Jeremy N. Ciporen

Treatment of coil embolization failed recurrent giant basilar tip aneurysms with bypass and surgical occlusion

Giant basilar tip aneurysms are a challenge to treat because of the complex anatomy and critical vessels that arise in this region. For large aneurysms, with multiple recurrences after coiling, when microsurgical clipping is not possible, a bypass to the posterior cerebral artery (PCA) can be helpful in providing definitive treatment. Two patients with giant basilar tip aneurysms were treated with bypass to the PCA. One patient had a microsurgical clipping and the other had a proximal occlusion of the basilar artery along with the bypass. Long-term angiographic and clinical follow-up was obtained. One patient had marked improvement in symptoms and a stable aneurysm remnant and the other patient had complete occlusion. Surgical treatment with a bypass to the PCA, with clipping of the aneurysm or proximal ligation of the basilar artery can be an effective treatment option for giant basilar tip aneurysms.

Cerebral venous sinus thrombosis complicated by subdural hematomas: Case series and literature review

Background: Cerebral venous sinus thrombosis (CVST) can cause elevated intracranial pressure, hemorrhagic venous infarct, and cortical subarachnoid hemorrhage. We present a case series and literature review to illustrate that CVST can also present with subdural hematoma (SDH). Case Description: Chart review was completed on a retrospective case series of CVST with spontaneous SDH. We also conducted a literature search. Over a 6 year interval, three patients with CVST and SDH were admitted to the neurointensive care unit. A 38-year-old woman had both SDH and a hemorrhagic venous infarct associated with a transverse sinus thrombosis. She was managed conservatively with long-term anticoagulation. A 68-year-old woman presented with an acute SDH requiring craniotomy and a thrombosed cortical vein was noted intraoperatively. Computed tomography venography showed thrombosis of the superior sagittal sinus. She had polycythemia vera with the V617 Jak2 gene mutation and was managed with aspirin and hydroxyurea. A 60-year-old male had recurrence of a spontaneous convexity SDH requiring reoperation. Neuroimaging identified ipsilateral transverse sinus thrombosis with retrograde flow into the opposite sinus. Manometry demonstrated elevated venous pressures and these normalized after thrombectomy. Angiography performed after endovascular treatment demonstrated a normal venous drainage pattern. There have been limited reports of SDH complicating CVST in the literature. Conclusion: This case series and literature review demonstrates that CVST can also present with spontaneous SDH with or without associated venous infarctions. Treatment must be individualized. This is the first published description of endovascular thrombectomy for recurrent symptomatic SDH due to CVST.

Overall survival benefit associated with adjuvant radiotherapy in WHO grade II meningioma

Background Adjuvant radiotherapy (RT) after surgical resection of World Health Organization (WHO) grade II meningioma, also known as atypical meningioma (AM), is a topic of controversy. The purpose of this study is to compare overall survival (OS) with or without adjuvant RT after subtotal resection (STR) or gross total resection (GTR) in AM patients diagnosed according to the 2007 WHO classification. Methods The National Cancer Database was used to identify 2515 patients who were diagnosed with AM between 2009 and 2012 and underwent STR or GTR with or without adjuvant RT. Propensity score matching was first applied to balance covariates including age, year of diagnosis, sex, race, histology, and tumor size in STR or GTR cohorts stratified by adjuvant RT status. Multivariate regression according to the Cox proportional hazards model and Kaplan-Meier survival plots with log-rank test were then used to evaluate OS difference associated with adjuvant RT. Results GTR is associated with improved OS compared with STR. In the subgroup analysis, adjuvant RT in patients who underwent STR demonstrated significant association with improved OS compared with no adjuvant RT (adjusted hazard ratio [AHR] 0.590, P = .045); however, adjuvant RT is not associated with improved OS in patients who underwent GTR (AHR 1.093, P = .737). Conclusions Despite the lack of consensus on whether adjuvant RT reduces recurrence after surgical resection of AM, our study observed significantly improved OS with adjuvant RT compared with no adjuvant RT after STR.

Comprehensive Stroke Center Treatment and Outcomes for Elderly Adults with Cerebral Aneurysms and Subarachnoid Hemorrhage

nary artery disease and cancer). Two hundred sixty-five (37.2%) wanted to live to the age of 100. CCI (dichotomized) or chronic diseases, except CDR-SOB scores/use of medications for Alzheimer’s disease (related to each other, P < .001), were not significantly associated with this desire. The results of the logistic regression analyses are in Table 1), showing differences between age groups. Through 2010, 65 men (9.0%) had died. Mortality was significantly lower in those wishing to live to the age of 100 (6.0%) than of those not wishing to (11.0%, P = .03).

