Editor-in-chief J.D. Pickard.
2006. XIII, 289 p. 84 illus. in color.
Hardcover. EUR 140.0
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Springer Wien New York
Achievements and Technical Standards in Neurosurgery is a periodical of the European Association of Neurosurgical Societies, intended for postgraduate education of young neurosurgeons. Its founding fathers are Bernard Pertuiset, Fritz Loew and Hugo Krayenbuhl. The purpose of this series is to acquaint a neurosurgical community with the latest achievements in neurosurgery and adjacent disciplines and to present detailed description of conventional surgical interventions, written by experienced clinicians.
Volume 31 is devoted both to general aspects of neurosurgery and specific problems of surgical anatomy and technique.
The first part (Achievements) contains a report, entitled Gene Technology Based Therapies in the Brain. It has been written by specialists of the University of Kuopio (Finland) under the guidance of T. Wirth. Gene therapy is one of the promising developments in modern medicine. Its use in cancer treatment has become a constantly expanding field of biological and medical research during the last decades. Gene therapy of diseases (not only oncologic ones) of the central nervous and cardiovascular systems is also a prospective trend of further studies.
Today a number of clinical trials, aimed at estimation of gene therapy efficacy, exceeds 1000. The majority of them concerns oncology. Possible use of gene therapy in treatment of Alzheimer’s disease, cerebral ischemia, parkinsonism is an object of serious and profound research. Some studies are devoted to gene therapy of epilepsy, amyotrophic lateral sclerosis, etc.
Experimental studies of growth factors have shown, that a glial cell line-derived neurotrophic factor (GDNF) is one of the most promising candidates for parkinsonism treatment. Its injection can protect nigral dopaminergic neurons and provide regeneration of damaged neurons. Today two clinical trials of parkinsonism gene therapy are being carried out.
As for Alzheimer’s disease, a nerve growth factor and its efficacy as a neuroprotector, providing survival of cholinergic neurons and preventing age degeneration, is being studied. One more prospective trend is neprilysin (NEP) gene transfer. According to experimental studies, an injection of NEP expressing lentiviruses into the hippocampus of transgenic mice results in reduction of a number of amyloid plaques by 50%.
Gene therapy of cerebrovascular diseases is aimed at prevention of vasospasm after subarachnoid hemorrhage; stimulation of a growth of vessels in an ischemic area for improvement of collateral circulation and thrombosis inhibition; prevention of restenosis after angioplasty. Vasospasm gene therapy is based on endothelial NOS gene transfer; eNOS improve NO-mediated relaxation of smooth muscle cells. An experimental intrathecal injection of adenovirus, containing the gene for eNOS, promotes increase of total cerebral blood flow.
Preservation of cerebral circulation in an ischemic focus can be achieved by a growth of vessels, ensuring collateral blood supply. Some growth factors, capable of inducing angiogenesis, are under clinical trials. It has been demonstrated, that experimental intrathecal adenoviral gene delivery of a basic fibroblast growth factor induces angiogenesis in bilateral paraventricular areas of rat brains.
Gene therapy of gliomas is a rather promising trend. One of the strategies is a combination of thymidine kinase with Gancillovir. Today there are seven clinical studies, carried out in this field. A combination of herpes simplex with the above drug and use of adenoviral vectors have given good prospective results. Besides, one can find information on both carried out or planned experimental and clinical studies with use of Escherichia coli genome, oncolytic viruses, antisense oligonucleotides, etc.
The review analyzes main problems of gene therapy of brain diseases, which include crossing the blood-brain barrier, search for gene transfer vectors and use of retroviruses, herpes simplex, adenoviruses and adeno-associated viruses with these purposes. Besides, cationic lipids and other poly-cationic carriers are considered as possible vectors.
Great attention is paid to ethical aspects of gene therapy.
Summarizing the aforesaid, it should be noted, that the present review is an excellent source of modern information on the state of the art in the field of gene therapy of brain diseases. It is a full-value description of achievements of experimental and clinical studies, trends and prospects of further research.
Technical Standards is a part, which includes five independent and original reports, devoted to different aspects of operative and clinical neurosurgery, topographic neurosurgical anatomy.
Topographic anatomy and operative surgery of the orbit and craniocerebral tumors are considered in the first two chapters. Anatomy of the Orbit and Its Surgical Approach by G. Hayek et al. (the University of Angers, France) describes surgical microanatomy on the basis of cadaver specimens. Surgical microanatomy is presented with taking into account topographic peculiarities of three main surgical approaches to the middle and posterior one third of the orbit. They are as follows: a superior access (it allows to reach an upper part of the orbit and to expose all segments of the optic nerve, including the intracranial one), a lateral access (it is performed above and below the lateral rectus muscle and permits to expose a lower part of the orbit) and a superolateral access, possessing advantages of both preceding routes. They can be used in surgical treatment of all intraorbital neoplasms. The only exclusion is tumors, located in an inferomedial quadrant of the orbit. Topographic anatomy of the orbit is discussed not only from a classical point of view, but also with taking into consideration peculiarities of main surgical approaches. It is done with detailed and step-by-step description of technique, used for preparation of anatomic structures.
