciences ,0302 clinical medicine ,Lumbar ,Erectile Dysfunction ,Paraparesis ,Paraganglioma ,Back pain ,Humans ,Medicine ,Paresthesia ,Spinal Cord Neoplasms ,Radiculopathy ,Aged ,Retrospective Studies ,Paraganglioma, Extra-Adrenal ,Lumbar Vertebrae ,business.industry ,Cauda equina ,Middle Aged ,medicine.disease ,Magnetic Resonance Imaging ,Tumor Burden ,Nerve sheath tumor ,Treatment Outcome ,Urinary Incontinence ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Female ,Surgery ,Neurology (clinical) ,Radiology ,medicine.symptom ,business ,Low Back Pain ,Fecal Incontinence ,030217 neurology & neurosurgery - Abstract
Background Paragangliomas are uncommon neuroendocrine tumors, rarely occurring in the lumbar spine. Primary lumbar paragangliomas are prominently vascularized, can present variably, and pose both diagnostic and surgical challenges. We report on a large case series with long-term follow-up and intraoperative footage to characterize the natural history, diagnostic approach, and operative approach to this rare surgical disease. Methods This is a single-center, retrospective cohort study including all patients with histologically confirmed primary lumbar paraganglioma treated at our tertiary neurosurgical center between 1997 and 2018. Clinical, radiologic, surgical, and histologic data were collected from medical records. Results There were 13 cases of primary lumbar paraganglioma (8 men [61.5%], 5 women [38.5%]; mean age, 51.3 years; range, 33.2–68.9 years). Symptom duration correlated with tumor size (Spearman r = 0.735, P = 0.01). The main presenting symptoms were lower back pain and radiculopathy, often long-standing with recent deterioration. Seven patients (53.8%) were admitted as emergency cases, including 3 with cauda equina syndrome. Preoperative differential diagnoses included nerve sheath tumor, ependymoma, meningioma, and disk herniation. The mean Ki-67 mitotic index was 5.7% (range, 1%–10%). Surgical resection improved pain in 8 of 13 patients (61.5%) and weakness improved in 5 of 5 patients (100%). Conclusions Primary lumbar paragangliomas are rare neoplasms of the cauda equina that typically progress slowly but may also present acutely. They are often related to the filum terminale, which should be resected prior to other attachments intraoperatively to prevent displacement of the tumor out of view. Total resection can be curative, and long-term follow-up in this series found no recurrence.
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- 2020
15. Letter: Postacute Cognitive Rehabilitation for Adult Brain Tumor Patients
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Jose Pedro Lavrador, Victoria Hurwitz, Carly Butler, Kapil Mohan Rajwani, Richard Gullan, Keyoumars Ashkan, Francesco Vergani, and Ranjeev Bhangoo
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Adult ,Cognition ,Brain Neoplasms ,Brain Injuries ,Humans ,Surgery ,Neurology (clinical) - Published
- 2022
16. Letter: Electromagnetic Navigation Systems and Intraoperative Neuromonitoring: Reliability and Feasibility Study
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Prajwal Ghimire, Jose Pedro Lavrador, Hannah Keeble, Richard Gullan, Francesco Vergani, Ranjeev Bhangoo, and Keyoumars Ashkan
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03 medical and health sciences ,0302 clinical medicine ,Surgery ,Neurology (clinical) ,030217 neurology & neurosurgery ,030218 nuclear medicine & medical imaging - Published
- 2021
17. Altered Motor Excitability in Patients With Diffuse Gliomas Involving Motor Eloquent Areas: The Impact of Tumor Grading
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Ranjeev Bhangoo, Sabina Patel, Szymon Hoppe, José Pedro Lavrador, Francesco Vergani, Richard Gullan, Josephine Jung, Keyoumars Ashkan, and Ifigeneia Gioti
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medicine.medical_specialty ,Neoplasm Grading ,business.industry ,medicine.medical_treatment ,medicine.disease ,Transcranial magnetic stimulation ,03 medical and health sciences ,Diffuse Glioma ,0302 clinical medicine ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Internal medicine ,Glioma ,Corticospinal tract ,medicine ,Cardiology ,Surgery ,Neurology (clinical) ,Primary motor cortex ,Evoked potential ,business ,030217 neurology & neurosurgery ,Motor cortex - Abstract
Background Diffuse gliomas have an increased biological aggressiveness across the World Health Organization (WHO) grading system. The implications of glioma grading on the primary motor cortex (M1)-corticospinal tract (CST) excitability is unknown. Objective To assess the excitability of the motor pathway with navigated transcranial magnetic stimulation (nTMS). Methods Retrospective cohort study of patients admitted for surgery with diffuse gliomas within motor eloquent areas. Demographic, clinical, and nTMS-related variables were collected. The Cortical Excitability Score (CES 0 to 2 according to the number of abnormal interhemispheric resting motor threshold (RMT) ratios) was calculated for patients where bilateral upper and lower limb mapping was performed. Results A total of 45 patients were included: 9 patients had a low-grade glioma and 36 patients had a high-grade glioma. The unadjusted analysis revealed an increase in the latency of the motor evoked potential of the lower limb with an increase of the WHO grade (P = .038). The adjusted analysis confirmed this finding (P = .013) and showed a relation between the increase in the WHO and a decreased RMT (P = .037) of the motor evoked responses in the lower limb. When CES was calculated, an increase in the score was related with an increase in the WHO grade (unadjusted analysis-P = .0001; adjusted analysis-P = .001) and in isocitrate dehydrogenase (IDH) wild-type tumors (unadjusted analysis-P = .020). Conclusion An increase in the WHO grading system and IDH wild-type tumors are associated with an abnormal excitability of the motor eloquent areas in patients with diffuse gliomas.
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- 2020
18. Pre- and Intraoperative Mapping for Tumors in the Primary Motor Cortex: Decision-Making Process in Surgical Resection
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Luciano Furlanetti, Keyoumars Ashkan, Sabina Patel, Christian Brogna, José Pedro Lavrador, Prajwal Ghimire, Francesco Vergani, Ranjeev Bhangoo, and Richard Gullan
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Adult ,Male ,Surgical resection ,medicine.medical_specialty ,Weakness ,Intraoperative Neurophysiological Monitoring ,medicine.medical_treatment ,Clinical Decision-Making ,Pyramidal Tracts ,Text mining ,medicine ,Humans ,Neuronavigation ,Aged ,Brain Mapping ,Surgical team ,Brain Neoplasms ,business.industry ,Motor Cortex ,Glioma ,Middle Aged ,Magnetic Resonance Imaging ,Transcranial Magnetic Stimulation ,Transcranial magnetic stimulation ,Corticospinal tract ,Surgery ,Neurology (clinical) ,Radiology ,Primary motor cortex ,medicine.symptom ,business ,Tractography - Abstract
Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan.Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (navigated transcranial magnetic stimulation [nTMS] and tractography), intraoperative mapping, and intraoperative provisional histologic information (smear with and without 5-aminolevulinic acid [5-ALA]) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection.Results A total of 10 patients (6 patients with metastatic precentral tumor; 1 patient with grade III and 2 patients with grade IV gliomas; 1 patient with precentral cavernoma) were included in the study. Most of the patients (60%) had a preoperative motor deficit. The nTMS documented M1 invasion in all cases, and in eight patients, the lesions were embedded within the CST. Overall, 70% of patients underwent gross total resection; 20% of patients underwent near-total resection of the lesions. In only one patient was no surgical resection possible after both preoperative and intraoperative mapping. Overall, 70% of patients remained stable postoperatively, and previous motor weakness improved in 20%.Conclusion The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) tests in patients with CST lesions provide a useful guide for resection. The inclusion of histologic information (smear with or without 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the center of the informed decision-making process.
