Second surgery for recurrent glioblastoma: A concise overview of the current literature

Optimal treatment for recurrent glioblastoma continues to evolve. Currently, however, there is no consensus in the literature on the role of reoperation in the management of these patients, as several studies provide evidence for a longer overall survival in selected patients with recurrent glioblastoma who underwent second surgery and other studies report a limited impact of second surgery in the clinical course. In this paper, a review of the current literature was performed to analyze the role of reoperation in patients with recurrent glioblastoma and to report the overall survival from diagnosis, progression-free survival and quality of life. Using PubMed and Ovid Medline databases, we performed a review of the literature of the last seven years, finding a total of 28 studies and 2279 patients who underwent second surgery, that were included in the final analysis. The median overall survival from diagnosis and the median survival from second surgery were 18.5 months and 9.7 months, respectively. Extent of resection at reoperation improves overall survival, even in patients with subtotal resection at initial operation. Preoperative performance status and age are important predictors of a longer survival, reason why younger patients with a good preoperative performance status could benefit from reoperation

Evaluation of aquaporins in the cerebrospinal fluid in patients with idiopathic normal pressure hydrocephalus

Brain aquaporin 1 (AQP1) and AQP4 are involved in cerebrospinal fluid (CSF) homeostasis and might participate in the origin of hydrocephalus. Studies have shown alterations of perivascular AQP4 expression in idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer’s disease (AD). Due to the overlapping of clinical signs between iNPH and certain neurological conditions, mainly AD, specific biomarkers might improve the diagnostic accuracy for iNPH. The goal of the present study was to analyze and quantify the presence of AQP1 and AQP4 in the CSF of patients with iNPH and AD to determine whether these proteins can be used as biomarkers of iNPH. We examined AQP1 and AQP4 protein levels in the CSF of 179 participants (88 women) classified into 5 groups: possible iNPH (81 participants), hydrocephalus associated with other neurological disorders (13 participants), AD (41 participants), non-AD dementia (32 participants) and healthy controls (12 participants). We recorded each participant’s demographic and clinical variables and indicated, when available in the clinical history, the record of cardiovascular and respiratory complications. An ELISA showed virtually no AQP content in the CSF. Information on the vascular risk factors (available for 61 patients) confirmed some type of vascular risk factor in 86% of the patients with possible iNPH and 58% of the patients with AD. In conclusion, the ELISA analysis showed insufficient sensitivity to detect the presence of AQP1 and AQP4 in CSF, ruling out the possible use of these proteins as biomarkers for diagnosing iNPH.This research was funded by grants PI16/00493 and PI19/01096 to M.E. from the Spanish Ministry of Economy and Competitiveness, co-financed by the Carlos III Health Institute (ISCIII) and European Regional Development Fund (FEDER). J.L.T-C. was partially supported by the Regional Government of Andalusia and FEDER funds through a program for recruitment of young researchers

Modified "Extended" Suboccipital Subtonsillar Clipping of a Ruptured Proximal Pica Aneurysm: Technical Note with Relevant Anatomical Demonstration

Background and importance: Lesions located lateral to the lower brainstem, such as proximal posterior inferior cerebellar artery (PICA) aneurysms, are surgically challenging. We report a case of a patient with a left proximal PICA aneurysm that was successfully clipped via a so-called "extended" suboccipital subtonsillar approach, which allowed us to obtain proper vascular control without removal of the atlas. The anatomy relevant for this approach has been studied. Methods: Three adult cadaveric heads were studied. The relevant neurovascular anatomy related to this approach was exposed. Hence, this technique was applied on the patient herewith reported. Case presentation: A 60-year-old man with sudden onset of severe headache, nausea, and vomiting was admitted to our hospital. Computed tomography of the brain showed diffuse subarachnoid hemorrhage, mainly distributed at the level of the perimesencephalic cisterns. Cerebral angiography revealed a 3-mm aneurysm arising at the origin of the left PICA. The aneurysm was considered unsuitable for coil embolization, so it was treated via a "modified" posterolateral suboccipital subtonsillar route. The modification consisted of accomplishing proper proximal vascular control at the extracranial segment of the vertebral artery (V3), without the need of further removal of the posterior portion of the atlas. The patient was discharged neurologically intact. Conclusions: The technique we suggested allowed no unnecessary removal of bone, with no need to drill the occipital condyle or remove the atlas, offered proper proximal vascular control in the early stage of the surgical procedure, and limited the quantity of temporary vascular clips inside the intracranial surgical field