Decision-making in management of sporadic vestibular schwannoma aims to identify the most appropriate options based on tumor characteristics, symptoms, health, and goals for each patient. Advances in ...knowledge of tumor natural history, improvements in radiation techniques, and achievements in neurologic preservation with microsurgery have shifted emphasis toward maximizing quality of life using a personalized approach. To empower patients to make informed decisions, we present a framework to help match patient values and priorities with reasonable expectations from modern management options. Introduced herein are practical examples of communication strategies and decision aids to support shared decision-making in modern practice.
To examine the demographics, tumor characteristics, treatments, and clinical outcomes of a large adult craniopharyngioma population.
The 2004–2018 National Cancer Database was queried to investigate ...adult patients with craniopharyngioma. Univariable and multivariable Cox hazard ratio analysis was conducted to analyze the overall survival (OS) impact of demographic and clinical variables.
A total of 666 adult patients with craniopharyngioma were identified with a mean age of 51 years (standard deviation 16 years). On multivariable analysis, independent of demographic and clinical variables, increased age, uninsured status, Medicaid, Medicare, Charlson–Deyo Comorbidity Index of 2, and tumor size greater than 40 mm were independently associated with worse OS. There was no significant difference in survival between histologic subtypes. Gross total resection (GTR) (hazard ratio HR 0.602, 95% confidence interval CI 0.384–0.942, P = 0.026) and subtotal resection (STR) with adjuvant radiotherapy (HR 0.316, 95% CI 0.140–0.710, P = 0.005) were independently associated with improved OS. GTR with radiotherapy trended towards improved OS (HR 0.601, 95% CI 0.334–1.083, P =0.090), but STR alone and radiotherapy alone demonstrated no significant difference in survival compared with no treatment on multivariable analysis. Kaplan–Meier survival models demonstrated improved survival with GTR, GTR + radiation therapy, and STR + radiation therapy. Patients undergoing endoscopic resection had significantly lower GTR rates and greater rates of adjuvant radiotherapy compared with open approaches but no difference in OS.
Adult patients with craniopharyngioma who underwent GTR or STR with adjuvant radiotherapy had significantly improved overall survival. Endoscopic approaches had lower rates of GTR but no difference in OS.
Background
Stereotactic needle biopsy remains the cornerstone for tissue diagnosis for tumors located in regions of the brain that are difficult to access through open surgery.
Objective
We perform a ...meta-analysis of the literature to examine the relation between number of samples taken during biopsy and diagnostic yield, morbidity and mortality.
Methods
We identified 2416 patients from 28 cohorts in studies published in PubMed database that studied stereotactic needle biopsies for tumor indications. Meta-analysis by proportions and meta-regression analyses were performed.
Results
On meta-analysis, the morbidity profile of the published needle biopsy studies clustered into three groups: studies that performed < 3 samples (n = 8), 3–6 samples (n = 13), and > 6 samples during biopsy (n = 7). Pooled estimates for biopsy related morbidity were 4.3%, 16.3%, and 17% for studies reporting < 3, 3–6, and > 6 biopsy samples, respectively. While these morbidity estimates significantly differed (p < 0.001), the diagnostic yields reported for studies performing < 3 biopsies, 3–6 samples, and > 6 samples were comparable. Pooled estimates of diagnostic yield for these three groups were 90.4%, 93.8%, and 88.1%, respectively. Mortality did not significantly differ between studies reporting differing number of samples taken during biopsy.
Conclusions
Our meta-analysis suggests that morbidity risk in needle biopsy is non-linearly associated with the number of samples taken. There was no association between the number of biopsies taken, and diagnostic yield or mortality.
Balloon test occlusion is a widely used method for predicting tolerance of vessel occlusion in the treatment of aneurysms, fistulae, and head and neck neoplasms. However, the false-negative rate is ...variably reported due in part to the diversity of perfusion monitoring methods.
To evaluate the rate of symptomatic ischemic events after a negative balloon test occlusion and determine whether perfusion monitoring methods contribute to differences in these rates.
PubMed was systematically searched for studies between 1990 and 2020 that reported rates of ischemic outcomes of parental vessel occlusion in patients who passed balloon test occlusion. A generalized linear mixed model meta-analysis was performed. Results were expressed as the rate of symptomatic ischemic events after parental vessel occlusion without vessel bypass in patients who passed balloon test occlusion.
Thirty-two studies met the inclusion criteria. The overall pooled rate of ischemic events after passing balloon test occlusion was 3.7% (95% confidence interval CI: 1.7–7.8). This rate was 3.8% (95% CI: 1.1–12.8) when monitored with angiography, 2.2% (95% CI: 0.4–10.2) when monitored by a form of computed tomography, and 5.3% (95% CI: 1.2–20.4) when monitored by 2 or more methods of perfusion assessment. The complication rate of balloon test occlusion was 0.8% (95% CI: 0.2–2.7).
Balloon test occlusion results in a low rate of subsequent ischemic events, without conclusive evidence of variation between methods of perfusion assessment. The choice of method should focus on reduction of complication risk, experience of the interventional team, and avoidance of prolonged test occlusion times.
Purpose
Pituitary apoplexy is a rare endocrine emergency. The purpose of this study is to characterize physiological changes involved in pituitary apoplexy, especially during the acute phase.
Methods
...A Cushing’s disease patient experienced corticotroph releasing hormone (CRH)-induced pituitary apoplexy during inferior petrosal sinus sampling (IPSS). The IPSS blood samples from the Cushing’s disease patient were retrospectively analyzed for cytokine markers. For comparison, we also analyzed cytokine markers in blood samples from two pituitary ACTH-secreting microadenoma patients and one patient with an ectopic ACTH-secreting tumor.