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- 2020
19. Deep brain stimulation reduces pain in children with dystonia, including in dyskinetic cerebral palsy
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Sarah Perides, Keyoumars Ashkan, Jean-Pierre Lin, Geraldine Lee, Margaret Kaminska, Daniel E. Lumsden, Hortensia Gimeno, and Richard Selway
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Adult ,Male ,030506 rehabilitation ,Pediatrics ,medicine.medical_specialty ,Deep brain stimulation ,Adolescent ,Deep Brain Stimulation ,medicine.medical_treatment ,Pain ,Severity of Illness Index ,Cerebral palsy ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Developmental Neuroscience ,Rating scale ,Severity of illness ,Humans ,Medicine ,Child ,Pain Measurement ,Dystonia ,business.industry ,Cerebral Palsy ,medicine.disease ,Treatment Outcome ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Cohort ,Etiology ,Female ,Neurology (clinical) ,0305 other medical science ,business ,030217 neurology & neurosurgery ,Dyskinetic cerebral palsy - Abstract
AIM To establish the prevalence of dystonic pain in children and their response to deep brain stimulation (DBS). METHOD Dystonic pain was assessed in a cohort of 140 children, 71 males and 69 females, median age 11 years 11 months (range 3y-19y 1mo), undergoing DBS in our centre over a period of 10 years. The cohort was divided into aetiological dystonia groups: 1a, inherited; 1b, heredodegenerative; 2, acquired; and 3, idiopathic. Motor responses were measured with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). RESULTS Dystonic pain was identified in 63 (45%) patients, 38% of whom had a diagnosis of cerebral palsy (CP). Dystonic pain improved in 90% of children and in all aetiological subgroups 1 year after DBS, while the BFMDRS motor score improved in 70%. Statistically significant improvement (p
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- 2020
20. Reliability of Intraoperative Monitoring in Patients with a Preexisting Motor Deficit: Case Report and Literature Review
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Noemia Pereira, Ravindran Visagan, Shami Acharya, Francesco Vergani, Keyoumars Ashkan, Ranjeev Bhangoo, José Pedro Lavrador, and Istvan Bodi
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Adult ,Male ,medicine.medical_specialty ,Weakness ,Intraoperative Neurophysiological Monitoring ,medicine.medical_treatment ,Context (language use) ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Contraindication ,Craniotomy ,Brain Neoplasms ,business.industry ,digestive, oral, and skin physiology ,Motor Cortex ,Glioma ,Evoked Potentials, Motor ,Surgery ,Paresis ,Hemiparesis ,030220 oncology & carcinogenesis ,Neurology (clinical) ,Neurosurgery ,Presentation (obstetrics) ,medicine.symptom ,Motor Deficit ,business ,030217 neurology & neurosurgery - Abstract
Background The use of intraoperative monitoring (IOM) in glioma surgery is a widely adopted and clinically validated adjunct to define safe zones of resection for the neurosurgeon. However, the role of IOM in cases of a significant preexisting motor deficit is questionable. Case Description We describe a case of a 25-year-old with a recurrent presentation of a left paracentral glioblastoma, admitted with intratumoral hemorrhage and subsequent acute severe right-sided weakness. The patient underwent a redo left parietal craniotomy and 5-aminolevulinic acid–guided resection with IOM. The severity of the weakness was not reflected by the pre- and intraoperative cortical motor evoked potentials (MEPs) that were reassuring. The patient's hemiparesis recovered to full power postoperatively. Conclusions Preoperative weakness is traditionally accepted as a relative contraindication to IOM and therefore its usefulness is questioned in this context. Our case challenges this assumption. We present the clinical course, review the cranial and spinal literature including the reliability of IOM in cases of preoperative motor deficit, and discuss the need for tailor-made IOM strategies.
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- 2020
21. Patient-reported experience measures in patients undergoing navigated transcranial magnetic stimulation (nTMS): the introduction of nTMS-PREMs
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Josephine Jung, Keyoumars Ashkan, Francesco Vergani, José Pedro Lavrador, Prajwal Ghimire, Sabina Patel, Richard Gullan, and Ranjeev Bhangoo
- Subjects
Adult ,Male ,medicine.medical_specialty ,Neurology ,medicine.medical_treatment ,Original Article - Neurosurgery general ,Logistic regression ,Unmet needs ,Likert scale ,nTMS ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,030212 general & internal medicine ,Patient Reported Outcome Measures ,PREMs ,Neuronavigation ,Neuroradiology ,Brain Mapping ,medicine.diagnostic_test ,business.industry ,Brain Neoplasms ,Quality of care ,Interventional radiology ,Middle Aged ,Transcranial Magnetic Stimulation ,Transcranial magnetic stimulation ,Physical therapy ,Anxiety ,Surgery ,Female ,Neurology (clinical) ,Neurosurgery ,medicine.symptom ,business ,030217 neurology & neurosurgery - Abstract
Background Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help address the quality of care of the patients. Objective Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation patient-reported experience measure (nTMS-PREMs) questionnaire among neurosurgical patients undergoing nTMS. Methods A single-centre prospective nTMS-PREMs 19-item questionnaire study was performed between February 2018 and December 2018 on patient referred for nTMS at our hospital. The Data was analysed using Likert scale, linear and logistic regression using statistical software (STATA 13.0®). Results Fifty patient questionnaires were collected (30 males, 20 females, mean age of 47.6 ± 2.1 years) among which 74% of patients underwent both motor and language mapping with a mean duration of 103.3 ± 5.1 min. An overall positive response was noted from the results of the questionnaire, tiredness and anxiety being the common effects noted. Patients with the left-sided disease appreciated more the conditions provided in our laboratory (Q4, p = 0.040) and increasing age was related to less confidence and trust (Q6, p = 0.038) in the staff performing the exam. Younger patients tolerated nTMS better than older patients (> 65 years). PubMed literature search resulted in no relevant articles on the use of PREMs in nTMS patients. Conclusion nTMS is a well-tolerated non-invasive tool and nTMS-PREMS provides a promising role in identifying the unmet needs of the patients and improving the quality of their care.
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- 2020
22. The verb and noun test for peri-operative testing (VAN-POP): standardized language tests for navigated transcranial magnetic stimulation and direct electrical stimulation
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Antonio Valentin, Ann-Katrin Ohlerth, Francesco Vergani, Roelien Bastiaanse, Keyoumars Ashkan, and Neurolinguistics and Language Development (NLD)
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Adult ,Male ,action naming ,Deep Brain Stimulation ,medicine.medical_treatment ,media_common.quotation_subject ,Verb ,Context (language use) ,computer.software_genre ,German ,nTMS ,03 medical and health sciences ,0302 clinical medicine ,Monitoring, Intraoperative ,Noun ,Humans ,Medicine ,Neuronavigation ,Original Article - Functional Neurosurgery - Other ,media_common ,standardization ,object naming ,Language Tests ,business.industry ,Transcranial Magnetic Stimulation ,DES ,language.human_language ,Agreement ,Test (assessment) ,Transcranial magnetic stimulation ,language mapping ,030220 oncology & carcinogenesis ,language ,Female ,Surgery ,Neurology (clinical) ,Artificial intelligence ,business ,computer ,030217 neurology & neurosurgery ,Natural language processing ,Sentence - Abstract
Background Protocols for intraoperative language mapping with direct electrical stimulation (DES) often include various language tasks triggering both nouns and verbs in sentences. Such protocols are not readily available for navigated transcranial magnetic stimulation (nTMS), where only single word object naming is generally used. Here, we present the development, norming, and standardization of the verb and noun test for peri-operative testing (VAN-POP) that measures language skills more extensively. Methods The VAN-POP tests noun and verb retrieval in sentence context. Items are marked and balanced for several linguistic factors known to influence word retrieval. The VAN-POP was administered in English, German, and Dutch under conditions that are used for nTMS and DES paradigms. For each language, 30 speakers were tested. Results At least 50 items per task per language were named fluently and reached a high naming agreement. Conclusion The protocol proved to be suitable for pre- and intraoperative language mapping with nTMS and DES.
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- 2020
23. Subthalamic Nucleus Deep Brain Stimulation in Post-Infarct Dystonia
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Luciano Furlanetti, Michael Samuel, Keyoumars Ashkan, and Kantharuby Tambirajoo
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Dystonia ,Deep brain stimulation ,business.industry ,medicine.medical_treatment ,Subthalamic nucleus deep brain stimulation ,Neuropsychology ,medicine.disease ,nervous system diseases ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Subthalamic nucleus ,surgical procedures, operative ,0302 clinical medicine ,nervous system ,Pain control ,Anesthesia ,medicine ,Surgery ,In patient ,Neurology (clinical) ,Cerebral infarcts ,business ,therapeutics ,030217 neurology & neurosurgery - Abstract
Dystonia secondary to cerebral infarcts presents months to years after the initial insult, is usually unilateral and causes significant morbidity. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is established as the most frequent target in the management of the dystonic symptoms. We report our experience with subthalamic nucleus (STN) DBS in 3 patients with post-infarct dystonia, in whom GPi DBS was not confidently possible due to the presence of striatal infarcts. Two patients had unilateral STN DBS implantation, whereas the third patient had bilateral STN DBS implantation for bilateral dystonic symptoms. Prospectively collected preoperative and postoperative functional assessment data including imaging, medication and neuropsychology evaluations were analyzed with regard to symptom improvement. Median follow-up period was 38.3 months (range 26–43 months). All patients had clinically valuable improvements in dystonic symptoms and pain control despite variable improvements in the Burke-Fahn-Marsden dystonia rating scores. In our series, we have demonstrated that STN DBS could be an alternative in the management of post-infarct dystonia in patients with abnormal striatal anatomy which precludes GPi DBS. A multidisciplinary team-based approach is essential for patient selection and management.
