The object of this study was to identify characteristic preoperative angiographic and MR imaging features of safely resectable insular gliomas and describe the surgical techniques and postoperative ...clinical outcomes.
Thirty-eight patients with insular gliomas underwent transsylvian resection between 1995 and 2007. Patient demographics, presenting symptoms, pathological findings, and neurological outcomes were retrospectively reviewed. Preoperative MR imaging-defined tumor volumes were superimposed onto the preoperative stereotactic cerebral angiograms to determine whether the insular tumor was confined lateral to (Group I) or extended medially around (Group II) the lenticulostriate arteries (LSAs).
Twenty-five patients (66%) had tumors situated lateral to the LSAs and 13 (34%) had tumors encasing the LSAs. Insular gliomas situated lateral to the LSAs led to significant medial displacement of these vessels (161 +/- 39%). In 20 (80%) of these 25 cases the boundaries between tumor and brain parenchyma were well demarcated on preoperative T2-weighted MR images. In contrast, there was less displacement of the LSAs (130 +/- 14%) in patients with insular gliomas extending around the LSAs on angiography. In 11 (85%) of these 13 cases, the tumor boundaries were diffuse on T2-weighted MR images. Postoperative hemiparesis or worsening of a preexisting hemiparesis, secondary to LSA compromise, occurred in 5 patients, all of whom had tumor volumes that extended medial to the LSAs. Gross-total or near-total resection was achieved more frequently in cases in which the insular glioma remained lateral to the LSAs (84 vs 54%).
Insular gliomas with an MR imaging-defined tumor volume located lateral to the LSAs on stereotactic angiography displace the LSAs medially by expanding the insula, have well-demarcated tumor boundaries on MR images, and can be completely resected with minimal neurological morbidity. In contrast, insular tumors that appear to surround the LSAs do not displace these vessels medially, are poorly demarcated from normal brain parenchyma on MR images, and are associated with higher rates of neurological morbidity if aggressive resection is pursued. Preoperative identification of these anatomical growth patterns can be of value in planning resection.
Neurosurgeons generate an enormous amount of data daily. Within these data lie rigorous, valid, and reproducible evidence. Such evidence can facilitate healthcare reform and improve quality of care. ...To measure the quality of care provided objectively, evaluating the safety and efficacy of clinical activities should occur in real time. Registries must be constructed and collected data analyzed with the precision akin to that of randomized clinical trials to accomplish this goal.
The Quality Outcomes Database (QOD) Tumor Registry was launched in February 2019 with 8 sites in its initial 1-year pilot phase. The Tumor Registry was proposed by the AANS/CNS Tumor Section and approved by the QOD Scientific Committee in the fall of 2018. The initial pilot phase aimed to assess the feasibility of collecting outcomes data from 8 academic practices across the United States; these outcomes included length of stay, discharge disposition, and inpatient complications.
As of November 2019, 923 eligible patients have been entered, with the following subsets: intracranial metastasis (17.3%, n = 160), high-grade glioma (18.5%, n = 171), low-grade glioma (6%, n = 55), meningioma (20%, n = 184), pituitary tumor (14.3%, n = 132), and other intracranial tumor (24%, n = 221).
The authors have demonstrated here, as a pilot study, the feasibility of documenting demographic, clinical, operative, and patient-reported outcome characteristics longitudinally for 6 common intracranial tumor types.
Sinonasal organized hematomas (OHs) are rare lesions that primarily localize to the maxillary sinus. The rate of growth of these masses has not been described in the literature. We present a case of ...a 59-year-old gentleman with polyostotic fibrous dysplasia who presented with acute loss of vision in the left eye from an expanding OH of the sphenoid sinusitis. After expanded endonasal, transpterygoid approach and debulking, patient experienced significant vision improvement. Close follow-up imaging preoperatively allowed radiologic documentation of the rate of OH growth and this is presented in detail.
Objective To present a large series of patients and examine the learning curve of the endonasal endoscopic transplanum, transtuberculum approach for primarily suprasellar or sellar-suprasellar ...tumors. Methods We identified 122 patients who underwent 126 surgeries using the transplanum, transtuberculum approach. Extent of resection was determined with volumetric analysis of magnetic resonance imagings. Results concerning vision, endocrine function, and complications were noted. Results Average tumor volume was 14 cm3 . The most frequent pathologies were pituitary macroadenoma (51.6%), craniopharyngioma (20.6%), and meningioma (15.9%). A total of 73% patients presented with visual compromise. Rates of gross total resection (GTR) and near total resection for the group as a whole were 58.1% and 13.7%, and for the patients in whom GTR was intended ( n = 90), rates of GTR and near total resection were 77.5% and 12.5% for a total of 90%. Extent of resection in this group was 97.6%. Vision improved in 52.4% and deteriorated in 4.8%. Favorable endocrine outcome occurred in 63.5%. The cerebrospinal fluid leak rate was 3.1% for the series as a whole. It improved from 6.3% in the first half of the series to 0 in the second half. Leak rates varied with technique from 11% (fat graft only) to 4.2% (gasket seal only) to 1.8% (fat plus nasoseptal flap) to 0 (gasket plus nasoseptal flap). The rate of other complications was 14.3% in the first half of the series and 1.6% in the second half. There was one infection (0.8%). Conclusions The endonasal endoscopic transtuberculum transplanum approach is a safe and effective minimal access approach to midline pathology in the suprasellar cistern.