Tumor Treating Fields Utilization in a Glioblastoma Patient with a Preexisting Cardiac Pacemaker: The First Reported Case

BACKGROUND Tumor-treating fields (TTFs) have become an important, evidence-based modality in the treatment of glioblastoma (GBM). In patients requiring cardiac pacemakers, TTF therapy is complicated by theoretical concerns regarding possible electrical interaction between the devices. CASE DESCRIPTION A 57-year-old man with past medical history of sick sinus syndrome requiring cardiac pacemaker implantation suffered an acute neurologic change associated with a left parieto-occipital lesion, which was found to be GBM. After completion of guideline-concordant chemoradiation, he chose to undergo TTF therapy. Because of the absence of cardiac symptoms and the theoretical risk of far-field sensing by the pacemaker of the TTF device (potentially resulting in pacemaker inhibition), the pacemaker was turned off before receiving TTF. Following TTF implementation, the patient responded well; he remains alive more than 25 months following his GBM diagnosis, exceeding the median 20.9-month survival of the recently completed phase III TTF randomized clinical trial for newly diagnosed GBM. Furthermore, he has exhibited neither cardiac morbidity nor adverse scalp reactions to TTF therapy. CONCLUSIONS The first reported case of successful TTF administration in a GBM patient with a previously implanted cardiac pacemaker may allay the concerns of neuro-oncologists, cardiologists, radiation oncologists, and all certified TTF prescribers regarding the applicability of TTF in suitable candidates with preexisting cardiac pacemakers. This case indicates that TTF therapy may be efficacious in patients with indwelling magnetic resonance image-conditional cardiac pacemakers turned to the off position and that physical removal of the pacemaker is not necessary before starting TTF.

Surgical Parameters for Minimally Invasive Trans–Eustachian Tube CSF Leak Repair: A Cadaveric Study and Literature Review

BACKGROUND Cerebrospinal fluid rhinorrhea from a lateral skull base defect refractory to spontaneous healing and/or conservative management is most commonly managed via open surgery. Approach for repair is dictated by location of the defect, which may require surgical exploration. The final common pathway is the eustachian tube (ET). Endoscopic ET obliteration via endonasal and lateral approaches is under development. Whereas ET anatomy has been studied, surgical landmarks have not been previously described or quantified. We aimed to define surgical parameters of specific utility to endoscopic ET obliteration. METHODS A literature review was performed of known ET anatomic parameters. Next, using a combination of endoscopic and open techniques in cadavers, we cannulated the intact ET and dissected its posterior component to define the major curvature position of the ET, defined as the genu, and quantified the relative distances through the ET lumen. The genu was targeted as a major obstacle encountered when cannulating the ET from the nasopharynx. RESULTS Among 10 ETs, we found an average distance of 23 ± 5 mm from the nasopharynx to the ET genu, distance of 24 ± 3 mm from the genu to the anterior aspect of the tympanic membrane and total ET length of 47 ± 4 mm. CONCLUSIONS Although membranous and petrous components of the ET are important to its function, the genu may be a more useful surgical landmark. Basic surgical parameters for endoscopic ET obliteration are defined.

Minimally invasive endoscopic repair of refractory lateral skull base cerebrospinal fluid rhinorrhea: case report and review of the literature

Cerebrospinal fluid (CSF) leaks occur in approximately 10% of patients undergoing a translabyrinthine, retrosigmoid, or middle fossa approach for vestibular schwannoma resection. Cerebrospinal fluid rhinorrhea also results from trauma, neoplasms, and congenital defects. A high degree of difficulty in repair sometimes requires repetitive microsurgical revisions-a rate of 10% of cases is often cited. This can not only lead to morbidity but is also costly and burdensome to the health care system. In this case-based theoretical analysis, the authors summarize the literature regarding endoscopic endonasal techniques to obliterate the eustachian tube (ET) as well as compare endoscopic endonasal versus open approaches for repair. Given the results of their analysis, they recommend endoscopic endonasal ET obliteration (EEETO) as a first- or second-line technique for the repair of CSF rhinorrhea from a lateral skull base source refractory to spontaneous healing and CSF diversion. They present a case in which EEETO resolved refractory CSF rhinorrhea over a 10-month follow-up after CSF diversions, wound reexploration, revised packing of the ET via a lateral microscopic translabyrinthine approach, and the use of a vascularized flap had failed. They further summarize the literature regarding studies that describe various iterations of EEETO. By its minimally invasive nature, EEETO imposes less morbidity as well as less risk to the patient. It can be readily implemented into algorithms once CSF diversion (for example, lumbar drain) has failed, prior to considering open surgery for repair. Additional studies are warranted to further demonstrate the outcome and cost-saving benefits of EEETO as the data until now have been largely empirical yet very hopeful. The summaries and technical notes described in this paper may serve as a resource for those skull base teams faced with similar challenging and otherwise refractory CSF leaks from a lateral skull base source.