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- 2020
24. Safety and accuracy of frameless electromagnetic-navigated (AXIEMTM)-guided brain lesion biopsies: a large single-unit study
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Afshan Safdar, Duranka Perera, Richard Gullan, Keyoumars Ashkan, Anastasios Giamouriadis, Ranjeev Bhangoo, and Francesco Vergani
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medicine.medical_specialty ,Neurology ,medicine.diagnostic_test ,business.industry ,Brain tumor ,Interventional radiology ,Neuropathology ,medicine.disease ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Biopsy ,medicine ,Surgery ,Neurology (clinical) ,Neurosurgery ,Radiology ,business ,Adverse effect ,030217 neurology & neurosurgery ,Neuroradiology - Abstract
Brain biopsies are required to establish a definitive histological diagnosis for brain lesions that have been identified on imaging in order to guide further treatment for patients. Various navigation systems are in use but little up to date evidence is available regarding the safety and accuracy of a frameless, electromagnetic technique to target brain lesions. Data was collected retrospectively on all patients that had brain biopsies at our institution from 01/01/2010 to 31/12/2017. Operation notes, neuropathology reports, and clinical notes on electronic patient record were used to determine whether biopsy of adequate identifiable abnormal tissue was achieved, whether a definitive diagnosis was established, any adverse events occurred, and if a repeat biopsy was carried out. Three hundred seventy-one AxiEM (Medtronic, Minneapolis, USA)-guided brain tumor biopsies were performed in this 8-year period. Three hundred forty-nine (94.07%) procedures provided definitive tissue diagnosis, 22 (5.93%) were non diagnostic; in 6 cases (1.62%), repeat biopsy was performed and adverse events which caused clinical compromise were observed in 4 patients (1.08%). The AxiEM is a fast, effective, and safe frameless and pinless neuronavigational system. It offers a high degree of accuracy required for the establishment of a definitive diagnosis, permitting optimal further treatment, and thus improving patient outcomes.
- Published
- 2019
25. First Human In Vivo Neuroelectrophysiology Recordings of Uncrossed Dentatothalamocortical White-Matter Connections: On the Fast Tract
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Christian Brogna, Noemia Perera, Prajwal Ghimire, Muriel M.K. Bruchhage, Eugenio Abela, Mark P. Richardson, Francesco Vergani, Ranjeev Bhangoo, and Keyoumars Ashkan
- Subjects
Cerebellum ,Neural Pathways ,Motor Cortex ,Humans ,Neurology (clinical) ,Evoked Potentials ,White Matter ,Electric Stimulation - Abstract
ObjectivesWe aim to demonstrate intraoperative recording of cerebellar to cortical pathways that have not been previously recorded in humans, though imaged.MethodsWe report 2 cases with intraoperative neurophysiologic mapping of cerebellocortical tracts. Direct electrical stimulation of subcortical cerebellum along with recordings of cortical evoked potential and motor muscle recordings was performed during surgery. MR tractography data from healthy participants were used to further illustrate the pathways.ResultsNeurophysiologic recordings showed large waveforms of evoked potentials in bilateral electrodes over premotor/motor cortices on stimulation of the dentate nucleus. EMG recordings showed responses in face and neck muscles on stimulation of the dentate nucleus at the motor threshold. We thus demonstrated first-in-human in vivo neurophysiologic evidence of cerebellum to cortex responses through an uncrossed dentatothalamocortical tract to the motor/premotor cortices.DiscussionThis technique provides a methodology for the direct mapping of the cerebellum and cerebello-cerebral connections. We hypothesize a direct structural connection from the dentate nucleus to the premotor and motor cortices, as well as to ipsilateral hemibody muscles, acting as a fast route of cerebellar output and back up for immediate motor responses. This will further help explain the modulatory effects of the cerebellum on motor, language, and cognitive functions.
- Published
- 2021
26. Commissural Inter-M1 Cortico-cortical Evoked Potential: A Proof of Concept Report
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Jose Pedro Lavrador, Hannah Keeble, Prajwal Ghimire, Francesco Fiorini, Ranjeev Bhangoo, Francesco Vergani, Richard Gullan, and Keyoumars Ashkan
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Brain Mapping ,Motor Cortex ,Humans ,Surgery ,Neurology (clinical) ,Wakefulness ,Evoked Potentials, Motor ,Evoked Potentials ,Electric Stimulation ,Neurosurgical Procedures - Abstract
Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years thanks to significant advances in anesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake, and combined intraoperative mapping techniques were responsible for an improvement in the functional outcomes in neurosurgery, providing reliable and reproducible mapping of both projection and association fibers involved in motor control.We report inter-M1 cortico-cortical evoked potential (CCEP) recording during asleep resection of a bilateral parasagittal meningioma with intraoperative neuromonitoring and motor mapping.CCEPs were recorded between both M1 cortices with bipolar stimulations of both supplementary motor areas (10.5-11.5 μV).Here, we provide evidence of intraoperative mapping of commissural fibres involved in motor control in a patient with asleep technique as well as a review of the potential tracts involved in the connectivity underlying the motor function.
- Published
- 2021
27. Continuous Microdebrider-Based Dynamic Subcortical Motor Mapping: A Technical Advance in Tubular Retractor-Assisted Surgery
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Mathew J. Gallagher, Jose P. Lavrador, Pedro Coelho, Ana Mirallave-Pescador, Cristina Bleil, Richard Gullan, Keyoumars Ashkan, Francesco Vergani, and Ranjeev Bhangoo
- Subjects
Brain Mapping ,Microsurgery ,Brain Neoplasms ,Humans ,Surgery ,Neurology (clinical) - Abstract
Transsulcal minimally invasive parafasicular (TsMIP) approaches to brain tumor resection use tubular retractors to minimize iatrogenic brain injury. Dynamic cortical and subcortical continuous neurophysiological mapping facilitates safer resection of motor-eloquent tumors.To describe a new technique to address the challenge of combining TsMIP with tubular retractors and dynamic subcortical mapping using a single electrified stimulating microdebrider instrument.We adapted the NICO Myriad microdebrider with continuous monopolar stimulation electrification using high-frequency stimulation with the train-of-5 technique. We performed continuous subcortical mapping using this device and compared it with standard dynamic monopolar subcortical mapping using a suction stimulation device. We found no significant difference in recorded stimulation response.Using a single operating instrument that provides synchronous tumor resection and monopolar subcortical mapping with the NICO Brainpath tubular retractor, we observed increased degrees of movement, faster surgical resection times with an enlarged working channel down the retractor, and improved safety because the stimulating probe sits 2 mm deep to the resection window.We show that the adapted device is reliable and provides similar stimulation response as conventional subcortical mapping. We advocate the use of our adapted microdebrider in TsMIP tubular retractor approaches.
- Published
- 2021
28. Functional neurological disorders in patients with brain tumours
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Katia Cikurel, Charmaine Toh, Francesco Vergani, Dorothy Joe, José-Pedro Lavrador, Gerald T. Finnerty, Keyoumars Ashkan, Najma Khan-Bourne, Ranjeev Bhangoo, Paul Shotbolt, and Julia Johnson
- Subjects
Cancer Research ,Pediatrics ,medicine.medical_specialty ,Neurologic Oncology ,business.industry ,BNOS 2021 Abstracts ,MEDLINE ,medicine.disease ,Epilepsy ,Quality of life (healthcare) ,Hemiparesis ,Oncology ,Medicine ,Psychological testing ,Meningeal Neoplasm ,Neurology (clinical) ,medicine.symptom ,business ,Adverse effect - Abstract
Aims Signs and symptoms that develop in people with brain tumours are often attributed to their tumour. The prevalence and management of functional neurological symptoms in brain tumour patients have received little attention. This is surprising because functional neurological symptoms complicate management greatly and misdiagnosis can lead to inappropriate treatment and iatrogenic side-effects. Therefore, we investigated the presentation, diagnosis and management of functional neurological disorders (FND) in patients who had a brain or meningeal tumour. Method A retrospective case review was performed from 2017 - 2021 to identify adult brain tumour patients who developed a functional neurological disorder that caused significant disability necessitating expedited investigations. All patients attended a regional neuro-oncology centre. We recorded type of brain tumour and diagnostic investigations. The onset of functional symptoms was divided into three time windows: before tumour diagnosis, after diagnosis and before treatment or after tumour treatment. A neuropsychological review looked for evidence of previous adverse life events. Therapeutic interventions for functional neurological disorder and their outcomes were documented. The case review was combined with a systematic review of the literature to identify the published presentations of functional neurological disorder in the adult brain tumour population. MEDLINE, EMBASE and PsycINFO databases were searched for studies published between January 1980 and February 2021. Results Six patients (5 female, 1 male) were identified from the case review with a median age of 41 (range 29 - 56) years old. Four patients had non-epileptic attack disorder, which was diagnosed with videotelemetry of habitual attacks. One patient had a functional hemiparesis with normal central motor conduction time. One patient had a functional speech disorder with normal EEG. Half of these patients had functional neurological symptoms prior to surgery/oncological treatment. Five patients (83%) were referred for further neuropsychiatric or psychological evaluation. A history of significant psychological trauma prior to the brain tumour diagnosis was elicited in four (66%) patients. Conclusion Patients with either a brain or meningeal tumour may develop functional neurological symptoms. Our findings suggest the possibility that diagnosis of a brain tumour may precipitate a debilitating functional neurological disorder. The neurobiological basis for functional neurological disorders is being actively investigated. There are suggestions in the literature that some brain diseases increase the risk of developing a functional neurological disorder. Further work is needed to determine whether this is true for patients with brain tumours. Increased awareness of functional neurological disorders will improve management. Withdrawal of unnecessary treatment, such as anticonvulsant drugs, reduces the risk of iatrogenic side effects. Initiation of multi-disciplinary care pathways, e.g. physiotherapy, speech and language therapy and psychological treatments, promotes recovery. Collectively, these interventions improve our patients’ quality of life.
