RESUMEN

SUMMARY: Atypical teratoid/rhabdoid tumor (AT/RT) is a highly malignant central nervous system neoplasm usually seen in young children and infants. Prognosis for AT/RT is poor, with most patients dying within 1 year of presentation. AT/RT most commonly occurs intracranially. Location in the spine, though previously reported, is rare, and imaging findings have not been emphasized in the past. We present a case of AT/RT occurring in the thoracolumbar spine of a child and review available clinical and imaging findings in previously reported cases of spinal AT/RT.

Asunto(s)

RESUMEN

STUDY DESIGN: A case series of 12 patients who underwent spine surgery in an intraoperative magnetic resonance imager (IMRI). OBJECTIVES: To determine the advantages, limitations, and potential applications to spine surgery of the IMRI. SUMMARY OF BACKGROUND DATA: Existing stereotactic navigational systems are limited because images are obtained before surgery and are not updated to reflect intraoperative changes. In addition, they necessitate manual registration of fiducial landmarks on the patient's anatomy by the surgeon to the previously obtained image data set, which is a potential source of error. The IMRI eliminates these difficulties by using intraoperative acquisition of MRI images for surgical navigation with the capacity for both image update and image-guided frameless stereotaxy. The IMRI is a novel cryogenless superconducting magnet with an open configuration that allows the surgeon full access to the patient during surgery and intraoperative imaging. METHODS: T1- and T2-weighted fast spin echo images were obtained for localization, after surgical exposure and after decompression during the course of 12 spine surgeries performed in the IMRI. RESULTS: The authors performed a series of 12 procedures in the IMRI that included three lumbar discectomies, three anterior cervical discectomies with allograft fusion, three cervical vertebrectomies with allograft fusion, two cervical foraminotomies, and one decompressive cervical laminectomy. The system provided rapid and accurate localization in all cases. The adequacy of decompression by MRI during surgery was confirmed in 10 of 12 cases. CONCLUSIONS: The IMRI provided accurate and rapid localization in all cases and confirmed the adequacy of decompression in the majority of cases. Future applications of the IMRI to spine surgery may include intraoperative guidance for resection of spine and spinal cord tumors and trajectory planning for spinal endoscopy or screw fixation.

Asunto(s)

RESUMEN

OBJECTIVE: To assess the application accuracy of intraoperative magnetic resonance imaging for frameless stereotactic surgery, and to evaluate the performance of intraoperative magnetic resonance imaging for the brain biopsy, a standard stereotactic procedure. METHODS: A series of spatial coordinate and phantom experiments were performed to analyze the application accuracy of the system. A prospective analysis of 68 consecutive patients undergoing stereotactic brain biopsy was then performed. RESULTS: The spatial coordinate experiments revealed a mean overall error in acquisition of 0.2 mm. The phantom experiments demonstrated a 1:1 correlation between the magnetic resonance image of a stereotactically guided probe and its relationship to a target and the actual relationship of the probe and target. Sixty-eight brain biopsies were successfully performed in all intracranial compartments except the sella. The radiographic abnormality was localized successfully in all patients (100%). Sixty-six (97.1%) of the biopsies yielded diagnostic tissue. Two biopsies (2.9%) were complicated by intraparenchymal hemorrhage. One expanding temporal lobe hemorrhage was evacuated by immediate craniotomy in the magnet with no postoperative sequelae. A deep hemorrhage from a lymphoma was managed conservatively with interval resolution of symptoms. There were no infections. There was no perioperative mortality. CONCLUSION: Intraoperative magnetic resonance imaging allows excellent target localization, provides true real-time imaging to account for anatomic changes during surgery, and permits intraoperative confirmation that the biopsy needle has reached the targeted lesion. Immediate postoperative imaging in the operating room allows assessment of adverse events and the potential for immediate management of hemorrhagic complications.

