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Journal of Korean Neurosurgical Society Jul 2015Treatment of Leptomeningeal carcinomatosis (LMC) from solid cancers has not advanced noticeably since the introduction of intra-cerebrospinal fluid (CSF) chemotherapy in... (Review)
Review
Treatment of Leptomeningeal carcinomatosis (LMC) from solid cancers has not advanced noticeably since the introduction of intra-cerebrospinal fluid (CSF) chemotherapy in the 1970's. The marginal survival benefit and difficulty of intrathecal chemotherapy injection has hindered its wide spread use. Even after the introduction of intraventricular chemotherapy with Ommaya reservoir, frequent development of CSF flow disturbance, manifested as increased intracranial pressure (ICP), made injected drug to be distributed unevenly and thus, the therapy became ineffective. Systemic chemotherapy for LMC has been limited as effective CSF concentration can hardly be achieved except high dose methotrexate (MTX) intravenous administration. However, the introduction of small molecular weight target inhibitors for primary cancer treatment has changed the old concept of 'blood-brain barrier' as the ultimate barrier to systemically administered drugs. Conventional oral administration achieves an effective concentration at the nanomolar level. Furthermore, many studies report that a combined treatment of target inhibitor and intra-CSF chemotherapy significantly prolongs patient survival. Ventriculolumbar perfusion (VLP) chemotherapy has sought to increase drug delivery to the subarachnoid CSF space even in patients with disturbed CSF flow. Recently authors performed phase 1 and 2 clinical trial of VLP chemotherapy with MTX, and 3/4th of patients with increased ICP got controlled ICP and the survival was prolonged. Further trials are required with newly available drugs for CSF chemotherapy. Additionally, new LMC biologic/pharmacodynamic markers for early diagnosis and monitoring of the treatment response are to be identified with the help of advanced molecular biology techniques.
PubMed: 26279806
DOI: 10.3340/jkns.2015.58.1.1 -
Cureus Jul 2017Ommaya reservoir placement has been an option for patients requiring cerebrospinal fluid (CSF) access since the 1960s. It is preferred to repeat lumbar punctures, both...
Ommaya reservoir placement has been an option for patients requiring cerebrospinal fluid (CSF) access since the 1960s. It is preferred to repeat lumbar punctures, both in terms of patient comfort and the consistency of intrathecal drug concentration. Technological developments have advanced the placement technique, allowing for better accuracy and reduced complications. Freehand placement was first augmented with pneumoencephalograms and intraoperative computerized tomography (CT), then with optical-based navigation, and finally by utilizing electromagnetic neuronavigation. We outline a method of placement using electromagnetic neuronavigation and intraoperative endoscopic visualization, which allows for both real-time guidance and the confirmation of placement while maintaining tract patency for the entirety of the procedure. We make our incision and burr hole near Kocher's point. The neuronavigation stylet is placed in a peel-away sheath (Cook Medical, Bloomington, Indiana, US), which allows us to advance into the ventricle under real-time neuronavigation guidance. After the ventricle is entered, the stylet may be withdrawn and an endoscope advanced down the sheath. The intraventricular anatomy and catheter placement are confirmed. The burr hole reservoir is attached to a ventricle catheter that has been trimmed based on trajectory measurement on preoperative imaging. The reservoir-catheter construct can then be placed and the sheath removed from around it. This method provides a high level of confidence in appropriate catheter placement.
PubMed: 28944129
DOI: 10.7759/cureus.1490 -
Zhurnal Voprosy Neirokhirurgii Imeni N.... 2017Craniopharyngiomas are benign epithelial tumors having a dysembryogenetic origin, which are usually located in the sellar/parasellar and/or third ventricle regions.... (Review)
Review
Craniopharyngiomas are benign epithelial tumors having a dysembryogenetic origin, which are usually located in the sellar/parasellar and/or third ventricle regions. Gross total resection is the modern standard of treatment for these tumors because of a low recurrence rate. However, this surgery in some patients with craniopharyngioma often leads to the development or worsening of diencephalic disorders poorly responding to treatment. Perhaps, in these cases, subtotal or partial tumor resection or implantation of an Ommaya reservoir into the tumor cyst followed by stereotactic radiotherapy/radiosurgery may provide better functional outcomes and higher life quality in patients, with tumor growth control being reasonable (according to the published data, the mean 10-year disease-free survival is 66.9% after total tumor resection and 79.6% after combined treatment). The paper presents a review of the literature on radiological treatment of craniopharyngiomas. We discuss the issues of indications, optimal timing of radiotherapy/radiosurgery, its efficacy, and treatment outcomes in terms of complications and quality of life. Particular attention is paid to enlargement of craniopharyngioma cysts during and after radiological treatment.
