Joshua Loewenstern

Is Psychiatric Depression a Presenting Neurologic Sign of Meningioma? A Critical Review of the Literature with Causative Etiology

BACKGROUNDnBenign meningiomas constitute 80%-90% of all meningiomas and represent the most common type of central nervous system tumor in adults. The vast majority of meningiomas are minimally symptomatic or asymptomatic early in their onset and thereby can often result in delayed diagnosis. Early diagnosis of meningioma is critical, as it can maximize treatment options and improve outcomes and survival. Although seizures and focal neurologic deficits are considered to be the most prevalent symptoms, depression also may be an important and significant sign. A subtle neurologic depression may be an even early presenting sign of meningioma and may precede more traditional presenting symptoms.nnnMETHODSnWe performed a comprehensive literature review that analyzes the results of prospective studies and case reports on this topic.nnnRESULTSnOur findings show evidence to suggest that depression may be correlated with meningioma presentation. Its prevalence is possibly increased with an anterior location of the tumor.nnnCONCLUSIONSnFor patients who exhibit nuances of depression without a history of psychiatric illness, an index of suspicion for meningioma may be warranted.

Diabetes Comorbidity Increases Risk of Postoperative Complications in Traumatic Thoracic Vertebral Fracture Repair: A Propensity Score Matched Analysis

BACKGROUNDnThoracic vertebral fracture repair after a traumatic injury can be associated with significant risk for postoperative complications. Surgical outcomes are further complicated by patient comorbidity, particularly diabetes mellitus. This study compared outcomes and complication rates for traumatic thoracic vertebral fracture repair in a matched sample of patients with diabetes and nondiabetic control subjects.nnnMETHODSnPatients with a surgical repair of a trauma-induced thoracic vertebral fracture treated from 2010 to 2015 were identified from the Trauma Quality Improvement Program database, yielding 5557 cases. Patients with comorbid diabetes were matched by propensity score matching (PSM) with patients without diabetes on age, race, and body type and were compared by postoperative complications and clinical outcomes.nnnRESULTSnPrior to PSM, the diabetes group was older on average and had a greater proportion of patients who were obese (Ps < 0.001). After PSM, each group consisted of 544 patients (Nxa0= 1088) and no longer differed by any baseline characteristic. Comorbid diabetes was associated with longer average length of hospital stay and greater frequency of several major and minor postoperative complications (Ps < 0.05), including prolonged intensive care, pneumonia, acute renal failure, stroke, pressure ulcers, and urinary tract infections, but no differences were found in reoperation rates or in-hospital mortality.nnnCONCLUSIONSnDiabetes comorbidity can significantly increase the risk of postoperative complications after traumatic thoracic vertebral fracture repair, which may lead to delayed recovery and greater health care-related costs. This finding is an important consideration for surgical decision-making and patient counseling on treatment options with this comorbid condition.

Optical Coherence Tomography in the Management of Skull Base Fibrous Dysplasia with Optic Nerve Involvement

BACKGROUNDnFibrous dysplasia (FD) of the skull base can manifest with optic nerve compression. As most patients initially do not experience vision loss, controversy exists whether to proceed with prophylactic surgical decompression or elect for conservative observation. Optical coherence tomography (OCT), a physiologic imaging modality widely used to assess the condition of the retinal nerve fiber layer (RNFL), has been useful in monitoring compressive tumors on the optic nerve. This study evaluated potential use of OCT in management of patients with fibrous dysplasia and optic nerve involvement.nnnMETHODSnSix patients with suspected optic nerve compression who underwent OCT imaging as part of a neuro-ophthalmic examination were reviewed over a 2-year period. Patient records were evaluated for visual examination measures, most notably the presence of optic neuropathy, and radiographic measures on computed tomography. Measures were compared by age-adjusted RNFL thickness (above or below fifth percentile) on OCT imaging.nnnRESULTSnTwo patients were found to have mild optic neuropathy in 1 eye each. Three of 12 eyes fell below the age-adjusted fifth percentile of RNFL thickness. Presence of optic neuropathy was associated with abnormal age-adjusted RNFL thickness but not with optic nerve compression (Pxa0= 0.45).nnnCONCLUSIONSnAbnormal RNFL thickness as measured by OCT better predicted the presence of optic neuropathy than computed tomography alone. OCT may be a valuable imaging modality to monitor patients with fibrous dysplasia for development of optic neuropathy during periods of conservative watchful waiting.