Asunto(s)

RESUMEN

PURPOSE: To review preliminary experience with an open-bore magnetic resonance (MR) imaging system for guidance in intracranial surgical procedures. MATERIALS AND METHODS: A vertically oriented, open-configuration 0.5-T MR imager was housed in a sterile procedure room. Receive and transmit surface coils were wrapped around the patient's head, and images were displayed on monitors mounted in the gap of the magnet and visible to surgeons. During 2 years, 200 intracranial procedures were performed. RESULTS: There were 111 craniotomies, 68 biopsies, 12 intracranial cyst evaluations, four subdural drainages, and five transsphenoidal pituitary resections performed with the intraoperative MR unit. In each case, the intraoperative MR system yielded satisfactory results by allowing the radiologist to guide surgeons toward lesions and to assist in treatment. In two patients, hyperacute hemorrhage was noted and removed. The duration of the procedure and the complication rate were similar to those of conventional surgery. CONCLUSION: Intraoperative MR imaging was successfully implemented for a variety of intracranial procedures and provided continuous visual feedback, which can be helpful in all stages of neurosurgical intervention without affecting the duration of the procedure or the incidence of complications. This system has potential advantages over conventional frame-based and frameless stereotactic procedures with respect to the safety and effectiveness of neurosurgical interventions.

Asunto(s)

RESUMEN

OBJECTIVE: We used three-dimensional reconstructed magnetic resonance images for planning the operations of 16 patients with various cerebrovascular diseases. We studied the cases of these patients to determine the advantages and current limitations of our computer-assisted surgical planning system as it applies to the treatment of vascular lesions. METHODS: Magnetic resonance angiograms or thin slice gradient echo magnetic resonance images were processed for three-dimensional reconstruction. The segmentation, based on the signal intensities and voxel connectivity, separated each anatomic structure of interest, such as the brain, vessels, and skin. A three-dimensional model was then reconstructed by surface rendering. This three-dimensional model could be colored, made translucent, and interactively rotated by a mouse-controlled cursor on a workstation display. In addition, a three-dimensional blood flow analysis was performed, if necessary. The three-dimensional model was used to assist in three stages of surgical planning, as follows: 1) to choose the best method of intervention, 2) to evaluate surgical risk, 3) to select a surgical approach, and 4) to localize lesions. RESULTS: The generation of three-dimensional models allows visualization of pathological anatomy and its relationship to adjacent normal structures, accurate lesion volume determination, and preoperative computer-assisted visualization of alternative surgical approaches. CONCLUSION: Computer-assisted surgical planning is useful for patients with cerebrovascular disease at various stages of treatment. Lesion identification, therapeutic and surgical option planning, and intraoperative localization are all enhanced with these techniques.

Asunto(s)

RESUMEN

OBJECTIVE: We have treated patients with brain surface tumors by using video registration of a three-dimensional image to the surgical field, to identify eloquent cortices, localize the lesions, and define the tumor margins. "Skin-to-skin" registration using the skin surface to produce alignment was performed earlier but was difficult in areas with few prominent registration landmarks. For this reason, "vessel-to-vessel" registration using the cortical vessels as fiducials was applied to 17 cases, to improve accuracy. This article presents the advantages and limitations of vessel-to-vessel registration, as determined from the data for these cases. The accuracy is also estimated. METHODS: A three-dimensional model was reconstructed from magnetic resonance imaging data, and a two-dimensional projection was superimposed on the video image of the actual surgical field. The tumor was resected with guidance from the registered video image. The two-dimensional projection accuracy of vessel-to-vessel registration was compared with that of skin-to-skin registration by using a phantom study. RESULTS: All 17 tumors underwent gross total resection, and the patients experienced no major permanent neurological deficits. In the phantom study, the two-dimensional, projected, target registration error of a tumor with skin-to-skin registration was estimated as 8.9 +/- 5.3 mm and that with vessel-to-vessel registration was 1.3 +/- 1.4 mm (99th percentile confidence intervals, 24.8 and 5.5 mm, respectively). CONCLUSION: Video registration using cortical surface vessels is practical and improves two-dimensional projection accuracy significantly, compared with skin registration.

