Mott [jsc. Sobell [Jyz. Hartley [kr2. Flanagan [KTi. Wendell Allison [kX4. Gully [Kye. Pacat [MLP. Lind [MLs. Khalitov [NnK. Kanold, Lee Stiff [PHm. Giblin [PS6. Norman Vincent Peale [qcN. Carlos Pestana [rhV. Russell [RSH. Amrhein [rvW. Rowe, Zhang Jie [sb1. Dorfman [SL1. Meir Barak [SQD. Surgent [SRZ. Kapandji MD [T1I. Hummel [TcJ. Schatzberg [tkI. Robbins [uFd.
Cunningham [URt. Quenot [UXV. Seuss [v0g. Robb [v4T. This new edition has been revised and expanded to include new data where relevant, and also features a new chapter on pituitary surgery. Landmark Papers in Neurosurgery 2e remains a key collection of the most important trials and studies in neurosurgery, allowing the reader to rapidly extract key results, and making it essential reading for all neurosurgeons and trainees in the field.
Get BOOK. Landmark Papers in Neurosurgery. Author : Reuben D. Advances in the practice of psychiatry have occurred in "fits and starts" over the last several decades. These advances are evident to anyone long affiliated with the field and are best appreciated through direct experience of living through the times. These advances can also be gleaned from historical overviews in. Landmark Papers in Otolaryngology. Otolaryngological conditions affect people of all ages from newborns to older members of society, and have serious consequences for daily functions such as breathing, taste, and communication.
In addition, a North American trial, the HeADDFIRST trial hemicraniectomy and durotomy on deterioration from infarction-related swelling trial , was carried out between and , although this was only ever published in abstract form.
Sequential-design, multicenter, randomised, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction DECIMAL trial. Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction.
Trials ; 7: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised trials. Lancet Neurol ; 6: — Neurology ; 60 Suppl 1 : A Decompressive hemicraniectomy and durotomy for malignant middle cerebral artery infarction. Neurocrit Care ; 8: — Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review.
Exclusion criteria also similar: significant pre-stroke disability; significant haemorrhagic infarction; coagulopathy; poor neurological state e. Recruitment to DESTINY was discontinued early because a predetermined analysis at 6 months showed a significant benefit of surgery on mortality. Absolute reduction in death of There were no significant differences in the outcome measures between the three trials at the time of the pooled analysis.
The absolute risk reduction ARR for mortality at 12 months was Functional outcomes not reported. Critique The pooled analysis of three ongoing trials is almost unique in the literature and the results of this pooled analysis are in keeping with reported findings from uncontrolled case series. In fact, although surgery reduced mortality, a greater number of survivors tenfold are left with moderately severe disability. The authors of the pooled analysis have been careful to emphasize, therefore, that patients and clinicians need to be willing to accept the possibility of this survival outcome.
From one perspective, therefore, hemicraniectomy for MMI is a life-saving procedure. An alternative view is that hemicraniectomy saves lives at the cost of producing unacceptable levels of disability in the survivors.
Various criticisms have been raised against these trials, including the issue of whether non-blinding of treatment arms had any effect on patient management, and in particular the use of intensive care resources in the two groups. For example, in the DECIMAL trial all patients undergoing surgery received mechanical ventilation as compared to just over only two-thirds of patients managed medically.
Whether this was an effect of non-blinding remains open to question Mayer, Various other concerns regarding the results have been raised and the way in which physicians and surgeons will use the information. For example, there is a tendency to avoid hemicraniectomy in patients with dominant hemisphere MMI due to the perception that global aphasia is a cruel outcome that should be avoided at all costs.
Mayer has pointed out that the benefit of hemicraniectomy in the pooled analysis was independent of the presence or absence of aphasia and that dominant hemisphere involvement may not necessarily be an acceptable reason for withholding hemicraniectomy Mayer, One of the greatest criticisms of these trials is whether the criteria for patient selection can really reflect any degree of understanding of the natural history of MMI.