Peritumoral Edema Relative to Meningioma Size Predicts Functional Outcomes after Resection in Older Patients

BACKGROUNDnResection of meningiomas in older adults is associated with increased complications and postoperative functional deficits. Extent of peritumoral edema (PTE), which has been associated with surgical prognosis, may represent a preoperative risk marker for poorer outcomes in older adults.nnnOBJECTIVEnTo quantitatively evaluate the relationship between preoperative PTE and postresection outcomes in older meningioma patients.nnnMETHODSnOne hundred twelve older meningioma patients (agexa0≥xa060) with evidence of PTE on MRI were reviewed. Extent of PTE, measured as a ratio of edema to tumor volume (edema index, EI) using semiautomatic image-processing software, was correlated with postresection outcomes. Other preoperative factors were included as covariates in multivariate analyses. Results were compared to matched nonedema older patients. Receiver operating characteristic (ROC) curve analysis was performed to identify cut-off EI values to predict postoperative outcomes.nnnRESULTSnEI was associated with functional decline (as measured by Karnofsky Performance Status, KPS) at 6 mo, 1, 2 yr, and most recent follow-up (Psxa0<xa0.05), but not among the nonedema matched patients. Seizure or prior stroke additionally trended towards increasing the likelihood of lower KPS at 2 yr (odds ratioxa0=xa03.06) and last follow-up (odds ratioxa0=xa05.55), respectively. ROC curve analysis found optimal cut-off values for EI ranging from 2.01 to 3.37 to predict lower KPS at each follow-up interval. Sensitivities ranged from 60% to 80%, specificities from 78% to 89%, and positive and negative predictive values from 38% to 58% and 80% to 97%.nnnCONCLUSIONnPreoperative PTE may represent a significant marker of poor functional outcome risk in older adults and provides a quantitative measurement to incorporate into surgical decision-making.

Patient Radiation Exposure in Transradial versus Transfemoral Yttrium-90 Radioembolization: A Retrospective Propensity Score–Matched Analysis

PURPOSEnTo compare differences in patient radiation exposure (PRE) during transarterial yttrium-90 (90Y) radioembolization (TARE) between transradial access (TRA) and transfemoral access (TFA).nnnMATERIALS AND METHODSnA total of 810 consecutive first-time TARE procedures in patients from 2013 to 2017 were retrospectively reviewed. A propensity score-matching (PSM) analysis matched TRA and TFA groups on the basis of patient age, sex, weight, height, cancer type, 90Y microsphere type, and number of previous procedures from the same and opposite approaches. Matched groups were then compared by PRE measures fluoroscopy time (FT), dose-area product (DAP), and cumulative air kerma (AK). Effect size for each PRE measure was calculated.nnnRESULTSnBefore PSM, TRA and TFA groups differed significantly in mean age, weight, and number of previous procedures from the same and opposite approach (all P < .05). After PSM, each group consisted of 302 procedures (overall, nxa0= 604) and no longer differed in any procedure performed before surgery measure. TRA did not differ from the matched TFA group regarding median FT (9.50 vs 9.40 minutes, Pxa0= .095), median DAP (67,066 vs 67,219 mGy·cm2; Pxa0= .19), or median AK (323.63 vs 248.46 mGy; Pxa0= .16). Effect sizes were 0.068, 0.054, and 0.110 for FT, DAP, and AK, respectively.nnnCONCLUSIONSnNo statistical differences were found for PRE measures between the matched TRA and TFA approach groups. Furthermore, practical effect sizes were considered to be small for AK and less than small for FT and DAP, and therefore, any differences in PRE between the radial and femoral approaches for TARE are minor and unlikely to be noticeable in everyday clinical practice.

