Diana G. Douleh

Type 2 Diabetes Mellitus is an Independent Risk Factor for PostoperativeComplications in Patients Surgically Treated for Meningioma

Objectives: Increased risk of perioperative complications in patients with type 2 diabetes mellitus (DM) has previously been noted with regard to a number of different operations. We sought to study the relative rates of postoperative complications after the surgical resection of an intracranial meningioma based on a pre-existing diagnosis of diabetes. Methods: We conducted a retrospective cohort study on 259 patients who underwent a primary meningioma resection at our institution between 2001-2013. The medical record was reviewed to identify a pre-existing diagnosis of type 2 DM and any postoperative complications prior to discharge. The duration of postoperative hospital stay, intensive care unit (ICU) stay, perioperative changes in Karnofsky Performance Status (KPS) scores, and any postoperative emergency department (ED) presentation within 90 days of the operation were also recorded for each patient. Multivariable logistic regression models were built to determine the impact of a history of diabetes on postoperative complications and post-discharge presentation to the ED. Multivariable linear regression models were designed to assess the predictors of lengthier hospitalization and ICU stays in addition to differential postoperative changes in KPS scores. Results: Forty-one (16%) patients had diagnoses of type 2 DM prior to clinical presentation. In multivariate analyses, patients with a pre-existing history of diabetes had a higher risk of postoperative complications, postoperative ED presentation, and deterioration in functional status in addition to lengthier durations of hospitalization and ICU stay (p<0.001, p=0.008, p<0.001, p=0.007, p<0.001). Conclusions: Patients with pre-existing diagnoses of type 2 DM have a significantly increased risk of immediate postoperative complications following the resection of an intracranial meningioma. Type 2 DM also predicts increased lengths of postoperative hospital stay, decreased postoperative performance status, and increased risk of postoperative ED presentation.

Comparison of Ankle Fusion Rates With and Without Anterior Plate Augmentation.

Background: The optimal fixation construct for tibiotalar arthrodesis continues to be debated. While biomechanical data and clinical series support anterior plate augmentation, comparative studies assessing its use are sparse. The purpose of this study was to compare the rates of successful tibiotalar arthrodesis with and without anterior plate augmentation of a compression screw construct. Methods: We studied 64 patients (65 ankles) undergoing tibiotalar arthrodesis done by a single surgeon over a 10-year period (2006-2016) with anterior plate augmentation beginning in 2010. Twenty-six ankles had a construct using compression screws only and 39 ankles had anterior plate augmentation of a compression screw construct. We reviewed clinical notes, operative reports, and postoperative radiographs to evaluate for union, incidence of revision, and postoperative complications. Results: The nonunion rate in the compression screw (CS) cohort was 15.4% and 7.7% in the anterior plate augmentation (AP) cohort (P = .33). The revision rate was 7.7% in the CS group and 2.6% in the AP cohort (P = .34). The use of autograft harvested through a separate incision was 19.2% and 17.9% in the CS and AP cohorts, respectively. There were 2 deep postoperative infections in the AP group and none in the patients with CS only (P = .24). There were no superficial wound complications in either group. Conclusion: Anterior plate augmentation was a viable fixation strategy in tibiotalar arthrodesis. In a trend toward an improved rate of fusion and decreased revision rate in the anterior plate augmentation cohort. Level of Evidence: Level III, retrospective comparative series.

Intracranial Marginal Zone B-Cell Lymphoma Mimicking Meningioma.

BACKGROUND Marginal zone B-cell lymphoma of the meninges is a rare pathologic subtype of central nervous system lymphoma that can mimic the radiologic appearance of meningioma. CASE DESCRIPTION We present a unique case of a 57-year-old man who presented with neurologic symptoms of severe headache, memory loss, mental status changes, and depression. Subsequent magnetic resonance imaging of the brain demonstrated an enhancing mass tracking along the anterior falx and anterior skull base with extension into the ethmoid sinus, which was radiographically consistent with meningioma. However, pathologic examination revealed numerous sheets of plasma cells and plasmacytoid lymphocytes that were immunopositive for CD20. These combined features were indicative of marginal zone B-cell lymphoma. No evidence of systemic disease was found. CONCLUSIONS Although rare, marginal zone B-cell lymphoma must be considered in the differential diagnosis of an extra-axial enhancing mass. We review the contemporary literature and discuss preoperative radiologic differentiation of these 2 very different histopathologies.

