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Phoenix, AZ, United States

Chung S.S.,Barrow Neurological Institute
Therapeutic Advances in Neurological Disorders | Year: 2015

Topiramate has been widely utilized worldwide as an effective medication against partial- and generalized-onset seizures. Extended-release topiramate was developed to provide patients with the convenience of once-daily dosing and potentially improved tolerability by reducing serum concentration fluctuation. USL255 is a once-daily, extended-release formulation of topiramate, which was recently approved in the USA. Compared with immediate-release topiramate taken twice daily, once-daily USL255 provides equivalent topiramate exposure with a 26% reduction in plasma fluctuations. A multinational, phase III, randomized, double-blind, placebo-controlled clinical trial in patients with refractory partial-onset seizures demonstrated that USL255 (200 mg/day) significantly improved seizure control and was well tolerated with low overall neuropsychiatric and neurocognitive adverse events. © The Author(s), 2015.

The transciliary supraorbital approach (TCSO) provides an anterior view for visualizing sellar, parasellar, and suprasellar structures. Whether an orbital osteotomy adds to this exposure has not been quantified. We quantitatively evaluated the TCSO and benefits of an additional orbital osteotomy for exposing common sites of anterior circulation aneurysms. Under image guidance, TCSO and orbital osteotomy were performed on 10 sides of 5 cadaver heads to quantify exposures of 4 surgical targets: (1) the junction of the anterior cerebral and anterior communicating arteries (ACoA); (2) the internal carotid artery (ICA) at the level of the posterior communicating artery (PCoA); (3) the bifurcation of the ICA; and (4) the middle cerebral artery (MCA) bifurcation. Horizontal and vertical angles of attack and surgical freedom for instrument manipulation were measured before and after the orbital rim and roof were removed. An orbital osteotomy significantly increased surgical freedom to the ACoA (from 471.15 +/- 182.14 mm2 to 683.35 +/- 283.78 mm2, P = .021); PCoA (from 746.58 +/- 242.78 mm2 to 966.23 +/- 360.22 mm2, P = .007); ICA bifurcation (from 616.08 +/- 310.95 mm2 to 922.38 +/- 374.88 mm2, P = .002); and MCA bifurcation (from 1160.77 +/- 412.03 mm2 to 1597.71 +/- 733.18 mm2, P = .004). There were no significant differences in horizontal angles of attack. The vertical angles of attack were significantly greater after orbital osteotomy, principally with the ACoA and ICA bifurcation as targets. TCSO combined with orbital osteotomy improves exposure. Removing the orbital rim and roof increases the area for instrument use and improves the vertical angle of attack to common sites in the anterior circulation involving aneurysms.

Sanai N.,Barrow Neurological Institute
Current Opinion in Neurology | Year: 2012

PURPOSE OF REVIEW: In recent years, the safety and efficacy of neurosurgical intervention has rapidly improved for brain tumor patients. Technological advances, combined with refined intraoperative techniques, now enable well tolerated surgical access to any region of the human brain. For patients with gliomas, these improvements have redefined the clinical possibilities, and here we review several emerging operative strategies that are essential for next-generation neurosurgical oncologists and major brain tumor centers. RECENT FINDINGS: The value of glioma extent of resection remains controversial, but review of the modern literature reveals important opportunities for early neurosurgical intervention. Although microsurgical resection must be balanced by the risk of neurological compromise, improvements in intraoperative stimulation techniques now enable resection of highly eloquent tumors with minimal morbidity. Additionally, the emergence of fluorescence-guided surgery as a new operative paradigm provides a unique opportunity to resect tumors to the margins of microscopic infiltration. SUMMARY: Neurosurgical intervention remains the first step in effective glioma management. With intraoperative mapping techniques, aggressive microsurgical resection can be safely pursued even when tumors occupy essential functional pathways. With the development of tumor-specific fluorophores, such as 5-aminolevulinic acid, real-time microscopic visualization of tumor infiltration can be surgically targeted prior to adjuvant therapy. © 2012 Wolters Kluwer Health / Lippincott Williams & Wilkins.

Craig A.D.B.,Barrow Neurological Institute
Annals of the New York Academy of Sciences | Year: 2011

An ascending sensory pathway that underlies feelings from the body, such as cooling or toothache, terminates in the posterior insula. Considerable evidence suggests that this activity is rerepresented and integrated first in the mid-insula and then in the anterior insula. Activation in the anterior insula correlates directly with subjective feelings from the body and, strikingly, with all emotional feelings. These findings appear to signify a posterior-to-anterior sequence of increasingly homeostatically efficient representations that integrate all salient neural activity, culminating in network nodes in the right and left anterior insulae that may be organized asymmetrically in an opponent fashion. The anterior insula has appropriate characteristics to support the proposal that it engenders a cinemascopic model of human awareness and subjectivity. This review presents the author's views regarding the principles of organization of this system and discusses a possible sequence for its evolution, as well as particular issues of historical interest. © 2011 New York Academy of Sciences.

Craig A.D.,Barrow Neurological Institute
Brain structure & function | Year: 2010

This article addresses the neuroanatomical evidence for a progression of integrative representations of affective feelings from the body that lead to an ultimate representation of all feelings in the bilateral anterior insulae, or "the sentient self." Evidence for somatotopy in the primary interoceptive sensory cortex is presented, and the organization of the mid-insula and the anterior insula is discussed. Issues that need to be addressed are highlighted. A possible basis for subjectivity in a cinemascopic model of awareness is presented.

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