Eric Barbarite

Awake craniotomy for brain tumor resection: The rule rather than the exception?

Objective: Awake craniotomy (AC) has seen an expanded role in brain tumor surgery over the past few decades. AC allows intraoperative cortical mapping and the continuous assessment of neurophysiological parameters, which are otherwise unattainable under general anesthesia (GA). The ability of AC to analyze eloquent brain areas makes it a powerful method for reducing the risks associated with tumor resection, especially in motor and language cortex. We present a review of the literature to examine the benefits and limits of using AC over GA. Methods: A literature search was performed using the Medline and PubMed databases from 1970 and 2012 that compared craniotomy for tumor resection under GA and AC. Data of interest included length of hospital stay, operating time, extent of resection, and neurological sequelae. Results: A total of 8 studies with 951 patients (411 utilizing AC and 540 utilizing GA) were included in this review. Our interpretation of the literature suggests that AC (4 d, n=110) results in a shorter hospital stay than GA (9 d, n=116). Mean extent of resection was slightly less under awake conditions (41%, n=321) versus GA (44%, n=444), and postoperative deficits were less frequent under awake conditions (7%, n=411) versus GA (23%, n=520). Surgery time was slightly less in the AC group (165 min, n=324) versus GA (168 min, n=477). Conclusions: Given the effectiveness of AC for resection of eloquent tumors, the data suggests an expanded role for AC in brain tumor surgery regardless of tumor location.

Search for Biomarkers of Intracranial Aneurysms: A Systematic Review

INTRODUCTION Intracranial aneurysms (IAs) remain a devastating clinical challenge, and the pathogenesis of IA formation and progression continues to be unclear. Biomarker analysis can help us understand IA development. The authors performed a systematic review of current literature on genetic and serum biomarkers for IAs in an attempt to identify diagnostic/prognostic factors for ruptured and unruptured aneurysms. METHODS All relevant studies on PubMed that reported blood/cerebrospinal fluid (CSF) biomarkers and genes that regulate biomarker levels for IAs were assessed for whether the biomarkers/genes studied correlated with IA formation and rupture. RESULTS Thirty-three studies were reviewed. IAs are associated with an increase in levels of immunologic markers, particularly complement C3 and C9, immunoglobulins IgG and IgM, M1/M2 macrophages, monocytes, and B and T lymphocytes; increase in blood and CSF levels of adhesion molecules; selectins found on vascular endothelium, platelets, and leukocytes; doubled ratios of elastase-to-alpha-1-antitrypsin as controls; elevated levels of neurofilament heavy chain SM135 and S-100 post rupture; and locus 19q13 with many candidate genes. CONCLUSION Though the pathophysiology of the disease remains unclear, the current literature supports the role of inflammatory and cell adhesion molecules, enzymes and hormones that effect cerebral vasculature, and other cerebral proteins related to brain and vascular damage in both the formation and progression to rupture of IAs. Future investigations are needed to validate results from previous studies and identify new diagnostic/prognostic biomarkers of IAs.

The Management of Intracranial Aneurysms During Pregnancy: A Systematic Review.

Hemodynamic changes during pregnancy may favor the formation and rupture of intracranial aneurysms. Despite this risk, guidelines for managing intracranial aneurysms during pregnancy have not been clearly defined. The objective of this review is to describe the treatment options for pregnant women with intracranial aneurysms, and to report the maternal and fetal outcomes associated with different treatment strategies. A search of the literature was conducted using the PubMed database for the period January 1991 through June 2015. Aneurysm characteristics and management, pregnancy management, and maternal and fetal outcomes were evaluated. The most recent search was performed in June 2015. In total, 50 aneurysms (44 patients) were evaluated. Rupture was confirmed upon imaging in 36 aneurysms (72%), and most aneurysms ruptured during the third trimester (77.8%). Coil embolization was associated with a lower complication rate than clipping in patients with ruptured aneurysms (9.5% vs 23.1%). For patients with unruptured aneurysms, surgical management was associated with 31.9% fewer complications compared to no treatment. Most patients underwent Cesarean delivery (84%), and a combined neurosurgical-obstetrical procedure was used for 8 patients with ruptured aneurysms near term. Adverse outcomes were reported in 11.9% of children. Treatment of intracranial aneurysms during pregnancy is safe and effective. Furthermore, we suggest that coil embolization be considered a first line treatment over clipping for surgical management of the pregnant population. Going forward, we encourage the establishment of formal guidelines for managing intracranial aneurysms during pregnancy.

Review of adult laryngotracheal stenosis: pathogenesis, management, and outcomes.

Purpose of reviewAdult laryngotracheal stenosis (LTS) is a potentially life-threatening disorder that can be difficult to diagnose and treat. Much is unknown regarding the etiology of airway stenosis, and while many patients do well with standard surgical management, the recurrence rate is significant. Few medical therapies exist, but there is a growing need. Recent findingsSeveral basic science studies have shown a role of inflammatory signaling pathways in the development of LTS. Infectious processes may also play a role in development of stenosis, while treatment with anti-inflammatory and immunosuppressive medications has shown some promise in preventing disease. Several risk factors, such as diabetes, BMI, length of stenosis, and need for T-tube, have been identified that portend worse surgical outcomes and may assist physicians in choosing appropriate treatment. SummaryWhile adult LTS is a complex, challenging clinical entity, there is promising research into the inflammatory origins of the disorder, which may open up groundbreaking new avenues of medical treatment.

Revisiting the Relationship Between Ethnicity and Outcome in Glioblastoma Patients

Background: Relationships between various ethnicities and glioma subtype have recently been established. As a tertiary referral center for Latin America and the Caribbean, our institution treats a diverse glioblastoma (GBM) population. We sought to clarify the role of ethnicity on patient prognosis in GBM and also compared these findings to a group consisting of elderly patients. We included ‘elderly’ as a group because the subgroups for ethnicities within them were too small. It allowed us to put in scope the effects of ethnicities on the overall survival. Material and Methods: After Institutional Review Board approval, 235 patients with GBM were retrospectively identified. A total of 140 patients were separated into four groups: White adults (n = 47), Hispanic adults (n = 27), elderly (n = 58), and Black adults (n = 6). Overall survival (OS) was our primary endpoint. Results: Overall survival in the White adult group was 24.3 months, compared to 13.0 months in the Hispanic adult group, 20.2 months in the Black group, and 13.8 months in the elderly group (p = 0.01). In the Hispanic group, hypertension (37.9%, p = 0.01) and diabetes (24.1%, p = 0.009) were significantly more prevalent compared to the White adult cohort. No difference in insurance status or postoperative complications was found between subgroups. Conclusion: Based on our analysis, Hispanic adults may have a decreased survival compared to White adults. However, the incidence of hypertension and diabetes was markedly higher in our Hispanic adult cohort; thus, estimating the risk of ethnicity and comorbidities on patient prognosis may be difficult. A prospective study correlating the genome and subgroup prognosis may help elucidate the role of ethnicity in GBM patients.

Open airway reconstruction in adults: Outcomes and prognostic factors

PURPOSE The purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6months post-operatively. MATERIALS AND METHODS Retrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables. RESULTS Thirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46-17.3; p=0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6months (HR 4.15, 95% CI 1.56-10.86; p=0.004). CONCLUSIONS Tracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.