Neurosurgical Concepts and Approaches for Orbital Tumors, written by J.C. Marchal et al. (the University of Nancy, France), is a logic continuation of the first chapter. Chapter II deals with neurosurgical aspects of orbital neoplasms or, to be more precise, with posterior two thirds of the orbit, involving the optic nerve and its canal. The authors dwell on pathomorphology, peculiarities of topographic anatomy of main groups of orbital tumors, the most spread surgical approaches to different segments of the orbit, problems of its reconstruction after interventions. An original view on the relationship between a type of pathology, surgical access and a method of reconstruction is presented. The authors stick to the opinion, that a lateral approach is to be performed in schwannomas and cavernomas, a subfrontal transorbital access - in optic nerve gliomas and a pterional access - in spheno-orbital meningiomas, neurofibromas, fibrous dysplasia and complex reconstruction of the orbit walls. Use of algorithms, proposed by the authors, permits to transform a multidisciplinary problem into a monodisciplinary one (neurosurgical), to determine specific methods of treatment and to prognosticate a degree of both operation invasiveness and success.
Thus, the chapters, devoted to foundations of cranio-orbital pathology, topographic anatomy and surgery of orbital neoplasms, contain profound and up-to-date information, which is easy to understand. They highlight new aspects of this complex surgical pathology and are of extreme importance for young neurosurgeons.
Endoscopic Third Ventriculostomy in Treatment of Hydrocephalus in Pediatric Patients, written by specialists of children’s neurosurgical clinics of Rome and Naples (Italy) under the guidance of C. Di Rocco, is the biggest and somewhat most important chapter from the point of view of practical neurosurgery. It is known, that surgical treatment of hydrocephalus in general and in children in particular is a pressing problem of neurosurgery. Today endoscopic third ventriculostomy (ETV) is a universally recognized alternative to liquor-shunting operations, demanding implantation of rather expensive shunt devices. Our home literature lacks textbooks and reports on this topic. This chapter, describing the state of the art, can occupy an important place in medical literature as an additional source of information on surgical treatment of hydrocephalus. It contains a full-value historical review and useful data on anatomy of the ventricular system. The chapter is one of a few reports, presenting detailed description of available technical equipment for endoscopic interventions and prospects of endoscopic technologies development. In particular, it concerns creation of videoscopes with 1 CCD chip cameras, positioned at a proximal tip of endoscopes. It makes an optic system simpler and less expensive and increases an image quality. The chapter includes detailed discussion of technical aspects and nuances of a procedure performance with a special emphasis on such key moments, as stoma creation with application of different perforating and dilating materials.
Besides technical aspects, the chapter contains profound analysis of main indications for ETV with consideration of hydrocephalus pathogenesis in each specific case. A separate section deals with criteria for estimation of intervention efficacy in early and late postoperative periods. Original methods of monitoring and neurovisualization, as well as their use for assessment of changes in the cerebrospinal system after ETV, are described. Great attention is paid to prevention and correction of different complications. Unfortunately, the report lacks data, comparing efficacy of ETV and conventional methods of ventriculomegaly treatment. It does not allow to come to a final conclusion on preferable use of this or that method in every specific case. One more factor, somehow reducing the report significance, is age limitation. Nevertheless, the chapter is the most valuable part for young practicing neurosurgeons.
Minimally Invasive Procedures for Treatment of Failed Back Surgery Syndrome, written by a group of authors from the University of Geneva under the guidance of P. Mavrocordatos, describes development of FBSS after interventions on the lumbosacral spine, diagnostic methods and economic problems. The authors dwell on minimally invasive interventional ways of diagnosis and treatment (provocative discography, medicamental blocks of medial branches, blocks of the sacroiliac joint). They describe original algorithms for conventional and differential diagnosis of various pain syndromes. According to the authors, treatment should be limited to use of such minimally invasive methods, as intradiscal electrotherapy (in dicogenic pain syndromes) or radio-frequency neurotomy of articular branches (in articular pain). In case of leg pain, they recommend to use therapeutic epidural puncture or endoscopy-assisted injections, electrostimulation of the spinal cord, itrathecal administration of opiates and local anesthetics. Despite a high rate of unfavorable outcomes of spinal surgery, described methods of treatment of pain syndromes are not widespread in our home neurosurgery. Thus, this report is of great interest.
Surgical Anatomy of Calvarial Skin and Bones with Particular Reference to Neurosurgical Approaches is a concluding chapter by H.D. Fournier et al. (the University of Angers). As a matter of fact, it is the only chapter of the present book, which is intended for beginners, studying neurosurgery. It contains general and well-known information on anatomy of arteries and veins, innervation of the scalp, basic landmarks of the skull base and fornix and substantiates the most frequent use of two approaches (pterional and parasigmoid).
In conclusion it should be emphasized, that Achievements and Technical Standards in Neurosurgery contains a lot of interesting data on urgent problems of modern neurosurgery. This information is highly useful for those, studying or practicing neurosurgery. It meets all the requirements, laid on educational literature and can be recommended for training neurosurgeons-residents.