The processes which determine which patients develop fatal brain oedema are not understood and there is clearly a need for larger imaging studies to evaluate the natural history of these lesions before we can fully elucidate the role of surgical or other interventions. The decision to perform hemicraniectomy for MMI is still a matter for consideration on an individual case-by-case basis. Issues regarding the optimal timing of surgery still need to be resolved.
However, no conclusions can be drawn about those patients operated on after this time period. Surgical decompression for MMI remains a complex dilemma for both physicians, surgeons, and their patients. Mayer SA. Hemicraniectomy: a second chance on life for patients with space-occupying MCA infarction. More recently, with the advent of carotid stenting, trials have compared surgery to interventional radiological procedures.
These are discussed in a separate section. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.
Endarterectomy for asymptomatic carotid artery stenosis. JAMA ; — Carotid endarterectomy and prevention of cerebral ischaemia in symptomatic carotid stenosis.
By degree of stenosis, i. A subsequent analysis divided the latter into 70— Multiplanar anteroposterior, oblique, and lateral selective ICA angiogram was required.
Before , 4-monthly clinic visits. After , annual visits, bi-annual telephone assessments. If a stroke occurred, the patient had an extra clinic visit. All patients underwent annual carotid ultrasound scan.
All patients had enteric-coated aspirin as well as antihypertensive, antilipidaemic and antidiabetic therapies, if required. Several later studies including those in Europe showed similar results. Outcome Measures Primary Endpoint Fatal or non-fatal stroke ipsilateral to the randomized carotid artery.
Results Baseline characteristics were similar in the two groups. Therefore, patients with severe stenosis were not enrolled after but were continued to be followed up until Benefits were greatest for men, those with hemispheric symptoms, and recent stroke. The benefit of endarterectomy for asymptomatic patients is somewhat more controversial.
However, in this trial, the investigators had an extremely low day complication rate of only 2. Timing of surgery is an important factor.
The cumulative risk results in this study show that the greatest risk of stroke is in the first 6 months of symptoms with a decrease continuing until approximately 2 years. After this, the difference between surgery and conservative treatment is less clear. Therefore, when interpreting the trial results, surgeons should consider whether the patients still have symptoms as well as the degree of stenosis. Another important factor to consider is the how the degree of stenosis has been measured.
The trial investigators state that the narrowest portion of the stenosis should not be As the trial used angiography, it says nothing about the degree of stenosis as measured by ultrasonography, a technique commonly used by some centres. This question has been the subject of other subsequent studies and is beyond the scope of this section.
The publication of the Clinical Alert as well as the paper had a profound effect on the rates of carotid endarterectomy. Prior to this, rates of carotid endarterectomy fell as studies questioned the use of the procedure. After the NASCET trial, indications for surgery were clearly defined, and provided operations were performed by skilled surgeons in high-volume centres, benefit was clear.
Therefore, rates increased in the s but in selected patients. These results were subsequently confirmed. With the advancement of endovascular stenting techniques, it became inevitable that stenting of carotid arteries would become a viable alternative to surgery. But which technique is better and which has the lowest complication rate? There are a number of studies in the year period from to that have looked at this. On the basis of these studies, there are only minor differences between treatments in the immediate day period after surgery but longer-term follow-up may show differences.
Lancet Neurol ; 7: — Long-term results of carotid stenting versus endarterectomy in high-risk patients. Number of patients assigned to stenting versus assigned to surgery Length of follow-up 2 years Number of centres.
SPACE is one of the largest early trials looking at stent versus surgery for carotid stenosis. It is the equivalent of NASCET except that the two conditions are surgery and stenting rather than surgery and conservative treatment. Essentially, the study showed that there is little difference in outcome between the two groups. However, the The results of this study are similar to other stent versus surgery trials. Each centre had to demonstrate, in advance, their expertise in dealing with carotid artery stenosis, and quality committees were set up to define guidelines.