Asunto(s)

RESUMEN

OBJECTIVE: We have worked in conjunction with scientists from the General Electric Corporation over 6 years to develop an open-bore MR imaging system (0.5 T) enabling optimal vertical access of surgeon and assistant to the patient, and real-time imaging during major neurosurgical procedures. METHODS: The intraoperative MR system (MRT) is located in a specially modified operative suite that combines the features of an MR-imaging suite with a fully functional operating room. An MR-compatible anesthesia machine and patient-monitoring device are located next to the magnet. The position of instruments, platforms and supports may be mapped in the operative field using 3 charge-coupled device video cameras mounted in the overhead support truncheon that follow various light-emitting diodes on the devices (Pixsys). The MR image plane can be defined as the axial, coronal or sagittal views through a point along the vector beneath the Pixsys tripod. A variety of surface coils were designed to take full advantage of full open patient access. The software, implemented by a technologist located outside the MR room, is now equivalent to that available on the commercial 0.5-tesla Signa Advantage system. Development of very robust 3-dimensional software in conjunction with the Surgical Planning Laboratory (SPL) at the Brigham & Women's Hospital is the subject of significant effort. The MRT system has been shown to possess imaging capabilities comparable, or even slightly superior (by 10%), to a conventional 0.5-tesla MR scanner. Two modified liquid-crystal display screens are mounted on the magnet housing for the surgeon to monitor the images during the procedures. Projection into larger screens or the operating microscope is under development. RESULTS: We have performed 110 neurosurgical cases in MRT as of January 29, 1997, including 47 biopsies, 6 catheter placements, 4 cyst drainages, 47 craniotomies for resection, 3 spinal cases (1 syrinx drainage), and 3 laser tumor ablations. CONCLUSIONS: MRT is especially useful in guiding biopsies and resections near cysts, ventricles and critical vascular structures where preoperative images with framed/frameless techniques would be inadequate to show anatomic changes during the procedure. Real-time images of a biopsy needle within the abnormal area are very useful in cases of subtle pathologic change. More complete resection of infiltrative tumor is readily accomplished. SPL image fusion of SPECT and neurofunctional data (e.g. from magnetic stimulation preoperatively) into the imaging space enables the surgeon to better visualize tumor invasion or neural function in real-time imaging during resection. Imaging of thermal gradients for cryoprobe or laser ablation, and combination with endoscopy and robotics will offer additional benefit in the performance of difficult neurosurgical procedures.

Asunto(s)

RESUMEN

We have used three-dimensional reconstruction magnetic resonance imaging techniques to understand the anatomic complexity of operative brain lesions and to improve preoperative surgical planning. We report our experience with 14 cases, including intra- and extra-axial tumors and a vascular malformation. In each case, preoperative planning was performed using magnetic resonance imaging-based three-dimensional renderings of surgically critical structures, such as eloquent cortices, gray matter nuclei, white matter tracts, and blood vessels. Simulations, using the interactive manipulation of three-dimensional data, provided an efficient and comprehensive way to appreciate the anatomic relationships. Interactive three-dimensional computer-assisted preoperative simulations provided otherwise inaccessible information that was useful for the surgical removal of brain lesions.

Asunto(s)

