Silky Chotai

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.

Surgical outcomes using wide suboccipital decompression for adult Chiari I malformation with and without syringomyelia

Posterior fossa decompression with or without duraplasty is the most common surgical technique employed to treat Chiari-1 malformation (CM). There is considerable debate as to whether large versus small craniectomy leads to better outcomes. The aim of this study was to report our technique and outcomes using a wide suboccipital craniectomy with arachnoid sparing duraplasty. A retrospective review of medical records for symptomatic CM patients with and without syringomyelia was conducted. Follow-up results were obtained via telephone interviews and medical records. Favorable outcome was defined as improvement in self-rated overall status and/or improvement in Glasgow outcome scale (GOS) score. Poor outcome was defined as worsening of either self-rated overall status or GOS score postoperatively. Mean age of 28 female and 2 male patients was 36.6 years (range 20-67). Seven (23%) patients had syringomyelia, one (3%) had hydrocephalus, and two (7%) had prior surgery. Mean follow-up was 27.5 months (range 5-72). Favorable, acceptable, and poor outcomes were achieved in 90%, 3%, and 7% respectively. 87% of respondents indicated they would choose surgery if they had to make a decision again. The most common complication was pseudomeningocele (23%) followed by CSF leak (10%) and meningitis (7%). One transient (3%) neurologic complication occurred. Surgical technique of wide bony decompression of posterior fossa with arachnoid sparing pericranial duraplasty demonstrates favorable outcomes with an acceptable complication rate for patients with symptomatic CM. Prior CM decompression and non-autologous dural graft were associated with poor outcome. Further study is needed to determine the optimal extent of bony decompression.

Lateral transzygomatic middle fossa approach and its extensions: surgical technique and 3D anatomy.

BACKGROUND Various approaches to lesions involving the middle fossa and cavernous sinus (CS), with and without posterior fossa extension have been described. In the present study, we describe the surgical technique for the extradural lateral tranzygomatic middle fossa approach and its extensions, highlight relevant 3D anatomy. METHODS Simulations of the lateral transzygomatic middle fossa approach and its extensions were performed in four silicon-injected formalin fixed cadaveric heads. The step-by-step description and relevant anatomy was documented with 3D photographs. RESULT The lateral transzygomatic middle fossa approach is particularly useful for lesions involving the middle fossa with and without CS invasion, extending to the posterior fossa and involving the clinoidal region. This approach incorporates direct lateral positioning of patient, frontotemporal craniotomy with zygomatic arch osteotomy, extradural elevation of the temporal lobe, and delamination of the outer layer of the lateral CS wall. Extradural drilling of the sphenoid wing and anterior clinoid process allows entry into the CS through the superior wall and exposure of the clinoidal segment of the ICA. Posteriorly, drilling the petrous apex allows exposure of the ventral brainstem from trigeminal to facial nerve and can be extended to the interpeduncular fossa by division of the superior petrosal sinus. CONCLUSION The present study illustrates 3D anatomical relationships of the lateral transzygomatic middle fossa approach with its extensions. This approach allows wide access to different topographic areas (clinoidal region and clinoidal ICA, the entire CS, and the posterior fossa from the interpeduncular fossa to the facial nerve) via a lateral trajectory. Precise knowledge of technique and anatomy is necessary to properly execute this approach.

Hypofractionated intensity modulated radiotherapy with temozolomide in newly diagnosed glioblastoma multiforme

We conducted a phase I study to determine (a) the maximum tolerated dose of peri-radiation therapy temozolomide (TMZ) and (b) the safety of a selected hypofractionated intensity modulated radiation therapy (HIMRT) regimen in glioblastoma multiforme (GBM) patients. Patients with histological diagnosis of GBM, Karnofsky performance status (KPS)≥ 60 and adequate bone marrow function were eligible for the study. All patients received peri-radiation TMZ; 1 week before the beginning of radiation therapy (RT), 1 week after RT and for 3 weeks during RT. Standard 75 mg/m(2)/day dose was administered to all patients 1 week post-RT. Dose escalation was commenced at level I: 50mg/m(2)/day, level II: 65 mg/m(2)/day and level III: 75 mg/m(2)/day for 4 weeks. HIMRT was delivered at 52.5 Gy in 15 fractions to the contrast enhancing lesion (or surgical cavity) plus the surrounding edema plus a 2 cm margin. Six men and three women with a median age of 67 years (range, 44-81) and a median KPS of 80 (range, 80-90) were enrolled. Three patients were accrued at each TMZ dose level. Median follow-up was 10 months (range, 1-15). Median progression free survival was 3.9 months (95% confidence interval [CI]: 0.9-7.4; range, 0.9-9.9 months) and the overall survival 12.7 months (95% CI: 2.5-17.6; range, 2.5-20.7 months). Time spent in a KPS ≥ 70 was 8.1 months (95% CI: 2.4-15.6; range, 2.4-16 months). No instance of irreversible grade 3 or higher acute toxicity was noted. HIMRT at 52.5 Gy in 15 fractions with peri-RT TMZ at a maximum tolerated dose of 75 mg/m(2)/day for 5 weeks is well tolerated and is able to abate treatment time for these patients.