Multidisciplinary teams comprising interventionalists, vascular surgeons, and neurologists decided on each case. Results There were no differences in baseline characteristics between the two groups; were randomized to endarterectomy and to stenting. The day rates of primary endpoint events in the intention-to-treat analysis was 6.
With adjustment for major protocol violations, this was 5. Indeed, carotid endarterectomy patients tended to have better outcomes in most of the day endpoints. More patients in the angioplasty group received double antiplatelet treatment e. With regard to 2-year outcomes, there were no significant differences but the trend was for fewer complications in the surgery group.
With regard to mortality, there were 32 deaths in the angioplasty group, compared to 28 in the carotid endarterectomy group Kaplan—Meier estimates of 6. The Kaplan—Meier estimates of ipsilateral strokes or death within 2 years plus any periprocedural strokes or death was 9. Subgroup analyses revealed that there was an age-related increase in primary outcome events in patients with carotid angioplasty with stenting compared to no change across age groups in the surgical group.
Conclusions This study failed to show a non-inferiority of carotid angioplasty and stenting versus carotid endarterectomy for the day complication rates.
Indeed, overall, surgery was the favourable option. However, there was no difference between the two treatments and risk of cerebrovascular events at 2 years. Critique The SPACE trial is a large, randomized trial that failed to show that carotid artery stenting is better than carotid endarterectomy.
However, as commented on by Wiesmann et al. As the frequency was much higher in each arm, it was underpowered to establish non-inferiority of stenting versus surgery and would require a further — patients. However, the results agree broadly with most of the other similar trials that are listed earlier in this section.
The main difference with the SAPPHIRE trial is that the latter looks at patients at high risk for carotid endarterectomy and as a consequence has higher complication rates for both treatments.
One of the main criticisms of these trials is that the follow-up usually limited to 2 years is aimed at complications related to the procedures rather than longterm re-stenosis rates.
If long-term re-stenosis is due to progression of atherosclerosis, one might expect re-stenosis There is some evidence that most of the re-stenoses in the trial were related to intimal hyperplasia and this may have overestimated the incidence, though this has not been proven.
A further criticism, stated by the SPACE investigators themselves, is that the trial did not look at secondary prevention strategies such as lipidlowering drugs or smoking status. In summary, of all of the studies, carotid angioplasty plus stenting has been shown to have a slightly higher periprocedural up to 30 days stroke risk but surgery has a higher rate of cranial nerve palsy or myocardial infarction.
There is no difference between the periprocedural disabling stroke and death risks between the two groups. Also, there is no evidence that an embolic protection device influences outcome. Impact on Field This study has shown that there is little advantage of stenting over surgery for carotid stenosis, but at the same time there are only minor differences in complication rates. Stent-protected angioplasty versus carotid endarterectomy in patients with carotid artery stenosis: meta-analysis of randomized trial data.
Eur Radiol ; 18 12 : — There is a wealth of published literature in this area that continues to expand, seemingly exponentially. We have included, therefore, in this chapter a selection of studies that address certain key issues that we feel are directly relevant to the practising neurooncological surgeon today. We open this chapter by considering a randomized trial of the role of steroids in the management of cerebral oedema associated with brain tumours.
The use of dexamethasone for this purpose was the result of work by Joseph Galicich, Lyle French, and James Melby from the University of Minnesota in the s Galicich et al. The study chosen for inclusion in this chapter is the randomized trial carried out by Vecht et al.
The next two sections address two important areas of neuro-oncology: the role of surgery and adjuvant radiotherapy for single brain metastases.
In those patients without a known primary lesion, neurosurgical intervention may be necessary in order to obtain a tissue diagnosis. In those with multiple cerebral metastases, radiotherapy is the accepted treatment option. However, the situation is more complex in patients with a single brain metastasis and known extracranial disease and we have included the three largest and most widely referenced trials that have addressed the role of surgery in addition to radiotherapy in this situation Patchell et al.