RESUMEN

The field of image-guided neurosurgery has developed under the premise that integrating the enhanced discrimination powers of CT scan and MR imaging into the operating room improves the accuracy, safety and precision of neurosurgery, and expand the realm of surgically treatable lesions. Through cooperation between General Electric Corporation and the Brigham and Women's Hospital, and open-configuration MR suite was designed and implemented to attain these goals through real-time, intraoperative MR imaging in a true surgical suite. This system allows intraoperative acquisition of MR images without moving the patient, online image-guided stereotaxy without preoperative imaging, and "real-time" tracking of instruments in the operative field registered to the MR images. The design and implementation of neurosurgery in the open-configuration MR imaging suite are summarized in this article.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: The spread of systemic cancer to the brain is a common complication for cancer patients. Conventional radiotherapy offers modest palliation, and surgery is helpful only for the patient with a single metastasis in an accessible location. Stereotactic radiosurgery, a technique that permits the precise delivery of a high dose of radiation to a small intracranial target while sparing the surrounding normal brain, has been used as an alternative treatment for brain metastases. PURPOSE: Our medical center's 7-year experience with radiosurgery for metastases was reviewed to establish the effectiveness of the treatment and to understand the prognoses in patients so treated. METHODS: Retrospective analysis of hospital records, from 248 consecutive patients (421 lesions) that were treated with radiosurgery between May 1986 and May 1993, was performed. Patients were only excluded for a Karnofsky performance score of less than 70, evidence of acute neurologic deterioration, or tumor diameter more than 4 cm. Median follow-up was 26.2 months. Seventy-six percent of patients had recurrent disease, 69% had evidence of systemic disease, 69% had a single metastasis. Treatment was performed using a 6-MeV linear accelerator. The median tumor volume was 3 cm3. The median treatment dose was 1500 cGy. Whole brain radiotherapy was given to all newly diagnosed patients. Patients were followed by neurological examination and neuroimaging at regular intervals. Local control of disease was defined as a lack of progression of solid-contrast enhancement on computed tomography scan or magnetic resonance imaging. RESULTS: Median overall survival from radiosurgery was 9.4 months. The absence of active systemic disease, younger than 60 years of age, two or fewer lesions, and female sex were significantly associated with increased survival (two-sided P < .05). Actuarial local control rates were approximately 85% at 1 year and 65% at 2 years. Factors associated with a significantly decreased local control rate were location below the tentorium, recurrent tumor, and larger tumor volume (two-sided P < .05). Radioresponsive and radioresistant tumor types had similar control rates. The median drop in Karnofsky performance score at 1 year was 10%. CONCLUSIONS: The results of this retrospective analysis show that radiosurgery is an effective, minimally invasive outpatient treatment option for small intracranial metastases. Results of this study also indicate that radiosurgery not only provides local control rates equivalent to those from surgical series but is also effective in treating patients with surgically inaccessible lesions, with multiple lesions, or with tumor types that are resistant to conventional treatment.

Asunto(s)

RESUMEN

Heterotrimeric GTP-binding proteins from bovine brain were resolved by fast protein liquid chromatography chromatography using Mono Q columns. Two distinct forms of the protein Go were identified. Both forms had stochiometric amounts of alpha- and beta gamma-subunits. The a-subunits of both forms were recognized by an alpha o-specific antiserum, but not by any of the alpha i-specific antisera. The two forms showed distinct migration patterns on 9% sodium dodecyl sulfate-polyacrylamide gels containing 4-8 M urea gradients. Neither form comigrated with the recombinant alpha o1. Both the recombinant alpha o1 and the most abundant form of Go were recognized by an antiserum, H-660, against a peptide encoding amino acids 3-17 of alpha i2. H-660 has been shown previously to recognize alpha o and alpha i (Mumby, S. M., Pang, I. K., Gilman, A. G., and Sternweis, P. C. (1988) J. Biol. Chem. 263, 2020-2026). This more abundant form is called Go A most likely corresponds to the cloned alpha o1. The less abundant form, Go B, was not recognized by H-660. However, both forms of bovine brain Go were recognized by GC/2, an antiserum against the N-terminal region of alpha o1. Hence alpha oA and alpha oB may be different in their N terminus regions. Neither form of bovine brain Go was recognized by an antisera made to a peptide encoding the unique regions of the cloned alpha o2 from HIT cells (Hsu W. H., Rudolph, U., Sanford, J., Bertrand, P., Olate, J., Nelson, C., Moss, L.E., Boyd, A. E., III, Codina, J., and Birnbaumer, L. (1990) J. Biol. Chem. 265, 11220-11226). Go A and Go B have similar guanine nucleotide binding and release properties. Both release GDP within 1 min in the absence of added Mg2+. Both bind guanosine (GTP gamma S) rapidly as well. However Go A binds GTP gamma S about 2.5-fold faster than Go B, in the absence of added Mg2+ ion. Both forms of Go as well as the recombinant alpha o (alpha o1) can increase muscarinic stimulation of inositol trisphosphate-mediated Cl- current in Xenopus oocytes. These data indicate that we have identified two structurally distinct forms of Go that have different guanine nucleotide binding properties and are capable of functioning in the receptor-regulated phospholipase C pathway in Xenopus oocytes.