To describe the surgical techniques and postoperative clinical outcomes with the occipital transtentorial (OT) approach in patients harboring lesions arising from the precentral cerebellar fissure, ...posterior incisural space, and adjoining structures.
Twenty-two patients underwent microsurgical resection of intra-axial lesions arising within the precentral cerebellar fissure and posterior incisural space between 1997 and 2006. Patient demographics, presenting symptoms, pathology, and neurological outcomes were retrospectively reviewed. Pre- and postoperative magnetic resonance imaging scans were evaluated to determine the anatomic extensions of the lesion and the degree of surgical resection. Patients with lesions primarily confined to the pineal and posterior third ventricle approached by a supracerebellar infratentorial trajectory were excluded from this study.
Of the 22 patients reported in this series, 17 (77%) had contrast-enhancing lesions, and 5 (23%) had nonenhancing lesions arising from the precentral cerebellar fissure and posterior incisural space. The lesions were oriented dorsomedial to the midbrain and diencephalon in 6 patients (27%), dorsolateral in 14 patients (64%), and lateral in 2 patients (9%). A lateral OT approach directed under the occipitotemporal junction was used in 16 patients (73%), and an interhemispheric OT approach was used in 6 patients (27%). Transient visual field loss occurred in 3 patients (14%); it resolved by the third follow-up month. Gross total resection or near-total resection of the imaging-defined lesion volume was achieved in 19 patients (86%).
The OT approaches provide excellent exposure for lesions of the precentral cerebellar fissure, posterior incisural space, and adjacent structures. The lateral OT approach directed under the occipitotemporal junction provides an inline view for lesions situated posterolateral to the brainstem. It also provides an inferiorly directed view under the venous system into the precentral cerebellar fissure and fourth ventricular roof. Visual field deficits are minimized by directing the trajectory under the occipitotemporal junction instead of retracting along the interhemispheric corridor. The interhemispheric OT approach was primarily used for lesions extending superiorly, in the midline or near midline, above the tentorium and venous system into the splenium of corpus callosum, lateral ventricle, and posterior thalamus, where extensive lateral retraction was not required.
Summary
Purpose: Surgical resection of single, dominant, epileptogenic lesions in patients with tuberous sclerosis complex (TSC) is now accepted as an effective therapy. However, patients with ...symptomatic tubers in eloquent cortex are sometimes not offered surgery because of the concern for postoperative neurologic morbidity. In this study, we examine our results in children undergoing surgery for resection of tubers and associated seizure foci in rolandic and perirolandic cortex.
Methods: Between 1998 and 2008, 52 pediatric patients (mean age 4 years) with TSC underwent epilepsy surgery at the NYU Comprehensive Epilepsy Center. Fifteen of these patients underwent multistage surgery for invasive mapping of seizure foci and surrounding functional cortex followed by resection of tubers/seizure foci in or near rolandic cortex. Data were retrospectively collected and neurologic outcomes were tabulated.
Results: Postoperatively, four patients (27%) had either new hemiparesis or worsening of a preexisting hemiparesis. However, all patients were back to their neurologic baselines at 3‐month follow‐up, yielding no permanent postoperative deficits. The modified Engel outcome was class I in nine patients (60%), class II in three patients (20%), class III in two patients (13%), and class IV in one patient (7%) after 40 months mean follow‐up.
Discussion: Surgical resection of tubers and associated epileptogenic foci in rolandic and perirolandic cortex in children with TSC is feasible, with low neurologic morbidity, and yields good seizure control. These results suggest that tubers and perituberal epileptogenic foci can be safely resected even in eloquent regions because of reorganization of functional cortex or because these lesions contain no neurologic function.
