Samuel Sommaruga

Macrovascular Lesions Underlying Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a morbid disease with a high case fatality rate. Prognosis, rehemorrhage rates, and acute, clinical decision making are greatly affected by the underlying etiology of hemorrhage. This review focuses on the evaluation, diagnosis, and management of structural, macrovascular lesions presenting with ICH, including ruptured aneurysms, brain arteriovenous malformations, cranial dural arteriovenous fistulas, and cerebral cavernous malformations.

The Subjective Experience of Patients Undergoing Shunt Surgery for Idiopathic Normal Pressure Hydrocephalus

OBJECTIVE The counseling of patients with idiopathic normal pressure hydrocephalus (iNPH) is difficult; there is variability in the diagnostic criteria, and a definitive diagnosis can be made only postoperatively. A patients clinical response to shunting is also difficult to predict. This study examines the subjective experience of patients treated for iNPH, to identify the challenges patients face and to improve patient outcomes and satisfaction. METHODS We reviewed a consecutive series of patients diagnosed with iNPH who underwent ventriculoperitoneal shunt surgery between January 2012 and March 2016 at our institution. Semistructured telephone interviews were conducted with 31 patients. Interviews were analyzed using the principles of grounded theory. RESULTS Thirty-one patients who underwent shunt surgery for iNPH were interviewed to reach saturation of themes. Seven themes were identified: 1) long preoperative course causes morbidity; 2) the decision to have shunt surgery is easy to make; 3) patients primarily desire to gain independence; 4) patients show variable levels of anxiety; 5) comorbid conditions interfere with postoperative assessment; 6) patients stand by their decision to have shunt surgery; and 7) outside information is used before surgery. CONCLUSIONS Patients often present to the neurosurgeon frustrated and desperate after a long preoperative course. It is important to acknowledge the uncertainty regarding diagnosis and response to shunting when counseling patients. Comorbid conditions interfere with the ability to assess progression of iNPH and the effectiveness of the shunt. Patient caregivers play a large role in decision making and clinical course and should be included when counseling patients.

148 Management of Unruptured Intracranial Aneurysms in the Elderly: A Cost-Effectiveness Analysis

INTRODUCTION: Radiation necrosis (RN) following Gamma knife radiosurgery (GKRS) for brain metastases (BM) can occur in up to 30% of patients. Apparent diffusion coefficient (ADC) is a measure of the magnitude of diffusion within tissue and is calculated using standard MRI. The aim of study was to evaluate the role of ADC in differentiating RN and recurrent tumor. METHODS: Forty-one patients with BMs who demonstrated lesion growth and underwent surgical intervention following GKRS at Cleveland Clinic (2006-2017) were included in this retrospective study. The ADC values of the growing lesions and the contralateral hemisphere were calculated using Agfa IMPAX software C ©. These values were correlated to the percentage of RN obtained from surgical pathology. The area under the nonparametric ROC curve and Spearman’s rank correlation coefficients were used for analysis. RESULTS: The mean age of the patient was 59.9 yr (range: 2586) and lung cancer (63.4%) was the most common systemic malignancy. The mean initial (pre-GK) target volume of the lesions was 8.0 cc (range: 0.135-45.6) and median GKRS dose was 19.0 Gy. Surgical resection or biopsy was performed at a median of 176 d following GKRS. Two variables were statistically significant predictors of predominate RN (75-100%) in the surgical specimen: (i) ADC of the lesion on the preresectionMRI and (ii) initial target volume. ADC> 1.5 within the lesion on MRI predicted for risk of significant RN on pathological evaluation of the lesion (P< .05). Similarly, when the initial target volume was large (>10 cc), the risk of significant necrosis in the pathological specimen was elevated (P < .05). CONCLUSION: Our data suggest that lesion ADC on MRI prior to surgery and the initial target volume can predict RN with reasonable accuracy. These findings can be validated using a larger sample size to enhance the precision of accuracy estimates.