Asunto(s)

Asunto(s)

RESUMEN

Receptors stimulating phospholipase C do so through heterotrimeric GTP-binding proteins to produce two second messengers, inositol 1,4,5-trisphosphate (InsP3) and diacylglycerol. In spite of the detailed understanding of phospholipase C structure and phosphatidyl inositol signalling, the identity of the GTP-binding protein involved is so far unknown. To address this issue, we have used the Xenopus oocyte in which muscarinic receptors couple to phospholipase C through a pertussis toxin-sensitive GTP-binding protein. In this cell, InsP3 mobilizes intracellular Ca2+ to evoke a Cl- current. The magnitude of this Cl- current is proportional to the amount of InsP3 in the cell, and therefore can be used as an assay for InsP3 production. We report here that the activated alpha-subunit of the GTP-binding protein GO, when directly injected into oocytes, evokes a Cl- current by mobilizing Ca2+ from intracellular InsP3-sensitive stores. We also show that holo-GO, when injected into oocytes, can specifically enhance the muscarinic receptor-stimulated Cl- current. These data indicate that GO can serve as the signal transducer of the receptor-regulated phospholipase C in Xenopus oocytes.

Asunto(s)

RESUMEN

1. Membrane currents were studied in voltage-clamped Xenopus laevis oocytes which had been injected with total rat brain RNA. 2. When the membrane potential was stepped from -100 to +10 mV, two components of outward current were observed which were named Tout1 and Tout2. 3. Both Tout1 and Tout2 were eliminated in chloride-free or calcium-free media and blocked by 9-anthroic acid, indicating that they represented calcium-dependent chloride currents. 4. Both currents were dependent on extracellular calcium (1.8-10 mM), with Tout1 showing a greater sensitivity to changes in calcium concentration. 5. Tout2 but not Tout1 was blocked by intracellular injection of 300-600 pmol, BaCl2 (final concentration in the oocyte: 0.3-0.6 mM). Injection of KCl had no effect on either Tout1 or Tout2. 6. Tout2 but not Tout1 was enhanced by low concentrations of serotonin (0.5-2 nM). This effect was blocked by 0.1 microM-mianserin. Higher concentrations (above 10 nM) of serotonin decreased the amplitude of Tout2. The effect of serotonin was blocked by the protein kinase inhibitor, H-7 (25 microM). 7. Tout2 but not Tout1 was enhanced by 10 nM-phorbol myristate acetate. Higher concentrations of the phorbol ester decreased the amplitude of Tout2. 8. It is concluded that in oocytes injected with RNA there is an induction of a novel component of the calcium-induced chloride current (Tout2). This current reflects a second process of chloride channel opening which can be enhanced by serotonin via activation of protein kinase C.

Asunto(s)

RESUMEN

Heterotrimeric guanine nucleotide-binding proteins (G-proteins) can be categorized into molecularly divergent groups by their differential sensitivity to pertussis toxin. Receptors specifically use either pertussis toxin-sensitive or-insensitive G-proteins to couple to specific effectors. Receptor stimulation of phospholipase C, however, is pertussis toxin sensitive in some systems and pertussis toxin insensitive in others. We studied the coupling of receptors to phospholipase C by expressing receptors from both systems into a single cell, the Xenopus oocyte. [Arg8]Vassopressin (AVP) receptors from liver and cholecystokinin-8(sulfated) (CCK) receptors from brain were expressed in oocytes by intracellular injection of RNA. Both receptors stimulated a Ca2+-dependent Cl- current which can also be evoked by intracellular injection of inositol 1,4,5-tris-phosphate. Hence, receptor stimulation of phospholipase C was measured as the evoked Ca2+-dependent Cl- current. The liver AVP receptor, which is known to stimulate phospholipase C in a pertussis toxin-insensitive manner (Lynch, C. J., Prpic, V., Blackmore, P. F., and Exton, J. H. (1986) Mol. Pharmacol. 29, 196-203), was found to stimulate phospholipase C through a pertussis toxin-sensitive pathway in the Xenopus oocyte. The CCK receptor from brain stimulated phospholipase C through a pertussis toxin-insensitive pathway. Both AVP and CCK stimulation of phospholipase C were attenuated by the intracellular injection of excess G-protein beta gamma subunits. Neither pertussis toxin treatment nor intracellular injection of beta gamma subunits affected any steps subsequent to inositol 1,4,5-tris-phosphate production. From these data we conclude that both the pertussis toxin-sensitive and -insensitive pathways for receptor coupling to phospholipase C are transduced by heterotrimeric G-proteins. We also find that there is a lack of coupling fidelity of receptors to G-proteins in stimulation of phospholipase C which can be influenced by the membrane environment.