Combined Iron Oxide Nanoparticle Ferumoxytol and Gadolinium Contrast Enhanced MRI Defines Glioblastoma Pseudo-progression

BACKGROUND Noninvasively differentiating therapy-induced pseudoprogression from recurrent disease in patients with glioblastoma is prospectively difficult due to the current lack of a biologically specific imaging metric. Ferumoxytol iron oxide nanoparticle MRI contrast characterizes innate immunity mediated neuroinflammation; therefore, we hypothesized that combined ferumoxytol and gadolinium enhanced MRI could serve as a biomarker of glioblastoma pseudoprogression. METHODS In this institutional review board-approved, retrospective study, we analyzed ferumoxytol and gadolinium contrast enhanced T1-weighted 3T MRI in 45 patients with glioblastoma over multiple clinical timepoints. Isocitrate dehydrogenase 1 (IDH-1) mutational status was characterized by exome sequencing. Sum of products diameter measurements were calculated according to Response Assessment in Neuro-Oncology criteria from both gadolinium and ferumoxytol enhanced sequences. Enhancement mismatch was calculated as the natural log of the ferumoxytol to gadolinium sum of products diameter ratio. Analysis of variance and Students t-test assessed differences in mismatch ratios. P-value <0.05 indicated statistical significance. RESULTS With the development of pseudoprogression we observed a significantly elevated mismatch ratio compared with disease recurrence (P < 0.01) within IDH-1 wild type patients. Patients with IDH-1 mutation demonstrated significantly reduced mismatch ratio with the development of pseudoprogression compared with disease recurrence (P < 0.01). Receiver operator curve analysis demonstrated 100% sensitivity and specificity for the use of mismatch ratios as a diagnostic biomarker of pseudoprogression. CONCLUSION Our study suggests that ferumoxytol to gadolinium contrast mismatch ratios are an MRI biomarker for the diagnosis of pseudoprogression in patients with glioblastoma. This may be due to the unique characterization of therapy-induced neuroinflammation.

Crisis Management Simulation: Establishing a Dual Neurosurgery and Anesthesia Training Experience

Background: Simulation training has been shown to be an effective teaching tool. Learner management of an intraoperative crisis such as a major cerebrovascular bleed requires effective teamwork, communication, and implementation of key skill sets at appropriate time points. This study establishes a first of a kind simulation experience in a neurosurgery/anesthesia resident (learners) team working together to manage an intraoperative crisis. Methods: Using a cadaveric cavernous carotid injury perfusion model, 7 neurosurgery and 6 anesthesia learners, were trained on appropriate vascular injury management using an endonasal endoscopic technique. Learners were evaluated on communication skills, crisis management algorithms, and implementation of appropriate skill sets at the right time. A preanatomic and postanatomic examination and postsimulation survey was administered to neurosurgery learners. Anesthesia learners provided posttraining evaluation through a tailored realism and teaching survey. Results: Neurosurgery learners’ anatomic examination score improved from presimulation (33.89%) to postsimulation (86.11%). No significant difference between learner specialties was observed for situation awareness, decision making, communications and teamwork, or leadership evaluations. Learners reported the simulation realistic, beneficial, and highly instructive. Conclusions: Realistic, first of kind, clinical simulation scenarios were presented to a neurosurgery/anesthesia resident team who worked together to manage an intraoperative crisis. Learners were effectively trained on crisis management, the importance of communication, and how to develop algorithms for future implementation in difficult scenarios. Learners were highly satisfied with the simulation training experience and requested that it be integrated more consistently into their residency training programs.

Long-term stroke risk of single-fraction photon-based stereotactic radiosurgery for meningioma

OBJECTIVES A recent randomized study of fractionated radiation therapy (RT) examining 44 subtotally resected/recurrent benign meningioma patients revealed that at median follow-up of 17.1 years, the risk of stroke following proton-photon RT was 20.5%; the average stroke developed 5.6 years following RT completion (Sanford et al., 2017). This stroke risk is up to 10 times higher than the 2-6% rate expected for the general population of ages 40-79 (Mozaffarian et al., 2015). The stroke rate following single-fraction stereotactic radiosurgery (SRS) has not been previously studied in meningioma patients. PATIENTS AND METHODS A PubMed database search for relevant articles examining SRS for meningioma with minimum mean/median follow-up of six years was undertaken. Stroke rate was assessed either from direct description in manuscripts, or from extrapolating post-SRS complications from reported clinical examinations (i.e. hemiparesis/weakness, pituitary dysfunction following treatment of cavernous sinus lesions). Results were then culled to determine an overall stroke rate. RESULTS Fourteen studies met inclusion criteria; 1431 patients received photon-based SRS for meningioma with a sufficient long-term follow-up. Median/mean follow-up ranged from 75 to 144 months. Operative resection prior to SRS occurred in 769/1377 patients (55.8%) for whom surgical history was reported. Twenty-four patients suffered a stroke following SRS, yielding a rate of 1.7%. CONCLUSIONS The long-term stroke rate following single-fraction photon-based SRS for benign meningioma was 1.7%, more than twelve times lower than for fractionated proton-photon RT and comparable to that expected for the general population. The majority of patients underwent resection prior to SRS. These findings indicate that for patients with benign meningioma desiring to avoid the high stroke risk of fractionated proton-photon RT, SRS has a comparable stroke risk profile to observation. Such findings are pertinent for radiation oncology, neuro-oncology, and neurosurgery management of these patients.