Primary management of atypical meningioma: treatment patterns and survival outcomes by patient age

PurposeThe initial management of atypical meningiomas poses a distinct clinical challenge in that treatment protocols have not been fully established, and outcomes, especially differences by patient age, have not been broadly measured. The National Cancer Database (NCDB) allows for analysis of a large, diverse patient population to determine clinical parameters and survival outcomes based on the initial treatment of patients with atypical meningiomas.MethodsAnalysis of the NCDB yielded 3611 atypical meningioma patients treated between 2008 and 2012. Principal treatment paradigms included surgery with or without radiation. Survival estimates were calculated using Kaplan–Meier curves stratified by age at diagnosis for each treatment paradigm. Subset analysis was performed for socio-economic factors.ResultsOverall 5-year survival rate was 77.6% and declined with increasing patient age (pu2009<u20090.0001). Five-year survival for patients ≤u200945xa0years undergoing surgery alone was 89.3 vs. 44.4% for those >u200975xa0years (pu2009<u20090.0001). For patients undergoing surgery with adjuvant radiation, 5-year survival was 93.7% in those ≤u200945xa0years and 54.1% in those >u200975xa0years (pu2009<u20090.0001). Use of adjuvant radiation was stable over time. Private-insured patients were more likely to receive adjuvant radiation (pu2009=u20090.0001).ConclusionsPatients treated for atypical meningioma have high rates of 5-year survival. A marginal survival benefit of adjuvant radiation was observed for patients <u200955 and >u200975xa0years, while patients between 55 and 75xa0years tended to have slightly improved survival with surgery alone. Though surgery remains the standard of care in the primary treatment of atypical meningioma, the decision to administer radiation post-operatively has remained controversial.

Cerebral Radiation Necrosis: An Analysis of Clinical and Quantitative Imaging and Volumetric Features

BACKGROUNDnRadiation therapy is an effective treatment for primary brain tumors and intracranial metastases but can occasionally precede new enhancing lesions on imaging studies that are difficult to discern between tumor recurrence (TR) and radiation necrosis (RN). The aim of this study was to identify clinical presentation and imaging patterns of RN compared with TR that may obviate the need for invasive definitive biopsy.nnnMETHODSnPatients who received radiation therapy and subsequently presented with a new intracranial lesion were reviewed from 2001 to 2016; 27 patients were identified with adequate records and confirmed pathology to have RN present or TR only. Patient and lesion characteristics were assessed using univariate and multivariate logistic regression analyses. Sensitivity and specificities were calculated for imaging features and quantitatively segmented lesion and edema volumes for identifying RN.nnnRESULTSnKarnofsky performance scale score at presentation significantly predicted pathologic diagnosis on univariate analysis (Pxa0= 0.044). Radiation dosage and time from radiation therapy to lesion onset did not differ among pathologic diagnosis groups. No differences existed between RN and TR on quantitative imaging analyses. Multivariate logistic regression found higher Karnofsky performance scale score to be an independent factor associated with TR relative to RN (odds ratio 1.26, 95% confidence interval 1.02-1.56, Pxa0= 0.030).nnnCONCLUSIONSnDiagnostic imaging can often be inaccurate in detecting RN alone, even with quantitative volume assessment. Functional status on repeat presentation may increase the likelihood of accurate diagnosis before definitive biopsy when neuroimaging remains unclear.

Cervical Burst Fracture in a Patient with Contiguous 2-Level Cervical Stand-Alone Cages

BACKGROUNDnCervical stand-alone interbody cages have seen increasingly wider use over the plate-and-screw construct in single-level anterior cervical discectomy and fusion (ACDF) in the treatment of cervical disc herniation and degenerative spondylotic conditions. Despite positive clinical outcomes, the efficacy and safety of using these devices in contiguous multilevel ACDF has remained controversial. This report discusses a burst fracture seen as a complication in multilevel cervical stand-alone cage use.nnnCASE DESCRIPTIONnA 39-year-old woman with a history of C5-C6 and C6-C7 ACDF with contiguous stand-alone interbody cages 2 years prior, presented with recurrent arm and neck pain with myelopathy. Computed tomography scan revealed a burst fracture of the C6 vertebral body with retropulsion of fragments compressing the spinal cord.nnnCONCLUSIONSnThis case suggests that use of cervical stand-alone cages in contiguous levels may cause late complications despite good instrumentation and illustrates the need for more careful consideration of technique selection in multilevel ACDF.