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- 2021
29. Evaluation of Intraoperative Surgical Adjuncts and Resection of Glioblastoma (ELISAR GB): A UK and Ireland, multicentre, prospective observational cohort study
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Michael D. Jenkinson, Georgios Solomou, Keyoumars Ashkan, Kathrin Whitehouse, Puneet Plaha, Rory J Piper, Daniel M Fountain, Danyal Z. Khan, Stephen J. Price, Colin Watts, Angelos G. Kolias, Ali Gharooni, and Melissa Gough
- Subjects
Cancer Research ,medicine.medical_specialty ,medicine.diagnostic_test ,Neurologic Oncology ,business.industry ,BNOS 2021 Abstracts ,Magnetic resonance imaging ,Debulking ,medicine.disease ,Intraoperative MRI ,Oncology ,Medicine ,Neurology (clinical) ,Diffusion Tractography ,Radiology ,business ,Prospective cohort study ,Cohort study ,Glioblastoma - Abstract
Aims Extent of resection is associated with better survival in patients with glioblastoma. Numerous surgical adjuncts can be used to achieve maximal safe resection - including fluorescence-guidance with 5-aminolevulinic acid (5-ALA), neuronavigation, intraoperative ultrasound (IoUS), intra-operative MRI (iMRI), tractography, electrophysiological monitoring and awake surgery. We evaluated the availability, use and operative aim and success associated with these adjuncts. Method This is a prospective cohort study of 27 of 31 neurosurgical centres in the UK and Ireland from 6 January to 19 March 2020. Consecutive cases were identified through neuro-oncology multidisciplinary meetings. Eligible cases included adults with a supratentorial histopathologically confirmed glioblastoma with pre/post-operative reported T1-weighted MRI with contrast deemed suitable for resection. Outcomes included the availability and usage of surgical adjuncts, and the percentage of operations that achieved their aim of complete resection, defined as complete resection of enhancing tumour (CRET) on post-operative T1-MRI. We present the initial descriptive statistics from this national study. Results 232 patients with glioblastoma were included. In 142 patients (61.2%) the surgical aim was CRET. 5-ALA and neuronavigation were available in all centres (Figure 1). The most commonly used neurosurgical adjunct was neuronavigation (88.2%) (Figure 2). The proportion of patients receiving 5-ALA in CRET and debulking-only groups was 65.0% and 48.9%, respectively. 35 different combinations of adjuncts were found in total, with 13 unique combinations only used in one instance (Figures 1 & 2). CRET was achieved in 69/142 (45.8%) patients in which was the aim. 9/90 (10%) patients in the debulking-only group achieved CRET, of which 7/9 (77.8%) had received 5-ALA. Of the three most frequently used combination of adjuncts for patients deemed feasible for CRET, the most successful in terms of achieving CRET was the combined use of neuronavigation, 5-ALA and IoUS, with post-operative CRET at 47.4% (Figure 3). Conclusion ELISAR-GB has collated prospective data to demonstrate the current use of intraoperative adjuncts in the UK and Ireland. There is marked heterogeneity with regards to combinations of adjuncts used. A CRET of 47% is lower than would be expected compared to previously published literature, possibly due to a more stringent definition of complete resection in this study. Based on these early descriptive results, there is no clear combination of adjuncts that shows superiority and use of 5-ALA does not always result in CRET when it is the surgical aim. Of interest, 5-ALA is being used for operations that do not aim for complete resection, a change in indication. The FUTURE GB trial will provide more conclusive evidence on the efficacy of surgical adjuncts to maximise extent of resection.
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- 2021
30. CTIM-27. AUTOLOGOUS TUMOR LYSATE-LOADED DENDRITIC CELL VACCINATION IMPROVES SURVIVAL IN PATIENTS WITH NEWLY DIAGNOSED AND RECURRENT GLIOBLASTOMA: SURVIVAL RESULTS FROM A PHASE 3 TRIAL
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Linda M Liau, Keyoumars Ashkan, Steven Brem, Jian Campian, John Trusheim, Fabio Iwamoto, David Tran, George Anstass, Charles Cobbs, Jason Heth, Michael Salacz, Stacy D'Andre, Robert Aiken, Yaron Moshel, JooYeon Nam, Clement Pillainayagam, Stephanie Wagner, Kevin Walter, Rekha Chaudary, Samuel Goldlust, Ian Lee, Daniela Bota, Heinrich Elinzano, Jai Grewal, Kevin Lillehei, Tom Mikkelsen, Tobias Walbert, Steve Abram, Andrew Brenner, Matthew Ewend, Simon Khagi, Darren Lovick, Jana Portnow, Lyndon Kim, William Loudon, Nina Martinez, Reid Thompson, David Avigan, Karen Fink, Francois Geoffroy, Pierre Giglio, Oleg Gligich, Dietmar Krex, Scott M Lindhorst, Jose Lutzky, Hans-Joerg Meisel, Minou Nadji-Ohl, Lhagva Sanchin, Andrew Sloan, and Marnix Bosch
- Subjects
Cancer Research ,Oncology ,Neurology (clinical) - Abstract
BACKGROUND Standard of care (SOC) and patient survival in glioblastoma have changed little in the past 17 years. We evaluated in a phase 3 trial whether adding an autologous tumor lysate-loaded dendritic cell vaccine (murcidencel) to SOC extends survival. Patients and METHODS Newly diagnosed glioblastoma patients were randomized 2:1 to either murcidencel or placebo. Under a crossover design, all patients could receive murcidencel following tumor recurrence. All parties remained blinded regarding treatments before recurrence. Patients thus received murcidencel at new diagnosis (nGBM) or at recurrence (rGBM) following crossover from placebo. The primary and secondary endpoints compare overall survival (OS) with contemporaneous, matched external controls. Four sets of analyses were conducted to ensure rigorous matching of the controls, reduce biases, and confirm the robustness of the results. RESULTS 331 patients were enrolled. With the crossover, 89% received murcidencel. Median OS (mOS) for nGBM patients (n = 232) was 19.3 months from randomization (22.4 months from surgery) with murcidencel vs. 16.5 months from randomization in the controls (HR = 0.80, p = 0.002). Survival at 48 months from randomization was 15.7% vs. 9.9%, and at 60 months was 13% vs. 5.7%. For rGBM (n = 64), mOS was 13.2 months from relapse vs. 7.8 months in the controls (HR = 0.58, p < 0.001). Survival at 24 months post-recurrence was 20.7% vs. 9.6%, and at 30 months post-recurrence was 11.1% vs 5.1%. In nGBM patients with methylated MGMT (n = 90), mOS was 30.2 months from randomization (33 months from surgery) with murcidencel vs. 21.3 months from randomization in the controls (HR = 0.74, p = 0.027). The treatment was well tolerated, with only 5 serious adverse events deemed at least possibly related to the vaccine. CONCLUSION Clinically meaningful and statistically significant survival extension was seen in both nGBM and rGBM patients treated with murcidencel and SOC compared with contemporaneous, matched external controls who received SOC alone.