E-050 First-Line Treatment by Embolization with Intention-to-Cure in the Management of Cranial Dural Arteriovenous Fistulas

Introduction/purpose Cranial dural arteriovenous fistulas (dAVFs) represent abnormal arteriovenous shunts supplied by dural arteries. Their natural history and presentation depend on the pattern of venous drainage encapsulated in the Borden classification. When cortical venous reflux (CVR) is present, aggressive management is mandated. The treatment of cranial dAVFs lacking CVR may be warranted. Treatment modalities include surgical disconnection, radiosurgery, and embolization (alone or in combination). Here we report our early experience in the management of cranial dAVFs using a philosophy of first-line embolization with intention-to-cure. Materials and methods A series of consecutive cranial dAVFs (n = 14) treated by a single operator (CM) at Yale-New Haven Hospital (November 2011 – March 2016) were analyzed. The mean age at presentation was 61 ± 12 years (57% male). The locations of cranial dAVFs included transverse sinus (n = 6), cavernous sinus (n = 2), anterior skull base (n = 2), straight sinus (n = 2), hypoglossal canal (n = 1), and midline cerebellar (n = 1). Borden types included I (n = 1), II (n = 3), and III (n = 10). Borden types II/III lesions presented most commonly with venous congestion±hemorrhage (80%). A trans-venous approach was prioritized as a first-line treatment strategy. When a trans-venous approach was not possible, as in a majority of type III lesions (80%), a trans-arterial embolization was performed with intention-to-cure, i.e., penetration of liquid embolic into the draining vein. Mean angiographic and clinical follow-up were 12.4 ± 12.2 months (median = 7.1 months, range = 2.1–40.1 months) and 19.4 ± 15.4 months (median = 13.7 months, range = 2.1–44.7 months), respectively. Cure was defined as elimination of CVR on follow-up imaging. Results The overall cure rate of cranial dAVFs treated using a first-line embolization with intention-to-cure philosophy was 71.4%. Three patients required an additional treatment modality (2 Gamma Knife radiosurgery and 1 open surgery) resulting in an overall cure rate of 92.6%. A single, elderly patient who presented with a cerebellar hemorrhage died 10 days after a partial trans-arterial embolization due to the severity of her initial hemorrhage. First-line trans-venous embolization resulted in an overall higher embolization-only cure rate (86%) compared to first-line trans-arterial embolization (57%). Both approaches were associated with low permanent morbidity (overall 7.1%) however the trans-venous approach was fraught with more frequent technical complications, e.g., coil migration. Of note, a single case of trans-venous embolization of a Borden type II transverse sinus dAVF was associated with conversion to a type III lesion complicated by a small, delayed intraparenchymal hemorrhage and new visual field deficit from which the patient completely recovered. Her residual dAVF spontaneously thrombosed resulting in a durable cure. Conclusions A philosophy of first-line embolization with intention-to-cure of cranial dAVFs is both safe and effective with low morbidity and high, durable cure rates. When possible, a trans-venous route is preferred with higher chances of immediate cure using embolization as a standalone therapy. Disclosures B. Cord: None. S. Sommaruga: None. J. Yeung: None. M. Johnson: None. C. Matouk: None.

Abstract 2393: Kidneys of VHL patients reveal the origin of renal clear cell carcinoma

VHL disease is a classic tumor suppressor gene syndrome characterized by development of specific types of tumors in selective organs with nervous system and kidney being most consistently affected. Detailed studies on human spinal cord and cerebellum have previously revealed earliest stages of CNS tumorigenesis and the morphologic sequence resulting in development of frank tumors. To elucidate earliest stages of renal clear cell carcinoma, we performed a similar approach in kidney tissues of four VHL patients and three sporadic control cases. From all cases, blocks of interest were procured, followed by serial sectioning and 3dimensional reconstruction of potential precursor lesions. The results reveal an abundance of foci with aberrant mesonephric clear cell proliferations that initially develop along the tubular lining, but have the potential to aggregate within individual tubules. This stage is followed by microscopic invasive clear cell aggregations which represent tumor precursor structures. This study presents evidence for a consistent morphologic sequence for renal clear cell carcinogenesis. Molecular analysis of early steps within this sequence will allow for identification of earliest genetic and proteomic changes in the future. Therapeutic targeting of earliest changes may allow to develop preventive strategies for renal cancer development for VHL patients, potentially also for the non-VHL population. Citation Format: Mayyan Mubarak, Samuel Sommaruga, David Voigt, Xiacao Xu, Steve Kim, Ailin Song, Alexander O. Vortmeyer. Kidneys of VHL patients reveal the origin of renal clear cell carcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2393.