Topics: Combined Modality Therapy; Craniopharyngioma; Disease-Free Survival; Humans; Kaplan-Meier Estimate; Neoplasm, Residual; Pituitary Irradiation; Pituitary Neoplasms; Postoperative Complications; Radiosurgery
PubMed: 28665393
DOI: 10.17116/neiro201781394-106 -
Cancers Jun 2019The central nervous system (CNS) may be considered as a sanctuary site, protected from systemic chemotherapy by the meninges, the cerebrospinal fluid (CSF) and the... (Review)
Review
The central nervous system (CNS) may be considered as a sanctuary site, protected from systemic chemotherapy by the meninges, the cerebrospinal fluid (CSF) and the blood-brain barrier (BBB). Consequently, parenchymal and CSF exposure of most antineoplastic agents following intravenous (IV) administration is lower than systemic exposure. In this review, we describe the different strategies developed to improve delivery of antineoplastic agents into the brain in primary and metastatic CNS tumors. We observed that several methods, such as BBB disruption (BBBD), intra-arterial (IA) and intracavitary chemotherapy, are not routinely used because of their invasiveness and potentially serious adverse effects. Conversely, intrathecal (IT) chemotherapy has been safely and widely practiced in the treatment of pediatric primary and metastatic tumors, replacing the neurotoxic cranial irradiation for the treatment of childhood lymphoma and acute lymphoblastic leukemia (ALL). IT chemotherapy may be achieved through lumbar puncture (LP) or across the Ommaya intraventricular reservoir, which are both described in this review. Additionally, we overviewed pharmacokinetics and toxic aspects of the main IT antineoplastic drugs employed for primary or metastatic childhood CNS tumors (such as methotrexate, cytosine arabinoside, hydrocortisone), with a concise focus on new and less used IT antineoplastic agents.
PubMed: 31200562
DOI: 10.3390/cancers11060824 -
Journal of Korean Neurosurgical Society Dec 2023To evaluate the usefulness of a cranial implantable chemoport, the H-port, as an alternative to the Ommaya reservoir for intraventricular chemotherapy/cerebrospinal...
OBJECTIVE
To evaluate the usefulness of a cranial implantable chemoport, the H-port, as an alternative to the Ommaya reservoir for intraventricular chemotherapy/cerebrospinal fluid (CSF) access in patients with leptomeningeal metastasis (LM).
METHODS
One hundred fifty-two consecutive patients with a diagnosis of LM and who underwent H-port installation between 2015 and 2021 were evaluated. Adverse events associated with installation and intraventricular chemotherapy, and the rate of increased intracranial pressure (ICP) control via the port were evaluated for safety and efficacy. These indices were compared with published data of Ommaya (n=89), from our institution.
RESULTS
Time-to-install and installation-related complications of intracranial hemorrhage (n=2) and catheter malposition (n=5) were not significantly different between the two groups. Intraventricular chemotherapy-related complications of CSF leakage occurred more frequently in the Ommaya than in the H-port group (13/89 vs. 3/152, respectively, p<0.001). Intracranial hemorrhage during chemotherapy occurred only in the Ommaya group (n=4). The CSF infection rate was not statistically different between groups (14/152 vs. 12/89, respectively). The ICP control rate according to reservoir type revealed a significantly higher ICP control rate with the H-port (40/67), compared with the Ommaya result (12/58, p<0.001). Analyzing the ICP control rate based on the CSF drainage method, continuous extraventricular drainage (implemented only with the H-port), found a significantly higher ICP control rate than with intermittent CSF drainage (33/40 vs. 6/56, respectively, p<0.0001).
CONCLUSION
The H-port for intraventricular chemotherapy in patients with LM was superior for ICP control; it had equal or lower complication rates than the Ommaya reservoir.
PubMed: 38061763
DOI: 10.3340/jkns.2023.0178 -
Journal of Neurosciences in Rural... May 2012Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital...
Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital aqueductal stenosis, posterior third ventricle tumor, cerebellar infarct, Dandy-Walker malformation, vein of Galen aneurism, syringomyelia with or without Chiari malformation type I, intraventricular hematoma, post infective, normal pressure hydrocephalus, myelomeningocele, multiloculated hydrocephalus, encephalocele, posterior fossa tumor and craniosynostosis. It is also indicated in block shunt or slit ventricle syndrome. Proper Pre-operative imaging for detailed assessment of the posterior communicating arteries distance from mid line, presence or absence of Liliequist membrane or other membranes, located in the prepontine cistern is useful. Measurement of lumbar elastance and resistance can predict patency of cranial subarachnoid space and complex hydrocephalus, which decides an ultimate outcome. Water jet dissection is an effective technique of ETV in thick floor. Ultrasonic contact probe can be useful in selected patients. Intra-operative ventriculo-stomography could help in confirming the adequacy of endoscopic procedure, thereby facilitating the need for shunt. Intraoperative observations of the patent aqueduct and prepontine cistern scarring are predictors of the risk of ETV failure. Such patients may be considered for shunt surgery. Magnetic resonance ventriculography and cine phase contrast magnetic resonance imaging are effective in assessing subarachnoid space and stoma patency after ETV. Proper case selection, post-operative care including monitoring of ICP and need for external ventricular drain, repeated lumbar puncture and CSF drainage, Ommaya reservoir in selected patients could help to increase success rate and reduce complications. Most of the complications develop in an early post-operative, but fatal complications can develop late which indicate an importance of long term follow up.