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- 2022
31. How Can Clinical Teams Support Patients With a Brain Tumour Diagnosis With Sex Relationships and Intimacy?
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Ellie Kostick, Jessica La, Victoria Hurwitz, Sarah Hedges, Charlotte Robinson, Aeron Suarez, Keyoumars Ashkan, Ranjeev Bhangoo, Richard Gullan, Francesco Vergani, Lucy Brazil, Omar Al-Salihi, Angela Swampillai, Kazumi Chia, Katia Cikurel, Dorothy Joe, Gerald Finnerty, and Jose Pedro Lavrador
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS There is a gap in supporting patients with sexual relationships and intimacy. The aim of this study is to establish if patients with a brain tumour feel they are able to ask questions and concerns about sex, relationships and intimacy following diagnosis; is there an unmet need and how can this be addressed. METHOD An anonymous survey was sent to patients known to a neuro-oncology team. Questions were in relation to their experiences of sex relationships and intimacy. Patients were asked if they had concerns about changes in their relationships since their diagnosis. They were also asked for their comments on the subject so we can better understand how as a service we can improve to ensure holistic care. RESULTS There are 40 responses. The majority of respondents had concerns about their relationship since diagnosis and that their relationships have changed. 57% were concerned about a physical relationship with a partner/ future partners. 50% agreed their physical relationship had changed. 45% of people agreeing their emotional relationships have changed. 38 out of the 40 people questioned, had not asked their clinical team for advice about sex and relationships. 46% suggested clinicians initiating these conversations. CONCLUSION Sex relationships and intimacy are significant for most adult populations, encompassing connection with their loved ones, self esteem and psychological and emotional well-being. With brain tumour diagnosis this part of people’s lives can hugely impacted. Historically clinicians have found this a difficult subject to discuss. Further work is required to understand the barriers initiating this subject
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- 2022
32. The Management and Outcomes of Butterfly Gliomas at a U.K. Neurosurgical Unit
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Siddharth Sinha, Adam Avnon, Andrea Perera, Jose Pedro Lavrador, and Keyoumars Ashkan
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS Butterfly glioblastomas (bGBM) are a rare subset of WHO grade IV tumours, that carry a poor prognosis with a median survival ranging between 3 to 6 months. Our study aims to add to the literature on how these tumours should be best managed when presenting to a neurosurgical unit. METHOD We performed a retrospective analysis from January 2009 to June 2021 of the electronic patient records of single large neurosurgical centre in London. We assessed patient demographics, initial clinical presentation, tumour characteristics (location, mutation, volumetric size), clinical management and overall survival (Kaplan-Meier estimator). RESULTS 42 cases of bGBM were identified. These patients were managed with radiotherapy alone (n=3), with biopsy +/- adjuvant therapy (n=36) or attempted surgical resection (n=3). A further 38 cases of suspected bGBM were identified based on presentation and radiological imaging, however these patients were managed conservatively and did not undergo tissue diagnosis. No significant difference in survival was seen between conservative management compared to biopsy alone, with radiotherapy only or chemotherapy only (P=0.499) However, survival was significantly increased when patients received adjuvant chemoradiotherapy following biopsy or resection (P=0.04). CONCLUSION Butterfly glioblastoma has a devastating prognosis. Our study would suggest that unless a patient completes full adjuvant therapy with both chemotherapy and radiotherapy following biopsy or resection, they should be managed conservatively. This avoids unnecessary procedural interventions and can be deemed cost saving to the NHS. A larger prospective cohort study is recommended.
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- 2022
33. Impact of Tubular Retractor-Assisted Transsulcal Minimal Invasive Parafascicular Approach for Deep-Seated Lesions in Cortical Vascularization
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Pablo de la Fuente, Kapil Rajwani, Sally Ann Price, Francesco Vergani, Keyoumars Ashkan, Richard Gullan, Ranjeev Bhangoo, and Jose Pedro Lavrador
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS Assess the impact of tubular retractor-assisted transsulcal minimal invasive parafascicular approaches(tsMIPS) in the cortical vascularization using indocianin green angiography(ICGA) during removal of deep-seated cerebral tumours. METHOD Single-centre prospective cohort study of patients with deep-seated lesions – distance to nearest sulcus > 10mm - where ICGA was performed. Zeiss FLOW800 Software was used to analyse the following variables - delay time, speed, time to peak and rise time - before and after insertion of the tubular retractor (NICO BrainPath). RESULTS 13 patients were enrolled. 60 regions-of-interest were analysed. The most common pathology was high grade glioma (69%). The average depth of tumours was 34,2mm (23– 45mm) and the time-under-retraction 166mins (45-280 mins). The most common vascular pattern before-after tubular retractor was: increase on the delay time, time to peak and rising time (present in 8 patients) and a decrease on the speed (present in 7 patients). Two patients had a mayor neurological deficit after the surgery. Both had the same flow pattern with an increase on the speed and decrease on the time to peak and rise time, the delay was indifference. CONCLUSION This is the first study assessing the impact of tubular retractor-assisted tsMIPS in cortical vascularization during deep-seated lesion resection. The most common cortical vascular pattern is: an increase on the delay time, time to peak and rising time and a decrease on the speed. The two patients who presented vascular injury shared the same pattern (increase on the speed, decrease on the time to peak and rise time, with indifference delay).
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- 2022
34. Photodynamics of Subependymal Giant Cell Astrocytoma (SEGA) with 5-Aminolevulinic Acid (5-ALA/Gliolan©)
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Imran Ghani, Sabina Patel, Istvan Bodi, Francesco Vergani, Keyoumars Ashkan, Ranjeev Bhangoo, and Jose Pedro Lavrador
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS 5-ALA (Gliolan©) is a valuable surgical tool used predominantly in high grade tumours, which utilises tissue fluorescence to improve the visualisation of the brain-tumour interface. This ensures safe maximal resection, while preserving healthy brain. While Gliolan© use in low grade tumours has previously been reported with variable results, reports of its use and success in the context of SEGA are extremely rare. This report highlights the use of Gliolan© in a patient presenting with a Subependymal Giant Cell Astrocytoma (in a background of tuberous sclerosis), facilitating maximal safe resection and preserving eloquent tissue. METHOD Tumour resection was performed with pre-operative DTI-fiber tracking and mapping. A transsulcal minimal invasive parafascicular approach (tsMIPS) was carried out with assistance of NICO BrainPath© tubular retractor system (60x13.5), neuronaviagtion, Gliolan©, intra-operative neuro monitoring (IONM), and ultrasound guidance RESULTS The tumour was found to have both bright and pale fluorescence in the cystic and solid components respectively. Resection was limited to the soft cystic component only, as the solid tumour component showed anatomical attachment to the subgenual area and the fornix. No fluorescence was perceived at the end of resection. The patient made a good recovery with no post-operative deficits. Histopathology confirmed subependymal giant cell astrocytoma (SEGA, WHO grade I). No adjuvant treatment was required CONCLUSION This reports suggests 5-ALA may be beneficial in the safe resection of SEGAs. Further studies and technological advances in the area of photodynamics, imaging, and intra-operative mapping may be helpful to fully evaluate the efficacy of 5-ALA in SEGAs and other low-grade tumours.
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- 2022
35. Exploring the Role of Specialist Physiotherapy in Awake Craniotomy Surgery for the Neuro-Oncology Patient
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Amy Jones, Sally Price, Jose Pedro Lavrador, Richard Gullan, Francesco Vergani, Ranjeev Bhangoo, Kapil Rajwani, Keyoumars Ashkan, and Ana Mirallave-pescador@nhs.net
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Cancer Research ,Oncology ,Neurology (clinical) - Abstract
AIMS To describe the methods used to assess and monitor motor function during awake craniotomy surgery for tumour resection. METHOD A service review was carried out over 10 months. Patients with highly motor eloquent lesions – invasion of primary motor cortex or fronto-parietal connections involved in motor cognition – were included. Clinical notes were reviewed and summarised using descriptive analysis. Dexterity and grip strength were measured using 9-hole peg test and handheld dynameter pre/intra and post-operatively. Patient occupation/interests were reported to guide bespoke assessments to trial intra-operatively. RESULTS From April 2021 to January 2022, 13 patients (mean age 39.7 years, 4 female:10 male, 9 low grade:5 high grade gliomas) were included. Mean score 9-hole peg test 22.2sec pre-operatively, 30.6sec post-operatively; handheld dynameter 26.7kg pre-operatively, 18.4kg post-operatively. At discharge 5 of 7 impaired patients demonstrated motor improvement. For motor coordination, motor tasks used frequently included repetitive finger tapping, open/closed hand. Bespoke tasks included texting/writing, playing instruments, and computer games. Movement was closely monitored and verbal feedback given to the neurosurgeons throughout. With video analysis movement comparisons were made. CONCLUSION The role of physiotherapy in awake surgery is evolving to provide movement analysis for complex motor tasks such as upper limb sequencing and dexterity. A combination of standard and bespoke assessments have been trialled and their feasibility within surgery tested. A post-operative deterioration of motor function (power and cognition) is expected after surgery for highly eloquent motor gliomas. However, intraoperative motor assessment for motor cognition allows function preservation and potentiates its recovery.
