Christina Huang Wright

Brain metastases: epidemiology

Brain metastases (BM) are the most commonly diagnosed type of central nervous system tumor in the United States. Estimates of the frequency of BM vary significantly, as there is no nationwide reporting system for metastases. BM may be the first sign of a previously undiagnosed cancer, or occur years or decades after the primary cancer was diagnosed. Incidence of BM varies significantly by primary cancer site. Lung, breast, and melanoma continue to be the leading cause of BM. These tumors are increasingly more common as new therapeutics, advanced imaging, and improved screening have led to lengthened survival after primary diagnosis for cancer patients. BM are difficult to treat, and for most individuals the diagnosis of BM generally portends a poor prognosis.

Effect of Dural Substitute and Technique on Cranioplasty Operative Metrics: A Systematic Literature Review

BACKGROUND Cranioplasty after decompressive craniectomy can be associated with significant morbidity. Dural substitutes during the initial decompression could improve outcomes. METHODS We performed a systematic literature review of online peer-reviewed databases to determine the effect of dural substitutes during decompressive craniectomy on operative metrics and outcomes after subsequent cranioplasty. RESULTS Nine studies from 2006 to 2018 had reported the results from 922 patients undergoing autologous cranioplasty. Seven types of dural substitute were described, including biologic and synthetic materials. Compared with no graft, the use of dural substitutes was associated with significantly decreased operative times and surgical blood loss during subsequent cranioplasty. One study evaluated dual-layer substitutes and documented superior results compared with single layer. The most commonly reported complications were infection and cerebrospinal fluid leak; however, a significant reduction in complications was seen in only 1 study. CONCLUSIONS The use of dural substitutes was associated with superior operative metrics, complication rates, and long-term outcomes.

Reliable Identification of Benign Clinical Course in Aneurysmal Subarachnoid Hemorrhage: A Simple and Qualitative Algorithm

BACKGROUND A reliable method to specifically identify low vasospasm risk in aneurysmal subarachnoid hemorrhage (aSAH) patients has not been previously proposed. OBJECTIVE To develop a clinical algorithm using admission aSAH clinical severity and subarachnoid blood distribution to identify patients at low risk of clinical vasospasm. METHODS Clinical severities, admission noncontrasted head computerized tomography (CT) scan, and incidences of vasospasm among 291 aSAH patients treated at our institution were evaluated. Admission head CTs were assessed for distributions of cisternal and ventricular blood. Patients with the following 4 criteria experienced considerably lower risk of vasospasm: (1) Hunt Hess grade 1 to 2, (2) Lack of thick subarachnoid blood filling 2 adjacent cisterns, (3) Lack of thick interhemispheric blood, and (4) Lack of biventricular intraventricular hemorrhage. RESULTS One hundred thirty-three patients (45.7%) developed cerebral vasospasm. Hunt Hess grade greater than 2 (odds ratio [OR] 4.52, 95% confidence interval [CI] 2.74-7.46), adjacent cistern blood (OR 4.1, 95% CI 2.51-6.7), interhemispheric thick blood (OR 5.72, 95% CI 3.41-9.59), and biventricular intraventricular hemorrhage (OR 1.92, 95% CI 1.19-3.02) were significant risk factors. Application of our algorithm yielded a sensitivity of 29%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 54.5%, which was superior compared to metrics from current institutional practice criteria. Inter-rater agreement was substantial at mean kappa = 0.75. CONCLUSION Application of our novel clinical algorithm produced successful identification of aSAH patients who experience zero risk of clinical vasospasm. Our algorithm is simple to apply with high reliability and is superior to currently available clinical and radiographic metrics.

Percutaneous transoral clivoplasty and upper cervical vertebroplasties for multifocal skeletal lymphangiomatosis resulting in complete resolution of pain: case report

Lymphangiomatosis is a rare congenital disorder that results in multiorgan system lymphatic invasion. Symptoms due to axial skeletal involvement can range from chronic bone pain to severe deformity resulting in radiculopathy, myelopathy, and even paralysis. The authors present a case of lymphangiomatosis of the clivus, C-1, and C-2, resulting in chronic pain. The patient was successfully treated with percutaneous transoral clivoplasty and vertebroplasty, without disease progression or return of symptoms at 2 years.

354 Diagnostic Utility of Cerebral Biopsy Following Suggestive Cerebral Angiogram in the Workup of Central Nervous System Vasculitis.

INTRODUCTION The gold standard for diagnosis of central nervous system vasculitis (CNSV) is cerebral biopsy. Cerebral angiography, however, has become a common diagnostic tool for workup of this disease. Few analyses have been performed which examine the value of angiography as a stand-alone diagnostic entity or the value of cerebral biopsy in the setting of positive angiography. METHODS A retrospective review was performed for all patients who underwent both cerebral angiography and cerebral biopsy for the workup of a presumptive diagnosis of CNSV at a single center from 2005 to 2016. The results were then subjected to statistical analyses. RESULTS A total of 57 patients over the period of 2005 to 2016 underwent angiography for workup of presumed CNSV. Twenty patients exhibited angiograms suggestive of vasculitis and 28 patients underwent cerebral biopsy. Only one was positive. The negative predictive value (NPV) for angiography was 94.11% (confidence interval, 71.31-99.85). Specificity was 59.26%. Positive predictive value (PPV) was unable to be calculated based on these data, given that angiography did not accurately predict biopsy diagnosis. Of note, the patient with biopsy-proven vasculitis exhibited negative angiography. Only 3.7% of biopsies were positive for vasculitis. CONCLUSION Cerebral angiography shows high NPV for CNSV. Angiography did not accurately predict diagnosis in a single case in this series. The prevalence of disease is too low to accurately ascertain PPV. Biopsy results are positive in a minority of cases; however, a large percentage of patients receive steroid treatment in the face of negative results. Cerebral biopsy may not be warranted in cases of positive angiography given the low likelihood of the disease. It may also not be indicated in cases of negative angiography given the high NPV. Surgical risks of cerebral biopsy can likely be avoided without significantly altering the course of treatment for many of these patients.

Ultrasound Guided Local Endovascular Coiling of an Iatrogenic Superficial Temporal Artery Pseudoaneurysm.

Pseudoaneurysms of the superficial temporal artery are rare and may be treated by manual compression, surgical intervention, coil embolization, or percutaneous thrombin injection. We present a novel technique of local ultrasound guided low-profile coil embolization of the superficial temporal artery with both satisfactory cosmetic and surgical results.