Results
Acute elevation of interleukin 6 (IL-6) and matrix metalloproteinase 9 (MMP9) was observed in the IPSS blood sample on the apoplectic hemorrhagic site of the tumor. In contrast, such a change was not observed in the blood samples from the contralateral side of the apoplexy patient and in other IPSS samples from two non-apoplexy Cushing’s disease patient and a patient with ectopic Cushing’s syndrome.
Conclusion
IL-6 and MMP9 may be involved in the acute process of pituitary apoplexy in Cushing’s disease.
Abstract
BACKGROUND
Gross total resection (GTR) of contrast-enhancing tumor is associated with increased survival in primary glioblastoma. Recently, there has been increasing interest in performing ...supratotal resections (SpTRs) for glioblastoma.
OBJECTIVE
To address the published results, which have varied in part due to lack of consensus on the definition and appropriate use of SpTR.
METHODS
A crowdsourcing approach was used to survey 21 neurosurgical oncologists representing 14 health systems nationwide. Participants were presented with 11 definitions of SpTR and asked to rate the appropriateness of each definition. Participants reviewed T1-weighed postcontrast and fluid-attenuated inversion-recovery magnetic resonance imaging for 22 anatomically distinct glioblastomas. Participants were asked to assess the tumor location's eloquence, the perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans.
RESULTS
Most neurosurgeons surveyed (n = 18, 85.7%) agree that GTR plus resection of some noncontrast enhancement is an appropriate definition for SpTR. Overall, moderate inter-rater agreement existed regarding eloquence, equipoise, and personal treatment plans. The 4 neurosurgeons who had performed >10 SpTRs for glioblastomas in the past year were more likely to recommend it as their treatment plan (P < .005). Cases were divided into 3 anatomically distinct groups based upon perceived eloquence. Anterior temporal and right frontal glioblastomas were considered the best randomization candidates.
CONCLUSION
We established a consensus definition for SpTR of glioblastoma and identified anatomically distinct locations deemed most amenable to SpTR. These results may be used to plan prospective trials investigating the potential clinical utility of SpTR for glioblastoma.
Telomerase supports the proliferation of progenitor cells and tumor cells by adding telomere repeats to chromosome ends. The low abundance and restricted expression pattern of telomerase have ...limited our knowledge of this important enzyme. A new telomerase protein, TCAB1, sheds light on the pathway that governs telomerase holoenzyme assembly and function in vivo. TCAB1 is a component of active telomerase and is required for the telomerase holoenzyme to accumulate in Cajal bodies and to elongate telomeres. These findings provide important new insights into how telomerase functions in cancer and in stem cell biology.
•Exploring influence of race on surgical recommendations for skullbase chondrosarcomas.•Disparity against African-Americans for surgical resection of skull base chondrosarcomas.•Results raise ...awareness among neurosurgical care providers regarding racial disparity.
There is increased appreciation of racial disparities in the delivery of neurosurgical care. Here, we explore whether race influences surgical recommendations in the management of skull base chondrosarcomas.
We identified 493 patients with skull base chondrosarcoma using the Surveillance, Epidemiology, and End Results (SEER) registry (November 2017 submission). Regression analyses were performed to identify demographic variables associated with recommendation against surgery. Univariate and multivariate cox proportional hazards models were used for survival analysis.
In a univariate analysis, we found that the African-American race was associated with an increased likelihood of surgeon recommendation against surgery (OR = 4.416, 95% CI = 1.893–10.302, p = 0.001). This association remained robust in the multivariate model that controlled for other covariates, including age of diagnosis (OR = 5.091, 95% CI = 2.127–12.187, p < 0.001). For patients who received a recommendation against surgery, the likelihood of dying from non-chondrosarcoma causes was comparable between Caucasian and African-American patients, suggesting that the prevalence and severity of medical conditions that increase the risk of death were comparable between these cohorts (HR = 0.466, 95% CI = 0.057–3.802, p = 0.475). The likelihood of dying from chondrosarcoma was comparable between Caucasian and African-American patients who underwent surgery (HR = 0.982, 95% CI = 0.353–2.732, p = 0.973), suggesting absence of race-specific surgical benefits.
We identified a racial disparity against African-Americans in recommendations for surgical resection of skull base chondrosarcomas.
Abstract
Aneurysms of the posterior circulation pose a unique challenge due to higher rupture rates, higher recurrence rates following endovascular treatment, and extended open cranial base ...approaches required to reach the ventrally located brainstem circulation. While endovascular therapy has made tremendous strides in successful treatment for most posterior circulation aneurysms, open microscopic approaches remain essential in specific circumstances. Here, we present a case of a patient who presented with acute, severe headache, and sixth nerve palsies, and who was found to have hydrocephalus and a dissecting aneurysm at the anterolateral medullary segment of the posterior inferior cerebellar artery (PICA). Interestingly, this patient had a history of alpha-1 antitrypsin deficiency that has been linked with spontaneous aortic and cervical arterial dissections. The fusiform geometry of the dissecting aneurysm was deemed suboptimal for endovascular treatment, so an open microsurgical approach for occipital artery to PICA bypass and aneurysm trapping was planned. Because this patient had cerebral edema in the setting of a ruptured aneurysm and hydrocephalus, a far lateral craniotomy combined with drilling of the occipital condyle and jugular tubercle was critical to enhance exposure of the first segment of the PICA and to minimize brain retraction. In this video, we highlight the key steps and nuances for harvest of the occipital artery, achieving control of the extracranial vertebral artery, performing the transcondylar and transtubercular far lateral approach, and bypass with trapping technique for these challenging posterior circulation aneurysms.
The link to the video can be found at: https://youtu.be/dqgblwX6t0Q.
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