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- 2022
36. Deep brain stimulation-induced neuroprotection: A critical appraisal
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Keyoumars Ashkan, Maria Alexandra Velicu, and Luciano Furlanetti
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Brain Diseases ,Movement Disorders ,Deep Brain Stimulation ,Pediatrics, Perinatology and Child Health ,Brain ,Humans ,Neurology (clinical) ,General Medicine ,Neuroprotection - Abstract
Over the last two decades deep brain stimulation (DBS) has become a widely used therapeutic alternative for a variety of neurological and psychiatric diseases. The extensive experience in the field of movement disorders has provided valuable knowledge and has led the path to its application to other hard-to-treat conditions. Despite the recognised symptomatic beneficial effects, its capacity to modify the course of a disease has been in constant debate. The ability to demonstrate neuroprotection relies on a thorough understanding of the functioning of both normal and pathological neural structures, as well as their stimulation induced alterations, all of which to this date remain incomplete. Consequently, there is no consensus over the definition of neuroprotection nor its means of quantification or evaluation. Additionally, neuroprotection has been indirectly addressed in most of the literature, challenging the efforts to narrow its interpretation. As such, a broad spectrum of evidence has been considered to demonstrate disease modifying interventions. This paper aims to provide a critical appraisal of the current evidence on potential neuroprotective effects of DBS in neurodegenerative brain disorders.
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- 2021
37. Intraoperative Sneezing Secondary to Indirect Olfactory Nerve Stimulation
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Miljyot Singh Sangha, Kapil Mohan Rajwani, Ana Mirallave Pescador, Keyoumars Ashkan, Francesco Vergani, Ranjeev Bhangoo, and Jose Pedro Lavrador
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Surgery ,Neurology (clinical) - Published
- 2022
38. 5-Aminolevulinic Acid-Guided Resection in Grade III Tumors-A Comparative Cohort Study
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Asfand Baig Mirza, Jose Pedro Lavrador, Ioannis Christodoulides, Timothy Martyn Boardman, Amisha Vastani, Qusai Al Banna, Razna Ahmed, Irena C. F. Norman, Christopher Murphy, Sharmila Devi, Anastasios Giamouriadis, Francesco Vergani, Richard Gullan, Ranjeev Bhangoo, and Keyoumars Ashkan
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Adult ,Cohort Studies ,Brain Neoplasms ,Humans ,Surgery ,Neurology (clinical) ,Aminolevulinic Acid ,Glioma ,Retrospective Studies - Abstract
The benefits of using 5-aminolevulinic acid (5-ALA) in resection of grade IV tumors have been extensively researched. However, few studies have investigated the use of 5-ALA in grade III gliomas.To discover whether 5-ALA provides significant benefit in assisting resection of grade III gliomas.A single-center, retrospective cohort study between January 2013 and January 2019 of adult patients with grade III gliomas. Patients were separated into a 5-ALA-guided surgery group (5-ALA-GS) and non-5-ALA-guided surgery group (non-5-ALA-GS). Primary outcome was overall survival (OS); secondary outcomes were both postoperative and 6-month performance status (PS6m), and extent of resection (EoR).Sixty-nine patients with grade III gliomas were included (39 and 30 patients in the 5-ALA-GS group and non-5-ALA-GS group, respectively). There was no significant difference in tumor characteristics between the groups. No significant difference was observed in OS (P = .072) and EoR (P = .609) between both the groups. In a subgroup of the 5-ALA-GS where gross total resection (GTR) was achieved, there was a better OS (P = .043). Significantly worse outcomes were seen postoperatively (P = .044) and at PS6m (P = .041) in the 5-ALA-GS group, mainly because of the poorer outcome in the subtotal resection subgroup.Despite the benefits of 5-ALA in grade IV glioma surgery, these benefits are limited to a smaller group of patients with grade III tumors where there is sufficient fluorescence to allow GTR. In this cohort of patients, 5-ALA use may result in worse neurological outcomes particularly when GTR is not feasible and therefore caution is warranted.
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- 2021
39. Restricted truncal sagittal movements of rapid eye movement behaviour disorder
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Danielle Wasserman, Silvia Gullone, Iain Duncan, Mattia Veronese, Valentina Gnoni, Sean Higgins, Adam Birdseye, Emine Cigdem Gelegen, Peter J. Goadsby, Keyoumars Ashkan, K. Ray Chaudhuri, Giulio Tononi, Panagis Drakatos, and Ivana Rosenzweig
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Cellular and Molecular Neuroscience ,Neurology ,Neurology (clinical) - Abstract
Unlike sleep-walkers, patients with rapid-eye-movement-behaviour disorder (RBD) rarely leave the bed during the re-enactment of their dreams. RBD movements may be independent of spatial co-ordinates of the ‘outside-world’, and instead rely on (allocentric) brain-generated virtual space-maps, as evident by patients’ limited truncal/axial movements. To confirm this, a semiology analysis of video-polysomnography records of 38 RBD patients was undertaken and paradoxically restricted truncal/thoraco-lumbar movements during complex dream re-enactments demonstrated.
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- 2021
40. Fixed-Life or Rechargeable Batteries for Deep Brain Stimulation: Preference and Satisfaction Among Patients With Hyperkinetic Movement Disorders
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Xian Qiu, Yuhan Wang, Zhengyu Lin, Yunhao Wu, Wenying Xu, Yiwen Wu, Bomin Sun, Keyoumars Ashkan, Chencheng Zhang, and Dianyou Li
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Battery (electricity) ,medicine.medical_specialty ,Movement disorders ,Deep brain stimulation ,medicine.medical_treatment ,Tourette syndrome ,03 medical and health sciences ,0302 clinical medicine ,Medicine ,hyperkinetic movement disorders ,RC346-429 ,Implanted device ,030304 developmental biology ,Original Research ,Dystonia ,0303 health sciences ,business.industry ,medicine.disease ,Patient preference ,implantable pulse generators ,Preference ,deep brain stimulation ,Neurology ,Physical therapy ,movement disorders ,dystonia ,Neurology. Diseases of the nervous system ,Neurology (clinical) ,medicine.symptom ,business ,030217 neurology & neurosurgery - Abstract
Background: Deep brain stimulation (DBS) is an established treatment for hyperkinetic movement disorders. Patients undergoing DBS can choose between the use of a rechargeable or non-rechargeable battery for implanted pulse generators (IPG).Objectives: In this study, we aimed to evaluate patient preferences and satisfaction with rechargeable and non-rechargeable batteries for IPGs after undergoing DBS.Methods: Overall, 100 patients with hyperkinetic movement disorders (dystonia: 79, Tourette syndrome: 21) who had undergone DBS took a self-designed questionnaire to assess their satisfaction and experience with the type of battery they had chosen and the factors influencing their choice.Results: Of the participants, 87% were satisfied with the stimulating effects of the treatment as well as the implanted device; 76% had chosen rechargeable devices (r-IPGs), 71.4% of whom recharged the battery themselves. Economic factors were the main reason for choosing both r-IPG and non-rechargeable IPG (nr-IPG). The questionnaire revealed that 66% of the patients checked their r-IPG battery every week. The mean interval for battery recharge was 4.3 days.Conclusions: The majority of the patients were satisfied with their in-service-IPG, regardless of whether it was a r-IPG or nr-IPG. Affordability was the main factor influencing the choice of IPG. The majority of the patients were confident in recharging the battery of their r-IPG themselves; only 11% of patients experienced difficulties. Understanding the recharge process remains difficult for some patients and increasing the number of training sessions for the device may be helpful.
- Published
- 2021
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41. Multicellular 'hotspots' harbor high-grade potential in lower-grade gliomas
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Gerald T. Finnerty, Alastair J Kirby, José Pedro Lavrador, Keyoumars Ashkan, Istvan Bodi, Ranjeev Bhangoo, and Francesco Vergani
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0301 basic medicine ,IDH1 ,Angiogenesis ,glia ,Brain tumor ,Biology ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Glioma ,medicine ,nestin ,AcademicSubjects/MED00300 ,Protoporphyrin IX ,vessel co-option ,Human brain ,Nestin ,malignant progression ,medicine.disease ,030104 developmental biology ,medicine.anatomical_structure ,Oncology ,chemistry ,030220 oncology & carcinogenesis ,Basic and Translational Investigations ,Cancer research ,Surgery ,AcademicSubjects/MED00310 ,Neurology (clinical) ,Ex vivo ,brain tumor - Abstract
BackgroundLower-grade gliomas may be indolent for many years before developing malignant behavior. The mechanisms underlying malignant progression remain unclear.MethodsWe collected blocks of live human brain tissue donated by people undergoing glioma resection. The tissue blocks extended through the peritumoral cortex and into the glioma. The living human brain tissue was cut into ex vivo brain slices and bathed in 5-aminolevulinic acid (5-ALA). High-grade glioma cells avidly take up 5-ALA and accumulate high levels of the fluorescent metabolite, Protoporphyrin IX (PpIX). We exploited the PpIX fluorescence emitted by higher-grade glioma cells to investigate the earliest stages of malignant progression in lower-grade gliomas.ResultsWe found sparsely distributed “hot-spots” of PpIX-positive cells in living lower-grade glioma tissue. Glioma cells and endothelial cells formed part of the PpIX hotspots. Glioma cells in PpIX hotspots were IDH1 mutant and expressed nestin suggesting they had acquired stem-like properties. Spatial analysis with 5-ALA-conjugated quantum dots indicated that these glioma cells replicated adjacent to blood vessels. PpIX hotspots were formed in the absence of angiogenesis.ConclusionOur data show that PpIX hotspots represent microdomains of cells with high-grade potential within lower-grade gliomas and identify locations where malignant progression could start.
