Search

Background: Surgical innovation is different from the introduction of novel pharmaceuticals. To help address this, in 2009 the IDEAL Collaboration (Idea, Development, Exploration, Assessment, Long-term follow-up) introduced the five-stage framework for surgical innovation. To evaluate the framework feasibility for novel neurosurgical procedure introduction, two innovative surgical procedures were examined: the endoscopic endonasal approach for skull base meningiomas (EEMS) and the WovenEndobridge (WEB device) for endovascular treatment of intracranial aneurysms. Methods: The published literature on EEMS and WEB devices was systematically reviewed. Identified studies were classified according to the IDEAL framework stage. Next, studies were evaluated for possible categorization according to the IDEAL framework. Results: Five hundred seventy-six papers describing EEMS were identified of which 26 papers were included. No prospective studies were identified, and no studies reported on ethical approval or patient informed consent for the innovative procedure. Therefore, no clinical studies could be categorized according to the IDEAL Framework. For WEB devices, 6229 articles were screened of which 21 were included. In contrast to EEMS, two studies were categorized as 2a and two as 2b. Conclusion: The results of this systematic review demonstrate that both EEMS and WEB devices were not introduced according to the (later developed in the case of EEMS) IDEAL framework. Elements of the framework such as informed consent, ethical approval, and rigorous outcomes reporting are important and could serve to improve the quality of neurosurgical research. Alternative study designs and the use of big data could be useful modifications of the IDEAL framework for innovation in neurosurgery.

BACKGROUND: Meningioma are common benign intracranial tumours, that can cause severe neurological and daily functional problems, sometimes requiring lifelong care and support. Current practice and guidelines lack focus on these long-term sequelae. Value-Based Healthcare (VBHC) initiatives aim to increase the value of care for patients, but continuous evaluation and improvement of these initiatives is required. According to the Plan-Do-Study-Act (PDSA) cycle, a model for continuous healthcare evaluation and improvement, we explored issues in meningioma care trajectories, possible high impact initiatives to improve these issues, and the implementability of these initiatives. MATERIAL AND METHODS: Previously, issues in the meningioma care trajectories were identified through a survey by The Netherlands Comprehensive Cancer Organisation. Using a grounded theory approach, a thematic framework was constructed based on this data and used for further data collection through three semi-structured interviews with patient-partner dyads (i.e. pairs) and four focus groups with patient-partner dyads and healthcare providers (both two focus groups). RESULTS: Issues in meningioma care trajectories reported by patient-partner dyads and healthcare providers were related to information, care and support, logistics, and diagnostics and treatment. Most important issues were lack of information about intervention and outcomes, and lack of support after treatment. A reported solution for many issues was the incorporation of a case manager. Other possible solutions were implementation of routine use of patient-reported outcome measures (PROMs) or a rehabilitation program, and formalization of these care trajectories. The most important barriers for these solutions were budget, capacity, ICT infrastructure, qualified personnel, and know-how. CONCLUSION: Implementation of a few simple solutions (e.g. case manager) may improve the majority of experienced issues in meningioma care trajectories. Information on the identified barriers and facilitators can be used to ensure successful implementation of these practice changing initiatives, which need iterative evaluation in PDSA cycles.

Cerebellar haemorrhage is an unusual complication of supratentorial neurosurgery. Several causative pre-operative factors and medical risk factors may predispose patients to cerebellar haemorrhage, however its etiology remains still unclear. Only two case reports have previously described the occurrence of cerebellar haemorrhage after subdural haematoma evacuation by burr-hole trepanation. We present two patients with this rare postoperative complication of minor supratentorial neurosurgery and possible underlying pathophysiological mechanisms are discussed. Our two cases support the post- rather than per-operative pathogenetic hypothesis. Although the complication is associated with a significant morbidity and mortality, most cases follow a benign course.