We have also included the only randomized trial to consider the role of radiotherapy as an adjunct to surgery for a single brain metastasis Patchell et al. There is considerable controversy regarding the role of surgery for multiple cerebral metastases, and a survey of the literature reveals several conflicting views from published case series.
Perhaps in a future edition we will be able to critique the results of a randomized controlled trial in this area. Stereotactic radiosurgery for brain metastases has also been evaluated by two prospective randomized trials and we have included these here Andrews et al. The next sections of the chapter deal with the management of high-grade gliomas. We have included four of the larger and well-designed studies addressing this issue Keles et al. Following on from this we have looked at key studies evaluating the role of chemotherapy in high-grade glioma.
The benefits of chemotherapy in glioblastoma have been controversial and this has been reflected by different approaches to the treatment of glioblastoma in Europe and the United States over the last 25 years. This trial showed the greatest improvement in This temozolomide trial has led to the routine use of temozolomide chemotherapy in patients with glioblastomas. There is also a growing body of evidence to support the role of localized chemotherapy by way of carmustine wafers and we have included the two largest trials conducted on this issue Brem et al.
The next section considers brachytherapy for high-grade gliomas. This modality received quite a bit of attention in the s. Several large randomized controlled trials, however, found that it was of no benefit. These are landmark studies as the findings resulted in the discontinuation of this therapy.
We have considered two of these landmark trials in this section Laperriere et al. The following sections deal with low-grade gliomas LGGs —two retrospective studies which evaluate the extent of resection on outcome for LGGs McGirt et al. The role of radiotherapy in the management of LGGs presents a difficult dilemma for the neurosurgical oncologist.
We have, therefore, included a section that looks at these trials together Karim et al. In this second edition we have included two further sections relevant to neurosurgeons, which we feel were overlooked in the first edition. The first is a clinicopathological study describing dysembryoplastic neuroepithelial tumours DNTs Daumas-Duport et al. This landmark study is pertinent to all neurosurgeons because of its description of a new surgically curable entity which if properly identified allows this subgroup of young patients to avoid unnecessary adjuvant therapy.
Furthermore, the study demonstrates the limitations of our histopathological grading systems for brain tumours. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG randomised trial. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for the treatment of brain metastases—a randomised controlled trial.
Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas.
Dysembryoplastic neuroepithelial tumor: a surgically curable tumor of young patients with intractable partial seizures. Report of thirty-nine cases. Use of dexamethasone in treatment of cerebral oedema associated with brain tumours. Lancet ; 46— A randomized trial on dose-response in radiation therapy of low-grade cerebral glioma.
Randomised trial on the efficacy of radiotherapy for cerebral low-grade glioma in the adult: European Organization for Research and Treatment of Cancer Study with the Medical Research Council study BRO4: an interim analysis. The effect of extent of resection on time to tumor progression and survival in patients with glioblastoma mulitforme of the cerebral hemisphere. Cancer ; — A multivariate analysis of patients with glioblastoma multiforme: prognosis, extent of resection, and survival.
Randomized study of brachytherapy in the initial management of patients with malignant astrocytoma. Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Genesis of the use of corticosteroids in the treatment and prevention of brain oedema. A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with a single cerebral metastasis. A randomized trial of surgery in the treatment of single metastases to the brain.
Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. The Brain Tumor Cooperative Group NIH Trial 87— a randomized comparison of surgery, external radiotherapy, and carmustine versus surgery, interstitial radiotherapy boost, external radiation therapy, and carmustine.
J Clin Oncol ; — Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry ; 22— Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas.
Fluorescenceguided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled mulitcentre phase III trial. Lancet Oncol ; 7: — Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. Interstitial chemotherapy with carmustine with carmustine-loaded polymers for high-grade gliomas: a randomised double-blind study. Neurosurgery ; 44— Long-term efficacy of early versus delayed radiotherapy for low-grade astrocytoma and oligodendroglioma in adults: the EORTC randomised trial.
Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol ; — Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain tumors: a randomized controlled study of doses 4, 8 and 16 mg per day. Neurology ; — Debulking or biopsy of malignant glioma in elderly people—a randomized study. Acta Neurochir Wein ; 5— A cooperative clinical trial. A phase 3 trial of local chemotherapy with biodegradable carmustine BCNU wafers Gliadel wafers in patients with primary malignant glioma.
Neuro-Oncology ; 5: 79— Gliadel wafer in initial surgery for malignant glioma: long-term follow-up of a multi-center controlled trial. Acta Neurochir Wein ; — The trial was carried out in the Netherlands in the early s.
Outcome Measures Primary Endpoints Neurological status. Functional status Karnofsky score. Quality of life. Side effects: standardized questionnaire and clinical examination.
Assessment at 1, 4, and 8 weeks. Ninety-two per cent follow-up at 4 weeks. There were no significant differences in the improvement of Karnofsky scores between dosing regimens at 1 week or any other time point. Conclusions After 1 week, 4 mg is as effective as 16 mg of dexamethasone in patients with no impending signs of brain herniation. Toxic effects of dexamethasone are dose dependent and are much more frequent if 16 mg is administered for prolonged periods 1 month or more.
Brain oedema is one of the greatest factors contributing to neurological decline and impairment of quality of life in patients with brain tumours. The use of steroids in the management of brain tumours was established in the s and s after a number of observations by several clinicians. In , Kofman et al. They reported benefits from the administration of prednisolone to a series of 20 patients with brain tumours Kofman et al.
Following this, Joseph Galicich, at the University of Minnesota, noted a circadian periodicity in the permeability of the blood—brain barrier in mice that was directly reciprocal to the endogenous corticosteroid circadian rhythms.
This observation led to a trial showing that dexamethasone was beneficial in treating patients with neurological deficits from brain tumours Galicich et al. This study by Galicich et al. The use of dexamethasone is associated with the risk of adverse effects including cushingoid facies, psychosis, diabetes, and peptic ulceration.
The later trial by Vecht et al. The follow-up period and outcome assessments used by Vecht and colleagues were appropriate to answer these questions. The trial design included two series because interim analysis revealed that the effect of a dose difference of 8 mg may be too small. The trial established the efficacy and dosing of dexamethasone for cerebral oedema in patients with brain tumours.
On the basis of their results, Vecht and colleagues recommended the following dosing regimens: Neurological status of patient. J Lancet ; 46— Treatment of cerebral metastases from breast carcinoma with prednisolone. All three trials compared surgical resection plus radiotherapy versus radiotherapy alone. The first study was carried out in the University of Kentucky in the United States between and Patchell et al.
The second study was carried out in the Netherlands between and Vecht et al. All RCTs. Goal of surgery in all three trials was total removal of the brain metastasis. Biopsy was undertaken to confirm the diagnosis in the radiotherapy arms in the studies by Patchell et al.
Stratification by location consisted of dividing lesions into supratentorial and infratentorial groups. All trials carried out an intention-to-treat analysis.
Outcome Measures Primary Endpoints Survival was the primary outcome in all three trials. In addition, the recurrence of intracerebral metastasis was a primary outcome in the Patchell et al. Other Significant Findings Patchell et al. Vecht et al. Mintz et al. Conclusions Two out of the three trials found that surgery plus radiotherapy is superior to radiotherapy alone for single cerebral metastasis. Patchell et al. Critique Prior to the only evidence supporting the role of surgery for single cerebral metastases in patients with known systemic disease came from published case series that may have been biased by selecting only patients in good clinical condition for surgery.
Uncontrolled case series looking at the effectiveness of surgery in brain metastases provided conflicting results and, therefore, the role of surgery in these patients remained to be determined. Previous studies had revealed that the median survival for untreated brain metastases is approximately 1 month but this could be improved to 3 months in the majority of patients with steroids and WBRT Cairncross et al.
It is important to note that only half of patients with brain metastases have a single metastasis.
0コメント