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- 2021
42. Deep brain stimulation for phantom limb pain
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David Pang and Keyoumars Ashkan
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Adult ,Phantom Limb ,Deep Brain Stimulation ,Pediatrics, Perinatology and Child Health ,Motor Cortex ,Humans ,Pain Management ,Neurology (clinical) ,General Medicine ,Child - Abstract
Phantom limb pain is a rare cause of chronic pain in children but it is associated with extremely refractory pain and disability. The reason for limb amputation is often due to treatment for cancer or trauma and it has a lower incidence compared to adults. The mechanism of why phantom pain exists remains uncertain and may be a result of cortical reorganisation as well as ectopic peripheral input. Treatment is aimed at reducing both symptoms as well as managing pain related disability and functional restoration. Neuromodulatory approaches using deep brain stimulation for phantom limb pain is reserved for only the most refractory cases. The targets for brain stimulation include the thalamic nuclei and motor cortex. Novel targets such as the anterior cingulate cortex remain experimental as cases of serious adverse effects such as seziures have limited their widespread uptake. A multidisciplinary approach is crucial to successful rehabilitation using a biopsychosocial pain management approach.
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- 2021
43. An audit on the diagnosis of primary CNS lymphoma
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Ranjeev Bhangoo, José-Pedro Lavrador, Lucia Yin, Gerald T. Finnerty, Katia Cikurel, Keyoumars Ashkan, Dorothy Joe, Shireen Kassam, Richard Gullan, and Francesco Vergani
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Oncology ,Cancer Research ,medicine.medical_specialty ,business.industry ,BNOS 2021 Abstracts ,Audit ,Primary CNS Lymphoma ,hemic and lymphatic diseases ,Internal medicine ,Oral Presentations ,medicine ,AcademicSubjects/MED00300 ,AcademicSubjects/MED00310 ,Neurology (clinical) ,business - Abstract
Aims Primary central nervous system lymphoma (PCNSL) is a rare form of non–Hodgkin lymphoma with exclusive manifestations in the central nervous system, leptomeninges and eyes. It forms around 5% of all primary brain tumours. It is an aggressive tumour which has a poor prognosis if left untreated. It is imperative that diagnosis is made timely so treatment can be started promptly. Therefore, we performed an audit looking into the speed of diagnostic process of PCNSL in our tertiary Neuro–oncology Unit. Method Single-centre retrospective review of PCNSL cases referred to a tertiary Neuro–Oncology Unit over a six month period from June to November 2020. Results A total of 1309 cases were discussed in the Neuro–oncology MDT meeting over the study period. Fourteen cases (6 male, 8 female; median age [range] 66 [59–83] years) were identified as highly likely PCNSL. Neuroimaging suggested PCNSL as the likely diagnosis in twelve patients. Twelve patients were started on steroids after CT or MRI brain scans. Nine patients had a surgical target and proceeded to have diagnostic brain biopsy. Two patients had different working diagnoses and three patients were deemed unsuitable for brain surgery. One patient required repeat brain biopsy. A tissue diagnosis was made in twelve patients. One patient deteriorated rapidly and one patient had a brain lesion that was deemed too high risk for surgery. The median time between neuroimaging and biopsy was 25 days. The median time taken from first investigation to the pathological confirmation of PCNSL was 36 days (range 6–86 days). Conclusion The chief reason for delay in diagnosis of PCNSL was that patients were started on steroids before diagnostic investigations were completed. Steroids caused the brain lesions to become smaller or disappear. Accordingly, time was needed to allow withdrawal of steroids before diagnostic investigations could be repeated. Diagnostic delays may have been exacerbated by logistical issues associated with COVID–19. We propose that there needs to be greater awareness of how early introduction of steroids can markedly delay the diagnosis of PCNSL.
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- 2021
44. Preoperative and intraoperative anatomical-functional mapping in insular glioma surgery: integrated model to improve surgical outcome
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Francesco Vergani, Ranjeev Bhnagoo, Keyoumars Ashkan, Richard Gullan, José Pedro Lavrador, and Prajwal Ghimire
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Cerebral Cortex ,medicine.medical_specialty ,Brain Mapping ,Intra operative ,business.industry ,Brain Neoplasms ,Glioma surgery ,Glioma ,Outcome (game theory) ,Pre operative ,Surgery ,Functional mapping ,Treatment Outcome ,medicine ,Humans ,Neurology (clinical) ,business - Published
- 2021
45. Middle Frontal Gyrus and Area 55b: Perioperative Mapping and Language Outcomes
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Sally Rosario Hazem, Mariam Awan, Jose Pedro Lavrador, Sabina Patel, Hilary Margaret Wren, Oeslle Lucena, Carla Semedo, Hassna Irzan, Andrew Melbourne, Sebastien Ourselin, Jonathan Shapey, Ahilan Kailaya-Vasan, Richard Gullan, Keyoumars Ashkan, Ranjeev Bhangoo, and Francesco Vergani
- Subjects
medicine.medical_specialty ,Tumor resection ,Inferior frontal gyrus ,Audiology ,lcsh:RC346-429 ,nTMS ,medicine ,Middle frontal gyrus ,perioperative mapping ,speech arrest ,language network ,lcsh:Neurology. Diseases of the nervous system ,Original Research ,business.industry ,Perioperative ,area 55b ,language mapping ,Neurology ,Superior frontal gyrus ,DTI ,TMS ,Neurology (clinical) ,business ,Language network ,Tractography ,Cohort study - Abstract
Background:The simplistic approaches to language circuits are continuously challenged by new findings in brain structure and connectivity. The posterior middle frontal gyrus and area 55b (pFMG/area55b), in particular, has gained a renewed interest in the overall language network.Methods:This is a retrospective single-center cohort study of patients who have undergone awake craniotomy for tumor resection. Navigated transcranial magnetic simulation (nTMS), tractography, and intraoperative findings were correlated with language outcomes.Results:Sixty-five awake craniotomies were performed between 2012 and 2020, and 24 patients were included. nTMS elicited 42 positive responses, 76.2% in the inferior frontal gyrus (IFG), and hesitation was the most common error (71.4%). In the pMFG/area55b, there were seven positive errors (five hesitations and two phonemic errors). This area had the highest positive predictive value (43.0%), negative predictive value (98.3%), sensitivity (50.0%), and specificity (99.0%) among all the frontal gyri. Intraoperatively, there were 33 cortical positive responses—two (6.0%) in the superior frontal gyrus (SFG), 15 (45.5%) in the MFG, and 16 (48.5%) in the IFG. A total of 29 subcortical positive responses were elicited−21 in the deep IFG–MFG gyri and eight in the deep SFG–MFG gyri. The most common errors identified were speech arrest at the cortical level (20 responses−13 in the IFG and seven in the MFG) and anomia at the subcortical level (nine patients—eight in the deep IFG–MFG and one in the deep MFG–SFG). Moreover, 83.3% of patients had a transitory deterioration of language after surgery, mainly in the expressive component (p= 0.03). An increased number of gyri with intraoperative positive responses were related with better preoperative (p= 0.037) and worse postoperative (p= 0.029) outcomes. The involvement of the SFG–MFG subcortical area was related with worse language outcomes (p= 0.037). Positive nTMS mapping in the IFG was associated with a better preoperative language outcome (p= 0.017), relating to a better performance in the expressive component, while positive mapping in the MFG was related to a worse preoperative receptive component of language (p= 0.031).Conclusion:This case series suggests that the posterior middle frontal gyrus, including area 55b, is an important integration cortical hub for both dorsal and ventral streams of language.