Endoscopic-assisted microsurgical techniques at the craniovertebral junction: 4 illustrative cases and literature review

BACKGROUND Endoscopic-assisted microsurgery (EAM) techniques are employed to improve visualization of the surgical field while minimizing brain retraction and trauma to neurovascular structures. There have been several reports in the literature on the indications and advantages of endoscopic-assisted techniques when operating at the craniovertebral junction (CVJ). The purpose of this study was to present illustrative cases and to perform a literature review of endoscopic-assisted microsurgical techniques at the CVJ. METHODS A review of the literature was compiled through MEDLINE/OVID and using cross-references of articles on Pubmed. Illustrative cases from the senior authors clinical series are presented to highlight indications and the utility of EAM at the CVJ. RESULTS Our literature review supports the utility of the endoscope in the transoral, transcervical, lateral, far lateral and posterolateral approaches. In particular EAM can be used in the transoral approach to increase surgical exposure of the clivus and minimize the need to split the soft palate while in the far lateral and posterolateral approaches, EAM can improve visualization down narrow or deep surgical corridors to help identify critical neurovascular structures and minimize the need for extensive bony removal. In general, the endoscope can be used to look around bony, vascular, or neoplastic lesions to visualize the surgical space behind these structures as well as to assess for tumor remnants after microsurgical resection. CONCLUSION EAM techniques can improve illumination and visualization of the surgical field at the CVJ. In addition, the EAM techniques can help to minimize the need for brain retraction or extensive exposures. Utilization of both the endoscope and the microscope allows the surgeon to benefit from the advantages of each modality.

Successful resection of anterior and anterolateral lesions at the craniovertebral junction using a simple posterolateral approach

Tumors at the craniovertebral junction (CVJ) often present a challenge due to proximity to vital neurovascular structures. In the last few decades, many authors have proposed complex surgical approaches to access pathologies located anterior or anterolateral to the CVJ with the hopes of reducing morbidity. We propose that the simple posterolateral approach in a semi-sitting position can be used to resect most anterior and anterolateral CVJ tumors safely and effectively. We retrospectively reviewed the clinical series of 10 patients treated by the senior author using the posterolateral suboccipital approach to treat anterior or anterolateral CVJ pathologies. We describe our surgical techniques, outcomes, and present illustrative patients. Gross total resection was achieved in eight patients (80%). Good functional outcome (Glasgow Outcome Scale 4-5) was obtained in all patients. Preoperative symptoms and deficits were improved (78%) or stable (22%) in all patients. There was one (10%) surgical complication that was cerebrospinal fluid leak requiring reoperation. There was no permanent morbidity or mortality in this series. There were two (20%) medical complications including deep vein thrombosis and pulmonary embolus. There were three (30%) transient neurologic complications, dysphagia in two and dysarthria in one, all of which resolved completely in early follow-up. The majority of anterior or anterolateral CVJ lesions can be successfully removed using the simple posterolateral approach.

Quantitative analysis of the effect of brainstem shift on surgical approaches to anterolateral tumors at the craniovertebral junction.

Many anterolateral craniovertebral junction (CVJ) tumors can safely be resected using a simple posterolateral approach given the surgical corridor provided by brainstem shift. We sought to study how increasing anterolateral CVJ lesion size affects exposure in the posterolateral and far lateral approaches. Six cadaveric heads were used. A posterolateral approach was performed on one side and a far lateral with one-third condyle resection on the other side. Clival and brainstem exposure and surgical freedom were measured. A balloon catheter was used to simulate 10, 15, and 20mm anterolateral mass lesions. Mean clival exposure was significantly greater with the far lateral approach (197.4 versus [vs] 135.0 mm(2), p=0.03) with no balloon, but this difference disappeared with lesion sizes of 10 mm (246.8 vs 237.9 mm(2), p=0.79), 15 mm (306.7 vs 262.4 mm(2), p=0.25), and 20 mm (360.0 vs 332.7 mm(2), p=0.64). Mean brainstem exposure was significantly greater with the far lateral approach for 0 mm (127.8 vs 65.8 mm(2), p<0.01), 10 mm (129.5 vs 87.5 mm(2), p=0.045), and 15 mm (140.1 vs 97.8 mm(2), p=0.01) lesions. There was no difference at 20 mm (146.7 vs 147.8 mm(2), p=0.97). Medial-lateral surgical freedom was greater with the far lateral approach for all sizes. The results of this study provide insight on one important variable in the decision-making process to select the optimal approach for anterolateral CVJ tumors.

Effect of Posterior Fossa Decompression for Chiari Malformation-I on Scoliosis

Background/Aims: Scoliosis is common in patients with Chiari malformation-I (CM-I). This study examined the change in scoliosis severity after posterior fossa decompression (PFD) for CM-I. Methods: We conducted a retrospective review at a single tertiary center for children undergoing PFD with untreated scoliosis, and identified 17 patients with complete follow-up data and imaging. Results: Overall, scoliosis improved in 7 (41.2%) patients, worsened in 9 (52.9%), and remained unchanged in 1 (5.9%) after PFD (mean follow-up of 7.8 ± 4.1 months). We found that 3 of the 8 (38%) children with early-onset scoliosis eventually needed scoliosis corrective surgery, which was needed in 7 of the 9 (78%) patients with adolescent-onset scoliosis. In addition, only 1 patient (17%) with a preoperative scoliosis curve <35 degrees and 9 patients (82%) with a curve ≥35 degrees required surgery for scoliosis correction despite PFD (p = 0.018). Conclusion: In certain patients, PFD for CM-I may lead to improvement or stabilization of scoliosis.