In recent years much has become known about the substrates in the brain involved in the regulation of masculine sexual behavior and the involvement of specific neurochemicals in these brain areas. In the present paper the experimental data concerning the involvement of a number of brain areas in sexual behavior are reviewed, in relation to an incentive motivational theory of sexual behavior. The review is restricted to the involvement of opioids and dopamine, of which the role in sexual motivation and behavior is best documented. Opioids in the medial preoptic area (mPOA) impair sexual performance, although the endogenous opioids systems may be quiescent in normal, sexually active rats. Dopamine in the mPOA has a facilitative role in the masculine sexual performance. The corticomedial amygdala is involved in processing of sensory information, especially olfactory stimuli, which are subsequently directed towards the mPOA. Local β-endorphin infusion interferes with this processing. Endogenous opioids in the ventral tegmental area activate the mesoaccumbens dopamine system and stimulate the sexual motivation. Increased dopamine transmission in the nucleus accumbens correlates with increased sexual motivation and vice versa. The basolateral amygdala plays an essential role in the association of environmental stimuli with reward and therefore in the expression of conditioned sexual motivation. Finally, the reviewed data are integrated and a comprehensive view on the relations between various neural substrates is composed.

Background:A vast number of generic and disease specific questionnaires are used to measure health-related quality of life (HRQoL) in meningioma research. We aimed to assess the relevance of issues mentioned in these questionnaires and to compare the patient’s perspective with the perspective of the health care professional (HCP) on meningioma-related symptoms and problems.Methods:A systematic literature search was conducted to identify all HRQoL items and questionnaires. Both patients and HCPs had to rate the relevance of each item on a 4-point Likert scale (ranging from ‘not at all’ to ‘very much’): items were relevant when ≥ 30% of patients or HCPs scored the items as relevant. For each questionnaire the percentage of relevant items was assessed. All identified items were categorized into different domains of HRQoL, which were discussed in semi-structured interviews with both groups. The aim of these interviews was to reveal all issues of meningioma patients, including issues not present in the existing questionnaires.Results:Included in this study were 14 patients (mean age 56 years, 71% female) and 7 HCPs (2 neurosurgeons, 2 neurologists, 2 radiotherapists, 1 rehabilitation specialist, mean experience 15 years). Fourteen different questionnaires were found in the literature, including 140 unique issues. Patients and HCPs considered 25–60% and 90–100% of the items of each questionnaire as relevant, respectively. When comparing the 12 most relevant issues as assessed by meningioma patients and HCPs, only 5 issues were the same. Issues missing in the already existing questionnaires were mostly issues in the psychological and cognitive domains (e.g. multitasking and stress-management).Conclusion:Existing HRQoL questionnaires do not fully cover the problems of meningioma patients. Patients and HCPs differ in opinion what the most relevant issues are of meningioma patients. Both findings support the need to develop and validate an HRQoL questionnaire specific for meningioma patients.

Objective: Postoperative radiotherapy is standard treatment for patients with a glioblastoma multiforme (GBM). However, a GBM is radioresistant and almost always recurs, even after a high dose of radiation. A GBM is characterized by its extensive neo-angiogenesis, which can be attributed to the high levels of vascular endothelial growth factor (VEGF). The scope of this study is to investigate the VEGF secretion by GBM cells with different radiosensitivity after irradiation. Methods:Three human GBM cell lines (U251, U251-NG2 and U87) were irradiated with single doses of 0, 5, 10 and 20 Gy of gamma(3)-rays from a Cs-137 source. VEGF levels in medium were measured by ELISA at 24, 48 and 72 h after radiation. Cell survival was measured by the XTT assay 7 days after irradiation. Results:Following single dose radiation, the VEGF levels showed a dose dependent increase in U251, U251-NG2 and U87 glioma cells. Both base-line and radiation-enhanced VEGF levels were about 10-fold higher in U87 compared to U251 and U251-NG2 cells. In addition, in the XTT assay, the U87 was more radioresistant than both U251 and U251-NG2 cell lines (dose modifying factor (DMF) = 1.6 and 1.7 resp). Conclusion:Irradiation enhanced VEGF secretion in all three tested glioma cell lines (up to eight times basal levels). It is tempting to associate the radiation-enhanced VEGF secretion with an increased angiogenic potential of the tumor, which may be a factor in radioresistance