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- 2021
46. Low-Grade Glioma Case Series: Lessons Learned from an Evolving 10-Year Single-Institution Multidisciplinary Team Practice
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Ranjeev Bhangoo, Josephine Jung, Shami Acharya, Keyoumars Ashkan, José Pedro Lavrador, Priya Sekhon, Ravindran Visagan, Francesco Vergani, and Richard Gullan
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Adult ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,Biopsy ,Risk Assessment ,Neurosurgical Procedures ,Cohort Studies ,03 medical and health sciences ,Disability Evaluation ,0302 clinical medicine ,Postoperative Complications ,Glioma ,medicine ,Adjuvant therapy ,Grade II Glioma ,Humans ,Radical surgery ,Retrospective Studies ,Patient Care Team ,Series (stratigraphy) ,medicine.diagnostic_test ,business.industry ,Brain Neoplasms ,General surgery ,Margins of Excision ,Chemoradiotherapy, Adjuvant ,Middle Aged ,medicine.disease ,Survival Analysis ,Radiation therapy ,Treatment Outcome ,030220 oncology & carcinogenesis ,Surgery ,Female ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Cohort study ,Follow-Up Studies - Abstract
Low-grade gliomas are a heterogeneous group with significant changes in their management during the last decade.To assess how our multidisciplinary team approach to the management of low-grade glioma has evolved over the past 10 years and its implications for outcomes.Retrospective single-center cohort study of adult patients with a pathologically confirmed diagnosis of World Health Organization grade II glioma between 2009 and 2018. Demographic, clinical, and pathologic data were collected.Ninety-five patients were included. There was a statistically significant difference in the surgical approach, with more patients having gross total resection (45.7% vs. 18.4%) and fewer patients having a biopsy (21.8% vs. 49.0%) (P = 0.002) after 2014. There was a significantly better overall survival after 2014 (2014, 16.3%; ≥2014, 0 deaths; P = 0.010) measured at the mean time of follow-up. The use of adjuvant chemotherapy (P = 0.045) and radiotherapy (P = 0.001) significantly decreased after 2014. A subgroup analysis showed that the impact of extent of surgical resection was the greatest for survival in the 1p19q noncodeleted tumors (P = 0.029) and for seizure outcomes in the 1p19q codeleted group (P = 0.018). There was no statistically significant increase in neurologic disability with more radical surgery, incorporating intraoperative neuromonitoring, as measured by modified Rankin Scale score (P0.05).More radical surgery was associated with increased survival, less need for postoperative adjuvant therapy and better seizure control, without significant morbidity. Molecular markers are useful tools for stratification of benefits after such surgery.
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- 2021
47. Comparison of direct MRI guided versus atlas-based targeting for subthalamic nucleus and globus pallidus deep brain stimulation
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Harutomo Hasegawa, Nilesh Mundil, Keyoumars Ashkan, Mariane Melo, and Luciano Furlanetti
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Dystonia ,Parkinson's disease ,Deep brain stimulation ,business.industry ,medicine.medical_treatment ,General Medicine ,Globus pallidus internus ,medicine.disease ,03 medical and health sciences ,Subthalamic nucleus ,0302 clinical medicine ,medicine.anatomical_structure ,Globus pallidus ,Atlas (anatomy) ,030220 oncology & carcinogenesis ,medicine ,Surgery ,Neurology (clinical) ,business ,Neuroscience ,030217 neurology & neurosurgery ,Mri guided - Abstract
Purpose: The subthalamic nucleus (STN) and globus pallidus internus (GPi) targets for deep brain stimulation (DBS) can be defined by atlas coordinates or direct visualisation of the target on MRI. ...
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- 2021
48. Subthalamic Stimulation Improves Quality of Sleep in Parkinson Disease: A 36-Month Controlled Study
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Europar, Anna Sauerbier, Philipp Alexander Loehrer, Pablo Martinez-Martin, Jan Niklas Petry-Schmelzer, Michael T. Barbe, Veerle Visser-Vandewalle, Gereon R. Fink, Keyoumars Ashkan, Alexandra Rizos, Lars Timmermann, K. Ray Chaudhuri, Haidar S. Dafsari, Stefanie T Jost, Angelo Antonini, Monty Silverdale, and Julian Evans
- Subjects
0301 basic medicine ,Male ,Sleep Wake Disorders ,medicine.medical_specialty ,Deep brain stimulation ,Parkinson's disease ,medicine.medical_treatment ,Dopamine Agents ,Scopa ,Anxiety ,Hospital Anxiety and Depression Scale ,03 medical and health sciences ,Cellular and Molecular Neuroscience ,0302 clinical medicine ,Quality of life ,Outcome Assessment, Health Care ,medicine ,nonmotor symptoms ,quality of life ,sleep dysfunction ,subthalamic nucleus ,Humans ,Longitudinal Studies ,ddc:610 ,Aged ,business.industry ,Depression ,Parkinson Disease ,Middle Aged ,medicine.disease ,nervous system diseases ,030104 developmental biology ,surgical procedures, operative ,Propensity score matching ,Physical therapy ,Observational study ,Female ,Neurology (clinical) ,medicine.symptom ,business ,030217 neurology & neurosurgery ,Follow-Up Studies - Abstract
Background: Sleep disturbances and neuropsychiatric symptoms are some of the most common nonmotor symptoms in Parkinson’s disease (PD). The effect of subthalamic stimulation (STN-DBS) on these symptoms beyond a short-term follow-up is unclear. Objective: To examine 36-month effects of bilateral STN-DBS on quality of sleep, depression, anxiety, and quality of life (QoL) compared to standard-of-care medical therapy (MED) in PD. Methods: In this prospective, controlled, observational, propensity score matched, international multicenter study, we assessed sleep disturbances using the PDSleep Scale-1 (PDSS), QoL employing the PDQuestionnaire-8 (PDQ-8), motor disorder with the Scales for Outcomes in PD (SCOPA), anxiety and depression with the Hospital Anxiety and Depression Scale (HADS), and dopaminergic medication requirements (LEDD). Within-group longitudinal outcome changes were tested using Wilcoxon signed-rank and between-group longitudinal differences of change scores with Mann-Whitney U tests. Spearman correlations analyzed the relationships of outcome parameter changes at follow-up. Results: Propensity score matching applied on 159 patients (STN-DBS n = 75, MED n = 84) resulted in 40 patients in each treatment group. At 36-month follow-up, STN-DBS led to significantly better PDSS and PDQ-8 change scores, which were significantly correlated. We observed no significant effects for HADS and no significant correlations between change scores in PDSS, HADS, and LEDD. Conclusions: We report Class IIb evidence of beneficial effects of STN-DBS on quality of sleep at 36-month follow-up, which were associated with QoL improvement independent of depression and dopaminergic medication. Our study highlights the importance of sleep for assessments of DBS outcomes.
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- 2021
49. Inter-dural spinal cyst with acute thoracic compressive myelopathy: anatomical aspects of spinal dura, case report and literature review
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Istvan Bodi, José Pedro Lavrador, Prajwal Ghimire, Jozef Jarosz, Andrea Perera, Gordan Grahovac, and Keyoumars Ashkan
- Subjects
musculoskeletal diseases ,Pathology ,medicine.medical_specialty ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Spinal cyst ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,food and beverages ,General Medicine ,medicine.disease ,Spinal disease ,Ganglion cyst ,03 medical and health sciences ,0302 clinical medicine ,Compressive myelopathy ,030220 oncology & carcinogenesis ,parasitic diseases ,Medicine ,Synovial cyst ,Surgery ,Neurology (clinical) ,business ,030217 neurology & neurosurgery - Abstract
Inter-dural juxta-facet spinal cysts occur rarely. They form as part of the degenerative spinal disease process and can be misdiagnosed as synovial cysts or ganglion cysts. We report the case of a thoracic inter-dural juxta-facet spinal cyst causing acute compressive thoracic myelopathy.The data was collected retrospectively from patient records. The literature review was performed in PubMed.We report a case of symptomatic inter-dural juxta-facet thoracic spinal cyst. The literature review showed a variety of different spinal cysts including arachnoid cyst, discal cyst, ganglion cyst, epidermoid cyst and synovial cysts. Micro-instability and repeated microtrauma associated with degenerative changes are most likely contributors to its formation. Asymptomatic cysts can show spontaneous resolution. When symptomatic, they can be managed with surgical excision with good patient outcome.Inter-dural spinal cysts can be diagnosed and surgically excised to produce excellent post-operative outcome. High pre-operative index of suspicion of this diagnosis together with good understanding of the intraoperative anatomy are essential to avoid inadvertent dural breach.
- Published
- 2020
50. In Reply: Altered Motor Excitability in Patients With Diffuse Gliomas Involving Motor Eloquent Areas: The Impact of Tumor Grading
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José Pedro Lavrador, Ifigeneia Gioti, Szymon Hoppe, Josephine Jung, Sabina Patel, Richard Gullan, Keyoumars Ashkan, Ranjeev Bhangoo, and Francesco Vergani
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Brain Neoplasms ,Motor Cortex ,Humans ,Surgery ,Neurology (clinical) ,Glioma ,Neoplasm Grading - Published
- 2020
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