title: Real-time image-guided direct convective perfusion of intrinsic brainstem lesions. Technical note.
abstract: Recent preclinical studies have demonstrated that convection-enhanced delivery (CED) can be used to perfuse the brain and brainstem with therapeutic agents while simultaneously tracking their distribution using coinfusion of a surrogate magnetic resonance (MR) imaging tracer. The authors describe a technique for the successful clinical application of this drug delivery and monitoring paradigm to the brainstem. Two patients with progressive intrinsic brainstem lesions (one with Type 2 Gaucher disease and one with a diffuse pontine glioma) were treated with CED of putative therapeutic agents mixed with Gd-diethylenetriamene pentaacetic acid (DTPA). Both patients underwent frameless stereotactic placement of MR imaging-compatible outer guide-inner infusion cannulae. Using intraoperative MR imaging, accurate cannula placement was confirmed and real-time imaging during infusion clearly demonstrated progressive filling of the targeted region with the drug and Gd-DTPA infusate. Neither patient had clinical or imaging evidence of short- or long-term infusate-related toxicity. Using this technique, CED can be used to safely perfuse targeted regions of diseased brainstem with therapeutic agents. Coinfused imaging surrogate tracers can be used to monitor and control the distribution of therapeutic agents in vivo. Patients with a variety of intrinsic brainstem and other central nervous system disorders may benefit from a similar treatment paradigm.
authors.affiliation: Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA. lonserr@ninds.nih.gov
authors.forename: Russell R
authors.initials: RR
authors.lastname: Lonser
authors.forename: Katherine E
authors.initials: KE
authors.lastname: Warren
authors.forename: John A
authors.initials: JA
authors.lastname: Butman
authors.forename: Zenaide
authors.initials: Z
authors.lastname: Quezado
authors.forename: R Aaron
authors.initials: RA
authors.lastname: Robison
authors.forename: Stuart
authors.initials: S
authors.lastname: Walbridge
authors.forename: Raphael
authors.initials: R
authors.lastname: Schiffman
authors.forename: Marsha
authors.initials: M
authors.lastname: Merrill
authors.forename: Marion L
authors.initials: ML
authors.lastname: Walker
authors.forename: Deric M
authors.initials: DM
authors.lastname: Park
authors.forename: David
authors.initials: D
authors.lastname: Croteau
authors.forename: Roscoe O
authors.initials: RO
authors.lastname: Brady
authors.forename: Edward H
authors.initials: EH
authors.lastname: Oldfield
mesh_terms: D001933:Brain Stem / Q000098:blood supply / Q000473:pathology / Q000601:surgery; D002408:Catheters, Indwelling; D002528:Cerebellar Neoplasms / Q000473:pathology* / Q000601:surgery*; D002560:Cerebrovascular Circulation / Q000502:physiology; D003287:Contrast Media; D005158:Facial Paralysis / Q000150:complications / Q000503:physiopathology; D019786:Gadolinium DTPA; D005776:Gaucher Disease / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D005910:Glioma / Q000098:blood supply / Q000473:pathology / Q000601:surgery; D006801:Humans; D007231:Infant, Newborn; D007430:Intraoperative Care; D008279:Magnetic Resonance Imaging; D008297:Male; D019635:Neurosurgical Procedures; D010477:Perfusion / Q000379:methods*; D011149:Pons / Q000098:blood supply / Q000473:pathology / Q000601:surgery; D025321:Surgery, Computer-Assisted / Q000295:instrumentation*
chemical_list: D003287:Contrast Media; D019786:Gadolinium DTPA