Objective To review the authors' experience with Gamma Knife radiosurgery (GKR) for small recurrent high-grade gliomas (HGGs) following prior radical resection, external-beam radiation therapy ...(EBRT), and chemotherapy with temozolomide (TMZ). Methods The authors retrospectively analyzed 26 consecutive adults (9 women and 17 men; median age 60.4 years; Karnofsky Performance Status KPS ≥70) who underwent GKR for recurrent HGGs from 2004–2009. Median lesion volume was 1.22 cc, and median treatment dose was 15 Gy. Pathology included glioblastoma multiforme (GBM; n = 16), anaplastic astrocytoma (AA; n = 5), and anaplastic mixed oligoastrocytoma (AMOA; n = 5). Two patients lost to follow-up were excluded from radiographic outcome analyses. Results Median overall survival (OS) for the entire cohort from the time of GKR was 13.5 months. Values for 12-month actuarial survival from time of GKR for GBM, AMOA, and AA were 37%, 20% and 80%. Local failure occurred in 9 patients (37.5%) at a median time of 5.8 months, and 18 patients (75%) experienced distant progression at a median of 4.8 months. Complications included radiation necrosis in two patients and transient worsening of hemiparesis in one patient. Multivariate hazard ratio (HR) analysis showed KPS 90 or greater, smaller tumor volumes, and increased time to recurrence after resection to be associated with longer OS following GKR. Conclusions GKR provided good local tumor control in this group of clinically stable and predominantly high-functioning patients with small recurrent HGGs after radical resection. Meaningful survival times after GKR were seen. GKR can be considered for selected patients with recurrent HGGs.
To describe the surgical approaches, the radiographic and clinical outcomes, and the long-term follow-up of patients harboring thalamic pilocytic astrocytomas after radical resection by means of a ...stereotactic volumetric technique.
Seventy-two patients with thalamic pilocytic astrocytomas underwent stereotactic volumetric resection by the senior author (PJK) at the Mayo Clinic between 1984 and 1993 (44 patients) and at New York University Medical Center between 1993 and 2005 (28 patients). Patient demographics, presenting symptoms, surgical approaches, neurological outcomes, pathology, initial postoperative status, and long-term clinical and radiographic follow-up were retrospectively reviewed.
On preoperative neurological examinations, 54 of the 72 patients had neurological deficits; of these, 48 had hemiparesis. Postoperative imaging demonstrated gross total resection in 58 patients and minimal (<6 mm) residual tumor in 13 patients. Tumor resection was aborted in one patient. On immediate postoperative examination, 16 patients had significant improvements in hemiparesis. Six patients had worsening of a preexisting hemiparesis and one had a new transient postoperative hemiparesis. There was one postoperative death. After 13 to 20 years of follow-up in the Mayo group (mean, 15 +/- 3 yr) and 1 to 13 years of follow-up in the New York University group (mean, 8 +/- 3 yr), 67 patients were recurrence/progression-free, one had tumor recurrence, and three had progression of residual tumor. There were two shunt-related deaths. On long-term neurological follow-up, 27 patients had significant improvements in hemiparesis; one patient with a postoperative worsening of a preexisting hemiparesis remained unchanged. There were no patients with new long-term motor deficits after stereotactic resection.
Gross total removal of thalamic pilocytic astrocytomas with low morbidity and mortality can be achieved by computer-assisted stereotactic volumetric resection techniques. Gross total resection of these lesions confers a favorable long-term prognosis without adjuvant chemotherapy and/or radiation therapy and leads to the improvement of neurological deficits.
Abstract Objective The goal of the work described here was to assess the efficacy and safety of vagus nerve stimulation in a cohort of patients with tuberous sclerosis complex with refractory ...epilepsy. Furthermore, we examined the impact of vagus nerve stimulation failure on the ultimate outcome following subsequent intracranial epilepsy surgery. Methods A retrospective review was performed on 19 patients with refractory epilepsy and TSC who underwent vagus nerve stimulator (VNS) implantation. There were 11 (58%) females and 8 (42%) males aged 2 to 44 years when the VNS was implanted (mean: 14.7 ± 12 years). Twelve patients underwent primary VNS implantation after having failed a mean of 7.1 antiepileptic drugs. Two patients (17%) had generalized epilepsy, one had a single seizure focus, three (25%) had multifocal epilepsy, and six (50%) had multifocal and generalized epilepsy. Seven patients were referred for device removal and evaluation for intracranial procedures. One patient in the primary implantation group was lost to follow-up and excluded from outcome analysis. Results All implantations and removals were performed without permanent complications. The duration of treatment for primary VNS implants varied from 8.5 months to 9.6 years (mean: 4.9 years). Mean seizure frequency significantly improved following VNS implantation (mean reduction: 72%, P < 0.002). Two patients had Engel Class I (18%), one had Class II (9%), seven had Class III (64%), and one had Class IV (9%) outcome. Three patients with poor response to vagus nerve stimulation therapy at our center underwent resection of one or more seizure foci (Engel Class I, two patients; Engel Class III, one patient). Seven patients referred to our center for VNS removal and craniotomy underwent seizure focus resection (6) or corpus callosotomy (1) (Engel Class II: 2, Engel III: 2; Engel IV: 3). In total, 8 of 10 (80%) patients experienced improved seizure control following intracranial surgery (mean reduction: 65%, range: 0–100%, P < 0.05). Conclusions VNS is a safe and effective treatment option for medically refractory epilepsy in patients with tuberous sclerosis complex. Nine of 11 patients (82%) experienced at least a 67% reduction in seizure burden. Lack of response to vagus nerve stimulation does not preclude subsequent improvement in seizure burden with intracranial epilepsy surgery.
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