Actinomycosis Mimicking Tolosa-Hunt Syndrome in a 6-Year-Old Boy: Case Report

Tolosa-Hunt syndrome is an idiopathic inflammatory process of the cavernous sinus or orbit manifesting as painful ophthalmoplegia. In this report, we detail the case of a 6-year-old boy who presented with several weeks of unilateral headache and diplopia. He was found to have an infiltrative process involving the bilateral cavernous sinuses and pituitary gland on MRI. Given a progressing infiltrative central nervous system process on repeat MRI and the development of cerebral salt wasting, a biopsy was performed revealing actinomycosis. To our knowledge, this is the first reported case of actinomycosis masquerading as Tolosa-Hunt syndrome in a child.

Early postoperative emergency department presentation predicts poor long-term outcomes in patients surgically treated for meningioma

Previous authors have identified a number of factors that predict morbidity, mortality, and recurrence in patients undergoing resection of a meningioma. We sought to study a novel potential prognostic indicator: early postoperative visit to the emergency department (ED). We conducted a retrospective cohort study on 239 patients who underwent a meningioma resection at our institution between 2001 and 2013 with over 3 months of follow-up postoperatively. All postoperative entries in the medical record were reviewed to identify any ED visit with a neurologic or wound-related complaint within a 90 day postoperative period. The relationships between ED presentation, tumor grade, and extent of surgical resection with future risk of operative recurrence and mortality were analyzed using Fishers exact test. Variables associated with increased risks of mortality or operative recurrence in a univariate analysis were then included in the multivariate logistic regression model. Patients with a postoperative ED visit were found to be significantly more likely to die during the follow-up period (23.0% versus 4.85%, p<0.0001) or develop an eventual operative recurrence (12.2% versus 3.0%, p=0.0131). Postoperative ED presentation was found to be associated with a higher risk of mortality and operative recurrence independent of pathological tumor grade (p<0.0001 and p=0.0102, respectively). Presentation to the ED is associated with significantly higher rates of future operative recurrence and mortality in patients with recent meningioma resections. This poor prognostic relationship is independent of tumor pathological grade. Increased vigilance and follow-up may be warranted in such patients.

Type 2 diabetes is an independent negative prognostic factor in patients undergoing surgical resection of a WHO grade I meningioma.

OBJECTIVES In recent years, there has been increased recognition of the relationship between type 2 diabetes mellitus (DM) and poor outcomes following a variety of surgical procedures. We sought to study the role of type 2 DM as a prognostic factor affecting the long-term survival of patients undergoing surgical resection of a WHO Grade I meningioma. METHODS We conducted a retrospective cohort study on 196 patients who had a WHO Grade I meningioma resected at our institution between 2001 and 2013. The medical record was reviewed to identify a pre-existing diagnosis of type 2 DM. Patient mortality was reviewed by medical record and Social Security Death Index (SSDI). Variables associated with survival in a univariate analysis were included in the multivariate Cox model if P<0.10. Variables with probability values >0.05 were then removed from the multivariate model in a step-wise fashion. RESULTS 33 (17%) patients had pre-existing diagnoses of type 2 DM prior to clinical presentation. Mean survival time in diabetic patients was 52.1 months compared to 160.9 months in non-diabetics. The decreased survival rate and time in patients with type 2 DM were found to be statistically significant (p=0.008 and p<0.0001, respectively). In a multivariate Cox analysis, a pre-existing history of type 2 DM was independently associated with decreased survival following the resection of a WHO Grade I meningioma (HR=2.6, p=0.045). CONCLUSIONS A pre-existing diagnosis of type 2 DM is an independent negative prognostic indicator following the resection of a WHO Grade I meningioma.

Angioplasty is an Effective Treatment for Vasospasm Following Pituitary Apoplexy and Tumor Resection

Pituitary apoplexy is a clinical syndrome characterized by acute headache, visual changes, and decreased consciousness occurring in association with hemorrhage or infarct of an existing pituitary adenoma. Surgical management involves tumor resection and decompression of surrounding structures including the optic apparatus. Vasospasm is a rare but potentially devastating complication of pituitary apoplexy. We present a case of pituitary apoplexy in a 28-year-old male treated with emergent endoscopic transsphenoidal resection. On postoperative day seven, following surgical resection, the patient developed neurologic deficits and motor weakness, and severe vasospasm was diagnosed. This is a novel case of intra-arterial verapamil and angioplasty used to treat vasospasm following surgical decompression for pituitary apoplexy. The patient experienced complete recovery of motor deficits following treatment. The authors propose angioplasty as an effective treatment for postoperative vasospasm following transphenoidal surgery for pituitary apoplexy in the presence of focal vessel stenosis.