Asunto(s)

RESUMEN

This study examines the mechanism of guanine nucleotide-binding protein (G protein) coupling of receptors to phospholipase C. The Xenopus oocyte has a muscarinic receptor-activated Cl- current that is mediated by inositol 1,4,5-trisphosphate. Modulation of the muscarinic receptor-evoked Cl- current was examined under voltage clamp in oocytes injected with resolved G-protein subunits. The presence of an alpha subunit of G proteins in oocytes was shown by pertussis toxin-labeling of a 41-kDa band in oocyte membranes. The presence of the beta subunit of G proteins was demonstrated by immunoblotting experiments with an antiserum (U-49) that is specific for the beta subunit. Pertussis toxin treatment of oocytes resulted in the uncoupling of muscarinic receptors from activation of the Cl- current. Cells microinjected with 1.5 ng of human erythrocyte beta gamma-subunit complex or 1.0 ng of bovine brain beta gamma-subunit complex showed approximately a 95% reduction in the evoked Cl- current. Cells injected with equal volumes of protein storage vehicle showed no change in response. Cells injected with boiled beta gamma subunits, bovine serum albumin, or resolved alpha subunits also showed no reduction in response. Cells injected with various concentrations of beta gamma subunits showed a concentration dependence with half-maximal inhibition of the muscarinic activated Cl- current at about 10 nM. Cells injected with 1.0 ng of bovine brain beta gamma subunits could not respond to bath-applied agonist but could generate the Cl- current on intracellular injection of inositol 1,4,5-trisphosphate. These observations suggest that there is a G protein responsible for muscarinic receptor-mediated signal transduction through phospholipase C and that it is an alpha beta gamma heterotrimer. It appears that the mode of action of the G protein in the phospholipase C system may be similar to that of the hormone-activated adenylyl cyclase.

Asunto(s)

RESUMEN

Oocytes of the African frog Xenopus laevis are shown by electrophysiological methods to possess receptors for corticotropin-releasing factor (CRF), arginine-vasopressin (AVP) and cholecystokinin (CCK). Oocytes surrounded by their follicular cell envelope responded to CRF or AVP with an outward hyperpolarizing current. This current was mediated by an increased conductance of K+ ions. Pretreatment with the adenylate cyclase activator forskolin or with the cAMP phosphodiesterase inhibitor isobutylmethylxanthine (IBMX) potentiated the responses to these peptides indicating that the cAMP second messenger system may mediate the responses. Oocytes stripped of the follicular envelope, which cannot generate cAMP-dependent K+ currents, did not respond to either CRF or AVP. Oocytes exposed to CCK responded with an inward depolarizing current. This current was carried by an increased conductance to Cl-ions. Removal of the follicular cell layer did not affect the response to CCK. The shape, time course, and reversal potential of the Cl-current suggest that CCK acts through the phosphatidylinositol pathway.

Asunto(s)

RESUMEN

Total RNA was extracted from 15-day-old whole rat brains. Microinjection of the RNA into Xenopus laevis oocytes induced electrophysiological responsiveness to cholecystokinin-8 (CCK) and bombesin (BBS) but not to corticotropin-releasing factor (CRF) or somatostatin. The responses to CCK and BBS were similar in shape, time course, and reversal potential to that induced by receptor mediated phospholipid breakdown and that which is induced by intracellular injection of IP3. These responses were not blocked by atropine or by mianserin, did not require extracellular Ca2+ and were completely suppressed by intracellular injection of EGTA.

Asunto(s)