PubMed: 22865970
DOI: 10.4103/0976-3147.98222 -
Pediatric Neurology Feb 2017Intrathecal delivery methods have been used for many decades to treat a broad range of central nervous system disorders. A literature review demonstrated that... (Review)
Review
Intrathecal delivery methods have been used for many decades to treat a broad range of central nervous system disorders. A literature review demonstrated that intracerebroventricular route is an established and well-tolerated method for prolonged central nervous system drug delivery in pediatric and adult populations. Intracerebroventricular devices were present in patients from one to 7156 days. The number of punctures per device ranged from 2 to 280. Noninfectious complication rates per patient (range, 1.0% to 33.0%) were similar to infectious complication rates (0.0% to 27.0%). Clinician experience and training and the use of strict aseptic techniques have been shown to reduce the frequency of complications.
Topics: Central Nervous System Agents; Drug Delivery Systems; Humans; Injections, Spinal
PubMed: 28089765
DOI: 10.1016/j.pediatrneurol.2016.10.022 -
Journal of Medical Biography Sep 2023Dr Ayub Khan Ommaya (1930-2008) was a pioneering figure in the field of neurosurgery, with a particular focus on traumatic brain injury. As history books have held, he...
Dr Ayub Khan Ommaya (1930-2008) was a pioneering figure in the field of neurosurgery, with a particular focus on traumatic brain injury. As history books have held, he was a man of great intellect and vision, possessing a rare combination of scientific rigour and compassionate empathy. One of Dr Ommaya's most notable contributions was his development of the Ommaya reservoir, a device used to deliver drugs directly into the brain. This groundbreaking technology transformed the treatment of brain tumours and other neurological disorders, enabling clinicians to administer medications with unprecedented precision and efficacy. From his groundbreaking research on traumatic brain injury to his visionary invention of the Ommaya reservoir, Ommaya's legacy continues to inspire and inform the work of countless medical professionals around the world. This historical paper delves into Ommaya's remarkable life story, highlighting his extraordinary contributions to the field of neurosurgery.
PubMed: 37722807
DOI: 10.1177/09677720231198502 -
Clinical Interventions in Aging 2024The effect of Ommaya reservoirs on the clinical outcomes of patients with intraventricular hemorrhage (IVH) remains unclear.
BACKGROUND
The effect of Ommaya reservoirs on the clinical outcomes of patients with intraventricular hemorrhage (IVH) remains unclear.
OBJECTIVE
We aimed to determine the effect of combining the Ommaya reservoir and external ventricular drainage (EVD) therapy on IVH and explore better clinical indicators for Ommaya implantation.
METHODS
A retrospective analysis was conducted on patients diagnosed with IVH who received EVD-Ommaya drainage between January 2013 and March 2021. The patient population was divided into two groups: the Ommaya-used group, comprising patients in whom the Ommaya drainage system was activated post-surgery, and the Ommaya-unused group, comprising patients in whom the system was not activated. The study analyzed clinical, imaging, and outcome data of the patient population.
RESULTS
A total of 123 patients with IVH were included: 75 patients in the Ommaya-used group and 48 patients in the Ommaya-unused group. The patients in the Ommaya-used group showed a lower 3-month GOS than those in the Ommaya-unused group (p<0.0001). The modified Graeb scale (mGS) in the Ommaya-unused group was significantly lower than that in the Ommaya-used group before the operation (p<0.01) but not after surgery (p>0.05). The GCS in the Ommaya-unused group was significantly lower than that in the other group, and there was a close correlation between the GCS and 3-month GOS (p<0.0001). The GCS score showed significance in predicting the use of Ommaya (p<0.001).
CONCLUSION
The study demonstrated that combining EVD and Ommaya drainage was a safe and feasible treatment for IVH. Additionally, preoperative GCS was found to predict the use of Ommaya drainage in subsequent treatment, providing valuable information for pre-surgery decision-making.
Topics: Humans; Cerebral Hemorrhage; Drainage; Drug Delivery Systems; Retrospective Studies
PubMed: 38192377
DOI: 10.2147/CIA.S436522 -
Cureus Sep 2021The literature is rich with many studies reporting different treatment modalities and approaches for cystic craniopharyngioma (CC), including microsurgery,...
The literature is rich with many studies reporting different treatment modalities and approaches for cystic craniopharyngioma (CC), including microsurgery, neuroendoscopic transventricular approach, endoscopic transnasal surgery, stereotactic drainage, and Ommaya reservoir insertion. The goals of this manuscript are to report the successful treatment of an atypical case of CC using the neuroendoscopic transventricular approach (NTVA) as well as discuss the different surgical modalities for these tumors following a comprehensive review of the literature. Our patient is a nine-year-old female with a large CC who was managed using the NTVA. No complications or recurrence occurred over two years of follow-up. Results of our literature review showed lower recurrence and complication rates of the NTVA compared to other surgical modalities.The NTVA is potentially efficient, reliable, and safe for managing CC and cystic-dominant craniopharyngiomas, with low recurrence and complication rates compared to microsurgery and Ommaya reservoir insertion. Future randomized clinical studies comparing the various treatment modalities of CC are needed to solidify these conclusions.
PubMed: 34692333
DOI: 10.7759/cureus.18123